Long-term outcomes after recurrent acute thoracic aortic dissection: Insights from the International Registry of Aortic Dissection

OBJECTIVE

With an aging population and advancements in imaging, recurrence of thoracic aortic dissection is becoming more common.

METHODS

All patients enrolled in the International Registry of Aortic Dissection from 1996 to 2023 with type A and type B acute aortic dissection were identified. Among them, initial dissection and recurrent dissection were discerned. The study period was categorized into 3 eras: historic era, 1996 to 2005; middle era, 2006 to 2015; most recent era, 2016 to 2023. Propensity score matching was applied between initial dissection and recurrent dissection. Outcome of interests included long-term survival and cumulative incidence of major aortic events defined by the composite of reintervention, aortic rupture, and new dissection.

RESULTS

The proportion of recurrent dissection increased from 5.9% in the historic era to 8.0% in the most recent era in the entire dissection cohort. In patients with type A dissection, propensity score matching between initial dissection and recurrent dissection yielded 326 matched pairs. Kaplan-Meier curves showed similar long-term survival between the 2 groups. However, the cumulative incidence of major aortic events was significantly higher in the recurrent dissection group (40.3% ± 6.2% vs 17.8% ± 5.1% at 4 years in the initial dissection group, P = .02). For type B dissection, 316 matched pairs were observed after propensity score matching. Long-term survival and the incidence of major aortic events were equivalent between the 2 groups.

CONCLUSIONS

The case volume of recurrent dissection or the ability to detect recurrent dissection has increased over time. Acute type A recurrent dissection was associated with a higher risk of major aortic events than initial dissection. Further judicious follow-up may be crucial after type A recurrent dissection.

Axillary vs Femoral Arterial Cannulation in Acute Type A Dissection: International Multicenter Data

BACKGROUND

Cannulation strategy in acute type A dissection (ATAD) varies widely without known gold standards. This study compared ATAD outcomes of axillary vs femoral artery cannulation in a large cohort from the International Registry of Acute Aortic Dissection (IRAD).

METHODS

The study retrospectively reviewed 2145 patients from the IRAD Interventional Cohort (1996-2021) who underwent ATAD repair with axillary or femoral cannulation (axillary group: n = 1106 [52%]; femoral group: n = 1039 [48%]). End points included the following: early mortality; neurologic, respiratory, and renal complications; malperfusion; and tamponade. All outcomes are presented as axillary with respect to femoral.

RESULTS

The proportion of patients younger than 70 years in both groups was similar (n = 1577 [74%]), as were bicuspid aortic valve, Marfan syndrome, and previous dissection. Patients with femoral cannulation had slightly more aortic insufficiency (408 [55%] vs 429 [60%]; P = .058) and coronary involvement (48 [8%] vs 70 [13%]; P = .022]. Patients with axillary cannulation underwent more total aortic arch (156 [15%] vs 106 [11%]; P = .02) and valve-sparing root replacements (220 [22%] vs 112 [12%]; P < .001). More patients with femoral cannulation underwent commissural resuspension (269 [30.9%] vs 324 [35.3%]; P = .05). Valve replacement rates were not different. The mean duration of cardiopulmonary bypass was longer in the femoral group (190 [149-237] minutes vs 196 [159-247] minutes; P = .037). In-hospital mortality was similar between the axillary (n = 165 [15%]) and femoral (n = 149 [14%]) groups (P = .7). Furthermore, there were no differences in stroke, visceral ischemia, tamponade, respiratory insufficiency, coma, or spinal cord ischemia.

CONCLUSIONS

Axillary cannulation is associated with a more stable ATAD presentation, but it is a more extensive intervention compared with femoral cannulation. Both procedures have equivalent early mortality, stroke, tamponade, and malperfusion outcomes after statistical adjustment.

Impact of transcatheter heart valve type on outcomes of surgical explantation after failed transcatheter aortic valve replacement: the EXPLANT-TAVR international registry

BACKGROUND

There are limited data on the impact of transcatheter heart valve (THV) type on the outcomes of surgical explantation after THV failure.

AIMS

We sought to determine the outcomes of transcatheter aortic valve replacement (TAVR) explantation for failed balloon-expandable valves (BEV) versus self-expanding valves (SEV).

METHODS

From November 2009 to February 2022, 401 patients across 42 centres in the EXPLANT-TAVR registry underwent TAVR explantation during a separate admission from the initial TAVR. Mechanically expandable valves (N=10, 2.5%) were excluded. The outcomes of TAVR explantation were compared for 202 (51.7%) failed BEV and 189 (48.3%) failed SEV.

RESULTS

Among 391 patients analysed (mean age: 73.0±9.8 years; 33.8% female), the median time from index TAVR to TAVR explantation was 13.3 months (interquartile range 5.1-34.8), with no differences between groups. Indications for TAVR explantation included endocarditis (36.0% failed SEV vs 55.4% failed BEV; p<0.001), paravalvular leak (21.2% vs 11.9%; p=0.014), structural valve deterioration (30.2% vs 21.8%; p=0.065) and prosthesis-patient mismatch (8.5% vs 10.4%; p=0.61). The SEV group trended fewer urgent/emergency surgeries (52.0% vs 62.3%; p=0.057) and more root replacement (15.3% vs 7.4%; p=0.016). Concomitant cardiac procedures were performed in 57.8% of patients, including coronary artery bypass graft (24.8%), and mitral (38.9%) and tricuspid (14.6%) valve surgery, with no differences between groups. In-hospital, 30-day, and 1-year mortality and stroke rates were similar between groups (allp>0.05), with no differences in cumulative mortality at 3 years (log-rank p=0.95). On multivariable analysis, concomitant mitral surgery was an independent predictor of 1-year mortality after BEV explant (hazard ratio [HR] 2.00, 95% confidence interval [CI]: 1.07-3.72) and SEV explant (HR 2.00, 95% CI: 1.08-3.69).

