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Biomedical subjects

Mirko Doss

Publications and source records attributed to Mirko Doss.

At least 19 recordsLinked to original sources
PubMed2006

Transapical approach for sutureless stent-fixed aortic valve implantation: experimental results.

OBJECTIVE: Percutaneous aortic valve implantation has been performed in patients with severe aortic stenosis judged as nonsurgical candidates. We evaluated a facilitated transapical antegrade approach for potential use in surgical high-risk patients. METHODS: A pericardial xenograft fixed within a 23-mm stent (Cribier-Edwards aortic prosthesis, Edwards Inc., Irvine, CA, USA) was implanted using a transapical approach in fifteen 35-45 kg pigs. A limited or a full sternotomy was used to transapically introduce a crimped valve through a 24-F sheath. Deployments were performed on the beating heart either with ventricular unloading using femoro-femoral cardiopulmonary bypass (CPB) or rapid ventricular pacing (RVP), all under fluoroscopic and echocardiographic visualization. RESULTS: All valves were successfully deployed at the target site with acceptable visualization of the noncalcified annulus. Valve migration occurred in six procedures (three distal and three retrograde) secondary to inadequate reduction of ventricular output, unfavorable annular anatomy, excessive crimping of the valve, and dislodgement by the delivery balloon. Exact positioning of the valve into the target area was confirmed by autopsy at the end of the procedures. Paravalvular leak was noted in five implants. CONCLUSIONS: The transapical approach provides a safe, accurate, and effective route for facilitated antegrade delivery of a stent-fixed valve. Advanced stent design will lead to better stability of the implant and may minimize the risk of paravalvular leakage in future. Identifying the appropriate population for human feasibility trials remains a challenge.

Animals↗
PubMed2006

[Endovascular interventions of the descending thoracic aorta].

Endovascular interventions of the descending thoracic aorta have been established as an alternative to conventional open surgery. Initially, they were limited to elective patients with a high risk profile for open surgery, but soon their use was extended to emergencies as well. In the elective setting, endovascular interventions significantly lowered short-term morbidity and mortality. These excellent perioperative results were reproducible in the emergency setting, thereby leading to superior outcomes for patients treated by endovascular stent grafts when compared to the conventional open surgical approach. However, some questions regarding long-term durability of these devices remain unanswered. Stent-graft failures at mid and long-term follow-up have been reported in the literature. The progressive nature of stent graft-related mid- and long-term complications stresses the need for continued surveillance of these patients.

Aortic Dissection↗
PubMed2006

Left ventricular remodeling impacts the function of the Quattro stentless mitral valve bioprosthesis (a 4-year experience).

OBJECTIVE: The St Jude Quattro stentless mitral valve prosthesis (QMV) is sutured to the mitral annulus and the papillary muscle heads, thereby preserving the subvalvular apparatus. After mitral valve replacement, remodeling of the left ventricle is often observed, causing a dilated ventricle to shrink in diameter. It was our objective to assess these changes in left ventricular (LV) geometry and evaluate its effects on the function of the QMV. METHODS: From September 1997 to October 2000, 24 patients received QMV at our institution. The patients were followed up at yearly intervals (mean 4.1 +/- 2.2 years). All pre- and postoperative echocardiograms were evaluated, with attention focused on the subvalvular apparatus, leaflet morphology, and occurrence of late mitral regurgitation. In addition, all clinical outcomes and valve-related complications were recorded. RESULTS: Forty-one percent of patients (10/24) developed late mitral regurgitation (mild, n = 5; moderate, n = 5). The site of regurgitation was located at the 2 commissures in all cases. In 8 patients, changes in LV diameter had occurred. The point of leaflet coaptation had shifted away from the annulus in 4 patients. The overall mortality was 12.3%, and the postoperative stroke rate was 12.3%. CONCLUSIONS: Midterm changes in LV geometry seem to affect the competence of the QMV. Predicting these changes and subsequently adapting the sizing procedure remain a challenging task. The high rate of late valve incompetence and poor clinical outcomes has prompted us to discontinue recruitment of patients for this trial.

