Pulmonary artery aneurysms: Preoperative, intraoperative, and postoperative findings.

BACKGROUND: Pulmonary artery aneurysms (PAAs) are a rare but potentially lethal cardiovascular pathology. PAAs tend to develop in young patients with no gender discrepancy; they are most often associated with congenital heart disorders but also with systemic infections, vasculitis, pulmonary arterial hypertension, chronic pulmonary embolism, and malignancies. Dissection and rupture carry significant morbidity and mortality, thus patients require careful management, especially those with associated pulmonary hypertension. Given the rarity of this condition, physicians have yet to establish standard treatment guidelines. Most studies published to date are case reports with one or two patients; here, we describe our experience with six cases of large PAAs treated surgically at our institution. METHODS: We identified and retrospectively analyzed clinical data for patients who underwent surgery for PAAs between 2009 and 2017. RESULTS: The average age at surgery was 59.73 years, five patients were females, and 83.3% had baseline hypertension. Systolic murmurs were the most common clinical finding. The average aneurysmal size was 65.0 mm. We repaired the PAA with a woven Dacron graft (22-26 mm) in four patients. We performed concomitant pulmonary valve procedures on five patients: four replacements and one repair. Mean pump and cross-clamp times were 108.5 and 65 minutes. Operative and 30-day mortality was 0%. Average length of stay was 10.5 days. CONCLUSIONS: Postoperative mortality was 0%; all patients showed improvement of symptoms after surgery. These findings confirm that PAA repair has an acceptable risk profile in select patients.

Sinus of Valsalva aneurysm repairs: Operative technique and lessons learned.

OBJECTIVE: Sinus of Valsalva (SOV) aneurysms are rare and data on operative management are limited. They can cause right ventricular outflow tract or pulmonary artery compression, and rupture may be fatal. In this study, we describe our experience with the repair of 13 SOV aneurysms. METHODS: All patients who underwent SOV aneurysm repair from May 2001 to December 2017 at our single tertiary referral center were reviewed retrospectively. RESULTS: Thirteen patients (92% male) with a mean age of 60 years underwent repair of an SOV aneurysm; mean aneurysm diameter was 5.9 ± 0.8 cm and four patients (30.7%) presented with rupture into another cardiac chamber. Operative interventions included six Bentall procedures, five patch repairs (one with aortic valve replacement [AVR]), and two primary aneurysm closures both with concomitant AVR. There were no strokes, myocardial infarctions, re-explorations, or deaths in the postoperative period. After an average of 2.25 years, computed tomographic imaging in five patients demonstrated no aneurysm recurrence. CONCLUSIONS: Surgery is a safe option for both ruptured and nonruptured SOV aneurysms. A variety of repair strategies may be used. Larger studies are needed.

AngioVac for extraction of venous thromboses and endocardial vegetations: A meta-analysis.

BACKGROUND: AngioVac is a new device for filtering intravascular thrombi and emboli. Publications on the device are limited and underpowered to objectively estimate its safety and efficacy. We aimed to overcome this by performing a meta-analysis on the results of AngioVac for treating venous thromboses and endocardial vegetations. METHODS: A systematic literature review was performed to identify all articles reporting cardiac vegetation and/or thrombosis extraction using AngioVac. Endpoints were successful removal, operative mortality, conversion to open surgery, hospital stay, recurrent thromboembolism, and follow-up mortality. Random effect model was used, and pooled event rates (PERs) and incidence rate (IR) were calculated. RESULTS: A total of 42 studies with 182 patients (81 vegetation and 101 thrombosis) were included. Overall mean follow-up times were 3.1 and 0.7 years in vegetation and thrombosis patients, respectively. The PERs for successful removal were 74.5 (confidence interval [CI]: 48.2-90.2), 80.5 (CI: 70.0-88.0), and 32.4 (CI: 17.0-52.8) in vegetation, right atrial/caval venous thrombi, and pulmonary emboli (PE) patients, respectively. The PERs for operative mortalities were 14.6 (CI: 7.7-25.8), 14.8 (CI: 8.5-24.5), and 32.3 (CI: 15.1-56.3), respectively. The PERs for conversion to open surgery were 25.0 (CI: 9.3-51.9) and 12.3 (CI: 5.4-25.6) in vegetation and thrombosis patients, respectively. The IR of recurrent thromboembolism was 0.18 per person per year (PPY) (CI: 0.00-14.69) in vegetation and 0.19 PPY (CI: 0.08-0.48) in thrombosis patients. IR of follow-up mortality was 0.37 PPY (CI: 0.11-1.21) in thrombosis patients. CONCLUSIONS: AngioVac is a viable option for extracting right-sided vegetations and right atrial/caval venous thrombi. Rates of successful extraction and mortality are significantly worse for PE.

