We present Stanford’s experience with patients post–arterial switch operation presenting with chest pain found to have hemodynamically significant myocardial bridging. The evaluation of symptomatic patients post–arterial switch should not only include assessment for coronary ostial patency but also for nonobstructive coronary conditions such as myocardial bridging. (Level of Difficulty: Advanced.)

Central MessageGood communication between ED physicians/primary care physicians and cardiovascular surgeons can minimize risk of litigations in cases of acute aortic dissections.See Article page 600. Good communication between ED physicians/primary care physicians and cardiovascular surgeons can minimize risk of litigations in cases of acute aortic dissections. See Article page 600. The authors1Palancappai A. Sellke F. Medical malpractice litigations involving aortic dissection.J Thorac Cardiovasc Surg. 2022; 164: 600-608Abstract Full Text Full Text PDF Scopus (6) Google Scholar are to be commended for their efforts to educate us about causes for litigation surrounding the diagnosis and treatment of acute aortic dissections. They have searched a commercially available legal database and extracted 135 cases over a 25-year period. However, given an incidence of ∼7 cases per 100,000 population per year, there are ∼23,000 cases per year, and certainly far more than 135 malpractice suits over a 25-year period, as the authors acknowledge. Nevertheless, the etiology of these claims may be representative and thus instructive. The 3 most common bases for litigation were failure to diagnose, failure to test, and treatment delay. Other less commonly cited bases included failure to interpret tests, failure to refer, procedural error, and failure to properly discharge. These reasons illustrate the major weaknesses of this manuscript, namely the failure of a legal database to give us relevant medical information. For failure to test, it would be important to know what tests were performed, and specifically if a computed tomography angiography of the chest was performed. For treatment delay, it would help to know the actual interval from emergency department (ED) presentation to diagnosis, since the clock is ticking, with 1 death per hour for the first 48 hours. This may also be relevant to the 15 cases diagnosed only at autopsy, especially if the patient died shortly after presentation. Keeping in mind that aortic dissections have been frequently described as the "Great Masquerader," one must remain vigilant for the atypical presentation. While we expect these patients to present with chest pain, or difficulty breathing, in fact fewer than 50% and 15%, respectively, do present in that manner. Although we are aware of the need to constrain resources, a computed tomography scan of the chest is a very effective diagnostic modality to rule out the 3 most common and potentially lethal diseases likely to be encountered in the ED, namely myocardial infarction, pulmonary embolus, and aortic dissection. What, then, can a surgeon do to facilitate the diagnosis and minimize the possibility of litigation? Primarily, maintain good communication with your ED staff. With the exception of large referral centers, aortic dissections present relatively infrequently, and the average ED physician may see only a handful in a lifetime. Their index of suspicion could be increased if we emphasized other important features, such as any change in neurologic status, a poorly perfused extremity, a pulse deficit, the presence of a murmur of aortic insufficiency, or an enlarged aorta especially as visualized in the lateral chest radiograph. If we work together, we can minimize these events. For me personally, going into any malpractice litigation with only a 50% likelihood of a favorable outcome is far from a comfortable situation! Medical malpractice litigations involving aortic dissectionThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 2PreviewMedical malpractice litigation arises when a discrepancy exists between a patient's expectation of acceptable medical care and the care the patient receives. Aortic dissection is a frequently misdiagnosed and often-fatal condition. The purpose of this study was to characterize trends of medical malpractice litigations arising from aortic dissection, investigate the etiology, and analyze predictive factors regarding the verdict. Full-Text PDF

Redo cardiac surgery requiring arch replacement can be performed by experienced surgeons with low mortality and good 10 year durability. Risk factors predicting worse outcomes include older age, decreased BMI, emergency procedures, and longer pump runs. The necessity for total versus hemi-arch replacement also Predicts worse 30 day mortality and decreased 10 year survival. Re-Operative Aortic Arch Surgery in a Contemporary SeriesSeminars in Thoracic and Cardiovascular SurgeryVol. 34Issue 2PreviewRe-operative aortic arch operations (REDO) following previous cardiac surgery are challenging procedures associated with significant morbidity and mortality. We investigated post-operative outcomes for patients undergoing REDO and identified risk-factors for mortality in a contemporary series. From 1/2005-6/2018, 365 consecutive patients at an academic center underwent REDO: 257 HEMIARCH and 108 COMPLETE arch (45 stage I elephant trunk, 63 total arch) replacements. Outcomes included mortality and major adverse events. Full-Text PDF

