Two presentations of acute coronary syndrome with progression of giant right coronary artery aneurysm; a case report.

Background: Giant coronary aneurysms are a rare finding on coronary angiography. Given its very low prevalence, little is known about optimal management of this coronary pathology. Case summary: In this case report, we review the two presentations of a patient with acute coronary syndrome during a 6-year period. With regard to the second presentation, we review the investigations that demonstrate the progression of a coronary aneurysm in the right coronary artery as well as the Heart Team evaluations that resulted in surgical treatment of the coronary aneurysm. Discussion: Following perspectives on prevalence and risk factors, we emphasize upon the available data with regard to interventional options in coronary aneurysms and describe the considerations with regard to interventional treatment in patients with giant coronary aneurysms. Finally, we discuss the available literature with regard to antithrombotic regimens in patients with coronary aneurysms.

One-Year Outcomes of Transcatheter Aortic Valve Implantation Using the Direct Aortic Approach.

BACKGROUND: The direct aortic (DA) approach allows for transcatheter aortic valve implantation (TAVI) in patients with difficult peripheral vascular anatomy. The CoreValve ADVANCE Direct Aortic (ADVANCE DA) study was performed to assess the outcomes of DA TAVI with the CoreValve System (Medtronic, Minneapolis, MN) in routine practice. METHODS: Patients were selected for the DA approach by local cardiac surgical teams, and TAVI was performed with patients under general anesthesia. Safety events were adjudicated according to the Valve Academic Research Consortium-2 definitions by an independent clinical events committee. All imaging data, including that from multislice computed tomography and follow-up echocardiography, were analyzed by an independent core laboratory. RESULTS: From September 2012 to February 2014, 100 patients were enrolled (52.0% male, age 81.9 ± 5.9 years, The Society of Thoracic Surgeons Score 5.9 ± 3.2%) at 9 centers in Europe. Peripheral vascular disease was present in 51.0% of patients, and 38.0% had diabetes. Of the 100 patients enrolled, 92 underwent TAVI. At 30 days after TAVI, 98.1% were free of moderate or severe paravalvular leak. At 1 year, 16 patients had died (Kaplan-Meier rate 17.9%), 1 (1.1%) patient had had a stroke, classified as nondisabling, and 15 (17.0%) patients had received a permanent pacemaker. Most patients experienced improved quality of life as measured by the Kansas City Cardiomyopathy Questionnaire overall summary score (mean change from baseline to 1 year, 39.6 ± 26.3; p < 0.01). CONCLUSIONS: The DA approach provides a feasible alternative for patients with challenging anatomic features that may otherwise preclude use of the TAVI procedure.

Mid-term haemodynamic and clinical results after aortic valve replacement using the Freedom Solo stentless bioprosthesis versus the Carpentier Edwards Perimount stented bioprosthesis.

OBJECTIVES: The aim of this study was to investigate the mid-term haemodynamic and clinical results after aortic valve replacement (AVR) using the Sorin Freedom Solo (SFS) stentless bioprosthesis, compared with the standard Carpentier Edwards Perimount (CEP) stented bioprosthesis. METHODS: In this retrospective cohort study of prospectively collected data, 116 patients were included in the SFS group (53 males; median age 74 years, range 56-85 years), and 122 patients in the CEP group (85 males; median age 73 years, range 43-88 years) between July 2007 and January 2013. Echocardiography was performed at 6 weeks after surgery in our centre, and the most recent echocardiography (in our centre or in referring cardiology departments) was requested. Between September 2013 and April 2014, all patients were called by the same researcher to gain clinical follow-up data. RESULTS: Mid-term mortality was 16.4% in the SFS group (19 patients) and 21.3% in the CEP group (26 patients); (P = 0.3). The mean transvalvular gradient was 7.4 ± 3.1 mmHg in the SFS group, and 11.6 ± 3.2 mmHg in the CEP group at 6 weeks postoperatively (P < 0.001). When stratified by labelled valve size, mean gradients were significantly lower in the SFS group for every size (P ≤ 0.03). After 3.3 ± 1.4 years of follow-up, the mean gradient was still significantly lower in the SFS group than that in the CEP group (P < 0.001). Clinical follow-up showed relatively low complication rates. CONCLUSION: These data suggest that the Sorin Freedom Solo stentless bioprosthesis is as safe as the Carpentier Edwards bioprosthesis, and provides better short- and mid-term haemodynamic performance than the Carpentier Edwards bioprosthesis.

