Aortic rupture during endovascular repair of a postoperative coarctation pseudoaneurysm in an adult: Emergency lifesaving stent graft implantation.

We present a case with aortic rupture during an operation of thoracic endovascular aortic repair of an anastomotic pseudoaneurysm. This happened after the use of a low-pressure remodeling balloon inside the covered part of the deployed endografts. It was successfully treated with a second more centrally in the aortic arch-implanted endograft with full coverage of the left subclavian artery orifice. This patient had a history of surgically operated aortic coarctation.

Repair of descending thoracic aortic aneurysms with Ankura Thoracic Stent Graft.

OBJECTIVE: The aim of the study was to present the results for patients with atherosclerotic aneurysm of the descending thoracic aorta (DTA) treated with a novel thoracic stent graft. METHODS: A single-center retrospective review of prospectively collected data was performed. We extracted demographic variables as well as atherosclerotic comorbidities and operation-related and imaging-related data from patients' medical records. We estimated technical success rate, in-hospital and 30-day mortality, and mortality at the end of follow-up as well as complication and reintervention rate in our study cohort. Follow-up computed tomography angiography was performed after 1 month and 6 months and yearly thereafter. RESULTS: A total of 30 patients (80% male; mean age, 73.7 ± 6.33 years) were treated with Ankura Thoracic Stent Graft (Lifetech, Shenzhen, China) for DTA aneurysm from February 2014 until June 2017. Technical success of the thoracic endovascular aortic repair (TEVAR) was 97% (29/30 patients). A surgical conduit was required in one patient; in three patients, we intentionally covered the left subclavian artery because of insufficient proximal landing zone. No aorta-related deaths were recorded during follow-up. During the early postoperative period, two patients (7%) with long DTA coverage developed paralysis or paraparesis, which immediately resolved after lumbar drainage. No renal complications requiring dialysis were observed. One patient (3%) developed postoperative pulmonary infection, whereas access site complications were 7%. Two symptomatic patients treated outside instructions for use (7%) developed early type IA endoleak and one patient (3%) developed type IB endoleak; type II endoleak was recorded in 3% of the study cohort. During the 30-day postoperative period, two patients died of non-TEVAR-related causes, one of gastrointestinal bleeding and the other of pulmonary infection. During a median follow-up of 31.7 (range, 38.4) months, two more patients also died of non-TEVAR-related causes, one of stroke from carotid artery disease and the other of motor vehicle trauma. In the rest of the cohort, no other adverse events were noted. CONCLUSIONS: This novel endograft showed early evidence of a safe, effective, and durable endoprosthesis for the treatment of DTA aneurysms.

Antegrade cardioplegia as a possible cause of acute saphenous vein endothelial damage in patients undergoing on pump coronary artery bypass surgery.

BACKGROUND: The administration of antegrade cardioplegia through vein grafts after the completion of each distal anastomosis is a common practice. However, the cardioplegic solution may disrupt the vein endothelium and contribute to late vein graft atherosclerotic disease. This study aimed at evaluating the possible impact of the cardioplegic solution on vein graft endothelium. METHODS: Total of 52 patients (16 women and 36 men) aged 68±8.5 years old that underwent on pump coronary revascularization with at least one vein graft were enrolled. Sections of grafts from the greater saphenous vein were obtained prior to and after delivery of potassium antegrade cardioplegic solution through them. These sections were then examined histologically with immunochemical stain and CD34 index. The endothelial damage and length of vein specimens of both graft sections were evaluated. RESULTS: The endothelial damage of vein specimens appeared to be increased significantly with exposure to antegrade cardioplegia in male and female patients (P from Wilcoxon tests <0.001, for both genders). The increase in the length of vein specimens was significant too (P from Wilcoxon test <0.001 for men and P=0.001 for women). CONCLUSIONS: Antegrade cardioplegia delivered through vein grafts causes substantial damage on vein endothelium. This may have an adverse effect on long-term graft patency.

Coronary artery bypass grafting and paraparesis; is there a correlation?

Adult cardiac surgery is associated with significant perioperative morbidity and mortality rates, mainly in elderly patients with co-morbidities. A series of postoperative complications may arise and delay the recovery of patients undergoing cardiac surgery. Such complications also increase the burden of resource use and may affect late survival rates. Neurological complications appear mainly as stroke of varying degrees, with impairment of mobility and ability of the patient. We describe a rare case of progressive paraparesis after on-pump coronary artery bypass grafting, and review its aetiology, diagnosis and management.

