Echocardiographic Changes in Cardiac Function After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.

BACKGROUND: Evidence suggests thoracic stent grafts increase the aortic stiffness postimplantation. Our objective was to examine the effect of thoracic aortic stenting on heart function, as demonstrated with echocardiography. METHODS: We considered nonrandomized studies examining echocardiographic parameters (left ventricle ejection fraction (LVEF), left ventricle end-diastolic (LVED) and end-systolic diameter (LVESD), posterior wall thickness (LVPWT), interventricular septal thickness (IVST), mass, and mass index) pre and poststent graft implantation in patients with thoracic aortic diseases (aneurysm, dissection, and blunt injury). MEDLINE and CENTRAL were searched (up to March 2021) for eligible studies. The National Institutes of Health Quality Assessment Tool was used for risk of bias assessment. Echocardiographic data pre and postimplantation were compared using the pooled standardized mean difference (SMD) and 95% confidence interval (CI). RESULTS: Four studies were included in the meta-analysis. Three of the studies were judged to be "good" quality and one "fair". Nonsignificant differences pre and postimplantation were found for ejection fraction (SMD = -0.53, 95% CI = -1.8 to 0.728, P = 0.406), IVST (SMD = -0.79, 95%, CI = -3.25 to 1.66, P = 0.52), EDD (SMD = -0.10, 95% CI = -0.48 to 0.28, P = 0.60), ESD (SMD = -0.66, 95% CI = -2.35 to 1.02, P = 0.44), and PWT (SMD = -2.20, 95% CI = -5.89 to 1.47, P = 0.24). A trend toward an increase in mass postimplantation was found (SMD = 0.28, 95%, CI = -0.03 to 0.60, P = 0.08), but there was no significant difference in mass index (SMD = 0, 95%, CI = -0.195 to 0.195, P = 1). CONCLUSIONS: Thoracic aortic stenting does not appear to significantly impact cardiac physiology as indicated by echocardiographic parameters.

Effects of Several Preharvest Canopy Applications on Yield and Quality of Table Grapes (Vitis vinifera L.) Cv. Crimson Seedless.

Modern viticultural areas are being confronted with the negative impacts of global warming on yield and fruit composition, with especially adverse effects on anthocyanin synthesis. Novel and sustainable tools, such as biostimulants, may represent a viable alternative to traditional cultural practices, thus promoting eco-friendly strategies to enhance the yield, fruit quality and abiotic stress tolerance of grapevines. 'Crimson Seedless' is a late-season red table grape variety, and due to climatic warming, its berries are frequently failing to acquire the commercially acceptable red color. Canopy applications of different biostimulants, namely, Kelpak®, Sunred®, Cytolan®, LalVigne™ Mature as well as Ethrel® Top, were tested on grapevine cv. Crimson Seedless grown under semi-arid Mediterranean conditions in order to evaluate their effects on yield and fruit quality. Some of the products were sprayed in canopies at labeled doses, and some were applied at doses reported in other studies. For the control treatment, canopies were sprayed with water. Sampling started at veraison and was repeated at 10-day intervals to measure the evolution of berry weight, length and diameter, as well as the total soluble solids and titratable acidity of the juice. The grapes were harvested when the berries of one of the treatments attained the commercially acceptable color. The greatest improvements in the red berry color were achieved with Sunred® (at a dose of 4 L ha-1) and Ethrel® Top (250 ppm plus glycerol at 1%), each applied at veraison and 10 days later. The different applications had varying effects on productivity and qualitative parameters. Only Sunred® improved the accumulation of anthocyanin and the overall acceptability of table grapes by consumers. The obtained results clearly demonstrate that applying Sunred® can improve the yield and qualitative parameters of the red table grape variety 'Crimson Seedless', indicating that this biostimulant could be a viable alternative to the most widely used plant growth regulator, ethephon.

Epicardial cardioverter defibrillator implantation due to post-fontan ventricular tachycardia.

