Comparative Analysis of Long-Term Outcomes in Valve-Sparing Aortic Root Reimplantation: Full Sternotomy versus Mini-Sternotomy Approach.

Background: Aortic valve-sparing aortic root replacement (VSARR) David procedure has not been routinely performed via minimally invasive access due to its complexity. Methods: We compared our results for mini-VSARR to sternotomy-VSARR from another excellence center. Results: Eighty-four patients, 62 in the sternotomy-VSARR group and 22 in the mini-VSARR group, were included. A baseline, the aneurysm dimensions were higher in the mini-VSARR group. Propensity matching resulted in 17 pairs with comparable characteristics. Aortic cross-clamp and cardiopulmonary bypass times were significantly longer in the mini-VSARR group, by 60 and 20 min, respectively (p < 0.001). In-hospital outcomes were comparable between the groups. Drainage volumes were numerically lower, and hospital length of stay was, on average, 3 days shorter (p < 0.001) in the mini-VSARR group. At a median follow-up of 5.5 years, there was no difference in mortality (p = 0.230). Survival at 1, 5 and 10 years was 100%, 100%, and 95% and 95%, 87% and 84% in the mini-VSARR and sternotomy-VSARR groups, respectively. No repeat interventions on the aortic valve were documented. Echocardiographic follow-up was complete in 91% with excellent durability of repair regardless of the approach: no cases of moderate/severe aortic regurgitation were reported in the mini-VSARR group. Conclusions: The favorable outcomes, reduced drainage, and shorter hospital stays associated with the mini-sternotomy approach underscore its potential advantages expanding beyond cosmetic outcome.

Mini-David procedure. Procedural considerations.

The main goal of minimally invasive surgery is to reduce the perioperative trauma, accelerate patient mobilization and reduce the length of hospital stay. Due to the development of modern technology, these treatments can be offered to a wider group of patients. For many years, aortic root surgery consisted of mechanical conduit implantation and, therefore, necessitated life-long anticoagulation. At present, in patients with aortic root aneurysm and significant aortic valve regurgitation, it is possible to perform minimal-access valve sparing surgical procedures. The current paper is a brief description of the surgical technique for aortic root aneurysm surgery with preservation of the patient's own valve using the David procedure.

Transition from Simple V-V to V-A and Hybrid ECMO Configurations in COVID-19 ARDS.

In SARS-CoV-2 patients with severe acute respiratory distress syndrome (ARDS), Veno-Venous Extracorporeal Membrane Oxygenation (V-V ECMO) was shown to provide valuable treatment with reasonable survival in large multi-centre investigations. However, in some patients, conversion to modified ECMO support forms may be needed. In this single-centre retrospective registry, all consecutive patients receiving V-V ECMO between 1 March 2020 to 1 May 2021 were included and analysed. The patient cohort was divided into two groups: those who remained on V-V ECMO and those who required conversion to other modalities. Seventy-eight patients were included, with fourteen cases (18%) requiring conversions to veno-arterial (V-A) or hybrid ECMO. The reasons for the ECMO mode configuration change were inadequate drainage (35.7%), inadequate perfusion (14.3%), myocardial infarction (7.1%), hypovolemic shock (14.3%), cardiogenic shock (14.3%) and septic shock (7.1%). In multivariable analysis, the use of dobutamine (p = 0.007) and a shorter ICU duration (p = 0.047) predicted the conversion. The 30-day mortality was higher in converted patients (log-rank p = 0.029). Overall, only 19 patients (24.4%) survived to discharge or lung transplantation. Adverse events were more common after conversion and included renal, cardiovascular and ECMO-circuit complications. Conversion itself was not associated with mortality in the multivariable analysis. In conclusion, as many as 18% of patients undergoing V-V ECMO for COVID-19 ARDS may require conversion to advanced ECMO support.

Midterm results of less invasive approach to ascending aorta and aortic root surgery.

BACKGROUND: Minimally invasive aortic valve (AV) surgery has become widely accepted alternative to standard sternotomy. Despite possible reduction in morbidity, this approach is not routinely performed for aortic surgery. Current report aimed to demonstrate early and mid-term outcomes in patients undergoing minimally invasive aortic root- and ascending aorta-replacement with or without concomitant AV replacement (AVR). METHODS: Between 2011 and 2018, 167 selected low- and intermediate risk patients (mean age: 64.1±11.3; 70% men; EuroSCORE II 2.58±3.26) underwent minimally invasive aortic surgery. The "V" shaped partial upper sternotomy was performed through a 6-cm skin incision. Patients were divided into minimally invasive root reimplantation/replacement/remodelling (root RRR), supracoronary aorta replacements (SCAR) and SCAR+AVR. Kaplan-Meier estimates of survival were used. RESULTS: Mean follow-up was 3.1 year (max 7.7 years). Of 167 patients, 82 (49%) underwent SCAR; 44 (26%) SCAR + AVR. Forty-one patients (25%) underwent minimally invasive root RRR. Average aortic diameter was 6.00±0.46 cm. The cardiopulmonary bypass and aortic cross-clamp time were 152.0±46.8 and 101.8±36.8 minutes. There was one conversion to sternotomy. Median intensive care unit stay was 2.0 (IQR: 1.0-3.0) days. Thirty-day mortality was 1%. Within investigated follow-up, there was one late reoperation due to aortic valve thrombosis; late survival was estimated at 95% without differences between types of surgery: hazard ratio, 0.81; 95% CI: 0.36-1.81; P=0.61. CONCLUSIONS: Minimally invasive aortic surgery performed through "V" shaped partial upper sternotomy is feasible and safe in selected patients regardless of the extent of repair, from supracoronary aorta replacements to complex root surgery.

