Hybrid repair of acute type B dissection with aberrant right subclavian artery and bicarotid trunk.

Patients with type B aortic dissection (TBAD) often present as an emergency. Operative repair of TBAD can be indicated for selected patients in the setting of hemodynamic instability or rupture. Thoracic endovascular aortic repair of TBAD has achieved significant popularity. Variant aortic arch anatomy can present a significant clinical challenge in patients with an inadequate proximal landing zone for thoracic endovascular aortic repair. A three-stage, hybrid aortic arch debranching and endovascular repair of a ruptured TBAD in a patient with a bicarotid trunk and an aberrant right subclavian artery was successfully performed using a unique technical approach.

Preoperative Statin use is not Associated with a Reduced Risk of Atrial Fibrillation After Cardiac Surgery.

Introduction: Postoperative atrial fibrillation (POAF) is prevalent after cardiac surgery and associated with significant morbidity and costs. Statins are commonly used in this population and may be a preventative strategy for PAOF. We wished to examine the effect of preoperative statin use on the risk of POAF after cardiac surgery. Methods: A retrospective, observational study was conducted using data from 489 adult patients who underwent cardiac surgery at a single institution. Univariate analyses and unconditional logistic regression were used to determine the impact of preoperative statin use on the probability of developing POAF, while controlling for the baseline risk of POAF and the use of amiodarone prophylaxis (AMP). A baseline risk index was calculated for each patient using a previously validated model. Patients with chronic atrial fibrillation or missing data were excluded. Results: Mean patient age was 63 (SD=13) years, 73% were male, 68% underwent isolated coronary artery bypass grafting, 16% underwent isolated valve surgery, with 13% underwent combined CABG and valve surgeries, and 3% underwent other forms of cardiac surgery. POAF occurred in 27% of patients receiving statins and 24% of those not receiving statins (p=0.3792). After controlling for baseline risk of POAF and the use of AMP, we found that preoperative statins were not associated with reductions in POAF (OR=1.19, 95%CI=0.782-1.822, p=0.4118). Conclusions: Multiple factors impact the development of POAF after cardiac surgery including patient demographics, comorbidities, surgical type, and concomitant medications. In this study, after adjustment for these factors the preoperative use of statins did not significantly influence the development of POAF.

Leiomyosarcoma of the inferior vena cava: a case report and review of the literature.

A 68-year-old white female presented with two years of progressively worsening dyspnea. Echocardiography revealed a large right atrial mass and partial obstruction of the inferior vena cava. Further imaging revealed a cystic dense mass in the inferior vena cava and right atrium. Immunohistochemical stains were consistent with leiomyosarcoma. Intraoperatively, the tumor was noted to originate from the posterior aspect of the inferior vena cava. The patient underwent successful resection of the mass. Adjuvant radiation therapy was completed. The patient's dyspnea gradually improved and she continues to remain disease free five years post-resection.

Risk-stratified evaluation of amiodarone to prevent atrial fibrillation after cardiac surgery.

BACKGROUND: Amiodarone prophylaxis (AMP) reduces the prevalence of postoperative atrial fibrillation (POAF) after cardiac surgery. We investigated the impact of AMP on the frequency and duration of POAF, the intensive care unit and hospital length of stay, and its cost-effectiveness in a risk-stratified cohort. METHODS: A retrospective, observational analysis of 509 patients who underwent cardiac surgery in 2003 was performed. Data sources included The Society of Thoracic Surgeons national database; medical and medication administration records; and the activity-based cost data from our institution. Risk stratification for POAF was determined using a validated risk index. Cost-effectiveness was determined from the hospital's perspective. RESULTS: The mean patient age was 63 years, 27% were female, 80% underwent coronary artery bypass grafting, and 29% underwent valve surgery. When a risk-stratified evaluation was made, 50% of patients were at an elevated risk for having POAF develop. When compared with nonprophylaxed patients, those receiving AMP (59%) experienced less POAF (31% vs 22%; p = 0.027) and shorter durations of POAF (4.7 vs 2.7 days; p = 0.025). In the elevated-risk group, AMP clinically (but not significantly) reduced length of stay in the intensive care unit (101 vs 68 hours; p > 0.05) and post-procedural hospital length of stay (9.7 vs. 7.9 days, p > 0.05). In the elevated-risk group, AMP was robustly cost-effective in reducing POAF. CONCLUSIONS: Amiodarone prophylaxis reduced the prevalence and duration of POAF. Baseline risk for POAF was a major determinant of the overall cost-effectiveness of AMP. The greatest cost savings with AMP was seen in patients at an elevated risk for POAF. These findings suggest the need for risk stratification when prescribing AMP.