Bioprosthesis↗
PubMed2006

Transapical aortic valve implantation: an animal feasibility study.

BACKGROUND: Percutaneous aortic valve implantation has recently been performed in nonsurgical patients with severe aortic stenosis. Retrograde valve delivery has been problematic because of the size of the delivery system and concomitant peripheral vascular disease. We investigated a minimally invasive approach through the left ventricular apex for antegrade placement of a device-deliverable valve. METHODS: Transapical aortic valve implantation was performed using a 23-mm equine valve mounted on a stainless steel stent in 24 swine (weight range, 35 to 45 kg). A limited or full sternotomy approach was used to access the apex of the heart. The crimped valve was introduced through a sheath in the left ventricular apex. Fluoroscopy and echocardiography were used for guidance. Deployments were performed on the beating heart either with ventricular unloading using femoral extracorporeal circulation or rapid ventricular pacing. RESULTS: All valves were successfully delivered at the selected target site with acceptable visualization of the noncalcified aortic annulus. Valve migration occurred during eight deployments (two distal and six retrograde) secondary to persistent cardiac output, unfavorable annular anatomy, and dislodgement by the delivery catheter. Exact positioning of the nonmigrated valves at the aortic annulus was examined by necropsy of all animals at the end of the procedures. Paravalvular leak was noted in 14 of 18 (77.8%) valves remaining in situ. CONCLUSIONS: The transapical approach was used for the successful antegrade placement of a stented valve, obviating the technical problems associated with a large delivery system transiting the peripheral vascular system. Stent design contributing to paravalvular leak remains problematic.

Animals↗
PubMed2006

Stentless bioprostheses improve postoperative coronary flow more than stented prostheses after valve replacement for aortic stenosis.

OBJECTIVE: In some randomized studies, stentless aortic valves have demonstrated hemodynamic advantages in comparison with stented prostheses. The effect of more physiologic flow dynamics on coronary artery flow has not been investigated yet. This study compares coronary perfusion after aortic valve replacement with stented or stentless porcine bioprostheses in a prospective randomized study. METHODS: A total of 24 patients (73 +/- 6 years) referred for treatment of aortic stenosis were randomized to aortic valve replacement with stented (Medtronic Mosaic; (Medtronic Inc, Minneapolis, Minn) or stentless (Medtronic Freestyle; Medtronic Inc) prostheses. Coronary flow was measured by means of magnetic resonance imaging preoperatively, 5 days after the operation, and 6 months postoperatively, then with evaluation of coronary flow reserve. Echocardiography was performed to quantify transvalvular gradients and left ventricular mass regression. RESULTS: Coronary flow increased in both groups significantly (P < .001) after aortic valve replacement. This increase was higher in the stentless group compared with that seen in the stented group (343 +/- 137 vs 221 +/- 66 mL/min). Also, coronary flow reserve was higher for stentless valves (3.4 +/- 0.3 for stentless valves and 2.3 +/- 0.1 for stented valves). Mean pressure gradients for Freestyle valves were lower (10 +/- 4 and 8 +/- 3 mm Hg, respectively, vs 19 +/- 6 postoperatively and 15 +/- 4 mm Hg at follow-up for Mosaic valves, P < .05). Left ventricular mass regression was similar in both groups. CONCLUSIONS: Normalization of coronary artery flow after aortic valve replacement for aortic stenosis was more pronounced for stentless valves compared with stented valves. The fact that the stentless design also demonstrated a superior hemodynamic performance with lower pressure gradients might be explained by the design being closer to physiologic anatomy and thus the presence of lower turbulence levels in the sinuses of Valsalva.

Aged↗
PubMed2006

Impact of mechanical and biological aortic valve replacement on coronary perfusion: a prospective, randomized study.

