Vasileios Tsiopoulos

Aortic Expansion Rate in Patients With Dilated Post-Stenotic Ascending Aorta Submitted Only to Aortic Valve Replacement: Long-Term Follow-Up

OBJECTIVES This study was conceived to describe the evolution of aortic dimensions in patients with moderate post-stenotic ascending aorta dilation (50 to 59 mm) submitted to aortic valve replacement (AVR) alone. BACKGROUND The appropriate treatment of post-stenotic ascending aorta dilation has been poorly investigated. METHODS Ninety-three patients affected by severe isolated calcific aortic valve stenosis in the tricuspid aortic valve accompanied by moderate dilation of the ascending aorta (50 to 59 mm) were submitted to AVR only. All patients were followed for a mean of 14.7 ± 4.8 years by means of periodic clinical evaluations and echocardiography and tomography scans of the thorax. RESULTS Operative mortality was 1.0% (1 patient). During the follow-up, 16 patients died and 2 had to be reoperated for valve dysfunction. No patients experienced acute aortic events (rupture, dissection, pseudoaneurysm), and no patient had to be reoperated on the aorta. There was not a substantial increase in aortic dimensions: mean aortic diameter was 57 ± 11 mm at the end of the follow-up versus 56 ± 02 mm pre-operatively (p = NS). The mean ascending aorta expansion rate was 0.3 ± 0.2 mm/year. CONCLUSION In the absence of connective tissue disorders, AVR alone is sufficient to prevent further aortic expansion in patients with moderate post-stenotic dilation of the ascending aorta. Aortic replacement can probably be reserved for patients with a long life expectancy.

Case series of resection of pelvic leiomyoma extending into the right heart: surgical safeguards and clinical follow-up

Objective To analyze the clinical features, surgical management and oncologic results of a series of six patients undergoing seven operations for resection of uterine leiomyoma extending into the right cardiac chambers. Methods A retrospective review of patients operated on for surgical resection of a pelvic leiomyomatous mass originating from the uterus and extending into the right cardiac chambers was performed. The most common symptoms at presentation were syncope and dyspnea; two patients were asymptomatic. Four patients had been misdiagnosed as having intracardiac thrombus or primary cardiac tumor. The intracardiac and upper intracaval portion was removed under circulatory arrest in moderate hypothermia; the remaining portion was removed by caval incision. In one patient with cardiogenic shock, the sole intracardiac portion of the mass was removed at primary surgery. A mean of 2.8 ± 1.5 years of follow-up was available, consisting of clinical and radiological tests (computed tomography scan, echocardiography). Results There were no cases of operative mortality in the present series. No recurrence was observed at the end of the follow-up in all cases of complete resection of the mass from its intracardiac to its pelvic end. Conversely, in the only case in which partial resection was performed due to the patients clinical condition, recurrence of the intracardiac involvement was observed 6 months after primary surgery. Conclusion Radical resection is curative for uterine leiomyomatosis extending into the right cardiac chambers. Surgery can be afforded with acceptable risks. A high level of suspicion for intracardiac extension of pelvic leiomyomatosis should be retained in the presence of a floating mass within the right cardiac chambers. Such a finding should prompt radiographic evaluation of the abdomen and the pelvis.

Contemporary Results for Isolated Aortic Valve Surgery

BACKGROUND We aimed to give an overview of the contemporary status of aortic valve replacement. MATERIALS AND METHODS This single-center prospective study was initiated in January 2003. From this date on, every patient with aortic valve disease admitted to our hospital was reviewed by a cardiologist and a surgeon to determine eligibility for replacement. In no instance was the operation denied in the absence of surgical consultation. All operations were performed using a median sternotomy, with cardiopulmonary bypass and cardioplegic arrest. RESULTS A total of 873 cases were screened until the end of the study. We identified three groups of patients: Group 1 (inoperable cases) consisted of 15 patients (1 %); Group 2 (high-risk cases) included 99 patients with an additive EuroSCORE ≥ 10 or an expected mortality > 20 % (logistic model); Group 3 (moderate- to low-risk cases) consisted of 759 patients with an additive EuroSCORE < 10 or an expected mortality < 20 %. In-hospital mortality was 6.0 % (6/99) for Group 2 and 0.3 % (3/759) for Group 3. Major complications occurred in 5 patients of Group 2 (5 %) and in 9 patients of Group 3 (1.1 %). At predischarge echocardiography, 99.3 % of the implanted valves were perfect. At a follow-up of 28.9 ± 12.3 months 798/849 patients were alive; 89 % of them (711) were in NYHA 1-2. CONCLUSIONS Surgical aortic valve replacement provides excellent results and has a low operative mortality even in high-risk patients. Surgical consultation for every aortic patient resulted in an extremely low rate of surgery refusals. Our data should be regarded as a benchmark for transcatheter techniques.

