Left ventricular fibroma presenting as esophageal spasm: A case report.

Primary tumors of the heart are rare with fibromas most commonly identified in utero or infancy and rarely developing in adulthood. Patients with cardiac fibromas are often asymptomatic until tumor enlargement results in obstructive and nonspecific symptoms. A 39-year-old female presented with 5-year history of recurrent chest pain with functional dysphagia, indicative of esophageal spasm. Imaging identified a large left ventricular (LV) fibroma compressing the esophagus provoking esophageal spasm. The fibroma was excised measuring 51 × 39 mm. This case describes presentation with esophageal spasm, contributing a novel presentation of LV fibroma to the literature.

Coronary Artery Revascularization in Heart Transplant Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is the primary cause of late mortality after heart transplantation. We look to provide a comprehensive review of contemporary revascularization strategies in CAV. METHODS: PubMed and Web of Science were systematically searched by 3 authors. 1,870 articles were initially screened and 24 were included in this review. RESULTS: PCI is the main revascularization technique utilized in CAV. The pooled estimates for restenosis significantly favored DES over BMS (OR 4.26; 95% CI: 2.54-7.13; p < 0.00001; I2 = 4%). There were insufficient data to quantitatively compare mortality following DES versus BMS. There was no difference in short-term mortality between CABG and PCI. In-hospital mortality was 0.0% for CABG and ranged from 0.0 to 8.34% for PCI. One-year mortality was 8.0% for CABG and 5.0-25.0% for PCI. CABG had a potential advantage at 5 years. Five-year mortality was 17.0% for CABG and ranged from 14 to 40.4% following PCI. Select measures of postoperative morbidity trended toward superior outcomes for CABG. CONCLUSION: In CAV, PCI is the primary revascularization strategy utilized, with DES exhibiting superiority to BMS regarding postoperative morbidity. Further investigation into outcomes following CABG in CAV is required to conclusively elucidate the superior management strategy in CAV.

A randomized trial comparing axillary versus innominate artery cannulation for aortic arch surgery.

BACKGROUND: Cerebral protection remains the cornerstone of successful aortic surgery; however, there is no consensus as to the optimal strategy. OBJECTIVE: To compare the safety and efficacy of innominate to axillary artery cannulation for delivering antegrade cerebral protection during proximal aortic arch surgery. METHODS: This randomized controlled trial (The Aortic Surgery Cerebral Protection Evaluation CardioLink-3 Trial, ClinicalTrials.gov Identifier: NCT02554032), conducted across 6 Canadian centers between January 2015 and June 2018, allocated 111 individuals to innominate or axillary artery cannulation. The primary safety outcome was neuroprotection per the appearance of new severe ischemic lesions on the postoperative diffusion-weighted-magnetic resonance imaging. The primary efficacy outcome was the difference in total operative time. Secondary outcomes included 30-day all-cause mortality and postoperative stroke. RESULTS: One hundred two individuals (mean age, 63 ± 11 years) were in the primary safety per-protocol analysis. Baseline characteristics between the groups were similar. New severe ischemic lesions occurred in 19 participants (38.8%) in the axillary versus 18 (34%) in the innominate group (P for noninferiority = .0009). Total operative times were comparable (median, 293 minutes; interquartile range, 222-411 minutes) for axillary versus (298 minutes; interquartile range, 231-368 minutes) for innominate (P for superiority = .47). Stroke/transient ischemic attack occurred in 4 (7.1%) participants in the axillary versus 2 (3.6%) in the innominate group (P = .43). Thirty-day mortality, seizures, delirium, and duration of mechanical ventilation were similar in both groups. CONCLUSIONS: diffusion-weighted magnetic resonance imaging assessments indicate that antegrade cerebral protection with innominate cannulation is safe and affords similar neuroprotection to axillary cannulation during aortic surgery, although the burden of new neurological lesions is high in both groups.

Cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic. METHODS: A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed. RESULTS: Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID-19, they were most worried with exposing their family to COVID-19 (81%), followed by contracting COVID-19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID-19 burden, with higher COVID-19 burden institutions more likely to resort to PPE conservation strategies. CONCLUSIONS: The present study demonstrates the impact of COVID-19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.

