Comparison of Right Ventricular Outflow Tract Reconstruction Techniques on Mid-Term Pulmonic Valve Fate.

Introduction: The pulmonic valve-sparing technique (PVS) is an emerging approach of right ventricular outflow tract reconstruction in tetralogy of Fallot (TOF) correction aimed at reducing the incidence of pulmonic regurgitation (PR) and the need for subsequent reintervention. This study aims to compare the long-term occurrence of moderate to severe PR/stenosis (PR/PS) between three different approaches. Patients and Methods: We conducted a retrospective cohort study involving 173 patients who underwent TOF correction at Chiang Mai University hospital between January 2006 and December 2016. The patients were divided into three groups: transannular patch (TAP; n = 88, 50.9%), monocusp insertion (MCI; n = 40, 23.1%), and PVS (n = 45, 26%). The study assessed freedom from moderate to severe PR/PS. Results: The median overall follow-up time was 79.8 months (interquartile range: 50.7-115.5 months. The PVS exhibited larger PV Z-score (-2.6 ± 2.3 mm, P < .001), with predominantly tricuspid morphology (64.4%). The PVS had significantly shorter median ventilator time, intensive care unit stay, hospital stay, and longer median follow-up time. Postoperative moderate-severe PR was lower in the PVS group (P < .001), with no significant difference in PS (P = .356) and complications among the groups. Freedom from moderate-severe PR/PS was longer in the MCI group (2.8, 0.2-42.3 months vs 30.9, 0.2-50.9 months, respectively). Multivariable analysis showed TAP and MCI had a higher risk of developing moderate-severe PR (hazard ratio [HR] 2.51; 95% confidence interval [CI] 1.23-5.13 vs HR 1.41; 95%CI 0.59-3.38) but lower risk of moderate-severe PS (HR 0.14; 95%CI 0.02-0.9 vs HR 0.39; 95%CI 0.05-3.19). Conclusion: Pulmonic valve-sparing reconstruction showed promise in preventing late moderate-severe PR in patients with favorable PV anatomy. However, it should be noted that this technique is associated with a higher incidence of PS.

Comparison between mitral valve repair and replacement in active infective endocarditis.

BACKGROUND: Mitral valve repair has been proved to provide better outcomes when compared with replacement in degenerative disease. However, it is still unclear that benefits of repair still remain in active endocarditis. Patient clinical conditions and severity of tissue destruction might limit successful durable repair. METHODS: Of all 247 patients who received surgery during active phase of native left-sided endocarditis from Jan 2006 to Dec 2017, 114 had mitral valve procedures due to active infection of mitral valve apparatus (38 repair and 76 replacement). Perioperative data and mid-term outcomes were retrospectively compared. RESULTS: Mean age was 46.4 years old. Repair group had significantly less patients with NYHA class IV (18.4% vs 56.6%, p = 0.001). Both groups had preserved ejection fraction but accompanied by severe pulmonary hypertension. Major organism was streptococci (50%) and timing of surgery was 11 days after diagnosis. Bypass and cross-clamp time were similar but repair group had significantly less combined procedures. Bi-leaflet involvement was common (47.4% vs 57.6%) and valve lesions were comparable. There was 13.2% of postoperative moderate to severe mitral regurgitation in repair group without recurrent endocarditis. Repair group tended to have better 5-year survival estimates (91.6% vs 70.0%, p = 0.08) with comparable reoperation rate (7.9% vs 2.6%). By logistic regression analysis, mitral valve replacement was more likely to be performed in patients with decompensated heart failure and combined procedures. CONCLUSIONS: Mitral valve repair during active endocarditis can be safely performed with good mid-term outcomes, especially in selected group of patients without extremely high surgical risk.

Race predictors and hemodynamic alteration after an ultra-trail marathon race.

