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Brown JA, Yousef S, Garvey J, Ogami T, Serna-Gallegos D, Sá MP, Thoma F, Zhu J, Phillippi J, Sultan I. Reinterventions After Repair of Acute Type A Aortic Dissection: Incidence, Outcomes, and Risk Factors. Ann Thorac Surg 2024; 117:915-921. [PMID: 38036024 DOI: 10.1016/j.athoracsur.2023.11.014] [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] [Received: 05/22/2023] [Revised: 10/19/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND This study reports the incidence, outcomes, and risk factors for aortic reinterventions after repair of acute type A aortic dissection (ATAAD). METHODS This was an observational study of aortic operations from 2010 to 2021. All patients with ATAAD undergoing open aortic arch reconstruction were included. Patients were dichotomized by the need for reintervention, which included reinterventions proximal to or distal to the index aortic repair. Propensity matching was used to determine the impact of reintervention on long-term outcomes. The cumulative incidence function for reintervention was estimated, and multivariable Fine-Gray analysis was performed to identify variables associated with reintervention, with death treated as a competing event. RESULTS We identified 601 patients undergoing surgery for ATAAD. An aortic reintervention was required in 71 (11.8%), comprising a proximal reintervention in 12 patients, a distal reintervention in 56, and both in 3. The cumulative incidence of reintervention was 11.6% (95% CI, 8.9%-14.6%) at 5 years and was 16.0% (95% CI, 12.2%-20.3%) at 10 years, with a median time to reintervention of 4.0 years (interquartile range, 0.9-7.5 years). Multivariable analysis using the Fine-Gray method showed no operative variables were associated with reinterventions. Among the 71 reinterventions, there were 4 (5.6%) operative deaths. After propensity matching, there was no difference in Kaplan-Meier survival estimates across each group (P = .138 by log-rank statistics). CONCLUSIONS The cumulative incidence of aortic reintervention after ATAAD repair was reasonably low (16% at 10 years), reinterventions were relatively safe (6% operative mortality), and reinterventions did not significantly impact long-term survival.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph Garvey
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michel Pompeu Sá
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Julie Phillippi
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Vervoort D, An KR, Deng MX, Elbatarny M, Fremes SE, Ouzounian M, Tarola C. The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch. Can J Cardiol 2024; 40:478-495. [PMID: 38052303 DOI: 10.1016/j.cjca.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mimi X Deng
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Huang M, Lian Y, Zeng Z, Li J. D-dimer, C-reactive protein and matrix metalloproteinase 9 for prediction of type A aortic dissection patient survival. ESC Heart Fail 2024; 11:147-154. [PMID: 37849442 PMCID: PMC10804169 DOI: 10.1002/ehf2.14552] [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: 12/16/2022] [Revised: 08/29/2023] [Accepted: 09/20/2023] [Indexed: 10/19/2023] Open
Abstract
AIMS Acute type A aortic dissection (ATAAD) is a life-threatening condition requiring prompt diagnosis and treatment. Surgery is an effective treatment for ATAAD, but the in-hospital mortality rate in the 30 day perioperative period is still as high as 9-30%. It is critical to identify biological factors for preoperative assessment of post-operative survival in patients with ATAAD. METHODS AND RESULTS This is a retrospective study, investigating the association of combined measurements of d-dimer, C-reactive protein (CRP), and matrix metalloproteinase 9 (MMP9) for 1 year of survival in patients with ATAAD. Data from 247 patients who underwent surgery were analysed, including 89 patients who did not survive and 158 patients who survived within 1 year after surgery. Pearson's correlation analysis was carried out to determine the correlations between CRP in whole blood, d-dimer in plasma, and CRP in whole blood. Receiver operating characteristic (ROC) analysis was used to analyse the value of preoperative whole blood CRP, plasma d-dimer, and serum MMP9 concentration and the combined detection model in predicting death of patients with ATAAD. Deceased patients with ATAAD exhibited higher age, hypertension prevalence, systolic blood pressure, white blood cell count, whole blood CRP, plasma d-dimer, and serum MMP9 levels compared with survivors. Preoperative CRP, d-dimer, and MMP9 levels were significantly higher in patients with ATAAD compared with healthy controls. Positive correlations were observed between CRP and d-dimer, CRP and MMP9, and d-dimer and MMP9 in patients with ATAAD. ROC analysis showed that the combined detection model of CRP, d-dimer, and MMP9 had the highest predictive value for 1 year of survival (area under the curve = 0.88). CONCLUSIONS Combined measurement of CRP, d-dimer, and MMP9 is associated with 1 year of survival in patients with ATAAD.
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Affiliation(s)
- Minjie Huang
- Department of Vascular Surgery, Quanzhou First Hospital Affiliated to Fujian Medical University, Fujian East Street, Quanzhou, 362000, Fujian, China
| | - Yujie Lian
- Department of Vascular Surgery, Quanzhou First Hospital Affiliated to Fujian Medical University, Fujian East Street, Quanzhou, 362000, Fujian, China
| | - Zhongyan Zeng
- Department of Vascular Surgery, Quanzhou First Hospital Affiliated to Fujian Medical University, Fujian East Street, Quanzhou, 362000, Fujian, China
| | - Jiahong Li
- Department of Vascular Surgery, Quanzhou First Hospital Affiliated to Fujian Medical University, Fujian East Street, Quanzhou, 362000, Fujian, China
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4
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Elendu C, Amaechi DC, Elendu TC, Ibhiedu JO, Torubiri AO, Okoye OK. Comprehensive review of aortic aneurysms, dissections, and cardiovascular complications in connective tissue disorders. Medicine (Baltimore) 2023; 102:e36499. [PMID: 38050214 PMCID: PMC10695548 DOI: 10.1097/md.0000000000036499] [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: 08/10/2023] [Accepted: 11/15/2023] [Indexed: 12/06/2023] Open
Abstract
Connective tissue disorders, including Marfan syndrome (MS) and Ehlers-Danlos syndrome (EDS), are characterized by genetic mutations affecting connective tissue structural integrity. These disorders significantly elevate the risk of aortic dissection, a life-threatening condition. This comprehensive review delves into the intricate interplay between connective tissue disorders and aortic dissection, shedding light on the clinical features, pathophysiology, genetic underpinnings, diagnostic approaches, clinical management, associated comorbidities, and prognosis, mainly focusing on MS and EDS, while also exploring rare connective tissue disorders and forms of cutis laxa contributing to aortic pathology.
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Affiliation(s)
| | | | | | | | | | - Osinachi K. Okoye
- Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Awka, Nigeria
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5
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Dietze Z, Kang J, Madomegov K, Etz CD, Misfeld M, Borger MA, Leontyev S. Aortic arch redo surgery: early and mid-term outcomes in 120 patients. Eur J Cardiothorac Surg 2023; 64:ezad419. [PMID: 38109680 DOI: 10.1093/ejcts/ezad419] [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: 09/25/2023] [Revised: 12/04/2023] [Accepted: 12/14/2023] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVES The aim of this study was to analyse the indications, surgical extent and results of treatment, as well as determine the risk factors for adverse outcomes after redo arch surgery. METHODS Between January 1996 and December 2022, 120 patients underwent aortic arch reoperations after primary proximal aortic surgery. We retrospectively analysed perioperative data, as well as early and mid-term outcomes in these patients. RESULTS Indications for arch reintervention included new aortic aneurysm in 34 patients (28.3%), expanding post-dissection aneurysm in 36 (30.0%), aortic graft infection in 39 (32.5%) and new aortic dissection in 9 cases. Two patients underwent reoperation due to iatrogenic complications. Thirty-one patients (25.8%) had concomitant endocarditis. In-hospital and 30-day mortality rates were 11.7% and 15.0%, respectively. Stroke was observed in 11 (9.2%) and paraplegia in 1 patient. Prior surgery due to aneurysm [odds ratio 4.5; 95% confidence interval (CI) 1.4-17.3] and critical preoperative state (odds ratio 5.9; 95% CI 1.5-23.7) were independent predictors of 30-day mortality. Overall 1- and 5-year survival was 65.8 ± 8.8% and 51.2 ± 10.6%, respectively. Diabetes mellitus (hazard ratio 2.4; 95% CI 1.0-5.1) and peripheral arterial disease (hazard ratio 4.7; 95% CI 1.1-14.3) were independent predictors of late death. The cumulative incidence of reoperations was 12.6% (95% CI 6.7-20.4%) at 5 years. Accounting for mortality as a competing event, connective tissue disorders (subdistribution hazard ratio 4.5; 95% CI 1.6-15.7) and interval between primary and redo surgery (subdistribution hazard ratio 1.04; 95% CI 1.02-1.06) were independent predictors of reoperations after redo arch surgery. CONCLUSIONS Despite being technically demanding, aortic arch reoperations are feasible and can be performed with acceptable results.