BACKGROUND AND AIM OF THE STUDY: Coronary perfusion is impaired in patients with aortic stenosis (AS). Aortic valve replacement (AVR) leads to improvement, but not complete restoration, of coronary flow. Previous studies have shown that postoperative coronary flow rate and coronary reserve in mechanical valves is dependent on valve design and orientation. The study aim was to investigate acute changes in coronary perfusion in patients undergoing mechanical or biological valve replacement in a prospective, randomized clinical study. METHODS: Forty patients undergoing AVR for AS underwent MRI scanning to measure coronary flow preoperatively and at five days after surgery. Patients scheduled for mechanical AVR (n = 20) were randomized to a tilting disc (Medtronic Hall) or bileaflet (Medtronic ADVANTAGE) prosthesis; the biological-valve group (n = 20) received a stented (Medtronic Mosaic) or stentless (Medtronic Freestyle) valve. Valve sizes were comparable in all groups. Patients also underwent echocardiography both preoperatively and postoperatively to measure transvalvular pressure gradients. The rate-pressure product (RPP) was calculated as a marker of myocardial oxygen demand and cardiac workload. RESULTS: The mean preoperative coronary flow rate was 90 +/- 32 ml/min, and this increased after AVR in all patients. The rise in the mechanical-valve groups was comparable for the two tested valves, whereas in the biological-valve groups a significantly higher increase for stentless valves was present (p < 0.05). Mean pressure gradients for the Hall and ADVANTAGE valves were equal; for biological valves, the Mosaic demonstrated a higher mean gradient (19 +/- 6 mmHg) than the Freestyle (10 +/- 4 mmHg) (p < 0.05). The RPP was lower for ADVANTAGE (mechanical group) and for Freestyle valves (biological group). CONCLUSION: Coronary artery flow was increased following AVR in all valve groups. The rise was significantly more distinct for Medtronic Freestyle stentless valves compared to the three other valve substitutes. As the stentless design also demonstrated superior hemodynamics and a lower myocardial oxygen demand with lower pressure gradients and lower RPP, this may have a positive impact on the clinical long-term outcome of this valve.

Age Factors↗
PubMed2005

Echocardiographic assessment in minimally invasive mitral valve surgery.

BACKGROUND: Due to limited exposure, removal of intracavitary air and visual assessment of cardiac function during minimally invasive procedures are not always possible. We analysed the utility of intraoperative transesophageal echocardiography (TEE) and postoperative transthoracic echocardiographic (TTE) in minimally invasive mitral valve (MV) procedures. MATERIAL/METHODS: We evaluated data from 163 consecutive patients undergoing isolated minimally invasive MV replacement (n=40) or repair (n=123) via small right anterolateral thoracotomy (121 complex mitral procedures). Cardioplegic arrest was achieved using either endoaortic (n=23) or transthoracic aortic clamp (n=140). In addition to preoperative TTE, TEE was used intraoperatively before and after cardiopulmonary bypass (CPB). Postoperative TTE was performed to monitor valve function at 3 and 12 months, and at 5-year follow-up. RESULTS: Pre-CPB TEE was useful to assess valve dysfunction and assist in placement of the arterial and venous cannulas. During CPB, placement and positioning of the endoclamp were guided effectively in all but 4 patients, in whom recurrent balloon migration necessitated secondary transthoracic aortic clamping. TEE detected one acute retrograde aortic dissection and one circumflex artery occlusion. After 18.7+/-10.6 months follow-up, all patients except three improved symptomatically and had consistently good valve function. CONCLUSIONS: Intraoperative TEE is essential for minimally invasive MV surgery, because it allows immediate control of valve function before and after surgery. It is useful to detect unexpected complications requiring immediate remedy. Postoperative echocardiographic results show that minimally invasive MV surgery is a good alternative to conventional surgery even in complex MV repairs.

Adolescent↗
PubMed2005

Aortic leaflet replacement with the new 3F stentless aortic bioprosthesis.

