M. Pasic

Reoperations after operation on the thoracic aorta: Etiology, surgical techniques, and prevention

Recurrent aortic aneurysms, persistent or new dissection, new onset of valvular and coronary artery disease, graft infection, and prosthetic endocarditis are not rare after thoracic aortic operations; they can be difficult to diagnose and represent a formidable surgical challenge. Between 1977 and 1991, 876 operations were performed on the thoracic aorta in our institution: 340 in dissections, 299 in true aneurysms, 150 for aortic remodeling and external wall support during aortic valve replacement, and 87 for miscellaneous causes. During the same period, there were 193 additional reoperations. Vascular reoperations on abdominal aorta and peripheral arteries accounted for 73 cases and are not further discussed in this study. The reasons for reoperation (n = 130) in 120 patients were: failure of biologic valves (n = 23); aneurysm recurrence in a proximal or distal aortic segment (n = 21); pseudoaneurysm formation at suture lines (n = 13); new dissection or dilatation involving ascending aorta (n = 11), aortic arch (n = 13), and descending aorta (n = 10); aneurysm after aortic remodeling (n = 13); new onset of valvular disease (n = 5); and new onset of coronary disease (n = 5). Infected aortic graft and prosthetic endocarditis accounted for 10 reoperations, and a planned two-staged procedure was performed in 6 patients. Omitting the failed biologic valves, reoperations were performed on the aortic segment previously operated on in 69.3% of the cases and on other thoracic segments in 30.7%. Overall hospital mortality rate after reoperation was 5.8%. A significant decrease in operative mortality was observed in the most recent period (3.0% between 1989 and 1991). Reoperations are technically demanding, and some of them are preventable; therefore (1) graft inclusion technique should be abandoned in ascending aortic operation due to formation of false aneurysms; (2) in patients with Marfan syndrome, complete repair of the diseased aorta should be attempted during the initial operation; (3) aortic arch dissection should be repaired definitively during the first operation in low-risk patients; (4) biological valves should be avoided in aneurysm operations; and (5) homograft replacement is the treatment of choice in prosthetic endocarditis or in infected composite graft after an aortic valve or ascending aortic operation.

Mycotic Aneurysm of the Abdominal Aorta: Extra-Anatomic versus in Situ Reconstruction

Between 1973 and 1991, 12 patients with mycotic aneurysm of the abdominal aorta underwent operation. There were four elective and eight emergency procedures. In situ reconstruction was performed in six patients and extra-anatomic reconstruction with axillobifemoral bypass grafting in six. The hospital mortality rate was 25% (three patients) and another three died during the follow-up period of mean 5.5 years. Descending aorta-bifemoral bypass was performed in two patients without signs of chronic local infection 1 and 2 years after previous axillobifemoral bypass. Late complications were peripheral embolization in one patient after in situ reconstruction and a total of five thromboses of the axillofemoral bypass in three patients. Extra-anatomic bypass grafting remains the method of choice for the majority of patients with mycotic aneurysm of the abdominal aorta. In situ reconstruction seems to be an appropriate procedure for a highly selected group of patients.

Treatment of mycotic aneurysm of the aorta and its branches: The location determines the operative technique

Twenty-seven patients with mycotic aneurysms of the aorta and its major branches were operated on between 1969 and 1991. There were 24 males and three females ranging in age from 6 to 84 years (mean age for adults 63 years). Sixteen of the 27 (59%) aneurysms were ruptured and in situ repair was undertaken in 20 (74%) patients. The mean follow-up was 5.8 years (range: 8 months to 16 years). Four patients (15%) died during the hospital stay and 23 survived. There were eight late deaths, two of which were a direct result of the aneurysm. The estimated 1- and 5-year survival rates were 62 and 36%, respectively. Extra-anatomic reconstruction is the method of choice for the majority of patients with mycotic aneurysm of the infrarenal abdominal aorta and iliac arteries. In situ repair after an extensive debridement of the aneurysmal wall and all infected tissue combined with antibiotic therapy is a satisfactory method of treating mycotic aneurysms of other locations, and for a highly selected group of patients with infrarenal mycotic aortic aneurysms.

