Use of the Perceval Sutureless Valve in Active Prosthetic Aortic Valve Endocarditis.

BACKGROUND: Surgical treatment of active prosthetic aortic valve endocarditis presents a challenge for cardiac surgeons because of tissue friability and destruction caused by infection. Sutureless prostheses, such as the Perceval S (LivaNova, Saluggia, Italy), have emerged as an option among the different surgical approaches for these complicated cases. METHODS: This study presents data from 9 patients who underwent aortic valve re-replacement with the Perceval S because of active prosthetic aortic valve endocarditis between January 2014 and August 2016. Hemodynamic performance (mean transprosthetic gradient and type of aortic regurgitation) was assessed intraoperatively after weaning from cardiopulmonary bypass, at discharge, and to 6 months postoperatively. RESULTS: After weaning from cardiopulmonary bypass, cases 1 and 3 through 6 had no or trivial aortic regurgitation, cases 7 and 8 presented with trivial to mild regurgitation, case 9 showed mild intraprosthetic regurgitation, and case 2 had mild periprosthetic regurgitation. Cases 4 and 7 died of septic shock and multiorgan failure in the perioperative period. In the remaining patients, severity of aortic regurgitation maintained practically invariable at discharge compared with intraoperative results. These 7 patients did well at 6-month follow-up, with good clinical and hemodynamic performance of the Perceval S prosthesis. The median of mean transprosthetic gradient was 11 mm Hg (interquartile range: 10 to 12 mm Hg). Only patient 2 showed mild periprosthetic regurgitation; patient 9 showed mild intraprosthetic insufficiency, and the remaining patients had no or trivial regurgitation. CONCLUSIONS: The sutureless Perceval S valve is a reasonable alternative for surgical treatment of prosthetic aortic valve endocarditis.

Repair of Late Retrograde Type A Aortic Dissection After TEVAR: Causes and Management.

One of the most feared complications of thoracic endovascular aortic repair (TEVAR) and hybrid arch repair is retrograde type A aortic dissection (RTAD). More than two-thirds of RTAD occurs in the immediate postoperative period and first postoperative month. In presentations beyond that point, progression of the native aortopathy must be considered. We report a late presentation of an RTAD seven months after hybrid repair of an aortic intramural hematoma with an ulcer-like projection, and review the causes and management of this TEVAR complication.

Blunt traumatic aortic injuries of the ascending aorta and aortic arch: a clinical multicentre study.

OBJECTIVE: To report the clinical and radiological characteristics, management and outcomes of traumatic ascending aorta and aortic arch injuries. METHODS: Historic cohort multicentre study including 17 major trauma patients with traumatic aortic injury from January 2000 to January 2011. RESULTS: The most common mechanism of blunt trauma was motor-vehicle crash (47%) followed by motorcycle crash (41%). Patients sustaining traumatic ascending aorta or aortic arch injuries presented a high proportion of myocardial contusion (41%); moderate or greater aortic valve regurgitation (12%); haemopericardium (35%); severe head injuries (65%) and spinal cord injury (23%). The 58.8% of the patients presented a high degree aortic injury (types III and IV). Expected in-hospital mortality was over 50% as defined by mean TRISS 59.7 (SD 38.6) and mean ISS 48.2 (SD 21.6) on admission. Observed in-hospital mortality was 53%. The cause of death was directly related to the ATAI in 45% of cases, head and abdominal injuries being the cause of death in the remaining 55% cases. Long-term survival was 46% at 1 year, 39% at 5 years, and 19% at 10 years. CONCLUSIONS: Traumatic aortic injuries of the ascending aorta/arch should be considered in any major thoracic trauma patient presenting cardiac tamponade, aortic valve regurgitation and/or myocardial contusion. These aortic injuries are also associated with a high incidence of neurological injuries, which can be just as lethal as the aortic injury, so treatment priorities should be modulated on an individual basis.

Aortic injuries in crush trauma patients: different mechanism, different management.

