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Fernando RJ, Coleman SR, Alghanem F, Sanders J, Kothari P, Vanneman MW, Ochieng PO, Augoustides JG. The Year in Aortic Surgery: Selected Highlights From 2023. J Cardiothorac Vasc Anesth 2024; 38:1860-1870. [PMID: 38960802 DOI: 10.1053/j.jvca.2024.05.002] [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: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 07/05/2024]
Abstract
This article reviews the recent and relevant literature to the field of aortic surgery. Specific areas highlighted include outcomes of Stanford type A dissection, management of acute aortic syndromes, management of aortic aneurysms, and traumatic aortic injury. Although the focus was on articles from 2023, literature from prior years also was included, given that this article is the first of a series. Notably, the pertinent sections from the 2022 American College of Cardiology/American Heart Association Guidelines for the Diagnosis and Management Aortic Disease are discussed.
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Affiliation(s)
- Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest University School of Medicine, Winston Salem, NC.
| | - Scott R Coleman
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest University School of Medicine, Winston Salem, NC
| | - Fares Alghanem
- Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health, Detroit, MI
| | - Joseph Sanders
- Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health, Detroit, MI
| | - Perin Kothari
- Division of Cardiovascular & Thoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Matthew W Vanneman
- Division of Cardiovascular & Thoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Peter O Ochieng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Chandiramani A, Al-Tawil M, Rajasekar T, Elleithy A, Kakar S, Haneya A, Zeinah M, Harky A. Incidence Rates of Penn Classes and Class-Specific Mortality in Acute Type A Aortic Dissection Patients: An Epidemiologic Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2024; 38:1558-1568. [PMID: 38644098 DOI: 10.1053/j.jvca.2024.03.018] [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: 10/07/2023] [Revised: 02/28/2024] [Accepted: 03/13/2024] [Indexed: 04/23/2024]
Abstract
Acute type A aortic dissection (ATAAD) is a life-threatening emergency that is associated with a high morbidity and mortality rate. One of the complications is end-organ ischemia, a known predictor of mortality. The primary aims of this meta-analysis were to summarize the findings of observational studies investigating the utility of the Penn classification system and to analyze the incidence rates and mortality patterns within each class. The electronic databases PubMed, MEDLINE, and Embase were searched through to April 2023. These were filtered by multiple reviewers to give 10 studies that met the inclusion criteria. The extracted data included patient characteristics, and primary outcomes were the incidence rates of different Penn classes, along with the corresponding mortality for each class. Out of 1,512 studies identified during the initial search, 10 studies, including 4,494 patients, met the inclusion criteria. The pooled incidence of Penn A was highest at 0.55 (95% CI 0.52, 0.58), followed by Penn B at 0.21 (95% CI 0.17, 0.25), and finally Penn C at 0.14 (95% CI 0.11, 0.17). Patients with Penn BC were found to be at the highest risk of death, as their early mortality rates were 0.36 (95% CI 0.31, 0.41). Within those populations, the subtype with the highest individual mortality was Penn C at 0.21 (95% CI 0.15, 0.27), followed by Penn B at 0.19 (95% CI 0.15, 0.23) and Penn A at 0.07 (95% CI 0.05, 0.10). Among patients presenting with ATAAD, class A was most frequently observed, followed by classes B, C, and BC. These findings indicate an incremental increase in mortality rates with the progression of Penn classification.
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Affiliation(s)
| | | | | | | | - Sahil Kakar
- Department of Ear, Nose, and Throat Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Mohamed Zeinah
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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Takahashi B, Kamohara K, Morokuma H, Yunoki J. Sex-Related Differences Between Patients Undergoing Surgery for Acute Type A Aortic Dissection. Cureus 2024; 16:e60276. [PMID: 38872697 PMCID: PMC11171434 DOI: 10.7759/cureus.60276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2024] [Indexed: 06/15/2024] Open
Abstract
Introduction This study aimed to evaluate the sex-specific characteristics and surgical outcomes in patients with acute type A aortic dissection (ATAAD). Materials and methods We reviewed the surgical records of patients who underwent ATAAD repair at our institution between 2004 and 2020 (n=213). Results Of the 213 patients, 100 (46.9%) were male, and 113 (53.1%) were female. Males were younger than females (62.5 vs. 72.9 years, p<0.0001). Females had more nonspecific symptoms (p=0.04), more frequently developed ATAAD before noon (45.0% vs. 53.1%, p=0.01), and had a significantly longer time from onset to surgery (425.1 vs. 595.8 min, p=0.03). The ascending aorta was replaced more frequently in females than in males (54.5% vs. 72.8%, p<0.01). No significant difference was observed in the in-hospital mortality rate between males and females (9.0% vs. 10.6%, p=0.69). The multivariable logistic analysis demonstrated that being male was not an independent predictor of operative mortality (OR, 0.96; 95% CI, 0.18-5.21; p=0.96). At 10 years, males had significantly better long-term survival rates in the unadjusted cohort than females (79.4% vs. 55.9%, p=0.02). Conclusions Male sex was not an independent predictor of early death in patients with ATAAD after surgery, although significant differences were noted in terms of age, onset time, chief complaint, imaging findings, and surgical procedures. A sex-based management strategy involving specific differences should be considered to improve outcomes.
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Affiliation(s)
- Baku Takahashi
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, JPN
| | - Keiji Kamohara
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, JPN
| | - Hiroyuki Morokuma
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, JPN
| | - Junji Yunoki
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, JPN
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Brown JA, Yousef S, Garvey J, Ogami T, Serna-Gallegos D, Sá MP, Thoma F, Zhu J, Phillippi J, Sultan I. Reinterventions After Repair of Acute Type A Aortic Dissection: Incidence, Outcomes, and Risk Factors. Ann Thorac Surg 2024; 117:915-921. [PMID: 38036024 PMCID: PMC11317993 DOI: 10.1016/j.athoracsur.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/19/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND This study reports the incidence, outcomes, and risk factors for aortic reinterventions after repair of acute type A aortic dissection (ATAAD). METHODS This was an observational study of aortic operations from 2010 to 2021. All patients with ATAAD undergoing open aortic arch reconstruction were included. Patients were dichotomized by the need for reintervention, which included reinterventions proximal to or distal to the index aortic repair. Propensity matching was used to determine the impact of reintervention on long-term outcomes. The cumulative incidence function for reintervention was estimated, and multivariable Fine-Gray analysis was performed to identify variables associated with reintervention, with death treated as a competing event. RESULTS We identified 601 patients undergoing surgery for ATAAD. An aortic reintervention was required in 71 (11.8%), comprising a proximal reintervention in 12 patients, a distal reintervention in 56, and both in 3. The cumulative incidence of reintervention was 11.6% (95% CI, 8.9%-14.6%) at 5 years and was 16.0% (95% CI, 12.2%-20.3%) at 10 years, with a median time to reintervention of 4.0 years (interquartile range, 0.9-7.5 years). Multivariable analysis using the Fine-Gray method showed no operative variables were associated with reinterventions. Among the 71 reinterventions, there were 4 (5.6%) operative deaths. After propensity matching, there was no difference in Kaplan-Meier survival estimates across each group (P = .138 by log-rank statistics). CONCLUSIONS The cumulative incidence of aortic reintervention after ATAAD repair was reasonably low (16% at 10 years), reinterventions were relatively safe (6% operative mortality), and reinterventions did not significantly impact long-term survival.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph Garvey
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michel Pompeu Sá
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Julie Phillippi
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Özçınar E, Yazıcıoğlu L, Dikmen N, Durmaz O, Guven A, Cahit Sarıcaoğlu M, Akca F, Ada A. Selective cerebral extracorporeal circulation-enhanced total endovascular arch replacement using in situ fenestration. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2024; 32:236-242. [PMID: 38933306 PMCID: PMC11197407 DOI: 10.5606/tgkdc.dergisi.2024.26062] [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: 02/22/2024] [Accepted: 04/07/2024] [Indexed: 06/28/2024]
Abstract
In this article, we present a newly designed cerebral perfusion technique during the in situ fenestration procedure with three covered stent placement in an endovascular total aortic arch repair of a 68-year-old male patient. This technique enables the endovascular repair of the ascending aorta and aortic arch pathologies with commonly available thoracic aorta stent grafts in a safer and more effective manner.
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Affiliation(s)
- Evren Özçınar
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Levent Yazıcıoğlu
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Nur Dikmen
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Oguzhan Durmaz
- Department of Cardiovascular Surgery, Perfusion Unit, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Aysegul Guven
- Department of Anesthesiology and Reanimation, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Mehmet Cahit Sarıcaoğlu
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Fatma Akca
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Altan Ada
- Department of Cardiovascular Surgery, Perfusion Unit, Ankara University Faculty of Medicine, Ankara, Türkiye
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Takagi S, Goto Y, Yanagisawa J, Ogihara Y, Okawa Y. Strategy for acute DeBakey type I aortic dissection considering midterm results: a retrospective cohort study comparing ascending aortic replacement and total arch replacement with frozen elephant trunk technique. J Cardiothorac Surg 2024; 19:15. [PMID: 38247014 PMCID: PMC10801927 DOI: 10.1186/s13019-024-02484-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 01/14/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Acute type A aortic dissection is treated with an emergency procedure that uses ascending aortic replacement (AAR). However, to avoid a residual dissected aorta with a false lumen, total arch replacement (TAR) is required. The frozen elephant trunk (FET) technique is a promising surgical approach that promotes false lumen obliteration in a single step. Therefore, this retrospective single-center study aimed to evaluate the operative outcomes of AAR and TAR with FET. METHODS Between 2007 and 2021, 143 patients with acute DeBakey type I aortic dissection underwent a central repair using AAR (n = 95) or TAR with FET (n = 43). All perioperative variables, the duration of all-cause mortality, and aortic events defined as dilatation of the distal aorta > 5 cm, new occurrences of aortic dissection, distal aortic surgery, and distal aortic rupture were recorded. We compared these perioperative variables and mid-term results with an additional focus on distal aortic events. RESULTS Patient background data did not differ between the two groups. Perioperative results for the TAR with FET group vs the AAR group showed similar operative times (306 vs 298 min, P = 0.862), but the TAR group had longer cardiopulmonary bypass times (154 vs 179 min, P < 0.001). The freedom from all-cause death for the TAR vs AAR groups using the Kaplan-Meier method was 81.9% vs 85.4% and 78.0% vs 85.4% (P = 0.407) at 1 and 3 years, respectively. Freedom from aorta-related events was 90.6% vs 97.6% and 69.3% vs 87.0% (P = 0.034) at 1 and 3 years, respectively. CONCLUSIONS TAR with FET had comparable perioperative results to AAR in acute DeBakey type I aortic dissection and was considered a valuable method to avoid aorta-related events in the midterm.
