A highly penetrant ACTA2 mutation of thoracic aortic disease.

BACKGROUND: The role of ACTA2 mutations in Familial Aortic Disease has been increasingly recognized. We describe a highly penetrant variant (R118Q) in a family with aortic disease. CASE REPORT: A patient presented to us for elective repair of an ascending aortic aneurysm with a family history of his mother expiring after aortic dissection. Genetic testing revealed he was a heterozygous carrier of the ACTA2 missense mutation R118Q. Subsequently, all living family members were tested for this variant and a full medical history was obtained to compile a family tree for the variant and penetrance of an aortic event (defined as lifetime occurrence of aortic surgery / dissection). In total 9 family members were identified and underwent genetic testing with 7/9 showing presence of the ACTA2 R118Q mutation or an aortic event. All patients over the age of 50 (n = 4) had an aortic event. Those events occurred at ages 54, 55, 60, and 62 (mean event at 57.8 ± 3.9 years). Three family members with the variant under the age of 40 have not had an aortic event and most are undergoing regular aortic surveillance via CT scan. CONCLUSIONS: Existing studies of known ACTA2 mutations describe a 76% aortic event rate by 85 years old. The R118Q missense mutation is a less common ACTA2 variant, estimated to be found in about 5% of patients with known mutations. Prior studies have predicted the R118Q mutation to have a slightly decreased risk of aortic events compared to other ACTA2 mutations. In this family, however, we demonstrate 100% penetrance of aortic disease above age 50. In today's era of excellent outcomes in elective aortic surgery, our team aggressively offers elective repair. We advocate for strict aortic surveillance for patients with this variant and would consider elective aortic replacement at 4.5 cm, or at an even smaller diameter in patients with a strong family history of dissection who are identified with this mutation.

Patent Ductus Arteriosus Exclusion Technique Using Thoracic Endovascular Aortic Repair.

A large patent ductus arteriosus is an uncommon discovery in an adult. A 2.7-cm patent ductus arteriosus was found in a 31-year-old man with heart failure symptoms. Owing to the size, an occluder device failed to prevent left-to-right shunting, and consideration was given for alternatives to percutaneous closure, including traditional open repair vs thoracic endovascular aortic repair (TEVAR). After a left carotid-subclavian artery bypass was performed, the patient underwent a zone 2 deployment of TEVAR graft. TEVAR exclusion is a useful technique in adults, particularly in the setting of a large or calcified ductus.

Rescue therapy for symptomatic spinal cord ischemia after thoracic endovascular aortic repair.

OBJECTIVE: Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) can cause permanent neurologic deficits and poor long-term survival. Targeted treatment of new SCI symptoms after TEVAR (rescue therapy [RT]) might improve/resolve neurologic symptoms but few data characterize the association of specific interventions with SCI outcomes. We evaluated the effectiveness of post-TEVAR RT at our tertiary aortic center. METHODS: Our institutional TEVAR database was reviewed for SCI incidence and details of RT. This included cerebrospinal fluid drainage (CSFD), medical therapy, and optimization of spinal cord oxygen delivery. SCI outcomes were categorized at discharge as paralysis/paraparesis and temporary/permanent. RESULTS: Nine hundred forty-three TEVAR procedures were performed in 869 patients from 2011 to 2020. Post-TEVAR SCI occurred in 7.8% (n = 74) with permanent paraplegia in 1.5%. Older patient age, chronic obstructive pulmonary disease, and previous abdominal aortic surgery were predictive of SCI. Half (n = 37) of SCI episodes resulted in only temporary paralysis/paraparesis. Rescue postoperative cerebrospinal fluid drains were implanted in 3.7% (n = 35) of procedures and was predicted by higher American Society of Anesthesiologists class, lower serum hemoglobin level, elevated international normalized ratio, bilateral iliac artery occlusion, nonelective procedures, and penetrating atherosclerotic ulcer/intramural hematoma indication. The most commonly used RTs were emergent placement of or increased drainage from an existing cerebrospinal fluid drain (87.8%), induced/permissive hypertension (77.0%), corticosteroid bolus (36.5%), and naloxone infusion (33.8%). Neurologic improvement occurred in 68.9% (n = 51/74). New/increased drainage was associated with improved SCI outcome. CONCLUSIONS: Permanent paraplegia from post-TEVAR SCI is rare (1.5%). Older patients with comorbidities carry greater post-TEVAR SCI risk. SCI symptoms improved/resolved with CSFD and multimodal RT in 68.9% of patients, but no intervention was independently associated with improvement. TEVAR centers should have robust protocols for timely and safe CSFD placement to augment RT strategies for SCI.

