Search

Aortic dissection is a potentially lethal disease whose incidence in pregnant women can be up to 100 times that of the remaining adult population. In most cases, it presents as typical chest pain. We report the case of a 37yo obese woman diagnosed with chronic type A aortic dissection documented by a radiological finding 10 months after delivery., (Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Anomalous origin of one pulmonary artery from the aorta is rare. We report a case of a three-month-old infant with aortopulmonary window and anomalous origin of the right pulmonary artery from the ascending aorta. He underwent surgery with anastomosis of the right pulmonary artery, ligation of the aortopulmonary window and the patent duct. He was released under medical treatment and had no signs of pulmonary hypertension or heart failure.

Pulmonary hypertension (PHT) and the resulting right ventricle dysfunction are important risk factors in patients who undergo cardiac surgery. The treatment of PHT and right ventricle dysfunction should be focused on maintaining the correct right ventricle after load, improving right ventricle function and reducing the right ventricle pre-load and therefore reducing pulmonary vascular resistance by means of vasodilators. A combined therapy of vasodilators and medicines which have different mechanisms of action, is becoming an option for the treatment of PHT. We present a 65 year old woman that suffered from mitral regurgitation, aortic valve disease, tricuspid and ascending aortic dilation with 115mmHg of pulmonary artery pressure (by ultrasound evaluation). The patient was operated on of mitral, aortic valve and tricuspid plastia and proximal aortic artery plastia as well. Previosly to surgery the patient suffered right ventricle dysfunction and PHT and was treated with nitric oxide, intravenous sildenafil and levosimendan. Subsequent evolution was satisfactory, PHT being controlled, without arterial hypotension nor respiratory alterations., (Copyright © 2013 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

We describe the detection of postoperative neurologic complications by means of monitoring cerebral oximetry during cardiac surgery. A 54-year-old man underwent emergency surgery for aortic dissection, type A. Cerebral oximetry was monitored by near-infrared spectroscopy. At the start of total cardiopulmonary bypass through the axillary artery, cerebral oxygen saturation fell more than 50% from baseline in both hemispheres. Saturation did not improve on optimizing factors that influence cerebral blood flow. Improvement came only when the recently inserted arterial cannula was switched to the ascending aortic prosthetic graft. After surgery, the patient was diagnosed with anoxic brain injury. We believe that the detected fall in cerebral oxygen saturation during axillary artery cannulization probably coincided with the occurrence of anoxic brain injury.

Cannulation of the axillary artery is one possible means of establishing cardiopulmonary bypass during surgery of the ascending aorta and aortic arch. Use of a Dacron graft for cannulation has a number of advantages. In this article, we report our experience with this technique in seven consecutive patients in whom we performed an ascending aorta replacement. The associated procedures involved were aortic root reconstruction using David's procedure in two patients, the Bentall procedure in one, the hemi-arch technique in two, the complete arch and elephant trunk technique in one, aortic valve repair in one, and Valsalva sinus reconstruction in one. Circulatory arrest with antegrade cerebral perfusion was carried out in three cases. There was no in-hospital mortality, and there were no vascular or infectious complications related to axillary access. One patient presented with transient paresthesia of the brachial plexus. In all cases, cardiopulmonary bypass flow was adequate.

The aorta is considered as pathologically dilatated when the diameter of the aortic root and of the ascending aorta is exceeding 50% of its standard diameter for a determined body masc. The aortic root dilatation is frequently associated with valve's pathology, rupture and dissection are two serious events that might occur; are linked with high mortality and are closely connected to aortic diameter and to wall's pathology, so that the elective indication is essential and it basically depends on those two factors. There are different technical alternatives, anatomical and functional, of the aortic root, the procedure's election is most specially based on patient's age, on pathological substract, on anticoagulation risk, and on possible infection, etc. We wish to report our experience performed from 1990 onto 2004 with 364 cases of aortic root surgery, of which 312 were elective interventions and 52 were emergencies, with a mortality of 4.8% and 19.2% respectively, and a global mortality of 6.8% using the different procedures. The choice of procedure is a multifactorial decision and it is necessary try offering the patient, the most idoneus individualized solution, according to personal characteristics. The different surgical techniques (valved conduits, remodelling procedures, biological grafts, etc.) can be carried out with low figures of morbid-mortality and excellent long term outcomes.

