Periareolar Incision for Endoscopic Cardiac Surgery: How to Do It?

Minimally invasive cardiac surgery (MICS) has demonstrated its efficacy in diminishing postoperative pain, accelerating early recovery, and facilitating a prompt return to daily activities. Notably, the periareolar incision has gained prominence owing to its superior cosmesis. This article elucidates the procedural details for implementing periareolar incision access in MICS and providing insights into its technique and applications.

Intercostal Lung Hernias Presenting After Minimally Invasive Cardiac Surgery.

INTRODUCTION: With the introduction of minimally invasive cardiac surgery, more commonly cases of lung herniation are starting to appear. Acquired lung hernias are classified as postoperative, traumatic, pathologic, and spontaneous. Up to 83% of lung hernias are intercostal. Herein, we describe patients presenting with intercostal lung hernias following minimally invasive cardiac surgery at a single center in Medellín, Colombia. METHODS: We conducted a retrospective search of all patients presenting with intercostal lung hernias secondary to minimally invasive cardiac surgery at our clinic in Medellín since the beginning of our program, from 2010 to 2022. Mini-sternotomies were excluded from our study. We reviewed the incision type and other possible factors leading to intercostal lung hernia development. We also describe the approach taken for these patients. RESULTS: From 2010 up until 2022, 803 adult patients underwent minimally invasive cardiac surgeries through a mini-thoracotomy. At the time of data retrieval, nine patients presented with intercostal lung hernias at the previous incision site. Five hernias (55%) were from right 2nd intercostal parasternal mini-thoracotomies for aortic valve surgeries. Four hernias (45%) were from right 4th intercostal lateral mini-thoracotomies for mitral valve surgeries. Our preferred repair technique is a video-assisted thoracoscopic mesh approach. CONCLUSION: Minimally invasive cardiac surgical approaches are becoming more routine. Proper wound closure is critical in preventing lung hernias. Additionally, timely diagnosis and opportune hernia surgery using video-assisted thoracoscopic mesh repair can prevent further complications.

Emergency laparotomy and endoscopic gastrostomy in patients on extra-corporeal membrane oxygenation (ECMO) support.

INTRODUCTION: An infrequent yet known complication of ECMO is abdominal compartment syndrome requiring emergency laparotomy. Also, the need for prolonged enteral nutrition while on ECMO may require endoscopic gastrostomy to maintain adequate nutritional status. Here we describe our experience with emergency laparotomy and endoscopic gastrostomy in patients on ECMO support. METHODS: We retrieved patient histories from our clinical archives and performed a retrospective description of all patients taken to an emergency laparotomy or endoscopic gastrostomy while on ECMO support at our cardiovascular referral center from July 2019 through June 2024. RESULTS: During the research period of 5 years a total of 401 patients were placed on ECMO support for either cardiogenic shock or respiratory failure. A total of 27 (7%) patients required an abdominal intervention while on ECMO. 14 (3.5%) patients required emergency laparotomy and 13 (3.2%) of patients required endoscopic gastrostomy tube placement. Overall 30-day mortality of all patients requiring a general surgery procedure while on ECMO support was 33%. CONCLUSION: ECMO support can result in many complications despite its many benefits. Patients who require emergency laparotomy while on ECMO have lower survival-to-discharge and higher mortality at 30 days. Endoscopic gastrostomy however, can be safely performed on ECMO with little to no bleeding complications despite anticoagulation.

Cardiothoracic surgery training in Africa: History and developments.

Objective: Cardiovascular disease is the leading cause of death globally, responsible for 17.5 million deaths each year, 80% of which occur in low- and middle-income countries, including countries in Africa. Cardiothoracic surgery, with its heavy financial outlay, is unavailable in many African countries. Many African healthcare givers are under the erroneous impression that the cardiovascular surgical landscape of Africa is blank. This review aims at describing the cardiothoracic surgery practice in Africa, the different training programs in the region, and its future prospects. Method: Through a literature review, the authors elaborate on key points, such as healthcare and cardiothoracic surgery in Africa, African cardiothoracic practice and training, and the future of cardiothoracic surgery in Africa. Results: African countries with established cardiothoracic surgery capacity and training programs still face several challenges across multiple levels, including a persistent low enrollment rate in residency programs, insufficient local expertise, a lack of financial resources, an inadequate health infrastructure, and a skewed health insurance reimbursement system. Thus, there is still a growing burden of surgically correctable cardiovascular disease in these countries. Conclusions: Cardiothoracic surgery in Africa has faced great challenges due to resource constraints, but it has demonstrated resilience and growth through diverse models and initiatives. The burden of cardiovascular diseases in Africa remains high, yet the capacity to provide cardiothoracic surgery is limited. With investment, support, and the implementation of comprehensive healthcare policies, cardiothoracic surgery practice can improve in this region and this can make a significant impact on the health and well-being of its population.

