Late reoperations after acute aortic dissection repair: Single-center experience.

BACKGROUND: After repair of acute type A aortic dissection, aortic complications can develop, and reoperations might be necessary. In our retrospective study, we wanted to assess early and late outcomes in this cohort of patients. METHODS: From September 2005 to July 2012, 21 consecutive patients previously operated on for acute type A aortic dissection underwent 27 redo aortic surgical procedures. Indications for redo procedures were: enlargement of the false lumen in the residual aorta (18 events), severe aortic regurgitation with or without aortic root dilatation (8 events), suture dehiscence and pseudoaneurysm at the proximal or distal aortic graft anastomosis (5 events) or at the coronary button anastomosis in patients who previously underwent a Bentall procedure (1 patient). In all cases, total or partial cardiopulmonary bypass was used. Hypothermic cardiocirculatory arrest was needed in 22 (81%) procedures. RESULTS: Hospital mortality was 3.7% (1/27), reexploration for bleeding and paraplegia rates were 7.4% and 7.4%, respectively. Marfan patients received 3.2 procedures per patient vs. 1.5 in non-Marfan patients (p < 0.01). At a mean follow-up of 6.5 years, 2 aortic events occurred: 1 aortic death, and 1 additional aortic redo surgery. CONCLUSIONS: When procedures are carried out on elective basis, redo aortic surgery can be performed in all segments of the aorta with good early and late outcomes. Close lifelong clinical and radiological follow-up is mandatory. After repair of acute type A aortic dissection, Marfan patients are more prone to develop late complications, with a more rapid evolution.

Femoral cannulation with long arterial cannula in aortic dissection.

The optimal cannulation site in repair of DeBakey type I aortic dissection is controversial, and malperfusion during cardiopulmonary bypass is facilitated by retrograde flow. We propose the use of a long arterial cannula through the femoral artery to achieve a proximal antegrade perfusion. The tip of the cannula is placed in the true lumen of the distal aortic arch through the common femoral artery (Seldinger technique and transesophageal echography guidance). In 9 patients, there was one case of operative mortality (cardiac death), and no cases of perioperative stroke, bowel ischemia, severe renal failure, or local complications. Proximal perfusion can achieved rapidly and through an easily accessible site.

Results of reoperation on the aortic root and the ascending aorta.

BACKGROUND: Reoperations on the aortic root and the ascending aorta after previous aortic valve and proximal aortic surgery are increasingly frequent and highly demanding. The scarce comparability of the published series and the heterogeneity of clinical pictures contribute to the challenges of this subgroup. METHODS: Forty-one patients (2004 to 2010) who were reoperated on the aortic root and the ascending aorta for aneurysmal, pseudoaneurysmal, or infectious disease were retrospectively analyzed from a prospectively filled-in database. RESULTS: Mean logistic European system for cardiac operative risk evaluation was 29.8%. At index reoperation, procedures were classic Bentall (51%), prosthesis-sparing operation (17%), supracoronary ascending aortic replacement plus aortic valve replacement-repair (22%), and root replacement using valved homografts (9.7%). Distally, the operation involved the arch in 51% of cases (17 hemiarch replacement, 4 total transverse arch, 3 elephant trunk). Operative mortality was 12% and rate of major operative morbidity was 17%. At a mean 26-months follow-up, the patients surviving the operation had a good survival and functional class. The rate of adverse events during the follow-up was acceptable. CONCLUSIONS: Reoperations on the aortic root-ascending aorta in the elective patients have respectable operative mortality-morbidity despite the high-risk profile, and are justified by the excellent follow-up survival. The mortality can be diminished by integrated surgical strategies and optimal myocardial protection. Our findings encourage complete resection of borderline dilated ascending aortic-root tissue at primary and redo operation.

Extracorporeal circulation by peripheral cannulation before redo sternotomy: indications and results.

OBJECTIVES: Cardiac reoperations are challenging and time-consuming, and have a high risk for reentry injuries. We discuss the indications, advantages, and technologic features of cardiopulmonary bypass by peripheral cannulation before resternotomy. METHODS: Of 610 redo cardiac interventions from 2000 to 2006, 158 (25.9%) were performed with peripheral cannulation and ongoing cardiopulmonary bypass before resternotomy. This was indicated in the following: close adhesions between the sternum and the anterior cardiac surface; ascending aorta or bypass grafts (computed tomography scan); and patients with functional tricuspid regurgitation, hemodynamic/electric instability, previous mediastinitis, or depressed ejection fraction. Intraoperative transesophageal echocardiography was always performed. RESULTS: Venous drainage was obtained by cannulation of the common femoral vein (Seldinger technique) and right internal jugular vein (percutaneously). Arterial nonocclusive cannula was placed in the femoral artery (Seldinger technique). Cardiopulmonary bypass time before cardiotomy was 35 +/- 14.7 minutes. There were 5 perioperative deaths, none due to reentry injury. Damage to mediastinal structures at resternotomy occurred in 4 cases. In all cases, peripheral cardiopulmonary bypass allowed adequate and comfortable repair. The operative time was 296 +/- 60 minutes. The average total postoperative bleeding was 264 +/- 38 mL/m(2). No patient experienced complications related to femoral cannulation. The Seldinger method allowed little vascular trauma and intraoperative patency of femoral vessels. CONCLUSION: In selected patients, cardiopulmonary bypass before resternotomy is a valid and reproducible option to render cardiac reoperations safer and more expeditious in the reentry phase. The absence of cannulae in the operating field makes the procedure more comfortable. The liberal use of this strategy is recommended in redo cases.

