Anas Sarraj

Bloodless Cardiac Surgery in Jehovah's Witnesses: Outcomes Compared With a Control Group

INTRODUCTION AND OBJECTIVES Some patients, such as Jehovahs Witnesses, refuse to use blood products, which can make it difficult to achieve the same outcomes as in the general population. The objective of this study was to determine whether clinical characteristics and surgical outcomes in Jehovahs Witnesses undergoing cardiac surgery are similar to those in other patients. METHODS Paired-group retrospective cohort study. All Jehovahs Witnesses undergoing cardiac surgery between January 1998 and September 2006 were included (n=59). Cases were matched on a 1:1 basis according to sex, age (5) years, year and type of surgery, and need for repeat surgery. Preoperative, intraoperative and postoperative data were analyzed. RESULTS The mean age of cases was 62.5 (11.1) years with 57.6% being female. Some 30.5% had had at least one previous cardiac intervention. The clinical characteristics of the two groups were similar. Hemoglobin and hematocrit levels were higher in Jehovahs Witnesses both before (13.6 g/dL vs 12.9 g/dL; P=.01, and 40.7% vs 39%; P=.09) and after (11 g/dL vs 10 g/dL; P=.003, and 34.2% vs 30.7%; P=.001) surgery. Jehovahs Witnesses experienced significantly less bleeding, were intubated for fewer hours, and had shorter stays in both intensive care and the hospital. There was no difference in the rate of postoperative complications or mortality. CONCLUSIONS The clinical characteristics of Jehovahs Witnesses were similar to those of the control group. The complication rate was also similar in these patients, though the number of hours of mechanical ventilation was less, 24-hour bleeding was less, and the hospital stay was shorter. Mortality was similar in the two groups.

Cell saving systems do not reduce the need of transfusion in low-risk patients undergoing cardiac surgery.

OBJECTIVES Cell saving systems have been widely used to reduce blood loss and need of transfusions. These device are mainly indicated in complex cardiac surgery procedures and in those patients with a high risk of bleeding. However, it is not clear if there is a benefit of a cell saver (CS) system in low-risk patients undergoing cardiac surgery. Our aim was to analyze if the use of CS systems reduce the need of blood products in low-risk patients undergoing cardiac surgery. METHODS Between February and June 2009 all low-risk patients (EuroSCORE<10%) undergoing coronary or valve procedure were selected (n=63). Exclusion criteria were: combined procedure, aorta procedure, redo surgery, emergency procedures, creatinine levels>2 mg/ml, anemic patients and patients with a body surface area (BSA)<1.6 m2. Patients were randomized to undergo cardiac surgery with a cell saving system (group CS) (n=34) or without (control group, CO) (n=29). All patients received tranexamic acid during the procedure. Need of blood products and clinical outcomes were analyzed in both groups. RESULTS Mean age was 64.7±12.3 years old with 33% of female patients. Baseline clinical characteristics and preoperative blood count cell were similar in both groups. Mean CS blood reinfused was 461±174 ml (maximum: 985 minimum: 259). A total of 59 red blood packages were transfused in 25 patients (mean 1.02±1.3; range: 0-5). The proportion of patients being transfused was similar in both groups (CS: 40% vs. CO: 46.4%; P=0.79). Eleven plasma packages were transfused (CS: 8 vs. CO: 3; P=0.77) and three platelet pools were used in group CS and none in group CO (P=0.08). Multivariate analysis showed that preoperative hemoglobin levels>13.3 g/dl [relative risk (RR): 0.29; confidence interval (CI): 0.09-0.99] and BSA>1.74 (RR: 0.19; CI: 0.54-0.68) were protective against blood transfusion. CONCLUSIONS In low-risk patients CS system did not reduce the need of blood transfusion. Clinical outcomes were similar regardless of the use of a cell saver system. A low preoperative hemoglobin level and a low BSA were related with the use of blood products.

Adjustable Segmental Tricuspid Annuloplasty: Technical Advantages and Midterm Results

BACKGROUND Adjustable segmental tricuspid annuloplasty is a new recently published procedure. The purpose of this prospective study was to present the technical advantages of this new tricuspid annuloplasty and analyze its early and midterm results. METHODS Between January 2004 and December 2006, 17 patients who had moderate or severe pure functional tricuspid regurgitation (TR) underwent adjustable segmental tricuspid annuloplasty. The mean age of the patients was 64.3 +/- 10.4 years and the majority were female (94%). All patients had recent preoperative transthoracic echocardiography (TTE). Three postoperative TTE were performed: (I) before the hospital discharge; (II) between 3 and 6 months after surgery; and (III) at a mean 30.4 +/- 13.8 months of follow-up. We studied the tricuspid valve, right ventricle, and left ventricle. RESULTS No hospital mortality was reported. Progressive overall clinical improvement was observed. Serial postoperative TTE revealed the following: (1) 13 patients with mild or less than mild TR, 1 patient with residual moderate TR, 1 patient with early moderate TR related to poor left ventricular function, and 1 patient with late severe TR due to a transvenous pacemaker lead; (2) the indexed tricuspid annulus diameter normalized in all patients; (3) pulmonary hypertension gradually regressed; and (4) right ventricular end-diastolic diameter and inferior vena cava diameter gradually decreased throughout the study. CONCLUSIONS Adjustable segmental tricuspid annuloplasty is an improved and efficient procedure for functional TR because it is more selective, more adjustable and more resistant. It may be adversely influenced by poor left ventricular function and by the presence of a pacemaker lead.

