Axillary artery cannulation reduces early embolic stroke and mortality after open arch repair with circulatory arrest

OBJECTIVE: To evaluate the efficacy of axillary artery cannulation for early embolic stroke and operative mortality, we retrospectively compared the outcomes between patients with or without axillary artery cannulation during open aortic arch repair with circulatory arrest. METHODS: Between January 2004 and December 2017, 468 patients underwent open aortic arch repair with circulatory arrest using antegrade cerebral perfusion and were divided into 2 groups according to the site of arterial cannulation: the axillary artery (axillary group, n = 352) or another site (nonaxillary group, n = 116) groups. Embolic stroke was defined as a physician-diagnosed new postoperative neurologic deficit lasting more than 72 hours, generally confirmed by computed tomography or magnetic resonance imaging. RESULTS: After propensity score matching, the patients' characteristics were comparable between the groups (n = 116 in each). The incidences of acute type A dissection, aortic rupture, shock, or emergency operation were similar between groups. The incidence of early embolic stroke was significantly lower in axillary group (n = 3 [2.6%] vs n = 10 [8.6%]; P = .046). Also, 30-day mortality (n = 3 [2.6%] vs n = 10 [8.6%]; P = .046) and in-hospital mortality (n = 3 [2.6%] vs n = 11 [9.5%]; P = .027) occurred significantly lower in the axillary group. CONCLUSIONS: Axillary artery cannulation reduced the early embolic stroke and early mortality after open arch repair with circulatory arrest. Axillary artery cannulation as the arterial cannulation site during open arch repair with circulatory arrest may be helpful in preventing embolic stroke and reducing early mortality.ope

The Effect of Pulsatile Flow on bMSC-Derived Endothelial-Like Cells in a Small-Sized Artificial Vessel Made by 3-Dimensional Bioprinting

Replacement of small-sized vessels is still challenging. This study is aimed at investigating the possibility of small-sized artificial vessels made by 3-dimensional bioprinting and the effect of pulsatile flow on bMSC-derived endothelial-like cells. Cells were harvested from rabbit bone marrow and primary cultured with or without growth factors. Endothelial differentiation was confirmed by the Matrigel tube formation assay, Western blot, and qRT-PCR. In addition, embedment of endothelial-like cells in an artificial vessel was made by 3-dimensional bioprinting, and the pulsatile flow was performed. For pumped and nonpumped groups, qRT-PCR was performed on CD31 and VE-cadherin gene expression. Endothelial-like cells showed increased gene expression of CD31 and VE-cadherin, and tube formation is observed at each week. Endothelial-like cells grow well in a small-sized artificial vessel made by 3-dimensional bioprinting and even express higher endothelial cell markers when they undergo pulsatile flow condition. Moreover, the pulsatile flow condition gives a positive effect for cell observation not only on the sodium alginate hydrogel layer but also on the luminal surface of the artificial vessel wall. We have developed an artificial vessel, which is a mixture of cells and carriers using a 3-dimensional bioprinting method, and applied pulsatile flow using a peristaltic pump, and we also demonstrated cell growth and differentiation into endothelial cells. This study suggests guidelines regarding a small-sized artificial vessel in the field of tissue engineering.ope

Joint Statement of the Korean Society for Thoracic and Cardiovascular Surgery and the Korean Society for Coronary Artery Surgery on Chapter 7.1 in the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions Guideline for Coronary Artery Revascularization

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Effect of postoperative constrictive physiology on early outcomes after off-pump coronary artery bypass grafting.

