Aortic aneurysm formation following coarctation repair by Dacron patch aortoplasty.

We describe the finding of an aortic aneurysm in an asymptomatic 43-year-old male, who was managed by Dacron patch aortoplasty for native coarctation of the aorta 25 years before. The role of magnetic resonance angiography as standard imaging technique in lifelong postoperative surveillance is discussed subsequently. (Neth Heart J 2010;18:376-7.).

Rupture of right coronary sinus of Valsalva aneurysm into right ventricle.

A sinus of Valsalva aneurysm is a rare cardiac anomaly that may be congenital or acquired; a coexisting cardiac lesion might be present. If the aneurysm ruptures, it causes acute symptoms of dyspnoea. Echocardiography and cardiac magnetic resonance imaging are useful for diagnosis. The treatment of choice is surgery. We present a case of a patient with acute onset of symptoms due to a ruptured sinus of Valsalva aneurysm. (Neth Heart J 2010;18:209-11.).

Thoracoabdominal aortic aneurysm repair: results of conventional open surgery.

OBJECTIVES: The aim of this study is to report our experience in the surgical repair of thoracoabdominal aortic aneurysms (TAAAs) over the last 27 years against the background of evolving surgical techniques. METHODS: We reviewed the prospectively collected data of 571 patients who underwent open TAAA repair between 1981 and 2008. Data were analysed using univariate and multivariate analysis (logistic regression). Pre-, intra- and postoperative risk factors were used to develop risk models for in-hospital mortality, spinal cord deficit and renal failure. Recent published series were used to highlight the different treatment modalities and explore results. RESULTS: Seventy patients (12.3%) died in the hospital, the 30-day mortality was 8.9%, 37 patients (6.5%) required postoperative dialysis and 47 patients (8.3%) developed paraplegia or paraparesis. The incidence of paraplegia in the left heart bypass group was 4.4%. The predictors for hospital mortality were increasing age (odds ratio 1.096 per year, 95% confidence interval (CI): 1.05-1.14) and the need for haemodialysis (odds ratio 10, 95% CI: 4.7-21.1). For postoperative spinal cord deficit, we found three protecting factors: age above 75 years (odds ratio 0.14, 95% CI: 0.19-1.09), the presence of a post-dissection aneurysm (odds ratio 0.4, 95% CI: 0.17-0.94) and the combined use of cerebrospinal fluid drainage and motor-evoked potentials (odds ratio 0.28, 95% CI: 0.14-0.56). The urgency of procedure (odds ratio 4, 95% CI: 1.8-9) and preoperative serum creatinine level (odds ratio 1.007 per micromole per litre, 95% CI: 1.0-1.01) were significant risk factors for renal failure. CONCLUSIONS: Open TAAA repair intrinsically has substantial complications, of which spinal cord ischaemia and renal failure are the most devastating, despite major progress in our understanding of the pathophysiology and operative strategy. An overview of the results of recently published series is given along with an analysis of our data.

Revascularization strategy in patients with severe concurrent severe carotid and coronary artery disease: ''failure to move forward is reason to regress''.

In the absence of randomized trials, the optimal management of patients with concomitant carotid and coronary artery disease remains disputable. The initial studies of combined or staged carotid endarterectomy in these patients were conceived in an attempt to reduce perioperative mortality. Although encouraging results have been reported with combined carotid endarterectomy and cardiac surgery, this combination requires long operative times and remains a surgical challenge. Recent studies have shown that carotid angioplasty and stenting prior to cardiac surgery is a feasible and effective minimal invasive technique. However, the effect of carotid stenting on the incidence of death and stroke after cardiac surgery is indistinct. Carotid stenting followed by cardiac surgery may provide a valuable treatment for patients with combined carotid and cardiac disease. The high rate of freedom from death and stroke during follow-up supports the long-term durability of this strategy. In the present review, we highlight the available data on carotid stenting and cardiac surgery.

Ascending-descending aortic bypass for the treatment of concomitant severe co-arctation, aortic valve disease and hypoplastic aortic arch.

