Does systemic immune-inflammation index predict the short outcomes after an acute type A aortic dissection repair? Promising biomarker for acute aortic syndrome.

The retrospectively presented by Xu et al. assessed the value of the systemic immune-inflammation index (SII) in the prediction of short-term outcomes in patients undergoing surgery for acute type A aortic dissection (ATAAD). The authors concluded that SII is a reliable biomarker that can predict postoperative short-term outcomes and this marker could be potentially applied to stratification and patient selection with ATAAD. Although the study is retrospective, it is well-matched and conducted in a large volume center and the surgical technique was standard for all procedures. In addition, there was no statistical difference in cardiopulmonary bypass, aortic cross-clamp and deep hypothermic time, comorbidities, blood and blood products transfusion between the study groups. In addition, 90.7% of patients underwent elephant trunk technique for ATAAD repair, while the 30-day mortality and postoperative temporary and permanent neurological dysfunctions were 14.8% and 11.1%, respectively. Randomized controlled and prospective studies are warranted to clarify these well-documented results to apply this useful biomarker in clinical practice for patients with the acute aortic syndrome.

Does deep hypothermic circulatory arrest with versus without retrograde cerebral perfusion affect the outcomes after proximal aortic arch aneurysm and acute type A aortic dissection repair? Different pathologies and cerebral protection techniques with similar results.

Hypothermic circulatory arrest is used for proximal and total aortic arch correction in patients with aortic arch aneurysm and acute or chronic type A aortic dissection. Different cerebral perfusion techniques have been proposed for reducing morbidity and mortality rate. The study of Arnaoutakis et al. showed that deep hypothermic circulatory arrest with or without retrograde cerebral perfusion for proximal aortic aneurysm and acute type A aortic dissection correction had similar results with regard to morbidity and mortality rate. In addition, the short circulatory arrest time contributes for favorable outcomes of these patients. Although antegrade cerebral perfusion with hypothermic circulatory is widely used by many cardiac surgeons, deep hypothermic circulatory arrest with or without retrograde cerebral perfusion remains an alternative and safe method for brain protection in patients undergoing proximal aortic arch aneurysm or acute type A aortic dissection repair.

Can regional cerebral oxygen saturation monitoring during circulatory arrest time predict postoperative neurological dysfunction in patients undergoing surgical pulmonary thromboendarterectomy? Useful index for short- and long-term outcomes.

A hypothermic circulatory arrest is usually used to correct thoracic aorta pathologies. The emergency treatment of acute type A aortic dissection and elective repair of aortic arch pathologies are the most common indications for using hypothermic circulatory arrest. A hypothermic circulatory arrest can also be used for surgical pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension. Intervals with total circulatory arrest offer a clear surgical field for thrombus and emboli removal from the pulmonary artery branches. The price to pay for intermittent circulatory arrest during pulmonary thromboendarterectomy is postoperative neurological dysfunction due to brain hypothermia and hypoperfusion. A noninvasive method for cerebral monitoring during cardiac surgery is real-time regional cerebral oxygen saturation (rSO2 ). Liu et al. report that continuous monitoring of rSO2 during surgical pulmonary thromboendarterectomy may reduce the long cerebral hypoperfusion time and prevent postoperative neurological dysfunction.

Acute renal failure after acute type A aortic dissection repair. Insidious postoperative complication with poor short- and long-term prognosis.

Acute type A aortic dissection (ATAAD) is a life-threatening aortic disease. Many systems and organs are affected by malperfusion which presents preoperatively and postoperatively. Postoperative acute renal failure after ATAAD constitutes a severe and insidious complication. Acute renal damage is observed in many patients with ATAAD preoperatively and it burdens the renal function postoperatively. Renal replacement therapy represents an additional risk factor for short-, mid-, and long-term outcomes after ATAAD repair. Brown et al.'s present study highlight the clinical significance of this complication. Also, they remind us of the importance of optimizing perioperative renal protective strategies in patients undergoing ATAAD repair.

