Ivancarmine Gambardella

Impact of preoperative pulmonary function on outcomes after open repair of descending and thoracoabdominal aortic aneurysms

Objective: To evaluate the impact of preoperative pulmonary function on outcomes after open repair of descending thoracic (DTA) and thoracoabdominal aortic (TAAA) aneurysms. Methods: The outcomes of patients undergoing open repair of DTA or TAAA were analyzed in relation to the results of preoperative pulmonary function tests. Receiver operating characteristic was adopted to assess the effect of forced expiratory volume in one second (FEV1) on the incidence of mortality. Logistic regression analysis and propensity score matching were used. Results: Between 1997 and 2015, 726 patients underwent open DTA or TAAA repair. Pulmonary function tests were available in 711 (97.9%). Receiver operating characteristic analysis revealed the cutoff value of FEV1 to be 50%. Propensity score matching led to 149 pairs of patients with FEV1 below and above 50% with only limited residual imbalance. In the matched population operative mortality was 11.4% and 6.0% in patients with FEV1 ≤ 50% and FEV1 ≥ 51%, respectively (P = .10). The incidence of major adverse events was 33.1% in cases with FEV1 ≤ 50% and 19.5% in those with FEV1 ≥ 51% (P = .008). FEV1 ≤ 50% was associated with a 6.99× increase in the risk of major postoperative adverse events at logistic regression analysis. Conclusions: Preoperative FEV1 < 50% is strongly predictive of increased respiratory failure, tracheostomy, and operative mortality in patients undergoing open DTA/TAAA repair. For these very high‐risk patients with either extensive TAAAs or anatomy unsuitable for endovascular repair, medical therapy may offer the best long‐term survival.

Surgical Treatment of Renal Cell Carcinoma With Cavoatrial Involvement: A Systematic Review of the Literature

The treatment of renal cell carcinoma (RCC) with cavoatrial involvement represents a major surgical challenge. To date, many surgical strategies have been proposed. However, general agreement on the best approach does not yet exist. Deep hypothermic circulatory arrest (DHCA) is the most commonly used method and allows complete tumor resection without increasing operative risk. Cardiopulmonary bypass (CPB) without circulatory arrest and methods using no CBP were also proposed, without a clear evidence of superiority of 1 technique over the others. Further studies are needed to evaluate the possible role of alternative techniques compared with deep hypothermic circulatory arrest.

Open repair of descending thoracic and thoracoabdominal aortic aneurysms in patients with preoperative renal failure

OBJECTIVES To evaluate surgical outcomes in open repair of thoracoabdominal aortic (TAAA) and descending thoracic aortic aneurysms (DTA) in patients with preoperative renal failure (PRF). METHODS Our database was examined for all patients undergoing open TAAA/DTA repair. Patients with a creatinine greater than or equal to 1.5 gm/dl or on haemodialysis were defined as having PRF and were compared to those having normal preoperative renal function. Logistic and Cox regression analysis were used to identify independent determinants of in-hospital outcomes and long-term survival. RESULTS From 1997 to 2015, 711 patients underwent open TAAA/DTA repair. Two hundred and two were categorized as having PRF, of which, 22 where on preoperative haemodialysis. PRF patients had significantly worse comorbidities; smoking (95.5% vs 69.0%; P  < 0.001), chronic pulmonary disease (65.8% vs 29.7%; P  < 0.001), peripheral vascular disease (44.1% vs 19.4%; P  < 0.001) and diabetes (16.3% vs 6.7%; vs P  < 0.001). Operative mortality (OM) was seven-times higher in patients with PRF (14.2 vs 2.2%; P  < 0.001). Logistic regression analysis showed that PRF was a predictor of OM [odds ratio (OR): 4.91; confidence interval (CI): 2.01-11.97; P  < 0.001] and major adverse events (OR: 2.05; CI: 1.21-3.46; P  = 0.007). Kaplan-Meier 5-years survival was significantly lower in PRF patients (45.0% vs 69.8%; P  < 0.001). CONCLUSIONS PRF predicts higher OM and major adverse events incidence following open TAAA/DTA repair. Long-term survival is negatively impacted. Strategies for improving preoperative and intraoperative renal function may lead to better outcomes.

Implantation of a Poly-L-Lactide GCSF-Functionalized Scaffold in a Model of Chronic Myocardial Infarction.

