Repeat Surgery in Chronic Aortic Dissection: A New Technique without Touching the Native Aorta.

BACKGROUND: Repeat surgery of the chronically dissected aorta following repair of a Type-A acute aortic dissection (AAD) still represents a challenge. The proposed surgical options are as follows: (1) staged procedure with elephant trunk (ET) technique, (2) traditional frozen elephant trunk (FET) intervention, and (3) beating heart cerebral vessel debranching followed by thoracic endovascular aortic repair (TEVAR). However, a marked enlargement of the proximal descending thoracic aorta might make it difficult to perform FET/ET intervention. Furthermore, because in conventional surgery for AAD, a prosthetic graft replacement is generally limited to the ascending aorta, and in repeat surgery, this short Dacron graft rarely provides enough room to allow a beating heart cerebral vessel debranching and obtaining a reliable landing zone for the implantation of a firmly anchored stent graft. METHODS: We retrospectively reviewed all the five consecutive patients treated in our institution, between 2014 and 2017, for chronic aortic dissection after successful surgical treatment of acute Type-A aortic dissection with graft replacement limited to the ascending aorta. The five patients underwent repair utilizing a modified FET technique with total aortic arch and upper descending aorta exclusion without touching the native dissected aorta. RESULTS: No early- or midterm mortality was observed. Mean time interval between the initial and the reoperative procedure was 26 months (range, 3-80 months). No patient had a minor/major neurologic event. Mean circulatory arrest time was 16 minutes (range, 11-25 minutes). Mean follow-up time was 22 months (range, 9-42 months). CONCLUSIONS: We report our initial experience with a modified FET technique realized by anastomosing the stent graft with the previously implanted ascending aortic graft in Hishimaru's zone 0 and by rerouting all cerebral vessels without "touching" the native chronically dissected aorta. A larger number of patients and a longer follow-up will be required to confirm these initial encouraging results.

Retrograde pulmonary perfusion as an adjunct to standard pulmonary embolectomy for acute pulmonary embolism.

Mortality rates for pulmonary embolectomy in patients with acute massive pulmonary embolism have decreased in recent years. However, it still ranges from 30 to 45% when surgery is performed on critically ill patients, and the mortality rates reach 60% in patients who have experienced a cardiac arrest before the procedure. The causes of death in these patients are generally attributed to right heart failure due to persistent pulmonary hypertension, intractable pulmonary oedema, and massive parenchymal and intrabronchial haemorrhage. Clinical and experimental findings indicate that venous air embolism causes severe or even lethal damage to the pulmonary microvasculature and the lung parenchyma consequent to the release of endothelium-derived cytokines. These findings are similar to those observed when severely compromised patients undergo pulmonary embolectomy for air entrapped in the pulmonary artery during embolectomy, which may lead to fatal outcomes. Retrograde pulmonary perfusion (RPP), besides enabling the removal of residual thrombotic material from the peripheral branches of the pulmonary artery, fills the pulmonary artery with blood and prevents pulmonary air embolism. We believe that the use of RPP as an adjunct to conventional pulmonary embolectomy decreases the morbidity and mortality rates associated with pulmonary embolectomy in critically ill patients.

Left-atrial-appendage occluder migrates in an asymptomatic patient.

Percutaneous closure of the left atrial appendage (LAA) is a new approach to the prevention of cardioembolic events in patients with atrial fibrillation. We implanted an LAA occlusion device (Amplatzer™ Cardiac Plug) in a 70-year-old woman via a transseptal approach. Upon her discharge from the hospital, a transthoracic echocardiogram showed stable anchoring of the device; 6 months after implantation, a routine transthoracic echocardiogram revealed migration of the occluder into the left ventricular outflow tract, in the absence of symptoms. We surgically removed the device from the mitral subvalvular apparatus and closed the LAA with sutures. This case shows that percutaneous LAA occlusion can result in serious adverse events, including device migration in the absence of signs or symptoms; therefore, careful follow-up monitoring is mandatory.

Severe post-ischemic elongation of the anterior papillary muscle: an unusual cause of mitral insufficiency in a 75-year-old man.

As a complication of myocardial ischemia, severe elongation of the anterior papillary muscle with resultant mitral valve insufficiency is a rare clinical finding. Using echocardiography, we accurately diagnosed this condition in a 75-year-old man. The patient underwent successful plication of the elongated anterior papillary muscle and the implantation of polytetrafluoroethylene neochordae tendineae.

[Aortic valve replacement on two octogenarians awake patients without tracheal intubation, with thoracic epidural anesthesia]. / Sostituzione valvolare aortica in due pazienti ottuagenari coscienti senza intubazione tracheale in anestesia peridurale toracica.

The association of advanced age with various comorbidities increases the risk of mortality and morbidity in cardiac surgery. The utilization of high thoracic epidural anesthesia (HTEA) in this setting presents numerous potential benefits, including early recovery of consciousness and of spontaneous ventilation, hemodynamic stability, enhanced analgesia, improved pulmonary function, and earlier recovery. Moreover, this anesthesiological technique allows the performance of surgical procedures on the conscious patient, thus making continuous monitoring of the cerebral function feasible. We have employed HTEA without tracheal intubation on 2 gravely compromised octogenarian patients who underwent aortic valve replacement for critical aortic stenosis. Epidural anesthesia without tracheal intubation in these patients permitted the avoidance of general anesthetics and allowed the continuous evaluation of their cognitive function. Further, by avoiding the positive pulmonary pressures of mechanical ventilators, the technique contributed to preserve physiologic intrapulmonary pressures, thus positively affecting the pulmonary circulation. In our opinion, the utilization of HTEA without tracheal intubation may decrease the surgical risk in selected patients.

Retrograde pulmonary perfusion improves results in pulmonary embolectomy for massive pulmonary embolism.

Mortality rates for pulmonary embolectomy in patients with acute massive pulmonary embolism have decreased in recent years. However, they still range from 30% to 45% when the surgery is performed on critically ill patients, and the rates reach 60% in patients who have experienced cardiac arrest before the procedure. The causes of death in these patients are generally attributed to right heart failure due to persistent pulmonary hypertension, intractable pulmonary edema, and massive parenchymal and intrabronchial hemorrhage. Clinical and experimental findings indicate that venous air embolism causes severe or even lethal damage to the pulmonary microvasculature and the lung parenchyma consequent to the release of endothelium-derived cytokines. These findings are similar to those observed when severely compromised patients undergo pulmonary embolectomy-air entrapped in the pulmonary artery during embolectomy can lead to fatal outcomes. Besides enabling the removal of residual thrombotic material from the peripheral branches of the pulmonary artery, retrograde pulmonary perfusion fills the pulmonary artery with blood and prevents pulmonary air embolism. In this retrospective study, we analyzed a series of 21 consecutive critically ill patients in whom we applied retrograde pulmonary perfusion while performing standard pulmonary embolectomy. No patient died or experienced major postoperative complications. We believe that the use of retrograde pulmonary perfusion decreases morbidity and mortality rates associated with pulmonary embolectomy in critically ill patients.