Low-Cost Innovations in Global Cardiac Surgery.

Cardiovascular diseases are the leading cause of morbidity and mortality worldwide, costing the lives of 18 million people annually, with up to one-third being attributable to cardiac surgical conditions. Approximately 6 billion people do not have access to safe, timely, and affordable cardiac surgery, predominantly affecting populations living in low-middle income countries. Cardiac surgical care is costly, resulting in few centers in variable-resource contexts operating continuously or with the resources observed in higher-resource environments. As a result, innovations may be formally developed or informally adopted to bypass resource constraints and ensure care delivery. Innovations have been observed across the cardiac surgical care continuum and across settings, potentially benefiting both high-income countries, where growing health care costs are becoming unsustainable, and low- and middle-income countries, where competing health agendas may limit investments into cardiac surgery. This narrative review attempts to address the costs associated with cardiac surgery, placing an emphasis on frugal innovations in the perioperative and postoperative care spectrum.

Twenty-five Years of Lung Transplantation in Medellín: Overcoming the Challenges of an Emerging Country.

The first successful lung transplant in Colombia was performed on October 28, 1997 in Medellín by Alberto Villegas Hernández at the "Clínica Cardiovascular Santa María" today called the Cardio VID Clinic. Here we present both survival outcomes and characteristics of the oldest and most experienced lung transplant program in Colombia. We conducted a retrospective study of all patients taken to lung transplantation at the Cardio VID Clinic in Medellín, Colombia from October 1997 to October 2022. Patient information from our institutional database and transplant archives were retrieved and reviewed. From October 1997 to October 2022, a total of 153 patients underwent orthotopic lung transplantation at our institution in Medellín, Colombia. Mean recipient age was 48±13 years, the youngest patient was 15 years old and the oldest patient was 73 years old at the time of transplant. 74 (48,4%) patients were men and 79 (51,6%) were women. Lung transplant survival in Medellin at 1-month, 1-year, 5-years and 10-years were 68%, 50%, 31% and 12% respectively. Although health care coverage in Colombia reaches nearly 100%, socioeconomic hurdles during post-transplant care, non-returning patients, infections and traumatic donor deaths lead to high mortality rates. Due to these factors, establishing successful and sustainable lung transplant programs in these settings is challenging.

Extra-corporeal membrane oxygenation and emergency C-section for a pregnant COVID-19 positive patient.

INTRODUCTION: Data on extra-corporeal membrane oxygenation (ECMO) therapy for pregnant patients with Coronavirus 2019 (COVID-19) infection are limited. Here we report a case of an emergency cesarean section performed while the COVID-19 positive mother was on ECMO support. CASE REPORT: A 36-year-old COVID-19 positive patient at 26 weeks gestational age presented with respiratory failure requiring extra-corporeal membrane oxygenation therapy. Nine days later fetal distress demanded an emergency C-section. After 5 weeks on ECMO, the patient was weaned off. Both mother and child were discharged. DISCUSSION: The decision to perform an urgent C-section is one that requires meticulous thought from the attending team. Pulmonary maturation is key as pregnancy may need to be terminated at any time during ECMO. CONCLUSION: Data on ECMO support for pregnant patients with COVID-19 infection are scarce. Best results can be achieved ensuring adequate anticoagulation, meticulous choice of cannulas, continued fetal monitoring, early lung maturation, and precision timing of delivery.

Cardiovascular Surgery in Panama: Evolution and Training.

Cardiovascular surgery in Panama has depended on constant contributions and support from other developed countries. Although cardiac surgery has reached important milestones, cardiac surgery training is still evolving. Here, we provide a look into both the development and training of cardiac surgery in the Republic of Panama and the importance of international training.

MitraClip as bridge to mitral valve replacement in the setting of ischemic cardiogenic shock and papillary muscle rupture.

MitraClip implantation has been reported in severe mitral regurgitation following ischemic papillary muscle rupture in surgically high-risk patients with cardiogenic shock. Here we present a case of a 68-year-old female patient who suffered an ischemic papillary muscle rupture resulting in severe mitral prolapse and had a MitraClip implanted. Three months later, due to progressive symptoms, she was taken to surgery and had an elective minimally invasive mitral valve replacement. Informed consent was given and ethics board approval was obtained.

Miniature Minimally Invasive Pulmonary Banding in Neonates (MINI-MICS): A Novel Technique.

Single-ventricular cardiopathies are challenging conditions requiring multiple surgical interventions to hopefully achieve adulthood. In neonates, pulmonary artery banding allows ventricular adaptation and pulmonary vascular bed protection. Here we present a novel minimally invasive approach to pulmonary artery banding through a 1.5 cm left parasternal minithoracotomy. This technique not only allows for a less traumatic first procedure but also a less manipulated mediastinum and untouched sternum for the consequent surgeries to come. This technique is reproducible in experienced hands and shows favorable and promising results when performed properly.

