Aortic Replacement Research Articles

Mid-term outcomes of total neointima implantation in surgical repair of acute type A aortic dissection.

Total neointima implantation (patch neointima technique + triple-branched stent graft placement) has been performed in proximal aortic repair for acute type A aortic dissection (ATAAD) for more than 10 years at a center. However, there is no report on the mid-term outcomes with a control group of the surgical procedure. Consequently, the authors aimed to evaluate the safety and efficacy of this technique in this study. Patients who underwent the total neointima implantation were classified as Group A, and those who underwent the conventional aortic root reconstruction with the "sandwich" technique and the total aortic arch replacement were classified as Group B. Furthermore, the authors described the preoperative characteristics, operative data, and patient outcomes. Group A patients experienced a shorter surgery duration, lower volumes of perioperative bleeding, and fewer red blood cell transfusions. The incidence of neurological complications was significantly reduced in Group A. All patients maintained a normal range of proximal aortic sizes after surgery. Kaplan-Meier analysis revealed no significant differences between the patients in the two groups regarding cumulative mortality and the incidence of moderate-to-severe aortic insufficiency. In well-selected patients, total neointima implantation is an alternative procedure for the surgical repair of ATAAD.

Risk assessment for aortic dissection in Turner syndrome: The role of the aortic growth rate.

The risk of aortic dissection (AoD) is increased in Turner syndrome (TS) but predicting those at risk is difficult. Based on scarce evidence, preventive aortic surgery is recommended when aortic diameter increases >5 mm/year.To investigate the aortic growth rate in TS and TS-related conditions associated with aortic growth. We also reported our experience of women who suffered aortic dissection (AoD), and who had preventive aortic replacement. 151 adult TS were retrospectively identified. Women who had more than one transthoracic echocardiogram (TTE) after age 16 years were included in the aortic growth study. Aortic diameters at sinuses of Valsalva (SoV) and ascending aorta (AA) were analysed by two experts. 70/151 women had more than one TTE (interscan interval 4.7 years). Mean aortic growth was 0.13 ± 0.59 mm/year at SoV and 0.23 ± 0.82 mm/year at AA. Known risk factors for aortic dilatation and TS-related conditions were not associated with aortic growth. 4/151 women experienced AoD (age 25±8 years): two had paired scans for aortic growth, which was 0.67 mm/year at both SoV and AA in the first woman, and 11 mm/year (SoV) and 4 mm/year (AA) in the second. Only 1/4 of women with AoD survived; she used a TS cardiac-alert card to inform emergency personnel about her risk of AoD. 5/151 had a preventive aortic replacement, but one died post-operatively. Mean aortic growth in our TS population was increased compared to non-TS women and was not associated with currently known risk factors for AoD, suggesting that aortic growth rate itself could be a useful variable to stratify who is at risk for AoD.

Which Gelatin and Antibiotic Should Be Chosen to Seal a Woven Vascular Graft?

Among the vascular prostheses used for aortic replacement, 95% are woven or knitted grafts from polyester fibers. Such grafts require sealing, for which gelatin (Gel) is most often used. Sometimes antibiotics are added to the sealant. We used gelatin type A (GelA) or type B (GelB), containing one of the three antibiotics (Rifampicin, Ceftriaxone, or Vancomycin) in the sealant films. Our goal was to study the effect of these combinations on the mechanical and antibacterial properties and the cytocompatibility of the grafts. The mechanical characteristics were evaluated using water permeability and kinking radius. Antibacterial properties were studied using the disk diffusion method. Cytocompatibility with EA.hy926 endothelial cells was assessed via indirect cytotoxicity, cell adhesion, and viability upon direct contact with the samples (3, 7, and 14 days). Scanning electron microscopy (SEM) and energy dispersive spectrometry (EDS) were used to visualize the cells in the deep layers of the graft wall. "GelA + Vancomycin" and "GelB + vancomycin" grafts showed similar good mechanical characteristics (permeability~10 mL/min/cm2, kinking radius 21 mm) and antibacterial properties (inhibition zones for Staphilococcus aureus~15 mm, for Enterococcus faecalis~12 mm). The other samples did not exhibit any antibacterial properties. The cytocompatibility was good in all the tested groups, but endothelial cells exhibited the ability to self-organize capillary-like structures only when interacting with the "GelB + antibiotics" coatings. Based on the results obtained, we consider "GelB + vancomycin" sealant to be the most promising.

