Lessons learned from the EACTS-MSTCVS quality fellowship: a call to action for continuous improvement of cardiothoracic surgery outcomes in Europe.

The Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS), a pioneer in initiating and nurturing quality improvement strategies in statewide cardiothoracic surgery, has been running the Quality Collaborative (MSTCVS-QC) program since 2001. This initiative has significantly grown over the years, facilitating at least 4 in-person meetings annually. It actively engages cardiac and general thoracic surgeons, data managers and researchers from all 32 non-federally funded cardiothoracic surgery sites across Michigan. Broadening its influence on joint learning and clinical outcomes, the MSTCVS-QC formed a strategic partnership with Blue Cross Blue Shield of Michigan, the state's largest private insurer, to further promote its initiatives. The MSTCVS-QC, operating from a dedicated QC centre employs an STS-associated database with additional aspects for data collection and analysis. The QC centre also organizes audits, facilitates collaborative meetings, disseminates surgical outcomes and champions the development and implementation of quality improvement initiatives related to cardiothoracic surgery in Michigan. Recognizing the MSTCVS-QC's successful efforts in advancing quality improvement, the European Association for Cardiothoracic Surgery (EACTS) introduced a fellowship program in 2018, facilitated through the EACTS Francis Fontan Fund (FFF). This program allows early-career academic physicians to spend 4-6 months with the MSTCVS-QC team in Ann Arbor. This article chronicles the evolution and functionality of the MSTCVS-QC, enriched by the experiences of the inaugural 4 EACTS/FFF fellows. Our objective is to emphasize the critical importance of fostering a culture of quality improvement and patient safety in the field of cardiothoracic surgery with open discussion of audited, high-quality data points. This principle, while implemented locally, has implications and value extending far beyond Europe, resonating globally.

Left subclavian artery coverage during emergent TEVAR in a patient with ipsilateral functional arteriovenous fistula.

Coverage of the left subclavian artery origin is required to achieve adequate proximal seal during up to 40% of TEVAR cases. The evidence regarding left subclavian artery revascularization in patients undergoing elective or emergent TEVAR with left subclavian artery coverage is weak, and there is ongoing debate whether revascularization should be performed routinely of selectively. Beyond this debate, there is a lack of data about left subclavian artery coverage during TEVAR in end-stage renal disease patients with a functional left upper limb atreriovenous fistula. We present the case of a patient with a left distal radiocephalic arteriovenous fistula who underwent emergent TEVAR with left subclavian artery coverage for ruptured type B aortic dissection. The arteriovenous fistula remains functional on a 3-month follow-up, and the patient did not develop symptoms related to posterior stroke, spinal cord ischemia, limb ischemia, or vertebrobasilar insufficiency.

Rare vascular involvement in Behçet's disease: Coronary artery pseudoaneurysm.

Behçet's disease is a relapsing, inflammatory, multi-systemic disease. Coronary arterial involvement in Behçet's disease is very rare with a prevalence of less than 0.5%. We report the case of a 34-year-old man who presented with a coronary artery pseudoaneurysm associated with Behçet's disease. The patient underwent a successful left internal thoracic artery to left anterior descending artery bypass graft procedure, and remains symptom-free in a 6-month follow up with normal electrocardiogram.

Acute upper limb ischemia as a complication of tunneled hemodialysis catheter placement via the right internal jugular vein.

Arterial injury during internal jugular vein cannulation can cause devastating complications such as stroke, hematoma, hemothorax, pseudoaneurysm, AV fistula, or even death. Acute upper limb ischemia caused by inadvertent arterial puncture during internal jugular vein cannulation has been rarely reported. The present report describes the case of a patient who experienced right upper limb ischemia caused by subclavian artery thrombosis developed during attempted placement of a tunneled hemodialysis catheter via the right internal jugular vein. The patient underwent an emergency brachial embolectomy and recovered uneventfully.

Acute Limb Ischemia in Hospitalized COVID-19 Patients.

