Surgical pulmonary embolectomy: state of the art.

Acute pulmonary embolism is a significant cause of morbidity and mortality. Patients in life-threatening conditions require timely and effective interventions to improve pulmonary perfusion. The indications for surgical embolectomy in the thrombolysis era have been limited. This article discusses surgical techniques and outlines the position of surgical embolectomy concerning other treatment modalities.

Acute pulmonary embolism with coexisting right heart thrombi in transit-surgical treatment of 20 consecutive patients.

OBJECTIVES: The presence of right heart thrombi in transit (RHTiT) in the setting of acute pulmonary embolism (PE) is associated with high mortality. The optimal management in such cases is inconclusive. We present the results of surgical treatment of 20 consecutive patients diagnosed with high- or intermediate-high-risk PE with coexisting RHTiT. METHODS: A retrospective analysis was performed of all consecutive patients undergoing surgical treatment in the Medicover Hospital between 2013 and 2021 for acute PE with coexisting thrombi in-transit in right heart cavities. The diagnosis was based on echocardiography, computed tomography pulmonary angiography and laboratory tests. Eligibility criteria for surgical treatment were acute PE with RHTiT, right ventricular overload on imaging studies and significantly elevated levels of cardiac troponin and NTproBNP. All patients were operated on with extracorporeal circulation using deep hypothermia and total circulatory arrest. The primary end point was hospital all-cause mortality; secondary end points were perioperative complications and long-term mortality. RESULTS: The analysis included 20 patients. There was no in-hospital death. Nearly one-third of patients required temporal hemofiltration for postoperative renal failure, but this did not involve the need for dialysis at discharge. No neurological complications occurred in any patient. The mean follow-up was 46 months (range 13-98). There was 1 death in the long-term follow-up, not related to PE. CONCLUSIONS: Surgical treatment of patients with acute PE and coexisting RHTiT can provide favourable results.

Transapical beating heart mitral valve repair with the NeoChord system: early outcomes of a single-center experience.

INTRODUCTION: Trans-apical beating heart off-pump mitral valve (MV) repair is a novel surgical technique for treating mitral regurgitation (MR) caused by degenerative flail/prolapse (DLP). AIM: To present early outcomes of a single-center experience with transapical beating heart mitral valve repair with the NeoChord system. MATERIAL AND METHODS: Thirty-seven patients with severe symptomatic MR were treated with the NeoChord technique between September 2015 and December 2018 (78% men; mean age: 62.3 ±13.4 years). We evaluated standard cardiac surgery perioperative complications as well as those related to the NeoChord technique as well as early surgical success as defined by the reduction of MR to less than moderate by implantation of at least 2 neochordae. RESULTS: During this series we had no hemodynamic instability due to bleeding or arrhythmia. There were no transapical technique-related adverse events such as a leaflet perforation or tear, a major native chord rupture, which would require implantation of a new chord, ventricular apex rupture, or left atrial perforation. There were no major adverse events including death, stroke or acute myocardial infarction. Nine (24%) patients developed an episode of perioperative atrial fibrillation. We were able to conclude the operation in 98% of our patients with less than moderate MR. One (2%) patient had moderate MR at the conclusion of the operation. CONCLUSIONS: Trans-apical off-pump MV repair with the NeoChord system is a safe, minimally invasive procedure, with few minor complications. In well-selected candidates it provides successful treatment of degenerative MR. Results are anatomy dependent, so preoperative patient selection is crucial.

Transapical off-pump mitral valve repair. First experience with the NeoChord system in Poland (report of two cases).

BACKGROUND: Artificial chord implantation to repair a flail or prolapsing mitral valve leaflet requires open heart surgery and cardiopulmonary bypass. AIM: Transapical off-pump artificial chordae implantation is a new surgical technique proposed to treat degenerative mitral valve regurgitation. The procedure is performed using the NeoChord DS1000 system (NeoChord, Inc., St. Louis Park, MN, USA), which facilitates both implantation and lenght adjustment of the artificial chordae under two (2D)- and three (3D)-dimensional transoesophageal echocardiographic (TEE) guidance on a beating heart. METHODS: Two male patients aged 60 and 55 years with severe mitral regurgitation due to posterior leaflet prolapse underwent transapical off-pump artificial chordae implantation on September 3, 2015. The procedure was performed by left minithoracotomy under general anaesthesia in a cardiac surgical theatre, using 2D and 3D TEE guidance. RESULTS: Early procedural success as confirmed by 3D TEE was achieved in both patients, with implantation of 6 artificial chordae in the first patient and 3 artificial chordae in the second patient. Both procedures were uneventful, and no postoperative complications were noted. The patients were discharged home on the 8th and 6th postoperative day, respectively. CONCLUSIONS: The NeoChord DS1000 system allows both implantation and lenght adjustment of artificial chordae under 2D and 3D TEE guidance on a beating heart. Our initial experience in 2 patients with posterior mitral leaflet prolapse indicates that the procedure is feasible and safe.