Anxiety-depressive disorders in patients before and in the long terms after aortic replacement

To study the structure and dynamics of anxiety-depressive disorders in patients with dissection/aneurysm of the ascending aorta and aortic arch before and in the long term after surgical treatment and to identify factors associated with disturbances in psycho-emotional status. We examined 124 patients with dissection/aneurysm of the ascending aorta and arch before and in the long-term period after aortic replacement, assessing anxiety and depression using the Generalized Anxiety Disorder (GAD-7) and Beck Depression Questionnaires. Multivariate regression analysis was used to identify factors associated with clinically significant anxiety and depressive disorders. Average scores on the GAD and the depression scale before surgery decreased from 6.5 (4.0-9.0) and 12.0 (8.0-16.0) to 3.0 (2.0-5.0) and 6.0 (3.0-10.0) (p<0.05) respectively, in the long-term postoperative period. There was no significant decrease in the proportion of patients with clinically significant levels of GAD and depression (p>0.05). Before surgery, clinically significant anxiety and depressive disorders are associated with older age, chronic cerebrovascular insufficiency (CCI) and atrial fibrillation (AF) in the hospital period. After surgery, clinically significant GAD was associated with older age, CCI, and a history of stroke. Depressive disorders were associated with older age and a history of stroke. In all patients with aortic disease, GAD and depression of varying severity are recorded; clinically significant GAD and depression are recorded in 19.2 and 23.2% of cases. In the long-term postoperative period, there is no significant decrease in the proportion of patients with clinically significant levels of GAD and depression, which amounted to 10.1 and 13.1%. Clinically significant anxiety and depressive disorders before and after surgery are associated with older age and the history of cerebrovascular disorders. In addition, the baseline clinically significant anxiety and depressive disorders showed an association with the subsequent development of AF in the early postoperative period.

Clinical Features and Postoperative Mobilization following Total Aortic Arch Replacement.

Open thoracic aortic surgery is believed to necessitate more intensive rehabilitation. This study aimed to compare the progress of postoperative rehabilitation between standard and delayed mobilization. A retrospective review was conducted on 199 patients who underwent isolated total aortic arch replacement via median sternotomy. Cases of in-hospital mortality and postoperative stroke were excluded. Based on the current guidelines for cardiovascular rehabilitation of the Japanese Circulation Society, patients were categorized into standard mobilization (could sit on the edge of bed within 2 days) and delayed mobilization (could not do so) groups. Rehabilitation progress was compared among both groups. Initial mobilization was delayed in 100 patients (delayed mobilization group), primarily because of respiratory failure (46.0%). Preoperative risk characteristics, including EuroSCORE II (median, 2.9 versus 3.5), were similar between the standard and delayed mobilization groups. The delayed mobilization group had longer operation (median, 6.1 versus 8.0 hours, P < 0.001) and cardiopulmonary bypass (median, 3.2 versus 4.1 hours, P < 0.001) times. Independent ambulation occurred earlier in the standard mobilization group (median, 6.0 versus 8.0 days, P < 0.001).In conclusion, early initiation of sitting on the edge of the bed within 2 days was associated with earlier independent ambulation during postoperative rehabilitation, which supports the current guidelines. Longer operation and cardiopulmonary bypass times were associated with delayed mobilization initiation, suggesting the need for more tailored approaches in such cases.

Serum Lidocaine Levels in Adult Patients Undergoing Cardiac Surgery With del Nido Cardioplegia

