Thoracoscopic Left Atrial Appendage Occlusion with the AtriClip PRO2: An Experience of 144 Patients.

AIM: To report the clinical outcomes of thoracoscopic left atrial appendage occlusion (LAAO) with the AtriClip PRO2 device (Atricure Inc, Mason, OH, USA). Stroke risk reduction with LAAO in patients with atrial fibrillation is now well-established. Many surgical and percutaneous techniques have been used, with varying rates of success. The percutaneous devices have had issues with procedural complications and peridevice flow. Thoracoscopic AtriClip offers an epicardial linear closure of the appendage at its ostium. This study sought to evaluate its safety and efficacy in achieving complete LAA closure. METHOD: This is a prospective series of thoracoscopic AtriClip PRO2 as a standalone procedure or a thoracoscopic AtriClip deployed as an adjunct to minimal access cardiac and thoracic surgery. Study ethical approval was granted by the hospital Human Research Ethics Committee. RESULTS: In total, 144 thoracoscopic AtriClip procedures were conducted by a single surgeon from 2017 to 2022, 56 standalone and 88 concomitant. There was no mortality or major morbidities. A 100% success in complete LAA closure was observed, with 87% complete follow-up imaging. For patients that underwent standalone AtriClip after cessation of anticoagulation, no thromboembolic phenomena were seen in the 180 patient-years of follow-up. CONCLUSIONS: This study demonstrates that thoracoscopic placement of AtriClip is safe and effective in achieving consistent and complete LAAO. Future randomised trials will be useful to compare outcomes with percutaneous devices.

Sternal sparing aortic valve replacement via right anterior minithoracotomy: An early experience.

Purpose: This study aims to evaluate the perioperative outcomes of aortic valve replacement (AVR) via right anterior minithoracotomy (RAT) during the learning curve. Methods: It was a retrospective, observational, cohort study of patients who underwent RAT AVR from June 2015 to April 2022. Primary outcomes measured were 30-day morbidity and mortality. Results: A total of 107 consecutive patients underwent elective RAT AVR. Our patients were mostly male (78.5%), elderly (mean 68.7 years), and obese (34.6%). A majority of the patients (93.5%) were of low operative risk. Median cross-clamp and bypass times were 95 and 123 minutes respectively. There was a statistically significant correlation between increase in number of cases and decrease in operative time. All patients had no paravalvular leak at discharge. There were no operative cardiovascular mortality or major morbidity including stroke, myocardial infarction, renal failure requiring dialysis, or vascular complication. No patient required intraoperative conversion to full sternotomy for completion of AVR. Conclusion: Our study demonstrated that RAT AVR can be safely introduced. The learning curve required in performing RAT AVR can be safely negotiated through training, previous experience in minimally invasive surgery, careful patient selection including use of preoperative computed tomography of the aorta, and introduction of sutureless/rapid deployment valves.

Isolated Ventricular Septal Rupture in a Suicide Jumper.

Ventricular septal rupture is an extremely rare sequelae of blunt chest trauma, and is mostly diagnosed postmortem. We present a case of a large isolated traumatic ventricular septal rupture after a suicide attempt by jumping from a height of 5 stories, which was successfully treated with surgical closure. (Level of Difficulty: Intermediate.).

Emergency on-pump beating heart reconstructive coronary artery bypass grafting for entrapped percutaneous coronary intervention equipment.

BACKGROUND: Equipment entrapment during percutaneous coronary intervention (PCI) may lead to acute ischemia necessitating emergency surgery. CASE PRESENTATION: This is the first case report where emergency surgery had to be performed on beating heart, for removal of retained PCI equipment, due to an incidental finding of severely atheromatous aorta precluding cross-clamp. Ultrasound-guided aortic cannulation and off-pump strategy made the complex reconstruction of left anterior descending artery possible. CONCLUSIONS: PCI equipment entrapment and subsequent myocardial ischemia, with or without hemodynamic compromise, necessitates emergency surgery and should involve an early discussion with a cardiothoracic team. Each case poses different challenges and requires surgical planning to devise an individualized management strategy. Intraoperative finding of atheromatous aorta may be managed with pump-assisted beating heart surgery and clampless technique to achieve satisfactory results.

