Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis.

BACKGROUND & AIMS: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. METHODS: An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. RESULTS: A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p = 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p = 0.001). CONCLUSIONS: Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed. IMPACT AND IMPLICATIONS: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.

[Surgical treatment of aortic root aneurysm: comparison of Bentall procedure and David reimplantation of aortic valve]. / Chirurgická lécba aneuryzmatu aortálního korene: srovnání Bentallovy operace a reimplantace aortální chlopne podle Davida.

INTRODUCTION: The aortic root aneurysm is associated with a more frequent occurrence of aortic dissection and development of aortic regurgitation. The aim of this study was to compare outcomes of composite graft replacement and valve sparing root replacement in treating aortic root aneurysms. METHODS: From January 2006 to December 2015 a total of 137 patients (mean age 46.3 ± 14.5, range 16-65) underwent elective surgery for aortic root aneurysm without valvular structural defects. Replacement by mechanical composite graft (Bentall procedure) has been performed in 46 patients while 91 patients underwent valve sparing root replacement (David procedure). The mean length of follow-up has been 77 months. RESULTS: There was no operative death. Overall 9 patients died during follow-up. Five patients were after Bentall procedure and 4 were after reimplantation of aortic valve. Thromboembolic and bleeding complications were observed in 7 patients, 5 of them were after Bentall surgery and 2 after reimplantation of the aortic valve. Five patients after reimplantation of aortic valve underwent reoperation. Four of these patients had aortic valve replacement and in 1 case aortic homograft was implanted. CONCLUSION: Bentall procedure used to be the standard treatment for patients with aortic root aneurysms. During the past two decades, aortic valve sparing procedure has gained widespread use to reduce thromboembolic and bleeding complications.Key words: aortic root aneurysm - composite graft replacement - valve-sparing root replacement.

Adjuvant cardioprotection in cardiac surgery: update.

Cardiac surgery patients are now more risky in terms of age, comorbidities, and the need for complex procedures. It brings about reperfusion injury, which leads to dysfunction and/or loss of part of the myocardium. These groups of patients have a higher incidence of postoperative complications and mortality. One way of augmenting intraoperative myocardial protection is the phenomenon of myocardial conditioning, elicited with brief nonlethal episodes of ischaemia-reperfusion. In addition, drugs are being tested that mimic ischaemic conditioning. Such cardioprotective techniques are mainly focused on reperfusion injury, a complex response of the organism to the restoration of coronary blood flow in ischaemic tissue, which can lead to cell death. Extensive research over the last three decades has revealed the basic mechanisms of reperfusion injury and myocardial conditioning, suggesting its therapeutic potential. But despite the enormous efforts that have been expended in preclinical studies, almost all cardioprotective therapies have failed in the third phase of clinical trials. One reason is that evolutionary young cellular mechanisms of protection against oxygen handling are not very robust. Ischaemic conditioning, which is among these, is also limited by this. At present, the prevailing belief is that such options of treatment exist, but their full employment will not occur until subquestions and methodological issues with the transfer into clinical practice have been resolved.