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PURPOSE: We aim to quantify multiaxial cardiac pulsatility-induced deformation of the thoracic aorta after ascending thoracic endovascular aortic repair (TEVAR) as a part of the GORE ARISE Early Feasibility Study. MATERIALS AND METHODS: Fifteen patients (7 females and 8 males, age 73±9 years) with ascending TEVAR underwent computed tomography angiography with retrospective cardiac gating. Geometric modeling of the thoracic aorta was performed; geometric features including axial length, effective diameter, and centerline, inner surface, and outer surface curvatures were quantified for systole and diastole; and pulsatile deformations were calculated for the ascending aorta, arch, and descending aorta. RESULTS: From diastole to systole, the ascending endograft exhibited straightening of the centerline (0.224±0.039 to 0.217±0.039 cm-1, p<0.05) and outer surface (0.181±0.028 to 0.177±0.029 cm-1, p<0.05) curvatures. No significant changes were observed for inner surface curvature, diameter, or axial length in the ascending endograft. The aortic arch did not exhibit any significant deformation in axial length, diameter, or curvature. The descending aorta exhibited small but significant expansion of effective diameter from 2.59±0.46 to 2.63±0.44 cm (p<0.05). CONCLUSION: Compared with the native ascending aorta (from prior literature), ascending TEVAR damps axial and bending pulsatile deformations of the ascending aorta similar to how descending TEVAR damps descending aortic deformations, while diametric deformations are damped to a greater extent. Downstream diametric and bending pulsatility of the native descending aorta was muted compared with that in patients without ascending TEVAR (from prior literature). Deformation data from this study can be used to evaluate the mechanical durability of ascending aortic devices and inform physicians about the downstream effects of ascending TEVAR to help predict remodeling and guide future interventional strategies. CLINICAL IMPACT: This study quantified local deformations of both stented ascending and native descending aortas to reveal the biomechanical impact of ascending TEVAR on the entire thoracic aorta, and reported that the ascending TEVAR muted cardiac-induced deformation of the stented ascending aorta and native descending aorta. Understanding of in vivo deformations of the stented ascending aorta, aortic arch and descending aorta can inform physicians about the downstream effects of ascending TEVAR. Notable reduction of compliance may lead to cardiac remodeling and long-term systemic complications. This is the first report which included dedicated deformation data regarding ascending aortic endograft from clinical trial.
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BACKGROUND: Operative mortality for type A aortic dissection is still 10-20% at centers of excellence. Additionally, 10-20% are not considered as viable candidates for open surgical repair and not offered life-saving emergency surgery. ARISE is a multicenter investigation evaluating the novel GORE® Ascending Stent Graft (ASG; Flagstaff, AZ). OBJECTIVE: The purpose of this study is to assess early feasibility of using these investigational devices to treat ascending aortic dissection. METHODS: This a prospective, multicenter, non-randomized, single-arm study that enrolls patients at high surgical risk with appropriate anatomical requirements based on computed tomography imaging at 7 of 9 US sites. Devices are delivered transfemorally under fluoroscopic guidance. Primary endpoint is all-cause mortality at 30 days. Secondary endpoints include major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days, 6 months, and 12 months. RESULTS: Nineteen patients were enrolled with a mean age of 75.7 years (range 47-91) and 11 (57.9%) were female. Ten (52.6%) had DeBakey type I disease, and the rest were type II. Sixteen (84.2%) of the patients were acute. Patients were treated with safe access, (7/19 (36.8%) percutaneous, 10/19 (52.6%) transfemoral, 2/19 (10.5%) iliac conduit), delivery, and deployment completed in all cases. Median procedure time was 154 mins (range 52-392) and median contrast used was 111 mL (range 75-200). MACCE at 30 days occurred in 5 patients including mortality 3/19 (15.8%), disabling stroke in 1/19 (5.3%), and myocardial infarction in 1/19 (5.3%). CONCLUSION: Results from the ARISE early feasibility study of a specific ascending stent graft device to treat ascending aortic dissection are promising.
