- Email: [email protected]
Interrupted Aortic Arch With Massive Saccular Collateral Aneurysm in an Adult
316
CASE REPORT SASAKI ET AL ADULT SURGICAL CASE OF INTERRUPTED AORTIC ARCH
Ann Thorac Surg 2014;98:316–8
the field is contaminated, and later definitive and elective complete repair resecting all prosthetic material is often required after the patient has been stabilized [6]. Positron emission tomography/computed tomography can be useful in determining if an implanted endograft has been infected despite suppressive antibiotic treatment and whether secondary complete repair is necessary. Our patient had relatively little obstruction of his coarctation repair after balloon dilation of a stent that was already in place. Had there been residual obstruction or no previous stent at the coarctation, a salvage axillobifemoral bypass would have been mandatory to ensure distal perfusion.
gradient between upper and lower extremities disappeared and renal function was normalized. Thoracic collateral aneurysmectomy and a simultaneous bypass from the left subclavian artery to the descending aorta with postoperative normalization of ischemic renal insufficiency are extremely rare in adult patients with IAA, and the remaining abdominal collateral aneurysms require careful monitoring. (Ann Thorac Surg 2014;98:316–8) Ó 2014 by The Society of Thoracic Surgeons
References
FEATURE ARTICLES
1. Connolly HM, Schaff HV, Izhar U, Dearani JA, Warnes CA, Orszulak TA. Posterior pericardial ascending-to-descending aortic bypass: an alternative surgical approach for complex coarctation of the aorta. Circulation 2001;104:I133–7. 2. Myers PO, Tissot C, Cikirikcioglu M, Kalangos A. Complex aortic coarctation, regurgitant bicuspid aortic valve with VSD and ventricular non-compaction: a challenging combination. Thorac Cardiovasc Surg 2011;59:313–6. 3. Brink J, Lee MGY, Konstantinov IE, et al. Complications of extra-anatomic aortic bypass for complex coarctation and aortic arch hypoplasia. Ann Thorac Surg 2013;95:676–81. 4. McCarthy MJ. Open or endovascular repair of secondary aortoenteric fistulae? Eur J Vasc Endovasc Surg 2011;41:635–6. 5. Kakkos SK, Antoniadis PN, Klonaris CN, et al. Open or endovascular repair of aortoenteric fistulas? A multicentre comparative study. Eur J Vasc Endovasc Surg 2011;41:625–34. 6. Stellmes A, Allmen Von R, Derungs U, et al. Thoracic endovascular aortic repair as emergency therapy despite suspected aortic infection. Interact Cardiovasc Thorac Surg 2013;16: 459–64.
Interrupted Aortic Arch With Massive Saccular Collateral Aneurysm in an Adult Yuki Sasaki, MD, Takeshiro Fujii, MD, Noritsugu Shiono, MD, Tomoyuki Katayanagi, MD, Shinnosuke Okuma, MD, Megumi Wakayama, MD, Kazutoshi Shibuya, MD, and Yoshinori Watanabe, MD Division of Cardiovascular Surgery, Departments of Surgery and Surgical Pathology, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
A 49-year-old man was diagnosed with an interrupted aortic arch (IAA), a massive saccular thoracic collateral aneurysm, ischemic renal insufficiency, and multiple abdominal collateral aneurysms. A bypass from the left subclavian artery to the descending aorta and thoracic collateral aneurysmectomy proceeded simultaneously through a posterolateral thoracotomy. The pressure Accepted for publication Sept 4, 2013. Address correspondence to Dr Sasaki, Division of Cardiovascular Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Omori-nishi 6-11-1, Ota-ku, Tokyo 143-8541, Japan; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
I
