Bilateral antegrade selective cerebral perfusion has the undisputed advantage of being more physiological and theoretically ensuring complete perfusion of the whole brain. However, it requires longer execution times and manipulation of the epiaortic vessels. On the other hand, unilateral selective cerebral perfusion (u-ASCP) avoids the vessels manipulation, placement of catheters into the ostia of the great vessels which clutters the operative field and incurs both atherosclerotic and air embolism risk. Neverthless, an ongoing debate about which technique yields the best clinical outcomes is still open.
If it an’t broke, don’t fix itBerhane Worku MD1, Meghann M Fitzgerald21: Department of Cardiothoracic Surgery, Weill Cornell Medical College2. Department of Anesthesiology, Weill Cornell Medical CollegeAntifibrinolytics and TEGCorresponding Author:Berhane WorkuDepartment of Cardiothoracic SurgeryWeill Cornell Medical College525 East 68th Street M-404New York, NY 10065Despite evidence of associated morbidity and mortality, blood products are administered to over half of cardiac surgical patients, accounting for approximately 20% of their worldwide use1,2. These statistics attest to the ubiquitous and refractory nature of bleeding after cardiac surgery. In an attempt to curb the excessive use of blood products after cardiac surgery viscoelastic testing in the form of thromboelastography (TEG) and rotational thromboelastometry (ROTEM) have been increasingly utilized. Rapid intraoperative assessment allows for targeted correction of coagulopathy due to residual heparinization, coagulation factor deficiency, hypofibrinogenemia, and platelet dysfunction. Hyperfibrinolysis can also be assessed, although management is rarely altered as the routine administration of lysine analog antifibrinolytics has been given a class I recommendation by the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists and has become the standard practice at most cardiac surgical centers.Cardiopulmonary bypass is known to result in transient t-PA and subsequent d-dimer level elevations (a marker of hyperfibrinolysis)3,4. The efficacy of the lysine analog antifibrinolytics, tranexamic acid andε-aminocaproic acid, have been extensively studied in this setting. D-dimer levels are significantly blunted by antifibrinolytics, and an abundance of literature demonstrates reductions in chest tube bleeding, blood product use, and reoperation for bleeding with the use of these agents4-6. A similar amount of evidence points to their safety, with no increase in thrombotic complications, including stroke, myocardial infarction, graft closure, or mortality seen5-7. A higher risk of seizures is noted with tranexamic acid, although this appears to be dose dependent and nonexistent with ε-aminocaproic acid2. If the ultimate goal is to reduce bleeding and blood product usage, it would seem that antifibrinolytics offer one way to do this safely.In the current manuscript, Sussman et. al. retrospectively analyze 78 cardiac surgical patients who had an intraoperative TEG performed with the goal of describing the distribution of fibrinolytic phenotypes in this population8. Forty five percent demonstrated physiologic fibrinolysis, 32% hypo fibrinolysis, and 23% hyperfibrinolysis (LY30 <0.8%, 0.8-3%, >3%). Forty seven percent received antifibrinolytic agents. Outcomes including “morbidity” and time with chest tube were higher in those who received antifibrinolytics. This is a perhaps the first study of its kind to describe the prevalence of hyperfibrinolysis in cardiac surgical patients as measured by point of care testing. It is also a very relevant study in an era in which the benefits of targeted therapy for coagulopathy are increasingly recognized.The current data suggests that half of patients undergoing cardiac surgery demonstrate physiologic fibrinolysis and a third demonstratehypo fibrinolysis (a theoretically pro thrombotic state)8. The worse outcomes seen in patients receiving antifibrinolytics suggests that their administration in the setting of a potentially prothrombotic state was to blame. However, several limitations merit mention. It appears that TEG is not routinely performed on all patients. The population under study may therefore reflect one undergoing more extensive surgery with more coagulopathy in whom TEG is more likely to be performed. Since the actual timing of the TEG is not detailed, the true baseline fibrinolytic phenotype of patients treated with antifibrinolytics is not clear as the TEG results may have been obtained after the initiation of antifibrinolytics. Furthermore, while surgical procedures performed weren’t delineated, patients receiving antifibrinolytics more frequently had “valve disease” and “heart failure” and underwent on-pump surgery. Patients receiving antifibrinolytic therapy were therefore sicker and likely underwent more extensive on-pump valve surgery, while patients who did not receive antifibrinolytics were most likely undergoing off-pump coronary bypass surgery. Finally, the