Adrian Ursulescu

Minimally Invasive Access Aortic Arch Surgery

Objective Median sternotomy is still the standard approach for aortic arch surgery. Minimally invasive techniques promise faster recovery with shorter hospital stay due to thoracic stability, reduced pain, and superior cosmetic results. However, safety is a concern in complex aortic surgery. The aim of our study was to demonstrate that aortic arch surgery via partial upper sternotomy is viable, safe, and equivalent to standard procedure both in terms of its safety and the risk of major adverse cardiac and cerebrovascular events. Methods We interrogated our prospectively collected database and identified a total of 21 nonemergent patients operated on at our center between October 2008 and February 2015. Indication for operation was aneurysmatic disease in 18 and aortic dissection in 3 patients. Data were analyzed for in-hospital mortality, stroke, bleeding complications, and acute kidney injury. Results Mean ± standard deviation age of patients was 69.3 ± 14.4 years, 57.1% were female, and mean ± standard deviation logistic EuroSCORE was 17.0 ± 7.2%. Surgery on the aortic arch comprised proximal arch in 9, hemiarch in 9, and total arch replacement plus frozen elephant trunk in 3 patients. Concomitant procedures included aortic root repair in 10, aortic root replacement in 2, and aortic valve replacement in 3 patients. We lost one patient because of septic shock, no stroke occurred, but a transient neurologic deficit in three and a postoperative delirium in four patients. Re-exploration for bleeding was necessary in two patients, and one patient had acute kidney injury. Conclusions Minimally invasive aortic arch surgery via partial upper sternotomy does not increase the risk of morbidity or mortality. Thus, in experienced hands, it is viable, safe, and therefore favorable and as a result should be offered to more patients.

Clinical outcome and quality of life after reoperative CABG: off-pump versus on-pump - observational pilot study.

BackgroundCoronary artery bypass grafting (CABG) on cardiopulmonary bypass (CBP) is associated with significant morbidity and mortality. In high-risk patients, doomed for reoperation the adverse effects of CBP may be more striking. We evaluated the results of reoperative CABG (redo-CABG) by either off-pump (OPCAB) or on-pump (ONCAB). Clinical endpoints were perioperative myocardial infarction, mortality, survival and as the most striking difference between prior studies the quality of life (QoL).MethodsWe performed a prospective, non-randomized assessment for patients who underwent redo-CABG by redo-OPCAB (n = 40) or redo-ONCAB (n = 40) at our institution between January 2007 and December 2010. For evaluation of QoL the SF-36 health survey was used with self-administered assessment.ResultsDuring follow-up 37 of 40 patients were alive in the redo-OPCAB group versus 32 of 40 patients in the redo-ONCAB group (p < 0.05). The shorter operation time, less blood loss, fewer perioperative myocardial infarctions, the higher rate of totally arterial revascularisation and shorter intensive care stay were the significantly beneficial differences for patients in the redo-OPCAB group (p < 0.05). The 3-year survival rate was higher in the redo-OPCAB group with 81 ± 12% versus 63 ± 9%in the redo-ONCAB group. The quality of life survey did not reveal any significant differences between both groups.ConclusionIn conclusion, with our present retrospective study, we could demonstrate the safety and efficacy of the redo-OPCAB technique with even higher 3-year survival rate. Both techniques seem to have similar impact on the outcome of patients.

Concomitant therapy: off-pump coronary revascularization and transcatheter aortic valve implantation

OBJECTIVES Significant coronary artery disease (CAD) is common among patients evaluated for transcatheter aortic valve implantation (TAVI). Only little data exist on outcome of patients undergoing concomitant off-pump coronary revascularization and TAVI. The goal of this study was to analyse the impact of concomitant off-pump revascularization on early clinical outcome and 2-year follow-up of patients undergoing TAVI. METHODS A total of 70 patients with significant CAD and aortic valve stenosis were included between January 2011 and January 2016. Decision to perform concomitant off-pump coronary revascularization and TAVI was made by the interdisciplinary heart team according to the SYNTAX score. Prospectively assigned data were analysed retrospectively and follow-up was performed up to 2 years. RESULTS Mean age was 82.2 ± 4.0 years and 43 (61.4%) patients were male. Mean logistic European system for cardiac operative risk evaluation and Society of Thoracic Surgeons European system for cardiac operative risk evaluation score were 35.9 ± 21.9% and 12.2 ± 7.9%, respectively. SYNTAX score was 29.0 ± 12.9. Access site for TAVI was transapical in 60.0% and transaortic in 40.0%. Procedural success was 94.3%. Eighty percent of the patients had none or trace paravalvular leakage after TAVI. Severe complications requiring consecutive surgical aortic valve replacement occurred in 2 patients (2.9%). The use of cardiopulmonary bypass due to haemodynamic instability or conversion to surgical aortic valve replacement was necessary in 7 patients (10.0%). Stroke occurred in 1 patient (1.4%). Re-exploration for bleeding was necessary in 6 patients (8.6%). Thirty-day mortality was 14.3%. Two-year survival was 68.4% (95% confidence interval: 55.7-81.1%). CONCLUSIONS Simultaneously performed complete off-pump coronary revascularization is a feasible and valid option in patients with significant CAD undergoing TAVI.

