[Minimally invasive ascending aortic replacement in patient with chronic aortic dissection type A (in Russian only)]. / Protezirovanie voskhodiashchei aorty iz mini-dostupa u patsienta s khronicheskoi dissektsiei aorty tipa A.

It is presented case report of minimally invasive surgical repair of chronic aortic dissection type A in a 61-year-old patient. Perspective minimally invasive surgical approach is suggested for this pathology in order to improve quality of life and rehabilitation after cardiac surgery. Surgical technique and features are comprehensively described.

Modified predictive score based on frailty for mid-term outcomes in open total aortic arch surgery.

OBJECTIVES: The aim of this study was to seek a new predictor of mid-term survival of surgical total aortic arch replacement (SAR) by evaluating indices relevant to frailty. METHODS: Between October 2012 and March 2017, 113 consecutive patients underwent elective surgical total aortic arch replacement with antegrade cerebral perfusion under circulatory arrest at a single cardiovascular institute. In addition to common parameters, Katz index of activities of daily living, nutritional status, skeletal muscle mass volume, swallowing and motor functions were used to evaluate patients' frailty. RESULTS: The associated variables with mid-term all-cause death include the following: age ≥79 years was assigned 4 points; 68 years ≤age <79 years, 1 point; age <68 years, 0 point; Canadian Study of Health and Aging (CSHA) scale ≥4, 1 point; serum albumin level <3.7 g/dl, 2 points; 3.7 g/dl ≤ serum albumin level <4.25 g/dl, 1 point; serum albumin level ≥4.25 g/dl, 0 point or Katz index of activities of daily living index <6, 2 points each, according to the hazard ratio. The total score was reclassified into the low-risk (0-5) (n = 96) and high-risk (6-9) (n = 17) groups. Percentage of complicated patients was as follows: aided walking (11.5% and 47.1%; P = 0.001), dysphagia (13.5% and 41.2%; P = 0.012) and no discharge to home (13.5% and 47.1%; P = 0.003) in the low- and high-risk groups, respectively. The Kaplan-Meier curve revealed a significant decrease of 3-year survival according to the risk grades (96.2% and 33.9%; P < 0.001). CONCLUSIONS: Risk stratification for mid-term mortality of elective surgical total aortic arch replacement was achieved by simple score relevant to frailty. The risk classification was correlated with postoperative waning of physical functions.

Factores de riesgo coronarios en pacientes con prótesis aórtica durante rehabilitación cardiaca / Risk coronary factors in patients with aortic prosthetic during cardiac rehabilitation

Introducción: se realizó un estudio de intervención con todos los pacientes sometidos a cirugía de sustitución valvular protésica aórtica que acudieron a rehabilitarse en el Departamento de Rehabilitación Cardiovascular del Hospital Hermanos Ameijeiras durante el año 2011. Objetivo: caracterizar el comportamiento de los factores de riesgo coronario. Métodos: la muestra estuvo conformada por 16 pacientes. Se halló que el rango etario más frecuente fue el de 55-64 años, el sexo masculino y el color de piel blanca. La prótesis valvular de tipo mecánica fue implantada en todos los pacientes. Se observó mejoría en la capacidad funcional posterior a la rehabilitación cardíaca, se logró reducir el sedentarismo, la obesidad y el hábito de fumar, así como el incremento del número de pacientes hipertensos y diabéticos controlados. No ocurrieron complicaciones en la mayoría de los pacientes durante la rehabilitación. Conclusión: mediante la rehabilitación cardíaca se logró disminuir los FRC asociado a un bajo índice de complicaciones(AU)

