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Brown JA, Zhu J, Navid F, Serna-Gallegos D, Sehra R, Warraich N, Bianco V, Aranda-Michel E, Sultan I. Preservation versus replacement of the aortic root for acute type A aortic dissection. J Thorac Cardiovasc Surg 2024; 167:2037-2046.e2. [PMID: 35989123 DOI: 10.1016/j.jtcvs.2022.04.053] [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: 11/28/2021] [Revised: 03/27/2022] [Accepted: 04/11/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To determine the impact of aortic root preservation versus aortic root replacement (ARR) after acute type A aortic dissection (ATAAD) repair. METHODS In this observational study of consecutive aortic surgeries between 2007 and 2021, patients with ATAAD were identified via a prospectively maintained institutional database and were stratified by root preservation versus ARR (including valve-sparing and complete ARR). Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed. RESULTS Among the 601 patients underwent aortic arch reconstruction for ATAAD, 370 (61.6%) underwent root preservation and the other 231 (38.4%) underwent ARR, with a median follow-up of 6.3 years (interquartile range, 3.8-9.6 years). Cardiopulmonary bypass and ischemic times were longer in the ARR group, but intraoperative variables were otherwise similar between the groups, including cannulation strategy and extent of distal repair. There were no between-group differences in postoperative outcomes, including operative mortality, stroke, mechanical ventilation time, renal failure, reexploration for bleeding, and total length of stay. At a 1-year follow-up, the incidence of aortic regurgitation (moderate or greater) was similar in the 2 groups. On multivariable Cox regression, ARR was not associated with improved long-term survival compared with root preservation (hazard ratio, 1.13; 95% confidence interval, 0.82-1.56; P = .44). Late reinterventions on the aortic root or valve were similar in the 2 groups and was 2.0% for the overall cohort. CONCLUSIONS These findings suggest that aortic root preservation may achieve similar midterm outcomes as ARR after ATAAD repair.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jianhui Zhu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rishabh Sehra
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Nav Warraich
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Sá MP, Jacquemyn X, Awad AK, Brown JA, Chu D, Serna-Gallegos D, Kari FA, Sultan I. Valve-Sparing Aortic Root Replacement With Reimplantation vs Remodeling: A Meta-analysis. Ann Thorac Surg 2024; 117:501-507. [PMID: 37831047 DOI: 10.1016/j.athoracsur.2023.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/18/2023] [Accepted: 08/15/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Long-term outcomes of valve-sparing aortic root replacement (VSARR) with reimplantation vs remodeling in patients undergoing aortic root surgery remains a controversial subject. METHODS This study was a pooled meta-analysis of Kaplan-Meier-derived data from comparative studies published by December 31, 2022. RESULTS Fifteen studies met our eligibility criteria, comprising 3044 patients (1991 in the reimplantation group and 2018 in the remodeling group). Patients who underwent VSARR with remodeling had a higher risk of all-cause death (hazard ratio [HR], 1.54; 95% CI, 1.16-2.03; P = .002, log-rank test P < .001). Landmark analysis (with 4 years as the landmark time point) demonstrated that survival was lower in patients who underwent VSARR with remodeling (HR, 2.15; 95% CI, 1.43-3.24; P < .001) in the first 4 years. Beyond the 4-year time point, no difference in survival was observed (HR, 1.04; 95% CI, 0.72-1.50; P = .822). The risk for need of aortic valve and/or root reintervention was higher in patients undergoing VSARR with remodeling (HR, 1.49; 95% CI, 1.07-2.07; P = .019, log-rank test P < .001). We did not find statistically significant coefficients for the covariates of age, female sex, connective tissue disorders, bicuspid aortic valve, aortic dissection, coronary bypass surgery, total arch replacement, or annular stabilization, which means that these covariates did not modulate the effects observed in our pooled analyses. CONCLUSIONS VSARR with reimplantation is associated with better overall survival and lower risk of need for reintervention over time compared with VSARR with remodeling. Regarding overall survival, we observed a time-varying effect that favored the reimplantation technique up to 4 years of follow-up, but not beyond this time point.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Ahmed K Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Fabian A Kari
- Section of Pediatric and Congenital Cardiac Surgery, European Pediatric Heart Center, Ludwig Maximilian University (LMU) University Hospital and German Heart Center, Munich, Germany
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Chung MM, Yu A, Zhao Y, Wist E, Hohri Y, Kurlansky P, Leb J, O'Donnell TFX, Patel V, Takayama H. Utility of structured follow-up imaging after aortic surgery. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00112-0. [PMID: 38342429 DOI: 10.1016/j.jtcvs.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/16/2024] [Accepted: 02/01/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Although postoperative follow-up after aortic surgery is recommended by guidelines, its clinical utility is not well documented. We hypothesized that structured follow-up imaging by an aortic program would improve outcomes. We then documented radiologic findings on asymptomatic postoperative imaging. METHODS All patients who survived to discharge after open thoracic aortic surgery between January 2017 and July 2021 were included, excluding endocarditis. Patients who followed at our center and received scheduled imaging were compared with patients who did not. Survival was analyzed by the method of Kaplan-Meier, and reintervention was assessed using the Fine-Gray subhazard function. Routine imaging was reviewed for aortic growth, pseudoaneurysm, and perigraft density. RESULTS After aortic surgery, the cumulative incidence of follow-up was 38.6% at 3 years postoperatively. Patients with follow-up were more likely to have a dissection and fewer comorbidities but were similar in regards to socioeconomic factors and distance to hospital. After matching and accounting for immortal time bias, patients with follow-up had a greater reintervention rate (26.0% vs 9.0%) with similar survival (98.7% vs 95.2%, P = .110) at 4 years. The cumulative incidence of pseudoaneurysm, significant perigraft density, and growth ≥3 mm/year on routine imaging was 49.7% at 3 years. CONCLUSIONS Implementation of structured follow-up imaging by an aortic program resulted in low clinical compliance. Follow-up was associated with increased rates of aortic reintervention. Clinically relevant radiologic findings were common on asymptomatic imaging and increased throughout 5-year follow-up rather than plateauing in the early postoperative period.