BackgroundLidocaine in del Nido cardioplegia solution prolongs the refractory period of cardiomyocytes, yielding a longer arrest per dose. Serum lidocaine concentrations >8 mg/L are associated with seizure and cardiotoxicity. We evaluated serum lidocaine concentrations in patients receiving del Nido solution during cardiac surgery. MethodsForty consecutive patients undergoing cardiac surgical procedures with del Nido cardioplegia were selected for serum lidocaine concentration measurements determined immediately after aortic cross-clamp removal. Variables included weight, body surface area, operation, cardiopulmonary bypass time, aortic cross-clamp time, and total volume of del Nido solution. The primary outcome was serum lidocaine concentration relative to total volume of del Nido solution. Descriptive statistics and Pearson correlations were computed. ResultsMedian weight was 78.3 kg (range, 43-132.4 kg), and mean body surface area was 1.9 ± 0.2 m2. Operations included coronary artery bypass grafting (n = 26 [65%]), a combination procedure (n = 5 [12.5%]), isolated mitral valve repair or replacement (n = 4 [10%]), isolated aortic valve replacement (n = 3 [7.5%]), and aortic repair or replacement (n = 2 [5%]). Median total volume of del Nido solution was 1870 mL (range, 800-5800 mL). Mean serum lidocaine concentration was 2.2 ± 0.6 mg/L. Serum lidocaine concentration was weakly correlated with del Nido solution volume (R2 = 0.21). The highest total volume of del Nido solution (5800 mL) did not yield the highest serum lidocaine concentration of 3.5 mg/L. ConclusionsSerum lidocaine concentration during cardiac surgical procedures weakly correlates with the volume of del Nido solution used and does not reach toxic levels even at high doses of del Nido solution. The results of this study may help alleviate concerns for lidocaine toxicity with high doses of del Nido solution.

Predictive Value of Serum CIRP in Acute Kidney Injury after Total Aortic Arch Replacement

Predictive Value of Serum CIRP in Acute Kidney Injury after Total Aortic Arch Replacement

Blood loss as the main cause of organ dysfunction after simultaneous ascending aorta and aortic arch replacement

Blood loss as the main cause of organ dysfunction after simultaneous ascending aorta and aortic arch replacement

Rapid formation of aortoesophageal fistula complicated by mycotic thoracic aortic aneurysm secondary to infective endocarditis.

A 73-year-old man was admitted with four weeks of intermittent fever. He had a history of total aortic arch replacement for aortic arch aneurysm four years prior. CT scans showed no abnormalities before admission. Repeated blood cultures yielded Streptococcus anginosus and Prevotella melaninogenica, suggesting infective endocarditis (IE). Transesophageal echocardiography revealed a vegetation on the aortic valve, confirming IE. He suddenly presented with massive hematemesis and hypotension. Endoscopy revealed an elevated lesion with a laceration but no active bleeding in the esophagus. CT scans showed a thoracic aneurysm involving the esophagus. A diagnosis of aortoesophageal fistula (AEF) complicated by mycotic thoracic aortic aneurysm (MTAA) was made, and he underwent stent graft interpolation followed by minimally invasive esophagectomy. MTAAs are more prone to rupture than arteriosclerotic aneurysms as they are usually not true but pseudoaneurysms. Antecedent infection, including endocarditis, sepsis, predisposes to MTAA. AEF is a rare but life-threatening cause of gastrointestinal bleeding characterized by Chiari's triad. There have been no reports of such rapid formation of AEF after the graft replacement, as shown here. A recent article reported a rapid formation (16 days) of AEF after thoracic endovascular aortic repair, emphasizing prosthetic infection as the most important risk factor. Our case underscores the importance of suspecting AEF and conducting repeated appropriate examinations even if initial examinations do not reveal any aneurysms.

Diabetes Mellitus Predicts Severe Respiratory Failure After Aortic Arch Replacement

Objective: The lung is a target organ of diabetes mellitus (DM) via glycation of pulmonary elastin and collagen. In addition, hyperglycemia facilitates hypercapnic respiratory failure, which is instead mitigated by low‐carbohydrate high‐lipid (LC‐HL) nutrition. We sought to determine the association between diabetes and severe respiratory failure (SRF, i.e., need of reintubation\tracheostomy) after open aortic arch replacement (AAR).Methods: Machine learning algorithms were evaluated for precision and recall (F2 score) and for clinical applicability to predict SRF. Conditional regression evaluated independent predictors of SRF after 1:2 propensity‐score matching.Results: Information on diabetic status was available in 1275 patients undergoing AAR (1997–2023). Although support vector machine presented the highest F2 score (F2 = 0.337), conditional inference trees provided the most clinically applicable algorithm: diabetes was the best predictor of SRF, which occurred in 20/150 diabetics (13.3%) vs. 40/1125 nondiabetics (3.6%) (p &lt; 0.01). In diabetics, left ventricular ejection fraction (LVEF) was the next best predictor of SRF, which occurred in 8/20 diabetics with LVEF ≤ 30% (40%) vs. 12/130 diabetics with LVEF &gt;30% (9.2%) (p = 0.02). In nondiabetics, chronic obstructive pulmonary disease (COPD) was the next best predictor of respiratory failure, which occurred in 14/177 nondiabetics with COPD (7.9%) vs. 26/948 nondiabetics without COPD (2.7%) (p = 0.01). In the matched sample, diabetes was independently able to predict SRF (OR 2.20, 95% CI 1.10 | 4.42).Conclusions: DM was the best predictor of SRF after AAR. Strict glycemic control and LC‐HL nutrition should be evaluated as measures to reduce postoperative SRF in diabetic patients.

