The ascending aorta and arch have until recently been one of the last bastions of cardiovascular surgery, where life-threatening diseases impose the need for prompt correction and reversal of the impending adverse prognosis. Though a disease where dogmatic recommendations prevail, with upfront surgical intervention in the mind of every physician, type A acute aortic dissection (AAD) is a subject still blurred by many uncertainties. Endovascular intervention for the treatment of type A AAD are rapidly progressing and utilization of transcatheter therapies in the ascending aorta for treating type A AAD has demonstrated technical success in small studies, low early mortality rates, and relatively acceptable aorta-related mortality rates in the long-term. These findings strengthen the preponderant role of the endovascular heart surgeon on the management of these procedures, where a combination of wire skill training and surgical proficiency encompassing all technical options available makes it distinctive and resourceful, able to provide complete resolution to each multicomponent of this disease in one setting, besides the promptness to repair the inherent complications that are to accompany these interventions. Transcatheter procedures and open surgery are to coexist side by side and to be regarded as complementary rather than competing. Substantial more refinement and technological innovation will be necessary before endovascular repair of type A AAD comes to widespread use, the ideal timespan for cardiovascular surgeons to be involved, and prepared to take on the challenges of leading this new enterprise.
Spinal cord ischemia remains a dreadful complication after thoracoabdominal aortic aneurysm repair. The role of cerebrospinal fluid drain in such patients needs further clarifications. Tam and colleagues carried out an interesting decision analysis study that supports the routine use of the cerebrospinal fluid drain after thoracoabdominal aneurysm repair. They also demonstrated that the use of the cerebrospinal drain was safe. Here, we firstly discuss the paper's finding and methodology and, secondly, we try to simply explain what a decision analysis study is and, broadly, and how to construct a Markov model.
Determining Prosthesis-Patient Mismatch after TAVR: Which is the Best Method?Authors: Cesar E. Mendoza, MD1 and Diego Celli, MD2Affiliations: 1Division of Cardiovascular Disease, Jackson Memorial Hospital, Miami, Florida;2Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida.Affiliation addresses: 11801 NW 9th Ave, Suite #209 33136 Miami, Florida, United States; 21611 NW 12th Ave 33136, Miami, Florida, United States.Corresponding author: Cesar E. Mendoza, MD; firstname.lastname@example.org; 1611 NW 12th Ave, East Tower 3019, Miami, Florida 33136.Disclosures: Authors have no relationships with the industry. This work is not under consideration in any other journal.Funding: No grants, contracts, and other forms of financial support were used to perform this manuscript.In the last decade, the medical community has witnessed an accelerated development of multiple devices for the transcatheter management of aortic stenosis. Recently, transaortic valve replacement (TAVR) was granted approval for its use in all types of surgical risk patients underscoring its importance in cardiovascular practice. While evidence has shown non-inferiority of TAVR versus surgical aortic valve replacement (SAVR) , it still has inherent intra- and post-procedural complications, prosthesis-patient mismatch (PPM) is one of them.Since the seminal work published by Rahimtoola in 1978 , several studies have investigated PPM. The incidence of PPM after SAVR ranges from 20% to 50% with severe cases having an occurrence rate from 5% to 25%. [3-5]. Severe PPM has been associated with significantly abnormal prosthetic valve echocardiographic parameters and adverse clinical outcomes including a higher risk of mortality [3,5-7]. Although initial studies showed a lower incidence of PPM after TAVR [8, 9], most recent data surprisingly depict an uptrend incidence of PPM with later-generation TAVR prostheses . Regardless of the true global PPM incidence, the number of cases in the severe category remain within robust margins (5% - 36%). Perhaps, more interestingly, the association of TAVR with adverse outcomes is not firm. Indeed, there are conflicting reports, with some studies showing a weak association [11,12], no association [13, 14, 15], or association in particular group of patients .PPM occurs when the effective orifice area (EOA) of a normally functioning prosthesis is too small in relation to the patient’s body size and cardiac output requirements, and this diagnosis must be done after ruling out dysfunction of the prosthesis heart valve. Historically, surgical aortic valve replacement was the method of choice in the management of aortic stenosis; as such, surgeons relied on the manufacturer’s predicted EOA charts to aid in the determination of the minimum valve size for any given valve model. The predicted EOA index (EOAi), which is calculated by dividing the reference value for the prosthesis model and size by the body surface area (BSA) of the patient, has been frequently used to identify PPM in the SAVR studies. Similarly, all contemporary TAVR studies have used the same index for the same purpose; but