Surgical Technology International
43rd Edition
December 2023 - ISSN:1090-3941
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State of the Art Review of Surgical Techniques for icroaxial Flow Pump Implantation
Gaik Nersesian, MD, Yuriy Hrytsyna, MD, Anna Stegmann, MD, Christoph Starck, MD, Volkmar Falk, MD, Jörg Kempfert, MD, Evgenij Potapov, MD, Pia Lanmüller, MD, Deutsches Herzzentrum der Charité, Berlin, Germany
1728
Recently, temporary mechanical circulatory support (tMCS) has been increasingly used for cardiogenic shock therapy. Originally designed as a bail-out option for patients who could not be weaned from cardiopulmonary bypass, the indications for tMCS have been expended and now enable us to support a wide range of patients with various cardiac pathologies. Modern tMCS devices include microaxial flow pumps (mAFP) which are small, versatile systems that can provide both acute cardiac support and cardiac protection for high-risk interventions. In this paper, we review different surgical implantation techniques with modern mAFP as well as specific aspects of preoperative indications and patient evaluation.
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3D Reconstruction for a Complex Pediatric Redo Aortic Arch Surgery in a 9-Year-Old Ukrainian Refugee
Luigi Garufi, MD, Alvise Guariento, MD, Francesco Bertelli, MD, Vladimiro Vida, MD, PhD, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
1738
Redo aortic surgery poses significant challenges, particularly in complex scenarios involving congenital heart conditions that have been previously operated on several years prior. The integration of three-dimensional (3D) reconstruction and printing holds immense potential to greatly improve surgical precision, particularly in critical situations.
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Long-Term Results After Aortic Valve Replacement with Last-Generation Stentless Prostheses
Guglielmo Stefanelli, MD, Fabio Sgura, MD , Marco Meli, MD, University Hospital, Modena, Italy, Francesca M. Menozzi, MD, Ospedale Vignola Hospital, Vignola, Italy, Luca Weltert, MD, Associate Professor, European Hospital, Rome, Italy
1683
Introduction: The purpose of this study was to evaluate the long-term clinical and hemodynamic results in patients affected by severe aortic valve disease after aortic valve replacement with third-generation stentless aortic prostheses (3F® stentless equine pericardial [Medtronic plc, Minneapolis Minnesota] and Pericarbon Freedom™ stentless bovine pericardial [LivaNova plc, London, United Kingdom]) and to analyze the benefits and the drawbacks associated to their use.
Materials and Methods: Between June, 2003 and Sept, 2015 a cohort of 548 consecutive patients affected by aortic valve disease received an aortic valve replacement using a last-generation stentless pericardial aortic prosthesis at our unit. Respectively, 322 patients received a Pericarbon Freedom™ and 226 received a 3F® aortic valve. Size ranged between 19 and 29, with prevalence of 23 and 25 devices. Mean age at operation was 71± 11 years, 57% of patients were males, the mean logistic EuroScore was 8.9 ± 7.2 and 44.2% received concomitant procedures. The mean extracorporeal circulation (ECC) time was 119.2 ± 40.6. The mean cross clamp time was 90.5’ ± 21.4’. In 30 patients, the aortic prosthesis was included in a Dacron tube straight graft for a Bentall operation.
Results: Early/in-hospital mortality was 2.55% (14 cases) for the entire cohort. In patients receiving isolated aortic valve replacement (AVR), it was 0.91% (5 cases). Follow up ranged between six months and 12 years (median follow-up time: 6.77 years). During follow up, 137 patients died of all causes (25%), of whom 32 patients died of cardiac causes (5.8%). Cardiac survival probability was 91% at 12 years. All surviving patients were in NYHA class I at last follow up. Actuarial freedom from structural valve deterioration was 86% at 12 years. Freedom from endocarditis was 95% at 12 years. Freedom from a valve-related reoperation at 12 years follow up was 95%. Mean residual transprosthetic gradient at 12 years was 10.3 ± 4.8MmHg.
Conclusions: Last-generation stentless pericardial valves offer excellent hemodynamics and adequate durability and freedom from structural deterioration at 12 years follow up. The implantation technique of a stentless valve is a little more demanding when compared to a stented valve, but it can be easily reproduced after minimal training. Incidence of endocarditis and thromboembolic events is low and comparable to stented pericardial valves. Young and active patients, and patients with large BSA where a patient-prosthesis mismatch may be anticipated are, in our opinion, ideal candidates to receive these kinds of valves.
