Chittoor B. Sai-Sudhakar

Laparoscopic sleeve gastrectomy in morbidly obese patients with end-stage heart failure and left ventricular assist device: medium-term results.

BACKGROUND Morbid obesity precludes patients with end-stage heart failure from becoming cardiac transplant candidates. This study evaluates the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) as a means to transplant candidacy in such patients. METHODS Morbidly obese patients with end-stage heart failure, who were ineligible for cardiac transplantation and underwent LSG between 2008 and 2013, were reviewed retrospectively. Demographic characteristics, perioperative details, percentage of excess weight loss (%EWL), and status of transplant candidacy were analyzed. RESULTS Six patients (3 men) with end-stage heart failure and morbid obesity underwent LSG. Three patients (50%) had a left ventricular assist device (LVAD) in place at the time of surgery. Median age was 34 (31-66) years and mean preoperative body mass index (BMI) was 47.6±3.0 kg/m2. Median operative time was 90 (66-141) minutes, with a median length of stay of 7 (4-16) days. There were no perioperative deaths. One patient suffered a spontaneous flank hematoma. The same patient also had thrombosis of the LVAD pump at 3 weeks postoperatively, requiring an uneventful device exchange. At median follow-up of 22 (12-70) months, the mean %EWL was 51.4±10.3% with a decrease in BMI to 34.3±2.4 kg/m2 (P<.05). All patients had lost sufficient weight to become transplant eligible within 12 months of surgery. Two patients had undergone successful transplantation and another 2 were on the transplant list. CONCLUSION LSG appears to be a safe, technically feasible, and effective method for obtaining adequate weight loss in morbidly obese patients with end-stage heart failure and mechanical circulatory support, subsequently improving their access to cardiac transplantation. This is the largest case series to date of this high-risk group of patients undergoing LSG.

First evidence of sternal wound biofilm following cardiac surgery.

Management of deep sternal wound infection (SWI), a serious complication after cardiac surgery with high morbidity and mortality incidence, requires invasive procedures such as, debridement with primary closure or myocutaneous flap reconstruction along with use of broad spectrum antibiotics. The purpose of this clinical series is to investigate the presence of biofilm in patients with deep SWI. A biofilm is a complex microbial community in which bacteria attach to a biological or non-biological surface and are embedded in a self-produced extracellular polymeric substance. Biofilm related infections represent a major clinical challenge due to their resistance to both host immune defenses and standard antimicrobial therapies. Candidates for this clinical series were patients scheduled for a debridement procedure of an infected sternal wound after a cardiac surgery. Six patients with SWI were recruited in the study. All cases had marked dehiscence of all layers of the wound down to the sternum with no signs of healing after receiving broad spectrum antibiotics post-surgery. After consenting patients, tissue and/or extracted stainless steel wires were collected during the debridement procedure. Debrided tissues examined by Gram stain showed large aggregations of Gram positive cocci. Immuno-fluorescent staining of the debrided tissues using a specific antibody against staphylococci demonstrated the presence of thick clumps of staphylococci colonizing the wound bed. Evaluation of tissue samples with scanning electron microscope (SEM) imaging showed three-dimensional aggregates of these cocci attached to the wound surface. More interestingly, SEM imaging of the extracted wires showed attachment of cocci aggregations to the wire metal surface. These observations along with the clinical presentation of the patients provide the first evidence that supports the presence of biofilm in such cases. Clinical introduction of the biofilm infection concept in deep SWI may advance the current management strategies from standard antimicrobial therapy to anti-biofilm strategy.

Impact of induction immunosuppression on survival in heart transplant recipients: a contemporary analysis of agents.

The impact of induction immunosuppression on long‐term survival in heart transplant recipients is unclear. Over the past three decades, practices have varied as induction agents have changed and experiences grew. We sought to evaluate the effect of contemporary induction immunosuppression agents in heart transplant recipients with the primary endpoint of survival, utilizing national registry data.