Long-term survival of patients submitted to a Fontan procedure is reduced because of arrhythmias. Late post-Fontan ventricular tachycardia is extremely rare, but it can be fatal. Consequently, the implantation of an implantable cardioverter defibrillator may be required. The implantation of such a device after a Fontan operation can be rather difficult due to anatomic reasons that exclude transvenous approach. Epicardial ICD implantation is a treatment option for these patients. Transatrial approach, shock ICD coils placement in azygos vein or directly in the pericardium are possible alternatives. We hereby present a successful epicardial implantable cardioverter defibrillator implantation in a post-Fontan 39-year-old man suffering from ventricular tachycardia.

Aortic rupture during endovascular repair of a postoperative coarctation pseudoaneurysm in an adult: Emergency lifesaving stent graft implantation.

We present a case with aortic rupture during an operation of thoracic endovascular aortic repair of an anastomotic pseudoaneurysm. This happened after the use of a low-pressure remodeling balloon inside the covered part of the deployed endografts. It was successfully treated with a second more centrally in the aortic arch-implanted endograft with full coverage of the left subclavian artery orifice. This patient had a history of surgically operated aortic coarctation.

Oesophageal necrosis after thoracic endovascular aortic repair: a minimally invasive endovascular approach-a dramatic complication.

There are few cases in the literature reporting dysphagia caused by oesophageal compression by the aorta due to acute or chronic aortic pathology. This type of dysphagia is called dysphagia aortica. Thoracic endovascular aortic repair is nowadays the treatment of choice for anatomically suitable patients experiencing complicated Type B aortic dissection. Oesophageal necrosis is a rare but fatal complication following thoracic endovascular aortic repair. Extrinsic oesophageal compression by the thrombosed aneurysmal sac, a mediastinal haematoma or extensive thrombosis in the false lumen of a dissected aorta and acute vascular occlusion of the oesophageal supply are possible mechanisms. When oesophageal necrosis is suspected, endoscopic examination and computed tomography imaging should be performed repeatedly. Oesophagoscopy will confirm the diagnosis revealing a black, diffusely necrotic and ulcerated oesophageal mucosa. It is critical to intervene before full-thickness oesophageal wall necrosis and mediastinitis occur. Guidelines are absent because of the rarity of this complication. Moreover, lack of a large series does not permit the establishment of guidelines either. However, oesophagectomy of the impaired oesophagus is the only chance for survival. Unfortunately, survival rates are disappointing. Prevention and awareness is the cornerstone of success. Early endoscopic examination when oesophageal necrosis is suspected due to even minimal symptoms will detect this fatal menace on time.

Repair of descending thoracic aortic aneurysms with Ankura Thoracic Stent Graft.

OBJECTIVE: The aim of the study was to present the results for patients with atherosclerotic aneurysm of the descending thoracic aorta (DTA) treated with a novel thoracic stent graft. METHODS: A single-center retrospective review of prospectively collected data was performed. We extracted demographic variables as well as atherosclerotic comorbidities and operation-related and imaging-related data from patients' medical records. We estimated technical success rate, in-hospital and 30-day mortality, and mortality at the end of follow-up as well as complication and reintervention rate in our study cohort. Follow-up computed tomography angiography was performed after 1 month and 6 months and yearly thereafter. RESULTS: A total of 30 patients (80% male; mean age, 73.7 ± 6.33 years) were treated with Ankura Thoracic Stent Graft (Lifetech, Shenzhen, China) for DTA aneurysm from February 2014 until June 2017. Technical success of the thoracic endovascular aortic repair (TEVAR) was 97% (29/30 patients). A surgical conduit was required in one patient; in three patients, we intentionally covered the left subclavian artery because of insufficient proximal landing zone. No aorta-related deaths were recorded during follow-up. During the early postoperative period, two patients (7%) with long DTA coverage developed paralysis or paraparesis, which immediately resolved after lumbar drainage. No renal complications requiring dialysis were observed. One patient (3%) developed postoperative pulmonary infection, whereas access site complications were 7%. Two symptomatic patients treated outside instructions for use (7%) developed early type IA endoleak and one patient (3%) developed type IB endoleak; type II endoleak was recorded in 3% of the study cohort. During the 30-day postoperative period, two patients died of non-TEVAR-related causes, one of gastrointestinal bleeding and the other of pulmonary infection. During a median follow-up of 31.7 (range, 38.4) months, two more patients also died of non-TEVAR-related causes, one of stroke from carotid artery disease and the other of motor vehicle trauma. In the rest of the cohort, no other adverse events were noted. CONCLUSIONS: This novel endograft showed early evidence of a safe, effective, and durable endoprosthesis for the treatment of DTA aneurysms.

