Perventricular device closure of a large residual perimembranous interventricular septal defect after previous surgical correction

A 21 years albanian patient was referred with important residual left to right shunt. He was undergone 7 years before conventional surgical correction of a perimembranous ventricular septal defect (VSD). The patient underwent sternotomy and perventricular device closure of the residual employing a 16 mm multifenestrated atrial septal defect occlude, which was positioned through the anterior wall of the right ventricle. across the defect. The previous autologous pericardial patch was compressed into the double umbrella device. We may conclude that perventricular device closure can employed successfully in patients with residual perimembranous VSD after previous surgical repair as an alternative to the conventional surgery with excellent hemodynamic and postoperative outcome. Such a technique should be part of the surgical armamentarum

Mitral Valve Replacement Surgery in Redo Patients with Mix Blood Cardioplegia (MBC) Protection

Aim of Study: Redo patient undergoing valve surgery are always a challenge for both cardiac surgeon and anesthesiologists. Mix blood cardioplegia has had a profound impact on cardiac surgery. but there have been few studies on its use in mitral valve replacement, especially in redo patient. The purpose of this study was to determine whether mix blood cardioplegia offers any advantages in redo patient undergoing mitral valve replacement.Patients and Methods:  20 patient, who have had a previous mitral valve surgery and were scheduled for mitral valve replacement with or without tricuspid repair, were randomized retrospectively to one of two groups of 10 with different technique of myocardial protection: group A (10 patients) had cold crystalloid cardioplegia, and group B(10 patients) had mix blood cardioplegia, a technique modified on our clinic condition (made by mixing  400-500ml oxygenated blood from oxygenator  and 10ml KCL 7.5%) . Systemic hypothermia was 28°C in Group A and between 32°C and 33°C in Group B. The results were primarily assessed on the basis of clinical outcome, such as hematocrit level intra and post CPB, maximum dose of inotropic support, spontaneous rhythm recovery after aortic cross clamping, length of intensive care unit stay and secondly on postoperative blood loss and blood requirements. Results: There were no preoperative or operative differences between the groups with regard to age, sex, diagnosis, rhythm, New York Heart Association functional class, left ventricular ejection fraction, estimated pulmonary artery systolic pressure, operation, or duration of the operation, CPB, or aortic cross clamping and the time when the patients underwent the first operation. There was one death in group A (10% mortality). The changes in hematocrit level differs significantly between the two groups on the post CPB period (p=0,02) There appeared to be a trend towards better spontaneous recovery of sinus rhythm after removal of the aortic cross clamp in group B compared with group A, the difference did reach statistical significance. (p=0.002). Patients on group A required more inotropic support than Group B (p=0.005). There were differences even on blood requirements postoperatively, more dominant these  requirement were in group A (p=0.02).Discussion: Mix Blood Cardioplegia had beneficial effects in clinical outcome in redo patients undergoing mitral valve replacement surgery. This may be due to its better preservation of high-energy phosphates and endogenous amino acids, less anerobic metabolic activity on reperfusion, reduced release of cardiac troponin T, and improved post-ischemic functional recovery. Keywords: Miocardial protection, cardiopulmonary bypass CPB, Mix Blood Cardioplegia (MBC) DOI: 10.7176/ALST/82-04 Publication date:October 31st 202

Perioperative Evaluation of Heart Echinococcus Cyst in a 14-Year-Old Child

BACKGROUND: Echinococcosis of the heart has a rate 0.02–2% of all hydatid diseases. Clinical presentation is depending of the location of hydatid cyst in the heart. Patients can be an asymptomatic case or lethal stroke, arrhythmias, valvular dysfunction, pulmonary edema, cardiac tamponade, cardiac failure, shock, and even death. CASE REPORT: We present a case report, a 14-year-old child with 2 weeks of sore throat, whooping cough, subfebrile condition, sweating, fatigue and physical weakness, nausea, abdominal pain, and decreased appetite. He came to emergency room with cardiogenic shock and pulmonary edema. He was diagnosed with intramyocardial hydatid cyst. CONCLUSION: Echinococcus cyst lesion in the LV in lateral wall, not communicating with the LV cavity, has been removed successfully with on-pump technique in a 14-year-oldchild. Median sternotomy was preferred and cardiopulmonary bypass has been considered the safest method. Supplemental medical therapy with albendazole is recommended to reduce the risk of recurrence

Deep sternal infections after in situ bilateral internal thoracic artery grafting for left ventricular myocardial revascularization: predictors and influence on 20-year outcomes

