Results of ascending aortic and arch replacement for type A aortic dissection.

OBJECTIVE: The outcomes of emergency surgery for type A acute aortic dissection have improved. However, ascending aortic replacement sometimes leads to dilatation of the distal aorta. The present study reviewed our outcomes of ascending aortic replacement and total arch replacement in patients with type A acute aortic dissection. METHODS: A total of 253 patients with type A acute aortic dissection underwent a central repair operation. Our standard technique was ascending aortic replacement. Total arch replacement was performed only when entry existed in the major curvature of the aortic arch and the proximal descending aorta. A total of 169 patients (67%) underwent ascending aortic replacement, and 84 patients (33%) underwent total arch replacement. Hospital death due to initial surgery, dilatation of the distal aorta greater than 5 cm, new occurrence of aortic dissection, any distal aortic surgery, and aortic-related deaths were defined as distal aortic events. RESULTS: The mortality was 7.1% in the ascending aortic replacement group and 6.0% in the total arch replacement group. Postoperative computed tomography was performed in 162 patients in the ascending aortic replacement group. The false lumen of the residual aortic arch had thrombosed and healed in 94 patients (58%) and remained present in 68 patients (42%). The distal aortic event-free rate in the ascending aortic replacement group decreased from 74% at 5 years to 51% at 9 years, and the rate in the total arch replacement group was 83% at 5 to 9 years (P < .01). For the ascending aortic replacement group, more patients with a dissected arch had a distal aortic event compared with patients with a healed arch (P < .01). CONCLUSIONS: Total arch replacement was associated with fewer distal aortic events. We may expand the indications for total arch replacement in stable patients.

Mid-term outcomes of simultaneous mitral valve repair in patients with miral regurgitation and concomitant annulo-aortic ectasia.

OBJECTIVE: This study investigated the mid-term outcomes of simultaneous mitral valve repair in patients with mitral regurgitation (MR) and concomitant annulo-aortic ectasia. METHODS: The study included 26 patients with MR and annulo-aortic ectasia [mean age 46.0 ± 19.9 (10-86) years] who underwent simultaneous mitral valve repair between January 2007 and March 2018. Of these 26 patients, 11 (42.3%) were diagnosed with Marfan syndrome and 10 (38.5%) with Barlow's disease. All patients underwent complete ring annuloplasty; a semi-rigid ring was used in 14 (53.8%) and a semi-flexible ring (anterior-flexible) in 12 patients (46.2%). All patients underwent valve-sparing root replacement using the reimplantation technique. RESULTS: The overall 3-year survival rate was 95.7 ± 4.3%. The 3-year freedom from > moderate MR rate was 94.7 ± 5.1%, and the 3-year freedom from > moderate aortic regurgitation (AR) rate was 86.7 ± 7.3%. The 3-year freedom from reoperation rate was 100%. The 3-year freedom from > moderate MR rate was 100% in the semi-rigid ring group and 85.7 ± 13.2% in the semi-flexible ring group (log-rank test, p = 0.5371). The 3-year freedom from > moderate AR rate was 100% in the semi-rigid ring group and 72.9 ± 16.5% in the semi-flexible ring group (log-rank test, p = 0.0815). CONCLUSIONS: Simultaneous mitral valve repair in patients with MR and concomitant annulo-aortic ectasia showed favorable mid-term outcomes.

Importance of main pancreatic duct dilatation in IPMN undergoing surveillance.

