Roberto Gaeta

Aortic Valve Infective Endocarditis: Could Multi-Detector CT Scan Be Proposed for Routine Screening of Concomitant Coronary Artery Disease Before Surgery?

Usefulness of the coronary artery study has been questioned in patients with infective valve endocarditis. Fatal events are reported in the literature due to embolization of endocarditic vegetations during cardiac catheterization. For this reason, many authors do not recommend preoperative invasive coronary studies in these patients. We report the case of a 56-year-old patient with prosthetic valve endocarditis with vegetations, and concomitant risk factors for coronary disease. We did preoperative coronary screening using multi-detector computed tomographic scan imaging, which may be useful for noninvasive imaging of the coronary arteries in these patients with high risk of embolization.

Type A aortic dissection involving the carotid arteries: carotid stenting during open aortic arch surgery

Aortic dissection involving the arch can be complicated by extension to the supra-aortic branches. Carotid dissection may be symptomatic or asymptomatic at the time of surgery. Dissection or re-dissection of repaired carotid may happen later, with symptoms occurring days after the surgical repair, increasing the morbidity and mortality of those patients. We report a case of a patient with type A aortic dissection involving the aortic arch and extending to the supra-aortic branches. During surgery the dissection was seen extending to the distal carotid arteries with tears in the inner wall. After use of surgical glue as a sealant, seeing the persistent fragility and the presence of spiral form tears in the internal wall of the carotid arteries, intraoperative stenting of the common carotid arteries was performed using two stents to prevent carotid re-dissection and ischemic stroke in the postoperative period. In patients with aortic dissection and extension into the carotid arteries, especially with presence of tears of the inner wall, after use of a glue as a sealant of the two dissected layers, if the repaired artery wall results are still fragile, use of intraoperative carotid stenting may be of help in preventing late re-dissection.

Surgical approach for isolated aortic valve replacement with patent coronary grafts

We read with interest the paper of Khaladj and co-workers [1]. The authors performed AVR through redo full sternotomy on 39 patients with still patent coronary grafts (30 LIMA grafts). On the basis of their results the authors showed that high risk patients can be operated with lower risk than anticipated by EuroSCORE risk stratification. They conclude that: ‘old fashioned surgical approach should still be considered the gold standard of treatment for high risk AVR’. We would like to analyse two aspects:

Surgery After “Full-Metal Jacket”: A Dangerous Pathway

I read with interest the papers by both Mataro and colleagues [1] and Demirsoy and associates [2] about coronary bypass grafting to a full-metal jacket left anterior descending coronary artery. I, as many others, face this peculiar aspect of myocardial revascularization [3]. It is difficult to make an absolute statement about any of the described surgical options [1, 2]. In my opinion, the proper surgical technique has to be chosen according to a precise anatomic pattern. It is not unusual to get some piece of information about the condition of the lumen and wall beyond the coronary occlusion only at surgery, after opening the artery. A proper policy could be to perform either “stentectomy” (open endarterectomy and stent removal) plus grafting or grafting alone according to the lumen size and the wall status. Doing only a graft in the presence of an almost totally covered left anterior descending coronary artery may be not convenient. Leaving a segment of stented wall beyond the anastomotic site may jeopardize the long-term graft function. In this case it could be safer to do a stentectomy plus a graft instead of just a graft. Grafting only could be a reasonable alternative providing the stented area is well above the anastomotic site, the coronary bed beyond the occluded area is not grossly affected, and the lumen size is bigger than 1.0 mm. Maybe the most important issue is trying not to get into this kind of trouble. A good practical warning given by the heart team could be not to keep stenting a left anterior descending coronary artery that does not want to stay open. Any attempt may result in an exercise of wishful thinking. The full-metal jacket approach could be considered a good example ofmedical obstinacy, and the cardiologistmust know that the fate of a multiple-stented left anterior descending coronary arterymay be poor [4]. Both surgical options should be considered as rescue therapy having probably suboptimal long-term results.

Open aortic arch surgery: how to reduce air embolism risk during antegrade cerebral perfusion

Antegrade cerebral perfusion (ACP) is used widely, with the aim of obtaining cerebral protection during open aortic arch surgery. ACP is considered by many to be the reason for improvements in the clinical outcome of this type of surgery. However, perioperative cerebral complications may still occur. Cerebral complications during ACP are considered to be due mainly to embolic events rather than hypoperfusion. We believe that many of the embolic events during ACP may be due to air embolism rather than to vessel manipulation only. To reduce the risk of air embolism during ACP, we propose an easy technique, with the suggested steps to be followed in an exact sequence.

