Cardiac Surgery
Misc
Left pericardiotomy for prevention of POAF - Video
- Myocardial protection
Suboptimal cardioplegia delivery is a problem that results in short and long term cardiac dysfunction, primarily in the septum which is wholly subendocardial. The septum is responsible for about 80% of RV function and a considerable deal of LV function.
Delivery:
Antegrade vs retrograde (suboptimal with coronary stenoses vs unreliable for right protection) in vs mixed
Warm vs cold (vs ischemic protection)
Continuous vs intermittent (optimal protection vs bloodless surgical field)
Hot shot - Controlled reperfusion with 3-5 minutes of warm cardioplegia before releasing clamp, shown to reduce mortality.
Solution:
Blood vs crystalloid (Blood is superior, oxygen delivery, limitation of hemodilution, buffering)
Meta analysis: Decreased Low Output Syndrome (OR 0,54), reduced CKMB release, similary MI and mortality)
Polarizing vs non polarizing
Strategy
Integrated method - Mix of antegrade/retrograde, warm induction -> cold cardioplegia -> Hot shot, intermittent/continuous. Shown to minimize mortality and post op cardiac dysfunction
Warm induction - Active resuscitation for energy depleted hearts before asystole. Seems to lower mortality in marginal hearts
Retrograde cardioplegia - Technique
- CPB
Hage - Hypothermic circulatory arrest: >24 degrees is better than below, antegrade or retrograde cerebral perfusion is protective against death and stroke
Cytosorb - 60 patients - Mitral endocarditis, retrospective, Post op sepsis:16,7/39,3%, Sepsis mortality: 0/17,9%, Mortality 10/17,9%,
Anti thrombin 3 for Heparin Resistance - AT3 MOA: Natural anticoagulant, inhibits thrombin and other factors, activity enhanced by heparin.
Heparin resistance = Failure to achieve ACT 600 with 600 U/kg heparin (skv fyrstu greininni). Solved with 500-1000 U of antithrombin III. Antithrombin is present in FFP as well.
Mechanism of heparin resistance: Subnormal AT3 activity due to acquired AT3 deficiency resulting from prior heparin exposure
- Technical
Needle types - Rb-2 (Minni) og V-7 (stærri)
- Complications
Iatrogenic Aortic Dissection: 0,06% of ascending aortic cannulation, 0,6% in femoral cannulation and 0,5% axillary cannulation. Mortality is estimated at 30%.
-Post Operative
Post operative atrial fibrillation and anticoagulation: New onset POAF after CABG vs NVAF, cohort. Anticoagulation:8,4%/42,9%, Thromboembolism HR: 0,67, thromboembolism risk was similar for postop patients with or without POAF. New onset POAF after CABG does not need anticoagulation.
Postcardiotomy syndrome - Systematic Review: Retrospective studies,
Definition: 2 of 5 criteria (new or worsening pericardial effusion, new or worsening pleural effusion, fever without an alternative cause, pleuritic chest pain, pleural/pericardial rubbing)
Median incidence: 16%, unclear pathophysiology, higher incidence with younger age, lower BMI and history of pericarditis
EACTS perioperative medication guidelines:
Aspirin: Decreased early mortality after CABG (1,3%/4,0%), myocardial infarction (2,8%/5,4%), stroke (1,3%/2,6%), renal failure (0,9%/3,4%)
Rec: Preoperative and early postoperative administration of ASA, continued indefinitely (Clopidogrel is an acceptable alternative)
CABG
EACTS guidelines on myocardial revascularization
Precondition with Levosimendan in low cardiac output (EF>40%) patients (n=54)
48 hour preconditioning, infusion without loading dose. Historic cohort compared with prospective cohort (Simdax arm)
Simdax/Control - Postop low cardiac output (15,4%/61%), shorter ICU LOS (2d/4d)
- Technical
