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Levine D, Patel P, Zhao Y, Chung M, Singh S, Childress P, Chodisetty S, Leshnower B, Kurlansky P, Smith CR, Chen E, Takayama H. Valve-sparing aortic root replacement versus composite valve graft with bioprosthesis in patients under age 50. J Thorac Cardiovasc Surg 2024; 168:992-1002.e1. [PMID: 37480983 DOI: 10.1016/j.jtcvs.2023.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/16/2023] [Accepted: 07/16/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Although the unique risks of implanting a prosthetic valve after aortic valve (AV) surgery in young patients are well established, studies of aortic root replacement (ARR) are lacking. We investigated long-term outcomes after valve-sparing root replacement (VSRR) versus the use of a composite valve graft with bioprosthesis (b-CVG) in patients age <50 years. METHODS A total of 543 patients age <50 years underwent VSRR (n = 335) or b-CVG (n = 208) between 2004 and 2021 from 2 aortic centers, excluding those with dissection or endocarditis. Endpoints included mortality over time, reoperative aortic valve replacement (AVR), and development of greater than moderate aortic insufficiency (AI) or aortic stenosis (AS). Fine and Gray competing risk regression was used to compare the risk of reintervention. Propensity score matching (PSM) balanced patient comorbidities, and landmark analysis isolated outcomes beginning 4 years postoperatively. RESULTS Compared with VSRR, b-CVG was associated with lower 12-year survival (88.6% vs 92.9%; P = .036) and a higher rate of AV reintervention (37.6% vs 12.0%; P = .018). After PSM, survival was similar in the 2 arms (93.4% for b-CVG vs 93.0% for VSRR; P = .72). However, both Fine and Gray multivariable risk regression and PSM showed that b-CVG was independently associated with AV reintervention at >4 years postoperatively (Fine and Gray: subdistribution hazard ratio, 4.3 [95% confidence interval, 1.8-10.2; P = .001]; PSM: 35.7% for b-CVG versus 14.3% for VSRR; P = .024]). PSM rates of greater than moderate AI/AS at 10 years were more than 2-fold greater in the b-CVG arm compared with the VSRR arm (37.1% vs 15.9%; P = .571). CONCLUSIONS b-CVG in young patients is associated with early valvular degeneration, with increasing rates of reoperative AVR occurring even within 10 years. In contrast, VSRR is durable with excellent survival. In eligible young patients, every effort should be made to retain the native AV.
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Affiliation(s)
- Dov Levine
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Parth Patel
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Yanling Zhao
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Megan Chung
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Sameer Singh
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Patra Childress
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Shreya Chodisetty
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Bradley Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Craig R Smith
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Edward Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY.
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Levine D, Patel P, Wang C, Pan C, Dong A, Leshnower B, Kurlansky P, Smith CR, Chen E, Takayama H. Valve-sparing root replacement versus composite valve graft root replacement: Analysis of more than 1500 patients from 2 aortic centers. J Thorac Cardiovasc Surg 2024; 168:770-780.e6. [PMID: 37245627 DOI: 10.1016/j.jtcvs.2023.05.022] [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: 12/25/2022] [Revised: 03/31/2023] [Accepted: 05/03/2023] [Indexed: 05/30/2023]
Abstract
OBJECTIVES The long-term outcomes comparing valve-sparing root replacement, composite valve graft with bioprosthesis, and mechanical prosthesis have yet to be explored. We investigated the long-term survival and reintervention rates after 1 of 3 major aortic root replacements in patients with tricuspid aortic valves and patients with bicuspid aortic valves. METHODS A total of 1507 patients underwent valve-sparing root replacement (n = 700), composite valve graft with bioprosthesis (n = 703), or composite valve graft with mechanical prosthesis (n = 104) between 2004 and 2021 in 2 aortic centers, excluding those with dissection, endocarditis, stenosis, or prior aortic valve surgery. End points included mortality over time and cumulative incidence of aortic valve/proximal aorta reintervention. Multivariable Cox regression compared adjusted 12-year survival. Fine and Gray competing risk regression compared the risk and cumulative incidence of reintervention. Propensity score-matched subgroup analysis balanced the 2 major groups (composite valve graft with bioprosthesis and valve-sparing root replacement), and landmark analysis isolated outcomes beginning 4 years postoperatively. RESULTS On multivariable analysis, both composite valve graft with bioprosthesis (hazard ratio, 1.91, P = .001) and composite valve graft with mechanical prosthesis (hazard ratio, 2.62, P = .005) showed increased 12-year mortality risk versus valve-sparing root replacement. After propensity score matching, valve-sparing root