Tengis Tkebuchava

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.

Aortobronchial and aortoesophageal fistulae as risk factors in surgery of descending thoracic aortic aneurysms

OBJECTIVE Assess outcome of patients with descending thoracic aortic aneurysms complicated by aortobronchial and aortoesophageal fistulae in comparison to patients undergoing repair of aortic aneurysms without fistulae. METHODS In a consecutive series of 145 patients (age 60 +/- 12 years) with repair of descending thoracic and thoracoabdominal aortic aneurysms, 11 patients (8%; age 63 +/- 9; NS) primarily presented for hematemesis and/or hemoptysis. In 8/11 patients (73%) an aortobronchial fistula was identified, and 3/11 patients (27%) suffered from an aortoesophageal fistula. Five of 11 patients (45%) had undergone previous aortic surgery in the same region. RESULTS Extent of aortic segments (range 1-8) replaced was 3.1 +/- 1.4 for all versus 2.6 +/- 0.9 for fistulae (NS). Aortic cross clamp time was 38 +/- 22 min for all versus 45 +/- 15 min for fistulae (NS). Mortality at 30 days was 18/145 (12%) for all versus 16/134 (12%) without fistulae versus 2/11 (18%) with fistulae (NS). Paraparesis and or paraplegia was observed in 11/145 (8%) for all versus 10/134 (7%) without fistulae versus 1/11 (9%) for cases with fistulae (NS). Nine additional patients died after hospital discharge, seven without fistulae and two with fistulae (days 80, and 120) bringing the 1-year mortality up to 23/134 (17%) without fistulae versus 4/11 (36%) with fistulae (NS). Further analysis shows that the 1-year mortality accounts for 1/8 patients (13%) with aorto-bronchial fistulae versus to 3/3 patients (100%) with aorto-esophageal fistulae (esophageal versus bronchial fistula: P = 0.018; esophageal versus no fistula: P = 0.006). CONCLUSIONS Outcome of patients suffering from descending thoracic aortic aneurysms complicated by aorto-bronchial fistulae can be similar to that without fistulae, whereas for cases complicated by aorto-esophageal fistulae the prognosis seems to remain poor even after successful hospital discharge.

Embolization of biologic glue during repair of aortic dissection

A 72-year-old patient was operated on because of an acute type A aortic dissection with the primary entry located in the aortic arch and with retrograde involvement of the ascending aorta. Complete replacement of the aortic arch and the ascending aorta was performed after the dissected aortic layers had been readapted and sealed with gelatin-resorcin-formaldehyde biologic glue. Postoperative neurologic status was judged to be normal. The patient died 3 weeks postoperatively of septic shock. Postmortem examination of the brain revealed several small lesions, and microscopy showed very small particles of polymerized glue in the afferent vessels of ischemic cerebral and meningeal regions.

Kartagener's syndrome: Clinical presentation and cardiosurgical aspects

BACKGROUND Long-term observations in patients with Kartageners syndrome (situs inversus, bronchiectasis, and sinusitis) are rare. The role of additional cardiac malformations and their surgical repair is not well known. METHODS Nine patients (5 female and 4 male) with Kartageners syndrome were identified and followed. Four patients had associated cardiac anomalies; 4 underwent total surgical repair at the ages of 4 (2 patients), 7, and 34 years. RESULTS The postoperative period was uneventful, and these 4 patients are doing well 7 months and 2, 9, and 19 years after repair. The other patients are being treated with conservative therapy and are in relatively good condition. CONCLUSIONS This disease can be temporarily benign when treated with antibiotics and physiotherapy. Associated cardiac anomalies seem to be quite common, and such patients need careful cardiologic follow-up. Surgical intervention can be safely performed in patients suffering from Kartageners syndrome associated with a congenital cardiac malformation and produces good long-term results. Bilateral lung transplantation seems to be the therapy of choice in patients with respiratory insufficiency but without concomitant cardiac anomalies.

