A Gender-Focused Analysis of 36 Perioperative Risk Factors on Long Term Survival of Acute Type A Aortic Dissection - Equal Chances?

We focused on gender specific perioperative risk factors for the survival of an acute Stanford type A aortic dissection. A cohort of 147 patients undergoing surgery since 2004 was studied in a 9 year follow-up. Analysis was performed using Cox-proportional hazard model focusing on 36 variables. Survival after 1 y (5y, 10y) was 98% (88%, 50%). Early mortality was 25%, 27% female, with a higher age (+10 y, mean, 64 ± 10 y) than men. In the 7th decade, percentage of women was as twofold higher and threefold higher in the 8th decade. Survival probability (Log rank test) for the first postoperative year was 0.82/0.77 (female/male) for 5 years 0.70/0.71, and 0.46/0.50 for 10 years. Risk factor analysis showed women having a high hazard ratio for death in case of re-sternotomy (16.543), bleeding (8.1), and renal insufficiency (3.4). Only EURO-Score (1.103, p=0.038) and length of hospital stay (0.849, p=0.015) were significant risk factors for death. The survival curve declines between 5 and 10 years (88% to 50%). In male patients, age and resternotomy had a significant influence on survival. Women had a higher incidence for aortic type a dissection in the 7th and 8th decades. Gender did not influence survival

Optimizing Outcome in Stanford Type A Aortic Dissection- A 10 Year Analysis Focusing on Surgical Techniques and Neurological Outcome

Background: Today, surgical repair of aortic type A dissections is routinely mandatory but some complications remain despite technical advances over several decades. The most important complications are neurological deficits that have been quantified with an incidence of up to 25% in international trials. In this study, we focused on the postoperative outcome over a ten year period after surgical repair of type A dissections. A special focus has been put on specific complications, neurological outcome and technical advances with modern surgical techniques including cannulation strategy. Methods: A cohort of 147 patients undergoing surgery since 2004 was studied in a retrospective analysis with 10 year follow-up. Analysis was performed using Cox-proportional hazard model focusing on more than 30 variables. Results: Survival after 1y (5, 10y) was 98% (88%, 50%). Early mortality of all patients declined to 14% in the last years. 27% were female, with a higher age than men (+10y, mean, 64+10y). Gender did not influence survival. Survival probability (Log rank test) for the first postoperative year was 0.82/0.77 (female/male) for 5 years 0.70/0.71, and 0.46/ 0.50 for 10 years. Preoperatively, the carotid arteries were compromised in 25% of patients. Neurological deficits were preoperatively present in 11% of patients. Of those, a percentage of one third (33%) was reversible. Postoperatively, major and minor neurological deficits could be seen in 22% of all patients. Over the time, the incidence of postoperative complications could be reduced (from nearly 27% to 10%). The vascular access via truncal cannulation technique showed a significant lower risk vs. all other cannulation sites (p=0.0168). Conclusions: The incidence of neurological complications could be reduced, either as reversible preoperative deficits or postoperative new complications. Neurological disorders with concomitant carotid obstructions should lead clinicians to an extensive diagnostic approach, i.e. spreading the diagnostic look towards supraaortic/brachiocephalic branches of the aorta. By establishing technical modifications and surgical advancements, we could achieve a 50% reduction of postoperative neurological deficits from nearly 20% to below 10% and also of mortality rates from nearly 30% to about 15%. This is reflected by a growing number of longtime survivors. Adopting modern perfusion techniques helps reducing the incidence of those disabilities that bear an enormous subjective medical and also economic burden

Intraoperative visualization of a deformed left main stent during surgical aortic valve replacement

Background While coronary artery bypass grafting is typically considered first choice for the treatment of left main stenosis, there is a trend towards left main stenting due to a steadily aging population in western countries with a high operative risk and patients with single vessel coronary artery disease affecting the left main artery. Nevertheless left main stenting remains controversial, especially in patients with concomitant indications for open-heart surgery. Case presentation We want to present a case of a 78-year-old male patient with high-grade aortic stenosis who underwent surgical aortic valve replacement at our heart center due to anatomical contraindications for transcatheter aortic valve replacement. Stenting of the left main coronary artery was performed three years earlier due to single vessel coronary artery disease while moderate aortic valve stenosis was under surveillance at the time of the intervention. Intraoperatively we found the stent to be deformed inside the left main coronary artery, covering nearly 25% of the coronary ostium. So injection of cardioplegia directly into this ostium, as we perform normally, was not possible without further damaging the stent and/or the opening of the ostium. We had to insert cardioplegia via the retrograde way, so via the coronary sinus. Conclusion While left main stenting can be reasonable for a specific population of patients, it should be used cautiously in patients with concomitant indications for open-heart surgery in the near future and a low perioperative risk profile