PURPOSE: Clinical trials with the new 3F stentless aortic bioprosthesis began October 2001, and as one of the first centers to implant this prosthesis in humans, we would like to present our experiences with this new device. DESCRIPTION: The 3F aortic bioprosthesis is a stentless biological heart valve fabricated from three equal leaflets of equine pericardium, assembled in a tubular shape, and implanted in the native aortic root to replace the patient's diseased aortic leaflets. Between January 2002 and August 2002, 24 3F aortic bioprostheses were implanted at our institution. Effective orifice area, mean gradients, and ejection fraction were evaluated by echocardiography at discharge and at 12-month follow-ups after surgery. EVALUATION: At 12-month follow-ups, the 3F bioprosthesis showed a good hemodynamic performance with a significant drop of mean gradients to 10.3 mm Hg, a mean effective orifice area of 1.7 cm2, and a mean ejection fraction of 61.5%. CONCLUSIONS: The clinical performance of the new 3F aortic bioprosthesis is comparable with regular stentless aortic valves. However its unique design facilitates implantation.

Adult↗
PubMed2005

Pericardial patch augmentation for reconstruction of incompetent bicuspid aortic valves.

PURPOSE: Reoperation rates after repair of bicuspid aortic valves are higher than for mitral valve reconstruction. Secondary changes and small coaptation surface render repair unreliable. Satisfactory results have been reported for patch augmentation for tricuspid aortic valves. We have applied this technique for the repair of bicuspid aortic valves. DESCRIPTION: Our technique retains the bicuspid morphology of the incompetent aortic valve. A strip of glutaraldehyde-fixed pericardium is sutured to the free edge of the fused leaflet. A large coaptation surface is created, and competence of the bicuspid valve is achieved. EVALUATION: Sixteen patients underwent reconstruction of their bicuspid aortic valves by pericardial patch augmentation. There were no intraoperative or postoperative deaths. The degree of aortic regurgitation was none to trivial for all patients at a mean follow-up of 3.1 +/- 3.4 months. Planimetric effective orifice areas ranged above 2 cm2. Mean aortic gradients were 8.2 +/- 4.8 mm Hg, and the mean height of coaptation surface was 14.7 +/- 2.1 mm. CONCLUSIONS: The pericardial patch augmentation technique increases coaptation surface, and thus provides reliable early competence of reconstructed bicuspid aortic valves.

Adult↗
PubMed2005

Do pulmonary autografts provide better outcomes than mechanical valves? A prospective randomized trial.

BACKGROUND: The objective of this study was to compare the performance of pulmonary autografts with mechanical aortic valves, in the treatment of aortic valve stenosis. METHODS: Forty patients with aortic valve stenoses, and below the age of 55 years, were randomly assigned to receive either pulmonary autografts (n = 20) or mechanical valve (Edwards MIRA; Edwards Lifesciences, Irvine, CA) prostheses (n = 20). Clinical outcomes, left ventricular mass regression, effective orifice area, ejection fraction, and mean gradients were evaluated at discharge, 6 months, and one year after surgery. Follow-up was complete for all patients. RESULTS: Hemodynamic performance was significantly better in the Ross group (mean gradient 2.6 mm Hg vs 10.9 mm Hg, p = 0.0005). Overall, a significant decrease in left ventricular mass was found one year postoperatively. However, there was no significant difference in the rate and extent of regression between the groups. There was one stroke in the Ross group and one major bleeding complication in the mechanical valve group. Both patients recovered fully. CONCLUSIONS: In our randomized cohort of young patients with aortic valve stenoses, the Ross procedure was superior to the mechanical prostheses with regard to hemodynamic performance. However, this did not result in an accelerated left ventricular mass regression. Clinical advantages like reduced valve-related complications and lesser myocardial strain will have to be proven in the long term.

Aortic Valve Stenosis↗
PubMed2005

Emergency endovascular interventions for acute thoracic aortic rupture: four-year follow-up.

