World Journal of Cardiovascular Surgery

Journal Information
ISSN / EISSN : 2164-3202 / 2164-3210
Published by: Scientific Research Publishing, Inc. (10.4236)
Total articles ≅ 273
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Joseph A. Gancayco, Alexander P. Kossar, Codruta Chiuzan, Isaac George
World Journal of Cardiovascular Surgery, Volume 12, pp 135-152;

Background: Functional mitral regurgitation (FMR) is an increasing burden as population ages. Mitral valve repair (MVr) is the preferred surgical treatment of FMR despite limited evidence supporting its efficacy. Mitral valve replacement (MVR) is the alternative procedure typically reserved for patients who are at higher risk or refractory to MVr. The present study aims to determine which of the two procedures is more effective in the surgical treatment of FMR. Methods: 344 charts of FMR patients who received either MVr (n = 263) or MVR (n = 81) from 2004-2016 at our institution were reviewed. Treatment efficacy was assessed based on heart failure (HF)-readmission and survival rates within 5 years from discharge. Propensity score approach with inverse probability weighting and Cox regression models were employed to evaluate procedural impact on survival and rehospitalizations, respectively. Follow-up echocardiographic data from the original cohort was assessed for differences in metrics between procedural groups at >6 months (MVr: n = 75; MVR: n = 23) and 1 year (MVr: n = 75; MVR: n = 18) post-op. Results: MVR patients had a lower risk of being readmitted for HF within 5 years compared to the MVr group (HR-adj (95% CI): 0.60 (0.41 - 0.88), p = 0.008). MVR patients also had a higher overall risk of death (HR-adj (95% CI): 1.82 (1.05 - 3.16), p = 0.034) but this was borderline significantly different at 5 years cut-off (p = 0.057). Conclusions: Higher HF readmission in MVr patients than in sicker, higher surgical-risk MVR patients reflects the inadequacy of MVr to treat FMR. Novel approaches to MVR may be necessary to adequately manage FMR.
Farid Gharagozloo, Mark Meyer, Robert Poston
World Journal of Cardiovascular Surgery, Volume 12, pp 39-69;

Background: Historically, the pathophysiology of Hiatal Hernias (HH) has not been fully understood. As a result, the surgical therapy of HH has focused primarily on gastrointestinal symptoms and Gastroesophageal Reflux (GERD). This treatment strategy has been associated with poor relief of symptoms and poor long-term outcomes. In fact, until recently, most patients with HH have been watched and referred for surgery as a last resort. Recent experience has shown that a large (giant) Hiatal Hernia (GHH) is a common problem known to impact adjacent organs such as the hearts and lungs. Those referred for surgical repair often complain of dyspnea, which is erroneously attributed to pulmonary compression or aspiration, but has been shown to be from tamponade caused from compression of the heart by herniated abdominal contents. This article reviews the present understanding of GHH, the cardiac complications which result from GHH, and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH. Methods: In a prospective cohort study, we evaluated patients undergoing RRHH with at least a 2-year follow-up. All patients undergoing elective (RRHH) were identified preoperatively and enrolled prospectively in this study. Preoperative characteristics, medical comorbidities, and clinical information were all recorded prospectively and recorded into a secure surgical outcomes database. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and at postoperative time points of 1 month, 1 year, and 2 years. Patients routinely had a barium swallow postoperatively before discharge but did not undergo a barium swallow, an endoscopy, or a CT scan study at the 1-month time point unless indicated by symptoms. At 6 months, 1 year, and yearly intervals thereafter, all patients received an endoscopy study to ascertain the presence of a recurrence, regardless of symptoms. Recurrence was defined as over 2 cm or 10% of the stomach above the diaphragm detected by CT, esophagogram or endoscopy. In addition, an extensive search was conducted using Pub Med in order to extract references to the cardiovascular complications of HH. Results: 423 patients underwent RRHH. With a long-term follow-up, there was a significant decrease in the Median Symptom Severity Score from 42.0 preoperatively, to 3.0 postoperatively. Recurrence was seen in 5 patients (5/423) for a recurrence rate of 1.1%. Conclusion: This experience has been the basis of two important realizations: 1) all patients with GHH have at least some degrees of clinically relevant compression of the inferior vena cava and the left atrium which causes tamponade and cardiogenic dyspnea which completely resolves after successful surgical repair; and 2) primary care providers and gastroenterologists who usually treat patients for GHH repair rarely recognize cardiac compression and tamponade as the cause of the shortness of breath and gradual increase in dyspnea on exertion and progressive fatigability in these patients. This article reviews the present understanding of GHH, the cardiac complications which result from GHH and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH.
Farid Gharagozloo
World Journal of Cardiovascular Surgery, Volume 12, pp 70-84;

