Ahmed Ouda

Transapical Endovascular Deployment of a Stent-Graft in the Thoracic Descending Aorta

We report the case of a 74-year-old man with a large aneurysm (60 mm) of the descending thoracic aorta. Because of severe calcification and kinking of the iliac vessels, the expected access-related complication during the endovascular repair urged us to search for an alternative strategy. Having good experience with transcatheter aortic valve implantation, we thought that the transapical approach may be the best option in this case. The stent-graft was successfully deployed through the heart apex without any complications. The postoperative imaging showed an excellent result.

Right Ventricular Reduction as an Adjunct Procedure in Tricuspid Valve Repair

Functional tricuspid regurgitation secondary to mitral valve disease can not be attributed to the dilatation of the tricuspid annulus alone. Furthermore, geometrical changes of the right ventricle lead to tethering of the tricuspid valve leaflets and thereby to an incomplete leaflet coaptation. With this pathologic entity, conventional isolated tricuspid valve annuloplasty will presumably result in significant residual tricuspid regurgitation. The surgical goal should be the reduction of tricuspid annulus dilatation and annihilation of tethering forces on the tricuspid leaflets. In combination with conventional tricuspid valve annuloplasty, right ventricular reduction surgery, as demonstrated, may be effective in reaching these goals and hereby avoiding residual tricuspid regurgitation in this patient population.

Sutureless Aortic Valve Replacement International Registry (SU-AVR-IR): design and rationale from the International Valvular Surgery Study Group (IVSSG)

BACKGROUND Sutureless aortic valve replacement (SU-AVR) is an innovative approach which shortens cardiopulmonary bypass and cross-clamp durations and may facilitate minimally invasive approach. Evidence outlining its safety, efficacy, hemodynamic profile and potential complications is replete with small-volume observational studies and few comparative publications. METHODS Minimally invasive aortic valve surgery and high-volume SU-AVR replacement centers were contacted for recruitment into a global collaborative coalition dedicated to sutureless valve research. A Research Steering Committee was formulated to direct research and support the mission of providing registry evidence warranted for SU-AVR. RESULTS The International Valvular Surgery Study Group (IVSSG) was formed under the auspices of the Research Steering Committee, comprised of 36 expert valvular surgeons from 27 major centers across the globe. IVSSG Sutureless Projects currently proceeding include the Retrospective and Prospective Phases of the SU-AVR International Registry (SU-AVR-IR). CONCLUSIONS The global pooling of data by the IVSSG Sutureless Projects will provide required robust clinical evidence on the safety, efficacy and hemodynamic outcomes of SU-AVR.

Transapical endovascular stenting of penetrating atherosclerotic ulcer of ascending aorta.

A 71-year-old woman presented with acute chest pain and was admitted at our institution. Computed tomography revealed a penetrating atherosclerotic ulcer in the ascending aorta with extensive intramural hematoma. A transapical endovascular stenting was successfully performed. Computed tomography at a 6-month follow-up visit revealed a type I endoleak, which was restented through the same approach. Despite initial satisfactory results, follow-up revealed a persistent endoleak, so that a high-risk open surgical repair was required. Surgical replacement of the ascending aorta was successfully performed without postoperative neurologic deficit.

Isolated Rupture of the Right Upper Pulmonary Vein: A Blunt Cardiac Trauma Case

A 37-year-old woman who sustained blunt chest trauma as a result of a car accident was found unconscious at the accident site with signs of circulatory compromise. Computed tomographic trauma screening excluded thoracic, intracranial, and intra-abdominal bleeding, or other pathologic findings, except a small circumferential hemopericardium. Echocardiography revealed a hemopericardium that was partially clotted and the beginning of compression of the right ventricle. Because of progressive hemodynamic compromise, the decision was made for operative exploration. After a median sternotomy, the resultant excessive bleeding necessitated extracorporeal circulation. Careful inspection revealed isolated rupture of the upper right pulmonary vein, which was successfully repaired.

Is repeated administration of blood-cardioplegia really necessary?

