Wrapping of the ascending aorta revisited-is there any role left for conservative treatment of ascending aortic aneurysm?

Transcatheter Aortic Valve Implantation for Severe Chronic Aortic Regurgitation

Transcatheter aortic valve implantation (TAVI) has revolutionised the management of aortic valve disease, offering a less invasive alternative to traditional surgical valve replacement for severe aortic stenosis (AS). TAVI for pure aortic regurgitation (AR) is less well established, and, in fact, it was previously labelled as a relative contraindication. However, TAVI has been utilised for selected cases of pure or predominant AR. The primary limitations regarding the use of TAVI in AR are related to the absence of anatomical factors seen in patients with AS that have contributed to the safe and stable functioning of current-generation prostheses. These include aortic root dilatation, mobile valve leaflets and labile blood pressure within the aortic root, which may further increase the risk of valve migration and periprosthetic leak after deployment. Furthermore, patients with AR have more heterogeneous aortic root anatomies when compared to the population of patients with calcific or degenerative AS. This review article describes the current evidence for the off-label use of TAVI in pure AR and the various clinical syndromes associated with AR where there may be specific challenges in the application of TAVI.

The impact of prophylactic ascending aortic replacement on the long-term prognosis of hybrid arch repair

OBJECTIVES

To investigate the impact of prophylactic zone 0 replacement with prosthetic grafts on the long-term prognosis and perioperative safety of zone 0 hybrid arch repair (HAR) when zone 0 is neither dilated nor pathologic.

METHODS

115 patients whose zone 0 aorta was neither dilated nor pathologic and who underwent zone 0 HAR from January 2009 to December 2020 were retrospectively reviewed, and divided into two groups depending on whether zone 0 was replaced, with 46 patients in the no-replacement group and 69 patients in the replacement group. Inverse probability of treatment weighting (IPTW) was used to balance the baseline difference, and outcomes were compared after IPTW adjustment. The primary endpoints were overall survival and adverse aortic events (AAEs). The secondary endpoints were early composite adverse events and other perioperative complications. Subgroup analysis was performed by age, diagnosis, zone 0 maximum diameter and risk stratification.

RESULTS

The 5-year IPTW-adjusted overall survival rate was 84% in the no-replacement group, 90% in the replacement group, respectively (P=.61). With death as a competing risk, the IPTW-adjusted cumulative incidence of AAEs at 5 and 10 years was 23% and 41% in the no-replacement group, and 14% and 25% in the replacement group, respectively (sHR=0.56, 95%CI=0.23∼1.39; P=.23). Considering proximal complications alone, the replacement group exhibited lower 5-year (3% vs 18%) and 10-year (6% vs 36%) cumulative incidences of proximal complications (sHR=0.11, 95%CI=0.01∼0.91, P=.04) after IPTW adjustment. Subgroup analysis demonstrated that the benefits of zone 0 replacement in reducing AAEs were observed in the age≤60-year-old (sHR=0.15, 95%CI=0.03∼0.75, P=.02) and type B aortic dissection (TBAD) (sHR=0.24, 95%CI=0.07∼0.82, P=.02) subgroups. Additionally, zone 0 replacement did not increase early composite adverse event morbidity (9% vs 21%, P=.08) or early mortality (7% vs 6%, P=.87).

CONCLUSIONS

Although zone 0 was neither dilated nor pathologic, prophylactic zone 0 replacement in zone 0 HAR significantly reduced the incidence of proximal complications, without impairing perioperative safety. Additionally, this strategy was associated with benefits in reducing AAEs in younger and TBAD patients. Thus, prophylactic zone 0 replacement should be considered for reconstructing a stable proximal landing zone in zone 0 HAR.

Moderately dilated ascending aorta-The right wrap?

External reinforcement of the dilated or thin-walled aorta has been tried for nearly half a century. A range of materials has been used as external support. This commentary assesses the evidence that exists regarding the efficacy of wrapping the aorta as well as compares the different options available with a particular focus on the usage of the autologous pericardium.