it nevertheless was measured using Doppler-echocardiography data.In this issue of JOCS, Catalano et al report that the utility of EOAi charts to predict PPM after TAVR for native aortic stenosis may be limited. Indeed, they found in their study that the pre-TAVR prediction of PPM using tables of expected EOA varies significantly from actual PPM measured on intraoperative transesophageal echocardiography using the continuity equation. Although this is a relatively small single-center study, the authors provided information worthy of additional consideration.First, they identified that EOAi charts overestimated the number of patients with PPM for Sapien 3 valves (25.3% predicted versus 13.7% actual) and underestimated the number of patients with PPM for Evolut valves (1.8% predicted versus 11.6% actual), yielding a limited utility for this instrument on pre-operative prediction of PPM in TAVR. Interestingly, a recent publication by Ternacle et al.  provides a different perspective on this topic. It reports that the predicted EOAi was found to be useful to reclassify the majority of patients diagnosed with measured PPM following TAVR to no PPM at all. Furthermore, they found that both methods had a different association with hemodynamic outcomes. In this regard, EOAi and mean transprosthetic gradient had a more powerful correlation when using the predicted EOAi versus the measured EOAi. Based on these findings, the Ternacle’s study suggests that the use of measured EOAi grossly overestimates the incidence of PPM. The discrepancy between both studies may be explained by the inherent variability in using different Doppler echocardiography imaging modalities to measure EOA. As Catalano et al rightly pointed out, the prosthesis data acquisition and measurements obtained by intraoperative transesophageal echocardiography in their study may not be comparable with its counterpart transthoracic modality, and this particular difference should be taken into account when interpreting the results above mentioned.Second, it is also clear from Catalano’s study that determining the best method to diagnose PPM following TAVR is paramount, but at the same time troublesome due to several factors. First, the pressure recovery phenomenon, a portion of the transprosthetic pressure gradient lost initially at the vena contracta level that recovers later after the prosthetic valve, is not accounted for by Doppler assessment of the maximum transvalvular flow velocities. This may cause overdiagnosis of PPM after TAVR. Second, measured EOA is influenced by the patient’s hemodynamic condition at the time of the evaluation and by the known technical pitfalls on the acquisition of images and measurement performance. Third, the use of the EOA indexed for body surface area may overestimate the severity of PPM in obese patients (body mass index ≥30 kg/m2).Certainly, Catalano’s study allows for a better discussion on the diagnosis and clinical implications of PPM following TAVR. However, the question of what method is a more accurate parameter to determine PPM remains unanswered. Clearly, further research is needed as TAVR is more frequently performed and new TAVR prostheses become available. Accurate prediction of PPM in this setting will help guide the operator’s decision on proper prosthesis size and type.
Surgical checklists such as ‘World Health Organization (WHO) Surgical Safety Checklist’ are made to make surgery safer, simple and to reduce human errors. Similar to this concept, Ali M et al and others have implemented the ‘haemostasis checklist’ and it had shown reduction in incidence of re-exploration in patients who underwent surgery using cardiopulmonary bypass (CPB). However, there is still scarcity of literature about the effect of these checklists on re-exploration after off-pump coronary artery bypass grafting (OPCABG).
I read with interest the manuscript by Masroor and co-authors on the strategy of surgical repair for left atrial appendage perforation following implantation of Watchman device. The authors present the successful management of this complications and they comment on the preferred therapeutic strategy. This is a particular sensitive subject nowadays, since the widespread use and the constant growth of a variety of transcatheter cardiac interventions has inevitably increased the number of patients who are exposed to this type of complication.
It has been long believed that ischemic mitral regurgitation is secondary to left ventricular remodelling and the mitral per se remains unaffected. This proviso has recently been challenged and the mitral valve has been described as a structure that responds and adapts to challenges and attempts to correct the mitral regurgitation. The response of mitral valves in this setting can be incomplete or can even be mal-adapted. The ability of the mitral valve to respond in this manner has been described as “mitral plasticity”. Endothelial to Mesenchymal transition and Valvular Interstitial Cells are key to this mitral plasticity and function through a complex array of signalling pathways. Identification and manipulation of these pathways may provide a possibility to correct the incomplete or mal-adapted mitral valve responses. Surgical treatment can also be tailored based on whether the valve has maladapted or has undergone incomplete adaptation.
