Factors affecting early and long-term outcomes after completion pneumonectomy

Objective: To identify factors that affect operative mortality and morbidity and long-term survival after completion pneumonectomy. Methods: We retrospectively reviewed the charts of consecutive patients who underwent completion pneumonectomy at our cardiothoracic surgery department from January 1996 to December 2005. Results: We identified 69 patients, who accounted for 17.8% of all pneumonectomies during the study period; 22 had benign disease and 47 malignant disease (second primary lung cancer, n = 19; local recurrence, n = 17; or metastasis, n = 11). There were 50 males and 19 females with a mean age of 60 years (range, 29–80 years). Postoperative mortality was 12% and postoperative morbidity 41%. Factors associated with postoperative mortality included obesity (p = 0.005), coronary artery disease (p = 0.03), removal of the right lung (p = 0.02), advanced age (p = 0.02), and renal failure (p < 0.0001). Preoperative renal failure was the only significant risk factor for mortality by multivariate analysis (p = 0.036). Bronchopleural fistula developed in seven patients (10%), with risk factors being removal of the right lung (p = 0.04) and mechanical stump closure (p = 0.03). Overall survival was 65% after 3 years and 46% after 5 years. Long-term survival was not affected by the reason for completion pneumonectomy. Conclusion: Although long-term survival was acceptable, postoperative mortality and morbidity rates remained high, confirming the reputation of completion pneumonectomy as a challenging procedure. Significant comorbidities and removal of the right lung were the main risk factors for postoperative mortality. Improved patient selection and better management of preoperative renal failure may improve the postoperative outcomes of this procedure, which offers a chance for prolonged survival.     

Emergency stent-graft placement for hemorrhage control in acute thoracic aortic rupture

Objective: To report mid-term results of stent-graft (SG) implantation in acute thoracic aortic rupture as alternative to conventional open surgery with its associated high morbidity and mortality rates. Methods: Out of a series of 69 patients undergoing thoracic aortic SG implantation since 1998, 24 (mean age 57±19 years, range 20–85-years-old) patients were treated on an emergency basis for hemorrhage control. The indication for SG placement was acute traumatic aortic rupture in 15 patients, type B dissection with contained rupture in 3 patients, penetrating aortic ulcer with periaortic hematoma in 3 patients, and thoracic aortic aneurysm rupture in 3 patients. Preoperative assessment was done by computed tomography (CT) scanning and echography. Patients were treated in the angiography suite by implantation of Excluder (n=18), Talent (n=4), Corvita (n=1), and Vanguard (n=1) self-expanding grafts. Local anesthesia was the most frequently used anaesthesiologic technique. Results: Technical success rate of SG deployment was 100%. The early postoperative mortality was 12.5% (3 of 24). One patient suffered temporary paraplegia (4%). There was no intervention-related mortality during the mean follow-up of 34.1 months. Two secondary endoleaks were successfully treated with additional SG placement at 2 and 12 months postoperative, respectively. Conclusions: Emergency SG repair to control hemorrhage in patients with an acute thoracic aortic rupture is a less-invasive attractive and rational treatment option, especially if associated lesions or co-morbidity may interfere with the surgical outcome. Long-term follow-up results will be helpful to clarify procedure durability bounded by material failure and postoperative aneurysm or aortic wall remodelling.     

Endovascular management of pseudo-aneurysms after previous surgical repair of congenital aortic coarctation

Objective: Whatever the surgical technique used, false aneurysm formation is one of the long-term complications of repair of aortic coarctation. Conservative management is associated with a 100% rate of rupture. The conventional surgical approach is complex and associated with high morbidity and mortality rates. We report our experience of endovascular management of pseudo-aneurysms after previous surgical repair of congenital aortic coarctation. Methods: Between October 2005 and 2006, stent-grafting of pseudo-aneurysms after previous surgical repair of congenital aortic coarctation was performed in four patients. Median age was 31.5 years (range: 24–38). Two patients had undergone two previous interventions. The last previous surgery consisted of graft interposition (N = 2), subclavian flap aortoplasty (N = 1) and aorto-aortic bypass (N = 1). Median size of the pseudo-aneurysm was 31.5 mm (range: 20–58). Mean time between the last surgery and endovascular treatment was 24 years (range: 3–32). One patient was treated emergently because of hemoptysis in relation with an aorto-bronchial fistula, the three other patients were treated electively. A transfemoral approach was used in all patients. The Zenith TX2^® (Cook) thoracic stent-graft was used in all the patients, one patient underwent previous dilatation at the coarctation level. When present, the ostium of the left subclavian artery was always covered (N = 3). Results: No major complication occurred during the procedure and no patient died during the follow-up. One patient presented a type II endoleak which spontaneously healed during the first month. Another patient with his left subclavian artery covered presented claudication of the left arm requiring a carotid-subclavian bypass. After a median follow-up of 7.5 months (range: 1–12.9), the patients were asymptomatic and CT scans demonstrated complete exclusion of all treated postcoarctation aneurysms without recoarctation and without any stent-graft-related complication. Conclusions: The endovascular management of pseudo-aneurysms after previous surgical repair of congenital aortic coarctation is feasible. This approach was safe and effective. Long-term clinic and imaging follow-up is mandatory.     