Objective: To present our experience in the echocardiographic diagnosis of anomalous origin of one pulmonary artery from the ascending aorta (AOPA). To analyze its clinical presentation, treatment and outcomes with special emphasis in the echocardiographic data., Method: We reviewed restrospectively the clinical, hemodynamic data, and surgical findings of patients with an echocardiographic diagnosis of AOPA studied in the Hospital Infantil of Mexico "Federico Gomez" from 1991 to 2002., Results: The study includes 12 children with AOPA; Seven were males. The average age at diagnosis was two months; 4 in neonatal period, 3 under 1 year and 5 older than 1 year. The diagnosis was established prospectively by echocardiography in all patients and it was confirmed by angiography in 8 and at surgery in 9. Ten had anomalous origin of right pulmonary artery. The associated anomalies were patent ductus arteriosus in 6, ventricular septal defect in 2 and aortopulmonary window, atrioventricular discordance, double outlet right ventricle and tetralogy of Fallot in one case each. Nine underwent corrective surgery of all the anomalies. One patient died on the sixth postoperative day; the remaining are in good condition without stenosis at the site of the anastomosis. Surgery was refused in one. One patient was not candidate to surgery due to advanced obstructive pulmonary vascular disease (OPVD) and one case is awaiting surgery., Conclusion: The diagnosis of AOPA may be established with precision through echocardiography. Cardiac catheterization is seldom needed to confirm morphology but is mandatory in older children with suspected of OPVD.

In a prospective study made between 1 September 1996 and 31 December 2001, pediatric patients with a diagnosis of supravalvular aortic stenosis confirmed by a reduction in the aortic inner diameter and a gradient > or = 50 mmHg were detected. Of 83 patients with aortic stenosis, only 7 (8.4%) had supravalvular aortic stenosis. All 7 patients underwent surgical treatment consisting of resection of fibrous tissue and reconstruction of the ascending aorta with a preclotted Dacron patch. One patient with severe, diffuse stenosis died and the another had perioperative heart failure, cardiac arrest and reversible neurological sequelae. A significant decrease in the postoperative gradient was obtained (p < 0.05). At present all surviving patients are free of symptoms. It was concluded that supravalvular aortic stenosis is infrequent in Mexico. In our experience, surgical treatment produced good results and success depended on the magnitude and type of stenosis.

Introduction and Objectives: Aortopulmonary septal defect is an uncommon congenital cardiac anomaly. To date, approximately 300 cases have been reported. We present our experience, emphasizing the importance of early correction to avoid irreversible pulmonary hypertension., Patients and Method: Between 1979 and 2000, seven patients underwent surgical repair of this heart defect in our hospital. Two had type I (proximal), 4 had type II (distal) and 1 had type III (complete). Complex associated cardiac anomalies were present in 4 cases: type A interruption of the aortic arch in 2 cases, hypoplastic aortic arch in 1 and transposition of great arteries with ventricular septal defect in 1. Four cases (57%) were diagnosed by echocardiography. In all patients diagnoses were confirmed by cardiac catheterization. Patient records were reviewed retrospectively, with special attention to clinical, echocardiographic and hemodynamic data as well as surgical characteristics., Results: No intraoperative deaths occurred. The patient with associated transposition of great arteries died 22 days after surgery as a result of severe pulmonary hypertension. The remaining patients are asymptomatic without treatment after a mean follow-up period of 69 months., Conclusions: Even though aortopulmonary septal defect is a rare anomaly, it should be considered whenever the course of complex congenital heart disease includes early cardiac failure and pulmonary hypertension. Repair before 6 months will prevent irreversible damage of pulmonary vessels.

Objective: To describe complications and mortality in patients diagnosed of Stanford's type A (Daily) dissection of the ascending aorta requiring circulatory arrest for emergency placement of an aortic graft., Patients and Methods: Retrospective study of 21 patients treated between December 1992 and November 1997., Results: Hypertension was the disease most often associated with the diagnosis (in 8 of the 21 patients). Preoperative mortality was 9.5% (2 of the 21 patients), no deaths occurred in the operating room and postoperative mortality was 15.8% (3 of the 19 patients who underwent surgery). Durations in mean time (SD) in minutes were as follows: anesthesia-surgery 437.9 (92), extracorporeal circulation 192.5 (47), aortic clamping 82.6 (20), circulatory arrest 30.5 (8). Retrograde cerebral circulation was carried out during circulatory arrest in all cases. Mean temperature during this period was 14.9 degrees C. During the postoperative period we recorded three permanent neurological complications, six cases of acute renal failure and seven respiratory complications, specifically one instance of adult respiratory distress syndrome and six of pneumonia, the most common. Consumption of blood products was high, with great interindividual variation., Conclusion: Anesthesia for and recovery from surgery for acute aortic dissection is complex and associated with a high rate of postoperative complication and high consumption of blood products.

