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Chung M, Rajesh K, Hohri Y, Zhao Y, Wang C, Chan C, Kaku Y, Takeda K, George I, Argenziano M, Smith C, Kurlansky P, Takayama H. Adverse Technical Events During Aortic Root Replacement. Ann Thorac Surg 2024; 118:845-853. [PMID: 38936593 DOI: 10.1016/j.athoracsur.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/20/2024] [Accepted: 06/05/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Although adverse technical events during aortic root replacement (ARR) are not uncommon and are extremely challenging, there is scant literature to help surgeons prepare for such situations. We describe our experience of outstanding technical events during ARR. METHODS This is a retrospective study of 830 consecutive ARRs at a single center from 2012 to 2022. Technical events were defined as intraoperative events that led to an unplanned cardiac procedure, need for mechanical circulatory support, or additional aortic cross-clamping. Logistic regression identified factors associated with operative mortality and technical events. RESULTS Technical events occurred in 90 patients (10.8%) and were attributed to bleeding (n = 26), nonischemic ventricular dysfunction (n = 23), residual valve disease (n = 20), myocardial ischemia (n = 19), and iatrogenic dissection (n = 2). Prior sternotomy (odds ratio [OR], 2.38; 95% CI, 1.36-4.19; P = .002) and complex aortic valve disease (OR, 3.09; 95% CI, 1.09-8.75; P = .03) were associated with technical events. Patients with technical events had higher rates of operative mortality (6.7% vs 2.3%, P = .03) and all major postoperative complications. Surgical indications of dissection (OR, 13.57; 95% CI, 4.95-37.23; P < .001) and complex aortic valve disease (OR, 14.09; 95% CI, 3.67-54.02; P < .001) but not adverse technical events (OR, 2.42; 95% CI, 0.81-7.26; P = .11) were associated with operative mortality. CONCLUSIONS Adverse technical events occurred in 10.8% of ARRs and were associated with reoperative sternotomies. Technical events are associated with increased postoperative complications.
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Affiliation(s)
- Megan Chung
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Kavya Rajesh
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yu Hohri
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yanling Zhao
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York
| | - Chunhui Wang
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York
| | - Christine Chan
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yuji Kaku
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Isaac George
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Michael Argenziano
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Craig Smith
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York.
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Ferraresi M, Katsarou M, Luigi Molinari AC, Segreti S, Rossi G. Endovascular repair of ascending aortic pathologies in patients unfit for open surgery: case series and literature review. J Vasc Surg Cases Innov Tech 2024; 10:101455. [PMID: 38510094 PMCID: PMC10951535 DOI: 10.1016/j.jvscit.2024.101455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/26/2024] [Indexed: 03/22/2024] Open
Abstract
The number of vascular centers performing endovascular repair of ascending aortic disease is constantly increasing. Accordingly to the guidelines, open surgical repair remains the gold standard for these pathologies. However, approximately one quarter of patients are deemed unfit for open surgery. In this study, we describe three cases of ascending thoracic endovascular aortic repair (TEVAR) performed at our center. All the patients were deemed unfit for open surgery by the aortic team. Two patients had an ascending aortic pseudoaneurysm, and the third had a focal type A aortic dissection. In two cases, we used two abdominal aortic cuffs deployed from zone 0B to zone 0C, with no need for supra-aortic trunk debranching. In one case, we performed a "reverse" extrathoracic debranching, and we deployed a thoracic endograft from zone 0B to zone 2. Complications included one minor stroke and one inguinal hematoma. In one patient with an infected pseudoaneurysm, we performed ascending TEVAR as a bridge strategy for open repair. This patient developed a type Ia endoleak; however, clinical stabilization and infection control were obtained, and he was able to undergo heart surgery successfully. He underwent a second reintervention to treat superior mesenteric embolic occlusion. At 2 years of follow-up, all three patients were alive. Our preliminary experience demonstrates the technical feasibility and clinical appropriateness of ascending TEVAR using standard, commercially available endografts. However, no consensus has been reached regarding some critical aspects, such as the development of a standardized technique or the efficacy of the currently available devices. The improvements in graft design and the adoption of the "aortic team" approach could help in the near future to standardize the procedure, establish appropriate indications, and ensure good clinical outcomes.
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Affiliation(s)
- Marco Ferraresi
- Division of Vascular Surgery, Cardio-Thoracic-Vascular Department, Alessandro Manzoni Hospital, Lecco, Italy
| | - Maria Katsarou
- Division of Vascular Surgery, Cardio-Thoracic-Vascular Department, Alessandro Manzoni Hospital, Lecco, Italy
| | | | - Sara Segreti
- Division of Vascular Surgery, Cardio-Thoracic-Vascular Department, Alessandro Manzoni Hospital, Lecco, Italy
| | - Giovanni Rossi
- Division of Vascular Surgery, Cardio-Thoracic-Vascular Department, Alessandro Manzoni Hospital, Lecco, Italy
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Norton EL, Kalra K, Leshnower BG, Wei JW, Binongo JN, Chen EP. Redo aortic surgery: Does one versus multiple affect outcomes? JTCVS OPEN 2023; 16:158-166. [PMID: 38204648 PMCID: PMC10775125 DOI: 10.1016/j.xjon.2023.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/29/2023] [Accepted: 09/21/2023] [Indexed: 01/12/2024]
Abstract
Objective Redo aortic surgery has a higher risk of morbidity and mortality because it is technically complex due to mediastinal adhesions, infection, and previously implanted prostheses. In this study, we sought to benchmark our single-center experience comparing outcomes in patients undergoing aortic surgery after 1 versus multiple previous cardiac operations. Methods Between 2004 and 2019, 429 patients underwent redo aortic surgery. They were classified as aortic surgery after 1 previous surgery (first redo surgery, n = 360) and aortic surgery after 2 or more (multiple) previous surgeries (multiple redo surgery, n = 69). Postoperative outcomes and long-term survival were compared, and risk factors for mortality were identified. Results Thirty-day mortality was lower in first redo surgery compared with multiple redo surgery (12.3% vs 21.7%, P = .03). Age, cardiopulmonary bypass time, intra-aortic balloon pump use, postoperative cerebrovascular accident, absence of postoperative atrial fibrillation, intra-aortic balloon pump, and multiple redo surgery were independent predictors of 30-day mortality. Long-term survival was similar at 15 years. Patients who received first redo surgery were older (57.9 ± 14.0 years vs 50.3 ± 15.8 years, P = .0001) and had a higher incidence of hypertension (84.7% vs 73.9%, P = .02), whereas patients who received multiple redo surgery had a higher incidence of cerebrovascular disease (31.9% vs 20.3%, P = .03). Aortic valve replacement was the most common previous operation with higher incidence in multiple redo surgery. Incidence of previous aortic surgery was similar. Cardiopulmonary bypass (246 ± 67.3 minutes vs 219.9 ± 57.5 minutes, P = .009) and crossclamp times (208.2 ± 51.8 vs 181.9 ± 50.8 minutes, P = .004) were longer in multiple redo surgery. Incidence of reentry injury and balloon pump insertion were similar. Extracorporeal membrane oxygenation use was higher in multiple redo surgery. Postoperative complications occurred at similar rates, except for higher incidence of dialysis in multiple redo surgery (14.5% vs 7.2%, P = .04). Conclusions Multiple redo aortic procedures have a higher morbidity and mortality compared with first redo aortic procedures, with linearly increasing short-term mortality risk but similar long-term survival with the number of redo procedures.
