Is a severe preoperative condition a contraindication for aortic valve-sparing reimplantation in type A aortic dissection?

BACKGROUND

Type A aortic dissection (TAAD) surgical management is still under debate. The purpose of this study was to demonstrate the feasibility and safety of the aortic valve-sparing root reconstruction (AVSR) procedure in 92 consecutive patients operated for TAAD, even when preoperative condition was severe (malperfusion, shock or both).

METHODS

Our hospital database was reviewed to identify all patients who underwent an AVSR procedure for TAAD over 14 years. From May 2000 to June 2014, 92 consecutive patients were studied regarding to their preoperative condition.

RESULTS

Age (61±13 years) and logistic Euroscore (23.4±15.3%) as well as cross-clamping (113±39 min), cardiopulmonary bypass (142±49 min) and circulatory arrest (22±13 min) times were collected. Hospital mortality was 16.3%. Mean follow-up was complete for a mean period of 27.6 months. One patient had early reoperation for aortic insufficiency. Actuarial survival at 1 year was 82.5%. The analysis of each group showed comparable mortality and morbidity in between patients.

CONCLUSIONS

Based upon our experience in the management of TAAD, a reimplantation procedure could be performed regardless preoperative malperfusion or shock, with an acceptable postoperative over mortality or morbidity. A word of caution should be brought to patients over 70 years old.

Analysis of risk factors for postoperative mortality in acute type A aortic dissection patients under different critical levels

We built up a risk stratification model to divide acute type A aortic dissection (aTAAD) patients into low- and high-risk groups, further, to evaluate the risk factors for postoperative mortality. A total of 1364 patients from 2010 to 2020 in our center were retrospectively analyzed. More than twenty clinical variables were related with postoperative mortality. The postoperative mortality of the high-risk patients was doubled than the low-risk ones (21.8% vs 10.1%). The increased operation time, combined coronary artery bypass graft, cerebral complications, re-intubation, continuous renal replacement therapy and surgical infection were risk factors of postoperative mortality in low-risk patients. In addition, postoperative lower limbs or visceral malperfusion were risk factors, axillary artery cannulation and moderate hypothermia were protective factors in high-risk patients. A scoring system for quick decision-making is needed to select appropriate surgical strategy in aTAAD patients. For low-risk patients, different surgical treatments can be performed with similar clinical prognosis. Limited arch treatment and appropriate cannulation approach are crucial in high-risk aTAAD patients.

Comparison of outcomes between aortic root replacement and supra-coronary interposition graft for type A aortic dissection: A retrospective case series

BACKGROUND

The decision to conserve or replace the native aortic valve following acute type-A aortic dissection (ATAAD) is an area of cardiac surgery without standardized practice. This single-center retrospective study analysed the long-term performance of the native aortic valve and root following surgery for ATAAD.

METHODS

Between 2009 and 2018 all cases ATAAD treated at Royal Brompton and Harefield NHS Foundation Trust were analysed. Patients were divided into two groups: (a) ascending aorta (interposition) graft (AAG) without valve replacement and (b) nonvalve-sparing aortic root replacement (ARR). Preoperative covariates were compared, as well as operative characteristics and postoperative complications. Long-term survival and echocardiographic outcomes were analysed using regression analysis.

RESULTS

In total, 116 patients were included: 63 patients in the AAG group and 53 patients in the ARR group. In patients where the native aortic valve was conserved, nine developed severe aortic regurgitation and two patients developed dilation of the aortic root requiring subsequent replacement during the follow-up period. Aortic regurgitation at presentation was not found to be associated with subsequent risk of developing severe aortic regurgitation or reintervention on the aortic valve. Overall mortality was observed to be significantly lower in patients undergoing AAG (17.5% vs. 41.5%, p = .004).

CONCLUSIONS

With careful patient selection, the native aortic root shows good long-term durability both in terms of valve competence and stable root dimensions after surgery for ATAAD. This study supports the consideration of conservation of the aortic valve during emergency surgery for type-A dissection, in the absence of a definitive indication for root replacement, including in cases where aortic regurgitation complicates the presentation.

Early and midterm results of valve-sparing aortic root reconstruction with a bovine pericardium patch for patients with acute type a aortic dissection

Objectives

We evaluated the feasibility, effectiveness, and safety of valve-sparing aortic root reconstruction with a bovine pericardium patch for patients with acute type A aortic dissection (ATAAD).

