Cardiac Manifestation of Rosai-Dorfman Disease: A Case Report and a Systematic Review.

BACKGROUND: Rosai-Dorfman disease is a rare condition that typically presents as a nodal disease. Cardiac involvement is extremely uncommon, occurring in 0.1-0.2% of cases, which has hindered our understanding. We report a case of Rosai-Dorfman disease (RDD) related cardiac manifestation in a patient without nodal involvement. Further, we conduct a comprehensive review of the literature to consolidate data on how patients with cardiac manifestations of RDD are typically managed and treated. METHODS: A systematic review of PubMed, Web of Science, and Embase was conducted to identify cases of RDD with cardiac involvement. Out of 464 studies identified, 42 publications encompassing 43 patients met the criteria and were incorporated in this review. We gathered data on patient demographics, as well as their management and treatment approaches. Additionally, we share our own experience with a patient who presented with a cardiac mass related to RDD. RESULTS: Out of the 43 patients, only 20.9% (n = 9) had a documented history of RDD prior to cardiac manifestations. Nodal involvement was reported in 32.6% (n = 14), while extranodal extracardiac involvement was reported in 46.5% (n = 20). Upon presentation, the most prevalent symptoms were dyspnea (48.8%, n = 21), chest discomfort (41.9%, n = 18), and lower extremity edema (16.3%, n = 7). Cardiac manifestations were most frequently found in the right atrium (41.9%, n = 18) and pericardium (18.6%, n = 8). Treatment encompassed systemic medical therapy (34.9%, n = 15) and cardiac surgery (39.5%, n = 17). The median follow-up period was 12 months (with a range of 1 to 36), and 8 patients (18.6%) experienced mortality. Our patient, who had a cardiac mass in the left atrium, underwent resection and has remained symptom-free without any recurrence for the past 5 years. CONCLUSION: The frequency of cardiac related-RDD manifestations may be greater than initially perceived. These results underscore the significance of identifying RDD and its cardiac-related presentations, facilitating timely diagnosis and treatment for affected individuals.

A Rare Presentation of Systolic Anterior Motion Occurring Eight Years After Mitral Valve Replacement.

Systolic anterior motion (SAM) is the dynamic displacement of mitral valve leaflets anteriorly toward the left ventricular outflow tract (LVOT) during systole. SAM-like physiology has been reported to occur shortly after mitral valve replacement (MVR) surgery; occurrence beyond two years after surgery is very rare. A 55-year-old woman who had bioprosthetic MVR eight years earlier for non-rheumatic mitral stenosis presented to the emergency room with progressive dyspnea and sudden-onset chest pressure. Physical examination noted a grade 3/6 systolic murmur at the cardiac apex, a soft diastolic murmur at the left sternal border, and diffuse expiratory wheezing. B-type natriuretic peptide (BNP) was elevated (286 pg/mL). Transthoracic echocardiography (TTE) showed mitral regurgitation and severe aortic insufficiency; the mitral prosthesis was protruding into the LVOT, causing LVOT obstruction with a peak gradient of 16.3 mmHg and peak velocity of 2.0 m/s. Transesophageal echocardiography (TEE) confirmed severe bioprosthetic MV dysfunction, severe aortic regurgitation, and SAM-like physiology. Left cardiac catheterization showed normal coronaries. She underwent repeat MVR and aortic valve replacement. She was started on daily aspirin and warfarin post-operatively, then discharged home on post-operative day 10. During post-operative office visits, she reported no complications. SAM-like physiology was absent in a two-month follow-up TTE, with reduced LVOT peak gradient of 6.5 mmHg and peak velocity of 1.3 m/s. Dynamic SAM-induced LVOT obstruction could be asymptomatic or result in severe heart failure with 20% risk of sudden cardiac death. SAM may occur within days following MVR or may have a delayed presentation. Medical management, including beta-blockade, is the cornerstone of initial management, while structural damage to the prosthetic valve mandates repeating mitral valve replacement surgery. This case highlights the importance of long-term follow-up of patients after MVR to assess for SAM, which could occur with or without degenerative changes of the prosthetic valve.

Advanced experience allows robotic mitral valve repair in the presence of extensive mitral annular calcification.

