Case Reports

small intestinal submucosa ECM grafts.1-2 Although we have not shown cellular regeneration, our findings of contractile activity support the continued use and study of CorMatrix ECM cardiac repair. References 1. Robinson KA, Li J, Mathison M, Redkar A, Cui J, Chronos NA, et al. Extracellular matrix scaffold for cardiac repair. Circulation. 2005;112(9 Suppl):I135-43.

2. Badylak S, Obermiller J, Geddes L, Matheny R. Extracellular matrix for myocardial repair. Heart Surg Forum. 2003;6:E20-6. 3. Mewhort HE, Turnbull JD, Meijndert HC, Ngu JM, Fedak PW. Epicardial infarct repair with basic fibroblast growth factor–enhanced CorMatrix-ECM biomaterial attenuates postischemic cardiac remodeling. J Thorac Cardiovasc Surg. Epub 2013 Sep 26. 4. Yanagawa B, Rao V, Yau TM, Cusimano RJ. Initial experience with intraventricular repair using CorMatrix Extracellular Matrix. Innovations. 2013;8:348-52. 5. Kawata T, Kitamura S, Kawachi K, Morita R, Yoshida Y, Hasegawa J. Systolic and diastolic function after patch reconstruction of left ventricular aneurysms. Ann Thorac Surg. 1995;59:403-7.

Staged total aortic hybrid repair for DeBakey type I dissection: Report of a case Marco Di Eusanio, MD, PhD, Paolo Berretta, MD, Luigi Lovato, MD, and Roberto Di Bartolomeo, MD, Bologna, Italy Open surgical repair for extensive aortic disease represents a great challenge, and staged approaches involving multiple hybrid procedures have emerged as an appealing alternative to conventional open repair.1 We report a case of DeBakey type I aortic dissection treated with a total aortic repair through a staged hybrid approach. CLINICAL SUMMARY A 45-year-old man who had undergone a Bentall procedure for an acute DeBakey type I aortic dissection (Figure 1, A-C) 7 years previously was referred to our institution. Computed tomographic scan (Figure 1, D-F) documented a chronic postdissection aneurysm of the aortic arch and thoracoabdominal aorta (70 mm) with proximal entry tears at the brachiocephalic trunk and aortic isthmus. At the descending thoracic aorta, the true lumen was narrow (4 mm) and circumferentially dissected; multiple reentry tears were located in the distal aorta, and all visceral vessels originated from the true lumen except for the right renal artery. A staged hybrid approach was offered. The patient initially underwent a complete arch replacement with a wide fenestration of the descending intimal flap and elephant trunk construction. The arch vessels were reimplanted by means of the separate graft From the Department of Cardiac Surgery, University of Bologna, Sant’Orsola-Malpighi Hospital, Bologna, Italy. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Sept 25, 2013; revisions received Nov 5, 2013; accepted for publication Dec 5, 2013; available ahead of print Feb 7, 2014. Address for reprints: Marco Di Eusanio, MD, PhD, Cardiac Surgery Department, University of Bologna, Sant’Orsola-Malpighi Hospital, Via Massarenti 9, 40128, Bologna, Italy (E-mail: [email protected]). J Thorac Cardiovasc Surg 2014;147:e43-6 0022-5223/$36.00 Copyright Ó 2014 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2013.12.005

