Axillary cerebral perfusion for arch surgery in acute type A dissection under moderate hypothermia

Backgound: Aortic arch surgery is still associated with increased mortality and morbidity especially in acute type A aortic dissection. Adequate brain protection is essential and commonly performed by either antegrade selective perfusion of the brachiocephalic arteries or an interval of profound hypothermic circulatory arrest. We present our experience for open aortic arch repair with continuous antegrade brain perfusion by means of direct cannulation of the right axillary artery, under moderate hypothermia in patients with acute type A aortic dissection. Methods: In, 25 consecutive patients (17 men) with a mean age of 62.6 ± 14.8 years, aortic repair extended to the arch, for acute type A aortic dissection, was performed through a midline sternotomy. The right axillary artery was used for arterial systemic and brain perfusion at a rectal temperature of 25-27 °C. Results: Mean duration of CPB and aortic cross-clamping was 241 ± 55 and 155 ± 72 min, respectively. The mean duration of circulatory arrest of the lower body and brain perfusion was 39.7 (range, 24-55 min). All the patients survived the procedure and all but one were discharged from hospital. One patient had left arm paralysis which he recovered the first postoperative month. There were no other transient or permanent neurologic deficits. A CT scan was performed at discharge for routine postoperative evaluation. There were no local neurovascular complications related to the cannulation site except for one local re-exploration for bleeding. Conclusions: The absence of any major permanent neurologic deficit or any visceral damages in our patients suggests that continuous moderate hypothermic cerebral perfusion, with an interval of circulatory arrest of the lower body, is adequate for acute type A aortic dissection surgery, allowing safe open repair of the distal aortic arc

Transcutaneous aortic valve implantation using the carotid artery access: Feasibility and clinical outcomes

Background: Transcarotid access is an alternative route for transcutaneous aortic valve implantation (TAVI) in patients with impossible transfemoral access.Aims: We evaluated the safety, effectiveness and early and late clinical outcomes of CoreValve® implantation via the common carotid artery.Methods: Eighteen patients (10 men, 8 women; mean age 84 ± 5 years) at high surgical risk (mean EuroSCORE II 16 ± 13%) with significant peripheral artery disease underwent TAVI via common carotid artery access under general anaesthesia. Mean aortic valve area was 0.64 ± 0.13 cm2 (0.36 ± 0.07 cm2/m2).Results: At a mean follow-up of 605 ± 352 days, two patients (11%) had died in hospital, on days 6 and 20, as a result of sepsis with multiorgan failure (n = 1) or pneumonia (n = 1). There were no perioperative deaths, myocardial infarctions or strokes. Perioperative prosthesis embolization occurred in one patient (6%), requiring implantation of a second valve. In-hospital complications occurred in four patients (23%): blood transfusion for transient significant bleeding at the access site in one patient (6%); permanent pacemaker implantation in two patients (11%); and pericardial drainage in one patient (6%). The rate of event-free in-hospital stay was 66%. Post-procedural echocardiography showed very good haemodynamic performance, with a mean gradient of 8 ± 3 mmHg. Moderate paravalvular leak was present in one patient (6%). Mean intensive care unit stay was 48 ± 31 h; mean in- hospital stay was 7 ± 3 days.Conclusion: TAVI performed by transcarotid access in this small series of severely ill patients was associated with a low incidence of complications, which were associated with the procedure itself rather than the access route

One-stage repair with a new integrated stent-Dacron prosthesis for type B aortic dissection

We describe one-stage repair for a dilated chronic type B aortic dissection in a 55-year-old man by means of a new integrated stent-graft-Dacron prosthesis (Jotec, Hechingen, Germany)

Axillary cerebral perfusion for arch surgery in acute type A dissection under moderate hypothermia

Aortic arch surgery is still associated with increased mortality and morbidity especially in acute type A aortic dissection. Adequate brain protection is essential and commonly performed by either antegrade selective perfusion of the brachiocephalic arteries or an interval of profound hypothermic circulatory arrest. We present our experience for open aortic arch repair with continuous antegrade brain perfusion by means of direct cannulation of the right axillary artery, under moderate hypothermia in patients with acute type A aortic dissection

Massive thromboembolism due to transcatheter ASD closure with ASDOS device

Transcatheter occlusion of atrial septal defects (ASD) is currently being investigated as an attractive alternative to surgical correction. Thromboembolic events are rare in both techniques. However, we report a case of massive systemic embolization and residual left atrial thrombus after secundum ASD transcatheter closure by the ASDOS device (Atrial Septal Defect Occlusion System, Dr. Ing Osypka Corporation, Germany). The patient was successfully treated by femoral embolectomies, surgical removal of the device and closure of the ASD without a patch. No thrombophilia was found on subsequent exploration. Transcatheter ASD closure with the ASDOS device may therefore expose the patient to severe embolic complications. Further evaluation is needed before this technique can be safely recommended

Short-term outcomes of aortic valve neocuspidization for various aortic valve diseases

Objectives: Bioprosthetic valve deterioration remains a major limitation following aortic valve replacement. Favorable results have been reported with an autologous pericardium aortic valve neocuspidization. Methods: Seventy patients (31 women and 39 men) (mean age, 62 ± 12 years) with aortic stenosis (n = 52 [74%]) or aortic regurgitation (n = 18 [26%]) underwent the aortic valve neocuspidization procedure. Thirty-four patients (49%) had a tricuspid valve, 35 (50%) had a bicuspid valve, and 1 (1%) had a monocuspid valve. European System for Cardiac Operative Risk Evaluation and Society of Thoracic Surgeons scores were, respectively, 2.2% ± 2% and 2.0% ± 1.8%. Four patients (6%) had active endocarditis and 2 (3%) had endocarditis sequelae. One patient (1%) had fibroelastoma. A combined procedure was performed in 33 patients (46%). Results: The follow-up period was 24 ± 12 months. One patient (1%) died in hospital and 1 patient (1%) underwent conventional valve replacement for significant aortic regurgitation. Postoperative peak and mean pressure gradients were respectively 14 ± 5 and 8 ± 3 mm Hg. Aortic valve area was 2.5 ± 0.6 cm2. During follow-up, no patients died. Reintervention occurred in 2 patients (3%). At last follow-up, peak pressure gradient was 13 ± 7 mm Hg, mean pressure gradient was 7 ± 4 mm Hg, and aortic valve area was 2.3 ± 0.7 cm2. There was 1 recurrence of moderate aortic stenosis (1%). All patients were in New York Heart Association functional class I (90%) or II (10%). Freedom from major valve-related events was 92.1%, (98.5% for death, 95.2% for reintervention, and 95.2% for endocarditis). Conclusions: In our experience, the midterm outcomes of the aortic valve neocuspidization procedure with autologous glutaraldehyde fixed pericardium were acceptable for survival, operative risk and valve-related complications, for our all-comer patient population with various aortic valve diseases.</p