Unsuccessful treatment of a collapsed thoracic stent graft by Palmaz stent.

A Gore TAG Excluder stent graft was deployed in a 35-year-old woman for an isthmic saccular aneurysm. At 12-hour follow-up, we diagnosed a proximal collapse. A Palmaz stent was used to reopen the proximal segment. Two months later, she presented with a transient ischemic attack (embolic process) related to a suboptimal apposition of the Palmaz stent in the distal aortic arch. This led to open surgical replacement of the ascending aorta and aortic arch with reimplantation of the supraaortic branches. Reopening of a stent graft collapse with a Palmaz stent might be a short-term solution; however, its presence can lead to embolic complications.

Comparison of bilateral internal thoracic artery revascularization using in situ or Y graft configurations: a prospective randomized clinical, functional, and angiographic midterm evaluation.

BACKGROUND: Bilateral internal thoracic arteries (BITA) demonstrated superiority over other grafts to the left coronary system in terms of patency and survival benefit. Several BITA configurations are proposed for left-sided myocardial revascularization, but the ideal BITA assemblage is still unidentified. METHODS AND RESULTS: From 03/2003 to 08/2006, 1297 consecutive patients underwent isolated bypass surgery in our institution. 481 patients met the inclusion criteria for randomization, and 304 (64%) were randomized. Patients were allocated to BITA in situ grafting (n=147) or Y configuration (n=152) then evaluated for clinical, functional, and angiographic outcome after 6 months and 3 years. Patient telephone interviews were conducted every 3 months and a stress test performed twice yearly under the referring cardiologist's supervision. Angiographic follow-up was performed 6 months after surgery. The primary and secondary end points were, respectively, major adverse cerebrocardiovascular events (MACCE) and the proportion of ITA grafts that were completely occluded at follow-up angiography. More arterial anastomoses were performed in patients randomized to the Y than the in situ configuration (3.2 versus 2.4; P<0.001). No significant difference between the 2 groups in terms of hospital mortality or morbidity was found. At follow-up, there was no significant difference in any MACCE rate between the 2 groups. 450 out of 464 anastomosis (97%) in the BITA Y group and 287 of 295 (97%) in the BITA in situ group were controlled patent (P=0.99). CONCLUSIONS: Excellent patency rates were achieved using both BITA configurations with no significant differences in terms of MACCE up to 19 months postoperatively, but longer-term results remain to be established.

Comparison of saphenous vein graft versus right gastroepiploic artery to revascularize the right coronary artery: a prospective randomized clinical, functional, and angiographic midterm evaluation.

OBJECTIVE: Despite its theoretic advantage over saphenous vein grafts, the right gastroepiploic artery graft has not been accepted as the ideal conduit to revascularize the right coronary artery. We therefore prospectively randomized these 2 grafts types to compare their clinical, functional, and angiographic evolution at 6 months and 3 years. METHODS: From 2003 to 2006, 1397 consecutive patients underwent isolated revascularization at the University of Louvain Medical School. Of this group, 370 patients met the inclusion criteria for randomization and 66% of those were randomized. The right coronary artery was revascularized with saphenous vein grafts in 116 patients and with right gastroepiploic arteries in 122 patients. All patients underwent angiographic control 6 months postoperatively. The end points were major adverse cerebrocardiovascular events and proportion of grafts patent or functional at follow-up angiography. RESULTS: There were no significant differences between the 2 groups in terms of hospital events. At follow-up there was no significant difference in major adverse cerebrocardiovascular events between the 2 groups. At the 6-month angiographic follow-up, 91% of the anastomoses in the right gastroepiploic artery group and 95% of the anastomoses in the saphenous vein graft group were controlled patent (P = .92). In nonoccluded right coronary arteries, the proportion of patent grafts was significantly lower and the proportion of nonfunctioning grafts was significantly higher in the right gastroepiploic artery group than in the saphenous vein graft group. CONCLUSION: There were no significant patency or major adverse cerebrocardiovascular events rate differences between the 2 groups; however, the number of functional grafts was significantly higher in the saphenous vein graft group. Careful selection of the coronary target is mandatory to obtain good results in gastroepiploic artery grafting.

Angiographic predictors of 6-month patency of bypass grafts implanted to the right coronary artery a prospective randomized comparison of gastroepiploic artery and saphenous vein grafts.

