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Background Aortic annular erosion is a serious complication of aortic valve endocarditis or previous aortic valve replacement. This study examined the outcomes of a technique for left ventricular outflow tract reconstruction using a polyester tube graft, followed by translocation of the aortic valve and coronary arteries. Methods A total of 23 patients with extensive annular erosion resulting from endocarditis or previous aortic valve replacement with or without pseudoaneurysm formation, or occurring after excision of the native valve, underwent suture of a polyester tube graft in the left ventricular outflow tract below the annulus, replacement of the aortic valve and proximal ascending aorta with a composite graft, and reimplantation of the coronary arteries with the use of interposition polyester grafts. The mean age of the patients was 50 years, and 57% were men. Results There were no hospital deaths. The mean duration of follow-up was 6.5 years and extended to 16 years. Actuarial survival at 1, 5, and 10 years was 86.7%, 82.2%, and 62.6%, respectively. Two patients required reoperation for a graft-graft pseudoaneurysm and for degeneration of a porcine bioprosthesis. Echocardiograms obtained at a mean of 75 months postoperatively in 15 of the 23 patients demonstrated normal left ventricular outflow tract dimensions and velocities and a mean effective valve orifice area of 1.07 cm2/m2. All coronary artery grafts were patent on angiography a mean of 40 months postoperatively in 13 patients. Conclusions Extended experience with this technique confirms its safety and effectiveness for patients with extensive destruction of the aortic annulus. It represents a suitable alternative to other currently used techniques.

Background Uncertainty remains regarding the optimal method of brain protection for procedures that require repair or replacement of the aortic arch. We examined the early outcomes of a technique for brain protection in patients undergoing partial aortic arch (hemiarch) replacement that involves deep hypothermic circulatory arrest (DHCA) and retrograde cerebral perfusion (RCP) of cold blood from the superior vena cava toward the end of the arrest interval. Methods During a recent 15-year interval, 520 patients underwent elective or urgent/emergent ascending aortic and hemiarch replacement as an isolated (47 patients) or combined (473 patients) procedure employing DHCA (mean nasopharyngeal temperature at circulatory arrest, 17.1°C and mean duration, 19.3 minutes) supplemented with RCP of cold blood from the superior vena cava toward the end of the arrest interval (mean, 6.7 minutes). The mean age of the patients was 59.5 years, and 65% were male. Results The in-hospital and 30-day mortality rates were 1.2% (six patients). Seven patients (1.4%) sustained a stroke and 19 patients (3.7%) had transient neurologic dysfunction that completely resolved by the time of hospital discharge. Four patients (0.77%) developed postoperative renal failure requiring dialysis. Twenty-one patients (4%) required ventilator support for >48 hours and five patients (0.96%) required a tracheostomy. The median hospital length of stay was 6 days. Conclusion DHCA with a brief interval of RCP is a safe and effective technique for brain protection during hemiarch aortic replacement. RCP reduces the duration of brain ischemia and permits removal of particulate matter and air from the arterial circulation.

Background A variety of intraoperative strategies are currently used for organ protection during open operations on the thoracoabdominal aorta. We report our experience with cardiopulmonary bypass and hypothermic circulatory arrest as the primary modality for organ protection, focusing on the early outcomes. Methods During a 30-year interval, 285 patients underwent thoracoabdominal aortic aneurysm repair with the use of cardiopulmonary bypass with an interval of circulatory arrest (72 Crawford extent I, 107 extent II, 104 extent III, and 2 extent IV). Degenerative aneurysms were present in 72.6% and aortic dissections in 26.4% of patients. Emergent operations for rupture or acute dissection were required in 6.7% of the patients. Results Thirty-day mortality was 7.4% and was highest for the Crawford extent II and extent III patients (10.3% and 6.7%, respectively). Permanent paralysis or paraplegia occurred in 15 patients (5.3%). The rates were highest for the extent II and extent III patients (6.5% and 6.7%, respectively). Cerebrospinal fluid drainage had no impact on the development of spinal cord injury, and implantation of intercostal/lumbar arteries had a protective effect only in patients with extent II repair. Stroke occurred in 4.2% of patients and renal failure that required dialysis occurred in 6.2%. One-year actual survival was 90.4%. Conclusions Our extended experience with this technique confirms its safety and effectiveness when used on a routine basis. The rates of spinal cord injury and permanent renal failure are among the lowest reported in the literature. Particularly favorable outcomes were observed in younger patients and patients undergoing elective operations.

Rationale Saphenous vein graft disease remains a major limitation of coronary artery bypass graft surgery (CABG). Up to 20% of vein grafts will occlude within the first year after CABG despite standard aspirin antiplatelet therapy. However, more potent postoperative platelet inhibition with ticagrelor may improve graft patency. The goal of this study will be to evaluate the efficacy of ticagrelor, as compared to aspirin, for the prevention of saphenous vein graft occlusion following CABG. Study design The Ticagrelor Antiplatelet Therapy to Reduce Graft Events and Thrombosis (TARGET) study is a multi-center double-blind randomized controlled trial enrolling patients who have undergone multi-vessel CABG with at least one saphenous vein graft. Patients are being randomized to receive either aspirin 81 mg twice per day or ticagrelor 90 mg twice per day for 2 years starting within 7 days after surgery. The projected enrollment is 150 patients in each arm (300 total patients). Patients will undergo computed tomography (CT) coronary angiography at 1 and 2 years after surgery to assess the incidence of vein graft occlusion and stenosis. Conclusion To our knowledge, this trial is the first prospective study to evaluate the impact of early postoperative ticagrelor on 1- and 2-year graft patency after CABG. Furthermore, it is also the first trial to use a novel antiplatelet agent as a standalone, without aspirin, after CABG. Should ticagrelor reduce the incidence of postoperative graft occlusion, the results of this study will redefine modern antiplatelet management following coronary bypass surgery ( ClinicalTrials.gov NCT02053909 ).