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Affiliation(s)
- Sho Takagi
- Department of Cardiovascular Surgery, Toyohashi Heart Center, 21-1 Gobudori, Oyama-Cho, Toyohashi, 441-8530, Japan.
| | - Yoshihiro Goto
- Department of Cardiovascular Surgery, Toyohashi Heart Center, 21-1 Gobudori, Oyama-Cho, Toyohashi, 441-8530, Japan
| | - Junji Yanagisawa
- Department of Cardiovascular Surgery, Toyohashi Heart Center, 21-1 Gobudori, Oyama-Cho, Toyohashi, 441-8530, Japan
| | - Yui Ogihara
- Department of Cardiovascular Surgery, Toyohashi Heart Center, 21-1 Gobudori, Oyama-Cho, Toyohashi, 441-8530, Japan
| | - Yasuhide Okawa
- Department of Cardiovascular Surgery, Toyohashi Heart Center, 21-1 Gobudori, Oyama-Cho, Toyohashi, 441-8530, Japan
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Yamana F, Kuratani T, Domae K, Sakamoto T, Hata M, Shirakawa Y, Masai T, Sawa Y. The Efficacy of Second-Stage Endovascular Repair Strategy for Acute Type A Aortic Dissection. J Endovasc Ther 2023:15266028231214206. [PMID: 38050851 DOI: 10.1177/15266028231214206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
PURPOSE To evaluate the usefulness of a hybrid treatment strategy for acute type A aortic dissection (AAAD). METHODS We retrospectively evaluated the outcomes of 39 partial arch replacements (PAR; 26 male/13 female, mean age=67.9 years) in 62 patients with AAAD operated at our hospital from January 2019 to January 2023. The technique included PAR with graft-designed landing length and translocated the brachiocephalic artery inflow site during the initial surgery to minimize the invasiveness of the surgery. Thereafter, second-stage thoracic endovascular aortic repair (second TEVAR) for distal aortic events in the chronic phase was performed. RESULTS There was 1 case of 30-day mortality (2.6%) and 2 cases of postprocedural cerebral infarction (5.1%). The cumulative survival rates were 97.4%/1 year and 97.4%/3 years. The cumulative freedom from aorta-related second-stage procedure for the distal aortic event after initial PAR, which was performed in 13 patients (33.3%), was 63.9%/1 year and 59.7%/3 years. All patients requiring re-intervention after initial PAR underwent a second TEVAR with a 100% success rate and no postoperative complications. CONCLUSION Initial PAR for AAAD in anticipation of the second TEVAR is a valuable strategy for enabling minimally invasive additional treatment of aorta-related re-intervention for distal aortic events in the chronic phase. CLINICAL IMPACT This study provides detailed information on the hybrid aortic repair strategy of the initial open partial arch repair and second staged endovascular repair for the acute type A aortic dissection. Based on this study, distal aortic re-intervention after initial open partial arch repair was necessary only in about 30% of cases, and no cases of SCI were observed in the initial treatment or in the second-stage endovascular repair and no cases of distal SINE were observed after the second staged endovascular repair. Overall, the results suggest that limiting the initial open partial arch repair can achieve good perioperative and early outcomes of initial surgery, and that second staged endovascular re-intervention for distal aortic events can be performed reliably, safely, and with minimal invasiveness.
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Affiliation(s)
- Fumio Yamana
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Toru Kuratani
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Keitaro Domae
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Tomohiko Sakamoto
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Masatoshi Hata
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Yukitoshi Shirakawa
- Department of Cardiovascular Surgery, Osaka General Medical Center, Osaka, Japan
| | - Takafumi Masai
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
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Shimamoto T, Komiya T, Matsuo T. Clinical impact of turn-up anastomosis in the treatment of type A acute aortic dissection. Asian Cardiovasc Thorac Ann 2023; 31:759-767. [PMID: 37731318 DOI: 10.1177/02184923231203753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
BACKGROUND The management of anastomosis and hemostasis of the dissected aorta remains challenging. This study aims to establish an optimal surgical strategy for type A acute aortic dissection by reviewing single-center data using the turn-up anastomosis technique. METHODS Between 2003 and 2015, 264 consecutive patients with type A acute aortic dissection who underwent emergency surgery within 14 days of symptom onset were enrolled. RESULTS The mean age of the patients was 67.7 ± 13.4 years, and 129 were males. The operative time and surgical bleeding were 390.9 ± 144.5 min and 2983.8 ± 3026.5 mL, respectively. In-hospital mortality was observed in 25 patients (9.4%), and 3 (1.1%) experienced uncontrolled bleeding (from the aortic root in two patients and coagulopathy due to dabigatran in one patient). Immediate reopening for bleeding was performed in 20 patients, and bleeding from the aortic anastomosis was observed at three proximal and two distal sites. Proximal re-dissection was observed in 18 patients; in all of which, glue was used, although two re-ruptures of the aortic root were observed among those without glue use. The rates of freedom from all-cause death, aortic death, and aortic events at postoperative 5 years were 78.5 ± 2.7%, 86.8 ± 2.1%, and 74.4 ± 2.9%, respectively. When these values were stratified according to the operative extent, no significant differences were observed. CONCLUSIONS Turn-up anastomosis facilitates short circulatory arrest, short operative time, and stable hemostasis, with few anastomotic complications during surgery for type A acute aortic dissection.
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Affiliation(s)
- Takeshi Shimamoto
- Department of Cardiovascular Surgery, Hamamatsu Rosai Hospital, Shizuoka, Japan
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Takehiko Matsuo
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Okayama, Japan
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Vekstein AM, Doberne JW, Weissler EH, Wojnarski CM, Long CA, Williams AR, Plichta RP, Gaca JG, Hughes GC. Tailored approach and outcomes of aortic arch reconstruction after acute type A dissection repair. J Thorac Cardiovasc Surg 2023; 166:996-1008.e1. [PMID: 35282930 DOI: 10.1016/j.jtcvs.2022.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/11/2022] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE After limited root/ascending with or without hemiarch repair for acute type A aortic dissection (ATAAD), 20% to 30% of patients require distal reintervention, frequently for arch pathology. In this report, we describe an institutional algorithm for arch management after previous limited ATAAD repair and detail operative and long-term outcomes. METHODS From August 2005 to April 2021, 71 patients status post previous limited ATAAD repair underwent reoperative arch repair involving zones 1 to 3 for aneurysmal degeneration of residual arch dissection including complete cervical debranching with zone 0/1 thoracic endovascular aortic repair in 6 (8%), open total arch in 13 (18%), type I hybrid arch repair in 23 (32%), and type II/III hybrid arch repair in 29 (41%). RESULTS Mean age was 59 ± 12 years; time from index ATAAD repair to reoperation was 4 (interquartile range, 2-9) years. There were 2 (2.8%) in-hospital deaths and 2 (2.8%) postdischarge deaths within 30 days of surgery. Three patients suffered stroke (4.2%) and 2 (2.8%) had acute renal failure requiring dialysis. Overall Kaplan-Meier survival was 78%, 70%, and 58% at 1, 3, and 5 years, respectively. Institutional experience appeared to play a significant role in early and late outcomes, because there have been no operative mortalities in the past 9 years and improved survival of 87% versus 66%, 79% versus 58%, and 79% versus 40% at 1, 3, and 5 years in comparisons of the past 9 years with the previous era (P = .01). CONCLUSIONS Aneurysmal degeneration of residual arch dissection after limited ATAAD repair presents a complex reoperative challenge. An algorithmic operative approach tailored to patient anatomy and comorbidities yields excellent early and late outcomes, which continue to improve with increasing institutional experience.
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Affiliation(s)
- Andrew M Vekstein
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Julie W Doberne
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - E Hope Weissler
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Charles M Wojnarski
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Adam R Williams
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ryan P Plichta
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Nappi F, Alzamil A, Salsano A, Avtaar Singh SS, Gambardella I, Santini F, Fiore A, Perocchio G, Demondion P, Mesnildrey P, Schoell T, Bonnet N, Leprince P. Lactate-Based Difference as a Determinant of Outcomes following Surgery for Type A Acute Aortic Dissection: A Multi-Centre Study. J Clin Med 2023; 12:6177. [PMID: 37834821 PMCID: PMC10573384 DOI: 10.3390/jcm12196177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023] Open
Abstract
Type A acute aortic dissection (TAAAD) is a serious condition within the acute aortic syndromes that demands immediate treatment. Despite advancements in diagnostic and referral pathways, the survival rate post-surgery currently sits at almost 20%. Our objective was to pinpoint clinical indicators for mortality and morbidity, particularly raised arterial lactate as a key factor for negative outcomes. METHODS All patients referred to the three cardiovascular centres between January 2005 and December 2022 were included in the study. The inclusion criteria required the presence of a lesion involving the ascending aorta, symptoms within 7 days of surgery, and referral for primary surgical repair of TAAAD based on recommendations, with consideration for other concomitant major cardiac surgical procedures needed during TAAAD and retrograde extension of TAAAD. We conducted an analysis of both continuous and categorical variables and utilised predictive mean matching to fill in missing numeric features. For missing binary variables, we used logistic regression to impute values. We specifically targeted early postoperative mortality and employed LASSO regression to minimise potential collinearity of over-fitting variables and variables measured from the same patient. RESULTS A total of 633 patients were recruited for the study, out of which 449 patients had complete preoperative arterial lactate data. The average age of the patients was 64 years, and 304 patients were male (67.6%). The crude early postoperative mortality rate was 24.5% (110 out of 449 patients). The mortality rate did not show any significant difference when comparing conservative and extensive surgeries. However, malperfusion had a significant impact on mortality [48/131 (36.6%) vs. 62/318 (19.5%), p < 0.001]. Preoperative arterial lactates were significantly elevated in patients with malperfusion. The optimal prognostic threshold of arterial lactate for predicting early postoperative mortality in our cohort was ≥2.6 mmol/L. CONCLUSION The arterial lactate concentration in patients referred for TAAAD is an independent factor for both operative mortality and postoperative complications. In addition to mortality, patients with an upper arterial lactate cut-off of ≥2.6 mmol/L face significant risks of VA ECMO and the need for dialysis within the first 48 h after surgery. To improve recognition and facilitate rapid transfer and surgical treatment protocol, more diligent efforts are required in the management of malperfusion in TAAAD.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Almothana Alzamil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Italy DISC Department, University of Genoa, 16145 Genoa, Italy; (A.S.); (F.S.); (G.P.)
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Weill Cornell Medicine–New York, Presbyterian Medical Center, 505 E 70th St., New York, NY 10065, USA;
| | | | - Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Italy DISC Department, University of Genoa, 16145 Genoa, Italy; (A.S.); (F.S.); (G.P.)
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Créteil, France;
| | - Giacomo Perocchio
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Italy DISC Department, University of Genoa, 16145 Genoa, Italy; (A.S.); (F.S.); (G.P.)
| | - Pierre Demondion
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47–83, 75013 Paris, France; (P.D.); (P.L.)
| | - Patrick Mesnildrey
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Thibaut Schoell
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Nicolas Bonnet
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Pascal Leprince
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47–83, 75013 Paris, France; (P.D.); (P.L.)
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11
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Shetty V, Rajan VKA, makwana RK, Shetty DP, Narayan P. Total aortic arch replacement in acute type A aortic dissection - a single institutional experience. Indian J Thorac Cardiovasc Surg 2023; 39:489-496. [PMID: 37609625 PMCID: PMC10441847 DOI: 10.1007/s12055-023-01500-z] [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: 11/13/2022] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 08/24/2023] Open
Abstract
Aim Total arch replacement in the presence of acute aortic dissections is one of the most challenging areas of aortic surgery. Data on outcome in the Indian scenario is sparse. The aim of this study was to assess the outcome of arch replacements in a single tertiary care center. Material and methods In this single-center experience, 20 patients underwent total arch replacement between 2012 and 2022. Demographic, intraoperative, and postoperative data were abstracted from hospital records. Only patients with acute type A aortic dissection needing an arch repair were included. Patients with hemi-arch repairs, hybrid repairs, and those operated upon due to aneurysmal disease were excluded from the study. Comparison was made between survivors and non-survivors. Temporal trends for the procedure were assessed. Results The study included 20 patients who underwent total aortic arch replacement (TAR) during the study period (2012-2022). The mean age was 49.3 ± 12.5 years, and 15 (75%) of the patients were males. Seven (35%) patients were operated within 24 h of symptom onset. Permanent stroke was seen in 1 (5%) patient and temporary neurological dysfunction was observed in 1 (5%) patient. The re-exploration rate was 6 (30%) in the entire cohort and in-hospital mortality was 4 (20%). Follow-up was complete in 18 (90%) of the study population and 14 (87.5%) among survivors. There was one late death in our study which occurred after 46 months of the index operation. The overall mean survival was 76.1 months (95% CI: 49.86-102.43). Conclusion TAR can be performed both with acceptable mortality and morbidity in the presence of acute aortic dissections.
