Self-pay insurance status is associated with failure of medical therapy in patients with acute uncomplicated type B aortic dissection

BACKGROUND

Traditionally, acute uncomplicated type B aortic dissections are managed medically, and acute complicated dissections are managed surgically. Self-pay patients with medically managed acute uncomplicated type B aortic dissections may fare worse than their insured counterparts.

METHODS

In this single-center, retrospective cohort study, demographics, follow-up, and outcomes of patients with acute type B aortic dissections from 2011 to 2020 were analyzed.

RESULTS

In total, 159 patients presented with acute type B aortic dissections; 102 were complicated and managed with thoracic endovascular aortic repair, and 57 were uncomplicated and managed medically. A total of 32% (n = 51) were self-pay. Self-pay patients were from areas with worse area deprivation indices (71% vs 63%, P = .024). They more often reported alcohol abuse (28% vs 7%, P < .001), cocaine/methamphetamine use (16% vs 5%, P = .028), and nonadherence to home antihypertensives (35% vs 11%, P < .001). Self-pay patients less often had a primary care physician (65% vs 7%, P < .001) or took antihypertensives before admission (31% vs 58%, P = .003). Self-pay patients frequently required financial assistance at discharge (63%), most often using charity funds (46%). Few patients (7%) qualified for our hospital's financial assistance program, and most (78%) remained uninsured at the first follow-up. Self-pay acute uncomplicated type B aortic dissections patients had the lowest rate of follow-up (31% vs 66%, P < .001) and were more likely to represent emergently (75% vs 0%, P = .033) compared to insured acute uncomplicated type B aortic dissections patients. Self-pay patients were more likely to follow up after thoracic endovascular aortic repair for acute complicated type B aortic dissections (82% vs 31%, P < .001).

CONCLUSION

Self-pay patients have multiple, interconnected, complex socioeconomic factors that likely influence preadmission risk for dissection and post-discharge adherence to optimal medical management. Further research is needed to clarify treatment strategies in this high-risk group.

Volume-failure-to-rescue relationship in acute type A aortic dissections: An analysis of The Society of Thoracic Surgeons Database

OBJECTIVE

To determine the relationship between volume of cases and failure-to-rescue (FTR) rate after surgery for acute type A aortic dissection (ATAAD) across the United States.

METHODS

The Society of Thoracic Surgeons adult cardiac surgery database was used to review outcomes of surgery after ATAAD between June 2017 and December 2021. Mixed-effect models and restricted cubic splines were used to determine the risk-adjusted relationships between ATAAD average volume and FTR rate. FTR calculation was based on deaths associated with the following complications: venous thromboembolism/deep venous thrombosis, stroke, renal failure, mechanical ventilation >48 hours, sepsis, gastrointestinal complications, cardiopulmonary resuscitation, and unplanned reoperation.

RESULTS

In total, 18,192 patients underwent surgery for ATAAD in 832 centers. The included hospitals' median volume was 2.2 cases/year (interquartile range [IQR], 0.9-5.8). Quartiles' distribution was 615 centers in the first (1.3 cases/year, IQR, 0.4-2.9); 123 centers in the second (8 cases/year, IQR, 6.7-10.2); 66 centers in the third (15.6 cases/year, IQR, 14.2-18); and 28 centers in the fourth quartile (29.3 cases/year, IQR, 28.8-46.0). Fourth-quartile hospitals performed more extensive procedures. Overall complication, mortality, and FTR rates were 52.6%, 14.2%, and 21.7%, respectively. Risk-adjusted analysis demonstrated increased odds of FTR when the average volume was fewer than 10 cases per year.

CONCLUSIONS

Although high-volume centers performed more complex procedures than low-volume centers, their operative mortality was lower, perhaps reflecting their ability to rescue patients and mitigate complications. An average of fewer than 10 cases per year at an institution is associated with increased odds of failure to rescue patients after ATAAD repair.

