A Strategy for Minimizing Circulatory Arrest Duration in Complex Aortic Arch Procedures.

Background and Objectives: Aortic arch pathologies represent a surgical challenge. The challenge is partly due to the necessity of complex cerebral, visceral, and myocardial protection measures. Aortic arch surgery generally requires a significant duration of circulatory arrest, which includes deep hypothermia levels with the associated sequelae. This retrospective observational study shows the feasibility of a strategy that reduces circulatory arrest duration and eliminates the need for deep hypothermia during the procedure. Materials and Methods: Between January 2022 and January 2023, 15 patients (n = 15) with type A aortic dissection underwent total arch replacement with a frozen elephant trunk. Cardiopulmonary bypass and organ perfusion were established via arterial lines in the right axillary artery and one of the femoral arteries. In the latter vessels, a y-branched arterial cannula was used (ThruPortTM), allowing for endo-clamping of the stent part of the frozen elephant trunk with a balloon and subsequent perfusion of the lower body. Results: Applying this modified perfusion technique, circulatory arrest time could be reduced to a mean of 8.1 ± 4.2 min, and surgery was performed at a mean lowest body temperature of 28.9 ± 2.3 °C. The mean ICU and hospital stays were 18.3 ± 13.7 days and 23.8 ± 11.7 days, respectively. The rate for 30-day survival was 100%. Conclusions: By applying our modified perfusion technique, the circulatory arrest duration was below ten minutes. As a consequence, deep hypothermia could be avoided, and surgery could be performed at moderate hypothermia. Future studies will have to show whether these changes may be translated into a clinical benefit for our patients.

Conduction Disorders after Surgical Aortic Valve Replacement Using a Rapid Deployment Aortic Valve Prosthesis: Medium-Term Follow-Up.

BACKGROUND: We have previously reported that the incidence of postoperative conduction disorders, especially left bundle branch block (LBBB), after implantation of a rapid deployment Intuity™ Elite aortic valve prosthesis (Edwards Lifesciences, Irvine, CA, USA), was significantly increased compared with conventional aortic valve replacement. We were now interested in how these disorders behaved at intermediate follow-up. METHODS: All 87 patients who had undergone surgical aortic valve replacement (SAVR) using the rapid deployment Intuity™ Elite prosthesis and were shown to have conduction disorders at the time of hospital discharge were followed up after surgery. These patients' ECGs were recorded at least 1 year after surgery, and the persistence of the new postoperative conduction disorders was assessed. RESULTS: At hospital discharge, 48.1% of the patients had developed new postoperative conduction disorders, with LBBB being the predominant conduction disturbance (36.5%). At medium-term follow-up (526 days, standard deviation (SD) = 169.6, standard error (SE) = 19.3 days, respectively), 44% of the new LBBB and 50% of the new right bundle branch block (RBBB) had disappeared. There was no new atrio-ventricular block III (AVB III) that occurred. One new pacemaker (PM) was implanted during follow-up because of AVB II Mobitz type II. CONCLUSIONS: At medium-term follow-up after the implantation of a rapid deployment Intuity™ Elite aortic valve prosthesis, the number of new postoperative conduction disorders, especially LBBB, has considerably decreased but remains high. The incidence of postoperative AV block III remained stable.

Postoperative ST-segment elevation caused by mechanical compression of the native right coronary artery by a pericardial drainage tube.

ST-segment elevation is often the first remarkable sign of postoperative cardiac ischaemia. It requires prompt diagnostic measures and an early treatment to improve the patient's outcome. We describe a case of early postoperative ST-segment elevation due to mechanical compression of the native right coronary artery by a pericardial drainage tube in a patient after replacement of the ascending aorta.

Coronary Anastomosis In Stent-Useful to Do When No Other Alternative Is Given?

