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Journal of the American College of Cardiology 05/2013; · 14.16 Impact Factor
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Rebecca T Hahn,
Philippe Pibarot,
William J Stewart,
Neil J Weissman,
Deepika Gopalakrishnan,
Martin G Keane,
Saif Anwaruddin,
Zueyue Wang,
Martin Bilsker,
Brian R Lindman,
Howard C Herrmann,
Susheel K Kodali,
Vinod H Thourani, Lars G Svensson,
Jodi J Akin,
William N Anderson,
Martin Leon,
Pamela S Douglas
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ABSTRACT: OBJECTIVE: s: To compare echocardiographic findings in patients with critical aortic stenosis following surgical (SAVR) or transcatheter aortic valve replacement (TAVR) BACKGROUND: The Placement of Aortic Transcatheter Valves trial randomized patients 1:1 to SAVR or TAVR METHODS: Echocardiograms were obtained at baseline, discharge, 30 days, 6 months, 1 year, and 2 years post procedure and analyzed in a core laboratory. For the analysis of post-implant variables, the first interpretable study (≤ 6 mos) was used. RESULTS: Both groups showed a decrease in aortic valve gradients and increase in effective orifice area (EOA) (p < 0.0001) which remained stable over 2 years. Compared to SAVR, TAVR resulted in: larger indexed EOA (p = 0.038), less prosthesis-patient mismatch (p = 0.019), and more total and paravalvular aortic regurgitation (AR) (p < 0.0001). Baseline echocardiographic univariate predictors of death were: lower peak transaortic gradient in TAVR patients; low left ventricular diastolic volume (LVDV), low stroke volume, and greater severity of mitral regurgitation in SAVR patients. Post-implantation echocardiographic univariate predictors of death were: larger LVDV, systolic volume (LVSV) and EOA, decreased ejection fraction, and greater AR in TAVR patients; smaller LVSV and LVDV, low stroke volume, smaller EOA and prosthesis-patient mismatch in SAVR patients. CONCLUSIONS: Patients randomized to either SAVR or TAVR experience enduring, significant reductions in transaortic gradients and increase in EOA. Compared to SAVR, TAVR patients had higher indexed EOA, lower prosthesis-patient mismatch and more AR. Univariate predictors of death for the TAVR group and SAVR groups differed and may allow future refinement in patient selection. CLINICAL TRIAL INFO: : PARTNER; http://clinicaltrials.gov/show/NCT00530894; NCT00530894.
Journal of the American College of Cardiology 04/2013; · 14.16 Impact Factor
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ABSTRACT: OBJECTIVE: Aortic stenosis is the most common valvular pathology in the elderly. Transcatheter aortic valve replacement has emerged as a safe and feasible alternative for high-risk patients. However, a significant number of patients are still not transcatheter aortic valve replacement candidates because of poor peripheral access and chest pathology. We report the use of alternative access options for such patients. METHODS: Seven patients who had poor peripheral access and chest pathology had transcatheter aortic valve replacement using alternative access techniques. Five patients had the valve delivered by direct cannulation of the aorta via a mini-sternotomy, and 1 patient had the valve delivered via a mini-right thoracotomy. In 1 patient, the right subclavian artery was cannulated. Intraprocedural and 30-day outcome data were analyzed. RESULTS: The mean age of patients was 85.00 ± 9.59 years, with a Society of Thoracic Surgeons score of 16.81% ± 6.87% and logistic European System for Cardiac Operative Risk Evaluation of 21.59% ± 8.46%. Procedural success was 100%. Procedural and 30-day mortality were zero. There were no access-related complications or neurologic events. Two patients had worsening renal function that did not require dialysis. All patients were discharged with a median hospital stay of 7 days. In our experience of 135 transapical or alternative access patients, 5 died (307%) and for 257 transfemoral patients, 1 died (0.4%). CONCLUSIONS: Despite the high surgical risk of the study population, these techniques had excellent outcome with no mortality and acceptable morbidity. With the use of currently available technologies, these approaches are promising and offer alternative options in patients with no access and prohibitive chest pathology or pulmonary function.
