Stephen D. Waterford

Left Subclavian Arterial Coverage and Stroke During Thoracic Aortic Endografting: A Systematic Review.

Stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). Whether left subclavian artery (LSA) coverage and LSA revascularization affect stroke rate is debated. Whether patients with aneurysms or dissections undergoing TEVAR have higher stroke rates is also debated. We report a systematic review of 63 studies comprising more than 3,000 patients. We conclude that stroke risk after TEVAR is increased by LSA coverage, and that LSA revascularization reduces stroke risk. LSA revascularization may lower the rate of posterior stroke. TEVAR for aneurysm is associated with increased stroke risk compared to TEVAR for dissection.

Postoperative myocardial infarction in acute type A aortic dissection: A report from the International Registry of Acute Aortic Dissection

Objective: Postoperative myocardial infarction remains a serious complication in cardiac surgery. The incidence and impact of this condition in acute type A aortic dissection are poorly understood. Methods: A total of 1445 patients with acute type A aortic dissection who underwent surgery were enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2013. Individuals with preoperative myocardial infarction at hospital presentation and a history of myocardial infarction were excluded. Patients with postoperative myocardial infarction (n = 38, 2.6%) were compared with those without postoperative myocardial infarction (n = 1407, 97.4%). Results: The postoperative myocardial infarction group was more often of white race (100% vs 90%, P = .043) with bicuspid aortic valve (15.6% vs 4.5%, P = .015). Imaging demonstrated more aortic root involvement (75.8% vs 49.5%, P = .003), pericardial effusion (65.5% vs 44.1%, P = .022), and coronary artery compromise (27.3% vs 10.2%, P = .022). Patients with postoperative myocardial infarction were more frequently hypotensive or in shock during surgery (42.9% vs 25.5%, P = .021). Patients with postoperative myocardial infarction were more likely to have undergone root replacement (54.5% vs 33.3%, P = .011), coronary artery bypass grafting (28.6% vs 7.4%, P < .001), or aortic valve replacement (40.0% vs 23.8%, P = .027), and less likely to have had complete arch replacement (2.8% vs 14.0%, P = .050). Median circulatory arrest time was higher in postoperative myocardial infarction (60 vs 38 minutes, P = .024). In‐hospital mortality (57.9% vs 16.3%, P < .001) and Kaplan–Meier estimates of 5‐year mortality (P = .007) were distinctly higher in postoperative myocardial infarction. Conclusions: Postoperative myocardial infarction is a devastating complication of type A aortic dissection repair. It is associated with bicuspid aortic valve, root involvement, pericardial effusion, and extent of surgical repair. Patients with postoperative myocardial infarction have higher serious postoperative complications, in‐hospital mortality, and 5‐year mortality rates than those without postoperative myocardial infarction.

Aortic Hemiarch Replacement through a J-Shaped Lower Partial Sternotomy.

Minimally invasive cardiac surgical techniques include the use of partial sternotomy for aortic valve and mitral valve replacement. Partial sternotomy is associated with less pain, better chest and upper-sternal stability, shorter hospital stays, and faster recoveries. However, aortic arch operations are still typically performed through median sternotomies. We describe the case of a 77-year-old woman who underwent elective hemiarch replacement because of an asymptomatic ascending aortic aneurysm. She requested a minimal incision. Our J-shaped partial lower sternotomy adequately exposed the proximal aorta and enabled all cannulations to be performed through the sternotomy. The patient had an uncomplicated postoperative course. We think that a partial sternotomy for ascending aortic and hemiarch replacement can be considered in selected patients for whom the procedures benefits are important.

Total Aortic Arch Revascularization with Extra-anatomic Bypass for Takayasu Arteritis.

Total arch replacement with median sternotomy and hypothermic circulatory arrest is described for Takayasu arteritis (TA) with aortic arch and supra-aortic trunk involvement.(1,2) We report aortic arch revascularization using extra-anatomic bypass through partial sternotomy, without cardiopulmonary bypass, in a TA patient. Avoidance of cardiopulmonary bypass may enhance outcomes and represent an attractive approach to arch revascularization in TA.