Stroke and pump thrombosis following left ventricular assist device implantation: The impact of the implantation technique.

Objectives: Several studies have shown the potential advantage of less-invasive surgery (LIS) for left ventricular assist device (LVAD) implantation. This study aims to determine the impact of LIS on stroke and pump thrombosis events after LVAD implantation. Methods: Between January 2015 and March 2021, 335 consecutive patients underwent LVAD implantation using either conventional sternotomy (CS) or the LIS technique. Patient characteristics was prospectively collected. All patients were followed up until October 2021. Logistic multivariate regression and propensity-matched analyses were performed to account for confounding factors. Results: A total of 242 patients (F = 32; 13.0%) underwent LVAD implantation with CS and 93 patients (F = 8; 8.6%) with the LIS approach. Propensity matching generated two groups, including 98 patients in the CS group and 67 in the LIS group. Intensive care unit stay for the LIS group patients was significantly shorter than that for the CS group patients [2 (IQR: 2-5) days vs. 4 (IQR: 2-12) days, p < 0.01]. There were no significant differences in the incidence of stroke events (14% in CS vs. 16% in the LIS group; p = 0.6) or in pump thrombosis (6.1% in CS vs. 7.5% in the LIS group; p = 0.8) between the groups. The hospital mortality rate in the matched cohort was significantly lower in the LIS group (7.5% vs. 19%; p = 0.03). However, the 1-year mortality rate showed no significant difference between both groups (24.5% in CS and 17.9% in LIS; p = 0.35). Conclusions: The LIS approach for LVAD implantation is a safe procedure with potential advantage in the early postoperative period. However, the LIS approach remains comparable to the sternotomy approach in terms of postoperative stroke, pump thrombosis, and outcome.

Simultaneous minimally invasive LVAD implantation and extracorporeal RVAD placement by patient with pectus excavatum and biventricular acute heart failure.

The optimal surgical approach in patients with pectus excavatum (PEx) who need cardiac surgery remains uncertain. The challenge is even greater, if it is already foreseeable that the patient will be needed further procedure in the next future. We describe a novel sternotomy-sparing approach for minimal-invasive biventricular assist device (BiVAD) implantation in a patient with an acute heart failure (HF) due to dilated cardiomyopathy and severe PEx. Moreover, alternative approaches for ventricular assist device (VAD) implantation and timing of the repair of PEx will be discussed.

Application of a clampless hemostatic device (HeartString®) for outflow graft anastomosis.

Performing an aortic anastomosis with a prosthetic graft (e.g. for left ventricular assist device implantation or veno-arterial extracorporeal membrane oxygenation) requires side-clamping of the aorta. Clamping of aorta is particularly challenging in redo cases and/or in patients with a short ascending aorta and open coronary artery bypass grafts, or atherosclerotic disease of the aorta. In this video tutorial, we provide a thorough description of the surgical technique for applying the HeartString® Proximal Seal System (MAQUET Holding B.V. & Co. KG, Rastatt, Germany) for the anastomosis of the aorta with a prosthesis graft. The feasibility of using the HeartString® device has been demonstrated and no procedure-related complications were experienced.

Thoracic Endovascular Aortic Repair for Aortoesophageal Fistula after Covered Rupture of Aortic Homograft: A Durable Option?

A 63-year-old woman underwent replacement of the aortic root, ascending aorta, and partial arch due to Type A aortic dissection. Shortly thereafter, a replacement of the distal aortic arch and descending aorta was performed. Three years later, the patient developed an aortoesophageal fistula (AEF) resulting in re-replacement of the distal aortic arch and proximal descending aorta with a cryopreserved aortic homograft. Six weeks post-discharge, the patient was readmitted due to recurrent AEF. A thoracic endovascular stent graft was implanted to cover the aortic rupture, followed by correction of an esophageal lesion. The patient was monitored closely over time.

Outcomes of secondary procedures after primary thoracic endovascular aortic repair†.