OBJECTIVES: The purpose of this study was to define the pre-operative angiographic variables that could influence graft patency and flow pattern. BACKGROUND: Saphenous vein grafts (SVG) and pedicled right gastroepiploic artery (RGEA) grafts are routinely used to revascularize the right coronary artery (RCA). Little is known about the predictive value of objective pre-operative angiographic parameters on the 6-month graft patency and on the interest of these parameters to select the optimal graft material in individual cases. METHODS: We prospectively enrolled 172 consecutive patient candidates for coronary revascularization. Revascularization of the RCA was randomly performed with SVG in 82 patients or with the RGEA in 90 patients. Both groups were comparable with respect to all pre-operative continuous and discrete variable and risk factors. All patients underwent a systematic angiographic control 6 months after surgery. Pre-operative angiographic parameters included minimal lumen diameter (MLD), percent stenosis and reference diameter of the RCA measured by quantitative angiography (CAAS II system, Pie Medical, Maastricht, the Netherlands), location of the stenosis, run off of the RCA, and regional wall motion of the revascularized territory. RESULTS: A significant difference in the distribution of flow patterns was observed between SVG and RGEA. In multivariate analysis, graft-dependent flow pattern was significantly associated with both MLD and percent stenosis of the RCA in the RGEA group but with percent stenosis only in the SVG group. In the RGEA group, the proportion of patent grafts was higher when MLD was below a threshold value lying in the third MLD quartile (0.77 to 1.40 mm). CONCLUSIONS: Pre-operative angiography predicts graft patency in RGEA, whereas the flow pattern in SVG is significantly less influenced by quantitative angiographic parameters.

Algorithm for primary closure in sternal wound infection: a single institution 10-year experience.

OBJECTIVES: To evaluate a simple treatment algorithm in sternal wound infection (SWI) allowing for primary closure and to describe the different surgical techniques and their associated morbidity and mortality. METHODS: A retrospective analysis of all patients operated on between 1996 and 2004 in a single tertiary care institution. All epidemiological and surgical data were prospectively collected in our database. Univariate and multivariate analysis were used to determine preoperative and perioperative risks factors for 90-day and long-term mortality. RESULTS: Out of 5905 procedures, 146 sternal wound infections were documented (2.4%). The respective incidence of SWI for CABG, isolated valve, or combined procedures were 2.8%, 1.1%, and 3.2%. Pathogens involved were S. epidermidis (44.5%), S. aureus (31.5%), and gram-negative rods (19.2%). Re-operation was required in 131/146 patients. Mean time to the first re-operation was 17.3+/-12 days. Modalities of treatment consisted of drainage alone (44 patients), rewiring (25 patients), debridement, rewiring and mediastinal lavage (52 patients), and partial/complete sternal resection (10 patients). Additional procedures were required in 49 patients (37.7%). The 90-day mortality for uninfected patients and patients with superficial SWI were 4.4% and 2.8% (p=0.78) whereas for patients with deep SWI, 90-day mortality was 14.5% (DSWI vs others, p<0.0001). CONCLUSIONS: Deep sternal wound infection (DSWI) remains a dreadful complication in contemporary cardiac surgery while risk factors are currently well defined. Using a simple approach of primary closure together with liberal use of vascularized flaps has allowed us to achieve satisfactory short-term outcome in this subset of patients.

Repair of trileaflet aortic valve prolapse: mid-term outcome in patients with normal aortic root morphology.

We described our mid-term results in repairing prolapsing aortic cusps in 21 patients with aortic regurgitation and normal aortic root morphology. Aortic regurgitation was moderate-severe in five patients and severe in 16 patients. Prolapse involved the left cusp in four patients (19%), the right cusp in 10 patients (47%) and the non-coronary cusp in 7 (33%) patients. Correction of the prolapsing cusp was achieved by either free edge plication, triangular resection or resuspension with polytetrafluoroethylene sutures, frequently associated to a subcommissural annuloplasty. There was no hospital death. At discharge transthoracic echocardiography, 18 patients (85%) showed no residual aortic regurgitation and three patients (14%) had trivial aortic regurgitation with a central jet. Mean clinical follow-up was 27.2+/-17.1 months (range: 10-72 months). Overall survival was 90.5%. At follow-up transthoracic echocardiography, fourteen patients (73%) were free from aortic regurgitation and five patients (26%) had mild aortic regurgitation without clinical signs of congestive heart failure. Correction of valve prolapse appears a reasonable extension of the original techniques of valve-preserving surgery.

The Ross procedure: clinical and echocardiographic follow-up in 219 consecutive patients.

