The use of balloon-expandable Sapien-3 valve in redo aortic valve replacement and the potential risk of left main stem occlusion.

Redo aortic valve surgery for the failure of a previously implanted valve is always challenging. In case of small-sized implanted valves, the use of a balloon-expanding Sapien-3 valve can enhance the final effective orifice area, avoid annulus enlargement complex techniques, and can reduce operative time and morbidities. We describe a case where after explanting a failed 19 mm St. Jude mechanical aortic valve and further deployment of a 23 mm Sapien-3 valve, the left coronary ostia was obstructed by the skirt of the transcatheter prosthesis. After careful removal of a little part of the skirt, we were able to restore the coronary flow and the patient had a favorable outcome.

Twenty-year experience with skeletonized bilateral internal thoracic arteries for surgical myocardial revascularization. A single center experience.

BACKGROUND AND AIM OF THE STUDY: The mammary artery shows excellent long-term patency and encourages the use of skeletonized bilateral internal thoracic arteries (BITA) for coronary surgery. We analyzed the long-term outcome of patients operated for myocardial revascularization with BITA in a single center. MATERIALS AND METHODS: Clinical data and surgical details of patients undergoing coronary surgery with BITA were prospectively collected and retrospectively analyzed. Selected variables were studied as risk factors for sternal wound complication and a subanalysis of clinical outcome for patients aged 70 years or greater was performed. A long-term follow-up of the study group is provided. RESULTS: From January 2001 to November 2021, 750 patients underwent myocardial revascularization using BITA grafts (mean age: 61 ± 9.5 years; males: 91%) at our institute. Patients with triple-vessel disease were 81%, 15.3% of all procedures were performed off-pump and 3.6% were urgent cases. Hospital mortality was 0.5%. Sternal wound complication was observed in 67 patients (9.0%) with 7 deep sternal wound infections (0.9%). Female gender (odds ratios [OR]: 3.7, p < 0.01), BMI >30 (OR: 1.8, p = 0.04), smoking (OR: 1.8, p = 0.02), and chronic kidney failure (OR: 3.7, p = 0.05) were independent predictors for sternal complications. During a mean follow-up time of 8.7 ± 5.3 years, 34 patients (4.5%) underwent a repeated myocardial revascularization, and there were 89 all-cause deaths (11.9%) and the cumulative survival at 5, 10, 15, and 20 years was 97%, 89%, 76%, and 60% for the whole study group 92%, 74%, 47%, and 43% for the subgroup of elderly patients (mean age: 74 ± 3.5 years). CONCLUSIONS: Use of skeletonized bilateral thoracic arteries shows low-rate of wound infection and good long-term outcome with low risk of repeated revascularizations, regardless of patients' age.

Early predictors of mortality in refractory cardiogenic shock following acute coronary syndrome treated with extracorporeal membrane oxygenator.

We aimed to analyze the outcome and identify predictors of hospital mortality in patients with refractory cardiac arrest (CA) complicating acute coronary syndromes (ACS) and requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment. Between Jan-2005 and Dec-2019, 51 patients underwent urgent VA-ECMO implantation for CA in ACS. Patients were divided in two groups: "in-hospital" cardiac arrest (IHCA) and "out-of-hospital" cardiac arrest (OHCA). Prospectively collected data were retrospectively analyzed and compared between groups. Predictors for hospital mortality were investigated. IHCA and OHCA patients were 32 (62.7%) and 19 (37.3%), respectively. The groups differed for: male gender (72% vs 95%; p = 0.070), lactate peak level (8.5 ± 4.3vs10.7 ± 2.9; p = 0.023), total elapsed time from CA to VA-ECMO implantation in both groups (p < 0.001) and elapsed time from CA (IHCA group) or hospital arrival (OHCA group) to VA-ECMO implantation (38 min vs 80 min; p = 0.001). At logistic regression analysis, concomitant lactate level greater than 8.0 mmol/L and elapsed time from CA to VA-ECMO ≥ 30 min were predictors of increased mortality (OR 3.9; 95% CI 1.19-12.79; p = 0.025) for the entire population. In-hospital mortality was 60.8% (31/51 patients): 68.4% in OHCA group and 56.2% in IHCA group. No risk factors related to 30-day mortality resulted significant at univariable analysis. When rapidly instituted, VA-ECMO improves survival in patients with refractory cardiac arrest allowing coronary syndrome treatment. The association of an elapsed time from CA to VA-ECMO implantation longer than 30 min and a preoperative lactate peak level over 8.0 mmol/L predict a poor outcome, independently from being IHCA or OHCA.

