Romuald Cichoń

Is thoracoscopic patent ductus arteriosus closure superior to conventional surgery

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether thoracoscopic patent ductus arteriosus (PDA) closure is superior to conventional surgery. Altogether 821 papers were found using the reported search, 11 of which represented the best 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. Eleven studies included in the analysis consisted of two prospective and three retrospective, non-randomized studies and six case series. Four included studies focused only on preterm infants, three studies enrolled neonates and the other four analysed all age groups from neonates to older children or young adults. There were no differences in mortality between video-assisted thoracoscopic surgery (VATS) and conventional surgery. Two studies suggested that VATS offers shorter operative times. Two papers observed shorter hospital stay, although the other two noted no significant difference. A large prospective trial found VATS to be associated with a lower number of postoperative complications in neonates and infants, whereas other studies suggested no significant differences in short-term postoperative complications. There is little evidence to suggest better musculoskeletal status and cosmesis in neonates following VATS. Conversion from thoracoscopy to thoracotomy described in six papers was seldom and it did not lead to any additional complications. All observational studies confirmed that both techniques are free from major adverse cardiovascular complications and these two techniques can be safely used in all patients qualified for surgical PDA closure. Two studies compared cost-effectiveness between the two techniques; one of them described VATS as significantly more cost-efficient, whereas the other study observed no difference. However, it should be noted that data were provided from different countries and time periods. The results presented suggest that there are no significant differences in early clinical outcomes between VATS and thoracotomy in all age groups. However, where differences have been shown, such as pain, postoperative complications, length of hospital and ICU stay and cost, these favour the VATS approach.

Common carotid artery access for transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is an alternative method of treatment for severe symptomatic aortic stenosis in patients who are at high risk of surgical aortic valve replacement (AVR). In randomised clinical trials TAVI was shown to be superior to standard medical therapy in a cohort of inoperable patients and non-inferior to AVR in high-risk operable patients. Additionally, in a recent trial with self-expandable prosthesis use, TAVI was associated with lower mortality compared with surgery. Usually, femoral arteries are the most common vascular access to deliver the bioprosthesis; however, in some cases (up to 20%) this route may not be applied because of significant peripheral artery disease or tortuosity. In this article, we present the first two TAVI procedures in Poland performed via the left common carotid artery.

Wilms' Tumor With Intra-Atrial Extension: Treatment and Management.

Wilms’ tumor is the most common renal cancer in children. It can grow for a long time without any characteristic symptoms, causing only fever, abdominal pain, nausea, or vomiting, which is the reason why it is often discovered accidentally. In 1% to 4% of the cases, nephroblastoma leads to complications in the form of intravascular and intra-atrial extension. We present a case of a five-year-old boy with Wilms’ tumor extending into the inferior vena cava, right atrium, and then prolapsing through the tricuspid valve into the right ventricle.

What is the impact of preoperative aspirin administration on patients undergoing coronary artery bypass grafting

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether continuation of administration of preoperative aspirin until the day of coronary artery bypass grafting (CABG) could minimize postoperative mortality, prevalence of postoperative myocardial infarction (MI) with or without influence on postoperative bleeding, packed red blood cell (PRBC) transfusion and reoperation for bleeding. Altogether, 662 papers were found using the reported search, 7 of which represented the best 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. Seven studies, included in this review, consisted of five meta-analyses and two randomized controlled trials. One meta-analysis, involving 27 533 patients submitted to CABG, showed that the administration of preoperative aspirin decreased postoperative 30-day mortality by 27%. Another meta-analysis, including 1437 patients, showed that preoperative aspirin decreased the incidence of perioperative MI by 44%, the effect being even more pronounced with low-dose aspirin, which reduced the prevalence of perioperative MI by 63%. One RCT showed that preoperative aspirin is associated with reduced long-term hazard of MI or repeated revascularization. Four meta-analyses and two RCTs showed that preoperative aspirin is associated with increased postoperative bleeding, PRBC transfusion and reoperation for bleeding. However, this was not the case with preoperative administration of low-dose aspirin. The results presented in these studies suggest that preoperative aspirin administration in patients undergoing CABG has a significant benefit in reducing the incidence of perioperative MI and 30-day mortality rate, as well as reduced long-term hazard of MI or repeated revascularization. At a higher dose (>100 mg/day), postoperative bleeding, PRBC transfusion and reoperation for bleeding increased. However, with low-dose aspirin (≤100 mg/day), these benefits were not at the expense of increased postoperative bleeding or transfusion.

