Aggressive progression of penetrating atheromatous ulcer of the descending thoracic aorta

The treatment of acute aortic pathologies continues to evolve with enhanced imaging capabilities. This case report highlights the rapid progression of penetrating atherosclerotic ulcer to pseudoaneurysm development and subsequent treatment with thoracic endovascular stent graft.

Endovascular abdominal aortic stent grafting in unrecognized Salmonella aortitis

Abdominal endovascular graft infection is a rare but life-threatening complication of endovascular repair that can be challenging to manage. This report delineates the progression of a unique set of events leading to Salmonella graft infection and investigates current treatment options.

Open heart surgery for removal of polymethylmethacrylate after percutaneous vertebroplasty

We describe a 73-year-old woman who had a right atrial-inferior vena caval thrombus and pulmonary thromboembolism develop after percutaneous vertebroplasty with methylmethacrylate. Our patient subsequently underwent open-heart surgery to effectively remove the bulk of the foreign material. This case illustrates the need for close monitoring of patients undergoing percutaneous vertebroplasty and emphasizes the importance of prompt diagnosis and treatment.

Endovascular repair of the descending thoracic aorta for penetrating atherosclerotic ulcer disease

The pathological variants of acute aortic syndromes include classic dissection, intramural hematomas, and penetrating atherosclerotic ulcers (PAUs). The subject of the appropriate management and treatment of PAUs continues to expand as this disease entity is increasingly identified. The application of thoracic endografting, or thoracic endovascular aortic repair (TEVAR), to treat these acute aortic pathologies is clearly evolving and the ultimate effectiveness and durability of thoracic endografting remains to be determined as clinical experience increases. The disease pathology of PAUs and the use of endovascular stent graft placement in PAU disease are closely examined in this manuscript.

Endovascular repair of the descending thoracic aorta for penetrating atherosclerotic ulcer disease

The pathological variants of acute aortic syndromes include classic dissection, intramural hematomas, and penetrating atherosclerotic ulcers (PAUs). The subject of the appropriate management and treatment of PAUs continues to expand as this disease entity is increasingly identified. The application of thoracic endografting, or thoracic endovascular aortic repair (TEVAR), to treat these acute aortic pathologies is clearly evolving and the ultimate effectiveness and durability of thoracic endografting remains to be determined as clinical experience increases. The disease pathology of PAUs and the use of endovascular stent graft placement in PAU disease are closely examined in this manuscript.

Circumferential Involvement of an Acute Type B Aortic Dissection: A Unique Case

A case of a 35-year-old woman with acute circumferential type B aortic dissection is presented. A review of the literature demonstrated that circumferential aortic dissection is limited to a small number of case reports and a small case series of type A lesions. This is the first report of a circumferential type B dissection. The case highlights the need to fully evaluate patients with acute aortic dissection and illustrates the unique data provided by transesophageal echocardiography and helical computed tomographic angiography.

Effectiveness of same day percutaneous coronary intervention followed by minimally invasive aortic valve replacement for aortic stenosis and moderate coronary disease ("hybrid approach")

In 2005, the investigators described a "hybrid" cardiovascular interventional strategy combining percutaneous coronary intervention (PCI) for coronary artery disease (CAD) followed by valve surgery for patients with urgent complex CAD and valve disease to reduce morbidity and mortality. This hybrid approach has been extended prospectively in elderly, high-risk patients with aortic stenosis scheduled for elective minimally invasive aortic valve replacement (MI-AVR) who, on preoperative coronary angiography, were found to have moderate CAD amenable to PCI. In this prospective, observational series, 18 patients (mean age 76 years) underwent elective hybrid MI-AVR with PCI from May 2003 to February 2006. Five patients had undergone previous coronary artery bypass grafting. Patients underwent coronary angiography the day of (n = 12) or evening before (n = 6) MI-AVR, and after identifying moderately severe CAD, all 18 underwent the implantation of drug-eluting stents to the affected coronary arteries, followed by MI-AVR. Although all patients received standard doses of antiplatelet medications, including acetylsalicylic acid (325 mg before PCI and 325 mg/day thereafter) and clopidogrel (300 mg after PCI, 75 mg/day thereafter for 90 days for the Cypher stent), there were no reoperations for bleeding; only 8 of 18 patients required postoperative blood transfusions. One patient died postoperatively from a colonic perforation, and there were no late mortalities after a mean follow-up of 19 months. In conclusion, this hybrid strategy has low morbidity and mortality and may be a new therapeutic option for older, high-risk patients with combined CAD and aortic valve disease.

