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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses considerations for deciding on surgical intervention for aortic root endocarditis must be a reasonable prospect of recovery with satisfactory quality of life. It also looks at traditional and evolving management strategies for thoracoabdominal dissections.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EValvular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EAortic Root Endocarditis: When Is Surgery Indicated?\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EThe overriding consideration when deciding on surgical intervention for aortic root endocarditis, said Gonzalo V. Gonzalez-Stawinski, MD, Cleveland Clinic, Cleveland, OH, must be a reasonable prospect of recovery with satisfactory quality of life. To determine when surgical intervention is indicated, Dr. Gonzalez-Stawinski directed the audience to the 2006 ACC\/AHA Guidelines for the Management of Patients with Valvular Heart Disease \u003Cem\u003E[Circulation\u003C\/em\u003E 2006;114], which he summarized as follows:\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ENative Endocarditis\u003C\/h2\u003E\n         \u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n               \u003Cp id=\u0022p-3\u0022\u003ESurgery is clearly indicated in the presence of aortic stenosis or aortic insufficiency that results in congestive heart failure: aortic or mitral regurgitation with elevated left ventricular end diastolic pressure or volumes, fungal or highly resistant organisms, conduction abnormalities, abscesses, or fistulas\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n               \u003Cp id=\u0022p-4\u0022\u003ESurgery is reasonable for recurrent emboli and persistent vegetations despite appropriate antibiotic therapy\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n               \u003Cp id=\u0022p-5\u0022\u003ESurgery may be considered for mobile vegetations \u226510 mm with or without embolization\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EProsthetic Endocarditis\u003C\/h2\u003E\n         \u003Cul class=\u0022list-unord \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n               \u003Cp id=\u0022p-6\u0022\u003ESurgery is indicated for patients in heart failure, rupture or splitting of the prosthesis, left ventricular outflow tract obstruction or worsening regurgitation, or development of complications (ie, abscess)\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n               \u003Cp id=\u0022p-7\u0022\u003ESurgery is reasonable for persistent bacteremia or recurrent emboli despite appropriate antibiotic therapy\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n               \u003Cp id=\u0022p-8\u0022\u003EPrompt surgical intervention should be undertaken in the presence of worsening aortic insufficiency, hemodynamic deterioration, enlarging vegetations, recurrent embolisms, new cardiac structural abnormalities, or protracted fever\/bacteremia despite appropriate medical antibiotic therapy\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\n         \u003Cp id=\u0022p-9\u0022\u003E\u201cIn the absence of the above, medical management may be appropriate for a select group of patients,\u201d said Dr. Gonzalez-Stawinski, including uncomplicated prosthetic valve endocarditis caused by first infection with a sensitive organism.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EThoracoabdominal Aortic Aneurysm (TAA): When to Refer\u003C\/h2\u003E\n         \u003Cp id=\u0022p-10\u0022\u003ERobert S. Dieter, MD, Loyola University, Maywood, IL, reviewed the types of TAA and suggested criteria that can be used when referring patients for surgery.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EAscending Thoracic Aneurysms\u003C\/h2\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EIn the absence of special circumstances, such as Loeys-Dietz or Marfan Syndrome, Dr. Dieter suggested that patients with ascending thoracic aneurysms should be referred for resection when the diameter of the aneurysm is \u22655.5 cm (\u22655 cm in patients with high risk of aortic rupture, such as Marfan Ehlers-Danlon, or familial thoracic aortic aneurysm) and has a growth rate of \u22650.5 to 1 cm\/year in symptomatic patients [Peripheral Arterial Disease eds Dieter RS, Dieter RA, Jr. Dieter RA III, McGraw-Hill 2009].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-6\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EBicuspid Aortic Valve (BAV) Aneurysms\u003C\/h2\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EThe indications for resection of aneurysms that are associated with a BAV include: [Braverman AC et al. \u003Cem\u003ECurr Probl Cardiol\u003C\/em\u003E 2005; Cecconi M et al. \u003Cem\u003EJ Cardiovasc Med\u003C\/em\u003E (Hagerstown) 2006].\u003C\/p\u003E\n         \u003Cul class=\u0022list-unord \u0022 id=\u0022list-3\u0022\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n               \u003Cp id=\u0022p-13\u0022\u003EAortic diameter \u0026gt;5.0 cm\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\n               \u003Cp id=\u0022p-14\u0022\u003EAortic ratio \u0026gt;1.5 or 1.4 in women who wish to become pregnant\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-9\u0022\u003E\n               \u003Cp id=\u0022p-15\u0022\u003EGrowth rate \u0026gt;3 mm\/yr\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-10\u0022\u003E\n               \u003Cp id=\u0022p-16\u0022\u003ESymptomatic aneurysm\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-11\u0022\u003E\n               \u003Cp id=\u0022p-17\u0022\u003ELarge sinus of Valsalva aneurysm associated with BAV\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-12\u0022\u003E\n               \u003Cp id=\u0022p-18\u0022\u003EPatients with BAV undergoing valve replacement for valve dysfunction who have an aortic diameter \u0026gt;4 cm or a ratio \u0026gt;1.4\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-7\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EDescending Thoracic Aortic Aneurysms\u003C\/h2\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EPatients with a descending TAA should be referred for resection if they are symptomatic, the aneurysm is \u0026gt;6 cm and has a growth rate \u0026gt;10 mm\/year, and there are symptoms of compression (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/2\/30\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Descending Thoracic (Abdominal) Aneurysms: When to Refer.