Coronary endarterectomy technique and postoperative treatment - Video
Total arterial revasc - Technique
Radialis harvesting - Technique
Harvesting of the Gastroepiploic Artery
Intraoperative Graft Patency Validation
TTFM (Flödemätare): Flow: Acceptable >20 mL/min, Pulsatility Index (resistance measure): Ideally <3, acceptable <5
The Use if Intraoperative Transit Time Flow Measurement for CABG - Systematic review & Expert opinion
Pulsatility Index (PI): Delta(peak flow & minimum flow)/Mean graft flow. Represents an estimate of flow resistance
Put probe on the grafts perpendicularly, that is: on a straight graft, without the graft bending
Interpretation of TTFM should happen in the context of what was expected (size of runoff and so on)
Place probe distally if possible
A MGF of >15-20 ml/min and PI <3 (<5 for RCA) Should prompt suspicion of graft malfunction
- Patient Selection
State-of-the-Art Coronary Artery Bypass Grafting - Review
Gaudino et al - CABG vs PCI - Meta Analysis all RCTs, N: 13 260, follow-up: 5,3 yrs, HR all-cause mortality 1,17, cardiac mortality 1,24
Sabatine et al - CABG vs PCI Left main, all RCTs, N: 4394, 5 year mortality 10,2% vs 11,2%, 0,2% difference per year. Higher risks of repeat revasc or myocardial infarction, no difference in stroke
Left main disease
NOBLE - PCI vs CABG for left main stenosis - at 5 years (2020)
600 vs 600 patients. MACCE 28% vs 19%, mortality 9% vs 9%, Later myocardial infarct 8% vs 3%, repeat revasc 17% vs 10%
EXCEL - PCI vs CABG for left main stenosis - at 5 years (2019)
950 vs 950 patients, low or intermediate complexity. Mortality 13% vs 9,9% (NS), stroke 2,9% vs 3,7% (NS), repeat revasc 16,9% vs 10%
PCI or CABG for left main coronary artery disease: the SWEDEHEART registry - (2023)
Retrospectively, all patients undergoing PCI or CABG for left main stenosis, Sweden 2005-2015 (11 137 pts). IPW analysis, Mortality HR 1,5, MACCE HR 2,8.
EACTS/ECS LM recommendations: Review of NOBLE/EXCEL as well as review of PRECOMBAT/SYNTAX
Multivessel disease
SYNTAX - 1800 patients, RCT, 3 vessel disease and/or left main disease, CABG or PCI with 1st gen DES (MACCE includes repeat revasc)
1 yr follow up (2009) (CABG/PCI): Death (%) 3,5/4,4 (NS), MACCE (%) 17,8/12,4, Stroke (%) 2,2/0,6, Repeat revasc (%) 13,5/5,9
3 yr follow up (2011) (CABG/PCI): Death (%) 6,7/8,6 (NS), MACCE (%) 20,2/28,0, Stroke (%) 3,4/2,0 (NS), Repeat revasc (%) 10,7/19,7
5 yr follow up (2013) (CABG/PCI): Death (%) 9,2/14,6, MACCE (%) 24,2/37,5, Stroke (%) 3,5/3,0 (NS), Repeat revasc (%) 12,6/25,4
10 yr follow up (2019) (CABG/PCI): Death (%) 24/28 (NS)
Freedom trial - RCT, 1900 patients with diabetes and multivessel disease, CABG vs PCI (DES)
2 yr follow up (2012) (CABG/PCI): RCT, N:1900, Median follow-up 3,8 yr. Death (%) 10,9/16,3, MACCE (%) 18,7/26,6, Stroke (%) 5,2/2,4, Later Myocardial Infarction (%) 6,0/13,9
10 year follow-up (FREEDOM Follow-On study) (2019) N: 943, Mortality HR 1,36 , 23,7%/18,7%
FAME 3 - RCT, 1500 pat with 3VD (CABG/FFR guided PCI)
1 year follow-up (2021) Composite (death, myocardial infarction, stroke) 6,9%/10,6% (HR 1,5), Death 0,9%/1,6% (HR 1,7), Stroke 1,1%/0,9% (HR 0,9), Repeat revasc 3,9%/5,9% (1,5)
Left Ventricular Dysfunction
STICH Trial - RCT, 1212 patients with EF => 35% and CAD (2002-2007) randomized to CABG or medical therapy
5 yr follow up (2011) - Death (%) 36/41 (NS), Cardiovascular death (%) 28/33
10 yr follow-up (2016) - Death (%) 58,9/66,1, Cardiovascular death (%) 40,5/49,3
REVIVED trial - RCT, 700 pts with EF <35%, PCI vs medical therapy
No mortality difference (31,7% vs 32,6% mortality at 41 month follow up)
