Surgical repair of descending thoracic and thoracoabdominal aortic aneurysm involving the distal arch: Open proximal anastomosis under deep hypothermia versus arch clamping technique

BackgroundSurgical repair of a descending thoracic and thoracoabdominal aortic aneurysm (DTA/TAAA) involving the distal arch is challenging and requires either deep hypothermic circulatory arrest (DHCA) or crossclamping of the distal arch. The aim of this study was to compare these 2 techniques in the treatment of DTA/TAAA involving the distal arch.MethodsFrom 1994 to 2012, 298 patients underwent open repair of DTA/TAAA through a left thoracotomy. One hundred seventy-four patients with distal arch involvement who were suitable for either DHCA (n = 81) or arch clamping (AC; n = 93), were analyzed. In-hospital outcomes were compared using propensity scores and inverse-probability-of-treatment weighting adjustment to reduce treatment selection bias.ResultsEarly mortality was 11.1% in the DHCA group and 8.6% in the AC group (P = .58). Major adverse outcomes included stroke in 16 patients (9.2%), low cardiac output syndrome in 15 (8.6%), paraplegia in 10 (5.7%), and multiorgan failure in 10 (5.7%). After adjustment, patients who underwent DHCA were at similar risk of death (odds ratio [OR], 1.14; P = .80) and permanent neurologic injury (OR, 0.95; P = .92) to those who underwent AC. Although prolonged ventilator support (>24 hours) was more frequent with DHCA than with AC (OR, 2.60; P = .003), DHCA showed a tendency to lower the risk of paraplegia (OR, 0.15; P = .057).ConclusionsCompared with AC, DHCA did not increase postoperative mortality and morbidity, except for prolonged ventilator support. However, DHCA may offer superior spinal cord protection to AC during repair of DTA/TAAA involving the distal arch

Titanium Plate Fixation for a Dehisced Sternum Following Coronary Artery Bypass Grafting: A Case Report

Sternal dehiscence is one of the most troublesome complications following cardiac surgery. Treatment failure and consequent lethal results are very common, even with all the efforts to resolve sternal dehiscence such as removal of infectious tissue, muscle flap interposition, and sternal rewiring. We report on a case of sternal osteomyelitis following coronary artery bypass grafting that was successfully treated with wide sternal resection, titanium plate fixation, and pectoralis muscle flap interposition

The impact of sequential versus single anastomoses on flow characteristics and mid-term patency of saphenous vein grafts in coronary bypass grafting

ObjectiveTo assess the influence of bypass grafting technique on the flow characteristics and mid-term patency of saphenous vein coronary bypass grafts.MethodsIn the present study, 309 patients who underwent either sequential (group A, N = 84 grafts) or individual (group B, N = 244 grafts) saphenous vein coronary bypass grafting between February 2002 and September 2007 were investigated. Individual bypassing only was performed in 212 patients, and sequential bypassing only was performed in 78 patients. The remaining 19 patients received both. A total of 436 distal anastomoses were performed with 328 saphenous vein grafts. The intraoperative flow characteristics and the graft patency were assessed with the transit time flow meter and serial multi-detector computed tomography coronary angiograms, respectively.ResultsGroup A showed a higher mean flow compared with group B at 49.4 ± 27.4 mL/min versus 37.1 ± 20.1 mL/min, respectively (P = .001). The mean flow increased linearly as the number of anastomoses increased per graft (P < .001). Graft patency at 3 years was 93.3% ± 3.4% in group A and 86.5% ± 3.1% in group B (P = .048). After adjustment for baseline characteristics, group A showed a tendency for superior mid-term patency than group B (hazard ratio 0.362; 95% confidence interval, 0.129–1.017; P = .0538).ConclusionsSequential bypass grafts were associated with higher mean flows and superior mid-term patency compared with individual grafts. These findings suggest the more favorable results of sequential bypass grafting to be attributed to the enhanced flow hemodynamics

Long-term Mortality in Adult Orthotopic Heart Transplant Recipients

Heart transplantation is now regarded as the treatment of choice for end-stage heart failure. To improve long-term results of the heart transplantation, we analyzed causes of death relative to time after transplantation. A total of 201 consecutive patients, 154 (76.6%) males, aged ≥ 17 yr underwent heart transplantation between November 1992 and December 2008. Mean ages of recipients and donors were 42.8 ± 12.4 and 29.8 ± 9.6 yr, respectively. The bicaval anastomosis technique was used since 1999. Mean follow up duration was 6.5 ± 4.4 yr. Two patients (1%) died in-hospital due to sepsis caused by infection. Late death occurred in 39 patients (19.4%) with the most common cause being sepsis due to infection. The 1-, 5-, and 10-yr survival rates in these patients were 95.5% ± 1.5%, 86.9% ± 2.6%, and 73.5% ± 4.1%, respectively. The surgical results of heart transplantation in adults were excellent, with late mortality due primarily to infection, malignancy, and rejection. Cardiac deaths related to cardiac allograft vasculopathy were very rare

Mild-to-moderate functional tricuspid regurgitation in patients undergoing mitral valve surgery

ObjectiveThe decision to repair mild-to-moderate functional tricuspid regurgitation (TR) during mitral valve surgery remains controversial. We evaluated the effects of tricuspid valve (TV) repair for functional mild-to-moderate TR during mitral valve surgery.MethodsWe enrolled 959 patients with mild-to-moderate functional TR who underwent mitral valve surgery with (repair group n = 431) or without (control group n = 528) concomitant TV repair from January 1994 to September 2010.ResultsThere were no significant differences in early mortality or major morbidity rates. Median follow-up was 64.8 months (range, 0.03-203.6 months). After adjustment for baseline characteristics using a propensity score adjustment model, the repair group had similar risks for TV reoperation (hazard ratio [HR], 0.46; 95% confidence interval [CI], 0.10-2.07; P = .31); congestive heart failure (HR, 1.12; 95% CI, 0.37-3.36; P = .84); death (HR, 1.41; 95% CI, 0.82-2.42; P = .22); and the composite of death, TV reoperation, and congestive heart failure (HR, 1.24; 95% CI, 0.76-2.03; P = .39) compared with the control group. On multivariate Cox-regression analysis, old age, atrial fibrillation without a Maze procedure, diabetes mellitus, chronic renal failure, poor left ventricular ejection fraction, and redo surgery emerged as significant independent risk factors for the composite outcome of death, TV reoperation, and congestive heart failure.ConclusionsEarly or late clinical benefits of concomitant TV repair for mild-to-moderate TR during mitral valve surgery were uncertain through a long-term follow-up of 959 patients. Several preoperative factors and the performance of Maze procedure for AF seem to be more important than TV repair in overall clinical outcomes

Hybrid Procedure for a Traumatic Aortic Rupture Consisting of Endovascular Repair and Minimally Invasive Arch Vessel Transposition without Sternotomy

Emergency surgical repair for acute traumatic aortic ruptures has been associated with a high peri-procedural mortality rate. Endovascular stent-grafting, as a less invasive procedure, has shown encouraging results. This report describes a patient with a short landing zone, who was treated by transposing the supra-aortic branch without sternotomy, followed by covered stent-grafting with an extended proximal bare portion to enhance fixation