OBJECTIVE: High mortality and paraplegia rates associated with the surgical management of acute thoracic aortic ruptures limit its success. It was our objective to evaluate whether emergency endovascular interventions would improve the outcomes of these patients. METHODS: Sixty patients aged 28 to 83 years were admitted to our institution with an acute rupture of the thoracic aorta (27 ruptured aneurysms, 15 perforated type B dissections, 18 traumatic ruptures). Twenty-eight patients were treated surgically with cardiopulmonary bypass, and 32 patients were acutely treated with an endovascular stent graft. Medical records were reviewed for prehospital and emergency department data, operative findings, and outcomes. Patients were followed up at yearly intervals with high-resolution multidetector computed tomographic angiography. RESULTS: Perioperatively, there were 1 death (3.1%) among the 32 patients in the endovascular group and 5 deaths (17.8%) among the 28 patients in the surgical group. There were 4 late deaths in the endovascular group and 1 in the surgical group. There were 2 access failures in the endovascular group. There were 1 stroke in the endovascular group and 1 case of paraplegia in the surgical group. Three patients in the endovascular group had endovascular leaks develop that required reintervention. Two patients in the endovascular group had late thrombosis of the left subclavian artery. CONCLUSION: Despite encouraging early outcomes, midterm results suggest a trend toward increased reintervention and late complication rates in the endovascular group. Therefore continued surveillance of patients treated with stent grafts is necessary.

Aged↗
PubMed2005

Valve opening and closing dynamics after different aortic valve-sparing operations.

BACKGROUND AND AIM OF THE STUDY: Aortic valve resuspension for ascending aortic aneurysm repair is associated with removal of the sinus of Valsalva. This may cause changes in leaflet motion and thus impact on long-term durability. The opening and closing characteristics of the aortic valve leaflets after reimplantation were studied using a published technique and a modification to create a 'neosinus', and the results compared to those of an age-matched control group. METHODS: Between September 1995 and March 2002, 25 patients underwent normal aortic root reconstruction (group A), while in a further 21 patients the modified neosinus technique was used (group B). In both groups, the native valve was preserved and suspended inside a tubular prosthesis, with reimplantation of the coronary arteries. Transthoracic and transesophageal studies of aortic valve dynamics were performed intraoperatively, before hospital discharge, and at one year after surgery in all patients; the data were compared with those from a separate group of 25 matched control individuals (group C). RESULTS: The valve opening velocity was 61.3+/-20.1, 46.3+/-8 and 29.2+/-9.8 cm/s in groups A, B and C, respectively (group A versus B, p = 0.003; A versus C, p <0.0001; B versus C, p <0.0001). Closing velocity was increased to 57.5+/-23 and 43.8+/-7 cm/s in groups A and B, compared to 23.6+/-7 cm/s in group C (A versus B, p = 0.012; A versus C, p <0.0001; B versus C, p = 0.0002). In seven group A patients, the leaflets touched the prosthetic wall during systole. Slow systolic closing displacement (SCD) amounted to 7.3+/-6 % of maximal opening in group A and 12.6+/-5 % in group B (p = 0.05), compared to 21.1+/-8.3% in group C (group A versus group C, p <0.0001; B versus C, p = 0.002). CONCLUSION: Reimplantation of the natural aortic valve in a prosthetic graft causes abnormally high opening and closing speeds, with possibly increased stress. The study results showed lower valve opening and closure dynamics after the creation of a sinus bulge compared to the conventional reimplantation technique. However, mid-term clinical observations showed favorable valve competence for both types of repair. Further long-term follow up is necessary to prove whether more physiological leaflet dynamics lead to improved durability.

Adolescent↗
PubMed2004

Automatic connector devices for proximal anastomoses do not decrease embolic debris compared with conventional anastomoses in CABG.

