Impact of surgically placed radiopaque markers during aortic root surgery on facilitating secondary diagnostic and therapeutic interventions.

BACKGROUND: Implantation of radiopaque markers during aortic root surgery might possibly facilitate upcoming coronary angiography or transcatheter aortic valve implantation. Aim of this study was to report the impact of surgically placed radiopaque markers on procedural characteristics and on angiographic outcomes. METHODS: We retrospectively analyzed baseline characteristics, preoperative and postoperative data as well as procedural findings. In addition, a subgroup analysis of all patients who underwent coronary angiography after aortic root surgery was performed to report radiation time and contrast media used. RESULTS: A total of 469 patients underwent aortic root surgery between January 2008 and April 2020. Patients were divided into two groups: group w/ markers (n = 182) and group w/o markers (n = 287). A propensity score matching was performed resulting in a total of 28 patients w/ markers and 28 patients w/o markers. Aortic cross-clamp time did not differ statistically significantly between the group w/o markers and the group w/ markers (124.0 [96.0-150.0] versus 123.0 [110.0-149.0] min, p = 0.09). There was no increased probability for requirement of postoperative angiography in the group w/o markers compared to the group w/ markers (11.8% versus 15.4%, p = 0.27). There was no statistically significant difference in the radiation time 5.5 [3-6.5] versus 5 [2.5-7.5] min, p = 0.62) nor in the amount of contrast media used (85 [77.5-100] versus 80 [60-90] ml, p = 0.07). CONCLUSIONS: Surgically placed radiopaque markers during aortic root surgery do not increase operative risk and have the potential for facilitating secondary diagnostic and therapeutic interventions.

The David procedure for quadricuspid aortic valve repair.

Quadricuspid aortic valves are rare but may result in significant aortic regurgitation requiring surgery. To date, valve-sparing root replacement is frequently done in patients with bi- and tricuspid aortic valve pathologies with preserved cusp tissue. Nevertheless, little is known about quadricuspid repair, especially in regard to the optimal surgical technique for long-term durability. We hereby provide a surgical guide to valve-sparing aortic root replacement using the David technique in a young patient with severe aortic regurgitation.

Composition of the surgical team in aortic arch surgery-a risk factor analysis.

OBJECTIVES: The aim of this study was to analyse the influence of varying experiences within each surgical team to identify team-related risk factors on clinical outcomes after total aortic arch replacement. METHODS: Each surgeon was rated from 1 to 5, and a surgical team's score was calculated (operating surgeon + assisting surgeon = team score) by relying on each member's experience. A composite end point (mortality, stroke or spinal cord injury) was defined. RESULTS: Total aortic arch replacement was performed in 264 patients by 19 cardiovascular surgeons. Analysis revealed that the composite end point was attained more frequently when the team score was <7 (n = 23; 29%) than >7 (n = 35; 19%) (P = 0.015). There was a significant difference depending on the surgeon's experience [3 = 23 (35%); 4 = 9 (22%); 5 = 26 (17%); P = 0.008] and whether he was equally experienced (n = 9, 45%) or not as the assisting surgeon (n = 49, 20%; P = 0.015). Logistic regression revealed age >70 years [OR 2.93 (1.52-5.66); P = 0.001], previous stroke [OR 3.02 (1.36-6.70); P = 0.007], acute type A aortic dissection [OR 2.58 (1.08-6.13); P = 0.033], previous acute kidney injury [OR 2.27 (1.01-5.14); P = 0.049] and 2 surgeons with the same experience [OR 4.01 (1.47-10.96); P = 0.007] as predictors for the composite end point. CONCLUSIONS: Total aortic arch replacement is equally safe whether an experienced surgeon carries it out or assists the procedure. A less experienced team may raise the risk for postoperative complications. Our data suggest an association of equally experienced surgeons in a team with worse outcomes than teams possessing different experience levels.

Recannulation of the right axillary artery in reoperative proximal thoracic aortic surgery is safe.

OBJECTIVES: To evaluate the safety and efficacy of recannulating the axillary artery in reoperative proximal thoracic aortic surgery. METHODS: Between 2008 and 2020, we evaluated patients who underwent reoperative proximal thoracic aortic surgery. The patients were divided into 2 groups: (i) patients with no previous right axillary artery cannulation (primary cannulation group) and (ii) patients with a previous cannulated right axillary artery (recannulation group). We analysed the intraoperative data, cannulation-related complications, postoperative outcomes and compared the 2 groups (primary cannulation versus recannulation). RESULTS: The patient (n = 132) baseline characteristics did not differ significantly between the 2 groups. There was no statistically significant difference in regard to the duration of surgery, cardiopulmonary bypass, aortic cross-clamp and antegrade cerebral perfusion time nor in regard to the total number of patients with cannulation-related complications between the 2 groups [n = 8 (8.0%) vs n = 1 (3.1%), P = 0.34]. The incidence of iatrogenic axillary artery dissection, iatrogenic aortic dissection, iatrogenic aortic dissection leading to death, axillary artery thrombosis, need for surgical repair, brachial plexus injury rates, malperfusion, high perfusion resistance and hyperperfusion syndrome revealed no significant difference between the 2 groups (P > 0.05). There were 11 (11.0%) cases of stroke in the primary cannulation group and 1 (3.1%) in the recannulation group (P = 0.18). CONCLUSIONS: Recannulation of the right axillary artery in reoperative proximal thoracic aortic surgery is not associated with worse clinical outcomes and can be safely and effectively performed, also representing a preventive and rescue measure. Previous cannulation of the axillary artery should not hinder the decision for recannulation.