Methods

From January 2016 to January 2021, 895 consecutive patients with ATAAD received surgical treatment at our hospital. After applying our exclusion criteria, 508 patients were included in this research. Based on the attending surgeon's judgment and preference, 192 patients underwent our novel surgical novel surgical technique of valve-sparing aortic root reconstruction (repair group [RG]) and 316 patients underwent the Bentall procedure (Bentall group [BG]).

Results

In the RG, the early mortality rate was 4.2% (8/192). In the BG, the early mortality rate was 5.1% (16/316). There were no significant differences between groups. The incidence of postoperative renal failure in the BG was significantly higher than that in the RG. The mean follow-up time was 2.93 years (standard deviation, ±1.38 years). There were no significant differences between groups regarding ATAAD-related mortality and reoperation. In the RG, the rate of freedom from aortic root reoperation at 5 years was 98.2%, and the grade of aortic regurgitation 6 months later was significant less than that before surgery, and it did not worsen during later follow-up.

Conclusions

Valve-sparing aortic root reconstruction with a bovine pericardium patch can be successfully performed for selected patients with ATAAD and is associated with low in-hospital and late mortality rates and low root reoperation rates during early and midterm follow-up.

Comparison of two techniques in proximal anastomosis in acute type A aortic dissection

Background

The proximal anastomosis is an important procedure during the acute type A aortic dissection (AAAD) surgery. The conventional method is a double patch sandwich technique with Teflon felt. Adventitial eversion and prosthesis eversion technique as a novel approach has been applied to many patients in our center. Herein, This technique would be introduced, and the perioperative and 1-year follow-up results of the two different anastomosis methods were also evaluated.

Methods

Between December 2017 and May 2021, 143 AAAD patients who underwent total arch replacement (TAR) and frozen elephant trunk (FET) implantation were included in this retrospective study. Patients were divided into the eversion technique group (adventitial eversion and prosthesis eversion technique for proximal anastomosis, n = 64) and the sandwich technique group (n = 79).

Results

The medical records were analyzed and compared between the groups. The mean operation time was 466 ± 73 min in the eversion technique group and 513 ± 81 min in the sandwich technique group (P < 0.001). Compared with the sandwich technique group, the eversion technique group also showed a shorter time on proximal anastomosis (38 ± 12 min vs. 58 ± 20 min, P < 0.001), cardiopulmonary bypass (195 ± 26 vs. 211 ± 40 min, P = 0.003), and aortic cross-clamp (120 ± 23 min vs. 134 ± 27 min, P = 0.002). Furthermore, a decreased proportion of >600 ml fresh frozen plasmas transfusion was observed in eversion technique group (10.9% vs. 34.2%, P = 0.002). No statistical differences were found in the postoperative morbidities and 1-year follow-up outcomes.

Conclusion

Proximal anastomosis with adventitial eversion and prosthesis eversion technique is a promising surgical option for AAAD patients, with favorable perioperative and 1-year follow-up results.

Ministernotomy approach to aortic arch inclusion and frozen elephant trunk in the treatment of acute Stanford A aortic dissection

This study aimed to report our results of ministernotomy approach to Liu’s aortic root repair technique, Liu’s aortic arch inclusion technique with frozen elephant trunk (FET) in the treatment in type A aortic dissection (TAAD). We retrospectively analyzed data on 68 Stanford A aortic dissection patients from October 2017 to March 2020. All patients underwent Liu’s aortic root repair technique, Liu’s aortic arch inclusion technique with FET and mild-moderate hypothermic circulatory arrest combined with ministernotomy approach. 154 TAAD patients between January 2014 and December 2016 underwent complete sternotomy were selected as control group. Clinical characteristics, data during operation, in-hospital and postoperative outcomes of these patients were observed. The mean hypothermic circulatory arrest time in ministernotomy Patients was 39.3 ± 7.9 min, aortic cross-clamp time was 105.9 ± 12.8 min, cardiopulmonary bypass time was 152.8 ± 24.3 min. Three patients died of multiple organ dysfunction syndrome in ministernotomy Patients. Perioperative temporary neurological dysfunction occurred in three (4.41%) patients, and 53 (77.9%) patients did not require any blood product transfusion during and after operation in ministernotomy Patients. Postoperative CT angiography (CTA) examination at 6-32 months showed excellent outcomes except in three (4.41%) cases where arch false lumen patency persisted. The Liu’s aortic root repair technique, Liu’s aortic arch inclusion technique with FET and mild-moderate hypothermia circulatory arrest simplify the surgical procedure and reduce bleeding, which can be accomplished through minimally invasive approach.

