Novel technique: staged hybrid surgical and endovascular treatment of acute Type A aortic dissections with aortic arch involvement.

AIM: The standard approach for treating acute Type A aortic dissections (TAD) is replacement of the ascending aorta utilizing hypothermic circulatory arrest (HCA), which is associated with significant morbidity and frequently leaves a residual aortic arch dissection. We describe a staged surgical and endovascular technique of ascending aorta replacement and simultaneous aorto-innominate artery bypass without HCA, followed 4 weeks later by carotid-carotid bypass and endovascular exclusion of the remaining arch dissection with a thoracic endograft. METHODS: From December 2004 to December 2005, 5 consecutive patients (mean age 58 +/- 6.9 years) with TADs underwent the staged procedure. All patients underwent replacement of the ascending aorta and aorto-innominate bypass. Two patients subsequently underwent the second endovascular stage. In one patient the aortic false lumen completely thrombosed following the first surgical stage and two patients are currently awaiting the endovascular stage. RESULTS: There were no major adverse events (death, cerebrovascular accident or paraplegia) following the first surgical stage. One patient suffered a transient minor stroke. The 2 patients who underwent the second endovascular stage showed no immediate adverse events. Postoperative CT scans have demonstrated that the false channel was excluded from the aortic arch down to the distal end of the endograft in the descending aorta in each case, but became patent further downstream. CONCLUSIONS: This procedure appears safe and feasible. It may allow for a more definitive treatment of TADs than the standard surgical approach. It can be adapted by low volume centers, surgeons untrained in aortic arch repair, and in high risk patients.

Great vessels transposition and aortic arch exclusion.

AIM: We describe our experience in endovascular repair of Thoracic Aortic Aneurysms and Dissections (TAAD) involving the aortic arch in high risk patients (HRP). METHODS: Twenty-nine patients presented with TAAD involving the aortic arch and were treated by endovascular exclusion. Pathologies were as follows: atherosclerotic aneurysms of the descending thoracic aorta in 15 cases, acute Stanford type A dissections in 6 cases, Stanford type B dissections in 7 cases (1 acute), and 1 false aneurysm of the ascending aorta. Total-arch transpositions of all supra-aortic vessels (aortic debranching) to the ascending aorta were done in 11 cases throught median sternotomy. We performed carotido-carotid bypass (hemi-arch transposition) in 16 patients by cervicotomy. Secondary to surgical transpositions, we placed endovascular stentgrafts in all but 2 patients for final exclusion, the 2 remaining being planned for later exclusion. The Talent, Excluder, TAG and Zenith endografts were used in 12, 3, 1 and 4 cases respectively. Banding technique was associated in some cases. RESULTS: All surgical transpositions were successful although 1 led to a minor stroke (1/29=3.5%), which worsened to major stroke after endovascular exclusion. Endovascular procedures were performed in all but one case (26/27=96.3%). Two patients (2/26=7.7%) died from catheterization related complications after endovascular exclusion (iliac rupture and left ventricle perforation). One patient had a delayed minor stroke (1/26=3.8%). Recirculation was found in 13.3% (2/15) of aneurysms and 27.3% of thoracic false channels. During a mean follow-up of 15.7 months (13 days to 45.5 months), 1 patient (1/26=3.8%) who had preoperative chronic pulmonary failure died at 6 months from respiratory worsening. We observed one case (3.8%) of unilateral limb palsy unrelated to cerebral ischemia, which we successfully treated by cerebrospinal fluid (CSF) drainage. No stent-related complication was seen. One new type 1 endoleak appeared at 12 months on an aneurysm, which resolved after stentgraft extension. Three thoracic dissection false channels remained patent during follow-up, of which one was retrograde originating distally in the descending aorta. CONCLUSIONS: Secondary endovascular exclusion of thoracic aortic diseases involving the arch in HRP is made feasible thanks to the preliminary aortic debranching. Total-arch transposition may be of greater interest in case of proximal neck length uncertainty and potential embolization from the aortic arch. Mid-term results are good although patients must be followed carefully to detect aortic recirculation and enlargement.

Endovascular treatment of thoracic aortic aneurysms.