A systematic review and meta-analysis of endovascular versus open surgical repair for the traumatic ruptured thoracic aorta.

OBJECTIVE: The purpose of this study was to compare clinical outcomes between open repair and thoracic endovascular aortic repair (TEVAR) in traumatic ruptured thoracic aorta. METHODS: A comprehensive search was undertaken of the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all published data comparing open vs endovascular repair. Databases were evaluated to July 2018. Odds ratios (ORs), weighted mean differences, or standardized mean differences and their 95% confidence intervals (CIs) were analyzed. The primary outcomes were stroke, paraplegia, and 30-day mortality rates; secondary outcomes were requirement for reintervention and 1-year and five-year mortality rates. RESULTS: A total of 1968 patients were analyzed in 21 articles. TEVAR was performed in 29% (n = 578) and open repair in 71% (n = 1390). TEVAR and open repair did not differ in the mean age of patients (42.1 ± 14 years vs 44.1 ± 14 years; P = .48). There was no difference in duration of intensive care and total hospital stay between TEVAR and open repair groups (12.7 ± 11.1 days vs 12.6 ± 8 days [P = .35] and 27.5 ± 14.6 days vs 25.9 ± 11 days [P = .80], respectively). Similarly, no statistically significant difference in postoperative paraplegia or stroke rate was noted between TEVAR and open repair (1.4% vs 2.3% [OR, 1.27; 95% CI, 0.59-2.70; P = .54] and 1% vs 0.5% [OR, 0.63; 95% CI, 0.18-2.18; P = .46]). Lower 30-day and 1-year mortality was noted in TEVAR (7.9% vs 20% [OR, 2.94; 95% CI, 1.92-4.49; P < .00001] and 8.7% vs 17% [OR, 2.11; 95% CI, 0.99-4.52; P = .05]). There was no difference in 5-year mortality (23% vs 17%; OR, 0.07; 95% CI, -0.07 to 0.20; P = .33). However, there was a higher rate of reintervention at 1 year in the endovascular group (0% vs 6%; OR, 0.17; 95% CI, 0.03-0.96; P = .04). CONCLUSIONS: TEVAR carries lower in-hospital mortality and provides satisfactory perioperative outcomes compared with open repair in traumatic ruptured thoracic aorta. It also provides a favorable 1-year survival at the expense of higher reintervention rates.

Local Versus General Anesthesia in Nonemergency Endovascular Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis.

The purpose of this systematic review was to assess the perioperative clinical outcomes in using local/regional anesthesia (LA/RA) or general anesthesia (GA) in patients undergoing endovascular abdominal aortic aneurysm repair. A comprehensive electronic literature search was undertaken from inception to September 2018, identifying all randomized and nonrandomized studies comparing LA/RA versus GA in patients with abdominal aortic aneurysm who underwent endovascular repair. A total of 12,024 patients (n = 1,664 LA/RA, n = 10,360 GA) were analyzed from 12 observational studies included in this analysis. No difference in mean age between LA/RA and GA group was noted (73.8 ± 7.8 y v 72.4 ± 7.6 y, 95% confidence interval 0.85 [-0.08 to 1.79]; p = 0.07). No differences in preoperative rate of chronic obstructive pulmonary disease, ischemic heart disease, diabetes mellitus, and American Society of Anesthesiologists grades were noted between the 2 groups (p = 0.21, p = 0.85, p = 0.46, and p = 0.67, respectively). Shorter total surgical time in LA/RA patients was reported (135 ± 40 min v 164 ± 43 min; p < 0.00001). Shorter hospital stay was observed in LA/RA patients (3.6 ± 3.3 d v 4.6 ± 5 d; p = 0.002). No difference in cardiac or renal complications was noted between the LA/RA and GA groups postoperatively (2.7% v 2.5%; p = 0.46 and 1.2% v 1.6%; p = 0.13). Similarly, no difference in vascular complications was noted in LA/RA versus GA patients (8.4% v 7.7%; p = 0.44). Thirty-day morality was not different between the 2 cohorts (2% v 1.7%; p = 0.97). Use of LA/RA in selective endovascular abdominal aortic aneurysm repair procedures provides satisfactory and comparable perioperative outcomes with those of GA, with the advantage of a shorter hospital stay. A large randomized controlled trial or multicenter study is required to confirm the present study's findings.