The Journal of thoracic and cardiovascular surgery 03/2013; · 3.41 Impact Factor
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ABSTRACT: BACKGROUND: =0.036). Postoperative myocardial infarction was more frequent in patients with AS compared with controls (3.0% versus 1.1%; P=0.001). Combined primary outcome was significantly worse for both moderate and severe AS patients compared with respective controls (4.4% versus 1.7%; P=0.002; and 5.7% versus 2.7%; P=0.02, respectively). High-risk surgery, symptomatic severe AS, coexisting mitral regurgitation, and preexisting coronary disease were significant predictors of primary outcome in patients with AS.Conclusion-Presence of AS adversely affects postoperative outcomes among patients undergoing NCS, evidenced by a higher 30-day mortality and postoperative myocardial infarction after NCS.
Circulation Cardiovascular Quality and Outcomes 03/2013; · 4.91 Impact Factor
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ABSTRACT: Percutaneous transcatheter aortic valve replacement was introduced in 2002, but its effectiveness remained to be assessed.
A prospective, randomized trial (the Placement of Aortic Transcatheter Valves, or PARTNER) was designed with 2 arms: PARTNER A (n = 699) for high-risk surgical patients (Society of Thoracic Surgeons score >10%, surgeon assessed risk of mortality >15%) and PARTNER B (n = 358, patients inoperable by assessment of 2 surgeons). PARTNER A patients were divided into femoral artery access transcatheter aortic valve replacement or none (n = 207), and then randomized to open aortic valve replacement (n = 351) or device (n = 348). Inclusion criteria included valve area <0.8 cm(2), gradient >40 mm Hg or peak >64 mm Hg, and survival >1 year. The end point of the study was 1-year mortality.
Thirty-day mortality for PARTNER A was 3.4% for transcatheter aortic valve replacement and 6.5% for aortic valve replacement; 1-year mortality was 24.2% and 26.8%, respectively (P = .001 for noninferiority). The respective prevalence of stroke was 3.8% and 2.1% (P = .2), although for all neurologic events, the difference between transcatheter aortic valve replacement and aortic valve replacement was significant (P = .04), including 4.6% for femoral artery access transcatheter aortic valve replacement versus 1.4% for open aortic valve replacement (P = .05). For PARTNER B-transcatheter aortic valve replacement versus medical treatment-30-day mortality was 5.0% versus 2.8% (P = .41), and at 1 year, mortality was 30.7% versus 50.7% (P < .001), respectively. Hospitalization cost of transcatheter aortic valve replacement for PARTNER B was $78,542, or $50,200 per year of life gained. Analysis of PARTNER A strokes showed that hazard with transcatheter aortic valve replacement peaked early, but thereafter remained constant in relation to aortic valve replacement. Two-year PARTNER A data showed paravalvular regurgitation was associated with increased mortality, even when mild (P < .001). Continued access to transapical transcatheter aortic valve replacement (n = 853) showed a mortality of 8.2% and decline in strokes to 2.0%. Of the 1801 Cleveland Clinic patients reviewed to December 2010, 214 (12%) underwent transcatheter aortic valve replacement with a mortality of 1%; in 2011, 105 underwent transcatheter aortic valve replacement: 34 transapical aortic valve replacement, with no deaths, and 71 femoral artery access aortic valve replacement with 1 death.
The PARTNER A and B trials showed that survival has been remarkably good, but stroke and perivalvular leakage require further device development.
The Journal of thoracic and cardiovascular surgery 03/2013; 145(3 Suppl):S11-6. · 3.41 Impact Factor
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ABSTRACT: Objective: Kommerell diverticulum carries the risk of rupture or dissection if left untreated. Various methods of
repair have been described, and options have recently expanded to include the hybrid approach. This study
describes hybrid repair techniques for Kommerell diverticulum and assesses outcomes.
Methods: Between 2005 and 2010, a total of 10 patients underwent hybrid repair of Kommerell diverticulum
(3 right-sided arches) by elephant trunk with endovascular completion (n ¼ 4), frozen elephant trunk (n ¼ 3), or
stent grafting with cervical debranching (n ¼ 3). Mean age at procedure was 57 � 25.5 years. Subclavian artery
revascularization was performed preoperatively (n ¼ 4), intraoperatively (n ¼ 3), or postoperatively (n ¼ 3),
either as carotid-to-subclavian bypass (n ¼ 7; n ¼ 3 bilateral) or originating from the ascending aorta
(n ¼ 3). Data were obtained from the prospectively collected database and chart review.
