Transversal Arch Clamping for Complete Resection of Aneurysms of the Distal Ascending Aorta without Open Anastomosis.

BACKGROUND: The extent of aortic replacement for aneurysms of the distal ascending aorta remains controversial and opinions vary between standard cross-clamp resection and open hemiarch anastomosis in circulatory arrest and selective cerebral perfusion. As the deleterious effects of extended circulatory arrest are well-known, borderline indication for distal ascending aorta aneurysm repair must be outweighed against the potential risk of complications related to the open anastomosis. In the present study, we describe our own approach consisting of "transversal arch clamping" for exhaustive resection of aneurysms of the distal ascending aorta without open anastomosis and we present the postoperative outcomes. METHODS: Between May 2017 and December 2019, 35 patients with aneurysm of the ascending aorta (20 male, 15 female) underwent replacement with repair of the lesser curvature without circulatory arrest. Pre-operative, intraoperative, and postoperative clinical outcomes were retrospectively withdrawn from our institutional database and analyzed. RESULTS: Maximal diameter of distal ascending aorta was 47.5 mm. Patient median age was 66 years (IQR 14) (range 42-86). Preoperative logistic median EuroSCORE II was 17% (IQR 11.3). Median duration of cardiopulmonary bypass and cardiac arrest were 137 (IQR 64) and 93 (IQR 59) min, respectively. In-hospital and 30-day mortality were 0%. There were no cases with acute low output syndrome, surgical re-exploration for bleeding, kidney injury requiring dialysis, or wound infection. Disabling stroke was observed in one patient (2.9%). There was one case of major ventricular arrhythmia (2.9%). CONCLUSIONS: Our institutional experience suggests that this novel technique is safe and feasible. It facilitates complete resection of the aortic ascending aneurysm avoiding circulatory arrest, antegrade cerebral perfusion, additional peripheral cannulation, and all related complications.

Stent erosion after treatment of coarctation of right-sided aorta and successful surgical management.

We present a case of surgical treatment of a pseudoaneurysm of the right-sided aortic arch after stent implantation for primary coarctation in a 36-year-old woman with a previous history of ventricle septal defect closure in early childhood. As a first step, she underwent a left carotid to subclavian artery bypass for an aberrant left subclavian artery and as a second step a 'beating heart' aortic arch and descending aorta replacement via resternotomy. The postoperative course was uneventful.

Aortic valve replacement in a patient with extra-anatomic aortic and subclavian bypasses. / Zamena aortal'nogo klapana u patsienta s ékstraanatomicheskimi aortal'nymi i podkliuchichnymi shuntami.

The patient was 62-year-old male who successfully underwent an anatomic repair of aortic coarctation at the age of 15 and an extra-anatomic ascending aorta- to-descending aorta bypass (graft size 20 mm) and an extra-anatomic ascending aorta to the left subclavian artery bypass (graft size 10 mm) at the age of 49. As he grew older he started presenting clinical symptoms of aortic stenosis. The echocardiogram showed a bicuspid aortic valve with severe stenosis and a mean gradient of 65 mm Hg. Despite the high surgical risk, we decided to perform an open valve replacement with installing the CPB prior to re-sternotomy with a simultaneous cannulation of the axillary and femoral arteries by reason of interrupted descending aorta. The postoperative course was uneventful.

Surgery of secondary mitral insufficiency in patients with impaired left ventricular function.

BACKGROUND: Secondary mitral insufficiency (SMI) is an indicator of a poor prognosis in patients with ischemic and dilated cardiomyopathies. Numerous studies corroborated that mitral valve (MV) surgery improves survival and may be an alternative to heart transplantation in this group of patients.The aim of the study was to retrospectively analyze the early and mid-term clinical results after MV repair resp. replacement in patients with moderate-severe to severe SMI and left ventricular ejection fraction (LVEF) below 35%. METHODS: We investigated 40 patients with poor LVEF (mean, 28 +/- 5%) and SMI who underwent MV repair (n = 26) resp. replacement (n = 14) at the University Hospital Muenster from January 1994 to December 2005. All patients were on maximized heart failure medication. 6 pts. had prior coronary artery bypass grafts (CABG). Twenty-seven patients were in New York Heart Association (NYHA) class III and 13 were in class IV. Eight patients were initially considered for transplantation. During the operation, 14 pts had CABG for incidental disease and 8 had tricuspid valve repair. Follow-up included echocardiography, ECG, and physician's examination and was completed in 90% among survivors. Additionally, the late results were compared with the survival after orthotope heart transplantation (oHTX) in adults with ischemic or dilated cardiomyopathies matched to the same age and time period (148 patients). RESULTS: Three operative deaths (7.5%) occurred as a result of left ventricular failure in one and multiorgan failure in two patients. There were 14 late deaths, 2 to 67 months after MV procedure. Progress of heart failure was the main cause of death. 18 patients who were still alive took part on the follow-up examination. At a mean follow-up of 50 +/- 34 (2-112) months the NYHA class improved significantly from 3.2 +/- 0.5 to 2.2 +/- 0.4 (p < 0.001). The LVEF improved significantly from 29 +/- 5% to 39 +/- 16 (p < 0.05). There were no differences in survival after MV repair or replacement. The 1-, 3-, 5-year survival rates in the study group were 80%, 58% and 55% respectively. In the group of patients after oHTX the survival was accordingly 72%, 68%, 66% (p > 0.05). CONCLUSION: High risk mitral valve surgery in patients with cardiomyopathy and SMI offers a real mid-term alternative method of treatment of patients in drug refractory heart failure with similar survival in comparison to heart transplantation.