Intraoperative Hemi-Diaphragm Electrical Stimulation Demonstrates Attenuated Mitochondrial Function without Change in Oxidative Stress in Cardiothoracic Surgery Patients

Mechanical ventilation during cardiothoracic surgery is life-saving but can lead to ventilator-induced diaphragm dysfunction (VIDD) and prolong ventilator weaning and hospital length of stay. Intraoperative phrenic nerve stimulation may preserve diaphragm force production to offset VIDD; we also investigated changes in mitochondrial function after stimulation. During cardiothoracic surgeries (n = 21), supramaximal, unilateral phrenic nerve stimulation was performed every 30 min for 1 min. Diaphragm biopsies were collected after the last stimulation and analyzed for mitochondrial respiration in permeabilized fibers and protein expression and enzymatic activity of biomarkers of oxidative stress and mitophagy. Patients received, on average, 6.2 ± 1.9 stimulation bouts. Stimulated hemidiaphragms showed lower leak respiration, maximum electron transport system (ETS) capacities, oxidative phosphorylation (OXPHOS), and spare capacity compared with unstimulated sides. There were no significant differences between mitochondrial enzyme activities and oxidative stress and mitophagy protein expression levels. Intraoperative phrenic nerve electrical stimulation led to an acute decrease of mitochondrial respiration in the stimulated hemidiaphragm, without differences in biomarkers of mitophagy or oxidative stress. Future studies warrant investigating optimal stimulation doses and testing post-operative chronic stimulation effects on weaning from the ventilator and rehabilitation outcomes.

Dysphagia after cardiac surgery: Prevalence, risk factors, and associated outcomes

OBJECTIVES

The study objectives were to determine the prevalence of swallowing impairment in adults after cardiac surgery and examine associated risk factors and health-related outcomes.

METHODS

A prospective single-center study was conducted in postoperative adult cardiac surgery patients with no history of dysphagia. A standardized fiberoptic endoscopic evaluation of swallowing was performed within 72 hours of extubation. Blinded raters completed validated outcomes of swallowing safety and efficiency. Demographic, surgical, and postoperative health-related outcomes were collected. Univariate and multivariable regression analyses were performed with odds ratios (OR) and 95% confidence intervals (CIs).

RESULTS

In 182 patients examined, imaging confirmed inefficient swallowing (residue) in 52% of patients and unsafe swallowing in 94% (65% penetrators, 29% aspirators). Silent aspiration was observed in 53% of aspirators, and 32% did not clear aspirate material. Independent risk factors for aspiration included New York Heart Association III and IV (OR, 2.9; CI, 1.2-7.0); reoperation (OR, 2.0; CI, 0.7-5.5); transesophageal echocardiogram images greater than 110 (OR, 2.6; CI, 1.1-6.3); intubation greater than 27 hours (OR, 2.1; CI, 0.8-5.3); and endotracheal tube size 8.0 or greater (OR, 3.1; CI, 1.1-8.6). Patients with 3 or 4 identified risk factors had a 16.4 (CI, 3.2-148.4) and 22.4 (CI, 3.7-244.7) increased odds of aspiration, respectively. Compared with nonaspirators, aspirators waited an additional 85 hours to resume oral intake, incurred $49,372 increased costs, and experienced a 43% longer hospital stay (P < .05). Aspiration was associated with pneumonia (OR, 2.6; CI, 1.1-6.5), reintubation (OR, 5.7; CI, 2.1-14.0), and death (OR, 2.8; CI, 1.2-9.0).

CONCLUSIONS

Tracheal aspiration was prevalent, covert, and associated with increased morbidity and mortality.

