Dmitry Bobylev

Decellularized aortic homografts for aortic valve and aorta ascendens replacement

OBJECTIVES The choice of valve prosthesis for aortic valve replacement (AVR) in young patients is challenging. Decellularized pulmonary homografts (DPHs) have shown excellent results in pulmonary position. Here, we report our early clinical results using decellularized aortic valve homografts (DAHs) for AVR in children and mainly young adults. METHODS This prospective observational study included all 69 patients (44 males) operated from February 2008 to September 2015, with a mean age of 19.7 ± 14.6 years (range 0.2–65.3 years). In 18 patients, a long DAH was used for simultaneous replacement of a dilated ascending aorta as an extended aortic root replacement (EARR). Four patients received simultaneous pulmonary valve replacement with DPH. RESULTS Thirty-nine patients (57%) had a total of 62 previous operations. The mean aortic cross-clamp time in isolated cases was 129 ± 41 min. There was 1 conduit-unrelated death. The mean DAH diameter was 22.4 ± 3.7 mm (range, 10–29 mm), the average peak gradient was 14 ± 15 mmHg and the mean aortic regurgitation grade (0.5 = trace, 1 = mild) was 0.6 ± 0.5. The mean effective orifice area (EOA) of 25 mm diameter DAH was 3.07 ± 0.7 cm2. DAH annulus z-values were 1.1 ± 1.1 at implantation and 0.7 ± 1.3 at the last follow-up. The last mean left ventricle ejection fraction and left ventricle end diastolic volume index was 63 ± 7% and 78 ± 16 ml/m2 body surface area, respectively. To date, no dilatation has been observed at any level of the graft during follow-up; however, the observational time is short (140.4 years in total, mean 2.0 ± 1.8 years, maximum 7.6 years). One small DAH (10 mm at implantation) had to be explanted due to subvalvular stenosis and developing regurgitation after 4.5 years and was replaced with a 17 mm DAH without complication. No calcification of the explanted graft was noticed intraoperatively and after histological analysis, which revealed extensive recellularization without inflammation. CONCLUSIONS DAHs withstand systemic circulation, provide outstanding EOA and appear as an alternative to conventional grafts for AVR in young patients. EARR using DAH is a further option in aortic valve disease associated with aorta ascendens dilatation as it avoids the use of any prosthetic material.

Immediate surgical coronary revascularisation in patients presenting with acute myocardial infarction

BackgroundThe number of patients presenting with acute myocardial infarction (AMI) and being untreatable by interventional cardiologists increased during the last years. Previous experience in emergency coronary artery bypass grafting (CABG) in these patients spurred us towards a more liberal acceptance for surgery. Following a prospective protocol, patients were operated on and further analysed.MethodsWithin a two year interval, 127 patients (38 female, age 68±12 years, EuroScore (ES) II 6.7±7.2%) presenting with AMI (86 non-ST-elevated myocardial infarction (NSTEMI), 41 STEMI) were immediately accepted for emergency CABG and operated on within six hours after cardiac catheterisation (77% three-vessel-disease, 47% left main stem stenosis, 11% cardiogenic shock, 21% preoperative intraaortic balloon pump (IABP), left ventricular ejection fraction 48±15%).Results30-day-mortality was 6% (8 patients, 2 NSTEMI (2%) 6 STEMI (15%), p=0.014). Complete revascularisation could be achieved in 80% of the patients using 2±1 grafts and 3±1 distal anastomoses. In total, 66% were supported by IABP, extracorporal life support (ECLS) systems were implanted in two patients. Logistic regression analysis revealed the ES II as an independent risk factor for mortality (p<0.001, HR 1.216, 95%-CI-Intervall 1.082-1.366).ConclusionsQuo ad vitam, results of emergency CABG for patients presenting with NSTEMI can be compared with those of elective revascularisation. Complete revascularisation obviously offers a clear benefit for the patients. Mortality in patients presenting with STEMI and cardiogenic shock is substantially high. For these patients, other concepts regarding timing of surgical revascularisation and bridging until surgery need to be taken into consideration.

