Cannulation strategies for acute type A dissection-role of central cannulation.

OBJECTIVES: The purpose of this study was to assess the safety and efficacy of direct cannulation of the ascending aorta in comparison with cannulating peripheral arteries. METHODS: We retrospectively analysed type A dissection patients [n = 107; median (interquartile range [IQR]) age, 64 [53-73] years] from January 2008 to March 2018. The cohort was divided into 2 groups: direct ascending aorta cannulation (group A, n = 47; median [IQR] age, 69 [54-74] years; 34% female) and non-aortic cannulation (group B, n = 60; median [IQR] age, 62 [52-72] years; 20% female). Postoperative outcomes and long-term survival were compared. RESULTS: Baseline characteristics were not significantly different between the 2 groups, except for higher creatinine in group B (median 0.9 vs 1.1, P = 0.028) and higher prevalence of dyslipidaemia in group A (58.7% vs 38.3%, P = 0.037). Overall early mortality was 12.1% (n = 13); 12.8% (n = 6) in group A and 11.7% (n = 7) in group B (P = 0.863). The incidence of stroke was 10.6% (n = 5) in group A and 6.7% (n = 4) in group B (P = 0.463). After adjusting for CPB and circulatory arrest times, there was no group difference in the length of ICU (P = 0.257) or hospital stay (P = 0.118), all-cause reoperation (P = 0.709), peak postoperative creatinine (P = 0.426) and lactate values (n = 60; P = 0.862). Overall survival at 1, 3 and 5 years was 84%, 78% and 73%, respectively, with no difference between the 2 groups after adjustment (P = 0.629). CONCLUSIONS: Direct cannulation of the ascending aorta is a safe cannulation strategy for type A dissection repair, offering the opportunity for rapid arterial cannulation and antegrade perfusion.

Long-term survival following postoperative myocardial infraction after coronary artery bypass surgery.

BACKGROUND: Postoperative myocardial infraction (MI) is a serious complication among patients undergoing Coronary Artery Bypass Grafting (CABG). Data on the impact of postoperative MI on patients undergoing CABG, specifically with respect to their long term outcomes are sparse. METHODS: We retrospectively analyzed all patients who underwent isolated CABG between January 2014 and December 2016 and identified those who fulfilled the definition of the type 5MI following CABG according to the Fourth Universal Definition of Myocardial Infarction. RESULTS: A total of 4,642 CABG patients were identified, of whom 141 (3.04%) were diagnosed with postoperative MI. The mean follow-up time was 5.1±2.07 years (range, 4.4-6.9 years). Postoperative MI was more common in patients with recent acute coronary syndrome, when compared to stable angina (22.8% vs. 31.9%; P=0.011) and in those with non-elective versus planned surgery (28.4% vs. 18.4%; P=0.003). Postoperative MI after CABG was associated with an increased rate of postoperative complications, including cardiac tamponade and re exploration for bleeding. Mortality after postoperative MI was higher at short-term follow-up (up to one year) and long-term follow-up (up to five years). The risk factors for postoperative MI after CABG were incomplete revascularization (IR) [OR (95% CI): 2.25 (1.59-3.12), P=0.001], non-elective surgery [OR (95% CI): 1.68 (1.10-2.54), P=0.015] and female gender [OR (95% CI): 1.48 (1.01-2.18), P=0.045]. CONCLUSIONS: PMI after CABG is associated with reduced short- and long-term survival. The main risk factors for postoperative MI are IR, female gender, and non-elective surgery.

Endoscopic Robotic Retrieval of a Migrated Subclavian Vein Stent from the Right Ventricle.

A 54-year-old woman with end-stage renal disease on hemodialysis with access through a right arm arteriovenous fistula presented with right arm swelling. Venography demonstrated right subclavian vein stenosis. A balloon angioplasty of the stenotic vein was unsuccessful, and she subsequently underwent stent placement with balloon angioplasty. Ten days following the procedure, she developed acute shortness of breath. Transthoracic echocardiogram demonstrated the migration of the venous stent into the right ventricle. Using an endoscopic robotic approach, the stent was successfully extracted from the beating heart.

Central Partial Bypass Management Technique for Distal Arch Surgery.

Circulatory arrest and left heart bypass are the most common approaches to manage perfusion during distal arch surgery. We report a novel perfusion technique utilized in the treatment of aneurysmal Komerrell's diverticulum (KD) and aberrant subclavian artery (ASA) that allows for a reliable conduct of perfusion. From 2016 to 2020, 12 adult patients with aneurysmal KD and ASA underwent repair of distal arch through lateral thoracotomy ipsilateral to the arch side using central partial bypass. Once the patients were fully heparinized the lower thoracic aorta and the right atrium were cannulated. The cannulas were connected to the cardiopulmonary bypass (CPB) circuit with an oxygenator. Partial bypass was initiated. Ventilation via anesthesia was continued as the mode of gas exchange to the upper body while the CPB circuit provided gas exchange to the lower body. In all patients, CPB was initiated allowing the patient to maintain a mean arterial pressure >60 mmHg in the femoral artery and a mean arterial pressure (MAP) >80 mmHg in the radial artery to allow adequate native ejection into the proximal circulation. The venous line was partially occluded to control the radial pressure. The aorta was cross clamped proximal and distal to the KD to isolate the aorta to be replaced. KD was excised in all patients having performed contralateral subclavian to carotid transposition previously. Once the aorta was reconstructed, clamps were released and the patients were weaned off CPB. All were extubated on the same day and there was no early mortality.

Aortopathy in tetralogy of Fallot-a collective review.

The pathophysiology of aortic diseases in Tetralogy of Fallot has been analyzed in various studies, focusing on the histopathology of the aortic root, altered hemodynamics, and effect of early corrective repair on the incidence of aortic root dilatation. In this review article, we sought to integrate these studies for a better understanding of the natural history and practical implications of aortic root dilatation in Tetralogy of Fallot. This better equips us to appropriately implement potentially effective interventions.

Bentall’s Procedure in Pediatric Mixed Connective Tissue Disease Syndrome: Management of Pediatric Aortic Aneurysm - A Brief Review.

Mixed connective tissue disease (MCTD) syndrome in children may lead to large aortic aneurysms, which in turn pose a difficult surgical problem. Valve-sparing root replacement is not always a viable option as the disease process invariably affects the aortic valve leaflets. Among pediatric patients, the Ross procedure is contraindicated on account of weakness of the pulmonary root, while Bentall surgery is the 'gold standard' treatment of aortic aneurysm, with reproducible and excellent long-term results. The case is presented of a three-year-old girl with a large thoracic aortic aneurysm in whom Bentall's surgery was performed, with a good result. The present patient, with MCTD syndrome, was too young to have undergone aortic root replacement with a composite mechanical valved graft.