Publications by authors named "Christian D Etz"

111 Publications

Effect of cerebrospinal fluid pressure elevation on spinal cord perfusion during aortic cross-clamping with distal aortic perfusion.

Eur J Cardiothorac Surg 2021 Apr 11. Epub 2021 Apr 11.

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Objectives: Distal aortic perfusion (DaP) is a widely accepted protective adjunct facilitating early reinstitution of visceral perfusion during extended thoracic and thoraco-abdominal aortic repair. DaP has also been suggested to secure distal inflow to the paraspinal collateral network via the hypogastric arteries and thereby reduce the risk of spinal cord ischaemia. However, an increase in cerebrospinal fluid (CSF) pressure is frequently observed during thoracoabdominal aortic aneurysm repair. The aim of this study was to evaluate the effects of DaP on regional spinal cord blood flow (SCBF) during descending aortic cross-clamping and iatrogenic elevation of cerebrospinal fluid pressure.

Methods: Eight juvenile pigs underwent central cannulation for cardiopulmonary bypass according to our established experimental protocol followed by aortic cross-clamping of the descending thoracic and abdominal aorta-mimicking sequential aortic clamping-with the initiation of DaP. Thereafter, CSF pressure elevation was induced by the infusion of blood plasma until baseline CSF pressure was tripled. At each time-point, microspheres of different colours were injected allowing for regional SCBF analysis.

Results: DaP led to a pronounced hyperperfusion of the distal spinal cord [SCBF up to 480%, standard deviation (SD): 313%, compared to baseline]. However, DaP provided no or only limited additional flow to the upper and middle segments of the spinal cord (C1-Th7: 5% of baseline, SD: 5%; Th8-L2: 24%, SD: 39%), which was compensated by proximal flow only at C1-Th7 level. Furthermore, DaP could not counteract an experimental CSF pressure elevation, which led to a further decrease in regional SCBF most pronounced in the mid-thoracic spinal cord segment.

Conclusions: Protective DaP during thoraco-abdominal aortic repair may be associated with inadequate spinal protection particularly at the mid-thoracic spinal cord level ('watershed area') and result in the adverse effect of a potentially dangerous hyperperfusion of the distal spinal cord segments.
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http://dx.doi.org/10.1093/ejcts/ezab167DOI Listing
April 2021

Mid-term results after isolated tricuspid valve surgery in the presence of right ventricular leads.

J Cardiovasc Surg (Torino) 2021 Apr 8. Epub 2021 Apr 8.

University Clinic for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Background: Patients with tricuspid valve (TV) disease and indication for TV surgery frequently have permanent pacemaker (PM) or defibrillator (AICD) leads, placed in the right ventricle (RV). The aim of this study was to analyse postoperative results and mid-term outcomes after isolated TV surgery (with no further concomitant cardiac procedures) in the presence of permanent RV leads.

Methods: From January 2005 to January 2019 a total of 80 patients (mean age: 67.7±10.3 yrs; 56.3% male) with isolated TV disease and presence of at least one permanent RV lead in place were referred to our institution for isolated TV repair / replacement; patients with concomitant procedures were excluded for this analysis. All data were retrospectively analysed. The follow-up was 98% complete.

Results: Mean follow-up time was 4.3±3.9 years. Mean preoperative clinical NYHA status was 3.0±0.8, left ventricular ejection fraction 50.7±12.9%, mean pulmonary artery pressure 23.8±9.3mmHg, creatinine 125.7±57.5μmol/l, mean MELD-XI Score (Model of Endstage-Liver Disease excluding INR) was 14.6±5.0 μmol/l. Thirty-day mortality was 6.3% with a 5-years survival of 58.2±6.0%. Cox regression analysis revealed the MELD-XIScore as the only highly significant predictor for postoperative mortality (p=0.002).

Conclusions: In conclusion, Hepatorenal dysfunction-possibly indicating long lasting TV failure- could be a factor for limited postoperative survival in our patient cohort. This finding could unterline our hypothesis, that early TV surgery may achieve better postoperative survival, even in patients with TV disease caused by RV leads. Further investigations are needed.
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http://dx.doi.org/10.23736/S0021-9509.21.11803-8DOI Listing
April 2021

Proximal aortic aneurysms: correlation of maximum aortic diameter and aortic wall thickness.

Eur J Cardiothorac Surg 2021 Apr 5. Epub 2021 Apr 5.

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Objectives: The goal of therapy of proximal aortic aneurysms is to prevent an aortic catastrophe, e.g. acute dissection or rupture. The decision to intervene is currently based on maximum aortic diameter complemented by known risk factors like bicuspid aortic valve, positive family history or rapid growth rate. When applying Laplace's law, wall tension is determined by pressure × radius divided by aortic wall thickness. Because current imaging modalities lack precision, wall thickness is currently neglected. The purpose of our study was therefore to correlate maximum aortic diameter with aortic wall thickness and known indices for adverse aortic events.

Methods: Aortic samples from 292 patients were collected during cardiac surgery, of whom 158 presented with a bicuspid aortic valve and 134, with a tricuspid aortic valve. Aortic specimens were obtained during the operation and stored in 4% formaldehyde. Histological staining and analysis were performed to determine the thickness of the aortic wall.

Results: Patients were 62 ± 13 years old at the time of the operation; 77% were men. The mean aortic dimensions were 44 mm, 41 mm and 51 mm at the aortic root, sinotubular junction and ascending aorta, respectively. Aortic valve stenosis was the most frequent (49%) valvular dysfunction, followed by aortic valve regurgitation (33%) and combined dysfunction (10%). The maximum aortic diameter at the ascending level did not correlate with the thickness of the media (R = 0.07) or the intima (R = 0.28) at the convex sample site. There was also no correlation of the ascending aortic diameter with age (R = -0.18) or body surface area (R = 0.07). The thickness of the intima (r = 0.31) and the media (R = 0.035) did not correlate with the Svensson index of aortic risk. Similarly, there was a low (R = 0.29) or absent (R = -0.04) correlation between the aortic size index and the intima or media thickness, respectively. There was a similar relationship of median thickness of the intima in the 4 aortic height index risk categories (P < 0.001).

Conclusions: Aortic diameter and conventional indices of aortic risk do not correlate with aortic wall thickness. Other indices may be required in order to identify patients at high risk for aortic complications.
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http://dx.doi.org/10.1093/ejcts/ezab147DOI Listing
April 2021

Postoperative outcome after reoperative isolated tricuspid valve surgery-is there a predictor for survival?