The aim of this work was to question the necessity of repeated administration of warm blood cardioplegia in modern cardiac surgery. A consecutive series of 4014 patients underwent cardiosurgical procedures in the period from January 2001 to December 2006 in our centre, where modified Calafiore warm blood-cardioplegic solution was used. 1708 patients received a single shot of cardioplegia instead of repeated blood cardioplegia (every 20 min). A multivariate analysis was performed using logistic regression models to reveal the statistical significance of the effect of single-shot cardioplegia on the occurrence of: death, intraoperative need of inotropics, intraoperative intra-aortic balloon pump (IABP), postoperative infarction, arrhythmia, postoperative need for inotropics and postoperative IABP. The results showed statistical insignificance concerning mortality (P=0.704), intraoperative IABP (P=0.247), postoperative inotropics (P=0.273), postoperative IABP (P=0.678), postoperative arrhythmia (P=0.661). Single-shot cardioplegia showed a positive effect concerning postoperative myocardial infarction (P=0.003). However, it showed an unfavourable effect concerning intraoperative inotropics (P=0.038) and postoperative dialysis (P=0.015). The clinical safety of the first shot of warm blood cardioplegia might be exceeding 20 min. In the light of increasingly short cross-clamping time, the safety of the first shot might be long enough to cover the whole cross-clamping time.

Transapical aortic stenting: an initial case series.

AIMS The standard approach for thoracic endovascular aortic repair (TEVAR) is transfemoral; however, calcifications and tortuosity of the access vessels might be so extensive as to increase the operative risk markedly or preclude the procedure. This study evaluates the transapical approach as an alternative route for TEVAR in such patients. METHODS AND RESULTS From June 2011 to July 2013, the institutions interdisciplinary board for aortic diseases initially denied TEVAR for eight patients with thoracic aortic pathology due to extensive calcification and tortuosity of the distal vessels. The transapical approach was suggested and approved by the board. All procedures were performed in a hybrid operating room through a left mini-thoracotomy. The stent grafts were implanted in either the proximal descending or the ascending aorta. The deployment was performed under rapid ventricular pacing. Procedural success was 100%. There were no intraoperative complications. One patient needed re-exploration. There was no 30-day mortality. In follow-up, one patient suffered type 1B endoleak, which required surgery after one year. CONCLUSIONS The transapical approach for TEVAR (TaTEVAR) is a feasible option for patients with distal aorta/iliac vessels unsuitable for transfemoral access. It might be even more beneficial for TEVAR of the ascending aorta.

Protective Effect of Previous Cardiac Operation: Survival of Contained Right Ventricular Rupture

Although cardiac contusions are common, cardiac rupture is an uncommon sequela of blunt chest trauma. The mortality rate associated with cardiac rupture is very high, and patients usually do not survive long enough to reach the hospital. We report a 66-year-old man with a history of coronary artery bypass grafting 15 years previously, who was involved in a traffic accident and experienced multiple trauma, including a small contained rupture of the right ventricular outflow tract. He survived, and a false aneurysm developed at the site of the rupture within the next 6 months. The patient then underwent a cardiac operation, and the aneurysm was successfully resected. The intraoperative and postoperative courses were uneventful. In this case, the previous cardiac operation with the resulting pericardial adhesions proved to be lifesaving.

Anastomotic leak after surgical repair of type A aortic dissection – prevalence and consequences in midterm follow-up

BACKGROUND This study reports the mid-term prevalence and therapeutic consequences of anastomotic leaks after surgery for Stanford type A aortic dissections. PATIENTS AND METHODS From July 2007 to July 2013, 93 patients survived surgery for acute type A dissections at our center and underwent a standardized follow-up. The pre-, peri-, and postoperative as well as the midterm results were collected prospectively. Follow-up computed tomography (CT) imaging was performed 7 days, 3, and 12 months after surgery, and yearly thereafter, to assess the presence or progression of anastomotic leaks at the aorto-prosthesis anastomotic sites. RESULTS The mean follow-up was 4 years (1534 ± 724 days). Follow-up CT revealed anastomotic leaks in 4 patients (4.3 %). All leaks developed during midterm follow-up and half of them did not increase with time. Two patients required redo surgery for an increase in periaortic extravasation and compression of neighboring structures. Further analysis was not able to reveal independent risk factors for development or deterioration of leaks. CONCLUSIONS Anastomotic leaks after surgery for Stanford Type A aortic dissection can develop in midterm follow-up, even after initially excellent results. Meticulous follow-up is mandatory to detect possible deterioration and a need for redo surgery.

The venous U-turn: a unique variant of total anomalous superior systemic venous return

A 74-year-old male patient was planned for a permanent pacemaker implantation for a bradycardiac atrial fibrillation after successful aortic valve replacement. Intra-operatively, advancing the ventricular lead via the right cephalic vein, it was impossible to reach the right atrium ( Panel A ). Suspecting an anomaly of the venous system, a phlebography was performed …