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Affiliation(s)
- Varun Shetty
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
| | | | | | - Devi Prasad Shetty
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Pradeep Narayan
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
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12
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Nappi F, Avtaar Singh SS, Gambardella I, Alzamil A, Salsano A, Santini F, Biancari F, Schoell T, Bonnet N, Folliguet T, Fiore A. Surgical Strategy for the Repair of Acute Type A Aortic Dissection: A Multicenter Study. J Cardiovasc Dev Dis 2023; 10:253. [PMID: 37367418 DOI: 10.3390/jcdd10060253] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/24/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023] Open
Abstract
Type A acute aortic dissection is associated with significant morbidity and mortality, with prompt referral imaging and management to tertiary referral centers needed urgently. Surgery is usually needed emergently, but the choice of surgery often varies depending on the patient and the presentation. Staff and center expertise also play a major role in determining the surgical strategy employed. The aim of this study was to compare the early- and medium-term outcomes of patients undergoing a conservative approach extended only to the ascending aorta and the hemiarch to those of patients subjected to extensive surgery (total arch reconstruction and root replacement) across three European referral centers. A retrospective study was conducted across three sites between January 2008 and December 2021. In total, 601 patients were included within the study, of which 30% were female, and the median age was 64.4 years. The most common operation was ascending aorta replacement (n = 246, 40.9%). The aortic repair was extended proximally (i.e., root n = 105; 17.5%) and distally (i.e., arch n = 250; 41.6%). A more extensive approach, extending from the root to the arch, was employed in 24 patients (4.0%). Operative mortality occurred in 146 patients (24.3%), and the most common morbidity was stroke (75, 12.6%). An increased length of ICU admission was noted in the extensive surgery group, which comprised younger and more frequently male patients. No significant differences were noted in surgical mortality between patients managed with extensive surgery and those managed conservatively. However, age, arterial lactate levels, "intubated/sedated" status on arrival, and "emergency or salvage" status at presentation were independent predictors of mortality both within the index hospitalization and during the follow-up. The overall survival was similar between the groups.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
| | | | - Ivancarmine Gambardella
- Department of Cardiothoracic Surgery, Weill Cornell Medicine-New York, Presbyterian Medical Center, New York, NY 10065, USA
| | - Almothana Alzamil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
| | - Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, DISC Department, University of Genoa, 16126 Genoa, Italy
| | - Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, DISC Department, University of Genoa, 16126 Genoa, Italy
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00231 Helsinki, Finland
| | - Thibaut Schoell
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
| | - Nicolas Bonnet
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
| | - Thierry Folliguet
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France
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13
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Kim DJ, Song JY, Shin HB, Lee SH, Lee S, Youn YN, Yoo KJ, Joo HC. Effects of Residual Arch Tears on Late Outcomes After Hemiarch Replacement for DeBakey I Dissection. Ann Thorac Surg 2023; 115:896-903. [PMID: 36167097 DOI: 10.1016/j.athoracsur.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 08/14/2022] [Accepted: 09/06/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND This study evaluated the effect of residual arch tears on late reinterventions and arch dilatation after hemiarch replacement for patients with acute DeBakey type I aortic dissection. METHODS Between January 1995 and October 2018, 160 consecutive patients who underwent hemiarch replacement for DeBakey type I dissection were retrospectively enrolled. They were divided into patients with (n = 73) and without (n = 87) residual arch tears. The arch tears group was subdivided into the proximal/middle arch (n = 26) and distal arch (n = 47) groups to evaluate arch growth rates according to the locations of residual arch tears. The endpoints were arch growth rate and late arch and composite events. RESULTS The arch diameter increased significantly over time in patients with residual arch tears (1.620 mm/y, P < .001). The increase occurred more rapidly when residual tears occurred at the distal arch than at the proximal/middle arch level (2.101 vs 1.001 mm/y). In the adjusted linear mixed model, residual arch tears or luminal communications at the distal arch level were significant factors associated with increases in the arch diameter over time. The 10-year freedom from late arch and composite event rate was significantly lower for patients with residual arch tears than for those without (82.4% vs 95.5%, P = .001; and 68.0% vs 89.3%, P = .002, respectively). CONCLUSIONS Residual arch tears are significant factors associated with late arch dilatation and reinterventions, especially for patients with distal arch tears. Extensive arch replacement during the initial surgery to avoid residual arch tears may improve long-term outcomes.
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Affiliation(s)
- Do Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea; Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon-Young Song
- Department of Thoracic and Cardiovascular Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Han-Bit Shin
- Office of Biostatistics, Medical Research Collaboration Center, Ajou Research Institute for Innovation, Ajou University Medical Center, Suwon, Korea
| | - Seung Hyun Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sak Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Nam Youn
- Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Jong Yoo
- Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun-Chel Joo
- Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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14
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Nappi F, Petiot S, Salsano A, Avtaar Singh SS, Berger J, Kostantinou M, Bonnet S, Gambardella I, Biancari F, Almazil A, Santini F, Chaara R, Fiore A. Sex-Based Difference in Aortic Dissection Outcomes: A Multicenter Study. J Cardiovasc Dev Dis 2023; 10:jcdd10040147. [PMID: 37103025 PMCID: PMC10143202 DOI: 10.3390/jcdd10040147] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Background: Type A Acute Aortic Dissection (TAAAD) repair is a surgical emergency associated with high morbidity and mortality. Registry data have noted several sex-specific differences in presentation with TAAAD which may account for the differences in men and women undergoing surgery for this condition. Methods: A retrospective review of data from three departments of cardiac surgery (Centre Cardiologique du Nord, Henri-Mondor University Hospital, San Martino University Hospital, Genoa) between January 2005 and 31 December 2021 was conducted. Confounders were adjusted using doubly robust regression models, a combination of regression models with inverse probability treatment weighting by propensity score. Results: 633 patients were included in the study, of which 192 (30.3%) were women. Women were significantly older with reduced haemoglobin levels and pre-operative estimated glomerular filtration rate compared to men. Male patients were more likely to undergo aortic root replacement and partial or total arch repair. Operative mortality (OR 0.745, 95% CI: 0.491–1.130) and early postoperative neurological complication results were comparable between the groups. The adjusted survival curves using IPTW by propensity score confirmed the absence of a significant impact of gender on long-term survival (HR 0.883, 95% CI 0.561–1.198). In a subgroup analysis of women, preoperative levels of arterial lactate (OR 1.468, 95% CI: 1.133–1.901) and mesenteric ischemia after surgery (OR 32.742, 95% CI: 3.361–319.017) were significantly associated with increased operative mortality. Conclusions: The advancing age of female patients alongside raised preoperative level of arterial lactate may account for the increasing preponderance among surgeons to perform more conservative surgery compared to their younger male counterparts although postoperative survival was similar between the groups.
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15
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Narita M, Tsutsui M, Ushioda R, Kikuchi Y, Shirasaka T, Ishikawa N, Kamiya H. Proximal and extended aortic arch replacement in acute DeBakey type I aortic dissection. Front Surg 2023; 10:1081167. [PMID: 36860951 PMCID: PMC9968786 DOI: 10.3389/fsurg.2023.1081167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023] Open
Abstract
Objective This study aimed to compare the short- and long-term outcomes of proximal repair vs. extensive arch surgery for acute DeBakey type I aortic dissection. Subjects From April 2014 to September 2020, 121 consecutive patients with acute type A dissection were surgically treated at our institute. Of these patients, 92 had dissections extending beyond the ascending aorta. Methods Of the 92 patients, 58 underwent proximal repair, including aortic root and/or hemiarch replacement, and 34 underwent extended repair, including partial and total arch replacement. Perioperative variables and early and late postoperative results were statistically analyzed. Results The duration of surgery, cardiopulmonary bypass, and circulatory arrest was significantly shorter in the proximal repair group (p < 0.01). The overall operative mortality rate was 10.3% in the proximal repair group and 14.7% in the extended repair group (p = 0.379). The mean follow-up period was 31.1 ± 26.7 months in the proximal repair group and 35.3 ± 26.8 months in the extended repair group. During follow-up, the cumulative survival and freedom from reintervention rates at 5 years were 66.4% and 92.9% in the proximal repair group, and 76.1% and 72.6% in the extended repair group, respectively (p = 0.515 and p = 0.134). Conclusions No significant differences were found in the rates of long-term cumulative survival and freedom from aortic reintervention between the two surgical strategies. These findings suggest limited aortic resection achieves acceptable patient outcomes.
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Affiliation(s)
- Masahiko Narita
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | | | - Ryouhei Ushioda
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Yuta Kikuchi
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Tomonori Shirasaka
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Natsuya Ishikawa
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
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16
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Chemtob RA, Ede J, Herou E, Larsson M, Nozohoor S, Sjögren J, Wierup P, Zindovic I. Limited Distal Repair Results in Low Rates of Distal Events Following Surgery for Acute Type A Aortic Dissection. Semin Thorac Cardiovasc Surg 2023; 35:7-15. [PMID: 34774770 DOI: 10.1053/j.semtcvs.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 11/11/2022]
Abstract
To investigate mortality and reoperation rates following limited distal repair after acute type A aortic dissection (ATAAD) at a single medium volume institution. We analyzed all patients that underwent limited distal repair (ascending aortic or hemiarch replacement) following ATAAD between January 1998 and April 2020 at our institution. During the study period, 489 patients underwent ATAAD surgery, of which 457 (94%) underwent limited distal repair with a 30-day mortality of 12.9%. Among 30-day survivors, late follow-up was 97.7% complete with a mean follow-up of 6.0 ± 5.5 years. In all, 50 patients (11%) required a reoperation during the study period at a mean of 3.4 ± 3.4 years after initial repair, with a 30-day mortality of 12%. An aortic reoperation was required in 4.1 (2.0-6.1)%, 10.3 (7.1-13.6)%, 15.1 (10.9-19.4)%, and 18.0 (13.0-22.9)% of patients at 1, 5, 10, and 15 years. A distal reoperation was required in 3.0 (1.2-4.7)%, 8.0 (5.1-10.9)%, 10.3 (6.8-13.8)%, and 12.4 (8.2-16.5)% of patients and 4.4 (2.3-6.4)%, 10.4 (7.1-13.7)%, 13.9 (9.8-18.0)%, and 16.9 (12.0-21.9)% of patents had a distal event at 1, 5, 10, and 15 years, respectively. Limited distal repair with an ascending aortic or hemiarch replacement was associated with acceptable survival and rates of reoperations and distal events. Limited distal repair is a safe and feasible standard approach to ATAAD surgery at a medium-volume center.
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Affiliation(s)
- Raphaelle A Chemtob
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden; Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Jacob Ede
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Erik Herou
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mårten Larsson
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Shahab Nozohoor
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Johan Sjögren
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Per Wierup
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden; Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Igor Zindovic
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden.
