ascending aorta

The Bentall procedure is a surgical repair of an ascending aortic or aortic root aneurysm in combination with aortic valve disease. Less commonly, it is used to repair aortic dissection affecting the aortic root and valve. During the procedure, a composite aortic valve graft is used to replace the proximal ascending aorta and aortic valve. The procedure is performed through a median sternotomy during cardiopulmonary bypass. In this modification of the original procedure, coronary artery circulation is maintained by removing a full-thickness "button" of aorta surrounding the coronary ostia, making it easier to implant the proximal end of the coronary arteries into openings made in the aortic vascular graft.

Echocardiographic assessment prior to valve surgery is crucial for clinical decision making, timing of surgery, planning the adequate surgical therapy and predicting the patient's outcome. Description of transvalvular velocities is not enough for sending a patient to the operating room. There are specific functional and morphological characteristics of each valve dysfunction that have to be addressed by the echocardiographer prior to surgery. Evaluation of the aortic valve, annulus, root, ascending aorta, left ventricular outflow tract and left ventricular function are important. In knowing these characteristics the surgeon may choose the appropriate valve and operation techniques and assess the need for additional surgical procedures. A detailed evaluation of valve morphology and function in context with cardiac hemodynamics should be achieved during echocardiography. This step-by-step evaluation allows the correct diagnosis and classification of patient's outcome. In conclusion, an echohemodynamic approach enables the cardiac surgeon to plan and perform the adequate surgical procedure.

Objective: We report the combined early results from two centers in the United Kingdom using a composite conduit consisting of a bileaflet mechanical valve incorporated into a gelatin-impregnated, ultra-low porosity, woven polyester graft (Carbo-Seal; Sulzer ...

There is a growing need for patient-specific cardiac models for intervention planning, outcome prediction or assessment of cardiac disease progression. However, most of the recent work in cardiovascular simulation relies on generic heart models built from at most one cardiac phase with simplified motion, driven by fluid dynamics equations. We propose to advance the state-of-the-art by exploiting a comprehensive, patient-specific left heart model extracted from 4D Computed Tomography (CT) data. Explicit physiological constrains are captured in the modeling of the left ventricle (including outflow tract), left atrium (including pulmonary veins), mitral valve, and aortic valve (including ascending aorta). By using this patient-specific model as an input to a 3D Navier-Stokes solver we derive realistic hemodynamics, constrained by the local anatomy, along the entire heart cycle. We present a differential assessment of the flow dynamics corresponding to specific heart conditions. The simulation results shed light upon the functional differences between one normal and two diseased hearts-one with a dilated aortic root and one with a bicuspid aortic valve.

Case report. An 8-month-old girl presented with poor ventricular function and mitral insufficiency after reimplantation of an anomalous left coronary artery at another institution. After her mother had a full-term uncomplicated pregnancy, at age 3 months, the patient had been evaluated for shortness of breath with feeding. She was found to have congestive heart failure and a cardiac murmur. Left heart catheterization and coronary angiography revealed an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). The patient underwent open-heart surgery with surgical reimplantation of the left coronary artery to the anterior aspect of the ascending aorta on Nov 30, 2004, at another institution. She had a slow postoperative recovery, requiring mechanical ventilation for 1 week after surgery. Upon discharge, she showed clinical improvement and did well for some time. At age 7 months, the patient was not gaining weight appropriately and was reevaluated for coronary ischemia. Left heart catheterization on March 14, 2005, revealed an enlarged left atrium and left ventricle, as well as a reduced left ventricular (LV) ejection fraction (EF) of 18%. Right heart catheterization was normal. Coronary angiography revealed significant narrowing and near occlusion of the left main coronary artery. The right coronary artery was observed to be enlarged and provided collateral flow to the left coronary system. At that point, the patient came to the Cleveland Clinic (Cleveland, Ohio) for a second opinion. Echocardiography at our institution revealed moderate LV dilatation (2.8 cm in diastole) and mild LV systolic dysfunction (EF, 50%). Given the uncertainty about the significance of the lesion in the left main coronary artery and the discrepancy in LV function, an alternative functional test was considered. The patient proceeded to cardiac positron emission

The aims of this study were (1) to demonstrate the feasibility of computational fluid dynamic (CFD) modelling of realistic blood flow in the mouse aortic arch, and (2) to determine the relation of wall shear stress and atherosclerosis in the mouse aortic arch. ApoE knockout mice were chosen for this study. The blood flow fraction in the major branches of

Radionuclide images were acquired in t,~e LAD best septal projection, on a 64 x 64 pixets matrix. The examinations were performed within one hour and the results were I:!indly reviewed in two laberatodes and compared by linear regression analysis. Results: mean EABD right ventricutsr FAC was 31 ± 6%; mean TAPSE 18-4-4 mm and mean radionuciide RVEF 33 :~ 5.

We report the case of a type II aortic dissection involving the pulmonary autograft after a Ross procedure 6 years earlier. A dissection flap was present in both the native ascending aorta and right coronary sinus of the autograft. At reoperation, the valve was spared using a root remodeling technique.

Background: Aortic root replacement after a previous operation on the aortic valve, aortic root, or ascending aorta remains a major challenge. Methods: Records of 56 consecutive patients (44 men; mean age, 56.4 Ϯ 13.6 years) undergoing reoperative aortic root replacement between June 1994 and June 2005 were reviewed retrospectively. Results: Reoperation was performed 9.4 Ϯ 6.7 years after the last cardiac operation. Indications for reoperation were true aneurysm (n ϭ 14 [25%]), false aneurysm (n ϭ 10 [18%]), dissection or redissection (n ϭ 9 [16%]), structural or nonstructural valve dysfunction (n ϭ 10 [18%]), prosthetic valve-graft infection (n ϭ 12 [21%]), and miscellaneous (n ϭ 1 [2%]). Procedures performed were aortic root replacement (n ϭ 47 [84%]), aortic root replacement plus mitral valve procedure (n ϭ 5 [9%]), and aortic root replacement plus arch replacement (n ϭ 4 [7%]). In 14 (25%) patients coronary artery bypass grafting had to be performed unexpectedly during the same procedure or immediately after the procedure to re-establish coronary perfusion. Hospital mortality reached 17.9% (n ϭ 10). Multivariate logistic regression analysis revealed the need for unplanned perioperative coronary artery bypass grafting as the sole independent risk factor for hospital death (P ϭ .005). Actuarial survival was 83.8% Ϯ 4.9% at 1 month, 73.0% Ϯ 6.3% at 1 year, and 65.7% Ϯ 9.0% at 5 years after the operation. One patient had recurrence of endocarditis 6.7 months after the operation and required repeated homograft aortic root replacement. Conclusion: Reoperative aortic root replacement remains associated with a high postoperative mortality. The need to perform unplanned coronary artery bypass grafting during reoperative aortic root replacement is a major risk factor for hospital death. The optimal technique for coronary reconstruction in this setting remains to be debated. From the Departments of Chirurgie Thoracique et Cardiovasculaire a and Réanimation Médicale,

