Early outcomes in re-do operation after acute type A aortic dissection: results from the multicenter REAAD database.

This study provides early results of re-operations after the prior surgical treatment of acute type A aortic dissection (AAD) and identifies risk factors for mortality. Between May 2003 and January 2014, 117 aortic re-operations after an initial operation for AAD (a mean time from the first procedure was 3.98 years, with a range of 0.1-20.87 years) were performed in 110 patients (a mean age of 59.8 ± 12.6 years) in seven European institutions. The re-operation was indicated due to a proximal aortic pathology in ninety cases: twenty aortic root aneurysms, seventeen root re-dissections, twenty-seven aortic valve insufficiencies and twenty-six proximal anastomotic pseudoaneurysms. In fifty-eight cases, repetitive surgical treatment was subscripted because of distal aortic pathology: eighteen arch re-dissections, fifteen arch dilation and twenty-five anastomotic pseudoaneurysms. Surgical procedures comprised a total of seventy-one isolated proximals, thirty-one isolated distals and fifteen combined interventions. In-hospital mortality was 19.6 % (twenty-three patients); 11.1 % in patients with elective/urgent indication and 66.6 % in emergency cases. Mortality rates for isolated proximal, distal and combined operations regardless of the emergency setting were 14.1 % (10 pts.), 25.8 % (8 pts.) and 33.3 % (5 pts.), respectively. The causes of death were cardiac in eight, neurological in three, MOF in five, sepsis in two, bleeding in three and lung failure in two patients. A multivariate logistic regression analysis revealed that risk factors for mortality included previous distal procedure (p = 0.04), new distal procedure (p = 0.018) and emergency operation (p < 0.001). New proximal procedures were not found to be risk factors for early mortality (p = 0.15). This multicenter experience shows that the outcome of REAAD is highly dependent on the localization and extension of aortic pathology and the need for emergency treatment. Surgery in an emergency setting and distal re-do operations after previous AAD remain a surgical challenge, while proximal aortic re-operations show a lower mortality rate. Foresighted decision-making is needed in cases of AAD repair, as the results are essential preconditions for further surgical interventions.

Biological and clinical outcomes in the elderly with left ventricular dysfunction: Are there differences between on-pump and off-pump coronary artery bypass grafting?

AIM: To compair biological and clinical outcomes after off-pump coronary artery bypass grafting (OPCABG) and conventional on-pump coronary artery bypass grafting (CCABG) in the elderly with left ventricular (LV) dysfunction. MATERIAL OF STUDY: We retrospectively reviewed 90 consecutive patients aged more than 75 years with preoperative left ventricular ejection fraction (LVEF) < 50% who underwent isolated coronary artery bypass grafting at our Institution between January 2000 and July 2009. According to operative technique, patients were categorized in to the OPCABG group (39 patients) or in to the CCABG group (51 patients). We compared postoperative CK, CK-MB, troponin T serum levels and major adverse cardiac and cerebrovascular events (MACCE). RESULTS: The overall in-hospital mortality was 2% (2/90) and was similar in both groups (p=0.8336). Mean troponin T levels at 6,24,48 hours after operation were significantly lower in the OPCABG group (p=0.0001; p=0.0021; p=0.0070, respectively). Overall survival was 77.6% at 10 years and no significant difference in MACCE was observed (p=0.3016). DISCUSSION: Our results show a lower incidence of myocardial injury in OPCABG group, but there aren't differences in term of MACCE in both groups. Recent studies have indicated the advantages of OPCABG in the elderly patients, reporting a reduction of postoperative morbidity and organ dysfunction. However these studies not analyzed the impact of LV dysfunction on early and late postoperative outcomes in high-risk patients. CONCLUSIONS: In the elderly with LV dysfunction, the OPCABG technique showed lower incidence of postoperative myocardial injury. However, at the follow-up, this does not reflect any significant differences in incidence of MACCE.

Coronary artery bypass grafting in the octogenarian. Is complete revascularization always necessary?