Background: an intervention study was performed in all patients that were submitted to aortic prosthetic valve replacement surgery that began rehabilitation at the Cardiac Rehabilitation Unit Department of Hermanos Ameijeiras Hospital during the year 2011. Objective: to characterize the behavior of coronary risk factors. Methods: the sample was comprised of 16 patients. It was observed that the most frequent age rank was 55-64 years and most of the patients were male and white. All patients received mechanical aortic valve replacement. An improvement in the functional capacity in patients after cardiac rehabilitation was observed. Sedentary life, obesity and smoking habit were cut down and there was an increase in the number of controlled diabetic and hypertensive patients. Complications did not occur in the majority of patients during rehabilitation. Conclusions: cardiac rehabilitation diminished FRC associated to a low rate of complications(AU)

Factores de riesgo coronarios en pacientes con prótesis aórtica durante rehabilitación cardiaca / Risk coronary factors in patients with aortic prosthetic during cardiac rehabilitation

Introducción: se realizó un estudio de intervención con todos los pacientes sometidos a cirugía de sustitución valvular protésica aórtica que acudieron a rehabilitarse en el Departamento de Rehabilitación Cardiovascular del Hospital Hermanos Ameijeiras durante el año 2011. Objetivo: caracterizar el comportamiento de los factores de riesgo coronario. Métodos: la muestra estuvo conformada por 16 pacientes. Se halló que el rango etario más frecuente fue el de 55-64 años, el sexo masculino y el color de piel blanca. La prótesis valvular de tipo mecánica fue implantada en todos los pacientes. Se observó mejoría en la capacidad funcional posterior a la rehabilitación cardíaca, se logró reducir el sedentarismo, la obesidad y el hábito de fumar, así como el incremento del número de pacientes hipertensos y diabéticos controlados. No ocurrieron complicaciones en la mayoría de los pacientes durante la rehabilitación. Conclusión: mediante la rehabilitación cardíaca se logró disminuir los FRC asociado a un bajo índice de complicaciones

Background: an intervention study was performed in all patients that were submitted to aortic prosthetic valve replacement surgery that began rehabilitation at the Cardiac Rehabilitation Unit Department of Hermanos Ameijeiras Hospital during the year 2011. Objective: to characterize the behavior of coronary risk factors. Methods: the sample was comprised of 16 patients. It was observed that the most frequent age rank was 55-64 years and most of the patients were male and white. All patients received mechanical aortic valve replacement. An improvement in the functional capacity in patients after cardiac rehabilitation was observed. Sedentary life, obesity and smoking habit were cut down and there was an increase in the number of controlled diabetic and hypertensive patients. Complications did not occur in the majority of patients during rehabilitation. Conclusions: cardiac rehabilitation diminished FRC associated to a low rate of complications

[Hybrid surgical management of a saccular aneurysm of the aortic arch].

The present article aims to describe a clinical case of hybrid surgical intervention consisting in complete prosthetic repair of the aortic arch in a high-risk male patient diagnosed with a gigantic saccular aneurysm of the aortic arch. The patient was subjected to a hybrid operation--an operation of endovascular prosthetic repair of the thoracic portion of the aorta with the Gore Tag stent graft in a combination with bypass grafting of the left common carotid and left subclavian arteries with the Gore bifurcated stent graft, autovenous aortocoronary bypass grafting of the CA without artificial circulation. The postoperative period was uneventful with the patient's favourable convalescence and rehabilitation occurring within the shortest terms possible. According to the findings of MSCT-aortography, fulfilment of the arteries of the aortic arch with contrast medium was satisfactory. The residual cavity of the aneurysm was completely isolated from the blood flow, with no endoleak. The arteries of the aortic arch were opacified through the bifurcation prosthesis from the ascending portion of the aorta. Hybrid surgical interventions appear to possess all positive properties of endovascular (according to the findings of the EVAR1 and EVAR2 Trials) and traditional open surgery, thus allowing of both avoiding threatening complications and minimizing the terms of rehabilitation. This technique might thus be considered a useful tool to be included into the basic armamentarium of the vascular surgeon as an option of revascularization.

Thoracic endovascular aortic repair: impact of urgency on outcome and quality of life.

