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Yang S, Zhang YY, Zi YF, Pu L, Qian X, Ren L, Li YB, Jin ZH, Liu JF, Yuan Z, Li YX. Cabrol procedure and its modifications: a systematic review and meta-analysis. J Cardiothorac Surg 2024; 19:153. [PMID: 38532449 DOI: 10.1186/s13019-024-02642-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 03/11/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND The Cabrol procedure has undergone various modifications and developments since its invention. However, there is a notable gap in the literature regarding meta-analyses assessing it. METHODS A systematic review and meta-analysis was conducted to evaluate the effectiveness and long-term outcomes of the Cabrol procedure and its modifications. Pooling was conducted using random effects model. Outcome events were reported as linearized occurrence rates (percentage per patient-year) with 95% confidence intervals. RESULTS A total of 14 studies involving 833 patients (mean age: 50.8 years; 68.0% male) were included in this meta-analysis. The pooled all-cause early mortality was 9.0% (66 patients), and the combined rate of reoperation due to bleeding was 4.9% (17 patients). During the average 4.4-year follow-up (3,727.3 patient-years), the annual occurrence rates (linearized) for complications were as follows: 3.63% (2.79-4.73) for late mortality, 0.64% (0.35-1.16) for aortic root reoperation, 0.57% (0.25-1.31) for hemorrhage events, 0.66% (0.16-2.74) for thromboembolism, 0.60% (0.29-1.26) for endocarditis, 2.32% (1.04-5.16) for major valve-related adverse events, and 0.58% (0.34-1.00) for Cabrol-related coronary graft complications. CONCLUSION This systematic review provides evidence that the outcomes of the Cabrol procedure and its modifications are acceptable in terms of mortality, reoperation, anticoagulation, and valve-related complications, especially in Cabrol-related coronary graft complications. Notably, the majority of Cabrol procedures were performed in reoperations and complex cases. Furthermore, the design and anastomosis of the Dacron interposition graft for coronary reimplantation, considering natural anatomy and physiological hemodynamics, may promise future advancements in this field.
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Affiliation(s)
- Sen Yang
- Department of Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Ya-Yong Zhang
- Department of Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Yun-Feng Zi
- Department of Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Lei Pu
- Department of Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xu Qian
- Department of Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Le Ren
- Department of Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Yong-Bo Li
- Department of Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Zhi-Hao Jin
- Department of Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Jian-Feng Liu
- Department of Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Zhuo Yuan
- Department of Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Ya-Xiong Li
- Department of Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China.
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China.
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Lu Q, Lin W, Zhang R, Chen R, Wei X, Li T, Du Z, Xie Z, Yu Z, Xie X, Liu H. Validation and Diagnostic Performance of a CFD-Based Non-invasive Method for the Diagnosis of Aortic Coarctation. Front Neuroinform 2020; 14:613666. [PMID: 33362500 PMCID: PMC7756015 DOI: 10.3389/fninf.2020.613666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 11/13/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose: The clinical diagnosis of aorta coarctation (CoA) constitutes a challenge, which is usually tackled by applying the peak systolic pressure gradient (PSPG) method. Recent advances in computational fluid dynamics (CFD) have suggested that multi-detector computed tomography angiography (MDCTA)-based CFD can serve as a non-invasive PSPG measurement. The aim of this study was to validate a new CFD method that does not require any medical examination data other than MDCTA images for the diagnosis of CoA. Materials and methods: Our study included 65 pediatric patients (38 with CoA, and 27 without CoA). All patients underwent cardiac catheterization to confirm if they were suffering from CoA or any other congenital heart disease (CHD). A series of boundary conditions were specified and the simulated results were combined to obtain a stenosis pressure-flow curve. Subsequently, we built a prediction model and evaluated its predictive performance by considering the AUC of the ROC by 5-fold cross-validation. Results: The proposed MDCTA-based CFD method exhibited a good predictive performance in both the training and test sets (average AUC: 0.948 vs. 0.958; average accuracies: 0.881 vs. 0.877). It also had a higher predictive accuracy compared with the non-invasive criteria presented in the European Society of Cardiology (ESC) guidelines (average accuracies: 0.877 vs. 0.539). Conclusion: The new non-invasive CFD-based method presented in this work is a promising approach for the accurate diagnosis of CoA, and will likely benefit clinical decision-making.
