B Reiter

Customized Transapical Thoracic Endovascular Repair for Acute Type A Dissection

A 67-year-old patient with severe comorbidities and acute type A aortic dissection with pericardial tamponade was treated with an endograft introduced through a mini-thoracotomy and puncture of the left ventricular apex. Final angiography showed complete coverage of the dissection. Early and 6-month follow-up computed tomography showed full apposition of the endograft without residual dissection. Transapical thoracic endovascular repair of acute type A aortic dissection appears to be feasible and is associated with minimal physiologic compromise. It may provide a less invasive alternative for patients with increased operative mortality.

Initial experience of pacemaker and implantable cardioverter defibrillator lead extraction with the new GlideLight 80 Hz laser sheaths

OBJECTIVES Laser lead extraction is a challenging procedure, especially in patients with old or multiple pacemaker (PM) or implantable cardioverter defibrillator (ICD) leads. The mechanical force is a leading cause of complications during the extraction procedure. Use of new laser sheaths, which deliver a rate of 80 pulses per second, may probably reduce intraoperative adverse events by reduction of extraction force. METHODS Between January 2012 and April 2013, 76 PM and ICD leads were treated in 38 patients using GlideLight 80 Hz laser sheaths. Indications for lead removals were pocket infection (42.1%), septicaemia or endocarditis (23.7%), lead dysfunction (31.6%) and upgrade from PM to ICD (2.6%). Data on procedural success rates, intra- and postoperative outcomes, as well as 30-day mortality were collected into a database and analysed retrospectively. RESULTS The mean patient age was 62.0 ± 17.7 years (range 18-83), and 73.7% were male. The mean time from initial lead implantation was 96.0 ± 58.3 months (range 24-288). Thirty-seven (48.7%) PM and 39 (51.3%) ICD leads had to be extracted. The mean procedural time was 68.3 ± 27.3 min (range 35-115). Seventy-two of 76 leads (94.8%) were completely removed, partial removal was achieved in 2 (2.6%) leads and a failure of extraction occurred in 2 (2.6%) leads. The overall complication rate was 5.2%, including one major (superior vena cava perforation) (2.6%) and one minor (pocket haematoma) (2.6%) complication. No death occurred during the 30-day follow-up. CONCLUSIONS The GlideLight 80 Hz laser sheath allows safe and effective removal of chronically implanted PM and ICD leads, combining high procedural success with low complication rates.

Trends in Surgical Aortic Valve Replacement in More Than 3,000 Consecutive Cases in the Era of Transcatheter Aortic Valve Implantations

Objectives Biological prostheses for surgical aortic valve replacement (sAVR) are increasingly being considered in patients < 60 years of age. Likely, preserving the option of performing a transcatheter valve-in-valve (ViV) procedure in cases of structural valve deterioration has contributed to this development. We assessed the use pattern in sAVR over an 11-year period. Methods From 2002 through 2012, a total of 3,172 patients underwent sAVR at our center. Results Mean age was 70.4 ± 10.6 years and mortality was 1.9%. From 2002 to 2012, mean manufacturer given valve size increased from 22.8 ± 1.7 to 23.9 ± 2.0 mm (p < 0.001). Mean true internal diameter and effective orifice area increased from 19.6 to 20.3 mm (p = 0.027) and 1.41 to 1.56 cm(2) (p < 0.001), respectively. Use of mechanical valves decreased from 10.9 to 1.8% (p < 0.001), and patients were younger in 2012 than in 2002 (52.8 ± 16.5 vs. 41.0 ± 14.3 years; p = 0.028). Conclusion Profound change of use pattern in sAVR was observed as indication for biological prostheses became more liberal. Larger prostheses were implanted during the observational period. Especially in younger patients, optimal sizing is essential to preserve the option for subsequent ViV procedures.

Reversed Frozen Elephant Trunk Technique to Treat a Type II Thoracoabdominal Aortic Aneurysm

Purpose: To describe a hybrid technique of reversed frozen elephant trunk to treat thoracoabdominal aortic aneurysms (TAAA) through an abdominal only approach. Technique: The technique is demonstrated in a 29-year-old Marfan patient with a chronic type B aortic dissection previously treated with a thoracic stent-graft who presented with a thoracoabdominal false lumen aneurysm. Through an open distal retroperitoneal approach to the abdominal aorta, a frozen elephant trunk graft was implanted over a super-stiff wire upside down with the stent-graft component in the thoracic aorta. Following deployment of the stent-graft proximally and preservation of renovisceral perfusion in a retrograde manner, the renovisceral vessels were sequentially anastomosed to the elephant trunk graft branches, thus reducing the ischemia time of the end organs. The aortic sac was then opened, and the distal part of the hybrid graft was anastomosed with a further bifurcated graft to the iliac vessels. Conclusion: The reversed frozen elephant trunk technique is feasible for hybrid treatment of TAAAs via an abdominal approach only. This has the benefit of substantially reducing the trauma of thoracic exposure, thus preserving major benefits of open thoracoabdominal surgery, such as the presence of short bypasses to the renovisceral vessels and reimplantation of lumbar arteries to reduce spinal cord ischemia.

Change of indicational spectrum for laser lead extraction of infected or dysfunctional pacemaker or ICD leads in a single center: experiences in 235 consecutive patients

Objective: In 2009 new HRS guidelines for pacemaker or ICD lead removal have changed the indication spectrum substantially. Non-functional leads have become a class I indication for removal in experienced centers. Here we describe our experience with laser-lead-extraction using the excimer laser with regards to the new guidelines. Methods: Between 2001 and 2009 235 patients with pacemaker or ICD-lead infection or dysfunction underwent laser-lead-extraction at our center. Lead locking stylets, 14–16 French Laser Sheaths and an excimer-laser as energy source were used. Indications for lead removal were compared with regard to the time-point of the operation. Results: 435 leads were removed in 235 patients using the excimer laser technique (mean time after implantation 7±4.7 years). From 2001 until 2005 main indication for lead removal was lead infection (45/57 pts.) or subclavian vein or SVC thrombosis (7/57 pts.). From 2006–2009 non-functional non-infected leads were extracted in increasing frequency (85/178 pts.) even exceeding the number of extracted infected leads (75/178 pts.). Lead extraction was securely performed in all patients. Mean operation time was 69±29min. Mean fluoroscopy time was 7.1±3.8min. 4 of 235 patients (1.7%) developed significant bleeding and underwent immediate sternotomy for surgical hemostasis with uneventful postoperative course and no long-term complications. Conclusion: In the hands of experienced surgeons laser extraction allows complete removal of pacemaker or ICD leads with very low risk. Therefore non-functional non-infected leads can consequently be judged as class I indications for lead removal as recommended by the HRS guidelines of 2009.