Peppino Pugliese

Risk of late reoperations in patients with acute type A aortic dissection : impact of a more radical surgical approach

OBJECTIVE To evaluate the incidence and risk factors for reoperations on the pre-isthmic aorta after repair of type A acute aortic dissection. METHODS From January 1979 to December 1996, 178 patients (125 males and 53 females with a mean age of 57 +/- 9 years) underwent emergency surgery for acute type A aortic dissection with an overall operative mortality rate of 21%. One hundred and forty-one patients (100 males and 41 females, aged 58 +/- 12 years), were discharged after successful replacement of the ascending aorta in 136 cases (96%) with extension to the transverse arch in 22 (16.2%) and associated total root or aortic valve replacement in 31 (22.8%) and 6 (4.4%) cases, respectively. Intimal tear resection and direct primary anastomosis of the aorta were performed in 5 patients (4%). Total follow-up was 690 patient-years, mean 5.1 +/- 4.1 years, with an actuarial survival rate at 5,10 and 15 years of 88%, 73% and 42%, respectively. RESULTS Nineteen patients (13%), 13 males and 6 females, aged 50 +/- 10 years, required a total of 22 reoperations with an actuarial freedom from reoperation at 5, 10 and 15 years of 94%, 64% and 35%, respectively. Initial repair consisted of replacement of the ascending aorta in 16 (84%) cases, with total root replacement in 2 (12%) and isolated aortic valve replacement in 1 (6%). Three patients (16%) were treated by intimal tear resection and direct primary anastomosis of the aorta. Mean interval between initial repair and reoperation was 5.2 +/- 3.1 years and indication to re-do surgery were severe aortic regurgitation in 2 (11%), aneurysmal evolution of the false lumen in 4 (21%) or both in 13 (68%). Extensive aortic reconstruction comprising simultaneous graft replacement of the aortic root, ascending aorta and aortic arch was necessary in 13 cases (68%), isolated replacement of the ascending aorta in 3 (16%), aortic valve in 2 (11%) and aortic arch in 1 (5%). There were 1 hospital (5%) and 2 late (11%) deaths at a mean follow-up of 2.5 +/- 2.4 years, with an actuarial survival at 5 years of 88%. Retrospective analysis of our total experience revealed that the introduction of the open distal anastomosis technique since 1990, reduced the incidence of reoperation from 11/46 (24%) to 8/95 (8.4%) (P < 0.05). However, also with this strategy 8/73 (11%) patients surviving replacement limited to the ascending aorta required reoperation versus none of the 22 patients surviving repair extended to the aortic arch. Three out of 5 (60%) patients undergoing intimal tear resection and primary anastomosis of the aorta early in our experience, required reoperation. CONCLUSIONS Management of patients with acute type A aortic dissection may include one or more surgical procedures after the initial emergency repair. Reoperations carry a low operative risk with good long-term survival and their incidence is reduced by routine open distal anastomosis and aggressive replacement of the aortic arch. Intimal tear resection and primary anastomosis of the aorta appear to be associated with increased risk of reoperation.

Preservation of the aortic valve in acute type A dissection complicated by aortic regurgitation