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Affiliation(s)
- Elizabeth L. Norton
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Kanika Kalra
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Bradley G. Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Jane W. Wei
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Jose N. Binongo
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Edward P. Chen
- Division of Cardiothoracic Surgery, Duke University School of Medicine, Durham, NC
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Slisatkorn W, Sanphasitvong V, Luangthong N, Kaewsaengeak C. Tips and tricks in redo aortic surgery. Indian J Thorac Cardiovasc Surg 2022; 38:163-170. [PMID: 35463713 PMCID: PMC8980975 DOI: 10.1007/s12055-021-01322-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/25/2022] Open
Abstract
Redo aortic surgery is challenging, and the operative risk is higher than that in primary aortic surgery. Preoperative imaging is a crucial guide for a safe re-entry. Scrutinized preparing in cannulation and organ protection strategies have affected surgical outcomes. With comprehensive planning and meticulously executed surgery, mortality and morbidity can be acceptable. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-021-01322-x.
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Affiliation(s)
- Worawong Slisatkorn
- Division of Cardio-Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700 Thailand
| | - Vutthipong Sanphasitvong
- Division of Cardio-Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700 Thailand
| | - Nutthawadee Luangthong
- Division of Cardio-Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700 Thailand
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Dun Y, Shi Y, Guo H, Liu Y, Qian X, Sun X, Yu C. Outcome of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement. J Thorac Dis 2021; 13:1531-1542. [PMID: 33841945 PMCID: PMC8024838 DOI: 10.21037/jtd-20-3081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background There are limited data regarding the clinical outcomes of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement (AVR). We aimed to analyze outcomes of reoperative aortic root or ascending aorta replacement after prior AVR. Methods Eighty patients with prior AVR underwent reoperative aortic root or ascending aorta replacement in our hospital. The indications were root or ascending aortic aneurysm in 36 patients, root or ascending aortic dissection in 37, root false aneurysm in 2, prosthesis valve endocarditis (PVE) with root abscess in 2, Behçet’s disease (BD) with root destruction in 3 patients. An elective surgery was performed in 63 patients and an emergent surgery in 17. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test. Results The operative techniques included ascending aorta replacement in 14 patients, ascending aorta replacement with AVR in 3, prosthesis-sparing root replacement (PSRR) in 35, Bentall procedure in 24, and Cabrol procedure in 4 patients. Operative mortality was 1.3% (1/80). A composite of adverse events occurred in 5 patients, including 1 operative death, 2 stroke and 3 renal failure necessitating hemodialysis. The mean follow-up was 35.5±22.1 months. Five late deaths occurred. The Kaplan-Meier survival at 1 year, 3 years and 6 years were 97.5%, 91.1% and 84.1%, respectively. Aortic events developed in 3 patients. The freedom from aortic events at 1-year, 3-year, and 6-year were 100%, 96.3% and 88.9%, respectively. There were no differences in survival and freedom from aortic events between the elective group and the emergent group. Conclusions Reoperative aortic root or ascending aorta replacement after prior AVR could be performed to treat the root or ascending pathologies after AVR, with satisfactory early and midterm outcomes.
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Affiliation(s)
- Yaojun Dun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Shi
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwei Guo
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanxiang Liu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Idhrees AM, Velayudhan BV, Jacob A. Prosthetic valve sparing aortic root replacement-A persuasive option in well-functioning aortic valve prosthesis. J Card Surg 2021; 36:1786-1792. [PMID: 33533042 DOI: 10.1111/jocs.15402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 01/04/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Only limited data is available on prosthetic valve sparing aortic root replacement after aortic valve replacement. The aim of the present study was to assess the short- and midterm outcomes of the patients who underwent such procedures. METHODS From June 2004 to March 2018, 21 patients underwent this procedure. The mean age was 51.2 ± 10.2 years with a male predominance (85.7%). The mean time interval from aortic valve replacement to the present surgery was 10.62 years. RESULTS One patient died in immediate postoperative period who was taken up for emergency surgery-acute type A aortic dissection. Kaplan-Meier estimates of 1, 3, and 5 year survival were 95.2% ± 0.04%, 85.7% ± 0.07% and 85.7% ± 0.07%, respectively. No cardiac or aortic reinterventions were performed during follow up with a 100% freedom from reoperation at 5 years. Fifteen patients (71.43%) had aortopathy and had borderline pathology at the time of first surgery, with all of them having a tear either in the aortic sinuses or pervious aortotomy site. CONCLUSION The favorable short and midterm results suggests that prosthetic valve sparing aortic root replacement is a valid option when possible. Utmost care has to be taken at the primary surgery especially in patients with aortopathy, trying to avoid the need for a second surgery.
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Affiliation(s)
- A Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, India
| | - Bashi V Velayudhan
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, India
| | - Aju Jacob
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, India
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Zhou Z, Liang M, Huang S, Wu Z. Reimplantation versus remodeling in valve-sparing surgery for aortic root aneurysms: a meta-analysis. J Thorac Dis 2020; 12:4742-4753. [PMID: 33145047 PMCID: PMC7578473 DOI: 10.21037/jtd-20-1407] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Valve-sparing aortic root replacement (VSARR), which includes reimplantation and remodeling techniques, has been developed as an important treatment for aortic root aneurysms. We aimed to evaluate the outcomes of reimplantation versus remodeling techniques in valve-sparing surgery for aortic root aneurysms. Methods A systematic review and meta-analysis was performed by searching PubMed, Embase and the Cochrane Library until November 2019. Fourteen retrospective cohort studies comparing reimplantation with remodeling techniques for aortic root aneurysms were included and contained at least one of the following outcomes: early mortality, late mortality, aortic valve-related reoperation, and postoperative moderate to severe aortic regurgitation (AR). Results The outcomes of 1,672 patients (1,011 underwent reimplantation surgery, and 661 underwent remodeling) were analyzed. Compared with remodeling, the reimplantation technique was associated with a significantly lower risk of late mortality (RR =0.34; 95% CI, 0.17–0.71; P=0.004; I2=37%) and reoperation (RR =0.31; 95% CI, 0.12–0.76; P=0.01; I2=55%). There was no significant difference in early mortality (RR =0.69; 95% CI, 0.31–1.53; P=0.36; I2=0%), postoperative moderate to severe AR (RR =0.64; 95% CI, 0.31–1.32; P=0.22; I2=36%) or postoperative stroke (RR =1.26; 95% CI, 0.58–2.75; P=0.56; I2=0%) between the two groups. No evidence of publication bias was detected. Conclusions The current meta-analysis indicate that patients who undergo reimplantation procedures have a significantly lower risk of late mortality and reoperation than those who undergo remodeling procedures. Early mortality, postoperative moderate to severe AR and stroke were comparable between the two techniques.