Dysphonia as a Presenting Symptom of a Giant Left Atrial Sarcoma Developing within Five Years

An 83-year-old woman presented with a new onset of dyspnea and dysphonia. Physical examination revealed no abnormalities. Computerized tomography, bidimensional echocardiography, and cardiac magnetic resonance confirmed the presence of a cardiac mass in the left atrium. Surgical resection was uneventful and showed the origin of the mass in the ostium of the left inferior pulmonary vein. Histological evaluation revealed undifferentiated pleomorphic sarcoma with myxoid features. This case highlights the importance of considering cardiac neoplasms as a rare differential diagnosis, including rare and misleading clinical presentations

Comparison of clinical outcome variables in patients with and without etomidate-facilitated anesthesia induction ahead of major cardiac surgery: a retrospective analysis

Introduction It is well known that etomidate may cause adrenal insufficiency. However, the clinical relevance of adrenal suppression after a single dose of etomidate remains vague. The aim of this study was to investigate the association between the administration of a single dose of etomidate or an alternative induction regime ahead of major cardiac surgery and clinical outcome parameters associated with adrenal suppression and onset of sepsis. Methods The anesthesia and intensive care unit (ICU) records from patients undergoing cardiac surgery over five consecutive years (2008 to 2012) were retrospectively analyzed. The focus of the analysis was on clinical parameters like mortality, ventilation hours, renal failure, and sepsis-linked serum parameters. Multivariate analysis and Cox regression were applied to derive the results. Results In total, 3,054 patient records were analyzed. A group of 1,775 (58%) patients received a single dose of etomidate; 1,279 (42%) patients did not receive etomidate at any time. There was no difference in distribution of age, American Society of Anesthesiologists physical score, duration of surgery, and Acute Physiology and Chronic Health Evaluation II score. Postoperative data showed no significant differences between the two groups in regard to mortality (6.8% versus 6.4%), mean of mechanical ventilation hours (21.2 versus 19.7), days in the ICU (2.6 versus 2.5), hospital days (18.7 versus 17.4), sepsis-associated parameters, Sequential Organ Failure Assessment score, and incidence of renal failure. Administration of etomidate showed no significant influence (P = 0.6) on hospital mortality in the multivariate Cox analysis. Conclusions This study found no evidence for differences in key clinical outcome parameters based on anesthesia induction with or without administration of a single dose of etomidate. In consequence, etomidate might remain an acceptable option for single-dose anesthesia induction

Can we rely on out-of-hospital blood samples? A prospective interventional study on the pre-analytical stability of blood samples under prehospital emergency medicine conditions

Background: Prehospital intravenous access provides the opportunity to sample blood from an emergency patient at the earliest possible moment in the course of acute illness and in a state prior to therapeutic interventions. Our study investigates the pre-analytical stability of biomarkers in prehospital emergency medicine and will answer the question whether an approach of blood sampling out in the field will deliver valid laboratory results. Methods: We prepared pairs of blood samples from healthy volunteers and volunteering patients post cardio-thoracic surgery. While one sample set was analysed immediately, the other one was subjected to a worse-than-reality treatment of 60 min time-lapse and standardized mechanical forces outside of the hospital through actual ambulance transport. We investigated 21 parameters comprising blood cells, coagulation tests, electrolytes, markers of haemolysis and markers of cardiac ischemia. Bland-Altman analysis was used to investigate differences between test groups. Differences between test groups were set against the official margins of test accuracy as given by the German Requirements for Quality Assurance of Medical Laboratory Examinations. Results: Agreement between immediate analysis and our prehospital treatment is high as demonstrated by Bland-Altman plotting. Mechanical stress and time delay do not produce a systematic bias but only random inaccuracy. The limits of agreement for the tested parameters are generally within clinically acceptable ranges of variation and within the official margins as set by the German Requirements for Quality Assurance of Medical Laboratory Examinations. Discussion: We subjected blood samples to a standardized treatment marking a worse-than-reality scenario of prehospital time delay and transport. Biomarkers including indicators of myocardial ischemia showed high pre-analytical stability. Conclusion: We conclude the validity of blood samples from a prehospital environment

Technical and Procedural Aspects of a Staged Repair of a Giant Post-Dissection Aneurysm by Using Endosizing- Based Endovascular Stenting Following Aortic Surgical Repair with Simultaneous Debranching Technique

We report on a giant aortic post-dissection aneurysm of the ascending and descending aorta that was removed in a staged procedure using debranching technique on extracorporeal circulation and later on treated with endovascular repair using a fitted stent after endosizing

