Overall approaches to cardiac tumors:Still an unsolved enigma?

Cardiac tumors are neoplasms involving heart structures at any level,meaning the myocardium,valves,and cardiac chambers.When considering cardiac masses,it is not uncommon for surgeons to be surprised when they diagnose one.The real incidence of this complex group of diseases has been explored only after cardiac diagnostic tools became more appropriate.Despite differential diagnosis being relevant,surgical indication is usually requested for all malignant cardiac tumors and also for many types of benign tumors.The development of cardiac imaging techniques,therefore,has been the key point for a better understanding of the history of cardiac tumors and especially of the relevance of surgical indication in such conditions.Systematic and combined applications of echocardiography,cardiac computed tomography and magnetic resonance allow in the majority of case a clear definition of the nature of a newly discovered cardiac mass.The presence of a Li-Fraumeni syndrome seems to be the trigger aspect in accelerating the propensity of developing a cardiac tumor.Despite the revolutionary usefulness of the cardiac imaging techniques available,it is still considered a hazard to diagnose a malignant cardiac mass just with radiological imaging;the mainstay of the final diagnosis stands in surgical excision of the mass and histopathological report.

Health Systems Strengthening to Tackle the Global Burden of Pediatric and Congenital Heart Disease: A Diagonal Approach

1 Background Congenital heart disease(CHD)is the most common major congenital anomaly,affecting approximately one in every 100 live births[1].Among congenital anomalies,66%of preventable deaths are due to CHD,and 58%of the avertable morbidity and mortality due to congenital anomalies would result from scaling congenital heart surgery services[2].Every year,nearly 300,000 children and adults die from CHD,the majority of whom live in low-and middle-income countries(LMICs)[3].Approximately 49%of all individuals with CHD will require surgical or interventional care at some point in their lifetime[4];as a result of advances in access to and the delivery of such services,over 95%of children born with CHD in high-income countries now live into adulthood[3].Here,adults have surpassed children in the number of CHD cases at a ratio of 2:1[5].

Effects of vitamin family members on insulin resistance and diabetes complications

The following letter to the editor highlights the article“Effects of vitamin D supplementation on glucose and lipid metabolism in patients with type 2 diabetes mellitus and risk factors for insulin resistance”in World J Diabetes 2023 Oct 15;14(10):1514-1523.It is necessary to explore the role of vitamin family members in insulin resistance and diabetes complications.

The rationale and design of the minocycline plus amiodarone versus amiodarone alone (MINAA) trial for the prevention of atrial fibrillation after cardiac surgery

Objectives: Amiodarone administration is presently considered in the prevention of new-onset postoperative atrial fibrillation (PAF) after cardiac operations, but relapse of PAF requiring anticoagulation therapy at hospital discharge is prevalent despite amiodarone prophylaxis. PAF is also associated with increased morbidity and mortality including complications resulting from long-term anticoagulation therapy. Currently, the most effective therapy to prevent PAF after cardiac surgery remains undetermined. Inflammatory mechanisms may be partly responsible for PAF. Minocycline, a tetracycline antibiotic, has specifically an atrial myocytes anti-apoptotic effect, decreases right atrial tissue inflammation and oxidative stress activity. These observations led to this trial’s hypothesis that the addition of minocycline to amiodarone may favorably affect suppression of PAF. Methods: This trial compares the efficacy and safety of minocycline plus amiodarone versus amiodarone alone, in the prevention of PAF among adult patients undergoing cardiac procedures. All patients receive Beta-blocker agent. The primary outcome is PAF occurrence. Secondary outcomes include thromboembolic stroke, need for pharmacologic or electric cardioversion, mediastinal exploration for sepsis or for anticoagulation-related bleeding, serious drug side effects, length of hospital stay and 30-day mortality from cardiovascular causes. Results: This is an ongoing prospective single center randomized controlled clinical trial. Conclusion: The trial provides information on the comparative effectiveness of this low-risk prevention therapy of PAF that could be integrated in clinical practice. (Clinicaltrials.gov number, NCT 01422148).

