Long-term viability and extensibility of an in situ regenerated canine aortic wall using hybrid warp-knitted fabric

Open in a separate window OBJECTIVESMany surgical materials promoting tissue regeneration have been explored for use in paediatric cardiac surgery. The aim of this study is to evaluate the long-term viability and extensibility of the canine aortic wall regenerated using a novel synthetic hybrid fabric.METHODSThe sheet is a warp-knitted fabric of biodegradable (poly-l-lactic acid) and non-biodegradable (polyethylene terephthalate) yarns coated with cross-linked gelatine. This material was implanted as a patch to fill an oval-shaped defect created in the canine descending aorta. The tissue samples were explanted after 12, 24 or 36 months (N = 3, 2, 2, respectively) for histological examination and biomechanical testing.RESULTSThere was no shrinkage, rupture or aneurysmal change after 24 months. The regenerated wall showed prototypical vascular healing without material degeneration, chronic inflammation, calcification or abnormal intimal overgrowth. Bridging tissue across the patch was well-formed and had expanded over time. The biodegradable yarns had completely degraded at 24 months after implantation, as scheduled, but the regenerated aortic wall demonstrated satisfactory levels of mechanical strength and extensibility in tensile strength tests.CONCLUSIONSThe sheet achieved good long-term viability and extensibility in the regenerated aortic wall. These findings suggest that it is a promising surgical material for repairing congenital heart defects. Further developments of the sheet are required, including clinical studies.     

Can surgical repair for pectus excavatum contribute to lung growth?

 Open in a separate windowOBJECTIVESThis study investigates whether the surgical correction of chest deformity is associated with the growth of the lung parenchyma after surgery for pectus excavatum.METHODSTen patients with pectus excavatum who were treated by the Nuss procedure were examined. The preoperative and postoperative computed tomography (2.5 ± 1.2 years after surgery) scans were performed, and the Haller index, lung volume and lung density were analyzed using a three-dimensional image analysis system (SYNAPSE VINCENT, Fujifilm, Japan). The radiological lung weight was calculated as follows: lung volume (ml) × lung density (g/ml).RESULTSThe average age of the 10 patients (men 8; women 2) was 13.8 years (range: 6–26 years). The Haller index was significantly improved from the preoperative value of 5.18 ± 2.20 to the postoperative value of 3.68 ± 1.38 (P = 0.0025). Both the lung volume and weight had significantly increased by 107.1 ± 19.6% and 121.6 ± 11.3%, respectively, after surgery.CONCLUSIONSA significant increase in the weight of the lung after surgical correction suggests that the growth of the lung parenchyma is associated with the correction of chest deformity in younger patients with pectus excavatum.     

The efficacy of transbronchial indocyanine green instillation for fluorescent-guided wedge resection

 Open in a separate windowOBJECTIVESThe purpose of this study was to investigate the feasibility of lung wedge resection by combining 3-dimensional (3D) image analysis with transbronchial indocyanine green (ICG) instillation, in order to delineate the intended area for resection.METHODSFrom December 2017 to July 2020, 28 patients undergoing wedge resection (17 primary lung cancers, 11 metastatic lung tumours) were enrolled, and fluorescence-guided wedge resection was attempted. Virtual sublobar resections were created preoperatively for each patient using a 3D Image Analyzer. Surgical margins were measured in each sublobar resection simulation in order to select the most optimal surgical resection area. After transbronchial instillation of ICG, near-infrared thoracoscopic visualization allowed matching of the intended area for resection to the virtual sublobar resection area. To investigate the effectiveness of ICG instillation, the clarity of the ICG-florescent border was evaluated, and the distance from the true tumour to the surgical margins was compared to that of simulation.RESULTSMean tumour diameter was 12.4 ± 4.3 mm. The entire targeted tumour was included in resected specimens of all patients (100% success rate). The shortest distances to the surgical margin via 3D simulation and by actual measurement of the specimen were11.4 ± 5.4 and 12.2 ± 4.1 mm, respectively (P = 0.285) and were well correlated (R² = 0.437). While all specimens had negative malignant cells at the surgical margins, one loco-regional recurrence was observed secondary to the dissemination of neuroendocrine carcinoma.CONCLUSIONSICG-guided lung wedge resection after transbronchial ICG instillation and preoperative 3D image analysis allow for adequate negative surgical margins, providing decreased risk of local recurrence.     