Outcomes of Liu's aortic root repair and valve preservation in patients with type A dissection and aortic regurgitation

OBJECTIVES

To evaluate short- and medium-term outcomes following Liu's aortic root repair and valve preservation in patients with acute type A aortic dissection complicated by moderate-to-severe aortic regurgitation (AR).

METHODS

From October 2011 to July 2018, a total of 324 consecutive patients underwent emergency surgery for acute type A aortic dissection. There were 122 patients (38%) with moderate-to-severe AR, of whom 82 (67%) underwent Liu's aortic root repair and valve preservation. Aortic computed tomography angiography and echocardiography were performed at discharge, 6 and 12 months postoperatively, and annually thereafter. We focused on assessing the survival and aortic root and valve durability in the 82 patients.

RESULTS

The 30-day, 1-year, 3-year and 6-year survival estimates were 94%, 90%, 85% and 81%, respectively. At a median follow-up of 36.5 (interquartile range 24.9-50.9) months, all patients were free from reoperation. No residual false lumens in the aortic root, recurrent aortic root dissections or aortic root pseudoaneurysms were observed during the follow-up period. Only 1 patient (1%) presented with moderate AR at 6 months, which remained asymptomatic with no significant changes over a 3-year period. The remaining patients showed satisfactory valve function with an AR grade of mild (27%) or trace or none (72%). In the competing risk analysis, the incidence of recurrence of AR was 2% at 8 years.

CONCLUSIONS

Liu's aortic root repair and valve preservation is a safe and effective operative strategy that achieves favourable short- and medium-term outcomes for acute type A aortic dissection with moderate-to-severe AR.

Fate of the Preserved Sinuses of Valsalva After Emergency Repair for Acute Type A Aortic Dissection

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.

Differences of patients' characteristics in acute type A aortic dissection - surgical data from Belgian and Japanese centers

Background

It is well known that there are major differences between the Japanese and Western population regarding the incidence of ischemic heart disease and stroke. The purpose of this study was to evaluate differences of patients’ characteristics between Belgian and Japanese cohort with acute type A aortic dissection.

Methods

In 487 patients (297 male patients, mean age 61.9 ± 12.2 yrs) who underwent surgery for acute type A aortic dissection, baseline preoperative and intraoperative data were collected. Belgian patients (n = 237) were compared to Japanese patients (n = 250). Clinical data included patient demographics, history, status at presentation, imaging study results and intraoperative findings.

Results

The Japanese cohort had significantly more women (48.8% vs. 28.7%, p < 0.0001), lower BMI (24.2 vs. 26.4, p < 0.0001) and lower prevalence of hypertension (49.2% vs. 65.8%, p = 0.0002). More DeBakey type I dissections and less type III dissections with retrograde extension were reported in Belgium than in Japan (77.2% vs. 48.4%, p < 0.0001, 3.4% vs. 38.7%, p < 0.0001, respectively). More entries were found in the ascending aorta (78.5% vs. 58.5%, p < 0.0001) and aortic arch (24.9% vs. 13.7%, p = 0.0018) in Belgian patients than in Japanese patients, who had more entries in the descending aorta or undetected entries.

Conclusions

In acute type A aortic dissection, Belgian patients reveal striking differences from Japanese patients regarding gender distribution, entry tear location and type of dissection. Japanese women are more likely to develop acute type A aortic dissection than Belgian women. (234 words).

Late Echocardiographic Study of Aortic Valve and Aortic Root after Surgery for Type A Acute Aortic Dissection

Objective:

In case of concomitant aortic regurgitation (AR) valve, sparing operation is considered the first choice in selected patients. The aim of this retrospective clinical and echocardiographic study was to evaluate the long-term survival results of conservative approach and the determinants of recurrent AR.

Methods:

From 2000 to 2011, fifty patients (median: 63 years and interquartile range: 53–72) underwent an aortic valve-sparing procedure for acute aortic dissection, and discharged alive. The long-term clinical and echocardiographic outcome was analyzed.

Results:

Late all-causes mortality was 18% (nine patients) at a median follow-up of 55.8 months. Ten patients (20%) underwent re-operations, five of them for aortic valve/root recurrent disease; freedom from proximal re-operation was 90%. Two-third of the patients had a preoperative AR grade <3; a non-negligible number of patients with acute significant AR (23% with grade ≥3) at the time of surgery underwent conservative aortic valve surgery. At a median echocardiographic follow-up of 50.5 months, we found no significant correlation between late recurrent AR and AR grade at the time of surgery and the aortic root diameter. Late recurrent AR grade was significantly higher in patients who underwent aortic commissures and cusps resuspension than those who underwent lone ascending aorta replacement (2.29 ± 1.05 vs. 1.58 ± 1.03, P = 0.028).