Pediatric Cardiac Surgical Patterns of Practice and Outcomes in Europe and China:An Analysis of the European Congenital Heart Surgeons Association Congenital Heart Surgery Database

Background:The European Congenital Heart Surgeons Association(ECHSA)Congenital Heart Surgery Database(CHSD)was founded in 1999 and is open for worldwide participation.The current dataset includes a large amount of surgical data from both Europe and China.The purpose of this analysis is to compare patterns of practice and outcomes among pediatric congenital heart defect surgeries in Europe and China using the ECHSA-CHSD.Methods:We examined all European(125 centers,58,261 operations)and Chinese(13 centers,23,920 operations)data in the ECHSA-CHSD from 2006-2018.Operative mortality,postoperative length of stay,median patient age and weight were calculated for the ten benchmark operations for China and Europe,respectively.Results:Benchmark procedure distribution frequencies differed between Europe and China.In China,ventricular septal defect repair comprised approximately 70%of procedures,while Norwood operations comprised less than one percent of all procedures.Neonatal cardiac procedures were rare in China overall.For procedures in STAT mortality category 1,Chinese centers had lower operative mortality rates,while procedures in categories 3 and 5 mortality is lower in European centers.Operative mortality over the time period decreased from 3.89%to 1.64%for the whole cohort,with a sharper decline in China.This drop coincides with an increase of submitted procedures over this 13-year-period.Conclusion:Chinese centers had higher programmatic volume of congenital heart surgeries,while European centers have a more complex case mix.Palliation for patients with functionally univentricular heart was performed less commonly in China.These comparison of patterns of practice and outcomes demonstrate opportunities for continuing bidirectional transcontinental collaboration and quality improvement.

Ultrasonographic Diagnosis of an Isolated Cardiac Metastasis in a Patient with High-Grade Gastrointestinal Stromal Tumor

Aims: Secondary cardiac tumours are rare conditions, often difficult to suspect. We aim to describe the diagnostic potential of transthoracic and transesophageal echocardiography in this field, and to discuss their reliability as modalities of choice for preoperative diagnosis. Methods and Results: We used several complementary diagnostic approaches: Color-Doppler transthoracic echocardiography, transesophageal echocardiography, regional myocardial perfusion test and three-dimensional transthoracic echocardiography. The latter was employed to confirm the previously performed tests. All tests revealed the presence of an echogenic, oval-shaped and well-delimited mass in the basal part of intervenetricular septum. Conclusion: Even though it was initially asymptomatic and characterized by scarce clinical manifestations, the intra-cardiac mass was reliably identified in this patient by means of the cited diagnostic modalities, which also allowed adequate surgical planning. The immunohistochemical examination revealed the secondary nature of this tumour. Basic and advanced echocardiography examinations were crucial in the decision-making process.

Analysis of the effects of donor and recipient hepatitis C infection on kidney transplant outcomes in the United States

BACKGROUND As Hepatitis C virus infection(HCV+)rates in kidney donors and transplant recipients rise,direct-acting antivirals(DAA)may affect outcomes.AIM To analyze the effects of HCV+in donors,recipients,or both,on deceased-donor(DD)kidney transplantation(KT)outcomes,and the impact of DAAs on those effects.METHODS The Organ Procurement and Transplantation Network data of adult first solitary DD-KT recipients 1994-2019 were allocated into four groups by donor and recipient HCV+status.We performed patient survival(PS)and death-censored graft survival(DCGS)pairwise comparisons after propensity score matching to assess the effects of HCV+in donors and/or recipients,stratifying our study by DAA era to evaluate potential effect modification.RESULTS Pre-DAA,for HCV+recipients,receiving an HCV+kidney was associated with 1.28-fold higher mortality(HR 1.151.281.42)and 1.22-fold higher death-censored graft failure(HR 1.081.221.39)compared to receiving an HCV-kidney and the absolute risk difference was 3.3%(95%CI:1.8%-4.7%)for PS and 3.1%(95%CI:1.2%-5%)for DCGS at 3 years.The HCV dual-infection(donor plus recipient)group had worse PS(0.56-fold)and DCGS(0.71-fold)than the dual-uninfected.Donor HCV+derived worse post-transplant outcomes than recipient HCV+(PS 0.36-fold,DCGS 0.34-fold).In the DAA era,the risk associated with HCV+in donors and/or recipients was no longer statistically significant,except for impaired PS in the dual-infected vs dual-uninfected(0.43-fold).CONCLUSION Prior to DAA introduction,donor HCV+negatively influenced kidney transplant outcomes in all recipients,while recipient infection only relatively impaired outcomes for uninfected donors.These adverse effects disappeared with the introduction of DAA.