Total arch replacement in octogenarians

 Open in a separate windowOBJECTIVESWe investigated the effect of a preoperative age ≥80 years on postoperative outcomes in patients who underwent isolated elective total arch replacement using mild hypothermic lower body circulatory arrest with bilateral antegrade selective cerebral perfusion.METHODSA total of 140 patients who had undergone isolated elective total arch replacement between January 2007 and December 2020 were enrolled in the present study. We compared postoperative outcomes between 30 octogenarian patients (≥80 years old; Octogenarian group) and 110 non-octogenarian patients (≤79 years old; Non-Octogenarian group).RESULTSOverall 30-day mortality and hospital mortality were 0% in both groups, and there was no significant difference in overall survival between the 2 groups (log-rank test, P = 0.108). Univariable Cox proportional hazard analysis showed that age as continuous variable was only the predictor of mid-term all-cause death (hazard ratio 1.08, 95% confidence interval 1.01–1.16; P = 0.037), but not in the Octogenarians subgroup (P = 0.119).CONCLUSIONSPreoperative age ≥80 years is not associated with worse outcomes postoperatively after isolated elective total arch replacement with mild hypothermic lower body circulatory arrest and bilateral antegrade selective cerebral perfusion.     

Late surgical conversion of failed Multilayer Flow Modulator stenting in thoraco-abdominal aneurysms

 Open in a separate windowOBJECTIVESThe aim of this study was to report the outcomes of open or hybrid repair of failed thoraco-abdominal aortic aneurysm endovascular treatment with Multilayer Flow Modulator (MFM) stents.METHODSAll patients who underwent open or hybrid repair of a failed MFM aortic treatment were retrospectively analysed. Perioperative and postoperative data, as well as midterm survival, were assessed.RESULTSBetween 2013 and 2020, 39 patients received an open or hybrid conversion after endovascular treatment. Five of them [13%; 4 males; median age 68 years (interquartile range 66–76)] were previously treated with aortic MFM stents (Cardiatis, Isnes, Belgium). Among these, the median interval between index repair and conversion was 84 months (interquartile range 75–84). The median aneurysm diameter was 9.6 cm (interquartile range 8–10). Renovisceral vessels steno-occlusion was highly prevalent: 2 renal arteries were occluded; 3 coeliac trunks, 2 renal arteries and 1 superior mesenteric artery had a >70% ostial stenosis. Open standard thoraco-abdominal aneurysm conversion was performed in 3 fit patients, while a hybrid approach with visceral debranching and tube endografting was performed in 2 high-risk patients. Two patients (2 open repairs) died intraoperatively, and 1 (hybrid repair) postoperatively. The 2 successfully treated patients are alive at 4- and 34-month follow-up, respectively, with patent visceral branches.CONCLUSIONSOpen or hybrid thoraco-abdominal aortic aneurysm treatment after failed endovascular aortic repair with MFM stents might be the only surgical option to address sac enlargements and ruptures or branch-related failures. However, both procedures had a poor prognosis due to both the impaired preoperative patient’s status and the surgical complexity in the presented series.     

Modified capitonnage technique for giant pulmonary hydatid cyst surgery

 Open in a separate windowOBJECTIVESThis study investigated the effectiveness of the modified technique (Aydin Technique), which was applied for capitonnage in the surgical treatment of giant pulmonary hydatid cysts.METHODSTwenty-two cases were operated on for giant hydatid cysts with a total of 23 modified techniques for capitonnage (bilateral giant hydatid cyst in 1 case) in our clinic between January 2018 and December 2020. The demographic data were recorded.RESULTSThirteen out of 22 (59.1%) of cases were male and 9 (40.9%) were female. The mean age was 22.0 ± 15.8 and 14 cases (63.6%) were children. Hydatid cysts were intact in 13 (56.5%) cases and ruptured in 10 (43.5%) cases. Hydatid cyst diameters were on average 123 ± 21 mm. A modified method was performed for capitonnage in all cases while decortication was performed in 2 (8.7%) cases due to pleural thickening. Radiological atelectasis was observed in 6 cases (27.3%) postoperatively. The patients with atelectasis recovered without any clinical problem and no intervention was needed. In 1 case, an infection developed at the incision site. Postoperative prolonged air leak, empyema and mortality were not observed in any of the cases. The postoperative mean length of hospital stay was 7.18 ± 2.15 days. The mean follow-up period was 19.5 ± 11.5 months. No recurrence was encountered in the follow-up of the patients.CONCLUSIONSThe results of this study may suggest to perform this new-described modified Aydin technique to avoid major capitonnage complications of the giant pulmonary hydatid cyst surgery.     