Hemodynamic Assessment in Bicuspid Aortic Valve Disease and Aortic Dilation: New Insights From Voxel-By-Voxel Analysis of Reverse Flow, Stasis, and Energetics

Objectives: Clinical management decisions surrounding ascending aorta (AAo) dilation in bicuspid aortic valve (BAV) disease benefit from personalized predictive tools. 4D-flow MRI may provide patient-specific markers reflective of BAV-associated aortopathy. This study aims to explore novel 4D-flow MRI parametric voxel-by-voxel forward flow, reverse flow, kinetic energy and stasis in BAV disease. We hypothesize that novel parametric voxel-by-voxel markers will be associated with aortic dilation and referral for surgery and can enhance our understanding of BAV hemodynamics beyond standard metrics.

Methods: A total of 96 subjects (73 BAV patients, 23 healthy controls) underwent MRI scan. Healthy controls had no known cardiovascular disease. Patients were clinically referred for AAo dilation assessment. Indexed diameters were obtained by dividing the aortic diameter by the patient’s body surface area. Patients were followed for the occurrence of aortic surgery. 4D-flow analysis was performed by a single observer in five regions: left ventricular outflow tract (LVOT), AAo, arch, proximal descending aorta (PDAo), and distal descending aorta (DDAo). In each region peak velocity, kinetic energy (KE), forward flow (FF), reverse flow (RF), and stasis were measured on a voxel-by-voxel basis. T-tests (or non-parametric equivalent) compared flow parameters between cohorts. Univariate and multivariate analyses explored associations between diameter and parametric voxel-by-voxel parameters.

Results: Compared to controls, BAV patients showed reduced stasis (p < 0.01) and increased RF and FF (p < 0.01) throughout the aorta, and KE remained similar. In the AAo, indexed diameter correlated with age (R = 0.326, p = 0.01), FF (R = −0.648, p < 0.001), RF (R = −0.441, p < 0.001), and stasis (R = −0.288, p < 0.05). In multivariate analysis, FF showed a significant inverse association with AAo indexed diameter, independent of age. During a median 179 ± 180 days of follow-up, 23 patients (32%) required aortic surgery. Compared to patients not requiring surgery, they showed increased KE and peak velocity in the proximal aorta (p < 0.01), accompanied by increased RF and reduced stasis throughout the entire aorta (p < 0.01).

Conclusion: Novel voxel-by-voxel reverse flow and stasis were altered in BAV patients and are associated with aortic dilation and surgical treatment.

Severe aortic wall degeneration after aortic wrapping

We report a case in whom aortic wrapping had been performed for aortic dilatation. Ten years later, further progression of aortic root diameter was documented (root size of 66 mm). We performed complete replacement of the proximal aorta. Macroscopically and microscopically, there was extreme degeneration and thinning of the aorta under the graft.

The long-term fate of ascending aorta aneurysm after wrapping versus replacement

OBJECTIVE

The study objective was to examine the long-term fate of aortic diameter expansion at 4 cardiac regions (annulus, sinus, ascending aorta, and proximal arch) after wrapping or replacement during aortic valve surgery of the moderately dilated ascending aorta.

METHODS

From January 1995 to December 2018, 964 consecutive patients who underwent aortic valve replacement at our institution were reviewed. Of them, 204 (mean age, 60.7 ± 7.4 years) underwent ascending aorta wrapping (n = 96) or replacement (n = 108) for a moderately dilated ascending aorta (40 to 55 mm). The overall fate of the aortic diameter was analyzed with a linear mixed-effect model. The median follow-up duration was 7.1 years.

