Late Surgical Outcomes Research Articles

Acute type a aortic intramural hematoma complicated with preoperative hemopericardium: early and late surgical outcome analyses

BackgroundAcute type A aortic intramural hematoma (ATAIMH) is a variant of acute type A aortic dissection (ATAAD), exhibiting an increased risk of hemopericardium and cardiac tamponade. It can be life-threatening without emergency treatment. However, comprehensive studies of the clinical features and surgical outcomes of preoperative hemopericardium in patients with ATAIMH remain scarce. This retrospective study aims to investigate the clinical features and early and late outcomes of patients who underwent aortic repair surgery for ATAIMH complicated with preoperative hemopericardium.MethodsWe investigated 132 consecutive patients who underwent emergency ATAIMH repair at this institution between February 2007 and August 2020. These patients were dichotomized into the hemopericardium (n = 58; 43.9%) and non-hemopericardium groups (n = 74; 56.1%). We compared the clinical demographics, surgical information, postoperative complications, 5-year cumulative survival rates, and freedom from reoperation rates. Furthermore, multivariable logistic regression analysis was utilized to identify independent risk factors for patients who underwent re-exploration for bleeding.ResultsIn the hemopericardium group, 36.2% of patients presented with cardiac tamponade before surgery. Moreover, the hemopericardium group showed higher rates of preoperative shock and endotracheal intubation and was associated with an elevated incidence of intractable perioperative bleeding, necessitating delayed sternal closure for hemostasis. The hemopericardium group exhibited higher blood transfusion volumes and rates of re-exploration for bleeding following surgery. However, the 5-year survival (59.5% vs. 75.0%; P = 0.077) and freedom from reoperation rates (93.3% vs. 85.5%; P = 0.416) were comparable between both groups. Multivariable analysis revealed that hemopericardium, cardiopulmonary bypass time, and delayed sternal closure were the risk factors for bleeding re-exploration.ConclusionsThe presence of hemopericardium in patients with ATAIMH is associated with an elevated incidence of cardiac tamponade and unstable preoperative hemodynamics, which could lead to perioperative bleeding tendencies and high complication rates. However, patients of ATAIMH complicated with hemopericardium undergoing aggressive surgical intervention exhibited long-term surgical outcomes comparable to those without hemopericardium.

Efficacy and predictors of success on laryngomalacia surgery: experience from a tertiary pediatric care center in Brazil

ObjectivesLaryngomalacia is the most common congenital cause of stridor; the natural history of the disease runs through to complete resolution by the age of two. Severe cases are characterized by cyanosis, hypoxia, apnea, furcular and/or subcostal retractions, aspirations, pulmonary hypertension, and failure to thrive and must undergo surgery. This study aimed to evaluate the success rates of supraglottoplasty in our hospital and evaluate the predictive factors for surgical success. MethodsCohort study, prospectively planned. 75 patients undergoing endoscopic surgery from July 2007 to July 2016 were analyzed at the Santo Antônio Children’s Hospital. The primary outcome was percentage of surgical success, defined as the absence of respiratory symptoms or presence of a mild stridor without retractions on the first post-operative month (late success). The secondary outcomes were the early surgical success (absence of respiratory symptoms or presence of a mild stridor without retractions on the first post-operative day). Results39 (58.2%) were male, with an average of 4.9 months. Surgical success on the first day was 80.6% (n=54). At the end of the 1st month, surgical success was 88.6%, considering only those who completed assessment. Twenty-one (34%) presented comorbidities. Presence of comorbidities, pharyngomalacia and GERD were associated with a worse result on the 1st postoperative day, whereas, at the end of the first month, presence of comorbidities, concomitant injuries (tracheo and bronchomalacia) and pharyngomalacia were the predictive variables of surgery failure. ConclusionSupraglottoplasty has high rates of efficacy and low morbidity. The presence of comorbidities and pharyngomalacia has shown association with a worse early and late surgical outcome. Synchronous airway lesions predict a worse surgical result at the end of the first month. GERD was associated with obstructive symptomatology only in the 1st post-operative day. Level of evidenceLevel 3 of evidence, according to the “The Oxford 2011 Levels of Evidence” from Oxford Centre for Evidence-Based Medicine.

