Manoj Kuduvalli

Risk of morbidity and in-hospital mortality in obese patients undergoing coronary artery bypass surgery

OBJECTIVES Obesity is often perceived to be a risk factor for adverse outcomes following coronary artery bypass graft (CABG) surgery. Several studies have been unclear about the relationship between obesity and the risk of adverse outcomes. The aim of this study was to examine the relationship between obesity and in-hospital outcomes following CABG, while adjusting for confounding factors. METHODS A total of 4713 consecutive patients undergoing isolated CABG between April 1997 and September 2001 were retrospectively analyzed. Body mass index (BMI) was used as the measure of obesity and was grouped as non-obese (BMI <30), obese (BMI 30-35), and severely obese (BMI > or =35). Associations between obesity and in-hospital outcomes were assessed by use of logistic regression to adjust for differences in patient characteristics. RESULTS A total of 3429 patients were defined as non-obese, compared to 1041 obese and 243 severely obese. There was no association between obesity and in-hospital mortality, stroke, myocardial infarction, re-exploration for bleeding and renal failure. Obesity was significantly associated with atrial arrhythmia (adjusted odds ratio (OR) 1.19, P = 0.037 for the obese; adjusted OR 1.52, P = 0.008 for the severely obese) and sternal wound infections (adjusted OR 1.82, P = 0.002 for the obese; adjusted OR 2.10, P = 0.038 for the severely obese). The severely obese patients were 4.17 (P < 0.001) times more likely to develop harvest site infections. Severely obese patients were also more likely to have prolonged mechanical ventilation and post-operative stays, compared to non-obese patients. CONCLUSIONS Obese patients are not associated with an increased risk of in-hospital mortality following coronary artery bypass surgery. In contrast, there is a significant increased risk of morbidities and post-operative length of stay in obese patients compared to non-obese patients.

Norwood-type operation with adjustable systemic–pulmonary shunt using hemostatic clip

The postoperative course of a patient with hypoplastic left heart syndrome after a first-stage Norwood operation is governed to a large extent by the balance between the systemic and pulmonary circulations. Here we describe a simple and convenient technique for establishing an optimally sized systemic-pulmonary shunt by the application of a hemostatic clip. The method has been used in 6 patients.

Long-term outcomes in thoracoabdominal aortic aneurysm repair for chronic type B dissection.

INTRODUCTION Open repair for chronic aortic dissection remains a challenging surgical option. Different centers report diverse experiences and outcomes pertaining to thoracoabdominal aortic aneurysm repair (TAAAR) for chronic type B dissection. We highlight our centers experience and results on a background of published literature and current evidence. METHODS We reviewed 214 open TAAAR performed between October 1998 and February 2014. Of these, chronic type B dissection was present in 62 (29.0%) patients. We reviewed these patients in terms of demographics, operative characteristics and outcomes. Thirteen (21.0%) patients had surgery on the descending thoracic aorta [Category A =2 (3.2%), B =0 (0%), C =11 (17.7%)] and 49 (79.0%) in the thoracoabdominal thoracic aorta [Crawford extent I =5 (8.1%), extent II =39 (62.9%), extent III =4 (6.5%), extent IV =1 (1.6%)]. Left heart bypass was used in 12 (19.4%) patients. RESULTS The composite in-hospital endpoint, adverse outcome-defined as operative death, renal failure necessitating dialysis at discharge, stroke, or permanent paraplegia or paraparesis-occurred after 28 (45.2%) procedures. There were 14 (22.6%) operative deaths. In-hospital mortality was seven (16.3%) out of 43 elective patients, and increased to seven (36.8%) of the 19 non-elective ones. Permanent paraplegia or paraparesis occurred after two (3.2%) cases, stroke occurred after seven (11.3%) and renal failure requiring dialysis occurred after 16 (25.8%). Mean follow-up time was 3.2 years and actuarial 5-year mortality was 27.4% [nine (14.5%) elective and eight (12.9%) non-elective patients]. CONCLUSIONS TAAAR in chronic type B dissection carries a substantial risk of early adverse outcomes. The results could be well alleviated with cases directed towards specialized regional and supra-regional centers. Although the endovascular approaches offer relatively low mortality and morbidity, there is a lack of long-term data and guidelines on their use. There is a need for a multidisciplinary international registry on the management of thoracoabdominal aortic aneurysms and dissection. This would provide a degree of guidance on relevant clinical and surgical judgments and outcomes.

Hybrid theatres: nicety or necessity?