Aortic valve leaflet sparing and salvage surgery: evolution of techniques for aortic root reconstruction

Over the past 20 years, a series of procedures have been designed to reconstruct the aortic root of patients with aortic insufficiency, in whom the pathology and hence the surgery spares the valve leaflets. Such techniques have various names. Usually ‘valve sparing’ is used in context with chronic aortic dissection or aortic root aneurysm as in patients with Marfan's syndrome. ‘Aortic valve salvage’ tends to be the term of choice for similar surgical reconstruction in the setting of aortic dissection. ‘Aortic valve repair’ is often chosen when direct surgical procedures are performed on the leaflets themselves. All of the techniques have evolved based upon an increased understanding of the functional anatomy of the aortic root complex. The different technical approaches, their applications and results need to be understood by the cardiology community. The failure modes for such techniques are specific and different from prosthetic valve failure modes, but are adequately followed with echocardiography. Over two-thirds of patients remain free of re-development of significant aortic insufficiency at 8–10 years following surgery. The overall patient survival is more dependent upon the underlying cardiovascular status of the patient than the surgical technique itself. Perioperative mortalities vary between 0 and 6% and are comparable to composite valve+graft techniques and isolated aortic valve replacement, in which the operative mortality approximates 3.3–4%. Long-term results are good to excellent and spare the patient anticoagulation and prosthetic valve disease.     

Early and late outcome of operated and non-operated acute dissection of the descending aorta

Objective: At present debate continues concerning the optimal mode of treatment for type B dissections. Controversies are mainly due to discordant results regarding survival following medical or surgical treatment. We assessed early and long-term outcome of acute dissection of the descending aorta treated by emergency aortic replacement, medical treatment or delayed surgery. Methods: Between 1980 and 1995, 225 patients were hospitalized in the medical or surgical departement of our institution with the diagnosis of acute type B aortic dissection. A total of 38 patients (16.8%) underwent replacement of the descending aorta within the first week after hospital admission. Primary indications for immediate surgery were: rupturing aneurysm (n=15), diameter of the descending aorta (n=13), malperfusion of the thoracoabdominal aorta (n=8) and pseudocoarctation syndrome with uncontrollable hypertension (n=2). All other patients (n=187) underwent primary conservative treatment on the intensive care unit, including appropriate anti-hypertensive medication. In 12 of them, surgery was denied because of age or significant concomitant diseases. Results: Hospital mortality after urgent or emergency surgery was 21% (8/38 patients) for the overall time period. There has been a significant decrease in hospital mortality during the last 5 year-period (12% versus 30% between 1980 and 1994). Causes of death were: cardiac failure in 3, bleeding complications in 2, postoperative mesenteric ischemia in 2 and septicemia in one patient. From the 30 operative survivors, 9 (30%) patients required further surgery on the native aorta after a mean follow-up of 48±13 months. Hospital mortality during conservative treatment was 17.6% (33/187 patients). Main causes of death were rupture in 14, thoraco-abdominal malperfusion in 13 and cardiac failure in 3 patients, whereas in 3 patients, the cause of death could not be evaluated. In this group, 9 patients had to be shifted to early surgery during the initial hospitalization because of impending rupture (n=4), rapidly increasing diameter (n=2) and suspicion of intestinal ischemia (n=3). After hospital discharge, surgery for chronic dissection was performed in 47 patients, mainly because of expanding descending aortic aneurysm. Hospital mortality was 8% (4/47 patients). Actuarial survival rates after surgery during the first admission were 85±6% at 5 years and 61±8% at 10 years, versus 76±5 and 50±7% respectively, following conservative treatment (P<0.001). Conclusion: Nowadays, acute type B dissection can be treated surgically with a reasonable perioperative risk. Despite aggressive anti-hypertensive treatment, hospital mortality of primary conservative treatment is still high and a substantial percentage of patients requires surgery during initial hospitalization. Main causes of death in both groups are rupture and abdominal malperfusion: therefore, closed clinical and radiologic assessment of the whole thoraco-abdominal aorta is of utmost importance. Long-term results are satisfying; unlimited radiographic follow-up allows for detection of potential severe complications and for proper planning of elective reoperations when indicated.     

Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries

From November, 1976, to June, 1983, 100 patients, 84 male and 16 female patients ranging in age from 13 to 74 years, were operated on for aortic insufficiency associated with an aneurysm of the ascending aorta. Twenty patients were in New York Heart Association Class I, 22 in Class II, 51 in Class III, and seven in Class IV. The surgical treatment in all cases consisted of total replacement of the ascending aorta with a tube graft containing a prosthetic aortic valve and reimplantation of the coronary arteries by an intermediate tube graft according to the technique already reported. In 68 patients an uncomplicated annulo-aortic ectasia existed, and in 32, an aortic dissection; nine of the latter group were operated on during the acute phase. The operative mortality for the entire group was 4% (four deaths). One patient has been lost to follow-up during a period ranging from 18 months to 8 years (average 54 months). The late mortality has been 11/96. Among the 84 survivors, clinical improvement is readily apparent (89% are in Class I or II). Twenty-five patients have been restudied by angiography, which revealed a satisfactory coronary and aortic appearance in all cases with neither stenosis nor aneurysm. The actuarial survival rate is 75% at 8 years. In conclusion, the treatment of aortic insufficiency associated with an aneurysm of the ascending aorta by insertion of a composite graft and reimplantation of the coronary arteries through an intermediate Dacron tube is a reliable method with low mortality and excellent long-term results.     

Management of congenital tracheal stenosis in infancy

Objective: Congenital tracheal stenosis (CTS) is a very infrequent malformation. Till recently, the outlook for these patients was dismal because medical management was the only way of treatment. Surgical and endoscopical techniques developed in the last years have improved the prognosis. We review the short- and long-term outcomes of a single institution experience in the management of children with CTS, comparing different treatment modalities. Methods: Between 1991 and 2004, 19 cases of CTS have been managed in our Unit. Respiratory symptoms varied from mild stridor on exertion to severe distress. Bronchoscopy was performed for diagnostic purposes in all cases; other imaging techniques (computed tomography (CT), magnetic resonance imaging (MRI), bronchography, angiography, doppler-ultrasound) were performed on an individual basis. According to clinical and endoscopical features, patients were classified into three groups. The following data have been studied in each case: sex, age at diagnosis and treatment, anatomical type, associated anomalies, treatment modality, complications, outcome and time of follow-up. Results: Ten boys and nine girls have been included in this study. Age at diagnosis ranged from 3 days to 7 years (median, 4 months) and 84% of cases showed associated anomalies. Five patients presented mild or no symptoms and have been managed expectantly. The other 14 cases were operated on because of persistent or severe clinical symptoms. The following procedures were performed: slide tracheoplasty (n = 7), costal cartilage tracheoplasty (n = 5), tracheal resection and reconstruction (n = 3), endoscopical dilatation (n = 3), stent placement (n = 1), and laser resection (n = 1). Three patients required two or more procedures and surgical survival rate is 78%. Overall mortality in the series is 21% and all survivors (15 patients) are asymptomatic or show mild symptoms with respiratory infections only. Follow-up is complete, ranging from 8 months to 12.3 years (mean, 5 years). Conclusions: Bronchoscopy is our preferred diagnostic tool. Selection of the type of treatment depends on the patient's clinical status and the anatomical pattern of the stenosis. In symptomatic cases with short-segment stenosis (<30% of total tracheal length), we prefer tracheal resection with end-to-end anastomosis; for long-segment stenosis (>30%), slide tracheoplasty is our procedure of choice.     

