Hybrid treatment for thoracoabdominal aortic aneurysms in patients with Marfan syndrome.

Marfan syndrome is a heritable disorder of connective tissue leading to aortic aneurysms and other cardiovascular complications associated with reduced life expectancy. Although contemporary management of ascending aortic disease requires open surgical reconstruction, the combined retrograde visceral revascularization and endovascular exclusion (hybrid procedure) of entire thoracoabdominal aorta has been introduced for the management of descending thoracic and abdominal aortic pathology. The present experience reports 2 cases of thoracoabdominal aortic aneurysms, in Marfan patients, previously submitted to major cardiovascular surgical procedures, through a hybrid approach.

Diffusion in ternary aqueous systems containing human serum albumin and precipitants of different classes.

The mutual diffusion coefficients for two aqueous ternary systems, both containing a protein, human serum albumin (HSA, component 1), were measured. The first system contained a neutral polymer, polyethylene glycol (PEG, component 2), and the second an "organic solvent", 2-methyl-2,4-pentanediol (MPD, component 3). Both PEG and MPD are used as co-precipitants in HSA crystallization protocols. Measurements were performed at constant protein concentration, with increasing precipitant content. The results obtained for the two systems were discussed and compared. In both cases, the two main diffusion coefficients, relative to the motion of the protein and of the precipitant under their own concentration gradient, can be interpreted in terms of non-specific volume interactions between the solutes. Particularly, it was showed that any possible direct HSA-MPD interaction may not have a significant effect on the values of these two diffusion coefficients. Differences arise between the cross precipitant's diffusion coefficients, relative to the motion of the precipitant under the protein concentration gradient, D(i1) with i = 2, 3. In the case of PEG, the D(21) trend vs. c(2) can be simply interpreted in terms of an "exclude volume" effect. In contrast, in the case of MPD, the D(31)vs. c(3) trend seems to indicate a more complex mechanism of transport. Because the cross precipitant's diffusion coefficient plays an important role in the crystallization process, the implication of the observed difference on the crystallization procedure was also discussed.

On the interpretation of transport properties of sodium cholate and sodium deoxycholate in binary and ternary aqueous mixtures.

Sodium cholate (NaC) and sodium deoxycholate (NaDC) in binary and ternary aqueous mixtures were investigated by means of surface tension, electron paramagnetic resonance spectroscopy (EPR), small angle neutron scattering (SANS) and mutual diffusion coefficient analysis. Concerning the NaC-H(2)O and NaDC-H(2)O binary mixtures, the surface tension, EPR and diffusion measurements confirmed the formation of micelles above a well detectable critical concentration. The SANS data indicated for both systems, the formation of ellipsoidal micelles whose major axis increased with concentration and minor axis remained constant. The data were interpreted under the assumption that aggregate growth occurred via hydrogen bonding of small aggregates along one preferential direction. For the NaC-NaDC-H(2)O ternary mixtures, the surface tension and EPR results were in good agreement with the Clint model prediction for the ideal mixed micellization. Based on this model, the SANS data enabled a complete description of the mixed aggregates in terms of dimensions, composition and concentration. In turn, this strategy allowed for a satisfactory interpretation of the main and cross-term diffusion coefficient trends, which are quite complex.

Left Main Coronary Artery Stent Misadventure.

Coronary artery bypass grafting has long been the standard of care for patients with left main coronary artery (LMCA) disease. Lately, percutaneous coronary intervention (PCI) has become a suitable alternative for these patients, but the procedure may be challenging. We describe 2 cases of LMCA PCI failure requiring surgical intervention. (Level of Difficulty: Advanced.).

Postoperative ascending aortic gigantic pseudoaneurysm: Endovascular treatment with the use of a septal occluder plug.

