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Zhou Y, Fan R, Jiang H, Liu R, Huang F, Chen X. A novel nomogram model to predict in-hospital mortality in patients with acute type A aortic dissection after surgery. J Cardiothorac Surg 2024; 19:362. [PMID: 38915077 PMCID: PMC11194955 DOI: 10.1186/s13019-024-02921-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/15/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Acute type A aortic dissection is a dangerous disease that threatens public health. In recent years, with the progress of medical technology, the mortality rate of patients after surgery has been gradually reduced, leading that previous prediction models may not be suitable for nowadays. Therefore, the present study aims to find new independent risk factors for predicting in-hospital mortality and construct a nomogram prediction model. METHODS The clinical data of 341 consecutive patients in our center from 2019 to 2023 were collected, and they were divided into two groups according to the death during hospitalization. The independent risk factors were analyzed by univariate and multivariate logistic regression, and the nomogram was constructed and verified based on these factors. RESULTS age, preoperative lower limb ischemia, preoperative activated partial thromboplastin time (APTT), preoperative platelet count, Cardiopulmonary bypass (CPB) time and postoperative acute kidney injury (AKI) independently predicted in-hospital mortality of patients with acute type A aortic dissection after surgery. The area under the receiver operating characteristic curve (AUC) for the nomogram was 0.844. The calibration curve and decision curve analysis verified that the model had good quality. CONCLUSION The new nomogram model has a good ability to predict the in-hospital mortality of patients with acute type A aortic dissection after surgery.
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Affiliation(s)
- Yifei Zhou
- School of Medicine, Southeast University, Nanjing, Jiangsu, 210009, China
- The Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, 210006, People's Republic of China
| | - Rui Fan
- The Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, 210006, People's Republic of China
| | - Hongwei Jiang
- The Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, 210006, People's Republic of China
| | - Renjie Liu
- School of Medicine, Southeast University, Nanjing, Jiangsu, 210009, China
- The Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, 210006, People's Republic of China
| | - Fuhua Huang
- The Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, 210006, People's Republic of China.
| | - Xin Chen
- School of Medicine, Southeast University, Nanjing, Jiangsu, 210009, China.
- The Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, 210006, People's Republic of China.
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Preventza O, Henry J, Khan L, Cornwell LD, Simpson KH, Chatterjee S, Amarasekara HS, Moon MR, Coselli JS. Unplanned readmissions, community socioeconomic factors, and their effects on long-term survival after complex thoracic aortic surgery. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00093-X. [PMID: 38295953 DOI: 10.1016/j.jtcvs.2024.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE We evaluated community socioeconomic factors in patients who had unplanned readmission after undergoing proximal aortic surgery (ascending aorta, aortic root, or arch). METHODS Unplanned readmissions for any reason within 60 days of the index procedure were reviewed by race, acuity at presentation, and gender. We also evaluated 3 community socioeconomic factors: poverty, household income, and education. Kaplan-Meier survival curves were used to assess long-term survival differences by group (race, acuity, and gender). RESULTS Among 2339 patients who underwent proximal aortic surgery during the 20-year study period and were discharged alive, our team identified 146 (6.2%) unplanned readmissions. Compared with White patients, Black patients lived in areas characterized by more widespread poverty (20.8% vs 11.1%; P = .0003), lower income ($42,776 vs $65,193; P = .0007), and fewer residents with a high school diploma (73.7% vs 90.1%; P < .0001). Compared with patients whose index operation was elective, patients who had urgent or emergency index procedures lived in areas with lower income ($54,425 vs $64,846; P = .01) and fewer residents with a high school diploma (81.1% vs 89.2%; P = .005). Community socioeconomic factors did not differ by gender. Four- and 6-year survival estimates were 63.1% and 63.1% for Black patients versus 89.1% and 83.0% for White patients (P = .0009). No significant differences by acuity or gender were found. CONCLUSIONS Among readmitted patients, Black patients and patients who had emergency surgery had less favorable community socioeconomic factors and poorer long-term survival. Earlier and more frequent follow-up in these patients should be considered. Developing off-campus clinics and specific postdischarge measures targeting these patients is important.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, University of Virginia Health, Charlottesville, Va; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex.