In recent years there has been a convergence of approaches to the treatment of cardiovascular disease with combined cardiology, radiology and surgical multidisciplinary team (MDT) based management. This is particularly true with the advent of transcatheter (transfemoral and transapical) aortic valve replacement1 as well as the new combined open and endovascular approaches to thoraco‐abdominal aneurysms,2 including single stage combined coronary artery bypass grafting (CABG) and abdominal aortic endovascular aneurysm repair (EVAR).3 However, there has also been a more longstanding, and commonly although not exclusively, staged hybrid approach in the form of combining percutaneous coronary intervention (PCI) with surgical coronary revascularization and surgical valve repair or replacement in appropriate patients.4–6 As such, it is inevitable new operating enviroments have emerged in the form of so‐called ‘hybrid theatres’ allowing single stage, hybrid endovascular and open intervention for a range of morbidities in children and adults.7,8 This manuscript discusses briefly the design and function of a hybrid theatre, including its perceived advantages and disadvantages. By way of example we review our activity in this environment over the first year of opening. We discuss whether this resource is a nicety or necessity in adopting hybrid approaches. Design and function of the hybrid theatre As part of the development of a regional thoracic aortic aneurysm service a purpose‐built hybrid theatre was constructed (Philips) and opened in Liverpool in April 2007. A number of detailed descriptions of hybrid theatres exist8–10 and we therefore restrict the discussion here to a brief overview. Broken down into its basic structural components, the hybrid theatre is simply an operating theatre with built‐in radiological screening capabilities. In truth, however, the hybrid theatre is more than simply the sum of its parts. The bespoke C‐arm image intensifier is built into the ceiling of the operating room and able to move both longitudinally and rotate around the axis of the patient (Figures 1a and b). As such, the theatre complex is designed with ample space, allowing for dedicated cardiopulmonary bypass equipment as well as the paraphernalia associated with general anaesthesia. Other equipment, including transoesophageal echocardiography, cell salvage, electrocautery and pacing, are easily accommodated. Multiple monitors allow easy access to data at all points around the table. High quality overhead lights allow for good visibility. Consistent with a normal catheter laboratory the theatre is designed with a control/viewing room with dedicated image processing, as well as catheter store room, surgical scrub room and anteroom. Lead aprons are available. Other devices such as contrast injector and defibrillator are stored in theatre. It is not only the close proximity of this multidisciplinary equipment which makes this a unique environment, but the fact that it engenders a collaborative approach to the management of complex disease. Figure 1a and 1b Hybrid theatre showing the theatre table, roof-mounted C‐arm, perfusion, anaesthetic and surgical equipment Hybrid approaches to elective cardiovascular disease The hybrid activity in the theatre is coordinated by two MDT meetings attended regularly by consultant representation from cardiology and radiology, as well as both vascular surgery and cardiac surgery, and intensive care medicine. The specialization of these two groups centres on endovascular approaches to thoraco‐abdominal aortic disease and transfemoral/transapical aortic valve replacement. Hybrid thoracic endovascular aneurysm repair (TEVAR)/open procedures A team of three cardiac surgeons with an interest in thoraco‐abdominal aneurysms attend a weekly thoracic aneurysm clinic, with regional and supra regional referrals from the full range of medical specialties. Complex cases requiring endovascular solutions or combined endovascular/open approaches (hybrid or staged) are referred to a monthly MDT meeting attended by cardiac and vascular surgeons with input from both interventional and non-interventional radiologists. During the first year of coming online, a range of truly hybrid interventions have been performed. These include abdominal endovascular aneurysm repairs (EVAR) with simultaneous coronary artery bypass grafting (CABG), arch-related TEVAR with arch vessel bypass, TEVAR with femoral–femoral cross‐over graft, as well as a full range of isolated TEVAR procedures ( Table 1). Table 1 Surgical activity 2007–2008 Transfemoral and transapical aortic valve replacement A regular MDT comprising interventional cardiologists, cardiac surgeons and anaesthetists/intensivists discusses possible suitable patients for this approach. To date we have early experience with transfemoral and transpical aortic valve replacement and found the hybrid theatre exceptionally well suited for this activity.

