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Pleural effusions appearing within the first 30 postoperative days following coronary artery bypass grafting (CABG) are classified as early and believed to be directly related to the surgery. The characteristics of such effusions are well-described. Orthotopic heart transplantation is also known to be complicated by pleural effusions; however, their characteristics have not been systematically reported. We assessed the features of early postoperative pleural effusions after heart transplantation and compared them to those of early effusions following CABG.

Background: Cardiac surgery is considered a contraindication in patients with advanced liver cirrhosis (LC) due to increased mortality and morbidity. There are limited data on the treatment strategy and management of this population. We aimed to present our strategy and evaluate the clinical outcome of cardiac surgery in patients with LC., Methods: Our strategy was (i) to list patients for liver transplant (LT) at the time of cardiac surgery; (ii) to maintain high cardiopulmonary bypass (CPB) flow (index up to 3.0 L/min/m 2 ) based on hyper-dynamic states due to LC; and (iii) to proceed to LT if patients' liver function deteriorated with an increasing model for end-stage liver disease Na (MELD-Na) score after cardiac surgery. Thirteen patients (12 male and 1 female [mean age, 63.0]) with LC who underwent cardiac surgery between 2017 and 2024 were retrospectively analyzed., Results: Six patients were listed for LT. Indications for cardiac surgery included coronary artery disease (N = 7), endocarditis (N = 2), and tricuspid regurgitation (N = 1), tricuspid stenosis (N = 1), mitral regurgitation (N = 1), and hypertrophic obstructive cardiomyopathy (N = 1). The Child-Pugh score was A in five, B in six, and C in one patient. The procedure included coronary artery bypass grafting (N = 6), single valve surgery (mitral valve [N = 2] and tricuspid valve [N = 1]), concomitant aortic and tricuspid valve surgery (N = 2), and septal myectomy (N = 1). Two patients had a history of previous sternotomy. The perfusion index during CPB was 3.1 ± 0.5 L/min/m 2 . Postoperative complications include pleural effusion (N = 6), bleeding events (N = 3), acute kidney injury (N = 1), respiratory failure requiring tracheostomy (N = 2), tamponade (N = 1), and sternal infection (N = 1). There was no in-hospital death. There was one remote death due to COVID-19 complication. Preoperative and postoperative highest MELD-Na score among listed patients was 15.8 ± 5.1 and 19.3 ± 5.3, respectively. Five patients underwent LT (1, 5, 8, 16, and 24 months following cardiac surgery) and one patient remains on the list. Survival rates at 1 and 3 years are 100% and 75.0%, respectively., Conclusion: Cardiac surgery maintaining high CPB flow with LT backup is a feasible strategy in an otherwise inoperable patient population with an acceptable early and midterm survival when performed in a center with an experienced cardiac surgery and LT program., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Remnant vascular grafts may result in significant neurological deficits owing to compression of adjacent neural structures. We report this finding in two cases after extracorporeal membrane oxygenation decannulation and removal of an arteriovenous fistula in the upper extremity. In both cases, removal of the graft, patch arteriotomy, and external neurolysis resulted in significant recovery of neurological function. We review the preoperative workup, diagnostic studies, and technical approach to treatment in an effort to increase recognition among vascular and cardiovascular surgeons and to demonstrate a safe and effective management option through a multidisciplinary approach., Competing Interests: None., (© 2024 The Authors.)

Background: This study sought to analyze the details of strokes after acute type A dissection repair (ATAD) using a right axillary artery (RAX) first approach., Methods: A total of 356 consecutive ATAD repairs from 2005 to 2022 were analyzed on the basis of arterial cannulation site. Strokes were evaluated by head computed tomography., Results: The rate of RAX cannulation was 82.6% (n = 294), with a 38.2% rate of antegrade cerebral perfusion use, both of which had increased over the years. The non-RAX group had more cardiogenic shock (RAX, 16.3% vs non-RAX, 37.1%; P < .001), cerebral malperfusion (8.8% vs 25.8%, respectively; P < .001), and innominate artery dissection (45.9% vs 69.2%, respectively; P = .007). Eight patients died before undergoing a full neurologic assessment. The overall stroke rate was 8.4% (n = 30), and it was lower in the RAX group (5.1% vs 24.2%; P < .001). All strokes were ischemic, with concomitant hemorrhagic strokes occurring in 6 patients. Strokes diagnosed immediately after surgery (perioperative stroke) accounted for 70% (n = 21 of 30) of cases. Strokes predominantly affected the right anterior circulation (right anterior, 80% vs left anterior, 46.7% vs left posterior, 26.7%; P = .013), independent of arterial cannulation site. The proposed mechanism of perioperative strokes was not uniform (embolism, 33.3%; hypoperfusion, 42.8%; embolism and hypoperfusion, 14.3%; lacunar infarct, 10%), whereas most postoperative strokes were embolic (77.8%). The mean National Institutes of Health Stroke Scale score was 20.6 ± 9.9, and the modified Rankin score at discharge was 4.1±2.2., Conclusions: Most strokes in ATAD occurred perioperatively from various mechanisms predominantly affecting the right anterior circulation irrespective of the arterial cannulation site. This complication is most likely the result of unstable hemodynamics and dissection of the innominate artery (IA) or its downstream vessels., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: With growing experience of acute type A aortic dissection repair, Zone 2 arch repair has been advocated. The aim of this study is to compare the outcome between "proximal-first" and "arch-first" Zone 2 repair., Methods: From January 2015 to March 2023, 45 patients underwent Zone 2 arch repair out of 208 acute type A aortic dissection repairs: arch-first, N = 19, and proximal-first technique, N = 26, since January 2021. Indications were aortic arch or descending tear, complex dissection in neck vessels, cerebral malperfusion, or aneurysm of the aortic arch., Results: The lowest bladder temperature was higher in the proximal-first technique (24.9 °C vs 19.7 °C, P  < .001). Cardiopulmonary bypass (230 vs 177.5 minutes, P  < .001), myocardial ischemic (124 vs 91 minutes, P  < .001), and lower-body circulatory arrest (87 vs 28 minutes, P  < .001) times were shorter in the proximal-first technique. The arch-first group required more packed red blood cells (arch-first, 2 units vs proximal-first, 0 units, P  = .048), platelets (arch-first, 4 units vs proximal-first, 2 units, P  = .003), and cryoprecipitates (arch-first, 2 units vs proximal-first, 1 unit, P  = .024). Operative mortality and major morbidities were higher in the arch-first group (57.9% vs 11.5%, P  = .001). One-year survival was comparable (arch-first, 89.5% ± 7.0% vs proximal-first, 92.0% ± 5.5%, P  = .739). Distal intervention was successfully performed in 5 patients (endovascular, N = 3, and open repair, N = 2)., Conclusions: Zone 2 arch repair using the proximal-first technique for acute type A aortic dissection repair yields shorter lower-body ischemic time with a warmer core temperature, resulting in shorter cardiopulmonary bypass time, less blood product use, and fewer morbidities when compared with the arch-first technique., (© 2023 The Author(s).)

