The frozen elephant trunk technique: a new treatment for thoracic aortic aneurysms.
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Aged↗
Biomedical subjects
Christian Hagl
Publications and source records attributed to Christian Hagl.
The gut-first approach for repair of Crawford extent III thoracoabdominal aortic aneurysms.
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Aged↗
Diabetes and evidence of atherosclerosis are major risk factors for adverse outcome after elective thoracic aortic surgery.
BACKGROUND: To predict risk after elective repair of ascending aorta and aortic arch aneurysms, we studied 464 consecutive patients. METHODS: Adverse outcome (stroke or hospital death) was analyzed in 372 patients who underwent proximal repair and 92 patients who underwent aortic arch replacement from 1986 to the present. Preoperative risk factors with a P value less than.2 in a univariate analysis were entered into a multivariate model, and an equation incorporating independent risk factors was derived separately for proximal aorta and arch surgery. RESULTS: Age more than 65 years (P =.04), diabetes (P =.02), cause (P =.01), and prolonged total cerebral protection time (duration of hypothermic circulatory arrest and selective cerebral perfusion, P =.001) were significant univariate risk factors for elective proximal aortic repair. Diabetes (P =.005, odds ratio 5.1), atherosclerosis (P =.003, odds ratio 4.0), and dissection (P =.048, odds ratio 2.5) were independent factors. For elective arch surgery, female sex (P =.07), age more than 65 years (P =.04), coronary artery disease (P =.02), diabetes (P =.06), cause (P =.07), and prolonged total cerebral protection time (P =.025) were univariate risk factors. Female sex (P =.05, odds ratio 4.7), coronary artery disease (P =.02, odds ratio 6.5), diabetes (P =.13, odds ratio 4.0), and total cerebral protection time (P =.03, odds ratio 1.02/min) were independent factors. To calculate risk of adverse outcome (P), enter 1 if factor is present, 0 if absent, and estimate total cerebral protection time (in minutes). [equation: see text]. CONCLUSION: In this large series of patients, the presence of diabetes and manifestations of atherosclerosis emerge as extremely important risk factors for adverse outcome after ascending aorta or arch surgery, displacing age. Multivariate equations derived from these data allow more precise calculation of risk for each individual contemplating elective surgery.
Adolescent↗
Technical advances of pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension.
OBJECTIVE: To minimize the side-effects of circulatory arrest times and profound hypothermia in patients undergoing pulmonary thromboendarterectomy (PTE) for chronic thromboembolic pulmonary hypertension (CTEPH). METHODS: Between March 2000 and June 2002, 30 patients (in New York Heart Association (NYHA) class III or IV) were operated for CTEPH using our modified technique. It includes moderate hypothermic (28-32 degrees C), total cardiopulmonary bypass (CPB) and simultaneous selective antegrade cerebral perfusion and occlusion of the bronchial arteries by introducing an occlusive balloon catheter into the descending aorta. The preoperative pulmonary vascular resistance in the cohort was 873+/-248dynes/s/cm(-5). RESULTS: Mean total CPB, cross-clamp times and duration of anterograde cerebral perfusion were 132+/-40, 98+/-21 and 21+/-10min, respectively. Mean core temperature 29.5+/-1.9 degrees C. The duration of postoperative mechanical ventilatory support was 34+/-44h and the mean stay in the ICU was 5+/-9 days. Seven patients had mild to moderate lung reperfusion injury, one transient neurological dysfunction. Three patients (10%) died during their hospital stay, two for multiorgan failure and one for persistent pulmonary hypertension. All patients had a significant pulmonary hemodynamic improvement and all achieved NYHA class I (P<0.01) status 4 weeks after discharge, remaining stable at a median follow-up time of 16 months (range, 1-29 months) postoperatively. CONCLUSIONS: These technical advances improve neurological outcome, control back-bleeding from bronchial arteries and avoid prolonged rewarming phases in patients undergoing PTE.