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Affiliation(s)
- Qiyang Lu
- College of Automation Science and Technology, South China University of Technology, Guangzhou, China.,Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Weiyuan Lin
- College of Automation Science and Technology, South China University of Technology, Guangzhou, China.,Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ruichen Zhang
- Department of Information Engineering, Northwestern Polytechnical University, Xi'an, China
| | - Rui Chen
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiaoyu Wei
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Tingyu Li
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhicheng Du
- Guangdong Key Laboratory of Medicine, Department of Medical Statistics and Epidemiology, Health Information Research Center, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Zhaofeng Xie
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhuliang Yu
- College of Automation Science and Technology, South China University of Technology, Guangzhou, China.,School of Medicine, South China University of Technology, Guangzhou, China
| | - Xinzhou Xie
- Department of Information Engineering, Northwestern Polytechnical University, Xi'an, China
| | - Hui Liu
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Medicine, South China University of Technology, Guangzhou, China
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Myocardial ischemia 10 years after a modified Cabrol procedure in a 42-year-old patient with Marfan syndrome. BMC Cardiovasc Disord 2020; 20:461. [PMID: 33109088 PMCID: PMC7590664 DOI: 10.1186/s12872-020-01740-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/12/2020] [Indexed: 11/10/2022] Open
Abstract
Background Marfan syndrome, a genetic disorder of the connective tissue, may cause aortic root dilation with aortic insufficiency, aortic dissection and mitral prolapse with mitral insufficiency. We present a case of a late complication of the modified Cabrol procedure that included replacing the ascending aorta with a composite graft. Case presentation In February 2019, a 42-year-old female patient with Marfan syndrome who presented with chest pain was sent to the Emergency Department. She had undergone the modified Cabrol procedure 10 years prior. Upon presenting, laboratory analysis revealed elevated troponin-I levels. Electrocardiogram showed new inverted T waves over lead I, aVL and V4 to V6. Contrast computed tomography (CT) revealed thrombosis in the Dacron graft. Percutaneous coronary angiography was conducted, and a large thrombus in the graft was noted. Thrombolytic therapy and percutaneous coronary intervention were performed, after which the patient had no more symptoms and was discharged without complications. Conclusions Aortic root surgery, including the Cabrol or modified Cabrol procedure, is necessary for complicated cases of aortic dilations, such as in patients with Marfan syndrome, even though the Cabrol or modified Cabrol procedure has a high complication rate. Regarding this case, we were surprised by the timing of the myocardial ischemia and the position of the thrombus, which differed from other cases. To better manage such a patient’s condition and to detect the formation of thrombus early, completeness of the graft and possible stenosis of the anastomosis site to avoid preventable myocardial ischemia, we suggest that patients should have regular image follow-up, even years after the Cabrol or modified Cabrol procedure.
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Fukuda K. Percutaneous intervention for an occluded left Cabrol graft. J Cardiol Cases 2019; 20:205-208. [PMID: 31762834 DOI: 10.1016/j.jccase.2019.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/03/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022] Open
Abstract
Percutaneous intervention for surgical reconstruction of a coronary artery is a challenging and complex procedure for interventional cardiologists. Particularly in settings of acute coronary syndrome, urgent revascularization may be critical for the prognosis of patients. Therefore, it is important that physicians have knowledge of various surgical techniques for coronary reconstruction. The Cabrol procedure is one of the surgical techniques after aortic root replacement, but it is rarely used at present. Here we describe a case of successful percutaneous revascularization for an occluded left Cabrol graft in acute ST-elevation myocardial infarction with cardiogenic shock. <Learning objective: Percutaneous intervention for surgical reconstruction of coronary artery is challenging. In coronary artery reconstruction, computed tomography angiography might be extremely useful. We describe a case of successful percutaneous revascularization for the occluded left Cabrol graft.>.
