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Di Marco L, Gliozzi G, Votano D, Murana G, Leone A, Cavalli GG, Brillanti G, Pacini D. Reoperations on the ascending aorta and aortic arch: A retrospective series of 453 patients. J Thorac Cardiovasc Surg 2024; 167:897-907.e3. [PMID: 35690473 DOI: 10.1016/j.jtcvs.2022.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 02/22/2022] [Accepted: 03/09/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The study objective was to analyze the outcomes of reoperative thoracic aortic surgery at our institution from January 1986 to December 2018 to identify specific risk factors for early and late mortality. METHODS Two groups of patients were identified: aortic root or ascending aorta repair (group 1: proximal repair, 218 patients, 48%) and arch surgery or descending thoracic aorta repair (group 2: distal repair, 235 patients, 52%). Primary end points were 30-day mortality, 10-year survival, and freedom from aortic reoperations. RESULTS The 30-day mortality (6.4% vs 8.1%) and in-hospital mortality (8.3% vs 11.9%) were similar (P > .05) in the 2 groups. Multivariable analysis identified female gender (odds ratio, 8.60, P < .01), endocarditis (odds ratio, 2.96, P = .04), and cardiopulmonary bypass time (odds ratio, 1.02, P < .01) as risk factors for 30-day mortality. Mean follow-up time was 163 months (confidence interval, 147-179). Long-term survival at 1, 5, and 10 years was 91.2%, 79.4%, and 66.3% in the proximal repair group and 80.7%, 68.8%, the and 55.3% in distal repair group, respectively (P = .03). According to the indication, 1-, 5-, and 10-year survivals were 92.1%, 82.3%, and 68.8% in degenerative aneurysms; 82.7%, 72.4%, and 56.3% in residual dissections; 80.9%, 65.4%, and 50.3% in endocarditis and pseudoaneurysms; 69.2%, 52.7%, and 42.2% in acute type A aortic dissections, respectively (P < .01). Competing risk analysis showed a significantly different cumulative incidence of reoperation at 1, 5, and 10 years between the 2 groups: 0.50%, 0.50%, and 0.90%, respectively, for the proximal repair group, and 0.40%, 4.30%, and 7.70%, respectively, the for distal repair group (P < .01). CONCLUSIONS In our experience, short- and long-term results of reoperative thoracic aortic surgery were satisfactory in chronic aneurysms but poor in aortic dissections, pseudoaneurysms, and active endocarditis. Reoperative aortic surgery carries a high risk, regardless of the anatomic extension of the procedure.
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Affiliation(s)
- Luca Di Marco
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy.
| | - Gregorio Gliozzi
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy
| | - Daniela Votano
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy
| | - Giacomo Murana
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy
| | - Alessandro Leone
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy
| | - Giulio Giovanni Cavalli
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy
| | - Giorgia Brillanti
- Division of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy
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Patel PM, Levine D, Dong A, Yamabe T, Wei J, Binongo J, Leshnower BG, Takayama H, Chen EP. True redo-aortic root replacement versus root replacement after any previous surgery. JTCVS OPEN 2023; 16:167-176. [PMID: 38204664 PMCID: PMC10775063 DOI: 10.1016/j.xjon.2023.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/08/2023] [Accepted: 08/28/2023] [Indexed: 01/12/2024]
Abstract
Objective The impact of previous aortic root replacement (True-Redo) versus any previous operation (Any-Redo) on outcomes after reoperative aortic root replacement (redo-ROOT) is largely unknown. In this first multi-institutional study, the clinical impact True-Redo versus Any-Redo in the setting of redo-ROOT was reviewed. Methods From 2004 to 2021, 822 patients underwent redo-ROOT at 2 major academic centers: 638 Any-Redo and 184 True-Redo. Matching based on preoperative demographics and concomitant operations resulted in 174 matched pairs. An independent risk factor analysis was performed to determine risk factors for early and late mortality. Results Patients in the True-Redo group were younger, at 49.9 ± 15.1 versus 55.3 ± 14.7 years, P < .001. Concomitant operations were largely similar between the 2 groups, P > .05. Median cardiopulmonary bypass time (P < .001) and aortic crossclamp time (P = .03) were longer for True-Redo group. In-hospital mortality was 13% (109) and was without significant difference between groups, P = .41. Ten-year survival was 78% versus 76% for True-Redo versus Any-Redo groups respectively, P = .7. Landmark survival analysis at 4 years' postoperatively on the matched groups found that patients in the True-Redo group had improved survival outcomes (P = .046). Risk factors of in-hospital mortality consisted of older age (P < .0001), lower ejection fraction (P = .02), and male patient (P = .0003). Conclusions Clinical outcomes following redo-ROOT are excellent. Performance of a True-Redo-ROOT does not result in worse in-hospital morbidity or mortality and has improved survival benefit at midterm follow-up when compared with patients in the Any-Redo group. The decision to perform a redo-ROOT must be taken seriously and must be individualized in a patient-specific manner for optimal outcomes.
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Affiliation(s)
- Parth M. Patel
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Dov Levine
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Andy Dong
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Tsuyoshi Yamabe
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Jane Wei
- 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
| | - Bradley G. Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Hiroo Takayama
- Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Edward P. Chen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, NC
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Norton EL, Kalra K, Leshnower BG, Wei JW, Binongo JN, Chen EP. Redo aortic surgery: Does one versus multiple affect outcomes? JTCVS OPEN 2023; 16:158-166. [PMID: 38204648 PMCID: PMC10775125 DOI: 10.1016/j.xjon.2023.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/29/2023] [Accepted: 09/21/2023] [Indexed: 01/12/2024]
Abstract
Objective Redo aortic surgery has a higher risk of morbidity and mortality because it is technically complex due to mediastinal adhesions, infection, and previously implanted prostheses. In this study, we sought to benchmark our single-center experience comparing outcomes in patients undergoing aortic surgery after 1 versus multiple previous cardiac operations. Methods Between 2004 and 2019, 429 patients underwent redo aortic surgery. They were classified as aortic surgery after 1 previous surgery (first redo surgery, n = 360) and aortic surgery after 2 or more (multiple) previous surgeries (multiple redo surgery, n = 69). Postoperative outcomes and long-term survival were compared, and risk factors for mortality were identified. Results Thirty-day mortality was lower in first redo surgery compared with multiple redo surgery (12.3% vs 21.7%, P = .03). Age, cardiopulmonary bypass time, intra-aortic balloon pump use, postoperative cerebrovascular accident, absence of postoperative atrial fibrillation, intra-aortic balloon pump, and multiple redo surgery were independent predictors of 30-day mortality. Long-term survival was similar at 15 years. Patients who received first redo surgery were older (57.9 ± 14.0 years vs 50.3 ± 15.8 years, P = .0001) and had a higher incidence of hypertension (84.7% vs 73.9%, P = .02), whereas patients who received multiple redo surgery had a higher incidence of cerebrovascular disease (31.9% vs 20.3%, P = .03). Aortic valve replacement was the most common previous operation with higher incidence in multiple redo surgery. Incidence of previous aortic surgery was similar. Cardiopulmonary bypass (246 ± 67.3 minutes vs 219.9 ± 57.5 minutes, P = .009) and crossclamp times (208.2 ± 51.8 vs 181.9 ± 50.8 minutes, P = .004) were longer in multiple redo surgery. Incidence of reentry injury and balloon pump insertion were similar. Extracorporeal membrane oxygenation use was higher in multiple redo surgery. Postoperative complications occurred at similar rates, except for higher incidence of dialysis in multiple redo surgery (14.5% vs 7.2%, P = .04). Conclusions Multiple redo aortic procedures have a higher morbidity and mortality compared with first redo aortic procedures, with linearly increasing short-term mortality risk but similar long-term survival with the number of redo procedures.
