Preoperative Troponin Levels Research Articles

Is del Nido cardioplegia safe in isolated coronary bypass surgery? It may be possible with this method

Objectives: This study aimed to share the early results of the del Nido (DN) solution used with a different method in patients who underwent isolated coronary bypass. Patients and methods: The retrospective study included 150 patients (123 males, 27 females; mean age: 59.8±9.7 years; range, 38 to 84 years) who underwent isolated coronary bypass operation between January 2020 and May 2022. The DN solution was applied differently from the practice in the literature. Seventy-five percent of the dose calculated according to the body weight of the patients was administered at the first moment. The remaining amount was continued to be given through the saphenous veins as distal anastomoses were made. When the cross-clamp was lifted, all grafts were tied to the aorta cannula, and the coronary vascular bed was cleared. Follow-up of patients was done routinely. Results: The mean preoperative ejection fraction was 49.9±5.6, and the mean postoperative ejection fraction value was 50.3±5.0 (p=0.079). A statistically significant difference was found between the preoperative troponin level and the postoperative troponin level at 6 h (p<0.001). However, there was no significant difference between the postoperative 6 h and the postoperative 24 h. Spontaneous rhythm occurred at the termination of cardiopulmonary bypass in most of the patients (97%). No permanent pacing was required in any patient. An intra-aortic balloon pump was used in nine patients, and extracorporeal membrane oxygenation was used in two patients. Two patients died in the early period. Conclusion: The use of DN with this method seems to be a reliable alternative to eliminate hesitations in isolated coronary bypass surgery.

Comparison of Early and Late Surgeries after Coronary Stent Implantation in Patients with Normal Preoperative Troponin Level: A Retrospective Study

Current guidelines recommend delaying noncardiac surgery for 6 months after drug eluting stent implantation. However, this recommendation is largely based on limited evidence and various event definitions. Whether early surgery within 6 months of coronary stent implantation increases myocardial injury in patients with normal preoperative high-sensitivity cardiac troponin I (hs-cTnI) has not yet been investigated. This retrospective study assessed patients who received coronary stent implantation and underwent noncardiac surgery (vascular, abdominal, or thoracic) between 2010 and 2017 with normal preoperative hs-cTnI (n = 186). Patients were divided into early (within 6 months of PCI) and late (after 6 months of PCI) groups. The primary endpoint was the incidence of myocardial injury as diagnosed by hs-cTnI within 3 days post-operation. The secondary outcomes were myocardial infarction, stent thrombosis, emergent coronary revascularization, major bleeding (bleeding requiring transfusion or intracranial bleeding), stroke, renal failure, heart failure, or death within 30 days post-operation. Inverse probability treatment weighting (IPTW) was carried out to adjust for the intergroup baseline differences. Myocardial injury occurred in 28.6% (8/28) and 27.8% (44/158) of the early and late groups, respectively, with no difference between groups (odds ratio [OR] 1.067, 95% confidence interval [CI] 0.404, 2.482; p = 0.886). Secondary outcomes did not differ between the groups. IPTW analysis also showed no differences in myocardial injury and secondary outcomes between the groups. In conclusion, early surgery within 6 months after coronary stent implantation did not increase the incidence of myocardial injury in patients with normal preoperative hs-cTnI.

Does Preoperative Troponin Level Impacts Outcomes after Coronary Artery Bypass Grafting?

Does Preoperative Troponin Level Impacts Outcomes after Coronary Artery Bypass Grafting?

Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction (NIHR Health Informatics Collaborative: TROP-CABG study)

Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction(NIHR Health Informatics Collaborative:TROP-CABG study). Benedetto et al. BackgroundThe optimal timing of coronary artery bypass grafting (CABG) in patients with non-ST elevation myocardial infarction (NSTEMI) and the utility of pre-operative troponin levels in decision-making remains unclear. We investigated (a) the association between peak pre-operative troponin and survival post-CABG in a large cohort of NSTEMI patients and (b) the interaction between troponin and time-to-surgery. Methods and resultsOur cohort consisted of 1746 patients (1684 NSTEMI; 62 unstable angina) (mean age 69 ± 11 years,21% female) with recorded troponins that had CABG at five United Kingdom centers between 2010 and 2017. Time-segmented Cox regression was used to investigate the interaction of peak troponin and time-to-surgery on early (within 30 days) and late (beyond 30 days) survival. Average interval from peak troponin to surgery was 9 ± 15 days, with 1466 (84.0%) patients having CABG during the same admission. Sixty patients died within 30-days and another 211 died after a mean follow-up of 4 ± 2 years (30-day survival 0.97 ± 0.004 and 5-year survival 0.83 ± 0.01). Peak troponin was a strong predictor of early survival (adjusted P = 0.002) with a significant interaction with time-to-surgery (P interaction = 0.007). For peak troponin levels <100 times the upper limit of normal, there was no improvement in early survival with longer time-to-surgery. However, in patients with higher troponins, early survival increased progressively with a longer time-to-surgery, till day 10. Peak troponin did not influence survival beyond 30 days (adjusted P = 0.64). ConclusionsPeak troponin in NSTEMI patients undergoing CABG was a significant predictor of early mortality, strongly influenced the time-to-surgery and may prove to be a clinically useful biomarker in the management of these patients.

Abstract 14169: Implications of Elevated Troponin on Time-to-Surgery in Non-ST Elevation Myocardial Infarction (NIHR Health Informatics Collaborative: Trop-CABG Study)

Background: The optimal timing of coronary artery bypass grafting(CABG) in patients with non-ST elevation myocardial infarction (NSTEMI) and the utility of pre-operative troponin levels in decision-making remains unclear. We investigated (a)the association between peak pre-operative troponin and survival post-CABG in a large cohort of NSTEMI patients and (b)the interaction between troponin and time-to-surgery. Methods: Our cohort consisted of 1746 NSTEMI patients(mean age 69±11 years, 21% female) with recorded troponins that had CABG at five United Kingdom centers between 2010 and 2017. Time-segmented Cox regression was used to investigate the interaction of peak troponin and time-to-surgery on early(within 30 days) and late(beyond 30 days) survival. Results: Average interval from peak troponin to surgery was 9±15 days, with 1466(84.0%) patients having CABG during the same admission. Sixty patients died within 30-days and another 211 died after a mean follow-up of 4±2years(30-day survival 0.97±0.004 and 5-year survival 0.83±0.01). Peak troponin was a strong predictor of early survival(adjusted P=0.002) with a significant interaction with time-to-surgery(P interaction=0.007). For peak troponin levels &lt;100 times the upper limit of normal, there was no improvement in early survival with longer time-to-surgery. However, in patients with higher troponins, early survival increased progressively with a longer time-to-surgery, till day 10. Peak troponin did not influence survival beyond 30 days(adjusted P=0.64). Conclusions: Peak troponin in NSTEMI patients undergoing CABG was a significant predictor of early mortality, strongly influenced the time-to-surgery and may prove to be a clinically useful biomarker in the management of these patients.

The predictive value of high-sensitive troponin I for perioperative risk in patients undergoing gastrointestinal tumor surgery.

