Image Predictors of Treatment Outcome after Thoracic Aortic Dissection Repair.

Treatment of thoracic aortic dissection remains highly challenging and is rapidly evolving. Common classifications of thoracic aortic dissection include the Stanford classification (types A and B) and the DeBakey classification (types I to III), as well as a new supplementary classification geared toward endovascular decision making. By using various imaging techniques, the extent of the dissection, the location of the primary intimal tear, the shape of the aortic arch, and the zonal involvement of the aortic arch-factors that affect the treatment strategy-can easily be identified. Thoracic endovascular aortic repair (TEVAR) is generally performed in two groups of patients: (a) those with a surgically repaired type A dissection, and (b) those with a complicated type B dissection. Several imaging findings can help predict the course of remodeling of the dissected aorta after a repaired type A dissection and TEVAR. A spectrum of imaging findings exist with regard to favorable (positive) or failing (negative) remodeling. A schematic model with imaging support allows the classification of important causes of failing remodeling into proximal and distal groups, on the basis of the origin of the refilling of the false lumen and the underlying pathophysiology of pressurization. Refilling of the false lumen of the aorta after repair of a type A dissection is usually secondary to a persistent intimal tear at the aortic arch, a leak of the distal graft anastomosis, or refilling from the false lumen of a dissected aortic arch vessel. After TEVAR, false lumen refilling is most commonly due to an incomplete seal of the proximal landing related to the aortic tortuosity, an arch branch stump, a supra-arch chimney stent, or the TEVAR technique. Online supplemental material is available for this article. ©RSNA, 2018.

Optimal Approach for Repair of Left Atrial-Esophageal Fistula Complicating Radiofrequency Ablation.

Left atrial-esophageal fistula after endovascular radiofrequency ablation for cardiac arrhythmias is a life-threatening complication. Immediate surgical repair offers the best chance for survival. The optimal surgical technique is unknown. We describe our recommended surgical approach.

Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection.

BACKGROUND: Controversy exists regarding the optimal extent of repair for type A aortic dissection. Our approach is to replace the ascending aorta, and only replace the aortic root or arch when intimal tears are present in those areas. We examined intermediate outcomes with this approach to acute type A aortic dissection repair. METHODS: Between March 2005 and October 2016, 195 patients underwent repair of acute type A aortic dissection. Repair was categorized by site of proximal and distal anastomosis and extent of repair. Mean follow-up was 31.0 ± 30.9 months. Kaplan-Meier analysis was used to assess survival. Multiple variable Cox proportional hazards modeling was utilized to identify factors associated with overall mortality. RESULTS: Overall survival was 85.1%, 83.9%, 79.1%, and 74.4% at 6, 12, 36, and 60 months, respectively. Eight patients required reintervention. The cumulative incidence of aortic reintervention at 1 year with death as a competing outcome was 3.95%. Multiple variable regression analysis identified factors such as age, preoperative renal failure, concomitant thoracic endograft, postoperative myocardial infarction and sepsis, and need for extracorporeal membrane oxygenation as predictive of overall mortality. Neither proximal or distal extent of repair, nor need for reintervention affected overall survival (proximal: hazard ratio 1.63, 95% confidence interval: 0.75 to 3.51, p = 0.22; distal: hazard ratio 1.12, 95% confidence interval: 0.43 to 2.97, p = 0.81; reintervention: hazard ratio 0.03, 95% confidence interval: 0.002 to 0.490, p < 0.01). CONCLUSIONS: A selective approach to root and arch repair in acute type A aortic dissection is safe. If aortic reintervention is needed, survival does not appear to be affected.

Comparison of intravascular ultrasound- and centerline computed tomography-determined aortic diameters during thoracic endovascular aortic repair.