Risk factors and outcome of aortic surgery patients with hypothermic circulatory arrest: can urine NGAL predict acute kidney injury?

Hypothermic circulatory arrest (HCA) is useful to protect visceral organs during aortic operations. The degree of hypothermia and the influence of renal damage remain controversial. To evaluate the incidence of acute kidney injury (AKI) comparing moderate HCA (MHCA) and deep HCA (DHCA) and determine risk factors and ability of urine neutrophil gelatinase associated lipocalin (u-NGAL) to predict AKI. We prospectively enrolled 58 patients who underwent aortic replacement with HCA during May 2019-August 2021. Patients were divided into 2 groups: DHCA (15-20°C) and MHCA (20-25°C). The primary outcome was incidence of AKI. Secondary outcomes included risk factors of AKI. Baseline characteristics were not different between the 2 groups. There were 37 patients in the DHCA group and 21 patients in the MHCA group. Each group was mostly diagnosed with acute type A aortic dissection (60.3%). The operation was hemiarch replacement (51.7%). The overall incidence of AKI was 65.6% according to KDIGO criteria; there was no statistically significant difference between DHCA and MHCA groups. Urine NGAL level at cut-off point > 20 ng/ml at hour 0 and > 70 ng/ml at hour 6 could predict AKI. Operation time more than 360 minutes was found to be a risk factor for AKI. In hospital mortality rates and neurological outcomes were not statistically significantly different between DHCA and MHCA groups. AKI is common in patients undergoing HCA with an overall incidence of more than 60%. Risk factors of AKI after aortic surgery include long operative time. U-NGAL in the early post-operative period can predict AKI.

A Case of Myocardial Infarction with Non-obstructive Coronary Arteries Complicated by a Ventricular Septal Rupture: The Challenge of Achieving Hemodynamic Stability Using Impella Devices.

The prognosis of myocardial infarction with non-obstructive coronary arteries (MINOCA) is reported to be as worse as myocardial infarction with obstructive coronary arteries. However, its mechanical complications are still poorly understood. A 71-year-old woman developed MINOCA after ascending aortic replacement surgery. During treatment, the patient experienced cardiogenic shock due to a ventricular septal rupture (VSR). The introduction of Impella devices reduced the left-to-right shunt and improved the patient's hemodynamics. Finally, a scheduled surgical repair was performed under stable conditions. In this report, we focused on the pathophysiology of MINOCA-related VSR and discussed the effectiveness of Impella devices as a bridge to surgical repair and circulatory backup during the perioperative period.

Hereditary Aortic Aneurysms and Dissections: Clinical Diagnosis and Genetic Testing.

Hereditary aortic aneurysms and dissections, such as Marfan syndrome, differ in that they occur in younger patients without generally recognized risk factors, have a predilection for the thoracic rather than the abdominal aorta, and are at risk for dissection even at smaller aortic diameters. Early diagnosis, careful follow-up, and early intervention, such as medication to reduce aortic root growth and prophylactic aortic replacement to prevent fatal aortic dissection, are essential for a better prognosis. Molecular genetic testing is extremely useful for early diagnosis. However, in actual clinical practice, the question often arises as to when and to which patient genetic testing should be offered since the outcome of the tests can have important implications for the patient and the relatives. Pre- and post-test genetic counseling is essential for early intervention to be effective. (This article is a secondary translation of Jpn J Vasc Surg 2023; 32: 261-267.).

Temporal trends in the utilization and outcome of transcatheter aortic valve replacement across racial and ethnic groups. A nationwide analysis.

