Early and late outcomes after open ascending aortic surgery: 47-year experience in a single centre

Endovascular Intervention for Aortic Dissection Is "Ascending"

Ascending aorta diseases represent an important cause of mortality worldwide. Notably, acute and chronic thoracic aorta pathologies have increased during the last years, but medical therapy does not seem to influence their natural history. Currently, although open surgery is the first choice of treatment, many patients are still rejected or have poor outcomes. In this scenario, endovascular treatment is raised as a valuable option. In this review we describe the limitations of conventional surgery and the state-of-art of endovascular ascending aorta repair.

Proximal aortic repair in dialysis patients: A national database analysis

OBJECTIVES

Dialysis is a well-established risk factor for morbidity and mortality after cardiovascular procedures. However, little is known regarding the outcomes of proximal aortic surgery in this high-risk cohort.

METHODS

Perioperative (in-hospital or 30-day mortality) and 10-year outcomes were analyzed for all the patients who underwent open proximal aortic repair with the diagnosis of nonruptured thoracic aortic aneurysm (aneurysm, n = 325) or type A aortic dissection (dissection, n = 461) from 1987 to 2015 using the US Renal Data System database.

RESULTS

In patients with aneurysm, perioperative mortality was 12.6%. The 10-year mortality was 81% ± 3%. Age 65 years or more (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.03 to 1.78; P = .03), chronic obstructive pulmonary disease (HR, 1.68; 95% CI, 1.01-2.82; P = .047), and Black race (HR, 1.46; 95% CI, 1.09-1.97; P = .01) were independently associated with worse 10-year mortality. In patients with dissection, perioperative mortality was 24.3% and 10-year mortality was 87.9% ± 2.2%. Age 65 years or more (HR, 1.49; 95% CI, 1.19-1.86; P < .001), congestive heart failure (HR, 1.39; 95% CI, 1.11-2.57; P = .004), and diabetes mellitus as the cause of dialysis (HR, 1.75; 95% CI, 1.2-2.57; P = .004) were independently associated with worse 10-year mortality. Black race (HR, 0.74; 95% CI, 0.6-0.92; P = .008) was associated with a better outcome.

CONCLUSIONS

We described challenging perioperative and 10-year outcomes for dialysis patients undergoing proximal aortic repair. The present study suggests the need for careful patient selection in the elective repair of proximal aortic aneurysm for dialysis-dependent patients, whereas it affirms the feasibility of emergency surgery for acute type A aortic dissections.

Should We Operate on Thoracic Aortic Aneurysm of 5-5.5cm in Bicuspid Aortic Valve Disease Patients?

BACKGROUND

This study aims to determine the long-term outcomes and rate of reoperation among BAV patients with aortic diameter of 5-5.5cm who underwent immediate surgical repair versus surveillance.

METHODS

A total of 148 BAV patients with aortic aneurysm measuring 5-5.5cm were identified between 1993 to 2019. Patients were categorized into two groups: immediately operated (n=89), versus watched group (n=59) i.e., monitored until either symptomatic, aortic diameter ≥ 5.5 cm or operated at surgeons' discretion/patient preference.

RESULTS

Compared to the immediately operated group the watched group had significantly lower proportion of proximal aorta replacement (86% vs 100%). The mean size of proximal thoracic aorta at initial encounter, including aortic root, ascending, and arch, for the watched group was 52.1 ± 1.62mm and 52.6 ± 1.81mm in the immediately operated group, p=0.06. There was no significant difference in 10-year survival between the watched group 94% (95% CI: 79%, 99%) vs immediately operated group 96.5% (95% CI: 86%, 99%), p=0.90. Initial operation rate for the watched group during 10-year follow-up was 85%. The operative mortality in both groups was 0%. The 10-year reoperation rate between groups was similar: 3.5% (95% CI: 0.9%, 9.1%) in the immediately operated group vs 7.7% (95% CI: 2.4%, 17.1%) in the patients who eventually had surgery in the watched group, p= 0.30.

CONCLUSIONS

Our study showed that the rate of reoperation was similar between groups and survival outcomes were acceptable in observed asymptomatic BAV patients without significant family history and with proximal aortic diameter of 5-5.5cm.

Management of Ascending Aorta and Aortic Arch: Similarities and Differences Among Cardiovascular Guidelines

BACKGROUND

Ascending aorta and aortic arch diseases have an increasing interest among cardiovascular specialists regarding diagnosis and management. Innovations in endovascular surgery and evolution of open surgery have extended the indications for treatment in patients previously considered unfit for surgery. The aim of this systematic review of the literature was to present and analyze current cardiovascular guidelines for overlap and differences in their recommendations regarding ascending aorta and aortic arch diseases and the assessment of evidence.