| | - Jaymie Henry
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Lubna Khan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Katherine H Simpson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
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Dietze Z, Kang J, Madomegov K, Etz CD, Misfeld M, Borger MA, Leontyev S. Aortic arch redo surgery: early and mid-term outcomes in 120 patients. Eur J Cardiothorac Surg 2023; 64:ezad419. [PMID: 38109680 DOI: 10.1093/ejcts/ezad419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/04/2023] [Accepted: 12/14/2023] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVES The aim of this study was to analyse the indications, surgical extent and results of treatment, as well as determine the risk factors for adverse outcomes after redo arch surgery. METHODS Between January 1996 and December 2022, 120 patients underwent aortic arch reoperations after primary proximal aortic surgery. We retrospectively analysed perioperative data, as well as early and mid-term outcomes in these patients. RESULTS Indications for arch reintervention included new aortic aneurysm in 34 patients (28.3%), expanding post-dissection aneurysm in 36 (30.0%), aortic graft infection in 39 (32.5%) and new aortic dissection in 9 cases. Two patients underwent reoperation due to iatrogenic complications. Thirty-one patients (25.8%) had concomitant endocarditis. In-hospital and 30-day mortality rates were 11.7% and 15.0%, respectively. Stroke was observed in 11 (9.2%) and paraplegia in 1 patient. Prior surgery due to aneurysm [odds ratio 4.5; 95% confidence interval (CI) 1.4-17.3] and critical preoperative state (odds ratio 5.9; 95% CI 1.5-23.7) were independent predictors of 30-day mortality. Overall 1- and 5-year survival was 65.8 ± 8.8% and 51.2 ± 10.6%, respectively. Diabetes mellitus (hazard ratio 2.4; 95% CI 1.0-5.1) and peripheral arterial disease (hazard ratio 4.7; 95% CI 1.1-14.3) were independent predictors of late death. The cumulative incidence of reoperations was 12.6% (95% CI 6.7-20.4%) at 5 years. Accounting for mortality as a competing event, connective tissue disorders (subdistribution hazard ratio 4.5; 95% CI 1.6-15.7) and interval between primary and redo surgery (subdistribution hazard ratio 1.04; 95% CI 1.02-1.06) were independent predictors of reoperations after redo arch surgery. CONCLUSIONS Despite being technically demanding, aortic arch reoperations are feasible and can be performed with acceptable results.
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Affiliation(s)
- Zara Dietze
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Jagdip Kang
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | | | - Christian D Etz
- Department of Cardiac Surgery, Rostock University Hospital, Rostock, Germany
| | - Martin Misfeld
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, NSW, Australia
| | - Michael A Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Sergey Leontyev
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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4
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Amin A, Etheridge GM, Amarasekara HS, Green SY, Orozco-Sevilla V, Coselli JS. Aortic arch repair: lessons learned over three decades at Baylor College of Medicine. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:393-405. [PMID: 35621061 DOI: 10.23736/s0021-9509.22.12376-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The treatment of complex aortic arch disease continues to be among the most demanding cardiovascular operations, with a considerable risk of death and stroke. Since January 1990, our single-practice service has performed over 3000 repairs of the aortic arch. Our aim was to describe the progression of our technical approach to open aortic arch repair. Our center's surgical technique has evolved considerably over the last three decades. When it comes to initial arterial cannulation, we have shifted away from femoral artery cannulation to innominate and axillary artery cannulation. During difficult repairs, this transition has made it easier to use antegrade cerebral perfusion rather than retrograde cerebral perfusion, which was commonly used in the early days. Brain protection tactics during open aortic arch procedures have evolved from profound (≤14 °C) hypothermia during circulatory arrest to moderate (22-24 °C) hypothermia. Aortic arch repair is performed through a median sternotomy and may treat acute aortic dissection, chronic aortic dissection, or degenerative aneurysm. Reoperative repair - that necessitating redo sternotomy - is common in patients undergoing aortic arch repair. The majority of repairs will include varying portions of the ascending aorta and may involve the aortic valve or the aortic root. In some patients, repair may extend into the proximal descending thoracic aorta; this includes elephant trunk, frozen elephant trunk, and antegrade hybrid approaches.
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Affiliation(s)
- Arsalan Amin
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Ginger M Etheridge
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Hiruni S Amarasekara
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Susan Y Green
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Vicente Orozco-Sevilla
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
- Texas Heart Institute, Houston, TX, USA
- Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
| | - Joseph S Coselli
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA -
- Texas Heart Institute, Houston, TX, USA
- Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
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5
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Ohira S, Malekan R, Kai M, Goldberg JB, Spencer PJ, Lansman SL, Spielvogel D. Reoperative Total Arch Repair Using a Trifurcated Graft and Selective Antegrade Cerebral Perfusion. Ann Thorac Surg 2021; 113:569-576. [PMID: 33857494 DOI: 10.1016/j.athoracsur.2021.03.090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/23/2021] [Accepted: 03/29/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND This study reviews the outcomes of our reoperative total arch repair (TAR) technique using a trifurcated graft and selective antegrade cerebral perfusion (SACP). METHODS Fifty patients underwent reoperative TAR from January 2005 to September 2020, with either a one-stage (N=9), or two-stage repair (N=41). The two-stage technique includes minimal dissection of the mediastinal structures, an arch-first technique using a trifurcated graft, and construction of a classical elephant trunk via a partial transverse incision distally in the old-graft or in the aorta just distal to the old graft. RESULTS The median age was 63 years. Chronic dissection was the most frequent indication (88%) and 98% had undergone a previous proximal aortic repair at a median interval of 3.0 years. The median cardiopulmonary bypass, myocardial ischemic, SACP, and lower body circulatory arrest times were 226, 103, 97, and 98 minutes, respectively. The minimum nasopharyngeal and bladder temperature were 16.5 °C, and 20.0 °C. Operative mortality was 2% and the incidence of stroke, and spinal cord injury (SCI) were 2%, and 0%. Stage II repair was performed in 37 patients (open: 33 patients, endovascular: 4 patients), with two mortalities and no SCI. The median duration between stage I and II was 63 days. Survival and aortic event free rates at 3 years were 88.4 ±4.9%, and 89.8 ±5.0%. CONCLUSIONS We report a reoperative TAR technique that minimizes dissection of the cardiac structures, simplifies the distal anastomosis, and protects vital organs, such as the brain, heart, and spinal cord.
