Current surgical management of chronic thromboembolic pulmonary disease.

Chronic thromboembolic pulmonary disease (CTEPD) with or without pulmonary hypertension (PH) is an important potential consequence of venous thromboembolic disease. Untreated CTEPD with pulmonary hypertension (CTEPH) is associated with high rates of morbidity and mortality. Several treatment options are now available for patients with CTEPD and CTEPH, including pulmonary endarterectomy (PEA), balloon pulmonary angioplasty, medical therapy or a combination of therapies. Choice of treatment depends on the location of the thromboembolic disease burden, presence and severity of PH and patient factors, including frailty, parenchymal lung disease and other comorbidities. PEA is a complex surgery that can result in excellent outcomes and resolution of disease, but also comes with the risk of serious perioperative complications. This manuscript examines the history of PEA and its place in Australasia, and reports on outcomes from the main Australasian CTEPH expert centre. It provides a summary of up-to-date guidance on how PEA should be utilised in the overall management of these patients and describes opportunities and challenges for the future diagnosis and management of this disease, particularly in the Australasian setting.

Predictors of Late Atrial Fibrillation Recurrence After Cardiac Surgery.

BACKGROUND: Although postoperative atrial fibrillation (POAF) frequently occurs early after cardiac surgery, there is a paucity of data evaluating predictors and timing of late atrial fibrillation (AF) recurrence. OBJECTIVES: The authors sought to evaluate predictors of late AF recurrence in patients undergoing cardiac surgery. METHODS: We retrospectively reviewed cardiac surgery patients from 2010 to 2018 with no preoperative diagnosis of AF or atrial flutter. We recorded incidence and timing of late AF recurrence, defined as occurring ≥12 months following surgery. RESULTS: 1,031 patients were included (mean age at surgery 64 ± 12 years, 74% male). Early POAF was recorded in 445 patients (43%). POAF was usually transient, with total AF duration <48 hours in 72% and reversion to sinus rhythm at discharge in 91%. At 4.7 ± 2.4 years follow-up, late AF occurred in 139 patients (14%). Median time to AF recurrence was 4.4 years post-surgery (Q1-Q3: 2.6-6.2 years). Late AF was significantly more likely among patients with early POAF than those without (23% vs 6%; P < 0.001), with highest incidence (38%) in those with POAF duration >48 hours. In a multivariable analysis, early POAF duration >48 hours was a significant predictor of late AF recurrence (HR: 5.9). Surgery type and CHA2DS2-VASc score were not predictive of late AF events. CONCLUSIONS: Post-operative AF episodes of duration ≥48 hours predict recurrent AF episodes over long-term follow-up after cardiac surgery. Implications for arrhythmia surveillance and anticoagulation in patients with longer duration POAF episodes require further study.

HeartMate 3 implantation with an emphasis on the biventricular configuration.

OBJECTIVES: Right ventricular failure following implantation of a durable left ventricular assist device (LVAD) is a major driver of mortality. Reported survival following biventricular (BiVAD) or total artificial heart (TAH) implantation remains substantially inferior to LVAD alone. We report our outcomes with LVAD and BiVAD HeartMate 3 (HM3). METHODS: Consecutive patients undergoing implantation of an HM3 LVAD between November 2014 and December 2021, at The Alfred, Australia were included in the study. Comparison was made between the BiVAD and LVAD alone groups. RESULTS: A total of 86 patients, 65 patients with LVAD alone and 21 in a BiVAD configuration underwent implantation. The median age of the LVAD and BiVAD groups was 56 years (Interquartile range 46-62) and 49 years (Interquartile range 37-55), respectively. By 4 years after implantation, 54% of LVAD patients and 43% of BiVAD patients had undergone cardiac transplantation. The incidence of stroke in the entire experience was 3.5% and pump thrombosis 5% (all in the RVAD). There were 14 deaths in the LVAD group and 1 in the BiVAD group. The actuarial survival for LVAD patients at 1 year was 85% and BiVAD patients at 1 year was 95%. CONCLUSIONS: The application of HM 3 BiVAD support in selected patients appears to offer a satisfactory solution to patients requiring biventricular support.

