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Patel PM, Olakunle OE, Dong A, Chiou E, Wei J, Binongo J, Leshnower B, Chen EP. Acute type A aortic syndromes: outcomes are independent of aortic root/valve management. Indian J Thorac Cardiovasc Surg 2024; 40:123-132. [PMID: 38389780 PMCID: PMC10879474 DOI: 10.1007/s12055-023-01602-8] [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: 04/20/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 02/24/2024] Open
Abstract
Purpose Clinical outcomes following various surgical intervention strategies for aortic root and valve pathology during repair of acute type A aortic syndromes were studied and compared. Methods From 2004 to 2019, 634 patients underwent acute type A aortic repair. Patients were divided into 4 groups: Valve Resuspension (n = 456), Isolated Valve Replacement (AVR) (n = 24), Valve and Root Replacement (ROOT) (n = 97), and Valve Sparing Root Replacement (VSRR) (n = 57). The primary endpoint was midterm survival and multivariable risk factor analysis was performed. Results The mean age was 55.4 ± 13 years, 424 (67%) were male, and overall early mortality was 12%. Early mortality was 13%, 8%, 11%, and 7% for the Valve Resuspension, AVR, ROOT, and VSRR groups respectively, p = 0.43. Five-year survival was 74%, 86%, 73%, and 84% for the Valve Resuspension, AVR, ROOT, and VSRR groups respectively, p = 0.46. There was no difference in late stroke, renal failure, heart block, and late bleeding (p > 0.05 for all). At late follow-up, AVR and ROOT patients had a higher mean gradient versus Valve Resuspension and VSRR patients, p < 0.0001. For the total cohort, risk factors for late mortality included preoperative peripheral vascular disease (hazard ratio (HR) 2.3, 95% confidence interval (CI) 1.2-4.4, p = 0.009) and preoperative dialysis (HR 2.8, 95% CI 1.3-6.1, p = 0.01). Conclusion Mid-term survival following repair of acute type A aortic dissection is not independently associated with a specific type of aortic valve intervention. Native valve preservation leads to acceptable mid-term valve hemodynamics and should be the preferred therapy in this emergent clinical setting. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-023-01602-8.
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Affiliation(s)
- Parth Mukund Patel
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Oreoluwa Elizabeth Olakunle
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Andy Dong
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Edward Chiou
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Jane Wei
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Jose Binongo
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Bradley Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Edward Po Chen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University School of Medicine, Duke University Medical Center, 2310 Erwin Road, 8660 HAFS Building, Durham, NC 27710 USA
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2
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Sá MP, Jacquemyn X, Awad AK, Brown JA, Chu D, Serna-Gallegos D, Kari FA, Sultan I. Valve-Sparing Aortic Root Replacement With Reimplantation vs Remodeling: A Meta-analysis. Ann Thorac Surg 2024; 117:501-507. [PMID: 37831047 DOI: 10.1016/j.athoracsur.2023.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/18/2023] [Accepted: 08/15/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Long-term outcomes of valve-sparing aortic root replacement (VSARR) with reimplantation vs remodeling in patients undergoing aortic root surgery remains a controversial subject. METHODS This study was a pooled meta-analysis of Kaplan-Meier-derived data from comparative studies published by December 31, 2022. RESULTS Fifteen studies met our eligibility criteria, comprising 3044 patients (1991 in the reimplantation group and 2018 in the remodeling group). Patients who underwent VSARR with remodeling had a higher risk of all-cause death (hazard ratio [HR], 1.54; 95% CI, 1.16-2.03; P = .002, log-rank test P < .001). Landmark analysis (with 4 years as the landmark time point) demonstrated that survival was lower in patients who underwent VSARR with remodeling (HR, 2.15; 95% CI, 1.43-3.24; P < .001) in the first 4 years. Beyond the 4-year time point, no difference in survival was observed (HR, 1.04; 95% CI, 0.72-1.50; P = .822). The risk for need of aortic valve and/or root reintervention was higher in patients undergoing VSARR with remodeling (HR, 1.49; 95% CI, 1.07-2.07; P = .019, log-rank test P < .001). We did not find statistically significant coefficients for the covariates of age, female sex, connective tissue disorders, bicuspid aortic valve, aortic dissection, coronary bypass surgery, total arch replacement, or annular stabilization, which means that these covariates did not modulate the effects observed in our pooled analyses. CONCLUSIONS VSARR with reimplantation is associated with better overall survival and lower risk of need for reintervention over time compared with VSARR with remodeling. Regarding overall survival, we observed a time-varying effect that favored the reimplantation technique up to 4 years of follow-up, but not beyond this time point.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Ahmed K Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Fabian A Kari
- Section of Pediatric and Congenital Cardiac Surgery, European Pediatric Heart Center, Ludwig Maximilian University (LMU) University Hospital and German Heart Center, Munich, Germany
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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3
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Abdalghafoor T, Salah A, Kindawi A. Editorial note. Int J Cardiol 2023; 382:20-21. [PMID: 37061095 DOI: 10.1016/j.ijcard.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 04/07/2023] [Indexed: 04/17/2023]
Affiliation(s)
| | - Amr Salah
- Cardiothoracic Anaesthesia and Intensive care, Heart Hospital, Doha, Qatar
| | - Ali Kindawi
- Departments of Cardiothoracic Surgery, Heart Hospital, Doha, Qatar
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4
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Sá MP, Tasoudis P, Jacquemyn X, Van den Eynde J, Rad AA, Weymann A, Ruhparwar A, Caranasos TG, Ikonomidis JS, Chu D, Serna-Gallegos D, Sultan I. Long-term outcomes of valve-sparing root versus composite valve graft replacement for acute type A aortic dissection: Meta-analysis of reconstructed time-to-event data. Int J Cardiol 2023; 382:12-19. [PMID: 37004942 DOI: 10.1016/j.ijcard.2023.03.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/28/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVES To evaluate the long-term outcomes of valve-sparing aortic root replacement (VSARR) versus composite aortic valve graft replacement (CAVGR) in the treatment of acute type A aortic dissections (ATAAD). METHODS We performed a pooled meta-analysis of Kaplan-Meier-derived time-to-event data from studies with longer follow-up beyond the immediate postoperative period. RESULTS Seven studies met our eligibility criteria, comprising a total of 858 patients (367 patients in the VSARR groups and 491 patients in the CAVGR group). We found no statistically significant differences in the overall survival between the groups over time (HR 0.83, 95%CI 0.63-1.10, P = 0.192), but we observed a higher risk of reoperation in the VSARR group when compared with the CAVGR group (HR 9.99, 95% CI 2.23-44.73, P = 0.003). The meta-regression revealed statistically significant positive coefficients for age (P < 0.001) in the analysis of survival, which means that this covariate has a modulating effect on this outcome. The higher the mean age, the higher the HR for overall mortality was found to be with VSARR as compared with CAVGR. Other covariates such as female sex, hypertension, diabetes, connective tissue disorders, bicuspid aortic valve, hemiarch and/or total arch replacement, concomitant coronary bypass surgery did not seem to have any effect on the outcomes. CONCLUSION VSARR did not confer a better (or worse) survival over time in patients with ATAAD, but it was associated with higher risk of reoperations in the long run.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America.
| | - Panagiotis Tasoudis
- Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, NC, United States of America
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Arian Arjomandi Rad
- Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Thomas G Caranasos
- Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, NC, United States of America
| | - John S Ikonomidis
- Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, NC, United States of America
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
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5
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Abstract
The clinical outcome of severe aortic regurgitation (AR) remains suboptimal, but surgery has been shown to have survival benefit over medical therapy. Postoperative survival is inferior in patients with reduced left ventricular function, and therefore early surgical intervention is recommended. Aortic valvuloplasty (AVP) is an attractive option to avoid the major drawbacks of prosthetic valves but has not been widely adopted. The etiology of AR is classified functionally into three groups: normal leaflet motion (type I), cusp prolapse (type II), and restriction (type III). Type I with dilatation of the sinus of Valsalva (type Ib) can be repaired by aortic valve reimplantation or aortic root remodeling with similar valve stability. Type I with dilatation of the aortic annulus (type Ic) can be managed by annuloplasty. Type II can be corrected by plication or resuspension techniques. Pericardial patch is necessary in AVP for type Id (perforation/fenestration) and type III but is associated with risk of recurrence. Bicuspid aortic valve is classified according to commissure angle: symmetrical, asymmetrical, and very asymmetrical. Tricuspidization is recommended for repair of very asymmetrical valves to avoid postoperative stenosis. Recent progress has achieved similar reoperation rates between bicuspid and tricuspid aortic valve repair. For Marfan syndrome, valve-sparing root replacement is advantageous compared to Bentall operation regarding late survival, thromboembolic and hemorrhagic events, and endocarditis. Similar findings have been reported in acute aortic dissection. Both remodeling and reimplantation procedures provide similar favorable outcomes in these settings. Recent advances in AVP are summarized by quantitative assessment of cusp configuration (effective height and geometric height), graft size decision, use of template to cut the graft, and videoscopic assessment of post-repair cusp configuration. Due to these advances, AVP shows superior results to replacement surgery. Further concrete evidence with larger case volumes and longer observation periods are necessary to popularize AVP.
