Composite Reconstruction of the Right Atrium and the Superior Vena Cava With Pericardial Patches and a Vascular Prosthesis

<p>This video demonstrates the surgical treatment of a patient with a right heart angiosarcoma who underwent radical resection followed by composite reconstruction of the right atrium and the superior vena cava (SVC), with bovine pericardial patches and a polytetrafluoroethylene (PTFE) vascular prosthesis. The right atrium is the structure most often affected by cardiac sarcoma.<br></p><p>The patient was a 43-year-old man with no history of serious illness. On the day of onset, he suddenly felt unwell when he was working and he then collapsed. He was brought to a hospital by ambulance. His blood pressure was 60 mm Hg, and his heart rate was 180 beats per minute. A plain computed tomography (CT) scan showed massive pericardial effusion. A thoracentesis was performed, and the tube drained sanguineous fluid. He underwent emergency coronary angiogram. His coronary arteries did not show any stenosis; however, the right coronary angiogram revealed staining of a tumor from the sinus nodal artery. Enhanced CT was performed, which showed a massive tumor occupying most of the right atrium and extending into the SVC. The patient was transferred to another hospital, where he underwent an urgent operation the day after admission.</p><p>In the pericardial sac, a hematoma was present, attached to the right atrial appendage. The ascending aorta, the SVC, and the inferior vena cava (IVC) were cannulated. An atrial incision was made just above the IVC. The authors then made a second incision at the SVC. The atrial incision was extended from the IVC to the SVC, while carefully inspecting and feeling the quality of the wall. The aorta was clamped, and the SVC was transected. The right side of the left atrium was incised to resect the atrial septum. The right coronary artery was identified and taped from its origin along the atrioventricular groove toward the acute margin. The sinus nodal artery, which was the tumor-feeding artery in this case, was identified and divided. The atrioventricular groove was dissected, and the entire right atrial wall was resected in one block. The defect of the left atrial wall, including the atrial septum and the roof of the left atrium, was reconstructed using an oval-shaped bovine pericardial patch. The left atrium was deaired and closed.</p><p>Regarding the right atrium, the only parts remaining were the tricuspid annulus, the coronary sinus, and the small part of the lower free wall near the IVC. Another bovine pericardial patch was used to reconstruct the right atrium. To the commissure between the anterior leaflet and the septal leaflet, the patch was trimmed in the exact angle of the anteroseptal commissure in order to prevent tricuspid regurgitation, and it was directly sewn to the tricuspid annulus. In the dorsal side, the patch was sewn along the coronary sinus with 4-0 polypropylene sutures with minimal residual tissue of the right atrium. The orifice of the coronary sinus was placed in the neo-right atrium. The authors used a generous-sized patch so that it would bulge with atrial pressure to form a three-dimensional dome as a neo-right atrium. They think it is better to do this, because one theoretical disadvantage of their technique may be the fact that the volume of the reconstructed neo-right atrium is smaller and has less compliance than the native right atrium.</p><p>The authors then made an end-to-end anastomosis between a PTFE prosthesis and the SVC. A 16 mm graft was chosen based on the diameter of the distal end of the native SVC. The aorta was unclamped, and the surgeons were able to determine the adequate length of the graft easily. They then trimmed the PTFE prosthesis in an oblique fashion to make a cobra-head anastomosis. The authors made a long incision on the pericardial patch, and then made an end-to-end anastomosis using 5-0 polypropylene running sutures to make a generous cobra head. Their goal was that this smooth and large orifice would contribute to better flow characteristics and a decreased tendency to thrombus formation inside the neo-right atrium. The patient came off cardiopulmonary bypass easily. There were no problems with hemostasis.</p><p>Since the superior cavoatrial junction, including the site of the sinus node, had been resected, an epicardial ventricular electrode was implanted. A pathological examination showed angiosarcoma. The postoperative course was uneventful. A pacemaker generator was implanted on the seventh postoperative day. Postoperative CT showed a well-reconstructed left atrium, new right atrium, and SVC. Postoperative echocardiogram showed no significant tricuspid regurgitation.</p><p>Extensive right atrial resection is often required in cases of cardiac sarcoma. The authors recommend their technique because it is simple, reproducible, and carries little risk of kinking or deformity.</p><p><br></p><p><strong>Suggested Reading</strong></p><ol><li>Benassi F, Maiorana A, Melandri F, Stefanelli G. A case of primary cardiac angiosarcoma: extensive right atrial wall reconstruction with autologous pericardium. <em><a href="https://doi.org/10.1111/j.1540-8191.2009.00910.x">J Card Surg. 2010;25(3):282-284</a></em>.</li><li>Furukawa N, Gummert J, Borgermann J. Complete resection of undifferentiated cardiac sarcoma and reconstruction of the atria and the superior vena cava: case report. <em><a href="https://doi.org/10.1186/1749-8090-7-96">J Cardiothorac Surg. 2012;7:96</a></em>.</li></ol

