Objective: An increasing number of elderly patients are referred for pulmonary endarterectomy. The distinction between operable and inoperable lesions has been challenged over time. Hence, we developed alternative cardiopulmonary bypass management and cerebral protection strategies to obtain satisfactory surgical results according to the changing patient features. Methods: From April 1994 to March 2011, 347 pulmonary endarterectomies were performed at our center. We began with the technique championed by the San Diego Group, adopting a single period of deep hypothermic circulatory arrest for each side (group A). Since 2003, we began to perform short periods of intermittent deep hypothermic circulatory arrest followed by periods of reperfusion (group B). We then adopted moderate, instead of deep, hypothermia (group C). Finally, we modified our technique further performing shorter (5-7-minute) periods of circulatory arrest (group D). Results: The hemodynamic results after surgery were excellent in all 4 groups. The patients' age increased significantly. A trend toward an increase in the number of Jamieson type 3 lesions was observed. Associated with our protocol changes, we observed better postoperative respiratory function, a reduction in the length of mechanical ventilation and postoperative infections, and a remarkable improvement in uneventful postoperative courses. Despite the increased total circulatory arrest time, a trend toward a reduction in the incidence of transient neurologic events was observed, and operative mortality was not affected. Conclusions: In our experience, our alternative strategy resulted in a better combination of surgical accuracy and cerebral protection and improved outcomes.
Background: Use of a minimally invasive approach for isolated aortic valve surgery is increasing. However, management of the root and/or ascending aorta through a miniinvasive incision is not so frequent. The aim of this study is to report our initial experience with surgery of the ascending aorta through a ministernotomy approach. Methods: We retrospectively analyzed 102 patients treated for ascending aorta disease through a ministernotomy. Several types of surgeries were performed, including isolated or combined surgical procedures. Pre-operative and operative parameters and in-hospital clinical outcomes were retrospectively analyzed. Results: Patient mean age was 63.9 ± 13.6 years (range 29-85). There were 33 (32.4%) female and 69 (67.6%) male patients. Preoperative logistic EuroSCORE I was 7.4% ± 2.1%. Mean cardiopulmonary bypass and aortic cross-clamp time were 123.7 ± 36.9 and 100.8 ± 27.5 min, respectively. In-hospital mortality was 0%. Conclusions: Our experience shows that surgery of the ascending aorta with or without combined procedures can be safely performed through an upper ministernotomy, without compromising surgical results. Although our series is not large, we believe that the experience gained on the isolated aortic valve through a ministernotomy can be safely reproduced in ascending aorta surgery as a routine practice.
The presence of high titre of IgG isotype a-PL antibodies significantly influences preoperative characteristics of patients undergoing PEA. Furthermore, despite that no significant differences were shown in major end points, the presence of high titre of a-PL did interfere with postoperative course as caused by an increased rate of minor and transient neurological impairment (TNI). An accurate monitoring especially during hypothermic circulatory arrest (CA) period seems, therefore, mandatory in this subgroup of patients undergoing PEA.
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