Axillary artery cannulation reduces early embolic stroke and mortality after open arch repair with circulatory arrest

OBJECTIVE: To evaluate the efficacy of axillary artery cannulation for early embolic stroke and operative mortality, we retrospectively compared the outcomes between patients with or without axillary artery cannulation during open aortic arch repair with circulatory arrest. METHODS: Between January 2004 and December 2017, 468 patients underwent open aortic arch repair with circulatory arrest using antegrade cerebral perfusion and were divided into 2 groups according to the site of arterial cannulation: the axillary artery (axillary group, n = 352) or another site (nonaxillary group, n = 116) groups. Embolic stroke was defined as a physician-diagnosed new postoperative neurologic deficit lasting more than 72 hours, generally confirmed by computed tomography or magnetic resonance imaging. RESULTS: After propensity score matching, the patients' characteristics were comparable between the groups (n = 116 in each). The incidences of acute type A dissection, aortic rupture, shock, or emergency operation were similar between groups. The incidence of early embolic stroke was significantly lower in axillary group (n = 3 [2.6%] vs n = 10 [8.6%]; P = .046). Also, 30-day mortality (n = 3 [2.6%] vs n = 10 [8.6%]; P = .046) and in-hospital mortality (n = 3 [2.6%] vs n = 11 [9.5%]; P = .027) occurred significantly lower in the axillary group. CONCLUSIONS: Axillary artery cannulation reduced the early embolic stroke and early mortality after open arch repair with circulatory arrest. Axillary artery cannulation as the arterial cannulation site during open arch repair with circulatory arrest may be helpful in preventing embolic stroke and reducing early mortality.ope

The feasibility and safety of off pump coronary bypass surgery in emergency revascularization

의과대학/석사Background: The efficacy and safety of off-pump coronary bypass grafting (OPCAB) in emergency revascularization remains controversial despite its widespread use. The aim of our study is to exam the applicability and safety of OPCAB in patients who were indicated for emergency surgery. Methods: This single center study reviewed indication, operative data, and early and long-term outcomes of 113 patients (age, 66.5±9.3 years; logistic EuroScore, 14.4±13.5) who underwent emergency OPCAB from January 2003 to December 2014 and were followed up (93.8% rate) for a mean 51.1±40.3 (range, 1-135) months. Results: Emergency OPCAB in the 113 patients studied was associated with favorable surgical outcomes (on-pump conversion, 4.4%; number of distal anastomoses per patient, 3.04+0.87; IMA use, 98.2%; and complete revascularization, 82.3%); in-hospital (mortality, 5.3%; low cardiac output syndrome, 5.3%; stroke, 2.7%; pulmonary complications, 8.8%; renal failure, 11.5%; ventilator use duration, 61.59+126.62 hours; ICU stay, 4.77+6.59 days; and hospital stay, 14.98+9.66 days). The 10-year outcomes (survival, 77.0+0.6%; and major cerebral and cardiovascular events, 52.0+1.6%) were also comparable. Conclusion: Our study suggests that emergency OPCAB can be performed safely and effectively with improved hospital outcomes and comparable long term results. OPCAB strategy can be considered as a good option in emergency revascularization.ope

Chondrosarcoma of the Heart

Chondrosarcoma is a rare entity of malignant tumor which arises from cartilaginous tissue, and the literatures on this disease are scarce. The first-line of treatment for cardiac chondrosarcoma is surgery. Due to early local recurrence and distant metastasis, the prognosis is poor even after complete surgical excision. We present a case of chondrosarcoma in the left atrium causing functional mitral stenosis which required urgent surgical intervention, and the successful treatment outcome.ope

Impact of High-Dose Statin Pretreatment in Patients with Stable Angina during Off-Pump Coronary Artery Bypass.