METHODS

The English medical literature was searched using the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from January 2009 to December 2020. Recommendations on selected topics were analyzed, including issues from definitions and diagnosis (imaging and biomarkers) and indications for treatment to management, including surgical techniques, of the most important ascending aorta and aortic arch diseases.

RESULTS

The initial search identified 2414 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from multidisciplinary, cardiovascular societies published between 2010 and 2019. The definition of non-A-non-B aortic dissection is lacking from most of the guidelines. There is a disagreement regarding the class of recommendation and level of evidence for the diameter of ascending aorta as an indication. The indication for treatment of aortic disease may be individualized in specific cases while the growth rate may also affect the decision making. The role of endovascular techniques has not been established in current guidelines except by 1 society. Supportive evidence level in the management of aortic arch diseases remains limited.

CONCLUSION

In current recommendations of cardiovascular societies, the ascending aorta and aortic arch remain a domain of open surgery despite the introduction of endovascular techniques. Recommendations of the included societies are mostly based on expert opinion, and the role of endovascular techniques has been highlighted only from 1 society. The chronological heterogeneity apparent among guidelines and the inconsistency in evidence level should be also acknowledged. More data are needed to develop more solid recommendations for the ascending aorta and aortic arch diseases.

Do oral anticoagulants impact outcomes and false lumen patency after repair of acute type A aortic dissection?

OBJECTIVE

The study objective was to analyze the effects of chronic oral anticoagulation on long-term outcomes after repair of type A acute aortic dissection and its influence on false lumen fate.

METHODS

We studied 188 patients (median age, 62 years; 74% were male) who underwent repair of type A aortic dissection; patients receiving postoperative chronic oral anticoagulation (n = 59) were compared with those receiving antiplatelet therapy alone (n = 129).

RESULTS

Median age was similar: 60 years (18-79 years; OAC group) versus 64 years (22-86; no-OAC group) (P = .11); patients taking anticoagulants were more frequently male (88% vs 67%, P = .003). After a median follow-up of 8.4 years (2 months to 30 years), 58 patients died, 18 of aortic-related causes, and 37 patients underwent aortic reintervention. After multivariable adjustment, anticoagulation showed no significant effect on long-term survival (hazard ratio, 0.85; 95% confidence interval, 0.41-1.76; P = .66) or risk of reintervention (hazard ratio, 0.55; 95% confidence interval, 0.27-1.15; P = .11). Analysis of 127 postoperative computed tomography scans showed a patent false lumen in 53% of anticoagulated patients versus 38% of nonanticoagulated patients (P = .09): partially thrombosed in 8% versus 28% (P = .01) and thrombosed in 39% versus 34% (P = .63), respectively. In patients with a control computed tomography, there were 6 late aortic-related deaths, 1 among anticoagulated patients and 5 in those who were not.

CONCLUSIONS

Chronic anticoagulation after repair of type A acute aortic dissection favors persistent late false lumen patency, which is not a risk factor for late mortality or reoperation. Chronic anticoagulation can be administered safely to patients with repaired type A acute aortic dissection regardless of its specific indication.

Covid-19 positivity affects outcome of cardiac surgical patients

INTRODUCTION

In this report we describe the clinical presentation, laboratory findings and outcomes of four patients that were referred for urgent cardiothoracic intervention and tested positive for COVID-19.

METHODS

The St. Elizabeth's Medical Center Institutional Review Board exempted the study from review (waived review). In each case, verbal informed consent was obtained by the study participant or health care proxy.

RESULTS

The majority of the patients undergoing surgery had low Society of Thoracic Surgeons score and uneventful operating time. The mortality was very high and driven primarily by the viral syndrome. Laboratory markers that have been associated with disease severity in the general population were also prognostic in our population.

CONCLUSION

Our study shows that these patients have very high mortality, whereas prevention and preoperative screening is required in preventing nosocomial spreading of the disease.

Association between institutional case volume and mortality following thoracic aorta replacement: a nationwide Korean cohort study

Background

The inverse relationship between case volume and postoperative mortality following high-risk surgical procedures have been reported. Thoracic aorta surgery is associated with one of the highest postoperative mortality. The relationship between institutional case volume and postoperative mortality in patients undergoing thoracic aorta replacement surgery was evaluated.

Methods

All thoracic aorta replacement surgeries performed in Korea between 2009 and 2016 in adult patients were analyzed using an administrative database. Hospitals were divided into low (< 30 cases/year), medium (30–60 cases/year), or high (> 60 cases/year) volume centers depending on the annual average number of thoracic aorta replacement surgeries performed. The impact of case volume on in-hospital mortality was assessed using the logistic regression.

