Impact of Aortic Valve Function and the Need for Aortic Valve Repair on Long-Term Outcomes of Valve-Sparing Aortic Root Replacement: 13-Year Experience of David Operation.

BACKGROUND: The best approach for aortic root disease remains controversial. Composite valve-graft conduit (CVG) replacement offers good results at short-term and long-term follow-up; on the other hand, valve-sparing aortic root replacement (VSARR) has proven to be an excellent treatment alternative. This study aimed to analyse the outcomes after VSARR and compare whether preoperative moderate or severe aortic regurgitation (AR) and or the need for aortic valve repair (AVR) during this procedure influenced survival and freedom from reoperation rates. METHODS: From September 2005 to June 2018, 104 patients underwent VSARR using the reimplantation technique: 64% presented with preoperative moderate or severe AR, concomitant AVR was performed in 43.3%, Marfan syndrome was present in 16.3%, and 12.5% had a bicuspid aortic valve. Complete follow-up was obtained in 91% of the sample, echocardiographic results were available for 86% and the mean follow-up time was 1,893 days. RESULTS: In-hospital mortality was 2.9% and one death occurred 42 days after hospital discharge. In the latest echocardiographic assessment, 88.3% presented with mild AR or better. Freedom from reoperation at 8 years was 95.4%. There was no case of endocarditis and one patient had a stroke 2 years after the operation. There were no between-group differences in morbidity, mortality and complications during the follow-up. CONCLUSION: VSARR can be performed with low mortality rates and reasonable durability of the aortic valve. Neither moderate or severe AR nor the need for aortic valve repair during the procedure altered survival and freedom from reoperation.

The learning curve effect on outcomes with frozen elephant trunk technique for extensive thoracic aorta disease.

OBJECTIVE: The purpose of this study was to analyze the learning curve effect on hospital mortality, postoperative outcomes, freedom from reintervention in the aorta and long-term survival after frozen elephant trunk (FET) operation. METHODS: From July 2009 to June 2018, 79 patients underwent surgery with the FET technique. They had type A aortic dissection (acute 7.6%, chronic 33%), type B aortic dissection (acute 1.26%, chronic 34.2%), and complex thoracic aortic aneurysm (24%). 27.8% were reoperations and 43% received concomitant cardiac procedures. To compare the results, the sample was divided into group 1 (G1) (first half of the sample - operations from 2009 to 2014) and group 2 (G2) (first half of the sample - operations from 2015 to 2018). RESULTS: The in-hospital mortality was 20.25%, 30.7% for G1 and 10% for G2 (P = .02). The mean cardiopulmonary bypass time, myocardial ischemia time, and selective cerebral perfusion at 25°C time were 154 ± 31, 118 ± 32, and 59 ± 12 minutes, respectively, similar for both groups. Stroke and spinal cord injury occurred in four and two patients, with no difference between groups (P = .61 and P = .24). The necessity for secondary intervention on the downstream aorta for both groups was also similar (P = .136). Five of sixty-three surviving patients died during the follow-up period and the estimated survival rate was different between groups 49% vs 88% (P = .007). CONCLUSION: The learning curve with the FET procedure had a significant impact on hospital mortality and midterm survival over the follow-up period, albeit did not influence the freedom from reintervention on the downstream aorta.

When Aortic Stenting Alone Does Not Solve It: Mass Effect of Thoracic Aneurysms.

Thoracic aneurysms can potentially cause substantial compression of adjacent structures, creating substantial symptoms. We present a case of a 56-year-old woman with fatigue and dyspnea for 6 months. We discuss her initial endovascular treatment, which was insufficient to improve symptoms, and further surgical intervention was needed to solve the issue.

Complication of hybrid treatment in type B aortic dissection diagnosed by echocardiography.