Objectives The long-term function of branch grafts to the visceral and renal arteries during open thoracoabdominal aortic aneurysm repair is unknown. We assessed the patency of single and multiple branch grafts with postoperative imaging studies in patients followed for up to 13 years. Methods A total of 99 of 130 patients undergoing open thoracoabdominal aortic aneurysm repair who received a total of 298 branch grafts to the celiac, superior mesenteric, and renal arteries were evaluated with serial imaging studies at 6- to 12-month intervals. The mean duration of angiographic follow-up was 40.4 months and extended to 159 months. Thirty-three patients receiving 74 grafts were followed for more than 5 years, and 7 patents receiving 22 grafts were followed for more than 10 years. Eighty-four grafts were grafted to the celiac artery, 73 grafts were grafted to the superior mesenteric artery, 71 grafts were grafted to the left renal artery, and 70 grafts were grafted to the right renal artery. Results Nine graft occlusions occurred in 6 patients. One of these patients died of intestinal ischemia after occlusion of the celiac and superior mesenteric artery grafts, and 1 patient developed occlusion of both renal artery grafts and remains on dialysis. Five graft occlusions in the other 4 patients were asymptomatic, and no interventions were required. One additional patient developed significant stenosis of the celiac, superior mesenteric, and right renal arteries and underwent successful percutaneous angioplasty. No other patient required intervention. Freedom from occlusion of the 298 grafts at 1, 5, and 10 years is 98%, 97%, and 93%, respectively. Conclusions This represents the largest series of patients with branch grafts for open thoracoabdominal aortic aneurysm repair with extended angiographic follow-up. The favorable long-term graft patency rates represent a benchmark against which methods for establishing flow to the visceral and renal arteries using alternative techniques can be compared.

Background: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute Type A aortic dissection with axillary or femoral artery cannulation. Methods: A total of 305 patients from five academic medical centers underwent acute Type A aortic dissection repair via axillary (n = 107) or femoral (n = 198) artery cannulation between January 2000 and December 2010. Major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality, and Cox regression hazard ratios were calculated to determine predictors of long-term mortality. Results: Operative mortality was not influenced by cannulation site (16% for axillary cannulation vs. 19% for femoral cannulation, p = 0.64). In multivariate logistic regression analysis, hemodynamic instability (p < 0.001) and prolonged cardiopulmonary bypass time (>200 min; p = 0.05) emerged as independent predictors of operative mortality. Stroke rates were comparable between the two techniques (14% for axillary and 17% for femoral cannulation, p = 0.52). Five-year actuarial survival was comparable between the groups (55.1% for axillary and 65.7% for femoral cannulation, p = 0.36). In Cox regression analysis, predictors of long-term mortality were: age (p < 0.001), stroke (p < 0.001), prolonged cardiopulmonary bypass time (p = 0.001), hemodynamic instability (p = 0.002), and renal failure (p = 0.001). Conclusions: The outcomes of femoral versus axillary arterial cannulation in patients with acute Type A aortic dissection are comparable. The choice of arterial cannulation site should be individualized based on different patient risk profiles.

Background: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute type A aortic dissection by the method of cerebral perfusion used. Methods: A total of 324 patients from five academic medical centers underwent repair of acute type A aortic dissection between January 2000 and December 2010. Of those, antegrade cerebral perfusion (ACP) was used for 84 patients, retrograde cerebral perfusion (RCP) was used for 55 patients, and deep hypothermic circulatory arrest (DHCA) was used for 184 patients during repair. Major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality and Cox Regression hazard ratios were calculated to determine the predictors of long term mortality. Results: Operative mortality was not influenced by the type of cerebral protection (19% for ACP, 14.5% for RCP and 19.1% for DHCA, P=0.729). In multivariable logistic regression analysis, hemodynamic instability [odds ratio (OR) =19.6, 95% confidence intervals (CI), 0.102–0.414, P 200 min(OR =4.7, 95% CI, 1.962–1.072, P=0.029) emerged as independent predictors of operative mortality. Actuarial 5-year survival was unchanged by cerebral protection modality (48.8% for ACP, 61.8% for RCP and 66.8% for no cerebral protection, log-rank P=0.844). Conclusions: During surgical repair of type A aortic dissection, ACP, RCP or DHCA are safe strategies for cerebral protection in selected patients with type A aortic dissection.

Loeys-Dietz syndrome due to mutations in TGFBR1 and 2 is associated with early and aggressive aortic aneurysm and branch vessel disease. There are reports of uncomplicated pregnancy in this condition, but there is an increased risk of aortic dissection and uterine rupture. Women with underlying aortic root aneurysm are cautioned about the risk of pregnancy-related aortic dissection. Prophylactic aortic root replacement is recommended in women with aortopathy and aortic root dilatation to lessen the risk of pregnancy. There is limited information in the literature about the outcomes of pregnancy after root replacement in Loeys-Dietz syndrome. We present a case series of three women with Loeys-Dietz syndrome who underwent elective aortic root replacement for aneurysm disease and subsequently became pregnant and underwent Cesarean section delivery. Each of these women were treated with beta blockers throughout pregnancy. Surveillance echocardiograms and noncontrast MRA studies during pregnancy remained stable demonstrating no evidence for aortic enlargement. Despite the normal aortic imaging and careful observation, two of the three women suffered acute aortic dissection in the postpartum period. These cases highlight the high risk of pregnancy following aortic root replacement in Loeys-Dietz syndrome. Women with this disorder are recommended to be counseled accordingly. © 2016 Wiley Periodicals, Inc.

Objectives Advances in endovascular surgery have brought into question the role of open operative treatment of chronic thoracoabdominal aortic dissection. In this context, we evaluated our experience with open repair of this condition using a single operative technique. Methods From January 1986 to January 2014, 69 patients with chronic thoracoabdominal aortic dissection underwent open repair using total cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA). The degree of repair was as follows: Crawford extent I, 13 patients (19%), Crawford extent II, 41 patients (59%), and Crawford extent III, 15 patients (22%). Thirty patients (43%) had Marfan or Loeys-Dietz syndrome. Fifty-three patients (77%) had previous operations on the thoracic or abdominal aorta. Results The 30-day mortality rate was 5.8% (4 patients). Stroke occurred in 2 (3%) of 66 operative survivors, and spinal cord ischemic injury in 4 (6%). Temporary dialysis for new-onset renal failure was required in 4.5% of hospital survivors and tracheostomy in 10.6%. Survival after 1, 5, and 10 years was 87%, 65%, and 40%, respectively. Eighteen patients (26%) required a total of 20 subsequent operations on the thoracic or abdominal aorta of whom 15 had Marfan or Loeys-Dietz syndrome. Three of these procedures were for contiguous distal aortic disease and 10 were for patch aneurysms of the intercostal or visceral/renal arteries. Conclusions Open thoracoabdominal aortic repair for chronic dissection using CPB and HCA can be accomplished with mortality and morbidity rates that are comparable with those reported for endovascular or hybrid techniques. Open repair should remain a viable and primary option for the management of this condition until the long-term effectiveness of alternative methods of treatment is clearly established.