Background. Improved techniques in cerebral and myocardial protection have made replacement of the chronically aneurysmal ascending thoracic aorta a safe and effective procedure. We hypothesized that patients with severe ascending or aortic arch atherosclerosis were at greater risk for operative complications during ascending aortic replacement because of the diffuse nature of their atherosclerotic process. Methods. We retrospectively analyzed the records of 17 patients who received ascending aortic replacement during elective coronary artery bypass grafting (CABG) because of the intraoperative finding of severe atherosclerosis. All 17 patients underwent tube graft replacement of the ascending aorta under hypothermic circulatory arrest and retrograde cerebral perfusion before coronary artery bypass grafting. The outcomes for these patients were compared with those of a control group of 89 consecutive patients who underwent replacement for ascending thoracic aortic aneurysm. Results. The hospital mortality rate for replacement of the ascending thoracic aorta for severe atherosclerosis was 23.5% (4/17) versus 2.25% (2 of 89) for the control group (p ‫؍‬ 0.006). The incidence of cerebrovascular accident in the atherosclerotic group was 17.6% (3/17) and 3.37% (3/89) for the control group (p ‫؍‬ 0.051). Nine of 17 atherosclerotic patients (52.9%) had operative morbidity. Only 20.2% (18 of 89) of the control patients had nonfatal postoperative complications. Conclusions. The severely atherosclerotic ascending aorta is a marker of diffuse atherosclerosis. Despite improved techniques of myocardial and cerebral protection, we have been unable to duplicate our success with ascending thoracic aneurysm repair. Preoperative screening of the ascending aorta by chest computed tomography may be appropriate in select high-risk patients to determine operability.

Objective: Cardiac surgery is associated with intraoperative cerebral emboli, which can result in postoperative neurological complications. A new ultrasonic transducer (EmBlocker TM) can be positioned on the ascending aorta and activation of the EmBlocker TM is expected to divert emboli to the descending aorta, thereby decreasing emboli in the cerebral arteries. In this preliminary animal study, safety and efficiency of this technology were examined. Methods: In 14 pigs (AE70 kg), a median sternotomy was performed and the EmBlocker TM was positioned on the aorta ascendens at the level of the bifurcation of the aorta and the innominate artery. In one animal temperature measurements were performed. During these measurements, the EmBlocker TM was activated for four periods of 120 s of high power (1.5 W/cm 2) and for four periods of 600 s of low power (0.5 W/cm 2). In the safety study (n = 6), the EmBlocker TM was activated twice the expected clinical duration (eight periods of 120 s of high power and, subsequently, one period of 20 min of low power). Tissue samples (control and sonicated) were collected after 1 week for histopathological evaluation (aorta, trachea, esophagus, vagus nerves). In the efficiency study (n = 7), extracorporeal circulation was installed. Emboli (air and solid (1200, size 500 mm-750 mm)) were introduced in the proximal ascending aorta and the EmBlocker TM was alternately activated with high power for solid emboli injections and low power for air emboli injections. Transcranial Doppler (TCD) was used to analyse middle cerebral artery blood flow for occurrence of embolic signals, which were manually counted offline. Results: Histopathology revealed no difference between control and sonicated tissue. There is a rise in temperature during EmBlocker TM activation, but in all measured tissues it was within limits; less then 42 8C for 2 min in the aorta wall directly under the EmBlocker TM. Use of the EmBlocker TM significantly reduced emboli in the cerebral arteries in an animal model; air emboli with 65% (left) and 69% (right) and solid emboli with 49% (left) and 50% (right). Conclusions: The new ultrasound technology can safely be applied and is capable of reducing emboli in the cerebral arteries during extracorporeal circulation. Use of the EmBlocker TM in cardiac surgery bears the potential to lower the risk of postoperative neurological complications. Clinical feasibility studies are in progress.

The intracellular bacterium Chlamydophila (“Chlamydia”) pneumoniae is a pathogen for several respiratory diseases and may be a factor in the pathogenesis of chronic diseases of aging including atherosclerosis and Alzheimer's disease. We assessed whether aging is coupled with increased burden of infection in BALB/c mice after intranasal infection by C. pneumoniae. Six- and twenty-month-old BALB/c mice were infected intranasally with 5 × 104 inclusion forming units (IFU) or 5 × 105 IFU of C. pneumoniae. Lung, brain, and heart tissue were analyzed for infectious C. pneumoniae and for Chlamydophila antigen by immunohistochemistry. At both doses, aging was associated with a decreased proportion of animals that cleared infection from the lung and greater burden of infectious organism within the lung. We observed dose-dependent spread to the heart/ascending aorta in animals infected with C. pneumoniae. In mice given 5 × 104 IFU, spread to the heart by day 14 was only observed in old mi...

The aim was to review our experience with the surgical repair of the anomalous origin of the right pulmonary artery (AORPA) from the aorta. Materials and Method: Between January 1991 and March 2001, five patients with AORPA underwent surgical correction. One patient presented isolated AOPA from the aorta. Implantation of the anomalous PA to the main PA trunk was performed by (1) direct anatomosis employing an autologous pericardial patch in two patients; (2) using an aortic flap in two patients with AORPA; and (3) using an aortic and pulmonary flaps in another patient. The mean follow-up time was 27 months. Results: One patient died due to progressive heart failure unresponsive to inotropic support. Early postoperative pulmonary hypertension crisis was identified in patient 4, that was managed by intravenous prostacyclin. The same patient necessitated mechanical ventilation for 11 days. The mean residual gradient for all survivors was 9.5 ± 4 mmHg. The postoperative Tc-99 m scintigraphy demonstrated 72 ± 4.5(%) lung perfusion. At follow-up the survival was 100%. None of the followed patients required reoperation. Conclusion: The AORPA from the aorta is a rare but important entity, necessitating a scrupulous preoperative and intraoperative evaluation. The techniques employing autologous tissues for enlarging and lengthening the AORPA seem to be associated with better results in terms of postoperative restenosis

