Comparison between arch zones in modified frozen elephant trunk procedure for complex thoracic aortic diseases

Abstract Introduction: The aim of this study is to compare postoperative outcomes and follow-up of two different modifications facilitating surgical technique of frozen elephant trunk (FET) procedure for complex thoracic aortic diseases - zone 0 (fixation with total arch debranching) and zone 3 (fixation with islet-shape arch repair). Methods: From May 2012 to December 2018, data were collected from 139 patients who had been treated with FET procedure for complex thoracic aortic diseases. According to Ishimaru arch map, patients with proximal anastomotic site of hybrid graft at zone 0 and zone 3 were grouped as Group A (n=58, 41.7%) and Group B (n=81, 58.3%), respectively. Mean age of study population was 54.7±11.4 years, and 111 patients were male (79.9%). Results: In-hospital mortality was observed in 20 (14.4%) patients (n=12, acute type A aortic dissection, and n=4, previous aortic dissection surgery). There was no significant difference between both groups in terms of in-hospital mortality. Four patients from Group A and three patients from Group B had permanent neurological deficit (P=0.32). Three patients from both groups had transient spinal cord ischemia (P=0.334). Although mean total perfusion time was longer in Group A, duration of visceral ischemia, when compared with Group B, was shorter (P<0.001). Five-year survival rate was 82.8% in Group A and 81.5% in Group B (P=0.876). Conclusion: FET procedure is a feasible repair technique in the treatment of complex aortic diseases, providing satisfactory early results. Because of its advantageous aspects, zone 0 fixation with debranching is the preferred technique in our clinic.

Comparison between Arch Zones in Modified Frozen Elephant Trunk Procedure for Complex Thoracic Aortic Diseases.

INTRODUCTION: The aim of this study is to compare postoperative outcomes and follow-up of two different modifications facilitating surgical technique of frozen elephant trunk (FET) procedure for complex thoracic aortic diseases - zone 0 (fixation with total arch debranching) and zone 3 (fixation with islet-shape arch repair). METHODS: From May 2012 to December 2018, data were collected from 139 patients who had been treated with FET procedure for complex thoracic aortic diseases. According to Ishimaru arch map, patients with proximal anastomotic site of hybrid graft at zone 0 and zone 3 were grouped as Group A (n=58, 41.7%) and Group B (n=81, 58.3%), respectively. Mean age of study population was 54.7±11.4 years, and 111 patients were male (79.9%). RESULTS: In-hospital mortality was observed in 20 (14.4%) patients (n=12, acute type A aortic dissection, and n=4, previous aortic dissection surgery). There was no significant difference between both groups in terms of in-hospital mortality. Four patients from Group A and three patients from Group B had permanent neurological deficit (P=0.32). Three patients from both groups had transient spinal cord ischemia (P=0.334). Although mean total perfusion time was longer in Group A, duration of visceral ischemia, when compared with Group B, was shorter (P<0.001). Five-year survival rate was 82.8% in Group A and 81.5% in Group B (P=0.876). CONCLUSION: FET procedure is a feasible repair technique in the treatment of complex aortic diseases, providing satisfactory early results. Because of its advantageous aspects, zone 0 fixation with debranching is the preferred technique in our clinic.

Primary Cardiac Angiosarcoma with Rare Presenting Feature and Successful Surgical Treatment.

Primary angiosarcoma is a rare clinical entity, it's typically located within the right atrium and known to be rapidly fatal. A 37-year-old female was presented with a history of recurrent facial paralysis and left hemiparesis. A cranial mass was identified at cranial magnetic resonance imaging and she underwent neurosurgery operation. The immunohistochemical examination was determined as metastatic cardiac angiosarcoma. The tumor, as well as part of the right pericardium, were resected. A piece of bovine pericardium was used to reconstruct the right atrial wall. Tricuspid valve was reconstructed with ring annuloplasty. Due to resection of right coronary artery with the tumor, coronary bypass surgery was performed successfully. The patient is currently healthful without any recurrence and complaint 12 months after the diagnosis as followed up.