OBJECTIVES: Endovascular repair of the descending thoracic aorta is a very promising technique in elective and, particularly, emergency situations. This study assessed the impact of urgency of the procedure on outcome and mid-term quality of life in surviving patients. METHODS: Post hoc analysis of prospectively collected data of 58 consecutive patients (January 2001-December 2005) with surgical pathologies of the descending thoracic aorta treated by endovascular means. Six patients were excluded due to recent operations on the ascending aorta before thoracic endovascular repair. The remaining patients (n=52) were 69+/-10 years old, and 43 were men (83%). Twenty-seven had been treated electively, and 25 for emergency indications. Reasons for emergency were acute type B aortic dissections with or without malperfusion syndrome in 14, and aortic ruptures in 11 cases. Follow-up was 29+/-16 months. Endpoints were perioperative and late morbidity and mortality rates and long-term quality of life as assessed by the short form health survey (SF-36) and Hospital Anxiety and Depression Scale questionnaires. RESULTS: Cohorts were comparable regarding age, sex, cardiovascular risk factors, and comorbidities. Perioperative mortality was somewhat higher in emergency cases (12% vs 4%, p=0.34). Paraplegia occurred in one patient in each cohort (4%). Overall quality of life after two and a half years was similar in both treatment cohorts: 72 (58-124) after emergency, and 85 (61-105) after elective endovascular aortic repair (p=0.98). Normal scores range from 85 to 115. Anxiety and depression scores were in the normal range and comparable. CONCLUSIONS: Thoracic endovascular aortic repair is an excellent and safe treatment option for the diseased descending aorta, particularly in emergency situations. Early morbidity and mortality rates can be kept very low. Mid-term quality of life was not affected by the urgency of the procedure. Similarly, mid-term anxiety and depression scores were not increased after emergency situations.

Self-management program improves anticoagulation control and quality of life: a prospective randomized study.

OBJECTIVE: Previous retrospective studies suggest that patients' self management of oral anticoagulants leads to improved control. In this prospective randomized study, we investigated the effects of self management on the control of anticoagulant therapy and quality of life. Comparison with the conventional management through the Dutch Thrombosis Service is addressed. METHODS: Between January 2005 and June 2007, 62 consecutive patients who underwent elective mechanical aortic valve replacement were included in this study. Patients were randomized into two groups: (1) conventional group controlled by the Local Thrombosis Service, and (2) self management group using CoaguChek. Primary endpoints were the total number of international normalized ratio (INR) values within the target range as well as the quality of life measurements (SF-36v2) one year postoperatively. RESULTS: The number of INR values within the target range (2.5-4.5) was significantly higher in the self management group (mean=72.9+/-11%) than in the conventional group (53.9+/-14%; p=0.01). Both groups showed an improvement in the quality of life scores one year postoperatively. However, postoperative improvement was statistically significant in the self management group regarding the physical component summary only (p=0.001). CONCLUSION: Despite the well-organized INR control by the Thrombosis Service in The Netherlands, self management program after adequate training improves the INR control. Postoperative improvement in the quality of life scores was significant in the self management group with regards to the physical component summary only. Further studies are needed to describe whether self management program will reduce the risk of bleeding and/or thrombo-embolism.

Transcranial motor-evoked potentials following intra-aortic cold blood infusion facilitates detection of critical supplying artery of spinal cord.