OBJECTIVE: Unique rough-terrain ultra-trail running races have increased in popularity. Concerns regarding the suitability of the candidates make it difficult for organizers to manage safety regulations. The purpose of this study was to identify possible race predictors and assess hemodynamic change after long endurance races. METHODS: We studied 228 runners who competed in a 66 km-trail running race. A questionnaire and noninvasive hemodynamic flow assessment including blood pressure, heart rate, stroke volume, stroke volume variation, systemic vascular resistance, cardiac index, and oxygen saturation were used to determine physiologic alterations and to identify finish predictors. One hundred and thirty volunteers completed the questionnaire, 126 participants had a prerace hemodynamic assessment, and 33 of these participants completed a postrace assessment after crossing the finish line. The participants were divided into a finisher group and a nonfinisher group. RESULTS: The average age of all runners was 37 years (range of 24-56 years). Of the 228 runners, 163 (71.5%) were male. There were 189 (82.9%) finishers. Univariable analysis indicated that the finish predictors included male gender, longest distance ever run, faster running records, and lower diastolic pressure. Only a lower diastolic pressure was a significant predictor of race finishing (diastolic blood pressure 74-84 mmHg: adjusted odd ratio 3.81; 95% confidence interval [CI] =1.09-13.27 and diastolic blood pressure <74 mmHg: adjusted odd ratio 7.74; 95% CI =1.57-38.21) using the figure from the multivariable analysis. Among the finisher group, hemodynamic parameters showed statistically significant differences with lower systolic blood pressure (135.9±14.8 mmHg vs 119.7±11.3 mmHg; p<0.001), faster heart rate (72.6±10.7 bpm vs 96.4±10.4 bpm; p<0.001), lower stroke volume (43.2±13.6 mL vs 29.3±10.1 mL; p<0.001), higher stroke volume variation; median (interquartile range) (36% [25%-58%] vs 53% [33%-78%]; p<0.001), and lower oxygen saturation (97.4%±1.0% vs 96.4%±1.0%; p<0.001). Systemic vascular resistance and cardian index did not change significantly. CONCLUSION: The only race finishing predictor from the multivariable analysis was lower diastolic pressure. Finishers seem to have a hypovolemic physiologic response and a lower level of oxygen saturation.

Postoperative Pericardial Adhesion Prevention Using Collagen Membrane in Pigs: A Pilot Study.

OBJECTIVE: The operating procedure of a resternotomy in open-heart surgery is a complicated procedure with potentially problematic outcomes partly due to potential adhesions in the pericardial cavity and retrosternal space. Use of a collagen membrane has shown encouraging results in adhesion prevention in several regions of the body. This study was designed to evaluate the effectiveness of the use of this collagen membrane in the prevention of pericardial adhesions. MATERIALS AND METHODS: A total of 12 pigs were divided randomly into 2 groups: an experimental group in which collagen membranes were used and a control group. After sternotomy and an anterior pericardiectomy, the epicardial surface was exposed to room air and irrigated with saline, and an epicardial abrasion was performed using a sponge. The pericardial defect was repaired using a collagen membrane in the experimental group or left uncovered in the control group. After 8 to 12 weeks, the pigs were killed, and a resternotomy was performed by a single-blinded surgeon enabling the evaluation of adhesions. The heart was then removed and sent for microscopic assessment conducted by a single-blinded pathologist. RESULTS: The resternotomy operations performed using a collagen membrane demonstrated a nonstatistically significant trend of fewer macroscopic and microscopic adhesions in all regions (P > .05), particularly in the retrosternal and defect regions. CONCLUSIONS: This study showed nonstatistically significant differences between the outcomes in the collagen membrane group and the control group in both macroscopic and microscopic adhesion prevention. Due to the many limitations in animal study design, further studies in human models will be needed before the true value of this procedure can be evaluated.

Huge cardiac myxoma in pregnancy.

A 28-year-old pregnant woman presented at 28 weeks of gestation. She was diagnosed to have a left atrial myxoma 2 years earlier, but was lost to follow-up. During this pregnancy, the transthoracic echocardiography showed a 9 cm mass in the left atrium obstructing mitral valve inflow, interfering with mitral valve closure, causing severe mitral regurgitation and severe pulmonary hypertension. However, there were no clinical signs of pulmonary and systemic congestion or obstruction. Based on the clinical symptoms of the patient, the echocardiographic findings and the term of her pregnancy, the patient decided to schedule for a vaginal delivery with surgical correction after delivery. She gave birth at 32 weeks of gestation. During labour, pulmonary oedema developed but was detected early and it responded to therapy. Two weeks after delivery, a right anterior thoracotomy was performed to facilitate the removal of the left atrial myxoma and repair of the mitral valve.