Background: There is paucity of data regarding reoperation after acute type A aortic dissection (ATAD) repair., Methods: From October 2006 to March 2022, 75 patients received 123 reoperations after ATAD (proximal, n = 17; distal, n = 103; and both, n = 3) utilizing redo sternotomy (RS, n = 68), left thoracotomy (LT, n = 44), and endovascular approach (TEVAR, n = 11). The axillary artery cannulation was utilized in 97.1% of the RS cases. A classic elephant trunk technique was used as a 2-staged procedure for distal pathology. Most LT repairs (95.5%) were completed above the celiac axis., Results: Index ATAD repairs were predominantly ascending/hemiarch repair (73.3%). The median duration from the index repair was 2.0 years. Most reoperations were elective procedures (82.1%). Hospital mortality was 2.4% (RS, 1.5%; LT, 4.5%; TEVAR, 0%), and the stroke rate was 1.6%. There was no spinal cord ischemia. The 5-year overall survival and freedom from aortic mortality or procedure were 85.2% ± 5.6% and 80.6% ± 6.1%, respectively. There were 7 distal reinterventions (prior TEVAR, n = 3; prior LT, n = 4). Two patients required LT repair after prior TEVAR and 3 patients received infrarenal aortic repair after prior LT repair. Computed tomography after completion of the distal repair (n = 45) showed an increase of distal aorta at each level as follows: celiac axis 1.2 mm/y; renal artery 1.0 mm/y; and terminal aorta 1.2 mm/y., Conclusions: Reoperation after ATAD repair can be safely performed as an elective procedure at experienced centers. Staged distal interventions utilizing classic elephant trunk insertion and open repair above the celiac axis showed durable outcomes., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic has led to a boom in the use of V-V ECMO for ARDS secondary to COVID. Comparisons of outcomes of ECMO for COVID to ECMO for influenza have emerged. Very few comparisons of ECMO for COVID to ECMO for ARDS of all etiologies are available., Objectives: To compare clinically important outcome measures in recipients of ECMO for COVID to those observed in recipients of ECMO for ARDS of other etiologies., Methods: V-V ECMO recipients between March 2020 and March 2022 consisted exclusively of COVID patients and formed the COVID ECMO group. All patients who underwent V-V ECMO for ARDS between January 2014 and March 2020 were eligible for analysis as the non-COVID ECMO comparator group. The primary outcome was survival to hospital discharge. Secondary outcomes included ECMO decannulation, ECMO duration >30 days, and serious complications., Results: Thirty-six patients comprised the COVID ECMO group and were compared to 18 non-COVID ECMO patients. Survival to hospital discharge was not significantly different between the two groups (33% in COVID vs. 50% in non-COVID; p = 0.255) nor was there a significant difference in the rate of non-palliative ECMO decannulation. The proportion of patients connected to ECMO for >30 days was significantly higher in the COVID ECMO group: 69% vs. 17%; p = 0.001. There was no significant difference in serious complications., Conclusion: This study could not identify a statistically significant difference in hospital survival and rate of successful ECMO decannulation between COVID ECMO and non-COVID ECMO patients. Prolonged ECMO may be more common in COVID. Complications were not significantly different., Competing Interests: Declaration of Competing Interest None of the authors has any relevant competing interest to disclose., (Copyright © 2022. Published by Elsevier Inc.)