Background: The incidence and potential factors influencing deep sternal wound infection (DSWI) in a cohort of patients undergoing coronary artery bypass grafting (CABG) using skeletonized bilateral internal thoracic artery (BITA) was explored. Furthermore, we studied influence of DSWI on long-term survival, major adverse cardiac events (MACEs) and repeat coronary revascularization (RCR).Methods: The study cohort consisted of 1,325 consecutive patients who were divided in two groups: patients experiencing DSWI (n=33, group 1) and those who did not have sternal infection (n=1,292, group 2). A logistic regression model was employed to find predictors of DSWI whereas Cox regression and a competing risk models were carried out to test predictors of late death, MACE and RCR, respectively. Follow up was 100% complete and ranged from 1 to 245 months. Median follow-up was 103 months (IQR, 61 to 189 months). Cumulative follow-up was 16,430 patient years.Results: The incidence of DSWI was 2.4%. Multivariable logistic regression analysis found any single independent predictor of DSWI. However, the association of peripheral vascular disease (PVD) and diabetes increased the risk by 1.4 and 1.6 times. When DM was associated with obesity the risk increased by 2.1 and 2.6 times compared to the single factors, respectively. Obese female patients were at a 1.6-fold higher risk when compared to the association of DM with obesity. DSWI was not an independent predictor of long-term survival (HR, 2.31; 95% CI: 0.59–9.12), RCR (SHR, 2.89; 95% CI: 0.65–10.12), or MACE (SHR, 1.98; 95% CI: 0.44–8.56).Conclusions: With an accurate patient selection (i.e., exclusion of obese diabetic females) and strict DM control BITA represents a first choice for most of CABG patients, even at high risk for DSWI. The occurrence of DSWI does not influence long-term survival and late outcomes. Our findings should be confirmed by further larger research.</br

Retrograde autologous priming RAP reduces deep hemodilution during cardiopulmonary bypass CPB

Immediate hemodilution and rapid decrease in osmotic pressure at the time of CBP onset are associated with the aforementioned organic dysfunctions. Decreased osmotic pressure increases effective filtration pressure and microvascular filtration. Consequently, an increase in pulmonary interstitial fluid and myocardial edema is observed after discontinuation of CBP. Retrograde autologous priming (RAP) is a means to effectively and safely restrict the hemodilution caused by the direct homologous blood transfusion and reduce the blood transfusion requirements during cardiac surgery.   Materials and Methods The study included 40 patients scheduled to undergo coronary surgical revascularization, divided into two groups: the RAP group and the non-RAP group. The average age in both groups is 55 years (SD 5).   Conclusion A significant benefit was observed between the two groups in the study regarding the amount of transfused blood (1.55 -SD 0.88) / (2.15 -SD 0.81). This is a very important fact in favor of using the RAP technique, taking into account the reduction of the risk for complications carried by heterologous transfusion. Also, a significant reduction in the use of donated blood at a time when the problems of blood insufficiency in the collection centers are known, is equally important. The hospitalization (days of staying) in the ICU is also significantly lower in the RAP group (2.6 -SD 0.68) / (3.1-SD 0.64). This should be related to the faster activation of RAP in patients as a result of faster return to normal weight (with less fluid load), better ventilator function, and faster decline of cerebral edema. Keywords: Retrograde autologous priming (RAP), hemodilution, cardiopulmonary bypassCPB)   DOI: 10.7176/ALST/81-04 Publication date: August 31st 202

Surgical Risk Factors for Ischemic Stroke Following Coronary Artery Bypass Grafting. A Multi-Factor Multimodel Analysis

Background: Ischemic stroke after coronary artery bypass (CABG) has been often linked to aortic manipulation during surgery. Objectives: The objective of the study was to estimate the rate of postoperative ischemic stroke within 30 days from CABG by surgical risk factors alone or in combination. Methods: The multinomial propensity score for multiple treatments was used to create six models with a total of 16,255 consecutive patients undergoing isolated CABG. For each model, a different classification variable was used to stratify patients. Results: Balance achieved in all models was substantial, enabling unbiased estimation of the treatment estimand. Both off-pump techniques with (0.009; 95% CI 0.006–0.011) or without proximal anastomoses (0.005; 0.005–0.003), and surgery performed on the beating heart using cardiopulmonary bypass with (0.009; 0.006–0.011) or without proximal anastomoses (0.024; 0.021–0.029) showed a mean stroke estimate significantly lower than the other techniques. Off-pump surgery and on-pump surgery without an aortic cross-clamp yielded nearly equal incidences of stroke (0.012; 0.008–0.015 and 0.018; 0.012–0.023, respectively). Using an aortic cross-clamp significantly increased the stroke estimate (0.075; 0.061–0.088), whereas using a side-biting clamp did not (0.039; 0.033–0.044). The number of aortic touches (0.029; 0.026–0.031) and the number of proximal anastomoses (0.044; 0.035–0.047) did not significantly increase the incidence of stroke. Conclusions: Aortic cross-clamping was found to be the primary cause of post-CABG ischemic stroke. Instead, additional aortic manipulation from a side-biting clamp, on-pump surgery, multiple aortic touches, number of proximal anastomoses, and aortic cannulation were found not to increase the estimate of stroke significantly. Further research on this topic is warranted

A modified 'single patch' technique for complete atrioventricular septal defect correction

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