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Affiliation(s)
- Elizabeth L. Norton
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Kanika Kalra
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Bradley G. Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Jane W. Wei
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Jose N. Binongo
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Edward P. Chen
- Division of Cardiothoracic Surgery, Duke University School of Medicine, Durham, NC
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Vekstein AM, Hughes GC, Chen EP. Open arch surgery in the redo setting: contemporary outcomes. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:415-424. [PMID: 35621063 DOI: 10.23736/s0021-9509.22.12388-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Aortic arch reconstruction after prior cardiac surgery is technically complex, especially after proximal aortic surgery. While multiple surgical adaptations in the redo setting have been described, traditional open reconstruction remains the most common approach with significant variability in outcomes in prior reports. This study describes institutional adaptations to surgical technique and perioperative care and assesses operative and long-term outcomes after redo-aortic arch repair in the modern era. METHODS Patients undergoing hemi- or total arch reconstruction after prior cardiac surgery (2005-2022) were identified from a prospectively maintained institutional database. Strategic adaptations in approach over the study interval included a shift towards Type II hybrid arch repair for patients with "mega-aorta," redo-cannulation of the axillary artery when necessary, and adoption of transfusion and early extubation protocols. Outcomes of interest included 30-day/in-hospital adverse events and actuarial long-term overall and aorta-specific survival. RESULTS The study cohort included 214 patients undergoing hemi-arch (N.=154, 72%) or total arch (N.=60, 28%) after prior cardiac surgery (50% prior proximal aortic surgery). Surgical indications included degenerative aneurysm (47%, N.=101), residual arch dissection after prior type A repair (29%, N.=61), acute or chronic type A dissection (18%, N.=39) or other (6%, N.=13). 30-day/in-hospital mortality was 6% (5% hemi-arch; 10% total arch) and stroke was 3% (3% hemi-arch; 2% total arch). At median follow-up of 56 months, overall 5- and 10-year survival was 76% and 58% (hemi-arch: 81%, 62%; total arch: 63%, 43%); aorta-specific survival was 91% and 90% (hemi-arch: 96%, 94%; total arch: 79%, 79%). CONCLUSIONS In this modern single-institution series, a systematic approach to redo-arch repair yields excellent operative outcomes and late aorta-specific survival. Reduced late overall survival reflects the comorbidity burden of this population. Open reconstruction continues to play an important role in reoperative arch repair in the modern era.
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Affiliation(s)
- Andrew M Vekstein
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA -
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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5
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OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6553745. [DOI: 10.1093/icvts/ivac058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/24/2022] [Indexed: 11/13/2022] Open
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Risteski P, Radacki I, Zierer A, Lenos A, Moritz A, Urbanski PP. Reoperative Aortic Arch Surgery under Mild Systemic Hypothermia: Two-Center Experience. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2021; 9:60-66. [PMID: 34619801 PMCID: PMC8526143 DOI: 10.1055/s-0041-1725073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The aim of the study was to assess the indications, surgical strategies, and outcomes after reoperative aortic arch surgery performed generally under mild hypothermia. METHODS Ninety consecutive patients (60 males, mean age, 55 ± 16 years) underwent open reoperative aortic arch surgery after previous cardiac aortic surgery. The indications included chronic-progressive arch aneurysm (55.5%), chronic aortic dissection (17.8%), contained arch rupture (16.7%), and graft infection (10%). The reoperation was performed through a repeat sternotomy (96%) or clamshell thoracotomy (4%) using antegrade cerebral perfusion under mild systemic hypothermia (28.9 ± 2.5°C) in all except three patients. RESULTS The surgery comprised hemiarch or total arch replacement in 41 (46%) and 49 (54%) patients, respectively. The distal extension included classic or frozen elephant trunk technique, each in 12 patients, and total descending aorta replacement in 4 patients. Operative mortality was 6 (6.7%) among all patients, with age identified as the only independent predictor of operative mortality (p = 0.05). Permanent and transient neurologic deficits occurred in 1% and 9% of the patients, respectively. Estimated survival at 8 years was 59 ± 8% with advanced heart failure predictive for late mortality (p = 0.014). Freedom from second reoperation or intervention on the aorta was 78 ± 6% at 8 years, with most of these events occurring downstream in patients with chronic degenerative aneurysms. CONCLUSION Aortic arch reoperations performed using antegrade cerebral perfusion under mild systemic hypothermia offer favorable operative outcomes with an exceptionally low rate of neurologic morbidity without any difference between hemiarch and complex arch procedures.
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Affiliation(s)
- Petar Risteski
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Isabel Radacki
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Andreas Zierer
- Department of Cardiac, Vascular, and Thoracic Surgery, Kepler University Hospital, Linz, Austria
| | - Aris Lenos
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Anton Moritz
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Paul P Urbanski
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
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Lou X, Leshnower BG, Binongo J, Beckerman Z, McPherson L, Chen EP. Re-Operative Aortic Arch Surgery in a Contemporary Series. Semin Thorac Cardiovasc Surg 2021; 34:377-382. [PMID: 33971297 DOI: 10.1053/j.semtcvs.2021.03.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/04/2021] [Indexed: 11/11/2022]
Abstract
Re-operative aortic arch operations (REDO) following previous cardiac surgery are challenging procedures associated with significant morbidity and mortality. We investigated post-operative outcomes for patients undergoing REDO and identified risk-factors for mortality in a contemporary series. From 1/2005-6/2018, 365 consecutive patients at an academic center underwent REDO: 257 HEMIARCH and 108 COMPLETE arch (45 stage I elephant trunk, 63 total arch) replacements. Outcomes included mortality and major adverse events. Long-term survival was determined with Kaplan-Meier analysis, and risk-factors for mortality were assessed with Cox proportional hazards regression. Operative mortality for the entire cohort was 6.8%, and rates of stroke, cardiac arrest, and renal failure were 6.0%, 7.4%, and 10.4%. Compared to HEMIARCH, COMPLETE patients had an increased incidence of renal failure requiring dialysis (15.7% vs 8.2%, p = 0.031) and re-exploration for bleeding or delayed chest closure (19.4% vs. 11.7%, p = 0.051). Although operative mortality was similar in both cohorts, long-term follow-up mortality (38.0% vs 26.8%, p = 0.047) was higher among COMPLETE vs. HEMIARCH. Predictors of overall mortality among all-comers undergoing REDO included older age, low body surface area, endocarditis, ejection fraction <30%, emergent status of operation, extended cardiopulmonary bypass duration, intra-aortic balloon pump use, and a more extensive arch operation. Previous aortic surgery was not a risk-factor for mortality. Among all-comers undergoing REDO, survival was 81.4% at 1 year, 66.7% at 5 years, and 56.4% at 10 years of follow-up. While early postoperative outcomes are similar among HEMIARCH and COMPLETE, a more extensive arch-replacement is an independent risk-factor for overall mortality in REDO. Using appropriate clinical indications in the current era, REDO remains a viable option for selected patients.
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Affiliation(s)
- Xiaoying Lou
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jose Binongo
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ziv Beckerman
- Dell Children's Medical Center, The University of Texas at Austin
| | - LaRonica McPherson
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
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Ohira S, Malekan R, Kai M, Goldberg JB, Spencer PJ, Lansman SL, Spielvogel D. Reoperative Total Arch Repair Using a Trifurcated Graft and Selective Antegrade Cerebral Perfusion. Ann Thorac Surg 2021; 113:569-576. [PMID: 33857494 DOI: 10.1016/j.athoracsur.2021.03.090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/23/2021] [Accepted: 03/29/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND This study reviews the outcomes of our reoperative total arch repair (TAR) technique using a trifurcated graft and selective antegrade cerebral perfusion (SACP). METHODS Fifty patients underwent reoperative TAR from January 2005 to September 2020, with either a one-stage (N=9), or two-stage repair (N=41). The two-stage technique includes minimal dissection of the mediastinal structures, an arch-first technique using a trifurcated graft, and construction of a classical elephant trunk via a partial transverse incision distally in the old-graft or in the aorta just distal to the old graft. RESULTS The median age was 63 years. Chronic dissection was the most frequent indication (88%) and 98% had undergone a previous proximal aortic repair at a median interval of 3.0 years. The median cardiopulmonary bypass, myocardial ischemic, SACP, and lower body circulatory arrest times were 226, 103, 97, and 98 minutes, respectively. The minimum nasopharyngeal and bladder temperature were 16.5 °C, and 20.0 °C. Operative mortality was 2% and the incidence of stroke, and spinal cord injury (SCI) were 2%, and 0%. Stage II repair was performed in 37 patients (open: 33 patients, endovascular: 4 patients), with two mortalities and no SCI. The median duration between stage I and II was 63 days. Survival and aortic event free rates at 3 years were 88.4 ±4.9%, and 89.8 ±5.0%. CONCLUSIONS We report a reoperative TAR technique that minimizes dissection of the cardiac structures, simplifies the distal anastomosis, and protects vital organs, such as the brain, heart, and spinal cord.
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Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY.
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Joshua B Goldberg
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Philip J Spencer
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Steven L Lansman
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
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Shea NJ, D'Angelo AM, Polanco AR, Allen P, Sanchez JE, Kurlansky P, Patel VI, Takayama H. Higher Institutional Volume Reduces Mortality in Reoperative Proximal Thoracic Aortic Surgery. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 8:59-65. [PMID: 33152786 PMCID: PMC7644294 DOI: 10.1055/s-0040-1713860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective
This study aims to determine the impact of institutional volume on mortality in reoperative proximal thoracic aortic surgery patients using national outcomes data.