CONCLUSIONS

In the EXPLANT-TAVR global registry, BEV and SEV groups had different indications for surgical explantation, with more root replacements in SEV failure, but no differences in midterm mortality and morbidities. Further refinement of TAVR explantation techniques are important to improving outcomes.

Editor's Choice - Trends in Management and Outcomes of Type B Aortic Dissection: A Report From the International Registry of Aortic Dissection

OBJECTIVE

To describe the trends in management and outcomes of patients with acute type B aortic dissection in the International Registry of Acute Aortic Dissection.

METHODS

From 1996 - 2022, 3 908 patients were divided into similar sized quartiles (T1, T2, T3, and T4). In hospital outcomes were analysed for each quartile. Survival rates following admission were compared using Kaplan-Meier analyses with Mantel-Cox Log rank tests.

RESULTS

Endovascular treatment increased from 19.1% in T1 to 37.2% in T4 (ptrend < .001). Correspondingly, medical therapy decreased from 65.7% in T1 to 54.0% in T4 (ptrend < .001), and open surgery from 14.8% in T1 to 7.0% in T4 (ptrend < .001). In hospital mortality decreased in the overall cohort from 10.7% in T1 to 6.1% in T4 (ptrend < .001), as well as in medically, endovascularly and surgically treated patients (ptrend = .017, .033, and .011, respectively). Overall post-admission survival at three years increased (T1: 74.8% vs. T4: 77.3%; p = .006).

CONCLUSION

Considerable changes in the management of acute type B aortic dissection were observed over time, with a significant increase in the use of endovascular treatment and a corresponding reduction in open surgery and medical management. These changes were associated with a decreased overall in hospital and three year post-admission mortality rate among quartiles.

Who needs their descending thoracic aorta anyway? Extra-anatomic bypass for aorto-bronchial fistula after TEVAR

BACKGROUND

Aortobronchial fistula after TEVAR remains a vexing clinical problem associated with high mortality. Although a combination of endovascular and open surgical strategies have been reported in managing this pathology, there is as yet no definitive treatment algorithm that can be used for all patients. We discuss our approach to an aortobronchial fistula associated with an overtly infected aortic endograft.

CASE PRESENTATION

A 49-year-old female sustained a traumatic aortic transection 14 years prior, managed by an endovascular stent-graft. Due to persistent endoleak, she underwent open replacement of her descending thoracic aorta 4 years later. Ten years after her open aortic surgery, the patient presented with hemoptysis, and a pseudoaneurysm at her distal aortic suture line was identified on computed tomography, whereupon she underwent placement of an endograft. Eight weeks later, she presented with dyspnea, recurrent hemoptysis, malaise and fever, with clinical and radiographic evidence of an aortobronchial communication and an infected aortic stent-graft. The patient underwent management via a two-stage open surgical approach, constituting an extra-anatomic bypass from her ascending aorta to distal descending aorta and subsequent radical excision of her descending aorta with all associated infected prosthetic material and repair of the airway.

CONCLUSION

Aortobronchial fistula after TEVAR represents a challenging complex clinical scenario. Extra-anatomic aortic bypass followed by radical debridement of all contaminated tissue may provide the best option for durable longer-term outcomes.

Acute Kidney Injury in Patients Undergoing Surgery for Type A Acute Aortic Dissection

BACKGROUND

Acute kidney injury (AKI) after repair of type A acute aortic dissection (TAAAD) has been shown to affect both short- and long-term outcomes. This study aimed to validate the impact of postoperative AKI on in-hospital and long-term outcomes in a large population of dissection patients presenting to multinational aortic centers. Additionally, we assessed risk factors for AKI including surgical details.

METHODS

Patients undergoing surgical repair for TAAAD enrolled in the International Registry of Acute Aortic Dissection database were evaluated to determine the incidence and risk factors for the development of AKI.

RESULTS

A total of 3307 patients were identified. There were 761 (23%) patients with postoperative AKI (AKI group) vs 2546 patients without (77%, non-AKI group). The AKI group had a higher rate of in-hospital mortality (n = 193, 25.4% vs n = 122, 4.8% in the non-AKI group, P < .001). Additional postoperative complications were also more common in the AKI group including postoperative cerebrovascular accident, reexploration for bleeding, and prolonged ventilation. Independent baseline characteristics associated with AKI included a history of hypertension, diabetes, chronic kidney disease, evidence of malperfusion on presentation, distal extent of dissection to abdominal aorta, and longer cardiopulmonary bypass time. Kaplan-Meier survival curves revealed decreased 5-year survival among the AKI group (P < .001).

CONCLUSIONS

AKI occurs commonly after TAAAD repair and is associated with a significantly increased risk of operative and long-term mortality. In this large study using the International Registry of Acute Aortic Dissection database, several factors were elucidated that may affect risk of AKI.