The Pediatric Heart Network randomized trial of atenolol versus losartan in the Marfan syndrome showed no treatment differences in the rates of aortic-root growth or clinical outcomes. In this report we present treatment effects on aortic stiffness and determine whether baseline aortic stiffness predicts aortic-root growth and clinical outcomes. Echocardiograms at 0, 6, 12, 24, and 36 months from 608 subjects (6 months to 25 years) who met original Ghent criteria and had a maximum aortic-root z-score (ARz) >3 were centrally reviewed. Stiffness index (SI) and elastic modulus (EM) were calculated for aortic root and ascending aorta. Data were analyzed using multivariable mixed effects modeling and Cox regression. Heart rate-corrected aortic-root SI over 3 years decreased with atenolol but did not change with losartan (-0.298 ± 0.139 vs 0.141 ± 0.139/year, p = 0.01). In the entire cohort, above-median aortic-root SI (>9.1) and EM (>618 mm Hg) predicted a smaller annual decreas...

Background: Heart failure is a common and often fatal disease. Numerous animal models are used to study its aetiology, progression and treatment. This article aims to demonstrate two minimally invasive models of congestive heart failure in a rabbit model and a precise method to assess cardiac performance. Methods: Fifty New Zealand White rabbits underwent cervicotomy incision and were then divided into three groups. Aortic regurgitation (AR group) was induced in 17 animals by catheter lesion through the right carotid artery, proximal aortic constriction (AC group) was created in 17 animals by metallic clip placement in the ascending aorta through a neck incision, while 16 animals served as controls (CO group). Eight weeks later, myocardial function and contractility indices were assessed by sonomicrometry crystals. Hearts were then collected for morphometric measurements and left ventricular tissues were subjected to immunohistochemical analysis of fibrosis, necrosis and apoptosis. Statistical analysis was by analysis of variance (ANOVA) with a Dunnett's post hoc test or by Kruskal-Wallis test with Dunn's post hoc test as appropriate, with significance at p 0.05. Results: The model of aortic regurgitation indicated early stages of heart failure by volume overload with increased end-diastolic and end-systolic volumes, stroke volume, cardiac output and pressure-volume loop areas. The elastance was higher in the control group compared with that in the AC and AR groups (131.00 AE 51.27 vs 88.77 AE 40.11 vs 75.29 AE 50.70; p = 0.01). The preload recruitable stroke work was higher in the control group compared with that in the AC and AR groups (47.70 AE 14.19 vs 33.87 AE 7.46 vs 38.58 AE 9.45; p = 0.01). Aortic constriction produced left ventricular concentric hypertrophy. Fibrosis appeared in both heart failure models and was elevated by aortic constriction when compared with that in controls. Necrosis and apoptosis indices were very low in all the groups. Clinical signs of congestive heart failure were not present. Conclusions: The two heart failure models we describe were relatively simple to create and maintain, minimally invasive, accurate, inexpensive and, importantly, had a low mortality rate. These models rapidly induced deterioration of contractility indices and onset of fibrosis, the hallmarks of early myocardial dysfunction associated with heart failure. Sonomicrometry assessments were able to detect early contractility changes prior to clinical signs.

We present a series of 130 consecutive patients operated for aortic valve replacement (AVR) using the standard MIRA prosthesis between January 1999 and March 2001. Most of the patients were male (sex ratio 2) with a mean age of 61.5 ^ 9.5 years. The prosthesis was implanted using the continuous suture technique. The mean diameter of the implanted prostheses was 23 mm. This series was composed of 66 % of isolated AVR. The associated operative procedures were as follows: coronary artery bypass grafting 23%, replacement of the ascending aorta 6%, replacement of the mitral valves 8 % and mitral valvuloplasty 3%. A short-term follow-up was performed and echocardiography data at 6 ^ 2.1 months were collected. Operative mortality ð,30 days) was 2.32 % for the isolated AVR. No structural dysfunction, endocarditis or paraprosthetic leakage were observed. Postoperative ultrasound echography at 6 months revealed a transpros-thetic gradient of 14.8 ^ 4.2 mmHg for the mean prosthesis diameter of...

Background. It is believed that, compared with stented valves, stentless bioprostheses at the aortic position offer a larger orifice area.Methods. During the past 45 months, we have implanted 211 various types of aortic prostheses in our clinic. In the subcoronary position, we have used the Medtronic Freestyle, Toronto SPV, and Cryolife O’Brien prostheses, and as an aortic root replacement, the

Aim: To report palliative embolization of a false aneurysm over the distal suture line of an ascending aorta graft replacement. Material and Method: A 78-year-old male patient was admitted for increasing bleeding of a chronic Manubrium ulceration, 20 months after coronary artery bypass ...

Objective: The purposes of this study were to evaluate the histologic characteristics of the aortic wall and the risk factors related to histopathology and aortic dilatation in patients undergoing intracardiac repair of tetralogy of Fallot. Methods: Operatively excised full-thickness aortic wall tissue from 98 consecutive patients undergoing intracardiac repair of tetralogy of Fallot aged 6 months to 47 years (mean 104.5 Ϯ 102.8 months; median 72 months) were studied by light microscopy. The receiver operating characteristic curve analysis was done to quantify the diagnostic accuracy of loss of lamellar counts and multiple logistic regression models. Results: Twenty-five (25.5%) aortic tissue specimens were indicated as histologically normal and were used as normal controls. The incidence of elastic fragmentation, increased ground substance, medionecrosis, smooth muscle disarray, and fibrosis was 74.5%, 54%, 39.8%, 26.5%, and 57.1%, respectively. A lamellar count of less than 60 was associated with a sensitivity of 80% and a specificity of 87.67%. Area under the receiver operating characteristic curve indicated that 93.37% (standard error Ϯ 0.039) of the time the value of lamellar count was lower for the abnormal histopathology group than for the normal group (P Ͻ .001). The risk of aortic dilatation was 15.97 times higher in patients with histopathologically abnormal aorta. Conclusions: The majority of aortic media of the ascending aorta in cyanotic tetralogy of Fallot indicates significant loss of lamellar units and pre-existing intrinsic aortopathy. The changes are present since infancy and are more pronounced in older patients subjected to long-standing cyanosis and volume overload and may account for or may coexist with the higher incidence of aortic dilatation encountered in these patients.

