Direct Transcatheter Valve Deployment via Sternotomy for Complex Aortic Valve Reoperation.

Reoperative aortic valve replacement is associated with increased morbidity. Valve-in-valve transcatheter aortic valve replacement offers a less invasive alternative to traditional reoperation. However, cases of valve failure after valve-in-valve transcatheter aortic valve replacement represent a complex surgical challenge.

Outcomes of delayed sternal closure after complex aortic surgery.

Objective: Open chest management during complex proximal aortic surgery may sometimes be necessary. Infectious complications such as mediastinitis and late aortic graft infection remain a concern. The objective of this study was to report our experience with open chest management and delayed sternal closure after complex proximal aortic surgery.

Intraoperative skeletal muscle ischemia contributes to risk of renal dysfunction following thoracoabdominal aortic repair.

Objective: Renal dysfunction is among the most commonly occurring morbidities following descending thoracic and thoracoabdominal aortic repair. We hypothesized that myoglobin nephrotoxicity might arise from leg ischemia caused by femoral artery cannulation, which is required for distal aortic perfusion. Lacking complete historical laboratory data on myoglobinemia, we studied somatosensory evoked potential (SSEP) changes in the leg (a functional marker of leg ischemia), as a surrogate predictor of acute postoperative renal failure.

Multilevel somatosensory evoked potentials and cerebrospinal proteins: indicators of spinal cord injury in thoracoabdominal aortic aneurysm surgery.

Objective: Multilevel somatosensory evoked potentials (SSEP) and the release of biochemical markers in cerebrospinal fluid (CSF) were investigated to identify patients with spinal cord ischemia during thoracoabdominal aortic repair and/or a vulnerable spinal cord during the postoperative period.

Methods: Thirty-nine consecutive patients undergoing elective aneurysm repair using distal aortic perfusion and cerebrospinal fluid drainage were studied. Continuous SSEP were monitored using nerve stimulation of the right and left posterior tibial nerves with signal recording at the level of both common peroneal nerves, the cervical cord and at the cortical level.

Update on outcomes of acute type B aortic dissection.

Background: The optimal treatment of acute type B aortic dissection remains controversial. This study reports early clinical outcomes of medical management for acute type B aortic dissection.

Methods: Between January 2001 and April 2006, data on 159 consecutive patients (55 women [35%]) with the confirmed diagnosis of acute type B aortic dissection were prospectively collected and analyzed.

Acute type A aortic dissection complicated by stroke: can immediate repair be performed safely?

Objective: Emergency surgical intervention for acute type A aortic dissection complicated by stroke remains controversial. The urgency of immediate repair in this setting is tempered by the concern that cerebral reperfusion may worsen neurologic outcome. The purpose of this study was to report and analyze our results with acute type A aortic dissection complicated by stroke.

The hybrid elephant trunk procedure: a single-stage repair of an ascending, arch, and descending thoracic aortic aneurysm.

Surgical repair of extensive aortic aneurysms requires a two-stage approach. We present the case of a single-stage repair using a hybrid procedure. This case demonstrates the technical feasibility of repairing properly selected extensive aortic aneurysms in a single procedure.

Outcomes of medical management of acute type B aortic dissection.

Background: Currently, the optimal treatment of acute type B aortic dissection remains controversial. The purpose of this study was to report early clinical outcomes of medical management for acute type B aortic dissection.

Methods And Results: Between January 2001 and March 2005, 129 consecutive patients with the confirmed diagnosis of acute type B aortic dissection were studied.

Robotic replacement of the descending thoracic aorta: an alternative to endovascular therapy?

Background: : Replacement of the descending thoracic aorta is traditionally performed via a left thoracotomy. Endovascular treatment of descending thoracic aortic aneurysms has recently evolved as an alternative treatment for selected patients, yet no long-term results are available. The authors replaced the descending thoracic aorta in a group of pigs with an interposition Dacron graft using a closed-chest, totally robotic technique.

Superior vena caval bypass using the superficial femoral vein for treatment of superior vena cava syndrome.

We present the case of a 71-year-old woman who had benign, symptomatic, superior vena cava syndrome that was treated with open surgical bypass using the superficial femoral vein. The patient had an uneventful hospital course and experienced relief of her symptoms. We conclude that the superficial femoral vein is an acceptable bypass conduit for open surgical management of superior vena cava syndrome.

Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair.

Background: Cross-clamp time has been reported to correlate with risk of neurologic deficit after thoracoabdominal aortic aneurysm repair. Introduction of cerebrospinal fluid drainage and distal aortic perfusion (adjunct) has greatly reduced the incidence of neurologic deficit. We reevaluated the effect of cross-clamp time before and after introduction of adjunct during a 13-year period.

Surgical repair of extensive aortic aneurysms.

We present our 14-year experience in the management of extensive aortic aneurysms. Significant progress has been made in reducing the morbidity and mortality associated with these procedures. Our strategies for organ protection, operative techniques, including the elephant trunk technique, and surgical results are discussed.

