Thomas Schachner

Axillary artery cannulation in surgery of the ascending aorta and the aortic arch

Potential advantages of axillary artery perfusion instead of femoral perfusion are antegrade aortic flow with decreased risk of atheremboli, low risk of false lumen perfusion in aortic dissections, avoidance of groin manipulation, and a possibility of antegrade cerebral perfusion during cardiocirculatory arrest. In 20 patients undergoing proximal aortic surgery, perfusion via the axillary artery was performed with direct cannulation or with an end-to-side anastomosed Gore-Tex graft. In two patients conversion to femoral artery cannulation was necessary. There were no axillary complications, hospital mortality was three out of 22, and no stroke occurred.

Intraoperative angiography for quality control in MIDCAB and OPCAB

We present our initial experience with intraoperative angiographic evaluation of coronary artery bypass grafts placed on the beating heart. Thirty-three grafts were investigated in 23 patients. Transfemoral angiography was performed using an OEC 9800 mobile C-arm. Spasm of the graft and/or target vessel was present in 11 grafts, two grafts were severely stenosed requiring surgical revision. In a third case an additional bypass graft was placed due to angiography findings. There was no hospital mortality and no significant perioperative myocardial ischemic event. All patients were free of angina 6 months postoperatively. Intraoperative angiography seems to reveal valuable information in beating heart coronary surgery.

Aorto-Esophageal Fistula After Thoracic Endovascular Aortic Repair: Successful Open Treatment

We present the case of a 56-year-old patient suffering from an aorto-esophageal fistula after complex treatment of acute Type A dissection including thoracic endovascular aortic repair (TEVAR) of the descending aorta. Open surgical descending replacement using a pericardial patch, as well as esophagectomy, was performed. After a long and complicated hospital stay, the patient finally recovered and was discharged in stable condition. By choosing an aggressive surgical approach the patient survived this devastating complication of TEVAR, which is associated with high mortality.

Evolving Knowledge About Age and Hypothermic Circulatory Arrest in Aortic Surgery

In ascending aortic surgery, progress in surgical and perfusion technology is continuous and quiet and does not produce frequent reports of short-term success. Changes in strategy show their effects years after their implementation, and may then be recommended to the broad community to adapt therapeutic strategy and thus to improve overall outcome. An example is the report by the Berne group1 in the current issue of Circulation on the effect of age on mortality and neurological injury in patients after surgical repair with hypothermic circulatory arrest in acute and chronic proximal thoracic pathology. Traditionally, age has been associated with a higher risk for both mortality and neurological injury, as has been shown by large databases such as the International Registry of Acute Aortic Dissection (IRAD).2 As a consequence, some centers refuse surgery in elderly patients because of dismal results, especially loss of quality of life, which has emerged as one of the most important surrogates for treatment success.3 Article see p 1407 However, the aforementioned reports stem from a time when deep hypothermic circulatory arrest was used as the only adjunctive technique for brain protection. Improvements in modern surgical therapy of aortic aneurysms include several important changes: subclavian artery perfusion, heparin-coated circuits for cardiopulmonary bypass, and most important, antegrade cerebral perfusion via the subclavian artery or selective perfusion catheters of supraaortic branches. Antegrade cerebral perfusion allows operating on the aortic arch in moderate hypothermia, thus reducing the side effects of deep hypothermia (eg, coagulopathy, inflammatory reactions). Additionally, concomitant treatment of the descending thoracic aorta with an open placement of a stent graft enables even more extensive repair of pathologies of the entire thoracic aorta. Commercially available trifurcated prostheses facilitate surgical aortic arch repair …

Relative amplitude index: A new tool for prediction of the impact of periprosthetic regurgitation on outcome after transcatheter aortic valve implantation