OBJECTIVE: Mitral annular calcification is underdiagnosed in patients with mitral regurgitation. After excision, it may require reconstruction of the atrioventricular groove and decreases the probability of valve repair. We reviewed the safety and efficacy of totally endoscopic robotic mitral valve repair in the presence of mitral annular calcification, with an emphasis on pathology and repair techniques. METHODS: Between May 2011 and August 2017, the same 2-surgeon team attempted totally endoscopic robotic mitral valve repair in 64 mitral annular calcification cases, accounting for 12.8% of our experience. Mitral annular calcification associated with a calcified posterior leaflet was not considered for totally endoscopic robotic mitral valve repair. When possible, the mitral annular calcification was excised en bloc using electrocautery, the posterior leaflet separated from the mitral annular calcification and spared, the atrioventricular groove was reconstructed, the posterior leaflet was reattached to the neoannulus, and the repair was completed with annuloplasty. RESULTS: The median age of patients was 65 years, with 21 (32.8%) aged less than 60 years, and 34 (53.1%) were women. The etiology was Barlow's disease in 54 patients (84%). Repair was converted to replacement in 2 patients (3.1%). Cryoablation was performed in 8 patients (12.5%), hybrid percutaneous coronary intervention was performed in 5 patients (7.8%), and tricuspid annuloplasty was performed in 2 patients (3.1%). Median aortic occlusion was 122 minutes, excluding cases with concomitant tricuspid repair. Thirty-three patients (52%) were extubated in the operating room. The median length of stay was 4 days. Residual mitral regurgitation on discharge transthoracic echocardiogram was none to mild in all patients. None of the patients had a perioperative stroke or needed a pacemaker. Thirty-day mortality was 2 (3.1%). CONCLUSIONS: Mitral annular calcification is present in a significant percentage of patients with mitral regurgitation, especially in Barlow's disease, including younger patients. By using a variety of repair techniques, totally endoscopic robotic mitral valve repair can be performed safely and effectively in most mitral annular calcification cases with a noncalcified posterior leaflet.

Robotic Approach to Mitral Valve Surgery in Septo-Octogenarians.

Advanced age confers higher Society of Thoracic Surgeons (STS) predicted risks of mortality and longer hospital lengths of stay (LOS) in patients undergoing mitral valve surgery; some consider it a contraindication to robotic-assisted approaches. We analyzed the feasibility and safety of totally endoscopic robotic mitral valve surgery (TERMS) in patients ≥70 years. From 5/11 to 4/18, 570 consecutive patients underwent TERMS by the same 2-surgeon team utilizing the da Vinci Xi Surgical System. Differences in patient demographics, intraoperative variables, and outcomes were analyzed between septo-octogenarian (patients ≥70 years) and younger patients (<70 years). Patients requiring left ventricle patch reconstruction following mitral annular calcification resection were excluded. For those patients with STS predicted risk scores (n = 439), our outcomes were compared to those STS predictions. Patients ≥70 comprised 25% of our TERMS cohort. Patients ≥70 had higher rates of preoperative atrial fibrillation and congestive heart failure, and significantly higher STS predicted risks of mortality. Patients ≥70 had greater incidence of concomitant cryoablation, hybrid percutaneous coronary intervention, and tricuspid repair. Patients ≥70 did not have longer cardiopulmonary bypass or aortic occlusion times. Thirty-day mortality was similar between groups (P = 0.151). Median LOS was 1 day longer for patients ≥70, 4 vs 3 days (P < 0.001). Short LOS (<6 days) was achieved in 72% of patients ≥70, markedly outperforming the STS predicted rates (36%). Advanced age is not a limiting factor for robotic mitral valve surgery in most patients. TERMS in patients ≥70 years matched STS benchmark performance outcomes and provided excellent recovery as evidenced by the short LOS (<6 days) experienced by the majority of septo-octogenarian patients.

Prosthetic valve endocarditis five months following transcatheter aortic valve implantation and review of literature.

There are only a few cases of prosthetic valve endocarditis (PVE) following transcatheter aortic valve implantation (TAVI) reported in the literature. Though not very frequent, this is a serious concern because patients are high risk for surgical aortic valve replacement (SAVR) by definition, and explanting the endocarditic prosthetic valve followed by SAVR increases risk even higher.

Safety and efficacy of retrograde cerebral perfusion as an adjunct for cerebral protection during surgery on the aortic arch.

