Native pulmonary valve massive endocarditis in a drug-addicted patients with Covid-19 pneumonia: a case report.

BACKGROUND: Pulmonary valve (PV) infective endocarditis is a rare pathology. Association between acute endocarditis and Covid pneumonia is equally poorly investigated. CASE PRESENTATION: We present the case of a 50-year-old male active drug-abuser admitted for native PV endocarditis with huge and mobile vegetations and a concomitant interstitial SARS-Cov2 pneumonia. Surgical timing was carefully evaluated, and the patient was first treated with Remdesivir to prevent ARDS evolution. After 5 days he underwent PV replacement with bioprosthesis via patch enlargement of RVOT and a tricuspid valve De-Vega annuloplasty. The postoperative course was uneventful with complete resolution of sepsis and viremia. CONCLUSIONS: The association between infective endocarditis and Covid pneumonia is emerging in the recent months. The reorganization in cardiac surgery hub centers resulted in an increase of urgencies referral, with consequent relative observation of some pathologies (i.e., endocarditis). The widespread administration of antibiotics and corticosteroids during the first phase of the pandemic could have contributed to the development of a moderate immunodepression of the general population and, during the pandemic, patients have been reluctant to access to hospital care, and this diagnostic delay could contribute to misdiagnosis or late presentation. We believe that in the present case, the strategy of immediate viral and respiratory stabilization, followed by a timely surgical procedure, allowed an excellent outcome in a very complicated situation.

Congenital left ventricular aneurysm with myocardial noncompaction pattern.

Congenital left ventricular aneurysm or diverticulum is very rare. Most congenital left ventricular aneurysms are asymptomatic but some cause systemic embolization, left ventricular free wall rupture, or ventricular arrhythmias causing sudden cardiac death. A 29-year-old woman with congenital left ventricular aneurysm and nonsustained ventricular tachycardia underwent surgical plication of the aneurysm with left ventricular reshaping to improve heart failure symptoms, prevent rupture of the aneurysm wall and the possibility of thrombus formation, and excise the fibrotic tissue of the left ventricular aneurysm, which could be a trigger for left ventricular aneurysm arrhythmias. The postoperative course was unremarkable.

Excessive Pannus Overgrowth on the Aortic Side of Trifecta Valve Causing Severe Regurgitation.

Structural valve deterioration represents the most important concern regarding the implantation of a biologic heart valve in young patients. Several strategies have been proposed to improve prosthesis design in order to optimize performance and durability. This report describes an early and specific mode of valve degeneration of prostheses with outward-mounted pericardial leaflets resulting from pannus overgrowth on the aortic side. This led to leaflet retraction in two consecutive cases 4 and 6 years after the first implantation of a Trifecta valve (St. Jude Medical, St. Paul, MN).

Endovascular repair of traumatic thoracic aortic injury: final results from the relay endovascular registry for thoracic disease.

BACKGROUND: In blunt thoracic aortic injury, thoracic endovascular aortic repair (TEVAR) offers a less invasive alternative to open chest surgery. New reliable and accurate stent grafts have widened the endovascular treatment options. We report our experience with the Relay stent graft Bolton Medical, Sunrise, FL; Barcelona, Spain) for treatment of this injury. METHODS: Relay Endovascular Registry for Thoracic Disease (RESTORE) is a multicenter, prospective European registry, which enrolled patients treated with the Relay stent graft for thoracic aortic diseases from April 2005 to January 2009. Regular follow-up examinations were conducted for up to 24 months. This paper analyzes the cohort of patients treated for traumatic aortic injury. RESULTS: Forty adult trauma patients from 12 European centers underwent TEVAR. Mean age was 40 years and 34 patients were male. The proximal landing zone involved aortic arch zones 1 to 2 in 40% and zone 3 in 55% of procedures. Technical success was achieved in all cases. One (2.5%) patient suffered a rupture of the iliac artery. No patient developed procedure-related paraplegia or required conversion to open surgery. Follow-up imaging demonstrated complete exclusion of the traumatic tear and regression of the false aneurysms without endoleak or graft infolding. One late device-related complication was reported; penetration of the distal end of the stent graft treated by stent-graft extension. Thirty-day mortality was 2.5 % (n = 1), and late mortality 2.5% due to a secondary accident. Actuarial 2-year survival was 93.7%. CONCLUSIONS: Thoracic endovascular aortic repair with the Relay stent graft is a safe and effective treatment for patients with traumatic aortic injury.