Are Penetrating Aortic Ulcers Best Treated Using an Endovascular Approach?

BACKGROUND

Optimal treatment for penetrating aortic ulcers has yet to be determined. Although open surgical repair is an effective therapeutic option, less invasive alternatives such as endoluminal grafting are emerging as a potential adjunct for the treatment of penetrating aortic ulcers isolated to the descending thoracic aorta. We reviewed our cumulative experience with thoracic endografting for penetrating aortic ulcers of the descending thoracic aorta.

METHODS

Between March 2003 and September 2005, 21 patients with penetrating aortic ulcers of the descending thoracic aorta were treated with Gore TAG thoracic endoluminal stent-grafts as part of a single-center investigational device exemption protocol.

RESULTS

Mean patient age was 73 +/- 12 years, and 7 (33%) of 21 were men and 14 (67%) were women. Patients presented with both acute (<14 days; 16/21, 76.2%) and chronic symptoms (5/21, 23.8%). The endoluminal stent-graft was successfully delivered in all 21 patients. No endoleaks were detected at 30-days postprocedurally or in follow-up (mean follow-up, 14 +/- 18 months). The 30-day mortality was 0%, and overall mortality was 4.8% (1/21), which was unrelated to the endovascular intervention.

CONCLUSIONS

Endovascular therapy for penetrating aortic ulcers of the descending thoracic aorta is safe and feasible. The number of patients diagnosed with penetrating aortic ulcers is expected to increase as improved imaging systems are becoming more commonplace. As a result, new and safer treatment paradigms will become even more important in the treatment of aortic diseases. Compared with historical surgical results, endovascular therapy for penetrating aortic ulcers of the descending thoracic aorta appears to have less operative mortality and is as equally effective as open surgical repair. Long-term surveillance and continued investigation are warranted.

Endovascular Treatment of a Thoracic Aortic Pseudoaneurysm After Previous Open Repair

The use of endovascular stents to treat descending thoracic aortic pathologies is emerging as a less invasive therapy to treat high-risk patients. This case report describes the presentation of a patient with a pulsatile mass on her back. The patient's computed tomographic scan revealed the mass to be an extension of a large psuedoaneurysm from the site of a previous repair of her thoracic aorta for a dissecting aneurysm several years earlier. The psuedoaneurysm was successfully treated with an endovascular stent and the patient was discharged home on postoperative day 5.

Midterm Results of the Edge-to-Edge Technique for Complex Mitral Valve Repair

BACKGROUND

The edge-to-edge technique (E2E) has been advocated for the complex repair of myxomatous mitral valves. We compared outcomes of E2E performed in patients at risk for systolic anterior motion (SAM) versus outcomes in patients with residual mitral regurgitation (MR) after repair completion.

METHODS

A total of 1,612 patients had repair of myxomatous mitral valves between June 1997 and December 2003 at Brigham and Women's Hospital. The E2E was used in 72 (4.5%) patients. Fifty-two patients (52/72; group I) had E2E for persistent MR after complex repair. Twenty patients (20/72; group II) had E2E for high risk of post-repair SAM and left ventricular outflow tract obstruction. Mean age of the patients was 61 +/- 14 years; 47 were male, average New York Heart Association class at admission was 2.4 +/- 0.6, and mean left ventricular ejection fraction was 56 +/- 12%.

RESULTS

The operative mortality was zero. Immediate postoperative MR was significantly improved in all patients compared with the preoperative grade (p value < 0.0005). Mean follow-up was 388 days. In those in whom E2E was used for residual MR without SAM risk (group I), postoperative MR (> or = 2+) was detected in 15 of 52 patients at 6 months. In group II, SAM was completely eliminated and the mean MR grade in the immediate postoperative period was 0.5 +/- 0.7. There was no long-term recurrence of MR in group II.