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6
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Alhussaini M, Jeng EI, Martin TD, Fillion A, Beaver TM, Arnaoutakis GJ. Florida sleeve is a safe and effective technique for valve salvage in acute stanford type A aortic dissection. J Card Surg 2021; 37:39-46. [PMID: 34652039 DOI: 10.1111/jocs.16078] [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: 09/06/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Valve-sparing root replacement is commonly used for management of aortic root aneurysms in elective setting, but its technical complexity hinders its broader adoption for acute type-A aortic dissection (ATAAD). The Florida sleeve (FS) procedure is a simplified form of valve sparing aortic root reconstruction that does not require coronary reimplantation. Here, we present our outcomes of the FS repair in patients with dilated roots in the setting of an ATAAD. METHODS We retrospectively reviewed 24 consecutive patients (2002-2018) treated with FS procedure for ATAAD. Demographic, operative, and postoperative outcomes were queried from our institutional database. Long term follow-up was obtained from clinic visits for local patients, and with telephone and telehealth measures otherwise. RESULTS Mean age was 49 ± 14 years with 19 (79%) males. Marfan syndrome was present in 4 (16.7%) patients and 14 (58.3) had ≥2+ aortic insufficiency (AI). Nine (37.2%) had preoperative mal-perfusion or shock. The FS was combined with hemi-arch replacement in 15 (62.5%) patients and a zone-2 arch replacement in 9 (37.5%) patients. There were 2 (8.3%) early postoperative mortalities. Median follow-up period was 46 months (range, 0.3-146). The median survival of the entire cohort was 143.4 months. One patient (4.2%) required redo aortic valve replacement for unrelated aortic valve endocarditis at 30 months postoperatively. CONCLUSION FS is simplified and reproducible valve-sparing root repair. In appropriate patients, it can be applied safely in acute Stanford type-A aortic dissection with excellent early and long-term results.
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Affiliation(s)
| | - Eric I Jeng
- Department of Surgery, Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Tomas D Martin
- Department of Surgery, Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Amber Fillion
- Department of Surgery, Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Thomas M Beaver
- Department of Surgery, Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - George J Arnaoutakis
- Department of Surgery, Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
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7
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Dang Van S, Laribi J, Pinaud F, Binuani P, Willoteaux S, Baufreton C, Fouquet O. Preservation of the Aortic Root During Type A Aortic Dissection Surgery: An Effective Strategy? AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2021; 9:67-75. [PMID: 34619800 PMCID: PMC8526144 DOI: 10.1055/s-0041-1725074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background
Management of the aortic root during acute Type A aortic dissection (TAAD) repair remains controversial in term of long-term evolution and reoperation. The aim of this study was to assess the long-term outcomes of the aortic root after conservative management during primary surgery.
Methods
One hundred sixty-four consecutive patients were included in this monocentric retrospective study. The primary endpoint was reoperation on the aortic root during long-term follow-up. Forty-six patients had aortic root replacement (ARR) and 118 had supracoronary aortic replacement (SCR). The 10-year survival, occurrence of significant aortic regurgitation, and radiologic aortic root dilatation in each group were assessed during follow-up.
Results
Patients from ARR group were younger than those from SCR group (
p
< 0.0001). Median follow-ups of ARR group and SCR group are 4.4 (interquartile range [IR]: 2.6–8.3) and 6.15 (IR: 2.8–10.53) years, respectively. Reoperation of the aortic root during long-term follow-up was similar in both groups (ARR group: 5.1%, SCR group: 3.3%,
p
= 0.636). The 10-year survivals of ARR and SCR groups were 64.8 ± 12.3% and 46.3 ± 5.8% (
p
= 0.012), respectively. Long-term significant aortic regurgitation occurred in one patient (1.7%) and seven patients (7.6%) of the ARR and SCR groups (
p
= 0.176), respectively. Radiologic aortic root diameters in the SCR group were similar between postoperative period and follow-up studies (
p
= 0.58). Reoperation on the distal aorta (
p
= 0.012) and patent radiologic false lumen of the descending aorta (
p
= 0.043) were independent risk factors of late death.
Conclusion
SCR is an effective technique for primary TAAD surgery and does not increase the rate of late reoperation on the aortic root.
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Affiliation(s)
- Simon Dang Van
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Jihed Laribi
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Frédéric Pinaud
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Patrice Binuani
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Serge Willoteaux
- Department of Radiology, University Hospital of Angers, Angers, France
| | - Christophe Baufreton
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France.,Mitovasc Institute INSERM U1083 UMR-CNRS 6214, University Hospital of Angers, Angers, France
| | - Olivier Fouquet
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France.,Mitovasc Institute INSERM U1083 UMR-CNRS 6214, University Hospital of Angers, Angers, France
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8
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Maskell P, Brimfield M, Ahmed A, Harky A. In patients undergoing valve-sparing aortic root replacement, is reimplantation superior to remodelling? Interact Cardiovasc Thorac Surg 2021; 32:441-446. [PMID: 33313815 DOI: 10.1093/icvts/ivaa290] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 09/20/2020] [Accepted: 10/27/2020] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients undergoing valve-sparing aortic root replacement, is reimplantation superior to remodelling? The purpose of this best evidence topic was to re-review the updated evidence that has become available in the near decade since the previous review published in 2011. Altogether more than 300 papers were found using the reported search, of which 8 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The included studies have significant limitations relating to low-level evidence study design, variable outcome collection and limited significance testing with direct comparison. Long-term outcomes such as survival, recurrence of aortic regurgitation and valve reintervention were largely equal between the two procedures across the studies. This review, updated from the previous best evidence topic, continues to suggest that there are no clear recommendations or even consensus to guide clinical decision-making when choosing between remodelling or reimplantation approaches to valve-sparing aortic root replacement. To date, no study provides strong clinical benefit to favour either procedure in terms of perioperative outcomes, medium-long term survival or reintervention of the aortic valve. As such, procedure selection should be based upon patient factors and valve evaluation, combined with surgeon preference and experience.