JAG tearing technique with radiofrequency guide wire for aortic fenestration in thoracic endovascular aneurysm repair.

An innovative approach, the JAG tearing technique, was performed during thoracic endovascular aneurysm repair in a patient with previous surgical replacement of the ascending aorta with a residual uncomplicated type B aortic dissection who developed an aneurysm of the descending thoracic aorta with its lumen divided in two parts by an intimal flap. The proximal landing zone was suitable to place a thoracic stent graft. The distal landing zone was created by cutting the intimal flap in the distal third of the descending thoracic aorta with a radiofrequency guide wire and intravascular ultrasound catheter.

Endovascular treatment of patients with types A and B thoracic aortic dissection using Relay thoracic stent-grafts: results from the RESTORE Patient Registry.

PURPOSE: To evaluate the safety and performance of Relay stent-grafts in patients with acute or chronic aortic dissections. METHODS: Patients with types A or B aortic dissections suitable for treatment with Relay stent-grafts and followed for 2 years after thoracic endovascular aortic repair (TEVAR) were identified from a company-sponsored registry database established in January 2006. Ninety-one consecutive patients (69 men; mean age 65 years) underwent TEVAR with Relay stent-grafts for dissection. Most patients (76, 84%) had type B dissections; 61 of all patients were classified as chronic and 30 as acute. RESULTS: The technical success rate was 95% (97% in acute, 95% in chronic, and 93% in type B dissections). The type I endoleak rate was 7% (7% in acute and 8% in chronic dissections); all occurred in patients with type B dissections. Paraplegia, paraparesis, and stroke occurred in 4, 1, and 2 patients, respectively; 2 cases of paraplegia occurred in patients with acute type B dissections. Thirty-day mortality was 8% (13% in acute and 5% in chronic dissections); all deaths occurred in patients with type B dissections. The 2-year survival rate was 82% in the overall population and 84% in patients with type B dissections. CONCLUSION: The combination of Relay's features, such as stent conformability, radial force, atraumatic design, and controlled deployment and fixation, may contribute to the safety of the Relay stent-grafts for the treatment of thoracic aortic dissections, including acute and chronic type B dissections.

Final operative and midterm results of the European experience in the RELAY Endovascular Registry for Thoracic Disease (RESTORE) study.

PURPOSE: Thoracic endovascular aortic repair is increasingly becoming the standard treatment of many thoracic aortic pathologies. New reliable and accurate stent grafts are emerging to widen the endovascular treatment options. We report the results of RELAY (Bolton Medical, Barcelona, Spain) in the large RELAY Endovascular Registry for Thoracic Disease (RESTORE) European registry. METHODS: RESTORE is a multicenter, prospective European registry involving 22 centers in seven European countries. The RELAY device is composed of a stent graft (self-expanding nitinol stents and a polyester vascular graft) and a delivery device specifically designed for the thoracic aorta. Included were acute and elective patients presenting with a variety of pathologies (aneurysms, dissections, ulcerations, intramural hematomas, pseudoaneurysms) and lesions in different aortic and anatomic locations (ascending, arch, descending and thoracoabdominal). RESULTS: The registry enrolled 304 patients from April 2005 to January 2009. All-cause mortality at 30 days was 7.2%. Freedom from all cause mortality and freedom from device- and procedure-related mortality at 2 years were 78.5% and 95.9%, respectively. An average of 1.26 graft components were used per patient, with a technical success of 97.7% irrespective of the etiology. Early endoleak rate was 4.6%. Perioperatively, stroke and paraplegia were registered in 1.6% and 2.0%, respectively. CONCLUSIONS: The results of RESTORE support the safety of thoracic endovascular aortic repair with the RELAY stent graft, even in acute and complicated situations. The device was highly efficient in angulated aortic anatomies, with acceptable mortality and a low rate of neurologic complications.

Prevalence of risk factors, coronary and systemic atherosclerosis in abdominal aortic aneurysm: comparison with high cardiovascular risk population.

