Mid-term outcomes of an alternative remodelling technique for aortic root replacement without coronary ostial mobilisation or reimplantation.

BACKGROUND: We compare the early and late outcomes of a modified aortic root remodelling (ARR) technique for aortic root replacement without mobilisation or reimplantation of the coronary ostia, with those of the modified Bentall-de Bono procedure. METHODS: A retrospective observational study was performed comprising 181 consecutive patients who underwent aortic root replacement with a modified Bentall-de Bono procedure (104 patients) or ARR (77 patients) between January 2013 and December 2019. Primary endpoints included hospital mortality and late survival. Secondary endpoints included incidence of post-operative complications and freedom from late re-operation. RESULTS: ARR procedures were performed with shorter cross-clamp times and comparable cardiopulmonary bypass times to modified Bentall-de Bono procedures. The incidence of early post-complications was comparable between groups. 30-day mortality was numerically lower with ARR than the modified Bentall-de Bono procedure. Over 7-year follow-up, 4 patients (3.8%) required repeat aortic surgery after a modified Bentall-de Bono procedure, and none after ARR. Long-term mortality after ARR and after modified Bentall-de Bono procedures was 17.1% and 22.7%, respectively. The cumulative incidence of reintervention on the aortic root/valve was 3.2% after a modified Bentall-de Bono procedure and 0% after ARR. When adjusted for other independent risk factors, late mortality was not influenced by the procedure performed, although competing risk adjusted for age showed that the modified Bentall-de Bono procedure was associated with an increased risk of aortic root/aortic valve re-operation. CONCLUSIONS: The modified ARR technique is associated with reduced myocardial ischaemia time, lower post-operative mortality and aortic re-intervention rates compared to a modified Bentall-de Bono procedure. It may be considered a safe and feasible procedure for aortic root/ascending aortic replacement offering good long-term outcomes.

Single-Stage Off-Pump Hybrid Repair of Kommerell's Diverticulum with Right-Sided Aortic Arch Using a Surgeon-Customized Vascular Prosthesis.

We report the successful single-stage hybrid management of Kommerell's diverticulum associated with a right-sided aortic arch in a 63-year-old woman. She underwent total aortic arch debranching utilizing a surgeon-customized vascular prosthesis, without cardiopulmonary bypass or deep hypothermic circulatory arrest, and concomitant zone-0 endovascular stent-graft deployment.

Surgical aortic valve replacement in the era of transcatheter aortic valve implantation: a review of the UK national database.

OBJECTIVES: To date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore 'real-world' practice. DESIGN: Retrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants' demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed. SETTING: 27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis. PARTICIPANTS: 31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG. RESULTS: In-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: <60 years=2.0%, 60-75 years=1.5%, >75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes. CONCLUSIONS: Surgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease.

Metastatic renal cell carcinoma extending to the left atrium through the inferior pulmonary vein.

Metastatic renal cell carcinoma with involvement through the pulmonary veins to the left atrium is very rare. We report the case of a 70-year-old male with metastatic renal cell carcinoma to the right lower lobe of the lung abutting the inferior pulmonary vein with extension to the left atrium without pre-operative evidence. Surgical resection was achieved through a posterolateral thoracotomy. Lung masses that abut the pulmonary veins should prompt further investigation with a pre-operative transoesophageal echocardiogram to minimize unexpected intraoperative findings.

Computational fluid dynamics of a novel perfusion strategy during hybrid thoracic aortic repair.

BACKGROUND AND AIM: To mitigate the risk of perioperative neurological complications during frozen elephant trunk procedures, we aimed to computationally evaluate the effects of direct cerebral perfusion strategy through a left carotid-subclavian bypass on hemodynamics in a patient-specific thoracic aorta model. METHODS: Between July 2016 and March 2019, 11 consecutive patients underwent frozen elephant trunk operation using the left carotid-subclavian bypass with a side graft anastomosis and right-axillary cannulation for systemic and brain perfusion. A multiscale model realized coupling three-dimensional computational fluid dynamics was developed and validated with in vivo data. Model comparison with direct antegrade cannulation of all epiaortic vessels was performed. Wall shear stress, wall shear stress spatial gradient, and localized normalized helicity were selected as hemodynamic indicators. Four cerebral perfusion flows were tested (6 to 15 mL/kg/min). RESULTS: Direct cerebral perfusion of the left subclavian bypass resulted in higher flow rates with augmented speeds in all epiaortic vessels in comparison with traditional perfusion model. At the level of the left vertebral artery (LVA), a speed of 22.5 vs 21 mL/min and mean velocity of 3.07 vs 2.93 cm/s were registered, respectively. With a cerebral perfusion flow of 15 mL/kg, lower LVA wall shear stress (1.596 vs 2.030 N/m2 ), and wall shear stress gradient (1445 vs 5882 N/m3 ) were observed. A less disturbed flow considering the localized normalized helicity was documented. No patients experienced neurological/spinal cord damages. CONCLUSIONS: Direct perfusion of a left carotid bypass proved to be cerebroprotective, resulting in a more physiological and stable anterior and posterior cerebral perfusion.