This case illustrates an unusual and fatal complication after endovascular treatment of type B aortic dissection and highlights the role of echocardiography in the early diagnosis of complications. In this case, a patient with previous diagnosis of chronic type B aortic dissection and moderate aortic regurgitation underwent endovascular repair of the proximal descending aorta and conservative surgical correction of the aortic valve. On early postoperative, a transesophageal echocardiogram and aortic angiotomography demonstrated proximal endoleak by contrast extravasation around the proximal graft attachment site, causing compression of the stent in its middle portion, resulting in narrowing with reduced cross-sectional area.

Why do aortas cleave or dilate? Clues from an electronic scanning microscopy study in human ascending aortas.

In ascending aorta aneurysms (AscAA) the whole vessel wall dilates, while in aortic dissections (AD) the wall cleaves into two sheets. Both may present fine elastic fragmentation and a decrease in collagen. We analyzed whether alterations in the three-dimensional structure of these fibers could be involved in the pathogenesis of AscAA/AD. Specimens obtained at surgery for these diseases (n = 4 for each) and on coronary artery bypass surgery (controls, n = 4) were submitted to treatments which either preserve collagen or the elastic structure. These samples were examined by scanning electron microscopy. In all groups most of the collagen fibers were packed, forming laminar structures very similar to the elastic lamellae. In AscAA/AD, the fibers showed signs of degradation and/or fragmentation. Elastic tissue was distributed in large sheets with fenestrations, with smaller branches between them. In 1 of the dissection cases and 2 of the aneurysm cases elastic sheet fragmentation, which under light microscopy seems to be located at random, had a pattern of clefts which were irregular but approximately transversal to the main axis of the wall. The recognition of this pattern and the degradation/fragmentation of collagen and elastic fibrils facilitates understanding of why the wall is weak and affected by aneurysms and dissections.

Rare association between giant-cell aortitis and giant-cell aortic valvulitis.

Giant cell arteritis (GCA) is a type of chronic vasculitis that affects medium and large-caliber arteries, frequently related to aortic involvement and, consequently, to aneurysm formation. However, associated valvulitis with giant cells is uncommon. We describe the case of a 50-year-old female patient with aortic aneurysm and valvular insufficiency, whose anatomopathological examination revealed giant-cell aortic valvulitis associated with giant cell aortitis.

Nonatherosclerotic Giant Right Coronary Artery Aneurysm.

We present an unusual case of a 67-year-old woman with an incidental finding of a cardiac mass on a chest computed tomography. Coronary angiotomography confirmed the diagnosis of right coronary artery aneurysm, with 5.7×5.7 cm. The patient underwent aneurysm resection and coronary bypass surgery, with subsequent histologic study suggestive of arteritis sequelae. Giant coronary artery aneurysms have a high risk of complications and aneurysm exclusion must be beneficial. This is a rare condition that can also be part of a systemic inflammatory disease.

Protective effects of 17ß-oestradiol on coagulation and systemic inflammation after total occlusion of the descending aorta in male rats.

OBJECTIVES: The surgical treatment for diseases of the descending aorta is related to a high mortality rate because of the activation of a systemic inflammatory process due to ischaemia and reperfusion (I/R) injury. Activation of coagulation can contribute to the inflammatory process, resulting in microcirculatory damage and multiple organ failure. Our goal was to evaluate the role of prophylactic intravenous 17ß-oestradiol (E2) in coagulation, the inflammatory response and hepatic injury after occlusion of the descendent proximal aorta in male rats. METHODS: Wistar male rats were randomized and allocated to 3 groups (n = 8 per group): sham, surgically manipulated; IR, animals subjected to I/R; and E2, animals treated with E2 (280 µg/kg, intravenously) before I/R. I/R was induced by insertion of a 2-Fr Fogarty arterial embolectomy catheter in the descending aorta, which was occluded for 20 min, followed by a reperfusion period of 2 h. Serological markers, platelet aggregation, hepatic vascular flow, systemic and liver inflammatory response and apoptosis were analysed. The coagulation process was evaluated by thromboelastometry. RESULTS: The aortic occlusion led to a reduction in plasma fibrinogen concentration in parallel with increased clotting time, greater clot firmness and reduced lysis. E2 treatment was able to increase fibrinogen, prevent the increase in clotting time and normalize clot firmness, but it exerted only a mild effect on clot lysis. Platelet aggregation was increased by IR, and E2 treatment was able to reduce it. There was a reduction in flow percentage in the IR group that was not prevented by E2. In parallel, higher aggregate formation was observed in the vessels of the IR group of animals. There was increased systemic release of interleukin-1-ß, interleukin-6 and interleukin-10 in the IR group, which was reduced in the treated animals. CONCLUSIONS: The current results suggest that pretreatment with E2 before an ischaemic period induced by occlusion of the proximal descending aorta is effective in preventing alterations in coagulation and systemic inflammation due to I/R injury.