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Affiliation(s)
- Megan M Chung
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Annie Yu
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Yanling Zhao
- Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY
| | - Elizabeth Wist
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Yu Hohri
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Paul Kurlansky
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY; Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY
| | - Jay Leb
- Department of Radiology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Thomas F X O'Donnell
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Virendra Patel
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY.
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Li X, Wang B, Wang X, Wang Z. The mid-term outcomes of aortic-root repair is not inferior to Bentall procedure in acute type-A aortic dissection. Asian J Surg 2024; 47:911-915. [PMID: 37951742 DOI: 10.1016/j.asjsur.2023.10.080] [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: 08/10/2023] [Revised: 10/03/2023] [Accepted: 10/20/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE Bentall procedure used to be standard operation for involved aortic root in acute type A aortic dissection (ATAAD). But aortic root repair for preserving valve is still controversial in ATAAD. This study aimed to evaluate the midterm outcomes of aortic root repair by comparing with Bentall approach. METHODS A retrospective analysis of 1075 ATAAD patients with aortic root involvement was conducted. The patients were divided into aortic root repair group (n = 447) and Bentall group (n = 628). The propensity score matching analysis (PSMA) was used to adjust the baseline. RESULTS The median follow-up was 44 months (interquartile range, 17-65 months; range, 1-130 months). The 30-day mortality in the repair and replacement groups was 15.0 % and 12.9 % (P = 0.327) respectively; the late overall mortality was 15.9 % and 14.0 % (P = 0.394) respectively. The Kaplan-Meier 10-year survival and free-from-reoperation was 86.0 % and 92.5 % respectively in the repair group. After PSMA, the cumulative survival rate [Hazard Ratio (HR) 0.685; 95 % Confidence Interval (CI) 0.457-1.027; P = 0.747]) and reoperation rate (HR 0.308; 95 % CI 0.070-1.355; P = 0.157) was not significantly higher in the repair group than in the Bentall group. CONCLUSION The mid-term outcome of aortic root repair is probably not inferior to Bentall procedure. Therefore, root repair is an alternative approach in ATAAD with the advantage of preserving native valve.
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Affiliation(s)
- Xiaoyong Li
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, 238# Jiefang Road, Wuhan, Hubei Province, 430000, China
| | - Bo Wang
- Department of Cardiovascular Surgery, Wuhan Asia Heart Hospital Affiliated Wuhan University, 753# Jinghan Road, Wuhan, Hubei Province, 430004, China
| | - Xiao Wang
- Department of Cardiovascular Surgery, Wuhan Asia Heart Hospital Affiliated Wuhan University, 753# Jinghan Road, Wuhan, Hubei Province, 430004, China
| | - Zhiwei Wang
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, 238# Jiefang Road, Wuhan, Hubei Province, 430000, China.
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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6
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Lin TW, Wu HY, Tsai MT, Hu YN, Wang YC, Roan JN, Luo CY, Kan CD. Aortic root remodeling after surgical repair of acute type A aortic dissection using different anastomosis techniques. JTCVS Tech 2023; 21:18-25. [PMID: 37854808 PMCID: PMC10580100 DOI: 10.1016/j.xjtc.2023.06.018] [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: 01/09/2023] [Revised: 05/24/2023] [Accepted: 06/07/2023] [Indexed: 10/20/2023] Open
Abstract
Background After surgical repair of acute type A aortic dissection (aTAAD), remodeling of the residual aortic segments is the key outcome parameter associated with late reoperation or aorta-related adverse events. In this study, we analyzed the surgical outcomes of aTAAD using either a telescopic or continuous anastomosis technique, focusing on their impact on aortic root remodeling during the longitudinal follow-up. Methods Between 2012 and 2018, 112 surgical repairs of aTAAD with ascending aorta replacement and without aortic arch or aortic root replacement were performed. The medical records were reviewed retrospectively, and early and late outcomes were compared between the telescopic and continuous anastomosis techniques. The generalized estimating equation method was used to analyze the effects of different anastomosis techniques on serial aortic root remodeling. Results The telescopic anastomosis technique was used in 46 cases (41.1%), and the conventional continuous anastomosis technique was used in 66 cases (58.9%). There were no differences in in-hospital mortality or the incidence of major complications between the groups. The telescopic anastomosis group demonstrated stable postoperative regression of the aortic root diameter during follow-up. In contrast, the continuous anastomosis group showed a progressive dilatation of the aortic root. There was a trend toward better aortic root adverse event-free survival rates in the telescopic anastomosis group (P = .081). Conclusions The telescopic anastomosis technique is a safe alternative to the continuous anastomosis technique in the surgical repair of aTAAD, with comparable early results. In addition, telescopic anastomosis was associated with beneficial aortic root remodeling in the medium term compared with continuous anastomosis.
