Davide Pacini

Brain protection using antegrade selective cerebral perfusion: a multicenter study

BACKGROUND To evaluate the results of antegrade selective cerebral perfusion as a method of brain protection during surgery of the thoracic aorta and to determine predictors of hospital mortality and adverse neurologic outcome. METHODS Between October 1995 and March 2002, 588 patients underwent aortic surgery with the aid of antegrade selective cerebral perfusion. There were 334 men (56.8%); the mean age was 63.7 +/- 11.8 years. One hundred sixty-two patients (27.6%) underwent urgent operation. The separated graft technique was employed to reimplant the arch vessels in 230 patients (65.3%) of the 352 requiring aortic arch replacement. Associated procedures were performed in 254 patients (43.2%). One hundred twelve patients underwent elephant trunk procedure. The mean cerebral perfusion time was 67 +/- 37 minutes. RESULTS The overall hospital mortality rate was 8.7%. A logistic regression analysis revealed urgent operation, recent central neurologic event, tamponade, unplanned coronary artery revascularization and pump time to be independent predictors of hospital mortality (p < 0.05). The permanent neurologic dysfunction rate was 3.8%. A logistic regression analysis showed tamponade to be independent predictor of permanent neurologic dysfunction (p < 0.05). The transient neurologic dysfunction rate was 5.6%. Recent central neurologic event, tamponade, coronary disease, and aortic valve replacement were indicated as independent predictors of transient neurologic dysfunction by logistic regression (p < 0.05). CONCLUSIONS In our experience the utilization of antegrade selective cerebral perfusion resulted in encouraging results in terms of hospital mortality and brain complications. Neither the extent of the replacement nor the duration of the cerebral perfusion had an impact on hospital mortality and neurologic outcome.

Surgical Indications and Timing of Repair of Traumatic Ruptures of the Thoracic Aorta

BACKGROUND The outcome of patients with acute traumatic rupture of the thoracic aorta after motor vehicle accidents is strongly conditioned by injuries to other districts. The timing of repair is controversial when the patients arrive alive to the hospital. METHODS A series of 42 patients with acute traumatic rupture of the thoracic aorta observed between January 1980 and June 1996 was divided into two groups: group I underwent immediate repair (21 patients) and in group II operation was performed after intensive medical treatment and management of the associated lesions and monitoring of the aortic tear. RESULTS The mortality in group I patients was 19% and the morbidity was more significant than in group II where no deaths were reported and complications were minor. CONCLUSIONS Patients with acute traumatic rupture of the thoracic aorta may have a better fighting chance if aortic operation is postponed to the most favorable moment after undergoing life-sustaining measures and management of the major associated lesions. Needless to say, evolution should be closely monitored by computed tomographic scans and magnetic resonance imaging.

EuroSCORE performance in valve surgery: a meta-analysis.

BACKGROUND The European System for Cardiac Operative Risk Evaluation (EuroSCORE) was developed to predict immediate outcomes after adult cardiac operations, but less than 30% of the cases used to develop this score were valve procedures. We studied EuroSCORE performance in valve procedures. METHODS We performed a meta-analysis of published studies reporting the assessment of discriminatory power of the EuroSCORE by receiver operating characteristics (ROC) curve analysis in adult valve operations. A comparison of observed and predicted mortality rates was also performed. RESULTS A literature search identified 37 potentially eligible studies, and 12 were selected for meta-analysis comprising 26,621 patients with 1250 events (mortality rate, 4.7%). Meta-analysis of these studies provided an average area under the curve (AUC) value of 0.730 (95% confidence interval [CI], 0.717 to 0.743). The same results were obtained when meta-analyses were performed separately in studies categorized on reliability of uncertainty estimation: in the seven studies reporting reliable uncertainty estimation (8175 patients with 358 events; mortality rate, 4.4%), the ROC curve provided an average AUC value of 0.724 (95% CI, 0.699 to 0.749). The five studies not reporting reliable uncertainty estimation (18,446 patients with 892 events; mortality rate, 4.8%) had an average AUC of 0.732 (95% CI, 0.717 to 0.747). We documented a constant trend to overpredict mortality by EuroSCORE, both in the additive and especially in the logistic form. CONCLUSIONS The EuroSCORE has low discrimination ability for valve surgery, and it sensibly overpredicts risk. Alternative risk scoring algorithms should be seriously considered.