Baseline neutrophil-to-lymphocyte ratio and efficacy of SGLT2 inhibition with empagliflozin on cardiac remodelling

Aims: The neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation and plays a critical role in the assessment and prognosis in patients with heart failure. The EMPA-HEART CardioLink-6 trial demonstrated that patients with type 2 diabetes (T2D) and coronary artery disease (CAD) treated with a sodium-glucose transport protein 2 inhibitor for 6 months experienced regression in left ventricular mass. Given this, we evaluated the relationship of baseline NLR and cardiac reverse remodelling in the entire cohort of this trial. Methods and results: A total of 97 individuals were randomized to receive empagliflozin (10 mg/day) or placebo for 6 months. The primary outcome of the trial was change in left ventricular mass indexed to body surface area (LVMi) from baseline to 6 months as measured by cardiac magnetic resonance imaging. In our analysis, the cohort was stratified above and below an NLR level of 2. To assess the treatment effect on the 6 month change in NLR, we used a linear model adjusting for baseline differences in NLR [analysis of covariance (ANCOVA)] that included an interaction term between the baseline NLR and treatment. To assess the treatment effect on the 6 month change in LVMi in each of the subgroups divided by baseline NLR, we used an ANCOVA adjusting for baseline differences in LVMi that included an interaction term between the subgroups and treatment. The results of the regression models were summarized as adjusted differences with two-sided 95% confidence intervals (CIs). Patients who exhibited an elevated baseline NLR demonstrated higher LVMi and left ventricular end-diastolic volume indexed to body surface area than those with a lower NLR. In patients with an NLR Conclusions: Empagliflozin treatment is associated with consistent reductions in LVMi in patients with T2D and CAD independent of baseline NLR.</p

Impact of diabetes duration on left ventricular mass regression with empagliflozin

Aims: The duration of type 2 diabetes mellitus (T2DM) is an important determinant of diabetes severity. The EMPA-HEART CardioLink-6 trial reported significant left ventricular (LV) mass indexed to body surface area (LVMi) regression in patients treated with the sodium-glucose cotransporter 2 inhibitor (SGLT2i) empagliflozin for 6 months. This exploratory sub-analysis of the same trial investigated the association between T2DM duration and LVMi regression. Methods and results: A total of 97 individuals with T2DM and coronary artery disease (CAD) were randomly assigned to receive empagliflozin 10 mg daily or placebo. LVMi was measured at the baseline and 6 month visit using cardiac magnetic resonance imaging. The study population was divided into those with a baseline T2DM duration Conclusions: In the EMPA-HEART CardioLink-6 trial, empagliflozin treatment was associated with reductions in LVMi in people with T2DM and CAD irrespective of the duration of diabetes assessed categorically above and below 10 years.</p

The association between anthropometric indicators of obesity and cardiac reverse remodelling with empagliflozin in patients with type 2 diabetes and coronary artery disease

