Bachar Ghassan El Oumeiri

Extending the Scope of Mitral Valve Repair in Rheumatic Disease

BACKGROUND Repair of rheumatic mitral valves has met with limited success because hemodynamic obstruction may persist after repair because of residual diseased leaflet tissue and lack of suppleness. Over the past decade, we have developed and implemented an aggressive approach to rheumatic mitral valve repair with radical excision of the diseased leaflets area, and subvalvular apparatus and subsequent reconstruction, with the objective of removing all diseased valvular tissue. METHODS From July 1996 to June 2007, 78 patients underwent mitral valve repair for rheumatic valve disease. Over the same time interval, 54 patients underwent mitral valve replacement. Mean age was 56.4 +/- 16 years. Clinical follow-up (mean 60 +/- 36 months) was complete in 100% of patients, and echocardiographic follow-up (mean 52 +/- 37 months) was 96% complete. RESULTS There was no hospital mortality or early reoperations. Overall survival was 94% +/- 6% at 8 years, and 95% of patients were in New York Heart Association functional class II or less. Three patients (4%) required reoperation for mitral restenosis and 2 underwent re-repair. At 8 years of follow-up, freedom from cardiac death and mitral valve reoperation were 98% +/- 2% and 94% +/- 5%, respectively. Freedom from valve-related events at 5 and 10 years was 90% +/- 8% and 86% +/- 11%, and freedom from significant mitral regurgitation was 98% +/- 2% at 5 years and 83% +/- 9% at 8 years. CONCLUSIONS A more aggressive approach to resection of diseased valvular tissue with subsequent reconstruction is feasible, with good midterm results, and may extend the scope of valve repair in rheumatic disease patients.

Reoperation for ascending aorta false aneurysm using deep hypothermia and circulatory arrest.

OBJECTIVES Ascending aorta false aneurysms after cardiac surgery are uncommon. Resternotomy is hazardous and may result in massive and uncontrollable hemorrhage if the false aneurysm is entered. Here we report our experience with the use of deep hypothermia and circulatory arrest to avoid this risk. METHODS From March 2000 to December 2007, seven patients (mean age 50 years) were reoperated for an ascending aorta false aneurysm. Three patients had undergone an aortic valve replacement (n=2) or an aortic valve repair (n=1). Three had undergone an ascending aorta replacement with a valved conduit (n=2) or an aortic valve repair (n=1) for type A dissection. One had undergone a coronary artery bypass grafting. Mean delay to reoperation was 133 months (range 22-324 months). Two patients had positive blood cultures (Staphylococcus species). Cardiopulmonary bypass was established by extramediastinal access. Patients were cooled to 18 °C. RESULTS Resternotomy was performed uneventfully under total circulatory arrest in all patients. Four patients underwent an ascending aorta replacement with a valved conduit (n=2) or a dacron conduit (n=2) associated with a mitral valve replacement in one patient. Direct suture was performed in two patients and in one patient the aorta was repaired using a saphenous vein patch. There was one hospital death. Mean follow-up was 53 months (range 14-90 months). CONCLUSION Resternotomy under circulatory arrest and deep hypothermia is a safe technique well-adapted to patients with an ascending aorta false aneurysm.

Recycling of internal thoracic arteries in reoperative coronary surgery: in-hospital and midterm results

BACKGROUND Selected patients, presenting for reoperative coronary surgery with patent internal thoracic arteries (ITAs), may benefit from techniques to salvage and reuse these ITA grafts. We have termed this practice the recycling of ITAs. The purpose of this study is to report our short-term and midterm results using various recycling techniques. METHODS Between April 1996 and February 2009, 60 patients underwent ITA recycling at our institution. Information regarding survival and cardiac events was obtained from a prospectively maintained, institutional database. Survival and freedom from major adverse cardiac events were calculated using Kaplan-Meier analysis. Mean follow-up duration was 60 ± 36 months. RESULTS Mean age was 64 ± 9 years and the mean time to reoperation was 117 ± 68 months. The patent ITA served as an inflow for a composite Y graft in 39 patients and was distally reimplanted on the same coronary vessel in 9 patients. A combination of these two techniques was used in 8 patients. Other techniques were used in the remaining 4 patients. Freedom from cardiac death was 93% ± 7% and 85% ± 9% at 1 and 5 years and freedom from major adverse cardiac events was 93% ± 7% and 81% ± 11% at 1 and 5 years, respectively. CONCLUSIONS Recycling of ITA grafts during reoperative coronary artery bypass grafting is safe and feasible in selected patients. These techniques can be useful in selected young patients to avoid saphenous vein graft or in patients with a lack of graft conduits.