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Affiliation(s)
- Ting-Wei Lin
- Division of Cardiovascular Surgery, Department of Surgery, E-DA Hospital and College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsuan-Yin Wu
- Division of Cardiovascular Surgery, Department of Surgery, E-DA Hospital and College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Meng-Ta Tsai
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Ning Hu
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Chen Wang
- Division of Cardiovascular Surgery, Department of Surgery, E-DA Hospital and College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jun-Neng Roan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chwan-Yau Luo
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
| | - Chung-Dann Kan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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8
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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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9
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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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10
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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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11
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Perone F, Guglielmo M, Coceani M, La Mura L, Dentamaro I, Sabatino J, Gimelli A. The Role of Multimodality Imaging Approach in Acute Aortic Syndromes: Diagnosis, Complications, and Clinical Management. Diagnostics (Basel) 2023; 13:diagnostics13040650. [PMID: 36832136 PMCID: PMC9954850 DOI: 10.3390/diagnostics13040650] [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] [Received: 01/10/2023] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023] Open
Abstract
Acute aortic syndromes are life-threatening conditions with high morbidity and mortality. The principal pathological feature is acute wall damage with possible evolution towards aortic rupture. Accurate and timely diagnosis is mandatory to avoid catastrophic consequences. Indeed, misdiagnosis with other conditions mimicking acute aortic syndromes is associated with premature death. In this view, cardiovascular imaging is necessary for the correct diagnosis and management. Echocardiography, computed tomography, magnetic resonance imaging, and aortography allow for diagnosis, guarantee immediate treatment, and detect associated complications. Multimodality imaging is essential in the diagnostic work-up to confirm or rule out acute aortic syndromes. The aim of this review is to highlight the contemporary evidence on the role of single cardiovascular imaging techniques and multimodality imaging in the diagnosis and management of acute aortic syndromes.
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Affiliation(s)
- Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic “Villa delle Magnolie”, Castel Morrone, 81020 Caserta, Italy
| | - Marco Guglielmo
- Department of Cardiology, Division of Heart and Lungs, Utrecht University Medical Center, 3584 CX Utrecht, The Netherlands
| | - Michele Coceani
- Diagnostic and Interventional Cardiology Unit, Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
| | - Lucia La Mura
- Department of Advanced Biomedical Sciences, University Federico II of Naples, 80133 Naples, Italy
| | - Ilaria Dentamaro
- Cardiology Department and Cardiovascular Imaging Laboratory, Hospital Miulli, 70124 Bari, Italy
| | - Jolanda Sabatino
- Pediatric and Congenital Cardiology Unit, Department for Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy
| | - Alessia Gimelli
- Imaging Department, Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
- Correspondence:
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12
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Abstract
The clinical outcome of severe aortic regurgitation (AR) remains suboptimal, but surgery has been shown to have survival benefit over medical therapy. Postoperative survival is inferior in patients with reduced left ventricular function, and therefore early surgical intervention is recommended. Aortic valvuloplasty (AVP) is an attractive option to avoid the major drawbacks of prosthetic valves but has not been widely adopted. The etiology of AR is classified functionally into three groups: normal leaflet motion (type I), cusp prolapse (type II), and restriction (type III). Type I with dilatation of the sinus of Valsalva (type Ib) can be repaired by aortic valve reimplantation or aortic root remodeling with similar valve stability. Type I with dilatation of the aortic annulus (type Ic) can be managed by annuloplasty. Type II can be corrected by plication or resuspension techniques. Pericardial patch is necessary in AVP for type Id (perforation/fenestration) and type III but is associated with risk of recurrence. Bicuspid aortic valve is classified according to commissure angle: symmetrical, asymmetrical, and very asymmetrical. Tricuspidization is recommended for repair of very asymmetrical valves to avoid postoperative stenosis. Recent progress has achieved similar reoperation rates between bicuspid and tricuspid aortic valve repair. For Marfan syndrome, valve-sparing root replacement is advantageous compared to Bentall operation regarding late survival, thromboembolic and hemorrhagic events, and endocarditis. Similar findings have been reported in acute aortic dissection. Both remodeling and reimplantation procedures provide similar favorable outcomes in these settings. Recent advances in AVP are summarized by quantitative assessment of cusp configuration (effective height and geometric height), graft size decision, use of template to cut the graft, and videoscopic assessment of post-repair cusp configuration. Due to these advances, AVP shows superior results to replacement surgery. Further concrete evidence with larger case volumes and longer observation periods are necessary to popularize AVP.
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13
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Kim CH, Song SW. How we repair acute type A dissection in Gangnam severance hospital. Asian Cardiovasc Thorac Ann 2023; 31:48-50. [PMID: 35678833 DOI: 10.1177/02184923221106776] [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
Total arch replacement for aortic dissection is traditionally associated with high mortality and morbidity rates. Here, we share our strategies for improving surgical outcomes such as Y incision, unilateral antegrade cerebral perfusion, Teflon felt neo-media formation, and reinforcement of the anastomosis site.