A previously developed poly-l-lactide scaffold releasing granulocyte colony-stimulating factor (PLLA/GCSF) was tested in a rabbit chronic model of myocardial infarction (MI) as a ventricular patch. Control groups were constituted by healthy, chronic MI and nonfunctionalized PLLA scaffold. PLLA-based electrospun scaffold efficiently integrated into a chronic infarcted myocardium. Functionalization of the biopolymer with GCSF led to increased fibroblast-like vimentin-positive cellular colonization and reduced inflammatory cell infiltration within the micrometric fiber mesh in comparison to nonfunctionalized scaffold; PLLA/GCSF polymer induced an angiogenetic process with a statistically significant increase in the number of neovessels compared to the nonfunctionalized scaffold; PLLA/GCSF implanted at the infarcted zone induced a reorganization of the ECM architecture leading to connective tissue deposition and scar remodeling. These findings were coupled with a reduction in end-systolic and end-diastolic volumes, indicating a preventive effect of the scaffold on ventricular dilation, and an improvement in cardiac performance.

The role of neo‐sinus reconstruction in aortic valve‐sparing surgery

The aim of this study was to evaluate the clinical and echocardiographic results and the predictors of outcomes in patients undergoing valve‐sparing operation (VSO) at two aortic centers. In addition, we sought to evaluate the potential effect of recreation of the sinuses of Valsalva (SV) on the outcome of valve‐sparing procedures.

Long Term Outcome of Cryopreserved Allograft for Aortic Valve Replacement

Objective The most efficient surgical approach to severe aortic valve disease in the young adult is still debated: cryopreserved aortic allograft offers excellent hemodynamic and avoid anticoagulation, but long‐term durability is influenced by structural valve deterioration (SVD). This study aimed to describe long‐term results of aortic allografts and to identify factors influencing long‐term durability. Methods From January 1993 to August 2010, 210 patients underwent aortic allograft replacement via the free‐hand subcoronary implantation technique (N = 55) or root replacement with coronary reimplantation (N = 155). Clinic and echocardiographic follow‐up was updated to April 2016. Results Overall mortality and cardiac mortality occurred in 80 (38.1%) and 64 (30.5%) patients, respectively. Reoperation was required in 69 cases (32.8%), whereas SVD required reoperation in 57 cases (27.1%). No early endocarditis occurred, whereas late endocarditis occurred in 4 patients. The free‐hand technique seems to be associated with improved left ventricular remodeling compared with the root‐replacement technique, and smaller allograft size represents a predictor of reoperation independently on the surgical technique used. In the overall population, there were 44 women of childbearing age, and 37 patients remained pregnant during the follow‐up of the study. No differences were found in the clinical outcomes among women who had children and who did not. Conclusions Cryopreserved allograft is a valid option, especially in complex infective endocarditis and in women of childbearing age. A careful choice of allograft size and implantation technique can reduce the risk of SVD.

Early clinical outcome after aortic root replacement using a biological composite valved graft with and without neo-sinuses

OBJECTIVES: This study was conceived to compare the results of aortic root replacement using a composite biological valved graft with or without neo-sinuses of Valsalva. METHODS: We compared the early clinical outcomes of 421 patients who underwent aortic root replacement using a handmade biological composite valved graft with or without neo-sinuses (198 and 223 patients, respectively). Propensity matching based on the most important preoperative clinical variables resulted in a cohort of 210 patients (105 pairs) with comparable baseline variables. RESULTS: No difference in early clinical outcome was found between the unmatched groups. At a mean follow-up of 28.8 months, 11 patients required reoperation on the aortic valve (2.6%). Seven of the cases of reoperation were in the group without neo-sinuses (P = 0.83). In the propensity-matched groups, the type of graft used did not affect early and late clinical outcome and incidence of reoperations. CONCLUSIONS: The early clinical outcome of patients submitted to aortic root replacement using a handmade biological composite valved graft is equally good in the presence and in the absence of neo-sinuses.

Secondary Open Aortic Procedure Following Thoracic Endovascular Aortic Repair: Meta‐Analytic State of the Art