Radiopaque preventive landmarks' placement during stentless bioprosthesis implantation.

BACKGROUND: In patients with aortic stenosis, bioprosthetic valves are increasingly used. Although their benefits, they are also presenting limitations, as their time-related degeneration. Reoperation which was, until a few years ago, the only treatment for this condition, carries a significant surgical risk, especially in patients with multiple comorbidities, so the benefit of less invasive technique enabling the implantation of aortic valve prosthesis [transcatheter aortic valve-in-surgical aortic valve (TAV-in-SAV)] by a percutaneous access is remarkably important. Eligible patients are judged by a heart team, and imaging plays a key role in this selection, focusing on correct identification of bioprosthetic aortic valves type and size, evaluation of patients at increased anatomical risk for coronary artery occlusion. Radiolucency of stentless bioprosthetic valves, represent a significant challenge. METHODS: Surgical aortic valve replacements (SAVRs) with a bioprosthesis were performed using a stentless valve with no radiopaque components (Solo Smart, Sorin). The chosen method, in order to evaluate the results of the operation, was computed tomography (CT) scanning (64-slice MDCT, Brilliance, Philips). The study consisted of a thin sliced contrast electrocardiograph (ECG) gated chest CT (1 systolic cardiac phase), trying to simulate the required assessment of aortic root and the radiopaque placed markers. RESULTS: As surgical implant technique varies and may impact the relationship of the prosthetic annulus to the coronary ostia, marking the aortic annulus during the operation in order to have some useful radiopaque landmarks, is a great assistance promoting better orientation and correct identification of the position of the bioprosthetic valve. Although the implantation of metallic vascular clips at the level of aortic annulus (in any commissure or in the middle of any cups) was considered, the decision was to position three metallic clips bellow the aortic annulus in the three stiches ligated during the solo valve implantation. CONCLUSIONS: We are suggesting the preventive implantation of radiopaque landmarks, during SAVRs using tissue valves which are lacking fixed anatomic markers, as a guide for a presumptive TAV-in-SAV procedure, keeping in mind that appropriate guidance is crucial and can prevent valve misplacement, coronary obstruction and other potentially lethal complications.

Factors associated with early cardiac complications following transcatheter aortic valve implantation with transapical approach.

PURPOSE: To estimate the incidence of postprocedural early cardiac complications among patients undergoing transcatheter aortic valve implantation, through transapical approach (TA-TAVI), and to identify factors independently associated with the occurrence of them. PATIENTS AND METHODS: A retrospective cohort study of 90 patients, who had undergone TA-TAVI in a tertiary hospital of Liverpool, UK, during a 5-year period (September 2008-October 2013), was conducted. Data on patient demographics, periprocedural characteristics and cardiac complications presented within 30-day post TA-TAVI were collected, retrospectively, using the hospital's electronic database. RESULTS: The overall 30-day incidence of cardiac complications was estimated at 18.9% (n=17/90). The rate of new onset of atrial fibrillation (AF), atrioventricular block requiring permanent pacemaker implantation, shockable cardiac arrest rhythm and cardiac tamponade was 11.1%, 3.3%, 2.2% and 2.2%, respectively. Bivariate analysis found that absence of preoperative AF (p=0.01), receiving of oral inotropes preprocedurally (p=0.01), intravenous inotropic support postprocedurally (p=0.01) and requirement for postprocedural tracheal intubation (p=0.001) were the main factors associated with increased probability for patient cardiac morbidity. CONCLUSION: It seems that patients with absence of AF and oral inotropic support preprocedurally and those with post TA-TAVI mechanical ventilatory and intravenous inotropic support have greater probability to develop cardiac complications. This knowledge allows the early identification of high-risk patients and supports clinicians to apply both preventive and therapeutic interventions for the optimum patient management and care. In addition, administrators could allocate the health care system resources effectively.