OBJECTIVE: The best adjunct for cerebral protection during aortic arch reconstruction remains controversial. Retrograde cerebral perfusion (RCP) as an adjunct to profound hypothermic circulatory arrest (PHCA) extends the tolerable period of brain ischemia by flushing emboli and air from the cerebral circulation while maintaining hypothermia. We examined our experience with RCP to determine its efficacy in patients undergoing complex arch reconstruction. METHODS: We retrospectively evaluated 879 patients undergoing arch reconstruction using RCP from July 1997 to March 2013. Perioperative risk factors were analyzed as predictors of neurologic injury and mortality. Survival for the type of arch reconstruction and for the interval of PHCA was calculated. RESULTS: Of the 879 patients, 671 underwent hemiarch and 208 total arch replacement. The mean age was 65 ± 13.3 years, and 61.6% were men. The total arch patients had longer mean periods of PHCA (39 vs 21 minutes, P < .001) and RCP (37 vs 19 minutes, P < .001). However, the incidence of transient neurologic dysfunction (3.0% vs 2.4%, P < .813) and permanent neurologic dysfunction (1.3% vs 1.9%, P < .519) was similar for both techniques. Mortality was greater in the hemiarch group (4.8% vs 0.5%, P < .003). Patients requiring >40 minutes of PHCA had outcomes similar to those requiring less. The 1-, 5-, and 10-year survival was similar, regardless of the procedure performed or interval of PHCA. CONCLUSIONS: RCP is a safe and effective adjunct for cerebral protection during arch surgery. Patients requiring more extensive arch reconstruction are not at greater risk of permanent neurologic dysfunction or perioperative mortality.

TandemHeart device as rescue therapy in the management of acute heart failure.

BACKGROUND: The TandemHeart device (THD) is a pump system that can be deployed percutaneously (PC) or via conventional surgical (CS) cannulation; it is capable of supporting one or both ventricles. It is a versatile system designed for use as a rescue device in acute heart failure and as a bridge to decision in moribund patients. METHODS: Retrospective analysis was conducted on all patients who underwent a THD implant; either PC or CS; at our institution. Univariate analysis was done using Fisher's exact and Chi-square tests for categorical variables and Wilcoxon Rank Sum test for continuous ones. RESULTS: 51 adult patients were identified: 10 PC and 41 CS. Mean age was 58.9 ± 12.8 years, and 31% were female. In hospital mortality was 61%. Univariate predictors of death were prolonged support (74% versus 46%, P = .04) and higher lactic acid levels (5.3 ± 4.9 versus 2.3 ± 1.9 mmol/L, P = .012). The length of stay (LOS) for survivors was 59.8 ± 30.0 days. CONCLUSION: Uni- or bi-ventricular unloading can be successfully achieved using the THD, either trans-thoracically or percutaneously, with an acceptable complication profile.

The outcome of surgical management of type A aortic dissection.

BACKGROUND: Type A aortic dissection is a serious and fatal condition. METHODS: We retrospectively evaluated the outcome following repair of ascending aortic dissection in a contemporary cohort of 108 patients with a mean age of 59.5 ± 13.8 years, who were treated between 2006 and 2011. Most patients were male (70, 65%). RESULTS: Circulatory arrest with a mean duration of 22 ± 16 min was performed in 42 (38.9%) patients. Perioperative mortality was 15.7% (n = 17). Univariate analysis showed that cardiopulmonary bypass time (p = 0.0006), age >60 years (p = 0.028), cardiogenic shock at presentation (p = 0.02), New York Heart Association class II-IV (p = 0.038), hemopericardium (p = 0.0035), and preoperative cerebrovascular accident (p = 0.02) were predictors of mortality. Multivariate analysis indicated that age >60 years (odds ratio 7.7, 95% confidence interval: 1.52-38.96, p = 0.0136), preoperative cerebrovascular accident (odds ratio 25.2, 95% confidence interval: 2.45-258.9, p = 0.0066), hemopericardium (odds ratio 41.6, 95% confidence interval: 5.38-320.7, p = 0.0003), and cardiopulmonary bypass time (odds ratio 1.85, 95% confidence interval: 1.32-2.57, p = 0.0003) were independent predictors of perioperative mortality. The 1- and 4-year survival was 80% ± 3.8% and 69% ± 5.7%, respectively. Age >60 years (hazard ratio 3.3, 95% confidence interval: 1.4-7.9, p = 0.0064) was the only independent predictor of long-term mortality. CONCLUSION: Our results identify the major risk factors for perioperative and long-term mortality. Age is an independent risk factor for mortality.

