Hybrid three-stage repair of mega-aortic syndrome with the Lupiae technique: 10-year results.

BACKGROUND: Mega-aortic syndrome (MAS) is a rare disease carrying a poor prognosis if treated conservatively. Open repairs of these aneurysms are invasive, while totally endovascular repairs are associated with higher rates of late reintervention due to endoleaks, compromising long-term prognosis. We describe the 10-year results of a hybrid three-stage approach to MAS using the Lupiae technique. METHODS: Between 2006 and 2016, 27 patients with MAS extending from the ascending aorta to the iliac arteries (MAS type III) underwent: (I) a surgical aortic arch debranching, using the Vascutek Lupiae™ multibranched graft to create a proximal Dacron landing zone; (II) an abdominal aorta debranching to create a distal Dacron landing zone and (III) the implantation of multiple endovascular stents to exclude any residual aneurysm between the two landing zones. RESULTS: One patient died following the first stage, and another following the second stage of the repair (overall mortality 7.4%). The interval between the first and the second stage was 58.3±16.1 days. The interval between the second and the third stage was 47.7±13.1 days. Four-year survival was 88.6%±6.2% while 10-year survival was 51.7%±17.9%. One patient had a type III endoleak after the third stage that self-resolved within 6 months without intervention. No patient had type I or II endoleaks and none underwent redo procedures. Mean follow-up was 5.9±3.6 years and completeness was 100%. CONCLUSIONS: Three-stage hybrid repairs using the Lupiae technique can be safely performed in MAS type III patients. Short intervals between the stages should mitigate the risk of rupture during the waiting periods and may enhance patient compliance, but to achieve this, the burden and the complexity of the first stage must be carefully weighted. Our strategy improves the long-term survival of these patients compared to their natural history and is less invasive than an open repair. The adoption of Dacron landing zones appears to be associated with very low rates of reintervention due to endoleaks.

Congenital Aorto-Right Ventricular Fistula Associated with Pulmonary Hypertension in an Old Female Patient.

We report a late clinical presentation of an aorto-right ventricular fistula (RVF) extending from the right sinus of Valsalva into the RV outflow tract with significant left-to-right shunt and severe pulmonary hypertension. A three-dimensional transesophageal echocardiogram and a chest-computed tomography scans were performed to better characterize the abnormality. Aorto- RVF can be either congenital or acquired, secondary to endocarditis, Valsalva aneurysm rupture, chest trauma, or aortic dissection.

Transcatheter Simultaneous Double-Transapical Access for Paravalvular Mitral Leak Closure Using the Occlutech PLD.

A 67-year-old patient with rheumatic heart valve disease had undergone two cardiac surgeries at the age of 30 years, then re-do with mitral valve replacement at 50 years. She presented with congestive heart failure and hemolytic anemia. Doppler echocardiography showed moderate-severe mitral regurgitation due to paravalvular mitral valve leak (PVML) and severe pulmonary hypertension. Transesophageal echocardiography demonstrated severe PVML secondary to a large 20 mm-long PVML defect. Due to comorbidities, the heart team deemed a third reoperation at very high surgical risk; therefore, the patient was considered most suitable for a transcatheter approach to PVML closure. Two Occlutech paravalvular leak devices were successfully delivered using a simultaneous double-transapical access with double-wire technique.

Cardiac troponin I release after coronary artery bypass grafting operation: effects on operative and midterm survival.

BACKGROUND: Markers of myocardial necrosis are usually elevated in patients who have undergone a coronary bypass operation with cardiac arrest. The preferred marker in detecting acute myocardial ischemia is cardiac troponin I (cTnI). However, its ability to predict short-term and, particularly, midterm outcome after coronary bypass operations is uncertain. METHODS: Two hundred thirty unselected patients undergoing surgical revascularization had cTnI measured preoperatively and 11 times postoperatively. Receiver operating characteristic curves were constructed using cTnI postoperative peak values in order to assess the prognostic sensitivity and specificity of the test. The cut-off value of 13 ng/mL was used to assess the prognostic significance of the peak cTnI postoperative release for short-term and midterm outcomes. RESULTS: One hundred forty-six patients (63.5%) had postoperative cTnI peak values less than 13 ng/mL (mean peak value, 6.6 +/- 3.1 ng/mL) and 84 patients (36.5%) had postoperative cTnI peak values greater than 13 ng/mL (mean peak value, 45.5 +/- 59.9 ng/mL). Patients with peak cTnI greater than 13 ng/mL were older and had higher preoperative cTnI values. They required both longer cross-clamp time and CPB time. Moreover, hospital death in the cTnI greater than 13 ng/mL group (9.5% versus 0.7%, p = 0.0009) was significantly higher. Multivariate analysis showed that cTnI greater than 13 ng/mL was the only independent predictor of hospital death (odds ratio 10.33, p = 0.04) and hospital death from cardiac causes. A 2-year follow-up demonstrates that cTnI postoperative release had no influence on midterm mortality and hospitalization for due to cardiac illness. CONCLUSIONS: Cardiac troponin I is a valuable marker for immediate myocardial damage after coronary bypass operations. Its postoperative release does not predict midterm outcome.

Early onset of heparin-induced thrombocytopenia with thrombosis after open heart surgery: importance of an early diagnosis and Lepirudin treatment.

Heparin-induced thrombocytopenia with thrombosis (HITT) is a rare complication of cardiac surgery with cardiopulmonary bypass. We report two cases of HITT treated with the direct thrombin inhibitor Lepirudin. Immediate diagnosis was essential to prompt heparin discontinuation and successful early Lepirudin administration in the first case. In the second, the presence of an intra-aortic balloon pump delayed HITT recognition, and Lepirudin infusion could not prevent limb amputation. In both cases HITT occurred earlier (< 5 days after heparin exposure) than its usual presentation.