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Davorin Sef

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MD PhD FEBCTS Cardiac Surgeon

Board Certification by the European Board of Cardiothoracic Surgery (FEBCTS, Fellowship of the European Board of Cardio-Thoracic Surgery in Adult Cardiac)

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Papers by Davorin Sef

Dynamic associations between adverse events after lung transplantation and allograft ischemic time

European journal of cardio-thoracic surgery, 2024

Objective: The effect of allograft ischemic time (AIT) on postoperative events after lung transpl... more Objective: The effect of allograft ischemic time (AIT) on postoperative events after lung transplantation (LTx) remains unclear. This study aims to assess the feasibility of extending the duration of AIT. Methods: The United Network for Organ Sharing database was queried for adult LTx from 4 May 2005 to 30 June 2020. Patients were divided as per AIT into standard (SIT, <6 hours) and prolonged (PIT, ≥6 hours) groups using propensity score matching and evaluated on a continuous scale using restricted cubic splines. The primary outcome was overall 1-year and 5-year survival. Results: Among 11,438 propensity matched recipients, SIT and PIT showed no differences in overall 1-year (P= 0.29) or 5-year (P= 0.29) survival. PIT independently predicted early postoperative ventilator support for >48 hours (OR=1.33, 95% CI:1.22-1.44), dialysis (OR=1.55, 95% CI:1.30-1.84), primary graft dysfunction (PGD; OR=1.28, 95% CI:1.09-1.50), and acute rejection (AR; OR=1.42, 95% CI:1.24-1.62), and interestingly, decreased 5-year bronchiolitis obliterans syndrome (BOS; HR=0.91, 95%CI:0.85-0.97). In relative risk curves, 1-year mortality, prolonged ventilation, dialysis, and PGD steadily increased per hour as AIT extended. The risk of AR and 5year BOS also showed significant changes between 5 and 8 hours of AIT. In contrast, 5-year mortality remained constant despite rising AIT. Conclusions: Prolonged AIT worsened early outcomes such as PGD, but improved BOS freedom at later timepoints. Despite this, both short-and long-term survival were similar between PIT and SIT patients. Dynamic risk changes in post-transplant events should be noted for prolonged ischemia lung use.

Aortic arch replacement in patients with previous repair of acute aortic dissection: a systematic review and meta-analysis

Eur J Cardiothorac Surg, 2024

Objectives: Despite the popularity of the frozen elephant technique procedure in recent years, ev... more Objectives: Despite the popularity of the frozen elephant technique procedure in recent years, evidence is scarce regarding its utilisation for aortic arch replacement following previous acute aortic dissection repair. In this systematic review and meta-analysis, we aimed to analyse clinical outcomes of aortic arch replacement in patients with previous repair of acute aortic dissection.

Management of A Patient with an Unusual Trajectory of a Temporary Trans-Venous Pacing Lead

World Journal of Cardiology, 2024

Perforation of the right ventricle during placement of pacing wires is a welldocumented complicat... more Perforation of the right ventricle during placement of pacing wires is a welldocumented complication and can be potentially fatal. Use of temporary pacemaker, helical screw leads and steroids use prior to implant are recognised as risk factors for development of post-permanent pacemaker effusion. We reported an unusual case of pacing wire perforating interventricular septum into the left ventricle that occurred during the implant procedure performed in another institution. After the preoperative work-up and transfer to our tertiary cardiothoracic centre, the patient underwent successful surgical management. In conclusion, early recognition and timely diagnosis using advanced multimodality imaging can guide surgical intervention and prevent unfavourable consequences of device-related complications.

Minimally Invasive Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease: A Systematic Review

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery, 2024

Objective: We conducted a systematic review of all available evidence on the feasibility and safe... more Objective: We conducted a systematic review of all available evidence on the feasibility and safety of minimally invasive coronary artery bypass grafting (MICS CABG) in patients with multivessel coronary artery disease (CAD). Methods: A systematic literature search in PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science was performed to identify all relevant studies evaluating outcomes of MICS CABG among patients with multivessel CAD and including at least 15 patients with no restriction on the publication date. Results: A total of 881 studies were identified, of which 26 studies met the eligibility criteria. The studies included a total of 7,556 patients. The average patient age was 63.3 years (range 49.5 to 69.0 years), male patients were an average of 77.8% (54.0% to 89.8%), and body mass index was 29.8 kg/m 2 (24.5 to 30.1 kg/m 2). Early mortality and stroke were on average 0.6% (range 0% to 2.0%) and 0.4% (range 0% to 1.3%), respectively. The average number of grafts was 2.8 (range 2.1 to 3.7). The average length of hospital stay was 5.6 days (range 3.1 to 9.3 days). Conclusions: MICS CABG appears to be a safe method in well-selected patients with multivessel CAD. This approach is concentrated at dedicated centers, and there is no widespread application, although it has potential to be widely applicable as an alternative for surgical revascularization. However, large randomized controlled studies with longer follow-up are still required to compare the outcomes with conventional CABG and other revascularization strategies.

Perioperative and Long-Term Outcomes of Acute Stanford Type A Aortic Dissection Repair in Octogenarians

Medical Science, 2024

Background: The aims of this study were to assess the perioperative morbidity, mortality and long... more Background: The aims of this study were to assess the perioperative morbidity, mortality and long-term survival of octogenarians undergoing acute type A aortic dissection repair (ATAAD), and to compare open and closed distal anastomosis techniques. Methods: This was a single-centre retrospective study (2007–2021). Open versus closed distal anastomosis were compared. Uni- and multivariable logistic regression analyses were performed to identify independent predictors of in-hospital mortality. Kaplan–Meier and Cox proportional hazards methods were used to compare long-term survival. Results: Fifty octogenarian patients were included (median age—82 years; closed distal—22; open distal—28). Median cardiopulmonary bypass time was 187 min (open distal vs. closed distal group; 219 min vs. 115.5 min, p < 0.01, respectively). Median cross-clamp time was 93 min (IQR; 76–130 min). Median circulatory arrest time was 26 min (IQR; 20–39 min) in the open-distal group. In-hospital mortality was 18% (open distal; 14.2% vs. closed distal; 22.7%, p = 0.44). Stroke was 26% (open distal; 28.6% vs. closed distal; 22.7%, p = 0.64). Median survival was 7.2 years (IQR; 4.5–11.6 years). Survival was comparable between open and closed distal groups (median 10.6 vs. 7.2 years, p = 0.35, respectively). Critical preoperative status (HR; 3.2, p = 0.03) and composite endpoint (renal replacement therapy, new neurological event, length of stay > 30 days or return to theatre; HR; 4.1, p = 0.02) predicted adverse survival. Open distal anastomosis did no impact survival. Conclusions: ATAAD repair in selected octogenarians has acceptable short- and long-term survival. There is no significant difference between open versus closed distal anastomosis strategies.