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Affiliation(s)
- Perry Maskell
- Department of Surgery, Cambridge University NHS Foundation Trust, Cambridge, UK
| | | | - Amna Ahmed
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Cardiac Surgery, Alder Hey Children Hospital, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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9
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Vekstein AM, Chen EP, Andersen ND. Commentary: Dissecting Out the Root of the Matter. Semin Thorac Cardiovasc Surg 2021; 34:428-429. [PMID: 34087375 DOI: 10.1053/j.semtcvs.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew M Vekstein
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
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10
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Li J, Sun Y, Zhou T, Wang Y, Sun Y, Lai H, Wang C. David reimplantation with simultaneous total arch replacement and stented elephant trunk for acute type A aortic dissection. J Thorac Cardiovasc Surg 2021; 161:2017-2026.e2. [DOI: 10.1016/j.jtcvs.2019.10.164] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 10/11/2019] [Accepted: 10/28/2019] [Indexed: 01/04/2023]
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11
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Ok YJ, Kang SR, Kim HJ, Kim JB, Choo SJ. Comparative outcomes of total arch versus hemiarch repair in acute DeBakey type I aortic dissection: the impact of 21 years of experience. Eur J Cardiothorac Surg 2021; 60:967-975. [PMID: 33880505 DOI: 10.1093/ejcts/ezab189] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES With the goal of evaluating the impact of experiences at our centre on comparative outcomes between total arch and hemiarch repairs, we reviewed our 21 years of experience with operations for acute type I aortic dissection. METHODS Between 1999 and 2019, a total of 365 patients (177 women; 56.8 ± 12.9 years) with acute type I aortic dissection who had a hemiarch (n = 248) or a total arch replacement (n = 117) were evaluated, and the trends in comparative outcomes were analysed. RESULTS Over time, deep hypothermic circulatory arrest and retrograde cerebral perfusion were replaced by moderate hypothermia and antegrade cerebral perfusion with the introduction of dedicated aortic surgeons. Overall, operative deaths decreased from 11.0% in time quartile 1 to 2.2% in time quartile 4 (P = 0.090). After adjustment with the use of inverse probability weighting, the total arch group compared with the hemiarch group was at a similar risk of mortality [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.22-2.43; P = 0.71] but at a greater risk of neurological deficit (OR 3.28, 95% CI 1.23-8.98; P = 0.017) in the earlier half period (1999-2009). In the later period (2009-2019), however, both the risks of mortality (OR 0.32, 95% CI 0.03-1.59; P = 0.23) and of neurological injuries (OR 0.42, 95% CI 0.12-1.18; P = 0.13) were comparable between the 2 groups (P for interaction in terms of neurological deficit = 0.007). The multivariable logistic regression model revealed that dedicated aortic surgeons independently contributed to decreased risk of death (OR 0.30, 95% CI 0.09-0.84; P = 0.036). CONCLUSIONS These findings indicate that accumulating institutional experiences, along with resultant improvements in surgical strategies and outcomes, may neutralize the surgical risk gap between total arch and hemiarch repair in acute type I aortic dissection.
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Affiliation(s)
- You Jung Ok
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Ri Kang
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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12
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Khachatryan Z, Herajärvi J, Leontyev S, Borger MA. Valve-sparing aortic root replacement can be done safely and effectively in acute type A aortic dissection. J Thorac Cardiovasc Surg 2021; 164:814-819. [PMID: 33934897 DOI: 10.1016/j.jtcvs.2021.02.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 01/16/2023]
Affiliation(s)
- Zara Khachatryan
- University Clinic of Cardiac Surgery, Leipzig Heart Centre, Leipzig, Germany
| | - Johanna Herajärvi
- University Clinic of Cardiac Surgery, Leipzig Heart Centre, Leipzig, Germany
| | - Sergey Leontyev
- University Clinic of Cardiac Surgery, Leipzig Heart Centre, Leipzig, Germany
| | - Michael A Borger
- University Clinic of Cardiac Surgery, Leipzig Heart Centre, Leipzig, Germany.
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13
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Ehrlich T, Karliova I, Froede L, Giebels C, Kunihara T, Schäfers HJ. Aortic Root Remodeling in Acute Aortic Dissection. Thorac Cardiovasc Surg 2020; 69:329-335. [PMID: 33260233 DOI: 10.1055/s-0040-1718937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To evaluate the long-term results of remodeling in acute aortic dissection type A (AADA) to define operative risk and root and valve stability. METHODS Between October 1995 and December 2018, a total of 352 patients were treated surgically for AADA. Of these, 90 patients with AADA (<2 weeks from onset; age: 57 ± 15 years; 70 males) with a root diameter of >43 to 45 mm (depending on patient size) (48 ± 4.1 mm) underwent aortic root remodeling and were analyzed further. As the control group, we chose the patients with normally sized aortic roots who had been treated by tubular replacement only (n = 227). Other procedures were performed in 35 cases. RESULTS Early mortality was 9% in the remodeling group versus 15% in the tubular ascending aortic replacement (TAR). Actuarial survival at 10 and 15 years was 68 ± 5% and 58.3 ± 6.4%, respectively, in the root remodeling group versus 68 ± 4% and 66 ± 4% in the TAR group (p = 0.99). Freedom from reoperation on the aortic valve or root was 95 ± 3% at 10 years and at 89 ± 6% at 15 years. Freedom from proximal reoperation after TAR at 10 and 15 years was 93 ± 3% and 91 ± 3% (n = 31 patients at risk), respectively, not statistically different from that after remodeling (p = 0.75). CONCLUSIONS The long-term stability of aortic root remodeling for enlarged roots with AADA was comparable to TAR preserving a normal aortic root.
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Affiliation(s)
- Tristan Ehrlich
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Irem Karliova
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Lennart Froede
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Christian Giebels
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Takashi Kunihara
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
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14
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Abd Al Jawad M. Modified selective aortic root reconstruction with valve repair for treatment of Stanford A aortic dissection. THE CARDIOTHORACIC SURGEON 2020. [DOI: 10.1186/s43057-020-00021-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Acute aortic dissection is a serious emergency with a significant impact on mortality and morbidity. Many patients present with hemodynamic instability that may prevent them from being transported to more experienced centers. We aim to present our experience with a modified limited root approach in terms of the operative details and early results.
Results
This retrospective study included 27 patients who presented with Stanford A aortic dissection and underwent modified selective root replacement. All patients were followed up using transthoracic echocardiography at 6 months postoperatively and at yearly intervals thereafter. Computed tomography (CT) angiography was performed 12 months after the initial surgery.
A total of 92.6% of patients required concomitant aortic valve repair. There was no operative mortality related to the operation itself; however, four patients died during the follow-up period. One patient developed new severe aortic regurgitation in the 6th month of follow-up. One patient developed a pseudoaneurysm related to the suture line that was diagnosed by CT angiography in the 16th month of follow-up.
Conclusions
The early results of modified selective root reconstruction with aortic valve repair are promising. This procedure is a quick, reliable, easily reproducible, and technically undemanding valve-sparing treatment for acute aortic root dissection.
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15
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Toh S, Ang J, George JJ, Jayawardena O, Mahbub S, Harky A. Outcomes in techniques of valve sparing aortic root replacement: A systematic review and meta-analysis. J Card Surg 2020; 36:178-187. [PMID: 33085112 DOI: 10.1111/jocs.15132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To compare clinical outcomes of reimplantation versus remodeling in patients undergoing valve-sparing aortic root replacement (VSRR) surgery. METHOD Electronic database search at PubMed, Scopus, Embase, Ovid, and Google scholar was performed from inception to January 2020. Primary outcomes were aortic valve (AV) reintervention and postoperative grade of aortic insufficiency (AI) while secondary outcomes were 30-day mortality, reoperation for bleeding, and operative times. RESULTS A total of 21 articles met the inclusion criteria. A total of 1283 patients had reimplantation while 1150 had remodeling. No difference in preoperative demographics was noted except reimplantation patients were younger (48 ± 16 vs. 56 ± 15 years; p < .00001). The cardiopulmonary bypass and aortic cross-clamp times were shorter in the remodeling cohort (168 ± 38 vs. 150 ± 37 min; p = .0001 and 133 ± 31 vs. 112 ± 30 min; p = .0002, respectively). No difference in concomitant total arch surgery (14% in reimplantation vs. 15% in remodeling; p = .53). Postoperatively, there were similar stroke rates (3% in both cohorts; p = .54), rates of reoperation for bleeding (9% in reimplantation vs. 12% in remodeling; p = .88), and 30-day mortality (3% in reimplantation vs. 4% in remodeling; p = .96). No difference in early AV reintervention (1% in reimplantation vs. 2% in remodeling; p = .07), and late AV reintervention (4% in reimplantation vs. 7% in remodeling; p = .07). The AI of +2 grade was significantly lower in the reimplantation cohort (5% vs. 8%; p = .01). CONCLUSION Our study shows comparable clinical outcomes between both techniques. The practice of each technique is largely center and surgeon dependent. Larger sample size cohorts with minimal confounding factors are required to confirm the above findings.
