Genetic Disorders of the Thoracic Aorta and Indications for Surgery.

Genetic disorders of the aorta are rare but can lead to life-threatening thoracic aortic aneurysms. Although the genetic causes of many of these connective tissue diseases are well defined, others such as familial thoracic aortic aneurysm and bicuspid aortic valve aortopathy are not. The natural history of genetic thoracic aortic aneurysms is not well understood or predictable, and surgical guidelines for treatment remain imprecise. Future research should strive to provide in-depth and detailed genetic profiling to drive clinical management, including medical and surgical therapies.

Percutaneous Repair of Aortic Pseudoaneurysms: A Case Series.

BACKGROUND: Aortic pseudoaneurysms (APSAs) are an uncommon but serious complication of aortic surgery with potentially fatal complications if left untreated. Operative repair is associated with significant morbidity and mortality. Percutaneous APSA repair may reduce the risk of these complications and represents an alternative option for patients. We report our experience with percutaneous intervention for the treatment of APSAs. METHODS AND RESULTS: We retrospectively reviewed all patients at our institution who underwent percutaneous APSA repair with Amplatzer septal occluders and vascular plugs between January 2004 and September 2014. Ten patients are included in this study, representing our first cases of percutaneous APSA repair. Follow-up was performed with serial computed tomographic angiography. The primary outcome was the success rate of device deployment. Secondary outcomes included success rate of complete APSA exclusion, postprocedural symptoms, and periprocedural and postprocedural complications. Mean clinical follow-up time was 12 months (range, 5-30 months) and mean imaging follow-up time was 29 months (range, 14-52 months). Device deployment was successful in all patients, although 2 patients required reintervention due to device malposition and the discovery of additional defects on postprocedure CT angiography. There were no periprocedural or postprocedure complications. Long-term follow-up imaging was available for 7 patients and revealed complete APSA exclusion in 4 patients. One out of the remaining 3 patients ultimately required operative intervention. CONCLUSIONS: Percutaneous APSA repair can be performed safely with a good procedural success, albeit with variable long-term results. This procedure may be considered as an alternative to surgical repair in select patients.

Randomized trial of fondaparinux versus heparin to prevent graft failure after coronary artery bypass grafting: the Fonda CABG study.

We sought to assess the feasibility of comparing the efficacy and safety of fondaparinux versus heparin for prevention of graft failure and major CV events in patients undergoing coronary artery bypass grafting (CABG). Patients undergoing CABG were randomized to receive postoperative injections of fondaparinux or heparin in-hospital. After discharge, the fondaparinux group received fondaparinux and the heparin group received placebo injections for 30 days post surgery. Efficacy outcomes were graft failure, death, MI, and stroke at 30 days. Safety outcomes were bleeding, transfusion, and reoperation. 100 patients were recruited, 99 were randomized, 49 received fondaparinux and 50 received heparin. CT angiography was performed in 97% of patients. 188 grafts in the treatment group and 189 grafts in the heparin group were imaged. A similar proportion of patients treated with fondaparinux compared with heparin had at least one occluded graft (18.8% fondaparinux vs. 14.9% heparin, P = 0.62) and a similar number of grafts were occluded in each treatment group (all grafts: 4.8% vs. 4.8%, P = 0.99; saphenous vein grafts 4.2% vs. 4.2%, P = 0.98). There was no difference between treatment groups in death, MI, stroke, bleeding events, or reoperation. One in 10 patients undergoing CABG had at least one occluded graft at 30 days and one in 20 grafts is occluded by 30 days. Fondaparinux appears to be a safe alternative to heparin after CABG and it is feasible to conduct a definitive RCT using CT angiography to evaluate the effect of fondaparinux treatment on graft patency.

Pulmonary artery catheters: evolving rates and reasons for use.

OBJECTIVE: Randomized trials have demonstrated risks and failed to establish a clear benefit for the use of the pulmonary artery catheter. We assessed rates of pulmonary artery catheter use in multiple centers over 5 yrs, variables associated with their use, and how these variables changed over time (2002-2006). DESIGN: A multicenter longitudinal study using the Hamilton Regional Critical Care Database. A two-level multiple logistic regression analysis was used to determine significant variables associated with pulmonary artery catheter use and whether these varied over time. SETTING: Academic intensive care units in Hamilton, Canada. PATIENTS: We identified patients from five intensive care units who received a pulmonary artery catheter within the first 2 days of intensive care unit admission. INTERVENTIONS: Pulmonary artery catheter use over a 5-yr period. MEASUREMENTS AND MAIN RESULTS: Among 15,006 patients, 1,921 (12.8%) had a pulmonary artery catheter. Adjusted rates of pulmonary artery catheter use decreased from 16.4% to 6.5% over 5 yrs. Determinants of pulmonary artery catheter use included Acute Physiology and Chronic Health Evaluation II score (odds ratio [OR], 1.05; confidence interval [CI], 1.04-1.06; p < .0001), elective surgical status (OR, 2.82; CI, 2.29-3.48; p < .0001), postabdominal aortic aneurysm repair (OR, 10.91; CI, 8.24-14.45; p < .0001), cardiogenic shock (OR, 5.31; CI, 3.35-8.42; p < .0001), sepsis (OR, 2.83; CI, 1.94-4.13; p < .0001), vasoactive infusion use (OR, 4.04; CI, 3.47-4.71; p < .0001), and mechanical ventilation (OR, 2.21; CI, 1.86-2.63; p < .0001). Physician's base specialty and local intensive care unit were also associated with pulmonary artery catheter use (p < .0001). The determinants of pulmonary artery catheter use did not change over time. CONCLUSIONS: We observed a >50% reduction in the rate of pulmonary artery catheter use over 5 yrs. Patient factors predicting pulmonary artery catheter use were illness severity, specific diagnoses, and the need for advanced life support. Nonpatient factors predicting pulmonary artery catheter use were intensive care unit and the attending physician's base specialty.