Primary lymphoma of the aorta presenting as a descending thoracic aortic aneurysm.

We describe a case of primary lymphoma of the thoracic aorta that presented as an aneurysm of the descending thoracic aorta. The aortic tumor was successfully resected with 2-year disease-free survival.

Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage.

Background: The benefit of distal aortic perfusion and cerebrospinal fluid drainage over the "clamp and sew" technique during repairs of the descending thoracic aorta is still being debated. The purpose of this report is to analyze our experience with regard to neurologic deficit (paraplegia and paraparesis) and mortality using the adjuncts of distal aortic perfusion and cerebrospinal fluid drainage.

Methods: Between February 1991 and September 2004, we repaired 355 descending thoracic aortic aneurysms.

Glomerular filtration rate is superior to serum creatinine for prediction of mortality after thoracoabdominal aortic surgery.

Background: Clinically evident renal disease (dialysis, history of renal insufficiency, or serum creatinine >2.0 mg/dL) is a known risk factor for mortality after thoracoabdominal aortic aneurysm repair. We extended this concept to the questions of whether subclinical renal disease is also a risk factor and how best to identify subclinical disease.

Correlations of cerebrospinal fluid pressure with hemodynamic parameters during thoracoabdominal aortic aneurysm repair.

Central venous pressure (CVP) has long been thought to correlate with cerebrospinal fluid (CSF) pressure during thoracoabdominal aortic aneurysm repair. We examined hemodynamic factors during thoracoabdominal aortic aneurysm surgery to determine their relationship with CSF pressure and aortic cross-clamping. Hemodynamic parameters and CSF pressure were measured in 124 patients at six different stages during repair of descending thoracic or thoracoabdominal aortic aneurysms: skin incision, left lung collapse, pump on, aortic clamp on, aortic clamp off, and pump off.

Cerebral monitoring with transcranial Doppler ultrasonography improves neurologic outcome during repairs of acute type A aortic dissection.

Objective: Neurologic complications after repair of acute type A aortic dissection remain significant. The use of power M-mode transcranial Doppler monitoring to verify cerebral blood flow during these repairs might decrease cerebral ischemia by correcting malperfusion. The purpose of this study was to analyze the use of power M-mode transcranial Doppler monitoring during repairs of acute type A dissection with regard to neurologic outcome.

Staged repair of extensive aortic aneurysms: long-term experience with the elephant trunk technique.

Objective: This paper reports our experience of a large series of elephant trunk patients accumulated over 12 years.

Summary Background Data: Extensive aneurysms of the ascending/arch and descending thoracic or thoracoabdominal aorta are significant surgical problems that have potential for great morbidity. We adopted a staged approach known as the elephant trunk procedure in 1991, and we have used it with some modifications since that time.

Preoperative and operative predictors of delayed neurologic deficit following repair of thoracoabdominal aortic aneurysm.

Purpose: Delayed neurologic deficit has been recognized in recent years as a source of morbidity following thoracic and thoracoabdominal aortic repair. We wanted to find risk factors specifically significant for delayed neurologic deficit. In this initial study we looked at preoperative and operative risk factors.

Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair: ten years of organ protection.

Objective: To report the long-term results of our experience using cerebrospinal fluid drainage and distal aortic perfusion in descending thoracic and thoracoabdominal aortic repair.

Summary Background Data: Repair of thoracoabdominal and thoracic aortic aneurysm by the traditional clamp-and-go technique results in a massive ischemic insult to several major organ systems. Ten years ago, we began to use distal aortic perfusion and cerebrospinal fluid drainage (adjunct) to reduce end-organ ischemia.

Determination of cerebral blood flow dynamics during retrograde cerebral perfusion using power M-mode transcranial Doppler.

Background: Retrograde cerebral perfusion (RCP) during profound hypothermic circulatory arrest has been used as an adjunct for cerebral protection for repairs of the ascending and transverse aortic arch. Transcranial Doppler ultrasound has been used to monitor cerebral blood flow during RCP with varying success. The purpose of this study was to characterize cerebral blood flow dynamics during RCP using a new mode of monitoring known as transcranial power motion-mode (M-mode) Doppler ultrasound.

Cardiac function predicts mortality following thoracoabdominal and descending thoracic aortic aneurysm repair.

Objective: Previous studies have identified age, renal failure and aneurysm extent as predictors of mortality following thoracoabdominal and descending thoracic aortic aneurysm (TAA) repair. We studied the impact of coronary artery disease (CAD) and cardiac function on 30-day mortality following TAA repair.

Methods: Between February 1991 and May 2001, we performed 854 TAA repairs.

Analysis of short-term multivariate competing risks data following thoracic and thoracoabdominal aortic repair.

Objective: Estimating the overall successfulness of a treatment can be difficult when success is defined by freedom from multiple endpoints that are each subject to competing risks. We describe a method for modeling short-term competing outcomes.

Methods: We used polytomous categorical variable modeling to describe the 30-day onset of renal failure, neurologic deficit, stroke or death (events) following repair of 841 thoracoabdominal aortic aneurysms.