Safe cross-clamp time using Custodiol®-histidine-tryptophan-ketoglutarate cardioplegia in the adult.

INTRODUCTION: Safe cross-clamp time using single-dose Custodiol®-histidine-tryptophan-ketoglutarate cardioplegia has not been established conclusively. METHODS: Immediate post-operative outcomes of 1,420 non-consecutive, cardiac surgery patients were reviewed retrospectively. Predictors of a combined endpoint made of in-hospital mortality and any major complication post-surgery were found with the multivariable method. Analysis of variance was used to evaluate the impact of cross-clamp time on most relevant complications. Discriminatory power and cut-off value of cross-clamp time were established for in-hospital mortality and each of the major complications (receiver operating characteristic curve analysis). A comparative analysis (with propensity matching) with multidose cold blood cardioplegia on in-hospital mortality post-surgery was performed in non-coronary surgery patients. RESULTS: Coronary, aortic valve and mitral valve surgery and surgery on thoracic aorta were performed in 45.4%, 41.9%, 49.5%, 20.6% of cases, respectively. In-hospital mortality and the rate of any major complication post-surgery were 6.5% and 41.9%, respectively. Cross-clamp time had significant impact on in-hospital mortality and almost all major post-operative complications, except neurological dysfunctions (p = 0.084), myocardial infarction (p = 0.12) and mesenteric ischaemia (p = 0.85). Areas under the receiver operating characteristic curve and the optimal cut-off values for in-hospital mortality and any major complication were of 0.657, 0.594, >140 and >127 minutes, respectively. Comorbidities-adjusted odds ratio for any major complication of cross-clamp time <127 minutes was 1.86 (p < 0.0001). Despite similar in-hospital mortality (p = 0.57), there was an earlier significant increase of mortality in Custodiol-HTK than in multidose cold blood propensity-matched, non-coronary surgery patients. CONCLUSIONS: The use of Custodiol-HTK cardioplegia is associated with a low risk of serious post-operative complications provided that cross-clamp time is of 2 hours or less.

The Risk of Neurological Dysfunctions after Deep Hypothermic Circulatory Arrest with Retrograde Cerebral Perfusion.

OBJECTIVE: Retrograde cerebral perfusion (RCP) is a brain protection technique that is adopted generally for anticipated short periods of deep hypothermic circulatory arrest (DHCA). However, the real impact of this technique on cerebral protection during DHCA remains a controversial issue. METHODS: For 344 (59.5%) of 578 consecutive patients (mean age, 66.9 ± 10.9 years) who underwent cardiovascular surgery under DHCA at the present authors' institution (1999-2015), RCP was the sole technique of cerebral protection that was adopted in addition to deep hypothermia. Surgery of the thoracic aorta was performed in 95.9% of these RCP patients; in 92 cases there was an aortic arch involvement. Outcomes were reviewed retrospectively. The focus was on postoperative neurological dysfunctions. RESULTS: There were 33 (9.6%) in-hospital deaths. Thirty-one (9%) patients had permanent neurological dysfunctions and 66 (19.1%) transitory neurological dysfunctions alone. Age older than 74 years (odds ratio [OR], 1.88, P = .023), surgery for acute aortic dissection (OR, 2.57; P = .0009), and DHCA time longer than 25 minutes (OR, 2.44; P = .0021) were predictors of neurological dysfunctions. The 10-year nonparametric estimate of freedom from all-cause death was 61.8% (95% confidence interval, 57.8%-65.8%). Permanent postoperative neurological dysfunctions were risk factors for cardiac or cerebrovascular death (hazard ratio, 2.6; P = .039) even after an adjusted survival analysis (P < .04). CONCLUSIONS: According to the study findings, RCP, in addition to deep hypothermia, combines with a low risk of neurological dysfunctions provided that DHCA length is 25 minutes or less. Permanent postoperative neurological dysfunctions are predictors of poor late survival.

Bilateral internal thoracic artery grafting in octogenarians: where are the benefits?