RESULTS

After propensity score matching, the baseline maximal ascending aortic diameter median value was 47.3 ± 3.1 mm and 49.4 ± 13.5 mm in the wrapping and replacement groups, respectively. The annulus, sinus, and ascending aorta did not redilate in either group. The proximal aortic arch diameter significantly increased over time (0.343 mm/year; P = .006) in the wrapping group but not in the replacement group (0.066 mm/year; P = .649). Multivariable competing risk analysis identified the initial ascending aorta diameter at the wrapping procedure as an independent risk factor of proximal arch redilation (0.071 ± 0.037, P < .001). The cutoff value was an initial ascending aorta diameter of 47.2 mm for the prediction proximal arch redilation (area under the curve, 0.703; P = .014).

CONCLUSIONS

Aortic wrapping and replacement may be long-term durable treatment options in patients with a moderately enlarged ascending aorta. We suggest careful evaluation of redilation in the proximal arch after an aorta wrapping procedure.

Personalized external aortic root support

OBJECTIVES

Implantation of a personalized external aortic root support (PEARS) can prevent dilatation of the aortic root and ascending aorta in patients with aortopathy of various aetiologies. Because PEARS is an emerging technology, all aspects concerning indications, surgical technique and safety should be elucidated. Our goal was to summarize all of these aspects so that physicians and patients would have sufficient information to evaluate this alternative approach.

METHODS

Between April 2004 and March 2020, 317 patients underwent PEARS operations at 25 surgical centres in 9 countries.

RESULTS

The most common indication was Marfan syndrome (57%). The single perioperative death represented a mortality of 0.3%. The long-term experience comprises 871 patient/years with 1 patient living for 15 years and 19 patients living for more than 10 years.

CONCLUSIONS

PEARS seems to be a promising method of treatment of dilatation of the aortic root and/or ascending aorta. Multicentre observational studies are needed to gain more experience because this operation is still uncommon and the number of operations per surgeon/centre is low.

Life Expectancy after Surgery for Ascending Aortic Aneurysm

Introduction: The life expectancy of patients who undergo ascending aortic replacement is unknown. The life expectancy of a population depends on a collection of environmental and socio-economic factors of the territory where they reside. Our aim was to compare the life expectancy of patients undergoing surgery for ascending aortic aneurysm with that of the general population matching by age, sex, and territory. In addition, we aimed to know the late complications, causes of death and risk factors. Methods: All patients who underwent elective replacement of an ascending aortic aneurysm at our institution between 2000 and 2019 were included. The long-term survival of the sample was compared with that of the general population using data of the National Institute of Statistics. Results: For patients who survived the postoperative period, observed cumulative survival at three, five and eight years was 94.07% (95% CI 91.87%-95.70%), 89.96% (95% CI 86.92%-92.33%) and 82.72% (95% CI 77.68%-86.71%). Cumulative survival of the general population at three, five and eight years was 93.22%, 88.30%, and 80.27%. Cancer and cardiac failure were the main causes of death. Conclusions: Long-term survival of patients undergoing elective surgery for ascending aortic aneurysm who survive the postoperative period completely recover their life expectancy.

Concomitant Wrapping of a Moderately Dilated Ascending Aorta during Aortic Valve Replacement: Postoperative Remodeling of a Distinctive Aorta

PURPOSE

The long-term outcomes of aortic wrapping in patients with ascending aortic aneurysms, which are rare, but can be fatal, remain poorly understood. This retrospective study analyzed the outcomes of aortic diameter, including aortic root, ascending aorta, and proximal arch diameters, after aortic wrapping during aortic valve replacement surgery.

MATERIALS AND METHODS

Ninety-six patients with ascending aortic dilation of 40-55 mm who underwent aortic wrapping during aortic valve replacement were selected for this study. Aortic diameter was measured at three levels perioperatively and at follow-up (median time of 9.1±4.2 years). A linear mixed-effects model was used to analyze aortic diameter expansion.

