Integrated Aortic-Valve-And-Ascending-Aortic Replacement vs. Partial Replacement in Bicuspid Aortic Valve-Related Aortopathy

Objective: We sought to evaluate the outcomes of integrated aortic-valve and ascending-aortic replacement (IR) vs. partial replacement (PR) in patients with bicuspid aortic valve (BAV)-related aortopathy.Methods: We compared long-term mortality, reoperation incidence, and the cumulative incidence of stroke, bleeding, significant native valve or prosthetic valve dysfunction, and the New York Heart Association (NYHA) functional classes II-IV between inverse probability-weighted cohorts of patients who underwent IR or PR for BAV-related aortopathy in a single center from 2002 to 2019. Patients were stratified into different aortic diameter groups (“valve type” vs. “aorta type”).Results: Among patients with “valve type,” aortic valve replacement in patients with an aortic diameter > 40 mm was associated with significantly higher 10-year mortality than IR compared with diameter 35–40 mm [17.49 vs. 5.28% at 10 years; hazard ratio (HR), 3.22; 95% CI, 1.52 to 6.85; p = 0.002]. Among patients with “aorta type,” ascending aortic replacement in patients with an aortic diameter 52–60 mm was associated with significantly higher 10-year mortality than IR compared with diameter 45–52 mm (14.49 vs. 1.85% at 10 years; HR, 0.04; 95% CI, 1.06 to 85.24; p = 0.03).Conclusion: The long-term mortality and reoperation benefit that were associated with IR, as compared with PR, minimizing to 40 mm of the aortic diameter among patients with “valve type” and minimizing to 52 mm of the aortic diameter among patients with “aorta type.”Trial Registration: Treatment to Bicuspid Aortic Valve Related Aortopathy (BAVAo Registry): ChiCTR.org.cn no: ChiCTR2000039867.

Hybrid Repair with Reversed Sequence Supra-aortic Debranching in Ruptured Arch Aneurysm

Aortic arch pathology in a high-risk patient in whom the resternotomy approach is unfeasible due to treated mediastinitis after ascending aortic replacement presents a unique challenge for hybrid arch repair (HAR) because of the need for supra-aortic debranching from unusual inflow sites other than the ascending aorta. This report describes a “reversed sequence” extra-anatomical supra-aortic debranching procedure as a salvage technique performed to enable HAR. An 83-year-old woman with a history of ascending aortic replacement for type A aortic dissection, mediastinitis complicated by sternal osteomyelitis, and a chest wall reconstructed with a rectus abdominis myocutaneous flap presented with chest pain because of a contained dissecting arch aneurysm rupture. The patient underwent supra-aortic debranching from the bilateral common femoral arteries and thoracic endovascular aortic repair to the ascending aorta under cerebral near-infrared spectroscopy (NIRS) monitoring. Completion imaging by angiography demonstrated successful exclusion of the ruptured aneurysm. The regional cerebral oxygen saturation level, monitored by NIRS, did not change markedly during surgery. The patient was neurologically intact with adequate cerebral blood flow assessed postoperatively by 123I-IMP single photon emission computed tomography. Total debranching of the supra-aortic vessels from the common femoral artery for inflow is feasible and provides adequate cerebral perfusion. This procedure may offer an alternative treatment option in patients with complex conditions involving aortic arch pathology.

Word of caution on adding hemiarch replacement to a proximal aortic aneurysm repair: long-term outcome analysis of over 1,000 patients