Role of preoperative intravenous iron therapy to correct anemia before major surgery: a systematic review and meta-analysis.

BACKGROUND: Preoperative anemia is a common comorbidity that often necessitates allogeneic blood transfusion (ABT). As there is a risk associated with blood transfusions, preoperative intravenous iron (IV) has been proposed to increase the hemoglobin to reduce perioperative transfusion; however, randomized controlled trials (RCT) investigating this efficacy for IV iron are small, limited, and inconclusive. Consequently, a meta-analysis that pools these studies may provide new and clinically useful information. METHODS/DESIGN: Databases of MEDLINE, EMBASE, EBM Reviews; Cochrane-controlled trial registry; Scopus; registries of health technology assessment and clinical trials; Web of Science; ProQuest Dissertations and Theses; Clinicaltrials.gov; and Conference Proceedings Citation Index-Science (CPCI-S) were searched. Also, we screened all the retrieved reference lists. SELECTION CRITERIA: Titles and abstracts were screened for relevance (i.e., relevant, irrelevant, or potentially relevant). Then, we screened full texts of those citations identified as potentially applicable. RESULTS: Our search found 3195 citations and ten RCTs (1039 participants) that met our inclusion criteria. Preoperative IV iron supplementation significantly decreases ABT by 16% (risk ratio (RR): 0.84, 95% confidence interval [CI]: 0.71, 0.99, p = 0.04). In addition, preoperatively, hemoglobin levels increased after receiving IV iron (mean difference [MD] between the study groups: 7.15 g/L, 95% CI: 2.26, 12.04 g/L, p = 0.004) and at follow-up > 4 weeks postoperatively (MD: 6.46 g/L, 95% CI: 3.10, 9.81, p = 0.0002). Iron injection was not associated with increased incidence of non-serious or serious adverse effects across groups (RR: 1.13, 95% CI: 0.78, 1.65, p = 0.52) and (RR: 0.96, 95% CI: 0.44, 2.10, p = 0.92) respectively. CONCLUSIONS: With moderate certainty, due to the high risk of bias in some studies in one or two domains, we found intravenous iron supplementation is associated with a significant decrease in the blood transfusions rate, and modest hemoglobin concentrations rise when injected pre-surgery compared with placebo or oral iron supplementation. However, further full-scale randomized controlled trials with robust methodology are required. In particular, the safety, quality of life, and cost-effectiveness of different intravenous iron preparations require further evaluation.

Long-term Outcomes Following Mechanical or Bioprosthetic Aortic Valve Replacement in Young Women.

BACKGROUND: Studies performed to date reporting outcomes after mechanical or bioprosthetic aortic valve replacement (AVR) have largely neglected the young female population. This study compares long-term outcomes in female patients aged < 50 years undergoing AVR with either a mechanical or bioprosthetic valve. METHODS: In this propensity-matched study, we compared outcomes after mechanical AVR (n = 57) and bioprosthetic AVR (n = 57) between 2004 and 2018. The primary outcome of this study is survival. Secondary outcomes include the rate of reoperation, stroke, myocardial infarction, rehospitalization for heart failure, and incidence of serious adverse events. Outcomes were measured over 15 years, with a median follow-up of 7.8 years. RESULTS: In patients receiving a mechanical AVR vs a bioprosthetic AVR, overall survival at median follow-up was equivalent, at 93%. There is a lower rate of reoperation in patients receiving a mechanical AVR vs a bioprosthetic AVR (1.8% vs 8.8%). The rate of new-onset atrial fibrillation was significantly higher in the mechanical AVR group vs the bioprosthetic AVR group (18.2% vs 7.3%). No significant difference was seen in the rate of serious adverse events. CONCLUSIONS: These results provide contemporary data demonstrating equivalent long-term survival between mechanical and bioprosthetic AVR, with higher rates of new atrial fibrillation after mechanical AVR, and higher rates of reoperation after bioprosthetic AVR. These results suggest that either valve type is safe, and that preoperative assessment and counselling, as well as the follow-up, medical treatment and indications for intervention, must be a collaborative decision-making process between the clinician and the patient.

