Biomedical subjects

Steven L Lansman

Publications and source records attributed to Steven L Lansman.

16 recordsLinked to original sources

PubMed2007

Surgical treatment of heart failure in the elderly.

Heart failure (HF) in elderly patients who may benefit from surgical therapy is usually secondary to ischemic or valvular heart disease. When referring such patients for surgery, life expectancy, along with the expectations of the patient and family with regard to the surgical treatment, must be considered. The goals of cardiac surgery in this patient population are to maintain or improve cardiac function, decrease HF episodes, reduce hospital admissions,and improve functional class. Safer surgical techniques developed during the last two decades have allowed high-risk patients well into their 80s to undergo complex cardiac operations with decreasing morbidity and mortality. Successful surgical intervention often leads to a more productive and independent life for elderly patients who have HF.

Aged↗

PubMed2006

Long-term results of tacrolimus monotherapy in cardiac transplant recipients.

BACKGROUND: Conventional immunosuppression for heart transplantation is associated with various adverse effects. Tacrolimus monotherapy (TM) is an alternative strategy that minimizes exposure to additional immunosuppressants. METHODS: We retrospectively reviewed clinical data for all adult transplant recipients between January 1, 1996 and May 1, 2004. Clinical outcomes were analyzed according to immunosuppressive regimen. RESULTS: A total of 167 heart transplants were performed at our center. Eight patients died before receiving calcineurin inhibitors and were excluded from analysis. The mean follow-up for the 159 surviving patients was 1,520 +/- 78 days. Ninety of 124 patients initially treated with tacrolimus and corticosteroids were weaned to TM without the use of an anti-proliferative agent (Group A), resulting in an overall success rate of 75% at an average of 271 +/- 18 days after transplant. The remaining 69 recipients were treated with other tacrolimus- or cyclosporine-based regimens (Group B). Survival was significantly greater in Group A. The prevalence of high-grade rejection within the first year and incidence of cardiac allograft vasculopathy were similar between groups. Ten patients (11%) in Group A required recommencement of combination immunosuppression at an average of 768 +/- 772 days. CONCLUSIONS: TM is achievable in the majority of cardiac transplant recipients. Patients who tolerated reduced immunosuppression enjoyed greater survival than those treated with other regimens, without additional high-grade rejection or vasculopathy. These promising results remain to be confirmed in a prospective trial.

Adult↗

PubMed2005

Lack of sensitization and equivalent post-transplant outcomes with the Novacor left ventricular assist device.

BACKGROUND: Ventricular assist devices (VADs) are increasingly used to support critically ill heart failure patients awaiting transplantation. Previous work has focused on the Thoratec Heartmate VE device, use of which is associated with pre-formed antibody production. We reviewed our cumulative experience with the Worldheart Novacor VAD as a bridge to transplantation (BTT). METHODS: From January 1989 through October 2002, 39 patients required a VAD bridge, with 26 of 39 surviving to transplantation. Antibody levels were assessed by complement-dependent cytotoxicity assay at routine intervals and expressed as panel reactive antibody (PRA) levels. Post-transplant allograft rejection, coronary vasculopathy, and survival were compared between Novacor-supported patients and non-VAD transplant recipients. RESULTS: PRA values did not significantly change after VAD implantation (12.4% +/- 11.2% vs 14.8% +/- 12.3%, p = 0.28). Survival for the BTT patients was 80.4%, 75.7%, 64.0%, 64.0%, and 64.0%, respectively, for 1, 3, 5, 7, and 10 years post-transplant, with similar results for non-BTT patients. The freedom from coronary vasculopathy was 90.2%, 90.2%, 72.2%, and 72.2%, respectively, at 1, 3, 5, and 7 years post-transplant. CONCLUSIONS: First, to our knowledge, this study is the first to examine the incidence of allosensitization after Novacor implant in detail. In contrast with previous results of work with other VAD systems, as assessed by PRA levels, Novacor patients did not become sensitized. Second, compared with 220 non-BTT patients who received transplants during a similar time frame, Novacor BTT patients had equivalent rejection profiles and survival. Finally, the incidence of transplant-associated coronary artery disease was lower than in previous reports.

Adult↗

PubMed2005

Long-term integrity of teflon felt-supported suture lines in aortic surgery.

