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Background: Aortic arch pathology often requires staged segmental repairs. Total aortic arch replacement with frozen elephant trunk (FET) offers surgical options for these pathologies. The Jotec E-vita Open NEO™ branched prosthesis was introduced in 2020; we sought to share our initial experience focusing on the prosthesis selection strategies, surgical techniques, anastomosis-bleeding and graft-oozing control methods, and early clinical outcomes from two Asian centers. Methods: We performed a retrospective cohort study in patients with aortic arch pathologies who underwent total arch replacement using the FET procedure with Jotec E-vita Open NEO™ branched prosthesis from two Asian centers between October 2020 and August 2021. The primary outcome was overall 30-day mortality, and the secondary outcomes were operative complications. Results: Twenty-five consecutive patients underwent total arch replacement with FET with the novel hybrid prosthesis. Overall 30-day mortality from both centers was 0%. Overall mean operative, cardiopulmonary bypass, hypothermic circulatory arrest, and selective antegrade cerebral perfusion times were 353.4±80.5, 183.2±39.6, 57.2±14.7, and 138.2±28.6 minutes, respectively. No patient developed stroke. Permanent spinal cord injury (SCI) was recorded in one patient (4%) and one (4%) had transient lower limb weakness that resolved after spinal drainage. There was no requirement of re-sternotomy for hemostasis. Conclusions: We reported a multicenter Asian case series with the novel FET hybrid prosthesis demonstrating the feasibility and safety of promising initial clinical outcomes. The technique of circumferential reinforcement of vascular anastomosis for hemostasis may be one of the methods for lowering the rates of re-sternotomy for hemostasis, and proper surgical or transfusion strategies would overcome the excessive oozing of the prosthesis. Long-term follow-up is required for further evaluation of aortic pathology progression and device-related outcomes.
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INTRODUCTION: Open surgery is the gold standard treatment for aortic arch disease. However, due to its complexity, open arch replacement is associated with considerable risk of mortality and morbidity. METHOD: We report a case of a 71-year-old gentleman with multiple comorbidities and symptomatic 7 cm aortic arch aneurysm who was treated with a single-stage carotid-carotid and left carotid-axillary bypass followed by zone 0 aortic arch stenting with bimodular Nexus™ stent graft. RESULTS: Post-operatively, the patient suffered from a minor stroke with full neurological recovery. Follow-up computed tomography of the aorta 3 years post-stenting showed excellent stent position with no endoleak and complete resolution of the saccular aneurysm. DISCUSSION: The midterm result of our patient who was successfully treated with an off-the-shelf single branch, bimodular stent graft system is excellent with complete resolution of the arch saccular aneurysm at 3-year after the operation.
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Aneurisma da Aorta Torácica , Aneurisma Aórtico , Doenças da Aorta , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma Aórtico/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Prótese Vascular , Implante de Prótese Vascular/métodos , Humanos , Masculino , Stents , Resultado do TratamentoRESUMO
BACKGROUND: Novel clinical challenges are faced by cardiac surgeons under the coronavirus disease 2019 (COVID-19) pandemic. Amidst the uncertainties faced due to the socioeconomic and public health impact, there is little evidence surrounding COVID-19 vaccination in patients undergoing cardiac surgery. Timing of vaccination and postvaccination adverse effects are required parameters to discuss with cardiac surgical patients. METHODS: This is a single-center, retrospective observational study. All patients who underwent adult cardiac surgery at the Prince of Wales Hospital, Hong Kong from January 2021 to December 2021 were included. Postoperative clinical outcomes, COVID-19 vaccination status, and vaccination-related adverse effects were collected. RESULTS: A total of 426 patients; 117 (27%) underwent isolated coronary artery bypass grafting, 111 (26%) underwent valvular surgery, and 97 (23%) underwent aortic surgery. Patients received either Sinovac CoronaVac or Pfizer BNT162b2 vaccine. Overall vaccination rate with at least 1 dose was 52% (n = 212), 15% (n = 63) received the first dose before surgery, 36% (n = 149) received the first dose vaccination after surgery. Rate of completion with second and third doses of vaccination were 22% (n = 89) and 4.9% (n = 20), respectively. The mean timing of first dose of vaccine after surgery was 216 ± 84 days from operation. Three (1.4%) patients recorded vaccination-related complications. CONCLUSIONS: COVID-19 vaccination is safe in patients who received major cardiac surgery, with low adverse effects recorded and no vaccine-related mortality observed. A time frame of 3-6 months after cardiac surgery receiving COVID-19 vaccination is reasonable and could serve as a guidance for future COVID-19 vaccination booster programs.