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Affiliation(s)
- Steven Toh
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | - Juliana Ang
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | - Joel Jacob George
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | - Ovin Jayawardena
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | - Samiha Mahbub
- Department of Medicine, St. George's University of London, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Integrative Biology, Faculty of Health Science, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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16
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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: 7] [Impact Index Per Article: 1.8] [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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17
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Harky A, Singh VP, Khan D, Sajid MM, Kermali M, Othman A. Factors Affecting Outcomes in Acute Type A Aortic Dissection: A Systematic Review. Heart Lung Circ 2020; 29:1668-1681. [PMID: 32798049 DOI: 10.1016/j.hlc.2020.05.113] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/10/2020] [Accepted: 05/18/2020] [Indexed: 11/17/2022]
Abstract
Acute type A aortic dissection is a clinical emergency and is associated with significant morbidity and mortality rates if not managed promptly in specialised and high-volume centres. The mortality rate is increased by 1% for each hour delay in management; however, with advancement in clinical practice, diagnostic imaging and clinician awareness, this has been dramatically reduced to below 30% in most international centres. Not only timing of recognition of the pathology, but also other factors can significantly affect outcomes of such critical pathology. This includes, but is not limited to, age, extent of the pathology, existence of connective tissue disorders, hypertension, diabetes mellitus and surgeon experience. This narrative review will focus on current clinical practice and the evidence behind optimising each factor to minimise adverse outcomes in such high-risk cohort.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; School of Medicine, University of Liverpool, Liverpool, UK.
| | | | - Darab Khan
- School of Medicine, University of Liverpool, Liverpool, UK
| | | | - Muhammed Kermali
- Faculty of Medicine, St. George's, University of London, London, UK
| | - Ahmed Othman
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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18
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Saw LJ, Lim‐Cooke M, Woodward B, Othman A, Harky A. The surgical management of acute type A aortic dissection: Current options and future trends. J Card Surg 2020; 35:2286-2296. [DOI: 10.1111/jocs.14733] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Li Jing Saw
- School of MedicineUniversity of Liverpool Liverpool UK
| | | | - Beth Woodward
- College of Medical and Dental SciencesUniversity of Birmingham Birmingham UK
| | - Ahmed Othman
- Department of Cardiothoracic SurgeryLiverpool Heart and Chest Hospital Liverpool UK
| | - Amer Harky
- School of MedicineUniversity of Liverpool Liverpool UK
- Department of Cardiothoracic SurgeryLiverpool Heart and Chest Hospital Liverpool UK
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19
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Frankel WC, Green SY, Orozco-Sevilla V, Preventza O, Coselli JS. Contemporary Surgical Strategies for Acute Type A Aortic Dissection. Semin Thorac Cardiovasc Surg 2020; 32:617-629. [PMID: 32615305 DOI: 10.1053/j.semtcvs.2020.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/21/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Abstract
Surgical techniques and organ protection strategies for acute type A aortic dissection (ATAAD) have evolved considerably over the years. Nonetheless, open surgical repair remains a complex procedure, and there is a lack of consensus regarding many aspects of repair. In patients with dissection limited to the ascending aorta (DeBakey type II), repair typically involves replacement of only the affected segment, barring substantial aortic dilation to address elsewhere. In contrast, most patients with ATAAD have dissection extending into the thoracoabdominal aorta (DeBakey type I); in these cases, consideration must be given as to how much of the aortic arch and distal aorta to incorporate into the index repair, and several open and hybrid options exist. Herein, we review contemporary surgical strategies for ATAAD and clarify specific areas of controversy, in an effort to elucidate the optimal operative approach. In general, a limited index repair aimed at ensuring operative survival is typically the best option, whereas extended repair should be reserved for carefully selected patients who are most likely to benefit.
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Affiliation(s)
- William C Frankel
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas.
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20
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Zhan Y, Norman AV, Kawabori M. A 38-Year-Old Woman With Worsening Dyspnea After Giving Birth. JAMA Cardiol 2020; 5:609-610. [PMID: 32293650 DOI: 10.1001/jamacardio.2019.5731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Yong Zhan
- CardioVascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Anthony V Norman
- CardioVascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Masashi Kawabori
- CardioVascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
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21
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Beckmann E, Martens A, Krueger H, Kaufeld T, Korte W, Stettinger A, Haverich A, Shrestha ML. Aortic valve-sparing root replacement (David): learning curve and impact on outcome. Interact Cardiovasc Thorac Surg 2020; 30:754-761. [DOI: 10.1093/icvts/ivz324] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 12/05/2019] [Accepted: 12/19/2019] [Indexed: 12/16/2022] Open
Abstract
Abstract
OBJECTIVES
Aortic valve-sparing root replacement (David procedure) offers the benefit of preserving the native aortic valve but is often criticized for being technically challenging and time-consuming. We analysed whether the surgeon’s level of experience affects the early and long-term outcome after the David procedure.
METHODS
From July 1993 to October 2015, a total of 582 patients underwent aortic valve-sparing David I procedure at our institution. A retrospective review with follow-up (mean follow-up time 8.6 ± 5.6 years) was performed. Statistical analysis of the surgeon’s level of experience was performed as a categorical variable, after patients were chronologically assigned to groups of tens. Study end points assessing the surgeon’s learning curve included both measures of patient outcome and measures of task efficiency. Study end points included both short- and long-term outcomes.
RESULTS
Analysis of task efficiency showed that there was a statistically significant inverse correlation between the surgeon’s level of experience and both cardiopulmonary bypass time (P = 0.026) and aortic cross-clamp time (P = 0.017). Analysis of patient outcome revealed that the incidence of aortic valve-related reoperation during follow-up showed a significant inverse correlation with the surgeon’s level of experience (P = 0.048). Cox regression analysis found that the surgeon’s level of experience (odds ratio 0.802, 95% confidence interval 0.673–0.957; P = 0.014) was a significant risk factor for aortic valve-related reoperation-free survival during follow-up.
CONCLUSIONS
There is a surgeon’s learning curve for aortic valve-sparing David procedure. The surgeon’s experience has a direct impact on both the perioperative outcome and the long-term performance of the aortic valve.
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Affiliation(s)
- Erik Beckmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Martens
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Heike Krueger
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tim Kaufeld
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wilhelm Korte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alissa Stettinger
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Malakh Lal Shrestha
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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22
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The fate of aortic root and aortic regurgitation after supracoronary ascending aortic replacement for acute type A aortic dissection. J Thorac Cardiovasc Surg 2019; 161:483-493.e1. [PMID: 31839222 DOI: 10.1016/j.jtcvs.2019.09.183] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 09/05/2019] [Accepted: 09/18/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the fate of the preserved aortic root after supracoronary aortic replacement for acute type A aortic dissection. METHODS Between October 1999 and March 2018, 339 patients underwent supracoronary aortic replacement for acute type A aortic dissection at our institution. Late outcomes were evaluated, including overall survival, aortic-related death, and aortic root-related reoperation. The median follow-up was 3.7 years (1.4-8.4 years). RESULTS Operative mortality was 46 patients (13.6%). The cumulative incidences at 5 years for aortic root-related reoperation, aortic-related death, and non-aortic related death were 2.5%, 14.5% and 12.4%, respectively. Multivariable Cox hazard regression analysis demonstrated greater sinus of Valsalva diameter and number of commissural detachments to be significant risk factors for a composite outcome consisting of aortic-related death or aortic root-related reoperation. Mixed-effects regression demonstrated that sinus of Valsalva diameter significantly increased with time (P < .001), and aortic regurgitation significantly worsened (P < .001). CONCLUSIONS Sinus of Valsalva diameter and commissural detachment were independent predictors of unfavorable outcomes after supracoronary aortic replacement. Close follow-up is particularly necessary for these patients, and aortic root replacement at the time of initial operation may lead to more favorable late outcomes.
