Percutaneous cardioplegic arrest before repeat sternotomy in patients with retrosternal aortic aneurysm

Bilateral antegrade cerebral perfusion during hypothermic circulatory arrest before sternal reentry for aortic pseudoaneurysm repair

Sternal reentry for repair of aortic pseudoaneurysms poses a unique technical challenge to prevent exsanguination. Initiation of peripheral cardiopulmonary bypass and deep hypothermic circulatory arrest prior to reentry are the cornerstones of a successful surgical approach. Adjunctive bilateral antegrade cerebral perfusion increases safe arrest time and reduces neurologic morbidity. Herein, we describe our safe reentry technique for aortic pseudoaneurysm repair in two patients.

Aortic root allograft reoperations

OBJECTIVE

To investigate outcomes after aortic root allograft reoperation, identify risk factors for morbidity and mortality, and describe practice evolution since publication of our 2006 allograft reoperation study.

METHODS

From January 1987 to July 2020, 602 patients underwent 632 allograft-related reoperations at Cleveland Clinic: 144 before 2006 (early era, which suggested radical explant was superior to aortic-valve-replacement-within-allograft [AVR-only]), and 488 from 2006 to present (recent era). Indications for reoperation were structural valve deterioration in 502 (79%), infective endocarditis in 90 (14%), and nonstructural valve deterioration/noninfective endocarditis in 40 (6.3%). Reoperative techniques included radical allograft explant in 372 (59%), AVR-only in 248 (39%), and allograft preservation in 12 (1.9%). Perioperative events and survival were assessed among indications, techniques, and eras.

RESULTS

Operative mortality by indication was 2.2% (n = 11) for structural valve deterioration, 7.8% (n = 7) in those with infective endocarditis, and 7.5% (n = 3) for nonstructural valve deterioration/noninfective endocarditis, and by surgical approach 2.4% (n = 9) after radical explant, 4.0% (n = 10) for AVR-only, and 17% (n = 2) for allograft preservation. Operative adverse events occurred in 4.9% (n = 18) of radical explants and 2.8% (n = 7) of AVR-only procedures (P = .2). Patients undergoing radical explants received larger valves than those undergoing AVR-only (median, 25 vs 23 mm).

CONCLUSIONS

Aortic root allograft reoperations present a technical challenge but can be performed with low mortality and morbidity. Radical explant offers outcomes similar to AVR-only while allowing for implant of larger prostheses. Increasing experience with allograft reoperations has permitted excellent outcomes; thus, risk of reoperation should not dissuade surgeons from using allografts for invasive aortic valve infective endocarditis and other indications.

Hypothermic Circulatory Arrest in Median Sternotomy Hemorrhage During Redo Aortic Surgery

INTRODUCTION

This study summarizes the clinical data of patients who developed sternotomy hemorrhage during redo aortic surgery and analyzes the clinical experience of using hypothermic circulatory arrest.

METHODS

We retrospectively analyzed the medical records of patients who developed sternotomy hemorrhage during redo aortic surgery from May 2018 to August 2021. General anesthesia with single-lumen tracheal intubation was used. Femoral artery, vein, and superior vena cava cannulation were used if cardiopulmonary bypass was required according to the situation, and right superior vein or apical cannulation was selected for left heart drainage.

RESULTS

A total of 11 patients were enrolled in this study, comprising nine males and two females, with an average age of 44.3±16.7 years. All cases were successfully completed without cerebrovascular complications or paraplegia. Two patients died during hospitalization, two patients died during the follow-up after discharge, and the remaining patients are recovering well.

CONCLUSION

The femoral-femoral bypass with hypothermic circulatory arrest technique is a safe and reliable method to use in cases of sternotomy hemorrhage during redo aortic surgery.

Aortosubpulmonary Fistula after Konno-Rastan Aortoventriculoplasty

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Degeneration of a Konno patch can result in a complicated aortic pseudoaneurysm.

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Multimodality imaging was required for diagnosis and intraoperative management.

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Peripheral cardiopulmonary bypass and retroplegic cardiac arrestprior to sternotomy can prevent fatal hemorrhage.

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An endovascular aortic occlusion device can be used to “clamp” the aorta.

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Multimodal imaging and a multidisciplinary team were required for optimal results.

Modern practice and outcomes of reoperative cardiac surgery

OBJECTIVES

To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest.

METHODS

From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect.

RESULTS

Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2).

CONCLUSIONS

Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy.

Multimodality Imaging in the Evaluation of Ascending Aortic Pseudoaneurysms to Guide Complex Surgical Management

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Treatment of an AAP is surgical.

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The CorMatrix patch can lead to degradation and pseudoaneurysm formation.

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Use of multimodality imaging is key to evaluate, diagnose, and guide operation.