Chronic Disease↗
Hypothermic circulatory arrest during ascending and aortic arch surgery: the theoretical impact of different cerebral perfusion techniques and other methods of cerebral protection.
Operations on the thoracic aorta using hypothermic circulatory arrest are still associated with significant morbidity and mortality due to neurological complications. During the last decades, different cerebral protection techniques have been introduced into clinical practice to reduce the incidence of such complications. Furthermore clinical as well as basic researches have been performed to improve the outcome after these operations. Currently different cerebral perfusion methods are in clinical use and the superiority of one or the other method is a matter of controversial discussion. This review has been undertaken to evaluate the theoretical impact of these different methods of cerebral protection. Based on the experience of the authors the pros and cons are discussed with clinical and experimental reports from the literature.
Aorta↗
Organ protection during hypothermic circulatory arrest.
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Animals↗
[Recent developments in surgery of the thoracic aorta].
Aortic surgery is under continuous development. This applies to the aortic root where more and more reconstructive efforts are being made but also to intraoperative means of organ protection. Likewise, the endoluminar stent graft approach to downstream pathologies of the aorta has broadened the classical treatment option "replacement" by "exclusion". Some of these evolving changes in operative strategies and indications are discussed on the basis of a single-center experience.
Aortic Dissection↗
Aortic valve reimplantation in ascending aortic aneurysm: risk factors for early valve failure.
BACKGROUND: Aortic root reconstruction by reimplantation of the native valve represents a new therapeutic option for ascending aortic aneurysms. Information about long-term follow-up is limited, and possible predictors for failure of reconstruction have not been evaluated so far. METHODS: After aortic valve reimplantation 101 patients were followed in a prospective observational study. From this cohort the first 75 consecutive patients with a complete 1-year follow-up were chosen for further analysis. Clinical and echocardiographic data were obtained preoperatively, intraoperatively, and early postoperatively, as well as after 1 year of follow-up. RESULTS: No mortality was observed within the first 30 days. There were 52 male patients, mean age was 49.1+/-20.6 years, observation period was 35.6+/-20.6 months, and Marfan's syndrome was present in 22 patients. Although in 67 patients a stable valve function could be demonstrated, 5 patients presented with mild aortic insufficiency or had to be operated on again for secondary valve failure (n = 3). Analyzing possible demographic, disease-related, and procedure-related risk factors in a multivariable approach, only level of coaptation within the graft (as assessed by echocardiography) could be identified as being related to the subsequent development of aortic insufficiency. Coaptation level within the tube graft (type A) resulted in a mean aortic regurgitation grade of 0.3+/-0.5 as compared with a mean grade of 2.5+/-0.6 for a coaptation type C (below the prosthesis; p < 0.001). CONCLUSIONS: Aortic valve reimplantation is a promising alternative to alloprosthetic composite replacement. A level of coaptation within the tube graft is essential to achieve valve competence.
Adolescent↗
Results of valve-sparing aortic root reconstruction in 158 consecutive patients.
BACKGROUND: This study assesses the durability and clinical outcome of valve-sparing aortic root reconstruction using the reimplantation technique in a single center cohort. METHODS: From July 1993 to July 2001, 158 patients underwent replacement of the ascending aorta with native valve reimplantation. Mean age of patients was 52 +/- 17 years (9 to 84 years), 103 were men (65%). Thirty-four patients (22%) suffered from Marfan's syndrome. Aortic dissection Stanford type A was present in 29 patients (19%) (22 acute, 7 chronic), and concomitant partial or total arch replacement was necessary in 57 patients (36%). One or more additional procedures were performed in 28 patients (18%). Mean follow-up was 36 +/- 25 months (0.4 to 96 months). RESULTS: Thirty-day mortality was 3.8% (6 patients), but only 2.2% in elective patients. Mean bypass time was 169 +/- 50 minutes (99 to 440 minutes), aortic cross-clamp time was 129 +/- 31 minutes (79 to 205 minutes). In patients undergoing arch replacement, circulatory arrest was 26 +/- 18 minutes (7 to 99 minutes). During follow-up, there were 5 (3.3%) cardiac-related late deaths. Grade of aortic insufficiency (AI) decreased from 2.3 +/- 1.1 (0 to 4) preoperatively to 0.23 +/- 0.44 (0 to 2) postoperatively (p < 0.0001). Six patients required aortic valve replacement, 4 of those due to progressive AI. Average grade of AI increased significantly to 0.42 +/- 0.61 (0 to 3) at latest evaluation (p = 0.002). Two patients experienced a transient ischemic attack within the first postoperative week. No further thromboembolic complications were noticed. All patients presented with a favorable exercise tolerance. CONCLUSIONS: The aortic valve reimplantation technique achieves excellent clinical outcome with few complications even in complex pathologies. Lack of anticoagulation and favorable durability encourage wider and earlier use of this technique.