Ascending Aorta Endovascular Repair of a Symptomatic Penetrating Atherosclerotic Ulcer with a Custom-Made Endograft.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has become lately the procedure of choice in the treatment of most pathologies of descending thoracic aorta. Aortic arch aneurysms also came to be treated by TEVAR with various hybrid techniques or custom-made scalloped/fenestrated stent grafts. Zone 0; ascending TEVAR is more challenging than TEVAR of the descending thoracic aorta or aortic arch because of the more complex pathology, hemodynamics, and anatomy. Ascending TEVAR can be a lifesaving treatment in selected high surgical risk patients. CASE REPORT: A 71-year-old male with known history of respiratory insufficiency, coronary artery disease, and low left ventricle ejection fraction, presented to emergency department with acute thoracic pain. As the initial laboratory tests and the electrocardiogram were negative for acute coronary syndrome, a computed tomography (CT) scan was performed that showed a 20 mm large and 17 mm depth penetrating atherosclerotic ulcer (PAU) in the middle portion of ascending thoracic aorta. After medical therapy administration, the thoracic pain was controlled, and due to the high surgical risk of the patient, high incidence of aortic rupture due to PAU, and favorable anatomic conditions was scheduled the implantation of a custom-made (due to short ascending aorta) stent graft (Bolton, Relay Plus). A pacemaker was implanted 1 week before the operation to induce rapid ventricular pacing during the stent-graft deployment. During the operation, the patient was under general anesthesia as it was our first case treated in this way. The delivery of the graft was achieved through a right femoral artery cut open by an extra-stiff guide wire (Lunderquist Cook) that was placed through an angio-catheter into the left ventricle of the heart. The final positioning and deployment of the graft was achieved under rapid ventricular pacing, and the final angiogram after the withdraw of the graft delivery system showed exclusion from circulation of PAU, patency of coronary arteries, and brachiocephalic trunk with competent aortic valve. CONCLUSIONS: TEVAR of the ascending aorta is a safe and feasible technique indicated mainly unfit for open surgery patients.

Celiac Artery Avulsion Secondary to Blunt Trauma: A Case Report.

Celiac artery (CA) injuries are very rare and are often associated with high mortality. These injuries are associated more often with penetrating trauma rather than blunt trauma injury. Our case highlights a blunt trauma injury of CA in a hemodynamically stable patient without any symptoms that was treated conservatively.

The perceval S aortic valve implantation in patients with porcelain aorta; is this ideal option?

We would like to present in this paper a patient with severe aortic valve stenosis referred to our department for surgical aortic valve replacement. In this patient, it was intraoperatively detected an unexpected heavily calcified porcelain ascending aorta. We present the treatment options in this situation, the difficulties affronted intraoperatively, the significance of the preoperative chest computed tomography scan and the use of the Perceval S aortic valve as ideal bioprosthesis implantation. This is a self-expanding, self-anchoring, and sutureless valve with a wide indication in all patients requiring aortic bioprosthesis.

Cardiac surgery or interventional cardiology? Why not both? Let's go hybrid.

A hybrid strategy, firstly performed in the 1990s, is a combination of tools available only in the catheterization laboratory with those available only in the operating room in order to minimize surgical morbidity and face with any cardiovascular lesion. The continuous evolution of stent technology along with the adoption of minimally invasive surgical approaches, make hybrid approaches an attractive alternative to standard surgical or transcatheter techniques for any given set of cardiovascular lesions. Examples include hybrid coronary revascularization, when an open surgical anastomosis of the left internal mammary artery to the left anterior descending coronary artery is performed along with stent implantation in non-left anterior descending coronary vessels, open heart valve surgery combined with percutaneous coronary interventions to coronary lesions, hybrid aortic arch debranching combined with endovascular grafting for thoracic aortic aneurysms, hybrid endocardial and epicardial atrial fibrillation procedures, and carotid artery stenting along with coronary artery bypass grafting. The cornerstone of success for all of these methods is the productive collaboration between cardiac surgeons and interventional cardiologists. The indications and patient selection of these procedures are still to be defined. However, high-risk patients have already been shown to benefit from hybrid approaches.