Reflection From UK Aortic Group: Frozen Elephant Trunk Technique as Optimal Solution in Type A Acute Aortic Dissection.

Diseases of the thoracic aorta are increasing in prevalence worldwide. Recent data indicated wide regional variation in the volume and complexity of aortic cases undertaken in United Kingdom cardiac centers, especially in case of acute type A aortic dissection (ATAAD) conditions. Patients treated in high-volume centers with a specific multidisciplinary aortic program had a significant reduction in ATAAD mortality when compared with low-volume centers. Following the initial phase of a national aortic center reorganization, the current study reflects the initial experience of a national collective of cardiothoracic surgeons with expertise in complex aortic surgery, using frozen elephant trunk as standard technique for the surgical treatment of patients affected by ATAAD. Between June 2013 and October 2017, 66 ATAAD patients (45% women) underwent hybrid aortic arch and frozen elephant trunk repair with the Thoraflex hybrid graft at 8 UK high-volume aortic centers. The in-hospital mortality accounted for 8 patients (12%). Postoperative temporary or permanent neurologic events and temporary renal replacement therapy occurred in 17% and 20% of patients, respectively. No spinal cord injury events were documented. Our data were similar to those reported in literature in the 2 largest experiences with the use of frozen elephant technique in ATAAD condition (in-hospital/30-day mortality: 11-12%). This initial experience demonstrated that frozen elephant technique can potentially be adopted as standard approach in life-threatening aortic diseases, with acceptable complication and mortality rates.

Short- and medium-term survival following coronary artery bypass surgery in British Indo-Asian and white Caucasian individuals: impact of diabetes mellitus.

Previous studies have suggested that South Asian (SA) ethnicity is a predictor of poorer outcome after coronary artery bypass grafting (CABG). Our aim was to identify potential reasons for the higher postoperative mortality in SA patients and investigate all these reasons. All individuals undergoing isolated CABG in a tertiary cardiac centre from April 2002 to September 2007. In total, there were 2897 subjects (2623 white subjects; 274 SA subjects) who were included in an observational study showing the effect of ethnicity on the medium-term survival following CABG. Survival at 30 days and survival up to five years (median 2.7 years) were measured. SA subjects undergoing CABG were younger (62+/-9 vs. 66+/-9 years, P<0.001), less obese [body mass index (BMI) 26+/-4 vs. 28+/-4 kg/m(2), P<0.001] and had a higher prevalence of diabetes mellitus (58% vs. 33%, P<0.001) compared with white subjects. Thirty-day mortality was higher in SA subjects (2.6% vs. 1.0%, P=0.02). Non-diabetic SA had similar 30-day mortality, five-year survival and life expectancy compared to non-diabetic white subjects. In contrast, diabetic SA had a higher 30-day mortality (3.8% vs. 1.4%, P=0.01) and worse life expectancy compared to diabetic white subjects. The higher early postoperative mortality observed in SA patients is related to higher incidence of diabetes among them. SA diabetics have a significantly higher postoperative mortality and worse overall life expectancy. Ethnicity per se is not an independent predictor of short- or medium-term survival after CABG.

TNF-alpha gene promoter polymorphism at nucleotide -308 and the inflammatory response and oxidative stress induced by cardiac surgery: role of heart failure and medical treatment.