Aortic valve replacement: Results and predictors of mortality from a contemporary series of 2256 patients

OBJECTIVE The studys objectives were to evaluate results and identify predictors of hospital and mid-term mortality after primary isolated aortic valve replacement; compare early and mid-term survival of patients aged more than 80 years or less than 80 years; and assess the effectiveness of the logistic European System for Cardiac Operative Risk Evaluation in predicting the risk for hospital mortality in octogenarians with a logistic European System for Cardiac Operative Risk Evaluation greater than 15% who are undergoing aortic valve replacement. METHODS Data from 2256 patients undergoing primary isolated aortic valve replacement between January 2003 and December 2007 were prospectively collected in a Regional Registry (Regione Emilia Romagna Interventi Cardiochirurgia) and analyzed to estimate hospital and mid-term results. RESULTS Overall hospital mortality was 2.2%. By multivariate analysis, New York Heart Association III and IV, Canadian Cardiovascular Society III and IV, pulmonary artery pressure greater than 60 mm Hg, dialysis, central neurologic dysfunction, and severe chronic obstructive pulmonary disease emerged as independent predictors of hospital mortality. At 3 years, the survival was 89.3%. The same predictors of hospital mortality plus ejection fraction of 30% to 50% and age more than 80 years emerged as independent risk factors for 3-year mortality. Compared with younger patients, octogenarians had a higher hospital mortality rate (3.72% vs 1.81%; P = .0143) and a reduced 3-year survival (82.3% vs 91.3%; P < .001). Three-year survival of octogenarians was comparable to the expected survival of an age- and gender-matched regional population (P = .157). The observed mortality rate in octogenarians with a logistic European System for Cardiac Operative Risk Evaluation greater than 15% (mean: 22.4%) was 7% (P < .001). CONCLUSIONS This study provides contemporary data on the characteristics and outcome of patients undergoing first-time isolated aortic valve replacement.

Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the Vascular Domain of EACTS

The implementation of new surgical techniques offers chances but carries risks. Usually, several years pass before a critical appraisal and a balanced opinion of a new treatment method are available and rely on the evidence from the literature and experts opinion. The frozen elephant trunk (FET) technique has been increasingly used to treat complex pathologies of the aortic arch and the descending aorta, but there still is an ongoing discussion within the surgical community about the optimal indications. This paper represents a common effort of the Vascular Domain of EACTS together with several surgeons with particular expertise in aortic surgery, and summarizes the current knowledge and the state of the art about the FET technique. The majority of the information about the FET technique has been extracted from 97 focused publications already available in the PubMed database (cohort studies, case reports, reviews, small series, meta-analyses and best evidence topics) published in English.

Multicenter early experience with extended aortic repair in acute aortic dissection: Is simultaneous descending stent grafting justified?

OBJECTIVE In acute type A aortic dissection, the extension of repair to downstream aorta has been controversially discussed. We present the early results of a multicenter study using a hybrid stent graft prosthesis. METHODS Between January 2005 and January 2010, the data from 191 patients after combined proximal aortic replacement and antegrade stent grafting were collected in the database of the International E-vita open Registry. Of the 191 patients, 68 underwent surgery for acute aortic dissection and were included in the present study. Hypothermic circulatory arrest and selective cerebral perfusion were routinely used. Computed aortic imaging was performed for false lumen evaluation during follow-up. RESULTS The in-hospital mortality rate was 13% (9/68). Along the stent graft, the rate of immediate complete false lumen thrombosis was 86% (51/59) and increased during follow-up (23 ± 17 months) to 94% (46/49). Distally, complete or partial false lumen thrombosis was initially observed in 61% (36/59) and in 82% (40/49) after follow-up. The 1- and 3-year actuarial survival rate was 82% and 74%, respectively. CONCLUSIONS Extended thoracic aortic repair of acute aortic dissection with a hybrid stent graft is feasible at acceptable early mortality and promotes false lumen thrombosis around the stent graft and below.

Retrograde and antegrade cerebral perfusion: results in short elective arch reconstructive times.

BACKGROUND Debate remains regarding optimal cerebral circulatory management during relatively noncomplex, short arch reconstructive times. Both retrograde cerebral perfusion with deep hypothermic circulatory arrest (RCP/DHCA) and antegrade cerebral perfusion with moderate hypothermic circulatory arrest (ACP/MHCA) have emerged as established techniques. The aim of the study was to evaluate perioperative outcomes between antegrade and retrograde cerebral perfusion techniques for elective arch reconstruction times less than 45 minutes. METHODS Between 1997 and September 2008, 776 cases from two institutions were reviewed to compare RCP/DHCA and ACP/MHCA perfusion techniques. At the University of Pennsylvania, 682 were treated utilizing RCP/DHCA cerebral protection. At the University of Bologna, 94 were treated with ACP/MHCA and bilateral cerebral perfusion. RESULTS Mean cerebral ischemic time and visceral ischemic time differed between RCP/DHCA and ACP/MHCA (p < 0.001). Multivariate analysis showed age more than 65 years, atherosclerotic aneurysm, and cross-clamp time as predictors of the composite endpoint of mortality, neurologic event, and acute myocardial infarction. There was no significant difference in permanent neurologic deficit, temporary neurologic dysfunction, or renal failure, between RCP/DHCA and ACP/MHCA. Mortality was comparable across both techniques. CONCLUSIONS Both RCP/DHCA and ACP/MHCA have emerged as effective techniques for selected aortic arch operations with low morbidity and mortality. Univariate analysis revealed no statistically significant differences in primary or secondary outcomes between techniques for aortic reconstruction times less than 45 minutes. Data from this study demonstrate that selective use of either RCP/DHCA or ACP/MHCA provides excellent cerebral and visceral outcomes for elective open aortic surgery with short arch reconstructive times.