A rare postoperative complication of aortic root replacement is pseudoaneurysm formation. Surgical repair may be rather challenging particularly in patients who are elder and with significant comorbidities. Endovascular approach may also be technically demanding, given the high blood velocity and the anatomical challenges of the area of the aortic root and the ascending aorta. We would like to describe a case of an 85-year-old patient with history of prosthetic graft aortic root replacement who had been developed a 7-cm pseudoaneurysm with sternotomy diastasis and extension in the subcutaneous tissue, 7 years after the initial operation. Given the comorbidities, open repair was not considered a valid option and successful endovascular repair with the use of a ventricular septal occluder plug followed. One-year follow-up confirmed satisfactory exclusion of the pseudoaneurysm with no migration of the endovascular device and no other complication. This is one of the rare cases on endovascular repair of an ascending aorta postoperative pseudoaneurysm.

Mild and moderate renal dysfunction: impact on short-term outcome.

BACKGROUND: Preoperative renal dysfunction is an important risk factor in cardiac surgery. Thus, the association between creatinine clearance (ClCr) and mechanical ventilation time and ICU length of stay, independent of other established preoperative risk indicators, was analyzed. METHODS: In our study, 156 consecutive patients underwent open-heart surgery at the Department of Cardiac Surgery, University Hospital St. Andrea, Rome, and were prospectively studied for the relation between the ClCr, using the formula develop by Cockroft and Gault, and ICU length of stay and mechanical ventilation time. The 156 patients were divided into two groups in relation of ClCr: group A (n=78) ClCr<70 ml/min; group B (n=78) ClCr>70 ml/min. RESULTS: In multivariate analysis, ICU length of stay was influenced by ClCr<70 ml/min, hypertension and COPD. ICU stay was median 48 h (range 24-72) in group A versus 24h (range 20.7-44) in group B (p=0.0001). In multivariate analysis, only ClCr<70 ml/min and EuroScore were associated with increasing VAM. VAM was median 8h (range 5.7-13.2) in group A versus 6h (range 4-10) in group B (p=0.001). CONCLUSIONS: Our study demonstrates that after short-term outcome follow-up, preoperative mild renal dysfunction is an independent predictor of ICU length of stay and mechanical ventilation time.

Right coronary artery arising from the pulmonary trunk.

The right coronary artery (RCA) abnormally originating from the pulmonary trunk (PT) is a rare congenital anomaly. Our patient is a 62-year-old woman with longstanding systemic arterial hypertension and angina pectoris. Angiographic images documented the RCA arising from the PT, and coronary angiography showed severe stenosis (70%) on the distal tract of the left anterior descending artery. The primary treatment of the anomalous origin of RCA from the pulmonary artery is surgical technique. Our surgeons opted for coronary reimplantation; 6-month follow-up has shown very good results, with complete disappearance of symptoms.

Residual SYNTAX score following coronary artery bypass grafting.

Objectives: To quantify residual coronary artery disease measured using the SYNTAX score (SS) and its relation to outcomes after coronary artery bypass grafting (CABG). Methods: We conducted a retrospective analysis on a consecutive series of 1608 patients [mean age 68 years, standard deviation (SD): 7, F:M, 242:1366] undergoing first-time isolated CABG from 2004 to 2015. The baseline SS was retrospectively determined from preoperative angiograms, and the residual SS (rSS) was measured during assessment of the actual operative report for each patient after CABG. Patients were then stratified according to tercile cut points of low (rSS low 0-11, N = 537), intermediate (rSS mid >11-18.5, N = 539) and high residual SS (rSS high >18.5, N = 532). The Cox regression model was used to investigate the impact of rSS on major adverse cardiac and cerebrovascular events (MACCE) at 1 year. Results: The mean preoperative SS was 26.6 (SD: 9.4) (range 10.1-53), and the residual SS after CABG was 15.3 (SD: 8.4) (range 0-34) ( P < 0.001 versus preoperative). At 1 year, cumulative incidence of MACCE in the low rSS was 1.5% ( N = 8/537), 4.5% ( N = 24/539) in the intermediate and 8.8% ( N = 47/532) in the high rSS group. Kaplan-Meier analysis showed a statistically significant difference of MACCE-free survival between the three groups (log-rank test, P < 0.001). The estimated MACCE-free survival rate at 1 year was 98.1% [standard error (SE): 1.6] for the rSS low , 95.5% (SE: 1.9) for the rSS mid , and 90.5% (SE: 1.3) for the rSS high group, respectively. After multivariable adjustment, the rSS high group was independently associated with a higher incidence of MACCE at 1 year (hazard ratio 1.92, 95% confidence interval 1.21-3.23) compared to the rSS low group. Conclusions: These unanticipated findings suggest that a residual SS may be a useful tool for risk stratification of patients undergoing isolated first-time CABG. Our study may set the stage for further investigations addressing this important clinical question.