Severe pulmonary vein stenosis in association with IgG4 gammopathy: An unusual case.

IgG4-related disease (IgG4-RD)is a multifactorial and systemic immune-mediated disease. Pulmonary vein stenosis related to IgG4 is a rare entity. We report a case of a 57-year-old male who presented with vague symptoms of weakness, easy fatigue, shortness of breathing, chest tightness, and occasional palpitations. The patient was admitted, and investigations were arranged in the form of anterior mediastinotomy and pleural biopsies were taken to look for a possible diagnosis. The histopathology was reported as IgG4-related immunopathy. A transoesophageal echocardiogram was performed and this showed severe stenosis of left superior pulmonary vein. In patients with rare pathologies such as IgG4-RD, a transesophageal can be a useful diagnostic aid especially in patients with severely impaired renal functions which does not allow utilization of contrast computed tomography.

The Future of Open Heart Surgery in the Era of Robotic and Minimal Surgical Interventions.

It has been over two decades since the very first robotic cardiac surgery was performed. Over the years, there has been an increase in the demand for less invasive cardiac surgical techniques. Developments in technology and engineering have provided an opportunity for robotic surgery to be applied to a variety of cardiac procedures, including coronary revascularisation, mitral valve surgery, atrial fibrillation ablation, and others. In coronary revascularisation, it is becoming more widely used in single vessel, as well as hybrid coronary artery approaches. Currently, several international centres are specialising in a totally endoscopic coronary artery bypass surgery involving multiple vessels. Mitral valve and other intracardiac pathologies such as atrial septal defect and intracardiac tumour are also increasingly being addressed robotically. Even though some studies have shown good results with robot-assisted cardiac surgery, there are still concerns about safety, cost and clinical efficacy. There are also limitations and additional challenges with the management of cardiopulmonary bypass and myocardial protection during robotic surgery. Implementing novel strategies to manage these challenges, together with careful patient selection can go a long way to producing satisfactory results. This review examines the current evidence behind robotic surgery in various aspects of cardiac surgery.

Mitroflow and Perimount Magna 10 years outcomes a direct propensity match analysis to assess reintervention rates and long follow-up mortality.

OBJECTIVES: Biological valves are the most commonly used prostheses for aortic valve replacement (AVR) surgery in the UK. The aim of this retrospective observational study was to compare 10-year outcomes of Perimount Magna and Mitroflow bioprosthesis implanted in a single center. METHODS: The medical records of patients undergoing AVR in Liverpool Heart and Chest Hospital between 1999 and 2014 were examined. All data were collected retrospectively, and a propensity match analysis was performed with a ratio 3:1 to analyze 10-year outcomes. The primary outcomes were all-cause mortality rates and aortic valve reintervention rates. RESULTS: A total of 2608 patients were included; Mitroflow bioprosthesis was used in 352 patients while Perimount Magna was used in 2256 patients. Median (interquartile range [IQR]) follow-up for the entire data set was 6.95 (4.99, 9.69) years. After 10 years, the all-cause mortality rate was higher in Mitroflow cohort 34.8% vs 14.7% (P < .001). A higher rate of aortic valve reintervention was observed in the Mitroflow cohort (4.7% vs 1%, P < .001). CONCLUSIONS: There were significant differences in survival and reintervention-free survival rate between the two groups considered. The implant of the Perimount Magna valve seems to have a better short-term and long-term outcome over Mitroflow valve. Such results require larger studies to be validated.