How to cope with a temporarily aborted transplant program: solutions for a prolonged waiting period

BACKGROUND Due to budgetary restrictions our university heart transplant program came to a standstill to be gradually restarted early 2011. Consequently waiting-times for transplantation increased dramatically beyond the usual 10-15 months. We reviewed the clinical results of this peculiar transplant program over the past 4 years. METHODS Since March 2011 until February 2015, 65 patients (age 48±23 years) were listed for heart transplantation. Eight patients (11%) of whom three in high emergency were transplanted without any form of mechanical assistance. Fifty-one patients required a left ventricular assist device (LVAD) Heartware (Heartware Inc., Miami Lakes, FL, USA) as a bridge-to-transplant due to terminal heart failure. Merely 5 listed patients remain without assistance. RESULTS One patient without assistance and 11 LVAD patients (22%) died on the waiting-list. Meanwhile 10 LVAD patients were transplanted after a 2-year waiting time (770±717 days). Four transplanted patients died of early graft failure none after LVAD explantation. Survival at 1 and 3 years was respectively 78 (72%) and 83 (78%) for transplanted and assisted patients (log-rank P=0.056). Cox multivariable regression analysis identified crash-to-burn patients (P=0.002) and waiting-times over 2 years (P=0.044) as risk factors for early death, while age above 60 (P=0.008) and ischemic aetiology (P=0.029) and pulmonary hypertension (P=0.092) were risk factors for survival. CONCLUSIONS In times of donor shortage mechanical assistance proves very effective as bridge-to-transplant in patients for whom candidacy follows the standard inclusion procedures. In our settings, a steep increase in LVAD implantation served to salvage patients for whom transplantation became jeopardized due to an ever increasing waiting-time. Circulatory LVAD support could be considered as primary therapy in the future.

FIVE YEARS FOLLOW-UP AFTER Y-GRAFT ARTERIAL REVASCULARIZATION: ON PUMP VERSUS OFF PUMP; PROSPECTIVE CLINICAL TRIAL

OBJECTIVES We report our comparative experience of on-pump and off-pump full arterial coronary artery bypass grafting (CABG) using both internal mammary arteries (IMAs) anastomosed as a Y-graft. METHODS A single-center clinical study was conducted prospectively between January 2003 and May 2008. It compared the short- and mid-term clinical outcomes of on- and off-pump arterial revascularization where the left internal mammary artery (LIMA) was anastomosed to the left anterior descending (LAD) artery while the free right internal mammary artery (RIMA) graft taking off from the LIMA was used to bypass different coronary targets. RESULTS One hundred and ninety-two patients were divided into 77 on-pump and 115 off-pump procedures based on the intention to treat. The mean age in both groups was 60.2+/-11.7 and 68.1+/-10.6 years, respectively (P<0.05). Mean predictive logistic EuroSCORE was 3.5+/-6.7% for the on-pump group and 7.3+/-8.6% for the off-pump group (P<0.0001). Mean number of distal anastomoses were 2.7+/-0.6 (group ON) and 2.5+/-0.6 (group OFF) (P=NS). Postoperative mortality was two patients (2.6%) in the on-pump group and four patients (3.4%) in the off-pump group (P=0.63). No major adverse cardiac event, no stroke and no late death were reported during the follow-up that averaged 36.5+/-18.6 months. Angina recurrence was three patients (2.6%) in off-pump and two patients (3.5%) in on-pump group (P=NS). CONCLUSIONS The use of a free RIMA as Y-graft from the LIMA performed off pump eradicates aortic manipulations and provides complete revascularization to high-risk patients with mortality similar to the one of a lower risk population operated on pump. The morbidity and cost was lower in the off-pump group. This advocates for the widespread usage of the technique in high-risk patients.

Unusual 30-year durability of Hancock II porcine bioprosthesis in tricuspid position.

Highlights • Bioprosthesis durability.• Hancock II valve.• Tricuspid position.

A bullet through the aortic arch

A 45-year-old male was admitted in shock at the emergency department with a gunshot wound to the chest. The entry wound was located in the middle of the sternum at the level of the 3rd intercostal space. Surprisingly, emergency echocardiography detected no pericardial effusion. The aortic CT-angiography revealed two separate perforations of the aortic arch: one at the base of the brachio-cephalic trunk (Panels A, B, C, D, arrow), another at the origin of the left subclavian artery (Panels A, B, C, D, arrowhead) and a rupture of the superior thoracic artery and a pulmonary contusion of the right upper lobe. The bullet fragments were found lodged in the body of the 4th thoracic vertebra after having perforated the oesophagus (Panel C, curved arrow). The patient was rushed to the operating room and the aortic arch was successfully repaired under deep hypothermia and circulatory arrest without major blood loss. A stent was placed in the oesophagus. The patient recovered completely and was discharged after 10 days. Aortic arch gunshot wounds are almost always lethal. In our patient’s case, his miraculous survival might be due to the bleeding containment from the aorta by the surrounding fatty tissues. After initial resuscitation, patients with thoracic gunshot wounds should be transferred to trauma centres. The extent of internal lesions caused by thoracic gunshot wounds is difficult to precisely evaluate with the physical examination only and the threshold for ordering chest computed tomography should be low.