Delayed Surgery of Traumatic Aortic Rupture: Role of Magnetic Resonance Imaging

BACKGROUND Traumatic aortic rupture (TAR) is a pathological entity with a high mortality, both spontaneous and perioperative. Delayed surgical repair has been proposed when associated lesions are stabilized. The aim of this study was to validate MRI for detecting both the presence and type of TAR and to monitor posttraumatic aneurysm and associated lesions. METHODS AND RESULTS Twenty-four consecutive patients with acute chest trauma and suspected aortic rupture, as suggested by emergency CT or chest radiographs, were subjected to MRI and/or angiography in random order. Such parameters as the presence and type of lesion; presence of periaortic, pericardial, mediastinal, or pleural effusion; and presence of associated lesions were considered in every patient. Follow-up imaging was performed exclusively by MRI every 1 to 2 months. TAR was present in 20 patients. No patient underwent surgery in the acute phase; 14 patients underwent surgery at 6.8 +/- 2.7 months; 5 are waiting for surgery; and 1 healed spontaneously. There was no overall mortality. For detection of TAR, the accuracy of MRI was 100%; angiography, 84%; and CT, 69%. In detecting the type of lesion, the diagnostic accuracy of MRI was 92%. During follow-up, a significant increase in the posttraumatic aneurysm was observed in 2 patients, and surgical repair was initiated. CONCLUSIONS In chest trauma patients, MRI provides complete anatomic data to assess the severity of aortic and thoracic lesions. Moreover, along with the concept of delayed surgical repair of TAR, MRI is the ideal modality to monitor and follow TAR before surgical repair.

Arch replacement and downstream stent grafting in complex aortic dissection: first results of an international registry.

OBJECTIVES Arch replacement combined with antegrade stent grafting of the descending aorta represents a hybrid surgical approach for extensive thoracic aortic disease. This multicentre study evaluates the early results of this method in complex aortic dissection (AD). METHODS Retrospective data acquisition was achieved by institution of an international registry. A hybrid stent graft with integrated vascular prosthesis for arch replacement (E-vita open®) was used. From January 2005 to March 2009, 106 patients (mean age 57; 77% male) with complex AD (55 acute, 51 chronic) were studied. RESULTS As many as 49/106 (46%) patients underwent emergency surgery. Stent-graft deployment and arch replacement (95 total, 11 subtotal) were performed under hypothermic circulatory arrest (HCA (8±6min) and selective antegrade cerebral perfusion (SACP) (74±23min). Stent-graft placement into the true lumen was successful in all but one case (99%). Ascending aortic replacement was performed in 91/106 (86%), aortic valve repair/replacement in 49/106 (46%), coronary artery bypass grafting (CABG) in 17/106 (16%) and mitral valve repair in 2/106 (2%). Cardiopulmonary bypass (CPB) and cardiac arrest times were 242±64 and 144±44min, respectively. In-hospital mortality was 12% (13/106; six acute, seven chronic AD) and new strokes observed in 5/106 (5%). The false lumen (FL) was evaluated in 96/106 (91%) patients postoperatively. At first follow-up computed tomography (CT)-examination, thoracic FL thrombosis was 93% (76 complete, 13 partial) and 58% (31 complete, 25 partial) in the thoraco-abdominal aorta. CONCLUSIONS By combining arch replacement with downstream stent grafting, one-stage repair of complex aortic dissection with almost unanimous thoracic FL thrombosis can be achieved at acceptable perioperative risk.

Incidence, Etiology, Histologic Findings, and Course of Thoracic Inflammatory Aortopathies

BACKGROUND The aims of this study were to detect the incidence of thoracic histologically proven aortitis in a large series of 788 patients operated on for thoracic aortic disease, to describe the surgical and histologic features of inflammatory thoracic aortopathies, and to evaluate the frequency of postsurgical complications and mortality. METHODS Thirty-nine patients (4.9%) were affected by aortitis (mean age, 72.6 +/- 9.6). There were 24 women (61.5%). Thirty-four (87.2%) were operated on because of aneurysms and 5 because of dissection. In all cases the diagnosis of aortitis was incidental and was made on the basis of histopathologic findings. RESULTS Histologically, there were 30 cases of giant cell aortitis (76.9%), 3 inflammatory aneurysms (7.7%), 2 cases of aspecific lymphoplasmacellular aortitis (5.1%), 1 of Takayasu aortitis, 1 of systemic erythematosus lupus-associated aortitis, and 1 of Behçets disease-associated aortitis. The only case of infectious aortitis was a syphilitic aortitis. In 79.5% of cases, inflammatory infiltrates were moderate to severe in degree; the most widespread inflammation was seen in Takayasu aortitis, systemic erythematosus lupus-associated aortitis, and in Behçets disease. The overall in-hospital mortality was 10.3% (4 of 39 patients). Neurologic complications occurred in 4 patients (10.3%). CONCLUSIONS During surgery of the thoracic aorta, an inflammatory etiology of aneurysms is found in almost 5% of cases. The inflammatory process is in a histologically advanced phase, often with systemic development. Surgery can be associated with high morbidity and mortality.