This report describes a one-stage treatment of a 30-year-old patient suffering from severe aortic valve insufficiency, aortic co-arctation, dilatation of the ascending aorta and arcus hypoplasia. The patient underwent aortic valve, ascending aorta and arch replacement through median sternotomy. The aorta was ligated at the level of the co-arctation, which was located in the proximal part of the descending aorta, and an ascending-descending bypass was created using a transhiatic approach. The postoperative course was complicated by a cerebrovascular accident.

Measurements of cerebrospinal fluid concentrations of S100beta protein during and after thoracic endovascular stent grafting.

OBJECTIVES: Thoracic endovascular aortic repair is associated with postoperative spinal cord ischemia in approximately 1 to 12.5% of all cases. S100beta is a protein that is released during acute damage of the central nervous system. This study was performed to determine the concentration of S100beta in cerebrospinal fluid during and after stenting of the thoracic aorta in patients at high risk for spinal cord ischemia. DESIGN: Prospective clinical study. MATERIALS AND METHODS: Eight patients who underwent elective thoracic aortic stent grafting underwent lumbar spinal fluid drainage. These patients were at high risk to develop spinal cord ischemia. METHODS: CSF samples for analysis of S100beta protein were drawn after induction of anesthesia, during stenting, once every hour the following six hours and 20 hours after repair. RESULTS: No significant increase in S100beta protein could be detected in CSF and no neurological deficits were detected postoperatively. CONCLUSIONS: The results of this study show us that there is no significant release of S100beta protein in CSF during stenting of the thoracic aorta in this subgroup of patients at high risk for spinal cord ischemia, consistent with clinical exam that there was no significant damage to the central nervous system.

[Diagnostic image (307). A man with dysphagia]. / Diagnose in beeld (307). Een man met dysfagie.

A 51-year-old man suffered from longstanding dysphagia due to a large aneurysm of the thoracoabdominal aorta.

[Trachea compression due to a Kommerell diverticulum in a patient with a right-sided aorta]. / Tracheacompressie door divertikel van Kommerell bij een rechtszijdige aorta.

A 64-year-old man who was evaluated for a long history of a discontinuous barking cough with difficulty in coughing up sputum was found to have 90% stenosis of the trachea. Further imaging studies revealed a right-sided descending aorta with an aberrant left subclavian artery arising from a Kommerell diverticulum. This caused the compression of the trachea. The compression was relieved by transposition of the aberrant left subclavian artery to the ascending aorta and replacement of the aneurysmatic part of the aorta by an endoprosthesis.

Clinical prospective study of biochemical markers and evoked potentials for identifying adverse neurological outcome after thoracic and thoracoabdominal aortic aneurysm surgery.

BACKGROUND: Neurological deficit after repair of a thoracic or thoracoabdominal aortic aneurysm (TAA/TAAA) remains a devastating complication. The aim of our study was to investigate the clinical value of biochemical markers [S-100B, neurone-specific enolase (NSE) and lactate dehydrogenase (LD)], evoked potentials and their combinations for identifying adverse neurological outcome after TAA/TAAA surgery. METHODS: From 69 patients, cerebrospinal fluid and blood samples for biochemical analysis were drawn after the induction of anaesthesia, during the cross-clamp period, 5 min, 2, 4, 6, 8, and 19 h, respectively, after reperfusion. In addition, continuous perioperative recording of motor-evoked potentials after transcranial electrical stimulation (tcMEP) and somatosensory-evoked potentials was carried out. Furthermore, neurological examinations were performed. RESULTS: In patients with a defined decrease in lower extremity tcMEP during the cross-clamp period, we found that combinations of the serum concentrations of S-100B and tcMEP ratios at 4, 6, and 8 h after reperfusion had a positive and negative predictive value of 100% in predicting adverse neurological outcome after TAA/TAAA surgery. Furthermore, combinations of the serum concentrations of S-100B and NSE or LD at 19 h after reperfusion had both a positive and negative predictive value of 100% in identifying patients with adverse outcome after TAA/TAAA repair. CONCLUSIONS: TcMEP monitoring during TAA/TAAA surgery seems to be an effective but not completely sufficient guide in our protective multi-modality strategy. Combinations of the serum concentrations of S-100B and tcMEP ratios during the early reperfusion period might be associated with adverse neurological complications. Furthermore, biochemical markers could detect central nervous system injury on the first postoperative day and may have prognostic value.