Impact of atrial remodeling on heart rhythm after radiofrequency ablation and mitral valve operations.

BACKGROUND: This study was conducted to determine the effect of left atrial structural remodeling on heart rhythm after radiofrequency ablation concomitant to mitral valve operation. METHODS: Sixty-six consecutive patients with of atrial fibrillation (AF) and mitral valve disease underwent radiofrequency ablation and mitral valve operation. Heart rhythm was evaluated before and at 3, 6, and 12 months postoperatively. Biopsy specimens of the posterior wall of the left atrium were evaluated for the extent of fibrosis, myocyte diameter, intensity of inflammatory infiltrates, degree of myocytolysis, and capillary density. RESULTS: Ten patients died and 1 patient was lost to follow-up. Heart rhythm at 12 months was used to divide the remaining 55 patients into two groups: group I, 34 with sinus rhythm; group II, 21 with AF. Paroxysmal AF preoperatively was more frequent among group I patients, and persistent/long-standing persistent AF in group II (p=0.0006). Groups I and II differed significantly in myocyte diameter (17.9±3.5 vs 20.3±4.6 µm, p=0.04), fibrosis percentage (38.7%±11.2% vs 47.6%±12.3%, p=0.009), inflammatory infiltrates (p=0.02), and preoperative left atrial diameter (5.03±0.7 vs 5.5±0.8 cm, p=0.04). No differences were found in capillary density (797.9±500.6 vs 946.0±373.7/mm2, p=0.3) and myocytolysis (p=0.4). Multivariate analysis showed myocyte diameter (p=0.047) and fibrosis (p=0.014) were independent predictors for an AF persistence at 12 months. CONCLUSIONS: Left atrial structural remodeling strongly affects heart rhythm after concomitant radiofrequency ablation and mitral valve operation.

[Thrombus in transit - two cases of patients with massive pulmonary embolism treated with thrombolysis]. / Thrombus in transit - dwa przypadki masywnej zatorowosci plucnej leczone trombolitycznie.

Two cases of large, free-floating right heart thrombi in patients with massive pulmonary embolism and a history of deep vein thrombosis are presented. In a 30-year-old male with prominent obesity and a history of hypertension, disappearance of the thrombus at the end of alteplase infusion coexisted with onset of haemodynamic stabilization. In a 70-year-old female, the thrombus, which persisted despite streptokinase administration, translocated suddenly (during echocardiography) to the pulmonary artery, which resulted in a deterioration in her status. After alteplase administration following heparin infusion, steady clinical and echocardiographic improvement was observed.

[Surgery for massive pulmonary embolism following coronary angioplasty--a case report]. / Masywna zatorowosc tetnicy plucnej leczona operacyjnie u chorej po angioplastyce wiencowej.

A case of a 49-year-old female with acute coronary syndrome is presented. The patient underwent coronary angioplasty with stent implantation. Due to the recurrence of pain and dyspnea a repeated coronary angiography was performed 3 hours later which confirmed good result of angioplasty. For the next 48 hours a local compression on both femoral arteries was maintained and the patient received full anticoagulant and antiplatelet treatment. However, clinical condition of the patient continued to deteriorate. Echocardiography and spiral computerised tomography revealed the presence of a massive pulmonary embolism. The patient underwent surgery and fully recovered.

[Ear lobe crease as a factor of potential risk for coronary artery disease?--World news review and own research]. / Bruzda platka usznego wskaznikiem potencjalnego zagrozenia choroba wiencowa?--przeglad doniesien swiatowych oraz badania wlasne.

The aim of this study was to define the value of ear-lobe crease as the marker of potential risk of coronary artery disease on the basis of world's reports and own research. The test group consisted of 92 patients who were classified to coronary-artery bypass graft using coronarography. Patients were divided into 3 groups (A-without ELC, B-ELC on one ear, C-ELC bilateral). Detailed statistical analysis of coronarography results and incidence of coronary disease risk factors in each group was done. Obtained data allowed to evaluate the correlation between existence of the crease and extent of atherosclerotic changes in coronary vessels.

[Coronary artery fistula between pulmonary trunk and left descending coronary artery--description of two cases]. / Przetoka miedzy pniem tetnicy plucnej a galezia zstepujaca lewej tetnicy wiencowej--opis 2 przypadków.

Fistulas connecting coronary arteries with trunk of pulmonary artery are the most common congenital defects of coronary arteries. Depending on the size of fistula they cause IHD symptoms of different intensification (Coronary Steal Phenomenon). The symptoms appear very often in advanced age. In this study two patients with coronary-pulmonary artery fistula accompanied by another heart defects (VSD or stenosis of aortic valve), but with no IHD-symptoms, are presented. To find possible coronary arteries malformations, it seems to be useful to perform the catheterization of coronary arteries in all patients, who are qualified for surgical procedure because of heart's disease. It also concerns younger patients with VSD (under 35) in whom coronarography is not a routine procedure.