Biomedical subjects

Karl M Dossche

Publications and source records attributed to Karl M Dossche.

10 recordsLinked to original sources

PubMed2005

The Ross operation: an evaluation of a single institution's experience.

BACKGROUND: Pulmonary autograft aortic root replacement was used in adults. Risk factors for aortic valve incompetence (AI) and pulmonary homograft valve stenosis are identified. METHODS: From February 1991 through May 2003, 103 patients, with a mean age of 35.2 +/- 9.5 years, underwent aortic root replacement with the pulmonary autograft. Annulus reinforcement (reduction annuloplasty or use of root ring) was carried out in 45 patients. In all but 1 patient, the right ventricular outflow tract was reconstructed with a cryopreserved pulmonary homograft. Mean follow-up duration was 6.0 +/- 2.8 years (range 0.3 to 11 years). RESULTS: There were no hospital deaths. Overall patient survival was 98.9 +/- 1.0% at 1 year and 97.3 +/- 1.9% at 10 years. Autograft function follow-up resulted in 5 patients requiring reoperation for aortic incompetence. The univariate risk factors for aortic incompetence at discharge and during follow-up were respectively annulus reinforcement (p = 0.05) and bicuspic aortic valve (p = 0.05). Reoperation for homograft failure occurred in 1 patient. During follow-up, 24 patients (25.5%) developed homograft stenosis (gradient > 20 mm Hg). Univariate analysis indicated the diameter of the homograft (p = 0.001) as factor associated with stenosis during follow-up. Cox regression identified smaller diameter of the homograft (p = 0.001) and older age of donor (p = 0.002) as independent risk factor for the development of homograft stenosis. CONCLUSIONS: The Ross operation can be performed with few complications. Although both the aortic autograft and the pulmonary homograft have limited durability, this has not yet resulted in considerable reoperation rates and associated morbidity and mortality.

Adolescent↗

PubMed2005

Valve-related events after aortic root replacement with cryopreserved aortic homografts.

BACKGROUND: Aortic root replacement with aortic homografts for various pathologic conditions involving the aortic root has yielded good early results. To assess mid-term valve-related events, a follow-up study was conducted. METHODS: From February 1989 through January 2003, 213 patients with a mean age of 51.3 +/- 11.8 years underwent aortic root replacement with a cryopreserved aortic homograft. Bacterial endocarditis (58.7%) was the predominant indication for surgery (native valve endocarditis, n = 73; prosthetic valve endocarditis, n = 52). Of the 197 hospital survivors, 194 were entered in the follow-up study (98.5% complete). Endpoints of the study were death, valve-related death, reoperation for valve failure, endocarditis, thromboembolic events, and anticoagulant-related bleeding events. Follow-up was conducted between February and April 2003. RESULTS: Overall hospital mortality was 7.5% (n = 16; 70% confidence limits, 5.6% to 9.4%). Mean follow-up was 5.8 years (range, 0.3 to 14.3). In total, 20 late deaths occurred (10.3%); of these, 5 were valve-related. The overall survival at 5 and 10 years is 87.3% +/- 2.4% and 70.8% +/- 5.3%, respectively. Twenty-one patients (10.8%) required reoperation, either for structural valve deterioration (n = 12), false aneurysm (n = 3), endocarditis of the homograft (n = 3), or for other reason (n = 3). Mortality for reoperation was 28.6% (n = 6). Five-year and 10-year freedom from reoperation is 94.5% +/- 1.8% and 76.4% +/- 5.3%, respectively. Endocarditis of the homograft was reported in 4 patients (3.2%), of whom 1 patient was treated medically and 3 required reoperation. Thromboembolic events (n = 1) and anticoagulant-related bleeding events (n = 0) were rarely seen. A recent echocardiographic study was available in 124 patients (71.3%). Aortic regurgitation grade I to II was reported in 121 patients (97.6%). CONCLUSIONS: Cryopreserved aortic homografts function well on mid-term evaluation. The incidence of structural valve failure is acceptable. Reoperations for homograft endocarditis carry a high mortality rate.