BACKGROUND: Although the ultimate success of aortic operations depends upon the integrity of graft-to-aorta anastomoses, little is known about different techniques used to assure their longevity. We report the incidence of reoperation for suture line disruptions arising from anastomoses using reinforcement with Teflon felt. METHODS: Since 1987, 1475 patients underwent 2281 anastomoses in the thoracic aorta (mean 1.55/anastomoses per patient). All patients were followed with at least yearly computed tomographic scans, for a total follow-up of 6483.8 patient-years. Those requiring reoperation were reviewed retrospectively for evidence of suture line disruption. RESULTS: Only 34 patients, with a mean age of 55.1 years old (range 26-85 years old) underwent reoperation for suture-line disruptions following vascular graft-to-aorta anastomosis using Teflon felt. The previous operation was a Bentall procedure in 15 (44%); ascending aorta replacement in 9 (26%); total arch replacement in 6 (18%); descending aorta replacement in 2 (6%); thoracoabdominal repair in 1 (3%); and sinus of Valsalva repair in 1 (3%). The incidence of suture line disruption was 0.0052 per patient-year, and 0.0034 per anastomosis-year. The mean interval between operations was 55.9 months (range 4-180 months). In 21%, the pseudoaneurysm originated from the proximal anastomosis; in 71% from the distal anastomosis; in 3% from both; in 3% from the innominate artery; and in 3% from a sinus of Valsalva repair. In only 1 patient was there evidence of infection. Reoperation involved ascending aorta replacement in 11 patients, and total arch replacement in 13 patients. Adverse outcome, such as hospital death or permanent stroke, occurred in 8% (3 patients). CONCLUSIONS: Use of Teflon felt to support aortic suture lines yields a very low incidence of suture line disruptions: 1 per 191 patient-years, or 1 per 296 anastomosis-years. Teflon felt reinforcement provides a secure, long-lasting graft-to-aorta anastomosis with minimal risk of infection.

Adolescent↗

PubMed2005

Aortic arch replacement using a trifurcated graft: simple, versatile, and safe.

BACKGROUND: Hypothermic selective antegrade cerebral perfusion during aortic arch replacement may prevent adverse neurologic sequelae. It can be provided via balloon-tipped catheters or a branched graft sewn to the brachiocephalic vessels. We report a consecutive series of total arch replacement using a trifurcated graft. METHODS: From September 1999 through October 2004, 109 patients underwent nonemergent total arch replacement using this technique. The graft, placed during a period of hypothermic circulatory arrest, was used for selective cerebral perfusion during the arch reconstruction. RESULTS: Adverse outcomes were seen in 9 (8.3%) patients: hospital death in 5 (4.6%), and stroke in 5 (4.6%). Transient neurologic dysfunction was noted in 6 (5.5%) patients. Mean duration of hypothermic circulatory arrest was 31.2 +/- 6.6 minutes and selective cerebral perfusion was 65.3 +/- 20.9 minutes. Reoperation for bleeding was required in 3 (2.8%) patients and prolonged intubation in 15 (13.8%). Median intensive care unit stay was 3 days (interquartile range 2-4; range, 1 to 108) and hospital stay was 9 (interquartile range 8-15; range, 5 to 108). CONCLUSIONS: The trifurcated graft technique results in low rates of perioperative mortality, temporary neurologic dysfunction, and stroke. It may reduce cerebral embolization as it requires no instrumentation of the aortic arch to establish selective cerebral perfusion and, although it mandates hypothermic circulatory arrest to place the graft, this interval is reliably brief enough to fall within accepted safe limits. This strategy leaves no residual arch tissue behind, and allows placement of an elephant trunk proximal to one or more arch vessels if anatomically indicated.

Adult↗

PubMed2004

Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement.