BACKGROUND: Abdominal aortic aneurysm (AAA) is considered a manifestation of atherosclerosis, however there are epidemiologic, biochemical, and structural differences between occlusive atherosclerosis and AAA. The pathogenesis of AAA involves several factors, first of all destruction of collagen and elastin in the aortic wall. Classical risk factors may influence the evolution and development of AAA, though no consistent association has been found. Aims of the study were to evaluate associations between risk factors and to establish the prevalence of carotid, peripheral vascular and coronary atherosclerosis in patients with AAA. METHODS: We studied 98 patients with AAA (Group 1) awaiting surgery compared with high cardiovascular risk population having two or more risk factors (n=82 Group 2). We evaluated traditional risk factors and we studied by eco-doppler and echocardiography the presence of carotid peripheral and coronaric atherosclerosis in two groups. RESULTS: We found a higher incidence of AAA in males (p < 0.01). The prevalence of infrarenal AAA was significantly higher than suprarenal AAA (81 vs. 17 p < 0.001). No differences in total cholesterol (199 +/- 20 vs. 197 +/- 25 mg/dl), low-density lipoprotein (142 +/- 16 vs. 140 +/- 18 mg/dl), triglycerides (138 +/- 45 vs. 144 +/- 56 mg/dl), glycemia (119 +/- 15 vs. 122 +/- 20 mg/dl), and fibrinogen (388 +/- 154 vs. 362 +/- 92 mg/dl) were found between groups. We demonstrated significant differences for cigarette smoking (p < 0.002), systolic and diastolic blood pressure (150 +/- 15 vs. 143 +/- 14 mmHg and 88 +/- 6 vs. 85 +/- 7 mmHg, p < 0.0001 and p < 0.05, respectively) and high sensititivity C reactive protein (2.8 +/- 1.3 vs. 1.3 +/- 0.7 mg/dl, p < 0.001). High-density lipoprotein (HDL) cholesterol levels were significant greater in Group 1 than Group 2 (p < 0.003). Subgroups of patients with AAA and luminal thrombus showed higher fibrinogen levels (564 +/- 235 vs. 341 +/- 83 mg/dl, p < 0.001) and lower HDL than in controls (46.6 +/- 6.5 vs. 52.1 +/- 7.8 mg/dl, p < 0.01). We did not find any difference in body mass index, or prevalence of coronary and peripheral atherosclerosis between groups. Conversely, we found higher prevalence of carotid atherosclerosis in Group 2 (9% vs. 25%, p < 0.004). CONCLUSION: Our AAA patients had fewer and different risk factors respect to patients with atherosclerosis. Only elevated blood pressure, C reactive protein, and smoking showed a significant association with AAA. Atherosclerosis in other arterial districts did not differ respect to subjects with high cardiovascular risk. Our results confirm the hypothesis that AAA and atherosclerosis are two different pathological entities with different risk profiles.

Biological features (inflammation and neoangiogenesis) and atherosclerotic risk factors in carotid plaques and calcified aortic valve stenosis: two different sites of the same disease?

Neoangiogenesis and inflammation have a pivotal role in atherosclerosis. Observations support the hypothesis that calcified aortic valve stenosis is an inflammatory process, similar to atherosclerosis in tissue features and risk factors. We studied 2 groups of cases: 47 were affected by hemodynamic atherosclerotic carotid plaque (group 1) and 35 by severe calcified aortic valve stenosis (group 2). We compared the groups for atherosclerosis risk factors, morphologic features, and immunohistochemical phenotypes. In both groups, men, smokers, and hypertensive subjects prevailed, and histologic analysis showed an elevated score for T-lymphocyte infiltrates, neoangiogenesis, calcium, and sclerosis. Adhesion molecule expression was present in both lesions. Expression of intercellular adhesion molecule 1 correlated with inflammatory infiltrates (group 1, P = .0007; group 2, P = .06). Neoangiogenesis also correlated with inflammatory infiltrates (group 1, P = .035; group 2, P = .045). In valves, neoangiogenesis correlated with calcium (P = .048). Carotid plaque and calcified valve stenosis showed common risk factors and biologic hallmarks of a chronic inflammatory process. Inflammation and neoangiogenesis have a crucial role in plaque evolution and in the progression of aortic valve stenosis.

Limited role of aortic size in the genesis of acute type A aortic dissection.