Objective: The impact of paravalvular leaks (PL) on hemodynamic performance after transcatheter valve implantation (TAVI) remains disputable. Using common hemodynamic parameters such as the diastolic blood pressure or the blood pressure amplitude after the procedure has not provided reproducible results. The aim of our study was to systematically evaluate changes of hemodynamic parameters by using the relative amplitude index (RAI) and to assess its impact on outcome. Methods: PL were prospectively evaluated by echocardiography during TAVI and before discharge in 77 patients after TAVI. The RAI was retrospectively calculated according to the formula: RAI =((Post TAVI blood pressure amplitude)/(Post TAVI systolic blood pressure)- (Pre TAVI blood pressure amplitude)/(Pre TAVI systolic blood pressure)) x 100%. Univariate and multivariate analysis for risk factors for perioperative mortality was performed and an ROC analysis for RAI cut-off value was calculated. Results: The incidence of no PL mild, moderate and severe PL after TAVI was 20%, 62%, 15% and 3%, respectively. Evaluation by diastolic pressure or post TAVI amplitude did not correlate to perioperative outcome. RAI increased from 0.7 ± 7% in the abscence of PL to 5.1 ± 8% in moderate to severe regurgitation (p = 0.027). A cutoff value of RAI = 13% was associated with increased perioperative mortality. Patients with a RAI> 13 had increased perioperative mortality (27 vs. 4%, p = 0.005), cardiac (9 vs. 0%, p < 0.001), and lung complications (27 vs. 4%, p < 0.001) and acute renal injury (20 vs. 8%, p = 0.002). Increased periprocedural RAI was associated with higher cardiac (33 vs. 15%, p = 0.011), renal (50 vs. 8%, p = 0.024) and lung comlications (7 vs. 0%, p = 0.005) at 1 year. RAI< 13 was an independent predictor of perioperative mortality (RR = 3.4, (CI = 1.8 – 5.0), p = 0.017). Conclusion: The RAI is useful non-invasive, easy-to-measure tool to predict the effect of paravalvular regurgitation on perioperative and 1-year outcome in patients with PL after TAVI.

Skeletal myoblasts and angiopoietic progenitor cells reduce infarct size, apoptosis and improve cardiac function in a model of chronic ischemia

Introduction: Cellular cardiomyoplasty using skeletal myoblasts or angiopoietic progenitor cells offers a promising approach for the treatment of ischemic heart failure. Although several studies have shown encouraging results in settings of acute and semi-chronic myocardial infarction, the efficacy of cell therapy on the chronic ischemic heart remains undetermined. Methods: A model of chronic ischemia was created using LAD-ligation in nude rats. A. culture medium, B. homologous skeletal myoblats, and C. human AC-133+ cells were injected in the infarct and peri-infarct area four weeks after infarction. Assessment of myocardial function was performed using echocardiography 1 to 2 months after injections. Infarct size, fibrosis and cardiomyocyte apoptosis were quantified to evaluate the effect of the two cell-therapy strategies using histology. Results: Echocardiographic studies revealed an amelioration of left ventricular dilatation in animals receiving skeletal myoblasts (0.62±0.13) or AC-133 group (0.64±0.16, vs. 0.76±0.09 in the control group, p=0.03). Left ventricular ejection fraction improved significantly after cell transplantation (Myoblasts: 65.2±11.1, AC-133: 62.6±7.8, vs. control: 48.6±8.9, p=0.0013). Quantification of scar tissue showed a significant reduction of infarct area in cell-treated animals (Myoblasts: 22.3±9.1%, AC-133: 17.8±7.6%, vs. controls: 36.5±8.2%, p=0.008). Improvement of myocardial function was associated with reduced apoptotic index in animals after cellular cardiomyoplasty (Myoblasts: 3.2±0.9, AC-133: 2.3±0.6, vs. controls: 10.3±1.6). Conclusions: Transplantation of skeletal myoblasts or angiopoietic progenitor cells leads to improvement of left ventricular function, and reduction of scar size and myocardial apoptosis in a model of chronic ischemia.