Primary cardiac angiosarcoma with rare presenting feature and successful surgical treatment

Abstract Primary angiosarcoma is a rare clinical entity, it's typically located within the right atrium and known to be rapidly fatal. A 37-year-old female was presented with a history of recurrent facial paralysis and left hemiparesis. A cranial mass was identified at cranial magnetic resonance imaging and she underwent neurosurgery operation. The immunohistochemical examination was determined as metastatic cardiac angiosarcoma. The tumor, as well as part of the right pericardium, were resected. A piece of bovine pericardium was used to reconstruct the right atrial wall. Tricuspid valve was reconstructed with ring annuloplasty. Due to resection of right coronary artery with the tumor, coronary bypass surgery was performed successfully. The patient is currently healthful without any recurrence and complaint 12 months after the diagnosis as followed up.

Outcomes After Surgical Resection of Primary Non-Myxoma Cardiac Tumors.

OBJECTIVE: Primary cardiac tumors are rare lesions with different histological type. We reviewed our 17 years of experience in the surgical treatment and clinical results of primary non-myxoma cardiac tumors. METHODS: Between July 2000 and February 2017, 21 patients with primary cardiac tumor were surgically treated in our institution. The tumors were categorized as benign non-myxomas and malignants. Data including the demographic characteristics, details of the tumor histology and grading, cardiac medical and surgical history, surgical procedure of the patients were obtained from the hospital database. RESULTS: Eleven patients were diagnosed with benign non-myxoma tumor (male/female:7/4), ranging in age from 10 days to 74 years (mean age 30.9±26.5 years). Papillary fibroelastoma was the most frequent type (63.6%). There were two early deaths in benign group (all were rhabdomyoma), and mortality rate was 18%. The mean follow-up period was 69.3±58.7 months (range, 3 to 178 months). All survivals in benign group were free of tumor-related symptoms and tumor relapses. Ten patients were diagnosed with malignant tumor (sarcoma/lymphoma:8/2, male/female:3/7), ranging in age from 14 years to 73 years (mean age 44.7±18.9 years). Total resection could be done in only three (30%) patients. The mean follow-up period was 18.7±24.8 months (range, 0-78 months). Six patients died in the first 10 months. CONCLUSION: Complete resection of the cardiac tumors, whenever possible, is the main goal of surgery. Surgical resection of benign cardiac tumors is safe, usually curative and provides excellent long-term prognosis. On the contrary, malignant cardiac tumors still remain highly lethal.

Outcomes after surgical resection of primary non-myxoma cardiac tumors

Abstract Objective: Primary cardiac tumors are rare lesions with different histological type. We reviewed our 17 years of experience in the surgical treatment and clinical results of primary non-myxoma cardiac tumors. Methods: Between July 2000 and February 2017, 21 patients with primary cardiac tumor were surgically treated in our institution. The tumors were categorized as benign non-myxomas and malignants. Data including the demographic characteristics, details of the tumor histology and grading, cardiac medical and surgical history, surgical procedure of the patients were obtained from the hospital database. Results: Eleven patients were diagnosed with benign non-myxoma tumor (male/female:7/4), ranging in age from 10 days to 74 years (mean age 30.9±26.5 years). Papillary fibroelastoma was the most frequent type (63.6%). There were two early deaths in benign group (all were rhabdomyoma), and mortality rate was 18%. The mean follow-up period was 69.3±58.7 months (range, 3 to 178 months). All survivals in benign group were free of tumor-related symptoms and tumor relapses. Ten patients were diagnosed with malignant tumor (sarcoma/lymphoma:8/2, male/female:3/7), ranging in age from 14 years to 73 years (mean age 44.7±18.9 years). Total resection could be done in only three (30%) patients. The mean follow-up period was 18.7±24.8 months (range, 0-78 months). Six patients died in the first 10 months. Conclusion: Complete resection of the cardiac tumors, whenever possible, is the main goal of surgery. Surgical resection of benign cardiac tumors is safe, usually curative and provides excellent long-term prognosis. On the contrary, malignant cardiac tumors still remain highly lethal.

Comparison of Early Outcomes with Three Approaches for Combined Coronary Revascularization and Carotid Endarterectomy.

