Ascending Aorta Dissection Before 5.5 cm Diameter; "It Wasn't Raining When Noah Built the Ark".

INTRODUCTION: The aim of this study was to compare mean maximum ascending aortic diameter at the time of acute aortic dissection with the current surgical threshold for elective ascending aortic operations on non-syndromic thoracic aortic aneurysms. MATERIAL AND METHODS: All consecutive non-syndromic adult patients admitted for acute type A aortic dissection in a single tertiary centre were prospectively enrolled from April 2020 to March 2021. The primary endpoint was the difference between mean maximum aortic diameter at the time of dissection and the 5.5 cm threshold for elective repair. Secondary endpoints included 30-day/in-hospital mortality, aortic length and comparison with normal controls, length/height ratio index, "actual" preoperative Euroscore II and "predicted" Euroscore II if electively operated. RESULTS: Among 31 patients ageing 67.3±12.03 years on average, mean maximum aortic diameter at the time of dissection was 5.13±0.66 cm, significantly lower than the guidelines-derived surgical threshold of 5.5 cm (p=0.004). Mean aortic length was 11±1.47 cm, also significantly longer compared normal controls reported in the literature (p<0.001). The 30-day/in-hospital mortality was 35.5%. Mean length/height ratio index was 6.18±0.76 cm/m. Finally, mean "actual" preoperative Euroscore II was 10.43±4.07 which was significantly higher than the 1.47±0.57 "predicted" Euroscore II (p<0.05). CONCLUSIONS: The maximum aortic diameter at the time of acute type A aortic dissection of non-syndromic cases was significantly lower than the current recommendation for elective repair. Lowering of the current diameter-based surgical threshold of 5.5 cm may be profitable in terms of prevention, but further investigations should be undertaken. Length-based thresholds could also add to timely aortic dissection prevention.

Intraoperative accurate assessment of septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM).

Surgical restoration of the left ventricular outflow tract (LVOT) is necessary for patients suffering from hypertrophic obstructive cardiomyopathy (HOCM), when symptoms are present despite the administration of medical treatment. One point of great significance during the procedure is the evaluation of the LVOT gradient after completion of septal myectomy. Most physicians choose to measure this value by transesophageal echocardiography (TEE) in combination with the direct measurement with the use of needles inserted into the aorta and left ventricle. In this article, we present the implementation of a new technique to estimate the peak-to-peak pressure gradient between the left ventricle and the aorta intraoperatively using a single double lumen central venous catheter inserted through the antegrade cardioplegia cannulation site across the aortic valve into the left ventricle.

A Case of a Large Cephalic Vein Aneurysm.

Vein aneurysms represent a rare clinical entity with a wide range of clinical symptoms. We present a case of a 67-year-old male who presented with a large, bluish, easily compressible, soft tissue mass in the lateral side of his forearm, which was mildly tender and it had been worsening during the last year. A color duplex ultrasound revealed local venous dilatation of the cephalic vein, measuring 6.3 × 3.2 cm. The patient was operated under local anesthesia and the lesion was removed. Histology showed thinning of the inner and middle layers of the cephalic vein and incipient replacement of the outer layer by acellular fibrous tissue with progressive decrease of elastic, smooth muscle and collagen fibers of the inner and middle layers, compatible with an aneurysm of the cephalic vein. Large cephalic vein aneurysms might cause nerve compression and require surgical removal before permanent neurological defect occurs.

Endovascular stent grafting for ascending aorta diseases.

