CARDIOTHORACIC SURGEON

COVID 19 is the most recent cause of adult respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) can support gas exchange in patients failing conventional mechanical ventilation, but its role is still controversial. We conducted a systematic review and meta-analysis on ECMO for COVID-associated ARDS to study its outcome.

CENTRAL, MEDLINE/PubMed, Cochrane Library, and Scopus were systematically searched from inception to May 28, 2020. Studies reporting five or more patients with COVID-19 infection treated venovenous with ECMO were included. The main outcome assessed was mortality and ICU/hospital discharge. Baseline, procedural, outcome, and validity data were systematically appraised and pooled with random-effect methods. The validity of all the included observational studies was appraised with the Newcastle Ottawa scale. Meta-regression and publication bias were tested. This trial was registered with PROSPERO under registration number CRD42020183861.

From 1647 initial citations, 34 full-text articles were analyzed and 12 studies were selected, including 194 patients with confirmed COVID-19 infection requiring ICU admission and venovenous ECMO treatment. Median Newcastle-Ottawa scale was 6 indicating acceptable study validity. One hundred thirty-six patients reached an endpoint of weaning from ECMO with ICU/hospital discharge or death while the rest were still on ECMO or in the ICU. The median Berlin score for ARDS prior to starting ECMO was III. Patients received mechanical ventilation before ECMO implementation for a median of 4 days and ECMO was maintained for a median of 13 days. In hospital and short-term mortality were highly variable among the included studies ranging between 0 and 100%. Random-effect pooled estimates suggested an overall in-hospital mortality risk ratio of 0.49 (95% confidence interval 0.259 to 0.721; I² = 94%). Subgroup analysis according to country of origin showed persistent heterogeneity only in the 7 Chinese studies with pooled estimate mortality risk ratio of 0.66 (I² = 87%) (95% CI = 0.39-0.93), while the later larger studies coming from the USA showed pooled estimate mortality risk ratio of 0.41 (95% CI 0.28-0.53) with homogeneity (p=0.67) similar to France with a pooled mortality risk ratio of 0.26 (95% CI 0.08-0.43) with homogeneity (p=0.86). Meta-regression showed only younger age as a predictor of mortality (p=0.02). Publication bias was excluded by visualizing the funnel plot of standard error, Egger’s test with p=0.566, and Begg and Mazumdar test with p=0.373.

The study included the largest number of patients with outcome findings of ECMO in this current pandemic. Our findings showed that the use of venovenous ECMO at high-volume ECMO centers may be beneficial for selected COVID 19 patients with severe ARDS. However, none of the included studies involve prospective randomized analyses; and therefore, all the included studies were of low or moderate quality according to the Newcastle-Ottawa scale. In the current era and environment of the pandemic, it will likely be very challenging to conduct a prospective randomized trial of ECMO versus no-ECMO for COVID-19. Therefore, the information contained in this systematic review of the literature is valuable and provides important guidance.

The study protocol link is at www.crd.yorl.ac.uk/PROSPERO under registration number CRD42020183861.

Pleurodesis is defined as symphysis between two layers of pleura to prevent recurrence of effusion, and it is the best available treatment for recurrent effusions of incurable malignancies. An ideal agent must be highly effective, safe, inexpensive, and readily available which is yet to be identified.

The aim of this study was to assess our results of medical pleurodesis, using 3 different chemical agents: bleomycin ampoules, doxycycline capsules, povidone–iodine solution, through two different routes, chest tube and small bore indwelling catheter.

Over a period of 5 years, 104 patients with malignant recurrent pleural effusion underwent pleurodesis at our university hospital, using 3 different agents and two routes of delivery.

Fifty patients were male, patients’ age ranged from 22 to 74 years (57.55 ± 9.02). Fifty-nine patients (56.7%) had right-sided effusion, 61 patients (58.7%) had massive effusion. All patients were dyspneic. The rout of effusion drainage and sclerosing agent instillation was chest tube in 64 patients (61.5%) and small indwelling catheter in 40 patients. Forty-three patients received bleomycin, 36 patients received doxycycline, and 25 patients received povidone–iodine. The total success rate was 78.8%.