BACKGROUND: The objective of this study is to report the clinical and radiological characteristics and early and long-term survival of a series of acute traumatic aortic injuries (ATAI) in crush trauma patients, and to compare such data with our last 30 years experience managing ATAI in deceleration non-crush trauma patients. METHODS: From January 1980 to December 2010, 5 consecutive ATAI in crush trauma and 69 in non-crush trauma patients were admitted at our institution. ISS, RTS and TRISS scores were similar in both groups. RESULTS: Overall in-hospital mortality was 24.3%. There was no in-hospital mortality in crush patients and 26.1% in non-crush patients (p=0.32). All aortic-related complications occurred in non-crush patients. Median follow-up was 129 months (range 3-350 months). Non-crush group survival was 76.8% at 1 year, 73.6% at 5 years, and 71.2%% at 10 years. There was no mortality during follow-up in the crush group. Mean (SD) peak creatine phosphokinase was significantly higher in crush group than in non-crush group: 7598 (3690) IU/L vs. 3645 (2506) IU/L; p=0.041. Incidence of acute renal injury was higher in crush trauma patients (100% vs. 36.2%; p=0.018). Low-severity injuries were more common in crush trauma patients (100% in crush patients vs. 43.5% in non-crush patients, p=0.04). CONCLUSIONS: Aortic injuries in crush thoracic trauma patients seem to present in a different clinical scenario from aortic injuries in high-speed thoracic trauma thus requiring distinct considerations. When planning the initial management of aortic injuries in crush trauma, the increased risk of rhabdomiolysis and subsequent acute renal failure, as well as a tendency to develop lower-risk aortic wall injuries, must be considered.

Traumatic aortic injury score (TRAINS): an easy and simple score for early detection of traumatic aortic injuries in major trauma patients with associated blunt chest trauma.

PURPOSE: To develop a risk score based on physical examination and chest X-ray findings to rapidly identify major trauma patients at risk of acute traumatic aortic injury (ATAI). METHODS: A multicenter retrospective study was conducted with 640 major trauma patients with associated blunt chest trauma classified into ATAI (aortic injury) and NATAI (no aortic injury) groups. The score data set included 76 consecutive ATAI and 304 NATAI patients from a single center, whereas the validation data set included 52 consecutive ATAI and 208 NATAI patients from three independent institutions. Bivariate analysis identified variables potentially influencing the presentation of aortic injury. Confirmed variables by logistic regression were assigned a score according to their corresponding beta coefficient which was rounded to the closest integer value (1-4). RESULTS: Predictors of aortic injury included widened mediastinum, hypotension less than 90 mmHg, long bone fracture, pulmonary contusion, left scapula fracture, hemothorax, and pelvic fracture. Area under receiver operating characteristic curve was 0.96. In the score data set, sensitivity was 93.42 %, specificity 85.85 %, Youden's index 0.79, positive likelihood ratio 6.60, and negative likelihood ratio 0.08. In the validation data set, sensitivity was 92.31 % and specificity 85.1 %. CONCLUSIONS: Given the relative infrequency of traumatic aortic injury, which often leads to missed or delayed diagnosis, application of our score has the potential to draw necessary clinical attention to the possibility of aortic injury, thus providing the chance of a prompt specific diagnostic and therapeutic management.

Traumatic aortic injuries associated with major visceral vascular injuries in major blunt trauma patients.

BACKGROUND: The objectives of this study were to report the clinical and radiological characteristics and outcomes of a series of acute traumatic aortic injuries (ATAIs) with associated injury to major aortic abdominal visceral branches (MAAVBs). METHODS: From January 2000 to August 2011, 10 consecutive major blunt trauma patients with associated ATAI and injury to MAAVBs (group A) and 42 major blunt trauma patients presenting only an ATAI without MAAVB injuries (group B) were admitted to our institution. RESULTS: Overall in-hospital mortality was 32.7%. In-hospital mortality in group A was 40% and in group B it was 31% (p = 0.86). Observed in-hospital mortality was slightly lower than the expected in-hospital mortality in both groups. Mean peak creatine phosphokinase was significantly higher in group A than in group B patients (23,008 ± 33,400 vs. 3,970 ± 3,495 IU/L; p < 0.001). Acute renal injury occurred in 50% of group A and in 26.2% of group B patients. Hemodiafiltration was required in 30% of group A and in 9.5% of group B patients. Median follow-up time was 64 months (range = 1-130 months). Group A survival was 60% at 1, 5 and 10 years. Group B survival was 69% at 1 year and 63.3% at 5 and 10 years (p = 0.15). CONCLUSIONS: Aortic injuries associated with MAAVB injuries in major trauma patients seem to present in a different clinical scenario. These patients present increased risk of rhabdomyolysis, visceral ischemia, and acute renal failure, as well as higher in-hospital mortality. A multidisciplinary approach combining endovascular and open surgical techniques for a staged treatment of these life-threatening aortic and MAAVB injuries is mandatory in this critical subset of trauma patients.