OBJECTIVE: In order to determine whether critical intercostal artery is present in the aneurysm during descending thoracic or thoracoabdominal aortic surgery, changes of transcranial motor-evoked potentials (Tc-MEPs) were monitored following infusion of cold blood into the aorta as an adjunct 'on-site assessment'. Accuracy of this method was evaluated. METHODS: Fourteen patients were examined for Tc-MEPs changes following infusion of cold blood (4 degrees C, 300-450 ml) into the aneurysm. The intercostal arteries in the aneurysm were reconstructed when the Tc-MEPs amplitude decreased to below 50% of the baseline within 3 min after cold blood infusion. When the amplitude did not decrease, every intercostal artery in the aneurysm was ligated. RESULTS: The Tc-MEPs amplitude did not decrease in eight cases (57%), while it decreased in six cases (43%). In the former, no case presented with paraplegia despite every intercostal artery being ligated. In the latter, the amplitude recovered after reconstruction in four patients, who had no paraplegia postoperatively. In the remaining two cases, however, the amplitude did not recover: one died of multiple organ failure with postoperative assessment unfeasible; the other developed paraplegia following surgery. Except one case with operative death, both sensitivity and specificity of our criteria with cold blood infusion was 100% in this series. CONCLUSIONS: Cold blood infusion into the clamped segment of aorta accelerates Tc-MEPs changes and can possibly reduce ischemic insults of spinal cord during diagnostic process, while it accurately detects presence of critical intercostal artery in the segment. This method appears to be promising adjunct on-site assessment.

What determines and are the consequences of surveillance intensity after endovascular abdominal aortic aneurysm repair?

Follow-up examinations are advised 1, 3, 6, 12, 18, and 24 months and yearly thereafter by the European Collaborating Group on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR). The aim of this study was to evaluate the determinants and consequences of surveillance completeness. Patients who underwent endovascular abdominal aortic aneurysm repair between October 1996 and August 2004 and enrolled in the EUROSTAR registry were analyzed. Two groups were compared: patients who attended all scheduled visits (group A) and those who came infrequently (group B). Odds ratios and hazard rates (HRs) with 95% confidence intervals (CIs) were determined to detect which patient characteristics and complications were associated with follow-up intensity. Of the 4,433 patients, 1,538 (35%) attended all scheduled visits until the end of follow-up (group A). Analysis of patient characteristics demonstrated that intensive visitors were more often smokers, hyperlipemic, and considered unfit for open surgery or general anesthesia. Complications during follow-up, including endoleaks (24% vs. 20%), kinking (3.5% vs. 2.5%), and migration (4.9% vs. 3.5%), appeared significantly more frequently in group A. Despite intensive follow-up of this category, still a greater proportion died (12% vs. 9%, adjusted HR = 1.5, 95% CI 1.2-1.8). After 84 months of follow-up, the cumulative survival rates in groups A and B were 71% and 74%, respectively (p < 0.0001). It seems that follow-up intensity was based on baseline patient characteristics. High-risk patients had, despite more intensive surveillance, still more complications after adjustment for patient, morphological, and center-specific characteristics. Further assessment is indicated to evaluate the effectiveness of different frequencies of surveillance visits.

Factors impacting functional health and resource utilization following abdominal aortic aneurysm repair by open and endovascular techniques.

We assessed the impact on patient outcomes of comorbidities and type of aneurysm repair, open vs. endovascular aortic repair (EVAR). Functional health status was measured prospectively using the Short Form 36 (SF-36) Health Survey. Length of stay (LOS) and need for postdischarge resources (nursing and rehabilitation) were compared between groups. We reviewed the records of 218 patients (126 open, 92 EVAR) who underwent intervention between 1998 and 2003. The SF-36 was completed preoperatively and at intervals ranging from 2 weeks to 1 year after intervention. To identify factors impacting outcome, univariate and multivariate analyses were performed. Overall mortality was 1.9%: 3.2% for open repair and 0% for EVAR (p = 0.13). Physical and mental health were higher during the 3 months following EVAR compared with open repair: physical function (PF) (65.2 +/- 4.1 vs. 54.0 +/- 4.1), vitality (VT) (55.5 +/- 2.5 vs. 44.9 +/- 3.4), and emotional role (ER) (74.9 +/- 5.0 vs. 51.4 +/- 6.7) (analysis of variance p < 0.05). Women following EVAR had decreased physical summary scores (PSS) (34.8 +/- 2.5 vs. 40.4 +/- 1.1, p < 0.05) compared with men postprocedure despite no difference preoperatively. Congestive heart failure (CHF) was an independent factor that negatively impacted PF, body pain (BP), and PSS. EVAR was associated with improved VT and ER. Differences among open repair and EVAR diminished over time. LOS (in days) was greater for open vs. EVAR (9.2 +/- 0.78 vs. 2.0 +/- 0.17) and in women following both open (11.8 +/- 1.5 vs. 8.0 +/- 0.9) and EVAR (3.2 +/- 0.9 vs. 1.8 +/- 0.1) procedures (p < 0.05). Factors that adversely affected LOS were open repair, age, renal insufficiency, pulmonary disease, CHF, and female gender. Following EVAR, patients were less likely to require home care or transfer to a rehabilitation facility than after open repair (14.1 vs. 36.0%, p < 0.05). Women were significantly more likely to require postdischarge care after open repair (48.7 vs. 30.1%) and EVAR (41.7 vs. 10.0%) (p < 0.05). Logistic regression identified female gender, open repair, advanced age, and pulmonary disease as independent predictors of need for postdischarge care. Those patients undergoing abdominal aortic aneurysm (AAA) repair by open technique (compared to EVAR) had significantly impaired functional health with regard to PF, VT, and ER in the first 3 months after surgery. CHF and hypertension also significantly impaired individual functional health scores. Of significance was that female gender was associated with increased LOS and increased utilization of postdischarge nursing and rehabilitation resources following both open and endovascular surgery for AAA.

