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Surgical Procedure in Immunoglobulin G4–Related Ascending Aortitis?

Immunoglobulin G4 (IgG4)-related fibroinflammatory systemic disease accounts for 7% of all noninfectious aneurysms of the thoracic aorta. A patient was admitted with a symptomatic ascending aortic aneurysm and thickened aortic wall (outer/inner diameter 55/45 mm), which was replaced. Probes revealed IgG4-related aortitis associated with a primary tuberculosis infection. Corticosteroid and antituberculosis therapies were used, and the patients clinical evolution was favorable. The optimal treatment strategy of IgG4-related aortitis, a new entity, remains vague. Inner aortic diameter alone does not justify aortic replacement, but wall thickening may mimic intramural hematoma. In this particular case of IgG4-related aortitis, immunosuppressive treatment alone, as an alternative to a surgical procedure, may be debatable.

Is our heart a well-designed pump? The heart along animal evolution

A carrier system for gases and nutrients became mandatory when primitive animals grew larger and developed different organs. The first circulatory systems are peristaltic tubes pushing slowly the haemolymph into an open vascular tree without capillaries (worms). Arthropods developed contractile bulges on the abdominal aorta assisted by accessory hearts for wings or legs and by abdominal respiratory motions. Two-chamber heart (atrium and ventricle) appeared among mollusks. Vertebrates have a multi-chamber heart and a closed circulation with capillaries. Their heart has two chambers in fishes, three chambers (two atria and one ventricle) in amphibians and reptiles, and four chambers in birds and mammals. The ventricle of reptiles is partially divided in two cavities by an interventricular septum, leaving only a communication of variable size leading to a variable shunt. Blood pressure increases progressively from 15 mmHg (worms) to 170/70 mmHg (birds) according to the increase in metabolic rate. When systemic pressure exceeds 50 mmHg, a lower pressure system appears for the circulation through gills or lungs in order to improve gas exchange. A four-chamber heart allows a complete separation of systemic and pulmonary circuits. This review describes the circulatory pumping systems used in the different classes of animals, their advantages and failures, and the way they have been modified with evolution.

Survival After Surgical Drainage of Malignant Pericardial Effusion

ObjectivesManagement of malignant pericardial effusion (PE) is complex. Cardiac surgeons are not necessarily familiar with or are challenged by the many underlying etiologies. Analyzing risk factors for mortality may help to estimate the benefit of surgery in high-risk patients.MethodsPatients undergoing a surgical pericardiotomy for malignant PE, between 2001 and 2011, were included. The influence of tumor type, disease extension, intra-pericardial tumor infiltration on early mortality and long-term survival as well as freedom from symptoms after drainage, and the use of sclerosing agents on PE recurrence rates was analyzed.ResultsPE drainage was performed on 46 patients 12xa0±xa030xa0months after tumor diagnosis. Malignant diseases were lung cancers (50xa0%), breast cancers (15xa0%), lymphoma and leukemia (13xa0%), cancers of the digestive tract (13xa0%), and others (9xa0%). 80xa0% of patients were symptomatic and symptom relief was achieved in 65xa0%. Nobody died during surgery. Recurrence rate was 4xa0%. Early in-hospital mortality was 22xa0%. After 1xa0year, 29xa0% of patients were alive. Eleven patients (24xa0%) had a complete tumor regression. Metastatic spread (pxa0<xa00.001), pericardial infiltration (pxa0=xa00.02), and intra-pericardial Bleomycin (pxa0=xa00.01) injection were associated with increased mortality. Hematological malignancies had a better prognosis for survival.ConclusionSurgical pericardiotomy is safe, associated with a low recurrence rate and symptom relief in the majority of dyspneic patients. Intra-pericardial Bleomycin may reduce recurrent effusion but does not ameliorate survival. Long-term survival rate was low with an increased mortality in cases of metastatic spreading, pericardial infiltration, and as the tumor of origin: breast cancers. Leukemic and lymphatic tumors have better prognosis.

Transaortic transcatheter aortic valve replacement with the Sapien? valve and the first generations of Ascendra?.

Traditionally, the transcatheter aortic valve replacement is performed through a transapical, a transfemoral or a trans-subclavian approach. Recently, the transaortic approach for transcatheter aortic valve replacement through the distal part of the ascending aorta was successfully implemented in order to avoid peripheral vascular access-related complications and apical life-threatening haemorrhage. The Sapien™ stent valve has great transaortic potential because it can be loaded upside down in different generations of delivery systems. However, because of their health regulatory systems and despite the launch, in 2012, of the latest generation of the Ascendra™ delivery system, the Ascendra+™, specifically designed for transapical and transaortic valve placements, several countries are still using the first generations of Ascendra™ (Ascendra™ 1 and 2). This device was specifically designed for transapical procedures, and retrograde stent-valve positioning through the stenotic aortic valve may be very challenging and risk the integrity of the aorta. We describe the manoeuvre required in order to pass the stenotic aortic valve safely in a retrograde direction using the Sapien™ stent valve and the first generations of Ascendra™.