BackgroundThe incidence of cardiovascular events in perioperative period of gastrointestinal tumor surgery cannot be ignored, and studies have shown that level of postoperative troponin is related to the postoperative risk of non-cardiac surgery. However, the relationship between pre-operative troponin levels and perioperative risk of gastrointestinal tumor surgery is unclear. Thus, we aimed to evaluate the value of high-sensitive cardiac troponin I (hs-cTnI) prior to gastrointestinal tumor surgery for perioperative risk assessment.MethodsIn this retrospective cohort study, 1259 patients who underwent gastrointestinal tumor surgery and had been tested for hs-cTnI on admission within 7 days prior to surgery were retrospectively recruited from January 2018 to June 2020. The primary combined endpoint including in-hospital all-cause mortality, acute myocardial infarction, cardiac arrest or ventricular fibrillation and acute decompensated heart failure. The secondary endpoint included total hospital stay and requirement of intensive care treatment.FindingsCompared with patients with normal hs-cTnI, those with elevated hs-cTnI (> 0·028 ng/ml) were more likely to experience the combined endpoint (28·2% versus 2·7%, P < 0·001) and there was also an increasing rate of in mortality in elevated hs-cTnI group (2·4% versus 0·3%, P = 0·057). The length of total hospital stay was significantly longer in patients with elevated hs-cTnI (24·8 ± 16·3 versus 19·5 ± 7·9, P = 0·003) and the number of patients requiring intensive care treatment was also higher (22·6% versus 4·2%, P < 0·001). The area under the ROC curve assessing hs-cTnI in predicting in-hospital mortality was 0·787 [95% confidence interval (CI) 0·612–0·963, P = 0·015] and for combined endpoint was 0·822 [95% CI 0·766–0·879, P < 0·001]. Hs-cTnI > 0·028 ng/ml was associated with significantly higher cardiovascular event rate in patients with the revised cardiac index ≤ 1. The positive likelihood ratio of hs-cTnI (> 0·028 ng/ml) for predicting combined endpoint reaches 10.5 in patients with Lee index = 0. In multivariate logistic analyses, hs-cTnI was one of the best predictors for the combined endpoint [odds ratio (OR) 5·924 (95%CI: 2·869–12·233), P < 0·001].InterpretationHs-cTnI provides powerful prognostic information for patients undergoing gastrointestinal tumor surgery, and therefore provides reliable prognostic information incremental to revised cardiac index.

The Predictive Value of High-Sensitive Troponin I for Perioperative Risk in Patients Undergoing Gastrointestinal Tumor Surgery

Background: The incidence of cardiovascular events in perioperative period of gastrointestinal tumor surgery cannot be ignored, and studies have shown that postoperative troponin is related to the postoperative risk of non-cardiac surgery. However, the relationship between pre-operative troponin levels and perioperative risk of gastrointestinal tumor surgery is unclear. Thus, we aimed to evaluate the value of high-sensitive cardiac troponin I (hs-cTnI) prior to gastrointestinal tumor surgery for perioperative risk assessment. Methods: 1259 patients who underwent gastrointestinal tumor surgery and had been tested for hs-cTnI on admission within 7 days prior to surgery were retrospectively recruited. The primary endpoint was in-hospital all-cause mortality and the combined endpoint including death, acute myocardial infarction, cardiac arrest and acute decompensated heart failure. The secondary endpoint included total hospital stay and requirement of intensive care treatment. Findings: Compared with patients with normal hs-cTnI (≤0.028ng/ml), those with elevated hs-cTnI were more likely to experience the combined endpoint (28·2% versus 2·7%, P < 0·001) and there was also an increasing rate of in mortality in elevated hs-cTnI group (2·4% versus 0·3%, P = 0·057). The length of total hospital stay was significantly prolonged in patients with elevated hs-cTnI (24·8 ± 16·3 versus 19·5 ± 7·9, P = 0·003) and the number of patients requiring intensive care treatment was also higher (22.6% versus 4.2%, P ＜0·001). The area under the ROC curve assessing hs-cTnI in predicting in-hospital mortality was 0·787 [95% confidence interval (CI) 0·612 - 0·963, P = 0·015] and for combined endpoint was 0·822 [95%CI 0·766 - 0·879, P ＜0·001], which was larger than revised cardiac index. Hs-cTnI＞0·028 ng/ml was associated with higher cardiovascular event rate according to the stratification of the revised cardiac index. In multivariate logistic analyses, hs-cTnI was the strongest independent predictor for the combined endpoint [odds ratio (OR) 7·454 (95%CI: 3·872-14·348); P < 0·001]. Interpretation: High sensitivity troponin I provides powerful prognostic information for patients undergoing gastrointestinal tumor surgery, and therefore provides strong prognostic information incremental to revised cardiac index. Funding: The Fundamental Research Funds for the Central Universities and the National Natural Science Foundation of China. Declaration of Interest: No potential conflict of interest was reported by the authors. Ethics Approval Statement: The study has been approved by the local ethical boards of the sixth affiliated hospital of Sun Yat-sen University.