Left Atrial Myxoma in Pregnancy: Management Strategy Using Minimally Invasive Surgical Approach.

This case report concerns a young woman who, during her pregnancy, suffered severe mitral regurgitation. It was discovered at the same time that she had a left atrial myxoma. During the early postpartum period she successfully underwent an anterior minithoracotomy to remove the left atrial myxoma in conjunction with repair of the mitral valve. The thoracotomy approach in this specific patient was chosen as it would give a better chance of successful mother-child bonding because the patient would be able to avoid the precautions which would have been necessary following a sternotomy, especially the limitation of her ability to hold her child during the first 4-6 weeks postoperatively.

Additional effects of topical tranexamic acid in on-pump cardiac surgery.

Objective Postoperative bleeding after cardiac surgery is commonly associated with hyperfibrinolysis. This study was designed to evaluate the efficacy of topical tranexamic acid in addition to intravenous tranexamic acid in reducing bleeding in cardiac surgery cases. Methods From July 1, 2014 to September 30, 2015, 82 patients who underwent elective on-pump cardiac surgery were randomized into a tranexamic acid group and a placebo group. In the tranexamic acid group, 1 g of tranexamic acid dissolved in 100 mL of normal saline solution was poured into the pericardium during sternal closure; the placebo group had 100 mL of saline only. Two patients were excluded from the study due to obvious surgical bleeding. The primary endpoint was total blood loss 24 h after surgery. Repeated measures with mixed models was used to analyze bleeding over time. Results There was no significant difference in demographic and intraoperative data except for a significantly lower platelet count preoperatively in the tranexamic acid group ( p = 0.030). There was no significant difference in postoperative drainage volumes at 8, 16, and 24 h, postoperative bleeding over time (coefficient = 0.713, p = 0.709), or blood product transfusion between the groups. There were no serious complications. Conclusions Topical tranexamic acid is safe but it adds no additional efficacy to the intravenous application in reducing postoperative blood loss. Intravenous tranexamic acid administration alone is sufficient antifibrinolytic treatment to enhance the hemostatic effects during on-pump cardiac surgery.

Magnesium Sulfate Reduces Incidence of Atrial Fibrillation after Coronary Arterial Bypass Surgery: What Is the Proper Dose? A Randomized Trial.

Background: Atrial fibrillation (AF) is a common complication after cardiac surgery and impacts length of hospital stay, greater utilization of health care resources, and increases morbidity and mortality. Magnesium sulfate (MgSO4 ) has been well documented in its effect of AF reduction after cardiac surgery especially in coronary artery bypass grafting (CABG) but the dosages are still not settled. Material and Method: Eighty-eight elective CABG cases were randomized to receive a high dose (10 gm) or low dose (5 gm) MgSO4 and were blinded into bottle 1 (n = 46) and bottle 2 (n = 42). Patients were closely observed with continuous ECG monitoring in the first 24 hours then observed for clinical symptoms until discharge. Results: The demographic data were comparable except for a higher body weight in the high dose group (60.21±11.32 kg vs. 65.85±12.2 kg, p = 0.03) and higher incidence of diabetes in high dose group (52.4% vs. 28.3%, p = 0.02). Intraoperative data were similar. No complications were related to MgSO4 except one patient in the high dose group that experienced flushing and abdominal discomfort during administration. Immediate postoperative serum magnesium was higher in the high dose group but rapidly returned to similar level one day postoperatively. AF occurred in nine patients (10.23%), four in the low dose and five in the high dose group and there was no statistical significance (p = 0.62). Conclusion: Current data suggested the safety and effectiveness of MgSO4 for the reduction of the incidence of AF during postoperative CABG surgery. However, there was no statistical difference between the dosages of MgSO4 supplement. The 5-gm-MgSO4 supplement was effective in AF prevention and could avoid the adverse effect from high dose MgSO4 infusion.