Alessandro Vivacqua

Morbidity of Bleeding After Cardiac Surgery: Is It Blood Transfusion, Reoperation for Bleeding, or Both?

BACKGROUND Etiology for increased morbidity in patients (2% to 8%) undergoing reoperation for bleeding after cardiac surgery is unclear. Recent work suggests that it may be related to red-cell transfusion, but what role does reoperation itself play? We sought to determine prevalence of and risk factors for reoperation for bleeding, separate the effect of reoperation from that of transfusion on hospital mortality and major morbidity, and identify the source of bleeding. METHODS From January 1, 2000 to January 1, 2010, 18,891 primary and repeat coronary artery bypass grafting, valve, or combined operations were performed. Risk factors for reoperation were identified by multivariable logistic regression. Hospital mortality and major morbidity were compared in propensity-matched patients requiring reoperation and not. Medical records from 2005 to 2010 were reviewed to determine bleeding source. RESULTS A total of 566 patients (3.0%) underwent reoperation for bleeding, with considerable variability over time. Risk factors included older age, higher acuity, greater comorbidity, aortic valve surgery, longer myocardial ischemic and cardiopulmonary bypass durations, and surgeon. Mortality was higher for propensity-matched patients requiring reoperation; 8.5% (68% confidence interval [CI] 7.3% to 9.9%) versus 1.8% (CI 1.2% to 2.5%). Both greater transfusion and reoperation were independently associated with increased risk of mortality and major morbidity. At reoperation, technical factors (74%), coagulopathy (13%), both (10%), or other (3.3%) causes were responsible for bleeding. CONCLUSIONS Transfusion and reoperation for bleeding both contribute to postoperative mortality and morbidity. Technical reasons are at the root of most bleeding, emphasizing a major focus for process improvement to minimize need for reoperation and blood use.

Long-term durability of bicuspid aortic valve repair.

BACKGROUND Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation, occurring in 1% to 2% of the population. Eventually, 20% develop clinically important valvar regurgitation requiring surgical intervention. Aortic valve repair avoids anticoagulation and prosthetic valve-related complications. This study evaluated long-term durability of BAV repair. METHODS From 1985 to 2011, 728 patients, mean age 42±12 years, underwent BAV repair at Cleveland Clinic. Mean follow-up was 9.0±6.2 years (median, 8.3). Factors associated with repair durability (expressed as aortic valve reoperations and echocardiographically estimated gradients and regurgitation) and survival were identified. RESULTS Hospital mortality was 0.41% (n=3), and stroke occurred in 0.27% (n=2). Freedom from aortic valve reoperation at 10 years was 78%. Risk of reoperation was highest immediately after operation and fell rapidly to approximately 2.6%/year up to 15 years. Primary reasons for reoperation were cusp prolapse (38%), aortic stenosis or regurgitation (17%), and aortic regurgitation from root aneurysm (15%). Aortic valve gradients showed an early initial peak, rapidly declined, then rose steadily, accompanied by an increase in left ventricular mass. Survival was 94% at 10 years. A risk factor for early death was greater preoperative mitral valve regurgitation, and for late death, older age at operation, more severe symptoms, and poorer left ventricular function. CONCLUSIONS BAV repair is safe and durable with low mortality, low prevalence of reoperation, and good long-term survival. Cusp prolapse from technical errors and natural progression of disease are the most common causes for reoperation, but progressive natural increase in valve gradient accounts for a substantial proportion as well.

Midterm Results of David Reimplantation in Patients With Connective Tissue Disorder

BACKGROUND Few series have examined follow-up risks of the David reimplantation operation in patients with connective tissue disorder. Hence, we assessed its midterm safety and effectiveness for Marfan syndrome and other connective tissue disorders, such as Ehlers-Danlos, Loeys-Dietz, and marfanoid syndromes. METHODS Of 313 patients who underwent modified David reimplantation, 178 identified as having connective tissue disorders underwent operation from January 1, 1991, to December 31, 2010. These disorders included Marfan (84%), marfanoid (8.4%), Loeys-Dietz (5.6%), Ehlers-Danlos (1.1%), and other syndromes (1.1%). Concomitant procedures included mitral valve repair in 7.3% and an atrial fibrillation procedure in 3.4%. RESULTS There were no operative or 30-day deaths. Complications included prolonged ventilation (3%), renal failure (3%), reoperation for bleeding (2.2%), and permanent stroke (0.56%). Eight-year survival was 94% and freedom from aortic valve reoperation at 6 years was 92%. Of the 7 aortic valve reoperations, 3 were attributable to endocarditis and 3 to technical failure. One reoperation was performed at another hospital, and the reason could not be determined. There were no late strokes or hemorrhagic events. At 4 years, approximately 70% of patients had no aortic valve regurgitation, and 18% were in grade 1+. CONCLUSIONS Prophylactic root and valve preservation using David reimplantation is safe and provides excellent midterm effectiveness and low risk of late events except for endocarditis.

Hybrid Thoracoabdominal Aneurysm Repair With Antegrade Visceral Debranching From the Ascending Aorta: Concomitant Cardiac Surgery and Stent-Grafting

Patients with thoracoabdominal aneurysm that require concomitant cardiac surgery present a complex surgical challenge. A staged hybrid technique including combined cardiac surgery and visceral revascularization from the ascending aorta, followed by endovascular aneurysmal exclusion is reported in four patients. No perioperative death and no neurological complications were observed. The surgical technique is described.