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Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY.
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Joshua B Goldberg
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Philip J Spencer
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Steven L Lansman
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
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Abe N, Okada K, Tanaka H, Okita Y. Valve-sparing aortic root replacement after type A aortic dissection repairs. Asian Cardiovasc Thorac Ann 2020; 29:381-387. [PMID: 33249852 DOI: 10.1177/0218492320977981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Aortic root reoperation after aortic dissection repair sometimes requires aortic root replacement. A valve-preserving technique should be applied when the aortic cusp is normal. Valve-sparing aortic root reconstruction using the reimplantation technique resolves aortic valve regurgitation, root dilatation, and pseudoaneurysm in the proximal anastomosis. Our experience in aortic root reoperation is presented. METHODS From January 2000 to March 2019, 26 patients underwent reoperative valve-sparing aortic root reconstruction using the reimplantation technique. The time from the initial operation to reoperation was 69.3 ± 51.6 months. Aortic root reoperation was required for a fragile wall at the previous proximal anastomosis or aortic root dilatation. We aimed to stabilize the aortic root without valve regurgitation. The native aortic cusp was aggressively preserved when nearly normal. Indications included root dilatation (n = 13), pseudoaneurysm of the previous proximal anastomosis (n = 11), and aortic valve regurgitation (n = 4). RESULTS There was no early postoperative mortality. Follow-up was 49 ± 47 months (range 4-161 months). The 3, 5, and 10-year survival was 88.9% ± 7.4%, 88.9% ± 7.4%, and 77.8% ± 12.2%, respectively. Freedom from recurrence of a greater than moderate degree of aortic valve regurgitation at 3, 5, and 10 years was 86.5% ± 8.9%, 86.5% ± 8.9%, and 86.5% ± 8.9%, respectively. One patient underwent aortic valve replacement for recurrent aortic valve regurgitation 15 months after the valve-sparing reoperation. CONCLUSIONS Midterm outcomes of reoperative valve-sparing aortic root reconstruction using the reimplantation technique and postoperative aortic valve performance were satisfactory.
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Affiliation(s)
- Noriyuki Abe
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kenji Okada
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Tanaka
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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7
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Preventza O, Amarasekara H, Price MD, Chatterjee S, Green SY, Woodside S, Zhang Q, LeMaire SA, Coselli JS. Propensity score analysis in patients with and without previous isolated coronary artery bypass grafting who require proximal aortic and arch surgery. J Thorac Cardiovasc Surg 2020; 164:1390-1396.e2. [PMID: 33419538 DOI: 10.1016/j.jtcvs.2020.10.153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 10/26/2020] [Accepted: 10/30/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The risk posed by previous isolated coronary artery bypass grafting (CABG) in patients who require proximal aortic or aortic arch surgery is unclear. We compared outcomes of ascending aortic and arch procedures in patients with and without previous CABG. METHODS Using propensity scores, we created 2 matched groups of patients who underwent proximal aortic surgery, including total arch repairs, at our institution: 126 patients who underwent isolated CABG before the index operation and 126 without previous CABG. Forty-four percent of aortic operations were emergency procedures. Eighty-six patients had a patent previous left internal mammary graft. We compared outcomes between the 2 groups and calculated Kaplan-Meier survival curves. RESULTS The following outcomes were recorded for the patients with previous isolated CABG versus no CABG: operative mortality, 15.9% versus 11.1% (P = .3); 30-day mortality, 13.5% versus 7.1% (P = .1); persistent stroke, 6.3% versus 4.8% (P = .6); and renal failure necessitating hemodialysis at discharge, 7.9% versus 4.0% (P = .2). Previous CABG did not independently predict any adverse outcome, even though patients who underwent previous CABG more frequently needed intra-aortic balloon support (P < .01). The P value for the overall intergroup difference in long-term survival was .06. CONCLUSIONS This is one of the largest studies yet reported to examine the impact of previous isolated CABG on proximal aortic or arch surgery outcomes. Although these results may be specific to aortic centers of excellence, in this complicated patient cohort, previous isolated CABG did not independently predict any adverse outcome. These results could serve as a benchmark for assessing future endovascular therapies.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
| | - Hiruni Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Matt D Price
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Sandra Woodside
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Qianzi Zhang
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
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Coselli JS, Krause HM, Green SY, Zhang Q, Amarasekara HS, Price MD, Preventza O, LeMaire SA. A 23-year experience with the reversed elephant trunk technique for staged repair of extensive thoracic aortic aneurysm. J Thorac Cardiovasc Surg 2020; 163:1252-1264. [PMID: 33419554 DOI: 10.1016/j.jtcvs.2020.09.148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/24/2020] [Accepted: 09/29/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The reversed elephant trunk technique permits staged repair of extensive thoracic aortic aneurysm in patients whose distal (ie, descending thoracic and thoracoabdominal) aorta is symptomatic or disproportionately large compared with their proximal aorta (ie, ascending aorta and transverse aortic arch). We present our 23-year experience with the reversed elephant trunk approach. METHODS Between 1994 and 2017, 94 patients (median age 62 [46-69] years) underwent stage 1 reversed elephant trunk repair of the distal aorta. Fifty-three patients (56%) had aortic dissection, and 31 patients (33%) had heritable thoracic aortic disease. Eighty-eight operations (94%) were Crawford extent I or II thoracoabdominal aortic repairs. Twenty-seven patients (29%) underwent