Chronic kidney disease as major determinant of the renal risk related to on-pump cardiac surgery: a single-center cohort study

Abstract Background: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication and is associated with the poorest outcomes. Therefore, early prediction of CSA-AKI remains a major issue. Severity scores such as the STS score could estimate the risk of AKI preoperatively. The main objective of this study was to evaluate the risk factors of on-pump CSA-AKI and to assess the performance of the STS score in order to predict CSA-AKI. Patients: We identified 252 patients with on-pump cardiac surgery, and the STS score was defined retrospectively. Results: AKI occurred in 14.6% (n = 37/252) of patients and renal replacement therapy was required in 21.6% of AKI (n = 8/37). CSA-AKI was associated with 35.1% in-hospital mortality (vs. 1.4%) and nearly doubled length of stay (14.5 vs. 8.0 d). The risk of CSA-AKI was mainly determined by preoperative morbidities such as chronic kidney disease, peripheral vascular disease, and severe congestive heart failure. Long cardio-pulmonary bypass time was also a determinant. CSA-AKI + patients exhibited higher STS renal risk (5.6% vs. 2.0%; p < 0.0001), resulting in a good discrimination between AKI + and AKI − patients (area under curve [AUC] 0.80). Interestingly, a basal renal function ≤55 ml/min/1.73m2 was as good as the STS score to predict CSA-AKI (AUC 0.75; P 0.26). Conclusions: On-pump CSA-AKI was observed in nearly 15% of cases and was associated with poorer outcomes. Interestingly, the risk of CSA-AKI could be estimated preoperatively, thanks to the basal renal function, which exhibited an equal performance to the STS score.

Composite indices of upstream pulmonary vascular impedance and capacitance do not help in identifying patients who should undergo pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension

Background Chronic thromboembolic pulmonary hypertension (CTEPH) is potentially curable by surgical pulmonary endarterectomy (PEA). Patient selection for PEA is crucial and depends mainly on discriminating between those with proximal accessible disease and distal disease. In this study we evaluated the value of composite indices such as upstream resistance (Zup) and capacitance (Cp) for partitioning of pulmonary vascular resistance and surgical outcome. Methods We retrospectively reviewed data from 30 patients who underwent PEA between 2007 and 2012. Zup, defined as the ratio between the mean pulmonary artery pressure (PAPm) minus diastolic pulmonary artery pressure (PAPd) and PAPm minus pulmonary artery occlusion pressure (POAP), was computed preoperatively as was the Cp, defined as the ratio of stroke volume over pulse pressure. We assessed the use of these indices to predict pulmonary haemodynamics after PEA. Results Postoperatively, total pulmonary vascular resistance (tPVR) was > 400 dynes·s·cm-5 in 11 patients (37%); nine patients were treated with an endothelin receptor antagonist (ERA) and had unsatisfactory surgical results. Preoperative Cp was identical in both groups (0.9945 ± 0.06867 vs. 1.348 ± 0.1961, P = 0.14). Zup was higher in the group with better haemodynamic outcomes (50.29% ± 3.266) than in the ERA group (38.59% ± 2.86) (P

Surgical treatment of atrial fibrillation.