OBJECTIVE: Emboli generated during cardiac surgery have been associated with aortic clamping and manipulation. Proximal anastomotic devices are thought to be less traumatic by eliminating partial clamping, potentially resulting in fewer adverse outcomes. Intra-aortic filtration has been shown to effectively capture particulate debris. We compared the amount of debris released using intra-aortic filtration and the clinical outcomes between conventionally handsewn and automated proximal anastomoses. METHODS: Seventy-seven patients undergoing primary coronary artery bypass grafting with cardiopulmonary bypass were enrolled in a prospective randomized study. Patients were assigned to the anastomotic device Group I (Symmetry Aortic Connector, n = 39) or the conventional handsewn anastomosis control Group II (n = 38). Proximal anastomoses were performed before cardiopulmonary bypass in both groups. Intra-aortic Filter 1 (EMBOL-X)was deployed prior to partial clamping or puncturing the aorta for device application and removed after the proximal anastomosis was completed. Prior to cross-clamp removal, a second filter was inserted (Filter 2). A core laboratory performed quantitative and histologic analyses of the debris captured. Clinical outcomes included adverse events, neurocognitive test scores, graft patency, and mortality. RESULTS: Preoperative variables and risk factors were not significantly different between Groups I and II (EuroSCORE 3.9+/-2.6 vs. 4.2+/-2.5). Filter analyses showed no significant difference between Groups I and II in Filter 1 or 2 for either surface area of particles or total number of particles (P> 0.005). There was a significant decrease between Filters 1 and 2 in both Groups for surface area of particles (Group I: 18.5+/-23.8 mm2 vs. 10.7+/-16.3 mm2, P = 0.017; Group II: 15.0+/-15.4 mm2 vs. 6.9+/-.6.5 mm2, P = 0.004), and for total number of particles in Group II (8.6+/-3.7 vs. 7.1+/-2.4, P = 0.023). No significant differences were observed between Group I (device) and Group II (control) outcomes for myocardial infarction, neurocognitive deficit, stroke, length of stay, graft occlusion, or mortality. CONCLUSIONS: The application of proximal aortic connectors without partial clamping does not reduce particulate emboli or affect clinical outcomes compared with conventional anastomoses. Cross-clamping during cardiopulmonary bypass produces less particulate debris than conventional or automated proximal anastomoses performed off-pump, suggesting a major source of emboli is the anastomotic process.

Adult↗
PubMed2003

Urgent thoracic aortal dissection and aneurysm: treatment with stent-graft implantation in an angiographic suite.

The aim of this study was to evaluate the feasibility of endoluminal stent-graft placement in an angiographic suite for the treatment of emergent type-B aortic dissections and ruptured thoracic aortal aneurysms. Twenty-six patients with either urgent type-B dissection (n=8) or aneurysms (n=18) of the descending thoracic aorta were chosen for stent-graft implantation. All patients received a multidetector-row CT angiography of the whole aorta and pelvic arteries prior to stent-graft implantation. All procedures were performed in a fully equipped digital subtraction angiography (DSA) suite under general anesthesia. In 20 patients Talent LPS tube grafts and in 4 patients an Excluder graft were used. Access was achieved via surgical cut-down in the left (n=7) or right (n=19) groin. Sealing was successful in 24 patients. The proximal covered portion of the stent graft was placed across the left subclavian artery in 2 patients. Procedural success was achieved in 23 of 24 patients. One patient required a second stent-graft placement before the aneurysm was sealed. One patient with an acute perforation of the descending aorta died due to cardiac failure prior to stent-graft implantation. In 1 patient stent-graft delivery failed due to severe calcification of both common iliac arteries. Endoluminal treatment of both urgent type-B aortic dissections and thoracic aortal aneurysms with stent graft is an attractive alternative treatment to surgical repair. The placement of stent grafts in an angiographic suite is a safe and feasible method with good clinical effectiveness and, so far, good clinical outcome.

Acute Disease↗
PubMed2003

Emergent endovascular stent grafting for perforated acute type B dissections and ruptured thoracic aortic aneurysms.

