Surgical management of primary aortic thrombus in thoracic aorta.

Background: Primary aortic thrombus (PAT) in the absence of underlying aortic pathology such as atherosclerosis or aneurysm is quite rare and presents with various symptoms related to distal embolization. Treatment options include anticoagulation alone, open surgical thrombectomy, endovascular repair, and a combination of these approaches. The optimal management strategy remains controversial. Methods: Between 2016 and 2020, 10 patients (6 females; mean age, 49.1 years) presented to our institution with PAT in the thoracic aorta. All 10 patients were active tobacco users, and 6 patients were found to have an underlying hypercoagulable state. Locations of the PAT included the ascending aorta in 4 patients, the descending thoracic aorta in 3 patients, and the aortic root, aortic arch, and thoracoabdominal aorta in 1 patient each. At presentation, 2 patients had developed myocardial infarction, and 2 others had cerebral infarction. All patients but 1, who was managed medically for PAT, underwent open surgical thrombectomy via either sternotomy or left thoracotomy. Concomitant procedures included coronary artery bypass grafting in 2 patients and pulmonary thromboembolectomy in 1 patient. There were no operative deaths. During a median follow-up of 18 months, 2 patients developed recurrent PAT, owing primarily to poor compliance with anticoagulation. One patient required redo open thrombectomy. Two patients had mesenteric ischemia necessitating small bowel resection. Conclusions: Open surgical thrombectomy of the thoracic aorta can be performed with low mortality and morbidity; however, PAT can recur, especially in patients who have difficulty managing anticoagulation.

Early and late results of mitral valve repair with anterior leaflet patch augmentation.

OBJECTIVES: The aim of this study was to determine the long-term results of mitral valve (MV) repair with anterior leaflet patch augmentation. METHODS: Between 2012 and 2015, 45 patients underwent MV repair using the anterior leaflet patch augmentation technique at our institution. The mean age of the patients was 65.9 ± 13.0 years (16 males). We reviewed the MV pathology and the surgical techniques used and assessed the early and late results. RESULTS: In terms of MV pathology, 43 patients (95.6%) had pure mitral regurgitation (MR) and 2 patients (4.4%) had mixed mitral stenosis and MR. Rheumatic changes were seen in 18 patients (40.0%). Postoperative echocardiography showed that 95.6% of patients had none to mild MR. During a median follow-up period of 5.5 years (range 0.1-8.3 years), there were 8 late deaths. Nine patients (20%) required reoperation. The mean interval between the initial operation and redo operation was 3.7 ± 3.1 years (range: 0.4-7.8 years). The causes of reoperation included patch dehiscence (n = 4), progression of mitral stenosis (n = 2), band dehiscence (n = 1), patch enlargement (n = 1) and unknown (n = 1). Eight patients underwent MV replacement and 1 underwent repeat MV repair. The freedom from reoperation at 3 and 5 years was 85.7 ± 6.7% and 81.2 ± 7.7%, respectively. CONCLUSIONS: Anterior leaflet patch augmentation can provide excellent early results in the majority of the patients even in the presence of rheumatic pathology; however, we observed late reoperation in 20% of patients. Thus, this technique should be used with caution and careful follow-up with serial echocardiography is essential.

Minimally invasive mitral valve replacement after transcatheter edge-to-edge repair.

Percutaneous transcatheter edge-to-edge mitral valve repair is available for treatment of both functional and degenerative mitral regurgitation (MR). This technique may be unsuccessful resulting in significant residual or recurrent MR. We described a successful minimally invasive mitral valve replacement in a patient with severe functional MR due to left ventricular dysfunction who previously underwent a transcatheter edge-to-edge repair.

Computed tomography angiography is not accurate in predicting surgical prosthetic aortic valve implant size.

BACKGROUND: Multidetector computed tomography is vital in preoperative sizing for transcatheter aortic valve replacement. The purpose of this study is to determine whether preoperative transcatheter aortic valve replacement multidetector computed tomography accurately predicts surgical aortic valve prosthesis size. METHODS: Between July 2012 and July 2017, 102 patients who underwent surgical aortic valve replacement had preoperative aortic valve sizing by multidetector computed tomography. The aortic annulus diameter calculated using multidetector computed tomography was compared with intraoperative valve sizing during surgical aortic valve replacement. RESULTS: Forty-one (40.2%) of the 102 patients studied had multidetector computed tomography aortic valve measurements that were accurate. Implanted valves were smaller than multidetector computed tomography calculation in 40 patients (39.2%) and were larger in 21 patients (20.6%). Multidetector computed tomography measurements remained inconsistent with intraoperative sizing regardless of aortic annulus diameter. The variance between multidetector computed tomography annulus measurements and intraoperative sizing was statistically significant. CONCLUSIONS: Preoperative aortic annulus measurements by our institutional transcatheter aortic valve replacement multidetector computed tomography protocol differed substantially from surgical implant size. There was no trend toward over nor under sizing for the entire cohort. However, patients with large measured annulus diameter were more likely to have a smaller valve implanted than predicted, and patients with small measured annulus diameter were more likely to have a larger valve implanted than predicted. These results may affect preoperative planning for patients undergoing aortic valve replacement.