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Affiliation(s)
- Chong Hoon Kim
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, 65655Gangnam Severance Hospital, Seoul, Republic of South Korea
| | - Suk-Won Song
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, 65655Gangnam Severance Hospital, Seoul, Republic of South Korea
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14
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 358] [Impact Index Per Article: 179.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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15
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 114] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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16
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Kakar S, Adam S, Panda A, Sabry H, Harky A. Replace it or preserve it? How outcomes differ using different techniques. J Card Surg 2022; 37:4406-4407. [PMID: 36183402 DOI: 10.1111/jocs.16982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/19/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Sahil Kakar
- Centre for Medical Education, School of Medicine, Queen's University of Belfast, Belfast, UK
| | - Sana Adam
- Centre for Medical Education, School of Medicine, St George's University, London, UK
| | - Abinash Panda
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Haytham Sabry
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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17
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Dang Van S, Laribi J, Pinaud F, Binuani P, Willoteaux S, Baufreton C, Fouquet O. Preservation of the Aortic Root During Type A Aortic Dissection Surgery: An Effective Strategy? AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2021; 9:67-75. [PMID: 34619800 PMCID: PMC8526144 DOI: 10.1055/s-0041-1725074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background
Management of the aortic root during acute Type A aortic dissection (TAAD) repair remains controversial in term of long-term evolution and reoperation. The aim of this study was to assess the long-term outcomes of the aortic root after conservative management during primary surgery.
Methods
One hundred sixty-four consecutive patients were included in this monocentric retrospective study. The primary endpoint was reoperation on the aortic root during long-term follow-up. Forty-six patients had aortic root replacement (ARR) and 118 had supracoronary aortic replacement (SCR). The 10-year survival, occurrence of significant aortic regurgitation, and radiologic aortic root dilatation in each group were assessed during follow-up.
Results
Patients from ARR group were younger than those from SCR group (
p
< 0.0001). Median follow-ups of ARR group and SCR group are 4.4 (interquartile range [IR]: 2.6–8.3) and 6.15 (IR: 2.8–10.53) years, respectively. Reoperation of the aortic root during long-term follow-up was similar in both groups (ARR group: 5.1%, SCR group: 3.3%,
p
= 0.636). The 10-year survivals of ARR and SCR groups were 64.8 ± 12.3% and 46.3 ± 5.8% (
p
= 0.012), respectively. Long-term significant aortic regurgitation occurred in one patient (1.7%) and seven patients (7.6%) of the ARR and SCR groups (
p
= 0.176), respectively. Radiologic aortic root diameters in the SCR group were similar between postoperative period and follow-up studies (
p
= 0.58). Reoperation on the distal aorta (
p
= 0.012) and patent radiologic false lumen of the descending aorta (
p
= 0.043) were independent risk factors of late death.
Conclusion
SCR is an effective technique for primary TAAD surgery and does not increase the rate of late reoperation on the aortic root.
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Affiliation(s)
- Simon Dang Van
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Jihed Laribi
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Frédéric Pinaud
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Patrice Binuani
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Serge Willoteaux
- Department of Radiology, University Hospital of Angers, Angers, France
| | - Christophe Baufreton
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France.,Mitovasc Institute INSERM U1083 UMR-CNRS 6214, University Hospital of Angers, Angers, France
| | - Olivier Fouquet
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France.,Mitovasc Institute INSERM U1083 UMR-CNRS 6214, University Hospital of Angers, Angers, France
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18
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Maskell P, Brimfield M, Ahmed A, Harky A. In patients undergoing valve-sparing aortic root replacement, is reimplantation superior to remodelling? Interact Cardiovasc Thorac Surg 2021; 32:441-446. [PMID: 33313815 DOI: 10.1093/icvts/ivaa290] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 09/20/2020] [Accepted: 10/27/2020] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients undergoing valve-sparing aortic root replacement, is reimplantation superior to remodelling? The purpose of this best evidence topic was to re-review the updated evidence that has become available in the near decade since the previous review published in 2011. Altogether more than 300 papers were found using the reported search, of which 8 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The included studies have significant limitations relating to low-level evidence study design, variable outcome collection and limited significance testing with direct comparison. Long-term outcomes such as survival, recurrence of aortic regurgitation and valve reintervention were largely equal between the two procedures across the studies. This review, updated from the previous best evidence topic, continues to suggest that there are no clear recommendations or even consensus to guide clinical decision-making when choosing between remodelling or reimplantation approaches to valve-sparing aortic root replacement. To date, no study provides strong clinical benefit to favour either procedure in terms of perioperative outcomes, medium-long term survival or reintervention of the aortic valve. As such, procedure selection should be based upon patient factors and valve evaluation, combined with surgeon preference and experience.