BACKGROUND: Ideal perfusion during ascending aorta-arch surgery should allow easy implementation of antegrade cerebral perfusion while avoiding atheroembolization or false lumen perfusion in dissections. We report favorable experience with direct axillary artery cannulation. METHODS: Between 1999 and 2003, 284 patients with a mean age of 62.2 years (25 to 85), underwent axillary artery cannulation using a right angle wire-reinforced catheter. During this interval, attempted axillary cannulation was abandoned in only 14 patients because of inadequate backflow or other complications. Eighty-five patients were female. Severe aortic arteriosclerosis or degeneration was present in 209, aortic dissection in 63, and Marfan disease or aortitis in 12. The Bentall procedure was done in 144 patients, arch replacement in 86, the Yacoub procedure in 18, thoracoabdominal aneurysm repair in 16, and coronary artery bypass grafting in 20. Reoperations were at 30.2%. RESULTS: Adverse outcome (hospital death or permanent stroke) occurred in 6.6% (n = 19). Thirteen patients (4.6%) died before hospital discharge, and 13 patients (4.6%; 9 of whom died) suffered permanent stroke. Transient neurologic dysfunction occurred in 9.2% (n = 26). Mean duration of hypothermic circulatory arrest, used in 246 patients, was 26 +/-7 minutes. Mean duration of antegrade cerebral perfusion, used in 139 patients, was 47 +/- 23 minutes. In 93%, the right axillary artery was cannulated. Complications included 2 cases (0.7%) of brachial plexus injury (one transient), and 3 (1%) of localized dissection. CONCLUSIONS: Our results suggest that axillary artery cannulation, successful in 95% of patients, may be the optimal technique for reducing perfusion-related morbidity and adverse outcome in operations for acute dissection, atherosclerotic, and degenerative aneurysmal disease. It deserves serious consideration in all patients older than 65 requiring cardiopulmonary bypass.

Adult↗

PubMed2004

Technical advances in total aortic arch replacement.

BACKGROUND: We compared the effects of using hypothermic circulatory arrest (HCA) alone, HCA combined with selective cerebral perfusion (SCP), and use of SCP with a trifurcated graft (T) on outcome after aortic arch repair. METHODS: One hundred fifty patients, median age 66 years (range, 27 to 85), underwent total arch replacement between 1988 and 2002; 75 were female. We retrospectively compared the results of three patient groups roughly comparable with regard to preoperative risk factors: 45 patients using HCA beginning in 1988; 67 patients using HCA/SCP beginning in 1994; and 38 patients utilizing a trifurcated arch graft in conjunction with SCP through the axillary artery (HCA/SCP/T) since 2000. The groups were well matched with regard to median age (66, 68, and 66 years), urgency (emergent 11%, 13%, 5%; urgent 24%, 9%, 18%; and elective 64%, 78%, 76%), and several other known risk factors (p = not significant). RESULTS: An adverse outcome-hospital death or permanent stroke-occurred in 14%: in 16% with HCA, in 16% with HCA/SCP, and in 8% with HCA/SCP/T. Transient neurologic dysfunction among patients surviving without stroke was lower with HCA/SCP/T (11%) than with HCA (33%) or HCA/SCP (17%). Mean duration of HCA was 52 +/- 16 minutes with HCA alone versus 45 +/- 10 minutes with HCA/SCP and 31 +/- 7 minutes with HCA/SCP/T (p < 0.0001 for groups HCA and HCA/SCP combined versus HCA/SCP/T). Mean duration of SCP was 57 +/- 25 minutes with HCA/SCP versus 62 +/- 24 minutes with HCA/SCP/T (p = not significant). Comparison of the groups of patients who had comparable preoperative risk factors for adverse outcome showed a trend toward lower adverse outcome and transient neurologic dysfunction rates using HCA/SCP/T; a significant reduction in respiratory (p < 0.001), infectious (p = 0.015) and cardiac (p = 0.005) complications in HCA/SCP/T compared with the earlier groups; and significantly shorter durations of intensive care (p < 0.0001) and hospitalization (p = 0.004). CONCLUSIONS: Our results suggest that HCA/SCP is superior to HCA alone for preventing cerebral injury during operations on the aortic arch. By further reducing embolic risk as well as duration of HCA, HCA/SCP/T with axillary artery cannulation may be the optimal technique for averting adverse outcomes, reducing complications, and shortening hospital stay after aortic arch repair.

Adult↗

PubMed2003

Aortic arch reconstruction using a trifurcated graft.

Cerebral protection and prevention of atheroembolism remain challenges in aortic arch reconstruction. To reduce neurologic complications, we developed a "no-touch" technique in which a trifurcated graft is anastomosed to the arch vessels during hypothermic circulatory arrest, reducing the risk of embolization while minimizing cerebral ischemia by permitting antegrade cerebral perfusion as arch reconstruction is completed.

Anastomosis, Surgical↗

PubMed2003

Is the Bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event-free survival?