Primary cardiac lymphoma is rare, with a frequency of 1.0% to 1.6% among cardiac malignant tumors. Chemotherapy is often selected as first-line treatment for primary cardiac lymphoma. However, when the tumor causes heart failure or life-threatening hemodynamic collapse, antecedent urgent surgery is required. We herein report a successful case of complete tumor resection and reconstruction of the right atrium and right ventricle using a bovine pericardial patch combined with tricuspid valve replacement in a patient with a huge primary cardiac lymphoma filling the right heart that manifested as tricuspid valve stenosis and subsequent heart failure.
Left ventricular surgical remodeling (LVSR) has been, for long time, the procedure applied for large dyskinetic, or akinetic, areas as a consequence of a myocardial infarction, manly located in the left anterior descending area. Many surgical techniques were developed, aimed to a pure reduction of the volume of the left ventricular cavity or to add to volume reduction a more physiologic conical shape. The expansion of interventional procedures invaded most of the fields before treated only by cardiac surgeons. In this issue, Pillay describes an hybrid technique, involving both interventional cardiologists and cardiac surgeons, aimed to LV volume reduction after an anterior myocardial infarction. A series of internal (right ventricular septum) and external (anterior wall) anchors are implanted to approximate the LV free wall to the anterior septum, consequently excluding the scarred myocardium. Although some limitations of this study, the Authors have to be commended for having revitalized a procedure almost eliminated from the surgical scenario
In secondary mitral regurgitation, the concept that the mitral valve (MV) is an innocent bystander, has been challenged by many studies in the last decades. The MV is a living structure with an intrinsic plasticity that reacts to changes in stretch or in mechanical stress activating bio-humoral mechanisms that have, as purpose, the adaptation of the valve to the new environment. If the adaptation is balanced, the leaflets increase both surface and length and the chordae tendinae lengthen: the result is a valve with different characteristics, but able to avoid or to limit the regurgitation. However, if the adaptation is unbalanced, the leaflets and the chords do not change their size, but become stiffer and rigid, with moderate or severe regurgitation. These changes are mediated mainly by a cytokine, the transforming growth factor β (TGF-β), which is able to promote the changes that the MV needs to adapt to a new hemodynamic environment. In general, mild TGF-β activation facilitates leaflet growth, excessive TGF-β activation, as after a myocardial infarction, results in profibrotic changes in the leaflets, with increased thickness and stiffness. The MV is then a plastic organism, that reacts to the external stimuli, trying to maintain its physiologic integrity. This review has the goal to unveil the secret life of the MV, to understand which stimuli can trigger its plasticity and to explain why the equation “large heart=moderate/severe mitral regurgitation” and “small heart=no/mild mitral regurgitation” does not work into the clinical practice.
Objective.As aneurysm related events and rupture is not eliminated, postoperative lifelong surveillance is mandatory after endovascular aneurysm repair(EVAR).For surveillance colored Doppler ultrasound(CDUS) is a standard method of noninvasive evaluation having the advantages of availability, cost-effectiveness and lack of nephrotoxicity and radiation.We evaluated CDUS for primary surveillance tool after elective EVAR by comparing with computerized tomography. Methods.Between 2018-2020, 84 consecutive post-EVAR patients were evaluated.Firstly, CDUS was performed by two Doppler operators from the Radiology and computed tomographic angiography (CTA) was performed.A reporting protocol was organized for endoleak detection and largest aneurysm diameter. Results.Among 84 patients, there were 11 detected endoleaks(13,1%) with CTA and 7 of them was detected with CDUS (r=0,884,p<0.001).There is an insufficiency in detecting low flow by CDUS.Eliminating this frailty, there was a strong correlation of aneurysm sac diameter measurement between CTA and CDUS (r=0,777,p<0,001).The sensitivity and specificity of CDUS was 63,6% and 100% respectively.The accuracy was 95,2%.Positive and negative predictive values were 100% and 94,8%.Bland-Altman analysis and linear regression analysis showed no proportional bias (mean difference of 1.5±2.2mm,p=0.233). Conclusions.CDUS promises accurate results without missing any potential complication requiring intervention as Type I or III endoleak.Lack of detecting type II endoleaks may be negligible as sac enlargement was the key for reintervention in this situation and CDUS has a remarkably high correlation with CTA in sac diameter measurement. CDUS may be a primary surveillance tool for EVAR and CTA will be reserved in case of aneurysm sac enlargement,detection of an endoleak,inadequate CDUS or in case of unexplained abdominal symptomatology
It is of paramount importance that early graft failure is recognized in a timely manner and that an appropriate treatment is delivered immediately in order to reduce the extent of myocardial damage and improve clinical outcome. Therefore, urgent angiography allows both identification of the underlying cause of early graft failure and immediate treatment according to the findings. So far, recent evidence shows that PCI to native coronary arteries is associated with higher procedural success rate with less complications leading to the better clinical outcome.