CONTEXTE: Les études réalisées à ce jour portant sur le bilan après un remplacement mécanique ou bioprothétique de la valve aortique (RVA) ont largement négligé la population de jeunes femmes. Cette étude compare le pronostic à long terme chez les patientes âgées de moins de 50 ans qui subissent un RVA par une valve mécanique ou bioprothétique. MÉTHODES: Dans cette étude d'appariement par score de propension, nous avons comparé les résultats après un RVA mécanique (n = 57) et un RVA bioprothétique (n = 57) entre 2004 et 2018. Le principal critère d'évaluation consiste en l'étude de la survie. Les critères d'évaluation secondaires comprennent le taux de réopération, d'accident vasculaire cérébral, d'infarctus du myocarde, de réhospitalisation pour insuffisance cardiaque et l'incidence des événements indésirables graves. Les critères d'évaluation ont été mesurés sur une période de 15 ans, avec un suivi médian de 7,8 ans. RÉSULTATS: Pour les patientes soumises à un RVA mécanique par rapport à un RVA bioprothétique, la survie globale au suivi médiane était équivalente à 93 %. Le taux de réopération est plus faible chez les patientes avec un RVA mécanique que chez celles soumises à un RVA bioprothétique (1,8 % contre 8,8 %). Le taux de fibrillation auriculaire d'apparition récente était significativement plus élevé dans le groupe ayant eu un RVA mécanique que dans le groupe ayant eu un RVA bioprothétique (18,2 % contre 7,3 %). Aucune différence significative n'a été observée concernant le taux d'événements indésirables graves. CONCLUSIONS: Ces résultats fournissent des données actualisées démontrant une survie à long terme équivalente entre les RVA mécaniques et bioprothétiques, avec des taux plus élevés de fibrillation auriculaire d'apparition récente après une RVA mécanique, et des taux plus élevés de réopération après une RVA bioprothétique. Ces résultats suggèrent que chaque type de valve est sûr, et que l'évaluation et le counselling préopératoire, ainsi que le suivi, le traitement médical et les indications d'intervention, doivent être un processus de décision concerté entre le clinicien et le patient.

Dissected Aorta Repair Through Stent Implantation trial: Canadian results.

OBJECTIVES: We describe the Canadian results of the Ascyrus Medical Dissection Stent (AMDS), a novel partially uncovered aortic arch hybrid graft implanted antegrade during hypothermic circulatory arrest to promote true lumen expansion and enhance aortic remodeling. METHODS: From March 2017 to February 2018, 16 consecutive patients (66 ± 12 years; 38% female) presented with acute type A aortic dissections and underwent emergent surgical aortic repair with AMDS implantation. All patients presented with DeBakey I aortic dissection, with evidence of malperfusion in 50% (n = 8) of patients. All cases were performed under hypothermic circulatory arrest with an additional average duration for AMDS implantation time of 2.1 minutes. RESULTS: All 16 device implantations were successful. Overall 30-day mortality was 6.3% (n = 1) and stroke occurred in 6.3% (n = 1) of cases. There was no incidence of device-related aortic injury or aortic arch branch vessel occlusion. During the follow-up period, 12 patients had completed at least 1 postoperative computed tomography scan. At initial follow-up computed tomography scan, complete or partial thrombosis, and remodeling of the aortic arch occurred in 91.7% of cases (n = 11/12) and in the proximal descending thoracic aorta, complete or partial thrombosis, and remodeling occurred in 91.7% (n = 11/12). CONCLUSIONS: Preliminary results suggest that the AMDS is a safe, feasible and reproducible adjunct to current surgical approaches for acute DeBakey I aortic dissection repair. Further, the AMDS manages malperfusion and promotes early positive remodeling in the aortic arch and distal dissected segments, with favorable FL closure rates at follow-up. Ongoing follow-up will provide additional insight into the long-term effects of the AMDS.

Preoperative Predictors of Mortality in Short-Term Continuous-Flow Ventricular Assist Devices.