Preoperative Aspirin Therapy Reduces Early Mortality in Patients Undergoing Cardiac Surgery

We read with interest the study performed by Ma and associates, which failed to demonstrate any impact on the 30-day, all-cause mortality in patients receiving aspirin (ASA) prior to coronary artery bypass grafting (CABG). However, recent studies have shown that the preoperative administration of ASA may be of benefit not only to patients undergoing CABG but also to patients undergoing other cardiac procedures. In order to determine whether a preoperative ASA continuation has any impact on the 30-day, all-cause mortality, we performed an updated meta-analysis of preoperative ASA use in patients undergoing all cardiac surgical procedures. Current through May 2015, all articles concerning preoperative ASA and postoperative all-cause mortality were identified through OVID SP and a manual search of MEDLINE, EMBASE, and COCHRANE Central Registry of Controlled Trials. The exclusion criteria were as follows: the use of clopidogrel, dipyridamole, integrilin, ticagrelor, heparin, or vitamin K antagonists prior to the surgery; age less than 18; studies using per-protocol analysis; and those not presenting mortality within 30 days following surgery. Finally, 17 trials (12 observational nonrandomized and 5 randomized controlled trials) comparing patients undergoing cardiac surgery, in whom preoperative ASA had been continued until the surgery, with patients in whom aspirin had been withdrawn no less than 7 days prior to the surgery or who had been randomized to receive placebo, were included. Presented analysis involved altogether 30 786 patients, the majority of whom underwent CABG (89.4%, n 1⁄4 27 533), while the remaining underwent valve surgery (4.9%, n 1⁄4 1523), CABG with concomitant valve surgery (3.1%, n 1⁄4 982), or other cardiac procedures (2.4%, n 1⁄4 748). Pooled analysis showed a 27% statistically significant reduction in 30-day all-cause mortality in patients receiving ASA preoperatively (odds ratio: 0.73 [95%confidence interval: 0.57-0.94]; P 1⁄4 .0127; Figure 1). There was no significant between-studies heterogeneity (I 1⁄4 11.51%, Q 1⁄4 19.21, P 1⁄4 .32). No difference was seen on a fixed-effect analysis, neither when any single study was omitted. Our analysis differs from the previous report in 2 aspects. First, it involves patients undergoing all cardiac procedures with the great majority receiving CABG. Second, it gathers the most up-to-date evidence. Despite the results of Ma et al, we conclude that there might be an approximately 30% reduction in mortality in patients undergoing cardiac surgery when using ASA within the 7 days preoperatively. Most of the included patients underwent CABG (92.5%), therefore preoperative continuation of ASA may reduce 30-day mortality in patients undergoing surgical coronary revascularization. Although there is a statistically significant reduction in early mortality in our analysis, this conclusion is substantially limited by the absence of any support from the randomized controlled trials and the sole reliance on nonhypothesis testing, nonrandomized observational studies. In this letter, we do not address the bleeding risk reports by Ma et al, with preoperative aspirin use in patients undergoing cardiac surgery. We should thus await conclusive results of large, well-powered randomized clinical trials and a careful risk–benefit analysis of an early mortality benefit, despite any excess bleeding risk before forming any judgments or making recommendations to use preoperative aspirin in patients undergoing cardiac surgery.