BACKGROUND The aim of the present study was to verify the efficacy of preserving the aortic valve in patients with acute type A aortic dissection complicated by significant aortic regurgitation. METHODS From January 1979 to December 1996, 178 patients (125 males; mean age 57 +/- 9 years) underwent emergency surgery for acute type A aortic dissection, with an overall operative mortality rate of 21%. Based on a retrospective analysis of the preoperative angio- or echocardiographic findings, the 141 survivors were divided into 2 groups: Group 1 (G1) included 80 patients (57%) with no or mild aortic regurgitation, and Group 2 (G2) the remaining 61 patients with moderate-to-severe aortic regurgitation. The native aortic valve was preserved by means of a uniform technique consisting of reconstruction of the aortic root and sinotubular junction in 99 patients (70%) [68 in G1 (85%) and 31 in G2 (51%)]. Forty-two patients required aortic valve (8 patients; 6%) or total root replacement (34 patients; 24%). RESULTS At a mean follow-up of 4 +/- 3.6 years (range, 6 months to 19 years), 19 of the 99 patients with a preserved aortic valve developed moderate-to-severe aortic insufficiency [19%; 7/68 in G1 (10%) and 12/31 in G2 (39%)]. Multivariate analysis revealed that moderate-to-severe preoperative aortic valve insufficiency was a significant risk factor for development of postoperative aortic valve regurgitation (p = 0.008). Reoperation was necessary in 7 G1 patients (10%) and in 8 G2 patients (26%), with an actuarial freedom from reoperation at 5 and 10 years of 93% +/- 7% and 80% +/- 9% in G1 patients, and 81% +/- 8% and 40% +/- 15% in G2 patients (p = 0.045). CONCLUSIONS Preservation of the aortic valve and aortic root is recommended in patients with acute type A aortic dissection and absent or mild aortic insufficiency. Patients presenting with moderate-to-severe aortic regurgitation and treated conservatively present an increased risk of recurrent valvular insufficiency.

Predictors of postoperative complications in high-risk octogenarians undergoing cardiac operations

BACKGROUND Cardiac operations in octogenarians are currently reserved for selected patients with severe symptoms and low extracardiac comorbidity; early and midterm results are satisfactory. We evaluated the outcome of high-risk octogenarians undergoing cardiac operations and investigated the predictors of postoperative complications. METHODS Between June 1998 and March 2001, 73 consecutive octogenarians (mean age = 83.1 +/- 3.0 years) hospitalized and awaiting operation in our Department were analyzed for postoperative complications. We recorded the main risk factors for cardiovascular disease, symptoms of heart failure, previous myocardial infarction, reoperation, left ventricular ejection fraction, use of intraaortic balloon pump, surgical priority, and operative risk. Cerebrovascular disease, peripheral vascular disease, chronic obstructive pulmonary disease, and renal failure were the preoperative extracardiac comorbidities considered. We adopted a multidisciplinary approach to perioperative management. RESULTS Surgical procedures included coronary artery bypass grafting in 36 patients (49.3%), valve procedures in 20 (27.4%), and combined coronary artery bypass grafting and valve procedures in 17 patients (23.3%). In-hospital death occurred in 6 patients (8.2%). Twenty-one patients (28.8%) had major postoperative complications including renal failure (15.1%), respiratory failure (8.2%), and myocardial infarction (8.2%). The main predictors of postoperative complications were New York Heart Association functional class IV, Canadian Cardiovascular Society angina class 4, and prolonged aortic cross-clamping time. CONCLUSIONS Cardiac operations can achieve satisfactory results even in high-risk octogenarians. Early surgical intervention before severe symptoms appear, and a multidisciplinary approach to perioperative management, may reduce postoperative complications.

Tricuspid valve repair with the Cosgrove-Edwards annuloplasty system: early clinical and echocardiographic results

BACKGROUND The use of flexible rings for tricuspid valve repair is becoming popular. The purpose of this study was to evaluate the Cosgrove-Edwards annuloplasty system for tricuspid regurgitation. METHODS From June 1998 to December 2000, 22 patients with significant secondary tricuspid regurgitation underwent tricuspid valve repair with the Cosgrove-Edwards annuloplasty system. All patients had disease of left-sided heart valves in addition to tricuspid disease; 34 concomitant procedures were performed. Twenty-one patients (95.5%) were in preoperative New York Heart Association functional class 3 or 4. The mean follow-up was 19.9 +/- 9.7 months. RESULTS There were two in-hospital nonvalve-related cardiac deaths (9.1%) and one noncardiac death after discharge (4.5%). All survivors were in New York Heart Association functional class 1 or 2; their tricuspid regurgitation was well controlled within grade 1+ and there was a significant reduction of systolic pulmonary artery pressure. Five (83.3%) of the 6 survivors with preoperative pulmonary hypertension had no or trivial residual tricuspid regurgitation. CONCLUSIONS The Cosgrove-Edwards annuloplasty system is very effective in the treatment of secondary tricuspid regurgitation, also in the presence of pulmonary hypertension.

