Surgical Technology International
39th Edition
November 2021 - ISSN:1090-3941
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Total Artificial Heart Update
Jack Copeland, MD, Emeritus Professor of Cardiothoracic Surgery, Banner University Hospital, Tucson, AZ, Steve Langford, BSEE, Joseph Giampietro, RN, BSN, John Arancio, BA, SynCardia Systems, Tucson, AZ, Francisco Arabia, MD, MBA, Banner University Medical Center, Phoenix, AZ
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The SynCardia Total Artificial Heart (TAH, SynCardia Systems, Tucson, AZ) is the only biventricular cardiac replacement approved for bridge to transplantation by the U.S. Food and Drug Administration (FDA) and which carries the European Union CE mark. It has been implanted in about 2000 patients. In experienced centers, 60 to 80 % of implanted patients have been transplanted and over 80 % of those transplanted have lived for over 1 year.
The SynCardia TAH has supported potential cardiac recipients with irreversible biventricular failure for up to 6 years, providing physiologic pulsatile flows of 6 to 8 L/min at filling pressures of less than 10 mmHg allowing for optimal perfusion and recovery of organs such as the kidneys and liver. It is a tested device that provides a method for recovering potential transplant candidates who rapidly decompensate from biventricular failure or who have chronic cardiac failure from a variety of etiologies.
This article covers the history, mechanical function and monitoring, implantation, patient selection and management, and outpatient use. It also reviews outcome data from the original FDA study as well as contemporary data from experienced centers.
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Twenty Years’ Experience with Endovenous Laser Ablation for Varicose Veins: A Critical Appraisal of the Original Procedure
Bernardus Carolus Vincentius Maria Disselhoff, MD, PhD, Mosaderma Clinics, Hoensbroek, The Netherlands, Daan Joan der Kinderen, MD, PhD, Sanalink, The Netherlands
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Objective: A critical appraisal of the original procedure of endovenous laser ablation (EVLA) for varicose veins.
Method: Evaluation of all practical aspects of the procedure.
Results: EVLA procedures are performed in a strictly ambulatory setting with tumescent local anesthesia (TLA). Technical improvements have resulted in the need for fewer incisions and re-punctures, less ecchymosis, and fewer technical failures. Administration of an appropriate amount of TLA via an infusion pump has reduced the risk of nerve injury, administration time, and pain during the procedure. Use of a 1470-nm diode laser and a radial fiber have significantly improved patient satisfaction and reduced the occurrence of complications such as pain, tightness, ecchymosis, and the need for additional procedures. Lastly, there are only a few indications left for high ligation and stripping.
Conclusion: Over the past 20 years, EVLA has evolved into an effective, cost-efficient, and safe procedure that provides high patient satisfaction.
Techniques for Robotic-Assisted Surgical Myocardial Revascularization
Andrea Amabile, MD, Caroline Komlo, MD, Arnar Geirsson, MD,Yale University School of Medicine, Karel M. Van Praet, MD, Timo Z. Nazari-Shafti, MD, Markus Kofler, MD, Jörg Kempfert, MD, Volkmar Falk, MD, Stephan Jacobs, MD, German Heart Center Berlin, Germany, Gianluca Torregrossa, MD, Lankenau Heart Institute, Main Line Health, Philadelphia, USA, Husam H. Balkhy, MD, University of Chicago Medicine, Chicago, IL, USA
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The two current strategies for robotic-assisted, surgical myocardial revascularization are minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass grafting (TECAB). We discuss the rationale underlying the benefits of robotic assistance in surgical myocardial revascularization, and detail the technical steps to safely and effectively perform these two procedures.
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Placement of Simultaneous Inferior Vena Cava Filter During Emergent Open Pulmonary Thromboembolectomy
Paul Lajos MD, Clinical Associate Professor of Surgery, Ronald Bangiyev MPH, Buffalo General Medical Center, Buffalo, New York, Scott Safir MD, Ageliki Vouyouka MD, Professor of Surgery, Peter Faries MD, Professor of Surgery, Alan Weinberg MS, Associate Professor, Mount Sinai Medical Center, New York, New York, Ramachandra Reddy MD, Clinical Professor of Surgery, Baylor Scott White Clinic, Temple, Texas
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Background: This study retrospectively reviewed results of simultaneous (SIM) inferior vena cava (IVC) filter and separate (SEP) IVC filter placement with open pulmonary thromboembolectomy (PTE) in pulmonary embolism and its clinical outcomes.
