Techniques of Proximal Root Reconstruction and Outcomes Following Repair of Acute Type A Aortic Dissection.

BACKGROUND: The goal of this study was to compare the early and late outcomes of different techniques of proximal root reconstruction during the repair of acute Type A aortic dissection, including aortic valve (AV) resuspension, aortic valve replacement (AVR), and a root replacement procedure. METHODS: All patients who underwent acute Type A aortic dissection repair between January 2000 and October 2010 at four academic institutions were compiled from each institution's Society of Thoracic Surgeons Database. This included 189 patients who underwent a concomitant aortic valve (AV) procedure; 111, 21, and 57 patients underwent AV resuspension, AVR, and the Bentall procedure, respectively. The median age of patients undergoing a root replacement procedure was significantly younger than the other two groups. Early clinical outcomes and 10-year actuarial survival rates were compared. Trends in outcomes and surgical techniques throughout the duration of the study were also analyzed. RESULTS: The operative mortality rates were 17%, 29%, and 18%, for AV resuspension, AVR, and root replacement, respectively. Operative mortality (p = 0.459) was comparable between groups. Hemorrhage related re-exploration did not differ significantly between groups (p = 0.182); however, root replacement procedures tended to have decreased rates of bleeding when compared to AVR (p = 0.067). The 10-year actuarial survival rates for the AV resuspension, Bentall, and AVR groups were 72%, 56%, and 36%, respectively (log-rank p = 0.035). CONCLUSIONS: The 10-year actuarial survival was significantly lower in those receiving AVR compared to those receiving root replacement procedures or AV resuspension. Operative mortality was comparable between the three groups.

Aortic valve replacement in octogenarians with prior cardiac surgery.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been advocated for very elderly patients with aortic stenosis, and prior cardiac surgery as a less invasive treatment option. Although surgical aortic valve replacement (AVR) is safe and effective in selected elderly patients, the perioperative and mid-term outcomes of AVR in very elderly with prior cardiac surgery are unknown. METHODS: The Society of Thoracic Surgeons (STS) Database at our center enrolled 3,735 patients after AVR since 1997. In this time interval, we identified 61 patients 80 years and older who underwent AVR for severe AS or failed aortic bioprosthesis after having prior cardiac surgery. All clinical parameters were derived from the STS database. Follow-up mortality was assessed using the Social Security Death Index. RESULTS: The average age of the patients was 83 ± 2 years, 77% were male, and 75% underwent an isolated coronary artery bypass graft (CABG) as their first cardiac procedure. The mean ejection fraction was 0.53 ± 0.13. The CABG was performed concurrently in 49% of patients at the time of redo sternotomy and AVR. Stented bioprosthesis was implanted in 61% of patients and stentless in 39%. Perioperative mortality was 1.6% (1 of 61). One, 3, 5, and 7 year survival rates were 85%, 69%, 63%, and 43%, respectively. Patients with AVR only had similar survival to patients who underwent concomitant AVR and CABG. Type of aortic prosthesis did not influence postoperative survival. CONCLUSIONS: In selected patients over the age of 80 with history of prior cardiac surgery, AVR can be performed safely with very good mid-term outcomes. Age alone should not be exclusion criteria for surgical AVR in octogenarians with prior cardiac surgery.

Home-based exercise: promising rehabilitation for symptom relief, improved functional status and quality of life for post-surgical lung cancer patients.

BACKGROUND: Post-thoracotomy non-small cell lung cancer (NSCLC) patients report cancer-related fatigue (CRF) as a severe symptom that may increase the occurrence and severity of other symptoms while decreasing functional status and quality of life (QOL). The aim of this pilot study was to describe the effects of a home-based rehabilitative exercise intervention on CRF, other symptoms, functional status, and QOL for post-surgical NSCLC patients starting within days after hospital discharge. METHODS: Seven post-thoracotomy NSCLC patients completed the Brief Fatigue Inventory (BFI) measuring CRF severity, and the M.D. Anderson Symptom Inventory measuring symptom severity at pre- and post-surgery, and at the end of each week of the six-week intervention. Additionally, the Medical Outcomes Short-Form-36 measuring physical and mental functional status; and the Quality of Life Index (QLI) measuring QOL were completed pre- and post-surgery, after week 3, and at the end of the intervention (week 6). RESULTS: Participants had a mean age of 65 years, a mean of 6 co-morbid conditions, and initiated the intervention within 4 days after hospital discharge. Participants' CRF severity scores were reduced to mild levels while the mean number of symptoms decreased from 10.4 post-surgery to 7.0 at week 6 with lower levels of severity and interference. Likewise, participants' post-intervention functional status and QOL improved to near or above pre-surgical levels. CONCLUSIONS: The exercise intervention for post-surgical NSCLC patients showed promising preliminary efficacy in improving CRF, other symptom severity, functional status, and QOL. Further testing via a two-arm randomized controlled trial is being conducted.

