Post-Dissection Single-Stage Arch and Descending Aorta Replacement via Clamshell Incision.

Residual dissections after type A repairs are common and can result in aneurysm formation. Surgery is complex and considered high risk, particularly if there is arch involvement. A single-stage "arch-first" technique via clamshell incision is an excellent option in certain circumstances and herein we detail a variation of this approach using a trifurcated graft.

Dual inflow, total-arterial, anaortic, off-pump coronary artery bypass grafting: how to do it.

Coronary surgery performed on an arrested heart, using one internal mammary artery and a saphenous vein carries two main potential drawbacks: the known failure rate of vein grafts and the relatively high rate of neurologic injury. To address these concerns, we describe a technique that achieves complete revascularization without manipulating the ascending aorta (anaortic, off-pump) and utilizing total arterial grafts. All patients undergo thorough preoperative investigation, including bilateral carotid, vertebral and subclavian artery Duplex ultrasounds. A pulmonary artery catheter, transoesophageal echocardiography, and point-of-care coagulation testing are used in each case. The left and right internal mammary arteries and non-dominant radial artery are harvested using a fully skeletonised technique. Wide bilateral extrapleural retrothymic tunnels are developed and the pericardium is opened widely to facilitate cardiac positioning. A tandem graft is constructed with the right internal mammary artery (RIMA) in situ and radial artery using an end-to-end anastomosis. This graft is brought into the pericardium and through the transverse sinus in order to graft the lateral and inferior walls with multiple sequential distal anastomoses. The left internal mammary artery (LIMA) in situ is used to graft the anterior wall. Four main cardiac positions (high and low lateral walls, inferior and anterior walls) are obtained using a combination of off-pump stabilizer positioning, alternate tension on pericardial 'heart-strings', table tilting and folded wet sponges. All distal anastomoses are performed using silastic intracoronary shunts and an off-pump myocardial stabilizer. All grafts are checked using transit-flow time measurements. Milrinone is continued overnight and dual antiplatelet therapy is continued for 3 months postoperatively.

Long Term Outcomes Following Freestyle Stentless Aortic Bioprosthesis Implantation: An Australian Experience.

BACKGROUND: The Freestyle stentless bioprosthesis (FSB) has been demonstrated to be a durable prosthesis in the aortic position. We present data following Freestyle implantation for up to 10 years post-operatively and compare this with previously published results. METHODS: A retrospective cohort analysis of 237 patients following FSB implantation occurred at five Australian hospitals. Follow-up data included clinical and echocardiographic outcomes. RESULTS: The cohort was 81.4% male with age 63.2±13.0 years and was followed for a mean of 2.4±2.3 years (range 0-10.9 years, total 569 patient-years). The FSB was implanted as a full aortic root replacement in 87.8% patients. The 30-day all cause mortality was 4.2% (2.0% for elective surgery). Cumulative survival at one, five and 10 years was 91.7±1.9%, 82.8±3.8% and 56.5±10.5%, respectively. Freedom from re-intervention at one, five and 10 years was 99.5±0.5%, 91.6±3.7% and 72.3±10.5%, respectively. At latest echocardiographic review (mean 2.3±2.1 years post-operatively), 92.6% had trivial or no aortic regurgitation. Predictors of post-operative mortality included active endocarditis, acute aortic dissection and peripheral vascular disease. CONCLUSIONS: We report acceptable short and long term outcomes following FSB implantation in a cohort of comparatively younger patients with thoracic aortic disease. The durability of this bioprosthesis in the younger population remains to be confirmed.

Anaortic off-pump coronary artery bypass grafting in the elderly and very elderly.

BACKGROUND: Elderly patients undergoing surgical revascularisation may disproportionately benefit from avoiding manipulation of the ascending aorta and cardiopulmonary bypass. In this multi-centre observational study, we sought to determine the 30-day outcomes of anaortic off-pump coronary artery bypass (OPCAB) in an elderly and very-elderly population. METHODS: Data were prospectively collected for all patients aged >70 years old (y) undergoing anaortic OPCAB at three hospitals between January 2002 and October 2011. Analysis was carried out on two age sub-groups (70-79 y vs. ≥80 y). Multiple logistic regression was used to identify predictors of post-operative 30-day mortality. RESULTS: In total, 1135 patients >70 years underwent anaortic OPCAB - 817 (72%) patients were aged 70-79 y while 318 (28%) were aged ≥80 y. The rate of mortality and morbidity for both groups was low: 30-day mortality (70-79 y: 1.8%; ≥80 y: 2.8%) or permanent stroke (70-79 y: 0.2%; ≥80 y: 0.9%). Chronic lung disease, a history of previous myocardial infarction and left main disease were independent predictors of 30-day mortality. CONCLUSIONS: OPCAB is associated with low rates of 30-day mortality and peri-operative stroke in this elderly and very elderly patient cohort. Anaortic OPCAB can provide excellent short-term post-operative outcomes and may give the elderly and very elderly population the opportunity to benefit from surgical coronary revascularisation.

