Faculty Bibliography

This is a man in his late 70s with a history of myocardial infarction and congenital factor XI (FXI) deficiency, who underwent urgent coronary artery bypass surgery for coronary artery disease. He demonstrated less than 2% factor XI activity on serological assay. Preoperatively, the patient was managed with only a non-therapeutic heparin drip, forgoing any preoperative factor resuscitation. Intraoperatively, the patient received fresh frozen plasma administration for post-bypass coagulopathy based on real-time assessment of bleeding. This resuscitation strategy advocates for the use of factor products based on clinical assessment as opposed to prophylactic resuscitation. Further research is required on the appropriate resuscitation strategy for FXI deficiency in the cardiac surgery patient. Practitioners should select a protocol that accounts for deficient factor XI levels, coagulopathy associated with cardiopulmonary bypass and the volume status of the patient.

Marantic endocarditis is defined as a sterile endocarditis that is rarely encountered in clinical practice. This case series illustrates five cases of marantic endocarditis. All cases were diagnosed on trans thoracic echocardiography and verified on transesophageal echocardiography. The first three cases occur in the setting of antiphospholipid syndrome; the last two occur in the setting of advanced malignancy. Two cases were treated successfully with anticoagulation, while two others required valvular surgery. One case resulted in mortality. The treatment course of these five patients mirrors certain patterns described in the literature.

Background and Objective: With the advent of minimally invasive approaches, coronary artery bypass grafting (CABG) surgery has evolved to maintain good outcomes and improve patient experience. The increased use of robotic and hybrid platforms in cardiac surgery has allowed for smaller incisions, quicker recovery times, while maintaining acceptable outcomes. While minimally invasive techniques are growing in popularity, sternotomy remains the most common means of exposure. The following manuscript explores the opportunities that mini thoracotomy, robotic surgery, and hybrid coronary revascularization (HCR) provide to the modern cardiac surgeon. Methods: A comprehensive search strategy was constructed on minimally invasive approaches for CABG. All resulting articles were manually screened and selected for chapter review. Key Content and Findings: The chapter reviews the data on CABG via mini-Thoracotomy incision, robotic CABG, and HCR. It also discusses patient selection and cost analysis. With careful patient selection, minimally invasive approaches to CABG can provide equivalent or better outcomes to standard open CABG. Some limitations to the growth in its popularity may be the need for a higher patient volume in order for hospitals to justify investing in robotic technology. However, with equivalent survival outcomes and better patient recovery, minimally invasive CABG is the future of surgical treatment of coronary artery disease. Conclusions: Through smaller incisions and robotic platforms, minimally invasive CABG is a safe and effective option for cardiac surgery patients. Future research is required into how best to finance minimally invasive surgery (MIS) CABG modalities in order to make it more readily available to the general public.

BACKGROUND:The benefits of fast-track extubation in the intensive care unit (ICU) after cardiac surgery are well established. Although extubation in the operating room (OR) is safe in carefully selected patients, widespread use of this strategy in cardiac surgery remains unproven. This study was designed to evaluate perioperative outcomes with OR vs ICU extubation in patients undergoing nonemergency, isolated coronary artery bypass grafting (CABG). METHODS:The Society of Thoracic Surgeons (STS) data for all single-center patients who underwent nonemergency isolated CABG over a 6-year interval were analyzed. Perioperative morbidity and mortality with ICU vs OR extubation were compared. RESULTS:Between January 1, 2017 and December 31, 2022, 1397 patients underwent nonemergency, isolated CABG; 891 (63.8%) of these patients were extubated in the ICU, and 506 (36.2%) were extubated in the OR. Propensity matching resulted in 414 pairs. In the propensity-matched cohort, there were no differences between the 2 groups in incidence of reintubation, reoperation for bleeding, total operative time, stroke or transient ischemic attack, renal failure, or 30-day mortality. OR-extubated patients had shorter ICU hours (14 hours vs 20 hours; P < .0001), shorter postoperative hospital length of stay (3 days vs 5 days; P < .0001), a greater likelihood of being discharged directly to home (97.3% vs 89.9%; P < .0001), and a lower 30-day readmission rate (1.7% vs 4.1%; P = .04). CONCLUSIONS:Routine extubation in the OR is a feasible and safe strategy for a broad spectrum of patients after nonemergency CABG, with no increase in perioperative morbidity or mortality. Wider adoption of routine OR extubation for nonemergency CABG is indicated.

Objective: Homograft aortic root replacement provides an excellent hemodynamic restoration of valve function for prosthetic aortic valve endocarditis, but is susceptible to degeneration and calcification. The optimal surgical intervention for valvular disease after homograft root replacement is controversial due to the high risk of morbidity and mortality with reintervention.
Method(s): This video demonstrates a case of redo sternotomy with mechanical aortic valve replacement (AVR) in a patient post 2 previous AVRs and a porcelain homograft. A 38-year-old female presented in heart failure from prosthetic valve endocarditis, with a history of systemic lupus erythematosus, complicated by end-stage renal failure requiring dialysis and lupus anticoagulant.
Result(s): The patient had severe prosthetic aortic insufficiency, severe mitral regurgitation, and severe tricuspid regurgitation. A third-time redo sternotomy was performed. A mechanical sized #17 valve was placed in the aortic position and a #23 sized mechanical valve was placed in the mitral position. A bovine patch aortoplasty of the aorta was required after the calcified wall shattered into fragments upon transection with a patch of bovine pericardium. Postoperative echo revealed preserved left ventricular and right ventricular function with good function of the mechanical aortic and mitral valves.
Conclusion(s): Mechanical AVR, without replacement of the aortic root, is a feasible and potentially effective method of reestablishing a functional aortic valve in a patient with a severely calcified aortic homograft

Immunoglobulin G4-related disease is a systemic fibroinflammatory disease; pericardial involvement has occasionally been reported in publications. A 79-year-old man with biopsy-proven immunoglobulin G4-related disease with pleural involvement was admitted in acute heart failure, with imaging and hemodynamic studies consistent with constrictive pericarditis. He was treated with corticosteroids for 2 months with partial response manifest by decreases in pericardial thickening and immunoglobulin G4 levels. However, persistent constriction required pericardiectomy, leading to significant symptomatic improvement. (Level of Difficulty: Intermediate.).

We report what appears to be the first case of biopsy-proven nonvalvular endocarditis with biventricular apical infected thrombi. A 47-year-old man presented with hypoxic respiratory failure from a multilobar pneumonia due to methicillin-resistant Staphylococcus aureus (MRSA). Transthoracic echocardiography and cardiac magnetic resonance imaging revealed biventricular apical masses suggestive of nonvalvular endocarditis with infected thrombi. Given concern for ongoing septic embolization to the lungs and brain despite appropriate antimicrobial therapy, the masses were surgically resected. Culture and histopathology confirmed MRSA-positive infected thrombi. In this case report, we highlight the differential diagnosis of apical masses and the role of multimodality imaging.

A case is presented in which a preoperatively diagnosed hydatid cyst was found to be a mature cystic teratoma on pathological examination. Diagnostic dilemmas surrounding each disease are discussed.

Here we present a case of a 38 year old male with an incidentally found right upper lobe lung mass. The patient underwent thoracoscopic resection of the mass which revealed a myxoid spindle cell lipoma. This is an exceedingly rare location for this tumor biology and here we discuss its pathological features and treatment options.