Abstract 301: Inhibition Of Tlr-7 Signaling Attenuates TAAD Formation

The critical role for chronic inflammation in the development of thoracic aortic aneurysms and dissections (TAADs) has been recognized in both experimental and clinical settings. However, challenges remain on translating this knowledge to clinical applications. In this study, we tested the hypothesis that TLR-7 signaling triggered by self-RNAs substantiates chronic inflammation, promoting TAAD formation. A mouse TAAD model induced by SMC-specific deletion of Tgfbr1 ( Tgfbr1 iko ) was used. In this model, the expression of TLR-7 was progressively upregulated during the early stages, resulting in a two-fold differential at two weeks compared to control aortas ( P =0.003). RNAScope assays showed that cells located in the media and adventitia were responsible for the upregulation. Additionally, immunofluorescence (IF) staining showed that TLR-7 is induced in human TAADs. Treatment with hydroxychloroquine, which inhibits TLR-7 receptor function, significantly reduced the number of intimal/medial tears ( P =0.026) and mitigated intramural hemorrhage ( P =0.007) compared with vehicle controls (n=7/group). Further assays with bone marrow derived dendritic cells demonstrated that RNAs, particularly small RNAs, extracted from TAADs induced significantly higher IFNα/β levels compared with normal aortas ( P =0.025). Similarly, RNAs extracted from Tgfbr1 iko SMCs induced higher levels of IFNα, IP-10, and MCP1 compared with those harvested from wild type SMCs. Necroptosis (labeled with RIPK3 and pMLKL) and RNA-oxidation (labeled with 8-OHG) were evident in the media of TAADs, and might serve as the source for the endogenous TLR-7 ligand. Finally, treatment with the TLR-7 specific inhibitor, M5049, at a dose of 1.0 or 5.0 mg/kg/day via oral gavage prevented dilation of TAADs at four weeks compared with vehicle controls (9% vs. 8% vs. 23%, P<0.001). In conclusion, self-RNAs released from stressed and dying cells is associated with chronically inflamed aortic tissue and promotes TAAD development via triggering TLR-7 signaling. Blocking TLR-7 signaling may represent a novel strategy to treat human TAADs.

The Effect of COVID-19 on Cardiac Surgical Volume and its Associated Costs

The COVID-19 pandemic significantly affected health care and in particular surgical volume. However, no data surrounding lost hospital revenue due to decreased cardiac surgical volume have been reported. The National Inpatient Sample database was used with decreases in cardiac surgery at a single center to generate a national estimate of decreased cardiac operative volume. Hospital charges and provided charge to cost ratios were used to create estimates of lost hospital revenue, adjusted for 2020 dollars. The COVID period was defined as January to May of 2020. A Gompertz function was used to model cardiac volume growth to pre-COVID levels. Single center cardiac case demographics were internally compared during January to May for 2019 and 2020 to create an estimate of volume reduction due to COVID. The maximum decrease in cardiac surgical volume was 28.3%. Cumulative case volume and hospital revenue loss during the COVID months as well as the recovery period totaled over 35 thousand cases and 2.5 billion dollars. Institutionally, patients during COVID months were younger, more frequently undergoing a CABG procedure, and had a longer length of stay. The pandemic caused a significant decrease in cardiac surgical volume and a subsequent decrease in hospital revenue. This data can be used to address the accumulated surgical backlog and programmatic changes for future occurrences.

Massive Tension Hemothorax After Pacemaker Implantation

A case of an 85-year-old male on apixaban and clopidogrel undergoing pacemaker implantation is described. After procedure he developed unilateral tension hemothorax and required emergent drainage and exploratory thoracotomy. No vascular, cardiac, or pulmonary source was identified. After multidisciplinary discussions, it was speculated that spontaneous intercostal vessel rupture due to forceful coughing and elevated blood pressure during the procedure was the most likely cause of bleeding.

Thoracic Surgery Foundation Research Awards: Leading the Way to Excellence

BACKGROUND

Combining clinical and research excellence has become an increasingly difficult endeavor for thoracic surgeons, with typical success rates for the NHLBI and NCI being 25.1% and 11.3% respectively. The Thoracic Surgery Foundation (TSF), which is an arm of the Society of Thoracic Surgeons, provides research awards and grants aimed at early career faculty to assist in securing federal peer reviewed funding. The aim of this study was to assess the impact of these awards.