Aortic valve neocuspidization with in-body tissue-engineered autologous membranes: preliminary results in a long-term goat model

 Open in a separate windowOBJECTIVESAortic valve neocuspidization has shown satisfactory clinical outcomes; however, autologous pericardium durability is a concern for young patients. This study applied an autologous collagenous membrane (Biosheet^®), produced by in-body tissue architecture, to aortic valve neocuspidization and investigated its long-term outcome in a goat model.METHODSMoulds were embedded subcutaneously in 6 goats. After 2 months, Biosheets formed in the moulds. We performed aortic valve neocuspidization using a portion of the sheets with a thickness of 0.20–0.35 mm, measured by optical coherence tomography. Animals were subjected to echocardiography and histological evaluation at 6 months (n = 3) and 12 months (n = 3). As a control, the glutaraldehyde-treated autologous pericardium was used in 4 goats that were similarly evaluated at 12 months.RESULTSAll animals survived the scheduled period. At 6 months, Biosheets maintained valve function and showed a regeneration response: fusion to the annulus, cell infiltration to the leaflets and appearance of elastic fibres at the ventricular side. After 12 months, the regenerative structure had changed little without regression, and there was negligible calcification in the 1/9 leaflets. However, all cases had one leaflet tear, resulting in moderate-to-severe aortic regurgitation. In the pericardium group, three-fourths of the animals experienced moderate-to-severe aortic regurgitation with a high rate of calcification (9/12 leaflets).CONCLUSIONSBiosheets may have regeneration potential and anti-calcification properties in contrast to autologous pericardium. However, in order to obtain reliable outcome, further improvements are required to strictly control and optimize its thickness, density and homogeneity.     

Work in progress report of a multicentre retrospective observational study to evaluate the association between the airflows and the intrapleural pressures digitally recorded after video-assisted lobectomy

 Open in a separate windowOBJECTIVESDigital chest drainage systems allow real-time and continuous monitoring and recording of air leak flow rate and intrapleural pressure (IPP) from the immediate postoperative period to the chest drainage removal. A multicentre retrospective observational analysis of consecutive patients undergoing pulmonary lobectomy for lung cancer was performed to evaluate the association between the airflow and IPP digitally recorded during the immediate postoperative period after video-assisted thoracic surgery (VATS) lobectomy for lung cancer. Here, we present a work in progress report. METHODSAll patients treated with VATS lobectomies for lung cancer were included. Multiple airflow measurements and minimum and maximum IPP through the chest tubes were digitally monitored and recorded using microelectronic mechanical sensor technology. The PALs were defined as an air leak lasting >5 days from the conclusion of the surgical procedure. The cessation of air leaks was defined as an airflow <10 ml/min during 6 consecutive hours.RESULTSThis analysis comprised 76 patients who underwent VATS lobectomy for lung cancer. Nineteen patients (25%) showed prolonged air leaks (PAL) (≥5 days). The operative time was higher in the PAL group (mean difference = 44 min) without a statistically significant difference. Before the 7th postoperative hours, there were no statistically significant differences in IPPs.CONCLUSIONSPatients with PAL showed less negative IPP in the first 24 postoperative hours. Therefore, the 7th—24th postoperative hours were critical in PAL prediction since the mechanism for PAL seems to develop after the 7th postoperative hour.     

