Cardiovascular and Thoracic Open

We report three cases undergoing reoperation with previous aortic homograft implantation due to structural valve deterioration.

For two cases with severe calcified aortic wall of the homograft and dehiscence of the aortic root, aortic root replacement was indicated. For the last case with less calcified aortic wall, aortic valve replacement was indicated via the aortotomy on the homograft, which required patch plasty for the defect of the stiff aortic wall.

The distribution and extent of calcification of the aortic homograft would be the most important factor to determine operative procedures, contributing to successful outcomes.

Minimally invasive approaches have become a feature of cardiac surgery. We compared the outcomes of atrial septal defect closure through either a right thoracotomy or a median sternotomy in adults.

Patients who underwent atrial septal defect closure of ostium secundum defects through either a right thoracotomy (n = 14) or a median sternotomy (n = 7) were analyzed. The atrial septal defect was closed with cardiac arrest of the ascending aorta clamped under a cardiopulmonary bypass in both groups.

The preoperative characteristics of the two groups did not significantly differ. The durations of cardiopulmonary bypass and of cardiac arrest were significantly longer, but the amount of intraoperative blood loss was significantly lower, in the right thoracotomy than in the median sternotomy group. The early postoperative course did not significantly differ between the groups, whereas postoperative minor complications developed in three and two patients in the right thoracotomy and median sternotomy groups, respectively.

The outcomes of atrial septal defect closure through a right thoracotomy and a median sternotomy were comparable, suggesting that right thoracotomy is a safe and effective alternative to median sternotomy for atrial septal defect closure in adults.

Chylous discharge can rarely occur after cardiac surgery through a median sternotomy. Conservative or surgical treatment might be chosen based on the amount of the discharge.

We report the case of a patient who developed chylomediastinum after aortic valve replacement through a median sternotomy. A 79-year-old woman underwent aortic valve replacement through a median sternotomy for aortic valve stenosis. The thymus exhibited fatty degeneration and was divided with ligation at the mid-portion of the body without separation between the right and left lobes.

On the second postoperative day, 100mL of milky fluid was observed from the drainage tube of the retrosternal space after oral intake. We diagnosed the patient with chylomediastinum based on the characteristic appearance of the fluid and the relationship between the oral intake and the event. The drainage and low-fat total parenteral nutrition were continued for 1 week, leading to complete disappearance of the chylous discharge.

Gentle and minimal exploration is required during venous snaring and thymus division for cardiac surgery through a median sternotomy, and minor chylomediastinum could be cured conservatively.

The study aimed to assess the influence of the calcification of the ascending aorta on surgical mortality, postoperative stroke, and completeness of coronary revascularization in patients undergoing off-pump coronary artery bypass grafting with graft strategy tailored to its calcification severity.

We examined the clinical records of 726 patients who underwent off-pump coronary artery bypass grafting. The age at operation was 71 ± 8 years. Calcification of the ascending aorta was graded as none–mild (less than spotty) in 668 (92.0%), moderate (<1/4 of circumference) in 26 (3.6%), and severe (>1/4) in 32 (4.4%) by preoperative non-contrast computed tomography. There were no significant differences in the number of distal anastomoses per patient among the three groups (3.3 ± 1.1, 2.9 ± 1.0, and 3.0 ± 0.9, respectively; p = 0.85). Graft strategy was tailored for each patient. Proximal anastomosis with partial clamp was used in 43.8%, 7.7%, and 3.1%, respectively (p < 0.001), while anastomotic devices were used in 6.8%, 30.1%, and 28.1%, respectively (p < 0.001). Other patients had aortic no-touch technique. There were four hospital deaths in the none–mild group (0.6%, p = 0.85). Stroke occurred in 1 (0.1%) patient, an aortic no-touch technique patient with none–mild calcification. Complete revascularization was not possible in 1 (0.1%) patient in the severe calcification group. Patency of saphenous vein graft of distal anastomosis was not different among groups.

Influence of the calcification of the ascending aorta was minimized by tailoring graft strategy to calcification severity. It can practically abolish postoperative stroke while maintaining coronary revascularization success rates.

To report two cases of cardiac injury following blunt thoracic trauma without external evidence of injury.

Case report and review of the literature.

A 23-bed pediatric intensive care unit in an academic children’s hospital.

Two children presented following significant thoracic trauma without external evidence of injury. Cardiac injury was not initially suspected, and lack of definitive diagnostic evaluation led to a delay in diagnosis and definitive treatment.