Methods
The Nationwide Inpatient Sample was queried from 1998 to 2011 for patients with diagnoses of thoracic aneurysm and/or dissection who underwent open mediastinal repair. A total of 103,860 patients were identified. A total of 1,430 patients had prior cardiac surgery. Patients were further stratified into groups by institutional aortic volume: low (<12 cases/year), medium (12–39 cases/year), and high (40+ cases/year) volume. Multivariable risk-adjusted analysis accounting for emergent status and aortic dissection among other factors was performed to determine the impact of institutional volume on mortality.
Results
Overall mortality was 12% in the reoperative population. When the redo cohort was divided into tertiles, high-volume group had a 5% operative mortality compared with 9 and 15% for the medium- and low-volume groups, respectively. Multivariable analysis revealed that patients operated on at low- (odds ratio [OR] = 5.0, 95% confidence interval [CI]: 2.6–9.6,
p
< 0.001) and medium-volume centers (OR = 2.1, 95% CI: 1.1–4.2,
p
= 0.03) had higher odds of mortality when compared with patients operated on at high-volume centers.
Conclusions
High-volume aortic centers can significantly reduce mortality for reoperative aortic surgery, compared with lower volume institutions.
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Affiliation(s)
- Nicholas J Shea
- Department of Surgery, New York-Presbyterian Hospital, Columbia University Aortic Surgery Center, Columbia University Irving Medical Center, New York, New York
| | - Alex M D'Angelo
- Department of Surgery, New York-Presbyterian Hospital, Columbia University Aortic Surgery Center, Columbia University Irving Medical Center, New York, New York
| | - Antonio R Polanco
- Department of Surgery, New York-Presbyterian Hospital, Columbia University Aortic Surgery Center, Columbia University Irving Medical Center, New York, New York
| | - Philip Allen
- Department of Surgery, New York-Presbyterian Hospital, Columbia University Aortic Surgery Center, Columbia University Irving Medical Center, New York, New York
| | - Joseph E Sanchez
- Department of Surgery, New York-Presbyterian Hospital, Columbia University Aortic Surgery Center, Columbia University Irving Medical Center, New York, New York
| | - Paul Kurlansky
- Department of Surgery, New York-Presbyterian Hospital, Columbia University Aortic Surgery Center, Columbia University Irving Medical Center, New York, New York
| | - Virendra I Patel
- Department of Surgery, New York-Presbyterian Hospital, Columbia University Aortic Surgery Center, Columbia University Irving Medical Center, New York, New York
| | - Hiroo Takayama
- Department of Surgery, New York-Presbyterian Hospital, Columbia University Aortic Surgery Center, Columbia University Irving Medical Center, New York, New York
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Sun GL, Sun LZ, Zhu JM, Liu YM, Ge YP, Xu SJ. Clinical characteristics and risk factors for fatal outcome of patients receiving Sun's procedure after previous cardiac surgery. Asian J Surg 2020; 44:87-92. [PMID: 32360296 DOI: 10.1016/j.asjsur.2020.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 01/14/2020] [Accepted: 03/25/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Cardiac reoperation has always been a difficult problem in clinical practice. Because of the difficulty of operation, the incidence of complications and mortality rate is high. Secondary aortic surgery, especially the reoperation involving arch, has higher risk and is more difficult for patients with renal failure. Sun's operation (total arch replacement + stent elephant nose) has achieved good results in the treatment of diseases involving aortic arch, and occupies an important position in the treatment of patients with secondary arch lesions after cardiac surgery. METHODS A total of 395 patients with a history of cardiac surgery were recorded in our center from January 1, 2009 to December 31, 2017, among whom 118 (30.1%) patients underwent aortic reoperation via the original incision using Sun's aortic procedure owing to postoperative great vessel disease. We analyzed the clinical data and survival time, and used Cox regression to analyze the risk factors for 30-day mortality as well as long term mortality. RESULTS The interval between the last operation and the present operation was 0.08-19 years. Sixteen patients died within 30 days after operation and the average mortality rate was 13.6%. During the follow-up period, 28 patients died, with the mortality rate of 23.7%. As of December 31, 2017, the longest survival time was 9.36 years, and the survival time of 70 patients was more than 3.05 years. The main risk factor associated with the 30-day survival was cardiopulmonary bypass (CPB) time. The longer the CPB time was, the greater the risk of death was. The main risk factors associated with the long-term survival were CPB time and 24-h bleeding volume. The longer the CPB time was, the more the 24-h bleeding volume was, the higher long-term mortality rate was. CONCLUSION The second Sun's operation, as a surgical treatment after cardiac surgery, showed a high survival rate, with long survival time and good curative effect. CPB is the main risk factor for the 30-day survival state after operation, and CPB time and 24-h bleeding volume are the main risk factors for the long-term survival state after operation.
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Affiliation(s)
- Guang-Long Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, 100029, Beijing, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, 100029, Beijing, China.
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, 100029, Beijing, China
| | - Yong-Min Liu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, 100029, Beijing, China
| | - Yi-Peng Ge
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, 100029, Beijing, China
| | - Shi-Jun Xu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, 100029, Beijing, China
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11
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Uchida T, Hamasaki A, Kuroda Y, Yamashita A, Sadahiro M. Simple Redo Proximal Thoracic Aortic Surgery with Peripheral Cardiopulmonary Bypass and Minimal Dissection. Ann Thorac Cardiovasc Surg 2020; 26:55-59. [PMID: 31554770 PMCID: PMC7046932 DOI: 10.5761/atcs.nm.19-00187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Reoperations on the proximal thoracic aorta are increasingly observed after previous aortic or cardiac operations. Redo proximal aortic surgery remains challenging with an increased mortality compared to first-time operations. For a successful redo proximal aortic surgery in a patient with complex pathological conditions, the surgical procedure and cardiopulmonary bypass (CPB) should be simplified as much as possible. Herein, we report our experience of proximal aortic reoperations in which the strategy consisted of an axillo-axillary (jugular) and a femoro-femoral CPB in combination with minimal dissection of surgical adhesions. Satisfactory full-flow CPB was achieved with peripheral cannulations and the aid of vacuum-assisted venous drainage. A suitable surgical view of the proximal aorta was obtained without dissection of the heart. There was no operative mortality and the peripheral CPB was well managed without technical problems. We consider that the proposed strategy makes proximal aortic reoperations safe and simple.
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Affiliation(s)
- Tetsuro Uchida
- Second Department of Surgery, Faculty of Medicine, Yamagata University, Yamagata, Yamagata, Japan
| | - Azumi Hamasaki
- Second Department of Surgery, Faculty of Medicine, Yamagata University, Yamagata, Yamagata, Japan
| | - Yoshinori Kuroda
- Second Department of Surgery, Faculty of Medicine, Yamagata University, Yamagata, Yamagata, Japan
| | - Atsushi Yamashita
- Second Department of Surgery, Faculty of Medicine, Yamagata University, Yamagata, Yamagata, Japan
| | - Mitsuaki Sadahiro
- Second Department of Surgery, Faculty of Medicine, Yamagata University, Yamagata, Yamagata, Japan
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12
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Piffaretti G, Grassi V, Lomazzi C, Brinkman WT, Navarro TP, Jenkins MP, Trimarchi S, Bernardes RC, Procopio RJ, Schneider JE, AbuRahma AF, Kaufman JA, Pearce BJ. Thoracic endovascular stent graft repair for ascending aortic diseases. J Vasc Surg 2019; 70:1384-1389.e1. [DOI: 10.1016/j.jvs.2019.01.075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/11/2019] [Indexed: 12/29/2022]
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13
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Serraino GF, Zanobini M, Beghi C, Maselli D, Bashir M, Mastroroberto P, Mariscalco G. Perspective. Reoperative Bentall: choice of conduits. Indian J Thorac Cardiovasc Surg 2019; 35:127-129. [PMID: 33061077 DOI: 10.1007/s12055-017-0607-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 10/06/2017] [Accepted: 10/12/2017] [Indexed: 11/24/2022] Open
Abstract
The Bentall procedure represents the gold standard in the treatment of patients requiring aortic root replacement. The most common indications for redo Bentall are structural degeneration or graft infection. Redo aortic root replacement can be performed with low perioperative morbidity and death. The choice of the best conduit is still up for debate but is mandatory to guarantee the best and most durable option for the patient. New options are available to reduce mortality in older or fragile patients and can modify the conduit choice.