Pulmonary valve prostheses: patient’s lifetime procedure load and durability. Evaluation of the German National Register for Congenital Heart Defects

 Open in a separate windowOBJECTIVESWe evaluated 4384 procedures performed between 1957 and 2018, collected in the National Register for Congenital Heart Defects, conducted on 997 patients with 1823 pulmonary valve replacements (PVRs), including 226 implanted via catheter [transcatheter valve (TCV)]. Main study targets are as follows: TCV benefit, valve type durability, decade-wise treatment changes and procedure frequencies over the lifetime of a PVR patient.METHODSWe studied TCV impact on surgical valve replacement (via Kaplan–Meier); pulmonary valve type-specific performance (Kaplan–Meier and Cox regressions with age group as stratification or ordinary variable); procedure interval changes over the decades (Kaplan–Meier); procedure load, i.e. frequency of any procedure/surgical PVR/interventional or surgical PVR by patient age (multistate analyses).RESULTSTCV performance was equivalent to surgical PVRs and extended durability significantly. Homografts were most durable; Contegras lasted comparably less in older; and Hancock devices lasted less in younger patients. Matrix P-valves showed poorer performance. Age group stratification improves the precision of valve-specific explantation hazard estimations. The current median interval between procedures is 2.6 years; it became significantly shorter in most age groups below 40 years. At 30 years, 80% of patients had undergone ≥3 procedures, 20% ≥3 surgical PVRs and 42% ≥3 surgical or interventional PVRs.CONCLUSIONSTCVs doubled freedom from explantation of conventional valves. Homografts’ age group-specific explantation hazard ratio was lowest; Matrix P’s hazard ratio was highest. Age-stratified Cox regressions improve the precision of prosthesis durability evaluations. The median time between procedures for PVR patients shortened significantly to 2.6 years. At 30 years, 42% had ≥3 PVRs.     

Chest wall resection and reconstruction for primary and metastatic sarcomas: an 11-year retrospective cohort study

 Open in a separate windowOBJECTIVESChest wall sarcomas are rare, aggressive malignancies, the management of which mainly revolves around surgery. Radical tumour excision with free margins represents the optimal treatment for loco-regional clinically resectable disease. The objective of this study was to review our 11-year experience with chest wall resection for primary and metastatic sarcomas, focusing on surgical techniques and strategies for reconstruction. METHODSRetrospective analysis of a comprehensive database of patients who underwent chest wall resection for primary or secondary sarcoma at our Institute from January 2009 to December 2019.RESULTSOut of 26 patients, 21 (81%) suffered from primary chest wall sarcoma, while 5 (19%) had recurring disease. The median number of resected ribs was 3. Sternal resection was performed in 6 cases (23%). Prosthetic thoracic reconstruction was deemed necessary in 24 cases (92%). Tumour recurrence was observed in 15 patients (58%). The median overall survival was 73.6 months. Primary and secondary tumours showed comparable survival (P = 0.49). At univariate analysis, disease recurrence and infiltrated margins on pathological specimens were associated with poorer survival (P = 0.014 and 0.022, respectively). In patients with primary sarcoma, the median progression-free survival was 13.3 months. Associated visceral resections were significantly associated to postoperative complications (P = 0.02).CONCLUSIONSChest wall resection followed by prosthetic reconstruction is feasible in carefully selected patients and should be performed by experienced surgeons with the aim of achieving free resection margins, resulting in improved long-term outcomes.     

The feasibility of mitral valve device foldoplasty: an in vivo study to evaluate durable retention

 Open in a separate windowOBJECTIVESWe have previously shown in experimental settings that a leaflet foldoplasty device reduces redundant leaflet area to re-establish mitral valve (MV) coaptation. The current study investigates the in vivo device retention and functional durability following foldoplasty.METHODSThe prototype is of superelastic nitinol formed into a 3-dimensional shape. It is unfolded to engage a specified area of leaflet tissue and then folded to exclude this tissue from the coaptation surface. Design modifications were made and tested in benchtop studies to determine the optimal design for durable retention within the leaflet. To evaluate in vivo performance, posterior leaflet chordae were severed in Yorkshire pigs to produce complete posterior leaflet prolapse and severe mitral regurgitation. Design modifications were then used for MV repair. Five animals that underwent repair using the optimal design were observed for 2 weeks postoperative to evaluate the functional result and implant retention.RESULTSDevice position and orientation were maintained at 2 weeks while preserving the functional MV repair in all 5 animals. Coaptation height was 5.5 ± 1.5 mm, which was not significantly different from a baseline of 4.9 ± 0.8 mm. The degree of leaflet excursion was 41.0 ± 16.0 compared to a baseline of 58.7 ± 27.5.CONCLUSIONSDevice foldoplasty is a new concept for MV repair based on the reduction of redundant leaflet tissue area. This study demonstrates the feasibility of safe maintenance of this repair without early dislodgement or embolization.     