A 4-year-old girl presented 6 months after initial injury and evaluation with massive right ventricular dilatation secondary to traumatic tricuspid regurgitation. The second patient, an 11-year-old boy, underwent a laparotomy for suspected abdominal pathology delaying diagnosis of his traumatic ventricular septal defect and definitive repair until clinical hemodynamic deterioration occurred.

Clinicians should maintain a high index of suspicion for cardiac injury in patients with a significant mechanism of thoracic trauma despite external evidence. Standard screening tests are often inadequate and echocardiography should be performed for any suspected cardiac trauma.

To observe the efficiency and safety of direct and indirect three arch vessels’ cannulation for bilateral antegrade cerebral perfusion during total arch replacement.

Between 2002 and 2014, 130 patients underwent total arch replacement with direct and 66 patients with indirect cannulation for antegrade cerebral perfusion under moderate hypothermia. Patients were assigned to the direct cannulation group based on the condition of the aortic arch vessels. Demographics and concomitant surgeries were similar in the two groups. Patient characteristics, surgical and haemodynamic measurements, and postoperative neurologic findings were observed.

Aortic cross-clamping (120 ± 42 vs 139 ± 65 min; p = 0.032) and cardiopulmonary bypass (178 ± 57 vs 206 ± 71 min; p = 0.025) times were lower in the direct cannulation group. There were no differences in overall hospital mortality (4% vs 6%; p = 0.87), selective antegrade cerebral perfusion time (91 ± 52 vs 100 ± 65 min; p = 0.185), and incidence of neurologic deficit (3% vs 9%; p = 0.07). Indirect cannulation led to more frequent re-exploration for bleeding (5% vs 13%; p = 0.0356). There was no difference in midterm survival (log-rank p = 0.103; mean follow-up times: 4.74 years (direct cannulation), 5.50 years (indirect cannulation)).

Direct cannulation during mild systemic hypothermia yields excellent outcomes while reducing time and rate of reoperation for bleeding and can be used in total arch replacement without increasing morbidity and mortality.

The objectives of this study were to investigate the changes in routine laboratory tests and rotational thromboelastometry variables after cardiopulmonary bypass and to investigate the association of these variables with postoperative blood loss.

Blood was obtained at baseline, at admission to the intensive care unit, and at the first postoperative day. Rotational thromboelastometry tests and measurements of haemoglobin, haematocrit, platelet count, and plasma fibrinogen level (Clauss method) were performed. Excessive bleeding was defined as >1000 mL of chest tube drainage after surgery within 24 h.

After cardiopulmonary bypass, haemotocrit was decreased by 21%. Platelet count and fibrinogen level decreased more (35% and 42%, respectively). The largest change was found for clot formation time of INTEM (intrinsically activated coagulation) (+73%). Platelet count was not reflected by maximal clot firmness of PLATEM (platelet component specific coagulation). The decreases in FIBTEM (fibrinogen specific coagulation) maximum clot firmness and fibrinogen at the intensive care unit admission were comparable. Test results outside the reference range were associated with higher median blood loss when compared to values within the reference range, with most significant association for fibrinogen (p < 0.001) and FIBTEM maximal clot firmness (p = 0.016). At baseline, the ability of rotational thromboelastometry parameters to predict postoperative blood loss >1000 mL is higher than the predictive value of fibrinogen (area under the curve = 0.642; 95% confidence interval: 0.487–0.796), but only areas under the curve of APTEM (extrinsically activated coagulation with exclusion of fibrinolysis component) were significantly higher (p⩽0.05). At intensive care unit admission, the highest area under the curve was 0.689 (95% confidence interval: 0.549–0.828) for FIBTEM maximum clot firmness.

Rotational thromboelastometry could be a useful point-of-care method to monitor haemostasis because it is a faster and more informative method, and it has a slightly higher predictive ability for blood loss compared to fibrinogen.

Descending necrotizing mediastinitis has been known to be a life-threatening condition. It is most likely to be lethal without a prompt diagnosis and aggressive surgical management. In the surgical management of this subset of mediastinitis, a debate remains as to whether a transthoracic incision should be mandatory in addition to cervical approach.

This is a single-center retrospective study performed at Cipto Mangunkusumo Hospital from January 2012 to June 2014. Patients with descending necrotizing mediastinitis were treated with broad-spectrum antibiotics and with cervical and transthoracic approach (via sternotomy) surgical debridement.

There were 16 consecutive cases of descending necrotizing mediastinitis. One patient did not undergo sternotomy and was ruled out from the study. The mean intensive care unit stay was 26.4 days, with a mean hospital stay of 46.7 days. There were three mortality cases reported and a total of three cases that needed reoperation. There was neither post-operative sternal dehiscence nor osteomyelitis found.