BackgroundTranscatheter aortic valvular replacement (TAVR) improves outcomes in patients with aortic stenosis (AS). However, data describing racial disparities in the utilization and outcomes of TAVR are limited. We aimed to evaluate the utilization trends and outcomes of TAVR across racial and ethnic groups. MethodsAll patients who underwent TAVR in the United States from 2016 through 2020 were identified from the National Inpatient Sample database. Patients were classified according to their racial and ethnic groups as Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Hispanic, and Asian. We assessed racial and ethnic differences in the outcomes of TAVR using multivariate logistic regression analysis adjusting for age, sex, insurance, income, hospital location and teaching status, bed size, region, and the Charlson Comorbidity Index. ResultsOf the 280,290 patients who underwent TAVR, 89.5% were NHW, 4.24% were NHB, 4.9% were Hispanic, and 1.39% were Asian people. In 2016, the rates of all-TAVR procedures were 1.48 per 1000 patients among NHW group but 0.39 in NHB, 0.4 in Hispanic, and 0.47 in the Asian group. A steep rise was noted in the rate of TAVR among NHW but not in the NHB, Hispanic, and Asian groups. NHB patients had lower mortality rates (adjusted Odds Ratio [aOR]: 0.56; CI 0.35–0.88 p = 0.014) compared to their NHW counterparts. ConclusionThe racial and ethnic gap in the utilization of TAVR widened during the study period with minority groups being disproportionately less likely to receive TAVR. NHB patients who received TAVR had lower mortality rates than NHW.

A highly penetrant ACTA2 mutation of thoracic aortic disease

BackgroundThe role of ACTA2 mutations in Familial Aortic Disease has been increasingly recognized. We describe a highly penetrant variant (R118Q) in a family with aortic disease.Case reportA patient presented to us for elective repair of an ascending aortic aneurysm with a family history of his mother expiring after aortic dissection. Genetic testing revealed he was a heterozygous carrier of the ACTA2 missense mutation R118Q. Subsequently, all living family members were tested for this variant and a full medical history was obtained to compile a family tree for the variant and penetrance of an aortic event (defined as lifetime occurrence of aortic surgery / dissection). In total 9 family members were identified and underwent genetic testing with 7/9 showing presence of the ACTA2 R118Q mutation or an aortic event. All patients over the age of 50 (n = 4) had an aortic event. Those events occurred at ages 54, 55, 60, and 62 (mean event at 57.8 ± 3.9 years). Three family members with the variant under the age of 40 have not had an aortic event and most are undergoing regular aortic surveillance via CT scan.ConclusionsExisting studies of known ACTA2 mutations describe a 76% aortic event rate by 85 years old. The R118Q missense mutation is a less common ACTA2 variant, estimated to be found in about 5% of patients with known mutations. Prior studies have predicted the R118Q mutation to have a slightly decreased risk of aortic events compared to other ACTA2 mutations. In this family, however, we demonstrate 100% penetrance of aortic disease above age 50. In today’s era of excellent outcomes in elective aortic surgery, our team aggressively offers elective repair. We advocate for strict aortic surveillance for patients with this variant and would consider elective aortic replacement at 4.5 cm, or at an even smaller diameter in patients with a strong family history of dissection who are identified with this mutation.

Diagnostic Accuracy of an Algorithm for Discriminating Presumed Solid and Gaseous Microembolic Signals During Transcranial Doppler Examinations.

The aim of the work described here was to assess the diagnostic accuracy of a new algorithm (SGA-a) for time-domain analysis of transcranial Doppler audio signals to discriminate presumed solid and gaseous microembolic signals and artifacts (SGAs). SGA-a was validated by human experts in an artifact cohort of 20 patients subjected to a 1-h transcranial Doppler exam before cardiac surgery (cohort 1). Emboli were validated in a cohort of 10 patients after aortic valve replacement in a 4-h monitoring period (cohort 2). The SGA misclassification rate was estimated by testing SGA-a on artifact-free test files of solid and gaseous emboli. In cohort 1 (n=24,429), artifacts were classified with an accuracy of 94.5%. In cohort 2 (n=12,328), the accuracy in discriminating solid/gaseous emboli from artifacts was 85.6%. The 95% limits of agreement for, respectively, the numbers of presumed solids and gaseous emboli, artifacts and microembolic signals of undetermined origin were [-10, 10], [-14, 7] and [-9, 16], and the intra-class correction coefficients were 0.99, 0.99 and 0.99, respectively. The rate of misclassification of solid test files was 2%, and the rate of misclassification of gaseous test files was 12%. SGA-a can detect presumed solid and gaseous microembolic signals and differentiate them from artifacts. SGA-a could be of value when both solid and gaseous emboli may jeopardize brain function such as seen during cardiac valve and/or aortic arch replacement procedures.