Death, reoperation, and late cardiopulmonary function after truncus repair

ObjectiveTo identify the late surgical outcomes of truncus arteriosus. MethodsFifty consecutive patients with truncus arteriosus who underwent surgery between 1978 and 2020 at our institute were enrolled in this retrospective, single institutional cohort study. The primary outcome was death and reoperation. The secondary outcome was late clinical status, including exercise capacity. The peak oxygen uptake was measured by a ramp-like progressive exercise test on a treadmill. ResultsNine patients underwent palliative surgery, which resulted in 2 deaths. Forty-eight patients went on to truncus arteriosus repair, including 17 neonates (35.4%). The median age and body weight at repair were 92.5 days (interquartile range, 10-272 days) and 3.85 kg (interquartile range, 2.9-6.5 kg), respectively. The survival rate at 30 years was 68.5%. Significant truncal valve regurgitation (P = .030) was a risk factor for survival. Survival rates were similar between in the early 25 and late 25 patients (P = .452). The freedom from death or reoperation rate at 15 years was 35.8%. Significant truncal valve regurgitation was a risk factor (P = .001). The mean follow-up period in hospital survivors was 15.4 ± 12 years (maximum, 43 years). The peak oxygen uptake, which was performed in 12 long-term survivors at a median duration from repair of 19.7 years (interquartile range, 16.8-30.9 years), was 70.2% of predicted normal (interquartile range, 64.5%-80.4%). ConclusionsTruncal valve regurgitation was a risk factor for both survival and reoperation, thus improvement of truncal valve surgery is essential for better life prognosis and quality of life. Slightly reduced exercise tolerance was common in long-term survivors.

Early and Late Surgical Outcomes after Geometrical Infarct Exclusion for Post-Infarct Ventricular Septal Perforation.

Ventricular septal perforation (VSP) is a critical complication of acute myocardial infarction. Various surgical procedures for it have been developed; however, surgical outcomes remain unsatisfactory. In 2010, we introduced geometrical infarct exclusion (GIE) as a modification of the Komeda-David technique. This retrospective study compared the surgical outcomes of our geometric infarct exclusion technique to those of other surgical procedures. This study included 38 patients who underwent surgery for VSP. They were divided into patients who underwent GIE (GIE group; n = 17) and those who underwent other procedures (non-GIE group; n = 21). The clinical outcomes of the two groups were compared. Operation, cardiopulmonary bypass, and cardiac arrest times in the GIE group were significantly longer than those in the non-GIE group (p <0.001). A residual shunt was observed in one patient (5.8%) in the GIE group and eight (38.0%) in the non-GIE group (p = 0.026). No patients in the GIE group required a reoperation for the residual shut, while two patients required it in the non-GIE group (p = 0.492). Operative mortality was insignificantly different between the two groups. Geometric infarct exclusion has a longer procedural time than does other surgical procedures but can reduce the rates of residual shunts and reoperations.

Orchidopexy for congenital and acquired undescended testes ‐ Long‐term follow up needed

AbstractIntroductionUndescended testis (UDT) is the most common urological anomaly in boys with orchidopexy as the standard of treatment. However, characteristics of UDT and long‐term outcomes after orchidopexy had not been reported in our locality. This study aimed to review the late surgical outcomes of these patients in our centre.MethodsA retrospective review was performed on patients under 16 years old with orchidopexy done for UDT from 2005 to 2010. Patient demographics, UDT characteristics, pre‐operative imaging, peri‐operative complications and any late testicular ascent or atrophy were documented. Only those with 1‐year follow up after operation were included for long‐term outcome analysis.ResultsA total of 331 testes in 290 boys were included; 244 (73.7%) testes were congenital while 43 (13%) were acquired UDT. Of the 43 acquired UDT, 28 (65.1%) had been followed up by us for retractile testis and had significantly earlier orchidopexy than those who had not (6 vs 9.6 years; P = .04). More patients with acquired UDT had hypospadias (20%) compared with 2.3% in those with congenital UDT (P &lt; .001). The median follow up time was 8 years (1‐13 years) and the overall success rate of orchidopexy was 93.8% (271/289). The median time to detect any late complication was 17.5 months (3‐46 months).ConclusionAcquired UDT accounted for at least 13% of orchidopexies in our centre. Patients after orchidopexy should have a minimum follow up time of 4 years in order to detect any late failures. Early referral of retractile testes to a specialised paediatric surgical centre for regular follow up is recommended for earlier detection of acquired UDT. Boys with a history of hypospadias and retractile testes had higher risk of acquired UDT.

