Charles C. Miller

Risk stratification : a practical guide for clinicians

Preface Introduction 1. Risk 2. Collecting data 3. Risk and published studies 4. Applying published risk estimates to local data 5. Interpreting risk models 6. Advanced issues 7. Appendices Index.

Staged repair of extensive aortic aneurysm: improved neurologic outcome.

OBJECTIVEnWe reviewed the adjuncts for brain and spinal cord protection and modifications of operative techniques.nnnSUMMARY BACKGROUND DATAnTwo-staged repair--the elephant trunk technique--has provided the means for successful repair of massive aortic aneurysms, although historically morbidity has been high.nnnMETHODSnBetween February 1991 and February 1996, we operated on 512 patients for thoracic aortic aneurysm. Preoperative, intraoperative, or postoperative predictors of morbid outcomes were studied in 63 patients treated with the elephant trunk technique. Data were analyzed by contingency table methods.nnnRESULTSnAfter stage 1, there were no strokes among patients who received retrograde cerebral perfusion (0 of 53), two strokes occurred among patients who did not receive retrograde cerebral perfusion (2 of 10 [20%]), and early mortality occurred in 4 of the 63 patients (6%). Interval mortality occurred in 6 of 59 patients (10%); 3 (50%) of these 6 deaths were due to distal aortic aneurysm rupture. Thirty-eight patients have undergone stage two repair thus far. There was no incidence of neurologic deficit after stage 2, and early mortality occurred in 1 of the 38 patients (3%).nnnCONCLUSIONSnExtensive aortic aneurysm can be successfully treated using the elephant trunk technique. In this group of patients, retrograde cerebral perfusion eliminated neurologic complications.

Aortic valve disease in Marfan syndrome.

The Marfan syndrome patient undergoes care by many different physicians for the treatment of the varied systems affected by this connective tissue disorder. The most frequent visits are to a cardiologist, with referral to a cardiovascular surgeon who attends to the problems of dilatation and dissection of the ascending aorta. Follow-up is lifelong. Although currently some surgeons prefer to resuspend rather than replace the aortic valve, composite valve graft replacement for aortic root dilatation and aortic valve insufficiency has steadily improved patient outcome. At the same time, the almost daily discoveries of genetic science show great promise in eliminating connective tissue disorders such as Marfan syndrome in the not-too-distant future.