Outcomes of open surgical repair for chronic type B aortic dissections.

OBJECTIVE: Open surgical repair (OSR) for chronic type B aortic dissection (CTBAD) has an associated morbidity and mortality. The role of thoracic endovascular aortic repair (TEVAR) in CTBAD has not been determined. We analyzed our contemporary experience of CTBAD undergoing OSR to identify high-risk patients who may be considered for TEVAR. METHODS: From 1999 to 2010, 221 patients had repair of descending thoracic and thoracoabdominal aortic aneurysms, including 86 patients with CTBADs. We analyzed this cohort for mortality, complications, length of stay, and reinterventions. RESULTS: OSR was performed in 25 (29%) and 61 (71%) patients for descending thoracic and thoracoabdominal CTBAD, respectively. Median age was 57.0 years (interquartile range [IQR], 52.0-64.2 years), and median diameter was 6.0 cm (IQR, 5.0-6.9 cm). Fifty-nine patients (69%) were male. Eight (9%) were treated for rupture. Follow-up duration was 4.6 years (IQR, 2.8-6.9 years). Hospital mortality occurred in five patients (5.8%). Cardiopulmonary bypass was used in 83 patients (97%) and deep hypothermic arrest in 36 (42%). Two patients (2.3%) each developed paraplegia, stroke, and renal failure requiring permanent hemodialysis in the postoperative period. Length of stay was 13.5 days (IQR, 10.0-21.0 days). Univariate predictors of hospital death included redo operations and prolonged pump time (P < .05). Six patients (7%) had aortic-related reoperations at 4.3 years (IQR, 2.7-5.2 years): one for an ascending aortic aneurysm and five for descending aortic aneurysms. Overall survival at 1, 5, and 7 years was 92%, 83%, and 70%, respectively, and freedom from reoperation was 99%, 90%, and 86%, respectively. CONCLUSIONS: OSR of CTBAD is a durable option with low mortality. Patients requiring redo operations or anticipated prolonged pump time need further evaluation to determine whether conventional OSR or TEVAR, if feasible, is the optimal treatment option.

Profiling the Biomechanical Responses to Workload on the Human Myocyte to Explore the Concept of Myocardial Fatigue and Reversibility: Rationale and Design of the POWER Heart Failure Study.

It remains unclear why some patients develop heart failure without evidence of structural damage. One theory relates to impaired myocardial energetics and ventricular-arterial decoupling as the heart works against adverse mechanical load. In this original study, we propose the novel concept of myocardial fatigue to capture this phenomenon and aim to investigate this using human cardiomyocytes subjected to a modern work-loop contractility model that closely mimics in vivo cardiac cycles. This proof-of-concept study (NCT04899635) will use human myocardial tissue samples from patients undergoing cardiac surgery to develop a reproducible protocol to isolate robust calcium-tolerant cardiomyocytes. Thereafter, work-loop contractility experiments will be performed over a range of preload, afterload and cycle frequency as a function of time to elicit any reversible reduction in contractile performance (i.e. fatigue). This will provide novel insight into mechanisms behind heart failure and myocardial recovery and serve as a valuable research platform in translational cardiovascular research.

A giant coronary artery aneurysm in the right coronary artery.

Aneurysms of the coronary arteries are uncommon occurrences that usually develop secondary to atherosclerosis and are often asymptomatic. They are usually diagnosed incidentally during investigation for ischemic heart disease or at autopsy for sudden death. We present a case of a "giant" right coronary artery aneurysm (CAA) discovered incidentally at surgery. Pathological examination confirmed that this was a true aneurysm showing marked thinning of the media and fibrocalcific plaques with small, multifocal areas of lymphocytic infiltrates.

Review of pediatric airway malacia and its management, with emphasis on stenting.

Malacia of the pediatric airway presents itself in a variety of clinical circumstances. Pediatric airway stenting is a more recent treatment modality. Complications may necessitate stent removal. This is usually performed bronchoscopically. We were forced to surgically remove a complicated airway stent. The Palmaz stent had been inserted for bronchomalacia presenting after interrupted aortic arch surgery in a 4-month old child with DiGeorge syndrome. This prompted us to review pediatric airway malacia, its management options and long-term outcomes, in an attempt to crystallize the current status of this relatively uncommon and difficult issue. The role of stents is analysed.

First report of no-react bovine internal mammary artery performance and patency.