Background Thoracic endovascular aortic repair is characterized by a substantial need for reintervention. Secondary open aortic procedure becomes necessary when further endoluminal options are exhausted. This synopsis and quantitative analysis of available evidence aims to overcome the limitations of institutional cohort reports on secondary open aortic procedure. Methods and Results Electronic databases were searched from 1994 to the present date with a prospectively registered protocol. Pooled quantification of pre/intraoperative variables, and proportional meta‐analysis with random effect model of early and midterm outcomes were performed. Subgroup analysis was conducted for patients who had early mortality. Fifteen studies were elected for final analysis, encompassing 330 patients. The following values are expressed as “pooled mean, 95% confidence interval.” Type B dissection was the most common pathology at index thoracic endovascular aortic repair (51.2%, 44.4–57.9). The most frequent indication for secondary open aortic procedure was endoleak (39.7%, 34.6–45.1). More than half of patients had surgery on the descending aorta (51.2%, 45.8–56.6), and one fourth on the arch (25.2%, 20.8–30.1). Operative mortality was 10.6% (7.4–14.9). Neurological morbidity was substantial between stroke (5.1%, 2.8–9.1) and paraplegia (8.3%, 5.2–13.1). At 2‐year follow‐up, mortality (20.4%, 11.5–33.5) and aortic adverse event (aortic death 7.7%, 4.3–13.3, tertiary aortic open procedure 7.4%, 4.0–13.2) were not negligible. Conclusions In the secondary open aortic procedure population, type B dissection was both the most common pathology and the one associated with the lowest early mortality, whereas aortic infection and extra‐anatomical bypass were associated with the most ominous prognosis.

Biological solutions to aortic root replacement: valve-sparing versus bioprosthetic conduit‡

OBJECTIVES Valve-sparing operations and root replacement with a biologic composite conduit are viable options in aortic root aneurysm. This study was conceived to compare the early and mid-term results of these 2 procedures. METHODS From September 2002 to November 2015, 749 consecutive patients underwent either a valve-sparing operation or a root replacement with a biologic composite conduit at 2 institutions. Propensity score matching was used to compare similar cohorts of patients in the overall population and in the ≤ 55 and ≥ 65-year age groups. RESULTS Overall operative mortality was 0.4%, mean age 57.4 ± 14.3 years, 84.6% were male. Individuals in the biologic composite conduit group were older and had worse preoperative risk profiles [chronic pulmonary disease (5.5% vs 0.9%; P  = 0.001), diabetes (6.4% vs 1.5%; P  = 0.001) and NYHA > 2 (25.2% vs 5.2%; P  < 0.001)]. Mean follow-up was 27.5 ± 28.4 months. In the unmatched population, there was no difference in in-hospital deaths (0 in the valve-sparing versus 3 in the biologic composite conduit group; P  = 0.12). These findings were confirmed in the propensity-matched populations. During follow-up, more patients in the biologic composite conduit group underwent reoperation on the aortic valve (2.6% vs 1.5%; P  = 0.026) resulting in a freedom from reoperation of 97.4% vs 98.5%, respectively. Separate analysis for patients stratified by age revealed no difference in outcomes. CONCLUSIONS In case of aortic root aneurysm, both valve-sparing operations and root replacement with a biologic composite conduit provide excellent outcomes. However, at mid-term follow-up the use of biologic composite conduit is associated with a higher risk of reoperation.

Reoperative repair of descending thoracic and thoracoabdominal aneurysms

OBJECTIVES To evaluate the results of reoperation on descending thoracic and thoracoabdominal aneurysms. METHODS Sixty‐nine consecutive patients undergoing reoperative aneurysm repair (20 descending thoracic and 49 thoracoabdominal) were compared to 602 contemporary primary repairs. Propensity matching was used to reduce observable differences in preoperative characteristics. RESULTS The reoperation group was younger (60.2 vs 65.3 years, P = 0.005) and less were extent I or II (28.6% vs 76%, P < 0.001). In the reoperation group, 82.6% were repaired with clamp‐and‐sew, 14.5% circulatory arrest and 2.9% partial bypass versus the primary surgery group 62.1%, 8.1% and 29.7%, respectively (P < 0.001). In the reoperation versus primary surgery group, respectively, spinal drainage was used in 73.9% vs 83.7% (P = 0.05), intercostal reimplantation in 11.6% vs 44.2% (P < 0.001), and cold renal perfusion in 36.2% vs 19.8% (P = 0.001). Operative mortality was comparable (8.7% vs 5.3% primary, P = 0.25) but the reoperative extent I subgroup had higher mortality (20% vs 3.1%; P = 0.04). Incidence of major complications was comparable (stroke 0 vs 0.9%, tracheostomy 5.8% vs 8%, renal failure 7.2% vs 5%, spinal cord injury 4.3% vs 2.7%; P > 0.05 for all variables), with the exception of myocardial infarction (2.9% vs 0.5%, P = 0.028). Five‐year survival was 57.6% in reoperations and 58% in the primary surgery group (P = 0.878). No differences in the in‐hospital and follow‐up outcomes were found in the propensity matched comparison. CONCLUSIONS Reoperative repair of descending thoracic and thoracoabdominal aneurysms can be safely performed with reasonable in‐hospital and follow‐up outcomes compared to primary aneurysm repair.