Intrapericardial migration of dislodged sternal struts as late complication of open pectus excavatum repairs

AbstractWe present a case of sternal steel strut dislodgement and migration in a patient undergoing Ravitch repair for pectus excavatum (PE) 37 years ago. Broken struts perforated the right ventricle and right ventricular outflow tract (RVOT) and additionally migrated into the left upper lobar bronchus.Dislodged sternal struts represent rare complications after surgical repair of patients suffering from pectus excavatum. Reviewing the literature, only five cases of intrapericardial migration of dislodged sternal struts or wires have been reported so far.In our case, the first strut was removed from the airways through a left antero-lateral thoracotomy. Using cardiopulmonary bypass, a second strut was removed via ventriculotomy. These life-threatening sequelae underscore the importance of postoperative follow-up and early removal of osteosynthetic materials used in open PE repair. Accurate preoperative localization of migrated materials and availability of CPB support are crucial for successful surgical removal.IntroductionThe migration of dislodged sternal steel struts or wires into the pericardium and cardiac cavities is a rare but life-threatening complication of open pectus excavatum (PE) repair [1]. Removal of these materials poses a challenge for cardiothoracic surgeons. Herein, the authors report a case of migration of dislodged steel struts through the right ventricle and right ventricular outflow tract (RVOT) into the left upper lobar bronchus in a patient who underwent Ravitch repair 37 years ago.

Aortic root replacement in a patient with bicuspid pulmonary valve late after arterial switch operation.

Mild to moderate neoaortic root dilatation late after arterial switch operation (ASO) is a well-documented morbidity, but rarely needs surgical replacement. Here, we report on a 22-year-old man, who developed marked dilatation of neoaortic root and needed an aortic root replacement with mechanical conduit. His aortic valve was bicuspid. Only three cases have been reported for surgical replacement of aortic root after ASO, and two of them had bicuspid neoaortic valves. We suspect that a bicuspid neoaortic valve may be a risk factor for marked dilatation of the aortic root late after ASO.

Long-term results after repair of anomalous origin of left coronary artery from the pulmonary artery: Takeuchi repair versus coronary transfer

OBJECTIVES: We evaluated long-term results of two different repair strategies of anomalous origin of left coronary artery from pulmonary artery (ALCAPA) in two German surgical centres. METHODS: We performed a retrospective review of patients who underwent ALCAPA repair between November 1980 and October 2012. Ventricular function was assessed by standardized transthoracic echocardiographic studies. RESULTS: A total of 30 patients with a median age of 0.4 years (range 0.05–37.6 years) underwent ALCAPA repair. Nineteen patients received coronary transfer, 9 underwent Takeuchi repair (creation of an intrapulmonary tunnel) and 2 were treated by closure of the ALCAPA. There was one concomitant mitral valve repair. The total follow-up was 244.8 years with a mean follow-up of 8.16 ± 6.7 years (range 0.06–24.3 years). There was no late mortality. None of the patients treated with coronary transfer or Takeuchi repair died. One moribund patient who received coronary ligation in the 1980s died perioperatively. The 10-year rate of freedom from reoperation was 94.1% for patients treated with coronary transfer. For patients with Takeuchi repair, the 10-year rate of freedom from reoperation was 71.1% (P = 0.146). At last followup, left ventricular end-diastolic diameter (LVEDD) and function measured by fractional shortening was normal in all patients. The mean shortening fraction improved from 20.25 ± 10.86% to 35.7 ± 4.8%, with the most remarkable change taking place in the first year, and the mean LVEDD indexed to normal improved from 42 ± 34% above normal values preoperatively to 3 ± 12% at the last follow-up (P < 0.01). The number of patients with moderate-to-severe mitral regurgitation (MR) improved from 50% to 6.7% (2 of 30) at the last followup. In all children receiving ALCAPA repair under the age of 6 months, MR was absent or trivial at the last follow-up. Eight years after Takeuchi repair, 79.9% of these patients suffered from at least moderate pulmonary regurgitation, in contrast to 0% after coronary transfer (P < 0.001). CONCLUSIONS: Survival rates and long-term left ventricular function were excellent for both surgical strategies. Mitral regurgitation resolved in all patients operated during their first year of life independent of the type of repair. Takeuchi repair, however, led to significant pulmonary regurgitation.

