Modified "sutureless" anastomosis for primary repair of supracardiac total anomalous pulmonary venous connection.

Repair of total anomalous pulmonary venous connection (TAPVC) is associated with a risk of recurrent pulmonary venous obstruction. In this article we describe a technique of primary repair using a posterior approach in which a modified sutureless anastomosis is constructed by suturing the left atrium to the posterior pericardium that surrounds the pulmonary venous confluence. This technique avoids trauma to the pulmonary venous wall and minimizes the risk of distortion of the anastomosis, factors that have been implicated in the occurrence of subsequent pulmonary venous obstruction.

Efficacy, feasibility, and pitfalls of transseptal approach in beating-heart mitral valve surgery.

BACKGROUND: Mitral valve surgery can be performed through the trans-atrial or the trans-septal approach. Although the trans-atrial is the preferred method, the trans-septal approach has also been used recently and has a particular value in beating-heart mitral valve surgery. Herein we report our experience with beating-heart mitral valve surgery via trans-septal approach, and discuss its advantages and pitfalls. METHODS: Between 2000 and 2007, 214 patients underwent mitral valve procedures using the beating-heart surgical approach. RESULTS: One hundred and forty-three patients (66.8%) had mitral valve replacement, 68 patients (31.7%) mitral valve repair, and 82 patients (38.3%) concomitant valve procedures. Coronary artery bypass grafting was simultaneously performed in 30 (14%) patients. Thirty-day mortality was 7.4%, reoperation for bleeding 7%, stroke 0.4%, and myocardial infarction 0.4%, and failed mitral valve repair 0.9%. CONCLUSION: Our experience suggests that beating-heart mitral valve surgery is facilitated by using the trans-septal approach.

Pectoralis Plane Block for Pacemaker Insertion: A Successful Primary Anesthetic.

Effective anesthesia, analgesia, and hemodynamic stability is important to maintain during pacemaker implantation surgery, especially in the elderly population and patients with compromised cardiac function. As a strategy to avoid the need for intravenous (IV) anesthetics, peripheral nerve block techniques may be used in these specific cases. We report a case of successful pacemaker implantation surgery in a patient with severe Aortic Stenosis (AS) and Sick Sinus Syndrome (SSS) using unilateral pectoralis plane block for surgical anesthesia. Since general anesthesia was considered risky, monitored anesthesia care utilizing peripheral nerve block was planned. A single shot left side pectoralis plane block (PECS II) was done under ultrasound guidance injecting a total of 20 mL of 0.5% Ropivacaine with 1% Lidocaine. No sedation was needed. The patient tolerated the procedure with no significant hemodynamic changes. Patient did not require opioids post-operative and was discharged home in stable condition the next day. This case highlights that PECS block can also provide effective surgical anesthesia for relatively long procedures avoiding the risk of complications associated with IV anesthesia in high risk cardiovascular patients. Additionally, these blocks can provide an opioid sparing option for post-operative management in pacemaker implantation surgeries.

Multiple valve surgery with beating heart technique.

BACKGROUND: Multiple valve surgery was performed utilizing beating heart technique through simultaneous antegrade/retrograde perfusion with blood. We herein report our experience with this technique in patients with multiple valve disease processes. METHODS: Of 520 consecutive patients operated upon utilizing this method between 2000 and 2007, 59 patients underwent multiple valve surgery. Mean age was 54.2 +/- 13.8 years (range, 21 to 83) with 41 males (69.5%) and 18 females (30.5%). Double-valve and triple-valve operations were performed in 54 and 5 patients, respectively. RESULTS: Of 32 mitral valve replacements, there were 30 biological (93.8%) and 2 mechanical (6.2%) mitral valves. Aortic valve replacement was performed in 25 patients: 22 (88%) with biological and 3 (12%) with mechanical prostheses. Two patients had mitral and tricuspid valve repair. The most common procedure was mitral valve replacement plus tricuspid valve repair (16 patients; 27.1%), mitral valve replacement plus aortic replacement (14 patients; 23.7%), and mitral valve repair plus tricuspid repair (13 patients; 22%). Concomitant coronary artery bypass grafting was performed in 7 (11.8%) of 59 patients. Mean hospital stay was 25.6 +/- 29.6 days (range, 3 to 195; median, 17). Early mortality (less than 30 days) occurred in 5 patients (8.4%), and late mortality (more than 30 days) occurred in 2 patients (3.4%). Reoperation for bleeding was needed in 5 patients (8.4%). Intra-aortic balloon pump was required preoperatively and postoperatively in 4 and 1 patients, respectively. Clinical and echocardiographic follow-up in 33 patients at 11.8 +/- 16.4 months (range, 1 to 80) showed preserved postoperative left ventricular ejection fraction. Three patients had perivalvular leaks on follow-up but required no surgery. Nineteen patients were lost to follow-up. CONCLUSIONS: This study demonstrates the feasibility and safety of beating heart techniques in multiple valve operations. Further studies are needed to fully evaluate the potential benefits of this method of myocardial perfusion as a means to eliminate ischemia-reperfusion injury, and to preserve ventricular function in multiple valvular surgery.

Complex aortic valve surgery for endocarditis using the beating-heart technique.

OBJECTIVE: : Surgical outcomes of aortic valve surgery for endocarditis are poor. Postoperative deterioration of left ventricular (LV) function may contribute to this process. To enhance preservation of myocardial function during aortic valve surgery, we have used a beating-heart technique of myocardial protection without cardioplegic arrest. The aim of this article is to report our initial clinical experience with this technique. METHODS: : We identified 30 consecutive patients with endocarditis who underwent aortic valve repair (one patient) or replacement using either a mechanical prosthesis (four patients) or a biologic prosthesis (25 patients) with beating-heart technique. There were 22 men and eight women (mean age 52.8 ± 16.1 years). There were one elective, 22 urgent/emergent, and seven "salvage" operations. Two patients had preoperative stroke, five respiratory failure, three renal failure, 12 congestive heart failure, eight septic shock, and one previous coronary artery bypass grafting. The etiology of the infection was identified in 15 patients (50%). Ten patients had severe, seven moderate, and four mild aortic insufficiency. All patients had vegetations, four had annular abscesses, and two had intracardiac fistulas. RESULTS: : Eight patients (26.6%) had redo procedures. Concomitant procedures included aortic and mitral valve procedure (14 patients), tricuspid valve procedure (two patients), and coronary artery bypass grafting (one patient). Aortic annular reconstruction was required in four patients (13.2%). Total CPB time was 125 ± 67 minutes. Intra-aortic balloon pump was needed in one patient. Two patients (6.6%) had a stroke unrelated to air embolism. Mean follow-up was 7.9 ± 12 months. Early mortality (30 days) was 13.3% (four patients), and late mortality was 10% (three patients). Total mortality was 18% in urgent/emergent cases, and 42% in salvage operations. There was no statistical difference between preoperative and postoperative echocardiographic values of LV function (ejection fraction and fractional shortening). LV end-diastolic dimension decreased postoperatively (P = 0.03), whereas LV end-systolic dimension and left atrial size were unchanged. CONCLUSIONS: : Our study did not show improved survival benefits of beating-heart aortic valve surgery compared with historical series in which conventional myocardial protection was used. However, our findings suggest that beating-heart technique is an alternative strategy of myocardial protection that may contribute to preservation of LV function in patients undergoing complex operations for aortic valve endocarditis.