R27 A Single Centre Five Year Retrospective Case Study Analysing Risk Factors and Surgical Outcomes of Secondary Tricuspid Regurgitation Progression

Delayed Tricuspid Regurgitation after isolated left sided heart surgery is associated with decreased exercise tolerance and poor quality of life. This study aims to identify independent Predictor of Late TR progression and Surgical outcomes.

Abstract 15704: Morbidity and Mortality After Anatomic Repair of Congenitally Corrected Transposition of the Great Arteries: Understanding Risks for Patient and Family Counseling

Introduction: Anatomic repair of congenitally corrected transposition of the great arteries (ccTGA) generally poses short-term risk for presumed long-term functional benefit by restoring the left ventricle to the systemic circulation. Understanding early and late surgical outcomes is crucial for counseling patients and families. Methods: All patients with anatomic repair at a single institution from 1993-2018 were included. Follow-up data was obtained by contact with patients’ primary cardiologists. The primary outcome was long-term survival and the secondary outcome was freedom from reintervention. Univariate Cox proportional hazard model was used to identify risk factors for mortality. In-hospital mortality and morbidity were compared between the most recent (2010-2018) and past surgical eras. Results: Anatomic repair was performed in 118 patients: 64 Senning/arterial switch operations (ASO) and 54 Senning/Rastelli operations. Survival was 85%, 82%, and 70% at 1, 10, and 20 years after repair, respectively, and was significantly lower in the Senning/Rastelli group compared to Senning/ASO (Hazard ratio 3.0, p=0.01; Figure 1). Preoperative factors associated with mortality were heterotaxy syndrome (p=0.03) and right ventricular systolic dysfunction (p=0.01). During a median follow up of 9.4 years, 47 of 98 patients (48%) required surgical or catheter-based reintervention; median freedom from reintervention was 11.7 years. For the most recent era, 30 of 32 patients (94%) with Senning/ASO and 19 of 22 patients (86%) with Senning/Rastelli operations survived to hospital discharge. In-hospital morbidity was similar between eras (30% in 1993-2009 and 28% in 2010-2018, p=0.82). Conclusions: Short- and long-term outcomes are favorable following Senning/ASO. Mortality following Senning/Rastelli operations remains high, highlighting the need for careful patient selection and family counseling.

A small incision technique for repairing involutional lower eyelid entropion.

The objective of this paper is to describe and review our experience with Goldberg's small incision technique for use with involutional entropion. Retrospective consecutive interventional case series with validated late surgical outcomes were reported. All involutional entropion cases with horizontal laxity of less than 8mm were repaired with a small incision technique. Retractors were separated from the tarsus by blunt dissection made from three 4mm horizontal incisions. Three 6-0 double-armed polyglactin sutures were used to tighten retractors and the orbicularis oculi muscle. The sutures were removed 3weeks postoperatively or earlier if overcorrection continued during the first week of the postoperative period. Data were obtained for a postoperative follow-up period of at least 24months. A total of thirty-seven lower eyelids from thirty-one patients with involutional entropion were included in the study. Primary operations were performed on 31 eyelids and reoperations on six eyelids. The mean follow-up time was 40 ± 11months. Thirty-six (97.3%) of the eyelids had no recurrence. As overcorrection was seen postoperatively in ten eyelids (27%), a number of sutures had to be removed earlier than planned. The ectropion eventually resolved, and no recurrence was seen during follow-up in these patients. In our practice, the small incision technique has been highly effective in involutional entropion repair, with minimal complications. Although this approach does not directly address lateral canthal tendon laxity, the procedure has the advantages of being easy to learn and also that it can be combined with other procedures for tendon laxity.