Results: There was no in-hospital mortality, nor were there any cases of respiratory or renal failure. There were
no cases of paraplegia, but there was 1 stroke. Two patients had type 2 endoleaks develop; 1 required subclavian
coil embolization. Mean hospital stay was 8.73 � 4 days. After repair, there were no ruptures, no significant
growth, and all patients remain free of symptoms.
Conclusions: Hybrid repair is a safe and effective surgical treatment option for Kommerell diverticulum.
Selection of the specific type of intervention is based on patient anatomy and comorbid conditions. (J Thorac
Cardiovasc Surg 2013;-:1-4)
The Journal of thoracic and cardiovascular surgery 02/2013; · 3.41 Impact Factor
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ABSTRACT: The study sought to contrast risk profiles and compare outcomes of patients with severe aortic stenosis (AS) and coronary artery disease (CAD) who underwent aortic valve replacement (AVR) and coronary artery bypass grafting (AS+CABG) with those of patients with isolated AS who underwent AVR alone.
In patients with severe AS, CAD is often an incidental finding with underappreciated survival implications.
From October 1991 to July 2010, 2,286 patients underwent AVR+CABG and 1,637 AVR alone. A propensity score was developed and used for matched comparisons of outcomes (1,082 patient pairs). Analyses of long-term mortality were performed for each group, then combined to identify common and unique risk factors.
Patients with AS+CAD versus isolated AS were older, more symptomatic, and more likely to be hypertensive, and had lower ejection fraction and greater arteriosclerotic burden but less severe AS. Hospital morbidity and long-term survival were poorer (43% vs. 59% at 10 years). Both groups shared many mortality risk factors; however, early risk among AS+CAD patients reflected effects of CAD; late risk reflected diastolic left ventricular dysfunction expressed as ventricular hypertrophy and left atrial enlargement. Patients with isolated AS and few comorbidities had the best outcome, those with CAD without myocardial damage had intermediate outcome equivalent to propensity-matched isolated AS patients, and those with CAD, myocardial damage, and advanced comorbidities had the worst outcome.
Cardiovascular risk factors and comorbidities must be considered in managing patients with severe AS. Patients with severe AS and CAD risk factors should undergo early diagnostics and AVR+CABG before ischemic myocardial damage occurs.
Journal of the American College of Cardiology 02/2013; 61(8):837-48. · 14.16 Impact Factor
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Turki B Albacker,
Eugene H Blackstone,
Sarah J Williams,
A Marc Gillinov,
Jose L Navia,
Eric E Roselli,
Suresh Keshavamurthy,
Gösta B Pettersson,
Tomislav Mihaljevic,
Douglas R Johnston,
Joseph F Sabik,
Bruce W Lytle, Lars G Svensson
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ABSTRACT: OBJECTIVE: In patients with pulmonary dysfunction, it is unclear whether a less-invasive approach for aortic valve replacement is well tolerated or even beneficial. We investigated whether a partial upper J-incision for aortic valve replacement leads to more favorable outcomes than a full sternotomy in patients with chronic lung disease by using forced expiratory volume in 1 second as a surrogate. METHODS: From January 1995 to July 2010, 6931 patients underwent primary isolated aortic valve replacement; 655 had forced expiratory volume in 1 second measured and expressed as percent of predicted (FEV1%; 368 via J-incision, 287 via full sternotomy). Postoperative outcomes were compared among 223 propensity-matched pairs. RESULTS: Patients diagnosed with chronic lung disease had longer median intensive care unit (41 vs 27 hours, P = .001) and postoperative (7.1 vs 6.1 days, P < .0001) lengths of stay than those without chronic lung disease. At normal values of FEV1%, little difference was observed in either of these times for J-incision versus full sternotomy; however, at progressively lower FEV1%, these times lengthened, with increasing benefit for J-incision. Among propensity-matched patients, other postoperative complications were similar. Early survival (93% vs 89% at 1 year, P = .07) was possibly higher in matched patients with J-incision, but late survival was similar (P = .9). Patients with FEV1% less than 50 who underwent J-incision had the greatest survival advantage, which persisted for 5 years. CONCLUSIONS: In patients with preoperative respiratory dysfunction, a less-invasive partial upper J-incision for aortic valve replacement can lead to more favorable outcomes than a full sternotomy, including shorter intensive care unit and postoperative lengths of stay and better early survival, which are amplified with decreasing pulmonary function.