Thoracic endovascular repair first for extensive aortic disease: the staged hybrid approach

OBJECTIVES Repair of extensive aortic disease carries a significant risk of death and morbidity, the most feared complication being spinal cord ischaemia. Objectives of this study are to characterize patients, describe repair methods and assess feasibility and safety of hybrid staged repair for treatment of extensive aortic disease. METHODS From to 2001 to 2013, 22 patients underwent extensive aortic repair that included a thoracic endovascular aortic repair (TEVAR) first followed by an open completion repair extending through the visceral and infrarenal aorta for degenerative aneurysm and dissection. At the time of initial repair, all patients were deemed to be at a high risk for conventional open repair and had extensive disease. Indications for open completion included emergency failure of TEVAR (n = 3), early two-stage approach (n = 6) and delayed disease progression after TEVAR (n = 13). The median interval between stages was 6.5 months. The mean age was 56 ± 14 years, 5 patients had connective tissue disorder and the mean maximum aortic diameter was 58 ± 16 mm preoperatively. RESULTS There was no death or major complication after initial TEVAR, but the operative mortality rate was 9% (n = 2) after the open procedure. One of these patients died from intraoperative myocardial infarction during emergency repair, and the other had disseminated intravascular coagulation during delayed repair for disease progression after TEVAR. Other complications included paralysis in 1 (4.5%), tracheostomy in 2 (9%) and dialysis in 1 (4.5%), and there was 1 reoperation for bleeding (4.5%). The median follow-up was 37 (range 3.3-93) months and there were no late deaths. There were four late reoperations for proximal disease progression leading to Type 1 endoleak (n = 2), Type A dissection (n = 1) and root aneurysm (n = 1). CONCLUSIONS Use of a TEVAR-first approach in combination with a staged open repair is a safe and feasible treatment strategy for repair of extensive aortic disease. A staged hybrid approach to aortic repair in patients at high risk for total aortic replacement may limit morbidity.

Parachute-like Asymmetric Mitral Valve Associated With Mitral Valve Cleft and Atrial Septal Defect in an Adult

e M p a p o APARACHUTE MITRAL VALVE (PMV) is a rare congenital cardiac defect characterized by focalized attachment of he chordae tendineae of both leaflets to a single papillary muscle. n contrast to true PMV, a parachute-like asymmetric mitral alve (PLAMV) has 2 separate papillary muscles, one being ore pronounced with all chordae inserted into this domiant muscle. Most frequently, the involved dominant muscle s a posteromedial papillary muscle. The present case report escribes an occurrence of PLAMV coincident with mitral alve cleft (MVC) and an atrial septal defect (ASD) in an dult. To the best of the authors’ knowledge, the occurrence f PLAMV in association with MVC and ASD has not been escribed in the literature in an adult patient.

Total arch replacement after a failed repair for Takayasu's ascending aortitis.

The constellation of Takayasus disease most commonly includes aortitis with resultant coarctations and aneurysm formation. Surgical repair of these lesions can be compromised by the chronic inflammation of Takayasus arteritis. We present a case of a 22-year-old female with Takayasus disease who had undergone an ascending and aortic hemiarch replacement then subsequently developed anastomotic dehiscence and re-expansion of the previous aneurysmal sac. Complete aneurysm resection and replacement of the ascending aorta and aortic arch was performed on repeated surgery.

Endoscopic Repair of Recurrent Tracheoesophageal Fistula With an Atrial Septal Occluder Device

A 32-year-old woman presented with recurrent trachea-esophageal fistula. Although she had undergone open repair three times in her first year of life, a residual small leak was left. In the past 2 years she had experienced several lower respiratory tract infections and she had lost 5 kilograms in the past 2 months. Recent argon plasma coagulation cauterization and clipping of the fistula had failed, so an alternative technique with placement of an atrial septal occluder device was used to obliterate the fistula. A follow-up barium swallow showed no more communication to the tracheobronchial tree, and endoscopy demonstrated epithelialization. At her 3-year follow-up visit she was asymptomatic.

Left Ventricular Outflow Tract Papillary Fibroelastoma Presenting With Non-ST-Segment Elevation Myocardial Infarction

![Figure][1] A 61-year-old female presented at the emergency department with chest pain and shortness of breath. The initial electrocardiogram was negative for ischemia; however, cardiac enzyme levels were mildly elevated with an initial serum troponin I level of 1.15 ng/ml. The patient was

Surgical Management of Right Aortic Arch with Tailored Surgical Approach

Abstract  Background and Aim of Study: Right‐sided aortic arch is a rare congenital anomaly for which different surgical approaches have been reported. This study reviewed our experience with several techniques. Methods: We retrospectively reviewed 17 patients undergoing right‐sided arch repair at the Cleveland Clinic from 2001 to 2010. Computed tomographic angiograms of the aorta and its branches were reviewed and correlated with patient presentation and surgical approach. Results: Fourteen patients had type II right aortic arch with aberrant left subclavian artery. Fifteen patients presented with obstructive symptoms. Surgical approach included right thoracotomy (11 patients), left thoracotomy (two patients), full sternotomy (one patient), and hybrid repair (three patients). Cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest was used in 11 patients, and two patients had partial CPB. Left subclavian artery bypass was performed in seven patients. Median duration of intubation was 1.9 days. Average length of intensive care unit stay was three days and average hospital stay 11 days. Postoperative outcomes included respiratory failure (one patient), renal failure (one patient), bloodstream infection (two patients), and death (one patient). No patient had stroke or paraplegia. In‐hospital death occurred in one patient, and all survivors were alive and asymptomatic for a mean of 38 months. Conclusion: The surgical treatment for right‐sided aortic arch can be performed with excellent perioperative outcomes when tailored to patient presentation and anatomic configuration. Patients with obstructive symptoms benefit from open or hybrid surgical treatment, with immediate relief of compression. Patients with aneurysmal dilatation without compression symptoms can be managed with open, endovascular, or hybrid surgical intervention. (J Card Surg 2012;27:511‐517)