Fifteen-year experience and outcomes of pericardiectomy for constrictive pericarditis.

BACKGROUND AND AIM: Constrictive pericarditis has multiple etiologies and can lead to disabling symptoms and severe heart failure with poor quality of life. Surgical pericardiectomy is the cornerstone of management. All patients undergoing pericardiectomy at our institution were reviewed with the goal of analyzing preoperative and intraoperative factors that may be associated with long-term outcomes. METHODS: A retrospective review of our cardiac surgery database identified all patients who underwent pericardiectomy for constrictive pericarditis between 1997 and 2012. Demographic, comorbidity, operative, and outcome data were analyzed. RESULTS: Thirty-six patients underwent pericardiectomy for constrictive pericarditis over 15 years. Etiologies included idiopathic (n = 20, 55.6%), postoperative (n = 11, 30.5%), postradiation (n = 3, 8.3%), and tuberculosis (n = 2, 5.6%). Total pericardiectomy was performed in 35 patients. The average preoperative cardiac index was 2.6 L/min/m(2) with a significant increase to 3.1 L/min/m(2) noted in the immediate postoperative period (p = 0.03). There were no perioperative mortalities. The 1-year, 5-year, 10-year, and 15-year survival rates were 97.2%, 94.6%, 86.5%, and 78.3%, respectively. On multivariate analysis, preoperative heart failure (hazard ratio 2.2, p = 0.06), elevated preoperative total bilirubin (>2.7 mg/dL, hazard ratio 6.8, p = 0.02), and elevated creatinine (>1.4 mg/dL, hazard ratio 3.1, p = 0.05) were risk factors for increased long-term mortality. Kaplan-Meier survival analysis showed a significant decrease in overall survival associated with postradiation etiology (p = 0.05). CONCLUSIONS: Pericardiectomy can be performed with low mortality and immediate improvement in hemodynamics. Those patients with compromised cardiac output, abnormal hepatic or renal function, or with previous radiation therapy have reduced long-term survival.

Risk factors predicting the postoperative outcome in 134 patients with active endocarditis.

BACKGROUND: Surgery remains the cornerstone in management of endocarditis. METHODS: In this retrospective cohort we evaluated the operative outcome of patients with infective endocarditis. The SPSS program was used to analyze the data. RESULTS: A total of 134 predominantly male patients (60%) with a mean age of 55 ± 12.4 years were examined. The procedures included single valve (n = 88; 66%), double/multiple valves (n = 29; 22%), and valve-coronary artery bypass graft (CABG) (n = 16; 12%). Perioperative mortality was 11.9% (n = 16). In the multivariate analysis, dialysis (odds ratio [OR] = 7.88; 95% confidence interval [CI] [1.78-34.77]; P = .006), sepsis (OR = 19.5; 95% CI [2.76-137.9]; P = .002), and perfusion time (95% CI [1.00-1.02]; P = .003) were independent predictors of perioperative mortality. The overall long-term survival at 28 months was 69.2% ± 4%. Dialysis (P = .0001) was a predictor of mortality, whereas elevated creatinine in nondialysis patients (P = .0002) was not. In the multivariate analysis, dialysis (hazard ratio [HR] 4.06%; 95% CI [0.936-8.526]; P = .0002), CABG (HR 2.32; 95% CI [1.086-4.978]; P = .0299), chronic obstructive pulmonary disease (HR 2.20; 95% CI [1.027-4.739]; P = .0426), and double/multiple valve procedure (HR 3.0; 95% CI [1.467-6.206]; P = .0027) were risk factors for long-term mortality. CONCLUSION: Renal failure but not renal insufficiency is a risk factor for short and long-term mortality.

Orthotopic heart transplantation in patients with persistent left superior vena cava: bicaval and biatrial techniques.