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Affiliation(s)
- Giuseppe Filiberto Serraino
- Department of experimental and clinical medicine, University Magna Graecia of Catanzaro, Germaneto, Catanzaro Italy
| | - Marco Zanobini
- Cardiac Surgery Department, IRCCS Cardiologico Monzino, Milan, Italy
| | - Cesare Beghi
- Cardiac Surgical Department, Insubria University of Varese, Varese, Italy
| | - Daniele Maselli
- Cardiac Surgical Department, S.Anna Hospital, Catanzaro, Italy
| | - Mohamad Bashir
- Cardiothoracic Surgery, Barts Health NHS Trust, London, UK
| | - Pasquale Mastroroberto
- Department of experimental and clinical medicine, University Magna Graecia of Catanzaro, Germaneto, Catanzaro Italy
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital Groby Road, Leicester, UK
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14
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Abi Akar R, Tence N, Jouan J, Borik W, Menasché P, Fabiani JN, Latremouille C, Achouh P. Ten-year follow-up of unreplaced Valsalva sinuses after aortic valve replacement in bicuspid aortic valve disease. Arch Cardiovasc Dis 2019; 112:305-313. [DOI: 10.1016/j.acvd.2018.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 10/24/2018] [Accepted: 11/15/2018] [Indexed: 10/27/2022]
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15
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Gabel JA, Patel ST, Tomihama RT, Hasaniya NW, Abou-Zamzam AM, Kiang SC. Debranching of Supra-aortic Vessels via Femoral Artery Inflow for Late Ascending Aortic Rupture. Ann Vasc Surg 2018; 57:49.e1-49.e5. [PMID: 30476606 DOI: 10.1016/j.avsg.2018.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 11/28/2022]
Abstract
A 56-year-old man with a history of Marfan's syndrome, total arch replacement, descending thoracic endovascular aortic repair, and twice redo sternotomy for pseudoaneurysm repair, presented with a pulsatile chest mass secondary to a contained rupture of the ascending aorta. The patient underwent supra-aortic debranching via the superficial femoral artery and ascending thoracic stent-graft placement under continuous transesophageal echocardiography. Completion angiography demonstrated successful exclusion of the contained rupture. Postoperatively, the patient was neurologically intact, the pulsatile mass resolved, and the bypass grafts remained patent. Chronic respiratory failure and multidrug-resistant pneumonia led to late mortality. This case demonstrates that hybrid repair is effective in the emergent setting of ascending aortic rupture. Debranching of the ascending arch using the superficial femoral artery as inflow is feasible and provides adequate cerebral perfusion despite the length of the bypass. The use of transesophageal echocardiography during stent-graft deployment allows precise device placement in the high-risk area of the ascending aorta proximal to the innominate artery.
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Affiliation(s)
- Joshua A Gabel
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Sheela T Patel
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Roger T Tomihama
- Department of Radiology, Loma Linda University Health, Loma Linda, CA
| | - Nahidh W Hasaniya
- Department of Cardiothoracic Surgery, Loma Linda University Health, Loma Linda, CA
| | - Ahmed M Abou-Zamzam
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Sharon C Kiang
- Department of Vascular Surgery, Loma Linda University Health, Loma Linda, CA.
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16
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Neri E, Tucci E, Tommasino G, Guaccio G, Ricci C, Lucatelli P, Cini M, Ceresa R, Benvenuti A, Muzzi L. Intimal re-layering technique for type A acute aortic dissection-reconstructing the intimal layer continuity to induce remodeling of the false channel. J Vis Surg 2018; 4:82. [PMID: 29780728 DOI: 10.21037/jovs.2018.04.09] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 03/31/2018] [Indexed: 11/06/2022]
Abstract
Background Residual false channel is common after repair of type A acute aortic dissection (TAAAD). Starting from our recent series of TAAAD patients we carried out a retrospective analysis, regarding the failure of primary exclusion at the time of the initial operation. We classified the location of the principal entry tears perfusing the residual false channel. The proposed technique represents our attempt to correct the mechanism of false channel perfusion during primary repair. We describe a new technique designed to address some limitations of standard hemiarch aortic replacement. Its goal are: (I) to reinforce the intimal layer at the arch level; (II) to eliminate inter-luminal communications at the arch level using suture lines around the arch vessels; (III) to provide an elephant trunk configuration for further interventions. Methods Between August 2016 and January 2018, 11 patients underwent emergency surgery using this technique; 7 were men; the median age was 74 years. All patients were treated using systemic circulatory arrest under moderate hypothermia (26 °C) and selective cerebral perfusion. All patients had supra-coronary repair; 1 patient had aortic valve replacement + CABG. In the first two patients a manual suture around supra-aortic trunks was used; the subsequent seven patients were treated with a mechanical suture bladeless device. CT scan follow up was performed in all survivors with controls before discharge 3 months and 1 year after operation. Results No patient died in the operating room and no neurologic deficit was observed in this initial experience. One patient died in POD 5th for low cardiac output syndrome. Median ICU stay was 3 days (IQR, 2-6 days). Hospital mean length of stay was 15.2±8 days. Median cardiopulmonary bypass time was 130 min (IQR, 110-141 min); median arrest time for re-layering was 17 min (IQR, 16-20 min); median total arrest was 36 min (IQR, 29-39 min). Distal aortic anastomosis was performed in zone 0 in 4 patients, zone 1, with innominate replacement, in 5 patients, in zone 2, with branches to innominate and left common carotid arteries, in 2 patients. Median follow up (closing date 06/01/2018) was 443 days (IQR, 262-557 days); no late deaths occurred. No dehiscence at the level of stapler or manual sutures was observed. Proximal 1/3 of the thoracic aorta false channel was obliterated in all cases but one; in 3 cases complete exclusion of the false channel was obtained after operation. In one case stent graft completion was required. Conclusions This technique combines the advantages of arch replacement to the simplicity of anterior hemiarch repair. This study demonstrates the safety of the procedure and the possibility to induce aortic remodeling without complex arch replacement.
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Affiliation(s)
- Eugenio Neri
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
| | - Enrico Tucci
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
| | - Giulio Tommasino
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
| | - Giulia Guaccio
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
| | - Carmelo Ricci
- Interventional Radiology Unit, Siena University Hospital, Siena, Italy
| | | | - Marco Cini
- Interventional Radiology Unit, Siena University Hospital, Siena, Italy
| | - Roberto Ceresa
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
| | - Antonio Benvenuti
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
| | - Luigi Muzzi
- Institute of Cardiac Surgery, Siena University Hospital, Siena, Italy
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17
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Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2017; 154:1831-1839.e1. [DOI: 10.1016/j.jtcvs.2017.08.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 07/09/2017] [Accepted: 08/01/2017] [Indexed: 01/15/2023]
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18
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Esaki J, Leshnower BG, Binongo JN, Lasanajak Y, McPherson L, Thourani VH, Chen EP. Reoperative aortic root replacement: Outcome in a contemporary series. J Thorac Cardiovasc Surg 2017; 154:800-808.e3. [DOI: 10.1016/j.jtcvs.2017.04.084] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 04/01/2017] [Accepted: 04/26/2017] [Indexed: 10/19/2022]
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19
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Di Bartolomeo R, Berretta P, Pantaleo A, Murana G, Cefarelli M, Alfonsi J, Barberio G, Leone A, Di Marco L, Pacini D. Long-Term Outcomes of Open Arch Repair After a Prior Aortic Operation: Our Experience in 154 Patients. Ann Thorac Surg 2017; 103:1406-1412. [DOI: 10.1016/j.athoracsur.2016.08.090] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 10/20/2022]
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20
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Berretta P, Di Marco L, Pacini D, Cefarelli M, Alfonsi J, Castrovinci S, Di Eusanio M, Di Bartolomeo R. Reoperations versus primary operation on the aortic root: a propensity score analysis. Eur J Cardiothorac Surg 2017; 51:322-328. [PMID: 28186292 DOI: 10.1093/ejcts/ezw250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/09/2016] [Accepted: 06/22/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- Paolo Berretta
- Division of Cardiac Surgery, "G. Mazzini" Hospital, Teramo, Italy
| | - Luca Di Marco
- Department of Cardiac Surgery, S.Orsola-Malpighi-Hospital-University of Bologna, Bologna, Italy
| | - Davide Pacini
- Department of Cardiac Surgery, S.Orsola-Malpighi-Hospital-University of Bologna, Bologna, Italy
| | - Mariano Cefarelli
- Department of Cardiac Surgery, S.Orsola-Malpighi-Hospital-University of Bologna, Bologna, Italy
| | - Jacopo Alfonsi
- Department of Cardiac Surgery, S.Orsola-Malpighi-Hospital-University of Bologna, Bologna, Italy
| | | | - Marco Di Eusanio
- Division of Cardiac Surgery, "G. Mazzini" Hospital, Teramo, Italy
| | - Roberto Di Bartolomeo