Background: Obesity is an established risk factor for heart failure and is associated with a high risk of cardiovascular (CV) disease.1, 2 While body mass index (BMI) is a commonly utilized metric of obesity, other anthropometric measures such as waist circumference and waist-to-hip ratio have been shown to be independent predictors of CV risk.3, 4 Sodium-glucose cotransporter-2 inhibitors (SGLT2i) offer CV benefits to people living with or without diabetes, irrespective of baseline BMI.5, 6 Although a recent meta-analysis of translational studies suggested that SGLT2i-associated left ventricular (LV) remodelling may be linked to the cardioprotective benefits of SGLT2i,7 whether SGLT2 inhibition uniformly promotes LV mass regression across baseline anthropometric variables is unknown. In the randomized, placebo-controlled Effects of Empagliflozin on Cardiac Structure in Patients with Type 2 Diabetes (EMPA-HEART) CardioLink-6 trial, empagliflozin assignment for 6 months resulted in significant regression in LV mass indexed to baseline body surface area (LVMi).8 This sub-analysis of the EMPA-HEART CardioLink-6 trial investigated the relationship between anthropometric indicators of obesity at baseline and empagliflozin-mediated LVMi regression over the 6-month treatment period.</p

Effect of empagliflozin on cardiac remodelling in South Asian and non-South Asian individuals: insights from the EMPA-HEART CardioLink-6 randomised clinical trial

Background: This exploratory sub-analysis of the EMPA-HEART CardioLink-6 trial examined whether the previously reported benefit of the sodium-glucose cotransporter 2 (SGLT2) inhibitor empagliflozin on left ventricular (LV) mass (LVM) regression differs between individuals of South Asian and non-South Asian ethnicity. Methods: EMPA-HEART CardioLink-6 was a double-blind, placebo-controlled clinical trial that randomised 97 individuals with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) to either empagliflozin 10 mg daily or placebo for 6 months. LV parameters and function were assessed using cardiac magnetic resonance imaging. The 6-month changes in LVM and LV volumes, all indexed to baseline body surface area, for South Asian participants were compared to those for non-South Asian individuals. Results: Compared to the non-South Asian group, the South Asian sub-cohort comprised more males, was younger and had a lower median body mass index. The adjusted difference for LVMi change over 6 months was -4.3 g/m2 (95% confidence interval [CI], -7.5, -1.0; P = 0.042) for the South Asian group and -2.3 g/m2 (95% CI, -6.4, 1.9; P = 0.28) for the non-South Asian group (Pinteraction = 0.45). There was no between-group difference for the adjusted differences in baseline body surface area-indexed LV volumes and LV ejection fraction. Conclusions: There was no meaningful difference in empagliflozin-associated LVM regression between South Asian and non-South Asian individuals living with T2DM and CAD in the EMPA-HEART CardioLink-6 trial. Trial registration: ClinicalTrials.gov Identifier: NCT02998970 (First posted on 21/12/ 2016).</p

The impact of statins on postdischarge atrial fibrillation after cardiac surgery: secondary analysis from a randomized trial

Background Whether statins reliably reduce the risk of postoperative atrial fibrillation (POAF) in patients undergoing cardiac surgery remains controversial. We sought to determine the impact of statin use on new-onset postdischarge POAF in the Post-Surgical Enhanced Monitoring for Cardiac Arrhythmias and Atrial Fibrillation (SEARCH-AF) CardioLink-1 randomized controlled trial. Methods We randomized 336 patients with risk factors for stroke (CHA2DS2-VASc score ≥ 2) and no history of preoperative atrial fibrillation (AF) to 30-day continuous cardiac rhythm monitoring after discharge from cardiac surgery with a wearable, patched-based device or to usual care. The primary endpoint was the occurrence of cumulative AF and/or atrial flutter lasting for ≥ 6 minutes detected by continuous monitoring, or AF and/or atrial flutter documented by a 12-lead electrocardiogram within 30 days of randomization. Results The 260 patients (77.4%) discharged on statins were more likely to be male (P = 0.018) and to have lower CHA2DS2-VASc scores (P = 0.011). Patients treated with statins at discharge had a 2-fold lower rate of POAF than those who were not treated with statins in the entire cohort (18.4% vs 8.1%, log-rank P = 0.0076). On multivariable Cox regression including the CHA2DS2-VASc score adjustment, statin use was associated with a lower risk of POAF (hazard ratio 0.43, 95% confidence interval: 0.25-0.98, P = 0.043). Use of statins at a higher intensity was associated with lower risk of POAF, suggestive of a dose–response effect (log-rank Ptrend = 0.0082). Conclusions The use of statins was associated with a reduction in postdischarge POAF risk among patients undergoing cardiac surgery. The routine use of high-intensity statin to prevent subacute POAF after discharge deserves further study.</p