Objective: This study aims to compare three different surgical approaches for combined coronary and carotid artery stenosis as a single stage procedure and to assess effect of operative strategy on mortality and neurological complications. Methods: This retrospective study involves 136 patients who had synchronous coronary artery revascularization and carotid endarterectomy in our institution, between January 2002 and December 2012. Patients were divided into 3 groups according to the surgical technique used. Group I included 70 patients who had carotid endarterectomy, followed by coronary revascularization with on-pump technique, group II included 29 patients who had carotid endarterectomy, followed by coronary revascularization with off-pump technique, group III included 37 patients who had coronary revascularization with on-pump technique followed by carotid endarterectomy under aortic cross-clamp and systemic hypothermia (22-27ºC). Postoperative outcomes were evaluated. Results: Overall early mortality and stroke rate was 5.1% for both. There were 3 (4.3%) deaths in group I, 2 (6.9%) deaths in group II and 2 (5.4%) deaths in group III. Stroke was observed in 5 (7.1%) patients in group I and 2 (6.9%) in group II. Stroke was not observed in group III. No statistically significant difference was observed for mortality and stroke rates among the groups. Conclusion: We identified no significant difference in mortality or neurologic complications among three approaches for synchronous surgery for coronary and carotid disease. Therefore it is impossible to conclude that a single principle might be adapted into standard practice. Patient specific risk factors and clinical conditions might be important in determining the surgical tecnnique.

Comparison of early outcomes with three approaches for combined coronary revascularization and carotid endarterectomy

Abstract Objective: This study aims to compare three different surgical approaches for combined coronary and carotid artery stenosis as a single stage procedure and to assess effect of operative strategy on mortality and neurological complications. Methods: This retrospective study involves 136 patients who had synchronous coronary artery revascularization and carotid endarterectomy in our institution, between January 2002 and December 2012. Patients were divided into 3 groups according to the surgical technique used. Group I included 70 patients who had carotid endarterectomy, followed by coronary revascularization with on-pump technique, group II included 29 patients who had carotid endarterectomy, followed by coronary revascularization with off-pump technique, group III included 37 patients who had coronary revascularization with on-pump technique followed by carotid endarterectomy under aortic cross-clamp and systemic hypothermia (22-27ºC). Postoperative outcomes were evaluated. Results: Overall early mortality and stroke rate was 5.1% for both. There were 3 (4.3%) deaths in group I, 2 (6.9%) deaths in group II and 2 (5.4%) deaths in group III. Stroke was observed in 5 (7.1%) patients in group I and 2 (6.9%) in group II. Stroke was not observed in group III. No statistically significant difference was observed for mortality and stroke rates among the groups. Conclusion: We identified no significant difference in mortality or neurologic complications among three approaches for synchronous surgery for coronary and carotid disease. Therefore it is impossible to conclude that a single principle might be adapted into standard practice. Patient specific risk factors and clinical conditions might be important in determining the surgical tecnnique.

Surgical treatment of aortic valve endocarditis: a 26-year experience.

OBJECTIVE: We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years. METHODS: From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years. RESULTS: Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up. CONCLUSION: Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low.

Surgical treatment of double valve endocarditis.

BACKGROUND: We have retrospectively analyzed the results of the operations made for aortic infective endocarditis with mitral involvement in a single center in 19 years. METHODS: From May 1992 to January 2011, we have operated on 72 patients with infective endocarditis of the aortic valve with mitral valve involvement. Fifty-two patients (72.2%) were male and the mean age was 40.5 ± 15.5 (9-73) years. The blood cultures were positive in 33 patients (45.8%) and the most commonly identified microorganism was Streptococcus. Nine patients (12.5%) had prosthetic valve endocarditis. The mean duration of follow-up was 6.8 ± 4.7 (0.1-16.9) years, adding up to a total of 156.1 patient/years. RESULTS: A total of 155 procedures were performed on these 72 patients. The most commonly performed procedure was aortic valve replacement, in 63 patients (87.5%). Aortic annular involvement was present in 9 cases (12.5%). In-hospital mortality was seen in 13 patients (18.1%). Postoperatively, 13 (18.1%) patients had low cardiac output, 9 (12.5%) had heart block, and only 1 of them required permanent pacemaker implantation. The actuarial survival rates for 1, 5, and 10 years were 96.4% ± 2.5%, 84.4% ± 5.1%, and 77.4 ± 6.7%, respectively. CONCLUSIONS: Double-valve endocarditis is a serious condition and the surgeon must be aware of the high rates of mortality and morbidity in these patients. Although no association was found, heart blocks and septic embolization must be handled with caution. The patients generally do well after surgery, and recurrences and reoperations decrease by the second year after operation.