Outcomes of acute type A aortic dissection during the COVID-19 pandemic: An analysis of the Society of Thoracic Surgeons Database.

PURPOSE: There have been reported reductions of hospital presentation for acute cardiovascular conditions such as myocardial infarction and acute type A aortic dissection (ATAAD) in the United States during the COVID-19 pandemic. This study examined presentation patterns and outcomes of ATAAD in North America immediately before, and during, the COVID-19 pandemic. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) was queried to identify patients presenting with ATAAD in the 12 months pre-pandemic (March 2019-February 2020), and during the early pandemic (March through June 2020). Demographics and operative characteristics were compared using χ² test and Wilcoxon Rank-sum test. The median annual case volume designated low-volume centers versus high-volume centers (>10 cases per month). Step-wise variable selection was used to create a risk set used for adjustment of all multivariable models. RESULTS: There were 5480 patients identified: 4346 pre-pandemic and 1134 during pandemic. There was significantly lower volume of median cases per month during the COVID-19 pandemic period (286 interquartile range [IQR]: 256-306 vs. 372 IQR: 291-433,p = .0152). In historically low-volume centers (<10 cases per year), there was no difference in volume between the two periods (142 IQR: 133-166 vs. 177 IQR: 139-209, p = NS). In high-volume centers, there was a decline during the pandemic (140 IQR: 123-148 vs. 212 IQR: 148-224, p = .0052). There was no difference in overall hospital-to-hospital transfers during the two time periods (54% of cases pre-pandemic, 55% during). Patient demographics, operative characteristics, malperfusion rates, and cardiac risk factors were similar between the two time periods. There was no difference in unadjusted operative mortality (19.01% pre-pandemic vs. 18.83% during, p = .9) nor major morbidity (52.42% pre-pandemic vs. 51.24% during, p = .5). Risk-adjusted multivariable models showed no difference in either operative mortality nor major morbidity between time periods. CONCLUSIONS: For patients presenting to the hospital with ATAAD during the first surge of the pandemic, operative outcomes were similar to pre-pandemic despite a 30% reduction in volume. Out-of-hospital mortality from ATAAD during the pandemic remains unknown. Further understanding these findings will inform management of ATAAD during future pandemics.

Safety of cerebrospinal fluid drainage for spinal cord ischemia prevention in thoracic endovascular aortic repair.

Objective: Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) is associated with permanent neurologic deficit and decreased survival. Prophylactic cerebrospinal fluid (CSF) drainage (CSFD) in TEVAR is controversial. We evaluated the usage of CSFD in TEVAR at our tertiary aortic center. Methods: Our institutional TEVAR database was reviewed to determine the frequency of CSFD usage/complications. Complications were categorized as mild (headache/CSF leak not requiring intervention, urinary retention), moderate (headache/CSF leak requiring intervention, drain malfunction requiring replacement), or severe (intrathecal hemorrhage, CSFD-attributable neurologic deficit). The relationships between CSFD complications and patient/procedural characteristics, CSFD placement timing, and survival were analyzed. Results: Nine hundred thirty-six TEVAR procedures were performed in 869 patients from 2011 to 2020. Three hundred ninety CSFD drains were placed in 373 (41.7%) TEVAR patients. Most CSFD drains (89.5%) were pre-TEVAR. Most post-TEVAR drains were placed for new SCI symptoms (n = 21). Twenty-five patients (6.4%) suffered 32 CSFD complications. Most (n = 17) were mild in severity. Severe CSFD complications occurred in 5/432 (1.1% CSF drains) patients. No patient/procedural characteristics were predictive of CSFD complications. Post implant CSFD placement for new SCI symptoms conferred an increased risk of CSFD complication (odds ratio, 6.9; 95% CI, 2.42-19.6; P < .01). The long-term survival of the CSFD complication cohort did not differ from the overall population. Conclusions: Post-TEVAR CSFD placement for new SCI symptoms was associated with substantially greater risk of CSFD complications. Avoidance of post-implant therapeutic drain placement might be the key to prevention of CSFD complications, favoring a strategy of selective pre-implant drain placement in patients at higher risk for SCI.