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17
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Sá MP, Jacquemyn X, Tasoudis PT, Van den Eynde J, Erten O, Sicouri S, Dokollari A, Torregrossa G, Kurz S, Heuts S, Nienaber CA, Coselli JS, Ramlawi B. Long-term outcomes of total arch replacement versus proximal aortic replacement in acute type A aortic dissection: Meta-analysis of Kaplan-Meier-derived individual patient data. J Card Surg 2022; 37:4256-4266. [PMID: 36086999 DOI: 10.1111/jocs.16852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/21/2022] [Accepted: 07/28/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To evaluate the long-term outcomes of a conservative approach (with proximal aortic replacement with or without hemiarch replacement) versus an aggressive approach (with total aortic arch replacement) in the treatment of acute type A aortic dissection (ATAAD). METHODS We performed a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing the aforementioned approaches to treat patients with ATAAD. RESULTS Eighteen studies met our eligibility criteria, comprising 5243 patients with follow-up (Conservative: 3676 patients; Aggressive: 1567 patients). We observed a statistically significant difference in overall survival favoring the aggressive approach (hazard ratios [HR] 0.86, 95% confidence interval [CI] 0.76-0.98, p = .022), but no statistically significant difference in the risk of reoperation (HR 0.89, 95% CI 0.66-1.2, p = .439) in the overall follow-up. Landmark analyses revealed that, in the first 3 months after the procedure, mortality rates were comparable between conservative and aggressive approaches (HR 1.04, 95% CI 0.88-1.24, p = .627), but the results beyond 3 months showed improved survival in patients undergoing the aggressive surgical procedure (HR 0.71, 95% CI 0.59-0.85, p < .001). The landmark analyses also revealed that, in the first 7 years after the procedure, reoperation rates were comparable between the approaches (HR 1.03, 95% CI 0.76-1.40, p = .848), but the results beyond 7 years showed a lower risk of reoperation in patients undergoing the aggressive surgical procedure (HR 0.10, 95% CI 0.01-0.75, p = .025). CONCLUSION The aggressive approach seems to confer better long-term survival and lower risk of the need for reoperation in the follow-up of patients treated for ATAAD.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Panagiotis T Tasoudis
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | | | - Ozgun Erten
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Serge Sicouri
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Alexander Dokollari
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Gianluca Torregrossa
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Stephan Kurz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charité-Universitätsmedizin, Berlin, Germany
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, The Royal Brompton & Harefield NHS Trust, London, UK
| | - Joseph S Coselli
- Department of Surgery, Division of Cardiothoracic Surgery, Michael E. DeBakey Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,CHI St Luke's-Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Basel Ramlawi
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
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18
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Ma L, Chai T, Yang X, Zhuang X, Wu Q, Chen L, Qiu Z. Outcomes of hemi- vs. total arch replacement in acute type A aortic dissection: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:988619. [PMID: 36237909 PMCID: PMC9552831 DOI: 10.3389/fcvm.2022.988619] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/01/2022] [Indexed: 11/20/2022] Open
Abstract
Background Acute type A aortic dissections (ATAAD) pose a challenge to surgeons due to high mortality, and decision making regarding the appropriate procedure is controversial. This study compared the outcomes of hemiarch and total arch replacement for ATAAD. Methods The PubMed, Web of Science, Embase and Cochrane databases were searched for comparative studies on hemiarch versus total arch replacement that were published before May 1, 2022. Results We included 23 observational studies with a total of 4,576 patients. Combined data analysis showed that early mortality (RR = 0.82; 95% CI: 0.70–0.97; P = 0.02), incidence of postoperative permanent neurological dysfunction (RR = 0.72; 95%CI:0.54∼0.94; P = 0.02), and incidence of renal failure and dialysis (RR = 0.82; 95%CI:0.71∼0.96; P = 0.01) were all lower for hemiarch than for total arch replacement. However, hemiarch replacement had a higher rate of late mortality (RR = 1.37; 95%CI:1.10∼1.71; P = 0.005). There were no statistically significant differences between the two groups in terms of re-operation for bleeding, aortic re-operation, or postoperative pneumonia. Conclusion In this study, hemiarch replacement had better early outcomes but a higher late mortality rate than total arch replacement. Decisions regarding the extent of arch repair should be made according to location and extent of ATAAD and the experience of surgeons to ensure the most favorable prognosis. Systematic review registration: [INPLASY.COM], identifier [INPLASY202250088].
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Affiliation(s)
- Likang Ma
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, China
| | - Tianci Chai
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, China
| | - Xiaojie Yang
- Department of Thoracic Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Xinghui Zhuang
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, China
| | - Qingsong Wu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, China
- *Correspondence: Liangwan Chen,
| | - Zhihuang Qiu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, China
- Zhihuang Qiu,
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19
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Hayashi J, Nakajima H, Asakura T, Sho R, Tokunaga C, Takazawa A, Yoshitake A. Safety and arch complications after hemiarch versus total arch replacement with stented elephant trunk in acute type 1 dissection: Is a stent graft always beneficial? JTCVS OPEN 2022; 11:14-22. [PMID: 36172444 PMCID: PMC9510885 DOI: 10.1016/j.xjon.2022.06.014] [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: 07/26/2019] [Revised: 05/26/2022] [Accepted: 06/17/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE We aimed to determine the efficacy of total arch replacement with stented elephant trunk by comparing it with hemiarch replacement with and without open stent graft for acute aortic dissection type 1. METHODS We reviewed records of 177 patients who underwent hemiarch replacement (HAR group) (concomitant open stent, 125) and 98 patients who underwent total arch replacement (TAR group) (concomitant stented elephant trunk, 91) for acute type 1 dissection. Compared with the TAR group, the HAR group was older (68.1 vs 60.9 years; P < .01) and had more thrombosed false lumen (28.8% vs 4.1%, P < .01). RESULTS In-hospital death occurred for 7 patients in the HAR group and 1 patient in the TAR group (P = .17). More patients in the TAR group had a postoperative thrombosed false lumen, compared with the HAR group (68% vs 54%, P = .03). In patients with preoperative nonthrombosed false lumen in the HAR group, the rate of postoperative thrombosis was significantly lower than with versus without an open stent (31% vs 65%, P = .01). The rate of freedom from an aortic arch event in the TAR group at 5 years was significantly greater than that in the HAR group (100% vs 83.7%, P = .01). CONCLUSIONS Stented elephant trunk with TAR provided a high rate of false lumen thrombosis and a low incidence of arch events, whereas an open stent during HAR was not beneficial in terms of false lumen thrombosis and arch event prevention.
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Affiliation(s)
- Jun Hayashi
- Department of Cardiovascular Surgery, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Toshihisa Asakura
- Department of Cardiovascular Surgery, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Ri Sho
- Department of Public Health & Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Chiho Tokunaga
- Department of Cardiovascular Surgery, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Akitoshi Takazawa
- Department of Cardiovascular Surgery, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Akihiro Yoshitake
- Department of Cardiovascular Surgery, International Medical Center, Saitama Medical University, Saitama, Japan
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20
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Wada T, Yamamoto H, Takagi D, Kadohama T, Yamaura G, Kiryu K, Igarashi I. Aortic remodeling, reintervention, and survival after zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection: Midterm results. JTCVS Tech 2022; 14:29-38. [PMID: 35967231 PMCID: PMC9366877 DOI: 10.1016/j.xjtc.2022.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 05/24/2022] [Indexed: 12/13/2022] Open
Abstract
Objectives To investigate the midterm results after zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection. Methods Between October 2014 and April 2021, 196 patients underwent zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection. The true lumen area, aortic lumen area, and false lumen status were assessed at four aortic levels, the proximal and distal descending thoracic aorta (level A and level B, respectively), celiac artery branching (level C), and terminal aorta (level D). Aortic remodeling (postoperative area as a percentage of the preoperative area) was classified into 3 groups, positive (true lumen area ≥120% with aortic lumen <120% or true lumen area ≥80% with aortic lumen <80%), minimal (80% ≤ true lumen area and aortic lumen area <120%), and negative remodeling (all other changes). Results In-hospital mortality was 13 (6.6%) patients. The overall survival rate was 85.1% at 5 years. The freedom from distal aortic reintervention was 89.9% at 5 years. The prevalence of completely thrombosed or obliterated false lumen at 2 years was 96.8% at level A, 88.4% at level B, 47.2% at level C, and 27.6% at level D. The prevalence of positive aortic remodeling at 2 years was 84.7% at level A, 75.0% at level B, 29.2% at level C, and 16.7% at level D. Conclusions Zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection can avoid invasive aortic arch resection and facilitate aortic remodeling of the descending thoracic aorta. The FET effect on aortic remodeling is limited at the aortic level below the FET stent end.
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Key Words
- AL, aortic lumen
- ATAAD, acute type A aortic dissection
- CPB, cardiopulmonary bypass
- CT, computed tomography
- FET, frozen elephant trunk
- FL, false lumen
- TAR, total arch replacement
- TEVAR, thoracic endovascular aortic repair
- TL, true lumen
- Z-0-FET, zone 0 arch repair with frozen elephant trunk
- acute type A aortic dissection
- aortic remodeling
- dSINE, distal stent graft-induced new entry
- distal stent-induced new entry
- frozen elephant trunk
- zone 0 arch repair
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Affiliation(s)
- Takuya Wada
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiroshi Yamamoto
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Daichi Takagi
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Takayuki Kadohama
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Gembu Yamaura
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Kentaro Kiryu
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Itaru Igarashi
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
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21
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Mehdiani A, Sugimura Y, Wollgarten L, Immohr MB, Bauer S, Schelzig H, Wagenhäuser MU, Antoch G, Lichtenberg A, Akhyari P. Early Results of a Novel Hybrid Prosthesis for Treatment of Acute Aortic Dissection Type A With Distal Anastomosis Line Beyond Aortic Arch Zone Zero. Front Cardiovasc Med 2022; 9:892516. [PMID: 35911517 PMCID: PMC9329696 DOI: 10.3389/fcvm.2022.892516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/14/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Acute aortic dissection type A (AADA) is associated with high perioperative morbidity and mortality. A novel non-covered hybrid prosthesis (Ascyrus Medical Dissection Stent (AMDS) Hybrid Prosthesis, Cryolife/Jotec, Hechingen, Germany) can be easily implanted to stabilize the true lumen (TL), improve remodeling, and preserve organ perfusion. Although developed for implantation in aortic zone 0, occasionally, partial replacement of the aortic arch and further distal implantation of AMDS may appear favorable. Implantation of AMDS with anastomosis line beyond zone 0 has not been described yet. Materials and Methods Between 08/2019 and 12/2020, a total of n = 97 patients were treated due to AADA at a single University hospital. Of those, n = 28 received an AMDS hybrid prosthesis, of whom in eight patients, due to intraoperative finding the distal anastomosis line was placed distal to the brachiocephalic trunk. Three patients had AMDS implantation in zone I and four were treated by implantation of the prostheses in zone II, and one patient had the implantation performed in zone III. Clinical outcome and the development of a proportional area of TL and false lumen (FL) at defined levels of the thoracic aorta were analyzed. Results None of the surviving patients (87.5%) showed signs of clinical malperfusion (i.e., stroke, spinal cord injury, and need for dialysis). A postoperative CT scan showed an open TL in all patients. The proportion of TL with respect to total aortic diameter (TL+FL) was postoperatively significantly higher in zone III (p = 0.016) and at the level of T11 (p = 0.009). The mean area of TL+FL was comparable between pre- and postoperative CT-scan (p = n.s.). One patient with preoperative resuscitation died of multiple organ failure on extracorporeal life support on postoperative day 3. Conclusion Implantation of AMDS can be safely performed in patients who need partial replacement of the aortic arch beyond zone 0. The advantages of the AMDS can be combined with those of the total arch repair (remodeling of the arch and prevention of TL collapse) without the possible disadvantages (risk of spinal cord injury).
