Total aortic arch replacement with a branched graft and limited circulatory arrest of the brain

AbstractBackgroundTotal replacement of the aortic arch is commonly performed with either antegrade perfusion of the brachiocephalic arteries by means of direct cannulation or with an interval of hypothermic circulatory arrest of at least 30 to 40 minutes. We present a technique with a branched graft that uses antegrade brain perfusion without the need for direct cannulation of the brachiocephalic arteries or a separate perfusion circuit, with only a brief period of circulatory arrest of the brain.MethodsTwelve patients underwent resection of the aortic arch through either a midline sternotomy (4 patients) or a bilateral anterior thoracotomy (8 patients). The right axillary artery was used for arterial return and for brain perfusion. After establishing hypothermic circulatory arrest, the brachiocephalic arteries were detached from the aorta, flushed, and occluded with clamps. Hypothermic perfusion of the brain was established through the right axillary artery, and the brachiocephalic arteries were sequentially attached to the limbs of a branched aortic graft. Flow to the brain was then established in the antegrade direction through the axillary artery.ResultsThe mean duration of circulatory arrest of the brain at a mean nasopharyngeal temperature of 16°C was 8.8 minutes (range, 6-13 minutes). The subsequent period of hypothermic (20°C-22°C) brain perfusion, during which the 3 branches of the graft were attached to the brachiocephalic arteries, averaged 35 minutes (range, 23-44 minutes). All the patients survived the procedure and were discharged from the hospital. No patient sustained a permanent neurologic deficit. One patient had lethargy for 2 days, with full recovery. Nine of the 12 patients were extubated within 72 hours.ConclusionsThis technique obviates the need for direct cannulation of the brachiocephalic arteries and for a separate perfusion circuit and requires only a brief period of circulatory arrest of the brain

Replacement of the descending thoracic aorta: Contemporary outcomes using hypothermic circulatory arrest

ObjectiveRecent advances in endovascular repair have put into question the role of open surgery on the descending thoracic aorta. We evaluated our experience with replacement of the descending thoracic aorta using hypothermic circulatory arrest.MethodsFrom May 1989 to August 2008, 151 patients (mean age 62 ± 15 years) had descending thoracic aorta replacement using cardiopulmonary bypass and hypothermic circulatory arrest. Concurrent distal aortic arch repair was performed in 71 patients (47%). Seventeen patients (11%) had emergency operation.ResultsThe mean durations of bypass and circulatory arrest were 107 ± 34 and 32 ± 9 minutes, respectively. Stroke occurred in 5 patients (3.3%), spinal cord ischemic injury in 2 patients (1.3%; 1 paraplegia, 1 paraparesis), and renal failure requiring dialysis in 2 patients (1.3%). Thirty-day and 6-month mortality rates were 4.0% and 9.9%, respectively. Following emergency operation, the 30-day mortality rate was 17.6% compared with 2.2% after elective surgery (P = .02). Five- and 10-year survival rates were 71% and 45%, respectively. Five patients required reoperation on the graft or contiguous aorta at a mean of 5 ± 4 years after the initial repair. Five- and 10-year rates of freedom from reoperation were 96% and 92%, respectively.ConclusionsCardiopulmonary bypass with hypothermic circulatory arrest can be safely used for replacement of the descending thoracic aorta. Although more invasive than endovascular stent grafting, this open surgical technique provides definitive repair, maintenance of left subclavian artery patency, protection against spinal cord injury, and early mortality and morbidity rates that do not exceed those reported for endovascular repair

Late results of surgical and medical therapy for patients with coronary artery disease and depressed left ventricular function