There is limited information about the association between diabetes, its treatment, and long-term angiographic and clinical outcomes in patients undergoing coronary artery bypass graft surgery (CABG). We evaluated the association of diabetes and its treatment with 1-year angiographic graft failure and 5-year clinical outcomes in patients undergoing CABG.Using data from 3,014 patients in PREVENT IV, we analyzed angiographic and clinical outcomes in patients with and without diabetes and among those who did and did not receive insulin before CABG. Logistic regression and Cox proportional hazards models were used to adjust for differences in baseline variables.Overall, 1,139 (37.8%) patients had diabetes. Of these, 305 (26.8%) received insulin. One-year rates of vein graft failure were similar in patients with and without diabetes but, among diabetics, tended to be higher in patients who received insulin compared with those who did not. At 5 years, rates of death, myocardial infarction, or revascularization were higher among patients with compared with those without diabetes (adjusted hazard ratio 1.57; 95% CI 1.26-1.96; P.001) and, among diabetics, higher among those who received insulin (adjusted hazard ratio 1.15; 95% CI 1.02-1.30; P = .02).Patients with diabetes had similar rates of vein graft failure but worse clinical outcomes than patients without diabetes. Patients who received insulin had significantly worse clinical outcomes than patients who did not receive insulin. Further studies to better understand the mechanism behind these findings and to improve the outcomes of patients with insulin-requiring diabetes undergoing CABG surgery are warranted.

Objective The study objective was to analyze clinical outcomes, distal segmental aortic growth, and aortic reoperation rates after 1-stage open repair of extensive chronic thoracic aortic dissection via bilateral anterior thoracotomy. Methods Eighty patients underwent extensive 1-stage repair of chronic aortic dissection that included the ascending aorta, the entire aortic arch, and the varying lengths of the descending thoracic aorta. One half or more of the descending thoracic aorta was replaced in 62 (78%) of the 80 patients. Hospital mortality was 2.5% (2 patients). Stroke occurred in 1 patient (1.2%), spinal cord ischemic injury occurred in 1 patient (1.2%), and renal failure requiring long-term dialysis occurred in 2 patients (2.5%). Sixty-five of the 78 hospital survivors (83%) had serial imaging studies suitable for calculation of growth rates of the remaining dissected thoracic and abdominal aorta. Forty-seven patients were followed for more than 5 years, and 21 patients were followed for more than 10 years. Results The mean annual growth rate for the distal contiguous aorta was 1.7 mm/y. Forty aortas increased in diameter, 16 aortas remained unchanged, and 9 aortas decreased in diameter. Five patients required reoperation on the contiguous thoracic or abdominal aorta 8, 27, 34, 51, and 174 months postoperatively for progressive enlargement. Actuarial freedom from reoperation on the contiguous aorta at 5 and 10 years was 95.4% and 93%, respectively. Actuarial freedom from any aortic reoperation at 5 and 10 years was 89.2% and 84.4%, respectively. Actuarial survival for the entire cohort at 5 and 10 years was 76.4% and 52.6%, respectively, and survival free of any aortic operation was 68.6% and 43.9%, respectively. No patient whose cause of death was known died of aortic rupture. Conclusions Our extended experience with the 1-stage open procedure confirms its safety and durability for treatment of chronic aortic dissection with enlargement confined to the thoracic aorta. The procedure is associated with low operative risk and a low incidence of reoperation on the contiguous aorta. It represents a suitable alternative to the 2-stage, frozen elephant trunk, and hybrid procedures that are also used to treat this condition.

Total aortic arch replacement (TOTAL) is a complicated operation and has traditionally required deep hypothermic circulatory arrest. In this study, the impact of moderate hypothermic circulatory arrest (MHCA) and antegrade cerebral perfusion (ACP) for TOTAL were examined.The ARCH International aortic database was queried and 3,265 patients undergoing TOTAL using ACP were identified. Patients were divided into groups based on lowest cooling temperature: MHCA (20° to 28°C) or deep hypothermia (DHCA) (12° to 20°C). Propensity-matched scoring using 15 variables was used in 669 matched pairs. Multivariable analyses were performed.In the unmatched cohort, more patients underwent MHCA (2,586; 79.2%) who were also younger (p 0.001) and more frequently underwent emergent operations (p0.001) than DHCA patients. For the propensity-matched patients, there were significant differences in cardiopulmonary bypass (CPB) time (MHCA 200 minutes versus DHCA 243 minutes, p0.001), aortic crossclamp time (MHCA 120 minutes versus DHCA 142 minutes, p 0.001), and cerebral perfusion time (MHCA 63 minutes versus DHCA 58 minutes, p0.001). Of note, there was no difference in neurologic outcomes nor in-hospital mortality for the two temperature groups. Multivariable analysis of risk factors for mortality included CPB time (odds ratio [OR] 1.006; p0.001), concomitant mitral valve surgery (OR 3.070; p = 0.003), emergent operation (OR 2.924; p0.001), and poor ejection fraction (OR 3.133; p = 0.011). Independent risk factors for stroke included coronary artery disease (OR 1.856; p0.001), cerebral vascular disease (OR 2.172; p 0.001), emergent operation (OR 2.109; p0.001), and CPB time (OR 1.004; p0.001).In this series, TOTAL with MHCA and ACP can be safely performed with acceptable operative risk. MHCA and ACP represent an effective strategy for TOTAL and may obviate the need for DHCA.

Background— Coronary artery bypass grafting success is limited by vein graft failure (VGF). Understanding the factors associated with VGF may improve patient outcomes. Methods and Results— We examined 1828 participants in the Project of Ex Vivo Vein Graft Engineering via Transfection IV (PREVENT IV) trial undergoing protocol-mandated follow-up angiography 12 to 18 months post–coronary artery bypass grafting or earlier clinically driven angiography. Outcomes included patient- and graft-level angiographic VGF (≥75% stenosis or occlusion). Variables were selected by using Fast False Selection Rate methodology. We examined relationships between variables and VGF in patient- and graft-level models by using logistic regression without and with generalized estimating equations. At 12 to 18 months post–coronary artery bypass grafting, 782 of 1828 (42.8%) patients had VGF, and 1096 of 4343 (25.2%) vein grafts had failed. Demographic and clinical characteristics were similar between patients with and without VGF, although VGF patients had longer surgical times, worse target artery quality, longer graft length, and they more frequently underwent endoscopic vein harvesting. After multivariable adjustment, longer surgical duration (odds ratio per 10-minute increase, 1.05; 95% confidence interval, 1.03–1.07), endoscopic vein harvesting (odds ratio, 1.41; 95% confidence interval, 1.16–1.71), poor target artery quality (odds ratio, 1.43; 95% confidence interval, 1.11–1.84), and postoperative use of clopidogrel or ticlopidine (odds ratio, 1.35; 95% confidence interval, 1.07–1.69) were associated with patient-level VGF. The predicted likelihood of VGF in the graft-level model ranged from 12.1% to 63.6%. Conclusions— VGF is common and associated with patient and surgical factors. These findings may help identify patients with risk factors for VGF and inform the development of interventions to reduce VGF. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00042081.

