PubMed Health⌕ Search

Biomedical subjects

Marc A A M Schepens

Publications and source records attributed to Marc A A M Schepens.

11 recordsLinked to original sources
PubMed2005

Long-term results after 27 years of surgical treatment of acute type a aortic dissection.

BACKGROUND: This study investigates the determinants of long-term outcome and modalities of late death after surgical treatment of acute type A dissection. METHODS: Between 1974 and 2001, 315 consecutive patients were operated on for acute type A aortic dissection. Operative mortality was 22.9%. A series of 243 survivors of surgical treatment were followed up for as long as 27 years. Endpoints were death, cardiovascular reoperation, and neurologic events. Median follow-up was 4.5 years. Follow-up was 99.6% complete. RESULTS: Cumulative survival of discharged patients was 96.4% +/- 1.3%, 67.7% +/- 4.7%, and 39.4% +/- 12.0% at 1, 10, and 20 years, respectively. During follow-up, 47 patients died. Cause of death was cardiac failure in 7, hemorrhage due to rupture of the distal aorta in 7, stroke in 4, respiratory insufficiency in 4, sepsis in 3, malignancy in 2, and unknown in 20 patients. Multivariate analysis revealed advanced patient age and postoperative hemodialysis as perioperative indicators of late death (p < 0.05). Freedom from cardiovascular reoperation was 90.7% +/- 2.0% at 1 year, 60.9% +/- 5.1% at 10 years and 41.9% +/- 15.0% at 20 years. A total of 58 patients required 86 cardiovascular reoperations; aortic root or ascending aorta replacement was performed in 20, distal ascending aorta and arch replacement in 13, descending aorta replacement in 6, thoracoabdominal aorta replacement in 7, abdominal aorta replacement in 7, and miscellaneous reoperations in 6 patients. Multivariate analysis revealed male sex and left coronary artery dissection as significant determinants for late cardiovascular reintervention (p < 0.05). Cumulative incidence of stroke after 20 years was 3.8%. CONCLUSIONS: Acute type A dissection represents an emergency situation with acceptable long-term results for discharged survivors of surgical treatment.

Acute Disease↗
PubMed2005

Surgery for acute type A aortic dissection: the effect of antegrade selective cerebral perfusion on the early outcome of elderly patients.

BACKGROUND: The aim of this study was to evaluate early results and to determine predictive risk factors associated with an adverse outcome in elderly patients after acute type A aortic dissection repair using antegrade selective cerebral perfusion (ASCP). Adverse outcome was defined as the occurrence of death or permanent neurologic dysfunction. METHODS: From October 1995 to March 2002, 178 patients (group A < 75 years, n = 156, 87.6%; group B > 75 years, n = 22, 12.4%) underwent surgery for acute type A aortic dissection using ASCP and moderate hypothermia. An ascending aorta/hemiarch replacement was performed in 128/178 (71.9%) patients (group A 71.2%, group B 77.3%, p = NS), an ascending aorta and arch replacement in 50/178 (28.1%) patients (group A 28.8%, group B 22.7%, p = NS). Associated procedures were performed in 55/178 (20.9%) patients (group A 31.4%, group B 27.3%, p = NS), the arch vessels were reimplanted using the separated graft technique in 32/50 (64.0%) patients (group A 62.2%, group B 80.0%, p = NS). The mean ASCP time was 59 +/- 27 min. RESULTS: The overall adverse outcome rate was 20.8% (group A 21.2%, group B 18.2%, p = NS). The transient neurologic dysfunction rate was 9.5% (group A 9.5%, group B 5.6%, p = NS). A logistic regression analysis revealed cardiopulmonary bypass time (p = 0.045, odds ratio 1.03/min) to be the only independent predictor of adverse outcome in group A. CONCLUSIONS: During type A aortic dissection repair the implementation of ASCP resulted in an acceptable hospital mortality and neurologic outcome. If ASCP is used, the risk of hospital mortality and postoperative morbidity is similar in patients younger and older than 75 years. Duration of cardiopulmonary bypass still remains an important risk factor for hospital mortality and neurologic outcome in elderly patients.