Deep Versus Moderate Hypothermia in Acute Type A Aortic Dissection: A Propensity-Matched Analysis

BACKGROUND

The ideal temperature for hypothermic circulatory arrest (HCA) during acute type A aortic dissection (ATAAD) repair has yet to be determined. We examined the clinical impact of different degrees of hypothermia during dissection repair.

METHODS

Out of 240 cases of ATAAD between June 2014 and December 2019, 228 patients were divided into two groups according to lowest intraoperative temperature: moderate hypothermic circulatory arrest (MHCA) (20-28°C) versus deep hypothermic circulatory arrest (DHCA) (<20°C). From this, 74 pairs of propensity-matched patients were analysed with respect to operative data and short-term clinical outcomes. Independent predictors of a composite outcome of 30-day mortality and stroke were identified.

RESULTS

Mean lowest temperature was 25.5±3.9°C in the MHCA group versus 16.0±2.9°C in DHCA. Overall 30-day mortality of matched cohort was 11.5% (17 deaths), there were no significant different between matched groups. Cardiopulmonary bypass (CPB) times were longer in DHCA (221.0±69.9 vs 190.7±74.5 mins, p=0.01). Antegrade cerebral perfusion (ACP) during HCA predicted a lower composite risk of 30-day mortality and stroke (OR 0.38). Female sex (OR 4.71), lower extremity ischaemia at presentation (OR 3.07), and CPB >235 minutes (OR 2.47), all portended worse postoperative outcomes.

CONCLUSIONS

A surgical strategy of MHCA is at least as safe as DHCA during repair of acute type A aortic dissection. ACP during HCA is associated with reduced 30-day mortality and stroke, whereas female sex, lower extremity ischaemia, and longer CPB times are all predictive of poorer short-term outcomes.

Minimally Invasive Direct Coronary Artery Bypass: An Evolving Paradigm Over the Past 25 Years

OBJECTIVE

We have routinely utilized minimally invasive direct coronary artery bypass (MIDCAB) for revascularization of the left anterior descending (LAD) coronary artery. We examined how this procedure has evolved.

METHODS

A retrospective review was undertaken of 2,283 consecutive patients who underwent MIDCAB between 1997 and 2021. Patients were divided into 3 groups: group A from 1997 to 2002 (n = 751, 32.9%), group B from 2003 to 2009 (n = 452, 19.8%), and group C from 2009 to 2021 (n = 1,080, 47.3%). Risk profiles and short-term outcomes were analyzed for the entire cohort and for 293 propensity-matched patients drawn from each group.

RESULTS

The left internal mammary artery was harvested open in group A but with robotic assistance in group C. Thirty-day mortality was higher in group A versus group C (12 deaths, 1.6% vs 5 deaths, 0.5%, P = 0.044); this difference was negated after propensity matching. Group A had more comorbidities than group C, including peripheral vascular disease (17.7% vs 10.0%, P < 0.001), congestive heart failure (39.6% vs 18.0%, P < 0.001), and a history of stroke (17.9% vs 10.0%, P < 0.001), although diabetes mellitus was more common in group C (51.4% vs 31.0%, P < 0.001). Stroke was greater in group A (1.2% vs 0.0% vs 0.2%, respectively, P = 0.004), as was the need for prolonged ventilation (3.6% vs 0.2% vs 0.9%, respectively, P < 0.001), before and after propensity matching.

CONCLUSIONS

MIDCAB patients had less comorbidities than in the past. Robot-assisted MIDCAB was associated with lower stroke risk.

Survival after operative repair of acute type A aortic dissection varies according to the presence and type of preoperative malperfusion

OBJECTIVE

Approximately one-quarter of patients with acute type A aortic dissection (TAAD) present with concomitant malperfusion of coronary arteries, mesenteric circulation, lower extremities, kidneys, brain, and/or coma. It is generally accepted that TAAD patients who present with malperfusion experience higher mortality rates than patients without, although how specific malperfusion syndromes, alone or in combination, affect mortality is not well described.

METHODS

The International Registry of Acute Aortic Dissection database was queried for patients who underwent surgical repair of TAAD. Patients were stratified according to the presence/absence of malperfusion at presentation. Multivariable logistic regression was used to evaluate in-hospital mortality according to malperfusion type. Kaplan-Meier estimates were used to estimate 30-day postoperative survival.

RESULTS

Six thousand four hundred thirty-seven patients underwent surgical repair of acute TAAD, of whom 2642 (41%) had 1 or more preoperative malperfusion syndromes. Mesenteric malperfusion (adjusted odds ratio [AOR], 4.84; P < .001) was associated with the highest odds of in-hospital mortality, followed by coma (AOR, 1.88; P = .007), limb ischemia (AOR, 1.73; P = .008), and coronary malperfusion (AOR, 1.51; P = .02). Renal malperfusion (AOR, 1.37; P = .24) and neurologic deficit (AOR, 1.35; P = .28) were not associated with increased in-hospital mortality. In patients who survived to discharge, there was no difference in 1-year postdischarge survival in the malperfusion and no malperfusion cohorts (P = .36).

CONCLUSIONS

Survival during the index admission after TAAD repair varies according to the presence and type of malperfusion syndromes, with mesenteric malperfusion being associated with the highest odds of in-hospital death. Not only the presence of malperfusion but rather specific malperfusion syndromes should be considered when assessing a patient's risk of undergoing TAAD repair.