Limited vs. Extended Resection of Stanford Type A Acute Aortic Dissections

Medicina, 2024

This article is an open access article distributed under the terms and conditions of the Creative... more

Neuromonitoring During Endovascular Thoracoabdominal Aortic Aneurysm Repair: A Systematic Review

Annals of Vascular Surgery, 2024

Introduction Spinal cord ischemia (SCI) is a potentially devastating complication of thoracic end... more Introduction Spinal cord ischemia (SCI) is a potentially devastating complication of thoracic endovascular aortic repair (TEVAR) and fenestrated-branched endovascular aortic repair (F-BEVAR). The aim of this systematic review was to evaluate the efficacy of neuromonitoring modalities to mitigate the risk of SCI during TEVAR and F-BEVAR procedures. Materials and Methods Following the PRISMA guidelines, we conducted a detailed literature search of databases including PubMed, MEDLINE via Ovid, Embase, Scopus, and Cochrane CENTRAL, from 1998 to the present. Inclusion criteria were original research articles examining neuromonitoring during TEVAR and F-BEVAR. The primary outcome was the incidence of SCI, while the secondary outcome included early mortality. The quality of studies was assessed using the Newcastle-Ottawa Scale. Results From 1,450 identified articles, 11 met inclusion criteria, encompassing data from 1,069 patients. Neuromonitoring modalities included motor-evoked potentials (MEPs), somatosensory evoked potentials (SSEPs), and near-infrared spectroscopy (NIRS). The combination of MEPs and SSEPs was most commonly used, with 93% sensitivity and 96% specificity for detecting SCI risks. SCI incidence ranged from 3.8-17.3%, with permanent deficits occurring in 2.7-5.8% of cases. In-hospital mortality ranged from 0.4-8%. Risk factors for SCI were identified, including operation duration and extent of aortic coverage. Conclusion Neuromonitoring with MEPs and SSEPs appears to be effective in detecting perioperative SCI risk during TEVAR and F-BEVAR. However, discrepancies between neuromonitoring changes and actual SCI outcomes suggest the need for cautious interpretation. While the incidence of SCI remains variable, identified risk factors may guide clinical decisions, particularly in high-risk procedures. Future research should focus on prospective studies and randomized controlled trials to validate these findings and improve SCI prevention strategies in TEVAR and F-BEVAR.

Left Internal Thoracic Artery versus Saphenous Vein Grafts to Left Anterior Descending Artery after Isolated Coronary Artery Bypass Surgery

by Davorin Sef and Suvitesh Luthra

Life, 2024

Background: This study compared perioperative outcomes and long-term survival of saphenous vein g... more Background: This study compared perioperative outcomes and long-term survival of saphenous vein grafts (SVGs) versus left internal thoracic artery (LITA) to left anterior descending artery (LAD) in isolated coronary artery bypass graft surgery (CABG). Methods: In this retrospective, single-centre study, we included patients with primary isolated CABG from January 2001 to July 2022. Baseline demographics were compared between SVG-LAD and LITA-LAD. Univariable and multivariable regressions were performed for predictors of in-hospital death. Propensity score matching was performed for LITA-LAD vs. SVG-LAD. Kaplan-Meier survival curves were generated for comparison of survival. Cox proportional hazards model was used for predictors of survival. Results: A total of 8237 patients (1602 SVG-LAD/6725 LITA-LAD) were included. Median age was 67.9 years (LITA-LAD; 67.1 years vs. SVG-LAD; 71.7 years, p < 0.01). A total of 1270 pairs of SVG-LAD were propensity-matched to LITA-LAD. In matched cohorts, in-patient mortality (0.8% vs. 1.6%, LITA-LAD and SVG-LAD respectively; p = 0.07), deep sternal wound infection, new cerebrovascular events, renal replacement therapy and hospital stay >30 days were similar. SVG-LAD did not adversely affect in-hospital mortality (OR; 2.03, CI; 0.91, 4.54, p = 0.08). Median long-term survival was similar between the groups (13.7 years vs. 13.1 years for LITA-LAD and SVG-LAD respectively, log rank p < 0.31). SVG-LAD was not a predictor of adverse long-term survival. (HR; 1.06, 95% CI; 0.92, 1.22, p < 0.40). Long-term survival was better with LITA-LAD for LVEF <30% (log rank p < 0.03). Conclusions: There was no difference in the propensity-matched cohorts for use of SVG vs. LITA to the LAD. Further contemporary long-term studies are needed for substantiation.

Minimally invasive aortic surgery (MIAS)

Liječnički vjesnik, 2008

In this study we presented benefits of minimally invasive approach (MIAS) for treating abdominal ... more In this study we presented benefits of minimally invasive approach (MIAS) for treating abdominal aortic aneurysm (AAA) and aortoiliac occlusive disease (AIOD). MIAS technique consisted of minilaparotomy approach using incision length of 7-12 cm, intraabdominal small bowel retraction and standard aortic reconstruction with terminoterminal anastomosis or aortobifemoral bypass. Between December 2004 and January 2007 we perfomed 32 repairs for AAA and AIOD using MIAS technique. Mean infrarenal aortic cross clamp time was 48.5 +/- 17 minutes. Duration ofnasogastric suction and period before starting liquid diet was meanly 1.2 +/- 0.5 days. Mean time of stay in intensive care unit was 1.3 +/- 0.6 days, and hospital stay was 7.1 +/- 1.4 days. We had no 30-day mortality rate and there was no wound infection. MIAS technique is a safe method for the treatment of infrarenal AAA and AIOD including smaller wound size, shorter duration of postoperative ileus, intensive care unit stay and hospital stay, and lower hospital costs compared with those of standard way of treatment.

Assessment of Stroke Volume Index of Sutureless, Transcatheter and Stented Pericardial Valves in the Early Postoperative Period -a Propensity Matched Analysis

by Davorin Sef and Alessia Gambaro

Structural Heart, 2019

Objectives: Persistent or new onset low flow (LF), described as a stroke volume index (SVi) <35ml... more Objectives: Persistent or new onset low flow (LF), described as a stroke volume index (SVi) <35ml/m2/beat, is a predictor of poor outcomes after aortic valve intervention (AVI) in patients (pts) with severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF). We compared the rate of new onset or persistent LF in the in a cohort of propensity-matched pts undergoing aortic valve intervention by sutureless valve (SLV), stented pericardial valves (SPV) or transcatheter valves (TAVI). Methods: Among 423 pts with severe aortic stenosis (AS) and preserved left ventricular function (LVEF) who underwent AVI between 2014 and 2017, a cohort of 30 consecutive pts with SLV were matched with 30 with SPV and 30 patients who had TAVI. Preoperative and perioperative characteristics with echocardiographic results including SVi were assembled and analyzed. Results: LF AS was present in 50% of SPV, 72% of TAVI and 40% of SLV pts pre-operatively, with a median preoperative SVi of 35.02 (28.7-38.94), 30.65 (29.51-38.51) and 37.76 (31.28-42.62) 35ml/m2/beat, respectively. Predischarge LVEF was similar amongst the groups. Postoperative mean transvalvular gradients in SLV, SPV and TAVI were 16.00 (11.08-19.90), 11.79 (8.71-13.00) and 9.00 (6.12-11.20) mmHg respectively while median SVi 30.96 (28.29-41.23), 38.2 (27.57-43.16) and 37.18 (29.55-44.42) 35ml/m2/beat. Postoperative persistent or new-onset LF was significantly more prevalent in the SLV (57%) as compared with SPV (41%) or TAVI group (38%) (P<0.05). Conclusions: In pts with severe AS and preserved LVEF, AVI with TAVI and SPV was associated with improved SVi, and lower rates of persistent or new onset LF when compared with SLV. Further follow-up is required to evaluate long-term outcomes of both valve types.