[Diagnostic image (200). A woman with acute pain between the scapulae]. / Diagnose in beeld (200). Een vrouw met acute pijn tussen de schouderbladen.

A 71-year-old woman presented with an acute onset of interscapular pain due to an intramural haematoma of the ascending part of the aorta. She was treated with an emergency ascending aorta graft replacement.

[Ischemia of the lower limbs as a symptom of acute dissection of the ascending aorta]. / Ischemie van de benen als symptoom van een acute dissectie van de aorta ascendens.

A 27-year-old man, two 54-year old men and a 64-year-old woman presented with aspecific symptoms: acute pain and tingling in the shoulders plus paraplegia; exertional dyspnoea and tingling in both feet for the past week; increasing shortness of breath and cold, pale legs and feet for the past week; acute retrosternal pain, incontinence and paraparesis. The cause was dissection of the ascending aorta (type A). Following the operation, the legs were amputated because of ischaemia. The 27-year-old man and one of the 54-year-old men died; the other two patients made a satisfactory recovery. Acute type-A aortic dissection is a life-threatening disease that must be recognised early because it is an absolute indication for emergency surgery. The initial manifestation of type-A dissection may be very aspecific. Post-operative lower limb ischaemia, as the first symptom of this disease, is rare and usually disappears after surgery for type-A dissection. In some cases, however, ischaemia persists and alters the post-operative course dramatically.

Stroke related to cardiac and/or aortic surgery: an overview.

In recent years there has been an increasing awareness of atheromatous disease of the aorta and its role has become more evident in relation to neurologic deficits following cardiac and aortic surgery. Specific surgical events can release emboli blocking cerebral arteries and cause catastrophic neurologic sequelae plagueing the patients, their families and the health care system. The extent of the problem is illustrated and the pathophysiologic mechanisms are explained. Special attention is given to the calcified aorta and the preventive actions that can be undertaken by the surgeon to avoid cerebral damage. Aortic surgery cannot be separated from cardiac surgery and therefore specific aortic problems related to cerebral damage are highlighted such as aortic dissection and aortic arch replacement.

Thoracic and thoracoabdominal aortic aneurysm repair: use of evoked potential monitoring in 118 patients.

PURPOSE: Paraplegia is the most dreaded and severe complication of surgery on the descending thoracic aorta (TAA) and thoracoabdominal aorta (TAAA). The functional integrity of the spinal cord can be monitored by means of intraoperative recording of myogenic-evoked responses after transcranial electrical stimulation (tcMEP) and somatosensory-evoked potential (SEP) monitoring. In this study, we evaluated the results of evoked potential monitoring and the adequacy of the strategy followed. METHOD: The spinal cord of 118 patients (78 men; age, 65 +/- 12 years; 79 TAAAs, 39 TAAs) undergoing surgery on the TAA or TAAA was monitored with tcMEP and SEP. Spinal cord protection was achieved by means of a multimodality approach: moderate hypothermia (32 degrees C rectal temperature), continuous cerebrospinal fluid drainage to keep the pressure less than 10 mm Hg, reimplantation of intercostal arteries, left ventricular bypass grafting, and staged clamping. In the case of evoked potential changes more than 50% of baseline, the strategy was adjusted: reattachment of more segmental arteries when technically feasible, higher distal and proximal perfusion pressures, and enhanced cerebrospinal fluid drainage. RESULTS: Forty-two of 118 patients (35.6%) had a more than 50% of baseline tcMEP reduction during cross-clamping. At this point, only 5 of those 42 cases were also associated with SEP reduction of more than 50% of baseline. On the basis of the tcMEP findings, the strategy was adjusted. Five patients had postoperative paraplegia (4.2%). CONCLUSION: tcMEP monitoring seems to be a useful adjunct of the protective techniques and may cause substantial adjustments in strategy, reducing the incidence of postoperative paraplegia.