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Affiliation(s)
- Perry Maskell
- Department of Surgery, Cambridge University NHS Foundation Trust, Cambridge, UK
| | | | - Amna Ahmed
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Cardiac Surgery, Alder Hey Children Hospital, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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19
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Vendramin I, Lechiancole A, Piani D, Deroma L, Tullio A, Sponga S, Milano AD, Onorati F, Bortolotti U, Livi U. Type A acute aortic dissection with ≥40-mm aortic root: results of conservative and replacement strategies at long-term follow-up. Eur J Cardiothorac Surg 2021; 59:1115-1122. [PMID: 33367649 DOI: 10.1093/ejcts/ezaa456] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/04/2020] [Accepted: 11/15/2020] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES We evaluated the long-term results of aortic root (AR) preservation and replacement in patients operated on for acute type A aortic dissection. METHODS Out of 302 patients discharged after repair of acute aortic dissection (1977-2019), 124 patients had an AR ≥40 mm, which was preserved in 84 (68%, group A) patients and replaced in 40 (32%, group B) patients. Group B patients were younger (mean age 57 ± 12 vs 62 ± 11 years, P = 0.07), with a mean AR of 47 vs 43 mm and ≥moderate aortic insufficiency in 65% vs 30%. Survival, causes of death and reoperations were analysed at mean follow-up of 9 ± 8 years (6 months to 40 years). RESULTS Actuarial survival of discharged patients at 5, 10 and 15 years was 97% (0.89-0.99), 78% (0.67-0.90) and 75% (0.64-0.88) in group A, and 85% (0.71-0.95), 62% (0.44-0.78) and 57% (0.39-0.76) in group B (log-rank test P = 0.2). Nine patients in group A (7 patients for aortic insufficiency and dilatation of the root and 2 patients for pseudoaneurysm) and 1 patient of group B (pseudoaneurysm of the right coronary button) required proximal reoperation without deaths. At 5, 10 and 15 years, the cumulative incidence of proximal aortic reoperations was 5%, 9% and 25% in group A, and 0%, 3% and 3% in group B (P = 0.02). At multivariable analysis AR >45 mm [hazard ratio (HR) 6.8, P = 0.026] and age (HR 0.9, P = 0.016) were independently associated with proximal reoperation. CONCLUSIONS AR preservation in acute type A dissection showed acceptable long-term outcomes. Nevertheless, a more aggressive approach appears a valid option, especially in patients with AR diameter >45 mm.
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Affiliation(s)
- Igor Vendramin
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Andrea Lechiancole
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Daniela Piani
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Laura Deroma
- Health Management Department, University Hospital of Udine, Udine, Italy
| | - Annarita Tullio
- Department of Hygiene and Clinical Epidemiology, University Hospital of Udine, Udine, Italy
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Aldo D Milano
- Division of Cardiac Surgery, Department of Emergencies and organ transplantation, University of Bari, Bari, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona Medical School, Verona, Italy
| | - Uberto Bortolotti
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Ugolino Livi
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
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20
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Bojko MM, Habertheuer A, Bavaria JE, Suhail M, Hu RW, Harmon J, Desai ND, Milewski RK, Williams ML, Szeto WY, Mossey J, Vallabhajosyula P. Recurrent aortic insufficiency after emergency surgery for acute type A aortic dissection with aortic root preservation. J Thorac Cardiovasc Surg 2021; 161:1989-2000.e6. [DOI: 10.1016/j.jtcvs.2020.01.116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 01/02/2020] [Accepted: 01/07/2020] [Indexed: 12/18/2022]
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21
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Malaisrie SC, Szeto WY, Halas M, Girardi LN, Coselli JS, Sundt TM, Chen EP, Fischbein MP, Gleason TG, Okita Y, Ouzounian M, Patel HJ, Roselli EE, Shrestha ML, Svensson LG, Moon MR. 2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg 2021; 162:735-758.e2. [PMID: 34112502 DOI: 10.1016/j.jtcvs.2021.04.053] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 01/16/2023]
Affiliation(s)
- S Christopher Malaisrie
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill.
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa
| | - Monika Halas
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC
| | | | - Thomas G Gleason
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Hospitals, Ann Arbor, Mich
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Malakh L Shrestha
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
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22
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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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23
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Toh S, Ang J, George JJ, Jayawardena O, Mahbub S, Harky A. Outcomes in techniques of valve sparing aortic root replacement: A systematic review and meta-analysis. J Card Surg 2020; 36:178-187. [PMID: 33085112 DOI: 10.1111/jocs.15132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To compare clinical outcomes of reimplantation versus remodeling in patients undergoing valve-sparing aortic root replacement (VSRR) surgery. METHOD Electronic database search at PubMed, Scopus, Embase, Ovid, and Google scholar was performed from inception to January 2020. Primary outcomes were aortic valve (AV) reintervention and postoperative grade of aortic insufficiency (AI) while secondary outcomes were 30-day mortality, reoperation for bleeding, and operative times. RESULTS A total of 21 articles met the inclusion criteria. A total of 1283 patients had reimplantation while 1150 had remodeling. No difference in preoperative demographics was noted except reimplantation patients were younger (48 ± 16 vs. 56 ± 15 years; p < .00001). The cardiopulmonary bypass and aortic cross-clamp times were shorter in the remodeling cohort (168 ± 38 vs. 150 ± 37 min; p = .0001 and 133 ± 31 vs. 112 ± 30 min; p = .0002, respectively). No difference in concomitant total arch surgery (14% in reimplantation vs. 15% in remodeling; p = .53). Postoperatively, there were similar stroke rates (3% in both cohorts; p = .54), rates of reoperation for bleeding (9% in reimplantation vs. 12% in remodeling; p = .88), and 30-day mortality (3% in reimplantation vs. 4% in remodeling; p = .96). No difference in early AV reintervention (1% in reimplantation vs. 2% in remodeling; p = .07), and late AV reintervention (4% in reimplantation vs. 7% in remodeling; p = .07). The AI of +2 grade was significantly lower in the reimplantation cohort (5% vs. 8%; p = .01). CONCLUSION Our study shows comparable clinical outcomes between both techniques. The practice of each technique is largely center and surgeon dependent. Larger sample size cohorts with minimal confounding factors are required to confirm the above findings.