Management of perioperative myocardial ischaemia after isolated coronary artery bypass graft surgery

by Davorin Sef and Kresimir Stambuk

Open Heart, 2019

Objectives Updated knowledge about perioperative myocardial ischaemia (MI) after coronary artery ... more Objectives Updated knowledge about perioperative myocardial ischaemia (MI) after coronary artery bypass grafting (CABG) and treatment of acute graft failure is needed. We analysed main factors associated with perioperative MI and effects of immediate coronary angiography-based treatment strategy on patient outcome. Methods Among 1119 consecutive patients with coronary artery disease who underwent isolated CABG between January 2011 and December 2015, 43 (3.8%) patients underwent urgent coronary angiography due to suspected perioperative MI. All the data were prospectively collected and retrospectively analysed. The primary endpoint was 30-day mortality; postoperative left ventricular ejection fraction) and major adverse cardiac events were secondary endpoints. Results Overall, 30-day mortality in patients with CABG was 1.4% while in patients who developed perioperative MI was 9% (4 patients). Angiographic findings included incorrect graft anastomosis, graft spasm, dissection, acute coronary artery thrombotic occlusion and ischaemia due to incomplete revascularisation. Emergency reoperation (Redo) was performed in 14 (32%), acute percutaneous coronary intervention (PCI) in 15 (36%) and conservative treatment (Non-op) in 14 patients. Demographic and preoperative clinical characteristics between the groups were comparable. Postoperative LVEF was significantly reduced in the Redo group (45% post-op vs 53% pre-op) and did not change in groups PCI (56% post-op vs 57% pre-op) and Non-op (58% post-op vs 57% pre-op). Conclusions Urgent angiography allows identification of the various underlying causes of perioperative MI and urgent treatment when this is needed. Urgent PCI may be associated with improved clinical outcome in patients with early graft failure.

Bridge to heart transplantation using the Levitronix CentriMag short-term ventricular assist device

Artificial Organs, 2020

To the Editor, Due to a variety of devices with different advantages and disadvantages, the role ... more To the Editor, Due to a variety of devices with different advantages and disadvantages, the role of short-term mechanical circulatory support (MCS) as a bridge to transplant (BTT) remains controversial. The Levitronix CentriMag is a short-term ventricular assist device (VAD) CE marked for 30-days use, and can be used as a BTT in patients with decompensated end-stage heart failure to provide hemodynamic stabilization and potential end-organ function recovery allowing further evaluation for a long-term plan. 1,2 It provides longer support time with adequate flow and sufficient ventricular unloading in comparison with current percutaneous short-term MCS devices. Critically ill patients are challenging to deal with because of the presence of end-stage organ failure and the outcome of these patients remains poor. However, it is reported that the CentriMag seems to reduce mortality and morbidity in patients with cardiogenic shock. 3 We have conducted a retrospective analysis of outcomes with the CentriMag device as a BTT or to a candidacy (BTC) and presented in part our data at the 27th Congress of the International Society for Mechanical Circulatory Support, held October 21-23, 2019 in Bologna, Italy. A total of 28 patients have been supported with the CentriMag device as a BTT (17 patients) or BTC (11 patients) between March 2004 and June 2018 due to decompensated end-stage heart failure. The most common etiology was dilated cardiomyopathy (75%). Institutional Ethics Committee approval was obtained, and all patients or their family members gave their written informed consent. These were critically ill patients who needed initial salvage with this device, despite being on maximal inotropic support and optimal medical treatment, and they were not candidates for a long-term ventricular assist device (LT-VAD) or heart transplantation (HTx) at the time of presentation. Surgical technique was described by our group earlier. 1,2 All these patients were listed for HTx after being accepted by multidisciplinary transplant team based on a good clinical recovery and improvement of end-organ dysfunction. Patients' perioperative characteristics are shown in Table 1. One of the major findings in our study was that 30-days and 1-year mortality were 7% (2 patients) and 11% (3 patients), respectively. Average duration of support (38.7 days)

Robotic-assisted two-patch repair of right partial anomalous pulmonary venous connection and sinus venosus defect

by Davorin Sef and Vinay Badhwar

JTCVS Techniques, 2020

Partial anomalous pulmonary venous connections remain uncommon, particularly in the adult. We pre... more

Clinically significant incidental findings during preoperative computed tomography of patients undergoing cardiac surgery

Interactive Cardiovascular and Thoracic Surgery, 2020

With the development of minimally invasive cardiac surgery, chest and abdominal computed tomograp... more With the development of minimally invasive cardiac surgery, chest and abdominal computed tomography (CT) scans are becoming an integral part of preoperative assessment and planning. Therefore, the number of incidental findings (IFs) detected with CT is rising. We aimed to investigate the frequency of clinically significant IFs on chest and abdominal CT scans performed during the preoperative assessment of patients undergoing adult cardiac surgery in a 2-year period. In a cohort of 401 patients (mean age 67.4 ± 12.3, female gender 28.9%, median logistic EuroSCORE 5.8 [0.9, 90.5]) who underwent chest or abdominal CT imaging during the study period, we identified 75 patients (18.7%) with clinically significant IFs who needed a further treatment or work-up to confirm the diagnosis or postoperative follow-up. Our data indicate that clinically significant IFs in patients referred for cardiac surgery are frequent. It is important to identify clinically significant Ifs, as a clear postoperative follow-up plan should be made.

Is it better to treat bypass graft or native coronary artery following early graft failure?

Journal of Cardiac Surgery, 2020

Several studies have already shown that coronary angiography and PCI can be safely performed afte... more Several studies have already shown that coronary angiography and PCI can be safely performed after CABG. It is of paramount importance that early graft failure is recognized in a timely manner and that an appropriate treatment is delivered immediately in order to reduce the extent of myocardial damage and improve clinical outcome. Therefore, urgent angiography allows both identification of the underlying cause of early graft failure and immediate treatment according to the findings. So far, recent evidence shows that PCI to native coronary arteries is associated with higher procedural success rate and less complications leading to the better clinical outcome.

Utilization of extracorporeal membrane oxygenation in DCD and DBD lung transplants: a 2-year single-center experience

Transplant International, 2020

Donation after circulatory death (DCD) has the potential to expand the lung donor pool. We aimed ... more Donation after circulatory death (DCD) has the potential to expand the lung donor pool. We aimed to assess whether DCD affected the need for perioperative extracorporeal membrane oxygenation (ECMO) and periop-erative outcomes in lung transplantation (LTx) as compared to donation after brain death (DBD). All consecutive LTxs performed between April 2017 and March 2019 at our tertiary center were analyzed. Donor and recipient preoperative characteristics, utilization of ECMO, and periopera-tive clinical outcomes were compared between DCD and DBD LTx. Multi-variate models (frequentist and Bayes) were fitted to evaluate an independent effect of DCD on the intra-and postoperative need for ECMO. Out of 105 enrolled patients, 25 (23.8%) were DCD LTx. Donors' and preoperative recipients' characteristics were comparable between the groups. Intraoperatively, mechanical circulatory support (MCS) was more common in DCD LTx (56.0% vs. 36.2%), but the adjusted difference was minor (RR = 1.16, 95% CI 0.64-2.12; P = 0.613). MCS duration, and first and second lung ischemia time were longer in the DCD group. Postopera-tively, DCD recipients more commonly required ECMO (32.0% vs. 7.5%) and the difference remained considerable after adjustment for the pre-and intraoperative covariates: RR = 4.11 (95% CI 0.95-17.7), P = 0.058, Bayes RR = 4.15 (95% CrI 1.28-13.0). Sensitivity analyses (two DCD-DBD matching procedures) supported a higher risk of postoperative ECMO need in DCD patients. Incidence of delayed chest closure, postoperative chest drainage, and renal replacement therapy was higher in the DCD group. Early postoperative outcomes after DCD LTx appeared generally comparable to those after DBD LTx. DCD was associated with a higher need for postoperative ECMO which could influence clinical outcomes. However, as the DCD group had a significantly higher use of EVLP with more common ECMO preoperatively, this might have contributed to worse outcomes in the DCD group.