The use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization is usually discouraged in the very elderly because of increased risk of perioperative complications. The aim of the study was to analyze early and late outcomes of BITA grafting in octogenarians. From January 1999 throughout February 2014, 236 consecutive octogenarians with multivessel coronary artery disease underwent primary isolated coronary bypass surgery at the authors' institution. Six of these patients underwent emergency surgery and were excluded from this retrospective study; consequently, 135 BITA patients were compared with 95 single internal thoracic artery (SITA) patients according to early and late outcomes. Between BITA and SITA patients, there was no significant difference in the operative risk (EuroSCORE II: 8 ± 7.7 vs. 7.6 ± 6.1 %, p = 0.65). There was a lower aortic manipulation in BITA patients. Hospital mortality (3 vs. 4.2 %, p = 0.44) and perioperative complications were similar except that only BITA patients experienced sternal wound infection (5.2 %, p = 0.022). The mean follow-up was 4.7 ± 3.3 years. There were no differences between the two groups in overall survival (p = 0.79), freedom from cardiac and cerebrovascular deaths (p = 0.73), major adverse cardiac and cerebrovascular events (p = 0.63) and heart failure hospital readmission (p = 0.64). Predictors of decreased late survival were diabetes (p = 0.0062) and congestive heart failure (p = 0.0004). BITA grafting can be routinely used in octogenarians with atherosclerotic ascending aorta without an increase in hospital mortality or major adverse cardiac and cerebrovascular complications. However, there is an increased risk of sternal wound infection without a demonstrable long-term benefit.

Bioprosthetic pulmonary valve dysfunction in a primary cardiac sarcoma survivor: Clinical considerations and treatment options.

The case highlights the good survival after radical surgery and chemotherapy of a cardiac sarcoma, and the need for close follow-up due to possible early postsurgical complications.

Cardiac Vascular Hamartoma: Adult Diagnosis and Cardiac Reconstruction.

Cardiac hamartoma is a rare benign tumor of the heart, and the vascular type is an extremely rare histologic diagnosis. A small number of cases have previously been described in childhood. We report the case of a 63-year-old woman with an incidentally detected cardiac mass that was finally diagnosed as vascular hamartoma. Approval for publication was obtained from the patient.

A 20-year experience in cardiac tumors: a single center surgical experience and a review of literature.

INTRODUCTION: Cardiac tumors are rare and heterogeneous entities which still remain a diagnostic and therapeutic challenge. The treatment for most cardiac tumors is prompt surgical resection. We sought to provide an overview of surgical results from a series of consecutive patients treated at our tertiary care center during almost a 20-year experience. METHODS AND RESULTS: In this single center study, 55 consecutive patients with diagnosis of cardiac tumor underwent surgical treatment from January 2002 to April 2021. Of these, 23 (42%) were male and the mean age was 62 ±â€Š12 years. Fifteen (27%) patients were symptomatic at the time of the diagnosis, mostly for dyspnea and palpitations. The most frequent benign cardiac tumor was myxoma (32; 58%), occurring mainly in the left atrium (31; 97%). Pleomorphic sarcoma was the most frequent primary malignant cardiac tumor (4; 7%), mainly located in the ventricles (1; 25% in the left ventricle; 2; 50% in the right ventricle). In all cases of benign tumors surgery was successful with no relapses. Two (50%) pleomorphic sarcomas showed subsequent relapses. After a median follow-up of 44 months, 15 (27%) patients died. Although malignant tumors presented a limited survival, benign tumors showed a very good prognosis. CONCLUSION: Cardiac tumors require a multidisciplinary approach to guarantee a prompt diagnosis and appropriate treatment. In our surgical experience, outcome after surgery of benign tumors was excellent, while malignant tumors had poor prognosis despite radical surgery.

Clinical Validation of a Coronary Surgery Technique That Minimizes Aortic Manipulation.

