Erik Beckmann

Do not leave the heart arrested. Non-cardioplegic continuous myocardial perfusion during complex aortic arch repair improves cardiac outcome

OBJECTIVES Myocardial protection with cardioplegia alone may be inadequate during complex aortic arch surgery, potentially resulting in postoperative myocardial insufficiency. We hypothesized that non-cardioplegic continuous myocardial perfusion (CMP) is feasible and safe to protect the heart while operating on the aortic arch, and improves cardiac outcome. METHODS Between April 2010 and April 2014, 144 patients (60% male, age: 60 ± 13 years) underwent complex aortic arch repair in our institution using prefabricated, branched aortic arch grafts. In 36 patients, the hearts were protected with a combination of cardioplegic cardiac arrest during cardiac procedures and subsequent non-cardioplegic CMP group during aortic arch repair. In 108 patients, myocardial protection was achieved by cardioplegic arrest (CA group) only. RESULTS Preoperative risk factors were comparable in both groups. Acute aortic dissection was the indication for surgery in 42% (CMP) and 44% (CA) of patients; 22% (CMP) and 29% (CA) of patients underwent reoperations. Concomitant cardiac procedures were similar. CMP patients received a frozen elephant trunk more frequently (89 vs 66%, P = 0.0096). Cardiopulmonary bypass time (242 ± 50 vs 264 ± 68 min; P = 0.046), and cardiac ischaemic time (49 ± 32 vs 149 ± 56 min, P < 0.0001) were significantly lower in the CMP group. There were no conversions to CA in the CMP group. Aortic arch repair was not prolonged by CMP. Low cardiac output syndrome occurred less frequently in the CMP group (3 vs 22%, P = 0.0052). Thirty-day mortality was significantly lower in the CMP group (6 vs 21%, P = 0.040). There were no cardiac deaths in the CMP group (0 vs 9%, P = 0.067). Neurological outcome was comparable. Blood loss was higher in the CA group (P < 0.001). CONCLUSIONS Routinely protecting the heart during complex aortic arch repair with non-cardioplegic CMP is a valuable new concept. The CMP technique is feasible and safe, does not prolong aortic arch repair, reduces myocardial damage and improves cardiac outcome. Further evaluation in a larger patient cohort is warranted to establish this novel technique.

Biological heart valves.

Abstract Cardiac valvular pathologies are often caused by rheumatic fever in young adults, atherosclerosis in elderly patients, or by congenital malformation of the heart in children, in effect affecting almost all population ages. Almost 300,000 heart valve operations are performed worldwide annually. Tissue valve prostheses have certain advantages over mechanical valves such as biocompatibility, more physiological hemodynamics, and no need for life-long systemic anticoagulation. However, the major disadvantage of biological valves is related to their durability. Nevertheless, during the last decade, the number of patients undergoing biological, rather than mechanical, valve replacement has increased from half to more than three-quarters for biological implants. Continuous improvement in valve fabrication includes development of new models and shapes, novel methods of tissue treatment, and preservation and implantation techniques. These efforts are focused not only on the improvement of morbidity and mortality of the patients but also on the improvement of their quality of life. Heart valve tissue engineering aims to provide durable, “autologous” valve prostheses. These valves demonstrate adaptive growth, which may avoid the need of repeated operations in growing patients.

Surgical treatment of coronary artery aneurysms

Coronary artery aneurysms (CAA) are rare. We present our experience with the surgical treatment of patients with CAAs.

Aortic valve replacement with sutureless prosthesis: better than root enlargement to avoid patient-prosthesis mismatch?