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23
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Schamberger L, Leontyev S, Davierwala PM, Von Aspern K, Lehmann S, Misfeld M, Borger MA. David aortic valve-sparing reimplantation versus biological aortic root replacement: a retrospective analysis of 411 patients. Indian J Thorac Cardiovasc Surg 2019; 36:97-103. [PMID: 33061190 DOI: 10.1007/s12055-019-00873-4] [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: 05/22/2019] [Revised: 08/29/2019] [Accepted: 09/01/2019] [Indexed: 11/27/2022] Open
Abstract
Objectives This study aimed to compare short- and long-term results for patients undergoing either aortic valve-sparing reimplantation (David) procedure (AVr-D) or biological aortic root replacement (Bentall) procedure (ARr-B-bio) for aortic root pathology. Methods We compared outcomes for patients who underwent AVr-D (n = 261) or ARr-B-bio (n = 150) between 2000 and 2015 at our institution. The mean age of patients was 55 ± 13 years and 21.7% (n = 89) were female. ARr-B-bio patients were significantly older than AVr-D patients (58 ± 10 vs 53 ± 15 years, p < 0.001) and had a significantly lower incidence of connective tissue disorders (2.0% vs 16.9%, p < 0.001). Follow-up was complete in 88% of patients. Results Mortality at 30 days was 1.2% (n = 5) overall, at 0.4% (n = 1) significantly lower in the AVr-D group compared with 2.7% (n = 4) in the ARr-B-bio group (p = 0.04). Postoperative low cardiac output was more common in ARr-B-bio patients (n = 4) versus AVr-D patients (n = 0; p = 0.008). The occurrence of postoperative strokes was 2.2% (n = 9) in both groups, without significant differences (p = 0.84). Five- and ten-year survival was 93.7 ± 1.8% and 84.4 ± 4.7% in patients who received AVr-D and 90.9 ± 2.6% and 84.6 ± 5.4% for ARr-B-bio patients (log-rank p = 0.37). Using Cox regression analysis, age (HR 1.06; 95% CI 1.02-1.10, p = 0.002), smoking (HR 2.74; 95% CI 1.28-5.86, p = 0.01), and emergency surgery (HR 6.58; 95% CI 1.69-25.54, p = 0.007) were found to be independent predictors of long-term mortality.There was no difference in freedom from reoperation between AVr-D (89.4 ± 3.4% at 10 years) and ARr-B-bio (80.4 ± 7.5% at 10 years, log-rank p = 0.66) patients, nor for freedom from stroke, bleeding, myocardial infarction, or endocarditis during follow-up. Conclusions Short-term outcomes for both AVr-D and ARr-B-bio are excellent in patients with aortic root pathology. The long-term outcomes were associated with comparable survival and freedom from reoperation. AVr-D may be preferable to ARr-B-bio in patients with suitable pathoanatomy.
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Affiliation(s)
- Lukas Schamberger
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
| | - Sergey Leontyev
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
| | - Piroze Minoo Davierwala
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
| | - Konstantin Von Aspern
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
| | - Sven Lehmann
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
| | - Michael Andrew Borger
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
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Kato Y, Sasaki K, Yamauchi H, Kanno Y, Jinno T, Yamada M, Kiyama H, Koyanagi T. Aortic root remodelling with external ring annuloplasty in acute type A aortic dissection. Interact Cardiovasc Thorac Surg 2019; 30:85-90. [DOI: 10.1093/icvts/ivz227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
To investigate the early and mid-term results of aortic root remodelling with external ring annuloplasty in acute type A aortic dissection.
METHODS
From January 2015 to April 2019, a total of 194 patients underwent emergency or urgent operation for acute type A aortic dissection in our hospital. Of these, outcomes in 18 patients who underwent valve-sparing aortic root remodelling with external ring annuloplasty were retrospectively evaluated.
RESULTS
The mean age of the 18 patients was 49 ± 14 years. Fourteen patients (78%) were men. Five patients had Marfan syndrome and 2 patients had bicuspid aortic valve. Two patients had coronary malperfusion and 1 patient had cerebral malperfusion. All 18 patients underwent aortic root remodelling with external ring annuloplasty. Cusp repair using central cusp plication was required in 9 patients. Concomitant procedures were hemiarch replacement in 8 patients, total arch replacement in 7 patients, partial arch replacement in 1 patient and coronary artery bypass grafting to the right coronary artery in 3 patients. Thirty-day mortality rate was 5.6% (1 of 18). Postoperative echocardiography showed aortic regurgitation of <1+ in all patients. During follow-up (mean 56 ± 41 months), 1 case of recurrent aortic regurgitation required aortic valve replacement.
CONCLUSIONS
Aortic root remodelling with external ring annuloplasty may be an appropriate treatment in middle-aged or younger patients presenting with acute type A aortic dissection.
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Affiliation(s)
- Yasuyuki Kato
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Kenichi Sasaki
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Hidetaka Yamauchi
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Yasuyuki Kanno
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Taiyo Jinno
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Muneaki Yamada
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Hiroshi Kiyama
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Toshiya Koyanagi
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
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25
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Salmasi MY, Theodoulou I, Iyer P, Al-Zubaidy M, Naqvi D, Snober M, Oo A, Athanasiou T. Comparing outcomes between valve-sparing root replacement and the Bentall procedure in proximal aortic aneurysms: systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2019; 29:911-922. [DOI: 10.1093/icvts/ivz211] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 07/18/2019] [Accepted: 07/20/2019] [Indexed: 01/16/2023] Open
Abstract
AbstractIn aortic root aneurysms, the challenge of a valve-sparing aortic root replacement (VSRR) procedure is to ensure durable aortic valve function without reintervention. Although the Bentall procedure defers the durability of valve function to the prosthesis, short- and long-term complications tend to be higher. The aim of this study was to compare the outcomes of VSRR and Bentall procedures in patients with aortic root aneurysms. A systematic literature review was conducted using PubMed regarding the outcomes of the Bentall procedure compared with those of VSRR from the inception of the 2 procedures until July 2018. Studies with short- and long-term comparative data were included. An initial search yielded 9517 titles. Thirty-four studies were finally included for meta-analysis (all retrospective, non-randomized), comprising 7313 patients (2944 valve-sparing and 4369 Bentall procedures) with no evidence of publication bias. Operative mortality was found to be significantly lower in the VSRR group [odds ratio (OR) 0.51, 95% confidence interval (CI) 0.37–0.70; P < 0.001] despite overall higher cardiopulmonary bypass and aortic cross-clamp times. The 5-year survival rate was also more favourable in the VSRR group (OR 1.93 95% CI 1.15–3.23; P < 0.05). Significantly lower rates of cerebral thromboembolism (OR 0.668, 95% CI 0.477–0.935; P = 0.019) and heart block (OR 0.386, 95% CI 0.195–0.767; P = 0.007) were also found after VSRR. There was no significant difference in rates of reoperation between the groups at long-term follow-up (OR 1.32, 95% CI 0.75–2.33; P = 0.336). Meta-regression of patient and operative covariates yielded no influence on the main outcomes (P > 0.05). These findings suggest that VSRR is an appropriate and potentially better treatment option for a root aneurysm when the aortic valve is repairable.
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Affiliation(s)
| | - Iakovos Theodoulou
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Priyanka Iyer
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | | | - Danial Naqvi
- Faculty of Medicine, Imperial College London, London, UK
| | | | - Aung Oo
- Department of Cardiac Surgery, Barts Heart Centre, St. Bartholomew's Hospital, London, UK
| | - Thanos Athanasiou
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
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Aubin H, Akhyari P, Rellecke P, Pawlitza C, Petrov G, Lichtenberg A, Kamiya H. Valve-Sparing Aortic Root Replacement as First-Choice Strategy in Acute Type a Aortic Dissection. Front Surg 2019; 6:46. [PMID: 31448282 PMCID: PMC6691777 DOI: 10.3389/fsurg.2019.00046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/22/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Although, in theory, valve-sparing aortic root replacement (David procedure) is an ideal surgical option for acute aortic dissection type A (AADA) it is usually not regarded as the first-choice treatment due to the emergency setting and the relative complexity of the procedure. Here, we report the results of a consecutive, single-surgeon series of 45 AADA patients with the David procedure as first-choice treatment strategy. Methods and Results: Between September 2009 and July 2013 a total of 49 patients with AADA were consecutively operated by the same surgeon at our institution. The David procedure was the treatment of choice for the proximal aorta unless aortic valve pathology or critical preoperative patient status advocated against it. Median follow-up was 5.0 years (CI95%, 4.0-6.0). Out of the 45 patients included in this study the David procedure was performed in 28 patients (62.2%), while in 17 patients (37.8%) an alternative surgical strategy had to be pursued. Although X-clamping (168.5 ± 41.7 vs. 110.3 ± 51.1 min; p = 0.001), cardiopulmonary bypass (CPB) (245.0 ± 62.4 vs. 211.8 ± 123 min; p = 0.029) and total operation time (383.8 ± 88.5 vs. 312.8 ± 144.8; p = 0.047) were significantly longer in the David-group as compared to the non-David group, there was no difference in major complication rate as well as 30-day (17.9 vs. 23.5%; p = 0.645) and 5-year mortality (28.6 vs. 35.3%) between groups. Conclusions: This small series indicates that the David procedure may be safe and feasible as a primary surgical treatment strategy for AADA.