Adolescent↗
Acute type B aortic dissection: surgical therapy.
BACKGROUND: Surgery for acute type B aortic dissection is associated with significant mortality. We report the results for 34 consecutive patients who underwent urgent surgery because they met criteria for operation during the acute phase (< 14 days) of acute type B dissection. METHODS: The average patient age was 64 (32 to 88) years. Indications for surgery were persistent pain (12), threatened exsanguination (18), malperfusion (renal [3], limb [3]), rapid aortic enlargement (4), and uncontrolled hypertension (1). The mean interval from onset of pain to operation was 7 (1 to 14) days. Resection included the proximal descending aorta in 32, the distal aortic arch in 10, extension to the diaphragm in 10, and involved a thoracoabdominal procedure in 3. Surgical techniques included hypothermic circulatory arrest (16 [47%]), distal bypass, monitoring of somatosensory-evoked potentials, sequential intercostal sacrifice (average, 5.6 pairs), cerebrospinal fluid drainage, and steroid administration. RESULTS: There was no hospital mortality. Important complications occurred in 16 patients (47%): 10 respiratory requiring tracheostomy, six infectious, four dialysis, two myocardial infarctions, and two neurologic (one transient stroke, one paraplegia). Mean intensive care unit and hospital stays were 10 (3 to 32) and 35 (7 to 107) days. Survival at 5 and 10 years was 80% and 57%, respectively (mean follow-up, 5.8 years). CONCLUSIONS: Patients meeting criteria for urgent surgery have a low perioperative risk for mortality and paraplegia, and are relatively free from long-term aorta-related complications. These findings warrant consideration of earlier surgery for appropriate patients with acute type B aortic dissection.
Acute Disease↗
Replacing the ascending aorta and aortic valve for acute prosthetic valve endocarditis: is using prosthetic material contraindicated?
BACKGROUND: The use of prosthetic material (rather than a homograft) for ascending aorta/aortic valve replacement (Bentall procedure) in cases of acute prosthetic valve endocarditis is controversial. We report favorable results using this technique almost exclusively (a homograft was used in only 3 patients with hematological problems) during a 12-year interval. METHODS: Twenty-eight patients (55 +/- 14 years; 22 male) underwent a Bentall procedure for acute prosthetic valve endocarditis between 1988 and 2000. Twenty-five patients had undergone previous aortic valve replacement (1 with concomitant mitral valve replacement, 4 with coronary artery bypass grafting), and 3 had had a previous Bentall operation. The median interval between initial surgery and reoperation was 13 months (range, 1 to 106). Sixty-eight percent of operations were urgent or emergencies. Ninety-three percent of patients had significant aortic regurgitation; complete annuloaortic dehiscence occurred in 71%, and in 57%, an abscess was found. Causative organisms were identified in 25 of 28 patients: Staphylococcus epidermidis (9), Staphylococcus aureus (7), Streptococcus viridans (6), Pseudomonas (2), and Legionella (1). RESULTS: Twenty-three patients had mechanical and 5 had biological valves implanted during the Bentall procedure. Hypothermic circulatory arrest was used in 64%. Hospital mortality was 11%: there was one intraoperative death, and two before discharge (one cardiac, one sepsis). Eighty-nine percent survived without stroke. During follow-up (median, 44.5 months; complete in 92%), 1 patient died of recurrent endocarditis at 4 months. CONCLUSIONS: These results indicate that prosthetic root replacement may be superior to use of a homograft for acute aortic prosthetic valve endocarditis, with only a 4% incidence of recurrent endocarditis and reoperation.