Background: The goal of this study was to compare operative mortality and actuarial survival between patients presenting with and without hemodynamic instability who underwent repair of acute Type A aortic dissection. Previous studies have demonstrated that hemodynamic instability is related to differences in early and late outcomes following acute Type A dissection occurrence. However, it is unknown whether hemodynamic instability at the initial presentation affects early clinical outcomes and survival after repair of Type A aortic dissection. Methods: A total of 251 patients from four academic medical centers underwent repair of acute Type A aortic dissection between January 2000 and October 2010. Of those, 30 presented with hemodynamic instability while 221 patients did not. Median ages were 63 years (range 38-82) and 60 years (range 19-87) for patients presenting with hemodynamic instability compared to patients without hemodynamic instability, respectively (P = 0.595). Major morbidity, operative mortality, and 10-year actuarial survival were compared between groups. Results: Operative mortality was profoundly influenced by hemodynamic instability (patients with hemodynamic instability 47% versus 14% for patients without hemodynamic instability, P < 0.001). Actuarial 10-year survival rates for patients with hemodynamic instability were 44% versus 63% for patients without hemodynamic instability (P = 0.007). Conclusions: Hemodynamic instability has a profoundly negative impact on early outcomes and operative mortality in patients with acute Type A aortic dissection. However, late survival is comparable between hemodynamically unstable and non-hemodynamically unstable patients.

In vitro and animal model data suggest that intraoperative preservation solutions may influence endothelial function and vein graft failure (VGF) after coronary artery bypass graft (CABG) surgery. Clinical studies to validate these findings are lacking. To evaluate the effect of vein graft preservation solutions on VGF and clinical outcomes in patients undergoing CABG surgery. Data from the Project of Ex-Vivo Vein Graft Engineering via Transfection IV (PREVENT IV) study, a phase 3, multicenter, randomized, double-blind, placebo-controlled trial that enrolled 3014 patients at 107 US sites from August 1, 2002, through October 22, 2003, were used. Eligibility criteria for the trial included CABG surgery for coronary artery disease with at least 2 planned vein grafts. Preservation of vein grafts in saline, blood, or buffered saline solutions. One-year angiographic VGF and 5-year rates of death, myocardial infarction, and subsequent revascularization. Most patients had grafts preserved in saline (1339 [44.4%]), followed by blood (971 [32.2%]) and buffered saline (507 [16.8%]). Baseline characteristics were similar among groups. One-year VGF rates were much lower in the buffered saline group than in the saline group (patient-level odds ratio [OR], 0.59 [95% CI, 0.45-0.78; P

Objective Patients with primary aortic coarctation or complications of a previous coarctation repair may seek treatment as adults. Management options include open, endovascular, hybrid, and extra-anatomic repairs. We evaluated the results of open direct repair with total cardiopulmonary bypass and hypothermic circulatory arrest. Methods Twenty-seven patients with primary coarctation with or without associated aortic abnormalities or with complications of a previous coarctation repair were treated during a 20-year interval. Mean age was 37 years (range, 15-71 years). Thirteen patients had primary coarctation (7 with associated aneurysms), 3 patients had aneurysms of the aorta above or below a noncritical narrowing of the aorta at the isthmus ("pseudocoarctation"), and 11 patients had previous repair of a coarctation. The previous repairs were bypass grafting of the coarctation (n = 5), interposition grafting (n = 3), patch angioplasty (n = 2), and primary repair (n = 1). Results Mean durations of cardiopulmonary bypass, hypothermic circulatory arrest and hypothermic fibrillation were 104, 36, and 76 minutes, respectively. There were no in-hospital deaths, and no patients sustained stroke, spinal cord ischemic injury, or renal or respiratory failure. Thirteen patients received no blood products. No patient has had evidence of recurrent coarctation or aneurysm formation. Conclusions Cardiopulmonary bypass with hypothermic circulatory arrest is a safe and suitable technique for treatment of primary and recurrent coarctation. It is associated with low operative risk and absence of major complications.

OBJECTIVE: A number of factors limit the effectiveness of current aortic arch studies in assessing optimal neuroprotection strategies, including insufficient patient numbers, heterogenous definitions of clinical variables, multiple technical strategies, inadequate reporting of surgical outcomes and a lack of collaborative effort. We have formed an international coalition of centres to provide more robust investigations into this topic. METHODS: High-volume aortic arch centres were identified from the literature and contacted for recruitment. A Research Steering Committee of expert arch surgeons was convened to oversee the direction of the research. RESULTS: The International Aortic Arch Surgery Study Group has been formed by 41 arch surgeons from 10 countries to better evaluate patient outcomes after aortic arch surgery. Several projects, including the establishment of a multi-institutional retrospective database, randomized controlled trials and a prospectively collected database, are currently underway. CONCLUSIONS: Such a collaborative effort will herald a turning point in the surgical management of aortic arch pathologies and will provide better powered analyses to assess the impact of varying surgical techniques on mortality and morbidity, identify predictors for neurological and operative risk, formulate and validate risk predictor models and review long-term survival outcomes and quality-of-life after arch surgery.

Background The clinical characteristics, management, and outcomes of patients who had intraoperative aortic dissection (IAD) have not been thoroughly investigated. This study compared early and late clinical outcomes in patients with IAD vs spontaneous (non-IAD) acute type A aortic dissection. Methods Between January 1, 2000, and July 1, 2008, 251 patients from 4 academic medical centers underwent repair of acute type A aortic dissection; of those, 11 had IAD. The mean age was 72 ± 9 years for patients experiencing IAD and 59 ± 13 years for those with non-IAD ( p = 0.001). Patients with IAD were more likely to have coronary artery disease ( p = 0.003) and a history of arrhythmia ( p = 0.038). Rates for major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Results Operative mortality was not adversely influenced by IAD (27% IAD vs 17% non-IAD, p = 0.42). There were no differences in the rates of reoperation for bleeding (10% IAD vs 20% non-IAD, p = 0.69), stroke (18% IAD vs 18% non-IAD, p ≥ 0.99), or acute renal failure (9% IAD vs 22% non-IAD, p = 0.47) between the two groups. Actuarial 5-year survival was 64% for IAD patients vs 73% for non-IAD patients ( p = 0.33). Conclusions IAD does not adversely influence early outcomes and actuarial 5-year survival of patients with type A dissection.

