Evaluation of the PAS-Port Proximal Anastomosis System in coronary artery bypass surgery (the EPIC trial)

ObjectiveDuring coronary surgery, proximal vein graft anastomoses have been performed by using an aortic partial occlusion clamp to allow for a hand-sewn anastomosis. The purpose of this multicenter, prospective, randomized trial was to evaluate the efficacy of the PAS-Port device (Cardica, Inc, Redwood City, Calif), which allows an automated proximal anastomosis to be performed without aortic clamping.MethodsBetween June 22, 2006, and March 22, 2007, 220 patients requiring coronary artery bypass grafting with at least 2 vein grafts were enrolled. Within each patient, 1 graft was randomly assigned to receive a PAS-Port device, and the other was assigned to receive a hand-sewn anastomosis to the ascending aorta. The primary end point was angiographic patency (<50% stenosis) 9 months after surgical intervention. Secondary end points included average time to complete each anastomosis and 9-month freedom from major adverse cardiac events.ResultsOne hundred eighty-three patients received matched grafts that were angiographically assessed at 9 months. The 9-month graft patency was 82.0% (150/183) for hand-sewn and 80.3% (147/183) for PAS-Port grafts. The patency rate of PAS-Port anastomoses was statistically noninferior to that of hand-sewn anastomoses (95% lower confidence limit for difference, −7.95%). The freedom from major adverse cardiac events at 9 months was 97.7% for PAS-Port (95% confidence interval, 94.5%–99.0%) and 98.2% for hand-sewn (95% confidence interval, 95.1%–99.3%) grafts. The PAS-port device was associated with a 4.6 ± 3.9–minute reduction in anastomotic time compared with that seen with a hand-sewn anastomosis (P < .001).ConclusionsThe PAS-Port proximal anastomotic device produces an effective anastomosis with a 9-month patency rate that is comparable with that of a hand-sewn anastomosis. It allows for construction of a proximal anastomosis without aortic clamping and requires less time than a hand-sewn anastomosis

Aorto-bronchial and aorto-pulmonary fistulation after thoracic endovascular aortic repair: an analysis from the European Registry of Endovascular Aortic Repair Complications

OBJECTIVES To learn upon incidence, underlying mechanisms and effectiveness of treatment strategies in patients with central airway and pulmonary parenchymal aorto-bronchial fistulation after thoracic endovascular aortic repair (TEVAR). METHODS Analysis of an international multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2012 with a total caseload of 4680 TEVAR procedures (14 centres). RESULTS Twenty-six patients with a median age of 70 years (interquartile range: 60-77) (35% female) were identified. The incidence of either central airway (aorto-bronchial) or pulmonary parenchymal (aorto-pulmonary) fistulation (ABPF) in the entire cohort after TEVAR in the study period was 0.56% (central airway 58%, peripheral parenchymal 42%). Atherosclerotic aneurysm formation was the leading indication for TEVAR in 15 patients (58%). The incidence of primary endoleaks after initial TEVAR was n = 10 (38%), of these 80% were either type I or type III endoleaks. Fourteen patients (54%) developed central left bronchial tree lesions, 11 patients (42%) pulmonary parenchymal lesions and 1 patient (4%) developed a tracheal lesion. The recognized mechanism of ABPF was external compression of the bronchial tree in 13 patients (50%), the majority being due to endoleak formation, further ischaemia due to extensive coverage of bronchial feeding arteries in 3 patients (12%). Inflammation and graft erosion accounted for 4 patients (30%) each. Cumulative survival during the entire study period was 39%. Among deaths, 71% were attributed to ABPF. There was no difference in survival in patients having either central airway or pulmonary parenchymal ABPF (33 vs 45%, log-rank P = 0.55). Survival with a radical surgical approach was significantly better when compared with any other treatment strategy in terms of overall survival (63 vs 32% and 63 vs 21% at 1 and 2 years, respectively), as well as in terms of fistula-related survival (63 vs 43% and 63 vs 43% at 1 and 2 years, respectively). CONCLUSIONS ABPF is a rare but highly lethal complication after TEVAR. The leading mechanism behind ABPF seems to be a continuing external compression of either the bronchial tree or left upper lobe parenchyma. In this setting, persisting or newly developing endoleak formation seems to play a crucial role. Prognosis does not differ in patients with central airway or pulmonary parenchymal fistulation. Radical bronchial or pulmonary parenchymal repair in combination with stent graft removal and aortic reconstruction seems to be the most durable treatment strateg

