Surgical exclusion of a saccular aneurysm within a patent ductus arteriosus in an adult patient with Ortner's syndrome

In adult the patent ductus arteriosus is a rare condition associated sometimes with lethal complications. We describe the case of a 44-year-old woman with a history of systemic lupus erythematosus admitted to our hospital with hoarseness and severe dyspnea. Clinical imaging examinations indicated a saccular aneurysm within a persistent ductus arteriosus with signs of impending rupture. Patient was not considered suitable for transcatheter closure and therefore she underwent open aortic repair. The procedure was uneventful and any significant complications occurred during postoperative course.

Contemporary Management Strategies for Chronic Type B Aortic Dissections: A Systematic Review

Background

Currently, the optimal management strategy for chronic type B aortic dissections (CBAD) is unknown. Therefore, we systematically reviewed the literature to compare results of open surgical repair (OSR), standard thoracic endovascular aortic repair (TEVAR) or branched and fenestrated TEVAR (BEVAR/FEVAR) for CBAD.

Methods

EMBASE and MEDLINE databases were searched for eligible studies between January 2000 and October 2015. Studies describing outcomes of OSR, TEVAR, B/FEVAR, or all, for CBAD patients initially treated with medical therapy, were included. Primary endpoints were early mortality, and one-year and five-year survival. Secondary endpoints included occurrence of complications. Furthermore, a Time until Treatment Equipoise (TUTE) graph was constructed.

Results

Thirty-five articles were selected for systematic review. A total of 1081 OSR patients, 1397 TEVAR patients and 61 B/FEVAR patients were identified. Early mortality ranged from 5.6% to 21.0% for OSR, 0.0% to 13.7% for TEVAR, and 0.0% to 9.7% for B/FEVAR. For OSR, one-year and five-year survival ranged 72.0%-92.0% and 53.0%-86.7%, respectively. For TEVAR, one-year survival was 82.9%-100.0% and five-year survival 70.0%-88.9%. For B/FEVAR only one-year survival was available, ranging between 76.4% and 100.0%. Most common postoperative complications included stroke (OSR 0.0%-13.3%, TEVAR 0.0%-11.8%), spinal cord ischemia (OSR 0.0%-16.4%, TEVAR 0.0%-12.5%, B/FEVAR 0.0%-12.9%) and acute renal failure (OSR 0.0%-33.3%, TEVAR 0.0%-34.4%, B/FEVAR 0.0%-3.2%). Most common long-term complications after OSR included aneurysm formation (5.8%-20.0%) and new type A dissection (1.7–2.2%). Early complications after TEVAR included retrograde dissection (0.0%-7.1%), malperfusion (1.3%–9.4%), cardiac complications (0.0%–5.9%) and rupture (0.5%–5.0%). Most common long-term complications after TEVAR were rupture (0.5%–7.1%), endoleaks (0.0%–15.8%) and cardiac complications (5.9%-7.1%). No short-term aortic rupture or malperfusion was observed after B/FEVAR. Long-term complications included malperfusion (6.5%) and endoleaks (0.0%-66.7%). Reintervention rates after OSR, TEVAR and B/FEVAR were 5.8%-29.0%, 4.3%-47.4% and 0.0%-53.3%, respectively. TUTE for OSR was 2.7 years, for TEVAR 9.9 months and for B/FEVAR 10.3 months.

Conclusion

We found a limited early survival benefit of standard TEVAR over OSR for CBAD. Complication rates after TEVAR are higher, but complications after OSR are usually more serious. Initial experiences with B/FEVAR show its feasibility, but long-term results are needed to compare it to OSR and standard TEVAR. We conclude that optimal treatment of CBAD remains debatable and merits a patient specific decision. TUTE seems a feasible and useful tool to better understand management outcomes of CBAD.

Standardized Protocol to Analyze Computed Tomography Imaging of Type B Aortic Dissections

Purpose: To propose a standard measuring protocol for type B aortic dissections so as to improve comparability between studies reporting aortic dimensions. Methods: Fifteen computed tomography (CT) scans of type B aortic dissections were measured with a standard protocol by 2 independent observers using postprocessing software. The following parameters were assessed: true, false, and total lumen diameter; true and false lumen volume; and entry tear size, location, and number. Diameters were measured in a perpendicular plane at 2, 10, and 20 cm from the left subclavian artery and 5 cm from the most distal renal artery. True lumen volume was assessed from the left subclavian artery to the aortic bifurcation, while the false lumen volume was from the start to end up to the aortic bifurcation. Entry tear location was assessed in relation to the left subclavian artery. Intra- and interobserver repeatability and agreement were evaluated using the Bland-Altman method, an a priori set of acceptable differences, and Lin’s concordance correlation coefficient (LCCC). Results: Intra- and interobserver mean differences for aortic diameter and true and false lumen volumes were generally within the limits of agreement and the a priori differences; the LCCC showed excellent agreement. Entry tear location, size, and number were difficult to measure in a repeatable manner, with inconsistent correlation coefficients, especially between the 2 observers. Conclusion: This protocol showed acceptable repeatability for aortic diameter and aortic volume measurements. Assessment of entry tears proved challenging and associated with less favorable results. Additionally, investigators are urged to be more transparent regarding the measurement methodology used in studies describing aortic dimensions.