Neurologic complications after off-pump coronary artery bypass grafting with and without aortic manipulation: meta-analysis of 11,398 cases from 8 studies.

OBJECTIVE: Neurologic complications after coronary artery bypass grafting remain a concern. Off-pump coronary artery bypass grafting is a surgical strategy proposed to decrease this risk. Use of an off-pump anaortic technique, which leaves the ascending aorta untouched, may result in further reductions. This systematic review of all published evidence compares neurologic complications after anaortic off-pump coronary artery bypass grafting versus that with aortic manipulation. METHODS: PubMed and Embase were searched up to August 2008. Experts were contacted, and reference lists of retrieved articles were hand searched. The search process was not limited to English-language sources. Observational studies comparing standard off-pump coronary artery bypass grafting technique with anaortic technique were eligible for inclusion if they reported neurologic complications (stroke and transient ischemic attack). Meta-analysis was conducted to assess differences between groups with regard to neurologic complications. RESULTS: Electronic search identified 1428 abstracts, which resulted in retrieval and detailed review of 331 full-text articles. Eight observational studies reported neurologic complications in 5619 anaortic off-pump coronary artery bypass grafting cases and 5779 cases with aortic manipulation. Postsurgical neurologic complications were significantly lower in anaortic off-pump coronary artery bypass grafting cases (odds ratio, 0.46; 95% confidence interval, 0.29-0.72; I(2) = 0.8%; P = .0008). CONCLUSIONS: Avoidance of aortic manipulation during off-pump coronary artery bypass grafting decreases neurologic complications relative to standard technique in which the ascending aorta is manipulated. In patients at high risk for stroke or transient ischemic attack, we recommend avoidance of aortic manipulation during off-pump coronary artery bypass grafting.

Anaortic, total-arterial, off-pump coronary artery bypass surgery: how to do it.

Several large series have demonstrated that performing off-pump coronary artery bypass surgery without manipulating the ascending aorta (anaortic) utilising all-arterial grafts provides superior protection against neurological injury. Recent series comparing percutaneous coronary intervention (PCI) with surgical revascularisation have demonstrated superior results for surgery over PCI. However, a significant criticism of coronary artery surgery remains the higher incidence of neurological injury when compared to PCI. We present a simple and reproducible technique for anaortic, total-arterial off-pump coronary artery revascularisation.

Anaortic techniques reduce neurological morbidity after off-pump coronary artery bypass surgery.

BACKGROUND: Stroke remains one of the most devastating complications of cardiac surgery. Advocates of off-pump coronary revascularisation (OPCAB) maintain that post-operative neurologic morbidity is reduced by avoiding aortic cannulation and cross-clamping, and by eliminating the systemic effects of cardiopulmonary bypass. We sought to determine whether completing off-pump coronary surgery without any aortic manipulation ("anaortic" technique) afforded any additional neurological protection, as compared to off-pump grafting in which the aorta was utilised for graft inflow. METHODS: A comprehensive review of prospectively collected data was undertaken of all patients undergoing OPCAB in our institution between January 2002 and December 2006. Cases requiring intra-operative conversion to cardiopulmonary bypass were excluded from further analysis. Patients having OPCAB surgery with aortic manipulation were compared to those having OPCAB surgery without aortic manipulation. Multiple logistic regression was used to identify possible predictors of post-operative neurologic morbidity, with particular focus on the role of aortic manipulation. RESULTS: During the period of review, 1758 patients underwent OPCAB, of which 1201 (68.3%) were completed without aortic manipulation, constituting the "anaortic" cohort. This group was compared with the remaining 557 patients, which included fashioning at least one aorto-conduit anastomosis, utilising either a side-biting aortic clamp or a no-clamp proximal anastomotic device. The two groups of patients were well-matched with respect to risk factors for adverse neurologic outcomes. Nine patients sustained focal neurological deficits (transient or permanent) in the peri-operative period, constituting a stroke rate of 0.51% for the entire series. The incidence of peri-operative neurological deficit in the anaortic group was 0.25% compared with 1.1% in the aortic manipulation group (odds ratio (OR) 0.23, 95% confidence interval (CI) 0.06-0.92, p=0.037). Advanced age was also associated with peri-operative neurological injury (OR 1.1, 95% CI 1.01-1.20, p=0.017). CONCLUSIONS: Off-pump coronary artery surgery is associated with a low incidence of peri-operative stroke. Completing the surgical procedure without manipulating the ascending aorta in any way ("anaortic" technique) offers additional neurological protection and should be the goal in all suitable off-pump coronary cases.