Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 2014
The use of monitoring or device lines through the ascending aorta may be necessary for a variety ... more The use of monitoring or device lines through the ascending aorta may be necessary for a variety of clinical situations. The technique provided in this article allows percutaneous closure of these entry sites with a closed chest.
Background. Optimal treatment for penetrating aortic ulcers has yet to be determined. Although op... more Background. Optimal treatment for penetrating aortic ulcers has yet to be determined. Although open surgical repair is an effective therapeutic option, less invasive alternatives such as endoluminal grafting are emerging as a potential adjunct for the treatment of penetrating aortic ulcers isolated to the descending thoracic aorta. We reviewed our cumulative experience with thoracic endografting for penetrating aortic ulcers of the descending thoracic aorta.
This manuscript presents a published record of the use and efficacy of the extracellular matrix C... more This manuscript presents a published record of the use and efficacy of the extracellular matrix CorMatrix and why it may be superior to other materials used for aortic root enlargement. The potential benefits of an extracellular matrix are the natural ingrowth and development of native arterial cells and structure.
Systemic lupus erythematosus (SLE) is an autoimmune disease in which organs, tissues, and cells u... more Systemic lupus erythematosus (SLE) is an autoimmune disease in which organs, tissues, and cells undergo damage mediated by tissue-binding autoantibodies and immune complexes. We describe the case of a 23-year-old African American woman with a history of recurrent pneumonias. Computed tomography, magnetic resonance imaging (MRI), and echocardiographic evaluations, as well as clinical and laboratory findings, indicated a diagnosis of SLE with inflammatory aortitis secondary to SLE vasculitis. A repeat MRI revealed a rapidly expanding aortic root and ascending aorta that required prompt operative repair. The ascending aorta and aortic root were replaced with a mechanical valved conduit, and a coronary artery bypass to the posterior descending artery was performed because of related erosion into the intima of the right coronary ostium. The patient has done well postoperatively. Aortitis and aortic aneurysms are an uncommon manifestation of SLE, and a literature search revealed an apparent association between aortic aneurysms and steroid medications for SLE. This case is the first report of aortitis resulting in a nondissecting aortic root aneurysm in an SLE patient without a history of steroid use, indicating that all SLE patients, including those without a history of steroid use, require screening for aortic disease to improve surgical outcomes and to prevent fatal complications.
Address reprint requests to Ronald M. Fairman, MD, Department of Surgery, University of Pennsylva... more Address reprint requests to Ronald M. Fairman, MD, Department of Surgery, University of Pennsylvania Medical Center, 3400 Spruce St. 4 Silverstein Pavilion, Philadelphia, PA 19104. ... No abstract is available. To read the body of this article, please view the PDF online.
Journal of Vascular and Interventional Radiology, 2008
The present report describes three cases of thoracic aortic endograft infolding or collapse invol... more The present report describes three cases of thoracic aortic endograft infolding or collapse involving the Gore TAG system. The cases include a penetrating aortic injury, a blunt aortic injury, and a symptomatic type B dissection. In the first case, infolding occurred in a delayed fashion after a normal-appearing 3-month follow-up computed tomographic angiogram. In the other two cases, infolding occurred during the immediate postoperative phase. One of the patients underwent explantation and surgical repair. The other two underwent endovascular repair of the infolded endograft by placement of a balloon-expandable stent in one case and a self-expanding stent in the other.
Journal of the American Society of Echocardiography, 2007
A case of a 35-year-old woman with acute circumferential type B aortic dissection is presented. A... more A case of a 35-year-old woman with acute circumferential type B aortic dissection is presented. A review of the literature demonstrated that circumferential aortic dissection is limited to a small number of case reports and a small case series of type A lesions. This is the first report of a circum-ferential type B dissection. The case highlights the need to fully evaluate patients with acute aortic dissection and illustrates the unique data provided by transesophageal echocardiography and helical computed tomographic angiography.