BACKGROUND: Accurate sizing of stent grafts during thoracic endovascular aortic repair (TEVAR) is critical for a successful outcome. Centerline measurements using three-dimensional reconstruction of preoperative computed tomography angiography (CTA) is the current standard for stent graft sizing. However, this technique is predicated on an idealized straightened aorta and does not account for the variability in the aortic diameter during the cardiac cycle or the overall status of the patient's volume. Intravascular ultrasound (IVUS) offers real-time cross-sectional imaging of the aorta orthogonal to the support wire, thereby providing an adjunctive method for aortic diameter determination at the time of TEVAR. METHODS: A retrospective review was performed on all patients who underwent TEVAR for nontraumatic aortic pathology from July 2015 to December 2015. Preoperative CTA images were reconstructed on a dedicated three-dimensional workstation. CTA centerline aortic diameter measurements were performed in major and minor axes at 1-cm intervals from the left subclavian origin to 20 cm distally. The IVUS images were acquired intraoperatively through 1-cm stepwise pullback along the aorta from the left subclavian origin to 20 cm. IVUS aortic diameters were measured at the maximum phase during the cardiac cycle. The average values of major and minor axes diameters from both modalities were calculated at each location for comparison. Linear regression analysis was performed to evaluate correlation, and Bland-Altman plots assessed agreement between different imaging modalities. RESULTS: During the study period, 26 patients underwent TEVAR. Of these, 20 patients had adequate CTA and IVUS images, providing 355 paired measurements. There was a high correlation between CTA- and IVUS-determined aortic diameters (R = 0.62; P < .001). However, Bland-Altman analysis showed that, compared with CT, IVUS resulted in larger aortic diameters, with the mean difference of 3.09 mm. There was a significant variability between IVUS and CTA with the standard deviation of difference (SD diff) of 4.56 mm. When stratified by the aortic position, a high degree of agreement was observed at the base of the left subclavian (position 0), with a mean difference of -2.69 mm and an SD diff of 4 mm. The agreement was the lowest at the angulated aortic segments (2 cm to 7 cm distal to the subclavian origin) with a mean difference up to 7.96 mm and an SD diff up to 8.27 mm. CONCLUSIONS: IVUS imaging and centerline CTA may provide significantly different aortic diameter measurements, particularly in angulated aortic segments. Caution must be taken when sizing a stent graft using CTA alone, particularly in an angulated proximal landing zone.

The Utility of Nurse-Managed Extracorporeal Life Support in an Adult Cardiac Intensive Care Unit.

BACKGROUND: The use of extracorporeal life support (ECLS) worldwide has increased exponentially since 2009. The patient requiring ECLS demands an investment of hospital resources, including personnel. Educating bedside nurses to manage ECLS circuits broadens the availability of trained providers. METHODS: Experienced cardiothoracic intensive care unit (CTICU) nurses underwent training to manage ECLS circuits, including volume assessment, treatment of arterial blood gas values, the physiology of ECLS, and recognition of common emergencies. In addition to lectures and a written examination, simulation using water circuits and an ICU model allowed assessment of skills and understanding of concepts. Performance assessments were completed regularly at the bedside, and skills revalidation occurred every 6 months. A sequential cohort of 40 patients was tracked over 1 year. RESULTS: Despite doubling the census of ECLS patients in 1 year, management by specially trained CTICU nurses has positively affected patient care and outcomes. At a single institution, 40 patients had a median of 6 days (interquartile range, 2 to 226 days) of support in 2014, leading to 767 patient-days of support. Survival to hospital discharge increased to 45% in 2014. Most survivors were weaned from support. Neurologic injury was the most common cause of death, followed by failure to qualify for advanced therapies. CONCLUSIONS: With on-going education and assessment, including crisis training, physiology, and cannulation strategies, CTICU nurses can safely operate ECLS circuits and can increase the availability of appropriately trained providers to accommodate the exponential increase in ECLS occurrences without negatively affecting outcomes and generally at a lower cost.

A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients.

OBJECTIVES: Right anterior minithoracotomy with central arterial cannulation is our preferred technique of minimally invasive aortic valve replacement (AVR). We compared perioperative outcomes with this technique to those via sternotomy. METHODS: Between March 1999 and December 2013, 492 patients underwent isolated AVR via either sternotomy (SAVR, n = 198) or minimally invasive right anterior thoracotomy (MIAVR, n = 294) in our institution. Univariate comparisons between groups were made to evaluate overall outcomes and adverse events. To control treatment selection bias, propensity scores were constructed from core patient characteristics. A propensity score-stratified analysis of outcome and adverse events was then performed. RESULTS: Overall mortality was 2.5 and 1.0% in the SAVR and MIAVR groups, respectively. Hospital and ICU stays were shorter, there was less intraoperative blood product usage, and fewer wound infections in the MIAVR group. There were no differences in other adverse events, including strokes. The composite end-point of alive and adverse event-free was significantly more common in the MIAVR group (83 vs 74%, P = 0.002). After adjusting for the propensity score, hospital and ICU stays remained shorter and intraoperative blood product usage remained less in the MIAVR group. There was no difference in mortality, stroke or other adverse events between groups. CONCLUSION: Minimally invasive AVR via an anterior right thoracotomy with predominately central cannulation can be performed with morbidity and mortality similar to that of a sternotomy approach. There appear to be advantages to this minimally invasive approach when compared with sternotomy in terms of less intraoperative blood product usage, lower wound infection rates and decreased hospital stays. If mortality and the occurrence of adverse events are taken together, MIAVR may be associated with better outcomes. As minimally invasive AVR becomes more common, further long-term follow-up is needed and a prospective multicentre randomized trial would be warranted.

