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Objectives: Antegrade selective cerebral perfusion (ASCP) represents the best method of cerebral protection during surgery of the thoracic aorta. However, brain integrityand metabolism after antegrade cerebralperfusion have not yetbeen investigated. We assessed cerebralpositron emission tomography (PET), diffusion-weighted imaging, proton magnetic resonance spectroscopy and cognitive functions in patients undergoing either ASCP or coronary artery bypass grafting (CABG) to elucidate whether cerebral perfusion was associated with postoperative neuronal alterations, metabolic deficit or cognitive decline. Methods: Seventeen patients undergoing aortic arch surgery using ASCP with moderate hypothermia (26 8C) (ASCP group) and 15 patients undergoing elective on-pump CABG (CABG group) were prospectively enrolled in the study. Brain PET, diffusion-weighted imaging, proton magnetic resonance spectroscopy and neuropsychometric testing were performed preoperatively, and at 1 week and 6 months postoperatively (T1, T2 and T3, respectively). Patient data were compared for statistic analysis with a normal database made up of healthy subjects. Results: One patient in each group was excluded because they refused postoperative evaluation. There were neither strokes nor hospital deaths. Two patients suffered from temporary neurological dysfunction (one in each group). Proton magnetic resonance spectroscopy did not reveal significant alterations in cortical N-acetyl-aspartate (NAA) content within and between the groups at T2 and T3. In the ASCP group, brain diffusion-weighted magnetic resonance showed a significant increase of the apparent diffusion coefficient values, reflecting vasogenic cerebral oedema, at T2, that disappeared at T3. Magnetic resonance detected new focal brain lesions in two CABG group patients. In seven ASCP group patients, PETscan showed glucose hypometabolism in the occipital lobes at T2, which disappeared in five patients at successive examination (T3). Significant cognitive decline was not observed in any patient. Test score changes between and within groups were not significant. Conclusions: There was no evidence of ischaemic brain injury after ASCP even if some degree of reversible brain oedema secondary to cardiopulmonary bypass (CPB) was present. The cognitive outcomes in patients undergoing ASCP were comparable to patients undergoing coronary artery bypass. The lack of left subclavian artery perfusion during cerebral perfusion leads to temporary glucose hypometabolism in the occipital lobes without neuronal injury. # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objective - Aortic valve-sparing operations have shown excellent results in patients with aortic root and or ascending aorta aneurysm. Aortic valve regurgitation is frequently detected in these patients as a result of significant dilation of the aortic root. The aim of this study was to assess the impact of preoperative aortic incompetence degree on the early and midterm outcomes of sparing surgery. Methods - From September 2001 to July 2006,84 patients with aortic root aneurysm underwent aortic valve-sparing surgery according to the reimplantation technique. Depending on preoperative grade of aortic insufficiency (Al), two groups were identified: 31 patients (study group, SG) with Al grade III-IV and 53 (control group, CG) with Al grade II or less. The Gelweave Valsalva prosthesis was used in 76 patients (90.5%). Intraoperative, perioperative variables and outcomes at follow-up were retrospectively compared between the groups. Results - Patient demographics and types of operations were comparable between groups. Early mortality rates were almost identical in both groups (3.2% SG vs. 5.7% CG; P = 0.961); at follow-up (FU), no patient died in both groups. Grade III-IV Al was similar in both groups early postoperatively (6.4% SG vs. 3.8% CG; P = 0.981) and during follow-up (13.3% vs. 8%; P = 0.755). Reoperaton rate for Al was 3.3% in SG vs. 6% in CG (P = 0.980). Conclusions - Preoperative degree of aortic regurgitation does not impair the outcomes of the valve-sparing operation which seem to depend on more factors. Early results were affected by the learning curve but midterm outcomes showed a progressive improvement. Patients with satisfactory reconstruction show stable results over time.

a lady who cares about her physical appearance. More importantly, the procedures are executed off-pump. The second benefit is safety: capture of the dislocated occluder through the inferior partial median sternotomy is relatively easier than other approaches for perfect exposure. When the capture or the closure procedure is failed for some reason, the incision can be extended upward, and conventional surgical closure can be performed immediately. To our knowledge, this is the first case in which a dislocated occluder has been captured without CPB and in which the peratrial device closure was performed after the failure of percutaneous occluder implantation. The case reminds us that capture of a dislocated occluder without CPB is technically feasible and that peratrial device closure might be a new direction for therapy of septal defects.

ObjectiveThe operative timing and management of acute traumatic aortic rupture are matters of debate. We reviewed our experience with endovascular repair of acute traumatic aortic rupture, focusing on these topics.MethodsFrom 1998 to 2007, 31 patients were referred to our institute for acute traumatic rupture of the descending aorta. In 11 patients (group I) an early stent graft procedure was performed, whereas in 16 patients (group II) endovascular repair was delayed. The median time from trauma was 24 hours in group I and 1.5 months in group II. Eight (25.8%) patients had a short proximal neck (

A new bio-prosthetic valved conduit (Bio-Valsalva) has recently been introduced into surgical practice in order to offer a valid option for elderly patients undergoing composite aortic root replacement. The conduit is made up of a stentless porcine valve (elan valve) pre-sewn inside a triple layer Valsalva prosthesis and it is entirely preserved in a glutaraldehyde solution. In our Department, 21 patients (16 males, mean age 67.8+/-5.5 years) underwent aortic root replacement using the Bio-Valsalva prosthesis. Composite root replacement was extended to the hemiarch in three cases while a complete arch replacement was performed in two patients. Type A aortic dissection was present in two cases while a bicuspid aortic valve was detected in eight patients. In-hospital mortality was 4.7% (1 patient). Re-thoracotomy for bleeding was performed in one case. The median in-hospital stay was 12 days. The median follow-up was six months and is 100% complete. There were no re-operations or structural deterioration during this early phase of observation. The Bio-Valsalva graft, readily available in different sizes, demonstrates ease of implantability and shows good haemostatic characteristics. More patients and a longer follow-up are necessary to confirm the advantages of this graft.