Persistent left superior vena cava (LSVC) is the most common congenital venous abnormality. With the increasing number of children who survive into adulthood with congenital heart malformations, the recognition of persistent LSVC among patients with advanced heart failure is likely to rise. We present two cases of orthotopic heart transplantation in the setting of LSVC successfully managed with biatrial and bicaval techniques.

Hybrid arch debranching and proximal endograft extension to repair a type I endoleak after endovascular thoracic aneurysm repair.

Endovascular repair of complex aortic disease has emerged over the past decade as an alternative to traditional open repair, especially for patients with significant medical comorbidities and/or anatomic challenges, such as reoperative fields. However, the possibility of graft migration and endoleak mandates long-term follow-up of these grafts. We present a patient who underwent hybrid repair after stent graft migration and proximal type I endoleak after thoracic endovascular aneurysm repair. This approach allowed us to avoid extensive surgery that would also necessitate circulatory arrest.

Repair of aortic root in patients with aneurysm or dissection: comparing the outcomes of valve-sparing root replacement with those from the Bentall procedure / Reparação de raiz aórtica em pacientes com aneurisma ou dissecção: comparando os resultados da técnica de substituição valve-sparing com os da operação de Bentall

INTRODUCTION: Management of aortic root aneurysm or dissection has been the subject of much discussion that has led to some modifications. The current trend is a valve-sparing root replacement. We compared the outcome following valve sparing root repair with Bentall procedure. METHODS: We retrospectively evaluated 70 patients who underwent root replacement for aneurysm or dissection and compared the outcomes of valve-sparing root replacement with those of the Bentall procedure from January 2007 to December 2011 at our institution. RESULTS: Twenty-five patients had valve-sparing aortic root replacement (VSR, including reimplantation or remodeling) (23 males and 2 females), and 45 patients had the Bentall procedure (34 males and 11 females). Patients who underwent a VSR were younger with a mean age of 55.4 ± 14.8 years compared to those who underwent the Bentall procedure with a mean age of 60.6 ± 12.7 (P=ns). The preoperative aortic insufficiency (AI) in the VSR group was moderate in 8 (32%) patients, and severe in 6 (24%). Preoperative creatinine was 1 ± 0.35 mg/dl in the VSR group and 1.1 ± 0.87 mg/dl in the Bentall group. In the VSR group, 3 (12%) patients had emergency surgery; by contrast, in the Bentall group, 8 (17%) patients had emergent surgery. Concomitant coronary artery bypass grafting (excluding coronary reimplantation) was performed in 8 (32%) patients in the VSR group and in 12 (26.6%) patients in the Bentall group (P=0.78); additional valve procedures were performed in 2 (8%) patients in the VSR group and in 11 (24.4%) patients in the Bentall group. The perioperative mortality was 8% (n=2) and 13.3% (n=6), for the VSR and Bentall procedures, respectively (P=0.7, ns). The total duration of intensive care unit stay was 116.6 ± 106 hours for VSR patients and 152.5 ± 218.2 hours for Bentall patients (P=0.5). The overall length of stay in the hospital was 10 ± 8.1 days for VSR and 11 ± 9.52 days for Bentall (P=0.89). The one-year survival was 92% for the VSR group and 79.0% for the Bentall group. The seven-year survival for the VSR group was 92% and 79% for the Bentall group (95% CI [1.215 to 0.1275], P=0.1). CONCLUSION: Aortic valve-sparing root replacement can be performed with acceptable morbidity and mortality with a comparable long-term survival to the Bentall procedure.