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COVID-19 , Procedimentos Cirúrgicos Cardíacos , Adulto , Vacina BNT162 , COVID-19/epidemiologia , COVID-19/prevenção & controle , Vacinas contra COVID-19 , Humanos , Estudos Retrospectivos , VacinaçãoRESUMO
A patient who underwent candy-plug insertion in the year 2016 developed type 1B endoleak with rapid enlargement of distal descending thoracic aortic aneurysm in the year 2021 despite the initial successful false lumen occlusion and thrombosis. Open conversion with Crawford extent 3 thoracoabdominal aortic replacement was performed successfully and the patient was discharged home without any major complications.
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Aneurisma da Aorta Torácica , Dissecção Aórtica , Implante de Prótese Vascular , Procedimentos Endovasculares , Dissecção Aórtica/cirurgia , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Humanos , Desenho de Prótese , Stents , Resultado do TratamentoRESUMO
BACKGROUND AND AIM: The Valiant NavionTM stent graft system is a third-generation low profile thoracic endograft designed for thoracic endovascular aortic repair. In this population analysis, we report on the first Asian all-comers experience and outcomes who underwent thoracic endovascular aortic repair with the use of this new stent graft system. METHODS: Between May 2019 and October 2020, 21 patients with different aortic pathologies were prospectively recruited and retrospectively analyzed. Important clinical and device-related outcomes were evaluated. The endpoints included short-term survival, technical success, access failures, major vascular and clinical complications, endoleaks, and hospital stay. RESULTS: The commonest indication of stenting was penetrating aortic ulcers (28.6%) and six (28.6%) patients had emergency stenting performed for aortic transection or rupture. 30 days of survival postprocedure was recorded and complete. There were no major vascular complications. Deployment accuracy was 100%, and the technical success rate was 94.7% (18/19) with one patient having a Type 2 endoleak on follow-up imaging. No neurological complications were noted. The mean operative time was 95 ± 73.6 min and the mean fluoroscopy time was 16.2 ± 10.8 min. Mean hospital stay for elective zone 2, 3, and 4 stenting was 5.3 ± 3.8 days, and only one patient postzone 1 thoracic endovascular aortic repair required a brief (0.5 days) ICU stay. All procedures were performed via the percutaneous transfemoral route with 100% success in percutaneous closure. CONCLUSION: This first reported Asian case series demonstrated versatility, safety, and efficacy of the Valiant NavionTM stent in Asian patients with different aortic pathologies.
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Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Humanos , Desenho de Prótese , Estudos Retrospectivos , Stents , Resultado do TratamentoRESUMO
Aortic arch pathologies have been a surgical challenge, involving cerebral, visceral and myocardial protection. Innovative techniques including total arch replacement and frozen elephant trunk had evolved over last decades with promising mid-term outcomes. We evaluate our mid-term outcomes on total arch replacement with frozen elephant trunk and the role of timely second staged interventions. Between August 2014 and April 2020, 41 patients with aortic arch pathologies underwent total arch replacement with frozen elephant trunk with Thoraflex-Hybrid-Plexus device (Vascutek, Inchinnan, Scotland). Patients' perioperative, clinical and radiological outcomes were reviewed. Post discharge survival (nâ¯=â¯37) at 3 year was 100%. Overall survival of 85.3% over a median follow up of 3.3 years, inpatient mortality of 9.8%. Distribution of aortic pathologies with acute type A dissection or intramural hematoma (nâ¯=â¯15, 36.6%), thoracic aortic aneurysm, including arch and descending aortic aneurysm (nâ¯=â¯9, 22%) and chronic aortic dissection including chronic type A and type B dissections (nâ¯=â¯13, 31.7%). Mean operative, circulatory arrest, and antegrade cerebral perfusion time were 417 ± 121 minutes, 89 ± 28 minutes, and 154 ± 43 minutes, respectively. Second stage procedures were performed in 32% and distal stent graft induced new entry was observed in 19% of patients. We reported an Asian series of Thoraflex with outstanding midterm clinical outcomes, given descending aortic pathologies were tackled with a timely second stage interventions. The observation of aortic remodeling and distal stent graft induced new entry requires further investigations.