BACKGROUND: Periprocedural treatment with high-dose statins is known to have cardioprotective and pleiotropic effects, such as anti-thrombotic and anti-inflammatory actions. We aimed to assess the efficacy of high-dose rosuvastatin loading in patients with stable angina undergoing off-pump coronary artery bypass grafting (OPCAB). MATERIALS AND METHODS: A total of 142 patients with stable angina who were scheduled to undergo surgical myocardial revascularization were randomized to receive either pre-treatment with 60-mg rosuvastatin (rosuvastatin group, n=71) or no pre-treatment (control group, n=71) before OPCAB. The primary endpoint was the 30-day incidence of major adverse cardiac events (MACEs). The secondary endpoint was the change in the degree of myocardial ischemia as evaluated with creatine kinase-myocardial band (CK-MB) and troponin T (TnT). RESULTS: There were no significant intergroup differences in preoperative risk factors or operative strategy. MACEs within 30 days after OPCAB occurred in one patient (1.4%) in the rosuvastatin group and four patients (5.6%) in the control group, respectively (p=0.37). Preoperative CK-MB and TnT were not different between the groups. After OPCAB, the mean maximum CK-MB was significantly higher in the control group (rosuvastatin group 10.7+/-9.75 ng/mL, control group 14.6+/-12.9 ng/mL, p=0.04). Furthermore, the mean levels of maximum TnT were significantly higher in the control group (rosuvastatin group 0.18+/-0.16 ng/mL, control group 0.39+/-0.70 ng/mL, p=0.02). CONCLUSION: Our findings suggest that high-dose rosuvastatin loading before OPCAB surgery did not result in a significant reduction of 30-day MACEs. However, high-dose rosuvastatin reduced myocardial ischemia after OPCAB.ope

A Retrospective Comparison of Hemodynamic and Clinical Outcomes between Two Differently Designed Aortic Bioprostheses for Small Aortic Annuli

The Trifecta valve has externally mounted leaflets; it differs from classic internally mounted valves (e.g., Carpentier-Edwards [C-E]). We evaluated post-implantation hemodynamics and clinical outcomes of these bioprostheses in small aortic annuli. From January 2015 to April 2019, 490 patients who underwent aortic valve replacement (AVR) were reviewed retrospectively. Altogether, 183 patients received 19 or 21 mm diameter C-E (n = 121) or Trifecta (n = 62) prostheses. To minimize confounding variables, we performed propensity-score matching analysis. The mean transvalvular pressure gradient (TVPG) was significantly lower in the Trifecta than in the C-E group at discharge (12.9 ± 4.8 vs. 15.0 ± 5.3 mmHg, p = 0.044). TVPG change over time was not significantly different between groups (p = 0.357). Left ventricular mass index decreased postoperatively (reduction: C-E, 28.1%; Trifecta, 30.1%, p = 0.879). No late mortality, severe patient-prosthesis mismatch, moderate-to-severe paravalvular leakage, structural valve degeneration, or valve thromboses were observed. Freedom from valve-related events at 3 years were similar for C-E (97.9% ± 2.1%) and Trifecta (97.7% ± 2.2%) patients (log-rank p = 0.993). Bioprosthesis design for small annuli significantly affected TVPG immediately after AVR. However, hemodynamics over time and clinical outcomes did not differ between the two designs.ope

Aortic valve replacement in patients aged 50 to 69 years: Analysis using Korean National Big Data

