RESUMEN
On July 31, 2023, the Trifecta valve was withdrawn from the market after concerns regarding early (≤5 years) structural valve deterioration (SVD), mainly as aortic regurgitation (AR). Our aim was to determine the timing, mechanism, and impact of bioprosthetic SVD in patients who underwent redo aortic valve replacement (redo-AVR) with either redo-SAVR or valve-in-valve transcatheter aortic valve replacement (TAVR) using Trifecta versus other bioprosthetic valves. Patients who underwent redo-AVR for SVD at our institution were categorized into 2 groups based on the valve type: Trifecta versus non-Trifecta. Multivariate Cox proportional hazard model and Kaplan-Meier curves were used to compare mortality. A total of 171 patients were included; 58 (34%) had previous SAVR with a Trifecta valve and 113 (66%) with non-Trifecta valve. A total of 103 patients (60%) underwent valve-in-valve TAVR and 68 redo-SAVR (40%). The age, gender, and Society of Thoracic Surgeons score were similar between Trifecta and non-Trifecta groups. In patients with bioprosthetic valves requiring redo-AVR, Trifecta valves had an earlier onset of greater than moderate AR (4.5 vs 11.9 years, p <0.001) and earlier time to redo-AVR (5.5 vs 12 years, p <0.001). AR was more common as the mechanism of SVD in Trifecta versus non-Trifecta valves (55.2% vs 30.1%, p = 0.006). All-cause adjusted mortality from index SAVR was higher in the Trifecta than in non-Trifecta group (hazard ratio 4.1, 95% confidence interval 1.5 to 11.5, p = 0.007). In conclusion, compared with non-Trifecta valves, Trifecta valves exhibit early SVD primarily as AR and progress rapidly to significant SVD requiring redo-AVR. Mortality is significantly higher with Trifecta than in non-Trifecta valves, potentially impacting the results of SAVR versus TAVR studies.
Asunto(s)
Insuficiencia de la Válvula Aórtica , Bioprótesis , Prótesis Valvulares Cardíacas , Diseño de Prótesis , Falla de Prótesis , Reoperación , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Insuficiencia de la Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/mortalidad , Masculino , Femenino , Reoperación/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Estudios Retrospectivos , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/mortalidad , Válvula Aórtica/cirugía , Factores de Tiempo , Complicaciones Posoperatorias/epidemiología , Implantación de Prótesis de Válvulas Cardíacas/métodosRESUMEN
BACKGROUND AND AIM OF STUDY: Right-sided aortic arch is a rare congenital anomaly for which different surgical approaches have been reported. This study reviewed our experience with several techniques. METHODS: We retrospectively reviewed 17 patients undergoing right-sided arch repair at the Cleveland Clinic from 2001 to 2010. Computed tomographic angiograms of the aorta and its branches were reviewed and correlated with patient presentation and surgical approach. RESULTS: Fourteen patients had type II right aortic arch with aberrant left subclavian artery. Fifteen patients presented with obstructive symptoms. Surgical approach included right thoracotomy (11 patients), left thoracotomy (two patients), full sternotomy (one patient), and hybrid repair (three patients). Cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest was used in 11 patients, and two patients had partial CPB. Left subclavian artery bypass was performed in seven patients. Median duration of intubation was 1.9 days. Average length of intensive care unit stay was three days and average hospital stay 11 days. Postoperative outcomes included respiratory failure (one patient), renal failure (one patient), bloodstream infection (two patients), and death (one patient). No patient had stroke or paraplegia. In-hospital death occurred in one patient, and all survivors were alive and asymptomatic for a mean of 38 months. CONCLUSION: The surgical treatment for right-sided aortic arch can be performed with excellent perioperative outcomes when tailored to patient presentation and anatomic configuration. Patients with obstructive symptoms benefit from open or hybrid surgical treatment, with immediate relief of compression. Patients with aneurysmal dilatation without compression symptoms can be managed with open, endovascular, or hybrid surgical intervention.