Myocardial bridging in hypertrophic cardiomyopathy: a plea for surgical correction.

Myocardial bridging may be associated with an unfavorable prognosis in patients with hypertrophic cardiomyopathy. We describe a case of a young symptomatic patient with myocardial bridging associated with hypertrophic cardiomyopathy successfully treated by surgical unroofing. Such a procedure should be strongly recommended in patients with hypertrophic cardiomyopathy.

Left ventricular aneurysm repair: early survival.

BACKGROUND: The aim of this study was to evaluate the early survival in patients submitted to left ventricular (LV) repair and concomitant myocardial revascularization. METHODS: We retrospectively reviewed the records of 51 patients who were submitted to LV repair and concomitant myocardial revascularization between January 1998 and June 2003. Of 51 patients (44 males with a mean age of 60+/-9.2 years, and 7 females with a mean age of 61+/-6.5 years), 29 (56.9 %) were submitted to the McCarthy technique, 16 (31.3 %) to the technique that was described by Jatene and modified by Dor, and 6 (11.8%) to the Cooley technique (linear repair). The mean preoperative LV ejection fraction was 36.5+/-7.7 %, the mean preoperative LV end-diastolic diameter was 61.8+/-3.9 mm, the mean preoperative LV end-systolic diameter was 49.9+/-5.1 mm, the mean preoperative interventricular septal thickness was 9.7+/-1.7 mm, and finally, the mean posterior wall thickness was 8.9+/-1 mm. The mean follow-up was 30.7+/-23.4 months (range 11-82 months). RESULTS: One patient died during surgery (1.9%) and one early postoperatively (1.9%). The causes of death were respectively irreversible ventricular fibrillation and low cardiac output syndrome. The overall survival at follow-up was 98% (49 patients). One patient died during follow-up of myocardial infarction. At follow-up, all patients presented with improved clinical symptoms, and had a better mean NYHA functional class with respect to the preoperative value (3.3+/-0.3 vs 2.0+/-0.5, p < 0.05). Besides, the mean CCS angina class decreased in all patients (3.4+/-0.2 vs 1.9+/-0.3, p < 0.05). The average LV ejection fraction increased from 36.3+/-7.7 to 44.3+/-4.9% (p < 0.001), the average LV end-diastolic diameter decreased from 61.7+/-3.9 to 55.5+/-5.6 mm (p < 0.001), and the average LV end-systolic diameter decreased from 49.9+/-5.1 to 40.4+/-5.1 mm (p < 0.001). No statistically significant difference was found between the preoperative and postoperative data regarding the interventricular septal thickness (9.7+/-1.7 vs 10.3+/-1.6 mm, p = NS), and the posterior wall thickness (9.7+/-1 vs 8.8+/-1.3 mm, p = NS). CONCLUSIONS: LV aneurysm repair and concomitant myocardial revascularization may be performed with an acceptable surgical risk and a good early survival.

Off-pump versus on-pump coronary artery bypass: does number of grafts performed represent a selection bias in comparative studies? Results from a matched cohort comparison.

