Mini-thoracotomy in redo mitral valve surgery: safety and efficacy of a standardized procedure.

BACKGROUND: Re-operative mitral valve surgery is sometimes burdened by a greater technical difficulty and a higher complications rate than the first operation. Minimally invasive cardiac surgery has become routine, and it could significantly reduce the surgical risk in redo surgery. The objective of our retrospective observational study is to assess the results of cardiac reoperations in patients with mitral valve disease approached trough a 5-7 cm right mini-thoracotomy. METHODS: From February 2017 to December 2019, 65 patients underwent re-operative mitral valve surgery in our institution. Cardiopulmonary bypass (CPB) was started by cannulation of the femoral and jugular vein and femoral artery or alternatively right axillary artery. Patients enrolled had a mean age of 66.6±11.5 years. Patients were divided into three groups based on the procedure adopted: external aortic cross-clamp (EAC), EndoAortic balloon occlusion (EABO) and ventricular fibrillation (VF). Major complications were evaluated and compared with a propensity matched population of patients undergoing elective isolated mitral valve surgery via right minithoracotomy (MVS). RESULTS: The average time between last operation and reoperation was 7.1±3.4 years. Fourteen patients (21%) underwent mitral valve repair and 51 patients (78%) underwent mitral valve replacement; 9 patients (14%) received tricuspid valve surgery. There was no statistically significant difference in CPB time between the groups. Seven patients (11%) had a postoperative renal failure, 5 patients (8%) underwent surgical reopening for bleeding; incidence of post-operative stroke and pace-maker implantation was 3% for both. No deaths were registered during in-hospital stay and at 30-days echocardiographic control all patients respect the criterions of device success according with MVARC. Propensity matched patients of group redo had a longer CPB time (100.8±42.7 versus 72.8±16.7 min, P<0.001) and cross-clamp time (71.9±30.7 versus 59±10.7 min, P<0.001) respect to first operation mitral valve surgery patients. CONCLUSIONS: Minimally invasive mitral valve redo surgery is a safe procedure. Less invasive techniques in redo surgery could minimize morbidity and mortality without prolonging the duration of CPB.

Anomalous coronary sinus: A predictor of challenging redo mitral surgery.

In the spectrum of congenital heart diseases, anomalies involving the venous coronary sinus have received relatively little attention, although they are often associated with major congenital defects, such as atrioventricular septal defects. In cases of mitral surgery in patients with these conditions, it is mandatory to keep the problem in mind and to respect the coronary sinus when approaching the left atrium and the mitral valve.

Preoperative atorvastatin reduces bleeding and blood products use in patients undergoing on-pump coronary artery bypass grafting.

AIMS: Statins are a widely recognized weapon in the primary and secondary prevention of coronary artery disease for their pleiotropic effects. However, recent reports from the cerebrovascular and pharmacological literature are insinuating concerns about a potential increase in the haemorrhagic risk among statin users.The effect of statins in postoperative bleeding should be carefully investigated in major cardiac surgery that exposes per se to risk of bleeding. METHODS: In this retrospective cohort study, we evaluated 441 patients who received atorvastatin until surgery and 213 patients who had never been treated with statins, undergoing elective primary isolated on-pump coronary artery bypass grafting. Postoperative bleedings, blood products use and complications were monitored during hospitalization. RESULTS: Preoperative and intraoperative variables were similar between groups. Early and overall postoperative bleedings were reduced among statin users, who had lower C-reactive protein values in the first postoperative day. Atorvastatin carries a strong protective effect against major bleedings, with a propensity score-adjusted odds ratio of 0.28 (P < 0.01). Also, blood products use for statin-treated patients was lower compared with controls, with fewer transfused patients and fewer red-packed cells units per transfused patient. CONCLUSION: Preoperative atorvastatin use is associated with reduced risk of bleeding and blood products use after coronary artery bypass grafting, likely due to a reduction in the postoperative inflammatory response. Statin continuation at the highest tolerable dose should be encouraged before cardiac surgery. The preoperative use of statins in cardiac surgery as 'bleeding-preventers' might have profound clinical implications.

Off-pump coronary artery bypass grafting versus optimal medical therapy alone: effectiveness of incomplete revascularization in high risk patients.

BACKGROUND: Geriatric patients with multivessel coronary artery disease (CAD) are a challenging group to treat; these cases elicit discussion within heart teams regarding the actual benefit of undertaking major surgery on these patients and often lead to abandon the surgical option. Percutaneous procedures represent an important option, but coronary anatomy may be unfavorable. Off-pump coronary artery bypass (OPCAB) provides good quality graft on left anterior descending (LAD) without exposing the patient to cardiopulmonary bypass, and might be the ideal choice in patients with multiple comorbidities, not eligible to percutaneous or on-pump procedures. The objective of this study was to compare survival during a mid-term follow-up in high-risk patients with no percutaneous alternative, either treated with OPCAB or discharged in medical therapy. METHODS: We retrospectively evaluated from June 2008 to June 2013, 83 high-risk patients with multivessel CAD were included: 42 were treated with incomplete off-pump revascularization using left internal mammary artery (LIMA) on LAD; 41 were discharged in optimal medical therapy (OMT), having refused surgery. Follow-up ended in March 2015, with a telephonic interview. Primary endpoint was survival from all-cause mortality; secondary endpoints were survival from cardiac-related mortality and freedom from non-fatal major adverse cardiac events (MACEs). RESULTS: During follow up, 11 deaths in OPCAB group and 27 deaths in OMT group occurred. Death was due to cardiac factors in 6 and 15 patients, respectively. MACEs were observed in 6 patients in OPCAB group and in 4 patients in OMT group. With regards to survival from all-cause mortality, patients who underwent OPCAB survived more than those discharged in OMT (Log Rank < 0.001), and OMT group carries a propensity score-adjusted hazard ratio of 3.862 (P < 0.001). With regards to survival from cardiac-related events, patients who underwent OPCAB survived more than those discharged in OMT (Log Rank = 0.002), and OMT group carries a propensity score-adjusted hazard ratio of 3.663 (P = 0.010). There is no statistically significant difference concerning freedom from MACEs (Log Rank = 0.273). CONCLUSIONS: For high-risk patients with multivessel CAD, not eligible to on-pump complete revascularization surgery or percutaneous procedures, incomplete revascularization with OPCAB LIMA-on-LAD offers benefits in survival when compared to OMT alone.

