Frozen elephant trunk versus conventional proximal repair of acute aortic dissection type I

Objective

The extent of surgery and the role of the frozen elephant trunk (FET) for surgical repair of acute aortic dissection type I are still subjects of debate. The aim of the study is to evaluate the short- and long-term results of acute surgical repair of aortic dissection type I using the FET compared to standard proximal aortic repair.

Methods

Between October 2009 and December 2016, 172 patients underwent emergent surgery for acute type I aortic dissection at our center. Of these, n = 72 received a FET procedure, while the other 100 patients received a conventional proximal aortic repair. Results were compared between the two surgery groups. The primary endpoints included 30-day rates of mortality and neurologic deficit and follow-up rates of mortality and aortic-related reintervention.

Results

Demographic data were comparable between the groups, except for a higher proportion of men in the FET group (76.4% vs. 60.0%, p = 0.03). The median age was 62 years [IQR (20), p = 0.17], and the median log EuroSCORE was 38.6% [IQR (31.4), p = 0.21]. The mean follow-up time was 68.3 ± 33.8 months. Neither early (FET group 15.3% vs. proximal group 23.0%, p = 0.25) nor late (FET group 26.2% vs. proximal group 23.0%, p = 0.69) mortality showed significant differences between the groups. There were fewer strokes in the FET patients (FET group 2.8% vs. proximal group 11.0%, p = 0.04), and the rates of spinal cord injury were similar between the groups (FET group 4.2% vs. proximal group 2.0%, p = 0.41). Aortic-related reintervention rates did not differ between the groups (FET group 12.1% vs. proximal group 9.8%, p = 0.77).

Conclusion

Emergent FET repair for acute aortic dissection type I is safe and feasible when performed by experienced surgeons. The benefits of the FET procedure in the long term remain unclear. Prolonged follow-up data are needed.

The phenomenology of pareidolia in healthy subjects and patients with left- or right-hemispheric stroke

Pareidolia are perceptions of recognizable images or meaningful patterns where none exist. In recent years, this phenomenon has been increasingly studied in healthy subjects and patients with neurological or psychiatric diseases. The current study examined pareidolia production in a group of 53 stroke patients and 82 neurologically healthy controls who performed a natural images task. We found a significant reduction of absolute pareidolia production in left- and right-hemispheric stroke patients, with right-hemispheric patients producing overall fewest pareidolic output. Responses were categorized into 28 distinct categories, with 'Animal', 'Human', 'Face', and 'Body parts' being the most common, accounting for 72% of all pareidolia. Regarding the percentages of the different categories of pareidolia, we found a significant reduction for the percentage of "Body parts" pareidolia in the left-hemispheric patient group as compared to the control group, while the percentage of this pareidolia type was not significantly reduced in right-hemispheric patients compared to healthy controls. These results support the hypothesis that pareidolia production may be influenced by local-global visual processing with the left hemisphere being involved in local and detailed analytical visual processing to a greater extent. As such, a lesion to the right hemisphere, that is believed to be critical for global visual processing, might explain the overall fewest pareidolic output produced by the right-hemispheric patients.

Minimally invasive strategies of surgical coronary artery revascularization for the aging population

BACKGROUND

The increasing prevalence of elderly or frail patients with severe coronary disease, who are not suitable for interventional coronary revascularization, necessitates the exploration of alternative treatment options. A less invasive approach, such as minimally-invasive off-pump coronary-artery-bypass (MICS-CABG) grafting through mini-thoracotomy, which avoids both extracorporeal circulation and sternotomy, may be more appropriate for this patient population. This study, a retrospective, monocentric analysis, aimed to evaluate the long-term outcomes of these patients.

METHODS

The study included 172 patients aged 80 years or older, who underwent MICS-CABG between 2007 and 2018. The patients underwent single, double, or triple-vessel revascularization using the left internal thoracic artery, and in some cases, the radial artery or saphenous vein. Follow-up, mean duration of 50.4±30.8 months, was available for 163 patients (94.7%).