OBJECTIVE: Increased dimension of the aortic root and proximal aorta is considered a significant risk factor for catastrophic events that involve the ascending aorta. The objective of this study was to determine the possible correlation between pre-dissection aortic diameter and the occurrence of Stanford type A aortic dissection. METHODS: Samples of dissected ascending aortas were obtained from 220 patients at the time of their operation. Two groups were identified: patients with connective tissue disorders (Group 1, n=94) and those without (Group 2, n=126). Measurements of the true (intimal) lumen were conducted and extrapolated as reliable approximation of pre-dissection aortic diameter. The possible association of intimal diameter with anthropometric and demographic data was analyzed. RESULTS: Median aortic diameter was, respectively, 41.8 and 41.3mm for patients with and without connective tissue disorders (41.4mm for the entire cohort). Data analysis indicated that 57% of patients had aortic diameter above 40 mm, while patients with frank aneurysm accounted only for 10%; this proportion was higher in Group 1 compared to Group 2 (17.2% vs 4.7%). Poor or no correlation was demonstrated between aortic size and any of the anthropometric or demographic variables assayed. Significant subgroup differences were found among patients with a history of cigarette smoking, hypertension, diabetes, chronic renal insufficiency, and bicuspid aortic valve. CONCLUSION: Although aortic diameter remains a strong indication for preventive surgery in patients with inherited connective tissue disorders, acute aortic dissection occurs rarely in the setting of true ascending aortic aneurysms, and despite normal or near-normal aortic size in more than one-third of subjects. Dissection superimposing on small aortic diameters can be regarded as an expression of substantial functional tissue susceptibility to aortic catastrophic events.

Cannulation of the extrathoracic left common carotid artery for thoracic aorta operations through left posterolateral thoracotomy.

The femoral artery is the usual site of arterial cannulation in thoracic aorta operations through left posterolateral thoracotomy that require cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA). The advantage of this perfusion route is in limiting the duration of circulatory arrest. It is associated, however, with the risk of retrograde embolization or, in cases involving aortic dissection, malperfusion of vital organs. To prevent these risks, we have used the extrathoracic left common carotid artery as the perfusion route. From December 1999 to January 2003, we used cannulation of the left extrathoracic common carotid artery in 42 thoracic aorta operations through posterolateral thoracotomy with an open proximal anastomosis technique during DHCA. The indication for thoracic aortic repair was atherosclerotic ulcer in 7 cases, chronic aortic aneurysm in 18, acute type B dissection in 5, and chronic type B dissection in 12. Cannulation of the extrathoracic left common carotid artery was successful in all patients. Postoperative recovery was uneventful, with no cerebrovascular events in all cases. No cannulation-related complications were observed. One patient died from cardiac insufficiency on postoperative day 5. No peripheral neurological deficits (paraplegia or paraparesis) were observed. Postoperative complications included atrial fibrillation in five patients, reoperation to control hemorrhage in six, respiratory insufficiency in nine, and renal insufficiency in six. These results indicate that cannulation of the left extrathoracic common carotid artery is a useful, reliable method for proximal perfusion during CPB in patients undergoing repair of the descending thoracic aorta through left posterolateral thoracotomy. By providing effective perfusion of the brain, this technique can prolong safe DHCA time. Another advantage is the prevention of cerebral emboli, ensuring retrograde flow to the aortic arch.

Residual dissection of the brachiocephalic arteries: significance, management, and long-term outcome.

OBJECTIVES: Residual dissection of the brachiocephalic arteries after operations for acute type A dissection is considered a benign condition that does not expose patients to late neurologic events. This retrospective study, conducted on an outpatient clinic basis between June 1995 and May 2003, had the objectives of evaluating the consequences of residual dissection of the brachiocephalic arteries, investigating the long-term outcomes of patients with this condition, and illustrating our approach to the condition. METHODS: Forty-two of 137 patients with spontaneous aortic dissection were identified as having residual dissection of the brachiocephalic arteries. There were 30 men and 12 women, with median age of 64.8 years. Patients were followed for a median time of 3.17 years (25th-75th percentile, 1.43-4.40 years; maximum, 7.5 years). The main outcome was the occurrence of cerebral ischemic events (transient ischemic attack or stroke) or death. The functional consequences of brachiocephalic artery dissection were studied by using duplex scanning and transcranial Doppler ultrasonography. RESULTS: Twenty-four focal neurologic complications occurred in 13 of 42 patients (incidence, 30.9%); major strokes occurred in 6 patients, and none were fatal. Minor strokes occurred in 12 patients. In all patients the damaged territory was dependent on a dissected artery. Kaplan-Meier (90-months) freedom from focal neurologic events was 55.7% (95% confidence interval, 33.7%-72.9%). Mean time of freedom from focal neurologic events was 64.5 months (95% confidence interval, 53.1-75.9 months). Positive transcranial Doppler monitoring for microembolic signals was 24.1%, and patients with clinical symptoms had higher microembolic signal counts than did those without symptoms (8.4/h vs 1.9/h, P <.001). Reduced cerebrovascular reactivity to hypercapnia, calculated by using the breath-holding index values, was associated with severely impaired brachiocephalic artery perfusion. The multivariable model for predictors of late stroke (minor and major) included the following variables: microembolic signal count (1 signal/h increase; relative risk, 1.27 [95% CI, 1.12-1.77]), breath-holding index (0.10 increase; relative risk, 0.91 [95% CI, 0.87-0.94]), and the presence of at least one carotid axis with a thrombosed false channel (relative risk, 0.82 [95% CI, 0.64-0.93]). Sixteen operations were performed in 12 patients to relieve residual dissection. CONCLUSIONS: These results suggest an increased risk of ischemic events ipsilateral to the dissected arteries. Strict follow-up and identification of subjects at risk implies the exact knowledge of vessel anatomy and perfusion status. Ultrasonographic transcranial Doppler examination plays an important role in the clinical work-up of these patients.