Superior late patency of small-diameter dacron grafts seeded with omental microvascular cells: An experimental study☆☆☆

The purpose of the study was to investigate the effect of omental microvascular cell seeding on the patency of small-diameter Dacron prostheses usable for coronary artery bypass grafting. In a canine carotid artery model, each dog (n = 64) received one seeded and one similar nonseeded Dacron prosthesis (internal diameter = 4 or 6 mm). Enzymatically harvested omental microvascular cells (omentum = 27.6 +/- 5.9 g [+/- the standard deviation]; range, 17 to 50 g) were seeded prior to implantation. The seeding density was 1.91 +/- 0.26 [+/- the standard error] x 10(6) cells/cm2 of graft surface. Dipyridamole (75 mg/d) and acetylsalicylic acid (325 mg/d) were administered orally for 4 weeks postoperatively. The prostheses were explanted between 2 and 52 weeks after placement. The results were assessed by angiography; light, scanning electron, and transmission electron microscopy; and morphometry. The seeded grafts developed a uniform luminal monolayer of endothelial cells with minimal platelet or cellular deposition. These grafts also had a significantly higher overall patency rate and significantly larger thrombus-free surface areas than the nonseeded grafts. The overall actuarial patency rates at 1 week, 5, 12, 26, and 52 weeks were 100%, 98%, 93%, 93%, and 93%, respectively, for seeded Dacron grafts and 100%, 91%, 61%, 54%, and 18%, respectively, for nonseeded grafts. The patency rates of Dacron grafts usable for coronary artery bypass grafting are significantly improved by seeding with omental microvascular cells in a canine model.

Sternal cleft associated with vascular anomalies and micrognathia

Sternal defects combined with craniofacial vascular defects are rare. We report on a 45-year-old woman with a sternal cleft associated with craniofacial and brain hemangiomata, an aneurysm of the aortic arch, anomalous origin of the coronary arteries, a left superior vena cava, micrognathia, supraumbilical midline raphe, and a cervical cyst. The surgical procedure consisted of the resection and replacement of the aortic arch and the innominate artery with reimplantation of the left carotid artery into the graft under circulatory arrest and deep hypothermia. The presence of sternal cleft is an indication for the search for other asymptomatic internal vascular anomalies.

Should cardiac transplantation for congenital heart disease be delayed until adult age

The number of pediatric heart transplantations for complex congenital heart disease has increased over the last years, but little experience has been reported in adolescent and adult populations. Between 1987 and 1992, 14 patients (mean age 33.2 years, range 14 to 51 years) were transplanted in our institution because of structural congenital heart disease (n = 9) or other rare disorders of the endomyocardial morphogenesis (n = 5). The main diagnosis included transposition of the great arteries, congenitally corrected transposition of the great vessels, left superior vena cava, tricuspid atresia with right ventricular hypoplasia, double outlet right ventricle with transposition, left ventricular sinusoidal malformation and right ventricular dysplasia. In several cases there were additional intracardiac malformations, including ventricular septum defect, atrial septum defect as well as different forms of pulmonary stenosis. Seven patients had undergone one or more palliative repairs that consisted of modified Blalock-Taussig shunts, Glenns cavopulmonary anastomosis, Waterstone shunt, Blalock-Hanlon atrioseptectomy and Brock pulmonary valvotomy. Two patients had undergone Senning procedure for transposition of the great arteries. The donor cardiectomy was modified in order to include complete inflow and outflow tissue in the explant and transplantation could be performed without prosthetic material in all patients; deep hypothermic cardiac arrest was never necessary in this series. There was no early or late mortality after a mean follow-up of 37 months (range 4 to 74 months); postoperative echocardiography and cardiac catheterization demonstrated perfect anatomical and functional results in all patients. Adolescent and adult patients with complex congenital cardiac diseases can be transplanted with a very low perioperative risk, even after several prior operative procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Simultaneous revascularization for critical coronary and peripheral vascular ischemia

Patients with coronary artery disease can exhibit substantial vascular involvement, and patients with vascular disease have a high incidence of coronary disease. Simultaneous coronary artery bypass grafting and treatment of vascular disease was performed in 32 patients with strong indications for surgical treatment of coronary artery disease and critical peripheral vascular ischemia operated on from 1980 until 1990. Overall hospital mortality was 3.1%; 1 patient died of myocardial infarction 2 days after urgent combined revascularization because of unstable angina pectoris and subacute occlusion of the aortoiliac bifurcation. Early mortality was 0% in patients undergoing elective operations. Eight-year actuarial survival was 87.5%. Combined procedures can be performed with acceptable risk and with encouraging long-term results in this special group of patients; they may improve prognosis in patients with diffuse atherosclerosis.