- Department of Cardiac Surgery, S.Orsola-Malpighi-Hospital-University of Bologna, Bologna, Italy
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21
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Preventza O, Coselli JS, Garcia A, Akvan S, Kashyap S, Simpson KH, Price MD, de la Cruz KI, Spiliotopoulos K, Cornwell LD, Bakaeen FG, Omer S, Cooley DA. Aortic root surgery with circulatory arrest: Predictors of prolonged postoperative hospital stay. J Thorac Cardiovasc Surg 2016; 153:511-518. [PMID: 27964981 DOI: 10.1016/j.jtcvs.2016.10.090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 09/30/2016] [Accepted: 10/07/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Little is known about the outcomes of aortic root operations that involve inducing hypothermic circulatory arrest for relatively extensive proximal aortic surgery. We attempted to identify predictors of postoperative hospital length of stay (LOS) and factors that affect postoperative recovery. METHODS During 2006-2014, 247 of 265 patients (93.2%) with disease extending into the aortic arch survived aortic root operations (206 elective, 41 urgent/emergent) in which hypothermic circulatory arrest with moderate hypothermia was used. Stepwise multivariate regression analysis was performed to identify predictors of LOS (as a continuous variable) and prolonged LOS (defined as LOS >9 days, the median for the cohort). By this definition, 111 patients (45%) had prolonged LOS and 136 (55%) did not. RESULTS Preoperative factors that independently predicted longer LOS in the entire cohort included age (P = .0014), redo sternotomy (P = .0047), and intraoperative packed red blood cell (PRBC) transfusion (P = .0007). Redo sternotomy and intraoperative PRBC transfusion also predicted longer LOS in 3 subgroup analyses: one of elective cases, one from which total arch replacement procedures were excluded, and one limited to patients who were discharged home. Age predicted longer LOS in the non-total arch (hemiarch) replacement patients. Ventilator support >48 hours (P < .0001) was associated with longer LOS. Elective aortic valve-sparing root replacement predicted a shorter LOS than valve replacement in multivariate regression analysis (P = .028). CONCLUSIONS In patients undergoing aortic root surgery with hypothermic circulatory arrest for disease extending into the aortic arch, reducing intraoperative PRBC transfusion except when absolutely necessary may reduce postoperative LOS and expedite recovery. Performing aortic valve-sparing root replacement, when feasible, may also reduce LOS.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Andrea Garcia
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Shahab Akvan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Sarang Kashyap
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Katherine H Simpson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Matt D Price
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Kim I de la Cruz
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Konstantinos Spiliotopoulos
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Faisal G Bakaeen
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Shuab Omer
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Denton A Cooley
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
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22
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Lau C, Gaudino M, Mazza A, Munjal M, Girardi LN. Reoperative Aortic Valve Replacement in a Previous Biologic Composite Valve Graft. Ann Thorac Surg 2016; 102:e477-e480. [PMID: 27772615 DOI: 10.1016/j.athoracsur.2016.04.095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 04/20/2016] [Accepted: 04/25/2016] [Indexed: 10/20/2022]
Abstract
Structural valve deterioration with biologic composite valve grafts previously required reoperative aortic root replacement. We present a technique for avoiding repeated root replacement. Exposure is by a transverse incision through the Dacron graft. The valve is disassembled within the graft, and a new prosthesis is implanted. We used this technique in 11 patients with good success.
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Affiliation(s)
- Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Andrea Mazza
- Department of Cardiovascular Sciences, Catholic University, Rome, Italy
| | - Monica Munjal
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
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23
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Iribarne A, Keenan J, Benrashid E, Wang H, Meza JM, Ganapathi A, Gaca JG, Kim HW, Hurwitz LM, Hughes GC. Imaging Surveillance After Proximal Aortic Operations: Is it Necessary? Ann Thorac Surg 2016; 103:734-741. [PMID: 27677566 DOI: 10.1016/j.athoracsur.2016.06.085] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 06/16/2016] [Accepted: 06/22/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Current guidelines for imaging surveillance after proximal aortic repair are not evidence based. This study sought to characterize the incidence and causes of reintervention after proximal aortic operations to provide data to guide the frequency and duration of postoperative surveillance. METHODS Data on all patients undergoing proximal aortic operations (ascending, with or without root, with or without aortic valve replacement, or with or without arch) during a 9-year period (n = 869) at a single institution were prospectively collected. Patients who required reintervention on the proximal or distal aorta were identified and causes for reintervention determined. Planned two-stage repairs and index procedures done at other hospitals were excluded. The primary end point was the time to the first reintervention, and competing-risk Cox regression was used to model reintervention risk. RESULTS Reinterventions occurred in 4.3% of patients (n = 37), with 48.6% (n = 18) involving the proximal aorta and 51.4% (n = 19) the distal. Median time to reintervention was 2.8 years (interquartile range, 1.5 to 3.6 years). For index aneurysm cases, reintervention for aneurysm of the descending/thoracoabdominal aorta and root were most common. Of the 6 root aneurysms/pseudoaneurysms, 5 (83%) were due to degeneration of a stentless porcine aortic root. For index type A dissections, reintervention for aneurysm of the descending/thoracoabdominal aorta and arch were most common. The mean duration of follow up was 4.2 ± 2.5 years. The 9-year actuarial freedom from reintervention was 92.9%. Cox regression showed index type A dissection was a significant predictor of time to aortic reintervention (hazard ratio, 2.01; 95% confidence interval, 1.04 to 3.9; p = 0.038). CONCLUSIONS Reinterventions after proximal aortic operations are uncommon; most occur within 3 years of the index operation and involve the proximal and distal aorta nearly equally. Patients with type A dissection or stentless porcine roots require aggressive surveillance, whereas a more liberal approach is suitable for patients without such risk factors. This strategy may reduce the lifetime radiation burden and health care costs.
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Affiliation(s)
- Alexander Iribarne
- Section of Cardiac Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jeffrey Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Hanghang Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - James M Meza
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Asvin Ganapathi
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Han W Kim
- Division of Cardiology, Duke Cardiovascular Magnetic Resonance Center, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Lynne M Hurwitz
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
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24
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Kayatta MO, Chen EP. Optimal temperature management in aortic arch operations. Gen Thorac Cardiovasc Surg 2016; 64:639-650. [PMID: 27501694 DOI: 10.1007/s11748-016-0699-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 07/26/2016] [Indexed: 01/26/2023]
Abstract
Hypothermic circulatory arrest is a critical component of aortic arch procedures, without which these operations could not be safely performed. Despite the use of hypothermia as a protective adjunct for organ preservation, aortic arch surgery remains complex and is associated with numerous complications despite years of surgical advancement. Deep hypothermic circulatory arrest affords the surgeon a safe period of time to perform the arch reconstruction, but this interruption of perfusion comes at a high clinical cost: stroke, paraplegia, and organ dysfunction are all potential-associated complications. Retrograde cerebral perfusion was subsequently developed as a technique to improve upon the rates of neurologic dysfunction, but was done with only modest success. Selective antegrade cerebral perfusion, on the other hand, has consistently been shown to be an effective form of cerebral protection over deep hypothermia alone, even during extended periods of circulatory arrest. A primary disadvantage of using deep hypothermic circulatory arrest is the prolonged bypass times required for cooling and rewarming which adds significantly to the morbidity associated with these procedures, especially coagulopathic bleeding and organ dysfunction. In an effort to mitigate this problem, the degree of hypothermia at the time of the initial circulatory arrest has more recently been reduced in multiple centers across the globe. This technique of moderate hypothermic circulatory arrest in combination with adjunctive brain perfusion techniques has been shown to be safe when performing aortic arch operations. In this review, we will discuss the evolution of these protection strategies as well as their relative strengths and weaknesses.
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Affiliation(s)
- Michael O Kayatta
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA.
