Clinical and Surgical Evaluations of Reoperation After Mechanical Mitral Valve Replacement Due to Different Etiologies

Background:This study aimed to evaluate the clinical and surgical characteristics of patients who required reoperation after mechanical mitral valve replacement (MVR).Methods:We retrospectively identified 204 consecutive patients who underwent reoperation after mechanical MVR between 2009 and 2018. Patients were categorized according the reason for reoperation (perivalvular leakage, thrombus formation, or pannus formation). The patients' medical and surgical records were studied carefully and the rates of in-hospital complications were calculated.Results:The mean age was 51±12 years and 44% of the patients were male. The reasons for reoperation were perivalvular leakage (117 patients), thrombus formation (35 patients), and pannus formation (52 patients). The most common positions for perivalvular leakage were at the 6–10 o'clock positions (proportions of ≥25% for each hour position). Most patients had an interval of >10 years between the original MVR and reoperation. The most common reoperation procedure was re-do MVR (157 patients), and 155 of these patients underwent concomitant cardiac procedures. There were 10 in-hospital deaths and 32 patients experienced complications. The 10-year survival rate was 82.2 ± 3.9% in general, and the group of lowest rate was patients with PVL (77.5 ± 5.2%). The independent risk factors were “male” (4.62, 95% CI 1.57–13.58, P = 0.005) and “Hb <9g/dL before redo MV operation” (3.45, 95% CI 1.13–10.49, P = 0.029).Conclusion:Perivalvular leakage was the most common reason for reoperation after mechanical MVR, with a low survival rate in long term follow-up relatively.

Noonan syndrome and pregnancy outcomes

Background: Noonan syndrome is a genetic disorder with high prevalence of congenital heart defects, such as pulmonary stenosis, atrial septal defect and hypertrophic cardiomyopathy. Scarce data exists regarding the safety of pregnancy in patients with Noonan syndrome, particularly in the context of maternal cardiac disease. Study design: We performed a retrospective chart review of patients at Yale-New Haven Hospital from 2012 to 2020 with diagnoses of Noonan syndrome and pregnancy. We analysed medical records for pregnancy details and cardiac health, including echocardiograms to quantify maternal cardiac dysfunction through measurements of pulmonary valve peak gradient, structural heart defects and interventricular septal thickness. Results: We identified five women with Noonan syndrome (10 pregnancies). Three of five patients had pulmonary valve stenosis at the time of pregnancy, two of which had undergone cardiac procedures. 50% of pregnancies (5/10) resulted in pre-term birth. 80% (8/10) of all deliveries were converted to caesarean section after a trial of labour. One pregnancy resulted in intra-uterine fetal demise while nine pregnancies resulted in the birth of a living infant. 60% (6/10) of livebirths required care in the neonatal intensive care unit. One infant passed away at 5 weeks of age. Conclusions: The majority of mothers had pre-existing, though mild, heart disease. We found high rates of prematurity, conversion to caesarean section, and elevated level of care. No maternal complications resulted in long-term morbidity. Our study suggests that women with Noonan syndrome and low-risk cardiac lesions can become pregnant and deliver a healthy infant with counselling and risk evaluation.

The impact of the COVID-19 pandemic on hospital services for patients with cardiac diseases: a scoping review

Aim: To assess the impact of the COVID-19 pandemic on hospital care for cardiac patients. Methods and results: Scoping review, including studies with empirical data on changes in the use of health services measured by performance indicators during January - June 2020. Database searches yielded 6277 articles, of which 838 articles met the inclusion criteria during initial screening. After full-text screening, 94 articles were considered for data extraction. In total, 1637 indicators were retrieved, showing large variation in the indicators and their definitions. Most of the indicators that provided information on changes in number of admissions (n=118, 88%) signalled a decrease in admissions; 88% (n=15) of the indicators showed patients delayed presentation and 40% (n=54) showed patients in a worse clinical condition. A reduction in diagnostic and treatment procedures was signalled by 95% (n=18) and 81% (n=64) of the indicators reporting on cardiac procedures, respectively. Length of stay decreased in 58% (n=21) of the indicators and acute coronary syndromes treatment times increased in 61% (n=65) of the indicators. Outpatient activity decreased in 94% (n=17) of the indicators related with outpatient care, whereas telehealth utilization increased in 100% (n=6). Outcomes worsened in 40% (n=35) of the indicators, and mortality rates increased in 52% (n=31). Conclusion: All phases of the hospital cardiac care pathway were affected. This information could support the planning of care during the ongoing pandemic and in future events. Furthermore, to ensure continuity of care during crises, fostering the use of standardised indicators is paramount.

Early Coronary Angiography Is Associated with Improved 30-Day Outcomes among Patients with out-of-Hospital Cardiac Arrest

We evaluated the association between early coronary angiography (CAG) and outcomes in resuscitated out-of-hospital cardiac arrest (OHCA) patients, by linking data from the Singapore Pan-Asian Resuscitation Outcomes Study, with a national registry of cardiac procedures. The 30-day survival and neurological outcome were compared between patients undergoing early CAG (within 1-calender day), versus patients not undergoing early CAG. Inverse probability weighted estimates (IPWE) adjusted for non-randomized CAG. Of 976 resuscitated OHCA patients of cardiac etiology between 2011–2015 (mean(SD) age 64(13) years, 73.7% males), 337 (34.5%) underwent early CAG, of whom, 230 (68.2%) underwent PCI. Those who underwent early CAG were significantly younger (60(12) vs. 66(14) years old), healthier (42% vs. 59% with heart disease; 29% vs. 44% with diabetes), more likely males (86% vs. 67%), and presented with shockable rhythms (69% vs. 36%), compared with those who did not. Early CAG with PCI was associated with better survival and neurological outcome (adjusted odds ratio 1.91 and 1.82 respectively), findings robust to IPWE adjustment. The rates of bleeding and stroke were similar. CAG with PCI within 24 h was associated with improved clinical outcomes after OHCA, without increasing complications. Further studies are required to identify the characteristics of patients who would benefit most from this invasive strategy.

