Redo-aortic valve replacement in prior stentless prosthetic aortic valves: Transcatheter versus surgical approach.

OBJECTIVES: The objective was to compare outcomes of redo-aortic valve replacement (AVR) via surgical or transcatheter approach in prior surgical AVR with large percentage of prior stentless surgical AVR. BACKGROUND: With the introduction of transcatheter aortic valve replacement (TAVR), patients with increased surgical risks now have an alternative to redo surgical AVR (SAVR), known as valve-in-valve (ViV) TAVR. Stentless prosthetic aortic valves present a more challenging implantation for ViV-TAVR given the lack of structural frame. METHODS: We performed a retrospective study of 173 subjects who have undergone SAVR (N = 100) or ViV-TAVR (N = 73) in patients with prior surgical AVR at Wake Forest Baptist Medical Center from 2009 to 2019. Our study received the proper ethical oversight. RESULTS: The average ages in redo-SAVR and ViV-TAVR groups were 58.03 ± 13.86 and 66.57 ± 13.44 years, respectively (p < 0.0001). The redo-SAVR had significantly lower STS (2.78 ± 2.09 and 4.68 ± 5.51, p < 0.01) and Euroscores (4.32 ± 2.98 and 7.51 ± 8.24, p < 0.05). The redo-SAVR group had higher percentage requiring mechanical support (8% vs. 0%, p < 0.05) and vasopressors (53% vs. 0%, p < 0.0001), longer length of stay (13.65 ± 11.23 vs. 5.68 ± 7.64 days, p < 0.0001), and inpatient mortality (16% vs. 2.78%, p < 0.005). At 30-day follow-up, redo-SAVR group had higher rates of acute kidney injury (10% vs. 0%, p < 0.01), however ViV-TAVR group had more new left bundle branch blocks (6.85% vs. 0%, p < 0.05). No significant differences regarding re-hospitalization rates, stroke, or death up to 1-year. CONCLUSION: Although the ViV-TAVR group had higher risk patients, there were significantly fewer procedural complications, shorter length of stay, and similar mortality outcomes up to 1-year follow-up.

Combined management of esophagopericardial fistula sustained after catheter ablation for atrial fibrillation.

INTRODUCTION: Radiofrequency ablation (RFA) is an effective treatment modality for atrial fibrillation (AF); however, serious complications can occur. We present the case of a highly morbid consequence, the esophagopericardial fistula (EPF). CASE: A hemodynamically unstable patient with a history of AF and recent RFA presented with chest pain and was found to have pneumopericardium and pericardial effusion. The patient went to the operating room emergently for combined management with surgical pericardial window and endoscopic stent placement. CONCLUSION: EPF must be on the differential diagnosis while evaluating patients who develop constitutional symptoms or sudden onset chest pain days or weeks after catheter ablation for AF. Early detection followed by aggressive management with a combined surgical and endoscopic approach may be considered for successful treatment of this type of postablation esophageal perforation if an atrioesophageal fistula is effectively ruled out.

Angiotensin II for Critically Ill Patients With Shock After Heart Transplant.

Patients undergoing heart transplant are at high risk for vasodilatory shock in the postoperative period, due to a combination of vascular dysfunction from end-stage heart failure and inflammatory response to cardiopulmonary bypass and, increasingly, long-term exposure to nonpulsatile blood flow in those who have received a left ventricular assist device as a bridge to transplant. Patients who have this vasoplegic syndrome, which may be refractory to traditional agents used in the treatment of shock, are vulnerable to organ dysfunction and death. Angiotensin II (ANG-2) is of increasing interest as an adjunct to traditional therapy, both for improvement in blood pressure and for sparing the use of high-dose catecholamine vasopressors. This case series describes the use of ANG-2 in 4 clinical scenarios for the treatment of shock due to heart transplant surgery, supporting its use in this role and justifying further prospective studies to clarify the appropriate place for ANG-2 in the hierarchy of adjunctive therapies.