Mid-Term Clinical Outcomes and Hemodynamic Performances of Trifecta and Perimount Bioprostheses following Aortic Valve Replacement.

Aims of the Study: We evaluated the clinical outcome and the hemodynamic and freedom from structural valve degeneration of two standard aortic bioprostheses. Methods: Clinical results, echocardiographic findings and follow-up data of patients operated for isolated or combined aortic valve replacement with the Perimount or the Trifecta bioprosthesis were prospectively collected, retrospectively analysed and compared. We weighted all the analyses by the inverse of the propensity of choosing either valves. Results: Between April 2015 and December 2019, 168 consecutive patients (all comers) underwent aortic valve replacement with Trifecta (n = 86) or Perimount (n = 82) bioprostheses. Mean age was 70.8 ± 8.6 and 68.8 ± 8.6 years for the Trifecta and Perimount groups, respectively (p = 0.120). Perimount patients presented a greater body mass index (27.6 ± 4.5 vs. 26.0 ± 4.2; p = 0.022), and 23% of them suffered from angina functional class 2-3 (23.2% vs. 5.8%; p = 0.002). Mean ejection fraction was 53.7 ± 11.9% (Trifecta) and 54.5 ± 10.4% (Perimount) (p = 0.994), with mean gradients of 40.4 ± 15.9 mmHg (Trifecta) and 42.3 ± 20.6 mmHg (Perimount) (p = 0.710). Mean EuroSCORE-II was 7 ± 11% and 6 ± 9% for the Trifecta and Perimount group, respectively (p = 0.553). Trifecta patients more often underwent isolated aortic valve replacement (45.3% vs. 26.8%; p = 0.016) and annulus enlargement (10.5% vs. 2.4%; p = 0.058). All-cause mortality at 30 days was 3.5% (Trifecta) and 8.5% (Perimount), (p = 0.203) while new pacemaker implantation (1.2% vs. 2.5%; p = 0.609) and stroke rate (1.2% vs. 2.5%; p = 0.609) were similar. Acute MACCE were observed in 5% (Trifecta) and 9% (Perimount) of patients with an unweighted OR of 2.22 (95%CI 0.64-7.66; p = 0.196) and a weighted OR of 1.10 (95%CI: 0.44-2.76, p = 0.836). Cumulative survival at 24 months was 98% (95%CI: 0.91-0.99) and 96% (95%CI: 0.85-0.99) for Trifecta and Perimount groups, respectively (log-rank test; p = 0.555). The 2-year freedom from MACCE was 94% (95%CI: 0.65-0.99) for Trifecta and 96% (95%CI: 0.86-0.99) for Perimount (log-rank test; p = 0.759, HR 1.46 (95%CI: 0.13-16.48)) in the unweighted analysis (not estimable in the weighted analysis). During the follow-up (median time: 384 vs. 593 days; p = 0.0001) there were no re-operations for structural valve degeneration. Mean valve gradient at discharge was lower for Trifecta across all valve sizes (7.9 ± 3.2 vs. 12.1 ± 4.7 mmHg; p < 0.001), but the difference did not persist during follow-up (8.2 ± 3.7 mmHg for Trifecta, 8.9 ± 3.6 mmHg for Perimount; p = 0.224); Conclusions: Postoperative outcome and mid-term follow-up were similar. An early better hemodynamic performance was detected for the Trifecta valve but did not persist over time. No difference in the reoperation rate for structural valve degeneration was found.

Percutaneous Venous Cannulation for Minimally Invasive Cardiac Surgery: The Safest and Effective Technique Described Step-by-Step.