BACKGROUND: The association between risk of pancreatic cancer and a dilated main pancreatic duct (MPD) in intraductal papillary mucinous neoplasm (IPMN) is debated. The aim of this study was to assess the role of MPD size in predicting pancreatic cancer in resected IPMNs and those kept under surveillance. METHODS: All patients with IPMN referred to the Pancreas Institute, University of Verona Hospital Trust, from 2006 to 2016 were included. The primary endpoint was the occurrence of malignancy detected at surgery or during follow-up. RESULTS: The final cohort consisted of 1688 patients with a median follow-up of 60 months. Main pancreatic duct dilatation was associated with other features of malignancy in both the resected and surveillance groups. In patients who underwent resection, only a MPD of at least 10 mm was an independent predictor of malignancy. In patients kept under surveillance, MPD dilatation was not associated with malignancy. Fifteen of 71 patients (21 per cent) with malignancy in the resection cohort had a dilated MPD alone, whereas only one of 30 (3 per cent) under surveillance with MPD dilatation alone developed malignancy. Patients with a dilated MPD and other worrisome features had an increased 5-year cumulative incidence of malignancy compared with those with a non-dilated duct (11 versus 1·2 per cent; P < 0·001); however, the risk of malignancy was not significantly increased in patients with a dilated MPD alone (4 versus 1·2 per cent; P = 0·448). CONCLUSION: In patients under surveillance, a dilated MPD alone was not associated with an increased incidence of malignancy in IPMN.

Screening of Mechanical Complications of Dilated Pulmonary Artery Related to the Risk for Sudden Cardiac Death in Patients with Pulmonary Arterial Hypertension by Transthoracic Echocardiography.

BACKGROUND: In patients with pulmonary arterial hypertension (PAH), the mechanical complications of pulmonary artery (PA) enlargement are related to sudden cardiac death (SCD). The aim of this study was to investigate the prevalence of PA enlargement, the correlation of main PA (MPA) diameter with other echocardiographic parameters, and the role of transthoracic echocardiography in screening for such complications. METHODS: Among 298 patients who were followed for PAH, patients with PA enlargement (>40 mm) by transthoracic echocardiography were consecutively enrolled in a prospective manner. The presence of left main and airway compression, PA dissection, or PA thrombus was determined with cardiac computed tomography. RESULTS: Forty-six patients (15.4%; mean age, 49 ± 14 years; 32.6% men) with dilated MPAs were enrolled. Mechanical complications were present in 16 patients (34.8%). Those with complications had more dilated MPAs compared with patients without (mean PA diameter, 55.6 ± 12.2 vs 46.7 ± 4.3 mm; P = .012). Other echocardiographic parameters of the right heart, such as right ventricular systolic pressure, showed no differences (P > .05 for all). The area under the receiver operating characteristic curve for MPA diameter was 0.750 (95% CI, 0.577-0.923; P = .009), with the highest sensitivity and specificity values for the presence of complications being 85.7% and 58.6%, respectively, according to an MPA diameter of 46.5 mm. CONCLUSIONS: Mechanical complications related to sudden cardiac death in patients with PAH with dilated PAs are common. The overall performance of transthoracic echocardiography as a screening tool for predicting such complications appears reasonable. Given the burden of sudden cardiac death, measurement of PA diameter should be routinely included over the course of follow-up, especially in patients with PAH.

[APPLICATIONS ENDOVASCULAR HEMOSTASIS TREATMENT OF PULMONARY HEMORRHAGE].

Rentgenoendovascular embolization of bronchial arteries was performed in 222 patients about pulmonary hemorrhage (PH) of different nature. Resistant hemostasis was achieved in 198 (89.9%) patients. The possibility of endovascular hemostasis in patients in advanced lung cancer complicated by PH. Hemostasis was ineffective in 24 (10.8%) patients. Died 5 (2.2%) patients due to unresectable lung cancer. The reasons for ineffective hemostasis were analysed.

Marfan Sartan: a randomized, double-blind, placebo-controlled trial.