Considering there are no post-operative sternal-related infection reported in this study, sternotomy should be considered as an access in descending necrotizing mediastinitis management. In the three mortality cases reported, two patients came with preoperative sepsis and one had iatrogenic subclavian artery injury.

Aortic dissection requires operation for some reasons.

We experienced a case for infected thrombus caused by Escherichia coli in the false lumen of the descending aorta 3 years after ascending aortic replacement for acute aortic dissection.

A deep sternal wound infection caused by Staphylococcus species after the initial surgery had been successfully treated with both administration of antibiotics for 8 weeks and omental transfer. Replacement of the descending aorta resulted in successful outcomes.

A thrombosed false lumen with a low blood flow may be vulnerable to bacteremia.

The aim was to examine the predictability of stage of disease (FEV₁) and measures of strength (arm and leg) to arm and leg ergometry capacity of patients with chronic respiratory diseases.

A total of 44 chronic respiratory disease patients, 16 males and 28 females (mean age = 59.8 ± 11.9 years), with an FEV₁ of 22%–89% predicted (mean FEV₁% predicted = 54.6 ± 18.3) participated. All participants completed spirometry, Medical Research Council grade, anthropometric assessment, submaximal arm and leg ergometry testing, grip strength, and isokinetic quadriceps and hamstrings strength and endurance testing.

To determine contributing and predictor variables of arm and leg ergometry capacity, multiple linear and binary regression analyses were performed. Multiple regression analysis demonstrated that quadriceps strength (N m), FEV₁% and grip strength (kg) predicted 64% of peak wattage during submaximal leg ergometry testing (adjusted R² = 64%, F = 26.387 and p = 0.00). Quadriceps strength showed the highest predictability of peak leg ergometry wattage (p = 0.00, β = 0.844 and t = 6.238), followed by grip strength and FEV₁% (p = 0.038, β = −0.270 and t = −2.143 and p = 0.028, β = −0.230 and t = 2.279, respectively). A second regression analysis determined that quadriceps strength (N m), FEV₁% and grip strength (kg) predicted 53% of peak wattage during submaximal arm ergometry testing (adjusted R² = 0.53, F = 17.018 and p = 0.00). Quadriceps strength was the only independent variable that showed predictability of peak arm ergometry wattage (p = 0.00, β = 0.793 and t = 5.125). The odds ratio analysis indicated that chronic respiratory disease patients with high quadriceps strength have 13.76 times higher odds of having high peak arm ergometry wattage. This odds ratio equated to an 85% probability of having high arm ergometry peak wattage if quadriceps strength is high.

In summary, the main factors predicting leg ergometry capacity were quadriceps strength, FEV₁ and grip strength. Quadriceps strength was the only statistically significant predictor of peak arm ergometry wattage, suggesting a relationship between arm and leg functionality in chronic obstructive pulmonary disease patients.

Pulmonary embolism may cause cardiac arrest secondary to obstruction of blood flow. Traditional treatment strategies include anticoagulation, thrombolysis, and mechanical extraction. Some advocate for support with extra corporeal membrane oxygenation; however, surgical therapies are contraindicated following thrombolytics.

We describe the emergent use of peripheral extra corporeal membrane oxygenation following thrombolytic therapy for a saddle pulmonary embolism associated with multiple episodes of cardiac arrest.

The patient was stabilized with peripheral extra corporeal membrane oxygenation, anticoagulated and subsequently weaned from extra corporeal membrane oxygenation without any major bleeding complications.

The administration of thrombolytics should not be a contraindication for extra corporeal membrane oxygenation in patients with massive pulmonary embolism associated with hemodynamic instability.

Infective endocarditis is a microbial infection of the endothelial surface of heart and great vessels frequently involving Mitral and Aortic valve. Pulmonary valve endocarditis leading to Severe Pulmonary Regurgitation is extremely rare and is often diagnosed late due to non specificity of symptoms. We intend to report such a case to bring the attention of everyone the long term consequences of Pulmonary Regurgitation. Here we also describe method of replacing Pulmonary valve with Bioprosthetic Aortic valve.

We describe the technique of replacement of pulmonary valve with Bioprosthetic Aortic valve in case of severe Pulmonary regurgitation.

The patient successfully underwent replacement of both Pulmonary and Tricuspid valve with bioprosthetic valve and was discharged from the hospital on seventh post operative day. During successive follow up there was considerable improvement in exercise tolerance and she being presently in NYHA class II.

Pulmonary valve replacement with bioprosthetic tissue valve should be considered for patients with Pulmonary regurgitation and volume overload of Right ventricle. Emphasis should be on Right ventricle dilatation before setting of RV dysfunction rather then severity of Pulmonary regurgitation alone.