Aneurysms of a single aortic sinus are not uncommon and it may also involve dilation of the ascending aorta as well. The dilated aortic sinus usually alters the geometry of the aortic root and patients will present more often with an aortic insufficiency. Both ruptured and non-ruptured sinus of valsalva aneurysm (SOVA) can be complicated by aortic regurgitation, occurring in up to 30% to 50% of patients . Unruptured SOVA are asymptomatic, but can present as dyspnea, palpitations, angina or arrhythmia. The treatment options for unruptured SOVA include aortic root reconstruction or replacement, aortic valve repair or replacement, Bentall procedure or patch repair of the SOVA.Aortic valve resuspension is a widely practised in repair for acute Type A aortic dissection. This procedure was first described by Walter G Wolfe from the Duke University, Durham. In his original series, 24 of the 30 patients with acute aortic dissection had resuspension of the aortic valve. Further “a woven Dacron® graft was then sutured beginning at the junction of the left and right coronary cusps. The graft was fashioned and sutured above the left coronary orifice around and down to the commissure of the left and non-coronary cusps. The graft suture line was then extended along the non-coronary cusp and then around the right coronary artery completing the suture line ”. Three years later, in his updated case series he added, “the proplapsing portion of the aortic valve (usually the non-coronary cusp) was resuspended with pledgeted sutures in order to restore competency of the valve ”. It worth noting that he described a surgical procedure wherein, the aortic valve was resuspensed and supracoronray aorta was replaced.In the recently published article , the authors have successfully performed a “Wolfe Procedure” in a 78 year old female and followed up the patient for 2 years. Though authors have conscientiously extricated the option of root repair or replacement, it still raises a few concerns about the procedure which they have performed. The authors mention of a “predominant expansion of the non-coronary sinus and thinning of the wall at the level of FC 22 mm and SV 76, 7x62 mm, ST-zone 38 mm”. Though not sure of the abbreviations, Figure 1 shows an enlarged non-coronary aortic sinus. Dilated aortic sinus / annulus will distort the aortic root leading to aortic insufficiency. It is surprising that the authors have not mentioned about the status of the aortic valve and is highly inconceivable that the patient will not be having any aortic valve insufficieny for such a large aneurysm. The status of Aortic root aneurysm was detected in preoperative echocardiogram, while the status of the aortic valve was noted intraoperatively - “aortic valve leaflets did not close due to the expansion of the non-coronary sinus” . Though they have not mentioned about the aortic valve while presenting the case report, but when opening the discussion, they mention that the, “case report describes the treatment of an aortic root aneurysm by the replacement of the aortic valve together with the placement of an interposition graft with proximal scallop to recreate the non-coronary sinus (i.e., Wolfe procedure)” . It is not clear whether the authors have replaced the aortic valve in their patient or they describe in general. In either of the situations, the procedure describe by Wolfe does not mandate replacement of aortic valve; it is rather a resuspension of the valve.They have argued that the Euroscore II of 19.39% is high in regards to “patient’s age, female sex, the center’s estimated surgical volume, and the present comorbidities ”. It has to be noted that ‘Center’s surgical volume’ is not a variable in Euroscore II. It should be further emphasised, that the authors have not any mentioned any comorbidities of the patients including the left ventricular function while presenting the case. Earlier studies have reported the overestimation of surgical risk in septuagenarians and octogenarians by Euroscore II [5,6,7]. It is a well-known fact that the coronary artery of elderly patients has to be evaluated before any open heart surgery; more so when have symptoms of angina. Though the authors mention that the elderly lady had coronary heart disease with class III angina pectoris, there is no description of the native coronary arteries in the manuscript. Atrial fibrillation or arrythimas are well known presentation symptom for patients with SOVA. This may be due to compression of the coronary arteries or any chamber(s) of the heart. A preoperative CT aortagram could have added value in this regard which the authors have not provided. It is mentioned that there is “dilation of the ascending, arch, and descending aorta” preoperatively. After the procedure the size of the aortic arch is 28 mm. It is so intriguing to know the mechanism of decrease in aortic arch size postoperatively after the so called “Wolfe Procedure”. As an aortic surgeon it is curious to note the ‘plunger-top’ of a syringe buried inside the vascular graft in Figure 3. Not sure why and how it was buried, but it would be of great value, if the authors could describe the technique of using the same in detail in a separate manuscript.