The current cardiac surgical landscape, with the expansion of minimally invasive operations, ECMO, and some interventional therapies, requires a thorough knowledge of peripheral cannulation techniques. In particular, venous cannulation may appear trivial and complication-free, but this does not reflect the reality. A venous cannulation which is not perfectly performed can lead to serious life-threatening complications in several steps. The technique we describe step by step is the current gold standard in terms of safety and efficacy: from the use of ultrasound for ultrasound-guided puncture to safe advancement of super stiff guidewires by means of a sentinel catheter, and concluding with smooth insertion of the venous cannula over the stiff guidewire up to the SVC. Moreover, a list of bailout maneuvers to solve complications is presented along with a report of institutional clinical experience since the adoption of this technique.

Morphologic and angiographic analysis to assess the safety of a biodegradable mitral annuloplasty ring.

BACKGROUND AND AIM OF THE STUDY: Although iatrogenic ischemic complications due to occlusion of the circumflex coronary artery following mitral ring annuloplasty are rare, they may be fatal if not recognized and treated promptly. The study aim was to assess the implantation safety of a novel biodegradable intra-annular mitral valvuloplasty ring in ex-vivo cadaveric human hearts. METHODS: Ten fresh-frozen human cadaveric hearts were washed, and filled with surgical gauze in order to mimic the heart's anatomic shape and position. Following left atriotomy, the biodegradable annuloplasty ring was implanted using the intra-annular implantation technique. Pre- and post-implantation coronary angiography was used to evaluate the dominance of the coronary circulation, and to assess coronary patency. The coronary arteries and veins were then filled with red and green latex solutions respectively, after which the hearts were fixed in 4% formaldehyde for four weeks. The distances between the annuloplasty ring, the coronary arteries, and coronary sinus were measured through perpendicular cuts at the levels of the anterolateral commissure (L-1), the mid-point of the posterior annulus (L-2), and the posteromedial commissure (L-3). RESULTS: Nine hearts had a right coronary artery dominance, and one had a balanced coronary circulation. None of the hearts demonstrated any abnormalities or occlusion of the circumflex coronary arteries after ring implantation. The mean distances between the circumflex coronary arteries and the ring were 7.2 +/- 2.7 mm, 11 +/- 2.4 mm, and 10.7 +/- 3.8 mm at L-1, L-2 and L-3, respectively. The mean distances between the coronary sinus and the ring were 11.8 +/- 3.4 mm, 9.8 +/- 2.3 mm, and 11 +/- 3.7 mm at L-1, L-2 and L-3, respectively. The implantation depth of the ring was 2-3 mm from the endocardial surface. CONCLUSION: The present observations suggest that implantation of the intra-annular biodegradable annuloplasty ring is safe, as confirmed by angiography and measurement of the distances between the ring and the adjacent coronary vasculature.

Preoperative intra aortic balloon pumps in patients undergoing coronary artery bypass grafting.

BACKGROUND: The intra aortic balloon pump (IABP) is a mechanical assist device which improves cardiac function. The device has a well-established place in algorithms for managing low cardiac output following cardiac surgery. There is increasing evidence that certain cardiac surgery patients benefit from a period of preoperative augmentation with the intra aortic balloon pump. OBJECTIVES: To determine the effect of the preoperative intra aortic balloon pump on mortality and morbidity in a number of different patients groups undergoing coronary artery bypass grafting. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 3, 2009), MEDLINE (2000 to August 2009), EMBASE (1998 to August 2009), BIOSIS previews (1969 to August 2009) and ISI Proceedings (1990 to August 2009) were searched. References and ongoing registers of studies were checked. No language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials (RCTs) of any size or length were included. DATA COLLECTION AND ANALYSIS: Papers were assessed for inclusion by two authors independently and differences were settled by consensus with a third author. Date are presented in the form of odds ratios (OR) and 95% confidence intervals (CI). MAIN RESULTS: Six trials were included (five on-pump and one off-pump). This update adds the results of one further trial. Data from a total of 255 patients were included in the meta-analysis of mortality outcomes; all on-pump. Generally, the patients were considered as "high risk" and 132 were treated preoperatively with IABP and 123 served as controls. There were four hospital deaths in the intervention arm and 23 in the non-intervention arm (OR 0.18, 95% CI 0.08 to 0.41; P<0.0001). In a subgroup analysis, low cardiac index (<2.0 L/min/m(2)) was noted in 21 out of 105 patients in the treatment arm and 59 patients out of 88 in the non-treatment arm (OR 0.14, 95% CI: 0.08 to 0.25; P<0.00001). An off-pump versus on-pump analysis was not possible due to the limited number of off-pump studies. However a single well-conducted RCT suggested favourable effect of the preoperative IABP in off-pump patients. AUTHORS' CONCLUSIONS: Evidence suggests that preoperative IABP may have a beneficial effect on mortality and morbidity in specific high risk patient groups undergoing coronary artery bypass grafting, however there are many problems with the quality, validity and generalisability of the trials. However, the available evidence is not robust enough to extend the use of IABP to truly elective, high risk patients. Defining more precisely which patient groups may benefit would be the challenge for the future.