Factor eight inhibiting bypass activity for refractory bleeding in acute type A aortic dissection repair: A propensity-matched analysis

BACKGROUND

Perioperative bleeding and transfusion have been associated with adverse outcomes after cardiac surgery. The use of factor eight inhibiting bypass activity (FEIBA) in managing bleeding after repair of acute Stanford type A aortic dissection (ATAAD) has not previously been evaluated. We report our experience in utilizing FEIBA in ATAAD repair.

STUDY DESIGN AND METHODS

A retrospective review was undertaken of all consecutive patients who underwent repair of ATAAD between July 2014 and December 2019. Patients were divided into two groups, dependent upon whether or not they received FEIBA intraoperatively: "FEIBA" (n = 112) versus "no FEIBA" (n = 119). From this, 53 propensity-matched pairs of patients were analyzed with respect to transfusion requirements and short-term clinical outcomes.

RESULTS

Thirty-day mortality for the entire cohort was 11.7% (27 deaths), not significantly different between patient groups. Those patients who received FEIBA demonstrated reduced transfusion requirements for all types of blood products in the first 48 h after surgery as compared with the "no FEIBA" cases, including red blood cells, platelets, plasma, and cryoprecipitate (p < .0001). There was no significant difference in major postoperative morbidity between the two groups. The FEIBA cohort did not demonstrate an increased incidence of thrombotic complications (stroke, deep venous thrombosis, pulmonary thromboembolism).

DISCUSSION

When used as rescue therapy for refractory bleeding following repair of ATAAD, FEIBA appears to be effective in decreasing postoperative transfusion requirements whilst not negatively impacting clinical outcomes. These findings should prompt further investigation and validation via larger, multi-center, randomized trials.

Age, sex, and contemporary outcomes in surgical repair of type A aortic dissection: Insights from the National Inpatient Sample

Objective

Acute type A aortic dissection (ATAAD) is a surgical emergency with significant morbidity and mortality, as well as significant center-level variation in outcomes. Our study aims to leverage a nationally representative database to assess contemporary in-hospital outcomes in surgical repair of ATAAD, as well as the association of age and sex with outcomes.

Methods

The National Inpatient Sample was queried to identify hospital discharge records of patients aged ≥18 years who underwent urgent surgical repair of ATAAD between 2017 and 2018. Patients with a diagnosis of thoracic aortic dissection, who underwent surgical intervention of the ascending aorta, were identified. Patient demographics were assessed, and predictors of in-hospital mortality were identified.

Results

We identified 7805 weighted cases of surgically repaired ATAAD nationally, with an overall mortality of 15.3%. Mean age was 60.0 ± 13.6 years. There was a male predominance, although female subjects made up a larger proportion of older age groups—female subjects up 18.4% of patients younger than 40 years with ATAAD but 53.6% of patients older than 80 years. In multivariable analysis controlling for sex, race, comorbidities, and malperfusion, age was a significant predictor of mortality. Patients aged 71 to 80 years had a 5.3-fold increased risk of mortality compared with patients ≤40 years old (P < .001), and patients aged >80 years had a 6.8-fold increased risk of mortality (P < .001). Sex was not significantly associated with mortality.

Conclusions

Surgical repair of ATAAD continues to carry high risk of morbidity and mortality, with outcomes impacted significantly by patient age, regardless of patient comorbidity burden.

Robotic-assisted closed-chest management of a fungal-infected prosthetic aortic graft: a case report

Background

Fungal prosthetic graft infections are associated with high mortality, typically requiring aggressive surgical debridement. We present an alternative, minimally invasive approach to address these challenging clinical cases.

Case presentation

A 76-year-old Caucasian male with prior aortic root and arch replacement presented with localized chest wall tenderness after being hit by a car door. Computed tomography angiogram incidentally identified fluid in the anterior mediastinum, surrounding his ascending aortic graft. Rather than undertaking a high-risk reoperative sternotomy and redo complex aortic reconstruction, we elected to proceed with a robotic-assisted, minimally invasive debridement of the aortic graft, coupled with an omental wrap, entirely within the closed chest. Microbiology was positive for Aspergillus species. The patient made an uncomplicated recovery and was discharged home on antifungal therapy, likely to continue indefinitely.

Conclusions

Infected prosthetic aortic grafts can be successfully managed with debridement and pedicled omental flap coverage via a minimally invasive approach within the closed chest, obviating the morbidity of a complex reoperative open procedure.

Transfusion in Root Replacement for Aortic Dissection: STS Adult Cardiac Surgery Database Analysis

BACKGROUND

Transfusion in acute aortic syndromes has been studied in a limited fashion. We sought to describe contemporary transfusion practice for root replacement in acute (Stanford) type A aortic dissection (ATAAD).

METHODS

The STS Adult Cardiac Surgery Database was interrogated to identify patients who underwent primary aortic root replacement for ATAAD (July 2014 - June 2017). Patients (n = 1558) were stratified by type of root replacement. Multivariate regression was used to determine those variables associated with transfusion and postoperative morbidity.

