BACKGROUND:Vasoplegic syndrome is associated with high mortality. Methylene blue (MB) is a guanylate cyclase inhibitor that ameliorates this re-distributive type of shock. This study aims to investigate the outcome in patients who received MB early postoperatively. METHODS:2753 patients who underwent cardiac surgery utilizing cardiopulmonary bypass at our institution in a time interval of two years were identified. The incidence of vasoplegic syndrome was 7.2% (n = 200). Pharmacy records identified 84 patients (group 1, MB group) who received methylene blue and 116 patients (group 2, Control group) who didn't receive the drug. This single-center retrospective cohort study's primary outcome was in-hospital mortality. Secondary outcomes were postoperative hemodialysis, serum lactate levels at 24 h postoperatively, and intensive care unit stay length in days. RESULTS:MB patients have a shorter ICU stay as compared to the control group (9 ± 8 days vs. 16 ± 6.9; p-value <.001). In the control group, postoperative hemodialysis was higher (20% in the MB group and 40% in the control group; p-value <.05). At 24 h post-op, the methylene blue group had reduced serum lactate levels (1.8 ± 1.2 vs. 4 ± 1.8 in the control group; p-value <.001). The methylene blue group had a decreased 24-hour norepinephrine dose (1.5 ± 1.2 vs. 2.8 ± 2 in the control group; p-value <.05). In-hospital mortality was not significantly different between the two groups (38% in the MB group vs. 43% in the control group). CONCLUSION:Early postoperative administration of methylene blue in patients with vasoplegic syndrome shortens intensive care unit stay and contributes to less end-organ damage.

Background Cardiac myxomas are the most common primary cardiac neoplasms. Case Description We present a case of a middle-aged lady with cardiac myxoma in her left atrium awaiting semi-elective surgery. During the preoperative period, the patient presented emergently with acute bilateral lower limb ischemia. This lady was fortunate to have these emboli fired towards a tissue with ischemia tolerance capacity. If these emboli had been directed toward the central nervous system, this patient would have experienced devastating complications and even death. Conclusion This presentation opens the debate on the timing of surgical intervention in myxoma patients.

Hedinger Syndrome or carcinoid heart disease is a rare cardiac complication of neuroendocrine tumors (NET) affecting the tricuspid and pulmonary valves. Following is a case description of a patient undergoing treatment for a neuroendocrine tumor with liver metastasis, referred with symptomatic tricuspid valve regurgitation and pulmonary valve stenosis for surgical valve replacement. Planned surgical valve replacement was successfully performed before the onset of severe right ventricular failure or pulmonary hypertension in this case of carcinoid heart disease. An interdisciplinary approach and regular follow up is recommended in such cases.

The outcome of the patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) is also influenced by the renal and hepatic organ functions. Risk stratification, using scores such as EURO Score II or STS Short-Term Risk Calculator for patients undergoing cardiac surgery with cardiopulmonary bypass, ignores the quantitative renal and hepatic function; therefore, MELD-Score was applied in these cases. We retrospectively examined patient data using the MELD score as a predictor of mortality. To perform a univariate analysis of the data, patients were classified into three groups based on the MELD Score: MELD < 10 (Group 1), MELD 10 to 19 (Group 2), and MELD ≥ 20 (Group 3). A total of 11,477 participants were included in the study, though several patients with either missing MELD scores or lack of creatinine, bilirubin, or INR levels were dropped from the original cohort. Eventually, 10,882 patients were included in the analysis. The primary outcome was defined as postoperative, in-hospital mortality. Secondary outcomes such as postoperative bleeding, including the requirement for repeat thoracotomy, postoperative neurological complications, and assessment of catecholamines on weaning from cardiopulmonary bypass/ requirement of mechanical circulatory support were examined. A higher MELD score was associated with increased postoperative mortality. Patients with MELD > 20 experienced a 31.2% postoperative mortality, compared to Group 1 (4.6%) and Group 2 (17.5%). The highest rates of postoperative bleeding (13.8%) and, repeat thoracotomy (13.2%) & postoperative pneumonia (17.4%) were seen in Group 3 (threefold increase when compared to Group 1, renal failure requiring dialysis (N = 235, 2.7% in Group 1 v/s N = 78, 22.9% in Group 3) or requiring high dose catecholamines post-operatively or mechanical circulatory support (IABP/ECLS). Incidentally, an increased MELD Score was not associated with a significant increase in the postoperative incidence of stroke/TIA or the presence of sternal wound infections/complications. A higher mortality was observed in patients with reduced liver and renal function, with a significant increase in patients with a MELD score > 20. As the current risk stratification scores do not consider this, we recommend applying the MELD score before considering patients for cardiac surgery.