nterrupted aortic arch (IAA) is a very uncommon congenital disorder in adulthood, and reports of surgical interventions are sparse. Here, we describe treatment of a massive saccular thoracic collateral aneurysm in an adult with IAA, multiple abdominal collateral aneurysms, and renal insufficiency. A 49-year-old man who had undergone rehabilitation for sequelae of a cerebral hemorrhage at another hospital had hypertension and hypotension in the upper and lower extremities, respectively. Computed tomography confirmed IAA (type A), a saccular thoracic collateral aneurysm, with a diameter of 50 mm, in the thoracic cavity (Fig 1A), and multiple collateral aneurysms in the abdomen (Fig 1B). Several antihypertensive drugs were prescribed to prevent cerebral hemorrhage and aneurysmal rupture. He was referred to our institution for a detailed investigation. Although systolic blood pressure in the upper extremities had been controlled at around 120 mm Hg, hypotension in the lower extremities on admission was around 50 mm Hg. Consequently, renal insufficiency (serum creatinine level, 3.8 mg/dL; estimated glomerular filtration rate, 14 mL/min/1.73 m2) had progressed. He was admitted for preoperative assessment and infusions to preserve the kidneys. Selective angiography for a massive thoracic aneurysm revealed an inflow vessel arising from the suprascapular artery and an outflow vessel reaching the descending aorta. Surgical intervention was recommended to prevent thoracic aneurysmal rupture and to improve blood pressure and thus the ischemic renal disease. The operation proceeded through a fourth left intercostal posterolateral thoracotomy. The thoracic aneurysm firmly adhered to the descending aorta and was incised after partial clamping. The inflow and outflow vessels were then sutured from inside the aneurysm. A planned bypass from the left subclavian artery to the descending aorta proceeded using an 18-mm J Graft SHIELD NEO (Junken Medical Co, Ltd, Tokyo, Japan) without cardiopulmonary bypass. The pathologic findings of the thoracic collateral aneurysmal wall extracted during the procedure indicated an indistinct inner elastic lamina and atheromatous degeneration (Fig 2). The number of smooth muscle cells was decreased and collagen fibers were increased in the tunica media, indicating that the aneurysmal wall was likely to be fragile and inflexible and at a consequential high risk of rupture. The postoperative 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.025
Ann Thorac Surg 2014;98:316–8
CASE REPORT SASAKI ET AL ADULT SURGICAL CASE OF INTERRUPTED AORTIC ARCH
317
Fig 1. Preoperative 3-dimensional computed tomography. (A) Left anterior oblique image shows an interrupted aortic arch just distal to the left subclavian artery. Interrupted type A aortic arch was diagnosed. A massive thoracic aneurysm (diameter, 50 mm) is evident. (B) Anteroposterior view of the abdomen. Image shows multiple abdominal collateral aneurysms (arrows). Bilateral kidneys are of normal size. (AN ¼ aneurysm; Lt. SCA ¼ left subclavian artery.)
Comment
claudication caused by hypotension in the lower limbs [1]. If these conditions are neglected, advanced complications such as ascending aortic aneurysm, aortic regurgitation [2, 3], and subarachnoid hemorrhage [4] will result. Renal insufficiency might be 1 symptom of IAA in adulthood caused by hypotension in the lower half of the body. Sakellaridis and colleagues [5] described a patient with preoperatively confirmed renal insufficiency similar to that in our patient. Although their operative FEATURE ARTICLES
course was uneventful. Three-dimensional computed tomography after operation confirmed the patency of the bypass graft and the disappearance of the thoracic collateral aneurysm (Fig 3). The pressure gradient between the upper and lower extremities disappeared, and renal function became normalized.
An IAA is usually diagnosed and treated on an emergency basis during the neonatal period. However, some patients with IAA might survive into adulthood if collateral arteries are abundant and if severe intracardiac anomalies are absent. The characteristic symptoms of IAA in adulthood are headache and heart failure resulting from hypertension in the upper extremities and
Fig 2. Pathologic findings of the thoracic collateral aneurysmal wall extracted during the operation. The inner elastic lamina is indistinct and atheromatous degeneration (circle) is evident. Smooth muscle cells are decreased and collagen fibers (arrows) are increased in the tunica media (elastica van Gieson stain, original magnification 200).