Perioperative transfusion practice in patients undergoing lung transplantation – experience from a 7-year period

Journal of Cardiothoracic and Vascular Anesthaesia, 2020

Introduction Perioperative allogenic blood product transfusion is common in lung transplantation ... more Introduction Perioperative allogenic blood product transfusion is common in lung transplantation (LTx), particularly after an increased utilization of extracorporeal membrane oxygenation (ECMO) throughout the peritransplant period. The risks of massive transfusion of blood products are well-known, and may negatively influence LTx outcomes (1). We analyzed perioperative transfusion practice among the LTx recipients at our institution. Methods All consecutive patients who underwent LTx at Harefield Hospital between January 2012 and December 2018 were analyzed. Patients bridged to LTx with ECMO and preoperatively mechanically ventilated were included. Data were extracted from our institutional electronic system. The use of red blood cells (RBCs), fresh frozen plasma (FFP), and platelets (PLT) intraoperatively and postoperatively within the first 48 hours was investigated. Transfusion of >10 units of RBCs was considered as massive transfusion. Results A total of 304 LTx recipients (male gender 54.9%, mean age 45.9±12.3 years) underwent bilateral sequential single LTx (97.4%) or single LTx (2.6%). The most common diagnosis was cystic fibrosis (CF; 42.4%). Re-transplantation was performed in 3.3%. The percentage of recipients bridged to LTx with ECMO was 9.2% (20 patients with veno-venous [VV] ECMO, 5 with veno-arterial [VA] ECMO and 3 with Novalung). Intraoperative ECMO was required in 30 (9.9%) patients (11 VV ECMO/19 VA ECMO) and cardiopulmonary bypass (CPB) in 107 (35.2%), whereas 167 (54.9%) patients were operated off-pump. Postoperatively, ECMO was utilized in 35 (11.5%) patients (24 VA ECMO/10 VV ECMO/1 Novalung). Of these, 26 (74.3%) patients required conversion to ECMO following unsuccessful weaning from CPB, 6 (17.1%) continued to be supported after intraoperative ECMO, and 3 (8.6%) were initially operated off-pump. The median number of RBCs in the first 48 hours was 4 (0-71) units, FFP 2 (0-37) and PLT 1 (0-21). The overall incidence of patients requiring >10 units of RBCs in the first 48 hours was 22.1%, including all patients with idiopathic pulmonary arterial hypertension (IPAH), 50% of patients who underwent re-transplantation, and 31.8% of patients with CF. Patients who needed intraoperative MCS support had a higher incidence of massive transfusion (43% in the CPB group vs. 40% in the ECMO group vs. 5.4% in the off-pump group). The overall 30-day mortality rate was 6.9%, which increased to 23.9% among patients with massive transfusion. Discussion We performed a descriptive analysis of perioperative transfusion practice in a tertiary centre over a 7-year period and showed that MCS, IPAH, re-transplantation, and CF were associated with massive transfusion. Overall, we demonstrated a reasonably low incidence of perioperative blood transfusion and excellent 30-day survival. Further analysis is needed to investigate which perioperative factors may help minimize allogenic blood product usage in LTx and improve postoperative outcomes.

Minimally invasive aortic valve replacement with sutureless bioprosthesis through right minithoracotomy with completely central cannulation—Early results in 203 patients

Journal of Cardiac Surgery, 2020

Objectives Minimally invasive aortic valve replacement (mini‐AVR) might improve clinical outcomes... more Objectives Minimally invasive aortic valve replacement (mini‐AVR) might improve clinical outcomes, particularly in high‐risk and elderly patients. Sutureless/rapid deployment bioprosthesis can offer advantage of decreasing the cross‐clamp time (XCT) and easing the procedure. Our aim was to evaluate the safety and perioperative outcomes of mini‐AVR using sutureless bioprothesis via the right minithoracotomy approach with our modified technique of central cannulation. Methods We performed a single‐center retrospective analysis of 203 patients consecutively undergoing isolated AVR between March 2016 and June 2018 with the right minithoracotomy approach and our modified technique of central cannulation. Aortic valve diseases were stenosis (89.9%), regurgitation (1.6%), and mixed valve disease (8.5%). Patients with concomitant procedures were excluded. Primary endpoints were 30‐day and 4‐month mortality. Results Mean age was 76 ± 6.2 years, 63 (31%) patients were 80 years or older. Cardiopulmonary bypass and XCT were 60.5 (39–153) and 35 (24–76) min, respectively. Thirty‐day and 4‐month mortality were 1% (two patients). We have observed minor paravalvular leak (PVL) which occurred in seven patients (3.4%), and no moderate/severe PVL was found perioperatively. One patient developed moderate/severe PVL during the 4‐month follow‐up. There was no structural valve degeneration. Two (1%) patients needed conversion to full sternotomy, and two (1%) patients to ministernotomy. Conclusions Mini‐AVR via the right minithoracotomy approach with central cannulation is an effective and safe procedure and demonstrates excellent early clinical outcomes. This approach can be particularly valuable in higher risk and elderly patients.

Bilateral internal thoracic artery use in coronary artery bypass grafting in the post-ART era -Perspective

International Journal of Surgery, 2020

There is still lack of convincing evidence about the superiority of bilateral internal thoracic a... more There is still lack of convincing evidence about the superiority of bilateral internal thoracic artery (BITA) use in coronary artery bypass grafting (CABG) and BITA grafts continue to be underutilized. Arterial Revascularization Trial (ART) did not demonstrate the superiority of BITA versus single ITA grafting after 10 years. We have reviewed the most recent literature, assessed the current status as well as indications of BITA grafting in the post-ART era. We believe that BITA grafting is not appropriate for all patients especially in light of the findings of ART. However, the use of BITA is justified in patients of younger age and those without comorbidities (poorly controlled diabetes, obesity, chronic obstructive pulmonary disease, previous mediastinal irradiation, long-term steroid use, elderly women). Further prospective randomized studies with long-term follow-up are needed to validate the benefits of BITA grafting.

Valvular complications following the Impella device implantation

Journal of Cardiac Surgery, 2021

Background Despite clear clinical benefits, there is limited evidence regarding possible complica... more Background Despite clear clinical benefits, there is limited evidence regarding possible complications of the novel mechanical support device Impella. Aortic and mitral valve regurgitation or injury are rare but potential complications following implantation of the Impella device. Methods To evaluate valvular complications after the Impella device implantation, we have performed a comprehensive search of literature on multiple sites on this topic. Results and Conclusion Ten case reports and one observational retrospective study were identified, with a total number of 19 patients identified. This article aims to draw attention to potential periprocedural complications relating to the Impella, in particular iatrogenic aortic and mitral valve injuries. Moreover, we have summarized our recommendations emphasizing the need for careful management and meticulous follow‐up of these patients to avoid such potentially devastating complications.