The Journal of thoracic and cardiovascular surgery 01/2013; · 3.41 Impact Factor
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Jocelyn M Beach,
Tomislav Mihaljevic,
Jeevanantham Rajeswaran,
Thomas Marwick,
Samuel T Edwards,
Edward R Nowicki,
James Thomas, Lars G Svensson,
Brian Griffin,
A Marc Gillinov,
Eugene H Blackstone
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ABSTRACT: OBJECTIVES: We sought to understand the factors modulating left heart reverse remodeling after aortic valve replacement, the relationship between the preoperative symptoms and modulators of left heart remodeling, and their influence on long-term survival. METHODS: From October 1991 to January 2008, 4264 patients underwent primary aortic valve replacement for aortic stenosis. Changes in the time course of left ventricular reverse remodeling were assessed using 5740 postoperative transthoracic echocardiograms from 3841 patients. RESULTS: Left ventricular hypertrophy rapidly declined after surgery, from 137 ± 42 g/m(2) preoperatively to 115 ± 27 by 2 years and remained relatively constant but greater than the upper limit of normal. The most important risk factor for residual left ventricular hypertrophy was greater preoperative left ventricular hypertrophy (P < .0001). Other factors included a greater left atrial diameter (reflecting diastolic dysfunction), a lower ejection fraction, and male gender. An increased postoperative transprosthesis gradient was associated with greater residual left ventricular hypertrophy; however, its effect was minimal. Preoperative severe left ventricular hypertrophy and left atrial dilatation reduced long-term survival, independent of symptom status. CONCLUSIONS: Severe left ventricular hypertrophy with left atrial dilatation can develop from severe aortic stenosis, even without symptoms. These changes can persist, are associated with decreased long-term survival even after successful aortic valve replacement, and could be indications for early aortic valve replacement if supported by findings from an appropriate prospective study.
The Journal of thoracic and cardiovascular surgery 01/2013; · 3.41 Impact Factor
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Lars G Svensson,
David H Adams,
Robert O Bonow,
Nicholas T Kouchoukos,
D Craig Miller,
Patrick T O'Gara,
David M Shahian,
Hartzell V Schaff,
Cary W Akins,
Joseph Bavaria, [......],
Bruce W Lytle,
Michael J Mack,
T Brett Reece,
George R Reiss,
Eric Roselli,
Craig R Smith,
Vinod H Thourani,
E Murat Tuzcu,
John Webb,
Mathew R Williams
The Annals of thoracic surgery 01/2013; · 3.74 Impact Factor
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Lars G Svensson,
Eugene H Blackstone,
Mazin Alsalihi,
Lillian H Batizy,
Eric E Roselli,
Rebecca McCullough,
Alessandro Vivacqua,
Rocio T Moran,
A Marc Gillinov,
Maran Thamilarasan,
Brian Griffin,
Donald F Hammer,
William J Stewart,
Joseph F Sabik,
Bruce W Lytle
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ABSTRACT: BACKGROUND: Few series have examined follow-up risks of the David reimplantation operation in patients with connective tissue disorder. Hence, we assessed its midterm safety and effectiveness for Marfan syndrome and other connective tissue disorders, such as Ehlers-Danlos, Loeys-Dietz, and marfanoid syndromes. METHODS: Of 313 patients who underwent modified David reimplantation, 178 identified as having connective tissue disorders underwent operation from January 1, 1991, to December 31, 2010. These disorders included Marfan (84%), marfanoid (8.4%), Loeys-Dietz (5.6%), Ehlers-Danlos (1.1%), and other syndromes (1.1%). Concomitant procedures included mitral valve repair in 7.3% and an atrial fibrillation procedure in 3.4%. RESULTS: There were no operative or 30-day deaths. Complications included prolonged ventilation (3%), renal failure (3%), reoperation for bleeding (2.2%), and permanent stroke (0.56%). Eight-year survival was 94% and freedom from aortic valve reoperation at 6 years was 92%. Of the 7 aortic valve reoperations, 3 were attributable to endocarditis and 3 to technical failure. One reoperation was performed at another hospital, and the reason could not be determined. There were no late strokes or hemorrhagic events. At 4 years, approximately 70% of patients had no aortic valve regurgitation, and 18% were in grade 1+. CONCLUSIONS: Prophylactic root and valve preservation using David reimplantation is safe and provides excellent midterm effectiveness and low risk of late events except for endocarditis.