Five-year real world outcomes of GeoForm ring implantation in patients with ischemic mitral regurgitation.

BACKGROUND: Reductive ring annuloplasty represents the current standard surgical therapy for ischemic mitral regurgitation (IMR); however, the clinical results have been suboptimal. Etiology-specific prostheses such as the GeoForm annuloplasty ring have been designed to better address the annular and subvalvular perturbations associated with IMR. However, clinical experience is limited, and mid-term results are lacking. METHODS: We reviewed the clinical outcomes of 86 patients who had undergone implantation of a GeoForm ring at our center from 2005 to 2011. Perioperative mortality and clinical parameters were derived from The Society of Thoracic Surgeons database. Follow-up survival was assessed using the Social Security Death Index. Surviving patients were interviewed by telephone for valve-specific follow-up data and to complete the Medical Outcomes Study, short-form, 36-item, quality-of-life questionnaire. RESULTS: The mean grade of IMR preoperatively was 3.1±0.8 (range, 1-4+), 0.2±0.4 in the immediate postoperative period, and 0.7±0.7 at the last mean follow-up point of 41 months; only 2 patients developed ≥2+IMR during the follow-up period, for a 5-year freedom from recurrent 2+ IMR of 86%. The mean left ventricular end-diastolic and end-systolic diameters decreased from before to after surgery from 6.0±0.0 cm to 5.3±09 cm and 5.0±0.9 cm to 4.3±1.1 cm, respectively (P<.001). Perioperative mortality was 5.8% (5 of 86), and 1-, 3-, and 5-year survival was 87%, 81%, and 75%, respectively. At the last follow-up point, 80% of patients were in New York Heart Association class I and II, and their quality of life was equal to, or better than, age-matched controls from the general population. CONCLUSIONS: Implantation of the GeoForm ring offers very good control of IMR, with low rate of recurrent IMR at mid-term follow-up. The use of this prosthesis was associated with good perioperative mortality, mid-term survival, and quality of life.

A rehabilitation program for lung cancer patients during postthoracotomy chemotherapy.

OBJECTIVE: The objective of this pilot study was to describe the effects of a 16-week home-based rehabilitative exercise program on cancer-related fatigue (CRF), other symptoms, functional status, and quality of life (QOL) for patients with non-small cell lung cancer (NSCLC) after thoracotomy starting within days after hospital discharge and continuing through the initiation and completion of chemotherapy. MATERIALS AND METHODS: Five patients with NSCLC completed the Brief Fatigue Inventory (measuring CRF severity) and the MD Anderson Symptom Inventory (measuring symptom severity) before and after thoractomy, and at the end of each week of the 16-week exercise program. Additionally, the Medical Outcomes Study Short Form-36 (measuring physical and mental functional status) and the Quality of Life Index (measuring QOL) were completed before and after thoracotomy, after weeks 3, 6, 12, and 16 (the end of the exercise program). Further, the 6-minute walk test (measuring functional capacity) was administered before thoracotomy, prior to the initiation of chemotherapy and/or radiation therapy, and at the end of the 16-week exercise program, after completion of chemotherapy. RESULTS: Participants had a mean age of 63 years and a mean of five comorbid conditions; the exercise program was initiated within 4 days after hospital discharge. Participants' CRF severity scores were reduced to mild levels, while the mean number of symptoms decreased from 9 postthoracotomy to 6 after the exercise program, with mean levels of severity and interference decreasing to below prethoracotomy levels. Likewise, participants' functional status and QOL after completing the exercise program improved to near or above prethoracotomy levels. CONCLUSION: The home-based, light-intensity exercise program for NSCLC patients receiving and completing adjuvant chemotherapy postthoracotomy showed promising trends in improving CRF severity, other symptom severity, functional status, and QOL. Further testing via a two-arm randomized controlled trial is being conducted.

Virtual reality bringing a new reality to postthoracotomy lung cancer patients via a home-based exercise intervention targeting fatigue while undergoing adjuvant treatment.