Adolescent↗

PubMed2004

Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch.

BACKGROUND: This study compares the results of the separated graft technique and the en bloc technique as a method of arch vessels reimplantation during surgery of the aortic arch and determines the predictive risk factors associated with hospital mortality and adverse neurologic outcome during aortic arch repair. METHODS: Between October 1995 and March 2002, 352 patients (mean age 64.9 +/- 11.3 years; urgent status: 49/352 [13.9%]) underwent surgery of the aortic arch using the separated graft technique (group A: n = 230 [65.3%]) and the en bloc technique (group B: n = 122 [34.7%]) to reimplant the arch vessels. An aortic arch replacement was performed in 32 patients (9.1%), an ascending aorta and arch replacement in 222 patients (53.1%), an aortic arch and descending aorta replacement in 16 patients (4.5%), and a complete replacement of the thoracic aorta in 82 patients (23.3%). Brain protection was achieved by means of antegrade selective cerebral perfusion in all patients. The mean cardiopulmonary bypass time was 204.8 +/- 61.9 minutes (group A: 199.7 +/- 57.0 minutes; group B: 214.5 +/- 69.4 minutes; p = 0.033), the mean myocardial ischemic time was 121.5 +/- 43.2 minutes (group A: 116.7 +/- 38.9 minutes; group B: 130.80 +/- 49.4 minutes; p = 0.003), and the mean antegrade selective cerebral perfusion time was 84.5 +/- 36.4 (group A: separated graft technique 91.3 +/- 36.3 minutes; group B: 70.6 +/- 32.7 minutes; p = 0.000). RESULTS: Overall hospital mortality was 6.8% (group A: 6.5%; group B: 7.4%; p = not significant [NS]). The permanent neurologic dysfunction rate was 3.5% (group A: 4.0%; group B: 2.5%; p = NS). The transient neurologic dysfunction rate was 5.4% (group A: 5.5%; group B: 5.2%, p = NS). Postoperative systemic morbidity was similar in the two groups. A logistic regression analysis revealed preoperative cardiac tamponade (p = 0.011; odds ratio [OR] = 5.9) and cardiopulmonary bypass time (p = 0.010; OR = 1.01/min) to be independent predictors of hospital mortality. None of the analyzed preoperative variables were associated with an increased risk of permanent neurologic dysfunction. Age more than 70 years old (p = 0.029, OR = 5.7), myocardial revascularization (p = 0.001, OR = 2.9), and pump time (p = 0.013, OR = 1.01/min) were indicated as independent predictors of transient neurologic dysfunction by logistic regression. CONCLUSIONS: Antegrade selective cerebral perfusion was confirmed to be a safe method of cerebral protection allowing complex aortic arch operations to be performed with acceptable results in terms of hospital mortality and neurologic outcome. The separated graft technique had no adverse impact on hospital mortality and morbidity.

Adult↗

PubMed2004

AneuRx stent-graft failure four years after TAA exclusion.

PURPOSE: To present a case of graft material disruption 4 years after thoracic aortic aneurysm (TAA) exclusion with the AneuRx stent-graft. CASE REPORT: In 1999, a 62-year-old man underwent successful exclusion of a descending 98-mm TAA with 2 AneuRx stent-grafts. A type I distal endoleak was diagnosed 1 month later, and a distal extension cuff was placed just proximal to the celiac trunk. One year later, a new endoleak was discovered (presumed to be type II); the patient refused proposed thrombin injection to seal the leak. The diameter of the aneurysm enlarged gradually, and in 2003, he presented with a ruptured TAA and a massive left-sided hemathorax. The patient underwent urgent open surgical repair using extracorporeal circulation; the 3 stent-grafts were removed. Unfortunately, the patient died from cardiac failure 2 days later. Macroscopic examination showed several disruptions of the graft fabric and a stent fracture, which presumably explains the endoleak and rupture. CONCLUSIONS: This case reaffirms the necessity of long-term stent-graft surveillance.