Effects of cell-saving devices and filters on transfusion in cardiac surgery: a multicenter randomized study.

BACKGROUND: Cell-saving devices (CS) are frequently used in cardiac surgery to reduce transfusion requirements, but convincing evidence from randomized clinical trials is missing. Filtration of salvaged blood in combination with the CS is widely used to improve the quality of retransfused blood, but there are no data to justify this approach. METHODS: To determine the contribution of CS and filters on transfusion requirements, we performed a multicenter factorial randomized clinical trial in two academic and four nonacademic hospitals. Patients undergoing elective coronary, valve, or combined surgical procedures were included. The primary end point was the number of allogeneic blood products transfused in each group during hospital admission. RESULTS: From 738 included patients, 716 patients completed the study (CS+filter, 175; CS, 189; filter, 175; neither CS nor filter, 177). There was no significant effect of CS or filter on the total number of blood products (fraction [95% confidence interval]: CS, 0.96 [0.79, 1.18]; filter, 1.17 [0.96, 1.43]). Use of a CS significantly reduced red blood cell transfusions within 24 hours (0.75 [0.61,0.92]), but not during hospital stay (0.86 [0.71, 1.05]). Use of a CS was significantly associated with increased transfusions of fresh frozen plasma (1.39 [1.04, 1.86]), but not with platelets (1.25 [0.93, 1.68]). Use of a CS significantly reduced the percentage of patients who received any transfusion (odds ratio [95% confidence interval]: 0.67 [0.49, 0.91]), whereas filters did not (0.92 [0.68, 1.25]). CONCLUSIONS: Use of a CS, with or without a filter, does not reduce the total number of allogeneic blood products, but reduces the percentage of patients who need blood products during cardiac surgery.

Effect of storage time of transfused plasma on early and late mortality after coronary artery bypass grafting.

OBJECTIVES: Because some concern has been raised about the storage time of red blood cells and outcomes after cardiac surgery, we investigated whether longer storage time of transfused plasma increases the risk for early or late mortality among patients who have undergone coronary artery bypass grafting. METHODS: We retrospectively analyzed the data of all 10,626 patients who underwent isolated coronary artery bypass grafting in Catharina Hospital, Eindhoven, The Netherlands, between January 1998 and December 2007. All patients who received at least 1 unit of plasma intraoperatively or during the first 5 postoperative days were studied. They were divided into 3 groups (only younger plasma, only older plasma, and any older plasma groups) according to the storage time of the plasma (cutoff point, 323 days). RESULTS: After we had excluded 122 patients who were unavailable for follow-up, we found that 375 of the remaining patients (n = 745) received only younger plasma 370 patients received any older plasma, and 200 patients received only older plasma (mean follow-up, 1565 ± 1137 days; median follow-up, 1629 days). The storage time of plasma, when entered as either a continuous variable or a dichotomous variable, was a risk factor for early but not late mortality. Log-rank testing revealed no statistical difference in long-term survival among the groups. CONCLUSIONS: Longer storage time of plasma is a risk factor for early but not late mortality among patients who have undergone coronary artery bypass grafting.

Thrombocytopenia after aortic valve replacement: comparison between mechanical and biological valves.

BACKGROUND AND AIM OF THE STUDY: Concerns have been recently raised regarding the postoperative decrease in platelet count after aortic valve replacement (AVR). Thus, a retrospective analysis was conducted of patients after AVR with regards to postoperative platelet count. METHODS: The data were analyzed from all patients undergoing AVR with (n = 829) or without (n = 1,230) coronary artery bypass grafting (CABG) at a single center between January 1998 and May 2009. The lowest (minimum) platelet count within the first five postoperative days was determined. RESULTS: The patients received either an ATS mechanical prosthesis (ATS; n = 401), a St. Jude Medical mechanical prosthesis (SJM; n = 791), a Carpentier-Edwards Perimount bioprosthesis (CEP; n = 618), a Medtronic Freestyle stentless bioprosthesis (FRE; n = 213), or a Sorin Freedom Solo stentless bioprosthesis (SFS; n = 36). By using a multivariate linear regression model, the following independent risk factors for a lower postoperative platelet count were revealed: age, body surface area, active endocarditis, preoperative platelet count, duration of extracorporeal circulation, number of grafts, valve size, and units of transfused fresh-frozen plasma and red blood cells. On entering the type of prosthesis into the multivariate linear regression analysis, together with the other risk factors, patients with CEP and FRE valve prostheses had a lower minimum postoperative platelet count than those with mechanical prostheses (ATS and SJM). CONCLUSION: Patients undergoing AVR with the Carpentier-Edwards Perimount bioprosthesis or a Medtronic Freestyle stentless bioprosthesis had a lower minimum platelet count within the first five postoperative days, compared to patients receiving ATS and St. Jude Medical mechanical prostheses. No differences were identified between the Sorin Freedom Solo and all other valve prostheses.

