Intermediate Follow-Up of Balloon-Expandable Versus Self-Expanding Transcatheter Aortic Valve Implantation in Patients With Small Aortic Annuli.

The clinical impact of prosthesis-patient mismatch (PPM) in patients with small aortic annuli who underwent transcatheter aortic valve (AV) implantation with either balloon-expandable (BE) or self-expanding (SE) valves remains controversial. We assessed in-hospital and intermediate clinical outcomes in 573 patients with transfemoral transcatheter AV implantation with a small AV annulus, defined as an AV annulus area ≤430 mm2. A total of 337 patients treated with a 23-mm BE valve (SAPIEN 3, Ultra) were compared with 236 patients treated with a 26-mm SE valve (Evolut series). Valve-in-valve cases were excluded, and late echo follow-up (mean 674 ± 438 days) was assessed in a subset of 292 patients (51.0%). Well-matched BE and SE cohorts did not differ with respect to major in-hospital outcomes, other than a borderline increase in vascular complications and composite bleeding in patients with SE. Patients with BE had a higher incidence of severe PPM on discharge echocardiography (16.9% vs 6.8%, p <0.002). The mean AV gradient at 30 days was higher for patients with BE (12.2 ± 4.2 vs 6.2 ± 7.9 mm Hg, p <0.001) and at late follow-up (14.0 ± 8.2 vs 7.2 ± 3.5 mm Hg, p <0.001). The follow-up left ventricular ejection fraction and incidence of >mild aortic insufficiency were similar. All-cause mortality for the 2 cohorts was similar, with an overall mean (95% confidence interval) survival time of 61.2 months (57.8 to 64.5; p = 0.98). There were no significant survival differences between combined patients with BE and SE with no, moderate, or severe PPM, with an overall mean (95% confidence interval) survival time of 32.5 (30.5 to 34.5) months combining valve types (p = 0.23). In conclusion, despite an increased incidence of PPM with higher mean AV gradients that persist on late echocardiography in the BE cohort, patients with BE and SE with small aortic annuli have similar clinical outcomes at intermediate follow-up. Moderate and severe PPM had no impact on survival at a mean follow-up of 32.5 months.

Low-Dose vs Standard Warfarin After Mechanical Mitral Valve Replacement: A Randomized Trial.

BACKGROUND: Current guidelines recommend a target international normalized ratio (INR) range of 2.5 to 3.5 in patients with a mechanical mitral prosthesis. The Prospective Randomized On-X Anticoagulation Clinical Trial (PROACT) Mitral randomized controlled noninferiority trial assessed safety and efficacy of warfarin at doses lower than currently recommended in patients with an On-X (Artivion, Inc) mechanical mitral valve. METHODS: After On-X mechanical mitral valve replacement, followed by at least 3 months of standard anticoagulation, 401 patients at 44 North American centers were randomized to low-dose warfarin (target INR, 2.0-2.5) or standard-dose warfarin (target INR, 2.5-3.5). All patients were prescribed aspirin, 81 mg daily, and encouraged to use home INR testing. The primary end point was the sum of the linearized rates of thromboembolism, valve thrombosis, and bleeding events. The design was based on an expected 7.3% event rate and 1.5% noninferiority margin. RESULTS: Mean patient follow-up was 4.1 years. Mean INR was 2.47 and 2.92 (P <.001) in the low-dose and standard-dose warfarin groups, respectively. Primary end point rates were 11.9% per patient-year in the low-dose group and 12.0% per patient-year in the standard-dose group (difference, -0.07%; 95% CI, -3.40% to 3.26%). The CI >1.5%, thus noninferiority was not achieved. Rates (percentage per patient-year) of the individual components of the primary end point were 2.3% vs 2.5% for thromboembolism, 0.5% vs 0.5% for valve thrombosis, and 9.13% vs 9.04% for bleeding. CONCLUSIONS: Compared with standard-dose warfarin, low-dose warfarin did not achieve noninferiority for the composite primary end point. (PROACT Clinicaltrials.gov number, NCT00291525).

