Current Role and Outcomes of Ascending Aortic Replacement for Severe Nonaneurysmal Aortic Atherosclerosis
ABSTRACT Severe atherosclerosis of the ascending aorta is a challenging issue potentially affecting indications for surgery, operative choices, and patients' outcome. No standard treatment has emerged to date, and uncertainties persist about criteria for selecting patients and procedures.
Replacement of the atherosclerotic ascending aorta was performed in 64 patients at time of either aortic (n = 49), mitral (n = 21), or tricuspid (n = 7) valve surgery. Coronary artery bypass grafting was performed in 53 patients, and the majority of patients underwent combined procedures (n = 49). Mean age was 72.0 +/- 7.6 years. The expected operative mortality, by logistic European System for Cardiac Operative Risk Evaluation, was 29.0% accounting for ascending aortic replacement and 13.1% disregarding it. Circulatory arrest under deep hypothermia, eventually combined with either retrograde or antegrade brain perfusion, was required in 61 cases.
Early death, stroke, and myocardial infarction rates were 10.9%, 6.3%, and 7.8%, respectively. Factors univariately associated with early deaths were preoperative renal failure requiring dialysis (p = 0.001) and longer cardiopulmonary bypass (p = 0.001) and cardioplegia (p = 0.008) times. Cumulative survival at 1, 3, and 5 years was 86% +/- 4%, 74% +/- 6%, and 68% +/- 8%, respectively.
Replacement of the atherosclerotic ascending aorta can be carried out at acceptable mortality rates despite the high rates of preoperative comorbidity and the significant incidence of postoperative complications.
Conference Paper: Polynomial approach to the synthesis of stable fuzzy systems[Show abstract] [Hide abstract]
ABSTRACT: We discuss the problem of synthesis of stable Takagi-Sugeno-Kang (TSK) fuzzy systems (1985). This approach is based on a polytopic input-output representation of the fuzzy system model and the fuzzy controller. A procedure for designing fuzzy controllers is also developedFuzzy Information Processing Society, 1996. NAFIPS. 1996 Biennial Conference of the North American; 07/1996
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ABSTRACT: In patients with calcification of the ascending aorta, postoperative stroke and mortality rates remain high after conventional aortic valve replacement, but the results of trans-apical aortic valve implantation in these patients are not known. We evaluate the outcome of trans-apical aortic valve implantation in patients with severely calcified ascending aorta in a single center with expanded procedural experience. Between April 2008 and July 2010, 258 patients underwent trans-apical aortic valve implantation using Edwards Sapien valve. By computed tomography (CT) scan, we identified 46 (18%) patients with severe calcification of the ascending aorta (16 with porcelain aorta and 30 with severe, but not complete, calcification). Of 46 patients (mean age 77 ± 10 years, range 63-90 years; EuroSCORE (European System for Cardiac Operative Risk Evaluation) 45 ± 22%; STS (Society of Thoracic Surgeons) score 23 ± 13) with calcified aorta, 15 received 23-mm valves and 31 patients 26-mm valves. Primary valve implantation was successful in 44 patients and a second valve was implanted (valve-in-valve) in two. Six patients underwent concomitant interventions (three elective percutaneous coronary intervention (PCI), one off-pump coronary artery bypass (OPCAB), one tricuspid valve reconstruction, and one left-ventricular (LV) aneurysmectomy). The final procedural results showed valve incompetence (trace or grade 1) in 17 (37%) patients and paravalvular leak in 15 (32.6%) (trace in 10 and grade 1 in five). There was no 30-day mortality. Postoperatively, cranial CT showed new cerebral ischemia areas in three patients (6.2%), but only one patient (2.1%) experienced postoperative neurological deficit (temporary aphasia). Survival at 6 and 12 months was 88% and 85.2%, respectively. Trans-apical aortic valve implantation can be performed safely in patients with aortic valve stenosis and severe calcification of the ascending aorta.European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 08/2011; 40(2):463-8. DOI:10.1016/j.ejcts.2010.11.075 · 2.81 Impact Factor
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ABSTRACT: OBJECTIVES: New surgical and perfusion techniques allow the avoidance of deep hypothermia during open aortic arch surgery, which is generally necessary in patients with an unclampable porcelain aorta. The aim of the study was to evaluate operative and long-term results in patients with a porcelain aorta who underwent conventional cardiac surgery using current surgical and perfusion techniques. METHODS: Between November 2003 and February 2012, 30 consecutive patients (mean age 68 ± 11 years, 10 patients had previous cardiac surgery with use of glue in 5 of them) with porcelain aorta diagnosed by computed tomography and defined as a severe circular calcification of the proximal thoracic aorta were referred for cardiac surgery. All patients underwent conventional surgery with arterial cannulation of the innominate (8) or a carotid artery (22) for arterial return. During mild hypothermic circulatory arrest, unilateral cerebral perfusion through the arterial line was performed for cerebral protection. The valve surgery consisted of aortic, mitral or double valve repair in 23, 3 and 4 cases, respectively. Aortic surgery (17 complete root replacements with valve composite grafts and 22 arch replacements) and coronary revascularization due to coronary heart disease (15) were the most frequent concomitant procedures. RESULTS: Thirty-day mortality was 3.3% (1 patient died of bowel ischaemia caused by severe stenosis of the celiac and upper mesenteric arteries) and the rate of permanent neurological deficit was 3.3% as well. Two further patients died during the follow-up at age 91 and 82 years, respectively; however, no death was cardiac or valve related. The actuarial survival at 5 years was 87.3 ± 7.2%. There were no cardiac reoperations, new interventions or aortic- or valve-related events noted during the median follow-up of 45 months (range 0.1-106.0). CONCLUSIONS: Conventional cardiac and aortic surgery offers definitive repair and can be performed safely using current perfusion and operative techniques. Although more invasive, this surgical technique provides mortality and morbidity rates that do not exceed those reported for transcatheter valve implantation. The curative replacement of the pathological proximal aorta, which is one of the most main sources of cerebral embolism, leads to excellent neurological outcome during mid- to long-term follow-up.European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 01/2013; DOI:10.1093/ejcts/ezs695 · 2.81 Impact Factor