Aortic Root Enlargement or Sutureless Valve Implantation?

Aortic valve replacement (AVR) in patients with a small aortic annulus is a challenging issue. The importance of prosthesis-patient mismatch (PPM) post aortic valve replacement (AVR) is controversial but has to be avoided. Many studies support the fact that PPM has a negative impact on short and long term survival. In order to avoid PPM, aortic root enlargement may be performed. Alternatively and keeping in mind that often some comorbidities are present in old patients with small aortic root, the Perceval S suturelles valve implantation could be a perfect solution. The Perceval sutureless bioprosthesis provides reasonable hemodynamic performance avoiding the PPM and providing the maximum of aortic orifice area. We would like to see in the near future the role of the aortic root enlargement techniques in the era of surgical implantation of the sutureless valve (SAVR) and the transcatheter valve implantation (TAVI).

The formation of bronchocutaneous fistulae due to retained epicardial pacing wires: A literature review.

Temporary epicardial pacing wires during open-heart surgery are routinely used both for diagnostic and treatment purposes. In complicated cases where patients are unstable or the wires are difficult to remove, the pacing wires are cut at the skin level and allowed to retract by themselves. This procedure rarely causes complications. However, there have been cases reporting that retained pacing wires are linked to the formation of sterno-bronchial fistulae, which may present a while after the date of operation and are usually infected. This review aims to study the cases presenting sterno-bronchial fistulae due to retained epicardial pacing wires and to highlight the important factors associated with these. It is important to note these complications, as fistulae may cause a variety of problems to the patient if undiagnosed and left untreated. With the aid of scans such as fistulography, fistulae can be identified and treated and will improve the patients' health dramatically.

Iatrogenic dissection of the descending aorta: Conservative or endovascular treatment?

Transcatheter aortic valve implantation (TAVI) is without any doubt a standard technique and the treatment of choice of severe aortic valve stenosis (AVS) in very high-operative risk patients. However, a number of complications may occur and has been described. Improper valve position, valve migration, paravalvular regurgitation, conduction disturbances, stroke and aortic dissection have been succeeded despite the perfection of the technique. For anyone of the complications above described, a solution may be invented. We present an interesting case of an 81-year-old woman with severe AVS treated through TAVI due to very high operative risk. This female, 12 days later presented with thoracic pain and shortness of breath and through the computed tomography of the chest performed was diagnosed a dissection of the descending aorta. She successfully underwent on thoracic endovascular aortic repair. In this report, we refer the bibliographic data and we discuss the treatment options in these cases.

Hybrid treatment of a true thyreocervical trunk aneurysm in a patient with Type B aortic dissection.

We would like to describe a case with a complex aortic disease treated in hybrid fashion. We present an interesting case of a 65-year-old man with a medical history of hypertension, hyperlipidemia, and coronary artery disease percutaneously treated. An acute Type B aortic dissection occurred and treated with the implantation of a stent-graft which occluded the left subclavian artery due to its extension to the aortic arch. This event required a carotid-subclavian artery bypass due to ischemia of the left arm. An aneurysm in the innominate artery also detected, was treated with another stent-graft implantation 3 months later. At 5-year follow-up, an aneurysm of the thyreocervical trunk was found while the stent-graft of the aorta was well-tolerated without endoleak and the carotid-subclavian graft was patent. The aneurysm was asymptomatic but considering the risk of spontaneous rupture of an aneurysm of this size, elective surgery was indicated. Because the aneurysm was very close to the brachiocephalic bifurcation, open surgical repair would require a sternotomy. The right common carotid artery and right subclavian artery were exposed. The thyrocervical trunk, right internal mammary artery and right vertebral artery were occluded by ligations to isolate the aneurysm. An 8-mm Dacron graft was anastomosed end-to-end to the distal part of subclavian artery. We would like through this case, discuss the role of the hybrid cardiovascular surgery to minimize the postoperative complications in complex cardiovascular pathology. We also discuss the international bibliography about the thyreocervical trunk aneurysm and the treatment options.

Aortic valve replacement in elderly with small aortic root and low body surface area; the Perceval S valve and its impact in effective orifice area.