UNLABELLED: Descending thoracic aortic aneurysms (TAA) and chronic dissections have high morbidity and mortality rates. For 10 years, the evolution of both imaging techniques and aortic stent-graft design has brought a new therapeutic hope for patients at high risk for surgery presenting non-ruptured or emergency cases of TAA. Our goal is to describe the endovascular technique, review its state of the art and compare its mid-term results to those of conventional surgery. We also describe surgical ways to manage complex TAA, involving the aortic arch and/or the celiac aorta, as therapeutic solutions for high risk patients for surgery with unfitted anatomy for endovascular repair. After a review of the literature dealing with the natural history, the etiology, and the surgical treatment, we describe the endovascular devices, the conventional stent-grafting technique and we detail the adjunctive procedures we used to manage complex cases. We then retrospectively report our personal 38-patient experience from October 1999 to February 2003. Thirty-three patients presented with TAA and the average age was 70 years old (35-88), while the male/female ratio was 5.3. All of them were at high risk for surgery, of which 27% required adjunctive procedures to achieve proximal and/or distal neck management. The in-hospital death rate was 9%. We reported no case of paraplegia and only 1 patient with post-operative regressive stroke (3%). All the aneurysmal sacs were successfully excluded without early endoleak. During follow-up period (mean: 2 years; 1-40 months), we observed a late death rate of 10%. All aneurysmal sac remained excluded by the endografts and no stent-graft migration was observed. No late endoleak appeared during the follow-up course, but 1 patient presented a proximal aortic enlargement, which required total transposition of the supra-aortic vessels and stent-graft extension. The endovascular repair of TAA and chronic dissections proved to be feasible and offers hopeful mid-term RESULTS: With a very low morbidity-mortality rate, compared to surgery, the endovascular technique may represent an unquestionable therapeutic options, especially for patients at high risk for surgery. However, long-term results are needed to point out the durability of descending thoracic aortic stent-grafting. Neck management must be encouraged in order to avoid type 1 endoleaks in cases with short landing zones.

Perivalvular abscesses associated with endocarditis; clinical features and prognostic factors of overall survival in a series of 233 cases. Perivalvular Abscesses French Multicentre Study.

AIMS: The purposes of this study were to determine the clinical features and to identify prognostic factors of abscesses associated with infective endocarditis. METHODS AND RESULTS: During a 5-year period from January 1989, 233 patients with perivalvular abscesses associated with infective endocarditis were enrolled in a retrospective multicentre study. Of the patients, 213 received medical surgical therapy and 20 medical therapy alone. No causative microorganism could be identified in 31% of cases. Sensitivity for the detection of abscesses was 36 and 80%, respectively using transthoracic and transoesophageal echocardiography. Surgical treatment consisted of primary suture of the abscess (38%), insertion of a felt aortic or mitral ring using Teflon or pericardium (42%), or debridment of the abscess cavity (20%). The 1 month operative mortality was 16%. Actuarial rates for overall survival at 3 and 27 months in operated patients were 75 +/- 10% and 59 +/- 11%, respectively. Increasing patient age, staphylococcal infection, and fistulization of the abscess were found to be independent risk factors in both 1 month and overall operative mortality. Renal failure was a risk factor predictive of operative mortality at 1 month, whereas uncontrolled infection and circumferential abscess were regarded as risk factors predictive of overall operative mortality. CONCLUSION: The data determined prognostic factors of abscesses associated with infective endocarditis.

[Coronary surgery on the beating heart under extracorporeal circulation in high-risk patients. An acceptable compromise?]. / La chirurgie coronaire à coeur battant sous circulation extracorporelle chez les patients à haut risque. Un compromis acceptable?

Coronary artery surgery with cardioplegia in high risk patients carries a risk of myocardial ischaemia and, without cardiopulmonary bypass, is not always technically feasible. The authors assessed an alternative, surgery on the beating heart with haemodynamic assist by cardiopulmonary bypass in 43 consecutive patients with poor left ventricular function (mean ejection fraction: 0.26), evolving myocardial ischaemia or acute myocardial infarction, old age (mean: 79.5 years) and comorbid conditions. Results were assessed mainly on clinical criteria. In addition, 9 patients had pre- and post-cardiopulmonary bypass measurements of markers of myocardial ischaemia (troponine Ic) and systemic inflammation (interleukines 6 and 10, elastase). In 6 cases, right atrial biopsy was analysed for expression of messenger ribonucleic acid coding for heat shock protein (HSP) 70; the data were compared with those of patients operated under warm blood cardioplegia. There was one cardiac death and one myocardial infarction. Myocardial conservation was confirmed by the minimal increase in troponine Ic levels and the significant increase in HSP 70 in RNA suggesting myocardial adaptation to stress. On the other hand, the minimal concentrations of mediators of inflammation were not significantly changed. In selected high risk patients, coronary revascularisation on the beating heart under cardiopulmonary bypass could be a valuable alternative. It conserves the potentially deleterious effects of cardiopulmonary bypass but peroperative global myocardial ischaemia, an important factor in the aggressivity of cardiac surgery, is eliminated.