RESULTS

The mean age of the patients was 83.2±3.0 years, 77.3% of them were male. The EuroSCORE I additive was 11.0±12.1. There were no conversions to sternotomy or cardiopulmonary-bypass. The postoperative 30-day mortality rate was 2.9%, with 5 deaths. The in-hospital rate of major adverse cardiac and cerebrovascular events was 4.7% (perioperative myocardial infarction 1.2%, perioperative stroke 2.3%, repeat revascularization 1.2%). Acute renal kidney injury, (stage 3 KDOQI or more), occurred in 5 patients (2.9%) and new-onset atrial fibrillation in 6 patients (3.5%). The 1-, 3-, 5- and 8-year actuarial survival rate of the 30-day survivors was 97%, 82%, 73%, and 42%, respectively.

CONCLUSIONS

MICS-CABG grafting is associated with excellent early and long-term outcomes in eligible octogenarians.

Concomitant intra-atrial excision of the left atrial appendage during robotic-assisted minimally invasive cardiac surgery

Objective

Surgical closure of the left atrial appendage (LAA) in patients with atrial fibrillation undergoing cardiac surgery can decrease the risk of stroke and thromboembolism and should therefore be considered. In minimally invasive, thoracoscopic, or robotic-assisted mitral valve surgery, however, external procedures such as clip application or epicardial resection are not feasible due to anatomic limitations and the reduced size of the access port. Internal suture closing techniques bear the risk of recurrent LAA reperfusion, so far. We present a novel surgical technique of LAA excision and subsequent defect closure from the interior aspect of the atrium.

Methods

We developed this novel technique during robotic-assisted cardiac surgeries. In short, the LAA is invaginated into the left atrium, excised completely at the base using scissors and the stump is then closed from the inside with a two-layer looped PTFE suture. We give a detailed step-by-step description of the technique.

Results

A total of 20 patients received intra-atrial LAA excision so far. Complete resection of the LAA without any residual stump or bleeding was achieved in all cases. There were no procedure-related complications.

Conclusion

The intra-atrial LAA excision technique shows promising preliminary results regarding efficacy, safety, and reproducibility during robotic-assisted cardiac operations and could be recommended for all right-sided minimally invasive cardiac surgical procedures.

Surgical atrial appendage closure: time for a randomized study

Atrial fibrillation (AF) is the most common arrhythmia and is assumed to affect more than 30 million people worldwide. Studies report that the left atrial appendage (LAA) plays an important role in thrombus formation and is considered the embolic source in 90% of affected patients with non-valvular and 57% with valvular AF. Oral anticoagulants have been the standard of care for stroke prevention in patients with AF for decades. However, bleeding complications and noncompliance are barriers to effective embolic protection. Therefore, as an alternative to conventional anti-thrombotic therapy, surgical LAA occlusion, which may lead to a reduced risk of thromboembolism, has received increasing attention. However, the procedure can be associated with additional risks such as prolonged operation time, damage to the circumflex coronary artery, and incomplete LAA occlusion. This review discusses some of the observational studies that have examined the impact of LAA occlusion on stroke, the LAAOS III (Left Atrial Appendage Occlusion Study) trial, which provided definitive evidence for the benefit of surgical LAA occlusion on ischemic stroke, which surgical methods are safe and effective for LAA occlusion, and whether oral anticoagulation can be stopped after surgical removal of the LAA.

OUP accepted manuscript

We report about a 61-year-old man who, 6 years after initial uncomplicated mitral valve repair and 3 months after treatment of a pseudo-aneurysm of the ascending aorta with a Dacron patch, was admitted in our institution with an infection of the vascular graft, which was associated with sternal osteomyelitis and purulent cutaneous fistula. In a re-redo procedure, the proximal aortic arch and the ascending aorta were replaced with a cryopreserved aortic homograft. The infected part of the sternum was resected and the defect was covered by mobilizing the mediastinal tissue and with a bilateral muscle flap. The patient was discharged 20 days after surgery. This treatment concept outlines the benefit of cryopreserved aortic homograft when faced with a complex thoracic aortic infection.