Background: The mediastinum is a complex anatomical region which contains many vital structures. Many aspects of mediastinal surgery, like that for other anatomic regions, have evolved from a maximally invasive approach involving a median sternotomy, anterior mediastinotomy, mediastinoscopy or thoracotomy, to a minimally invasive video-assisted approach. Robotic surgery is presently the most advanced form of minimally invasive surgery. Methods: We reviewed our experience with a robotic approach to mediastinal pathology. In addition, an extensive search was conducted using PubMed, in order to extract references for the application of robotics to surgical conditions of the mediastinum. Results: The first robotic procedure by our group was a mediastinal procedure in 2003. In the past eighteen years, 203 patients have undergone robotic surgery for mediastinal pathology. There were 119 procedures for the Anterior Mediastinum, 33 procedures for the Middle Mediastinum, and 51 procedures for the Posterior Mediastinum. 78 patients underwent robotic thymectomy using a left-sided approach. 43/78 (55%) patients underwent radical thymectomy for Myasthenia Gravis. Thymoma was histologically identified in 32% of patients with Myasthenia Gravis. In patients with thymoma, there was no tumor recurrence. In patients with Myasthenia Gravis, the overall improvement rate after robotic radical complete thymectomy was 91% (39/43). Following robotic surgery for the mediastinal disease, the median hospitalization was 3 days, major complications occurred in 0.9% of patients and there was no mortality. Conclusion: With the advent of robotic surgery, many of the current surgical approaches to diseases of the mediastinum will likely be replaced over time by robotic surgery. When applied to the mediastinum, robotics has a number of benefits when compared to conventional Video-Assisted Thoracic Surgery (VATS) including three-dimensional visualization, magnification of the operative field, precise instrument movement, and improved dexterity. Much of the mediastinal disease encountered in an adult is benign, making it especially suited to a minimally invasive approach. With the use of the robot, a complete anatomical and oncological procedure can be performed through a number of small incisions or ports, while at the same time providing the patient with minimally invasive benefits including shorter hospitalizations, quicker returns to preoperative activity, less pain, less inflammatory response and better cosmesis. The excellent range of motion of the robotic instruments makes them particularly suitable to maneuver around the vital structures and the rigid axial skeleton encountered in various compartments of the mediastinum, and for reaching those “distant” areas of the mediastinum that are difficult to explore and dissect with conventional Video-Assisted Thoracic Surgery (VATS).
Salih Fehmi Katırcıoğlu, Hasan Attila Keskin
World Journal of Cardiovascular Surgery, Volume 12, pp 21-27;

A 58-year-old male patient with LAD diffuse had hyperlipidemia and hypertension. Preoperative angiography showed that he had triple-vessel disease with diffusely diseased LAD. In echocardiography, EF was detected as 60 % (52 - 70) and PAP 25 (12 - 25) mmHg and 2 degrees of tricuspid insufficiency. In this case report, we will present our LAD endarterectomy case. Surgical technique: after standard general anesthesia, cardiopulmonary bypass procedure and moderate hypothermia, cold cardioplegic arrest. Longitudinal long LAD endarterectomy was performed (approximately 10 cm long). A dissector was used to develop on the plane between media and atheroma. Gentle traction was made to light off the atheroplaque with the coronary artery branches, distal and proximal part of the LAD. We assumed that the distal part of the LAD was free from plaque. Then we made the same procedure to the proximal part of the LAD. Luckily, we observed that proximal atheroplaque was also harvested. After completing the endarterectomy, antegrade cardioplegia was administrated to wash and any debris is LAD; also we tried the distal part of the LAD. Via retrograde cardioplegia administrated, we did also observe the bolus return of cardioplegia via retrograde way. After making the same coronary end arteriotomy was successful, we used saphenous vein as a patch for LAD reconstruction. We made only patch plasty like a carotid endarterectomy. Posto- perative follow-up period was 120 months. According to 8 years angiography result, LAD patch plasty was working relatively well. The patient did not have any complaints. We made coronary angiography 10 years after the operation and observed that our patch plasty was occluded but the patient has still class II symptoms with an EF value of 40%.
Farid Gharagozloo, Mark Meyer, Jay Redan
World Journal of Cardiovascular Surgery, Volume 12, pp 105-117;