ZusammenfassungDie große Anzahl von Publikationen aus jüngster Zeit zur chirurgischen Therapie von Vorhofflimmern (VHF), in denen verschiedenste Methoden angewandt wurden, erschwert eine exakte Angabe zur Erfolgsrate der chirurgischen Behandlung von VHF. Infolgedessen ist der „Gold Standard“ der chirurgischen Operationstechnik unzureichend definiert.MethodikIn der vorliegenden Übersicht wurde die Effektivität alternativer Energiequellen (Radiofrequenz-Mikrowelle und Kryoablation; Gruppe 1) mit der klassischen „cut and sew“-Cox-Maze III (Gruppe II), für die eine Sinusrhythmus-(SR) und somit Erfolgs- Rate von 97–99% angegeben wird, in der operativen Therapie von VHF verglichen. Wir führten eine Computer-gestützte Suche in Pub-Med- und Medline-Datenbanken durch. Nur englischsprachige Originalarbeiten zur chirurgischen Therapie von VHF, die einen klinischen Endpunkt berichteten (inklusive der postoperativen SR-Rate), wurden berücksichtigt. Folgende Daten wurden analysiert: Die absolute Zahl und der Prozentsatz behandelter Patienten, Geschlechtsverteilung, Arrhythmietyp (permanent oder paroxysmal), Operationstyp (begleitende Mitralklappenoperation, begleitende andere Operation, alleinige VHFOperation), die postoperative Morbidität (Blutungen, Notwendigkeit einer intraaortalen Ballonpumpe, zerebrovaskuläre Ereignisse), postoperative Schrittmacher-Implantation, 30-Tages-Mortalität, Überleben und Anzahl der Patienten im SR. Mittelwerte für Alter (in Jahren), linksatrialen Diameter (mm), präoperative Dauer des VHF (Jahre) und der linksventrikulären Ejektionsfraktion (%) wurden ebenfalls betrachtet.ErgebnisseWir schlossen 48 Studien mit insgesamt 3832 Patienten in die Analyse ein; 2279 in Gruppe I und 1553 in Gruppe II. Die mittlere VHF-Dauer (5,4 und 5,5 p=0,90), der linksatriale Diameter (55,5 und 57,8 mm, p=0,23) und die linksventrikuläre Ejektionsfraktion (57 und 58%, p=0,63) waren vor Operation nicht unterschiedlich, jedoch waren die Patienten der Gruppe II jünger (55,0 versus 61,2 Jahre; p=0,005) und hatten häufiger paroxysmales (22,9 versus 8,0%) und „lone“ VHF (19,3 versus 1,6%). Die postoperative SR-Rate für Gruppe I und II waren 78,3 und 84,9% (p=0,03). Alternative Energiequellen wurden vor allem zur Behandlung von permanentem VHF angewandt (92,0%), fast immer im Zusammenhang mit einer weiteren chirurgischen Prozedur (98,4%) und insbesondere in Kombination mit Nicht-MitralklappenOperationen (18,5%). Nach Korrektuktur dieser Parameter waren die postoperativen SR-Raten für die Gruppen I und II nicht mehr signifikant unterschiedlich.SchlussfolgerungenWir fanden keinen signifikanten Unterschied bezüglich des Anteils an Patienten mit postoperativem SR zwischen der klassischen ,cut and sew‘-Operationstechnik und alternativen Energiequellen in der chirurgischen Therapie von Vorhofflimmern.SummaryBackgroundThe recently published overwhelming number of publications on the surgical treatment of AF, using a wide variety of techniques, blurred any precise appreciation of the nowadays surgical treatment of AF. As a consequence, the “state of the art” of the surgical technique of AF is ill-defined.ObjectivesIn this review the efficacy of the alternative sources of energy (radiofrequency-microwave and cryoablation; (group I) and the classical “cut and sew” Cox-Maze III (group II), which claims a 97–99% sinus rhythm (SR) success rate, were evaluated in the surgical treatment of atrial fibrillation (AF).MethodsA computerized search in the PubMed and Medline database was conducted. Only original, English written, clinical manuscripts on the surgical treatment of atrial fibrillation citing the clinical outcome, including the postoperative sinus rhythm, were included. The following data were registered: the absolute numbers and percentages of treated patients, gender (male versus female) distribution, the type of arrhythmia (permanent or paroxysmal AF), type of surgery (mitral or non-mitral valve or a lone AF surgical procedure), postoperative morbidity (bleeding, the use of an intra-aortic balloon pump, cerebral vascular accident), postoperative pacemaker implantations, 30-day mortality, survival and sinus rhythm conversion. The mean values for age (years), left atrial diameter (mm), preoperative duration of AF (years) and left ventricular ejection fraction (%) were also recorded.ResultsForty-eight studies were included comprising 3832 patients: 2279 in group I and 1553 in group II. The mean duration of AF, left atrial diameter and LVEF were 5.4 versus 5.5 years (p=0.90), 55.5 versus 57.8 mm (p=0.23) and 57 versus 58% (p=0.63). The postoperative SR rates for group I and II were 78.3 versus 84.9% (p=0.03). However, the “cut and sew” Cox-Maze III was conducted in younger patients (55.0 versus 61.2 years; p=0.005), more often to treat paroxysmal (22.9 versus 8.0%) and lone AF (19.3 versus 1.6%). Alternative sources of energy were predominantly used to treat permanent AF (92.0%), almost always as a concomitant surgical procedure (98.4%) and increasingly in combination with non-mitral valve surgery (18.5%). After correction for these variations, the postoperative SR conversion rates for group I and II did not differ significantly anymore.ConclusionsWe could not identify any significant difference in the postoperative SR conversion rates between the classical ‘cut and sew’ and the alternative sources of energy, which were used to treat atrial fibrillation.Atrial fibrillation is a very common arrhythmia that carries a considerable risk of thromboembolic complications. Surgical treatment is an effective way to convert atrial fibrillation into sinus rhythm and significantly prevents thromboembolism postoperatively. In this review we describe recent advancements in the surgical options and detail our strategy for the surgical treatment of atrial fibrillation.