Cost analysis of a coaching intervention to increase use of transradial percutaneous coronary intervention

Background The transradial approach (TRA) to cardiac catheterization is safer than the traditional transfemoral approach (TFA), with similar clinical effectiveness. However, adoption of TRA remains low, representing less than 50% of catheterization procedures in 2015. Peer coaching is one approach to facilitate implementation; however, the costs of this strategy for cardiac procedures such as TRA are unclear. Methods We conducted an activity-based costing analysis (ABC) of a multi-center, hybrid type III implementation trial of a coaching intervention designed to increase the use of TRA. We identified the key activities of the intervention and determined the personnel, resources, and time needed to complete each activity. The personnel cost per hour and the activity duration were then used to estimate the cost of each activity and the total variable cost of the implementation. Fixed costs related to designing and running the implementation were calculated separately. All costs are reported in 2019 constant US dollars. Results The total cost of the coaching intervention implementation was $374,863. Of the total cost, $367,752 were variable costs due to travel, preparatory work, in-person coaching, post-intervention evaluation, and administrative time. We estimated fixed costs of $7112. The mean marginal cost of implementing the intervention at only one additional medical center was $52,536. Conclusions We provide granular cost estimates of a conceptually rooted implementation strategy designed to increase the uptake of TRA for cardiac catheterization. We estimate that implementation costs stemming from the coaching approach would be offset after the conversion of approximately 409 to 1363 catheterizations from TFA to TRA. Our estimates provide benchmarks of the expected costs of implementing evidence-based, but expertise-intensive, cardiac procedures. Trial registration ISRCTN, ISRCTN66341299. Registered 7 July 2020—retrospectively registered

Non-Invasive Continuous Measurement of Haemodynamic Parameters—Clinical Utility

The evaluation and monitoring of patients’ haemodynamic parameters are essential in everyday clinical practice. The application of continuous, non-invasive measurement methods is a relatively recent solution. CNAP, ClearSight and many other technologies have been introduced to the market. The use of these techniques for assessing patient eligibility before cardiac procedures, as well as for intraoperative monitoring is currently being widely investigated. Their numerous advantages, including the simplicity of application, time- and cost-effectiveness, and the limited risk of infection, could enforce their further development and potential utility. However, some limitations and contradictions should also be discussed. The aim of this paper is to briefly describe the new findings, give practical examples of the clinical utility of these methods, compare them with invasive techniques, and review the literature on this subject.

Comparison of the safety and efficacy between minimally invasive cardiac surgery and median sternotomy in a low-risk mixed Asian population in Singapore

Introduction: Minimally invasive cardiac surgery (MICS) has attracted increasing attention, with institutions increasingly adopting this approach over conventional median sternotomy (MS). This study aimed to describe the outcomes of minimally invasive cardiac surgery in our institution as the only centre with an established MICS programme in Singapore. Methods: Patients who had undergone cardiac procedures such as heart valve replacement or repair, coronary artery bypass grafting or atrial septal defect repair were included in the study. We analysed 4063 patients who had undergone MS and 390 patients who had undergone MICS between January 2009 and February 2020. Results: Over the years, the number of MICS procedures performed increased, along with an increase in MICS operations with two or more concomitant cardiac procedures and a decrease in postoperative length of stay. Compared with patients who underwent MS, those who underwent MICS had shorter length of postoperative hospital stay (p < 0.001). On multivariate analysis, patients who underwent MICS had lower rates of atrial fibrillation (p = 0.021), reoperation (p = 0.028) and prolonged ventilation (p < 0.001). However, the rates of other postoperative complications were comparable between patients who underwent MICS and those who underwent MS. Conclusion: In our institution, MICS is a safe, reproducible and efficacious technique that yields superior outcomes compared with conventional MS procedures, in some aspects. The results of this study provide further evidence and support towards adopting the minimally invasive approach to cardiac surgery in a carefully selected group of cardiac patients in Singapore.

CORONARY ARTERY FISTULA, WHERE ARE WE NOW?''

In the study “Long-term outcomes following surgical repair of coronary artery fistula in adults”, Wada and associates, retrospectively evaluated 13 consecutive patients that underwent surgical repair of CAF No deaths, significant ST-T changes or CAF-related events were reported in a follow-up period of 66.2 months, and 1 patient showed poor contrast RCA#2 on postoperative coronary CT with a myocardial scintigraphy showing no significant change compared to the preoperative state Coronary artery fistulas (CAF) are rare congenital or acquired malformations in the connection of the coronary vessels, first described by Krause in 1865 (2). They can be classified as coronary-cameral fistulas, which connect coronary arteries with any of the heart chambers, or coronary artery malformations, which connect coronary arteries with systemic or pulmonary vessels. Congenital CAFs are normally a result of abnormal embryological development, acquired CAFs are commonly a result of cardiac traumatic injuries, and iatrogenic CAFs are usually a result of interventional cardiac procedures. This condition is still highly undiagnosed, as around 75% of incidentally-found CAFs are small and clinically silent, but it is estimated that CAFs are present in about 0.9% of the general population In our experience, we have a CAF incidence of 0.05% in 10,000 cardiac surgeries, which have demonstrated beneficial outcomes of the surgical repair of CAFs in adults . Authors of this article must be congratulated for the successful development of the study and for the contributions to the literature on this rare condition