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Affiliation(s)
- Zhuoming Zhou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Mengya Liang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Suiqing Huang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Zhongkai Wu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
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Sandhu HK, Tanaka A, Zaidi ST, Perlick A, Miller CC, Safi HJ, Estrera AL. Impact of redo sternotomy on proximal aortic repair: Does previous aortic repair affect outcomes? J Thorac Cardiovasc Surg 2020; 159:1683-1691. [DOI: 10.1016/j.jtcvs.2019.04.089] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 03/20/2019] [Accepted: 04/01/2019] [Indexed: 10/26/2022]
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Sun GL, Sun LZ, Zhu JM, Liu YM, Ge YP, Xu SJ. Clinical characteristics and risk factors for fatal outcome of patients receiving Sun's procedure after previous cardiac surgery. Asian J Surg 2020; 44:87-92. [PMID: 32360296 DOI: 10.1016/j.asjsur.2020.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 01/14/2020] [Accepted: 03/25/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Cardiac reoperation has always been a difficult problem in clinical practice. Because of the difficulty of operation, the incidence of complications and mortality rate is high. Secondary aortic surgery, especially the reoperation involving arch, has higher risk and is more difficult for patients with renal failure. Sun's operation (total arch replacement + stent elephant nose) has achieved good results in the treatment of diseases involving aortic arch, and occupies an important position in the treatment of patients with secondary arch lesions after cardiac surgery. METHODS A total of 395 patients with a history of cardiac surgery were recorded in our center from January 1, 2009 to December 31, 2017, among whom 118 (30.1%) patients underwent aortic reoperation via the original incision using Sun's aortic procedure owing to postoperative great vessel disease. We analyzed the clinical data and survival time, and used Cox regression to analyze the risk factors for 30-day mortality as well as long term mortality. RESULTS The interval between the last operation and the present operation was 0.08-19 years. Sixteen patients died within 30 days after operation and the average mortality rate was 13.6%. During the follow-up period, 28 patients died, with the mortality rate of 23.7%. As of December 31, 2017, the longest survival time was 9.36 years, and the survival time of 70 patients was more than 3.05 years. The main risk factor associated with the 30-day survival was cardiopulmonary bypass (CPB) time. The longer the CPB time was, the greater the risk of death was. The main risk factors associated with the long-term survival were CPB time and 24-h bleeding volume. The longer the CPB time was, the more the 24-h bleeding volume was, the higher long-term mortality rate was. CONCLUSION The second Sun's operation, as a surgical treatment after cardiac surgery, showed a high survival rate, with long survival time and good curative effect. CPB is the main risk factor for the 30-day survival state after operation, and CPB time and 24-h bleeding volume are the main risk factors for the long-term survival state after operation.
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Affiliation(s)
- Guang-Long Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, 100029, Beijing, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, 100029, Beijing, China.
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, 100029, Beijing, China
| | - Yong-Min Liu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, 100029, Beijing, China
| | - Yi-Peng Ge
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, 100029, Beijing, China
| | - Shi-Jun Xu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, 100029, Beijing, China
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Greco R, Muretti M, Djordjevic J, Jin XY, Hill E, Renna M, Petrou M. Surgical Complexity and Outcome of Patients Undergoing Re-do Aortic Valve Surgery. Open Heart 2020; 7:e001209. [PMID: 32201590 PMCID: PMC7076261 DOI: 10.1136/openhrt-2019-001209] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/28/2020] [Accepted: 02/17/2020] [Indexed: 11/04/2022] Open
Abstract
Objectives Re-do aortic valve surgery carries a higher mortality and morbidity compared with first time aortic valve replacement (AVR) and often requires concomitant complex procedures. Transcatheter aortic valve replacement (TAVR) is an option for selective patients. The aim of this study is to present our experience with re-do aortic valve procedures and give an insight into the characteristics of these patients and their outcomes. Methods Retrospective review of 80 consecutive re-do aortic valve procedures. Results Mean patients’ age was 51.80±18.73 years. Aortic regurgitation (AR) was present in 51 (65.4%) patients and aortic stenosis (AS) in 38 (48.7%). Indications for reoperation were: infective endocarditis (IE) (23.8%), bioprosthetic degeneration (12.5%), mechanical valve dysfunction (5%), paravalvular leak (6.2%), patient–prosthesis mismatch (3.8%), native valve disease (25%), aortic aneurysm, pseudoaneurysm and dissection (35%), aortic root/homograft degeneration (27.5%). Forty-one (51.2%) patients underwent re-do AVR, 39 (48.8%) re-do complex aortic valve surgery (28 root, 23 ascending aorta and 6 hemiarch procedures) and 37.5% concomitant procedures. A bioprosthesis was implanted in 43.8%, a mechanical valve in 37.5%, a composite graft in 2.5%, a Biovalsalva graft in 6.2% and a homograft in 10% of patients. In-hospital mortality was 3.8% and incidence of major complications was low. Conclusions A significant proportion of patients were young (61%<60 y), required complex aortic procedures (49%) or presented with contraindications for TAVR (mechanical valve, AR, IE, proximal aortic disease, need for concomitant surgery). Re-do aortic surgery remains the only treatment for such challenging cases and can be performed with acceptable mortality and morbidity in a specialised aortic centre.
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Affiliation(s)
- Renata Greco
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mirko Muretti
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jasmina Djordjevic
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Xu Yu Jin
- Department of Cardiac Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nulfield Division of Clinical Lab Sciences, Oxford University, Oxford, UK
| | - Elaine Hill
- Department of Cardiothoracic Anaesthesia, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Maurizio Renna
- Department of Cardiothoracic Anaesthesia, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mario Petrou
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Serraino GF, Zanobini M, Beghi C, Maselli D, Bashir M, Mastroroberto P, Mariscalco G. Perspective. Reoperative Bentall: choice of conduits. Indian J Thorac Cardiovasc Surg 2019; 35:127-129. [PMID: 33061077 DOI: 10.1007/s12055-017-0607-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 10/06/2017] [Accepted: 10/12/2017] [Indexed: 11/24/2022] Open
Abstract
The Bentall procedure represents the gold standard in the treatment of patients requiring aortic root replacement. The most common indications for redo Bentall are structural degeneration or graft infection. Redo aortic root replacement can be performed with low perioperative morbidity and death. The choice of the best conduit is still up for debate but is mandatory to guarantee the best and most durable option for the patient. New options are available to reduce mortality in older or fragile patients and can modify the conduit choice.