Preoperative troponin levels and outcomes of coronary surgery following myocardial infarction.

This study evaluates the impact of peak preoperative troponin level on outcomes of coronary artery bypass grafting (CABG) for non-ST-elevation myocardial infarction (NSTEMI). This was a retrospective review of patients undergoing isolated CABG from 2011 to 2018 with the presentation of NSTEMI. Patients were stratified into low- and high-risk groups based on median preoperative peak troponin (1.95 ng/dl). Major adverse cardiac and cerebrovascular events (MACCE) and mortality were compared. Multivariable analysis was performed to model risk factors for MACCE and mortality. This study included 1211 patients, 607 low-risk (≤1.95 ng/dl) and 604 high-risk (>1.95 ng/dl). Patients were well-matched with respect to age and comorbidity. High-risk patients had lower median preoperative ejection fraction (46.5% [interquartile range {IQR}: 35.0%-55.0%] vs. 53.0% [IQR: 40.0%-58.0%]) and higher incidence of preoperative intra-aortic balloon pump (15.9% vs. 8.73%). Intensive care unit and hospital length of stay were longer in the high-risk group, but increasing troponin level was not associated with prolonged intensive care or hospital length of stay (>4 and >14 days, respectively) after risk adjustment. Postoperative complications and 30-day, 1- and 5-year rates of both MACCE and survival were similar between groups. Peak troponin greater than 1.95 ng/dl was not associated with increased hazards for MACCE, mortality, or readmission in multivariable modeling. In subanalysis, neither increasing troponin as a continuous variable nor peak troponin greater than 10.00 ng/ml were associated with increased hazards for these outcomes. Preoperative troponin levels do not appear to be predictive of short- or long-term outcomes following CABG, and clinical decisions regarding surgical revascularization should not be dictated by these measurements.

Association of pre-operative troponin levels with major adverse cardiac events and mortality after noncardiac surgery: A systematic review and meta-analysis.

Circulating cardiac troponin levels are powerful predictors of prognosis in many clinical settings, but their association with outcomes after noncardiac surgery is unclear. The aim of this systematic review was to summarise current evidence on the association of pre-operative troponin elevation with postoperative major adverse cardiac events (MACE) and mortality in patients undergoing noncardiac surgery. Systematic review of observational studies with meta-analysis. PubMed, EMBASE and Science Citation Index Expanded (ISI Web of Science) from their inception to 1 October 2017. Observational studies reporting the associations between pre-operative troponin levels and MACE and all-cause mortality after noncardiac surgeries were included. Ten studies met the eligibility criteria. The entire body of evidence addressing the research question was based on a total of 10 371 patients: 4.7 to 68.3% (median 23.8%) of patients had elevated troponin levels before surgery. Elevated pre-operative troponin was significantly associated with short-term MACE (seven studies, 5180 patients: odds ratio (OR) 6.92, 95% confidence interval (CI) 3.85 to 12.42), short-term mortality (five studies, 6103 patients: OR 4.23, 95% CI 2.27 to 7.89) and long-term mortality (two studies, 760 patients: OR 2.51, 95% CI 1.47 to 4.29). The associations remained significant when only multivariate-adjusted results were analysed. Overall, the reviewers' certainty about the summary estimates of the associations was very low. Current evidence suggests that pre-operative high troponin levels are significantly associated with adverse cardiac events and mortality after noncardiac surgery. This systematic review was registered in the International Prospective Register of Systematic Reviews (Centre for Reviews and Dissemination 42017077837).

Incidence of myocardial injury after non-cardiac surgery: Experience at Groote Schuur Hospital, Cape Town, South Africa.