Giant left coronary ostial aneurysm after modified Bentall procedure in a Marfan patient.

We performed surgical repair of a giant left coronary ostial aneurysm after aortic root replacement using composite valve graft (modified Bentall procedure) in a patient with Marfan syndrome. Aneurysmal formation in the left main stem itself is very rare. In order to avoid mobilizing the coronary ostium from severe adhesions after previous surgery and to reduce the tension on the anastomosis, the left main trunk was reconstructed using an interposition Dacron graft. In aortic root surgeries in Marfan patients, the size of the side hole on the composite graft should be kept relatively small to fit the diameter of the native coronary arteries for prevention of coronary buttons from forming aneurysms at the level of the coronary button anastomosis. In addition, close observation to the coronary button anastomosis is indispensable in postoperative check-up.

Endoscopic cardiac tumor resection.

BACKGROUND: The purpose of this study is to report our 9 years' experience with endoscopic cardiac tumor resection using the port access approach. METHODS: From March 1997 to December 2005, 27 patients (mean age, 56.2 +/- 16.9 years; 70% female) underwent endoscopic cardiac tumor resection using endocardiopulmonary bypass and endoaortic-balloon clamp technique. Nineteen (70%) patients presented in New York Heart Association class I, 4 patients presented with embolic stroke, and 4 patients presented with atrial arrhythmias. All patients underwent echocardiography on admission, intraoperatively, at discharge, and at follow-up evaluation. Eight patients additionally required mitral valve replacement (n = 1), tricuspid valve replacement (n = 1), mitral valve repair (n = 2), mini-maze (n = 1), and closure of patent foramen ovale (n = 3). Mean follow-up was 3.4 +/- 2.7 years. RESULTS: Mean endoaortic-balloon clamp and endocardiopulmonary bypass times were 68.8 +/- 30.8 minutes and 112.2 +/- 41.5 minutes, respectively. There were no conversions to sternotomy. Tumors resected were classified as left atrial myxoma (n = 20), right atrial myxoma (n = 3), lipoma (n = 1), intravenous leiomyoma involving the inferior vena cava and the tricuspid valve (n = 1), plexiform tumor of the sinoatrial node (n = 1), and papillary fibroelastoma of aortic valve noncoronary cusp (n = 1). There were no hospital deaths. Mean intensive care unit and hospital stays were 1.4 +/- 1.1 days and 7.3 +/- 3.4 days, respectively. Postoperative complications were evolving stroke (n = 1), re-exploration for bleeding (n = 1), and myocardial ischemia requiring stenting (n = 1). Follow-up failed to demonstrate residual or recurrent tumor. One patient had a small residual atrial septal defect. Ninety-two percent of patients appreciated the cosmetic result and fast recovery. CONCLUSIONS: Endoscopic cardiac tumor resection is feasible and a valid oncologic approach with an attractive cosmetic advantage over median sternotomy.

Current strategies in the surgical treatment of atrial fibrillation: review of the literature and Onze Lieve Vrouw Clinic's strategy.

Atrial fibrillation is the most common rhythm disturbance in clinical practice. It is a major source of stroke and morbidity. Although the Cox maze procedure effectively eliminates atrial fibrillation in most patients, the procedure has not found widespread application. As a consequence, new operations that use alternative sources of energy, such as radiofrequency, microwave, cryothermy, laser, and ultrasound have emerged to surgically create lesion sets to treat atrial fibrillation. This article reviews the fundamentals and current strategies in the surgical treatment of atrial fibrillation.

Minimally invasive versus standard approach aortic valve replacement: a study in 506 patients.

BACKGROUND: Minimally invasive aortic valve replacement through partial upper sternotomy has been shown to reduce surgical trauma, and, supposedly, decrease postoperative pain, blood loss, and hospital stay. METHODS: From October 1997 until November 2004, 506 patients received isolated aortic valve replacement, of which 232 underwent the minimal access J-sternotomy approach (group 1). The control group (group 2) consisted of 274 patients who underwent aortic valve replacements by median sternotomy. We retrospectively reviewed outcomes of the patients in the early follow-up period. RESULTS: In group 1 and group 2, respectively, early mortality was 2.6% (6 patients) and 4.4% (12 patients). The minimal access group had reduced aortic cross-clamp and cardiopulmonary bypass times compared with conventional group: 61.8 +/- 16.6 versus 69.5 +/- 16.6 minutes (p < 0.05) and 88.8 +/- 23.2 versus 100.2 +/- 22.6 minutes (p < 0.05), respectively. Mean blood loss was lower in group 1 compared with group 2 (p < 0.05). Intensive care unit and hospital stays were shorter in the minimal access group: 2.1 +/- 2.5 versus 2.5 +/- 5.3 days (p = nonsignificant) and 10.8 +/- 7.1 versus 12.8 +/- 10.6 days (p < 0.05), respectively. CONCLUSIONS: Aortic valve replacement can be performed safely through a partial upper sternotomy on a routine basis for isolated aortic valve disease.