We compared mortality rates league tables for six cardiac surgery centres developed using an administrative database (integrated with information on patients' EuroSCORE) with those drawn from a specialised clinical database. Data from 4017 patients undergoing cardiac surgery over the period January 1st-December 31st 2003, and identified both databases were used. Case mix adjusted in-hospital mortality rates were estimated relying on information provided by each database, and league tables were drawn from both. The correlation between the two league tables was assessed through the Spearman correlation coefficient. League tables drawn from the two sources identified the same 'best' and 'worst' centres and the Spearman correlation coefficient confirmed a high level of agreement between the two rankings (r=0.89; P

Background:Nonsteroidalanti-inflammatorydrugsandopioidsareroutinelyusedaftercardiacsurgeryin orderto mitigatepostoperativepain; however, thesedrugsareburdenedbysideeffects.Tramadoland paracetamol arebelievedto belackingin suchside effects.Theaim of thisstudy was to examine the efficacy of intravenous paracetamol as an adjunctive analgesic to a tramadol-based background analgesia after cardiac surgery. Methods: A total of 113 patients participated in this single center, placebo-controlled, double-blind, randomized trial. Fifty-six patients were randomized to receive paracetamol and 57 to placebo. Intravenous study drug (1 g) was administered 15 min before the end of surgery and every 6 h for 72 h. Standard analgesia (tramadol) and anti-emetic prophylactic regimen (ondansetron) were available to both patient groups. Postoperative pain was evaluated by visual analog scale, and it was measured at rest and during a deep breath. A rescue dose of 2—5 mg of intravenous morphine was administered whenever the VAS score was greater than 3. Results: Baseline characteristics were equivalent between the two groups. At 12, 18, 24 h after the end of operation, patients who received paracetamol had significantly less pain at rest (p = 0.0041, 0.0039, 0.0044, respectively); after this time the two groups did not differ. During a deep breath the difference was significant only at 12 h (p = 0.0040). Paracetamol group required less cumulative morphine than placebo group (48 mg vs 97 mg) even if the difference did not reach statistical significance (p = 0.274). Conclusions: In patients undergoing cardiac surgery, intravenous paracetamol in combination with tramadol provides effective pain control. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Background: Introduced by DePaulis in 2000, the Gelweave Valsalva graft (Sulzer Vascutek, Refrewshire, Scotland) is a modified Dacron conduit (DuPont, Wilmington, DE), with prefashioned sinuses of Valsalva. The aim of this study was to evaluate the mid-term results of the reimplantation valve-sparing aortic root replacement using the Gelweave Valsalva prosthesis in Marfan syndrome patients. Methods: A retrospective review was performed of 35 patients with Marfan syndrome in four centers who underwent the reimplantation valve-sparing aortic root replacement using the Gelweave Valsalva prosthesis. Results: The patients were predominantly men, with a mean age of 36.5 ± 12.6 years (range, 14 to 62 years). Two patients presented with acute type A dissections and underwent emergent operations. Elective hemiarch reconstruction using hypothermic circulatory arrest was required in 11 patients. Aortic valve cusp repair was performed in 2 patients. There were no operative or hospital deaths, and no patients died during follow-up. The mean follow-up was 19 months (range, 1 to 60 months). Significant (>2+) aortic insufficiency (AI), requiring aortic valve replacement, developed in 3 patients during follow-up that requiring aortic valve replacement. The 5-year freedom from reoperation owing to structural valve deterioration was 88.9% ± 8.1%. There were no episodes of clinically significant thromboembolism. Conclusions: Reimplantation valve-sparing aortic root replacement with the Gelweave Valsalva prosthesis in Marfan patients provides satisfactory mid-term results, thus encouraging further use of this type of repair. However, long-term results are needed in order to define the durability of this technique. © 2007 The Society of Thoracic Surgeons.

We report a case of damage to the circumflex coronary artery during mitral valve repair using sliding leaflet technique in a patient with a posterior mitral leaflet prolapse and coronary artery disease who underwent mitral valve reconstruction using Carpentier's technique and coronary artery bypass grafting. This case underscores the risk of circumflex coronary artery injury during mitral valve reconstruction, especially in patients with left coronary dominance or codominance, and therefore emphasizes the importance of knowing the coronary artery anatomy preoperatively. The use of intraoperative transesophageal echocardiography is mandatory for the evaluation of mitral valvuloplasty.