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Affiliation(s)
- Giuseppe Filiberto Serraino
- Department of experimental and clinical medicine, University Magna Graecia of Catanzaro, Germaneto, Catanzaro Italy
| | - Marco Zanobini
- Cardiac Surgery Department, IRCCS Cardiologico Monzino, Milan, Italy
| | - Cesare Beghi
- Cardiac Surgical Department, Insubria University of Varese, Varese, Italy
| | - Daniele Maselli
- Cardiac Surgical Department, S.Anna Hospital, Catanzaro, Italy
| | - Mohamad Bashir
- Cardiothoracic Surgery, Barts Health NHS Trust, London, UK
| | - Pasquale Mastroroberto
- Department of experimental and clinical medicine, University Magna Graecia of Catanzaro, Germaneto, Catanzaro Italy
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital Groby Road, Leicester, UK
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Kaskar A, Bohra DV, Rao K R, Shetty V, Shetty D. Primary or secondary Bentall-De Bono procedure: are the outcomes worse? Asian Cardiovasc Thorac Ann 2019; 27:271-277. [PMID: 30776904 DOI: 10.1177/0218492319832775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study was to compare the outcomes of a primary and secondary Bentall-De Bono procedure. METHODS From 2008 to 2015 (8-year period), 308 patients underwent a Bentall-De Bono procedure in our institute. The mean age was 43 ± 13 years and 80% were men. Twenty-eight patients had prior cardiac surgery through a median sternotomy (group 1) and 280 underwent a primary Bentall-De Bono procedure (group 2). Various preoperative and perioperative parameters were analyzed before and after propensity-score matching. RESULTS Before propensity-score matching, patients undergoing a secondary Bentall-De Bono procedure had a worse preoperative profile, as indicated by a higher EuroSCORE II ( p < 0.0001), with hospital mortality in group 1 of 14% (4/28) and 5% (14/280) in group 2 ( p = 0.069). After propensity-score matching, there was no significant difference in EuroSCORE II ( p = 0.922) or hospital mortality ( p = 0.729). After adjusting for the different variables, repeat sternotomy could not be identified as an independent predictor of postoperative mortality or morbidity. Survival at the end of 1 and 5 years in both groups showed no significant differences before or after propensity-score matching ( p = 0.328 and p = 0.356, respectively). In Cox multivariable regression analysis, reoperation was not identified as an independent factor for survival before ( p = 0.559) or after propensity-score matching ( p = 0.365). CONCLUSION A secondary Bentall-De Bono procedure can be performed with acceptable mortality and morbidity, and with midterm survival rates comparable to those of a primary Bentall-De Bono procedure.
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Affiliation(s)
- Ameya Kaskar
- Department of Cardiac Surgery, Narayana Institute of Cardiac Sciences, Bangalore, India
| | - Deepak V Bohra
- Department of Cardiac Surgery, Narayana Institute of Cardiac Sciences, Bangalore, India
| | - Rahul Rao K
- Department of Cardiac Surgery, Narayana Institute of Cardiac Sciences, Bangalore, India
| | - Varun Shetty
- Department of Cardiac Surgery, Narayana Institute of Cardiac Sciences, Bangalore, India
| | - Devi Shetty
- Department of Cardiac Surgery, Narayana Institute of Cardiac Sciences, Bangalore, India
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Gabel JA, Patel ST, Tomihama RT, Hasaniya NW, Abou-Zamzam AM, Kiang SC. Debranching of Supra-aortic Vessels via Femoral Artery Inflow for Late Ascending Aortic Rupture. Ann Vasc Surg 2018; 57:49.e1-49.e5. [PMID: 30476606 DOI: 10.1016/j.avsg.2018.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 11/28/2022]
Abstract
A 56-year-old man with a history of Marfan's syndrome, total arch replacement, descending thoracic endovascular aortic repair, and twice redo sternotomy for pseudoaneurysm repair, presented with a pulsatile chest mass secondary to a contained rupture of the ascending aorta. The patient underwent supra-aortic debranching via the superficial femoral artery and ascending thoracic stent-graft placement under continuous transesophageal echocardiography. Completion angiography demonstrated successful exclusion of the contained rupture. Postoperatively, the patient was neurologically intact, the pulsatile mass resolved, and the bypass grafts remained patent. Chronic respiratory failure and multidrug-resistant pneumonia led to late mortality. This case demonstrates that hybrid repair is effective in the emergent setting of ascending aortic rupture. Debranching of the ascending arch using the superficial femoral artery as inflow is feasible and provides adequate cerebral perfusion despite the length of the bypass. The use of transesophageal echocardiography during stent-graft deployment allows precise device placement in the high-risk area of the ascending aorta proximal to the innominate artery.
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Affiliation(s)
- Joshua A Gabel
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Sheela T Patel
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Roger T Tomihama
- Department of Radiology, Loma Linda University Health, Loma Linda, CA
| | - Nahidh W Hasaniya
- Department of Cardiothoracic Surgery, Loma Linda University Health, Loma Linda, CA
| | - Ahmed M Abou-Zamzam
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Sharon C Kiang
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, CA.
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Keeling WB, Hunting J, Leshnower BG, Stouffer C, Binongo J, Chen EP. Salvage Coronary Artery Bypass Predicts Increased Mortality During Aortic Root Operation. Ann Thorac Surg 2018; 106:1727-1734. [PMID: 30171853 DOI: 10.1016/j.athoracsur.2018.06.079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/18/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Aortic root replacement (ROOT) has been an established therapy, yet the impact of adding coronary artery bypass grafting (CABG) to ROOT (CABG-R) is unknown. The purpose of this research was to investigate the impact of CABG on the outcomes of ROOT. METHODS A retrospective review from 2004 to 2016 of patients undergoing nonemergent ROOT surgical procedure was performed. Cohorts were established based on the presence or absence of added CABG. A propensity-score weighted comparison of outcomes was then conducted. RESULTS A total of 867 patients met inclusion criteria and were analyzed (711 ROOT [72.0%], 156 CABG-R [18.0%]). CABG-R patients were older and had higher proportions of previous valve operation, hypertension, endocarditis, immunosuppressive therapy, renal insufficiency, and redo operation (all p < 0.01). Indications for CABG included anatomy (n = 48, 30.8%), coronary artery disease (80, 51.3%), and ventricular failure (28, 17.9%). The permanent stroke rate was not significantly increased with the addition of CABG-R (p = 0.06). Thirty-day mortality was 5.5% for the entire cohort but was substantially higher in patients who underwent concomitant CABG (3.4% ROOT, 15.4% CABG-R). Mortality rates were highest among patients with acute ventricular failure and CABG (28.8%) compared with patients who underwent CABG for coronary artery disease (6.3%) or patients for anatomy (22.9%; p = 0.003). CONCLUSIONS CABG-R results in increased postoperative morbidity or mortality compared with isolated ROOT. Outcomes, however, are influenced by the specific clinical indication. CABG for coronary artery disease was associated with similar outcomes compared with isolated ROOT. Patients undergoing unplanned CABG for acute ventricular failure had the worst outcomes, thus underscoring the importance of technical success during coronary reimplantation.