replacement displayed improved 12-year survival versus composite valve graft with bioprosthesis (87.9% vs 78.8%, P = .033). Adjusted 12-year reintervention risk in patients receiving composite valve graft with bioprosthesis or composite valve graft with mechanical prosthesis versus valve-sparing root replacement was similar (composite valve graft with bioprosthesis subdistribution hazard ratio, 1.49, P = .170) (composite valve graft with mechanical prosthesis subdistribution hazard ratio, 0.28, P = .110), with a cumulative incidence of 7% in valve-sparing root replacement, 17% in composite valve graft with bioprosthesis, and 2% in composite valve graft with mechanical prosthesis (P = .420). Landmark analysis at 4 years showed an increased incidence of late reintervention in composite valve graft with bioprosthesis versus valve-sparing root replacement (P = .008). CONCLUSIONS Valve-sparing root replacement, composite valve graft with mechanical prosthesis, and composite valve graft with bioprosthesis demonstrated excellent 12-year survival, with valve-sparing root replacement associated with better survival. All 3 groups have low incidence of reintervention, with valve-sparing root replacement showing decreased late postoperative need for reintervention compared with composite valve graft with bioprosthesis.
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Affiliation(s)
- Dov Levine
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Parth Patel
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Chunhui Wang
- Center for Innovation and Outcomes Research, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Cheryl Pan
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Andy Dong
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Bradley Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Craig R Smith
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Edward Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY.
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Singh SK, Levine D, Patel P, Norton E, Wang C, Kurlansky P, Childress P, Chung M, Olakunle O, George I, Leshnower B, Chen EP, Takayama H. Reintervention after valve-sparing aortic root replacement: A comprehensive analysis of 781 David V procedures. J Thorac Cardiovasc Surg 2024; 167:1229-1238.e7. [PMID: 37156363 DOI: 10.1016/j.jtcvs.2023.04.013] [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: 03/05/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Studies of reintervention after valve-sparing aortic root replacement (VSRR) are limited by sample size and failure to evaluate all types of reinterventions, including distal aorta and transcatheter interventions. In this report, reintervention after VSRR using a large patient cohort was comprehensively analyzed. METHODS In a series involving 2 academic aortic centers, 781 consecutive patients from 2005 to 2020 undergoing David V VSRR for aortic aneurysm (91%) or dissection (9%) were included. Median age was 50 years, and 23% had a bicuspid aortic valve (AV). Median follow-up was 7.0 years. Open or transcatheter reintervention on the AV, proximal, or distal thoracic aorta was identified. Cumulative incidence was calculated, and subdistribution hazard models identified factors associated with reintervention. Time-dependent incidence of reintervention was plotted using risk-hazard functions. RESULTS Sixty-eight reinterventions (57 open, 11 transcatheter) were performed. Reinterventions were divided by indication into degenerative AV (n = 26, including 1 transcatheter aortic valve replacement), endocarditis (n = 11), proximal aorta (n = 8), and distal aorta (n = 23, including 10 thoracic endovascular aortic repairs). Risk of reintervention for endocarditis peaked 1 to 3 years after VSRR, whereas other indications had stable, low rates of occurrence throughout the follow-up period. The cumulative incidence of reintervention was 12.5% whereas the cumulative incidence of AV reintervention was 7.0% at 10 years and was associated with residual postoperative aortic insufficiency. In-hospital mortality after reintervention was 3%. CONCLUSIONS Reintervention rates after VSRR are relatively low in long-term follow-up and can be performed with acceptable operative risk. The majority of reinterventions are performed for indications other than AV degeneration, with the timing of reintervention varying by the specific clinical indication.
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Affiliation(s)
- Sameer K Singh
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Dov Levine
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Parth Patel
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Elizabeth Norton
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Chunhui Wang
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Paul Kurlansky
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Patra Childress
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Megan Chung
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Oreoluwa Olakunle
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Isaac George
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Bradley Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Irving Medical Center, New York, NY.
