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Objective: Controversy remains regarding the optimal neuroprotection strategy for elective hemiarch replacement (HEMI). This study sought to compare outcomes in patients who underwent HEMI utilizing the 2 most common contemporary methods of cerebral protection., Methods: The ARCH international aortic database was queried, and 782 patients undergoing elective HEMI with circulatory arrest from 2007 to 2012 were identified. There were 418 patients who underwent HEMI using moderate hypothermia (nasopharyngeal temperature 20.1 to 28.0 °C) and antegrade cerebral perfusion (MHCA/ACP). There were 364 patients who underwent HEMI using deep hypothermia (nasopharyngeal temperature 14.1 to 20 °C) and retrograde cerebral perfusion (DHCA/RCP). Adverse outcomes were compared between the groups using both univariable and multivariable analyses., Results: Patients who underwent MHCA/ACP were older (64 vs 61 years, P = 0.01) and more frequently had peripheral vascular disease than DHCA/RCP patients (28.5% vs 7.1%, P < 0.001). Patients in the DHCA/RCP group had a greater incidence of full aortic root replacement (55.8% vs 26.4%, P < 0.001) and more frequently had a central cannulation strategy (83% vs 55.7%, P < 0.001). Cardiopulmonary bypass (170 vs 157 min, P = 0.002) and aortic cross-clamp (134 vs 92 min, P < 0.001) times were significantly longer in the DHCA/RCP group. On univariable analysis, overall mortality was statistically similar between groups (MHCA/ACP 3.4% vs DHCA/RCP 2.3%, P = 0.47), but permanent neurologic deficits were significantly lower in the DHCA/RCP cohort (MHCA/ACP 3.9% vs DHCA/RCP 1.0%, P = 0.02). Multivariable analysis showed no difference in mortality nor perioperative stroke between perfusion cohorts., Conclusions: Both MHCA/ACP and DHCA/RCP are excellent neuroprotective strategies that produce low mortality in patients undergoing elective HEMI. DHCA/RCP may demonstrate theoretically improved neurologic outcomes compared with MHCA/ACP, but this topic warrants further study., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: During congenital heart surgery, the pulmonary valve and root may be placed into the systemic position, yielding a "neoaortic" valve. With the stress of systemic pressure, the pulmonary roots can dilate, creating aneurysms and/or neoaortic insufficiency (neoAI). This report analyzes the early outcomes of patients undergoing neoaortic valve repair incorporating geometric ring annuloplasty., Methods: Twenty-one patients underwent intended repair at six centers and formed the study cohort. Thirteen had previous Ross procedures, five had arterial switch operations, and three Fontan physiology. Average age was 21.7 ± 12.8 years (mean  ±  SD), 80% were male, and 11 (55%) had symptomatic heart failure. Preoperative neoAI Grade was 3.1  ±  1.1, and annular diameter was 30.7  ±  6.5 mm., Results: Valve repair was accomplished in 20/21, using geometric annuloplasty rings and leaflet plication (n = 13) and/or nodular release (n = 7). Fourteen had neoaortic aneurysm replacement (13 with root remodeling). Two underwent bicuspid valve repair. Six had pulmonary conduit changes, one insertion of an artificial Nodulus Arantius, and one resection of a subaortic membrane. Ring size averaged 21.9  ±  2.3 mm, and aortic clamp time was 171  ±  54 minutes. No operative mortality or major morbidity occurred, and postoperative hospitalization was 4.3  ±  1.4 days. At discharge, neoAI grade was 0.2  ±  0.4 ( P  < .0001), and valve mean gradient was ≤20 mm Hg. At average 18.0  ±  9.1 months of follow-up, all patients were asymptomatic with stable valve function., Conclusions: Neoaortic aneurysms and neoAI are occasionally seen late following Ross, arterial switch, or Fontan procedures. Neoaortic valve repair using geometric ring annuloplasty, leaflet reconstruction, and root remodeling provides a patient-specific approach with favorable early outcomes.

We report a case of an 18-year-old female who presented with severe aortic stenosis and insufficiency, eight years following resection of a subaortic membrane. On echocardiography, she was found to have a completely fused or nullicuspid valve, with three equal sinuses and three commissural fusions. Aortic valve repair included leaflet tricuspidization, three commissurotomies, trileaflet ring annuloplasty, and pericardial leaflet reconstruction. At one year follow-up, the patient is asymptomatic, with stable gradients.

Circulatory management during replacement of the aortic arch is complex and involves a period of circulatory arrest to provide a bloodless field during arch vessel anastomosis. To guard against ischemic brain injury, tissue metabolic demand is reduced by systemically cooling the patient prior to circulatory arrest. Neurophysiological intraoperative monitoring (NIOM) is often used during the course of these procedures to provide contemporaneous assessment of brain status to help direct circulatory management decisions and detect brain ischemia. In this review, we discuss the characteristics of electrocerebral activity through the process of cooling, circulatory arrest, and rewarming as depicted through commonly used NIOM modalities, including electroencephalography and peripheral nerve somatosensory-evoked potentials. Attention is directed toward the role NIOM has traditionally played during deep hypothermic circulatory arrest, where it is used to define the point of electrocerebral inactivity or maximal cerebral metabolic suppression prior to initiating circulatory arrest while also discussing the evolving utility of NIOM when systemic circulatory arrest is initiated at more moderate degrees of hypothermia in conjunction with regional brain perfusion. The use of cerebral tissue oximetry by near-infrared spectroscopy as an alternative NIOM modality during surgery of the aortic arch is addressed as well. Finally, special considerations for NIOM and the detection of spinal cord ischemia during hybrid aortic arch repair and emerging operative techniques are also discussed., (© The Author(s) 2016.)