Acute Disease↗
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↗
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

Is extended arch replacement for acute type a aortic dissection an additional risk factor for mortality?

BACKGROUND: We report our experience with surgery for acute type A aortic dissection with involvement of the aortic arch. METHODS: From January 1986 to December 2001, 277 patients underwent surgery for acute type A aortic dissection. In 70 patients (25.3%), surgery was extended into the aortic arch: hemiarch and total arch replacement in 53 (75.7%) and 17 (24.3%) patients, respectively. Deep hypothermic circulatory arrest was used in 19 patients, antegrade selective cerebral perfusion in 38, and combined deep hypothermic circulatory arrest with antegrade selective cerebral perfusion in 13. RESULTS: Operative mortality was 18.6% (13/70) after extended replacement into the arch versus 21.7% (45/207) after surgery limited to the ascending aorta (p = 0.62). Multivariate analysis did not reveal significant risk factors for operative mortality. Postoperatively, 5 patients (8.1%) had a new postoperative cerebral vascular accident (CVA). Multivariate analysis showed an earlier date of operation as the only independent determinant for a new postoperative CVA (p = 0.0162, RR = 0.80/year, 95% CI = 0.67 to 0.96). None of the patients, operated on with antegrade selective cerebral perfusion, had a new cerebral deficit. Comparing the different methods of cerebral protection, multivariate risk analysis revealed antegrade selective cerebral perfusion as a significant protective factor against new postoperative CVA (p = 0.0110, OR = 0.12, 95% CI = 0.02 to 0.61). Survival at 5 and 10 years was 66.6.5% and 40.0%, respectively, after replacement of the aortic arch versus 68.7% and 57.7%, respectively, after replacement of the ascending aorta (p = 0.96). Freedom from aortic arch reoperation was 96.3% at 5 and 77.0% at 10 years versus 86.6% and 75.1% in both groups, respectively (p = 0.21). CONCLUSIONS: Extended replacement into the aortic arch during surgery for acute type A dissection does not influence early and late results. The best cerebral protection seems to be obtained with antegrade selective cerebral perfusion.

Acute Disease↗
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

Operative risk factors of type A aortic dissection: analysis of 252 consecutive patients.

OBJECTIVE: We examined operative risk factors for postoperative death after surgery for acute type A aortic dissection. METHODS: Between 1974 and 1999, 252 patients, 163 men and 89 women (mean+/-SD age, 58+/-12 years) underwent surgery for acute type A aortic dissection. Fifty-eight (23.0%) were in cardiogenic shock at time of surgery. Most patients underwent ascending aorta replacement which was combined with aortic valve replacement by means of a composite graft in 30 (11.9%) patients and an isolated aortic valve replacement in 16 (6.3%) patients. RESULTS: The overall operative mortality rate was 25.0% (n=63); 27.0% for patients operated upon with aortic cross-clamping, 23.7% after deep hypotherm circulatory arrest and 23.3% after antegrade selective cerebral perfusion (ASCP) (p=0.73). Multivariate analysis revealed iatrogenic dissection (p=0.0096, odds ratio=5.7), preoperative cardiopulmonary resuscitation (p=0.0095, odds ratio=5.5) and every quarter of an hour longer extracorporeal circulation (p=0.049, odds ratio=1.1) as independent risk factors for operative mortality. Aortic valve replacement or Bentall procedure (p=0.0185, odds ratio=0.3) were protective factors. There were 44 new postoperative strokes: 4.7% in the group operated upon with and 20.1% in the group without ASCP (p=0.01). CONCLUSION: In order to avoid cardiogenic shock and preoperative cardiopulmonary resuscitation, patients with acute type A aortic dissection should be treated promptly. The choice to use an aortic valve prosthesis or Bentall procedure when applicable seems to benefit the postoperative early survival. The risk of new postoperative neurological events might be reduced by avoiding the appliance of an aortic cross-clamp and by using ASCP.

Adolescent↗
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

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↗