Feasibility and clinical outcome after minimally invasive valve-sparing aortic root replacement

Objectives This study aims to examine the feasibility and clinical course after minimally invasive David procedure compared with those via a conventional median sternotomy. Methods One hundred and ninety-two consecutive patients who underwent elective valve-sparing aortic root replacement (David procedure) with or without additional cusp repair for aortic regurgitation ( n  = 17, 8.9%), dilatation of the aortic root ( n  = 95, 49.5%) or a combination of both pathologies ( n  = 80, 41.7%) were included. Patients with systemic disorders, such as Marfans syndrome, and emergency cases were excluded. Assessment of quality of life was performed by modified Short Form Health Survey (SF-36) questionnaire. To minimize baseline differences, a matched pair analysis was conducted. Results One hundred and seventeen patients (60.9%) received a minimally invasive hemisternotomy (Group 1), 75 patients a conventional median sternotomy (39.1%, Group 2). Patients of Group 1 were significantly younger (56.5 ± 13.6 vs 64.8 ± 11.6, P  < 0.001). Understandably, concomitant cardiac procedures were more frequent in Group 2 ( n  = 7 [6.0%] vs n  = 48 [64.0%], P  < 0.001). In hospital, mortality was 0.9% in Group 1 (1/117) and 2.7% in Group 2 (2/75; P  = 0.562). Blood loss was significantly less in Group 1 (542.6 ± 441.8 vs 996.7 ± 822.6 ml, P  < 0.001). Duration of mechanical ventilation (10.2 ± 21.8 vs 26.9 ± 109.0 h, P  < 0.001) and ICU-stay (1.9 ± 3.6 vs 3.2 ± 5.6 days, P  < 0.001) were significantly shorter in the minimally invasive group, but this differences did not remain after matching. According to SF-36 questionnaire, patients in the minimally invasive group tend to have a higher quality of life. Conclusions Minimally invasive valve-sparing aortic root replacement can be done safely via an upper partial sternotomy in experienced hands even if additional cusp repair is required.

Combined David and Frozen Elephant Trunk Procedure in Acute Aortic Dissection

BACKGROUND  Valve sparing aortic root repair by reimplantation (David procedure) is an established technique in acute aortic dissection Stanford type A involving the aortic root. In DeBakey type I dissection, aortic arch replacement using the frozen elephant trunk (FET) was introduced to promote aortic remodeling of the downstream aorta. The combination of these two complex procedures represents a challenging surgical strategy and was considered too risky so far. METHODS  All patients with acute aortic dissection DeBakey type I undergoing valve sparing aortic root repair by reimplantation technique of David combined with extended aortic repair using the FET at our center between October 2009 and December 2016 were evaluated. Outcomes are compared with patients who underwent prosthetic aortic root replacement and FET for aortic dissection in the same timeframe. RESULTS  A total of 28 patients received combined David and FET procedure, while 20 patients received prosthetic aortic root replacement and FET procedure. Thirty-day mortality was 10.7% (n = 3) for the David group and 20% (n = 4) for the root replacement group (p = 0.43). Postoperative echocardiographic control revealed an excellent aortic valve function with regurgitation grade 0° or maximum grade I° and a mean gradient of 4.3 ± 2.1 mm Hg in all patients in the David group versus 7.2 ± 2.4 mm Hg in the aortic root replacement group, p = 0.003. Computed tomography angiography scan showed positive aortic remodeling in all but three patients (91.9%). Mid-term follow-up survival was 82.1% in the David group and 68.4% in the root replacement group, p = 0.28. There was no need for reintervention at the root or descending aorta. CONCLUSION  Simultaneous application of the David and FET procedure in patients with acute aortic dissection is safe and feasible in experienced hands as compared with standard aortic root replacement plus FET. The mid-term outcomes are encouraging and noninferior to conventional surgery results.