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Affiliation(s)
- Zara Dietze
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Jagdip Kang
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | | | - Christian D Etz
- Department of Cardiac Surgery, Rostock University Hospital, Rostock, Germany
| | - Martin Misfeld
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, NSW, Australia
| | - Michael A Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Sergey Leontyev
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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Benk J, Berger T, Gottardi R, Walter T, Kondov S, Rylski B, Czerny M, Kreibich M. Perioperative Mass Transfusion Affects In-Hospital but Not Follow-Up Survival in Patients with Acute Type A Aortic Dissection. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1825. [PMID: 37893543 PMCID: PMC10608168 DOI: 10.3390/medicina59101825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/04/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: The aim of this study was to analyze the influence of mass transfusion on the postoperative outcome and survival in patients presenting with acute Type A aortic dissection. Materials and Methods: Between 2002 and 2020, a total of 505 patients were surgically treated for an acute Type A aortic dissection. Mass transfusion was defined as the peri- and postoperative replacement by transfusion of 10 units. Patient characteristics and outcomes were analyzed and compared between patients with and without mass transfusion. Results: Mass transfusion occurred in 105 patients (20%). The incidences of symptomatic coronary malperfusion (p = 0.017) and tamponade (p = 0.043) were higher in patients with mass transfusion. There was no statistically significant difference in the distal extension of the aortic dissection between the two groups. A valved conduit was significantly more common in patients with mass transfusion (p = 0.007), while the distal aortic repair was similar between the two groups. Cardiopulmonary bypass time (p < 0.001), cross clamp time (p < 0.001) and in-hospital mortality were significantly higher in patients with mass transfusion (p < 0.001), but the survival after discharge (landmark-analysis) showed equal survival between patients with and without mass transfusion (log rank: p = 0.4). Mass transfusion was predictive of in-hospital mortality (OR: 3.308, p < 0.001) but not for survival after discharge (OR: 1.205, p = 0.661). Conclusions: Mass transfusion is necessary in many patients with acute Type A aortic dissection. These patients present sicker and require longer surgery. However, mass transfusion does not influence survival after discharge.
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Affiliation(s)
| | | | | | | | | | | | | | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (J.B.); (T.B.); (R.G.); (T.W.); (S.K.); (B.R.); (M.C.)
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7
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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: 8] [Impact Index Per Article: 8.0] [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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Kim DJ, Song JY, Shin HB, Lee SH, Lee S, Youn YN, Yoo KJ, Joo HC. Effects of Residual Arch Tears on Late Outcomes After Hemiarch Replacement for DeBakey I Dissection. Ann Thorac Surg 2023; 115:896-903. [PMID: 36167097 DOI: 10.1016/j.athoracsur.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 08/14/2022] [Accepted: 09/06/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND This study evaluated the effect of residual arch tears on late reinterventions and arch dilatation after hemiarch replacement for patients with acute DeBakey type I aortic dissection. METHODS Between January 1995 and October 2018, 160 consecutive patients who underwent hemiarch replacement for DeBakey type I dissection were retrospectively enrolled. They were divided into patients with (n = 73) and without (n = 87) residual arch tears. The arch tears group was subdivided into the proximal/middle arch (n = 26) and distal arch (n = 47) groups to evaluate arch growth rates according to the locations of residual arch tears. The endpoints were arch growth rate and late arch and composite events. RESULTS The arch diameter increased significantly over time in patients with residual arch tears (1.620 mm/y, P < .001). The increase occurred more rapidly when residual tears occurred at the distal arch than at the proximal/middle arch level (2.101 vs 1.001 mm/y). In the adjusted linear mixed model, residual arch tears or luminal communications at the distal arch level were significant factors associated with increases in the arch diameter over time. The 10-year freedom from late arch and composite event rate was significantly lower for patients with residual arch tears than for those without (82.4% vs 95.5%, P = .001; and 68.0% vs 89.3%, P = .002, respectively). CONCLUSIONS Residual arch tears are significant factors associated with late arch dilatation and reinterventions, especially for patients with distal arch tears. Extensive arch replacement during the initial surgery to avoid residual arch tears may improve long-term outcomes.
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Affiliation(s)
- Do Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea; Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon-Young Song
- Department of Thoracic and Cardiovascular Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Han-Bit Shin
- Office of Biostatistics, Medical Research Collaboration Center, Ajou Research Institute for Innovation, Ajou University Medical Center, Suwon, Korea
| | - Seung Hyun Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sak Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Nam Youn
- Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Jong Yoo
- Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun-Chel Joo
- Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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9
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Kreibich M, Siepe M, Berger T, Beyersdorf F, Soschynski M, Schlett CL, Czerny M, Rylski B. Intervention rates and outcomes in medically managed uncomplicated descending thoracic aortic dissections. J Thorac Cardiovasc Surg 2023; 165:958-965.e4. [PMID: 34001355 DOI: 10.1016/j.jtcvs.2021.03.126] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 03/22/2021] [Accepted: 03/31/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate the long-term incidence and outcome of aortic interventions for medically managed uncomplicated thoracic aortic dissections. METHODS Between January 2012 and December 2018, 91 patients were discharged home with an uncomplicated, medically treated aortic dissection (involving the descending aorta with or without aortic arch involvement, no ascending involvement). After a median period of 4 (first quartile: 2, third quartile: 11) months, 30 patients (33%) required an aortic intervention. Patient characteristics, radiographic, treatment, and follow-up data were compared for patients with and without aortic interventions. A competing risk regression model was analyzed to identify independent predictors of aortic intervention and to predict the risk for intervention. RESULTS Patients who underwent aortic interventions had significantly larger thoracic (P = .041) and abdominal (P = .015) aortic diameters, the dissection was significantly longer (P = .035), there were more communications between both lumina (P = .040), and the first communication was significantly closer to the left subclavian artery (P = .049). A descending thoracic aortic diameter exceeding 45 mm was predictive for an aortic intervention (P = .001; subdistribution hazard ratio: 3.51). The risk for aortic intervention was 27% ± 10% and 36% ± 11% after 1 and 3 years, respectively. Fourteen patients (47%) underwent thoracic endovascular aortic repair, 11 patients (37%) thoracic endovascular aortic repair and left carotid to subclavian bypass, 3 patients (10%) total arch replacement with the frozen elephant trunk technique, and 2 patients (7%) thoracoabdominal aortic replacement. We observed no in-hospital mortality. CONCLUSIONS The need for secondary aortic interventions in patients with initially medically managed, uncomplicated descending aortic dissections is substantial. The full spectrum of aortic treatment options (endovascular, hybrid, conventional open surgical) is required in these patients.
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Affiliation(s)
- Maximilian Kreibich
- Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany.
| | - Matthias Siepe
- Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Tim Berger
- Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Soschynski
- Faculty of Medicine, Department for Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Department for Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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10
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Pedroza AJ, Dalal AR, Krishnan A, Yokoyama N, Nakamura K, Tognozzi E, Woo YJ, Macarthur JW, Fischbein MP. Outcomes of Reoperative Aortic Root Replacement After Previous Acute Type A Dissection Repair. Semin Thorac Cardiovasc Surg 2023:S1043-0679(23)00016-3. [PMID: 36758660 DOI: 10.1053/j.semtcvs.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023]
Abstract
Limited aortic root repair for acute type A dissection is associated with greater risk of proximal reoperations compared to full aortic root replacement. Surgical outcomes for patients undergoing reoperative root replacement after previous dissection repair are unknown. This study seeks to determine outcomes for these patients to further inform the debate surrounding optimal upfront management of the aortic root in acute dissection. Retrospective record review of all patients who underwent full aortic root replacement after a previous type A dissection repair operation at a tertiary academic referral center from 2004-2020 was performed. Among 57 cases of reoperative root replacement after type A repair, 35 cases included concomitant aortic arch replacements, and 21 cases involved coronary reconstruction (unilateral or bilateral modified Cabrol grafts). There were 3 acute postoperative strokes and 4 operative mortalities (composite 30-day and in-hospital deaths, 7.0%). Mid-term outcomes were equivalent for patients who required arch replacement compared to isolated proximal repairs (81.8% vs 80.6% estimated 5-year survival, median follow-up 5.53 years. Reoperative root replacement after index type A dissection repairs, including those with concomitant aortic arch replacement and/or coronary reconstruction is achievable with acceptable outcomes at an experienced aortic center.
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Affiliation(s)
- Albert J Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Alex R Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Aravind Krishnan
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Nobu Yokoyama
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Ken Nakamura
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Emily Tognozzi
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - John W Macarthur
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California..