Insulin-like growth factor binding protein related protein 1 knockdown attenuates hepatic ?brosis via the regulation of MMPs/TIMPs in mice

Background: Previous research suggested that insulin-like growth factor binding protein related protein 1(IGFBPrP1), as a novel mediator, contributes to hepatic fibrogenesis. Matrix metalloproteinases(MMP) and tissue inhibitors of metalloproteinases(TIMP) play an essential role in hepatic fibrogenesis by regulating homeostasis and remodeling of the extracellular matrix(ECM). However, the interaction between IGFBPrP1 and MMP/TIMP is not clear. The present study was to knockdown IGFBPrP1 to investigate the correlation between IGFBPrP1 and MMP/TIMP in hepatic fibrosis. Methods: Hepatic fibrosis was induced by thioacetamide(TAA) in mice. Knockdown of IGFBPrP1 expression by ultrasound-targeted microbubble destruction-mediated CMB-shRNA-IGFBPrP1 delivery, or inhibition of the Hedgehog(Hh) pathway by cyclopamine treatment, was performed in TAA-induced liver fibrosis mice. Hepatic fibrosis was determined by hematoxylin and eosin and Sirius red staining. Hepatic expression of IGFBPrP1, α-smooth muscle actin( α-SMA), transforming growth factor β 1(TGF β1), collagen I, MMPs/TIMPs, Sonic Hedgehog(Shh), and glioblastoma family transcription factors(Gli1) were investigated by immunohistochemical staining and Western blotting analysis. Results: We found that hepatic expression of IGFBPrP1, TGF β1, α-SMA, and collagen I were increased longitudinally in mice with TAA-induced hepatic fibrosis, concomitant with MMP2/TIMP2 and MMP9/TIMP1 imbalance and Hh pathway activation. Knockdown of IGFBPrP1 expression, or inhibition of the Hh pathway, reduced the hepatic expression of IGFBPrP1, TGF β1, α-SMA, and collagen I and re-established MMP2/TIMP2 and MMP9/TIMP1 balance. Conclusions: Our findings suggest that IGFBPrP1 knockdown attenuates liver fibrosis by re-establishing MMP2/TIMP2 and MMP9/TIMP1 balance, concomitant with the inhibition of hepatic stellate cell activation, down-regulation of TGF β1 expression, and degradation of the ECM. Furthermore, the Hh pathway mediates IGFBPrP1 knockdown-induced attenuation of hepatic fibrosis through the regulation of MMPs/TIMPs balance.

Short and long term outcomes of 200 patients supported by continuous-flow left ventricular assist devices

AIM: To study the institutional experience over 8 years with 200 continuous-flow(CF)- left ventricular assist devices(LVAD).METHODS: We evaluated our institution's LVAD database and analyzed all patients who received a CF LVAD as a bridge to transplant(BTT) or destination therapy from March 2006 until June 2014. We identified 200 patients, of which 179 were implanted with a Heart Mate II device(Thoratec Corp., Pleasanton, CA) and 21 received a Heartware HVAD(Heart Ware Inc., Framingham, MA).RESULTS: The mean age of our LVAD recipients was 59.3 years(range 17-81), 76%(152/200) were males, and 49% were implanted for the indication of BTT. The survival rate for our LVAD patients at 30 d, 6 mo, 12 mo, 2 years, 3 years, and 4 years was 94%, 86%, 78%, 71%, 62% and 45% respectively. The mean duration of LVAD support was 581 d(range 2-2595 d). Gastrointestinal bleeding(was the most common adverse event(43/200, 21%), followed by right ventricular failure(38/200, 19%), stroke(31/200, 15%), re exploration for bleeding(31/200, 15%),ventilator dependent respiratory failure(19/200, 9%) and pneumonia(15/200, 7%). Our driveline infection rate was 7%. Pump thrombosis occurred in 6% of patients. Device exchanged was needed in 6% of patients. On multivariate analysis, preoperative liver dysfunction, ventilator dependent respiratory failure, tracheostomy and right ventricular failure requiring right ventricular assist device support were significant predictors of post LVAD survival.CONCLUSION: Short and long term survival for patients on LVAD support are excellent, although outcomes still remain inferior compared to heart transplantation. The incidence of driveline infections, pump thrombosis and pump exchange have declined significantly in recent years.

Percutaneous transcatheter closure of mitral paravalvular leak via transarterial retrograde approach

Repeat surgery has usually been considered the first choice to solve paravalvular leaks of prosthetic valves, but it cames a high operative risk, a high mortality rate and an increased risk for re-leaks. Percutaneous closure of such defects is possible, and different approaches and devices are used for this purpose. For mitral paravalvular leaks, constructing an arterio-venous wire loop for delivering the closure device through an antegrade approach is the most commonly used technique. Transcatheter closure can also be performed through a transapical approach or retrograde transfemoral arterial approach. We present a case of 68-year-old man with a mitral paravalvular leak that was suc- cessfully closed using an Amplatzer~ Duct Occluder H, via retrograde transfemoral arterial approach under three-dimensional transesophag- eal echocardiographic guidance, without the use of a wire loop. The initial attempt to cross the paravalvular defect was unsuccessful, but the obstacle was finally overcome by introducing complex interventional techniques.