Completeness of revascularization
Post hoc Syntax Extended Study: PCI vs CABG, more often incomplete revasc in PCI (56,6%/36,8%)
Increased 10 yr mortality with incomplete revascularization with PCI compared with CABG(33,5%/23,7%)
Retrospective, weighted analysis of completeness of revascularization
889/2467 patients (incomplete/complete revasc) - 5 yr survival 82,1% vs 86,5%
Stable Angina
ISCHEMIA trial: RCT, N: 5200, Conservative vs invasive (PCI 75%/CABG 25%) for stable angina, no difference in mortality at 3,2 years follow-up
- Conduits
Conduit selection:
SVG
CABG RCT APT vs DAPT: 1 year SVG failure rate was around 12-14%
Aortocoronary Saphenous Vein Graft Disease - 6/10 year patency of SVG - 75%/60%
No touch versus conventional SVG: RCT, N:2655, Outcome: CT angio occlusion at 12 months (3,7% vs 6,5%, OR 0,56), Recurrence of angina (OR 0,55)
LIMA
LIMA vs SVG: N: 6000, 10 year mortality 93,4%/88 % fyrir 1 vessel disease, 90%/79,5% f 2VD, 82,6%/71,0% f 3VD, RR for mortality 1,61
BIMA
BIMA (ART trial) - BIMA vs LIMA, N: 1548. Enginn mortality munur vid 10 ar, enginn munur á composite outcome vid 10 ar, Crossover meaning that as-treated analysis showed a HR of 0,81
Radialis
10 yr follow up: a. Radialis compared with SVG, Composite death/Myocardial infarction (HR 0,77), Death (0,73) (Post hoc), myocardial infarction (HR 0,74), repeat revasc (HR 0,62)
RAPCO trial: 394 pat <70 yr randomized between RITA and a. Radialis for second graft and 225 pat <70 yr RA vs SVG
10 year patency (RITA/RA) 80%/89% (HR 0,45 for graft failure), 10 yr survival 83,7%/90,9% (HR 0,53 for 10 yr mortality)
10 year patency (SVG/RA) 71%/85% (HR 0,40 for graft failure), 10 yr survival 65,2%/72,6% (HR 0,76 for 10 yr mortality)
15 year patency (RITA/RA) 15 yr survival 70%/78% (HR 0,69)
15 year patency (SVG/RA) 15 yr survival 37%/48% (HR 0,74)
Radial artery vs SVG: Meta analysis, 1036 patients, mean follow up 5 years, lower risk of occlusion (HR 0,44), myocardial infarction (HR 0,72) and repeat revasc (HR 0,5) but not death (0,9)
Gaudino et al: Meta analysis, N: 1000, median follow up 10 years, Composite OR 0,73, Death HR 0,73
Any Arterial
Rocha et al - Retrospective, prop match, arterial vs SVG: 2132 patient pairs - Óbreytt early mortality, MACCE RR: 0,78, death RR: 0,8, reinfarct RR 0,69
TAG
Velja arterial grafting hja yngri sjuklingum med high grade stenosis (eykur patency a arterial gröftum)
FFR should not control graft targets but may be of use in conduit selection. Stenoses with a highly significant FFR gradient are more amenable to arterial grafts than borderline significant stenoses, which should probably receive SVG
Intracoronary stent restenosis - UpToDate
BMS > Usually develops restenosis early, 6-12 months - 12-14% requires reintervention at one year, HR after that 1,7% annually
DES > 1st gen restenosis rate 13-16% at 5 years, 2nd gen restenosis rate 5-6,3% at 5 years
Endoscopic vs conventional SVG - Ekki significant munur á primary outcome né fótasýkingum
Vein mapping of the Saphenous Vein - Technique
- Prognosis
Aortic valve
- Technical
Aortic Root Enlargement - Nicks/Manougian
Aortic annular enlargement - Y incision (modified Nicks)
David Aortic root reconstruction - Incl how to make the coronary buttons
- Patient selection
Asymptomatic severe aortic stenosis - Intervention of conservative care - RCT, N:145, asymptomatic patients with very severe aortic stenosis
Minna mortality með aðgerð en conservative, 6 ára follow up, Mortality 7% vs 21%, favouring surgery
Severe aortic stenosis, RCT, Intermediate risk patients(4-8% 30d mortality) (Partner 2, sponsored by TAVI company):