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Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Assistência ao Convalescente , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Humanos , Alta do Paciente , Estudos Retrospectivos , Stents , Resultado do TratamentoRESUMO
OBJECTIVES: Transcatheter aortic valve implantation is a recognized treatment for patients with severe aortic stenosis at all risk groups. However, permanent pacemaker rates remain high for self expandable transcatheter valves and permanent pacemaker implantation has been associated with increased morbidity. In this analysis we aim to evaluate short term clinical outcomes post self expandable transcatheter aortic valve implantation and determine risk factors for permanent pacemaker implantation. METHODS: 88 patients with severe aortic stenosis with transcatheter aortic valve implantation performed between the year 2016-2018 were retrospectively analyzed. Outcomes of interest included 1- year all cause mortality, 30-day major adverse cardiovascular events, permanent pacemaker and paravalvular leak rates. Survival analysis was performed with Kaplan Meier analysis and risk factors for survival and permanent pacemaker rates were identified with log rank test and regression analysis. RESULTS: The mean age of the cohort was 80.3 +/- 6.9 years. The mean STS score was 9.25. The 30 day all-cause mortality was 5.7% and 1-year all cause mortality was 16.7%. 80 patients had transfemoral transcatheter aortic valve implantation, and a majority of the patients (85.2%) were implanted with Corevalve Evolut R device. The device success rate was 88.6%. Multivariate analysis identified concomitant severe coronary artery disease (OR = 18.2 +/- 0.9; P = 0.002), pre transcatheter aortic valve implantation atrial fibrillation (OR = 8.6 +/- 0.91; P = 0.02) and post procedural disabling stroke (OR = 32.6 +/- 1.35; P = 0.01) as risk factors for 1-year mortality. The 30-day pacemaker rate was 17.6%. The presence of right bundle branch block (OR 11.1 +/- 0.86; P = 0.005), non-coronary cusp implantation depth (OR = 1.34 +/- 0.15; P = 0.05) and a non coronary cusp implantation depth / membranous septal length ratio of more than 50% were associated with post procedural pacemaker implantation (OR = 29.9 +/- 1.72; P = 0.05). Among the 15 patients with post procedural pacemaker implantation, 40% were found to be non-pacemaker dependent at 1 year. CONCLUSION: Short term outcomes of transcatheter aortic valve implantation in severe aortic stenosis patients are promising. Pacemaker rates remain high. More studies are needed to evaluate the factors that influence pacemaker rates and dependence to further improve transcatheter aortic valve implantation outcomes.
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Estenose da Valva Aórtica/cirurgia , Bloqueio de Ramo/epidemiologia , Bloqueio Cardíaco/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/epidemiologia , Fibrilação Atrial/epidemiologia , Estimulação Cardíaca Artificial , Comorbidade , Doença da Artéria Coronariana/epidemiologia , Feminino , Bloqueio Cardíaco/terapia , Próteses Valvulares Cardíacas , Humanos , Masculino , Razão de Chances , Marca-Passo Artificial , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Resultado do TratamentoRESUMO
BACKGROUND: Management of acute type A intramural hematoma (IMH) is a controversial topic. In our study, we aim to analyze the survival outcomes in local patients with acute type A IMH and a meta-analysis on survival in type A IMH treated medically versus surgically was performed. METHODS: From 2014 to 2019, 65 patients with acute type A IMH were selected for analysis. Primary outcome of interest was 1 year all cause survival. The rate of aortic-related events in the medical group was evaluated. PubMed and Embase were searched for meta-analysis. RESULTS: The mean age of our cohort was 61.7±9.7 years. Of the 65 patients, 40% had emergency operation. Overall 1-year survival was 96.9%. The 1-year survival was 94.9% for the medical group. 46.2% of the medical group required aortic intervention at a mean duration of 191±168 days. Maximal aortic diameter (MAD) ≥45 mm was predictive of aortic-related events in the medical group (OR: 7.0; 95% CI, 1.7-29.4; P=0.008). For the meta-analysis, 21 studies were identified, and 900 patients were included. Emergent surgery was associated with improved survival in type A IMH (OR: 0.76; 95% CI, 0.29-1.97, P=0.58; I2=27%). CONCLUSIONS: The 1-year survival after type A IMH was promising, regardless of approach. The conservative-first approach was found to be safe & feasible, and upfront surgery remained the management of choice in general. Patients with MAD ≥45 mm was associated with subsequent aortic intervention in the medical-first group.