subsequent stage 2 repair of the proximal aorta; 14 patients (52%) required redo median sternotomy. The median time between the stage 1 and 2 operations was 18.8 (4.8-69.3) months. RESULTS The operative mortality was 10% (9/94) for stage 1 repairs and 4% (1/27) for stage 2 repairs; 1 patient with heritable thoracic aortic disease died after stage 1 repair (1/31, 3%), and 1 patient died after stage 2 repair (1/13, 8%). Two patients (2%) had ruptures after stage 1 repair; 1 resulted in death, and 1 precipitated emergency stage 2 repair. In total, 36 patients (38%) who survived stage 1 repair died before stage 2 reversed elephant trunk completion repair could be performed. CONCLUSIONS Managing extensive aortic aneurysm with the 2-stage reversed elephant trunk technique yields acceptable short-term outcomes. This technique is useful for the reversed elephant trunk in patients who require distal aortic repair before proximal repair and is particularly effective in patients with heritable thoracic aortic disease. The low number of patients returning for completion repair is concerning. Rigorous surveillance is needed.
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Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Heidi M Krause
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Qianzi Zhang
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Matt D Price
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex.
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9
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Supra-aortic vessel reconstruction in total arch replacement for acute type A dissection: Comparison of en bloc and separate graft techniques. Asian J Surg 2019; 42:482-487. [DOI: 10.1016/j.asjsur.2018.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 09/19/2018] [Accepted: 09/25/2018] [Indexed: 11/24/2022] Open
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10
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Preventza O, Tan CW, Orozco-Sevilla V, Euhus CJ, Coselli JS. Zone zero hybrid arch exclusion versus open total arch replacement. Ann Cardiothorac Surg 2018; 7:372-379. [PMID: 30155416 DOI: 10.21037/acs.2018.04.03] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Open total aortic arch replacement is one of the most technically demanding operations in cardiothoracic surgery, requiring operator expertise and intraoperative and postoperative teamwork. Despite current advancements in the field of open aortic surgery with regard to intraoperative brain protection and postoperative care, the morbidity and mortality associated with open total arch operations varies. Endovascular and hybrid procedures involving the use of zone 0 as a landing zone allow fair comparison between open total arch and hybrid operations. Hybrid procedures involving all of the other landing zones [1-4] should not be compared with open total arch replacement, as the extent of the pathology is different.
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Affiliation(s)
- Ourania Preventza
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Corinne W Tan
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Caleb J Euhus
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Joseph S Coselli
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
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11
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Neri E, Tucci E, Tommasino G, Guaccio G, Ricci C, Lucatelli P, Cini M, Ceresa R, Benvenuti A, Muzzi L. Intimal re-layering technique for type A acute aortic dissection-reconstructing the intimal layer continuity to induce remodeling of the false channel. J Vis Surg 2018; 4:82. [PMID: 29780728 DOI: 10.21037/jovs.2018.04.09] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 03/31/2018] [Indexed: 11/06/2022]
Abstract
Background Residual false channel is common after repair of type A acute aortic dissection (TAAAD). Starting from our recent series of TAAAD patients we carried out a retrospective analysis, regarding the failure of primary exclusion at the time of the initial operation. We classified the location of the principal entry tears perfusing the residual false channel. The proposed technique represents our attempt to correct the mechanism of false channel perfusion during primary repair. We describe a new technique designed to address some limitations of standard hemiarch aortic replacement. Its goal are: (I) to reinforce the intimal layer at the arch level; (II) to eliminate inter-luminal communications at the arch level using suture lines around the arch vessels; (III) to provide an elephant trunk configuration for further interventions. Methods Between August 2016 and January 2018, 11 patients underwent emergency surgery using this technique; 7 were men; the median age was 74 years. All patients were treated using systemic circulatory arrest under moderate hypothermia (26 °C) and selective cerebral perfusion. All patients had supra-coronary repair; 1 patient had aortic valve replacement + CABG. In the first two patients a manual suture around supra-aortic trunks was used; the subsequent seven patients were treated with a mechanical suture bladeless device. CT scan follow up was performed in all survivors with controls before discharge 3 months and 1 year after operation. Results No patient died in the operating room and no neurologic deficit was observed in this initial experience. One patient died in POD 5th for low cardiac output syndrome. Median ICU stay was 3 days (IQR, 2-6 days). Hospital mean length of stay was 15.2±8 days. Median cardiopulmonary bypass time was 130 min (IQR, 110-141 min); median arrest time for re-layering was 17 min (IQR, 16-20 min); median total arrest was 36 min (IQR, 29-39 min). Distal aortic anastomosis was performed in zone 0 in 4 patients, zone 1, with innominate replacement, in 5 patients, in zone 2, with branches to innominate and left common carotid arteries, in 2 patients. Median follow up (closing date 06/01/2018) was 443 days (IQR, 262-557 days); no late deaths occurred. No dehiscence at the level of stapler or manual sutures was observed. Proximal 1/3 of the thoracic aorta false channel was obliterated in all cases but one; in 3 cases complete exclusion of the false channel was obtained after operation. In one case stent graft completion was required. Conclusions This technique combines the advantages of arch replacement to the simplicity of anterior hemiarch repair. This study demonstrates the safety of the procedure and the possibility to induce aortic remodeling without complex arch replacement.
