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Journal of Cardiac Surgery is a peer-reviewed, open access publication devoted to contemporary surgical treatment of cardiac disease.
Journal of Cardiac Surgery maintains an Editorial Board of practicing researchers from around the world, to ensure manuscripts are handled by editors who are experts in the field of study.
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Aortic Coarctation Associated with Distal Aortic Arch Hypoplasia in Neonates Can Be Effectively Repaired through Left Thoracotomy
Objectives. Aortic coarctation in neonates remains a clinical challenge. Low weight, arch hypoplasia and ductal dependence have been identified as risk factors for recurrent coarctation. We hypothesized that a tailored surgical technique may prevent recurrence. Methods. Retrospective evaluation of neonates treated for coarctation through thoracotomy was done. No primary percutaneous procedure was performed and repairs through sternotomy were excluded. Aortic hypoplasia was defined as a ratio arch diameter (mm)/patient’s weight (kg) < 1. Extended end-to-end anastomosis (EEEA), subclavian flap (Waldhausen) and Amato aortoplasty were performed. Mortality and recurrent obstruction requiring re-intervention were assessed. Results. Records of 340 consecutive patients (2003–2019) were analyzed. Preoperative median age and weight were, respectively, 10 days (1–30) and 3080 grams (1400–5180). Arch hypoplasia was documented in 31 patients (9.1%). Prostaglandin was infused in 220 (65.3%). Critical preoperative status was documented in 35 (10.8%). EEEA repair was performed in 273 (80.3%), Waldhausen was performed in 42 (12.4%), and Amato was performed in 25 (7.4%). The last two were more likely to be performed in the presence of arch hypoplasia ( < 0.0001). Hospital mortality occurred in 2 patients (0.6%). Thirty-six procedures (31 percutaneous/5 surgical) were performed for recurrent arch obstruction in 33 patients. Three late deaths occurred. Low-weight, hypoplastic arch, and ductal dependency did not influence the outcome. All survivors were free from residual coarctation at a mean follow-up of 3.6 ± 3.4 years postoperatively. Conclusions. Surgical repair remains the procedure of choice for neonatal coarctation. A tailored approach using alternative techniques seemed to offer comparable results even in presence of associated risk factors.
Minimally Invasive Mitral Valve Repair with Artificial Chordae: Insights from a 6-Year Single-Center Study
Purpose. Minimally invasive mitral valve repair (MIMVR) has been demonstrated to be safe and effective, but technical difficulty, outcome variation, and lack of standardized protocols undermine the utility of artificial chordae. This study aims to analyze the midterm outcomes of repair using artificial chordae through right minithoracotomy. Methods. A retrospective cohort study was conducted on consecutive patients who underwent MIMVR using artificial chordae at a single center in Vietnam between April 2016 and April 2022. Valve repairs were separated into two groups based on a previously validated complexity score: simple repair (Group 1) and intermediate-to-complex repair (Group 2). Demographic variables, comorbidities, operative characteristics, surgical outcomes, and follow-up data on survival and mitral regurgitation (MR) grade were analyzed. The learning curve was assessed by comparing the number of procedures with operation time and aorta cross-clamp time. Primary endpoints included survival and freedom from recurrent MR at four years. Results. Ninety patients were identified, including 41 simple and 49 intermediate-to-complex repairs. The mean age was 50.5 ± 12.9 years. Both groups had similar preoperative characteristics. The perioperative and postoperative outcomes were favorable, with no cases requiring mitral valve replacement. The median follow-up time was 30.3 months (18.2–40.4), and there were two (2.2%) cardiac deaths, with one in each group. The Kaplan–Meier survival estimates for Groups 1 and 2 at 12 and 24 months were 97% vs. 100% and 97% vs. 96%, respectively (95% CI = 0.05–12.2, ), and estimates for freedom from recurrent MR were 97% vs. 92% and 97% vs. 88%, respectively (95% CI = 0.49–12.0, ). There was a negative association between the volume of operations and the duration of operation and aortic cross-clamp time, leading to shorter durations. Conclusion. Based on our single-center experience, MIMVR using artificial chordae via right mini-thoracotomy can be safely and effectively performed in resource-limited countries for patients with MR. This approach has been shown to be applicable for a range of MR complexities, from simple to intermediate-to-complex MV repairs, and has demonstrated promising results in terms of midterm freedom from MR recurrence.
Thoracoscopic Surgical Biatrial Ablation vs. Catheter Ablation in Patients with Persistent Atrial Fibrillation
Background. Limited randomized controlled studies showed that thoracoscopic surgical left atrial ablation was not superior to catheter ablation (CA) in patients with persistent atrial fibrillation (PerAF). Right atrium might play an important role in triggering and maintaining atrial fibrillation (AF) in patients with PerAF. This study aimed to compare the efficacy of thoracoscopic surgical biatrial ablation versus CA in patients with PerAF. Methods. Patients with PerAF underwent thoracoscopic surgical biatrial ablation or CA were included in this study. Propensity score matching (1 : 2) was applied to select patients in CA group and surgical ablation (SA) group. The primary endpoint was to compare the probability of freedom from atrial tachyarrhythmias between SA and CA. Atrial tachyarrhythmia recurrence was defined as any atrial tachyarrhythmias longer than 30 s documented by 24-hour Holter monitoring after the 3-month blanking period. Results. After propensity score matching, 51 patients in surgical biatrial ablation group and 102 patients in CA group were enrolled (mean left atrial diameter: 45.8 mm). The probability of freedom from atrial tachyarrhythmias on antiarrhythmia drugs was 62.7%, 60.6%, and 60.6% in SA group and 42.0%, 39.6%, and 36.7% in CA group at 12, 24, and 36 months, respectively ( = 0.011), and off antiarrhythmia drugs were 56.9%, 52.5%, and 52.5% in SA group and 36.0%, 31.4%, and 27.5% in CA group at 12, 24, and 36 months, respectively ( = 0.007). After adjustment of age, sex, left atrial diameter, and AF duration history, multivariable Cox regression analysis suggested that SA procedure was an independent factor to reduce the risk of atrial tachyarrhythmia recurrence (HR: 0.589, 95% CI 0.370–0.937, = 0.025). Conclusion. Compared with CA, thoracoscopic surgical biatrial ablation might achieve superior effectiveness for patients with PerAF.
