Outcomes of aortic arch repair using the frozen elephant trunk technique: analysis of a Scandinavian center's results over 14 years.

BACKGROUND: The frozen elephant trunk (FET) technique enables repair of aortic arch pathology, with possibility for endovascular treatment of distal thoracic aortic disease. We aimed to study outcomes of FET repair of complex aortic arch disease at a Scandinavian tertiary referral center. METHODS: All patients who underwent FET repair of the aortic arch 2006-2020 were included. Survival, complication and reintervention rate, and aortic remodeling were analyzed. RESULTS: Fifty patients were included: 23 complex thoracic aortic aneurysms involving the aortic arch (TAA), 19 with chronic aortic dissections (CAD) (16 Stanford type A, 3 type B) and 8 acute aortic dissections (AAD) (7 Stanford type A, 1 type B). Thirty-day mortality was: TAA=22% (N.=5), CAD=5% (N.=1), AAD=37% (N.=3). Rate of disabling stroke: TAA=22% (N.=5), CAD=5% (N.=1), AAD=25% (N.=2). Rate of permanent spinal cord injury: TAA=9% (N.=2), CAD=5% (N.=1), AAD=0%. 5-year survival: TAA=53%, CAD=83%, AAD=63%. 5-year reintervention-free survival was TAA=83% and CAD=36%. There were no reinterventions in the AAD group. 13/19 (68%) of CAD patients underwent distal stent graft extension during follow-up. On last CT follow-up (median 32 months), 78% of CAD had false lumen thrombosis along the stent graft and 11% in the abdominal aorta. In thoracic aorta there was a mean 64% expansion (P<0.001) of true and 39% reduction (P=0.007) of false lumen diameter. In abdominal aorta, both true and false lumen expanded. CONCLUSIONS: Despite the advantages of the FET technique, repair of extensive aortic arch disease remains associated with high rates of mortality and major neurologic complications. FET repair of CAD induces favorable remodeling in the thoracic aorta.

Myocardial External Efficiency in Asymptomatic Severe Primary Mitral Regurgitation Using 11C-Acetate PET.

Subjects with asymptomatic moderate-to-severe or severe primary mitral regurgitation are closely observed for signs of progression or symptoms requiring surgical intervention. The role of myocardial metabolic function in progression of mitral regurgitation is poorly understood. We used 11C-acetate PET to noninvasively measure myocardial mechanical external efficiency (MEE), which is the energetic ratio of external cardiac work and left ventricular (LV) oxygen consumption. Methods: Forty-seven patients in surveillance with mitral regurgitation and no or minimal symptoms prospectively underwent PET, echocardiography, and cardiac MRI on the same day. PET was used to simultaneously measure cardiac output, LV mass, and oxygen consumption to establish MEE. PET findings were compared between patients and healthy volunteers (n = 9). MEE and standard imaging indicators of regurgitation severity, LV volumes, and function were studied as predictors of time to surgical intervention. Patients were followed a median of 3.0 y (interquartile range, 2.0-3.8 y), and the endpoint was reached in 22 subjects (47%). Results: MEE in patients reaching the endpoint (23.8% ± 5.0%) was lower than in censored patients (28.5% ± 4.5%, P = 0.002) or healthy volunteers (30.1% ± 4.9%, P = 0.001). MEE with a cutoff lower than 25.7% was significantly associated with the outcome (hazard ratio, 7.5; 95% CI, 2.7-20.6; P < 0.0001) and retained independent significance when compared with standard imaging parameters. Conclusion: MEE independently predicted time to progression requiring valve surgery in patients with asymptomatic moderate-to-severe or severe primary mitral regurgitation. The study suggests that inefficient myocardial oxidative metabolism precedes clinically observed progression in mitral regurgitation.

Technical eligibility for endovascular treatment of the aortic arch after open type A aortic dissection repair.

OBJECTIVE: The objective was to report on the technical eligibility of patients previously treated for Stanford type A aorta dissection for endovascular aortic arch repair based on contemporary anatomic criteria for an arch inner-branched stent graft. METHODS: All patients treated for type A aorta dissection from 2004 to 2015 at a single aortic center were identified. Extent of repair and use of circulatory arrest were reported. Survival and reoperation were assessed using Kaplan-Meier and competing risk models. Anatomic assessment was performed using 3-dimensional computed tomography imaging software. Primary outcome was survival of 1 year or more and fulfillment of the arch inner-branched stent graft anatomic criteria. RESULTS: A total of 198 patients were included (158 DeBakey I, 32 DeBakey II, and 8 intramural hematoma). Mortality was 30 days (16.2%), 1 year (16.3%), and 10 years (45.0%). A total of 129 patients had imaging beyond 1 year (mean, 47.8 months), and 89 patients (69.0%) were eligible for arch inner-branched stent grafting. During follow-up, 19 patients (14.7%) met the threshold criteria for aortic arch treatment, of whom 14 (73.7%) would be considered eligible for arch inner-branched stent graft. Patients who underwent type A aorta dissection repair with circulatory arrest and no distal clamp were more often eligible for endovascular repair (88.8%) than those operated with a distal clamp (72.5%; P = .021). Among patients who did not meet the arch inner-branched stent graft anatomic criteria, the primary reasons were mechanical valve (40%) and insufficient proximal seal (30%). CONCLUSIONS: More than two-thirds of patients post-type A aorta dissection repair are technically eligible for endovascular arch inner-branched stent graft repair. The development of devices that can accommodate a mechanical aortic valve and a greater awareness of sufficient graft length would significantly increase availability.