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Affiliation(s)
- Eugenio Neri
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
| | - Enrico Tucci
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
| | - Giulio Tommasino
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
| | - Giulia Guaccio
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
| | - Carmelo Ricci
- Interventional Radiology Unit, Siena University Hospital, Siena, Italy
| | | | - Marco Cini
- Interventional Radiology Unit, Siena University Hospital, Siena, Italy
| | - Roberto Ceresa
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
| | - Antonio Benvenuti
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
| | - Luigi Muzzi
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
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12
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Di Bartolomeo R, Berretta P, Pantaleo A, Murana G, Cefarelli M, Alfonsi J, Barberio G, Leone A, Di Marco L, Pacini D. Long-Term Outcomes of Open Arch Repair After a Prior Aortic Operation: Our Experience in 154 Patients. Ann Thorac Surg 2017; 103:1406-1412. [DOI: 10.1016/j.athoracsur.2016.08.090] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 10/20/2022]
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13
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Lin ZB, Ci HB, Li Y, Cheng TP, Liu DH, Wang YS, Xu J, Yuan HX, Li HM, Chen J, Zhou L, Wang ZP, Zhang X, Ou ZJ, Ou JS. Endothelial microparticles are increased in congenital heart diseases and contribute to endothelial dysfunction. J Transl Med 2017; 15:4. [PMID: 28049487 PMCID: PMC5210308 DOI: 10.1186/s12967-016-1087-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 11/18/2016] [Indexed: 11/24/2022] Open
Abstract
Background We previously demonstrated that endothelial microparticles (EMPs) are increased in mitral valve diseases and impair valvular endothelial cell function. Perioperative systemic inflammation is an important risk factor and complication of cardiac surgery. In this study, we investigate whether EMPs increase in congenital heart diseases to promote inflammation and endothelial dysfunction. Methods The level of plasma EMPs in 20 patients with atrial septal defect (ASD), 23 patients with ventricular septal defect (VSD), and 30 healthy subjects were analyzed by flow cytometry. EMPs generated from human umbilical vascular endothelial cells (HUVECs) were injected into C57BL6 mice, or cultured with HUVECs without or with siRNAs targeting P38 MAPK. The expression and/or phosphorylation of endothelial nitric oxide synthase (eNOS), P38 MAPK, and caveolin-1 in mouse heart and/or in cultured HUVECs were determined. We evaluated generation of nitric oxide (NO) in mouse hearts, and levels of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) in cultured HUVECs and in mice. Results EMPs were significantly elevated in patients with ASD and VSD, especially in those with pulmonary hypertension when compared with controls. EMPs increased caveolin-1 expression and P38 MAPK phosphorylation and decreased eNOS phosphorylation and NO production in mouse hearts. EMPs stimulated P38 MAPK expression, TNF-α and IL-6 production, which were all inhibited by siRNAs targeting P38 MAPK in cultured HUVECs. Conclusions EMPs were increased in adult patients with congenital heart diseases and may contribute to increased inflammation leading to endothelial dysfunction via P38 MAPK-dependent pathways. This novel data provides a potential therapeutic target to address important complications of surgery of congenial heart disease. Electronic supplementary material The online version of this article (doi:10.1186/s12967-016-1087-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ze-Bang Lin
- Division of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China.,The Key Laboratory of Assisted Circulation, Ministry of Health, Guangzhou, 510080, People's Republic of China.,National and Guangdong Province Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, People's Republic of China
| | - Hong-Bo Ci
- Division of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China.,The Key Laboratory of Assisted Circulation, Ministry of Health, Guangzhou, 510080, People's Republic of China.,National and Guangdong Province Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, People's Republic of China
| | - Yan Li
- Division of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China.,The Key Laboratory of Assisted Circulation, Ministry of Health, Guangzhou, 510080, People's Republic of China.,National and Guangdong Province Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, People's Republic of China