Exercise Hemodynamics and Quality of Life after Aortic Valve Replacement for Aortic Stenosis in the Elderly Using the Hancock II Bioprosthesis.

Background and Aim. While aortic valve replacement for aortic stenosis can be performed safely in elderly patients, there is a need for hemodynamic and quality of life evaluation to determine the value of aortic valve replacement in older patients who may have age-related activity limitation. Materials and Methods. We conducted a prospective evaluation of patients who underwent aortic valve replacement for aortic stenosis with the Hancock II porcine bioprosthesis. All patients underwent transthoracic echocardiography (TTE) and completed the RAND 36-Item Health Survey (SF-36) preoperatively and six months postoperatively. Results. From 2004 to 2007, 33 patients were enrolled with an average age of 75.3 ± 5.3 years (24 men and 9 women). Preoperatively, 27/33 (82%) were New York Heart Association (NYHA) Functional Classification 3, and postoperatively 27/33 (82%) were NYHA Functional Classification 1. Patients had a mean predicted maximum V O2 (mL/kg/min) of 19.5 ± 4.3 and an actual max V O2 of 15.5 ± 3.9, which was 80% of the predicted V O2 . Patients were found to have significant improvements (P ≤ 0.01) in six of the nine SF-36 health parameters. Conclusions. In our sample of elderly patients with aortic stenosis, replacing the aortic valve with a Hancock II bioprosthesis resulted in improved hemodynamics and quality of life.

Contemporary use of balloon aortic valvuloplasty in the era of transcatheter aortic valve implantation.

The development of transcatheter aortic valve implantation (TAVI) has increased the use of balloon aortic valvuloplasty (BAV) in treating aortic stenosis. We evaluated our use of BAV in an academic tertiary referral center with a developing TAVI program. We reviewed 69 consecutive stand-alone BAV procedures that were performed in 62 patients (mean age, 77 ± 10 yr; 62% men; baseline mean New York Heart Association functional class, 3 ± 1) from January 2009 through December 2012. Enrollment for the CoreValve(®) clinical trial began in January 2011. We divided the study cohort into 2 distinct periods, defined as pre-TAVI (2009-2010) and TAVI (2011-2012). We reviewed clinical, hemodynamic, and follow-up data, calculating each BAV procedure as a separate case. Stand-alone BAV use increased 145% from the pre-TAVI period to the TAVI period. The mean aortic gradient reduction was 13 ± 10 mmHg. Patients were successfully bridged as intended to cardiac or noncardiac surgery in 100% of instances and to TAVI in 60%. Five patients stabilized with BAV subsequently underwent surgical aortic valve replacement with no operative deaths. The overall in-hospital mortality rate (17.4%) was highest in emergent patients (61%). The implementation of a TAVI program was associated with a significant change in BAV volumes and indications. Balloon aortic valvuloplasty can successfully bridge patients to surgery or TAVI, although least successfully in patients nearer death. As TAVI expands to more centers and higher-risk patient groups, BAV might become integral to collaborative treatment decisions by surgeons and interventional cardiologists.

Minimally invasive approach to the supradiaphragmatic inferior vena cava: total thoracoscopic caval isolation.

Minimally invasive techniques for cardiac operations have evolved in safety and popularity. To our knowledge, a thoracoscopic technique for control of the inferior vena cava (IVC) has not been previously described. We report a case of a right renal cell cancer with tumor extension into the IVC. Total thoracoscopic isolation and occlusion of the IVC were performed. Intraoperative real-time transesophageal echocardiography confirmed complete cessation of caval flow upon cinching the Rummel tourniquet. As extensive intra-abdominal operations are more often being attempted laparoscopically or robotically, video-assisted thoracoscopic IVC occlusion for proximal control for tumors extending into the cava can be achieved to offer a minimally invasive thoracic approach.

Thoracic aortic stent-grafting for acute, complicated, type B aortic dissections.