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Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Disección de la Aorta Ascendente , Procedimientos Endovasculares , Humanos , Femenino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Masculino , Prótesis Vascular , Estudios Prospectivos , Resultado del Tratamiento , Diseño de Prótesis , Stents , Complicaciones Posoperatorias/etiología , Aneurisma de la Aorta Torácica/cirugíaRESUMEN
PURPOSE: Patients with complicated ascending aortic pathology, including patients with acute type A aortic dissection may be at extreme risk for open repair. Thoracic endovascular aortic repair (TEVAR), infrequently used for the ascending aorta, may be considered an alternative in this setting. We describe early results for emergency and compassionate (E&C) use of a novel endograft, specifically designed for use to treat pathology of the ascending aorta. MATERIALS AND METHODS: This case series evaluated 19 patients (mean age, 68.84±13.12 years; 57.9% female) treated with ascending TEVAR for acute and chronic acute (4), subacute (1), or chronic (1) aortic dissection or pseudoaneurysm (13). Six of the 19 patients (31.5%) were treated under compassionate use and 13 patients (68.4%) were treated under the emergency use exemption. Ten patients (52.6%) received additional devices to extend treatment into the arch and descending aorta. RESULTS: Device delivery was achieved in all patients (100%). Thirty-day mortality and stroke occurred in 3 patients (15.8%) and in 1 patient (5.3%), respectively. In 1 patient (5.3%), with an Unanticipated Adverse Device Event, the aorta ruptured when the endograft eroded into the adventitial portion of dissection site at the posterior aspect of the ascending wall. Devices were explanted in 2 patients (10.5%), 353 and 610 days after the index procedure, respectively. Six patients had endoleaks (31.6%), including type I (n=2, 10.5%), type II endoleaks (n=3, 15.8%), and indeterminate endoleak (n=1, 5.3%). CONCLUSIONS: Delivery and deployment of a novel ascending thoracic stent graft with or without an additional branched arch extension is feasible in patients with complex anatomy and pathology, including acute aortic dissection and pseudoaneurysm. Additional experience with this novel device will further refine the patient population most suitable for endovascular ascending aortic repair for these pathologies. CLINICAL IMPACT: This study describes a novel stent graft specifically designed for treatment of ascending aortic pathology, including acute type A dissection. The patients described in this series constituted a group outside the formal US FDA sponsored clinical trial, and were those accepted as part of an emergency and compassionate use basis.
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Aortic dilation is common in patients with congenital heart disease including those with a bicuspid aortic valve, connective tissue disease, coarctation of the aorta, and conotruncal defects. In addition, neo-aortic dilation has been described in patients after aortic reconstruction including the Norwood procedure, the arterial switch operation, and the Ross procedure. Although aortic catastrophe is rare in patients with congenital heart disease, common pathologic endpoints in these patients likely manifest with similar aortic tissue behavior. A lifelong care model with similar indications for surveillance and prophylactic repair to other more common aortopathies is therefore warranted. Still, reoperative aortic arch reconstruction in these patients is often a complex and high-risk endeavor, and in all cases, a tailored and adaptable plan ensuring adequate myocardial and cerebral protection with appropriate rescue measures is paramount. A surgical team taking on these challenging cases should possess an armamentarium of open, hybrid, and endovascular techniques which can be individualized to a patient's unique anatomy, surgical history, and concomitant lesions as well as the team's measured outcomes and experience.
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Coartación Aórtica , Enfermedades de la Aorta , Procedimientos Endovasculares , Cardiopatías Congénitas , Enfermedades de las Válvulas Cardíacas , Humanos , Aorta Torácica/cirugía , Aorta Torácica/anomalías , Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/complicaciones , Enfermedades de las Válvulas Cardíacas/cirugía , Cardiopatías Congénitas/cirugía , Coartación Aórtica/cirugía , Enfermedades de la Aorta/complicaciones , Enfermedades de la Aorta/cirugíaRESUMEN
BACKGROUND: The implications of left ventricular remodeling and dysfunction before and after aortic valve replacement (AVR) for mixed aortic valve disease (MAVD) are not well understood. This study aims to evaluate the impact of AVR on left ventricular (LV) systolic function in MAVD, and determine the prognostic value of postoperative LV global longitudinal strain (LV-GLS) and LV ejection fraction (LVEF). METHODS: We retrospectively assessed 489 consecutive patients with MAVD (defined as at least moderate aortic stenosis and at least moderate aortic regurgitation) and baseline LVEF ≥50%, who underwent AVR between February 2003 and August 2018. All patients had baseline echocardiography, whereas 192 patients underwent postoperative echocardiography between 3 and 18 months after AVR. The primary endpoint was all-cause mortality. RESULTS: Mean age was 65 ± 15 years, and 65% were male. AVR in MAVD patients has a neutral effect on LV systolic function quantitated by LVEF and LV-GLS. During a median follow-up period of 5.8 years, 65 patients (34%) of 192 patients with follow-up echocardiography died. The patients with postoperative LVEF ≥50% had better survival than those with postoperative LVEF <50% (P < .001). Furthermore, among patients with postoperative LVEF ≥50%, mortality differed between patients with postoperative LV-GLS worse than -15% and those with postoperative LV-GLS better than -15% (P < .001). CONCLUSIONS: In patients with MAVD who underwent AVR, the mean postoperative LV-GLS and LVEF remain at a similar value to baseline. However, worse postoperative LV-GLS and LVEF were both independently associated with higher mortality in this population.
