Contemporary Analysis of Descending Thoracic and Thoracoabdominal Aneurysm Repair

Background— Endovascular repair of thoracic aneurysm has demonstrated low risks of mortality and spinal cord ischemia (SCI), but few large series have been published on endovascular thoracoabdominal aneurysm repair, and reports suffer from a lack of accurate comparison with similar open surgical procedures.

Methods and Results— A consecutive cohort of patients with thoracic and thoracoabdominal aneurysms treated electively with endovascular repair (ER) or surgical repair (SR) techniques between 2001 and 2006 were analyzed. The association between repair technique and SCI was evaluated with univariable analysis. Adjustments for potential confounders and for the propensity to receive ER or SR were also performed in multivariable analysis. A total of 724 patients (352 ER, 372 SR) underwent repair. The mean age was 67 years, and 65% were male. ER patients were on average 9 years older ( P <0.001), had more comorbid conditions, and more frequently had prior distal repair ( P <0.001) or underwent a type I or IV repair. SR patients more commonly had chronic dissection or required type II or type III repairs ( P <0.001). Mortality at 30 days (5.7% ER versus 8.3% SR, P =0.2) and 12 months (15.6% ER versus 15.9% SR, P =0.9) was similar. A borderline difference in SCI was found between repair techniques: 4.3% of ER and 7.5% of SR patients ( P =0.08) had SCI. In patients with ER, prior distal aortic operation was associated with the development of SCI in univariable analysis (odds ratio 4.1, 95% confidence interval 1.4 to 11.7). Multivariable analysis showed that the type of required repair (type I, II, III, or IV) was the primary factor associated with the development of SCI in ER and SR patients.

Conclusion— No significant difference in the incidence of mortality or SCI was found between ER and SR techniques. The strongest factor associated with SCI remains the extent of the disease. Further studies are indicated to compare ER with patients considered eligible for SR.

Mitral valve abnormalities in hypertrophic cardiomyopathy: echocardiographic features and surgical outcomes

BACKGROUND

Functional and intrinsic mitral valve (MV) abnormalities are common in hypertrophic cardiomyopathy (HCM); however, morphologic characteristics constituting indications for surgical intervention are incompletely defined. This study was conducted to define the echocardiographic features of MV pathology in patients with HCM and relate these to repairability of the MV, MV procedures performed, durability of repair, and survival.

METHODS

From 1986 to 2003, 851 patients with HCM underwent operation, and 115 had a concomitant MV procedure. Detailed analysis of their 784 transthoracic and transesophageal echocardiograms, performed intraoperatively and postoperatively, was conducted. Outcomes were assessed by cross-sectional follow-up.

RESULTS

Sixty-seven patients (58%) underwent MV repair, and 48 (42%) had MV replacement. The mean left ventricular outflow tract peak gradient was 70 +/- 50 mm Hg. Systolic anterior motion was present in 95%. Valve abnormalities were degenerative in 36 (31%), myxomatous in 23 (20%), papillary muscle in 23 (20%), restrictive chordal in 22 (19%), restrictive leaflet in 80 (70%), and long leaflet in 64 (56%). Patients undergoing MV repair had higher prevalence of long leaflets and degenerative MV pathology. The anterior mitral leaflet was 3.0 +/- 0.49 cm in the repair group vs 2.5 +/- 0.40 cm in the replacement group (p = 0.0001). MV replacement patients were older, more symptomatic, and had more renal dysfunction and lower hematocrits. By 3 years, 91% of patients with a repair were free of reoperation.

CONCLUSIONS

Intrinsic MV pathology is frequently observed in HCM patients with symptomatic obstruction who undergo myectomy. Echocardiography can identify MV features predictive of successful valve repair. Repair, although durable, is feasible in only about half of patients.