Central MessageCO2 surgical field insufflation remains controversial. The video clips contained within this manuscript are illustrative and may support specific diffusion devices. Further trials will be necessary.See Article page 958. CO2 surgical field insufflation remains controversial. The video clips contained within this manuscript are illustrative and may support specific diffusion devices. Further trials will be necessary. See Article page 958. Carbon dioxide (CO2) field insufflation is an attractive adjunct during open heart surgery because of the markedly increased solubility of CO2 in blood versus air. However, to date this strategy remains unproven. I can recall from the distant past, before the use of CO2 insufflation, and before the availability of transesophageal echocardiography (TEE), many patients awakening from cardiac surgery experienced confusion and severe agitation but without focal neurologic deficits. These were considered to secondary to air emboli, and such patients were deemed “airheads.” Fortunately, these symptoms cleared within 3 to 4 days without obvious long-term sequalae. With the advent of TEE, which allowed visualization of gaseous bubbles within cardiac chambers, deairing maneuvers could be more directed, and more complete, and at about the same time, many surgeons added CO2 insufflation to their routines. With this combined regimen, to my admittedly imperfect recollection, this postoperative agitated state virtually disappeared. However, other than anecdotal reports, is there any valid evidence for improved neuroprotection? Chaudhuri and colleagues1Chaudhuri K. Storey E. Lee G.A. Bailey M. Chan J. Rosenfeldt F.L. et al.Carbon dioxide insufflation in open chamber cardiac surgery: a double-blind, randomized clinical trial of neurocognitive effects.J Thorac Cardiovasc Surg. 2012; 144: 646-653Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar demonstrated significantly more rapid and complete clearing of intracardiac air after left-sided valve procedures in a randomized trial with and without CO2, as judged by blinded anesthesiologist assessment from the TEE. Herrmann and colleagues2Herrmann M. Ebert A.D. Galazky I. Wunderlich M.T. Kunz W.S. Huth C. Neurobehavioral outcome prediction after cardiac surgery: role of neurobiochemical markers of damage to neuronal and glial brain tissue.Stroke. 2000; 31: 645-650Crossref PubMed Scopus (163) Google Scholar demonstrated significantly lower levels of S100β at 2 and 48 hours after a pump run, suggesting less axonal injury, and Martens and colleagues3Martens S. Neumann K. Sodemann C. Deschka H. Wimmer-Greinecker G. Moritz A. Cardon dioxide field flooding reduces neurologic impairment after open-heart surgery.Ann Thorac Surg. 2008; 85: 543-547Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar similarly demonstrated less prolonged p300 peak latencies in the CO2 group versus controls. However, there have been no definitive trials, to my knowledge, demonstrating fewer neurologic deficits or less neurocognitive decline. So what are we to do? Based on the increased solubility of CO2 in blood, the trivial added expense, and more efficient and shortened deairing times, CO2 could offer additional protection with little downside. The excellent videos and discussion in the manuscript by Vandenberghe and colleagues4Vandenberghe S. Iseli D. Demertzis S. Direct visualization of carbon dioxide field flooding: optical and concentration level comparison of diffusor effectiveness.J Thorac Cardiovasc Surg. 2020; 159: 958-968Abstract Full Text Full Text PDF Scopus (4) Google Scholar highlight marked differences in dispersion patterns with different devices and flow rates, which may affect efficacy with this technique. Going forward, randomized controlled trials using diffusors that can effectively maintain a homogenous CO2 cloud over the operative field may be necessary to demonstrate a clinical benefit. The prevention of even one “airhead” would seem worth the effort. Direct visualization of carbon dioxide field flooding: Optical and concentration level comparison of diffusor effectivenessThe Journal of Thoracic and Cardiovascular SurgeryVol. 159Issue 3PreviewCarbon dioxide field flooding during open-heart surgery is intended to avoid blood-air contact, bubble formation, and embolism, and therefore potential neurologic and other ischemic complications. The inert gas is invisible, and thus its use and effectiveness are heavily debated. We intended to provide better insight in the behavior of the gas via direct concentration measurements and visualization of the gas cloud. Full-Text PDF

BACKGROUND:Myocardial bridge (MB) of the left anterior descending (LAD) coronary artery occurs in approximately 25% of the population. When medical therapy fails in patients with a symptomatic, hemodynamically significant MB, MB unroofing represents the optimal surgical management. Here, we evaluated minimally invasive MB unroofing in selected patients compared with sternotomy. METHODS:MB unroofing was performed in 141 adult patients by sternotomy on-pump (ST-on, n = 40), sternotomy off-pump (ST-off, n = 62), or minithoracotomy off-pump (MT, n = 39). Angina symptoms were assessed preoperatively and 6 months postoperatively using the Seattle Angina Questionnaire. Matching included all MT patients and 31 ST-off patients with similar MB characteristics, no previous cardiac operations or coronary interventions, and no concomitant procedures. RESULTS:MT patients tended to have a shorter MB length than ST-on and ST-off patients (2.57 vs 2.93 vs 3.09 cm, P = .166). ST-on patients had a longer hospital stay than ST-off and MT patients (5.0 vs 4.0 vs 3.0 days, P < .001), and more blood transfusions (15.2% vs 0.0% vs 2.6%, P = .002). After matching, MT patients had a shorter hospital stay than ST-off patients (3.0 vs 4.0 days, P = .005). No deaths or major complications occurred in any group. In all groups, MB unroofing yielded significant symptomatic improvement regarding physical limitation, angina stability, angina frequency, treatment satisfaction, and quality of life. CONCLUSIONS:We report our single-center experience of off-pump minimally invasive MB unroofing, which may be safely performed in carefully selected patients, yielding dramatic improvements in angina symptoms at 6 months after the operation.

The Stanford classification of aortic dissection was described in 1970. The classification proposed that type A aortic dissection should be surgically repaired immediately, whereas type B aortic dissection can be treated medically. Since then, diagnostic tools and management of acute type A aortic dissection (ATAAD) have undergone substantial evolution. This paper evaluated historical changes of ATAAD repair at Stanford University since the establishment of the aortic dissection classification 50 years ago. The surgical approaches to the proximal and distal extent of the aorta, cerebral perfusion methods, and cannulation strategies were reviewed. Additional analyses using patients who underwent ATAAD repair at Stanford University from 1967 through December 2019 were performed to further illustrate the Stanford experience in the management of ATAAD. While technical complexity increased over time, post-operative survival continued to improve. Further investigation is warranted to delineate factors associated with the improved outcomes observed in this study.

