George J. Arnaoutakis

Concomitant antegrade stent grafting of the descending thoracic aorta during transverse hemiarch reconstruction for acute DeBakey I aortic dissection repair improves aortic remodeling

Concomitant endovascular stent grafting of the descending thoracic aorta during open repair for acute DeBakey I aortic dissection can be performed in patients with extensive dissection and malperfusion. We analyzed the effects of this strategy on distal aortic remodeling.

Tricuspid valve endocarditis in the era of the opioid epidemic

We reviewed our institutional experience with tricuspid valve endocarditis to understand the impact of the opioid epidemic on the incidence of right heart endocarditis.

Programmatic Changes to Reduce Mortality and Morbidity in Humanitarian Congenital Cardiac Surgery

Background: This report documents the outcomes of cardiac surgical mission trips organized by the International Childrens Heart Foundation (ICHF), a nongovernmental organization that provides congenital heart surgery services to the developing world, and discusses factors associated with a reduction of mortality and morbidity in this setting. Methods: A retrospective review of a prospectively maintained database was conducted to identify any patient who underwent surgical intervention during the course of an ICHF mission trip. Results: From 2008 to 2016, a total of 223 trips were made to 23 countries and 3,783 operations were performed. Over 40 unique types of operations were performed with repairs of atrial septal defects (ASDs; n = 479), ventricular septal defects (VSDs; n = 760), teratology of Fallot (n = 473), and ligation of patient ductus arteriosus (PDA; n = 242), comprising the majority of cases. Several organizational policy changes were instituted in 2015. These include the requirement of the host site to have a fully functional blood bank and access to medical subspecialties, the ICHF providing 24-hour intensivist coverage, and not performing surgery on patients weighing less than 10 kg until local capacity has been developed. The overall mortality rate fell to 2.3% from 8.1% after the implementation of these policies. The mortality for ASD repair, VSD repair, PDA ligation, and the repair of tetralogy of Fallot fell from 1.2% to 0%, 1.8% to 0%, 0% to 0%, and 5.6% to 5.1%, respectively. The reoperation rate fell from 11% to 3% and reoperation for a bleeding indication fell from 6% to 2%. Conclusions: Programmatic-level changes have been associated with reduced rates of mortality and morbidity in humanitarian congenital cardiac surgery.

The future is now: An endovascular option for type A aortic dissection

From the Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa. Disclosures: W.Y. Szeto is on the Consultant/Advisory Board for Micro Interventional Devices, Inc, and received research grants from Edwards Lifesciences Corp, Medtronic, Inc, LivaNova, and Bolton Medical. G J. Arnaoutakis has nothing to disclose with regard to commercial support. Received for publication Aug 15, 2016; accepted for publication Aug 15, 2016. Address for reprints: Wilson Y. Szeto, MD, Division of Cardiovascular Surgery, Penn Presbyterian Medical Center, University of Pennsylvania Medical Center, 51 N 39th St, Heart and Vascular Pavillion 2A, Philadelphia, PA 19104 (E-mail: wilson.szeto@uphs.upenn.edu). J Thorac Cardiovasc Surg 2016;-:1-2 0022-5223/

Endovascular approaches to the ascending aorta are right around the corner

36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.08.034

Achieving safe and expeditious distal limb perfusion in femoral venoarterial extracorporeal life support

Endovascular technology has revolutionized the surgical management for patients with descending thoracic aortic pathology.Overthelastdecade,therehasbeengrowinginterest in applying these technologies to treat various pathologies of the aortic arch and ascending aorta, primarily acute type A aortic dissection and ascending aortic pseudoaneurysm (AAP) (Figure 1). Several technical challenges remain, however. These include the complex anatomy of the aortic root; the close spatial relationships among the aortic root,

Hybrid aortic arch repair: The ultimate solution or a stop along the way to a total endovascular arch reconstruction?

ischemia than the previously used 8F to 10F cannulae. We believe that this small but adequate distal perfusion cannula allows for both forward flow and flow around the cannula into a potentially nonperfused area between the 2 cannulae. (5) Finally, we directly connect the side-arm of the distal perfusion cannula to the arterial return cannula, limiting the length of tubing between the 2 cannulae (Figure 1). We do not routinely perform open cannulation for access to the SFA or verify flow to the lower extremity via angiography. As stated in the article, this cohort of patients are often critically ill, are in cardiopulmonary shock, and have poor physiologic reserve. Therefore, we believe transport to the operating room for open cannulation and angiography may be imprudent. Furthermore, in our experience, open cannulation is associated with a significant risk of wound infection. With the percutaneous strategy proposed, our rate of ischemia is acceptably low and avoids the potential morbidity associated with transport to the operating room. We advocate bedside, ultrasound-guided, percutaneous cannulation of the SFA with a 6F wire-reinforced distal perfusion cannula.

The Impact of Deep Versus Moderate Hypothermia on Postoperative Kidney Function After Elective Aortic Hemiarch Repair

In their article in this issue of The Journal, Faure and colleagues 1 report their single-center experience with hybrid repair of chronic dissection-related aortic arch aneurysms. They combined aortic great vessel debranching with thoracic endovascular aortic repair to address the aortic arch pathology completely. In this series of 33 patients, there were no in-hospital deaths. At a respectable mean follow-up of 20 months, the overall mortality was 12% at last follow-up. Therewas a 24% incidence of endoleak overall, and 8 patients required some form of major reintervention, not all of which were for endoleak. Given this high-risk group of patients, Faure and colleagues 1 are to be commended on their excellent outcomes. Surgical treatments to address aortic arch pathology traditionally have involved open techniques of total arch replacement with circulatory arrest and reimplantation of the great arteries. Even in a high-risk patient population, excellent results can be achieved, and many centers continue to advocate this open surgical approach as the criterion standard. 2 The rapid expansion of thoracic endovascular technology in the past 15 years, however, is transforming traditional open repair paradigms. Furthermore, innovative hybrid repair approaches, such as those described by Faure and colleagues, 1 with a combination of open and endovascular techniques, have expanded the risk profile of patients and scope of aortic pathologies amenable to surgical therapies. 3-6 With continued evolution in this field, we need to reassess critically the current status of surgical options for treating aortic arch pathologies. It is also imperative that we seek collaborative approaches to studying aortic arch aneurysm