Background— The internal mammary artery (IMA) is the preferred conduit for bypassing the left anterior descending (LAD) artery in patients undergoing coronary artery bypass grafting. Systematic evaluation of the frequency and predictors of IMA failure and long-term outcomes is lacking. Methods and Results— The Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV trial participants who underwent IMA-LAD revascularization and had 12- to 18-month angiographic follow-up (n=1539) were included. Logistic regression with fast false selection rate methods was used to identify characteristics associated with IMA failure (≥75% stenosis). The relationship between IMA failure and long-term outcomes, including death, myocardial infarction, and repeat revascularization, was assessed with Cox regression. IMA failure occurred in 132 participants (8.6%). Predictors of IMA graft failure were LAD stenosis Conclusions— IMA failure was common and associated with higher rates of repeat revascularization, and patients with intermediate LAD stenosis or with an additional bypass graft to the diagonal branch had increased risk for IMA failure. These findings raise concerns about competitive flow and the benefit of coronary artery bypass grafting in intermediate LAD stenosis without functional evidence of ischemia. Clinical Trial Registration— URL: http:/www.clinicaltrials.gov . Unique identifier: NCT00042081.

Background— Vein graft failure (VGF) is common after coronary artery bypass graft surgery, but its relationship with long-term clinical outcomes is unknown. In this retrospective analysis, we examined the relationship between VGF, assessed by coronary angiography 12 to 18 months after coronary artery bypass graft surgery, and subsequent clinical outcomes. Methods and Results— Using the Project of Ex Vivo Vein Graft Engineering via Transfection IV (PREVENT IV) trial database, we studied data from 1829 patients who underwent coronary artery bypass graft surgery and had an angiogram performed up to 18 months after surgery. The main outcome measure was death, myocardial infarction, and repeat revascularization through 4 years after angiography. VGF occurred in 787 of 1829 patients (43%). Clinical follow-up was completed in 97% of patients with angiographic follow-up. The composite of death, myocardial infarction, or revascularization occurred more frequently among patients who had any VGF compared with those who had none (adjusted hazard ratio, 1.58; 95% confidence interval, 1.21–2.06; P =0.008). This was due mainly to more frequent revascularization with no differences in death (adjusted hazard ratio, 1.04; 95% confidence interval, 0.71–1.52; P =0.85) or death or myocardial infarction (adjusted hazard ratio, 1.08; 95% confidence interval, 0.77–1.53; P =0.65). Conclusions— VGF is common after coronary artery bypass graft surgery and is associated with repeat revascularization but not with death and/or myocardial infarction. Further investigations are needed to evaluate therapies and strategies for decreasing VGF to improve outcomes in patients undergoing coronary artery bypass graft surgery.

Objective Aortic annular erosion is a serious complication of aortic valve endocarditis or previous aortic valve replacement without endocarditis, and its surgical management is challenging. We present the early and midterm results of a technique for left ventricular outflow tract and aortic root reconstruction with a polyester tube graft and translocation of the aortic valve and coronary arteries. Methods A polyester tube graft is placed into the left ventricle and sutured to the left ventricular outflow tract below the area of erosion. The graft is then everted and sutured to a composite graft. Interposition polyester grafts from the coronary arteries are attached to the composite graft above the valve. This technique has been used in 12 cases. All but 1 patient had previously undergone aortic root or aortic valve replacement, and 4 had endocarditis of prosthetic (n = 2) or aortic allograft (n = 2) valves. Results There were no in-hospital deaths. There was 1 early death from pulmonary embolism at 1 postoperative month and 2 late deaths at 15 and 64 postoperative months, both resulting from heart failure. The remaining 9 patients are alive at 3 to 132 postoperative months. Actuarial 5-year survival is 75%. Conclusions Left ventricular outflow tract reconstruction with translocation of the aortic valve and coronary arteries for annular erosion is a useful technique that safely excludes the area of annular erosion and eliminates left ventricular outflow tract obstruction. The procedure can be safely performed with satisfactory early outcomes and 5-year survival.

Background— Limited information exists on the intermediate-term graft patency and 5-year clinical outcomes of patients receiving saphenous vein grafts with multiple (m-SVG) versus single distal targets (s-SVG) during coronary artery bypass graft (CABG) surgery in the current era. Methods and Results— We studied the association of the use of m-SVG versus s-SVG conduits with 1-year SVG failure (defined as ≥75% angiographic stenosis) and 5-year clinical events (death; death or myocardial infarction [MI]; and death, MI, or revascularization) in 3014 patients undergoing their first CABG surgery enrolled in the Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV. Of 3014 patients enrolled in PREVENT IV, 1045 (34.7%) had ≥1 m-SVGs during CABG. Vein graft failure at 1-year was higher for m-SVG compared with s-SVG (adjusted odds ratio 1.24, 95% confidence interval 1.03 to 1.48). At 5 years, the adjusted composite of death, MI (including perioperative MI), or revascularization (hazard ratio 1.15, 95% confidence interval 1.00 to 1.31) and death or MI (hazard ratio 1.21, 95% confidence interval 1.03 to 1.43) were significantly higher in patients receiving m-SVGs. Conclusions— In patients undergoing first CABG surgery, the use of m-SVG was associated with a higher 1-year vein graft failure rate and trends toward worse clinical outcomes. Additional studies are needed to better understand the most appropriate conduit to improve long-term graft patency and clinical outcomes of patients undergoing CABG surgery. In the meantime, these data should encourage the use of s-SVG over m-SVG when feasible.

Objective Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with substantial cumulative mortality for the 2 procedures and death in the interval in between, often from aortic rupture. We have used a 1-stage procedure for operative repair of most, or all, of the thoracic aorta. Methods Ninety-five patients were treated using a bilateral anterior thoracotomy with transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Fifty-six patients had chronic type A aortic dissections (all but 2 patients had a previous operation), 36 patients had degenerative aneurysms, and 3 patients had chronic type B aortic dissections with proximal extension. The ascending aorta and aortic arch were replaced in all patients combined with resection of varying lengths of descending aorta. Results In-hospital mortality was 8.4% (8 patients). Morbidity included reoperation for bleeding (11%), mechanical ventilation for more than 72 hours (48%), tracheostomy (17%), and renal dialysis (8%). Stroke occurred in 1 patient (1%). Seven of the 93 operative survivors (7.6%) have undergone successful reoperation on the graft (4 patients) or the contiguous aorta (3 patients). Conclusions The 1-stage, arch-first technique is a safe and suitable alternative to 2-stage procedures for repair of thoracic aortic disease. Its effectiveness relative to more recently developed hybrid procedures awaits further analysis of long-term performance.