Background This study evaluates the midterm clinical results of valve-preserving aortic root reconstruction by means of a modified conduit incorporating sinuses of Valsalva. Methods During a 5-year period, 151 patients with aneurysm of the aortic root underwent a reimplantation type of valve-sparing procedure using the Gelweave Valsalva prosthesis that incorporates sinuses of Valsalva. There were 121 males (80.1%), and the mean age was 56.4 ± 14.4 years (range, 14 to 83). Fourteen percent of the patients had Marfan syndrome and 8.6% had bicuspid aortic valve. Seven patients (4.6%) suffered from acute aortic dissection. Aortic replacement was extended to the arch in 14 patients (9.3%). Sixteen patients (10.6%) had associated cusp repair. Results In-hospital mortality was 3.3%, and it was significantly higher among patients operated on for acute dissection ( p = 0.001) and in symptomatic patients (III–IV New York Heart Association class; p = 0.021). Follow-up (mean, 18 months; range, 1 to 60) was 100% complete. There were 2 late deaths. Ten patients (6.8%) had 3 to 4+ aortic regurgitation, and 8 of these required late aortic valve replacement. Cusp repair was associated with a high incidence of late aortic valve replacement ( p = 0.005). At 5 years, freedom from aortic valve replacement and freedom from grade 3 to 4 aortic insufficiency was 90.8% ± 3.3% and 88.7% ± 3.6%, respectively. Conclusions The reimplantation valve-sparing procedure with the Gelweave Valsalva prosthesis provides satisfactory results for patients with aortic root aneurysm. Aortic cusp repair may lead to late aortic insufficiency. Proper leaflet evaluation is of paramount importance in preventing residual valve regurgitation.

A case of aorto-ostial stenosis and ascending aortic aneurysm is useful not only to discuss about some technical issues of percutaneous procedures and surgery, but also to highlight the importance of coordination between cardiologists and surgeons.

BACKGROUND Aortic valve-sparing operations have provided very good clinical outcomes. However, there is still a debate about valve durability because of the absence of the Valsalva sinuses, and various techniques have been proposed to reproduce the native anatomy of the aortic root. We reviewed our total experience with aortic valve-sparing operations to determine early and midterm outcomes. METHODS Between July 2001 and August 2004, 85 patients underwent valve-sparing operations. There were 67 (78.8%) male and 18 (21.2%) female patients with a mean age of 58.8 +/- 14.6 years. Sixty-five patients with an aortic root aneurysm underwent the David I reimplantation technique, and a Gel-weave Valsalva graft was used in 57 patients. Twenty patients with an ascending aortic aneurysm underwent replacement of the ascending aorta with sinotubular junction reduction. RESULTS There were 3 in-hospital deaths (3.5%) and 2 late deaths. Two of 4 patients with acute aortic dissection died. The 3-year survival for patients with an aortic root aneurysm was 95.4% +/- 2.6%, and for patients with an ascending aortic aneurysm it was 89.2% +/- 7.3 (P = .464). Seven patients developed 3 to 4+ aortic insufficiency, and 5 of them required aortic valve replacement. The 3-year freedom rate from grade 3 to 4 aortic insufficiency was 88.9% +/- 5.2% for patients with an aortic root aneurysm and 88.2% +/- 7.8% for those with an ascending aortic aneurysm. At 3 years, the freedom rates from late aortic valve replacement were 92.2% +/- 4.9% in the aortic root aneurysm group and 88.2% +/- 7.8% in the ascending aortic aneurysm group. CONCLUSIONS Aortic valve-sparing operations showed excellent results in patients electively operated on for aortic root ectasia, and the results in acute aortic dissection were very disappointing. The Gelweave Valsalva prosthesis demonstrated ease of implantability and good reproduction of the pseuodosinuses. Long-term follow-up is necessary to determine if this graft will enhance the function and increase the durability of the aortic valve.

Aneurysm development after repair of aortic coarctation is not a rare complication, but it is highly related to hypoplasia of the transverse aortic arch. The optimal management of such cases is not clearly established. We propose a single-stage transmediastinal re-repair using moderate hypothermic cardiopulmonary bypass and antegrade selective cerebral perfusion.

During the last decade, a considerable increase in the number of operations on the thoracic aorta has been observed. Although patient’s outcomes have improved considerably, this surgery is still associated with significant morbidity and mortality due to neurological complications. Various methods have been proposed and widely used as means to protect the brain from ischemic damage. This review summarizes the principal methods of cerebral protection, describes the advantages and disadvantages of each method and their impact on patient outcomes, and discusses the different surgical techniques proposed to minimize the risk of cerebral injuries.