INTRODUÇÃO: Manejo de aneurisma da aorta ou dissecção da raiz tem sido objeto de muita discussão que levou a algumas modificações. A tendência atual é o uso da técnica de substituição valve-sparing (VSR). Nós comparamos o resultado da reparação da raiz utilizando a técnica de substituição valve-sparing com o procedimento de Bentall. MÉTODOS: Foram avaliados, retrospectivamente, 70 pacientes submetidos à substituição da raiz de aneurisma ou dissecção, comparando os resultados da técnica de substituição valve-sparing com os do procedimento Bentall de janeiro de 2007 a dezembro de 2011 em nossa instituição. RESULTADOS: Vinte e cinco pacientes foram submetidos à substituição da valva aórtica com o uso da técnica valve-sparing (VSR, incluindo o reimplante ou remodelação) (23 homens e duas mulheres), e 45 pacientes pelo procedimento de Bentall (34 homens e 11 mulheres). Pacientes que se submeteram à VSR eram mais jovens, com idade média de 55,4 ± 14,8 anos em comparação àqueles que foram submetidos ao procedimento Bentall, idade média de 60,6 ± 12,7 anos (P = ns). A insuficiência aórtica pré-operatória no grupo VSR foi moderada em oito (32%) pacientes e grave em seis (24%). Creatinina pré-operatória foi 1 ± 0,35 mg/dl, no grupo do VSR, e 1,1 ± 0,87 mg/dl, no grupo de Bentall. No grupo VSR, três (12%) pacientes foram operados em caráter de emergência e, no grupo de Bentall, oito (17%). Revascularização do miocárdio concomitante (excluindo reimplante coronariano) foi realizada em oito (32%) pacientes no grupo VSR e, em 12 (26,6%), no grupo de Bentall (P=0,78); procedimentos valvares adicionais foram realizados em 2 (8%) pacientes no grupo do VSR e em 11 (24,4%) no grupo de Bentall. A mortalidade perioperatória foi de 8% (n = 2) e 13,3% (n = 6), para os procedimentos de VSR e Bentall, respectivamente (P=0,7, ns). O tempo de internação na unidade de terapia intensiva foi de 116,6 ± 106,0 horas para pacientes VSR e 152,5 ± 218,2 horas para pacientes Bentall (P=0,5). O tempo de permanência no hospital foi de 10 ± 8,1 dias para VSR e 11 ± 9,52 dias para Bentall (P=0,89). A sobrevida em um ano foi de 92,0 % para o grupo VSR e 79,0% para o grupo de Bentall. A sobrevivência de sete anos para o grupo VSR foi de 92% e 79% para o grupo de Bentall (IC95% [1,215 a 0,1275], P=0,1). CONCLUSÃO: A técnica valve-sparing substituição da raiz aórtica pode ser realizada com a morbidade e mortalidade aceitáveis, e sobrevivência aceitável a longo prazo comparável com o procedimento de Bentall.

Recently patented transcatheter aortic valves in clinical trials.

The most widely used heart valve worldwide is the Edwards Sapien, which currently has 60% of the worldwide transcatheter aortic valve implantation (TAVI) market. The CoreValve is next in line in popularity, encompassing 35% of the worldwide TAVI market. Although these two valves dominate the TAVI market, a number of newer transcatheter valves have been introduced and others are in early clinical evaluation. The new valves are designed to reduce catheter delivery diameter, improve ease of positioning and sealing, and facilitate repositioning or removal. The most recent transcatheter valves for transapical use include Acurate TA (Symetis), Engager (Medtronic), and JenaValve the Portico (St Jude), Sadra Lotus Medical (Boston Scientific), and the Direct Flow Medical. These new inventions may introduce more effective treatment options for high-risk patients with severe aortic stenosis. Improvements in transcatheter valves and the developing variability among them may allow for more tailored approaches with respect to patient's anatomy, while giving operators the opportunity to choose devices they feel more comfortable with. Moreover, introducing new devices to the market will create a competitive environment among producers that will reduce high prices and expand availability. The present review article includes a discussion of recent patents related to Transcatheter Aortic Valves.

A case series of a hybrid approach to aortic arch disease.

OBJECTIVE: Debranching of the aortic arch and endovascular stent placement as a combination therapy for complex aortic arch pathology has emerged over the past few years as an alternative to traditional repair. This hybrid approach is a viable option for patients who would not tolerate conventional arch replacement, as well as for patients with a failed stent graft of the descending aorta and a subsequent type I endoleak. METHODS: We retrospectively reviewed the preoperative characteristics and postoperative outcomes of 5 patients who underwent debranching of the aortic arch and implantation of an endovascular stent across the aortic arch between 2008 and 2011. Data were analyzed with the Student t test and the Kaplan-Meyer method. RESULTS: The mean age was 70.6 ± 18 years; 4 men and 1 woman were evaluated. One patient had previous aortic surgery for dissection. The preoperative morbidities included arrhythmia (1 patient), chronic obstructive pulmonary disease (2 patients), cerebrovascular accident (1 patient), diabetes mellitus (2 patients), coronary artery disease (2 patients), and active angina (1 patient). One patient had a myocardial infarction 3 weeks before surgery. The primary technical-success rate was 100%, and none of the patients died in the perioperative phase. The mean follow-up time was 22 ± 18.4 months, and the median follow-up time was 13.8 months (range, 7.13-50.7 months). Two patients died during follow-up. The pathology of the aorta in the patients who died was arch aneurysm; the 3 remaining patients are alive and regularly followed at our institution. CONCLUSION: The combination of surgery and simultaneous endovascular stenting in the operating room is an alternative approach for patients who are poor candidates for traditional arch repair under circulatory arrest.