Materials and Methods: From November 2006 to May 2014, 23 patients (14 females and 9 males; median age 58 years; range, 21–88 years) underwent emergent PTE for submassive (12) or massive (11) pulmonary embolism (PE). All had a preoperative computed tomography (CT) scan and echocardiography consistent with right ventricular (RV) strain. Mean cardiopulmonary bypass times and temperatures; chest tube outputs; length of stay; perioperative complications; and survival were compared between groups.
Results: There were 13 patients in the SIM group and 10 in the SEP group. PE consisted of 14 acute (60.9%) and nine acute on chronic (39.1%). There were seven deaths (30.4%). Median follow up was 44 days (range, 2–2204 days). Follow up was 81% complete in surviving patients. Actuarial survival at one and three years was 83% for the SIM group and 43% for the SEP group, respectively. There were no differences in cardiopulmonary bypass (CPB) times and temperatures, chest tube outputs, or length of stay between groups. Using multivariable logistic regression, we found SIM was associated with increased survival (p=0.09). Further analysis showed patients >55 years in the SEP group were at significantly higher risk of death (hazard ratio [HR]=7.1:1; 95% confidence interval [CI]: 1.55, 32.5, p=0.011).
Conclusion: IVC filter placement can be performed simultaneously and safely at PTE. Age >55 years and PTE with IVC filter placed separately were at significantly higher risk of death. A larger cohort is needed to evaluate efficacy of simultaneous IVC filter placement and PTE.
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Transcatheter Aortic Valve Implantation in Bicuspid Aortic Valve Pathology: Current Evidence and Technical Challenges
Andreas Schaefer, MD, MHBA, Lenard Conradi, MD,Professor, University Heart and Vascular Center Hamburg, Hamburg, Germany
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Transcatheter aortic valve implantation (TAVI) is an established therapy for severe symptomatic aortic valve stenosis (AS) in patients at high and intermediate risk for surgical aortic valve replacement (SAVR). Current evidence also suggests at least non-inferiority of TAVI in low-risk patients compared to SAVR. However, there are special subsets of patients and anatomical circumstances in which TAVI is traditionally considered a suboptimal treatment strategy due to procedure inherent increased risks (e.g., rupture of cardiac chambers in patients with severe calcifications of the left ventricular outflow tract, valve migration in very large aortic annuli). One of these special subsets is bicuspid AS. Bicuspid aortic valve disease is the most common congenital heart defect and most frequent reason for AS in patients <70 years of age. Bicuspid aortic valve pathology is characterized by special anatomical complexities like asymmetrical cusp proportion and calcium distribution, a more pronounced annular ellipticity compared to tricuspid aortic valves and concomitant dilation of the thoracic aorta. These factors have led physicians to traditionally indicate TAVI more reluctantly in those patients in the past.
In this article, current evidence for TAVI for bicuspid AS is discussed and technical challenges are highlighted.
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Preoperative Sucrosomial Iron Supplementation Increases Haemoglobin and Reduces Transfusion Requirements in Elective Heart Surgery Patients: A Prospective Randomized Study
Luca Pierelli, MD, Professor of Hematology, Sapienza University, Rome, Italy, Alessandro De Rosa, MD, Maria Beatrice Rondinelli, MD, San Camillo Forlanini Hospital, Rome, Italy, Mauro Falco, MD, European Hospital, Rome, Italy, Elsie Papi, MD, Franco Turani, MD, Aurelia Hospital, Rome, Italy, Luca Weltert, MD, Professor of Medical Statistics, San Camillus International University for Health Sciences, Rome, Italy
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ClinicalTrials.gov Identifier:
NCT03560687
Background: Low preoperative haemoglobin is frequently observed in heart surgery patients and is associated with a significant decrease in haemoglobin between post-operative days 2 and 3, known as haemoglobin drift. Overall, these patients tend to receive many RBC transfusions. Since iron homeostasis is often impaired in these patients, restoration of iron availability might override iron-restricted erythropoiesis. However, reduced tolerance to oral iron salts has limited this strategy to intravenous iron administration.