Surgical treatment of aortic valve endocarditis: a 26-year experience / Tratamento cirúrgico da endocardite da válvula aórtica: 26 anos de experiência

Objective: We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years. Methods: From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years. Results: Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up. Conclusion: Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low. .

Objetivo: Analisamos, retrospectivamente, os resultados das operações realizadas para endocardite valvar aórtica em um único centro em 26 anos. Métodos: De junho de 1985 a janeiro de 2011, 174 pacientes foram operados por endocardite da válvula aórtica. Cento e trinta e oito (79,3%) pacientes eram do sexo masculino e a média de idade foi de 39,3 ± 14,4 (9-77) anos. Vinte e sete (15,5%) pacientes apresentavam endocardite na prótese valvar. O tempo médio de acompanhamento foi de 7,3 ± 4,2 anos (0,1- 18,2) totalizando 1.030,8 paciente/ano . Resultados: Duzentos e oitenta e dois procedimentos foram realizados. O procedimento mais realizado foi a substituição da valva aórtica por prótese mecânica (81,6 %). A mortalidade intra-hospitalar ocorreu em 27 (15,5%) casos. No pósoperatório, 25 (14,4% ) pacientes apresentaram baixo débito cardíaco e 17 (9,8%) bloqueio cardíaco . As taxas de sobrevida atuarial para 10 e 15 anos foram 74,6±3,7% e 61,1±10,3%, respectivamente. A mortalidade intra-hospitalar foi encontrada esteve associada com o sexo feminino, operação de emergência, insuficiência renal pós-operatória e baixo débito cardíaco. A mortalidade a longo prazo foi significativamente associada com o envolvimento da válvula mitral. O sexo masculino encontrado mostrou-se um fator de risco para a recorrência no seguimento. Conclusão: A cirurgia para tratamento da endocardite da válvula aórtica apresenta mortalidade. Operação de emergência, o sexo feminino, insuficiência renal pós-operatória e baixo débito cardíaco são fatores de risco significativos. O risco de recorrência e necessidade de reoperação são baixos. .

Midterm results of axilloaxillary cardiopulmonary bypass.

BACKGROUND: Total axilloaxillary cardiopulmonary bypass (CPB) is an alternative peripheral cannulation technique that has the advantages of antegrade flow during CPB, monohemispherical brain perfusion in case of circulatory arrest, and achieving excellent decompression of the heart during sternotomy. The results of this strategy, particularly beyond the immediately postoperative period, are not well known. METHODS: Eleven patients with huge aortic aneurysms (>80 mm) and/or acute-subacute ascending aorta dissections underwent surgery with totally axilloaxillary CPB. Short- and midterm outcomes, including survival and complications relating to axilloaxillary cannulation, were reported. RESULTS: All attempts at axillary artery cannulation were successful. Ten of the 11 axillary vein cannulation attempts were successful, and the target pump flow was achieved via the axillary vein alone. Postoperatively, clinical examinations revealed no cases of arm ischemia or compartment syndrome. Three patients (27.3%) experienced ipsilateral brachial plexus neuropathy that produced right hand weakness. The neuropathy was transient in 2 patients, and the symptoms resolved completely. Hospital death occurred in 1 (9.1%) of the 11 patients. The mean (±SD) follow-up time was 956 ± 292 days. One of the survivors died on postoperative day 105 from subacute graft infection and sepsis. The right arms of all 9 of the living patients were examined physically and by Doppler ultrasonography. We found a chronic recanalized thrombotic change in the subclavian vein in 1 patient (11.1%), who had no complaints. CONCLUSIONS: Axilloaxillary CPB is an alternative technique that can be used under certain conditions. Adding axillary venous cannulation to axillary artery cannulation at least does not increase the risk of a procedure that uses the axillary artery alone, either in the early or mid term.