A pseudoaneurysm of the ascending aorta is an unusual and potentially fatal complication after aortic surgical operations. TEE and CT scan are the investigations of choice. Surgical treatment is mandatory. We describe the successful management of a pseudoaneurysm of the ascending aorta, with aorto-sternal-cutaneous fistula requiring right axillary and femoral artery cannulation with Remote Access Perfusion(R) aortic cannula (Estech(R), California, USA). Behaving like this we avoid hypotermic circulatory arrest, provide safe reentry and prevent an impending rupture.

Objective: Prolonged bleeding during cardiovascular surgery presents a risk for the patient and increases the time and cost of surgery. TachoSil W is a ready-to-use haemostatic agent that consists of an equine collagen patch coated with human fibrinogen and thrombin. This trial evaluated the efficacy and safety (30 days post-surgery) of TachoSil surgical patch compared with standard haemostatic fleece for the control of bleeding in patients undergoing cardiovascular surgery. Methods: Patients scheduled for elective surgery on the heart, ascending aorta or aortic arch requiring cardiopulmonary bypass were eligible for this open-label multicentre trial. After primary haemostatic measures, patients were randomised to TachoSil or conventional haemostatic fleece if an area of persisting haemorrhage was identified (target area). After the application of trial treatment, haemostasis was evaluated at 3 min (primary endpoint). If haemostasis was not achieved, trial treatment was reapplied and haemostasis assessed at 6 min (secondary endpoint). Results: A total of 120 patients were randomised and 119 received trial treatment (TachoSil, n = 59; standard treatment, n = 60). Twenty-six percent of patients were female and the mean age was 67 years (range: 23-86 years). Baseline characteristics were similar in both the groups. Bleeding occurred mainly from the aorta (56%), right ventricle (16%) or right atrium (13%), more often from a vessel (68%) than tissue (32%), and was assessed to be arterial in 74% of cases. TachoSil was significantly superior to standard haemostatic fleece in controlling bleeding after insufficient primary haemostasis, with 75% (95% confidence interval (CI): 0.64-0.86) of the TachoSil group achieving haemostasis at 3 min compared with only 33% (95% CI: 0.21-0.45) of the standard treatment group (p < 0.0001). This difference persisted at 6 min, with 95% of patients achieving haemostasis in the TachoSil group compared with 72% in the standard treatment group (p = 0.0006). Three (5%) TachoSil patients compared with 17 (28%) standard treatment patients failed to achieve haemostasis at 6 min and received rescue treatment. TachoSil was well tolerated with adverse events generally similar in the two treatment groups. Conclusions: TachoSil was significantly superior to standard haemostatic fleece material in obtaining effective and fast intra-operative haemostasis in cardiovascular surgical procedures. TachoSil was safe and well tolerated.

Objective To investigate early haemodynamic changes after transfemoral transcatheter aortic valve implantation (TAVI) and the relationship with myocardial injury and neurohormonal activation. Design Single-centre prospective observational study. Setting Tertiary cardiac centre. Patients 42 patients undergoing transfemoral TAVI were included in this study. Main outcome measures Haemodynamic measurements and echocardiography-derived indices characterising myocardial function were recorded at baseline, 6 and 24 h postprocedure. Postprocedural myocardial injury was quantified using serum troponin I and CK-MB levels. In addition, biomarkers of myocardial dysfunction/heart failure and neurohormonal activation were measured. Results 6 h Post-TAVI there was a significant deterioration in both systolic and diastolic function as measured by dP/dt max /EDV, myocardial performance index and mean E/e' index. Recovery of myocardial function was observed at 24 h. These haemodynamic changes were associated with a significant increase in both troponin I (0.0760.01 vs 1.5960.21 mg/l, p<0.005) and CK-MB (1.9960.19 vs 6.8260.7 ng/ml, p<0.005). There was a positive correlation among myocardial injury and NT-BNP (r¼0.34, p<0.0005), aldosterone (r¼0.56, p<0.0001) and ST2 levels (r¼0.21, p<0.05). Conclusions This is the first study to demonstrate that procedurally successful TF-TAVI results in a transient depression of both systolic and diastolic left ventricular function within the first 24 postoperative hours, despite impressive relief of previously severe, chronic pressure overload. The rise in the markers of myocardial damage suggests that this may be due to periprocedural myocardial injury. Complete recovery of contractility is generally observed after 24 h.

There is a growing need for patient-specific cardiac models for intervention planning, outcome prediction or assessment of cardiac disease progression. However, most of the recent work in cardiovascular simulation relies on generic heart models built from at most one cardiac phase with simplified motion, driven by fluid dynamics equations. We propose to advance the state-of-the-art by exploiting a comprehensive, patient-specific left heart model extracted from 4D Computed Tomography (CT) data. Explicit physiological constrains are captured in the modeling of the left ventricle (including outflow tract), left atrium (including pulmonary veins), mitral valve, and aortic valve (including ascending aorta). By using this patient-specific model as an input to a 3D Navier-Stokes solver we derive realistic hemodynamics, constrained by the local anatomy, along the entire heart cycle. We present a differential assessment of the flow dynamics corresponding to specific heart conditions. The simulation results shed light upon the functional differences between one normal and two diseased hearts-one with a dilated aortic root and one with a bicuspid aortic valve.

6. Morykwas MJ, Faler BJ, Pearce DJ, Argenta LC. Effects of varying levels of subatmospheric pressure on the rate of granulation tissue formation in experimental wounds in swine. Ann Plast Surg 2001;47:547-51. 7. Sjogren J, Gustafsson R, Wackenfors A, Malmsjo M, Algotsson L, Ingemansson R. Effects of vacuum-assisted closure on central hemodynamics in sternotomy wound model. Interact

Subtle or discrete (class 3 in the classification of the European Society of Cardiology) dissection is the most neglected variant of aortic dissection. This study was conducted to define the clinical manifestations, diagnostic findings, and outcomes of subtle or discrete dissection involving the ascending aorta. The clinical and surgical records, preoperative studies, and outcomes of 109 consecutive patients with ascending aortic dissection observed from 1995 to 2005 were reviewed. Eight patients (7.3%) had discrete dissection. Five patients presented with acute anterior chest pain, 2 with abdominal pain, and 4 with syncope. The mean diameter of the ascending aorta was 44 ؎ 8.8 mm. The intimal tears were located in all patients on the posterior aspect of the ascending aorta 1 to 40 mm above the left coronary ostium; its length varied from 2.8 to 12.3 mm. Preoperative aortography, magnetic resonance imaging, and computed tomography could not identify the discrete intimal tears. Transesophageal echocardiography provided unique diagnostic information on (1) subtle intimal discontinuity, (2) circumscribed intramural hematoma, and (3) discrete pericardial fluid around the dissected aorta. Six patients underwent emergency surgery on the basis of echocardiographic findings, and they were all alive at follow-up. Compared with patients with classic aortic dissection, those with discrete dissection had lower operative mortality (0% vs 26%, p ‫؍‬ 0.11), shorter hospital stay (7.2 ؎ 2.8 vs 21 ؎ 19 days, p ‫؍‬ 0.01), and less frequent need for blood transfusions (0% vs 39%, p ‫؍‬ 0.02). In conclusion, elevated clinical suspicion and detailed transesophageal echocardiographic examination are important for the early identification of discrete aortic dissection, leading to prompt surgery, shorter hospital stays, and better outcomes.