The Stanford classification of aortic dissection was described in 1970. The classification proposed that type A aortic dissection should be surgically repaired immediately, whereas type B aortic dissection can be treated medically. Since then, diagnostic tools and management of acute type A aortic dissection (ATAAD) have undergone substantial evolution. This paper evaluated historical changes of ATAAD repair at Stanford University since the establishment of the aortic dissection classification 50 years ago. The surgical approaches to the proximal and distal extent of the aorta, cerebral perfusion methods, and cannulation strategies were reviewed. Additional analyses using patients who underwent ATAAD repair at Stanford University from 1967 through December 2019 were performed to further illustrate the Stanford experience in the management of ATAAD. While technical complexity increased over time, post-operative survival continued to improve. Further investigation is warranted to delineate factors associated with the improved outcomes observed in this study.

Central MessageFirst-time experience with endograft repair of complicated acute type B aortic dissection in patients with Marfan syndrome.See Article page 1787 in the November 2018 issue. First-time experience with endograft repair of complicated acute type B aortic dissection in patients with Marfan syndrome. See Article page 1787 in the November 2018 issue. Faure and colleagues1Faure E.M. El Batti S. Abou Rjeili M. Ben Abdallah I. Julia P. Alsac J.-M. Stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection in patients with Marfan syndrome: midterm outcomes and aortic remodeling.J Thorac Cardiovasc Surg. 2018; 156: 1787-1793Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar are to be congratulated for their courageous study using endograft technology in patients with Marfan syndrome. Most of us avoid stent grafting in this population unless absolutely necessary. Given the difficulties of managing these patients with complicated acute type B aortic dissection in both the short and long term with open techniques, the addition of these techniques will greatly facilitate our management of these patients. However, some caveats remain. Although not experienced in this report, thoracic stent grafts in the distal arch do have the possibility of producing an acute retrograde type A aortic dissection, which further complicates management of this difficult disease. Also, early in our experience with acute type B aortic dissection, we experienced an episode of paraplegia after implanting a 20-cm endograft and thereafter tried to minimize the extent of distal coverage. Additional coverage with uncovered stents does not appear to increase that incidence. We also have some good follow-up to 21 years, although not in a patient with Marfan syndrome, suggesting that this management strategy is both effective and durable. It is hoped that new technology will be developed to allow distal aortic expansion with some fenestrated tubular device that will be less likely to cause intimal tears than uncovered “Z” stents and allow perfusion of intercostal and lumbar arteries, as well as all abdominal visceral arteries. We look forward to longer-term follow-up of these patients in regard to the late integrity of these repairs. Stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection in patients with Marfan syndrome: Midterm outcomes and aortic remodelingThe Journal of Thoracic and Cardiovascular SurgeryVol. 156Issue 5PreviewThe study objective was to assess the midterm outcomes and aortic remodeling in patients with Marfan syndrome with complicated acute type B aortic dissection treated with stent-assisted, balloon-induced intimal disruption and relamination. Full-Text PDF Open Archive

BACKGROUND For the management of descending thoracic aortic aneurysms, recent evidence has suggested that outcomes of open surgical repair may surpass thoracic endovascular aortic repair (TEVAR) in as early as 2 years. OBJECTIVES The purpose of this study was to evaluate the comparative effectiveness of TEVAR and open surgical repair in the treatment of intact descending thoracic aortic aneurysms. METHODS Using the Medicare database, a retrospective study using regression discontinuity design and propensity score matching was performed on patients with intact descending thoracic aortic aneurysms who underwent TEVAR or open surgical repair between 1999 and 2010 with follow-up through 2014. Survival was assessed with restricted mean survival time. Perioperative mortality was assessed with logistic regression. Reintervention was evaluated as a secondary outcome. RESULTS Matching created comparable groups with 1,235 open surgical repair patients matched to 2,470 TEVAR patients. The odds of perioperative mortality were greater for open surgical repair: high-volume center, odds ratio (OR): 1.97 (95% confidence interval [CI]: 1.53 to 2.61); low-volume center, OR: 3.62 (95% CI: 2.88 to 4.51). The restrictedmean survival time difference favored TEVAR at 9 years, -209.2 days (95% CI: -298.7 to -119.7 days; p < 0.001) for open surgical repair. Risk of reintervention was lower for open surgical repair, hazard ratio: 0.40 (95% CI: 0.34 to 0.60; p < 0.001). CONCLUSIONS Open surgical repair was associated with increased odds of early postoperative mortality but reduced late hazard of death. Despite the late advantage of open repair, mean survival was superior for TEVAR. TEVAR should be considered the first line for repair of intact descending thoracic aortic aneurysms in Medicare beneficiaries. (c) 2019 by the American College of Cardiology Foundation.

BACKGROUND Limited intimal tears (LITs) of the aorta (Class 3 dissection variant) are the least common form of aortic pathology in patients presenting with acute aortic syndrome (AAS). LITs are difficult to detect on imaging and may be underappreciated. OBJECTIVES This study sought to describe the frequency, pathology, treatment, and outcome of LITs compared with other AAS, and to demonstrate that LITs can be detected pre-operatively by contemporary imaging. METHODS The authors retrospectively reviewed 497 patients admitted for 513 AAS events at a single academic aortic center between 2003 and 2012. AAS were classified into classic dissection (AD), intramural hematoma, LIT, penetrating atherosclerotic ulcer, and rupturing thoracic aortic aneurysm. The prevalence, pertinent risk factors, and detailed imaging findings with surgical and pathological correlation of LITs are described. Management, early outcomes, and late mortality are reported. RESULTS Among 497 patients with AAS, the authors identified 24 LITs (4.8% of AAS) in 16 men and 8 women (17 type A, 7 type B). Patients with LITs were older than those with AD, and type A LITs had similarly dilated ascending aortas as type A AD. Three patients presented with rupture. Eleven patients underwent urgent surgical aortic replacement, and 2 patients underwent endovascular repair. Medial degeneration was present in all surgical specimens. In-hospital mortality was 4% (1 of 24), and in total, 5 patients with LIT died subsequently at 1.5 years (interquartile range [IQR]: 0.3 to 2.5 years). Computed tomography imaging detected all but 1 LIT, best visualized on volume-rendered images. CONCLUSIONS LITs are rare acute aortic lesions within the dissection spectrum, with similar presentation, complications, and outcomes compared with AD and intramural hematoma. Awareness of this lesion allows pre-operative diagnosis using high-quality computed tomography angiography. (C) 2018 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.