Impact of postoperative hyperlactatemia in orthotopic heart transplantation.

BACKGROUND: Hyperlactatemia (HL) is a common phenomenon after cardiac surgery which is related to tissue hypoperfusion and hypoxia and associated with poor outcomes. It is also often seen in the postoperative period after orthotopic heart transplantation (OHTx), but the association between HL and outcomes after OHTx is not well known. We evaluated the incidence and outcome of HL after OHTx. METHODS: This was a retrospective study of 209 patients who underwent OHTx between January 2011 and December 2020. Patients were classified into 3 groups according to their peak lactate levels within the first 72 h postoperatively: group 1, normal to mild hyperlactatemia (<5 mmol/L, n = 42); group 2, moderate hyperlactatemia (5-10 mmol/L, n = 110); and group 3, severe hyperlactatemia (>10 mmol/L, n = 57). The primary composite endpoint was all-cause mortality or postoperative initiation of veno-arterial extracorporeal membrane oxygenation (VA ECMO) within 30 days. Secondary endpoints included duration of mechanical ventilation, intensive care unit length of stay, and hospital length of stay. RESULTS: Patients with higher postoperative peak lactate levels were more commonly transplanted from left ventricular assist device support (33.3 % vs 50.9 % vs 64.9, p < 0.01) and had longer cardiopulmonary bypass time [127 min (109-148) vs 141 min (116-186) vs 153 min (127-182), p = 0.02]. Composite primary endpoint was met in 18 patients (8.6 %) and was significantly more common in patients with higher postoperative peak lactate levels (0.0 % vs 6.4 % vs 19.3 %, p < 0.01). CONCLUSIONS: Severe hyperlactatemia following orthotopic heart transplant was associated with an increased risk of post-transplant VA ECMO initiation and mortality at 30 days.

Hypothermic oxygenated perfusion (HOPE) safely and effectively extends acceptable donor heart preservation times: Results of the Australian and New Zealand trial.

BACKGROUND: Cold static storage preservation of donor hearts for periods longer than 4 hours increases the risk of primary graft dysfunction (PGD). The aim of the study was to determine if hypothermic oxygenated perfusion (HOPE) could safely prolong the preservation time of donor hearts. METHODS: We conducted a nonrandomized, single arm, multicenter investigation of the effect of HOPE using the XVIVO Heart Preservation System on donor hearts with a projected preservation time of 6 to 8 hours on 30-day recipient survival and allograft function post-transplant. Each center completed 1 or 2 short preservation time followed by long preservation time cases. PGD was classified as occurring in the first 24 hours after transplantation or secondary graft dysfunction (SGD) occurring at any time with a clearly defined cause. Trial survival was compared with a comparator group based on data from the International Society of Heart and Lung Transplantation (ISHLT) Registry. RESULTS: We performed heart transplants using 7 short and 29 long preservation time donor hearts placed on the HOPE system. The mean preservation time for the long preservation time cases was 414 minutes, the longest being 8 hours and 47 minutes. There was 100% survival at 30 days. One long preservation time recipient developed PGD, and 1 developed SGD. One short preservation time patient developed SGD. Thirty day survival was superior to the ISHLT comparator group despite substantially longer preservation times in the trial patients. CONCLUSIONS: HOPE provides effective preservation out to preservation times of nearly 9 hours allowing retrieval from remote geographic locations.

Alternatives to transvenous lead placement in a patient undergoing surgical tricuspid valve repair.