Surgical treatment of complications associated with the Angio-Seal vascular closure device.

Vascular closure devices are used to provide quick hemostasis and early ambulation after percutaneous interventions. The Angio-Seal (AS) vascular closure device forms a mechanical seal by closing the puncture site located between a bioabsorbable anchor within the lumen and a collagen sponge on the adventitia. Although morbidities associated with AS are reportedly infrequent, even the slightest inaccuracy in device implantation may result in displacement of these device components, leading to sudden and severe complications. We report the surgical treatment of complications associated with the use of AS in four patients, including acute limb ischemia, pseudoaneurysm formation, significant hemorrhage, and hypovolemic shock. A common factor in all these cases was that the components of the AS device were displaced from their original site of implantation, stressing the importance of proper device placement. All patients underwent successful surgical vascular repair. Our report highlights the need for exercising extreme care during device implantation, and also the requirement for vigilant inspection for any associated vascular complications commencing immediately after device implantation. It is vital that these device components are actively looked for and removed during surgical exploration so as to prevent future complications.

Is obesity associated with poorer outcomes in patients undergoing minimally invasive mitral valve surgery?

OBJECTIVES: High body mass index (BMI) makes minimally invasive mitral valve surgery (MIMVS) more challenging with some surgeons considering this a contraindication. We sought to determine whether this is because the outcomes are genuinely worse than those of non-obese patients. METHODS: This is a retrospective cohort study of all patients undergoing MIMVS ± concomitant procedures over an 8-year period. Patients were stratified into 2 groups: BMI ≥ 30 kg/m2 and BMI ˂ 30 kg/m2, as per World Health Organization definitions. Baseline characteristics, operative and postoperative outcomes and 5-year survival were compared. RESULTS: We identified 296 patients (BMI ≥30, n = 41, median 35.3, range 30-43.6; BMI <30, n = 255, median 26.2, range 17.6-29.9). The groups were well matched with regard to baseline characteristics. There was only 1 in-hospital mortality, and this was in the BMI < 30 group. There was no difference in repair rate for degenerative disease (100% vs 96.3%, P > 0.99 respectively) or operative durations [cross-clamp: 122 min interquartile range (IQR) 100-141) vs 125 min (IQR 105-146), P = 0.72, respectively]. There were only 6 conversions to sternotomy, all in non-obese patients. There was no significant difference in any other perioperative or post-operative outcomes. Using the Kaplan-Meier analysis, there was no significant difference in 5-year survival between the 2 groups (95.8% vs 95.5%, P = 0.83, respectively). CONCLUSIONS: In patients having MIMVS, there is insufficient evidence to suggest that obesity affects either short- or mid-term outcomes. Obesity should therefore not be considered as a contraindication to this technique for experienced teams.

Surgical treatment of pleural empyema in Coronavirus disease 19 patients: the Southern Switzerland experience.