BACKGROUND:Although myocardial bridges (MBs) are traditionally regarded as incidental findings, it has been reported that adult patients with symptomatic MBs refractory to medical therapy benefit from unroofing. However, there is limited literature in the pediatric population. The aim of our study was to evaluate the indications and outcomes for unroofing in pediatric patients. METHODS:We retrospectively reviewed all pediatric patients with MB in our institution who underwent surgical relief. Clinical characteristics, relevant diagnostic data, intraoperative findings, and postoperative outcomes were evaluated. RESULTS:Between 2012 and 2016, 14 pediatric patients underwent surgical unroofing of left anterior descending artery MBs. Thirteen patients had anginal symptoms refractory to medical therapy, and 1 patient was asymptomatic until experiencing aborted sudden cardiac arrest during exercise. Thirteen patients underwent exercise stress echocardiography, all of which showed mid-septal dys-synergy. Coronary computed tomography imaging confirmed the presence of MBs in all patients. Intravascular ultrasound imaging confirmed the length of MBs: 28.2 ± 16.3 mm, halo thickness: 0.59 ± 0.24 mm, and compression of left anterior descending artery at resting heart rate: 33.0 ± 11.6%. Invasive hemodynamic assessment with dobutamine confirmed the physiologic significance of the MBs with diastolic fractional flow reserve: 0.59 ± 0.13. Unroofing was performed with the patient under cardiopulmonary bypass (CPB) in the initial 9 cases and without CPB in the subsequent 5 cases. All patients were discharged without complications. The 13 symptomatic patients reported resolution of symptoms on follow-up, and improvement in symptoms and quality of life was documented using the Seattle Angina Questionnaire version 7. CONCLUSIONS:Unroofing of MBs can be safely performed in pediatric patients, with or without use of CPB. In symptomatic patients, unroofing can provide relief of symptoms refractory to medical therapy.

Central MessageThe management of acute aortic dissections with a primary tear in the arch is controversial. IRAD investigators describe their management strategies.See Article page 66 in the January 2019 issue. The management of acute aortic dissections with a primary tear in the arch is controversial. IRAD investigators describe their management strategies. See Article page 66 in the January 2019 issue. Acute aortic dissections with entry tear in the aortic arch comprise approximately 4% to 10% of acute dissections, but their management is controversial. For the arch A group, most surgeons would agree that early surgical intervention is indicated to prevent early rupture. However, the extent of surgical repair still remains somewhat controversial. Goals of surgical repair include resecting the dissected ascending aorta, preserving aortic valve function, ensuring coronary artery patency, eliminating the arch entry site, and ensuring true lumen perfusion of the arch vessels. For the arch B group, enthusiasm for surgical intervention is less uniform, especially in uncomplicated cases, because arch reconstruction during a period of circulatory arrest managed through a left thoracotomy approach can be challenging. The observations of the International Registry of Acute Aortic Dissection (IRAD) investigators lend significant clarity to these dilemmas. Arch A dissections were most frequently managed by open surgical intervention (78%), with a surgical mortality of 15.3%, which was lower than the mortality for endovascular management (25%) or medical management (24.3%). Interestingly, medical management was elected for 24% of patients, presumably because of extreme surgical risk. Unfortunately, the distal extent of repair is not reported, with open hemiarch reconstruction likely used for patients with the entry tear along the lesser curvature of the arch and total arch repair for patients with tears along the greater curvature. Endovascular repair was infrequently used (4%), although that approach may become more common with more advanced endovascular devices. For arch B dissections, open surgical management was infrequently used (19%) compared with endovascular (25%) and medical (51%) management. Open surgical repair was associated with a higher mortality (31%) than endovascular (14%) or medical (14%) management, likely for reasons associated with the difficulty of arch procedures approached through a left thoracotomy. Going forward, it will be interesting to note the relative use of endovascular techniques, because these procedures become more commonly used for complicated and even uncomplicated acute type B aortic dissections. This experience accumulated from IRAD centers of excellence demonstrates patient-specific approaches for arch tears, especially of the arch B variety, and I suspect endovascular interventions will become more prevalent going forward. It must also be appreciated that these centers have extensive experience with the management of acute aortic dissections, a critical element when considering extensive arch reconstructions for these patients. These patients with arch A especially may benefit from transfers to institutions with significant experience with acute dissections and operations on the aortic arch. We are indeed indebted to the IRAD investigators for these valuable insights. Acute aortic dissections with entry tear in the arch: A report from the International Registry of Acute Aortic DissectionThe Journal of Thoracic and Cardiovascular SurgeryVol. 157Issue 1PreviewTo analyze presentation, management, and outcomes of acute aortic dissections with proximal entry tear in the arch. Full-Text PDF Open ArchiveNotice of CorrectionThe Journal of Thoracic and Cardiovascular SurgeryVol. 157Issue 6PreviewRe: Mitchell RS. Acute aortic dissections with entry tear in the aortic arch: International Registry of Acute Aortic Dissection to the rescue. J Thorac Cardiovasc Surg. 2018;156:1794. Full-Text PDF Open Archive