We introduce a technique of coronary button reconstruction in performing a redo Bentall procedure. A coronary button is prepared leaving a 3 to 4 mm rim of old Dacron graft surrounding the previous button. The Dacron rim may be sewn to the new aortic root graft directly or via an interposed 8- or 10-mm graft, using a modified Cabrol technique. If the button is comprised of good tissue and can be well-mobilized, it is removed from the Dacron rim and anastomosed directly to the new Dacron graft., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: This study seeks to assess the outcomes of direct axillary artery (AX) cannulation for thoracic aortic surgery., Methods: From October 2009 to November 2021 direct AX cannulation was planned in 515 patients for thoracic aortic pathology. An important aspect of our technique is that the cannula is not inserted deeper than 3 cm. AX cannulation-related events included shift of cannulation site from the initial site, vascular injury, and iatrogenic dissection., Results: Half of the patients had acute type A dissection (ATAD). An angled cannula was used in 442 patients and a straight cannula in 73 patients (14.2%) after August 2020. A previously cannulated AX was reused in 36 patients (7.0%). Mortality and stroke rates were 5.4% (ATAD vs non-ATAD: 8.0% vs 2.8%, P = .008) and 2.7% (ATAD vs non-ATAD: 4.6% vs 0.8%, P = .034), respectively. AX cannulation-related events were observed in 2.7% of patients. There was no difference in the vascular injury rate between ATAD and non-ATAD cases (1.6% vs 0.4%, respectively; P = .385), between different cannula types (angled vs straight: 0.9% vs 1.4%, P = 1.00), or between primary and redo AX cannulation cases (0.8% vs 2.8%, respectively; P = .791). On multidetector computed tomography analysis using automated 3-dimensional images, the mean distance from the thoracoacromial artery to the vertebral artery on the right and left sides was 8.70 cm and 8.69 cm, respectively., Conclusions: Direct AX cannulation for thoracic aortic repair is safe and carries a low rate of vascular injury, especially in elective cases. Our direct cannulation technique, which includes not inserting a cannula deeper than 3 cm, seems to be safe in not occluding the vertebral artery., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Massive pulmonary embolism (MPE) is associated with a 20-50% mortality rate with guideline directed therapy. MPE treatment with surgical embolectomy (SE) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) have shown promising results. In the context of a surgical management strategy for MPE, a comparison of outcomes associated with VA-ECMO or SE was performed. A retrospective review of a single institution cardiac surgery database was performed, identifying MPE treated with SE or VA-ECMO between 2005-2020. Primary outcome was in-hospital survival. 59 MPE [27 (46.8%) VA-ECMO vs 32 (54.2%) SE] were identified. All presented with elevated cardiac biomarkers, tachycardia (mean heart rate 113 ± 20 beats/minute), hypotension (mean systolic blood pressure 85 ± 22 mm Hg) and vasopressors requirement, without significant differences between cohorts. Preoperative CPR was performed in 37.3% (22/59), without a significant difference between cohorts. More VA-ECMO presented with questionable neurologic status (GCS ≤ 4) [9/27 (33.3%) vs 2/32 (6.2%), P = 0.008] and more VA-ECMO failed thrombolysis [8/27 (29.6) vs 2/32 (6.3), P = 0.014]. All presented with severe RV dysfunction, by discharge all had normalization of echocardiographic RV function. Overall mortality was 10.2%, with a trend toward higher mortality among VA-ECMO [14.9% (4/27) vs 6.3% (2/32) P = 0.14]. CPR was independently associated with death (OR 10.8, P = 0.02) whereas treatment modality was not (OR 0.24). In an extremely unstable MPE population VA-ECMO and SE were safely performed with low mortality while achieving RV recovery. Adverse outcomes were more closely associated with preoperative CPR than with treatment modality., (Copyright © 2021 Elsevier Inc. All rights reserved.)