Extracorporeal membrane oxygenation as a bridge to lung transplantation may not impact overall mortality risk after transplantation: results from a 7-year single-centre experience

OBJECTIVES Extracorporeal membrane oxygenation (ECMO) has an important role in bridging patients to lung transplantation. In this study, we present our experience with pretransplant ECMO during the last 7 years and investigate its impact on graft outcomes. METHODS Records of all lung-transplanted patients at our institution between January 2010 and April 2017 were retrospectively reviewed. Graft survival was compared between patients who required pretransplant ECMO (pre-Tx ECMO+) and patients who did not (pre-Tx ECMO-). Risk factors for in-hospital mortality and graft survival were identified using a binary logistic regression and the Cox regression analyses, respectively. RESULTS Among the 917 patients transplanted during the study period, 68 (7%) required ECMO as a bridge to transplantation [awake strategy, n = 57 (84%) patients]. Median bridging time was 9 days. Among pre-Tx ECMO+ patients, the need for haemodialysis at any point during bridging emerged as an independent risk factor for in-hospital mortality (odds ratio 7.79, 95% confidence interval 1.21-50.24; P = 0.031). Although in-hospital mortality was significantly higher in pre-Tx ECMO+ versus pre-Tx ECMO- patients (15% vs 5%, P = 0.003), overall graft survival did not differ between groups (79% vs 90% and 61% vs 68% at 1 and 5 years, respectively, P = 0.13). Pretransplant ECMO did not emerge as a risk factor for graft survival in the multivariable analysis. CONCLUSIONS If applied in selected patients in a high-volume centre, pretransplant ECMO as a bridge to transplantation results in impaired, but still high in-hospital, survival and does not impact graft survival.

Surgical repair of Shone's complex with anomalous origin of the left coronary artery arising from the right pulmonary artery

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly. ALCAPA from the right pulmonary artery (RPA) is a small subset of this anomaly, with only a few reported cases to date. We describe an extremely uncommon association of Shones complex with ALCAPA from the RPA in a case where simultaneous surgery for both anomalies was successfully carried out in a neonate.

Extramedullary haematopoiesis presented as intrathoracic tumour in a patient with alpha-thalassaemia

The authors report a case of extramedullary haematopoiesis (EMH) presenting as an intrathoracic tumour in a patient with alpha-thalassaemia. CT scan and MRI of the chest were obtained and followed by tumour excision. Compared to beta-thalassaemia, only two cases of EMH in patients with alpha-thalassaemia have been described in the literature. A possible reason for this disparity is discussed.

Migration of an endovascular stent into the right ventricle following deployment in the inferior vena cava after liver transplantation

Figure 1: (A) Computed tomography imaging revealed migration of the intravascular stent (white arrow) into the right ventricle (PA, pulmonary artery; RV, right ventricle). (B) Intraoperative photo. After establishing extracorporeal circulation and cardioplegic arrest, the right atrium was opened for access to the right ventricle. We found the stent (black arrow), fixed on the trabecular ventricular wall.

Double semilunar valve replacement in complex congenital heart disease using decellularized homografts

OBJECTIVES Patients with complex congenital heart disease often require multiple reoperations, resulting in increased rates of operative morbidity and mortality. Decellularized heart valves (DHVs) have led to reduced reoperation rates compared with current other valve substitutes when used for pulmonary valve replacement and have also shown very auspicious early results in aortic valve replacement. The aim of the work was to analyse the outcome of a single-stage decellularized valve implantation in the aortic and pulmonary position. METHODS A prospective follow-up of all patients who received a single-stage double semilunar valve replacement using DHV at our institution. RESULTS Since 2011, 5 patients underwent combined semilunar valve replacement with DHV at our institution: two following a Ross procedure (31-year-old man and 38-year-old woman) and 3 after repair of the truncus arteriosus communis (2-year-old boy and 11-year-old and 16-year-old girls). All patients had undergone previous surgery. The Ross patients had preceding valve procedures, and the patients with truncus arteriosus communis had undergone 1 repair and subsequent operative procedures. Despite challenging operations (median bypass time 346 min, range 275-477 min; median cross-clamp time 229 min, range 140-307 min), there was no perioperative mortality or reoperations. Four of the patients were extubated within 24 h, and the other patient was extubated on postoperative day 2. During follow-up, a good semilunar valve and biventricular heart function was present in all 5 patients, and the New York Heart Association functional class was I for all the patients at the time of their latest follow-up (median 31 months, range 8-82 months). The mean echocardiographic gradient of decellularized aortic homografts was 5.4 ± 3.2 mmHg and 11.6 ± 4.2 mmHg for the decellularized pulmonary homografts. Valvular regurgitation was 0 or 0-I for all DHVs. CONCLUSIONS A single-stage double semilunar valve replacement with DHV has shown promising early results in these 5 very complex cases, providing an additional surgical option after multiple preceding valve procedures in young patients.