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Affiliation(s)
- Keisuke Fukuda
- Department of Cardiology, Kishiwada Tokushukai Hospital, 4-27-1 Kamori, Kishiwada, Osaka, 596-0042, Japan
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Schulman-Marcus J, Cochran-Caggiano N, El-Hajjar M, Singh C. An acutely occluded Cabrol graft presenting as an acute coronary syndrome. BMJ Case Rep 2019; 12:12/7/e229793. [PMID: 31340947 DOI: 10.1136/bcr-2019-229793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The Cabrol technique employs a synthetic graft to connect the coronary arteries to an aortic graft in patients with complex disease of the ascending aorta. Acute Cabrol graft thrombosis is a life-threatening situation that presents as acute coronary syndrome, as it leads to acute coronary hypoperfusion. We present a patient with unstable anginal symptoms who had undergone aortic surgery 6 months prior to presentation. Cardiac catheterisation was concerning for aortic dissection yet was later revealed to be acute occlusion of a Cabrol graft. The patient ultimately died of cardiogenic shock. We review the Cabrol technique, complications and management of acute graft thrombosis.
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Affiliation(s)
| | | | | | - Chanderdeep Singh
- Division of Cardiothoracic Surgery, Albany Medical College, Albany, NY, USA
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Dagenais F. What if "Cabrol" Lost Half of Its Mustache? Semin Thorac Cardiovasc Surg 2018; 31:207-208. [PMID: 30423372 DOI: 10.1053/j.semtcvs.2018.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 11/02/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Francois Dagenais
- Department of Cardiac Surgery, Institut Universitaire de Cardiology et Pneumologie de Québec, Québec, Canada.
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Cheng YT, Leb JS, Bloom M, Melehy AN, Sanchez JE, Polanco A, George I, Takayama H. Use Side Branch of the Aortic Graft to Facilitate Coronary Reconstruction During Complex Aortic Surgery. Semin Thorac Cardiovasc Surg 2018; 31:201-206. [PMID: 30292905 DOI: 10.1053/j.semtcvs.2018.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 09/26/2018] [Indexed: 11/11/2022]
Abstract
The interposition graft could be used for difficult coronary reconstruction during aortic root replacement. We introduced a new technique that utilizes side branch of an aortic graft to facilitate coronary reconstruction. The present study describes this technique and its outcomes. We retrospectively reviewed 234 patient charts of those who underwent aortic root replacement between January 2013 and November 2017. Within this group, 6 patients required coronary reconstruction with branches of aortic graft and were included in this study. All patients were reoperative cases, 3 of which were for acute type A aortic dissection. The mean cardiopulmonary and aortic cross clamp times were 317.2 ± 35.1 minutes and 153.3 ± 75.4 minutes, respectively. All patients survived to discharge with a median hospital stay of 20.5 days (interquartile range: 13.75-27.75). During a median follow-up of 221 days (interquartile range: 197.78-1208), no patients experienced major adverse cardiovascular events. Four patients underwent radiographic follow-up, which confirmed patent interposition grafts (5/5). The use of branches from the aortic graft for coronary reconstruction is feasible with satisfactory outcomes.
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Affiliation(s)
- Yi-Tso Cheng
- Department of Surgery, Buddhist Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan
| | - Jay S Leb
- Department of Radiology, Columbia University Medical Center, New York, New York
| | - Michael Bloom
- Department of Radiology, Columbia University Medical Center, New York, New York
| | - Andrew N Melehy
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Joseph E Sanchez
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Antonio Polanco
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Isaac George
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Hiroo Takayama
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York.