Cerebral autoregulation after hypothermic circulatory arrest in operations on the aortic arch.

BACKGROUND: The purpose of this study was to determine whether patients who undergo thoracic aorta repairs with the aid of hypothermic circulatory arrest experience impairments in cerebral autoregulation, and to ascertain the influence of three different techniques of cerebral protection on autoregulatory function. METHODS: Sixty-seven patients undergoing elective aortic arch procedures with hypothermic circulatory arrest were tested for cerebral dynamic autoregulation using continuous transcranial Doppler velocity and blood pressure recordings. Twenty-three patients were treated using hypothermic circulatory arrest without adjuncts (group 1), 25 using antegrade cerebral perfusion (group 2), and 19 using retrograde cerebral perfusion (group 3). RESULTS: There were no hospital deaths. Two major strokes occurred in this series; 9 patients experienced temporary neurologic dysfunction: in all these patients severe impairment of cerebral autoregulation was observed. Cerebral autoregulation in the immediate postoperative period was preserved only in patients treated with antegrade cerebral perfusion. Severe impairments were observed in the other two groups in which the degree of autoregulatory response was inversely correlated to the duration of the cerebral protection time during hypothermic circulatory arrest. Postoperative improvement of autoregulatory function was observed in the majority of patients. Our data suggest the exposure to brain damage in the presence of autoregulation impairment, thus indicating that postoperative hypotensive phases may further contribute to neurologic impairment. CONCLUSIONS: The status of cerebral autoregulation in the postoperative period after hypothermic circulatory arrest procedures is profoundly altered. The degree of impairment is influenced by the cerebral protection technique. This study indicates the beneficial role of antegrade perfusion during hypothermic circulatory arrest for the preservation of this function and suggests that postoperative cerebral autoregulation impairment can be regarded as an expression of central nervous system injury.

Nonocclusive intestinal ischemia in patients with acute aortic dissection.

BACKGROUND: In aortic dissection, visceral complications that result from aortic branch compromise have been described extensively, whereas intestinal ischemia not associated with the false lumen anatomy has rarely been discussed. The aim of this report is to identify clinical factors that may contribute to the development of this form of acute mesenteric ischemia, to profile the patients at greatest risk, and to review diagnostic and treatment methods that emerged from our experience. METHODS: With a computerized database, we identified 371 patients who underwent treatment in our institution with a diagnosis of aortic dissection between July 15, 1985, and January 10, 2001. Mesenteric ischemia was present in 73 patients (19%). In 36 patients (9%), bowel ischemia was not associated with a false lumen anatomy or an extension of the dissection process. From a general analysis of the determinants of mesenteric ischemia in aortic dissection, we investigated, with univariate and multivariate analysis, the specific characteristics of these patients with nonocclusive ischemia. A retrospective analysis of the oxygen metabolic profile of patients who underwent operation also was performed. RESULTS: The mortality rate in patients with nonocclusive mesenteric ischemia was 86%; sepsis and multiple organ failure were the causes of death in all nonsurvivors. Surgical treatment was beneficial only in the early phases of the disease. The results of the multivariate analysis showed the multifactorial origin of nonocclusive mesenteric ischemia; cerebral ischemia, thrombosis of the false lumen, severe coagulation disorders, chronic obstructive pulmonary disease, aortic calcinosis, prolonged hypotension, chronic renal insufficiency, and low cardiac output were independent predictors of the condition. In patients who underwent operation, the significant risk factors were severe coagulation disorders, postoperative cerebral ischemia, maximal oxygen extraction rate of more than 0.40, aortic calcinosis, chronic obstructive pulmonary disease, thrombosis of the false lumen, inotropic support, and chronic renal insufficiency. An oxygen extraction rate of more than 0.4 at 6 hours after operation was found to be an index of intestinal damage sufficient to initiate an evaluation for visceral ischemia. Significant differences with occlusive ischemia also were evidenced with this study. CONCLUSION: In aortic dissection, nonocclusive mesenteric ischemia shows some unique clinical and individual predisposing factors. Most instrumental investigations are of poor diagnostic value, and prognosis is poor, especially when mesenteric gangrene had already taken place. Prevention can be exercised only with a heightening of our awareness of this condition and with timely correction of metabolic disturbances. In suspected cases, an aggressive surgical attitude may represent the only means for reducing mortality.