[Cardiac abscess in infectious endocarditis. A multicenter study apropos of 233 cases. The Working Group on Valvulopathy of the French Society of Cardiology]. / Abcès cardiaques dans l'endocardite infectieuse. Etude multicentrique à propos de 233 cas. Groupe de travail sur les valvulopathies de la Société française de cardiologie.

The aim of this retrospective multicenter study was to determine present characteristics of infectious endocarditis complicated by abscess and to identifying predictive factors of mortality. The files of 233 patients with infectious endocarditis complicated by perivalvular abscesses between January 1989 and December 1993 were analysed. Two hundred and thirteen patients underwent medico-surgical treatment (175 aortic and 38 mitral abscesses) and 20 patients underwent medical treatment alone (17 aortic and 3 mitral abscesses). The abscess was observed on native valves in 156 cases and valve prostheses in 77 cases. The causative organism was identified in 69% of cases : the commonest organism was the staphylococcus. The diagnostic sensitivity of transthoracic and transoesophageal echocardiography was 36 and 80% respectively. The operative mortality at one month was 16%. Patients over 65 years of age, staphylococcal infection, renal failure and fistulisation of the abscess, were identified as independent predictive factors of mortality at one month. The survival rate three months after surgery was 75 +/- 10% and 59 +/- 11% at 27 months. An age over 65, staphylococcal infection, uncontrolled infection, circumferential abscess and fistulisation were independent predictive factors of global mortality (the first month and after). The mortality rate in unoperated patients was 40%: cardiac failure and fistulisation of the abscess detected by echocardiography were predictive factors of mortality on univariate analysis.

On-pump, beating-heart coronary artery operations in high-risk patients: an acceptable trade-off?

BACKGROUND: Current cardioplegic techniques do not consistently avoid myocardial ischemic damage in high-risk patients undergoing coronary artery bypass grafting. Alternatively, revascularization without cardiopulmonary bypass is not always technically feasible. We investigated whether an intermediary approach based on maintenance of a beating heart with cardiopulmonary bypass support but without aortic cross-clamping might be an acceptable trade-off. METHODS: Thirty-seven consecutive patients underwent coronary artery bypass grafting (with an average of two grafts per patient) in a pump-supported, non-cross-clamped beating heart. Inclusion criteria were poor left ventricular function (18 patients; mean ejection fraction, 0.25), evolving myocardial ischemia or infarction (11 patients, 5 of whom were in cardiogenic shock), and advanced age (3 patients; mean age 79.5 years) with comorbidities. Results were assessed primarily on the basis of clinical outcome. In addition, measurements of plasma levels of markers of myocardial damage (troponin Ic) and systemic inflammation (interleukin-6, interleukin-10, elastase) were done in 9 patients before and after bypass. In 6 patients, right atrial biopsy specimens were taken before and after bypass and processed by Northern blotting for the expression of messenger ribonucleic acid coding for the cardioprotective heat-shock protein 70. These biologic data were compared with those from control patients who underwent warm cardioplegic arrest within the same time span. RESULTS: There was one cardiac-related death (2.7%), one Q-wave myocardial infarction, and no strokes. Four other deaths occurred from noncardiac causes, yielding an overall mortality rate of 13.5%. Limitation of myocardial injury was demonstrated by the minimal increase in postoperative troponin Ic levels (3.3 +/- 1.0 micrograms/L versus 6.6 +/- 1.5 micrograms/L in controls; p < 0.05) and the finding that heat-shock protein 70 messenger ribonucleic acid levels (expressed as a percentage of an internal standard) were significantly increased after bypass compared with pre-bypass values (279% +/- 80% versus 97% +/- 21%; p < 0.05). In the control group (cardioplegia), end-arrest values of heat-shock protein 70 messenger ribonucleic acid were not significantly changed from baseline (148% +/- 49% versus 91% +/- 29%), a finding suggesting a defective adaptive response to surgical stress. Conversely, peak levels of inflammatory mediators were not significantly different between the two groups. The eight grafts to the left anterior descending coronary artery that were assessed angiographically, by transthoracic Doppler echocardiography, or both methods were patent with satisfactory anastomoses. CONCLUSIONS: In select high-risk patients, on-pump, beating-heart coronary artery bypass grafting may be an acceptable trade-off between conventional cardioplegia and off-pump operations. It is still associated with the potentially detrimental effects of cardiopulmonary bypass but eliminates intraoperative global myocardial ischemia.