Suppression of prostacyclin (PGI 2 ) biosynthesis may explain the increased incidence of myocardi... more Suppression of prostacyclin (PGI 2 ) biosynthesis may explain the increased incidence of myocardial infarction and stroke which has been observed in placebo controlled trials of cyclooxygenase (COX)-2 inhibitors. Herein, we examine if COX-2-derived PGI 2 might condition the response of the vasculature to sustained physiologic stress in experimental models that retain endothelial integrity. Deletion of the PGI 2 receptor (the IP) or suppression of PGI 2 with the selective COX-2 inhibitor, nimesulide, both augment intimal hyperplasia while preserving luminal geometry in mouse models of transplant arteriosclerosis or flow-induced vascular remodeling. Moreover, nimesulide or IP deletion augments the reduction in blood flow caused by common carotid artery ligation in wild-type mice. Generation of both thromboxane (TxA 2 ) and the isoprostane, 8, 12 -iso iPF 2␣ -VI, are increased in the setting of flow reduction and the latter increases further on administration of nimesulide. Deletion of the TxA 2 receptor (TP) reduces the hyperplastic response to nimesulide and carotid ligation, despite further augmentation of TP ligand production. Suppression of COX-2 derived PGI 2 or deletion of PGI 2 receptor (IP) profoundly influences the architectural response of the vasculature to hemodynamic stress. Mechanism based vascular remodeling may interact with a predisposition to hypertension and atherosclerosis in contributing to the gradual transformation of cardiovascular risk during extended periods of treatment with selective inhibitors of COX-2. (Circ Res. 2005;96:0-0.)
The use of endovascular stents to treat descending thoracic aortic pathologies is emerging as a l... more The use of endovascular stents to treat descending thoracic aortic pathologies is emerging as a less invasive therapy to treat high-risk patients. This case report describes the presentation of a patient with a pulsatile mass on her back. The patient's computed tomographic scan revealed the mass to be an extension of a large psuedoaneurysm from the site of a previous repair of her thoracic aorta for a dissecting aneurysm several years earlier. The psuedoaneurysm was successfully treated with an endovascular stent and the patient was discharged home on postoperative day 5.
tine. In those patients, bromocriptine was not given because the role of prolactin in the pathoge... more tine. In those patients, bromocriptine was not given because the role of prolactin in the pathogenesis of PPCM was not yet known. However, the current knowledge of the benefit of prolactin inhibition suggests an additive effect, independent from ventricular unloading by mechanical support.
Background. Acute type A dissections require surgery to prevent death from proximal aortic ruptur... more Background. Acute type A dissections require surgery to prevent death from proximal aortic rupture or malperfusion. Most series over the past decade have reported a death rate in the range of 15% to 30%. The objective of this study is to examine the effect of an integrated surgical approach on the treatment of acute type A dissections.
Background. Optimal treatment for penetrating aortic ulcers has yet to be determined. Although op... more Background. Optimal treatment for penetrating aortic ulcers has yet to be determined. Although open surgical repair is an effective therapeutic option, less invasive alternatives such as endoluminal grafting are emerging as a potential adjunct for the treatment of penetrating aortic ulcers isolated to the descending thoracic aorta. We reviewed our cumulative experience with thoracic endografting for penetrating aortic ulcers of the descending thoracic aorta.
Background. The edge-to-edge technique (E2E) has been advocated for the complex repair of myxomat... more Background. The edge-to-edge technique (E2E) has been advocated for the complex repair of myxomatous mitral valves. We compared outcomes of E2E performed in patients at risk for systolic anterior motion (SAM) versus outcomes in patients with residual mitral regurgitation (MR) after repair completion.