Peripheral vascular disease as a predictor of survival after coronary artery bypass grafting: comparison with a matched general population.

BACKGROUND: The European system for cardiac operative risk evaluation, the most popular European scoring system in cardiac surgery, uses the extracardiac arteriopathy as a risk factor for early mortality. We studied the effect of peripheral vascular disease (PVD) on early and late mortality in a large group of patients undergoing isolated coronary artery bypass surgery (CABG) surgery. METHODS: During a ten-year period (January 1998 through December 2007) 10,626 patients underwent isolated CABG in our hospital. The primary endpoints of this study were early and late all-cause mortality. For each year of the study period, general population cohorts were matched with the patient groups for age and gender (expected survival). RESULTS: Out of 10,504 patients included in the analysis, 1,222 (11.63%) patients had PVD. The PVD was identified as an independent risk factor for late mortality (death at any time after hospital discharge) (hazard ratio of 1.67 [1.43 to 1.95], p < 0.0001), but not for early mortality (death within 30 days or before discharge) (hazard ratio of 1.06 [0.70 to 1.60], p = 0.776). Patients without PVD had a better survival than patients with PVD (log-rank p < 0.0001) and even a better survival compared to the normal Dutch population survival (p value < 0.002). The PVD patients had a worse than expected survival (log-rank p < 0.0001). CONCLUSIONS: Peripheral vascular disease is an independent risk factor only for late mortality but not for early mortality. Compared with age-matched and sex-matched cohorts from the general Dutch population, the ten-year survival of patients with peripheral vascular disease was worse; whereas the survival of patients with no peripheral vascular disease was better.

Anti-inflammatory effects of alkaline phosphatase in coronary artery bypass surgery with cardiopulmonary bypass.

Laboratory and clinical data have implicated endotoxin as an important factor in the inflammatory response to cardiopulmonary bypass. Alkaline phosphatase prevents endotoxin-induced systemic inflammation in animals and humans. We assessed the effects of the administration of bovine intestinal alkaline phosphatase on surgical complications in patients undergoing coronary artery bypass grafting. In a double blind, randomized, placebo-controlled study, a total of 63 patients undergoing coronary artery bypass grafting were enrolled. Bovine intestinal alkaline phosphatase or placebo was administered as an intravenous bolus followed by continuous infusion for 36 hours. The primary endpoint was reduction of post-surgical inflammation. No significant safety concerns were identified. The overall inflammatory response to coronary artery bypass grafting with cardiopulmonary bypass was low in both placebo and bovine intestinal alkaline phosphatase patient group. Five patients in the placebo group displayed a significant TNFalpha response followed by an increase in plasma levels of IL-6 and IL-8. Such a TNFalpha response was not observed in the bovine intestinal alkaline phosphatase group, suggesting anti-inflammatory activity of bovine intestinal alkaline phosphatase. Other variables related to systemic inflammation showed no statistically significant differences. Bovine intestinal alkaline phosphatase can be administered safely in an attempt to reduce the inflammatory response in coronary artery bypass grafting patients with a low to intermediate EuroSCORE. The anti-inflammatory effects might be more pronounced in patients developing more fulminant postoperative inflammatory responses. This will be investigated in a further trial with inclusion of patients undergoing complicated cardiac surgery, demanding extended cardiopulmonary bypass and aortic cross clamp time. In this review article some recent patents related to the field are also discussed.

Long-term results of coronary artery bypass grafting in patients with left ventricular dysfunction.