AIMS: To evaluate the benefit of adding Losartan to baseline therapy in patients with Marfan syndrome (MFS). METHODS AND RESULTS: A double-blind, randomized, multi-centre, placebo-controlled, add on trial comparing Losartan (50 mg when <50 kg, 100 mg otherwise) vs. placebo in patients with MFS according to Ghent criteria, age >10 years old, and receiving standard therapy. 303 patients, mean age 29.9 years old, were randomized. The two groups were similar at baseline, 86% receiving ß-blocker therapy. The median follow-up was 3.5 years. The evolution of aortic diameter at the level of the sinuses of Valsalva was not modified by the adjunction of Losartan, with a mean increase in aortic diameter at the level of the sinuses of Valsalva of 0.44 mm/year (s.e. = 0.07) (-0.043 z/year, s.e. = 0.04) in patients receiving Losartan and 0.51 mm/year (s.e. = 0.06) (-0.01 z/year, s.e. = 0.03) in those receiving placebo (P = 0.36 for the comparison on slopes in millimeter per year and P = 0.69 for the comparison on slopes on z-scores). Patients receiving Losartan had a slight but significant decrease in systolic and diastolic blood pressure throughout the study (5 mmHg). During the study period, aortic surgery was performed in 28 patients (15 Losartan, 13 placebo), death occurred in 3 patients [0 Losartan, 3 placebo, sudden death (1) suicide (1) oesophagus cancer (1)]. CONCLUSION: Losartan was able to decrease blood pressure in patients with MFS but not to limit aortic dilatation during a 3-year period in patients >10 years old. ß-Blocker therapy alone should therefore remain the standard first line therapy in these patients.

Transcatheter aortic valve implantation in patients with ascending aortic dilatation: safety of the procedure and mid-term follow-up†.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) does not enable concomitant or simultaneous ascending aortic intervention. This investigation evaluates the safety of TAVI in patients with ascending aortic dilatation and demonstrates mid-term follow-up. METHODS: From November 2007 to December 2012, among 1143 patients with severe aortic stenosis screened for TAVI, a cohort of 457 patients met the inclusion criteria. Of these, a total of 98 patients [71% males, median age 85.0 (9.0) years] were diagnosed with concomitant ascending aortic dilatation (4.0-5.0 cm). An additional 2 patients had an ascending aortic diameter of >5.0 cm. The mid-term follow-up (652.2 patient-years) was 100% complete. RESULTS: There was no iatrogenic dissection in patients with dilatated ascending aorta. Intraoperative aortic rupture occurred in 1 patient with mildly dilatated ascending aorta. One-year survival rates in patients with dilatated and non-dilatated ascending aorta were 65 of 75 (87%) and 201 of 242 (83%, P = 0.573). The mean ascending aortic diameter remained stable at 4.1 (0.2) and 4.7 (0.2) cm in patients with mild and moderate dilatation, respectively, with a median follow-up of 14 months after TAVI. Two patients with an aortic diameter of over 5.0 cm survived the procedure and expired 7 and 20 months after TAVI due to tumour and heart failure, respectively. CONCLUSIONS: Ascending aortic dilatation is diagnosed in almost one-fourth of patients treated with TAVI. Their intraprocedural risk of adverse aortic events is low. The ascending aortic dilatation does not affect mid-term survival in the TAVI population.

Concomitant replacement of the dilated ascending aorta during aortic valve replacement; does it increase the perioperative morbidity and mortality risks?

BACKGROUND: Concerns of increased surgical risks with ascending aortic replacement have led surgeons to manage post-stenotic aortic dilatation more conservatively during aortic valve replacement (AVR). The present study aimed to assess the prognostic implications and surgical risks of replacing the dilated aorta during AVR. METHODS: Between January 1999 and March 2010, 134 patients who received surgery for aortic stenosis and post-stenotic dilatation (aorta size ≥40 mm) were included in the present study. AVR was performed in 92 patients (AVR group) while aortic valve and ascending aorta replacement (AVR + aorta group) were performed in 42 patients. Overall survival was compared between the two groups using Cox proportional hazard model after adjustment with inverse-probability-of-treatment weighting. RESULTS: The mean follow-up duration was 3.5 ± 3 years. There were no significant differences in the operative mortality and morbidity between the two groups. The late cardiac deaths were also not significantly different between the two groups (p = 1.00). In the AVR group, the ascending aortic expansion rate which was 0.18 mm/year over a mean follow-up duration of 2.3 ± 2.2 years by echocardiography showed a positive correlation with time (r = 0.3, p = 0.08). A relatively greater aortic expansion rate was identified as a risk factor for late mortality (p = 0.015, HR 1.08 (CI: 1.02 to 1.15). CONCLUSIONS: Concomitant replacement of the dilated ascending aorta during AVR did not increase the immediate postoperative morbidity or mortality risks and tended to exert a long-term beneficial effect on the risk of late mortality.