The edge-to-edge technique as a trick to rescue an imperfect mitral valve repair

OBJECTIVE The edge-to-edge (E-to-E) technique in mitral valve repair (MVR) is promising especially to correct mitral insufficiency (MI) caused by complex mitral valve lesions. We tested this technique to improve residual MI straight after conventional MVR. METHODS From September 1998 to January 2002, 108 consecutive patients underwent MVR with current techniques for pure MI. Intraoperative transesophageal echocardiography was performed before and after MVR. At the end of cardiopulmonary bypass (CPB), 11 patients presented residual mitral regurgitant jet area (MRA) > or =2.0 cm(2). The E-to-E technique was used to improve this residual MI, without taking-down the original MVR. RESULTS There were no hospital deaths. One patient died of non-valve-related cardiac death about 6 months after hospital discharge. At intraoperative ecocardiography, residual MRA improved from 3.0 +/- 0.8 cm(2), after conventional MVR, to 0.7 +/- 0.9 cm(2), after the E-to-E technique (P = 0.00014). Additional CPB time of 14.9 +/- 2.8 min was needed. These echocardiographic results were confirmed at follow-up of 13.8 +/- 8.1 months. CONCLUSIONS The E-to-E technique is a simple, rapid, effective, and durable option to reduce residual MI and rescue an imperfect conventional MVR.

Posterior Enlargement of the Small Annulus during Aortic Valve Replacement versus Implantation of a Small Prosthesis

Twenty-two patients with a small aortic annulus were identified among 196 consecutive patients undergoing aortic valve replacement (AVR). The 11 patients in Group 1 underwent posterior enlargement aortic annuloplasty, and the 11 in Group 2 received a small aortic prosthesis (less than or equal to 21 mm). The two groups were unselected. Core hypothermia, cardioplegia, and local cooling were employed for all operations. Isolated AVR was performed in 3 patients in each group. In Group 1, the mean increase in diameter of the annulus was 4.82 mm, which resulted in a mean area increase of 169.91 mm2 (51.7%). Mean aortic cross-clamp times were 140.4 minutes and 93.5 minutes in Groups 1 and 2, respectively. There were 2 operative deaths in Group 1, and 1 operative and 1 late death in Group 2. Mean follow-up was 26.5 months for Group 1 and 43.4 months for Group 2. No thomboembolic or bleeding episodes have been recorded. Considerations and conclusions are offered from the study of this small series of patients.

Preliminary experience in mitral valve repair using the Cosgrove-Edwards annuloplasty ring.

There is a wide range of annuloplasty systems available now. However, controversy concerning the choice of annuloplasty device persists. We analyzed our preliminary experience in mitral valve repair using the Cosgrove-Edwards annuloplasty ring. To correct their mitral insufficiency (MI), 118 consecutive patients (mean age, 60.4+/-15.1 years) underwent mitral repair using this annuloplasty device. NYHA functional class 3 or 4 were present in 86.4%. Degenerative heart disease was the cause of MI in 36.6% of the patients, ischemic heart disease in 25.4%, Barlows disease in 17.8%, and idiopathic dilated cardiomyopathy in 7.6%. Mitral surgical procedures included quadrangular resection and sliding of the posterior leaflet, posterior leaflet decalcification, anterior leaflet repair, the edge-to-edge technique, and chordal repair. Mean follow-up was 25.1+/-14.0 months. There were four in-hospital non-valve-related cardiac deaths, and one in-hospital non-cardiac death. No cases of systolic anterior motion were observed. NYHA functional class improved from 3.3+/-0.7, before repair, to 1.3+/-0.6, at follow-up (P=0.00012), MI from 3.6+/-0.5 to 0.5+/-0.6 (P=0.0096), and left ventricular ejection fraction from 52.0+/-12.2% to 55.4+/-12.0% (P=0.044). Three-year actuarial rates of survival, freedom from thromboembolism, and freedom from mitral reoperation were 96.9, 97.9, and 96.4%, respectively. The Cosgrove-Edwards annuloplasty ring does not combine with systolic anterior motion. It minimizes MI secondary to all causes, and preserves left ventricular function.