Clarifying the Pulmonary Arterial Morphology and Pulmonary Blood Supply in Patients with Tetralogy of Fallot and Pulmonary Atresia on Computed Tomography Angiography
Aim. The present study sought to characterize the pulmonary arterial morphology and pulmonary blood supply in patients of tetralogy of Fallot and pulmonary atresia (TOF-PA) on CT angiography. Materials and Methods. We retrospectively reviewed our departmental database to identify patients with TOF-PA evaluated using CT angiography. The images were analysed to detect the presence of main and branch pulmonary arteries and pulmonary arterial confluence, presence of major aortopulmonary collateral arteries (MAPCAs), laterality and relation with pulmonary arterial morphology, and presence of patent arterial duct and associated intra- and extracardiac anomalies. Results. TOF-PA was identified in 177 patients (114 (64.4%) males; median age: 9 months). Pulmonary arteries were confluent in 142/177 (80.2%) patients. According to Somerville classification, type II pulmonary atresia was the most frequent pattern seen in 127/177 (71.8%). Based on McGoon’s ratio, pulmonary arteries were adequate for surgery in 123/177 (69.5%) patients. Patent arterial duct was present in 84/177 (47.5%) patients while MAPCAs were present in 124 (70.1%) patients, of which 72/124 (58.1%) patients had at least 1 essential MAPCA supplying either lung. According to Congenital Heart Surgeons’ Society classification, type B pulmonary arterial anatomy was the most prevalent, seen in 103/177 (57.6%) patients. Conclusion. TOF-PA is associated with marked morphologic variability in the pulmonary arterial arborization to supply the lungs. Cardiac CT angiography can accurately delineate the pulmonary arterial morphology, sources of pulmonary blood supply, and associated cardiovascular anomalies in patients with TOF-PA which aids in planning appropriate surgical management including decisions regarding the need for unifocalization of MAPCAs.
A Prediction Model for Neonatal Coarctation Repair Involving Fetal and Neonatal Echocardiographic Parameters
Objective. The aim of this study is to investigate the predictive value of fetal and neonatal echocardiographic parameters for neonatal coarctation repair in fetuses suspected of coarctation of the aorta (CoA), establish a prediction model for neonatal coarctation repair, and verify its predictive effectiveness and clinical applicability. Methods. From September 2017 to September 2022, fetuses suspected with CoA were enrolled. They were divided into two groups based on the need for neonatal coarctation repair. Fetal and neonatal echocardiographic parameters and clinical characteristics were collected retrospectively. Univariate and multivariate logistic regressions were applied to select significant predictors, which were further used to establish the nomogram prediction model. The area under the curve (AUC) of the receiver operating characteristic (ROC) was employed to quantify its discrimination ability. The calibration curve was drawn for internal verification, and the decision curve analysis (DCA) and clinical impact curve (CIC) were used to evaluate the clinical applicability of the prediction model. Results. This study included 50 infants suspected of CoA prenatally, of which 16 (32%) received aortic coarctation repair in the neonatal period and 34 (68%) did not. Multivariable logistic regression analysis revealed that the fetal echocardiographic parameter aortic isthmus/ductus arteriosus (AoI/DA) diameter ratio and the neonatal echocardiographic parameters such as the distance from left common carotid to left subclavian artery (LCSA) and the diameter of distal transverse aortic arch (DTAA) were independent predictors for neonatal coarctation repair. The ROC curve of the model showed excellent predictive value (AUC = 0.943). The calibration curve of the prediction model exhibited good fitness. The DCA and CIC demonstrated that the model had good clinical utility. Conclusion. The prediction model, which combines the fetal echocardiographic parameter AoI/DA diameter ratio and the neonatal echocardiographic parameters distance of LCSA and DTAA diameter, has an exceptional level of clinical value and prediction accuracy.
Prediction of Postoperative Acute Kidney Injury Risk Factors for Acute Type A Aortic Dissection Patients after Modified Triple-Branched Stent Graft Implantation by a Perioperative Nomogram: A Retrospective Study
Objective. Predicting risk factors for acute kidney injury (AKI) after total arch replacement via modified triple-branched stent graft (MTBSG) implantation in patients with acute type A aortic dissection (AAAD) by conducting a nomogram. Methods. We collected the clinical data of 254 patients with AAAD who underwent MTBSG implantation surgery in our center. The independent risk factors of postoperative AKI were screened by univariate and multivariate logistic regression analysis and combined into a nomogram. We use receiver operating characteristic (ROC) curves, decision curve analysis (DCA), clinical impact curve (CIC), and calibration plots to evaluate the accuracy of the nomogram model. Results. Multiple logistic regression analysis showed that the risk factors of AKI after MTBSG implantation were age, malperfusion syndrome, preoperative serum creatinine, cardiopulmonary bypass time, and amount of red blood cell (RBC) transfusion. Based on these five risk factors, we established a nomogram model. The good accuracy and clinical applicability of the model were verified by drawing ROC curve (area under the curve (AUC) = 0.854), DCA curve, CIC curve, and calibration curve. Conclusions. Using perioperative clinical data to establish a nomogram model of AKI in patients with AAAD who received MTBSG implantation can be used as a tool to predict the occurrence of AKI after operation.