BACKGROUND: To minimize aortic manipulation and maximize use of arterial conduits are aims of modern coronary surgery. METHODS: From March 2012 to October 2016, 890 consecutive patients with multivessel coronary disease underwent isolated coronary operations using both internal thoracic arteries (ITAs). In 205 (23%; mean age, 67.6 ± 9.2 years), the right ITA was proximally transected and used as a free graft, while its in situ stump was elongated with a saphenous vein graft. The new arteriovenous I conduit was directed to the inferolateral cardiac wall. Operative data and early outcomes of these patients (I group) were compared with the remaining 685 patients (control [C] group). Early and late outcomes were also compared in 184 pairs identified with propensity score matching. RESULTS: Between the I and C groups there was no significant difference in expected operative risk (European System for Cardiac Operative Risk Evaluation II, p = 0.28), although diseased ascending aorta (p < 0.0001) and critical preoperative state (p = 0.027) were more frequent in the I group. Despite a higher number of coronary anastomoses (mean, 4 ± 0.9 vs 3.7 ± 1, p < 0.0001), cardiopulmonary bypass time was shorter in the I group both in overall (86.7 ± 23.7 vs 105.7 ± 34.2 minutes, p < 0.0001) and matched series (86.8 ± 24.1 vs 108.8 ± 31.9 minutes, p < 0.0001). In-hospital mortality (1% vs 1.9%, p = 0.54) and the rates of postoperative complications were similar. During the follow-up period, no intergroup difference was found in matched patients in the nonparametric estimates of freedom from all-cause death (p = 0.39) and major adverse cardiac and cerebrovascular events (p = 0.44). CONCLUSIONS: Surgery using this arteriovenous I conduit is safe, minimizes aortic manipulation, shortens cardiopulmonary bypass time, and aids complete revascularization.

Diagnosis and management of severe atherosclerosis of the ascending aorta and aortic arch during cardiac surgery: focus on aortic replacement.

OBJECTIVE: Severe atherosclerosis of the ascending aorta and arch frequently causes difficulties during heart operations, hindering surgical manoeuvres and potentially leading to systemic embolism. The aim of our study was to assess the safety and effectiveness of replacing the atherosclerotic ascending aorta in this setting. METHODS: Aortic atherosclerosis was characterized by epiaortic ultrasonographic scanning in 90.1% of 1927 consecutive adult patients undergoing cardiac operations, and by computed tomographic chest scanning in selected cases. Thirty-six of the 152 patients requiring major derangements from our standard practice due to aortic atherosclerosis underwent replacement of the ascending aorta and constitute the study group. Replacement of the aorta was extended to the arch in 13 cases (36.1%). It was associated with single or multiple valve surgery in 34 patients (94.4%) and with coronary revascularization in 30 (83.3%). Two patients (5.6%) underwent coronary bypass grafting without valve surgery. A cryoablation procedure was associated in three patients with permanent atrial fibrillation. Deep hypothermic circulatory arrest was employed in 34 patients (94.4%), while proximal aortic disease allowed conventional distal crossclamping in 2 cases. The risk of operative mortality was estimated by the logistic EuroSCORE both with and withholding the variable "surgery of the thoracic aorta". All survivors were followed-up for 1-41 months (16+/-12). RESULTS: Two patients died in the hospital (5.6%) and two during follow-up, for a cumulative survival of 91.3% and 85.6% at 1 and 3 years, respectively (hospital deaths included). The hospital death rate compared favourably with the expected estimates of 25.5% (p<0.05) and 10.3% (p=0.67) obtained by the EuroSCORE full model and without "aortic surgery", respectively. In-hospital adverse neurologic events occurred in six patients (16.7%), including stroke in one patient (2.8%) and neurocognitive disturbances in five (13.9%), although they were all transient and cleared before discharge. Excess bleeding required re-exploration in four patients (11.1%), and one more patient underwent emergency grafting for acute postoperative coronary occlusion. Ten patients (38.5%) were intubated for longer than 24h. CONCLUSION: Despite significant perioperative morbidity, replacement of the severely atherosclerotic aorta is worth consideration to avert expectedly higher death and stroke rates.

Liberal bilateral internal thoracic artery use in people with diabetes neutralizes the negative impact of insulin-requiring status.