Acquired von Willebrand syndrome and mitral valve prosthesis leakage. A pilot study.

BACKGROUND: Of patients with severe aortic stenosis, 15-25% present with bleeding episodes possibly attributable to acquired von Willebrand syndrome (AVWS). AVWS associated with mitral valve prosthesis leakage has not been reported. METHODS AND RESULTS: Five patients receiving appropriate oral anticoagulation showed mitral valve prosthesis leakage and bleeding episodes; all of them required hospitalization and two blood transfusions, and a von Willebrand factor (VWF) analysis was performed. Two patients with normal functioning metallic prosthesis valves were included as controls. Before surgery, after cessation of acenocumarol, the patients had prolonged activated partial thromboplastin time; four had prolonged closure time (CT) from the platelet function analyzer. Factor VIII procoagulant activity (FVIII:C), VWF ristocetin cofactor activity (VWF:RCo), and VWF collagen binding (VWF:CB) were considerably elevated, while VWF antigen (VWF:Ag) was most elevated. Disproportionate VWF:RCo/VWF:Ag and VWF:CB/VWF:Ag ratios were seen with the loss of large VWF multimers. Following surgery, all parameters were markedly increased and the ratios, CT, and multimeric VWF profile became normal. CONCLUSIONS: Acquired VWF qualitative alterations in mitral valve prosthesis leakage may be associated with or contribute to bleeding diathesis. AVWS should be taken into consideration in patients with mitral valve prosthesis leakage with bleeding diathesis not explained by excessive oral anticoagulation.

Role of conservative management in traumatic aortic injury: comparison of long-term results of conservative, surgical, and endovascular treatment.

OBJECTIVE: The purpose of this study is to compare early and long-term results in terms of survival and cardiovascular complications of patients with acute traumatic aortic injury who were conservatively managed with patients who underwent surgical or endovascular repair. METHODS: From January 1980 to December 2009, 66 patients with acute traumatic aortic injury were divided into 3 groups according to treatment intention at admission: 37 patients in a conservative group, 22 patients in a surgical group, and 7 patients in an endovascular group. Groups were similar with regard to gender, age, Injury Severity Score, Revised Trauma Score, and Trauma Injury Severity Score. RESULTS: In-hospital mortality was 21.6% in the conservative group, 22.7% in the surgical group, and 14.3% in the endovascular group (P = .57). In-hospital aortic-related complications occurred only in the conservative group. Median follow-up time was 75 months (range, 5-327 months). Conservative group survival was 75.6% at 1 year, 72.3% at 5 years, and 66.7% at 10 years. Surgical group survival remained at 77.2% at 1, 5, and 10 years, whereas survival in the endovascular group was 85.7% at 1 and 5 years (P = .18). No patient in the surgical or endovascular group required reintervention because of aortic-related complications, whereas 37.9% of the conservative group had an aortic-related complication that required surgery or caused the patient's death during the follow-up period. Cumulative survival free from aortic-related complications in the conservative group was 93% at 1 year, 88.5% at 5 years, and 51.2% at 10 years. Cox regression confirmed the initial type of aortic lesion (hazard ratio, 2.94; P = .002) and a Trauma Score-Injury Severity Score greater than 50% on admission (hazard ratio, 1.49; P = .042) as risk factors for the appearance of aortic-related complications. Two peaks in the complication rate of the conservative group were detected in the first week and between the first and third months after blunt thoracic trauma. CONCLUSIONS: The advent of thoracic aortic endografting has enabled a revolution in the management of acute traumatic aortic injury in patients with multisystem trauma with a low in-hospital morbimortality. Nonoperative management may be only a therapeutic option with acceptable survival in carefully selected patients. The natural history of these patients has revealed a marked trend of late aortic-related complications developing, which may justify an endovascular repair even in some low-risk patients.

Mitral valve repair for ischemic mitral regurgitation using the Carpentier-McCarthy-Adams IMR ETlogix® ring: medium-term echocardiographic findings.