More crossover in surgery group (7,5%vs 1,7%)
2 year: (sAVR/TAVI%): Death 18/16,7, stroke 8,9/9,5, Aortic valve reintervention 0,5/0,7, A fib 27,5/11,5
5 year: (sAVR/TAVI%): Death 42,1/46, stroke 12,5/15,3, Aortic valve reintervention 0,8/3,2, A fib 30,4/15,8
Severe aortic stenosis, RCT, low-risk patients (<4% 30d mortality) (Partner 3, sponsored by Edwards)
1000 patients, TAVR vs sAVR, 8,6% withdrawal from sAVR group, 1,4% from TAVR group, concomitant procedures in 26,4% sAVR group, 7,9% TAVR group, mean age 73 years, STS score 1,9%
1 year: (sAVR/TAVR%): Death 2,5/1,0 (NS), Stroke 3,1/1,2 (NS), Death or disabling stroke 3,1/1,0, composite endpoint (death, stroke, rehospitalization) 15,1/8,5
2 year: (sAVR/TAVR): Death 3,2/2,4 (NS), Stroke 3,6/2,4 (NS), Death or disabling stroke 3,8/3,0 (NS), composite endpoint (death, stroke, rehospitalization) 17,1/11,5
Study outcome variables are diverging, The Mean gradient is statistically but not clinically significant (11,8/13,6), favoring surgery, PVL 2,3/26,0
5 year: (sAVR/TAVR): Death 8,2/10 (NS), Stroke 6,4/5,8 (NS), Death or disabling stroke Not reported?, composite endpoint (death, stroke, rehospitalization) 27,2/22,8 (NS)
Severe Aortic Stenosis, RCT, Low-risk patients (Evolut Low Risk). STS score 1,9-2. 1400 patients
4 year: (sAVR/TAVR): Death 12,1/9,0 (NS), Stroke 3,8/2,9 (NS), Composite (Death/Stroke) 14,1/10,7
Severe aortic stenosis, STS Registry, Low-risk patients, 42 500 patients, 8 year follow-up
Same inclusion criteria as Partner 3/Evolut Low Risk. 1, 3, 5, 8-year mortality (2,6%, 4,5%, 7,1%, 12,4%). Dramatically less than industry-sponsored RCTs
Severe aortic stenosis, RCT sAVR/TAVI, intermediate-risk patients (STS 4,5±1,6%, 79,8±6,2 years), N: 1660 (SURTAVI)
2 year follow-up: Mortality 11,6%/11,4% (NS), Stroke 8,4%/6,2% (NS)
5-year follow-up: Presented at TCT 2021, Mortality 30,8%/31,3% (NS)
Severe aortic stenosis, RCT, >69 years, all-comers (Notion): TAVI/sAVR, 280 patients, 79,1±4,8 years old, STS score 3±1,7%
1 year follow-up: Mortality 4,9%/7,5% (NS), Stroke 2,9%/4,6% (NS)
5-year follow-up: Mortality 27,6%/28,9% (NS), Stroke 9%/7,4% (NS), Lower gradients in TAVI group, 8,2% developed moderate/severe AI vs none in surgical group, more pacemakers in TAVI group, more atrial fibrillation in sAVR group
10-year follow-up: Mortality 62,7%/64,0% (NS), Stroke 9,7%/16,4% (NS) More severe SVD in SAVR group (10% vs 1,5%), more PVL in TAVI (18% vs 5,2%). Same IE risk, 7,3%
Meta analysis of 6 RCTs, >6 000 patients, TAVI/SAVR
Lower 1 year mortality, HR 0,85
Superior results after 40 months, for SAVR. HR 1,31 (40-60 months)
- Prosthesis/Technique selection
mAVR/bAVR in non-elderly - Minnkað life expectancy með báðum týpum
bAVR - Mortality risk: 2,39%/year, reintervention: 1,82%/year, structural valve deterioration 1,59%/year, thromboembolism 0,53%/year, endocarditis: 0,48%/year,
mAVR - Mortality risk: 1,55%/year, thromboembolism: 0,9%/year, major bleeding:0,85%/year, non-structural valve deterioration: 0,49%/year, endocarditis: 0,41%/year, reintervention: 0,51%/year
Expected durability of biological aortic valves:
Structural valve deterioration: A gradual process of dysfunction secondary to stenosis (40%), insufficiency (30%) or a combination (30%). No universal definition but basically a new severe stenosis (calcification and pannus) or insufficiency (Leaflet tear)
Pericardial valves have a tendency to develop stenosis, porcine valves insufficiency
Risk factors for SVD: Younger age at implantation, hypercalcemia, hyperphosphatemia, renal failure, arterial hypertension, PPM (increased stress on valve), larger BSA, diabetes, smoking,