A review of most relevant complications of transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) has emerged for treating aortic stenosis in patients who are poor candidates for surgical aortic valve replacement. Currently, the balloon-expandable Edwards Sapien valve-which is usually implanted via a transfemoral or transapical approach-and the self-expanding CoreValve ReValving system-which is designed for retrograde application-are the most widely implanted valves worldwide. Although a promising approach for high-risk patients, the indication may be expanded to intermediate- and eventually low-risk patients in the future; however, doing so will require a better understanding of potential complications, risk factors for these complications, and strategies to individualize each patient to a different access route and a specific valve. This paper reviews the most relevant complications that may occur in patients who undergo catheter-based aortic valve implantation.

The hybrid repair of a penetrating ulcer in a patient with a bovine arch; debranching followed by endovascular stent placement.

Aortic arch disease has conventionally been a subject for open surgical repair, which may require circulatory arrest, accompanied by a long perfusion and extended cross-clamp time. A 2-stage approach utilizing an elephant trunk procedure followed by a descending aortic replacement, or utilizing a frozen elephant trunk with endovascular extension is not well tolerated by multimorbid patients. On the other hand, the endovascular repair of an aortic arch disease is limited by aortic branching. Hybrid repair consists of revascularization of arch vessels followed by endovascular stenting.

Extracorporeal membrane oxygenation as a temporizing approach in a patient with shock, myocardial infarct, and a large ventricle septal defect; successful repair after six days.

Rupture of the ventricular septum occurs in 1% to 2% of all acute myocardial infarctions (MI) requiring surgical intervention in the majority of cases. Furthermore, patch dehiscence and residual shunt are major problems following repair in the acute stage. A delay in repair may prevent patch dehiscence. We now describe the technique used for a successful repair of a ruptured ventricular septal defect following six days of extracorporeal membrane oxygenation support.

The significance of prosthesis type on survival following valve replacement in dialysis patients.

BACKGROUND AND AIM OF THE STUDY: The type of valve prosthesis used in dialysis patients remains the subject of controversy, while calcification of the bioprosthesis has also been of concern. METHODS: In this retrospective study, an analysis was performed of the morbidity and mortality of patients with end-stage renal disease who underwent either mitral valve replacement (MVR) or aortic valve replacement (AVR) between 2006 and 2011. RESULTS: A total of 95 patients (55 males, 40 females; median age 61 years; range: 32-85 years) was examined. Of these patients, 58 received bioprosthetic valves and 37 mechanical valves. The perioperative mortality was 21% (n = 20); 11 patients (11.6%) died in the biologic valve group (BVG) and nine (9.5%) in the mechanical valve group (MVG) (p = 0.6). Univariate analysis showed that preoperative risk factors such as early extubation < 6 h (p = 0.028), peak perioperative lactate level (p = 0.0003), prolonged perfusion time (p = 0.05), body mass index > 30 kg/m2 (p = 0.08), and body surface area > 2 m2 (p = 0.04) were predictors of mortality. The multivariate model showed perfusion time to be the only independent risk factor for perioperative mortality (Odds ratio 1.24 for every 30 min beyond 150 min average, CI 1.006-1.543, p = 0.0098). Long-term survival was negatively impacted by concomitant coronary artery bypass grafting, preoperative arrhythmia (p = 0.04), and a postoperative intubation time > 6 h (p = 0.012). The one- and five-year survivals for the BVG were 65 +/- 6.4% and 34 +/- 11%, respectively. The one-year and 40-month survivals for the MVG were 53 +/- 8% and 37 +/- 10%, respectively (p = 0.49). CONCLUSION: The overall survival of dialysis patients was poor, but the type of prosthetic valve had no effect on either perioperative mortality or long-term survival.