The effect of cardioplegic supplementation with sildenafil on cardiac energetics in a piglet model of cardiopulmonary bypass and cardioplegic arrest with warm or cold cardioplegia.

Cardioplegic cardioprotection strategies used during paediatric open-heart surgery remain suboptimal. Sildenafil, a phosphodiesterase 5 (PDE-5) inhibitor, has been shown to be cardioprotective against ischemia/reperfusion injury in a variety of experimental models and this study therefore tested the efficacy of supplementation of cardioplegia with sildenafil in a piglet model of cardiopulmonary bypass and arrest, using both cold and warm cardioplegia protocols. Piglets were anaesthetized and placed on coronary pulmonary bypass (CPB), the aorta cross-clamped and the hearts arrested for 60 min with cardioplegia with or without sildenafil (10 nM). Twenty minutes after removal of cross clamp (reperfusion), attempts were made to wean the pigs from CPB. Termination was carried out after 60 min reperfusion. Throughout the protocol blood and left ventricular tissue samples were taken for analysis of selected metabolites (using HPLC) and troponin I. In both the cold and warm cardioplegia protocols there was evidence that sildenafil supplementation resulted in faster recovery of ATP levels, improved energy charge (a measure of metabolic flux) and altered release of hypoxanthine and inosine, two purine catabolites. There was no effect on troponin release within the studied short timeframe. In conclusion, sildenafil supplementation of cardioplegia resulted in improved cardiac energetics in a translational animal model of paediatric CPB surgery.

Validation of the German Registry for Acute Aortic Dissection Type A Score in predicting 30-day mortality after type A aortic dissection surgery.

OBJECTIVES: No reliable scores are available to predict mortality following surgery for type A acute aortic dissection (TAAAD). Recently, the German Registry of Acute Aortic Dissection Type A (GERAADA) score has been developed. We aim to compare how the GERAADA score performs in predicting operative mortality for TAAAD to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II. METHODS: We calculated the GERAADA score and EuroSCORE II in patients who underwent TAAAD repair at the Bristol Heart Institute. As there are no precise criteria to calculate the GERAADA score, we used 2 methods: a Clinical-GERAADA score, which evaluated malperfusion with clinical and radiological evidence, and a Radiological-GERAADA score, where malperfusion was assessed by computed tomography scan alone. RESULTS: 207 consecutive patients had surgery for TAAAD, and the observed 30-day mortality was 15%. The Clinical-GERAADA score showed the strongest discriminative power with an area under the curve (AUC) of 0.80 [95% confidence interval (CI) 0.71-0.89], while the Radiological-GERAADA score had an AUC of 0.77 (95% CI 0.67-0.87). EuroSCORE II showed acceptable discriminative power with an AUC of 0.77 (95% CI 0.67-0.87). CONCLUSIONS: Clinical GERAADA score performed better than the other scores and it is specific and easy to use in the context of a TAAAD. Further validation of the new criteria for malperfusion is needed.

Endoscopic Robotic Retrieval of a Migrated Subclavian Vein Stent from the Right Ventricle.

A 54-year-old woman with end-stage renal disease on hemodialysis with access through a right arm arteriovenous fistula presented with right arm swelling. Venography demonstrated right subclavian vein stenosis. A balloon angioplasty of the stenotic vein was unsuccessful, and she subsequently underwent stent placement with balloon angioplasty. Ten days following the procedure, she developed acute shortness of breath. Transthoracic echocardiogram demonstrated the migration of the venous stent into the right ventricle. Using an endoscopic robotic approach, the stent was successfully extracted from the beating heart.

Perspectives of Surgeons from Atlanta, USA.