Asunto(s)
Aorta Torácica/anomalías , Enfermedades de la Aorta/cirugía , Injerto Vascular/métodos , Anciano , Aorta Torácica/cirugía , Enfermedades de la Aorta/congénito , Enfermedades de la Aorta/diagnóstico , Enfermedades de la Aorta/mortalidad , Puente Cardiopulmonar/métodos , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Complicaciones Posoperatorias , Estudios Retrospectivos , Esternotomía , Toracotomía , Resultado del Tratamiento , Injerto Vascular/mortalidadRESUMEN
OBJECTIVE: The present prospective noninferiority randomized trial was designed to demonstrate the safety and efficacy of a single dose of Custodiol histidine-tryptophan-ketoglutarate compared with repetitive cold-blood cardioplegia. METHODS: From October 2012 to May 2014, 110 patients were randomly assigned to 1 of 2 groups: Group 1 (55 patients) received repetitive cold-blood cardioplegia, and group 2 (55 patients) received single-dose Custodiol histidine-tryptophan-ketoglutarate. Isolated aortic valve replacement, isolated mitral valve replacement, and multivalve procedures represented the most frequent operations, with 39 cases (71%) in group 1 and 49 cases (89%) in group 2. There was no difference in cardiopulmonary bypass time (102 ± 26 minutes vs 99 ± 19 minutes, P = .70) or aortic crossclamp time (77 ± 19 minutes vs 74 ± 17 minutes, P = .33). All patients underwent preoperative electrocardiogram and determination of creatine kinase-MB, troponin I, left ventricular ejection fraction, and regional wall motion. Postoperative cardiac biomarkers were checked at 7, 24, and 48 hours, and an echocardiogram was obtained to check for left ventricular function abnormalities. RESULTS: There was no difference in cardiac biomarkers release between the 2 groups at baseline and 7, 24, and 48 hours postoperatively (creatine kinase, P = .18, troponin P = .23). Left ventricular function was similar between groups preoperatively and at 24 hours after surgery. No death or myocardial infarction was observed in either group. There were no differences in intensive care unit length of stay, incidence of atrial fibrillation, use of inotropes or vasopressors support, time of intubation, or creatinine levels. CONCLUSIONS: A single dose of Custodiol histidine-tryptophan-ketoglutarate cardioplegia is not inferior to repeated cold-blood cardioplegia during elective cardiac surgery.
Asunto(s)
Soluciones Cardiopléjicas/administración & dosificación , Paro Cardíaco Inducido/métodos , Corazón/fisiología , Anciano , Soluciones Cardiopléjicas/efectos adversos , Soluciones Cardiopléjicas/uso terapéutico , Forma MB de la Creatina-Quinasa/sangre , Femenino , Glucosa/administración & dosificación , Glucosa/efectos adversos , Glucosa/uso terapéutico , Hemodinámica/fisiología , Humanos , Tiempo de Internación , Masculino , Manitol/administración & dosificación , Manitol/efectos adversos , Manitol/uso terapéutico , Persona de Mediana Edad , Complicaciones Posoperatorias , Cloruro de Potasio/administración & dosificación , Cloruro de Potasio/efectos adversos , Cloruro de Potasio/uso terapéutico , Procaína/administración & dosificación , Procaína/efectos adversos , Procaína/uso terapéutico , Estudios Prospectivos , Troponina I/sangreRESUMEN
Myxomas are the most common benign cardiac neoplasms in adults. The vast majority of cardiac myxomas arise from the left atrium near the fossa ovalis of the intra-atrial septum. There have been reports of myxomas arising from the ventricles accounting for about 5% of cases. In our literature review, we have found 55 reported cases of myxomas originating from the mitral valve reported in the adult population dating back to 1871. The majority of these cases presented with embolic complications or syncope. We present an incidental mitral valve myxoma which we excised in efforts to prevent debilitating complications.
RESUMEN
Bioprosthetic aortic valve degeneration may present as acute, severe aortic regurgitation and cardiogenic shock. Such patients may be unsuitable for emergency valve replacement surgery due to excessive risk of operative mortality but could be treatable with transfemoral valve-in-valve transcatheter aortic valve implantation (TAVI). There is a paucity of data regarding the feasibility of valve-in-valve TAVI in patients presenting with cardiogenic shock due to acute aortic insufficiency from stentless bioprosthetic valve degeneration. We present one such case, highlighting the unique aspects of valve-in-valve TAVI for this challenging patient subset.