Myocardial injury after non-cardiac surgery (MINS) is a newly recognised entity identified as an independent risk factor associated with increased 30-day all-cause mortality. MINS increases the risk of death in the perioperative period by ~10-fold. More than 80% of patients with MINS are asymptomatic, so the majority of diagnoses are missed. Awareness of MINS is therefore important for perioperative physicians. To investigate the incidence of MINS after elective elevated-risk non-cardiac surgery at Groote Schuur Hospital, Cape Town, South Africa (SA). Patients aged ≥45 years undergoing elective elevated-risk non-cardiac surgery were enrolled via convenience sampling. The new fifth-generation high-sensitivity cardiac troponin T blood test was used postoperatively to identify MINS. Preoperative troponin levels were not measured. Among 244 patients included in the study, the incidence of MINS was 4.9% (95% confidence interval (CI) 2.8 - 8.5), which was not significantly different from that in a major international prospective observational study (VISION) (8.0% (95% CI 7.5 - 8.4)); p=0.080. Our SA cohort had a lower cardiovascular risk profile but a similar incidence of MINS to that described in international literature. The impact of MINS on morbidity and mortality is therefore likely to be proportionally higher in SA than in published international studies. The limited sample size and lower event rate weaken our conclusions. Larger studies are required to establish patient and surgical risk factors for MINS, allowing for revision of cardiovascular risk prediction models in SA.

Does Preoperative Troponin Level Impact Outcomes After Coronary Artery Bypass Grafting?

As a marker of myocardial injury, troponin level correlates with adverse outcomes after myocardial infarction (MI). We hypothesized that patients with a higher preoperative troponin level would have increased morbidity and mortality after coronary artery bypass grafting (CABG). Preoperative troponin measurements were available for 1,272 patients who underwent urgent or emergent isolated CABG at our institution from 2002 to 2016. Logistic regression assessed the risk-adjusted effect of peak troponin level on morbidity and mortality. Long-term survival analysis was performed with Kaplan-Meier and Cox proportional hazards models. Preoperative troponin was positive in 835 patients (65.6%). The median peak troponin for this group was 3.2 ng/mL (interquartile range, 0.6 to 11.9 ng/mL), with a median time from peak troponin to the operation of 3 days (interquartile range, 1 to 4 days). Positive troponin was associated with more significant comorbid conditions and more extensive coronary artery disease. Operative mortality (3.7% versus 1.1%, p= 0.009), major morbidity (11.7% versus 3.9%, p < 0.001), and long-term mortality (median survival 12.5 years versus 13.6 years, p= 0.01) were increased in the positive troponin group. After risk adjustment, positive troponin was not independently associated with increased operative mortality (odds ratio, 2.61; p= 0.053). Adjusted and unadjusted analysis showed the peak preoperative troponin level did not independently predict death at any time point (all odds ratios, 1.0; p > 0.05). A positive preoperative troponin correlates with worse outcomes after CABG, but risk adjustment eliminates much of the short-term predictive value of this biomarker. Peak troponin level does not influence outcomes after CABG and is a poor predictor of events when The Society of Thoracic Surgeons predictive models are used.

Does Preoperative Troponin Level Impact Outcomes after Coronary Artery Bypass Grafting?

Does Preoperative Troponin Level Impact Outcomes after Coronary Artery Bypass Grafting?

97 Can pre-operative troponin levels predict post-operative mortality following non-cardiac surgery?

IntroductionDespite advances in surgical and anaesthetic techniques, non-cardiac surgery still has a significant mortality. We hypothesised that pre-operative troponin levels might predict post-operative mortality.MethodsPatients undergoing elective and urgent/emergency non-cardiac surgery...

Timing of Preoperative Troponin Elevations and Postoperative Mortality After Noncardiac Surgery

Even small elevations in preoperative troponin levels have been shown to be associated with adverse outcomes. However, there are currently limited data on the relationship between troponin increase and timing of surgery. We performed a single-institution, retrospective cohort study of 6030 individuals with a troponin measurement made during the 30 days preceding a noncardiac surgical procedure. Subjects with detectable troponin levels were separated into terciles based on both the magnitude of the value and the time elapsed between this value and the surgery. For those undergoing nonemergent procedures, these 9 cohorts were compared with the group of individuals with undetectable preoperative troponin levels using bivariable and multivariable logistic regression. Thirty-day mortality was 4.7% in the group with undetectable troponin levels and increased with higher concentrations, with rates of 8.9%, 12.7%, and 12.7% in the low, medium, and high tercile groups, respectively. Unadjusted risk of 30-day mortality was highest in those with the highest troponin levels and shortest duration between the measurement and surgery (odds ratio, 4.497; 95% confidence interval, 2.058-9.825). After adjusting for subject characteristics, troponin remained associated with 30-day mortality in several groups, including individuals with troponin levels in the normal range. Higher levels of preoperative cardiac troponin I were associated with higher postoperative mortality, and longer time to surgery appeared to reduce this risk for individuals with mild preoperative troponin elevations. Prospective studies are needed to determine whether delaying surgery in patients with elevated preoperative troponin levels improves postoperative outcomes.