AIM: The aim of this study was to investigate whether the completeness of revascularization affects the outcomes in the octogenarian. MATERIAL OF STUDY: We retrospectively reviewed 130 consecutive octogenarians who underwent isolated coronary artery bypass grafting (CABG) between January 2003 and September 2010. According to operative technique, patients were categorized in Complete Revascularization (CRV) Group (96 patients) and in Incomplete Revascularization (IRV) Group (34 patients). Follow-up was 98% complete (mean: 30 ± 25 months). RESULTS: The overall in-hospital mortality was 13% and was similar in both groups (p=0.0553). Multivariate regression analysis identified preoperative left ventricular ejection fraction ≤ 40% (p= 0.0060; OR= 0.19) and NHYA class > II (p= 0.0042; OR= 0.17) as risk factor for in-hospital death. Cox regression analysis not identified incomplete revascularization as risk factor for early or late death (p= 0.1381 and p= 0.8865). No differences in 5-year survival and freedom from major adverse cardiac and cerebrovascular events (MACCE) was found between two groups (p=0.8865 and p=0.6283). DISCUSSION: CRV is important in young patients undergoing CABG, but this principle remains less absolute in elderly patients. In our study, the survival benefit of CRV was less in octogenarians. Probably, the major benefit of CRV was seen in patients less than 80 years of age. This makes sense because these patients have a longer expected survival, and there were more patients available to statistically confirm any difference in outcome. CONCLUSIONS: In octogenarians undergoing CABG, IRV does not affect survival and freedom from MACCE. Patients' preoperative conditions are important in determining short and long term outcomes.

Aortic valve replacement with smaller prostheses in elderly patients: does patient prosthetic mismatch affect outcomes?

BACKGROUND AND AIM OF THE STUDY: To evaluate the influence of patient-prosthesis mismatch (PPM) on survival, and quality of life (QOL) after aortic valve replacement (AVR) in elderly patients with small prosthesis size. METHODS: Between 2005 and 2010, 142 patients older than 65 years were discharged from the hospital after AVR with 19 or 21 mm prosthesis for aortic stenosis. Their median age was 79 years (range 66 to 91). Prosthesis effective orifice area (EOA) was derived from the continuity equation and PPM was defined as an indexed EOA (IEOA) < 0.85 cm(2)/m(2). Patients having IEOA < 0.75 cm(2)/m(2) and IEOA < 0.60 cm(2)/m(2) were also investigated. Mean follow-up was 23 months (range 1 to 58) and was 98% complete. RESULTS: PPM was found in 86 patients, 63 had an IEOA ≤ 0.75 cm(2) /m(2), and 23 had an IEOA ≤ 0.60 cm(2) /m(2). The groups were similar except for older age (p = 0.0364), larger body surface area (p = 0.0068), more male gender (p = 0.0186), and more EF < 40% in patients with PPM. Survival at 58 months was 81 ± 6.4% and was not influenced by PPM (p = 0.9845). At Cox analysis only preoperative NYHA class (p = 0.0064) was identified as an independent risk factor for late death. The SF12 test was used to analyze the QOL of patients and it did not reveal differences between groups. CONCLUSIONS: PPM does not affect survival in this series of elderly patients. We believe that more aggressive surgical procedures are not justified in these patients.

Fate of the preserved aortic root after treatment of acute type A aortic dissection: 23-year follow-up.