Fig 3. Postoperative 3-dimensional computed tomographic scan in left anterior oblique view. It reveals disappearance of thoracic collateral aneurysm. Arrows indicate the bypass graft from left subclavian artery to descending aorta.
318
FEATURE ARTICLES
CASE REPORT YAMANE ET AL AORTIC AND MITRAL TRANSCATHETER VALVE-IN-VALVE
Ann Thorac Surg 2014;98:318–21
strategy succeeded, they did not describe the source of the renal insufficiency or the status of postoperative renal function. Our patient had undergone antihypertensive therapy because of a cerebral hemorrhage caused by hypertension in the upper extremities. Consequently, renal insufficiency might have gradually advanced because of hypotension in the lower half of the body. Preoperative CT showed that the size of the bilateral kidneys was essentially normal. Thus, postoperative renal function was probably improved by increasing renal blood flow. Management of the massive thoracic collateral aneurysm then became the essential focus for this patient. Although a similar patient with an IAA and a descending thoracic aortic aneurysm has been described, that patient was treated only by an extraanatomical bypass through a left thoracotomy without resection of the aneurysm [6]. However, the collateral thoracic aneurysm in our patient arose from a branch of the suprascapular artery. Because the collateral arteries in patients with IAA can rupture spontaneously [7], resection of the thoracic aneurysm should have been the absolute option for our patient. In fact, pathologic findings of the thoracic aneurysmal wall extracted during the operation indicated a fractured lamina elastica interna and tunica media. Therefore, we supposed that the thoracic collateral aneurysm was in a state of imminent preoperative rupture. Besides, the diameter of the remaining multiple abdominal collateral aneurysms required periodic monitoring. Most surgeons seem to select a bypass from the ascending to the descending aorta through a median sternotomy to facilitate cardiopulmonary bypass with cardiac arrest and complex cardiac surgical procedures to treat IAA [2, 7]. However, we resected the massive thoracic aneurysm through a left posterolateral thoracotomy. Furthermore, an extraanatomical bypass without cardiopulmonary bypass was feasible for the abundant collateral arteries. Clamping the left subclavian artery set blood pressure in the right radial artery relatively high to generate a mean femoral artery pressure of more than 40 mm Hg [1, 8]. We preserved the intercostal arteries by partially clamping the descending aorta [3]. These strategies resulted in an uneventful majorevent–free postoperative course. We successfully resected a massive thoracic collateral aneurysm, constructed a bypass from the left subclavian artery to the descending aorta, and normalized postoperative renal function in an adult patient with very rare IAA and multiple abdominal collateral aneurysms; however, the remaining multiple abdominal collateral aneurysms required careful monitoring.
4. Cao YH, Zhang GY, Han JL. Isolated interrupted aortic arch complicated by subarachnoid hemorrhage in an adult patient. Neurol India 2009;57:806–7. 5. Sakellaridis T, Argiriou M, Panagiotakopoulos V, et al. Latent congenital defect: interrupted aortic arch in an adult—case report and literature review. Vasc Endovascular Surg 2010;44: 402–6. 6. Yu W, Chen CJ, Wang X, et al. Interrupted aortic arch accompanied by a giant saccular aneurysm in a 53-year-old man. Eur J Echocardiogr 2011;12:909. 7. Sai Krishna C, Bhan A, Sharma S, et al. Interruption of aortic arch in adults: surgical experience with extra-anatomic bypass. Tex Heart Inst J 2005;32:147–50. 8. Backer CL, Stewart RD, Kelle AM, et al. Use of partial cardiopulmonary bypass for coarctation repair through a left thoracotomy in children without collaterals. Ann Thorac Surg 2006;82:964–72.