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Estenosis de la Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Disfunción Ventricular Izquierda , Humanos , Masculino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Femenino , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Pronóstico , Estudios Retrospectivos , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Disfunción Ventricular Izquierda/complicaciones , Disfunción Ventricular Izquierda/diagnóstico por imagen , Función Ventricular Izquierda , Volumen SistólicoRESUMEN
OBJECTIVE: Limited data exists on management and outcomes of patients presenting with type A aortic dissection (TAAD) and acute lower extremity ischemia (ALI). The role of limb-related revascularization and optimal treatment strategy remains undefined. The objective of this study was to analyze dissection characteristics, treatment modalities, and outcomes of patients undergoing proximal aortic repair for TAAD with ALI. METHODS: Consecutive patients who underwent proximal aortic repair for TAAD were identified from a prospectively maintained database. Clinical data, imaging, operative details, and outcomes of patients with TAAD and ALI were retrospectively analyzed. Kaplan-Meier methodology was used to estimate overall and amputation-free survival. Log-rank tests were used to compare overall curves. Predictors of revascularization and in-hospital mortality were determined using multivariable logistic regression analysis. RESULTS: From 2010 to 2018, 463 patients with TAAD underwent proximal aortic repair. A total of 81 patients (17%) presented with ALI; 48% (39/81) with isolated ALI, and 52% (42/81) with ALI and renovisceral malperfusion. Thirty percent (24/81) required revascularization in addition to proximal aortic repair. Revascularization strategies involved endovascular (46%; 11/24), open (33%; 8/24), and hybrid (21%; 5/24) interventions. The major amputation rate was 4% (3/81), and in-hospital mortality was 21% (17/81). Amputation-free survival was significantly lower in patients requiring revascularization compared with those who did not (log-rank P = .023). Overall survival did not significantly differ between the two groups (log-rank P = .095). Overall survival was significantly lower in patients with concomitant ALI and renovisceral malperfusion compared with those with isolated ALI (log-rank P = .0017). Distal extent of dissection flap into zone 11 (odds ratio [OR], 5.65; 95% confidence interval [CI], 1.58-20.2; P = .008) and partial/complete thrombosis of any iliac artery (OR, 3.94; 95% CI, 1.23-12.6; P = .021) were associated with increased risk of requiring an additional revascularization procedure. True lumen collapse at level of renovisceral aorta (OR, 8.84; 95% CI, 1.74-44.9; P = .0086) was associated with increased risk of in-hospital mortality. CONCLUSIONS: ALI resolves after proximal aortic repair of TAAD in most cases. Distal extent of aortic dissection into zone 11 and iliac thrombosis are risk factors for additional peripheral revascularization. True lumen collapse at the renovisceral aorta and TAAD with concomitant ALI and renovisceral malperfusion portends a poor prognosis. A multi-disciplinary team approach to manage these patients who present with ascending aortic dissection and distal malperfusion may improve outcomes in this complex population.