Eur J Cardiothorac Surg 2021 Mar 26. Epub 2021 Mar 26.

University Clinic for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Objectives: Reoperative tricuspid valve (TV) surgery is considered high risk even in the absence of additional concomitant cardiac procedures. The purpose of this study was to evaluate preoperative clinical parameters as predictors for survival after isolated reoperative TV surgery.

Methods: From January 2005 to January 2019, 85 patients (mean age: 66.7 ± 10.3 years, 34 male) with severe isolated TV regurgitation and prior cardiac surgery were referred to our centre for elective or urgent TV repair/replacement; patients with endocarditis were excluded. We retrospectively analysed preoperative hepatorenal function [reflected by widely used clinical and laboratory parameters and the Model of End-stage-Liver Disease excluding International Normalized Ratio (MELD-XI) score] as a predictor for postoperative survival.

Results: At hospital admission, the patients' average preoperative New York Heart Association class was 2.9 ± 0.6, left ventricular ejection fraction 52.5 ± 10.6%, mean pulmonary artery pressure 24.7 ± 8.0 mmHg, creatinine 115.4 ± 66.6 μmol/l, bilirubin 20.0 ± 19.6 μmol/l and the mean MELD-XI score was 13.3 ± 4.0 μmol/l. The mean follow-up was 5.4 ± 4.2 years. Thirty-day mortality was 5%, 5-year survival was 60.6 ± 5.4% and 10-year survival was 42.9 ± 6.5%. The multivariable Cox regression analysis evaluated the MELD-XI score [hazard ratio (HR 1.144, confidence interval 95% 1.0-1.3, P = 0.005] and diabetes mellitus (HR 2.27, confidence interval 95% 1.0-5.0, P = 0.04) as significant predictors for excess mortality while age and mean pulmonary artery pressure did not reliably predict clinical outcome.

Conclusions: Hepatorenal dysfunction was one main factor accounting for limited postoperative survival in our patient cohort. The MELD-XI score is easy to calculate and seems to reliably predict the perioperative risk in patients with prior cardiac surgery and indication for TV surgery.
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http://dx.doi.org/10.1093/ejcts/ezab134DOI Listing
March 2021

Magnetic resonance imaging in patients with postoperative spinal cord injury: 'one step at a time towards safer aortic repair'.

Eur J Cardiothorac Surg 2021 Feb 13. Epub 2021 Feb 13.

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

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http://dx.doi.org/10.1093/ejcts/ezab062DOI Listing
February 2021

Experimental near-infrared spectroscopy-guided minimally invasive segmental artery occlusion.

Eur J Cardiothorac Surg 2021 Feb 4. Epub 2021 Feb 4.

University Department for Cardiac Surgery, Leipzig Heart Center, Saxony, Germany.

Objectives: Minimally invasive staged segmental artery (SA) coil- and plug embolization is a new method for paraplegia prevention associated with extensive aortic procedures. Near-infrared spectroscopy of the paraspinal collateral network (cnNIRS) has emerged as a non-invasive method for spinal cord monitoring. The aim of this study was to evaluate cnNIRS to guide minimally invasive SA occlusion.

Methods: In a chronic large animal experiment, 18 juvenile pigs underwent two-stage minimally invasive staged SA coil- and plug embolization for complete SA occlusion. Coil-embolization was performed either by SA main stem occlusion (characteristic of pig anatomy) or separately for the left- and right SA. Lumbar cnNIRS was recorded during and after the procedure. Neurological status was assessed up to 3 days after complete SA occlusion.

Results: Mean time from SA coil embolization to minimum cnNIRS values was 11 ± 5 min with an average decrease from 101 ± 2% to 78 ± 8% of baseline (difference: -23 ± 9, P < 0.001). Lumbar cnNIRS demonstrated significant differences between left and right when SAs were occluded separately in all cases (-7 ± 4%, 1 min after first SA occlusion; P = 0.001). Permanent paraplegia occurred in 2 (11%) and any kind of neurological deficit-temporary or permanent-in 7 animals (39%). Association between lumbar cnNIRS and neurological outcome after minimally invasive staged SA coil- and plug embolization suggests positive correlation (R = 0.5, P = 0.052).

Conclusions: Lumbar cnNIRS independently reacts to unilateral SA occlusion. cnNIRS-guided SA occlusion is feasible and may become a useful adjunct facilitating adequate and complete vessel occlusion.
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http://dx.doi.org/10.1093/ejcts/ezab005DOI Listing
February 2021

Spinal cord protection in thoracoabdominal aortic aneurysm surgery: a multimodal approach.

J Cardiovasc Surg (Torino) 2021 Jan 26. Epub 2021 Jan 26.

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany -

Spinal cord injury is one major complication of open and endovascular thoracic and thoracacoabdominal aortic aneurysm repair. Despite numerous neuroprotective adjuncts, the incidence of SCI remains high. This review article discusses established and novel adjuncts for spinal cord protection, including priming and preconditioning of the paraspinal collateral network, intraoperative systemic hypothermia, distal aortic perfusion, motor- and somatosensory evoked potentials and non-invasive cnNIRS monitoring as well as peri- and postoperative drainage of cerebrospinal fluid. Regardless of the positive influence of many of these strategies on neurologic outcome, to date no strategy assures definitive preservation of spinal cord integrity during and after aortic aneurysm repair.
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http://dx.doi.org/10.23736/S0021-9509.21.11783-5DOI Listing
January 2021

Ischemic spinal cord injury - experimental evidence and evolution of protective measures.

Ann Thorac Surg 2021 Jan 9. Epub 2021 Jan 9.

University Department for Cardiac Surgery, Leipzig Heart Center, Struempellstrasse 39, 04289 Leipzig, Germany. Electronic address:

Background: Paraplegia remains one of the most devastating complications of descending and thoracoabdominal aortic repair. The aim of this review is to outline the current state of art in the rapidly developing field of spinal cord injury (SCI) research.

Methods: A review of PubMed and Web of Science databases was performed using the following terms and their combinations: spinal cord, injury, ischemia, ischemia-reperfusion, ischemic spinal cord injury, paraplegia, paraparesis. Articles published before July 2019 were screened and included if considered relevant.