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25
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Piffaretti G, Galli M, Lomazzi C, Franchin M, Castelli P, Mariscalco G, Trimarchi S. Endograft repair for pseudoaneurysms and penetrating ulcers of the ascending aorta. J Thorac Cardiovasc Surg 2016; 151:1606-14. [DOI: 10.1016/j.jtcvs.2015.12.055] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 12/18/2015] [Accepted: 12/24/2015] [Indexed: 11/30/2022]
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26
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Preventza O, Garcia A, Kashyap SA, Akvan S, Cooley DA, Simpson K, Rammou A, Price MD, Omer S, Bakaeen FG, Cornwell LD, Coselli JS. Moderate hypothermia ≥24 and ≤28°C with hypothermic circulatory arrest for proximal aortic operations in patients with previous cardiac surgery. Eur J Cardiothorac Surg 2016; 50:949-954. [PMID: 27190198 DOI: 10.1093/ejcts/ezw163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 04/13/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To determine whether, in patients with previous cardiac operations, moderate hypothermia (between 24 and 28°C) for hypothermic circulatory arrest (HCA) during antegrade cerebral perfusion (ACP) is safe for use during surgery on the proximal aorta and transverse aortic arch. METHODS Over a 7-year period, 118 patients underwent ascending aortic and hemiarch repair (n = 70; 59.3%), total arch replacement (n = 47; 39.8%) or ascending aortic replacement to treat porcelain aorta (n = 1; 0.9%). Simultaneous procedures included aortic root repair or replacement (n = 33; 28.0%) and coronary artery bypass grafting (n = 21; 17.8%). All patients had previously undergone cardiac operations via a median sternotomy. Eighteen patients (15.3%) had more than 1 previous sternotomy, and 24 patients (20.3%) required emergent/urgent operation. Median cardiopulmonary bypass, cardiac ischaemic, circulatory arrest and ACP times (min) were 136.0 [118-180 interquartile range (IQR)], 91.0 (68-119 IQR), 34.0 (21-59 IQR) and 33.5 (20-59 IQR), respectively. The median temperature when HCA was initiated was 24.2°C (24.1-24.8°C IQR). RESULTS The operative mortality rate was 10.2% (n = 12). Six patients (5.1%) had a permanent stroke, and 16 patients (13.6%) had a composite adverse outcome (operative mortality and/or a permanent neurological event and/or permanent haemodialysis at discharge). Preoperative renal disease was significantly more prevalent (P= 0.020) and the median circulatory arrest time significantly longer (48.5 vs 33 min; P= 0.058) in patients with composite adverse outcomes. Multivariable analysis of the redo patients showed that age (P =0.025), preoperative renal disease (P =0.024) and ACP time (P =0.012) were independent risk factors for a new postoperative renal injury. CONCLUSIONS Moderate hypothermia for HCA during ACP is being used with increasing frequency, but has not been thoroughly evaluated in patients undergoing cardiovascular reoperations. Our experience suggests that in patients with previous cardiac surgery who are undergoing hemiarch and total aortic arch operations, moderate hypothermia is safe and produces respectable results.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA .,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Andrea Garcia
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Sarang A Kashyap
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Shahab Akvan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Denton A Cooley
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Kiki Simpson
- The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Athina Rammou
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Matt D Price
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Shuab Omer
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Faisal G Bakaeen
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
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Malaisrie SC, Duncan BF, Mehta CK, Badiwala MV, Rinewalt D, Kruse J, Li Z, Andrei AC, McCarthy PM. The addition of hemiarch replacement to aortic root surgery does not affect safety. J Thorac Cardiovasc Surg 2015; 150:118-24.e2. [PMID: 25896462 DOI: 10.1016/j.jtcvs.2015.03.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 02/27/2015] [Accepted: 03/15/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES A hemiarch reconstruction, using deep hypothermic circulatory arrest, is the conventional approach for proximal aortic arch reconstruction, but it carries risks of neurologic events and coagulopathy. The addition of a hemiarch reconstruction to an aortic root replacement may prevent future aortic arch pathology. Outcomes of this approach at a tertiary care institution were examined to determine whether the addition of a hemiarch reconstruction to an aortic root replacement conferred any additional risk. METHODS A total of 384 patients underwent an aortic root replacement between April 2004 and June 2012. Of them, 177 (46%) had hemiarch replacement. Propensity score matching yielded 133 pairs of patients receiving hemiarch and non-hemiarch. RESULTS Sinus segment diameter was similar between groups; ascending aortic diameter was greater in the hemiarch group (median 50 vs 44 mm; P < .001). The hemiarch group had longer perfusion (median 186 vs 120.5 minutes; P < .001) and crossclamp times (median 140 vs 104 minutes; P < .001); median circulatory arrest was 13 minutes. There was no difference, hemiarch versus no hemiarch, in 30-day mortality (3.0% vs 1.5%; P = .41), stroke (2.3% vs 4.5%; P = .31), reoperation for bleeding (11% vs 10%; P = .84), or overall survival (5-year 88.0% [95% confidence interval, 81.9-94.0] vs 91.4% [95% confidence interval, 85.8-96.9], P = .24). CONCLUSIONS In this series, aortic root replacement ± hemiarch reconstruction had low mortality. Addition of hemiarch replacement extended perfusion times but not at the expense of safety. Hemiarch reconstruction should be performed when the aortic root aneurysm extends into the distal ascending aorta.
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Affiliation(s)
| | - Brett F Duncan
- Division of Cardiothoracic Surgery, Northwestern University, Chicago, Ill
| | - Chris K Mehta
- Division of Cardiothoracic Surgery, Northwestern University, Chicago, Ill
| | - Mitesh V Badiwala
- Division of Cardiothoracic Surgery, Northwestern University, Chicago, Ill
| | - Dan Rinewalt
- Division of Cardiothoracic Surgery, Northwestern University, Chicago, Ill
| | - Jane Kruse
- Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, Ill
| | - Zhi Li
- Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, Ill
| | | | - Patrick M McCarthy
- Division of Cardiothoracic Surgery, Northwestern University, Chicago, Ill
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Jassar AS, Desai ND, Kobrin D, Pochettino A, Vallabhajosyula P, Milewski RK, McCarthy F, Maniaci J, Szeto WY, Bavaria JE. Outcomes of aortic root replacement after previous aortic root replacement: the "true" redo root. Ann Thorac Surg 2015; 99:1601-8; discussion 1608-9. [PMID: 25754965 DOI: 10.1016/j.athoracsur.2014.12.038] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 11/30/2014] [Accepted: 12/08/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Aortic reoperations are technically challenging. This study evaluated outcomes after "true" redo root replacement (previous full root replacement) stratified by cause of prosthesis failure. METHODS Data were compared for 793 patients who underwent a first-time sternotomy (de novo group) and 120 patients who had previously undergone full aortic root replacement (redo group), of which 76 underwent reoperation due to structural valve deterioration (degenerative group), and 44 due to endocarditis (infection group). RESULTS Overall mortality was 4% (n = 28) in the de novo group and 5% (n = 6) in the redo group (p = 0.43) (degenerative group, 3%, infection group, 9%; p = 0.19). The infection group had an increased incidence of renal failure, sternal infection, prolonged ventilation, reoperation for bleeding, multisystem failure, and sepsis, and an increased hospital length of stay. The degenerative group and the de novo group had a similar risk of perioperative death and major complications. The 5-year survival was 86.3% ± 1.3% for the de novo group and 77.3% ± 4.6% for the redo group (p ≤ 0.01; degenerative, 86.3% ± 5%; infection, 65.3% ± 7.7%; p < 0.01; p = 0.98 for de novo vs degenerative). Multivariate analysis demonstrated that reoperation for degenerative failure did not increase the risk of perioperative or late death. CONCLUSIONS Redo aortic root replacement can be performed with low perioperative morbidity and death. The presence of infection increases the risk of complications and worsens survival. However, redo root replacement for degenerative failure can be performed with similar short-term complication risk and midterm survival as de novo root replacement.