Cerebral protection using deep hypothermic circulatory arrest versus retrograde cerebral perfusion for aortic hemiarch reconstruction.

BACKGROUND: With evolutions in technique, recent data encourage the use of cerebral perfusion during aortic arch repair. However, a randomized data have demonstrated higher rates of neurologic injury according to MRI lesions using antegrade cerebral perfusion during hemiarch reconstruction. METHODS: This was a retrospective review of two institutional aortic center databases to identify adult patients who underwent aortic hemiarch reconstruction for elective aortic aneurysm or acute type A aortic dissection. Patients were stratified according to cerebral protection method: (1) deep hypothermic circulatory arrest (DHCA) group versus (2) DHCA/retrograde cerebral perfusion (RCP) group. RESULTS: A total of 320 patients and 245 patients underwent hemiarch reconstruction for aortic aneurysm electively and aortic dissection, respectively. In aneurysmal pathology, the DHCA group included 133 patients and the DHCA/RCP group included 187 patients. Operative mortality was 0.8% in the DHCA group and 2.7% in the DHCA/RCP group (p = 0.41). Kaplan-Meier survival estimates revealed comparable 2-year survival (p = 0.14). In dissection, 43 patients and 202 patients were included in the DHCA group and the DHCA/RCP group, respectively. Operative mortality was equivalent between the two groups (11.6% in the DHCA group and 9.4% in the DHCA/RCP group, p = 0.58). Long-term survival was similar at 2 years between the groups (p = 0.06). Multivariable analysis showed cerebral perfusion strategy was not associated with the composite outcome of operative mortality and stroke. CONCLUSIONS: In treating both elective and acute ascending aortic pathologies with hemiarch reconstruction, both DHCA alone or in combination with RCP yield comparable results.

Misdiagnosis of Thoracic Aortic Emergencies Occurs Frequently Among Transfers to Aortic Referral Centers: An Analysis of Over 3700 Patients.

Background Acute aortic syndromes may be prone to misdiagnosis by nonreferral aortic centers with less diagnostic experience. We evaluated regional variability in these misdiagnosis trends among patients transferred to different regional quaternary care centers with presumed acute aortic syndromes. Methods and Results Two institutional aortic center databases were retrospectively reviewed for emergency transfers in patients diagnosed with acute aortic dissection, intramural hematoma, penetrating aortic ulcer, thoracic aortic aneurysm, or aortic pseudoaneurysm between 2008 and 2020. Transferring diagnoses versus actual diagnoses were reviewed using physician notes and radiology reports. Misdiagnoses were confirmed by a board-certified cardiothoracic surgeon. A total of 3772 inpatient transfers were identified, of which 1762 patients were classified as emergency transfers. The mean age was 64 years (58% male). Patients were transferred from 203 medical centers by ground (51%) or air (49%). Differences in transfer diagnosis and actual diagnosis were identified in 188 (10.7%) patients. Of those, incorrect classification of Type A versus B dissections was identified among 23%, and 30% of patients with a referring diagnosis of an acute aortic dissection did not have one. In addition, 14% transferred for contained/impending rupture did not have signs of rupture. All misdiagnoses were secondary to misinterpretation of imaging, with motion artifacts (n=32, 17%) and postsurgical changes (n=44, 23%) being common sources of diagnostic error. Conclusions Misdiagnosis of acute aortic syndromes commonly occurred in patients transferred to 2 separate large aortic referral centers. Although diagnostic accuracy may be improving, there are opportunities for improved physician awareness through standardized web-based imaging education.

Timing surgery and hemorrhagic complications in endocarditis with concomitant cerebral complications.