Short-term continuous-flow ventricular assist devices (STCF-VADs) are increasingly being utilized to support critically ill patients, despite limited information regarding overall outcomes. All adult patients supported with an STCF-VAD between June 2009 and December 2015 were included in this retrospective single-center study. Associations between preoperative characteristics and unsuccessful bridge (death on device or within 30 days postdecannulation) were assessed using logistic regression. A total of 61 patients (77% male) were identified with a median age at implant of 54.6 years. Left VADs were implanted in 51%, right VADs in 21%, and both VADs in 28%, and patients were supported for a median of 11 days. Overall, 23% were weaned to recovery, 13% underwent heart transplantation, 16% converted to long-term VADs, and 48% had an unsuccessful bridge. In multivariable analysis, only renal insufficiency or dialysis (odds ratio = 7.53; p = 0.002) remained a significant independent predictor of an unsuccessful bridge. Short-term continuous-flow VADs can successfully bridge adult patients with mortality around 50%. Preimplant renal insufficiency or dialysis is correlated with an unsuccessful bridge in our patient population, likely reflecting the severity of illness preimplant. Further studies are required to determine whether this factor remains significant in a larger patient population.

Left ventricular assist device for ventricular recovery of anabolic steroid-induced cardiomyopathy.

Herein we report a case of a 26-year-old gentleman with severe cardiomyopathy likely secondary to anabolic-androgenic steroid (AAS) abuse who received a HeartMate II (Abbott Laboratories, Abbott Park, IL) left ventricular assist device (LVAD) for rapidly deteriorating heart failure with hemodynamic compromise. Following 18 months on LVAD support, excellent recovery of ventricular function was achieved to allow for LVAD discontinuation. Given that active substance abuse is a contraindication to heart transplantation, few options remain for patients with AAS induced heart failure. Our case demonstrates that LVAD therapy can be an important intervention for bridging to candidacy, recovery or destination therapy.

A Systematic Review of the Cost-Effectiveness of Long-Term Mechanical Circulatory Support.

BACKGROUND: Mechanical circulatory support (MCS) is an option for the treatment of medically intractable end-stage heart failure. MCS therapy, however, is resource intensive. OBJECTIVE: The purpose of this report was to systematically review the MCS cost-effectiveness literature as it pertains to the treatment of adult patients in end-stage heart failure. METHODS: We conducted a systematic search and narrative review of available cost- effectiveness and cost-utility analyses of MCS in adult patients with end-stage heart failure. RESULTS: Eleven studies analyzing the cost-effectiveness or cost-utility of MCS were identified. Seven studies focused on bridge to transplantation, three studies focused on destination therapy, and one study presented analyses of both strategies. Two articles evaluated the cost-effectiveness of the HeartMate II (Thoratec Corp., Pleasanton, CA). Incremental cost-effectiveness ratios between MCS and medical management ranged between $85,025 and $200,166 for bridge to transplantation and between $87,622 and $1,257,946 for destination therapy (2012 Canadian dollars per quality-adjusted life-year). Sensitivity analyses indicated that improvements in survival and quality of life and reductions in device and initial hospital-stay costs may improve the cost-effectiveness of MCS. CONCLUSIONS: Current studies suggest that MCS is likely not cost-effective with reference to generally accepted or explicitly stated thresholds. Refined patient selection, complication rates, achieved quality of life, and device/surgical costs, however, could modify the cost-effectiveness of MCS.

Knowledge, attitudes, and practice preferences of Canadian cardiac surgeons toward the management of acute type A aortic dissection.