OBJECTIVE: Conventional open surgery encompassing cardiopulmonary bypass has been traditionally used for the treatment of ascending aorta diseases. However, more than one in five of these patients will be finally considered unfit for open repair. We conducted a systematic review and meta-analysis to investigate the role of thoracic endovascular aortic repair (TEVAR) for aortic diseases limited to the ascending aorta. METHODS: The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We investigated patients' baseline characteristics along with early (30 days/in-hospital stay) and late (beyond 30 days/in-hospital stay) outcomes after TEVAR limited to the ascending aorta and not involving the arch vessels. Separate analyses for case reports and case series were conducted, and pooled proportions with 95% confidence intervals (CIs) of outcome rates were calculated. RESULTS: Approximately 67% of the patients had a prior cardiac operation. TEVAR was performed mainly for acute or chronic Stanford type A dissection (49%) or pseudoaneurysm (28%). The device was usually delivered through the femoral artery (67%), and rapid ventricular pacing was used in nearly half of the patients. Technical success of the method was 95.5% (95% CI, 87.8-99.8). Among the early outcomes, conversion to open repair was 0.7% (95% CI, 0.1-4.8), whereas mortality was 2.9% (95% CI, 0.02-8.6). We estimated a pooled rate of 1.8% (95% CI, 0.1-7.0) for neurologic events (stroke or transient ischemic attack) and 0.8% (95% CI, 0.1-5.6) for myocardial infarction. Late endoleak was recorded in 16.4% (95% CI, 8.2-26.0), and 4.4% (95% CI, 0.1-12.4) of the population died in the postoperative period. Finally, reoperation was recorded in 8.9% (95% CI, 3.1-16.4) of the study sample. CONCLUSIONS: TEVAR in the ascending aorta seems to be safe and feasible for selected patients with various aortic diseases, although larger studies are required.

Perceval-S over time. Clinical outcomes after ten years of usage.

BACKGROUND: Perceval-S has become a reliable and commonly used option in surgical aortic valve replacement (AVR) since its first implantation in humans 15 years ago. Despite the fact that this aortic valve has been proven efficient enough in the short and mid-term period, there is still lack of evidence for the long-term outcomes. MATERIALS AND METHODS: This is an observational retrospective study in a high-volume cardiovascular center. Pertinent data were collected for all the patients in whom Perceval-S was implanted from 2013 to 2020. RESULTS: The total number of patients was 205 with a mean age 76.4 years. Mean survival time was 5.5 years (SE = 0.26). The overall survival probability of patients undergoing aortic valve replacement with Perceval-S at 6 months was 91.0% (Standard Error SE = 2.0%), at one year 88.4% (SE = 2.3%) and at 5-years 64.8% (SE = 4.4%). A detrimental cardiac event leading to death was the probable cause of death in 35 patients (55.6%). The initiation of Transcatheter Aortic Valve Replacement (TAVR) program in our center in 2017 was associated with a decline in the number of very high-risk patients treated with sutureless bioprosthesis. This fact is demonstrated by the significant shift towards lower surgical risk cases, as median Euroscore II was reduced from 5,550 in 2016 to 3,390 in 2020. Mini sternotomy was implemented in 79,5% of cases favoring less invasive approach. Low incidence of reinterventions, patient prosthesis mismatch and structural valve degeneration was detected. CONCLUSIONS: The survival rate after aortic valve replacement with implantation of Perceval-S is satisfactory in the long-term follow-up. Cases of bioprosthesis dysfunction were limited. Mini sternotomy was used in the majority of cases. TAVR initiation program impacted on the proportion of patients treated with Perceval-S with reduction of high-risk patients submitted to surgery.

Delayed simultaneous aortoesophageal and aortobronchial fistulae post thoracic endovascular aortic repair (TEVAR).

Aortoesophageal and aortobronchial fistulae after thoracic endovascular aortic repair (TEVAR) are rare and life-threatening conditions. No clear guidance exists in the literature for the optimal therapeutic management of such cases. This case demonstrates a delayed simultaneous aortoesophageal and aortobronchial fistulae treated conservatively with culture-guided antibiotic therapy and combined endovascular management.

Current issues on simultaneous TAVR (Transcatheter Aortic Valve Replacement) and EVAR (Endovascular Aneurysm Repair).

Simultaneous EVAR and TAVR is technically feasible and is a reliable option in high-risk patients.

Epicardial cardioverter defibrillator implantation due to post-fontan ventricular tachycardia.

Long-term survival of patients submitted to a Fontan procedure is reduced because of arrhythmias. Late post-Fontan ventricular tachycardia is extremely rare, but it can be fatal. Consequently, the implantation of an implantable cardioverter defibrillator may be required. The implantation of such a device after a Fontan operation can be rather difficult due to anatomic reasons that exclude transvenous approach. Epicardial ICD implantation is a treatment option for these patients. Transatrial approach, shock ICD coils placement in azygos vein or directly in the pericardium are possible alternatives. We hereby present a successful epicardial implantable cardioverter defibrillator implantation in a post-Fontan 39-year-old man suffering from ventricular tachycardia.

Oesophageal necrosis after thoracic endovascular aortic repair: a minimally invasive endovascular approach-a dramatic complication.