Combined epicardial and endocardial ablation for atrial fibrillation: Best practices and guide to hybrid convergent procedures.

The absence of strategies to consistently and effectively address nonparoxysmal atrial fibrillation by nonpharmacological interventions has represented a long-standing treatment gap. A combined epicardial/endocardial ablation strategy, the hybrid Convergent procedure, was developed in response to this clinical need. A subxiphoid incision is used to access the pericardial space facilitating an epicardial ablation directed at isolation of the posterior wall of the left atrium. This is followed by an endocardial ablation to complete isolation of the pulmonary veins and for additional ablation as needed. Experience gained with the hybrid Convergent procedure during the last decade has led to the development and adoption of strategies to optimize the technique and mitigate risks. Additionally, a surgical and electrophysiology "team" approach including comprehensive training is believed critical to successfully develop the hybrid Convergent program. A recently completed randomized clinical trial indicated that this ablation strategy is superior to an endocardial-only approach for patients with persistent atrial fibrillation. In this review, we propose and describe best practice guidelines for hybrid Convergent ablation on the basis of a combination of published data, author consensus, and expert opinion. A summary of clinical outcomes, emerging evidence, and future perspectives is also given.

Risk stratification using serum lactate in patients undergoing surgical pulmonary embolectomy.

BACKGROUND: Surgical pulmonary embolectomy (SPE) has been around since the early days of cardiac surgery. But with the increase in thrombolytic and intervention options, indications of SPE have been limited. Literature suggests that risk stratification has been a key step in getting good results. We are analyzing serum lactate levels for risk stratification in massive and submassive pulmonary embolism (PE). METHODS: This study is a retrospective analysis of 82 cases that underwent SPE between January 1997 and January 2020. Patients were divided into two groups stratified by venous serum lactate levels on the first admission (Group I: normolactatemia <2 mmol/L, Group II: hyperlactatemia, >2 mmol/L). Primary endpoints were all-cause in-hospital mortality and secondary endpoints were cardiopulmonary bypass time, extracorporeal membrane oxygenator (ECMO) insertion, low cardiac output, blood product use, and right ventricular functions in the follow-up. RESULTS: Our study had an overall follow-up of 23 years with a median of 3.18 years. Overall, the in-hospital mortality rate was 8.54%. Group II had a higher mortality rate (P = .015) and morbidity incidences like cardiopulmonary bypass time (P = .008), ECMO insertion (P = .036), and open chest after surgery (P = .015). Although 5-year survival was better in group I a compared to group II (81%, 95% CI, 69%-93% vs 65%, 95% CI, 46%-84%), the log rank test showed no statistical survival difference among both groups on long-term follow-up. CONCLUSIONS: Long term survival after SPE is good and these results can further be improved by proper PE risk stratification. Alongside computed tomography and echocardiography, the importance of biomarkers like serum lactate can be explored in the PE management algorithm.

Outcomes of video-assisted thoracoscopic surgery lobectomy in septuagenarians.

BACKGROUND: Spread of technology and increased surveillance have led to more patients with lung cancers being identified than ever before. Increasingly, patients from the elderly population are referred for surgery; however, many studies do not focus on this patient group. We reviewed the outcomes of septuagenarians who underwent lobectomy via an open thoracotomy (OT) or video-assisted thoracoscopic surgery (VATS) approach to determine whether the VATS approach would result in superior post-operative outcomes. METHODS: Between January 2010 and June 2016, a total of 96 patients aged 70 years or older underwent a lobectomy for non-small cell lung carcinoma. Patients who underwent resection for metastatic disease, small cell lung cancer or neuroendocrine tumour were excluded. Demographic details, early and late post-operative outcomes including post-operative arrhythmia, myocardial infarction, respiratory failure, cerebrovascular events, infection, prolonged air leak, delirium, readmission and 30-day mortality were studied. Mean follow-up duration was 23 ± 19.1 months. RESULTS: Seventy-five patients underwent lobectomy via a VATS approach and 21 patients underwent lobectomy via an OT approach. There was no 30-day mortality and no difference in overall survival between the two techniques (P = 0.25). There was no significant difference between the two techniques with regard to post-operative stroke, myocardial infarction, atrial fibrillation, pneumonia, delirium or bronchopleural fistula. VATS patients had a significantly shorter mean hospital length of stay (VATS 4.7 days, OT 9.3 days, P = 0.005). CONCLUSION: Septuagenarians with non-small cell lung carcinoma can successfully undergo curative lung resection with a low incidence of post-operative complications.