AIMS: Bilateral internal thoracic artery (BITA) grafts are underused in insulin-dependent diabetic patients because of increased risk of postoperative complications. The impact of the insulin-requiring status on outcomes after routine BITA grafting was investigated in this retrospective study. METHODS: Skeletonized BITA grafts were used in 3228 (71.6%) of 4508 consecutive patients having multivessel coronary disease who underwent isolated coronary bypass surgery at the authors' institution from January 1999 to August 2015. Among these BITA patients, diabetes mellitus and the insulin-requiring status were present in 972 (30.1%) and 237 (7.3%) cases, respectively. After the one-to-one propensity score-matching, 215 pairs of insulin-dependent/noninsulin-dependent people with diabetes were compared as the postoperative outcomes. The operative risk was calculated for each patient according to the logistic European System for Cardiac Operative Risk Evaluation (logistic EuroSCORE). RESULTS: As expected, insulin-dependent people with diabetes had higher risk profiles than noninsulin-dependent people with diabetes (median logistic EuroSCORE, 4.1 vs. 3.5%, P = 0.086). However, there were no differences in in-hospital mortality both in unmatched and propensity score-matched series (2.5 vs. 2%, P = 0.65 and 2.8 vs. 1.9%, P = 0.52, respectively). In propensity score-matched pairs, only prolonged invasive ventilation (P = 0.0039) and deep sternal wound infection (P = 0.071) were more frequent in insulin-dependent people with diabetes. No differences were found as the late outcomes. CONCLUSION: In diabetic patients, the insulin-requiring status is by itself a risk factor neither for in-hospital death nor for poor late outcomes after routine BITA grafting. Only the risk of prolonged invasive ventilation and deep sternal wound infection are increased early after surgery.

The impact of epiaortic ultrasonographic scanning on the risk of perioperative stroke.

OBJECTIVE: To assess the impact of epiaortic scanning on the incidence of perioperative stroke in patients undergoing cardiac surgery. METHODS: Patients consecutively enrolled in our surgical database between January 2000 and August 2004 were subdivided into three groups depending on the planned use of epiaortic ultrasonographic scan. Patients treated before the availability of the equipment constituted group A (n=366). Epiaortic scanning was next performed selectively in group B (n=1116) and finally adopted on a regular basis in group C patients (n=690). Comparisons of stroke rates were performed in the whole series both according to the actual use of epiaortic scan and to the intended scan policy. A sub-analysis was additionally performed in the CABG cohort, where expected stroke rates could also be estimated by a validated model. Multivariable analysis was employed to identify predictors of early stroke. RESULTS: In the whole series, total stroke rates were 3.3%, 1.1%, and 1.9% for groups A, B, and C, respectively (p=0.02). Correspondingly, in the CABG cohort they were 3.4%, 0.5%, and 1.7%, respectively (p=0.002), with no substantial change following risk-adjustment. For the CABG cohort, total stroke rates were no different from expected estimates in the no-scan group A patients (3.4% vs 3.9%, ns). On the other hand, they were lower than expected in groups B+C (0.9% vs 2.8%, p=0.001), in patients actually scanned (1.4% vs 3.4%, p=0.01) and, among the latter, in those with significant aortic pathology (1.3% vs 4.5%, p=0.03). The risk reduction was particularly evident for early strokes, with no difference between scan groups: the rates were 0.5% and 0.6% for groups B and C, respectively, versus 2.2% in group A for the whole series (p<0.03), and 0.4% and 0.5% versus 1.9% in group A (p=0.02) for the CABG cohort. By multivariable analysis a no-scan policy (OR=4.0, 95% CL 1.4-11.4) and extracardiac arteriopathy (OR=3.0, 95% CL 1.1-8.0) were independently associated with early stroke. CONCLUSIONS: The use of epiaortic scanning is associated with a lower risk of intraoperative adverse events leading to early postoperative stroke.

Disseminated echinococcosis: follow your heart.

: In this report, we present a rare case of cardiac echinococcosis presenting with cerebral haemorrhage due to rupture of a mycotic aneurysm in a peripheral branch of the media cerebral artery. Further investigations lead to discovery of multiple cysts in the heart and liver. The complementary use of transthoracic and transoesophageal echocardiography, MRI and computed tomography lead to the final diagnosis of disseminated echinococcosis and allowed precise evaluation of the anatomical and structural characteristics of the cardiac mass, its boundaries and its relationship with the surrounding anatomic structures.

A predictive scoring system for deep sternal wound infection after bilateral internal thoracic artery grafting.