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Aneurisma de la Aorta Torácica/complicaciones , Disección Aórtica/complicaciones , Procedimientos Endovasculares/métodos , Isquemia/etiología , Extremidad Inferior/irrigación sanguínea , Enfermedad Aguda , Disección Aórtica/diagnóstico , Disección Aórtica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico , Aneurisma de la Aorta Torácica/cirugía , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Isquemia/epidemiología , Isquemia/cirugía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: Racial disparities in cardiovascular risk factors and disease outcomes have been well documented. A knowledge gap exists regarding the role that health maintenance plays in the development and outcomes of type B aortic dissection (TBAD). In the present study, we evaluated the comparative presentation and short-term outcomes of patients with TBAD across race. METHODS: In the present single-center, retrospective study, TBAD patients who had been admitted to the intensive care unit from 2015 to 2020 were identified. Patients who had self-identified as Black (n = 57) or White (n = 123) were included. The demographics, socioeconomic status, and pre-event health maintenance were compared between the two groups. Socioeconomic disadvantage was quantified using the area deprivation index (ADI). Management strategies included nonoperative and surgical repair. The outcomes assessed included 30-day mortality, hospital length of stay, and the APACHE II (acute physiology and chronic health evaluation) score. RESULTS: The present study included 180 consecutive patients with TBAD. TBAD included complicated (n = 42) and uncomplicated (n = 138) cases, of which 79 had had high-risk features. Black patients were younger than were White patients (58.9 vs 67.6 years; P < .01) and were more likely to have end-stage renal disease (8.8% vs 0.8%; P = .01) and to present with anemia (10.5% vs 2.4%; P = .03). The TBAD anatomic features and management were similar in both groups. The rate of surgical intervention during hospitalization was 40% and 46% for the Black and White patients, respectively (P = .4). Black patients were more likely to be taking three or more hypertension agents (42.2% vs 16.4%; P = .005) and were less likely to be adherent to taking the prescribed agents (27.1% vs 6.7%; P < .001). Also, Black patients had fewer primary care physician visits before TBAD (P = .03) and more emergency department usage before TBAD (57.9% vs 26.9%; P < .001). Black patients had also had higher ADI scores (86.0 ± 14.6 vs 64.4 ± 21.3; P < .001). The median APACHE II score was the same for both Black and White patients (9 [interquartile range (IQR), 6-12] and 9 [IQR, 7-13], respectively; P = .7). The median hospital length of stay was identical for both groups (7 days; IQR, 5-13 days). The readmission rate was 24.5% for Black patients vs 15.5% for White patients (P = .16), with the 30-day mortality similar between the two groups (Black, 7.0%; White, 5.7%; P = .7). CONCLUSIONS: Black patients had presented at a younger age but with similar dissection morphology, rate of anatomic high-risk features, and APACHE II scores. The fewer primary care physician visits, greater emergency department usage, and higher ADI scores suggested lower health maintenance for the Black patients. White patients with TBAD were also highly deprived of health maintenance compared with the national percentile, indicating that TBAD is a disease that affects vulnerable populations, regardless of race.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Disección Aórtica/complicaciones , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/terapia , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Humanos , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: In the present review, we discuss the role of CT imaging in the management of aortic dissection, with a particular emphasis on endovascular treatment considerations. RECENT FINDINGS: Computed tomography imaging is a fundamental tool in the diagnosis and management of acute and chronic aortic dissection. Its diagnostic accuracy and high resolution contribute to and guide operative strategy. Persistent high mortality for patients who develop aortic dissections suggests a need for innovative diagnostic and treatment strategies. In the recent era, considerable advances have been made in computed tomography (CT) image acquisition, processing, and analysis as well as endovascular technologies with expanded roles in the treatment of aortic diseases.
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Enfermedades de la Aorta , Disección Aórtica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Aorta Torácica/cirugía , Humanos , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: Pregnancy-associated myocardial infarction is a principal cause of cardiovascular disease with a steadily rising incidence of 4.98 AMI events/100,000 deliveries over the last four decades in the USA. It is also linked with significant maternal and fetal morbidity and mortality, with maternal case fatality rate ranging from 5.1 to 37%. The management of acute myocardial infarction can be challenging in pregnant patients since treatment modalities and medication use are limited by their safety during pregnancy. RECENT FINDINGS: Limited guidelines exist regarding the management of pregnancy-associated myocardial infarction. Routinely used medications in myocardial infarction including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and statin therapy are contraindicated during pregnancy. Aspirin use is considered safe in pregnant women, but dual antiplatelet therapy and therapeutic anticoagulation can be associated with increased risk of maternal and fetal complications, and should only be used after a comprehensive benefit-to-risk assessment. The standard approach to revascularization requires additional caution in pregnant women. Percutaneous coronary intervention is generally considered safe but can be associated with high failure rates and poor outcomes depending on the etiology. Fibrinolytic therapy may have significant sequelae in pregnant patients, and hemodynamic management during surgery is complex and adds risk during pregnancy. Understanding the risks and benefits of the different treatment modalities available and their utility depending on the underlying etiology, encompassed with a multidisciplinary team approach, is vital to improve outcomes and minimize maternal and fetal complications.