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Affiliation(s)
- Hug Aubin
- Department of Cardiovascular Surgery, University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiovascular Surgery, University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Philipp Rellecke
- Department of Cardiovascular Surgery, University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Christina Pawlitza
- Department of Cardiovascular Surgery, University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - George Petrov
- Department of Cardiovascular Surgery, University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiovascular Surgery, University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
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Wu J, Huang Y, Qiu J, Saeed B, Yu C. Is valve-sparing root replacement a safe option in acute type A aortic dissection? A systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2019; 29:766-775. [PMID: 31365078 DOI: 10.1093/icvts/ivz180] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/18/2019] [Accepted: 06/24/2019] [Indexed: 12/26/2022] Open
Abstract
AbstractOBJECTIVESThere are conflicting views regarding the status of valve-sparing root replacement (VSRR) as a proper treatment for acute type A aortic dissection (AAAD). Our goal was to compare the early and late outcomes of VSRR versus those of the Bentall procedure in patients with AAAD.METHODSWe performed a systematic review and meta-analysis of 9 studies to compare the outcomes of VSRR with those of the Bentall procedure in patients with AAAD. We focused on the following issues: early and late mortality rates, re-exploration, thromboembolization/bleeding events, infective endocarditis and reintervention rates.RESULTSA total of 706 patients with AAAD who underwent aortic root surgery were analysed; 254 patients were treated with VSRR and 452 with the Bentall procedure. VSRR was associated with a reduced risk of early death [odds ratio (OR) 0.34; 95% confidence interval (CI) 0.21–0.57] and late death (OR 0.34; 95% CI 0.21–0.57) compared with the Bentall procedure. No statistically significant difference was observed between the VSRR and Bentall groups with pooled ORs (OR 0.77; 95% CI 0.47–1.27, OR 0.61; 95% CI 0.32–1.18 and OR 0.71; 95% CI 0.23–2.15) for re-exploration, thromboembolization/bleeding and postoperative infective endocarditis, respectively. An increased risk of reintervention was observed for the VSRR compared to the Bentall group (OR 3.79; 95% CI 1.27–11.30). The pooled rate of reintervention incidence was 1.6% (95% CI 0.0–3.7%) and 0.4% (95% CI 0.0–1.3%) for the VSRR and the Bentall groups, respectively.CONCLUSIONSVSRR in patients with AAAD can be performed in experienced centres with excellent short- and long-term outcomes compared to those with the Bentall procedure and thus should be recommended especially for active young patients.
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Affiliation(s)
- Jinlin Wu
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Huang
- School of Acu-moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Juntao Qiu
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bilal Saeed
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Cuntao Yu
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Al-Adhami A, Harky A, Bashir M, Kolvekar S. Replacing the ascending aorta in the elderly: do or do not. Indian J Thorac Cardiovasc Surg 2019; 35:106-111. [PMID: 33061074 DOI: 10.1007/s12055-018-0734-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/15/2018] [Accepted: 08/17/2018] [Indexed: 01/16/2023] Open
Abstract
Advanced age is a proven independent factor for perioperative morbidity and mortality in all forms of aortic surgery and forms an important variable in most available risk scores. Improvements in selection and perioperative management of high-risk elderly cohorts have reduced the incidence of adverse outcomes. Concerns remain however in the surgical and anesthesiology community that exposing elderly frail patients to ascending aortic surgery is associated with significant risk. As with many clinical scenarios, individualization of care for each patient is of paramount importance. With advances in our understanding of perioperative and intraoperative care, age should no longer be considered in isolation as a contraindication to ascending aortic surgery.
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Affiliation(s)
- Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, G81 4DY UK
| | - Amer Harky
- Department of Vascular Surgery, Countess of Chester, Chester, CH1 2UL UK
| | - Mohamad Bashir
- Department of Aortovascular Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
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Karciauskas D, Mizariene V, Jakuska P, Ereminiene E, Orda P, Ordiene R, Vaskelyte JJ, Nedzelskiene I, Kinduris S, Benetis R. Early and long-term results of aortic valve sparing aortic root reimplantation surgery for bicuspid and tricuspid aortic valves. Perfusion 2019; 34:482-489. [DOI: 10.1177/0267659119831926] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: To evaluate early and long-term clinical outcomes following aortic valve sparing aortic root reimplantation surgery in patients with leaking bicuspid and tricuspid aortic valves. Methods: The study consisted of 92 consecutive adult patients (tricuspid aortic valve group = 63 and bicuspid aortic valve group = 29) who underwent aortic valve sparing aortic root reimplantation surgery with or without aortic cusp repair for dilatation of the aortic root and/or aortic valve regurgitation at our institution from April 2004 to October 2016. Clinical outcomes were investigated using Kaplan–Meier and log-rank tests between groups. Results: The follow-up was 100% complete with a mean time of 5.3 ± 3.3 years. The 30-day in-hospital mortality was 3.1% in tricuspid aortic valve group and 3.4% in bicuspid aortic valve group patients. The overall survival rates at 10 years did not differ between bicuspid aortic valve and tricuspid aortic valve patient groups (96.6 ± 3.3% vs. 90.3 ± 4.2%, p = 0.3). Freedom from recurrent aortic valve regurgitation (>2+) at 10 years was 90.5 ± 4.1% in tricuspid aortic valve group and 75.7 ± 8.7% in bicuspid aortic valve group (p = 0.06). Freedom from aortic valve reoperation at 10 years was 100% in tricuspid aortic valve group and 83.9 ± 7.4% in bicuspid aortic valve group (p = 0.002). Conclusion: Aortic valve sparing aortic root reimplantation surgery is a safe and efficient technique, providing acceptable long-term survival with low rates of valve-related complications in both tricuspid aortic valve and bicuspid aortic valve patient groups. However, aortic valve reoperation rates at 10 years follow-up were higher in bicuspid aortic valve group patients compared to tricuspid aortic valve group patients.
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Affiliation(s)
- Dainius Karciauskas
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vaida Mizariene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Povilas Jakuska
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Egle Ereminiene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Paulius Orda
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rasa Ordiene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jolanta Justina Vaskelyte
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Irena Nedzelskiene
- Department of Dental and Oral Diseases, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Sarunas Kinduris
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimantas Benetis
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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30
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Valve-sparing root replacement in type A dissection: Age and experience matter. J Thorac Cardiovasc Surg 2018; 157:24-25. [PMID: 30557942 DOI: 10.1016/j.jtcvs.2018.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 11/21/2022]
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31
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Survival and reoperation after valve-sparing root replacement and root repair in acute type A dissection. J Thorac Cardiovasc Surg 2018; 156:2076-2082.e2. [DOI: 10.1016/j.jtcvs.2018.05.096] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 05/15/2018] [Accepted: 05/25/2018] [Indexed: 11/18/2022]
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Rosenblum JM, Leshnower BG, Moon RC, Lasanajak Y, Binongo J, McPherson L, Chen EP. Durability and safety of David V valve-sparing root replacement in acute type A aortic dissection. J Thorac Cardiovasc Surg 2018; 157:14-23.e1. [PMID: 30557940 DOI: 10.1016/j.jtcvs.2018.10.059] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 09/20/2018] [Accepted: 10/01/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Valve-sparing root replacement (VSRR) is an attractive option in type A aortic dissection (TAAD) repair for a young patient with normal cusp anatomy, but conventional root replacement using a composite valved-conduit (ROOT) remains the gold standard in this emergent clinical setting. We examine the long-term safety and durability of the David V VSRR compared with ROOT in TAAD repair. METHODS From March 2004 to April 2017, 136 patients underwent repair of acute TAAD using either ROOT (n = 77; 56.6%) or VSRR (n = 59; 43.4%). Annual echocardiograms were performed for follow-up in VSRR patients. Univariable regression, Kaplan-Meier, and competing risk analyses were performed. RESULTS Preoperative characteristics were similar between groups, except that VSRR patients were younger (mean age 43.5 ± 11.4 years VSRR vs 50.4 ± 3.0 years ROOT; P = .001). Both groups had similar rates of preoperative malperfusion or shock (29.3% VSRR vs 37.0% ROOT; P = .35) and ≥3+ aortic insufficiency (63% VSRR vs 76.8% ROOT). Thirty-day mortality in the VSRR group was 2/59 (3.4%) and 11/77 in the ROOT group (14.3%; P < .001). All-cause survival at 9 years was 92% (VSRR) and 59% (ROOT; P = .002). The incidence of aortic reintervention was similar between groups (20%-23% at 5 years; P = .81). At 9 years of follow-up, 5/52 (9.6%) VSRR patients had ≥2+ aortic insufficiency, and 1 patient required valve reintervention. CONCLUSIONS In highly-selected patients, the David V VSRR provides a safe repair of acute TAAD with concomitant root pathology and valve insufficiency. In our center, the incidence of valve-related reintervention at long-term follow-up is low after emergent repair.
