Beating‐Heart Coronary Artery Bypass Grafting With Miniaturized Cardiopulmonary Bypass Results in a More Complete Revascularization When Compared to Off‐Pump Grafting

The technique of miniaturized cardiopulmonary bypass (M‐CPB) for beating‐heart coronary artery bypass grafting (CABG) is relatively new and has potential advantages when compared to conventional cardiopulmonary bypass (CPB). M‐CPB consists of less tubing length and requires less priming volume. The system is phosphorylcholine coated and results in minimal pump‐related inflammatory response and organ injury. Finally, this technique combines the advantages of the off‐pump CABG (OPCAB) with the better exposure provided by CPB to facilitate complete revascularization. The hypothesis is that CABG with M‐CPB has a better outcome in terms of complete coronary revascularization and perioperative results as that compared to off‐pump CABG (OPCAB). In a retrospective study, 302 patients underwent beating‐heart CABG, 117 (39%) of them with the use of M‐CPB and 185 (61%) with OPCAB. After propensity score matching 62 patients in both groups were demographically similar. The most important intra‐ and early‐postoperative parameters were analyzed. Endpoints were hospital mortality and complete revascularization. Hospital mortality was comparable between the groups. The revascularization was significantly more complete in M‐CPB patients than in patients in the OPCAB group. Beating‐heart CABG with M‐CPB is a safe procedure and it provides an optimal operative exposure with significantly more complete coronary revascularization when compared to OPCAB. Beating‐heart CABG with the support of a M‐CPB is the operation of choice when total coronary revascularization is needed.     

Efficacy of Carbon Dioxide Insufflation for Cerebral and Cardiac Protection During Open Heart Surgery: A Systematic Review and Meta‐Analysis

In spite of widespread application around the world, there has been controversy on the cerebral and cardiac protection efficacy of carbon dioxide insufflation (CDI) during open heart surgery. To make a comprehensive evaluation, we screened all relevant published randomized controlled trials to perform the first systematic review and meta‐analysis for CDI during open heart surgery. We searched PubMed, EMBASE, the Cochrane Controlled Clinical Trial register, WANFAN, CQVIP, and CNKI database for published articles. Randomized controlled trials were included when the research provided data of neurological complications postoperatively, creatinine kinase, MB isoenzyme (CK‐MB) on the first postoperative day, or all‐cause mortality. We chose a fixed‐effects model when the trials showed low heterogeneity, otherwise a random effects model was used. The quality of studies was assessed by modified Jadad scale. Four studies were included in this meta‐analysis. The overall pooled relative risk (RR) for neurological complications was 1.59, 95% confidence interval (CI) = [0.57, 4.46], and the z‐score for overall effect was 0.89 (P = 0.37). The standardized mean difference of the CK‐MB between groups was 1.15, 95% CI = [?1.27, 3.56], and the z‐score for overall effect was 0.93 (P = 0.35). The overall pooled RR for all‐cause mortality was 0.5, 95% CI = [0.16, 1.64], and the z‐score for overall effect was 1.14 (P = 0.25). There was no significant difference between groups. Because of the insufficiency of powerful evidences, the cerebral and cardiac protection efficacy of CDI during open heart surgery needs to be further verified by more high‐quality trials.     

Gaseous Micro‐Emboli Activity During Cardiopulmonary Bypass in Adults: Pulsatile Flow Versus Nonpulsatile Flow