Transcatheter aortic valve replacement in the setting of left atrial appendage thrombus.

OBJECTIVES: Left atrial appendage thrombus (LAT) was an exclusion criterion in the seminal transcatheter aortic valve replacement (TAVR) trials; however, such patients do undergo TAVR in the 'real-world' setting. This study sought to analyse outcomes after TAVR in patients with LAT or spontaneous echo contrast (SEC). METHODS: All patients undergoing TAVR at our institution between March 2009 and December 2014 were prospectively analysed. The presence of LAT or SEC was determined via a retrospective chart review. Primary outcomes included 30-day and 1-year neurological events as well as mortality. RESULTS: Of the 369 patients undergoing TAVR, 3.8% (14) were found to have LAT and 6.8% (25) were found to have SEC, and they were separately compared to patients who did not have LAT or SEC. Significant differences were noted between groups with regard to preoperative renal function, atrial fibrillation and ejection fraction. Preoperative atrial fibrillation was the only independent predictor of LAT. No perioperative complications were associated with the presence of LAT or SEC. Specifically, no patient with LAT or SEC experienced a postoperative neurological event. While neither LAT nor SEC was an independent predictor of 30-day mortality, LAT was an independent predictor of 1-year mortality (odds ratio 3.573, 95% confidence interval 1.040-12.28; P = 0.042). CONCLUSIONS: The current study suggests that TAVR may be performed in patients with LAT and SEC with a low risk of embolic complications. While neither was an independent predictor of 30-day mortality, LAT was an independent predictor of 1-year mortality. Larger studies are needed to better study this phenomenon.

Standard imaging techniques in transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) has become a widely accepted therapeutic option for patients with severe, symptomatic aortic stenosis at intermediate, high, or extreme risk for conventional surgery as determined through a heart team approach. Two valve prostheses are currently available and the Food and Drug Administration (FDA) approved in the United States for TAVR: the self-expandable Medtronic CoreValve (Medtronic, Inc., Minneapolis, MN, USA) and the balloon-expandable Edwards Sapien Valve (Edwards Lifesciences, Irvine CA, USA). The preoperative evaluation for TAVR includes transthoracic echocardiography (TTE) for the diagnosis of aortic stenosis. Cardiac computed tomography (CTA) has become the imaging modality of choice for annular sizing. Aortic root dimensions and coronary ostia height, and the degree of annular and left ventricular outflow tract calcification are also assessed to estimate the risk of coronary obstruction, annular rupture, and postoperative aortic regurgitation. Finally, CTA is essential to determine the adequacy of the peripheral vasculature for a transfemoral approach. Intraoperatively, fluoroscopy is mandatory for valve positioning, whereas the use of TTE or transesophageal echocardiography (TEE) varies by center. TTE is used for postoperative surveillance of valve function.

Do pulmonary function tests improve risk stratification before cardiothoracic surgery?

OBJECTIVE: To assess the added value of pulmonary function tests (PFTs) and different classifications of chronic obstructive pulmonary disease (COPD) to the Society of Thoracic Surgeons (STS) risk model using a clinical definition of lung disease for predicting outcomes after cardiothoracic (CT) surgery. METHODS: We evaluated consecutive patients who underwent nonemergency cardiac surgery and underwent PFTs before CT surgery. We used the STS risk model 2.73 to estimate the postoperative risk for respiratory failure (RF; defined as the need for mechanical ventilation for ≥72 hours, or reintubation), prolonged postoperative stay (PPLS; defined as >14 days), and 30-day all-cause mortality. We plotted the receiver operating characteristics curve for STS score for each adverse event, and compared the resulting area under the curve (AUC) with the AUC after adding PFT parameters and COPD classifications. RESULTS: Of the 1412 patients with a calculated STS score, 751 underwent PFTs. The AUC of the STS score was 0.65 (95% confidence interval [CI], 0.55-0.74) for RF, 0.67 (95% CI, 0.6-0.74) for prolonged postoperative length of stay (PPLS), and 0.74 (95% CI, 0.6-0.87) for death. None of the PFT parameters or COPD classifications added to the predictive ability of STS for RF, PPLS, or 30-day mortality. CONCLUSIONS: Adding individual PFT parameters or different COPD classifications to STS score calculated using clinically based classification of lung disease did not improve model discrimination. Thus, routine preoperative PFTS may have limited clinical utility in patients undergoing CT surgery when the STS score is readily available.