Pragnesh Joshi

Custodiol for myocardial protection and preservation: a systematic review

INTRODUCTION Custodiol cardioplegia is attractive for minimally invasive cardiac surgery, as a single dose provides a long period of myocardial protection. Despite widespread use in Europe, there is little data confirming its efficacy compared with conventional (blood or crystalloid) cardioplegia. There is similar enthusiasm for its use in organ preservation for transplant, but also a lack of data. This systematic review aimed to assess the evidence for the efficacy of Custodiol in myocardial protection and as a preservation solution in heart transplant. METHODS Electronic searches were performed of six databases from inception to October 2013. Reviewers independently identified studies that compared Custodiol with conventional cardioplegia (blood or extracellular crystalloid) in adult patients for meta-analysis; large case series that reported results using Custodiol were analyzed. Next, we identified studies that compared Custodiol with other organ preservation solutions for organ preservation in heart transplant. RESULTS Fourteen studies compared Custodiol with conventional cardioplegia for myocardial protection in adult cardiac surgery. No difference was identified in mortality; there was a trend for increased incidence of ventricular fibrillation in the Custodiol group that did not reach statistical significance. No difference was identified in studies that compared Custodiol with other solutions for heart transplant. CONCLUSIONS Despite widespread clinical use, the evidence supporting the superiority of Custodiol over other solutions for myocardial protection or organ preservation is limited. Large randomised trials are required.

Surgical Pulmonary Embolectomy: Experience in a Series of 37 Consecutive Cases

BACKGROUND Massive pulmonary embolism is a poorly tolerated condition. Treatment options in this condition include anticoagulation and primary reperfusion therapy - systemic thrombolysis, catheter based treatments or surgical embolectomy. There is little data on the relative efficacy of each treatment. METHODS The preoperative characteristics and outcomes of patients referred for surgical embolectomy between 2000-2014 was reviewed. Echocardiography was performed in the majority of patients before and after surgery. RESULTS Thirty-seven patients underwent pulmonary embolectomy between 2000-2014. One patient died within 30 days, another before leaving hospital. All other patients were alive at the time of follow-up (survival 94.6% at median 36 months). Median ventilation time was 24hours. Median hospital length of stay was 10.5 days. There was echocardiographic evidence of severe right ventricular strain (increased size and decreased function) before surgery, which was significantly improved to within the normal range by discharge, and follow-up. CONCLUSIONS Surgical embolectomy is a safe procedure, with low mortality, improved postoperative right ventricular function and pulmonary pressure, and good long-term outcome. Early relief of a large proportion of the clot burden can be life-saving. There should be consideration for its use as an initial treatment strategy in patients with massive or submassive pulmonary embolus with a large burden of proximal clot. A multidisciplinary approach for the treatment of these patients is required.

Extensive clot propagation involving the aorta and brachiocephalic artery: unusual consequence of paradoxical embolism.

A 73-year old woman with factor V Leiden deficiency and a history of deep venous thrombosis ceased taking oral warfarin. She sustained a massive cerebral infarct following extensive paradoxical embolism involving the brachiocephalic artery and the aorta (Fig. 1A and B). Transoesophageal echo findings (Fig. 2A and B) can be viewed in Supplementary Videos 1 and 2. Supplementary material (Videos 1 and 2) is available at EJCTS online. Video 1: Transoesophageal echocardiogram showing a large free-floating luminal thrombus within the aortic arch. Video 2: Transoesophageal echocardiogram demonstrating a large patent foramen ovale and an aneurysmal interatrial septum with a right-to-left shunt.

Right Ventricular Perforation during Femoral Venous Cannulation – Lessons Learned

Peripheral cannulation for cardiopulmonary bypass is increasingly used for minimally invasive and re-operative cardiac surgery. Transoesophageal echo (TOE) is used routinely to guide placement of the peripheral venous cannula in the right atrium/superior vena cava (SVC). We here present a case where despite use of TOE, placement of the venous cannula led to perforation of the right ventricular apex. We describe the surgical management of the problem and highlight strategies to avoid this complication.