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Affiliation(s)
- W Brent Keeling
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia.
| | - John Hunting
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Chad Stouffer
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Jose Binongo
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
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15
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Antoniou A, Bashir M, Harky A, Di Salvo C. Redo proximal thoracic aortic surgery: challenges and controversies. Gen Thorac Cardiovasc Surg 2018; 67:118-126. [DOI: 10.1007/s11748-018-0941-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/13/2018] [Indexed: 10/16/2022]
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16
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Maroto LC, Carnero M, Cobiella J, García M, Vilacosta I, Reguillo F, Villagrán E, Olmos C. Reoperation for composite valve graft failure: Operative results and midterm survival. J Card Surg 2018; 33:330-336. [PMID: 29726041 DOI: 10.1111/jocs.13710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY The replacement of a failed composite valve graft is technically more demanding and is associated with increased morbidity and mortality. We present our technique and outcomes for reoperations for composite graft failures. METHODS Between September 2011 and June 2017, 14 patients underwent a redo composite graft replacement. Twelve patients (85.7%) were male, and mean age was 58.4 years ± 12 standard deviation (SD). One patient had two previous root replacements. Indications for reoperation were endocarditis (8), aortic pseudoaneurysm (3), and aortic prosthesis thrombosis (3). Mean logistic EuroSCORE and EuroSCORE II were 30.8% and 14.7%, respectively. RESULTS A mechanical composite graft was used in 12 patients and biological composite grafts were used in two patients. Hospital mortality was 14.3% (n = 2). One patient (7.1%) required reoperation for bleeding, One patient (7.1%) had mechanical ventilation >24 h, and four patients (28.6%) required implantation of a permanent pacemaker. Median intensive care unit and hospital stays were 3 days (interquartile range [IQR] 1-5) and 10 days (IQR 6.5-38.5). One patient experienced recurrent prosthetic valve endocarditis 14 months after operation. On follow-up, 11 of 12 survivors were in New York Heart Association class I or II. Survival at 3 years was 85.7% ± 9.4% SD. CONCLUSIONS Composite valve graft replacement can be performed with acceptable morbidity and mortality with good mid-term survival.
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Affiliation(s)
- Luis C Maroto
- Department of Cardiac Surgery, Cardiovascular Institute, Clínico San Carlos Hospital, Madrid, Spain
| | - Manuel Carnero
- Department of Cardiac Surgery, Cardiovascular Institute, Clínico San Carlos Hospital, Madrid, Spain
| | - Javier Cobiella
- Department of Cardiac Surgery, Cardiovascular Institute, Clínico San Carlos Hospital, Madrid, Spain
| | - Mónica García
- Department of Cardiac Surgery, Cardiovascular Institute, Clínico San Carlos Hospital, Madrid, Spain
| | - Isidre Vilacosta
- Department of Cardiology, Cardiovascular Institute, Clínico San Carlos Hospital, Madrid, Spain
| | - Fernando Reguillo
- Department of Cardiac Surgery, Cardiovascular Institute, Clínico San Carlos Hospital, Madrid, Spain
| | - Enrique Villagrán
- Department of Cardiac Surgery, Cardiovascular Institute, Clínico San Carlos Hospital, Madrid, Spain
| | - Carmen Olmos
- Department of Cardiology, Cardiovascular Institute, Clínico San Carlos Hospital, Madrid, Spain
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Rowse PG, Egbe AC, Said SM. Facile conversion from biologic to mechanical prosthesis: A bailout for a hostile aortic root. J Thorac Cardiovasc Surg 2017; 155:e179-e181. [PMID: 29203217 DOI: 10.1016/j.jtcvs.2017.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/16/2017] [Accepted: 11/01/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Phillip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Alexander C Egbe
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Sameh M Said
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
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18
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Silva Guisasola J, Alvarez-Cabo R, Hernández-Vaquero D, Méndez RD. Ascending aorta reinterventions. J Thorac Dis 2017; 9:S448-S453. [PMID: 28616341 DOI: 10.21037/jtd.2017.05.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ascending aorta reinterventions present a challenge for surgeons as the technical difficulties of the procedure and the complex strategic approach can complicate successful treatment. These patients should be treated by surgical teams with ample experience in aortic diseases as they can be at high risk of mortality. The number of interventions on the ascending aorta and aortic arch and the use of biological conducts (lung autograft, homograft, etc.) have increased in recent years; therefore, the number of reinterventions can also be expected to increase, representing 10% of aortic surgical procedures. This article reviews the current status of ascending aorta reinterventions, analyzing the principal aspects of indication and surgical strategy, as well as the results published in the largest studies.
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Affiliation(s)
- Jacobo Silva Guisasola
- Department of Cardiac Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Rubén Alvarez-Cabo
- Department of Cardiac Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Rocío Díaz Méndez
- Department of Cardiac Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain
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Berretta P, Di Marco L, Pacini D, Cefarelli M, Alfonsi J, Castrovinci S, Di Eusanio M, Di Bartolomeo R. Reoperations versus primary operation on the aortic root: a propensity score analysis. Eur J Cardiothorac Surg 2017; 51:322-328. [PMID: 28186292 DOI: 10.1093/ejcts/ezw250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/09/2016] [Accepted: 06/22/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- Paolo Berretta
- Division of Cardiac Surgery, "G. Mazzini" Hospital, Teramo, Italy
| | - Luca Di Marco
- Department of Cardiac Surgery, S.Orsola-Malpighi-Hospital-University of Bologna, Bologna, Italy
| | - Davide Pacini
- Department of Cardiac Surgery, S.Orsola-Malpighi-Hospital-University of Bologna, Bologna, Italy
| | - Mariano Cefarelli
- Department of Cardiac Surgery, S.Orsola-Malpighi-Hospital-University of Bologna, Bologna, Italy
| | - Jacopo Alfonsi
- Department of Cardiac Surgery, S.Orsola-Malpighi-Hospital-University of Bologna, Bologna, Italy
| | | | - Marco Di Eusanio
- Division of Cardiac Surgery, "G. Mazzini" Hospital, Teramo, Italy
| | - Roberto Di Bartolomeo
- Department of Cardiac Surgery, S.Orsola-Malpighi-Hospital-University of Bologna, Bologna, Italy
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20
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Elective primary aortic root replacement with and without hemiarch repair in patients with no previous cardiac surgery. J Thorac Cardiovasc Surg 2016; 153:1402-1408. [PMID: 27939498 DOI: 10.1016/j.jtcvs.2016.10.076] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 10/03/2016] [Accepted: 10/20/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Excellent outcomes have been established for elective aortic root replacement (ARR). It is less clear whether extending the repair into the proximal aortic arch with hypothermic circulatory arrest increases risk. We examined the early outcomes of elective, primary ARR, with and without hemiarch replacement, in patients without previous cardiac surgery. METHODS Over a 4-year period, 140 non-redo patients (median age, 54 years) underwent elective, primary ARR for root aneurysms; 119 patients (85%) had hemiarch replacement, and 21 (15%) had only ascending aortic replacement. Valve-sparing ARR was performed in 41 cases (29.3%) and valve-replacing ARR in 99 (70.7%). Moderate hypothermic circulatory arrest and antegrade cerebral perfusion were used in 118 (99%) hemiarch repairs. RESULTS There were no operative deaths or permanent strokes. Complications included temporary renal dialysis (n = 1; 4.8%), transient neurologic deficit (n = 2; 9.5%), and tracheostomy (n = 2; 9.5%) after ascending aortic repair and bleeding requiring reoperation (n = 4; 3.4%), pericardial effusion requiring drainage (n = 9; 7.6%), and tracheostomy (n = 2; 1.7%) after hemiarch replacement. No stroke was observed in the hemiarch group (P = .022; univariate analysis). The extent of the repair into the proximal arch did not appear to be associated with any adverse effect. CONCLUSIONS In non-redo patients, elective primary ARR has excellent early outcomes, regardless of whether repair extends into the proximal arch. Additional elective hemiarch replacement with moderate hypothermic circulatory arrest and antegrade cerebral perfusion has a low risk of neurologic complications and should be performed if necessary. Long-term data are needed to compare the rates of reintervention in the aortic arch in patients with or without proximal arch replacement.