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Infarto del Miocardio , Intervención Coronaria Percutánea , Antagonistas de Receptores de Angiotensina , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Femenino , Humanos , Incidencia , Infarto del Miocardio/terapia , EmbarazoRESUMEN
BACKGROUND: Clostridium septicum is an anaerobic, motile, spore-forming, toxin-producing gram-positive bacillus that can lead to rapidly progressive gas gangrene due to the release of alpha toxin. Aortic aneurysm secondary to C. septicum infection is a rare condition with 60 cases reported in the literature; however, we have recently treated several patients with the condition in our large tertiary care and aortic center. METHODS: Blood and tissue culture results collected between January 2005 and January 2018 and maintained in the microbiology laboratory database at the Cleveland Clinic were reviewed to identify those with C. septicum reported. Each was reviewed to determine radiographic or histopathologic correlation with aortic disease. RESULTS: Seven cases of C. septicum aortitis were reviewed. Underlying malignant disease was found in four cases and a history of remote malignant disease in one case. The most common location for infection was the infrarenal abdominal aorta. Vascular surgery had previously been performed in three of the cases. Five of the seven patients underwent operative repair. All patients were treated with ß-lactam antibiotics. The two patients who did not undergo an operation died, which is consistent with the 100% mortality described in the literature. Of the five patients who underwent an operation, there was only one documented survivor and one was lost to follow-up. CONCLUSIONS: In the largest reported case series, only a small percentage of patients with C. septicum-infected aortic aneurysms survived >1 year. In the patients described, those who did not receive an operation had 100% mortality. Earlier recognition and prompt operation with appropriate antimicrobial therapy are needed to improve the outcome of patients diagnosed with this rare infection.
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Aneurisma Infectado/microbiología , Aneurisma de la Aorta/microbiología , Clostridium septicum , Gangrena Gaseosa/microbiología , Infecciones Relacionadas con Prótesis/microbiología , Aneurisma Infectado/mortalidad , Aneurisma Infectado/terapia , Aneurisma de la Aorta/mortalidad , Aneurisma de la Aorta/terapia , Gangrena Gaseosa/mortalidad , Gangrena Gaseosa/terapia , Humanos , Infecciones Relacionadas con Prótesis/mortalidad , Infecciones Relacionadas con Prótesis/terapia , Tasa de SupervivenciaRESUMEN
BACKGROUND: Little is known about graft patency after coronary artery bypass grafting (CABG) performed in patients on dialysis. Our aim was to assess patency of internal thoracic artery (ITA) grafts and saphenous vein grafts (SVGs) in these patients. METHODS: From 1/1997 to 1/2018, 500 patients on dialysis underwent primary CABG with or without concomitant procedures at Cleveland Clinic, 40 of whom had 48 postoperative angiograms for recurrent ischemic symptoms. Complete follow-up was obtained on all but 1 patient lost to follow-up 1 y after CABG. Thirty-six ITA grafts and 65 SVGs were evaluable for stenosis and occlusion. RESULTS: Two of 40 patients (5%) had emergency CABG; 3 (7.5%) with calcified aortas had a change in operative strategy to avoid ascending aortic manipulation, 2 (5%) had poor conduit quality, and 12 (30%) had severe diffuse atherosclerotic disease with calcification of the coronary targets causing technical difficulties. Thirty-three patients (82%) were bypassed with an in situ ITA and 3 (7.5%) had a free ITA graft. Three of 36 ITA grafts were occluded at 0.78, 1.8, and 9.4 y (too few to model). SVG patency was 52% and 37% at 1 and 2 y, respectively. CONCLUSIONS: Among patients on dialysis who underwent CABG, coronary angiography for ischemic symptoms in a select subset revealed that SVG patency was lower than expected from published reports in the general CABG population and may contribute to the poor prognosis of this cohort. Further work is needed to guide graft selection and improve graft patency in dialysis patients.
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Puente de Arteria Coronaria , Enfermedad Coronaria/cirugía , Supervivencia de Injerto , Fallo Renal Crónico/complicaciones , Diálisis Renal , Grado de Desobstrucción Vascular , Anciano , Enfermedad Coronaria/complicaciones , Enfermedad Coronaria/mortalidad , Femenino , Humanos , Fallo Renal Crónico/terapia , Masculino , Arterias Mamarias/trasplante , Persona de Mediana Edad , Vena Safena/trasplante , Resultado del TratamientoRESUMEN
Coronary subclavian steal syndrome (CSSS) is a rare cause of angina. It occurs in patients with prior coronary artery bypass grafting and, specifically, a left internal mammary artery (LIMA) to left anterior descending artery (LAD) graft and co-existent significant subclavian artery stenosis. In this context, there is retrograde blood flow through the LIMA to LAD graft to supply the subclavian artery beyond the significant stenosis. This potentially occurs at the cost of compromising coronary artery perfusion dependent on the LIMA graft. In this review, we present a case of a middle-aged female who suffered from CSSS and review the literature for the contemporary diagnosis and management of this condition.