Transcarotid Versus Transfemoral Transcatheter Aortic Valve Replacement (from a Propensity-Matched Comparison).

Previous reports comparing transcarotid (TC) versus transfemoral (TF) approaches for patients undergoing transcatheter aortic valve replacement have had inconsistent conclusions. We compared in-hospital and 1-year clinical outcomes, changes in quality of life, and direct hospital costs for 138 TC versus 1,926 TF procedures. Propensity matching based on the Society of Thoracic Surgery Predicted Risk of Mortality was used to compare 130 patients who underwent TC with 813 patients who underwent TF. Matched TC versus TF cohorts did not differ with respect to in-hospital mortality (0.0% vs 1.4%, p = 0.380), stroke (2.3% vs 2.5%, p = 0.917), major vascular complications (0.8% vs 2.2%, p = 0.268), composite bleeding complications (4.6% vs 6.4%, p = 0.647), requirement for permanent pacemaker (14.6% vs 12.9%, p = 0.426), postoperative hospital length of stay (3.3 ± 3.4 vs 3.1 ± 3.3 days, p = 0.467), or direct hospital costs ($52,899 ± 9,560 vs $50,464 ± 10,997, p = 0.230). Similarly, at 1-year, patients who underwent TC versus patients who underwent TF did not differ with respect to all-cause mortality (7.6% vs 6.4%, p = 0.659), hospital readmission (20.0% vs 23.9%, p = 0.635), or quality of life as measured by the Kansas City Cardiomyopathy Questionnaire score (84.0 ± 17.1 vs 88.4 ± 13.9, p = 0.062). Patients who underwent TC and TF did not differ with respect to in-hospital complications, length of hospital stay, and direct hospital costs, as well as 1-year mortality, readmission, and quality of life. These data add to ongoing support for the TC approach as the optimal alternative access for patients with transcatheter aortic valve replacement deferred from a transfemoral approach.

WITHDRAWN: Low-Dose Versus Standard Warfarin After Mechanical Mitral Valve Replacement: A Randomized Controlled Trial.

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Machine learning models for mitral valve replacement: A comparative analysis with the Society of Thoracic Surgeons risk score.

BACKGROUND: Current Society of Thoracic Surgeons (STS) risk models for predicting outcomes of mitral valve surgery (MVS) assume a linear and cumulative impact of variables. We evaluated postoperative MVS outcomes and designed mortality and morbidity risk calculators to supplement the STS risk score. METHODS: Data from the STS Adult Cardiac Surgery Database for MVS was used from 2008 to 2017. The data included 383,550 procedures and 89 variables. Machine learning (ML) algorithms were employed to train models to predict postoperative outcomes for MVS patients. Each model's discrimination and calibration performance were validated using unseen data against the STS risk score. RESULTS: Comprehensive mortality and morbidity risk assessment scores were derived from a training set of 287,662 observations. The area under the curve (AUC) for mortality ranged from 0.77 to 0.83, leading to a 3% increase in predictive accuracy compared to the STS score. Logistic Regression and eXtreme Gradient Boosting achieved the highest AUC for prolonged ventilation (0.82) and deep sternal wound infection (0.78 and 0.77) respectively. EXtreme Gradient Boosting performed the best with an AUC of 0.815 for renal failure. For permanent stroke prediction all models performed similarly with an AUC around 0.67. The ML models led to improved calibration performance for mortality, prolonged ventilation, and renal failure, especially in cases of reconstruction/repair and replacement surgery. CONCLUSIONS: The proposed risk models complement existing STS models in predicting mortality, prolonged ventilation, and renal failure, allowing healthcare providers to more accurately assess a patient's risk of morbidity and mortality when undergoing MVS.

Subclavian/Axillary Access for Self-Expanding Transcatheter Aortic Valve Replacement Renders Equivalent Outcomes as Transfemoral.

