The Replacement of the Ascending Aorta and Aortic Valve with a New Design Composite Graft: A Six-Year Experience

The problems encountered in coronary artery reattachment when the ascending aorta and aortic valve are replaced with a composite graft induced Gallucci and one of the authors to develop a new aortovalvular prosthesis in clinical practice. The unique transverse ovoidal shape of this graft is intended to conform to the natural aortic root and facilitate the coronary anastomoses and minimize bleeding. We present our 6-year experience with 56 patients operated upon with this prosthesis. In all patients we were able to connect the coronary arteries directly to the graft without complications including hemorrhage or distortion of the coronary ostia. The survivors were evaluated with chest X ray, two-dimensional echocardiography, and conventional or digital subtraction angiography to detect the presence of pseudoaneurysms at the site of the coronary anastomosis, reported by others that have used the composite graft technique. The notable absence of this complication in our patients at a mean follow-up of 41 months (range 3-71) documents that this ovoidal composite graft is a reliable tool in the treatment of aortic root pathology.     

Visualization of Pattern Flow in Abdominal Arteries by Transgastric Echocardiography After Aortic Dissection Repair

The persistence of false lumen after surgical repair of aortic dissection is frequent. This event has a negative impact on the prognosis and is secondary to the persistence of unrepaired entry sites and of dissected major aortic branches. We describe three cases in which visualization of a dissected celiac trunk with an anomalous flow pattern was possible with transesoghageal echocardiography. Two of these cases died in the early postoperative period and the echo findings were confirmed at necropsy. We suggest that visualization of anomalous pattern flow in the celiac trunk is of prognostic relevance because it plays a major role in mantaining the false lumen persistence and, therefore, should be part of the routine examination after surgical repair of aortic dissection.     

Variability of Left Ventricular Electromechanical Activation during Right Ventricular Pacing: Implications for the Selection of the Optimal Pacing Site

Background: The right ventricular septum (RVS) and Hisian area (HA) are considered more “physiological” pacing sites than right ventricular apex (RVA). Studies comparing RVS to RVA sites have produced controversial results. There are no data about variability of electromechanical activation obtained by an approach using fluoroscopy and electrophysiological markers. This study compared the variability of left ventricular (LV) electromechanical activation in patients undergoing short‐term RVA and RVS with that measured during HA pacing based on fluoroscopy and electrophysiological markers. Methods: Tissue Doppler echocardiography was performed in 142 patients before and after RVA (54), RVS (44), and HA (44) pacing. Electromechanical activation was assessed by: (1) electromechanical latency (EML)‐interval between QRS onset and mechanical activation of basal LV; (2) intra‐LV dyssynchrony (intra‐LV)‐interval between earliest to the latest LV basal motion. The intra‐ and interpatients variability among pacing groups were assessed. Results: Pacing from RVA showed longer EML and higher degree of intra‐LV than RVS and HA pacing. RVA and RVS showed a higher variability than HA pacing with regard to intrapatient changes of EML (RVA vs RVS, P = 0.4; RVS vs HA, P = 0.01, RVA vs HA, P = 0.0002) and intra‐LV (RVA vs RVS, P = 0.2; RVS vs HA, P = 0.04; RVA vs HA, P = 0.005). Similar results were found in interpatients variability from paced‐values. Conclusions: RVA and RVS pacing produce a variable effect on LV electromechanical activation that is significantly more pronounced than HA pacing. A pacing site such as HA selected by fluoroscopic and electrophysiological markers maintains baseline and homogeneous LV activation pattern. (PACE 2010; 566–574)     

Embolic Implications of Combined Risk Factors in Patients with Patent Foramen Ovale (the CARPE Criteria): Consideration for Primary Prevention Closure?

Background: Large patent foramen ovale (PFO), spontaneous right‐to‐left shunt, large atrial septal aneurysm (ASA), coagulation abnormalities, and prominent eustachian valve (EV) have all been independently suggested as risk factors for recurrent stroke. We sought to retrospectively evaluate risk of stroke and impact of transcatheter PFO closure in patients with concurrent large PFO, spontaneous right‐to‐left shunt, large ASA, coagulation abnormalities, and prominent EV. Methods: Between March 2006 and October 2008, 36 (mean age 44 ± 10.9 years, 28 females) out of 120 consecutive patients referred to our center for transcatheter PFO closure had concomitant diagnosis of (a) large PFO on transcranial Doppler (TCD) and transesophageal echocardiography (TEE), (b) spontaneous right‐to‐left shunt on TCD, (c) large ASA, (d) prominent EV, and (e) coagulation abnormalities. All patients fulfilled the standard current indications for transcatheter closure and underwent preoperative TEE and brain magnetic resonance imaging (MRI), with subsequent intracardiac echocardiographic‐guided transcatheter PFO closure. Results: Compared to the remaining PFO population in the same period, patients with all five concomitant features had more ischemic brain lesions on MRI, previous history of recurrent stroke, more frequently a history of venous thromboembolism, and more severe migraine with aura. The concomitance of all the features confers the highest risk of recurrent stroke (OR 9.9, 3.0–18 [95% CI], P < 0.001). Conclusions: Despite its small sample size and nonrandomized retrospective nature, this is the first study to suggest that patients with concurrence of all the investigated characteristics have potentially a higher risk of stroke compared to controls. We thus propose the CARP criteria as a basis for further larger, longitudinal studies to assess the potential benefits of transcatheter closure in this patient subset in the absence of clinical recurrent stroke.