technique with a 28-mm Siena 4-branched aortic graft (Vascutek Ltd, Glasgow, Scotland; Figure 1, G-I). Antegrade selective cerebral perfusion with moderate hypothermia was used for cerebral protection.2 Two months later, graft replacement (28 mm) of the descending thoracic aorta was performed with temporary left heart bypass, sequential clamping, and cerebrospinal fluid drainage for spinal and visceral protection (Figure 1, J-L). Four months later, the patient was readmitted for treatment completion of the residual thoracoabdominal aortic aneurysm. Through a median laparotomy with a transperitoneal approach, the infrarenal abdominal aorta was replaced and the visceral vessels were revascularized with a 28-mm multibranched Coselli thoracoabdominal graft (Vascutek). Selective renal perfusion with cold crystalloid solution was used for renal protection (Figure 2, A-D). During the same hospitalization, endovascular exclusion of the remaining thoracoabdominal aorta was then performed; 2 Valiant Medtronic stent-grafts (34-36 mm) were implanted with a 20% to 30% oversizing. Graft-to-graft overlaps of 4 and 3 cm were achieved in the proximal and distal landing zones, respectively. Cerebrospinal fluid drainage was applied for spinal cord protection. The predischarge computed tomographic scan showed a total aortic replacement with a partially thrombosed false lumen as a result of residual endograft porosity (Figure 2, E-H). All postoperative courses were totally uneventful. At 6-month follow-up, the patient remains well, with unchanged aortic appearances and stable aortic diameters.

DISCUSSION Reoperations for extensive open aortic replacement are associated with considerable morbidity and mortality. During the last decades, hybrid and endovascular repair

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FIGURE 1. Multidetector computed tomographic axial (A, D, G, and J), longitudinal (B, E, H, and K), and 3-dimensional (C, F, I, and L) images. A-C, Onset of DeBakey type I aortic dissection. D-F, Residual chronic postdissection aneurysm of the aortic arch and thoracoabdominal aorta (70 mm), with narrow and circumferentially dissected false lumen at the descending thoracic aorta, 7 years after Bentall procedure. G-I, Predischarge computed tomographic scan after complete arch replacement with fenestration of the descending intimal flap and elephant trunk construction. The white arrows indicate the free-floating segment of the elephant trunk. J-L, Predischarge computed tomographic scan after open replacement of two thirds of the descending aorta.

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FIGURE 2. Multidetector computed tomographic longitudinal (A and E), 3-dimensional (B, C, and F), and axial (D, G, and H) images. A-D, Computed tomographic scan after replacement of the infrarenal abdominal aorta and debranching of visceral vessels. E-H, Final computed tomographic scan after the 5-stage hybrid aortic repair. The entire native aorta, from root to iliac bifurcations, has been replaced.

techniques have emerged as interesting alternative options for high-risk patients.1 We have described a successful case of a 5-stage total aortic hybrid repair. Of note, after complete arch replacement with elephant trunk, endovascular repair of descending thoracic aorta was excluded, and an open replacement of two thirds of the descending aorta was performed instead. In fact, the extremely narrow and concentric true lumen (Figure 1, A

and D) would not have ensured a safe and fully open stent-graft deployment and would have carried a high risk of uncontrolled laceration of the distal intimal lamella. For abdominal aortic replacement and visceral vessel debranching, a prefabricated 4-branched Dacron polyester fabric graft was used. Relative to separate grafts for the branch arteries, this prosthesis, designed for revascularization of visceral vessels, can greatly simplify abdominal

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aortic debranching by reducing both the number of anastomoses and the risk of bleeding. Neurologic protection is a main concern during arch and thoracoabdominal aortic procedures. If antegrade selective cerebral perfusion has already shown to be the best method of brain protection,2 more recent experimental and clinical studies have introduced the collateral network concept to comprehend spinal vascular remodeling after extensive thoracoabdominal aortic interventions. This notion indicates that restoring a good spinal cord perfusion is a time-dependent process and supports staged thoracoabdominal aortic repair to reduce the incidence of postoperative spinal cord injury.3 Furthermore, relative to single-staged procedures, which combine at once the detrimental effects of visceral ischemia with those of nephrotoxic contrast media, staged repair seem to be associated with reduced postoperative renal failure rates and shorter hospital stay.4 We were well aware that a patient’s failure to complete treatment (as result of death while waiting or refusal) represents the main limitation of the staged approaches; however,