We report a simplified zone 2 arch repair using a trifurcated graft for acute type A aortic dissection. The right axillary artery is cannulated. After completion of proximal aortic repair using a 1-branched graft, a trifurcated graft is anastomosed to the ascending graft just above the proximal suture line or coronary buttons in case of Bentall procedure. Distal aortic anastomosis is performed at the zone 2 level under unilateral antegrade cerebral perfusion. Full cardiopulmonary bypass flow is resumed via the right axillary artery and ascending graft using both Y-shaped arterial limbs. The left common carotid and innominate arteries are sequentially anastomosed., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study assessed the safety of direct axillary artery (AX) cannulation for acute type A dissection (ATAD) repair, including the impact of innominate artery dissection (IAD)., Methods: Of 281 consecutive patients who underwent ATAD repair from 2007 to 2020, preoperative computed tomography was available in 200 (IAD, n = 101; non-IAD, n = 99). IAD with compromised true lumen was defined as dissection in which the false lumen was greater than 50% of the IA diameter (n = 75 of 101)., Results: AX cannulation was attempted in 188 patients (94.0%), with a 1.6% vascular injury rate (3 patients), comprising bypass to the distal AX in 2 patients and local dissection in 1 patient. Deep hypothermic circulatory arrest was used for the distal repair in 89.5% of patients. Right AX cannulation was used in 80.2% of patients with IAD and in 88.9% without IAD (P = .075). Patients with IAD had more cerebral (21.8% vs 5.1%, P = .001) and arm malperfsion (11.9% vs 4.0%, P = .075). Operative death and stroke were comparable between non-IAD (8.1% vs 7.9%, P = 1.00) and IAD (4.0% vs 5.3%, P = .689) groups. The right AX was successfully used in 77.3% of IAD patients with a compromised true lumen, with comparable hospital outcomes to noncompromised IAD patients. Upper extremity malperfusion, multiorgan malperfusion, low ejection fraction, and female sex were predictors for noncannulation of the right AX., Conclusions: Routine direct AX cannulation strategy is safe in ATAD repair. Right AX cannulation can be used in most patients with IAD, even with a compromised true lumen, with low mortality, stroke, and vascular injury rates., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study reviews the outcomes of our reoperative total arch repair technique using a trifurcated graft and selective antegrade cerebral perfusion., Methods: Fifty patients underwent reoperative total arch repair from January 2005 to September 2020, with either a one-stage repair (n = 9) or two-stage repair (n = 41). The two-stage technique includes minimal dissection of the mediastinal structures, an arch-first technique using a trifurcated graft, and construction of a classical elephant trunk through a partial transverse incision distally in the old graft or in the aorta just distal to the old graft., Results: The median age was 63 years. Chronic dissection was the most frequent indication (88%), and 98% had undergone a previous proximal aortic repair at a median interval of 3 years. The median cardiopulmonary bypass, myocardial ischemic, selective antegrade cerebral perfusion, and lower body circulatory arrest times were 226, 103, 97, and 98 minutes, respectively. The minimum nasopharyngeal and bladder temperature were 16.5°C and 20.0°C, respectively. Operative mortality was 2%, the incidence of stroke was 2%, and the incidence of spinal cord injury was 0%. Stage II repair was performed in 37 patients (open, 33 patients; endovascular, 4 patients), with 2 mortalities and no spinal cord injury. The median duration between stage I and II was 63 days. Survival and aortic event free rates at 3 years were 88.4% ± 4.9%, and 89.8% ± 5%, respectively., Conclusions: We report a reoperative total arch repair technique that minimizes dissection of the cardiac structures, simplifies the distal anastomosis, and protects vital organs, such as the brain, heart, and spinal cord., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Anant Jain (2021) Characteristics of early pleural effusions after orthotopic heart transplantation: comparison with coronary artery bypass graft surgery, (https://doi.org/10.4081/monaldi.2021.1740). The above article from the Monaldi Archives for Chest Disease published online on 24 November 2021, has been withdrawn by agreement between the journal's Editors-in-Chief, the Authors and PAGEPress Scientific Publications. This action has been agreed upon due to an administrative error by the publisher which caused the article to be published as an Accepted Article. The author is not responsible for this error. The publisher regrets any confusion this error may have caused.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension (PH) caused by thromboembolic disease with the secondary remodeling of the pulmonary vessels. The primary treatment of CTEPH is pulmonary thromboendarterectomy (PTE). However, some patients are not candidates for PTE because of surgically inaccessible thrombi or high operative risk and can be candidates for balloon pulmonary angioplasty (BPA), an emerging, lower risk treatment. This review discusses the patient selection, the technique, and comprehensive review of reported outcomes following BPA. BPA techniques have improved over the years, and so has its safety profile. Recent data show that after several sessions of BPA, patients who were not eligible for PTE had improvement in their hemodynamic profile, functional capacity, and 6-minute walk distance. Studies have shown that compared to riociguat, BPA has shown significant improvement in the functional capacity and hemodynamic measurements. Reperfusion pulmonary edema is a common complication after PTE and BPA, which may be due to vessel injury rather than pulmonary extravasation. Rates of complications have decreased especially after the use of optical coherence tomography, which helps in proper sizing of the balloons. Patients with CTEPH who are ineligible for PTE should be evaluated for BPA. In addition to medical therapy, BPA has shown promising clinical and hemodynamic outcomes in patients with CTEPH., Competing Interests: None., (AJCD Copyright © 2021.)

Objective: To review the outcomes of axillary artery (AX) and femoral artery (FA) cannulation for veno-arterial extracorporeal membraneous oxygenation (VA-ECMO)., Methods: From 2009 to 2019, 371 patients who were supported with VA-ECMO for cardiogenic shock were compared based on the arterial cannulation site: AX (n = 218) versus FA (n = 153)., Results: Patients in the AX group were older (61 years vs 58 years, P  = .011), had a greater prevalence of peripheral vascular disease (13.8% vs 5.2%, P  = .008), and were less likely to have undergone cardiopulmonary resuscitation preoperatively (18.8% vs 36.6%, P  < .001). Other characteristics were similar between groups, as were in-hospital outcomes, including survival to discharge (60.6% vs 56.9%), cerebrovascular accidents (12.4% vs 10.5%), cannulation-related bleeding (15.1% vs 17%), and length of VA-ECMO support (6 days). The incidence of leg ischemia (6.9% vs 15.7%, P  = .006), limb ischemia related to VA-ECMO cannulation (0% vs 10.5%), the need to switch the cannulation site (4.6% vs 14.7%), and wound complications (WCs; 2.8% vs 15%) including infection and additional procedure were significantly greater in the FA group ( P  < .001). In multiple logistic regression analysis, FA cannulation and primary graft failure after heart transplantation were independent risk factors for cannulation-related WC. In subgroup analysis among patients with primary graft failure, WCs were more prevalent in FA cannulation (3.6% vs 39.1%, P  = .001)., Conclusions: AX cannulation for VA-ECMO is a safe and effective alternative to FA cannulation. It can be considered especially for patients with limited groin access, peripheral vascular disease, or for primary graft failure after heart transplant., (© 2020 The Authors.)