Dynamic associations between adverse events after lung transplantation and allograft ischemic time

European journal of cardio-thoracic surgery, 2024

Objective: The effect of allograft ischemic time (AIT) on postoperative events after lung transpl... more Objective: The effect of allograft ischemic time (AIT) on postoperative events after lung transplantation (LTx) remains unclear. This study aims to assess the feasibility of extending the duration of AIT. Methods: The United Network for Organ Sharing database was queried for adult LTx from 4 May 2005 to 30 June 2020. Patients were divided as per AIT into standard (SIT, <6 hours) and prolonged (PIT, ≥6 hours) groups using propensity score matching and evaluated on a continuous scale using restricted cubic splines. The primary outcome was overall 1-year and 5-year survival. Results: Among 11,438 propensity matched recipients, SIT and PIT showed no differences in overall 1-year (P= 0.29) or 5-year (P= 0.29) survival. PIT independently predicted early postoperative ventilator support for >48 hours (OR=1.33, 95% CI:1.22-1.44), dialysis (OR=1.55, 95% CI:1.30-1.84), primary graft dysfunction (PGD; OR=1.28, 95% CI:1.09-1.50), and acute rejection (AR; OR=1.42, 95% CI:1.24-1.62), and interestingly, decreased 5-year bronchiolitis obliterans syndrome (BOS; HR=0.91, 95%CI:0.85-0.97). In relative risk curves, 1-year mortality, prolonged ventilation, dialysis, and PGD steadily increased per hour as AIT extended. The risk of AR and 5year BOS also showed significant changes between 5 and 8 hours of AIT. In contrast, 5-year mortality remained constant despite rising AIT. Conclusions: Prolonged AIT worsened early outcomes such as PGD, but improved BOS freedom at later timepoints. Despite this, both short-and long-term survival were similar between PIT and SIT patients. Dynamic risk changes in post-transplant events should be noted for prolonged ischemia lung use.

Aortic arch replacement in patients with previous repair of acute aortic dissection: a systematic review and meta-analysis

Eur J Cardiothorac Surg, 2024

Objectives: Despite the popularity of the frozen elephant technique procedure in recent years, ev... more Objectives: Despite the popularity of the frozen elephant technique procedure in recent years, evidence is scarce regarding its utilisation for aortic arch replacement following previous acute aortic dissection repair. In this systematic review and meta-analysis, we aimed to analyse clinical outcomes of aortic arch replacement in patients with previous repair of acute aortic dissection.

Management of A Patient with an Unusual Trajectory of a Temporary Trans-Venous Pacing Lead

World Journal of Cardiology, 2024

Perforation of the right ventricle during placement of pacing wires is a welldocumented complicat... more Perforation of the right ventricle during placement of pacing wires is a welldocumented complication and can be potentially fatal. Use of temporary pacemaker, helical screw leads and steroids use prior to implant are recognised as risk factors for development of post-permanent pacemaker effusion. We reported an unusual case of pacing wire perforating interventricular septum into the left ventricle that occurred during the implant procedure performed in another institution. After the preoperative work-up and transfer to our tertiary cardiothoracic centre, the patient underwent successful surgical management. In conclusion, early recognition and timely diagnosis using advanced multimodality imaging can guide surgical intervention and prevent unfavourable consequences of device-related complications.

Minimally Invasive Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease: A Systematic Review

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery, 2024

Objective: We conducted a systematic review of all available evidence on the feasibility and safe... more Objective: We conducted a systematic review of all available evidence on the feasibility and safety of minimally invasive coronary artery bypass grafting (MICS CABG) in patients with multivessel coronary artery disease (CAD). Methods: A systematic literature search in PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science was performed to identify all relevant studies evaluating outcomes of MICS CABG among patients with multivessel CAD and including at least 15 patients with no restriction on the publication date. Results: A total of 881 studies were identified, of which 26 studies met the eligibility criteria. The studies included a total of 7,556 patients. The average patient age was 63.3 years (range 49.5 to 69.0 years), male patients were an average of 77.8% (54.0% to 89.8%), and body mass index was 29.8 kg/m 2 (24.5 to 30.1 kg/m 2). Early mortality and stroke were on average 0.6% (range 0% to 2.0%) and 0.4% (range 0% to 1.3%), respectively. The average number of grafts was 2.8 (range 2.1 to 3.7). The average length of hospital stay was 5.6 days (range 3.1 to 9.3 days). Conclusions: MICS CABG appears to be a safe method in well-selected patients with multivessel CAD. This approach is concentrated at dedicated centers, and there is no widespread application, although it has potential to be widely applicable as an alternative for surgical revascularization. However, large randomized controlled studies with longer follow-up are still required to compare the outcomes with conventional CABG and other revascularization strategies.

Perioperative and Long-Term Outcomes of Acute Stanford Type A Aortic Dissection Repair in Octogenarians

Medical Science, 2024

Background: The aims of this study were to assess the perioperative morbidity, mortality and long... more Background: The aims of this study were to assess the perioperative morbidity, mortality and long-term survival of octogenarians undergoing acute type A aortic dissection repair (ATAAD), and to compare open and closed distal anastomosis techniques. Methods: This was a single-centre retrospective study (2007–2021). Open versus closed distal anastomosis were compared. Uni- and multivariable logistic regression analyses were performed to identify independent predictors of in-hospital mortality. Kaplan–Meier and Cox proportional hazards methods were used to compare long-term survival. Results: Fifty octogenarian patients were included (median age—82 years; closed distal—22; open distal—28). Median cardiopulmonary bypass time was 187 min (open distal vs. closed distal group; 219 min vs. 115.5 min, p < 0.01, respectively). Median cross-clamp time was 93 min (IQR; 76–130 min). Median circulatory arrest time was 26 min (IQR; 20–39 min) in the open-distal group. In-hospital mortality was 18% (open distal; 14.2% vs. closed distal; 22.7%, p = 0.44). Stroke was 26% (open distal; 28.6% vs. closed distal; 22.7%, p = 0.64). Median survival was 7.2 years (IQR; 4.5–11.6 years). Survival was comparable between open and closed distal groups (median 10.6 vs. 7.2 years, p = 0.35, respectively). Critical preoperative status (HR; 3.2, p = 0.03) and composite endpoint (renal replacement therapy, new neurological event, length of stay > 30 days or return to theatre; HR; 4.1, p = 0.02) predicted adverse survival. Open distal anastomosis did no impact survival. Conclusions: ATAAD repair in selected octogenarians has acceptable short- and long-term survival. There is no significant difference between open versus closed distal anastomosis strategies.