BACKGROUND The optimal management strategy for acute aortic type A dissection remains controversial. Whether a limited primary (index) repair would increase the need for late aortic reintervention is still an open debate. METHODS A total of 393 consecutive adult patients with acute type A aortic dissection who underwent cardiac surgery were analyzed. Our research hypothesis was whether limited aortic index repair (i.e., isolated aorta ascending replacement without an open distal anastomosis with and without a concomitant aortic valve replacement, including hemiarch replacement procedure) is associated with a higher incidence of late aortic reoperation compared with extended repair (i.e., any other surgical procedure that goes beyond that limited approach). RESULTS Type of the initial repair had no statically significant relationship with in-hospital mortality with a P-value of 0.12, however in multivariable analysis, cross-clamp time had a statistically significant relation with mortality (P = 0.4). From the patients who survived until discharge (N = 311), 40 patients needed a reoperation on the aorta; the mean interval until reoperation was 4.5 years. The relationship between the type of the initial repair and the need for reoperation didn't reach a statically significant value (P = 0.9). In-hospitable mortality after the second operation was 10% (N = 4). CONCLUSION We reached two conclusions. 1) An extended prophylactic repair in the initial operation of an acute type A aortic dissection might not lead to a lower incidence of reoperations on the aorta and could increase in-hospital mortality by increasing cross-clamp time, and 2) Reoperation on the aorta could be done safely with acceptable mortality outcomes.

Background Myxomas are the most common primary cardiac tumor in adults and are most commonly found within the left atrium. These are usually asymptomatic, detected incidentally, or present gradually with symptoms typical of heart failure. Case Description This case report is a description of a case of syncope caused by a large left atrial myxoma. Conclusion Atrial myxomas may present with transient loss of consciousness, especially when they prolapse through the atrioventricular valves or when embolization occurs. Non-invasive diagnostic tools (e.g., echocardiogram, cardiac computed tomography) should be considered to thoroughly evaluate cardiogenic causes of syncope.

INTRODUCTION:The Frozen Elephant Trunk technique is a well-established treatment for aortic dissections (Stanford Type A) involving the aortic arch and descending aorta. The Thoraflex™ Hybrid prosthesis (Vascutek Ltd.), consisting of a proximal flexible conduit and a distal self-expanding covered stent, has consistently shown positive results in the treatment of this condition.CASE DESCRIPTION:The following is a description of such a staged reconstruction using the Thoraflex™ Hybrid Ante-Flo™ device, performed in a patient previously diagnosed with Loeys-Dietz Syndrome. After clamping the aorta proximally, an incision was taken at the distal end of the stent. Here, the distal end of the new prosthesis was inserted into the true lumen of the descending aorta and the stent was deployed. Following this, a bypass was established via the left atrium, and blood was returned to the lower body using the perfusion arm of the prosthesis with the proximal part of the descending aorta clamped. The collar of the prosthesis was sutured proximally to the aorta near the inlying previous stent. Air was removed via the perfusion arm of the prosthesis, which was then oversewn.DISCUSSION:To date, hybrid prostheses have only been used on the proximal aorta in patients with aortic aneurysms and aortic dissections (Stanford Type A).CONCLUSION:Using the described technique, it is possible to reconstruct the aortic anatomy using the available prostheses with accuracy and minimal complications.

Abstract Background-Reconstruction of the thoracoabdominal aorta after dissection (Stanford Type A with extension into descending aorta) has limited surgical options. Described here is a novel technique for the staged surgical repair of the thoracoabdominal aorta after reconstruction of the ascending aorta with aortic arch using a hybrid prosthesis. Case presentation- The thoracoabdominal aorta is accessed via a lateral thoracotomy. After a left-left bypass to perfuse the descending aorta, the proximal end of the prosthesis is anastomosed to the proximal aorta and distal end of the new prosthesis is then inserted into the true lumen of the descending aorta and the stent is deployed. Conclusion-Using this technique, operative time is reduced with accurate reconstructions of the anatomy.