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11
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Sá MP, Jacquemyn X, Tasoudis PT, Van den Eynde J, Erten O, Sicouri S, Dokollari A, Torregrossa G, Kurz S, Heuts S, Nienaber CA, Coselli JS, Ramlawi B. Long-term outcomes of total arch replacement versus proximal aortic replacement in acute type A aortic dissection: Meta-analysis of Kaplan-Meier-derived individual patient data. J Card Surg 2022; 37:4256-4266. [PMID: 36086999 DOI: 10.1111/jocs.16852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/21/2022] [Accepted: 07/28/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To evaluate the long-term outcomes of a conservative approach (with proximal aortic replacement with or without hemiarch replacement) versus an aggressive approach (with total aortic arch replacement) in the treatment of acute type A aortic dissection (ATAAD). METHODS We performed a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing the aforementioned approaches to treat patients with ATAAD. RESULTS Eighteen studies met our eligibility criteria, comprising 5243 patients with follow-up (Conservative: 3676 patients; Aggressive: 1567 patients). We observed a statistically significant difference in overall survival favoring the aggressive approach (hazard ratios [HR] 0.86, 95% confidence interval [CI] 0.76-0.98, p = .022), but no statistically significant difference in the risk of reoperation (HR 0.89, 95% CI 0.66-1.2, p = .439) in the overall follow-up. Landmark analyses revealed that, in the first 3 months after the procedure, mortality rates were comparable between conservative and aggressive approaches (HR 1.04, 95% CI 0.88-1.24, p = .627), but the results beyond 3 months showed improved survival in patients undergoing the aggressive surgical procedure (HR 0.71, 95% CI 0.59-0.85, p < .001). The landmark analyses also revealed that, in the first 7 years after the procedure, reoperation rates were comparable between the approaches (HR 1.03, 95% CI 0.76-1.40, p = .848), but the results beyond 7 years showed a lower risk of reoperation in patients undergoing the aggressive surgical procedure (HR 0.10, 95% CI 0.01-0.75, p = .025). CONCLUSION The aggressive approach seems to confer better long-term survival and lower risk of the need for reoperation in the follow-up of patients treated for ATAAD.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Panagiotis T Tasoudis
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | | | - Ozgun Erten
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Serge Sicouri
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Alexander Dokollari
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Gianluca Torregrossa
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Stephan Kurz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charité-Universitätsmedizin, Berlin, Germany
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, The Royal Brompton & Harefield NHS Trust, London, UK
| | - Joseph S Coselli
- Department of Surgery, Division of Cardiothoracic Surgery, Michael E. DeBakey Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,CHI St Luke's-Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Basel Ramlawi
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
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12
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Aranda-Michel E, Bianco V, Yousef S, Brown J, Dai Y, Serna-Gallegos D, Hoskoppal A, Sultan I. National trends in thoracic aortic aneurysms and dissections in patients with Marfans and Ehlers Danlos syndrome. J Card Surg 2022; 37:3313-3321. [PMID: 35979682 DOI: 10.1111/jocs.16853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/20/2022] [Accepted: 07/11/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Connective tissue disorders predispose patients to earlier aortic dissections and aneurysms. However, there is limited large cohort data given its low incidence. METHODS The National Inpatient Sample was searched for all adults with Marfans (MFS) and Ehlers Danlos (EDS) disease between 2010 and 2017. ICD codes were used to select those with a type A aortic dissection or aneurysm. RESULTS There was a total of 19,567 cases, giving the estimated incidence of MFS and EDS of 18 and 22.4 per 100k people, respectively. After inclusion criteria, there were 2553 MF and 180 EDS patients. There was no statistical difference in mortality between the MFS and EDS cohorts (4.6% vs. 2.8%, p = .26). EDS patients were more likely to undergo a TEVAR procedure (2.8% vs. 1.0%, p = .03). MF patients were more likely to have a complication of acute kidney injury (p = .02). EDS patients were more likely older (50 vs. 42, p < .001) and female (47% vs. 33%, p < .001). MFS patients were more likely to have a type A aortic dissection (44% vs. 31%, p < .001). The majority (89%) of patients were treated at urban teaching hospitals. On univariable logistic regression, aortic dissection was a predictor for mortality (odds ratio 7.31, p < .001). The type of connective tissue disease was not a significant predictor. CONCLUSIONS National level estimates show low mortality for patients with MF or ED presenting to the hospital with aortic dissection or aneurysm. The differences in age and gender can guide surveillance for these patient populations, leading to more elective admissions and reduced hospital mortality.
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Affiliation(s)
- Edgar Aranda-Michel
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Valentino Bianco
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah Yousef
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yancheng Dai
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arvind Hoskoppal
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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13
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Widenka KJ, Kosiorowska M, Jakob H, Pacini D, Hemmer W, Grabenwoeger M, Sioris T, Moritz A, Tsagakis K. Early and midterm results of frozen elephant trunk operation with Evita open stent-graft in patients with Marfan syndrome: results of a multicentre study. BMC Cardiovasc Disord 2022; 22:333. [PMID: 35883019 PMCID: PMC9317434 DOI: 10.1186/s12872-022-02777-5] [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: 03/23/2022] [Accepted: 06/13/2022] [Indexed: 11/20/2022] Open
Abstract
Background Endovascular treatment of patients with Marfan syndrome (MFS) is not recommended. Hybrid procedures such as frozen elephant trunk (FET), which combines stent-graft deployment with an integrated non-stented fabric graft for proximal grafting and suturing, have not been previously evaluated. The aim of this study was to assess the safety and feasibility of FET operation in patients with MFS. Methods Patients enrolled in the International E-vita Open Registry (IEOR) who underwent FET procedure between January 2001 and February 2020 meeting Ghent criteria for MFS were included in the study. Early and midterm results were retrospectively analyzed. Preoperative, postoperative and follow-up computed tomography angiography scans were analysed. Results We analyzed 37 patients [mean age 38 ± 11 years, 65% men]. Acute or chronic aortic dissection was present in 35 (95%) patients (14 and 21 patients respectively). Two (5%) patients had an aneurysm without dissection. Malperfusion syndrome was present in 4 patients. Twenty-nine (78%) patients had history of aortic surgical interventions. The 30-day and in-hospital mortality amounted to 8 and 14% respectively. False lumen exclusion was present in 73% in stented segment in last postoperative CT. The overall 5-year survival was 71% and freedom from reintervention downstream was 58% at 5 years. Of the nine patients who required reintervention for distal aortic disease, one patient died. Conclusions FET operation for patients with MFS can be performed with acceptable mortality and morbidity. In long-term follow-up no reinterventions on the aortic arch were required. FET allows for easier second stage operations providing platform for surgical and endovascular reinterventions.
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Affiliation(s)
- Kazimierz Jan Widenka
- Department of Cardiac Surgery, University of Rzeszow Poland, 60 Lwowska Street 60, 35-301, Rzeszow, Poland.
| | - Monika Kosiorowska
- Department of Cardiac Surgery, University of Rzeszow Poland, 60 Lwowska Street 60, 35-301, Rzeszow, Poland
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, Essen, Germany
| | - Davide Pacini
- Department of Cardiac Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Wolfgang Hemmer
- Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany
| | | | - Thanos Sioris
- Tampere University Hospital Heart Center, Tampere, Finland
| | - Anton Moritz
- Department of Thoracic and Cardiovascular Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, Essen, Germany
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14
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Fibrillin-1 Gene Polymorphisms (rs145233125, rs11070646, rs201170905) Are Associated With the Susceptibility and Clinical Prognosis of DeBakey Type III Aortic Dissection in Chinese Han Population. J Cardiovasc Pharmacol 2022; 80:118-124. [PMID: 35500095 DOI: 10.1097/fjc.0000000000001282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/30/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT We aim to investigate whether genetic variants of the Fibrillin-1 (FBN1) gene were associated with DeBakey type III aortic dissection (AD) and its clinical prognosis in Chinese Han population. Three single-nucleotide polymorphisms (SNPs) (rs145233125, rs11070646, rs201170905) in FBN1 were analyzed in patients with DeBakey type III AD (159) and healthy subjects (216). Gene-environment interactions were evaluated to use generalized multifactor dimensionality reduction. Haplotype analysis of the 3 SNPs in the FBN1 gene was performed by Haploview software. Patients were followed up for average 4 years. G carriers of rs11070646 and rs201170905 in FBN1 have an increased risk of DeBakey type III AD. The interaction of FBN1 and environmental factors facilitated to the increased risk of DeBakey type III AD (cross-validation consistency = 10/10, P = 0.001). One of the most common haplotypes revealed an increased risk of DeBakey type III AD (CGG, P = 0.009). Recessive models of rs145233125 CC genotype ( P < 0.05) and rs201170905 GG genotype ( P < 0.001) were associated with an increased risk of death and recurrent chest pain of DeBakey type III AD. In conclusions, FBN1 gene polymorphisms contribute to DeBakey type III AD susceptibility. The interactions of gene and environment are related with the risk of DeBakey type III AD. C carriers of rs145233125 and G carriers of rs201170905 may be the adverse prognostic indicators of death and recurrent chest pain in DeBakey type III AD.