Background There is no consensus nor recommendation for the surgical management of a minimally dilated adjacent aortic segment, such as the proximal aortic arch, at the time of proximal aortic aneurysm repair. Consequently, clinical equipoise exists regarding whether to extend the proximal aortic aneurysm repair to include the proximal aortic arch, by performing a hemiarch replacement, to mitigate the future risk of aortic aneurysm-related events in the proximal aortic arch. We hypothesized that additional hemiarch replacement to excise a non- or minimally aneurysmal proximal aortic arch does not have clinical benefit in patients undergoing proximal aortic aneurysm repair. Purpose To compare the long-term survival and freedom from aortic-arch reoperation in patients undergoing proximal aortic aneurysm repair with and without additional hemiarch replacement. Methods A retrospective review was performed of all patients undergoing proximal aortic aneurysm repair at our Aortic Center between 2005 and 2019. Inclusion criteria included all patients with a diagnosed root or ascending aortic aneurysm undergoing root or ascending aortic replacement with or without hemiarch replacement. Exclusion criteria were Age <18 years, presence of aortic arch diameter ≥4.5 cm, type A aortic dissection, previous ascending aortic replacement, aneurysm rupture, and endocarditis. A total of 1132 patients (hemiarch =307) met inclusion criteria. Propensity score matching in a 2:1 ratio (573 non-hemiarch: 288 hemiarch) on 19 baseline characteristics was performed. The median follow-up was 29.7 months (range: 0.1–153.8 months). Results Hemiarch patients had a significantly lower 10-year survival rate (86.7%; 95% CI, 79.2–94.8 in non-hemiarch vs 81.9%; 95% CI, 75.9–88.3 in hemiarch; P=0.005). There was no significant difference in 10- year cumulative incidence of aortic-arch reintervention (0.7%; 95% CI, 0.3–1.9 in non-hemiarch vs 0.69%; 95% CI, 0.17–2.75 in hemiarch; P=0.99). Hemiarch patients had higher rates of in-hospital mortality (1% in non-hemiarch vs 4% in hemiarch; P<0.001), stroke (3% in non-hemiarch vs 6% in hemiarch; P=0.047), reoperation for bleeding (4% in non-hemiarch vs 9% in hemiarch; P=0.011), and respiratory failure (7% in non-hemiarch vs 13% in hemiarch; P=0.006). In multivariable COX analysis, hemiarch replacement was significantly associated with long-term mortality (HR, 2.19; 95% CI, 1.36–3.55; P<.001) but not with aortic-arch reintervention (HR, 1.14; 95% CI, 0.63–2.10, P=0.66). Conclusions Proximal aortic aneurysm repair with additional hemiarch was associated with higher mortality without a decrease in aortic-arch reintervention rates compared to isolated proximal aortic aneurysm repair. Furthermore, aortic arch reintervention rate was extremely low. These data call for caution in adding hemiarch replacement at the time of proximal aortic aneurysm repair. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Heath (NIH) 5T35HL007616-40 grant Matched Cohort: KM Survival Curve Matched Cohort: Cumulative Incidence

Systolic anterior motion of the mitral valve associated with acute type A aortic dissection: a case report describing one-step surgery of ascending aortic replacement and interventricular septal myectomy

Background Systolic anterior motion of the mitral valve associated with acute type A aortic dissection is rare in daily clinical practice. The prevention of systolic anterior motion is important, because once it occurs, the hemodynamics may become unstable, leading to a critical situation. In the surgical procedure to treat systolic anterior motion, the prevention of new iatrogenic aortic intimal tears is important in the context of acute type A aortic dissection. Case presentation We present a case of systolic anterior motion in a 68-year-old woman with an acute type A aortic dissection and suspected acute relative adrenal insufficiency. Preoperative transthoracic echocardiography revealed left ventricular outflow tract obstruction due to systolic anterior motion without left ventricular hypertrophy and interventricular septal bulging due to a narrow aorto-mitral angle. We successfully performed a one-step surgery for ascending aortic replacement and interventricular septal myectomy using the needle stick technique for the treatment of systolic anterior motion. Conclusions Concomitant interventricular septal myectomy using the needle stick technique with thoracic aortic replacement is a safe and feasible technique. Interventricular septal myectomy may be effective in preventing postoperative unstable hemodynamics due to systolic anterior motion in the management of acute aortic dissection.