BACKGROUND: To date, limited studies have been conducted regarding the safe timing of valvular repair for infectious endocarditis (IE) in patients with radiographic findings consistent with embolic stroke or infectious intracranial aneurysm (IIA). METHODS: A single-center, retrospective review of valvular surgeries for IE was performed (2011-2019). Outcomes for patients who underwent cranial image screening and those who did not were subsequently compared. RESULTS: 276 patients underwent valvular repair for IE; 186 (67.4%) were male. The mean age was 51.0 (17.4) years. Mean time from imaging to surgery was 7.5 days. 124 (44.9%) underwent baseline cranial imaging. Of these, 22 (17.7%) had findings concerning for ischemic stroke from embolic origin. 65 patients underwent baseline diagnostic cerebral angiography. 10 (15%) of these patients harbored an IIA. Four out of these 10 (40%) underwent intervention for an IIA. Two of the four who underwent intervention (50.0%) had ruptured IIAs. The remaining six (60%) patients with IIAs received treatment with antibiotics alone. None of the patients with IIAs suffered from symptomatic hemorrhage after valvular surgery. No significant difference in symptomatic hemorrhage after valvular surgery between those with ischemic embolic stroke compared to those without (ischemic stroke-4.5% vs. no ischemic stroke-1.0%; p = 0.32). CONCLUSIONS: Patients with radiographic evidence of ischemic stroke from septic emboli can safely undergo valvular surgery for IE without increased risk of symptomatic hemorrhage. We advocate for baseline CTA screening to evaluate for IIA in patients who present with a primary diagnosis of IE and propose a management algorithm.

George Daicoff: A Pioneering Surgeon and Humanitarian of The Southern Thoracic Surgical Association.

George Daicoff was a true pioneer who excelled in patient care, research, teaching, and advocacy; he performed cardiac surgery on thousands. He trained at Mayo Clinic under the tutelage of John Kirklin in 1966. He served on the faculty at University of Florida from 1967 to 1977 and became Chief of Thoracic and Cardiovascular Surgery at University of Florida. He then served as Chief of Cardiovascular Surgery at All Children's Hospital from 1977 to 1998. In 1972, he was one of 13 founding members of the Congenital Heart Surgeons' Society (CHSS), and in 1973, he was one of 10 surgeons to attend the first meeting of CHSS. Dr Daicoff won the 1970 Southern Thoracic Surgical Association President's Award for best scientific paper, and the 1996 Southern Thoracic Surgical Association Osler Abbot Award. In 2015, the Southern Thoracic Surgical Association Congenital Heart Surgery President's Award was named the George Daicoff Award.

Florida sleeve is a safe and effective technique for valve salvage in acute stanford type A aortic dissection.

OBJECTIVE: Valve-sparing root replacement is commonly used for management of aortic root aneurysms in elective setting, but its technical complexity hinders its broader adoption for acute type-A aortic dissection (ATAAD). The Florida sleeve (FS) procedure is a simplified form of valve sparing aortic root reconstruction that does not require coronary reimplantation. Here, we present our outcomes of the FS repair in patients with dilated roots in the setting of an ATAAD. METHODS: We retrospectively reviewed 24 consecutive patients (2002-2018) treated with FS procedure for ATAAD. Demographic, operative, and postoperative outcomes were queried from our institutional database. Long term follow-up was obtained from clinic visits for local patients, and with telephone and telehealth measures otherwise. RESULTS: Mean age was 49 ± 14 years with 19 (79%) males. Marfan syndrome was present in 4 (16.7%) patients and 14 (58.3) had ≥2+ aortic insufficiency (AI). Nine (37.2%) had preoperative mal-perfusion or shock. The FS was combined with hemi-arch replacement in 15 (62.5%) patients and a zone-2 arch replacement in 9 (37.5%) patients. There were 2 (8.3%) early postoperative mortalities. Median follow-up period was 46 months (range, 0.3-146). The median survival of the entire cohort was 143.4 months. One patient (4.2%) required redo aortic valve replacement for unrelated aortic valve endocarditis at 30 months postoperatively. CONCLUSION: FS is simplified and reproducible valve-sparing root repair. In appropriate patients, it can be applied safely in acute Stanford type-A aortic dissection with excellent early and long-term results.

Misdiagnosis of Thoracic Aortic Disease Occurs Commonly in Emergency Transfers.