Central MessageCompared with many high-volume centers (greater than 20 thoracoabdominal aortic aneurysm repairs per year), most hospitals are very low volume. with significantly higher mortality and morbidity.See Article page 2067. Compared with many high-volume centers (greater than 20 thoracoabdominal aortic aneurysm repairs per year), most hospitals are very low volume. with significantly higher mortality and morbidity. See Article page 2067. The report by Mkalaluh and colleagues1Mkalaluh S. Szczechowicz M. Dib B. Weymann A. Szabo G. Karck M. Open surgical thoracoabdominal aortic aneurysm repair: the Heidelberg experience.J Thorac Cardiovasc Surg. 2018; 156: 2067-2073Abstract Full Text Full Text PDF Scopus (13) Google Scholar in this issue of the Journal presents data on thoracoabdominal aortic aneurysm repair as a “contemporary collective” of patients undergoing open surgical repair in a non–high volume center, with mortality and morbidity “comparable to high-volume centers.” As a believer in the volume-outcome relationship, I found this surprising, especially for such a complex procedure with such high associated morbidity. Surgical outcomes for 38 patients during a 10-year interval were reported. By comparison, Coselli and coworkers2Coselli J.S. Amarasekara H.S. Green S.Y. Price M.D. Preventza O. de la Cruz K.I. et al.Open repair of thoracoabdominal aortic aneurysm in patients 50 years old and younger.Ann Thorac Surg. 2017; 103: 1849-1857Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar in Texas presented a study cohort of 3346 patients who underwent open TAAA repair during a 29-year period. Admittedly, Coselli and coworkers2Coselli J.S. Amarasekara H.S. Green S.Y. Price M.D. Preventza O. de la Cruz K.I. et al.Open repair of thoracoabdominal aortic aneurysm in patients 50 years old and younger.Ann Thorac Surg. 2017; 103: 1849-1857Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar set a high bar, but there are multiple centers with annual volumes larger than 15 to 20 patients. In their article, Mkalaluh and colleagues1Mkalaluh S. Szczechowicz M. Dib B. Weymann A. Szabo G. Karck M. Open surgical thoracoabdominal aortic aneurysm repair: the Heidelberg experience.J Thorac Cardiovasc Surg. 2018; 156: 2067-2073Abstract Full Text Full Text PDF Scopus (13) Google Scholar report an overall surgical mortality of 10.5% for the entire cohort. That cohort included, however,18 patients with connective tissue disorders and 20 without such disorders. For purposes of comparison, let us assume that patients with connective tissue disorders were younger than 50 years. Their mortality was 0%. These are not atypical results, because these patients are younger, with far fewer comorbidities. For patients who did not have connective tissue disorders, and were likely older than 50 years, mortality was 20% (4/20). For the Texas patients,2Coselli J.S. Amarasekara H.S. Green S.Y. Price M.D. Preventza O. de la Cruz K.I. et al.Open repair of thoracoabdominal aortic aneurysm in patients 50 years old and younger.Ann Thorac Surg. 2017; 103: 1849-1857Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar mortality for patients younger than 50 years was 3.25%, versus 8.2% for those older than 50 years. Although the Heidelberg data1Mkalaluh S. Szczechowicz M. Dib B. Weymann A. Szabo G. Karck M. Open surgical thoracoabdominal aortic aneurysm repair: the Heidelberg experience.J Thorac Cardiovasc Surg. 2018; 156: 2067-2073Abstract Full Text Full Text PDF Scopus (13) Google Scholar are certainly confounded by small numbers (the Achilles' heel of statistical comparisons), I suspect that this represents a real difference. Similarly, length of hospital stay differed greatly, at 21.5 days (16-35 days) in the study of Mkalaluh and colleagues1Mkalaluh S. Szczechowicz M. Dib B. Weymann A. Szabo G. Karck M. Open surgical thoracoabdominal aortic aneurysm repair: the Heidelberg experience.J Thorac Cardiovasc Surg. 2018; 156: 2067-2073Abstract Full Text Full Text PDF Scopus (13) Google Scholar versus 12 days (9-17 days) in the study of Coselli and coworkers,2Coselli J.S. Amarasekara H.S. Green S.Y. Price M.D. Preventza O. de la Cruz K.I. et al.Open repair of thoracoabdominal aortic aneurysm in patients 50 years old and younger.Ann Thorac Surg. 2017; 103: 1849-1857Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar although intensive care unit stays did not, at 3.5 days (2.3-21.5 days) versus 4 days (3-7 days), respectively. Perhaps more importantly, does this in fact represent a real-world experience? In a recent article3Weiss A. Anderson J.A. Green A. Chang D.C. Kansal N. Hospital volume of thoracoabdominal aneurysm repair does not affect mortality in California.Vasc Endovascular Surg. 2014; 48: 378-382Crossref PubMed Scopus (7) Google Scholar describing TAAA repairs in the state of California performed between 1995 and 2010, 122 hospitals performed only 1188 such procedures, or about 10 procedures per hospital during the 15-year period. Only 5 hospitals received a classification of high volume, defined as having performed 9 or more TAAA repairs in any single year. Overall mortality was 23.9%, which I think does, in fact, represent a real-world experience, with too many small hospitals performing large, complex operations for which they are ill-equipped. Compare a mortality of 8.2% for Cambria and associates4Conrad M.F. Crawford R.S. Davison J.K. Cambria R.P. Thoracoabdominal aneurysm repair: a 20-year perspective.Ann Thorac Surg. 2007; 83: S856-S861Abstract Full Text Full Text PDF PubMed Scopus (298) Google Scholar in 445 TAAA repairs during a 19-year span and Coselli and colleagues' report5Coselli J.S. Conklin L.D. LeMaire S.A. Thoracoabdominal aortic aneurysm repair: Review and update of current strategies.Ann Thorac Surg. 2002; 74 (discussion S1892-8): S1881-S1884Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar with a mortality of 4.8% in 1220 TAAA repairs during 12 years versus a nationwide average of 20.3%.6Derrow A.E. Seeger J.M. Dame D.A. Carter R.L. Ozaki C.K. Flynn T.C. et al.The outcome in the United States after thoracoabdominal aortic aneurysm repair, renal artery bypass, and mesenteric revascularization.J Vasc Surg. 2001; 34: 54-61Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar These results seem to support the volume-outcome relationship. This is even more concerning considering new 4 branch endografts are soon to hit the market, which will surely reduce further the volume of open surgical repairs. Would we not be better served by creating regional centers with dedicated hospital resources, processes, and perioperative support for these infrequent and highly complex procedures? Open surgical thoracoabdominal aortic aneurysm repair: The Heidelberg experienceThe Journal of Thoracic and Cardiovascular SurgeryVol. 156Issue 6PreviewOpen surgical repair of thoracoabdominal aortic aneurysm remains an important treatment option and continues to be challenging. The objective of this study was to investigate the results after open repair of thoracoabdominal aortic aneurysms in a contemporary non–high-volume center collective. Full-Text PDF Open Archive