BACKGROUND: In this prospective study, we investigated the determinants of long-term outcome, symptoms, and left ventricular function after coronary artery bypass grafting in patients with a moderate to severely decreased left ventricular ejection fraction. METHODS: Between 1997 and 1998, 75 consecutive patients with moderate to severe left ventricular dysfunction underwent coronary artery bypass grafting procedures. The operative mortality rate was 4.0%, and the 72 survivors were monitored for 8 years. The end points were mortality, symptomatic status (New York Heart Association [NYHA] functional class), and left ventricular function. RESULTS: The total survival rate after 8 years was 89.3%. During follow-up, 8 patients died. Death was attributed to a cardiac cause in 5 patients and to a noncardiac cause in 3. There was no statistically significant difference between preoperative and late postoperative NYHA functional class, despite a statistically significant improvement that persisted for up to 4 years after CABG. The results of echocardiography showed a statistically significant improvement in the left ventricular ejection fraction (from 0.322 +/- 0.06 preoperatively to 0.463 +/- 0.02 at follow-up, p < 0.001). Multivariate analysis revealed that the left ventricular end-systolic volume index, the presence of angina pectoris, and absence of symptoms of congestive heart failure were preoperative indicators of freedom from heart failure after coronary operations (p < 0.05). CONCLUSIONS: Coronary artery bypass grafting for patients with moderate-to-severe left ventricular dysfunction is associated with acceptable long-term results. The left ventricular end-systolic volume index is a simple noninvasive method to aid in the preoperative decision making in such patients.

Long-term results after 27 years of surgical treatment of acute type a aortic dissection.

BACKGROUND: This study investigates the determinants of long-term outcome and modalities of late death after surgical treatment of acute type A dissection. METHODS: Between 1974 and 2001, 315 consecutive patients were operated on for acute type A aortic dissection. Operative mortality was 22.9%. A series of 243 survivors of surgical treatment were followed up for as long as 27 years. Endpoints were death, cardiovascular reoperation, and neurologic events. Median follow-up was 4.5 years. Follow-up was 99.6% complete. RESULTS: Cumulative survival of discharged patients was 96.4% +/- 1.3%, 67.7% +/- 4.7%, and 39.4% +/- 12.0% at 1, 10, and 20 years, respectively. During follow-up, 47 patients died. Cause of death was cardiac failure in 7, hemorrhage due to rupture of the distal aorta in 7, stroke in 4, respiratory insufficiency in 4, sepsis in 3, malignancy in 2, and unknown in 20 patients. Multivariate analysis revealed advanced patient age and postoperative hemodialysis as perioperative indicators of late death (p < 0.05). Freedom from cardiovascular reoperation was 90.7% +/- 2.0% at 1 year, 60.9% +/- 5.1% at 10 years and 41.9% +/- 15.0% at 20 years. A total of 58 patients required 86 cardiovascular reoperations; aortic root or ascending aorta replacement was performed in 20, distal ascending aorta and arch replacement in 13, descending aorta replacement in 6, thoracoabdominal aorta replacement in 7, abdominal aorta replacement in 7, and miscellaneous reoperations in 6 patients. Multivariate analysis revealed male sex and left coronary artery dissection as significant determinants for late cardiovascular reintervention (p < 0.05). Cumulative incidence of stroke after 20 years was 3.8%. CONCLUSIONS: Acute type A dissection represents an emergency situation with acceptable long-term results for discharged survivors of surgical treatment.

Is extended arch replacement for acute type a aortic dissection an additional risk factor for mortality?

BACKGROUND: We report our experience with surgery for acute type A aortic dissection with involvement of the aortic arch. METHODS: From January 1986 to December 2001, 277 patients underwent surgery for acute type A aortic dissection. In 70 patients (25.3%), surgery was extended into the aortic arch: hemiarch and total arch replacement in 53 (75.7%) and 17 (24.3%) patients, respectively. Deep hypothermic circulatory arrest was used in 19 patients, antegrade selective cerebral perfusion in 38, and combined deep hypothermic circulatory arrest with antegrade selective cerebral perfusion in 13. RESULTS: Operative mortality was 18.6% (13/70) after extended replacement into the arch versus 21.7% (45/207) after surgery limited to the ascending aorta (p = 0.62). Multivariate analysis did not reveal significant risk factors for operative mortality. Postoperatively, 5 patients (8.1%) had a new postoperative cerebral vascular accident (CVA). Multivariate analysis showed an earlier date of operation as the only independent determinant for a new postoperative CVA (p = 0.0162, RR = 0.80/year, 95% CI = 0.67 to 0.96). None of the patients, operated on with antegrade selective cerebral perfusion, had a new cerebral deficit. Comparing the different methods of cerebral protection, multivariate risk analysis revealed antegrade selective cerebral perfusion as a significant protective factor against new postoperative CVA (p = 0.0110, OR = 0.12, 95% CI = 0.02 to 0.61). Survival at 5 and 10 years was 66.6.5% and 40.0%, respectively, after replacement of the aortic arch versus 68.7% and 57.7%, respectively, after replacement of the ascending aorta (p = 0.96). Freedom from aortic arch reoperation was 96.3% at 5 and 77.0% at 10 years versus 86.6% and 75.1% in both groups, respectively (p = 0.21). CONCLUSIONS: Extended replacement into the aortic arch during surgery for acute type A dissection does not influence early and late results. The best cerebral protection seems to be obtained with antegrade selective cerebral perfusion.

