Francisco Igor B. Macedo

Pulmonary embolectomy: recommendation for early surgical intervention.

Abstract  Background: Acute pulmonary embolism (PE) is a life‐threatening disease which often results in death if not diagnosed early and treated aggressively. Despite all efforts at improving outcomes, there is no consensus on the management of acute severe PE. Methods: From May 2000 to June 2009, 16 consecutive patients underwent surgical pulmonary embolectomy at our institution. Mean age was 45 ± 17 years (range, 14 to 76) with nine (56%) males and seven (43%) females. Preoperatively, all cases were classified as massive PE; seven (43%) patients were in hemodynamic collapse and emergently underwent operation while receiving cardiopulmonary resuscitation. Results: There were nine (56%) urgent/emergent and seven (44%) salvage patients undergoing surgical pulmonary embolectomy. Of nine nonsalvage patients, seven (77%) patients presented with moderate to severe right ventricular (RV) dilation/dysfunction. Mean cardiopulmonary bypass time was 43 ± 41 minutes (range, 9 to 161). Mean follow‐up duration was 48 ± 38 months (range: 0.3 to 109), with seven in‐hospital deaths (43%): mortality was 11% (1/9) in emergent operations and 85% (6/7) in salvage operations. Conclusions: Surgical pulmonary embolectomy should be considered early in the management of hemodynamically stable patients with PE who show evidence of RV dilation and/or failure, as it is associated with satisfactory outcomes. Conversely, pulmonary embolectomy has dismal results under salvage conditions. Revision of current guidelines for the surgical management of this condition may be warranted. (J Card Surg 2010;25:261‐266)

Multiple Valve Surgery with Beating Heart Technique

BACKGROUND Multiple valve surgery was performed utilizing beating heart technique through simultaneous antegrade/retrograde perfusion with blood. We herein report our experience with this technique in patients with multiple valve disease processes. METHODS Of 520 consecutive patients operated upon utilizing this method between 2000 and 2007, 59 patients underwent multiple valve surgery. Mean age was 54.2 +/- 13.8 years (range, 21 to 83) with 41 males (69.5%) and 18 females (30.5%). Double-valve and triple-valve operations were performed in 54 and 5 patients, respectively. RESULTS Of 32 mitral valve replacements, there were 30 biological (93.8%) and 2 mechanical (6.2%) mitral valves. Aortic valve replacement was performed in 25 patients: 22 (88%) with biological and 3 (12%) with mechanical prostheses. Two patients had mitral and tricuspid valve repair. The most common procedure was mitral valve replacement plus tricuspid valve repair (16 patients; 27.1%), mitral valve replacement plus aortic replacement (14 patients; 23.7%), and mitral valve repair plus tricuspid repair (13 patients; 22%). Concomitant coronary artery bypass grafting was performed in 7 (11.8%) of 59 patients. Mean hospital stay was 25.6 +/- 29.6 days (range, 3 to 195; median, 17). Early mortality (less than 30 days) occurred in 5 patients (8.4%), and late mortality (more than 30 days) occurred in 2 patients (3.4%). Reoperation for bleeding was needed in 5 patients (8.4%). Intra-aortic balloon pump was required preoperatively and postoperatively in 4 and 1 patients, respectively. Clinical and echocardiographic follow-up in 33 patients at 11.8 +/- 16.4 months (range, 1 to 80) showed preserved postoperative left ventricular ejection fraction. Three patients had perivalvular leaks on follow-up but required no surgery. Nineteen patients were lost to follow-up. CONCLUSIONS This study demonstrates the feasibility and safety of beating heart techniques in multiple valve operations. Further studies are needed to fully evaluate the potential benefits of this method of myocardial perfusion as a means to eliminate ischemia-reperfusion injury, and to preserve ventricular function in multiple valvular surgery.