The purpose of this study was to evaluate the efficiency, in terms of decreasing overall mortality (primary endpoint), of an immunoglobulin M (IgM)-enriched, polyclonal intravenous immunoglobulin preparation (IVIg) (Pentaglobin; Biotest AG, Dreieich, Germany) in the treatment of a group of patients affected by sepsis after cardiac surgery. A secondary endpoint was to evaluate which subgroup, on the basis of the infectious state when the patient enrolled, could benefit the most from the treatment. Another secondary endpoint was the evaluation of an improvement in the severity score or in other variables such as Glasgow Coma Scale; arterial pressure (systolic, average, and diastolic); heart rate; central venous pressure; cardiac index; respiratory rate; PaO(2), F(I)O(2), and the ratio of PaO(2) to F(I)O(2); pH, base excess, and bicarbonate; C reactive protein and leukocytes; platelets, prothrombin time, partial thromboplastin time, fibrinogen, and anti-thrombin III; creatinine; and bilirubin.Retrospective case-controlled study.Cardiovascular intensive care unit of a university hospital.Sixty-six patients who developed sepsis in the postoperative period after cardiac surgery were admitted to the cardiovascular intensive care unit from June 1, 2001, to June 30, 2003: 30 patients (45.5%) had valvular surgery, 18 (27.5%) had myocardial revascularization, 14 (21%) had thoracic aorta surgery, and 4 (6%) had other surgery.From the 66 patients diagnosed with sepsis, 22 patients (IVIg group) received IgM-enriched immunoglobulins in addition to the conventional therapy, whereas the other 44 patients (control group) were treated only with conventional therapy. The decision as to whether or not to administer the immunoglobulins was made by physicians in the intensive care unit.Of the 66 patients, 8 patients (3 from the IVIg group and 5 from the control group) had sepsis, 47 patients (15 from the IVIg group and 32 from the control group) had severe sepsis, and 11 patients had septic shock (4 from the IVIg group and 7 from the control group). The overall mortality rate was 31.8% without significant differences between groups (22.7% IVIg group v 36.4% control group, p = not significant). Among the 47 patients affected by severe sepsis, those from the control group had a mortality rate significantly higher than that of the IVIg group (12/32 [37.5%] v 1/15 [6.6%], p = 0.036 [2-sided Fisher exact test]). The 70-day survival rate was significantly higher in the IVIg group than in the control group (log-rank test, p0.04). No significant differences were found between study groups in Acute Physiology and Chronic Health Evaluation II or SOFA scores.The polyclonal IgM-enriched immunoglobulins did not significantly reduce the mortality rate in the overall study population. However, in the subgroup of patients with severe sepsis, they improved the survival rate significantly.

Surgical treatment of the thoracic aorta combined with endovascular stent grafting may be an interesting approach to diseases of the thoracic aorta in high-risk patients. A patient with a chronic post-dissection aneurysm of the aortic arch and proximal descending aorta developed, after surgery, a perianastomotic leak of the distal suture of the graft. We successfully treated the leak by means of an endovascular stent graft procedure. These combined procedures may be useful to resolve surgical complications particularly in case of high operative risk.

Background: Minimally invasive cardiac surgery (MICS) is a safe and satisfactory approach used mainly in mitral valve surgery with excellent results in many centers. Cardioplegia administration can be still a problem, especially when an endoaortic clamp is used. We retrospectively analyzed our early results with histidine-triptophane-ketoglutarate (HTK) solution used for myocardial protection in MICS. Methods: Between February 2003 and February 2004, 8 patients underwent mitral valve surgery using an endocardiopulmonary bypass (CPB) system and HTK solution as myocardial protection. The mean patient age was 67.7 ± 9.2 years, and the preoperative ejection fraction was normal in all patients. Three patients had valve repair and 5 had valve replacement. Mean CPB time was 129.2 ± 19.4 minutes, and aortic cross-clamp duration was 88.5 ± 15.4 minutes. Results: In every case HTK solution was used for only a single dose for cardioplegia at the beginning of the procedure, without any recalls. The heart restarted spontaneously at reperfusion in 6 of 8 cases (75%), and there were no significant modifications in electrocardiogram results or myocardial cytonecrosis enzymes (creatine kinase and its MB fraction) during the postoperative period. Conclusions: HTK solution is a cold crystalloid cardioplegia solution that has demonstrated its utility in MICS because it provides a safe long cardioplegic arrest time and it reduces the risk of inadequate coronary perfusion due to dislodgement of the endoaortic clamp. © 2004 Forum Multimedia Publishing, LLC.

Patients who underwent isolated aortic valve replacement could come to attention for new onset aortic disease or progression of borderline alterations not corrected at the first operation, especially in the subset of bicuspid valve disease. We describe our technique in redo operations for aortic root disease, using only a vascular graft and sparing the previously implanted valve prosthesis. In case of normally functioning mechanical prosthesis, we always left the valve in situ and substituted the aortic root with a Dacron conduit, extending the replacement if necessary to the other diseased portions of the thoracic aorta.

* Corresponding author. Address: Via Vittoria Colonna, 19, 20149 Milano, Italy. Tel.: C39 335 6548336; fax: C39 051 345990. E-mail address: emmanuel.villa@voila.fr (E. Villa). ostium. Imprecise stent positioning is disturbing in case of supplemental cardioplegia: unplanned conversion to retrograde infusion or neonatal arteriotomy-catheter for selective cannulation are needed (Fig. 1). European Journal of Cardio-thoracic Surgery 27 (2005) 712 www.elsevier.com/locate/ejcts