Isolated Cardiac Involvement of Rosai-Dorfman Disease

Rosai-Dorfman disease is a rare and multisystem disorder of unknown etiology. It commonly presents as cervical lymph node enlargement, but extranodal involvement may be presented in one-third of the cases. Usually, the clinical course of Rosai-Dorfman disease is benign but it can be malignant, both clinically and pathologically. Herein, we present an isolated cardiac case of extranodal Rosai-Dorfman disease without lymphadenopathy that involves the left ventricle in a symptomatic adult patient and a description of cardiac magnetic resonance imaging findings of this disease.

Restoration of atrial contractility after surgical cryoablation: clinical, electrical and mechanical results

To assess the electrical sinus rhythm (SR) recovery and the mechanical effectiveness of the atrial contraction by echocardiography is essential in patients undergoing atrial fibrillation (AF) surgery. Between September 2006 and May 2008, patients with chronic AF (n=33; permanent=23 or paroxysmal=10) underwent mitral surgery and surgical cryoablation for AF. Exclusion criteria were: AF that has persisted for 10 years and left atrium (LA) >65 mm. Echocardiography study was performed at six months after surgery. Mean age was 62 years (22 female, 11 male). Mean AF duration was three years (range 0.5-7.4). Mean atria size was 52.4+/-5.6 mm. Mitral valve surgery involved 32 prosthetic replacements and one mitral valve repair. There was no surgical mortality. Success rate for SR at three and six months was 90% and 82%, respectively. The only predictor of conversion to SR at six months was being at SR when discharge from the hospital. In patients in SR, echocardiographic study provided mechanical effectiveness of the atria in 100% of right atrium and 70% of the LA. Cryoablation for AF is an effective technique to recover electrocardiographic SR while being able to recover atrial contraction effectiveness.

Outcomes of Aortic Valve Replacement According to Surgical Approach in Intermediate and Low Risk Patients: A Propensity Score Analysis

BACKGROUND Previous trials have shown that, among high-risk patients with aortic stenosis, survival rates are similar for transcatheter aortic-valve implantation (TAVI) and surgical aortic valve replacement. The study aimed to compare the outcomes of aortic valve replacement according to the adopted surgical approach in intermediate and low risk patients. METHODS This is a retrospective, observational, cohort study of prospectively collected data from 421 patients undergoing isolated aortic valve replacement between 2011 and 2015. A multinomial logit propensity score model based on preoperative risk factors was used to match patients 1:1:1 between conventional replacement (CAVR), minimally invasive (MIAVR) and TAVI groups, resulting in 50 matched three cohorts. RESULTS After multinomial logit propensity score, the three groups were comparable in terms of preoperative characteristics. Mean age and Logistic EuroSCORE I of CAVR, MIAVR and TAVI groups were (84.2±5.1 vs. 82.3±4.8 vs. 85.6±4.9 years; p=0.002) and (11.4±3.6% vs. 8.3±3.4% vs. 15.8±5.4%; p<0.001) respectively. Overall mortality rates were similar for the three patient cohorts at one year. There were no significant differences related to stroke to 30 days. In the TAVI cohort, pacemaker implantation for new-onset total atrioventricular block became necessary in 30% of patients (p<0.001) and 16% of patients had some degree of paravalvular aortic regurgitation, which was more than mild (p<0.001). Total length of stay was shorter in the TAVI group when compared with surgical groups (11.5±5.3 vs. 10.1±6.9 vs 8.5±3.7 days; p=0.023). After discharge, the survival rate follow-up (average follow up: 46.7 months) was 70%, 84% and 72% for three cohorts (log Rank x2=2.40, p=0.3). CONCLUSIONS In our experience, the three aortic valve replacement approaches offer very good results. Differences in the rate of complications were found between groups. Depending on patients characteristics the Heart-Team group must offer the best surgical approach for each patient.

How Could These Mini Saccular Aneurysms of Ascending Aorta Be Classified

The wall of a true aneurysm is composed of all histologic layers of the aorta. A false aneurysm represents a small, contained rupture of aorta followed by bulging of the corresponding area that is usually sustained by a fibrous peel. Aortic dissection is defined as a separation of the lamellae of the aortic wall. Herein, we describe an unusual clinical presentation of aortic dissection in a 37-year-old male patient that presented severe aortic regurgitation and unusual bulges with linear intimal fissures in ascending aorta underwent mechanical aortic valve replacement and interposition of tubular vascular graft in ascending aorta.

New Presentation of Hemolysis After Papillary Muscles Approximation for Mitral Valve Repair

Hemolysis is a well-recognized complication after prosthetic valve replacement, especially with perivalvular leaks. Hemolytic anemia associated with mitral valve (MV) repair is less common. We report the case of a young man with severe hemolytic anemia caused by turbulence of blood flow through a very small quadrangle orifice due to early failure of MV repair. The patient underwent redo MV biologic prosthesis replacement and tricuspid valve annuloplasty. The hemolysis completely disappeared few months later. In this case, we describe a new presentation of mechanical hemolysis due to early failure of MV repair that has not been described in the literature.