There are few cases in the literature reporting dysphagia caused by oesophageal compression by the aorta due to acute or chronic aortic pathology. This type of dysphagia is called dysphagia aortica. Thoracic endovascular aortic repair is nowadays the treatment of choice for anatomically suitable patients experiencing complicated Type B aortic dissection. Oesophageal necrosis is a rare but fatal complication following thoracic endovascular aortic repair. Extrinsic oesophageal compression by the thrombosed aneurysmal sac, a mediastinal haematoma or extensive thrombosis in the false lumen of a dissected aorta and acute vascular occlusion of the oesophageal supply are possible mechanisms. When oesophageal necrosis is suspected, endoscopic examination and computed tomography imaging should be performed repeatedly. Oesophagoscopy will confirm the diagnosis revealing a black, diffusely necrotic and ulcerated oesophageal mucosa. It is critical to intervene before full-thickness oesophageal wall necrosis and mediastinitis occur. Guidelines are absent because of the rarity of this complication. Moreover, lack of a large series does not permit the establishment of guidelines either. However, oesophagectomy of the impaired oesophagus is the only chance for survival. Unfortunately, survival rates are disappointing. Prevention and awareness is the cornerstone of success. Early endoscopic examination when oesophageal necrosis is suspected due to even minimal symptoms will detect this fatal menace on time.

Radiopaque preventive landmarks' placement during stentless bioprosthesis implantation.

BACKGROUND: In patients with aortic stenosis, bioprosthetic valves are increasingly used. Although their benefits, they are also presenting limitations, as their time-related degeneration. Reoperation which was, until a few years ago, the only treatment for this condition, carries a significant surgical risk, especially in patients with multiple comorbidities, so the benefit of less invasive technique enabling the implantation of aortic valve prosthesis [transcatheter aortic valve-in-surgical aortic valve (TAV-in-SAV)] by a percutaneous access is remarkably important. Eligible patients are judged by a heart team, and imaging plays a key role in this selection, focusing on correct identification of bioprosthetic aortic valves type and size, evaluation of patients at increased anatomical risk for coronary artery occlusion. Radiolucency of stentless bioprosthetic valves, represent a significant challenge. METHODS: Surgical aortic valve replacements (SAVRs) with a bioprosthesis were performed using a stentless valve with no radiopaque components (Solo Smart, Sorin). The chosen method, in order to evaluate the results of the operation, was computed tomography (CT) scanning (64-slice MDCT, Brilliance, Philips). The study consisted of a thin sliced contrast electrocardiograph (ECG) gated chest CT (1 systolic cardiac phase), trying to simulate the required assessment of aortic root and the radiopaque placed markers. RESULTS: As surgical implant technique varies and may impact the relationship of the prosthetic annulus to the coronary ostia, marking the aortic annulus during the operation in order to have some useful radiopaque landmarks, is a great assistance promoting better orientation and correct identification of the position of the bioprosthetic valve. Although the implantation of metallic vascular clips at the level of aortic annulus (in any commissure or in the middle of any cups) was considered, the decision was to position three metallic clips bellow the aortic annulus in the three stiches ligated during the solo valve implantation. CONCLUSIONS: We are suggesting the preventive implantation of radiopaque landmarks, during SAVRs using tissue valves which are lacking fixed anatomic markers, as a guide for a presumptive TAV-in-SAV procedure, keeping in mind that appropriate guidance is crucial and can prevent valve misplacement, coronary obstruction and other potentially lethal complications.

Factors associated with early cardiac complications following transcatheter aortic valve implantation with transapical approach.