Twenty-four year experience with reoperations after ascending aortic or aortic root replacement

Objective: A retrospective analysis of early and late outcome for late (>4 weeks) reoperations on the ascending aorta or aortic root. Materials and methods: During a 24-year interval, starting in 1974, 834 patients underwent replacement of the ascending aorta (39.2%) or aortic root (60.8%). During the same period, 56 patients with a mean age of 51.1±14.4 years underwent reoperation after ascending aortic or aortic root replacement. Predominant indications for reoperation were false aneurysm in 25 (44.6%) patients and true aneurysm in 18 (32.1%) patients. Most frequent surgical procedures were redo aortic root replacement in 30 (53.6%) patients and closure of a false aneurysm in 14 (25.0%) patients. Median interval between the operations was 51 months. Eighteen (32.2%) patients underwent concomitant partial or total aortic arch replacement. Results: Hospital mortality was 5.4% (n=3; 70% CL: 2.4–8.4%). Cause of death was low cardiac output in two patients and rupture of the aorta at the distal suture line in one patient. Univariate analysis identified two or more previous operations (P=0.038) and the interval between initial operation and reoperation for complication of less than 8 months (P=0.005) as risk factors for hospital death. Multivariate analysis indicated operation for active endocarditis or vascular graft infection as an independent risk factor for hospital death (P=0.038, odds 14.6). Follow-up was complete, median 3.1 years. Nine (16.9%; 70% CL: 11.7–22.1%) patients died during that period. Estimated survival at 1, 5 and 10 years was 91.2, 84.0 and 76.4%. One patient underwent another reoperation. Estimated event-free survival at 1, 5 and 10 year is 84.3, 72.2 and 65.6%. Conclusion: False aneurysm formation and progression of aneurysmatic disease are the predominant causes for late reoperations after aortic root or ascending aortic replacement. Reoperations can be performed with low hospital mortality and good late results.     

Degenerative and atherosclerotic aneurysms of the thoracic aorta. Determinants of early and late surgical outcome

To identify significant predictors of early and late mortality, multivariate discriminant analyses were applied to the clinical outcome of 175 consecutive patients with thoracic aortic aneurysms operated upon over a 20 year span. Only atherosclerotic and degenerative aneurysms were included; the patients were segregated into two groups according to location of the aneurysm. The ascending aortic aneurysm group consisted of 124 patients, 85% of whom required concomitant aortic valve replacement. There were 51 patients in the descending aortic aneurysm group. Mean follow-up was 4.9 years (maximum of 19 years), with a total of 860 patient-years of follow-up. Multivariate analyses revealed that surgical priority and advanced age were independent determinants of hospital mortality in the ascending group; for the descending group, surgical priority and the presence of congestive heart failure were the strongest predictors of hospital mortality. Late mortality in the ascending group correlated with advanced age. Hypertension and the presence of preoperative congestive heart failure were independent determinants of late mortality in the descending group. Several variables did not have any independent bearing on hospital or late mortality, including etiology and location of the aneurysm, previous myocardial infarction, chronic lung disease, and concomitant aortic valve replacement. High-risk subgroups of patients with thoracic aortic aneurysms can be identified by these variables. Aggressive medical plus surgical management and operation prior to aneurysm rupture is necessary to improve both early and long-term survival rates.     

Risk factors for reoperation after relief of congenital subaortic stenosis

Background: Congenital subaortic stenosis entails a lesion spectrum, ranging from an isolated obstructive membrane, to complex tunnel narrowing of the left outflow associated with other cardiac defects. We review our experience with this anomaly, and analyze risk factors leading to restenosis requiring reoperation. Methods: From 1994 to 2006, 58 children (median age 4.3 years, range 7 days–13.7 years) underwent primary relief of subaortic stenosis. Patients were divided into simple lesions (n = 43) or complex stenosis (n = 15) associated with other major cardiac defects. Age, pre- and postoperative gradient over the left outflow, associated aortic or mitral valve insufficiency, chromosomal anomalies, arteria lusoria, and operative technique (membrane resection (22) vs associated myectomy (34) vs Konno (2)) were analyzed as risk factors for reoperation (Kaplan–Meier, Cox regression). Results: There was no operative mortality. Median follow-up spanned 2.7 years (range 0.1–10), with one late death at 4 months. Reoperation was required for recurrent stenosis in 11 patients (19%) at 2.6 years (range 0.3–7.5) after initial surgery. Risk factors for reoperation included complex subaortic stenosis (p = 0.003), younger age (p = 0.012), postoperative residual gradient (p = 0.019), and the presence of an arteria lusoria (p = 0.014). For simple lesions, no variable achieved significance for stenosis recurrence. Conclusions: Surgical relief of congenital subaortic stenosis, even with complex defects, yields excellent results. Reoperation is not infrequent, and should be anticipated with younger age at operation, complex defects, residual postoperative gradient, and an arteria lusoria. Myectomy concomitant to membrane resection, even in simple lesions, does not provide enhanced freedom from reoperation, and should be tailored to anatomic findings.     