BACKGROUND: Acute aortic syndromes (AASs) are prone to misdiagnosis by facilities with limited diagnostic experience. We assessed long-term trends in misdiagnosis among patients transferred to a tertiary care facility with presumed AASs. METHODS: Our institutional transfer center database was queried for emergency transfers in patients with a diagnosis of AASs or thoracic aortic aneurysm between January 2008 and May 2018. There were 784 patients classified as emergency transfer for presumed AAS. Transferring diagnosis and actual diagnosis were compared through a review of physician notes and radiology reports from referring facilities and our center. RESULTS: Mean age was 62 years, with 478 (61%) men. Differences in transferring diagnosis and actual diagnosis were identified in 89 patients (11.4%). Among misdiagnosed patients, the wrong classification of Stanford type A or type B dissections was identified among 24 patients (27%). No dissection was found in 23 patients (26%) with a referring diagnosis of aortic dissection. No signs of rupture were found in 18 patients (20%) transferred for contained/impending rupture. All misdiagnoses were secondary to misinterpretation of radiographic imaging, with motion artifacts in 14 (16%) and postsurgical changes in 22 (25%) being common sources of diagnostic error. Repeat scans were performed in 64 patients (72%) at our facility due to limited access to or suboptimal quality of outside imaging. CONCLUSIONS: Although AASs misdiagnosis rates appear to be improving from the prior decade, there are opportunities for improved physician awareness through campaigns such as "Think Aorta." Centralized web-based imaging may prevent the costly hazards of unnecessary emergency transfer.

Cor-Knot automated fastener in distal anastomosis of total aortic arch replacement: A case report.

Cor-Knot fastener use in sternotomy-based aortic arch procedures has not been reported. We present Cor-Knot fastener use over a Hegar dilator in an anatomically challenging total aortic arch replacement with no short-term and/or long-term complications.

Management of a spontaneous supra-aortic arterial dissection: a case report.

BACKGROUND: Acute DeBakey type I and type II aortic dissections are indications for emergent surgical repair; however, there are currently no standard protocols in the management of isolated supra-aortic dissections. Prompt diagnosis and management of an isolated innominate artery dissection are necessary to prevent distal malperfusion and thromboembolic sequelae. CASE PRESENTATION: A 50-year-old Caucasian gentleman presented with chest pain radiating to his jaw and right arm. He had no recent history of trauma. On physical exam, he was neurologically intact and malignantly hypertensive. Computed tomographic angiography of the chest and neck confirmed a spontaneous isolated innominate artery dissection without ascending aorta involvement. Given the lack of evidence for rupture, distal emboli, and/or end-organ malperfusion, the decision was made for initial non-operative management-anti-impulse regimen, antiplatelet therapy, and close follow-up. CONCLUSIONS: Medical management of a spontaneous isolated innominate artery dissection is appropriate for short-term and potentially long-term therapy. This not only spares the patient from a potentially unnecessary surgical operation but also provides the surgeon and the patient the time to plan for a surgical approach if it becomes necessary.

Complicated acute type B aortic dissection: update on management and results.

BACKGROUND: The role of thoracic endovascular aortic repair (TEVAR) has evolved and is now firmly established as a mainstay of therapy for acute complicated type B aortic dissection (acTBAD). However, several important issues remain unresolved including the optimal timing, sizing, graft selection, coverage length and utilization of adjunctive therapies to address false lumen perfusion. Therefore, the purpose of this study was to provide a contemporary perspective on the management and results for TEVAR of acTBAD. METHODS: All TEVAR patients (N.=159) with acTBAD from a single high-volume, academic medical center were analyzed. Comparative results across time-dependent cohorts (2005-2009 [N.=43] vs. 2010-2014 [N.=56] vs. 2015-2020 [N.=60]) are presented. RESULTS: 30-day mortality was 13%(N.=21) with a trend towards improvement over time (2005-2009, 18% vs. 2010-2020, 12%; P=0.1). Similarly, incidence of postoperative complications also declined: 2005-2009, 70% vs. 2010-2020, 36%(P-trend=0.08). One and 2-year freedom from aorta-related reintervention was 78±7% and 73±9% and did not differ across cohorts (log-rank P=0.5). Respective one and 5-year survival was 75±3% and 64±7%, but significantly improved with time (log-rank P<0.001). The corresponding one and five-year freedom from aorta-related mortality was 82±4% and 78±7% but did not change during the study interval (log-rank P=0.3). CONCLUSIONS: Outcomes for TEVAR of acTBAD continue to improve over time. This time-dependent analysis delineates how results have changed due to increasing experience, technologic evolution, and maturation of the peer reviewed evidence. These results along with the evidence-based review provided herein, provide an update on the management and results of TEVAR of acTBAD while highlighting specific controversies unique to the management of this challenging clinical problem.