| | - Tian-Pu Cheng
- Division of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China.,The Key Laboratory of Assisted Circulation, Ministry of Health, Guangzhou, 510080, People's Republic of China.,National and Guangdong Province Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, People's Republic of China
| | - Dong-Hong Liu
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China
| | - Yan-Sheng Wang
- State Key Laboratory of Respiratory Disease, Guangzhou, 510080, People's Republic of China.,Guangzhou Institute of Respiratory Disease, Guangzhou, 510080, People's Republic of China.,The First Affiliated Hospital of Guangzhou Medical University Guangzhou, Guangzhou, 510120, People's Republic of China
| | - Jun Xu
- State Key Laboratory of Respiratory Disease, Guangzhou, 510080, People's Republic of China.,Guangzhou Institute of Respiratory Disease, Guangzhou, 510080, People's Republic of China.,The First Affiliated Hospital of Guangzhou Medical University Guangzhou, Guangzhou, 510120, People's Republic of China
| | - Hao-Xiang Yuan
- Division of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China.,The Key Laboratory of Assisted Circulation, Ministry of Health, Guangzhou, 510080, People's Republic of China.,National and Guangdong Province Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, People's Republic of China
| | - Hua-Ming Li
- Division of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China.,The Key Laboratory of Assisted Circulation, Ministry of Health, Guangzhou, 510080, People's Republic of China.,National and Guangdong Province Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, People's Republic of China
| | - Jing Chen
- Division of Hypertension and Vascular Diseases, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China
| | - Li Zhou
- Division of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China.,The Key Laboratory of Assisted Circulation, Ministry of Health, Guangzhou, 510080, People's Republic of China
| | - Zhi-Ping Wang
- Division of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China.,The Key Laboratory of Assisted Circulation, Ministry of Health, Guangzhou, 510080, People's Republic of China
| | - Xi Zhang
- Division of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China.,The Key Laboratory of Assisted Circulation, Ministry of Health, Guangzhou, 510080, People's Republic of China
| | - Zhi-Jun Ou
- Division of Hypertension and Vascular Diseases, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China.,The Key Laboratory of Assisted Circulation, Ministry of Health, Guangzhou, 510080, People's Republic of China.,National and Guangdong Province Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, People's Republic of China
| | - Jing-Song Ou
- Division of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhong Shan Er Road, Guangzhou, 510080, People's Republic of China. .,The Key Laboratory of Assisted Circulation, Ministry of Health, Guangzhou, 510080, People's Republic of China. .,National and Guangdong Province Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, People's Republic of China. .,Guangdong Provincial Key Laboratory of Brain Function and Disease, Guangzhou, 510080, People's Republic of China.
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14
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de la Cruz KI, Green SY, Preventza OA, Coselli JS. Aortic Arch Replacement in Patients With Chronic Dissection: Special Considerations. Semin Cardiothorac Vasc Anesth 2016; 20:314-321. [PMID: 27418026 DOI: 10.1177/1089253216659144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The progressive expansion of residual, chronic DeBakey type I dissection often necessitates repair of the aortic arch and the distal aorta (ie, descending thoracic and thoracoabdominal aorta). The vast majority of patients with chronic aortic dissection facing aortic arch surgery are survivors of emergent proximal aortic repair for acute dissection, and thus, these patients now face a reoperative procedure necessitating a redo median sternotomy. One approach for repairing the chronic type I aortic dissection incorporates total transverse aortic arch replacement with and without an elephant trunk extension; an elephant trunk extension is a useful strategy, because the proximal descending thoracic aorta is commonly ectatic or aneurysmal at the time of aortic arch repair-using an elephant trunk approach facilitates subsequent repair in the distal aorta. Patients with chronic DeBakey type I dissection should participate in an imaging surveillance protocol.