Background. Left anterior descending artery myocardial bridges (MBs) range from clinically insignificant incidental angiographic findings to a potential cause of sudden cardiac death. Within this spectrum, a group of patients with isolated, symptomatic, and hemodynamically significant MBs despite maximally tolerated medical therapy exist for whom the optimal treatment is controversial. We evaluated supraarterial myotomy, or surgical unroofing, of the left anterior descending MBs as an isolated procedure in these patients.Methods. In 50 adult patients, we prospectively evaluated baseline clinical characteristics, risk factors, and medications for coronary artery disease, relevant diagnostic data (stress echocardiography, computed tomography angiography, stress coronary angiogram with dobutamine challenge for measurement of diastolic fractional flow reserve, and intravascular ultrasonography), and anginal symptoms using the Seattle Angina Questionnaire. These patients then underwent surgical unroofing of their left anterior descending artery MBs followed by readministration of the Seattle Angina Questionnaire at 6.6-month (range, 2 to 13) follow-up after surgery.Results. Dramatic improvements were noted in physical limitation due to angina (52.0 versus 87.1, p < 0.001), anginal stability (29.6 versus 66.4, p < 0.001), anginal frequency (52.1 versus 84.7, p < 0.001), treatment satisfaction (76.1 versus 93.9, p < 0.001), and quality of life (25.0 versus 78.9, p < 0.001), all five dimensions of the Seattle Angina Questionnaire. There were no major complications or deaths.Conclusions. Surgical unroofing of carefully selected patients with MBs can be performed safely as an independent procedure with significant improvement in symptoms postoperatively. It is the optimal treatment for isolated, symptomatic, and hemodynamically significant MBs resistant to maximally tolerated medical therapy. (C) 2017 by The Society of Thoracic Surgeons

Thoracic endovascular aortic repair has a lower perceived risk than open surgical repair and has become an increasingly popular alternative. Whether general consensus exists regarding candidacy for either operation among open and endovascular specialists is unknown. A retrospective review of isolated descending thoracic aortic aneurysm at our institution between January 2005 and October 2015 was performed, excluding trauma and dissection. Two cardiac surgeons, 2 cardiovascular surgeons, 1 vascular surgeon, and 1 interventional radiologist gave their preference for open vs endovascular repair. Interobserver agreement was assessed with the kappa coefficient. k-means clustering agnostically grouped various patterns of agreement. The mean rating was predicted using least absolute shrinkage and selection operator regression. Negative binomial regression predicted the discrepancy between our panel of raters and the historical operation. Generalized estimating equation modeling was then used to evaluate the association between the extent of discrepancy and the adverse perioperative outcome. There were 77 patients with preoperative imaging studies. Pairwise interobserver agreement was only fair (median weighted kappa 0.270 [interquartile range 0.211-0.404]). Increasing age and proximal neck length predicted an increasing preference for thoracic endovascular aortic repair in our panel; larger proximal neck diameter predicted a general preference for open surgical repair. Increasing proximal neck diameter predicted a larger discrepancy between our panel and the historical operation. Greater discrepancy was associated with adverse outcome. Substantial disagreement existed among our panel, and an exploratory analysis of the effect of increasing discrepancy demonstrated an association with adverse perioperative outcome. An investigation of the effect of a thoracic aortic team with open and endovascular specialists is warranted.