Protected iliofemoral venous thrombectomy in a pregnant woman with pulmonary embolism and ischemic venous thrombosis.

Although thromboembolism is uncommon during pregnancy and the postpartum period, physicians should be alert to the possibility because the complications, such as pulmonary embolism, are often life threatening. Pregnant women who present with thromboembolic occlusion are particularly difficult to treat because thrombolysis is hazardous to the fetus and surgical intervention by any of several approaches is controversial. A 22-year-old woman, in her 11th week of gestation, experienced an episode of pulmonary embolism and severe ischemic venous thrombosis of the left lower extremity The cause was determined to be a severe protein S deficiency in combination with compression of the left iliac vein by the enlarged uterus. The patient underwent emergency insertion of a retrievable vena cava filter and surgical iliofemoral venous thrombectomy with concomitant creation of a temporary femoral arteriovenous fistula. The inferior vena cava filter was inserted before the venous thrombectomy to prevent pulmonary embolism from clots dislodged during thrombectomy When the filter was removed, medium-sized clots were found trapped in its coils, indicating the effectiveness of this approach. The operation resolved the severe ischemic venous thrombosis of the left leg, and the patency of the iliac vein was maintained throughout the pregnancy without embolic recurrence. At full term, the woman spontaneously delivered an 8-lb, 6-oz, healthy male infant.

Extrathoracic cannulation of the left common carotid artery in thoracic aorta operations through a left thoracotomy: preliminary experience in 26 patients.

BACKGROUND: In aortic operations performed through a left thoracotomy, which require total bypass and deep hypothermic circulatory arrest, femoral artery cannulation is commonly used for arterial perfusion. This route limits the time of safe circulatory arrest and is associated with the risks of retrograde embolization or, in the case of aortic dissection, malperfusion of the vital organs. To overcome these problems, we have used cannulation of the extrathoracic left common carotid artery to ensure a central a route of arterial perfusion in these operations. The preliminary results are presented. METHODS: Between December 1999 and April 2001, we used left common carotid artery cannulation in 26 operations on the thoracic aorta performed through a posterolateral thoracotomy with an open technique during deep hypothermic circulatory arrest. Institutional review board approval and informed consent were obtained. The indications included perforating atherosclerotic ulcer (n = 5), chronic aortic aneurysm (n = 9), acute type B aortic dissection (n = 3), and chronic dissection of the thoracic aorta (n = 9). Transcranial Doppler ultrasonographic monitoring of both the right and left middle cerebral arteries was used to assess the adequacy of cerebral bihemispheric perfusion and to determine the differences in blood flow velocities throughout the procedure. RESULTS: Left common carotid artery cannulation was successful in all patients. All patients awoke from the operation, and none had cerebrovascular accidents. None died in the hospital, and complications related to carotid artery cannulation were not observed. None of the patients experienced postoperative paraplegia. In all patients transcranial Doppler monitoring indicated the absence of cerebral embolic phenomena throughout the entire procedure. Significant differences in middle cerebral artery flow velocities were observed at different phases of the procedures and between the right and left middle cerebral arteries during carotid cannulation and during selective cerebral perfusion. Nevertheless, the maximal drop of right middle cerebral artery blood velocity during selective perfusion through the left common carotid artery was within 50% of the left middle cerebral artery velocity, indicating adequate bihemispheric perfusion. CONCLUSIONS: In patients undergoing aortic operations through a left thoracotomy, extrathoracic left common carotid artery cannulation was a safe and effective means of providing proximal arterial inflow during cardiopulmonary bypass, which can be used to selectively perfuse the brain, as well as to prevent embolic phenomena in the arch vessels.

Bypassing a dilemma: intraoperative coronary angiography in acute aortic dissection.

Untreated coronary artery disease may complicate the clinical course of patients with Stanford type A acute aortic dissection. In these patients the role of coronary angiography for the assessment of coronary circulation is controversial and it is considered by some time consuming thus increasing the risk of rupture. We describe a case of acute type A aortic dissection that illustrates our approach to this problem.