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1.  Advances in thoracic aortic surgery: Arch replacement with axillary cannulation and thoracic stent grafts 
The Canadian Journal of Cardiology  2007;23(Suppl B):76B-79B.
During the past decade, significant advances in thoracic surgery have contributed to a decrease in the morbidity and mortality linked to surgery of the thoracic aorta. Drawing from the experiences at the Quebec Heart Institute, the present article focuses on the improvements in surgery of the aortic arch, mainly the use of the ‘arch-first technique’ and arterial cannulation through the right axillary artery. Furthermore, advances in the treatment of diseases of the descending aorta using thoracic stent grafts are delineated. The importance of establishing dedicated multi-disciplinary teams and follow-up clinics to ensure good outcomes in the treatment of these complex diseases is stressed.
PMCID: PMC2794471  PMID: 17932592
Aorta; Axillary cannulation; Cerebral protection; Surgery; Thoracic stent-graft
2.  Direction of persistent ischemic mitral jet after restrictive valve annuloplasty: Implications for interpretation of perioperative echocardiography 
The Canadian Journal of Cardiology  2007;23(Suppl B):48B-52B.
BACKGROUND:
Ischemic mitral regurgitation (MR) often persists after restrictive mitral valve annuloplasty (MVA) and is associated with a poor prognosis. It was hypothesized that the anterior displacement of the posterior aspect of the annulus caused by annuloplasty could induce a change in the direction of MR jet.
METHODS:
The echocardiograms of 21 patients who underwent restrictive MVA for ischemic MR and who had detectable postoperative MR were analyzed before and early after surgery to evaluate the direction of MR jet.
RESULTS:
The MR jet direction was posterior in 15 patients (72%) and central or anterior in six patients (28%) before the operation, compared with four patients (20%) and 17 patients (80%), respectively, after MVA (P<0.001). Overall, the jet direction was modified in 16 of 21 7patients (76%) following MVA. Among the subset of 11 patients with clinically significant persistent MR (vena contracta width greater than 3 mm), the MR jet direction changed in nine patients (82%) compared with their preoperative evaluation. Importantly, the initial clinical interpretation, based on a subjective evaluation, had classified MR severity as nonsignificant in six of 11 patients (55%), likely due to the eccentricity of the jet and its change in direction.
CONCLUSION:
The direction of the persistent MR jet early after annuloplasty is often different from that of preoperative MR jet and may lead to significant misinterpretation of the postoperative echocardiogram.
PMCID: PMC2794468  PMID: 17932587
Annuloplasty; Echocardiography; Ischemic mitral regurgitation; Jet direction; Mitral valve
4.  Postoperative outcome after coronary artery bypass grafting in chronic obstructive pulmonary disease 
BACKGROUND:
It is uncertain if the presence and severity of airflow obstruction in chronic obstructive pulmonary disease (COPD) is predictive of surgical morbidity and mortality after coronary artery bypass grafting (CABG).
METHODS:
Retrospective study of patients who underwent CABG between 1998 and 2003 in a university-affiliated hospital for whom a preoperative spirometry was available. COPD was diagnosed in smokers or ex-smokers 50 years of age or older in the presence of irreversible airflow obstruction. Patients were divided into three groups depending on the spirometry: controls (forced expiratory volume in 1 s [FEV1] 80% or more, FEV1/forced vital capacity [FVC] greater than 0.7), mild to moderate COPD (FEV1 50% or more and FEV1/FVC 0.7 or less) and severe COPD (FEV1 less than 50% and FEV1/FVC 0.7 or less).
RESULTS:
Among the 411 files studied, 322 (249 men, 68±8 years of age) were retained (controls, n=101; mild to moderate COPD, n=153; severe COPD, n=68). The mortality rate (3.0%, 2.6% and 0%, respectively) was comparable among the three groups. Patients with severe COPD had a slightly longer hospital stay than controls (mean difference 0.7±1.4 days, P<0.05). Pulmonary infections were more frequent in severe COPD (26.5%) compared with mild to moderate COPD (12.4%) and controls (12.9%), P<0.05. Atrial fibrillation tended to be more frequent in severe COPD than in the other two groups.