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Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/complicaciones , Síndrome de Robo Coronario-Subclavio/etiología , Anastomosis Interna Mamario-Coronaria/efectos adversos , Síndrome del Robo de la Subclavia/complicaciones , Angina de Pecho/etiología , Angiografía por Tomografía Computarizada , Enfermedad de la Arteria Coronaria/cirugía , Electrocardiografía , Femenino , Humanos , Persona de Mediana EdadRESUMEN
BACKGROUND: Data on testosterone replacement therapy and cardiovascular outcomes are conflicting, with the Food and Drug Administration requiring prescription testosterone preparations to indicate a possible increased cardiovascular risk. Whether patients on testosterone replacement therapy undergoing cardiac surgery have an increased risk of postoperative in-hospital mortality and cardiovascular events remains unknown. We therefore sought to identify the impact of testosterone replacement on the incidence of a composite of postoperative in-hospital mortality and cardiovascular events in men undergoing cardiac surgery. METHODS: After institutional review board approval, data from male American Society of Anesthesiologists III/IV patients ≥40 years of age who underwent cardiac surgery between May 2005 and March 2017 at the Cleveland Clinic (Cleveland, OH) main campus were included. The primary exposure was preoperative testosterone use. The primary outcome was a collapsed composite of postoperative in-hospital mortality and cardiovascular events, including myocardial infarction, stroke, and pulmonary embolism. The secondary outcome was a collapsed composite of minor cardiovascular events, including postoperative rhythm disturbance requiring permanent device, atrial fibrillation, and deep venous thrombosis. We compared patients who received testosterone and those who did not, using propensity score matching within surgical procedure matches. Moreover, as a sensitivity analysis, we used a multivariable logistic regression model to assess the association between testosterone replacement therapy and major or minor cardiovascular events adjusted for potential baseline and intraoperative confounders by including all eligible patients. RESULTS: Among 20,604 patients who met inclusion and exclusion criteria, 301 patients who used testosterone routinely within 1 month before the surgery were matched to 1505 of 20,303 patients who did not use testosterone. Among the matched cohort, 8 (2.7%) patients in the testosterone group and 45 (3.0%) in the nontestosterone group had ≥1 major cardiovascular adverse event after surgery. The adjusted odds ratio was 0.89 (95% CI, 0.41-1.90; P = .756), comparing testosterone to nontestosterone patients. As for the secondary outcomes, 89 (30%) patients in the testosterone group and 525 (35%) patients in the nontestosterone group had ≥1 minor cardiovascular event. The odds of minor events were not significantly different, with an odds ratio of 0.78 (95% CI, 0.60-1.02; P = .074) comparing testosterone to nontestosterone patients. CONCLUSIONS: Preoperative testosterone is not associated with a statistically significant increased incidence of a composite of postoperative in-hospital mortality and cardiovascular events after cardiac surgery.
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Procedimientos Quirúrgicos Cardíacos/métodos , Enfermedades Cardiovasculares/epidemiología , Terapia de Reemplazo de Hormonas/efectos adversos , Complicaciones Posoperatorias/epidemiología , Testosterona/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Enfermedades Cardiovasculares/mortalidad , Estudios de Cohortes , Mortalidad Hospitalaria , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Puntaje de Propensión , Estudios Prospectivos , Testosterona/uso terapéutico , Resultado del TratamientoRESUMEN
INTRODUCTION: Sutureless biological valves for surgical aortic valve replacement (SAVR), characterized by the absence of anchoring sutures at the aortic annulus, are gaining popularity because of ease and reproducibility of implant, shorter operating times, and enhancement of minimally invasive approaches. The stentless configuration of the sutureless valve was designed to achieve optimal hemodynamic performance. MATERIALS AND METHODS: PERSIST-AVR (PERceval Sutureless Implant versus STandard Aortic Valve Replacement) is a prospective, randomized, adaptive, open-label, international, postmarket trial (NCT02673697). The primary objective of the trial is to assess the safety and efficacy of the Perceval (LivaNova, London, UK) sutureless bioprosthesis among patients undergoing SAVR in the presence of severe aortic stenosis to demonstrate the noninferiority of Perceval as compared with standard sutured stented bioprosthetic aortic valve as an isolated procedure or combined with coronary artery bypass grafting. Sample size will be determined adaptively through interim analyses performed by an Independent Statistical Unit till a maximum of 1,234 patients, enrolled at â¼60 sites in countries where the device is commercially available. Patients will be followed up for 5 years after implant. The primary end point is the number of patients free from major adverse cardiac and cerebrovascular-related events at 1 year. Additional secondary outcomes will be assessed up to 5 years. DISCUSSION: PERSIST-AVR is the first prospective, randomized study comparing in-hospital and postdischarge outcomes in a robust population of patients undergoing SAVR with either the Perceval sutureless bioprosthesis or a conventional sutured stented bioprosthesis up to 5 years.