Impact of skeletonized harvesting of the internal thoracic artery on intrasternal microcirculation considering preparation quality

 Open in a separate windowOBJECTIVESPrevious studies have demonstrated the impact of internal thoracic artery (ITA) harvesting on microcirculation in parasternal tissues. However, the impact of skeletonized ITA harvesting on intrasternal microcirculation is unknown. Intraskeletal tissue perfusion has been proven to be crucial for deep wound healing. Furthermore, the impact of different levels of surgical preparation quality on intrasternal microcirculation has not been investigated yet.METHODSSternal microcirculation (sLDP) was monitored with a novel Laser Doppler Perfusion needle probe, while the ITA was skeletonized in a pig model. To mimic different levels of preparation quality, satellite veins were either coagulated or not during preparation. To show the effect of ideally avoiding any surgical manipulation on sLDP, the ITA was clipped in a third sham-harvested group. RESULTSsLDP was reduced highly significant to 71 [standard deviation (SD): 9]% (P < 0.001) after skeletonized harvesting of the ITA. Coagulation of the satellite veins as a detrimental surgical factor resulted in a significantly stronger reduction of sLDP to 56 (SD: 11)% (P < 0.05) compared to sLDP with non-coagulated satellite veins. ITA clipping reduced sLDP highly significant to 71 (SD: 8)% (P < 0.001) in the sham-operated group.CONCLUSIONSITA harvesting markedly impairs microcirculation of the sternum but remains unavoidable when coronary artery bypass grafting should be performed. Nevertheless, excessive surgical damage and coagulation of satellite veins is avoidable and should be reduced to a minimum to minimize the risk of deep sternal wound healing complications.     

Simultaneous transcatheter treatment of ascending aortic aneurysm with aortic and mitral regurgitation: an in vitro study

 Open in a separate windowOBJECTIVESWe sought to explore the efficacy of the endovascular repair of an ascending aortic aneurysm with aortic and mitral regurgitation by 2 novel valved stents.METHODSWe established models of ascending aortic aneurysms combined with aortic and mitral regurgitation in 10 pig hearts, then implanted self-expanding aortic fenestrated and mitral valved stents via the transapical approach. We applied a fluoroscopy-guided in vitro setting to test the approach, then analysed continuous circulating flushing at 37°C. Finally, we determined operating times, echocardiography and changes of coronary flow as well as fenestration alignment with the coronary ostia.RESULTSThis approach resulted in a 100% overall technical success rate, excellent handling properties and precise positioning. The time taken to implant the 2 valved stents was 59 ± 12 min. Flow of the left and right coronary arteries did not significantly decrease after the stents were implanted (330.4 ± 12.06 ml/min vs 289.4 ± 5.29 ml/min, P < 0.001; 376.8 ± 10.5 ml/min vs 350.0 ± 14.5 ml/min; P < 0.001). We found no obvious regurgitation and perivalvular leakage; nor did the gradients of the aortic and mitral valves as well as of the left ventricular outflow tract increase significantly. The final angiographic examination and profile of the coronary opening confirmed the good position of the valved stents, the exclusion of the aneurysm and the patency of both coronary arteries.CONCLUSIONSThese findings indicate the potential for combined transcatheter aortic root and mitral valve replacement in treating aortic root pathologies. In future, in vivo studies are expected to validate this approach and ascertain its durability.     

Surgery for mediastinal neurogenic tumours: a 25-year single-centre retrospective study