increased “morbidity” in patients receiving antifibrinolytics appear to be bleeding related (thrombotic complications were not listed separately). Perhaps additional antifibrinolytics were needed.The authors are to be commended for recognizing a lack of complete understanding of coagulation in the cardiac surgical population and attempting to determine the benefit of targeted antifibrinolytic therapy. Any time a practice is performed indiscriminately, there is room for improvement. However, before we contemplate altering an evidence-based practice that reduces bleeding, we need to demonstrate a benefit for such a change. Not all bleeding is purely surgical or purely medical; there is overlap. Few areas of medicine highlight how much art prevails over our current scientific understanding. Too many times since the introduction of point-of-care testing, the surgeon and anesthesiologist battle over the merits of administering blood products to a clinically bleeding patient with a normal coagulation profile. Targeted correction of coagulopathy is conceptually attractive, but the reality is not as clearly defined. Reductions in bleeding seen with antifibrinolytics occur both in on-pump and off-pump surgery which should be enough proof to continue its application until better evidence and understanding emerges6. Certainly, there is more work to be done, but with regard to antifibrinolytics it seems fitting to recognize: If it ain’t broke, don’t fix it.REFERENCESAbdelmotieleb M, Agarwal S. Viscoelastic testing in cardiac surgery. Transfusion 2020;60:52-60Harvey R, Salehi A. Con: Antifibrinolytics should not be used routinely in low-risk cardiac surgery. J Cardiothorac Vasc Anesth 2016;30:248-251Gielen C, Brand A, van Heerde W, Stijnen T, Klautz R, Eikenboom J. Hemostatic alterations during coronary artery bypass grafting. Thromb Res 2016;140:140-146Slaughter T, Faghih F, Greenberg C, Leslie J, Sladen R. The effects of ε-aminocaproic acid on fibrinolysis and thrombin generation during cardiac surgery. Anesth Analg 1997;85:1221-6Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, Cooper J, Marasco S, McNeil J, Bussieres JS, McGuinness S, Byrne K, Chan MTV, Landoni G, Wallace S. Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med 2017;376:136-48Zhang Y, Bai Y, Chen M, Zhou Y, Yu X, Zhou H, Chen G. The safety and efficiency of intravenous administration of tranexamic acid in coronary artery bypass grafting (CABG): a meta-analysis of 28 randomized controlled trials. BMC Anesthesiol 2019;19:104Kasrki J, Djaiani G, Carroll J, Iwanochko M, Seneviratne P, Liu P, Kucharczyk W, Fedorko L, David T, Cheng D. Tranexamic acid and early saphenous vein graft patency in conventional coronary artery bypass graft surgery: A prospective randomized controlled clinical trial. J Thorac Cardiovasc Surg 2005;130:309-14Sussman MS, Urrechaga EM, Cioci AC, Iyengar RS, Herrington TJ, Ryon EL, Namias N, Galbut DL, Salerno TA, Proctor KG. Do all cardiac surgery patients benefit from antifibrinolytic therapy? J Card Surg in press
Prediction scores and metrics are being increasingly utilized throughout the fields of cardiothoracic and congenital cardiac surgery to identify areas for perioperative optimization or guide therapeutic intent. Here, we review a novel submission by Yang and colleagues to the Journal of Cardiac Surgery identifying preoperative factors which predict adverse postoperative outcomes from cone reconstruction for Ebstein's anomaly.
The use of radial artery (RA) grafts for coronary bypass surgery has recently gained newer attention since it has been associated with significant reduction in the risk of midterm cardiac events. Surprisingly the use on the RA graft as second ‘best’ conduit has been limited among the surgical community. There may be several explanations for the little popularity of the RA graft; one of the reasons that could prevent surgeons to include the RA in the daily surgical armamentarium it is that patients with RA grafts may require postoperative calcium-channel blocker (CB) therapy. Due to the thick muscular wall, it seems possible that the RA would needs CB in order to prevent spasm and ameliorate patency. CBs are, however, associated with important side effects; also they have hypotensive effect that can hamper the use of other therapy such as beta-blocker or angiotensin-converting enzyme inhibitors. The evidence supporting the use of CB after RA graft (either in the early phase or as chronic calcium-blocker (CCB)) is weak. A the post-hoc analysis from the ‘RADIAL’ (Radial Artery Database International ALliance), showed that in patients with RA, the use of CB for at least 12 months was associated with better clinical and angiographic outcomes at mid-term follow-up, but confounders and bias may be responsible for the reported findings (as healthier patients are more likely to tolerate CB) . This review aims to summarize current evidences available on the topic and to serve as benchmark for evidence-based decision-making for CB prescription after RA grafting.