Background: The aim of this study was to compare the clinical outcomes and long-term survival in patients who underwent isolated aortic valve replacement (AVR) with mechanical versus bioprosthetic valves. Methods: Patients aged 50-69 years who had undergone AVR from 2002 to 2018 were identified and their characteristics were collected from Korean National Health Information Database formed by the National Health Insurance Service, Republic of Korea. Of the 5792 patients, 1060 patients were excluded due to missing values on characteristics. Of the 4732 study patients, 1945 patients (41.1%) had received bioprosthetic valves (Group B) and 2787 patients (58.9%) had received mechanical valves (Group M). A propensity score-matched analysis was performed to match 1429 patients in each group. Data on mortality, cardiac mortality, reoperations, cerebrovascular accidents, and bleeding complications were obtained. Results: The overall survival rates at 5 and 10 years postoperatively were 87.8% and 75.2% in the matched Group B and 91.2% and 76.7% in the matched Group M, respectively (p = .140). Freedom from cardiac death rates at postoperative 5 and 10 years were 95.6% and 92.4% in the matched Group B and 96.0% and 92.1% in the matched Group M, respectively (p = .540). The cumulative incidence of reoperation was higher in the matched Group B than in the matched Group M (p = .007), and the cumulative incidence of major bleeding was higher in the matched Group M than in the matched Group B (p = .039). Conclusion: In patients aged 50-69 years who underwent isolated AVR, the patients who received bioprosthetic valves showed similar cardiac mortality-free survival and long-term survival rates to the patients who received mechanical valves.ope

Comparison of Early Clinical Results of Transcatheter versus Surgical Aortic Valve Replacement in Symptomatic High Risk Severe Aortic Stenosis Patients

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been an alternative to conventional aortic valve replacement (AVR) in old and high risk patients. The goal of this study is to compare the early outcomes of conventional AVR vs. TAVI in high risk severe AS patients. METHODS: From January 2008 to July 2012, 44 high risk severe aortic stenosis patients underwent conventional AVR, and 15 patients underwent TAVI. We compared echocardiographic data, periprocedural complication, and survival. The mean follow-up duration was 14.5±10 months (AVR), and 6.8±3.5 months (TAVI), respectively. RESULTS: AVR group was younger (78.2±2.4 years vs. 82.2±3.0 years, p<0.001) and had lower operative risk (Euroscore: 9.4±2.7 vs. 11.0±2.0, p=0.044) than TAVI group. There was no significant difference in early mortality (11.4% vs. 13.3%, p=0.839), and 1 year survival (87.4%±5.3% vs. 83.1%±1.1%, p=0.805). There was no significant difference in postoperative functional class. There was no significant difference in periprocedural complication except vascular complication (0% [AVR] vs. 13.3% [TAVI], p=0.014). TAVI group had more moderate and severe paravalvular leakage. CONCLUSION: In this study, both groups had similar periprocedural morbidity, and mortality. However, TAVI group had more greater than moderate paravalvular leakage, which can influence long-term outcome. Since more patients are treated with TAVI even in moderate risk, careful selection of the patients and appropriate guideline need to be established.ope

Endovascular Repair versus Open Repair for Isolated Descending Thoracic Aortic Aneurysm

PURPOSE: To compare the outcomes of thoracic endovascular aortic repair (TEVAR) with those of open repair for descending thoracic aortic aneurysms (DTAA). MATERIALS AND METHODS: We compared the outcomes of 114 patients with DTAA and proximal landing zones 3 or 4 after TEVAR to those of 53 patients after conventional open repairs. Thirty-day and late mortality were the primary endpoints, and early morbidities, aneurysm-related death, and re-intervention were the secondary endpoints. RESULTS: The TEVAR group was older and had more incidences of dissecting aneurysm. The mean follow-up was 36±26 months (follow-up rate, 97.8%). The 30-day mortality in the TEVAR and open repair groups were 3.5% and 9.4% (p=0.11). Perioperative stroke and paraplegia incidences were similar between the groups [5.3% vs. 7.5% (p=0.56) and 7.5% vs. 3.5% (p=0.26), respectively]. Respiratory failure occurred more in the open repair group (1.8% vs. 26.4%, p<0.01). The incidence of acute kidney injury requiring dialysis was higher in the open repair group (1.8% vs. 9.4%, p<0.01). The cumulative survival rate was higher in the TEVAR group at 2 to 5 years (79.6% vs. 58.3%, p=0.03). The free from re-intervention was lower in the TEVAR group (65.3% vs. 100%, p=0.02), and the free from aneurysm-related death in the TEVAR and open repair groups were 88.5% and 86.1% (p=0.45). CONCLUSION: TEVAR is safe and effective for treating DTAAs with improved perioperative and long-term outcomes compared with open repair.ope