Pleurodesis is a safe acceptable palliative procedure for malignant pleural effusion with not yet definite ideal agent or rout. Hence, the availability and the expense of agent are important.

Needle embolism is a rare complication of intravenous habit. Clinical manifestations include recurrent pericarditis, tamponade, cardiac perforation, and infective endocarditis. We describe the case of needle embolization in a young intravenous opiate abuser.

We describe a rare complication of intravenous misuse in a 23-year-old patient. He presented at the emergency department with chest pain and shortness of breath. He complained of remittent fever ensued 6 months before. Echocardiographic and radiologic images revealed pericardial effusion and a needle fragment inside the pericardium. The needle was removed through left-anterior mini-thoracotomy, after CT-guided carbon tracking.

The presence of a foreign body within the heart resulted from the migration of a needle fragment from a peripheral vessel. It caused fever and recurrent pericarditis. In similar cases, surgical extraction is the therapy of choice.

The number of pediatric patients who survive open-heart surgery has increased in recent years and the complications seen in this patient group continue to decrease with each technological advance, including new surgical and neuroprotective techniques and the improvement in surgeons’ experience with this patient population. However, neurological complications, which are the most feared and difficult to manage, require long-term follow-up, and increase hospital costs remain a leading cause of mortality and morbidity in this cohort.

We evaluated the neurological physical examination, cranial computed tomography (CT), and magnetic resonance (MRI) records of 162 pediatric patients with neurological symptoms lasting more than 24 h after undergoing heart surgery in our clinic between June 2012 and May 2020. The patients’ ages ranged from 0 to 205 months, with a mean of 60.59 ± 46.44 months.

Of the 3849 pediatric cardiac surgery patients we screened, 162 had neurological complications in the early period (the first 10 days after surgery). The incidence was calculated as 4.2%; 69 patients (42.6%) experienced seizures, 17 (10.5%) experienced confusion, 39 (24.1%) had stupor, and 37 (22.8%) had hemiparesis. Of the patients who developed neurological complications, 54 (33.3%) died. Patients with neurological complications were divided into 3 groups: strokes (n = 90), intracranial bleeding (n = 37), and no radiological results (n = 35). Thirty-four patients (37.8%) in the stroke group died, as did 15 (40%) in the bleeding group, and 5 (14.3%) in the no radiological results group.

Studies on neurological complications after pediatric heart surgery in the literature are currently insufficient. We think that this study will contribute to a more detailed discussion of the issue. Responses to neurological events and treatment in the pediatric group may differ compared to the adult age group. Primary prevention methods should be the main approach in combating neurological complications; their formation mechanisms should be carefully monitored and preventive treatment strategies should be developed.

Perioperative myocardial infarction (PMI) increases morbidity and mortality after off-pump coronary artery bypass grafting (CABG). The objective of the current study was to characterize patients with PMI after off-pump CABG and identify its predictors.

We included 1181 patients who had off-pump CABG from 2010 to 2020; 59 patients (5%) had PMI. We compared patients with PMI to those without PMI. Patients with PMI were older (57 (25th–75th percentiles: 51–63) vs. 54 (48–60) years; P = 0.01) and had higher NYHA class (28 (47.46%) vs. 326 (29.06%): P = 0.01). The distal anastomosis time was longer in patients with PMI (28 (23–35) vs. 24 (16–30) min; P ˂ 0.001). Patients with PMI had higher postoperative low cardiac output (10 (18.18%) vs. 1 (0.1%): P ˂ 0.001), prolonged ventilation (12 (8–39) vs. 8 (6–10) h, P ˂ 0.001), ICU (71 (46–138) vs. 24 (23–42) h; P ˂ 0.001), and hospital stay (9 (6–15) vs. 7 (6–8) days; P ˂ 0.001). Mortality was significantly higher in patients with PMI (20 (33.9%) vs. 6 (0.53%); P ˂ 0.001). Older age (OR: 1.05 (95% CI: 1.01–1.1); P = 0.02), increased number of distal anastomoses (OR: 1.74 (95% CI: 1.20–2.50); P = 0.003), preoperative congestive heart failure (OR: 10.27 (95% CI: 2.58–40.95); P = 0.001), and thrombolysis within 24 h of surgery (OR: 15.34 (1.93–121.9); P = 0.01) were associated with increased PMI, while PMI was lower in male patients (OR: 0.42 (95% CI: 0.19–0.93); P = 0.03) and with higher body surface area (BSA) (OR: 0.08 (95% CI: 0.07–0.86); P = 0.04).