Ruptured penetrating ulcer of the ascending aorta with pulmonary artery compression

Pulmonary artery involvement has been reported in various degrees of complicated dissection of the ascending aorta. The prognosis remains poor without high-risk surgical intervention, but conservative management can be considered in high-risk cases. We report a case of nonoperative management of an octogenarian who presented with a contained rupture of his proximal ascending aorta, likely from a penetrating atherosclerotic ulcer. It was complicated by extrinsic compression of the pulmonary trunk and transient pulmonary hypertension without features of acute right heart failure. He remained alive at the one-year follow-up.

Systematic review protocol: single-dose histidine-tryptophan-ketoglutarate vs . intermittent crystalloid or blood cardioplegia

Studies that compare the use of HTK vs. blood or crystalloid cardioplegia for myocardial protection in cardiac surgery, randomized or non-randomized, will be selected. Large case series of adult cardiac surgery with the use of HTK for myocardial protection but without a comparator, including more than 100 patients will be included in a separate analysis. Electronic searches will be performed of Medline, the Cochrane Database of Systematic Reviews, Pubmed and EMBASE. Manual searches of reference lists will be used to identify any studies not found in the initial search. Only studies in English will be included. Abstracts, letters, and review articles will be excluded. Differences of opinion between reviewers will be discussed with a senior investigator. An in/out form will be prepared to assess studies for inclusion or exclusion using predetermined inclusion criteria. The inclusion of studies will be assessed by two independent reviewers, with differences of opinion resolved by discussion with a senior investigator. A PRISMA flow-diagram will summarize inclusion/exclusion of studies. Level of evidence for each study will be reported to assess the quality of the evidence.

Removal of Peritnoeo-venous-atrial shunt thrombus without cardiopulmonary bypass

Thrombus formation is not uncommon in longstanding intracardiac catheters, but formation of a thrombus at the tip of a Peritnoeo-venous-atrial shunt, causing obstruction of the tricuspid valve, is a rare complication and frequently unrecognized. A large intracardiac thrombus causing valve obstruction requires surgical removal with the support of cardiopulmonary bypass which is associated with significant morbidity. We successfully removed a thrombus attached to the tip of peritoneovenous shunt without cardiopulmonary bypass in a 25-year-old man.

Surgical Management of Caseous Calcification of the Mitral Annulus

Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification; it can manifest with conduction abnormalities or systemic embolization. It typically involves the posterior mitral annulus, and surgery is indicated for severe mitral valve dysfunction, for embolic complications or when the diagnosis is not certain. We describe a structured approach to the surgical management of CCMA using bovine pericardium to repair the defect.

Bronchoscopic retrieval of 14-cm aspirated dental suction tip.

An 87-year-old gentleman was referred following accidental aspiration of a metallic suction tip during a routine dental procedure. He was asymptomatic at presentation, and the object was seen on chest radiography (Figure 1). He underwent successful retrieval of the suction tip from his right lower lobe bronchus with the aid of a 5.5-mm rigid bronchoscope and a pair of alligator forceps (Figure 2). This was confirmed on a postoperative chest radiograph (Figure 3). The procedure was technically challenging due to the length of the foreign body, the type of device, and the limitations of current instruments employed in bronchoscopic retrieval. We achieved success without recourse to a thoracotomy, and the patient was discharged on the first postoperative day. Asian Cardiovascular & Thoracic Annals 2017, Vol. 25(1) 72–73 The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315591104 aan.sagepub.com

Warfarin or excipient allergy: a clinical dilemma resolved.

doi: 10.5694/mja15.00084 “it is possible to have dermatological adverse reactions to the colouring dyes in warfarin” A 57-year-old Asian woman was referred for surgical ablation of atrial fibrillation (AF), coronary revascularisation and mitral valve surgery. She had a history of paroxysmal AF, previous stroke, coronary artery disease and severe mitral regurgitation. In the work-up for surgery, she developed recurrent, pruritic maculopapular rashes involving her trunk and upper limbs on two occasions within 3 days of initiating oral anticoagulation with warfarin (Marevan, Aspen) for AF. There were no other changes to the patient’s longstanding medication regimen during this period. Her regular medications consisted of aspirin 100 mg and perindopril arginine 2.5 mg in the morning, and atorvastatin 80 mg at night. Longterm anticoagulation with warfarin was necessary due to planned mechanical valve replacement and ongoing paroxysmal AF. Subsequently, she was referred to a clinical immunologist for assessment of her reaction to warfarin. Since allergic reactions to warfarin are rare, a reaction to one of the dyes in the tablet was considered.