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15
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Othman AA, Elgharably H, Vargo PR, Ayyat KS, Bakaeen FG, Johnston DR, Tong MZ, Unai S, Kalahasti V, Sevensson LG, Roselli EE. Valve-Preserving Root Reimplantation Combined with Arch Procedure: Optimizing Patient Selection. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:201-208. [PMID: 35604783 DOI: 10.1177/15569845221094007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Patients with thoracic aortic disease commonly present with concomitant multisegment pathology. We describe the patient population, analyze outcomes, and define the patient selection strategy for valve-preserving aortic root reimplantation (VPARR) combined with the arch procedure. Methods: From 2008 to 2018, 98 patients underwent VPARR combined with the aortic arch procedure (hemi-arch, 50% [n = 49, limited repair]; total arch, 50% [n = 49, complete repair] including 39 with elephant trunk). Indications for surgery were aneurysmal disease (61%) and aortic dissection (39%). The median follow-up was 17 months (IQR, 8 to 60 months). Results: There were no operative deaths or paraplegia, and 5 patients underwent re-exploration for bleeding. During follow-up, 2 patients required aortic valve replacement for severe aortic insufficiency at 1 and 5 years, and 4 patients died. In the limited repair group, 1 patient underwent reintervention for aortic arch replacement, whereas 4 patients underwent planned intervention (1 endovascular and 3 open thoracoabdominal aortic repair). In the complete repair group, 23 patients underwent planned intervention (15 endovascular and 8 open thoracoabdominal repair). Conclusions: Single-stage, complete, proximal aortic repair including VPARR combined with total aortic arch replacement is as safe and feasible to perform as limited arch repair and facilitates further intervention in carefully selected patients with diffuse aortic pathology at centers of expertise.
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Affiliation(s)
- Ahmed A Othman
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,8959Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Haytham Elgharably
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Patrick R Vargo
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Kamal S Ayyat
- Lerner Research Institute, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Faisal G Bakaeen
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Douglas R Johnston
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Michael Z Tong
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Shinya Unai
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Vidyasagar Kalahasti
- Cardiovascular Medicine, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Lars G Sevensson
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Eric E Roselli
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
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16
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Kallenbach K, Büsch C, Rylski B, Dohle DS, Krüger T, Holubec T, Brickwedel J, Pöling J, Noack T, Hagl C, Jawny P, Böning A, Chalabi K, Karck M, Arif R. Treatment of the aortic root in acute aortic dissection type A: insights from the German Registry for Acute Aortic Dissection Type A. Eur J Cardiothorac Surg 2022; 62:ezac261. [PMID: 35511255 DOI: 10.1093/ejcts/ezac261] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 04/04/2022] [Accepted: 04/16/2022] [Indexed: 02/21/2024] Open
Abstract
OBJECTIVES Surgery of the aortic root in acute aortic dissection type A (AADA) remains a topic of vague evidence since the extend of dissection and surgeons' capability and interpretation of the disease vary remarkably. We aimed to interpret root operation strategies in the German Registry for Acute Aortic Dissection cohort. METHODS German Registry for Acute Aortic Dissection collected the data of 56 centres between July 2006 and June 2015. A total of 3382 patients undergoing operations for AADA were included and divided into 3 groups according to aortic root procedure types: supracommissural replacement (SCR), conduit replacement (CR) and valve sparing root replacement (VSRR). RESULTS Patients in SCR (2425, 71.7%) were significantly older than CR (681, 20.1%) and VSRR (276, 8.2%) (63.4 vs 57.5 vs 54.2 years; P < 0.001), more female (38.9% vs 32.0% vs 26.1%; P < 0.001) and presented with less aortic regurgitation (26.3% vs 57.1% vs 56.5%; P < 0.001). VSRR presented with slightly less multiple organ malperfusion (11.6% vs 12.0% vs 10.9%; P = 0.045) and were more often diagnosed for Marfan syndrome (2.4% vs 5.1% vs 9.1%; P < 0.001). Thirty-day mortality was lower for VSRR (11.6%) compared to SCR (16.1%) and CR (19.8%; P = 0.010). Despite longer procedural times, multivariable regression showed no influence of total arch replacement for VSRR on mortality compared to CR (odds ratio 0.264; 95% confidence interval, 0.033-2.117; P = 0.21). CONCLUSIONS SCR remains the procedure of choice in elderly and compromised patients. Extended root preservation techniques may be applied even in combination with extended aortic arch surgery for selected patients for AADA with promising early outcomes.
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Affiliation(s)
- Klaus Kallenbach
- Department of Cardiac Surgery, INCCI HaerzZenter, Luxembourg City, Luxembourg
- Department of Cardiac Surgery, University Hospital Heidelberg, German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | - Christopher Büsch
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel-Sebastian Dohle
- Department of Cardiac and Vascular Surgery, University Hospital Mainz, German Center for Cardiovascular Research (DZHK), Partner Site Mainz, Mainz, Germany
| | - Tobias Krüger
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, German Center for Cardiovascular Research (DZHK), Partner Site Frankfurt, Frankfurt, Germany
| | - Jens Brickwedel
- University Heart & Vascular Center Hamburg, Department of Cardiovascular Surgery, German Center for Cardiovascular Research (DZHK), Partner Site Hamburg, Hamburg, Germany
| | - Jochen Pöling
- Department of Cardiac Surgery, Schuechtermann Clinic, Bad Rothenfelde, Germany
| | - Thilo Noack
- University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Philipp Jawny
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Khaled Chalabi
- Department of Cardiac Surgery, INCCI HaerzZenter, Luxembourg City, Luxembourg
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Department of Cardiac Surgery, University Hospital Heidelberg, German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
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17
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Extending Aortic Replacement Beyond the Proximal Arch in Acute Type A Aortic Dissection: A Meta-Analysis of Short Term Outcomes and Long Term Actuarial Survival. Eur J Vasc Endovasc Surg 2022; 63:674-687. [DOI: 10.1016/j.ejvs.2021.12.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/07/2021] [Accepted: 12/28/2021] [Indexed: 12/29/2022]
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18
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Wang JX, Xue YX, Zhu XY, Chong HS, Chen Z, Zhou Q, Qu JZ, Wang DJ. The impact of age in acute type A aortic dissection: a retrospective study. J Cardiothorac Surg 2022; 17:40. [PMID: 35305695 PMCID: PMC8933992 DOI: 10.1186/s13019-022-01785-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background Acute type A aortic dissection (aTAAD) is a lethal disease and age is an important risk factor for outcomes. This retrospective study was to analyze the impact of age stratification in aTAAD, and to provide clues for surgeons when they make choices of therapy strategies.
Methods From January 2011 to December 2019, 1092 aTAAD patients from Nanjing Drum Tower Hospital received surgical therapy. Patients were divided into 7 groups according to every ten-year interval (20–80 s). The differences between the groups were analyzed in terms of the baseline preoperative conditions, surgical methods and postoperative outcomes of patients of different age groups. During a median follow-up term of 17 months, the survival rates were compared among 7 groups through Kaplan–Meier analysis.
Results The median age was 52.0 years old in whole cohort. The multiple comorbidities were more common in old age groups (60 s, 70 s, 80 s), while the 20 s group patients had the highest proportion of Marfan syndrome (28.1%). Preoperative hypotension was highest in 80 s (16.7%, P = 0.038). Young age groups (20–60 s) had a higher rate of root replacement and total arch replacement, which led to a longer duration of operation and hypothermic circulation arrest. The overall mortality was 14.1%, the tendency of mortality was increased with age except 20 s group (33.3% in 80 s, P = 0.016). The postoperative morbidity of gastrointestinal bleeding and bowel ischemia were 16.7% and 11.1% in 80 s group. Conclusions Age is a major impact factor for aTAAD surgery. Old patients presented more comorbidities before surgery, the mortality and complications rate were significantly higher even with less invasive and conservative surgical therapy. But the favorable long-term survival indicated that the simple or less extensive arch repair is the preferred surgery for patients over 70 years old. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-022-01785-y.
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19
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Zhu Y, Jian Z, Ma R, Wang Y, Xiao Y. Long-term outcomes after aortic root replacement for patients with Marfan syndrome. J Thorac Dis 2022; 13:6779-6789. [PMID: 35070362 PMCID: PMC8743404 DOI: 10.21037/jtd-21-577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 10/22/2021] [Indexed: 12/11/2022]
Abstract
Background A diversity of surgical strategies are used to treat Marfan syndrome patients with aortic disease. We sought to evaluate the long-term efficiency of aortic root replacement (ARR) for patients with Marfan syndrome. Methods Data were collected from 131 patients with Marfan syndrome and aortic disease who underwent ARR in our center. We retrospectively analyzed the long-term outcomes of these patients, among whom 68 had been diagnosed with aortic aneurysm (AA) and had undergone ARR. The remaining 63 patients had aortic dissection (AD); of these, 35 underwent ARR for limited ascending AD, while the others underwent ARR and total arch replacement combined with frozen elephant trunk (FET). Risk factors for survival and reoperation were identified. Results The operative mortality rate was 4.58%. Age >40 years was the sole risk factor for operative mortality. During follow-up, 12 deaths occurred. Patients aged <25 years and female patients were more prone to late death than were other patients. Indications for reoperation were noted in 22 patients, and the risk factors were age <30 years and female sex. At 5 years, the survival rate was 92.96%, and the freedom from reoperation rate was 88.36%. At 10 years, the survival rate was 85.25%, and the freedom from reoperation rate was 71.75%. The survival and freedom from reoperation rates were significantly higher in patients with AD than in those with AA. Specifically, chronic AD was a greater risk factor for late survival than was acute AD in patients with Marfan syndrome. Conclusions For patients with Marfan syndrome and aortic disease, ARR can be safely performed and results in low operative mortality and favorable long-term survival. Young and female patients have a higher risk for late death and reoperation. To prevent AD, surgical intervention should be promptly implemented following the diagnosis of aortic sinus dilation.