Background: Acute pulmonary embolism (PE) is associated with high morbidity and mortality because of right ventricular (RV) failure. There is evidence suggesting surgical therapy (surgical embolectomy or venoarterial extracorporeal membrane oxygenation [ECMO]) is safe and effective., Objectives: The aim of this study was to assess the safety and efficacy of surgical management of acute PE., Methods: Surgical embolectomy and/or venoarterial ECMO were compared, between 2005 and 2019, for massive PE (MPE) versus high-risk submassive PE (SMPE). RV recovery was defined as improvements in central venous pressure, pulmonary artery systolic pressure, RV/left ventricular ratio, and RV fractional area change., Results: One hundred thirty-six patients with PE (92 with SMPE and 44 with MPE) were identified. Patients with MPE more often presented with syncope (59.1% [26 of 44] vs. 25.0% [23 of 92]; p = 0.0003), Glasgow Coma Scale score ≤4 (22.7% [10 of 44] vs. 0% [0 of 92]), and failed thrombolysis (18.2% [8 of 44] vs. 4.3% [3 of 92]; p = 0.008). Pre-operative cardiopulmonary resuscitation occurred in 43.2% of patients with MPE (19 of 44). Most patients with SMPE were treated with embolectomy (98.9% [91 of 92]), while ECMO was used more in those with MPE (ECMO in 40.9% [18 of 44], embolectomy in 59.1% [26 of 44]). RV function improved as measured by central venous pressure (from 23.4 ± 4.9 to 10.5 ± 3.1 mm Hg), pulmonary artery systolic pressure (from 60.6 ± 14.2 to 33.8 ± 10.7 mm Hg), RV/left ventricular ratio (from 1.19 ± 0.33 to 0.87 ± 0.23; p < 0.005), and fractional area change (from 26.8 to 41.0; p < 0.005). Mortality was 4.4% (6 of 136; SMPE, 1.1% [1 of 92]; MPE, 11.6% [5 of 44]). Subgroup analysis showed morbidity and mortality were highly associated with pre-operative cardiopulmonary resuscitation., Conclusions: Surgical management of patients with MPE and high-risk SMPE is safe and highly effective at achieving RV recovery., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Esophagopericardial fistulas are rare. Most reported cases are related to malignancy or prior surgical intervention. We report a case of an esophagopericardial fistula presenting as pneumopericardium and purulent pericarditis in a patient with a history of caustic ingestion and an esophageal stent., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Current discussion regarding the management of acute type A aortic dissection is focused on whether to perform a standard hemiarch resection or perform an extended repair, in hopes of improving long-term outcomes by avoiding late, distal aortic sequelae. Critical to this discussion is an estimation of the short-term risks of an extended procedure and the magnitude of the late "downstream problem." Extension of the hemiarch to a total arch plus frozen elephant trunk does not improve survival; carries some increased perioperative risk, not the least of which is paraplegia; but decreases late aortic events, the most common of which is reoperation on the distal aorta. However, these reoperations are low frequency, primarily elective, low-risk events and it should be noted that extended index repairs do not eliminate or necessarily decrease the incidence of late reoperations. Routine extension of the index procedure puts 100% of patients at risk in order to protect a minority that may benefit. Therefore, it is important to select patients at high risk for reoperation if an extended repair is to be performed. Predictors that may identify this high-risk group include the size and location of the entry tear, aortic and luminal dimensions, degree of luminal flow and thrombosis, and the presence of a connective tissue disorder. Timing may also be important and, in patients at high risk for late events, early complications may be minimized by strategies that delay an extension of the proximal repair until the subacute period., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Hypertrophic cardiomyopathy (HCM), a disease formerly thought rare in clinical practice, is now believed to affect as many as 1 in 300 individuals, regardless of race or gender. Rising awareness, coupled with advanced imaging and the development of dedicated HCM centers of excellence, has led to more patients coming to clinical presentation. While some are diagnosed at a young age, others are diagnosed in middle age or well into advanced age. Unfortunately, many such patients have progressed clinically to overt heart failure, or have some combination of advanced symptoms including dyspnea, angina, pre-syncope or syncope, palpitations, and edema. Anatomic subsets, including those with mid-ventricular obstruction or apical disease, with or without apical aneurysm, have also been seen in increasing frequency. Fortunately, both percutaneous and surgical invasive options are available across the spectrum of disease severity and anatomy, with outcomes continuing to improve as the techniques and experience evolve. Advances in both approaches allow targeted and individualized treatment of the majority of these patients. This review will focus on interventional approaches to relief of obstruction, and will provide a current clinical algorithm from our center for determining when an interventional approach may be recommended or optimal over a surgical approach, and vice versa.