Anticoagulation for coexisting bioprosthetic aortic valve thrombosis and anticoagulant-related bleeding: "A double edge sword".

The choice of anticoagulant agents for newly implanted bioprosthetic valve varies significantly, particularly in the presence of postoperative atrial fibrillation with increasing use of nonvitamin K oral anticoagulation (NOACs) in recent years. We reported a challenging case with a coexisting bioprosthetic aortic valve thrombosis and significant anticoagulant-related bleeding. Clinical management strategy and brief literature review were presented.

En bloc spondylectomy for primary malignant fibrous histiocytoma of the thoracic spine with aortic involvement: case report.

In this article, the authors describe a 48-year-old man who initially presented with progressively worsening back pain. Magnetic resonance imaging revealed a soft-tissue mass involving the T10-11 vertebral bodies with extension anteriorly into the aorta as well as epidural extension without spinal cord compression. A biopsy of the mass showed findings consistent with a malignant fibrous histiocytoma (MFH). A total en bloc spondylectomy with resection and reconstruction of the involved aorta using a vascular graft was performed. The patient received postoperative radiation therapy and is neurologically intact at 18 months postoperatively. To the authors' knowledge, this is the first reported case of a spinal MFH resection with aortic reconstruction.

Giant pericardial lymphangioma--imaging, surgical, and pathologic correlations.

Pericardial lymphangiomas are extremely rare benign tumors of lymphatic origin that are usually diagnosed in children. These tumors are often asymptomatic but can cause symptoms secondary to mass effect. We report a case of a giant pericardial lymphangioma that was incidentally discovered in a 58-year-old woman and present imaging, surgical, and pathologic correlations.

Cannula design reduces particulate and gaseous emboli during cardiopulmonary bypass for coronary revascularization.

PURPOSE: The incidence of neurocognitive deficits after coronary bypass surgery remains problematic, with atheroembolism being one of the major causes. External manipulation of aorta and the "sandblasting" effect of the high-velocity perfusion jet can cause dislodgement of atheromatous debris. DESCRIPTION: A new arterial cannula features a tip configuration that diffuses the flow through multiple outlets, providing reduced velocity and shear with one central and three diverted flow streams. EVALUATION: Between March 2007 and July 2008 twenty patients having isolated coronary artery bypass operations were instrumented with an Embolus Detection and Classification transducer. These data were compared to 43 patients from a previous study using similar techniques except for a standard open-tip arterial cannula. Total embolic counts were markedly lower in the new cannula group (20±25 vs 174±378) as were both gaseous (11±15 vs 95±211) and particulate counts (9±11 vs 80±194). CONCLUSIONS: The select 3D cannula design reduces the sandblasting effect of the perfusion jet and, also, may direct emboli from the heart and cardiopulmonary bypass equipment away from the cerebral circulation.

Initial institutional experience with thoracoscopic assisted esophagectomy.

We report our initial experience with thoracoscopic assisted esophagectomy (TAE) in patients with esophageal carcinoma. Clinical outcome measures are reported for 14 consecutive patients who underwent thoracoscopically assisted esophagectomy at our institution between January 2007 and June 2009. These outcomes were compared with 18 patients who underwent open esophagectomy (OE) during this time. All 14 patients were male, with a median age of 63. All had distal esophageal adenocarcinoma: stage I (7), II A (2), II B (3), and III (2). Surgical approaches included laparotomy combined with thoracoscopy and cervical (n=12), or intrathoracic anastomosis (n=2). Compared with an open approach, the thoracoscopic assisted esophagectomies were longer (median time 460 vs. 386 minutes), and they were associated with less blood loss (250 mL vs. 500 mL) and less respiratory complications (14.3% vs. 27.8%). In our TAE group more lymph nodes were removed (median number 12 in TAE vs. 10 in OE). The overall morbidity was similar in both groups (42.8% in TAE vs. 50% in OE group), but the in-hospital mortality was reduced with TAE (7.1% with TAE vs. 16.7% with OE). TAE is feasible with a low conversion rate, acceptable morbidity, and low mortality.