Single Heartstring aortotomy for multiple off-pump venous bypass grafts

Off-pump coronary bypass grafting may decrease the rate of stroke, due to minimal aortic manipulation. For venous grafts, clampless hemostasis when performing the proximal anastomosis can be achieved using the Heartstring device. We describe a technique using a single device to suture two veins to one aortotomy. This technique requires less space and could be advantageous in very short, small, and calcified aortas. In to our experience, this technique is rapid, simple, easy to reproduce, and cost-saving.

Editorial Comment: Arterial switch, Réparation à l'étage ventriculaire, Rastelli or Nikaidoh?

Honjo and co-workers, from the Toronto group, proposed an anatomical complexity score of the left ventricular outflow tract obstruction (LVOTO) to help in choosing between a variety of surgical corrections in face of dextro-transposition of the great arteries (d-TGA) and LVOTO [1]. The decision on the best repair in the presented series of 28 patients was actually made in a standard fashion— with preoperative and intraoperative assessments—and the results were simply fantastic, apparently with no error of judgement. The proposed echocardiographically-derived scoring system was applied retrospectively and was subsequently correlated to the surgical procedure chosen. Not surprisingly, a correlation between the echocardiographic findings and the surgical option applied was found and coefficients of obstruction were further set. Will this new scoring system truly help us? We are not sure. The critical decision in this group of patients is mostly whether an arterial switch operation (ASO), with opening of the outflow tract, can still be achieved instead of an ‘intracardiac repair’, like the ‘Reparation a l’etage ventriculaire’ (REV), Rastelli or Nikaidoh procedures. The choice between these operations or a single ventricle pathway will continue to be guided by an ’eyeballing’ of the LVOT in echocardiographic views and will ultimately be influenced by intraoperative findings, as acknowledged by the surgical results of this study [2–4]. The preoperative echocardiography (with or without an obstruction scoring system) gives a clue—often a strong one—as to the possible options. Its value is certainly the clear definition of the multiple components of the obstruction, but a surgeon needs more than a crude anatomy to definitively plan his operation. He needs information on the resectability of these components, something that often appears only during surgery. A straddling papillary muscle will get a low obstructive score but will cause more trouble than an extensive tissue tag formation or a bulging conal septum. The two opposing philosophies in the repair of TGA-LVOTO relate to the choice of the second-best option after the ASO, namely either the REV/Rastelli procedure or the Nikaidoh procedure and its variant ‘the double root rotation’ [2–5]. Strong proponents of the Nikaidoh procedure, such as the Toronto group, do not really need a scoring system for the obstructive components as, per definition, they will reposition the aortic root beneath them. As a matter of fact, the decision between the two procedures in the presented study was not influenced by the obstructive components, but by the pattern of the coronary arteries alone. Strong proponents of the REV/Rastelli procedure consider that the relief of the obstructive components can be achieved in virtually all patients with an operation performed at the right time. To them, the Nikaidoh procedure is indicated mostly in cases of a restrictive ventricular septal defect, of a small right ventricle or when the whole ‘double root’ can be rotated, and the scoring system will merely remain an academic tool [5]. In their experience, the gap of the mitro-aortic discontinuity correlates more with the magnitude of the intracardiac repair (to ensure a wide open left outflow tract) than with the pattern of the obstructing components [6]. In this controversy, only surgeons undecided between these two schools of thought might take an interest in the scoring system [7]. Still, the scoring system is a valuable new tool, mostly in cases where it can identify these patients with a potential complete or partial function of the pulmonary valve. As for any scoring system established retrospectively, it must now be validated prospectively and further fine-tuned—especially in respect of the characteristics of the sub-pulmonary area and the pulmonary root and leaflets— because this is the component of the proposed complexity score that will reveal the patients for whom a successful ASO is still possible or on whom a ‘double root rotation’ can be performed [5].