Cardiopulmonary bypass (CPB) has a risk of cerebral injury, with an important role of gaseous micro‐emboli (GME) coming from the CPB circuit. Pulsatile perfusion is supposed to perform specific conditions for supplementary GME activity. We aimed to determine whether pulsatile CPB augments production and delivery of GME and evaluate the role of different events in GME activity during either type of perfusion. Twenty‐four patients who underwent on‐pump coronary artery bypass grafting surgery at the University of Verona were divided equally into two groups—pulsatile perfusion (PP) group and nonpulsatile perfusion (NP) group. The circuit included a JostraHL‐20 roller pump set in pulsatile or nonpulsatile mode, an open Sorin Synthesis membrane oxygenator with integrated screen‐type arterial filter, and phosphorylcholine‐coated tubes. Hemodynamic flow evaluation was performed in terms of energy equivalent pressure and surplus hemodynamic energy (SHE). GME were counted by means of a GAMPT BCC200 bubble counter (GAMPT, Zappendorf, Germany) with two probes placed at postpump and postarterial filter positions. Results were evaluated in terms of GME number, GME volume, number of over‐ranged GME from both probes, and series of filtering indexes. In PP mode, the pump produced and delivered along the circuit significantly higher amounts of SHE than in NP mode. At the venous postpump site, GME number was significantly higher during PP but no difference was found in terms of GME volume or number of over‐ranged bubbles. No significant difference in GME number, GME volume, or number of over‐ranges was found at the postarterial filter site. Filtering indexes were similar between the two groups. Neither type of perfusion was shown to contribute to excessive GME production during the most important perfusionist manipulation. Pulsatility leads to GME increment by splitting and size diminishing of the existing bubbles but not by additional gas production. PP augmented GME number at the venous postpump site, while mean volume remained comparable with NP. Sorin Synthesis oxygenator showed high efficacy in GME removal during either type of perfusion. Supplementary GME production and delivery during typical perfusionist manipulations did not depend on perfusion type.     

Effects of Mini‐Volume Priming During Cardiopulmonary Bypass on Clinical Outcomes in Low‐Bodyweight Neonates: Less Transfusion and Postoperative Extracorporeal Membrane Oxygenation Support

Mixing of autologous blood with priming volume has relatively significant effects on blood composition, especially in low‐bodyweight neonates. In an effort to reduce these effects, mini‐volume priming (MP) has been applied in cardiopulmonary bypass (CPB). The present study was designed to examine the effect of MP on clinical outcomes of low‐bodyweight neonates undergoing open heart surgery.We retrospectively reviewed medical records of low‐bodyweight (2.5 kg or less) neonates who underwent open heart surgery in our center from January 2000 to December 2014. A total of 64 patients were included. MP was introduced in 2007, and became a routine protocol in 2009. Preoperative and intraoperative characteristics included age, bodyweight, RACHS‐1, priming volume, CPB time, and aortic cross‐clamp time, transfusion, and hematocrit during CPB. Clinical outcomes included 30‐day mortality, postoperative extracorporeal membrane oxygenation (ECMO) support, open sternum status, prolonged mechanical ventilation care (>7 days), and acute renal failure. MP was utilized in 39 patients and conventional priming (CP) was used in 25 patients. The priming volume decreased to 126.0 mL in the MP group compared with 321.6 mL in the CP group. Transfusion volume during CPB was 87.3 mL in the MP group versus 226.8 mL in the CP group, and the difference was statistically significant (P < 0.001). Hematocrit at the end of the CPB and maximal decrease of hematocrit during CPB were not significantly different between the two groups. The 30‐day mortality rate was 12.8% in the MP group versus 20.0% in the CP group. Postoperative ECMO support was performed in 5.1% of patients in the MP group versus 17.4% of patients in the CP group. Open sternum status was required in 20.8% of patients in the MP group versus 10.3% of patients in the CP group, and prolonged ventilator care was required in 54.2% of patients in the MP group versus 38.5% of patients in the CP group. However, no statistical significance was measured in any of the clinical outcome measures. Larger priming volume and higher RACHS‐1 were significant risk factors of postoperative ECMO support in univariate and multivariate analysis. The results of the present study suggest that MP may be beneficial in avoiding transfusion without having a significant effect on the hematocrit. Clinical outcomes did not differ between the two groups. However, larger priming volume was a significant risk factor for postoperative ECMO support with RACHS‐1 category.     