Asunto(s)
Defectos del Tabique Interatrial/complicaciones , Insuficiencia de la Válvula Mitral/complicaciones , Válvula Mitral/anomalías , Ecocardiografía Transesofágica , Defectos del Tabique Interatrial/diagnóstico por imagen , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Músculos Papilares/anomalías , Adulto JovenRESUMEN
A 32-year-old woman presented with recurrent trachea-esophageal fistula. Although she had undergone open repair three times in her first year of life, a residual small leak was left. In the past 2 years she had experienced several lower respiratory tract infections and she had lost 5 kilograms in the past 2 months. Recent argon plasma coagulation cauterization and clipping of the fistula had failed, so an alternative technique with placement of an atrial septal occluder device was used to obliterate the fistula. A follow-up barium swallow showed no more communication to the tracheobronchial tree, and endoscopy demonstrated epithelialization. At her 3-year follow-up visit she was asymptomatic.
Asunto(s)
Endoscopía/instrumentación , Dispositivo Oclusor Septal , Fístula Traqueoesofágica/cirugía , Adulto , Femenino , Humanos , Recurrencia , Fístula Traqueoesofágica/diagnóstico por imagen , Fístula Traqueoesofágica/etiologíaRESUMEN
OBJECTIVES: Repair of extensive aortic disease carries a significant risk of death and morbidity, the most feared complication being spinal cord ischaemia. Objectives of this study are to characterize patients, describe repair methods and assess feasibility and safety of hybrid staged repair for treatment of extensive aortic disease. METHODS: From to 2001 to 2013, 22 patients underwent extensive aortic repair that included a thoracic endovascular aortic repair (TEVAR) first followed by an open completion repair extending through the visceral and infrarenal aorta for degenerative aneurysm and dissection. At the time of initial repair, all patients were deemed to be at a high risk for conventional open repair and had extensive disease. Indications for open completion included emergency failure of TEVAR (n = 3), early two-stage approach (n = 6) and delayed disease progression after TEVAR (n = 13). The median interval between stages was 6.5 months. The mean age was 56 ± 14 years, 5 patients had connective tissue disorder and the mean maximum aortic diameter was 58 ± 16 mm preoperatively. RESULTS: There was no death or major complication after initial TEVAR, but the operative mortality rate was 9% (n = 2) after the open procedure. One of these patients died from intraoperative myocardial infarction during emergency repair, and the other had disseminated intravascular coagulation during delayed repair for disease progression after TEVAR. Other complications included paralysis in 1 (4.5%), tracheostomy in 2 (9%) and dialysis in 1 (4.5%), and there was 1 reoperation for bleeding (4.5%). The median follow-up was 37 (range 3.3-93) months and there were no late deaths. There were four late reoperations for proximal disease progression leading to Type 1 endoleak (n = 2), Type A dissection (n = 1) and root aneurysm (n = 1). CONCLUSIONS: Use of a TEVAR-first approach in combination with a staged open repair is a safe and feasible treatment strategy for repair of extensive aortic disease. A staged hybrid approach to aortic repair in patients at high risk for total aortic replacement may limit morbidity.
Asunto(s)
Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/métodos , Adulto , Anciano , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
We describe the case of a patient who presented with transient ischemic attack 4 years after bicuspid aortic valve repair, ascending aorta, and hemiarch replacement. Workup included cross-sectional imaging consistent with thrombus in the ascending aorta graft. Warfarin was initiated, but another episode of cerebral ischemia occurred despite therapeutic anticoagulation. Surgery was performed to avoid further embolization as re-replacement with a homograft aorta. Histologic analysis of the material found within the graft demonstrated large B cell lymphoma. At 39 months' follow-up, there have been no additional episodes of embolization and no evidence of recurrent cancer.