Tricuspid regurgitation is a widely recognised phenomenon in patients with transvenous cardiac rhythm management (CRM) devices. If tricuspid valve repair or replacement is to be considered, what to do with the existing CRM system requires scrutiny with multidisciplinary input. We present a case of multifactorial tricuspid regurgitation in a 48-year-old female with giant cell myocarditis and a transvenous implantable cardioverter-defibrillator (ICD). Key considerations in management and alternative CRM options are discussed.

Heart-Lung Transplantation: Technical Modifications to Simplify the Procedure.

Heart-lung transplantation is a mature therapy but has perioperative complications, such as phrenic nerve dysfunction and mediastinal bleeding. We report our technical modifications to simplify the procedure.

Extracorporeal Membrane Oxygenation as a Bridge to Surgical Repair of Postinfarct Ventricular Septal Defect.

Postinfarct ventricular septal defect (PIVSD) is associated with high mortality and the management of these patients has been a challenge with little improvement in outcomes. We commenced a protocol of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for those patients who present in cardiogenic shock with the aim to improve end-organ function before definitive surgical repair to reduce postoperative mortality. This study reviewed the results of this strategy. This was a single-center, retrospective review of all patients who were admitted to our institution with PIVSD in cardiogenic shock from September 2015 to November 2019. Clinical and investigative data were evaluated. Eight patients were referred with PIVSD during this period in cardiogenic shock. One patient had an anterior PIVSD and the other seven had inferior PIVSD. Six patients underwent surgical repair at a median (interquartile range, IQR) of 7 (5-8) days after initiation of VA ECMO. Two patients did not undergo surgical repair. Five patients survived after surgery and one patient died postoperatively due to multiorgan failure. Preoperative use of VA ECMO is a feasible strategy for PIVSD and may improve the results of repair.

Surgical management of giant pulmonary artery aneurysms in patients with severe pulmonary arterial hypertension.

BACKGROUND AND AIM: Giant aneurysm of the pulmonary artery (PAA) is an extremely rare condition that may develop in patients with pulmonary arterial hypertension (PAH) which may be complicated by rupture, dissection or intravascular thrombus formation. The aim of this study was to examine available literature with regard to surgical strategies in patients undergoing transplantation for PAH with PAA. RESULTS: These patients were traditionally considered for heart-lung transplantation but more recently, there have been reports of successful lung transplantation with reconstruction of the pulmonary artery. CONCLUSIONS: Unless there is a mandatory indication for heart-lung transplantation, patients with PAH and PAA can undergo lung transplantation and reconstruction of the pulmonary artery without compromising the outcome.

Spontaneous echo contrast mimicking aortic root thrombus in a patient supported with extracorporeal membrane oxygenation.

Aortic root spontaneous echo contrast is a rare but significant finding. We report a 31-year-old female who was placed on venoarterial extracorporeal membrane oxygenation emergently for acute mitral regurgitation secondary to papillary muscle rupture. Following stabilization, subsequent transesophageal echocardiography suggested aortic root thrombus and prompted emergent surgery. However, further inspection with intraoperative transesophageal echocardiography revealed a spontaneous echo contrast which aided us in the intraoperative decision making.

A successful aggressive surgical and medical approach to pulmonary artery obstruction due to Mycobacterium abscessus infection post lung transplantation.

Mycobacterium abscessus infection following lung transplantation has historically been associated with poor outcomes. We report a case of bilateral lung retransplantation complicated by obstruction of the right pulmonary artery secondary to M. abscessus mycotic aneurysm. Aggressive surgical management, including reconstruction of the right pulmonary artery, was undertaken with prolonged antimicrobial therapy. Thirty-six months later, antibiotics have been discontinued and the patient has stable soft tissue chest wall disease with good graft function. Mortality and morbidity associated with M. abscessus infection is considerable but this case illustrates that with aggressive early management, outcomes may be favorable.

Impact of Discontinuation of Antiplatelet Therapy Prior to Isolated Valve and Combined Coronary Artery Bypass Graft and Valve Procedures on Short and Intermediate Term Outcomes.