METHODS

Faculty awardees of the TSF research awards from 1995 to 2019 were included in the study. The scholarly work of awardees was assessed using SCOPUS , MEDLINE, and google scholar for publications, citations and h-index. NIH RePorter and federal RePorter was used to search for any grants awarded to these individuals. For publications and citations associated with a TSF grant, a four-year window from the time of the research award was utilized.

RESULTS

Fifty-two research awards were given to early career faculty during this study period, 8 (15%) were awarded to MD PhDs. Six (12%) of awardees were female. Cardiac faculty were awarded 27 (52%) of awards and general thoracic faculty were awarded 25 (48%); of the cardiac faculty, 4 (17.4%) were congenital cardiac faculty. In the 4-year period following the TSF grant award, the mean number of published articles per awardee was 23 (interquartile range (IQR) 12-36) with a median citation count of 147 (IQR 32-327). The current median h-index was 26 (IQR 15-36) with 2,323 (IQR 1,173-4,568) median citations. Forty-eight percent of all awardees received at least 1 subsequent grant grant, with 40.4% being awarded from the NIH and25% having two or more NIH grants. Comparing academic position at the time of the award to current position, 54% of awardees had an advancement in their professional rank. On analyzing leadership positions, 42% of awardees were division chiefs, 21% were associate clinical directors, and 28% were clinical directors.

CONCLUSIONS

Being a recipient of the TSF award may position an individual to excel in academic medicine, with a large portion of awardees improving their academic standing with time. The rate of successful NIH grant funding after being a TSF awardee is higher than typical institutional success rates.

10-Year Trends in Aortic Dissection: Mortality and Weekend Effect within the US Nationwide Emergency Department Sample (NEDS)

BACKGROUND

This study examined changes in aortic dissection (AD) mortality from 2006 to 2017 and assessed the impact of weekday versus weekend presentation upon mortality.

METHODS

This observational study analyzed all records in the Nationwide Emergency Department Sample (NEDS) database. NEDS aggregates discharge data from 984 hospitals in 36 states and the District of Columbia in the United States of America. All patients with thoracic and thoracoabdominal AD recorded as their principal diagnosis were identified via ICD codes.

RESULTS

Patient characteristics (weekday|weekend) count: 26,759|9,640, P = 0.016; age (years): 65.2 ± 15.8|64.7 ± 16.2, P = 0.016; women: 11,318 (42.3%)|4,086 (42.4), P = 0.883; Charlson comorbidity index: 2.3 ± 1.7|2.3 ± 1.6, P = 0.025. There were 36,399 ED visits with diagnosed AD. Annual AD diagnoses increased by 70% from 2006 to 2017. From 2012-2017, patients had lower in-hospital mortality (9.9% versus 11.9%, P < 0.001) compared with 2006-2011. Patients reporting during the weekend had higher in-hospital mortality (11.8% versus 10.4%, P < 0.001) compared with weekdays. On multivariable analysis, year of presentation remained independently associated with in-hospital mortality, with 2012-2017 being associated with reduced mortality (odds ratio (OR) 0.90, 95% CI: 0.82, 0.99, P = 0.031), as compared with 2006-2011. Weekend presentation remained independently associated with worse in-hospital mortality (OR 1.17, 95% CI: 1.05, 1.29, P = 0.003) compared with weekday presentation.

CONCLUSION

Although AD mortality is decreasing, the patients presenting on the weekend were 13% more likely to die in the hospital compared with patients presenting during the week.

