Edvard Skripochnik

The outcome of surgical management of type A aortic dissection.

Background Type A aortic dissection is a serious and fatal condition. Methods We retrospectively evaluated the outcome following repair of ascending aortic dissection in a contemporary cohort of 108 patients with a mean age of 59.5 ± 13.8 years, who were treated between 2006 and 2011. Most patients were male (70, 65%). Results Circulatory arrest with a mean duration of 22 ± 16 min was performed in 42 (38.9%) patients. Perioperative mortality was 15.7% (n = 17). Univariate analysis showed that cardiopulmonary bypass time (p = 0.0006), age >60 years (p = 0.028), cardiogenic shock at presentation (p = 0.02), New York Heart Association class II–IV (p = 0.038), hemopericardium (p = 0.0035), and preoperative cerebrovascular accident (p = 0.02) were predictors of mortality. Multivariate analysis indicated that age >60 years (odds ratio 7.7, 95% confidence interval: 1.52–38.96, p = 0.0136), preoperative cerebrovascular accident (odds ratio 25.2, 95% confidence interval: 2.45–258.9, p = 0.0066), hemopericardium (odds ratio 41.6, 95% confidence interval: 5.38–320.7, p = 0.0003), and cardiopulmonary bypass time (odds ratio 1.85, 95% confidence interval: 1.32–2.57, p = 0.0003) were independent predictors of perioperative mortality. The 1- and 4-year survival was 80% ± 3.8% and 69% ± 5.7%, respectively. Age >60 years (hazard ratio 3.3, 95% confidence interval: 1.4–7.9, p = 0.0064) was the only independent predictor of long-term mortality. Conclusion Our results identify the major risk factors for perioperative and long-term mortality. Age is an independent risk factor for mortality.

Recently Patented Transcatheter Aortic Valves in Clinical Trials

The most widely used heart valve worldwide is the Edwards Sapien, which currently has 60% of the worldwide transcatheter aortic valve implantation (TAVI) market. The CoreValve is next in line in popularity, encompassing 35% of the worldwide TAVI market. Although these two valves dominate the TAVI market, a number of newer transcatheter valves have been introduced and others are in early clinical evaluation. The new valves are designed to reduce catheter delivery diameter, improve ease of positioning and sealing, and facilitate repositioning or removal. The most recent transcatheter valves for transapical use include Acurate TA (Symetis), Engager (Medtronic), and JenaValve the Portico (St Jude), Sadra Lotus Medical (Boston Scientific), and the Direct Flow Medical. These new inventions may introduce more effective treatment options for high-risk patients with severe aortic stenosis. Improvements in transcatheter valves and the developing variability among them may allow for more tailored approaches with respect to patients anatomy, while giving operators the opportunity to choose devices they feel more comfortable with. Moreover, introducing new devices to the market will create a competitive environment among producers that will reduce high prices and expand availability. The present review article includes a discussion of recent patents related to Transcatheter Aortic Valves.

Fluoroscopy time is not accurate as a surrogate for radiation exposure

Objective The Food and Drug Administration and the Vascular Quality Initiative still utilize fluoroscopy time as a surrogate marker for procedural radiation exposure. This study demonstrates that fluoroscopy time does not accurately represent radiation exposure and that dose area product and air kerma are more appropriate measures. Methods Lower extremity endovascular interventions (N = 145) between 2013 and 2015 performed at an academic medical center on a Siemens Artis-Zee floor mounted c-arm were identified. Data was collected from the summary sheet after every case. Scatter plots with Pearson correlation coefficients were created. A strong correlation was indicated by an r value approaching 1. Results Overall mean AK and DAP was 380.27 mGy and 4919.2 µGym2. There was a poor correlation between fluoroscopy time and total AK or DAP (r = 0.27 and 0.32). Total DAP was strongly correlated to cine DAP and fluoroscopy DAP (r = 0.92 vs. 0.84). The number of DSA runs and average frame rate did not affect AK or DAP levels. Mean magnification level was significantly correlated with total AK (r = 0.53). Conclusions Fluoroscopy time shows minimal correlation with radiation delivered and therefore is a poor surrogate for radiation exposure during fluoroscopy procedures. DAP and AK are more suitable markers to accurately gauge radiation exposure.