Long-term survival and frequency of reinterventions after proximal aortic surgery: a retrospective study†.

OBJECTIVES: We sought to analyse perioperative outcome, long-term mortality, frequency and causes of reintervention, and survival benefit in a contemporary cohort of patients undergoing proximal thoracic aortic surgery. METHODS: Participants comprised all patients undergoing open surgery for proximal thoracic aortic aneurysm (TAA) (n = 319) and thoracic aortic dissection type A (TAD) (n = 229) during 2005-2014 at the Department of Thoracic Surgery, Uppsala University Hospital. Long-term survival was compared to age- and sex-matched controls. Perioperative mortality and morbidity, event-free survival and causes of reoperation were also analysed. RESULTS: Long-term mortality was normalized in patients with TAA, and a survival benefit was seen as early as 20 months when corrected for time lost due to perioperative mortality. Long-term survivors undergoing surgery for TAD, on the other hand, had a 10-year mortality of 130% [95% confidence interval (95% CI) 120-140%] compared to age- and sex-matched controls. Moreover, their event-free survival was half that of patients with TAA (hazard ratio 2.3; 95% CI 1.7-3.2). Reintervention (i.e. reoperation or thoracic endovascular aortic repair) was also twice as common in the TAD patients (odds ratio 2.0; 95% CI 1.1-3.5). The dominant causes for reoperation among TAD patients were aortic insufficiency, aortic arch aneurysm and infection. CONCLUSIONS: Surgery for TAA is relatively safe, normalizes long-term mortality and confers an early survival benefit. However, TAD surgery carries a high risk of perioperative mortality and morbidity, as well as increased long-term mortality and risk of reintervention.

Pulsatility index variations using two different transit-time flowmeters in coronary artery bypass surgery.

OBJECTIVE: Transit-time flow measurement is widely accepted as an intra-operative assessment in coronary artery bypass grafting (CABG). However, the two most commonly applied flowmeters, manufactured by MediStim ASA and Transonic Inc., have different default filter settings of 20 and 10 Hz, respectively. This may cause different flow measurements, which will influence the reported results. The aim was to compare pulsatility index (PI) values recorded by the MediStim and Transonic flowmeters in two different clinical settings: (1) analysis of the flow patterns recorded simultaneously by both flowmeters in the same CABGs; and (2) evaluation of flow patterns under different levels of filter settings in the same grafts. METHODS: Graft flow and PI were measured using the two different flowmeters simultaneously in 19 bypass grafts. Finally, eight grafts were assessed under different digital filter settings at 5, 10, 20, 30, 50 and 100 Hz. RESULTS: The Transonic flowmeter provided substantially lower PI as compared with the MediStim flowmeter. By increasing the filter setting in the flowmeter, PI increased considerably. CONCLUSIONS: The Transonic flowmeter displayed a lower PI than the MediStim, due to a lower filter setting. In the Transonic,flow signals are filtered at a lower level, rendering a 'smoother' pattern of flow curves. Because different filter settings determine different PIs, caution must be taken when flow values and flowmeters are compared. The type of flowmeter should be indicated whenever graft flow measurements and derived indexes are provided [corrected].

Reconstruction of chronic aseptic sternal pseudoarthrosis after median sternotomy: initial experience with the Ley prosthesis.

It has previously been reported that the Ley prosthesis, a 0.5-mm-thick titanium alloy plate designed for reconstruction and stabilization of the unstable sternotomy, leads to shorter hospital stay and reduces the need for further surgical procedures in patients with postoperative mediastinitis after open heart surgery. We report our initial experience with the Ley prosthesis in patients with chronic aseptic sternotomy dehiscence. The study included 6 male patients (age 42-80 years) with opiate-derivate-dependent intractable pain and significantly reduced quality of life caused by noninfected sternal pseudoarthrosis and unstable sternotomy with large sternal bone tissue deficit. Four of the patients had undergone various surgical fixation procedures 8 days to 12 months after the primary operation. The patients were treated with reconstruction and stabilization of the sternum with the Ley prosthesis 10 to 40 months after the primary operation. In 1 patient bone transplantation was used. No immediate peri- or postoperative complications were observed, and all patients were discharged 4 to 11 days after surgery. One patient who received a bone transplant developed wound infection, and the prosthesis was removed 5 weeks after implantation. At 6-month follow-up all sternotomies were found stable, and patients reported that pain had decreased and quality of life was significantly improved. Our results demonstrate that the Ley prosthesis can be safely and efficiently used for the reconstruction and stabilization of the sternum in patients with intractable pain caused by noninfected postoperative sternal dehiscence and large sternal bone tissue deficit.

