Derek Brinster

Percutaneous Pulmonary Valve Implantation : Present Status and Evolving Future

Due to recurrent right ventricular outflow tract (RVOT) dysfunction, patients with complex congenital heart disease of the RVOT traditionally require multiple surgical interventions during their lifetimes. Percutaneous pulmonary valve implantation (PPVI) has been developed as a nonsurgical alternative for the treatment of right ventricular to pulmonary artery stenosis or pulmonary regurgitation. PPVI has been shown to be a safe and effective procedure in patients with dysfunctional surgical RVOT conduits. In this population, PPVI has the potential to improve symptoms, functional capacity, and biventricular hemodynamics. However, limitations to the anatomical substrate and size of the RVOT currently restrict PPVI eligibility to less than one-quarter of patients with RVOT dysfunction. The current review discusses contemporary practices in PPVI, evidence supporting the procedure, and future technologies and developments in the field.

Prestenting for prevention of melody valve stent fractures: A systematic review and meta-analysis

The role of right ventricular outflow tract (RVOT) prestenting in the prevention of Melody valve stent fractures (SFs) is not well defined. We aimed to perform a systematic review and meta‐analysis comparing the incidence of SF in Melody valve transcatheter pulmonary implants with and without prestenting.

Short- and intermediate-term outcomes of hybrid coronary revascularization for double-vessel disease

Objective We sought to evaluate midterm survival data and resource use for patients who received hybrid coronary revascularization for 2‐vessel coronary disease (robotic‐assisted left internal thoracic artery graft to left anterior descending coronary artery (minimally invasive direct coronary artery bypass), coupled with a stent to the circumflex or right coronary artery), compared with a concurrent cohort who had traditional coronary artery bypass grafting. Methods A comprehensive retrospective review was undertaken of our prospectively collected database from January 2009 to December 2016. We propensity matched 207 patients who underwent hybrid coronary revascularization for double‐vessel disease with patients who underwent coronary artery bypass grafting. Eight‐year survival data were obtained from the National Death Index. Results Thirty‐day mortality was 1 patient (0.5%) in each of the hybrid coronary revascularization and coronary artery bypass grafting groups. Eight‐year survival for the hybrid coronary revascularization group was 187 of 207 patients (90.3%) compared with 182 of 207 patients (87.9%) for the coronary artery bypass grafting cohort. End‐stage renal disease independently predicted late mortality in all patients (overall hazard ratio, 5.60, P < .001; hybrid coronary revascularization hazard ratio, 5.58, P = .002; coronary artery bypass grafting hazard ratio, 4.59, P = .006). Female patients who underwent hybrid coronary revascularization had a higher incidence of late death (hazard ratio, 2.47, P = .05). Length of stay and perioperative transfusion requirements were lower in the hybrid coronary revascularization group (P < .0001). Conclusions Hybrid coronary revascularization for double‐vessel coronary disease is associated with similar short‐term outcomes and intermediate‐term survival as traditional coronary artery bypass grafting. Hybrid coronary revascularization is associated with lower transfusion requirements and a shorter length of stay than coronary artery bypass grafting.

Rethinking the Paradigm: Modern Approach to Proximal Aortic Reconstruction Demonstrates Excellent Outcomes

BACKGROUND Techniques for aortic surgery continue to evolve. A real-world snapshot of patients undergoing elective surgery for aneurysm in the modern era is helpful to assist in deciding the appropriate timing for intervention. We herein describe our experience with 100 consecutive patients who underwent primary elective surgery for aneurysm of the proximal thoracic aorta over a two-year period at a single institution. METHODS The majority of our patients were male, mean age 61.19 ± 13.33 years. Two patients had Marfan syndrome. Twenty-eight patients had bicuspid aortic valve. Thirty-four patients underwent aortic root replacement utilizing a composite valve/graft conduit; 23 had valve-sparing root replacements. The ascending aorta was replaced in 89 patients; 80 (89.9%) of these included a period of circulatory arrest at moderate hypothermia utilizing unilateral selective antegrade cerebral perfusion. RESULTS Thirty-day mortality was zero. Perioperative stroke occurred in 2 patients, both of whom completely recovered prior to discharge. No patients required re-exploration for bleeding. One patient developed a sternal wound infection. Fifteen patients required readmission to hospital within thirty days of discharge. CONCLUSION Elective surgery for aneurysm of the proximal aorta is safe, reproducible, and is associated with outcomes that are superior to those seen in an acute aortic syndrome. It may be appropriate to offer surgery to younger patients with proximal aortic aneurysms at smaller diameters, even if their aortic dimensions do not yet meet traditional guidelines for surgical intervention.

Surgical repair of bilateral coronary artery fistulae and a left main coronary artery aneurysm following a failed percutaneous embolization

Coronary artery aneurysms (CAA) may involve all branches of the coronary artery vasculature including the left main coronary artery (LMCA), and may require transection of the aorta and pulmonary artery (PA) for exposure to perform the repair. In addition to rupture, CAAs may also fistulize to other structures including the PA and left ventricle. Although percutaneous coils have been used to occlude coronary artery fistulas (CAF), surgery remains the definitive therapy for CAF associated with CAAs. We present images of a patient who underwent surgical repair of both a LMCA aneurysm with a fistula to the right atrium (RA) and a right coronary artery (RCA) fistula to the LMCA following an unsuccessful percutaneous coil embolization.