Antenatal diagnosis of bowel dilatation in gastroschisis is predictive of poor postnatal outcome.

PURPOSE: Although gastroschisis infants usually have a good outcome, there remains a cohort of babies who fare poorly. We inquired whether the presence of bowel dilatation in utero is predictive of postnatal course in infants with gastroschisis. METHODS: We compared the clinical course of infants who had bowel dilatation with those who did not. Bowel dilatation was defined as more than 20 mm in cross-sectional diameter on ultrasound at any gestational age. Outcome measures used were length of time of parenteral nutrition, death, and surgery for intestinal failure. RESULTS: A review of 170 infants with gastroschisis identified 74 who had dilatation of more than 20 mm (43.5%). There was no significant difference in the incidence of intestinal atresia in those with bowel dilatation and those without (P = .07). Those with bowel dilatation spent a longer period on parenteral nutrition. There were significantly more deaths in the group with bowel dilatation (P = .01). There was no significant difference in the number of infants requiring surgery for intestinal failure between the 2 groups (P = .47). CONCLUSIONS: We found that sonographically detected bowel dilatation more than 20 mm in utero in fetuses with gastroschisis may have value in predicting clinically significant adverse postnatal outcomes.

CME: long-term outcome in asymptomatic patients with severe aortic regurgitation, normal left ventricular ejection fraction, and severe left ventricular dilatation.

BACKGROUND: Although the guidelines consider severe left ventricular (LV) dilatation a class IIaC indication for surgery in asymptomatic patients with severe aortic regurgitation (AR) and normal LV function, the optimal management remains controversial. We aimed to assess the LV enlargement, hypertrophy and function, and the outcomes in these patients by the presence of severe LV dilatation at baseline. METHODS: From our 20-year database, we identified all asymptomatic patients with severe AR and LV ejection fraction (EF) >50% and ≥2 echocardiograms ≥1 year apart. LV end-diastolic diameter >70 mm or LV end-systolic diameter >50 mm or LV end-systolic diameter index >25 mm/m(2) defined severe LV dilatation. A composite end point included onset of symptoms or LV dysfunction. RESULTS: Eighty-four patients (52 ± 18 years, 61 men) were enrolled and followed-up for 7.1 ± 5.1 years. Two groups were defined: 22 patients with and 62 patients without severe LV dilatation at baseline. The progression of LV dilatation and hypertrophy, and the LVEF at last exam were similar in both groups. Twelve of 22 and 34 of 62 patients (P = 0.59) reached the end point. Vasodilators did not modify the progression of LV enlargement/hypertrophy. Ten of 22 and 25 of 62 patients (P = 0.45) underwent surgery and had similar postoperative LV diameters, mass, EF. CONCLUSIONS: The progression of LV enlargement/hypertrophy and outcomes in asymptomatic patients with severe AR, normal LV function, and severe LV dilatation or the postoperative LV parameters were not influenced by the severe LV dilatation, suggesting that a close follow-up could delay surgery in this population.

Posthaemorrhagic ventricular dilatation in the premature infant: natural history and predictors of outcome.