RESULTS

Freedom from adverse aortic events (aortic dissection or rupture, reoperation, or sudden death) at 10 years was 97.9%. No significant dilation at the level of the sinuses of Valsalva (0.069 mm/year, p=0.524) or ascending aorta (0.152 mm/year, p=0.124) was observed. Significant dilation occurred at the proximal aortic arch (0.343 mm/year, p=0.006). Subgroup analysis with a multivariable linear mixed model identified initial ascending aortic diameter to be a significant predictor of proximal arch dilation (p=0.032). Receiver operating characteristic curve analysis revealed that the cut-off for the prediction of proximal arch redilation was an initial mid-ascending aortic diameter of 47.0 mm (area under the curve 0.747, 90% confidence interval 0.613-0.881, p=0.023).

CONCLUSION

Aortic wrapping could be considered as a safe and long-term therapeutic option. Redilation of the proximal arch should be carefully observed during long-term follow-up.

Wrapping of ascending aortic aneurysm with supra-aortic debranching and endovascular repair for aortic arch aneurysm and ruptured descending thoracic aortic aneurysm

We report a case of a hybrid surgical treatment of a 71-year-old fragile female with severe chronic obstructive pulmonary disease with a 5-year history of progressive back pain and diagnosis of descending thoracic aorta aneurysm (DTAA), but refused operation at first. Since the patient presented with an acute expanding painful pulsatile mass due to a ruptured DTAA contained by the subcutaneous tissue and had a high-risk surgical profile, we agreed that the simplest urgent operation should be performed. Cardiopulmonary bypass with or without deep hypothermic circulatory arrest was ruled out as an option. The initial approach would be permanent bypasses to the supra-aortic trunks and endovascular repair of the ruptured DTAA, but we ran into a problem: the absence of suitable diameter in the ascending aorta to land the prosthesis-zone 0. To overcome this obstacle, we opted to perform a diameter reduction of the ascending aorta by wrapping it with a Dacron tube to create a neck where we could land the endovascular prosthesis. Following this step bypasses from the proximal ascending aorta to the brachiocephalic artery, left common carotid artery and left subclavian artery were created. Since we gained ground to act in zone 0, the first endoprosthesis was landed in the wrapped zone and the aortic arch-from zone 0 to zone 3. The second and third endoprostheses covered the ruptured DTAA above the celiac trunk-zones 4 and 5. Good positioning of the endoprostheses was achieved and we attained procedural success.

Challenging corrective redo surgery in a patient presenting with severe aortic redilatation following an aortic root reduction aortoplasty with concomitant external wrapping

We report a case of severe long-term failure of an aortic root reduction aortoplasty with external wrapping. The patient presented 13 years after the initial surgery with a large redilatation of the aortic root and major atrophy of the native aortic root wall inside the external wrap. This subsequently necessitated challenging corrective redo surgery with a Bentall procedure. This case highlights the potential long-term risk of redilatation posed by using reduction aortoplasty with concomitant aortic external wrapping as a technique to treat largely aneurysmal aortic roots.

Efficacy of ascending aortic banding technique concomitant with type I hybrid aortic arch repair in high-risk patients

Banding of the ascending aorta has been introduced as a less complex procedure to optimize the proximal landing zone of the stent graft in hybrid aortic arch surgery. However, data about the long-term results and effects of this technique are still limited. We aimed to study the efficacy of banding of the ascending aorta in hybrid aortic arch repair. The study included 11 high-risk patients with dilated ascending aorta (wider than 38 mm in diameter) undergoing ascending aortic banding for hybrid arch repair. Clinical outcomes, including technical success, endoleaks, perioperative mortality and morbidity, and sequential remodeling of the ascending aorta were investigated. The average diameter of the ascending aorta had been reduced (p = 0.02) from 42.1 mm (range = 39.0-46.4) to 37.2 mm (range = 35.6-38.6) after banding procedure. The technical success rate was 100.0%. No type I endoleak occurred, but 2 cases of distal stent graft-induced new entry required re-interventions. The 5-year survival and freedom from aortic events rates both were 81.8%. The ascending aortic diameter remained stable and no proximal migration of the stent graft was observed during the study period. The 5-year results validated the durability of this therapeutic modality, especially in high-risk patients.