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Calcaterra D, Jazayeri MA, Turek JW, Parekh KR, Bashir M, Karam K, Farivar RS. Aortic Root Reconstruction with a New Dacron Graft Featuring Prefabricated Coronary Side Branches: Lessons Learned from the Cabrol Procedure. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2017; 5:1-10. [PMID: 28868309 DOI: 10.12945/j.aorta.2017.16.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 10/24/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Coronary button reimplantation can represent a technical challenge of aortic root reconstruction that can be associated with significant morbidity and mortality. With the goal of simplifying coronary reimplantation and reducing the incidence of related complications, we designed a new Dacron graft with prefabricated coronary branches to minimize coronary artery mobilization and prevent the potential mechanical complications of reattachment to the body of the graft. METHODS Between June 2010 and May 2012, we implanted the graft in eight patients (six males, two females) ranging in age from 42-68 years (mean, 54 years). Six procedures were modified Bentall reconstructions, and two procedures were valve-sparing root replacements using the reimplantation technique. RESULTS There were no complications and no morbidity or mortality related to coronary reattachment. All patients were alive and doing well at a mean follow-up of 26 months (range, 17-38 months). At an extended mean follow-up of 42 months (range, 25-56 months), one patient died of stroke-related complications. No radiologic or clinical evidence of impairment of coronary perfusion was identified in any patient. CONCLUSIONS The use of this new graft model may simplify the technique of root reconstruction and potentially lower the incidence of mechanical complications related to coronary button reimplantation.
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Affiliation(s)
- Domenico Calcaterra
- Minneapolis Heart Institute Cardiothoracic Surgery, Abbott Northwestern Hospital, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Mohammad-Ali Jazayeri
- Minneapolis Heart Institute Cardiothoracic Surgery, Abbott Northwestern Hospital, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Joseph W Turek
- Department of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Kalpaj R Parekh
- Department of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Mohammad Bashir
- Department of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Karam Karam
- Department of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Robert S Farivar
- Minneapolis Heart Institute Cardiothoracic Surgery, Abbott Northwestern Hospital, Hennepin County Medical Center, Minneapolis, Minnesota, USA
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Díaz R, Hernandez-Vaquero D, Álvarez-Cabo R, Pascual I, Corros C, Alperi A, Rozado J, Silva J, Morís C. Double pseudoaneurysm, recurrent subvalvular aortic membrane and small left ventricular outflow tract in the same patient: who dares? J Thorac Dis 2017; 9:S547-S550. [PMID: 28616353 DOI: 10.21037/jtd.2017.05.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patients with pseudoaneurysm in the left ventricular outflow tract (LVOT) commonly present vague and nonspecific symptoms making the diagnosis difficult. We present the case of a 37-year-old patient with two subvalvular pseudoaneurysms in whom a combined resection surgery, enlargement of the LVOT, aortic valve replacement (AVR) and aortic root replacement were performed using the technique of Cabrol.
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Affiliation(s)
- Rocío Díaz
- Heart Area, Central University Hospital of Asturias, Oviedo, Spain
| | | | | | - Isaac Pascual
- Heart Area, Central University Hospital of Asturias, Oviedo, Spain
| | - Cecilia Corros
- Heart Area, Central University Hospital of Asturias, Oviedo, Spain
| | - Alberto Alperi
- Heart Area, Central University Hospital of Asturias, Oviedo, Spain
| | - Jose Rozado
- Heart Area, Central University Hospital of Asturias, Oviedo, Spain
| | - Jacobo Silva
- Heart Area, Central University Hospital of Asturias, Oviedo, Spain.,University of Oviedo, Oviedo, Spain
| | - César Morís
- Heart Area, Central University Hospital of Asturias, Oviedo, Spain.,University of Oviedo, Oviedo, Spain
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Reconstruction of Intima and Adventitia Models into a State Undeformed by a Catheter by Using CT, IVUS, and Biplane X-Ray Angiogram Images. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2017; 2017:9807617. [PMID: 28154609 PMCID: PMC5244750 DOI: 10.1155/2017/9807617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 12/06/2016] [Indexed: 11/17/2022]
Abstract
The number of studies on blood flow analysis using fluid-structure interaction (FSI) analysis is increasing. Though a 3D blood vessel model that includes intima and adventitia is required for FSI analysis, there are difficulties in generating it using only one type of medical imaging. In this paper, we propose a 3D modeling method for accurate FSI analysis. An intravascular ultrasound (IVUS) image is used with biplane X-ray angiogram images to calculate the position and orientation of the blood vessel. However, these images show that the blood vessel is deformed by the catheter inserted into the blood vessel for IVUS imaging. To eliminate such deformation, a CT image was added and the two models were registered. First, a 3D model of the undeformed intima was generated using a CT image. In the second stage, a model of intima and adventitia deformed by the catheter was generated by combining the IVUS image and the X-ray angiogram images. A 3D model of intima and adventitia with the deformation caused by insertion of the catheter eliminated was generated by matching these 3D blood vessel models in different states. In addition, a 3D blood vessel model including bifurcation was generated using the proposed method.