Results: The review focuses on the topic of SCI and the developments concerning methods of monitoring, diagnostics and prevention of SCI.

Conclusions: Translation of novel technologies from bench to bedside and into everyday clinical practice is challenging, however each of the developing areas hold great promise in SCI prevention.
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http://dx.doi.org/10.1016/j.athoracsur.2020.12.028DOI Listing
January 2021

Real-Time Assessment of Spinal Cord Microperfusion in a Porcine Model of Ischemia/Reperfusion.

J Vis Exp 2020 12 10(166). Epub 2020 Dec 10.

Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf.

Spinal cord injury is a devastating complication of aortic repair. Despite developments for the prevention and treatment of spinal cord injury, its incidence is still considerably high and therefore, influences patient outcome. Microcirculation plays a key role in tissue perfusion and oxygen supply and is often dissociated from macrohemodynamics. Thus, direct evaluation of spinal cord microcirculation is essential for the development of microcirculation-targeted therapies and the evaluation of existing approaches in regard to spinal cord microcirculation. However, most of the methods do not provide real-time assessment of spinal cord microcirculation. The aim of this study is to describe a standardized protocol for real-time spinal cord microcirculatory evaluation using laser-Doppler needle probes directly inserted in the spinal cord. We used a porcine model of ischemia/reperfusion to induce deterioration of the spinal cord microcirculation. In addition, a fluorescent microsphere injection technique was used. Initially, animals were anesthetized and mechanically ventilated. Thereafter, laser-Doppler needle probe insertion was performed, followed by the placement of cerebrospinal fluid drainage. A median sternotomy was performed for exposure of the descending aorta to perform aortic cross-clamping. Ischemia/reperfusion was induced by supra-celiac aortic cross-clamping for a total of 48 min, followed by reperfusion and hemodynamic stabilization. Laser-Doppler Flux was performed in parallel with macrohemodynamic evaluation. In addition, automated cerebrospinal fluid drainage was used to maintain a stable cerebrospinal pressure. After completion of the protocol, animals were sacrificed, and the spinal cord was harvested for histopathological and microsphere analysis. The protocol reveals the feasibility of spinal cord microperfusion measurements using laser-Doppler probes and shows a marked decrease during ischemia as well as recovery after reperfusion. Results showed comparable behavior to fluorescent microsphere evaluation. In conclusion, this new protocol might provide a useful large animal model for future studies using real-time spinal cord microperfusion assessment in ischemia/reperfusion conditions.
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http://dx.doi.org/10.3791/62047DOI Listing
December 2020

Management of aortic root in type A dissection: Bentall approach.

J Card Surg 2021 May 20;36(5):1779-1785. Epub 2020 Dec 20.

Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany.

Background: We analyzed the results of the modified Bentall procedure in a high-risk group of patients presenting with acute type A aortic dissection (ATAAD).

Methods: ATAAD patients undergoing a modified Bentall between 1996 and 2018 (n = 314) were analyzed. Mechanical composite conduits were used in 45%, and biological ones using either a bioprosthesis implanted into an aortic graft (33%) or xeno-/homograft root conduits (22%) in the rest. Preoperative malperfusion was present in 34% of patients and cardiopulmonary resuscitation required in 9%.

Results: Concomitant arch procedures consisted of hemiarch in 56% and total arch/elephant trunk in 34%, while concomitant coronary artery surgery was required in 20%. The average cross-clamp and cardiopulmonary bypass times were 126 ± 43 and 210 ± 76 min, respectively, while the average circulatory arrest times were 29 ± 17 min. A total of 69 patients (22%) suffered permanent neurologic deficit, while myocardial infarction occurred in 18 cases (6%) and low cardiac output syndrome in 47 (15%). The in-hospital mortality rate was 17% due to intractable low cardiac output syndrome (n = 29), major brain injury (n = 16), multiorgan failure (n = 6), and sepsis (n = 2). The independent predictors of in-hospital mortality were critical preoperative state (odds ratio [OR], 5.6; p < .001), coronary malperfusion (OR, 3.6; p = .002), coronary artery disease (OR, 2.6; p = .033), and prior cerebrovascular accident (OR, 5.6; p = .002).

Conclusions: The modified Bentall operation, along with necessary concomitant procedures, can be performed with good early results in high-risk ATAAD patients presenting.
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http://dx.doi.org/10.1111/jocs.15271DOI Listing
May 2021

Anatomical description of the intraspinal collateral network: bringing the concept full circle-is the devil in the details?

Eur J Cardiothorac Surg 2021 Jan;59(1):144-146

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

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http://dx.doi.org/10.1093/ejcts/ezaa341DOI Listing
January 2021

Mapping the collateral network: Optimal near-infrared spectroscopy optode placement.

J Thorac Cardiovasc Surg 2020 Aug 11. Epub 2020 Aug 11.

University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany; Saxonian Incubator for Clinical Translation, University of Leipzig, Leipzig, Germany.

Background: Paraplegia after extensive aortic procedures is a disastrous complication, and maintenance of adequate spinal cord perfusion/oxygenation is pivotal to its prevention. Collateral network (CN) near-infrared spectroscopy (cnNIRS) has been introduced as a noninvasive method for indirect spinal cord oxygenation monitoring. However, the CN has not been investigated in its entirety using this monitoring modality. This study aimed to identify the optimal cnNIRS positioning in an acute large animal model for routine clinical use.

Methods: The paraspinous CN was measured from the high thoracic region to the low lumbar region (T4-L5) using cnNIRS in 10 juvenile pigs (plus reference data from 7 animals) during aortic ischemia and reperfusion. These data were compared with data on direct regional tissue perfusion of the CN and the spinal cord.

Results: After aortic cross-clamping, cnNIRS at the mid-thoracic to the low lumbar level decreased rapidly to a nadir at 10 minutes of distal ischemia (mean difference, 18.3 ± 11% to 44.5 ± 9%; P < .001 to .045), with more pronounced changes in the caudal regions. High thoracic cnNIRS remained stable (mean difference, 4.3 ± 4%; P = .915). Measurements of cnNIRS, CN, and spinal cord regional perfusion demonstrated comparable curve progressions starting from the mid-thoracic region (r = 0.5-0.7; P < .001).