Background. Improved techniques in cerebral and myocardial protection have made replacement of the chronically aneurysmal ascending thoracic aorta a safe and effective procedure. We hypothesized that patients with severe ascending or aortic arch atherosclerosis were at greater risk for operative complications during ascending aortic replacement because of the diffuse nature of their atherosclerotic process. Methods. We retrospectively analyzed the records of 17 patients who received ascending aortic replacement during elective coronary artery bypass grafting (CABG) because of the intraoperative finding of severe atherosclerosis. All 17 patients underwent tube graft replacement of the ascending aorta under hypothermic circulatory arrest and retrograde cerebral perfusion before coronary artery bypass grafting. The outcomes for these patients were compared with those of a control group of 89 consecutive patients who underwent replacement for ascending thoracic aortic aneurysm. Results. The hospital mortality rate for replacement of the ascending thoracic aorta for severe atherosclerosis was 23.5% (4/17) versus 2.25% (2 of 89) for the control group (p ‫؍‬ 0.006). The incidence of cerebrovascular accident in the atherosclerotic group was 17.6% (3/17) and 3.37% (3/89) for the control group (p ‫؍‬ 0.051). Nine of 17 atherosclerotic patients (52.9%) had operative morbidity. Only 20.2% (18 of 89) of the control patients had nonfatal postoperative complications. Conclusions. The severely atherosclerotic ascending aorta is a marker of diffuse atherosclerosis. Despite improved techniques of myocardial and cerebral protection, we have been unable to duplicate our success with ascending thoracic aneurysm repair. Preoperative screening of the ascending aorta by chest computed tomography may be appropriate in select high-risk patients to determine operability.

The goal of this study was to test the hypothesis that the absence of direct flow communication through intimal tear in aortic intramural hematoma (AIH) involving the ascending aorta has different clinical impact on clinical course compared with typical aortic dissection (AD). BACKGROUND Although emergent surgical repair has been applied for patients with proximal AIH as if it was typical AD, the natural history of proximal AIH is not known clearly yet. METHODS Direct comparison of the clinical data of 81 patients with proximal AD and 24 patients with AIH was performed retrospectively. RESULTS Patients with AIH were older (67 Ϯ 10 vs. 50 Ϯ 13, p ϭ 0.001), and female gender was more predominant in AIH (19/24 vs. 29/81, p ϭ 0.001). The development of mediastinal hemorrhage and pericardial and pleural effusion was more frequent in patients with AIH than it was in patients with AD. Although medical treatment was more frequently selected in the AIH group (75% vs. 15%, p ϭ 0.001) due to old age and other associated medical diseases, the mortality rate with medical treatment was much lower in patients with AIH than it was in patients with AD (6% vs. 58%, p ϭ 0.003). In follow-up imaging studies of 13 patients who survived AIH without surgical repair, seven patients showed complete resolution. Typical AD developed in three patients, and the other three patients showed focal AD only in the descending aorta. The two-year survival rate did not show significant difference (84% Ϯ 6% in AIH vs. 76% Ϯ 17% in AD, p ϭ 0.47). CONCLUSIONS Absence of continuous flow communication can explain a more favorable clinical course of AIH than for AD, and medical treatment with frequent imaging follow-up and timed elective surgery in cases with complications can be a rational option for patients with proximal AIH.

Background: Open graft replacement of the ascending aorta is the current treatment of choice for Stanford acute type A dissections. However, approximately 20% of patients are deemed unfit for open surgery. To determine if an endovascular option exists for this latter group of patients, we performed a computed tomography (CT)-based feasibility study. Methods: A cohort of consecutive patients presenting to the cardiovascular care unit (CVCU) for an acute Stanford type A aortic dissection between 2006 and 2009 was retrospectively analysed. Inclusion criterion was a high-quality preoperative angio-CT scan that could be analysed on a three-dimensional (3D) workstation. Numerous anatomical parameters of the dissection were studied, including the location and the length of the primary proximal entry tear. Finally, we determined which of the patients would have been potential candidates for an endovascular repair (stentgraft implantation). Results: A total of 102 patients were included in our study. The median distance of the primary entry tear to the closest coronary artery was 23 mm (range 0e128). The median true lumen and true þ false lumen (total) diameters at the level of the entry tear was 38 mm (range 22 e78) and 46 mm (range 28e93), respectively. The median length of the ascending aorta was 84 mm (range 40e130). An endovascular repair with a tubular stentgraft was deemed feasible in 37 patients. An additional eight patients were also candidates for a tubular endovascular repair but would have required a carotidecarotid cross over bypass. Finally, an arch-branched stentgraft could have been used in 13 patients to exclude an entry tear located in the arch.