Outcomes of Florida Sleeve Procedure in Patients with Bicuspid Versus Tricuspid Aortic Valve.

OBJECTIVE: Outcomes of the Florida Sleeve (FS) procedure in patients with bicuspid aortic valve (BAV) have not been reported before. We compared outcomes of the FS procedure between patients with BAV and those with tricuspid aortic valve (TAV). METHODS: From May 1, 2002 to January 1, 2016, 177 patients including 18 BAV and 159 TAV underwent the FS procedure. Baseline characteristics, perioperative outcomes, and echocardiographic measurements were compared between the 2 groups. Kaplan-Meier and life-table analyses were used to evaluate survival and freedom from reintervention rates. RESULTS: Mean ± standard deviation age and aortic root diameter were comparable in BAV and TAV groups, 47.83 ± 11.19 versus 49.59 ± 15.79 years (P = 0.55) and 56.57 ± 6.18 versus 55.17 ± 8.84 mm (P = 0.46), respectively. The 30-day mortality and stroke rates were zero in the BAV group and 1.88% (n = 3) in the TAV group (P = 1.00). One patient (5.55%) in the BAV group and 8 (5.03%) patients in the TAV group needed permanent pacemaker implantation (P = 0.62). Freedom from reoperation was 93% in the BAV group and 99% in the TAV group at 8 years (P = 0.041). Patient survival rate was 100% in the BAV group and 91% in the TAV group at 8 years (P = 0.42). Freedom from aortic insufficiency greater than mild was 93% in the BAV group and 96.5% in the TAV group at 5 years (P = 0.61). CONCLUSIONS: This is the first study reporting outcomes of the FS procedure in patients with BAV. This technique is feasible, and the results appear to be durable when compared to patients with TAV.

Pasteurella Multiocida infection resulting in a descending thoracic aorta mycotic pseudoaneurysm.

OBJECTIVE: Highlight our management of a Pasteurella Multiocida-infected descending thoracic aorta mycotic pseudoaneurysm. METHODS: Report a case of a canine bite resulting in a P. Multiocida descending thoracic aorta mycotic pseudoaneurysm. RESULTS: We present a 61-year-old gentleman who was initially seen in an emergency department after a canine bite. He was admitted and treated with a course of IV antibiotics for P. Multiocida bacteremia and discharged. Three weeks after discharge, he continued to feel generalized malaise and work-up was significant for a descending thoracic aorta mycotic pseudoaneurysm. The patient underwent a low left posterior lateral thoracotomy and femoral-femoral cardiopulmonary bypass for complete pseudoaneurysm resection and aortic replacement with a 24-mm Gelweave graft. Given purulence and gross infection, we planned for a staged approach, with a secondary washout and omental flap for biologic coverage of the graft. The patient did well clinically and was discharged at 14 days to rehabilitation with 6-week intravenous course of antibiotics. CONCLUSIONS: The patient's clinical course with subsequent follow-up suggest that complete resection of the mycotic pseudoaneurysm, followed by omental flap coverage is a viable strategy to manage mycotic aortic infections with virulent organisms.

J-Mart: aortic valve replacement with Florida sleeve aortic root reconstruction.

We highlight a technique combining an aortic valve replacement with the Florida sleeve repair. The patient is a 68-year-old man who had a 48-mm aortic root aneurysm and a 57-mm ascending aorta, presenting with symptomatic tri-leaflet severe aortic valve stenosis. He underwent a hemiarch, aortic valve replacement and Florida sleeve aortic root reconstruction. The patient recovered uneventfully and is now, at over 1 year postoperation, without evidence of recurrent aortic pathology.