Post-off-pump CABG PMI was associated with increased morbidity and mortality. Risk factors for PMI were older age, lower BSA, females, increased distal anastomoses, preoperative heart failure, and thrombolysis.

Aortic valve repair in rheumatic patients is not well-studied. We aimed to present our initial Egyptian experience in the aortic valve repair and compare it with the aortic valve replacement. The study included 85 patients who had an aortic valve surgery for aortic regurgitation (AR) in a single center from 2018 to 2020. We assigned the patients to either aortic valve repair (n= 39) or aortic valve replacement (n= 46). Fifty-nine patients (69.4%) had rheumatic heart disease. Study outcomes were hospital complications and the degree of aortic regurgitation after 6 months in patients who had aortic valve repair.

Patients who had replacement were significantly older (49.6± 7.2 vs. 43.8± 8.6 years: P= 0.002) and had more advanced New York Heart Association (P<0.001) and Canadian Cardiovascular Scoring (P= 0.03) classes. Hypertension (31 (67.4%) vs. 17 (43.6%); P= 0.03) and hypercholesteremia (18 (40%) vs. 17 (18.9%); P= 0.04) were more common in the replacement group. Patients who had replacement had a significantly higher percentage of valve retraction (P<0.001). Cardiopulmonary bypass (54.5 (49.5–60) vs. 45 (41–49) min; P<0.001) and ischemic times (36.5 (31–40) vs. 30 (28–33) min; P<0.001) were longer in patients who had an aortic valve replacement. Blood transfusion (28 (60.9%) vs. 11 (282%); P= 0.003) and ICU stay (24.5 (24–48) vs 23 (20–31) h; P= 0.01) were higher in the replacement group. Hospital mortality was non-significantly different between groups. Four patients had trivial AR (10.3%), and six had mild AR (15.4%) in the repair group. There was no difference in valve pathology or outcomes in aortic valve repair patients for degenerative versus rheumatic pathologies. After a 6-month follow-up, four patients had trivial AR (10.3%), and six patients had mild AR (15.4%) in the repair group.

Aortic valve repair could be an alternative to replacement in selected patients with rheumatic heart disease. Shorter cardiopulmonary bypass and ischemic times may improve repair outcomes compared to replacement.

Postoperative AF (PoAF) is a common complication of the early postoperative period of noncardiac, thoracic surgery and is associated with prolonged hospital stay. In order to investigate the predictors of PoAF in the specific setting of lung surgery of oncologic patients, we retrospectively analyzed 338 consecutive patients admitted to our department to be operated for lung cancer with a thoracotomy approach (i.e., open surgery). We determined this population’s prevalence, risk factors, and consequences of PoAF.

PoAF occurred in 35/338 (10.4%) patients and was significantly more frequent in older patients, with a best predictive value of 71 years at ROC curve analysis (AUC 0.70, p < 0.001) and in those with chronic renal failure (p = 0.01). The left atrial area was also significantly associated with the risk of PoAF (AUC 0.78, p = 0.000). PoAF was more frequent in patients with small cell and squamous cell carcinoma (p = 0.03). The occurrence of PoAF was associated with a longer hospital stay (p = 0.001) but not with higher long-term mortality (follow-up mean length: 3.3 ± 0.3 years). At multivariable analysis, the only independent predictors of PoAF were age (OR for 1-year increase 1.089, 95% CI 1.039–1.141, p 0.001) and open surgery (OR 2.07, 95% CI 1.0–4.29, p 0.047). At the 3-year follow-up, all patients were in sinus rhythm.