Fate of pulmonary arteries following Norwood Procedure

Objective: This study evaluated the requirement for surgical reoperation and catheter-based reintervention to central pulmonary arteries (CPAs) following Norwood Procedure (NP). We sought to identify the influence of various surgical techniques employed during NP on subsequent interventions. Methods: Between 1993 and 2004, 226 patients underwent Stage II following NP. Ninety-eight patients (43%) had completion of Fontan circulation (Stage III) and a further 107 (47%) are on course for Fontan completion with 21 (9%) inter-stage deaths. During NP, the aortic arch was reconstructed without additional material (n = 91, 40%) or with a pulmonary homograft patch (n = 135, 60%). Pulmonary blood flow was supplied by modified Blalock–Taussig shunt (n = 177, 78%) or right ventricle to pulmonary artery conduit (RV-PA; n = 49, 22%). The CPAs defect was closed directly (n = 69, 31%) or with a patch (n = 157, 69%). Complete resection of coarctation was performed in 126 patients (56%). Results: Ninety-seven patients (43%) required surgical reoperation to CPAs during Stage II. Actuarial freedom from reoperation was 60 ± 3%, 52 ± 4% and 50 ± 4% at 1, 5 and 10 years, respectively. On multivariable analysis, NP with RV-PA increased risk of reoperation (LR 8.3, 5.3–13.2; p < 0.001). Forty-one patients (18%) required catheter-based reintervention on CPAs. Actuarial freedom from reintervention was 98 ± 1%, 72 ± 4% and 58 ± 6% at 1, 5 and 10 years, respectively. CPA problems were almost exclusively limited to the proximal Left pulmonary artery. On multivariable analysis, catheter-based reintervention became more common with time. Complete resection of coarctation increased risk of reintervention (LR 3.9, 1.6–9.6; p < 0.005). Arch reconstruction and CPAs repair techniques did not affect risk of reoperation or reintervention on CPAs. Conclusions: CPA stenoses and hypoplasia need surgical attention in approximately half of all patients undergoing the NP. The need for reoperation is increased when using the RV-PA conduit technique (although the majority of these are performed as part of the Stage II procedure). Catheter reinterventions are almost exclusively confined to the left CPA and are increased when the arch is shortened by resection of the coarctation tissue at time of NP.     

Chronic dissection of the ascending aorta: surgical results during a 20-year period (previous surgery excluded)

Objective: We study here the surgical results of chronic dissection involving the ascending aorta over the last 20 years. Patients with previous cardiac surgery, or proximal aortic repair, were excluded. The patients survived an acute dissection, undiagnosed as pauci- or asymptomatic. The aorta was normal or pathological (atheromatous aneurysm in 15 cases, Marfan's disease in 12 cases, and annuloectasic disease in 18 cases). Two patients had a bicuspid aortic valve. Methods: Between January 1981 and December 2001, 77 patients (mean age 48 ± 15) underwent surgery for chronic dissection of the ascending aorta; 60 patients had severe aortic regurgitation, 12 had Marfan syndrome, and 18 had annuloaortic ectasia. Only the ascending aorta was dissected in 37 patients, the ascending aorta and arch in 26, and the whole aorta in 14. Coronary artery disease occurred in five patients. Statistical analysis was performed using SAS software. Different surgical procedures were used. The aortic arch was repaired in 40 cases; selective antegrade cerebral perfusion and partial circulatory arrest were used. Total aortic replacement was performed on four patients. Results: In-hospital mortality was 10%. The only risk factor was the extent of the dissection. The rate of neurologic stroke was 2.5%. Late survival rate was 42 ± 7.5% at 12 years for all the patients; it was 71 ± 10% when only the ascending aorta was dissected, 44 ± 11% when the ascending aorta and arch were dissected, and 33 ± 15% when the whole aorta was dissected (p = 0.0329). The extent of the dissection was the only risk factor for late mortality. Reoperation was required for one proximal and five distal problems. Conclusion: In chronic aortic dissection, in-hospital and late mortality were related to the extent of the dissection; in-hospital mortality remained unchanged during the operative period.     