BACKGROUND: The purpose of our study was to demonstrate the effectiveness of endovascular stent grafts in the treatment of acutely ruptured thoracic aortic aneurysms and type B dissections as an alternative to the conventional surgical approach in an emergency setting. METHODS: From January 2001 to October 2001, we deployed 11 emergent endovascular stent grafts into the thoracic aorta. We treated seven ruptured aortic aneurysms and four acutely perforated type B dissections. Aortic rupture was confirmed preoperatively by spiral computed tomography. In all cases, hemothorax was present. The average interval from onset of symptoms to treatment was 28.5 hours. We used nine Talent and two Excluder stent grafts. RESULTS: Deployment of the stent grafts was successful in nine cases. There were two cases of access failure due to small caliber of iliac arteries, and 1 of these patients died shortly after the procedure was abandoned, At 12 months of follow-up, there were no cases of paraplegia, stent migration, or endoleaks. There was, however, one temporary renal failure, and 2 patients required mechanical ventilation for more than 48 hours. CONCLUSIONS: Our experiences with emergency endovascular stent grafting show that the procedure is technically feasible, with less morbidity and mortality than conventional open surgery, in high-risk patients.

Adult↗
PubMed2003

Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience.

BACKGROUND: Surgical management of acute thoracic aortic ruptures is controversial, especially in patients with preexisting comorbidities; associated mortality and paraplegia rates remain high. It was our objective to evaluate whether treating these patients acutely with endovascular stent grafts would improve their outcome. METHODS: From November 1999 to February 2002 a total of 54 patients, age 28 to 83 years, were admitted to our institution with an acute rupture of the thoracic aorta (24 ruptured aneurysms, 14 perforated type B dissections, 16 traumatic ruptures). Twenty-eight patients were managed surgically using cardiopulmonary bypass (group 1), and 26 patients were treated acutely with an endovascular stent graft (group 2). The resuscitation protocol and interval from onset of symptoms to treatment was comparable in both groups. Medical records were reviewed for prehospitalization and emergency department data, operative findings, and outcomes. RESULTS: There were 5 of 28 deaths (17.8%) in the surgical group and 1 of 26 deaths (3.8%) in the endovascular group. In the surgical group 1 of 28 patients (3.6%) exhibited paraplegia; there were no cases of paraplegia in the endovascular group. There were 4 of 28 cases (14.3%) of renal failure in group 1 and 1 of 26 (3.8%) in group 2. In group 1, 8 patients (28.6%) required mechanical ventilation for more than 48 hours; there were 2 of 26 patients (7.7%) in group 2 with this ventilatory requirement. Three patients required a repeat thoracotomy for hemorrhage in the surgical group. There were two access failures in the endovascular group. CONCLUSIONS: In the treatment of acute ruptures of the thoracic aorta, the immediate outcome of patients treated with endovascular stent grafts appears to be better than with management by conventional surgical repair.

Adult↗
PubMed2003

The clamshell approach for the treatment of extensive thoracic aortic disease.

OBJECTIVE: Management of extensive thoracic aortic disease may present an immense technical challenge. The choice of surgical access and subsequent exposure determines whether a single-stage or a 2-stage approach can be adopted. METHODS: Fifteen patients with extensive thoracic aortic disease underwent resection of the ascending aorta, the aortic arch, and varying segments of the descending aorta. Four patients had concomitant coronary artery bypass grafting and 3 patients had aortic valve reconstruction. All patients were treated with a single-stage approach via a bilateral anterior thoracosternotomy (clamshell incision). RESULTS: There was 1 hospital death (6.6%). Two patients required reoperation for bleeding (13.3%). Two patients needed mechanical ventilation for more than 48 hours. Three patients suffered a stroke (20%). Two patients (13.3%) had transient neurologic dysfunction. None of the patients had renal failure. There were no wound infections in this group. CONCLUSION: The single-stage approach, via a clamshell incision, is a safe and effective procedure for patients who require treatment of extensive thoracic aortic disease and concomitant cardiac lesions.

Aged↗