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Affiliation(s)
- Yu Zhu
- Department of Cardiovascular Surgery, the Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Zhao Jian
- Department of Cardiovascular Surgery, the Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Ruiyan Ma
- Department of Cardiovascular Surgery, the Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Yong Wang
- Department of Cardiovascular Surgery, the Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Yingbin Xiao
- Department of Cardiovascular Surgery, the Second Affiliated Hospital, Army Medical University, Chongqing, China
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20
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Einfluss der bikuspiden und trikuspiden Aortenklappe bei Typ-A-Aortendissektion. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2021. [DOI: 10.1007/s00398-021-00468-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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21
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Zeigler SM, Sloan B, Jones JA. Pathophysiology and Pathogenesis of Marfan Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1348:185-206. [PMID: 34807420 DOI: 10.1007/978-3-030-80614-9_8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Marfan syndrome (MFS) is a systemic connective tissue disorder that is inherited in an autosomal dominant pattern with variable penetrance. While clinically this disease manifests in many different ways, the most life-threatening manifestations are related to cardiovascular complications including mitral valve prolapse, aortic insufficiency, dilatation of the aortic root, and aortic dissection. In the past 30 years, research efforts have not only identified the genetic locus responsible but have begun to elucidate the molecular pathogenesis underlying this disorder, allowing for the development of seemingly rational therapeutic strategies for treating affected individuals. In spite of these advancements, the cardiovascular complications still remain as the most life-threatening clinical manifestations. The present chapter will focus on the pathophysiology and clinical treatment of Marfan syndrome, providing an updated overview of the recent advancements in molecular genetics research and clinical trials, with an emphasis on how this information can focus future efforts toward finding betters ways to detect, diagnose, and treat this devastating condition.
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Affiliation(s)
- Sanford M Zeigler
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Brandon Sloan
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Jeffrey A Jones
- Division of Cardiothoracic Surgery, Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
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22
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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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23
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Abstract
Marfan syndrome (MFS) is an autosomal dominant, age-related but highly penetrant condition with substantial intrafamilial and interfamilial variability. MFS is caused by pathogenetic variants in FBN1, which encodes fibrillin-1, a major structural component of the extracellular matrix that provides support to connective tissues, particularly in arteries, the pericondrium and structures in the eye. Up to 25% of individuals with MFS have de novo variants. The most prominent manifestations of MFS are asymptomatic aortic root aneurysms, aortic dissections, dislocation of the ocular lens (ectopia lentis) and skeletal abnormalities that are characterized by overgrowth of the long bones. MFS is diagnosed based on the Ghent II nosology; genetic testing confirming the presence of a FBN1 pathogenetic variant is not always required for diagnosis but can help distinguish MFS from other heritable thoracic aortic disease syndromes that can present with skeletal features similar to those in MFS. Untreated aortic root aneurysms can progress to life-threatening acute aortic dissections. Management of MFS requires medical therapy to slow the rate of growth of aneurysms and decrease the risk of dissection. Routine surveillance with imaging techniques such as transthoracic echocardiography, CT or MRI is necessary to monitor aneurysm growth and determine when to perform prophylactic repair surgery to prevent an acute aortic dissection.
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24
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Gallingani A, Maestri F, Nicolini F, Formica F. Commentary: Another glimpse of light for patients with Marfan syndrome. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01158-2. [PMID: 34452761 DOI: 10.1016/j.jtcvs.2021.08.011] [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: 07/31/2021] [Revised: 07/31/2021] [Accepted: 08/03/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Alan Gallingani
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy; Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Maestri
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy; Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Nicolini
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy; Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Formica
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy; Department of Medicine and Surgery, University of Parma, Parma, Italy.
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25
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Farag M, Büsch C, Rylski B, Pöling J, Dohle DS, Sarvanakis K, Hagl C, Krüger T, Detter C, Holubec T, Borger MA, Böning A, Karck M, Arif R. Early outcomes of patients with Marfan syndrome and acute aortic type A dissection. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01123-5. [PMID: 34446289 DOI: 10.1016/j.jtcvs.2021.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/05/2021] [Accepted: 07/09/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acute aortic Stanford type A dissection remains a frequent and life-limiting event for patients with Marfan syndrome. Outcome results in this high-risk group are limited. METHODS The German Registry for Acute Aortic Dissection Type A collected the data of 56 centers between July 2006 and June 2015. Of 3385 patients undergoing operations for acute aortic Stanford type A dissection, 117 (3.5%) were diagnosed with Marfan syndrome. We performed a propensity score match comparing patients with Marfan syndrome with patients without Marfan syndrome in a 1:2 fashion. RESULTS Patients with Marfan syndrome were significantly younger (42.9 vs 62.2 years; P < .001), predominantly male (76.9% vs 62.9%; P = .002), and less catecholamine dependent (9.4% vs 20.3%; P = .002) compared with the unmatched cohort. They presented with aortic regurgitation (41.6% vs 23.0%; P < .001) and involvement of the supra-aortic vessels (50.4% vs 39.5%; P = .017) more often. Propensity matching revealed 82 patients with Marfan syndrome (21 female) with no significant differences in baseline characteristics compared with patients without Marfan syndrome (n = 159, 36 female; P = .607). Although root preservation was more frequent in patients with Marfan syndrome, procedure types did not differ significantly (18.3% vs 10.7%; P = .256). Aortic arch surgery was performed more frequently in matched patients (87.5% vs 97.8%; P = .014). Thirty-day mortality did not differ between patients with and without Marfan syndrome (19.5% vs 20.1%; P = .910). Multivariate regression showed no influence of Marfan syndrome on 30-day mortality (odds ratio, 0.928; 95% confidence interval, 0.346-2.332; P = .876). CONCLUSIONS Marfan syndrome does not adversely affect 30-day outcomes after surgical repair for acute aortic Stanford type A dissection compared with a matched cohort. Long-term outcome analysis is needed to account for the influence of further downstream interventions.
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Affiliation(s)
- Mina Farag
- Department of Cardiac Surgery, Marfan Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Christopher Büsch
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Bartosz Rylski
- Faculty of Medicine, Department of Cardiovascular Surgery, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Jochen Pöling
- Department of Cardiac Surgery, Schuechtermann Clinic, Bad Rothenfelde, Germany
| | - Daniel S Dohle
- Department of Cardiothoracic and Vascular Surgery, University Hospital, Johannes Gutenberg University, Mainz, Germany
| | | | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Tobias Krüger
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Christian Detter
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital and Johann Wolfgang Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Michael A Borger
- University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Marfan Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Department of Cardiac Surgery, Marfan Center, University Hospital Heidelberg, Heidelberg, Germany.
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26
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Jiang X, Chen B, Jiang J, Shi Y, Ma T, Fu W, Dong Z. Outcomes of endovascular therapy for Stanford type B aortic dissection in patients with Marfan syndrome. J Thorac Cardiovasc Surg 2021; 165:1999-2007.e1. [PMID: 34176615 DOI: 10.1016/j.jtcvs.2021.05.045] [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: 11/03/2020] [Revised: 05/13/2021] [Accepted: 05/18/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate the mid-term outcomes of thoracic endovascular aorta repair (TEVAR) for Stanford type B aortic dissection (TBAD) in patients with Marfan syndrome (MFS). METHODS Between January 2009 and December 2019, patients with MFS who underwent TEVAR for TBAD were enrolled. Demographic data, preoperative and perioperative clinical profiles, and follow-up data were collected and analyzed. The cumulative survival and freedom from reintervention rates were calculated with Kaplan-Meier analysis. RESULTS A total of 26 patients were enrolled. The mean age was 38.5 ± 10.7 (range, 24-64 years). The in-hospital mortality was 0. The cumulative survival rate was 88.1% (95% confidence interval [CI], 67.5%-98.5%) at 5 years and 82.9% (95% CI, 60.2%-93.3%) at 10 years. Patients with a thrombosed false lumen (FL) along the length of the stent had a significantly higher cumulative survival rate (P < .05) and freedom from reintervention (P = .01) than patients with patent FL. The freedom from reintervention was 83.4% (95% CI, 61.4% to 93.4%) at 5 years and 50.3% (95% CI, 21.4%-97.3%) at 10 years. There was no significant difference freedom from reintervention in freedom from reintervention between patients with and those without a previous aortic root procedure (P = .46). CONCLUSIONS TEVAR can be performed safely and effectively for TBAD in patients with MFS. Perioperative mortality and morbidity were low; however, lifelong close follow-up in the clinic and imaging are mandatory to prevent aortic rupture. Patients with a patent FL were at high risk of late death.