Late survival and freedom from myocardial infarction were determined for 192 patients with coronary artery disease and depressed left ventricular ejection fraction at rest (<35%) determined by biplane angiography who were evaluated between 1970 and 1977. Seventy-seven patients had coronary artery bypass grafting and 115 patients were treated medically and were considered surgical candidates. The medical and surgical groups were comparable in all baseline characteristics examined except frequency of three vessel disease and angina pectoris, which occurred in a significantly greater percent of the surgically treated patients (p < 0.01). Only three medically treated patients (2.6%) underwent coronary bypass grafting in the follow-up period.Seven year actuarial survival was 63% in the surgical and 34% in the medical group (p < 0.001). Ninety-three percent of patients in the surgical group and 81% of those in the medical group were free of nonfatal myocardial infarction (p = 0.01), and 62 and 33%, respectively, were alive and free of myocardial infarction (p < 0.001) at 7 years. Significant differences in survival favoring surgical treatment were observed for the subsets of patients with an ejection fraction of 25% or less (p = 0.0002) and 26 to 35% (p = 0.01), and for the subsets with three vessel coronary disease (p < 0.001), normal left ventricular end-diastolic volume (<100 ml/m2) (p = 0.005) and elevated end-diastolic volume (>100 ml/m2)(p = 0.001). After adjustment for other important prognostic variables, the type of treatment remained significant in predicting the relative risk (medical to surgical) of mortality at 5 and 7 years (2.58 and 2.12, respectively).These data corroborate the trends observed in several randomized trials of medical and surgical therapy in patients with abnormal left ventricular function. If hospital mortality for coronary artery bypass grafting is less than 5%, substantial benefit can be anticipated for the majority of patients with depressed ventricular function

Surgical Correction of Cor Triatriatum Associated with Pulmonary Artery Thrombosis in an Adult

We herein present a case of a successful correction of cor triatriatum associated with thrombotic pulmonary hypertension diagnosed in an adult female patient. We confirmed diagnosis using transthoracic and transesophageal echocardiography in addition to cardiac computed tomography and magnetic resonance imaging. Surgical repair comprised excision of the fibromuscular membranous septum in the left atrium, patch closure of an atrial septal defect, and reconstruction of the pulmonary arteries with a vascular graft. Cor triatriatum complicated pulmonary thrombotic hypertension with atrial septal defect is amenable to surgical correction with satisfactory results

Atherosclerosis of the ascending aorta is a predictor of renal dysfunction after cardiac operations

AbstractObjectives: Renal dysfunction occurring after cardiac operations has been attributed to various factors, but the importance of an atherosclerotic thoracic aorta has not been previously evaluated. The purpose of this study was to identify predictors of postoperative renal dysfunction (50% or more increase from preoperative values) and to evaluate the importance of atherosclerosis of the ascending aorta as a predictor of this complication. Methods: Nine hundred seventy-eight consecutive patients, 50 years of age and older with normal preoperative renal function (serum creatinine level of 1.5 mg/dL or less), who were scheduled to undergo cardiac surgery were prospectively evaluated. Atherosclerosis of the ascending aorta was assessed during the operation (with epiaortic ultrasound), and patients were divided into 3 groups according to its severity (normal-to-mild, moderate, and severe). Results: Univariate predictors of renal dysfunction at postoperative day 1 were atherosclerosis of the ascending aorta (P < .045) and postoperative low cardiac output (P = .05); at postoperative day 6 they were atherosclerosis of the ascending aorta (P < .0001), postoperative low cardiac output (P < .0001), advanced age (P = .001), decreased preoperative left ventricular function (P = .01), and female gender (P = .03). Multivariate analysis showed that atherosclerosis of the ascending aorta (odds ratio, 3.06; P = .04) was the only independent predictor of postoperative renal dysfunction at day 1 and that postoperative low cardiac output (odds ratio, 4.83; P < .0001), atherosclerosis of the ascending aorta (odds ratio, 2.13; P = .0006), and preoperative left ventricular dysfunction (odds ratio, 1.48; P = .028) were independent predictors of postoperative renal dysfunction at day 6. Conclusions: An atherosclerotic ascending aorta is an important predictor of postoperative renal dysfunction, possibly because atheroembolism to the kidneys occurs in the perioperative period (ie, during surgical manipulation of an atherosclerotic aorta) or because the diseased aorta may be a marker of widespread atherosclerotic disease that may predispose to perioperative renal dysfunction. (J Thorac Cardiovasc Surg 1999;117:111-6

Atherosclerosis of the ascending aorta is an independent predictor of long-term neurologic events and mortality

