Two-stage total cardioaortic replacement for end-stage heart and aortic disease in Marfan syndrome: case report and review of the literature

Combined heart transplantation and replacement of atheromatous proximal arch

Concomitant surgery on the aortic arch with hypothermic cardiac arrest in the setting of heart transplantation (HTX) is extremely rare. Herein, we report a case of combined HTX and proximal arch replacement at our institution.

Cardiomyopathy in Genetic Aortic Diseases

Genetic aortic diseases are a group of illnesses characterized by aortic aneurysms or dissection in the presence of an underlying genetic defect. They are part of the broader spectrum of heritable thoracic aortic disease, which also includes those cases of aortic aneurysm or dissection with a positive family history but in whom no genetic cause is identified. Aortic disease in these conditions is a major cause of mortality, justifying clinical and scientific emphasis on the aorta. Aortic valve disease and atrioventricular valve abnormalities are known as important additional manifestations that require careful follow-up and management. The archetype of genetic aortic disease is Marfan syndrome, caused by pathogenic variants in the Fibrillin-1 gene. Given the presence of fibrillin-1 microfibers in the myocardium, myocardial dysfunction and associated arrhythmia are conceivable and have been shown to contribute to morbidity and mortality in patients with Marfan syndrome. In this review, we will discuss data on myocardial disease from human studies as well as insights obtained from the study of mouse models of Marfan syndrome. We will elaborate on the various phenotypic presentations in childhood and in adults and on the topic of arrhythmia. We will also briefly discuss the limited data available on other genetic forms of aortic disease.

Myocardial Function, Heart Failure and Arrhythmia in Marfan Syndrome: A Systematic Literature Review

Marfan syndrome (MFS) is a heritable systemic connective tissue disease with important cardiovascular involvement, including aortic root dilatation and mitral valve prolapse. Life expectancy in patients with MFS is mainly determined by cardiovascular complications, among which aortic dissection or rupture are most dreaded. In recent years, heart failure and ventricular arrhythmia have drawn attention as extra-aortic cardiovascular manifestations and as additional reported causes of death. Imaging studies have provided data supporting a primary myocardial impairment in the absence of valvular disease or cardiovascular surgery, while studies using ambulatory ECG have demonstrated an increased susceptibility to ventricular arrhythmia. In this paper, current literature was reviewed in order to provide insights in characteristics, pathophysiology and evolution of myocardial function, heart failure and ventricular arrhythmia in MFS.

Cardioaortic replacement for a ruptured root pseudoaneurysm with pulsatile subcutaneous extension

Orthotopic heart transplantation with concomitant aortic surgery is rarely performed. Herein, we describe the successful management of a patient with an otherwise inoperable, ruptured aortic root pseudoaneurysm using combined cardioaortic replacement under hypothermic circulatory arrest.

Successful orthotopic heart transplantation in a patient with Marfan syndrome

Cardiovascular diseases represent the leading cause of mortality in patients with Marfan syndrome. Many treatments have been developed for patients with end-stage heart failure, among which orthotopic heart transplantation remains the gold standard. We report a successful orthotopic heart transplantation for a Marfan syndrome patient in end-stage heart failure.

Hypothermic Circulatory Arrest in Cardiac Transplantation

PURPOSE

Infrequently, hypothermic circulatory arrest (HCA) must be used during cardiac transplantation. Such cases may include concomitant aortic arch surgery, explantation of ventricular assist devices with outflow grafts or pseudoaneurysms closely abutting the sternum, and other scenarios for which dense mediastinal adhesions preclude exposure and anatomic dissection by conventional methods of adhesiolysis. Outcomes of heart transplantations performed with HCA have not been previously catalogued in the literature and are presented in the current case series.

METHODS

Between November 2012 and December 2014, 193 patients underwent heart transplantation at a single institution. Of these, 7 cases (3.6%) required implementation of HCA. Postoperative outcomes in these patients were analyzed using a prospectively maintained clinical database.