Removal of Peritnoeo-venous-atrial shunt thrombus without cardiopulmonary bypass.

Thrombus formation is not uncommon in longstanding intracardiac catheters, but formation of a thrombus at the tip of a Peritnoeo-venous-atrial shunt, causing obstruction of the tricuspid valve, is a rare complication and frequently unrecognized. A large intracardiac thrombus causing valve obstruction requires surgical removal with the support of cardiopulmonary bypass which is associated with significant morbidity. We successfully removed a thrombus attached to the tip of peritoneovenous shunt without cardiopulmonary bypass in a 25-year-old man.

Hybrid treatment of an isolated immunoglobulin G4-related internal thoracic artery aneurysm.

True aneurysms of the internal thoracic artery (ITA) are rare and are associated with vasculitides, connective tissue diseases, and infections. We report a case of a 3-cm immunoglobulin G4-positive ITA aneurysm that was excised by a hybrid approach involving open ligation of the ITA origin and video-assisted thoracoscopic aneurysmectomy. This novel technique was able to acquire tissue for histopathologic diagnosis through a minimally invasive means.

Surgical Management of Caseous Calcification of the Mitral Annulus.

Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification; it can manifest with conduction abnormalities or systemic embolization. It typically involves the posterior mitral annulus, and surgery is indicated for severe mitral valve dysfunction, for embolic complications or when the diagnosis is not certain. We describe a structured approach to the surgical management of CCMA using bovine pericardium to repair the defect.

Acute Structural Failure of the Trifecta Aortic Valve Bioprosthesis.

Advancements in bioprosthetic valve technology have greatly enhanced the haemodynamic performance and long-term durability of tissue valves. These features, along with the key advantage of avoiding lifelong anticoagulation, have made bioprosthetic valves increasingly attractive for clinicians and patients alike. The St Jude Trifecta valve is a novel, bovine pericardial bioprosthesis with promising early data for performance and safety. However, no prosthetic valve is perfect and prosthesis failure can occur with even the most reliable and well-designed devices. We report a case of early and acute structural deterioration (stent-post leaflet rupture) of the Trifecta valve, explanted after 33 months, in a 76-year-old male.

Sternal-Sparing Aortic Valve Replacement in a Patient with Osteogenesis Imperfecta: A Case Report.

The case described here is the first reported case of successful isolated aortic valve replacement (AVR) via a right anterior thoracotomy (RAT) in a patient with osteogenesis imperfecta (OI). The most common reported complication in patients with OI undergoing AVR or other cardiac surgery is bleeding and sternal complications. By using a RAT approach, it was possible to replace the aortic valve without major bleeding, transfusion, or sternal complications.

Ruptured penetrating ulcer of the ascending aorta with pulmonary artery compression.

Pulmonary artery involvement has been reported in various degrees of complicated dissection of the ascending aorta. The prognosis remains poor without high-risk surgical intervention, but conservative management can be considered in high-risk cases. We report a case of nonoperative management of an octogenarian who presented with a contained rupture of his proximal ascending aorta, likely from a penetrating atherosclerotic ulcer. It was complicated by extrinsic compression of the pulmonary trunk and transient pulmonary hypertension without features of acute right heart failure. He remained alive at the one-year follow-up.

Refractory ascites - a rare presentation of severe aortic regurgitation.

A 47 year-old male with a history of refractory ascites presented to our centre complaining of dyspnoea, abdominal distention, and weight gain. He was admitted under a medical team for investigation and management. Work-up excluded all common aetiologies of ascites. Echocardiography revealed severe aortic regurgitation (AR) with a dilated left ventricle but no right heart pathology or pulmonary hypertension. He underwent mechanical aortic valve replacement. Intra-operatively, a prolapsing left coronary leaflet of the aortic valve with frayed edges raised suspicion of resolved infective endocarditis. Postoperative course was uneventful. Following replacement of the aortic valve, the patient was completely free of ascites. This case demonstrates that ascites can be an unusual clinical presentation of severe aortic regurgitation, which may respond to aortic valve replacement.