CABG (Coronary Artery Bypass Grafting) has been the treatment of choice for coronary artery disease for over 50 years and is the most common cardiac surgery procedure performed. Traditionally CABG was performed with the use of cardiopulmonary bypass and the use of cardioplegia to allow the surgeon to operate on a stable field. In the mid-1990s, interest emerged in performing CABG without the use of cardiopulmonary bypass - off pump CABG. This invited commentary focuses on sharing our experience with Low Ejection fraction off-pump CABG and why this approach could be beneficial to this patient population.
Commentary:When Starting a MICS Program, Don’t Assume Excellence: Prove It!Rachel Eikelboom MD1,2, Rashmi Nedadur MD3,Roberto Vanin Pinto Ribeiro MD3, Bobby Yanagawa MD PhD31 Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada2 Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada3 Division of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, CanadaCorresponding author:Bobby Yanagawa MD, PhD, FRCSC Program Director, Division of Cardiac Surgery, University of Toronto Assistant Professor, Division of Cardiac Surgery, St. Michael’s Hospital 30 Bond Street, 8th Floor, Bond Wing Toronto, ON M5B 1W8 Canada Tel: 416 864 5706 Fax: 416 864 5031 Email: email@example.comWord count: 430Conflict of interest: The authors have no conflict of interest and have not received any funding.Central Figure:
Non-A non-B aortic dissections are an infrequent occurrence and represent a small proportion of aortic dissections. Treating this life-threatening medical emergency often requires surgeons to undertake some one of the most challenging surgical or endovascular cases in medicine. This literature review aims to define and classify non-A non-B dissections, describe their epidemiology as well as their pathology. This review also aims to discuss the range of surgical techniques employed in their treatment and management and to investigate the patient outcomes associated with each technique.
Invasion in cardiac surgery is maximum when cardiopulmonary bypass(CPB) is used. The period is of no consequence as all complications such as Bleeding, Cerebral. Renal , vascular and Inflammatory responses are initiated when CPB is used. The term minimally invasive is therefore most inappropriate when CPB is used irrespective of the type of operation, incision, cosmesis, and use of sophisticated technology.This editorial highlights the misuse of the term Minimally invasive cardiac surgery.
BOOK REVIEW: Technical Aspects of Modern Coronary Artery BypassRobert F Tranbaugh, MDDepartment of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NYData Availability: NAFunding: NoneConflict of Interest: NoneInternational Review Board: NAInformed Consent: NACorresponding author:Robert F Tranbaugh, MDDepartment of Cardiothoracic SurgeryWeill Cornell Medicine505 East 68th StreetNew York, NY 10065Rft9008@med.cornell.eduWord Count: 484After recently purging most of my reference textbooks (many from the 1970’s and 1980’s and including the big names from the “Golden Age” of cardiac surgery—Glenn, Sabiston and Kirklin), I wondered if the era of the well-recognized, authoritative textbook was over. I actually cannot remember the last textbook I purchased. While a resident at UCSF, textbooks were critically important as the library closed at midnight. I grew up with the “red book”, Dunphy and Way’s “currentSurgical Diagnosis and Treatment”. This paperback nicely covered the basics of surgery and, importantly, was readily available for residents well before Google. Primarily for sentimental reasons, I kept my 1983 edition.So, why a surgical textbook in 2021? What is the appeal, attraction and need?Gaudino’s “Technical Aspects of Modern Coronary Artery Bypass Grafting” has enormous appeal. For one, it is beautifully illustrated with very useful drawings along with attractive and detailed operative photos. At times, I felt like I was visiting the author-surgeon in his or her operating room. The world’s leading experts have provided detailed step by step technical instructions, which are clear, concise and very helpful. For cardiac surgeons considering starting a multiple arterial grafting (MAG) program, this textbook is a needed and wonderful resource.The attractions of Gaudino’s testbook are many. First, “Technical Aspects” clearly reflects Gaudino’s stellar and highly productive career as an investigator and practitioner of MAG. He has systematically addressed the details of MAG. Conduit selection, harvest and utilization are all outlined in exquisite step by step detail. Complex grafting techniques are reviewed and beautifully illustrated. I especially enjoyed Chapter 12 by Rocha and his colleagues on their nicely done essay on the proximal anastomosis, or what I consider to be “the forgotten anastomosis”. The authors review the many important technical details and critical issues impacting the patency of a bypass graft.All of the chapters are well written, beautifully illustrated, highly practical and very helpful for residents in training, for early career surgeons and for well-established cardiac surgeons interested in coronary artery bypass. Gaudino should also be commended for the addition of Chapter 23 by Fremes and Tatoulis on the management of perioperative ischemia and Chapter 24 by Lazar on optimizing medical therapy. These are incredibly important chapters on “non-technical” yet critical issues with excellent recommendations.Gaudino’s “Technical Aspects” is a clearly needed and a highly authoritative textbook which will serve as an excellent roadmap for surgeons interested in starting a MAG program. It hopefully will allow surgeons to move from the “house special” CABG (one internal mammary and veins) mentioned by Girardi in his thoughtful Foreward to more arterial grafting performed with greater confidence and commitment. “Technical Aspects” will also serve as an important resource for surgeons at all levels of training and expertise. I currently have lots of room on my near empty book shelf. “Technical Aspects” will be on my book shelf and belongs on yours!