Limited vs. Extended Resection of Stanford Type A Acute Aortic Dissections

Medicina, 2024

This article is an open access article distributed under the terms and conditions of the Creative... more

Neuromonitoring During Endovascular Thoracoabdominal Aortic Aneurysm Repair: A Systematic Review

Annals of Vascular Surgery, 2024

Introduction Spinal cord ischemia (SCI) is a potentially devastating complication of thoracic end... more Introduction Spinal cord ischemia (SCI) is a potentially devastating complication of thoracic endovascular aortic repair (TEVAR) and fenestrated-branched endovascular aortic repair (F-BEVAR). The aim of this systematic review was to evaluate the efficacy of neuromonitoring modalities to mitigate the risk of SCI during TEVAR and F-BEVAR procedures. Materials and Methods Following the PRISMA guidelines, we conducted a detailed literature search of databases including PubMed, MEDLINE via Ovid, Embase, Scopus, and Cochrane CENTRAL, from 1998 to the present. Inclusion criteria were original research articles examining neuromonitoring during TEVAR and F-BEVAR. The primary outcome was the incidence of SCI, while the secondary outcome included early mortality. The quality of studies was assessed using the Newcastle-Ottawa Scale. Results From 1,450 identified articles, 11 met inclusion criteria, encompassing data from 1,069 patients. Neuromonitoring modalities included motor-evoked potentials (MEPs), somatosensory evoked potentials (SSEPs), and near-infrared spectroscopy (NIRS). The combination of MEPs and SSEPs was most commonly used, with 93% sensitivity and 96% specificity for detecting SCI risks. SCI incidence ranged from 3.8-17.3%, with permanent deficits occurring in 2.7-5.8% of cases. In-hospital mortality ranged from 0.4-8%. Risk factors for SCI were identified, including operation duration and extent of aortic coverage. Conclusion Neuromonitoring with MEPs and SSEPs appears to be effective in detecting perioperative SCI risk during TEVAR and F-BEVAR. However, discrepancies between neuromonitoring changes and actual SCI outcomes suggest the need for cautious interpretation. While the incidence of SCI remains variable, identified risk factors may guide clinical decisions, particularly in high-risk procedures. Future research should focus on prospective studies and randomized controlled trials to validate these findings and improve SCI prevention strategies in TEVAR and F-BEVAR.

Left Internal Thoracic Artery versus Saphenous Vein Grafts to Left Anterior Descending Artery after Isolated Coronary Artery Bypass Surgery

by Davorin Sef and Suvitesh Luthra

Life, 2024

Background: This study compared perioperative outcomes and long-term survival of saphenous vein g... more Background: This study compared perioperative outcomes and long-term survival of saphenous vein grafts (SVGs) versus left internal thoracic artery (LITA) to left anterior descending artery (LAD) in isolated coronary artery bypass graft surgery (CABG). Methods: In this retrospective, single-centre study, we included patients with primary isolated CABG from January 2001 to July 2022. Baseline demographics were compared between SVG-LAD and LITA-LAD. Univariable and multivariable regressions were performed for predictors of in-hospital death. Propensity score matching was performed for LITA-LAD vs. SVG-LAD. Kaplan-Meier survival curves were generated for comparison of survival. Cox proportional hazards model was used for predictors of survival. Results: A total of 8237 patients (1602 SVG-LAD/6725 LITA-LAD) were included. Median age was 67.9 years (LITA-LAD; 67.1 years vs. SVG-LAD; 71.7 years, p < 0.01). A total of 1270 pairs of SVG-LAD were propensity-matched to LITA-LAD. In matched cohorts, in-patient mortality (0.8% vs. 1.6%, LITA-LAD and SVG-LAD respectively; p = 0.07), deep sternal wound infection, new cerebrovascular events, renal replacement therapy and hospital stay >30 days were similar. SVG-LAD did not adversely affect in-hospital mortality (OR; 2.03, CI; 0.91, 4.54, p = 0.08). Median long-term survival was similar between the groups (13.7 years vs. 13.1 years for LITA-LAD and SVG-LAD respectively, log rank p < 0.31). SVG-LAD was not a predictor of adverse long-term survival. (HR; 1.06, 95% CI; 0.92, 1.22, p < 0.40). Long-term survival was better with LITA-LAD for LVEF <30% (log rank p < 0.03). Conclusions: There was no difference in the propensity-matched cohorts for use of SVG vs. LITA to the LAD. Further contemporary long-term studies are needed for substantiation.

Minimally invasive aortic surgery (MIAS)

Liječnički vjesnik, 2008

In this study we presented benefits of minimally invasive approach (MIAS) for treating abdominal ... more In this study we presented benefits of minimally invasive approach (MIAS) for treating abdominal aortic aneurysm (AAA) and aortoiliac occlusive disease (AIOD). MIAS technique consisted of minilaparotomy approach using incision length of 7-12 cm, intraabdominal small bowel retraction and standard aortic reconstruction with terminoterminal anastomosis or aortobifemoral bypass. Between December 2004 and January 2007 we perfomed 32 repairs for AAA and AIOD using MIAS technique. Mean infrarenal aortic cross clamp time was 48.5 +/- 17 minutes. Duration ofnasogastric suction and period before starting liquid diet was meanly 1.2 +/- 0.5 days. Mean time of stay in intensive care unit was 1.3 +/- 0.6 days, and hospital stay was 7.1 +/- 1.4 days. We had no 30-day mortality rate and there was no wound infection. MIAS technique is a safe method for the treatment of infrarenal AAA and AIOD including smaller wound size, shorter duration of postoperative ileus, intensive care unit stay and hospital stay, and lower hospital costs compared with those of standard way of treatment.

Assessment of Stroke Volume Index of Sutureless, Transcatheter and Stented Pericardial Valves in the Early Postoperative Period -a Propensity Matched Analysis

by Davorin Sef and Alessia Gambaro

Structural Heart, 2019

Objectives: Persistent or new onset low flow (LF), described as a stroke volume index (SVi) <35ml... more Objectives: Persistent or new onset low flow (LF), described as a stroke volume index (SVi) <35ml/m2/beat, is a predictor of poor outcomes after aortic valve intervention (AVI) in patients (pts) with severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF). We compared the rate of new onset or persistent LF in the in a cohort of propensity-matched pts undergoing aortic valve intervention by sutureless valve (SLV), stented pericardial valves (SPV) or transcatheter valves (TAVI). Methods: Among 423 pts with severe aortic stenosis (AS) and preserved left ventricular function (LVEF) who underwent AVI between 2014 and 2017, a cohort of 30 consecutive pts with SLV were matched with 30 with SPV and 30 patients who had TAVI. Preoperative and perioperative characteristics with echocardiographic results including SVi were assembled and analyzed. Results: LF AS was present in 50% of SPV, 72% of TAVI and 40% of SLV pts pre-operatively, with a median preoperative SVi of 35.02 (28.7-38.94), 30.65 (29.51-38.51) and 37.76 (31.28-42.62) 35ml/m2/beat, respectively. Predischarge LVEF was similar amongst the groups. Postoperative mean transvalvular gradients in SLV, SPV and TAVI were 16.00 (11.08-19.90), 11.79 (8.71-13.00) and 9.00 (6.12-11.20) mmHg respectively while median SVi 30.96 (28.29-41.23), 38.2 (27.57-43.16) and 37.18 (29.55-44.42) 35ml/m2/beat. Postoperative persistent or new-onset LF was significantly more prevalent in the SLV (57%) as compared with SPV (41%) or TAVI group (38%) (P<0.05). Conclusions: In pts with severe AS and preserved LVEF, AVI with TAVI and SPV was associated with improved SVi, and lower rates of persistent or new onset LF when compared with SLV. Further follow-up is required to evaluate long-term outcomes of both valve types.