Percutaneous Inferior Vena Cava Valve Implantation May Improve Tricuspid Valve Regurgitation and Cardiac Output: Lessons Learned

Tricuspid valve regurgitation (TR) can be associated with poor prognosis. Transcatheter valve technology was adopted to treat the upstream effects of severe TR by placing a transcatheter valve in the inferior vena cava (IVC). In this study, we report off-label transcatheter valve implantation into the stented IVC in patients with severe TR for compassionate use. From September 2018 to February 2020, 6 inoperable patients with severe TR who failed medical treatment underwent percutaneous caval valve implantation (CAVI). Severity of TR was confirmed by intraoperative transesophageal echocardiography. Z-stents (Cook, Inc., Bloomington, IN, USA) were placed in the proximal IVC, and then a transcatheter valve was deployed in the suprahepatic cava without rapid pacing. Six patients, 2 females and 4 males, with a mean ± SD age of 74.7 ± 8.0 years were included. The procedure was successfully performed in all 6 patients (100%) employing a 29-mm SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA, USA) with supranominal volume. No procedural complication was detected. At 30 days, TR improved from severe to trace in 1 patient, to mild-moderate in 3 patients, and 2 patients remained with severe TR. Among patients with improved TR, left ventricular ejection fraction increased from 47.5% ± 18.5% to 55% ± 20.4% (P = 0.014). No patient had readmission at 30 days. Four patients needed rehospitalization within 6 months. Percutaneous CAVI is feasible and can be considered as a short-term palliative measure in patients with severe TR. CAVI can improve TR and potentially improve cardiac output in selected patients.

Vocal Fold Mobility Impairment After Cardiovascular Surgery: Incidence, Risk Factors, and Sequela

BACKGROUND

We aimed to determine the incidence and contributing risk factors of vocal fold mobility impairment (VFMI) in postoperative cardiovascular patients and evaluate the impact of VFMI on health-related outcomes.

METHODS

This single-site prospective study enrolled adults undergoing sternotomy or thoracotomy procedures who underwent a fiberoptic laryngoscopy examination within 72 hours of extubation. Potential demographic and surgical risk factors and health-related outcomes were collected. A blinded laryngologist assessed VFMI and mucosal injury. Descriptives, univariate and multivariable regression analyses with odds ratios (OR) were performed.

RESULTS

Of 185 eligible examinations, VFMI was confirmed in 25% of patients (7 complete, 39 partial VFMI) with left-sided involvement in 83% of cases. Laryngeal mucosal injury included granuloma (38%), posterior cricoid hypertrophy (37%), edema (29%), bruising (23%), and hemorrhage (9%). Independent risk factors for complete VFMI were aortic arch procedure (odds ratio 6.1), body mass index less than 25 (OR: 7.2), and African-American or Hispanic race (OR: 6.0). Patients with two or more identified risk factors had a 33.0 increased odds of complete VFMI compared with patients not having two or more risk factors. Compared with patients having normal vocal fold motion, patients with complete VFMI had a 2.7 increased odds of pneumonia, 5.7 higher odds of reintubation, a 7.3 times higher odds of death, and increased length of hospital stay and cost of care (P < .05).

CONCLUSIONS

Interdisciplinary postoperative care and laryngoscopy examination are recommended for high-risk patients to facilitate early detection and improve patient outcomes.

Time of day does not influence outcomes in acute type A aortic dissection: Results from the IRAD

BACKGROUND

Type A acute aortic dissection (TAAAD) represents a surgical emergency requiring intervention regardless of time of day. Whether such a "evening effect" exists regarding outcomes for TAAAD has not been previously studied using a large registry data.

METHODS

Patients with TAAAD were identified from the International Registry of Acute Aortic Dissections (1996-2019). Outcomes were compared between patients undergoing operative repair during the daytime (D), defined as 8 am-5 pm, versus the evening (N), defined as 5 pm-8 am.