Objective: Controversy still exists about averting expenditure of health care resources on the growing elderly population. This study evaluates clinical outcome of patients aged 75 years and older operated upon for acute type A aortic dissection. Methods: Between January 1990 and April 2004, of 247 patients undergoing emergency operation for acute type A aortic dissection at our Institution, 40 patients (16%) were aged 75 years and older (mean 78 AE 3 years, range 75-88 years) and represent the study population. On admission, 9 (22.5%) had cardiogenic shock/ hypotension, 20 (50%) cardiac tamponade, 14 (35%) kidney failure, 11 (27.5%) limb ischemia, 3 (7.5%) neurologic deficit, and 1 (2.5%) myocardial ischemia. Surgical procedures included isolated replacement of the ascending aorta in 34 patients (85%), associated with total root replacement in 5 (12.5%), and with aortic valve replacement in 1 (2.5%). Eleven patients (27.5%) underwent aortic arch replacement (hemiarch: n = 8, 20%; total arch: n = 3, 7.5%). Results: In-hospital mortality was 30% (12 patients). Mortality tended to be higher (8/21, 38% vs 4/19, 21%; p = NS) for patients presenting with any one of the following complications: tamponade, shock, brain and/or myocardial, renal, limb malperfusion. Actuarial survival at 1, 5, and 7 years was 93 AE 5%, 80 AE 8%, and 80 AE 8%, respectively, and freedom from reoperation 97 AE 2%, 97 AE 2%, and 97 AE 2%, respectively. Actuarial event-free rates were 94 AE 3%, 90 AE 5%, and 90 AE 5%. Seventy-four percent of survivors are in NYHA FC I, and quality of life test (RAND SF-36) revealed a generalized perception of independency and well-being, comparable to an age-matched population. Conclusions: Overall results for emergency repair of acute type A aortic dissection in the elderly justify intervention, particularly in uncomplicated cases. Expeditious referral and intervention by lowering pre-operative dissection-related complications and comorbidities might help to improve results. Survivors show functional status and quality of life similar to contemporary individuals.

Background. Improved techniques in cerebral and myocardial protection have made replacement of the chronically aneurysmal ascending thoracic aorta a safe and effective procedure. We hypothesized that patients with severe ascending or aortic arch atherosclerosis were at greater risk for operative complications during ascending aortic replacement because of the diffuse nature of their atherosclerotic process. Methods. We retrospectively analyzed the records of 17 patients who received ascending aortic replacement during elective coronary artery bypass grafting (CABG) because of the intraoperative finding of severe atherosclerosis. All 17 patients underwent tube graft replacement of the ascending aorta under hypothermic circulatory arrest and retrograde cerebral perfusion before coronary artery bypass grafting. The outcomes for these patients were compared with those of a control group of 89 consecutive patients who underwent replacement for ascending thoracic aortic aneurysm. Results. The hospital mortality rate for replacement of the ascending thoracic aorta for severe atherosclerosis was 23.5% (4/17) versus 2.25% (2 of 89) for the control group (p ‫؍‬ 0.006). The incidence of cerebrovascular accident in the atherosclerotic group was 17.6% (3/17) and 3.37% (3/89) for the control group (p ‫؍‬ 0.051). Nine of 17 atherosclerotic patients (52.9%) had operative morbidity. Only 20.2% (18 of 89) of the control patients had nonfatal postoperative complications. Conclusions. The severely atherosclerotic ascending aorta is a marker of diffuse atherosclerosis. Despite improved techniques of myocardial and cerebral protection, we have been unable to duplicate our success with ascending thoracic aneurysm repair. Preoperative screening of the ascending aorta by chest computed tomography may be appropriate in select high-risk patients to determine operability.

We sought to clarify the possible role of elastic properties of the ascending aorta in the development of cardiac disease associated with hypothyroidism (HT). A total of 37 patients with HT (age: 39.3 +/- 8.9 years) and 29 control subjects were studied. Ascending Aortic (Ao) diameter, Ao elastic indexes, strain (AoST), distensibility (AoD), stiffness index (AoSI), and pressure strain modulus were calculated from the echocardiographically derived Ao diameters. Myocardial performance index (MPI), E/A ratio, isovolumetric relaxation time (IVRT), deceleration time (DT) were measured by Doppler echocardiography to assess diastolic LV function. Patients were treated with levothyroxine and followed-up for 6 months. Thyroid function tests and echocardiographic measurements were repeated at the end of the study. AoD (cm2 dyn(-1) 10(-3)) and AoST (%) were significantly lower (3.8 vs. 6.1; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001, 7.4 vs. 12.6, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001; respectively), whereas AoSI was higher in HT patients (6.2 vs. 3.3; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). After treatment, AoD and AoST were increased (5.7; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001 and 11.8; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001; respectively), whereas AoSI was decreased significantly (3.7; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Also, early/late mitral peak velocity ratio (Emax/Amax) was significantly lower in HT patients (1.19 vs 1.34; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01), whereas MPI was higher (0.52 vs. 0.42; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). MPI showed a strong correlation with aortic root indexes [AoST (r =-0.61/P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001); AoD, (r =-0.57/P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.002); AoSI, (r = 0.53/P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.005)] in the HT group. After 6 months of therapy, MPI significantly decreased P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) and E/A ratios were normalized (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Ao root functions have an important role on diastolic LV function. Levothyroxine replacement therapy can reverse all of these adverse effects of HT.

Background. Replacement of the ascending aorta with a prosthetic graft is the preferred surgical procedure for an ascending aortic aneurysm. The choice of external wrapping of the aorta is a simple, fast, and effective method for moderately sized ascending aortic aneurysms with concomitant operations. In this study, we present the midterm results of 62 patients undergoing reduction aortoplasty with external wrapping and different cardiac procedures. Methods. The study group consisted of 48 male and 14 female patients with a mean age of 59.3 ؎ 6.0 years. Measurement of the ascending aorta diameters was obtained at three points: before surgery, during the early postoperative period, and during the follow-up. The mean preoperative aortic diameter was 52.7 ؎ 0.5 mm. In all patients, the ascending aortic aneurysm was repaired by reduction aortoplasty with external wrapping. Results. Mean follow-up time was 39.6 ؎ 18.0 months. There was only one mortality (1.6%) as a result of septic multiple-organ failure and no major surgical complications in the 30-day postoperative period. Reduction aortoplasty of the ascending aorta with external wrapping resulted in a significant reduction of the ascending aorta in all patients (p ‫؍‬ 0.000). There was an increase in the mean aortic diameter during the follow-up period (p ‫؍‬ 0.000). Although this increase was statistically significant, all measurements of the follow-up period were still within normal range. Conclusions. External wrapping of the aorta offers excellent results with very low mortality and morbidity, and it can be regarded as a safe and effective method for the treatment of ascending aortic aneurysm in selected patients. However, the patients should be carefully monitored for redilatation after the procedure.