Management of perioperative myocardial ischaemia after isolated coronary artery bypass graft surgery

by Davorin Sef and Kresimir Stambuk

Open Heart, 2019

Objectives Updated knowledge about perioperative myocardial ischaemia (MI) after coronary artery ... more Objectives Updated knowledge about perioperative myocardial ischaemia (MI) after coronary artery bypass grafting (CABG) and treatment of acute graft failure is needed. We analysed main factors associated with perioperative MI and effects of immediate coronary angiography-based treatment strategy on patient outcome. Methods Among 1119 consecutive patients with coronary artery disease who underwent isolated CABG between January 2011 and December 2015, 43 (3.8%) patients underwent urgent coronary angiography due to suspected perioperative MI. All the data were prospectively collected and retrospectively analysed. The primary endpoint was 30-day mortality; postoperative left ventricular ejection fraction) and major adverse cardiac events were secondary endpoints. Results Overall, 30-day mortality in patients with CABG was 1.4% while in patients who developed perioperative MI was 9% (4 patients). Angiographic findings included incorrect graft anastomosis, graft spasm, dissection, acute coronary artery thrombotic occlusion and ischaemia due to incomplete revascularisation. Emergency reoperation (Redo) was performed in 14 (32%), acute percutaneous coronary intervention (PCI) in 15 (36%) and conservative treatment (Non-op) in 14 patients. Demographic and preoperative clinical characteristics between the groups were comparable. Postoperative LVEF was significantly reduced in the Redo group (45% post-op vs 53% pre-op) and did not change in groups PCI (56% post-op vs 57% pre-op) and Non-op (58% post-op vs 57% pre-op). Conclusions Urgent angiography allows identification of the various underlying causes of perioperative MI and urgent treatment when this is needed. Urgent PCI may be associated with improved clinical outcome in patients with early graft failure.

Bridge to heart transplantation using the Levitronix CentriMag short-term ventricular assist device

Artificial Organs, 2020

To the Editor, Due to a variety of devices with different advantages and disadvantages, the role ... more To the Editor, Due to a variety of devices with different advantages and disadvantages, the role of short-term mechanical circulatory support (MCS) as a bridge to transplant (BTT) remains controversial. The Levitronix CentriMag is a short-term ventricular assist device (VAD) CE marked for 30-days use, and can be used as a BTT in patients with decompensated end-stage heart failure to provide hemodynamic stabilization and potential end-organ function recovery allowing further evaluation for a long-term plan. 1,2 It provides longer support time with adequate flow and sufficient ventricular unloading in comparison with current percutaneous short-term MCS devices. Critically ill patients are challenging to deal with because of the presence of end-stage organ failure and the outcome of these patients remains poor. However, it is reported that the CentriMag seems to reduce mortality and morbidity in patients with cardiogenic shock. 3 We have conducted a retrospective analysis of outcomes with the CentriMag device as a BTT or to a candidacy (BTC) and presented in part our data at the 27th Congress of the International Society for Mechanical Circulatory Support, held October 21-23, 2019 in Bologna, Italy. A total of 28 patients have been supported with the CentriMag device as a BTT (17 patients) or BTC (11 patients) between March 2004 and June 2018 due to decompensated end-stage heart failure. The most common etiology was dilated cardiomyopathy (75%). Institutional Ethics Committee approval was obtained, and all patients or their family members gave their written informed consent. These were critically ill patients who needed initial salvage with this device, despite being on maximal inotropic support and optimal medical treatment, and they were not candidates for a long-term ventricular assist device (LT-VAD) or heart transplantation (HTx) at the time of presentation. Surgical technique was described by our group earlier. 1,2 All these patients were listed for HTx after being accepted by multidisciplinary transplant team based on a good clinical recovery and improvement of end-organ dysfunction. Patients' perioperative characteristics are shown in Table 1. One of the major findings in our study was that 30-days and 1-year mortality were 7% (2 patients) and 11% (3 patients), respectively. Average duration of support (38.7 days)

Robotic-assisted two-patch repair of right partial anomalous pulmonary venous connection and sinus venosus defect

by Davorin Sef and Vinay Badhwar

JTCVS Techniques, 2020

Partial anomalous pulmonary venous connections remain uncommon, particularly in the adult. We pre... more

Clinically significant incidental findings during preoperative computed tomography of patients undergoing cardiac surgery

Interactive Cardiovascular and Thoracic Surgery, 2020

With the development of minimally invasive cardiac surgery, chest and abdominal computed tomograp... more With the development of minimally invasive cardiac surgery, chest and abdominal computed tomography (CT) scans are becoming an integral part of preoperative assessment and planning. Therefore, the number of incidental findings (IFs) detected with CT is rising. We aimed to investigate the frequency of clinically significant IFs on chest and abdominal CT scans performed during the preoperative assessment of patients undergoing adult cardiac surgery in a 2-year period. In a cohort of 401 patients (mean age 67.4 ± 12.3, female gender 28.9%, median logistic EuroSCORE 5.8 [0.9, 90.5]) who underwent chest or abdominal CT imaging during the study period, we identified 75 patients (18.7%) with clinically significant IFs who needed a further treatment or work-up to confirm the diagnosis or postoperative follow-up. Our data indicate that clinically significant IFs in patients referred for cardiac surgery are frequent. It is important to identify clinically significant Ifs, as a clear postoperative follow-up plan should be made.

Is it better to treat bypass graft or native coronary artery following early graft failure?

Journal of Cardiac Surgery, 2020

Several studies have already shown that coronary angiography and PCI can be safely performed afte... more Several studies have already shown that coronary angiography and PCI can be safely performed after CABG. It is of paramount importance that early graft failure is recognized in a timely manner and that an appropriate treatment is delivered immediately in order to reduce the extent of myocardial damage and improve clinical outcome. Therefore, urgent angiography allows both identification of the underlying cause of early graft failure and immediate treatment according to the findings. So far, recent evidence shows that PCI to native coronary arteries is associated with higher procedural success rate and less complications leading to the better clinical outcome.

Utilization of extracorporeal membrane oxygenation in DCD and DBD lung transplants: a 2-year single-center experience

Transplant International, 2020

Donation after circulatory death (DCD) has the potential to expand the lung donor pool. We aimed ... more Donation after circulatory death (DCD) has the potential to expand the lung donor pool. We aimed to assess whether DCD affected the need for perioperative extracorporeal membrane oxygenation (ECMO) and periop-erative outcomes in lung transplantation (LTx) as compared to donation after brain death (DBD). All consecutive LTxs performed between April 2017 and March 2019 at our tertiary center were analyzed. Donor and recipient preoperative characteristics, utilization of ECMO, and periopera-tive clinical outcomes were compared between DCD and DBD LTx. Multi-variate models (frequentist and Bayes) were fitted to evaluate an independent effect of DCD on the intra-and postoperative need for ECMO. Out of 105 enrolled patients, 25 (23.8%) were DCD LTx. Donors' and preoperative recipients' characteristics were comparable between the groups. Intraoperatively, mechanical circulatory support (MCS) was more common in DCD LTx (56.0% vs. 36.2%), but the adjusted difference was minor (RR = 1.16, 95% CI 0.64-2.12; P = 0.613). MCS duration, and first and second lung ischemia time were longer in the DCD group. Postopera-tively, DCD recipients more commonly required ECMO (32.0% vs. 7.5%) and the difference remained considerable after adjustment for the pre-and intraoperative covariates: RR = 4.11 (95% CI 0.95-17.7), P = 0.058, Bayes RR = 4.15 (95% CrI 1.28-13.0). Sensitivity analyses (two DCD-DBD matching procedures) supported a higher risk of postoperative ECMO need in DCD patients. Incidence of delayed chest closure, postoperative chest drainage, and renal replacement therapy was higher in the DCD group. Early postoperative outcomes after DCD LTx appeared generally comparable to those after DBD LTx. DCD was associated with a higher need for postoperative ECMO which could influence clinical outcomes. However, as the DCD group had a significantly higher use of EVLP with more common ECMO preoperatively, this might have contributed to worse outcomes in the DCD group.