Under-recognition of Acute Kidney Injury after Cardiac Surgery in the ICU Impedes Early Detection and Prevention

BACKGROUND

Acute kidney injury (AKI) is associated with high morbidity and mortality; therefore, prevention is important. The aim of this study was to systematically assess AKI incidence after cardiac surgery as documented in clinical routine compared to the real incidence because AKI may be under-recognized in clinical practice. Further, its postoperative management was compared to Kidney Disease: Improving Global Outcomes (KDIGO) recommendations because recognition and adequate treatment represent the fundamental cornerstone in the prevention and management of AKI.

METHODS

This retrospective single-center study included n = 100 patients who underwent cardiac surgery with cardiopulmonary bypass. The coded incidence of postoperative AKI during intensive care unit stay after surgery was compared to the real AKI incidence. Furthermore, conformity of postoperative parameters with KDIGO recommendations for AKI prevention and management was reviewed.

RESULTS

We found a considerable discrepancy between coded and real incidence, and conformity with KDIGO recommendations was found to be relatively low. The coded incidence was significantly lower (n = 12 vs. n = 52, p < 0.05), representing a coding rate of 23.1%. Regarding postoperative management, 90% of all patients had at least 1 episode with mean arterial pressure <65 mm Hg within the first 72 h. Furthermore, regarding other preventive parameters (avoiding hyperglycemia, stopping angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, avoiding contrast media, and nephrotoxic drugs), only 10 patients (20.8%) in the non-AKI group and in 5 (9.6%) subjects in the AKI group had none of all the above potential AKI-promoting factors.

CONCLUSIONS

AKI recognition in everyday clinical routine seems to be low, especially in lower AKI stages, and the current postoperative management still offers potential for optimization. Possibly, higher AKI awareness and stricter postoperative management could already achieve significant effects in prevention and treatment of AKI.

Novel Blood Biomarkers for a Diagnostic Workup of Acute Aortic Dissection

Acute aortic dissection (AAD) is a rare condition, but together with acute myocardial infarction (AMI) and pulmonary embolism (PE) it belongs to the most relevant and life-threatening causes of acute chest pain. Until now, there has been no specific blood test in the diagnostic workup of AAD. To identify clinically relevant biomarkers for AAD, we applied Proseek^® Multiplex assays to plasma samples from patients with AAD, AMI, PE, thoracic aortic aneurysm (TAA), and non-cardiovascular chest pain (nonCVD). Subsequently, we validated top hits using conventional immunoassays and examined their expression in the aortic tissue. Interleukin 10 (IL-10) alone showed the best performance with a sensitivity of 55% and a specificity of 98% for AAD diagnosis. The combination of D-dimers, high-sensitive troponin T (hs-TnT), interleukin 6 (IL-6), and plasminogen activator inhibitor 1 (PAI1) correctly classified 75% of AAD cases, delivering a sensitivity of 83% and specificity of 95% for its diagnosis. Moreover, this model provided the correct classification of 77% of all analyzed cases. Our data suggest that IL-10 shows potential to be a rule-in biomarker for AAD. Moreover, the addition of PAI1 and IL-6 to hs-TnT and D-dimers may improve the discrimination of suspected AAD, AMI, and PE in patients presenting with acute chest pain.

P0630EARLY CHANGES OF SEQUENTIAL URINE SEDIMENT ANALYSIS ARE INDICATIVE FOR DEVELOPMENT OF ACUTE KIDNEY INJURY AFER CARDIAC SURGERY

Background and Aims

Microscopic examination of urine sediment is a well-established and inexpensive technique for differential diagnosis of acute kidney injury. Especially renal tubular epithelial cells (RTEC) and granular casts (GC) have been shown to be a strong predictor of acute tubule necrosis (ATN), the assumed most common cause for AKI in cardiac surgery patients. So far, no study evaluated urine sediment before manifest AKI is evident. Therefore, the aim of this prospective trial was to evaluate if early changes of urine sediment parameters are indicative for development of acute kidney injury.