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Rajesh K, Levine D, Murana G, Castagnini S, Bianco E, Childress P, Zhao Y, Kurlansky P, Pacini D, Takayama H. Is surgical risk of aortic arch aneurysm repair underestimated? A novel perspective based on 30-day versus 1-year mortality. Eur J Cardiothorac Surg 2024; 65:ezae041. [PMID: 38318956 DOI: 10.1093/ejcts/ezae041] [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: 09/18/2023] [Revised: 01/11/2024] [Accepted: 02/01/2024] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVES The decision to undergo aortic aneurysm repair balances the risk of operation with the risk of aortic complications. The surgical risk is typically represented by perioperative mortality, while the aneurysmal risk relates to the 1-year risk of aortic events. We investigate the difference in 30-day and 1-year mortality after total arch replacement for aortic aneurysm. METHODS This was an international two-centre study of 456 patients who underwent total aortic arch replacement for aneurysm between 2006 and 2020. Our primary end-point of interest was 1-year mortality. Our secondary analysis determined which variables were associated with 1-year mortality. RESULTS The median age of patients was 65.4 years (interquartile range 55.1-71.1) and 118 (25.9%) were female. Concomitantly, 91 (20.0%) patients had either an aortic root replacement or aortic valve procedure. There was a drop in 1-year (81%, 95% confidence interval (CI) 78-85%) survival probability compared to 30-day (92%, 95% CI 90-95%) survival probability. Risk hazards regression showed the greatest risk of mortality in the first 4 months after discharge. Stroke [hazard ratio (HR) 2.54, 95% CI (1.16-5.58)], renal failure [HR 3.59 (1.78-7.25)], respiratory failure [HR 3.65 (1.79-7.42)] and reoperation for bleeding [HR 2.97 (1.36-6.46)] were associated with 1-year mortality in patients who survived 30 days. CONCLUSIONS There is an increase in mortality up to 1 year after aortic arch replacement. This increase is prominent in the first 4 months and is associated with postoperative complications, implying the influence of surgical insult. Mortality beyond the short term may be considered in assessing surgical risk in patients who are undergoing total arch replacement.
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Affiliation(s)
- Kavya Rajesh
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Dov Levine
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Giacomo Murana
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sabrina Castagnini
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Edoardo Bianco
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Patra Childress
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Yanling Zhao
- Center for Innovation and Outcomes Research, Columbia University, New York, NY, USA
| | - Paul Kurlansky
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
- Center for Innovation and Outcomes Research, Columbia University, New York, NY, USA
| | - Davide Pacini
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
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Ram E, Lau C, Dimagli A, Gaudino M, Girardi LN. Valve Sparing vs Composite Valve Graft Root Replacement: Propensity Score-Matched Analysis. Ann Thorac Surg 2024; 117:69-76. [PMID: 37541560 DOI: 10.1016/j.athoracsur.2023.05.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/25/2023] [Accepted: 05/30/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Both valve-sparing root replacement and composite valve graft (CVG) are acceptable options in aortic root replacement. We compare outcomes of these 2 approaches and durability of the aortic valve. METHODS A consecutive 1635 patients without acute dissection underwent primary aortic root replacement from 1997 to 2022; 473 (29%) underwent valve-sparing root replacement, and 1162 (71%) received CVG. Propensity score matching was used to reduce baseline differences. RESULTS The CVG group was older (59 ± 14 years vs 49 ± 14 years; P < .001) with more comorbidities, such as hypertension (88.4% vs 66.4%; P < .001), diabetes (7% vs 1.7%; P < .001), ischemic heart disease (5.1% vs 1.3%; P = .001), pulmonary disease (6.6% vs 1.3%; P < .001), renal impairment (8.6% vs 1.3%; P < .001), class III-IV heart failure (35% vs 9.2%; P < .001), bicuspid aortic valves (44.8% vs 24.1%; P < .001), and severe aortic insufficiency (50.2% vs 13.2%; P < .001). Operative mortality was 0.4% (0% in valve sparing); incidence of major postoperative complications was 2.9% (3.6% vs 1.1%; P = .009). Ten-year survival was 93.1% (91.2% vs 97.7%; hazard ratio [HR], 1.7; 95% CI, 0.9-3.3; P = .120). Mean follow-up was 65 ± 60 months; aortic valve reoperations were similar (5.8% vs 5.7%; HR, 0.8; 95% CI, 0.4-1.4; P = .401). Recurrent moderate-severe aortic insufficiency was less prevalent in CVG (6.1% vs 11.1%; HR, 0.14; 95% CI, 0.07-0.27; P < .001). Propensity score matching identified 225 pairs. There was no difference in 10-year survival or reoperations. Recurrent moderate-severe aortic insufficiency was higher with valve sparing. CONCLUSIONS Both valve-sparing operations and CVG provide excellent early and late outcomes out to 10 years. Valve sparing is associated with a higher risk for development of aortic insufficiency but no difference in reoperations.