Surgical treatment of culture-negative aortic infective endocarditis.

BACKGROUND: We retrospectively analyzed the results of operations done for culture-negative aortic infective endocarditis at a single center over a period of 26 years. METHODS: From June 1985 to January 2011, we operated on 82 patients with infective endocarditis of the aortic valve for which the results of culture were negative. Sixty-five of the patients (79.3%) were male and the patients' mean age was 38.0±14.4 years (range, 9 to 73 years). Nineteen of the patients (23.2%) had a history of previous cardiac surgery, and 16 of the patients (19.5%) had endocarditis of a prosthetic valve. Two patients (2.4%) had conduction blocks. The mean duration of follow-up was 7.1±4.3 years (range, 0.1 to 16.9 years), yielding a total of 477.0 patient-years for the study population. RESULTS: One hundred and thirty-eight procedures were done on the 82 patients in the study. The most common procedure was aortic valve replacement, which was done on 67 patients (81.7%). Thirty-nine patients (47.6%) had concomitant procedures done on the mitral valve. In-hospital death occurred in 14 patients (17.1%). Postoperatively, 17 patients (20.7%) had a low cardiac output and 9 patients (11.0%) had heart block, of whom 3 required implantation of a permanent pacemaker. The actuarial rate of survival of the patient population at 1, 5, 10, and 15 years was 92.5%±3.2%, 85.6%±4.5%, 82.5±5.3%, and 72.2±10.7% respectively. CONCLUSIONS: Culture-negative infective endocarditis is a major problem in the diagnosis and treatment of a significant proportion of cases of endocarditis. Most of the affected patients are in a healed state, which could be a cause of negative culture results. In-hospital mortality in patients with culture-negative infective aortic endocarditis is associated with a history of previous cardiac surgery, whereas long-term mortality in this patient population is associated with nonaortic procedures.

Surgical treatment of cardiac hydatid disease in 13 patients.

Cardiac hydatidosis is an uncommon but potentially fatal disease. It remains endemic in developed and developing countries. Its clinical presentation ranges from an absence of symptoms to congestive heart failure or other life-threatening sequelae. Herein, we report our clinical experience with the disease. From 1991 through 2009, 7 male and 6 female patients (mean age, 36 +/- 18.3 yr; age range, 10-68 yr) underwent surgical treatment at our hospital for cardiac hydatid disease. Cardiac hydatidosis was established as a component of multiorgan echinococcosis in 8 patients, and it was diagnosed upon echocardiographic examination in the other 5 during investigation of their nonspecific symptoms. Hydatid cysts were found in the left ventricle (in 5 patients); the right ventricle (in 3); the interventricular septum (in 2); and the interatrial septum, right atrium, and left atrium (in 1 each). All 13 patients underwent sternotomy and surgery under cardiopulmonary bypass. No intraoperative rupture or operative death occurred. The only sequela was complete atrioventricular block that necessitated pacemaker implantation in a patient whose hydatid cyst had involved the basal interventricular septum. All patients underwent subsequent treatment with albendazole (400 mg/d). One patient experienced a recurrence 1 year postoperatively. We discuss our surgical approaches, the outcomes in our patients, and diagnostic and therapeutic recommendations.

Aortic valve replacement for a patient with glucose-6-phosphate dehydrogenase deficiency and autoimmune hemolytic anemia.

Autoimmune hemolytic anemia and deficiency of glucose-6-phosphate deyhdrogenase (G6PD) result in severe hemolysis with different mechanisms. In patients with both pathologies, the effects of cardiopulmonary bypass on red blood cells and thrombocytes demand special care before and after open heart surgery. We evaluated the preoperative management and postoperative care of a patient with severe aortic insufficiency associated with G6PD deficiency and autoimmune hemolytic anemia who underwent aortic valve replacement.