Conclusions: cnNIRS is capable of detecting relevant changes during ischemia and reperfusion from the mid-thoracic level downward with characteristic oxygenation patterns corresponding to CN and spinal cord regional perfusion. For extensive aortic procedures, noninvasive cnNIRS placement appears to be useful from the mid-thoracic level (T7-T9) to the lower lumbar level (L3-L5) and also may serve as a versatile monitoring method for procedures limited to the proximal thoracic aorta.
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http://dx.doi.org/10.1016/j.jtcvs.2020.07.103DOI Listing
August 2020

Propensity score matched comparison of isolated, elective aortic valve replacement with and without concomitant septal myectomy: is it worth it?

J Cardiovasc Surg (Torino) 2021 Jun 4;62(3):258-267. Epub 2020 Sep 4.

Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany -

Background: Septal myectomy during open aortic valve replacement (AVR) is an effective surgical treatment for asymmetric secondary basal septal hypertrophy. Concerns regarding higher rates of complications associated with this procedure have been raised - such as permanent pacemaker implantation. The aim of this study was to compare outcomes and complications of patients with and without concomitant septal myectomy using propensity score matching applied to a large, consecutive single center cohort.

Methods: A total of 2199 consecutive patients undergoing either AVR with concomitant myectomy (AVR-M, N.=212) or AVR alone (N.=1987) were analyzed (2009-2015). Patients with previous cardiac or emergency surgery, concomitant cardiac procedures and endocarditis were excluded. As reference to previously published data, patient characteristics and outcomes of the overall cohort were examined and for comparison between groups propensity score matching utilized.

Results: In the unmatched cohort, AVR-M patients were older (71.2±8 vs. 67.6±10 years, P<0.001) and more often female (68% vs. 37%, P<0.001) in comparison to patients receiving only AVR. After matching (N.=374) no significant difference in baseline features was evident. No significant difference in hospital mortality (2.1% vs. 1.6%, P=1.000) and pacemaker-implantation rate (5.3% vs. 3.7%, P=0.621) was observed. Mid-term survival was comparable between the two groups (86.1±5% vs. 84.4±5% after 6 years, P=0.957). The overall patient cohort showed a survival comparable to that of an adjusted regional normal population (P=0.178).

Conclusions: This study demonstrates that concomitant myectomy in patients undergoing AVR is a safe surgical technique resulting in comparable hospital mortality and mid-term survival. Concomitant septal myectomy seems not to be associated with an increased pacemaker implantation rate.
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http://dx.doi.org/10.23736/S0021-9509.20.11443-5DOI Listing
June 2021

Surgical management of the aorta in BAV patients.

Prog Cardiovasc Dis 2020 Jul - Aug;63(4):475-481. Epub 2020 Jul 5.

University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany. Electronic address:

Patients with a bicuspid aortic valve (BAV) frequently develop aneurysms of the aortic root and tubular ascending aorta. Aneurysms of the aortic arch, in the absence of concomitant aortopathies, are much less common. According to the 2018 American Association of Thoracic Surgery consensus guidelines on BAV-related aortopathy, prophylactic surgical aortic repair / replacement is recommended starting at a maximum aortic diameter of 50 mm in patients with risk factors. Concomitant aortic surgery is also recommended at an aortic diameter of 45 mm in those patients with other indications for cardiac surgery (most commonly aortic valve procedures). The ultimate goal of prophylactic aortic surgery is the prevention of aortic catastrophes, e.g. aortic rupture or acute aortic dissection, which are associated with high morbidity and mortality. The surgical technique used - in elective and emergency cases - depends on the involvement and nature of the aortic valve disease, as well as the extent of aortic aneurysm formation. The current review focusses on the surgical management of the aortic root, tubular ascending aorta, and proximal aortic arch in BAV patients. Despite the abovementioned recommendations, many BAV patients develop acute aortic syndromes below the recommended aortic diameter thresholds. Further research is therefore required in order to identify high-risk BAV subgroups that would benefit from earlier surgical repair.
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http://dx.doi.org/10.1016/j.pcad.2020.06.013DOI Listing
October 2020

Near real-time bedside detection of spinal cord ischaemia during aortic repair by microdialysis of the cerebrospinal fluid.

Eur J Cardiothorac Surg 2020 09;58(3):629-637

University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany.

Objectives: Spinal cord ischaemia (SCI) remains the most devastating complication after thoraco-abdominal aortic aneurysm (TAAA) repair. Its early detection is crucial if therapeutic interventions are to be successful. Cerebrospinal fluid (CSF) is readily available and accessible to microdialysis (MD) capable of detecting metabolites involved in SCI [i.e. lactate, pyruvate, the lactate/pyruvate ratio (LPR), glucose and glycerol] in real time. Our aim was to evaluate the feasibility of CSF MD for the real-time detection of SCI metabolites.

Methods: In a combined experimental and translational approach, CSF MD was evaluated (i) in an established experimental large animal model of SCI with 2 arms: (a) after aortic cross-clamping (AXC, N = 4), simulating open TAAA repair and (b) after total segmental artery sacrifice (Th4-L5, N = 8) simulating thoracic endovascular aortic repair. The CSF was analysed utilizing MD every 15 min. Additionally, CSF was collected hourly from 6 patients undergoing open TAAA repair in a high-volume aortic reference centre and analysed using CSF MD.

Results: In the experimental AXC group, CSF lactate increased 3-fold after 10 min and 10-fold after 60 min of SCI. Analogously, the LPR increased 5-fold by the end of the main AXC period. Average glucose levels demonstrated a 1.5-fold increase at the end of the first (preconditioning) AXC period (0.60±0.14 vs 0.97±0.32 mmol/l); however, they decreased below (to 1/3 of) baseline levels (0.60±0.14 vs 0.19±0.13 mmol/l) by the end of the experiment (after simulated distal arrest). In the experimental segmental artery sacrifice group, lactate levels doubled and the LPR increased 3.3-fold within 30 min and continued to increase steadily almost 5-fold 180 min after total segmental artery sacrifice (P < 0.05). In patients undergoing TAAA repair, lactate similarly increased 5-fold during ischaemia, reaching a maximum at 6 h postoperatively. In 2 patients with intraoperative SCI, indicated by a decrease in the motor evoked potential of >50%, the LPR increased by 200%.