Background: With the increasing number of laparoscopic fundoplications, many more patients with a failed primary antireflux operation are being referred for complex redo procedures. The objective of this study was to evaluate our results of redo antireflux surgery using the Belsey Mark IV (BMIV) Repair. Methods: A retrospective analysis of the patients who underwent BMIV repair following a failed fundoplication was performed. The primary endpoint was failure of the redo procedure and recurrent hiatal hernia. Secondary endpoints were assessment of the functional results of the redo fundoplication and quality of life with a Dysphagia Score, and Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQOL) questionnaire. Results: 206 patients underwent surgery for failed primary fundoplication. Most patients had one prior antireflux surgery 148/206 (71.8%). The most common primary failed fundoplication was the Nissen procedure (189/206, 91.7%). The median time from the prior operation to the redo operation was 34 months. Median follow-up was 25.6 months. The Dysphagia score decreased from 3.6 ± 0.5 preoperatively to 1.0 ± 0.4 postoperatively (p Conclusion: Complete takedown and reestablishment of the normal anatomy, recognition of a short esophagus, and proper placement of the wrap are essential components of a redo antireflux procedure. The BMIV repair as the choice of reopertaive procedure results in excellent symptom relief, significant improvement in quality of life, and is associated with excellent medium-term durability in terms of recurrence of the hiatal hernia.
Raghda Basil Ismael Alkhateeb, Asmaa Saleem Esmail Ah-Ghurabi, Laith Saleh Alkaaby, Abdulsalam Y. Taha
World Journal of Cardiovascular Surgery, Volume 12, pp 153-172;

Background: Deep sternal wound infection (DSWI), or mediastinitis, is a devastating complication of coronary artery bypass grafting (CABG). This prospective study aimed to assess our management of DSWI in view of the published literature. Methods: Over 2-years (ending in January 2016), 29 patients (20 males) developed DSWI amongst 520 patients who underwent standard CABG surgeries (5.6%). Pre-, intra- and postoperative variables were documented. Whenever possible, the infections were culture-verified. Besides antibiotics, patients received one or more of the following therapies: drainage, debridement, closed irrigation, sternal re-wiring, vacuum-assisted closure (VAC), and bone resection. Results: the male to female ratio was 2.2:1. Mean age was 58.1 ± 7.3 years. The mean body mass index (BMI) was 27.9 ± 3.4 kg/m2. There were 18, 16 and 11 patients with diabetes mellitus (DM), hypertension and chronic obstructive pulmonary disease (COPD) respectively. Cardiopulmonary bypass (CPB) was utilized in 26 (89.7%) patients with a mean time of 117.5 ± 23.3 minutes. Most surgeries (n = 21, 72.4%) lasted 5 - 6 hrs. According to Pairolero classification, there were 3 (10.3%) Type I, 22 (75.9%) Type II and 4 (13.8%) Type III infections. Four (13.8%) cases were culture-verified. Twenty-three (79.3%) DSWIs were surgically managed. Sternal re-wiring was performed in 14 (48.3%) cases while VAC was added to other therapies in 2 (6.9%) patients. DSWIs completely resolved in 18 (62.0%) patients within 3 - 24 weeks while two (6.9%) patients died within 30 days. Conclusion: We have identified six independent risk factors for DSWI (male gender, obesity, DM, hypertension, COPD and CPB), five of them are modifiable.
Hozhan Hussein Blbas, Abdulameer Mohsin Hussein, Muhammad Mahmud Salim, Laith Saleh Alkaaby, Abdulsalam Y. Taha
World Journal of Cardiovascular Surgery, Volume 12, pp 173-183;