Mitral valve (MV) repair for mitral regurgitation (MR) due to posterior leaflet (PL) prolapse is achieved nowadays with a great success rate and a good survival, similar, in certain subgroups. In this paper, Sakaguchi et al describe their results in two groups of patients with PL prolapse. Some patients underwent resection (resection group) and others chordal replacement with/out limited resection (respect group). Results were similar in terms of survival and MR recurrence. Our goal is to eliminate, as much as possible, MR when a patient with degenerative MR is operated on. Reduction of the mitral orifice and consequently an increase of the transmitral gradient is the rule. MV repair for degenerative MR provides great results, but there is not a single surgical technique. A close evaluation of the anatomical findings will allow us to choose the best strategy for the individual patient. An open mind is the most important characteristic that a surgeon should have to repair a prolapsing PL without residual regurgitation and dangerous gradients.
Large studies demonstrated that moderate or severe patient-prosthesis mismatch (PPM) occurs in 44.2% to 65% of patients undergoing aortic valve replacement. If there is general agreement that patients with PPM have worse outcome than patients without, it is difficult to understand how to prevent this dangerous complication. The formula used to calculate the effective orifice area (EOA) of an implanted aortic prosthesis has many weak points that produce inconsistent results using the same prosthetic valve (type and size). The observed EOA (3 to 6 months postoperatively) of a #23 biological prosthesis can range from 0.9 to 3.5 cm², making PPM prevention impossible using projected EOA, where only the mean value is reported (1.83 cm² for the same #23 biological prosthesis). An EACTS-STS-AATS Valve Labelling Task Force has been established to suggest the manufacturers to present essential information on valvular prosthesis characteristics in standardized Valve Charts. For valves used in the aortic position, Valve Charts should include a standardized PPM chart to assess the probability of PPM after implantation. This will not solve completely the conundrum of prevention, but most likely it will be a step ahead.
The importance of del nido cardioplegia solution in coronary artery bypass surgeryMehmet Senel Bademcia MD, Cemal Kocaaslana MD Fatih Avni BayraktaraMD, Ahmet Oztekina MD, Huseyin Bilal Aydina MD, and Ebuzer Aydin a MD.a Istanbul Medeniyet University, Medicine Faculty, Department of Cardiovascular Surgery, Istanbul, TurkeyCorresponding Author: Mehmet Senel Bademci,M.D, Assist.Prof.Post Publication Corresponding Author: Mehmet Senel Bademci,M.D, Assist.Prof.Istanbul Medeniyet University Medicine Faculty, Department of Cardiovascular Surgery.Address: Dr. Erkin St. No:12 Kadikoy, Istanbul, 34722, Turkey.Mail address: firstname.lastname@example.orgDear Editor;We read with interest the article by Algarni  published entitled “Routine use of del Nido cardioplegia compared with blood cardioplegia in all types of adult cardiac surgery procedures.” Algarni KD. Routine use of del Nido cardioplegia compared with blood cardioplegia in all types of adult cardiac surgery procedures. J Card Surg. 2020;10.1111/jocs.15060In this study; Del Nido cardioplegia group has shorter aortic cross-clamp time for coronary artery by pass graft patients. But there is no sufficient data about the number of distal anastomosis between cardioplegia groups. If there is a significant difference between groups, this answer can change the aortic cross clamp times regardless of cardioplegia.We congratulate Algarni et al. for their valuable manuscript about cardioplegia solutions in coronary artery bypass surgery. We would like to hear authors’ opinion on this matter.References:1. Algarni KD. Routine use of del Nido cardioplegia compared with blood cardioplegia in all types of adult cardiac surgery procedures. J Card Surg. 2020;10.1111/jocs.15060.