Analysis of risk factors for in-hospital mortality in 177 patients who underwent isolated coronary bypass grafting and received intra aortic balloon pump.

BACKGROUND AND AIM OF THE STUDY: Intra-aortic balloon pump (IABP) is the most commonly used device for circulatory support of patients with heart disease. The aim of this study evaluated the risk factors for outcomes of patients who underwent isolated coronary bypass grafting and received IABP. METHODS: One hundred-seventy-seven patients underwent isolated coronary bypass grafting and received intraoperative IABP. All perioperative data were recorded. The primary end-point was in-hospital mortality, while the secondary end-points were the length of intensive care unit (ICU) stay and hospital length of stay (LOS). RESULTS: In-hospital mortality was 5.6% (10 patients). Multivariable logistic regression analysis showed that the risk factors for in-hospital mortality were preoperative plasma creatinine level and cardiopulmonary bypass (CPB) time (for both p < .05). Multivariable linear regression analysis showed that postoperative acute kidney injury (AKI), immediate plasma troponin after operation, numbers of grafts, and CPB time were predicted the hospital LOS, while postoperative AKI, preoperative left ventricular ejection fraction, and immediate plasma troponin after operation were predicted the lengths of ICU stay. CONCLUSION: Our analysis showed that increased preoperative plasma creatinine, postoperative renal dysfunction, and CPB time negatively affected the outcomes of patients who received intraoperative IABP insertion.

Antegrade and Retrograde Cerebral Perfusion During Acute Type A Aortic Dissection Repair in 290 Patients.

AIM: Hypothermia and selective brain perfusion is used for brain protection during an acute type A aortic dissection (ATAAD) correction. We compared the outcomes between antegrade and retrograde cerebral perfusion techniques after ATAAD surgery. METHOD: Between January 1995 and August 2017, 290 patients underwent ATAAD repair under deep hypothermic circulatory arrest/retrograde cerebral perfusion (DHCA/RCP) in 173 patients and moderate hypothermic circulatory arrest/antegrade cerebral perfusion (MHCA/ACP) in 117 patients. Outcomes of interest were: 30-day mortality, new-onset postoperative neurological complications, and length of intensive care unit (ICU) and in-hospital stays. RESULTS: No differences were observed between the preoperative details of both groups (p>0.05). Thirty-day (30-day) mortality did not differ between groups (RCP vs ACP, 22% vs 21.4%; p=0.90). New-onset postoperative permanent neurological dysfunctions and coma was similar in two group in 6.9% versus 10.3% of patients and 3.8% versus 6.8% patients of patients, respectively (p=0.69). The incidence of 30-day mortality and new postoperative neurological complications were similar in the RCP and ACP groups (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.39-2.83 [p=0.91] and OR, 1.7; 95% CI, 0.87-3.23 [p=0.11], respectively). There was no difference between length of stay in the ICU and overall stay in hospital between the RCP and ACP groups (p=0.31 and p=0.14, respectively). No difference in survival rate was observed between the RCP and ACP groups (hazard ratio, 1.2; 95% CI, 0.76-2.01 [p=0.39]). CONCLUSIONS: Thirty-day (30-day) mortality rate, new-onset postoperative neurological dysfunctions, ICU stay, and in-hospital stay did not differ between the MHCA/ACP and DHCA/RCP groups after ATAAD correction. Although the rates of 30-day mortality and postoperative neurological complications were high after ATAAD repair, ACP had no advantages over the RCP technique.

Long-Term Results after Modified Bentall Operation in 200 Patients.