OBJECTIVES: Despite long-term survival benefits, the increased risk of sternal complications limits the use of bilateral internal thoracic artery (BITA) grafts for myocardial revascularization. The aim of the present study was both to analyse the risk factors for deep sternal wound infection (DSWI), which complicates routine BITA grafting and to create a DSWI risk score based on the results of this analysis. METHODS: BITA grafts were used as skeletonized conduits in 2936 (70.6%) of 4160 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery at the authors' institution from 1 January 1999 to 2013. The outcomes of these BITA patients were reviewed retrospectively and a risk factor analysis for DSWI was performed. RESULTS: A total of 129 (4.4%) patients suffered from DSWI. Two multivariable analysis models were created to examine preoperative factors either alone or combined with intraoperative and postoperative factors. Female gender, obesity, diabetes, poor glycaemic control, chronic lung disease and urgent surgical priority were the predictors of DSWI common to both models. Two (preoperative and combined) models of a new scoring system were devised to predict DSWI after BITA grafting. The preoperative model performed better than five of six scoring systems for sternal wound infection that were considered; the combined model performed better than three considered scoring systems. CONCLUSIONS: A weighted scoring system based on risk factors for DSWI was specifically created to predict DSWI risk after BITA grafting. This scoring system outperformed the existing scoring systems for sternal wound infection after coronary bypass surgery. Prospective studies are needed for validation.

[A quality improvement program in cardiac surgery. Four-year experience from the Ospedali Riuniti of Trieste]. / Un programma di miglioramento della qualità in cardiochirurgia. Quattro anni di esperienza agli Ospedali Riuniti di Trieste.

BACKGROUND: Dissatisfaction with clinical outcomes prompted an intervention to assess and improve processes and outcomes in a cardiac surgery unit. METHODS: Starting on September 1st, 1998, 1836 consecutive patients requiring a heart operation in our unit were prospectively enrolled by recording a series of anamnestic, clinical and procedural descriptors in a dedicated database. Expected mortality rates were estimated by means of nine different stratification models, one of which also allowed the prediction of excess intensive care unit and total hospital length of stay. Communication within the team has been re-engineered during the time frame studied. Some procedures have been modified and some others newly introduced according to a problem-oriented approach. RESULTS: One hundred and twenty-one patients died before discharge or within 30 days of the operation. The overall observed mortality rate (6.6%) was not significantly different from the predicted estimates (relative risk-RR 0.9, 95% confidence interval-CI 0.7-1.2 compared with EuroSCORE and RR 1.2, 95% CI 0.9-1.6 compared with the "Provincial Adult Cardiac Care Network" model). Two out of seven "dedicated" coronary surgery models predicted a mortality rate significantly lower than observed. Both rates of intensive care and total postoperative length of stay exceeding predefined thresholds turned out to be significantly higher than the predicted estimates: 14.3 vs 10.1% for intensive care (RR 1.4, 95% CI 1.2-1.7) and 13.6 vs 10.6% for total postoperative stay (RR 1.3, 95% CI 1.1-1.5). During the study period the yearly raw mortality rate gradually decreased, for the series as a whole, from 9.5% during the year 1999 to 4.1% during the year 2002, and for the coronary surgery sample from 6.5 to 2.1%, with no significant differences from the expected estimates over the 3 most recent years. A similar trend was noted for both intensive care unit and total hospital length of stay. CONCLUSIONS: Implementing an internal continuous quality improvement program effectively assisted in improving surgical outcomes by motivating people involved, drawing attention to procedures to be re-engineered and by providing the proper benchmarks for assessing the results.

Current role and outcomes of ascending aortic replacement for severe nonaneurysmal aortic atherosclerosis.

BACKGROUND: Severe atherosclerosis of the ascending aorta is a challenging issue potentially affecting indications for surgery, operative choices, and patients' outcome. No standard treatment has emerged to date, and uncertainties persist about criteria for selecting patients and procedures. METHODS: Replacement of the atherosclerotic ascending aorta was performed in 64 patients at time of either aortic (n = 49), mitral (n = 21), or tricuspid (n = 7) valve surgery. Coronary artery bypass grafting was performed in 53 patients, and the majority of patients underwent combined procedures (n = 49). Mean age was 72.0 +/- 7.6 years. The expected operative mortality, by logistic European System for Cardiac Operative Risk Evaluation, was 29.0% accounting for ascending aortic replacement and 13.1% disregarding it. Circulatory arrest under deep hypothermia, eventually combined with either retrograde or antegrade brain perfusion, was required in 61 cases. RESULTS: Early death, stroke, and myocardial infarction rates were 10.9%, 6.3%, and 7.8%, respectively. Factors univariately associated with early deaths were preoperative renal failure requiring dialysis (p = 0.001) and longer cardiopulmonary bypass (p = 0.001) and cardioplegia (p = 0.008) times. Cumulative survival at 1, 3, and 5 years was 86% +/- 4%, 74% +/- 6%, and 68% +/- 8%, respectively. CONCLUSIONS: Replacement of the atherosclerotic ascending aorta can be carried out at acceptable mortality rates despite the high rates of preoperative comorbidity and the significant incidence of postoperative complications.