OBJECTIVES: The complexity of surgical treatment for acute type A dissection contributes to the variability in patient management. This study was designed to elucidate the contemporary practice preferences of cardiac surgeons regarding different phases of management of acute type A aortic dissection. METHODS: A 34-item questionnaire was distributed to all Canadian adult cardiac surgeons addressing the preoperative, intraoperative, and postoperative management of acute type A dissection. A total of 100 responses were obtained (82% of active surgeons in Canada). Outcomes were compared between high- and low-volume aortic surgeons. RESULTS: Seventy-six percent of respondents favored axillary artery cannulation. High-volume surgeons (>150 cases) were more likely to indicate a target lowest nasopharyngeal temperature more than 20 °C (53% vs 25%, P = .02). The majority of surgeons (65%) recommended using selective antegrade cerebral perfusion, with a significantly greater proportion for higher-volume aortic surgeons (P = .03). In addition, high-volume aortic surgeons were more likely to recommend aortic root replacement at smaller diameters (73% vs 55%, P = .02), to recommend more extensive distal aortic resection with routine open hemiarch anastomosis (85% vs 65%, P = .04), and to more commonly perform total arch reconstruction when needed (93% vs 77%, P = .04). In the follow-up period, frequency of serial imaging of the residual aorta was significantly higher for high-volume aortic surgeons (P = .04). CONCLUSIONS: This study identified some commonalities in practice preferences among Canadian cardiac surgeons for the management of acute type A aortic dissection. However, it also highlighted significant differences in temperature management, cerebral protection strategies, and extent of resection between high-volume and low-volume aortic surgeons.

Role of preoperative intravenous iron therapy to correct anemia before major surgery: study protocol for systematic review and meta-analysis.

BACKGROUND: Preoperative anemia is a common and potentially serious hematological problem in elective surgery and increases the risk for perioperative red blood cell (RBC) transfusion. Transfusion is associated with postoperative morbidity and mortality. Preoperative intravenous (IV) iron therapy has been proposed as an intervention to reduce perioperative transfusion; however, studies are generally small, limited, and inconclusive. METHODS/DESIGN: We propose performing a systematic review and meta-analysis. We will search MEDLINE, EMBASE, EBM Reviews, Cochrane-controlled trial registry, Scopus, registries of health technology assessment and clinical trials, Web of Science, ProQuest Dissertations and Theses, and conference proceedings in transfusion, hematology, and surgery. We will contact our study drug manufacturer for unpublished trials. Titles and abstracts will be identified and assessed by two reviewers for potential relevance. Eligible studies are: randomized or quasi-randomized clinical trials comparing preoperative administration of IV iron with placebo or standard of care to reduce perioperative blood transfusion in anemic patients undergoing major surgery. Screening, data extraction, and quality appraisal will be conducted independently by two authors. Data will be presented in evidence tables and in meta-analytic forest plots. Primary efficacy outcomes are change in hemoglobin concentration and proportion of patients requiring RBC transfusion. Secondary outcomes include number of units of blood or blood products transfused perioperatively, transfusion-related acute lung injury, neurologic complications, adverse events, postoperative infections, cardiopulmonary complications, intensive care unit (ICU) admission/readmission, length of hospital stay, acute kidney injury, and mortality. Dichotomous outcomes will be reported as pooled relative risks and 95% confidence intervals. Continuous outcomes will be reported using calculated weighted mean differences. Meta-regression will be performed to evaluate the impact of potential confounding variables on study effect estimates. DISCUSSION: Reducing unnecessary RBC transfusions in perioperative medicine is a clinical priority. This involves the identification of patients at risk of receiving transfusions along with blood conservation strategies. Of potential pharmacological blood conservation strategies, IV iron is a compelling intervention to treat preoperative anemia; however, existing data are uncertain. We propose performing a systematic review and meta-analysis evaluating the efficacy and safety of IV iron administration to anemic patients undergoing major surgery to reduce transfusion and perioperative morbidity and mortality. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015016771.

Massive left atrial sarcoma presenting with severe congestive heart failure.

Primary intimal sarcomas of the left atrium are extremely rare and highly aggressive tumours. To our knowledge, only 4 cases have been reported to date. We report on a 42-year-old man who presented with signs of congestive heart failure and was found to have an enormous left atrial bilobed tumour with obstruction of the mitral valve. The patient underwent a surgical excision of the sarcoma. The tumour recurred 8.5 months later and the patient required right pneumonectomy.

Outcomes of consecutive patients referred for consideration for transcatheter aortic valve implantation from an encompassing health-care region.