BACKGROUND: COVID-19 is a multisystemic disorder. Hematologic and cardiovascular involvement of COVID-19 causes thromboembolic events across multiple organs which mainly manifest as venous thromboembolism, and rarely, peripheral arterial thromboembolic events. In-situ thrombosis of a healthy, non-atherosclerotic native artery is rare, and COVID-19 has been reported to be a cause of this phenomenon. We aimed to report our institutional experience with COVID-19 patients who developed acute limb ischemia (ALI) during hospitalization or after discharge. METHODS: This was a single-center cross-sectional study. Records of all patients ≥18 years of age admitted to a tertiary center with a confirmed diagnosis of COVID-19 infection between September 1 and December 31, 2020 were retrospectively examined. Data regarding patient demographics, co-morbidities and outcomes were collected. Patients were followed-up during index hospitalization and for 30 days postdischarge. Acute limb ischemia was diagnosed by means of duplex ultrasound and computed tomography angiography in the presence of a clinical suspicion. RESULTS: A total of 681 consecutive patients (38.5% women) were hospitalized with a confirmed diagnosis of COVID-19 during the study period. Median age was 63 years (IQR, 52-74). In-hospital mortality occurred in 94 (13.8%) patients. Ninety (13.2%) patients required intensive care unit admission at some point of their hospital stay. Six (0.9%) patients (one woman) with a median age of 62 years experienced ALI (IQR, 59-64.3). All patients were receiving low molecular weight heparin when they developed ALI. The median of duration between COVID-19 diagnosis and ALI symptom onset was 13 days (IQR, 11.3-14). Three patients underwent emergent surgical thrombectomy combined with systemic anticoagulation, and 3 received systemic anticoagulation alone. Two patients with ALI did not survive to hospital discharge. Among survivors, 1 patient underwent bilateral major amputations, and another underwent a minor amputation within 1 month of hospital discharge. Symptoms of ALI completely resolved in 2 patients without sequelae. CONCLUSIONS: COVID-19 is a multisystemic disorder with involvement of hematologic and cardiovascular systems. Despite widespread use of thromboprophylaxis, hospitalized patients with COVID-19 are at increased risk of ALI, and subsequent limb loss or even death.

Normoxic management of cardiopulmonary bypass reduces myocardial oxidative stress in adult patients undergoing coronary artery bypass graft surgery.

INTRODUCTION: We aimed to investigate whether normoxic cardiopulmonary bypass would limit myocardial oxidative stress in adults undergoing coronary artery bypass grafting. METHODS: Patients scheduled to undergo elective isolated on-pump coronary artery bypass grafting were randomized to normoxia and hyperoxia groups. The normoxia group received 35% oxygen during anesthetic induction, 35% during hypothermic bypass, and 45% during rewarming. The hyperoxia group received 70%, 50%, and 70% oxygen, respectively. Coronary sinus blood samples were taken prior to initiation of cardiopulmonary bypass and after reperfusion for myocardial total oxidant and antioxidant status measurements. The primary endpoint was myocardial total oxidant status. Secondary endpoints were myocardial total antioxidant status and length of intensive care unit and hospital stay. RESULTS: Forty-eight patients were included. Twenty-two received normoxic management. Mean ± standard deviation of age was 58 ± 9.07 years. Groups were balanced in terms of demographics, risk factors, and operative data. Myocardial total oxidant status was significantly lower in the normoxia group following reperfusion (p = 0.03). There was no statistically significant difference regarding myocardial total antioxidant status and length of intensive care unit and hospital stay (p = 0.08, p = 0.82, and p = 0.54, respectively). CONCLUSIONS: Normoxic cardiopulmonary bypass is associated with reduced myocardial oxidative stress compared to hyperoxic cardiopulmonary bypass in adult coronary artery bypass patients.

Acute limb ischemia in a COVID-19 patient.

