Surgery of the ascending aorta via a right anterior minithoracotomy: initial surgical experience of a single center.

OBJECTIVES: Full median sternotomy (FMS) is the common surgical access for patients undergoing replacement of the ascending aorta (AA) with or without aortic valve replacement (AVR). The right anterior mini-thoracotomy (RAMT) approach has been increasingly adopted for AVR. This approach has been shown to decrease blood loss and hospital length of stay (LOS) compared with FMS. The RAMT approach may also be beneficial in selected patients requiring AA procedures with or without AVR. We present our initial clinical experience of patients who have undergone a RAMT for supracommissural replacement of the tubular AA with or without AVR. METHODS: This is a single-center retrospective review of 10 patients who underwent an elective RAMT for replacement of the tubular AA with or without AVR between November 2019 and January 2022. Clinical outcomes evaluated include 30-day mortality, intensive care and hospital LOS, time to extubation, operative times, as well as postoperative complications such as stroke and bleeding. RESULTS: Median cross-clamp and cardiopulmonary bypass times were 109 and 148 min, respectively. Median time to extubation was 2.5 h and median intensive care unit and hospital stay were 2 and 10 days, respectively. There were two re-thoracotomies for postoperative bleeding and two cases of sub-xiphoidal pericardial drainage for pericardial effusion. There were no strokes and no in-hospital nor 30-day mortalities. CONCLUSIONS: The replacement of the AA with or without concomitant AVR can be performed through a RAMT in carefully selected patients. However, the safety of this approach, as compared to full/partial median sternotomy, remains to be proven.

Key questions: Can ascending aorta surgery with or without aortic valve replacement be safely performed via right thoracotomy?Key Findings: A good experience of right thoracotomy approach helps performing ascending aorta surgery via that access in carefully selected patients.Take home message: Center with expertise in right thoracotomy can performed ascending aorta surgery through that access in carefully selected patients. However, the safety of this approach, as compared to full or partial median sternotomy, remains to be proven.

Successful heart transplantation from donation after euthanasia with distant procurement using normothermic regional perfusion and cold storage.

While euthanasia has been legalized in a growing number of countries, organ donation after euthanasia is only performed in Belgium, the Netherlands, Spain, and Canada. Moreover, the clinical practice of heart donation after euthanasia has never been reported before. We describe the first case of a heart donated after euthanasia, reconditioned with thoraco-abdominal normothermic regional perfusion, preserved using cold storage while being transported to a neighboring transplant center, and then successfully transplanted following a procurement warm ischemic time of 17 min. Heart donation after euthanasia using thoraco-abdominal normothermic regional perfusion is feasible, it could expand the heart donor pool and reduce waiting lists in countries where organ donation after euthanasia can be performed.

Efficacy of the RemoweLL cardiotomy reservoir for fat and leucocyte removal from shed mediastinal blood: a randomized controlled trial.

INTRODUCTION: Re-transfusion of lipid particles and activated leucocytes with shed mediastinal blood (SMB) can aggravate cardiopulmonary bypass-associated inflammation and increase the embolic load. This study evaluated the fat and leucocyte removal capacity of the RemoweLL cardiotomy reservoir. METHODS: Forty-five patients undergoing elective on-pump cardiac surgery were randomly allocated to filtration of SMB using the RemoweLL or the Admiral cardiotomy reservoir. The primary outcome was a drop in leucocytes and lipid particles obtained with the two filters. The effect of the filters on other blood cells and inflammatory mediators, such as myeloperoxidase (MPO), was also assessed. RESULTS: The RemoweLL cardiotomy filter removed 16.5% of the leucocytes (p<0.001) while no significant removal of leucocytes was observed with the Admiral (p=0.48). The percentage reductions in lipid particles were similar in the two groups (26% vs 23%, p=0.2). Both filters similarly affected the level of MPO (p=0.71). CONCLUSION: The RemoweLL filter more effectively removed leucocytes from SMB than the Admiral. It offered no advantage in terms of lipid particle clearance.