OBJECTIVES: The purpose of this study is to retrospectively evaluate, with an 'all-comers' approach, the survival and outcome of patients following secondary surgical or interventional procedures after thoracic endovascular aortic repair (TEVAR). METHODS: Between October 2002 and December 2013, 371 patients with different aortic pathologies underwent primary TEVAR at our institution. Fifty-six out of the 371 patients (15.1%, 18 females, mean age 62.3 ± 13.7 years) required secondary procedures, either interventionally (N = 31; 55.4%) or surgically (N = 25; 44.6%), due to stent graft-related complications. After TEVAR complications comprised endoleaks (N = 28; 7.5%), organ malperfusion (N = 9; 2.4%), aorto-oesophageal/-bronchial fistulae (N = 9; 2.4%), stent graft infections (N = 4; 1.1%), aneurysm progression (N = 3; 0.8%), retrograde type A aortic dissection (N = 2; 0.5%) and aortic regurgitation (N = 1; 0.3%). RESULTS: The overall in-hospital mortality rate was 10.7% (N = 5): open surgery (N = 1; 4%) versus reintervention (N = 5; 16%; P = 0.14). The cumulative survival rates after secondary procedures at 6 months, 1 year and 3 years were 80.4, 73.5 and 69.3%, respectively. Postoperative complications either for open surgery or reintervention comprised stroke (8 vs 9.6%; P = 0.82), paraplegia (4 vs 6.4%; P = 0.68), renal failure (16 vs 3.2%; P = 0.09), respiratory failure (12 vs 0%; P = 0.04), sepsis (16 vs 3.2%; P = 0.87), organ malperfusion (4 vs 3.2%; P = 0.87) and need for a tertiary procedure (8 vs 6.4%; P = 0.82). CONCLUSIONS: Stent graft complications after primary TEVAR were not infrequent and often required secondary procedures for definite treatment. Endoleaks (type Ia), organ malperfusion, stent graft infections, fistula formation and expanding aneurysm occurred predominantly during early and mid-term follow-up. Despite the high-risk nature of the complications, secondary open surgical or interventional procedures may be successfully performed with an acceptable outcome.

Extra-anatomic revascularization for preoperative cerebral malperfusion due to distal carotid artery occlusion in acute type A aortic dissection.

OBJECTIVES: Management of patients with acute aortic dissection type A (AADA) and cerebral malperfusion secondary to occlusion or stenosis of the left common carotid artery (LCCA) or right common carotid artery (RCCA) is a significant challenge. The aim of this study is to present our institutional strategy and postoperative results for this high-risk patient cohort. METHODS: Between November 2005 and July 2013, 23 of 354 consecutively operated AADA patients [median age: 66.3; interquartile range (IQR): 55.2-69.9] suffered from cerebral malperfusion due to bilateral (n = 1) or unilateral occlusion of the LCCA/RCCA (n = 22). AADA repair comprised hemi- (n = 14) or total (n = 9) arch replacement in combination with aortic valve repair (n = 7) or replacement (n = 11), root replacement (n = 15) and coronary bypass (n = 3). Extra-anatomic aorto-carotid bypass was performed in all patients. Aorto-carotid bypass was performed at the beginning of the procedure to allow for unilateral selective cerebral perfusion (n = 17; 73.9%) or during the procedure if persisting malperfusion was suspected by near-infrared spectroscopy (n = 6; 26.1%). RESULTS: The median follow-up was 15.2 months (IQR: 4.8-34.1) and 100% complete. Median hospital stay and ICU stay were 16.0 (IQR: 12.5-26.0) and 13.7 (IQR: 2.0-16.5) days, respectively. Rethoracotomy for haemorrhage or cardiac tamponade was performed in 6 (26.1%) patients. Other postoperative complications comprised low cardiac output with extracorporeal membrane oxygenation (n = 2; 8.7%), sepsis (n = 4; 17.4%), respiratory insufficiency (n = 10; 43.5%), renal failure with temporary dialysis (n = 7; 30.4%) and visceral malperfusion (n = 2; 8.7%) requiring stent grafting (n = 1) or laparotomy with intestinal resection (n = 1). New stroke with or without permanent sensory or motor deficit was diagnosed in 8 (34.8%) patients. Temporary neurological deficits were seen in 9 (39.1%) individuals. Hospital and 1-year mortality rates were 13.0 and 30.4%, respectively. Overall survival after 36 months of the 23 patients (Group I = Extra-anatomic bypass) versus the remaining 331 AADA patients without distal RCCA/LCCA occlusion (Group II = no extra-anatomic bypass) was 69.6% (n = 16) in Group I vs 72.5% (n = 240) in Group II (P = 0.90). CONCLUSION: Extra-anatomic bypass for LCCA or RCCA occlusion allows for early selective cerebral perfusion during AADA repair, and may reduce the risk of neurological complications in patients with preoperative cerebral malperfusion.

Emergency open surgery for aorto-oesophageal and aorto-bronchial fistulae after thoracic endovascular aortic repair: a single-centre experience†.