Transcatheter Valve-in-Valve Implantation for Early Prosthetic Valve Degeneration in Aortic and Mitral Positions Kentaro Yamane, MD, PhD, Tamim M. Nazif, MD, Omar Khalique, MD, Rebecca T. Hahn, MD, Martin B. Leon, MD, Susheel K. Kodali, MD, Mathew R. Williams, MD, and Isaac George, MD Division of Cardiothoracic Surgery, Department of Surgery, and Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
Recently, transcatheter valve-in-valve implantation has emerged as a new alternative to surgical reoperation for degenerated bioprosthetic valves, either in the aortic or mitral position. The early experience and outcome of this strategy appears promising in highly selected patient groups. Here we report a case of early structural valve degeneration in the aortic and mitral position in a patient with chronic hemodialysis successfully treated with transthoracic transcatheter valve-in-valve implantation. (Ann Thorac Surg 2014;98:318–21) Ó 2014 by The Society of Thoracic Surgeons
P
atients with end-stage renal disease (ESRD) on chronic hemodialysis (HD) undergoing cardiac surgery carry a high risk of perioperative morbidity, a poor long-term prognosis, and the risk of early structural valve degeneration (SVD) due to impaired calcium metabolism. The operative risk in this cohort more than doubles if the Accepted for publication Sept 10, 2013.
References 1. Gordon EA, Person T, Kavarana M, et al. Interrupted aortic arch in the adult. J Card Surg 2011;26:405–9. 2. Lafci G, Yalcinkaya A, Ecevit AN, et al. Single-stage aortic valve-sparing root replacement. Tex Heart Inst J 2012;39: 398–400. 3. Ogino H, Miki S, Matsubayashi K, et al. Two-stage repair for aortic regurgitation with interrupted aortic arch. Ann Thorac Surg 1998;65:1151–3. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Address correspondence to Dr George, Division of Cardiothoracic Surgery, New York Presbyterian Hospital, College of Physicians and Surgeons of Columbia University, Milstein Hospital Building, 7GN-435, 177 Fort Washington Ave, New York, NY 10032; e-mail: ig2006@ columbia.edu.
Drs Kodali and Williams disclose financial relationships with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.061
CASE REPORT SASAKI ET AL ADULT SURGICAL CASE OF INTERRUPTED AORTIC ARCH
Ann Thorac Surg 2014;98:316–8
the field is contaminated, and later definitive and elective complete repair resecting all prosthetic material is often required after the patient has been stabilized [6]. Positron emission tomography/computed tomography can be useful in determining if an implanted endograft has been infected despite suppressive antibiotic treatment and whether secondary complete repair is necessary. Our patient had relatively little obstruction of his coarctation repair after balloon dilation of a stent that was already in place. Had there been residual obstruction or no previous stent at the coarctation, a salvage axillobifemoral bypass would have been mandatory to ensure distal perfusion.
gradient between upper and lower extremities disappeared and renal function was normalized. Thoracic collateral aneurysmectomy and a simultaneous bypass from the left subclavian artery to the descending aorta with postoperative normalization of ischemic renal insufficiency are extremely rare in adult patients with IAA, and the remaining abdominal collateral aneurysms require careful monitoring. (Ann Thorac Surg 2014;98:316–8) Ó 2014 by The Society of Thoracic Surgeons
References
FEATURE ARTICLES
1. Connolly HM, Schaff HV, Izhar U, Dearani JA, Warnes CA, Orszulak TA. Posterior pericardial ascending-to-descending aortic bypass: an alternative surgical approach for complex coarctation of the aorta. Circulation 2001;104:I133–7. 2. Myers PO, Tissot C, Cikirikcioglu M, Kalangos A. Complex aortic coarctation, regurgitant bicuspid aortic valve with VSD and ventricular non-compaction: a challenging combination. Thorac Cardiovasc Surg 2011;59:313–6. 3. Brink J, Lee MGY, Konstantinov IE, et al. Complications of extra-anatomic aortic bypass for complex coarctation and aortic arch hypoplasia. Ann Thorac Surg 2013;95:676–81. 4. McCarthy MJ. Open or endovascular repair of secondary aortoenteric fistulae? Eur J Vasc Endovasc Surg 2011;41:635–6. 5. Kakkos SK, Antoniadis PN, Klonaris CN, et al. Open or endovascular repair of aortoenteric fistulas? A multicentre comparative study. Eur J Vasc Endovasc Surg 2011;41:625–34. 6. Stellmes A, Allmen Von R, Derungs U, et al. Thoracic endovascular aortic repair as emergency therapy despite suspected aortic infection. Interact Cardiovasc Thorac Surg 2013;16: 459–64.