The feasibility and safety of off-pump coronary bypass surgery in emergency revascularization

Background: The efficacy and safety of off-pump coronary artery bypass grafting (OPCAB) in emergency revascularization remains controversial despite its widespread use. The aim of our study was to examine the applicability and safety of OPCAB in patients who were indicated for emergency surgery. Methods: This single-center study reviewed the indication, operative data, and early and long-term outcomes of 113 patients (mean age, 67.2±9.0 years; logistic EuroSCORE, 14.3±13.5) who underwent emergency OPCAB from January 2003 to December 2014 and were followed up (94.6% completion rate) for a mean 51.1±40.3 (range, 1-135) months. Results: Emergency OPCAB was associated with favorable surgical outcomes (number of distal anastomoses per patient, 3.04±0.87; internal thoracic artery (IMA) use, 98.2%; complete revascularization, 79.6%) and in-hospital outcomes (mortality, 5.3%; low cardiac output syndrome, 5.3%; stroke, 2.7%; pulmonary complications, 8.8%; renal failure, 11.5%). Only five patients (4.4%) required on-pump conversion. The 10-year outcomes were also acceptable (survival, 75.4%±5.6%; major cerebral and cardiovascular events, 52.1%±1.8%). The multivariate risk factors for late mortality were peripheral vascular disease (HR 2.95, 95% CI: 1.11-11.83), cardiogenic shock (HR 3.67, 95% CI: 1.35-9.96), and incomplete revascularization (HR 3.41, 95% CI: 1.06-14.26). When patients were separated by whether the procedure was performed early (<2010) or late (≥2010) in the study period, the late period cohort had better outcomes despite containing higher-risk patients. Conclusions: Our study suggests that emergency OPCAB can be performed safely and effectively with good hospital outcomes and adequate long-term results. OPCAB strategy can be considered as a good option in emergency revascularization.ope

Role of False Lumen Area Ratio in Late Aortic Events After Acute Type I Aortic Dissection Repair

Background: The aim of this study was to investigate whether distal aortic maximum false lumen area (MFLA) ratio predicts late aortic dilation and reintervention after open repair of acute type I aortic dissection. Methods: We analyzed 309 nonsyndromic acute type I aortic dissection patients who were treated with a repair to the proximal aorta between 1994 and 2017. In 230 patients who did not show completely thrombosed false lumen on postoperative computed tomography, the MFLA ratio (MFLA/aortic area) on the descending thoracic aorta (DTA) was measured with postoperative computed tomography. Patients were divided into 3 groups according to the quartile range of MFLA ratio: low MFLA, <0.62 (n = 57); intermediate MFLA, 0.62 to 0.81 (n = 116); and high MFLA, ≥0.82 (n = 57). Results: The aortic expansion rate was significantly higher in the high MFLA group (11.1 ± 21.2 mm/y) compared with intermediate (3.0 ± 7.4 mm/y; P < .01) and low (0.6 ± 6.6 mm/y; P < .01) MFLA groups. High MFLA was found to be an independent risk factor for significant aortic expansion (adjusted hazard ratio, 5.26; 95% CI, 1.53-18.12; P < .01) and aorta-related reintervention (hazard ratio, 4.99; 95% CI, 2.23-11.13; P < .01), and the MFLA ratio was significantly related to proximal DTA reentry tears (adjusted odds ratio, 12974.3; P < .001; area under curve, 0.807). Conclusions: A high MFLA ratio on the DTA after acute type I aortic dissection repair is associated with increased risk of late aortic reintervention and distal aortic dilation. A high MFLA ratio is strongly associated with proximal DTA reentry tears.ope