Asian Cardiovascular and Thoracic Annals

Background: this study was performed to assess the results of aortic valve replacement in children with biological substitutes including homografts, pulmonary autografts (Ross procedure), and aortic valve reconstruction with autologous pericardium (Duran technique).

Methods: between March 1992 and July 2009, 73 children with aortic valve disease (mean age, 11.8 ± 2.7 years) underwent aortic valve replacement with biological substitutes including homografts, pulmonary autografts, and aortic valve reconstruction with autologous pericardium. Associated procedures were mitral valve repair in 32 and subaortic membrane resection in 3.

Results: early mortality was 1.4% (1 patient). Median follow-up was 94 months. Sixty (83.3%) survivors had insignificant aortic regurgitation. Reoperation was required in 7 (9.6%) patients: for autograft dysfunction alone in 2, autograft failure and failed mitral valve repair in 2, autograft dysfunction with severe pulmonary homograft regurgitation in 1, severe homograft aortic valve regurgitation in 1, and right ventricular outflow tract obstruction in 1. There were 4 (5.4%) late deaths. Actuarial reoperation-free, event-free, and aortic valve dysfunction-free survival were 92.5% ± 4%, 93.4% ± 3.3 %, 94% ± 2.9%, 86.2% ± 4.3%, respectively, at 94 months.

Conclusions: aortic valve replacement with biological substitutes is associated with acceptable hemodynamics and midterm results.

Background: Elevated high-sensitive C-reactive protein is a powerful independent predictor of cardiovascular events. However, there are scant data on its impact on midterm or long-term outcomes of coronary artery bypass grafting.

Method: We analyzed data of 2863 patients who underwent coronary artery bypass in 2006–2007. Early endpoints were hospital mortality and major morbidity. Midterm endpoints were overall mortality, major adverse cardiovascular events, and heart failure.

Results: During hospital stay, 26 patients died and 288 suffered major morbidity. After 3.6 years of follow-up, 56 patients had died, 105 had major adverse cardiovascular events, and 70 developed heart failure. Multivariate analysis revealed every 1 mg·L⁻¹ increase of high-sensitive C-reactive protein was associated with increased odds ratio for early mortality (odds ratio = 2.50, p = 0.002), major morbidity (odds ratio = 1.38, p = 0.02), and hazard ratio for midterm mortality (hazard ratio = 1.68, p = 0.03), major adverse cardiovascular events (hazard ratio = 1.48, p = 0.04), and heart failure (hazard ratio = 1.88, p = 0.01). Preoperative high-sensitive C-reactive protein > 2.5 mg·L⁻¹ predicted higher risks of early (hazard ratio = 2.69, p = 0.02) and midterm mortality (hazard ratio = 1.92, p = 0.02), major morbidity (hazard ratio = 1.46, p = 0.004), major adverse cardiovascular events (hazard ratio = 2.06, p < 0.001), and heart failure (hazard ratio = 1.71, p = 0.03).

Conclusions: Elevated high-sensitive C-reactive protein (>2.5 mg·L⁻¹) predicts poor early and midterm outcomes after coronary artery bypass.

Objectives: Ring annuloplasty combined with coronary artery bypass grafting is the standard approach for treatment of patients with ischemic mitral regurgitation. We evaluated mitral valve hemodynamic performance and recurrence of mitral regurgitation after ring annuloplasty.

Patients and methods: 40 consecutive patients (mean age, 70 ± 8 years) with chronic ischemic mitral regurgitation grade ≥2+ received annuloplasty with an IMR ETlogix ring. During follow-up (25.9 ± 15.5 months), 84% of surviving patients underwent exercise stress echocardiography to assess recurrence of mitral regurgitation and differences between rest and exercise mitral valve hemodynamic performance.

Results: Hospital mortality was 10%. During follow-up, we found no significant differences between left ventricular ejection fraction or end-diastolic and end-systolic diameters pre- and postoperatively (41% vs. 45%, 59 vs. 56 mm, and 49 vs. 46 mm, respectively), but there was a significant increase in mitral mean gradient with exercise (3.3 ± 1.2 vs. 7.8 ± 4 mm Hg, p < 0.001). Two patients had mitral regurgitation ≥grade III–IV.

Conclusions: Mitral annuloplasty with the IMR ETlogix ring provides effective correction of chronic ischemic mitral regurgitation, but this technique may induce functional mitral stenosis.