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Chiu P, Miller DC. Evolution of surgical therapy for Stanford acute type A aortic dissection. Ann Cardiothorac Surg 2016; 5:275-95. [PMID: 27563541 DOI: 10.21037/acs.2016.05.05] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small? The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results.
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Affiliation(s)
- Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, CA, USA
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, CA, USA
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12
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Di Marco L, Pacini D, Pantaleo A, Leone A, Barberio G, Marinelli G, Di Bartolomeo R. Composite valve graft implantation for the treatment of aortic valve and root disease: Results in 1045 patients. J Thorac Cardiovasc Surg 2016; 152:1041-1048.e1. [PMID: 27312787 DOI: 10.1016/j.jtcvs.2016.05.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 04/20/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Aortic root replacement using a composite graft is the treatment of choice for a large variety of aortic root conditions with a diseased aortic valve. The objective of the current study was to evaluate the long-term results of this procedure. METHODS Between 1978 and 2010, 1045 patients aged 58.7 ± 13.6 years underwent aortic root composite graft replacement using the following techniques: 95 Bentall operation; 926 the "button technique;" 24 the Cabrol technique. A mechanical composite valve graft was implanted in 69.6% of the patients. Six-hundred and thirty-five patients (62.3%) had annuloaortic ectasia and 162 (15.5%) had aortic dissection. RESULTS Early mortality was 5.3% (55/1045). Independent risk factors for early mortality at logistic regression analysis were age ≥70 years (P = .051; odds ratio [OR], 2.97), New York Heart Association III-IV (P = .052; OR, 1.88), reoperation (P = .021; OR, 2.36), urgency/emergency (P = .003; OR, 3.09), mitral valve replacement (P = .001; OR, 6.01), or coronary artery bypass grafting (CABG) (P < .001; OR, 4.39); while bicuspid aortic valve (BAV) (P = .013; OR, 0.21), and time of operation 2001-2011 (P = .025; OR, 0.60) were protective predictors for early mortality. Overall survival at 5, 10, and 20 years was 84.1% ± 1.3%, 65.5% ± 2.6%, and 40.7% ± 4.6%, respectively. Multivariate analysis revealed chronic renal insufficiency (P = .001; hazard ratio [HR], 3.48), chronic obstructive pulmonary disease (P = .027; HR, 1.94), aortic dissection (P = .001; HR, 2.63), Cabrol technique (P = .009; HR, 15.34), and CABG (P = .016; HR, 2.02) to be significant predictors of late death, and BAV (P = .010; HR, 0.43) to be a significant protective predictor. Freedom from thromboembolism, bleeding complications, and endocarditis was 93.7% ± 2.6%, 90.3% ± 3.1%, and 98.4% ± 1% at 20 years, respectively. Freedom from aortic reoperation was 91.8% ± 2.1% at 20 years and was significantly lower in patients with aortic dissection. CONCLUSIONS Within the limitations of this retrospective study, we can conclude that aortic root replacement for aortic root aneurysms can be performed with low morbidity and mortality and with satisfactory long-term results. Few late serious complications were related to the need for long-term anticoagulation or a prosthetic valve. Reoperation on the proximal or in the distal aorta was most commonly performed in patients with aortic dissection.