Procedural outcomes for transcatheter aortic valve implantation (TAVI) are well described. However, limited information exists regarding patient screening and selection. Thus, the purpose of the study was to review consecutive patients referred for TAVI from an inclusive-defined population. The Mazankowski Alberta Heart Institute TAVI program has maintained a prospective database on all referred patients. Patients are reviewed in outpatient clinic attended by a nurse, cardiologist, cardiac surgeon, and administrative assistant. After workup is complete, a TAVI Heart Team conference occurs to accept or reject each patient. Since November 2009, 276 patients (145 men and 131 women) have been referred with a steady increase in the number of referrals annually. Mean age was 82.2 years (men 81.6 and women 82.8), with 13% aged <70 years. Mean EuroSCORE was 13.8 and mean STS score was 5.7. Of the referred patients, 34% received TAVI, 17% were rejected, 12% underwent open AVR, 10% refused TAVI, and 27% are currently being assessed or followed. There were no differences in the mean EuroSCORE (13.4 vs 14.3; p = 0.64) or STS scores (5.2 vs 6.4; p = 0.13) of those accepted for TAVI versus those who were not. In conclusion, a team-based approach to assess this complex patient population is essential to ensure efficient and comprehensive evaluation, in turn determining appropriate care allocation. With expansion of clinical experience and the evidence supporting TAVI, the Heart Teams defined to assess this patient population will be burdened with increased clinical commitment and require appropriate support.

Coronary revascularization for patients with severe left ventricular dysfunction.

BACKGROUND: The efficacy of coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) in patients with coronary artery disease has been well defined by randomized controlled trials. However, patients with severe left ventricular dysfunction (ejection fraction <35%) were underrepresented in these trials, and management of these complex patients remains unclear. The purpose of this study was to compare the outcomes of patients with coronary artery disease and left ventricular dysfunction undergoing CABG versus PCI. METHODS: The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH), a clinical data collection and outcome monitoring initiative for the province of Alberta, Canada, was used to identify 2925 patients with coronary artery disease and left ventricular dysfunction undergoing CABG (n = 1,326) or PCI (n = 1,599) between 1995 and 2008. Patients were propensity matched to obtain comparable subgroups among left ventricular dysfunction patients. RESULTS: Cox proportional hazard analysis of the propensity-matched subgroups identified that CABG was significantly associated with lower rates of repeat revascularization and better survival compared with PCI at 1, 5, 10, and 15 years. Other significant independent predictors of poor long-term survival included age, renal failure, heart failure, diabetes mellitus, peripheral vascular disease, prior myocardial infarction, left main coronary artery disease, and prior CABG. CONCLUSIONS: For patients with coronary artery disease and left ventricular dysfunction, CABG was associated with lower rates of repeat revascularization and improved survival over PCI, after adjustment for baseline risk profile differences. Further research exploring the factors leading to use of a particular revascularization modality in this patient population is required.

Long-term mechanical circulatory support of an adult patient with Down syndrome.

Destination therapy with the HeartMate II left-ventricular assist device (Thoratec Corp, Pleasanton, CA) was undertaken in an adult patient with Down syndrome and end-stage heart failure. The patient was bridged to the HeartMate II with extracorporeal membrane oxygenation followed by the Levitronix CentriMag (Levitronix, Waltham, MA). HeartMate II implantation was complicated by coagulopathy. The patient spent 44 postoperative days in hospital and is currently stable in the community. No infections were acquired. Compliance training was delivered primarily to the patient's family. Destination therapy with the HeartMate II may be successfully implemented in eligible, socially supported Down syndrome patients.

Valvular reoperations by left thoracotomy in patients with pectus excavatum.

Several alternative approaches to the aortic and mitral valves have been reported recently. We describe a left anterior thoracotomy approach for valvular reoperations in 3 patients with Marfan syndrome and severe pectus excavatum.

Organ protection during thoracoabdominal aortic surgery: rationale for a multimodality approach.

Surgical repair of thoracoabdominal aortic aneurysms (TAAAs) remains a technically challenging operation that requires a systematic approach to prevent ischemic complications and achieve excellent clinical outcomes. Techniques for organ protection have evolved substantially over the past 20 years. This review describes our current multimodality approach to organ protection during TAAA repair.