Aortic valve replacement with the biocor PSB stentless xenograft

BACKGROUND The midterm clinical results after aortic valve replacement with the Biocor PSB stentless xenograft on all patients operated between October 1992 and October 1996 were reviewed. METHODS One hundred six patients, aged 70+/-6 years, had aortic valve replacement for aortic stenosis (67%), regurgitation (11%), or both (22%). Associated procedures were done in 49 patients (46%), including coronary artery bypass in 30 patients, mitral valve repair/replacement in 16, and ascending aorta replacement in 5 patients. Aortic cross-clamp and cardiopulmonary bypass times were 96+/-24 and 129+/-31 minutes, respectively. RESULTS There were 3 (3%) early deaths due to low output (2 patients) and cerebrovascular accident (1 patient). Follow-up of survivors ranged from 6 to 66 months (mean, 39+/-14 months). Survival was 94%+/-2% and 90%+/-3% at 1 and 5 years. There were 5 late deaths due to cardiac cause (2), cancer (2), and pulmonary embolism (1 patient). No patient had structural valve deterioration, whereas 100% and 95%+/-3% were free from valve-related events at 1 and 5 years. There were two reoperations due to narrowing of the left coronary ostium and endocarditis, with an actuarial freedom from reoperation of 99%+/-1% and 98+/-1% at 1 and 5 years, respectively. Functional results demonstrated a mean peak transprosthetic gradient of 16+/-12 mm Hg, with only 1 patient (1%) with a 55 mm Hg gradient. No cases of valve regurgitation greater than mild were recorded at follow-up. Assessment of New York Heart Association functional class demonstrated a significant improvement (2.9+/-0.6 versus 1.4+/-0.7; p=0.01). All patients were free from anticoagulation. CONCLUSIONS Aortic valve replacement using the Biocor PSB stentless xenograft offers excellent midterm survival, negligible valve deterioration, and a very low rate of valve-related events, which are comparable to estimates reported with other models of stentless xenografts and currently available stented xenografts. Hemodynamic performance is favorable and quality of life satisfactory.

Direct visualization of aorto-coronary bypass grafts by two-dimensional echocardiography: A new clinical application

An attempt was made to assess noninvasively the patency of aorto-coronary bypass grafts by two-dimensional echocardiography (2-D echo) in 21 patients who underwent myocardial revascularization. Fifteen patients had one graft while the other six had two grafts. All 21 patients underwent angiography 6–18 months after operation. A day before angiography a 2-D echo was performed with the aim of visualizing the bypass grafts. In 18 patients with 23 grafts (13 with 1 graft and 5 with 2 grafts) it was possible to visualize the tract of the graft, by 2-D echo; 16 were judged patent on 2-D echo and confirmed by selective angiography, while 5 grafts were considered occluded both on 2-D echo and angiography. The other 2 grafts were considered to be occluded on 2-D echo but angiographic control displayed their patency. In 3 patients 2-D echo failed to visualize grafts that were patent angiographically. These data must be considered preliminary and need validation in a larger number of patients. However it is reasonable to conclude that 2-D echo has a reliable capacity to predict graft patency. Such an application may be of value in sequential control of patients with aorto-coronary bypass surgery, especially when combined with other clinical and/or technical data.