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Dell'Aquila AM, Pollari F, Fattouch K, Santarpino G, Hillebrand J, Schneider S, Landwerht J, Nasso G, Gregorini R, Del Giglio M, Mikus E, Albertini A, Deschka H, Fischlein T, Martens S, Gallo A, Concistrè G, Speziale G, Regesta T. Early outcomes in re-do operation after acute type A aortic dissection: results from the multicenter REAAD database. Heart Vessels 2016. [PMID: 27770195 DOI: 10.1007/s00380-016-0907-x.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
This study provides early results of re-operations after the prior surgical treatment of acute type A aortic dissection (AAD) and identifies risk factors for mortality. Between May 2003 and January 2014, 117 aortic re-operations after an initial operation for AAD (a mean time from the first procedure was 3.98 years, with a range of 0.1-20.87 years) were performed in 110 patients (a mean age of 59.8 ± 12.6 years) in seven European institutions. The re-operation was indicated due to a proximal aortic pathology in ninety cases: twenty aortic root aneurysms, seventeen root re-dissections, twenty-seven aortic valve insufficiencies and twenty-six proximal anastomotic pseudoaneurysms. In fifty-eight cases, repetitive surgical treatment was subscripted because of distal aortic pathology: eighteen arch re-dissections, fifteen arch dilation and twenty-five anastomotic pseudoaneurysms. Surgical procedures comprised a total of seventy-one isolated proximals, thirty-one isolated distals and fifteen combined interventions. In-hospital mortality was 19.6 % (twenty-three patients); 11.1 % in patients with elective/urgent indication and 66.6 % in emergency cases. Mortality rates for isolated proximal, distal and combined operations regardless of the emergency setting were 14.1 % (10 pts.), 25.8 % (8 pts.) and 33.3 % (5 pts.), respectively. The causes of death were cardiac in eight, neurological in three, MOF in five, sepsis in two, bleeding in three and lung failure in two patients. A multivariate logistic regression analysis revealed that risk factors for mortality included previous distal procedure (p = 0.04), new distal procedure (p = 0.018) and emergency operation (p < 0.001). New proximal procedures were not found to be risk factors for early mortality (p = 0.15). This multicenter experience shows that the outcome of REAAD is highly dependent on the localization and extension of aortic pathology and the need for emergency treatment. Surgery in an emergency setting and distal re-do operations after previous AAD remain a surgical challenge, while proximal aortic re-operations show a lower mortality rate. Foresighted decision-making is needed in cases of AAD repair, as the results are essential preconditions for further surgical interventions.
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Affiliation(s)
- Angelo M Dell'Aquila
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Francesco Pollari
- Department of Cardiac Surgery, Cardiovascular Center, Klinikum Nuernberg, Paracelsus Medical University, Nuremberg, Germany
| | - Khalil Fattouch
- Department of Cardiovascular Surgery, Maria Eleonora Hospital GVM Care and Research, Palermo, Italy
| | - Giuseppe Santarpino
- Department of Cardiac Surgery, Cardiovascular Center, Klinikum Nuernberg, Paracelsus Medical University, Nuremberg, Germany
| | - Julia Hillebrand
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany.
| | - Stefan Schneider
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Jan Landwerht
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Giuseppe Nasso
- Department of Cardiovascular Surgery, Anthea Hospital GVM Care and Research, Bari, Italy
| | - Renato Gregorini
- Department of Cardiovascular Surgery, Cardiac Surgery Unit, Città di Lecce Hospital GVM Care and Research, Lecce, Italy
| | - Mauro Del Giglio
- Department of Cardiovascular Surgery, Maria Cecilia Hospital GVM Care and Research, Cotignola, Italy
| | - Elisa Mikus
- Department of Cardiovascular Surgery, Maria Cecilia Hospital GVM Care and Research, Cotignola, Italy
| | - Alberto Albertini
- Department of Cardiovascular Surgery, Maria Cecilia Hospital GVM Care and Research, Cotignola, Italy
| | - Heinz Deschka
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Theodor Fischlein
- Department of Cardiac Surgery, Cardiovascular Center, Klinikum Nuernberg, Paracelsus Medical University, Nuremberg, Germany
| | - Sven Martens
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Alina Gallo
- Department of Cardiac Surgery, San Martino University Hospital, University of Genova, Genoa, Italy
| | | | - Giuseppe Speziale
- Department of Cardiovascular Surgery, Anthea Hospital GVM Care and Research, Bari, Italy
| | - Tommaso Regesta
- Department of Cardiac Surgery, San Martino University Hospital, University of Genova, Genoa, Italy
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Dell’Aquila AM, Pollari F, Fattouch K, Santarpino G, Hillebrand J, Schneider S, Landwerht J, Nasso G, Gregorini R, del Giglio M, Mikus E, Albertini A, Deschka H, Fischlein T, Martens S, Gallo A, Concistrè G, Speziale G, Regesta T. Early outcomes in re-do operation after acute type A aortic dissection: results from the multicenter REAAD database. Heart Vessels 2016; 32:566-573. [DOI: 10.1007/s00380-016-0907-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 10/14/2016] [Indexed: 12/25/2022]
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23
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Iribarne A, Keenan J, Benrashid E, Wang H, Meza JM, Ganapathi A, Gaca JG, Kim HW, Hurwitz LM, Hughes GC. Imaging Surveillance After Proximal Aortic Operations: Is it Necessary? Ann Thorac Surg 2016; 103:734-741. [PMID: 27677566 DOI: 10.1016/j.athoracsur.2016.06.085] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 06/16/2016] [Accepted: 06/22/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Current guidelines for imaging surveillance after proximal aortic repair are not evidence based. This study sought to characterize the incidence and causes of reintervention after proximal aortic operations to provide data to guide the frequency and duration of postoperative surveillance. METHODS Data on all patients undergoing proximal aortic operations (ascending, with or without root, with or without aortic valve replacement, or with or without arch) during a 9-year period (n = 869) at a single institution were prospectively collected. Patients who required reintervention on the proximal or distal aorta were identified and causes for reintervention determined. Planned two-stage repairs and index procedures done at other hospitals were excluded. The primary end point was the time to the first reintervention, and competing-risk Cox regression was used to model reintervention risk. RESULTS Reinterventions occurred in 4.3% of patients (n = 37), with 48.6% (n = 18) involving the proximal aorta and 51.4% (n = 19) the distal. Median time to reintervention was 2.8 years (interquartile range, 1.5 to 3.6 years). For index aneurysm cases, reintervention for aneurysm of the descending/thoracoabdominal aorta and root were most common. Of the 6 root aneurysms/pseudoaneurysms, 5 (83%) were due to degeneration of a stentless porcine aortic root. For index type A dissections, reintervention for aneurysm of the descending/thoracoabdominal aorta and arch were most common. The mean duration of follow up was 4.2 ± 2.5 years. The 9-year actuarial freedom from reintervention was 92.9%. Cox regression showed index type A dissection was a significant predictor of time to aortic reintervention (hazard ratio, 2.01; 95% confidence interval, 1.04 to 3.9; p = 0.038). CONCLUSIONS Reinterventions after proximal aortic operations are uncommon; most occur within 3 years of the index operation and involve the proximal and distal aorta nearly equally. Patients with type A dissection or stentless porcine roots require aggressive surveillance, whereas a more liberal approach is suitable for patients without such risk factors. This strategy may reduce the lifetime radiation burden and health care costs.
