Background: Type A aortic dissection (TAAD) is a complex cardiovascular disease that is associated with high perioperative morbidity and mortality. The most effective approach is still being debated-such as the best cannulation technique, and conservative versus extensive initial surgery. We reviewed our experience over the last 20 years and examined for variables that correlated with observed outcomes.Methods: All patients who underwent TAAD repair were reviewed. Chi-Square tests, Fisher Exact tests and Wilcoxon tests were performed where appropriate. Survival and freedom from reoperations were analyzed with the Kaplan-Meier actuarial method.Results: Acute TAAD was associated with a higher incidence of permanent stroke (P=0.010), renal failure (P=0.025), prolonged mechanical ventilator support (P=0.004), higher operative mortality (P=0.039) and higher 30-day mortality (P=0.003) compared to chronic TAAD. There was a trend towards higher risk for transient neurologic events among patients who were reoperated on (P=0.057). Extensive proximal repair led to longer perfusion and cross clamp times (P<0.001) and the need for temporary mechanical support postoperatively (P=0.011). More patients that had extensive distal repair underwent circulatory arrest (P=0.009) with no significant differences in the incidence of peri-operative complications, early, middle and long-term survival compared to the conservative management group. Overall survival in our series was 66.73% and 46.30% at 5 and 10 years respectively (median survival time: 9.38 years). There was a significant improvement in operative mortality (P=0.002) and 30-day mortality (P=0.033) in the second decade of our study.Conclusion: TAAD is a complex disease with several options for its surgical management. Each technique has its own advantages and complications and surgical management should be individualized depending on the clinical presentation. We propose our present approach to maximize benefits in both the short and long term.

Coexistence of end-stage liver disease (ESLD) and severe valvular heart disease conveyed substantial risk for patients, oftentimes leading to exclusion from liver transplantation candidacy due to inability to safely offer cardiac surgery prior to transplantation. Several approaches have been described, including performing transplantation and valve surgery concurrently, or in sequence. Both options, however, have associated complications: catastrophic repercussion of peri-operative coagulopathy and organ dysfunction post-transplantation, respectively. The introduction of transcatheter procedures offered a safer alternative for high-risk patients; however, its recognized indications remained limited. A novel approach to this surgical dilemma by performing transcatheter aortic valve replacement (TAVR) for severe native aortic valve regurgitation in a patient on the liver transplant list has been presented. The procedure proved to be an effective management for the aortic valve insufficiency, improving our patient's hemodynamics in preparation for the subsequent orthotopic liver transplantation (OLT). © 2015 Wiley Periodicals, Inc.

W e describe a percutaneous transcatheter tricuspid valve-in-ring implantation using the Sapien XT prosthesis (Edward Lifesciences, Irvine, California) (1,2). A 68-year-old woman with rheumatic heart disease and 2 previous sternotomies including tricuspid valve repair with a 32-mm Carpentier-Edwards (Irvine, California) annuloplasty ring presented 2 years prior with severe tricuspid valve regurgitation (annulus dilation and tenting of the leaflet) and pulmonary hypertension (right ventricular systolic pressure of 46 mm Hg) related to left ventricular diastolic dysfunction. After multidisciplinary evaluation, a percutaneous approach was recommended to avoid increased risk of third-time redo sternotomy. The procedure was planned using a cardiac computed tomography-derived 3-dimensional printed model created using an Objet Connex 350 printer (Stratasys, Eden Prairie, Minnesota) (Figure 1). Using this model, the prosthesis size was selected and "test deployed" to verify adequacy (Online Video 1). The actual transcatheter tricuspid valvein-ring implantation was performed in the hybrid operating suite under general anesthesia. The right common femoral vein was accessed percutaneously. With an Amplatz super-stiff wire (Boston Scientific, Marlborough, Massachusetts) acting as a rail, a 29-mm Sapien XT valve was advanced across the tricuspid valve annulus. The stented valve was balloon inflated with an additional 1 cc of contrast saline solution to achieve optimal conical deployment (Figure 2, Online Video 2). Transesophageal echocardiography showed only mild perivalvular regurgitation in the septal region, as predicted in the printed model. Post-procedural 2-dimensional echocardiography showed mild tricuspid valve regurgitation with a transvalvular gradient of 3 mm Hg (Figure 3, Online Video 3). The patient's dyspnea improved prior to discharge from hospital 4 days later. The long-term effectiveness of this off-label procedure is still unknown and warrants further studies.

CT image showing the previous graft that was taken down and the reconstructed arch. Central MessageArch reconstruction after a previous aortic repair is challenging but can be done safely and with good early outcome.

Background: Group B streptococcus (GBS) is a common cause of early-onset neonatal sepsis in both developed and developing countries. Neonatal Early-Onset Disease (0-6 days of life) is acquired from mothers with vaginal/rectal colonization with GBS. Laboratory detection of GBS colonization status in pregnant women is therefore important for the selective prescription of antibiotic for the prevention of complications arising from Group B Streptococcus infection.Culture based screening has its limitations including poor turn -around time, and patients lost to follow up. The GeneXpert GBS ® (Cepheid) is a rapid screening test that can be performed intrapartum. Such a test should compare favourably to culture based screening methods.Methods & Materials: A total of 85 pregnant women who were between 27 and 37 weeks gestation were enrolled from a single large maternity clinic in our region. Three swabs were collected from each participant: 1 vaginal, 1 rectal and 1 vagino-rectal (Copan TM ). Each of the swabs was plated on Granada medium. The presence of typical orange colonies on the Granada medium were confirmed by Streptex ® agglutination. The vagino-rectal swab was also used for the GeneXpert GBS assay which was performed according to the manufacturer's instructions.Results: Twenty-five (29%) women were colonized by GBS by the Granada medium. Xpert GBS detected 23/85 (27%) positives. The Xpert GBS missed two specimens that were positive by culture and identified one additional positive, with a sensitivity of 87.5% and specificity of 98.4%. The PPV was 95.5% and NPV 95.2%.Conclusion: Xpert GBS had excellent performance compared to culture. Our study is the first in South Africa to evaluate the performance of Xpert GBS compared to the Granada medium for the rapid screening of pregnant women for GBS colonization. This realtime PCR assay is a potentially accurate test to identify GBS carriers at point of care. The Xpert GBS could enhance the identification of candidates for intrapartum antibiotic treatment, including women with preterm rupture of membranes or preterm labour.