Total Aortic Arch Replacement. Does a management protocol impact the results?

To describe the surgical protocol and the short and long-term results of aortic arch replacement surgery in a center in the metropolitan region of Santiago, Chile. Retrospective descriptive study from April 2015 to August 2022. Elective, urgent, and emergency patients were included, with diagnoses of arch aneurysm and acute or chronic type I and II DeBakey aortic dissection. Arterial cannulation at the brachiocephalic trunk, right axillary artery, or directly into the true lumen of the aortic dissection with Seldinger technique, guided by epiaortic and transesophagic ultrasound. Deep hypothermia at 24°C. Uni or bilateral antegrade cerebral perfusion according to runoff. Four devices were used: a straight tube, a tube with 3 or 4 branches, and a frozen elephant trunk. 37 patients were operated on; 24 of them were men. The average age was 57 years old. In seven patients, a straight tube with anastomosis was used with anastomosis on the island; in six patients, a tube with 3 branches; in ten patients, a tube with four branches; and in fourteen patients, a frozen elephant trunk. There were twenty-one patients (57%) with associated morbidity: prolonged mechanical ventilation 14 the most frequent, paralysis chordae in 7 patients; there were six neurological morbidities, one of them permanent, renal dysfunction in 5 patients, pneumonia associated with mechanical ventilation in 4 patients, reoperation due to bleeding in 4. There was no associated cardiac morbidity. Operative and global mortality at 30 days was 13.5%. Follow-up was closed in October 2022 and is complete in the 30 survivors; the average was 20 months. Two patients died in the follow-up at five years; the survival in the follow-up was 90%. The management protocol has good results regarding morbidity and mortality, similar to the international series.

Milestone Operations in Heart Valve and Aortic Replacement: Anniversaries Worth Remembering.

Seventy years ago, in 1952, Charles A. Hufnagel implanted a caged-ball prosthesis into the descending thoracic aorta, to treat a patient with aortic valve insufficiency. In 1962, 60 years ago, the first aortic homograft was implanted in a subcoronary position by Donald N. Ross and Brian G. Barratt-Boyes. Forty years ago, in 1982, the first anticalcification treatment was introduced in commercially manufactured porcine bioprostheses. All such important or even milestone events should be remembered, since they witness efforts made by those who have significantly influenced the clinical history of aortic and valvular diseases.

Contemporary experience with the Commando procedure for anterior mitral anular calcification

ObjectiveAnterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements. MethodsFrom January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs). ResultsBetween balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47). ConclusionsThe Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.

Refractory esophageal–mediastinal fistula successfully treated with endoluminal vacuum therapy and enteral nutrition using a double-lumen elemental diet tube: a case report

BackgroundAortic–esophageal fistula (AEF) after thoracic endovascular aortic repair (TEVAR) has a high fatality rate and is difficult to treat. Endoluminal vacuum therapy (EVT) has recently appeared and proven to be a useful method for anastomotic leakage.Case presentationA 76-year-old man underwent aortic arch replacement for a stent graft infection after TEVAR. Persistent mediastinitis and pyothorax were observed after aortic arch replacement, and further examination revealed an esophageal–mediastinal fistula (EMF). Over-the-scope clip (OTSC®) closure was performed to treat EMF but achieved no cure. Then, the patient was referred to our hospital. First, we removed the OTSC® that interfered with the treatment using the remOVE System® and started EVT using a double-lumen elemental diet tube (W–EDT®). The vacuum sponge was affixed to the vacuum side of W–EDT®, and enteral nutrition administered through W–EDT was combined with EVT. EMF was cured 11 days after EVT, and the patient was able to feed himself.ConclusionThe combination of EVT and enteral nutrition feeding using W–EDT® is a successful novel procedure to treat refractory EMF.