Kulvinder S. Lall

Emergency surgical retrieval of a migrated left atrial appendage occlusion device.

Although the initial results of patients who have had left atrial appendage (LAA) occlusion devices implanted have been promising, there have been associated complications requiring surgical intervention. We report a case of a LAA occlusion device migrating into the left ventricle requiring cardiac surgery to retrieve it.Although the initial results of patients who have had left atrial appendage (LAA) occlusion devices implanted have been promising, there have been associated complications requiring surgical intervention. We report a case of a LAA occlusion device migrating into the left ventricle requiring cardiac surgery to retrieve it.

The Impact of Weather Factors, Moon Phases, and Seasons on Abdominal Aortic Aneurysm Rupture

BACKGROUND Several studies have documented that weather factors, seasons of the year, time of the day, and even changes in moon phases have an impact on the occurrence of rupture of an abdominal aortic aneurysm (RAAA); however, the available data are confounding. The objective of this study was to determine the impact of these factors on the prevalence and mortality rate of RAAA. METHODS This is a retrospective analysis of medical records of patients treated for RAAA over a 10-year period. Weather data (i.e., atmospheric pressure, air temperature, humidity, visibility, and wind speed) and weather events (i.e., rain, snow, and storms, etc) were obtained from the local meteorologic weather station and analyzed for a correlation with RAAA. RESULTS Five hundred thirty patients with RAAA were identified, and these patients presented on 478 days during the 10-year study period (3,652 days), with the overall in-hospital mortality rate of 48.7%. The RAAA mortality was higher during weekends and national holidays, when compared to weekdays (59% vs 45%; P = 0.006) and in patients admitted between 3-7 am when compared to work day hours (65.5% vs 44.1%; P = 0.035). Season changes had no influence on the frequency of RAAA; however, summer seemed to be associated with an increase in mortality as opposed to autumn (54.4% vs 42.5%; P = 0.047). Mean atmospheric pressure (and fluctuations thereof) and other weather factors, including phases and parts of the moon, did not correlate with RAAA occurrence or its mortality. CONCLUSIONS Patients with RAAA who were admitted on weekends, national holidays and in late night hours had lower survival rates. Weather factors (including atmospheric pressure) do not influence the prevalence and mortality of RAAA.

Infected Calcified Homograft Root: A Sutureless Solution

Aortic valve reoperation after homograft root implantation is high risk and may be technically challenging. Dense calcification of the annulus may prevent suture placement and often necessitates impromptu high-risk redo root replacement. Although transcutaneous aortic valve implantation is an attractive option in such scenarios, in the context of endocarditis it is contraindicated. We describe a novel approach to aortic valve replacement in a patient with infective endocarditis of a heavily calcified homograft root, using a sutureless valve. This approach successfully avoided the need for redo root replacement with its attendant risks.

Reconstruction of the Right Atrium and Superior Vena Cava with Extracellular Matrix

We describe our technique for reconstructing the free right atrial wall and superior vena cava using CorMatrix (CorMatrix Alpharetta, GA, USA) extracellular matrix following resection of a large leiomyosarcoma. doi: 10.1111/jocs.12398 (J Card Surg 2015;30:351–354)

When should cardiopulmonary bypass be used in the setting of severe hypothermic cardiac arrest

A best evidence topic was written according to a structured protocol. The question addressed was regarding the indication and timing of the use of cardiopulmonary bypass (CPB), following severe hypothermic cardiac arrest. A total of 284 papers were found using the reported searches, of which nine represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were survival, rewarming speed, incidence of arrhythmia during rewarming, resolution of full neurological function, long-term neurological function, evidence of damage on neurological imaging and venous metabolic parameters in hypothermic patients. The most recent of the best evidence studies, a retrospective comparative study of 68 patients, demonstrated CPB rewarming to be far superior to conventional methods of rewarming, with mortality rates of 15.8 and 53.3%, respectively. Another study of similar size, comparing CPB with extracorporeal membrane oxygenation (ECMO) for rewarming, revealed superior survival rates with ECMO, 75 vs 34%. A systematic review of 68 patients demonstrated an overall survival of 60%, and 80% of survivors returning to a previous level of activity. Two smaller observational studies reported survival rates of 73.1 and 45.5%, respectively. A retrospective study analysing long-term neurological outcomes of survivors reported normal history and physical examination in 93.3%, normal neurovascular ultrasound in 100%, normal neuropsychological findings in 93.3% and normal brain magnetic resonance imaging in 86.7%. A small comparative study demonstrated a significant survival benefit when CPB was preceded with emergency thoracotomy, internal cardiac massage and warm mediastinal irrigation compared with CPB alone. We conclude that, following deep hypothermic circulatory arrest, the urgent use of cardiopulmonary bypass is widely indicated for rewarming where it has been shown to provide good survival and neurological outcomes far superior in comparison with conventional methods of rewarming.