Simultaneous aortic valve endocarditis and mycotic pseudoaneurysm of aortic coarctation.

OBJECTIVE: This study highlights the management strategy in simultaneous bicuspid aortic valve infective endocarditis and mycotic pseudoaneurysm of an aortic coarctation. METHODS: A staged repair of mycotic pseudoaneurysm of aortic coarctation and infective bicuspid aortic valve endocarditis. RESULTS: We present a 19-year old gentleman who was admitted with aching pain in his bilateral lower extremities with associated purpuric rash and fevers. Work-up was significant for severe aortic valve regurgitation and a pseudoaneurysm in the distal aortic arch. He underwent operative repair through a left posterior-lateral thoracotomy with femoral-femoral partial cardiopulmonary bypass. Intraoperative findings were significant for a juxta-ductal coarctation and pseudoaneurysm. The mycotic pseudoaneurysm and remnant ligamentum arteriosum were completely resected and were replaced with a 18 mm Gelweave graft (Terumo Cardiovascular Group, Ann Arbor, MI) from the distal arch to the descending thoracic aorta. The patient underwent a planned secondary washout and omental flap for biologic coverage of the graft. Subsequently, a staged aortic valve replacement was completed 1 week later. The patient's postoperative course was uncomplicated, and he was discharged with intact motor and sensory function. CONCLUSIONS: A staged approach is a prudent strategy to manage a patient with simultaneous endocarditis and aortic mycotic pseudoaneurysm, with precedence toward the most critical lesion.

Utilizing the index for mortality prediction after cardiac transplantation risk score to predict hospital resource consumption.

OBJECTIVE: The index for mortality prediction after cardiac transplantation (IMPACT) risk score incorporates 12 preoperative recipient-specific variables, and has been validated as an accurate predictor of short- and long-term mortality after orthotopic heart transplantation (OHTx). We believe it can also be used to predict hospital costs, and we hypothesize that higher preoperative IMPACT risk scores are associated with increased hospital resource consumption. METHODS: All OHTx patients ≥18 years of age at our institution were reviewed from 1 January 2000 to 31 December 2014. Total index hospitalization costs post-transplant were extracted and presented in 2014 consumer price index inflation-adjusted US dollars. Patients were stratified into quartiles (Q) according to IMPACT risk scores. Logarithmic transformation normalized cost data, and linear regression assessed for correlation. A comparison of cost between Q of IMPACT risk score was performed using rank-sum and Kruskal-Wallis tests. Survival was estimated using the Kaplan-Meier method. RESULTS: Three hundred fifty-six (n = 356) OHTx were performed during the study period. The median IMPACT score for the cohort was five (interquartile range [IQR] 3-6). Eight (2.2%) patients died within 30-days and 1-year Kaplan-Meier survival was 88.3%. The median length of stay (LOS) was 16 (IQR 14-24) days. The median hospital cost for index admission was $222 200 (IQR:$169 200-$313 700). Median LOS was longer in Q4 vs Q1 (18 days vs 15 days, P = .01) and index hospital costs in Q4 were significantly higher compared to Q1 patients ($280 400 vs $205 000, P < .01). There was a significant positive correlation between IMPACT risk score and cost (regression coefficient .04, P < .01). CONCLUSION: This is the first study in adult cardiac transplantation to identify a positive correlation between hospital cost and recipient risk using the IMPACT risk score. Cost and resource consumption for the index admission after OHTx were significantly higher in the highest IMPACT risk Q compared with patients in the lowest Q.

Endograft and external cinch to control hemorrhage in acute type A aortic dissection.

Acute DeBakey I or II aortic dissection (AD) is a surgical emergency with significant mortality if not repaired immediately. We present the case of a 49-year-old man with acute type I AD, who initially underwent zone 2 arch replacement for a primary arch tear. A calcified ductus arteriosus was noted during arch reconstruction. He exhibited exsanguinating hemorrhage from the proximal descending thoracic aorta upon an initial attempt to wean off cardiopulmonary bypass. Hemostasis was achieved with retrograde transfemoral thoracic endovascular aortic repair and transmediastinal external cinch around the descending aorta to obliterate false lumen flow.