The aims of this study were to review the principles underlying use of the Carpentier-McCarthy-Adams IMR ETlogix® asymmetric annuloplasty ring for the treatment of chronic ischemic mitral regurgitation and to report medium-term clinical outcomes observed at our center. The in-hospital mortality rate was 2.8%. Echocardiography at hospital discharge confirmed the absence of mitral regurgitation in 88.8% of patients. Patients underwent clinical and echocardiographic follow-up (median duration, 23 months; range, 12-44 months). Late follow-up echocardiography demonstrated the recurrence of moderate mitral regurgitation in 5.7% of patients and of moderate-to-severe mitral regurgitation in 2.9%. The rate of survival free from recurrence of ≥grade-2 mitral regurgitation was 95.2% at 15 months and 88.9% at 25 months. Mitral valve repair using the asymmetric Carpentier-McCarthy-Adams IMR ETlogix® ring in patients with chronic ischemic mitral regurgitation enabled regurgitation to be effectively corrected by producing asymmetric changes in the morphology of the mitral ring. Medium-term outcomes, with regard to the degree of mitral valve competence, were excellent.

Challenging endovascular repair of a critical aortic endograft migration and massive type III endoleak.

Type III endoleaks, which may be caused by endograft disconnection, pose the risk of aneurysm enlargement and rupture because the pressure in the aneurysmatic sac tends to equal the systolic aortic pressure. We report the endovascular treatment of a critical dislocation of two thoracic aorta endografts with subsequent massive aneurysmatic pressurization of the aneurysmatic sac, which led to its impending rupture. The aberrant migration of both endografts required a combined, right humeral and left femoral, approach to capture the guide wire with an endovascular snare in the aneurismal sac. Several maneuvers were necessary to avoid trapping the guide wire in one of the bare stents. A final 'push-pull' technique was used to loop the wire and advance the new endografts into the ascending aorta to achieve a correct exclusion of the endoleaks. The patient suffered a perioperative stroke which could have been a complication of wire manipulation in the highly atheromatous aortic arch. A review of several maneuvers which may be taken to prevent these complications has been performed.

Subclinical thrombosis of the ascending aorta: a possible paraneoplastic syndrome.

Thrombosis of the ascending aorta is a rare, potentially lethal complication. We report the case of a 56-year-old woman with a massive but subclinic thrombosis of the ascending aorta after two cycles of chemotherapy due to an epidermoid lung carcinoma stage T3 N2 M0. An emergent aortic thrombectomy was performed under deep hypothermic circulatory arrest. This thrombotic event occurred in an arterial vessel with high laminar flow, which is extremely uncommon and did not present any clinical manifestation.

Extrinsic compression of the left atrium by a mediastinal hematoma secondary to inadvertent carotid puncture.

We present the case of a 63-year-old man who underwent surgical closure of a paravalvular mitral leak. Immediately after surgery, transesophageal echocardiography revealed the appearance of a mediastinal hematoma encroaching on the left atrium and separating the esophageal probe from the posterior left atrial wall. The cause was an inadvertent puncture of the carotid artery, presumably during central venous line insertion prior to surgery.

Mid-term results of thoracic endovascular aortic repair in surgical high-risk patients.

Between May 2001 and June 2008, the outcome and morphological changes in thoracic aortic lesions of 20 surgical high-risk patients who underwent TEVAR were evaluated. Aortic lesions included 8 (40%) type B dissections, 5 (25%) atherosclerotic aneurysms, 4 (20%) penetrating ulcers and 3 (15%) traumatic aortic ruptures. All patients were classified as American Society of Anaesthesiologists class IV and obtained high scores in both the logistic European System for Cardiac Operative Risk Evaluation, median of 14.5% (range 8.1-65.7%), and the STS Parsonet 95 scoring system, median of 14 (range 10-52). Endovascular stent-graft deployment was technically successful in all cases. No surgical conversion occurred. Early mortality was observed in two patients. Clinical and imaging follow-up was available in all patients at a median time of 28 months (range 4-89 months). Overall actuarial survival was 90% at one and five years and 60% at seven years. Mean diameter of the descending aorta decreased from 51.1+/-13 mm to 45.3+/-8 mm (P=0.032). Mean reduction in dimension of aneurysms was 10.7+/-8 mm. Endovascular thoracic aorta repair will probably benefit more patients with multiple comorbidities that limit their life expectancy than patients with a lower profile.

[Chronic anemia in heart transplant patients: prevalence, predisposing factors and prognostic significance]. / Anemia crónica en el trasplante cardiaco. Prevalencia, factores predisponentes y significado pronóstico.