BACKGROUND: This retrospective analysis of a selected series of Bentall procedures may be useful in evaluating the results of valve-sparing operations, an increasingly popular alternative for replacement of the ascending aorta and aortic valve. METHODS: One hundred forty-two elective patients younger than 65 years without concomitant procedures who underwent replacement of the thoracic aorta and aortic valve between 1989 and 2000 were studied; 85% were men, and the median age was 46 years (range, 13 to 64 years). Degenerative disease of the aorta was the most common cause requiring operation (86%, including 46% with a bicuspid aortic valve); 8% had chronic dissection, and 6% had atherosclerotic aneurysms. The ascending aorta was replaced in 94 patients (66%); 45 patients (32%) underwent hemiarch replacement, and in 3 patients (2%) the total arch was replaced. A mechanical valve was used in 88%, and a biologic valve, in 12%. RESULTS: There were no intraoperative deaths. Two patients had a stroke postoperatively, one of which was fatal. Complications during follow-up included 2 cases of endocarditis, 1 peripheral thromboembolic event, and 10 instances of significant bleeding (requiring hospitalization or transfusion). Surgery for distal aortic segments was performed in 4 patients, but no patient required reoperation in the proximal aorta. Kaplan-Meier curves show overall survival is 0.95 (95% confidence intervals, 0.9 to 0.99) at 5 years and 0.93 (95% confidence intervals, 0.86 to 0.99) at 8 years, and event-free survival is 0.85 (95% confidence intervals, 0.78 to 0.92) at 5 years and 0.78 (95% confidence intervals, 0.68 to 0.88) at 8 years. CONCLUSIONS: The button Bentall procedure can be performed with excellent short-term and long-term results in relatively uncomplicated elective patients in whom aortic valve disease is combined with dilatation of the ascending aorta. Results of this traditional operation are the standard against which the long-term outcome of newer approaches, such as valve-sparing operations, should be compared.

Adolescent↗

PubMed2003

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↗

PubMed2003

Recent improvements in outcome with the Novacor left ventricular assist device.

BACKGROUND: The Novacor implantable, electrically powered, wearable, left ventricular assist device (LVAD) has been used as a bridge to transplantation at our institution since 1994. Recent changes in protocol have resulted in a decreased incidence of infections, thromboembolism, and mortality. METHODS: We reviewed the medical records of all 43 patients who received implantable LVADs at the Mount Sinai Medical Center. After 1998, a number of protocol modifications were instituted. Vascular grafts were changed from a low-porosity, woven polyester (Cooley) to a gelatin-sealed, knitted polyester graft (Vascutek), the devices were implanted pre-peritoneally rather than in the posterior rectus sheath, and extensive drainage of the chest and pre-peritoneal pocket was used. The following anti-coagulation regimen was used: low-molecular-weight Dextran for 1 day, initiated after chest tube drainage <50 cc/hour; then IV heparin for 10 to 14 days, beginning at 500 U/hour, slowly increasing partial thromboplastin time to 1.5 to 2 x control; and finally Coumadin, maintaining the international normalized ratio at 2.5 to 3.5. Daily aspirin, 325 mg, was begun on post-operative Day 7. We compared 22 patients who electively underwent surgery before the changes, Group I, with 18 patients treated thereafter, Group II. RESULTS: Groups I and II were well matched with regard to age (47 vs 44 years); cause of heart failure (idiopathic, 50% vs 44%; ischemic, 50% vs 56%), and duration of support (79 vs 76 days). The incidence of thromboembolic cerebrovascular events was significantly less in Group II (6%) than in Group I (23%), p = 0.025. The incidence of bleeding increased mildly in Group I. Pocket infections occurred in 27% of Group I patients vs 11% of Group II patients, p = 0.018. Only 2 patients (11%) in Group II died while receiving device support, vs 7 (32%) in Group I, p = 0.019. CONCLUSIONS: Our results indicate that pre-peritoneal implantation, use of a new generation of vascular grafts, extensive drainage, and a more restricted anti-coagulation regimen improve outcome after Novacor LVAD implantation for advanced heart failure.

Adolescent↗

PubMed2002

Tacrolimus in cardiac transplantation: efficacy and safety of a novel dosing protocol.