Abstract BACKGROUND: Constrictive pericarditis after coronary artery bypass surgery has been known to affect cardiac output by limiting diastolic ventricular filling. We aimed to assess the influence of postoperative constrictive physiology on the early outcomes of patients undergoing off-pump coronary artery bypass grafting (OPCAB). MATERIALS AND METHODS: Between January 2008 and July 2011, 903 patients underwent an isolated OPCAB and postoperative transthoracic-echocardiography. The patient cohort was classified into two groups: group A, constrictive physiology and group B, control group without constrictive physiology. Early outcomes were analyzed between the two groups. RESULTS: Of the total 903 patients, group A consisted of 153 patients (16.9%). The amount of blood loss in group A during the postoperative 24 hours was greater than that of group B, but this was not statistically significant (p=0.20). No significant differences were found in the mortality rates (group A, 0.6%; group B, 1.4%; p=0.40) and 30-day major adverse cardiac and cerebrovascular events (MACCEs; group A, 3.3%; group B, 6.1%; p=0.42). CONCLUSION: Postoperative constrictive physiology does not affect 30-day MACCEs or other major complications after OPCAB. The results of this study suggest that patients with early postoperative constrictive physiology do not need medical or surgical treatment, and that conservative care is sufficient.ope

Multimodality Imaging for Successful Surgical Treatment of Giant Cameral Fistula

Background: Symptomatic coronary-cameral fistula was rare, and it is typically treated with transcatheter closure. However, if the anatomy is not suitable for interventional treatment, surgical treatment should be considered. Patient and Methods: We investigated the double giant cameral fistula through multimodality imaging, and planned the surgical closure of the double outlets via the right and left atrium with on-pump beating heart coronary artery bypass grafting. Conclusion: Our procedure was successful without postoperative complication.ope

Clinical Outcomes of Endoscope-Assisted Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension

Purpose: Pulmonary thromboembolism is a potentially life-threatening condition in patients with heart disease; however, limited studies discussing long-term outcomes exist. This study aimed to investigate the long-term outcomes of pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH), focusing on the improvement of functional class and right ventricular (RV) pressure. Materials and methods: Clinical data of patients with CTEPH were obtained from Yonsei Hospital between May 2012 and December 2021, and reviewed retrospectively. Twenty-six patients underwent endoscope-guided PEA during the study period, and the mean follow-up duration was 24.8±23.4 months. Results: After PEA, most patients (88.5%) were weaned from inotropes without extracorporeal membrane oxygenation support during the first few days. Two patients (7.6%) had cerebrovascular accidents without neurological deficits. On echocardiography, the RV systolic pressure and tricuspid regurgitation grades significantly improved (p<0.001). Furthermore, the mean left ventricle end-diastolic diameter was significant increased (p=0.003), and the left ventricular end-systolic diameter increased (p<0.001). The median intensive care unit stay was 3.0±9.4 days, and median hospital stay 16.0±26.5 days. The 5-year survival rate was 95.5%, and the 5-year freedom rate of cardiac death was 100%. There was a marked improvement in New York Heart Association (NYHA) status (p<0.001). Cox regression suggested that the main pulmonary artery (MPA) involvement is a significant predictor of non-improvement in functional class post-PEA. Conclusion: Mortality rates are low and patients experience a marked improvement in NYHA class and health status after PEA. Moreover, MPA involvement may affect functional outcomes.ope

Enhanced Biocompatibility of Multi-Layered, 3D Bio-Printed Artificial Vessels Composed of Autologous Mesenchymal Stem Cells

Artificial vessels capable of long-term patency are essential clinical tools in vascular surgery that involves small vessels. On-going attempts to develop artificial vessels that complements restenosis have not been entirely successful. Here, we report on the fabrication of small-sized artificial vessels using a three-dimensional bio-printer. The fabrication employed biodegradable polycaprolactone and autologous MSCs harvested from the bone-marrow of canines. The MSCs were cultured and differentiated into endothelial-like cells. After confirming differentiation, artificial vessels comprising three-layers were constructed and implanted into the arteries of canines. The autologous MSCs printed on artificial vessels (cell-derived group) maintained a 64.3% patency (9 of 14 grafts) compared with artificial vessels without cells (control group, 54.5% patency (6 of 11 grafts)). The cell-derived vessels (61.9 cells/mm2 ± 14.3) had more endothelial cells on their inner surfaces than the control vessels (21 cells/mm2 ± 11.3). Moreover, the control vessels showed acute inflammation on the porous structures of the implanted artificial vessels, whereas the cell-derived vessels exhibited fibrinous clots with little to no inflammation. We concluded that the minimal rejection of these artificial vessels by the immune system was due to the use of autologous MSCs. We anticipate that this study will be of value in the field of tissue-engineering in clinical practice.ope