The Efficacy and Outcome of Ministernotomy Compared to Those of Standard Sternotomy for Aortic Valve Replacement

Background. Benefits of ministernotomy have been reported but not yet fully established in the current literature. Ministernotomy may be associated with less bleeding, less need for transfusion, and reduced hospital length of stay. Methods. We retrospectively evaluated 347 patients who underwent aortic valve replacement between 2007 and 2011 at our institution. Results. Standard sternotomy was performed in 303 patients (154 males, 50.8% and 149 females, 49.2%) and ministernotomy in 44 patients (13 males, 30% and 30 females, 70%); most of the patients in ministernotomy group were female (75%) . The mean age for ministernotomy patients was years and for sternotomy patients years . Significant preoperative morbidities (for ministernotomy and sternotomy, resp.) included stroke (11%, versus 18%, ; ), PVD (23%, versus 16%, ; ), COPD (25%, versus 17%, ; ), renal failure (0.0%, versus 8.8%, ; ), and previous heart surgery (9%, versus 9.5%, ; ). Intraoperative blood transfusion was required in 23% of ministernotomy patients and 30% of sternotomy patients , . Major postoperative complications (for ministernotomy and sternotomy, resp.) included exploration for bleeding (4.5%, versus 6%, ; ) and adverse neurologic events (4.5%, versus 1.6%, ; ). The length of stay (LOS) in the CCU was hours for the ministernotomy group and hours for the sternotomy group . The LOS was slightly shorter following ministernotomy ( days) compared to sternotomy ( days) . Perioperative mortality was 2.3% for ministernotomy and 3.3% for sternotomy . The 1-, 3-, and 7-year survival following ministernotomy was 93.8%, 93.8%, and 88.3%, respectively; following sternotomy, these rates were 87.7%, 83.7%, and 82.6%, respectively (95% CI 0.273 to 1.325, ). Conclusion. Ministernotomy is less invasive and is associated with less perioperative and postoperative bleeding and reduced LOS in CCU and in hospital.

Fifty years of hemodialysis access literature: The fifty most cited publications in the medical literature

Objectives The modern era of hemodialysis access surgery began with the publication in 1966 by Brescia et al. describing the use of a surgically created arteriovenous fistula. Since then, the number of patients on chronic hemodialysis and the number of publications dealing with hemodialysis access have steadily increased. We have chronicled the increase in publications in the medical literature dealing with hemodialysis access by evaluating the characteristics of the 50 most cited articles. Methods We queried the Science Citation Index from the years 1960–2014. Articles were selected based on a subject search and were ranked according to the number of times they were cited in the medical literature. Results The 50 most frequently cited articles were selected for further analysis and the number of annual publications was tracked. The landmark publication by Dr Brescia et al. was unequivocally the most cited article dealing with hemodialysis access (1109 citations). The subject matter of the papers included AV fistula and graft (9), hemodialysis catheter (9), complications and outcomes (24), and other topics (8). Most articles were published in nephrology journals (33), with fewer in surgery (7), medicine (7), and radiology (3) journals. Of the 17 journals represented, Kidney International was the clear leader, publishing 18 articles. There has been an exponential rise in the frequency of publications regarding dialysis access with 42 of 50 analyzed papers being authored after 1990. Conclusion As the number of patients on hemodialysis has increased dramatically over the past five decades, there has been a commensurate increase in the overall number of publications related to hemodialysis access

Short-term results of left subclavian artery salvage in blunt thoracic aortic injury with short proximal landing zones