OBJECTIVE: The objective of this study was to examine the fate of the native aortic root after replacement of the ascending aorta to treat acute type A aortic dissection. METHODS: Between June 1985 and January 2010, 319 consecutive patients (mean age, 63 ± 11 years) with acute type A aortic dissection underwent replacement of the ascending aorta with preservation of the aortic root. The aortic valve was also replaced in 21 of these patients (7%). The intervention was extended to the aortic arch in 210 patients (66%), of whom 173 (54%) underwent hemiarch replacement, and 37 (12%), total arch replacement. RESULTS: There were 109 (34%) in-hospital deaths. Of the 210 discharged patients, survival was 95%, 58%, and 27% at 1, 10, and 23 years, respectively. Freedom from reoperation on the proximal aorta was reported by 97%, 92%, and 82% patients at 5, 10, and 23 years, respectively. Twelve patients were reoperated for aortic root dilatation and 2 died during reoperation. Univariate and multivariate Cox regression analyses revealed that significant risk factors for proximal reoperation were age <60 years (P = .005; relative risk, 1.94) and Marfan syndrome (P = .011; relative risk, 2.76). At follow-up, 15 patients (11%) had an aortic root diameter of >45 mm, but they were not reoperated. CONCLUSIONS: For acute type A aortic dissection, replacement of the ascending aorta with root preservation shows long-term effectiveness with low reoperation and aortic root dilatation rates.

Cannulation techniques for temporary right and left ventricular support: simple solutions for a difficult problem.

End-stage cardiac failure where appropriate is best treated with cardiac transplantation. With improvements in medical therapy, the emergence of primary percutaneous coronary intervention, and an increasingly ageing population, patients with right, left or biventricular failure, who are not suitable for cardiac transplantation or long-term ventricular assist device therapy, present for cardiac surgery. The modern cardiac surgeon needs to have a safe strategy for dealing with these complex cases. We report two cases that illustrate simple and safe cannulation techniques for temporary left and right ventricular failure.

What is the optimal timing for surgery in infective endocarditis with cerebrovascular complications?

Neurologic dysfunction complicates the course of 10-40% of left-side infective endocarditis (IE). In right-sided IE, instead, when systemic emboli occur, paradoxical embolism should be considered. The spectrum of neurologic events includes embolic cerebrovascular complication (CVC), intracranial haemorrhage, ruptured mycotic aneurysm, transient ischaemic attack (TIA), meningitis, encephalopathy and brain abscess. Cardiopulmonary bypass might exacerbate neurological deficits due to: heparinization and secondary cerebral haemorrhage; hypotension and cerebral oedema in areas of the disrupted blood brain barrier. A best evidence topic was written according to a structured protocol. The question addressed was, whether there is an optimal timing for surgery in IE with CVCs. One hundred papers were found using the reported search criteria, and out of these 20 papers, provided the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results were tabulated. We found that evidence is conflicting because of lack of controlled studies. The optimal timing for the valve replacement depends on the type of neurological complication and the urgency of the operation. The new 2009 Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (IE) recommend a multidisciplinary approach and to wait for 1-2 weeks of antibiotics treatment before performing cardiac surgery. However, early surgery is indicated in: heart failure (class 1 B), uncontrolled infection (class 1 B) and prevention of embolic events (class 1B/C). After a stroke, surgery should not be delayed as long as coma is absent and cerebral haemorrhage has been excluded by cranial CT (class IIa level B). After a TIA or a silent cerebral embolism, surgery is recommended without delay (class 1 level B). In intracranial haemorrhage (ICH), surgery must be postponed for at least 1 month (class 1 level C). Surgery for prosthetic valve endocarditis (PVE) follows the general principles outlined for native valve IE. Every patient should have a repeated head CT scan immediately before the operation to rule out a preoperative haemorrhagic transformation of a brain infarction. The presence of a haematoma warrants neurosurgical consultation and consideration of cerebral angiography to rule out a mycotic aneurysm.

Surgical treatment of aortobronchial fistula after thoracic endograft failure.

Endovascular stent grafting has been recently considered as a less invasive alternative to either medical therapy or open surgical treatment for many patients with descending thoracic aortic disease. Late complications are rarely described in literature. Herein, we described the occurrence of an aorto-bronchial fistula and a retro-A dissection in a 73-year-old man after stent-grafting for a penetrating atherosclerotic ulcer (PAU) of the descending thoracic aorta and the successful surgical technique adopted in order to remove the stent-graft.