 Open in a separate windowOBJECTIVESMediastinal neurogenic tumours are uncommon and often benign neoplasms mostly located in the posterior mediastinum and usually diagnosed incidentally. We reviewed our results after surgical resection. We compared patient characteristics and tumour nature between children and adults. Differences between thoracoscopic and open approach were analysed.METHODSDepartmental thoracic surgical database was queried for primary mediastinal neurogenic tumours resected between 1992 and 2017. Data included demographics, pathology, tumour nature, symptoms, surgical approach and postoperative morbidity/mortality.RESULTSFifty-one patients (8 children and 43 adults) underwent tumour resection. Pathology revealed nerve sheath tumour in 1 child (12.5%) versus 36 adults (83.7%; P < 0.001) and ganglion cell tumour in 7 (87.5%) versus 5 (11.6%; P < 0.001). Two adults had a paraganglioma. Malignancy was present in 2 children (25%) versus 2 adults (4.6%; P = 0.049). All malignant tumours caused symptoms while most patients with benign tumours (38/47) were asymptomatic (P < 0.001). Surgical approach included thoracotomy, thoracoscopy and cervicotomy (n = 19/31/1) of which 2 were combined neurosurgical approach. All malignant tumours were approached via thoracotomy while the majority of patients with benign tumours (31/47) underwent thoracoscopy (P = 0.007). No significant difference was noted in overall morbidity between thoracoscopic versus open approach (45.2% vs 42.1%; P = 0.83). Hospital stay was significantly shorter following thoracoscopy (7.4 ± 3.3 vs 13.1 ± 9.8 days; P = 0.001).CONCLUSIONSChildren carry a higher incidence to present with a malignant tumour originating from ganglion cells while most tumours in adults are benign, originating from the nerve sheath. The majority of patients with mediastinal neurogenic tumours are asymptomatic. Most tumours are amenable for thoracoscopic resection.     

Measured versus predicted postoperative pulmonary function at repeated times up to 1 year after lobectomy

 Open in a separate windowOBJECTIVESPostoperative pulmonary function is difficult to predict accurately, because it changes from the time of the operation and is also affected by various factors. The objective of this study was to assess the accuracy of predicted postoperative forced expiratory volume in 1 s (FEV1) at different postoperative times after lobectomy.METHODSThis retrospective study enrolled 104 patients who underwent lobectomy by video-assisted thoracic surgery. Pulmonary function tests were performed preoperatively and postoperatively at 3, 6 and 12 months. We investigated time-dependent changes in FEV1. In addition, the ratio of measured to predicted postoperative FEV1 calculated by the subsegmental method was evaluated to identify the factors associated with variations in postoperative FEV1.RESULTSCompared with the predicted postoperative FEV1, the measured postoperative FEV1 was 8% higher at 3 months, 11% higher at 6 months and 13% higher at 12 months. The measured postoperative FEV1 significantly increased from 3 to 6 months (P = 0.002) and from 6 to 12 months (P = 0.015) after lobectomy resected lobe, smoking history and body mass index were significant factors associated with the ratio of measured to predicted postoperative FEV1 at 12 months (P < 0.001, P = 0.036 and P = 0.025, respectively).CONCLUSIONSPostoperative FEV1 increased up to 12 months after lobectomy by video-assisted thoracic surgery. The predicted postoperative pulmonary function was underestimated after 3 months, particularly after lower lobectomy.     

Internal thoracic artery graft ipsilateral to the arteriovenous fistula in haemodialysis patients

 Open in a separate windowOBJECTIVESThe aim of this study was to investigate the impact of in situ internal thoracic artery (ITA) grafting ipsilateral to the arteriovenous fistula (AVF) on postoperative outcomes in haemodialysis patients undergoing isolated coronary artery bypass grafting (CABG).METHODSWe reviewed 132 haemodialysis patients who underwent isolated CABG between January 2002 and December 2019. With a difference between the left and right upper arms blood pressure measurement of ≥20 mmHg, we did not use the ITA on the lower value side. We categorized patients into 55 patients (41.7%, ipsilateral group) whose left anterior descending artery was revascularized using the in situ ITA ipsilateral to the AVF, and 77 patients (58.3%, contralateral group) whose left anterior descending artery was revascularized using the ITA opposite the AVF. We compared patients’ postoperative outcomes after adjusting for their backgrounds using weighted logistic regression analysis and inverse probability of treatment weighting.RESULTSNo patients developed coronary steal postoperatively, and there was no significant difference in 30-day mortality between the groups (P = 0.353). The adjusted 5-year estimated rates of freedom from all-cause and cardiac death in the ipsilateral vs contralateral groups were 52.3% vs 54.0% and 78.2% vs 88.6%, respectively; survival curves were not statistically significantly different (P = 0.762 and P = 0.229, respectively).CONCLUSIONS In situ ITA grafting ipsilateral to the AVF was not associated with postoperative early and mid-term worse outcomes in haemodialysis patients undergoing isolated CABG.     