Low-Level Light Therapy Protects Red Blood Cells Against Oxidative Stress and Hemolysis During Extracorporeal Circulation

Aim: An activation of non-specific inflammatory response, coagulation disorder, and blood morphotic elements damage are the main side effects of the extracorporeal circulation (ECC). Red-to-near-infrared radiation (R/NIR) is thought to be capable of stabilizing red blood cell (RBC) membrane through increasing its resistance to destructive factors. We focused on the development of a method using low-level light therapy (LLLT) in the spectral range of R/NIR which could reduce blood trauma caused by the heart-lung machine during surgery. Methods: R/NIR emitter was adjusted in terms of geometry and optics to ECC circuit. The method of extracorporeal blood photobiomodulation was tested during in vivo experiments in an animal, porcine model (1 h of ECC plus 23 h of animal observation). A total of 24 sows weighing 90–100 kg were divided into two equal groups: control one and LLLT. Blood samples were taken during the experiment to determine changes in blood morphology [RBC and white blood cell (WBC) counts, hemoglobin (Hgb)], indicators of hemolysis [plasma-free hemoglobin (PFHgb), serum bilirubin concentration, serum lactate dehydrogenase (LDH) activity], and oxidative stress markers [thiobarbituric acid reactive substances (TBARS) concentration, total antioxidant capacity (TAC)]. Results: In the control group, a rapid systemic decrease in WBC count during ECC was accompanied by a significant increase in RBC membrane lipids peroxidation, while in the LLLT group the number of WBC and TBARS concentration both remained relatively constant, indicating limitation of the inflammatory process. These results were consistent with the change in the hemolysis markers like PFHgb, LDH, and serum bilirubin concentration, which were significantly reduced in LLLT group. No differences in TAC, RBC count, and Hgb concentration were detected. Conclusion: We presented the applicability of the LLLT with R/NIR radiation to blood trauma reduction during ECC.

Right atrial tumour in a patient with acute pancreatitis

Differential diagnosis of intracardiac tumours should include i.a. thrombi, vegetations and neoplasms. We present a case of a 72-year-old male with paroxysmal atrial fibrillation, who had been previously treated with dabigatran and whose anticoagulant treatment was subsequently changed to enoxaparin during hospitalisation due to acute pancreatitis. Initially, tumour of the ampulla of Vater was suspected. Echocardiography revealed a polycyclic, balloting tumour in the right atrium, originating from the inferior vena cava. Based on computed tomography, magnetic resonance imaging and gastroscopy, carcinoma of the ampulla of Vater was ruled out. Positron emission tomography was performed, showing no signs of metabolically active neoplastic growth. Anticoagulation with acenocoumarol was initiated, leading to a complete resolution of the mass in the right atrium and inferior vena cava.

Combined total aortic arch replacement associated with aortic valve replacement and subtotal thyroidectomy.

The aim of this study is to present a 57-year-old female patient in whom a combined total aortic arch replacement associated with aortic valve replacement and subtotal thyroidectomy was simultaneously performed. The patient was admitted to the Department of Neurology due to isolated seizure of the right upper limb, with progression of the paresis. The symptoms resolved after a few hours. Seven months earlier, the patient suffered from a haemorrhagic stroke in the right hemisphere due to an aneurysm of the distal branch of the callosomarginal artery. The pathology was then treated by embolisation of the aneurysm. During current hospitalisation, diagnostic tests showed goitre, paroxysmal atrial fibrillation, and aortic valve insufficiency. Computed tomography angiography confirmed aortic dissection — Stanford type A, with dissected aortic arch, brachiocephalic trunk, both common carotid arteries, and the left subclavian artery (Figs. 1, 2). After completed diagnostics, the patient was transferred to the Department of Cardiac Surgery for immediate operation. It was decided to perform a combined aortic valve replacement with total aortic arch replacement and subtotal thyroidectomy. Longitudinal skin incisions on the neck were performed to expose both carotid arteries. Median sternotomy was performed. Brachiocephalic trunk and the right atrium were cannulated. Extracorporeal circulation (ECC) was established and the patient was cooled to 28oC. The aorta was clamped, aortotomy was performed, and Calafiore blood cardioplegia was introduced into the coronary ostia. Aortic valve was replaced using a 21-mm bioprosthesis. Proximal anastomosis with a four-branched graft to the ascending aorta was performed. The selective antegrade cerebral perfusion started, and under circulatory arrest the distal part of the graft was anastomosed with the descending aorta above the left subclavian artery, also using a felt strip and Bio-Glue (Fig. 3). Circulation was restored through the graft. The four-branched graft was anastomosed with both common carotid arteries and the right subclavian artery. Due to dissection of the right internal carotid artery, the vessel was separately reconstructed. During reperfusion and rewarming, a subtotal thyroidectomy was performed (Fig. 4). The surgery took 7 h 10 min, ECC-time was 3 h 22 min, aortic cross clamp time was 1 h 57 min, and circulatory arrest time was 30 min. The postoperative period passed uneventfully. The patient, in a haemodynamically and respiratorily stable state, was discharged 12 days after the surgery to the Department of Cardiology for further rehabilitation. The simultaneous surgical procedures can be safely done after meticulous preparation and diagnostics as well as good constipated surgery sequence. It has to be stated, however, that it requires an individual approach in an environment of an experienced surgical team.