Double-stage venous cannulation combined with Avalon® cannula for potential prolongation of respiratory ECMO in end-stage pulmonary disease

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a treatment option to correct blood oxygenation in cases of severe respiratory failure. However, it is time-limited and, in cases of no- recovery, it is a bridge-to-lung transplant therapy. We report our experience of two patients waiting for emergency lung transplantation under VV-ECMO using the Avalon® cannula. Both presented signs of ECMO failure after prolonged support, i.e. increased hemolysis, decreased blood flow rate and increased negative pressure of the venous inflow line, leading to an inadequate systemic oxygenation. The addition of a second venous inflow line, by the insertion of another venous femoral cannula, significantly increased blood flow rate, decreasing both centrifugal pump rotation speed and negative pressure (suction) of the venous inflow line. These hemodynamic improvements, together with reduced blood consumption, were maintained during an additional week of ECMO support. Ultimately, both patients died from multi-organ failure due to the absence of available donor organs. Few cases having been described up until now, but the addition of a second venous drainage cannula to the Avalon® system could potentially improve hemodynamic parameters and, therefore, stabilize hypoxemic patients. This may be an option to gain time in long-lasting VV-ECMO support as a potential life-saving attempt.

Subaortic ventricular septal defect closure: is the principle of harmony for a longer function no longer valid?

Comment on : Results of two different approaches to closure of subaortic ventricular septal defects in children. [Eur J Cardiothorac Surg. 2014]

Impact of preoperative central neurologic dysfunction on patients undergoing emergency surgery for type A dissection.

BACKGROUNDnPreoperative central neurologic deficits in the context of acute type A dissection are a complex comorbidity and difficult to handle. The aim this study was to analyze this subgroup of patients by comparing them with neurologically asymptomatic patients with type A dissection. Results may help the surgeon in preoperative risk assessment and thereby aid in the decision-making process.nnnMETHODSnWe reviewed the data of patients admitted for acute type A dissection during the period from 1999 to 2010. Associated risk factors, time to surgery from admission, extension of the dissection, localization of central nervous ischemic lesions, and the influence of perioperative brain protective strategies were analyzed in a comparison of preoperative neurologically deficient to nondeficient patients.nnnRESULTSnForty-seven (24.5%) of a total of 192 patients had new-onset central neurologic symptoms prior to surgery. Concomitant myocardial infarction (OR 4.9, 95% CI 1.6-15.3, P=0.006), renal failure (OR 5.9, 95% CI 1.1-32.8, P=0.04), dissected carotid arteries (OR 9.2, 95% CI 2.4-34.7, P=0.001), and late admission to surgery at >6 hours after symptom onset (OR 2.7, 95% CI 1.1-6.8, P=0.04) were observed more frequently in neurologically deficient patients. These patients had a higher 30-day in-hospital mortality on univariate analysis (P=0.01) and a higher rate of new postoperative neurologic deficits (OR 9.2, 95% CI 2.4-34.7, P=0.02). Neurologic survivors had an equal hospital stay, and 67% of them had improved symptoms.nnnCONCLUSIONSnThe predominance of neurologic symptoms at admission may be responsible for an initial misdiagnosis. The concurrent central nervous system ischemia and myocardial infarction explains a higher mortality rate and a more extensive character of the disease. Neurologically deficient patients are at higher risk of developing new postoperative neurologic symptoms, but prognosis for the neurologic evolution of survivors is generally favorable.

Sarcoma of the heart: survival after surgery

OBJECTIVESnMalignant intracardiac tumours are rare, and consensus concerning the optimal therapeutic approach is lacking. We performed a retrospective medical analysis, identifying 9 patients having been operated for cardiac sarcomas. All of them had a complete postoperative long-term follow-up. To enhance understanding of the best therapeutic approach for future patients, it is crucial to reveal special medical problems and to analyse the potential impact they may have on disease course and survival rate in this specific patient group.nnnMETHODSnCardiac tumours operated on 2000 to the end of 2015 were reviewed. Late mortality during the follow-up period was determined. The impact of tumour extension, tumour localization, resection status (complete versus partial) and histopathological diagnosis on survival was analysed retrospectively.nnnRESULTSnOf all cardiac malignant tumours resected, sarcomas were, with an incidence of 0.14% (9 patients), the most frequent histological group admitted to cardiac surgery. All of the patients presented with cardiac symptoms. All of the patients survived the operation and all had relief or improvement of cardiac symptoms. The mean follow-up period was 17u2009±u200913u2009months. Five patients died after 6, 8, 12, 12 and 15u2009months, respectively. Four survivors (3 with a pulmonary artery tumour sarcoma and 1 with a left atrial sarcoma) had a mean follow-up of 26u2009±u200917u2009months. Macroscopically complete tumour resection, absence of metastatic spread and histological sarcoma type had an impact on follow-up survival.nnnCONCLUSIONSnAlthough cardiac sarcomas are rare, surgeons occasionally encounter them. A 1-year mortality rate of 44% reflects an unfavourable prognosis, but surgery seems to be a secure, reliable option in selected patients for treating cardiac symptoms and avoiding early cardiac-related deaths.