RESULTS

The HCA patients included 28% females, with mean age of 46 years, and 71% had nonischemic cardiomyopathies. The majority (N = 5, 71%) had prior ventricular assist device implantation, including 1 patient with a paracorporeal biventricular assist device. One of the remaining 2 patients had three previous surgeries for repair of tetralogy of Fallot, with a completely calcified right ventricular outflow tract and pulmonary arterial system. Mean HCA and cold ischemic times were 25 minutes (range, 9-34 minutes) and 285 minutes (range, 181-425 minutes), respectively. Mean postoperative length of stay was 31 days, and six of seven patients (86%) survived to hospital discharge. One patient expired as an outpatient 2 months following transplant. Rates of postoperative renal failure, respiratory failure, and stroke were 43%, 43%, and 29%, respectively.

CONCLUSION

On rare occasions, HCA must be instituted to safely conduct a complex heart transplantation procedure. Based on this small case series, these patients can be salvaged and discharged from the hospital, but may experience prolonged lengths of stay with moderate rates of other end-organ complications.

Type B aortic dissection triggered by heart transplantation in a patient with Marfan syndrome

Heart transplantation in patients with Marfan syndrome is challenging and raises concerns with regards to the haemodynamic and immunosuppressive-induced effects on the inherently fragile aorta. Most aortic events following transplantation reported so far in the literature occurred in patients with pre-existent distal aortic dissection. We report a case of successful orthotopic heart transplantation in a patient with Marfan syndrome that was complicated by late-onset type B dissection in pre-existing mild and stable distal aortic dilation. Serial aortic imaging revealed progressive growth at the level of the descending thoracic aorta. An open thoracoabdominal aortic repair procedure was successfully performed 6 months after the transplantation.

Combined procedure of heart transplantation and ascending aorta replacement

Concomitant heart transplantation and ascending aorta replacement is infrequent. In the few cases where this simultaneous procedure was performed, most patients were diagnosed with Marfan syndrome. We report the combined procedure of heart transplantation and ascending aorta replacement using the donor's ascending aorta, in a 70-year-old man who was not diagnosed with Marfan syndrome. This combined procedure can be performed successfully, providing a potentially life-saving heart transplant for patients with aortic disease of different etiologies.

Adult surgical experience with Loeys-Dietz syndrome

BACKGROUND

Loeys-Dietz syndrome (LDS) results from mutations in receptors for the cytokine transforming growth factor-β leading to aggressive aortic pathology sometimes accompanied by specific phenotypic features including bifid uvula, hypertelorism, cleft palate, and generalized arterial tortuosity. We reviewed our adult surgical experience with LDS in order to validate current recommendations regarding management of this newly described disease.

METHODS

All adult (≥ 18 years old) patients with LDS undergoing surgical treatment at a single referral institution from September 1999 to May 2013 were retrospectively reviewed.

RESULTS

Eleven adult LDS patients were identified by clinical criteria and genotyping. Seven (64%) experienced acute type A dissection at some point in their lives. All eventually required aortic root replacement, and 73% required multiple vascular surgical interventions. Over a mean follow-up of 65 ± 49 months, 2.8 cardiovascular procedures per patient were performed. In patients with type A dissection, a mean of 3.4 operations were performed versus 1.8 operations for patients without dissection. Total aortic replacement was required in 5 patients (45%) and 2 (18%) required neurosurgical intervention for cerebrovascular pathology. There was 1 late death from infectious complications, and no deaths from vascular catastrophe.

CONCLUSIONS

These results confirm the aggressive nature of LDS aortic pathology. However, the improved survival compared with earlier LDS reports suggest that aggressive treatment strategies may alter outcomes and improve the natural history of this syndrome.

Current management and outcome of chronic type B aortic dissection: results with open and endovascular repair since the advent of thoracic endografting

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment for chronic type B aortic dissection (CTBAD) at our institution. However, it remains incapable of treating all patients with CTBAD. The present study aims to review our contemporary results with open and endovascular CTBAD repairs since the advent of thoracic endografting.

METHODS

The records of all patients undergoing index repair of CTBAD (chronic DeBakey type IIIA, IIIB and repaired type I) at our institution between June 2005 and December 2013, were retrospectively reviewed.