BACKGROUND: To report a single-center experience of aortic stent-grafting for the treatment of acute, complicated, type B aortic dissections. METHODS: A retrospective review was conducted of the data obtained from all patients who underwent endovascular stent-grafting for acute, type B aortic dissection between 2006 and 2009. The primary and secondary endpoints were 30-day mortality and morbidity rates, respectively. RESULTS: In all, 104 thoracic endovascular aortic aneurysm repairs were performed during the study period. Nine (8.6%) patients (six men; mean age: 65 years) underwent thoracic endovascular aortic aneurysm repair for acute, complicated, type B aortic dissections. Seven (78%) patients had uncontrolled hypertension on presentation. Visceral branch vessel involvement of the dissection was limited to the celiac axis origin in one patient with no evidence of visceral malperfusion. The indication for repair was aortic rupture in five patients, renal malperfusion in two, and persistent pain in the remaining two. Average time taken from presentation to surgery was 5.5 days. Two patients presenting with aortic ruptures had retrograde extension of the dissection that required replacement of the aortic valve and ascending aorta. The mean length of thoracic aorta covered was 21 cm. Complete coverage of the left subclavian artery was required in three patients and partial coverage in two. On completion angiogram, two type I endoleaks were detected, one of which was resolved by postoperative day 5. The 30-day mortality rate was 22%. One mortality was secondary to aortic rupture. The other mortality was due to multiorgan system failure. Seven patients (78%) had one or more major complications. There were no strokes or paraplegia. CONCLUSION: The association of morbidity and mortality with endovascular stent-grafting for acute, complicated, type B aortic dissections is significant, which most likely reflects the lethal nature of the disease. The precise role of endovascular treatment in these patients remains to be defined.

Arch and visceral/renal debranching combined with endovascular repair for thoracic and thoracoabdominal aortic aneurysms.

OBJECTIVE: We report a single-center experience using the hybrid procedure, consisting of open debranching, followed by endovascular aortic repair, for treatment of arch/proximal descending thoracic/thoracoabdominal aortic aneurysms (TAAA). METHODS: From 2005 to 2010, 51 patients (33 men; mean age, 70 years) underwent a hybrid procedure for arch/proximal descending thoracic/TAAA. The 30-day and in-hospital morbidity and mortality rates, and late endoleak, graft patency, and survival were analyzed. Graft patency was assessed by computed tomography, angiography, or duplex ultrasound imaging. RESULTS: Hybrid procedures were used to treat 27 thoracic (16 arch, 11 proximal descending thoracic) and 24 TAAA (Crawford/Safi types I to III: 3; type IV: 12; type V: 9). The hybrid procedure involved debranching 47 arch vessels or 77 visceral/renal vessels using bypass grafts, followed by endovascular repair. Seventy-five percent of debranching and endovascular repair procedures were staged, with an average interval of 28 days. Major 30-day and in-hospital complications occurred in 39% of patients and included bypass graft occlusion in four, endoleak reintervention in two, and paraplegia in one. Mortality was 3.9%. During a mean follow-up of 13 months, three additional type II endoleaks required intervention, and one bypass graft occluded. No aneurysm rupture occurred during follow-up. Primary bypass graft patency was 95.3%. Actuarial survival was 86% at 1 year and 67% at 3 years. CONCLUSION: The hybrid procedure is associated with acceptable rates of mortality and paraplegia when used for treatment of arch/proximal descending thoracic/TAAA. These results support this procedure as a reasonable approach to a difficult surgical problem; however, longer follow-up is required to appraise its ultimate clinical utility.

Is transthoracic minimally invasive aortic valve replacement too time-consuming for the busy cardiac surgeon?

OBJECTIVE: : Transthoracic minimally invasive aortic valve replacement (TMI-AVR) is gaining popularity despite criticism that time from incision to the initiation of cardiopulmonary bypass (exposure time, ET), cardiopulmonary bypass time (CPBT), and cross-clamp time (XCT) is excessive. Database analysis was used to characterize these parameters and their associated learning curves. METHODS: : From 2004 to 2008, 101 patients underwent TMI-AVR at a single institution. Of them, 54 were men (53%) and 47 were women (47%). Mean age was 70 years (range, 24-90 years). ET includes 6-cm incision, second intercostals anterior thoracotomy, medial transection of the third rib, opening pericardial sac, retracing pericardium with stay sutures, placing aortic arterial, and right arterial venous bypass cannulae. ET, CPBT, XCT, and operating room times were calculated. Logarithmic trend analysis established associated learning curves. RESULTS: : ET steadily improved over time. ET decreased from an average of 51 minutes for the first 25 patients to 39 minutes for the most recent 25 patients. When surgeon experience reached 10 procedures, the ET trend line began to decline steadily and plateaued by 55 cases. Cross-clamp (55 ± 21 minutes), cardiopulmonary bypass (77 ± 31 minutes), and operating room times (304 ± 67 minutes) all remained constant. There were no early deaths or conversions to sternotomy. CONCLUSIONS: : ET learning curve for TMI-AVR was reflected after 10 procedures with continued gradual improvement. Reliability of TMI-AVR was observed in the absence of a learning curve for XCT, CPBT, and operating room times. A sternal-sparing transthoracic approach for AVR can be performed safely, with expected operative times equivalent to sternotomy.