Intraoperative ultrasonography‐guided surgery: An effective modality for breast conservation after neo‐adjuvant chemotherapy

Margin status is one of the significant prognostic factors for recurrence in breast‐conserving surgery (BCS). The issue that merits consideration for oncologic safety and cost‐effectiveness about the modalities to assure clear margins at initial surgical intervention remains controversial after neo‐adjuvant chemotherapy (NAC). The presented study aimed to assess the impact of intraoperative ultrasound (IOUS)‐guided surgery on accurate localization of tumor site, adequacy of excision with clear margins, and healthy tissue sacrifice in BCS after NAC. Patients who had IOUS‐guided BCS ater NAC were reviewed. No patient had preoperative localization with wire or radiotracer. Intraoperative real‐time sonographic localization, sonographic margin assessment during resection, macroscopic and sonographic examination of specimen, and cavity shavings (CS) were done as the standard procedure. No frozen assessment was performed. One hundred ninety‐four patients were included, in which 42.5% had pCR. IOUS‐guided surgery accomplished successful localization of the targeted lesions in all patients. Per protocol, all inked margins on CS specimens were reported to be tumor‐free in permanent histopathology. No re‐excision or mastectomy was required. For a setting without CS, the negative predictive value (NPV) of IOUS rate was 96%. IOUS was found to over and underestimate tumor response to NAC both in 2% of patients. IOUS‐guided surgery seems to be an efficient modality to perform adequate BCS after NAC with no additional localization method. Especially, when CS is integrated as a standard to BCS, IOUS seems to provide safe surgery for patients with no false negativity and a high rate of NPV.     

Vacuum‐Assisted Closure for Mediastinitis in Pediatric Cardiac Surgery: A Single‐Center Experience

Vacuum‐assisted closure (VAC) has been widely used to treat mediastinitis after congenital cardiac surgery, which is associated with a high risk of morbidity and mortality. The aim in this study is to review our 14 cases of mediastinitis treated with VAC therapy after congenital cardiac surgery. We retrospectively reviewed the medical records of 14 congenital heart patients with mediastinitis from January 2012 to March 2017. Patients with fever, wound discharge, sternal dehiscence, a positive wound culture or abscess diagnosed with computed tomography are accepted as mediastinitis. A VAC was applied to all our patients without irrigation or dressing the wound because of sterility concerns. The vacuuming of the wound was either 50 mm Hg or 75 mm Hg according to the sternal intactness. We gradually decreased the pressures and changed the VAC systems once every three days, after wound healing was seen and a negative culture was obtained and VAC was terminated. There were 14 patients (8 male and 6 female) with mediastinitis and all of them were treated using VAC. The mean age of the patients was 6.96 months (ranging from 0.5‐26 months). The mean weight was 5.16 kg (2.8‐12 kg). Three patients needed extracorporeal membrane oxygenation after the surgery. Mean onset of mediastinitis was 25.3 days. The wound cultures showed methicillin resistant coagulase negative streptococcus and methicillin‐sensitive staphylococcus aureus in most cases. Acinetobacter, serratia, pseudomonas, and klebsiella were the other bacterial species seen in cultures. Two patients had mediastinitis symptoms, but their cultures were negative. VAC systems were changed 3.85 times on average. Mean duration of hospital stay was 49.9 days (21‐104 days). One patient needed a muscle flap to close the thoracic cavity after mediastinitis. Two patients did not survive. Mediastinitis is a serious postoperative condition in pediatric cardiac surgery patients. Classical wound dressing and irrigation methods are not suitable in mediastinitis for the pediatric age group. Therefore, VAC therapy can be an effective way to successfully treat the situation.     

Outcomes of single‐port gasless laparoscopic breast‐conserving surgery for breast cancer: An observational study

To compare the clinical efficacy and aesthetic perspectives between single‐port gasless laparoscopic breast‐conserving surgery (SGL‐BCS) and traditional breast‐conserving surgery (T‐BCS) in early‐stage breast cancer. A total of 70 patients who were diagnosed with stage I or stage II breast cancer participated in this study, which 35 patients underwent SGL‐BCS, while others underwent T‐BCS. There were no death or severe intraoperative complications, and none of the patients exhibited regional recurrence, distant metastases, or any critical complications after 2 years follow‐up. SGL‐BCS is feasible and safe surgery, and has advantages in terms of a single, shorter, hidden incision, high‐satisficed aesthetic outcome and less intraoperative blood loss.     