Objective The use of an aortic patch containing the visceral and renal arteries is a well-established technique during thoracoabdominal aortic aneurysm (TAAA) repair. However, the retained aortic tissue may later become aneurysmal. We reviewed our TAAA repair experience using a presewn aortic branched graft to eliminate this risk. Methods Between March 2003 and December 2008, 52 patients with Crawford extent II and III TAAAs had surgical repair using a presewn aortic branched graft. Postoperative computed tomography (CT) scans with intravenous contrast were available for 41 patients (mean angiographic follow-up 2.3 years). The mean age of these 41 patients was 59 ± 16 years (range, 22-86), and 21 patients were female (51%). The indications for surgery were degenerative aneurysms in 30 patients (73%), type B dissections in 10 patients (24%), and visceral patch aneurysm in 1 patient (2.4%). Twenty-four patients (59%) underwent repair of a Crawford extent II TAAA and 17 patients (41%) had extent III TAAA repair. Results Patency of the branches to the visceral and renal arteries at 1 and 5 years was 100% and 98%, respectively. Of the 148 graft branches, 2 became occluded and 4 developed stenosis (2 patients). One patient required percutaneous stenting of 3 stenosed branches, and 1 patient died after acute occlusion of 2 branches and stenosis of a third. During the follow-up period that extended to 6.3 years, there were 10 late deaths. Six patients required reoperation on the aortic graft or contiguous aorta, but no reoperations have been required on the visceral abdominal aorta or its branches. Conclusion The use of a presewn aortic branched graft is a safe and suitable option for TAAA repair. With midterm follow-up, this technique seems to eliminate the risk of visceral patch aneurysms and results in favorable durability and patency.

Alice K. Jacobs, MD, FACC, FAHA, Chair 2009–2011; Sidney C. Smith, Jr, MD, FACC, FAHA, Immediate Past Chair 2006–2008[†††][1]; Jeffery L. Anderson, MD, FACC, FAHA, Chair-Elect; Cynthia D. Adams, MSN, PhD, FAHA[†††][1]; Christopher E. Buller, MD, FACC; Mark A. Creager, MD, FACC, FAHA

It is essential that the medical profession play a central role in critically evaluating the evidence related to drugs, devices, and procedures for the detection, management, or prevention of disease. Properly applied, rigorous, expert analysis of the available data documenting absolute and relative

Objective Recent advances in endovascular repair have put into question the role of open surgery on the descending thoracic aorta. We evaluated our experience with replacement of the descending thoracic aorta using hypothermic circulatory arrest. Methods From May 1989 to August 2008, 151 patients (mean age 62 ± 15 years) had descending thoracic aorta replacement using cardiopulmonary bypass and hypothermic circulatory arrest. Concurrent distal aortic arch repair was performed in 71 patients (47%). Seventeen patients (11%) had emergency operation. Results The mean durations of bypass and circulatory arrest were 107 ± 34 and 32 ± 9 minutes, respectively. Stroke occurred in 5 patients (3.3%), spinal cord ischemic injury in 2 patients (1.3%; 1 paraplegia, 1 paraparesis), and renal failure requiring dialysis in 2 patients (1.3%). Thirty-day and 6-month mortality rates were 4.0% and 9.9%, respectively. Following emergency operation, the 30-day mortality rate was 17.6% compared with 2.2% after elective surgery (P = .02). Five- and 10-year survival rates were 71% and 45%, respectively. Five patients required reoperation on the graft or contiguous aorta at a mean of 5 ± 4 years after the initial repair. Five- and 10-year rates of freedom from reoperation were 96% and 92%, respectively. Conclusions Cardiopulmonary bypass with hypothermic circulatory arrest can be safely used for replacement of the descending thoracic aorta. Although more invasive than endovascular stent grafting, this open surgical technique provides definitive repair, maintenance of left subclavian artery patency, protection against spinal cord injury, and early mortality and morbidity rates that do not exceed those reported for endovascular repair.

BACKGROUND Vein-graft harvesting with the use of endoscopy (endoscopic harvesting) is a technique that is widely used to reduce postoperative wound complications after coronary-artery bypass grafting (CABG), but the long-term effects on the rate of vein-graft failure and on clinical outcomes are unknown. METHODS We studied the outcomes in patients who underwent endoscopic harvesting (1753 patients) as compared with those who underwent graft harvesting under direct vision, termed open harvesting (1247 patients), in a secondary analysis of 3000 patients undergoing CABG. The method of graft harvesting was determined by the surgeon. Vein-graft failure was defined as stenosis of at least 75% of the diameter of the graft on angiography 12 to 18 months after surgery (data were available in an angiographic subgroup of 1817 patients and 4290 grafts). Clinical outcomes included death, myocardial infarction, and repeat revascularization. Generalized estimating equations were used to adjust for baseline covariates associated with vein-graft failure and to account for the potential correlation between grafts within a patient. Cox proportional-hazards modeling was used to assess long-term clinical outcomes. RESULTS The baseline characteristics were similar between patients who underwent endoscopic harvesting and those who underwent open harvesting. Patients who underwent endoscopic harvesting had higher rates of vein-graft failure at 12 to 18 months than patients who underwent open harvesting (46.7% vs. 38.0%, P

Background We evaluated a one-stage technique for extensive replacement of the thoracic aorta in patients with chronic aortic dissection. Methods Fifty-one patients with chronic expanding thoracic aortic dissections (48 type A, 3 type B with proximal extension) were treated with a single procedure using a bilateral anterior thoracotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Forty-six patients had previous operations: for acute type A aortic dissection (n = 36), aortic valve disease (n = 6), or coronary artery disease (n = 4). The ascending aorta and entire arch were replaced in all patients combined with varying lengths of the descending aorta. Results Hospital mortality was 3.9% (2 patients). Five patients (10%) required reoperation for bleeding. Two patients were discharged on ventilatory support and 2 on dialysis. No patient sustained a stroke, and paraplegia developed in one. The 5- and 7-year survival rates were 79% and 68%. Freedom from reoperation on the thoracic or abdominal aorta was 92% at 5 and 7 years postoperatively. Serial tomograms have documented substantial enlargement of the residual dissected aorta in only 2 patients (reoperated). Conclusions The technique is a safe and suitable alternative to the two-stage (elephant trunk technique) and hybrid procedures for treatment of chronic dissection with aneurysm of the thoracic aorta. It eliminates the risk of rupture in the interval between staged procedures and the risks associated with a second thoracic aortic procedure, and is associated with a low rate of reoperation on the remaining aorta.

