Forozan Navid

Great vessel and cardiac trauma: diagnostic and management strategies.

Blunt and penetrating trauma to the chest can result in great vessel or cardiac injury. Both the diagnosis and management of these thoracic injuries have evolved from more invasive to less invasive strategies paralleling the advent of sophisticated imaging tools and the development of endovascular therapies. Despite these advances, conventional open repair and reconstruction techniques remain important and are often the definitive means toward effective management of these severely injured patients. The following review outlines the historical perspective, diagnosis, and management of blunt thoracic aortic, blunt cardiac, and penetrating cardiac injuries.

Outcomes of persistent pulmonary hypertension following transcatheter aortic valve replacement

Objectives To determine the prevalence and factors associated with persistent pulmonary hypertension (PH) following transcatheter aortic valve replacement (TAVR) and its relationship with long-term mortality. Methods Consecutive patients who underwent TAVR from July 2011 through January 2016 were studied. The prevalence of baseline PH (mean pulmonary artery pressure ≥25 mm Hg on right heart catheterisation) and the prevalence and the predictors of persistent≥moderate PH (pulmonary artery systolic pressure (PASP)>45 mm Hg on 1 month post-TAVR transthoracic Doppler echocardiography) were collected. Cox models quantified the effect of persistent PH on subsequent mortality while adjusting for confounders. Results Of the 407 TAVR patients, 273 (67%) had PH at baseline. Of these, 102 (25%) had persistent≥moderate PH. Mortality at 2 years in patients with no baseline PH versus those with PH improvement (follow-up PASP≤45 mm Hg) versus those with persistent≥moderate PH was 15.4%, 16.6% and 31.3%, respectively (p=0.049). After adjusting for Society of Thoracic Surgeons Predicted Risk of Mortality and baseline right ventricular function (using tricuspid annular plane systolic excursion), persistent≥moderate PH remained associated with all-cause mortality (HR=1.82, 95% CI 1.06 to 3.12, p=0.03). Baseline characteristics associated with increased likelihood of persistent≥moderate PH were ≥moderate tricuspid regurgitation, ≥moderate mitral regurgitation, atrial fibrillation/flutter, early (E) to late (A) ventricular filling velocities (E/A ratio) and left atrial volume index. Conclusions Persistency of even moderate or greater PH at 1 month post-TAVR is common and associated with higher all-cause mortality.

Intercostal artery reimplantation with saphenous vein during thoracoabdominal aortic replacement

From the Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Sept 3, 2017; revisions received Oct 23, 2017; accepted for publication Nov 12, 2017; available ahead of print Dec 14, 2017. Address for reprints: Ibrahim Sultan, MD, Division of Cardiac Surgery, 5200 Centre Ave, Suite 715, Pittsburgh, PA 15232 (E-mail: sultani@upmc.edu). J Thorac Cardiovasc Surg 2018;155:1963-5 0022-5223/

Aortic root replacement with cryopreserved homograft for infective endocarditis in the modern North American opioid epidemic

36.00 Copyright 2017 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2017.11.028

Surgical cut down for vascular access with conscious sedation for transcatheter aortic valve replacement: the best of both worlds?

Objective: To study mid‐term survival in patients with infective endocarditis as a result of IV drug use undergoing aortic root replacement with cryopreserved aortic homograft. Methods: Patients undergoing aortic root homograft replacement from 2011‐2017 were studied retrospectively. Aortic root replacement was performed using a modified Bentall technique. Primary outcomes included both short‐term and mid‐term survival. Secondary outcomes included immediate postoperative complications. Results: A total of 138 patients underwent cryopreserved homograft replacement of the aortic root for aortic root abscesses. Eighty‐five patients (61.6%) underwent reoperative sternotomy, and 12 patients (8.7%) underwent second or third reoperative sternotomy. Sixty‐seven (48.5%) patients had severe aortic insufficiency preoperatively. Operative mortality was 12.3% (17 patients). Five patients (3.6%) sustained a permanent stroke. Twenty‐one patients (15.2%) required dialysis for renal failure, and 21 patients (15.2%) had complete heart block necessitating a permanent pacemaker. Estimated 5‐year mortality for the cohort was 43%. Conclusions: Cryopreserved homograft replacement is a safe and desirable option for high‐risk patients with infective endocarditis and aortic root abscess. Homograft accommodation for a widely debrided aortic annular bed provides a reasonable surgical strategy for patients needing aortic root replacement with annular abscess.