BACKGROUND: Increased TNF-alpha during cardiac surgery is thought to be responsible for perioperative complications. The TNF-alpha gene promoter polymorphism G/A at position -308 has been associated with enhanced TNF-alpha secretion, as has been heart failure. Therefore, the aims of this study were to investigate: (i) whether the TNF-alpha G/A polymorphism is associated with exacerbation of TNF-alpha plasma levels during cardiac surgery; (ii) whether TNF-alpha production is further increased by heart failure and influenced by medical treatment; and (iii) whether this polymorphism is associated with increased oxidative stress and perioperative complications. METHODS: The TNF-alpha gene promoter polymorphism was studied in 100 consecutive patients undergoing cardiac surgery. Of them, 65 were identified with the common allele G/G, whereas 34 patients were with the G/A polymorphism and 1 was A/A. TNF-alpha plasma levels (ELISA) and peroxynitrite content in peripheral blood lymphocytes (flow cytometry) were measured before surgery, before cardiopulmonary bypass (CPB), and 30 min, 4 and 24h after initiation of CPB. RESULTS: The changes observed in TNF-alpha plasma levels during cardiac surgery were unaffected by the G/A polymorphism. TNF-alpha values were elevated before surgery in patients with more advanced NYHA class (1.66+/-0.14, 2.29+/-0.06 and 2.57+/-0.11 ln(mmol/l+1), for NYHA I, II and III; p=0.004) but again they were not correlated with the G/A polymorphism. Peroxynitrite content in lymphocytes was similar upon the initiation of surgery in the G/A and G/G groups and also in all NYHA class groups, and thereafter levels were similarly increased by surgery in all groups. However, analysis of the effect of preoperative medication showed that the mitoK(ATP) channel opener nicorandil reduced TNF-alpha values before surgery and blunted the increase in peroxynitrite caused by surgery. Perioperative complications were not related to either TNF-alpha polymorphism or TNF-alpha and peroxynitrite levels. CONCLUSIONS: The TNF-alpha gene promoter polymorphism G/A at position -308 does not influence TNF-alpha plasma levels during cardiac surgery, is not associated with greater oxidative stress, and does not result in a greater incidence of perioperative complications. However, importantly, treatment with the mitoK(ATP) channel opener nicorandil prior to surgery significantly reduced basal TNF-alpha values and also the oxidative stress induced by surgery.

The topography of aortic atherosclerosis enhances its precision as a predictor of stroke.

BACKGROUND: Atherosclerosis of the thoracic aorta is an independent risk factor for stroke after cardiac surgery. No attention had so far been paid to its topography. The relationship between the topography of aortic atherosclerosis and stroke was studied in patients admitted for coronary surgery. METHODS: The extent and location of atherosclerosis in the ascending aorta and arch was assessed intraoperatively with epiaortic ultrasound and transesophageal echocardiography in 611 consecutive patients. They were followed for 5.5 +/- 1.7 years (mean +/- SE), amounting to 3,358 patient-years. RESULTS: The incidence of early postoperative (<30-day) stroke was 6.4% in patients with atherosclerosis of the ascending aorta and 1.5% in those without (p = 0.004). The five-year stroke-free survival rates (>30 days after the operation) for patients without aortic disease, with less than 50%, and with greater than 50% of the ascending aorta affected, were 95.3 +/- 0.9%, 91.8 +/- 2.1%, and 65.0 +/- 14.6%, respectively (p < 0.0001). CONCLUSIONS: Atherosclerosis of the ascending aorta stands out as a predictor of late stroke. High risk is predominantly linked to atheromas in its distal part and lesser curvature.

Successful use of venovenous extracorporeal membrane oxygenation in accidental hypothermic cardiac arrest.

Cardiopulmonary bypass is usually used for rewarming and for providing cardiac support in patients with severe hypothermia and cardiovascular instability. We report the first case of accidental severe hypothermia associated with prolonged cardiac arrest that was successfully managed by venovenous extracorporeal membrane oxygenation.

Aspire porcine bioprosthesis: ten years' experience.

BACKGROUND AND AIM OF THE STUDY: Clinical results of this multicenter study of the Aspire porcine valve were reported previously at eight years; the present report provides an update of valve performance to 10 years postoperatively. METHODS: A total of 749 patients (60% males; mean age 73+/-7 years) underwent implantation with the Aspire (Tissuemed) porcine bioprosthesis between 1991 and 2002, at three institutions. Follow up was complete for 98% of the cohort. The mean follow up period was 51.6+/-39.6 months (range: 0-181 months); total follow up was 3,159 patient-years (pt-yr). RESULTS: There were 617 aortic valve replacements (AVR), 96 mitral valve replacements (MVR) and 32 double valve replacements. There were 62 deaths (8.3%), one of which was valve-related. The late mortality rate was 9.3% per pt-yr (1.2%/pt-yr valve-related). Actuarial freedom from complications at 10 years was: thromboembolism 76+/-4% (2.6%/pt-yr); hemorrhage 73+/-4% (2.8%/pt-yr); structural valve deterioration (SVD) 96+/-2% (0.2%/pt-yr); non-structural deterioration 99+/-1% (0.1%/pt-y); prosthetic valve endocarditis 97+/-1% (0.3%/pt-yr); and reoperation 97+/-1% (0.4%/pt-yr). In patients aged >70 years, the 10-year actuarial freedom from SVD was 98+/-2% for AVR and 93+/-7% for MVR. Preoperative atrial fibrillation (AF) was a significant predictor of late mortality (p <0.001), thromboembolism (p = 0.05) and hemorrhage (p = 0.01). CONCLUSION: The Aspire porcine bioprostheses is a reliable choice for a tissue valve, for both the aortic and mitral positions, especially in patients aged >70 years. In elderly patients the presence of AF is a significant predictor of early and late mortality and morbidity.

