Percutaneous Transcatheter Valve-in-Valve Pulmonary and Tricuspid Replacement in Carcinoid Heart Disease.

Surgical valve replacement is the most effective treatment for carcinoid heart disease; however, reoperation for prosthetic valve failure is burdened by high risk. We report the first described percutaneous transcatheter pulmonary and tricuspid valve-in-valve replacement for bioprosthesis degeneration for any reason in a patient with carcinoid heart disease. (Level of Difficulty: Advanced.).

Reflection From UK Aortic Group: Frozen Elephant Trunk Technique as Optimal Solution in Type A Acute Aortic Dissection.

Diseases of the thoracic aorta are increasing in prevalence worldwide. Recent data indicated wide regional variation in the volume and complexity of aortic cases undertaken in United Kingdom cardiac centers, especially in case of acute type A aortic dissection (ATAAD) conditions. Patients treated in high-volume centers with a specific multidisciplinary aortic program had a significant reduction in ATAAD mortality when compared with low-volume centers. Following the initial phase of a national aortic center reorganization, the current study reflects the initial experience of a national collective of cardiothoracic surgeons with expertise in complex aortic surgery, using frozen elephant trunk as standard technique for the surgical treatment of patients affected by ATAAD. Between June 2013 and October 2017, 66 ATAAD patients (45% women) underwent hybrid aortic arch and frozen elephant trunk repair with the Thoraflex hybrid graft at 8 UK high-volume aortic centers. The in-hospital mortality accounted for 8 patients (12%). Postoperative temporary or permanent neurologic events and temporary renal replacement therapy occurred in 17% and 20% of patients, respectively. No spinal cord injury events were documented. Our data were similar to those reported in literature in the 2 largest experiences with the use of frozen elephant technique in ATAAD condition (in-hospital/30-day mortality: 11-12%). This initial experience demonstrated that frozen elephant technique can potentially be adopted as standard approach in life-threatening aortic diseases, with acceptable complication and mortality rates.

Prothrombin Complex Concentrate in Cardiac Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Prothrombin complex concentrate (PCC) has recently emerged as an effective alternative to fresh frozen plasma (FFP) in treating excessive perioperative bleeding. This systematic review and meta-analysis evaluated the safety and efficacy of PCC administration as first-line treatment for coagulopathy after adult cardiac surgery. METHODS: PubMed/MEDLINE, EMBASE, and the Cochrane Library were searched from inception to the end of March 2018 to identify eligible articles. Adult patients undergoing cardiac surgery and receiving perioperative PCC were compared with patients receiving FFP. RESULTS: A total of 861 adult patients from four studies were retrieved. No randomized studies were identified. Pooled odds ratios (ORs) showed that the PCC cohort was associated with a significant reduction in the risk of RBC transfusion (OR, 2.22; 95% confidence interval [CI], 1.45 to 3.40) and units of RBC received (OR, 1.34; 95% CI, 0.78 to 1.90). No differences were observed between the groups for reexploration for bleeding (OR, 1.09; 95% CI, 0.66 to 1.82), chest drain output at 24 hours (OR, 66.36; 95% CI, -82.40 to 216.11), hospital mortality (OR, 0.94; 95% CI, 0.59 to 1.49), stroke (OR, 0.80; 95% CI, 0.41 to 1.56), and occurrence of acute kidney injury (OR, 0.80; 95% CI, 0.58 to 1.12). A trend toward increased risk of renal replacement therapy was observed in the PCC group (OR, 0.41; 95% CI, 0.16 to 1.02). CONCLUSIONS: In patients with significant bleeding after cardiac surgery, PCC administration seems to be more effective than FFP in reducing perioperative blood transfusions. No additional risks of thromboembolic events or other adverse reactions were observed. Randomized controlled trials are needed to establish the safety of PCC in cardiac surgery definitively.

Cardiobacterium hominis prosthetic valve endocarditis: an infrequent infection.

A case of prosthetic aortic valve endocarditis due to Cardiobacterium hominis in a 67-year-old woman is described. The diagnosis was confirmed by a positive blood culture and echocardiographic detection of aortic valve vegetations. The patient underwent replacement of the valve with a homograft, and received antibiotics postoperatively. She remained well after 12 months.

Long-term outcomes in octogenarians following aortic valve replacement.

BACKGROUND: The aging of the population has resulted in an increasing number of elderly patients undergoing cardiac operations. We reviewed our experience in patients over the age of 80 undergoing primary aortic valve replacement (AVR) with or without CABG. METHODS: Between 2000 and 2008, 345 patients (226 male) ≥80 years underwent primary AVR in our unit. The notes of these patients were retrospectively reviewed and follow-up information was obtained from their general practitioners. They had a mean age of 82.9 ± 2.3 years and a median logistic EuroSCORE of 13.4 (IQR 9.4, 19.1). Isolated AVR was performed in 161 patients (45.5%), and 184 (51.6%) patients underwent combined AVR and CABG. A quality of life questionnaire was sent to all survivors. RESULTS: Hospital mortality occurred in 17 patients (4.9%), which was significantly lower than the mortality predicted by logistic EuroSCORE (16.2%, p < 0.01). Hospital mortality was comparable between patients undergoing isolated AVR and those undergoing additional CABG (4.3% vs. 5.4%, respectively). Actuarial survival at one and five years was 90.1 ± 1.6% and 77.2 ± 2.9%, respectively. There was a 62% response on the questionnaire showing 70% of the patients were NYHA I and 83.7% were satisfied with the operation outcome. CONCLUSIONS: AVR can be undertaken with excellent results in octogenarians and the current risk is significantly lower than what is predicted with conventional risk-scoring systems. Patients with advanced age should not necessarily be excluded from being candidates for AVR.

Floating intra-aortic thrombus presenting as distal arterial embolism.

Floating thrombi in the aorta are a rare finding in the absence of any coagulation abnormality. They often represent a surgical emergency. Our case refers to a 45-year-old woman who presented with acute ischemia of the upper extremity. This was a result of peripheral embolism originating in a floating thrombus in the ascending aorta. A free-floating lesion held by a pedicle from the lateral ascending aortic wall was demonstrated using computed tomography and magnetic resonance scans. There was no pre-existing clotting abnormality. Conservative treatment with oral anticoagulation was not successful in removing the lesion. Therefore, a surgical approach was selected through a median sternotomy and cardiopulmonary bypass. Under temporary hypothermic circulatory arrest, the ascending aorta was opened. The lesion was removed along with a rim of aortic wall, circulation was re-established and the aorta was reconnected with use of a synthetic interposition graft. Postoperative course was uneventful. The patient was discharged on oral anticoagulation. Histopathology confirmed the lesion as thrombus. Only a few cases of intra-aortic thrombus without any coagulation abnormality basis are described in literature. Occasionally, they present as distal embolism. Treatment should be surgical excision on cardiopulmonary bypass, a procedure performed safely with excellent outcome.

Acute thrombosis of a prosthetic mitral valve: a lesson in anticoagulation.

Prosthetic heart valve thrombosis is a potentially life-threatening complication of low anticoagulation. We present a case of acute prosthetic mitral valve thrombosis in a patient whose anticoagulation was inadequate after phenindione was changed to low molecular weight heparin. We discuss the diagnosis and treatment of this condition and highlight the danger of long-term low molecular weight heparin use in patients with prosthetic heart valves, especially those in the mitral position. We review the current guidelines for anticoagulation of prosthetic heart valves and discuss potential treatment options if adequate anticoagulation is not achieved by oral anticoagulant alone.