BACKGROUND: Iliofemoral arterial disease can preclude transfemoral (TF) transcatheter aortic valve replacement (TF-TAVR). Transthoracic access by direct aortic or a transapical approach imparts a greater risk of complications and death than TF access. We hypothesized that subclavian/axillary arterial (SCA) access offers equivalent risks and outcomes as TF access. METHODS: The outcomes of 202 patients from the CoreValve (Medtronic, Minneapolis, MN) United States Pivotal Trial Program treated with SCA access were propensity matched with patients treated with TF access and analyzed. RESULTS: Matching was successful, with no significant baseline differences in the SCA group and the TF group, except the SCA group had more past or present smokers (79.2% vs 61.4%, p < 0.001) and fewer patients with anemia requiring transfusion (18.5% vs 27.5%, p = 0.04). SCA patients experienced a significantly longer time from enrollment to procedure (8.6 ± 19.1 vs 5.3 ± 6.3 days; p = 0.02), likely the result of case planning. Significant differences in procedural outcomes include less post-TAVR balloon dilation (17.9% vs 26.7%, p = 0.03) and more general anesthesia (99.0% vs 89.6%, p < 0.001) for the SCA accesses. There were no differences in procedure time (57.8 ± 45.3 vs 57.5 ± 32.1 min, p = 0.94) or Valve Academic Research Consortium I-defined procedure success between groups (p = 0.89). Event rates at 30 days or 1 year were similar, with a trend toward fewer pacemakers with SCA accesses. CONCLUSIONS: Major morbidity and mortality rates SCA-TAVR are equivalent to TF-TAVR. The SCA should be the preferred secondary access site for TAVR because it offers procedural and clinical outcomes comparable to TF-TAVR and applies to most patients who are not TF candidates.

Techniques of Proximal Root Reconstruction and Outcomes Following Repair of Acute Type A Aortic Dissection.

BACKGROUND: The goal of this study was to compare the early and late outcomes of different techniques of proximal root reconstruction during the repair of acute Type A aortic dissection, including aortic valve (AV) resuspension, aortic valve replacement (AVR), and a root replacement procedure. METHODS: All patients who underwent acute Type A aortic dissection repair between January 2000 and October 2010 at four academic institutions were compiled from each institution's Society of Thoracic Surgeons Database. This included 189 patients who underwent a concomitant aortic valve (AV) procedure; 111, 21, and 57 patients underwent AV resuspension, AVR, and the Bentall procedure, respectively. The median age of patients undergoing a root replacement procedure was significantly younger than the other two groups. Early clinical outcomes and 10-year actuarial survival rates were compared. Trends in outcomes and surgical techniques throughout the duration of the study were also analyzed. RESULTS: The operative mortality rates were 17%, 29%, and 18%, for AV resuspension, AVR, and root replacement, respectively. Operative mortality (p = 0.459) was comparable between groups. Hemorrhage related re-exploration did not differ significantly between groups (p = 0.182); however, root replacement procedures tended to have decreased rates of bleeding when compared to AVR (p = 0.067). The 10-year actuarial survival rates for the AV resuspension, Bentall, and AVR groups were 72%, 56%, and 36%, respectively (log-rank p = 0.035). CONCLUSIONS: The 10-year actuarial survival was significantly lower in those receiving AVR compared to those receiving root replacement procedures or AV resuspension. Operative mortality was comparable between the three groups.

Comparison between antegrade and retrograde cerebral perfusion or profound hypothermia as brain protection strategies during repair of type A aortic dissection.

BACKGROUND: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute type A aortic dissection by the method of cerebral perfusion used. METHODS: A total of 324 patients from five academic medical centers underwent repair of acute type A aortic dissection between January 2000 and December 2010. Of those, antegrade cerebral perfusion (ACP) was used for 84 patients, retrograde cerebral perfusion (RCP) was used for 55 patients, and deep hypothermic circulatory arrest (DHCA) was used for 184 patients during repair. Major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality and Cox Regression hazard ratios were calculated to determine the predictors of long term mortality. RESULTS: Operative mortality was not influenced by the type of cerebral protection (19% for ACP, 14.5% for RCP and 19.1% for DHCA, P=0.729). In multivariable logistic regression analysis, hemodynamic instability [odds ratio (OR) =19.6, 95% confidence intervals (CI), 0.102-0.414, P<0.001] and CPB time >200 min(OR =4.7, 95% CI, 1.962-1.072, P=0.029) emerged as independent predictors of operative mortality. Actuarial 5-year survival was unchanged by cerebral protection modality (48.8% for ACP, 61.8% for RCP and 66.8% for no cerebral protection, log-rank P=0.844). CONCLUSIONS: During surgical repair of type A aortic dissection, ACP, RCP or DHCA are safe strategies for cerebral protection in selected patients with type A aortic dissection.