BACKGROUND: Although used for more than 20 years, optimal dosing strategies of most immunosuppressants have never been determined. Tacrolimus, one of the newer agents used in solid-organ transplantation, is gaining increasing popularity because of its ability to reverse refractory rejection in cyclosporine-treated patients and its favorable side-effect profile. As with many other immunosuppressive agents, absorption and metabolism vary between individuals, which complicates dosing. METHODS: We hypothesized that a 1-mg dose of tacrolimus may be used to gauge each patient's metabolism. A novel dosing scheme was evaluated to establish the safety and efficacy of this approach. Outcomes were incidence of renal insufficiency and treatment efficacy as assessed by the rejection grade on the first endomyocardial biopsy. RESULTS: The risk of renal insufficiency was low, with only a 3% rise in creatinine at 7 days posttransplant. The risk of renal insufficiency was highest during the first 3 days of tacrolimus therapy, and the change in tacrolimus level during this time was identified as the single best predictor of renal insufficiency. From days 4 to 7, the rise in tacrolimus level had much less influence on renal function. Ninety-two percent of patients had a low- or intermediate-grade first cardiac biopsy. CONCLUSIONS: It was shown that this conservative initial dosing approach, which guarantees renal safety, is not associated with an increased risk of allograft rejection. We conclude that administration of tacrolimus via a tailored protocol soon after transplantation ensures a safe and effective means of immunosuppression.

Adult↗

PubMed2002

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↗

PubMed2002

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↗

PubMed2002

Bioprosthetic valved conduit aortic root reconstruction: the Mount Sinai experience.

BACKGROUND: Patients requiring aortic root reconstruction who are deemed unable to take anticoagulants offer unique challenges to the surgeon. For these patients, we have been manufacturing composite conduits intraoperatively using stented bioprostheses. METHODS: During the 10-year period from April 1992 until May 2002, 141 patients (105 male, 36 female) from 34 to 88 years of age underwent aortic root reconstruction with biological valved conduits. Diagnoses included dissection (n = 28, 9 acute type A), degenerative (64), atherosclerotic (32), anuloaortic ectasia (9), endocarditis (5), and other causes (3). Preoperative risk factors included hypertension (90), smoking (63), coronary artery disease (48), and diabetes (6). Valved conduits were mainly constructed from pericardial valves and impregnated Dacron grafts. Distal anastomosis was performed open in all cases except 6; the ascending aorta only was replaced in 63 patients, a hemiarch reconstruction was used in 71, and more extensive arch reconstruction in 7. Additional cardiac procedures were performed in 59 patients. RESULTS: Two deaths occurred in the operating room (biventricular failure). Late hospital mortality was 11 of 141 (7.8%) of which 6 (55%) were cardiac, 2 (18.2%) were infectious, 2 (18.2%) were of other complications and 1 (9.1%) was unknown. Three patients (2.1%) sustained permanent and 3 transient strokes. No structural deterioration of the valve and an approximately 86% freedom from thromboembolic events was observed during 5 years. CONCLUSIONS: For patients for whom anticoagulation is contraindicated or undesirable, reconstruction of the aortic root with a stented bioprosthetic valved conduit offers an acceptable alternative to mechanical prostheses.

Adult↗

PubMed2002

Aortic arch replacement using a trifurcated graft and selective cerebral antegrade perfusion.

BACKGROUND: Aortic arch aneurysm repair remains associated with considerable mortality and risk of cerebral complications. We present results of a technique utilizing a three-branched graft for arch replacement, deep hypothermic circulatory arrest (HCA), and selective antegrade cerebral perfusion (SCP). METHODS: Between March 2000 and November 2001, 22 patients (11 female) aged 40 to 77 years (mean 64 +/- 11.2) underwent arch replacement utilizing the trifurcated-graft technique. Serial anastomosis of the branched graft to individual cerebral vessels was carried out during HCA, followed by arch reconstruction during SCP through the graft. All 22 patients had surgery electively. Eight patients (36%) had undergone previous aortic surgery. In 19 patients, arch replacement was part of an elephant trunk procedure; 2 patients had Bentall operations and 1 had isolated arch replacement. Concomitant coronary artery bypass grafting was performed in 6 patients (27%). Mean HCA duration was 30 +/- 6 minutes at a mean temperature of 11.4 +/- 0.8 degrees C. Mean duration of SCP was 52 +/- 18 minutes. RESULTS: Adverse outcome--death before hospital discharge or permanent stroke or both--occurred in 2 patients (9%). Two patients experienced transient neurologic dysfunction (9%). Two patients (9%) developed renal failure requiring short-term hemodialysis and pulmonary complications occurred in 2 patients. CONCLUSIONS: Cerebral protection and prevention of atheroembolism remain challenges in aortic arch reconstruction. To reduce neurologic complications we developed an aortic arch reconstruction technique in which a trifurcated graft is anastomosed to the brachiocephalic vessels during HCA, reducing the risk of embolization while minimizing cerebral ischemia by permitting antegrade cerebral perfusion as arch repair is completed.

Adult↗