Outcomes in the current surgical era following operative repair of acute Type A aortic dissection in the elderly: a single-institutional experience.

OBJECTIVES We reviewed our single-centre experience with emergent operative repair of Stanford Type A aortic dissections, with particular attention to outcomes in the elderly. METHODS Consecutive adult patients undergoing emergent operative repair of acute Type A aortic dissections between February 2004 and December 2011 at a single institution were identified. Patients were stratified into elderly (≥ 70 years) and control cohorts (<70 years). Kaplan-Meier analysis was used to evaluate survival. RESULTS A total of 117 patients undergoing emergent repair of Type A aortic dissection were identified during the study period, including 31 (26.5%) elderly and 86 (73.5%) control patients. The mean age in the elderly cohort was 78.0 ± 4.7 years, with 41.9% (13 of 31) being 80 years or older. The elderly and control groups were well matched with regard to preoperative comorbidities (each P>0.05) and the presence of malperfusion at presentation (elderly: 19.4 vs controls: 27.9%, P = 0.35). The most common site of tear involved the proximal ascending aorta (elderly: 83.9 vs controls: 84.9%), with fewer cases affecting the aortic arch (12.9 vs 14.0%; P = 0.75). Operative data, including cardiopulmonary bypass and aortic cross-clamp time, concomitant aortic valve procedures and arch replacement were also similar between cohorts. Fewer elderly patients underwent hypothermic circulatory arrest (67.7 vs 90.7%, P = 0.002). Overall survival to discharge was 87.2% (n = 102), with no difference in the elderly (83.9%; n = 26) vs controls (88.4%; n = 76; P = 0.52). The 30-day (elderly: 82.8 vs controls: 86.2%), 90-day (elderly: 79.0 vs controls: 84.8%) and 1-year (elderly: 75.4 vs controls: 84.8%) survivals were also comparable. CONCLUSIONS Excellent operative outcomes can be achieved in elderly patients undergoing emergent repair of Type A aortic dissections. Advanced patient age should therefore not serve as an absolute contraindication to operative repair in this high-risk cohort.

Endovascular Abdominal Aortic Aneurysm Repair in Patients with Ventricular Assist Devices

Long-term mechanical circulatory support devices are currently an established therapy for the management of end-stage heart failure, and current evidence supports their superiority in comparison to maximal medical therapy in these patients. Screening for peripheral arterial disease and abdominal aortic aneurysm (AAA) before left ventricular assist device (LVAD) implantation is recommended. Although repair of AAA before or during LVAD placement has been reported, management of patients with AAA after LVAD implantation needs to be further investigated. We describe our management and operative strategies in 2 patients on destination LVAD therapy who underwent successful endovascular AAA repair.

Traumatic aortic dissection associated with riding a roller coaster

Sir, We report a case of traumatic aortic dissection in a patient immediately after riding a roller coaster in which there were periods of rapid acceleration and deceleration over a short time span. A 34-year-oldmale with a history of poorly controlled hypertension and diabetes mellitus, complicated by chronic renal disease, developed suddenonset chest pain promptly following a ride on a roller coaster at a popular amusement park. The roller coaster had a top speed of 120 miles per hour with an initial rapid acceleration followed 17s later by an abrupt deceleration. He went home immediately afterward and treated himself with over-the-counter pain medications. His chest pain worsened over the next 2 days, and he subsequently presented to a local emergency department for evaluation. A computed tomographic scan of his chest identified a dissection of his ascending aorta extending into the arch with an accompanying dissection flap in the descending aorta [Figure 1]. He was transferred to our institution, expeditiously evaluated, and emergently taken to surgery. He underwent replacement of the ascending aorta and hemiarch with a 26-mm Hemashield (Maquet Corporation, Rastatt, Germany) tube graft under general anesthesia with deep hypothermic circulatory arrest. The surgical time was 5 h. Total blood products transfused consisted of only one unit of pooled platelets. His post-operative course was uncomplicated, aside from issues with blood pressure control. He was discharged home after operationon day 12 and remains well.