In 2005, the investigators described a &a... more In 2005, the investigators described a "hybrid" cardiovascular interventional strategy combining percutaneous coronary intervention (PCI) for coronary artery disease (CAD) followed by valve surgery for patients with urgent complex CAD and valve disease to reduce morbidity and mortality. This hybrid approach has been extended prospectively in elderly, high-risk patients with aortic stenosis scheduled for elective minimally invasive aortic valve replacement (MI-AVR) who, on preoperative coronary angiography, were found to have moderate CAD amenable to PCI. In this prospective, observational series, 18 patients (mean age 76 years) underwent elective hybrid MI-AVR with PCI from May 2003 to February 2006. Five patients had undergone previous coronary artery bypass grafting. Patients underwent coronary angiography the day of (n = 12) or evening before (n = 6) MI-AVR, and after identifying moderately severe CAD, all 18 underwent the implantation of drug-eluting stents to the affected coronary arteries, followed by MI-AVR. Although all patients received standard doses of antiplatelet medications, including acetylsalicylic acid (325 mg before PCI and 325 mg/day thereafter) and clopidogrel (300 mg after PCI, 75 mg/day thereafter for 90 days for the Cypher stent), there were no reoperations for bleeding; only 8 of 18 patients required postoperative blood transfusions. One patient died postoperatively from a colonic perforation, and there were no late mortalities after a mean follow-up of 19 months. In conclusion, this hybrid strategy has low morbidity and mortality and may be a new therapeutic option for older, high-risk patients with combined CAD and aortic valve disease.
The pathological variants of acute aortic syndromes include classic dissection, intramural hemato... more The pathological variants of acute aortic syndromes include classic dissection, intramural hematomas, and penetrating atherosclerotic ulcers (PAUs). The subject of the appropriate management and treatment of PAUs continues to expand as this disease entity is increasingly identified. The application of thoracic endografting, or thoracic endovascular aortic repair (TEVAR), to treat these acute aortic pathologies is clearly evolving and the ultimate effectiveness and durability of thoracic endografting remains to be determined as clinical experience increases. The disease pathology of PAUs and the use of endovascular stent graft placement in PAU disease are closely examined in this manuscript.
Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 2014
The use of monitoring or device lines through the ascending aorta may be necessary for a variety ... more The use of monitoring or device lines through the ascending aorta may be necessary for a variety of clinical situations. The technique provided in this article allows percutaneous closure of these entry sites with a closed chest.
Background. Optimal treatment for penetrating aortic ulcers has yet to be determined. Although op... more Background. Optimal treatment for penetrating aortic ulcers has yet to be determined. Although open surgical repair is an effective therapeutic option, less invasive alternatives such as endoluminal grafting are emerging as a potential adjunct for the treatment of penetrating aortic ulcers isolated to the descending thoracic aorta. We reviewed our cumulative experience with thoracic endografting for penetrating aortic ulcers of the descending thoracic aorta.
This manuscript presents a published record of the use and efficacy of the extracellular matrix C... more This manuscript presents a published record of the use and efficacy of the extracellular matrix CorMatrix and why it may be superior to other materials used for aortic root enlargement. The potential benefits of an extracellular matrix are the natural ingrowth and development of native arterial cells and structure.
Systemic lupus erythematosus (SLE) is an autoimmune disease in which organs, tissues, and cells u... more Systemic lupus erythematosus (SLE) is an autoimmune disease in which organs, tissues, and cells undergo damage mediated by tissue-binding autoantibodies and immune complexes. We describe the case of a 23-year-old African American woman with a history of recurrent pneumonias. Computed tomography, magnetic resonance imaging (MRI), and echocardiographic evaluations, as well as clinical and laboratory findings, indicated a diagnosis of SLE with inflammatory aortitis secondary to SLE vasculitis. A repeat MRI revealed a rapidly expanding aortic root and ascending aorta that required prompt operative repair. The ascending aorta and aortic root were replaced with a mechanical valved conduit, and a coronary artery bypass to the posterior descending artery was performed because of related erosion into the intima of the right coronary ostium. The patient has done well postoperatively. Aortitis and aortic aneurysms are an uncommon manifestation of SLE, and a literature search revealed an apparent association between aortic aneurysms and steroid medications for SLE. This case is the first report of aortitis resulting in a nondissecting aortic root aneurysm in an SLE patient without a history of steroid use, indicating that all SLE patients, including those without a history of steroid use, require screening for aortic disease to improve surgical outcomes and to prevent fatal complications.