Treatment With Methotrexate Associated With Lipid Core Nanoparticles Prevents Aortic Dilation in a Murine Model of Marfan Syndrome.

In Marfan syndrome (MFS), dilation, dissection, and rupture of the aorta occur. Inflammation can be involved in the pathogenicity of aortic defects and can thus be a therapeutic target for MFS. Previously, we showed that the formulation of methotrexate (MTX) associated with lipid nanoparticles (LDE) has potent anti-inflammatory effects without toxicity. To investigate whether LDEMTX treatment can prevent the development of aortic lesions in the MFS murine model. MgΔloxPneo MFS (n = 40) and wild-type (WT, n = 60) mice were allocated to 6 groups weekly injected with IP solutions of: (1) only LDE; (2) commercial MTX; (3) LDEMTX (dose = 1mg/kg) between 3rd and 6th months of life. After 12 weeks of treatments, animals were examined by echocardiography and euthanatized for morphometric and molecular studies. MFS mice treated with LDEMTX showed narrower lumens in the aortic arch, as well as in the ascending and descending aorta. LDEMTX reduced fibrosis and the number of dissections in MFS but not the number of elastic fiber disruptions. In MFS mice, LDEMTX treatment lowered protein expression of pro-inflammatory factors macrophages (CD68), T-lymphocytes (CD3), tumor necrosis factor-α (TNF-α), apoptotic factor cleaved-caspase 3, and type 1 collagen and lowered the protein expression of the transforming growth factor-ß (TGF-ß), extracellular signal-regulated kinases ½ (ERK1/2), and SMAD3. Protein expression of CD68 and CD3 had a positive correlation with an area of aortic lumen (r 2 = 0.36; p < 0.001), suggesting the importance of inflammation in the causative mechanisms of aortic dilation. Enhanced adenosine availability by LDEMTX was suggested by higher aortic expression of an anti-adenosine A2a receptor (A2a) and lower adenosine deaminase expression. Commercial MTX had negligible effects. LDEMTX prevented the development of MFS-associated aortic defects and can thus be a candidate for testing in clinical studies.

Brazilian Single-Center Experience with Aortic Root Replacement in 448 Patients: What Is the Best Technique?

INTRODUCTION: The objective of this study was to evaluate whether a surgery with the use of valved conduit is capable of leading to better immediate and late results than those obtained by the valve-sparing aortic root reconstruction technique. METHODS: Between January 2002 and June 2016, 448 patients underwent aortic root reconstruction. These were divided into three groups according to the technique used: 319 (71.2%) patients received mechanical valved conduits, 49 (10.9%) received biological valved conduits, and 80 (17.9%) underwent the valve-sparing aortic root reconstruction technique. The results were examined by univariate and multivariate analyses of Cox proportional hazards models with multiple logistic regression. RESULTS: The hospital mortality rate was 7.5%. The mortality rates were 8.2%, 12%, and 2.5% in the mechanical valved conduit, biological valved conduit, and aortic valve-sparing groups, respectively, with no significant difference between groups (P=0.1). Thromboembolic complications and reoperationfree survival were also similar (P=0.169 and P=0.688). However, valve-sparing aortic root replacement was superior in terms of long-term survival (P<0.001), hemorrhagic-free survival (P<0.001), and endocarditis-free survival (P=0.048). Multivariate analysis showed that the following aspects had an impact on mortality: age > 70 years (P<0.001; hazard ratio [HR] 1.05), preoperative acute kidney injury (P<0.0042; HR 2.9), diagnosis of dissection (P<0.01; HR 2.0), previous cardiac surgery (P<0.027; HR 2.3), associated coronary artery bypass grafting (P<0.038; HR 1.8), reoperation for postoperative tamponade (P<0.004; HR 2.2) and postoperative acute kidney injury (P<0.02; HR 3.35). CONCLUSION: Valve-sparing technique seems to be the operation of choice, whenever possible, for aortic root reconstruction.