Minimal invasive temporary percutaneous right ventricular circulatory support after left ventricular assist device implantation

 Open in a separate windowOBJECTIVESCardiogenic shock is a life-threatening situation with high mortality rates. Mechanical unloading of the left ventricle may be achieved via left ventricular assist device (LVAD) implantation. Postoperative right ventricular (RV) failure, however, has very limited therapeutic options and is associated with increased postoperative mortality. In this paper, we describe a percutaneous right heart bypass for temporary postoperative RV support.METHODSWe retrospectively examined all patients receiving percutaneous RV mechanical support after LVAD implantation. All patients receiving trans-jugular mechanical right heart bypass during or after LVAD implantation in our tertiary medical centre between November 2014 and December 2019 were examined retrospectively. The venous draining cannula was placed in the femoral vein; the pulmonary cannula was placed in the pulmonary artery using fluoroscopy.RESULTSIn total, 14 patients received RV support using the trans-jugular technique. Mean age was 48.4 ± 14.9 years. Nine patients were treated with mechanical circulatory support before LVAD implantation. Biventricular support was done in 7 patients. All patients were treated with an Heartware HVAD . Mean postoperative intensive care unit stay was 46.3 ± 32.4 days. Mean right heart bypass support time was 10.6 ± 4.3 days. Twelve patients (86%) could be bridged to RV recovery, RV assist device implantation or heart transplantation.CONCLUSIONSPercutaneous RV mechanical support is feasible, safe and shows acceptable outcome. Early implantation of RV support may contribute to successful outcome after LVAD implantation.     

Valve-sparing aortic root replacement in adult patients with congenital heart disease

 Open in a separate windowOBJECTIVESAortic root dilatation is frequently observed in patients with congenital heart defects (CHD), but has received little attention in terms of developing a best practice approach for treatment. In this study, we analysed our experience with aortic valve-sparing root replacement in patients following previous operations to repair CHD.METHODSIn this study, we included 7 patients with a history of previous surgery for CHD who underwent aortic valve-sparing operations. The underlying initial defects were tetralogy of Fallot (n = 3), transposition of great arteries (n = 2), coarctation of the aorta (n = 1), and pulmonary atresia with ventricle septum defect (n = 1). The patients’ age ranged from 20 to 40 years (mean age 31 ± 6 years).RESULTSDavid reimplantation was performed in 6 patients and a Yacoub remodelling procedure was performed in 1 patient. Four patients underwent simultaneous pulmonary valve replacement. The mean interval between the corrective procedure for CHD and the aortic valve-sparing surgery was 26 ± 3 years. There was no operative or late mortality. The patient with transposition of great arteries following an arterial switch operation was re-operated 25 months after the valve-sparing procedure due to severe aortic regurgitation. In all other patients, the aortic valve regurgitation was mild or negligible at the latest follow-up (mean 8.7 years, range 2.1–15.1 years).CONCLUSIONSValve-sparing aortic root replacement resulted in good aortic valve function during the first decade of observation in 6 of 7 patients. This approach can offer a viable alternative to root replacement with mechanical or biological prostheses in selected patients following CHD repair.     

Superior vena cava graft infection in thoracic surgery: a retrospective study of the French EPITHOR database

 Open in a separate windowOBJECTIVESTo report our experience on the management of superior vena cava graft infection.METHODSBetween 2001 and 2018, patients with superior vena cava synthetic graft or patch reconstruction after resection of intrathoracic tumours or benign disease were selected retrospectively from the French EPITHOR database and participating thoracic centres. Our study population includes patients with superior vena cava graft infection, defined according to the MAGIC consensus. Superior vena cava synthetic grafts in an empyema or mediastinitis were considered as infected.RESULTSOf 111 eligible patients, superior vena cava graft infection occurred in 12 (11.9%) patients with a polytetrafluoroethylene graft secondary to contiguous contamination. Management consisted of either conservative treatment with chest tube drainage and antibiotics (n = 3) or a surgical graft-sparing strategy (n = 9). Recurrence of infection appears in 6 patients. Graft removal was performed in 2 patients among the 5 reoperated patients. The operative mortality rate was 25%.CONCLUSIONSSuperior vena cava graft infection may develop as a surgical site infection secondary to early mediastinitis or empyema. Graft removal is not always mandatory but should be considered in late or recurrent graft infection or in infections caused by aggressive microorganisms (virulent or multidrug resistant bacteria or fungi).