Background: Cardiac myxomas are the most frequently encountered benign cardiac tumors that if left untreated are inexorably progressive and potentially fatal. Surgery is the only way of treatment, and if not treated with the right surgical technique recurrence occurs. Objectives: In this single center study we documented the patterns of presentation, localization, surgical approaches and outcome of cardiac myxomas. Methods: This is a retrospective study of 20 patients who underwent surgical removal of atrial myxoma from January 2010 to December 2015. All patients underwent general investigations, and echocardiography was performed on all patients and surgery was done using extracorporeal circulation and mild hypothermia. Results: The ages of the patients ranged from 14 years to 71 years, with a mean of 51.45 years. Most myxomas (75%) originated from left atrium, 20% from right atrium and biatrial in 5% of cases. The male-to-female ratio was 1:2.3 (14 females and 6 males). Myxomas were more common in blood group A+ and B+. Chief complaints were dyspnea (70%) and palpitation (50%). The majority of masses were attached to the interatrial septum (65%) and four of cases (20%) arose from the lateral wall. Right atrial trans-septal incision was used in 55% of cases. No recurrence was recorded in our study. Six patients had postoperative complications, mainly in the form of arrhythmia (3 cases), bleeding (0ne case) and renal failure (one case) which resulted in the death of the patient. Conclusions: Cardiac myxoma excision account for a very small percentage of cardiac procedures. Immediate surgical treatment is indicated because of high risk of embolization and sudden death. Cardiac myxomas can be excised with a low rate of mortality and morbidity. Follow-up examination, including echocardiography, should be performed regularly.
Suha Zubairi, Mohammad Hassan Mirza, Mohammad Saad Iqbal, Mubashir Zareen Khan, Muneer Amanullah
World Journal of Cardiovascular Surgery, Volume 12, pp 184-190;

Background and Aim: Mechanical prosthetic heart valves exert a lifelong thromboembolic complication requiring continuous antithrombotic therapy. Vitamin K antagonist is the recommended therapy of choice along with meticulous INR monitoring to achieve and maintain an INR of 2.0 - 3.0. The study aimed to assess the compliance of anticoagulant therapy in pediatric patients after AVR and to highlight the challenges faced during follow-ups. Methods: A retrospective study was conducted at NICVD Hospital in Karachi, Pakistan for a time frame of 2 years from 2020-2021 where 7 patients were selected. Data were collected using hospital medical records and then validated through a phone call mediated structured questionnaire-based interview. Results: 2 out of 7 patients in the case series were compliant to regular follow-ups and had their INR in the desired range owing to their higher education status and access to INR clinic for regular follow-up in urban setting. Younger patients in the case series were non-compliant. 4 out of 7 patients who were on dual anti-coagulant regimens including warfarin and aspirin were either closer or within the range than compared to those on single drug regimen. Conclusion: Compliance was observed in patients who had favorable demographics and higher education. Multiple recent trials including PROACT and PROACT XA are underway to develop novel treatment options apart from warfarin after mechanical aortic valve replacement. Home-based INR testing kits provide easy access to regular testing in remote areas. Multi-center studies are required for in-depth analysis regarding reasons of non-compliance in pediatric population.
Farid Gharagozloo, Mark Meyer
World Journal of Cardiovascular Surgery, Volume 12, pp 207-218;

Background: The use of a vascularized pedicle flap of diaphragmatic muscle (DF) for reconstructive procedures in the chest has many advantages. Yet, despite the excellent reported results, the use of DF has not been widespread. Some factors for the less widespread use of DF have been, concern about diaphragmatic function, hesitation to use such a vital muscle for reconstructive purposes, and most importantly, the technical aspects for the preparation of the flap. Methods: Using a cadaveric model, the vascular anatomy of the diaphragm and the steps for the preparation of the DF was defined and illustrated for both the right and left hemidiaphragm. Results: No perioperative mortality with the use of DF has been recorded. Function of the native diaphragm has not been impaired. Bronchopleural fistulas and pericardial defects have healed in all instances. Excellent repair has been achieved in all patients with esophageal lesions. The disruption of the repaired native diaphragm and visceral herniation has been reported but it has been attributed to the learning curve and the technique of repair. Conclusion: With a better understanding of the vascular anatomy of the diaphragm and a formal methodical approach to harvesting the DF, more surgeons will be encouraged to use DF with excellent results.
Vusal Hajiyev, Temirlan Erkenov, Elgun Hajiyev, Alexander Bauer, Andreas Smechowski, Seymur Musayev, Dirk Fritzsche
World Journal of Cardiovascular Surgery, Volume 12, pp 196-199;

Prolonged cardiorespiratory support can be achieved with ECMO that may provide time for myocardial recovery, prevent multiorgan dysfunction and reduce mortality. Left ventricle (LV) distension can worsen already distended and hypocontractile heart. Early recognition and aggressive management of LV distension are essential for the treatment of patients with low cardiac output. The case report presented intends to show advantages of left ventricular venting on ECMO after post-cardiotomy shock. With direct flow measurements on bypass-grafts before and after the vent implantation, it was possible to clearly demonstrate the importance of venting for myocardial perfusion.
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