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Affiliation(s)
- Eilon Ram
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
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Hu D, Blitzer D, Zhao Y, Chan C, Yamabe T, Kim I, Adeniyi A, Pearsall C, Kurlansky P, George I, Smith CR, Patel V, Takayama H. Quantifying the effects of circulatory arrest on acute kidney injury in aortic surgery. J Thorac Cardiovasc Surg 2023; 166:1707-1716.e6. [PMID: 35570021 DOI: 10.1016/j.jtcvs.2022.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES We aim to investigate the association between parameters surrounding circulatory arrest and postoperative acute kidney injury in aortic surgery. METHODS This is a single-center retrospective study of 1118 adult patients who underwent aortic repair with median sternotomy between January 2010 and May 2019. Acute kidney injury was defined on the basis of a modified version of the 2012 Kidney Disease Improving Global Outcomes Scale that excluded urine output. The primary outcome of interest was any stage of acute kidney injury. RESULTS Circulatory arrest was required in 369 patients, and 307 patients (27.5%) developed acute kidney injury: stage 1 in 241 patients, stage 2 in 38 patients, and stage 3 in 28 patients. Lower-body ischemia (the period during circulatory arrest without blood flow to kidneys) duration was not associated with acute kidney injury after multivariable logistic regression (1-40 minutes, odds ratio, 0.67; 95% confidence interval, 0.43-1.04; P = .075; >40 minutes, odds ratio, 0.67; 95% confidence interval, 0.29-1.55; P = .356). Hypertension (odds ratio, 1.65; 95% confidence interval, 1.09-2.54; P = .020), preoperative estimated glomerular filtration rate (odds ratio, 0.99; 95% confidence interval, 0.98-1.00; P = .010), packed red blood cell transfusion volume (odds ratio, 1.00; 95% confidence interval, 1.00-1.00; P = .028), and nadir temperature (odds ratio, 0.93; 95% confidence interval, 0.88-0.99; P = .013) were independently associated with acute kidney injury after multivariable analysis. Although there was a positive association between lower-body ischemia duration and development of acute kidney injury with univariable cubic spline, the positive curve was flattened after adjustment for the described variables. CONCLUSIONS Within the range of our clinical practice, prolonged lower-body ischemia duration was not independently associated with postoperative acute kidney injury, whereas nadir temperature was.
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Affiliation(s)
- Diane Hu
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY
| | - David Blitzer
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY
| | - Yanling Zhao
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY
| | - Christine Chan
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY
| | - Tsuyoshi Yamabe
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY; Department of Cardiovascular Surgery, Shonan-Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Ilya Kim
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY
| | - Adedeji Adeniyi
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY
| | - Christian Pearsall
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY
| | - Paul Kurlansky
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY
| | - Isaac George
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY
| | - Craig R Smith
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY
| | - Virendra Patel
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY.