Hydroxyethyl Starch 130/0.4 and the Risk of Acute Kidney Injury After Cardiopulmonary Bypass: A Single-Center Retrospective Study.

OBJECTIVES: To investigate whether using hydroxyethyl starch (HES) 130/0.4 as a pump prime and for intraoperative fluid therapy is associated with postoperative acute kidney injury (AKI) after adult cardiac surgery. DESIGN: Retrospective observational study. SETTING: University hospital, single center. PARTICIPANTS: Six hundred six adult patients who underwent on-pump cardiac surgery between April 2013 and June 2014 were included. INTERVENTIONS: Until July 2013, balanced HES 130/0.4 (Volulyte(®), Fresenius Kabi AG, Bad Homburg, Germany) was used both as a pump prime (1,500 mL) and for intraoperative fluid therapy (1,000 mL). From August 2013, HES was replaced entirely by a balanced crystalloid solution (Plasma-Lyte A, Baxter, Lessines, Belgium). MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the incidence of postoperative AKI during the first 48 postoperative hours, determined using the Acute Kidney Injury Network classification. Secondary outcomes included kidney function at postoperative day 7, postoperative dialysis or hemofiltration, postoperative pulmonary complications, lengths of intensive care unit and hospital stays, postoperative fluid balance and urinary output, surgical revision for bleeding, and 30-day mortality. Multivariable logistic regression was used to adjust for confounders. AKI occurred in 9.5% of crystalloid patients and in 21.5% of HES patients. Patients who received HES were about twice as likely to develop postoperative AKI as those treated with crystalloids (adjusted OR 2.26; 95% CI, 1.40-3.80; p = 0.02). HES patients also had a significantly more positive fluid balance and a lower urinary output during the first 48 postoperative hours. The incidence of surgical revision for bleeding was greater in the HES group (4.6% v 1.4%, p = 0.02). CONCLUSION: This study suggested that using balanced HES 130/0.4 as a pump prime and for intraoperative fluid therapy in adult patients undergoing on-pump cardiac surgery was associated with a greater incidence of AKI during the early postoperative period.

Incidence and outcomes of acute kidney injury after cardiac surgery using either criteria of the RIFLE classification.

BACKGROUND: Adult cardiac surgery is significantly associated with the development of acute kidney injury (AKI). Still, the incidence and outcomes of AKI vary according to its definition. Our retrospective monocentric study comparatively investigates the yield of RIFLE definition, which is based on the elevation of serum creatinine levels (SCr) or the reduction of urine output (UO), taking into account only one or both criteria. Pre- and per-operative risk factors for post-operative AKI were evaluated. METHODS: All adult patients undergoing cardiac surgery, with or without cardiopulmonary bypass, from April 2008 to March 2009 were included. Clinical, biological and surgical features were recorded. Baseline serum creatinine was determined as its value on day 7 before surgery. Post-operative AKI was diagnosed and scored based upon the highest serum creatinine and/or the lowest urine output. RESULTS: 443 patients (Male/Female ratio, 2.3; median age, 69y) were included, with 221 (49.9%) developing postoperative AKI. Elevated serum creatinine (AKISCr) and oliguria (AKIUO) was observed in 9.7% and 40.2%, respectively. AKI patients had a significantly higher BMI and baseline SCr. In comparison to AKIUO, AKISCr mostly occurred in patients with co-morbidities, and was associated with an increased mortality at 1-year post surgery. CONCLUSIONS: The use of standard RIFLE definition of AKI in a cohort of 443 patients undergoing cardiac surgery resulted in an incidence reaching 50%. Still, significant discrepancies were found between AKISCr and AKIUO regarding the incidence and outcomes. In line with previous reports, our data questions the utility of urine output as a criterion for AKI diagnosis and management after cardiac surgery.