Interrupted Aortic Arch With Massive Saccular Collateral Aneurysm in an Adult Yuki Sasaki, MD, Takeshiro Fujii, MD, Noritsugu Shiono, MD, Tomoyuki Katayanagi, MD, Shinnosuke Okuma, MD, Megumi Wakayama, MD, Kazutoshi Shibuya, MD, and Yoshinori Watanabe, MD Division of Cardiovascular Surgery, Departments of Surgery and Surgical Pathology, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
A 49-year-old man was diagnosed with an interrupted aortic arch (IAA), a massive saccular thoracic collateral aneurysm, ischemic renal insufficiency, and multiple abdominal collateral aneurysms. A bypass from the left subclavian artery to the descending aorta and thoracic collateral aneurysmectomy proceeded simultaneously through a posterolateral thoracotomy. The pressure Accepted for publication Sept 4, 2013. Address correspondence to Dr Sasaki, Division of Cardiovascular Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Omori-nishi 6-11-1, Ota-ku, Tokyo 143-8541, Japan; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
I
nterrupted aortic arch (IAA) is a very uncommon congenital disorder in adulthood, and reports of surgical interventions are sparse. Here, we describe treatment of a massive saccular thoracic collateral aneurysm in an adult with IAA, multiple abdominal collateral aneurysms, and renal insufficiency. A 49-year-old man who had undergone rehabilitation for sequelae of a cerebral hemorrhage at another hospital had hypertension and hypotension in the upper and lower extremities, respectively. Computed tomography confirmed IAA (type A), a saccular thoracic collateral aneurysm, with a diameter of 50 mm, in the thoracic cavity (Fig 1A), and multiple collateral aneurysms in the abdomen (Fig 1B). Several antihypertensive drugs were prescribed to prevent cerebral hemorrhage and aneurysmal rupture. He was referred to our institution for a detailed investigation. Although systolic blood pressure in the upper extremities had been controlled at around 120 mm Hg, hypotension in the lower extremities on admission was around 50 mm Hg. Consequently, renal insufficiency (serum creatinine level, 3.8 mg/dL; estimated glomerular filtration rate, 14 mL/min/1.73 m2) had progressed. He was admitted for preoperative assessment and infusions to preserve the kidneys. Selective angiography for a massive thoracic aneurysm revealed an inflow vessel arising from the suprascapular artery and an outflow vessel reaching the descending aorta. Surgical intervention was recommended to prevent thoracic aneurysmal rupture and to improve blood pressure and thus the ischemic renal disease. The operation proceeded through a fourth left intercostal posterolateral thoracotomy. The thoracic aneurysm firmly adhered to the descending aorta and was incised after partial clamping. The inflow and outflow vessels were then sutured from inside the aneurysm. A planned bypass from the left subclavian artery to the descending aorta proceeded using an 18-mm J Graft SHIELD NEO (Junken Medical Co, Ltd, Tokyo, Japan) without cardiopulmonary bypass. The pathologic findings of the thoracic collateral aneurysmal wall extracted during the procedure indicated an indistinct inner elastic lamina and atheromatous degeneration (Fig 2). The number of smooth muscle cells was decreased and collagen fibers were increased in the tunica media, indicating that the aneurysmal wall was likely to be fragile and inflexible and at a consequential high risk of rupture. The postoperative 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.025
Ann Thorac Surg 2014;98:316–8
CASE REPORT SASAKI ET AL ADULT SURGICAL CASE OF INTERRUPTED AORTIC ARCH
317
Fig 1. Preoperative 3-dimensional computed tomography. (A) Left anterior oblique image shows an interrupted aortic arch just distal to the left subclavian artery. Interrupted type A aortic arch was diagnosed. A massive thoracic aneurysm (diameter, 50 mm) is evident. (B) Anteroposterior view of the abdomen. Image shows multiple abdominal collateral aneurysms (arrows). Bilateral kidneys are of normal size. (AN ¼ aneurysm; Lt. SCA ¼ left subclavian artery.)