Recurrent Cardiac Constriction after Implantation of an Expanded Polytetrafluoroethylene Surgical Membrane.

One of the challenges compounding the complexity of reoperative cardiac surgery is the surgical adhesion, which can be responsible for adverse intraoperative events. Implantation of a substitute neo-pericardium has become a frequently used solution, with currently rising numbers of reoperations. We report the case of a 38-year-old man who developed recurrent delayed cardiac constriction following the implantation of an expanded polytetrafluoroethylene neo-pericardium. Careful preoperative planning is recommended to plan the optimal method of pericardioplasty, taking into account the pros and cons of each available material.

German Aortic Root Repair Registry-Insights From the First 400 Consecutive Patients.

BACKGROUND: The objective was to provide initial data from our prospective valve-sparing aortic root replacement (V-SARR) registry and reasons for conversion to prosthetic aortic valve replacement. METHODS: Six centers established an intention-to-treat-design V-SARR-registry (the German Aortic Root Repair Registry; first patient in October 2016); the main inclusion criterion was being scheduled for V-SARR as plan A. Clinical information, operative details, intraoperative valve/root measurements, and clinical and transthoracic echocardiography follow-up-data are documented. RESULTS: Of a total of 449 patients, we report data for 401 (81% male; mean age 51 ± 14 years). Overall, 350 patients underwent V-SARR as scheduled, group A (David variants I 55%, III 2%, IV 13%, V 24%, V-Stanford 2%, and Yacoub remodeling 2%); and 51 were converted to aortic valve replacement (group B). Median follow-up was 11 months (range, 0 to 2.6 years), cumulative follow-up was 279 patient-years. In group B, there were fewer connective tissue disorders (6% vs 16%), fewer patients had left ventricular ejection fraction greater than 50% (60% vs 90%), more had bicuspid aortic valves (45% vs 28%), and fewer patients had preoperative none/trace aortic regurgitation (2% vs 20%). Fewer patients in group B had rare types of bicuspid aortic valve (fused N/L, R/N, 10% vs 30%) and more had unbalanced roots (56% vs 40%). Immediate postoperative aortic regurgitation was none/trace in 79% and mild in 20%. At 30 days, the mean transvalvular pressure gradient was 7 ± 5 mm Hg. None of the patients died in hospital; two strokes occurred. One patient needed early aortic valve replacement as redo surgery. CONCLUSIONS: The main factors causing surgeons to convert a planned V-SARR to aortic valve replacement include asymmetry of aortic valve/root, severity of aortic regurgitation, safety reasons (left ventricular ejection fraction), and bicuspid aortic valves (but not rare types). The German Aortic Root Repair Registry will help us identify the impact on long-term outcomes of preoperative and postoperative valvular anatomy and various V-SARR types.

Direct Versus Side Graft Cannulation From the Right Axillary Artery in Thoracic Aortic Surgery.

BACKGROUND: The axillary artery can be cannulated for antegrade cerebral perfusion directly or by employing a prosthetic vascular graft anastomosed to the artery. METHODS: From 2008 until 2019, 688 patients underwent axillary artery cannulation. Of those, 287 underwent direct cannulation and 401 cannulation through a side graft. We identified risk factors for cannulation-related complications, and after propensity score matching, we compared the 2 matched cohorts' cannulation-related and postoperative outcomes. RESULTS: A smaller axillary-artery diameter (odds ratio = 0.70; 95% confidence interval, 0.56-0.87) and emergency surgery (odds ratio = 2.23; 95% confidence interval, 1.27-3.92) were identified as risk factors for cannulation-associated complications. In the propensity score-matched cohorts (n = 266 in each), the number of patients experiencing cannulation-related complications was significantly higher in the direct cannulation group than in the side-graft group (n = 33 [12.4%] versus n = 15 [5.6%]; P = .01). The direct group's incidence of iatrogenic axillary artery dissection was significantly higher (n = 17 [6.4%] versus n = 4 [1.5%] P = .008); their incidence of postoperative stroke was also significantly higher (n = 39 [14.7%] versus n = 21 [7.9%]; P = .025). Patients cannulated with a side graft needed more transfusions of blood products (median [IQR]: 3.0 [1.0-6.0] versus 4.0 [2.0-7.0;] P = .009). CONCLUSIONS: Cannulating the right axillary through a vascular prosthetic graft reduces cannulation-related complications such as iatrogenic axillary artery dissection and lowers stroke rates. To help prevent cannulation-related complications and stroke, we recommend the routine use of a side graft when cannulating the axillary artery.

Valve thrombosis 7 months after transcatheter aortic valve implantation.

A 77-year old man underwent transcatheter aortic valve implantation for severe aortic stenosis with a 29-mm Edwards-Sapien XT aortic valve bioprosthesis. Periprocedural transesophageal echocardiography and computed tomography showed good positioning and expansion of the prosthesis with only minor transvalvular insufficiency. On a routine checkup 7 months later, echocardiography and computed tomography showed a high transvalvular gradient suggestive of valve thrombosis, which could not be treated with warfarin. Because of rapid deterioration of the patient's clinical condition, an urgent surgical valve replacement was performed 4 weeks after initial notice of the valve thrombosis. The patient's postoperative stay was uneventful.