Method

Sequential urine sediment specimens were analyzed on day 0 (d0), day 1 (d1) and day 4 or 5 (d5) after cardiac surgery in n=37 patients. Urine analysis was conducted immediately after collection of urine specimens. Analysis includes detection of RTEC and GC as well as hyaline casts (HC), squamous epithelium (SE), erythrocyte count (EC) and leucocyte count (LC). Urine score (US) - consisting of RTEC and GC - which is described as indicative for ATN, was calculated as described previously. For detection of AKI, serum creatinine, serum cystatin c and urine output were recorded. Urine sediment changes over time were analyzed using differences between day of surgery (d0) and day 1 (d0-d1 = Δd1) or day 5 (d0-d5 = Δd5), respectively.

Results

Of the 37 included patients n=10 (27%) developed AKI within 5 days. According to the definition of KDIGO 2012, two patients developed Stage 1 (20%), six patients Stage 2 (60%) and two patients Stage 3 (20%) AKI. Median age was 67 years (IQR: 63.5-73.0). Mean HC, GC, RTEC and US tended to be higher in AKI patients from day one after surgery. Looking at the urine sediment changes over time (Median; IQR), Δd1 of RTEC (AKI: 0.65; 0.00 – 1.15 vs. No AKI: 0.00; -0.03 – 0.03; p=0.010), GC (AKI: 0.25; 0.00 – 0.50; No AKI: 0.00; -0.20 – 0.00; p=0.002) and US (AKI: 0.00; -0.25 – 0.00 vs. No AKI: 0.00; 0.00 – 1.00; p=0.047) were significant higher in AKI group. Also HC (AKI: 1.00; 0.00 – 1.00; No AKI: 0.00; -1.25 – 1.00; p&gt;0.05) tended to be higher in AKI on Δd1, whereas SE, EC and LC did not show any trend between both groups. Δd5 did not show any significant result between AKI and non-AKI. Because all of these patients were catheterised, the results on urinary erythrocyte count were interpreted with appropriate caution.

Conclusion

This is the first study evaluating sequential urine sediment measurements for early detection of AKI in cardiac surgery. According to these preliminary data, Δd1 of RTEC, GC and US is significant higher in AKI, suggesting that an increase from day of surgery to day 1 may be indicative for the development of AKI right before manifest AKI is evident. Therefore sequential urine sediment measurements could be useful for early detection of AKI after cardiac surgery.

Cardiogenic Shock Due to Leaflet Migration of On-X Aortic Mechanical Prosthesis

Cardiogenic shock is a life-threatening condition requiring fast and efficient diagnostic and therapeutic measures. In this case, the history of several cardiac surgeries hindered finding the correct diagnosis initially. After an ultima ratio cardiac redo operation the underlying cause was found intraoperatively: a defective mechanical valve prosthesis with migration of one of the two leaflets. Strikingly, this happened with a contemporary On-X prosthesis only 4 years after implantation. Timely echocardiography is of utmost importance in patients with prosthetic heart valves presenting in heart failure.

Results and Quality of Life after Minimally Invasive Ross Procedure

BACKGROUND AND AIM OF THE STUDY

Based on superior long-term results, an increasing interest in the Ross procedure for young adult patients can be observed. After the first publication of this challenging procedure through a minimally invasive access, this operation has become an alternative to conventional sternotomy at the authors' department. This analysis compares the results and quality of life of the conventional and the minimally invasive Ross procedures.

METHODS

By April 2013, a total of 136 patients had undergone the Ross procedure at the authors' institution. Preoperative parameters did not differ between the conventional group (C-group; n = 58; mean age 49 years) and the minimally invasive group (M-group; n = 78; mean age 50 years). Only the aortic cross-clamp time was longer for the M-group (151 versus 140 min).