PURPOSE: To estimate the incidence of postprocedural early cardiac complications among patients undergoing transcatheter aortic valve implantation, through transapical approach (TA-TAVI), and to identify factors independently associated with the occurrence of them. PATIENTS AND METHODS: A retrospective cohort study of 90 patients, who had undergone TA-TAVI in a tertiary hospital of Liverpool, UK, during a 5-year period (September 2008-October 2013), was conducted. Data on patient demographics, periprocedural characteristics and cardiac complications presented within 30-day post TA-TAVI were collected, retrospectively, using the hospital's electronic database. RESULTS: The overall 30-day incidence of cardiac complications was estimated at 18.9% (n=17/90). The rate of new onset of atrial fibrillation (AF), atrioventricular block requiring permanent pacemaker implantation, shockable cardiac arrest rhythm and cardiac tamponade was 11.1%, 3.3%, 2.2% and 2.2%, respectively. Bivariate analysis found that absence of preoperative AF (p=0.01), receiving of oral inotropes preprocedurally (p=0.01), intravenous inotropic support postprocedurally (p=0.01) and requirement for postprocedural tracheal intubation (p=0.001) were the main factors associated with increased probability for patient cardiac morbidity. CONCLUSION: It seems that patients with absence of AF and oral inotropic support preprocedurally and those with post TA-TAVI mechanical ventilatory and intravenous inotropic support have greater probability to develop cardiac complications. This knowledge allows the early identification of high-risk patients and supports clinicians to apply both preventive and therapeutic interventions for the optimum patient management and care. In addition, administrators could allocate the health care system resources effectively.

Perioperative neutrophil to lymphocyte ratio as a predictor of poor cardiac surgery patient outcomes.

PURPOSE: The purpose of the present study was to investigate the association between the perioperative neutrophil to lymphocyte ratio (NLR) and cardiac surgery patient outcomes. PATIENTS AND METHODS: A retrospective cohort study of 145 patients who underwent cardiac surgery in a tertiary hospital of Athens, Greece, from January to March 2015, was conducted. By using a structured short questionnaire, this study reviewed the electronic hospital database and the medical and nursing patient records for data collection purposes. The statistical significance was two-tailed, and p-values <0.05 were considered significant. The statistical analysis was performed with Mann-Whitney U test and Spearman's correlation coefficient, by using the Statistical Package for Social Sciences software (IBM SPSS 21.0 for Windows). RESULTS: The increased preoperative levels of NLR were associated with significantly higher mortality, both in-hospital (p=0.001) and 30-day (p=0.002), prolonged postoperative hospital length of stay (LOS), both in the cardiac intensive care unit (ICU) (p=0.002), and in-hospital (p=0.018), and likewise with delayed tracheal extubation (p≤0.001). Furthermore, patients with elevated NLR during the second postoperative day had significantly higher in-hospital mortality (p=0.018), increased incidence of pneumonia (p=0.022), higher probability of readmission to the ICU (p=0.002), prolonged ICU LOS (p≤0.001), and delayed tracheal extubation (p≤0.001). CONCLUSION: Increased perioperative NLR seems to be associated with significantly higher mortality and morbidity in cardiac surgery patients. At the same time, NLR is a significant and inexpensive biomarker for the early identification of patients at high risk for complications. In addition, NLR levels could lead clinicians to perform measures for the optimal therapeutic patient approach.

Predictors of length of stay and duration of tracheal intubation after transcatheter aortic valve implantation.

BACKGROUND: While short-term outcomes for patients undergoing transcatheter aortic valve implantation (TAVI) have long been studied, there is very little data on their predictors. We aimed to identify the predictors of outcomes, such as intensive care unit (ICU) and in-hospital length of stay (LOS), duration of postoperative intubation and in-hospital mortality, after TAVI procedures. METHODS: We conducted a retrospective cohort study of 162 consecutive patients with aortic valve disease, who were admitted to a tertiary hospital of Liverpool for TAVI, during a five-year period. The data was collected using of the hospital's structured database on November 2014. RESULTS: By using a multivariate analysis we found that any postoperative bleeding [odds ratio (OR) 2.71; 95% confidence interval (CI): 1.41-5.24] was the independent predictor of prolonged ICU-LOS, while older age (OR 1.11; 95% CI: 1.05-1.17) and transapical TAVI (OR 4.11; 95% CI: 1.94-8.71) were the predictors of prolonged in-hospital LOS. Additionally, patients treated with oral inotropic agents, preoperatively (OR 5.77; 95% CI: 2.21-15.01), non-diabetics (OR 3.07; 95% CI: 1.12-8.42) and those with any postoperative bleeding (OR 3.53; 95% CI: 1.68-7.43) had a significantly greater probability in remaining intubated postoperatively. The multivariate analysis did not reveal any predictor of in-hospital mortality. CONCLUSIONS: The above predictors permit the early identification of TAVI patients at high risk for longer hospitalization and increased mechanical ventilation. This piece of information is crucial for clinicians and administrators contributing to more efficient patient care planning and better allocation of healthcare resources.