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Affiliation(s)
- Xiaolang Jiang
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bin Chen
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junhao Jiang
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Shi
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Ma
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Zhihui Dong
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
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27
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The impact of genetic factors and testing on operative indications and extent of surgery for aortopathy. JTCVS OPEN 2021; 6:15-23. [PMID: 36003569 PMCID: PMC9390368 DOI: 10.1016/j.xjon.2021.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 11/22/2022]
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28
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Pitts L, Montagner M, Kofler M, Van Praet KM, Heck R, Buz S, Kurz SD, Sündermann S, Hommel M, Falk V, Kempfert J. State of the Art Review: Surgical Treatment of Acute Type A Aortic Dissection. Surg Technol Int 2021; 38:279-288. [PMID: 33823055 DOI: 10.52198/21.sti.38.cv1413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Acute type A aortic dissection (ATAAD) is a life-threatening event that requires immediate surgical treatment. Improvements in surgical treatment, graft technology, organ protection and imaging techniques have led to improved clinical outcomes. Individualized treatment concepts have emerged based on more advanced planning tools that allow for a tailored approach even in complex situations such as multi-level malperfusion. This review provides an overview of the current surgical treatment of ATAAD, focusing on new disease classifications, preoperative computed tomography angiography (CTA) assessment, new prosthesis and stent technologies, and organ-protection strategies.
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Affiliation(s)
- Leonard Pitts
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Matteo Montagner
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Karel M Van Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Roland Heck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Semih Buz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Stephan D Kurz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
| | - Simon Sündermann
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
| | - Matthias Hommel
- Department of Anesthesiology, German Heart Center Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
- Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
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29
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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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30
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A novel technique for the treatment of a ruptured para-anastomotic thoracic aortic aneurysm in the presence of a chronic abdominal aortic dissection. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:350-353. [PMID: 34095640 PMCID: PMC8163864 DOI: 10.1016/j.jvscit.2021.03.005] [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: 11/14/2020] [Accepted: 03/19/2021] [Indexed: 11/22/2022]
Abstract
We report the case of a 69-year-old woman with Marfan syndrome and a history of multiple thoracic aortic surgeries and a coexisting dissection of her abdominal aorta. She had presented with a ruptured para-anastomotic thoracic aortic aneurysm due to an infected graft. She was treated with two parallel Nellix endografts that were placed in the true and false lumens. The surrounding endobags were inflated with a polymer that completely sealed the ruptured aorta and preserved blood flow to the visceral arteries. Postoperative imaging showed complete exclusion of the aneurysm with patency of all aortic branches and no evidence of endoleak.
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31
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Subramaniam DR, Gutmark E, Andersen N, Nielsen D, Mortensen K, Gravholt C, Backeljauw P, Gutmark-Little I. Influence of Material Model and Aortic Root Motion in Finite Element Analysis of Two Exemplary Cases of Proximal Aortic Dissection. J Biomech Eng 2021; 143:1086152. [PMID: 32793953 DOI: 10.1115/1.4048084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Indexed: 01/25/2023]
Abstract
The risk of type-A dissection is increased in subjects with connective tissue disorders and dilatation of the proximal aorta. The location and extents of vessel wall tears in these patients could be potentially missed during prospective imaging studies. The objective of this study is to estimate the distribution of systolic wall stress in two exemplary cases of proximal dissection using finite element analysis (FEA) and evaluate the sensitivity of the distribution to the choice of anisotropic material model and root motion. FEA was performed for predissection aortas, without prior knowledge of the origin and extents of vessel wall tear. The stress distribution was evaluated along the wall tear in the postdissection aortas. The stress distribution was compared for the Fung and Holzapfel models with and without root motion. For the subject with spiral dissection, peak stress coincided with the origin of the tear in the sinotubular junction. For the case with root dissection, maximum stress was obtained at the distal end of the tear. The FEA predicted tear pressure was 20% higher for the subject with root dissection as compared to the case with spiral dissection. The predicted tear pressure was higher (9-11%) for root motions up to 10 mm. The Holzapfel model predicted a tear pressure that was lower (8-15%) than the Fung model. The FEA results showed that both material response and root motion could potentially influence the predicted dissection pressure of the proximal aorta at least for conditions tested in this study.
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Affiliation(s)
| | - Ephraim Gutmark
- Department of Aerospace Engineering and Engineering Mechanics, University of Cincinnati, Cincinnati, OH 45221-0070
| | - Niels Andersen
- Department of Cardiology, Aalborg University Hospital, Aalborg 9100, Denmark
| | - Dorte Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Kristian Mortensen
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Claus Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Philippe Backeljauw
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Iris Gutmark-Little
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229
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32
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Management of the aortic arch in patients with Loeys–Dietz syndrome. J Thorac Cardiovasc Surg 2020; 160:1166-1175. [DOI: 10.1016/j.jtcvs.2019.07.130] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 07/05/2019] [Accepted: 07/11/2019] [Indexed: 01/14/2023]
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33
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Type A Aortic Dissection—Experience Over 5 Decades. J Am Coll Cardiol 2020; 76:1703-1713. [DOI: 10.1016/j.jacc.2020.07.061] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/20/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022]
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34
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Commentary: Prophylactic total arch replacement in Loeys-Dietz syndrome: Perfect may be the enemy of good. J Thorac Cardiovasc Surg 2020; 164:27-28. [PMID: 32928551 DOI: 10.1016/j.jtcvs.2020.08.057] [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: 08/17/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/20/2022]
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35
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Tanaka A, Ornekian V, Estrera AL. Limited repair with tear-oriented approach for type A aortic dissection. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:278-284. [DOI: 10.23736/s0021-9509.20.11259-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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36
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Mehta CK, Bavaria JE. Distal repair after frozen elephant trunk: open or endovascular? Ann Cardiothorac Surg 2020; 9:226-227. [PMID: 32551256 DOI: 10.21037/acs-2020-fet-26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Christopher K Mehta
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Chen SW, Lin YS, Wu VCC, Lin MS, Chou AH, Chu PH, Chen TH. Effect of β-blocker therapy on late outcomes after surgical repair of type A aortic dissection. J Thorac Cardiovasc Surg 2020; 159:1694-1703.e3. [DOI: 10.1016/j.jtcvs.2019.05.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 04/26/2019] [Accepted: 05/16/2019] [Indexed: 01/16/2023]
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Interdisziplinäre Betreuung von Menschen mit Marfan-Syndrom – Genetik, bildgebende Untersuchung und kardiovaskuläres System. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-020-00364-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Norton EL, Hornsby WE, Wu X, Wolford BN, Graham SE, Willer CJ, Yang B. Aortic progression and reintervention in patients with pathogenic variants after a thoracic aortic dissection. J Thorac Cardiovasc Surg 2020; 162:1436-1448.e6. [PMID: 32199657 DOI: 10.1016/j.jtcvs.2020.01.094] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/01/2020] [Accepted: 01/21/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate aortic disease progression and reintervention after an initial thoracic aortic dissection in pathogenic variant carriers. METHODS Of 175 participants diagnosed with thoracic aortic dissection, 31 had a pathogenic variant (pathogenic group) across 6 genes (COL3A1, FBN1, LOX, PRKG1, SMAD3, TGFBR2) identified by whole exome sequencing. Those with benign or normal variants (benign/normal group, n = 144) comprised the control group. Clinical data were collected through medical record review (1985-2018) and supplemented with the National Death Index database (December 2018). RESULTS The entire cohort (n = 175) consisted of 108 type A aortic dissections and 67 type B aortic dissections, similarly distributed between groups. The pathogenic group was significantly younger (43 vs 56 years, P < .0001) and had significantly more aortic root replacements and similar extents of arch replacement at initial type A aortic dissection repair. The median follow-up time was 7.5 (4.6-12) years. After initial treatment, the pathogenic group required significantly more aortic reinterventions (median 1 vs 0, P < .0001) and mean cumulative aortic reinterventions for each patient (10 years: 1 vs 0.5, P = .029). Both incidence rate (12%/year vs 1.2%/year, P = .0001) and cumulative incidence of reinterventions (9 years: 70% vs 6%, P < .0001) for the preserved native aortic root were significantly higher in the pathogenic group, but were similar for the preserved native aortic arch and distal aorta between groups. Ten-year survival was similar in the pathogenic and benign/normal groups (92% vs 85%). CONCLUSIONS Aggressive aortic root replacement and similar arch management should be considered in pathogenic variant carriers at initial type A aortic dissection repair compared with benign/normal variant carriers.
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Affiliation(s)
| | - Whitney E Hornsby
- University of Michigan, Michigan Medicine, Ann Arbor, Mich; Department of Internal Medicine, Michigan Medicine, Ann Arbor, Mich
| | - Xiaoting Wu
- University of Michigan, Michigan Medicine, Ann Arbor, Mich; Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Brooke N Wolford
- University of Michigan, Michigan Medicine, Ann Arbor, Mich; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Mich
| | - Sarah E Graham
- University of Michigan, Michigan Medicine, Ann Arbor, Mich; Department of Internal Medicine, Michigan Medicine, Ann Arbor, Mich
| | - Cristen J Willer
- University of Michigan, Michigan Medicine, Ann Arbor, Mich; Department of Internal Medicine, Michigan Medicine, Ann Arbor, Mich; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Mich; Department of Human Genetics, University of Michigan, Ann Arbor, Mich.
| | - Bo Yang
- University of Michigan, Michigan Medicine, Ann Arbor, Mich; Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich.