We retrospectively analyzed the hospital mortality and neurologic outcome after surgery on the thoracic aorta with the aid of antegrade selective cerebral perfusion to determine a predictive risk model.Between October 1995 and May 2002, 462 patients (mean age 62.7 +/- 11.7 years) underwent surgery on the thoracic aorta using antegrade selective cerebral perfusion. The indication for surgery was acute type A dissection in 132 patients (28.6%), degenerative aneurysm in 258 (55.8%), and post-dissection aneurysm in 72 (15.6%). One hundred and forty-one patients (30.5%) were operated on urgently; concomitant procedures were performed in 190 patients (41.1%). The mean cerebral perfusion time was 63 +/- 39 min. Predictors of hospital mortality and neurologic outcome were identified by univariate and multivariate analysis of the preoperative and intraoperative variables.The hospital mortality rate was 10.2%. Stepwise logistic regression identified an urgency status (odds ratio--OR 5.2, p = 0.001), a history of a central neurologic event (OR 4.1, p = 0.007) and coronary artery bypass graft (OR 3.2, p = 0.039) as being independent determinants for hospital mortality. The transient neurologic dysfunction rate was 6.2%. An urgency status (OR 3.4, p = 0.003) and a history of a central neurologic event (OR 5.1, p = 0.002) were independent determinants of transient neurologic dysfunction. An urgency status (OR 6.0, p = 0.011) was the only independent determinant for permanent neurologic dysfunction (3.8%). A cerebral perfusion time90 min was not associated with an increased risk of hospital mortality and permanent or transient neurologic dysfunction.Antegrade selective cerebral perfusion proved to be a safe method of brain protection allowing complex aortic repair to be performed with encouraging results in terms of hospital mortality and neurologic outcome.

Aim The spectrum of histological alterations, namely atrial amyloidosis, in the right and left atria of patients with chronic persistent atrial fibrillation (AF) and rheumatic heart disease is not completely known. Methods and results One hundred and twenty-eight atrial appendages (66 left and 62 right), obtained from 72 patients with rheumatic valve disease and chronic AF undergoing cardiac surgery for valve replacement or repair and AF treatment were histologically evaluated for the presence of amyloid deposits. One hundred and four specimens of left and right auricles from 52 patients in sinus rhythm with severe chronic heart failure undergoing heart transplant were also analyzed (controls). Amyloid was found in 33 (46%) valvular patients with chronic persistent AF and in 6 (12%) controls. Amyloid was related to the presence and duration of AF, was more frequently found in left atrial samples and was independent of age. On stepwise logistic regression analysis, AF duration and female gender were independently related to amyloid deposition. Conclusions Patients with long-standing AF and rheumatic heart disease have a very high prevalence of atrial amyloidosis. Amyloid deposition is more frequent in left than in right atrial appendage and correlates with AF duration and female gender. Amyloid deposition could constitute an additional histological feature in the structural remodeling of atria during long-standing AF, at least in rheumatic valve disease. Persistence of AF might play a pivotal role in promoting amyloid deposition.

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.

Low birth weight or premature infants may require early surgical treatment of congenital cardiac lesions because of their poor clinical status. Even thought early repair or palliation is carried out with incremental risk factor for morbidity and mortality, it has been demonstrated to be preferable to medical management and delayed surgery. This retrospective study was undertaken to evaluate early and mid-term results in infants, weighing less than 2500 g, who underwent surgery other than patent ductus arteriosus closure.Since January 1993 to August 2002, 60 consecutive patients underwent early surgical treatment of congenital heart malformations at our institution. 27 patients were premature (born before 37 weeks of gestation). Ninety percent were severely symptomatic. Mean age at operation was 15.5 days (range 4-68 days). Mean weight was 2120 g (range 900-2500 g). Indications for surgery were: coarctation complex 11, transposition of great arteries 9, interrupted or severely hypoplastic aortic arch 9, hypoplastic left heart syndrome 7, truncus arteriosus 5, other 19. Thirty-five patients were operated on CPB, Deep Hypothermia with Circulatory Arrest was used in 9. Complete repair was achieved in 32 patients. Aortic arch reconstruction was required in 32 cases.There were nine early deaths (15%): heart failure (5), multiorgan failure (3), sepsis (1). Age, weight, prematurity, type of surgery and use of cardio pulmonary by-pass did not influence early mortality. Mean intensive care unit stay and duration of mechanical ventilation were 5.8 days and 75.5 h, respectively. Postoperative neurological complications did not occur in any patient. At follow-up (mean 48 months) there were nine late deaths. Kaplan-Meier survival at 60 months was 70%.Surgery for congenital heart disease can be performed in low weight critically ill infants with reduced, but still acceptable early and mid-term survival.

Background Composite valve graft replacement is currently the treatment of choice for a wide variety of lesions of the aortic root and the ascending aorta. In this study we report our experience with aortic root replacement using a composite graft. Methods Between October 1978 and May 2001, 274 patients (79.6% male and 20.4% female) with a mean age of 53.5 years underwent composite graft replacement of the aortic root. One hundred sixty-one patients (70.8%) had annuloaortic ectasia and 46 (16.8%) aortic dissection. The classic Bentall technique was used in 94 patients (34.3%), the "button technique" in 172 patients (62.8%), and the Cabrol technique in 8 patients (2.9%). Results The early mortality rate was 6.9% (19 of 274 patients). Cardiopulmonary bypass time longer than 180 minutes and associated coronary artery bypass grafting were found to be independent risk factors of early mortality. The actuarial survival rate was 77.7% at 5 years and 63% at 10 years. The independent risk factors for late mortality were coronary artery disease, chronic renal failure, and postoperative dialysis. The actuarial freedom from reoperation on the remaining aorta was higher among patients without Marfan syndrome (94.6% versus 79.6% at 10 years, p = 0.008). Conclusions Composite valve graft replacement can be performed with low hospital mortality and morbidity. The button technique offers some advantages and should be used whenever possible. In case of acute aortic dissection root replacement is usually not necessary. Marfan patients should be treated with early root replacement before dissection occurs.

