Annals of cardiothoracic surgery最新文献

Aortic dissection (AD) associated with pregnancy can have catastrophic consequences for the mother and/or fetus. AD occurs in 4-5 per 1,000,000 pregnancies and, despite its rarity, is the third most frequent maternal cardiovascular cause of death. AD associated with pregnancy is most likely to occur in the third trimester or postpartum period. In individuals with genetic aortopathy, pregnancy is considered a high-risk time for AD. There are management strategies in the preconception, antepartum, delivery and postpartum periods to optimize patient care. A multi-disciplinary team that includes capability to perform cardiovascular surgery is critical. Imaging modalities including maternal echocardiogram and magnetic resonance imaging can be safely performed in pregnancy for surveillance of the aortic size. Computed tomography (CT) scan is reserved for scenarios where there is a high index of suspicion for AD in a pregnant person to limit fetal exposure to radiation. After counseling about the potential risks of a pregnancy, the decision to pursue pregnancy is ultimately at the discretion of the individual. The duty of the cardio-obstetric team is to ensure that the patient and their family understand the risks of a pregnancy and the plan of care.

Sex discrepancies have been reported for patients with abdominal aortic aneurysm (AAA) for decades. Men have a higher prevalence of disease, earlier onset, less morphological features obstructing eligibility for repair and better survival, both short and long term. In more recent years, several attempts have been made to identify the biologic or pathogenic factors contributing to these sex differences, including socioeconomic factors though all have failed. The greatest challenge is to reveal the variable mechanism for development of disease for both women and men, and secondly to identify the factors contributing to the progression of disease, and eventual rupture. Evaluations of diagnosed patients have failed to detect any factors associated with development of disease which would give a distinct explanation for the profound sex differences. Considering the obvious earlier trigger for development in men compared to women, excluding smoking, hypertension, hyperlipidemia as certified sole triggers, the remaining factors to explore are sex hormones or biological mechanisms. This topical review explores the contemporary publications on sex hormones and their association with AAA in women and men. The findings confirm the lack of scientific evidence for the influence of female and male sex hormones on development or progression of aneurysm disease. Weak indications support that women probably benefit from a longer reproductive history as a contributing protection against AAA development, influenced by smoking and heredity. There is some evidence that could support that, as for other manifestations of cardiovascular diseases, low testosterone levels in men, can contribute to an increased risk for AAA development. The influence of higher circulating levels of female sex hormones on risk development in men remains to be evaluated. In conclusion, this area will expand during the next decade, by combining registry-based and translational databases in stratified analysis for women and men, giving us more evidence that will contribute to important risk factor estimations for future cohorts at risk of AAA development.

Minimally invasive staged segmental artery coil embolization (MIS²ACE) is an emerging technology for priming of the paraspinous collateral network prior to open or endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Its safety and efficacy have been previously proven in various experimental settings and confirmed in numerous multicentric pilot studies for open and endovascular repair. MIS²ACE is safe and has the potential to decisively reduce the risk of postoperative paraplegia, the most devastating complication of open and endovascular TAAA repair, still affecting up to 20% of patients. Up to now, MIS²ACE has been clinically implemented with excellent results, and is currently being investigated in the international, multicenter, randomized controlled trial PAPAartis, funded by the German Research foundation, and the European Union. MIS²ACE can be performed under local anesthesia, enabling continuous monitoring of neurological function, and in case of clinical signs of imminent ischemia, preemptive interruption of the procedure. A thorough evaluation of preoperative computed tomography (CT) imaging for identification of open and accessible segmental arteries (SAs) is critical. Segmental artery occlusion can be achieved with either micro coils, or vascular plugs. A maximum number of seven SAs is currently recommended to be occluded in the same session, and a minimum interval of 5 days should be awaited between either two MIS²ACE sessions or between MIS²ACE and the final repair. Adjuvant side-effects of MIS²ACE are the reduction in segmental back-bleeding during open repair leading to harmful steal phenomenon and the reduction of the incidence of type II endoleaks in endovascular repair. Current contraindications for MIS²ACE are emergency cases, hostile anatomy, and a shaggy aorta. Other neuroprotective adjuncts such as cerebrospinal fluid (CSF) drainage, permissive hypertension, motor-evoked potentials (MEP)/somato-sensory evoked potentials (SSEP) and monitoring of paraspinous muscle oxygenation by near-infrared spectroscopy should also be applied independent of prior MIS²ACE procedure.

Background: Some recent reports have demonstrated that preoperative Adamkiewicz artery (AKA) identification and its targeted reconstruction has provided satisfactory outcomes with respect to spinal cord protection. This paper investigates the impact of preoperative identification of the AKA on reducing the incidence of spinal cord injury (SCI) in open repair (OR) and endovascular repair (EVR) of descending thoracic aortic (dTA) and thoracoabdominal aortic aneurysm (TAA) repair.

Methods: The clinical data of patients with dTA and TAA treated between 2011 and 2022 were investigated. A total of 256 patients comprising of 201 males and 55 females, with a mean age of 72.1±10.0 years, were included. OR was used in 102 patients and EVR in 154 patients whose distal landing zone was below T8, all of which needed preoperative identification of the AKA.

Results: The AKA was identified in 207 (80.9%) patients, and was located in the level between T8 and T12 in 81.2%. In OR, the responsible arteries, including the identified AKA, were promptly reconstructed in 66 (64.7%) patients. In EVR, 65 (42.2%) patients had the AKA covered by an endovascular prosthesis. Deaths prior to 30 days occurred in seven (2.7%, four in OR and three in EVR) patients. In OR, SCI occurred in six (5.9%) patients including three (2.9%) with paraplegia and three (2.9%) with paraparesis, whereas in EVR ten (6.5%) patients had SCI, including two (1.3%) with paraplegia and eight (5.2%) with paraparesis. The incidence of SCI was significantly higher in patients with the AKA covered than those without it covered [13.8% (9 of 65) vs. 1.1% (1 of 89); P=0.002], whereas no significant differences were found between patients with or without the AKA reconstructed.

Conclusions: Preoperative identification of the AKA was useful enough to determine treatment strategies with less likelihood of SCI in both OR and EVR for dTA and TAA pathologies.