Introduction: Acute limb ischemia (ALI) is defined as an abrupt decrease in arterial perfusion of a limb with a threat to viability of the limb. Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2, and has been declared as a global pandemic by the World Health Organization. Patients with COVID-19 have deranged blood coagulation parameters and are prone to thromboembolic events. This hypercoagulable state caused by COVID-19 mainly manifests as venous thromboembolism. Peripheral arterial involvement is less frequent. We present a case of a spontaneous ALI in a COVID-19 patient. Case: A 62-year-old man with an insignificant past medical history presented with ALI 12 days after an initial diagnosis of COVID-19. He was on therapeutic doses of low molecular weight heparin when ischemic symptoms developed. A surgical thrombectomy was unsuccessful. He partially benefited from intravenous unfractionated heparin and iloprost infusions. He was discharged home on postoperative day 14, and is scheduled to have an amputation of the 1st toe. Conclusions: COVID-19 infection is associated with an increased incidence of thromboembolic events, including ALI. Even young and otherwise healthy patients may develop ALI despite the use of prophylactic anticoagulation. Management of ALI in COVID-19 patients might be harder than expected, due to the hypercoagulable state. Patients may benefit from prolonged postoperative unfractionated heparin administration.

Blunt Traumatic Aortic Injury: 10-Year Single-Center Experience.

OBJECTIVE: In blunt trauma patients, injury of the thoracic aorta is the second most common cause of death after head injury. In recent years, thoracic endovascular aortic repair (TEVAR) has largely replaced open repair as the primary treatment modality, and delayed repair of stable aortic injuries has been shown to improve mortality. In light of these major advancements, we present a 10-year institutional experience from a tertiary cardiovascular surgery center. METHODS: Records of patients who underwent endovascular or open repair of the ascending, arch or descending thoracic aorta between January 2009 and December 2018 were retrospectively analyzed. Patients without blunt traumatic etiology were excluded. Perioperative data were retrospectively collected from patient charts. Long-term follow-up was performed via data from follow-up visits and phone calls. RESULTS: A total of 1,667 patients underwent 1,740 thoracic aortic procedures (172 TEVAR and 1,568 open repair). There were 13 patients (12 males) with a diagnosis of blunt thoracic aortic injury. Mean patient age was 43.6 years (range, 16-80 years). Ten (77%) patients underwent TEVAR, two (15.4%) underwent open repair, and one (7.7%) was treated nonoperatively. Procedure-related stroke was observed in one (7.7%) case. Procedure-related paraplegia did not occur in any patients. Left subclavian artery origin was covered in seven patients. None developed arm ischemia. Hospital survivors were followed-up for an average of 60.2 months (range, 4-115 months) without any late mortality, endoleak, stent migration, arm ischemia, or reintervention. CONCLUSION: Blunt thoracic aortic injury is a rare but highly fatal condition. TEVAR offers good early and midterm results. Left subclavian artery coverage can be performed without major complications.

Combined mitral valve replacement and ravitch procedures in a patient with previous pneumonectomy: case report and review of the literature

Abstract Introduction: Significant anatomical and functional changes occur following pneumonectomy. Mediastinal structures displace toward the side of the resected lung, pulmonary reserve is reduced. Owing to these changes, surgical access to heart and great vessels becomes challenging, and there is increased risk of postoperative pulmonary complications. Methods: We performed a mitral valve replacement combined with a Ravitch procedure in a young female with previous left pneumonectomy and pectus excavatum. Results: She was discharged on postoperative day 9 and remains symptom-free 3 months after surgery. Conclusion: Thorough preoperative evaluation and intensive respiratory physiotherapy are essential before performing cardiac operations on patients with previous pneumonectomy.

Causes of Dyspnea after Cardiac Surgery.

OBJECTIVES: Postoperative dyspnea is common after cardiac surgery, even in low-risk patients. Cardiac surgeons and anesthesiologists are familiar with patients suffering from dyspnea in the early postoperative period, but in some cases, conventional treatment strategies may be ineffective, and a consultation with a pulmonologist may be required. The aim of this study is to investigate the causes of dyspnea after cardiac surgery in this particular patient group. MATERIALS AND METHODS: The hospital database was searched for non-emergency cardiac surgery for the period January 2014-October 2015. Individuals with an impaired spirometry result and a history of any pulmonic disease were excluded. Only patients for whom a pulmonary consultation was needed because of dyspnea in the postoperative course were enrolled in the study. Causes of dyspnea were analyzed according to consultation reports and computed tomography findings. RESULTS: One hundred and three patients were enrolled in the study. Of those, 67 (65%) were male, and the mean age was 61.50±9.43. The most common procedure was the coronary artery bypass grafting. Atelectasis (n=57, 42%) was the most common cause of dyspnea. The length of the intensive care unit (ICU) stay was significantly longer in the pneumonia group (p=0.012). Hospital mortality in the pneumonia group was significantly higher compared with other subgroups (p<0.001). CONCLUSION: After cardiac surgery, atelectasis was the most common cause of dyspnea, followed by pleural effusion and pneumonia. Patients who experienced dyspnea due to pneumonia had a longer ICU stay. Developing the treatment strategies with consideration of these causes may help reduce the length of stay, morbidity, and mortality in this patient group.

