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Park SJ, Kim HR, Kim HJ, Kim JB. Tailored surgical strategies for mini-access open total arch repair. JTCVS Tech 2024; 24:1-13. [PMID: 38835578 PMCID: PMC11145074 DOI: 10.1016/j.xjtc.2023.12.005] [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: 10/06/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 06/06/2024] Open
Abstract
Objective Open arch repair is perceived as a challenging, high-risk procedure, with a barrier against the use of a minimally invasive approach. We aimed to present a mini-access total arch replacement performed by stratified approaches and to evaluate perioperative outcomes to contribute to the body of evidence. Methods We evaluated 40 consecutive patients (aged 69.5 years; interquartile range, 65.6-76.3 years) undergoing elective total arch replacement using 5- to 8-cm upper mini-sternotomy between 2018 and 2022. Surgical strategies, including arterial inflow site and methods of branching vessel reconstruction, were systematically selected at the individual level. To evaluate comparative outcomes, contemporary cases undergoing total arch replacement via sternotomy with similar eligibility criteria served as a control group, and the inverse-treatment-weighting method was used to adjust for baseline characteristics. Results Arch-first anastomosis using trifurcate graft, distal-first anastomosis using 4-branch graft, and island anastomosis were used in 18 (45%), 12 (30.0%), and 10 (25%) patients, respectively. Lower body and cardiac ischemic times were 23.4 minutes (interquartile range, 18.0-29.0 minutes) and 66.7 minutes (interquartile range, 50.1-78.2 minutes). There was no early (30-day or in-hospital) mortality, and 2 patients experienced disabling stroke (5.0%). The contemporary control group comprised 55 patients. After an adjustment, a mini-access group showed lower risks of stroke (odds ratio, 0.88; 95% CI, 0.78-1.00; P = .049) and a composite of major complications (odds ratio, 0.79; 95% CI, 0.68-0.92; P = .003), compared with a sternotomy approach. Conclusions Based on present results, mini-access total arch replacement may be performed with reasonable safety and efficiency.
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Affiliation(s)
- Soo Jin Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, Korea
| | - Hong Rae Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, Korea
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Park SJ, Kim JB. Unsolved issues in acute type A aortic dissection. Asian Cardiovasc Thorac Ann 2023; 31:32-36. [PMID: 35291827 DOI: 10.1177/02184923221083365] [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: 11/17/2022]
Abstract
Surgery for acute type A aortic dissection remains challenging with considerable mortality and morbidity despite the remarkable advances in this field. Particularly, surgical outcomes of acute type A aortic dissection are known to be associated with the hospital volume. The optimal cerebral protective method and extent of surgery have been long-standing controversies in acute type A aortic dissection surgery. Given that data from randomized trial are not available and future trials are also unrealistic, observational data based on large registry or meta-analyses may alternatively provide reliable and reasonable evidence. With regard to neuroprotective methods for arch repair, currently available observational data strongly suggest that there are no overt superiority among unilateral-antegrade cerebral perfusion, bilateral-antegrade cerebral perfusion, and retrograde cerebral perfusion, by which their availabilities are still open in real clinical practices depending on institutional preferences. When deciding the extent of arch repair in acute DeBakey type I aortic dissection, multiple factors should be considered altogether such as aortic anatomic characteristics as well as patient's risk profiles for optimizing early safety and late aortic longevity.
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Affiliation(s)
- Sung Jun Park
- Department of Thoracic and Cardiovascular Surgery, 65542Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Mauduit M, Anselmi A, Soulami RB, Tomasi J, Flecher E, Langanay T, Corbineau H, Rouzé S, Verhoye JP. Early and long-term results of hypothermic circulatory arrest in aortic surgery: a 20-year single-centre experience. J Cardiovasc Med (Hagerstown) 2021; 22:572-578. [PMID: 33534299 DOI: 10.2459/jcm.0000000000001152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to document the postoperative outcomes of patients who underwent hypothermic circulatory arrest (HCA), the evolution of HCA management over time and to identify the risks factor for early mortality and postoperative stroke. METHODS Four hundred and twenty-four patients who underwent aortic surgery with HCA at our institution between January 1995 and June 2016 were consecutively included. RESULTS The main indications were degenerative aneurysm (254; 59.9%) and acute type A aortic dissection (146; 34.4%). Interventions were performed under deep (18.4 ± 0.9°C; n = 350; 82.5%) or moderate (23.9 ± 1.9°C; n = 74; 17.5%) hypothermia. Antegrade cerebral perfusion (ACP) was employed in 86 (20.3%) cases. The use of moderate hypothermia significantly increased from 2011, to become the preferred strategy in 2016. The in-hospital mortality was 12.5% and the postoperative stroke rate was 7.1%. Kaplan--Meier 5-year survival was 65.7%. Nonelective timing [odds ratio (OR) 4.05; P < 0.001], stroke (OR 3.77' P = 0.032), renal failure (OR 2.49; P = 0.023), redo surgery (2.42; P = 0.049) and CPB time (OR 1.05; P = 0.03) were independent risk factors for in-hospital mortality in multivariate analysis. Femoral cannulation was the only independent risk factor for stroke (OR 3.97; P = 0.002). The level of hypothermia and the use of ACP were not associated with either in-hospital mortality or postoperative stroke. CONCLUSION HCA might be widely considered to achieve a radical treatment of the aortic disease, provided that hypothermia is maintained below the 24°C safety threshold and ACP is used for HCA exceeding 30 min, to ensure optimal brain, spinal cord and visceral organs protection.