OBJECTIVES Aortic valve replacement in patients with a small aortic annulus may result in patient-prosthesis mismatch (PPM). Aortic root enlargement (ARE) can reduce PPM, but leads to extended cardiac ischaemia times. Sutureless valves have the potential to prevent PPM while reducing cardiac ischaemia times. METHODS Between January 2007 and December 2011, a total of 128 patients with a small aortic annulus underwent surgery for aortic valve stenosis at our centre. Thirty-six (17% male, n = 6) patients received conventional valve replacement with ARE and 92 (16% male, n = 18) subjects received sutureless valve implantation (Sorin Perceval). We conducted a comparative, retrospective study with follow-up. RESULTS The sutureless group showed a significantly higher age (79 years) than the ARE patients (62 years, P < 0.001) and received significantly more concomitant cardiac procedures (33%, n = 30 vs 6%, n = 2, P = 0.001). The mean operation, cardiopulmonary bypass and cross-clamp times were significantly lower in sutureless patients (147 ± 42, 67 ± 26 and 35 ± 13 min, respectively) than in ARE patients (181 ± 41, 105 ± 29 and 70 ± 19 min, respectively, P < 0.001). The mean postoperative effective orifice area (EOA) indexed to the body surface area was 0.91 ± 0.2 cm(2)/m(2) in ARE patients and 0.83 ± 0.14 cm(2)/m(2) in sutureless patients (P = 0.040). The rate of patients with severe PPM was 6% (n = 2) in ARE patients and 11% (n = 8%) in sutureless patients (not significant, n.s.). The 30-day mortality rates were 2% (n = 2) in sutureless patients and 6% (n = 2) in ARE patients (n.s.). The 1- and 5-year survival rates of the sutureless group were 92 and 54% years, respectively, whereas the 1- and 5-year survival rates of the ARE group were 76% (n.s.). CONCLUSIONS Although the sutureless valve patients received significantly more concomitant procedures, all operation-associated times were significantly shorter. Despite sutureless valve patients being older, the 30-day mortality and survival rates were comparable in the two groups. Since the indexed EOA was only slightly lower and the incidence of severe PPM was not significantly higher in the sutureless valve patients, we conclude that sutureless valve implantation is an alternative to conventional ARE to treat a small aortic annulus and avoid PPM, especially in geriatric patients who benefit from the quick implantation process.

Single-centre experience with the frozen elephant trunk technique in 251 patients over 15 years

OBJECTIVES Our goal was to present our 15-year experience (2001-2015) with the frozen elephant trunk (FET) technique. METHODS A total of 251 patients (82 with aortic aneurysms, 96 with acute aortic dissection type A, 4 with acute type B dissections, 52 with chronic aortic dissection type A, 17 with chronic type B dissection and 67 redo cases) underwent FET implantation with either the custom-made Chavan-Haverich (n = 66), the Jotec E-vita (n = 31) or the Vascutek Thoraflex hybrid (n = 154) prosthesis. The cases were assigned to an early period (2001-2011) and a contemporary period (2012-present). RESULTS Mean cardiopulmonary bypass time, aortic cross-clamp time, circulatory arrest time and selective antegrade cerebral perfusion time were 241 ± 72, 125 ± 59, 56 ± 30 and 81 ± 34 min, respectively. Incidence of rethoracotomy for bleeding, stroke, spinal cord injury, prolonged ventilatory support (>96 h) and long-term dialysis were 18, 14, 2, 24 and 2%, respectively. The in-hospital mortality rate was 11% (in acute aortic dissection type A, 12%). Of the 2 patients with graft infections, 1 died and the other had a protracted hospital stay. There were 49 second-stage procedures in the downstream aorta: either open surgical [n = 25 (thoraco-abdominal, n = 15; descending, n = 6; infrarenal, n = 4)] or transfemoral endovascular (n = 23). Elective thoracic endovascular aneurysm repair R implantation was successful in all 23 cases. CONCLUSIONS FET results are comparable with those of the published results of the conventional elephant trunk technique. FET is an ideal landing zone for subsequent transfemoral endovascular completion. Patients with graft infections may have dismal results.

Right-Sided Heart Failure and Extracorporeal Life Support in Patients Undergoing Pericardiectomy for Constrictive Pericarditis: A Risk Factor Analysis for Adverse Outcome