Background: Despite clear clinical benefits, there is limited evidence regarding possible complications of the novel mechanical support device Impella. Aortic and mitral valve regurgitation or injury are rare but potential complications following implantation of the Impella device. Methods: To evaluate valvular complications after the Impella device implantation, we have performed a comprehensive search of literature on multiple sites on this topic. Results and Conclusion: Ten case reports and one observational retrospective study were identified, with a total number of 19 patients identified. This article aims to draw attention to potential periprocedural complications relating to the Impella, in particular iatrogenic aortic and mitral valve injuries. Moreover, we have summarized our recommendations emphasizing the need for careful management and meticulous follow-up of these patients to avoid such potentially devastating complications.
Background: Infection after cardiovascular surgery is multifactorial. We sought to determine whether the anthropometric profile influence the occurrence of infection after isolated coronary artery bypass grafting (CABG). Methods: Between January 2011 and June 2016, 1,777 consecutive adult patients were submitted to isolated coronary artery bypass grafting. Mean age was 61.7 ± 9.8 years and 1,193 (67.1%) were males. Patients were divided into four groups according to the Body Mass Index (BMI) classification: underweight (BMI<18.5 kg/m2: N=17, 0.9%), normal range (BMI 18.5 – 24.99 kg/m2: N=522, 29.4%), overweight (BMI 25 – 29.99 kg/m2: N=796, 44.8%) and obese (>30 kg/m2: N=430, 24.2%). In-hospital outcomes were compared and independent predictors of infection were obtained through multiple Poisson regression with robust variation. Results: Independent predictors of any infection morbidity were female sex (RR 1.47, P=0.002), age > 60 years (RR 1.85, P<0.0001), cardiopulmonary bypass > 120 minutes (RR 1.89, P=0.0007), preoperative myocardial infarction < 30 days (RR 1.37, P=0.01), diabetes mellitus (RR 1.59, P=0.0003), ejection fraction < 48% (RR 2.12, P<0.0001) and blood transfusion (RR 1.55, P=0.0008). Among other variables, obesity, as well as diabetes mellitus, were independent predictors of superficial and deep sternal wound infection. Conclusions: Other factors rather than the anthropometric profile are more important in determining the occurrence of any infection after CABG. However, surgical site infection has occurred more frequently in obese patients. Appropriate patient selection, control of modifiable factors and application of surgical bundles would minimize this important complication.
Background COVID‐19 is usually mild, but patients can present with pneumonia, acute respiratory distress syndrome (ARDS) and circulatory shock. Although the symptoms of the disease are predominantly respiratory, involvement of the cardiovascular system is common. Patients with heart failure (HF) are particularly vulnerable when suffering from COVID‐19. Aim of the Review To examine the challenges faced by healthcare organisations, and mechanical circulatory support management strategies available to patients with heart failure, during the COVID-19 pandemic. Results Extracorporeal membrane oxygenation (ECMO) can be lifesaving in patients with severe forms of ARDS, or refractory cardio-circulatory compromise. The Impella RP can provide right ventricular circulatory support for patients who develop right side ventricular failure or decompensation caused by COVID-19 complications, including pulmonary embolus. HT are reserved for only those patients with a high short-term mortality. LVAD as a bridge to transplant may be a viable strategy to get at-risk patients home quickly. Elective LVAD implantations have been reduced and only patients classified as INTERMACS profile 1 and 2 are being considered for LVAD implantation. Delayed recognition of LVAD‐related complications, misdiagnosis of COVID‐19, and impaired social and psychological well‐being for patients and families may ensue. Remote patient care with virtual or telephone contacts is becoming the norm. Conclusions HF incidence, prevalence, and undertreatment will grow as a result of new COVID-19-related heart disease. ECMO should be reserved for highly selected cases of COVID-19 with a reasonable probability of recovery. Special considerations are needed for patients with advanced HF, including those supported by durable LVADs.