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Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Stents , Procedimientos Quirúrgicos sin Sutura/instrumentación , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Hemodinámica , Humanos , Vigilancia de Productos Comercializados , Estudios Prospectivos , Diseño de Prótesis , Recuperación de la Función , Índice de Severidad de la Enfermedad , Procedimientos Quirúrgicos sin Sutura/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
A woman had shortness of breath and a first-degree relative with a history of ascending aorta dissection. Imaging showed an isolated dilatation in the mid ascending aorta and a bicuspid aortic valve but no pulmonary infiltrates, effusion, or embolism and no aortic stenosis or regurgitation. What would you do next?
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Aneurisma de la Aorta Torácica , Enfermedad de la Válvula Aórtica Bicúspide , Adulto , Humanos , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/complicaciones , Válvula Aórtica/anomalías , Válvula Aórtica/diagnóstico por imagen , Enfermedad de la Válvula Aórtica Bicúspide/complicaciones , Enfermedad de la Válvula Aórtica Bicúspide/diagnóstico por imagen , Hallazgos Incidentales , Tomografía Computarizada por Rayos X , Femenino , EcocardiografíaRESUMEN
We report the repair of a 6.5 × 5.3-cm left main coronary artery aneurysm by marsupialization of the aneurysm sac and coronary artery bypass grafting.
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Procedimientos Quirúrgicos Cardiovasculares/métodos , Aneurisma Coronario/cirugía , Puente de Arteria Coronaria/métodos , Vasos Coronarios/cirugía , Anciano , Aneurisma Coronario/diagnóstico por imagen , Angiografía Coronaria , Femenino , Humanos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: In patients with a dilated proximal ascending aorta and trileaflet aortic valve, we aimed to assess (1) factors independently associated with increased long-term mortality and (2) the incremental prognostic utility of indexing aortic root to patient height. METHODS: We studied consecutive patients with a dilated aortic root (≥4 cm) that underwent echocardiography and gated contrast-enhanced thoracic aortic computed tomography or magnetic resonance angiography between 2003 and 2007. A ratio of aortic root area over height was calculated (cm2/m) on tomography, and a cutoff of 10 cm2/m was chosen as abnormal, on the basis of previous reports. All-cause death was recorded. RESULTS: The cohort comprised 771 patients (63 years [interquartile range, 53-71], 87% men, 85% hypertension, 51% hyperlipidemia, 56% smokers). Inherited aortopathies, moderate to severe aortic regurgitation, and severe aortic stenosis were seen in 7%, 18%, and 2%, whereas 91% and 54% were on ß-blockers and angiotensin-converting enzyme inhibitors, respectively. Aortic root area/height ratio was ≥10 cm2/m in 24%. The Society of Thoracic Surgeons score and right ventricular systolic pressure were 3.3±3 and 31±7 mm Hg, respectively. At 7.8 years (interquartile range, 6.6-8.9), 280 (36%) patients underwent aortic surgery (76% within 1 year) and 130 (17%) died (1% in-hospital postoperative mortality). A lower proportion of patients in the surgical (versus nonsurgical) group died (13% versus 19%, P<0.01). On multivariable Cox proportional hazard analysis, aortic root area/height ratio (hazard ratio, 4.04; 95% confidence interval [CI], 2.69-6.231) was associated with death, whereas aortic surgery (hazard ratio, 0.47; 95% CI, 0.27-0.81) was associated with improved survival (both P<0.01). For longer-term mortality, the addition of aortic root area/height ratio ≥10 cm2/m to a clinical model (Society of Thoracic Surgeons score, inherited aortopathies, hypertension, hyperlipidemia, medications, aortic regurgitation, and right ventricular systolic pressure), increased the c-statistic from 0.57 (95% CI, 0.35-0.77) to 0.65 (95% CI, 0.52-0.73) and net reclassification index from 0.17 (95% CI, 0.02-0.31) to 0.23 (95% CI, 0.04-0.34), both P<0.01. Of the 327 patients with aortic root diameter between 4.5 and 5.5 cm, 44% had an abnormal aortic root area/height ratio, of which 78% died. CONCLUSIONS: In patients with dilated aortic root and trileaflet aortic valve, a ratio of aortic root area to height provides independent and improved stratification for prediction of death.