Background Right ventricular failure is a life‐threatening postoperative complication after pericardiectomy. We conducted a retrospective study with a special emphasis on right ventricular failure. Methods Between June 1997 and September 2011, 69 patients underwent surgical pericardiectomy at our center. Mean age was 59 (± 15.5) years, and 49 (71%) patients were male. Causes of constrictive pericarditis included idiopathic (52%, n = 36), tuberculosis (9%, n = 6), postcardiotomy (12%, n = 8), radiation (4%, n = 3), renal insufficiency (12%, n = 8), and autoimmune disease (12%, n = 8). Concomitant cardiac surgery was performed in 33 (48%) patients. Results In‐hospital mortality rate was 14% (10/69 patients). Extracorporeal membrane oxygenation (ECMO) was necessary in 8 (12%) cases because of right (n = 7) or biventricular (n = 1) failure. Statistical analysis showed a significant correlation between early mortality and the following preoperative variables: postcardiotomy (p = 0.049), radiation (p = 0.009), pleural effusion (p = 0.012), ascites (p = 0.039), hepatic congestion (p = 0.023), absence of calcification on X‐ray (p = 0.041), tricuspid valve insufficiency (TI, p < 0.001), and low cardiac index (p = 0.003). Diuretic usage (p = 0.044), peripheral edema (p = 0.050), low voltage (p = 0.027), dip‐plateau sign (p = 0.027), elevated GGT (p < 0.001), and decreased serum protein (p < 0.001) correlated with ECMO implantation. Binary logistic regression identified pleural effusion (OR = 16.2, 95% CI = 1.4‐191.5), moderate/severe TI (OR = 28.8, 95% CI = 2.7‐306.8) and low cardiac index (OR = 25.3, 95% CI = 2.0‐315.6) as preoperative independent risk factors for early mortality, whereas elevated GGT (OR = 28.3, 95% CI = 2.4‐329.2) and decreased protein (OR = 24.7, 95% CI = 1.8‐343.7) could predict right ventricular failure with the need for ECMO. Conclusion We recommend nondelayed ECMO support in case of significant postoperative right‐sided heart failure. High‐risk patients might benefit from elective pre‐ or intraoperative ECMO implantation.

First series of left ventricular assist device exchanges to HeartMate 3

OBJECTIVES Left ventricular assist device (LVAD) exchange is becoming a standard surgical procedure. The exchange procedure is an opportunity to upgrade patients to a new generation pump that offers advanced reduction of adverse events or longer battery hours. METHODS We performed an analysis of 6 consecutive patients who underwent LVAD exchange to HeartMate 3 either from a HeartWare or HeartMate (HM) II device. Minimally invasive operations were performed through a lateral thoracotomy. Follow-up time was 6 months after LVAD exchange. RESULTS We present 4 patients with the HM II and 2 patients with the HeartWare ventricular assist device (HVAD) who underwent LVAD exchange to HM III. The average age was 57.5 years. At the time of the LVAD exchange, all patients were classified as Interagency Registry for Mechanically Assisted Circulatory Support level 3. In 5 cases, LVAD infection led to LVAD exchange (83%, 5/6). The remaining patient underwent LVAD exchange due to pump thrombosis (16%, 1/6). The 6-month survival rate after LVAD exchange was 100% (6/6). None of the patients was postoperatively supported by extracorporeal membrane oxygenation. No patient experienced postoperative relevant bleeding. One patient suffered minor cerebral bleeding (16.6%, 1/6). At the 6-month follow-up examination, 1 patient reported a single syncope and several low-flow alarms (1/6). The remaining 5 patients showed no adverse events or technical malfunctions of the VAD (5/6). CONCLUSIONS LVAD exchanges from HM II as well from HVAD to HM 3 are proven to be technically feasible. Due to the advantages and technical improvements of the new-generation pumps, this procedure is an excellent opportunity to give patients access to a superior generation of assist device.

Valve-sparing David I procedure in acute aortic type A dissection: a 20-year experience with more than 100 patients†

OBJECTIVES The aortic valve-sparing David procedure has been applied to the elective treatment of patients with aortic aneurysms with excellent results. The use of this technique in patients with acute aortic dissection type A (AADA) is still a matter of debate. We present our long-term experience with 109 patients with AADA who had the valve-sparing David I procedure. METHODS Between July 1993 and October 2015, 109 patients with AADA had the valve-sparing David I procedure at our centre. We conducted a retrospective review with follow-up. RESULTS The mean age was 54 ± 12 years; 78 (72%) patients were men. Marfan syndrome was present in 6 (5%) patients and bicuspid aortic valve in 3 (3%). Only 4 (4%) patients received the isolated David procedure; 50 (46%) underwent additional proximal, 13 (12%) subtotal and 42 (39%) total aortic arch replacement. The in-hospital mortality rate was 11% ( n  = 12). Intraoperative/discharge echocardiography showed aortic insufficiency ≤ I° in 93 of 97 patients (96%). Mean follow-up time was 8.3 ± 5.7 years. The survival rate after discharge at 1, 5 and 10 years was 94%, 90% and 78%, respectively. Thirteen percent ( n  = 13) of patients underwent valve-related reoperation. Freedom from valve-related reoperation at 1, 5 and 10 years was 96%, 88% and 85%, respectively. Compared to patients who underwent the David I procedure for any reason other than AADA, there were no significant differences in long-term survival rates ( P  = 0.29) and freedom from a valve-related reoperation ( P  = 0.39). CONCLUSIONS The valve-sparing David I procedure has acceptable long-term results even in emergent operations for AADA and is not inferior when performed in elective settings.