Mitochondria in aneurysms and dissections of the human ascending aorta.

Factors causing the weakness that underlies thoracic aorta aneurysms and dissections are not well known. Based on the findings of apoptosis and ischemic-like necrosis, we hypothesized a possible role for mitochondrial disturbances in the pathogenesis of these diseases. To evaluate if mitochondria at the aortic medial layer are damaged, samples of ascending aortas with aneurysms (n = 6), acute dissections (n = 5), and hypertensive (n = 9) and normotensive controls (n = 7) were analyzed by transmission electron microscopy. Number of mitochondria, areas of cytoplasm, and areas of mitochondria were measured, and area percentage of the cytoplasm corresponding to mitochondria, their number by unit of area, and their mean area were calculated in randomly taken photographs. Data were compared using one-way analysis of variance or Kruskal-Wallis tests. Significant differences (P ≤ 0.05) were found in the number of mitochondria and their mean area, showing opposite results: the number increased and the mean area decreased from normotensive controls to hypertensive controls to acute dissections to aneurysms, although post hoc tests showed that only the differences between the aneurysms and either both controls (number of mitochondria/mm2: 10.37 in normotensive controls, 15.61 in hypertensive controls, and 43.67 in aneurysms) or normotensive controls only (mean area: 2800.15 in normotensive controls vs 894.91 µm2 in aneurysms) were significant. In conclusion, there are more, smaller mitochondria in ascending aorta aneurysms. This pattern possibly corresponds to dysfunctional mitochondria, indicating that alterations in the dynamics of these organelles may play a role in the pathogenesis of thoracic aorta aneurysms and dissections.

Galectin-3 Levels in Patients with Chronic Constrictive Pericarditis. / Galectina-3 em Pacientes com Pericardite Constritiva Crônica.

Background Galectin-3 (Gal-3) is a proinflammatory, profibrotic molecule implicated in the pathogenesis of heart failure. The role of Gal-3 in patients with chronic constrictive pericarditis (CCP) is not clear. Objective The aim of this study was to assess plasma Gal-3 in patients with CCP and correlate it with clinical, functional and histologic parameters. Methods We prospectively evaluated 25 symptomatic patients with CCP referred for pericardiectomy and 21 healthy controls. Patients underwent clinical assessment, Gal-3 and B-type natriuretic peptide (BNP) measurements, echocardiography, cardiac magnetic resonance imaging and cardiopulmonary exercise test (CPET) at baseline. Six months after pericardiectomy CPET was repeated. An alpha error < 5% was considered statistically significant, with a confidence interval of 95%. Results Twenty-five patients with a median age of 45 years were included. Etiology was mainly idiopathic (n = 19, 76%); and 14 (56%) patients had NYHA functional class III/IV. Median BNP and Gal-3 were 143 (89-209) pg/dL and 14.8 (9.7-17.2) ng/mL, respectively. Gal-3 levels were not significantly higher in CCP patients than in control (p = 0.22). There were no significant correlations of Gal-3 with BNP, echocardiographic and cardiac magnetic resonance measures and histological findings. After pericardiectomy, it was found a statistically significant correlation between Gal-3 and the CPTE measures test duration (r = -0.79; p < 0.001) and exercise time (r = -0.79; p < 0.001). Conclusions Patients with CCP had normal levels of Gal-3 as compared to the controls. Gal-3 did not correlate with morphological and functional measures before pericardiectomy. However, the associations between Gal-3 and exercise intolerance after pericardiectomy may suggest a role of Gal-3 in prognosis prediction after pericardiectomy. (Arq Bras Cardiol. 2020; 114(4):683-689).