The Annals of thoracic surgery 12/2012; · 3.74 Impact Factor
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Suzanne V Arnold,
John A Spertus,
Yang Lei,
Keith B Allen,
Adnan K Chhatriwalla,
Martin B Leon,
Craig R Smith,
Matthew R Reynolds,
John G Webb, Lars G Svensson,
David J Cohen
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ABSTRACT: BACKGROUND: -Improving functional status and quality of life are important goals of treatment for patients with severe aortic stenosis. The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a health status measure designed for monitoring heart failure and has been used in studies of patients with aortic stenosis (AS). However, its psychometric properties have not yet been evaluated in patients with severe valvular heart disease. METHODS AND RESULTS: -We analyzed data from 955 patients who were enrolled in the PARTNER trial of transcatheter aortic valve replacement (TAVR) to evaluate the reliability, responsiveness, validity, and prognostic importance of the KCCQ in patients with severe AS. The KCCQ was administered to all patients at baseline and at 1, 6, and 12 months after randomization to medical therapy, TAVR, or surgical valve replacement. Among patients who were clinically stable, there were only small changes in the KCCQ domain scores over time (mean differences 0.1 to 4.2 points), and the intraclass correlation coefficients for the domains showed good agreement between paired assessments (0.65-0.76). In contrast, the domain scores of patients who underwent TAVR showed large changes after treatment (mean differences 13-30 points). The construct validity of each of the domains was demonstrated by comparing the domains against relevant reference measures (Spearman correlations 0.46-0.69). Finally, among 157 patients who were randomized to medical management, lower KCCQ overall summary scores at baseline were strongly associated with an increased risk of mortality over the following 12 months, even after adjusting for STS mortality risk score (HR 1.34 per 10 point reduction, 95% CI 1.17-1.54). CONCLUSIONS: -The KCCQ is a highly reliable, responsive, and valid measure of symptoms, functional status, and quality of life in patients with severe, symptomatic AS.
Circulation Heart Failure 12/2012; · 6.29 Impact Factor
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Matthew R Reynolds,
Elizabeth A Magnuson,
Yang Lei,
Kaijun Wang,
Katherine Vilain,
Haiyan Li,
Joshua Walczak,
Duane S Pinto,
Vinod H Thourani, Lars G Svensson,
Michael J Mack,
D Craig Miller,
Lowell E Satler,
Joseph Bavaria,
Craig R Smith,
Martin B Leon,
David J Cohen
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ABSTRACT: OBJECTIVES: The aim of this study was to evaluate the cost-effectiveness of transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (AVR) for patients with severe aortic stenosis and high surgical risk. BACKGROUND: TAVR is an alternative to AVR for patients with severe aortic stenosis and high surgical risk. METHODS: We performed a formal economic analysis based on cost, quality of life, and survival data collected in the PARTNER A (Placement of Aortic Transcatheter Valves) trial in which patients with severe aortic stenosis and high surgical risk were randomized to TAVR or AVR. Cumulative 12-month costs (assessed from a U.S. societal perspective) and quality-adjusted life-years (QALYs) were compared separately for the transfemoral (TF) and transapical (TA) cohorts. RESULTS: Although 12-month costs and QALYs were similar for TAVR and AVR in the overall population, there were important differences when results were stratified by access site. In the TF cohort, total 12-month costs were slightly lower with TAVR and QALYs were slightly higher such that TF-TAVR was economically dominant compared with AVR in the base case and economically attractive (incremental cost-effectiveness ratio <$50,000/QALY) in 70.9% of bootstrap replicates. In the TA cohort, 12-month costs remained substantially higher with TAVR, whereas QALYs tended to be lower such that TA-TAVR was economically dominated by AVR in the base case and economically attractive in only 7.1% of replicates. CONCLUSIONS: In the PARTNER trial, TAVR was an economically attractive strategy compared with AVR for patients suitable for TF access. Future studies are necessary to determine whether improved experience and outcomes with TA-TAVR can improve its cost-effectiveness relative to AVR. (THE PARTNER TRIAL: Placement of AoRTic TraNscathetER Valve Trial; NCT00530894).
