Freestyle aortic root bioprosthesis is a suitable alternative for aortic root replacement in elderly patients: a propensity score study.

BACKGROUND: The aim of this retrospective study was to compare the early and midterm clinical outcomes of aortic root replacement in elderly patients receiving the Freestyle stentless bioprosthesis (FSB) (Medtronic Inc, Minneapolis, MN) with younger patients receiving a mechanical valve conduit. METHODS: From January 2001 to December 2010, 185 consecutive patients underwent aortic root replacement. Of these, 79 (43%) patients received the Freestyle bioroot (Medtronic Inc, Minneapolis, MN) (group F) and 106 (57%) patients received a mechanical valve conduit (group M). Target endpoints were 30-day mortality, 5-year survival, 5-year freedom from cardiac death, and 5-year freedom from major adverse valve-related and cardiovascular events (MAVCE) (cardiac death, cerebrovascular accident, myocardial infarction, heart failure, valve prosthesis dysfunction requiring reoperation, and thromboembolic and hemorrhagic events). A propensity score model was built to adjust the results according to preoperative and operative characteristics of both groups. RESULTS: Thirty-day mortality was similar in both groups (F group, 2.5% versus M group, 5.7%; p=0.407). Unadjusted analysis showed no differences between groups, whereas adjusted analysis showed a significantly higher 5-year freedom from cardiac death and MAVCE in group F (group F, 98.6±1.9 versus group M, 88.0%±3.0%; p=0.038; group F, 97.4%±2.6% versus group M, 81.2%±3.6%; p=0.010). Multivariate analysis confirmed a significantly higher risk for 5-year MAVCE in patients who did not undergo implantation with the Freestyle bioprosthesis (hazard ratio [HR], 6.87; 95% confidence limit [CL], 1.43-15.09; p=0.016). CONCLUSIONS: In elderly patients, the FSB seems to be as safe as mechanical composite grafts in the perioperative period but results in superior freedom from MAVCE at 5 years postoperatively.

Embolization of an Amplatzer atrial septal closure device to the pulmonary artery.

A 44-year-old woman with a history of transient ischemic attack underwent closure of atrial septal defect with a 26 mm Amplatzer device. The device was released without residual shunt or impingement on intracardiac structures. Within seconds, the transesophageal echocardiography showed the initial dislodgement of the device from the atrial septum and its consequent slipping back into the right atrium close to the tricuspid valve. Soon after the device disappeared from the right atrium and it could be founded into the right ventricle under the tricuspid valve. The patient was transferred in the operating room for an emergency operation. The device could not be found in the right ventricle because its downstream migration. The Amplatzer septal occluder was identified by palpation into the pulmonary artery trunk: it was retrieved from the right ventricle through the pulmonary valve and the atrial septal defect was closed by running suture.

Effective method to control catastrophic hemorrhage during redo sternotomy.

Redo sternotomy is a challenging surgical procedure performed with increasing frequency; catastrophic hemorrhage is a rare but highly lethal complication. We report our experience in treating this complication in 3 cases of 307 reoperations and propose a simple method to control catastrophic hemorrhage during sternal reentry.

Antegrade cerebral perfusion by axillary artery and left carotid artery inflow at moderate hypothermia.

Cerebral protection during hypothermic circulatory arrest was obtained by combining right carotid perfusion through the axillary artery with selective perfusion of the left common carotid artery in ten patients. We believe that the proposed technique offers several advantages. (1) The axillary artery is generally free from atherosclerosis. (2) It eliminates the risk of retrograde embolization. (3) It provides antegrade perfusion of the true lumen in aortic dissection. (4) Antegrade cerebral perfusion is never interrupted. (5) Bihemispheric perfusion is assured. (6) The risk of air embolysm during carotid cannulation is reduced.