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Affiliation(s)
- Kim I de la Cruz
- Baylor College of Medicine, Houston, TX, USA .,Texas Heart Institute, Houston, TX, USA.,Baylor St. Luke's Medical Center, CHI St. Luke's Health System, Houston, TX, USA
| | | | - Ourania A Preventza
- Baylor College of Medicine, Houston, TX, USA.,Texas Heart Institute, Houston, TX, USA.,Baylor St. Luke's Medical Center, CHI St. Luke's Health System, Houston, TX, USA
| | - Joseph S Coselli
- Baylor College of Medicine, Houston, TX, USA.,Texas Heart Institute, Houston, TX, USA.,Baylor St. Luke's Medical Center, CHI St. Luke's Health System, Houston, TX, USA
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15
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Preventza O, Garcia A, Kashyap SA, Akvan S, Cooley DA, Simpson K, Rammou A, Price MD, Omer S, Bakaeen FG, Cornwell LD, Coselli JS. Moderate hypothermia ≥24 and ≤28°C with hypothermic circulatory arrest for proximal aortic operations in patients with previous cardiac surgery. Eur J Cardiothorac Surg 2016; 50:949-954. [PMID: 27190198 DOI: 10.1093/ejcts/ezw163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 04/13/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To determine whether, in patients with previous cardiac operations, moderate hypothermia (between 24 and 28°C) for hypothermic circulatory arrest (HCA) during antegrade cerebral perfusion (ACP) is safe for use during surgery on the proximal aorta and transverse aortic arch. METHODS Over a 7-year period, 118 patients underwent ascending aortic and hemiarch repair (n = 70; 59.3%), total arch replacement (n = 47; 39.8%) or ascending aortic replacement to treat porcelain aorta (n = 1; 0.9%). Simultaneous procedures included aortic root repair or replacement (n = 33; 28.0%) and coronary artery bypass grafting (n = 21; 17.8%). All patients had previously undergone cardiac operations via a median sternotomy. Eighteen patients (15.3%) had more than 1 previous sternotomy, and 24 patients (20.3%) required emergent/urgent operation. Median cardiopulmonary bypass, cardiac ischaemic, circulatory arrest and ACP times (min) were 136.0 [118-180 interquartile range (IQR)], 91.0 (68-119 IQR), 34.0 (21-59 IQR) and 33.5 (20-59 IQR), respectively. The median temperature when HCA was initiated was 24.2°C (24.1-24.8°C IQR). RESULTS The operative mortality rate was 10.2% (n = 12). Six patients (5.1%) had a permanent stroke, and 16 patients (13.6%) had a composite adverse outcome (operative mortality and/or a permanent neurological event and/or permanent haemodialysis at discharge). Preoperative renal disease was significantly more prevalent (P= 0.020) and the median circulatory arrest time significantly longer (48.5 vs 33 min; P= 0.058) in patients with composite adverse outcomes. Multivariable analysis of the redo patients showed that age (P =0.025), preoperative renal disease (P =0.024) and ACP time (P =0.012) were independent risk factors for a new postoperative renal injury. CONCLUSIONS Moderate hypothermia for HCA during ACP is being used with increasing frequency, but has not been thoroughly evaluated in patients undergoing cardiovascular reoperations. Our experience suggests that in patients with previous cardiac surgery who are undergoing hemiarch and total aortic arch operations, moderate hypothermia is safe and produces respectable results.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA .,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Andrea Garcia
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Sarang A Kashyap
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Shahab Akvan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Denton A Cooley
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Kiki Simpson
- The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Athina Rammou
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Matt D Price
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Shuab Omer
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Faisal G Bakaeen
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
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16
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Quintana E, Bajona P, Schaff HV, Dearani JA, Daly R, Greason K, Pochettino A. Open Aortic Arch Reconstruction After Coronary Artery Bypass Surgery: Worth the Effort? Semin Thorac Cardiovasc Surg 2015; 28:26-35. [PMID: 27568130 DOI: 10.1053/j.semtcvs.2015.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2015] [Indexed: 11/11/2022]
Abstract
Open aortic arch surgery after coronary artery bypass grafting (CABG) is considered a high-risk operation. We reviewed our surgical approach and outcomes to establish the risk profile for this patient population. In methods, from 2000-2014, 650 patients underwent aortic arch surgery with circulatory arrest. Of these, 45 (7%) had previous CABG. Complete medical record was available for review including all preoperative coronary angiograms and detailed management of myocardial protection. In results, the mean interval from previous CABG to aortic arch surgery was 6.8 ± 7.1 years. At reoperation, 33 (73%) patients had hemiarch replacement and 12 (27%) had a total arch replacement. The following were the indications for surgery: fusiform aneurysm in 20 (44%), pseudoaneurysm in 6 (13%), endocarditis in 4 (9%), valvular disease in 5 (11%), and acute aortic dissection in 10 (22%). There were 6 perioperative deaths (13%) and 1 stroke (2.2%). Selective antegrade cerebral perfusion was used in 13 patients (28.9%) and retrograde perfusion in 6 (13.3%). Survival was 74%, 65%, and 52% at 1, 3, and 5-year follow-up, respectively. Only predictors of early mortality were age (odds ratio = 1.20, CI: 1.01-1.44; P = 0.04) and nonuse of retrograde cardioplegia for myocardial protection (odds ratio = 6.80, CI: 1.06-43.48; P = 0.04). Intermediate survival of these patients was significantly lower than those of a sex-matched and age-matched population (P < 0.001). In conclusion, aortic arch surgery after previous CABG can be performed with acceptable early and midterm results and low risk of stroke. Perfusion strategies and myocardial protection contribute to successful outcomes.