Aneurysm, Ruptured↗

PubMed2003

Surgery for acute type A dissection using antegrade selective cerebral perfusion: experience with 122 patients.

BACKGROUND: Antegrade selective cerebral perfusion (ASCP) has proved to be a reliable method of brain protection during surgery of the thoracic aorta, but its use during aortic dissection surgery still remains controversial. In this study, we present our results after the operative repair of acute type A aortic dissections using ASCP and moderate hypothermic circulatory arrest. METHODS: Between October 1995 and August 2001, 122 patients (76 men, 46 women) underwent repair of acute type A aortic dissection with the aid of ASCP and open distal anastomosis. The average age of the patients was 61 +/- 12 (mean +/- standard deviation). Preoperative complications included cardiac tamponade (n = 34; 27.0%), aortic regurgitation (n = 27; 22.1%), and new neurological deficits (n = 11; 9%). RESULTS: Stepwise logistic regression revealed preoperative cardiac tamponade (p = 0.018) and new neurological deficits (p = 0.017) to be independent determinants for hospital mortality (19.7%). Permanent neurological complications occurred in 7% of the patients. Independent risk factors for temporary neurological dysfunction (11.2%) included cardiac tamponade (p = 0.019) and preoperative neurological deficits (p = 0.000). CONCLUSIONS: In our experience, the surgical treatment of acute type A aortic dissection with the aid of ASCP was associated with acceptable hospital mortality and neurologic morbidity rates.

Adult↗

PubMed2003

Brain protection using antegrade selective cerebral perfusion: a multicenter study.

BACKGROUND: To evaluate the results of antegrade selective cerebral perfusion as a method of brain protection during surgery of the thoracic aorta and to determine predictors of hospital mortality and adverse neurologic outcome. METHODS: Between October 1995 and March 2002, 588 patients underwent aortic surgery with the aid of antegrade selective cerebral perfusion. There were 334 men (56.8%); the mean age was 63.7 +/- 11.8 years. One hundred sixty-two patients (27.6%) underwent urgent operation. The separated graft technique was employed to reimplant the arch vessels in 230 patients (65.3%) of the 352 requiring aortic arch replacement. Associated procedures were performed in 254 patients (43.2%). One hundred twelve patients underwent elephant trunk procedure. The mean cerebral perfusion time was 67 +/- 37 minutes. RESULTS: The overall hospital mortality rate was 8.7%. A logistic regression analysis revealed urgent operation, recent central neurologic event, tamponade, unplanned coronary artery revascularization and pump time to be independent predictors of hospital mortality (p < 0.05). The permanent neurologic dysfunction rate was 3.8%. A logistic regression analysis showed tamponade to be independent predictor of permanent neurologic dysfunction (p < 0.05). The transient neurologic dysfunction rate was 5.6%. Recent central neurologic event, tamponade, coronary disease, and aortic valve replacement were indicated as independent predictors of transient neurologic dysfunction by logistic regression (p < 0.05). CONCLUSIONS: In our experience the utilization of antegrade selective cerebral perfusion resulted in encouraging results in terms of hospital mortality and brain complications. Neither the extent of the replacement nor the duration of the cerebral perfusion had an impact on hospital mortality and neurologic outcome.

Aorta, Thoracic↗

PubMed2003

Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion during ascending aorta-hemiarch replacement: a retrospective comparative study.