Coronary artery bypass grafting and paraparesis; is there a correlation?

Adult cardiac surgery is associated with significant perioperative morbidity and mortality rates, mainly in elderly patients with co-morbidities. A series of postoperative complications may arise and delay the recovery of patients undergoing cardiac surgery. Such complications also increase the burden of resource use and may affect late survival rates. Neurological complications appear mainly as stroke of varying degrees, with impairment of mobility and ability of the patient. We describe a rare case of progressive paraparesis after on-pump coronary artery bypass grafting, and review its aetiology, diagnosis and management.

Predictors of length of stay and duration of tracheal intubation after transcatheter aortic valve implantation.

BACKGROUND: While short-term outcomes for patients undergoing transcatheter aortic valve implantation (TAVI) have long been studied, there is very little data on their predictors. We aimed to identify the predictors of outcomes, such as intensive care unit (ICU) and in-hospital length of stay (LOS), duration of postoperative intubation and in-hospital mortality, after TAVI procedures. METHODS: We conducted a retrospective cohort study of 162 consecutive patients with aortic valve disease, who were admitted to a tertiary hospital of Liverpool for TAVI, during a five-year period. The data was collected using of the hospital's structured database on November 2014. RESULTS: By using a multivariate analysis we found that any postoperative bleeding [odds ratio (OR) 2.71; 95% confidence interval (CI): 1.41-5.24] was the independent predictor of prolonged ICU-LOS, while older age (OR 1.11; 95% CI: 1.05-1.17) and transapical TAVI (OR 4.11; 95% CI: 1.94-8.71) were the predictors of prolonged in-hospital LOS. Additionally, patients treated with oral inotropic agents, preoperatively (OR 5.77; 95% CI: 2.21-15.01), non-diabetics (OR 3.07; 95% CI: 1.12-8.42) and those with any postoperative bleeding (OR 3.53; 95% CI: 1.68-7.43) had a significantly greater probability in remaining intubated postoperatively. The multivariate analysis did not reveal any predictor of in-hospital mortality. CONCLUSIONS: The above predictors permit the early identification of TAVI patients at high risk for longer hospitalization and increased mechanical ventilation. This piece of information is crucial for clinicians and administrators contributing to more efficient patient care planning and better allocation of healthcare resources.

Undilatable Stent Neoatherosclerosis Treated with Ad Hoc Rotational Atherectomy.

A middle age woman with known ischemic heart disease and old stents in proximal left anterior descending coronary artery (LAD) was admitted to Coronary Care Unit with acute coronary syndrome. The coronary angiography showed one vessel disease with significant restenosis within the previously implanted stents. The lesion was tough and remained undilatable despite high pressure balloon inflation. Eventually, the balloon ruptured creating a massive dissection of the LAD beginning immediately after the distal part of the undilatable lesion. We proceeded with a challenging ad hoc rotational atherectomy of the lesion and finally stenting of the lesion. In-stent restenosis many years after stent implantation is considered to be mainly due to neoatheromatosis compared to intimal hyperplasia, making lesion treatment more difficult and unpredictable.

The formation of bronchocutaneous fistulae due to retained epicardial pacing wires: A literature review.

Temporary epicardial pacing wires during open-heart surgery are routinely used both for diagnostic and treatment purposes. In complicated cases where patients are unstable or the wires are difficult to remove, the pacing wires are cut at the skin level and allowed to retract by themselves. This procedure rarely causes complications. However, there have been cases reporting that retained pacing wires are linked to the formation of sterno-bronchial fistulae, which may present a while after the date of operation and are usually infected. This review aims to study the cases presenting sterno-bronchial fistulae due to retained epicardial pacing wires and to highlight the important factors associated with these. It is important to note these complications, as fistulae may cause a variety of problems to the patient if undiagnosed and left untreated. With the aid of scans such as fistulography, fistulae can be identified and treated and will improve the patients' health dramatically.

Is axillary superior to femoral artery cannulation for acute type A aortic dissection surgery?