Vascular Operations Performed by Cardiothoracic Surgeons: The Society of Thoracic Surgeons Survey.

BACKGROUND: Many cardiothoracic surgeons supplement their case volume through the performance of vascular surgical procedures. Information regarding this practice is not well defined. METHODS: In January of 2013, a survey was conducted of The Society of Thoracic Surgeons (STS) membership to assess the performance of vascular operations by cardiothoracic surgeons. RESULTS: The overall response rate was 8.7%. Of the surgeons practicing vascular surgery, 60% were aged 45 to 64 years and 92% were male. Eleven percent of surgeons are board certified in vascular surgery, and 61% have been practicing 16 or more years, with 33% practicing in the southern United States. Twenty-two percent of surgeons stated that at least 30% of their practice was devoted to vascular surgery. Eighty-one percent of respondents would like to see vascular surgery training become part of the formal curriculum for cardiothoracic surgery education, and 90% said that cardiothoracic surgery education should offer a cardiovascular track with emphasis on thoracic and vascular surgery, including endovascular surgery. CONCLUSIONS: This survey provides expanded data on the performance and breadth of practice of vascular surgery by the STS membership.

Axillary Versus Femoral Arterial Cannulation During Repair of Type A Aortic Dissection?: An Old Problem Seeking New Solutions.

BACKGROUND: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute Type A aortic dissection with axillary or femoral artery cannulation. METHODS: A total of 305 patients from five academic medical centers underwent acute Type A aortic dissection repair via axillary (n = 107) or femoral (n = 198) artery cannulation between January 2000 and December 2010. Major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality, and Cox regression hazard ratios were calculated to determine predictors of long-term mortality. RESULTS: Operative mortality was not influenced by cannulation site (16% for axillary cannulation vs. 19% for femoral cannulation, p = 0.64). In multivariate logistic regression analysis, hemodynamic instability (p < 0.001) and prolonged cardiopulmonary bypass time (>200 min; p = 0.05) emerged as independent predictors of operative mortality. Stroke rates were comparable between the two techniques (14% for axillary and 17% for femoral cannulation, p = 0.52). Five-year actuarial survival was comparable between the groups (55.1% for axillary and 65.7% for femoral cannulation, p = 0.36). In Cox regression analysis, predictors of long-term mortality were: age (p < 0.001), stroke (p < 0.001), prolonged cardiopulmonary bypass time (p = 0.001), hemodynamic instability (p = 0.002), and renal failure (p = 0.001). CONCLUSIONS: The outcomes of femoral versus axillary arterial cannulation in patients with acute Type A aortic dissection are comparable. The choice of arterial cannulation site should be individualized based on different patient risk profiles.

Effects of Gender on Outcomes and Survival Following Repair of Acute Type A Aortic Dissection.

Previous studies have demonstrated gender-related differences in early and late outcomes following type A dissection diagnosis. However, it is widely unknown whether gender affects early clinical outcomes and survival after repair of type A aortic dissection. The goal of this study was to compare the early and late clinical outcomes in women versus men after repair of acute type A aortic dissections. Between January 2000 and October 2010 a total of 251 patients from four academic medical centers underwent repair of acute type A aortic dissection. Of those, 79 were women and 172 were men with median ages of 67 (range, 20-87 years) and 58 years (range, 19-83 years), respectively (p < 0.001). Major morbidity, operative mortality, and 10-year actuarial survival were compared between the groups. Operative mortality was not significantly influenced by gender (19% for women vs. 17% for men, p = 0.695). There were similar rates of hemodynamic instability (12% for women vs. 13% men, p = 0.783) between the two groups. Actuarial 10-year survival rates were 58% for women versus 73% for men (p = 0.284). Gender does not significantly impact early clinical outcomes and actuarial survival following repair of acute type A aortic dissection.