Chronic thromboembolic pulmonary hypertension (CTEPH), classified as World Health Organization (WHO) group 4 pulmonary hypertension (PH), is an interesting and rare pulmonary vascular disorder secondary to mechanical obstruction of the pulmonary vasculature from thromboembolism resulting in PH. The pathophysiology is complex, beginning with mechanical obstruction of the pulmonary arteries, which eventually leads to arteriopathic changes and vascular remodeling in the nonoccluded arteries and in the distal segments of the occluded arteries mediated by thrombus nonresolution, abnormal angiogenesis, endothelial dysfunction, and various local growth factors. Based on available data, CTEPH is a rare disease entity occurring in a small proportion (0.5-3%) of patients after acute pulmonary embolism with an annual incidence ranging anywhere between 1 and 7 cases per million population. It is often underdiagnosed or misdiagnosed as idiopathic pulmonary arterial hypertension due to a lack of clinical suspicion or the under-utilization of radionuclide ventilation/perfusion scan. Although the current standard remains planar ventilation/perfusion scintigraphy as the initial imaging study to screen for CTEPH, and invasive pulmonary angiography with right heart catheterization as confirmatory modalities, they are likely to be replaced by modalities that can provide both anatomic and functional data while minimizing radiation exposure. Surgery is the gold standard treatment and offers better improvements in clinical and hemodynamic parameters compared with medical therapy. The management of CTEPH requires a multidisciplinary team, operability assessment, experienced surgical center, and the consideration of medical PH-directed therapies in patients who have inoperable disease, in addition to supportive therapies. Although, balloon pulmonary angioplasty is gaining interest to improve pulmonary hemodynamics and symptoms in CTEPH patients not amenable to surgery, further investigative randomized studies are needed to validate its use. It is very important for the present-day physician to be familiar with the disease entity and its appropriate evaluation to facilitate early diagnosis and appropriate management.

In patients undergoing coronary artery bypass grafting (CABG), intraoperative and postoperative major bleeding requiring blood transfusions and surgical reexploration is associated with increased mortality and morbidity. Our study hypothesized that exposure to clopidogrel is not significantly associated with increased risk for intraoperative bleeding, even when administered less than 5 days before CABG. We also aimed to determine variables associated with intraoperative packed red blood cell (iPRBC) transfusion. Patients of both sexes aged 18 years or older who underwent CABG from July 1, 2011 to December 31, 2012 were included in the analysis. Study population consisted of 2 groups-clopidogrel arm and nonclopidogrel arm. Patients were included in clopidogrel arm if they were exposed to clopidogrel in the past (as one of their home medications or received the medication for first time during the index hospitalization), whereas patients who never received clopidogrel were included in nonclopidogrel arm. We identified a total of 303 adult patients who underwent CABG with a mean age was 64.5 years. Mortality rate in our study was 0.99% (n = 3) with increased mortality in women as compared with men (3.27% vs. 0.41%, P = 04). The mean iPRBC transfused were 1.68 units, with higher units being transfused in women as compared with men (2.23 vs. 1.49 units, respectively, P = 0.03) and no significant difference between clopidogrel and nonclopidogrel arms (1.92 vs. 1.50, respectively, P = 0.18). After multivariate analysis, age [odds ratio (OR) = 1.03, P = 0.01], female sex (OR = 2.61, P = 0.006) and hypertension (OR = 7.10, P = 0.02) predicted increased iPRBC transfusion. Clopidogrel or nonclopidogrel status was not associated with increased iPRBC transfusion (OR = 1.06, P = 0.81). iPRBC transfusion rates were similar in both arms with age, female sex, and hypertension being an independent predictor of iPRBC transfusion.

Acute type A aortic dissection (ATAAD) is a vascular catastrophe, with a mortality of 1% per hour for the first 48 hours without surgical intervention. Of the diverse causes of morbidity and mortality associated with ATAAD, malperfusion, which complicates 20%-50% of cases, is particularly lethal. Although malperfusion can affect any vascular bed, this review focuses on the 3 most devastating: coronary, cerebral, and visceral malperfusion syndromes (MPS). Essentially, there are 3 methods of restoring flow to malperfused areas: central repair, fenestration, and direct revascularization of affected arteries. Of these, emergency central aortic repair is the accepted primary strategy, as it most expeditiously eliminates the risk of rupture, and accordingly, our protocol is to transfer ATAAD cases directly to the operating room. However, central repair is not necessarily the most expedient strategy for resolving malperfusion, and in some cases, malperfusion persists despite central repair. At some point, with certain cases of severe malperfusion, the mortality from end organ damage exceeds the mortality risk of rupture and recent reports suggest that these cases may be best managed by emergency reperfusion of the affected vascular bed, followed by central repair., (Copyright © 2016. Published by Elsevier Inc.)

Pregnancy engenders changes in hemodynamics and the aortic wall that make a woman more susceptible to aortic dilatation and dissection. This is particularly true of women with aortic dilatation and an aortopathy, including the inherited fibrillinopathies, bicuspid aortic valve, and Turner syndrome. Women in these risk groups may be served best by undergoing elective aortic surgery before becoming pregnant. However, some women present during pregnancy with significant aortic dilatation, rapid expansion, or aortic dissection, and strategies to deal with these situations, while optimizing maternal and fetal outcomes, change as gestation progresses. This review summarizes the approaches to the management of aortic diseases and the conduct of aortic surgery in pregnancy., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