RESULTS

Four thousand one-hundrd and ninety-seven surgically treated patients with TAAAD were identified, with 1824 patients undergoing daytime surgery (43.5%) and 2373 patients undergoing evening surgery (56.5%). Daytime patients were more likely to have undergone prior cardiac surgery (13.2% vs. 9.5%; p < .001) and have had a prior aortic dissection (4.8% vs. 3.4%; p = .04). Evening patients were more likely to have been transferred from a referring hospital (70.8% vs. 75.0%; p = .003). Daytime patients were more likely to undergo aortic valve sparing root procedures (23.3% vs. 19.2%; p = .035); however, total arch replacement was performed with equal frequency (19.4% vs. 18.8%; p = .751). In-hospital mortality (D: 17.3% vs. N. 16.2%; p = .325) was similar between both groups. Subgroup analysis examining the effect of weekend presentation revealed no significant mortality difference.

CONCLUSIONS

A majority of TAAAD patients underwent surgical repair at night. There were higher rates of postoperative tamponade in evening patients; however, mortality was similar. The expertise of cardiac-dedicated operative and critical care teams regardless of time of day as well as training paradigms may explain similar mortality outcomes in this high risk population.

Outcomes of Direct Transcatheter Aortic Valve Replacement Without Balloon Aortic Valvuloplasty Using a New Generation Valve

PURPOSE

We investigated the outcomes of patients who underwent Transcatheter Aortic Valve Replacement (TAVR) with and without Balloon Aortic Valvuloplasty (BAV) using the SAPIEN 3 (S3) valve.

METHODS

All patients who underwent TAVR using S3 valve were included. The primary outcomes were the incidence of stroke and significant paravalvular leak (PVL). Secondary outcomes were the incidence of mortality, balloon post dilation, and need for permanent pacemaker.

RESULTS

From July-2014 to April-2018, 34 (9%) patients underwent BAV prior to TAVR and 344 (91%) patients underwent direct TAVR without BAV using the S3 valve. The Society of Thoracic Surgeons (STS) risk score was similar between two groups; 5.8 ± 3.5 in no BAV group and 5.4 ± 3.3 in BAV group, p = 0.53. After TAVR, 6 (1.7%) patients in no BAV group but no patient in BAV group developed stroke (p = 1.0). No patient had severe PVL and only 5 patients (1.3%) had moderate PVL at 30-day; 4 (1.2%) in no BAV group and 1 (2.9%) in BAV group (p = 0.38). Forty-six patients (13.4%) in the no BAV group and 4 (11.8%) patients in the BAV group needed balloon post dilation (p = 1.0). Six (1.6%) patients died during hospitalization, all in the no BAV group (p = 1.0). Forty-five (11.9%) patients needed new pacemaker implantation; 44 (12.8%) patients in no BAV group and 1 (2.9%) patient in BAV group (p = 0.1). Two-year survival rate was 85% in no BAV group and 84% in BAV group (p = 0.46).

CONCLUSIONS

TAVR using S3 valves is associated with very low rates of post-TAVR stroke and significant PVL. Outcomes of direct TAVR are similar to the outcomes of TAVR with BAV, without an increased rate of stroke, significant PVL, or balloon post dilation.

Impact of Foley Catheter Placement by Medical Students on Rates of Postoperative Urinary Tract Infection

BACKGROUND

The aim of this study was to evaluate the impact of medical student placement of Foley catheters on rates of postoperative catheter-associated urinary tract infection (CAUTI).

STUDY DESIGN

We included adult surgical patients in our institutional National Surgical Quality Improvement Program (NSQIP) database, and defined CAUTI according to NSQIP criteria. A multivariable model risk-adjusting for patient and operative variables associated with CAUTI in univariate analysis (exploratory p < 0.20) evaluated the independent effect of medical student placement of Foley catheters on the odds of CAUTI.