RESULTS

A total of 107 patients underwent CTBAD repair, of whom 70% (n=75) underwent endovascular-based procedures [44 TEVAR, 27 hybrid arch and four hybrid thoracoabdominal aortic aneurysm (TAAA) repair] and 30% (n=32) underwent open procedures (nine open descending and 23 open TAAA). Connective tissue disease (CTD), prior aortic surgery and DeBakey dissection type were strongly associated with the choice of operation. The rates of stroke, paraplegia and operative mortality following endovascular-based repairs were 0%, 0% and 4% (n=3), respectively. Adverse neurologic events were higher following open repair, and rates of stroke, paraplegia, and operative mortality were 16% (n=5), 9% (n=3), and 6% (n=2), respectively. However, 1- and 5-year survival rates were similar for endovascular-based repairs (86% and 65%, respectively), and open repairs (88% and 79%, respectively). Over a median follow-up interval of 34 months, the rate of descending aortic reintervention was 24% (n=18) following endovascular-based repairs and 0% following open repairs (P=0.001). Forty-four percent (n=8) of descending aortic reinterventions were required to treat stent graft complications (five endoleak, two stent graft collapse and one stent graft-induced new entry tear) and the remainder were required to treat metachronous pathology (n=2) or progressive aneurysmal disease related to persistent distal fenestrations (n=8).

CONCLUSIONS

Endovascular repair of CTBAD was associated with excellent procedural and survival outcomes, but at the expense of further reinterventions. Open repair remains relevant for patients who are not candidates for endovascular repair and was associated with higher procedural morbidity but similar overall survival and fewer reinterventions.

Cardiovascular magnetic resonance in Marfan syndrome

This review provides an overview of Marfan syndrome with an emphasis on cardiovascular complications and cardiovascular imaging. Both pre- and post-operative imaging is addressed with an explanation of surgical management. All relevant imaging modalities are discussed with a particular focus on cardiovascular MR.

Midterm results with thoracic endovascular aortic repair for chronic type B aortic dissection with associated aneurysm

OBJECTIVE

Thoracic endovascular aortic repair for chronic type B aortic dissection with associated descending thoracic aneurysm remains controversial. Concerns include potential ischemic complications due to branch vessel origin from the chronic false lumen and continued retrograde false lumen/aneurysm sac pressurization via fenestrations distal to implanted endografts. The present study examines midterm results with thoracic endovascular aortic repair for chronic (>2 weeks) type B aortic dissection with associated aneurysm to better understand the potential role of thoracic endovascular aortic repair for this condition.

METHODS

Between March 2005 and December 2009, 51 thoracic endovascular aortic repair procedures were performed at a single institution for management of chronic type B dissection. The indication for thoracic endovascular aortic repair was aneurysm in all cases. A subset of 7 patients (14%) underwent placement of the EndoSure wireless pressure measurement system (CardioMEMS, Inc, Atlanta, Ga) in the false lumen adjacent to the primary tear for monitoring aneurysm sac/false lumen pulse pressure after thoracic endovascular aortic repair.

RESULTS

Mean patient age was 57±12 years (range, 30-82 years); 14 patients (28%) were female. Mean aortic diameter was 6.2±1.4 cm. There were no in-hospital/30-day deaths, strokes, or permanent paraplegia/paresis. There were no complications related to compromise of downstream branch vessels arising from the false lumen. Two patients (3.9%) who had preexisting ascending aortic dilation had retrograde acute type A aortic dissection; both were repaired successfully. Median postoperative length of stay was 4 days. Mean follow-up is 27.0±16.5 months (range, 2-60 months). Actuarial overall survival is 77.7% at 60 months with an actuarial aorta-specific survival of 98% over this same time period. Actuarial freedom from reintervention is 77.3% at 60 months. All patients with the EndoSure wireless pressure measurement system exhibited a decrease in aneurysm sac/false lumen pulse pressure indicating a depressurized false lumen. The aneurysm sac/false lumen pulse pressure ratio decreased from 52%±27% at the predischarge measurement to 14%±5% at the latest follow-up reading (P=.029).

CONCLUSIONS

Thoracic endovascular aortic repair for chronic type B dissection with associated aneurysm is safe and effective at midterm follow-up. Aneurysm sac/false lumen pulse pressure measurements demonstrate a significant reduction in false lumen endotension, thus ruling out clinically significant persistent retrograde false lumen perfusion and provide proof of concept for a thoracic endovascular aortic repair-based approach. Longer-term follow-up is needed to determine the durability of thoracic endovascular aortic repair for this aortic pathology.