Background-Single-center reports have identified retrograde ascending aortic dissection (rAAD) as a potentially lethal complication of thoracic endovascular aortic repair (TEVAR). Methods and Results-Between 1995 and 2008, 28 centers participating in the European Registry on Endovascular Aortic Repair Complications reported a total of 63 rAAD cases (incidence, 1.33%; 95% CI, 0.75 to 2.40). Eighty-one percent of patients underwent TEVAR for acute (n=26, 54%) or chronic type B dissection (n=13, 27%). Stent grafts with proximal bare springs were used in majority of patients (83%). Only 7 (15%) patients had intraoperative rAAD, with the remaining occurring during the index hospitalization (n=10, 21%) and during follow-up (n=31, 64%). Presenting symptoms included acute chest pain (n=16, 33%), syncope (n=12, 25%), and sudden death (n=9, 19%) whereas one fourth of patients were asymptomatic (n=12, 25%). Most patients underwent emergency (n=25) or elective (n=5) surgical repair. Outcome was fatal in 20 of 48 patients (42%). Causes of rAAD included the stent graft itself (60%), manipulation of guide wires/sheaths (15%), and progression of underlying aortic disease (15%). Conclusions-The incidence of rAAD was low (1.33%) in the present analysis with high mortality (42%). Patients undergoing TEVAR for type B dissection appeared to be most prone for the occurrence of rAAD. This complication occurred not only during the index hospitalization but after discharge up to 1050 days after TEVAR. Importantly, the majority of rAAD cases were associated with the use of proximal bare spring stent grafts with direct evidence of stent graft-induced injury at surgery or necropsy in half of the patients. (Circulation. 2009; 120[suppl 1]: S276-S281.)

Background-Concomitant aortic (AV) and mitral (MV) valve surgery accounts for 4% of all valve procedures in northern New England. We examined in-hospital and long-term mortality. Methods and Results-This is a report of a prospective study of 1057 patients undergoing concomitant AV and MV surgery from 1989 to 2007. The Social Security Administration Death Master File was used to assess long-term survival. Kaplan-Meier and log-rank tests were performed. In-hospital mortality was 15.5% (11.0% for patients <70 years, 18.0% for 70- to 79-year-olds, and 24% for those >= 80 years). Overall median survival was 7.3 years. Median survival without coronary artery bypass grafting was 9.5 years and with coronary artery bypass grafting was 5.7 years (P<0.001). Survival in women was worse than in men (7.3 versus 9.3, years, P=0.033). Median survival by age was 11.0 years for patients <70 years, 5.4 years for 70- to 79-year-olds, and 4.8 years for those >= 80 years. Median survival was not significantly different for patients >= 80 years compared with those who were 70 to 79 years old (P=0.245). Conclusions-Double-valve surgery has a high in-hospital mortality rate and a median survival of 7.3 years. After patients have survived surgery, long-term survival is similar between men and women, smaller and larger patients, and those receiving MV repair or replacement. Survival continues to decline after surviving surgery for patients >= 70 years old and those who undergo concomitant coronary artery bypass grafting. In patients <70 years, either mechanical valves in both positions or a tissue AV and mitral repair have the lowest in-hospital mortality and the best long-term survival. In patients >= 70 years, tissue valves in both positions have the best in-hospital and long-term survival. (Circulation. 2009; 120[suppl 1]: S155-S162.)

Background-The site of cannulation for repair of ascending aortic dissection remains controversial. We present our experience with ascending aortic cannulation for acute aortic dissection type A. Methods and Results-From January 1988 to September 2007, we operated on 242 patients for acute aortic dissection type A. Medical records of 235 patients who received ascending aortic cannulation or femoral cannulation were retrospectively reviewed. Long-term follow-up was complete in 97% of patients. Cannulation was accomplished in 82 patients through the ascending aorta and in 153 patients through the femoral artery. Preoperative patient characteristics were almost comparable between groups. Similarly, there were no differences in preoperative patient characteristics and intraoperative parameters including operation time, bypass time, cross-clamp time, hypothermic circulatory arrest time, and percentage of total arch replacement. The 30-day mortality rate was 14% in the aortic group and 23% in the femoral group (P=0.07), and incidence of stroke was 4.9% in the aortic group and 4.5% in the femoral group (P=0.86). During follow-up (mean, 5.5 years), survival at 5 years and 10 years was 65% and 41% in the aortic group and 64% and 46% in the femoral group, respectively (P=0.97). Conclusions-The cannulation site should be chosen according to the patient's pathology and status, and the present study suggests that ascending cannulation in patients with acute aortic dissection type A can be a safe alternative, offering acceptable early and long-term outcomes. (Circulation. 2009; 120[suppl 1]: S282-S286.)

