Distal Aortic Remodeling after Type A Dissection Repair: An Ongoing Mirage.

Remodeling is a commonly encountered term in the field of cardiothoracic surgery that is often used to describe various pathophysiological changes in the dimension, structure, and function of various cardiac chambers, including the aorta. Stanford type A or DeBakey type 1 aortic dissection (TAAD) is a perplexing pathologic condition that can present surgical teams with the need to navigate a maze of complex decision-making. Ascending or hemi-arch replacement leaves behind a significant amount of distal diseased aortic tissue, which might have a persistent false lumen or primary or secondary intimal tears (or communications between lumina), which can lead to dilatation of the aortic arch. Unfavorable aortic remodeling is a major cause of distal aortic deterioration after the index surgery. Cardiac surgeons are aware of post-surgical cardiac chamber remodeling, but the concept of distal aortic remodeling is still idealized. The contemporary literature from established aortic centers supports aggressive management of the residual aortic pathology during the index surgery, and with continuing technical advancements, endovascular stenting options are readily available for patients with TAAD or for complicated type B aortic dissection cases. This review discusses the pathophysiology and treatment options for favorable distal aortic remodeling, as well as its impact on mid- to long-term outcomes following TAAD repair.

Risk stratification using serum lactate in patients undergoing surgical pulmonary embolectomy.

BACKGROUND: Surgical pulmonary embolectomy (SPE) has been around since the early days of cardiac surgery. But with the increase in thrombolytic and intervention options, indications of SPE have been limited. Literature suggests that risk stratification has been a key step in getting good results. We are analyzing serum lactate levels for risk stratification in massive and submassive pulmonary embolism (PE). METHODS: This study is a retrospective analysis of 82 cases that underwent SPE between January 1997 and January 2020. Patients were divided into two groups stratified by venous serum lactate levels on the first admission (Group I: normolactatemia <2 mmol/L, Group II: hyperlactatemia, >2 mmol/L). Primary endpoints were all-cause in-hospital mortality and secondary endpoints were cardiopulmonary bypass time, extracorporeal membrane oxygenator (ECMO) insertion, low cardiac output, blood product use, and right ventricular functions in the follow-up. RESULTS: Our study had an overall follow-up of 23 years with a median of 3.18 years. Overall, the in-hospital mortality rate was 8.54%. Group II had a higher mortality rate (P = .015) and morbidity incidences like cardiopulmonary bypass time (P = .008), ECMO insertion (P = .036), and open chest after surgery (P = .015). Although 5-year survival was better in group I a compared to group II (81%, 95% CI, 69%-93% vs 65%, 95% CI, 46%-84%), the log rank test showed no statistical survival difference among both groups on long-term follow-up. CONCLUSIONS: Long term survival after SPE is good and these results can further be improved by proper PE risk stratification. Alongside computed tomography and echocardiography, the importance of biomarkers like serum lactate can be explored in the PE management algorithm.

Spindle cell lipoma of the aortic valve: a rare cardiac finding.

INTRODUCTION: A 64-year-old female presented with a 2-year history of worsening angina. METHODS: Subsequent investigations revealed aortic valve tumor. The patient had history of hypertension, coronary artery disease, atrial fibrillation, hyperlipidemia, and hyperthyroidism. The patient was nondiabetic, nonsmoker, and had marfanoid features. RESULTS: The tumor was excised, and aortic valve replacement was done using partial sternotomy (minimally invasive). Histology was suggestive of spindle cell lipoma of the aortic valve. DISCUSSION: Although lipomas have benign pathology and slow growth, they warrant surgical excision in view of possible fatal complications.

"Pulmonary slit" procedure for preventing tension on the left internal thoracic artery graft.

The gold-standard bypass graft to the left anterior descending coronary artery is the left internal thoracic artery harvested with its pedicle. At times, however, the length of the internal thoracic artery is insufficient for distal anastomosis. Different methods of lengthening the internal thoracic artery or of reducing the distance to the anastomosis site have been described, but at times even these may be inadequate. In order to extend the benefits of the left internal thoracic artery graft to more patients, we perform the "pulmonary slit" procedure as described here.

Novel strategies for recurrent cardiac myxoma.

A 21-year-old man presented with a stroke. Subsequent investigations revealed cardiac tumors in his left atrium and right ventricle. These were removed by conventional techniques. Histopathology confirmed them as myxomas. He had a complete neurologic recovery, but presented 2 years later with recurrence of a cardiac myxoma in his left ventricle and left atrium. This time, however, endoscopically assisted techniques were used. The tumor was excised with supplementary cryoablation. The patient made a quick recovery from this second procedure and has had no recurrence after a 1-year follow-up.

Aortic regurgitation with ventricular septal defect in the young.

This study was carried out to assess the outcome in patients who had aortic valve replacement compared to those who underwent aortic valve repair for aortic regurgitation associated with a ventricular septal defect. Of 300 patients undergoing ventricular septal defect closure between May 1990 and December 2003, 36 (12%) had moderate to severe aortic regurgitation; 7 underwent concomitant aortic valve repair and 29 had aortic valve replacement. The mean age of these 36 patients was 17.72 +/- 6.84 years, and 69% were male. Follow-up was 8.20 +/- 4.97 years in the valve replacement group and 4.1 +/- 0.8 years in the valve repair group. The freedom from re-operation after valve repair was 76% after 4 years. After one year of follow-up in 35 patients, 27 were in New York Heart Association class I (77%) and 8 were in class II (23%). After 8 years, 12/21 (57%) patients were in class I, 5 (24%) in class II, and 2 (10%) in class III. Of 22 patients who had a dilated left ventricle, 15 regained normal left ventricular function and volume. Valve repair is preferred, but increasing age makes valve replacement a better alternative.