Monica Munjal

Open repair of ruptured descending thoracic and thoracoabdominal aortic aneurysms

OBJECTIVE To evaluate the results of the open repair of ruptured thoracic and thoracoabdominal aortic aneurysms. METHODS From January 1997, a total of 100 consecutive open repairs of ruptured thoracic or thoracoabdominal aortic aneurysms were performed (43 thoracic and 57 thoracoabdominal). These patients were compared with contemporary cases that underwent repair of corresponding intact aneurysms. Propensity matching analysis was used to neutralize the differences in baseline characteristics. RESULTS Patients with ruptured aneurysm had a significantly worse baseline clinical profile. The surgical strategy adopted was similar in intact and ruptured aneurysms, with the exception of lower use of spinal drainage, intercostal reimplantation, and associated procedures in those with rupture (P < .001 for all comparisons). In the unmatched population, in-hospital mortality was 14% in the rupture group, and 4.2% in the intact group (P = .01). The incidence of postoperative myocardial infarction, need for tracheostomy, and need for dialysis was 3%, 19%, and 11% in the rupture, and 0.8%, 5.7%, and 4.2% in the intact series (P ≤ .01 for all variables). Five-year survival was 47.5% for the rupture, and 59.5% for the intact series (P < .001). In the matched population, no differences in postoperative and long-term outcome were found between the rupture and intact cases. Logistic regression analysis showed that female gender, urgent/emergent operation, and preoperative hemodialysis, but not ruptured aneurysm, were predictive of in-hospital major adverse events. CONCLUSIONS Open repair of ruptured thoracic and thoracoabdominal aortic aneurysms can be performed with a gratifying rate of success. For patients with similar preoperative comorbidities, postoperative survival is not affected by the presence of a ruptured aneurysm.

Outcomes of Open Repair of Mycotic Descending Thoracic and Thoracoabdominal Aortic Aneurysms

BACKGROUND The purpose of this study was to evaluate the short- and intermediate-term outcomes of open repair of mycotic thoracic and thoracoabdominal aneurysms. Contemporary surgical and perioperative techniques were utilized. METHODS From November 1997 to May 2014, 14 consecutive patients underwent open repair of descending thoracic (n = 9, 64.3%) and thoracoabdominal (n = 5, 35.7%) mycotic aortic aneurysms. All procedures were performed through the left side of the chest. Infected tissue was completely debrided and excised. Aortic continuity was restored in situ with a Dacron prosthesis (Macquet Corp, Oakland, NJ). Soft tissue coverage of the prosthesis was performed when anatomy and patient condition permitted. Perioperative outcomes, intermediate-term survival, and reinfection rates were examined. RESULTS All patients presented with either aneurysm-related symptoms or a clinical picture of sepsis. Diagnosis was confirmed utilizing computed tomography imaging. Mean age was 66 ± 13 years, 8 patients (57.1%) were male, and mean aneurysm size was 5.9 ± 1.3 cm. All patients were hypertensive, 3 (21.4%) had prior coronary revascularization, 7 (50%) had chronic pulmonary disease, 5 (35.7%) had diabetes mellitus, and 2 (14.3%) had end-stage renal disease requiring dialysis. Twelve patients (85.7%) had aneurysm-related pain, and 9 (64.3%) of them had contained rupture. Mean time from onset of illness to surgery was 36 days (range, 0 to 153). On preoperative blood cultures, 4 (28.6%) grew Staphylococcus aureus, 4 (28.6%) grew gram negative organisms, 2 (14.3%) grew mycobacterium, and 4 cultures (28.6%) had negative results. Empiric broad-spectrum antibiotics were initiated on all patients and adjusted based on final cultures. A majority of patients underwent repair utilizing a clamp-and-sew technique (n = 10, 71.4%); the remainder (n = 4, 28.6%) required repair under profound hypothermic circulatory arrest. After radical debridement of the infected tissue, grafts were placed in the normal anatomic position; 6 (42.9%) patients had additional soft tissue coverage, 5 (35.7%) utilizing an omental flap and 1 (7.1%), a serratus muscle flap. There was 1 in-hospital death (7.1%) secondary to ischemic bowel. Four patients (28.6%) required tracheostomy, and 1 (7.1%) had recurrent nerve injury. None of the patients incurred spinal cord injury, stroke, or new onset renal failure requiring dialysis. After surgery, all patients were given 6 weeks of intravenous antibiotics. Lifelong suppression therapy was maintained with oral antibiotics. There were no episodes of prosthetic graft infection on follow-up. Univariate analysis revealed that New York Heart Association functional class, diabetes, and preoperative renal dysfunction were preoperative risk factors for major adverse events. Mean follow-up time was 26.5 months (median 8.2; range, 1 to 142). Actuarial 5-year survival was 71%. CONCLUSIONS Open repair of mycotic descending thoracic and thoracoabdominal aortic aneurysms remains the gold standard of therapy. Aggressive intraoperative debridement with in situ prosthetic reconstruction permits a high rate of success in this very high risk cohort of patients. Lifelong antibiotic suppression therapy may prevent late prosthetic graft infection.