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Affiliation(s)
- Alexander Iribarne
- Section of Cardiac Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jeffrey Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Hanghang Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - James M Meza
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Asvin Ganapathi
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Han W Kim
- Division of Cardiology, Duke Cardiovascular Magnetic Resonance Center, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Lynne M Hurwitz
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
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24
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Cabasa A, Pochettino A. Surgical management and outcomes of type A dissection-the Mayo Clinic experience. Ann Cardiothorac Surg 2016; 5:296-309. [PMID: 27563542 DOI: 10.21037/acs.2016.06.01] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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 post-operatively (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. DISCUSSION 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.
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Affiliation(s)
- Alduz Cabasa
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alberto Pochettino
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Hosseini S, Rezaei Y, Motevalli M, Pouraliakbar H, Babaee T, Noohi F, Mestres CA. Suprasternal innominate artery cannulation for reoperative aortic surgery: a technical note. Interact Cardiovasc Thorac Surg 2016; 23:832-834. [PMID: 27365005 DOI: 10.1093/icvts/ivw214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/17/2016] [Accepted: 05/26/2016] [Indexed: 11/14/2022] Open
Abstract
Suprasternal cannulation of the innominate artery in aortic reoperations may be useful in specific situations. Over a period of 3.5 years, 9 patients (6 males, average age = 49.2 ± 16.1 years) underwent suprasternal cannulation prior to resternotomy. Cannulation was performed using a side graft. All operations were successfully completed. Two patients died after surgery because of coagulopathy and multiorgan failure. There were no complications related to access or technique, and no site complications were detected during follow-up. Suprasternal cannulation of the innominate artery may play a role in selected reoperations.
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Affiliation(s)
- Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Marzieh Motevalli
- Department of Radiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Pouraliakbar
- Department of Radiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Touraj Babaee
- Department of Anesthesiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Feridoun Noohi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Carlos A Mestres
- Department of Cardiovascular Surgery, Hospital Clinico, University of Barcelona, Barcelona, Spain
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Arch reconstruction after a previous ascending-to-descending aortic bypass for coarctation of the aorta. J Thorac Cardiovasc Surg 2016; 151:1760-3. [DOI: 10.1016/j.jtcvs.2016.01.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 01/15/2016] [Indexed: 11/23/2022]
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Malaisrie SC, Duncan BF, Mehta CK, Badiwala MV, Rinewalt D, Kruse J, Li Z, Andrei AC, McCarthy PM. The addition of hemiarch replacement to aortic root surgery does not affect safety. J Thorac Cardiovasc Surg 2015; 150:118-24.e2. [PMID: 25896462 DOI: 10.1016/j.jtcvs.2015.03.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 02/27/2015] [Accepted: 03/15/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES A hemiarch reconstruction, using deep hypothermic circulatory arrest, is the conventional approach for proximal aortic arch reconstruction, but it carries risks of neurologic events and coagulopathy. The addition of a hemiarch reconstruction to an aortic root replacement may prevent future aortic arch pathology. Outcomes of this approach at a tertiary care institution were examined to determine whether the addition of a hemiarch reconstruction to an aortic root replacement conferred any additional risk. METHODS A total of 384 patients underwent an aortic root replacement between April 2004 and June 2012. Of them, 177 (46%) had hemiarch replacement. Propensity score matching yielded 133 pairs of patients receiving hemiarch and non-hemiarch. RESULTS Sinus segment diameter was similar between groups; ascending aortic diameter was greater in the hemiarch group (median 50 vs 44 mm; P < .001). The hemiarch group had longer perfusion (median 186 vs 120.5 minutes; P < .001) and crossclamp times (median 140 vs 104 minutes; P < .001); median circulatory arrest was 13 minutes. There was no difference, hemiarch versus no hemiarch, in 30-day mortality (3.0% vs 1.5%; P = .41), stroke (2.3% vs 4.5%; P = .31), reoperation for bleeding (11% vs 10%; P = .84), or overall survival (5-year 88.0% [95% confidence interval, 81.9-94.0] vs 91.4% [95% confidence interval, 85.8-96.9], P = .24). CONCLUSIONS In this series, aortic root replacement ± hemiarch reconstruction had low mortality. Addition of hemiarch replacement extended perfusion times but not at the expense of safety. Hemiarch reconstruction should be performed when the aortic root aneurysm extends into the distal ascending aorta.
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Affiliation(s)
| | - Brett F Duncan
- Division of Cardiothoracic Surgery, Northwestern University, Chicago, Ill
| | - Chris K Mehta
- Division of Cardiothoracic Surgery, Northwestern University, Chicago, Ill
| | - Mitesh V Badiwala
- Division of Cardiothoracic Surgery, Northwestern University, Chicago, Ill
| | - Dan Rinewalt
- Division of Cardiothoracic Surgery, Northwestern University, Chicago, Ill
| | - Jane Kruse
- Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, Ill
| | - Zhi Li
- Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, Ill
| | | | - Patrick M McCarthy
- Division of Cardiothoracic Surgery, Northwestern University, Chicago, Ill
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28
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Jassar AS, Desai ND, Kobrin D, Pochettino A, Vallabhajosyula P, Milewski RK, McCarthy F, Maniaci J, Szeto WY, Bavaria JE. Outcomes of aortic root replacement after previous aortic root replacement: the "true" redo root. Ann Thorac Surg 2015; 99:1601-8; discussion 1608-9. [PMID: 25754965 DOI: 10.1016/j.athoracsur.2014.12.038] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 11/30/2014] [Accepted: 12/08/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Aortic reoperations are technically challenging. This study evaluated outcomes after "true" redo root replacement (previous full root replacement) stratified by cause of prosthesis failure. METHODS Data were compared for 793 patients who underwent a first-time sternotomy (de novo group) and 120 patients who had previously undergone full aortic root replacement (redo group), of which 76 underwent reoperation due to structural valve deterioration (degenerative group), and 44 due to endocarditis (infection group). RESULTS Overall mortality was 4% (n = 28) in the de novo group and 5% (n = 6) in the redo group (p = 0.43) (degenerative group, 3%, infection group, 9%; p = 0.19). The infection group had an increased incidence of renal failure, sternal infection, prolonged ventilation, reoperation for bleeding, multisystem failure, and sepsis, and an increased hospital length of stay. The degenerative group and the de novo group had a similar risk of perioperative death and major complications. The 5-year survival was 86.3% ± 1.3% for the de novo group and 77.3% ± 4.6% for the redo group (p ≤ 0.01; degenerative, 86.3% ± 5%; infection, 65.3% ± 7.7%; p < 0.01; p = 0.98 for de novo vs degenerative). Multivariate analysis demonstrated that reoperation for degenerative failure did not increase the risk of perioperative or late death. CONCLUSIONS Redo aortic root replacement can be performed with low perioperative morbidity and death. The presence of infection increases the risk of complications and worsens survival. However, redo root replacement for degenerative failure can be performed with similar short-term complication risk and midterm survival as de novo root replacement.