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What Does Minimally Invasive Mitral Valve Surgery Really Mean? Defining Totally Endoscopic Mitral Valve Surgery Through Meta Analysis
Jessica Katsiroubas, MD, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, Emily Manin, BS, Cornell University, Manhattan, New York, Jake L. Rosen, BA, Thomas Jefferson University, Philadelphia, Pennsylvania , Yoona Choe, BA, MS , Keertana Jonnalagadda, BS, Rowan University, Stratford, New Jersey, Idy Ding, BA, Temple University, Philadelphia, Pennsylvania , T. Sloane Guy, MD, MBA, FACS, FACC, Department of Cardiac Surgery, Georgia Heart Institute, Gainesville, Georgia
1715
Introduction: Minimally invasive approaches to mitral valve surgery are being performed with increasing frequency; however, many of these procedures still involve rib spreading and large incisions. The heterogeneity of self-reported “minimally invasive” approaches limits analysis of outcomes. This review aims to formally define totally endoscopic mitral valve surgery (TEMVS) and assess outcomes.
Materials and Methods: A comprehensive literature search in Pub-Med, Cochrane Library, and EMBASE was used to find studies reporting outcomes on totally endoscopic mitral valve surgery. “Totally endoscopic” was defined as incisions less than 3cm and the avoidance of rib spreading. The primary outcome was 30-day mortality and secondary endpoints included postoperative myocardial infarction (MI), stroke, early reoperation, wound infection, renal failure, and prolonged ventilation. Perioperative patient characteristics were also recorded and analyzed.
Results: Thirty-three studies (6031 patients) were included in our meta-analysis. The 30-day mortality rate was 0.33%, p=0.88. The most frequent complications were early reoperation (2.12%, p=0.44) and prolonged ventilation (1.46% p=<0.01). Rates of MI, stroke, and renal failure were each less than 1%. Patient characteristics including age, body mass index (BMI), and ejection fractions were also analyzed.
Conclusions: We propose a formal definition of TEMVS, which is performed through incisions less than 3cm and without rib spreading. Thirty-day mortality and other adverse sequelae of TEMVS are uncommon.
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Infective Endocarditis After Percutaneous Device Closure of Atrial Septal Defects: Incidence, Diagnosis, and Treatment. Case Report and Literature Review
Giuseppe Nasso MD, PhD, Ignazio Condello, PhD, Nicola Di Bari, MD, Giuseppe Speziale, MD, PhD , Walter Vignaroli, MD, Anthea Hospital, Bari, Italy, Mizar D’Abramo, MD, Sapienza University of Rome, Rome, Italy, Angelo De Luca, MD, Giovanni Melina, MD, PhD, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy, Claudio Larosa, MD, Giovanni Valenti, MD, Francesco Bartolomucci, MD, Bonomo Hospital, Andria, Italy, Stefano Sechi, MD, San Carlo di Nancy, Rome, Italy, Giuseppe Diaferia, MD, P.P.A. Canosa di Puglia, Italy, Maria Grazia De Rosis, MD, Azienda Ospedaliera Bari, Bari, Italy, Vincenzo Amodeo, MD, Ospedale degli Ungheresi, Polistena, Italy
1740
Infective endocarditis (IE) on atrial septal defect (ASD) closure devices, while extremely rare, has been reported to be more frequent early after the procedure. We describe a case of late IE after percutaneous closure of patent foramen ovale (PFO). We also performed a literature review on this subject.
We reviewed a total of 42,365 patients who were treated with percutaneous devices: 13,916 for ostium secundum (OS) (32%), 24,726 for PFO (58%) and 3,723 for OS+PFO (8%). Among these patients, we identified 50 cases of IE after atrial septal defect device closure (0.001%).
In contrast to previous reports, nearly 66% of IE in this setting occurred late, after at least 6 months from the procedure (33/50 patients). A statistical analysis clearly showed that the mean time from the procedure to IE increased in the last five years, probably associated with a change in antiplatelet therapy after ASD closure. Management of IE on an ASD occluder should always be discussed in the setting of a multidisciplinary heart team that includes a cardiologist, cardiac surgeon, and anesthetist. While surgical strategies gave excellent results, conservative management might be considered in cases of small IE vegetations and for patients in good general condition. However, in these cases, the patient must be closely observed with repeated blood and instrumental tests.