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Affiliation(s)
- Luca Di Marco
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Davide Pacini
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonio Pantaleo
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Leone
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Barberio
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Marinelli
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Roberto Di Bartolomeo
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Poullis M, Pullan M. Mechanism of failure of the Cabrol procedure: A computational fluid dynamic analysis. Med Hypotheses 2015; 85:774-8. [DOI: 10.1016/j.mehy.2015.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 10/06/2015] [Accepted: 10/11/2015] [Indexed: 10/22/2022]
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Calcaterra D, Farivar RS, Parekh KR, Bashir M, Karam K, Turek JW. Technique of Aortic Root Reconstruction Using a New Model of Dacron Graft with Prefabricated Coronary Branches. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014; 9:451-3. [DOI: 10.1177/155698451400900611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aortic root reconstruction is a demanding surgical procedure still associated with a significant morbidity. Arguably, the most demanding aspect of the operation is reestablishing continuity between the prosthetic graft replacing the aortic root and the coronary arteries. With the objective of simplifying the possible challenges of coronary reimplantation, we designed a new model of aortic root graft with prefabricated coronary branches. We used this technique in 8 patients (6 males, 2 females; mean age, 54 years). There were 6 modified Bentall procedures and 2 valve-sparing root replacements with the “reimplantation” technique. There was no mortality or morbidity related to the use of this new prosthetic graft. Our purpose was to report in detail the technique of aortic root reconstruction using this new graft with prefabricated coronary branches. The use of this graft may simplify the procedure and offer a valuable tool for aortic root reconstruction in cases where the reimplantation of the coronary buttons may represent a technical challenge.
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Affiliation(s)
- Domenico Calcaterra
- Abbott Northwestern Hospital Cardiothoracic Surgery, Minneapolis Heart Institute, Minneapolis, MN USA
| | - Robert S. Farivar
- Abbott Northwestern Hospital Cardiothoracic Surgery, Minneapolis Heart Institute, Minneapolis, MN USA
| | - Kalpaj R. Parekh
- Department of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA USA
| | - Mohammad Bashir
- Department of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA USA
| | - Karam Karam
- Department of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA USA
| | - Joseph W. Turek
- Department of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA USA
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Midterm experience with modified Cabrol procedure: safe and durable for complex aortic root replacement. J Thorac Cardiovasc Surg 2013; 147:1233-9. [PMID: 23628496 DOI: 10.1016/j.jtcvs.2013.03.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 02/25/2013] [Accepted: 03/14/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the early and late outcomes of the modified Cabrol technique as a method of coronary reimplantation during complex composite graft replacement of the ascending aorta. METHODS Between 1995 and 2012, 348 patients (mean age, 56 ± 14 years; 283 males and 65 females) underwent composite graft replacement of the ascending aorta, 40 of whom (mean age, 60 ± 12 years; 35 males and 5 females) had one or both coronary ostia reimplanted using a modified Cabrol technique with an 8- to 10-mm Dacron interposition graft. The mean clinical and radiologic (computed tomographic scan) postoperative follow-up was 39 months (range, 1-171 months), via our aortic database, patient interviews, and Social Security Death Index. RESULTS Cabrol reimplantation was necessitated by reoperations with anatomically fixed coronary ostia (n = 16, 40%), severely displaced coronary arteries (n = 15, 37.5%), button calcification (n = 4, 10%), coronary anomalies (n = 3, 7.5%), and coronary aneurysm (n = 2, 5%). Of the operations, 20% (8 patients) were urgent interventions. Early mortality was 3 (7.5%) of 40, none related to the Dacron interposition graft. Total late mortality was 16.2%, also not related to the coronary graft. Actuarial survivals were 0.88 ± 0.05, 0.79 ± 0.07, and 0.73 ± 0.08 at 1, 3, and 6 years, respectively. Radiologic follow-up was available for 31 (83.8%) of the surviving patients and revealed that the interposition graft was widely patent in all. CONCLUSIONS The modified Cabrol technique using a Dacron interposition graft showed good survival rates and excellent durability over time, confirmed radiographically. These data confirm that it is appropriate to use the Cabrol technique when technical complexity prevents bringing coronary buttons to the main aortic graft.