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Affiliation(s)
- Arminder S Jassar
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dale Kobrin
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alberto Pochettino
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Rita K Milewski
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fenton McCarthy
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jon Maniaci
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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Vendramin I, Meneguzzi M, Sponga S, Deroma L, Cimarosti R, Lutman C, Daffarra C, Livi U. Bicuspid aortic valve disease and ascending aortic aneurysm: should an aortic root replacement be mandatory?†. Eur J Cardiothorac Surg 2015; 49:103-9. [PMID: 25750009 DOI: 10.1093/ejcts/ezv069] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/14/2015] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES The higher risk of adverse aortic events in patients with bicuspid aortic valve (BAV) disease and ascending aorta aneurysm is known, but the management of moderate aortic root dilatation in younger patients is a controversial issue. The aim of the study was to compare survival in patients with or without root replacement. METHODS We reviewed 166 consecutive patients with BAV disease and concomitant ascending aorta aneurysm (mean ascending aorta diameter: 51.4 ± 7.2 mm) undergoing cardiac surgery from 1994 to 2010. A total of 77 patients underwent Bentall procedure (90.9% male, mean age: 55.7 ± 12.7 years, Bentall group), whereas the remaining 89 patients underwent aortic valve replacement with supracoronary ascending aorta replacement (SAAR 71.9% male, mean age: 60.5 ± 11.2 years, SAAR group, P = 0.002). The preoperative mean diameter of the root was 44.0 ± 7.2 mm in the Bentall, and 38.5 ± 4.8 mm in the SAAR group (P < 0.0001). RESULTS In-hospital mortality was 2.6% in the Bentall, and 2.3% in the SAAR groups. Overall survival was 84 and 81% in the Bentall (median follow-up: 105 months) versus 89 and 88% in the SAAR (median follow-up: 73 months) groups at 10 and 15 years (P = 0.36), respectively. The mean cardiopulmonary bypass (CPB) time was 201 ± 56 min and 174 ± 58 min (P = 0.0016), the mean cross-clamp time 156 ± 42 min and 132 ± 38 min (P = 0.0008) in the Bentall and SAAR groups, respectively. Four sudden deaths have occurred in the Bentall group and in 2 in the SAAR group. Progressive dilatation of the aortic root in the SAAR group was not significat (postoperative mean diameter: 36.3 ± 4.4 mm). Neither subgroup of patients in the SAAR with preoperative moderate dilatation of aortic root had significat aortic dilatation at the mean follow-up of 73 ± 39 months (preoperative diameter: 43.5 ± 2.3 mm versus postoperative: 39.1 ± 4.2 mm). One patient in Bentall and 1 in the SAAR groups were reoperated for tubular graft infection. CONCLUSIONS In patients with BAV disease, ascending aorta aneurysm and moderate dilatation of the root, the significat reduction of CPB and cross-clamp times, the stability of the residual root at long term and the low risk of adverse aortic events associated with SAAR compared with the Bentall procedure have led us to consider the isolated aortic valve replacement with supracoronary aorta replacement an alternative strategy to the Bentall procedure, especially in high-risk and older patients.
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Affiliation(s)
- Igor Vendramin
- Cardiothoracic Departement, University Hospital of Udine, Udine, Italy
| | - Matteo Meneguzzi
- Cardiothoracic Departement, University Hospital of Udine, Udine, Italy
| | - Sandro Sponga
- Cardiothoracic Departement, University Hospital of Udine, Udine, Italy
| | - Laura Deroma
- Cardiothoracic Departement, University Hospital of Udine, Udine, Italy
| | | | - Cristina Lutman
- Cardiothoracic Departement, University Hospital of Udine, Udine, Italy
| | - Cristian Daffarra
- Cardiothoracic Departement, University Hospital of Udine, Udine, Italy
| | - Ugolino Livi
- Cardiothoracic Departement, University Hospital of Udine, Udine, Italy
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Open aortic arch reconstruction after previous cardiac surgery: Outcomes of 168 consecutive operations. J Thorac Cardiovasc Surg 2014; 148:2944-50. [DOI: 10.1016/j.jtcvs.2014.05.087] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 05/13/2014] [Accepted: 05/27/2014] [Indexed: 11/20/2022]
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Tanaka Y, Mikamo A, Suzuki R, Kurazumi H, Kudo T, Takahashi M, Ikenaga S, Shirasawa B, Hamano K. Mortality and morbidity after total aortic arch replacement. Ann Thorac Surg 2014; 97:1569-75. [PMID: 24629302 DOI: 10.1016/j.athoracsur.2014.01.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Revised: 12/26/2013] [Accepted: 01/06/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Total aortic arch replacement is associated with considerable mortality and morbidity. Although operative death is the most extreme adverse clinical end point, postoperative morbidity can also be devastating for survivors. METHODS We examined the short-term and long-term outcomes of 146 patients who underwent total aortic arch replacements between September 2003 and September 2011. RESULTS The overall in-hospital mortality was 4.8%, and major postoperative morbidity during hospitalization occurred in 29 patients (19.9%). Multivariate analyses demonstrated that risk factors for hospital death were left thoracotomy (odds ratio [OR], 51.92; p=0.01), high preoperative serum creatinine values (OR, 3.88; p=0.02), and intraoperative blood loss (OR, 1.01; p=0.04). Ruptured aorta (OR, 7.13; p=0.02) and previous myocardial infarction (OR, 5.13; p=0.04) were identified as independent risk factors for major postoperative morbidity. The postoperative survival of all patients at 5 years was 76.7%±5%. After hospital discharge, the standardized mortality ratios showed no significant difference between hospital survivors and a comparable Japanese population and were 1.09 (p=0.41) among patients without major morbidity and 1.82 (p=0.12) among those with major morbidity. The development of renal failure requiring hemodialysis increased the risk of long-term death (hazard ratio, 5.59; p=0.03), even among hospital survivors. CONCLUSIONS Our approach for total arch replacement resulted in low in-hospital mortality and morbidity. Long-term outcomes are stable in hospital survivors, especially in the absence of a postoperative requirement for dialysis.
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Affiliation(s)
- Yuya Tanaka
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Akihito Mikamo
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan.
| | - Ryo Suzuki
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Hiroshi Kurazumi
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Tomoaki Kudo
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Masaya Takahashi
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Shigeru Ikenaga
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Bungo Shirasawa
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Kimikazu Hamano
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
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Della Corte A, Body SC, Booher AM, Schaefers HJ, Milewski RK, Michelena HI, Evangelista A, Pibarot P, Mathieu P, Limongelli G, Shekar PS, Aranki SF, Ballotta A, Di Benedetto G, Sakalihasan N, Nappi G, Eagle KA, Bavaria JE, Frigiola A, Sundt TM. Surgical treatment of bicuspid aortic valve disease: knowledge gaps and research perspectives. J Thorac Cardiovasc Surg 2014; 147:1749-57, 1757.e1. [PMID: 24534676 DOI: 10.1016/j.jtcvs.2014.01.021] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 01/17/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Alessandro Della Corte
- Division of Cardiac Surgery, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy.
| | - Simon C Body
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Anna M Booher
- Division of Cardiology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Mich
| | - Hans-Joachim Schaefers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Rita K Milewski
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | | | | | | | | | - Giuseppe Limongelli
- Cardiology Division, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Prem S Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sary F Aranki
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Andrea Ballotta
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | | | | | - Gianantonio Nappi
- Division of Cardiac Surgery, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy
| | - Kim A Eagle
- Division of Cardiology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Mich
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | | | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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Etz CD, von Aspern K, da Rocha e Silva J, Girrbach FF, Leontyev S, Luehr M, Misfeld M, Borger MA, Mohr FW. Impact of Perfusion Strategy on Outcome After Repair for Acute Type A Aortic Dissection. Ann Thorac Surg 2014; 97:78-85. [DOI: 10.1016/j.athoracsur.2013.07.034] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 07/01/2013] [Accepted: 07/02/2013] [Indexed: 10/26/2022]
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Amulraj EA, Kent WDT, Malaisrie SC. Aortoplasty for management of the dilated distal ascending aorta during proximal aortic reconstruction. Ann Thorac Surg 2013; 96:1499-1501. [PMID: 24088478 DOI: 10.1016/j.athoracsur.2013.04.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 03/19/2013] [Accepted: 04/08/2013] [Indexed: 11/24/2022]
Abstract
When aneurysms of the ascending aorta extend into the arch, the conventional approach is replacement with a Dacron graft, including a distal beveled hemiarch anastomosis with the patient under hypothermic circulatory arrest. For certain cases, we propose an alternative strategy combining replacement of the proximal and middle segments of the ascending aorta with external wrapping aortoplasty for the distal segment. This "turtleneck" aortoplasty achieves successful complete repair of the ascending aorta without the risks associated with circulatory arrest.
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Affiliation(s)
- Emmanuel A Amulraj
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois
| | - William D T Kent
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois.