A case of myocardial infarction effectively treated by emergency coronary stenting soon after a Bentall–De Bono aortic surgery

Postoperative ischemia may complicate cardiac surgery, despite myocardial protection and recent technical developments. Its medical management in the intensive cardiac care unit is usually efficient, although sometimes it requires the revision of the surgical site. In other cases, urgent coronary angiography and subsequent coronary stenting may resolve the situation. Ostial stenosis of coronary anastomoses is a well-known uncommon but dramatic complication after aortic surgery causing myocardial ischemia. Cases of effort angina have been described several months after surgery, but in some cases, acute myocardial infarction may occur days or weeks after intervention. We here describe an anteroseptal ST-elevation myocardial infarction soon after a Bentall aortic root replacement due to compression of the left main ostium by surgical glue, which has been effectively treated by emergency coronary stenting. This case highlights the importance of a joint management of acute myocardial ischemia after cardiac surgery by the cardiac surgeon and the interventional cardiologist.

Human epicardium-derived cells fuse with high efficiency with skeletal myotubes and differentiate toward the skeletal muscle phenotype: a comparison study with stromal and endothelial cells

EPDCs fuse with skeletal myotubes with higher efficiency when compared to MSCs and endothelial cells. Independently from the cell origin, all nuclei recruited inside myotubes express muscle-specific genes. VCAM1 expression in nonmuscle cells is induced by soluble factors secreted by myotubes, and its function is required for fusion to occur.

The use of internal thoracic artery grafts in patients with aortic coarctation

The choice of conduits for surgical revascularization in patients with aortic coarctation can be puzzling, as the internal thoracic arteries can be dilated, atherosclerotic and unsuitable for grafting. Reports in the literature are controversial: in some cases, the internal thoracic artery was not suitable for revascularization, while in others, it could be used with discordant outcomes. Here, we review the literature on the subject.

Different clinical pictures of penetrating ulcer of the aorta, an underrated aortic disease.

Penetrating ulcer of the aorta has been recognized as a distinct aortic disorder, defined by the ulceration of an atherosclerotic plaque. The lesion has the potential to evolve acutely into aortic rupture, but chronic pictures are possible. Late evolution into rupture, frank aortic dissection and progressive aortic enlargement have been documented. We discuss different modalities of presentation on the basis of recent clinical cases. As the optimal treatment, either surgical (open or endovascular) or medical, is based on a correct diagnosis, we highlight the importance of including aortic ulcers in the differential diagnosis of chest pain. Although endovascular treatment can be advisable in cases with favorable anatomic condition and in patients with multiple comorbidities, the open surgical option should be available given the heterogeneous location and clinical scenarios of these lesions.

Systematic bilateral internal mammary artery grafting: lessons learned from the CATHolic University EXtensive BIMA Grafting Study

OBJECTIVES Despite claims of feasibility, to date no study has examined the effect of systematic bilateral internal mammary artery (BIMA) use in a large cohort of real-world unselected patients. The CATHolic University EXtensive BIMA Grafting Study (CATHEXIS) registry was designed to assess the feasibility and safety of systematic BIMA grafting. METHODS The CATHEXIS was a single-centre, prospective, observational, propensity-matched study. The study was supposed to include 2 arms of 500 patients each: a prospective arm and a retrospective arm. The prospective arm included almost all patients referred for coronary artery bypass grafting (CABG) at our institution after the start of the CATHEXIS with very few exceptions. BIMA would have been used in all these patients. The retrospective arm included patients submitted to CABG before the start of the CATHEXIS and propensity matched to the prospective group (average BIMA use 50%; the radial artery was extensively used). Safety analyses were scheduled after enrolment of 200, 300 and 400 BIMA patients. RESULTS After the first 226 patients, the BIMA use percentage was 88.5% (200 of 226). In 178 (89%) patients, mammary arteries were used as Y graft. Postoperative mortality was 2%, and incidence of perioperative myocardial infarction, graft failure and sternal complications were 3.5%, 3% and 5.5%, respectively. No perioperative stroke occurred. The incidence of major adverse cardiac events (particularly graft failure and sternal complications) in the BIMA arm were significantly higher than those in the propensity-matched cohort; the study was stopped for safety. CONCLUSIONS In a real world setting the systematic use of BIMA was associated with a higher incidence of perioperative adverse events (particularly sternal complications). Individualization of the revascularization strategy and use of alternative arterial conduits are probably preferable to systematic use of BIMA.

On Pump Evaluation of the Anastomotic Patency of In Situ Arterial Grafts

We describe a variation of the standard intraoperative transit time flow evaluation that allows the assessment of the anastomotic patency of in situ arterial grafts before the release of the aortic cross clamp. The advantages of this technique are the immediate correction of technical imperfections and the evaluation of native competitive flow situations that may compromise long‐term patency. doi: 10.1111/jocs.12315 (J Card Surg 2014;29:487–489)

Coronary revascularization for absent left main artery.

(J Card Surg 2010;25:696‐697)