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Affiliation(s)
- Arash Mehdiani
- Department of Cardiac Surgery, Heinrich Heine University Duesseldorf, Düsseldorf, Germany
| | - Yukiharu Sugimura
- Department of Cardiac Surgery, Heinrich Heine University Duesseldorf, Düsseldorf, Germany
| | - Louise Wollgarten
- Department of Cardiac Surgery, Heinrich Heine University Duesseldorf, Düsseldorf, Germany
| | - Moritz Benjamin Immohr
- Department of Cardiac Surgery, Heinrich Heine University Duesseldorf, Düsseldorf, Germany
| | - Sebastian Bauer
- Department of Cardiac Surgery, Heinrich Heine University Duesseldorf, Düsseldorf, Germany
| | - Hubert Schelzig
- Department of Vascular and Endovascular Surgery, Heinrich Heine University Duesseldorf, Düsseldorf, Germany
| | - Markus Udo Wagenhäuser
- Department of Vascular and Endovascular Surgery, Heinrich Heine University Duesseldorf, Düsseldorf, Germany
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, Heinrich Heine University Duesseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Heinrich Heine University Duesseldorf, Düsseldorf, Germany
- *Correspondence: Artur Lichtenberg
| | - Payam Akhyari
- Department of Cardiac Surgery, Heinrich Heine University Duesseldorf, Düsseldorf, Germany
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22
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Suzuki R, Kurazumi H, Nawata R, Yokoyama T, Tsubone S, Matsuno Y, Shirasawa B, Mikamo A, Hamano K. Intimal-protected adventitial inversion technique accelerates the obliteration of a patent false lumen. J Card Surg 2022; 37:2600-2606. [PMID: 35771215 DOI: 10.1111/jocs.16720] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/09/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS The optimal procedure for reconstructing the dissected aortic stump for acute type A dissection remains controversial. We routinely used the intimal-protected adventitial inversion technique (iPAIT), a modified adventitial inversion technique, to protect the fragile intima by inserting a graft and assessed the safety and efficacy of this technique. METHODS Between August 2008 and April 2020, 146 consecutive patients with acute type A dissections underwent thoracic aortic surgery in our hospital. Extended total aortic arch replacement was performed in 119 patients (81.5%). Sixty-nine patients underwent treatment for distal aortic anastomosis with the iPAIT. To compare the iPAIT to a historical control, we assessed 69 iPAIT patients and 25 patients who underwent total arch replacement using gelatin-resorcinol-formaldehyde (GRF) glue. RESULTS Hospital mortality was 2.9% in the iPAIT group and 8.0% in the GRF group. Perioperative characteristics were similar between the two groups. However, postoperative computed tomography revealed that the obliteration rate was significantly higher in the iPAIT group (60/66, 90.9%) than in the GRF group (15/23, 65.2%) (p = .01), not including the patients who had died or developed severe renal dysfunction. The 8-year aortic event-free survival rate in the iPAIT group (81.3%) was significantly higher than that in the GRF group (47.4%). CONCLUSIONS The use of this technique for acute type A dissections resulted in a low mortality rate and demonstrated promising midterm survival and may accelerate the obliteration of a patent false lumen and prevent late aortic events.
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Affiliation(s)
- Ryo Suzuki
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Hiroshi Kurazumi
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Ryosuke Nawata
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Toshiki Yokoyama
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Sarii Tsubone
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Yutaro Matsuno
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Bungo Shirasawa
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Akihito Mikamo
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Kimikazu Hamano
- Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
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23
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Othman AA, Elgharably H, Vargo PR, Ayyat KS, Bakaeen FG, Johnston DR, Tong MZ, Unai S, Kalahasti V, Sevensson LG, Roselli EE. Valve-Preserving Root Reimplantation Combined with Arch Procedure: Optimizing Patient Selection. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:201-208. [PMID: 35604783 DOI: 10.1177/15569845221094007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Patients with thoracic aortic disease commonly present with concomitant multisegment pathology. We describe the patient population, analyze outcomes, and define the patient selection strategy for valve-preserving aortic root reimplantation (VPARR) combined with the arch procedure. Methods: From 2008 to 2018, 98 patients underwent VPARR combined with the aortic arch procedure (hemi-arch, 50% [n = 49, limited repair]; total arch, 50% [n = 49, complete repair] including 39 with elephant trunk). Indications for surgery were aneurysmal disease (61%) and aortic dissection (39%). The median follow-up was 17 months (IQR, 8 to 60 months). Results: There were no operative deaths or paraplegia, and 5 patients underwent re-exploration for bleeding. During follow-up, 2 patients required aortic valve replacement for severe aortic insufficiency at 1 and 5 years, and 4 patients died. In the limited repair group, 1 patient underwent reintervention for aortic arch replacement, whereas 4 patients underwent planned intervention (1 endovascular and 3 open thoracoabdominal aortic repair). In the complete repair group, 23 patients underwent planned intervention (15 endovascular and 8 open thoracoabdominal repair). Conclusions: Single-stage, complete, proximal aortic repair including VPARR combined with total aortic arch replacement is as safe and feasible to perform as limited arch repair and facilitates further intervention in carefully selected patients with diffuse aortic pathology at centers of expertise.
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Affiliation(s)
- Ahmed A Othman
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,8959Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Haytham Elgharably
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Patrick R Vargo
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Kamal S Ayyat
- Lerner Research Institute, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Faisal G Bakaeen
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Douglas R Johnston
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Michael Z Tong
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Shinya Unai
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Vidyasagar Kalahasti
- Cardiovascular Medicine, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Lars G Sevensson
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Eric E Roselli
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
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24
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Kallenbach K, Büsch C, Rylski B, Dohle DS, Krüger T, Holubec T, Brickwedel J, Pöling J, Noack T, Hagl C, Jawny P, Böning A, Chalabi K, Karck M, Arif R. Treatment of the aortic root in acute aortic dissection type A: insights from the German Registry for Acute Aortic Dissection Type A. Eur J Cardiothorac Surg 2022; 62:ezac261. [PMID: 35511255 DOI: 10.1093/ejcts/ezac261] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 04/04/2022] [Accepted: 04/16/2022] [Indexed: 02/21/2024] Open
Abstract
OBJECTIVES Surgery of the aortic root in acute aortic dissection type A (AADA) remains a topic of vague evidence since the extend of dissection and surgeons' capability and interpretation of the disease vary remarkably. We aimed to interpret root operation strategies in the German Registry for Acute Aortic Dissection cohort. METHODS German Registry for Acute Aortic Dissection collected the data of 56 centres between July 2006 and June 2015. A total of 3382 patients undergoing operations for AADA were included and divided into 3 groups according to aortic root procedure types: supracommissural replacement (SCR), conduit replacement (CR) and valve sparing root replacement (VSRR). RESULTS Patients in SCR (2425, 71.7%) were significantly older than CR (681, 20.1%) and VSRR (276, 8.2%) (63.4 vs 57.5 vs 54.2 years; P < 0.001), more female (38.9% vs 32.0% vs 26.1%; P < 0.001) and presented with less aortic regurgitation (26.3% vs 57.1% vs 56.5%; P < 0.001). VSRR presented with slightly less multiple organ malperfusion (11.6% vs 12.0% vs 10.9%; P = 0.045) and were more often diagnosed for Marfan syndrome (2.4% vs 5.1% vs 9.1%; P < 0.001). Thirty-day mortality was lower for VSRR (11.6%) compared to SCR (16.1%) and CR (19.8%; P = 0.010). Despite longer procedural times, multivariable regression showed no influence of total arch replacement for VSRR on mortality compared to CR (odds ratio 0.264; 95% confidence interval, 0.033-2.117; P = 0.21). CONCLUSIONS SCR remains the procedure of choice in elderly and compromised patients. Extended root preservation techniques may be applied even in combination with extended aortic arch surgery for selected patients for AADA with promising early outcomes.
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Affiliation(s)
- Klaus Kallenbach
- Department of Cardiac Surgery, INCCI HaerzZenter, Luxembourg City, Luxembourg
- Department of Cardiac Surgery, University Hospital Heidelberg, German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | - Christopher Büsch
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel-Sebastian Dohle
- Department of Cardiac and Vascular Surgery, University Hospital Mainz, German Center for Cardiovascular Research (DZHK), Partner Site Mainz, Mainz, Germany
| | - Tobias Krüger
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, German Center for Cardiovascular Research (DZHK), Partner Site Frankfurt, Frankfurt, Germany
| | - Jens Brickwedel
- University Heart & Vascular Center Hamburg, Department of Cardiovascular Surgery, German Center for Cardiovascular Research (DZHK), Partner Site Hamburg, Hamburg, Germany
| | - Jochen Pöling
- Department of Cardiac Surgery, Schuechtermann Clinic, Bad Rothenfelde, Germany
| | - Thilo Noack
- University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Philipp Jawny
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Khaled Chalabi
- Department of Cardiac Surgery, INCCI HaerzZenter, Luxembourg City, Luxembourg
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Department of Cardiac Surgery, University Hospital Heidelberg, German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
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25
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Extending Aortic Replacement Beyond the Proximal Arch in Acute Type A Aortic Dissection: A Meta-Analysis of Short Term Outcomes and Long Term Actuarial Survival. Eur J Vasc Endovasc Surg 2022; 63:674-687. [DOI: 10.1016/j.ejvs.2021.12.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/07/2021] [Accepted: 12/28/2021] [Indexed: 12/29/2022]
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26
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Crawford TC, Brown C, Grimm JC. Aortic Arch Management During Repair of Acute Type A Dissections: Don't Lose Sight of the Big Picture. Ann Thorac Surg 2022; 114:701-702. [PMID: 35351426 DOI: 10.1016/j.athoracsur.2022.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/05/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Todd C Crawford
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104.
| | - Chase Brown
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104
| | - Joshua C Grimm
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104
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27
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Zhang B, Sun X, Liu Y, Dun Y, Liang S, Yu C, Qian X, Gao H, Ren J, Wang L, Zhou S. Hybrid Technique on the Total Arch Replacement for Type A Aortic Dissection: 12-year Clinical and Radiographical Outcomes From a Single Center. Front Cardiovasc Med 2022; 9:820653. [PMID: 35295249 PMCID: PMC8918914 DOI: 10.3389/fcvm.2022.820653] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/06/2022] [Indexed: 11/26/2022] Open
Abstract
Objective Hybrid total arch replacement (HTAR) was an alternative for type A aortic dissection (TAAD). This study aimed to evaluate the clinical and radiographical outcomes of HTAR for TAAD and to evaluate the clinical outcomes of performing this procedure under mild hypothermia. Methods A total of 209 patients who underwent HTAR for TAAD were retrospectively analyzed and stratified into mild (n = 48) and moderate (n = 161) hypothermia groups to evaluate the effects of mild hypothermia on the clinical outcomes. Long-term clinical outcomes were evaluated by the overall survival and adverse aortic events (AAEs). A total of 176 patients with preoperative and at least one-time postoperative aortic computed tomography angiography in our institute were included for evaluating the late aortic remodeling (aortic diameter and false lumen thrombosis). Results The median follow-up period was 48.3 (interquartile range [IQR] = 28.4–73.7) months. The overall survival rate was 88.0, 83.2, and 77.1% at the 1, 5, and 10 years, respectively, and in the presence of death as a competing risk, the cumulative incidence of AAEs was 4.8, 9.9, and 12.1% at the 1, 5, and 10 years. The aortic diameters were stable in the descending thoracic and abdominal aorta (P > 0.05 in all the measured aortic segments). A total of 100% complete false lumen thrombosis rate in the stent covered and distal thoracic aorta were achieved at 1 year (64/64) and 4 years (18/18), respectively after HTAR. The overall composite adverse events morbidity and mortality were 18.7 and 10.0%. Mild hypothermia (31.2, IQR = 30.2–32.0) achieved similar composite adverse events morbidity (mild: 14.6 vs. moderate: 19.9%, P = 0.41) and early mortality (mild: 10.4 vs. moderate: 9.9%, P = 1.00) compared with moderate hypothermia (median 27.7, IQR = 27–28.1) group, but mild hypothermia group needed shorter cardiopulmonary bypass (mild: 111, IQR = 93–145 min vs. moderate: 136, IQR = 114–173 min, P < 0.001) and aortic cross-clamping (mild: 45, IQR = 37–56 min vs. moderate: 78, IQR = 54–107 min, P < 0.001) time. Conclusion Hybrid total arch replacement achieved desirable early and long-term clinical outcomes for TAAD. Performing HTAR under mild hypothermia was as safe as under moderate hypothermia. After HTAR for TAAD, dissected aorta achieved desirable aortic remodeling, presenting as stable aortic diameters and false lumen complete thrombosis. In all, HTAR is a practical treatment for TAAD.
