Advantages of intraoperative implantation of Impella 5.5 SmartAssist in the Management of Acute Post-Infarction Ventricular Septal Defect with cardiogenic shock.

BACKGROUND: Despite advances in surgical techniques and aggressive therapy of post-infarction ventricular septal defect (VSD) with cardiogenic shock, the overall morbidity and mortality is frustratingly high. The Impella 5.5 SmartAssist (Abiomed, Danvers, MA) is a surgically implanted temporary device, recently approved by the FDA ( https://www.businesswire.com/news/home/20190925005454/en/ ) for treatment of patients in cardiogenic shock, and may fill a technological gap for patients who require acute circulatory support after VSD closure. CASE PRESENTATION: We report our initial experience for two patients with post myocardial infarction VSD in the setting of cardiogenic shock supported with trans-aortic implantation Impella 5.5 SmartAssist. First patient had a posterior VSD with a left to right shunt (Qp/Qs ratio of 3.3), blood pressure 80/35 mmHg, right ventricle dysfunction, severe pulmonary arterial hypertension (an estimated systolic pulmonary artery pressure of 45 mmHg), and severe mitral valve regurgitation. Second patient was admitted for massive MI with large anterior VSD (Qp/Qs ratio of 2.8). Under cardiopulmonary bypass with cardioplegic arrest both patients underwent urgent VSD closure with trans-aortic implantation of the Impella. Minimal postoperative support was required. Patients were discharged on postoperative day 10 and 14 and remained well 3 months later. Follow-up echocardiogram showed no residual shunt. CONCLUSIONS: Early surgical implantation of Impella 5.5 SmartAssist can prevent multiorgan dysfunction and stabilize the patients in cardiogenic shock with post-myocardial infarction VSD.

Use of longitudinal rigid sternal fixation in prevention and treatment of wound complications among high-risk patients after cardiac surgery.

BACKGROUND: Traditionally, wire cerclage closure has been used to reapproximate the sternum after cardiac surgery. Recent evidence suggests that rigid sternal fixation may reduce the risk of wound complications. The aim of this study was to analyze our 10-year experience with longitudinal rigid sternal fixation (LRSF) for prevention and treatment of wound complications in high-risk patients. METHODS: We reviewed data from cardiac surgical database of patients who underwent LRSF, and compared their outcomes with conventional wire cerclage closure (CWS). Among these 319 patients were designated as having high-risk for the development of deep wound complications and received primary LRSF (treatment group). We matched their outcomes with 319 patients who met indications for LRSF however, underwent standard closure with CWC (control group). RESULTS: Both groups were comparable regarding preoperative and intraoperative variables. The benefit observed among matched patients who had undergone LRSF was largely driven by a decreased rate of deep wound infections (0.63% vs. 3.45% vs., p < .01), 30-day mortality (1.57% vs. 5.96%) and hospital length (8.2 vs. 11.7 days) p < .05, respectively. A multivariate logistic regression analysis found four independent risk factors for the development of sternal dehiscence. Sternal healing evaluated by computerized tomography scan using 6-point scale at 3 months after surgery was superior in LRSF patients. Pain scores were significantly lower in LRSF patients as well. CONCLUSIONS: In patients with an increased risk for sternal instability and wound infections after cardiac surgery, sternal reconstruction using LRSF is an effective technique to stabilize sternum for preventive and treatment purposes.

Cause of Ascending Aortic Dilatation in Patients with Bicuspid Aortic Valves: The Final Link.

BACKGROUND: This article discusses about the cause of dilatation of the ascending aorta in patients with congenitally bicuspid aortic valves (CBAVs). Some members of the profession believe that it is genetic, while others attribute it to turbulence. The author previously presented in vitro data proving that CBAVs are inherently morphological stenotic, even in the absence of measurable gradient and clinical symptoms. This article reinforces the view that the dilatation of the ascending aorta in patients with CBAV represents a "poststenotic dilatation" by demonstrating that the structure of the aortic wall is normal in infants who have CBAV as a sole cardiac anomaly. METHODS: The aortic wall was studied in newborns who had CBAV as the sole cardiovascular anomaly and in those where CABV was associated with other inborn cardiovascular defects. RESULTS: We found that in patients where CBAV is the sole cardiovascular anomaly, aortic structure is normal at birth, but abnormal if additional cardiovascular anomalies are present. CONCLUSIONS: Dilatation of the ascending aorta in patients, where CBAV is the only cardiovascular anomaly, is caused by turbulence (poststenotic dilatation). If additional cardiovascular anomalies are present, this process may be exaggerated by genetic abnormalities of the aortic wall.