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Affiliation(s)
- Steven Toh
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | - Juliana Ang
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | - Joel Jacob George
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | - Ovin Jayawardena
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | - Samiha Mahbub
- Department of Medicine, St. George's University of London, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Integrative Biology, Faculty of Health Science, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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24
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An Z, Tan MW, Yu SY, Ma Y, Lu FL, Xu ZY. Surgical Outcomes of Stent-Related Type A Dissection Compared with Spontaneous Type A Dissection. Ann Thorac Cardiovasc Surg 2020; 26:270-275. [PMID: 32161198 PMCID: PMC7641883 DOI: 10.5761/atcs.oa.19-00216] [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] [Indexed: 11/29/2022] Open
Abstract
Objective: Aortic endovascular stent implantation includes thoracic endovascular aortic repair (TEVAR), hybrid aortic repair (HAR), and ascending aorta stent implantation (AASI). In this study, we compared the surgical outcomes of stent-related type A dissection (SRTAD) compared with spontaneous type A dissection (STAD). Methods: From July 2011 to July 2014, we identified 17 SRTAD patients received surgical repair in our institution. Propensity score-matching was used to identify 34 STAD patients as controls. Results: Preoperative data of SRTAD group and STAD group had no statistical difference. Selective cerebral perfusion (SCP) time was longer in SRTAD group than in STAD group (P <0.05). SRTAD group had a longer cross-clamp time compared with STAD group (P <0.05). No intraoperative deaths in two groups. No differences in CPB time and concomitant procedures between two groups. In-hospital mortality was 11.76% (2 of 17) in SRTAD group and 2.9% (1 of 34) in STAD group (P <0.05). No differences were found in intensive care unit (ICU) time, ventilation, paraparesis, and other postoperative complications between SRTAD and STAD groups. No difference was found in survival rate between SRTAD and STAD groups in the postoperative 1-year follow-up. Conclusions: SRTAD patients received surgical repair had a higher in-hospital mortality compared with STAD, but no differences were found in postoperative complications and mid-term outcomes.
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Affiliation(s)
- Zhao An
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Meng-Wei Tan
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Shang-Yi Yu
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Ye Ma
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Fang-Lin Lu
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Yun Xu
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
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25
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Munir W, Harky A, Bashir M, Adams B. Does adding a root replacement in type A aortic dissection repair provide better outcomes? J Card Surg 2020; 35:3512-3520. [DOI: 10.1111/jocs.15028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 09/03/2020] [Indexed: 01/26/2023]
Affiliation(s)
- Wahaj Munir
- Barts and the London School of Medicine and Dentistry Queen Mary University of London London United Kingdom
| | - Amer Harky
- Department of Cardiac Surgery Alder Hey Children Hospital Liverpool United Kingdom
- Department of Cardiothoracic Surgery Liverpool Heart and Chest Hospital Liverpool United Kingdom
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart and Chest Hospital Liverpool United Kingdom
- Department of Integrative Biology, Faculty of Health Sciences University of Liverpool Liverpool United Kingdom
| | - Mohamad Bashir
- Department of Vascular Surgery Royal Blackburn Teaching Hospital Blackburn United Kingdom
| | - Benjamin Adams
- Aortovascular Surgery, Barts Heart Centre St. Bartholomew's Hospital London United Kingdom
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26
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Harky A, Singh VP, Khan D, Sajid MM, Kermali M, Othman A. Factors Affecting Outcomes in Acute Type A Aortic Dissection: A Systematic Review. Heart Lung Circ 2020; 29:1668-1681. [PMID: 32798049 DOI: 10.1016/j.hlc.2020.05.113] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/10/2020] [Accepted: 05/18/2020] [Indexed: 11/17/2022]
Abstract
Acute type A aortic dissection is a clinical emergency and is associated with significant morbidity and mortality rates if not managed promptly in specialised and high-volume centres. The mortality rate is increased by 1% for each hour delay in management; however, with advancement in clinical practice, diagnostic imaging and clinician awareness, this has been dramatically reduced to below 30% in most international centres. Not only timing of recognition of the pathology, but also other factors can significantly affect outcomes of such critical pathology. This includes, but is not limited to, age, extent of the pathology, existence of connective tissue disorders, hypertension, diabetes mellitus and surgeon experience. This narrative review will focus on current clinical practice and the evidence behind optimising each factor to minimise adverse outcomes in such high-risk cohort.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; School of Medicine, University of Liverpool, Liverpool, UK.