Non bacterial thrombotic endocarditis is a rare disease. The real incidence is not known and seems to range from 0.9 to 9.3%. Generally it is associated with cancer and rarely diagnosed antemortem. We describe the case of a female patient who suffered from ictus cerebri and acute myocardial infarction. She was admitted with diagnosis of papillary fibroelastoma arising from the right aortic leaflet. Her past medical history was characterized by gastrectomy, splenectomy and partial pancreatectomy for gastric cancer. The patient underwent successful resection of the mass that was attached to the right leaflet of the aortic valve closed to the aortic annulus. The histopathological examination revealed a mass composed of only thrombotic material. At the follow-up 1 year later the patient was in good clinical conditions (NYHA functional class I). Transthoracic echocardiography showed a good ventricular function, a continent aortic valve without recurrent mass. The suspicion of non bacterial thrombotic endocarditis should be aroused when diagnosis of endocardial mass is made in patients with previous cancers.

because they can both determine brain oedema, resulting in temporary metabolic alterations. Regarding the possible role of femoral cannulation with retrograde perfusion, we were not really convinced that it could be responsible for postoperative brain hypometabolism unless some sort of brain hypoperfusion occurs during cooling and rewarming. Furthermore, no new ischaemic lesions due to thromboembolism were documented in the magnetic resonance study in the ASCP group, even in patients in whom the femoral artery was cannulated. As we stated in the paper, an important limitation of this study, which has to be taken into account in evaluating the results, is the lack of preoperative assessment of the brain vascularization and its possible anatomical variation. In conclusion, we would like to confirm that patients with long ASCP time developed hypometabolism of the occipital lobes more frequently, due to the lack of subclavian artery perfusion during ASCP.

The optimal treatment for and timing of surgery to repair traumatic aortic injury are still controversial. Endovascular treatment is a viable option in patients with both acute and chronic aortic trauma. However, appropriate patient selection criteria, treatment timing, and long-term durability of endovascular repair remain to be defined. We sought to identify appropriate selection criteria and optimal timing of treatment as well as to assess the long-term durability of endovascular repair.From July 1997 to December 2001, 19 patients with traumatic aortic injury (11 patients with acute and eight with chronic injuries) were selected for endovascular treatment. In all patients, the lesions were sited at the proximal segment of the descending aorta at a distance of 10 +/- 17 mm (mean +/- SD) from the left subclavian artery. Nine of the patients with acute injuries were treated after clinical stabilization of other severe associated lesions, whereas two patients, in whom hemodynamic and imaging findings suggested an impending rupture, received emergency treatment. Single-detector helical CT or MR imaging was used for patient selection and stent-graft customization before treatment and for evaluation of patients during the follow-up period.Endovascular stent positioning was successful in all patients. None of the patients developed complications. Aneurysm exclusion and shrinkage were confirmed at followup examinations. A partial covering of the subclavian artery occurred in six patients without interrupting the blood flow. All patients remain asymptomatic after a mean follow-up period of 20 months (range, 1-56 months).Endovascular repair represents an alternative, minimally invasive treatment, particularly suitable for use in patients with traumatic aortic injuries. The decision of whether to provide immediate emergency treatment or to delay treatment should be based on the lesion characteristics on imaging and clinical findings. The durability of treatment seems to be related to the absence of alteration to the aortic wall at the extremities.

Papillary fibroelastomas are rare, benign, primary cardiac tumors, usually single and small. The neoplasm consists of a leafy, soft excrescence typically located on the cardiac valves. Although papillary fibroelastomas are usually an asymptomatic incidental finding at autopsy, or during cardiac operation, they are occasionally associated with embolic coronary or cerebral symptoms. A case of a patient is reported with papillary fibroelastoma of the mitral valve chordae, who presented several transitory ischemic attacks characterized by loss of conscience, visual bilateral deficit and right emiparesis. Because of their potential systemic embolization, we believe that these lesions should be always excised.

Background . The outcome of patients with acute traumatic rupture of the thoracic aorta after motor vehicle accidents is strongly conditioned by injuries to other districts. The timing of repair is controversial when the patients arrive alive to the hospital. Methods . A series of 42 patients with acute traumatic rupture of the thoracic aorta observed between January 1980 and June 1996 was divided into two groups: group I underwent immediate repair (21 patients) and in group II operation was performed after intensive medical treatment and management of the associated lesions and monitoring of the aortic tear. Results . The mortality in group I patients was 19% and the morbidity was more significant than in group II where no deaths were reported and complications were minor. Conclusions . Patients with acute traumatic rupture of the thoracic aorta may have a better fighting chance if aortic operation is postponed to the most favorable moment after undergoing life-sustaining measures and management of the major associated lesions. Needless to say, evolution should be closely monitored by computed tomographic scans and magnetic resonance imaging.

Primary cardiac tumours are relatively rare in the paediatric population, and they may occur with different signs and symptoms in foetal or post-natal life. The clinical manifestations of cardiac tumours in foetal life may include arrhythmias, congestive heart failure and hydrops. In post-natal life, cardiac tumours may cause cyanosis, respiratory distress, myocardial dysfunction, valvular insufficiency, arrhythmias, inflow or outflow tract obstructions and sudden death. Surgical treatment is essential when symptoms are present, while the role of medical therapy can merely be palliative. Results are various and related to the patients' and tumour characteristics. Primary benign heart tumours mainly have a good prognosis, while malignant neoplasms usually have a poor prognosis; in both cases, however, a strict follow-up is always mandatory in order to detect the recurrence of cardiac neoplasms after surgery.