Left Axillary Artery Cannulation Facilitates Reoperative Total Aortic Arch Replacement

Total aortic arch replacement remains a technically formidable procedure, particularly in patients with previous proximal aortic dissection repair. Our case discussion highlights a useful strategy for extracorporeal support and circulation management to facilitate total arch reconstruction in the reoperative setting, based on cannulation of the left axillary artery. Our preference is to use a left axillary artery approach to initiate cardiopulmonary bypass and to ultimately revascularize the left arm via an extra-anatomic graft. Our technique, as described, affords the option to initiate cardiopulmonary bypass before sternal re-entry, it reduces the risk of embolic complications and possible stroke, and it directly facilitates simple extra-anatomic debranching of the left subclavian artery, resulting in easier arch and great vessel reconstruction within the chest.

Transinnominate approach for transcatheter aortic valve replacement: single-centre experience of minimally invasive alternative access

OBJECTIVES Iliofemoral arteries have been the preferred access for transcatheter aortic valve replacement (TAVR). When these arteries are too small, calcified or tortuous, an alternative access must be considered. Transinnominate (TI) access is an extrathoracic approach that does not require manipulation of major neurovascular structures or the apex. The aim of this study is to evaluate the efficacy and safety of TI TAVR as an alternative access in patients with severe aortic stenosis not amenable to a transfemoral approach. METHODS Thirteen patients with severe aortic stenosis underwent TI TAVR between February 2016 and January 2017 at our institution. The average Society of Thoracic Surgeons (STS) score was 7.7 ± 4.5%. Eight patients had previous surgical revascularization, 7 of which involved the left thoracic artery. All patients underwent preoperative computed tomography angiography that revealed significant atheromatous and calcific disease of the iliofemoral vessels and/or the descending aorta. The innominate artery was found to be of appropriate calibre (>10 mm), free of plaque and easy to access via surgical incision. Fusion multimodality imaging was utilized in all cases to guide the procedure. RESULTS The innominate artery was accessed via a 2-inch right parasternal supraclavicular incision. Nine self-expandable valves and 4 balloon-expandable valves were implanted. Procedural success occurred in all cases without intraprocedural and in-hospital mortality. No neurological deficits or vascular complications were recorded; postoperative bleeding was trivial. Ten patients were discharged on Day 3 and 3 patients who required PPM on Day 5. CONCLUSIONS TI approach represents a safe, reproducible and minimally invasive hybrid technique for TAVR in high-risk patients. In our early experience, surgical trauma and perioperative complications are minimal with rapid patient recovery.

Undersized Stent Grafts for Acute Mesenteric Ischemia in Chronic Type B Dissection

Acute ischemia in chronic type B dissections carries high rates of morbidity and mortality. A 29-year-old woman with a chronic type B dissection presented with acute abdominal pain. Imaging revealed a worsening dissection with pseudocoarctation causing near complete occlusion of the true lumen by the false lumen. We placed purposefully undersized stent grafts to treat acute mesenteric ischemia by improving true lumen flow. The patient was discharged on postoperative day 4 without adverse events. We suggest that endovascular rescue by placing undersized stent grafts can provide improved flow to the mesenteric vessels with continued false lumen flow to vital organs.

MINIMALLY-INVASIVE, ALTERNATIVE ACCESS APPROACH TO TAVR UTILIZING THE TRANSINNOMINATE ARTERY

Transfemoral approach to transcatheter aortic valve replacement (TAVR) has been the preferred access for valve introduction and deployment. When iliofemoral anatomy is prohibitive, either due to severe calcification and/or tortuosity, alternative access requires consideration; options include

Therapeutic alternatives after aborted sternotomy at the time of surgical aortic valve replacement in the TAVI Era—Five centre experience and systematic review ☆

BACKGROUND We aimed to analyze causes, management, and outcomes of the unexpected need to abort sternotomy in aortic stenosis (AS) patients accepted for surgical aortic valve replacement (SAVR) in the transcatheter aortic valve implantation (TAVI) era. METHODS Cases of aborted sternotomy (AbS) were gathered from 5 centers between 2009 and 2014. A systematic review of all published cases in the same period was performed. RESULTS A total of 31 patients (71% males, 74±8years, LogEuroSCORE 11.9±7.4%) suffered an AbS (0.19% of all sternotomies). Main reasons for Abs included previously unknown porcelain aorta (PAo) in 83.9%, mediastinal fibrosis due to radiotherapy in 12.9%, and chronic mediastinitis in 3.2%. Median time between AbS and next intervention was 2.3months (IQR: 0.7-5.8) with no mortality within this period. Only a case was managed with open surgery. In 30 patients (96.8%) TAVI was performed with a rate of success of 86.7%. Three patients (9.7%) presented in-hospital death and 17 (54.8%) had in-hospital complications including heart failure (9.6%), major bleeding (6.9%), and acute kidney injury (9.6%). Older patients (76±8 vs. 70±8years, p=0.045), previous cardiac surgery (60% vs. 15.4%, p=0.029), and shorter time from AbS to next intervention (5.1±5 vs. 1±0.7months, p=0.001) were related to higher six-month mortality (22.6%). CONCLUSIONS The main reason for AbS was PAo. This entity was associated to a higher rate of complications and mortality, especially in older patients and with prior cardiac surgery. A preventive strategy in these subgroups might be based on imaging evaluation. TAVI was the most extended therapy.