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28
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Chen JW, Sainbayar N, Hsu RB. Outcome of emergency surgery for acute type A aortic dissection in octogenarians. J Card Surg 2022; 37:610-615. [PMID: 34996133 DOI: 10.1111/jocs.16219] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergency surgery for acute type A aortic dissection (AAAD) was usually avoided or denied in octogenarians because of high surgical mortality. Refined surgical techniques and improved postoperative care have led to an improved in-hospital outcome. However, a significant number of operative survivors suffered from postoperative complications and had compromised quality of life. We sought to assess the clinical outcome of emergency surgery using a standard conservative approach in octogenarians with AAAD. METHODS From 2004 to 2021, 123 patients underwent emergency surgery for AAAD by one surgeon using a standard conservative approach with right subclavian artery cannulation, no aortic cross-clamp, selective antegrade cerebral perfusion, moderate systemic hypothermia, reinforced sandwich technique, and a strategy of limited aortic resection. Hospital and late outcomes were assessed in patients with age >80 years. RESULTS Eighteen patients (15%) were octogenarians with seven males (39%) and median age of 82 years (range, 80-89). Hypertension was present in six patients (33%). None had diabetes mellitus, Marfan, or bicuspid aortic valve. Dissection was intramural hematoma in six (33%) and DeBakey type I in 15 patients (83%). Cardiac tamponade with shock was present in seven patients (39%). Ascending aortic grafting was performed in 17 patients, and additional hemiarch replacement in one patient. The hospital mortality rate was 17% (3/18). Fourteen patients (82%) were alive and well at discharge. CONCLUSIONS Emergency surgery for AAAD using a standard conservative approach showed an improved outcome in octogenarians. The majority of patients could return home with an acceptable living.
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Affiliation(s)
- Jeng-Wei Chen
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Nyamsuren Sainbayar
- Department of Cardiovascular Surgery, Third State Central Hospital, Ulan Bator, Mongolia
| | - Ron-Bin Hsu
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Einfluss der bikuspiden und trikuspiden Aortenklappe bei Typ-A-Aortendissektion. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2021. [DOI: 10.1007/s00398-021-00468-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kawahito K, Aizawa K, Kimura N, Yamaguchi A, Adachi H. Influence of residual primary entry following the tear-oriented strategy for acute type A aortic dissection. Eur J Cardiothorac Surg 2021; 61:1077-1084. [PMID: 34849682 DOI: 10.1093/ejcts/ezab456] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/09/2021] [Accepted: 08/19/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Although a tear-oriented strategy has contributed to improving short-term surgical outcomes of acute type A aortic dissection (ATAAD), long-term clinical influences of residual entry tear in the downstream aorta have not been fully investigated. The goal of this study was to assess the long-term surgical outcomes of ATAAD with or without a residual entry tear in the downstream aorta. METHODS Medical records of 1107 patients with ATAAD who underwent emergency surgery between 1990 and 2018 were retrospectively reviewed. A tear-oriented paradigm was adopted for the baseline strategy. The 837 patients in whom the entry tears were resected comprised the resected group, and the 270 patients with a residual entry tear comprised the residual group. Of these patients, 252 in each group were analysed using propensity score matching, and long-term outcomes were compared with or without residual entry. RESULTS Hospital deaths were lower in the resected group (3.2% vs 8.3%; P = 0.020). The survival rate was not significantly different between the groups: It was 83.8% and 68.5% in the resected group and 80.2% and 66.5% in the residual group at 5 and 10 years, respectively (P = 0.600). However, residual entry in the downstream aorta affected the distal aortic event-free survival rate (90.4% and 80.6% in the resected group and 82.3% and 67.4% in the residual group at 5 and 10 years, respectively; P = 0.003). Furthermore, multivariable risk analysis of 1107 patients confirmed that a residual entry in the downstream aorta was a risk factor for distal aortic events. CONCLUSIONS The tear-oriented strategy remains the gold standard for high-risk patients; however, the extensive operation might be considered for stable patients to reduce long-term aortic events.
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Affiliation(s)
- Koji Kawahito
- Division of Cardiovascular Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Kei Aizawa
- Division of Cardiovascular Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Naoyuki Kimura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University School of Medicine, Omiya-ku, Saitama-ken, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University School of Medicine, Omiya-ku, Saitama-ken, Japan
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Uimonen M, Olsson C, Jeppsson A, Geirsson A, Chemtob R, Khalil A, Hjortdal V, Hansson EC, Nozohoor S, Zindovic I, Gunn J, Wickbom A, Ahlsson A, Gudbjartsson T, Mennander A. Outcome after surgery for acute type A aortic dissection with or without primary tear resection. Ann Thorac Surg 2021; 114:492-501. [PMID: 34774491 DOI: 10.1016/j.athoracsur.2021.09.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/25/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The outcome in patients after surgery for acute type A aortic dissection without replacement of the part of the aorta containing the primary tear is undefined. METHODS Data of 1122 patients who underwent surgery for acute type A aortic dissection in eight Nordic centers from Jan 2005 to Dec 2014 were retrospectively analyzed. The patients with primary tear location either unfound, unknown, not confirmed or not recorded (n=243, 21.7%) were excluded from the analysis. The patients were divided into two groups according to whether the aortic reconstruction encompassed the portion of the primary tear (TR group, n=730) or not (TNR group, n=149). The restricted mean survival time ratios adjusted for patient characteristics and surgical details between the groups were calculated for all-cause mortality and aortic reoperation-free survival. The median follow-up time was 2.57 (inter-quartile range 0.53-5.30) years. RESULTS For the majority of the patients in the TR group, the primary tear was located in the ascending aorta (83.6%). The reconstruction encompassed both aortic root and the aortic arch in 7.4% in the TR group as compared with 0.7% in the TNR patients (P<0.001). There were no significant differences in all-cause mortality (adjusted restricted mean survival time ratio 1.01, 95% confidence interval 0.92-1.12, P=0.799) or reoperation-free survival (adjusted restricted mean survival time ratio 0.98, 95% confidence interval 0.95-1.02, P=0.436) between the TR group and TNR groups. CONCLUSIONS Primary tear resection alone does not determine the mid-term outcome after surgery for acute type A aortic dissection.
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Affiliation(s)
- Mikko Uimonen
- Tampere University Heart Hospital and Tampere University, Tampere, Finland
| | | | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden and Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Raphaelle Chemtob
- Department of Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Emma C Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden and Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Shahab Nozohoor
- Department of Cardiothoracic Surgery, Skane University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - Igor Zindovic
- Department of Cardiothoracic Surgery, Skane University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - Jarmo Gunn
- Turku University Hospital, Turku, Finland
| | | | | | - Tomas Gudbjartsson
- Landspitali University Hospital, Faculty of Medicine University of Iceland, Reykjavik Iceland
| | - Ari Mennander
- Tampere University Heart Hospital and Tampere University, Tampere, Finland,.
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Computational Fluid Dynamic Technique for Assessment of How Changing Character of Blood Flow and Different Value of Hct Influence Blood Hemodynamic in Dissected Aorta. Diagnostics (Basel) 2021; 11:diagnostics11101866. [PMID: 34679564 PMCID: PMC8534802 DOI: 10.3390/diagnostics11101866] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/02/2021] [Accepted: 10/04/2021] [Indexed: 11/17/2022] Open
Abstract
Using computer tomography angiography (CTA) and computational structural analysis, we present a non-invasive method of mass flow rate/velocity and wall stress analysis in type B aortic dissection. Three-dimensional (3D) computer models of the aorta were calculated using pre-operative (baseline) and post-operative CT data from 12 male patients (aged from 51 to 64 years) who were treated for acute type B dissection. A computational fluid dynamics (CFD) technique was used to quantify the displacement forces acting on the aortic wall in the areas of endografts placement. The mass flow rate and wall stress were measured and quantified using the CFD technique. The CFD model indicated the places with a lower value of blood velocity and shear rate, which corelated with higher blood viscosity and a probability of thrombus appearance. Moreover, with the increase in Hct, blood viscosity also increased, while the intensity of blood flow provoked changing viscosity values in these areas. Furthermore, the velocity gradient near the tear surface caused high wall WSS; this could lead to a decreased resistance in the aorta’s wall with further implications to a patient.
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Uchida K, Minami T, Cho T, Yasuda S, Kasama K, Suzuki S, Masuda M, Imoto K, Karube N, Goda M, Matsuki Y, Nemoto H, Izubuchi R, Kobayashi Y, Matsumoto A. Results of ascending aortic and arch replacement for type A aortic dissection. J Thorac Cardiovasc Surg 2021; 162:1025-1031. [DOI: 10.1016/j.jtcvs.2020.02.087] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
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Martin‐Blazquez A, Heredero A, Aldamiz‐Echevarria G, Martin‐Lorenzo M, Alvarez‐Llamas G. Non-syndromic thoracic aortic aneurysm: cellular and molecular insights. J Pathol 2021; 254:229-238. [PMID: 33885146 PMCID: PMC8251829 DOI: 10.1002/path.5683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/25/2021] [Accepted: 04/13/2021] [Indexed: 01/16/2023]
Abstract
Thoracic aortic aneurysm (TAA) develops silently and asymptomatically and is a major cause of mortality. TAA prevalence is greatly underestimated, it is usually diagnosed incidentally, and its treatment consists mainly of prophylactic surgery based on the aortic diameter. The lack of effective drugs and biological markers to identify and stratify TAAs by risk before visible symptoms results from scant knowledge of its pathophysiological mechanisms. Here we integrate the structural impairment affecting non-syndromic non-familial TAA with the main cellular and molecular changes described so far and consider how these changes are interconnected through specific pathways. The ultimate goal is to define much-needed novel markers of TAA, and so the potential of previously identified molecules to aid in early diagnosis/prognosis is also discussed. © 2021 The Authors. The Journal of Pathology published by John Wiley & Sons, Ltd. on behalf of The Pathological Society of Great Britain and Ireland.
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Affiliation(s)
| | - Angeles Heredero
- Department of Cardiac SurgeryFundación Jiménez Díaz, UAMMadridSpain
| | | | | | - Gloria Alvarez‐Llamas
- Department of ImmunologyIIS‐Fundación Jiménez Díaz, UAMMadridSpain
- REDInRENMadridSpain
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Zientara A, Rosselet-Droux K, Bruijnen H, Odavic D, Genoni M, Dzemali O. Freestyle aortic root prosthesis in combination with aortic replacement and open anastomosis: a retrospective analysis. J Cardiothorac Surg 2021; 16:185. [PMID: 34174918 PMCID: PMC8234670 DOI: 10.1186/s13019-021-01562-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Freestyle® bioprosthesis is used for pathologies of the aortic root. Additional resection of the ascending aorta and the proximal arch in dissections or aneurysms might be indicated. The aim was to assess mid-term outcome regarding prosthetic performance, stroke, reoperations, and survival in various pathologies comparing patients with and without additional procedures on the ascending aorta and proximal arch focusing on the standardised technique of unilateral antegrade cerebral perfusion under moderate hypothermia. METHODS Retrospective data analysis of 278 consecutive patients after Freestyle® root replacement between September 2007 and March 2017. Patients were divided in three categories due to the pathology of the aortic root (re-operation vs endocarditis vs dissection). Two groups based on the aortic anastomosis technique (open arch anastomosis (OA) versus non-open arch anastomosis (non-OA) were compared (119 OA vs 159 non-OA). Cardiovascular risk, previous cardiac events, intra- and postoperative data were evaluated. Inferential statistics were performed with Mann-Whitney U-test. Nominal and categorical variables were tested with Fisher-Freeman-Halton exact test. Kaplan-Meier estimate was used to assess survival. RESULTS The follow-up rate was 90% (median follow-up: 39.5 months). There were differences in the indication (endocarditis: OA 5 (4.2%) vs non-OA 36 (24%), p < 0.0001; dissection: OA 13 (10.9%) vs non-OA 2 (1.3%); p = 0.0007). OA patients had less perioperative stroke (1 (1%) vs 15 (10%), p = 0.001) and shorter hospital stay (9 vs 12 days, p = 0.0004). There were no differences in the mortality (in-hospital: OA 8 (7%) vs non-OA 8 (5%); p = 0.6; death at follow-up: OA 5 (5%) vs non-OA 15 (11%); p = 0.1). Overall valve performance showed a well-functioning valve in 97.3% at follow-up. CONCLUSION The valve performance showed excellent results regardless of the initial indication. The incidence of stroke was lower in patients receiving an open arch anastomosis using unilateral antegrade cerebral perfusion without elevated mortality or prolonged hospital stay.