Asunto(s)
Válvula Aórtica/cirugía , Prótesis Valvulares Cardíacas , Linfoma de Células B/complicaciones , Linfoma de Células B/patología , Células Neoplásicas Circulantes , Aorta , Humanos , Masculino , Persona de Mediana Edad , RecurrenciaRESUMEN
Patients with aortic pathology involving the ascending aorta, the arch, and the descending aorta present a complex surgical challenge. A one-step hybrid procedure with ascending aorta repair, arch debranching, and frozen elephant trunk is reported in five patients. Left subclavian artery side graft cannulation is used to perfuse the spinal cord during circulatory arrest time.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Cateterismo Cardíaco , Ecocardiografía Doppler , Hemodinámica , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Humanos , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation, occurring in 1% to 2% of the population. Eventually, 20% develop clinically important valvar regurgitation requiring surgical intervention. Aortic valve repair avoids anticoagulation and prosthetic valve-related complications. This study evaluated long-term durability of BAV repair. METHODS: From 1985 to 2011, 728 patients, mean age 42±12 years, underwent BAV repair at Cleveland Clinic. Mean follow-up was 9.0±6.2 years (median, 8.3). Factors associated with repair durability (expressed as aortic valve reoperations and echocardiographically estimated gradients and regurgitation) and survival were identified. RESULTS: Hospital mortality was 0.41% (n=3), and stroke occurred in 0.27% (n=2). Freedom from aortic valve reoperation at 10 years was 78%. Risk of reoperation was highest immediately after operation and fell rapidly to approximately 2.6%/year up to 15 years. Primary reasons for reoperation were cusp prolapse (38%), aortic stenosis or regurgitation (17%), and aortic regurgitation from root aneurysm (15%). Aortic valve gradients showed an early initial peak, rapidly declined, then rose steadily, accompanied by an increase in left ventricular mass. Survival was 94% at 10 years. A risk factor for early death was greater preoperative mitral valve regurgitation, and for late death, older age at operation, more severe symptoms, and poorer left ventricular function. CONCLUSIONS: BAV repair is safe and durable with low mortality, low prevalence of reoperation, and good long-term survival. Cusp prolapse from technical errors and natural progression of disease are the most common causes for reoperation, but progressive natural increase in valve gradient accounts for a substantial proportion as well.
Asunto(s)
Insuficiencia de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/anomalías , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Prótesis Valvulares Cardíacas , Centros Médicos Académicos , Adulto , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/mortalidad , Enfermedad de la Válvula Aórtica Bicúspide , Estudios de Cohortes , Ecocardiografía Doppler , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Ohio , Falla de Prótesis , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Medición de Riesgo , Tasa de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: High-performing health care organizations differentiate themselves by focusing on continuous process improvement initiatives aimed at enhancing patient outcomes. Reoperation for bleeding is an event associated with considerable morbidity risk. Hence, our primary objective was to develop and implement a formal operative checklist to reduce technical reasons for postoperative bleeding. METHODS: From January 1, 2011, through June 30, 2012, 5812 cardiac surgical procedures were performed at Cleveland Clinic (Cleveland, OH). A multidisciplinary team developed a simple, easy-to-perform hemostasis checklist based on the most common sites of bleeding. An extensive educational in-service was performed before limited, then universal, checklist implementation. Geometric charts were used to track the number of cases between consecutive reoperations for bleeding. We compared these before (phase 0) and after the first limited implementation phase (phase 1) and the universal implementation phase (phase 2) of the checklist. RESULTS: The average number of cases between consecutive reoperations for bleeding increased from 32 in phase 0 to 53 in both phase 1 (P = .002) and phase 2 (P = .01). CONCLUSIONS: A substantial reduction in reoperation for bleeding cases followed implementation of a formalized hemostasis checklist. Our findings underscore the important influence of memory aids that focus attention on surgical techniques to improve patient outcomes in a complex, operative work environment.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Lista de Verificación , Técnicas Hemostáticas , Evaluación de Procesos y Resultados en Atención de Salud , Hemorragia Posoperatoria/cirugía , Indicadores de Calidad de la Atención de Salud , Reoperación , Atención , Actitud del Personal de Salud , Competencia Clínica , Protocolos Clínicos , Técnicas de Apoyo para la Decisión , Conocimientos, Actitudes y Práctica en Salud , Humanos , Memoria , Ohio , Hemorragia Posoperatoria/diagnóstico , Hemorragia Posoperatoria/etiología , Evaluación de Programas y Proyectos de Salud , Factores de Riesgo , Flujo de TrabajoRESUMEN
BACKGROUND: Few series have examined follow-up risks of the David reimplantation operation in patients with connective tissue disorder. Hence, we assessed its midterm safety and effectiveness for Marfan syndrome and other connective tissue disorders, such as Ehlers-Danlos, Loeys-Dietz, and marfanoid syndromes. METHODS: Of 313 patients who underwent modified David reimplantation, 178 identified as having connective tissue disorders underwent operation from January 1, 1991, to December 31, 2010. These disorders included Marfan (84%), marfanoid (8.4%), Loeys-Dietz (5.6%), Ehlers-Danlos (1.1%), and other syndromes (1.1%). Concomitant procedures included mitral valve repair in 7.3% and an atrial fibrillation procedure in 3.4%. RESULTS: There were no operative or 30-day deaths. Complications included prolonged ventilation (3%), renal failure (3%), reoperation for bleeding (2.2%), and permanent stroke (0.56%). Eight-year survival was 94% and freedom from aortic valve reoperation at 6 years was 92%. Of the 7 aortic valve reoperations, 3 were attributable to endocarditis and 3 to technical failure. One reoperation was performed at another hospital, and the reason could not be determined. There were no late strokes or hemorrhagic events. At 4 years, approximately 70% of patients had no aortic valve regurgitation, and 18% were in grade 1+. CONCLUSIONS: Prophylactic root and valve preservation using David reimplantation is safe and provides excellent midterm effectiveness and low risk of late events except for endocarditis.