MitraClip as bridge to mitral valve replacement in the setting of ischemic cardiogenic shock and papillary muscle rupture.

MitraClip implantation has been reported in severe mitral regurgitation following ischemic papillary muscle rupture in surgically high-risk patients with cardiogenic shock. Here we present a case of a 68-year-old female patient who suffered an ischemic papillary muscle rupture resulting in severe mitral prolapse and had a MitraClip implanted. Three months later, due to progressive symptoms, she was taken to surgery and had an elective minimally invasive mitral valve replacement. Informed consent was given and ethics board approval was obtained.

Bench bioprosthetic aortic valve replacement in a donor heart before transplantation.

Critical donor shortages have impulsed the need to expand donor heart eligibility through the use of marginal hearts in cardiac transplantation. Donor valvular disease has been considered as an absolute contraindication for transplant. A 39-year-old male patient with end-stage non-compaction cardiomyopathy, an INTERMACS II heart failure, and a left ventricular ejection fraction of 8% was taken to an orthotopic heart transplantation. During donor bench graft examination, a congenital bicuspid and calcified aortic valve was found. The native bicuspid valve was removed and the annular calcification debrided; a #21 bioprosthetic aortic valve was then implanted.

Peri-operative nutrition in cardiovascular surgery: current pitfalls and future directions.

In the field of cardiovascular surgery, many areas are frequently evaluated to improve patient outcomes. Even though cardiac surgery has advanced significantly, peri-operative nutrition remains an area needing special attention and is under-considered in patient results. The three portions of cardiac surgical nutrition optimization are pre-operative, intra-operative and post-operative. All these, merit important clinical intervention which when done properly can significantly improve patient recovery and reduce morbidity and mortality. Here we provide a narrative review and recommendations for peri-operative nutritional optimization in cardiac surgery.

Cardiothoracic Surgery in the Caribbean

Abstract Introduction: Despite being one of the main vacation destinations in the world, health care in the Caribbean faces many difficulties. The challenges involved in these islands' medical care range from low-resource institutions to lack of specialized care. In the field of thoracic and cardiac surgery, many limitations exist, and these include the lack of access to cardiac surgery for many small islands and little governmental funding for minimally invasive approaches in thoracic surgery. Methods: Literature review was done using PubMed/MEDLINE and Google Scholar databases to identify articles describing the characteristics of thoracic and cardiac surgery departments on Caribbean islands. Articles on the history, current states of practice, and advances in cardiothoracic surgery in the Caribbean were reviewed. Results: Regardless of the middle to high-income profile of the Caribbean, there are significant differences in the speed of technological growth in cardiothoracic surgery from island to island, as well as disparities between the quality of care and resources. Many islands struggle to advance the field of cardiothoracic surgery both through lack of local cardiac surgery centers and limited financial funding for minimally invasive thoracic surgery. Conclusions: Cardiac and thoracic surgery in the Caribbean depend not only on the support from local government policies and proper distribution of healthcare budgets, but efforts by the surgeons themselves to change and improve institutional cultures. Although resource availability still remains a challenge, the Caribbean remains an important region that deserves special attention with regard to the unmet needs for long-term sustainability of chest surgery.

Video-Assisted Thoracoscopy For Penetrating Cardiac Box Injury in Stable Patients

Abstract Introduction: In high-volume trauma centers, especially in developing countries, penetrating cardiac box injuries are frequent. Although many aspects of penetrating chest injuries have been well established, video-assisted thoracoscopy is still finding its place in cardiac box trauma and algorithmic approaches are still lacking. The purpose of this manuscript is to provide a streamlined recommendation for penetrating cardiac box injury in stable patients. Methods: Literature review was carried out using PubMed/MEDLINE and Google Scholar databases to identify articles describing the characteristics and concepts of penetrating cardiac box trauma, including the characteristics of tamponade, cardiac ultrasound, indications and techniques of pericardial windows and, especially, the role of video-assisted thoracoscopy in stable patients. Results: Penetrating cardiac box injuries, whether by stab or gunshot wounds, require rapid surgical consultation. Unstable patients require immediate open surgery, however, determining which stable patients should be taken to thoracoscopic surgery is still controversial. Here, the classification of penetrating cardiac box injury used in Colombia is detailed, as well as the algorithmic approach to these types of trauma. Conclusion: Although open surgery is mandatory in unstable patients with penetrating cardiac box injuries, a more conservative and minimally invasive approach may be undertaken in stable patients. As rapid decision-making is critical in the trauma bay, surgeons working in high-volume trauma centers should expose themselves to thoracoscopy and always consider this possibility in the setting of penetrating cardiac box injuries in stable patients, always in the context of an experienced trauma team.