Perioperative transfusion practice in patients undergoing lung transplantation – experience from a 7-year period

Journal of Cardiothoracic and Vascular Anesthaesia, 2020

Introduction Perioperative allogenic blood product transfusion is common in lung transplantation ... more Introduction Perioperative allogenic blood product transfusion is common in lung transplantation (LTx), particularly after an increased utilization of extracorporeal membrane oxygenation (ECMO) throughout the peritransplant period. The risks of massive transfusion of blood products are well-known, and may negatively influence LTx outcomes (1). We analyzed perioperative transfusion practice among the LTx recipients at our institution. Methods All consecutive patients who underwent LTx at Harefield Hospital between January 2012 and December 2018 were analyzed. Patients bridged to LTx with ECMO and preoperatively mechanically ventilated were included. Data were extracted from our institutional electronic system. The use of red blood cells (RBCs), fresh frozen plasma (FFP), and platelets (PLT) intraoperatively and postoperatively within the first 48 hours was investigated. Transfusion of >10 units of RBCs was considered as massive transfusion. Results A total of 304 LTx recipients (male gender 54.9%, mean age 45.9±12.3 years) underwent bilateral sequential single LTx (97.4%) or single LTx (2.6%). The most common diagnosis was cystic fibrosis (CF; 42.4%). Re-transplantation was performed in 3.3%. The percentage of recipients bridged to LTx with ECMO was 9.2% (20 patients with veno-venous [VV] ECMO, 5 with veno-arterial [VA] ECMO and 3 with Novalung). Intraoperative ECMO was required in 30 (9.9%) patients (11 VV ECMO/19 VA ECMO) and cardiopulmonary bypass (CPB) in 107 (35.2%), whereas 167 (54.9%) patients were operated off-pump. Postoperatively, ECMO was utilized in 35 (11.5%) patients (24 VA ECMO/10 VV ECMO/1 Novalung). Of these, 26 (74.3%) patients required conversion to ECMO following unsuccessful weaning from CPB, 6 (17.1%) continued to be supported after intraoperative ECMO, and 3 (8.6%) were initially operated off-pump. The median number of RBCs in the first 48 hours was 4 (0-71) units, FFP 2 (0-37) and PLT 1 (0-21). The overall incidence of patients requiring >10 units of RBCs in the first 48 hours was 22.1%, including all patients with idiopathic pulmonary arterial hypertension (IPAH), 50% of patients who underwent re-transplantation, and 31.8% of patients with CF. Patients who needed intraoperative MCS support had a higher incidence of massive transfusion (43% in the CPB group vs. 40% in the ECMO group vs. 5.4% in the off-pump group). The overall 30-day mortality rate was 6.9%, which increased to 23.9% among patients with massive transfusion. Discussion We performed a descriptive analysis of perioperative transfusion practice in a tertiary centre over a 7-year period and showed that MCS, IPAH, re-transplantation, and CF were associated with massive transfusion. Overall, we demonstrated a reasonably low incidence of perioperative blood transfusion and excellent 30-day survival. Further analysis is needed to investigate which perioperative factors may help minimize allogenic blood product usage in LTx and improve postoperative outcomes.

Minimally invasive aortic valve replacement with sutureless bioprosthesis through right minithoracotomy with completely central cannulation—Early results in 203 patients

Journal of Cardiac Surgery, 2020

Objectives Minimally invasive aortic valve replacement (mini‐AVR) might improve clinical outcomes... more Objectives Minimally invasive aortic valve replacement (mini‐AVR) might improve clinical outcomes, particularly in high‐risk and elderly patients. Sutureless/rapid deployment bioprosthesis can offer advantage of decreasing the cross‐clamp time (XCT) and easing the procedure. Our aim was to evaluate the safety and perioperative outcomes of mini‐AVR using sutureless bioprothesis via the right minithoracotomy approach with our modified technique of central cannulation. Methods We performed a single‐center retrospective analysis of 203 patients consecutively undergoing isolated AVR between March 2016 and June 2018 with the right minithoracotomy approach and our modified technique of central cannulation. Aortic valve diseases were stenosis (89.9%), regurgitation (1.6%), and mixed valve disease (8.5%). Patients with concomitant procedures were excluded. Primary endpoints were 30‐day and 4‐month mortality. Results Mean age was 76 ± 6.2 years, 63 (31%) patients were 80 years or older. Cardiopulmonary bypass and XCT were 60.5 (39–153) and 35 (24–76) min, respectively. Thirty‐day and 4‐month mortality were 1% (two patients). We have observed minor paravalvular leak (PVL) which occurred in seven patients (3.4%), and no moderate/severe PVL was found perioperatively. One patient developed moderate/severe PVL during the 4‐month follow‐up. There was no structural valve degeneration. Two (1%) patients needed conversion to full sternotomy, and two (1%) patients to ministernotomy. Conclusions Mini‐AVR via the right minithoracotomy approach with central cannulation is an effective and safe procedure and demonstrates excellent early clinical outcomes. This approach can be particularly valuable in higher risk and elderly patients.

Bilateral internal thoracic artery use in coronary artery bypass grafting in the post-ART era -Perspective

International Journal of Surgery, 2020

There is still lack of convincing evidence about the superiority of bilateral internal thoracic a... more There is still lack of convincing evidence about the superiority of bilateral internal thoracic artery (BITA) use in coronary artery bypass grafting (CABG) and BITA grafts continue to be underutilized. Arterial Revascularization Trial (ART) did not demonstrate the superiority of BITA versus single ITA grafting after 10 years. We have reviewed the most recent literature, assessed the current status as well as indications of BITA grafting in the post-ART era. We believe that BITA grafting is not appropriate for all patients especially in light of the findings of ART. However, the use of BITA is justified in patients of younger age and those without comorbidities (poorly controlled diabetes, obesity, chronic obstructive pulmonary disease, previous mediastinal irradiation, long-term steroid use, elderly women). Further prospective randomized studies with long-term follow-up are needed to validate the benefits of BITA grafting.

Valvular complications following the Impella device implantation

Journal of Cardiac Surgery, 2021

Background Despite clear clinical benefits, there is limited evidence regarding possible complica... more Background Despite clear clinical benefits, there is limited evidence regarding possible complications of the novel mechanical support device Impella. Aortic and mitral valve regurgitation or injury are rare but potential complications following implantation of the Impella device. Methods To evaluate valvular complications after the Impella device implantation, we have performed a comprehensive search of literature on multiple sites on this topic. Results and Conclusion Ten case reports and one observational retrospective study were identified, with a total number of 19 patients identified. This article aims to draw attention to potential periprocedural complications relating to the Impella, in particular iatrogenic aortic and mitral valve injuries. Moreover, we have summarized our recommendations emphasizing the need for careful management and meticulous follow‐up of these patients to avoid such potentially devastating complications.