Retrograde ascending aortic dissection: a diagnostic and therapeutic challenge.

Aortic dissection with an entrance tear in the transverse aorta is generally considered to have the highest acute fatality rate of any type of dissection and the direction of its extension is the most difficult to predict. In a prospective study, we evaluated 61 consecutive patients (mean age 56.7 years, ranging from 21 to 75 years), presenting with ascending aortic dissection during a 36-month-period and tried to clarify the incidence of retrograde ascending aortic dissection. In 49 patients (80.3%), the intimal tear was located in the ascending aorta, whereas the dissection originated in the transverse aorta in 12 patients (19.7%); in this latter group, extension was strictly retrograde in 5 patients and in both directions in 7 patients. Three patients died before operation; 58 patients underwent aortic replacement/repair under moderate hypothermia; if the primary tear extended into the transverse aorta or was not found in the ascending aorta, the aortic arch was explored during a brief period of deep hypothermic circulatory arrest. The overall operative mortality was 12.1% (7/58); it was 10.4% (5/48) in ascending aortic dissection and 20% (2/10) in dissection of the transverse aorta. Age (P < 0.005), concomitant coronary artery disease (P < 0.01) and the site of intimal tear (P < 0.01) were significant predictive factors of operative risk. A tear in the transverse aorta is almost always associated with retrograde dissection and may simulate dissection with the entrance tear in the ascending aorta. Localization of the entrance tear remains a diagnostic challenge in aortic dissection but Doppler-echocardiography had a high sensitivity in this series (96.7%).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of cardiovascular complications in Marfan syndrome: a 27-year experience.

Fifty-two patients with Marfan syndrome and ascending aortic pathology were treated surgically between 1964 and 1990. The indication for primary operation was true aneurysm of the ascending aorta with or without aortic insufficiency in 35 patients (67%) and dissection in 17 (33%). Composite grafts were used in 28 patients (54%; group I) and other procedures on the ascending aorta in 24 patients (46%; group II). The latter included supracoronary graft replacement with or without aortic valve replacement or reconstruction (n = 13), and reconstruction of the ascending aorta with or without aortic valve replacement (n = 11). Composite graft insertion was combined with mitral valve surgery at the same operation in 3 patients (6%). The early mortality after primary operations was 7.7% (4 deaths) and the late mortality was 27% (14 deaths). Eight late deaths were related to cardiovascular complications. The mean follow-up was 6.7 years (range 1-27 years). The actuarial 5-, 10-, and 15-year survival rates for all patients were 82%, 63%, and 44%, respectively; for group I (composite grafts) they were 87%, 76%, and 57%; and for group II (other types of operations) they were 73%, 53%, and 37%. The incidence of late complications was much higher in group II than in group I (50% vs. 16%). At 5 and 10 years, the actuarial rates of freedom from late complications related to the primary operation were 88% and 80%, respectively, in group I and 65% and 18% in group II. Composite graft insertion is the operation of choice when approaching the ascending aorta and/or aortic valve in Marfan syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic homograft and mitral valve repair in a patient with Werner's syndrome

We report the case of a 66-year-old man suffering from Werners syndrome (adult progeria); he presented with several cardiac disorders, including coronary artery disease, aortic stenosis, and mitral regurgitation, mainly due to calcific deposits in the mitral annulus and the aortic cusps. Treatment consisted of mitral repair, homograft replacement of the aortic valve, and coronary artery bypass grafting. Avoidance of prosthetic material because of chronic infectious skin ulcers constituted the main goal of the operation.