Surgical management of a calcified homograft with associated severe aortic insufficiency is challenging because of the technical difficulty in occluding the aorta. We present a hybrid method of ...homograft occlusion during the cooling phase of a homograft replacement procedure that required the use of circulatory arrest.
Background
Use of recombinant activated factor VII (rFVIIa) to achieve hemostasis during cardiac surgery continues to be debated, as support for its efficacy and safety has not been consistent. We ...examined our experience with rFVIIa for achieving hemostasis in high‐risk patients undergoing complex ascending aortic surgery.
Methods
We reviewed patients who underwent complex ascending aortic surgery performed by a single surgeon (C. K. R.) from August 2014 to February 2019. Outcomes of patients who received rFVIIa were compared with those who did not.
Results
Of 59 consecutive patients, 20 patients (33.9%) received rFVIIa, whereas 39 (66.1%) did not. Median dose was 45.4 mcg/kg. rFVIIa was administered intraoperatively to 95% of patients who received it. Most patients underwent combined aortic valve, ascending aorta, and aortic arch surgery (80.0% vs. 64.1%, p = .52). Patients receiving rFVIIa had longer mean cross clamp times (212 vs. 173 min, p = .03) and received a greater median number of intraoperative blood products (18.5 vs. 12.0, p < .001). The number of patients who needed postoperative products (75.0% vs. 60.5%, p = .39), the median number of blood products transfused postoperatively (2 vs. 2, p = .40), and chest tube output (1138 vs. 805 ml, p = .17) were similar between groups. In‐hospital mortality was similar between groups (10.0% vs. 10.3%, p = 1.00). Incidences of postoperative stroke (10.0% vs. 13.5%, p = 1.00) and thromboembolic events (10.0% vs. 13.5%, p = 1.00) were similar.
Conclusions
Administration of rFVIIa intraoperatively for refractory bleeding during complex ascending aortic surgery provided hemostasis without greater in‐hospital mortality or a higher risk of stroke and thromboembolic events.
RATIONALE:Telomerase is a nuclear regulator of telomere elongation with recent reports suggesting a role in regulation of mitochondrial reactive oxygen species. Flow-mediated dilation in patients ...with cardiovascular disease is dependent on the formation of reactive oxygen species.
OBJECTIVE:We examined the hypothesis that telomerase activity modulates microvascular flow-mediated dilation, and loss of telomerase activity contributes to the change of mediator from nitric oxide to mitochondrial hydrogen peroxide in patients with coronary artery disease (CAD).
METHODS AND RESULTS:Human coronary and adipose arterioles were isolated for videomicroscopy. Flow-mediated dilation was measured in vessels pretreated with the telomerase inhibitor BIBR-1532 or vehicle. Statistical differences between groups were determined using a 2-way analysis of variance repeated measure (n≥4; P<0.05). L-NAME (N-nitro-L-arginine methyl ester; nitric oxide synthase inhibitor) abolished flow-mediated dilation in arterioles from subjects without CAD, whereas polyethylene glycol-catalase (PEG-catalase; hydrogen peroxide scavenger) had no effect. After exposure to BIBR-1532, arterioles from non-CAD subjects maintained the magnitude of dilation but changed the mediator from nitric oxide to mitochondrial hydrogen peroxide (% max diameter at 100 cm H2Ovehicle 74.6±4.1, L-NAME 37.0±2.0*, PEG-catalase 82.1±2.8; BIBR-1532 69.9±4.0, L-NAME 84.7±2.2, PEG-catalase 36.5±6.9*). Conversely, treatment of microvessels from CAD patients with the telomerase activator AGS 499 converted the PEG-catalase-inhibitable dilation to one mediated by nitric oxide (% max diameter at 100 cm H2Oadipose, AGS 499 78.5±3.9; L-NAME 10.9±17.5*; PEG-catalase 79.2±4.9). Endothelial-independent dilation was not altered with either treatment.
CONCLUSIONS:We have identified a novel role for telomerase in re-establishing a physiological mechanism of vasodilation in arterioles from subjects with CAD. These findings suggest a new target for reducing the oxidative milieu in the microvasculature of patients with CAD.
Functional mediastinal paragangliomas (PGs) are rare, catecholamine-secreting tumours. Surgical resection is the preferred treatment, but it can be complicated by catecholamine-related symptoms, ...involvement of cardiac structures and/or tumour supply from major blood vessels. We report a case of a man in his 30s with a subcarinal functional PG complicated by all three factors. The PG had arterial supplies from the right coronary and bronchial arteries, with mass effect on the left atrium. Given the high risk of intraoperative bleeding, catecholamine surges and injury to right coronary artery, we attempted a minimally invasive strategy that incorporates best practices from the few published cases on functional PGs. We show that a multidisciplinary approach involving alpha/beta blockade, preoperative embolisation of tumour blood supply, robotic-assisted tumour mobilisation and, if needed, open resection with cardiopulmonary bypass can be a safe strategy in the treatment of functional mediastinal paragangliomas adherent to cardiac structures.
Abstract
Small lymphocytic lymphoma (SLL) is rarely associated with thoracic aortic aneurysms. Aneurysm of the ascending aorta associated with SLL has never been reported before. We describe the case ...of an asymptomatic 68-year-old woman who presented with a 5.5-cm aneurysm of the ascending aorta and no prior history of hematological disorders. Following excision and repair, the surgical specimen showed infiltration of the aortic wall by lymphocytes, expressing markers consistent with SLL. While symptomatic SLL carries a poor prognosis, risk stratification tools are applied to guide management strategies in asymptomatic patients.
Background Chronic obstructive pulmonary disease (COPD) has been conventionally associated with increased operative mortality and morbidity after coronary artery bypass grafting. Some studies, ...however, challenge this association. Moreover, the effect of COPD on long-term survival after coronary artery bypass grafting has not been adequately assessed. Thus, in this clinical setting, both early and late outcome require further examination. Methods We studied 3,760 consecutive patients who underwent isolated coronary artery bypass grafting between 1992 and 2002. The propensity for COPD was determined by logistic regression analysis, and each patient with COPD was matched with 3 patients without COPD. Matched groups were compared for early outcome and long-term survival (mean follow-up, 7.6 years). Long-term survival data were obtained from the National Death Index. Results There were 550 patients (14.6%) with COPD. Multivariate analysis showed that patients with COPD were older and sicker. However, propensity-matched groups did not differ in terms of hospital mortality or major morbidity, although COPD was associated with a slightly longer hospital stay. In contrast, COPD patients had increased long-term mortality, with a hazard ratio of 1.28 (95% confidence intervals, 1.11 to 1.47; p = 0.001). Freedom from all-cause mortality at 7 years after CABG was 65% and 72% in matched patients with and without COPD, respectively ( p = 0.008). In patients with COPD, the hazard estimate was consistently increased up to 9 years postoperatively. Conclusions Chronic obstructive pulmonary disease, although not an independent predictor of increased early mortality and morbidity in this series, is a continuing detrimental risk factor for long-term survival.
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