BACKGROUND: The COVID-19 pandemic in late 2019 quickly stretched health care system across the globe. Mortalities, shortages in health care system capacity, and lack of experience in similar circumstances required innovation in the way health care is delivered. Health care systems changed operating schedules, staff work pattern, and how patients are cared for. The effects of these changes reached patients, staff and training in different ways. METHODS: We searched the Pubmed and EMBASE for articles related to COVID-19. We also searched local emails and information provided to staff during the pandemic RESULTS: The COVID-19 pandemic affected organizations, patients, and staff. The organizations and staff had to adapt to the times to provide a safe and appropriate service to our patients. CONCLUSION: The pandemic challenged and changed the way we work as health care providers, and how we train the future surgeons. Changes in the system were effective.

Management of the aortic root in type A aortic dissection: A valve sparing approach.

BACKGROUND: Type A acute aortic dissection (TAAAD) is rapidly fatal without emergency repair. Surgical outcomes have improved over the years with improvements in technique and postoperative care. Classically, supracomissural aortic replacement has been the standard of care. However, reintervention rates, particularly on the aortic root in certain groups of patients, shifted the focus towards improving long-term results of surgical repair. With regard to the aortic root, root replacement has been the gold standard. However, the surgical community realized that valve replacement in itself is a disease, and valve sparing aortic root replacement (VSRR) took center stage in the care of these patients. METHODS: We searched the Pubmed and EMBASE databases for articles related to VSRR and composite valve conduit (CVC) root replacement, and the long-term results of these techniques in TAAAD. RESULTS: Supracomissural repair is limited by reintervention, and CVC results are affected by complications related to the prosthetic valve. Conversely, VSRR is associated with good short-term outcomes, improvement in quality of life, and it is durable. CONCLUSION: VSRR is a sound technique in TAAAD in experienced hands.

Surgical versus balloon valvotomy in neonates and infants: results from the UK National Audit.

Objective: There are conflicting data on choosing balloon aortic valvoplasty (BAV) or surgical aortic valvotomy (SAV) in neonates and infants requiring intervention for aortic valve stenosis. We aim to report the outcome of both techniques based on results from the UK national registry. Methods: This is a retrospective study, including all patients under 1 year undergoing BAV/SAV between 2000 and 2012. A modulated renewal approach was used to examine the effect of reinterventions on outcomes. Results: A total of 647 patients (488 BAV, 159 SAV, 292 neonates) undergoing 888 aortic valve procedures were included, with a median age of 40 days. Unadjusted survival at 10 years was 90.6% after initial BAV and 84.9% after initial SAV. Unadjusted aortic valve replacement (AVR) rate at 10 years was 78% after initial BAV and 80.3% after initial SAV. Initial BAV and SAV had comparable outcomes at 10 years when adjusted by covariates (p>0.4). AVR rates were higher after BAV and SAV reinterventions compared with initial valvoplasty without reinterventions (reference BAV, HR=3 and 3.8, respectively, p<0.001). Neonates accounted for 29/35 of early deaths after the initial procedure, without significant differences between BAV and SAV, with all late outcomes being worse compared with infants (p<0.005). Conclusions: In a group of consecutive neonates and infants, BAV and SAV had comparable survival and freedom from reintervention as initial procedures and when performed as reinterventions. These findings support a treatment choice based on patient characteristics and centre expertise, and further research into the best patient profile for each choice.

Aortic root and hemiarch replacement in a patient with Loeys-Dietz and hypoplastic left heart syndromes.

A 15-year-old patient with hypoplastic left heart syndrome underwent 3-stage palliation by the age of 3 years. He was later diagnosed with Loeys-Dietz syndrome. On follow-up imaging, the neoaorta was dilated at 50 mm in diameter. He underwent aortic root replacement with a composite valve conduit and hemiarch replacement, using a boat-shaped Dacron graft. The uncertainty of how univentricular circulation would tolerate long bypass time steered us away from a total arch replacement. His postoperative recovery was uneventful. Imaging postoperatively demonstrated stable dilatation of the aorta distal to the hemiarch replacement. Considering the risk of reintervention, we elected to monitor the distal aorta. The combination of Loeys-Dietz syndrome and hypoplastic left heart syndrome presents unique challenges, rarely reported in the literature.