Surgical bioprosthesis freedom from SVD: 10 year 90,2%, 15 year 73,7%, 20 year 60%
Operative risk for aortic valve replacement reoperation is between 5,8-12,8%,
Valve in valve TAVI after SVD: 1 year mortality of 15%, 30 day at 8%, 95% success rate
Aortic valve sparing vs composite: Mean follow-up 5,8 ár
Same early mortality, bleeding, MI, thromboembolism
Significantly less late mortality with AVS (RR 0,68), Thromboembolism/Stroke (0,36) and bleeding (0,21)
ON-X Valves - Reduced Anticoagulation regiment: RCT, N=190 usual Warfarin regiment (2-3), N=185 INR 1,5-2,0 + 81 mg Aspirin
3,82 years of mean follow-up, major bleeding 3,26/1,48%/pt-yr, minor bleeding 3,41/1,32%/pt-yr, stroke 0,74/1,12%/pt-yr (NS), TIA 1,33/0,79%/pt-yr (NS)
Aortic Valve Repair Techniques
Concepts of Bicuspid Aortic Valve Repair
- Prognosis
PPM - Aukið renal failure, stroke og late mortality með moderate og severe PPM (x1,5 og x2,5)
PPM review - PPM er algengt og hættulegt, líklega hættulegast early post op þegar vi slegill er viðkvæmastur
Bicuspid aortic valve - Heritability ca 10% i 1° ættingjum, ca 10x líklegra í nánum ættingjum, 0,5-2,0% almennri population
Woldentorp et al - Syst review/Meta analys of TAVI patients - 3456 patients, 11,5% had subclinical valve thrombosis, that group had 3x the risk of stroke
Reop after TAVR - 123 patients, retroactive series on TAVR patients surgically reoperated - Mortality 17,1%, Observed mortality was higher than predicted STS score mortality
Pannus occurence on mechanical valves - Retrospective, 862 pat,
Incidence: 10 yr:0,3%, 20 yr: 5%, 25 yr: 9,9%
Risk factors: Small prosthesis (HR 0,74), Young age (HR 0,94), concomitant mitral valve replacement (HR 3,863)
Left ventricular remodeling after aortic valve surgery: N:211, 63% AS/37% AI, -> SAVR -> Echo follow-up 1,2 and/or 5 yrs
Both groups showed left ventricular mass regression, mostly by 1 year
Mitral Valve
10 Commandments of Mitral Valve Surgery
5 tips for mitral surgery - Video
Operative approaches to the left atrium and mitral valve
MitraClip - A Guide For Surgeons
- Patient selection
Functional Mitral Regurgitation
AHA/EACTS Guidelines:
Class I: Surgery is indicated in patients undergoing CABG and with EF <30%, with severe functional MI
Class IIa: Surgery should be considered in patients with symptomatic, severe secondary MI and who have an indication for revascularization as well as evidence of viable myocardium
Class IIb: Surgery may be considered in patients without indication for revascularization, with symptomatic, secondary MI and EF<30%, as well as low risk for surgery
Tricuspid valve
Diagnosis and management of tricuspid disease
Concomitant tricuspid repair, with mitral surgery
RCT, 400 pat, MMVP vs MVP/TVP in patients with MI and either moderate TI or anular dilatation
Lower 2 yr mortality, HR 0,69
Pulmonary Artery/Valve
Pulmonary artery aneurysms - No guideline recommendations, treat as aortic
GUCH
Surgical treatment for GUCH - Primer
- Technical
Surgical unroofing for anomalous coronary arteries
Ross procedure for Bicuspid valves
- Bicuspid Aortic Valve
Aortic dilatation in patients with BAV - 1,3% prevalence BAV, dilation in 20-80% of patients,
Aortic Surgery
- Pathophysiology
At the end of ventricular ejection, the pressure in the aorta falls much more slowly than in the left ventricle because the large central arteries, and particularly the aorta, are elastic and thus act as a reservoir during systole, storing some of the ejected blood, which is then forced out into the peripheral vessels during diastole (Windkessel effect).