BACKGROUND: Several retrospective studies comparing off-pump and on-pump coronary surgery and the largest randomized studies published to date showed a lower number of grafts performed in patients submitted to off-pump coronary artery bypass surgery (OPCAB). These findings bring about the question of the general applicability of the results. We eliminated the selection bias correlated with the number of grafts per patient by comparing the short-term outcomes of patients undergoing OPCAB and standard coronary artery bypass grafting (CABG) matched for number of grafts. METHODS: Eighty-seven consecutive patients undergoing OPCAB (group A) were selected from the database of our Institution during a 2-year period. Matching was performed by iterative selection prioritizing, in the following sequence: number of grafts, EuroSCORE, and age. A total of 87 patients operated upon with the on-pump technique represented the control group (group B). RESULTS: There were no significant differences in preoperative characteristics between the two groups. The number of grafts per patient was 2.2 +/- 0.5 in group A and 2.2 +/- 0.5 in group B. Early mortality did not differ between the two groups and it was 2.2% (2 patients) in group A and 3.4% (3 patients) in group B (p = NS). The incidence of myocardial infarction did not differ between the two groups. No patient in either group had stroke or coma. Five (5.7%) patients in group A and 7 (8.0%) patients in group B had atrial fibrillation (p = NS). CONCLUSIONS: We were unable to demonstrate any significant differences in short-term mortality or morbidity outcome between OPCAB and standard CABG patients Our findings suggest that excellent results can be obtained with both surgical approaches.

Unilateral Versus Bilateral Antegrade Cerebral Protection During Aortic Surgery: An Updated Meta-Analysis.

BACKGROUND: In the context of complex aortic surgery, despite the wide consensus about the use of moderate hypothermia in association with antegrade selective cerebral perfusion (ASCP), its bilateral administration is not always warranted. The aim of the present meta-analysis was to investigate outcomes of unilateral versus bilateral ASCP. METHODS: Outcomes investigated were postoperative mortality and neurologic permanent and temporary disease (PND and TND); separate analysis of heterogeneity using the Cochrane Q statistic was used to perform comparisons. Circulatory arrest (CA) time and temperature, and sample size were explored as potential causes for heterogeneity with meta-regression analysis. RESULTS: The study population consisted of 3,723 patients receiving bilateral ASCP and 3,065 patients receiving unilateral ASC. Pooled analysis showed similar rates of postoperative mortality: 9.8% (95% confidence interval [CI], 7.8% to 12.3%) for bilateral ASCP versus 7.6% (95% CI, 5.7% to 10.2%) for unilateral ASCP; p = 0.19. Postoperative PND rates as well did not differ significantly: 6.9% (95% CI, 5.0% to 9.4%) for bilateral ASCP versus 5.8% (95% CI, 3.8% to 8.7%) for unilateral ASCP; p = 0.53. Similar results yielded from TND analysis: 9.3 % (95% CI, 7.0% to 12.2%) versus 6.5% (95% CI, 4.5% to 9.5%), respectively, p = 0.14. Meta-regression analysis showed that longer CA times were associated with significantly increased mortality only among patients administered with unilateral ASCP (model Q 65.8, p < 0.0001). Furthermore, higher CA temperatures were associated with significantly reduced rates of mortality (Q 64.1, p = 0.001), PND (Q 52.3, p = 0.01), and TND (Q 62.2, p = 0.002) in both groups. CONCLUSIONS: Unilateral versus bilateral ASCP administration did not result in different mortality and neurologic morbidity rates. Nevertheless, among prolonged CA times unilateral ASCP resulted in poorer outcomes with respect to bilateral ASCP. Furthermore, moderate hypothermia was associated with best outcomes in both groups.

Reoperations in patients with patent left internal mammary artery.

In the past decade the rate of reoperative coronary bypass grafting has averaged 8%. In these patients adequate myocardial protection is often difficult because delivery of cardioplegia is frequently suboptimal when the internal mammary artery graft is patent. We describe a simple technique for performing cardiac reoperation in patients with a patent left internal mammary artery graft through a balloon catheter used for angioplasty and positioned in the left internal mammary artery graft. Our study included 3 patients and there were no operative deaths and complications.

Occluding clamp technique during coronary artery bypass grafting: single or double-clamp technique?