Primary repair of aortic arch obstruction with ventricular septal defect in preterm and low birth weight infants

Objective: Previous reports have suggested that prematurity and low birth weight are risk factors for definitive surgical intervention in congenital cardiac malformations. The following data review our experience with primary repair of the complex malformation of aortic arch obstruction with ventricular septal defect (VSD) in this patient population. Methods: Since 1988, 21 consecutive preterm (≤36 weeks) and/or low birth weight (<3000 g) infants with interrupted aortic arch (IAA; n=10), or aortic coarctation (n=11) with VSD, underwent primary arch repair and VSD closure. The mean weight at operation was 2310 g (range, 1200–2900 g), including 12 patients at ≤2500 g. The gestational age ranged from 30 to 41 weeks (mean, 36.4 weeks). Five patients with interrupted arch and two patients with coarctation also had severe subaortic stenosis, which was relieved by transatrial incision of the infundibular septum. Results: The overall hospital mortality was 14% (3/21). Death was related to low cardiac output in association with severe subaortic stenosis (n=2) and sepsis (n=1). Late mortality occurred in three patients, two of which were non-cardiac. The mean follow-up was 33 months. Two patients had significant recurrent arch obstruction, which was successfully relieved by balloon angioplasty and surgical correction in one each. The survival at 30 days, and at 1 and 3 years was 86, 76 and 70%, respectively. Conclusions: Complete primary repair of aortic arch obstruction with VSD can be achieved with good results, even in the preterm and low birth weight infant. Therefore, early surgical repair of this congenital malformation is recommended.     

Results of Aortic Surgery in Patients with Marfan Syndrome

Purpose We reviewed the outcome of aortic operations in patients with Marfan syndrome to evaluate the immediate and long-term results of surgical treatment.Methods Between January 1985 and June 2002, 22 patients with Marfan syndrome underwent surgical treatment for aortic diseases at our hospital. Eight patients had Stanford type A aortic dissection and ten patients had aortic root aneurysm with aortic regurgitation. We performed aortic root replacement in 21 patients. Subsequent aortic operations were done in 11 patients, 6 of whom required a third operation. Five patients underwent repeat surgery of the previously operated aortic segment. A collective a total of 42 aortic operations were performed in the 22 patients. Seven patients underwent total aortic replacement.Results The in-hospital mortality rate was 4.5%, and there were three late deaths: two caused by rupture of the dissected aorta, 17 months and 24 months after the last surgical intervention, respectively, and one caused by heart failure 27 months after a total aortic replacement. The overall actuarial survival was 90.2% at 5 years and 74.4% at 10 years.Conclusions Surgical treatment of patients with Marfan syndrome can be accomplished with low mortality; however, new aortic lesions should be promptly explored, and appropriately timed surgical treatment can substantially improve the prognosis of patients with Marfan syndrome.     

Lifetime gain related to cost of repair of ruptured abdominal aortic aneurysm in octogenarians.

OBJECTIVE: To report cost related to gained life years after repair of ruptured abdominal aortic aneurysms in patients aged 80 or older. DESIGN: A retrospective study based on prospectively registered data. PATIENTS AND METHODS: Fifty-three patients aged 80 or older were operated on for ruptured abdominal aortic aneurysm over a 20-year period from 1983 to 2002. Thirty-one (58%) patients had systolic BT <80 mmHg. Operative mortality (<30 days) and long-term survival were studied. The number of life-years gained from the operations was estimated. Based on diagnose related group (DRG) values, the cost of each gained life-year was calculated. RESULTS: The operative mortality was 47%. Long-term survival of those patients who survived the operation was similar to that of an age and sex matched population. The 53 operations resulted in 145 gained life-years, which leaves a mean survival of 2.7 years of all the patients and 5.2 years of those who survived the operation. The estimated cost per gained life year was euro6817. CONCLUSIONS: The operative mortality of ruptured abdominal aortic aneurysm remains high. The long-term survival of patients who survive the operation is acceptable. The price of each gained life-year is low, as compared to other established treatment modalities. Improved results with endovascular treatment may even decrease the cost per gained life year.     

