Faculty Bibliography

The model of surgery first and always for Type A aortic dissections has continued to evolve. During the last three decades, various studies have demonstrated that in select patients, surgery should be delayed or avoided. This case series examines three cases in which patients were medically treated. Furthermore, we review the literature and when surgery should be delayed for acute Type A aortic dissections.

BACKGROUND:Current guidelines recommend a diameter of 5-5.5 cm as the threshold for surgery on the ascending aorta. However, a study from the International Registry of Acute Aortic Dissection showed that nearly 60% occurred at <5.5 cm (the 'aortic size paradox')--leading to a debate whether the size threshold should be lowered. However, the study showing dissection at small size had no knowledge of the population at risk. Herein, we aim to calculate the relative risk of aortic dissection at sizes<5.5 cm by analyzing both the number of occurring dissections (numerator) and the population at risk at each aortic size (denominator). METHODS:Using a publicly available database of 3,573 multiethnic subjects (46% male, mean age 60.7 years) from the general population, we plotted a distribution curve of ascending aortic size (by magnetic resonance imaging). The relative risk of aortic dissection was calculated by dividing the proportion of dissections occurring at each size (numerator) by the proportion of aortas of that same size in the general population (denominator). RESULTS:The mean ascending aortic diameter of the reference population was 3.2 cm (±0.4 cm). The largest diameter was 4.9 cm in women and 5.0 cm in men. The proportion of subjects with an aorta <3.5 cm was 79.2%, that of subjects with 3.5-3.9 cm was 18.0%, that of subjects with 4.0-4.4 cm was 2.6%, and that of subjects with ≥4.5 cm was 0.22%. The relative risk of dissection in those categories was found to be 0.055, 2.5, 4.9, and 346.8, respectively. Patients with an aorta≥4.5 cm were 6,305 times more likely to suffer aortic dissection than those with an aorta<3.5 cm. CONCLUSIONS:The normal aorta is deceptively small, most commonly <3.5 cm. The aortic size paradox is a byproduct of the very large number of patients in small size ranges. This study fully supports current recommendations for surgical intervention at 5-5.5 cm.

OBJECTIVE:Aortic stenosis is the most common valvular pathology in the elderly. Transcatheter aortic valve replacement has emerged as a safe and feasible alternative for high-risk patients. However, a significant number of patients are still not transcatheter aortic valve replacement candidates because of poor peripheral access and chest pathology. We report the use of alternative access options for such patients. METHODS:Seven patients who had poor peripheral access and chest pathology had transcatheter aortic valve replacement using alternative access techniques. Five patients had the valve delivered by direct cannulation of the aorta via a mini-sternotomy, and 1 patient had the valve delivered via a mini-right thoracotomy. In 1 patient, the right subclavian artery was cannulated. Intraprocedural and 30-day outcome data were analyzed. RESULTS:The mean age of patients was 85.00 ± 9.59 years, with a Society of Thoracic Surgeons score of 16.81% ± 6.87% and logistic European System for Cardiac Operative Risk Evaluation of 21.59% ± 8.46%. Procedural success was 100%. Procedural and 30-day mortality were zero. There were no access-related complications or neurologic events. Two patients had worsening renal function that did not require dialysis. All patients were discharged with a median hospital stay of 7 days. In our experience of 138 transapical or alternative access patients, 7 died (5%) and for 257 transfemoral patients, 1 died (0.4%). CONCLUSIONS:Despite the high surgical risk of the study population, these techniques had excellent outcome with no mortality and acceptable morbidity. With the use of currently available technologies, these approaches are promising and offer alternative options in patients with no access and prohibitive chest pathology or pulmonary function.

OBJECTIVE:Transcatheter aortic valve replacement (TAVR) is performed as a stand-alone procedure in patients that are not suitable for surgical aortic valve replacement. However, a significant proportion of patients with severe aortic stenosis have coexisting coronary artery disease (CAD). We report concomitant TAVR and percutaneous coronary intervention (PCI) as a single procedure in such patients. METHODS:Three patients with severe aortic stenosis and CAD that were high risk for conventional surgery had concomitant alternative approach TAVR and PCI performed. Two patients had PCI and stent placement immediately after the deployment of the transapical transcatheter aortic valve, and one patient had a coronary artery stent placed just prior to the deployment of the transaortic transcatheter aortic valve. RESULTS:Two male patients and one female (age range 68-91 years) had 100% procedural success with resolution of symptoms and zero residual stenosis. There were no complications related to neurologic events, worsening renal function, or myocardial infarction. In-hospital and 30-day mortality was zero. All three patients were discharged home with a median hospital stay of eight days. CONCLUSIONS:In our small series of patients presented we demonstrate that PCI and TAVR performed concurrently in the hybrid operating room is a feasible option in patients undergoing TAVR with coexisting CAD. Furthermore, we propose this single-stage approach in such high-risk patients as it decreases the number of procedures performed and may theoretically lower cost and hospital stay.

OBJECTIVES/OBJECTIVE:Pulmonary emboli (PE) can result in significant hemodynamic instability that requires urgent intervention; however, the management of peripheral emboli has been controversial. PATIENTS AND METHODS/METHODS:We present two patients in whom a right ventricular assist device (RVAD) was used in treating peripheral pulmonary embolism, applying the technique of pulmonary artery catheter-directed thrombolysis after resuscitation with an RVAD. RESULTS:The clot burden was not suitable for surgical embolectomy due to its peripheral locations. The patients' hemodynamic conditions improved with thrombolytic therapy and gradually were weaned off the RVAD. Follow-up scans showed near resolution of all PE. CONCLUSION/CONCLUSIONS:Catheter-directed thrombolysis with an RVAD as an adjunct should be considered in management of peripheral PE.

We describe a case of a 66-year-old woman who presented with upper extremity hypertension and a pseudocoarctation-like picture secondary to an aortic arch intimal sarcoma.

Risk factors for aortic dissection include: hypertension, connective tissue disorders, chronic obstructive pulmonary diseases, and severe physical and emotional stress. Although dissection associated with extreme physical activity has been reported, to date, there have been no reports in the literature to our knowledge of acute dissection and recurrence both occurring during sexual activity. We report a case of a 34-year-old male who underwent emergency replacement of his aortic root and hemiarch for an aortic dissection precipitated by sexual intercourse.