A best evidence topic was written according to a structured protocol. The question addressed was whether axillary artery cannulation (AXC) is superior to femoral artery cannulation (FAC) in patients undergoing surgical repair of acute type A aortic dissection. A total of 90 studies were identified using the reported search, of which 10 represented the best evidence to answer the clinical question. There were nine retrospective studies and one meta-analysis. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. Four papers, including the meta-analysis, reported significantly increased mortality in patients undergoing surgery with FAC. From these, two papers, again including the meta-analysis, reported also significantly increased neurological dysfunction, and another one demonstrated significantly increased incidence of postoperative bleeding and sternal infections in this same group of patients. Two more studies reported decreased mortality, malperfusion and neurological complications in patients undergoing surgical repair with AXC, but no statistical analysis was performed. Three reports comparing AXC and FAC found no difference between the two groups in terms of operative mortality and major complications, while another one demonstrated increased incidence of postoperative mortality in patients undergoing surgery with AXC, most likely due to the presence of malperfusion of one or more organs preoperatively in those who died. Patients undergoing repair of type A aortic dissection may benefit from AXC, whenever this is technically feasible. Most reports show that inflow perfusion through the axillary artery will reduce overall mortality, and neurological and malperfusion complications when compared with FAC. However, it needs to be stressed that, in three reports, the superiority of AXC over FAC might be attributed to the fact that patients in the latter group were critically ill in haemodynamic collapse. Nevertheless, this indicates that the femoral artery remains a bailout option in the emergency situation when institution of cardiopulmonary bypass is required rapidly.

Does postoperative mechanical ventilation predispose to bronchopleural fistula formation in patients undergoing pneumonectomy?

A best evidence topic was written according to a structured protocol. The question addressed was whether postoperative mechanical ventilation has any effect on the incidence of development of bronchopleural fistulas (BPFs) in patients undergoing pneumonectomy. A total of 40 papers were identified using the reported search, of which 8, all retrospective, represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. Of the eight identified papers, six of them reported a statistically significant relationship between postoperative mechanical ventilation and the occurrence of bronchopleural fistula in patients undergoing pneumonectomy (P = 0.027-0.0001). In two of these studies, postoperative mechanical ventilation was identified during multivariate analysis as an independent predictor for the development of BPF after pneumonectomy (odds ratio 15.57 and 33.1), indicating a causal relationship whereas, in the other four reports, statistical significance was the result of univariate analysis. In another study, the difference between these two groups approached but did not reach statistical significance (P = 0.057). Finally, one study reported no association between postoperative mechanical ventilation and the development of post-pneumonectomy BPF (0.16). Apart from mechanical ventilation, pre-existing pleuropulmonary infection was reported by one study as an independent predictor for the development of post-pneumonectomy BPF whereas, in two other studies, its impact approached but did not reach statistical significance. Another study did not find any association between preoperative infection and postoperative BPF occurrence. In conclusion, the majority of the reported studies report a significant relationship between mechanical ventilation after pneumonectomy and the occurrence of BPF. Every effort should be made to achieve extubation at the earliest possible time to withdraw the effects of the continuous barotrauma on the bronchial stump, although its impact cannot be quantified. Performing pneumonectomy in the presence of infectious conditions may contribute to the development of postoperative BPF, but its role is less well defined.

Late Development of a Bronchocutaneous Fistula due to an Epicardial Cardioverter-Defibrillator Lead.

Cutaneous complications caused by a pacemaker or defibrillator are widely documented, but the development of a bronchocutaneous fistula has never been described before. We report the case of a 79-year-old man who was admitted to our hospital because of a seemingly superficial cutaneous infection, externalized defibrillator leads, and hemoptysis. Bronchoscopical investigation proved the existence of the fistula, which connected the epicardium, the left main bronchus, and the aforementioned site of skin infection. The patient refused an operation for the complete removal of the epicardial defibrillator and was treated conservatively. This case demonstrated that the long-term presence of foreign bodies in the epicardium may cause serious complications.

Perioperative prostate specific antigen levels among coronary artery bypass grafting patients: Does extracorporeal circulation and body temperature induce prostate specific antigen levels alterations?