Paradigm change in the management of patients with acute type A aortic dissection who had prior cardiac surgery

Abstract  Background: Acute type A aortic dissection (ATAAD) is a life‐threatening disease entity. Untreated, it usually results in death due to rupture of the proximal aorta into the pericardial cavity, leading to cardiac tamponade. Should patients who have had prior cardiac surgery presenting with ATAAD be treated emergently with surgery, or should they be managed medically? We herein present preliminary evidence that suggests that medical treatment, at least initially, is the best option for these patients. Surgery is indicated in the follow‐up, depending on increased size of the dissection or aorta, or to prevent or treat complications. Patients and Methods: From January 2004 to November 2009, ten consecutive male patients with prior cardiac surgery were admitted to hospital with the diagnosis of ATAAD. Mean age was 61.90 ± 14.68 years (range, 36 to 79 years), with nine (90%) males and one (10%) female. All were treated medically as the definitive form of management. Results: Mean follow‐up duration was 14.62 ± 11.12 months (range, 1 to 31 months). Overall mortality during follow‐up was 20% (two patients). Eight patients (80%) are alive and well. Conclusions: This initial experience with a small, consecutive series of patients, suggests that medical treatment is an option in the initial management of patients with ATAAD who had prior cardiac surgery. It appears that emergency surgery is seldom needed. A larger series of patients and longer follow‐up period are needed prior to recommending this treatment approach for such patients. (J Card Surg 2010;25:387‐389)

Management of lower extremity vascular injuries in pediatric trauma patients: a single Level I trauma center experience.

BACKGROUND Traumatic vascular injuries of the lower extremity in the pediatric population are rare but can result in significant morbidity. We aimed at describing our experience with such complex injuries, with associated patterns of injury, diagnostic and therapeutic challenges, and outcomes. METHODS From January 2006 to December 2011, 2,844 pediatric trauma patients presented at the Ryder Trauma Center, an urban Level I trauma center in Miami, Florida. Among them, 18 patients (0.6%) were evaluated for lower extremity traumatic vascular injuries. Variables collected included age, sex, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. RESULTS Mean (SD) age was ± 14.7 (2.6) years (range, 6–17 years), with 17 males (94.4%). Of the 18 traumatic pediatric patients, 32 vascular injuries were identified. All arterial injuries underwent definitive operative repair. Primary repair was performed in two patients (11.1%), six (33.3%) required saphenous vein interposition grafting as initial procedure, and eight (44.4%) underwent polytetrafluoroethylene grafting. Ligation was performed in major venous injuries and deep profunda branches. The overall survival in this series was 94.4%. CONCLUSION Peripheral vascular injuries of the lower extremity in the pediatric population can result in acceptable outcomes if managed early and aggressively. Surgical principles of vascular surgery are similar to those applied to an adult. We recommend that these injuries should be managed in a tertiary specialized center with a multidisciplinary team of trauma surgeons, and pediatricians, which can potentially decrease morbidity and mortality. LEVEL OF EVIDENCE Epidemiologic study, level III.

Results of beating heart mitral valve surgery via the trans-septal approach

OBJECTIVE Mitral valve surgery can be performed through the trans-atrial or the trans-septal approach. Although the trans-atrial is the preferred method, the trans-septal approach has also been used recently and has a particular value in beating-heart mitral valve surgery. Herein we report our experience with beating-heart mitral valve surgery via trans-septal approach, and discuss its advantages and pitfalls. METHODS Between 2000 and 2007, 214 consecutive patients were operated upon utilizing beating heart technique for mitral valve surgery. The operation was performed via transseptal approach with the aorta unclamped, the heart beating, with normal electrocardiogram and in sinus rhythm. RESULTS Mean age was 56.03 +/- 13.93 years (range: 19-86 years; median: 56 years). There were 131 (61.2%) males and 83 (38.8%) females. Of the prostheses used, 108 (50.5%) were biological, and 39 (18.2%) were mechanical. Mitral repairs were performed in 67 (31.3%) patients. Mean hospital stay was 17.4 +/- 20.0 days (range: 3-135 days; median: 11 days). Intra-aortic balloon pump (IABP) utilization was required in 12 (5.6%) of 214 patients. One-month mortality was 7.4%, and re-operation for bleeding was needed in 15 (7%) patients. CONCLUSIONS Beating-heart mitral valve surgery is an option for myocardial protection in patients undergoing mitral valve surgery. This technique is facilitated by the trans-septal approach due to reduced aortic insufficiency and improved visualization of the mitral apparatus.