Operative risk factors of type A aortic dissection: analysis of 252 consecutive patients.

OBJECTIVE: We examined operative risk factors for postoperative death after surgery for acute type A aortic dissection. METHODS: Between 1974 and 1999, 252 patients, 163 men and 89 women (mean+/-SD age, 58+/-12 years) underwent surgery for acute type A aortic dissection. Fifty-eight (23.0%) were in cardiogenic shock at time of surgery. Most patients underwent ascending aorta replacement which was combined with aortic valve replacement by means of a composite graft in 30 (11.9%) patients and an isolated aortic valve replacement in 16 (6.3%) patients. RESULTS: The overall operative mortality rate was 25.0% (n=63); 27.0% for patients operated upon with aortic cross-clamping, 23.7% after deep hypotherm circulatory arrest and 23.3% after antegrade selective cerebral perfusion (ASCP) (p=0.73). Multivariate analysis revealed iatrogenic dissection (p=0.0096, odds ratio=5.7), preoperative cardiopulmonary resuscitation (p=0.0095, odds ratio=5.5) and every quarter of an hour longer extracorporeal circulation (p=0.049, odds ratio=1.1) as independent risk factors for operative mortality. Aortic valve replacement or Bentall procedure (p=0.0185, odds ratio=0.3) were protective factors. There were 44 new postoperative strokes: 4.7% in the group operated upon with and 20.1% in the group without ASCP (p=0.01). CONCLUSION: In order to avoid cardiogenic shock and preoperative cardiopulmonary resuscitation, patients with acute type A aortic dissection should be treated promptly. The choice to use an aortic valve prosthesis or Bentall procedure when applicable seems to benefit the postoperative early survival. The risk of new postoperative neurological events might be reduced by avoiding the appliance of an aortic cross-clamp and by using ASCP.

Surgery for acute type A dissection using antegrade selective cerebral perfusion: experience with 122 patients.

BACKGROUND: Antegrade selective cerebral perfusion (ASCP) has proved to be a reliable method of brain protection during surgery of the thoracic aorta, but its use during aortic dissection surgery still remains controversial. In this study, we present our results after the operative repair of acute type A aortic dissections using ASCP and moderate hypothermic circulatory arrest. METHODS: Between October 1995 and August 2001, 122 patients (76 men, 46 women) underwent repair of acute type A aortic dissection with the aid of ASCP and open distal anastomosis. The average age of the patients was 61 +/- 12 (mean +/- standard deviation). Preoperative complications included cardiac tamponade (n = 34; 27.0%), aortic regurgitation (n = 27; 22.1%), and new neurological deficits (n = 11; 9%). RESULTS: Stepwise logistic regression revealed preoperative cardiac tamponade (p = 0.018) and new neurological deficits (p = 0.017) to be independent determinants for hospital mortality (19.7%). Permanent neurological complications occurred in 7% of the patients. Independent risk factors for temporary neurological dysfunction (11.2%) included cardiac tamponade (p = 0.019) and preoperative neurological deficits (p = 0.000). CONCLUSIONS: In our experience, the surgical treatment of acute type A aortic dissection with the aid of ASCP was associated with acceptable hospital mortality and neurologic morbidity rates.

Spontaneous external carotid-jugular fistula in repetitive hyperextension of the neck.

Arteriovenous malformations between the external carotid artery and the jugular vein are very uncommon. We describe our findings in a patient with symptoms of such a spontaneous fistula.