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Chung MM, Filtz K, Simpson M, Nemeth S, Kosuri Y, Kurlansky P, Patel V, Takayama H. Central aortic versus axillary artery cannulation for aortic arch surgery. JTCVS OPEN 2023; 14:14-25. [PMID: 37425444 PMCID: PMC10328800 DOI: 10.1016/j.xjon.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 07/11/2023]
Abstract
Objective Central aortic cannulation for aortic arch surgery has become more popular over the last decade; however, evidence comparing it with axillary artery cannulation remains equivocal. This study compares outcomes of patients who underwent axillary artery and central aortic cannulation for cardiopulmonary bypass during arch surgery. Methods A retrospective review of 764 patients who underwent aortic arch surgery at our institution between 2005 and 2020 was performed. The primary outcome was failure to achieve uneventful recovery, defined as having experienced at least 1 of the following: in-hospital mortality, stroke, transient ischemic attack, bleeding requiring reoperation, prolonged ventilation, renal failure, mediastinitis, surgical site infection, and pacemaker or implantable cardiac defibrillator implantation. Propensity score matching was used to account for baseline differences across groups. A subgroup analysis of patients undergoing surgery for aneurysmal disease was performed. Results Before matching, the aorta group had more urgent or emergency operations (P = .039), fewer root replacements (P < .001), and more aortic valve replacements (P < .001). After successful matching, there was no difference between the axillary and aorta groups in failure to achieve uneventful recovery, 33% versus 35% (P = .766), in-hospital mortality, 5.3% versus 5.3% (P = 1), or stroke, 8.3% versus 5.3% (P = .264). There were more surgical site infections in the axillary group, 4.8% versus 0.4% (P = .008). Similar results were seen in the aneurysm cohort with no differences in postoperative outcomes between groups. Conclusions Aortic cannulation has a safety profile similar to that of axillary arterial cannulation in aortic arch surgery.
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Affiliation(s)
- Megan M. Chung
- Division of Cardiothoracic and Vascular Surgery, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Kerry Filtz
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Michael Simpson
- Division of Cardiothoracic and Vascular Surgery, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Samantha Nemeth
- Center for Innovation and Outcomes Research, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Yaagnik Kosuri
- Division of Cardiothoracic and Vascular Surgery, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Virendra Patel
- Division of Cardiothoracic and Vascular Surgery, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
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8
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Yamabe T, Zhao Y, Kurlansky PA, Patel V, George I, Smith CR, Takayama H. Extent of aortic replacement and operative outcome in open proximal thoracic aortic aneurysm repair. JTCVS OPEN 2022; 12:1-12. [PMID: 36590741 PMCID: PMC9801234 DOI: 10.1016/j.xjon.2022.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/30/2022] [Accepted: 07/11/2022] [Indexed: 01/04/2023]
Abstract
Objectives There are few data to delineate the risk differences among open aortic procedures. We aimed to investigate the influence of the procedural types on the outcomes of proximal thoracic aortic aneurysm repair. Methods Among 1900 patients who underwent aortic replacement in our institution between 2005 and 2019, 1132 patients with aortic aneurysm who underwent a graft replacement of proximal thoracic aorta were retrospectively reviewed. Patients were divided into 4 groups based on the extent of the aortic replacement: isolated ascending aortic replacement (n = 52); ascending aortic replacement with distal extension with hemiarch, partial arch, or total arch replacement (n = 126); ascending aortic replacement with proximal extension with aortic valve or root replacement (n = 620); and ascending aortic replacement with distal and proximal extension (n = 334). "Eventful recovery," defined as occurrence of any key complications, was used as the primary end point. Odds ratios for inability to achieve uneventful recovery in each procedure were calculated using ascending aortic replacement as a reference. Results Overall, in-hospital mortality and stroke occurred in 16 patients (1.4%) and 24 patients (2.1%). Eventful recovery was observed in 19.7% of patients: 11.5% in those with ascending aortic replacement, 36.5% in those with partial arch or total arch replacement, 16.6% in those with proximal extension with aortic valve or root replacement, and 20.4% in those with distal and proximal extension (P < .001). With ascending aortic replacement as the reference, a multivariable logistic regression revealed partial arch or total arch replacement (odds ratio, 10.0; 95% confidence interval, 1.8-189.5) was an independent risk factor of inability to achieve uneventful recovery. Conclusions Open proximal aneurysm repair in the contemporary era resulted in satisfactory in-hospital outcomes. Distal extension was associated with a higher risk for postoperative complications.
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Affiliation(s)
- Tsuyoshi Yamabe
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY,Department of Cardiovascular Surgery, Shonan-Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Yanling Zhao
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Paul A. Kurlansky
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Virendra Patel
- Division of Aortic Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Isaac George
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Craig R. Smith
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY,Address for reprints: Hiroo Takayama, MD, PhD, Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, 177 Fort Washington Ave, New York, NY 10032.