Beating-heart valve surgery: is the introduction of lung perfusion/ventilation the next step?

Myocardial and pulmonary ischemia during cardiopulmonary bypass has been associated with postoperative cardiac and pulmonary dysfunction, as well as poor outcomes. Beating-heart valve surgery utilizing continuous coronary perfusion with warm oxygenated blood via the antegrade/retrograde routes, is a novel strategy for myocardial protection. Conceptually, it is proposed that maintenance of pulmonary perfusion and ventilation during the cardiopulmonary bypass period also might be advantageous. The most current evidence regarding these evolving techniques and further areas of research are discussed in this article.

Efficacy, Feasibility, and Pitfalls of Transseptal Approach in Beating-Heart Mitral Valve Surgery

Abstract  Background: Mitral valve surgery can be performed through the trans‐atrial or the trans‐septal approach. Although the trans‐atrial is the preferred method, the trans‐septal approach has also been used recently and has a particular value in beating‐heart mitral valve surgery. Herein we report our experience with beating‐heart mitral valve surgery via trans‐septal approach, and discuss its advantages and pitfalls. Methods: Between 2000 and 2007, 214 patients underwent mitral valve procedures using the beating‐heart surgical approach. Results: One hundred and forty‐three patients (66.8%) had mitral valve replacement, 68 patients (31.7%) mitral valve repair, and 82 patients (38.3%) concomitant valve procedures. Coronary artery bypass grafting was simultaneously performed in 30 (14%) patients. Thirty‐day mortality was 7.4%, reoperation for bleeding 7%, stroke 0.4%, and myocardial infarction 0.4%, and failed mitral valve repair 0.9%. Conclusion: Our experience suggests that beating‐heart mitral valve surgery is facilitated by using the trans‐septal approach.

Beating heart surgery with pulmonary perfusion and ventilation during cardiopulmonary bypass: target organs' perfusion without plegia.

Myocardial and pulmonary ischemia during cardiopulmonary bypass (CPB) is associated with cardiac and pulmonary dysfunction that may result in poor outcomes after cardiac surgery. Beating heart surgery and continuous pulmonary perfusion and ventilation represent emerging strategies targeting the cardiopulmonary bypass-induced ischemia and ischemia-reperfusion injury in susceptible organs--heart and lungs.

Beating heart valve surgery with lung perfusion/ventilation during cardiopulmonary bypass: do we need to break the limits?

Myocardial and pulmonary ischemia during cardiopulmonary bypass is associated with cardiac and pulmonary dysfunction that may result in poor outcomes after cardiac surgery. Beating heart valve surgery, utilizing continuous coronary perfusion with warm oxygenated blood, together with continuous pulmonary artery perfusion and alveolar ventilation during cardiopulmonary bypass, represents an emerging and exciting novel strategy for myocardial and pulmonary protection. In this article, we present preliminary clinical results, as well as basic and clinical evidence, indications, contraindications and limitations of these new evolving techniques.

Repair of an Acute Blunt Popliteal Artery Trauma via Endovascular Approach

Popliteal vascular trauma remains a challenging entity and carries the greatest risk of limb loss among the lower extremity vascular injuries. Operative management of patients presenting with traumatic popliteal vascular injuries continues to evolve. We present a case of successful endovascular repair with stent grafting of an acute blunt popliteal artery injury. Endovascular repair of traumatic popliteal vascular injuries appears as an attractive alternative to surgical repair in a very selective group of patients. Further investigation is still needed to define the safety and feasibility of endovascular approach in the management of traumatic popliteal vascular injuries.