BACKGROUND: Little is known about rehabilitation for postthoracotomy non-small cell lung cancer (NSCLC) patients. This research uses a perceived self-efficacy-enhancing light-intensity exercise intervention targeting a priority symptom, cancer-related fatigue (CRF), for postthoracotomy NSCLC patients. This article reports on phase II of a 2-phase study. Phase I focused on initiation and tolerance of exercise during the 6 weeks immediately after thoracotomy, whereas phase II addressed maintenance of exercise for an additional 10 weeks including participants initiating and completing chemotherapy and/or radiation therapy. OBJECTIVE: The objective of this study was to investigate the feasibility, acceptability, and preliminary efficacy of an exercise intervention for postthoracotomy NSCLC patients to include those initiating and completing adjuvant therapy. INTERVENTIONS/METHODS: A single-arm design composed of 7 participants postthoracotomy for NSCLC performed light-intensity exercises using an efficacy-enhancing virtual-reality approach using the Nintendo Wii Fit Plus. RESULTS: Despite most participants undergoing chemotherapy and/or radiation therapy, participants adhered to the intervention at a rate of 88% with no adverse events while giving the intervention high acceptability scores on conclusion. Likewise, participants' CRF scores improved from initiation through the conclusion of the intervention with perceived self-efficacy for walking at a light intensity continuously for 60 minutes, improving significantly upon conclusion over presurgery values. CONCLUSIONS: Postthoracotomy NSCLC patients maintained exercise for an additional 10 weeks while undergoing adjuvant therapy showing rehabilitation potential because the exercise intervention was feasible, safe, well tolerated, and highly acceptable showing positive changes in CRF self-management. IMPLICATIONS FOR PRACTICE: A randomized controlled trial is needed to further investigate these relationships.

Effects of Hemodynamic Instability on Early Outcomes and Late Survival Following Repair of Acute Type A Aortic Dissection.

BACKGROUND: The goal of this study was to compare operative mortality and actuarial survival between patients presenting with and without hemodynamic instability who underwent repair of acute Type A aortic dissection. Previous studies have demonstrated that hemodynamic instability is related to differences in early and late outcomes following acute Type A dissection occurrence. However, it is unknown whether hemodynamic instability at the initial presentation affects early clinical outcomes and survival after repair of Type A aortic dissection. METHODS: A total of 251 patients from four academic medical centers underwent repair of acute Type A aortic dissection between January 2000 and October 2010. Of those, 30 presented with hemodynamic instability while 221 patients did not. Median ages were 63 years (range 38-82) and 60 years (range 19-87) for patients presenting with hemodynamic instability compared to patients without hemodynamic instability, respectively (P = 0.595). Major morbidity, operative mortality, and 10-year actuarial survival were compared between groups. RESULTS: Operative mortality was profoundly influenced by hemodynamic instability (patients with hemodynamic instability 47% versus 14% for patients without hemodynamic instability, P < 0.001). Actuarial 10-year survival rates for patients with hemodynamic instability were 44% versus 63% for patients without hemodynamic instability (P = 0.007). CONCLUSIONS: Hemodynamic instability has a profoundly negative impact on early outcomes and operative mortality in patients with acute Type A aortic dissection. However, late survival is comparable between hemodynamically unstable and non-hemodynamically unstable patients.

Stentless root bioprosthesis for repair of acute type A aortic dissection.

OBJECTIVE: The superior hemodynamics and excellent long-term clinical performance of stentless xenografts are well described. However, the early and midterm clinical outcomes of stentless valves in patients with acute type A dissection are widely unknown. The current study evaluated the early and midterm clinical outcomes of stentless bioprosthesis for repair of acute type A aortic dissection. METHODS: Between May 2005 and December 2009, 24 of 80 patients underwent root replacement using the Medtronic Freestyle xenograft (Medtronic Inc, Minneapolis, Minn) at the Meijer Heart Center. Prospective data collection was used for retrospective review. Univariate comparisons of preoperative, intraoperative, and postoperative variables were performed between patients who underwent stentless root bioprosthesis for the correction of acute type A aortic dissection (n = 24). RESULTS: The mean age of patients was 57 years, with 15 patients aged less than 65 years. Axillary and femoral artery cannulation were used in 16 patients (67%) and 7 patients (29%), respectively. Median crossclamp and cardiopulmonary bypass times were 198 minutes (92-480 minutes) and 288 minutes (109-588 minutes), respectively. Median circulatory arrest time was 28 minutes (24-50 minutes). Operative mortality rate was 25%. Actuarial 5-year survival was 62.5%. No patients required redo aortic root replacement. CONCLUSIONS: Stentless valve implantation can be accomplished with satisfactory early and midterm clinical outcomes and is a valuable option in patients with acute aortic dissection who require root replacement.