Conclusions: CSF is widely available during and after TAAA repair, and CSF MD is feasible for detection of early anaerobic metabolites of SCI. CSF MD is a promising new tool combining bedside availability and real-time capacity to potentially enable rapid detection of imminent SCI, thereby maximizing chances to prevent permanent paraplegia in patients with TAAA.
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http://dx.doi.org/10.1093/ejcts/ezaa124DOI Listing
September 2020

Detrimental effects of cerebrospinal fluid pressure elevation on spinal cord perfusion: first-time direct detection in a large animal model.

Eur J Cardiothorac Surg 2020 08;58(2):286-293

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Objectives: Cerebrospinal fluid (CSF) drainage is routinely utilized to mitigate perioperative and postoperative spinal cord ischaemia in open and endovascular thoraco-abdominal aortic aneurysm repair to prevent permanent paraplegia. Clinical decision-making in the vulnerable perioperative period, however, is still based on limited clinical and experimental data. Our aim was to investigate the isolated effect of CSF pressure elevation on spinal cord perfusion in an established large animal model.

Methods: Ten juvenile pigs with normal (native) arterial inflow (patent segmental arteries and collaterals) underwent iatrogenic CSF pressure elevation (×2, ×3, ×4 from their individual baseline pressure). Each pressure level was maintained for 30 min to mimic clinical response time. After the quadrupling of CSF pressure, the dural sac was slowly depressurized against gravity allowing CSF pressure to passively return to baseline values. Measurements were taken 30 and 60 min after normalization, and microspheres for regional blood flow analysis were injected at each time point.

Results: Spinal cord perfusion decreased significantly at all mid-thoracic to lumbar cord segments at the doubling of CSF pressure and declined to values <53% compared to baseline when pressure was quadrupled. Normalizing CSF pressure led to an intense hyperperfusion of up to 186% at the cervical level and 151% within the lumbar region.

Conclusions: CSF pressure elevation results in a relevant impairment of spinal cord blood supply. Close perioperative and postoperative monitoring of CSF pressure is crucial for maintaining sufficient spinal cord perfusion. Radical and rapid withdrawal of CSF is followed by significant hyperperfusion in all spinal cord segments and may lead to 'drainage-related' iatrogenic reperfusion injury-aggravating the risk of delayed spinal cord injury-and should therefore be avoided.
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http://dx.doi.org/10.1093/ejcts/ezaa038DOI Listing
August 2020

Prevalence of permanent pacemaker implantation after conventional aortic valve replacement-a propensity-matched analysis in patients with a bicuspid or tricuspid aortic valve: a benchmark for transcatheter aortic valve replacement.

Eur J Cardiothorac Surg 2020 07;58(1):130-137

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Objectives: Elective treatment of aortic valve disease by transcatheter aortic valve replacement (TAVR) is becoming increasingly popular, even in patients with low risk and intermediate risk. Even patients with a bicuspid aortic valve (BAV) are increasingly considered eligible for TAVR. Permanent pacemaker implantation (PMI) is a known-frequently understated-complication of TAVR affecting 9-15% of TAVR patients with a potentially significant impact on longevity and quality of life. BAV patients are affected by the highest PMI rates, although they are frequently younger compared to their tricuspid peers. The aim of the study is to report benchmark data-from a high-volume centre (with a competitive TAVR programme) on PMI after isolated surgical aortic valve replacement (SAVR) in patients with BAV and tricuspid aortic valve (TAV).

Methods: We performed a retrospective single-centre analysis on 4154 patients receiving isolated SAVRs (w/o concomitant procedures), between 2000 and 2019, of whom 1108 had BAV (27%). PMI rate and early- and long-term outcomes were analysed. For better comparability of these demographically unequal cohorts, 1:1 nearest neighbour matching was performed.

Results: At the time of SAVR, BAV patients were on average 10 years younger than their TAV peers (59.7 ± 12 vs 69.3 ± 9; P < 0.001) and had less comorbidities; all relevant characteristics were equally balanced after statistical matching. Overall PMI rate was significantly higher in BAV patients (5.4% vs 3.8%; P = 0.03). BAV required PMI exclusively (100%) and TAV required predominately (96%) for persistent postoperative high-degree atrioventricular block. After matching, the PMI rate was similar (5.1% vs 4.4%, P = 0.5). In-hospital mortality in the matched cohort was 1% in both groups. Long-term survival was more favourable in BAV patients (94% vs 90% in TAV at 5 years; 89% vs 82% in TAV at 9 years; P = 0.013).

Conclusions: With SAVR, the overall incidence of PMI among BAV patients seems significantly higher; however, after propensity matching, no difference in PMI rates between BAV and TAV is evident. The PMI rate was remarkably lower among BAV patients after SAVR compared to the reported incidence after TAVR.
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http://dx.doi.org/10.1093/ejcts/ezaa053DOI Listing
July 2020

Gender-related differences in patients with acute aortic dissection type A.

J Thorac Cardiovasc Surg 2019 Nov 27. Epub 2019 Nov 27.

Department of Cardiac Surgery, INCCI HaerzZenter, Luxembourg City, Luxembourg.

Objective: Acute aortic dissection type A can occur in both genders at any age. Our aim was to report differences in presentation, treatment, and outcome in female and male patients with acute aortic dissection type A.

Methods: Between July 2006 and June 2015, 56 centers participating in the German Registry for Acute Aortic Dissection Type A reported on a total of 3380 patients. As many as 1234 (37%) were women and 2146 (63%) were men. We compared their clinical features and events occurring within 30 days after surgery.

Results: Women were significantly older than male patients (65.5 ± 12.7 years vs 59.2 ± 13.3 years; P < .001). Aortic dissection extended down to the abdominal aorta in 43% men and 39% women (P = .01). Visceral (4.9% vs 7.3%; P = .006) and renal malperfusion (7.7% vs 10.6%; P = .006) were more frequently diagnosed in men. Aortic roots were replaced more frequently in men (22% vs 18%; P < .001). Different aortic arch repair strategies were distributed similarly in both genders. The incidence of new hemiplegia or hemiparesis was also similar in men and women (P = .24). Thirty-day mortality did not differ between women and men (16.3% vs 16.6%; P = .18). In a logistically mixed-effect model, gender revealed no influence on 30-day mortality (odds ratio, 1.15; 95% confidence interval, 0.92-1.44; P = .21).