Novel Uses of Indocyanine Green in Thoracic Surgery: A Review and Case Series
Justin A. Olivera, BS, Medical Student, Isaac Faith, MS, Medical Student, Albert Einstein College of Medicine, Bronx, NY, Osita Onugha, MD, MBA, Associate Professor of Thoracic Surgery, Charles Drew University, Los Angeles, CA
1706
Indocyanine green (ICG) is a water-soluble molecule that emits fluorescence in the near-infrared light spectrum. Due to its fluorescence properties, safety profile, and cost-effectiveness, ICG is used in minimally invasive surgery, enabling real-time visualization of structures during the operation. Until recently, its use was mainly limited to robotic surgery, which required specific technological setups to visualize the fluorescence. With recent technological advancements, however, similar capabilities can now be integrated into smaller laparoscopic instruments, broadening the accessibility and usefulness of ICG. In this article, we present various innovative applications of ICG in thoracic surgery, drawing from recent developments in the field and our own experiences. Specifically, we focus on the novel role of ICG in the evaluation of gastric conduit perfusion, lung nodule localization, and thoracic duct ligation.
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Gaseous Micro-Embolic Activity and Goal-Directed Perfusion Management in a Closed System for Cardiopulmonary Bypass and Minimally Invasive Extracorporeal Circulation during Coronary Artery Bypass Grafting
Ignazio Condello, PhD, Giuseppe Nasso, MD, PhD, Giuseppe Speziale, MD, PhD, Anthea Hospital, Bari, Italy, Kurt Staessens, PhD, UZ Brussels, Jette, Belgium
1721
Background: Cardiopulmonary bypass (CPB) techniques are becoming minimally invasive in clinical practice. The literature describes various extracorporeal techniques which seek to eliminate air-blood contact and reduce both hemodilution and the contact surface such as in Minimally invasive Extracorporeal Circulation (MiECC) and closed systems for CPB. However, the delivery of micro-embolic activity in the circuit and metabolic activity in terms of oxygen delivery for Goal-Directed Perfusion (GDP) management, in relation to the patient's blood volume and central venous pressure, have never been related and correlated. In this report, we present a cohort study that investigated these aspects between the closed SVR2000 System and modular MiECC (both from Eurosets SRL, Medolla, Italy).
Materials and Methods: Data were collected retrospectively and used to compare 60 consecutive patients who underwent isolated coronary artery bypass grafting (CABG) surgery by two surgeons using an SVR2000 oxygenator in 30 procedures, with a matched cohort of patients from the same period who underwent isolated CABG surgery by two other surgeons using a modular MiECC in 30 procedures. The primary endpoints collected were data on micro-embolic activity, including the number of gaseous micro-emboli in the circuit during the procedure, the mean maintenance value of oxygen delivery (DO2) and data relating to venous return volume and central venous pressure (CVP).
Results: During the CPB procedures, the following values were recorded for the closed SVR2000 and MiECC groups, respectively: the average number of gaseous micro-emboli (GME) in the venous line, 833 ± 23 vs 1221 ± 45 (p = 0.028); GME in the outlet of the pump, 375 ± 45 vs 429 ± 76 (p = 0.89; GME in the arterial line, 189 ± 36 vs 205 ± 27 (p = 0.92), and the volume of GME in the arterial line (mL), 0.32± 12 vs 0.49± 17 (p = 0.93). The mean Indexed Oxygen Delivery (DO2i) during cross-clamp (ml/min/m2) was 319 ±12 vs 278 ±9 (p = 0.0019), respectively. The maximum mean volume of venous return in the soft-shell venous reservoir (ml) was 1801 ±128 vs 824 ±192 (p = 0.038). The mean central venous pressure (CVP) during cross-clamp (mmHg) was 0 ± 2 vs 6 ± 2 (p = 0.019).
Conclusions: In this study, the results in the closed SVR2000 group were not statistically inferior to those in the modular MiECC group in terms of gaseous micro-embolic activity during CPB. Our analysis showed an important reduction of GME delivery in both systems. The closed SVR2000 group showed better management for GDP in terms of DO2i, associated with the flexibility of dynamic volume management and the absence of cavitation and regulation of the rate per minute and pump flow, which were reported in the MiECC group. The SVR2000 and modular MiECC systems were both safe and effective in perioperative practice without iatrogenic problems.