The development of a pseudoaneurysms of the ascending aorta is a potential complication after composite grafts surgery for combined disorders that simultaneously affect the aortic valve and ascending aorta. Pseudoaneurysm has been reported to range from 7% to 25% of cases, and it is due to dehiscence of the suture line at anastomosis. Clinical spectrum, which depends on the location of this dehiscence varies from the totally asymptomatic patient to one with NYHA class IV heart failure, with the possibility of its clinical status rapidly worsening. We report a case of progressive haemodynamic deterioration as a consequence of a peri-annular dehiscence that led to a significant regurgitant volume from the pseudoaneurysm cavity to the left ventricle mimicking a severe aortic insufficiency. The role of echocardiography is reviewed in the diagnosis and the management of complications, as well as the necessary follow up of patients with composite aortic grafts.

Introduction: Improvement in cardiac surgery techniques has led to a considerable reduction in mortality following surgery of the aorta, dissection of the aorta and for aortic aneurysms. Although there are satisfactory vascular results following surgical repair, morbi-mortality related to neurological complications, both cerebral and spinal, is still very high. Repair of aortic lesions may lead to damage by two main mechanisms: ischemia secondary to prolonged obstruction of the aorta or to neurological lesions due to total circulatory arrest., Development: After description of the mechanisms leading to cerebral and spinal lesions and the risk factors involved, we discuss methods of vascular protection and other means of neuro-protection, both spinal and cerebral. Of the vascular techniques for spinal protection, the most useful ones are short-circuits, or active or passive shunts, and cardiopulmonary by-pass. Amongst the vascular techniques for cerebral protection we describe total circulatory arrest and methods of anterograde and retrograde cerebral perfusion, and when these may be used. As general measures for nervous system protection, we describe the use of hypothermia and drugs such as corticosteroids, free radical blockers, antagonists of the excitatory amino-acids etc., Conclusions: In spite of the number of studies done, the extreme sensitivity of the nervous system to ischemia has meant that in few cases have encouraging results been seen. Neurological damage continues to be the main cause of morbi-mortality in patients with dissection or aneurysm of the aorta.

Objectives: To assess the efficacy of a warm air convection (WAC) system to supplement the usual physical means (electric blanket, warm i.v. fluids and covering of exposed surfaces) for preventing an correcting hypothermia during surgery in 2 patient groups scheduled for vascular surgery., Patients and Methods: We studied 70 consecutive patients scheduled for vascular surgery. Group I: a WAC system, in addition to the usual methods, was used to attempt to maintain normal body temperatures in 35 consecutive patients. Fifteen were undergoing aortic surgery (group Ia) and 20 were undergoing revascularization of the lower extremities (group Ib). Group II: only the usual physical methods were used to maintain normal temperature in the remaining 35 patients, 15 of whom required aortic surgery (group IIa) and 20 of whom were undergoing revascularization of the lower extremities (group IIb). Type of anesthesia and monitoring were the same in all cases. Esophageal temperature (ET) and room temperatures were recorded at baseline and every 30 min until the end of surgery. ET was not allowed to fall below 35 degrees C in any patient and WAC was provided to patients in group II if they required it., Results: All patients in group II experienced a gradual decrease in ET, which became significant 30 min after start of surgery in group IIa and 60 min after start of surgery in group IIb. Temperature was stable during surgery in all patients in group I. All patients with ET of 35 degrees C in group II experienced a rise in temperature, which was significant after 60 min. when WAC was used., Conclusions: In vascular surgery, whether aortic or peripheral, patient temperature fell in spite of use of the usual physical methods for warming. Adding WAC for upper body warming prevented loss of heat. The WAC system was also effective for patients who needed to be rewarmed.