Aortic root surgery in the United States: a report from the Society of Thoracic Surgeons database.

OBJECTIVE: The purpose of the present study was to evaluate the early clinical outcomes of aortic root surgery in the United States. METHODS: The Society of Thoracic Surgeons database was queried to identify all patients who had undergone aortic root replacement from 2004 to early 2010 (n = 13,743). The median age was 58 years (range, 18-96); 3961 were women (29%) and 12,059 were white (88%). The different procedures included placement of a mechanical valve conduit (n = 4718, 34%), stented pericardial (n = 879, 6.4%) or porcine (n = 478, 3.5%) bioprosthesis, stentless root (n = 4309, 31%), homograft (n = 498, 3.6%), and valve sparing root replacement (n = 1918, 14%). RESULTS: The median number of aortic root surgeries per site was 2, and only 5% of sites performed >16 aortic root surgeries annually. An increased trend to use biostented (porcine or pericardial) valves during the study period (7% in 2004 vs 14% in 2009). The operative (raw) mortality was greater among the patients with aortic stenosis (6.2%) who had undergone aortic root replacement, independent of age. Mortality was greater in patients who had undergone concomitant valve or coronary artery bypass grafting or valve surgery (21%). The lowest operative mortality was observed in patients who had undergone aortic valve sparing procedures (1.9%). CONCLUSIONS: Most cardiac centers performed aortic root surgery in small volumes. The unadjusted operative mortality was greater for patients >80 years old and those with aortic stenosis, regardless of age. Valve sparing root surgery was associated with the lowest mortality. A trend was seen toward an increased use of stented tissue valves from 2004 to 2009.

Improved clinical outcomes and survival following repair of acute type A aortic dissection in the current era.

OBJECTIVES: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute type A aortic dissection during 2000-2005 and 2006-2010. METHODS: A total of 251 patients from four academic medical centres underwent repair of acute type A aortic dissection between January 2000 and October 2010. Of those, 111 patients underwent repair during 2000-2005, whereas 140 patients underwent repair during 2006-2010. Median ages were 62 years (range 20-83) and 58 years (range 30-80) for patients repaired from 2000-2005 compared with those repaired during 2006-2010, respectively (P = 0.180). Major morbidity, operative mortality and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality. RESULTS: Operative mortality was strongly influenced by surgical era (24% for 2000-2005 vs 12% for 2006-2010, P = 0.013). In multivariable logistic regression analysis, haemodynamic instability [odds ratio (OR) = 17.8, 95% confidence intervals (CIs) = 0.05-0.35, P <0.001], cardiopulmonary bypass time >200 min (OR = 9.5, 95% CI = 0.14-0.64, P = 0.002) and earlier date of surgery (OR = 5.8, 95% CI = 1.18-5.14, P = 0.016) emerged as independent predictors of operative mortality. Actuarial 5-year survival was worse for earlier compared with later date of surgery (64% for 2000-2005 vs 77% for 2006-2010, log-rank P <0.001). CONCLUSIONS: Surgical era significantly impacts early outcomes and actuarial survival following repair of acute type A aortic dissection.

Effects of Hemodynamic Instability on Early Outcomes and Late Survival Following Repair of Acute Type A Aortic Dissection.