RESULTS

There were 891 patients who had a Foley catheter placed by a surgical resident (61%; n = 547), operating room nurse (25%; n = 227), or medical student (13%; n = 117). After risk-adjustment, patients with Foleys placed by medical students were at a more than 4-fold increased risk of CAUTI (odds ratio [OR] 4.09, p = 0.02) compared with patients with catheters placed by nurses. Patients with catheters placed by residents did not have an increased risk-adjusted odds of CAUTI (OR 2.16, p = 0.15). Other significant predictors of postoperative CAUTI included female sex (OR 2.61, p = 0.01), partial/total functional dependence (OR 4.81, p = 0.008), blood transfusion (OR 34.7, p = 0.02), and increased length of Foley stay (OR 1.06, p < 0.001).

CONCLUSIONS

Surgical patients with Foley catheters placed by medical students are at increased risk-adjusted odds of postoperative CAUTI. More intense supervision of medical students during urinary catheter insertion in the operating room and improved education regarding sterile technique may be important factors in reducing rates of postoperative CAUTI in academic institutions.

Florida Sleeve Procedure Is Durable and Improves Aortic Valve Function in Marfan Syndrome Patients

BACKGROUND

The Florida sleeve (FS) procedure was developed as a simplified approach for repair of functional type I aortic insufficiency secondary to aortic root aneurysm. We evaluated postoperative aortic valve function, long-term survival, and freedom from reoperation in Marfan syndrome patients who underwent the FS procedure at our center.

METHODS

All Marfan syndrome patients undergoing FS procedure from May 2002 to December 2014 were included. Echocardiography assessment included left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), ejection fraction, and degree of aortic insufficiency (none = 0, minimal = 1, mild = 2, moderate = 3, severe = 4). Social Security Death Index and primary care physicians' report were used for long-term follow-up.

RESULTS

Thirty-seven Marfan syndrome patients, 21 (56.8%) men and 16 (43%) women with mean age of 35.08 ± 13.45 years underwent FL repair at our center. There was no in-hospital or 30-day death or stroke. Two patients required reoperation due to bleeding. Patients' survival rate was 94% at 1 to 8 years. Freedom from reoperation was 100% at 8 years. Twenty-five patients had postoperative follow-up echocardiography at 1 week. Aortic insufficiency grade significantly decreased after the procedure (preoperative mean ± SD: 1.76 ± 1.2 versus 1-week postoperative mean ± SD: 0.48 ± 0.71, p < 0.001), and mean LVEDD decreased from 52.23 ± 5.29 mm to 47.53 ± 8.89 mm (p = 0.086). Changes in LVESD (35.33 ± 9.97 mm to 36.58 ± 9.82 mm, p = 0.58) and ejection fraction (57.65% ± 6.22% to 55% ± 10.83%, p = 0.31) were not significant.

CONCLUSIONS

The FS procedure can be performed safely in Marfan syndrome patients with immediate improvement in aortic valve function. Long-term survival and freedom from reoperation rates are encouraging.

Inhaled amyl nitrite effectively reverses acute catastrophic thromboxane-mediated pulmonary hypertension in pigs

Acute catastrophic pulmonary vasoconstriction frequently leads to cardiovascular collapse. Rapid and selective pulmonary vasodilation is desired in order to restore haemodynamic stability. This pilot study examined the effectiveness of inhaled amyl nitrite as a selective pulmonary vasodilator. Nine adult swine were anaesthetized. Acute pulmonary hypertension with haemodynamic collapse was induced with a bolus administration of a thromboxane analogue, U46619. Six animals then received a capsule of amyl nitrite. The administration of inhaled amyl nitrite decreased mean pulmonary artery pressure from 42 +/- 3 to 22 +/ 3 mmHg at five minutes (p < 0.05), with a concomitant increase in cardiac output and mean arterial pressure. Pulmonary vascular resistance decreased from 4889 +/- 1338 to 380 +/- 195 dyne. sec. cm(-5) (by 92% from the maximal pulmonary hypertension change), with significant improvement in systemic haemodynamics. During acute thromboxane-mediated pulmonary hypertension with cardiovascular collapse, prompt administration of inhaled amyl nitrite was effective in restoring pulmonary and systemic haemodynamics within five minutes.