Valve-sparing aortic root repair (V-SARR) using the David reimplantation method is an increasingly popular alternative to composite valve graft aortic root replacement in patients with aortic root aneurysms or dissections who wish to avoid anticoagulation. Computed tomography (CT) with retrospective electrocardiograph (ECG)-gating has become routine before and following V-SARR at Stanford. CT allows accurate measurement of aortic dimensions and provides unprecedented three-dimensional (3D) images of the sinuses, the aortic valve cusps, and coronary arteries in patients with the Marfan syndrome (MFS), with a bicuspid aortic valve (BAV), or other aortic diseases. This helps the surgeon to conceptualize the size of the aortic grafts required and how much reduction is necessary proximally (aortic annulus) and distally. These maneuvers are used to reduce the aortic annular diameter (when necessary) and replace the sinuses and ascending aorta (T. David-V, Stanford modification V-SARR). Postoperative ECG-gated CT confirms the reconstructed geometry and reliably detects coronary or other anastomotic problems.

Central MessageCommentary on endovascular stent grafting of aortic dissection involving the aortic arch.See Article page 1631. Commentary on endovascular stent grafting of aortic dissection involving the aortic arch. See Article page 1631. Sometimes when handling a parcel shipped from a faraway place, one has to be especially careful because the items within may be breakable. If not clearly marked, the outside of the package may belie the fragility of the contents. Such is the case with a less invasive approach to aortic dissection, especially in the acute and subacute phase. Open surgery, unlike the endovascular approach, reveals the delicate nature of the diseased aorta in all its facets, and advances in surgical techniques and perioperative care continue to improve patient outcomes. Nonetheless, the outcomes, although better, are occasionally punctuated with mortality and lasting morbidity in some patients. In contrast, endovascular techniques rely on 3-dimensional reconstructed images to provide the pathoanatomy of the aorta before intervention, whereas deployment of novel devices is based mainly on the tried-and-true 2-dimensional radiologic images. Notwithstanding the sophistication of image processing or reconstruction, the “contents” and the nature of the disrupted aorta are not wholly revealed. Because of the challenging anatomic, geometric, and physiologic features of the aortic arch, progress in endovascular therapy in this portion has lagged relative to that in other segments of the thoracic and abdominal aorta. Developments in arch intervention have benefited, however, from lessons learned in treating these other “simpler” and straighter aortic regions. In view of the history of this technology and the learning process, from stent grafting for thoracic aortic aneurysmal disease in the 1990s to current methods of customized branched stent grafting preserving flow to the arch vessels, interventional approaches have steadily advanced with regard to imaging, materials, and deployment techniques, such as precise catheter manipulation and the use of the “traction” artery.1Lu Q. Feng J. Zhou J. Zhao Z. Li H. Teng Z. et al.Endovascular repair by customized branched stent-graft: a promising treatment for chronic aortic dissection involving the arch branches.J Thorac Cardiovascular Surg. 2015; 150: 1631-1638.e5Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 2Inoue K. Hosokawa H. Iwase T. Sato M. Yoshida Y. Ueno K. et al.Aortic arch reconstruction by transluminally placed endovascular branched stent graft.Circulation. 1999; 100: II316-II321PubMed Google Scholar, 3Chuter T.A. Schneider D.B. Reilly L.M. Lobo E.P. Messina L.M. Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection.J Vasc Surg. 2003; 38: 859-863Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 4Schoder M. Grabenwöger M. Hölzenbein T. Cejna M. Ehrlich M.P. Rand T. et al.Endovascular repair of the thoracic aorta necessitating anchoring of the stent graft across the arch vessels.J Thorac Cardiovasc Surg. 2006; 131: 380-387Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 5Lu Q. Jing Z. Zhao Z. Bao J. Feng X. Feng R. et al.Endovascular stent graft repair of aortic dissection type B extending to the aortic arch.Eur J Vasc Endovasc Surg. 2011; 42: 456-463Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 6Haulon S. Greenberg R.K. Spear R. Eagleton M. Abraham C. Lioupis C. et al.Global experience with an inner branched arch endograft.J Thorac Cardiovasc Surg. 2014; 148: 1709-1716Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar Not unexpectedly, however, substantial challenges unique to arch stent grafting remain. Acknowledging the important historic developments in treating arch pathology, Lu and colleagues1Lu Q. Feng J. Zhou J. Zhao Z. Li H. Teng Z. et al.Endovascular repair by customized branched stent-graft: a promising treatment for chronic aortic dissection involving the arch branches.J Thorac Cardiovascular Surg. 2015; 150: 1631-1638.e5Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar are careful in their approach to branched stent grafting. In part because of the need to customize the stent-graft devices (median of 22 days), all patients are technically treated as having “chronic” dissection, although many have intimal flaps that are fragile and mobile at the time of intervention. Most patients have retrograde type A dissections or type B dissections (with primary intimal tears in the descending thoracic aorta); a smaller number have type A dissections (with intimal tears in the ascending aorta or type B dissection localized to the arch). Although the goals of Lu and colleagues1Lu Q. Feng J. Zhou J. Zhao Z. Li H. Teng Z. et al.Endovascular repair by customized branched stent-graft: a promising treatment for chronic aortic dissection involving the arch branches.J Thorac Cardiovascular Surg. 2015; 150: 1631-1638.e5Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar—that is, to construct a device designed to provide adequate seal with sufficient landing zones, preserve arch branch perfusion, and avoid cervical bypass procedures—are laudable, the variability in pathoanatomic characteristics of arch dissection mandates otherwise at this time. So in actuality, instead of presenting multibranched arch stent grafting, Lu and colleagues1Lu Q. Feng J. Zhou J. Zhao Z. Li H. Teng Z. et al.Endovascular repair by customized branched stent-graft: a promising treatment for chronic aortic dissection involving the arch branches.J Thorac Cardiovascular Surg. 2015; 150: 1631-1638.e5Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar conservatively use a variety of single-branched graft configurations often combined with graft fenestrations, which must align with the takeoff of arch vessels, and/or cervical bypass procedures. In brief, many patients undergo single-branched stent grafting (n = 22). In some cases, single-branched stent grafts with 1 additional graft fenestration (n = 17) or 2 graft fenestrations (n = 10) are necessary. A creative solution in treating 2 patients involves the use of 2 single-branched stent grafts with 1 branch in the innominate artery and 1 branch in the left subclavian artery. This well-coordinated approach to these ill patients results in exclusion of proximal entry tears and patency of arch branches. Importantly, there were no perioperative strokes and only 1 death from a retrograde type A dissection 6 days after the procedure; a design change with a longer proximal landing length in the ascending aorta has been implemented to lessen the chance of retrograde dissection. In limited follow-up, there has been consistent evidence of false-lumen thrombosis and positive aortic remodeling. What can we learn from the experience so far to address the challenges of arch stent grafting? Main concerns and goals for endovascular repair include achieving an adequate seal proximally and distally with no endoleaks, maintaining cerebral perfusion, minimizing embolic events, and ultimately improving patient survival. The device must follow the contours of the arch and ascending aorta to achieve proper orientation, resist migration and arch vessel compromise within the hyperdynamic arch, and demonstrate long-term durability. Since the early years of stent-graft development to treat aortic disease, the need to define adequate proximal and distal landing zones has been of paramount importance; coupling this requirement with that of maintaining flow to critical arch branches necessitates further technologic advances yet to come. Incorporating mechanisms for self-alignment of graft branches and fenestrations will lessen the degree of manipulation and thus the potential for tissue injury and embolic events. And to have readily available devices and components will increase the utility of stent grafting so that those with acute aortic dissection can be considered for treatment. Endovascular stent grafting of the aortic arch must be approached with substantial planning and careful patient selection. Lest we damage the fragile contents within, when deploying an arch stent graft to optimize alignment and fixation, we must remember, “This side up—Handle with care.” Endovascular repair by customized branched stent-graft: A promising treatment for chronic aortic dissection involving the arch branchesThe Journal of Thoracic and Cardiovascular SurgeryVol. 150Issue 6PreviewThere is no approved special endovascular device for use in preventing entry tears in the distal part of ascending aorta or in the aortic arch and preserving the arch branch arteries. Thus, we have designed a novel branched stent-graft, and herein report the initial clinical outcomes. Full-Text PDF Open Access