Advancements in Access for End-Stage Renal Disease and the Creation of Endovascular Fistulas
Jessica Katsiroubas, MD, Susan Basharkhah, MD, Kevin Leong, MD, New York Presbyterian-Brooklyn Methodist Hospital, Brooklyn, New York, Tara Lamb, BS, Drexel University College of Medicine, Philadelphia, Pennsylvania, Nicole Ilonzo, MD, Assistant Professor Weill Cornell Medicine, New York, New York
1657
The prevalence of end-stage renal disease has increased significantly since the 1980s, and the demand for successful, safe, and durable hemodialysis access is rising. Autogenous arteriovenous fistulas continue to be the gold standard modality for hemodialysis access. Biologic and synthetic grafts are used with comparable outcomes but are not without their own complications. Newer developments in hemodialysis access utilize endovascular technology, including dual catheter-based systems and thermal resistance devices, which are pushing the boundaries of fistula creation optimistically forward.
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Cardiopulmonary Bypass Settings for the Prevention of Early Hypotension During CABG
Giuseppe Nasso, MD, PhD, Giuseppe Speziale, MD, PhD, Flavio Fiore, MD, Ignazio Condello, PhD, Anthea Hospital, GVM Care & Research, Bari, Italy, Francesco Bartolomucci, MD, Giovani Valenti, MD, Claudio Larosa, MD, Ospedale Lorenzo Bonomo, ASL BAT, Andria, Italy, Francesco Borrello, MD, Pugliese-Ciaccio Hospital, Catanzaro, Italy, Vincenzo Amodeo, MD, Ospedale Santa Maria degli Ungheresi, Polistena, Italy
1727
Background: Vasoplegic syndrome is a form of vasodilatory shock that can occur before, during or after cardiopulmonary bypass (CPB). We introduce a strategy to reduce the incidence of early hypotension phenomena during Coronary Artery Bypass Graft (CABG) procedures.
Materials and Methods: In this prospective cohort study, 100 patients underwent elective CABG with two perioperative CPB settings. The study group (50 patients) was managed with retrograde autologous priming (RAP), 3-minute stepwise for the institution of CPB, and pulsatile flow (PP). The control group (50 patients) was managed without RAP, with the rapid initiation of CPB, and non-pulsatile (NP) flow. The primary endpoints were MAP (mmHg), number of hypotensive phenomena (MAP < 50 mmHg for > 30 sec), the venous return volume on CPB (ml), the cardiac index (L/min/m2), hemoglobin (g/dL), indexed oxygen delivery (DO2i, ml/min/m2), the systemic vascular resistance index (SVRI, dynes s m2/cm5), number of 1-ml boluses of a vasoactive substance (norepinephrine), the positive fluid balance (ml), and the number of red blood cell units for transfusion.
Results: During CPB, the mean values in the study and control groups were as follows: MAP, 68± 7 vs 56 ± 7 (p-value, 0.0019); hypotensive phenomena, 3 ± 1 vs 8 ±2 (p-value, 0.019); venous return volume, 840±79 vs 1129 ±123 (p-value, 0.0017); cardiac index, 2.4 ± 0.4 vs 2.7 ±0.2 (p-value, 0.0023); hemoglobin, 9.13 ± 0.29 vs 7.8± 0.23 (p-value, 0.0001); DO2i, 301± 12 vs 276±23 (p-value, 0.0011); SVRI, 1879 ±280 vs 2210 ±140 (p-value, 0.0017); norepinephrine, 1±2 vs 8 ±3 (p-value, 0.0023); positive fluid balance, 750 ±212 vs 1450 ±220 (p-value, 0.005); and total number of red blood cell units for transfusion, 16 ±4.2 vs 27 ± 5.3 (p-value, 0.008).
Conclusions: In this prospective cohort study, during CPB, the study group showed a better preservation of MAP, SVRI, and DO2i, and a reduction of vasoconstrictor use in a CPB setting with the RAP technique, 3-minute stepwise for the initiation of CPB and pulsatile pump flow, compared to the control group. Further studies are needed to validate this perioperative approach to CPB.