Objective: Thoracic endovascular aortic repair (TEVAR) is the standard treatment of blunt thoracic aortic injury (BTAI). The concept of seal was derived from the treatment of aneurysms and has been adopted for BTAI. Given the location of injury in BTAI, left subclavian artery (LSA) coverage is sometimes necessary. In these often healthier aortas, a shorter proximal landing zone may be acceptable and beneficial in avoiding some complications. Current practice patterns vary, and long‐term effects of LSA coverage remain unknown. Methods: A single‐institution experience with BTAI for TEVAR was examined from 2006 to 2017. The primary outcome was failure of sealing, endoleak, or persistent aortic injury on follow‐up imaging. A centerline was used to measure the length of the landing zone, aortic diameter, and other parameters. Post‐TEVAR computed tomography scans were examined for evidence of residual aortic injury. Results: A total of 30 TEVARs were performed for BTAI. The mean age of the patients was 38.7 years (standard deviation [SD], 19.8 years), and 70% were male. The mean injury severity score was 36.75 (SD, 13.1). Treated patients had grade 2 (36.7%) or grade 3 (63.3%) BTAI. The LSA was salvaged in 23 cases and covered in seven cases. The mean landing zone in LSA uncovered cases was 16 mm (SD, 10.4 mm). There were 15 patients (65%) who had a landing zone <20 mm, and eight (35%) patients had a landing zone >20 mm. The mean landing zone in the seven covered cases was 1.8 mm (SD, 2.4 mm). Procedural success was 96% for the uncovered group and 100% for the covered group. On follow‐up imaging, there was only one residual endoleak in all surviving patients (n = 25). Five patients did not have postoperative imaging, two (7%) of whom died of nonaorta‐related issues. Conclusions: TEVAR for BTAI in patients with short proximal landing zones of 10 to 20 mm as well as in select patients with landing zones of 5 to 10 mm appears to be safe and efficacious. The aorta demonstrates no residual injury after TEVAR, with the graft acting potentially more as a bridge to allow healing. Long‐term issues regarding LSA coverage have been difficult to ascertain and to evaluate because of historically poor follow‐up in this population of patients. However, potential issues with LSA coverage and revascularization may be avoided by preserving the subclavian artery even with shorter proximal landing zones.

Delayed migration of a thrombosed aortic endograft within a thrombosed aneurysm sac resulting in continued sac expansion and rupture

We present the case of delayed migration of a thrombosed aortic endograft within a thrombosed aneurysm sac that expanded and ruptured. Dilation of the aortic neck likely led to endograft migration and exposure of the occluded endograft and aneurysm sac to systemic pressure. Although no endoleak was identified, a key finding on ultrasound showed mobility of the sac thrombus. This may be an indicator of flow within the sac that may predict potential for rupture. Despite thrombosis of the aortic sac and endograft, the risk of rupture still lingers, and thus continued surveillance of occluded endografts may be prudent.

Inguinal pain and fullness due to an intravascular leiomyoma in the external iliac vein

Intravascular leiomyomatosis (IVL) is a benign smooth muscle tumor that evolves from the pelvic veins and can spread to the central veins and heart. Cardiac involvement is the most commonly reported presentation. Initial diagnosis is difficult, and IVL is commonly misdiagnosed as thrombus or atrial myxoma. Appropriate imaging and a high clinical suspicion are required for accurate diagnosis. We report a rare case of IVL in the external iliac vein that recurred 4 years after hysterectomy. Only four cases have been reported in the literature to involve the external iliac vein as it has no direct connection to pelvic venous drainage.

PC172 Coverage of the Left Subclavian Artery in Blunt Thoracic Aortic Injury Is Not Necessary to Achieve Aortic Healing in Patients With Short Proximal Landing Zones