Objective: The aim of this study was to define the relative role of a right minithoracotomy (RT) versus standard median sternotomy (ST) for open aortic valve replacement (AVR)., Methods: A retrospective analysis was performed of all 1348 patients undergoing isolated, open AVR at a single institution during a 14-year period. Because relatively few patients were technically suitable for redo AVR with the RT approach (n = 20), all redo patients (n = 209) were excluded, leaving 1139 patients available for analysis. Patients converting from RT to ST approach (n = 15) were analyzed separately., Results: Relative to ST (n = 672), the RT patients (n = 452) were older with more stenosis but with more recent operation year, lower rate of congestive heart failure, higher ejection fraction, lower rate of endocarditis, and lower rate of renal disease than the ST AVR patients (all P < 0.0001). Right minithoracotomy AVR was associated with longer cardiopulmonary bypass times [157 (25) vs 131 (38), P = 0.0004] and clamp times [103 (20) vs 85 (27), P < 0.0001] but less transfusion (1.4 vs 3.4 U, P = 0.0003), less chest tube output (405 vs 950 mL, P < 0.0001), fewer reoperations for bleeding (0.4% vs 4%, P < 0.0001), shorter length of stay (6 vs 8 days, P = 0.03), and lower rate of atrial fibrillation (15% vs 20%, P = 0.03). Stroke, operative mortality, and survival were not significantly different between the groups., Conclusions: Given the biases of retrospective propensity-adjusted analysis, these data suggest that RT AVR is a safe alternative to ST AVR in selected patients, with advantages of avoiding sternotomy with associated bleeding, transfusion, and delayed wound healing, at the expense of longer pump and clamp times.

Background: Sternal wound infection (SWI) remains a devastating complication after cardiac surgery, decreasing long-term and short-term survival. In treating documented SWI, negative pressure wound therapy (NPWT) reduces wound edema and time to definitive closure and improves peristernal blood flow after internal mammary artery (IMA) harvesting. The authors evaluated NPWT as a form of "well wound" therapy in patients at substantial risk for SWI based on existing risk stratification models., Methods: Records of 57 adult cardiac surgery patients (September 2006 to April 2008) were reviewed. After preoperative risk assessment, NPWT was instituted on the clean, closed sternotomy immediately after surgery and continued 4 days postoperatively. Adverse postoperative events, including SWI, need for readmission, and other complications, were documented., Results: Mean age was 60.4 +/- 10 years, and 89.5% were male; 77.2% were obese (mean body mass index 35.3 +/- 6.7), 54.4% were diabetic, and 29 (50.9%) were both obese and diabetic. Coronary artery bypass (CAB) with single IMA was performed in 50.9% of the patients followed in frequency by combined CAB/valve, non-CAB surgery, and CAB with bilateral IMA. Estimated risk for SWI was 6.1 +/- 4%. All patients tolerated NPWT to completion. Thirty-day and in-hospital mortality was 1.8% and unrelated to DSWI. No treatment of SWI was required., Conclusions: In this high-risk cohort, 3 postoperative SWI cases were anticipated but may have been mitigated by NPWT. This is an easily applied and well-tolerated therapy and may stimulate more effective wound healing. Among patients with increased SWI risk, strong consideration should be given to NPWT as a form of "well wound" therapy.

Diseases of the thoracic aorta remain among the most lethal and difficult to treat conditions. In 2005, the US Food and Drug Administration approved the first endoprosthesis for the treatment of aneurysms of the descending thoracic aorta; at present, there are 3 thoracic devices approved by the US Food and Drug Administration. Although approved only for the treatment of descending aneurysms, thoracic endografting has other potential off-label applications, including acute and chronic aortic dissection and traumatic aortic transection. Endovascular repair of thoracic aortic pathology is emerging as the preferred treatment strategy in certain patients, as increasing data suggest that endovascular repair may be performed with lower peri-operative morbidity and mortality rates and similar midterm survival, when compared with standard open repair. However, because of anatomic constraints related to required endograft seal zones, a significant number of patients are excluded from standard endovascular repair. Hybrid techniques, including open aortic arch and thoracoabdominal debranching procedures, have been described to allow creation of proximal and/or distal landing zones for the stent graft seal. This review describes the surgical and anesthetic considerations relevant to thoracic endografting, with an emphasis on hybrid procedures used to treat more complex thoracic aortic pathology. Hybrid techniques may be performed with lower rates of morbidity and mortality than conventional open repair, and they appear to be a safe alternative to open repair for thoracoabdominal and aortic arch aneurysms in properly selected patients with significant comorbidity or prior open aortic surgery.