A policy to reduce stroke in patients with extensive atherosclerosis of the ascending aorta undergoing coronary surgery.

Since 1995 we have routinely used epiaortic scanning in cardiac surgery and since 1998 we have employed off-pump surgery for coronary revascularization. In patients with extensive atherosclerosis in the ascending aorta we tried to assess whether or not conversion from a planned on-pump to off-pump coronary surgery affects the incidence of postoperative stroke. We studied 28 consecutive patients with extensive atherosclerosis in the ascending aorta undergoing coronary surgery. Extensive atherosclerosis, detected by epiaortic ultrasound, was defined as involvement of 6 or more out of 12 segments. Since 1998 we have converted 15 patients with extensive atherosclerosis in the ascending aorta from on-pump to off-pump. Thirteen patients with similar disease who underwent on-pump before the introduction of off-pump were used as controls. The incidence of stroke in the off-pump group was 0% as compared with 31% in the coronary artery bypass grafting group (P=0.03). Y-grafts were used more often in the off-pump (47%) than in the on-pump group (0%, P<0.01). The non-touch technique of the ascending aorta was also more frequently used in the off-pump group (73 versus 0%, P<0.001). Off-pump reduces the incidence of stroke in patients with aortic atherosclerosis when the disease occupies 50% or more of the ascending aorta.

Incidence and clinical consequences of atrial fibrillation within 1 year of first-time isolated coronary bypass surgery.

BACKGROUND: Atrial fibrillation (AF) is the commonest complication during cardiac surgery, however, the long-term prevalence of AF following surgery and its clinical consequences remain unclear. PATIENTS AND METHODS: To investigate this, 877 consecutive patients undergoing first time CABG were followed for 1 year. Rhythm disturbances were diagnosed from serial ECGs and documented notes. The arrhythmia was treated medically and/or by cardioversion. RESULTS: Out of 877, 17 patients (1.9%) died in the hospital and out of the remaining 860 patients 844 (98.1%) had a complete 1-year follow-up. Patients were divided according to their age: Group I (50 to 59 years), Group II (60 to 69 years) and Group III (70 to 79 years). The prevalence of AF in the general population was taken from the Framingham Heart Study. Patients in groups I and II had a higher incidence of AF before the operation than the general population (1.5% versus 0.4% and 3.1% versus 1.6%, respectively, P<0.05) and also higher incidence of AF at the 1-year follow-up (2% versus 0.4% and 4.6% versus 1.6% respectively, P<0.05). The incidence of AF in group III did not differ from the general population before operation, at the 6-week and 1-year follow-ups. As expected most of the patients with preoperative AF remained in AF after 1-year of CABG surgery. Importantly, the incidence of newly developed AF was higher in patients that developed infection and renal dysfunction in the postoperative period. AF did not predict embolic events at any stage of the study. CONCLUSIONS: In conclusion, the incidence of AF for the first year following CABG is higher in patients <70 years but not in those >70 years when compared with the general population. AF was also associated to the occurrence of postoperative infection and renal dysfunction. Patients in this study were closely monitored and received timely appropriate treatment, and this may account for the absence of a relationship between AF and embolic events.

Aortic atheroma is related to number of particulates captured by intra-aortic filtration in CABG.

OBJECTIVE: Intra-aortic filtration during coronary artery bypass grafting (CABG) has the potential to harvest all particles embolized into the aorta proximal to the filter. The aim of this study was to determine risk factors for embolization of particles during CABG. METHODS: Forty consecutive patients undergoing conventional multi-vessel CABG were included in the study. Plaques of the ascending aorta were determined by epiaortic ultrasonography prior to aortic manipulation. Intra-aortic filters (Embol-X, Mountain View, CA) were inserted before removal of the aortic cross-clamp and extracted after end of cardiopulmonary bypass. Filters underwent histologic analysis at a core lab (Stanford University, Stanford, CA). RESULTS: The average number of proximal anastomoses was 2.2 (SD 0.55, range 1-3). All patients had particles in the filters. The average number of particles per filter was 10.5 (SD 5.4, range 2-23) with a mean surface area of 8.1mm(2) (SD 9.3, range 0.3-51.1). Fibrous atheroma was extracted from 85% (34/40) of the filters. Logistic regression explained 46% (r(2)=0.46, P<0.001) of the number of particles harvested by the filters. The most important independent risk factors for particles were number/grade of atheromas in the ascending aorta (P<0.01), obesity (P<0.02), hypertension (P<0.02) and number of proximal anastomoses (P<0.02). CONCLUSIONS: Atheroma in the ascending aorta is the most important risk factor for particle embolization during CABG. The number of particles correlated with the extent of atheromatous disease in the ascending aorta and logistic regression identified hypertension, obesity and the number of proximal anastomoses to have significant influence on the number of captured particulates.