Pathoanatomic Findings and Treatment During Hypertrophic Obstructive Cardiomyopathy Surgery: The Role of Mitral Valve.

BACKGROUND: To assess the role of the mitral valve apparatus (leaflets, chordae and papillary muscles, (PM)) in left ventricle outflow tract (LVOT) obstruction, and results of the surgical treatment for hypertrophic obstructive cardiomyopathy (HOCM). METHODS: Twenty-eight consecutive patients (58±11years, 53% female) undergoing HOCM surgery from 2007 to 2016 at our institute were retrospectively reviewed. Endpoints included the involvement of the mitral valve in LVOT obstruction, mortality, and changes in clinical and echocardiographic characteristics after HOCM surgery. RESULTS: Secondary chordae tendineae tractioning the anterior mitral leaflet to the interventricular septum, and systolic anterior motion were detected in 78% of the patients. Anomalous, hypertrophied, and fused PM with muscularis trabeculae hypertrophy were found in 50%, 25%, and 35% of the patients, respectively. Four patients had posterior leaflet redundancy. Secondary chordae (92%), PM, and muscularis trabeculae resection (71%), and PM splitting and elongation (28%) were added variably to septal myectomy (100%). Nine procedures (32%) on mitral valve leaflets were performed, involving six posterior and three anterior mitral leaflets. Long-term follow-up was 4±2.8years. There was no hospital mortality, and NYHA was reduced from 3±0.5 to 1±0.7 (p<0.0001), the LVOT gradient from 88±35 to 20±18mmHg (p<0.0001), mitral valve regurgitation from grade 3±1 to 1±0.7 (p<0.0001), and septum thickness from 18±3 to 14±2mm (p<0.0001). CONCLUSIONS: The mitral valve apparatus contributes with all its components variably to LVOT dynamic obstruction thus surgical correction in addition to extended myectomy is recommended to achieve the best outcome.

Aortic surgery in Marfan patients with severe pectus excavatum.

AIMS: The optimal surgical management of the aortic root phenotype Marfan patients with severe pectus excavatum is a subject of debate. All the available literature were reviewed according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) principles in order to assess the early outcomes of both pectus excavatum and aortic repair techniques. METHODS: Searches were done in PubMed and MEDLINE electronic databases dating from July 1953 to December 2015. RESULTS: A total of 97 peer-reviewed publications were retrieved, and 27 relevant publications were identified with a total of 39 Marfan patients with pectus excavatum who underwent ascending aorta and aortic root surgery. Emergency acute Type-A aortic dissection repair was reported in five cases. Concomitant pectus excavatum and aortic root repair and composite graft implantation were the most commonly performed procedures. Complications after a staged or a combined approach were uncommon and no deaths occurred. CONCLUSION: Aortic surgery in Marfan patients with pectus excavatum was carried out according to a variety of strategies, surgical techniques and accesses with low complications rate and no mortality. Many of these were well tolerated with minimal complications and no mortality.

Chronic Stanford type A aortic dissection.

: Chronic evolution of type A acute aortic dissection is not frequently observed in untreated patients because of the high mortality rate. Chronic aortic dissection is usually asymptomatic and may be incidentally discovered following an asymptomatic acute dissection. The life expectancy in these patients is prolonged by graft replacement therapy when the aortic diameter exceeds 55 mm. We report a case of a paucisymptomatic 78-year-old woman in whom chest X-ray revealed a right calcified mass.

Systemic or Endoventricular Thrombolysis to Treat HeartWare Left Ventricle Assist Device Thrombosis: A Clinical Dilemma.