Early and Late Surgical Outcomes after LigaSure and Conventional Diathermy Hemorrhoidectomy: A Comparative Randomized Study

Background: Hemorrhoidectomy is a known painful operation associated with a delayed convalescence. Aim: To report the early and late surgical outcomes after LigaSure and conventional diathermy hemorrhoidectomy. Patients and methods: Seventy-Seven patients with grade III and IV hemorrhoids were randomized into two groups; Group (I) treated with LigaSure hemorrhoidectomy and group (II) treated with conventional diathermy hemorrhoidectomy. The operative time, hospital stay, postoperative pain, analgesia, time of wound healing, return to work, postoperative complications and patients’ satisfactions were recorded in each group. Results: The patients treated with LigaSure hemorrhoidectomy had significantly less mean operative time (12.19 versus 35.3 min), postoperative pain score (5.12 versus 6.11), analgesia (11.97 versus 13.8 tablets) and time to return work (10.35 versus 14.94 days) than the patients who underwent conventional diathermy hemorrhoidectomy. Early postoperative complications were significantly less in the LigaSure group (P= 0.001), while late postoperative complications showed non- significant difference between both groups (P >0.05). Patients’ satisfactions were in favor of LigaSure group with significant statistical difference (P= 0.026). Conclusion: LigaSure is a superior alternative to conventional diathermy in doing hemorrhoidectomy due to less post- operative pain and analgesia, fast wound healing, early return to work and lower postoperative complications. Moreover, it is a simple and short time technique easy to learn.

Early and Late Surgical Outcomes of Acute Type A Aortic Dissection in Octogenarians

Although surgical outcomes of acute type A aortic dissection (ATAAD) have improved, it is still a high-risk procedure for octogenarians. This study analyzed early and late outcomes of surgical repair of ATAAD among octogenarians. From 1990 through 2016, 1,260 consecutive patients with ATAAD were emergently admitted to Jichi Medical University Hospitals. Of them, 1,026 patients who underwent emergency surgery for ATAAD within 48 hours of symptom onset were included in this retrospective study. Of these, 112 were aged 80 years or more (mean, 83.1 ± 2.7) and formed the octogenarian group; and 914 were aged less than 80 years (mean, 62.0 ± 11.4) and formed the control group. Early and late outcomes were compared. The inhospital mortality rate was 6.3% for theoctogenarian group and 7.4% for the control group(p= 0.85). No significant difference was observed in the causes of hospital death. Although the overall postoperative complication rate was not different (24.1% versus 23.0%), pneumonia was more frequent among octogenarians (p= 0.03). Multivariate analysis of hospital mortality did not indicate age 80 years or more as a risk factor. Overall postoperative survival for the octogenarian group was 84.6%, 70.5%, and 57.1% at 1, 3, and 5 years, respectively. For the control group, the rates were 89.1%, 85.6%, and 82.1%, respectively. Pneumonia and decrepitude were the major causes of remote death for the octogenarian group. No significant difference in the hospital mortality rate or the complication rate was observed between the groups. Emergency surgery for ATAAD in octogenarians could be performed with the same low risk observed for younger patients.

Rapid maxillary expansion in mouth breathers: a short-term skeletal and soft-tissue effect on the nose

IntroductionRapid maxillary expansion can change the form and function of the nose. The skeletal and soft tissue changes can influence the esthetics and the stability of the results obtained by the procedure. ObjectiveThe aim of this retrospective study was to evaluate the short-term effects of rapid maxillary expansion on the skeletal and soft tissue structures of the nose, in mouth-breathing patients, using a reliable and reproducible, but simple methodology, with the aid of computed tomography. MethodsA total of 55 mouth-breathing patients with maxillary hypoplasia were assessed and were divided into an experimental group treated with rapid maxillary expansion(39 patients, 23 of which were male and 16 female, with an average age of 9.7 years and a standard deviation of 2.28, ranging from 6.5 to 14.7 years) and a control group (16 patients, 9 of which were male and 7 female, with an average age of 8.8 years, standard deviation of 2.17, ranging from 5.11 to 13.7 years). The patients of the experimental group were submitted to multislice computed tomography examinations at two different points in time: (T1) pre-rapid maxillary expansion and (T2) three months after the procedure. The control group underwent to the same exams at the same intervals of time. Four skeletal and soft tissue variables were assessed, comparing the results of T1 and T2. ResultsThere was in the experimental group a significant increases in all the skeletal and soft tissue variables (p<0.05) but no significant alteration was found in the control group. When comparing the experimental group and the control group, the most important change occurred in the width of the pyriform aperture (p<0.001). ConclusionRapid maxillary expansion is capable of altering the shape and function of the nose, promoting alterations in skeletal and soft tissue structures. This kind of study may, in the future, permit the proper planning of esthetic procedures at the tip and base of the nose and also the performance of objective measurements in early or late surgical outcomes.