Surgical closure of patent ductus arteriosus in extremely low birth weight infants less than 750 grams

BACKGROUND Patent ductus arteriosus (PDA) occurs more frequently in premature infants. Depending on the degree of prematurity, these children often have other serious comorbidities that could have a significant impact on surgical outcome. AIM This study aimed to evaluate the clinical results of surgical ligation of PDA in extremely low body weight preterm infants with birth weight below 750 g, and to identify risk factors of mortality. METHODS A total of 31 preterm infants with birth weight below 750 g and significant PDA were operated between 2006 and 2016 through posterolateral thoracotomy (n = 16) or with the use of video-assisted thoracoscopic method (n = 15). Mean weight at the time of surgery was 750.8 ± 104.7 g. The gestational age ranged from 22 to 32 weeks. Data were retrospectively analysed, and prospective 100% follow-up was performed. RESULTS In-hospital mortality was 25.8% (n = 8). The type of surgery had no influence on the results. During the follow-up period lasting 5.2 ± 2.5 years, two other patients died. One-year and five-year probability of survival was 77.4% and 74.2%, respectively. The predominant cause of death was acute heart failure. All patients with preoperative renal dysfunction died in the postoperative period. Moreover, Cox regression analysis revealed renal dysfunction as an independent risk factor of early death. CONCLUSIONS Preterm infants with birth weight less than 750 g and significant PDA are highly challenging patients. Despite the recent advances in perioperative management with neonates, surgery is still associated with a high early mortality rate irrespective of the applied method.

Chirurgiczne zamknięcie przetrwałego przewodu tętniczego u noworodków z ekstremalnie niską urodzeniową masą ciała, poniżej 750 gramów

BACKGROUND Patent ductus arteriosus (PDA) occurs more frequently in premature infants. Depending on the degree of prematurity, these children often have other serious comorbidities that could have a significant impact on surgical outcome. AIM This study aimed to evaluate the clinical results of surgical ligation of PDA in extremely low body weight preterm infants with birth weight below 750 g, and to identify risk factors of mortality. METHODS A total of 31 preterm infants with birth weight below 750 g and significant PDA were operated between 2006 and 2016 through posterolateral thoracotomy (n = 16) or with the use of video-assisted thoracoscopic method (n = 15). Mean weight at the time of surgery was 750.8 ± 104.7 g. The gestational age ranged from 22 to 32 weeks. Data were retrospectively analysed, and prospective 100% follow-up was performed. RESULTS In-hospital mortality was 25.8% (n = 8). The type of surgery had no influence on the results. During the follow-up period lasting 5.2 ± 2.5 years, two other patients died. One-year and five-year probability of survival was 77.4% and 74.2%, respectively. The predominant cause of death was acute heart failure. All patients with preoperative renal dysfunction died in the postoperative period. Moreover, Cox regression analysis revealed renal dysfunction as an independent risk factor of early death. CONCLUSIONS Preterm infants with birth weight less than 750 g and significant PDA are highly challenging patients. Despite the recent advances in perioperative management with neonates, surgery is still associated with a high early mortality rate irrespective of the applied method.