Successful Repair of Primary Concomitant Aortobronchial and Aortoesophageal Fistulas

Combined aortobronchial and aortoesophageal fistulas developed after a rupture of a thoracoabdominal aneurysm in a 73-year-old man and were successfully repaired in a one-stage procedure. This case demonstrates that operation can be successful even in this desperate situation.

Cardiac surgery for Kartagener syndrome.

Two patients (one girl, one boy) with Kartagener syndrome (situs inversus, bronchiectasis, sinusitis), despite pulmonary problems and associated congenital cardiac anomalies, were operated on at the ages of 4 years and 7 years, respectively. They had had previous palliative treatment at the age of 3 months and 1.3 years, respectively. Both postoperative periods after total correction were without significant complications. Long-term follow-up was available for 9 and 19 years, respectively, with no manifestations of heart insufficiency. Both patients are physically active, and neither requires cardiac medication. Patients with Kartagener syndrome and associated congenital cardiac anomalies can successfully undergo multiple cardiac operations with good long-term outcome.

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.

Intravascular Gas Transfer: Membrane Surface Area and Sweeping Gas Flows Are of Prime Importance

Single and double hollow fiber intravascular gas exchangers were evaluated in an extracorporeal veno-venous bypass circuit (right atrium to pulmonary artery) including a tubular blood chamber (mimicking caval veins with an inner diameter of 26 mm) for evaluation of the membrane surface area/host vessel diameter gas transfer relationships. Six bovine experiments (body wt: 68 ± 4 kg) with staged ex vivo blood flows of 1, 2, 3, and 4 L/min and a device oxygen inflow of 0, 3, and 6 L/min (0 or 3 L/min/device) were performed. Total oxygen transfer at a blood flow of 1 L/min was 33 ± 4 ml/min for a gas flow of 3 L/min (one device) vs 60 ± 25 ml/min for a gas flow of 6 L/min (two devices); at a blood flow of 2 L/min, the corresponding oxygen transfer was 46 ± 16 ml/min for a gas flow of 3 L/min vs 95 ± 44 ml/min for a gas flow of 6 L/min; at a blood flow of 3 L/min, the corresponding oxygen transfer was 48 ± 24 ml/min for a gas flow of 3 L/min vs 92 ± 37 ml/min for a gas flow of 6 L/min (p < 0.01 for comparison of areas under the curves). Total carbon dioxide transfer at a blood flow of 1 L/min was 47 ± 18 ml/min for a gas flow of 3 L/min vs 104 ± 26 ml/min for a gas flow of 6 L/min; at a blood flow of 2 L/min, the corresponding carbon dioxide transfer was 59 ± 19 ml/min for a gas flow of 3 L/min vs 129 ± 39 ml/min for a gas flow of 6 L/min; at a blood flow of 3 L/min, the corresponding carbon dioxide transfer was 60 ± 22 ml/min for a gas flow of 3 L/min vs 116 ± 49 ml/min for a gas flow of 6 L/min (p < 0.01). For the given setup, the blood flow/gas transfer relationship is non linear, and a plateau is achieved at a blood flow of 2.5 L/min for O2 and CO2. Doubling membrane surface area and consecutively sweeping gas flows result in doubling of gas transfers at all tested blood flows. However, increased membrane surface area and blood flow produce a higher pressure drop that in turn limits the fiber density that can be used clinically.

LOW PRIME, HEPARIN COATED CENTRIFUGAL PUMPS

to be solved for improved perfusion. Design improvements for streamlined blood flow avoiding higher shear stress or zones with stagnant flow and surface modification2-6 can both contribute to reduce the activation of the multitude of cascades leading to the so-called whole body inflammatory response too. The present study was designed to evaluate the thromboresistance of low prime, heparin coated centrifugal pump heads for adult perfusion.

Ivemark syndrome. A case with successful surgical intervention.

A 19-day-old boy with Ivemark syndrome (splenic agenesis associated with complex cardiac malformations and visceral abnormality) underwent palliative surgery including Glenn and hemi-Fontan procedures. Five months later the child is alive and well. We believe that early palliative surgery is worthwhile in Ivemark syndrome with a single ventricle.