Objectives: Endovascular repair of the thoracic aorta (TEVAR) is the preferred treatment for blunt thoracic aortic injury (BTAI). Current stent grafts recommend a >20 mm proximal landing zone of healthy aorta, but these guidelines were based on treatment of aneurysms. Given the location of BTAI, this would often necessitate coverage of the left subclavian artery (LSA). In these often-healthier aortas, a shorter proximal landing zone may be acceptable. Current practice patterns still vary greatly regarding LSA coverage, and long-term effects of LSA coverage remain unknown. Methods: A total of 28 TEVARs, with 20 preserving the LSA and eight covering, were performed for BTAI over the past 10 years. The primary outcome was failure of sealing, endoleak, or lack of aortic healing on follow-up scans. TeraRecon medical imaging software (Foster City, CA) was used to examine the centerline length of healthy aorta from the LSA to the injury. Initial post-TEVAR computed tomography (CT) scans were examined for evidence of persistent dissection, pseudoaneurysm, or hematomas. Results: Mean age of the patients was 38.9 (standard deviation [SD], 20.2) years, with 71.4% male. The average Injury Severity Score was 36.75 (SD, 13.1). Treated patients had BTAI consisting of grade II (39%) or III (61%) injuries. In the uncovered cases, mean length of LSA to injury was 15.2 (SD, 8.4) mm of which 13 (65%) cases were <20 mm and seven (35%) were between 5 and 10 mm. In the eight covered cases, the mean length from the LSA was 2.9 (SD, 3.8) mm, of which 6 (75%) were <5 mm. Overall there was a 100% technical success rate with no evidence of endoleak or failure to seal. On follow-up imaging within 60 days there was no evidence of persistent aortic injury or endoleak in all surviving patients (n 1⁄4 25). Two patients (7%) died of massive intracranial injury, and one patient was lost to follow-up. Longterm follow-up (>1 year) was only 46.4%, but of these there was no evidence of endoleak or graft migration. Conclusions: TEVAR for BTAI in patients with short proximal landing zones of 5 to 10mm appears to be safe and efficacious to achieve healing. The aorta appears to heal quickly after TEVAR, with the graft acting more as a bridge to allow healing. Long-term issues regarding LSA coverage are unknown, and preservation should be attempted even in patients with short proximal landing zones.

Comparing the Importance of Hemodynamic Obstruction with Diastolic Dysfunction in Patients with Hypertrophic Obstructive Cardiomyopathy

Objective: Myomectomy is the cornerstone of therapy for hypertrophic obstructive cardiomyopathy (HOCM) in the presence of a high gradient. The importance of mechanical gradient across the left ventricle outflow track (LVOT) vs left ventricular diastolic dysfunction (LVDD) is debatable. Methods: We retrospectively analyzed data on 14 patients with HOCM who underwent myomectomy from 2007 to 2011 at our institution. All patients in this study were symptomatic. The purpose of this study was to assess the significance of immediate reduction of the gradient across the LVOT as well as improved LVDD and its correlation with hemodynamics. Results: A total of 14 patients with a mean age of 52.5 ± 19.0 years (male-female ratio of 5/8) were evaluated. The preoperative LVOT peak gradient was 76.9 ± 63.4 mmHg, the left atrial (LA) diameter was 41.9 ± 6.1 mm, and the septal thickness was 15.4 ± 3.2 mm. The relevant preoperative risk factors included DM (23.0%; n = 3), angina pectoris (15.4%; n = 2), cerebrovascular disease (CVD) (30.8%; n = 4), stroke (15.4%; n = 2), arrhythmias (30.8%; n = 4), and COPD (15.4%; n = 2). The concurrent procedures included mitral valve repair/ replacement (MVR) (30.8%; n = 4), aortic valve replacement (AVR) (23.0%; n = 3), coronary artery bypass grafting (CABG) (15.4%; n = 2), and modified MAZE procedure/ablation (15.4%; n = 2). The perioperative mortality was 7.7% (n = 1), and the long-term survival was 85.6% at a median follow up of 30 months. The postoperative LVOT gradient improved to 32.3 ± 24.4 mmHg and the septal thickness to 12.5 ± 3.8 mm. These differences were not statistically significant, likely due to small sample size. The postoperative complications included iatrogenic small VSD in one patient (who had myomectomy for a third time), atrial fibrillation (n = 4), cardiac arrest (7.7%; n = 1), neurologic adverse event (7.7%; n = 1), and new onset renal failure (7.7%; n = 1). We did not observe any new onset AV block. The length of stay (LOS) in the surgical critical care unit was 95.5 ± 112.7 hours. The overall hospital LOS was 15 ± 11.5 days. Conclusion: The septal myomectomy results showed an immediate reduction of the LVOT gradient, which translates into clinical and echocardiographic improvement.