BACKGROUND: No-React treatment is known to render tissues resistant to calcific degeneration and to reduce early inflammatory response. No-React bovine internal mammary artery (NR-IMA) is available for restricted use in Europe. In this first study, our aim was to use magnetic resonance imaging (MRI) to investigate the clinical performance and patency rates of this conduit. METHODS: Seven patients received 8 grafts with NR-IMA. Approval from the Medical Devices Agency of the United Kingdom was obtained for use of this material. One patient needed salvage coronary artery bypass grafting (CABG). Graft patency was investigated with cardiac MRI. One patient was excluded from the MRI study because of the presence of intracerebral metal clips. The mean follow-up period was 2.5 years with a range of 1 to 4.5 years. RESULTS: There was no mortality in this group. After treatment 6 patients were asymptomatic, and 1 patient had class II anginal symptoms. Four (57%) of the 7 NR-IMA grafts remained patent. The longest patency was 4.5 years in a patient who underwent salvage CABG. Other associated grafts in this cohort of patients were 5 left internal mammary arteries (all patent), 1 radial artery graft (patent), and 7 saphenous vein grafts (4 [57%] of 7 patent). There were no occluded NR-IMA grafts in a patient with patent vein grafts. CONCLUSION: We concluded that at 2.5 year follow-up, NR-IMA had a patency rate of 57% (4 of 7 cases). This rate matched the vein graft patency rate in this cohort of patients. With the longest patency of 4.5 years, use of NR-IMA seems to hold promise for the future.

Somatosensory-evoked potential-guided intercostal artery reimplantation in thoracoabdominal aortic aneurysm surgery.

OBJECTIVE: This study was undertaken to evaluate the use of somatosensory-evokedpotential (SSEP) monitoring on intercostal artery reimplantation (IAR) and spinal cord ischemia rates during thoracoabdominal ortic aneurysm repair. METHODS: Fifty-two patients had thoracoabdominal aortic aneurysm repair with IAR under SSEP guidance and 79 patients had repair with routine IAR without SSEP guidance from 1999 to 2010. RESULTS: No differences were observed between the two groups in age (63.1 ± 11.6 vs 64.8 ± 9.8 years), sex (57.7% vs 50.6% men), chronic dissections (40.4% vs 44.3%), renal insufficiency (11.5% vs 10.1%), and Crawford type 1 and 2 aneurysms (53.9% vs 53.9%). There was one case (1.9%) of immediate paraplegia and one case (1.9%) of delayed paraplegia in the SSEP group versus 2 cases (2.5%) of immediate paraplegia in the non-SSEP group (P = 0.92). In the SSEP group, 38 patients (73.1%) had SSEP changes, but only 15 (28.8%) required reimplantation. There were fewer IARs in the SSEP group compared with the non-SSEP group (28.8% vs. 59.5%, P = 0.004). No difference was observed in 30-day mortality between the SSEP and the non-SSEP group (3.9% vs. 7.6%, P = 0.48). CONCLUSIONS: The use of SSEP monitoring led to a significant decrease in the need for IAR without increasing the paraplegia rate.

Hybrid minimally invasive extraction of atrial clot avoids redo sternotomy in Jehovah's Witness.

We report the novel use of the AngioVac device in a percutaneous hybrid approach to remove a large right atrial clot as an effective and potentially lifesaving alternative to a very high-risk redo-sternotomy in a Jehovah's Witness patient.

Heterotaxy syndrome with azygous continuation-causing pseudo Budd-Chiari syndrome after cardiopulmonary bypass.

Heterotaxy syndrome with interruption of the inferior vena cava and direct hepatic vein inflow into the right atrium has important implications for cardiac surgery. We report a case causing pseudo Budd-Chiari syndrome after cardiopulmonary bypass.

Thoracic complications of nasogastric tube: review of safe practice.

OBJECTIVES: Insertion of a nasogastric tube, though a common clinical procedure, can produce unexpected complications. We sought to analyse the procedure, and explore means to improve its safety. METHODS: We present a case with a thoracic complication. We review the English literature for the range of complications, and collate all available clinical tests used to confirm enteric placement. RESULTS: We discuss the short-comings of the usual clinical tests and emphasise the more recent, but less mainstream, procedures that introduce more objectivity to the enteric tube placement. CONCLUSIONS: We provide summary points to guide the clinician in everyday practice.

A diagnostic challenge--an unusual right atrial mass, 12 years following atrial septal defect surgery.

A young girl presented with a right atrial mass, 12 years following ostium secundum atrial septal defect surgery. The unusual pathology and the various diagnostic considerations for an atrial mass are discussed.

Cardiac tamponade: a rare complication after pulmonary lobectomy.

OBJECTIVE: Pulmonary lobectomy for lung cancer is a well-established and safe operation. This report serves to highlight an important complication and an underlying essential surgical principle when performing pulmonary resections, to avoid a potentially fatal outcome. METHODS: A case report is presented. We describe an unusual case of cardiac tamponade complicating a left upper lobectomy. RESULTS: The few cases described in the literature are reviewed to reveal interesting causative mechanisms. The intrapericardial anatomy of the pulmonary hilum is discussed. CONCLUSIONS: A high index of clinical suspicion is required in refractory, unexplained hypotension after lung resection. Strict adherence to secure pulmonary vein ligation is as important as it is in dealing with the pulmonary artery.

Coronary ostial stenosis after aortic valve replacement, revisited.

Coronary artery occlusive disease that develops after an uncomplicated aortic valve replacement is well recognized. We present a case that required two further coronary operations and two salvage angioplasty procedures for a continuing fibrotic process in the ascending aorta. The literature and pathology are reviewed.