BACKGROUND: Composite graft replacement of the aortic root is the treatment of choice for an array of aortic root pathologies, such as annuloaortic ectasia, Marfan syndrome and acute or chronic aortic dissection type A. In this retrospective study of the authors' aortic surgery database, an exploration was made of factors related to early and long-term morbidity and mortality of patients who underwent this procedure. METHODS: Between 2000 and 2009, a total of 200 consecutive patients (male:female ratio 4:1; mean age 56.2 ± 11.66 years) underwent the modified Bentall operation at the authors' institution, with a composite graft (mechanical valve) being used to correct aortic root pathology. All preoperative, perioperative and postoperative data, as well as long-term follow up data, were retrieved from the authors' aortic surgery database. RESULTS: Preoperative characteristics of the patients included elective and emergency operations (83.1% and 15.9%, respectively). Intraoperative and 30-day mortalities were 2% and 3.5%, respectively, while the rate of postoperative cerebrovascular events was 1.5%. Long-term survival at a mean follow up of 110 months for the elective and emergency groups was 88.6% and 71.9%, respectively (p = 0.007). Moreover, during the same period new cerebrovascular events were observed in 5.8% of cases. Predictive factors for late survival were type of surgery (elective versus emergency; p = 0.023), conduit size (≤23 mm versus >23 mm; p = 0.053) , age >65 years (p = 0.001), intensive care unit stay (days; p <0.001) and postoperative creatinine level (p = 0.002). Survival rates at one, three, five and 10 years postoperatively were 93.5%, 92.5%, 91.5% and 85.9%, respectively. CONCLUSIONS: Patients who underwent the modified Bentall operation presented with minimal major adverse effects and demonstrated a good long-term survival.

Anesthetic management of patients undergoing transcatheter aortic valve implantation.

OBJECTIVE: To compare 2 anesthetic techniques, general anesthesia or monitored anesthesia care, performed by the same cardiac anesthesiologists for transcatheter aortic valve implantation in the authors' institution. DESIGN: A retrospective study. SETTING: A single specialized cardiac surgery center. PARTICIPANTS: Ninety-eight patients with severe aortic valve stenosis and a high logistic EuroSCORE considered not eligible to undergo conventional aortic valve replacement. INTERVENTION: General anesthesia or monitored anesthesia care. MEASUREMENTS AND MAIN RESULTS: General anesthesia was used in 57 and monitored anesthesia care in 41 patients. The authors compared the following parameters: Duration of procedure, transfusion requirements, cardiac indices, superior vena cava saturation (ScVO2) before and after the aortic valve implantation, hospital length of stay and 30-day mortality. The only significant differences between the groups concerned were the duration of anesthesia (p<0.001) and ScVO2 values. Anesthesia duration was prolonged significantly when general anesthesia was administered, and ScVO2 was significantly higher both before and after the valve implantation in the general anesthesia group. Thirty-day mortality was 5.3% in the general anesthesia group and 4.9% in the monitored anesthesia group. CONCLUSIONS: It would appear that both anesthetic techniques may be used for patients with a high logistic EuroSCORE undergoing transcatheter aortic valve implantation.

Current Challenges in Diagnosis and Treatment of Cardiovascular Disease.

Cardiovascular disease is a leading the cause of death worldwide among the various cardiac pathologies that directly or indirectly affect the quality of life of patients [...].

Outcomes of delayed chest closure after congenital heart surgery in neonates.

We present the outcomes of delayed chest closure in neonates who underwent congenital heart surgery under cardiopulmonary bypass. Eighty-one consecutive neonatal patients (age ≤ 28 days) with congenital heart diseases who underwent heart operations and after surgery, chest remained open in the intensive care unit until DCC. Correction of transposition of the great arteries pathology was the most common surgical procedure (48.1% of patients). Median sternal closure time from surgery was 3 (2-4) days. Median age of neonates was 9 (5-12) days. In addition, in 4 cases (4.9%) there was secretion from the surgical site after DCC and after taking cultures, in 2 (2.4%) of the cases a pathogen was identified. Multivariable linear regression analysis (adjusted to gender and CPB) showed that only the age-predicted the sternum closure time (ß=-0.09, 95%CI: - 0.16 to -0.02, p=0.02). In-hospital mortality was 6 (7.4%) patients. Although the DCC in neonates who underwent CHD surgical correction was related to a high mortality rate, only the age of neonates predicted the sternum closure time in the ICU.