BACKGROUND: External manipulation of the diseased aorta during cardiac surgery is the most important mechanism leading to the detachment of atherosclerotic debris due, especially, to the use of aortic clamping. The aim of the present study was to determine the best occluding clamp technique to minimize the risk of postoperative cerebrovascular accidents in patients who undergo isolated coronary artery bypass grafting (CABG): single-clamp technique (SCT) or double-clamp technique (DCT)? METHODS: Two hundred and eighty-one consecutive patients undergoing isolated CABG in our center between January 2001 and December 2003 were enrolled. SCT was used in 145 cases and DCT was used in 136 cases. Postoperative adverse events were retrospectively compared between these two groups. RESULTS: The aortic cross-clamp times were longer for patients in the SCT group, whereas the mean cardiopulmonary bypass time was shorter in the DCT group. There were no differences between the two groups in terms of postoperative stroke (0.6% SCT vs 0.7% DCT, p = NS) and hospital mortality (1.3% SCT vs 1.4% DCT, p = NS). CONCLUSIONS: The results of this study suggest that, among patients who undergo CABG, there are no differences in neurologic outcome between those in whom DCT was used and those in whom SCT was employed.

Blackish Pigmentation of the Aorta in Patient with Alkaptonuria and Heyde's Syndrome.

Alkaptonuria is an autosomal recessive trait resulting in an error of aromatic amino acids metabolism. Heyde's syndrome is a condition clustering together aortic valve stenosis and gastrointestinal bleeding from colonic angiodysplasia. At present, there is no report describing the association of the latter two syndromes in the same patient. Here we present the case of a patient with severe aortic stenosis, alkaptonuria, and Heyde's syndrome. The patient underwent aortic valve replacement by means of a valvular bioprosthesis and the histological examination of the aortic cusps revealed calcific degeneration. This was associated with stromal degeneration characterized by extra-cellular deposition of granular, brownish-pigmented material along with macrophages and multiple foci of calfication showing the same brownish pigmentation. This configuration represents the typical pattern of homogentisic acid accumulation known as ochronosis. The postoperative course was uneventful and the echocardiographic follow-up at 6 months postoperatively showed good-functioning of the aortic valve bioprosthesis.

Perioperative administration of enoximone and renal function after cardiac surgery: a propensity-matched analysis.

BACKGROUND: Perioperative administration of enoximone has been shown to improve hemodynamics, organ function, and inflammatory response. Aim of the present study is to evaluate the impact of enoximone on postoperative renal function after on-pump cardiac surgery. METHODS: A total of 3727 patients undergoing cardiac surgery at one Institution between May 2004 and November 2010 were reviewed. A propensity score was built and a 1:1 perfect matching was performed, providing two fairly comparable cohorts of 712 patients each, receiving or not enoximone after surgery. Renal function was evaluated by lower glomerular filtration rate (GFR) value reached postoperatively. RESULTS: Overall 30-day mortality rate was 4.3% (62/1424). Cumulative incidence of postoperative renal failure (RF) was 157/1424(11%), of which 99/1424(7%) needed renal replacement therapy. Mean lower postoperative GFR in patients who received or not enoximone was 63 ± 30.1 and 53.5 ± 26.1 ml/min/1.73 m(2) (p<0.0001), respectively. At multivariable analysis age (OR2.75, p=0.0004), diabetes (OR1.82, p=0.006), preoperative GFR (OR3.81, p<0.0001), preoperative cardiogenic shock (OR1.65, p=0.004), previous cardiac surgery (OR2.12, p=0.0002), type of intervention (OR1.96, p=0.005), and enoximone (OR0.38, p=0.001) were found to be independently associated with postoperative RF. Logistic regression analysis showed that the administration of enoximone (OR0.41, p=0.0001), and of no inotropes (OR0.27, p<0.0001) were protective vs. the occurrence of postoperative RF. CONCLUSION: Patients perioperatively receiving enoximone showed a statistically significant better renal function after cardiac surgery.

ß-Blockers improve survival of patients with chronic obstructive pulmonary disease after coronary artery bypass grafting.