The surgical treatment of diffuse subaortic stenosis by insertion of a left ventricular apico-aortic valved conduct and Konno-Rastan procedures often fails to provide satisfactory results. These procedures require the insertion of a prosthetic valve. Some patients with diffuse subaortic stenosis have a normal aortic orifice and the replacement of normal aortic valve is questionable. Since 1984 Vouhé' modification of the Konno' procedure was using this described with adequate relief of the diffuse subaortic stenosis preserving the aortic valve. We present our experience with 5 patients in 10 years was using this surgical alternative.

Between May 1993 and August 1994, 15 patients (10 men) with type A aortic dissection (9 acute) had a replacement of the ascending aorta and/or aortic arch with circulatory arrest with profound hypothermia and retrograde cerebral perfusion. Mean circulatory arrest time was 47.5 min (range 23 to 68 min). Three patients (20%) died in relation to postoperative bleeding. No patient had a new neurologic damage related to surgery. Ten patients were awake and oriented before 24 hours of the operation and another one before 48 hours; 4 patients required more than 48 hours to be completely awake and oriented. Two patients were operated on with a recent stroke. One of them recovered without sequelae before hospital discharge and the other one had a major regression of his brain damage. Two other patients had emergency surgery because of cardiac tamponade and cardiogenic shock. Both of them had a satisfactory recovery. Six patients presented azotemia but only 2 of them needed dialysis. There was no case of Q wave infarction nor congestive heart failure in the perioperative period. Follow-up was 100% completed (12 patients) with a mean of 9.8 months (range 5 to 18 months). One patient died on the 10th postoperative month because of a late infectious process. Eight patients are in functional class I and 3 in II. Ten of them are back to their usual activities'. Although retrograde cerebral perfusion is a new surgical technique, it seems to be a very valuable complement for brain protection in ascending aorta and/or aortic arch surgery with circulatory arrest with profound hypothermia.

Introduction and Objectives: The purpose of this study is to show our experience in the treatment of aneurysms of the ascending aorta in patients with previous aortic valve surgery., Methods: We studied retrospectively the clinical characteristics and operative methods of 9 patients who underwent surgery for aneurysm of the ascending aorta after previous aortic valve replacement., Results: Time interval between the first and subsequent reoperation was 8.4 +/- 3.5 years (range 4-15 years). During the first operation there were 5 cases who presented with aortic regurgitation and dilatation of the ascending aorta. Isolated valvular aortic replacement was performed in these patients. Two patients underwent valvular replacement and implantation of supracoronary aortic graft. In two other cases valvular replacement was done with wedge resection of the aortic sinuses. Reoperation was performed because to the following reasons: valvular prosthesis disfunction and aneurysm of the ascending aorta (3), valvular prosthesis disfunction and aneurysm of the aortic remnant located between the prosthesis and the supracoronary aortic graft (2), thrombosis of the prosthesis (1), dissection of the ascending aorta (2) and superior vena cava syndrome (1). There was one hospital death. Another patient died after 26 months because of graft infection. The other 7 patients are in functional class I., Conclusions: We conclude that an aggressive surgical approach should be adopted in patients with degenerative aortic regurgitation and moderate dilatation of the ascending aorta because of the rapid progression of the aortic disease. We advise complete replacement of the aortic root.

Arterial switch correction of transposition of the great arteries has been performed without mortality on 8 children, 7 neonates and one 6 years old child, at our institution. One infant and the 6 year old child has previous pulmonary artery banding and modified Blalock-Taussig shunts. The coronary cuffs were anastomosed to the neo-aorta using the "trap-door" technique described by Mee and in seven the Lecompte manoeuvre was used. Postoperative management included treatment for persistent pulmonary hypertension and left ventricular dysfunction. All patients were discharged in satisfactory condition, and continue to do so at a maximum follow-up of ten months. These results encourage us to elect the arterial switch procedure as the primary treatment of transposition of the great arteries.

A case of atypic coarctation at the aortic arch in an adult patient is described. Coarctation was surgically treated by a retrosternal bypass from the ascendant aorta to the supra-celiac aorta. After a short prelude the clinical case is summarized. Furthermore, the etiopathogenic features of the disease, the different diagnostic methods and the multiple surgical procedures are discussed. Finally, we briefly review the literature.

The aortopulmonary window is a rare congenital disease in which the aorta and pulmonary arteries are communicated by a defect of variable diameter. We review the clinical picture, diagnosis, associated lesions and treatment of four patients with this disease in a period between 1980 and 1990. Two patients had a distal and two a proximal type. There were associated lesions in three patients: Aortic arch interruption type A, patent ductus arteriosus, subaortic stenosis and a ventricular defect. All patients underwent surgical correction of a communication between 12 and 15 mm of diameter. We discuss diagnostic problems and treatment of this congenital disease.