Conclusions: Aortic dissection type A occurs almost twice as frequently in men. Women develop aortic dissection later in life. Despite women and men presenting at different ages and exhibiting varying dissection and malperfusion patterns, and the fact that men undergo complex proximal aortic repair more frequently, outcomes are similar in both genders.
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http://dx.doi.org/10.1016/j.jtcvs.2019.11.039DOI Listing
November 2019

Commentary: Optimal perfusion strategy for stroke risk reduction in type A aortic dissection repair-Still unresolved?

J Thorac Cardiovasc Surg 2020 06 9;159(6):2157-2158. Epub 2019 Sep 9.

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.08.029DOI Listing
June 2020

Bicuspid aortic valve patients show specific epigenetic tissue signature increasing extracellular matrix destruction.

Interact Cardiovasc Thorac Surg 2019 12;29(6):937-943

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Objectives: Patients with a bicuspid aortic valve (BAV) have an increased risk for developing thoracic aortic aneurysm, which is characterized by the destruction of the elastic media of the aortic wall. Several important enzymes have been characterized to play key roles in extracellular matrix homeostasis, namely matrix metalloproteinases (MMPs). In this study, we investigated MMP-2 levels and their epigenetic regulation via the miR-29 family.

Methods: Aortic tissue samples from 58 patients were collected during cardiac surgery, of which 30 presented with a BAV and 28 with a tricuspid aortic valve. Polymerase chain reaction, western blot analysis and immunohistochemistry were performed to analyse MMP-2. In addition, enzyme-linked immunosorbent assay measurements were carried out to investigate both MMP-2 and tissue inhibitor of metalloproteinase-2 levels. To examine the epigenetic regulation of aortic extracellular matrix homeostasis, we furthermore studied the expression levels of miR-29 via qRT-PCR.

Results: Patients with a BAV were significantly younger at the time of surgery, presented significantly less frequently with arterial hypertension and displayed more often with an additional valvular disease. On a molecular level, we found that MMP-2 is increased on gene and protein level in BAV patients. Tissue inhibitor of metalloproteinase-2 levels do not differ between the groups. Interestingly, we also found that only miR-29A is significantly downregulated in BAVs.

Conclusions: Our findings highlight the importance of MMP-2 in the context of extracellular matrix destruction in BAV patients. We present new evidence that miR-29A is a crucial epigenetic regulator of these pathomechanistic processes and might hold promise for future translational research.
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http://dx.doi.org/10.1093/icvts/ivz210DOI Listing
December 2019

Commentary: Functional assessment of circle of Willis-interesting observation or critical consideration?

J Thorac Cardiovasc Surg 2019 11 6;158(5):1305-1306. Epub 2019 Feb 6.

University Clinic of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.01.105DOI Listing
November 2019

Paraplegia prevention in aortic aneurysm repair by thoracoabdominal staging with 'minimally invasive staged segmental artery coil embolisation' (MIS²ACE): trial protocol for a randomised controlled multicentre trial.

BMJ Open 2019 03 4;9(3):e025488. Epub 2019 Mar 4.

Department of Cardiac Surgery, University Heart Center Leipzig, Leipzig, Germany.

Introduction: Spinal cord injury (SCI) including permanent paraplegia constitutes a common complication after repair of thoracoabdominal aortic aneurysms. The staged-repair concept promises to provide protection by inducing arteriogenesis so that the collateral network can provide a robust blood supply to the spinal cord after intervention. Minimally invasive staged segmental artery coil embolisation (MISACE) has been proved recently to be a feasible enhanced approach to staged repair.

Methods And Analysis: This randomised controlled trial uses a multicentre, multinational, parallel group design, where 500 patients will be randomised in a 1:1 ratio to standard aneurysm repair or to MISACE in 1-3 sessions followed by repair. Before randomisation, physicians document whether open or endovascular repair is planned. The primary endpoint is successful aneurysm repair without substantial SCI 30 days after aneurysm repair. Secondary endpoints include any form of SCI, mortality (up to 1 year), length of stay in the intensive care unit, costs and quality-adjusted life years. A generalised linear mixed model will be used with the logit link function and randomisation arm, mode of repair (open or endovascular repair), the Crawford type and the European System for Cardiac Operative Risk Evaluation (euroSCORE) II as fixed effects and the centre as a random effect. Safety endpoints include kidney failure, respiratory failure and embolic events (also from debris). A qualitative study will explore patient perceptions.

Ethics And Dissemination: This trial has been approved by the lead Ethics Committee from the University of Leipzig (435/17-ek) and will be reviewed by each of the Ethics Committees at the trial sites. A dedicated project is coordinating communication and dissemination of the trial.

Trial Registration Number: NCT03434314.
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http://dx.doi.org/10.1136/bmjopen-2018-025488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6429943PMC
March 2019

Aortic root enlargement to mitigate patient-prosthesis mismatch: do early adverse events justify reluctance?†.

Eur J Cardiothorac Surg 2019 Feb 20. Epub 2019 Feb 20.

Department of Cardiac Surgery, Heart Center Leipzig, University Leipzig, Leipzig, Germany.

Objectives:: Concomitant aortic root enlargement (ARE) at the time of surgical aortic valve replacement can be performed to avoid patient-prosthesis mismatch, an important predictor of adverse long-term outcome.

Methods:: We performed a single-centre, retrospective analysis of 4120 patients receiving isolated aortic valve replacement, of whom 171 (4%) had concomitant ARE between January 2005 and December 2015. The analysis of postoperative outcome and early mortality was performed. Owing to inequality of the groups, patients were matched 1:1.

Results:: The mean age of all 4120 patients was 68.8 ± 10.5 years, and comorbidities were equally balanced after matching. The mean aortic cross-clamp time, cardiopulmonary bypass time and total operative time were prolonged by 19, 20 and 27 min in the ARE group, respectively. Early mortality was not statistically significantly different with 1.4% in the surgical aortic valve replacement and 1.8% in the ARE group. Postoperative complications were <5% in all matched 338 patients: bleeding (3% vs 3%), pericardial effusion (3.0% vs 4.2%), sternal instability (1.8% vs 0%) and sternal wound infection (3.0% vs 1.2%). A significant higher number of patients had respiratory failure after ARE (unmatched: 17.1% vs 9.9%, P < 0.001; matched: 18.3% vs 9.5%, P = 0.028). Factors independently associated with overall mortality were age [hazard ratio (HR) 1.71], chronic obstructive pulmonary disease (HR 1.47), diabetes (HR 1.82), atrial fibrillation (HR 2.14) and postoperative respiratory failure (HR 2.84).