Background Traumatic aortic rupture (TAR) is a pathological entity with a high mortality, both spontaneous and perioperative. Delayed surgical repair has been proposed when associated lesions are stabilized. The aim of this study was to validate MRI for detecting both the presence and type of TAR and to monitor posttraumatic aneurysm and associated lesions. Methods and Results Twenty-four consecutive patients with acute chest trauma and suspected aortic rupture, as suggested by emergency CT or chest radiographs, were subjected to MRI and/or angiography in random order. Such parameters as the presence and type of lesion; presence of periaortic, pericardial, mediastinal, or pleural effusion; and presence of associated lesions were considered in every patient. Follow-up imaging was performed exclusively by MRI every 1 to 2 months. TAR was present in 20 patients. No patient underwent surgery in the acute phase; 14 patients underwent surgery at 6.8±2.7 months; 5 are waiting for surgery; and 1 healed spontaneously. There was no overall mortality. For detection of TAR, the accuracy of MRI was 100%; angiography, 84%; and CT, 69%. In detecting the type of lesion, the diagnostic accuracy of MRI was 92%. During follow-up, a significant increase in the posttraumatic aneurysm was observed in 2 patients, and surgical repair was initiated. Conclusions In chest trauma patients, MRI provides complete anatomic data to assess the severity of aortic and thoracic lesions. Moreover, along with the concept of delayed surgical repair of TAR, MRI is the ideal modality to monitor and follow TAR before surgical repair.

(1) Clearly, the absence of correlation between echocardiographic and histological findings (which is the main result of our paper) has two consequences: part of the patients without severe ascending aortic dilatation has advanced histological abnormalities, whereas part of the patients with aortic dilatation leading to surgical intervention lacks histological abnormalities. In our cohort of patients, 18 (14%) had root dilatation (dilatation isolated or prevailing at the sinusal portion), a percentage similar to that reported in Della Corte et al.’s paper [3]. (2) Regarding the site of sample retrieval, the retrospective nature of the paper did not allow us to perform targeted sampling and aortic samples were randomly obtained from the ascending aortic tract, distally to the sino-tubular junction. Additionally, the samples were not oriented or targeted at the level of maximal diameter. (3) Finally, we confirm that all patients with advanced atherosclerotic lesions were excluded from this study. Only patients with minor atherosclerotic lesions (including adaptive intimal thickening, intimal xantoma, pathological intimal thickening or early and small fibroatheroma) were included, according to the morphological classification of the atherosclerotic lesions by Virmani et al. [4] and more recently by Van Dijk et al. [5]. It is highly improbable that these lesions can have significant consequences on the medial layer structure.

Objetivo No hay informacion sustancial sobre el papel de la «trompa de elefante congelada» en la diseccion aguda de aorta tipo A (DATA). Presentar resultados iniciales con la tecnica en esta enfermedad. Material y metodos Entre enero de 2005 y diciembre de 2009, se han reparado 184 pacientes con enfermedad aortica compleja con endoprotesis integrada E-Vita Open®. En 60 se reparo una DATA. Edad media 58 ± 12; 47 varones (79%) y 4 Marfan (7%). Intervencion en menos de 24 h en 53 (88%); 28 (47%) malperfusion. Taponamiento 15 (25%), insuficiencia aortica 39 (65%), inotropicos 24 (40%). Un 100% sustitucion de aorta ascendente, 87% arco completo, 13% arco subtotal; reimplantacion de vasos 44 (73%). Resuspension valvular 22 (36%); derivacion coronaria 14 (23%). Duracion de CEC 244 ± 57, isquemia cardiaca 137 ± 41, perfusion cerebral bilateral selectiva anterograda 66 ± 18 min. Resultados Mortalidad hospitalaria 13% (8/60). Intubacion superior a 72 h 42%. Reexploracion 12 (20%). Dos accidentes cerebrovasculares (ACV) permanentes (3%), cuatro regresivos (7%). No paraplejia/paresia. Trombosis ide postoperatoria periprotesica 47/53 (89%), 38/41 (93%) en seguimiento. Trombosis completa distal a la endoprotesis 15/53 (28%), parcial 16/53 (30%); trombosis distal parcial 16 (30%) y 19 (46%). Supervivencia Kaplan-Meier 74% a 60 meses. Cuatro requirieron EVAR inferior a 30 dias; 3 en seguimiento. Libertad de intervenciones secundarias en la aorta distal 80% a 60 meses. Seguimiento medio 22 ± 17 meses. Conclusion La «trompa de elefante congelada» con la endoprotesis E-Vita Open® parece un abordaje efectivo en la DATA.