OBJECTIVES: Severe complications after thoracic endovascular aortic repair (TEVAR), such as secondary aorto-oesophageal (AOF) or aorto-bronchial fistulae (ABF), are most likely under-reported; however, once detected, emergent surgery becomes necessary. METHODS: Between June 2002 and September 2013, 10 (2.6%) of 374 patients (8 males; mean age 68 years, range: 49-77) were admitted with AOF (n = 8) or ABF (n = 2) post-TEVAR during follow-up (mean 12.9 months, range 0.2-48.1). The respective Ishimaru landing zones were 0 (n = 1), 2 (n = 3), 3 (n = 4) and 4 (n = 2). Median interval between TEVAR and AOF/ABF formation was 18.1 months (range 0.1-65.1). Symptoms on admission included haematemesis (n = 4), haemoptysis (n = 2), melena (n = 1), elevated C-reactive protein (n = 10), new-onset fever (n = 3), positive blood cultures (n = 8), dysphagia (n = 1), chest pain (n = 4), previous syncope (n = 1) and vertigo (n = 1). In 6 patients with AOF, stent graft removal required ascending aortic (n = 1), aortic arch (n = 1), left hemiarch (n = 2) and descending aortic (n = 6) replacement with concomitant oesophagectomy (n = 4) and cervical oesophagostomy (n = 1) or oesophageal repair (n = 2); another patient with AOF underwent oesophagectomy and cervical oesophagostomy via posterolateral thoracotomy without stent graft removal as a first-stage operation. One patient with ABF was treated by stent graft removal, aortic arch and descending aortic replacement in combination with bronchial repair. Two patients were deemed inoperable and treated conservatively. RESULTS: All patients survived the operation. Reoperation due to postoperative mediastinitis, haemorrhage, pericardial tamponade and wound infection was required in 4 (50%, 95% confidence interval [CI] [22, 78]) patients. In-hospital mortality was 25% (n = 2; 95% CI [7, 59]) due to mediastinitis with resulting multiorgan failure (n = 1) and aortic rupture with haemorrhagic shock (n = 1). One patient died due to unknown cause on postoperative day 158. No neurological complications occurred postoperatively. Postoperative complications comprised acute renal failure with temporary dependence on haemodialysis (n = 2) and respiratory insufficiency (n = 4) requiring percutaneous tracheostomy (n = 2). Both patients treated conservatively died after 4 and 81 days due to pulmonary haemorrhage and fulminant mediastinitis, respectively. CONCLUSIONS: AOF and ABF represent uncommon but fatal complications-if treated conservatively-after TEVAR that may occur during short- and mid-term follow-up. Surgery for AOF/ABF requires early diagnosis and should be performed promptly and in a radical fashion to totally excise all infected tissues in these high-risk patients.

Optimal treatment for patients with chronic Stanford type B aortic dissection: endovascularly, surgically or both?

OBJECTIVES: Patients with chronic Stanford type B aortic dissections (TBAD) are traditionally treated medically, but some of the affected thoracic and thoracoabdominal aortic segments progress to large aneurysms with a significant risk of rupture. The purpose of this study is to retrospectively evaluate, with an 'all-comers' approach, the survival and the outcome of patients following thoracic endovascular aortic repair (TEVAR) or conventional open surgery for chronic TBAD as a first-line therapy or a secondary option after failed medical treatment. METHODS: Between January 2000 and May 2010, 80 consecutive patients (59 males, median age 63, inter-quartile range (IQR) 55-69) suffering from chronic TBAD were treated at our institution. Thirty-three were treated medically (Group A, median age: 65, IQR: 58.5-71.5), 32 received TEVAR (Group B, median age: 62, IQR: 54-67.5) and 15 patients underwent conventional open surgery (Group C, median age: 61, IQR: 54-66). The median follow-up was 42 months (range: 0.1-124.7) and 100% complete. RESULTS: There were no significant differences with regard to age, gender and associated comorbidities between the treatment groups. The overall hospital mortality for chronic TBAD was 6.3% (n = 5); in-hospital mortalities for Groups A, B and C were 3.0, 6.2 and 13.4%, respectively. The incidence of major complications, such as paraplegia, malperfusion, renal failure and cardiac arrhythmia, did not significantly differ between the three groups. Postoperative stroke occurred more often after conventional open surgery (Group C: 13.3%; P = 0.07). Reintervention for TBAD pathology was required in Groups A, B and C in 12.1, 28.1 and 0%, respectively (P = 0.03). Secondary open surgery post-TEVAR was required in 7 cases (21.8%) with no postoperative paraplegia. CONCLUSIONS: Open surgery for extensive thoracic and thoracoabdominal repair in chronic TBAD may be performed with acceptable early and mid-term outcomes. TEVAR for aortic complications in patients with chronic dissection may be successfully performed as a first-stage procedure in order to stabilize the patient and serve as a 'bridge' to secondary open surgery. However, close surveillance is mandatory for the timely detection of aneurysm enlargement, malperfusion or impending rupture after TEVAR.