A custom-made scalloped stentgraft to preserve left subclavian artery flow in descending thoracic aortic disease with a short neck

In thoracic stentgrafting, a short proximal landing zone may necessitate intentional occlusion of the left subclavian artery, which may lead to brain, spinal cord, and left arm malperfusion. A scalloped stentgraft is designed for adequate proximal sealing and preserving the left subclavian artery flow. We performed a systematic review, describe the required pre-operative planning and details of the perioperative technique used and report our own experience. In literature, only 29 patients were reported so far using a proximal scalloped stentgraft. Results show a high technical success rate and low complication rate. These results are comparable to the results from our own institution. From these first small series the scalloped thoracic endovascular aortic repair appears to be a safe and relatively simple solution for thoracic aortic disease involving the left subclavian artery.

"First experience with JenaValve™: a single-centre cohort"

Aims

Since the introduction of transcatheter aortic valve implantation (TAVI), newer generation and novel devices such as the retrievable JenaValve™ have been developed. We evaluated the procedural and 6-month results of our first experience with implantation of the JenaValve™.

Methods and results

From June 2012 to December 2013, 24 consecutive patients (mean age 80 ± 7 years, 42 % male) underwent an elective transapical TAVI with the JenaValve™. Device success was 88 %. The mortality rate was 4 % at 30 days and 31 % at 6 months. TAVI reduced the mean transvalvular gradient (44.2 ± 11.1 mmHg vs. 12.3 ± 4.3 mmHg, p < 0.001) and increased the mean aortic valve area (0.8 3 ± 0.23 to 1.70 ± 0.44 cm²). A mild paravalvular leakage (PVL) occurred in 4 patients (18 %) and a moderate PVL in 1 patient (4 %). Mean New York Heart Association Functional Class improved from 2.9 ± 0.5 to 2.0 ± 0.8 at 30 days.

Conclusion

TAVI using the JenaValve™ prosthesis seems adequate and safe in this first experience cohort.

Transcatheter mitral paravalvular leakage closure: A beautiful last resort

We describe a case of a 54-year-old patient with rheumatic heart valve disease who was treated with double valve replacement (both aortic and mitral) twice. Two months after the second operation she developed a severe mitral paravalvular leakage (PVL) leading to cardiogenic shock for which she was hospitalized in the intensive care unit. Multiple weaning efforts proved to be unsuccessful because of persistent hemodynamic instability caused by the severe PVL. Since re-redo cardiac surgery would have meant an unacceptable high peri-operative risk it was decided in the heart team to close the PVL by a transcatheter technique. This was done successfully and led to a spectacular hemodynamic improvement. Just 24 h after closure of the PVL she could be discharged from the intensive care unit and the day after the procedure she came walking into the echocardiography laboratory for an echocardiographic evaluation. This case demonstrates not only the feasibility of transcatheter closure of a PVL but also that this can be a true life-saving act. <Learning objective: This case emphasizes that refractory heart failure can be a hard indication for closure of a PVL given the fast and complete clinical recovery after closure of the defect. Furthermore, it demonstrates the feasibility and the efficacy of transcatheter PVL closure, even when multiple devices have to be used to close the leak properly avoiding the risks inherent to redo cardiac surgery.>.

Early and late outcome after aortic root replacement with a mechanical valve prosthesis in a series of 528 patients

BACKGROUND

Aortic root replacement with a mechanical valve prosthesis is a widely accepted surgical technique. This study aims to evaluate short-term and long-term outcomes of this approach and to identify predictors of 30-day mortality.

METHODS

We retrospectively analyzed a consecutive series of 528 patients (mean age, 54±13 years) who underwent aortic root replacement for aneurysm (83%), acute type A dissection (15%), or endocarditis (2%) in the period between 1974 and 2008. The mean time of follow-up was 9.0±7.0 years (range, 0 to 36 years). Concomitant aortic surgery was performed in 71%, coronary revascularization in 18%, and mitral valve surgery in 3%. Selective antegrade cerebral perfusion was applied in 25% and deep hypothermic circulatory arrest in 28% of patients.

RESULTS

Overall 30-day mortality was 3.2% to 2.5% for elective surgery and 6.5% for urgent surgery. Morbidity included resternotomy for bleeding or tamponade (19%), pacemaker implantation (3.6%), myocardial infarction (4.0%), and neurologic damage (4.2%). Multivariate analysis revealed myocardial infarction (p<0.001) and the lack of glue use (p=0.018) as independent predictors of 30-day mortality. Subanalysis of the selective antegrade cerebral perfusion patients and the deep hypothermic circulatory arrest patients revealed infarction (p=0.005) and coronary artery disease (p=0.45) for selective antegrade cerebral perfusion and wrapping (p=0.035) for deep hypothermic circulatory arrest as independent risk factors. The survival rate was 87%, 73%, and 29% after 5, 10, and 25 years, respectively.

CONCLUSIONS

Aortic root replacement with a mechanical valve prosthesis can be performed safely with low mortality and acceptable morbidity. Perioperative myocardial infarction is the strongest independent risk factor of 30-day mortality.