Introduction: Although a myocardial bridge (MB) is a common, generally benign anatomic variant, a small subset of patients experience severe anginal symptoms related to their MB, resulting in significant physical limitations and a poor quality of life. Surgical unroofing (supra-arterial myotomy) is a treatment option when medical management fails, but little is known regarding the clinical outcomes of patients who undergo surgical unroofing. Methods: A total of 34 patients (10 men, 24 women) with severe angina and a hemodynamically significant MB underwent surgical unroofing. All patients had failed medical management and had undergone extensive testing prior to surgery, including exercise echocardiography, coronary computerized tomography angiography, invasive coronary angiography, intravascular ultrasound (a MB was defined as an echolucent half-moon sign and/or ≥10% systolic compression), and hemodynamic testing using an intracoronary pressure and Doppler flow wire at rest and during dobutamine stress to calculate a diastolic fractional flow reserve (dFFR) (the ratio of diastolic intracoronary pressure divided by aortic pressure), as well as the peak Doppler flow velocity. An abnormal dFFR was defined as ≤0.76 during dobutamine stress. A Seattle angina questionnaire (SAQ) was administered to evaluate symptoms and quality of life before and after surgery. Results: The mean age was 45.1 ± 15.7 years and median follow-up was 6.6 (2 - 13) months after surgery. There were no major complications during the pre, intra, or post-operative period of the surgery. Following surgery, patients reported a significant improvement in all five dimensions of the SAQ (figure). Conclusions: In carefully selected patients with severe angina secondary to a hemodynamically significant MB who have failed medical management, surgical unroofing appears to be a safe and effective option for improving physical limitations, anginal symptoms, and overall quality of life.

BACKGROUND:Diseases involving the descending thoracic aorta (DTA) represent a heterogeneous substrate with a variety of therapeutic options. Although thoracic endovascular aortic repair has been increasingly applied to DTA disease, open surgical repair is ostensibly more durable.METHODS:A total of 5,578 patients who underwent open DTA repair (Current Procedural Terminology code 33875) from 1999 to 2010 were identified from the Medicare database; 5,489 patients had complete data. Survival was assessed with Kaplan-Meier analysis. Cox regression determined predictors of death. Hospital and surgeon volume and variability were modeled, and their association with survival assessed.RESULTS:Median survival after open DTA repair was only 4.3 years (95% confidence interval: 4.0 to 4.6). The likelihood of death varied significantly by certain aortic diseases: aortic rupture and acute aortic dissection patients had the highest early mortality. Survival beyond 180 days was best for patients with acute aortic dissection and isolated thoracic aortic aneurysm, and lowest for patients with thoracoabdominal aneurysm and aortic rupture. Hospital and surgeon volume, as well as interhospital and intersurgeon variability, had associations with overall survival.CONCLUSIONS:Open DTA repair has treated a spectrum of aortic diseases in Medicare beneficiaries. Overall mortality was high, predominately confined to the initial postoperative hazard phase. Independent hospital and surgeon effects, hospital and surgeon volume, and a more recent date of surgery correlated with improved survival, while increased operative urgency and complexity correlated with worse outcomes. These observations argue for regionalization of DTA treatment for Medicare patients in specialized centers to concentrate expertise, which should translate into better outcomes.