CONCLUSION:
Mortality rate associated with CABG surgery is not influenced by the presence and severity of airflow obstruction in patients with COPD. The incidence of pulmonary infections and length of hospital stay were increased in patients with severe COPD.
PMCID: PMC2690441  PMID: 17315054
COPD; Coronary artery bypass; Heart surgery; Postoperative complications
5.  Recannulation of the Right Axillary Artery for Complex Aortic Surgeries 
Texas Heart Institute Journal  2005;32(2):194-197.
Owing to the increased use of the axillary artery for arterial inflow during cardiopulmonary bypass, patients with previous cannulation at this site who require reoperation will be encountered more and more frequently. We describe the cases of 2 patients who required recannulation of the axillary artery for complex reoperations of the thoracic aorta. The technique and pitfalls are described.
The decision was made to reuse the previous cannulation site at the right axillary artery due to the presence of large pseudoaneurysms in proximity to the sternum. The old 8-mm Dacron stump was found and excised, and a new 8-mm Dacron graft was sutured to the right axillary artery for arterial inflow. In the 1st patient, the Dacron side-graft enabled insertion and subsequent inflation of an EndoClamp® within the Dacron graft of the ascending aorta, which obviated profound hypothermia. In the 2nd patient, recannulation of the right axillary artery enabled us to open the sternum at low flow using moderate hypothermia, given that antegrade cerebral perfusion was easily accessible in the event of a more prolonged arrest time. Both patients recovered fully, without neurovascular complications secondary to the recannulation of the right axillary.
Recannulation of the right axillary artery is safe during complex reoperation of the thoracic aorta. It avoids retrograde perfusion in the often-diseased descending thoracic aorta. Furthermore, sternal reentry may be performed under moderate hypothermia, because antegrade cerebral perfusion can be initiated with ease.
PMCID: PMC1163469  PMID: 16107112
Aorta, thoracic/surgery; aortic aneurysm/surgery; axillary artery; cardiopulmonary bypass/methods; extracorporeal circulation/methods; vascular surgical procedures/methods
6.  Delayed Treatment of Contained Blunt Traumatic Aortic Rupture 
Texas Heart Institute Journal  2003;30(3):229-232.
A 45-year-old man sustained an intracerebral frontal hematoma and a contained aortic isthmic rupture in a head-on automobile collision. Due to the intracerebral hemorrhage, open repair was contraindicated. Treatment with a stent graft was selected but delayed until the next morning, because the correct stent size was unavailable. Two hours before the time scheduled for surgery, the patient experienced oxygenation problems and became hypotensive. Chest radiography revealed a new, severe left hemothorax. Fortunately, the stent graft had just arrived from the manufacturer, and it was deployed to seal the ruptured aorta. Immediate angiography showed good stent-graft position without any endoleak, as did a computed tomographic scan 2 days after the procedure. The patient was transferred to a rehabilitation unit to recover from his neurologic trauma. A 3-month follow-up computed tomographic scan showed the patient's condition to be unchanged. (Tex Heart Inst J 2003;30:229–32)
PMCID: PMC197324  PMID: 12959209
Aorta, thoracic/injuries/surgery; aortic rupture; stents
7.  Endoluminal Stenting of the Aorta 
Texas Heart Institute Journal  2002;29(3):216-217.
A 78-year-old woman with severe chronic obstructive pulmonary disease was admitted to the emergency room with hematemesis. With use of esophagoscopy, chest computed tomographic scanning, and aortography, we found a large descending aortic aneurysm and a penetrating ulcer of the proximal descending aorta. We determined that the patient had an aortoesophageal fistula and pseudoaneurysm that had originated from a ruptured penetrating ulcer of the mid-descending aorta.
We deployed two 100-mm stent grafts to seal the ruptured thoracic aorta. Six months later, the pseudoaneurysm was almost completely resolved, with no infection or endoleak. We advocate the use of endoluminal aortic stenting for aortoesophageal fistulas of aortic origin, particularly in patients with severe concomitant disease. (Tex Heart Inst J 2002;29:216–7)
PMCID: PMC124764  PMID: 12224728
Aortic diseases/complications; esophageal fistula/surgery; esophageal neoplasms; hematemesis/etiology; stents

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