PURPOSE: The purpose of this study is to compare the perioperative total prostate specific antigen (tPSA) levels among coronary artery bypass grafting (CABG) patients with and without extracorporeal circulation (ECC), to investigate the changes overtime of tPSA in each group separately and to determine the effect of body core temperature on tPSA levels. MATERIALS AND METHODS: A prospective study was conducted. Our sample was allocated to: (a) Seven patients who underwent off pump CABG (Group I) and (b) 16 CABG patients with ECC (Group II). The levels of tPSA were measured preoperatively (baseline), intra-operatively and at the 4(th) postoperative day. We compared the two groups on their tPSA levels and we investigated the changes of tPSA overtime in each group separately. RESULTS: Intra-operative serum samples were obtained in significantly lower body temperature in patients of Group II than in those of Group I (31°C vs. 36.9°C, P < 0.001). In each group separately, postoperative tPSA levels were increased significantly compared to the baseline values (2.55 ng/ml vs. 0.39 ng/ml for Group I, P = 0.005 and 4.36 ng/ml vs. 0.77 for Group II, P < 0.001). CABG patients with ECC had significantly lower intra-operative tPSA levels than the baseline values (0.67 ng/ml vs. 0.77 ng/ml, P = 0.008). We did not observe significant differences of tPSA levels between the two groups. CONCLUSIONS: CABG surgery affects similarly the perioperative tPSA independently the involvement of ECC. Although all patients had significantly higher early postoperative tPSA levels, only those who underwent CABG with ECC had exceeded normal values and significantly decreased intra-operative tPSA. Hypothermia seems to be the causal factor of tPSA reduction.

Is it safe and worthwhile to perform pulmonary resection after contralateral pneumonectomy?

A best evidence topic was written according to a structured protocol. The question addressed was whether pulmonary resection is safe and worthwhile in patients who have undergone previous pneumonectomy. A total of 141 studies were identified using the reported search, of which 8 represented the best evidence to answer the clinical question. Studies on multiple lung cancers with patients undergoing subsequent pulmonary resection after previous pneumonectomy, without outcome data specifically for this group of patients and case reports, were not included in this analysis. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. All studies were retrospective. In total, 102 patients underwent pulmonary resection after contralateral pneumonectomy, of which 96 had sublobar resections and 6 had lobectomies. Postoperative complications, reported in four of the eight studies, ranged from 21 to 44% (mean from four studies 36.8%). Four of the eight studies reported no mortality after pulmonary resection following pneumonectomy, whereas the other four reported mortality rates from 6.7 to 43%. For patients undergoing sublobar resections, the postoperative mortality was 6.2% (6/96), while for those submitted to lobectomy, mortality was 33.3% (2/6). Five-year survival rates ranged from 14% for metastatic disease to 50% for metachronous lung cancer. Due to the infrequent situation of a patient being considered for a pulmonary resection after contralateral pneumonectomy, this analysis was based on a limited number of patients from eight reports. Nevertheless, analysis of the data suggests that pulmonary resection for metastatic or metachronous disease can be performed with acceptable morbidity and low mortality in appropriately selected patients who have previously undergone a pneumonectomy. Sublobar resection is the treatment of choice whenever possible, for which long-term results are rewarding especially for patients with metachronous lung cancer.

Post-trauma "abrasive" right ventricular rupture without mediastinitis early post-CABG. Is the Robicsek closure technique necessary for all elderly patients?

INTRODUCTION: Right ventricular (RV) rupture with mediastinitis, is a very rare but extremely dangerous (even fatal) complication, following CABG surgery. PRESENTATION OF CASE: In this paper, we present the case of a post-trauma (after fall) RV rupture (without mediastinitis) in a patient who had undergone cardiac surgery several days ago. The cause of the rupture proved to be a broken bone piece from the lower sternal edge. DISCUSSION: RV rupture post-operatively caused by broken bone pieces or bone dislocation may occur through two mechanisms: either penetration of the RV, or through the "sandpaper effect". In order to prevent the rupture, we should be able to recognize patients with aggravating factors (age, weight) and choose intra-operatively a suitable closure technique. CONCLUSION: We propose that the technique that could prevent such ruptures is the Robicsek technique.