Cardiogenic shock: collaboration between cardiac surgery and cardiology subspecialties to bridge to recovery.

Acute cardiogenic shock is a lethal condition that results in death from myocardial failure, arrhythmia, or combinations of both. Aggressive medical, surgical, and interventional maneuvers have helped reduce the mortality. For the most advanced cases, ventricular assist devices have been used for persistent shock states. The purpose of this report is to describe the collaboration between cardiac surgery and cardiology subspecialty in an effort to promote native heart recovery in a complex case of cardiogenic shock requiring coronary artery bypass surgery, percutaneous coronary intervention, ventricular ablative therapy, and mechanical cardiac support.

Initial experience with the enclose proximal aortic anastomosis device during off-pump coronary artery bypass: an alternative to aortic side clamping.

BACKGROUND: The utilization of off-pump coronary artery bypass surgery (OPCAB) has resulted in the development of new technology to facilitate the creation of aorto-coronary graft anastomoses. Proximal aortic devices (PADs) enable the construction of a proximal aortic anastomosis without the use of a side-biting aortic clamp, thus reducing the risk of neurologic injury from particulate embolization. METHODS: One hundred ninety-seven patients underwent OPCAB at our institution between January 2003 and December 2004. Sixty (30.5%) patients had proximal aorto-coronary graft anastomoses constructed with the Novare Enclose PAD. The remaining 137 (69.5%) patients had graft construction with a standard aortic side-clamp technique. We compared the outcomes of these 2 cohorts to evaluate the safety and efficacy of the Novare Enclose PAD. RESULTS: One hundred seven proximal anastomoses were constructed in the PAD group, and 199 proximal were constructed in the side-clamp group. Three patients (1.5%), all in the side-clamp group, sustained permanent neurologic deficits after OPCAB. There were 2 cases of device malfunctions. There were no anastomotic thromboses, no reoperations for anastomotic hemorrhage, and no patients required anastomotic revision. Of the 197 patients in the series, there were 4 deaths, 2 in each group, resulting in an overall mortality rate of 2%. CONCLUSION: The Novare Enclose PAD is a safe device that facilitates suture construction of proximal aorto-coronary graft anastomosis. In a select group of patients, the use of this device may reduce the risk of neurologic injury when compared to the application of an aortic side-biting clamp for coronary bypass surgery.

Port-access-assisted aortic valve replacement: a comparison of minimally invasive and conventional techniques.

BACKGROUND: A hybrid Port-Access (PA) approach to aortic valve surgery (MPAVR) was designed as a less invasive aortic valve operation. The approach combines components of Port-Access technology with conventional cardiac surgical techniques via a limited sternal incision. This technique is compared to conventional aortic vale replacement (CAVR) for safety and efficacy. METHODS: One hundred eighty patients had aortic valve surgery between January 1, 2000, and June 30, 2004. Fifty-eight patients (32%) had primary isolated aortic valve replacement, 22 of those 58 patients (38%) underwent MPAVR procedures consisting of a limited inverted-T sternotomy, direct aortic cannulation, a percutaneous PA endocoronary sinus cardioplegia catheter, an endovent pulmonary artery catheter, and a percutaneous femoral endovenous return catheter. Thirty-six patients (62%) had aortic valve replacement by sternotomy and standard cardiopulmonary bypass techniques. The MPAVR and CAVR groups were compared for demographics and intraoperative and postoperative outcomes. RESULTS: Age, obesity, diabetes, New York Heart Association classification, ejection fraction, and other patient characteristics were not significantly different between the groups. MPAVR patients had lower Society of Thoracic Surgery risk scores (3.1 versus 3.9; P = .277). MPAVR patients were more likely to receive a stentless valve (36% versus 11%; P = .042) and required longer operative times (237 min versus 189 min; P <.001). Postoperative complications were minimal and equivalent. A single mortality in the CAVR group resulted in an overall mortality of 1.7%. CONCLUSION: This hybrid, less invasive PA-assisted approach to aortic valve surgery is safe and effective. A total sternotomy can be avoided in selected aortic valve patients. Results equivalent to CAVR can be expected with this minimal access operation.