BACKGROUND: A change in cardiac surgery practice over the past decade has seen an increase in urgent or inpatient referrals for surgery, with antiplatelet therapy often continued up until surgery. This study aims to identify the optimal timing for administration of aspirin to minimise risk of perioperative morbidity and mortality. METHODS: From a prospectively compiled database collected by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, we identified 8294 patients undertaking combined CABG and valve or isolated valve procedures while discontinuing aspirin. Time points for cessation of antiplatelet therapy were categorised as follows: <2 days, 3-7 days or >7 days preoperatively. We evaluated the association of adverse in-hospital events and intermediate term survival in each time category. RESULTS: Discontinuing aspirin 3 to 7 days from surgery decreased rates of perioperative MI (HR=0.300, p=0.027), return to theatre (HR=0.560, p=0.002) reduced drain output (HR=0.757, p=0.000) and red blood cell and platelet transfusions (HR=0.719, p=0.000 and HR=0.604, p=0.000 respectively) compared to patients continuing aspirin until <2 days from the procedure. Stopping aspirin <2 days from the date of surgery increased risk of perioperative MI (HR=5.919, p=0.000), reoperation for bleeding (HR=2.076, p=0.001), returning to theatre (HR=1.781, p=0.000), ICC drain losses (HR=1.337, p=0.000) and transfusion demands for red blood cells (HR=1.381, p=0.000) and platelets (HR=1.450, p=0.000) when compared to those discontinuing aspirin >7 days from surgery. CONCLUSION: Late discontinuation of aspirin before combined coronary artery bypass graft and valve procedures results in greater rates of bleeding and transfusion requirements. Earlier discontinuation of aspirin results in no benefit in intermediate term survival.

Familial Atrial Myxoma: Three Related Cases at an Australian Tertiary Institution.

Carney complex accounts for up to two-thirds of familial cardiac myxoma. It is a rare autosomal dominant syndrome, which is also characterized by multiple mucocutaneous lesions and endocrine tumors. We report on three first-degree relatives who underwent surgical resection at the same Australian tertiary institution. One patient re-presented with a recurrent tumor at an interval of 6 years. In this context, the role of interval surveillance, family screening, and genetic testing is explored. We recommend interval echocardiographic surveillance for affected individuals and first-degree relatives given the high risk of recurrence and the morbidity and mortality associated with cardiac tumors in any location.

Mycotic Pseudoaneurysms of the Coronary Arteries.

BACKGROUND: Mycotic coronary artery aneurysms are rare and are often fatal without early recognition and prompt surgical management. METHODS: We present a case of mycotic pseudoaneurysm of the left main coronary artery (LMCA) after disseminated methicillin-sensitive Staphylococcus aureus (MSSA) bacteraemia. A review of the literature in regards to the surgical management of coronary artery mycotic pseudoaneurysms was conducted. RESULTS: There were 26 reported cases of surgical management of coronary artery mycotic pseudoaneurysms. Coronary artery bypass surgery (CABG) and excision was the most common management (73.1% of cases reviewed). CONCLUSION: This case highlights the difficultly in diagnosing mycotic coronary artery pseudoaneurysms.

Is a Bioprosthetic Valve in the Aortic Position Desirable with a Continuous Flow LVAD?

Commissural fusion of the native aortic valve in a patient with a continuous flow left ventricular assist device (LVAD) is a known phenomenon. This may result in aortic insufficiency (AI) leading to symptomatic heart failure. In patients with AI at the time of LVAD implantation, repairing, or replacing the aortic valve is advisable. We describe a patient who had a severe dilated cardiomyopathy and moderate AI who underwent implantation of an LVAD and aortic valve replacement with a bioprosthesis that subsequently developed commissural fusion which was found at the time of heart transplantation. This case highlights the conundrum of the management of AI in patients requiring LVAD support.

[Feasibility of the use of absorbable sutures for closure of the sternum in adult cardiac surgery].