Tissue Engineering to Restore Cardiac Function

1. Introduction The purpose of cardiac surgery is to restore the injured heart to full function. For many congenital cardiac defects, appropriate repair is able to establish nearly normal cardiac function. One example of such repair is closing abnormal holes between cardiac chambers in young children, which usually restores normal function that persists for the lifetime of the child. However, the advent of surgery for ischemic heart disease has resulted in new challenges for cardiac surgeons.

Animal models of ex vivo lung perfusion as a platform for transplantation research

Ex vivo lung perfusion(EVLP) is a powerful experimental model for isolated lung research. EVLP allows for the lungs to be manipulated and characterized in an external environment so that the effect of specific ventilation/perfusion variables can be studied independent of other confounding physiologic contributions. At the same time,EVLP allows for normal organ level function and real-time monitoring of pulmonary physiology and mechanics. As a result,this technique provides uniqueadvantages over in vivo and in vitro models. Small and large animal models of EVLP have been developed and each of these models has their strengths and weaknesses. In this manuscript,we provide insight into the relative strengths of each model and describe how the development of advanced EVLP protocols is leading to a novel experimental platform that can be used to answer critical questions in pulmonary physiology and transplant medicine.

Organ assessment and repair centers: The future of transplantation is near

Solid organ transplantation is limited by suitable donor organ availability and the geographic limitations that lead to prolonged ischemic times. Ex vivo organ perfusion is an evolving technology that enables assessment of organ function prior to transplantation. As a byproduct, overall out of body organ times are able to be extended. The future implications organ assessment and repair centers utilizing this technology are discussed.

Acute Type A Aortic Dissection—Replacement of Ascending Aorta, Aortic Arch and Antegrade Stenting of the Descending Thoracic Aorta Using the Thoraflex™Hybrid Plexus Device (Terumo Aortic)—“Frozen Elephant Trunk”: The Plymouth Way!

Objectives: To describe our technique for the implantation of the Thoraflex Hybrid prosthesis for replacement of the aortic arch in a safe and reproducible way. Materials: Thoraflex™ Hybrid Plexus Device (Terumo Aortic). Design: Drawing on our own experience over the past 4 years in the management of acute type A aortic dissection, we have distilled the essentials of our “Frozen Elephant Trunk” technique which have led us through our own learning curve to the improved management of this taxing condition. Method/ Results: Small extension of the median sternotomy incision along the medial border of sternocleidomastoid muscle. End to side graft anastomosis near the origin of the left subclavian artery during cooling on bypass towards 20 degrees. Attention to cardiac protection and maintenance of cerebral perfusion during the shortened corporeal arrest period. Excellent results in 24 consecutive AAAD patients with just one hospital mortality. Conclusions: We believe we are entering a new phase in the treatment of AAAD, facilitated by the availability of a hybrid prosthesis which combines expanding stent technology with familiar surgical graft material. Our particular management of the left subclavian artery and of the cerebral circulation during implantation has contributed to an expeditious and reproducible method of treating dissection within the arch of the aorta and beyond.

Left main coronary stenosis as a late complication of percutaneous angioplasty:an old problem,but still a problem

Objective Accelerated left main coronary stenosis (LMCS) is a known potential late complication of coronary artery catheter procedures. The aim of this study was to assess the current occurrence of LMCS as a delayed complication of percutaneous angioplasty (PTCA) of the left coronary branches in our institution. Methods The medical records of patients referred for coronary artery by-pass surgery from the same Cardiology Unit in the January 2003 to December 2006 period and presenting a significant (> 50%) LMCS as a new finding following a PTCA of the left coronary artery branches, were reviewed. Patients with retrospective evidence of any LMCS at previous coronary angiographies preceding the percutaneous procedure were excluded. Results Thirty-seven patients (5 females, mean age 71.1±8.6 years) out of 944 (4%) having undergone a PTCA, fulfilled the inclusion criteria, 19 (51%) after a procedure also involving the LAD coronary artery. Extraback-up guiding catheters were used in most cases. Use of multiple wires or balloons was observed in 3 cases (8%). Rotablator and proximal occlusion device were used in one case respectively (3%). Twenty patients (54%) have had more than one percutaneous coronary intervention on the left coronary branches. The mean time elapsed from the first angioplasty and surgical intervention was 18.1±7.8 months. Conclusions The potential occurrence of LMCS following a percutaneous intervention procedure, especially when complicated and repeated, should not be underestimated in the current era. This evidence may offer the rationale to schedule non-invasive imaging tests to monitor left main coronary patency after the procedure as well as to fuel further research to develop less traumatic materials.