Background-Electric isolation of the pulmonary veins (PVs) can successfully treat patients with paroxysmal atrial fibrillation. However, it remains technically challenging to identify the left atrial-PV junction and sequentially position the ablation catheter in a point-by-point contiguous fashion to isolate the PVs. In this study, a novel endoscopic ablation system was used to directly visualize and ablate tissue at the left atrial-PV junction with laser energy. Methods and Results-This study consisted of 2 phases: a short-term (n = 9) and long-term (n = 11) canine experimental validation phase and a multicenter clinical feasibility phase (n = 30 paroxysmal atrial fibrillation patients). After transseptal puncture, the balloon-based endoscopic ablation system was advanced to each PV ostium, and arcs of laser energy (90 to 360) were projected onto the target left atrial-PV junction. Electric PV isolation was defined with a circular multielectrode catheter. In the short-term preclinical experimental phase, 15 of 17 targeted PVs (88%) were successfully isolated. Pathological examination revealed well-demarcated circumferential lesions with minimal endothelial disruption. In the long-term experiments, 9 of 10 targeted veins (90%) remained persistently isolated (at 4 to 8 weeks). In the clinical phase, 105 of 116 PVs (91%) were successfully isolated. After a single procedure, the 12-month drug-free rate of freedom from atrial fibrillation was 60% (18 of 30 patients). There were no significant PV stenoses, but adverse events included 1 episode of cardiac tamponade, 1 stroke without residual defect, and 1 asymptomatic phrenic nerve palsy. Conclusion-This study establishes the feasibility of a novel paradigm for AF ablation: direct visualization to guide catheter ablation of the left atrial-PV junction. (Circulation. 2009; 120: 12-20.)

Background-Aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR) and left ventricular (LV) dysfunction entails a higher surgical risk. Though it may improve symptoms and LV size, it is not known whether it translates into a survival benefit. Methods and Results-This retrospective cohort study included patients screened from our echocardiographic database between 1993 and 2007 for patients with severe AR and LV ejection fraction (EF) <= 35%. Charts reviews were conducted for clinical, pharmacological, and surgical information. Mortality data were obtained from the social security death index and analyzed as a function of AVR adjusted for the propensity score. Of the 785 patients with severe AR, 166 patients had severe LV dysfunction defined as an EF <= 35%: 69% of these were men, age 65 +/- 16 years, and LV EF was 23 +/- 8%. Kaplan-Meier analysis revealed that performance of AVR (n=53) was associated with a better survival (P=0.001). Adjusted for the propensity score, AVR was associated with a significantly lower mortality hazard (HR 0.59, CI 0.42 to 0.98, P=0.04). Conclusions-There is a clear reluctance to offer AVR in a large number of patients with severe AR associated with LV dysfunction. However, the performance of AVR in these patients is associated with a mortality benefit supporting the current ACC/AHA guidelines. (Circulation. 2009; 120[suppl 1]: S134-S138.)

Background-Autophagy is a molecular process that breaks down damaged cellular organelles and yields amino acids for de novo protein synthesis or energy provision. Mechanical unloading with a left ventricular assist device (LVAD) decreases the energy demand of the failing human heart. We tested the hypothesis that LVAD support reverses activation of autophagy. Methods and Results-Paired biopsy samples of left ventricular myocardium were obtained from 9 patients with idiopathic dilated cardiomyopathy (mean duration of LVAD support, 214 days) at the time of implantation and explantation of the LVAD. Transcript and protein levels of markers and mediators of autophagy and apoptosis were measured by quantitative reverse-transcription polymerase chain reaction and Western blotting. TUNEL assays, C9 immunohistochemistry, and 20S proteasome activity assays were also performed. Mechanical unloading significantly decreased mRNA transcript levels of Beclin-1, autophagy-related gene 5 (Atg5), and microtubule-associated protein-1 light chain-3 (MAP1-LC3 or LC3; P<0.02). Protein levels of Beclin-1, Atg5-Atg12 conjugate, and LC3-II were also significantly reduced after LVAD support (P<0.05). A significant increase in 20S proteasome activity was observed with unloading, in parallel to the decrease in autophagic markers. Although BNIP3 and the ratio of activated caspase 3 to procaspase 3 increased after LVAD support, Bcl-2 and TUNEL-positive nuclei were not significantly different between samples. Conclusions-Mechanical unloading of the failing human heart decreases markers of autophagy. These findings suggest that autophagy may be an adaptive mechanism in the failing heart, and this phenomenon is attenuated by LVAD support. (Circulation. 2009; 120[suppl 1]: S191-S197.)