Right pulmonary artery originating from the ascending aorta with tetralogy of fallot and pulmonary atresia.

Key Clinical Message: Anomalous origin of right pulmonary artery from the ascending aorta is a rare congenital heart malformation that results in early infant mortality. These patients are at risk for the early development of significant pulmonary hypertension. The surgical management during the early period of life is imperative. Abstract: Anomalous pulmonary artery originating from the ascending aorta (often called hemitruncus) is a rare congenital cardiac defect requiring immediate management in the neonatal period. We report a case of a rare variant of anomalous right pulmonary artery originating from the ascending aorta in combination with pulmonary atresia and tetralogy of Fallot. The above-mentioned combination makes the surgical management of such cardiac defect exceedingly demanding.

Descending aorta to right atrial fistula: Transcatheter embolization of a very rare anomaly with coils.

Key Clinical Message: Descending aorta to right atrial (RA) fistula is a rare and distinct clinical entity mimicking patent ductus arteriosus (PDA) and it may lead to rapid development of pulmonary vascular disease. Correct diagnosis and treatment, especially in the presence of other congenital heart defects, is very important. Interventional management is the treatment of choice. Abstract: We present a case report of a trisomy 21 infant with atrial and ventricular septal defects and small patent ductus arteriosus (PDA) complicated by the presence of descending aorta to right atrial (RA) fistula with large left to right shunt leading to rapid increase in pulmonary vascular resistance. Transcatheter occlusion of the fistula followed by closure of the PDA with Nit-Occlud coil systems led to decreased pulmonary pressure and resistance permitting successful surgical repair of the patient's intracardiac defects with good outcome over 3 years of follow-up. Descending aorta to RA fistula is a rare and distinct clinical entity mimicking PDA and its correct diagnosis and treatment, especially in the presence of other congenital heart defects, is very important as it may lead to rapid development of pulmonary vascular disease.

Desaturation after Fontan procedure due to systemic venous collateral and improvement after closure with embolization.

Key Clinical Message: Systemic to pulmonary venous collaterals (SPVCs) are common findings in patients with Fontan and may be responsible for desaturation in this group of patients. In selected cases, percutaneous closure of SPVCs with coils or vascular plugs could be offered as a safe and effective treatment modality for these patients. Abstract: A 27-year-old female patient who had operated primarily with Glenn operation and she underwent later a lateral tunnel Fontan operation. After 5 years, she presented with desaturation due to significant systemic to pulmonary venous collateral development, and a decision was made to proceed with interventional occlusion. Afterward, the arterial saturations increased.

Giant Cell Arteritis: Focusing on Current Aspects From the Clinic to Diagnosis and Treatment.

Giant cell arteritis (GCA) is a granulomatous arteritis involving large arteries, particularly the aorta and its major proximal branches, including the carotid and temporal arteries. GCA involves individuals over 50 years old. The etiopathogenesis of GCA may involve a genetic background triggered by unknown environmental factors (eg infections), the activation of dendritic cells as well as inflammatory and vascular remodeling. However, its pathogenetic mechanism still remains unclear, although progress has been made in recent years. In the past, inflammatory markers and arterial biopsy were considered as gold standard for the diagnosis of GCA. However, emerging imaging methods have been made more sensitive and specific for the diagnosis of GCA. Treatment includes biological and other modalities including interleukin-6 (IL-6) inhibitors.

Mitral valve surgery in octogenarians: Identifying factors that can guide clinical decision-making.