We report the first surgical series of patients developing pleural empyema after severe bilateral interstitial lung disease in confirmed severe acute respiratory syndrome coronavirus 2 infection. The empyema results in a complex medical challenge that requires combination of medical therapies, mechanical ventilation and surgery. The chest drainage approach was not successful to relieve the symptomatology and to drain the excess fluid. After multidisciplinary discussion, a surgical approach was recommended. Even though decortication and pleurectomy are high-risk procedures, they must be considered as an option for pleural effusion in Coronavirus disease-positive patients. This is a life-treating condition, which can worsen the coronavirus disease manifestation and should be treated immediately to improve patient's status and chance of recovery.

Preoperative diastolic function predicts the onset of left ventricular dysfunction following aortic valve replacement in high-risk patients with aortic stenosis.

INTRODUCTION: Left ventricular (LV) dysfunction frequently occurs after cardiac surgery, requiring inotropic treatment and/or mechanical circulatory support. In this study, we aimed to identify clinical, surgical and echocardiographic factors that are associated with LV dysfunction during weaning from cardiopulmonary bypass (CPB) in high-risk patients undergoing valve replacement for aortic stenosis. METHODS: Perioperative data were prospectively collected in 108 surgical candidates with an expected operative mortality >or=9%. All anesthetic and surgical techniques were standardized. Reduced LV systolic function was defined by an ejection fraction <40%. Diastolic function of the LV was assessed using standard Doppler-derived parameters, tissue Doppler Imaging (TDI) and transmitral flow propagation velocity (Vp). RESULTS: Doppler-derived pulmonary flow indices and TDI could not be obtained in 14 patients. In the remaining 94 patients, poor systolic LV was documented in 14% (n = 12) and diastolic dysfunction in 84% of patients (n = 89), all of whom had Vp <50 cm/s. During weaning from CPB, 38 patients (40%) required inotropic and/or mechanical circulatory support. By multivariate regression analysis, we identified three independent predictors of LV systolic dysfunction: age (Odds ratio [OR] = 1.11; 95% confidence interval (CI), 1.01 to 1.22), aortic clamping time (OR = 1.04; 95% CI, 1.00 to 1.08) and Vp (OR = 0.65; 95% CI, 0.52 to 0.81). Among echocardiographic measurements, Vp was found to be superior in terms of prognostic value and reliability. The best cut-off value for Vp to predict LV dysfunction was 40 cm/s (sensitivity of 72% and specificity 94%). Patients who experienced LV dysfunction presented higher in-hospital mortality (18.4% vs. 3.6% in patients without LV dysfunction, P = 0.044) and an increased incidence of serious cardiac events (81.6 vs. 28.6%, P < 0.001). CONCLUSIONS: This study provides the first evidence that, besides advanced age and prolonged myocardial ischemic time, LV diastolic dysfunction characterized by Vp

Management of Lower Limb Ischemia During Operative Repair of Acute Type A Aortic Dissection by Distal Crossover Grafts: a Case Series.

OBJECTIVE: To describe our experience of nine patients with extra-anatomical bypass for clinically ischemic distal limb during repair of acute Type A aortic dissection (ATAAD). METHODS: We retrospectively examined a series of nine patients who underwent surgery for ATAAD. We identified a subset of the patients who presented with concomitant radiographic and clinical signs of lower limb ischemia. All but one patient (axillobifemoral bypass) underwent femorofemoral crossover grafting by the cardiac surgeon during cooling. RESULTS: One hundred eighty-one cases of ATAAD underwent surgery during the study period with a mortality of 19.3%. Nine patients had persistent clinical evidence of lower limb ischemia (4.9%) and underwent extra-anatomical bypass during cooling. Two patients underwent additional fasciotomies. Mean delay from symptoms to surgery in these nine patients was 9.5 hours. Two patients had bilateral amputations despite revascularisation and, of note, had long delays in presentation for surgery (> 12 hours). There were no mortalities during these inpatient episodes. Outpatient radiographic follow-up at the first opportunity demonstrated 100% patency. CONCLUSION: Our experience suggests that, during complicated aortic dissection, limb ischemia may have a devastating outcome including amputation when diagnosis and referral are delayed. Early diagnosis and surgery are crucial in preventing this potentially devastating complication.