Background: Off-pump coronary artery bypass surgery should have a significantly lower risk of postoperated bleeding than on-pump surgery. However, the use of a cell saver has been considered necessary, with significant additional cost incurred. Can we consider performing off-pump coronary artery bypass surgery without a cell saver?

Patients and methods: A prospective observational study was performed in 68 consecutive patients operated on for 2- or 3-vessel coronary lesions by the off-pump technique.

Results: The mean number of distal anastomoses was 2.7 ± 0.7. Both internal thoracic arteries were used in 45 patients, and sequential revascularization was performed in 27, with 140 (77.8%) arterial grafts. Cell savers were used in 21 (30.9%) patients. In these 21 patients, the mean volume retransfused after treatment was 315 ± 177 mL. Postoperatively, 11 (16.2%) patients were transfused with packed red blood cells, with a mean volume of 636 ± 234 mL per patient. The 2 factors identified as associated with a higher risk of autotransfusion were female sex and a lower preoperative hemoglobin.

Conclusions: The use of a cell saver in off-pump surgery is useless in most cases. Careful surgical hemostasis is essential to limit hypovolemia.

Background: This study aimed to compare preoperative baseline Sonoclot variables between acyanotic and cyanotic congenital heart disease patients.

Methods: 100 patients aged from infancy to 9-years were studied. Fifty patients each from the cyanotic and acyanotic groups were studied for sonoclot parameters preoperatively. After inhalational anesthetic induction, blood was collected from the arterial line and analyzed in a Sonoclot analyzer to measure Sonoclot activated coagulation time, clot rate, and platelet function.

Results: Sonoclot activated coagulation time was normal in both groups, but lower in the cyanotic group (127.95 ± 51.4 s) than the acyanotic group (147.85 ± 45.48 s; p = 0.54). Both groups had abnormal clot rates and platelet function. The clot rate was significantly lower in the cyanotic group (19.31 ± 10.68 Uċmin⁻¹) than acyanotic group (24.88 ± 9.23 Uċmin⁻¹; p = 0.009). Platelet function was deranged in 31% of patients (cyanotic, 59%; acyanotic, 8%; p < 0.001). Platelet function was the most severely affected baseline parameter.

Conclusions: Pediatric acyanotic and cyanotic congenital heart disease patients have deranged coagulation parameters as assessed by the Sonoclot analyzer. The abnormality is more marked in cyanotic patients. Platelet function is the most severely affected parameter. These baseline parameters in conjunction with post-bypass parameters for an individual patient will help in the formulation of specific blood component transfusion guidelines.

Objective: To assess the impact of pre-procedural remote ischemic preconditioning on the incidence of myocardial complications following percutaneous coronary intervention.

Background: Ischemic preconditioning of a remote vascular territory improves the subsequent ischemic tolerance of distant organs.

Method: The Myocardial Event Reduction with Ischemic Preconditioning Therapy (MERIT) trial recruited 80 consecutive patients undergoing elective angioplasty with drug-eluting stents to receive two 5-min lower limb tourniquet occlusions or an un-inflated tourniquet (controls) 1 h before the procedure. The primary outcome was troponin T level at 24 h. Secondary outcomes were intra-procedural chest pain and ST-segment deviation.

Results: 6 patients in the control group and 2 in the ischemic preconditioning group had pre-procedural raised troponin T (p = 0.23). This increased to 16 (40%) in the control group and 5 (12.5%) in the study group at 24 h (p = 0.01). Fewer patients in the study group experienced intra-procedural chest pain (1 vs. 7, p = 0.056). Mean ST-segment deviation time was 13 ± 35 s in the study group and 58 ± 118 s in the control group (p = 0.02). At a mean follow-up of 11 months, the major adverse cardiac event rate did not differ significantly between the groups.

Conclusion: These data suggest that ischemic preconditioning reduces the absolute risk of post-procedure cardiomyocyte necrosis by 27.5%, and reduces intra-procedural chest pain and ST-segment deviation in patients undergoing percutaneous coronary interventions. We suggest its routine use in percutaneous coronary intervention, although the long-term prognostic impact in this patient group warrants further investigation.