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.

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.

Aortic symmetry index: Initial validation of a novel preoperative predictor of recurrent aortic insufficiency after valve-sparing aortic root reconstruction

From the Departments of Cardiothoracic Surgery and Anesthesiology, and Greenberg Division of Cardiology, Weill Cornell Medicine, New York, NY; and 3D and Computer Simulation Laboratory, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy. Disclosures: Authors have nothing to disclose with regard to commercial support. Drs Di Franco and Rong contributed equally to this article. Received for publication March 22, 2018; revisions received April 22, 2018; accepted for publication May 1, 2018; available ahead of print June 27, 2018. Address for reprints: Antonino Di Franco, MD, Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065 (E-mail: and2052@med.cornell.edu). J Thorac Cardiovasc Surg 2018;156:1393-4 0022-5223/

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

36.00 Copyright 2018 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2018.05.047 Schematic representation and mathematical formulas for aortic symmetry index.

Systematic bilateral internal mammary artery grafting: lessons learned from the CATHolic University EXtensive BIMA Grafting Study

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.

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

OBJECTIVES Despite claims of feasibility, to date no study has examined the effect of systematic bilateral internal mammary artery (BIMA) use in a large cohort of real-world unselected patients. The CATHolic University EXtensive BIMA Grafting Study (CATHEXIS) registry was designed to assess the feasibility and safety of systematic BIMA grafting. METHODS The CATHEXIS was a single-centre, prospective, observational, propensity-matched study. The study was supposed to include 2 arms of 500 patients each: a prospective arm and a retrospective arm. The prospective arm included almost all patients referred for coronary artery bypass grafting (CABG) at our institution after the start of the CATHEXIS with very few exceptions. BIMA would have been used in all these patients. The retrospective arm included patients submitted to CABG before the start of the CATHEXIS and propensity matched to the prospective group (average BIMA use 50%; the radial artery was extensively used). Safety analyses were scheduled after enrolment of 200, 300 and 400 BIMA patients. RESULTS After the first 226 patients, the BIMA use percentage was 88.5% (200 of 226). In 178 (89%) patients, mammary arteries were used as Y graft. Postoperative mortality was 2%, and incidence of perioperative myocardial infarction, graft failure and sternal complications were 3.5%, 3% and 5.5%, respectively. No perioperative stroke occurred. The incidence of major adverse cardiac events (particularly graft failure and sternal complications) in the BIMA arm were significantly higher than those in the propensity-matched cohort; the study was stopped for safety. CONCLUSIONS In a real world setting the systematic use of BIMA was associated with a higher incidence of perioperative adverse events (particularly sternal complications). Individualization of the revascularization strategy and use of alternative arterial conduits are probably preferable to systematic use of BIMA.

Reoperative repair of descending thoracic and thoracoabdominal aneurysms

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 Aortic Valve Replacement in a Previous Biologic Composite Valve Graft.

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.