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Affiliation(s)
- Joshua M Rosenblum
- Division of Cardiac Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga.
| | - Bradley G Leshnower
- Division of Cardiac Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Rena C Moon
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Yi Lasanajak
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Jose Binongo
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Ga
| | - LaRonica McPherson
- Division of Cardiac Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Edward P Chen
- Division of Cardiac Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
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Lee H, Cho YH, Sung K, Kim WS, Park KH, Jeong DS, Park PW, Lee YT. Clinical Outcomes of Root Reimplantation and Bentall Procedure: Propensity Score Matching Analysis. Ann Thorac Surg 2018; 106:539-547. [DOI: 10.1016/j.athoracsur.2018.02.057] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 01/29/2018] [Accepted: 02/20/2018] [Indexed: 11/28/2022]
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Mosbahi S, Stak D, Gravestock I, Burgstaller JM, Steurer J, Eckstein F, Ferrari E, Berdajs DA. A systemic review and meta-analysis: Bentall versus David procedure in acute type A aortic dissection. Eur J Cardiothorac Surg 2018; 55:201-209. [DOI: 10.1093/ejcts/ezy266] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/25/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Selim Mosbahi
- Department of General Surgery, County Hospital Freiburg, Freiburg, Switzerland
| | - Dushaj Stak
- Department of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Isaac Gravestock
- Horten Center for Patient-Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Jakob M Burgstaller
- Horten Center for Patient-Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Johann Steurer
- Horten Center for Patient-Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Friedrich Eckstein
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Enrico Ferrari
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
- Department of Cardiac Surgery, Cardiocentro Ticcino, Lugano, Lugano, Switzerland
| | - Denis A Berdajs
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
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35
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Yang B, Patel HJ, Sorek C, Hornsby WE, Wu X, Ward S, Thomas M, Driscoll A, Waidley VA, Norton EL, Likosky DS, Deeb GM. Sixteen-Year Experience of David and Bentall Procedures in Acute Type A Aortic Dissection. Ann Thorac Surg 2018; 105:779-784. [DOI: 10.1016/j.athoracsur.2017.09.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 08/07/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022]
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Tanaka H, Ikeno Y, Abe N, Takahashi H, Inoue T, Okita Y. Outcomes of valve-sparing root replacement in acute Type A aortic dissection. Eur J Cardiothorac Surg 2018; 53:1021-1026. [DOI: 10.1093/ejcts/ezx463] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/28/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hiroshi Tanaka
- Department of Cardiovascular Surgery, Kobe University, Kobe, Japan
| | - Yuki Ikeno
- Department of Cardiovascular Surgery, Kobe University, Kobe, Japan
| | - Noriyuki Abe
- Department of Cardiovascular Surgery, Kobe University, Kobe, Japan
| | | | - Takeshi Inoue
- Department of Cardiovascular Surgery, Kobe University, Kobe, Japan
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University, Kobe, Japan
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Kunihara T, Neumann N, Kriechbaum SD, Nomura R, Schäfers HJ. Long-Term Outcome of Aortic Root Remodeling for Patients With and Without Acute Aortic Dissection. Circ J 2017; 81:1824-1831. [PMID: 28652531 DOI: 10.1253/circj.cj-17-0182] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Valve-preserving aortic surgery is increasingly used in acute aortic dissection type A (AADA). The object of this study was to compare the long-term results of aortic root remodeling (remodeling) for patients with and without AADA.Methods and Results:Between October 1995 and December 2013, 776 patients underwent valve-preserving root replacement, of whom 59 patients with AADA (<2 weeks from onset, 56±16 years, 48 male) underwent remodeling (the remodeling-group); 7 patients had bicuspid anatomy (12%), 3 had Marfan syndrome (5%), and 1 had undergone previous cardiac surgery (2%). For this analysis the control group of patients who underwent remodeling for stable aneurysm (n=59) was generated using a propensity score matching. The long-term outcomes regarding survival and reoperation on the aortic valve were compared between the 2 groups. Pre- and intraoperative patients' characteristics were comparable between groups. Early death was 7% in the AADA group and 3% in the control group (P=0.40). Actuarial survival at 10 years of the AADA group (72±6%) was insignificantly lower than that of the control group (83±5%) (P=0.16). Freedom from reoperation at 10 years was similar (AADA group: 98±2%, control group: 97±3%, P=0.99). Multivariable Cox's proportional hazards model could not identify an independent predictor for late reoperation but advanced age for late death. CONCLUSIONS Long-term stability of remodeling was comparable between patients with and without AADA.
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Affiliation(s)
- Takashi Kunihara
- Department of Cardiovascular Surgery, The Cardiovascular Institute
| | - Niklas Neumann
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center
| | | | - Ryota Nomura
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center
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Valve-sparing aortic root surgery. CON: remodeling. Gen Thorac Cardiovasc Surg 2017; 67:82-92. [DOI: 10.1007/s11748-017-0833-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/06/2017] [Indexed: 01/05/2023]
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39
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Leontyev S, Borger MA. David operation for type A aortic dissection: risks and rewards. Eur J Cardiothorac Surg 2017; 52:325-326. [DOI: 10.1093/ejcts/ezx175] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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40
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Beckmann E, Martens A, Pertz J, Kaufeld T, Umminger J, Hanke JS, Schmitto JD, Cebotari S, Haverich A, Shrestha ML. Valve-sparing David I procedure in acute aortic type A dissection: a 20-year experience with more than 100 patients†. Eur J Cardiothorac Surg 2017; 52:319-324. [DOI: 10.1093/ejcts/ezx170] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 03/17/2017] [Indexed: 11/13/2022] Open
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Valdis M, Adams C, Chu MW, Kiaii B, Guo L. Comparison of outcomes of root replacement procedures and supracoronary techniques for surgical repair of acute aortic dissection. Can J Surg 2017; 60:198-204. [PMID: 28570214 PMCID: PMC5453763 DOI: 10.1503/cjs.009116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2016] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Surgical approach to type A acute aortic dissection (AADA) is usually dictated by the presenting anatomy. We compared long-term outcomes of AADA repaired with a root replacement versus a supracoronary tube graft, regardless of the proximal extent of the intimal tear. METHODS A single-centre, retrospective cohort of consecutive patients undergoing repair of AADA between December 1999 and March 2012 were stratified based on the proximal surgical procedure performed: supracoronary tube graft or root replacement. Imaging, chart reviews and clinical follow-ups were analyzed to identify the presenting anatomy and clinical outcomes. RESULTS We included the cases of 75 patients in our analysis: 54 received a supracoronary tube graft and 21 received a root replacement. The proximal tear was identified below the sinotubular junction in all patients in the root group and in 61% of patients in the supracoronary group. We detected no differences between the groups for in-hospital mortality, length of stay, or complications. However, the root group had significantly increased renal failure (0% v. 9.5%, p = 0.018), cardiopulmonary bypass time (198.4 ± 80.0 min v. 316.5 ± 102.5 min, p < 0.001), cross-clamp time (91.6 ± 34.9 min v. 191.3 ± 52.8 min, p < 0.001), duration of surgery (457.5 ± 129.9 min v. 611.6 ± 197.8 min, p < 0.001), and platelet transfusions (8.1 ± 7.6 v. 12.8 ± 8.7 units, p = 0.021) than the supracoronary group. Long-term follow-up demonstrated a greater incidence of 2+ aortic regurgitation among patients in the supracoronary group than the root group (29.7% v. 0.0%, p = 0.006); however, there was no difference between the groups in symptoms or reoperation. CONCLUSION In AADA, aortic root replacement involves a longer procedure with increased risk of early renal impairment. Long-term follow-up identified significantly more aortic regurgitation and root dilation in the supracoronary group than the root group, with a trend toward worse long-term survival. However, we found no difference between the groups in mortality, reoperation or New York Heart Association class.