Early and late surgical outcomes of ileal pouch-anal anastomosis within a defined population in Sweden

Ileal pouch-anal anastomosis (IPAA), has become the procedure of choice in patients requiring reconstructive surgery for ulcerative colitis or familial adenomatous polyposis. The aim of this population-based study was to present data prospectively registered and retrospectively evaluated on the short-term and the long-term results of 124 consecutive IPAA performed chronologically by three surgeons in a single referral centre. All patients who underwent IPAA from 1993 to 2012 were included. Early and late morbidity and mortality were evaluated. Early complications were observed in 25 patients. There was one death from cardiac failure, high output stoma occurred in six patients and wound infection occurred in four patients. Complications were associated with higher BMI (P=0.032). Four patients had to be reoperated. Peroperative bleeding was reduced when using an ultrasonically activated scalpel for the perimuscular dissection (P<0.00001). Clavien-Dindo grade III-V affected five patients. Only one patient developed anastomotic leak and septic complications.Late complications occurred in 61 patients. There was no procedure-related mortality. Pouchitis was the most common complication (n=37). Primary sclerosing cholangitis and age younger than 40 years were associated significantly with a three- and two-fold increased risk of pouchitis, respectively. Small bowel obstruction was the second most common complication (n=16), more common in women (P=0.031). The pouch failure rate was low: 2.4%. Clavien-Dindo grade III-V affected 13 patients. In the hands of experienced high-volume surgeons, IPAA is a safe procedure associated with a relatively low early morbidity as well as an acceptable late morbidity.

Repair of Parachute and Hammock Valve in Infants and Children: Early and Late Outcomes

Parachute and hammock valves in children remain one of the most challenging congenital malformations to correct. We report our institutional experience with valve-preserving repair techniques and the early and late surgical outcomes in parachute and hammock valves in infants and children. From January 1990-June 2014, 20 infants and children with parachute (n = 12, median age = 2.5 years, range: 2 months-13 years) and hammock (n = 8, median age = 7 months, range: 1 month-14.9 years) valves underwent mitral valve (MV) repair. Children with parachute valves have predominant stenosis, whereas those with hammock valves often have predominant insufficiency. Intraoperative findings included fused and shortened chordae with single papillary muscles in children with parachute valves. MV repair was performed using annuloplasty, commissurotomy, leaflet incision toward the body of the papillary muscles, and split toward its base. Children with hammock valves have dysplastic and shortened chordae, absence of papillary muscles with fused and thickened commissures. MV repair consisted of carving off a suitably thick part of the left ventricular wall carrying the rudimentary chordae. The degree and extent of incision and commissurotomy is determined by the minimal age-related acceptable MV diameter to avoid mitral stenosis. During a median duration of follow-up of 9.6 years (range: 6.4-21.4 years), cumulative survival rate and freedom from reoperation in parachute valves were 43.7 ± 1.6% and 53.0 ± 1.8%, respectively. In hammock valves, during a median duration of follow-up of 6.7 years (range: 2.7-19.4 years), cumulative survival rate and freedom from reoperation was 72.9 ± 1.6% and 30.0 ± 1.7%, respectively. Age less than 1 year proved to be a high-risk factor for reoperation and mortality (P < 0.005). In conclusion, children with parachute and hammock valves, repeat MV repair may be necessary during the course of follow-up. Infants have a greater risk for reoperation and mortality.