Obstruction of the right coronary artery ostium due to acute aortic dissection

Acute aortic dissection presents with a wide range of manifestations and it is frequently confused with acute coronary syndrome, leading to delayed diagnosis and inappropriate treatment. A high clinical index of suspicion is necessary. Longstanding arterial hypertension, elevated D-dimer levels and new onset atypical chest pain can help the clinician to perform a difficult differential diagnosis. We present a case of acute aortic dissection in a 68-year-old Italian woman with longstanding arterial hypertension, unknown ascending aortic aneurysm, normal D-dimer levels, new onset atypical chest pain and electrocardiographic images mimicking acute coronary syndrome. Also this case focuses attention on the importance of a correct evaluation of new onset chest pain.

Simultaneous Carotid Artery Stenting Combined With Open Heart Surgery: Another Indication

M IS C E L L A N E O U S the constitutions of recurrence between patients with and without a solid component, and the recurrence sites of the two groups showed no significant difference (p 1⁄4 0.923). Besides, the mean sizes of the primary tumors that recurred in different sites are listed in Table 2, and none of them was significantly larger. Second, we do not think that a retrospective study can determine the tumor size limit for adjuvant chemotherapy. It is randomized controlled trials that play the role of determination. Tumor size has been paid more attention to these years. On the basis of a new database, the International Association for the Study of Lung Cancer proposed the eighth edition of the TNM staging system of lung cancer in November 2014 [3]. The tumor size was classified in increments of 1 centimeter, which meant that more subgroups would be created in subsequent trials. Last, induction therapy is not recommended in any guideline for adenocarcinoma IB because there has been no evidence. However, Mouillet and colleagues [4] found that pathologic complete response after induction chemotherapy was a favorable prognostic factor in stage IB-II non-small cell lung cancer, and squamous cell carcinoma was predictive for pathologic complete response. It might be interesting to study whether specific subgroups of adenocarcinoma IB respond to induction chemotherapy, with the advent of the new classification of lung adenocarcinoma. Again, we thank Dr Baisi and his colleagues very much for their letter.

Subclavian artery access for transcatheter aortic valve implantation and cardiopulmonary support.

Transcatheter aortic valve implantation (TAVI) is an emerging treatment for high surgical risk patients with aortic valve stenosis. Different access approaches have been used for TAVI, including transfemoral, transapical and trans-subclavian. Percutaneous TAVI is mostly performed through retrograde transfemoral artery catheterization. However, in some patients, this approach is considered unfeasible or at risk of severe complications. Tortuosities and calcifications of diseased femoral and iliac arteries, as often encountered in elderly people, may prevent the use of this approach. The axillary or subclavian artery represents an alternative to the femoral route for TAVI. In the literature, there are case series of TAVI performed through the axillary/ subclavian access, using the self-expandable, nitinol-based device, CoreValve (Medtronic, Minneapolis, MN). Recently, the Edwards Sapien valve (Edwards Lifesciences, Irvine, CA) has been implanted by this route, indicating the growing favour of this approach. However, since transaxillary/subclavian access is currently used as an alternative route in patients with iliac femoral disease, when mechanical cardiopulmonary support is needed during a procedure, this may be difficult to execute through the femoral artery in an emergency. Recently, the axillary artery has been proposed as an alternative site of cannulation for Heartport-assisted mitral valve surgery in patients with concomitant peripheral vessel disease. Therefore, we propose the subclavian artery as a route for TAVI and arterial inflow for cardiopulmonary support. For our TAVI program we propose the following protocol for subclavian access: The subclavian artery is surgically exposed. An 8mm Dacron vascular graft is chosen. Latero-lateral anastomosis is performed between the subclavian artery and the vascular graft. The lateral branch of the vascular graft is used to perform the TAVI procedure. The other branch of the graft is clamped and would be used, only if mechanical cardiopulmonary support is needed, as an insertion site for the arterial cannula. As an alternative to the straight vascular prosthesis anastomosed in laterolateral fashion on the subclavian artery, a Y-shaped Dacron tube may be used instead. Venous drainage for cardiopulmonary bypass may be obtained through a percutaneous femoral approach. This technique wouldn’t help in cases of rupture or dissection of the subclavian artery or aorta. Instead, it could be useful in cases of haemodynamic instability due to abnormal deployment of the valve prosthesis. Persistent severe paravalvular leaks or EKG changes due to coronary obstruction or improper valve positioning would compromise haemodynamic conditions. After removal of the subclavian sheath, circulatory support can be started through the other line where the arterial cannula was inserted. Circulatory support would allow time for further surgical management in an emergency. We propose the above simple technique, believing it could prove useful in particular clinical settings.