| | | | - Darab Khan
- School of Medicine, University of Liverpool, Liverpool, UK
| | | | - Muhammed Kermali
- Faculty of Medicine, St. George's, University of London, London, UK
| | - Ahmed Othman
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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27
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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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28
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Midterm outcomes and durability of sinus segment preservation compared with root replacement for acute type A aortic dissection. J Thorac Cardiovasc Surg 2020; 163:900-910.e2. [DOI: 10.1016/j.jtcvs.2020.04.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 03/12/2020] [Accepted: 04/10/2020] [Indexed: 11/21/2022]
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29
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Czerny M, Eggebrecht H, Rousseau H, Mouroz PR, Janosi RA, Lescan M, Schlensak C, Böckler D, Ante M, Weijde EV, Heijmen R, Eckstein HH, Reutersberg B, Trimarchi S, Schmidli J, Wyss T, Frey R, Makaloski V, Brunkwall J, Mylonas S, Szeberin Z, Klocker J, Gottardi R, Schusterova I, Morlock J, Berger T, Beyersdorf F, Rylski B. Distal Stent Graft-Induced New Entry After TEVAR or FET: Insights Into a New Disease From EuREC. Ann Thorac Surg 2020; 110:1494-1500. [PMID: 32283085 DOI: 10.1016/j.athoracsur.2020.02.079] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 01/10/2020] [Accepted: 02/04/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND The study sought to learn about incidence and reasons for distal stent graft-induced new entry (dSINE) after thoracic endovascular aortic repair (TEVAR) or after frozen elephant trunk (FET) implantation, and develop prevention algorithms. METHODS In an analysis of an international multicenter registry (EuREC [European Registry of Endovascular Aortic Repair Complications] registry), we found 69 dSINE patients of 1430 (4.8%) TEVAR patients with type B aortic dissection and 6 dSINE patients of 100 (6%) patients after the FET procedure for aortic dissection with secondary morphological comparison. RESULTS The underlying aortic pathology was acute type B aortic dissection in 33 (44%) patients, subacute or chronic type B aortic dissection in 34 (45%) patients, acute type A aortic dissection in 3 patients and remaining dissection after type A repair in 3 (8%) patients, and acute type B intramural hematoma in 2 (3%) patients. dSINE occurred in 4.4% of patients in the acute setting and in 4.9% of patients in the subacute or chronic setting after TEVAR. After the FET procedure, dSINE occurred in 5.3% of patients in the acute setting and in 6.5% of patients in the chronic setting. The interval between TEVAR or FET and the diagnosis of dSINE was 489 ± 681 days. Follow-up after dSINE was 1340 ± 1151 days, and 4 (5%) patients developed recurrence of dSINE. Morphological analysis between patients after TEVAR with and without dSINE showed a smaller true lumen diameter, a more accentuated oval true lumen morphology, and a higher degree of stent graft oversizing in patients who developed dSINE. CONCLUSIONS dSINE after TEVAR or FET is not rare and occurs with similar incidence after acute and chronic aortic dissection (early and late). Avoiding oversizing in the acute and chronic settings as well as carefully selecting patients for TEVAR in postdissection aneurysmal formation will aid in reducing the incidence of dSINE to a minimum.
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Affiliation(s)
- Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, Bad Krozingen, Germany.
| | | | - Herve Rousseau
- Department of Radiology, Centre Hospitalier Universitaire de Rangueil, Toulouse, France
| | - Paul Revel Mouroz
- Department of Radiology, Centre Hospitalier Universitaire de Rangueil, Toulouse, France
| | - Rolf-Alexander Janosi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Mario Lescan
- Department of Cardiothoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Cardiothoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Dittmar Böckler
- Department of Vascular Surgery, Ruprecht-Karls University of Heidelberg, Heidelberg, Germany
| | - Marius Ante
- Department of Vascular Surgery, Ruprecht-Karls University of Heidelberg, Heidelberg, Germany
| | - Emma Vdr Weijde
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Germany
| | - Robin Heijmen
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Germany
| | - Hans Henning Eckstein
- Munich Aortic Centre, Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich Germany
| | - Benedikt Reutersberg
- Munich Aortic Centre, Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich Germany
| | - Santi Trimarchi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Jürg Schmidli
- Department of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Wyss
- Department of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Romina Frey
- Department of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Spyridon Mylonas
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Zoltan Szeberin
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | - Josef Klocker
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Roman Gottardi
- Department of Cardiovascular and Endovascular Surgery, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | | | - Julia Morlock
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, Bad Krozingen, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, Bad Krozingen, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, Bad Krozingen, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, Bad Krozingen, Germany
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30
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Long-term outcomes after valve-sparing anatomical aortic root reconstruction in acute dissection involving the root. J Thorac Cardiovasc Surg 2020; 159:1176-1184.e1. [DOI: 10.1016/j.jtcvs.2019.04.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 03/21/2019] [Accepted: 04/12/2019] [Indexed: 11/22/2022]
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31
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Fate of the Preserved Sinuses of Valsalva After Emergency Repair for Acute Type A Aortic Dissection. Ann Thorac Surg 2020; 110:1476-1483. [PMID: 32156587 DOI: 10.1016/j.athoracsur.2020.01.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/29/2019] [Accepted: 01/31/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients with acute type A aortic dissection (ATAAD) present with heterogeneous involvement of the aortic root complex. Despite this variation, the aortic root can usually be preserved the majority of the time by Teflon (WL Gore, Newark, DE) inlay patch reconstruction of the dissected sinuses of Valsalva (SOV). In this study, we report the long term anatomic, functional, and clinical outcomes associated with the preserved SOV after surgery for ATAAD. METHODS From 2002-2017, of 776 emergency ATAAD operations at a single institution, 558 (71.9%) underwent valve resuspension with SOV preservation. Echocardiography reports were reviewed to obtain postoperative SOV dimensions. Cumulative incidence of SOV dilation ≥ 4 5mm was calculated using the Fine-Gray method with death as a competing risk. Repeated-measures linear mixed effects model was used to determine risk factors for SOV growth over time. RESULTS During the follow-up period, 62 of 558 (11.1%) patients developed SOV diameter ≥ 45 mm. Cumulative incidence of SOV dilation ≥ 45 mm at 1, 5, and 10 years was 5.5%, 12.4%, and 18.9% respectively. In a multivariable Cox regression model, preoperative SOV diameter ≥ 45 mm was associated with a hazard ratio of 14.11 (95% confidence interval 7.03-31.62) for postoperative SOV dilation ≥ 45 mm. In a repeated-measures linear mixed effects model, preoperative and discharge SOV diameter were significant predictors of SOV dilation. Postoperative time course was also identified as significant indicating growth over time. CONCLUSIONS The preserved sinuses of Valsalva after surgery for ATAAD may be prone to progressive dilatation over time. Closer echocardiographic surveillance may be warranted in these patients.