We report the case of an infant operated on at 11 months, having been clinically, echocardiographically and hemodynamically diagnosed when 2 days at the age. In the Echo-Doppler study the visualisation of the tunnel and the presence of aortic regurgitation within it and in the left ventricular outflow tract confirmed the diagnosis. Surgical access to both orifices, aortic and left ventricular, through the tunnel (after incision in the same) allowed it to be closed with two Goretex patches from its external face. This technique has a double advantage: a) it avoids annular distortions or aortic valvular lesions, b) excluding the tunnel (partial resection of edges and subsequent continuous suture) any possibility of subpulmonary stenosis through compression is eradicated.

Anomalous origin of the right pulmonary artery from the ascending aorta is a rare congenital malformation associated with a high mortality during the first year of life. Up to 1990, 75 cases have been reported in the literature. We are reporting 2 cases diagnosed and operated before 3 months of age. Repair was facilitated by the use of deep hypothermic circulatory arrest. The duration of follow up is 5 and 6 years, respectively. Pre and postoperative cardiac catheterization pressure data and angiograms are shown. We review the literature, presenting the physiopathological, embryological and surgical features of this rare congenital anomaly.

We reviewed our experience with replacement of the ascending aorta and aortic valve with a composite graft and reimplantation of coronary arteries to the tube graft during 8 years interval from April, 1982, to April 1990. 24 patients underwent repair, the mean age was 49.83 years. Annuloaortic ectasia was the most common indication (58.33%), followed by aortic dissection (acute or chronic). Emergency operation was carried out in nine patients with aortic dissection (37.5%) and elective in 15. The mean duration of cardiopulmonary bypass was 118 +/- 4 minutes and of aortic clamping 83.85 +/- 2 minutes. Hospital mortality was 4.17%, reoperation for hemorrhage was 12.5% and perioperative morbidity for other causes was 34.7%. There were one late death. 20 patients were follow-up with a total of 638 patients-months (two patients excluded with insufficient follow-up and one late death). At last follow-up 14 patients were in functional class I. Eight year actuarial survival for the 24 patients was 91%. We believe that replacement of the ascending aorta and aortic valve with a composite graft and coronary arteries reimplantation to the tube graft is more than one satisfactory alternative to supracoronary graft replacement and aortic valve replacement. It offers the advantage of excluding all abnormal aortic tissue, eliminating the risk for later development of complications in the non excluded disease aorta. It supposes the method of choice for patients with anuloaortic-ectasia, aneurysms of the sinuses of Valsalva with aortic insufficiency, and aortic dissection with proximal affectation of coronary arteries and aortic valve.

To evaluate the potential advantages of the administration of extradural morphine to control postoperative pain and its effects on respiratory function, 39 patients were randomly assigned to one of two groups before aortic surgery. The first group (20 patients) received intravenous analgesia as required (control group). The second group (19 patients) received extradural morphine in a programmed fashion. During the immediate postoperative period the following parameters were measured in both groups: respiratory rate, vital capacity, peak expiratory volume in the first second, PaO2, PaCO2, arterial pH, heart rate, and systolic and diastolic blood pressure. In the group treated with morphine the postoperative increase in heart and respiratory rate was significantly smaller than in the control group (p less than 0.01). Postoperative forced pulmonary volumes were higher in the morphine group (p less than 0.01). However, there were no differences in time of hospitalization between both groups. There were more complications in the control group, but the difference did not reach statistical significance.

We present our 7 years' experience in the treatment of repeated stitch failure of the suture line on aortic valve replacements. We used a valved tube placed in the supra-coronary position. This technique prevented further stitch failure and also prevented postop infections. Of eight patients operated on, five had survived.

A child who developed apneic spells during feeding, following repair of oesophageal atresia is reported. Symptoms were relieved by suspending the aortic arch to the undersurface of the sternum. Tracheomalacia, its diagnostic and management is discussed.

There is not an extensive literature about nutritional value in Vascular Surgery. In this study, efficacy and cost/benefit relation in the application of Peripheric Parenteral Nutrition (PPN) in postoperative of aortic surgery, are investigated through two randomized groups, in patients with aortoiliac obstructive arteriopathy and who needed an aortobifemoral bypass.