Asunto(s)
Enfermedades del Tejido Conjuntivo/complicaciones , Enfermedades de las Válvulas Cardíacas/complicaciones , Enfermedades de las Válvulas Cardíacas/cirugía , Procedimientos Quirúrgicos Cardíacos/métodos , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Factores de TiempoRESUMEN
The constellation of Takayasu's disease most commonly includes aortitis with resultant coarctations and aneurysm formation. Surgical repair of these lesions can be compromised by the chronic inflammation of Takayasu's arteritis. We present a case of a 22-year-old female with Takayasu's disease who had undergone an ascending and aortic hemiarch replacement then subsequently developed anastomotic dehiscence and re-expansion of the previous aneurysmal sac. Complete aneurysm resection and replacement of the ascending aorta and aortic arch was performed on repeated surgery.
Asunto(s)
Fuga Anastomótica/cirugía , Aorta Torácica/cirugía , Reoperación/métodos , Arteritis de Takayasu/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Fuga Anastomótica/diagnóstico , Femenino , Estudios de Seguimiento , Humanos , Imagenología Tridimensional , Arteritis de Takayasu/diagnóstico , Tomografía Computarizada por Rayos X , Insuficiencia del Tratamiento , Adulto JovenRESUMEN
Patients with thoracoabdominal aneurysm that require concomitant cardiac surgery present a complex surgical challenge. A staged hybrid technique including combined cardiac surgery and visceral revascularization from the ascending aorta, followed by endovascular aneurysmal exclusion is reported in four patients. No perioperative death and no neurological complications were observed. The surgical technique is described.
Asunto(s)
Aorta/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/métodos , Stents , HumanosRESUMEN
BACKGROUND: Etiology for increased morbidity in patients (2% to 8%) undergoing reoperation for bleeding after cardiac surgery is unclear. Recent work suggests that it may be related to red-cell transfusion, but what role does reoperation itself play? We sought to determine prevalence of and risk factors for reoperation for bleeding, separate the effect of reoperation from that of transfusion on hospital mortality and major morbidity, and identify the source of bleeding. METHODS: From January 1, 2000 to January 1, 2010, 18,891 primary and repeat coronary artery bypass grafting, valve, or combined operations were performed. Risk factors for reoperation were identified by multivariable logistic regression. Hospital mortality and major morbidity were compared in propensity-matched patients requiring reoperation and not. Medical records from 2005 to 2010 were reviewed to determine bleeding source. RESULTS: A total of 566 patients (3.0%) underwent reoperation for bleeding, with considerable variability over time. Risk factors included older age, higher acuity, greater comorbidity, aortic valve surgery, longer myocardial ischemic and cardiopulmonary bypass durations, and surgeon. Mortality was higher for propensity-matched patients requiring reoperation; 8.5% (68% confidence interval [CI] 7.3% to 9.9%) versus 1.8% (CI 1.2% to 2.5%). Both greater transfusion and reoperation were independently associated with increased risk of mortality and major morbidity. At reoperation, technical factors (74%), coagulopathy (13%), both (10%), or other (3.3%) causes were responsible for bleeding. CONCLUSIONS: Transfusion and reoperation for bleeding both contribute to postoperative mortality and morbidity. Technical reasons are at the root of most bleeding, emphasizing a major focus for process improvement to minimize need for reoperation and blood use.