Should We Move Up the Clock on Preventive Intervention in Marfan's Disease?

Gradual dilatation of the ascending aorta is a common phenomenon in patients with Marfan's disease, which often leads to dissection and rupture. It is estimated that around two-thirds of the patients either die or require major surgery before the age of 42 years. In the mirror of the experience of 40 years with aortic wall reinforcement, the author forward the postulate that whenever the ascending aorta of an individual with proven Marfan's disease reaches adult size, that is, approximately 3.5 cm in diameter, the wall of his/her ascending aorta should be reinforced to prevent further expansion.

Single-stage hybrid repair of a ruptured Kommerell diverticulum associated with dextrorotation, bovine arch, and bicuspid aortic valve.

BACKGROUND: A strategy for the surgical repair of ruptured Kommerell diverticulum has not yet been established. The aim of this study is to demonstrate that this entity could be associated with a number of other cardiac anomalies and this lesion can be successfully treated by a hybrid approach. CASE PRESENTATION: The patient, with a combination of ruptured Kommerell diverticulum, dextrorotation, bovine arch, and bicuspid aortic valve, underwent emergency surgery. A single stage hybrid surgical/endovascular repair including subclavian artery revascularization, aortic resection with open proximal anastomosis under circulatory arrest, endovascular stenting, and valve repair was performed. Histological studies indicated the presence of the aortic wall media degeneration. Postoperative course was uneventful and patient is free of symptoms during 2-year follow up. CONCLUSIONS: Less invasive hybrid technique is safe and effective treatment option. Accumulated knowledge of Kommerell diverticulum has lead to understanding the best clinical treatment for this complicated aortic anomaly.

Right Atrial Anomalous Muscle Bundle Presenting with Acute Superior Vena Cava Syndrome and Pulmonary Embolism: Surgical Management.

BACKGROUND: An anomalous muscle bundle (AMB) crossing the right atrial cavity represents a pathologic finding with unproved clinical significance. This congenital anomaly may be difficult to recognize via echocardiography and could be confused with other intracavitary lesions. METHODS: We report the case of a 53-year-old woman presented to the cardiovascular service with acute superior vena cava (SVC) syndrome and submassive pulmonary embolism. RESULTS: The patient underwent venography, confirming SVC stenosis. A ventilation/perfusion lung scan showed 2 sizable perfusion defects because of pulmonary embolism. Magnetic resonance imaging and echocardiography imaging demonstrated a right atrium (RA) mass. Surgery was then carried out using standard cardiopulmonary bypass; the right atrial muscle bundle was excised, and SVC reconstruction was performed. The patient was discharged uneventfully and remains symptom-free at 2-year follow-up. CONCLUSIONS: In cases of nonmalignant pathology of SVC syndrome, appropriate studies should be conducted to exclude potential congenital abnormalities such as this AMB in the RA. Open-heart surgery is a viable treatment option in select cases.

Early Surgical Reconstruction of Sternum with Longitudinal Rigid Polymer Plating after Acute Chest Trauma.

PURPOSE: The surgical management of the patients with traumatic sternal fractures remains controversial. The aim of this study was to evaluate the effectiveness of an early surgical reconstruction of a displaced sternal fracture utilizing longitudinal rigid polymer fixation in the settings of an acute chest trauma. METHODS: To perform the sternal fixation, we utilized a longitudinal rigid plating system. The plate is made of polyether ether ketone (PEEK), an organic thermoplastic polymer. RESULTS: We used the entire length of the plate on each side of the fracture, secured in multiple places with 6-8 screws. Once the plates have been fully secured we tighten all the screws with a screwdriver. We demonstrated that the method minimizes pain and prevents the development of pulmonary complications. CONCLUSION: This technique provides cosmetically acceptable results, minimizing risk of sternal nonunion, and decreases length of hospitalization.

Successful Repair of Acute Type B and Retrograde Type A Aortic Dissection With Kidney Ischemia.