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Affiliation(s)
- Marion Mauduit
- Université Rennes1
- Department of Cardio-thoracic and Vascular Surgery, CHU Rennes, Rennes, France
| | - Amedeo Anselmi
- Université Rennes1
- Department of Cardio-thoracic and Vascular Surgery, CHU Rennes, Rennes, France
| | - Reda Belhaj Soulami
- Université Rennes1
- Department of Cardio-thoracic and Vascular Surgery, CHU Rennes, Rennes, France
| | - Jacques Tomasi
- Université Rennes1
- Department of Cardio-thoracic and Vascular Surgery, CHU Rennes, Rennes, France
| | - Erwan Flecher
- Université Rennes1
- Department of Cardio-thoracic and Vascular Surgery, CHU Rennes, Rennes, France
| | - Thierry Langanay
- Université Rennes1
- Department of Cardio-thoracic and Vascular Surgery, CHU Rennes, Rennes, France
| | - Hervé Corbineau
- Université Rennes1
- Department of Cardio-thoracic and Vascular Surgery, CHU Rennes, Rennes, France
| | - Simon Rouzé
- Université Rennes1
- Department of Cardio-thoracic and Vascular Surgery, CHU Rennes, Rennes, France
| | - Jean-Philippe Verhoye
- Université Rennes1
- Department of Cardio-thoracic and Vascular Surgery, CHU Rennes, Rennes, France
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Ok YJ, Kang SR, Kim HJ, Kim JB, Choo SJ. Comparative outcomes of total arch versus hemiarch repair in acute DeBakey type I aortic dissection: the impact of 21 years of experience. Eur J Cardiothorac Surg 2021; 60:967-975. [PMID: 33880505 DOI: 10.1093/ejcts/ezab189] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES With the goal of evaluating the impact of experiences at our centre on comparative outcomes between total arch and hemiarch repairs, we reviewed our 21 years of experience with operations for acute type I aortic dissection. METHODS Between 1999 and 2019, a total of 365 patients (177 women; 56.8 ± 12.9 years) with acute type I aortic dissection who had a hemiarch (n = 248) or a total arch replacement (n = 117) were evaluated, and the trends in comparative outcomes were analysed. RESULTS Over time, deep hypothermic circulatory arrest and retrograde cerebral perfusion were replaced by moderate hypothermia and antegrade cerebral perfusion with the introduction of dedicated aortic surgeons. Overall, operative deaths decreased from 11.0% in time quartile 1 to 2.2% in time quartile 4 (P = 0.090). After adjustment with the use of inverse probability weighting, the total arch group compared with the hemiarch group was at a similar risk of mortality [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.22-2.43; P = 0.71] but at a greater risk of neurological deficit (OR 3.28, 95% CI 1.23-8.98; P = 0.017) in the earlier half period (1999-2009). In the later period (2009-2019), however, both the risks of mortality (OR 0.32, 95% CI 0.03-1.59; P = 0.23) and of neurological injuries (OR 0.42, 95% CI 0.12-1.18; P = 0.13) were comparable between the 2 groups (P for interaction in terms of neurological deficit = 0.007). The multivariable logistic regression model revealed that dedicated aortic surgeons independently contributed to decreased risk of death (OR 0.30, 95% CI 0.09-0.84; P = 0.036). CONCLUSIONS These findings indicate that accumulating institutional experiences, along with resultant improvements in surgical strategies and outcomes, may neutralize the surgical risk gap between total arch and hemiarch repair in acute type I aortic dissection.