Conclusions:

Preoperative AR and late aortic root diameter were not the predictors of late AR. Late AR is higher in patients who underwent aortic commissures and cusps resuspension compared to the only replacement of the ascending aorta.

Comparison of Left Ventricular Volume and Ejection Fraction and Frequency and Extent of Aortic Regurgitation After Operative Repair of Type A Aortic Dissection Among Three Different Surgical Techniques

Differences in recurrence rate of aortic regurgitation (AR) and extent of left ventricular (LV) remodeling across the different surgical options in patients operated for type A aortic dissection remain unknown. The present evaluation compared the AR recurrence rate and changes in LV volumes and systolic function in valve-sparing aorta replacement (VSAR), supracoronary ascending aorta replacement (SCAR), and aortic valve and aorta replacement (AVAR). A total of 97 patients (58 ± 12 years, 62% men) with acute type A aortic dissection who underwent VSAR (n = 24), SCAR (n = 43), or AVAR (n = 30) were evaluated. Changes in LV volumes and function between postoperative and follow-up were compared using linear mixed models. Postoperative AR grades were not significantly different between groups. However, after median follow-up of 47 months, AR grade ≥2 was significantly more often observed in SCAR (55%) and VSAR (25%) compared to AVAR (0%, p <0.001). LV volumes remained stable in VSAR and AVAR but increased significantly in SCAR (LV end-diastolic volume: from 99 ± 4 to 131 ± 6 ml; p <0.001; LV end-systolic volume: from 49 ± 3 to 66 ± 5 ml; p = 0.002). In patients with recurrent AR grade ≥2 at follow-up, LV volumes increased, whereas patients without recurrent AR did not show significant LV dilatation. In conclusion, patients with acute type A aortic dissection who underwent SCAR or VSAR showed more frequently AR grade ≥2 recurrence compared to AVAR. However, only patients who underwent SCAR experienced adverse LV remodeling at follow-up. Recurrence of AR grade ≥2 was associated with adverse LV remodeling.

Aortic valve preservation and repair in acute Type A aortic dissection

OBJECTIVES

Repair and preservation of the aortic valve in Type A aortic dissection (AAD) remains controversial. We performed a meta-analysis of outcomes for aortic valve (AV) repair and preservation in AAD focusing on long-term valve-related events.

METHODS

Structured searches were performed in Embase (1980-2013) and PubMed (1966-2013) for studies reporting AV repair or preservation in AAD. Early mortality and linearized rates for late mortality and valve-related events were derived. Outcome data were pooled with an inverse-variance-weighted random-effects model.

RESULTS

Of 5325 screened articles, 19 observational studies met the eligibility criteria consisting of 2402 patients with a median follow-up of 4.1 [range: 3.1-12.6 years, total 13 733 patient-years (pt-yr)]. The cohort was principally male (median = 68.1%, range: 39-89) with a median age of 59 (range: 55-68) years and Marfan's syndrome was present in 2.5%. AV resuspension was performed in 95% of the patients and the remainder underwent valve-sparing root replacement (reimplantation = 2.5% and remodelling = 2.5%). Pooled early mortality rate was 18.7% [95% confidence interval (95% CI): 12.2-26.2%], and linearized late mortality rate was 4.7%/pt-yr (95% CI: 3.4-6.3). Linearized rate for AV reintervention was 2.1%/pt-yr (95% CI: 1.0-3.6), recurrent aortic insufficiency (>2+) was 0.9%/pt-yr (95% CI: 0.3-2.2) and endocarditis was 0.2%/pt-yr (95% CI: 0.1-0.5). The composite rate of thromboembolism and bleeding was 1.4%/pt-yr (95% CI: 0.7-2.2).

CONCLUSIONS

Patients surviving an AAD have a limited long-term survival. Preservation and repair of the aortic valve is associated with a moderate risk of reoperation, but a low risk of thromboembolism, bleeding and endocarditis.

Perioperative transesophageal echocardiography for aortic dissection

PURPOSE

Aortic dissection is an infrequent but serious condition that often requires immediate operative intervention. We explore recent developments in the classification of aortic dissection and perioperative transesophageal echocardiography that assist with quantifying the severity of disease and facilitate its management.