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Affiliation(s)
- Alicja Zientara
- Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, Sydney Street, London, SW3 6NP, UK.
| | | | - Hans Bruijnen
- Department of Vascular Surgery, City hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - Dragan Odavic
- Department of Cardiac Surgery, Triemli City hospital Zurich, Birmensdorferstrasse 497, 8063, Zurich, Switzerland
| | - Michele Genoni
- Rehabilitation Clinic Seewis, Cardiac Rehabilitation, Schlossstrasse 1, 7212, Seewis, Switzerland
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Birmensdorferstrasse 497, 8063, Zurich, Switzerland
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Pitts L, Montagner M, Kofler M, Van Praet KM, Heck R, Buz S, Kurz SD, Sündermann S, Hommel M, Falk V, Kempfert J. State of the Art Review: Surgical Treatment of Acute Type A Aortic Dissection. Surg Technol Int 2021; 38:279-288. [PMID: 33823055 DOI: 10.52198/21.sti.38.cv1413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Acute type A aortic dissection (ATAAD) is a life-threatening event that requires immediate surgical treatment. Improvements in surgical treatment, graft technology, organ protection and imaging techniques have led to improved clinical outcomes. Individualized treatment concepts have emerged based on more advanced planning tools that allow for a tailored approach even in complex situations such as multi-level malperfusion. This review provides an overview of the current surgical treatment of ATAAD, focusing on new disease classifications, preoperative computed tomography angiography (CTA) assessment, new prosthesis and stent technologies, and organ-protection strategies.
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Affiliation(s)
- Leonard Pitts
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Matteo Montagner
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Karel M Van Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Roland Heck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Semih Buz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Stephan D Kurz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
| | - Simon Sündermann
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
| | - Matthias Hommel
- Department of Anesthesiology, German Heart Center Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
- Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
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Grabenwöger M, Mach M, Mächler H, Arnold Z, Pisarik H, Folkmann S, Harrer ML, Geisler D, Moidl R, Winkler B, Bonatti J, Czerny M, Weiss G. Taking the frozen elephant trunk technique to the next level by a stented side branch for a left subclavian artery connection: a feasibility study. Eur J Cardiothorac Surg 2021; 59:1247-1254. [PMID: 33486518 PMCID: PMC8203250 DOI: 10.1093/ejcts/ezaa486] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/20/2020] [Accepted: 11/30/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Our goal was to develop a modified frozen elephant trunk (FET) prosthesis with a stented left subclavian artery (LSA) side branch for LSA connection and to perform preclinical testing in a human cadaver model. METHODS We measured aortic diameters, distance between and diameters of supra-aortic vessels and the distance from the LSA offspring to the level of the left vertebral artery offspring in 70 patients. Based on these measurements, a novel FET prosthesis was developed (Cryolife/Jotec, Hechingen, Germany) featuring a stented side branch for an intrathoracic LSA connection. The feasibility and ease of implantation were tested in 2 human cadaver models at the Anatomical Institute of the Medical University Graz. A covered stent graft (Advanta V12™ by Atrium Medical Corp., Hudson, NH, USA) was used for an LSA extension. RESULTS Accurate deployment of the novel FET prosthesis with anatomical orientation of the stented side branch towards the LSA ostium followed by consecutive stent graft deployment was feasible in both cases. Proximalizing the distal anastomosis level from zone 3 to zone 1 not only diminished the complexity of the procedure but substantially facilitated the completion of the distal anastomosis. A 2.5-cm long extension stent graft was sufficient to seal to the LSA and to maintain left vertebral artery patency in both cases. CONCLUSIONS This initial study in human anatomical bodies could demonstrate the feasibility of implanting a newly designed FET prosthesis. This evolution of the FET technique has the potential to substantially ease total aortic arch replacement by proximalization of the distal anastomosis into zone 1 and by shortening spinal and lower body hypothermic circulatory arrest times via a stented side branch to the LSA. This direct connection enables early restoration of systemic perfusion.
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Affiliation(s)
- Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Sigmund Freud University, Medical Faculty, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria,Corresponding author. Department of Cardiovascular Surgery, Clinic Floridsdorf Vienna, Brünner Strasse 68, 1210 Vienna, Austria. Tel: +43-1-277004308; e-mail: (M. Grabenwöger)
| | - Markus Mach
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Heinrich Mächler
- Department of Cardiac Surgery, Medical University Graz, Graz, Austria
| | - Zsuzsanna Arnold
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Harald Pisarik
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Sandra Folkmann
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Marie-Luise Harrer
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Daniela Geisler
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Reinhard Moidl
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Bernhard Winkler
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Sigmund Freud University, Medical Faculty, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Johannes Bonatti
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, Faculty of Medicine, Albert-Ludwigs-University, Freiburg, Germany
| | - Gabriel Weiss
- Sigmund Freud University, Medical Faculty, Vienna, Austria,Department of Vascular Surgery, Clinic Ottakring, Vienna, Austria
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Lau C, Robinson NB, Farrington WJ, Rahouma M, Gambardella I, Gaudino M, Girardi LN. A tailored strategy for repair of acute type A aortic dissection. J Thorac Cardiovasc Surg 2021; 164:1698-1707.e3. [PMID: 33558116 DOI: 10.1016/j.jtcvs.2020.12.113] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 11/16/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Innumerable surgical techniques are currently deployed for repairing acute type A aortic dissection (ATAAD). We analyzed our results using a conservative approach of root-sparing and hemiarch techniques in higher-risk patients and root and total arch replacement for lower-risk patients. METHODS We queried our aortic database for consecutive patients who underwent ATAAD repair. Patients who underwent conservative repair (group 1) were compared with those who underwent extensive repair (group 2) using univariable and multivariable analysis. RESULTS From 1997 to 2019, 343 patients underwent ATAAD repair. Two hundred forty had conservative repair (root-sparing, hemiarch) whereas 103 had extensive repair (root replacement and/or total arch). Group 1 was older with more comorbidities such as hypertension, previous myocardial infarction, and renal dysfunction. Group 2 had more connective tissue disease (2.1% vs 12.6%; P < .01), aortic insufficiency, and longer intraoperative times. The incidence of individual postoperative complications was similar regardless of approach. A composite of major adverse events (operative mortality, myocardial infarction, stroke, dialysis, or tracheostomy) was higher in the conservative group (15.1% vs 5.9%; P = .03). Operative mortality was 5.6% and not different between groups. Ten-year survival was similar with either surgical approach. Ten-year cumulative risk of reintervention was greater in group 2 (5.6% vs 21% at 10 years; P < .01). In multivariable analysis, ejection fraction and diabetes were predictors of major adverse events but not extensive approach. Extensive approach was a predictor of late reoperation (odds ratio, 3.03 [95% confidence interval, 1.29-7.2]; P = .01). CONCLUSIONS A tailored conservative approach to ATAAD leads to favorable operative outcomes without compromising durability.
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Affiliation(s)
- Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | | | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | | | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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Chabry Y, Porterie J, Gautier CH, Nader J, Chaufour X, Alsac JM, Reix T, Marcheix B, Koskas F, Ruggieri VG, Achouh P, Caus T. The frozen elephant trunk technique in an emergency: THORAFLEX French National Registry offers new insights. Eur J Cardiothorac Surg 2020; 59:ezaa325. [PMID: 33141214 DOI: 10.1093/ejcts/ezaa325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/04/2020] [Accepted: 07/18/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Our goal was to study the immediate outcome after an emergency frozen elephant trunk procedure with a Thoraflex™ Hybrid prosthesis (THP) in patients included in the EPI-Flex national registry and operated on in 21 French centres. METHODS All patients operated on in France between April 2016 and April 2019 for acute aortic syndromes and who had an frozen elephant trunk procedure with a THP were included in the study. The main end point was in-hospital mortality. The secondary end point was neuromorbidity, including paraplegia. The evolution of the main end point was monitored using a variable life-adjusted display graph with cumulative sum derivatives in order to stop inclusions in case the observed mortality became out of range compared to an expected mortality between 15% and 20%. RESULTS Enrolment ended on the scheduled date and included 109 patients. Most cases (54%) were performed at 3 centres, where more than 10 THP each were implanted (10-26). The observed mortality in the large-volume centres (22%) was comparable to that observed in the low-volume centres (20%). The individually risk-adjusted cumulative sum revealed that observed in-hospital mortality was statistically in line with that predicted by the log EuroSCORE. Analysis of the secondary end point revealed 8% cases of paraplegia, all of which appeared after treatment of the thoracic type A aortic dissection. CONCLUSIONS In France, THP for emergency frozen elephant trunk surgery outside high-volume centres did not result in excessive in-hospital deaths. However, a word of caution must be expressed regarding the prevention of medullar ischaemia even in emergency aortic surgery.
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Affiliation(s)
- Yuthiline Chabry
- Federation of Heart, Lung and Vessels, University Hospital Amiens-Picardie, Amiens, France
| | - Jean Porterie
- Department of Cardiac and Vascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Charles-Henri Gautier
- Department of Cardiac and Vascular Surgery, University Hospital European Hospital Georges-Pompidou, Paris, France
| | - Joseph Nader
- Federation of Heart, Lung and Vessels, University Hospital Amiens-Picardie, Amiens, France
| | - Xavier Chaufour
- Department of Cardiac and Vascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Jean Marc Alsac
- Department of Cardiac and Vascular Surgery, University Hospital European Hospital Georges-Pompidou, Paris, France
| | - Thierry Reix
- Federation of Heart, Lung and Vessels, University Hospital Amiens-Picardie, Amiens, France
| | - Bertrand Marcheix
- Department of Cardiac and Vascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Fabien Koskas
- Department of Vascular Surgery, University Hospital Pitié-Salpétrière, APHP, Paris, France
| | - Vito Giovanni Ruggieri
- Department of Thoracic and Cardiovascular Surgery, Robert Debré University Hospital, Reims, France
| | - Paul Achouh
- Department of Cardiac and Vascular Surgery, University Hospital European Hospital Georges-Pompidou, Paris, France
| | - Thierry Caus
- Federation of Heart, Lung and Vessels, University Hospital Amiens-Picardie, Amiens, France
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Ikeno Y, Yokawa K, Koda Y, Gotake Y, Henmi S, Nakai H, Yamanaka K, Inoue T, Tanaka H, Okita Y. The fate of the downstream aorta after open aortic repair for acute DeBakey type I aortic dissection: total arch replacement with elephant trunk technique versus non-total arch replacement†. Eur J Cardiothorac Surg 2020; 55:966-974. [PMID: 30481293 DOI: 10.1093/ejcts/ezy381] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/26/2018] [Accepted: 10/08/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the fate of the downstream aorta following open aortic repair for acute DeBakey type I aortic dissection comparing total arch replacement (TAR) with the elephant trunk (ET) technique versus non-total arch replacement (non-TAR). METHODS From October 1999 to December 2016, 267 patients underwent open repair for acute DeBakey type I aortic dissection. A tear-oriented strategy was mainly used to determine the extent of graft replacement. Hospital mortality was 10.0% (12/120 patients) in the TAR group and 17.0% (25/147 patients) in the non-TAR group (P = 0.070). Late outcomes were compared in 230 hospital survivors (TAR: n = 108 and non-TAR: n = 122). Mean follow-up was 6.5 ± 4.6 years. The aortic diameters were measured at 4 levels, across 6 time points using computed tomography. RESULTS Freedom from additional aortic surgery for distal dilation was significantly better in the TAR group than the non-TAR group (TAR: 97.5 ± 1.8% at 5 years and non-TAR: 88.2 ± 3.4% at 5 years, P = 0.045). Freedom from a distal aortic event was also significantly better in the TAR group compared with the non-TAR group (TAR: 97.2 ± 1.6% at 5 years and non-TAR: 80.7 ± 4.2% at 5 years, P = 0.013). In the non-TAR group, the aortic arch diameter significantly increased (P < 0.001). Significant aortic remodelling occurred at the proximal descending aorta in the TAR with ET group (P < 0.001). CONCLUSIONS The TAR with ET reduced the need for additional distal aortic repair compared to non-TAR. TAR with ET prevented unfavourable aortic growth in both the aortic arch and the proximal descending aorta.