Short- and long-term outcomes of aortic root repair and replacement in patients undergoing acute type A aortic dissection repair: Twenty-year experience

ObjectiveThe study objective was to evaluate the perioperative and long-term outcomes of aortic root repair and aortic root replacement and provide evidence for root management in acute type A aortic dissection.MethodsFrom 1996 to 2017, 491 patients underwent aortic root repair (n = 307) or aortic root replacement (n = 184) (62% bioprosthesis) for acute type A aortic dissection. Indications for aortic root replacement were intimal tear at the aortic root, root measuring 4.5 cm or more, connective tissue disease, or unrepairable aortic valvulopathy. Primary outcomes were in-hospital mortality, long-term survival, and reoperation rate for root pathology.ResultsPatients' median age was 61 years and 56 years in the aortic root repair group and aortic root replacement group, respectively. The aortic root replacement group had more renal failure requiring dialysis, previous cardiac intervention or surgery, heart failure, coronary malperfusion syndrome, acute myocardial infarction, and severe aortic insufficiency, as well as concomitant coronary artery bypass grafting, tricuspid valve repair, and longer cardiopulmonary bypass and aortic crossclamp times but similar arch procedures. Perioperative outcomes were similar in the aortic root repair and aortic root replacement groups, including in-hospital mortality (8.5% and 8.2%), new-onset renal failure requiring permanent dialysis, stroke, myocardial infarction, and sepsis. Kaplan–Meier 10-year survival was 62% and 65%, and the 15-year cumulative incidence of reoperation was 11% and 7% in the aortic root repair and aortic root replacement groups, respectively. The primary indication for root reoperation was aortic root aneurysm in the aortic root repair group and bioprosthetic valve deterioration in the aortic root replacement group.ConclusionsAortic root repair and aortic root replacement are appropriate surgical options for acute type A aortic dissection repair with favorable short- and long-term outcomes. Aortic root replacement should be performed for patients with acute type A aortic dissection presenting with an intimal tear at the aortic root, root aneurysm 4.5 cm or greater, connective tissue disease, or unrepairable aortic valvulopathy.     

The influence of gender on outcome after ruptured abdominal aortic aneurysm

BACKGROUND: The influence of gender on the management of coronary artery disease is well documented, but few reports exist regarding the influence of gender on the management of peripheral arterial disease. OBJECTIVE: The purpose of this study was to examine the influence of gender on selection for and short-term and long-term outcomes of repair of ruptured abdominal aortic aneurysm (RAAA) in a regional vascular surgery unit. METHODS: Analysis of the prospectively gathered Lothian Surgical Audit database identified 692 patients (542 male and 150 female) admitted with RAAA between January 1, 1983, and December 31, 1995. Case notes were reviewed for patients who were admitted but not operated on. Operative mortality was defined as death within the same hospital admission. Long-term survival data were obtained from the General Register Office (GRO1 records) through record linkage by the Information and Statistics Division of the National Health Service of Scotland. RESULTS: A total of 542 men (78%; median age, 72 years; age range, 46-93 years) and 150 women (22%; median age, 74 years; age range, 55-93 years) were admitted with RAAA (P =.12; Mann-Whitney U test). There was no significant difference in perioperative mortality between men and women. Although women who were not operated on (median age, 81 years; age range, 68-93 years) were significantly (P =.005) older than men who were not operated on (median age, 77 years; age range, 54-93 years), for any given age group, women appeared less likely than men to be offered surgical repair. Long-term survival after successful repair was comparable for the genders. CONCLUSIONS: Gender has no influence on either short-term or long-term outcome for patients undergoing operative repair of RAAA. However, women are less likely to be selected for operation than their male counterparts.     