Oxidative stress during coronary artery bypass operations: importance of surgical trauma and drug treatment.

OBJECTIVE: To investigate oxidative stress and myocardial injury at different stages of coronary artery bypass grafting (CABG). DESIGN: Twenty patients underwent CABG with use of cardiopulmonary bypass (CPB) and with intermittent sampling of plasma and urine. Main markers were: 8-iso-PGF2alpha (oxidative stress); troponin T (myocardial injury); and 15-keto-dihydro-PGF2alpha and hsCRP (inflammation). RESULTS: Plasma 8-iso-PGF2alpha increased after start of surgery, but there was no further rise during CPB or after aortic cross-clamp release and no significant myocardial arterio-venous differences. An increase in troponin T was seen early after the operation, but no relationship was established between 8-iso-PGF2alpha and troponin T. 8-iso-PGF2alpha levels were elevated by preoperative withdrawal of acetylsalicylic acid (ASA) but reduced by intraoperative use of heparin. 15-keto-dihydro-PGF2alpha was elevated during operation and hsCRP following operation. CONCLUSIONS: In the present study oxidative stress was multifactorial in origin with main impacts from surgical trauma, less from CPB and little if any from myocardial ischemia-reperfusion events. In addition, cardiovascular drugs in common use like ASA and heparin seemed to influence the pro- and antioxidant balance, a finding that has to be confirmed in future studies.

Effect of subcutaneous suture line and surgical technique on wound infection after saphenectomy in coronary artery bypass grafting: a prospective randomised study.

OBJECTIVE: The aim of the study was to evaluate the impact of an additional subcutaneous suture line on the incidence of postoperative (p.o.) infection at the vena saphena magna harvesting site (VSMHS) after coronary artery bypass grafting (CABG). METHODS: Two hundred and forty three patients undergoing CABG were included. Patients in Group A (n = 119) all operated by one physical assistant (PA) were prospectively randomised into Group A1 (n = 59) receiving intracutaneous closure suture alone whereas 60 patients (Group A2) received an additional subcutaneous suture line. Group B (n = 120), operated by surgical residents, served as control population. All patients were due to follow-up at six weeks p.o. RESULTS: Subcutaneous suture did not impact the p.o. infection rate (A2 vs. A1; 4/60 vs. 2/59, n.s.). A significant lower p.o. infection rate was observed in Group A vs. Group B (6/119 (5%) vs. 15/120 (13%) p < 0.05). CONCLUSION: Subcutaneous suture did not impact the p.o. infection rate at VSMHS. The infection rate observed in patients operated by an experienced PA was significantly lower than in patients operated by various surgical residents.

Guiding surgical cannulation of the inferior vena cava with transesophageal echocardiography.

UNLABELLED: We studied 150 adult cardiac surgery patients to assess visualization of the venous cannula and the venous system by intraoperative transesophageal echocardiography and to register the incidence of cannulation of hepatic veins. The quality of images, the dimensions of the venous system, the position of the venous cannula, and the adequacy of venous return were registered. Acceptable image quality of the inferior vena cava and the right hepatic vein (RHV) was obtained in 95% and 87% of cases, respectively. Considerable individual variations were found in the dimensions of the venous system. The cannula position could be determined in 99% of the cases. Ten percent of venous cannulae were primarily placed in the RHV. A short distance between the eustachian valve and the RHV possibly predisposes to cannulation of the RHV. No other patient-related factors were associated with cannula position. Placement of the cannula deep in the inferior vena cava was associated with reduced venous return and may be a more important cause of reduced return than a cannula positioned in a hepatic vein. IMPLICATIONS: Correct positioning of the venous cannula draining blood to the cardiopulmonary bypass circuit is important. Intraoperative transesophageal echocardiography allows satisfactory determination of the cannula position in nearly all patients. Ten percent of venous cannulae are primarily positioned in the right hepatic vein and not in the inferior vena cava as intended.

Secuestro pulmonar

En un período de 20 años, se operaron 15 casos de secuestro pulmonar (SP); 11 fueron hombres, y la edad media fue de 34 años (rango 10-56 años). Doce pacientes fueron sintomáticos. La angiografía preoperatoria practicada a trece pacientes, fue diagnóstica en todos los casos. En 86 por ciento de los pacientes el SP se localizó en el segmento basal posterior. La cirugía fue practicada en todos los casos sin mortalidad; catorce fueron intralobares (SIL) y no fue estralobar (SEL). En un paciente se encontró incidentalmente un carcinoma bronquioloalveolar. El SP aunque infrecuente es importante de tener en mente ya que puede asociarse a infecciones pulmonares crónicas severas y otras enfermedades muy incapacitantes o potencialmente letales, tales como el cáncer de pulmón. La cirugía es el tratamiento de elección, e idealmente requiere que el diagnóstico se haga preoperatoriamente, para detectar el vaso anómalo y evitar accidentes quirúrgicos que puede ser fatales; esto es ahora más fácil con la nueva tecnología no invasiva en imágenes, sin embargo un alto índice de sospecha es necesario.