Rare Case Report: Left Atrial Sarcoma Obstructing the Left Ventricular Inflow

Malignant cardiac tumors of the heart are extremely rare and may present tremendous diagnostic and therapeutic challenges. These tumors are able to infiltrate the heart and metastasize systemically. Early detection is often elusive as the clinical presentation is highly variable, posing significant diagnostic and therapeutic difficulties. Despite a multidisciplinary approach, the prognosis for patients with malignant cardiac tumors remains guarded. Early diagnosis and a multidisciplinary approach involving cardiac surgeons, oncologists and critical care specialists are crucial in the management of this disease. Further research is needed to better understand the pathomechanisms of tumor-related complications and to develop effective treatment strategies to improve patient outcomes. The rare case of a 78-year-old woman with left atrial tumor requiring emergency surgery for acutely developing mitral valve obstruction is presented. Pathology confirmed an undifferentiated pleomorphic sarcoma. This patient tragically did not survive, highlighting the difficulties of managing such a rare and deceptive heart disease.</jats:p

A Practical Approach to Systemic Mastocytosis Complications in Cardiac Surgery: A Case Report and Systematic Review of the Literature

(1) Background: Systemic mastocytosis is a rare, non-curable disease with potential life-threatening complications in patients receiving cardiac surgery. (2) Methods: This systematic review of the literature was prompted by the case of a life-threatening anaphylactic reaction during cardiac surgery related to systemic mastocytosis. The search of all types of studies, using several databases (Pubmed, Scopus and Web of Science), was conducted through September 2022 to identify the relevant studies. (3) Results: Twelve studies were included describing cases of patients undergoing cardiac surgery who were diagnosed with systemic mastocytosis. An adverse effect, namely anaphylaxis, has happened in three cases. Different strategies of premedication, intraoperative and postoperative management were used. In our case, the patient was admitted for elective biological aortic valve replacement due to severe aortic stenosis. Intraoperatively, the patient developed an anaphylactic shock during the administration of protamine after separation from the cardiopulmonary bypass. This anaphylaxis reaction was a complication of the pre-existing systemic mastocytosis and could be successfully managed by the administration of epinephrine, antihistamines and corticosteroids. (4) Conclusions: This systematic literature search and case report highlight the importance of careful preoperative planning, as well as coordination between cardiac surgeons, anesthesiologists and hemato-oncological specialists, in patients with rare but complication-prone diseases such as systemic mastocytosis

Pericardial tamponade, a diagnostic chameleon: from the historical perspectives to contemporary management

Background Pericardial tamponade (PT) early after cardiac surgery is a challenging clinical entity, not infrequently misrecognized and often only detected late in its course. Because the clinical signs of pericardial tamponade can be very unspecific, a high degree of initial suspicion is required to establish the diagnosis. In addition to clinical examination the deployment of imaging techniques is almost always mandatory in order to avoid delays in diagnosis and to initiate any necessary interventions, such as pericardiocentesis or direct cardiac surgical interventions. After a brief overview of how knowledge of PT has developed throughout history, we report on an atypical life-threatening cardiac tamponade after cardiac surgery. A 74-year-old woman was admitted for elective biological aortic valve replacement and aorto-coronary-bypass grafting (left internal mammary artery to left anterior descending artery, single vein graft to right coronary artery). On the 10th postoperative day, the patient unexpectedly deteriorated. She rapidly developed epigastric pain radiating to the left upper abdomen, and features of low peripheral perfusion and shock. There were no clear signs of pericardial tamponade either clinically or echocardiographically. Therefore, for further differential diagnosis, a contrast-enhanced computed tomography scan was performed under clinical suspicion of acute abdomen. Unexpectedly, active bleeding distally from the right coronary anastomosis was revealed. While the patient was prepared for operative revision, she needed cardiopulmonary resuscitation, which was successful. Intraoperatively, the source of bleeding was located and surgically relieved. The subsequent postoperative course was uneventful. Conclusions In the first days after cardiac surgery, the occurrence of life-threatening situations, such as cardiac tamponade, must be expected. Especially if the symptoms are atypical, the entire diagnostic armamentarium must be applied to identify the origin of the complaints, which may be cardiac, but also non-cardiac. Central message A high level of suspicion, immediate diagnostic confirmation, and rapid treatment are required to recognize and successfully treat such an emergency (Fig. 5). Perspective Pericardial tamponade should always be considered as a complication of cardiac surgery, even when symptoms are atypical. The full range of diagnostic tools must be used to identify the origin of the complaints, which may be cardiac, but also non-cardiac (Fig. 5)