Late Surgical Outcomes of Carotid Resection and Saphenous Vein Graft Revascularization in Patients with Advanced Head and Neck Squamous Cell Carcinoma

In head and neck squamous cell carcinoma, invasion of the carotid artery is a severe mortality predictor. We report an updated experience of 19 patients who underwent head and neck resection for squamous cell carcinoma with concomitant carotid reconstruction. This study aims to analyze overall survival rates, primary patency of the reconstructions, vascular and nonvascular complications, radiotherapy dosing as well as late follow-up and outcomes. From September 1997 to 2011, 19 patients with advanced squamous cell carcinoma with carotid artery invasion were submitted to resection and concomitant vascular reconstruction in a single referred oncological institution. Patient follow-up was done by means of periodic outpatient returns, where clinical and duplex scan evaluations were performed to study graft patency. The average length of follow-up was 23.3 (± 34.4) months. Nonvascular complications occurred in 6 patients (31.6%). Only 1 (5.3%) vascular complication was observed, resulting from the immediate occlusion of the carotid graft. All patients were submitted to preoperative, adjuvant, or curative intent radiotherapy during the course of the oncologic treatment, with varying doses. Overall disease-free survival, primary patency, and survival with patent graft rates in 5 years are respectively 12.9%, 93.1%, and 13.0%. Three patients (15.9%) are still alive, all without tumor recurrence, and present a disease-free long-term follow-up with patent grafts 21 months, 68 months, and 151 months after surgery. Aggressive surgical approach for patients with advanced squamous cell head and neck carcinoma with carotid invasion can lead to cure in a select group of patients. Saphenous vein grafts demonstrated favorable outcomes with low infection and high patency rates, suggesting a valid alternative for arterial reconstruction in these cases.

Postinflammatory medial meatal fibrosis: early and late surgical outcomes

To evaluate the primary and long-term surgical outcomes of patients with postinflammatory medial meatal fibrosis. A retrospective study was conducted of 14 ears (in 12 patients) with postinflammatory medial meatal fibrosis managed surgically. Outcome measures were primary (i.e. less than six months) and long-term (i.e. greater than five years) closure of the air-bone gap, and the incidence of otorrhoea and restenosis. At primary review, the mean air-bone gap ± standard deviation had decreased from 29.9 ± 11.6 dB to 12 ± 8.4 dB (p < 0.0006). Seven (50 per cent) ears had closure of the air-bone gap to within 10 dB. However, for the 9 ears receiving long-term review, the mean air-bone gap ± standard deviation increased to 19.3 ± 15.2 dB; there was no significant difference between this result and pre-operative values (p = 0.06). Of the 9 long-term review ears, 3 (33 per cent) showed closure of the air-bone gap to within 10 dB. Recurrent otorrhoea was the most common complication, occurring in 5 of the 9 long-term review ears (56 per cent); in addition, 3 (33 per cent) of these 9 ears developed restenosis. Over time, the success of surgery for postinflammatory medial meatal fibrosis diminishes. This was demonstrated in the present study by progressive post-operative hearing decline and a high prevalence of otorrhoea and restenosis.

Late surgical outcomes among congenital diaphragmatic hernia (CDH) patients: Why long-term follow-up with surgeons is recommended

BackgroundCDH patients experience multi-system morbidity. Despite apparent health, late childhood complications do occur. We reviewed the long-term surgical morbidity of our CDH patients to determine whether protracted clinical surveillance is warranted. MethodsA single-institution retrospective chart review of all CDH survivors treated from 1999 to 2011 who are followed at our CDH multidisciplinary clinic was performed. Descriptive and statistical analyses were performed to show risk of surgical complications over time. ResultsA total of 187 CDH patients were treated with 160 surviving to discharge (86%). Primary repair was performed in 115 (73%), and 42 (27%) underwent patch repair. CDH recurrence occurred in 23 (15%) at a median time of 0.7 (range 0–8.5) years (65% asymptomatic). Seventy percent of recurrences occurred before 2years and 17% after 4years. Bowel obstruction occurred in 12 (8%) at a median time of 0.7 (range 0.2–7.2) years post-repair, and chest deformity occurred in 13 (8%) at a median of 5 (range 1.1–6.8) years. For patch repairs, scoliosis occurred in 4 (10%) patients at a median age of 3 (range 0.6–5) years. ConclusionSurgical complications in CDH survivors are common, can occur many years later, and are frequently asymptomatic. Long-term surveillance of CDH patients is recommended for early identification and treatment of complications.