RESULTS

Transfusion was required in 90.5% of cases (n = 1410). Operative mortality for all patients was 17.3% (261 deaths). Intraoperative red blood cell (RBC) transfusion portended reduced short-term survival (odds ratio {OR} 2.00, p = 0.025). Massive postoperative transfusion was associated with prolonged ventilation (OR 13.47, p < 0.001), sepsis (OR 4.13, p < 0.001), and new dialysis-dependent renal-failure (OR 2.43, p < 0.001). Females were more likely to require transfusion (OR 3.03, p < 0.001), as were patients who had coronary bypass (OR 1.57, p = 0.009), and those in shock (OR 2.27, p < 0.001). Valve-sparing aortic root replacement (VSARR) was associated with reduced transfusion requirements vs. composite roots. Institutional case volume was not appreciably correlated with transfusion.

CONCLUSIONS

Most patients undergoing root replacement for aortic dissection require blood products. Composite root replacement is associated with a greater likelihood of transfusion than a valve-sparing operation. Transfusion independently foreshadows greater operative mortality.

Lifetime management for aortic stenosis: Planning for future therapies

A shift to lifetime management has gained more focus with the approval of low-risk transcatheter aortic valve replacement (TAVR). This paper is therefore focused on the different approaches for lifetime management. Herein we discuss the procedural safety, durability, performance, and future options for each lifetime management strategy. In younger patients that elect to undergo surgical aortic valve replacement (SAVR), options for bioprosthetic failure are TAV-in-SAV or redo SAVR. Among patients that undergo TAVR, options for valve failure include TAVR explant with SAVR or TAV-in-TAV. Additionally, there are patients who may require a third valvular intervention. The initial therapy may limit re-intervention options down the road. This review discusses how options for future therapies affect the decision of SAVR vs TAVR in younger patients.

Management of acute type A aortic dissection in the elderly: an analysis from IRAD

OBJECTIVES

We sought to examine management and outcomes of (Stanford) type A aortic dissection (TAAAD) in patients aged >70 years.

METHODS

All patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection database (1996-2018) were studied (n = 5553). Patients were stratified by age and therapeutic strategy. Outcomes for octogenarians were compared with those for septuagenarians. Variables associated with in-hospital mortality were identified by multivariable logistic regression.

RESULTS

In-hospital mortality for all patients (all ages) was 19.7% (1167 deaths), 16.1% after surgical intervention vs 52.1% for medical management (P < 0.001). Of the study population, 1281 patients (21.6%) were aged 71-80 years and 475 (8.0%) were >80 years. Fewer octogenarians underwent surgery versus septuagenarians (68.1% vs 85.9%, P < 0.001). Overall mortality was higher for octogenarians versus septuagenarians (32.0% vs 25.6%, P = 0.008); however, surgical mortality was similar (25.1% vs 21.7%, P = 0.205). Postoperative complications were comparable between surgically managed cohorts, although reoperation for bleeding was more common in septuagenarians (8.1% vs 3.2%, P = 0.033). Kaplan-Meier 5-year survival was significantly superior after surgical repair in all age groups, including septuagenarians (57.0% vs 13.7%, P < 0.001) and octogenarians (35.5% vs 22.6%, P < 0.001).

CONCLUSIONS

When compared with septuagenarians, a smaller percentage of octogenarians undergo surgical repair for TAAAD, even though postoperative outcomes are similar. Age alone should not preclude consideration for surgery in appropriately selected patients with TAAAD.

Transfusion in Elective Proximal Aortic Reconstruction: Where Do We Currently Stand?

Aortic procedures are associated with higher risks of bleeding, yet data regarding perioperative transfusion in this patient population are lacking. We evaluated transfusion patterns in patients undergoing proximal aortic surgery to provide a benchmark against which future standards can be assessed. Between June 2014 and July 2017, 247 patients underwent elective aortic reconstruction for aneurysm. Patients with acute aortic syndrome, endocarditis, and/or prior cardiac surgery were excluded. Transfusion data were analyzed by type of operation: ascending aorta replacement ± aortic valve procedure (group 1, n  = 122, 49.4%); aortic root replacement with a composite valve-graft conduit ± ascending aorta replacement (group 2, n  = 93, 37.7%); valve-sparing aortic root replacement (VSARR) ± ascending aorta replacement (group 3, n  = 32, 13.0%). Thirty-day mortality for the entire cohort was 2.02% (5 deaths). Overall, 75 patients (30.4%) did not require any transfusion of blood or other products. Patients in groups 1 and 3 were significantly more likely to avoid transfusion than those in group 2. Mean transfusion volume for any individual patient was modest; those who underwent VSARR (group 3) required less intraoperative red blood cells (RBC) than others. Intraoperative transfusion of RBC was independently associated with an increased risk of death at 30 days. Elective proximal aortic reconstruction can be performed without the need for excessive utilization of blood products. Composite root replacement is associated with a greater need for transfusion than either VSARR or isolated replacement of the ascending aorta.