Address reprint requests to Ronald M. Fairman, MD, Department of Surgery, University of Pennsylva... more Address reprint requests to Ronald M. Fairman, MD, Department of Surgery, University of Pennsylvania Medical Center, 3400 Spruce St. 4 Silverstein Pavilion, Philadelphia, PA 19104. ... No abstract is available. To read the body of this article, please view the PDF online.
Journal of Vascular and Interventional Radiology, 2008
The present report describes three cases of thoracic aortic endograft infolding or collapse invol... more The present report describes three cases of thoracic aortic endograft infolding or collapse involving the Gore TAG system. The cases include a penetrating aortic injury, a blunt aortic injury, and a symptomatic type B dissection. In the first case, infolding occurred in a delayed fashion after a normal-appearing 3-month follow-up computed tomographic angiogram. In the other two cases, infolding occurred during the immediate postoperative phase. One of the patients underwent explantation and surgical repair. The other two underwent endovascular repair of the infolded endograft by placement of a balloon-expandable stent in one case and a self-expanding stent in the other.
Journal of the American Society of Echocardiography, 2007
A case of a 35-year-old woman with acute circumferential type B aortic dissection is presented. A... more A case of a 35-year-old woman with acute circumferential type B aortic dissection is presented. A review of the literature demonstrated that circumferential aortic dissection is limited to a small number of case reports and a small case series of type A lesions. This is the first report of a circum-ferential type B dissection. The case highlights the need to fully evaluate patients with acute aortic dissection and illustrates the unique data provided by transesophageal echocardiography and helical computed tomographic angiography.
Suppression of prostacyclin (PGI 2 ) biosynthesis may explain the increased incidence of myocardi... more Suppression of prostacyclin (PGI 2 ) biosynthesis may explain the increased incidence of myocardial infarction and stroke which has been observed in placebo controlled trials of cyclooxygenase (COX)-2 inhibitors. Herein, we examine if COX-2-derived PGI 2 might condition the response of the vasculature to sustained physiologic stress in experimental models that retain endothelial integrity. Deletion of the PGI 2 receptor (the IP) or suppression of PGI 2 with the selective COX-2 inhibitor, nimesulide, both augment intimal hyperplasia while preserving luminal geometry in mouse models of transplant arteriosclerosis or flow-induced vascular remodeling. Moreover, nimesulide or IP deletion augments the reduction in blood flow caused by common carotid artery ligation in wild-type mice. Generation of both thromboxane (TxA 2 ) and the isoprostane, 8, 12 -iso iPF 2␣ -VI, are increased in the setting of flow reduction and the latter increases further on administration of nimesulide. Deletion of the TxA 2 receptor (TP) reduces the hyperplastic response to nimesulide and carotid ligation, despite further augmentation of TP ligand production. Suppression of COX-2 derived PGI 2 or deletion of PGI 2 receptor (IP) profoundly influences the architectural response of the vasculature to hemodynamic stress. Mechanism based vascular remodeling may interact with a predisposition to hypertension and atherosclerosis in contributing to the gradual transformation of cardiovascular risk during extended periods of treatment with selective inhibitors of COX-2. (Circ Res. 2005;96:0-0.)
