The fate of residual aortic regurgitation after ascending aorta replacement in type A aortic dissection

Acute type A aortic syndromes: outcomes are independent of aortic root/valve management

Purpose

Clinical outcomes following various surgical intervention strategies for aortic root and valve pathology during repair of acute type A aortic syndromes were studied and compared.

Methods

From 2004 to 2019, 634 patients underwent acute type A aortic repair. Patients were divided into 4 groups: Valve Resuspension (n = 456), Isolated Valve Replacement (AVR) (n = 24), Valve and Root Replacement (ROOT) (n = 97), and Valve Sparing Root Replacement (VSRR) (n = 57). The primary endpoint was midterm survival and multivariable risk factor analysis was performed.

Results

The mean age was 55.4 ± 13 years, 424 (67%) were male, and overall early mortality was 12%. Early mortality was 13%, 8%, 11%, and 7% for the Valve Resuspension, AVR, ROOT, and VSRR groups respectively, p = 0.43. Five-year survival was 74%, 86%, 73%, and 84% for the Valve Resuspension, AVR, ROOT, and VSRR groups respectively, p = 0.46. There was no difference in late stroke, renal failure, heart block, and late bleeding (p > 0.05 for all). At late follow-up, AVR and ROOT patients had a higher mean gradient versus Valve Resuspension and VSRR patients, p < 0.0001. For the total cohort, risk factors for late mortality included preoperative peripheral vascular disease (hazard ratio (HR) 2.3, 95% confidence interval (CI) 1.2-4.4, p = 0.009) and preoperative dialysis (HR 2.8, 95% CI 1.3-6.1, p = 0.01).

Conclusion

Mid-term survival following repair of acute type A aortic dissection is not independently associated with a specific type of aortic valve intervention. Native valve preservation leads to acceptable mid-term valve hemodynamics and should be the preferred therapy in this emergent clinical setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01602-8.

Aortic Root Reinforcement Combined with Vascular Grafts Eversion and Built-in Procedure (XJ-Procedure) for Acute Type A Aortic Dissection Surgery

INTRODUCTION

Current root reinforcement methods for acute type A aortic dissection (ATAAD) risk the tearing of endothelial tissue by sutures. This study proposed a novel technique for aortic root reinforcement and evaluated its effectiveness.

METHODS

Patients who diagnosed with ATAAD and had mild to moderate aortic root involvement, combined with aortic arch involvement undergoing Sun's procedure in the First Affiliated Hospital of Xi'an Jiaotong University from January 2020 to December 2021, were retrospectively enrolled. They were divided into two groups according to their surgical procedures of aortic root: continuous aortic root suture group (CARS group) and aortic root reinforcement combined with vascular grafts eversion and built-in procedure (XJ-procedure) group. The 30-day mortality rates and incidence of operation-related complications were evaluated.

RESULTS

The study cohort comprised 183 patients, including 114 in the XJ-procedure group. The 30-day mortality rates were 7.2% in the CARS group and 6.9% in the XJ-procedure group (P = 1.000). The incidence of residual aortic root dissection in the XJ-procedure group was lower than that in the CARS group before discharge (1.8% vs. 10.1%, P = 0.028), at 3-month (0% vs. 8.7%, P = 0.002) and 6-month (0% vs. 7.2%, P = 0.007) follow-up. In the CARS group, the incidence of anastomotic pseudoaneurysm was 2.9%, 2.9%, and 2.9% compared with none in the XJ-procedure group before discharge, at 3 and 6 months. The XJ-procedure group also showed less chest tube drainage in the first 24-h after the surgery, with lower incidence of hemodialysis and sepsis during hospitalization. No differences were observed in the incidence of bleeding necessitating reoperation and severe aortic regurgitation between the two groups.

CONCLUSIONS

The XJ-procedure did not increase 30-day mortality and effectively reduced the incidence of residual aortic root dissection during the 6-month follow-up. Subsequent studies with larger samples and prolonged follow-up are needed to evaluate it.

TRIAL REGISTRATION

NCT05751200. The video showed the partial process of the XJ-procedure in managing the aortic root in the ATAAD surgery. The vascular graft was folded outward about 15 mm, and the eversion was intermittently sutured to the full layers aortic wall using 2-0 pad polyester sutures. Then, the eversion of the graft and aortic wall were continuously sutured in one more turn using 3-0 polypropylene sutures. (XJ-procedure, aortic root reinforcement combined with vascular grafts eversion and built-in procedure; ATAAD, acute type A aortic dissection.). (MP4 297097 kb).

Effects of Residual Arch Tears on Late Outcomes After Hemiarch Replacement for DeBakey I Dissection

BACKGROUND

This study evaluated the effect of residual arch tears on late reinterventions and arch dilatation after hemiarch replacement for patients with acute DeBakey type I aortic dissection.

METHODS

Between January 1995 and October 2018, 160 consecutive patients who underwent hemiarch replacement for DeBakey type I dissection were retrospectively enrolled. They were divided into patients with (n = 73) and without (n = 87) residual arch tears. The arch tears group was subdivided into the proximal/middle arch (n = 26) and distal arch (n = 47) groups to evaluate arch growth rates according to the locations of residual arch tears. The endpoints were arch growth rate and late arch and composite events.

RESULTS

The arch diameter increased significantly over time in patients with residual arch tears (1.620 mm/y, P < .001). The increase occurred more rapidly when residual tears occurred at the distal arch than at the proximal/middle arch level (2.101 vs 1.001 mm/y). In the adjusted linear mixed model, residual arch tears or luminal communications at the distal arch level were significant factors associated with increases in the arch diameter over time. The 10-year freedom from late arch and composite event rate was significantly lower for patients with residual arch tears than for those without (82.4% vs 95.5%, P = .001; and 68.0% vs 89.3%, P = .002, respectively).

CONCLUSIONS

Residual arch tears are significant factors associated with late arch dilatation and reinterventions, especially for patients with distal arch tears. Extensive arch replacement during the initial surgery to avoid residual arch tears may improve long-term outcomes.

Imaging surveillance for complications after primary surgery for type A aortic dissection

Acute type A aortic dissection (ATAAD) is a life-threatening condition that requires emergency surgery to avert fatal outcome. Conventional surgical procedures comprise excision of the entry tear and replacement of the proximal aorta with a synthetic vascular graft. In patients with DeBakey type I dissection, this approach leaves a chronically dissected distal aorta, putting them at risk for progressive dilatation, dissection propagation and aortic rupture. Therefore, ATAAD survivors should undergo serial imaging for evaluation of the aortic valve, proximal and distal anastomoses, and the aortic segments beyond the distal anastomosis. The current narrative review aims to describe potential complications in the early and late phases after ATAAD surgery, with focus on their specific imaging findings.