Conclusions:: ARE can be performed safely in experienced centres with no significant increase in the risk of early postoperative surgical complications and early mortality. However, the surgeon and the intensive care unit team should be aware of an increased risk for postoperative respiratory failure in ARE patients.
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http://dx.doi.org/10.1093/ejcts/ezz016DOI Listing
February 2019

Evaluation of collateral network near-infrared spectroscopy during and after segmental artery occlusion in a chronic large animal model.

J Thorac Cardiovasc Surg 2019 07 11;158(1):155-164.e5. Epub 2018 Dec 11.

University Department for Cardiac Surgery, Leipzig Heart Center, Saxony, Germany; University of Leipzig, Saxonian Incubator for Clinical Translation, Saxony, Germany.

Objective: Ischemic spinal cord injury remains the most devastating complication after open and endovascular aortic repair. Collateral network near-infrared spectroscopy has been introduced to noninvasively monitor real-time spinal cord oxygenation. In view of recent advancements in endovascular treatment and minimally invasive staged preconditioning before aortic repair, this study sought to evaluate collateral network near-infrared spectroscopy during and after segmental artery occlusion in a chronic porcine model.

Methods: Surgery for segmental artery occlusion was performed in 12 juvenile pigs, and bilateral lumbar collateral network near-infrared spectroscopy was recorded. Two intervention groups were designed: Group 1 received subtotal segmental artery occlusion (mimicking reimplantation of crucial segmental arteries with patent T12/T13, N = 5), and group 2 received total occlusion (T4-L5, N = 7). Pigs were monitored over 3 days.

Results: All animals were paraplegic during the first 24 hours. The subtotal occlusion group completely recovered, whereas 57% of the total occlusion group remained paraplegic (N = 4/7). After segmental artery occlusion, collateral network near-infrared spectroscopy decreased from 92.3% ± 8% of baseline to 69.3% ± 18% after 10 minutes in the subtotal group (P = .003-.017) and from 90.1% ± 4% to 58.2% ± 9% in the total group (P < .001-.008). Throughout the postoperative period, collateral network near-infrared spectroscopy in the total occlusion group remained lower compared with the subtotal group (<30% baseline threshold, P < .05). Lumbar collateral network near-infrared spectroscopy and neurologic outcome were significantly correlated (R = 0.7, P < .001).

Conclusions: Lumbar collateral network near-infrared spectroscopy reacts to occlusion of segmental arteries and correlates with neurologic outcome. The preliminary data suggest that collateral network near-infrared spectroscopy may be a valuable noninvasive tool for detecting imminent spinal cord ischemia during and after aortic procedures involving segmental artery occlusion.
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http://dx.doi.org/10.1016/j.jtcvs.2018.11.105DOI Listing
July 2019

Optimal occlusion pattern for minimally invasive staged segmental artery coil embolization in a chronic porcine model.

Eur J Cardiothorac Surg 2019 Jul;56(1):126-134

University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany.

Objectives: Minimally invasive staged segmental artery coil- and plug embolization (MIS2ACE) has been introduced for spinal cord injury prevention prior to open or endovascular thoraco-abdominal aortic aneurysm repair. To date, no optimal pattern has been developed. The aim of this study was to identify the optimal MIS2ACE occlusion pattern.

Methods: Twenty-five juvenile pigs were randomly assigned to 3 MIS2ACE occlusion patterns (2 stages) and a control group [single-stage segmental artery (SA) occlusion, N = 7]. The first pattern started with occlusion of all lumbar segmental arteries in the first stage and the remaining thoracic arteries in the second stage (regional pattern, N = 6). In group 2, an alternating approach with occlusion of every other SA in the first stage and the remainder in the second stage was used (alternating pattern, N = 6). The third pattern started with occluding the watershed area between thoracic level 12 and lumbar level 2 in the first stage and the remaining arteries in the second stage (watershed pattern, N = 6). Neurological assessment at 6-h intervals and spinal cord tissue perfusion measurements via microspheres at 6 time points were performed. At the end of the experiments, the spinal cord was histopathologically examined.

Results: An average of 6 ± 2 coils were used per SA. In the control group a total of 57% (N = 4) of animals experienced permanent paraplegia, 1 animal (16%) of the alternating and watershed intervention group suffered from permanent paraplegia. Animals from the staged regional pattern did not experience permanent paraplegia. Furthermore, no evidence of significant tissue damage was observed (P < 0.05 vs control). Tissue perfusion of the lumbar spinal cord in the regional pattern group recovered within 3 days after the second stage to 89.2 ± 47 percent-of-baseline (P = 0.393), whereas mean perfusion of the other 2 intervention groups and the control remained significantly lower compared to the baseline (35.7 ± 16%, 30.2 ± 11% and 63.2 ± 19, P < 0.05).

Conclusions: This study provides evidence that MIS2ACE (minimally invasive staging) may result in less ischaemic spinal cord injury and favourable neurological outcomes compared to complete (1 stage) SA occlusion. A regional-based occlusion pattern (starting with the lumbar segmental arteries) seems to be the best 2-stage approach.
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http://dx.doi.org/10.1093/ejcts/ezy463DOI Listing
July 2019

Computed tomography improves the differentiation of infectious mediastinitis from normal postoperative changes after sternotomy in cardiac surgery.

Eur Radiol 2019 Jun 10;29(6):2949-2957. Epub 2019 Jan 10.

Department of Diagnostic and Interventional Radiology, University of Leipzig - Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany.

Objectives: To identify CT parameters independently associated with infectious mediastinitis after cardiac surgery and to improve the discrimination of patients with acute infection from those with normal postoperative changes.

Methods: In this single-center, retrospective, observational cohort study, we evaluated thoracic CT scans of poststernotomy cardiac surgery patients. Inclusion criteria were clinically suspected mediastinitis, unclear CT signs (e.g., retrosternal mass), and subsequent deep revision surgery. Revision surgery and microbiological samples determined the mediastinitis status. Overall, 22 qualitative and quantitative CT imaging parameters were assessed and associated with infectious mediastinitis in univariate and multivariate regression models. Discriminative capacity and incremental value of the CT features to available clinical parameters were determined by AUC and likelihood-ratio tests, respectively.