The acute chest syndrome of sickle cell disease following aortic valve replacement

The acute chest syndrome (ACS) of sickle cell disease (SCD) is a leading cause of death in SCD, with a high incidence following surgery, though only one case has been reported following cardiac surgery. We present a case of ACS in an adult undergoing aortic valve replacement (AVR) despite instituting established peri-operative optimization measures to prevent sickling. Early diagnosis of this condition in our patient as a distinct clinical entity facilitated appropriate, specific therapy and a good subsequent postoperative recovery. Greater recognition of this syndrome in the growing number of adult sickle cell patients presenting for cardiac surgery may help improve their outcome.

Is ministernotomy superior to right anterior minithoracotomy in minimally invasive aortic valve replacement

A best evidence topic was constructed according to a structured protocol. The question addressed was whether, in patients undergoing minimally invasive aortic valve replacement (AVR), right anterior thoracotomy (RT) or mini-sternotomy (MS) was superior in terms of postoperative outcome? A total of 840 publications were found using the reported search. Of these, 6 represented the best available evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In all, except 1 study, the primary outcome was early mortality, ranging from in-hospital mortality to 90 days postoperatively. The remaining study was a cost-benefit analysis. Four studies were non-randomized observational studies, one of which was multicentre. Two were meta-analyses of studies comparing minithoracotomy or MS with conventional sternotomy for AVR, rather than direct comparisons of the 2 minimal access techniques. We conclude that there is a lack of high-quality evidence comparing RT and MS for minimally invasive AVR, with no randomized controlled trials to date. The available evidence shows no difference in early mortality between RT and MS for surgical AVR. In studies that directly compared RT and MS, RT was found to be associated with reduced length of hospital stay, despite longer cardiopulmonary bypass times and cross-clamp times. One study reported groin complications (10.8%) with the RT group, where peripheral cannulation was used, while the other 5 studies did not comment on groin complications associated with peripheral cannulation. In the only cost-benefit analysis, RT was found to carry considerably more cost than MS over and above conventional AVR.

Ventricular remodelling and revascularization in severe left ventricular dysfunction

OBJECTIVE To evaluate the role of surgical revascularization in the presence of severe, global impairment of left ventricular function without discrete aneurysm formation or mitral regurgitation. The high mortality and morbidity associated with this group, together with the limited benefits tend to prompt referral for cardiac transplantation. METHODS Fifty-three patients initially referred for transplantation, in addition to coronary revascularization, underwent mitral annuloplasty (group A = 23), free wall remodelling by endoaneurysmorrhaphy (group B = 17) or mitral annuloplasty and free wall reconstruction (group C = 13). The mean ages were 59, 56 and 57 years for groups A, B and C, respectively. Detailed assessment of pre- and post-operative physical and psychological status were carried out. RESULTS Follow-up was for a mean period of 22-26 months. All patients reported substantial improvement in quality of life, both physical and psychological parameters and in NYHA functional class status. Objective evidence of improvement in ejection fraction was seen in all three groups but especially in group A. There were five early deaths, four were due to inadequate revascularization due to the poor quality of target vessels. There were three late deaths and one patient that required transplantation. CONCLUSION We conclude that patients with severe left ventricular dysfunction can be candidates for surgical revascularization and optimization of ventricular geometry with acceptable mortality. The importance of achieving complete revascularization is emphasized in this series.

Midterm Follow-Up of Haemodynamic Performance of the St. Jude Medical Trifecta Aortic Bioprosthesis in Young Patients Under 65.

The St. Jude Medical Trifecta aortic supra-annular bioprosthesis is regarded as the next generation in pericardial stented tissue valves. The unique design of tissue leaflets attached to the exterior of the valve stent provides unrivalled in-vivo mean gradients and haemodynamics.

Aortic Valve Replacement: Are We Spoiled for Choice?

Management of aortic valve disease and, in particular, aortic valve stenosis has evolved through the course of time from medical management and balloon valvuloplasty to the presumed gold-standard surgical intervention. However, with the advent of surgical innovation, intra- and postoperative patients monitoring, understanding of hemodynamic dysfunction, and choices of prosthesis, conventional surgical aortic valve replacements are currently being challenged in particular in moderate- and high-risk patients. Although the long-term results and survival are not robustly available, the durability of the new prosthesis, repair, and the freedom from reoperation remain debatable. In this review, we aim to highlight the surgical innovation attained, choices of aortic valve prosthesis, and also dwell on the current evidence, practice, and trend steered to managing patients with aortic valve stenosis.