Both ventricles of the heart contract together during a phase called ventricular systole, ejecting close to 140 mL of nearly incompressible blood from the adult human heart. This volume must be taken up by an expansion of the remainder of the circulatory system. Therefore, by necessity, the vasculature must be compliant to avoid rupture
This increases the resistance to the left ventricular ejection and increases left ventricular wall stress -> LV hypertrophy
This increases systolic pressure and pulse pressure
Increased pulse pressure can theoretically affect the coronary circulation negatively
The complianace mismatch at the anastomosis can result in dilatation of native aorta distal to the graft
- Aneurysm
Natural evolution of aortic aneurysms
Mean annual growth rate 0,1 +- 0,01 cm/yr. Rarely over 0,2 cm/yr
10 yr survival free from Adverse Aortic Events: <4 cm(97,8%), <4,5 cm (98,2%), <5 cm (97,3%), <5,5 cm (84,6%), <6 cm (80,4%), >6 cm (70,9%)
- Techniques
Linear Reduction Aortoplasty: Technique & results. (716 patients, retrospective)
No good data, retrospective data shows 3% redilatation rate, acceptable long term results, less mortality
Recommendations: Asc aorta <6cm, reduce to under 3,5cm, isolated aneurysm in asc, no patients with connective tissue disorders, patients with stenosis (CTD more likely with AI), if wrapped with Dacron graft -> anchor graft, ideal for patients who would not tolerate a longer operation
Open Repair of Thoracoabdominal Aortic Aneurysm
Neurological Complications: N:3154. Spinal ischemia 4,7%, 7,6% stroke, 8,8% operative mortality. A stent lenght of greater than 10 cm is a risk factor
- Aortic Dissection
2021 AATS Aortic Dissection Guidelines
Early mortality in ATAAD: 1996-2018, Surgical mortality at 48 hours, 4,4% (1% died before operation), 48 hour mortality with conservative treatment was 23,7% (,5% per hour)
Operative mortality 30%
Malperfusion presents in 16-33% of patients, pat with malperfusion and severe acidosis have a mortality rate of 92%
Mesenteric malperfusion syndrome (malperfusion with indicators of end-organ ischemia) has an operative mortality of 60% or higher, many groups delay definitive treatment until after perfusion has been restored (endovascularly) with good results (89% op mortality vs 25%)
Cerebral malperfusion occurs in 7-15% of patients with a type A dissection -> Higher mortality and risk of stroke. The best strategy is probably early intervention and deficits have been shown to reverse postoperatively.