Systematic Review Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis

BACKGROUND Despite recent advances in aortic surgery, acute type A aortic dissection remains a surgical emergency associated with high mortality and morbidity. Appropriate management is crucial to achieve satisfactory outcomes but the optimal surgical approach is controversial. The present systematic review and meta-analysis sought to access cumulative data from comparative studies between hemiarch and total aortic arch replacement in patients with acute type A aortic dissection. METHODS A systematic review of the literature using six databases. Eligible studies include comparative studies on hemiarch versus total arch replacement reporting short, medium and long term outcomes. A meta-analysis was performed on eligible studies reporting outcome of interest to quantify the effects of hemiarch replacement on mortality and morbidity risk compared to total arch replacement. RESULT Fourteen retrospective studies met the inclusion criteria and 2,221 patients were included in the final analysis. Pooled analysis showed that hemiarch replacement was associated with a lower risk of post-operative renal dialysis [risk ratio (RR) =0.72; 95% confidence interval (CI): 0.56-0.94; P=0.02; I(2)=0%]. There was no significant difference in terms of in-hospital mortality between the two groups (RR =0.84; 95% CI: 0.65-1.09; P=0.20; I(2)=0%). Cardiopulmonary bypass, aortic cross clamp and circulatory arrest times were significantly longer in total arch replacement. During follow up, no significant difference was reported from current studies between the two operative approaches in terms of aortic re-intervention and freedom from aortic reoperation. CONCLUSIONS Within the context of publication bias by high volume aortic centres and non-randomized data sets, there was no difference in mortality outcomes between the two groups. This analysis serves to demonstrate that for those centers doing sufficient total aortic arch activity to allow for publication, excellent and equivalent outcomes are achievable. Conclusions on differences in longer term outcome data are required. We do not, however, advocate total arch as a primary approach by all centers and surgeons irrespective of patient characteristics, but rather, a tailored approach based on surgeon and center experience and patient presentation.

True Aneurysm of a Dacron Tube Graft 19 Years After Repair of Coarctation of the Aorta

We report a 31-year old woman who presented with acute onset of shortness of breath 19 years after multiple repairs of a preductal coarctation of the aorta using a Dacron tube graft. Imaging studies showed an aneurysm had developed in the tube graft. The aneurysmal tube graft was replaced during an open repair.

Blunt Aortic Injury Secondary to Fragmented Tenth Thoracic Vertebral Body

We present a case of blunt traumatic aortic laceration following a motor vehicle crash. The aortic laceration was 4.5 cm above the coeliac axis and occurred because of an unstable tenth thoracic vertebral body. Open surgery was considered high risk, whereas an endovascular approach with an endoprosthesis placed at the exact anatomic location of the laceration was advocated.

Cerebral protection in hemi-aortic arch surgery

Surgical therapy for aortic arch disease usually requires a period of hypothermic circulatory arrest, which calls for cerebral protection strategies and adjuncts. The optimal strategy for protecting the brain from irreversible ischaemic damage during the period of circulatory arrest remains controversial. Patients present with diverse aortic pathologies and this may dictate different cerebral protection methods that are tailored for the circumstances of each individual case. The purpose of this overview is to describe each method of cerebral protection employed in hemi-aortic arch surgery and to explain their advantages and disadvantages. A surgical case on hemi-aortic arch replacement using retrograde cerebral perfusion is demonstrated (Video 1). We also present our hospital demographics and outcomes pertaining to cerebral protection in hemi-aortic arch surgery. Video 1 Cerebral protection in hemi-aortic arch surgery The current practices employed for brain protection during aortic arch surgery include: (I) deep hypothermic circulatory arrest (DHCA); (II) retrograde cerebral perfusion (RCP); and (III) selective antegrade cerebral perfusion (SACP).

Cannulating a Dissecting Aorta Using Ultrasound-Epiaortic and Transesophageal Guidance

Management of acute Stanford type A aortic dissection remains a major surgical challenge. Directly cannulating the ascending aorta provides a rapid establishment of cardiopulmonary bypass but consists of risks such as complete rupture of the aorta, false lumen cannulation, subsequent malperfusion and propagation of the dissection.We describe a technique of cannulating the ascending aorta in patients with acute aortic dissection that can be performed rapidly in hemodynamically unstable patients under ultrasound-epiaortic and transesophageal (TEE) guidance.

Combined Cardiac Surgery and Endovascular Repair of Abdominal Aortic Aneurysms

Purpose To report an initial experience of concomitant endovascular repair of abdominal aortic aneurysms (AAA) and cardiac surgery. Methods Records for 10 consecutive patients (all men; median age 68 years, range 60–79) with AAA treated by a multidisciplinary team at a tertiary specialist center were retrospectively reviewed. Each patient had independent indications for surgical correction of their cardiac disease and AAAs. The patients underwent endovascular aneurysm repair (EVAR) followed by cardiac surgery under the same anesthesia. Eight patients had concomitant coronary artery bypass grafting (CABG; 4 off-pump), 1 patient had CABG and left ventricular aneurysmectomy, and 1 patient required aortic root replacement. Results All combined procedures were performed successfully under a single general anesthesia and took a median of 508 minutes (range 425–625). Median intensive care stay was 3 days (range 2–4), while hospital stay was 8 days (range 7–21) days. There were no deaths in-hospital or within 30 days. Complications were minor and self-limiting; there were no instances of renal failure. At a median follow-up of 29 months (range 14–38), no EVAR-related secondary interventions were required. Conclusion Concomitant EVAR and cardiac surgery delivered by a multidisciplinary team is feasible, appears safe, and eliminates the risk associated with staged operations. Improved patient satisfaction and efficient use of resources are potential advantages.