This study assessed cardiac and pulmonary dysfunction in 26 asymptomatic patients with beta-thalassemia major. This investigation was a case-controlled study considering 10–20-year-old patients with beta-thalassemia major and no cardiac or pulmonary symptoms. Healthy individuals matched for age and sex were used as controls. At 48–72 h after blood transfusion, the patients underwent echocardiography and spirometry by a cardiologist and a pulmonologist. The results were compared to those of the control group. The right and left myocardial performance index, preejection period/ejection time ratio, ejection fraction, acceleration time, isovolumic contraction time, and bilateral isovolumic relaxation times in the study group demonstrated significant differences from the data of the controls. Right deceleration time was significantly different between the 2 groups. Myocardial performance index, peak early velocity of the right heart, and peak atrial velocity-to-peak early velocity ratio of the right side by Doppler tissue imaging were also significantly different between the 2 groups. Spirometry showed a significant difference in forced expiratory volume in 1 s/forced vital capacity between groups. Based on spirometry, pulmonary involvement in the patients was 77% restrictive. These findings show that systolic and diastolic dysfunction of the heart and pulmonary disturbances are unavoidable in patients with beta-thalassemia major.

Objective and background: Central vein stenosis occurs commonly after instrumentation of the major thoracic veins. We aimed to investigate factors that contributed to this condition in an Asian hemodialysis population, and the results of intervention.

Patients and methods: Hemodialysis patients diagnosed with central vein stenosis between January 2003 and December 2008, were identified from the records of the National University Hospital, Singapore. Eligible controls had a minimum of 2 years of hemodialysis via an arteriovenous fistula and/or central venous catheter, without clinical or radiological evidence of central vein stenosis.

Results: Central vein stenosis was diagnosed in 108 patients. The most common presenting features were arm swelling (32%) and failed hemodialysis catheter insertion (28%). The median frequency of permanent hemodialysis catheter insertion in those who subsequently developed venous stenosis (1.44 per patient per year) was 4 times that of controls (0.36 per patient per year; p < 0.001). Ischemic heart disease (p = 0.03) and in certain patients, arteriovenous fistula surgery were associated with the development of central vein stenosis; whereas line sepsis, diabetes, and hypertension were not. Central vein angioplasty was attempted in 53 patients; the primary patency was 52% at 1 year.

Conclusion: Central vein stenosis is associated with a higher frequency of hemodialysis catheter insertion and access surgery. Efforts to decrease permanent hemodialysis catheter use should reduce the incidence of central vein stenosis.

Objective: this study investigated the relationship between various parameters of venous blood gas analysis of gastric fundus veins and cervical esophagogastric anastomotic leaks after transhiatal esophagectomy.

Background: decreased tissue perfusion is one of the causes of anastomotic leak. There are various methods used to assess gastric conduit perfusion, with different results, and we lack a reliable method.

Method: this descriptive study, performed from March 2008 to October 2010, consisted of 45 patients with esophageal cancer who underwent transhiatal esophagectomy. After gastrolysis, blood samples were taken from a gastric fundus vein and submitted for venous blood gas analysis. The cervical wounds were examined 5 days postoperatively. The patients were divided into 2 groups based on the presence of leakage, and mean values of the venous blood gas analysis were compared.

Results: we observed significant differences in mean pH, PCO₂, and O₂ saturation between the 2 groups (p = 0.04, p = 0.03, and p = 0.04, respectively).

Conclusion: venous blood gas analysis of gastric fundus veins appears to be a feasible and fast method for intraoperative assessment of microperfusion in the gastric fundus.

Objectives: bronchogenic cysts are uncommon congenital cystic lesions. Most are incidentally detected and require surgical excision for histological diagnosis, symptom relief, and to prevent complications. Video-assisted thoracoscopic resection is preferable in suitable patients. In this study, we reviewed the clinical presentation, diagnosis, and thoracoscopic treatment of bronchogenic cysts.

Methods: from January 2001 to December 2011, 14 patients with bronchogenic cyst underwent thoracoscopic surgery for excision of the cyst. Their mean age was 24 years. Twelve patients were symptomatic (85.71%).

Results: the average maximum diameter of the cysts was 6.7 cm. The most common location of the cyst was the mediastinum (n = 10, 71.4%). All bronchogenic cysts were completely excised. In 7 cases, the procedure was converted to thoracotomy. The mean hospital stay following thoracoscopic surgery was 4 days. There was no recurrence on follow-up.

Conclusions: thoracoscopic excision of a bronchogenic cyst should be considered the first-line therapeutic option. Proper preoperative case selection can prevent conversion to thoracotomy due to major pleural adhesions. There should be a low threshold for conversion to thoracotomy if complete excision of the cyst is not possible, because this is the main goal of treatment to prevent recurrence.