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Di Bartolomeo R, Berretta P, Petridis FD, Folesani G, Cefarelli M, Di Marco L, Di Eusanio M. Reoperative surgery on the thoracic aorta. J Thorac Cardiovasc Surg 2013; 145:S78-84. [DOI: 10.1016/j.jtcvs.2012.11.055] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 08/13/2012] [Accepted: 11/28/2012] [Indexed: 10/27/2022]
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Tamura K, Arai H, Kawaguchi S, Makita S, Miyagi N, Watanabe T, Fujiwara T. Long-Term Results of Modified Bentall Procedure Using Flanged Composite Aortic Prosthesis. Ann Thorac Cardiovasc Surg 2013; 19:126-30. [DOI: 10.5761/atcs.oa.12.01943] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ryou HS, Kim S, Kim SW, Cho SW. Construction of healthy arteries using computed tomography and virtual histology intravascular ultrasound. J Biomech 2012; 45:1612-8. [DOI: 10.1016/j.jbiomech.2012.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 04/02/2012] [Accepted: 04/04/2012] [Indexed: 11/27/2022]
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Senanayake EL, Cooper GJ. Indirect re-implantation of the left coronary artery during aortic surgery. J Card Surg 2012; 27:205-10. [PMID: 22458276 DOI: 10.1111/j.1540-8191.2012.01421.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Indirect re-implantation of the left coronary artery (LCA) via an interposition graft simplifies difficult LCA re-implantation during aortic root replacement. Little information exists regarding the results of this technique. In this study, we report our experience. METHODS Between January 2001 and July 2008, of 82 aortic root replacements, 24 (mean age 48.2 years, 83% male) used the indirect re-implantation technique. All case notes were retrospectively analyzed. Indications for operation were; aortic root aneurysm (n = 16), acute dissection (n = 6), existent homograft calcification (n = 1), failed Ross procedure (n = 1). Reasons for indirect re-implantation were: difficult LCA mobilization secondary to previous cardiac surgery (n = 7), short left main stem (n = 6), acute dissection (n = 6), adherence to surrounding tissues (n = 5). All patients had yearly CT or MRI follow-up. RESULTS Mechanical and tissue valved conduits were implanted in 22 and two patients, respectively. Ten millimeters (n = 17) or 8 mm (n = 7) Dacron grafts were used for LCA re-implantation. Thirty-day mortality was 12.5%. Postoperative complications were: re-opening for bleeding (n = 2), pericardial effusion (n = 4), renal failure (n = 1). Over a median follow-up of 26 months (range 4 to 81), one developed a false aneurysm at the right coronary artery anastomosis five months postoperatively, which was subsequently repaired. All interposition grafts remained patent on MRI or CT. There were six late deaths. At median follow-up survival rate was 71%. CONCLUSIONS The indirect re-implantation of the LCA during aortic root replacements is a reliable, safe, and effective method in dealing with the LCA in difficult circumstances. Survival at 26 months is equivalent to other series of similar patients.
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Affiliation(s)
- Eshan L Senanayake
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, United Kingdom
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Kitamura T, Kigawa I, Fukuda S, Miyairi T, Takamoto S. Long term results with the Cabrol aortic root replacement. Int Heart J 2011; 52:229-32. [PMID: 21828949 DOI: 10.1536/ihj.52.229] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cabrol aortic root replacement is rarely performed in recent years because of potential coronary complications. The purpose of this study was to investigate its early and late results, including coronary complications, by evaluating our experience thus far. A retrospective lookup of patients who underwent Cabrol aortic root replacement between 1988 and 2001 found a total of 36 patients (24 men and 12 women) with a mean age of 45 years. Annuloaortic ectasia was the most frequent cause (n = 22), followed by chronic dissection (n = 5), acute dissection (n = 5), and aneurysm with prior aortic operation (n = 4). Early mortality occurred in one patient (2.8%). The mean follow-up period was 104 months. There were 7 late deaths, 4 of which were disease-related. The actuarial survival was 83.3% at 5 years and 72.9% at 10 years, and the freedom from reoperation was 87.9% at 5 years and 76.6% at 10 years. There were no reoperations on the ascending aorta. Coronary ostia were examined by angiography or 64-row multidetector computed tomography in 18 patients 43 to 189 months after the operation. Two patients developed stenosis or occlusion of the right coronary ostium. The early and late results of the Cabrol operation were favorable with the exception of coronary complications. The importance of careful follow-up for late coronary complications cannot be overemphasized.