EComment. Coronary endarterectomy with or without inflow conduit?

We read with great interest the work by Takahashi et al. [1], investigating early- and mid-term outcomes of off-pump endarterectomy of the left anterior descending (LAD) artery. The study spanned a 5-year period (2008-2012) and included 12 patients. The results of the present study indicate that coronary endarterectomy can be carried out with a low operative risk in suitable patients, for whom a vascular territory would otherwise not have been revascularized. Of note, there were no ischaemic events in the early- and mid-term follow-up period. Surgeons are faced with an increasing number of patients with diffuse and advanced coronary artery disease. Therefore, many patients with diffuse LAD disease are currently considered inoperable by conventional coronary artery bypass grafting (CABG). Coronary endarterectomy of the LAD and the on-lay patch with a left internal thoracic artery are considered by many as a valuable option when applied in a highly selective manner to only that small percentage of target vessels otherwise not graftable [2, 3]. Indications for endarterectomy of the LAD artery include the absence of a vessel lumen, failure to pass a 1-mm probe or in-stent restenosis [4]. Coronary endarterectomy is technically challenging and care must be taken in dissecting the core from the adventitia and during the on-lay anastomosis because side diagonal artery branches could inadvertently be occluded. The surgeon must ensure that the entire plaque is removed with proper distal tapering. If distal tapering is not observed, then the arteriotomy should be extended. The left internal thoracic artery to LAD graft has long been established as the cornerstone of improved early and late surgical outcomes for CABG. If the atherosclerotic core is removed, then competitive flow from the native coronary bed may cause occlusion of the inflow conduit, raising concerns about long-term durability of the left internal thoracic artery in this patient population. Although the internal thoracic artery is the best-equipped arterial conduit to withstand the competition between graft flow and native coronary flow, the risk of graft attrition is not insignificant [5]. Therefore, coronary patch reconstruction after endarterectomy without an inflow conduit can be performed in the absence of proximal LAD stenosis in order to avoid graft failure. The merits of endarterectomy and arterial patch reconstruction have been reiterated by the present study. In some patients, coronary endarterectomy may be considered as the last option, but there are still many unanswered questions regarding the indications and long-term results of this treatment. Conflict of interest: none declared

Late complications and distal growth rates of Marfan aortas after proximal aortic repair†

Conflicting results have been reported on late aortic growth and complication rates of the descending thoracic aorta in patients with Marfan syndrome (MFS) after proximal aortic surgery. Of 198 Marfan patients followed up regularly, 121 (43% David-I, 7% David-II, 11% supracoronary replacement, 52% mechanical conduit, 8% arch replacement) were analysed after proximal aortic surgery retrospectively. 97% had MFS1, 3% MFS2 (Loeys-Dietz-Syndrome); 56% were male and the mean age was 35 ± 13 years. 65% were initially operated on for root/ascending aortic aneurysm and 35% for aortic dissections. Using automated computed tomography angiography and magnetic resonance angiography cross-sectional analyses, the mean diameters of the distal arch, mid-descending and distal supradiaphragmatic descending thoracic aorta were measured at early and late follow-up (mean 6.3 years for aneurysms and 4.7 years for dissections). The mean duration of clinical follow-up was 7.6 years and the cumulative clinical follow-up comprised 894 patient-years. At 20 years, overall freedom from distal aortic complications and/or reintervention was 76% (51-86%) for aneurysms and 52% (28-71%) for dissections (P = 0.03). In non-dissected aortas, distal aortic growth was significant, but minimal: arches grew from 25.2 ± 0.6 to 26.3 ± 0.8 mm (P = 0.01), mid-descending aortas from 22.2 ± 0.5 to 24.9 ± 1.2 mm (P = 0.05) and distal descending aortas from 22.1 ± 0.7 to 24.2 ± 1.4 (P = 0.02, 0.58 mm/year ± 0.5 mm). Dissected distal aortas increased by a mean of 0.3 ± 0.5 mm/year. Dissection (P < 0.001), urgent procedure (P = 0.02) and hypertension (0.052) were associated with larger distal aortic diameters at late follow-up and more significant aortic growth over time. Late distal complication rates are low for patients initially presenting with aneurysms. The risk of late distal reoperation is dictated by the initial pathology and by the presence of an initial dissection and not by faster distal aortic growth. Strategies to completely restore a non-dissected anatomy might improve late surgical outcome in Marfan's syndrome.