Congestive heart failure is highly prevalent in the elderly population and left ventricular assist device has been increasingly used in this population. LVAD therapy is more costly than medical treatment but it increases the survival and quality of life of the elderly patients with low disease acuity. Therefore careful selection of candidates and implementation of LVAD therapy earlier in the course of the disease is crucial to improve outcomes. With the technical advances and improvement in clinical management, the financial burden of LVAD therapy in the elderly will become less, making this therapy more economically feasible.
Aortopulmonary window (APW) is a rare but serious congenital cardiac malformation, most patients with APW will die from congestive heart failure a few months after birth. However, in this case we presented is an extremely rare condition that consist of a type III APW and a ductus arteriosus originated left pulmonary artery. Preoperative diagnosis included echocardiography and chest computerized tomography revealed anatomical structure of the heart and great vessel clearly, cardiac catheterization indicated that the pulmonary resistances indices were 2.92 wood U⁄m^2 in LPA and 3.35 wood U⁄m^2 in RPA, Qp:Qs was 3.26. This patient underwent surgical correction at the age of 9 and successfully survived.
The authors in this manuscript have reported an increase in the number of vascular emergencies seen during the early phase of the COVID-19 pandemic in the Lombardy region of Italy. A significant increase in the number of acute limb ischaemia was seen during this phase along with other vascular emergencies. In this review, we have tried to examine this association between increase in vascular emergencies and COVID-19 infection. We have also described the differences in presentations, prognosis and procedural outcomes following operative interventions in these patients compared to the non-COVID patients. An attempt has been made to assess the role of adjunctive measures like intravenous heparin to improve outcomes.
To the Editor: The interesting and timely paper by Cain et al.1, in press in the Journal of Cardiac Surgery , provides important details concerning the devastating consequences of Mycobacterium chimaera (MC ) infection. In their patient extreme fragility of the mediastinal tissues was observed after repair of an acute aortic dissection; during follow-up multiple reoperations were required to treat recurrent dehiscence of the aortic grafts. Despite repeat explantation of foreign materials infection persisted with mediastinitis and eventual systemic diffusion with fatal outcome.MC infection after open cardiac surgery using cardiopulmonary bypass has been recently reported as a clinical outbreak worldwide and identified as originating by contaminated water in heater-cooler units2. Current experience shows that MC causes a slow-growing and extremely difficult to treat infection with an incubation period which has been recently demonstrated to be as long as >12 years3.We have recently treated a patient, quite similar to that reported by Cain et al.1, who presented with a pseudoaneurysm of the distal suture line twelve years after repair of type A aortic dissection4. At first operation replacement of the ascending aorta and hemiarch using of a Djumbodis®dissection system (Saint Come-Chirurgie, Marseille, France) was performed. At reoperation extremely fragile tissues were noted and, after removing the metallic stent, the aortic arch was replaced with a frozen elephant trunk technique. Cultures of the excised material grewMC . In this case we hypothesized that the stent played an important role in the onset of infection for at least 2 reasons: presence of foreign material in the blood stream and injury to the aortic wall by the edges of the stent. The case described by Cain et al.1 also supports our belief that extreme fragility of the aortic tissues caused by MB was a further important factor in the occurrence of this complication.Interestingly, a delayed diagnosis occurred in both cases; this most likely played a critical role in favouring development of extra‐cardiac manifestations of the disease, in reducing the effectiveness of antibiotic therapy due to immunologic impairment and causing a negative outcome in both patients.MB infection may have different locations ranging from single-organ to systemic manifestations5. When it involves the mediastinum and particularly the major vascular structures often results in life-threatening complications despite proper antimycobacterial treatment. An early diagnosis, even with significantly extended surveillance, appears extremely difficult due to slow-growing and long incubation period of MB .Although no specific guidelines are so far available, intra-operative prevention with improvement of setting and development of heater-cooler units is mandatory and should be based on specific recommendations5.