Adult↗
Valve-sparing aortic root reconstruction in patients with significant aortic insufficiency.
BACKGROUND: To assess the feasibility and outcome of the valve-sparing aortic root reimplantation technique in patients with severe preoperative aortic insufficiency (AI). METHODS: Within 8 years we have operated on 158 patients with aneurysms of the ascending aorta using the reimplantation technique. We identified 83 patients with AI grade 3 or 4 (mean 3.1 +/- 0.4) preoperatively (study group). This cohort was compared with 71 patients with AI grade 2 or less (mean 1.3 +/- 0.9; control group) with regard to mortality, operative variables, complications, need for reoperation, postoperative AI, and clinical presentation during follow-up. RESULTS: Patient demographics were comparable in both groups. However, Marfan's syndrome (32% versus 13%, p = 0.006) and acute type A aortic dissection (20% versus 8.4%, p = 0.059) were more frequent in the control group. In addition, bypass (177 +/- 60 minutes versus 160 +/- 36 minutes, p = 0.022) and cross clamp times (133 +/- 34 minutes versus 124 +/- 27 minutes, p = 0.049) were significantly longer in controls. Mortality was low in the study group and comparable with controls (30-day, 3.6% versus 4.2%; during follow-up, 3.8% versus 5.9%; p = not significant [NS]). Reoperation rate was almost identical in both groups (3.8% versus 4.4%, p = NS). Mean grade of AI was significantly higher in the study group early postoperatively (0.31 +/- 0.46 versus 0.18 +/- 0.42, p = 0.049) but comparable at the last visit (0.43 +/- 0.58 versus 0.42 +/- 0.62, p = NS). During follow-up neither thromboembolic complications nor bleeding events were noted in either group. Clinical performance at the last visit revealed no significant difference between the groups. CONCLUSIONS: Preoperative severe aortic insufficiency does not impair the excellent outcome seen after a mean of 3 years of follow-up in patients undergoing the reimplantation technique for valve-sparing aortic root reconstruction.
Adolescent↗
The impact of spinal angiography on the neurological outcome after surgery on the descending thoracic and thoracoabdominal aorta.
BACKGROUND: Neurologic complications remain one of the major concerns in surgery on the descending thoracic and thoracoabdominal aorta. The impact of preoperative spinal angiography on postoperative neurologic outcome was assessed. METHODS: Between September 1993 and December 1999, 109 patients (mean age, 58.2 years; range, 24 to 77) underwent preoperative spinal angiography: 50 (45.9%) for aneurysm and 59 (54.1%) for chronic dissection. Sixty-one patients (56.0%) underwent replacement of the descending thoracic aorta whereas the thoracoabdominal aorta was replaced in 48 (44.0%) patients. All intercostal or lumbar arteries that had previously been visualized as the origin of the great radicular artery (GRA) were preserved. RESULTS: The origin of the GRA was located by spinal angiography in 65 of the 109 patients (59.6%). It was found between level T-5 and L-3 and on the left side in 75.4% (49 of 65) patients. In patients with aneurysms, it was identified less frequently (48%) compared with patients with chronic dissection (69.5%, p = 0.02). The overall operative mortality rate was 5.5% (6 of 109 patients). There were 7 patients (6.4%) with postoperative paraplegia. In 3 of them the origin of the GRA had been reimplanted. CONCLUSIONS: Even in patients with an identified and subsequently reimplanted GRA, postoperative paraplegia could not always be prevented. Spinal angiography has no impact on the neurologic outcome of thoracic and thoracoabdominal aortic replacement.