Results

Across 83 hospitals, 4867 cases of thoracic aorta replacement were performed. In-hospital mortality was 8.6% (191/2222), 10.7% (77/717), and 21.9% (422/1928) in high, medium, and low volume centers, respectively. The adjusted risk of in-hospital mortality was significantly higher in medium (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.16–2.11, P = 0.004) and low volume centers (OR, 3.12; 95% CI, 2.54–3.85, P < 0.001) compared to high volume centers.

Conclusions

Patients who had underwent thoracic aorta replacement surgery in lower volume centers had increased risk of in-hospital mortality after surgery compared to those in higher volume centers. Our results may provide the basis for minimum case volume requirement or regionalization in thoracic aorta replacement surgery for optimal patient outcome.

Life Expectancy after Surgery for Ascending Aortic Aneurysm

Introduction: The life expectancy of patients who undergo ascending aortic replacement is unknown. The life expectancy of a population depends on a collection of environmental and socio-economic factors of the territory where they reside. Our aim was to compare the life expectancy of patients undergoing surgery for ascending aortic aneurysm with that of the general population matching by age, sex, and territory. In addition, we aimed to know the late complications, causes of death and risk factors. Methods: All patients who underwent elective replacement of an ascending aortic aneurysm at our institution between 2000 and 2019 were included. The long-term survival of the sample was compared with that of the general population using data of the National Institute of Statistics. Results: For patients who survived the postoperative period, observed cumulative survival at three, five and eight years was 94.07% (95% CI 91.87%-95.70%), 89.96% (95% CI 86.92%-92.33%) and 82.72% (95% CI 77.68%-86.71%). Cumulative survival of the general population at three, five and eight years was 93.22%, 88.30%, and 80.27%. Cancer and cardiac failure were the main causes of death. Conclusions: Long-term survival of patients undergoing elective surgery for ascending aortic aneurysm who survive the postoperative period completely recover their life expectancy.

Acute type A aortic dissection - a review

Acute type A aortic dissection (ATAAD) is still one of the most challenging diseases that cardiac surgeons encounter. This review is based on the current literature and includes the results from the Nordic Consortium for Acute Type-A Aortic Dissection (NORCAAD) database. It covers different aspects of ATAAD and concentrates on the outcome of surgical repair. The diagnosis is occasionally delayed, and ATAAD is usually lethal if prompt repair is not performed. The dynamic nature of the disease, the variation in presentation and clinical course, and the urgency of treatment require significant attentiveness. Many surgical techniques and perfusion strategies of varying complexity have been described, ranging from simple interposition graft to total arch replacement with frozen elephant trunk and valve-sparing root reconstruction. Although more complex techniques may provide long-term benefit in selected patients, they require significant surgical expertise and experience. Short-term survival is first priority so an expedited operation that fits in with the surgeon's level of expertise is in most cases appropriate.

Prevalence of thoracic aortic aneurysms and dilatations in patients with intracranial aneurysms

OBJECTIVE

The prevalence of intracranial aneurysms (IAs) is higher in patients with aortic aneurysms. However, there are lack of studies investigating prevalence of thoracic aortic aneurysms (TAAs) in patients with IAs. The objective of this study was to evaluate the prevalence and risk factors for thoracic aortic dilatations (TADs) and TAAs in patients with IAs.

METHODS

We retrospectively reviewed data from 1777 patients with diagnosed IAs at our institution between 2006 and 2016. We included 411 patients with saccular IAs and available imaging studies (computed tomography or magnetic resonance imaging) of all thoracic aortic segments. TAD was defined according to age- and sex-matched normograms, and TAA as a diameter of greater than 4.0 cm.

RESULTS

A total of 83 patients (20%) had TAD or TAA. The prevalence of TADs and TAAs were 18% (n = 74) and 8% (n = 31) without significant difference between unruptured and ruptured IAs (P = .7). Of the 74 patients with TAD, 22 (30%) had multiple TADs and 66% of the TADs located in the aortic arch. Older age (odds ratio [OR], 1.04; P = .006), rheumatic disease (OR, 4.73; P = .009) and alcohol abuse (OR, 4.77; P = .01) were significant risk factors for TAD/TAA.

CONCLUSIONS

The prevalence of TADs and TAAs is considerably greater in patients with IAs compared with reports from the general population, suggesting that IAs might be associated with aortopathy and might share a similar pathogenetic background with TADs/TAAs. Especially patients with IAs and a history of rheumatic disease and/or alcohol abuse are at high risk for TADs/TAAs.