Tricuspid annuloplasty significantly reduces early tricuspid regurgitation after biatrial heart transplantation.

BACKGROUND: The incidence of tricuspid annuloplasty (TR) observed early after cardiac biatrial implantation is unpredictable and in our experience not infrequently problematic. Although the bicaval method of implant may reduce the incidence of TR, its benefit has not been conclusively documented. METHODS: In an attempt to reduce the incidence of TR observed early after cardiac transplantation, 25 consecutive patients undergoing cardiac transplantation received donor heart tricuspid annuloplasty (TA) with either a DeVega or Ring technique. Early transthoracic echocardiograms were analyzed and compared with an immediately prior and consecutive cohort of 25 patients undergoing transplantation without TA. The biatrial technique of cardiac transplantation with a Cabrol modification was used for donor heart implant in both groups. Echocardiograms obtained 5 days after cardiac transplantation were reviewed in blinded fashion. TR was scored 0 = none, 1 = mild, 2 = moderate, and 3 = severe. RESULTS: Donor and recipient characteristics were not different between groups. No hospital deaths occurred in either group. Patients undergoing transplantation without TA had a higher TR score, 1.3 (range 0-3), than did patients with TA, 0.7 (range 0-1.5, p = 0.002). Moderate or severe TR was present in 8 of 25 patients without TA compared with 0 of 25 patients with TA (p = 0.004). No patients required permanent pacemaker. CONCLUSIONS: TA can significantly reduce the incidence of early postoperative TR after biatrial cardiac transplant without adding to the complexity of operation.

Myonecrosis following isolated coronary artery bypass grafting is common and associated with an increased risk of long-term mortality.

AIMS: We sought to evaluate the risk of long-term mortality with respect to post-operative elevation of the isoenzyme CK-MB following first-time isolated coronary artery bypass grafting (CABG) surgery. METHODS: Patients undergoing first-time isolated CABG between September 1992 and December 2001, at the Mid America Heart Institute, were included in this registry analysis. A sole CK-MB measurement was obtained at an average of 15.2h following CABG. The main endpoint was long-term mortality. RESULTS: There were 3667 patients included in this registry. The mean follow up was 5.1 years. The event-free survival rate was 80%, 78% and 73%, for the normal, 1-3 and >3 times by ULN groups respectively; log-rank p=0.0058. The event-free survival for the four CK-MB groups was 80%, 78%, 75% and 72% for the normal, 1-3 times, >3-5, and >5 times ULN groups respectively, log-rank p=0.0078. The CK-MB elevation following CABG remained a significant predictor following multivariate adjustment. With a point estimate of 1.04, 95% confidence limits 1.009-1.062, p=0.007. CONCLUSION: Elevation of the isoenzyme CK-MB is an important predictor of longterm mortality following coronary bypass grafting. These data support routine use of creatinine kinase measurement following bypass surgery to further delineate long-term risk.

A comparison of the recovery of health status after percutaneous coronary intervention and coronary artery bypass.

BACKGROUND: Selection of the optimum mode of coronary revascularization should not only be directed by technical outcomes, but should also consider patients' postprocedural health status, including symptoms, functionality, and quality of life. METHODS: Health status was analyzed and compared after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) using the Seattle Angina Questionnaire (SAQ). The SAQ was administered to 475 patients (252 PCI and 223 CABG) preprocedure and then monthly for 6 months and again at 1 year. Differences in baseline characteristics were controlled by multivariable risk adjustment, and outcomes over time were compared using repeated-measures analysis of variance. RESULTS: In-hospital, 6-and 12-month clinical outcomes were not different; however, 25% of PCI patients required at least one reintervention during the study period, compared with only 1% of CABG patients (p < 0.001). Although physical function decreased for CABG patients at 1 month (p < 0.001), it improved and was better than the PCI group by 12 months (p = 0.008). Relief of angina was greater for CABG than PCI when analyzed over time (p < 0.001), principally due to the adverse effects of restenosis in the PCI group. Multivariable analysis confirmed that CABG independently conferred greater angina relief compared with PCI (p < 0.001). At 12 months postprocedure, quality of life had improved to a greater extent for CABG than PCI (p = 0.004). CONCLUSIONS: Over 12 months of follow-up, health status was improved to a greater extent for CABG patients than for PCI patients, primarily due to the adverse influence of restenosis after PCI.