AbstractOBJECTIVESThis study was undertaken to determine whether atherosclerosis of the ascending aorta is a predictor of long-term neurologic events and mortality.BACKGROUNDAtherosclerosis of the thoracic aorta has been recently considered a significant predictor of neurologic events and peripheral embolism, but not of long-term mortality.METHODSLong-term follow-up (a total of 5,859 person-years) was conducted of 1,957 consecutive patients ≥50 years old who underwent cardiac surgery. Atherosclerosis of the ascending aorta was assessed intraoperatively (epiaortic ultrasound) and patients were divided into four groups according to severity (normal, mild, moderate or severe). Carotid artery disease was evaluated (carotid ultrasound) in 1,467 (75%) patients. Cox proportional-hazards regression analysis was performed to assess the independent effect of predictors on neurologic events and mortality.RESULTSA total of 491 events occurred in 472 patients (neurologic events 92, all-cause mortality 399). Independent predictors of long-term neurologic events were: hypertension (p = 0.009), ascending aorta atherosclerosis (p = 0.011) and diabetes mellitus (p = 0.015). The independent predictors of mortality were advanced age (p < 0.0001), left ventricular dysfunction (p < 0.0001), ascending aorta atherosclerosis (p < 0.0001), hypertension (p = 0.0001) and diabetes mellitus (p = 0.0002). There was >1.5-fold increase in the incidence of both neurologic events and mortality as the severity of atherosclerosis increased from normal-mild to moderate, and a greater than threefold increase in the incidence of both as the severity of atherosclerosis increased from normal-mild to severe.CONCLUSIONSAtherosclerosis of the ascending aorta is an independent predictor of long-term neurologic events and mortality. These results provide additional evidence that in addition to being a direct cause of cerebral atheroembolism, an atherosclerotic ascending aorta may be a marker of generalized atherosclerosis and thus of increased morbidity and mortality

Impact of aortic valve effective height following valve-sparing root replacement on postoperative insufficiency and reoperation

BACKGROUND: This study evaluated the impact of anatomic aortic root parameters during valve-sparing root replacement on the probability of postoperative aortic insufficiency and freedom from aortic valve reoperation. METHODS: From 1995 to 2020, 177 patients underwent valve-sparing root replacement (163 reimplantations, 14 remodeling). Preoperative and postoperative echocardiograms were analyzed to measure annulus and sinus diameters, effective height of leaflet coaptation, and degree of aortic insufficiency. Logistic regression was used to evaluate predictors of 2+ or greater late postoperative aortic insufficiency. Fine-Gray regression determined predictors for aortic valve reintervention. RESULTS: The study population included 122 (69%) men with a mean age of 43 ± 15 years. A total of 119 patients (67%) had an identified connective tissue disorder. The cumulative incidence of aortic valve reoperation was estimated as 7% at 5 years and 12% at 10 years. The probability of 2+ or greater late postoperative aortic insufficiency was inversely related to effective height during valve-sparing root replacement (P = .018). As postoperative effective height fell below 11 mm, the probability of 2+ or greater aortic insufficiency exceeded 10%. On multivariable logistic regression, effective height (odds ratio, 0.53; 0.33-0.86; P = .010), preoperative annulus diameter (odds ratio, 1.44; 1.13-1.82; P = .003), and degree of preoperative aortic insufficiency (odds ratio, 2.57; 1.45-4.52; P = .001) were associated with increased incidence of 2+ or greater late postoperative aortic insufficiency. On multivariable Fine-Gray regression, risk factors for aortic valve reintervention included preoperative annulus diameter (subdistribution hazard ratio, 1.28 [1.03-1.59], P = .027), history of 3+ or greater aortic insufficiency (subdistribution hazard ratio, 4.28; 1.60-11.44; P = .004), and 2+ or greater early postoperative aortic insufficiency (subdistribution hazard ratio, 5.22; 2.29-11.90; P \u3c .001). CONCLUSIONS: Measures to increase effective height during valve-sparing root replacement may decrease the risk of more than mild postoperative aortic insufficiency after repair and the need for aortic valve reoperation

Surgical repair for aortic dissection accompanying a right-sided aortic arch

Aortic anomaly in which a right-sided aortic arch associated with Kommerell's diverticulum and aberrant left subclavian artery is rare. The present report describes a patient with type-B aortic dissection accompanying aortic anomalies consisting of right-sided aortic arch and the left common carotid and left subclavian artery arising from Kommerell's diverticulum. As dissecting aortic aneurysm diameter increased rapidly, Single-stage surgical repair of extensive thoracic aorta was performed through median sternotomy and right posterolateral fifth intercostal thoracotomy, yielding favorable results. Our surgical procedures are discussed