Is the frozen elephant trunk procedure superior to the conventional elephant trunk procedure for completion of the second stage

OBJECTIVES Our goal was to compare the results and outcomes of second‐stage completion in patients who had previously undergone the elephant trunk (ET) or the frozen elephant trunk (FET) procedure for the treatment of complex aortic arch and descending aortic disease. METHODS Between August 2001 and December 2014, 53 patients [mean age 61 ± 13 years, 64% (n = 34) male] underwent a second‐stage completion procedure. Of these patients, 32% (n = 17) had a previous ET procedure and 68% (n = 36) a previous FET procedure as a first‐stage procedure. RESULTS The median times to the second‐stage procedure were 7 (0‐78) months in the ET group and 8 (0‐66) months in the FET group. The second‐stage procedure included thoracic endovascular aortic repair in 53% (n = 28) of patients and open surgical repair in 47% (n = 25). More endovascular interventions were performed in FET patients (61%, n = 22) than in the ET group (35%, n = 6, P = 0.117). The in‐hospital mortality rate was significantly lower in the FET (8%, n = 3) group compared with the ET group (29%, n = 5, P = 0.045). The median follow‐up time after the second‐stage operation for the entire cohort was 4.6 (0.4‐10.4) years. The 5‐year survival rate was 76% in the ET patients versus 89% in the FET patients (log‐rank: P = 0.11). CONCLUSIONS We observed a significantly lower in‐hospital mortality rate in the FET group compared to the ET group. This result might be explained by the higher rate of endovascular completion in the FET group. We assume that the FET procedure offers the benefit of a more ideal landing zone, thus facilitating endovascular completion.

Valve-sparing aortic root replacement (David I procedure) in Marfan disease: single-centre 20-year experience in more than 100 patients†

OBJECTIVES Valve-sparing aortic root replacement (VSARR) is recommended for patients with aortic root dilatation and preserved aortic valve cusp morphology. The durability of VSARR in Marfan patients has been questioned. The aim of our study was to establish the long-term outcomes of VSARR in Marfan patients. METHODS Between 1993 and 2015, 582 patients underwent VSARR (David I reimplantation) at our institution. Of these patients, 104 had Marfan disease. Thirteen surgeons performed the procedures in this group. The mean follow-up time was 12 ± 5.4 years (1201 patient-years). RESULTS Early mortality was 0.96%, and long-term survival was 91% at 10 years and 76% at 20 years in Marfan patients. Marfan patients had a significantly better survival compared to non-Marfan patients (P < 0.0001). Freedom from aortic-valve reoperation was 86% at 10 years and 80% at 20 years in Marfan patients. The reoperation rate was similar in Marfan and non-Marfan patients (P = 0.60). Morphological perioperative features (untreated prolapse, commissural plasty, cusp plasty and graft size mismatch) predicted long-term mortality (P = 0.0054). Graft size mismatch and untreated prolapse predicted structural valve deterioration (both P < 0.0001). Long-term valve function in event-free survivors was excellent [mean gradient 4.2 (2.9-6.9), 98% aortic regurgitation ≤ mild]. There were no valve-related thromboembolic or bleeding events. The endocarditis rate was 0.96%. Only 17% of the patients were on oral anticoagulants during the follow-up. CONCLUSIONS VSARR using the David I reimplantation technique results in excellent long-term outcomes in Marfan patients. We present the longest follow-up period so far. The genetic disease does not affect long-term valve function. The durability of the repair is affected by morphological perioperative criteria depending on surgical expertise, and dedicated training is recommended.