[Valvular homografts]. / Les homogreffes valvulaires.

Renewed interest in heart valve homografts is related to recent advances in viability. Increased viability is achieved by collecting explanted hearts from multi-organ donors and cryopreservation. Right access is usually used in case of hereditary cardiopathy to resect or repair the aortic, mitral and tricuspid valves. Life-long anticoagulant treatment can thus be avoided. Current mid-term and long-term results are very promising.

Ischemic preconditioning in cardiac surgery: a word of caution.

OBJECTIVE: Ischemic preconditioning is now established as an effective means of reducing infarct size. However, it remains uncertain whether preconditioning can improve the myocardial protection afforded by cardioplegia. The present study was designed to address this issue. METHODS: After the institution of cardiopulmonary bypass, 10 patients were preconditioned with 3 minutes of aortic crossclamping followed by 2 minutes of reperfusion before the onset of retrograde continuous warm cardioplegic arrest. Ten case-matched patients served as controls. Three blood samples were drawn simultaneously from the radial artery and the coronary sinus before bypass, at the end of the 5-minute preconditioning protocol or after 5 minutes of bypass in control patients, and at the end of cardioplegic arrest. These samples were assayed for creatine kinase MB isoenzyme and lactate. Right atrial biopsy specimens taken at the same time points were processed by Northern blotting for the expression of messenger ribonucleic acid of both c-fos and heat shock protein 70. RESULTS: At the end of arrest, the release of creatine kinase MB from the myocardium was markedly greater in preconditioned patients than in the controls. The transmyocardial lactate gradient was shifted toward production in the preconditioned group (+0.22 +/- 0.13 mmol/L) and toward extraction in the control group (-0.06 +/- 0.21 mmol/L). Molecular biology data did not suggest a protective effect of preconditioning. There were no clinical adverse events related to preconditioning. CONCLUSIONS: Preconditioning does not enhance cardioplegic protection and might even be deleterious. These results do not dismiss its use in cardiac operations. They rather emphasize the need for identifying pharmacologic mediators that could safely and effectively duplicate the cardioprotective effects of ischemic preconditioning.

Influence of temperature on neutrophil trafficking during clinical cardiopulmonary bypass.

BACKGROUND: The adhesion of neutrophils to endothelial cells and their subsequent transendothelial migration play a major role in inflammatory damage elicited by cardiopulmonary bypass (CPB) because these events are linked to the release of cytotoxic proteases and oxidants. However, the patterns of neutrophil trafficking in relation to systemic temperature during clinical CPB have not yet been characterized. METHODS AND RESULTS: Twenty case-matched patients undergoing warm (31.8 +/- 0.4 degrees C) or cold (26.3 +/- 0.5 degrees C, P < .0001 versus warm) bypass were studied. Blood samples were simultaneously collected from the right and left atria before, at the end of, and 30 minutes after CPB. Plasma levels of C3a, P- and E-selectins, elastase, and interleukin-8 were determined by immunoassays. The results demonstrate: (1) a rise in C3a, reflecting complement activation, (2) a fall in soluble E-selectin consistent with an increased adhesiveness of activated neutrophils, (3) a rise in soluble P-selectin expected to enhance endothelial adhesion of these neutrophils, (4) a rise in elastase, suggesting an adhesion-triggered neutrophil degranulation, and finally (5) a rise in interleukin-8 that is likely to promote transendothelial migration of adherent neutrophils. All of these changes occurred in the two groups of patients and were significant compared with prebypass values. However, in none of the groups was there a significant difference between right and left atrial values for any of the markers. The single difference between cold and warm bypass patients was a significant reduction of elastase release in the cold group (P < .001 versus the warm group). CONCLUSIONS: Clinical CPB is associated with biological changes suggesting the occurrence of neutrophil trafficking. Hypothermia provides only partial protection through a reduced release of elastase. Overall, these results reinforce the rationale for the development of therapeutic strategies targeted at blunting the neutrophil-mediated component of bypass-induced inflammatory damage.

Ultrasonic dissection: a useful adjunct to operation for calcified constrictive pericarditis.

We describe the use of an ultrasonic surgical dissector to remove calcified pericardium. This device proved to be useful for achieving safe and complete pericardial decortication in 2 patients.