Study Design and Methods: The purpose of this study was to assess whether preoperative supplementation with oral sucrosomial iron, a new iron-delivery technology with improved tolerance and bioavailability, might be an effective strategy for this patient population. One thousand consecutive patients were randomized and received either a one-month course of sucrosomial iron (60 mg/day) or no treatment prior to elective heart surgery at a single high-volume centre (ClinicalTrials.gov NCT03560687). Primary end-points were haemoglobin concentration on the day of hospital admittance and number of blood transfusions. Secondary end-points were haemoglobin drift, tolerance of treatment and cost-effectiveness of sucrosomial iron administration.
Results: Baseline haemoglobin in the treatment group was higher (by 0.67 g/dL; p<0.001) than that in the control group. The percentage of patients in the treatment group who required transfusion (35.4%) was half that in the control group (64.6%). The average number of transfused units per operation was 0.95 vs. 2.03 in the treatment and control groups, respectively. Haemoglobin drift was substantially similar in the two groups, and the tolerability of treatment was excellent (98%). The overall cost of treatment was 156 Euros less in the treatment group, expressed as a raw cost of transfusion.
Conclusion: In elective heart surgery, routine preoperative sucrosomial iron administration seems to be a safe, well-tolerated and cost-effective strategy to increase preoperative haemoglobin and reduce the need for allogeneic blood transfusions.
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Does Endovascular Repair for Blunt Traumatic Aortic Injuries Provide Better Outcomes Compared to its Open Technique? A Systematic Review and Meta-analysis
Shekhar Gogna, MD, MS, MBBS, Mahir Gachabayov, MD, PhD, Priya Goyal, MBBS, MS, Rifat Latifi, MD, FACS, FICS, FKCS, The Felicien Steichen Professor, Westchester Medical Center, Valhalla, NY
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Introduction: Traumatic aortic injuries are devastating events in terms of high mortality and morbidity in most survivors. We aimed to compare the outcomes of endovascular repair (ER) vs. open repair (OR) in the treatment of traumatic aortic injuries.
Methods: PubMed, Embase, and Cochrane Library were systematically searched. Postoperative mortality was the primary endpoint. Secondary endpoints included intensive care unit (ICU) length of stay, hospital length of stay, operating time, paraplegia, stroke, acute renal failure, and reoperation rate. The Mantel-Haenszel method (random-effects model) with odds ratios and 95% confidence intervals (OR (95% CI)), and the inverse variance method with the mean difference (MD (95% CI)), were used to measure the effects of continuous and categorical variables, respectively.
Results: A total of 49 studies involving 12,857 patients were included. Postoperative mortality was not significantly different between the two groups (p=0.459). Among secondary outcomes, the paraplegia rate was significantly lower after ER (p=0.032). Other secondary endpoints such as ICU length of stay (p=0.329), hospital length of stay (p=0.192), operating time (p=0.973), stroke rate (p=0.121), ARF rate (p=0.928), and reoperation rate (p=0.643) did not significantly differ between the two groups.
Conclusion: This meta-analysis found that ER was associated with a reduced paraplegia rate compared to OR for the management of traumatic aortic injury.
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Modified Sling Technique for Difficult Filter Retrieval
Pasquale Grillo, MD, Giuseppe Granata, MD, Anna Paola Savoldi, MD, Giovanni Maria Rodà, MD, University of Milan, Milan, Italy, Salvatore Alessio Angileri, MD, Anna Maria Ierardi, MD, Gianpaolo Carrafiello, MD, Professor, Università degli studi di Milano, Milan, Italy, Gianlorenzo Dionigi, MD, Professor, Istituto Auxologico Italiano IRCCS, Milan, Italy
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Caval filters are placed in the inferior vena cava (IVC) to prevent pulmonary thromboembolism in patients with deep vein thrombosis. If there is no indication for thrombo-embolic risk prevention, the filter can be removed to reduce potential filter-related complications.
Advanced endovascular techniques are frequently used to retrieve IVC filters. We describe an alternative filter-removal technique for use when standard techniques are not practicable.