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32
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Schäfers HJ. Commentary: Just because we can, should we do it? J Thorac Cardiovasc Surg 2019; 161:2028-2029. [PMID: 31818428 DOI: 10.1016/j.jtcvs.2019.11.005] [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: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany.
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33
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Xue Y, Zhou Q, Pan J, Cao H, Fan F, Zhu X, Chong H, Wang D. Root reconstruction for proximal repair in acute type A aortic dissection. J Thorac Dis 2019; 11:4708-4716. [PMID: 31903260 DOI: 10.21037/jtd.2019.10.62] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Retrospective compared the results of root reconstruction and root replacement for acute type A aortic dissection (ATAAD) patients and observed the rate of aortic insufficiency (AI) and aortic root dilation in the midterm follow-up period. Methods From 2008-2016, 427 ATAAD patients received surgical therapy in our center. There were 328 male and 99 female patients, aging from 22 to 83 years with a mean age of (51.1±12.5) years. These patients were divided into two major groups: 298 cases with root reinforcement reconstruction (Root Reconstruction), 129 cases with Bentall procedure (Root Replacement). Results The 30-day mortality was 7.7% (33/427), while no difference between the 2 procedures (8.1% and 7.0%, P=0.844). Cross-clamp, cardiopulmonary bypass, and circulatory arrest times of all the patients were 252.5±78.1, 173.6±68.9, 30.7±9.5 minutes, respectively. In the average follow-up time of (34.5±26.1) months, midterm survival rates were similar between the 2 procedures (86.2% and 86.0%, P=0.957). Only one patient received redo Bentall procedure because of severe aortic regurgitation and dilated aortic root (50 mm) in the Root Reconstruction Group. Conclusions The indication of root management of ATAAD is based on the diameter of aortic root, structure of aortic root, and the dissection involvement. For most ATAAD patients, aortic root reinforcement reconstruction is a feasible and safe method.
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Affiliation(s)
- Yunxing Xue
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Jun Pan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Hailong Cao
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Fudong Fan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Xiyu Zhu
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Hoshun Chong
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Dongjin Wang
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
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34
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Kato Y, Sasaki K, Yamauchi H, Kanno Y, Jinno T, Yamada M, Kiyama H, Koyanagi T. Aortic root remodelling with external ring annuloplasty in acute type A aortic dissection. Interact Cardiovasc Thorac Surg 2019; 30:85-90. [DOI: 10.1093/icvts/ivz227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
To investigate the early and mid-term results of aortic root remodelling with external ring annuloplasty in acute type A aortic dissection.
METHODS
From January 2015 to April 2019, a total of 194 patients underwent emergency or urgent operation for acute type A aortic dissection in our hospital. Of these, outcomes in 18 patients who underwent valve-sparing aortic root remodelling with external ring annuloplasty were retrospectively evaluated.
RESULTS
The mean age of the 18 patients was 49 ± 14 years. Fourteen patients (78%) were men. Five patients had Marfan syndrome and 2 patients had bicuspid aortic valve. Two patients had coronary malperfusion and 1 patient had cerebral malperfusion. All 18 patients underwent aortic root remodelling with external ring annuloplasty. Cusp repair using central cusp plication was required in 9 patients. Concomitant procedures were hemiarch replacement in 8 patients, total arch replacement in 7 patients, partial arch replacement in 1 patient and coronary artery bypass grafting to the right coronary artery in 3 patients. Thirty-day mortality rate was 5.6% (1 of 18). Postoperative echocardiography showed aortic regurgitation of <1+ in all patients. During follow-up (mean 56 ± 41 months), 1 case of recurrent aortic regurgitation required aortic valve replacement.
CONCLUSIONS
Aortic root remodelling with external ring annuloplasty may be an appropriate treatment in middle-aged or younger patients presenting with acute type A aortic dissection.
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Affiliation(s)
- Yasuyuki Kato
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Kenichi Sasaki
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Hidetaka Yamauchi
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Yasuyuki Kanno
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Taiyo Jinno
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Muneaki Yamada
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Hiroshi Kiyama
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Toshiya Koyanagi
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Saitama, Japan
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David TE. What to do when the acute type A aortic dissection involves the aortic sinuses. J Thorac Cardiovasc Surg 2018; 156:2083. [PMID: 30093153 DOI: 10.1016/j.jtcvs.2018.06.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 06/24/2018] [Accepted: 06/25/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery of the Peter Munk Cardiac Centre at Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada.
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