Adult↗
Impact of high intracranial pressure on neurophysiological recovery and behavior in a chronic porcine model of hypothermic circulatory arrest.
OBJECTIVE: This review was undertaken to determine whether high intracranial pressure (ICP) during reperfusion after hypothermic circulatory arrest (HCA) correlates with evidence of suboptimal cerebral protection in a chronic porcine model. METHODS: In concurrent studies of cerebral protection, 48 control pigs (24-31 kg) underwent 90 min of HCA at 20 degrees C using a strictly standardized protocol. Hemodynamic measurements, ICP and neurophysiological data (EEG, SSEP) were assessed before HCA and until 3 h postoperatively. ICP was measured using a Codman microtip catheter inserted directly into brain parenchyma. Neurological/behavioral evaluation (9=full recovery) was carried out daily through postoperative day (POD) 3. RESULTS: There were no significant hemodynamic or metabolic differences between individual animals. ICP (mmHg) increased significantly for the first 3 h after HCA: from baseline levels of 6.2+/-2.1 to 10+/-2.6 at 1 h, 11+/-3.2 at 2 h and 10+/-3.6 mmHg at 3 h; P<0.001 for the trend. EEG recovery 3 h after HCA was observed in 13 animals (27%), and correlated with lower ICP during reperfusion (P<0.001): with each 1 mmHg increase in ICP at 3 h, the odds of early EEG recovery decreased by a factor of 0.72. Lower ICP during reperfusion was also significantly associated with higher behavioral scores on POD 1 and 2, P<0.001. CONCLUSIONS: A significant rise in ICP may help explain the prolonged obtundation and confusion often seen clinically after HCA. If these small but consistent increases in ICP contribute to rather than reflect ischemic neuronal damage, simple maneuvers to reduce ICP may improve cerebral recovery after HCA.
Animals↗
Improved right heart function after myocardial preservation with 2,3-butanedione 2-monoxime in a porcine model of allogenic heart transplantation.
BACKGROUND: Right heart dysfunction is a major cause for early morbidity and mortality after heart transplantation. Experiments were designed to evaluate the influence of the calcium-desensitizing drug 2,3-butanedione 2-monoxime (BDM) on right heart function in a porcine model of heart transplantation. METHODS: Donor hearts of domestic pigs were arrested with BDM in Krebs solution (n = 7) and with BDM in Bretschneider's histidine-tryptophan-ketoglutarate (HTK) solution (n = 6). There were 2 control groups: University of Wisconsin (UW, n = 6) and HTK (n = 6). An isovolumic model was used in which the right ventricular volume was precisely controlled in vivo with an intracavitary high-compliance balloon. After 4 hours of ischemia, hearts were transplanted into recipients. After 1 and 2 hours of reperfusion, the right ventricular balloon volume was increased in 10-mL increments until right ventricular failure occurred and the developed pressures were recorded. RESULTS: Maximal right ventricular developed pressures were significantly different after 2 hours of reperfusion (UW: 35 +/- 13 mm Hg; HTK: 47 +/- 8 mm Hg; Krebs+BDM: 49 +/- 9 mm Hg; HTK+BDM: 50 +/- 6 mm Hg; P =.04). Hearts subjected to BDM could be loaded with a significantly increased volume after 1 hour and after 2 hours (UW: 57 +/- 10 mL vs HTK: 43 +/- 8 mL vs Krebs+BDM: 70 +/- 10 mL vs HTK+BDM: 67 +/- 15 mL; P =.002). Postischemic right ventricular enddiastolic compliance was significantly increased in groups treated with BDM after 1 hour (P =.02) and after 2 hours (P =.039). CONCLUSIONS: The drug BDM significantly improves right ventricular function in a heart transplantation model. The increase in volume load and developed right ventricular pressure achieved by BDM application would translate into a decreased risk of right ventricular failure after clinical transplantation.
Adenosine↗