Type A Acute Aortic Dissection Presenting With Cerebrovascular Accident at Advanced Age

Our aim was to analyze outcomes of patients aged 70 years or above presenting with type A acute aortic dissection (TAAAD) and cerebrovascular accident (CVA). A retrospective analysis of the International Registry of Acute Aortic Dissection (IRAD) was conducted. Patients aged 70 years or above (n = 1449) were stratified according to presence or absence of CVA before surgery (CVA: n = 110, 7.6%). In-hospital outcomes and mortality up to 5 years were analyzed. Additionally, in-hospital outcomes of patients who received medical management were described. No patient presenting with CVA over the age of 87 years underwent surgery. The rates of in-hospital mortality and post-operative CVA were significantly higher in patients presenting with CVA (in-hospital mortality: 32.7% vs 21.7%, P = 0.008; post-operative CVA: 23.4% vs 8.3%, P < 0.001). Presence of CVA was independently associated with significantly increased in-hospital mortality (odds ratio 2.99, 95% confidence interval 1.35 - 6.60, P = 0.007). In survivors of the hospital stay, presenting CVA had no independent influence on mortality up to 5 years (hazard ratio 1.52, 95% confidence interval 0.99 - 2.31, P = 0.54). In medically managed patients, exceedingly high rates of in-hospital mortality (71.4%) and CVA (90.9%) were noted. Patients presenting with TAAAD and CVA at ≥ 70 years of age are at significantly increased risk of in-hospital mortality, although long-term mortality is not affected in hospital survivors. Medical management is associated with poor outcomes. We believe that surgical management should be offered after critical assessment of comorbidities.

Sex-Based Aortic Dissection Outcomes From the International Registry of Acute Aortic Dissection

BACKGROUND

Worse outcomes have been reported for women with type A acute aortic dissection (TAAD). We sought to determine sex-specific operative approaches and outcomes for TAAD in the current era.

METHODS

The Interventional Cohort (IVC) of the International Registry of Acute Aortic Dissection (IRAD) database was queried to explore sex differences in presentation, operative approach, and outcomes. Multivariable logistic regression was performed to identify adjusted outcomes in relation to sex.

RESULTS

Women constituted approximately one-third (34.3%) of the 2823 patients and were significantly older than men (65.4 vs 58.6 years, P < .001). Women were more likely to present with intramural hematoma, periaortic hematoma, or complete or partial false lumen thrombosis (all P < .05) and more commonly had hypotension or coma (P = .001). Men underwent a greater proportion of Bentall, complete arch, and elephant trunk procedures (all P < .01). In-hospital mortality during the study period was higher in women (16.7% vs 13.8%, P = .039). After adjustment, female sex trended towards higher in-hospital mortality overall (odds ratio, 1.40; P = .053) but not in the last decade of enrollment (odds ratio, 0.93; P = .807). Five-year mortality and reintervention rates were not significantly different between the sexes.

CONCLUSIONS

In-hospital mortality remains higher among women with TAAD but demonstrates improvement in the last decade. Significant differences in presentation were noted in women, including older age, distinct imaging findings, and greater evidence of malperfusion. Although no distinctions in 5-year mortality or reintervention were observed, a tailored surgical approach should be considered to reduce sex disparities in early mortality rates for TAAD.

Moderate Versus Deep Hypothermia in Type A Acute Aortic Dissection Repair: Insights from the International Registry of Acute Aortic Dissection

BACKGROUND

The optimal strategy for cerebral protection during repair of type A acute aortic dissection has yet to be determined. We sought to determine the impact of differing degrees of hypothermia in patients undergoing acute dissection repair.

METHODS

All patients in the International Registry of Acute Aortic Dissection Interventional Cohort database who underwent type A acute aortic dissection repair between 2010 and 2018 were identified. Data for operative temperature were available for 1962 patients subsequently divided into 2 groups according to lowest temperature: moderate hypothermic circulatory arrest (MHCA) (20-28°C) versus deep hypothermic circulatory arrest (DHCA) (<20°C). We then propensity matched 362 pairs of patients and analyzed operative data and short-term outcomes.

RESULTS

The median lowest temperature was 25.0°C in the matched MHCA group as compared with 18.0°C in the DHCA group. For the entire cohort of 1962 patients, in-hospital mortality was 14.2% (278 deaths) but was not significantly different between DHCA and MHCA. The perioperative stroke rate was comparable between groups, before and after propensity matching. Circulatory arrest times were significantly longer in the MHCA cohort, regardless of matching. Use of antegrade or retrograde cerebral perfusion was similar in matched groups. There were no differences in 30-day survival or in other major postoperative morbidity between the 2 matched cohorts.

CONCLUSIONS

A surgical strategy of MHCA + antegrade cerebral perfusion is at least as safe as DHCA during repair of acute type A aortic dissection.

Preoperative multidetector computed tomography for isolated surgical aortic valve replacement: Planning for future transcatheter options

BACKGROUND

Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has become a valuable option in patients with bioprosthetic failure. However, potential issues with ViV TAVR may occur in patients with high-risk anatomy for coronary obstruction and patients with baseline smaller bioprosthetic valves at risk for patient prosthesis mismatch. The purpose of this study was, therefore, to use preoperative electrocardiography-gated, multidetector computed tomography (MDCT) in patients undergoing isolated surgical aortic valve replacement (SAVR) to (1) identify which would be high risk for coronary occlusion with ViV TAVR, and (2) predict intraoperative SAVR sizing.

METHODS

Among 223 patients from our institutions' database that underwent SAVR for aortic insufficiency (AI) or aortic stenosis (AS) between January 2012 and January 2020, 48 patients had MDCT imaging before surgery (AI; n = 31, AS; n = 17). Of all patients, 67% (n = 32) were bicuspid morphology.