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Affiliation(s)
- Arminder S Jassar
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dale Kobrin
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alberto Pochettino
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Rita K Milewski
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fenton McCarthy
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jon Maniaci
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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Tamer S, de Kerchove L, Manzano NC, Elkhoury G. Ross operation after failed valve-sparing reimplantation: pulmonary autograft inclusion into the previously implanted Valsalva graft. J Thorac Cardiovasc Surg 2013; 147:534-6. [PMID: 24189315 DOI: 10.1016/j.jtcvs.2013.08.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 07/15/2013] [Accepted: 08/29/2013] [Indexed: 11/25/2022]
Affiliation(s)
- Saadallah Tamer
- Department of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Laurent de Kerchove
- Department of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
| | - Norman Colina Manzano
- Department of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gebrine Elkhoury
- Department of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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Takano T, Wada Y, Seto T, Terasaki T, Fukui D, Amano J. Prosthesis-sparing aortic root replacement following aortic valve replacement. Asian Cardiovasc Thorac Ann 2013; 22:734-6. [DOI: 10.1177/0218492313482316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Reoperation on the aortic root is considered to be challenging because of high hospital mortality. Prosthesis-sparing aortic root replacement, in which the aortic prosthesis is preserved during reoperation, and could avoid passing sutures through the weakened aortic annuls after the initial prosthesis has been removed. We report 3 cases of prosthesis-sparing aortic root replacement. Prior procedures were aortic valve replacement and the Bentall operation 14 to 35 years previously. Postoperative courses were uneventful, with no signs of pseudoaneurysm or valve malfunction observed during follow-up periods of 93 to 360 days.
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Affiliation(s)
- Tamaki Takano
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Yuko Wada
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Tatsuichiro Seto
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Takamitsu Terasaki
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Daisuke Fukui
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Jun Amano
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
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Long-term results after proximal thoracic aortic redo surgery. PLoS One 2013; 8:e57713. [PMID: 23469220 PMCID: PMC3585872 DOI: 10.1371/journal.pone.0057713] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 01/25/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To evaluate early and mid-term results in patients undergoing proximal thoracic aortic redo surgery. METHODS We analyzed 60 patients (median age 60 years, median logistic EuroSCORE 40) who underwent proximal thoracic aortic redo surgery between January 2005 and April 2012. Outcome and risk factors were analyzed. RESULTS In hospital mortality was 13%, perioperative neurologic injury was 7%. Fifty percent of patients underwent redo surgery in an urgent or emergency setting. In 65%, partial or total arch replacement with or without conventional or frozen elephant trunk extension was performed. The preoperative logistic EuroSCORE I confirmed to be a reliable predictor of adverse outcome- (ROC 0.786, 95%CI 0.64-0.93) as did the new EuroSCORE II model: ROC 0.882 95%CI 0.78-0.98. Extensive individual logistic EuroSCORE I levels more than 67 showed an OR of 7.01, 95%CI 1.43-34.27. A EuroSCORE II larger than 28 showed an OR of 4.44 (95%CI 1.4-14.06). Multivariate logistic regression analysis identified a critical preoperative state (OR 7.96, 95%CI 1.51-38.79) but not advanced age (OR 2.46, 95%CI 0.48-12.66) as the strongest independent predictor of in-hospital mortality. Median follow-up was 23 months (1-52 months). One year and five year actuarial survival rates were 83% and 69% respectively. Freedom from reoperation during follow-up was 100%. CONCLUSIONS Despite a substantial early attrition rate in patients presenting with a critical preoperative state, proximal thoracic aortic redo surgery provides excellent early and mid-term results. Higher EuroSCORE I and II levels and a critical preoperative state but not advanced age are independent predictors of in-hospital mortality. As a consequence, age alone should no longer be regarded as a contraindication for surgical treatment in this particular group of patients.
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Keeling WB, Leshnower BG, Thourani VH, Kilgo PS, Chen EP. Outcomes following redo sternotomy for aortic surgery. Interact Cardiovasc Thorac Surg 2012; 15:63-8. [PMID: 22493099 DOI: 10.1093/icvts/ivs127] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Proximal thoracic aortic reconstruction performed with or without hypothermic circulatory arrest (HCA) is an effective surgical strategy for aortic pathology. In this study, the clinical outcomes of patients undergoing reoperative proximal thoracic aortic surgery were evaluated. A retrospective review was performed for reoperative proximal aortic surgery from 2004 to date. Patient data were abstracted from the society of thoracic surgeons (STS) institutional database and patient charts. Univariate analysis was conducted on the HCA group in order to determine the impact of variables on in-hospital mortality. Kaplan-Meier survival estimates were calculated for long-term survival analysis. One hundred and twenty-two patients were included in the analysis. Twenty-seven (22.1%) were female, and the mean age was 53.8 years. Seventy-seven (63.1%) patients had an aortic root replacement, and 93 (76.2%) patients underwent aortic arch replacement. Circulatory arrest was performed in 92 (75.4%) patients. Operative mortality occurred in 14 patients (11.5%). Complications included re-exploration for haemorrhage (nine patients, 7.4%), stroke (four, 3.3%), renal failure (13, 10.7%) and major adverse events (18, 14.8%). Univariate and multivariate analyses of HCA patients showed cardiopulmonary bypass (CPB) time, preoperative renal failure and prior coronary revascularization as independent predictors of mortality. Reoperative proximal aortic surgery can be performed with acceptable morbidity and mortality. These data also suggest that HCA represents a safe operative strategy for this patient population.
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Affiliation(s)
- William B Keeling
- Division of Cardiothoracic Surgery, University of Louisville, Louisville, KY, USA
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Luciani N, De Geest R, Anselmi A, Glieca F, De Paulis S, Possati G. Results of Reoperation on the Aortic Root and the Ascending Aorta. Ann Thorac Surg 2011; 92:898-903. [DOI: 10.1016/j.athoracsur.2011.04.116] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 04/22/2011] [Accepted: 04/29/2011] [Indexed: 11/30/2022]
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