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Affiliation(s)
- You Jung Ok
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Ri Kang
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kim SA, Pyo WK, Ok YJ, Kim HJ, Kim JB. Mini-access open arch repair. J Thorac Dis 2021; 13:2233-2241. [PMID: 34012574 PMCID: PMC8107538 DOI: 10.21037/jtd-20-3254] [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] [Indexed: 11/25/2022]
Abstract
Background The use of minimally invasive approaches is scarce in open aortic arch repair because of its perceived high operative risk and technical difficulty. Methods This study enrolled 59 consecutive patients (aged 58.2±13.2 years) undergoing elective arch replacement either through upper hemi-sternotomy (n=58) or mini-thoracotomy (n=1) between 2015 and 2020. Of these, 44 underwent hemiarch replacement and 15 underwent total arch replacement. Moderate hypothermic circulatory arrest was used for all patients while antegrade cerebral perfusion was selectively used for total arch repair. For more efficient distal aortic anastomosis in limited spaces, inverted graft anastomosis was utilized whenever possible. Results Hemi-sternotomy involved upper sternal separation down to the second, third, and fourth intercostal spaces in 1 (1.7%), 30 (50.8%), and 27 (45.8%) patients, respectively. Concomitant cardiac procedures included root replacement in 19 patients (32.2%) and aortic valve replacement in 21 patients (35.6%). Circulatory arrest, cardiac ischemic, cardiopulmonary bypass, and total procedural times were 8.9±3.4, 91.1±31.1, 114.6±46.2, and 250.3±79.5 min, respectively for total arch repair, and 25.0±12.1, 72.3±16.6, 106.0±16.9, and 249.1±41.7 min, respectively for hemiarch repair. Conversion to full-sternotomy was required in 1 patient (1.7%) due to bleeding. There was one case of mortality (1.7%) attributable to low-cardiac output syndrome following hemiarch repair concomitantly with Bentall procedure. Major complications included requirement for mechanical support in 1 (1.7%), temporary neurologic deficit in 1 (1.7%), newly initiated dialysis in 3 (5.1%), and re-exploration due to bleeding in 2 (3.4%). Conclusions Mini-access open arch repair is technically feasible and achieved excellent early outcomes.
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Affiliation(s)
- Shi A Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Kyung Pyo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - You Jung Ok
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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He J, Peng J, Li W, Zheng D, Cai S, Xu W, Huang J, Fan X. "Aorta-clamp" technique for surgical repair of acute type A aortic dissection-5 min circulatory arrest at 30 °C. J Thorac Dis 2019; 11:4717-4724. [PMID: 31903261 PMCID: PMC6940206 DOI: 10.21037/jtd.2019.10.47] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Deep hypothermic circulatory arrest (HCA), which causes perioperative complications, is the foundation of surgical treatment for acute type A aortic dissection (AAAD). To extensively replace the dissected aorta and avoid the negative impacts of HCA, we developed an "aorta-clamp" technique and examined its efficacy in repairing AAAD. Methods From November 2014 to August 2016, we recruited 59 consecutive patients (51.3±10.9 years) with AAAD into this study. We performed total arch replacement combined with an elephant trunk implantation using the "aorta-clamp" technique under a 30 °C HCA with continual bilateral antegrade cerebral perfusion. Results The average HCA time was 4.9±1.0 min. Twenty-three patients had increased serum creatinine (sCr) before surgery, suggesting an AAAD-associated acute kidney injury (AKI). The sCr level returned to normal in five patients after operation and in 15 before discharge. Six patients (10.2%) with preoperative AKI required postoperative dialysis, and two of these patients (3.4%) died of multiple organ failure. Two patients (3.4%) required re-exploration due to bleeding. One patient (1.7%) exhibited temporary neurologic deficits. There were no late deaths. Computed tomography (CT) examination confirmed the patency of the anastomotic sites and thrombus obliteration of the residual false lumen. Conclusions Using the "aorta-clamp" technique with continual bilateral antegrade cerebral perfusion, total arch replacement combined with an elephant trunk implantation can be performed under five minutes of mild (30 °C) HCA. Our data suggest that this technique for the surgical repair of AAAD is a safe, feasible and effective surgical approach with satisfactory early outcomes.
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Affiliation(s)
- Jie He
- Department of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510000, China.,Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Jihai Peng
- Department of Rehabilitation, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Wei Li
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Dingwen Zheng
- Department of Cardiovascular Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Shihao Cai
- Department of Cardiovascular Surgery, Xiamen Cardiovascular Hospital, Xiamen University, Xiamen 361005, China
| | - Wenliu Xu
- Department of Cardiothoracic Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Jinsong Huang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiaoping Fan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
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Kim WK, Kim JB. Commentary: Axillar cannulation and plan B. J Thorac Cardiovasc Surg 2019; 158:662-663. [PMID: 30660410 DOI: 10.1016/j.jtcvs.2018.12.019] [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: 12/05/2018] [Accepted: 12/05/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Wan Kee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Kim JB. Product review on "intimal re-layering technique" for arch repair. J Thorac Cardiovasc Surg 2018; 156:972-973. [PMID: 29779637 DOI: 10.1016/j.jtcvs.2018.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 04/09/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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