Troponin levels after ICD implantation with and without defibrillation testing and their predictive value for outcomes: Insights from the SIMPLE trial

The Shockless IMPLant Evaluation trial randomized 2500 patients receiving a first implantable cardioverter-defibrillator (ICD)/cardiac resynchronization therapy-defibrillator device to have either defibrillation testing (DT) or no DT. It demonstrated that DT did not improve shock efficacy or reduce mortality. This prospective substudy evaluated the effect of DT on postoperative troponin levels and their predictive value for total and arrhythmic mortality. Troponin levels were measured between 6 and 24 hours after ICD implantation in 2200 of 2500 patients. A postoperative serum troponin level above the upper limit of normal (ULN) was more common in patients undergoing DT (n = 509 [46.4%]) than in those not subjected to DT (n = 456 [41.3%]; P = .02). After excluding patients with known preoperative troponin levels above the ULN, consistent findings were observed (42.1% vs 37.5%; P = .04). During a mean follow-up of 3.1 ± 1.0 years, the annual mortality rate was increased in patients with postoperative troponin levels above the ULN (adjusted hazard ratio [HR] 1.43; 95% confidence interval [CI] 1.15-1.76; P = .001) irrespective of DT or no DT. Likewise, patients with elevated troponin levels had a significantly higher risk of arrhythmic death (adjusted HR 1.80; 95% CI 1.23-2.63; P = .002). The rate of first appropriate ICD shock (adjusted HR 0.89; 95% CI 0.71-1.12; P = .32) or failed appropriate shock (adjusted HR 1.02; 95% CI 0.59-1.76; P = .95) was similar in patients with or without troponin elevation. DT at the time of ICD implantation is associated with increased troponin levels, indicating subclinical myocardial injury caused by the procedure. Elevated troponin levels but not DT seem to predict clinical outcomes in ICD recipients.

77. High preoperative myocardial ischemia biomarkers as predictors of postoperative mortality after CABG surgery: Short and mid term outcome of tertiary center experience

Objectives To evaluate the predictivity of preoperative serum myocardial ischemia biomarkers for postoperative (PO) mortality in patients undergoing coronary artery bypass grafting (CABG) surgery. Patients & methods The study included 300 patients with mean age of 62.2 ± 4.2 years. Patients were evaluated for preoperative risk factors and donated fasting blood samples for ELISA estimation of preoperative serum levels of creatinine (sCr), cardiac troponin T (cTnT) and cTnI and Creatine Kinase-myoband (CK-MB) Isoenzyme. Intraoperative and PO complications were determined. The 30-day PO mortality rate and total mortality rate at the end of follow-up period were determined. Results All surgeries were conducted successfully without intraoperative mortalities or complications. One patient died during the 1st 30-days after surgery, 11 patients died during a mean follow-up period of 22 month for a follow-up mortality rate of 3.7% and a total mortality rate of 4%. Non-survivors were significantly (p Conclusion Old age, multiple diseased vessels and low left ventricular ejection fraction in conjunction with high preoperative serum levels of myocardial ischemia biomarkers could predict PO mortality after CABG surgery. However, high preoperative troponin levels were significantly superior predictor for PO mortality than CK-MB.