Syphilitic aortic aneurysms are uncommon today. A rare case of syphilitic aortic arch aneurysm with successful surgical treatment is reported. A 42-year-old man presented with upper airway obstruction. Chest radiography showed a superior mediastinal mass, and computed tomography revealed a large saccular aortic arch aneurysm that compressed the trachea. Dacron graft replacement of the aortic arch was successfully performed under circulatory arrest with antegrade cerebral perfusion.

A modification of the Lecompte procedure was used successfully for total correction in 2 boys aged 3 and 6 months with double-outlet left ventricle. The operative procedure and short-term results are evaluated.

A 39-year-old man presented with chest pain. Chest radiography and echocardiography indicated a possible cardiac tumor. Echocardiography, computed tomography, and magnetic resonance imaging revealed a tumor in the interatrial septum. The patient underwent tumor resection under cardiopulmonary bypass. A paraganglioma was diagnosed on the basis of histopathological findings.

A 69-year-old woman with invasive thymoma underwent chemoradiotherapy followed by surgical resection, including extended thymectomy, right upper lobectomy, and innominate vein and superior vena cava reconstruction with a polytetrafluoroethylene graft. Computed tomography on the 27th postoperative day revealed mediastinitis and right hemothorax; open debridement and evacuation were performed. Vacuum-assisted closure was initiated to heal the median incision. The wound gradually cleared, and the vacuum was terminated on the 150th postoperative day. On the 155th postoperative day, the patient suffered a sudden hemorrhage from the anterior thoracic wall. Computed tomography revealed a ruptured ascending aortic pseudoaneurysm surrounding the graft.

A right-sided aortic arch associated with an aberrant subclavian artery is a rare anomaly. Regardless, this condition is clinically relevant because mortality is associated with rupture, morbidity results from compression of mediastinal structures, and the surgery is complex. We describe the successful surgical repair of this vascular anomaly by totally debranching the neck vessels and placing an endovascular stent-graft to exclude the ruptured Kommerell’s diverticulum.

Cases of aorto-ventricular tunnel involving the right ventricle and more commonly, the left ventricle have been described. The site of origin is located above the right coronary cusp and occasionally, the left. We describe an aorto-left ventricular tunnel in a 16-year-old girl, with aneurysmal expansion into the right ventricular outflow tract. Its aortic origin was above the commissure of the right and noncoronary cusps of the aortic valve.

We report the case of a 47-year-old man with hypertrophic obstructive cardiomyopathy who underwent transcoronary ablation of septal hypertrophy and developed severe aortic regurgitation after the procedure. Intra-operatively, we found a wide perforation of the noncoronary cusp, and performed aortic valve replacement.

Pulmonary sequestration and mediastinal bronchogenic cysts are rare but well known to thoracic surgeons. However, their association is exceptional. We report such a case in a young adult. The common origin of these 2 malformations is discussed.

Synchronous carcinomas of the esophagus and other organs are relatively uncommon. A 65-year old man with synchronous carcinomas of the esophagus and stomach underwent esophageal reconstruction using a gastric tube following endoscopic submucosal dissection.

A 51-year-old man with adenoid cystic carcinoma in the main stem bronchus was treated by a left lower lobectomy. A 44-year-old man with adenoid cystic carcinoma in the peripheral small bronchi underwent a right sleeve upper lobectomy with tracheobronchoplasty and neo-carina reconstruction; because of positive tumor margins, radiotherapy was administered postoperatively. Both patients were alive without any signs of tumor after 30 and 24 months of follow-up, respectively.

Saphenous vein remains a widely used conduit in coronary surgery. However, the long-term success of surgical myocardial revascularization is largely limited by the development of neointimal hyperplasia and superimposed atherosclerosis in vein grafts. Although strategies for preventing vein graft failure have been constantly explored, few therapeutic interventions to date have shown sustained benefits in the clinical setting. The application of external support has emerged as a promising strategy for modulating the overall biomechanical responses in venous wall. Nonetheless, clinical translation of this intervention has been formerly challenged, primarily due to several technique limitations. The purpose of the current review is to summarize the possible mechanisms involved in the external support strategy for preventing vein graft failure. Furthermore, several previously tested biomaterials and delivery techniques are also highlighted.

Transaortic balloon catheter insertion for intra-aortic balloon assistance is a practical alternative to the standard transfemoral cannulation in patients with significant aortoiliac occlusive disease. We describe a technique whereby a transthoracic balloon is removed with the aid of video-assisted thoracoscopy.