RESULTS

With the use of virtual valve implantation, all patients with AI and bicuspid AS had feasible anatomy for ViV TAVR, while 38% of patients with tricuspid AS were high risk for coronary obstruction. There was a strong correlation between actual valve size implanted and preoperative MDCT measurements using annulus average diameter, area, and/or perimeter.

CONCLUSION

Preoperative MDCT in patients undergoing SAVR is a useful tool for lifetime management, particularly in patients with tricuspid AS. Decisions for surgical management may change based on MDCT's ability to predict intraoperative SAVR size and determine which patients may be high-risk candidates for future ViV TAVR due to coronary artery obstruction.

Time of day does not influence outcomes in acute type A aortic dissection: Results from the IRAD

BACKGROUND

Type A acute aortic dissection (TAAAD) represents a surgical emergency requiring intervention regardless of time of day. Whether such a "evening effect" exists regarding outcomes for TAAAD has not been previously studied using a large registry data.

METHODS

Patients with TAAAD were identified from the International Registry of Acute Aortic Dissections (1996-2019). Outcomes were compared between patients undergoing operative repair during the daytime (D), defined as 8 am-5 pm, versus the evening (N), defined as 5 pm-8 am.

RESULTS

Four thousand one-hundrd and ninety-seven surgically treated patients with TAAAD were identified, with 1824 patients undergoing daytime surgery (43.5%) and 2373 patients undergoing evening surgery (56.5%). Daytime patients were more likely to have undergone prior cardiac surgery (13.2% vs. 9.5%; p < .001) and have had a prior aortic dissection (4.8% vs. 3.4%; p = .04). Evening patients were more likely to have been transferred from a referring hospital (70.8% vs. 75.0%; p = .003). Daytime patients were more likely to undergo aortic valve sparing root procedures (23.3% vs. 19.2%; p = .035); however, total arch replacement was performed with equal frequency (19.4% vs. 18.8%; p = .751). In-hospital mortality (D: 17.3% vs. N. 16.2%; p = .325) was similar between both groups. Subgroup analysis examining the effect of weekend presentation revealed no significant mortality difference.

CONCLUSIONS

A majority of TAAAD patients underwent surgical repair at night. There were higher rates of postoperative tamponade in evening patients; however, mortality was similar. The expertise of cardiac-dedicated operative and critical care teams regardless of time of day as well as training paradigms may explain similar mortality outcomes in this high risk population.

The use of innominate artery cannulation for antegrade cerebral perfusion in aortic dissection

BACKGROUND

Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in acute aortic dissection.

METHODS

A multi-institutional retrospective review was undertaken of patients who underwent proximal aortic reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate artery cannulation for selective antegrade cerebral perfusion were selected for analysis.

RESULTS

Seventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections. Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n = 11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean hypothermic circulatory arrest time was 19 ± 13 min. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke occurred in 7 patients (9.3%).

CONCLUSIONS

This study is the first comprehensive review of direct innominate artery cannulation through median sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for delivering selective antegrade cerebral perfusion in these cases.

Acute Type A Aortic Dissection Repair After Hours: Does It Influence Outcomes?

BACKGROUND

Time of day has been associated with adverse outcomes in certain surgical pathologies. Because acute type A aortic dissection typically mandates immediate repair, relatively little attention has been paid to the potential impact of the day-night timing of the operation itself. We sought to determine whether patients with acute dissection treated during typical working hours demonstrated a difference in outcomes compared with those who required surgery after hours.

METHODS

We undertook a comprehensive review of our prospectively collected database from July 2014 to October 2018. A total of 164 consecutive patients underwent primary repair of an acute type A dissection. Based on the procedure start time, patients were divided into 2 groups: working hours (7 am to 4 pm, Monday to Friday; n = 60), and after hours (all other times, including weekends and holidays; n = 104). We propensity-matched 58 pairs of patients and analyzed perioperative data and short-term clinical outcomes.

RESULTS

Thirty-day mortality for all 164 patients was 10.4% (17 deaths), which was not significantly different between the matched groups (working-hours: 8 deaths [13.8%] versus after hours: 4 deaths [6.9%]; P = .36). Perfusion, cross-clamp, and circulatory arrest times did not differ between groups, nor did the types of aortic repairs performed. Postoperative complications were also comparable, including stroke, reoperation for bleeding, and new-onset renal failure requiring dialysis.

CONCLUSIONS

Thirty-day mortality and major morbidity after acute type A dissection repair are independent of when the operation is performed. Expeditious surgical intervention is recommended for all primary acute type A dissection, irrespective of time of day.

Necrotizing Infection of the Aortic Arch: Reconstruction Utilizing Unusual Extra-anatomic Bypass Grafts to Reroute Cerebral Blood Flow

Destructive infections of the aortic arch and great vessels are challenging to manage. We describe a novel technique for debranching the right cerebral and upper extremity arteries via composite extra-anatomic bypasses from the femoral artery, with subsequent homograft in-line reconstruction of the arch, in a patient with Staphylococcus sepsis and necrosis of the arch and great vessels.

Hybrid Minimally Invasive Approach for Combined Obstructive Coronary Artery Disease and Severe Aortic Stenosis

OBJECTIVE

There is a high prevalence of concomitant coronary artery disease (CAD) and aortic stenosis (AS), and these conditions can be treated with a variety of invasive and/or percutaneous approaches. The aim of this study is to demonstrate the feasibility, efficacy, and safety of a staged transcatheter aortic valve replacement (TAVR) after a hybrid minimally invasive direct coronary artery bypass surgery (MIDCAB) to treat combined complex CAD and AS.