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Aranson NJ, Patel PB, Mohebali J, Lancaster RT, Ergul EA, Clouse WD, Conrad MF, Patel VI. Presentation, surgical intervention, and long-term survival in patients with Marfan syndrome. J Vasc Surg 2020; 72:480-489. [PMID: 32085956 DOI: 10.1016/j.jvs.2019.10.060] [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: 10/16/2016] [Accepted: 10/07/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Patients with Marfan syndrome (MFS) often present with acute catastrophic aortic events at a young age and have a shortened life span. This study examines the impact of presentation and demographics on late survival in patients with MFS. METHODS Adults with confirmed MFS in our thoracic aortic center dataset were identified and statistical analysis performed to identify the incidence and predictors of aortic interventions and late mortality. RESULTS We identified 301 patients with a MFS initial diagnosis at age 17 years (interquartile range, 4-30 years) with presentation into our thoracic aortic center at 21 years (interquartile range, 8-34 years). The average follow-up in our center was 10 ± 10 years. Clinical features were 41% male, 86% white race, coronary artery disease 28%, hypertension 40%, peripheral vascular disease 19%, and anti-impulse agent in 51% (β-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, calcium channel blocker). Distribution of operative aortic pathology was isolated to the ascending aorta (70%) and descending aorta (8%). One hundred seventy-eight patients (59%) required primary aortic surgery (36% emergent). Primary procedures were cardiac (aortic valve/root) in nature in 94%. Seventy-four patients (42%) required multiple aortic procedures at a mean of 9.2 ± 6.9 years, involving the thoracoabdominal aorta in 65%, thoracic aorta in 37%, and abdominal aorta in 21%. Patients who required multiple aortic procedures were more likely (P < .05) to have coronary artery disease (50% vs 30%), and peripheral vascular disease (43% vs 18%). Multiple aortic procedures were also more likely (P < .05) in patients who developed de novo distal dissection (14% vs 0%), had prior dissection (47% vs 18%), or unknown MFS at the time of the initial procedure (27% vs 63%). Multivariable analysis identified prior dissection as an independent predictor of need for emergent surgery (odds ratio, 13.20; 95% confidence interval, 4.64-37.30; P < .05), as well as additional aortic surgery (odds ratio, 4.42; 95% confidence interval, 1.87-10.50; P < .05). Kaplan-Meier analysis showed similar 10-year survival with or without aortic interventions (82% with vs 89% without; P = .08). Late survival was decreased in patients undergoing emergent initial procedures (66% vs 89%; P < .01), as well as those undergoing multiple operations (74% vs 86%; P = .03). CONCLUSIONS These data indicate that, in the modern era, the mode of presentation and need for multiple procedures have a detrimental impact on late survival. Additionally, the presence of acute or chronic dissection predicts the need for additional aortic procedures during follow-up.
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Affiliation(s)
- Nathan J Aranson
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Priya B Patel
- Division of General Surgery, Rutgers Robert Wood Johnson University Hospital, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Robert T Lancaster
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Emel A Ergul
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | | | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Virendra I Patel
- New York Presbyterian-Columbia University Irving Medical Center, New York, NY.
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Li N, Zhang Y, Gao Y, Bai Y, An Z, Zhang G, Han Q, Lu F, Li B, Han L, Xu Z. Decision-making at initial surgery for type A aortic dissection in patients with Marfan syndrome: proximal or extensive repair. J Thorac Dis 2020; 11:4951-4959. [PMID: 32030210 DOI: 10.21037/jtd.2019.12.21] [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: 11/06/2022]
Abstract
Background Data on outcome of Stanford type A aortic dissection (TAAD) in Marfan syndrome (MFS) patients are limited. We investigated the full spectrum of reoperation and survival after initial surgery in MFS patients who suffered TAAD. Methods Retrospective analysis of 85 consecutive MFS patients in one-single center during the past 15 years. Results Overall, 85 MFS patients with TAAD underwent surgical repair [74% acute dissections; 80% DeBakey type I; 91% composite valved graft; 70% total arch replacement (TAR); 68% frozen elephant trunk (FET); 7% in-hospital mortality] at Changhai hospital affiliated to the Second Military Medical University over the past 15 years. Five (20.8%) patients in non-TAR group need aortic arch reintervention with resternotomy during follow-up, which is significantly higher than that in TAR group (P=0.001). Freedom from aortic arch reoperation in non-TAR group was all 78.7%±8.5% at 5, 10, and 15 years. No patient required aortic arch reoperation in TAR group (P=0.001). On the other hand, the FET was inserted into false lumen intentionally at initial surgery in 2 cases of chronic TAAD with narrowed true lumen. Scheduled thoracoabdominal aortic replacement was performed 6 months later. Both 2 patients are with well clinical outcomes. At last, we found that Debakey type and TAR at initial surgery were irrelevant to survival and reoperation for descending aorta. Conclusions TAR combined with FET is recommended in MFS patients when the aortic arch is dissected or enlarged. The FET could be inserted into the false lumen intentionally in selective case for scheduled 2-staged descending aortic repair.
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Affiliation(s)
- Ning Li
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Yu Zhang
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Yuan Gao
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Yifan Bai
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Zhao An
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Guanxin Zhang
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Qingqi Han
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Fanglin Lu
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - BaiLing Li
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Lin Han
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Zhiyun Xu
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
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Kreibich M, Rylski B, Czerny M, Pingpoh C, Siepe M, Beyersdorf F, Khurshan F, Vallabhajosyula P, Szeto WY, Bavaria JE, Desai ND, Branchetti E. Type A Aortic Dissection in Patients With Bicuspid Aortic Valve Aortopathy. Ann Thorac Surg 2020; 109:94-100. [DOI: 10.1016/j.athoracsur.2019.05.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 04/03/2019] [Accepted: 05/02/2019] [Indexed: 01/16/2023]
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Martinelli GL, Cotroneo A, Tolva V, Armienti F, Bobbio M, Musica G, Visetti E, Tesler UF. Repeat Surgery in Chronic Aortic Dissection: A New Technique without Touching the Native Aorta. AORTA (STAMFORD, CONN.) 2019; 7:163-168. [PMID: 32074646 PMCID: PMC7145437 DOI: 10.1055/s-0039-3402071] [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: 04/24/2018] [Accepted: 11/02/2019] [Indexed: 12/03/2022]
Abstract
BACKGROUND Repeat surgery of the chronically dissected aorta following repair of a Type-A acute aortic dissection (AAD) still represents a challenge. The proposed surgical options are as follows: (1) staged procedure with elephant trunk (ET) technique, (2) traditional frozen elephant trunk (FET) intervention, and (3) beating heart cerebral vessel debranching followed by thoracic endovascular aortic repair (TEVAR). However, a marked enlargement of the proximal descending thoracic aorta might make it difficult to perform FET/ET intervention. Furthermore, because in conventional surgery for AAD, a prosthetic graft replacement is generally limited to the ascending aorta, and in repeat surgery, this short Dacron graft rarely provides enough room to allow a beating heart cerebral vessel debranching and obtaining a reliable landing zone for the implantation of a firmly anchored stent graft. METHODS We retrospectively reviewed all the five consecutive patients treated in our institution, between 2014 and 2017, for chronic aortic dissection after successful surgical treatment of acute Type-A aortic dissection with graft replacement limited to the ascending aorta. The five patients underwent repair utilizing a modified FET technique with total aortic arch and upper descending aorta exclusion without touching the native dissected aorta. RESULTS No early- or midterm mortality was observed. Mean time interval between the initial and the reoperative procedure was 26 months (range, 3-80 months). No patient had a minor/major neurologic event. Mean circulatory arrest time was 16 minutes (range, 11-25 minutes). Mean follow-up time was 22 months (range, 9-42 months). CONCLUSIONS We report our initial experience with a modified FET technique realized by anastomosing the stent graft with the previously implanted ascending aortic graft in Hishimaru's zone 0 and by rerouting all cerebral vessels without "touching" the native chronically dissected aorta. A larger number of patients and a longer follow-up will be required to confirm these initial encouraging results.