Results: Overall 105 patients (82% men; 67.0 ± 10.3 years) underwent CT and deep revision surgery. Mediastinitis was confirmed in 83/105 (79%) patients. Among available clinical parameters, only C-reactive protein (CRP) was independently associated with infectious mediastinitis (multivariate odds ratio (OR) (per standard deviation) = 2.3; p < 0.001). In the CT, the presence of free gas, pleural effusions, and brachiocephalic lymph node size were independently associated with mediastinitis (multivariate ORs = 1.3-6.3; p < 0.001-0.039). Addition of these CT parameters to CRP increased the model fit significantly (X = 17.9; p < 0.001; AUC, 0.83 vs. 0.73).

Conclusion: The presence of free gas, pleural effusions, and brachiocephalic lymph node size in CT is independently associated with infectious mediastinitis in poststernotomy patients with retrosternal mass. These imaging features may help to differentiate mediastinitis from normal postoperative changes beyond traditional clinical parameters such as CRP.

Key Points: • Presence of free gas, pleural effusions, and brachiocephalic lymph node size on CT are associated independently with infectious mediastinitis. • Combination of these CT parameters increases the discriminatory capacity of clinical parameters such as CRP.
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http://dx.doi.org/10.1007/s00330-018-5946-5DOI Listing
June 2019

Outcomes After Thoracic Endovascular Aortic Repair With Overstenting of the Left Subclavian Artery.

Ann Thorac Surg 2019 May 30;107(5):1372-1379. Epub 2018 Nov 30.

Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, Freiburg, Germany.

Background: Our study aim was to evaluate the impact of left subclavian artery (LSA) flow preservation during thoracic endovascular aortic repair (TEVAR) on outcome.

Methods: Between August 2001 and October 2016, 176 patients (mean age, 61.3 ± 15.8 years) underwent TEVAR with complete LSA coverage. Fifty-five of those patients (31.3%) also underwent LSA revascularization, whereas 121 patients (68.7%) did not. Perioperative data were acquired retrospectively for statistical analysis at the three study institutions.

Results: Overall in-hospital and follow-up mortality was 8.5% (n = 15) and 9.1% (n = 16), respectively, including 88 urgent and emergent cases (50%). Stroke (independent of location) and permanent paraplegia rates were 6.8% and 6.3%, respectively, for the entire cohort. Isolated upper-left extremity malperfusion exclusively occurred in 12 (9.9%) of the 121 patients without LSA revascularization. Left-hemispheric stroke was observed four times more often in patients without LSA revascularization and left arm malperfusion (16.7% versus 3.7%, p = 0.095). Multivariate analysis identified no LSA revascularization (odds ratio [OR] 3.779, 95% confidence interval [CI]: 1.096 to 13.029, p = 0.035), two or more endografts (OR 3.814, 95% CI: 1.557 to 9.343, p = 0.003), and coronary artery disease (OR 3.276, 95% CI: 1.262 to 8.507, p = 0.015) as independent risk factors for procedure-related adverse events (left-hemispheric stroke, left arm malperfusion, and permanent paraplegia) after TEVAR with complete LSA overstenting.

Conclusions: Every 10th patient with LSA overstenting and no revascularization experienced left arm malperfusion. No LSA revascularization, extensive aortic coverage with two or more endografts, and coronary artery disease increased the risk of permanent paraplegia, left-hemispheric stroke, and left arm malperfusion. Patients should undergo LSA revascularization to prevent left vertebral artery-associated central neurologic complications and to maintain upper-left extremity perfusion.
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http://dx.doi.org/10.1016/j.athoracsur.2018.10.051DOI Listing
May 2019

Reply.

Ann Thorac Surg 2019 02 23;107(2):688. Epub 2018 Nov 23.

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

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http://dx.doi.org/10.1016/j.athoracsur.2018.10.038DOI Listing
February 2019

Ischaemic preconditioning of the spinal cord to prevent spinal cord ischaemia during endovascular repair of thoracoabdominal aortic aneurysm: first clinical experience.

EuroIntervention 2018 Sep;14(7):828-835

Department of Vascular Surgery, University Hospital Leipzig, Germany.

Aims: The purpose of our study was to report our experience with minimally invasive segmental artery coil embolisation (MISACE) to prevent spinal cord ischaemia (SCI) after endovascular repair (ER) of thoracoabdominal aortic aneurysm (TAAA).

Methods And Results: A cohort of 57 patients with TAAAs was treated by MISACE followed by ER between October 2014 and December 2017. The TAAA Crawford classification was: type I, n=5; type II, n=12; type III, n=27; type IV, n=13. The average maximum aortic diameter was 62.7±8.8 mm. Patients had a median of 5 coiled SAs (range: 1-19). MISACE was completed in one (n=22), two (n=24), three (n=7), four (n=3) or five (n=1) sessions. The maximum number of coiled SAs per session was six. After completion of MISACE, 77.7% of direct segmental arterial flow was occluded. After a mean of 83±62 days, 55 of the patients received total ER of their TAAA. At 30 days after ER, no patient developed SCI and three patients had died.

Conclusions: MISACE to precondition the paraspinous collateral network prior to endovascular repair of thoracoabdominal aortic aneurysm is clinically feasible. The safety profile is promising and there is good reason to explore this new staging strategy further.
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http://dx.doi.org/10.4244/EIJ-D-18-00200DOI Listing
September 2018

Bilateral Prosthetic Graft Stenosis After Supraaortic Debranching and Thoracic Endovascular Aortic Repair of the Transverse Arch.

Ann Thorac Surg 2018 12 5;106(6):e285-e287. Epub 2018 Jun 5.

Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany.

A 66-year-old patient presented to the Leipzig Heart Center in Leipzig, Germany with therapy-refractory hypotension with a history of postural presyncope 7 years after supraaortic debranching and thoracic endovascular aortic repair of the transverse arch. Arterial angiography with invasive blood pressure measurement revealed pronounced hypertension of the lower body (blood pressure, 270/120 mm Hg) and subtotal prosthetic graft stenosis of the bypasses to the innominate artery and to the left common carotid artery. Open reoperation for removal of the stenosed Y-limb prosthesis and extraanatomic supraaortic revascularization was successfully performed. Subtotal prosthetic graft stenosis with need for reoperation may occur as a long-term complication after supraaortic debranching and thoracic endovascular aortic repair.
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http://dx.doi.org/10.1016/j.athoracsur.2018.05.017DOI Listing
December 2018