Mitral valve surgery can now routinely be performed endoscopically.

BACKGROUND: There is an increasing interest in minimally invasive cardiac surgery. METHODS AND RESULTS: Since February 1, 1997 till April 1, 2002, 306 patients underwent endoscopic mitral valve surgery (226 repair, MVP; 80 replacement, MVR). Predominant valve pathology was degenerative in MVP (83.6%) and rheumatic in MVR (65%). Mean age was 61.5+/-12.9 years. Median preoperative functional class (MVP+MVR) and mitral regurgitation (MVP) were II and 4+. Statistical analysis included Kaplan-Meier and Cox regression methods. Mean follow-up was 19.6+/-17.3 months and complete. The procedure was successfully performed in all but 6 patients. Hospital mortality included 3 patients (1%) and was technology related in one. Postoperative morbidity included aggressive re-exploration (8.5%), new onset atrial fibrillation (17.0%), and pacemaker implantation (2.3%). There were 1 early and 10 late reoperations, 5 of which were because of endocarditis. Freedom from mitral valve reoperation at 4 years was 91+/-3.5%. No risk factors for reoperation could be detected. Echocardiographic follow-up showed a median degree of mitral regurgitation (MVP) of 0 and a small paravalvular leak in four patients (MVR). Ninety-four percent of the patients reported no or mild postoperative pain and 99.3% felt they had an esthetically pleasing scar. Ninety-three percent would choose the same procedure again and 46.1% were back at work within 4 weeks. CONCLUSIONS: Endoscopic mitral valve surgery can be performed safely but definitely requires a learning curve. Good results and a high patient satisfaction are guaranteed. It is now our exclusive approach for isolated atrioventricular valve disease.

Surgical treatment of tachyarrhythmias due to postinfarction left ventricular aneurysm with endoaneurysmorrhaphy and cryoablation.

OBJECTIVE: In this study, the efficacy of left ventricular (LV) endoaneurysmorrhaphy and cryoablation without intraoperative electrophysiologic mapping was evaluated in patients with postinfarction LV aneurysm and sustained ventricular tachycardia (VT). METHODS: A prospective study was performed on all patients operated with malignant VT in the presence of a resectable LV aneurysm between July 1990 and February 2001. RESULTS: The study included 31 patients, 20 men and 11 women, with a mean age of 65.5 years (47-84). Monomorphic, polymorphic VT or ventricular fibrillation was present in all patients prospectively, and VT was incessant in 11. Twenty-six patients had an anterior, four patients had an inferior and one patient a posterolateral myocardial wall infarction. All patients had a well-limited ventricular aneurysm. Ten patients had three, eight patients two and 13 patients had single vessel coronary artery disease. Mean preoperative ejection fraction was 34.8 +/- 14.5% (8-62) and mean end-diastolic volume index was 141.5 +/- 51.8 ml/m(2) (57-288). Six patients had mitral regurgitation grade III or IV. All patients underwent extensive cryoablation at the transition zone of scar and viable tissue and LV remodelling with prosthetic patch in 26 patients. Associated procedures were CABG in 19 patients (61%) and mitral valve reconstruction in six patients (19%). Postoperative electrophysiologic study (EPS) revealed freedom from VT induction in 25 patients and inducible VT in five patients. One patient had inducible polymorphic VT. Five patients received an implantable cardioverter defibrillator (ICD) and three patients had a permanent pacemaker implanted. After a mean follow-up of 30 +/- 27 months (6-132) there was one arrhythmia-related death. There was one early hospital readmission for clinical VT and no need for late ICD implantation. CONCLUSIONS: In patients suffering from ventricular arrhythmias in the presence of a complicated postinfarction LV aneurysm, combined 'blind' cryoablation and endoaneurysmorrhaphy offers excellent arrhythmia control and clinical and haemodynamic outcome.

Combined atrial fibrillation and mitral valve surgery using radiofrequency technology.

Recently, intraoperative radiofrequency ablation of the left atrium combined with mitral valve surgery has become widely used. In our center, 30 patients underwent this combined procedure; median sternotomy was used in 16 patients, and port access was used in 14 patients. At hospital discharge, 18 patients (60%) were no longer in atrial fibrillation, and at 6 months, 19 patients (65%) remained in sinus rhythm. All sinus rhythm patients had a well-defined transmitral A wave detectable by echocardiography. One patient sustained a major stroke. Two patients required pacemaker implantation. Such encouraging preliminary results have triggered worldwide interest in the percutaneous and surgical treatment of atrial fibrillation. However, the excellent long-term results with the classic Cox-Maze III operation have not yet been achieved with these newer approaches. Further basic and clinical research is required before a predictable simple and safe technique can be introduced as a new standard for the surgical treatment of atrial fibrillation in patients with or without structural heart disease.