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Affiliation(s)
- Tadashi Kitamura
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital, Tokyo, Japan
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Kourliouros A, Soni M, Rasoli S, Grapsa J, Nihoyannopoulos P, O'Regan D, Athanasiou T. Evolution and Current Applications of the Cabrol Procedure and Its Modifications. Ann Thorac Surg 2011; 91:1636-41. [DOI: 10.1016/j.athoracsur.2011.01.061] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 01/16/2011] [Accepted: 01/20/2011] [Indexed: 11/25/2022]
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Stamou SC, Murphy MC, Kouchoukos NT. Left ventricular outflow tract reconstruction and translocation of the aortic valve for annular erosion: early and midterm outcomes. J Thorac Cardiovasc Surg 2010; 142:292-7. [PMID: 21130469 DOI: 10.1016/j.jtcvs.2010.09.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 08/24/2010] [Accepted: 09/17/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Aortic annular erosion is a serious complication of aortic valve endocarditis or previous aortic valve replacement without endocarditis, and its surgical management is challenging. We present the early and midterm results of a technique for left ventricular outflow tract and aortic root reconstruction with a polyester tube graft and translocation of the aortic valve and coronary arteries. METHODS A polyester tube graft is placed into the left ventricle and sutured to the left ventricular outflow tract below the area of erosion. The graft is then everted and sutured to a composite graft. Interposition polyester grafts from the coronary arteries are attached to the composite graft above the valve. This technique has been used in 12 cases. All but 1 patient had previously undergone aortic root or aortic valve replacement, and 4 had endocarditis of prosthetic (n = 2) or aortic allograft (n = 2) valves. RESULTS There were no in-hospital deaths. There was 1 early death from pulmonary embolism at 1 postoperative month and 2 late deaths at 15 and 64 postoperative months, both resulting from heart failure. The remaining 9 patients are alive at 3 to 132 postoperative months. Actuarial 5-year survival is 75%. CONCLUSIONS Left ventricular outflow tract reconstruction with translocation of the aortic valve and coronary arteries for annular erosion is a useful technique that safely excludes the area of annular erosion and eliminates left ventricular outflow tract obstruction. The procedure can be safely performed with satisfactory early outcomes and 5-year survival.
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Affiliation(s)
- Sotiris C Stamou
- Division of Thoracic and Cardiovascular Surgery, Missouri Baptist Medical Center, St Louis, MO, USA
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Kourliouros A, Grapsa J, Nihoyannopoulos P, Athanasiou T. Modification of the Cabrol as a bailout procedure in complicated bicuspid valve aortopathy. Interact Cardiovasc Thorac Surg 2010; 12:199-201. [PMID: 21098512 DOI: 10.1510/icvts.2010.254961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The Cabrol technique is reserved where the conventional 'button' or Bentall techniques fail to maintain a tension-free anastomosis between the coronary arteries and aortic conduit. However, the side-to-side anastomosis of the interposition graft that connects the coronary ostia with the aorta in the Cabrol, may lead to kinking or tension, and subsequent occlusion. We present a case of successful Cabrol modification in a patient with bicuspid aortopathy where the graft to the right coronary artery was anastomosed directly onto the valved conduit and the graft to the left main stem onto the previous right aortocoronary graft in a T-fashion.
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Affiliation(s)
- Antonios Kourliouros
- Department of Cardiothoracic Surgery, St George's Hospital, and Department of Cardiovascular Sciences, Imperial College NHS Trust, Blackshaw Road, London SW17 0QT, UK.
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