The present study shows the association between age and open surgery with PoAF, furtherly highlighting that the incidence of arrhythmia leads to a longer hospital stay. Left atrium dilatation could identify at-risk patients. Those results suggest that older patients — especially those with larger left atrium areas — might benefit most from a VATS approach to further reduce the arrhythmia incidence. Such a finding supports the indication of a systematic echocardiographic evaluation before elective lung surgery, especially in patients with known clinical risk factors.

Giant coronary artery aneurysms (GCAA) are a rare disease entity with an estimated incidence of 0.02%. Atherosclerosis is the most common underlying factor in adulthood. Management guidelines lack the support of large-scale studies.

We present a case of a 58-year-old Caucasian male with complaints of stable dyspnea who was found to have a GCAA of the right coronary artery (RCA). Further evaluation revealed an aneurysm of 5.0 cm in diameter with a tortuous course, fistulation to the distal vena cava superior, and mass effect on the left atrium. Surgical deroofing and ligation of the aneurysm with venous bypassing of the right coronary artery were performed. There were no postoperative complications. Cardiac function had improved at 1-month follow-up and remained improved at 1-year follow-up.

Diagnosis and treatment strategy concerning GCAA remain challenging. Surgical treatment is advised in cases of giant aneurysms, multivessel disease, left main coronary artery (LMCA) involvement, mechanical complications (fistula, compression, or rupture), and concomitant valve surgery. Coronary angiography remains the gold standard for evaluation. However, coronary computed tomography angiography (CCTA) and cardiac magnetic resonance imaging (CMR) can add an important value for the clinician to assess myocardial viability and planning of surgical intervention.

Mechanical circulatory support has garnered significant popularity as both a bridge to transplant as well as a destination therapy for patients with end-stage heart failure. Right heart failure (RHF) is a devastating complication after LVAD placement and is very unpredictable. Assisted circulation of the left ventricle (LV) with an LVAD device could unmask an underlying RHF. However, otherwise healthy right ventricles (RVs) can develop RHF after LVAD placement as well due to poor adaptation to new filling pressures and altered hemodynamics. It has been proposed that preoperative volumetric measurements in the pulmonary and systemic vasculature may serve as indicators for a risk of RHF after LVAD implantation. The aim of this study is to examine a potential relationship of preoperative hemodynamic values such as pulmonary artery pulsatility index (PAPi) and the ratio of central venous pressure to pulmonary wedge pressure (CVP/PWP) as preoperative predictors for RHF post LVAD placement.

We retrospectively reviewed patients undergoing initially planned isolated LVAD implantation with or without concomitant procedures in our institution from January 1, 2017 to June 12, 2020. Data were gathered from hemodynamic records, echocardiographic interpretations, and clinical notes. Patients who had RHF after LVAD implantation but without hemodynamic data available within 14 days from the operation were excluded. Univariable analysis was performed.

Of the 114 patients who received planned isolated LVAD surgery, 70 (61.4%) experienced RHF within the first 7 days postoperatively. PAPi did not correlate significantly with RHF vs non-RHF among LVAD recipients (3.1 ± 2.1 vs. 3.8 ± 3.4P= 0.21). Pre-op CVP/PWP did not differ significantly between RHF and non-RHF patients (0.4 ± 0.2 vs. 0.5 ± 0.8P= 0.28). There was a nonsignificant correlation between elevated pre-op PWP and those with RHF vs those without,OR= 1.05 (95%CI: 1.00, 1.10). Pre-op systolic pulmonary artery pressure (SysPAP) was elevated in patients with post-LVAD RHF compared to those without (51.3 ± 12.3 vs. 47.2 ± 13.0,P= 0.09).

Preoperative hemodynamic variables such as PAPi or CVP/PWP did not show a significant correlation predicting RHF post LVAD implantation. Acute RHF post LVAD implantation remains a complex medical entity. Several studies have devised multivariable risk scores; however, their performance has been limited. Despite the widespread use of preoperative hemodynamics measurements as risk scores, our study suggests these scores are not as accurate as their use would suggest, particularly among especially morbid patient populations. More prospective studies are needed to accurately demonstrate how preoperative hemodynamics could predict and help prevent this catastrophic complication.