METHODS

Six patients with concomitant CAD and severe AS underwent staged treatment of their CAD with MIDCAB and TAVR. All patients had significant complex left main or left anterior descending artery (LAD) stenosis deemed to be not amenable to percutaneous coronary intervention (PCI).

RESULTS

The average syntax score was 22±8 and the Society of Thoracic Surgeons score for surgical AVR was 8±3%. All patients underwent a single vessel MIDCAB for revascularization of the LAD (three patients required additional PCI for non-LAD disease). Two patients had pre-TAVR balloon aortic valvuloplasty and one patient also required treatment of severe mitral valve regurgitation with percutaneous edge-to-edge repair (the MitraClip). There was no intraprocedural or hospital mortality. No neurological deficits or vascular complications were recorded.

CONCLUSIONS

A hybrid staged approach for combined complex CAD and severe AS with MIDCAB, PCI, and TAVR is a valid option in high-risk patients. The order and timing of these procedures must be tailored to the patient's clinical symptoms, stability, and severity of disease.

Aortic Pseudoaneurysm Causing Compression of the Left Main Coronary Artery

A 75-year-old man with a history of mechanical aortic valve replacement with aortic conduit for severe aortic insufficiency underwent routine screening computed tomography evaluation revealing right coronary anastomosis endoleak and proximal aortic root pseudoaneurysm.

Aortic Cannulation in DeBakey Type I Aortic Dissection Facilitates Subsequent Deployment of a Frozen Elephant Trunk

Arterial cannulation in acute DeBakey type I dissection can be difficult. Moreover, the residual dissected aorta is susceptible to further adverse events in the future. Implanting a stent-graft into the descending aorta during the initial dissection repair ('frozen elephant trunk') has been demonstrated to promote favourable aortic remodelling, mitigating some of these longer-term complications. We describe a technique for cannulation of the ascending aorta in acute dissection that facilitates expeditious antegrade deployment of a frozen elephant trunk.

Rethinking the Paradigm: Modern Approach to Proximal Aortic Reconstruction Demonstrates Excellent Outcomes

Background: Techniques for aortic surgery continue to evolve. A real-world snapshot of patients undergoing elective surgery for aneurysm in the modern era is helpful to assist in deciding the appropriate timing for intervention. We herein describe our experience with 100 consecutive patients who underwent primary elective surgery for aneurysm of the proximal thoracic aorta over a two-year period at a single institution.Methods: The majority of our patients were male, mean age 61.19 ± 13.33 years. Two patients had Marfan syndrome. Twenty-eight patients had bicuspid aortic valve. Thirty-four patients underwent aortic root replacement utilizing a composite valve/graft conduit; 23 had valve-sparing root replacements. The ascending aorta was replaced in 89 patients; 80 (89.9%) of these included a period of circulatory arrest at moderate hypothermia utilizing unilateral selective antegrade cerebral perfusion.Results: Thirty-day mortality was zero. Perioperative stroke occurred in 2 patients, both of whom completely recovered prior to discharge. No patients required re-exploration for bleeding. One patient developed a sternal wound infection. Fifteen patients required readmission to hospital within thirty days of discharge.Conclusion: Elective surgery for aneurysm of the proximal aorta is safe, reproducible, and is associated with outcomes that are superior to those seen in an acute aortic syndrome. It may be appropriate to offer surgery to younger patients with proximal aortic aneurysms at smaller diameters, even if their aortic dimensions do not yet meet traditional guidelines for surgical intervention.

Undersized Stent Grafts for Acute Mesenteric Ischemia in Chronic Type B Dissection

Acute ischemia in chronic type B dissections carries high rates of morbidity and mortality. A 29-year-old woman with a chronic type B dissection presented with acute abdominal pain. Imaging revealed a worsening dissection with pseudocoarctation causing near complete occlusion of the true lumen by the false lumen. We placed purposefully undersized stent grafts to treat acute mesenteric ischemia by improving true lumen flow. The patient was discharged on postoperative day 4 without adverse events. We suggest that endovascular rescue by placing undersized stent grafts can provide improved flow to the mesenteric vessels with continued false lumen flow to vital organs.

The use of CorMatrix extracellular matrix for aortic root enlargement

This manuscript presents a published record of the use and efficacy of the extracellular matrix CorMatrix and why it may be superior to other materials used for aortic root enlargement. The potential benefits of an extracellular matrix are the natural ingrowth and development of native arterial cells and structure.

Endovascular treatment of a malpositioned screw in the thoracic aorta after anterior spinal instrumentation: the screwed aorta

An interesting case report detailing the management of an aorta that was inadvertently screwed during spinal fixation. The management and imaging encompass the use of computer tomography and intravascular ultrasound to determine the trajectory of the screw and the successful management of the patient.

Aggressive progression of penetrating atheromatous ulcer of the descending thoracic aorta

The treatment of acute aortic pathologies continues to evolve with enhanced imaging capabilities. This case report highlights the rapid progression of penetrating atherosclerotic ulcer to pseudoaneurysm development and subsequent treatment with thoracic endovascular stent graft.