INTRODUCTION AND OBJECTIVES: Data on chronic anemia following heart transplantation (HT) are scarce and contradictory. Our aims were to determine the prevalence of chronic anemia after HT, to identify predisposing factors for the condition at 12 months, and to evaluate its influence on medium-term and long-term survival. METHODS: Retrospective analysis of patients who underwent HT between 1991 and 2005 (n=457). Chronic anemia was defined as a hemoglobin level <12 g/dL. RESULTS: The prevalence of post-HT chronic anemia was 75.5% at 1 month, 31% at 12 months, and 26.2% at 120 months. The condition was significantly more prevalent among women than men. Predisposing factors for chronic anemia 1 year post-HT were mild-to-moderate chronic renal failure (i.e., creatinine level >1.5 mg/dL; odds ratio [OR]=2.8; 95% confidence interval [CI], 1.5-5.0), female sex (OR=6.4; 95% CI, 3.1-13.2), and immunosuppression with mycophenolate mofetil compared with azathioprine (OR=2.6;, 95% CI, 1.4-4.8). The prevalence of chronic anemia 12 months after HT was independent of the donor's sex, the recipient's age, the etiology of the recipient's heart failure, diabetes mellitus, mild-to-moderate graft rejection, cytomegalovirus infection, and angiotensin-converting enzyme inhibitor treatment. The presence of chronic anemia 12 months after HT did not influence either long-term survival (mean, 11.5 years with chronic anemia vs. 13.0 years without) or actuarial survival. CONCLUSIONS: Post-HT chronic anemia is common, but improves with time and treatment. Predisposing factors for the condition 1 year post-HT include chronic renal failure, female sex, and immunosuppression with mycophenolate mofetil. The presence of chronic anemia does not appear to influence long-term survival.

[Aortic valve replacement with a Cryolife O'Brien stentless bioprosthesis]. / Reemplazo valvular aórtico con bioprótesis no soportada de Cryolife O'Brien.

INTRODUCTION AND OBJECTIVES: The Cryolife O'Brien xenograft is a stentless bioprosthesis constructed from noncoronary leaflets from three porcine aortic valves. The aim of this study was to investigate short-term results after aortic valve replacement with this composite xenograft. METHODS: Since October 1993, Cryolife O'Brien bioprostheses have been implanted in 210 patients. The patients' mean age was 70.9 (7.5) years (range 23-83 years). The indication was aortic stenosis in 132 cases, aortic insufficiency in 25 cases, and both lesions in 53 cases. Valve function was studied by echocardiography preoperatively, at discharge, and 6 and 12 months postoperatively. RESULTS: The 30-day mortality rate was 5.2% (11/210). Over time, the mean gradients decreased and the effective area index increased. In addition, the left ventricular mass index, wall thickness, and septum thickness also decreased shortly after surgery. CONCLUSIONS: Use of the Cryolife O'Brien stentless bioprosthesis demonstrated satisfactory results at 1-year follow-up. Additional follow-up is required to assess the performance of this bioprosthesis over the long term.

[Preoperative risk evaluation in beating-heart coronary artery bypass surgery]. / Evaluación preoperatoria del riesgo en la cirugía coronaria sin circulación extracorpórea.

INTRODUCTION AND OBJECTIVES: Operative risk stratification scales for use in cardiac surgery have been developed for patients who undergo procedures using extracorporeal circulation. The aims of the present study were to investigate the use of six preoperative risk stratification scales in patients undergoing beating-heart surgery and to identify risk factors for major complications and mortality in our group of patients who underwent revascularization using this approach. PATIENTS AND METHOD: Between January 1997 and December 2002, we performed 762 coronary artery bypass operations on the beating heart; 61 patients suffered major complications (8%) and 25 died (3.3%). Risk factors for major complications and death were identified using logistic regression analysis of prospectively collected data. The following risk scores were calculated for each patient: Parsonnet 95, Parsonnet 97, Euroscore, Cleveland, Ontario, and French. Receiver operating characteristic curves were used to compare the ability of each scale to predict mortality and major complications. RESULTS: In our patient group, the preoperative variables associated with increased risk were: need for cardiopulmonary resuscitation, renal dysfunction, peripheral vasculopathy, and the presence of severe left main coronary artery disease, three-vessel disease, or an impaired ejection fraction. CONCLUSIONS: Mortality and major complications were best predicted by the Parsonnet 95 and Euroscore scales.