Similar Cerebral Protective Effectiveness of Antegrade and Retrograde Cerebral Perfusion During Deep Hypothermic Circulatory Arrest in Aortic Surgery: A Meta‐Analysis of 7023 Patients

In aortic arch surgery, deep hypothermic circulatory arrest (DHCA) combined with cerebral perfusion is employed worldwide as a routine practice. Even though antegrade cerebral perfusion (ACP) is more widely used than retrograde cerebral perfusion (RCP), the difference in benefit and risk between ACP and RCP during DHCA is uncertain. The purpose of this meta‐analysis is to compare neurologic outcomes and early mortality between ACP and RCP in patients who underwent aortic surgery during DHCA. PubMed, EMBASE, and the Cochrane Library were searched using the key words “antegrade,” “retrograde,” “cerebral perfusion,” “cardiopulmonary bypass,” “extracorporeal circulation,” and “cardiac surgery” for studies reporting on clinical endpoints including early mortality, stroke, temporary neurologic dysfunction (TND), and permanent neurologic dysfunction (PND) in aortic surgery requiring DHCA with ACP or RCP. Heterogeneity was analyzed with the Cochrane Q statistic and I² statistic. Publication bias was tested with Begg's funnel plot and Egger's test. Thirty‐four studies were included in this meta‐analysis, with 4262 patients undergoing DHCA + ACP and 2761 undergoing DHCA + RCP. The overall pooled relative risk for TND was 0.722 (95% CI = [0.579, 0.900]), and the z‐score for overall effect was 2.9 (P = 0.004). There was low heterogeneity (I² = 18.7%). The analysis showed that patients undergoing DHCA + ACP had better outcomes than those undergoing DHCA + RCP in terms of TND, while there were no significant differences between groups in terms of PND, stroke, and early mortality. This meta‐analysis indicates that DHCA + ACP has an advantage over DHCA + RCP in terms of TND, while the two methods show similar results in terms of PND, early mortality, and stroke.     

Feasibility of a novel extraperitoneal two‐port laparoendoscopic approach for radical prostatectomy: An initial study

The aim of this study was to describe the surgical technique and to report the early outcomes of an original extraperitoneal two‐port laparoendoscopic approach for radical prostatectomy. A total of 22 consecutive patients diagnosed with early‐stage prostate cancer (cT1c, cT2N0) were operated on and included in this analysis. A multichannel port with three 5‐mm trocars, providing easier instrument handling, was inserted extraperitoneally through a 2.5‐cm lower umbilical “U” incision. An additional 12‐mm port was inserted into the left fossa to allow an adequate working angle to facilitate the most critical steps of the surgical procedures. The operation was successfully completed in all patients; one patient required an additional 5‐mm port to control bleeding. The median operation time was 259 min (range 207–453 min), and the fluid loss, including urine and blood, was 946 mL (range 257–1821 mL). The median Foley catheter indwelling period was 6 days (range 3–11 days) after surgery. No intraoperative complications occurred. Judging from this initial trial, this procedure can be safely carried out if the surgeon is familiar with conventional five‐port laparoscopic radical prostatectomy.     

A New Device for Intraoperative Renal Blood Flow Measurement During Open‐Heart Surgery: An Experimental Study and the Clinical Pilot Study

Renal blood flow (RBF) may vary during cardiopulmonary bypass and low flow may cause insufficient blood supply of the kidney triggering renal failure postoperatively. Still, a valid intraoperative method of continuous RBF measurement is not available. A new catheter combining thermodilution and intravascular Doppler was developed, first calibrated in an in vitro model, and the catheter specific constant was determined. Then, application of the device was evaluated in a pilot study in an adult cardiovascular population. The data of the clinical pilot study revealed high correlation between the flow velocities detected by intravascular Doppler and the RBF measured by thermodilution (Pearson's correlation range: 0.78 to 0.97). In conclusion, the RBF can be measured excellently in real time using the new catheter, even under cardiopulmonary bypass.