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Affiliation(s)
- Matthew Valdis
- From the Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, Ont
| | - Corey Adams
- From the Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, Ont
| | - Michael W.A. Chu
- From the Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, Ont
| | - Bob Kiaii
- From the Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, Ont
| | - Linrui Guo
- From the Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, Ont
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Kamohara K, Koga S, Takaki J, Yoshida N, Furukawa K, Morita S. Long-term durability of preserved aortic root after repair of acute type A aortic dissection. Gen Thorac Cardiovasc Surg 2017; 65:441-448. [DOI: 10.1007/s11748-017-0783-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/11/2017] [Indexed: 12/01/2022]
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Javadikasgari H, Roselli EE, Aftab M, Suri RM, Desai MY, Khosravi M, Cikach F, Isabella M, Idrees JJ, Raza S, Tappuni B, Griffin BP, Svensson LG, Gillinov AM. Combined aortic root replacement and mitral valve surgery: The quest to preserve both valves. J Thorac Cardiovasc Surg 2017; 153:1023-1030.e1. [DOI: 10.1016/j.jtcvs.2017.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 12/28/2016] [Accepted: 01/18/2017] [Indexed: 11/26/2022]
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Liu L, Qin C, Hou J, Zhu D, Zhang B, Ma H, Guo Y. One-stage hybrid surgery for acute Stanford type A aortic dissection with David operation, aortic arch debranching, and endovascular graft: a case report. J Thorac Dis 2017; 8:E1597-E1601. [PMID: 28149590 DOI: 10.21037/jtd.2016.12.81] [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: 02/05/2023]
Abstract
Acute Stanford type A aortic dissection requires an extremely complex surgical strategy and presents high risk of complications. Although many different procedures were reported to treat this aortic dissection, high mortality rate and incidences of complications still exist. This study presents a 59-year-old lady with acute Stanford type A aortic dissection, which originated from the aortic root to proximal part of right external iliac artery and involved the brachiocephalic trunk, left carotid artery, celiac trunk, and left renal artery. The patient underwent one-stage hybrid surgery of David procedures, debranching, and endovascular aortic repair under ultrasound-guided aortic arch cannulation cardiopulmonary bypass (CPB). The surgery was successfully performed, and the patient showed no post-operative complication. The one-staged hybrid surgery of David procedures, debranching, and endovascular aortic repair provides novel and well-designed combined techniques for treating complex acute Stanford type A aortic dissection. Our techniques significantly lowered the risks, thereby expanding the indications of surgical intervention for acute Stanford type A aortic dissection.
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Affiliation(s)
- Lulu Liu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Chaoyi Qin
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jianglong Hou
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Da Zhu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Bengui Zhang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Hao Ma
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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Settepani F, Cappai A, Basciu A, Barbone A, Moz M, Citterio E, Ornaghi D, Tarelli G. Impact of Cusp Repair on Reoperation Risk After the David Procedure. Ann Thorac Surg 2016; 102:1503-1511. [DOI: 10.1016/j.athoracsur.2016.04.061] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/31/2016] [Accepted: 04/18/2016] [Indexed: 11/28/2022]
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Gunn TM, Stamou SC, Kouchoukos NT, Lobdell KW, Khabbaz K, Patzelt LH, Hagberg RC. Techniques of Proximal Root Reconstruction and Outcomes Following Repair of Acute Type A Aortic Dissection. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2016; 4:33-41. [PMID: 27757401 DOI: 10.12945/j.aorta.2016.14.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 02/04/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The goal of this study was to compare the early and late outcomes of different techniques of proximal root reconstruction during the repair of acute Type A aortic dissection, including aortic valve (AV) resuspension, aortic valve replacement (AVR), and a root replacement procedure. METHODS All patients who underwent acute Type A aortic dissection repair between January 2000 and October 2010 at four academic institutions were compiled from each institution's Society of Thoracic Surgeons Database. This included 189 patients who underwent a concomitant aortic valve (AV) procedure; 111, 21, and 57 patients underwent AV resuspension, AVR, and the Bentall procedure, respectively. The median age of patients undergoing a root replacement procedure was significantly younger than the other two groups. Early clinical outcomes and 10-year actuarial survival rates were compared. Trends in outcomes and surgical techniques throughout the duration of the study were also analyzed. RESULTS The operative mortality rates were 17%, 29%, and 18%, for AV resuspension, AVR, and root replacement, respectively. Operative mortality (p = 0.459) was comparable between groups. Hemorrhage related re-exploration did not differ significantly between groups (p = 0.182); however, root replacement procedures tended to have decreased rates of bleeding when compared to AVR (p = 0.067). The 10-year actuarial survival rates for the AV resuspension, Bentall, and AVR groups were 72%, 56%, and 36%, respectively (log-rank p = 0.035). CONCLUSIONS The 10-year actuarial survival was significantly lower in those receiving AVR compared to those receiving root replacement procedures or AV resuspension. Operative mortality was comparable between the three groups.
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Affiliation(s)
- Tyler M Gunn
- Department of Cardiothoracic Surgery, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Sotiris C Stamou
- Department of Cardiothoracic Surgery, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Nicholas T Kouchoukos
- Division of Cardiothoracic Surgery, Missouri Baptist Medical Center, Saint Louis, Missouri, USA
| | - Kevin W Lobdell
- Department of Thoracic and Cardiovascular Surgery, Sanger Heart and Vascular Institute, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Kamal Khabbaz
- Division of Cardiothoracic Surgery, Department of Surgery and The Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lawrence H Patzelt
- Thoracic and Cardiovascular Surgery, Spectrum Health, Fred and Lena Meijer Heart and Vascular Institute, Grand Rapids, Michigan, USA
| | - Robert C Hagberg
- Department of Cardiac Surgery, Hartford Hospital, Hartford, Connecticut, USA
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Chiu P, Miller DC. Evolution of surgical therapy for Stanford acute type A aortic dissection. Ann Cardiothorac Surg 2016; 5:275-95. [PMID: 27563541 DOI: 10.21037/acs.2016.05.05] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small? The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results.
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Affiliation(s)
- Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, CA, USA
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, CA, USA
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Leshnower BG, Chen EP. When and how to replace the aortic root in type A aortic dissection. Ann Cardiothorac Surg 2016; 5:377-82. [PMID: 27563551 DOI: 10.21037/acs.2016.03.15] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Management of aortic root pathology during repair of acute type A aortic dissection (TAAD) requires a comprehensive evaluation of the patient's anatomy, demographics, comorbidities and physiologic status at the time of emergent operative intervention. Surgical options include conservative repair of the root (CRR) (with or without replacement of the aortic valve), replacement of the native valve and aortic root using a composite valve-conduit and valve sparing root replacement (VSRR). The primary objective of this review is to provide data for surgeons to aid in their decision-making process regarding management of the aortic root during repair of TAAD. No time or language restrictions were imposed and references of the selected studies were checked for additional relevant citations. Multiple retrospective reviews have demonstrated equivalent operative mortality between aortic root repair and replacement during TAAD. There is a higher incidence of aortic root reintervention with aortic root repair compared to aortic root replacement (ARR). Experienced, high-volume aortic centers have demonstrated the safety of VSRR in young, hemodynamically stable patients presenting with TAAD. In conclusion, aortic root repair can safely be performed in the vast majority of patients with TAAD. Despite the increased surgical complexity, ARR does not increase operative mortality and improves the freedom from root reintervention. VSRR can be performed in highly selected populations of patients with TAAD with durable mid-term valve function.
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Affiliation(s)
- Bradley G Leshnower
- Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Aortic root remodeling leads to good valve stability in acute aortic dissection and preexistent root dilatation. J Thorac Cardiovasc Surg 2016; 152:430-436.e1. [DOI: 10.1016/j.jtcvs.2016.03.076] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 03/27/2016] [Accepted: 03/30/2016] [Indexed: 11/21/2022]
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