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Affiliation(s)
- Yuki Ikeno
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Koki Yokawa
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Yojiro Koda
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Yasuko Gotake
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Soichiro Henmi
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Hidekazu Nakai
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Katsuhiro Yamanaka
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Takeshi Inoue
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Hiroshi Tanaka
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
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Jormalainen M, Raivio P, Biancari F, Mustonen C, Honkanen HP, Venermo M, Vento A, Juvonen T. Late Outcome after Surgery for Type-A Aortic Dissection. J Clin Med 2020; 9:jcm9092731. [PMID: 32847062 PMCID: PMC7563246 DOI: 10.3390/jcm9092731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/07/2020] [Accepted: 08/19/2020] [Indexed: 12/30/2022] Open
Abstract
The aim of this study was to evaluate all-cause mortality and aortic reoperations after surgery for Stanford type A aortic dissection (TAAD). We evaluated the late outcome of patients who underwent surgery for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. We studied 309 patients (DeBakey type I TAAD: 89.3%) who underwent repair of TAAD. Aortic root repair was performed in 94 patients (30.4%), hemiarch repair in 264 patients (85.4%) and partial/total aortic arch repair in 32 patients (10.4%). Hospital mortality was 13.6%. At 10 years, all-cause mortality was 34.9%, and the cumulative incidence of aortic reoperation or late aortic-related death was 15.6%, of any aortic reoperation 14.6%, reoperation on the aortic root 6.6%, on the aortic arch, descending thoracic and/or abdominal aorta 8.7%, on the descending thoracic and/or abdominal aorta 6.4%, and on the abdominal aorta 3.8%. At 10 years, cumulative incidence of reoperation on the distal aorta was higher in patients with a diameter of the descending thoracic aorta ≥35 mm at primary surgery (cumulative incidence in the overall series: 13.2% vs. 4.0%, SHR 3.993, 95%CI 1.316–12.120; DeBakey type I aortic dissection: 13.6% vs. 4.5%, SHR 3.610, 95%CI 1.193–10.913; patients with dissected descending thoracic aorta: 15.8% vs. 5.9%, SHR 3.211, 95%CI 1.067–9.664). In conclusion, surgical repair of TAAD limited to the aortic segments involved by the intimal tear was associated with favorable survival and a low rate of aortic reoperations. However, patients with enlarged descending thoracic aorta at primary surgery had higher risk of late reoperation. Half of the distal aortic reinterventions were performed on the abdominal aorta.
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Affiliation(s)
- Mikko Jormalainen
- Heart and Lung Center, Helsinki University Hospital, 00029 Helsinki, Finland; (M.J.); (P.R.); (A.V.); (T.J.)
| | - Peter Raivio
- Heart and Lung Center, Helsinki University Hospital, 00029 Helsinki, Finland; (M.J.); (P.R.); (A.V.); (T.J.)
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, 00029 Helsinki, Finland; (M.J.); (P.R.); (A.V.); (T.J.)
- Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, 90014 Oulu, Finland; (C.M.); (H.-P.H.)
- Department of Surgery, University of Turku, 20014 Turku, Finland
- Correspondence:
| | - Caius Mustonen
- Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, 90014 Oulu, Finland; (C.M.); (H.-P.H.)
| | - Hannu-Pekka Honkanen
- Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, 90014 Oulu, Finland; (C.M.); (H.-P.H.)
| | - Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital, 00029 Helsinki, Finland;
| | - Antti Vento
- Heart and Lung Center, Helsinki University Hospital, 00029 Helsinki, Finland; (M.J.); (P.R.); (A.V.); (T.J.)
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, 00029 Helsinki, Finland; (M.J.); (P.R.); (A.V.); (T.J.)
- Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, 90014 Oulu, Finland; (C.M.); (H.-P.H.)
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Ideale operative Therapie bei akuter Aortendissektion DeBakey-Typ I. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-020-00378-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Xue Y, Pan J, Cao H, Fan F, Luo X, Ge M, Chen Y, Wang D, Zhou Q. Different aortic arch surgery methods for type A aortic dissection: clinical outcomes and follow-up results. Interact Cardiovasc Thorac Surg 2020; 31:254-262. [PMID: 32632444 DOI: 10.1093/icvts/ivaa095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/06/2020] [Accepted: 05/03/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to investigate the clinical outcomes and follow-up results among 5 main aortic arch surgery methods for type A aortic dissection in a single centre.
METHODS
From 2002 to 2018, 958 type A aortic dissection patients who received surgical repair were divided into 5 groups according to the arch surgery method: hemiarch replacement (n = 206), island arch replacement (n = 54), total arch replacement with frozen elephant trunk (n = 425), triple-branched stent (n = 39) and fenestrated stent (n = 234). The indications for the different arch methods were related to the patient’s preoperative status, the location and extent of the dissection and the surgical ability of the surgeons. A comparative study was performed to identify the differences in the perioperative data, and the Kaplan–Meier analysis was used to assess the long-term survival and reintervention rates. Thirty matched surviving patients that were included in each group completed Computed tomography angiography to determine long-term reshaping effect.
RESULTS
The 30-day mortality rate was 15.8%, and there was no difference among the 5 groups (P = 0.848). The follow-up survival rates were similar among the 5 groups (P = 0.130), and the same was true for patients without reintervention (P = 0.471). In the propensity matching study, patients with stents (frozen elephant trunk, triple-branched stent, fenestrated stent) had a slower aortic dilation rate and a higher ratio of thrombosis in the false lumen at the descending aortic and abdominal aortic levels than patients without stents.
CONCLUSIONS
No standard method is available for arch surgery, and indications and long-term effects should be identified with clinical data. In our experiences, simpler surgical procedures could reduce mortality in critically ill patients and stents in the distal aorta could improve long-term reshape effects.
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Affiliation(s)
- Yunxing Xue
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Jun Pan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Hailong Cao
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Fudong Fan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Xuan Luo
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Min Ge
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Yang Chen
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Dongjin Wang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
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Berger T, Kreibich M, Rylski B, Morlock J, Kondov S, Scheumann J, Kari FA, Staier K, Maier S, Beyersdorf F, Czerny M, Siepe M. Evaluation of myocardial injury, the need for vasopressors and inotropic support in beating-heart aortic arch surgery. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:505-511. [DOI: 10.23736/s0021-9509.19.10893-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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45
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Frankel WC, Green SY, Orozco-Sevilla V, Preventza O, Coselli JS. Contemporary Surgical Strategies for Acute Type A Aortic Dissection. Semin Thorac Cardiovasc Surg 2020; 32:617-629. [PMID: 32615305 DOI: 10.1053/j.semtcvs.2020.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/21/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Abstract
Surgical techniques and organ protection strategies for acute type A aortic dissection (ATAAD) have evolved considerably over the years. Nonetheless, open surgical repair remains a complex procedure, and there is a lack of consensus regarding many aspects of repair. In patients with dissection limited to the ascending aorta (DeBakey type II), repair typically involves replacement of only the affected segment, barring substantial aortic dilation to address elsewhere. In contrast, most patients with ATAAD have dissection extending into the thoracoabdominal aorta (DeBakey type I); in these cases, consideration must be given as to how much of the aortic arch and distal aorta to incorporate into the index repair, and several open and hybrid options exist. Herein, we review contemporary surgical strategies for ATAAD and clarify specific areas of controversy, in an effort to elucidate the optimal operative approach. In general, a limited index repair aimed at ensuring operative survival is typically the best option, whereas extended repair should be reserved for carefully selected patients who are most likely to benefit.
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Affiliation(s)
- William C Frankel
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas.
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46
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Nienaber CA, Rosendahl U, Yuan X. What is the strategy for strategic arch resection in acute proximal aortic dissection? J Thorac Dis 2020; 12:3418-3421. [PMID: 32642268 PMCID: PMC7330757 DOI: 10.21037/jtd.2020.01.63] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK.,Department of Cardiology, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK
| | - Ulrich Rosendahl
- Department of Surgery, Aortic Centre, Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Xun Yuan
- Cardiology and Aortic Centre, Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK.,Department of Cardiology, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK
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47
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Velayudhan BV, Idhrees AM. Alternatives to the frozen elephant trunk in acute type A aortic dissection. Asian Cardiovasc Thorac Ann 2020; 29:623-626. [PMID: 32436716 DOI: 10.1177/0218492320928744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute type A aortic dissection remains one of the most challenging condition in cardiothoracic surgery, with a high mortality rate. Various improvements and innovations have happened over the years to better the outcome of this lethal condition. The frozen elephant trunk prosthesis has been developed to negate the long-term complications of acute type A aortic dissection, but at the cost of increased morbidity compared to hemiarch replacement. Although hemiarch and total arch replacement seem have less morbidity than the frozen elephant trunk technique, they do not address the long-term complications of the distal dissected aorta. Few surgeons now suggest hybrid aortic arch repair as a solution for acute type A aortic dissection. The long-term results need to be studied in all procedures before standardizing them. Although multiple strategies are evolving, the short-term goal of acute type A aortic dissection has not changed: to save the patient's life. The surgical strategy has to be tailored according to the patient's condition and the surgeon's experience.
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Affiliation(s)
- Bashi V Velayudhan
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospital), Chennai, India
| | - A Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospital), Chennai, India
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48
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A New Aortic Arch Inclusion Technique With Frozen Elephant Trunk for Type A Aortic Dissection. Ann Surg 2020; 271:978-983. [DOI: 10.1097/sla.0000000000003122] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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49
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Velayudhan BV, Idhrees M, Matalanis G, Park KH, Tang D, Sfeir PM, Hosseini S, Bashir M. Current status in decision making to treat acute type A dissection: limited versus extended repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:285-291. [PMID: 32337940 DOI: 10.23736/s0021-9509.20.11397-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Acute type A aortic dissection remains one of the most challenging conditions in aortic surgery. Despite the advancements in the field, the mortality rate still remains high. Though there is a general consensus that the ascending aorta should be replaced, the distal extension of the surgery still remains a controversy. Few surgeons argue for a conservative approach to reduce operative and postoperative morbidity while others considering the problems associated with "downstream problems" support an aggressive approach including a frozen elephant trunk. The cohort in the Indian subcontinent and APAC is far different from the western world. Many factors determine the decision for surgery apart from the pathology of the disease. Economy, availability of the suitable prosthesis, the experience of the surgeon, ease of access to the medical facility all contribute to the decision making to treat acute type A dissection.
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Affiliation(s)
- Bashi V Velayudhan
- Institute for Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospitals), Chennai, India
| | - Mohammed Idhrees
- Institute for Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospitals), Chennai, India -
| | | | - Kay-Hyun Park
- Bundang Hospital, Seoul National University, Seongnam, South Korea
| | - David Tang
- Queen Elizabeth Hospital (II), Kota Kinabalu, Malaysia
| | - Pierre M Sfeir
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaei Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Bashir
- Department of Vascular and Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
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50
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Commentary: Strategic surgery to type A dissection: A bird in the hand or 2 in the bush? J Thorac Cardiovasc Surg 2020; 162:1033-1034. [PMID: 32279968 DOI: 10.1016/j.jtcvs.2020.02.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 02/27/2020] [Accepted: 02/27/2020] [Indexed: 11/24/2022]
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