Background Many patients being referred for coronary artery bypass grafting have a history of percutaneous coronary intervention (PCI). Case Description In a patient after multiple PCI of the left anterior descending artery (LAD), repeated in-stent stenosis was diagnosed. The LAD being covered with stents to the periphery, no meaningful anastomosis with stent-free vessel was possible. After thorough discussion with the patient, the referring cardiologist, and our local heart team, an in-stent anastomosis was planned and created, that was found to be angiographically patent 21 months after surgery with the patient free from angina. Conclusion Without any alternative treatment method given, our approach of in-stent anastomosis confers a good mid-term angiographic result.

Tricuspid valve repair in acute endocarditis in a young patient with active IV drug abuse.

Right-sided infective endocarditis is common in patients who use intravenous drugs. However, even when leaflets are heavily damaged as a result of the endocarditis, an attempt of valve repair is worth a try. Tricuspid valve repair is superior to valve replacement because it is associated with  a lower rate of recurrence and reoperation.

New postoperative conduction abnormalities after the implantation of a rapid-deployment aortic valve prosthesis.

OBJECTIVES: Sutureless and rapid-deployment aortic valves have enlarged the selection of prostheses available for surgical aortic valve replacement. However, the rate of postoperative pacemaker implantation seems to have increased. METHODS: In addition to pacemaker implantation, we were interested in the incidence of new postoperative conduction abnormalities, namely left bundle branch block, right bundle branch block and atrioventricular block III after the implantation of the EDWARDS INTUITY Elite™ sutureless prosthesis. All patients undergoing isolated or concomitant surgical aortic valve replacement between May 2014 and May 2017 were included in the study. RESULTS: Two hundred patients were operated on. Of them, 14 patients dropped out because of concomitant endocardial or epicardial ablation or because of septal myectomy. Three more patients dropped out because the treatment was converted to conventional aortic valve replacement, and 183 patients remained. At the time of discharge from hospital, 38.1% of the 183 patients had new left bundle branch block, 2.5% of patients had new right bundle branch block and 9.6% had atrioventricular block III requiring either a pacemaker or defibrillator. The postoperative mean transvalvular gradient over the prosthesis was 8.4 ± 3.4 mmHg, the occurrence of paravalvular leakage more than trivial was 1% and hospital mortality was 3.3%. CONCLUSIONS: The incidence of new postoperative conduction abnormalities is considerable with the EDWARDS INTUITY Elite rapid-deployment aortic valve prosthesis. We will focus our future research on the follow-up of patients with postoperative left bundle branch block, which was the most frequently observed form of new conduction abnormality.

Massive Left Atrial Thrombus in Two Patients with Heparin-Induced Thrombocytopenia Type II after Cardiac Surgery.

Heparin-induced thrombocytopenia type II (HIT type II) can have devastating consequences in cardiac surgical patients. We report two cases of massive left atrial thrombus after mitral valve replacement and endocardial cryoablation in patients with HIT type II.

Severe aortic regurgitation after implantation of a sutureless valve prosthesis using an automatic knot fastener device.

We report the case of severe aortic regurgitation 8 months after implantation of a 25-mm sutureless pericardial aortic valve prosthesis. On echocardiography, the regurgitation was suspected to be paravalvular. The sutureless prosthesis had been implanted using an automatic knot fastener device, which renders the suture tails less pliable because of the metal clip that is crimped around the suture. The patient was reoperated, a paravalvular leak was not observed. The sutureless prosthesis was explanted and a conventional biologic valve prosthesis was implanted instead. On examination of the explanted valve prosthesis, a perforation was observed in one of the leaflets. The leaflet perforation was in alignment with one of the knots produced by the automatic knot fastener. Obviously, the leaflet had hit the knot repeatedly which had caused the perforation. We conclude that knots produced by an automatic fastener device have the potential to cause leaflet perforation.

Evolution of a minimally invasive mitral valve program.

Minimally invasive valve surgery is evolving into a procedure of choice in the treatment of mitral regurgitation (MR). Visualization techniques have improved vastly over the past decades. With the use of 3D technology rib retractors can be avoided, incision size has come down to a minimum without reducing and even improving the surgeons view.