RESULTS

One C-group patient died on the day of operation. Consecutively, survival was 99% for the follow up period of 1,093 ± 601 days. Valve-related reoperations were necessary for four patients. One C-group patient developed a distal pulmonary stenosis due to fibrotic scar tissue. Two M-group patients showed fistulas after early endocarditis, but the native valves could be preserved in these cases. One C-group patient with recurrent severe aortic regurgitation showed holes in two of three cusps. The SF-36 questionnaire detected better physical parameters (physical function, physical role function) for patients after minimally invasive access.

CONCLUSION

The minimally invasive Ross procedure allows the same excellent clinical outcome as the conventional technique. However, the physical quality of life is better with the minimally invasive procedure, in addition to an improved cosmetic result.

[Infectious agents in ocular adnexal tumours]

In recent years, infectious agents have been increasingly recognised as an important pathogenetic factor for various malignant tumours of the ocular adnexa. Many of these viruses and bacteria affect the cell cycle and physiological apoptosis. Ocular adnexal lymphoma (OAL), especially extranodal marginal cell lymphoma, is associated with Chlamydophila psittaci and Helicobacter pylori in certain geographic regions. Epstein-Barr virus seems to play a role in the natural killer/T-cell lymphoma subtype of the orbit, as has long been described for Burkitt lymphoma. Bacteria seem to induce reactive lymphoid proliferation, while viruses directly infect the lymphoid cells, affecting the cell cycle and suppressing apoptosis, with subsequent malignant transformation. In general, proteins leading to cell cycle progression, like retinoblastoma protein, are elevated, and proteins inhibiting cell cycle progression, like p16 and p21, are absent or unable to function normally. Inactivation of p53 by mutation of its DNA, which leads to elevation of defective p53 protein and inhibition of apoptosis, allows oncogenic by-chance mutations to become effective. Conjunctival intraepithelial neoplasia (CIN) is less strongly associated with HPV infection than is cervical intraepithelial neoplasia. Based on the localisation of CIN, ultraviolet B radiation seems to play a primary role, leading to p53 inactivation and subsequent inhibition of apoptosis. HIV positivity also seems to aid the development of CIN and conjunctival squamous cell carcinoma, with an increasing number of cases during recent years. Kaposi sarcoma rarely occurs at the ocular adnexa in HIV-positive individuals and seems to be associated with Kaposi sarcoma-associated Herpes virus (KSHV) or HHV8. The KSHV-encoded latency associated nuclear antigen (LANA) protein binds to the negative regulator glycogen-synthase kinase-3 (GSK-3), causing a cell cycle-dependent nuclear accumulation of GSK-3, which stabilises beta-catenin and increases its levels. The findings regarding these various infectious agents and cell cycle alterations might aid the development of new therapeutic strategies.

[An 85-year-old patient with recurrent episodes of confusion and absences]

Verwirrte Patienten sind in Klinik und Praxis häufig. Ihre Behandlung erfordert eine sorgfältige klinische Evaluation, um auch seltenere Ursachen zu erfassen. Differentialdiagnostisch sollte stets an die Hypoglykämie gedacht werden, die selten einmal durch ein Insulinom verursacht wird. Charakteristisch für das Insulinom sind neuroglykopenische Symptome wie Verwirrung, Seh- und Sprachstörungen, ungewöhnliches Verhalten, Agitation, Krampfanfälle, Koma und fokale neurologische Symptome. Diese treten bei einem Blutzucker unter 2.5 mmol/l auf. Bei nicht weniger als 20% der Patienten werden die Symptome als neurologische oder psychiatrische Erkrankung verkannt. Vor allem bei älteren Menschen wird die Diagnose des Insulinoms oft erst verzögert gestellt. Diagnostisch ist ein inadäquat hohes Serum-Insulin während einer spontanen Hypoglykämie oder im Fastentest.