Coarctation of aorta : A surgical journey

Since my placement as a trainee at Royal Hospital for Children, I became interested in pathophysiology of coarctation of aorta. It may seem a simple pathology which narrow the aortic lumen in distal arch but the story behind this simple pathology is more complex. In fact I was fascinated by the surgical repair techniques and it did not take long after expressing interest to find out “which technique is the best?”, I realised that this has been a historical question at least for the past 50 years. The review of coarctation repair in Scotland and evaluation of outcomes soon became operational while there was no previous such a regional study. Retrieving and reviewing of echocardiography images followed by measuring aortic parameters despite challenges soon became an exciting investigation. The systematic review of the literature was also a fascinating journey through the history where finding an answer for many questions on coarctation of aorta was challenged by a high degree of heterogeneity not only in the study design itself but also in the practice of the individual reporting institution. Apprising historical papers and studies from different part of the world was a rewarding experience; although the result of the search for the best technique was inconclusive. The “Future” Chapter is basically the conclusion of my journey with coarctation of aorta in this thesis. By observing current breakthroughs in technology and evolving computational modelling, the future of coarctation surgery has already been shaped. Maybe we have been looking for an answer for a historical question which probably should been made differently: “which technique is the best for which patient?

The quest for the optimal surgical management of tricuspid valve endocarditis in the current era: A narrative review

Tricuspid valve endocarditis (TVE) is a growing concern with increasing rates and mortality burden. The currently changing etiology, the antibiotic resistance and the raise in iatrogenic causes as with implantable cardiac devices [cardiac implantable electronic device (CIED)], represent a challenge for the management of these patients. The progressively widespread use of CIEDs is adding to the more commonly known intravenous (IV) drug abuse in the list of causes. Treatment strategies include medical therapy alone or surgery. From the surgical standpoint tricuspid valve repair, replacement or the staged procedure of valvectomy as bridge to replacement are available options. Treatment of endocarditis related to implantable device is another expanding field which requires a coordinated action with microbiologists in consideration of the microorganism antibiotic resistance. This review summarizes the currently available evidences on TVE including surgical indications, timing of interventions and technical considerations. The conflicting results of the available observational evidences and the non-unanimous consensus on many aspects of TVE impede to reach a definitive conclusion regarding the best management strategy and demands for randomized studies in this field

Hazards of tube thoracostomy in patients on a ventilator

A patient with post-pneumonia empyema complicated by type-2 respiratory failure required mechanical ventilation as part of his therapy. A pneumothorax was noted on his chest radiograph. This was treated with an intercostal chest drain (ICD). Unfortunately, he was still hypoxic, his subcutaneous emphysema was worsening and the ICD was bubbling. A computed tomography (CT) scan of chest demonstrated that the ICD has penetrated the right upper lobe parenchyma. A new ICD was inserted and the previous one was removed. Although both hypoxia and subcutaneous emphysema improved, the patient chronically remained on mechanical ventilation

Redo-redo aortic root replacement with a mechanical valved conduit in a patient with von Willebrand's disease: Case report

A 40 year-old female, with a history of cardiac surgery for congenital aortic valve stenosis and von Willebrand's disease (VWD) presented with increasing shortness of breath due to mixed aortic valve dysfunction. With a paucity of such cases in the literature, we describe the successful outcome of a patient with VWD who underwent elective redo-redo aortic root replacement with a mechanical valved conduit. She was given a three-month trial of warfarin pre-operatively to evaluate the extent of bleeding risk. Her post-operative course was uneventful and she was discharged home after six days

Analysis of incidence and reasons for re-intervention after aortic valve replacement using the Trifecta aortic bioprosthesis

Introduction: Trifecta bioprosthesis claims favourable haemodynamic performance. However, reports of structural valve deterioration (SVD) raise concerns of its long-term durability. We assessed outcomes with the Trifecta valve over a 10-year period. Methods: All patients receiving Trifecta bioprostheses between October 2011 and October 2020 were included. Perioperative and survival characteristics were prospectively collated in an independent database. Re-intervention was recorded as a surrogate for SVD. Results: 944 patients (mean age 72.82 years ± 8.13, 58% male) underwent aortic valve replacement with the Trifecta valve. At 10-years, 1.4% of patients required a redo operation, giving an overall freedom from re-intervention of 98.6%. The mean time to re-intervention was 48.87 months. Survival was 73.58% and 76.92% in patients who did not require re-intervention vs re-intervention group, respectively. Conclusions: In a large, single-centre cohort, the Trifecta aortic bioprosthesis had a 1.4% all-cause re-intervention rate at 10-years, with insignificant impact on survival

Repair of mitral subvalvular apparatus and a calcified left ventricle aneurysm

Left ventricle (LV) myocardial infarction may result in changes to the structure of the subvalvular apparatus. This may lead to a functional regurgitation if accompanied by annular dilatation preventing coaptation of leaflets. Scar tissue formation in the left ventricle may also lead to aneurysm of the left ventricle. This can then calcify, making repair of the leaflet technically challenging. We present a case of a mitral valve repair with concomitant repair of left ventricle aneurysm in a 75-year-old gentleman who suffered an ST-segment elevation myocardial infarction to the lateral wall 20 years ago. He presented with breathlessness on minimal activity, severe mitral regurgitation with a posteriorly oriented regurgitant jet and calcification of LV aneurysm on chest X-ray and computed tomography scan. Despite the challenging nature, it is possible to repair a mitral valve with concomitant calcified LV aneurysm formation. Long term outcomes are still unknown for this cohort of patients

Systematic review and meta-analysis of surgical ablation for atrial fibrillation during mitral valve surgery

Background: Surgical ablation has emerged as an acceptable treatment modality for patients with atrial fibrillation (AF) undertaking concomitant cardiac surgery. However, the efficacy of surgical ablation in patient populations undergoing mitral valve surgery is not well established. The present meta-analysis aims to establish the current randomized evidence on clinical outcomes of surgical ablation versus no ablative treatment in patients with AF undergoing mitral valve surgery. Methods: Electronic searches were performed using six databases from their inception to September 2013, identifying all relevant randomized controlled trials (RCTs) comparing surgical ablation versus no ablation in AF patients undergoing mitral valve surgery. Data were extracted and analyzed according to predefined clinical endpoints. Results: Nine relevant RCTs were identified for inclusion in the present analysis. The number of patients in sinus rhythm (SR) was significantly improved in the surgical ablation group compared to the non-ablation group at discharge. This effect on SR remained at all follow-up periods until >1 year. Results indicated that there was no significant difference between surgical ablation and no ablation in terms of 30-day mortality, all-cause mortality, pacemaker implantation, stroke, thromboembolism, cardiac tamponade, reoperation for bleeding and myocardial infarction. Conclusions: Results from the present meta-analysis demonstrate that the addition of surgical ablation for AF leads to a significantly higher rate of sinus rhythm in mitral valve surgical patients, with no increase in the rates of mortality, pacemaker implantation, stroke and thromboembolism. Further research should be directed at correlating different surgical ablation subtypes to cardiac and cerebrovascular events at long-term follow-up.12 page(s