OBJECTIVE: We sought to compare the results of ascending aorta-hemiarch replacement by using 2 different methods of cerebral protection in terms of hospital mortality, neurologic outcome, and systemic morbidity and to determine predictive risk factors associated with hospital mortality and neurologic outcome after ascending aorta-hemiarch replacement. METHODS: Between January 1995 and September 2001, 289 patients (mean age, 62.2 +/- 13.2 years; urgent status, 122/289 [42.2%]) underwent ascending aorta-hemiarch replacement with the aid of antegrade selective cerebral perfusion (161 patients) or deep hypothermic circulatory arrest (128 patients). RESULTS: Overall hospital mortality was 11.4% (deep hypothermic circulatory arrest group, 13.3%; antegrade selective cerebral perfusion group, 9.9%; P =.375). A logistic regression analysis revealed acute type A dissection (P =.001; odds ratio, 4.3) and age of greater than 70 years (P =.019; odds ratio, 2.5) to be independent predictors of hospital mortality. The permanent neurologic dysfunction rate was 9.3% (deep hypothermic circulatory arrest group, 12.5%; antegrade selective cerebral perfusion group, 7.6%; P =.075). Logistic regression analysis revealed acute type A dissection (P =.001; odds ratio, 6.7) and history of cerebral infarction-transient ischemic attack (P =.038; odds ratio, 3.4) to be independent predictors of permanent neurologic dysfunction. The transient neurologic dysfunction rate was 8.0% (deep hypothermic circulatory arrest group, 7.1%; antegrade selective cerebral perfusion group, 8.7%; P =.530). Acute type A dissection (P =.001; odds ratio, 5.1) was indicated as an independent predictor of transient neurologic dysfunction by means of logistic regression. Renal dysfunction (postoperative creatinine level of >250 micromol/L; deep hypothermic circulatory arrest, 10 [7.8%]; antegrade selective cerebral perfusion, 6 [3.7%]; P =.030), as well as prolonged intubation time (deep hypothermic circulatory arrest, 3.8 +/- 6.3 days; antegrade selective cerebral perfusion, 2.2 +/- 2.5 days; P =.005) were more common in the deep hypothermic circulatory arrest group. CONCLUSION: The use of antegrade selective cerebral perfusion and deep hypothermic circulatory arrest during ascending aorta-hemiarch replacement resulted in acceptable hospital mortality and neurologic outcome. Reduced postoperative intubation time and better renal function preservation were observed in the antegrade selective cerebral perfusion group.

Aorta↗

PubMed2002

Endovascular stent-grafting for descending thoracic aortic aneurysms.

OBJECTIVE: Endoluminal placement of covered stent-grafts emerges as a less-invasive alternative to open surgical repair of thoracic aortic aneurysms (TAA). The present report describes our experience with endovascular stent-grafting in the treatment of descending TAA. METHODS: From 1997 to 2001, 28 descending TAA's were treated in 27 patients (17 male, mean age 70 years) by endovascular stent-grafting. The aneurysms (mean diameter, 6.6 cm) had diverse causes, but the majority were due to atherosclerosis (71%). They were predominantly localized in the proximal (32%), central (39%), and distal part (22%) of the descending thoracic aorta. In two patients (7%), the entire thoracic aorta was treated. Preliminary subclavian-carotid artery transposition was performed in five patients. AneurX (n=6), Talent (n=9), and Excluder (n=13) stent-grafts were used. In 13 cases (46%), multiple stents were necessary for complete aneurysm exclusion. RESULTS: In 27 of 28 cases (96%), the endovascular stent-grafts were successfully deployed. In one patient, stent dislocation into the aneurysm required open surgical repair in a subsequent procedure. There was no operative mortality. None of the patients developed paraplegia or paraparesis. No distal embolization occurred. After a median follow-up of 21 months (range, 1-49 months), there was one non-related late death. There was no aneurysm rupture. Maximal aneurysm diameter either remained stable or decreased slightly over time in all but one patient with evidence of an endoleak. Endoleaks occurred in eight patients (29%) during follow-up. In five of them the endoleaks sealed spontaneously, whereas in two patients a distal extension was inserted. CONCLUSIONS: Endovascular repair of descending TAA's is a promising less-invasive alternative to open repair. Extended follow-up is necessary to determine its definite efficacy in the longer term.

Aged↗

PubMed2002

The elephant trunk technique: operative results in 100 consecutive patients.

