The impact of postoperative cerebrospinal fluid drainage on neurological improvement following thoracic aortic and thoracoabdominal aortic surgery.

Background: Various preventive measures and treatment methods exist to prevent paraplegia during thoracic aortic surgery. Postoperative cerebrospinal fluid drainage (CSFD) is one of the treatment options when paraplegia occurs. This study aimed to evaluate the neurological efficacy of postoperative CSFD in patients undergoing thoracic aortic and thoracoabdominal aortic surgery. Methods: We analyzed perioperative data from 85 patients who underwent perioperative CSFD for thoracic and thoracoabdominal aortic surgery between January 2006 and December 2022, focusing on neurological changes. A total of 61 patients (72%) received preoperative CSFD, and 24 patients (28%) received postoperative CSFD. Perioperative neurological data were analyzed with a focus on perioperative changes. Results: In the postoperative CSFD group, the manual muscle test (MMT) score before CSFD was 0.8, that just after CSFD was 2.4, and that at discharge was 3.0. Therefore, postoperative CSFD improved MMT scores compared with preoperative CSFD. The mean time between surgery completion and postoperative CSFD implantation was 9.8 hours. However, 6 (25%) of the patients who developed postoperative paraplegia and underwent early postoperative CSFD remained paraplegic without any improvement. In the preoperative CSFD group, there was only one case (2%) of postoperative paraplegia. Conclusions: Postoperative CSFD improved the neurological prognosis of individuals undergoing thoracic aortic and thoracoabdominal aortic surgery. However, 25% of the patients remained paraplegic despite postoperative CSFD.

Temperature analysis of aortic repair with hypothermic circulatory arrest to quantify the injury by cooling.

OBJECTIVES: We analyzed the temperature in proximal aortic repair with moderate hypothermic circulatory arrest (HCA) and evaluated the effect of the cooling status on postoperative outcomes. METHODS: A total of 340 patients who underwent elective ascending aortic replacement or total arch replacement with moderate HCA from December 2006 to January 2021 were studied. The change in body temperature trends recorded during surgery was shown graphically. Several parameters, such as the nadir temperature, cooling speed and the degree of cooling (cooling area), which was the area under curve of inverted temperature trends from cooling to rewarming as calculated by the integral method, were analyzed. The relationships between these variables and a major adverse outcome (MAO) postoperatively defined as prolonged ventilation (>72 h), acute renal failure, stroke, reoperation for bleeding, deep sternal wound infection or in-hospital death were evaluated. RESULTS: An MAO was observed in 68 patients (20%). The cooling area was larger in the MAO group than in the non-MAO group (1668.7 vs 1383.2°C min; P < 0.0001). A multivariate logistic model showed that old myocardial infarction, peripheral vascular disease, chronic renal dysfunction, cardiopulmonary bypass time and the cooling area were independent risk factors for an MAO (odds ratio = 1.1 per 100°C min; P < 0.001). CONCLUSIONS: The cooling area, which indicates the degree of cooling, shows a significant relationship with an MAO after aortic repair. This finding indicates that the cooling status with HCA can affect clinical outcomes.

Virtual Reality Simulation for Minimally Invasive Coronary Artery Bypass Grafting With Aortic No-Touch Total Arterial Grafting Technique.

OBJECTIVE: Virtual reality can be applied preoperatively by surgeons to gain precise insights into a patient's anatomy for planning minimally invasive coronary artery bypass grafting (CABG) with in situ arterial grafts. This study aimed to examine virtual reality simulation for minimally invasive CABG with in situ arterial grafts. METHODS: Preoperative stereolithographic files in 35 in situ arterial grafts were converted using 320-slice computed tomography and workstation. The accurate length and direction of each graft were confirmed through virtual reality glasses. The simulation of graft designs was performed by using an immersive virtual reality platform. RESULTS: The mean harvested lengths of in situ left internal thoracic artery (n = 17), right internal thoracic artery (n = 12), and gastroepiploic artery (n = 6) grafts predicted by virtual reality simulation were 21.4 ± 3.4 cm, 21.2 ± 3.6 cm, and 22.8 ± 4.8 cm. The required lengths of these grafts predicted by virtual reality simulation were 15.8 ± 2.3 cm, 16.4 ± 2.1 cm, and 14.5 ± 4.4 cm. Minimally invasive CABG using virtual reality simulation was completed in 17 patients, of whom 16 patients underwent aortic no-touch total arterial CABG. The surgical strategy was adjusted in 11.8% of the cases due to the 3-dimensional virtual reality-based anatomy evaluation. The early mortality and morbidity were 0%, and the patency of the graft was 100%. The median time to return to full physical activity was 7.1 days. CONCLUSIONS: This study demonstrated the successful development and clinical application of the first dedicated virtual reality platform for planning aortic no-touch total arterial minimally invasive CABG. Virtual reality simulation can allow the accurate preoperative understanding of anatomy and appropriate planning of the graft design with acceptable postoperative outcomes.

Minimally invasive coronary artery bypass grafting with ultrasonically skeletonized internal thoracic artery.

Objective: This study aimed to examine the feasibility and safety of minimally invasive cardiac surgery coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery in the authors' initial experience. Methods: From February 2012 to May 2021, 247 consecutive patients who underwent minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery were reviewed retrospectively. Internal thoracic arteries were harvested in a full skeletonized fashion using an ultrasonic scalpel via left minithoracotomy. Bilateral internal thoracic arteries were used in 108 patients, and the internal thoracic arteries as in situ grafts were used in 393 anastomoses. Total arterial revascularization was performed in 126 patients, and 142 patients underwent aortic nontouch minimally invasive coronary artery bypass grafting. Results: The patients' mean (range) age was 65.9 ± 11.5 (30-90) years. The mean (range) number of anastomoses performed was 2.6 ± 1.1 (1-6). Forty-six patients (18.6%) had 4 grafts, 94 patients (38.1%) had 3 grafts, and 60 patients (24.3%) had 2 grafts. Minimally invasive coronary artery bypass grafting was completed without conversion to sternotomy in all patients. Cardiopulmonary bypass was performed in 3 patients (1.2%), reinterventions due to bleeding were performed in 7 patients (2.8%), and chest wound infections were observed in 5 patients (2.0%). There was 1 (0.4%) mortality. Conclusions: Minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery is feasible and has shown good perioperative outcomes. This approach has the potential for further optimization with revascularization strategies.