Steel wires are commonly used to close median sternotomy during adult cardiac surgery. Disruption or infection of the sternum can occure in 0.3~8% of those patients. We report the use of absorbable sutures for the closure of sternotomy. Three figure of 8 ligations were made. Cranial side suture was placed through the sternal manubrium. Other sutures were placed through the intercostal spaces.Sutures were tied 6 or 7 times. Braided #2 polyglactin suture were used in a consecutive 150 patients. Looped (double) #1 monofilament polyglyconate sutures were used in a subsequent 150 patients. Both sutures with blunt needle are commercially available. None of the patients in either group required re-exploration of the sternum for bleeding and tamponade, and none developed wound infections or mediastinitis. Five patients in the polyglactin group developed seroma and/or instability of the sternum after more than 2 postoperative weeks, but none required surgical refixation of the sternum. These 5 patients had diabetes, chronic renal failure, autoimmune disease and/or chronic lung diseases. None of the patients in the polyglyconate group developed any trouble in their sternum. We conclude that polyglyconate sutures demonstrate good potential for use in closure of the sternum.

Simple and quick repair of cardiac rupture due to blunt chest trauma.

Atrial rupture following blunt chest trauma carries a high mortality rate. It can be difficult to maintain hemodynamic stability and control massive bleeding due to poor visualization. We describe a case in which bleeding control was obtained simply and effectively using a Satinsky clamp, allowing repair of atrial rupture without the use of cardiopulmonary bypass.

A device for ensuring the neochordae replacement in mitral valve repair.

We have developed a new device for maintaining artificial chordae at the appropriate length during the tying of Gore-Tex sutures (W. L. Gore and Assoc, Flagstaff, AZ). This double-armed, double-hooked device is inserted through the loop formed by the neochordae, which is anchored in the papillary muscle and passed through the prolapsing segment. The device pulls up both leaflets and maintains the neochordae at the same length as that of the opposing normal chordae. The prolapsed leaflet is suspended at the same height as the facing leaflet, enabling the accurate and reproducible placement of neochordae.

Surgical repair of pectus excavatum not requiring exogenous implants in 113 patients.

OBJECTIVE: Pectus excavatum is relatively common congenital chest deformity that is often accompanied by physical and psychological impairment. The surgical methods for pectus excavatum repair are the subject of some controversy. We review our experience using a procedure in which the introduction of exogenous material is unnecessary. METHODS: From July 1993 to March 2008, 113 patients underwent surgical repair of pectus excavatum. Sterno-costal elevation was adopted for 102 patients, including all of the paediatric patients and most of the adults. Sternal turnover was employed for 11 adult patients with severe asymmetric deformities. In sterno-costal elevation, a section of the third or fourth to the seventh costal cartilages as well as the lower tip of the sternum below the sixth cartilage junction are resected, and all of the cartilage stumps are re-sutured to the sternum. The secured ribs generate 0.5-10 kg of tension, pulling the sternum bilaterally, such that the resultant force causes the sternum to rise anteriorly. These forces are sufficient to correct the deformities and to prevent flail chest. In sternal turnover, the sternum is cut at the third intercostal space. The lower part of the sternum is turned over and fixed to the upper sternum with an overlap of 1cm. Sections of the third to the seventh rib cartilages are resected and affixed in the same fashion as in sterno-costal elevation. RESULTS: There were no operative deaths, and in all cases the deformities were corrected satisfactorily. Ninety-nine patients (88%) were graded as Excellent, and the remaining 14 (12%) were graded Good. None of the patients developed any life-threatening complications. No patient reported residual pain. No re-operations were required for any reasons. The patients resumed daily activities of all types, including contact sports, within 3 months after surgery. CONCLUSIONS: We believe that morbidity is one of the most important factors to be considered in operative invasions. Our technique represents a less-invasive and lower-risk procedure for the repair of pectus excavatum in any age group.