Acute type A aortic dissection: the prognostic impact of preoperative cardiac tamponade

Objective: Acute type A aortic dissection requires emergency surgery and is associated with considerable mortality. The aim of the study was to evaluate whether occurrence of preoperative cardiac tamponade with or without palpable pulses in these patients is associated with higher incidence of multiple organ failure (MOF) and in-hospital mortality. Methods: A retrospective cohort study included 87 patients with acute type A aortic dissection, who were admitted via an emergency department between December 1991 and December 1999 for emergency surgery. Impending cardiac tamponade (with palpable pulses) and severe cardiac tamponade (without palpable pulses) were recorded and patients were followed for occurrence of MOF and/or in-hospital mortality. Results: Impending cardiac tamponade with palpable pulses was diagnosed in 33 patients (38%), signs of severe cardiac tamponade without palpable pulses were found in seven patients (8%). MOF occurred in 41 patients (47%); 32 patients (37%) died during the present stay, all of them had MOF. Preoperative severe cardiac tamponade without palpable pulses was associated with a significantly increased risk for poor outcome (odds ratio (OR)=16.1, 70% confidence interval (CI) 4.8–71.7, P=0.04), particularly preoperative death (n=6 of 7). Impending cardiac tamponade with palpable pulses (OR=1.6, 70% CI 0.8–3.3, P=0.2) was not associated with the occurrence of MOF/death. Hemodynamic shock (OR=6.5, 70% CI 3.0–13.9, P=0.01) was also associated with poor outcome. Conclusion: Patients with acute type A aortic dissection and signs of preoperative cardiac tamponade without palpable pulses had a 16-fold increased risk for poor outcome, particularly preoperative death. In contrast, cardiac tamponade with palpable pulses was not associated with increased frequency of MOF/in-hospital mortality.     

15例主动脉夹层动脉瘤的外科治疗

目的 总结１９９２年６月至１９９８年６月对１５例主动脉夹层动脉瘤病人的外科治疗经验。方法 采用Ｃａｂｒｏｌ手术６例,Ｂｅｎｔａｌｌ手术４例,升主动脉与腹主动脉搭桥转流手术４例。升主动脉夹层缝闭加主动脉瓣成形１例。结果 １４例生存,１例Ｂｅｎｔａｌｌ手术左冠状动脉吻合口出血者死亡。结论ＤｅＢａｋｅｙ Ⅱ型病人,当冠状动脉开口直接缝合于带瓣管道上有困难时,采用Ｃａｂｒｏｌ手术有其优点－采用１根８ｍｍ直     

Early and long-term results of lung resection for non-small-cell lung cancer in patients with severe ventilatory impairment

Objective: To study clinical characteristics, surgical treatment modalities, early and long-term outcome of patients with severe ventilatory impairment undergoing lung resection for NSCLC. Methods: We performed a retrospective review of clinical records of all patients with severe chronic ventilatory impairment (FEV1 and/or FVC≤50% of predicted values) operated on for NSCLC in a 21-year period (1983–2003). Results: One hundred and six patients were operated on. Mean FEV1 and FVC were 40% (range 23–50%) and 69% (17–117%), respectively. An obstructive pattern was observed in 87 cases (82%). Extent of maximal exeresis was based on the assessment of predicted post-operative FEV1 (ppoFEV1). Major resections were contraindicated if ppoFEV1 was lower than 30%. Sixteen pneumonectomies, 73 lobectomies and 17 sublobar resections were carried out. Pathologic stages were I, II, IIIA and IIIB in 58, 26, 18 and 4 cases, respectively. Resection was complete in 104 patients. Operative mortality and morbidity were 8.5% (n=9) and 70% (n=74), respectively. Twenty-two patients needed prolonged (>48 h) mechanical ventilation. Overall mean ppoFEV1 loss was 9.1% (0–34%). If ppoFEV1 loss was >15%, the morbidity rate was 100%. Mean PaCO2 and ppoFEV1 loss were higher among patients who died (41 mmHg versus 37 mmHg, P=0.02 and 13.2% versus 8.5%, P=0.025, respectively) as compared with operative survivors. Among patients with PaCO2>39 mmHg and ppoFEV1 loss>15% (n=9), mortality rate was 33%. Overall 1-year and 5-year survival rates were 82 and 33%, respectively. Respiratory failure was the cause of late death in 2 patients. Among patients available at follow-up (n=85), respiratory function was considered subjectively improved, stable and worsened in 6 (7%), 62 (73%) and 17 (20%) cases, respectively. Eleven patients needed continuous oxygen therapy. Conclusions: Lung resection should not be denied a priori in patients with severe ventilatory impairment. Evaluation of predicted post-operative function often allows major resections, which are functionally economic, at the price of a high operative morbidity. Operative mortality, long-term survival and respiratory function are acceptable in the absence of a valid therapeutic alternative.