Endoventricular thrombolytic procedure (ETP) has been used to treat continuous-flow left ventricle assist device (CF-LVAD) thrombosis. The study aims to investigate the occurrence of complications after ETP. Data were retrospectively reviewed and analyzed in a series of patients who underwent CF-LVAD followed by ETP. Since November 2010, 20 patients underwent HeartWare CF-LVAD implantation at our institute. Four patients (20%) developed pump thrombosis and underwent a total of nine ETPs with tissue plasminogen activator infused into the left ventricle. The mean age was 60.2 ± 9 years. ETP was performed via either the femoral (n = 6) or radial artery (n = 3). Five ETPs (55.5%) were complicated by left and right radial artery occlusion, two by groin hematomas, and one by femoral artery false aneurysm. ETP carries a strong risk of vascular access complications that, in CF-LVAD patients, may add to the already complex clinical profile and economic burden; thus, a less invasive treatment is advisable whenever required.

The frozen elephant trunk for the treatment of chronic dissection of the thoracic aorta: a multicenter experience.

BACKGROUND: Because of the extensive involvement of the aorta, surgical treatment of its chronic dissection continues to represent a surgical challenge. We conducted a study of a multicenter experience to describe a multicenter experience in the treatment of this complex pathology, using the frozen elephant trunk (FET) technique. METHODS: Between January 2005 and May 2010, 240 patients underwent treatment with the FET technique and had their clinical data collected in the International E-vita Open Registry. Ninety of the patients, who were the population in the present study, underwent operations for chronic dissection of the aorta (type A, 77%). The mean age of these 90 patients was 57 ± 12 years, and 72 (80%) of the patients were male. Sixty-two patients (69%) had undergone a previous aortic operation. All of the procedures in the study were performed with the aid of antegrade selective cerebral perfusion. RESULTS: Total replacement of the aortic arch was done in 84 patients (93%). Cardiopulmonary bypass, myocardial ischemia, cerebral perfusion, and visceral ischemia times were 243 ± 65, 145 ± 48, 86 ± 24, and 75 ± 22 minutes, respectively. In-hospital mortality was 12% (11 patients). One patient died from a stroke and 8 patients (9%) died from ischemic spinal cord injury. The false lumen (FL) in the patients' aortae was evaluated with computed tomography after operation and during follow up. The rates of complete thrombosis of the FL around the elephant trunk were 69% and 79% at the first and last postoperative examinations, respectively. The rates of 4-year survival and freedom from aortic reoperation were 78% ± 5% and 96% ± 3%, respectively. CONCLUSIONS: The treatment of chronic aortic dissection (AD) with the FET technique is feasible, with respectable results. The rate of aortic reoperation with the use of this technique appears to be lower than that with a conventional approach to the repair of chronic AD. Ischemic spinal cord injury represents a concerning complication of the FET technique but seems to be unrelated to thrombosis of the FL.

[Extensive disease of the thoracic aorta: hybrid treatment with the frozen elephant trunk technique]. / Patologia estesa dell'aorta toracica: trattamento ibrido con la tecnica del frozen elephant trunk.

BACKGROUND: Aneurysms of the aortic arch extending beyond the origin of the left subclavian artery represent a challenging pathology in aortic surgery and, most commonly, are treated with different surgical, endovascular or hybrid two-staged procedures. In 2006, we initiated an intense surgical program with the frozen elephant trunk procedure that, combining together conventional surgery with endovascular techniques, allows single-stage treatment of patients with extended disease of the thoracic aorta. We here describe our surgical technique and the results with the single-stage frozen elephant trunk procedure. METHODS: Between January 2007 and August 2010, 87 patients were treated with the frozen elephant trunk procedure in our institution. The mean age was 62 ± 10 years. Indications for surgery included: chronic aneurysm (n=28; 32.2%), acute type A dissection (n=5; 5.7%), acute type B dissection (n=2; 2.3%), chronic type A dissection (n=41; 47.2%), chronic type B dissection (n=11; 12.6%). Forty-nine patients (56.4%) had undergone previous cardiac/aortic operations. Sixty-four associated aortic/cardiac operations were performed. RESULTS: Hospital mortality was 12.6%. Postoperatively, major neurological complications occurred in 4 patients (4.5%) and paraplegia in 6 (6.9%). Follow-up was 100% completed at a mean time of 15.0 ± 12.4 months. Estimated 3-year survival was 72.7 ± 8.3%. Endovascular extension was required in 14 patients (16.0%) with a technical/procedural success of 100%. CONCLUSIONS: Our preliminary results with the frozen elephant trunk in the above-mentioned high-risk group of patients were encouraging. The frozen elephant trunk, as a single-stage hybrid procedure, avoids peculiar drawbacks of staged procedures such as cumulative mortality of two major aortic procedures, interval mortality and failure to complete the final stage.