Surgery for Acute Aortic Dissection: An Easy and Cheap Method to Reinforce the Anastomosis

Abstract  Bleeding from the anastomotic site is a frequent complication of surgery for acute aortic dissection. Many methods have been devised in order to avoid this problem. We report a simple, easy technique to reinforce the anastomotic sites. One small 4‐mm‐high ring is cut from the same prosthesis and placed circumferentially inside the aorta edge. Another ring of the same width is opened in a “C” shape, and placed outside the aorta. The conduit was eventually sutured to the aorta in a standard fashion using a running 3‐0 polypropylene suture. The final result appeared good with no bleeding, and the rim lines appear clearer and the edges easier to suture because the Dacron is thinner than other used materials (that is, Teflon). In our opinion, this technique is a simple method to reinforce the anastomosis for both proximal and distal aorta.

Endovascular treatment of post-traumatic thoracic aorta lesions

Authors: Salvatore Lentini, Department of Thoracic and Cardiovascular Surgery, Policlinico G. Martino, Messina 98100 Italy; Filippo Benedetto, Roberto Gaeta, Francesco Spinelli doi:10.1510/icvts.2007.172304A We read with interest the article of Petrucci and colleagues, and we congratulate the authors for precise diagnostics and successful correction of this type of pathology w1x. Trauma of the thoracic aorta, both for blunt trauma, or as in the reported case for penetrating wound, show a very high incidence of mortality. Hospital mortality rate after aortic open surgery is between 15 and 30% w2–3x. Endovascular management can be an alternative w4x. The authors successfully treated this thoracic aorta pseudo-aneurysm by the insertion of an endovascular prosthesis. Between May 2005 and February 2007, we treated three patients with injury of the thoracic descending aorta, and concomitant haemothorax. All three patients had endovascular treatment. Size of the stent-graft was determined by contrast-enhanced CT and by angiographic images. At the end of the procedure, Digital Subtraction Angiography was performed in all patients to check stent-graft position, confirming complete pseudo-aneurysm exclusion and absence of endoleak. We used COOK thoracic endoprosthesis in two patients, and in the third one, we used two ‘iliac’ stent grafts (COOK iliac extension endograft) due to the small diameter (18–16 mm) of the descending aorta. Technical success rate of stent graft placement was 100%. There was no operative or postoperative mortality nor postoperative paraplegia. All are regularly seen in the out-patient clinic. The follow-up ranges from 10 to 19 months. The inclusion criteria to treat aortic injury with endovascular repair is dependent upon morphology of lesion, presence of concomitant injuries complicating open repair and availability of stent-grafts. The authors focused on the choice of an endovascular procedure, because the patient had already had a recent previous bilateral thoracotomy. We agree with this decision, and even more we think that in any case, even without previous thoracotomy, we would have treated the patient with an endovascular approach. In the patients we treated, in all of the three, there was associated haemothorax. We treated the patients anyway with endovascular approach, and we associated a video-assisted thoracoscopy to remove clotted residual blood from inside the chest. We think that treatment can be the same, both for blunt trauma and for penetrating thoracic aortic lesion, decreasing mortality and morbidity in comparison to open surgery. The second point, as reported by Petrucci, is the difficulty in some cases to find a stent graft of small dimension, because most medical centers have large sheaths since they treat aneurysmatic aortic lesions. In the case of a small size aorta, it is possible, as we did in one case, to adapt other smaller size grafts like the ones for the iliac artery. In conclusion, we agree, endovascular treatment of thoracic aortic lesions shows a very interesting alternative to open surgery both in blunt traumatic and penetrating lesions. Further studies with larger number of patients and longer follow-up are required to better evaluate the efficacy and the reproducibility of this approach in the treatment of this pathology.