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BACKGROUND: Coronary artery bypass grafting (CABG) is the standard of care for patients with ischemic cardiomyopathy (ICM). Despite recent evidence supporting the role of CABG, long term outcomes for patients with ICM remain poor and 10-year results post CABG in ICM patients are under-reported, especially among Asians. Uncertainty on whether CABG improves cardiac performance and survival in the long term remains. In this study, we aim to analyze 10-year results concerning cardiac performance and survival post CABG in Asian patients with left ventricular ejection fraction (LVEF) ≤35% and predominant heart failure symptoms, and identify perioperative risk factors affecting long term survival and cardiac function. METHODS: Thirty-six patients with LVEF <35% who had CABG performed between the year 2006-2009 were selected from local hospital records for retrospective analysis. Outcomes of interest included post-operative cardiac symptoms, LVEF & 10-year all-cause and cardiac-event free survival. Survival analysis was performed using Kaplan Meier analysis, and predictive factors were identified with log- rank test and logistic regression analysis. RESULTS: The mean age of the cohort was 62.9±9.9 years. Operative mortality within 30 days was 5.6%. The 10-year all-cause mortality rate was 55.6%. The mean duration of survival was 105.9±8.3 months. Of the patients who did not survive till 10 years, 65.0% died of cardiac-related causes, with non-ST elevation myocardial infarction being the commonest cause. CABG improved LVEF (24.9% to 32.2%; P<0.001) and 66.7% of patients remained with impaired LVEF ≤35% post CABG. Post op NYHA class 3-4 symptoms (OR: 6.3; P=0.012) was the only predictive factor for 10 year all-cause mortality and post op LVEF improvement ≥5% (OR: 5.8; 95% CI, 1.1-29.9; P=0.036) was associated with improvement in NYHA class. Completeness of revascularization and viability of myocardium were not predictive of survival or changes in LVEF or NYHA class. CONCLUSIONS: The 10-year survival rates of Asian patients with ICM were similarly disappointing as its counterparts in the west. A majority of patients still suffered from cardiac-event related deaths. Post CABG NYHA class was found to be important in determining success and adequacy of treatment in patients with ICM and improvement in LVEF ≥5% was predictive of improvement of symptoms. Neither completeness of revascularization or presence of myocardial viability had any impact on survival in our patient cohort.
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The Djumbodis™ dissection system was introduced as an alternative to aortic arch replacement in acute type A aortic dissection involving the arch. In our own experience, some patients with Djumbodis implantation developed distal aortic arch and descending aortic aneurysm during subsequent follow-up and required additional interventions. However, as there is a high incidence of fracture associated with the Djumbodis system, further endovascular interventions are not feasible. We report a case of successful open descending aortic replacement in a patient with a fractured Djumbodis stent system.
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Aneurisma da Aorta Torácica , Dissecção Aórtica , Implante de Prótese Vascular , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/cirurgia , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Dissecação , Humanos , Stents , Resultado do TratamentoRESUMO
Neurological complications remain a major burden in cardiac surgery, despite various intraoperative measures attempting to reduce its occurrence. Advancement of percutaneous approach in valve replacement has brought focus to the use of cerebral protection system (CPS). We reported a novel application of percutaneous CPS in open heart surgery for a patient with an extensive calcified left atrial thrombus to reduce risk of embolic stroke. Although, there is no evidence to advocate routine use of CPS in all open cardiac surgical patients, we believe it is a technically feasible and probably safe approach for neurological protection in high-risk patients.
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Procedimentos Cirúrgicos Cardíacos/métodos , Valva Mitral , Acidente Vascular Cerebral/prevenção & controle , Trombose , Calcificação Vascular , Idoso , Feminino , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/cirurgia , Cardiopatias/complicações , Cardiopatias/diagnóstico por imagem , Cardiopatias/patologia , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Estenose da Valva Mitral/complicações , Estenose da Valva Mitral/diagnóstico por imagem , Estenose da Valva Mitral/cirurgia , Trombose/complicações , Trombose/diagnóstico por imagem , Trombose/cirurgia , Calcificação Vascular/complicações , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/cirurgiaRESUMO
With the advent of advanced technology in performing diagnostics for lung cancer, an incremental increase in the number of patients with oligometastatic disease is currently being managed with intent to cure. As treatment of selected types of patients with oligometastasis show favourable outcomes, the past notion of managing these patients palliatively is fast becoming extinct. Selection of patients based on established criterion together with surgical metastasectomy combined with multiple ablative techniques with or without systemic chemotherapy offers a reasonable rate of treatment success which provides basis for treating such patient population. As more evidence becomes available to suggest that the oligometastatic state of lung cancer does exist, and are potentially curable, a better understanding of the condition is necessary for clinicians, and surgeons to provide optimal care. In this review we present some of the clinical basis which may cause a paradigm shift in management of patients with oligometastatic lung disease.