Differences in clinical characteristics, management, and outcomes of intraoperative versus spontaneous acute type A aortic dissection.

BACKGROUND: The clinical characteristics, management, and outcomes of patients who had intraoperative aortic dissection (IAD) have not been thoroughly investigated. This study compared early and late clinical outcomes in patients with IAD vs spontaneous (non-IAD) acute type A aortic dissection. METHODS: Between January 1, 2000, and July 1, 2008, 251 patients from 4 academic medical centers underwent repair of acute type A aortic dissection; of those, 11 had IAD. The mean age was 72 ± 9 years for patients experiencing IAD and 59 ± 13 years for those with non-IAD (p = 0.001). Patients with IAD were more likely to have coronary artery disease (p = 0.003) and a history of arrhythmia (p = 0.038). Rates for major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. RESULTS: Operative mortality was not adversely influenced by IAD (27% IAD vs 17% non-IAD, p = 0.42). There were no differences in the rates of reoperation for bleeding (10% IAD vs 20% non-IAD, p = 0.69), stroke (18% IAD vs 18% non-IAD, p ≥ 0.99), or acute renal failure (9% IAD vs 22% non-IAD, p = 0.47) between the two groups. Actuarial 5-year survival was 64% for IAD patients vs 73% for non-IAD patients (p = 0.33). CONCLUSIONS: IAD does not adversely influence early outcomes and actuarial 5-year survival of patients with type A dissection.

Too sick not to exercise: using a 6-week, home-based exercise intervention for cancer-related fatigue self-management for postsurgical non-small cell lung cancer patients.

BACKGROUND: Two prevalent unmet supportive care needs reported by the non-small cell lung cancer (NSCLC) population include the need to manage fatigue and attain adequate exercise to meet the physical demands of daily living. Yet, there are no guidelines for routine rehabilitative support to address fatigue and exercise for persons with NSCLC during the critical transition from hospital to home after thoracotomy. OBJECTIVE: The objective of this study was to evaluate the feasibility, acceptability, safety, and changes in study end points of a home-based exercise intervention to enhance perceived self-efficacy for cancer-related fatigue (CRF) self-management for persons after thoracotomy for NSCLC transitioning from hospital to home. INTERVENTIONS/METHODS: Guided by the principles of the Transitional Care Model and the Theory of Symptom Self-management, a single-arm design composed of 7 participants with early-stage NSCLC performed light-intensity walking and balance exercises in a virtual reality environment with the Nintendo Wii Fit Plus. Exercise started the first week after hospitalization for thoracotomy and continued for 6 weeks. RESULTS: The intervention positively impacted end points such as CRF severity; perceived self-efficacy for fatigue self-management, walking, and balance; CRF self-management behaviors (walking and balance exercises); and functional performance (number of steps taken per day). CONCLUSIONS: A home-based, light-intensity exercise intervention for patients after thoracotomy for NSCLC is feasible, safe, well tolerated, and highly acceptable showing positive changes in CRF self-management. IMPLICATIONS FOR PRACTICE: Beginning evidence suggests that a light-intensity in-home walking and balance intervention after hospitalization for thoracotomy for NSCLC is a potentially effective rehabilitative CRF self-management intervention. Next steps include testing of this health-promoting self-management intervention in a larger-scale randomized controlled trial.

Endovascular repair of thoracic aortoenteric fistulas.

Aortoesophageal fistula is a rare manifestation of thoracic aortic surgery or esophageal disease. We describe a patient who underwent emergent endovascular repair of an aortoesophageal fistula due to a ruptured penetrating ulcer of the descending thoracic aorta and review the literature on this subject.

Folding mitral valvuloplasty without posterior leaflet resection for calcified mitral annulus.

Mitral valve annular calcification has long been a challenge in repairing posterior mitral valve prolapse. Folding valvuloplasty of the posterior leaflet without resection provides a means of circumventing common procedural complications. This report demonstrates the success of folding valvuloplasty without resection in the treatment of mitral valve prolapse and severe annular calcification.