Pulmonary Embolism and Thrombus in Transit Through Patent Foramen Ovale.

Thrombus-in-transit through a patent foramen ovale (PFO) in a patient with pulmonary embolism (PE) is a rare event with high mortality rates. We report the case a of 53-year-old woman admitted for dyspnea, cough, hemoptysis, presyncope, tachycardia, and hypotension. A recent fall down the stairs with costal trauma was also reported. At transthoracic echocardiography, dilated right atrium with the presence of a large floating thrombus was found, protruding into the left atrium through a PFO; lower extremity vascular ultrasound showed right great saphenous vein thrombosis extended over the saphenofemoral junction up to the common femoral vein. CT scan showed submassive thromboembolism; surgical thrombectomy was, therefore, performed with the closure of the PFO; an inferior vena cava filter was also positioned for the prevention of recurrent episodes of thromboembolism. The patient was discharged in therapy with apixaban 5 mg twice a day. Two-month follow up was uneventful. Large thrombi in transit through PFO can be found at transthoracic echocardiography. The management, either medical or surgical, should be aimed at preventing systemic thromboembolism.

Mid-term results of the Lupiae technique in patients with De Bakey Type I acute aortic dissection.

OBJECTIVES: The late persistence of a patent and dilated false lumen into the thoracic aorta is associated to higher re-operation rates and to a worse prognosis after the surgical repair of De Bakey Type I acute aortic dissection (TIAAD). We present the mid-term results of a hybrid, two-stage technique for TIAAD aimed to reduce the risk of late expansion of the residual false lumen. METHODS: From May 2005 to January 2011, 49 patients with TIAAD were treated with the Lupiae technique. During the emergency operation, a Vascutek Lupiae™, a multi-branched Dacron prosthesis, was implanted to replace the ascending aorta, the aortic arch and to reroute the origin of the epiaortic vessels. The debranching of the aortic arch creates a long and stable Dacron landing zone on the ascending aorta suitable for further endovascular interventions. Postoperatively, 34 patients with a patent or partially thrombosed false lumen > 22 mm or a diameter of the descending aorta > 46 mm underwent the implant endovascular stentgrafts into the descending aorta. RESULTS: Three patients died after the first procedure. One patient died after the endovascular stage. No patient experienced paraplegia or stroke. The 6-year follow-up survival was 90 ± 4%. The obliteration of the false lumen was obtained in 94% of the patients. CONCLUSIONS: In patients with TIAAD, the debranching of the aortic arch with the Lupiae technique can be safely performed. This technique creates a long and stable landing zone that can be easily used for the deployment of endovascular stentgrafts in case of distal false lumen expansion.

Hybrid repair of thoracic and thoracoabdominal aortic aneurysms (mega aortic syndrome) with lupiae technique.

OBJECTIVE: Several techniques have been described for the treatment of thoracic and thoracoabdominal aneurysms in patients with mega aortic syndrome (MAS), but the incidence of stroke, spinal cord injury, and endoleaks remains high. We present the midterm results of a new hybrid, multistep technique to treat patients with MAS. METHODS: From November 2005 to January 2011, 80 patients with MAS underwent hybrid repair of thoracic and thoracoabdominal aneurysms with the Lupiae technique. Forty-six patients presented with chronic aortic aneurysms, and 34 patients who had undergone aortic arch debranching with the Lupiae graft for acute aortic dissection presented with an expanding false lumen into the residual aorta. Sixty patients underwent ascending aorta and arch replacement with a Gelweave Lupiae prosthesis plus epiaortic vessel debranching (thoracic Lupiae procedure). Fourteen patients underwent a thoracic Lupiae procedure plus partial visceral debranching (celiac trunk and superior mesenteric artery) through a mini-laparotomy. Six patients underwent a thoracic Lupiae procedure plus a complete visceral debranching (celiac trunk, superior mesenteric artery, and renal arteries) with the implant of a second Lupiae prosthesis to replace the abdominal aorta. After the surgical steps, all the surviving patients underwent an endovascular procedure to implant multiple stent grafts to exclude the residual segment of diseased aorta. RESULTS: In-hospital mortality was 8.4%, and the incidence of temporary renal failure was 5.2%. None of the patients had a stroke or a spinal cord injury, and none of the patients presented endoleaks immediately following the procedure or during the follow-up computed tomography scans. No deaths occurred during the 6-year follow-up after the hybrid procedure. CONCLUSIONS: These preliminary results showed that the Lupiae technique is a safe and effective option for the treatment of patients with MAS. Indeed, the Lupiae technique achieves complete exclusion of thoracic and thoracoabdominal aneurysms with a low risk of paraplegia and endoleaks.

Cardiac troponin I release after coronary artery bypass grafting operation: effects on operative and midterm survival.

BACKGROUND: Markers of myocardial necrosis are usually elevated in patients who have undergone a coronary bypass operation with cardiac arrest. The preferred marker in detecting acute myocardial ischemia is cardiac troponin I (cTnI). However, its ability to predict short-term and, particularly, midterm outcome after coronary bypass operations is uncertain. METHODS: Two hundred thirty unselected patients undergoing surgical revascularization had cTnI measured preoperatively and 11 times postoperatively. Receiver operating characteristic curves were constructed using cTnI postoperative peak values in order to assess the prognostic sensitivity and specificity of the test. The cut-off value of 13 ng/mL was used to assess the prognostic significance of the peak cTnI postoperative release for short-term and midterm outcomes. RESULTS: One hundred forty-six patients (63.5%) had postoperative cTnI peak values less than 13 ng/mL (mean peak value, 6.6 +/- 3.1 ng/mL) and 84 patients (36.5%) had postoperative cTnI peak values greater than 13 ng/mL (mean peak value, 45.5 +/- 59.9 ng/mL). Patients with peak cTnI greater than 13 ng/mL were older and had higher preoperative cTnI values. They required both longer cross-clamp time and CPB time. Moreover, hospital death in the cTnI greater than 13 ng/mL group (9.5% versus 0.7%, p = 0.0009) was significantly higher. Multivariate analysis showed that cTnI greater than 13 ng/mL was the only independent predictor of hospital death (odds ratio 10.33, p = 0.04) and hospital death from cardiac causes. A 2-year follow-up demonstrates that cTnI postoperative release had no influence on midterm mortality and hospitalization for due to cardiac illness. CONCLUSIONS: Cardiac troponin I is a valuable marker for immediate myocardial damage after coronary bypass operations. Its postoperative release does not predict midterm outcome.