Comment
claudication caused by hypotension in the lower limbs [1]. If these conditions are neglected, advanced complications such as ascending aortic aneurysm, aortic regurgitation [2, 3], and subarachnoid hemorrhage [4] will result. Renal insufficiency might be 1 symptom of IAA in adulthood caused by hypotension in the lower half of the body. Sakellaridis and colleagues [5] described a patient with preoperatively confirmed renal insufficiency similar to that in our patient. Although their operative FEATURE ARTICLES
course was uneventful. Three-dimensional computed tomography after operation confirmed the patency of the bypass graft and the disappearance of the thoracic collateral aneurysm (Fig 3). The pressure gradient between the upper and lower extremities disappeared, and renal function became normalized.
An IAA is usually diagnosed and treated on an emergency basis during the neonatal period. However, some patients with IAA might survive into adulthood if collateral arteries are abundant and if severe intracardiac anomalies are absent. The characteristic symptoms of IAA in adulthood are headache and heart failure resulting from hypertension in the upper extremities and
Fig 2. Pathologic findings of the thoracic collateral aneurysmal wall extracted during the operation. The inner elastic lamina is indistinct and atheromatous degeneration (circle) is evident. Smooth muscle cells are decreased and collagen fibers (arrows) are increased in the tunica media (elastica van Gieson stain, original magnification 200).
Fig 3. Postoperative 3-dimensional computed tomographic scan in left anterior oblique view. It reveals disappearance of thoracic collateral aneurysm. Arrows indicate the bypass graft from left subclavian artery to descending aorta.
318
FEATURE ARTICLES
CASE REPORT YAMANE ET AL AORTIC AND MITRAL TRANSCATHETER VALVE-IN-VALVE
Ann Thorac Surg 2014;98:318–21
strategy succeeded, they did not describe the source of the renal insufficiency or the status of postoperative renal function. Our patient had undergone antihypertensive therapy because of a cerebral hemorrhage caused by hypertension in the upper extremities. Consequently, renal insufficiency might have gradually advanced because of hypotension in the lower half of the body. Preoperative CT showed that the size of the bilateral kidneys was essentially normal. Thus, postoperative renal function was probably improved by increasing renal blood flow. Management of the massive thoracic collateral aneurysm then became the essential focus for this patient. Although a similar patient with an IAA and a descending thoracic aortic aneurysm has been described, that patient was treated only by an extraanatomical bypass through a left thoracotomy without resection of the aneurysm [6]. However, the collateral thoracic aneurysm in our patient arose from a branch of the suprascapular artery. Because the collateral arteries in patients with IAA can rupture spontaneously [7], resection of the thoracic aneurysm should have been the absolute option for our patient. In fact, pathologic findings of the thoracic aneurysmal wall extracted during the operation indicated a fractured lamina elastica interna and tunica media. Therefore, we supposed that the thoracic collateral aneurysm was in a state of imminent preoperative rupture. Besides, the diameter of the remaining multiple abdominal collateral aneurysms required periodic monitoring. Most surgeons seem to select a bypass from the ascending to the descending aorta through a median sternotomy to facilitate cardiopulmonary bypass with cardiac arrest and complex cardiac surgical procedures to treat IAA [2, 7]. However, we resected the massive thoracic aneurysm through a left posterolateral thoracotomy. Furthermore, an extraanatomical bypass without cardiopulmonary bypass was feasible for the abundant collateral arteries. Clamping the left subclavian artery set blood pressure in the right radial artery relatively high to generate a mean femoral artery pressure of more than 40 mm Hg [1, 8]. We preserved the intercostal arteries by partially clamping the descending aorta [3]. These strategies resulted in an uneventful majorevent–free postoperative course. We successfully resected a massive thoracic collateral aneurysm, constructed a bypass from the left subclavian artery to the descending aorta, and normalized postoperative renal function in an adult patient with very rare IAA and multiple abdominal collateral aneurysms; however, the remaining multiple abdominal collateral aneurysms required careful monitoring.