BACKGROUND: The goal of this study was to compare operative mortality and actuarial survival between patients presenting with and without hemodynamic instability who underwent repair of acute Type A aortic dissection. Previous studies have demonstrated that hemodynamic instability is related to differences in early and late outcomes following acute Type A dissection occurrence. However, it is unknown whether hemodynamic instability at the initial presentation affects early clinical outcomes and survival after repair of Type A aortic dissection. METHODS: A total of 251 patients from four academic medical centers underwent repair of acute Type A aortic dissection between January 2000 and October 2010. Of those, 30 presented with hemodynamic instability while 221 patients did not. Median ages were 63 years (range 38-82) and 60 years (range 19-87) for patients presenting with hemodynamic instability compared to patients without hemodynamic instability, respectively (P = 0.595). Major morbidity, operative mortality, and 10-year actuarial survival were compared between groups. RESULTS: Operative mortality was profoundly influenced by hemodynamic instability (patients with hemodynamic instability 47% versus 14% for patients without hemodynamic instability, P < 0.001). Actuarial 10-year survival rates for patients with hemodynamic instability were 44% versus 63% for patients without hemodynamic instability (P = 0.007). CONCLUSIONS: Hemodynamic instability has a profoundly negative impact on early outcomes and operative mortality in patients with acute Type A aortic dissection. However, late survival is comparable between hemodynamically unstable and non-hemodynamically unstable patients.

Preliminary biomarkers for identification of human ascending thoracic aortic aneurysm.

BACKGROUND: Human ascending thoracic aortic aneurysms (ATAAs) are life threatening and constitute a leading cause of mortality in the United States. Previously, we demonstrated that collagens α2(V) and α1(XI) mRNA and protein expression levels are significantly increased in ATAAs. METHODS AND RESULTS: In this report, the authors extended these preliminary studies using high-throughput proteomic analysis to identify additional biomarkers for use in whole blood real-time RT-PCR analysis to allow for the identification of ATAAs before dissection or rupture. Human ATAA samples were obtained from male and female patients aged 65 ± 14 years. Both bicuspid and tricuspid aortic valve patients were included and compared with nonaneurysmal aortas (mean diameter 2.3 cm). Five biomarkers were identified as being suitable for detection and identification of ATAAs using qRT-PCR analysis of whole blood. Analysis of 41 samples (19 small, 13 medium-sized, and 9 large ATAAs) demonstrated the overexpression of 3 of these transcript biomarkers correctly identified 79.4% of patients with ATAA of ≥4.0 cm (P<0.001, sensitivity 0.79, CI=0.62 to 0.91; specificity 1.00, 95% CI=0.42 to 1.00). CONCLUSION: A preliminary transcript biomarker panel for the identification of ATAAs using whole blood qRT-PCR analysis in men and women is presented.

Differences in clinical characteristics, management, and outcomes of intraoperative versus spontaneous acute type A aortic dissection.

BACKGROUND: The clinical characteristics, management, and outcomes of patients who had intraoperative aortic dissection (IAD) have not been thoroughly investigated. This study compared early and late clinical outcomes in patients with IAD vs spontaneous (non-IAD) acute type A aortic dissection. METHODS: Between January 1, 2000, and July 1, 2008, 251 patients from 4 academic medical centers underwent repair of acute type A aortic dissection; of those, 11 had IAD. The mean age was 72 ± 9 years for patients experiencing IAD and 59 ± 13 years for those with non-IAD (p = 0.001). Patients with IAD were more likely to have coronary artery disease (p = 0.003) and a history of arrhythmia (p = 0.038). Rates for major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. RESULTS: Operative mortality was not adversely influenced by IAD (27% IAD vs 17% non-IAD, p = 0.42). There were no differences in the rates of reoperation for bleeding (10% IAD vs 20% non-IAD, p = 0.69), stroke (18% IAD vs 18% non-IAD, p ≥ 0.99), or acute renal failure (9% IAD vs 22% non-IAD, p = 0.47) between the two groups. Actuarial 5-year survival was 64% for IAD patients vs 73% for non-IAD patients (p = 0.33). CONCLUSIONS: IAD does not adversely influence early outcomes and actuarial 5-year survival of patients with type A dissection.

Does the technique of distal anastomosis influence clinical outcomes in acute type A aortic dissection?