BACKGROUND: ß-Blockers are known to improve survival of patients with cardiovascular disease, but their administration in patients with chronic obstructive pulmonary disease (COPD) remains controversial. The aim of the present study was to assess the effect of ß-blocker administration in patients with COPD undergoing coronary artery bypass grafting. METHODS: A total of 388 consecutive patients with COPD who underwent isolated coronary artery bypass grafting were studied, and clinical follow-up was completed. Diagnosis of COPD was based on preoperative forced expiration volume; exacerbation episodes were defined as a pulsed-dose prescription of prednisolone or a hospital admission for an exacerbation. Two propensity-matched cohorts of 104 patients each either receiving or not receiving ß-blockers were identified. RESULTS: At baseline, there was no significant difference among groups. After a median follow-up of 36 months, there were 8 deaths in 104 patients (7.7%) receiving ß-blockers versus 19 deaths in 104 patients (18.3%) who did not receive ß-blockers (p = 0.03). Kaplan-Meyer analysis showed a survival of 91.8% ± 2.8% for patients taking ß-blockers versus 80.6% ± 4.0% for control subjects (χ(2), 29.4; p = 0.003; hazard ratio, 0.38). In addition, ß-blocker administration did not increase rates of COPD exacerbation, which was experienced by 46 of 104 patients (44.2%) receiving ß-blockers versus 45 of 104 patients (43.3%) not receiving ß-blockers (p = 0.99). CONCLUSIONS: This study showed that in patients with COPD undergoing coronary artery bypass grafting the administration of ß-blockers is safe and significantly improves survival at mid-term follow-up. Further randomized studies are needed to confirm these findings.

Metabolic syndrome affects midterm outcome after coronary artery bypass grafting.

BACKGROUND: Metabolic syndrome (MetS) is frequently associated with coronary artery disease, but data on the impact of MetS on long-term outcome of patients undergoing coronary artery bypass grafting are still lacking. The aim of the present study was to assess the effect of MetS on mortality and morbidity late after coronary artery bypass grafting. METHODS: A total of 1,726 consecutive patients who had elective coronary artery bypass grafting were retrospectively reviewed and clinical follow-up was completed (mean follow-up time, 34.4 months; range, 6 to 79 months). The MetS was diagnosed using the modified Adult Treatment Panel III criteria, and to eliminate covariate differences, a propensity score adjustment was used. Major adverse cerebral and cardiovascular events were investigated, and C-reactive protein levels were assessed both preoperatively, postoperatively, and at follow-up. RESULTS: A total of 798 of 1,726 patients (46.2%) met the diagnostic criteria for MetS. At follow-up, all-cause mortality (7% versus 4.6%; p=0.04), cardiac arrhythmias (35.3% versus 25.2%; p<0.0001), renal failure (12% versus 8.7%; p=0.03), and major adverse cerebral and cardiovascular events (52.4% versus 39.5%; p<0.0001) showed a significantly higher incidence in MetS patients. Variables correlated with late mortality at propensity-adjusted Cox proportional-hazards regression were age (p=0.0008), preoperative left ventricular ejection fraction (p=0.001), preoperative renal failure (p=0.001), and MetS (p=0.006). Higher C-reactive protein levels were found preoperatively (8.6±2.3 versus 5.14±3.1 mg/L; p<0.0001) and both early (71.2±9 versus 49.6±8.7 mg/L; p<0.0001) and late (7.4±2.7 versus 4.8±2.5 mg/L; p<0.0001) after surgery. CONCLUSIONS: The main finding of our study was the association between MetS and mortality both early and late after coronary artery bypass grafting. Thus, MetS should be recognized as an independent preoperative variable that can lead to the identification of high-risk patients and as a risk factor to correct with lifestyle modifications and pharmacologic therapy.

How to ensure a good flow to the arm during direct axillary artery cannulation.

We herein describe a simple and safe technique to avoid compartment syndrome/arm ischemia during direct right axillary artery cannulation, especially in patients who require long-term extracorporeal membrane oxygenation support.