Background: Bicuspid aortic valve (BAV) represents the most common cardiac congenital malformation in the adult age. It is frequently associated with dilatation, aneurysm and dissection of the ascending aorta. The purpose of the following study was to evaluate in patients with BAV: 1) the elastic properties of the ascending aorta, 2) the mechanical function of the left ventricle and 3) stiffness, elasticity and strain of the epi-aortic vessels wall. Methods: Forty BAV patients (28 M/12 F; age 20.9 ± 4.7 years; range 17-26) with no or mild valvular impairment were recruited with 40 control subjects (25 M/15 F; age 23.4 ± 3.4 years; range 15-31) matched for age, gender and body surface area (BSA). Aortic strain, aortic distensibility (AoDIS) and aortic stiffness index (AoSI) were derived. Left ventricular strain was acquired. Elastic properties of epi-aortic vessels were evaluated. Results: BAVs vs. controls had increased systolic and diastolic aortic diameters (p b 0.001). Aortic strain (%) was lower in BAVs than in controls (8.3 ± 3.6 vs. 11.2 ± 2.6; p b 0.001) as well as AoDIS (10 − 6 cm 2 dyn − 1) (6.5 ± 2.8 vs. 8.8 ± 2.9; p = 0.002), while AoSI was greater in BAVs (6.4 ± 3.5 vs. 3.9 ± 1.2; p b 0.001). Both AoDIS and aortic strain were related to aortic size in BAVs and controls. Left ventricular longitudinal (p = 0.01), circumferential (p = 0.01) and radial (p b 0.001) strain (%) were lower in BAVs. No significant differences were found in elastic properties of epi-aortic vessels. Conclusions: Bicuspid aortic valve is associated with an increased aortic stiffness and with a reduction of the aortic and left ventricular deformation properties. Epi-aortic vessels do not seem to be interested by the disease. The use of an echocardiographic method that can estimate the degree of aortic and left ventricular remodeling can provide great benefits in the selection of patients with BAV to be treated and in determining the time for beginning drug therapy.

The authors report an original case using cerebral retrograde perfusion alternating with carotid artery anterograde perfusion, during the surgical treatment of acute ascending aorta dissection. The patient was discharged on the 32nd post-operative day in a clinically controlled condition. The Mini Mental State Examination was applied after 30 days and showed normal cerebral cognitive activity. The authors believe that this method can give a protective effect to the brain during procedures involving aortic dissection or aneurysms, after evaluating its use after a significant series of cases.

We have retrospectively evaluated our results after aortic root and ascending aorta reoperations to determine risk factors of early death and late mortality. Methods. From January 1986 to April 2002, 73 patients underwent "reoperative" procedures on the aortic root and the ascending aorta. The mean age was 56.1±13.4 years and males numbered 62 (84.9%). The most frequent indication for reoperation was degenerative aortic aneurysm (49.3%) followed by post-dissection aneurysm (11%). Aortic root replacement with composite valve graft was performed in 47 patients (64.4%) and with aortic homograft in 2 (2.7%). Nineteen patients (26%) underwent ascending aorta replacement with tubular graft, and 4 (5.5%) underwent tailoring aortoplasty of the ascending aorta. Results. The 30-day mortality rate was 16.4% (12 patients). Mortality following elective operations was 8%, and that following urgent or emergency operations was 34.8% (p=0.002). Late survival of hospital survivors at 1, 5 and 10 years was 93.8%, 77.7% and 37%, respectively. In the multivariate Cox regression analysis chronic renal failure (p=0.003) and urgent or emergency operation (p=0.018) were found to be independent predictors of late mortality. Conclusions. Reoperations on the ascending aorta can be accomplished with acceptable early mortality and satisfactory long-term results. More radical treatment of the aortic pathology at the initial operation may reduce the need for further reoperations. A careful follow-up is extremely important for detecting complications of the first operation or progression of the aortic pathology before an emergency operation, predictive of poorer early and late outcome, is needed.

Although aortic dissection is uncommon in young women, it occurs more frequently during pregnancy, especially in the last trimester. Predisposing factors for aortic dissection are Marfan syndrome and other collagen diseases, chronic hypertension, aortic coarctation and cocaine abuse.We report a case of acute aortic dissection in a woman in the 33rd week of pregnancy with Marfan syndrome. After cesarean section,

A case is reported of a 30-year-old patient with an intrapericardial tumour with heart failure. After the diagnostic protocol, surgery was performed initially without extra-corporeal circulation (ECC). Due to the location, size and to the large connection with the most important vascular structures, the ascending aorta ruptured accidentally during resection and was replaced after using ECC in emergency. The postsurgical course was regular and the tumour was identi®ed histologically as a ®broma.

Background. Simultaneous measurement of ascending aorta and radial artery pressure shows that mean and diastolic pressures (DP) are in close agreement in normotensive adults, while systolic pressures (SP) are not. However, in the aortic pressure wave, a second systolic peak appears with increasing age and increases to represent the SP by age 32 yr, while in the radial artery, a second systolic de¯ection appears by age 40 yr. We suggest that the second radial systolic wave, sometimes seen during radial arterial pressure monitoring in older hypertensives, represents the aortic SP. We set out to evaluate whether the aortic and radial second systolic peaks agree, and since doubts exist about the agreement between aortic and radial DP in elderly hypertensive patients, we also assessed that relationship. Methods. We compared simultaneously recorded radial and aortic pressures from 21 anaesthetized adult patients using identical¯uid-®lled pressure measuring systems. Conclusions. The second radial pressure peak agreed with that in the aorta within a mean of 0.6 (SD 1.5) mm Hg. The difference between DP in the aorta and radial artery was ±1.4 (2) mm Hg. The radial±aortic SP and pulse pressure differences were 5.9 (7.6) and 7.3 (7.6) mm Hg, respectively. These results con®rm that when the radial artery pressure wave shows a ®rst and second, or only a second systolic shoulder/peak (on the right side of the pressure wave), the second represents the maximal ascending aortic SP, and that the radial and aortic DP are equivalent, even in older hypertensive patients.

We report a patient with type B aortic dissection which ruptured into the right hemithorax to call attention to this infrequent presentation and to accentuate the value of computed tomography angiography (CTA) with multiplanar reformatting in localizing the dissection and demonstrating the rupture site. CTA in combination with 2- and 3-dimensional reformatting is crucial for surgical planning because of the low specificity of transesophageal echocardiography in the ascending aorta.