BACKGROUND: The replacement of the diseased aortic valve with a pulmonary autograft has been shown to provide excellent hemodynamic results and to be associated with low morbidity and mortality rates. METHODS: From 1991 to 2005, 219 patients undergoing the Ross operation were identified. All patients underwent transthoracic echocardiography at discharge and were scheduled for a yearly study thereafter. The echocardiographic study consisted of a morphologic analysis of the pulmonary autograft with measurement of end-systolic diameters at three levels: annulus, sinuses of Valsalva, and origin of the ascending aorta 2 cm above the sinotubular junction. The dynamic analysis evaluated the function of the aortic autograft and the pulmonary homograft. Maximal and mean aortic and pulmonary transvalvular pressure gradients were investigated. RESULTS: The 30-day mortality was 1.8% (n = 4). Cardiac deaths were not related to the autograft. The 10-year actuarial survival was 95.7% +/- 2.1%. Six patients (2.8%) had grade 2 autograft valve regurgitation. No grade 3 or 4 pulmonary regurgitation was identified. At their most recent follow-up, 28 patients (13.1%) had grade 1 insufficiency of the pulmonary homograft, and 10 patients (4.6%) had a peak transvalvular gradient of 17.9 +/- 10.2 mm Hg. CONCLUSIONS: Our current experience suggests that replacement of the aortic root with a pulmonary autograft can be safely performed in infants, children, and adults and is associated with low mortality and morbidity rates. It constitutes an elegant alternative to the use of prosthetic valves in the treatment of aortic valve diseases.

Replacement of chordae tendineae with polytetrafluoroethylene (PTFE) sutures in mitral valve repair: early and long-term results.

BACKGROUND AND AIM OF THE STUDY: A variety of reliable techniques are now available for chordal disease management and repair of the anterior mitral valve leaflet prolapse. The study aim was to review the authors' experience with polytetrafluoroethylene (PTFE), using a standardized technique for length adjustment, and to analyze the long-term results in patients who underwent mitral valve repair. METHODS: A total of 111 patients (mean age 56.2 +/- 16.1 years) underwent mitral valve repair with PTFE neochordae, in addition to a variety of other surgical procedures. Etiologies were degenerative in 82 patients (73.9%), Barlow disease in 13 (11.7%), rheumatic in 10 (9%), and infection in six (5.4%). Prolapse of the anterior leaflet was present in 78 patients (70.3%), of the posterior leaflet in 15 (13.5%), a bileaflet prolapse was present in 12 (10.8%), and a commissural prolapse in six (5.4%). In all cases the anterior annulus was used as the reference level in order to assess the appropriate length of the PTFE neochordae. RESULTS: The mean number of PTFE neochordae used was 6 +/- 4 per patient. In-hospital mortality was 1.8% (n = 2); mean follow up was 36.8 +/- 25.6 months (range: 12-94 months). There were no late deaths. At five years postoperatively the patient overall survival was 98.2 +/- 1.8%, freedom from reoperation rate 100%, and freedom from grade 1+ mitral regurgitation rate 97.2 +/- 2.8%. There were no documented thromboembolism or hemorrhagic events. CONCLUSION: In degenerative and myxomatous mitral valve disease, leaflet prolapse can be successfully repaired by implantation of PTFE neochordae. Both immediate and long-term results proved the versatility, efficiency and durability of this technique.

Repair of bicuspid aortic valves in patients with aortic regurgitation.

BACKGROUND: Bicuspid aortic valve regurgitation can be caused by a defect in the valve itself or by dysfunction of one or more components of the aortic root complex. A successful repair thus requires correction of all aspects of the problem simultaneously. We review our experience addressing both the valve and the aortic root when correcting bicuspid valve regurgitation. METHODS AND RESULTS: Between 1996 and 2004, we treated 68 patients for aortic regurgitation. Thirty patients had isolated aortic regurgitation, and 38 had an associated ascending aortic aneurysm. All patients were treated using a standardized and integrated surgical technique, which included resection of the median raphe or leaflet plication, subcommissural annuloplasty, reinforcement of the leaflet free edge, and sinotubular junction plication. In the 38 patients with proximal aortic dilatation, reimplantation or remodeling of the aortic root was performed. Immediate postoperative echocardiography showed grade < or = 1 aortic regurgitation in all patients. Three patients nonetheless needed an early re-operation because of recurrent regurgitation. No hospital mortality was observed. At a mean follow-up of 34 months after surgery, all patients were in New York Heart Association (NYHA) class 1 or 2. Two patients needed a re-operation (23 and 92 months, respectively). Echocardiographic follow-up showed no progression of the regurgitation in 58 surviving patients. Four patients progressed to grade 2 regurgitation. CONCLUSIONS: Our data indicate that regurgitant bicuspid aortic valves, whether alone or in association with a proximal aortic dilatation, can be repaired successfully provided that both the valve and the aortic root problems are treated simultaneously.

Giant aneurysm of aortocoronary saphenous vein graft compressing the left pulmonary artery.

This is a case report of a 78-year-old patient with a 7-cm aneurysm of the saphenous vein graft that was used 17 years before to perform a coronary artery bypass grafting on the circumflex artery. CT scan displayed a mass with an internal lumen compressing the left atrium as well as the left pulmonary artery.