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Three-dimensional (3D) printing has been gaining much attention in the medical field in recent years. At present, 3D printing most commonly contributes in pre-operative surgical planning of complicated surgery. It is also utilized for producing personalized prosthesis, well demonstrated by the customized rib cage, vertebral body models and customized airway splints. With on-going research and development, it will likely play an increasingly important role across the surgical fields. This article reviews current application of 3D printing in thoracic surgery and also provides a brief overview on the extended and updated use of 3D printing in bioprinting and 4D printing.
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Hyperbilirubinemia is a known risk factor in patients undergoing open heart operations. Infective endocarditis often leads to valvular injury, such as rupture of chordae tendineae or leaflet perforation, which can cause acute heart failure in association with pulmonary hypertension and liver dysfunction. Here we present a patient with massive liver congestion, reflected by extreme hyperbilirubinemia, secondary to acute heart failure following mitral valve endocarditis that was successfully treated by emergency mitral and tricuspid valve repair.
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We describe a case of total arch replacement with frozen elephant trunk for chronic type B aortic dissecting aneurysm, which resulted in inadvertent landing of the frozen elephant trunk into the false lumen. A radiofrequency puncture system-assisted controlled endovascular fenestration of the dissection flap was performed at the upper abdominal aorta and subsequent thoracic endovascular stenting, successfully redirecting the blood flow from the false to the true lumen. Our case illustrated a possible way to seal distal reentry in chronic type B aortic dissection.
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Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Stents , Dissecção Aórtica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios XRESUMO
Thoracic endovascular aortic repair (TEVAR) offers a less invasive treatment for aortic arch aneurysms. Clinical challenges arise when there is inadequate proximal landing for zone 1 TEVAR, such that a median sternotomy with total aortic debranching is required before stent deployment. The chimney technique was reported as an alternative approach to stent the arch branches and avoid sternotomy, but it was still associated with considerable chance of a type IA endoleak. We report a case of aortic arch aneurysm with an inadequate proximal landing for zone 1 TEVAR that was treated with debranching of head and neck vessels followed by TEVAR and preemptive and targeted coil embolization of the arch aneurysmal sac. Postoperative computed tomography showed no significant endoleak, and the patient had an unremarkable recovery.
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Aneurisma da Aorta Torácica/terapia , Implante de Prótese Vascular , Embolização Terapêutica , Procedimentos Endovasculares , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Humanos , Masculino , Tomografia Computadorizada por Raios XRESUMO
In the modern era when screening and early surveillance of pulmonary nodules is increasing in importance, the management of the pulmonary nodule represents a different challenge to thoracic surgeons. The difficulty lies in the merging of sound surgical and oncological principles with more minimally invasive and appropriate lung sparing surgery. Furthermore, the intra-operative identification and surgical management of small and sometimes multi-focal pulmonary lesions remain challenging. There have been many developments and innovations in the field of video-assisted thoracoscopic surgery (VATS) to cater for the demands from increasing incidence of pulmonary nodules with associated paradigm shift in their surgical management. Recently, uniportal VATS and non-intubated VATS represent an even less invasive alternative to the conventional multiport VATS. The emergence of image guided VATS, hybrid operating theatre and fluorescence thoracoscopy have all contributed to improved precision of VATS lung resection, and are becoming important adjuncts to lung sparing surgery. In this chapter, some of these recent developments in VATS with emphasize on their importance in surgical management of the pulmonary nodule will be discussed.
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A 57-year-old man was incidentally found to have a dissected diverticulum of Kommerell originating from aberrant origin of right subclavian artery during follow-up for treated colon cancer. A right carotid-axillary bypass was followed by embolization of aberrant artery and the diverticulum by deployment of multiple detachable coils using the Penumbra Ruby System (Penumbra, Alameda, CA). Angiography after embolization showed exclusion of flow to the aberrant artery and a patent right carotid-axillary bypass. The patient recovered uneventfully and remained well for 12 weeks after the operation, without any complications. We believe this targeted endovascular approach can avoid complications related to the coverage of thoracic aorta and reduce the risk of access vessel trauma.