Effect of Preoperative Aspirin Replacement With Enoxaparin in Patients Undergoing Primary Isolated On-Pump Coronary Artery Bypass Grafting.

Management of preoperative antiplatelet therapy in coronary artery bypass grafting (CABG) is variable among surgeons: guidelines collide with prejudices because replacement of aspirin with low-molecular-weight heparin is still performed because of a presumed minor bleeding risk. This study aims to analyze postoperative bleedings and complications in patients scheduled for elective primary isolated on-pump CABG, depending on preoperative aspirin treatment or its replacement with enoxaparin. In this cohort study, we propensity score matched 200 patients in whom aspirin was stopped at least 5 days before CABG and replaced with enoxaparin and 200 patients who continued aspirin therapy until the day before surgery. Postoperative bleedings and complications were monitored during hospitalization. Among patients who continued aspirin treatment, mean overall bleeding was 701.0 ± 334.6 ml, whereas in the matched enoxaparin group, it was significantly greater (882.6 ± 64.6 ml, p value <0.001); this was associated with reduced postoperative complications, lower values of postoperative C-reactive protein in aspirin takers, and a presumed protective effect for statins. After propensity score adjustment, aspirin treatment carried a protective effect against major postoperative bleeding (odds ratio 0.312, p = 0.001). In conclusion, postoperative bleeding is reduced in patients who continued aspirin, likely due to a reduction in postoperative inflammation. The practice of empirically discontinuing aspirin and replacing it with enoxaparin before CABG should be abandoned. Patients with coronary artery disease referred to CABG should continue antiplatelet medications until the surgical procedure. Those results might be extended to patients under oral anticoagulant therapy requiring CABG.

Unconventional location for a cardiac lipoma: The anterior papillary muscle.

Primary cardiac tumors are uncommon, and lipoma is the second most frequent benign type after myxoma. The treatment of choice is surgery, with the complete excision of the mass. Nevertheless, in the absence of symptoms and clinical signs the indication for surgery is less defined, and close follow up may be recommended. In the case we are going to report the patient was followed by periodical clinical and echographic examination, always reconsidering the possibility of treatment. .

Coronary arterovenous fistula: to treat or not to treat?

We reported the case of a 68-year old male with chest pain. The coronary angiography showed the disease of the left anterior descending coronary artery and, incidentally, an arteriovenous coronary fistula between this coronary branch and the pulmonary artery. The patient underwent off-pump coronary bypass through a left mini thoracotomy. In the present case, after a series of detailed exams, we decided not to close the fistula for several reasons, but mainly because of the singular localization of an atherosclerotic plaque proximal to the origin of the fistula. Therefore, under specific conditions, it may not always be mandatory to close the coronary arteriovenous fistulas.

Ventricular perforation by pacemaker lead repaired with two hemostatic devices.

INTRODUCTION: Cardiac perforation is a rare, but potentially serious, complication of pacemaker implantation that may develop days or weeks after implantation. PRESENTATION OF CASE: In the current case, 92-year-old man underwent permanent pacemaker implantation, but he presented 3 weeks later with severe symptoms. Computed tomography showed protrusion of the tip of the ventricular electrode through the right ventricle and into the chest wall. During an urgent surgical intervention, the lead was disconnected and extracted. A sealing hemostatic device and an hemostatic patch were applied to repair the ventricle; the procedure was uneventfull. DISCUSSION: This case demonstrates how the correct diagnosis of ventricular perforation is crucial, and should be followed immediately by surgical planning. CONCLUSION: The hemostatic patch is a valuable alternative to sutures in patients with thin and fragile ventricular wall, unable to undergo stitching.

Severe stenosis of left coronary artery originating from right sinus of Valsalva treated with off-pump coronary artery bypass surgery.

Anomalous origin of the left coronary artery originating from the opposite sinus of Valsalva is a coronary anomaly with a consistently low prevalence rate. Different patterns have been described for this type of anomaly with respect to the position and course of the coronary arteries. The interarterial type can be considered a malignant variant, as it is characterized by a left main coronary artery that is positioned between the aortic root and the pulmonary artery root, and it frequently presents with syncope or aborted sudden cardiac death. Other symptoms or clinical presentations include the presence or development of angina, acute myocardial infarction and ventricular tachycardia. We present the case of a 49-year old man who presented with a new onset of chest pain; a coronary angiogram showed an anomalous left main coronary artery arising from the right Valsalva sinus, accompanied by a long and severe stenosis. It was found that multi-scan cardiac tomography is very useful in identifying the position of the coronary arteries when coronary anomalies occur.

Nickel allergy induced systemic reaction to an intracardiac amplatzer device.

Nickel hypersensitivity is reported in about 10-15% of the general population and manifests mainly with dermatological signs. Chest discomfort, palpitations, signs and symptoms of pericarditis, and migraine are symptoms reported in rare cases of nickel hypersensitivity after implantation of a cardiac device made of nickel. We present the case of a patient with a nickel allergy from an Amplatzer device in which the removal of the device produced resolution of the symptoms.