In our method, the filter hook is embedded within the IVC wall. To retrieve it, a long introducer is inserted; a guidewire and the "loop snare" retrieval system are then advanced through it with a coaxial system and positioned below the filter at the level of the common iliac vein confluence. The guidewire is then passed through the loop, creating a "sling" around the filter which allows the application of traction from the bottom upwards, releasing the hook from the wall.
The loop is then held under tension with the filter aligned in the IVC lumen, and the introducer is advanced distally to completely cover the filter, allowing complete retrieval of the filter without damaging the vessel walls.
This modified Sling technique is a safe and feasible method for complicated IVC filter retrieval.
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Platelet-Rich Fibrin in Combination with Local Antibiotics Optimizes Wound Healing After Deep Sternal Wound Problems and Prevents Reinfection
Ralf-Uwe Kuehnel, MD, Filip Schroeter, Dr. rer. nat., Torsten Mueller, Roya Ostovar, MD, Johannes M. Albes, MD, Professor, Heart Center Brandenburg, Department of Cardiovascular Surgery, University Hospital Brandenburg Medical School “Theodor Fontane”, Bernau, Germany
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Objective: Disturbed wound healing is a significant problem in patients after cardiac surgery. Problems with deep sternal wound healing are rare, but can be quite difficult to treat. Furthermore, the therapy is highly expensive and consumes many of the patient’s personal resources. Another major obstacle in this patient group is reinfection after secondary wound closure. We examined how to prevent early reinfection through the use of growth factors in combination with local antibiotics.
Methods: Our study included 232 patients with a deep sternal wound healing problem. After initial vacuum therapy, we planned secondary wound closure. During wound closure, we used only platelet-rich fibrin in a PRF group (109 patients). In another group (123 patients), we covered the wounds intraoperatively with a combination of PRF and local antibiotics (PRF CoDelivery). All patients were observed for 30 days for signs of early surgical site infection.
Results: After 30 days, 22 patients (20.2%) in the PRF group showed a persistent problem with wound healing with or without reinfection. In contrast, only 12 patients (9.8%) in the PRF CoDelivery group had this problem (p=0.023 PRF vs. PRF CoDelivery).
Conclusion: The combination of growth factors and antibiotics was associated with a significantly reduced incidence of early reinfection and thus can be expected to have a positive impact on wound healing in complicated scenarios. Furthermore, the combination of PRF and local antibiotics was easy to use. Further studies are needed to verify these initial findings.
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Intravascular Lithotripsy in the Treatment of Lower Extremity Peripheral Arterial Disease
Christopher M. Hatzis, MD, Justin M. George, MD, Rami O. Tadros, MD, FACS, FSVS, RPVI, Associate Professor, The Icahn School of Medicine at Mount Sinai, New York, New York Nicole Ilonzo, MD, Assistant Professor, Weill Cornell Medicine, New York-Presbyterian Brooklyn Methodist Hospital, New York, New York Lucyna Price, MD, Assistant Professor, Stony Brook Medicine, Stony Brook, New York
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Endovascular intervention has become first-line treatment for the majority of atherosclerotic lesions associated with peripheral artery disease. Traditionally, treatment modalities have included various types of balloon angioplasty and stenting. However, recent technological advancements have introduced the concept of endovascular lithotripsy as a novel alternative to angioplasty and stenting. This new addition to the armamentarium of surgeons and interventionalists has the potential to alter the treatment paradigm for patients with complex peripheral artery disease.