Single vs double antiplatelet therapy in acute coronary syndrome: Predictors of bleeding after coronary artery bypass grafting

AIM:To investigate the contribution of anti-platelet therapy and derangements of pre-operative classical coagulation and thromboelastometry parameters to major bleeding post-coronary artery bypass grafting(CABG).METHODS:Two groups of CABG patients were studied:Group A,treated with aspirin alone(n=50),and Group B treated with aspirin and clopidogrel(n=50).Both had similar preoperative,clinical,biologic characteristics and operative management.Classic coagulation parameters and rotational thromboelastometry(ROTEM)profiles were determined preoperatively for both groups and the same heparin treatment was administered.ROTEM profiles(INTEM and EXTEM assays)were analyzed,both for traditional parameters,and thrombin generation potential,expressed by area-under-curve(AUC).RESULTS:There was no significant difference betweenrates of major bleeding between patients treated with aspirin alone,compared with those treated with aspirin and clopidogrel(12%vs 16%,P=0.77).In the 14 cases of major bleeding,pre-operative classic coagulation and traditional ROTEM parameters were comparable.Conversely we observed that the AUC in the EXTEM test was significantly lower in bleeders(5030±1115 Ohm*min)than non-bleeders(6568±548Ohm*min)(P<0.0001).CONCLUSION:We observed that patients with a low AUC value were at a significantly higher risk of bleeding compared to patients with higher AUC,regardless of antiplatelet treatment.This suggests that thrombin generation potential,irrespective of the degree of platelet inhibition,correlates with surgical bleeding.

To ventricular assist devices or not:When is implantation of a ventricular assist device appropriate in advanced ambulatory heart failure?

Advanced heart failure has been traditionally treated via either heart transplantation,continuous inotropes,consideration for hospice and more recently via left ventricular assist devices(LVAD).Heart transplantation has been limited by organ availability and the futility of other options has thrust LVAD therapy into the mainstream of therapy for end stage heart failure.Improvements in technology and survival combined with improvements in the quality of life have made LVADs a viable option for many patients suffering from heart failure.The question of when to implant these devices in those patients with advanced,yet still ambulatory heart failure remains a controversial topic.We discuss the current state of LVAD therapy and the risk vs benefit of these devices in the treatment of heart failure.

Successful treatment of complete traumatic transection of the suprahepatic inferior vena cava with veno-venous and cardiopulmonary bypass with hypothermic circulatory arrest

To the Editor:Complete traumatic transection of the suprahepatic inferior vena cava(IVC)has almost invariably a fatal outcome.There are very few cases in the literature of patients that survived this type of injury.Here we presented a case that was approached multidisciplinary(trauma surgeon,liver transplant surgeon,perfusionist,anesthesiologist,and cardiac surgeon)with a successful outcome including early recovery of all body functions and quality of life.

Long Term Results of Valve Operations in Patients with Diabetes

Diabetes Mellitus (DM) adversely affects survival in patients with Coronary Artery Disease (CAD) undergoing Coronary Artery Bypass Grafting (CABG) surgery. The influence of diabetes on events after valve operations is less defined. We analyzed the effect of diabetes on short and long term outcomes in patients undergoing valvular operations. A total of 2200 patients had cardiac surgery at a single VA Medical Center between 1991 and 2008. 355 patients had undergone valve replacement or repair. Data documenting the presence of diabetes was collected prospectively and captured into the Veterans Affairs electronic medical record. Of the 355 patients who had a valvular operation, 259 (79%) had an Aortic Valve Replacement (AVR), 69 (20%) had a Mitral Valve Repair/Replacement (MVR), and 4 (1%) had a Tricsupid Valve Repair/Replacement (TVR), and 19% (n = 69) of all patients had diabetes. 44% of patients with DM and 38% of patients without DM had a combined valve and CABG procedure. During a total follow up of 18 yrs, 42 (60%) of patients with diabetes and 186 (65%) of patients without diabetes were alive (p = 0.118). At 1, 5, 10, 15 yrs survival in patients with versus without diabetes were 91% v 87%;71% v 74%;40% v 56%;23% v 48% (p = NS). The presence of diabetes does not appear to adversely effect long-term survival in patients undergoing valve operations.

Outcomes of continuous flow ventricular assist devices

Heart transplantation is commonplace, the supply is limited. Many exciting changes in the field of mechanical circulatory support have occurred in the past few years, including the axial flow pump. Left ventricular assist device(LVAD) therapy is ever evolving. As the use of LVAD therapy increases it is important to understand the indications, surgical considerations and outcomes.