Sirolimus-Embedded Silk Microneedle Wrap to Prevent Neointimal Hyperplasia in Vein Graft Model

We investigated the role of a sirolimus-embedded silk microneedle (MN) wrap as an external vascular device for drug delivery efficacy, inhibition of neointimal hyperplasia, and vascular remodeling. Using dogs, a vein graft model was developed to interpose the carotid or femoral artery with the jugular or femoral vein. The control group contained four dogs with only interposed grafts; the intervention group contained four dogs with vein grafts in which sirolimus-embedded silk-MN wraps were applied. After 12-weeks post-implantation, 15 vein grafts in each group were explanted and analyzed. Vein grafts applied with the rhodamine B-embedded silk-MN wrap showed far higher fluorescent signals than those without the wrap. The diameter of vein grafts in the intervention group decreased or remained stable without dilatation; however, it increased in the control group. The intervention group had femoral vein grafts with a significantly lower mean neointima-to-media ratio, and had vein grafts with an intima layer showing a significantly lower collagen density ratio than the control group. In conclusion, sirolimus-embedded silk-MN wrap in a vein graft model successfully delivered the drug to the intimal layer of the vein grafts. It prevented vein graft dilatation, avoiding shear stress and decreasing wall tension, and it inhibited neointimal hyperplasia.ope

Hemostatic efficacy of a flowable collagen-thrombin matrix during coronary artery bypass grafting: a double-blind randomized controlled trial

Background: Flowable hemostatic agents have the advantage of being able to be applied to irregular wound surfaces and difficult to reach areas. We sought to compare the effectiveness and safety of the flowable hemostatic sealants Collastat® (collagen hemostatic matrix, [CHM]) and Floseal® (gelatin hemostatic matrix, [GHM]) during off-pump coronary artery bypass (OPCAB). Methods: In this prospective, double-blind, randomized controlled trial, 160 patients undergoing elective OPCAB surgery were enrolled between March 2018 and February 2020. After primary suture of the aortocoronary anastomosis, an area of hemorrhage was identified, and patients received either CHM or GHM (n = 80, each). Study endpoints were the following: proportion of successful intraoperative hemostasis and time required for hemostasis overall postoperative bleeding, proportion of transfusion of blood products, and surgical revision for bleeding. Results: Of the total patients, 23% were female, and the mean age was 63 years (range 42-81 years). Successful hemostasis proportion within 5 min was achieved for 78 patients (97.5%) in the GHM group, compared to 80 patients (100%) in the CHM group (non-inferiority p = 0.006). Two patients receiving GHM required surgical revision to achieve hemostasis. There were no differences in the mean time required to obtain hemostasis [GHM vs. CHM, mean 1.49 (SD 0.94) vs. 1.35 (0.60) min, p = 0.272], as confirmed by time-to-event analysis (p = 0.605). The two groups had similar amounts of mediastinal drainage for 24 h postoperatively [538.5 (229.1) vs. 494.7 (190.0) ml, p = 0.298]. The CHM group required less packed red blood cells, fresh frozen plasma, and platelets for transfusion than the GHM group (0.5 vs. 0.7 units per patient, p = 0.047; 17.5% vs. 25.0%, p = 0.034; 7.5% vs. 15.0%, p = 0.032; respectively). Conclusions: CHM was associated with a lower need for FFP and platelet transfusions. Thus, CHM is a safe and effective alternative to GHM. Trial registration: ClinicalTrials.gov, NCT04310150.ope

Chondrosarcoma of the Heart

Chondrosarcoma is a rare entity of malignant tumor which arises from cartilaginous tissue, and the literatures on this disease are scarce. The first-line of treatment for cardiac chondrosarcoma is surgery. Due to early local recurrence and distant metastasis, the prognosis is poor even after complete surgical excision. We present a case of chondrosarcoma in the left atrium causing functional mitral stenosis which required urgent surgical intervention, and the successful treatment outcome.ope