BACKGROUND: The aim of this study is to see how the sutureless, stentless, Perceval S aortic valves behave when implanted in elderly patients with small aortic root and the comparison with a second group of patients with similar characteristics where a conventional stented bioprosthesis was implanted. This is a prospective randomized institutional study. METHODS: Our material is composed from 25 patients who underwent aortic valve replacement with sutureless self-anchoring Perceval S valve implantation (LivaNova), compared with 25 patients with conventional stented biological prosthesis implanted (soprano LivaNova group). The two groups of patients have similar demographic and medical characteristics with severe aortic stenosis. The study was conducted from January 2012 to June 2014. Preoperative, intraoperative and postoperative parameters were studied in order to investigate the utility of the Perceval S valves in this group of patients. RESULTS: The Perceval S valve implantation seems to be an interesting biological valve with good hemodynamic characteristics as compared with the typical biological prosthesis providing shorter ischemia time (40 ± 5.50 min vs 86 ± 15.86 min; p < 0.001), shorter extracorporeal circulation time (73.75 ± 8.12 min vs 120.36 ± 28.31 min p < 0.001), less operation time (149.38 ± 15.22 min vs 206.64 ± 42.85 min; p < 0.001) and better postoperative recovery. The postoperative gradients were 23.5 ± 19.20 mmHg vs 24.5 ± 19.90 mmHg respectively. The postoperative effective orifice area in these two groups were respectively 1.5 =/-0.19 cm(2) vs 1.1=/-0.5 cm(2) (p 0.002). Among the 25 patients of the Soprano stented valve, 3 (12 %) came back in 6 months with New York Heart Association (NYHA) 3. The PPM of these patients was the cause of readmission in the Hospital required diuresis and supplementary treatment. CONCLUSIONS: Aortic valve replacement with Perceval aortic valves in geriatric patients with comorbidities and small aortic annulus seems to be an alternative, safe and "fast" intervention with excellent short and mid-term results which provides a better effective orifice area.

Cardiac papillary fibroelastoma; when, how, why?

We would like to present an interesting case operated on in our department and discuss the international bibliography about this issue. We also present some interesting images of this case. Our material is composed from a 68-year-old woman treated by the authors. She presented with a small murmur in the auscultation while she was asymptomatic and then she diagnosed with a tumor on of the left coronary cusp of the aortic valve with the characteristics of papillary fibroelastoma. On the basis of the potential embolic risk either of the mass itself or of associated thrombus and the possibility of further enlargement, the patient although asymptomatic at the time of diagnosis was referred for elective surgical excision of the mass. She underwent on median sternotomy and through extracorporeal circulation the mass has been excised with the preservation of the well-functioning valve. Through this case, we would like to discuss the bibliography for the decision making in these cases. Hence, the aim of our study is that we have to keep in mind that this kind of friable mass may be the cause of embolism, stroke or coronary artery occlusion and must be excided in a conservative setting, sparing the aortic valve.

Simultaneous "traumatic Gerbode" and aortic rupture due to blunt chest trauma.

The Gerbode defect is characterized by a perimembranous ventricular septal defect between the left ventricle and the right atrium. This intracardiac shunt is a congenital defect but may be iatrogenic after valve surgery or atrioventricular node ablation, may be the result of endocarditis or may be traumatic. It is really rarely encountered as sequelae of non-penetrating heart trauma, and their clinical manifestations may often be unrecognized in the multi-injured patient. However, they are serious complications, and their diagnostic approach is not always feasible. We hereby present a case of a young man with the left ventricle to the right atrium communication after blunt thoracic trauma due to a car accident and concomitant rupture of the thoracic aorta. We present also the case and the ways of treatment according to the international bibliography.

Perceval S aortic valve implantation in an achondroplastic Dwarf.

Despite cardiovascular disease in patients with dwarfism is not rare; there is a lack of reports referring to cardiac interventions in such patients. Dwarfism may be due to achondroplasia or hormonal growth disorders. We present a 58-year-old woman with episodes of dyspnea for several months. She underwent on transthoracic echocardiography, and she diagnosed with severe aortic valve stenosis. She referred to our department for surgical treatment of this finding. In accordance of her anthropometric characteristics and her very small aortic annulus, we had the dilemma of prosthesis selection. We decided to implant a stentless valve to optimize her effective orifice area. Our aim is to present the successful Perceval S valve implantation and the descriptions of the problems coming across in operating on these special patients. To our knowledge, this is the first case patient in which a Perceval S valve is implanted according to the international bibliography.