Transcatheter Aortic Valve Implantation

Abstract Aortic valve stenosis is the most common valvular heart disease, with surgical aortic valve replacement being the therapeutic gold standard in the past. Transcatheter aortic valve implantation (TAVI) has developed to be a valid therapy option for patients with symptomatic severe aortic valve stenosis and high surgical risk, as it is deemed to be less invasive and traumatic. Since the first implantation in 2002, rapid developments took place in recent years, not only in regard to technical aspects—new devices and new access sites—but also in indications and patient selection. Currently, it is conflicting if TAVI should also be a therapy option for intermediate- and low-risk patients. However, complications such as paravalvular leakage, stroke, and bleeding events need to be kept in mind and should be addressed in further progressions.

Minimally Invasive Surgery for Aortic Aneurysms

Abstract Aortic aneurysms are characterized by an increased risk of dissection or rupture. The therapeutic goal is the elimination of the aneurysm. Depending on the diseased portion of the aorta current standard therapies are either surgical or interventional-endovascular, or hybrid procedures, which is a combination of both. In relation to the subject of this chapter, the surgical treatment is still the gold standard for the aortic root, ascending aorta up to aortic arch aneurysms. This section of the aorta is also accessible via the now established upper partial sternotomy. Thus, it is possible to perform all standard procedures in this aortic section as minimally invasive procedures by means of surgical access. The partial sternotomy is associated with better chest and sternal stability, less postoperative pain, shorter hospital stay and faster recovery, in addition to an improved cosmetic result. In our experience, the approach of the aortic valve up to extensive thoracic aortic disease involving the arch and the descending aorta treated using the frozen elephant trunk technique through a partial sternotomy is safe and feasible.

Surgical Treatment of Acute Aortic Syndrome

Abstract Acute aortic syndrome comprises a variety of pathologies of the aorta characterized by a breakdown of the intimal integrity leading to bleeding into the media layer. With the potential of life-threatening complications, it is an emergency condition requiring prompt and proper management. Nonetheless, it is still affected with high morbidity and mortality. The Stanford classification based upon the localization of affected aorta is guiding decision making for surgical treatment. Several treatment options, such as open surgical, endovascular, or hybrid techniques, were developed over the last years, and indications are discussed for different conditions and dependent on individual findings. Strategies are presented for intraoperative monitoring, cannulation for extracorporal circulation, perfusion, myocardial, and organ protection as well as management of complications. Emphasis is put on surgical techniques for aortic root repair, ascending aortic replacement, aortic arch, and descending aorta treatment.

One-stage hybrid aortic repair using the frozen elephant trunk in acute DeBakey type I aortic dissection

Background The extent of emergent surgery for acute DeBakey type I aortic dissection is discussed controversial. The frozen elephant trunk (FET) technique in addition to ascending and arch repair promotes aortic remodelling in the descending aorta and thus may provide superior long-term results in terms of less secondary re-interventions and reduced mortality linked to the downstream aorta. Methods Between October 2009 and December 2016, a total of 72 patients underwent emergent hybrid aortic repair using the FET for acute DeBakey type I aortic dissection at our centre. Data were analysed from our prospectively collected database and clinical and imaging mid-term follow-up was obtained. Results Implant success was 98.6% with an overall 30-day-mortality of 15.3%. New postoperative stroke was seen in 2.8%, new spinal cord injury in 4.2%. In follow-up (mean 37.8±21.2 months) cumulative survival was 75.0% with freedom from distal reintervention in 96.7% and aortic remodelling rate in the descending aorta in 96.5%. Conclusions Hybrid aortic repair using the FET in acute DeBakey type I aortic dissection does not elevate the perioperative risk of mortality and provides excellent aortic remodelling with low distal re-intervention rate in mid-term follow-up.

Minimally Invasive Coronary Artery Bypass Surgery

The minimally invasive coronary artery bypass grafting (CABG) surgery is defined as any innovation brought to the conventional CABG procedure to reduce the patient surgical trauma. This innovation could be the elimination of cardioplegic solution, the elimination of the heart-lung-machine, off-pump coronary artery bypass (OPCAB), the avoidance of the aortic manipulation, or the avoidance of the median sternotomy. The primary goal is to achieve graft patency rates equal to conventional CABG and to reduce repeated revascularization. The secondary goals are to reduce invasivity by reducing the surgical pain and the postoperative discomfort, facilitating a more rapid return to a normal social life and activity. Not of less interest are economic goals such as reduced length of hospital stay and decreased costs. Minimally invasive direct coronary artery bypass (MIDCAB) and minimally invasive cardiac surgery-coronary artery bypass grafting (MICS-CABG) represent the best alternative revascularization strategies to percutaneous coronary intervention (PCI) for patients with single-vessel or two-vessel disease, with chronic vessel occlusion or in-stent restenosis. The value of the minimally invasive coronary surgery will increase compared with the conventional CABG only if the same results can be reproduced with a decreased patient morbidity and mortality rate.