Acute dissection of thoracic aorta carries a risk of renal ischemia followed by the development of a kidney failure. The optimal surgical and nonsurgical management of these patients, timing of intervention, and the factors predicting renal recovery are not well delineated and remain controversial. We present a case of acute type B thoracic aortic dissection with left kidney ischemia. Evaluation of renal function was performed by the means of internationally accepted Risk, Injury, Failure, Loss of kidney function, End stage kidney disease and Acute Kidney Injury Network classifications for acute kidney injury, renal duplex sonography, and intravascular ultrasound that demonstrated left renal artery dissection with a flap completely compressing the true lumen. The patient underwent thoracic endovascular aortic repair and left renal artery stent and recovered well. Six months later, at the follow-up visit, retrograde type A aortic dissection was found, which was successfully repaired. Reversal of renal ischemia after aortic dissection depends on the precise assessment of renal function and prompt intervention.

An Extrapericardial Minimally Invasive Approach for Implantable Cardioverter Defibrillator.

The indications for placement of an implantable cardioverter defibrillators (ICDs) have greatly expanded over the last years. However, standard transvenous approach is not suitable for a subset of patients who cannot benefit from ICD therapy. Here, we have demonstrated the feasibility and efficacy of extrapericardial ICD placement through a minimally invasive access in intact hearts as well as in postmyocardial infarction large animal models. Based on our data, we conclude that extrapericardial ICD placement is a feasible approach that may be a valuable alternative or adjunct to current defibrillator lead systems.

Wilhelm Ebstein and the history of surgery for Ebstein's Disease.

In the mirror of the life-story of Wilhelm Ebstein, the discovery of "Ebstein's Disease" is presented. The readers are guided through the individual stages of the development of surgical treatment of the condition.

Hypoglycemia with intensive insulin therapy after cardiac surgery: predisposing factors and association with mortality.

BACKGROUND: Intensive insulin therapy has become a major therapeutic target in cardiac surgery patients. It has been associated, however, with an increased risk of hypoglycemia compared with conventional insulin therapy. Our study sought to identify the factors predisposing to hypoglycemia with intensive insulin therapy and investigate its effect on early clinical outcomes after cardiac surgery. METHODS: A concurrent cohort study of 2,538 consecutive patients undergoing cardiac surgery (coronary artery bypass grafting, valve, or bypass grafting and valve surgery) from January 2005 to March 2010 was carried out. Multivariable logistic regression analysis and propensity score matching were used (1) to identify the risk factors for developing hypoglycemia (blood glucose < 60 mg/dL) after cardiac surgery and (2) to compare major morbidity, operative mortality, and actuarial survival between patients in whom hypoglycemia developed (n = 77) and those in whom it did not (n = 2461). The propensity score-adjusted sample included 61 patients in whom hypoglycemia developed and 305 patients in whom it did not (1 to 5 matching). RESULTS: Risk factors for hypoglycemia included female gender (odds ratio [OR] = 2.3, 95% confidence intervals [CI] = 1.4-3.7; P < .001), diabetes (OR = 2.8, CI = 1.7-4.5; P < .001), hemodialysis (OR = 3.0, CI = 1.3-6.8; P = .009), intraoperative blood product transfusion (OR = 2.0, CI = 1.2-3.4; P = .010), and earlier date of surgery (years of surgery, 2005-2007; OR = 2.1, CI = 1.2-3.7; P = .007) . Hypoglycemia increased the risk for operative mortality in univariate (hypoglycemic 10% vs normoglycemic patients 2%; P < .001) but not in propensity score- adjusted analysis (OR= 2.5, 0.9-6.7; P = .11). The propensity score-adjusted analysis demonstrated a significant increase in hemorrhage-related reexploration (P = .048), pneumonia (P < .001), reintubation (P < .001), prolonged ventilatory support (P < .001), hospital length of stay (P < .001), and intensive care unit length of stay (P < .001) for the hypoglycemic compared with normoglycemic patients. Five-year actuarial survival was similar in the compared patient groups (hypoglycemic 75% vs normoglycemic 75%; P = .22). CONCLUSIONS: Hypoglycemia with intensive insulin therapy is independently associated with increased risk for respiratory complications and prolonged hospital and intensive care unit lengths of stay after cardiac surgery. In our study, hypoglycemia was not independently associated with increased risk of death.