The prevalence of heart failure continues to rise due to the aging population and longer survival of people with conditions that lead to heart failure, eg, hypertension, diabetes, and coronary artery disease. Although medical therapy has had an important impact on survival of patients and improving quality of life, heart transplantation remains the definitive therapy for patients that eventually deteriorate. Since the first successful heart transplantation in 1967, significant improvements have been made regarding donor and recipient selection, surgical techniques, and postoperative care. However, the number of potential organ donors has not changed and the growing number of patients in need for transplantation has resulted an increase in waiting list time, and the need for mechanical support. To overcome this issue, the United Network for Organ Sharing implemented an allocation system to prioritize the sickest patients on the list to receive organs. Despite the careful selection of patients, pretransplant immunological screening, and multidrug immunosuppressive regimens, acute and chronic rejections occur and potentially limit graft and patient survival. Treatment for rejection largely depends on the type of rejection, the presence of hemodynamic compromise, and time after transplantation. The limiting factor for long-term graft survival is allograft vasculopathy, an immune-mediated process causing diffuse narrowing of the coronary arteries. Percutaneous coronary intervention and coronary artery bypass surgery are often not an option for this vasculopathy due to the lack of focal lesions, and retransplantation is the only option in appropriate patients.

Objective: To review the contemporary practice in total arch replacement (TAR) by using the trifurcated graft technique., Methods: The evolution of the trifurcated graft technique in total arch replacement is described. Axillary artery perfusion with antegrade cerebral perfusion (ACP) is routinely performed, with systemic deep hypothermia based on the anticipated interval of lower body ischemia. Cerebral oxygen saturation is monitored and bilateral ACP (BACP) is performed if the adequacy of collateral circulation is questioned. Potential advantages and disadvantages of unilateral ACP (UACP) vs BACP are discussed., Results: The advantage of the trifurcated graft technique in TAR is that it facilitates the creation of an "elephant trunk" in the proximal arch, making the operation technically easier and avoiding the risk of recurrent laryngeal nerve injury. The technique is also versatile in a variety of aortic arch anatomies and pathologies, while enabling continuous ACP without hypothermic circulatory arrest for cerebral protection. UACP during TAR is acceptable for shorter intervals (<30-40 minutes) if combined with moderate hypothermia. BACP should be considered for prolonged ACP interval or if left cerebral oxygenation is inadequate during UACP., Conclusions: The trifurcated graft technique is a versatile method in TAR that can be applied to a diverse range of aortic anatomies, pathologies and hybrid arch procedures, with concomitant or staged endovascular options. UACP or BACP and lower body ischemia can be performed without adding significant complexity to the procedure, while conferring maximal cerebral, spinal, and lower body protection., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Over the course of the past 4 decades, the survival of patients with the Fontan circulation has improved and today they often present for noncardiac surgery anesthesia care. In patients with the Fontan circulation, pulmonary blood flow is passive and anesthetic management is directed at reducing pulmonary vascular resistance and maintaining adequate cardiac output. One-lung ventilation can have unfavorable effects on the Fontan circulation due to hypoxia, hypercarbia, and increased airway pressure. We present a case of successful one-lung ventilation in a patient with the Fontan circulation and describe the perioperative anesthetic management., (© The Author(s) 2014.)

Objectives: Patients with profound cardiovascular compromise have poor prognosis despite inotropic and intra-aortic balloon pump (IABP) support. Peripheral venoarterial extracorporeal membrane oxygenation (V-A ECMO) offers these patients temporary support as a bridge to various options including the 'bridge to recovery'., Methods: We studied the outcomes of 135 patients who underwent peripheral V-A ECMO and concomitant IABP implantation in our hospital from 2007 to 2012 for various clinical indications. The ECMO circuit consisted of a centrifugal pump and an oxygenator., Results: V-A ECMO was implanted in the cardiac catheterization laboratory in 51 patients (37.8%), at the bedside in 5 (3.7%) and in the operating room in 79 (58.5%). Mean duration of support was 8.5 ± 7.1 days. Median length of stay was 28 days (interquartile range 14-62). Complications included bleeding at the access site in 14.1%, stroke in 11.1% and vascular complications requiring intervention in 16.3%. Overall inhospital survival was 57.8% with outcomes including heart transplantation (3%), implantable left ventricular assist device (8.1% as bridge to transplantation and 6.7% as destination therapy), surgery (7.4%) and myocardial recovery (40.7%). Prior IABP use and axillary cannulation were independent predictors of reduced inhospital mortality, stroke or vascular injury., Conclusions: Peripheral V-A ECMO with IABP is an effective therapy for patients with severely compromised cardiovascular function. It offers reasonable survival and a spectrum of definitive options from 'bridge to recovery' to heart transplantation for the management of this critically ill population., (© 2014 S. Karger AG, Basel.)