PRINCIPAL FINDINGS

We describe the pivotal role of echocardiography in relation to key surgical considerations such as cannulation, aortic root surgery, perfusion in the aortic arch vessels, stenting in hybrid arch repair, and timing of preventative surgery.

CONCLUSION

Developments in the classification of aortic dissection have improved our perspective and understanding of the key presenting features that affect mortality. Improvements in patient outcome may be achieved in part by appropriately timed echocardiography-guided surgery.

The outcome of surgical management of type A aortic dissection

BACKGROUND

Type A aortic dissection is a serious and fatal condition.

METHODS

We retrospectively evaluated the outcome following repair of ascending aortic dissection in a contemporary cohort of 108 patients with a mean age of 59.5 ± 13.8 years, who were treated between 2006 and 2011. Most patients were male (70, 65%).

RESULTS

Circulatory arrest with a mean duration of 22 ± 16 min was performed in 42 (38.9%) patients. Perioperative mortality was 15.7% (n = 17). Univariate analysis showed that cardiopulmonary bypass time (p = 0.0006), age >60 years (p = 0.028), cardiogenic shock at presentation (p = 0.02), New York Heart Association class II-IV (p = 0.038), hemopericardium (p = 0.0035), and preoperative cerebrovascular accident (p = 0.02) were predictors of mortality. Multivariate analysis indicated that age >60 years (odds ratio 7.7, 95% confidence interval: 1.52-38.96, p = 0.0136), preoperative cerebrovascular accident (odds ratio 25.2, 95% confidence interval: 2.45-258.9, p = 0.0066), hemopericardium (odds ratio 41.6, 95% confidence interval: 5.38-320.7, p = 0.0003), and cardiopulmonary bypass time (odds ratio 1.85, 95% confidence interval: 1.32-2.57, p = 0.0003) were independent predictors of perioperative mortality. The 1- and 4-year survival was 80% ± 3.8% and 69% ± 5.7%, respectively. Age >60 years (hazard ratio 3.3, 95% confidence interval: 1.4-7.9, p = 0.0064) was the only independent predictor of long-term mortality.

CONCLUSION

Our results identify the major risk factors for perioperative and long-term mortality. Age is an independent risk factor for mortality.

Fibrin sealant patch for repair of acute type a aortic dissection

INTRODUCTION

The use of glues to repair disrupted tissue during acute type-A aortic dissection (TAD) surgery may be discontinuous, and cause embolization and cell necrosis. We report a method of fibrin sealant patch (FSP) to reinforce dissected aortic tissue with a collagen double layer coated with fibrinogen/thrombin on either side (TachoSil®; Takeda, Konstanz, Germany).

METHODS

In 12 patients (seven male, 66.9 ± 11.7 years) with acute TAD we performed FSP of the intima-media disruption at the proximal and distal anastomosis of the aorta. We analyzed the perioperative course and echocardiographical, radiological, and clinical outcomes up to one year. Additionally, we investigated the adhesive potential of the FSP in vitro.

RESULTS

In vitro, the adhesive strength of the FSP was 60 N/cm(2). In-hospital mortality was 8.3% (n = 1), recovery was satisfactory with no major neurologic events, mean ICU stay was 13.6 ± 6.0 days, mean hospital stay was 20.7 ± 4.4 days. A total of 7.0 ± 2.6 RBC, 3.4 ± 1.5 platelets, and 8.0 ± 4.3 FFP were transfused. One-year survival was 83.3%. In 6/6 DeBakey II dissections the intimal tear was completely resected, in 2/6 DeBakey I dissections the false lumen in the descending aorta completely collapsed. No redissections and no relevant aortic valve insufficiencies were seen during follow-up.

CONCLUSION

This analysis shows that FSP using a collagen matrix double layer coated with fibrinogen/thrombin is feasible, safe, and effective in repairing the dissected aortic tissue. It results in continuous reinforcement of aortic tissue and completely avoids the need for conventional glues.

"T-shaped" repair for commissural detachment in acute type A aortic dissection

Aortic insufficiency in patients with type A aortic dissection is commonly seen and, in most cases, is the consequence of commissural detachment. We report our method of aortic valve repair in which the valve commissure and detached intima are repaired by using a "T-shaped" polyester patch that fits well within the aortic root after removal of the clots in the proximal false lumen. The early results have proved this is an easy and effective way to repair valve commissural detachment and reconstruct the aortic root.