Analysis of >100,000 Cardiovascular Surgeries Performed at the Heart Institute and a New Era of Outcomes.

BACKGROUND: The current challenge of cardiovascular surgery (CVS) is to improve the outcomes in increasingly severe patients. In this respect, continuous quality improvement (CQI) programs have had an impact on outcomes. OBJECTIVE: To assess the evolution of the incidence and mortality due to CVS, as well as the current outcomes of the Hospital das Clínicas Heart Institute of the University of São Paulo Medical School (InCor-HCFMUSP). METHODS: An outcome analysis of CVSs performed at the InCor, between January 1984 and June 2019. We observed the surgical volume and mortality rates in 5 time periods: 1st (1984-1989), 2nd (1990-1999), 3rd (2000-2007), 4th (2008-2015) and 5th (2016-2019). The CQI program was implemented between 2015 and 2016. The analysis included the total number of surgeries and the evolution of the most frequent procedures. RESULTS: A total of 105,599 CCVs were performed, with an annual mean of 2,964 procedures and mortality of 5,63%. When comparing the 4th and the 5th periods, the average global volume of surgeries was increased from 2,943 to 3,139 (p = 0.368), bypass graft (CABG), from 638 to 597 (p = 0.214), heart valve surgery, from 372 to 465 (p = 0.201), and congenital heart disease surgery, from 530 to 615 (p = 0.125). The average global mortality went from 7.8% to 5% (p < 0.0001); in CABG surgery, from 5.8% to 3.1% (p < 0.0001); in heart valve surgery, from 14% to 7.5% (p < 0.0001) and in congenital heart disease surgery, from 12.1% to 9.6% (p < 0.0001). CONCLUSION: In spite of a recent trend towards increased surgical volume, there was a significant decrease in operative mortality in the groups studied. After the implementation of the CQI program, the mortality rates were closer to international standards.

Impact of pericardiectomy on exercise capacity and sleep of patients with chronic constrictive pericarditis.

BACKGROUND: Heart failure is associated with exercise intolerance and sleep- disordered breathing; however, studies in patients with chronic constrictive pericarditis are scarce. The purpose of our study was to assess exercise capacity and sleep in patients with chronic constrictive pericarditis (CCP) undergoing a pericardiectomy. METHODS: We studied consecutive patients scheduled for pericardiectomy due to symptomatic CCP. Were performed quality of life (Minnesota Living with Heart Failure Questionnaire-MLHFQ) and sleep questionnaires (Epworth, Pittsburgh Sleep Quality Index-PSQI), serum B-type natriuretic peptide (BNP), serum C-reactive protein, transthoracic echocardiography, cardiopulmonary exercise test and overnight polysomnography immediately before and six months after pericardiectomy. RESULTS: Twenty-five patients (76% males, age: 45.5±13.8 years, body mass index: 24.9±3.7 kg/m2, left ventricular ejection fraction: 60±6%) with CCP (76% idiopathic, 12% tuberculosis) were studied. As compared to the preoperative period, pericardiectomy resulted in reduction in BNP (143 (83.5-209.5) vs 76 (40-117.5) pg/mL, p = 0.011), improvement in VO2 peak (18.7±5.6 vs. 25.2±6.3 mL/kg/min, p<0.001), quality of life (MLHFQ score 62 (43,5-77,5) vs. 18 (8,5-22), p<0,001) and sleep (PSQI score 7.8±4.1 vs. 4.7±3.7, p<0.001) and no significant change in sleep disordered breathing (apnea hypopnea index-AHI 15.6 (8.3-31.7) vs. 14.6 (5.75-29.9) events/h, p = 0.253). CONCLUSION: Patients with symptomatic CCP showed reduced exercise capacity and sleep-disordered breathing. After pericardiectomy, there was improvement in exercise capacity and neutral effect on sleep-disordered breathing.