Objectives: A noninvasive continuous cardiac output system (NICO) has been developed recently. NICO uses a ratio of the change in the end-tidal carbon dioxide partial pressure and carbon dioxide elimination in response to a brief period of partial rebreathing to measure CO. The aim of this study was to compare the agreement among NICO, bolus (TDCO), and continuous thermodilution (CCO), with transittime flowmetry of the ascending aorta using an ultrasonic flow probe (UFP) before and after cardiopulmonary bypass (CPB). Design: Prospective, observational human study. Setting: Veterans Affairs Medical Center Hospital. Participants: Sixty-eight patients. Methods: Matched sets of CO measurements between NICO, TDCO, CCO, and UFP were collected in 68 patients undergoing elective CABG at specific time periods before and after separation from CPB. After anesthetic induction, all patients had an NICO sensor attached between the endotracheal tube and the breathing circuit, a PAC floated into the pulmonary artery for TDCO and CCO monitoring, and a UFP positioned on the ascending aorta and used for the reference CO. Bland-Altman analysis was used to compare the agreement among the different methods. Measurements and Main Results: Bland-Altman analysis of CO measurements before CPB yielded a bias, precision, and percent error of 0.04 L/min ؎ 1.07 L/min (44.8%) for NICO, 0.18 L/min ؎ 1.01 L/min (41.7%) for TDCO, and 0.29 L/min ؎ 1.40 L/min (57.5%) for CCO compared with simultaneous UFP CO measurements, respectively. After separation from CPB (average 29 mins), bias, precision, and percent error were ؊0.46 L/min ؎ 1.06 L/min (37.3%) for NICO, 0.35 L/min ؎ 1.39 L/min (46.1%) for TDCO, and 0.36 L/min ؎ 1.96 L/min (64.7%) for CCO compared with UFP CO measurements, respectively. Conclusions: Before initiation of CPB, the accuracy for all 3 techniques was similar. After separation from CPB, the tendency was for NICO to underestimate CO and for TDCO and CCO to overestimate it. NICO offers an alternative to invasive CO measurement.

Objectives: A noninvasive continuous cardiac output system (NICO) has been developed recently. NICO uses a ratio of the change in the end-tidal carbon dioxide partial pressure and carbon dioxide elimination in response to a brief period of partial rebreathing to measure CO. The aim of this study was to compare the agreement among NICO, bolus (TDCO), and continuous thermodilution (CCO), with transittime flowmetry of the ascending aorta using an ultrasonic flow probe (UFP) before and after cardiopulmonary bypass (CPB). Design: Prospective, observational human study. Setting: Veterans Affairs Medical Center Hospital. Participants: Sixty-eight patients. Methods: Matched sets of CO measurements between NICO, TDCO, CCO, and UFP were collected in 68 patients undergoing elective CABG at specific time periods before and after separation from CPB. After anesthetic induction, all patients had an NICO sensor attached between the endotracheal tube and the breathing circuit, a PAC floated into the pulmonary artery for TDCO and CCO monitoring, and a UFP positioned on the ascending aorta and used for the reference CO. Bland-Altman analysis was used to compare the agreement among the different methods. Measurements and Main Results: Bland-Altman analysis of CO measurements before CPB yielded a bias, precision, and percent error of 0.04 L/min ؎ 1.07 L/min (44.8%) for NICO, 0.18 L/min ؎ 1.01 L/min (41.7%) for TDCO, and 0.29 L/min ؎ 1.40 L/min (57.5%) for CCO compared with simultaneous UFP CO measurements, respectively. After separation from CPB (average 29 mins), bias, precision, and percent error were ؊0.46 L/min ؎ 1.06 L/min (37.3%) for NICO, 0.35 L/min ؎ 1.39 L/min (46.1%) for TDCO, and 0.36 L/min ؎ 1.96 L/min (64.7%) for CCO compared with UFP CO measurements, respectively. Conclusions: Before initiation of CPB, the accuracy for all 3 techniques was similar. After separation from CPB, the tendency was for NICO to underestimate CO and for TDCO and CCO to overestimate it. NICO offers an alternative to invasive CO measurement.

Objective: The treatment of coronary single vessel disease under minimally invasive surgical conditions was followed by the treatment of coronary multivessel disease using a new technique. Methods: Using this technique 100 patients (80 male, 20 female, median age 61.0 ± 8.9 years, ranged from 39 to 82 years) with coronary single vessel disease, double vessel disease or multivessel disease were treated between November 1996 and December 1997. Via a small (6-9 cm) left lateral chest incision in the second or third intercostal space, the left internal thoracic mammary artery (LIMA) was harvested and access to the central portion of the heart including the ascending aorta was obtained. In parallel, saphenous vein segments were harvested. Arterial cannulation was instituted via the ascending aorta, thus avoiding retrograde flow. In all patients except three the LIMA was used for the left anterior descending artery (LAD). In addition vein grafts were used for revascularization of the other coronary arteries. All cardiac anastomoses were performed during cardioplegic arrest after external aortic cross clamping and antegrade application of cardioplegia. Results: No death or intraoperative complications were observed in this series. The median hospital stay was 6.0 ± 1.4 days (median ± SEM). Postoperative complications were reexplored for bleeding (n = 1), delayed wound healing (n = 2), wound infections (n = 4), lymphatic fistulas (n = 4), and a chest wall hernia (n = 1). Conclusions: This minimally invasive surgical technique presents a safe alternative to conventional coronary artery surgery avoiding sternotomy related complications and decreasing hospital stay and morbidity.

To develop a clinically applicable method of minimally invasive mitral valve replacement (MVR) with cardioplegia, and examine the ability of carbon dioxide (CO 2) to improve de-airing. Methods: MVR was performed via a 5× 3-cm right lateral minithoracotomy in eight greyhounds. Peripheral cardiopulmonary bypass and an ascending aortic balloon catheter (endoaortic clamp) were used for cardioplegia and aortic root venting. The endoaortic clamp was inflated in the ascending aorta under fluoroscopy and cardioplegic solution was infused. In four dogs, CO 2 at 2 l/min was used to displace air in the chest. A left atriotomy was made, the valve exposed and a mechanical valve implanted. After left atrial closure, retained intracardiac gas was aspirated from the aortic root and collected in a bubble-trap. The endoclamp was deflated and the animal weaned from bypass. Results: A satisfactory MVR was performed in all cases. The clamp time was 64913 min and all dogs were stable post-bypass. In the CO 2 group, intrathoracic CO 2 was maintained above 86% and 0.190.1 ml of gas was collected, compared to 1.39 0.8 ml in the non-CO 2 group (PB0.05). Conclusions: Femoro-femoral bypass and use of the endoaortic clamp allow a safe and efficacious MVR via a right minithoracotomy in the dog. A high intrathoracic CO 2 concentration reduces the amount of retained intracardiac gas.