CONCLUSIONS

This study suggests that E2E eliminates SAM and long-term MR in patients with pre-repair echocardiographic predictors of SAM. The E2E is not efficacious in preventing long-term recurrent MR if performed for residual MR after complex mitral repair.

Advances in the treatment of acute type A dissection: an integrated approach

BACKGROUND

Acute type A dissections require surgery to prevent death from proximal aortic rupture or malperfusion. Most series over the past decade have reported a death rate in the range of 15% to 30%. The objective of this study is to examine the effect of an integrated surgical approach on the treatment of acute type A dissections.

METHODS

From January 1994 to April 2002, 163 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion to replace the aortic arch; HCA established after 3 minutes of electroencephalographic silence in neuromonitored patients (60%) or after 45 minutes of cooling in patients who were not neuromonitored (40%); reinforcement of the residual arch tissue with a Teflon felt "neo-media;" cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension or replacement with a biological or mechanical valved conduit. When HCA times were greater than 50 minutes, antegrade cerebral perfusion is used. Since Februay 1999, BioGlue has been used as an anastomotic adjunct in the repair of type A dissections.

RESULTS

Mean age was 62 +/- 14 years, with 68% men and 15% with previous cardiac surgery. Seven percent of patients presented with a preoperative neurologic deficit, and 3% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9.8%. Excluding the patients with preoperative strokes (7%) and those with postoperative stroke (3%), the in-hospital death rate was 6.6%. In 6 patients, prompt changes in circulatory management consisting of switching cannulation sites or cross-clamp release with direct temporary aortic arch fenestration occurred when there were sudden changes in electroencephalogram during cooling.

CONCLUSIONS

A standardized approach to the treatment of acute type A dissections has improved outcomes. Our 55% mortality in patients with preoperative cerebral vascular accident (CVA) suggests that this group may be candidates for medical or delayed surgical treatment. Conversely, our 6.6% mortality rate for neurologically intact patients warrants aggressive and expeditious surgical intervention.

New paradigms and improved results for the surgical treatment of acute type A dissection

OBJECTIVE

To examine the effect of an integrated surgical approach to the treatment of acute type A dissections.

SUMMARY BACKGROUND DATA

Acute type A dissection requires surgery to prevent death from proximal aortic rupture or malperfusion. Most series of the past decade have reported a death rate in the range of 15% to 30%.

METHODS

From January 1994 to March 2001, 104 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP) to replace the aortic arch; HCA established after 5 minutes of electroencephalographic (EEG) silence in neuromonitored patients (66%) or after 45 minutes of cooling in patients who were not neuromonitored (34%); reinforcement of the residual arch tissue with a Teflon felt "neo-media"; cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension (78%) or replacement with a biologic or mechanical valved conduit (22%).

RESULTS

Mean age was 59 +/- 15 (range 22-86) years, with 71% men and 13% redo sternotomy after a previous cardiac procedure. Mean cardiopulmonary bypass time was 196 +/- 50 minutes. Mean HCA with RCP time was 42 +/- 12 minutes (range 19-84). Mean cardiac ischemic time was 140 +/- 45 minutes. Eleven percent of patients presented with a preoperative neurologic deficit, and 5% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9%. Excluding the patients who presented neurologically unresponsive or with ongoing cardiopulmonary resuscitation (n = 5), the death rate was 4%. In six patients adverse cerebral outcomes were potentially avoided when immediate surgical fenestration was prompted by a sudden change in the EEG during cooling. Forty-five percent of neuromonitored patients required greater than 30 minutes to achieve EEG silence.

CONCLUSION

The authors have shown that the surgical integration of sinus segment repair or aortic root replacement, the use of EEG monitoring, partial or total arch replacement using RCP, routine antegrade graft perfusion, and the uniform use of transesophageal echocardiography substantially decrease the death and complication rates of acute type A dissection repair.