the previously mentioned arguments convinced us to subdivide treatment into fractions carrying less impact. In conclusion, a staged hybrid approach for total aortic repair is feasible and can represent a valid form of treatment for selected patients with extensive aortic disease. It may help reduce morbidity and mortality among these highrisk patients. References 1. Hughes GC, Barfield ME, Shah AA, Williams JB, Kuchibhatla M, Hanna JM, et al. Staged total abdominal debranching and thoracic endovascular aortic repair for thoracoabdominal aneurysm. J Vasc Surg. 2012;56:621-9. 2. Di Eusanio M, Schepens M, Morshuis W, Dossche K, Pacini D, Di Marco L, et al. Operations on the thoracic aorta and antegrade selective cerebral perfusion: our experience with 462 patients. Ital Heart J. 2004;5: 217-22. 3. Etz CD, Zoli S, Mueller CS, Bodian CA, Di Luozzo G, Lazala R, et al. Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg. 2010;139: 1464-72. 4. Lin PH, Kougias P, Bechara CF, Weakley SM, Bakaeen FG, Lemaire SA, et al. Clinical outcome of staged versus combined treatment approach of hybrid repair of thoracoabdominal aortic aneurysm with visceral vessel debranching and aortic endograft exclusion. Perspect Vasc Surg Endovasc Ther. 2012;24:5-13.

Temporary extracorporeal left ventricular assist device support for implantable left ventricular assist device replacement cases Matthew A. Schechter, MD,a Chetan B. Patel, MD,b Joseph G. Rogers, MD,b and Carmelo A. Milano, MD,a Durham, NC Replacement of an implantable left ventricular assist device (LVAD) may be required for infection, thrombosis, or mechanical or electrical failure.1,2 In certain instances, replacement of implantable LVADs poses a very high risk of either reinfection or death. This report describes 4 cases in which implantable LVADs required urgent removal but replacement of an implantable system was delayed by a period of support with an extracorporeal temporary device.

From the Department of Surgery,a Duke University Medical Center, Durham, NC; and the Department of Medicine,b Duke University Medical Center, Durham, NC. Disclosures: C.B.P. has served as a consultant for HeartWare Inc. J.G.R. and C.A.M. have served as consultants for Thoratec Corporation and HeartWare Inc. M.A.S has nothing to disclose with regard to commercial support. Received for publication Aug 27, 2013; revisions received Oct 31, 2013; accepted for publication Dec 5, 2013; available ahead of print Jan 25, 2014. Address for reprints: Carmelo A. Milano, MD, Division of Cardiac and Thoracic Surgery, Duke University Medical Center, Box 3043, Durham, NC 27710 (E-mail: [email protected]). J Thorac Cardiovasc Surg 2014;147:e46-8 0022-5223/$36.00 Copyright Ó 2014 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2013.12.009

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CLINICAL SUMMARY The first patient was a 58-year-old woman with ischemic cardiomyopathy who had received a HeartMate II (Thoratec Corporation, Pleasanton, Calif) as destination therapy. The patient presented approximately 18 months after implantation with persistent bacteremia and mediastinal purulence. Echocardiography showed vegetation around the inflow cannula. The decision was made to remove the device. Because of the extent of infection, the patient was supported with an extracorporeal device (Paracorporeal Ventricular Assist Device [PVAD]; Thoratec) while receiving antibiotic therapy. After 3 weeks of antibiotics, the patient had negative results of blood cultures and a normal white blood cell count. She was returned to the operating room, where the Thoratec PVAD was replaced with another HeartMate II device. The patient did well postoperatively and went on to live for approximately 3 years without any further episodes of bacteremia or other evidence of device infection. The second patient was a 63-year-old man who presented with recurrent fevers and staphylococcal bacteremia despite intravenous antibiotics 1 year after receiving

The Journal of Thoracic and Cardiovascular Surgery c April 2014

Staged total aortic hybrid repair for DeBakey type I dissection: report of a case.

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