Conversion of Left- to a Right-Sided Aortic Arch: A Radical Approach for Select Indications

OBJECTIVES Despite the established efficacy of transcatheter aortic valve replacement for aortic valve replacement, vascular complications remain a major cause of procedural morbidity and mortality. In this study, we evaluate the use of femoral artery cut down with conscious sedation and report outcomes and complications associated with this approach. METHODS Our study included 282 patients undergoing transcatheter aortic valve replacement with conscious sedation and surgical cut down for femoral access between 2015 and 2017. Data were prospectively recorded in the local institutional database and were retrospectively accessed. Descriptive statistics are presented, and a Kaplan-Meier time-to-event plot was used to estimate 1-year survival. RESULTS The mean age of the patients was 82.7 ± 7.31 years and consisted of 146 (52%) women. Echocardiographic data demonstrated a severe aortic stenosis with a mean area of 0.65 ± 0.16 cm2 and a mean gradient of 48.9 ± 13.3 mmHg. STS-PROM for the cohort was 7.2%, representing an intermediate risk group. Six (2.2%) patients died within 30 days after transcatheter aortic valve replacement. Major vascular complications occurred in 2 (0.7%) patients and minor vascular complications occurred in 6 (2.2%) patients in our cohort. Wound complications were observed in 2 (0.7%) patients. CONCLUSIONS We demonstrate that the use of conscious sedation and surgical cut down for femoral arterial access resulted in a major vascular complication rate of less than 1% and low in-hospital mortality rates without any significant increase in wound complications.

Hospital readmission rates are similar between patients with mechanical versus bioprosthetic aortic valves

Thoracic aortic graft infections, anomalous arch anatomy, and vascular rings may cause tracheal and/or esophageal compression. These circumstances often create challenging clinical dilemmas such that anatomical repair either does not eliminate the pathologic process completely or poses a measurable risk of recurrence. We describe a novel approach that facilitates complete relocation of the thoracic aorta to either prevent graft placement in an infected field or prevent tracheal and/or esophageal compression that effectively converts left-sided to right-sided arch anatomy.

TCT-676 Prevalence of Residual Mitral and Tricuspid Regurgitation (MR/TR) following Transcatheter Aortic Valve Replacement (TAVR): Residual Mod/Severe MR and TR is Associated with Higher Mortality post TAVR

The aim of this study was to evaluate hospital readmission rates and clinical outcomes between bioprosthetic (bAVR) and mechanical (mAVR) aortic valve replacements (AVR).

Nonoperative Management of Brachiocephalic Artery Dissection

NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, United States; Emory University School of Medicine, Atlanta, Georgia, United States; Emory University Hospital Midtown, Atlanta, Georgia, United States; Columbia University Medical Center, Wilson, North Carolina, United States; NewYorkPresbyterian Hospital/Columbia University Medical Center, New York, New York, United States; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, United States; The Heart Hospital Baylor Plano, Plano, Texas, United States

Outcomes of mitral valve surgery during concomitant aortic valve replacement

A 68-year-old man presented with complaints of right-sided neck and chest pain with systolic blood pressure greater than 200 mm Hg but denied any recent blunt trauma or whiplash events. A computed tomography angiography demonstrated an acute dissection involving the origin of the right brachiocephalic artery that extended into the right common carotid and right subclavian arteries. The patient was neurologically intact and computed tomography angiography of the brain demonstrated a stable arachnoid cyst and a brain perfusion scan demonstrated homogenous perfusion. In the absence of strong indications for arch replacement, the patient was treated with warfarin and clopidogrel to prevent further thrombotic potentiation.