[Post-operative cardiac rehabilitation programs for early returning to daily life activities: self-measurement of heart rate and blood pressure during staying at home trial].

BACKGROUND AND OBJECTIVES: Recently, early mobilization and discharge after cardiac surgery have been recommended. However, many patients are anxious about returning to daily life soon after undergoing heart operations. To resolve this problem, an individualized rehabilitation plan for each patient is important. Rehabilitation programs must estimate the level of cardiac function in daily life. This study evaluated self-measurements of heart rate and blood pressure during home-based exercise training. METHODS: Thirty-six patients, 28 men and 8 women (mean age 58 +/- 19 years) who underwent cardiac operations were enrolled in this study. None of the patients experienced postoperative complications. Changes in heart rate and blood pressure during daily activities at home were measured by the patients. This data was then used to plan individual rehabilitation programs. RESULTS: The blood pressure rose from 114 +/- 17 to 139 +/- 21 mmHg (mean increase of 25 +/- 15 mmHg) when the patients were asked to walk up and down a set of stairs. Thirteen patients (36%) exhibited an increase in blood pressure of 30 mmHg or more while ascending the stairs. The patients' blood pressure returned to its pre-exercise level after 5 min. The heart rate rose from 84 +/- 15 to 113 +/- 14 beats/min (mean increase of 29 +/- 8 beats/min) during the exercise. During the home-based training period, the maximum blood pressure was 133 +/- 22 mmHg, and the maximum heart rate was 97 +/- 13 beats/min. CONCLUSIONS: The patients were very careful during their trial outpatient period, as this was their first post-cardiac surgery experience. Consequently, the degree of exercise at home was even more mild than in hospital. Self-measurement of heart rate and blood pressure was feasible. By referring to these measurements, the patients were able to monitor and increase their level of exercise. This post-cardiac surgery rehabilitation program is helpful for early returning to daily life activities.

Audit of attendance rates for an infra-inguinal graft surveillance programme--how complete is your graft surveillance?

Much has been written on the subject of graft surveillance following infra-inguinal bypass graft surgery, but surprisingly little information exists on actual attendance rates for such programmes. The aim of this study was to calculate the attendance rate for graft surveillance at the vascular unit in Cheltenham. All patients who entered the graft surveillance programme following an infra-inguinal graft procedure over a 5-year period were included in the study. Partial and complete surveillance attendance rates were calculated for each year in the study period. Both rates were seen to rise over the 5-year period, from 31% to 78% and 0 to 38%, respectively. These attendance rates were much lower than were expected. Vascular units relying on such graft surveillance programmes should evaluate their own 'surveillance rates'.