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Aorta/anomalías , Válvula Aórtica/anomalías , Anciano , Aorta/diagnóstico por imagen , Aorta/cirugía , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Estudios de Cohortes , Ecocardiografía/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de RiesgoRESUMEN
OBJECTIVE: Long-term data regarding the safety and durability of thoracic endovascular aortic repair (TEVAR) are limited. The study objective was to evaluate the long-term outcomes of TEVAR in high-risk patients with descending thoracic aortic pathology. METHODS: High-risk patients were treated with thoracic endografts (2001-2011) under a prospective, physician-sponsored, investigational device exemption trial. Three-dimensional reconstructions and measurements were performed on computed tomography scans acquired before discharge, at 1, 6, and 12 months, and then yearly thereafter. RESULTS: The study included 200 patients, of whom 171 were treated for thoracic aneurysm, 28 for chronic dissection, and 1 for aortobronchial fistula. Patients were monitored for an average of 4.8 ± 3.3 years, and 93 (46.5%) were monitored for >5 years. Operative mortality was 6.5%. Survival at 30 days and at 1, 5, and 9 years was 94.0%, 85.8%, 55.6%, and 31.4%, and freedom from aneurysm-related death was 94.0%, 92.4%, 91.7%, 91.7%, respectively. Sixty-one endoleaks occurred in 54 patients (28%). Sixty-seven reinterventions were performed in 50 patients. Overall freedom from reintervention at 30 days, 1, 5, and 9 years was 87.9%, 82.9%, 75.5%, and 64.0%, respectively. Forty-seven reinterventions (70%) were thoracic aneurysm-related, 35 (74%) of which were endovascular procedures. Thirty of these were to correct endoleaks at a median of 1.4 years (interquartile range, 0.2-5.0 years). CONCLUSIONS: TEVAR is durable and associated with high long-term aneurysm-related survival. Long-term imaging follow-up remains critical to identify endoleaks or rare device durability issues, most of which can be monitored or managed with endovascular therapies.
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Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Stents , Anciano , Aorta Torácica/diagnóstico por imagen , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/mortalidad , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Angiografía por Tomografía Computarizada , Supervivencia sin Enfermedad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Imagenología Tridimensional , Estimación de Kaplan-Meier , Masculino , Ohio , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Estudios Prospectivos , Diseño de Prótesis , Interpretación de Imagen Radiográfica Asistida por Computador , Retratamiento , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: The need for permanent pacemaker implantation (PCM) following surgical aortic valve replacement (SAVR) is uncommon but can lead to increased hospital resource utilization. Using nationwide data, we sought to (1) identify hospital, patient, and procedure-level risk factors for PCM after SAVR and (2) determine incremental resource utilization. METHODS: We identified 659,692 patients from the Nationwide Inpatient Sample database who underwent SAVR with or without coronary artery bypass grafting (CABG), mitral valvuloplasty (MVr), or mitral valve replacement (MVR) between 1998 and 2009. Patients with pre-existing pacemakers, a concomitant Maze procedure, or endocarditis were excluded. Multivariable regression analysis and propensity matching were used for comparisons of outcomes and costs. RESULTS: Overall prevalence of PCM was 5.1% (n = 34,020; SAVR alone, 4.8%; SAVR + CABG, 4.6%; SAVR + MVr, 7.7%; SAVR + MVR, 10%). Important risk factors for PCM after SAVR were coexisting comorbidities, older age, and addition of mitral valve surgery. Hospital volume and teaching status, location, race, and sex were not associated with PCM. Among matched pairs, patients requiring PCM had lower in-hospital mortality (3.1% vs. 6.4%, p < 0.001) but longer median length of stay (12 vs. 9 days, p < 0.001) and higher hospital costs ($50,000 vs. $37,000, p < 0.001), and they were less likely to be discharged home (33% vs. 36%, p < 0.001). Factors associated with later PCM (postoperative day ≥6) included SAVR + MVR, female sex, fewer comorbidities, northeastern region, and higher hospital volume. Median hospital costs were greater ($57,000 vs. $48,000, p < 0.001) among patients whose pacemakers were implanted later. CONCLUSIONS: PCM following SAVR is associated with lower hospital mortality, but increased cost and length of stay. doi: 10.1111/jocs.12769 (J Card Surg 2016;31:476-485).