Hemorrhagic conversion of cerebral ischemia occured in only 5% of patients
Presenting with coma is not indicative of a worse neurologic outcome (although mortality is higher)
Prior cardiac surgery does not seem to be protective from tamponade and rupture risk
Resuscitation longer than 15 minutes increases mortality by a factor of 8,27
Non-A Non-B Dissection (Aortic arch eða type B með retrograde involvement of arch) - 14% 30D mortality með medical treatment, 3,6% með intervention og stroke 2,8%
Mechanical assist
LVAD
Left Ventricular Assist Device Implantation and Management: How I Teach It
Heartmate 3: Implantation Technique
ECMO
Baldetti - LV offloading improves outcomes with VA-ECMO (OR 0,54), Preload reduction (LV vent, Impella) is the better strategy (OR 0,34) than afterload reduction (IABP)
Misc
Long Term Assist Guidelines - Non-reversible, NYHA IIIB-IV, EF <25% + sequele,
Arrhytmia surgery
Guidelines - Allt IIa/B indications, success decreases with left atrial diameter
Pathophys review - Rationale for placement of lesions
Maze Technique - Video
Hybrid ablation - CONVERGE trial - RCT, N: 153, Patients with any atrial fibrillation/any LA size, Hybrid Convergent Ablation (subxiphoid epicardial + catheter endocardial ablation) vs Catheter Ablation
Primary Endpoint: freedom from AF at 12 months: 68%/50%
Concomitant Atrial Fibrillation -
2 pathophysiologic causes make surgery possible: The trigger foci that usually exist in the pulmonary veins, and the fact that fibrillation is maintained by macro re-entry circuits readily amenable to ablation
Indications: Symptomatic vs prognostic
Prognostic must be affected by the return of normal atrial function after surgery, which is decreased in patients with very large atria and persisting atrial fibrillation
Evidence:
Results at least double the effect of antiarrhythmic therapy, around 60% vs 24% with concomitant medical therapy
Lack of evidence:
Decreased mortality/stroke with antiarrhythmic therapy?
Return of normal atrial function after surgery? (Should at least be confirmed by ultrasound before stopping anticoagulants)
Left atrial appendage closure
LAAOS III: RCT, N: 4800, atrial fib patients, Left atrial appendage closure vs control. Follow up 3,8 years. Stroke/Systemic embolism HR 0,67, mortality NS
Gutierrez et al - Meta-analysis 280 585 patients, preoperative atrial fibrillation, surgical closure of LAA
Significantly reduced early stroke (RR 0,67) & late stroke (RR 0,71)
Patients with high burden of disease (>70% in atrial fibrillation) have the most utility
Long term mortality decreased with LAAc (RR 0,72)
Complex & misc techniques
- PFO
PFO vs ASD - Failure of closure vs failure of tissue formation (ASD usually bigger)
PFO closure results - Retrospective analys - Intraop PFO, enginn munur a stroke eða mortality, ef lagað -> aukið stroke risk x2,5 - 2,8% vs 1,2%)
AAN Guidelines - PFO is found in 1/4 of the general population. In patients <60 yrs with prior embolic infarct and no other mechanism of stroke -> PFO closure recommended due to absolute stroke recurrence risk reduction of 3,4% at 5 yrs.
- Technical
Commando/UFO procedure + Cleveland
Modified Ross procedure - Standard með Dacron graft til styrkingar utan um
Aortic valve repair: State of the art (Technique)
Surgical Aspects in Carcinoid Heart Disease
Aortic root replacement and reconstruction in destructive endocarditis
Samurai cannulation - Þegar óljóst með falska/sanna lumen til cannyleringar
Wire skills for surgeons (video)
Clampless cardioplegia (Total body)
HOCM
Long term survival better with surgical approach 5 yr (HR 1,31), 10 yr (HR 1,68)
The Cabrol Procedure - For achieving tensionless suture lines during coronary reimplantation
Cabrol patch for persistent bleeding from aortotomy
Dissection of the interatrial groove (Sondergaards)
Application of AtriClip (Video)
Surgery for post-infarction free wall rupture
65,7% in-hospital survival, among survivors 5-& 10 year survival rates were 81% & 75%
Post op in-hospital/30d mortality 43%.
18,4% mortality if operated on after a week vs 54,1% if operated on within the week
87% mortality rate if in cardiac shock
For survivors, 1, 5 & 10 year mortality was: 91%, 75% & 31%
Technique - Repair of posterior VSD
Dor Procedure for left ventricular aneurysm
- Zebras
Carney complex (Not Carney Syndrome): Multiple benign tumors most often affecting the heart, skin, and endocrine system. Endocrine abnormalities, skin pigment abnormalities, and cardiac myxomas.
Management of Coronary Artery Aneurysms:
Correlated with increased mortality and MACE
MACE Events decrease with anticoagulation
Indications for surgical intervention: Left main, multiple aneurysms, >20 mm, >4x reference vessel, SVG aneurysm (post CABG)
Surgical treatment: Open suture ligation and bypass,