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Englum BR, Andersen ND, Husain AM, Mathew JP, Hughes GC. Degree of hypothermia in aortic arch surgery - optimal temperature for cerebral and spinal protection: deep hypothermia remains the gold standard in the absence of randomized data. Ann Cardiothorac Surg 2013; 2:184-93. [PMID: 23977581 DOI: 10.3978/j.issn.2225-319x.2013.03.01] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 03/06/2013] [Indexed: 11/14/2022]
Affiliation(s)
- Brian R Englum
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Long-term results after proximal thoracic aortic redo surgery. PLoS One 2013; 8:e57713. [PMID: 23469220 PMCID: PMC3585872 DOI: 10.1371/journal.pone.0057713] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 01/25/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To evaluate early and mid-term results in patients undergoing proximal thoracic aortic redo surgery. METHODS We analyzed 60 patients (median age 60 years, median logistic EuroSCORE 40) who underwent proximal thoracic aortic redo surgery between January 2005 and April 2012. Outcome and risk factors were analyzed. RESULTS In hospital mortality was 13%, perioperative neurologic injury was 7%. Fifty percent of patients underwent redo surgery in an urgent or emergency setting. In 65%, partial or total arch replacement with or without conventional or frozen elephant trunk extension was performed. The preoperative logistic EuroSCORE I confirmed to be a reliable predictor of adverse outcome- (ROC 0.786, 95%CI 0.64-0.93) as did the new EuroSCORE II model: ROC 0.882 95%CI 0.78-0.98. Extensive individual logistic EuroSCORE I levels more than 67 showed an OR of 7.01, 95%CI 1.43-34.27. A EuroSCORE II larger than 28 showed an OR of 4.44 (95%CI 1.4-14.06). Multivariate logistic regression analysis identified a critical preoperative state (OR 7.96, 95%CI 1.51-38.79) but not advanced age (OR 2.46, 95%CI 0.48-12.66) as the strongest independent predictor of in-hospital mortality. Median follow-up was 23 months (1-52 months). One year and five year actuarial survival rates were 83% and 69% respectively. Freedom from reoperation during follow-up was 100%. CONCLUSIONS Despite a substantial early attrition rate in patients presenting with a critical preoperative state, proximal thoracic aortic redo surgery provides excellent early and mid-term results. Higher EuroSCORE I and II levels and a critical preoperative state but not advanced age are independent predictors of in-hospital mortality. As a consequence, age alone should no longer be regarded as a contraindication for surgical treatment in this particular group of patients.
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Di Bartolomeo R, Berretta P, Petridis FD, Folesani G, Cefarelli M, Di Marco L, Di Eusanio M. Reoperative surgery on the thoracic aorta. J Thorac Cardiovasc Surg 2013; 145:S78-84. [DOI: 10.1016/j.jtcvs.2012.11.055] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 08/13/2012] [Accepted: 11/28/2012] [Indexed: 10/27/2022]
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Di Eusanio M, Berretta P, Cefarelli M, Di Bartolomeo R. Root graft substitution after aortic valve replacement: sparing the valve prosthesis is a valid option. Eur J Cardiothorac Surg 2013; 44:427-30. [DOI: 10.1093/ejcts/ezt034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Behandlung akuter und chronischer Erkrankungen des Aortenbogens. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2012. [DOI: 10.1007/s00398-012-0912-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Pacini D, Di Marco L, Leone A, Di Bartolomeo R, Sodeck G, Englberger L, Carrel T, Czerny M. Antegrade selective cerebral perfusion and moderate hypothermia in aortic arch surgery: clinical outcomes in elderly patients. Eur J Cardiothorac Surg 2012; 42:249-53; discussion 253. [DOI: 10.1093/ejcts/ezr304] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Luciani N, De Geest R, Anselmi A, Glieca F, De Paulis S, Possati G. Results of Reoperation on the Aortic Root and the Ascending Aorta. Ann Thorac Surg 2011; 92:898-903. [DOI: 10.1016/j.athoracsur.2011.04.116] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 04/22/2011] [Accepted: 04/29/2011] [Indexed: 11/30/2022]
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Park CB, Greason KL, Suri RM, Michelena HI, Schaff HV, Sundt TM. Should the proximal arch be routinely replaced in patients with bicuspid aortic valve disease and ascending aortic aneurysm? J Thorac Cardiovasc Surg 2011; 142:602-7. [DOI: 10.1016/j.jtcvs.2010.08.086] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 08/18/2010] [Accepted: 08/29/2010] [Indexed: 10/18/2022]
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Park CB, Greason KL, Suri RM, Michelena HI, Schaff HV, Sundt TM. Fate of nonreplaced sinuses of Valsalva in bicuspid aortic valve disease. J Thorac Cardiovasc Surg 2011; 142:278-84. [DOI: 10.1016/j.jtcvs.2010.08.055] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 08/07/2010] [Accepted: 08/29/2010] [Indexed: 01/27/2023]
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Di Eusanio M, Berretta P, Bissoni L, Petridis FD, Di Marco L, Di Bartolomeo R. Re-operations on the proximal thoracic aorta: results and predictors of short- and long-term mortality in a series of 174 patients. Eur J Cardiothorac Surg 2011; 40:1072-6. [DOI: 10.1016/j.ejcts.2011.02.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Revised: 02/03/2011] [Accepted: 02/07/2011] [Indexed: 10/18/2022] Open
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Montalvo J, Razzouk A, Wang N, Bansal R, Rasi A, Hasaniya N, Floridia R, Bailey L. Aortic Root Surgery Does Not Increase the Operative Risk of Acute Type A Aortic Dissection. Am Surg 2011. [DOI: 10.1177/000313481107700128] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Controversy exists regarding aortic root reconstruction in the management of acute type A aortic dissection (AAD). One hundred fifty-four patients (mean age 56.9 ± 11.3 years) with AAD had surgical repair between 1996 and 2007. Group 1 (n = 110) required no aortic root surgery. Seventy-one patients had ascending aortic replacement. The aortic valve was repaired in 37 patients (34%) and replaced in one. Group 2 (n = 44) had aortic root surgery. Thirty-four patients had composite root replacement, and seven had a valve-sparing root replacement. Root reconstruction and separate valve replacement was accomplished in three. Hemiarch replacement was included in 39 (35.4%) Group 1 patients and in 12 (27.9%) Group 2 patients. Forty-nine of the 154 patients presented in cardiogenic shock. Multiple risk factors for operative mortality were analyzed. The overall operative mortality was 9.7 per cent: 11 per cent for Group 1 and 6.8 per cent for Group 2 ( P = NS). By multivariate analysis, preoperative shock ( P = 0.03, odds ratio [OR] = 5.48), postoperative ventricular arrhythmias ( P = 0.002, OR = 4.62), and packed red blood cell transfusion ( P = 0.002, OR = 1.15) were independent predictors of hospital death. Prompt surgical treatment of AAD before cardiogenic shock ensues can improve the outcome of patients. When indicated, aortic root surgery can be performed without increased mortality and morbidity.
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Affiliation(s)
- Jose Montalvo
- Loma Linda University Medical Center, Loma Linda, California
| | - Anees Razzouk
- Loma Linda University Medical Center, Loma Linda, California
| | - Nan Wang
- Loma Linda University Medical Center, Loma Linda, California
| | - Ramesh Bansal
- Loma Linda University Medical Center, Loma Linda, California
| | - Alfredo Rasi
- Loma Linda University Medical Center, Loma Linda, California
| | - Nahidh Hasaniya
- Loma Linda University Medical Center, Loma Linda, California
| | | | - Leonard Bailey
- Loma Linda University Medical Center, Loma Linda, California
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Knight J, Baumüller S, Kurtcuoglu V, Turina M, Turina J, Schurr U, Poulikakos D, Marshall W, Alkadhi H. Long-term follow-up, computed tomography, and computational fluid dynamics of the Cabrol procedure. J Thorac Cardiovasc Surg 2009; 139:1602-8. [PMID: 19913239 DOI: 10.1016/j.jtcvs.2009.09.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 09/04/2009] [Accepted: 09/17/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The Cabrol procedure is characterized by insertion of an ascending aortic composite graft with reimplantation of the coronary arteries by the interposition of a graft tube. Our purpose is to report the clinical long-term follow-up and computed tomographic findings in patients having undergone the Cabrol procedure and to determine blood flow in the Cabrol graft using computational fluid dynamics. METHODS Clinical follow-up (76.6 +/- 16.6 months) and dual-source computed tomographic angiography data of 7 patients (all men, mean age 54.9 +/- 9.6 years) with 12 Cabrol grafts (left main coronary artery, n = 7; right coronary artery, n = 5) were reviewed. In 2 patients, the right coronary artery was directly reattached to the aortic graft. Computational fluid dynamics were calculated using computed tomographic data of a patient with the Cabrol procedure and compared with those in a Valsalva graft and a healthy aortic root. RESULTS Computed tomography showed Cabrol graft occlusions to 1 of 7 (14%) left main and of 2 of 5 (40%) right coronary arteries. Six grafts to the left main and 3 to the right coronary artery were fully patent, similar to the 2 directly reattached right coronary arteries to the aortic graft. Computational fluid dynamics results show similar blood flow parameters into the coronaries for the healthy aortic root and Valsalva graft. In the Cabrol graft, a spiraling flow pattern with low flow into the right coronary artery was found (right coronary artery = 1 mL/min at both systole and diastole). CONCLUSIONS Our study indicates low flow rates particularly in the right Cabrol graft correlating with a higher incidence of occlusions of the right as compared with the left Cabrol graft at long-term follow-up.
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Affiliation(s)
- Joseph Knight
- Laboratory of Thermodynamics in Emerging Technologies, Department of Mechanical and Process Engineering, ETH Zurich, Switzerland
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