A 72-year-old man was referred to our department with a diagnosis of ascending aorta aneurysm discovered in a control chest radiograph. The patient had been operated on for thoracic aorta replacement in 1990, for abdominal aorta replacement in 1994, and for aortic valve replacement with biological prosthesis in 1998. After the operation and for the following 3 years the patient was well without any relevant clinical problem. Considering the roentgenographic image (Fig 1), which showed the massive enlargement of the mediastinum with pulmonary compression, a computed tomographic scan of the chest was performed. That imaging study demonstrated a large aneurysm of 10 cm in diameter (true lumen of 7 cm) with a large thrombus surrounding the distal ascending aorta and an intimal flap originating above the right coronary ostium (Fig 2A). Moreover the anterior wall of the ascending aorta was completely adherent to the sternum (Fig 2B). The aortic arch was also dissected and had a diameter of 55 mm. Spiral tomographic scan reconstruction showed the enormous dimensions of the ascending aorta, which was completely attached to the sternum (Fig 3). Surgery consisted of aortic valve and ascending aorta replacement according to the modified Bentall procedure and aortic arch replacement with separate reimplantation of the innominate artery, left common carotid, and left subclavian arteries. The ascending aorta presented as a dissection with a completely thrombosed false lumen. Histologic findings confirmed the dissected wall: the false lumen wall was formed by adventitia and media, which had signs of elastic fiber fragmentation. Femorofemoral cardiopulmonary bypass was carried out and antegrade selective cerebral perfusion with moderate hypothermia (nasopharyngeal temperature of 26°C) was performed for brain protection. The patient recovered successfully without any complications from his surgery. This case illustrates the potential dimensions the ascending aorta and the arch may reach by a chronic dissection and how diagnostic imaging procedures are so important for taking a correct and safe surgical approach. Address reprint requests to Dr Martin-Suarez, Unita Ospedaliera di Cardiochirurgia, Universita degli Studi di Bologna, Policlinico S. Orsola, Via Massarenti 9, 40138 Bologna, Italy; e-mail: docsofi@yahoo.com. Fig 1.

Objective The study's objectives were to evaluate results and identify predictors of hospital and mid-term mortality after primary isolated aortic valve replacement; compare early and mid-term survival of patients aged more than 80 years or less than 80 years; and assess the effectiveness of the logistic European System for Cardiac Operative Risk Evaluation in predicting the risk for hospital mortality in octogenarians with a logistic European System for Cardiac Operative Risk Evaluation greater than 15% who are undergoing aortic valve replacement. Methods Data from 2256 patients undergoing primary isolated aortic valve replacement between January 2003 and December 2007 were prospectively collected in a Regional Registry (Regione Emilia Romagna Interventi Cardiochirurgia) and analyzed to estimate hospital and mid-term results. Results Overall hospital mortality was 2.2%. By multivariate analysis, New York Heart Association III and IV, Canadian Cardiovascular Society III and IV, pulmonary artery pressure greater than 60 mm Hg, dialysis, central neurologic dysfunction, and severe chronic obstructive pulmonary disease emerged as independent predictors of hospital mortality. At 3 years, the survival was 89.3%. The same predictors of hospital mortality plus ejection fraction of 30% to 50% and age more than 80 years emerged as independent risk factors for 3-year mortality. Compared with younger patients, octogenarians had a higher hospital mortality rate (3.72% vs 1.81%; P = . 0143) and a reduced 3-year survival (82.3% vs 91.3%; P 001). Three-year survival of octogenarians was comparable to the expected survival of an age- and gender-matched regional population ( P = . 157). The observed mortality rate in octogenarians with a logistic European System for Cardiac Operative Risk Evaluation greater than 15% (mean: 22.4%) was 7% ( P 001). Conclusions This study provides contemporary data on the characteristics and outcome of patients undergoing first-time isolated aortic valve replacement.

Objective: The study was designed to validate euroSCORE II and ACEF (age, creatinine, and ejection fraction) scores in patients undergoing isolated or associated mitral valve surgery and compare them with logistic euroSCORE and Society of Thoracic Surgeons scores. Methods: Data on 3441 consecutive patients undergoing isolated or associated mitral valve surgery in a 6-year period were retrieved from 3 prospective institutional databases. Discriminatory power was assessed with the C index. Calibration was evaluated with calibration curves and associated statistics. Results: In-hospital mortality was 3.4%. Discriminatory power was uniformly good (for euroSCORE II: area under curve, 0.79; 95% confidence interval, 0.74-0.84; for logistic euroSCORE: area under the curve, 0.78; 95% confidence interval, 0.74-0.83; for ACEF: area under the curve, 0.73; 95% confidence interval, 0.69-0.79) but significantly higher in euroSCORE models (P

Objective In acute type A aortic dissection, the extension of repair to downstream aorta has been controversially discussed. We present the early results of a multicenter study using a hybrid stent graft prosthesis. Methods Between January 2005 and January 2010, the data from 191 patients after combined proximal aortic replacement and antegrade stent grafting were collected in the database of the International E-vita open Registry. Of the 191 patients, 68 underwent surgery for acute aortic dissection and were included in the present study. Hypothermic circulatory arrest and selective cerebral perfusion were routinely used. Computed aortic imaging was performed for false lumen evaluation during follow-up. Results The in-hospital mortality rate was 13% (9/68). Along the stent graft, the rate of immediate complete false lumen thrombosis was 86% (51/59) and increased during follow-up (23 ± 17 months) to 94% (46/49). Distally, complete or partial false lumen thrombosis was initially observed in 61% (36/59) and in 82% (40/49) after follow-up. The 1- and 3-year actuarial survival rate was 82% and 74%, respectively. Conclusions Extended thoracic aortic repair of acute aortic dissection with a hybrid stent graft is feasible at acceptable early mortality and promotes false lumen thrombosis around the stent graft and below.