Sutureless aortic valve with supracoronary ascending aortic replacement as an alternative strategy for composite graft replacement in elderly patients

Aortic valve disease is frequently associated with ascending aorta dilatation and can be treated either by separate replacement of the aortic valve and ascending aorta or by a composite valve graft. The type of surgery is depending on the exact location of the aortic dilatation and the concomitant valvular procedures required. The evidence for elective aortic surgery in elderly high-risk patients remains challenging and therefore alternative strategies could be warranted. We propose an alternative strategy for the treatment of ascending aortic aneurysm and aortic valve pathology with the use of a sutureless, collapsible, stent-mounted aortic valve prosthesis.

Surgical Aortic Arch Intervention at the time of Extended Ascending Aortic Replacement is Associated with Increased Mortality

Objective: To compare outcomes of hemiarch versus total arch repair during extended ascending aortic replacement. Methods: Between 2004 and 2017, 261 patients underwent hemiarch (n=149, 57%) or total arch repair (aortic debranching or Carrell patch technique, n=112, 43%) in the setting of extended replacement of the ascending aorta. Median follow-up was 17.2 (IQR 4.2–39.1) months. Multivariable models considering preoperative and intraoperative factors associated with mortality and aortic reintervention were constructed. Results: Survival was 89.0, 81.3, and 73.5% vs. 76.4, 69.5, and 61.7% at 1, 3, and 5 years in the hemiarch versus total arch groups, respectively (log-rank p=0.010). After adjustment for preoperative and intraoperative factors, the presence of a total arch repair (adjusted HR 2.53, 95% CI 1.39 – 4.62, p=0.003), and increasing age (adjusted HR per 10 years of age, 1.76, 95% CI 1.37 – 2.28, p<0.001) were associated with increased mortality. The cumulative incidence of aortic reintervention with death as a competing outcome was 2.6, 2.6, and 4.4% and 5.0, 10.3, and 11.9% in the hemiarch and total arch groups, respectively. After adjustment, the presence of a total arch repair was significantly associated with need for aortic reintervention (SHR 3.21, 95% CI 1.01 – 10.2, p=0.047). Conclusions: Overall survival after aortic arch repair in the setting of extended ascending aortic replacement is excellent, however, total arch repair and increasing age are associated with higher mortality and reintervention rates. A conservative approach to aortic arch repair can be prudent, especially in those of advanced age.

Endovascular Stent-Graft Repair of the Ascending Aorta: Assessment of a Specific Novel Stent-Graft Design in Phantom, Cadaveric, and Clinical Application

Purpose To test a stent-graft specifically designed for the ascending aorta in phantom, cadaver, and clinical application, and to measure deployment accuracy to overcome limitations of existing devices. Methods A stent-graft has been designed with support wires to fixate the apices toward the inner curvature, thereby eliminating the forward movement of the proximal end which can happen with circumferential tip capture systems. The device was deployed in three aortic phantoms, and in four cadavers, deployment precision was measured. Subsequently, the device was implanted in a patient to exclude a pseudoaneurysm originating from the distal anastomosis after ascending aortic replacement. Results The stent-grafts were successfully deployed in all phantoms and cadavers. Deployment accuracy of the proximal end of the stent-graft was within 1 mm proximally and 14 mm distally to the intended landing zone on the inner curvature, and 2–8 mm distal to the intended landing zone on the outer curvature. In clinical application, the pseudoaneurysm could be successfully excluded without complications. Conclusion The novel stent-graft design promises accurate placement in the ascending aorta. The differential deployment of the apices at the inner and outer curvatures allows deployment perpendicular to the aortic axis. Level of Evidence No level of evidence.

Bentall–de Bono procedure for acute aortic dissection

We present a patient with an acute type A aortic dissection that involves the aortic root. The high mortality of patients with this condition is often associated with operations performed by surgeons with minimal experience dealing with aortic diseases. Therefore, less-experienced surgeons often opt for less complicated techniques like supracoronary ascending aortic replacement. However, according to the latest guidelines for the management of aortic diseases, the aortic root should be replaced when it is compromised by the dissection. The Bentall–de Bono technique treats the aortic root and demands less experience than valve-sparing aortic surgery.