Outcome of Medically Versus Surgically Treated Patients With Chronic Thromboembolic Pulmonary Hypertension.

Chronic thromboembolic pulmonary hypertension (CTEPH) is an ominous disease leading to progressive right heart failure. Selected patients can be treated by pulmonary endarterectomy (PEA). We assessed long-term clinical outcome of patients with CTEPH who underwent PEA and patients who remained on medical treatment alone. A total of 112 consecutive patients with CTEPH referred between 1998 and 2008 to one center were followed for a mean of 35 (range 0-128) months after diagnosis. All the patients had advanced pulmonary hypertension at baseline. The operated group had higher World Health Organization functional class compared to the nonoperated group. No other differences in hemodynamic, echocardiographic, or biochemical parameters were observed at baseline. Despite the perioperative mortality rate of 9.1%, patients who underwent PEA had significantly lower long-term mortality compared to nonoperated patients (12.7% vs 34.8%; P = .003), and PEA survivors showed sustained clinical improvement. All efforts should be undertaken to perform PEA in all patients with operable CTEPH.

Computed tomography to predict surgical revascularization of a left anterior descending artery occlusion incompletely visualized by conventional angiography.

PURPOSE: Previous studies demonstrated that failure to visualize distal chronic total occlusion in conventional coronary angiography (CCA) does not preclude procedural success of coronary artery bypass grafting (CABG). We assessed the utility of computed tomography angiography (CTA) in guiding CABG to the occluded left anterior descending artery (LAD) incompletely visualized by CCA. MATERIALS AND METHODS: Twenty-four symptomatic patients rejected for revascularization of an occluded LAD on the basis of CCA underwent a preoperative CTA before intended transmyocardial laser revascularization. Off-pump CABG to the LAD was attempted in all patients depending on the intraoperative findings. The primary outcome was defined as procedural success of CABG to the LAD. RESULTS: The success rate for CABG was 79.2%. By CCA, Rentrop 0/1 was present in 6 patients (25%), whereas Rentrop 2 was present in 18 patients (75%). By CTA, Rentrop 3 was seen in all patients. Compared with the CABG-failure group, the CABG-success group showed a larger mean distal LAD diameter (1.7 ± 0.2 mm vs. 1.3 ± 0.1 mm; P=0.001). By receiver-operating curve analysis, a cutoff value of 1.5 mm for the mean distal LAD diameter predicted CABG availability with 100% specificity and 95% sensitivity. The distal LAD short length and intramyocardial course were other significant correlates of CABG failure compared with CABG success (60% vs. 5.3%, P=0.018; 80% vs. 0%, P<0.001). CONCLUSIONS: Noninvasive CTA is not only superior to CCA in delineating distal coronary occlusion but also very precisely predicts the procedural success of CABG. CTA represents a robust evaluation tool for coronary mapping of chronic total occlusion with doubtful distal anatomy in CCA.

A severe complication after ST-segment elevation myocardial infarction (Part 2).

We report the case of a 70-year-old woman with ST-segment elevation myocardial infarction of the anterior wall, complicated by ventricular septal rupture (two septal defects--VSDs) with symptoms of cardiogenic shock. After 6 weeks of conservative treatment with inotropes and intra-aortic balloon support, the patient underwent surgical repair of VSDs with good clinical outcome.

A severe complication after ST-segment elevation myocardial infarction (Part 1).

We report the case of a 70-year-old woman with ST-segment elevation myocardial infarction of the anterior wall, complicated by ventricular septal rupture (two septal defects--VSDs) with symptoms of cardiogenic shock. After 6 weeks of conservative treatment with inotropes and intra-aortic balloon support, the patient underwent surgical repair of VSDs with good clinical outcome.

[Thrombo-embolic pulmonary hypertension--do not spoil a chance for effective surgery!]. / Zakrzepowo-zatorowe nadcisnienie plucne--nie marnujmy szansy na skuteczne leczenie operacyjne!