New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications

OBJECTIVES To review the incidence, clinical presentation, definite management and 1-year outcome in patients with aorto-oesophageal fistulation (AOF) following thoracic endovascular aortic repair (TEVAR). METHODS International multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2011 with a total caseload of 2387 TEVAR procedures (17 centres). RESULTS Thirty-six patients with a median age of 69 years (IQR 56-75), 25% females and 9 patients (19%) following previous aortic surgery were identified. The incidence of AOF in the entire cohort after TEVAR in the study period was 1.5%. The primary underlying aortic pathology for TEVAR was atherosclerotic aneurysm formation in 53% of patients and the median time to development of AOF was 90 days (IQR 30-150). Leading clinical symptoms were fever of unknown origin in 29 (81%), haematemesis in 19 (53%) and shock in 8 (22%) patients. Diagnosis could be confirmed via computed tomography in 92% of the cases with the leading sign of a new mediastinal mass in 28 (78%) patients. A conservative approach resulted in a 100% 1-year mortality, and 1-year survival for an oesophageal stenting-only approach was 17%. Survival after isolated oesophagectomy was 43%. The highest 1-year survival rate (46%) could be achieved via an aggressive treatment including radical oesophagectomy and aortic replacement [relative risk increase 1.73 95% confidence interval (CI) 1.03-2.92]. The survival advantage of this aggressive treatment modality could be confirmed in bootstrap analysis (95% CI 1.11-3.33). CONCLUSIONS The development of AOF is a rare but lethal complication after TEVAR, being associated with the need for emergency TEVAR as well as mediastinal haematoma formation. The only durable and successful approach to cure the disease is radical oesophagectomy and extensive aortic reconstruction. These findings may serve as a decision-making tool for physicians treating these complex patient

Aortic valve replacement with or without myocardial revascularization in octogenarians. Can minimally invasive extracorporeal circuits improve the outcome?

OBJECTIVE: The positive impact of minimally invasive extracorporeal circuits (MiECC) on patient outcome is expected to be most evident in patients with limited physiologic reserves. Nevertheless, most studies have limited their use to low-risk patients undergoing myocardial revascularization. As such, there is little evidence to their benefit outside this patient population. We, therefore, set out to explore their potential benefit in octogenarians undergoing aortic valve replacement (AVR) with or without concomitant myocardial revascularization. METHODS: Based on the type of the utilized ECC, we performed a retrospective propensity score-matched comparison among all octogenarians (n = 218) who received a primary AVR with or without concomitant coronary artery bypass grafting in our institution between 2003 and 2010. RESULTS: A MiECC was utilized in 32% of the patients. The propensity score matching yielded 52 matched pairs. The 30-day postoperative mortality (2% vs. 10%; p=0.2), the incidence of low cardiac output (0% vs. 6%; p=0.2) and the Intensive Care Unit (ICU) stay (2.5 ± 2.6 vs. 3.8 ± 4.7 days; p=0.06) were all in favour of the MiECC group, but failed to reach statistical significance while the 90-day postoperative mortality did (2% vs. 16%; p=0.02). CONCLUSION: MiECCs have a positive influence on the outcome of octogenarians undergoing AVR with or without concomitant coronary artery bypass grafting. Their use should, therefore, be extended beyond isolated coronary artery bypass graft (CABG) surgery

Aortic root reimplantation for successful repair of an insufficient pulmonary autograft valve after the Ross procedure

AbstractJ Thorac Cardiovasc Surg 2002;124:1048-

German Heart Surgery Report 2016: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery

Based on a long-standing voluntary registry founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS), well-defined data of all cardiac, thoracic, and vascular surgery procedures performed in 78 German heart surgery departments during the year 2016 are analyzed. In 2016, a total of 103,128 heart surgery procedures (implantable defibrillator, pacemaker, and extracardiac procedures excluded) were submitted to the registry. Approximately 15.7% of the patients were at least 80 years of age, resulting in an increase of 0.9% compared with the data of 2015. For 37,614 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 4.4:1), an unadjusted in-hospital mortality of 2.9% was observed. Concerning the 33,451 isolated heart valve procedures (including 11,701 catheter-based procedures), the unadjusted in-hospital mortality was 4.3%. This annual updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, describes advancements in heart medicine, and is a basis for internal and external quality assurances for all participants. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is appropriate and patients are treated nationwide at all times