Early and late outcomes of cardiac surgery in octogenarians.

BACKGROUND: Expanding demand for cardiac surgery in the elderly requires constant assessment of selection criteria and outcomes. METHODS: Records of consecutive patients 80 years old or greater (n = 355) having cardiac operations from September 1998 through May 2007 were reviewed. There were 172 isolated coronary bypass grafting (CABG), 73 isolated valve, 79 valve and CABG combined, and 31 other procedures. RESULTS: Thirty-three (9.3%) deaths and 13 (3.7%) strokes occurred during the index hospital stay. Intensive care unit and hospital length of stay lasted 6.3 +/- 14.3 and 15.5 +/- 20.8 days, respectively. Overall cumulative 5-year survival was 65.5 +/- 3.3%, varying among procedures as follows: 67.9 +/- 4.4% for isolated CABG, 64.6 +/- 8.9% for valve surgery, 60.3 +/- 7.3% for combined coronary and valve surgery, and 63 +/- 10.7% for other procedures (p = 0.23). Ninety-seven percent of survivors lived at home. Risk factors for hospital death were emergency status, preoperative renal dysfunction, and postoperative complications such as myocardial infarction, cardiac failure requiring intraaortic balloon pumping, acute renal failure requiring replacement therapy, stroke, and ventilator dependency exceeding 48 hours. Among hospital survivors, risk factors for late death were carotid artery disease, chronic lung disease, renal dysfunction, and the occurrence of postoperative complications. CONCLUSIONS: Long-term survival of octogenarians submitted to a wide variety of cardiac operations was satisfactory despite substantial rates of early complications and deaths. Most survivors were free from cardiac symptoms. Postoperative complications were stronger risk factors for hospital deaths than preoperative comorbidities and procedural variables. Their impact on long-term survival was also significant.

Surgical management of the atherosclerotic ascending aorta: is endoaortic balloon occlusion safe?

BACKGROUND: Occlusion of the atherosclerotic ascending aorta by an endoaortic inflatable balloon has been proposed as an alternative to conventional cross-clamping to prevent injury to the vessel and distal embolization of debris. The safety and the effectiveness of endoaortic occlusion have not been documented in this setting. METHODS: Endoaortic occlusion was employed in 52 of 2,172 consecutive patients. Surgeon's choice was based on preoperative identification of aortic calcifications or intraoperative epiaortic ultrasonographic scanning. Deaths and strokes were analyzed casewise and in aggregate. RESULTS: In 10 patients (19.2%), the endoaortic balloon had to be replaced by the ordinary cross-clamp because of incomplete occlusion (n = 5), hindered exposure (n = 2), or balloon rupture (n = 3). In-hospital death occurred in 13 patients (25%), and stroke on awakening from anesthesia in 2 (3.8%). The death rate of patients treated by endoaortic occlusion was significantly higher compared with all other patients (4.2%, p < 0.0001) and with the expected estimate by European System for Cardiac Operative Risk Evaluation (10.5%, p = 0.05). By multivariable analysis, use of endoaortic occlusion was independently associated with in-hospital death (odds ratio = 5.609, 95% confidence interval: 2.684 to 11.719). Although the stroke rate was higher in the endoaortic occlusion group compared with all other patients, the difference was only possibly significant (3.8% versus 0.8%, p = 0.067). CONCLUSIONS: In this series, the endoaortic occlusion was frequently ineffective, and was associated with a significantly higher risk of in-hospital death and a numerically higher risk of stroke.