Chronic thromboembolic pulmonary hypertension (CTEPH) can be defined as pulmonary hypertension with persistent pulmonary perfusion defects causes by unresolved thrombi. All symptomatic CTEPH patients with documented pulmonary vascular resistance > 300 dyn*sec*cm(-5) and proximal lesions should be considered for surgical treatment--pulmonary endarterectomy. The role of pharmacological treatment remains controversial and should be restricted to inoperable cases and persistent pulmonary hypertension after pulmonary endarterectomy. Every year about 30 procedures is performed in two specialised centers in Poland with 1 year mortality at 8-9%. Number of procedures done gives the frequency of pulmonary endarterectomy at 0.7/million of population/year. Current data from UK indicate the actual ratio of surgical treatment of CTPH at 2/million/year. The article discusses reasons for CTEPH is underdiagnosed and why rate of surgical therapy in Poland is too low.

[From premature birth to cardiac surgery - severe heart failure due to infective endocarditis in pregnancy - a case report]. / Od przedwczesnego porodu do operacji kardiochirurgicznej - ciezka obukomorowa niewydolnosc serca w przebiegu infekcyjnego zapalenia wsierdzia u kobiety w ciazy.

A 25-year-old woman, gravida 2, para 1, without any previous medical history was admitted to the hospital because of the signs and symptoms of fetal distress. After a caesarean section the woman developed an acute heart failure. Echocardiography demonstrated massive vegetations attached to aortic and mitral valves with their destruction. Surgical treatment was performed immediately. The postoperative period was complicated by chronic atrioventricular third degree heart block, requiring implantation of a pacemaker. Finally the woman was discharged from hospital and is followed regularly in the out-patient cardiac clinic.

[Acute aortic dissection type A with concomitant myocardial infarction]. / Ostre rozwarstwienie aorty wstepujacej ze wspólistniejacym rozleglym zawalem serca - trudny problem kliniczny i diagnostyczny.

The authors describe a patient with acute aortic dissection type A complicated by left main coronary artery occlusion and acute myocardial infarction. The patient underwent urgent surgery, however, died 4 hours after operation.

[Coronary artery bypass grafting in a patient after percutaneous left main angioplasty with DES stent implantation]. / Pomostowanie tetnic wiencowych u chorej po uprzednio wykonanej przezskórnej angioplastyce i implantacji stentu do pnia lewej tetnicy wiencowej.

We present surgical treatment of acute coronary syndrome due to the left main stenosis in a patient in whom 6 months earlier percutaneous left main angioplasty with DES-stent implantation was performed. We discuss indications for percutaneous angioplasty and for coronary artery bypass grafting in patients with left main stenosis.

[Acute aortic dissection in a patient with advanced coronary artery disease--a case report]. / Ostre rozwarstwienie aorty wstepujacej po laserowej rewaskularyzacji miesnia sercowego. Opis przypadku.

A case of a 58-year-old male with acute aortic dissection is presented. A few months earlier the patient underwent transmyocardial laser revascularisation and implantation of venous graft to the left anterior descending coronary artery due to three-vessel disease. Acute aortic dissection was successfully treated by surgery. Therapeutic options in patients with acute aortic dissection and advanced coronary artery disease are discussed.

Intraoperative assessment of mitral valve and peri-operative results of surgical treatment of mitral valve disease in patients who previously underwent closed surgical and percutaneous transluminal mitral commissurotomy.

BACKGROUND: Surgical open or closed mitral commisurotomy and percutaneous transluminal mitral commissurotomy (PTMC) are the well-established therapies in patients with mitral valve stenosis. However, due to various factors the long-term effects may not be optimal in some patients, so they should undergo surgical mitral valve replacement. AIM: The intra-operative assessment of the morphology of mitral valve and the evaluation of the peri-operative results of surgical treatment in patients with mitral valve disease who previously underwent closed surgical commissurotomy followed by PTMC. METHODS: Twenty one patients (20 males, mean age 49 years) who underwent surgery due to mitral valve disease after closed mitral commissurotomy and PTMC, are presented. The time from closed mitral commissurotomy to PTMC was 3-42 years, and the time from PTMC to mitral valve replacement - 9 days to almost 9 years. RESULTS: One patient died on the second day after the operation because of left ventricular failure. The outcome of the remaining patients was good. Advanced changes of the mitral valve and subvalvular apparatus were present in the majority of patients. CONCLUSIONS: The results of the implantation of mitral valve prosthesis in patients who previously underwent closed surgical mitral commissurotomy and PTMC are good. In some patients with a history of closed surgical mitral commissurotomy, PTMC delays surgical replacement of the mitral valve. Advanced changes in the mitral valve leaflets and subvalvular apparatus are the causes of PTMC failure.