Randomized trial of aspirin and clopidogrel versus aspirin alone for the prevention of coronary artery bypass graft occlusion: the Preoperative Aspirin and Postoperative Antiplatelets in Coronary Artery Bypass Grafting study.

BACKGROUND: Routine use of postoperative aspirin after coronary artery bypass grafting (CABG) reduces graft failure and cardiovascular events. The efficacy and safety of adding clopidogrel to aspirin for the prevention of graft failure and cardiovascular events after CABG are unknown. We performed a pilot study measuring safety and efficacy outcomes of aspirin and clopidogrel therapy after CABG. METHODS: We randomized 100 patients undergoing CABG to receive placebo or clopidogrel started after surgery and for 30 days. All patients received aspirin 81 mg daily. Graft patency was measured by cardiac computed tomography angiography at 30 days. RESULTS: Clinical follow-up was complete for 99 patients, and 79 (80%) underwent computed tomography angiography. The proportion of patients with ≥1 occluded graft was not significantly different between placebo and clopidogrel groups (9/39 [23.1%] vs 7/40 [17.5%], relative risk 0.95, 95% CI 0.80-1.14, P=.54). Among radial artery grafts, the placebo group had a significantly higher number of occlusions or "string signs" compared with the clopidogrel group (7/16 [43.8%] vs 2/19 [10.5%], relative risk 0.24, 95% CI 0.06-1.00, P=.05). There was no difference between placebo and clopidogrel groups in the safety outcomes of total postoperative bleeding, transfusions, bleeding events, and reexploration and in the efficacy outcomes of nonfatal myocardial infarction, stroke, and death. CONCLUSIONS: This pilot study confirms a high rate of graft occlusion after CABG surgery and suggests that the addition of clopidogrel to aspirin is feasible and safe and may be superior for prevention of graft failure in radial artery grafts.

Antithrombotic management of patients with prosthetic heart valves: current evidence and future trends.

Over 4 million people worldwide have received a prosthetic heart valve, and an estimated 300,000 valves are being implanted every year. Prosthetic heart valves improve quality of life and survival of patients with severe valvular heart disease, but the need for antithrombotic therapy to prevent thrombotic complications in valve recipients poses challenges for clinicians and patients. Here, we review antithrombotic therapies for patients with prosthetic heart valves and management of thromboembolic complications. Advances in antithrombotic therapy and valve technologies are likely to improve the management of patients with prosthetic heart valves in developed countries, but the most important unmet need and potential for benefit from these new therapies is in developing countries where a massive and rapidly increasing burden of valvular heart disease exists.

Para-aortic arch abscess secondary to Staphylococcus aureus pneumonia.

Staphylococcus aureus is a relatively common pathogen causing pneumonia in the community, hospital ward and intensive care unit. Although pneumonia is responsible for significant morbidity and mortality, especially in elderly and immunocompromised patients, it is usually uncomplicated and resolves without complications. The case of a woman who developed a para-aortic abscess after a community-acquired S aureus pneumonia infection is presented. A number of diagnostic imaging modalities were used to reach the diagnosis. This complication has not been reported previously and it is likely secondary to suppurative lymphadenitis of a station 5 or 6 node. The patient was successfully managed nonsurgically with computed tomography-guided drainage and intravenous antibiotics.

The effect of pre-operative aspirin on bleeding, transfusion, myocardial infarction, and mortality in coronary artery bypass surgery: a systematic review of randomized and observational studies.

AIMS: To obtain estimates of the efficacy and safety of pre-operative aspirin in patients undergoing coronary artery bypass grafting (CABG). METHODS AND RESULTS: Eligible studies included randomized controlled trials (RCTs) and observational studies of patients undergoing CABG, comparing pre-operative aspirin with no aspirin/placebo, and reporting at least one of our primary outcomes. In eight RCTs (n = 805), pre-operative aspirin increased post-operative bleeding [Mean difference (MD), 104.9 mL; 95% confidence interval (CI), 19.2-190.6; P = 0.016] and reoperation [odds ratio (OR), 2.52; 95% CI, 1.18-5.38; P = 0.017), but not transfusion requirements (MD, 0.62 units; 95% CI, -0.06-1.30; P = 0.072). Subgroup analysis suggested that bleeding was increased with aspirin doses > or =325 mg/day, but not with lower doses. In 14 observational studies (n = 4485), pre-operative aspirin increased post-operative bleeding (MD, 113.6 mL; 95% CI, 45.2-182.0; P = 0.001) and transfusion requirements (MD, 0.34; 95% CI, 0.12-0.56 units; P = 0.002), but not reoperation (OR, 1.12; 95% CI, 0.69-1.83; P = 0.647). Neither analysis detected a significant effect on myocardial infarction or death. CONCLUSION: Pre-operative aspirin increases post-operative bleeding, but this may be avoided by the use of aspirin doses <325 mg/day. Most of the RCTs are old and the meta-analysis was underpowered for efficacy outcomes. A large randomized trial is necessary to determine the safety and efficacy of pre-operative aspirin in the setting of contemporary cardiac surgical practice.