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1880561354\u0022 data-figure-caption=\u0022Descending Thoracic (Abdominal) Aneurysms: When to Refer.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/2\/30\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/2\/30\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/2\/30\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11532\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-20\u0022 class=\u0022first-child\u0022\u003EDescending Thoracic (Abdominal) Aneurysms: When to Refer.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EPatients with TAA, regardless of location, should be referred to a cardiovascular surgeon or to an aortic program that comprises clinicians, imaging specialists, and cardiovascular surgeons who are interested in following these patients for the long term.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-8\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EThoracoabdominal Dissections: Traditional and Evolving Management Strategies\u003C\/h2\u003E\n         \u003Cp id=\u0022p-22\u0022\u003EBruce W. Lytle, MD, Cleveland Clinic, Cleveland, OH, used the results of several studies to provide a framework for understanding the possibilities and risks of endovascular and open surgery for TAAs.\u003C\/p\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EIn a comparison of procedure-related perioperative morbidity, mortality, and outcomes between patients who were treated with endovascular stent grafting (n=105) versus open surgical repair (n=93) of the descending aorta, Stone et al [Stone DH et al. \u003Cem\u003EJ Vasc Surg\u003C\/em\u003E 2006] showed a 50% reduction in mortality for patients in the endovascular group (7.6% vs 15.1% for patients in the open surgery group). The rates of reintervention and spinal cord ischemic (SCI) complications were similar. Although 48-month survival was lower in the endovascular group (54% vs 64% for open surgery patients; p=0.09), Dr. Lytle noted that many of these patients had significant comorbidities, and thus survival often was not related to their cardiovascular disease.\u003C\/p\u003E\n         \u003Cp id=\u0022p-24\u0022\u003EResults from a similar study, but in low-risk patients, showed relatively low 30-day mortality in both groups (2% and 12% in the endovascular and open groups, respectively). Although the stroke rate was similar in both groups (4%), respiratory failure was higher (20% in the open group vs 4% in the endovascular group), and SCI complications were lower in the endovascular group (3% vs 14% in the open group) [Appoo JJ et al. \u003Cem\u003EJ Thorac Cardiovasc Surg\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cp id=\u0022p-25\u0022\u003E\u201cWhen repairing TAAs, there are 3 choices,\u201d said Dr. Lytle. \u201cOpen surgery, hybrid \u2018debranching\u2019 combined with endografting, and endografting with branch grafts.\u201d All 3 have advantages and disadvantages.\u003C\/p\u003E\n         \u003Cp id=\u0022p-26\u0022\u003EOpen surgery has the advantage of a relatively long track record of success; however, an important consideration is that it is major surgery that is best performed at an institution that has significant experience with the procedure. An analysis of 1-year mortality after TAA using data from a California administrative database showed that the mortality rate for elective TAA open repair ranges from 20% in persons aged 50 to 59 years to \u0026gt;40% in persons aged 80 to 89 years [Rigberg et al. \u003Cem\u003EJ Vasc Surg\u003C\/em\u003E 2006]. Other disadvantages are that, although it is possible with this procedure, spinal cord revascularization does not eliminate spinal cord ischemia, and operative morbidity is substantial, particularly respiratory and renal complications.\u003C\/p\u003E\n         \u003Cp id=\u0022p-27\u0022\u003EThe objective of a hybrid strategy (ie, revascularization of the visceral branches followed by stenting) is, according to Dr. Lytle, to make a \u201chuge\u201d operation into a merely \u201cbig\u201d operation. While there have been at least 2 reports that have shown that it can be done [Black SA et al. \u003Cem\u003EJ Vasc Surg\u003C\/em\u003E 2006; Resch TA et al. \u003Cem\u003EJ Endovasc Ther\u003C\/em\u003E 2006], it is still major surgery and it does not eliminate the potential for paraplegia. Questions also have been raised about long-term patency. In Dr. Lytle\u0027s opinion, this approach includes disadvantages of both open surgery and endoscopic repair.\u003C\/p\u003E\n         \u003Cp id=\u0022p-28\u0022\u003EDr. Lytle prefers a totally endograft-based approach; however, this is also a very large and complicated procedure that is not without problems, including graft patient interface (proximal fixation, aortic degeneration), spinal cord revascularization (not possible today), cost, graft availability, and operator experience. Like the hybrid approach, we do know that an endograft-only strategy works. [Greenberg RK et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2008]. Dr. Lytle concluded by saying, \u201cEndoleaks can be repaired, and medium-term stability is high. Most importantly there is a major decrease in mortality.\u201d\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2009 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/9\/2\/30.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmkvq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmkvq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}