OBJECTIVE: To investigate the natural history and predictors of outcome of posthaemorrhagic ventriculomegaly in the very low birthweight (VLBW) infant. METHODS: All VLBW infants admitted between September 1994 and September 1997 to the neonatal intensive care units of Brigham and Women's Hospital (Boston), Children's Hospital (Boston), and Christchurch Women's Hospital (New Zealand) with germinal matrix intraventricular haemorrhage (IVH) were identified. All charts and ultrasound scans were reviewed to define the natural history and perinatal and/or postnatal factors of value in prediction of the course of posthaemorrhagic ventriculomegaly. Progressive ventricular dilatation (PVD) was defined from the results of serial cranial ultrasound scans. RESULTS: A total of 248 VLBW infants had evidence of IVH (22% of all VLBW infants, mean (SD) gestational age 26.8 (2.6) weeks). A quarter of the infants exhibited PVD. Spontaneous arrest of PVD occurred without treatment in 38% of infants with PVD. Of the remaining 62% with persistent PVD, 48% received non-surgical treatment only (pharmacological and/or drainage of cerebrospinal fluid by serial lumbar punctures), 34% received surgical treatment with insertion of a ventriculoperitoneal reservoir and/or shunt, and 18% died. The development of PVD after IVH and adverse short term outcome, such as the requirement for surgery, were predicted most strongly by the severity of IVH. CONCLUSIONS: These data reflect the natural history of PVD in the 1990s and show that, despite a slight reduction in its overall incidence, there appears to be a more aggressive course, with appreciable mortality and morbidity in the extremely premature infant. The major predictor of adverse short term outcome, defined as death or need for surgical intervention, was the severity of IVH. These findings may be valuable for the management of very small premature infants.

Effects of in vivo heregulin beta1 treatment in wild-type and ErbB gene-targeted mice depend on receptor levels and pregnancy.

Mice heterozygous (+/-) for either heregulin (HRG), ErbB2, or ErbB3 were created by gene targeting, resulting in the loss of one functional gene copy and an associated decrease in targeted protein. We examined the in vivo activity of recombinant HRG peptide, rHRG beta1 (amino acids 177 to 241), in the three heterozygous mouse lines and in wild-type (WT) mice, both pregnant and nonpregnant. Nonpregnant WT and HRG(+/-) mice of both sexes were sensitive to rHRG beta1 treatment as evidenced by a high mortality rate associated with abdominal enlargement and parietal cell loss. However, pregnant WT mice and ErbB2 and ErbB3 heterozygous mice treated with rHRG beta1 were less affected, with significantly lower mortality rates and a less severe abdominal phenotype. Histological analysis revealed extensive breast ductal hyperplasia in females of all genotypes after rHRG beta1 treatment. Hyperplasia of other epithelial tissues such as the pancreas and intestine and the growth of cardiac nerve bundles were also observed, independent of sex.

The role of contralateral ventricular dilatation following surgery for intracranial mass lesions.

Contralateral ventricular dilatation (CVD) has been described as an early indicator of tentorial herniation and has been associated with increased mortality and morbidity. Following surgery for supratentorial mass lesions, ipsilateral brain swelling often causes CVD. Drainage of CVD was performed in a series of 12 patients in whom no further lesion amenable to surgery was evident and after failure of other established methods of intracranial pressure (ICP) control. In 10 of the 12 patients the ICP was brought under control with a significant reduction in ICP (p < 0.05) when compared with predrainage ICP. Midline shift was reduced in seven patients. Therefore, following successful removal of intracranial mass lesions, patients who exhibit CVD should undergo drainage as an early measure.

Dealing with dilated ascending aorta during aortic valve replacement: advantages of conservative surgical approach.

Five to fifteen percent of patients undergoing aortic valve replacement (AVR) will have an ascending aortic aneurysm requiring a concomitant surgical procedure. On the other hand, a dilated ascending aorta is known to be a potential source of complications after AVR. From 1972 to 1988, 2278 AVR, either isolated or combined with a second cardiac procedure, were performed in our institution. In the same time interval, a dilated ascending aorta was treated in additional 291 consecutive patients during AVR. Three different surgical options were employed: aortic remodelling and external wall support in 164 patients (56.4%), composite graft replacement in 81 patients (27.8%) and a supracoronary graft in 46 patients (15.8%). Early mortality was 4.8%. Aortic remodelling plus external wall support had the lowest early mortality (1.8%) and the best 8-year survival (89.6%). Supracoronary grafting had a higher early mortality (6.4%) and lower 8-year survival (73.2%). The results of the composite graft were least favourable: early mortality was 9.8% and 8-year survival 76.5%. The results point out the necessity for instituting the appropriate surgical procedure for a dilated ascending aorta during AVR. They show that conservative aortic surgery with preservation of endothelial lining gives excellent early and late results.