Pericardial constriction after lung transplantation.

Pericardial constriction is extremely rare after lung transplantation. We present a case and review the potential contributing factors for pericardial constriction after lung transplantation. Treatment for this condition, irrespective of the cause, remains pericardiectomy.

Endovascular management of mycotic aortic aneurysms and associated aortoaerodigestive fistulas.

We evaluated the short- and intermediate-term results of endovascular aneurysm repair (EVAR) for mycotic aneurysms. We reviewed all patients undergoing EVAR for mycotic aneurysms at our institution. To be consistent with the existing literature, patients with associated aortoaerodigestive fistulas were included. Aneurysm location, demographics, clinical findings, EVAR success, morbidity, and short- (<30 days) and long-term mortality were reviewed. From 2000 to 2007, 326 patients underwent EVAR. Nine of these (3%) had treatment of a mycotic aneurysm. The average age was 72 years (range 53-86), and seven patients were male. Four of the aneurysms were located in the thoracic aorta, two in the abdominal aorta, and three in the thoracoabdominal aorta. Four patients presented with gastrointestinal bleeding, two with hemoptysis, one with hemothorax, and two with fever. Etiologies included bacteremia from endocarditis and central catheter infection, erosion of anastomotic aneurysms from a previous aortic repair or endograft, erosion of a penetrating ulcer with pseudoaneurysm, infected aortic repair, left chest empyema, and unknown in one patient. Methicillin-resistant Staphylococcus aureus was the only bacteria isolated in 56% of the patients. EVAR successfully excluded the aneurysm or fistula in all nine patients; however, five patients experienced at least one postoperative complication. Two patients expired within 30 days. After 30 days, four additional patients expired; three of these deaths were procedure/aneurysm-related. Of the three survivors, over a mean follow-up of 257 days (range 60-417), one has required excision of an infected endograft with extra-anatomic bypass grafting but is now alive and well. All three surviving patients and two out of four patients expiring after 30 days had received long-term postoperative antibiotics. Despite an in-hospital mortality of 22.2%, EVAR can be used to treat acute complications from mycotic aneurysms and associated aortoaerodigestive fistulas, such as gastrointestinal bleeding, hemoptysis, or hemodynamic instability. As a definitive treatment, EVAR remains suspect and therefore should be considered a bridge to open surgical repair.

Calcific constrictive pericarditis demonstrated on 99mTc-MDP bone scintigraphy.

The authors present a case of calcific constrictive pericarditis, imaged with bone scintigraphy. The patient presented with three months of shortness of breath, chest pain, and chest tightness during exercise, among other nonspecific symptoms. Although the diagnosis was made based on chest radiography and cardiac MRI, bone scintigraphy was used to corroborate the diagnosis of calcific constrictive pericarditis. Bone scintigraphy showed a pattern of tracer accumulation consistent with pericardial uptake. Calcific constrictive pericarditis was also confirmed at the time of surgery.

Neochordal repair of the posterior mitral leaflet.

BACKGROUND: Myxomatous mitral valve insufficiency is traditionally repaired by posterior leaflet quadrangular resection and reconstruction. A simplified repair technique without leaflet resection is described, and our initial experience is reviewed. METHODS: Thirty-nine consecutive patients with significant mitral regurgitation underwent repair since January 2000 by placement of expanded polytetrafluoroethylene sutures between the leading (coapting) edge of the posterior leaflet and the corresponding papillary muscle. An annuloplasty ring was placed, and no leaflet tissue was resected. Patient medical records were obtained and retrospectively reviewed. RESULTS: Twenty-five men and 14 women (median age, 61 years; range, 40-88 years) had their mitral valve repaired by a variety of surgical approaches, including robotic (18 patients), right thoracotomy (6 patients), and sternal (15 patients). Three patients have required valve replacement: 1 at the initial operation, 1 because of dehiscence of the annuloplasty ring, and 1 after subsequent rupture of a previously normal native chorda. At follow-up (median, 12 months), 92% (33/36) of the remaining patients had an intact mitral repair with no to mild regurgitation, 8.3% (3/36) of patients had moderate regurgitation, and 92% of all patients (36/39) were in New York Heart Association class I. There were no deaths. CONCLUSIONS: Myxomatous mitral regurgitation due to posterior leaflet insufficiency can be repaired without leaflet resection by placement of neochordae. This repair technique is effective and is readily accomplished by traditional and minimally invasive surgical approaches.