Collagen is reduced and disrupted in human aneurysms and dissections of ascending aorta.

In ascending aorta aneurysms, there is an enlargement of the whole vessel, whereas aortic dissections (ADs) are characterized by the cleavage of the wall into 2 sheets at the external half. We searched if alterations in collagen could be related to these diseases. Sections of aortas from 14 case patients with acute dissections, 10 case patients with aneurysms, and 9 control subjects were stained with picrosirius. Slides were analyzed under polarized microscopy to evaluate the structure of collagen fibers. The proportion of collagen was calculated in each half of the medial layer by color detection in a computerized image analysis system. Collagen appearance under polarized light was consistent with collagenolysis. The mean collagen proportions at the inner and outer halves, respectively, were 0.50 +/- 0.13 and 0.40 +/- 0.08 in the control group, 0.20 +/- 0.10 and 0.18 +/- 0.12 in the AD group, and 0.33 +/- 0.12 and 0.19 +/- 0.12 in the aneurysm group. The AD (P < .01) and control (P = .04) groups had less collagen at the external half; no difference was found in the aneurysm group (P = .71). In both halves, there was less collagen in the case patients than in the control subjects (all P < .01), but at the internal half, the decrease was significantly greater in the case patients with aneurysms than in those with dissections (P = .03; at the external half, P = .99). Aortic dissections and aneurysms show a decrease in collagen content that could be related to a weakness of the wall underlying the diseases, but the locations of the decrease differ: in dissections, it is situated mostly at the external portion of the media (site of cleavage), whereas in aneurysms, it is more diffuse, consistent with the global enlargement.

Use of 3D Printing in Preoperative Planning and Training for Aortic Endovascular Repair and Aortic Valve Disease.

INTRODUCTION: Three-dimensional (3D) printing has become an affordable tool for assisting heart surgeons in the aorta endovascular field, both in surgical planning, education and training of residents and students. This technique permits the construction of physical prototypes from conventional medical images by converting the anatomical information into computer aided design (CAD) files. OBJECTIVE: To present the 3D printing feature on developing prototypes leading to improved aortic endovascular surgical planning, as well as transcatheter aortic valve implantation, and mainly enabling training of the surgical procedure to be performed on patient's specific condition. METHODS: Six 3D printed real scale prototypes were built representing different aortic diseases, taken from real patients, to simulate the correction of the disease with endoprosthesis deployment. RESULTS: In the hybrid room, the 3D prototypes were examined under fluoroscopy, making it possible to obtain images that clearly delimited the walls of the aorta and its details. The endovascular simulation was then able to be performed, by correctly positioning the endoprosthesis, followed by its deployment. CONCLUSION: The 3D printing allowed the construction of aortic diseases realistic prototypes, offering a 3D view from the two-dimensional image of computed tomography (CT) angiography, allowing better surgical planning and surgeon training in the specific case beforehand.

Rare association between giant-cell aortitis and giant-cell aortic valvulitis

ABSTRACT Giant cell arteritis (GCA) is a type of chronic vasculitis that affects medium and large-caliber arteries, frequently related to aortic involvement and, consequently, to aneurysm formation. However, associated valvulitis with giant cells is uncommon. We describe the case of a 50-year-old female patient with aortic aneurysm and valvular insufficiency, whose anatomopathological examination revealed giant-cell aortic valvulitis associated with giant cell aortitis.

Perioperative Management of the Diabetic Patient Referred to Cardiac Surgery.

Currently there is a progressive increase in the prevalence of diabetes in a referred for cardiovascular surgery. Benefits of glycemic management (< 180 mg/dL) in diabetic patients compared to patients without diabetes in perioperative cardiac surgery. The purpose of this study is to present recommendations based on international evidence and adapted to our clinical practice for the perioperative management of hyperglycemia in adult patients with and without diabetes undergoing cardiovascular surgery. This update is based on the latest current literature derived from articles and guidelines regarding perioperative management of diabetic patients to cardiovascular surgery.