The purpose of this study was to evaluate clinical outcomes of two different surgical techniques for the repair of acute type A dissection: open distal anastomosis under deep hypothermic circulatory arrest (DHCA) compared with distal aortic clamping on hypothermic cardiopulmonary bypass (ACPB). Between January 2000 and July 2008, 82 patients underwent DHCA and 42 had ACPB. Major morbidity, operative mortality and five-year actuarial survival were compared between groups. There were no significant differences in the preoperative characteristics. Operative mortality (17% in DHCA vs. 21% in ACPB, P=0.63), reoperation for bleeding (20% in DHCA vs. 34% in ACPB, P=0.16) and stroke rates (16 DHCA vs. 24% in ACPB, P=0.33) were comparable between the two groups. Actuarial five-year survival rates were 74% for DHCA vs. 73% for ACPB, P=0.99. No significant differences in operative mortality, major morbidity and actuarial five-year survival were observed between DHCA and ACPB. There are some practical technical advantages if the distal anastomosis is performed in an open manner. More studies are required to determine the fate of the false lumen between the two techniques.

Changes in mitral valve annular geometry after repair: saddle-shaped versus flat annuloplasty rings.

BACKGROUND: Saddle-shaped annuloplasty rings are being increasingly used during mitral valve (MV) repair to conform the mitral annulus to a more nonplanar shape and possibly reduce leaflet stress. In this study utilizing three-dimensional transesophageal echocardiography we compared the effects of rigid flat rings with those of the saddle rings on the mitral annular geometry. Specifically we measured the changes in nonplanarity angle (NPA) before and after MV repair. METHODS: Geometric analysis on 38 patients undergoing MV repair for myxomatous and ischemic mitral regurgitation with full flat rings (n = 18) and saddle rings (n = 18) were performed. The acquired three-dimensional volumetric data were analyzed utilizing the "Image Arena" software (TomTec GmBH, Munich, Germany). Specifically, the degree of change in the NPA was calculated and compared before and after repair for both types of rings. RESULTS: Both types of annuloplasty rings resulted in significant changes in the geometric structure of the MV after repair. However, saddle rings lead to a decrease in the NPA (7% for ischemic and 8% for myxomatous MV repairs) (ie, made the annulus more nonplanar), whereas flat rings increased the NPA (7.9% for ischemic and 11.8% for myxomatous MV repairs) (ie, made the annulus less nonplanar); p value 0.001 or less. CONCLUSIONS: Implantation of saddle-shaped rings during MV repair surgery is associated with augmentation of the nonplanar shape of the mitral annulus (ie, decreases NPA). This favorable change in the mitral annular geometry could possibly confer a structural advantage to MV repairs with the saddle rings.

Management of aortic brucellosis with infection of a descending thoracic aortic stent graft.

A 74-year-old Iranian-born man initially presented with a penetrating atherosclerotic ulcer of the descending thoracic aorta. He underwent endovascular stenting of the lesion, but later presented with recurrent back pain and fever. He was then diagnosed with brucellosis and started on antimicrobial therapy, including 2 weeks of parenteral gentamicin and two oral agents that were poorly tolerated. Two years later he presented with fever, recurrent back pain, and new hemoptysis. He underwent successful resection of the descending thoracic aorta with in situ interposition graft reinforced with an omental wrap. Ten months postoperatively, the patient remains on lifelong suppressive antimicrobial therapy with ciprofloxacin and rifampin, without any sign of infection. No similar case has been previously reported in the English literature.

Hybrid myocardial revascularization: an integrated approach to coronary revascularization.

Coronary artery bypass surgery is beneficial in patients with complex coronary artery disease. The longevity of the left internal mammary artery (LIMA) placed to the left anterior descending (LAD) artery (LIMA-LAD) is between 92-99% at 15 years, and contributes substantially to the survival advantage in patients treated with surgical revascularization. The long-term patency of saphenous vein grafts (SVGs), commonly used (>95%) in surgical revascularization procedures, is less well-established, with up to 26% of SVGs failing in the first year. In selected patients, particularly in those patients with vessels poorly suited to SVGs, hybrid myocardial revascularization (HMR) has been used, combining a minimally invasive approach to the LIMA-LAD with drug-eluting stent placement of the non-LAD vessels. The advantages and disadvantages of hybrid myocardial revascularization are reviewed in this report.