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Affiliation(s)
- Gian Luca Martinelli
- Department of CardioVascular, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - Attilio Cotroneo
- Department of CardioVascular, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - Valerio Tolva
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy
| | - Felice Armienti
- Department of Radiology, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - Mario Bobbio
- Department of CardioVascular, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - Gabriele Musica
- Department of CardioVascular, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - Enrico Visetti
- Department of Anesthesia, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - Ugo Filippo Tesler
- Department of CardioVascular, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
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Rylski B, Georgieva N, Beyersdorf F, Büsch C, Boening A, Haunschild J, Etz CD, Luehr M, Kallenbach K. Gender-related differences in patients with acute aortic dissection type A. J Thorac Cardiovasc Surg 2019; 162:528-535.e1. [PMID: 31926709 DOI: 10.1016/j.jtcvs.2019.11.039] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Acute aortic dissection type A can occur in both genders at any age. Our aim was to report differences in presentation, treatment, and outcome in female and male patients with acute aortic dissection type A. METHODS Between July 2006 and June 2015, 56 centers participating in the German Registry for Acute Aortic Dissection Type A reported on a total of 3380 patients. As many as 1234 (37%) were women and 2146 (63%) were men. We compared their clinical features and events occurring within 30 days after surgery. RESULTS Women were significantly older than male patients (65.5 ± 12.7 years vs 59.2 ± 13.3 years; P < .001). Aortic dissection extended down to the abdominal aorta in 43% men and 39% women (P = .01). Visceral (4.9% vs 7.3%; P = .006) and renal malperfusion (7.7% vs 10.6%; P = .006) were more frequently diagnosed in men. Aortic roots were replaced more frequently in men (22% vs 18%; P < .001). Different aortic arch repair strategies were distributed similarly in both genders. The incidence of new hemiplegia or hemiparesis was also similar in men and women (P = .24). Thirty-day mortality did not differ between women and men (16.3% vs 16.6%; P = .18). In a logistically mixed-effect model, gender revealed no influence on 30-day mortality (odds ratio, 1.15; 95% confidence interval, 0.92-1.44; P = .21). CONCLUSIONS Aortic dissection type A occurs almost twice as frequently in men. Women develop aortic dissection later in life. Despite women and men presenting at different ages and exhibiting varying dissection and malperfusion patterns, and the fact that men undergo complex proximal aortic repair more frequently, outcomes are similar in both genders.
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Affiliation(s)
- Bartosz Rylski
- Faculty of Medicine, Department of Cardiovascular Surgery, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany.
| | - Nikolina Georgieva
- Faculty of Medicine, Department of Cardiovascular Surgery, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Faculty of Medicine, Department of Cardiovascular Surgery, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Christopher Büsch
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Andreas Boening
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | | | - Christian D Etz
- Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Maximilian Luehr
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Klaus Kallenbach
- Department of Cardiac Surgery, INCCI HaerzZenter, Luxembourg City, Luxembourg
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Kremer J, Farag M, Zaradzki M, Szabó G, Ruhparwar A, Kallenbach K, Karck M, Arif R. The reimplantation valve-sparing aortic root replacement technique for patients with Marfan syndrome: A single-center experience. Sci Rep 2019; 9:12021. [PMID: 31427685 PMCID: PMC6700152 DOI: 10.1038/s41598-019-48572-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/07/2019] [Indexed: 01/26/2023] Open
Abstract
Valve-sparing aortic root replacement (VSARR) through reimplantation technique is widely regarded as optimal surgical approach for Marfan syndrome (MFS) patients. Perioperative and long-term data from all MFS patients undergoing VSARR using David's technique at our center from 2007-2018 were analyzed. We included 56 patients with a mean age of 32.3 ± 12.3 years. Logistic EuroSCORE was 7.96 ± 5.2. Among others concomitant surgical procedures included aortic arch surgery (8.9%), mitral valve repair (23.2%) and replacement (1.7%). There were no operative deaths, nor in-hospital-mortality. One patient underwent re-exploration for bleeding, dialysis and pacemaker implantation was required in one case each. There was no occurrence of low-output syndrome nor neurological complications. Significant gender differences were not found, except for intraoperative blood transfusion occurring significantly more often in the female gender (p = 0.009). Despite significantly longer procedural times, concomitant surgery did not negatively impact overall outcome. Freedom of reoperation of the aortic root was 100% at 1 year, 97.7% at 8 years. Until last follow-up (61 ± 38 month) all patients survived, with no evidence of endocarditis. We emphasize once more that VSARR using David's procedure is a safe method for MFS patients with excellent long-term results even if concomitant procedures are performed.
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Affiliation(s)
- Jamila Kremer
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Mina Farag
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Marcin Zaradzki
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Gabor Szabó
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Klaus Kallenbach
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany.,INCCI HaerzZenter, Department of Cardiac Surgery, Luxembourg City, Luxembourg
| | - Matthias Karck
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany.
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Ikeno Y, Yokawa K, Nakai H, Yamanaka K, Inoue T, Tanaka H, Okita Y. Results of staged repair of aortic disease in patients with Marfan syndrome. J Thorac Cardiovasc Surg 2019; 157:2138-2147.e2. [DOI: 10.1016/j.jtcvs.2018.08.109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/11/2018] [Accepted: 08/24/2018] [Indexed: 01/16/2023]
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Rylski B, Pacini D, Beyersdorf F, Quintana E, Schachner T, Tsagakis K, Ronchey S, Durko A, De Paulis R, Siepe M, Roselli EE, Carrel T, Czerny M, Schoenhoff FS, Rylski B, Pacini D, Quintana E, Schachner T, Tsagakis K, Ronchey S, Durko A, Roselli EE, Schoenhoff FS, Beyersdorf F, Czerny M, De Paulis R, Siepe M. Standards of reporting in open and endovascular aortic surgery (STORAGE guidelines). Eur J Cardiothorac Surg 2019; 56:10-20. [DOI: 10.1093/ejcts/ezz145] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/11/2019] [Accepted: 04/16/2019] [Indexed: 12/24/2022] Open
Affiliation(s)
- Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Eduard Quintana
- Cardiovascular Surgery Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, University of Barcelona Medical School, Barcelona, Spain
| | - Thomas Schachner
- Innsbruck Medical University, University Clinic for Cardiac Surgery, Innsbruck, Austria
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Sonia Ronchey
- Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy
| | - Andras Durko
- Department of Cardio-Thoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Matthias Siepe
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Thierry Carrel
- Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Florian S Schoenhoff
- Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
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Holscher CM, Dakour Aridi H, Locham SS, Hicks CW, Canner JK, Malas M, Black JH. Aortic Surgery Outcomes of Marfan Syndrome and Ehlers-Danlos Syndrome Patients at Teaching and Nonteaching Hospitals. Ann Vasc Surg 2019; 55:175-181.e3. [DOI: 10.1016/j.avsg.2018.07.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/30/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022]
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Kimura N, Aizawa K, Kawahito K, Itagaki R, Yamaguchi A, Misawa Y, Siepe M, Czerny M, Beyersdorf F, Kari FA, Rylski B. Outcomes of Early-Onset Acute Type A Aortic Dissection - Influence of Etiologic Factors. Circ J 2018; 83:285-294. [PMID: 30584230 DOI: 10.1253/circj.cj-18-0969] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Outcomes of early-onset acute type A aortic dissection (ATAAD) associated with Marfan syndrome (MFS) are known, but not with other etiologies. Methods and Results: ATAAD patients from 2 centers (n=1,001) were divided into 2 groups: age ≤45 years (n=93) and age >45 years (n=908). Although in-hospital death and 10-year survival were similar (12% vs. 7% and 62.6% vs. 67.3%), the 10-year aortic event-free survival differed (50.0% vs. 80.2%; P<0.01). ATAAD patients from 3 centers (n=132), all aged ≤45 years, were divided into 5 groups: lone hypertension (HTN, n=71), MFS (n=23), non-syndromic familial thoracic aortic aneurysm and dissection (NS-FTAAD, n=16), bicuspid aortic valve (BAV, n=11), and no known etiologic factor (n=11). The incidence of severe aortic insufficiency varied between groups (HTN: 11%, MFS: 39%, NS-FTAAD: 38%, BAV: 55%, no known factor: 46%; P<0.01), whereas in-hospital death did not (14%, 22%, 0%, 0%, and 9%; P=0.061). The 10-year survival was 52.2%, 64.7%, 83.6%, 100%, and 90.9%, respectively, and 10-year aortic event-free survival was 55.6%, 36.3%, 77.5%, 90.0%, and 30.0%. Median descending aorta growth (mm/year) was 1.1 (0.1-3.4), 2.3 (0.3-5.3), 1.9 (1.3-2.7), 0.9 (-0.1-2.0), and 1.0 (-0.2-2.9) (P=0.15), respectively. CONCLUSIONS Late aortic events are common in young ATAAD patients. Known etiologic factors, though not BAV, negatively influence late outcomes in these patients.
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Affiliation(s)
- Naoyuki Kimura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University
| | - Kei Aizawa
- Department of Surgery, Division of Cardiovascular Surgery, Jichi Medical University
| | - Koji Kawahito
- Department of Surgery, Division of Cardiovascular Surgery, Jichi Medical University
| | - Ryo Itagaki
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University
| | - Yoshio Misawa
- Department of Surgery, Division of Cardiovascular Surgery, Jichi Medical University
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg
| | - Fabian Alexander Kari
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg
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Pyeritz RE. Marfan syndrome: improved clinical history results in expanded natural history. Genet Med 2018; 21:1683-1690. [DOI: 10.1038/s41436-018-0399-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/29/2018] [Indexed: 11/09/2022] Open
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