Objective: Surgery in octogenarians with acute type A aortic dissection is commonly avoided or denied because of the high surgical morbidity and mortality reported in elderly patients. We sought to compare clinical and quality of life outcomes between octogenarians and those aged less than 80 years who underwent surgical repair at New York Medical College., Methods: A total of 101 cases of acute type A aortic dissection repair between July 2005 and December 2011 were retrospectively analyzed, comparing 21 octogenarians with 80 concurrent patients aged less than 80 years. All patients underwent corrective surgery (ascending/hemiarch replacement in 71; Bentall in 22; David procedure in 2; Wheat procedure in 4; total arch replacement in 2) using deep hypothermic circulatory arrest. During follow-up, the RAND 36-Item Short Form Health Survey Questionnaire was used to assess quality of life., Results: Octogenarians (average, 85 years; range, 80-91 years) were compared with the younger group (average, 60 years; range, 30-79 years). The 2 groups had similar preoperative characteristics, but the younger group experienced more malperfusion (40% vs 9%, P = .002), were more likely to have undergone a Bentall procedure (26% vs 5%, P = .04), and had longer circulatory arrest times (20 ± 7 minutes vs 16 ± 9 minutes, P = .03). The overall hospital mortality was 9% (9/101). Among octogenarians, there were no hospital deaths, no late deaths during follow-up (mean, 17 months; range, 1-59 months), and emotional health scores were better than those of the younger patients (P = .04)., Conclusions: Surgery for acute type A aortic dissection should be offered to octogenarians because excellent surgical and quality of life outcomes can be achieved even in this elderly population., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: With the realization that hypothermia was neuroprotective, hypothermic selective antegrade cerebral perfusion was adopted by many surgical groups for aortic arch resection, prompting experimental and clinical studies to elaborate technical refinements and safe parameters of selective antegrade cerebral perfusion. We review the evidence for optimum management of perfusion pressure, flow, temperature, pH, hematocrit, and cannulation access., Methods: Underperfusion and overperfusion impair neurologic function after selective antegrade cerebral perfusion. Overperfusion--including excessive flow and pressure--is expressed experimentally as an increase in intracranial pressure, indicative of cerebral edema, and causes slow neurobehavioral recovery. As the safe limits of moderate and mild hypothermic selective antegrade cerebral perfusion are being explored in many aortic centers, the ischemic tolerance of the spinal cord during lower-body circulatory arrest becomes a new focus of concern., Results: Although a significant portion of the population has an incomplete circle of Willis, contralateral flow via extracranial collaterals has permitted the successful use of various cannulation techniques. Unilateral perfusion is adequate for short-term (<40 minutes) selective antegrade cerebral perfusion, even at higher temperatures (24 °C-28 °C). However, if prolonged periods of selective antegrade cerebral perfusion are anticipated, evidence suggests that better cerebral protection is obtained with bilateral selective antegrade cerebral perfusion., Conclusions: On the basis of these experimental and clinical studies, certain recommendations for the use of nonpulsatile selective antegrade cerebral perfusion can be made., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

We describe a combined aortic valve-sparing reimplantation procedure and mitral valve repair in a 20-year-old pregnant Marfan patient who presented at 12 weeks' gestation with an asymptomatic 5.3-cm aortic root aneurysm and moderate mitral regurgitation. Because the risk of aortic dissection and worsening mitral regurgitation becomes significant in the third trimester, elective intervention was undertaken at 14 weeks' gestation. The mother recovered uneventfully, and the baby was delivered at term by cesarean section. This case supports early elective surgery in pregnant Marfan patients with aortic and mitral diseases to avoid potentially fatal cardiovascular complications later in the pregnancy., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although commonly reserved as a last line of defense, experienced centers have reported excellent results with pulmonary embolectomy for massive and submassive pulmonary embolism (PE). We present a contemporary surgical series for PE that demonstrates the utility of peripheral extracorporeal membrane oxygenation (pECMO) for high-risk surgical candidates., Methods: Between June 2005 and April 2011, 29 patients were treated for massive or submassive pulmonary embolism, with surgical embolectomy performed in 26. Four high-risk patients were placed on pECMO, established by percutaneously cannulating the right atrium through a femoral vein and perfusing by a Dacron graft anastomosed to the axillary artery. A small, extracorporeal, rotary assist device was used, interposing a compact oxygenator in the circuit, and maintaining anticoagulation with heparin., Results: Extracorporeal membrane oxygenation was weaned in 3 of 4 patients after 5.3 days (5, 5, and 6), with normalization of right ventricular dysfunction and pulmonary artery pressure (44.0 ± 2.0 to 24.5 ± 5.5 mm Hg) by ECHO. Follow-up computed tomographies showed several peripheral, nearly resorbed emboli in 1 case and complete resolution in 2 others. The fourth patient, not improving after 10 days, underwent surgery where an embolic liposarcoma was extracted. For all 29 cases, hospital and 30-day mortality was 0% and all patients were discharged, with average postoperative length of stay of 15 days for embolectomy and 17 days for pECMO., Conclusions: Heparin therapy with pECMO support is a rapid, effective option for patients who might benefit from pulmonary embolectomy but are at high risk for surgery., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Patients that have undergone aortic valve replacement may subsequently present with an aortic root aneurysm, but with a normally functioning prosthetic valve. We describe our method of replacing the aortic root while retaining the existing aortic valve as the "completion Bentall procedure.", (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The term acute aortic syndrome refers to a heterogeneous group of conditions that cause a common set of signs and symptoms, the foremost of which is aortic pain. Various pathologic entities may give rise to this syndrome, but the topic has come to focus on penetrating aortic ulcer and intramural hematoma and their relation to aortic dissection. Penetrating aortic ulcer is a focal atherosclerotic plaque that corrodes a variable depth through the intima into the media. Intramural hematoma is a blood collection within the aortic wall not freely communicating with the aortic lumen, with restricted flow. It may represent a subcategory of aortic dissection that manifests different behavior by virtue of limited flow in the false lumen. This article reviews the current literature regarding acute aortic syndrome, focusing on management options., (Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)