Single-stage extensive replacement of the thoracic aorta: The arch-first technique

AbstractBackground: Single-stage extensive replacement of the thoracic aorta usually involves a period of circulatory arrest with performance of the graft–to–lower descending thoracic aorta anastomosis before performing the anastomosis to the arch vessels. To minimize the period of brain ischemia and reduce the potential for neurologic injury, we developed an alternative technique. Methods: In 6 patients with extensive aneurysms involving the entire thoracic aorta, exposure was obtained via a bilateral thoracotomy in the anterior fourth intercostal space with transverse sternotomy. A 10-mm graft was anastomosed to the aortic graft, opposite the site of the planned anastomosis to the arch vessels. During a single period of circulatory arrest (34-46 minutes), the aortic graft was attached to a cuff of aorta containing the arch vessels. The graft was then clamped on either side, and the arch was perfused with cold blood for 20 to 36 minutes. After the distal aortic anastomosis was completed, antegrade perfusion was established via the 10-mm graft. The proximal aortic anastomosis was performed last. Results: No patient sustained a permanent neurologic deficit. All 6 patients were discharged from the hospital. Conclusions: The “arch-first” technique, combined with a bilateral transverse thoracotomy, allows expeditious replacement of the thoracic aorta with an acceptable interval of hypothermic circulatory arrest and minimizes the risk of retrograde atheroembolism by establishing antegrade perfusion. (J Thorac Cardiovasc Surg 1999; 117:99-105

Migration of endovascular plug in hybrid repair of dysphagia lusoria

Aberrant right subclavian artery is the most common brachiocephalic artery congenital abnormality and may result in dysphagia from external compression by the aberrant artery on the esophagus. Repair of this anatomic variant can be performed by both open and hybrid endovascular techniques. This case illustrates a complication of a hybrid repair resulting in proximal migration of a vascular occlusion plug, presenting as recurrent dysphagia and need for open surgical extraction of the plug

The impact of left ventricular hypertrophy on early and long-term survival after coronary artery bypass grafting

Background: Left ventricular hypertrophy (LVH) can itself contribute to increased rates of cardiovascular events. We sought to determine the impact of LVH on in-hospital and long-term mortality after coronary artery bypass grafting (CABG). Methods: Between 1992 and 2003, 4140 consecutive patients underwent CABG. Long-term survival data (mean follow-up 7.0 years) were obtained from the National Death Index. The impact of LVH on in-hospital mortality was determined by multivariate logistic regression analysis. Patients with and without LVH were compared by Cox proportional hazard models and risk-adjusted Kaplan-Meier curves. Results: There were 977 patients (23.6%) with LVH. Their mean EuroSCORE was 7.4 +/- 3.4 and there were 40 in-hospital deaths (4.1%) in this group. Multivariate logistic regression showed that patients with LVH had less elective operations, higher Canadian Cardiovascular Society Functional Class, more previous myocardial infarctions and higher percentages of 3-vessel disease, hypertension, current congestive heart failure, malignant ventricular arrhythmias, chronic obstructive pulmonary disease, calcified aorta, low ejection fraction, intravenous nitroglycerine, previous percutaneous coronary interventions and smoking. After adjustment for all available pre,intra and postoperative variables LVH was not an independent predictor for in-hospital mortality (OR 1.04, 95% CIs 0.60-1.81, P=0.891). Risk-adjusted Kaplan-Meier survival curves showed decreased long-term survival in patients with LVH after the first 3 years (HR 1.24, 95% CIs 1.06-1.44, P=0.006). Conclusions: Patients with LVH showed similar in-hospital mortality when compared with patients without LVH. However, LVH was a detrimental risk factor for late mortality, especially after the third postoperative year. These data suggest the need for a more frequent long-term follow-up among patients with LVH undergoing CABG. (C) 2008 Elsevier Ireland Ltd. All rights reserved