Journal of the American College of Cardiology 11/2012; · 14.16 Impact Factor
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ABSTRACT: The first mechanical heart valve prosthesis designed by Dr Charles Hufnagel was implanted to the descending aorta of a 30 year old woman with severe aortic regurgitation in 1952(1). Eight years after the initial succesful prosthetic valve implantation, Dr Harken sutured a prosthetic valve (Starr Edwards Valve) to the aortic anulus after removing the diseased native valve. During the ensuing years different types of valves made from pyrolytic carbon were tried. Though successfully remedied the aortic valve disease, mechanical prosthesis required lifelong anticoagulation resulting in high rates of bleeding and thrombosis complications.
Circulation 10/2012; · 14.74 Impact Factor
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The Journal of thoracic and cardiovascular surgery 08/2012; · 3.41 Impact Factor
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Philippe Généreux,
John G Webb, Lars G Svensson,
Susheel K Kodali,
Lowell F Satler,
William F Fearon,
Charles J Davidson,
Andrew C Eisenhauer,
Raj R Makkar,
Geoffrey W Bergman,
Vasilis Babaliaros,
Joseph E Bavaria,
Omaida C Velazquez,
Mathew R Williams,
Irene Hueter,
Ke Xu,
Martin B Leon
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ABSTRACT: This study sought to identify incidence, predictors, and impact of vascular complications (VC) after transfemoral (TF) transcatheter aortic valve replacement (TAVR).
VC after TF-TAVR are frequent and may be associated with unfavorable prognosis.
From the randomized controlled PARTNER (Placement of AoRTic TraNscathetER Valve) trial, a total of 419 patients (177 from cohort B [inoperable] and 242 from cohort A [operable high-risk]) were randomly assigned to TF-TAVR and actually received the designated treatment. First-generation Edwards-Sapien valves and delivery systems were used, via a 22- or 24-F sheath. The 30-day rates of major and minor VC (modified Valve Academic Research Consortium definitions), predictors, and effect on 1-year mortality were assessed.
Sixty-four patients (15.3%) had major VC and 50 patients (11.9%) had minor VC within 30 days of the procedure. Among patients with major VC, vascular dissection (62.8%), perforation (31.3%), and access-site hematoma (22.9%) were the most frequent modes of presentation. Major VC, but not minor VC, were associated with significantly higher 30-day rates of major bleeding, transfusions, and renal failure requiring dialysis, and with a significantly higher rate of 30-day and 1-year mortality. The only identifiable independent predictor of major VC was female gender (hazard ratio [HR]: 2.31 [95% confidence interval (CI): 1.08 to 4.98], p = 0.03). Major VC (HR: 2.31 [95% CI: 1.20 to 4.43], p = 0.012), and renal disease at baseline (HR: 2.26 [95% CI: 1.34 to 3.81], p = 0.002) were identified as independent predictors of 1-year mortality.
Major VC were frequent after TF-TAVR in the PARTNER trial using first-generation devices and were associated with high mortality. However, the incidence and impact of major VC on 1-year mortality decreased with lower-risk populations.
Journal of the American College of Cardiology 07/2012; 60(12):1043-52. · 14.16 Impact Factor
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ABSTRACT: Right-sided aortic arch is a rare congenital anomaly for which different surgical approaches have been reported. This study reviewed our experience with several techniques.
We retrospectively reviewed 17 patients undergoing right-sided arch repair at the Cleveland Clinic from 2001 to 2010. Computed tomographic angiograms of the aorta and its branches were reviewed and correlated with patient presentation and surgical approach.
Fourteen patients had type II right aortic arch with aberrant left subclavian artery. Fifteen patients presented with obstructive symptoms. Surgical approach included right thoracotomy (11 patients), left thoracotomy (two patients), full sternotomy (one patient), and hybrid repair (three patients). Cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest was used in 11 patients, and two patients had partial CPB. Left subclavian artery bypass was performed in seven patients. Median duration of intubation was 1.9 days. Average length of intensive care unit stay was three days and average hospital stay 11 days. Postoperative outcomes included respiratory failure (one patient), renal failure (one patient), bloodstream infection (two patients), and death (one patient). No patient had stroke or paraplegia. In-hospital death occurred in one patient, and all survivors were alive and asymptomatic for a mean of 38 months.
The surgical treatment for right-sided aortic arch can be performed with excellent perioperative outcomes when tailored to patient presentation and anatomic configuration. Patients with obstructive symptoms benefit from open or hybrid surgical treatment, with immediate relief of compression. Patients with aneurysmal dilatation without compression symptoms can be managed with open, endovascular, or hybrid surgical intervention.