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Chung MM, Erwin WC, Ning Y, Zhao Y, Chan C, D'Angelo A, Kossar A, Spellman J, Kurlansky P, Takayama H. A novel dosing strategy of del Nido cardioplegia in aortic surgery. JTCVS OPEN 2022; 10:39-61. [PMID: 35795250 PMCID: PMC9255383 DOI: 10.1016/j.xjon.2022.04.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Objective While del Nido (DN) cardioplegia is increasingly used in cardiac surgery, knowledge is limited in its safety profile for operations with prolonged crossclamp time (CCT). We have introduced a unique redosing strategy for aortic surgery: all operations use DN with a 1000-mL initiation dose (750 mL antegrade, 250 mL retrograde) composed of 1:4 blood:DN crystalloid. At 90 minutes CCT and every 30 minutes thereafter, a 250-mL dose was introduced retrograde in a 4:1 (“reverse”) ratio. Additionally, at 90 minutes CCT and every 90 minutes thereafter, a reverse ratio dose of approximately 100 to 400 mL was introduced via the right coronary artery. Here, we analyze the outcomes of our unique redosing strategy used. Methods In total, 440 patients underwent aortic surgery between January 2015 and March 2021 under a single surgeon and received DN. Our primary end points were change in left ventricular ejection fraction (LVEF) and right ventricular systolic function based on echocardiography. Multivariable linear regression was used to analyze the relationship between CCT and outcomes. Results The median was 61 years old (interquartile range, 51-69), and 23% were female. Indication was aneurysm in 65% and dissection in 24%. Median preoperative LVEF was 60% (55%-62%). Median CCT and cardiopulmonary bypass times were 135 minutes (93-165 minutes) and 181 minutes (142-218 minutes), respectively. In-hospital mortality occurred in 3%. Multivariable linear regression showed CCT was not associated with change in LVEF or change in right ventricular systolic function. Conclusions Our unique method of redosing DN cardioplegia appears to provide safe and effective myocardial protection for aortic surgery.
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Mazine A, Chu MWA, El-Hamamsy I, Peterson MD. Valve-sparing aortic root replacement: a primer for cardiologists. Curr Opin Cardiol 2022; 37:156-164. [PMID: 35058413 DOI: 10.1097/hco.0000000000000951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to review the contemporary evidence supporting valve-sparing aortic root replacement as the best option for patients with aortic root aneurysms and preservable aortic valves as well as to review the technical variations and modern adjuncts of these operations that impact both short and long-term durability. RECENT FINDINGS In patients with an aortic root aneurysm, with or without aortic valve regurgitation, valve-sparing aortic root replacement provide excellent clinical outcomes and stable valve function over several decades. Successful execution of this operation depends on careful patient selection and a thorough understanding of the anatomical and physiological relationships between the various components of the aortic root. Echocardiography remains the mainstay of imaging to determine the feasibility of valve-sparing root replacement. SUMMARY Valve-sparing aortic root replacement is an excellent alternative to composite valve graft replacement in nonelderly patients with aortic root aneurysms. Dedicated aortic root surgeons perform several technical variations of valve-sparing procedures aimed at matching the specific aortic root disorder with the optimal operation.
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Affiliation(s)
- Amine Mazine
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mark D Peterson
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6538731. [DOI: 10.1093/ejcts/ezac104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 01/17/2022] [Accepted: 01/31/2022] [Indexed: 11/14/2022] Open
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Surgical options for aortic root aneurysm disease: which procedure, which patient. Curr Opin Cardiol 2021; 36:683-688. [PMID: 34354008 DOI: 10.1097/hco.0000000000000902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Several surgical repair strategies are available for patients with aortic root aneurysms. This review summarizes the indications for surgery, surgical treatment options, as well their associated outcomes. RECENT FINDINGS Despite the development and increasing adoption of valve sparing aortic root replacement, most patients with aortic root aneurysms still undergo placement of a composite valved graft. Valve sparing aortic root replacement may have a lower rate of bleeding and thrombotic complications during long-term follow-up with excellent long-term survival and low rates of aortic valve reintervention. SUMMARY Patients with aortic root aneurysms who are symptomatic or reach the recommended size criteria should undergo surgical repair. Most patients receive composite valve graft conduits with good outcomes. The presence of normal aortic leaflet tissue and minimal regurgitation, including those with connective tissue disorders, should be evaluated for valve sparing aortic root replacement. Valve sparing procedures are durable and obviate the need for lifelong anticoagulation and avoid the risk of structural degeneration of bioprosthetic valves.
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