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Affiliation(s)
- Eduard Quintana
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota; Cardiovascular Surgery Department, Hospital Clínic de Barcelona, Institut Clínic Cardiovascular, University of Barcelona Medical School, Barcelona, Spain
| | - Pietro Bajona
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota; Division of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hartzell V Schaff
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Richard Daly
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin Greason
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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17
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Fu L, Hu XX, Lin ZB, Chang FJ, Ou ZJ, Wang ZP, Ou JS. Circulating microparticles from patients with valvular heart disease and cardiac surgery inhibit endothelium-dependent vasodilation. J Thorac Cardiovasc Surg 2015; 150:666-72. [DOI: 10.1016/j.jtcvs.2015.05.069] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 05/19/2015] [Accepted: 05/23/2015] [Indexed: 12/30/2022]
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18
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Hemiarch and Total Arch Surgery in Patients With Previous Repair of Acute Type I Aortic Dissection. Ann Thorac Surg 2015; 100:833-8. [DOI: 10.1016/j.athoracsur.2015.03.095] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/25/2015] [Accepted: 03/30/2015] [Indexed: 11/17/2022]
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19
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Oderich GS, Pochettino A, Mendes BC, Roeder B, Pulido J, Gloviczki P. Endovascular Repair of Saccular Ascending Aortic Aneurysm After Orthotopic Heart Transplantation Using an Investigational Zenith Ascend Stent-Graft. J Endovasc Ther 2015; 22:650-654. [DOI: 10.1177/1526602815593537] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Purpose: To report the use of an investigational stent-graft to treat an ascending aortic aneurysm in a patient with a heart transplant. Case Report: A 48-year-old man presented with a 3.5×1.5-cm saccular aneurysm in the mid anterior ascending aorta, abutting the sternum. The patient’s history was notable for placement of a left ventricular assist device followed by orthotopic heart transplantation 2 years prior to treat end-stage familial dilated cardiomyopathy. Under compassionate use, a custom-designed ascending aortic stent-graft (Zenith Ascend) was successfully delivered via an 18-F system and deployed just distal to the origin of the left main coronary artery under pulmonary artery catheter–guided rapid ventricular pacing. The patient was discharged the next day, and 6-month follow-up was unremarkable. Imaging at 5 months showed an excluded aneurysm sac with no endoleak or migration. Conclusion: The ideal ascending aortic stent-graft should be low profile, conformable to the arch anatomy, with short tip delivery system and a stepwise deployment mechanism that allows precise placement relative to the ostia of the coronary arteries and the innominate artery. This case illustrates the advancement of endovascular techniques to the most challenging segment of the aorta to decrease morbidity and mortality in high-risk patients.
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Affiliation(s)
- Gustavo S. Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Bernardo C. Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Juan Pulido
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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20
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Idrees JJ, Roselli EE, Wojnarski CM, Feng K, Aftab M, Johnston DR, Soltesz EG, Sabik JF, Svensson LG. Prophylactic stage 1 elephant trunk for moderately dilated descending aorta in patients with predominantly proximal disease. J Thorac Cardiovasc Surg 2015; 150:1150-5. [PMID: 26433635 DOI: 10.1016/j.jtcvs.2015.07.077] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/14/2015] [Accepted: 07/22/2015] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Staged elephant trunk (ET) repair is a commonly performed procedure for extensive aortic disease. A significant proportion of patients with predominantly proximal aortic pathology often have in addition a moderately dilated descending aorta (<5 cm) that can progress over time. Objectives were to characterize patients, determine completion rate after prophylactic stage 1 ET, and assess outcomes. METHODS From 1992 to 2012, a total of 572 patients underwent stage 1 ET for degenerative aneurysm and dissection at Cleveland Clinic. Prophylactic stage 1 ET was performed in 117 (20.5%) who had predominantly proximal disease (5.5 ± 1 cm) with moderate dilation of the descending aorta (4 ± 0.6 cm). Aortic pathology included: aneurysm (n = 56 [48%]); chronic dissection (n = 41 [35%]); pseudoaneurysm (n = 9 [7.7%]); penetrating ulcer (n = 9 [7.7%]); and intramural hematoma (n = 2 [1.7%]). Other diagnoses included connective tissue disorder (12 [10%]); aortitis (20 [17%]); bicuspid aortic valve (9 [7.6%]); and previous type A dissection repair (27 [23%]). RESULTS Operative mortality was 0.8% (1 of 117). This patient suffered postoperative myocardial infarction and mesenteric ischemia, resulting in sepsis and death. Other complications included: stroke (n = 7 [6%]); tracheostomy (n = 6 [5%]); renal dialysis (n = 4 [3.3%]); and reoperation for bleeding (n = 7 [6%]). The mean follow-up time was 4 ± 3 years. Fifty-three (45%) patients completed the stage 2 ET (open: 20 [38%]; endovascular: 33 [62%]) at a median interval of 6 months (9 days-10 years). The mean descending diameter increased from 4.1 ± 0.6 cm to 5 ± 1 cm at the time of stage 2 completion. In 11 patients, stage 2 was performed for acute aortic events. Estimated survival at 1, 5, and 8 years was 94%, 88%, and 74%, respectively. CONCLUSIONS Prophylactic ET for moderately dilated descending aorta is an effective strategy for staged repair, especially in patients with chronic dissection, connective tissue disorder, and aortitis. In addition, this approach can be beneficial for emergency treatment of late distal aortic complications.
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Affiliation(s)
- Jay J Idrees
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Charles M Wojnarski
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ke Feng
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Muhammad Aftab
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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21
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Pichlmaier M, Reichelt A, Günther S, Hoffmann AL, Peterß S, Hagl C. Operative Strategien bei Typ-A-Dissektion. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2015. [DOI: 10.1007/s00398-015-0004-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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