Análise da técnica de takeuchi usada para o tratamento da origem anômala da artéria coronária esquerda do tronco pulmonar

Evaluation of a case series of anomalous origin of the left coronary artery from the pulmonary artery corrected with the Takeuchi procedure, analyzing their immediate and late surgical outcomes as well as the related morbidity. To report a case series of anomalous origin of the left coronary artery from the pulmonary artery corrected with the Takeuchi procedure. The analysis was based on data collected from the medical records of 12 patients undergoing surgical correction between 1981 and 2003. The mean age of the patients was 5.9 +/- 1.7 months. The predominant manifestation was heart failure, especially in the infants. The baseline electrocardiogram showed a Q wave in DI and aVL and signs of myocardial ischemia in ten cases. Echocardiogram with a pattern of dilated cardiomyopathy and mitral regurgitation was found in six patients. The mean age at surgical correction was 31.8 +/- 14.3 months. The immediate surgical mortality was 16% (two patients), from cardiac dysfunction. In the outpatient follow-up we observed that the symptoms, ischemic electrocardiographic changes, cardiac function and mitral regurgitation improved. Three cases progressed with supravalvar pulmonary stenosis during follow-up. This heart disease should be suspected in every infant presenting with heart failure. Surgical correction with the Takeuchi procedure has proven efficient, with a low mortality rate. Cardiac function returns to normal and mitral regurgitation improves after surgical correction.

Mitral annulus calcification: determinants of repair feasibility, early and late surgical outcome

The aim of this study was to determine the factors influencing the feasibility of valve repair and the surgical outcome in patients with mitral annulus calcification. In 124 patients with mitral annulus calcification undergoing surgery, two entities were distinguished: Barlow disease (myxomatous leaflets, n=60) and fibroelastic deficiency (FED) (normal leaflets, n=64). The calcification score was lower (1.9 vs 2.8); the annulus was more dilated (ring 35 vs 32 mm) and ruptured chordae were more frequent (77% vs 37%) in Barlow than in FED (p<0.001). The clinical profile was different: age (60+/-14 vs 73+/-8 years, p<0.001), systemic hypertension (22% vs 70%, p<0.001), chronic renal insufficiency (5% vs 22%, p<0.01), cancer (7% vs 25%, p<0.01). Multifocal atherosclerosis was less frequent in Barlow than in FED: carotid disease (17% vs 54%, p<0.001), aortic atheroma (21% vs 51%, p<0.001) and coronary disease (22% vs 56%, p<0.01). Echocardiography showed two different patterns in Barlow and FED: aortic valve stenosis (1.7% vs 31%), left atrial diameter (54 vs 49 mm), left ventricular end-diastolic diameter (62 vs 54 mm), interventricular septal thickness (11 vs 13 mm), and systolic pulmonary pressure (40 vs 56 mmHg), respectively (p<0.001). Bacterial endocarditis was observed in 24 cases (19%). The surgical technique was a valve repair in 68% and a replacement in 32%. The repair rate depended upon the extent of annulus calcifications (p<0.001) and the type of degenerative disease (95% vs 44% in Barlow and FED p<0.001). In-hospital mortality was 14% (Barlow: 5% vs FED: 23%, p<0.01). The mean follow-up was 50+/-41 months. Overall 5-year year survival was 76% (Barlow: 90% vs FED: 64%, p<0.001) and survival free from cardiac event was 69% at 5 years (Barlow: 87% vs FED: 52%, p<0.001). Five-year survival was higher following repair than replacement (84% vs 64% p<0.001). Chronic renal insufficiency and bacterial endocarditis were two predictors of early and late death (p<0.01). The aetiopathogeny of the degenerative mitral disease responsible for annulus calcifications corresponded to distinct anatomical, clinical and echographic patterns. It was a main determinant of repair feasibility, early and late surgical outcome.