BACKGROUND: Mitral valve surgery in octogenarians is a clinical challenge due to the impact of inherent, age-related comorbidities. Within the context of an aging population, the number of mitral surgery candidates over 80 has been gradually increasing. We sought to evaluate our institutional experience with mitral valve surgery in octogenarians to identify factors that may prove useful during the process of clinical decision-making. METHODS: We retrospectively reviewed our institutional database for all patients over 80 years of age who underwent mitral valve surgery in our department from October 2002 up to February 2021. The primary endpoints of our study were 30-day all-cause mortality and long-term survival after the first postoperative month. RESULTS: In total, 99 octogenarians underwent mitral valve surgery for various types of mitral pathology. In particular, 70 patients underwent mitral valve replacement with or without concomitant procedures and 29 underwent mitral valve repair with or without concomitant procedures. There was no difference between the two approaches in terms of 30-day mortality and long-term survival. Chronic kidney disease and total operative time were independent predicting factors for 30-day mortality. Etiology of mitral valve pathology and EuroSCORE II was independent predicting factors for long-term survival. CONCLUSIONS: The type of mitral valve surgery did not affect 30-day and long-term mortality rates in our study. Renal impairment and EuroSCORE II were independent predictors of 30-day mortality and long-term prognosis, respectively. Rheumatic valve disease was also associated with a poorer prognosis.

Outcomes after repair of complete atrioventricular canal with a modified single-patch technique: a retrospective study.

BACKGROUND: This study aimed to present the short- and midterm outcomes after complete atrioventricular canal defect (CAVC) repair using a single-patch technique. METHODS: This study included 30 children who underwent surgical correction of the CAVC using a single-patch technique. RESULTS: The median age of the patients was 5.7 months (interquartile range [IQR], 5.0-7.5 months), and 23 patients (76.7%) had type A CAVC. Fourteen patients (46.7%) were female and 17 (56.7%) had been diagnosed with Down syndrome. The in-hospital mortality rate was 0%. No deaths were observed during a median follow-up of 4 years (IQR, 3.5-5.0 years). Patients without Down syndrome were associated with late moderate mitral regurgitation (MR) (p=0.02). Late MR less than moderate degree was observed in 96.6%, 78.5%, and 50% of patients after 2, 4, and 5 years of follow-up, respectively, while late tricuspid valve regurgitation less than moderate degree was observed in 96.7%, 85.9%, and 59.0% of patients after 2, 4, and 6 years of follow-up, respectively. After a median follow-up of 4 years, only one patient had required surgical repair of a left ventricular outflow tract obstruction, which occurred 26 months after the first operation. Multivariable logistic regression analysis adjusted for the type of CAVC, sex, Down syndrome, age, and weight revealed that the absence of Down syndrome was a risk factor for late moderate MR (MR-2) (odds ratio, 0.05; 95% confidence interval, 0.006-0.50; p=0.01). CONCLUSION: A single-patch technique for CAVC surgical repair is a safe method with acceptable short- and midterm results.

Abnormal origin of right pulmonary artery from the ascending aorta in an infant ("Hemitruncus").

Key Clinical Message: Anomalous origin of right pulmonary artery from the ascending aorta is a rare congenital malformation and it needs surgical management. Consequences of this condition affect lead to pulmonary hypertension and severe pulmonary vascular disease. Abstract: Anomalous origin of right pulmonary artery from the ascending aorta is a rare congenital heart malformation that results in early infant mortality affecting the right pulmonary artery more than the left. These patients are at risk for the early development of significant pulmonary hypertension. The surgical management during the early period of life is imperative.

Monitoring of Levosimendan Administration in Patients with Pulmonary Hypertension Undergoing Cardiac Surgery and Effect of Two Different Dosing Schemes on Hemodynamic and Echocardiographic Parameters.