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Advances in Transcatheter Aortic Valve Therapy in Bicuspid Aortic Valve Disease: Insight into Patient Selection, Management, and Future Directions
Valeria Cammalleri, MD, PhD, Assistant Professor, Gianpaolo Ussia, MD, Professor , University Campus BioMedico of Rome, Italy, Mario Lusini, MD, PhD, Associate Professor , Ciro Mastroianni, MD, PhD, Associate Professor , Massimo Chello, MD, Professor , University Campus BioMedico of Rome, Italy , Francesco Nappi, MD, Assistant Professor, Centre Cardiologique du Nord St. Denis, France
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Bicuspid aortic valve (BAV) disease is the most common congenital abnormality and is characterized by a risk of premature aortic valve disease, predominantly aortic stenosis. Surgery remains the treatment of choice for patients with symptomatic BAV disease, but, in patients who are unsuitable for surgical aortic valve replacement, transcatheter aortic valve replacement (TAVR) is currently used as an alternative to surgery, although there is no official recommendation for their management, since BAV patients with severe aortic stenosis have been excluded from the major TAVR randomized clinical trials. Patients with BAV stenosis present anatomic challenges for treatment with TAVR. The BAV annulus often has an elliptical shape and is larger than the tricuspid valve, and is more likely to exhibit severe eccentric calcification. In addition, BAV is often associated with a dilated, horizontal ascending aorta, and effaced sinuses. The calcified raphe may also place differential stress on the expansion of the transcatheter valve, increasing the risk of suboptimal positioning and consequently the risk of paravalvular leakage, new pacemaker implantation, new-onset left bundle branch block, and annular rupture. Moreover, coronary obstruction may occur when leaflet fusion results in a longer leaflet. Although some of these challenges have been successfully overcome using new-generation devices, the complication rate is still relatively high and requires a deeper understanding of the patient’s specific complex and variable anatomy. Selection of the type and size of the transcatheter valve according to the patient’s individual anatomy is critical to achieving successful results. Therefore, given the increasing frequency of BAV stenosis in younger patients, and the worldwide expansion in the application of TAVR in younger and lower surgical-risk patients, preprocedural multimodality imaging involving CT scan and three-dimensional echocardiography is mandatory to understand the complex and variable anatomy of BAV disease and improve both procedural results and short- and long-term outcomes in these patients.
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Transcarotid Artery Revascularization and Advances in Vascular Surgery for Carotid Artery Disease
James Hu, MD, Andy Sohn, MD, New York Presbyterian Hospital - Brooklyn Methodist, Brooklyn, NY, USA, Justin George, MD, Mount Sinai Hospital, New York, NY, USA, Rajesh Malik, MD, Assistant Professor, Nicole Ilonzo, MD, Assistant Professor, Weill Cornell Medicine, New York, NY, USA
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Carotid artery atherosclerotic disease impacts over 2 million Americans annually. Since the advent of the carotid endarterectomy by Debakey in 1953, the surgical management of carotid artery stenosis has prevented cerebrovascular accidents. The technology utilized to manage carotid artery stenosis continued to evolve with the utilization of carotid artery stenting in 1989 and more recently transcarotid artery revascularization (TCAR). This review discusses the modern management of carotid artery stenosis with an emphasis on transcarotid artery revascularization (TCAR) and reversal of flow for reversal of flow for embolic protection.
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Large-bore Aspiration Thrombectomy for Acute Venous Thromboembolism
Andy Sohn, MD, James Hu, MD, New York Presbyterian Hospital - Brooklyn Methodist, Brooklyn, NY, USA, Jennifer Colnick, BA, VTE Consultant/Account Manager, Inari Medical, Irvine, CA, USA, Justin George, MD, Vascular Surgery Fellow, Mount Sinai Hospital, New York, NY, USA, Nicole Ilonzo, MD, Assistant Professor, Rajesh Malik, MD, Assistant Professor, Cornell Medicine, New York, NY, USA
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Pulmonary embolism can occur following dislodgement of deep venous thrombosis into the pulmonary artery circulation, which results in obstruction of the pulmonary artery system and can be fatal. The consequences of pulmonary embolism include hypotension, right heart strain, and hypoxia. In the long term, pulmonary embolism may lead to Chronic Thromboembolic Pulmonary Hypertension (CTEPH). Patients who develop hypotensive massive and submassive pulmonary embolism can be treated with large-bore aspiration thrombectomy. In the acute setting, this improves short-term outcomes by decreasing the ICU stay. It can also reduce the risk of CTEPH. Options for large-bore aspiration thrombectomy include the FlowTriever™ system (Inari Medical, Irvine, CA) and the Lightning 12 vascular thrombectomy system (Penumbra Inc., Alameda, CA). This review discusses the pathophysiology of pulmonary embolism, management, and options for large-bore aspiration thrombectomy.
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