ObjectiveLimited information exists on the impact of preoperative renal dysfunction on internal thoracic artery and saphenous vein graft failure and 2-year clinical outcomes in patients undergoing coronary artery bypass surgery.MethodsWe studied the impact of preoperative renal dysfunction (creatinine clearance < 60 mL/min) on 1-year internal thoracic artery and saphenous vein graft failure (defined as ≥ 75% angiographic stenosis) and 2-year clinical events (death; death or myocardial infarction; and death, myocardial infarction, or revascularization) in 3014 patients undergoing coronary artery bypass surgery enrolled in the Project of Ex-vivo Vein Graft Engineering via Transfection-IV study.ResultsOf 2973 patients (98.6%) with preoperative measurement of renal function, 440 (14.8%) had renal dysfunction. Most baseline comorbidities were higher in these patients. Two-year clinical events were higher in patients with preoperative renal dysfunction (adjusted death, myocardial infarction, or revascularization, hazard ratio 1.21, 95% confidence interval 0.97–1.50; adjusted death or myocardial infarction, hazard ratio 1.35, 95% confidence interval 1.05–1.74; adjusted death, hazard ratio 1.47, 95% confidence interval 0.98–2.21). However, saphenous vein graft (odds ratio 1.02, 95% confidence interval 0.79–1.33) and internal thoracic artery (odds ratio 0.76, 95% confidence interval 0.40–1.44) failure were similar in the 2 groups.ConclusionAlthough the risk of adverse clinical events is higher in patients with preoperative renal dysfunction, that of internal thoracic artery and saphenous vein graft failure is not. This suggests that factors other than graft failure account for the worse clinical outcomes in this high-risk cohort. Further studies are needed to identify other mechanisms of these worse outcomes so that appropriate measures can be developed to improve long-term outcomes in patients with renal dysfunction undergoing coronary artery bypass surgery.

While considered simple and effective, crystalloid antegrade cardioplegia solutions have had few prospective multicentre comparison trials.A commercial intracellular-type histidine-tryptophan-ketoglutarate (HTK) cardioplegia solution (Custodiol HTK; Köhler Chemie GmbH, Germany) designed for 4 h of protection after a single administration was compared with a standard extracellular multidose product (Plegisol [PL]; Hospira Inc, USA) in an open-label, randomized, prospective seven-institution trial. A total of 136 isolated coronary bypass patients were randomly assigned into two groups and stratified by ejection fraction into categories of 40% or greater (n=118) and 20% to 39% (n=18).The mean age of the study cohort was 62 years, of which 94% were men. Seventy per cent of patients had Canadian Cardiovascular Society class III angina and 75% had three-vessel disease anatomy. Cross-clamp times were nearly identical for patients in both cardioplegia groups; however, defibrillation was needed less often for patients who were treated with HTK (64% versus 91%, P0.01). Hospital and intensive care unit stays, creatine kinase isoenzyme MB curves, cardiac outputs, inotrope levels, and deaths or serious adverse events (PL=13, HTK=14) were very similar between groups. Logistic regression showed that myocardial infarction or possible treatment-related adverse events were associated with high cardiac troponin I (cTn-I) levels 6 h after the procedure (P=0.001), and HTK treatment (OR 3.5, P=0.01). The primary study end point (6 h post-ischemia cTn-I) favoured PL (16.7±13.2 μg/L versus 20.3±13.5 μg/L, P=0.01). Patients who underwent circumflex grafting had higher cTn-I levels with HTK (P0.001) and 48% required reinfusions due to cardiac warming. Longer intervals between doses correlated with high cTn-I levels (P=0.02). HTK provided prolonged protection with low cTn-I release (10 μg/L or less), although this occurred less frequently than with PL (17 versus 27 patients, P=0.06).HTK caused more structural protein release and adverse events than PL, even when reinfusion was implemented.

This analysis compares 1-year vein graft patency and major adverse cardiac and cerebral events (MACCE [death, myocardial infarction, or stroke]) in on-pump and off-pump patients enrolled in PREVENT IV (the PRoject of Ex-vivo Vein graft ENgineering via Transfection IV).The PREVENT IV was a multicenter (107 sites) randomized trial of edifoligide to prevent vein graft failure from neointimal hyperplasia in 3,014 patients undergoing primary, isolated coronary artery bypass grafting (CABG) with at least two vein grafts. One-year angiographic follow-up was completed on 1,920 patients (4,736 grafts) with MACCE follow-up on 99.4% of enrolled patients.In all, 2,377 procedures (78.9%) were on pump and 637 (21.1%) were off pump. On-pump patients had more chronic lung disease (17% versus 11%; p0.001), congestive heart failure (10% versus 7%; p = 0.03), lower mean ejection fraction (50% versus 55%; p0.001), and worse target artery quality (good 63.8% versus 68.1%; fair 26.4% versus 22.7%; poor 9.8% versus 9.2%; p0.001). Vein graft failure (more than 75% graft stenosis) in on- versus off-pump patients was 25.3% versus 25.7% (p = 0.62). After adjusting for differences in significant predictors of vein graft failure (target artery quality, surgery time, endoscopic vein harvest, more than 1 distal anastomosis/graft, and patient weight), the odds of vein graft failure was 0.82 (95% confidence interval: 0.67 to 1.00; p = 0.05) for on-pump versus off-pump patients. One-year mortality for on- versus off-pump patients was 3.3% versus 2.5% (p = 0.30); and MACCE was 15.4% versus 11.3% (p = 0.01). The adjusted hazard ratio for 1-year MACCE was 1.31 (95% confidence interval: 1.01-1.69; p = 0.01) for on pump versus off pump.Observed saphenous vein failure rate was 25% in both groups. One-year clinical outcomes (MACCE) were better with off-pump than with on-pump CABG, suggesting benefits not related to vein graft patency.

Between 43,000 and 47,000 people die annually in the United States from diseases of the aorta and its branches and continues to increase. For the thoracic aorta, these diseases are increasingly treated by stent-grafting. No prospective randomized study exists comparing stent-grafting and open surgical treatment, including for disease subgroups. Currently, one stent-graft device is approved by the Food and Drug Administration for descending thoracic aortic aneurysms although two new devices are expected to obtain FDA approval in 2008. Stent-graft devices are used "off label" or under physician Investigational Device Exemption studies for other indications such as traumatic rupture of the aorta and aortic dissection. Early first-generation devices suffered from problems such as stroke with insertion, ascending aortic dissection or aortic penetration from struts, vascular injury, graft collapse, endovascular leaks, graft material failure, continued aneurysm expansion or rupture, and migration or kinking; however, the newer iterations coming to market have been considerably improved. Although the devices have been tested in pulse duplicators out to 10 years, long-term durability is not known, particularly in young patients. The long-term consequences of repeated computed tomography scans for checking device integrity and positioning on the risk of irradiation-induced cancer remains of concern in young patients. This document (1) reviews the natural history of aortic disease, indications for repair, outcomes after conventional open surgery, currently available devices, and insights from outcomes of randomized studies using stent-grafts for abdominal aortic aneurysm surgery, the latter having been treated for a longer time by stent-grafts; and (2) offers suggestions for treatment.