OBJECTIVES: To describe morbidity and mortality in patients undergoing the elephant trunk (ET) implantation as the first stage in the repair of their mega aorta and to assess determinants for the occurrence of complications. METHODS: One hundred consecutive patients undergoing an ET implantation between 1984 and June 2001 were retrospectively analyzed. The ET was implanted as an extension of an isolated aortic arch (1%), an aortic valve replacement+ascending aorta+arch (14%), a root replacement+ascending aorta+arch (37%) and an ascending aorta+arch (48%). Indications for surgery were acute aortic dissection (1%), an inflammatory aneurysm (3%), chronic post-dissection (31%) or degenerative (65%) aneurysm. Marfan syndrome was present in six patients. For cerebral protection, we used isolated deep hypothermic circulatory arrest (7%), deep hypothermic circulatory arrest combined with uni- or bilateral antegrade cerebral perfusion (18%) or isolated uni- or bilateral antegrade cerebral perfusion (75%). Uni- and multivariate analysis was used. RESULTS: There were no intraoperative deaths. Hospital mortality was 8%. The causes of death were cardiac in one, rupture of a remote aneurysm in three, tamponade in one and sepsis in three. After multivariate analysis, no single factor emerged as a risk factor for hospital mortality. Permanent and transient neurologic dysfunction occurred in 4 and 2%, respectively. Univariate analysis showed the operative period before 1990 (P=0.029) and emergency (P=0.018) as significant factors for postoperative neurologic dysfunction; after stepwise logistic regression analysis, only emergent operation retained significance (P=0.005). Permanent hoarseness, total atrioventricular block requiring pacemaker implantation and re-thoracotomy for bleeding occurred in 17, 2 and 30%, respectively. CONCLUSIONS: The first step in the repair of a mega aorta, the implantation of an ET, can be performed with a low mortality and an acceptable morbidity. The risk of central neurologic damage is higher in emergency interventions.

Adult↗

PubMed2002

Antegrade selective cerebral perfusion during operations on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients.

OBJECTIVE: We retrospectively analyzed hospital mortality and neurologic outcome after operations on the thoracic aorta with the aid of antegrade selective cerebral perfusion to determine a predictive risk model. METHODS: Between October 1995 and May 2001, 413 patients (mean age, 63.0 +/- 11.5 years) underwent operations on the thoracic aorta with antegrade selective cerebral perfusion. Indications for surgical intervention were acute type A dissection in 116 (28.1%) patients, degenerative aneurysm in 227 (55.0%) patients, and postdissection aneurysm in 70 (16.9%) patients. One hundred twenty-five (30.3%) patients were operated on urgently; concomitant procedures were performed in 171 (41.4%) patients. Mean cerebral perfusion time was 63.0 +/- 38.7 minutes (range, 16-220 minutes). Preoperative and intraoperative factors were evaluated by means of univariate and multivariate analysis to identify predictors of hospital mortality and neurologic outcome. RESULTS: The hospital mortality was 9.4%. Stepwise logistic regression revealed urgency status (P =.000; odds ratio, 19.9) and recent history of a recent central neurologic event (P =.004; odds ratio, 8.0) to be independent determinants for hospital mortality. Temporary neurologic dysfunction occurred in 20 (5.1%) patients. Urgency status (P =.005; odds ratio, 7.5), history of a central neurologic event (P =.003; odds ratio, 8.6), and coronary artery bypass grafting (P =.019; odds ratio, 6.0) were independent determinants of temporary neurologic dysfunction. Urgency status (P =.003; odds ratio, 8.6) was the only independent determinant for permanent neurologic dysfunction, and it occurred in 15 (3.7%) patients. CONCLUSION: Antegrade selective cerebral perfusion is an effective method of brain protection. Cerebral perfusion times of longer than 90 minutes were not associated with an increased risk of hospital mortality or poorer neurologic outcome. Urgency status and recent history of central neurologic events were retained as important risk factors for hospital mortality and neurologic outcome.

Aged↗