Short- and midterm results after hybrid treatment of chronic aortic dissection with the frozen elephant trunk technique.

OBJECTIVE: The purpose of this study was to examine our experience with the frozen elephant trunk in patients with chronic aortic dissection. METHODS: In our Institution, between January 2007 and August 2010, 49 patients (mean age: 59.6 ± 9.0 years) underwent total arch replacement with the frozen elephant trunk technique for chronic aortic dissection (type A, n=2; residual type A, n=37; type B, n=10). Forty patients (81.6%) patients had undergone previous cardiovascular procedures. Associated cardiac procedures were indicated in 21 (42.8%) patients. Brain protection was achieved with antegrade selective cerebral perfusion in all cases. RESULTS: Hospital mortality (n=5) was 10.2%. Postoperative serious complications included coma (n=3; 6.1%), paraplegia (n=2; 4.1%), respiratory failure (n=6; 12.2%), and definitive dialysis (n=2; 4.1%). Follow-up was 100% completed (mean period: 12.9 ± 11.7 months). The estimated 1- and 3-year survival rates were 91.2 ± 4.2% and 81.6 ± 6.5%, respectively. Endovascular extension was required in 11 (22.4%) patients, with technical success of 100%. Complete thrombosis of the peri-stent false lumen was achieved in 82.9% of cases, with significant reduction of the false lumen diameter (preoperative: 36 ± 11 mm; postoperative: 24 ± 17 mm; p=0.001) and increase of the true lumen diameter (preoperative: 15 ± 5 mm; postoperative: 26 ± 6 mm; p=0.001). CONCLUSIONS: The frozen elephant trunk technique, allowing treatment of extensive disease of the thoracic aorta, was associated with encouraging short- and midterm results. Longer-term follow-up is warranted.

Treatment of complex disease of the thoracic aorta: the frozen elephant trunk technique with the E-vita open prosthesis.

OBJECTIVE: The treatment of complex aortic pathologies of the thoracic aorta remains a challenging issue in aortic surgery. The most recent development of the classic elephant trunk technique, the 'frozen elephant trunk' technique, represents the combination of an endovascular approach with a conventional surgical treatment for a hybrid approach. METHODS: Between January 2007 and July 2008, 34 patients were operated on for complex pathologies of the thoracic aorta using the frozen elephant trunk technique. There were 29 males (85.3%) and the mean age of 61.7+/-9.6 years. The majority of patients (n=18, 52%) presented type A chronic dissection, 7 (21%) patients had chronic aneurysm of distal aortic arch and 7 (21%) type B aortic dissection associated with ascending aorta/aortic arch aneurysm. There were two (6%) cases of acute aortic dissection. Nineteen patients (56%) underwent previous cardiovascular operations. RESULTS: The overall in-hospital mortality was 6% (two patients). No patient developed postoperative stroke. Ischemic spinal cord injury occurred in three cases (9%) (two paraparesis, one paraplegia). There were five cases (15%) of renal failure (dialysis) and four patients (12%) had pulmonary complications with prolonged mechanical ventilation. Four patients (12%) needed rethoracotomy for surgical bleeding. Six patients (18%) required extension of the descending thoracic aorta repair with endovascular treatment for persistent perfusion of the dilated false lumen. CONCLUSIONS: The frozen elephant trunk technique with the new E-vita open prosthesis combines surgical and interventional technologies and represents a feasible and efficient option in the treatment of complex aortic pathologies. Strict monitoring of the patient has to be carried out in order to detect possible evolution of the aortic lesion, which can require prompt treatment. However, long-term follow-up is required.