The natural history of the residual aorta after repair of acute type A aortic dissection is incompletely understood.During a 22-year period, 201 patients underwent repair of acute type A dissection by 25 surgeons. For 168 operative survivors, mean late follow-up for reoperation or death was 6.5 +/- 5.5 years and was 100% complete. Late blood pressure and medication history were available for 136 patients. Overall, 412 computed tomography scans were analyzed for segmental diameter and false lumen patency from 69 patients who underwent multiple follow-up imaging studies at our institution.Freedom from reoperation at 10 years (range, 1 to 170 months) was 74% +/- 5% (28 reoperations in 26 patients). A nonresected primary tear (p = 0.05), Marfan syndrome (p0. 001), elevated systolic blood pressure at follow-up (p = 0.008), and absence of beta-blocker therapy (p = 0.02) were independent predictors of late reoperation. Aortic growth between consecutive imaging studies was detected in 18% of intervals (62/343) affecting 49% patients (34/69), with mean yearly growth rate of 5.3 +/- 4.5 mm. Onset of enlargement was unpredictable and occurred 59 +/- 45 months postoperatively (range, 1 to 167 months). Risk factors for growth included aortic diameter (p0. 001), elevated systolic blood pressure (p = 0.04), and presence of a patent false lumen (p = 0.05). Maximum aortic diameter of less than 35 mm predicted growth in 11% of intervals, 35 to 49 mm in 22%, and more than 49 mm in 37% (p0.001). Different proximal or distal surgical strategies did not affect aortic growth or need for reoperation (p0.17).Optimal long-term outcome of patients with acute type A dissection demands rigorous antihypertensive therapy and lifelong radiographic follow-up because aortic enlargement can begin more than a decade postoperatively.

Background Secondary prevention medications are beneficial after acute coronary syndromes, but these benefits are less clear after coronary artery bypass graft surgery. We investigated whether greater use of secondary prevention medications after coronary artery bypass graft surgery is associated with improved clinical outcomes. Methods Patients undergoing coronary artery bypass graft surgery in the PREVENT IV trial (n = 2970) were surveyed for use of antiplatelet agents, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and lipid-lowering agents after hospital discharge and at 1 year. Patients were categorized based on their percentage use of indicated medications after hospital discharge. Cox modeling was used to determine the association between medication use categories and rates of death or myocardial infarction through 2 years after adjustment for clinical factors, the number of indicated medications, and treatment propensity. Results Rates of use of antiplatelet agents and lipid-lowering agents were high at discharge and at 1 year, but use of β-blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was suboptimal. There was a stepwise association between medication use at discharge and patient outcomes ( p for trend=0.014). Patients taking 50% or less of indicated medications at discharge had a significantly higher 2-year rate of death or myocardial infarction (8.0% versus 4.2%; adjusted hazard ratio, 1.69; 95% confidence interval, 1.12 to 2.55; p = 0.013) than those taking all indicated medications. Conclusions Greater use of indicated secondary prevention medications after coronary artery bypass graft surgery is associated with a lower 2-year rate of death or myocardial infarction. These data underscore the importance of appropriate secondary prevention measures to improve long-term clinical outcomes after coronary artery bypass graft surgery.

Background Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with a substantial cumulative mortality for the two procedures and death in the interval between, often from aortic rupture. We have used a one-stage approach for operative repair of most, or all, of the thoracic aorta. Methods Sixty-nine patients were treated using a bilateral anterior thoracotomy with transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Forty-two patients had chronic ascending aortic dissections (all but 1 had a previous operation), 24 had degenerative aneurysms, and 3 had chronic descending aortic dissections with proximal extension. The ascending aorta and aortic arch were replaced in all patients combined with resection of various lengths of descending aorta. Results In-hospital mortality was 7.2% (5 patients). Morbidity included reoperation for bleeding (13%), mechanical ventilation for more than 72 hours (50%), temporary tracheostomy (13%), and temporary renal dialysis (9%). No patient sustained a stroke. There have been 9 late deaths unrelated to the aortic disease. Four patients have undergone successful reoperation on the aorta for false aneurysm in 1, endocarditis in 1, and progression of disease in 2. Survival at 5 years was 71%. Conclusions The one-stage arch-first technique is a safe and suitable alternative to the two-stage procedure for repair of extensive thoracic aortic disease.

Patients with valvular heart disease, particularly aortic and mitral incompetence, may have significant derangement of myocardial function, often in the absence of significant symptoms, which directly affects early and late survival and functional status following valve replacement. With declining hospital mortiality rates and improved valvular prostheses, consideration must be given to valve replacement in patients of this type in order to preserve myocardial function. This should improve long-term survival and the functional results following valve replacement. Attention should be directed to identifying and closely observing patients of this type, perhaps with noninvasive techniques, and proceeding with valve replacement before irreversible myocardial damage has occured.

Background Coronary artery bypass graft (CABG) surgery with autologous vein graft (VG) conduit is one of the most frequently performed operations in the United States. Unfortunately, many VGs become occluded during long-term follow-up largely because of neointimal hyperplasia. A novel approach to preventing neointimal hyperplasia is with the double-stranded oligonucleotide edifoligide (Corgentech Inc, South San Francisco, Calif). Edifoligide inhibits E2F, a transcription factor that activates cell-cycle genes responsible for neointimal hyperplasia. Methods PREVENT IV is a phase-III, multicenter, randomized double-blind placebo-controlled trial of ex vivo treatment of autologous VGs with edifoligide in patients undergoing initial CABG surgery. The primary end point is VG failure, defined as death or ≥75% stenosis in a treated VG at 12- to 18-month angiographic follow-up. Secondary end points include major adverse cardiac events through at least 5 years and adverse events through 30 days. Results Enrollment of 3014 patients from 107 sites was completed on October 22, 2003. The baseline and procedural characteristics of the PREVENT IV population are generally well matched to a contemporary population of patients undergoing initial CABG from the Society of Thoracic Surgeons National Database. Angiographic follow-up is ongoing and scheduled to be completed in March 2005. Conclusions The PREVENT IV data will establish whether VG pretreatment with an E2F transcription factor decoy, edifoligide, can improve graft patency and reduce the long-term morbidity and mortality of patients undergoing CABG surgery.