4. Cao YH, Zhang GY, Han JL. Isolated interrupted aortic arch complicated by subarachnoid hemorrhage in an adult patient. Neurol India 2009;57:806–7. 5. Sakellaridis T, Argiriou M, Panagiotakopoulos V, et al. Latent congenital defect: interrupted aortic arch in an adult—case report and literature review. Vasc Endovascular Surg 2010;44: 402–6. 6. Yu W, Chen CJ, Wang X, et al. Interrupted aortic arch accompanied by a giant saccular aneurysm in a 53-year-old man. Eur J Echocardiogr 2011;12:909. 7. Sai Krishna C, Bhan A, Sharma S, et al. Interruption of aortic arch in adults: surgical experience with extra-anatomic bypass. Tex Heart Inst J 2005;32:147–50. 8. Backer CL, Stewart RD, Kelle AM, et al. Use of partial cardiopulmonary bypass for coarctation repair through a left thoracotomy in children without collaterals. Ann Thorac Surg 2006;82:964–72.
Transcatheter Valve-in-Valve Implantation for Early Prosthetic Valve Degeneration in Aortic and Mitral Positions Kentaro Yamane, MD, PhD, Tamim M. Nazif, MD, Omar Khalique, MD, Rebecca T. Hahn, MD, Martin B. Leon, MD, Susheel K. Kodali, MD, Mathew R. Williams, MD, and Isaac George, MD Division of Cardiothoracic Surgery, Department of Surgery, and Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
Recently, transcatheter valve-in-valve implantation has emerged as a new alternative to surgical reoperation for degenerated bioprosthetic valves, either in the aortic or mitral position. The early experience and outcome of this strategy appears promising in highly selected patient groups. Here we report a case of early structural valve degeneration in the aortic and mitral position in a patient with chronic hemodialysis successfully treated with transthoracic transcatheter valve-in-valve implantation. (Ann Thorac Surg 2014;98:318–21) Ó 2014 by The Society of Thoracic Surgeons
P
atients with end-stage renal disease (ESRD) on chronic hemodialysis (HD) undergoing cardiac surgery carry a high risk of perioperative morbidity, a poor long-term prognosis, and the risk of early structural valve degeneration (SVD) due to impaired calcium metabolism. The operative risk in this cohort more than doubles if the Accepted for publication Sept 10, 2013.
References 1. Gordon EA, Person T, Kavarana M, et al. Interrupted aortic arch in the adult. J Card Surg 2011;26:405–9. 2. Lafci G, Yalcinkaya A, Ecevit AN, et al. Single-stage aortic valve-sparing root replacement. Tex Heart Inst J 2012;39: 398–400. 3. Ogino H, Miki S, Matsubayashi K, et al. Two-stage repair for aortic regurgitation with interrupted aortic arch. Ann Thorac Surg 1998;65:1151–3. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Address correspondence to Dr George, Division of Cardiothoracic Surgery, New York Presbyterian Hospital, College of Physicians and Surgeons of Columbia University, Milstein Hospital Building, 7GN-435, 177 Fort Washington Ave, New York, NY 10032; e-mail: ig2006@ columbia.edu.
Drs Kodali and Williams disclose financial relationships with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.061