INTRODUCTION: The perioperative management of patients with pulmonary hypertension (PH) undergoing cardiac surgery represents one of the most challenging clinical scenarios. This fact mainly depends on the relationship existing between PH and right ventricular failure (RVF). Levosimendan (LS) is an inodilator that might be an effective agent in the treatment of PH and RVF. The aim of this study was to examine the impact of the duration of cardiopulmonary bypass (CPB) on the therapeutic drug monitoring of LS and to evaluate the effect of preemptive administration of LS on perioperative hemodynamic and echocardiographic parameters in cardiac surgical patients with preexisting PH. MATERIALS AND METHODS: In this study, LS was administered in adult patients undergoing cardiac surgery before CPB in order to prevent exacerbation of preexisting PH and subsequent right ventricular dysfunction. Thirty cardiac surgical patients with preoperatively confirmed PH were randomized to receive either 6 µg/kg or 12 µg/kg of LS after the induction of anesthesia. The plasma concentration of LS was measured after CPB. In this study, a low sample volume was used combined with a simple sample preparation protocol. The plasma sample was extracted by protein precipitation and evaporated; then, the analyte was reconstituted and detected using specific and sensitive bioanalytical liquid chromatography with mass spectrometry (LC-MS/MS) methodology. The clinical, hemodynamic, and echocardiographic parameters were registered and evaluated before and after the administration of the drug. RESULTS: A fast bioanalytical LC-MS/MS methodology (a run time of 5.5 min) was developed for the simultaneous determination of LS and OR-1896, its main metabolite in human plasma. The LC-MS/MS method was linear over a range of 0.1-50 ng/mL for LS and 1-50 ng/mL for its metabolite OR-1896. Measured plasma concentrations of LS were inversely related to the duration of CPB. LS administration before CPB during cardiac surgery was effective in reducing pulmonary artery pressure and improving hemodynamic parameters after CPB, with a more pronounced and durable effect of the drug at the dose of 12 µg/kg. Additionally, administration of LS at a dose of 12 µg/kg in cardiac surgical patients with PH before CPB improved right ventricular function. CONCLUSION: LS administration decreases pulmonary artery pressure and may improve right ventricular function in patients with PH undergoing cardiac surgery.

Outcomes after Transcatheter Mitral Valve Implantation: A Literature Review.

Mitral valve disease is the most common heart valve disease worldwide. Surgical mitral valve replacement or repair has been an established therapy in patients with severe mitral valve disease for many years. On the other hand, many patients with advanced mitral valve disease and severe comorbidities are treated conservatively and are excluded from the surgical procedure. Furthermore, in patients with severe comorbidities, transcatheter mitral valve repair by edge-to-edge technique with MitraClip or transcatheter mitral valve repair with a non-absorbable ring have been added as therapeutic options over the last few years. Alternative procedures for the treatment of patients with advanced prosthetic or native mitral valve diseases include transcatheter access for replacement or implantation of a new prosthetic valve in the diseased mitral valve. Promising results were published about short-term outcomes of patients who underwent the transcatheter mitral valve replacement. The current view and results of the transcatheter mitral valve implantation in patients with advanced native or prosthetic mitral valve disease are briefly discussed.

Risk Factors for Acute Postoperative Delirium in Cardiac Surgery Patients >65 Years Old

Background: Acute postoperative delirium is the most common neuropsychiatric disorder in cardiac surgery patients in the intensive care unit (ICU). The purpose of this study was to evaluate the possible risk factors of postoperative delirium (POD) for cardiac surgery patients in the ICU. Materials and Methods: The study population was composed of 86 cardiac surgery patients managed postoperatively in the cardiac surgery ICU. Presence of POD in patients was evaluated by the CAM-ICU scale. Results: According to the CAM-ICU scale, 22 (25.6%) patients presented POD; history of smoking, alcohol use, COPD, and preoperative permanent atrial fibrillation were associated with POD (for all, p < 0.05). The type of cardiac surgery operations, type of analgesia, and red blood cell transfusion in the ICU were not associated with POD (p > 0.05), while cardiac arrhythmia in the ICU, hypoxemia in the ICU after extubation (pO2 < 60 mmHg), and heart rate after extubation were predisposing factors for POD (for all, p < 0.05). Multivariable logistic regression analysis (adjusted to risk factors) showed that hypoxemia after extubation (OR = 20.6; 95%CI: 2.82−150), heart rate after extubation (OR = 0.95; 95% CI: 0.92−0.98), and alcohol use (OR = 74.3; 95%CI: 6.41−861) were predictive factors for acute postoperative delirium (for all, p < 0.05). Conclusion: Alcohol use and respiratory dysfunction before and after heart operation were associated with acute postoperative delirium in cardiac surgery ICU patients.