The use of endovascular stents to treat descending thoracic aortic pathologies is emerging as a l... more The use of endovascular stents to treat descending thoracic aortic pathologies is emerging as a less invasive therapy to treat high-risk patients. This case report describes the presentation of a patient with a pulsatile mass on her back. The patient's computed tomographic scan revealed the mass to be an extension of a large psuedoaneurysm from the site of a previous repair of her thoracic aorta for a dissecting aneurysm several years earlier. The psuedoaneurysm was successfully treated with an endovascular stent and the patient was discharged home on postoperative day 5.
tine. In those patients, bromocriptine was not given because the role of prolactin in the pathoge... more tine. In those patients, bromocriptine was not given because the role of prolactin in the pathogenesis of PPCM was not yet known. However, the current knowledge of the benefit of prolactin inhibition suggests an additive effect, independent from ventricular unloading by mechanical support.
Background. Acute type A dissections require surgery to prevent death from proximal aortic ruptur... more Background. Acute type A dissections require surgery to prevent death from proximal aortic rupture or malperfusion. Most series over the past decade have reported a death rate in the range of 15% to 30%. The objective of this study is to examine the effect of an integrated surgical approach on the treatment of acute type A dissections.
Background. Optimal treatment for penetrating aortic ulcers has yet to be determined. Although op... more Background. Optimal treatment for penetrating aortic ulcers has yet to be determined. Although open surgical repair is an effective therapeutic option, less invasive alternatives such as endoluminal grafting are emerging as a potential adjunct for the treatment of penetrating aortic ulcers isolated to the descending thoracic aorta. We reviewed our cumulative experience with thoracic endografting for penetrating aortic ulcers of the descending thoracic aorta.
Background. The edge-to-edge technique (E2E) has been advocated for the complex repair of myxomat... more Background. The edge-to-edge technique (E2E) has been advocated for the complex repair of myxomatous mitral valves. We compared outcomes of E2E performed in patients at risk for systolic anterior motion (SAM) versus outcomes in patients with residual mitral regurgitation (MR) after repair completion.
In 2005, the investigators described a &a... more In 2005, the investigators described a "hybrid" cardiovascular interventional strategy combining percutaneous coronary intervention (PCI) for coronary artery disease (CAD) followed by valve surgery for patients with urgent complex CAD and valve disease to reduce morbidity and mortality. This hybrid approach has been extended prospectively in elderly, high-risk patients with aortic stenosis scheduled for elective minimally invasive aortic valve replacement (MI-AVR) who, on preoperative coronary angiography, were found to have moderate CAD amenable to PCI. In this prospective, observational series, 18 patients (mean age 76 years) underwent elective hybrid MI-AVR with PCI from May 2003 to February 2006. Five patients had undergone previous coronary artery bypass grafting. Patients underwent coronary angiography the day of (n = 12) or evening before (n = 6) MI-AVR, and after identifying moderately severe CAD, all 18 underwent the implantation of drug-eluting stents to the affected coronary arteries, followed by MI-AVR. Although all patients received standard doses of antiplatelet medications, including acetylsalicylic acid (325 mg before PCI and 325 mg/day thereafter) and clopidogrel (300 mg after PCI, 75 mg/day thereafter for 90 days for the Cypher stent), there were no reoperations for bleeding; only 8 of 18 patients required postoperative blood transfusions. One patient died postoperatively from a colonic perforation, and there were no late mortalities after a mean follow-up of 19 months. In conclusion, this hybrid strategy has low morbidity and mortality and may be a new therapeutic option for older, high-risk patients with combined CAD and aortic valve disease.
The pathological variants of acute aortic syndromes include classic dissection, intramural hemato... more The pathological variants of acute aortic syndromes include classic dissection, intramural hematomas, and penetrating atherosclerotic ulcers (PAUs). The subject of the appropriate management and treatment of PAUs continues to expand as this disease entity is increasingly identified. The application of thoracic endografting, or thoracic endovascular aortic repair (TEVAR), to treat these acute aortic pathologies is clearly evolving and the ultimate effectiveness and durability of thoracic endografting remains to be determined as clinical experience increases. The disease pathology of PAUs and the use of endovascular stent graft placement in PAU disease are closely examined in this manuscript.
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