Combined Mitral Valve Replacement and Ravitch Procedures in a Patient with Previous Pneumonectomy: Case Report and Review of the Literature.

INTRODUCTION: Significant anatomical and functional changes occur following pneumonectomy. Mediastinal structures displace toward the side of the resected lung, pulmonary reserve is reduced. Owing to these changes, surgical access to heart and great vessels becomes challenging, and there is increased risk of postoperative pulmonary complications. METHODS: We performed a mitral valve replacement combined with a Ravitch procedure in a young female with previous left pneumonectomy and pectus excavatum. RESULTS: She was discharged on postoperative day 9 and remains symptom-free 3 months after surgery. CONCLUSION: Thorough preoperative evaluation and intensive respiratory physiotherapy are essential before performing cardiac operations on patients with previous pneumonectomy.

Coronary Artery Fistulae Involving Both Right and Left Coronary Arteries.

A coronary artery fistula is defined as an abnormal direct communication between any coronary artery and any of the cardiac chambers, superior vena cava, coronary sinus, pulmonary artery, and pulmonary veins. The right coronary artery (RCA) is the most common site of origin, and right heart chambers are the most common site of drainage. However, there are few cases reported in the literature in which the fistulae originate from both the right coronary and the left anterior descending arteries and drain into the pulmonary artery. We present a case with fistulae involving both right and left coronary arteries.

Management of Traumatic Aortic and Splenic Rupture in a Patient With Ascending Aortic Aneurysm.

Traumatic aortic rupture is rupture of all or part of the aortic wall, mostly resulting from blunt trauma to the chest. The most common site of rupture is the aortic isthmus. Traumatic rupture of the ascending aorta is rare. A 62-year-old man with a family history of ascending aortic aneurysm was referred to our hospital after a motor vehicle accident. He had symptoms of cardiogenic shock. A contrast-enhanced computed tomographic scan revealed rupture of the proximal ascending aorta and an ascending aortic aneurysm with a diameter of 55 mm at the level of the sinuses of Valsalva. Transthoracic echocardiography at the bedside revealed severe aortic valvular insufficiency. We performed a successful Bentall procedure. During postoperative recovery, the patient experienced a cerebrovascular accident. Transesophageal echocardiography did not reveal thrombosis of the mechanical prosthesis. The patient's symptoms resolved in time, and he was discharged from the hospital on postoperative day 47 without any sequelae. He has been symptom free during a 6-month follow-up period. We suggest that individuals who have experienced blunt trauma to the chest and have symptoms of traumatic aortic rupture and a known medical history of ascending aortic aneurysm should be evaluated for a rupture at the ascending aorta and the aortic isthmus.

Right Sided Aortic Arch Resembling Asthma.

Exertional dyspnoea and shortness of breath at rest are common complaints in asthmatic patients. However, symptoms sometimes do not resolve under optimal medical treatment. In such cases infrequent causes of dyspnoea may be the underlying basis. We present a 38-year-old patient who suffered from shortness of breath not amenable to medical treatment for asthma for five years. In her medical history, the patient was on salbutamol inhalation as well as budesonide/formoterol inhalation for 5 years and the symptoms did not ameliorate. We diagnosed a right sided aortic arch after investigations. In this rare anomaly, both trachea and oesophagus might be encircled and compressed by large vessels as well as the aortic arch. Although some signs of right sided aortic arch can be recognized in chest radiograph and spirometry, accurate diagnosis is made by contrast enhanced computed tomography or angiography. Delay in diagnosis of right sided aortic arch may result in unnecessary investigations and prolonged periods of ineffective treatment. Diagnosis of right sided aortic arch leads to improvement in symptoms and withdrawal of unnecessary treatment.