Journal of Cardiac Surgery 07/2012; 27(4):511-7. · 0.87 Impact Factor
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ABSTRACT: Open, hybrid, and endovascular procedures are used for grown-up patients with aortic coarctation and complications after repair, an expanding population. We sought to characterize patients and procedures, assess early and late outcomes, and describe indications to guide treatment of these complex patients.
Between May 1999 and January 2011, 110 patients underwent open (n=40), hybrid (n=11), or endovascular (n=59) repair of coarctation (n=43), recurrent aortic coarctation (n=42), or postrepair aneurysm (n=25). Mean age was 38±14 years. Sixty-eight had previous repairs (median 27 years earlier; range, 1 to 50). Twenty-two had prior cardiovascular operations other than coarctation and 50% had bicuspid valve. Fifty-nine concomitant procedures were performed in 45 patients (40%). Data were from the prospective database, chart review, and Social Security Death Index.
Technical success was achieved in 100%, with no hospital deaths, no strokes, and no paraplegia. Complications were uncommon and included respiratory failure (n=2, 1.8%), and temporary renal failure (n=2, 1.8%). Twenty-two patients required reinterventions, but half of those were planned. There was no difference in occurrence of unplanned reintervention between approaches (endovascular 12%, hybrid 18%, open 12.5%). Length of stay was 4.8±4.8 days. Transcoarct gradient fell from 37.6±18 mm Hg preoperatively to 7.0±6.9 mm Hg in coarctation patients. Postrepair aneurysm patients had no late ruptures, and maximum diameter shrunk from 5.9±1.3 cm preoperatively to 4.8±1.3 cm. Estimated survival at 1, 5, and 8 years was 95%, 95%, and 90%, respectively.
Coarctation, recurrent coarctation, and postrepair aneurysm/pseudoaneurysm in adolescent and adult patients can be safely and effectively managed with open, hybrid, or endovascular techniques. Optimal results are achievable in this complex population of patients with a multimodality approach tailored to surgical indication and anatomy. All survivors of coarctation repair require lifelong surveillance.
The Annals of thoracic surgery 06/2012; 94(3):751-6; discussion 757-8. · 3.74 Impact Factor
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The Journal of thoracic and cardiovascular surgery 06/2012; 144(3):e90-1. · 3.41 Impact Factor
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Stefan Toggweiler,
David A Wood,
Josep Rodés-Cabau,
Samir Kapadia,
Alexander B Willson,
Jian Ye,
Anson Cheung,
Jonathon Leipsic,
Ronald K Binder,
Ronen Gurvitch,
Melanie Freeman,
Christopher R Thompson, Lars G Svensson,
Eric Dumont,
E Murat Tuzcu,
John G Webb
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ABSTRACT: This study sought to evaluate outcomes after implantation of a second transcatheter heart valve (THV-in-THV) for acute THV failure.
Aortic regurgitation after transcatheter aortic valve replacement (TAVR) may be valvular due to prosthetic leaflet dysfunction or paravalvular due to poor annular sealing.
Patients undergoing aortic balloon-expandable TAVR at 3 centers were prospectively evaluated at baseline, intraprocedurally, at hospital discharge, and annually.
Of 760 patients undergoing TAVR, 21 (2.8%) received a THV-in-THV implant due to acute, severe regurgitation. Aortic regurgitation was paravalvular in 18 patients and transvalvular in the remaining 3 patients. THV-in-THV implantation was technically successful in 19 patients (90%) and unsuccessful in 2 patients (10%), who subsequently underwent open heart surgery. Mortality at 30 days and 1 year was 14.3% and 24%, respectively. After successful THV-in-THV, mean aortic valve gradient fell from 37 ± 12 mm Hg to 13 ± 5 mm Hg (p < 0.01); aortic valve area increased from 0.64 ± 0.14 cm(2) to 1.55 ± 0.27 cm(2) (p < 0.01); and paravalvular aortic regurgitation was none in 4 patients, mild in 13 patients, and moderate in 2 patients. At 1-year follow-up, 1 patient had moderate and the others had mild or no paravalvular leaks. The mean transvalvular gradient was 15 ± 4 mm Hg, which was higher than in patients undergoing conventional TAVR (11 ± 4 mm Hg, p = 0.02).
THV-in-THV implantation is feasible and results in satisfactory short- and mid-term outcomes.
05/2012; 5(5):571-7. · 1.07 Impact Factor