The Prognostic Significance of Elevated Troponin Levels in Patients with Normal Coronaries Undergoing Surgery for Aortic Valve Stenosis

The Prognostic Significance of Elevated Troponin Levels in Patients with Normal Coronaries Undergoing Surgery for Aortic Valve Steno Objective: The outcome of aortic valve replacement (AVR) in patients without occlusive coronary artery disease who present with raised pre-operative troponin is not clear. We therefore, investigated the operative mortality and morbidity in this subset of patients undergoing urgent surgery for aortic stenosis. Methods: From a pool of 595 AVR patients in our institution’s database from July 2007 to July 2013, we reviewed the notes of all patients who underwent urgent surgery for aortic stenosis (n=57) and identified those with raised pre-operative troponin (n=16). We compared the observed operative mortality and major morbidity rates between patients with raised preoperative troponin levels (group I) and those with normal troponin levels (group II), and also with their predicted outcomes. Results: The baseline and operative characteristics for the two groups were comparable. There was a trend towards higher operative mortality for group I patients (18.8% versus 7.3% for group II, P=.07). Whereas, the observed operative mortality for group I far exceeded the predicted (18.8% vs 12.5%, p=.05), for group II the observed was slightly lower than the predicted operative mortality (7.3% vs 9.3%, p=.63). On the other hand, the observed mortality was well below the predicted for the elective patients. Conclusion: Patients with aortic stenosis and raised preoperative troponin undergoing urgent AVR may be at risk of higher operative mortality than predicted by the EuroScore. Further studies in this high risk group are warranted.

Acute Aortic Dissection with Intimal Layer Prolapse into the Left Ventricle

34-year-old male presented with acute onset ofsearing chest pain and was preoperatively diagnosedwith a Type A dissection limited to the ascendingaorta and arch. His preoperative troponin levels werenot elevated. The patient was scheduled for urgentrepairofaTypeAascendingaortaandtransversearchdissection under hypothermic circulatory arrest usingselective antegrade cerebral perfusion. The intraopera-tive transesophageal echocardiogram (TEE) examina-tion was performed using the Philips 5500 ultrasoundmachine with a Philips OmniPlane III ultrasoundprobe.Multiple views of the left ventricle (LV) revealed alarge intimal flap, prolapsing several centimeters intothe LV outflow tract during diastole. Severe (4)aortic insufficiency (AI) was diagnosed with colorflow Doppler, but regurgitant flow was containedwithin the prolapsing, intimal “sock.” No evidence ofregurgitantflowbeyondtheprolapsedintimallayerinthe LV outflow tract was demonstrated (Fig. 1). TheLV was dilated with moderate, global hypokinesis. Noregional wall motion abnormalities were noted andthe ejection fraction was estimated at 40%.Careful comparison of the aortic valve (AV) inmidesophageal (ME) long axis, and ME AV short axis(SAX) views suggested functional, bicuspid leafletexcursion, mild thickening, and no significant leafletcalcification or stenosis. The aorta was 2.6 cm at theAV annulus, 4.8 cm at the sinus of Valsalva, 7.2 cm atthe sino-tubular junction, and larger than 7.5 cm in thevisualized portion of the ascending aorta.Surgical inspection confirmed the diagnosis of bi-cuspid AV. The left/right coronary cusp was partiallyfused with a congenital cleft from the midportion tothe free leaflet edge. The intima of the sinus ofValsalva was 80% circumferentially torn, with ananchor point surrounding the left main coronary ostia.The surgeon performed a valve-sparing aortic rootreplacement using the David V re-implantation tech-nique with 32-mm Gelweave Valsalva graft (VascutekUSA Inc). The valve annulus was reduced in circum-ference with an aortic valvuloplasty, and the AV cuspcleft was closed with interrupted sutures. A buttonre-implantation of the left coronary ostia into the graftwas possible. The right coronary ostium was partiallydisrupted, and a saphenous vein graft bypass wasperformed.The patient was successfully weaned after 304 minof cardiopulmonary bypass, including 27 min of deephypothermic circulatory arrest. Moderate inotropicsupport was required. The cardiac function was de-pressed from baseline to an estimated 30% ejectionfraction. No new-onset regional wall motion abnor-malities were demonstrated.The postcardiopulmonary bypass TEE examinationrevealed a functional bicuspid valve with good excur-sion of leaflets and no subsequent aortic insufficiency.Planimetry of the effective orifice area measured 2.10cm