In Germany, the use of TAVR increased substantially between 2007 and 2013, whereas the use of surgical aortic-valve replacement decreased modestly. Patients undergoing TAVR were older and at higher ...operative risk. Mortality decreased over time in both groups.
Surgical aortic-valve replacement was a major clinical advance in the 1960s
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and offered a cure for aortic stenosis, a condition for which no disease-modifying pharmacologic therapy is available. Surgical replacement remained the only treatment option until 2007, when devices for transcatheter aortic-valve replacement (TAVR) were approved.
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Since then, TAVR has become established not only as an effective therapy for patients for whom surgery is not an option
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but also as an alternative for high-risk patients.
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The introduction of TAVR has led to questions about the effect of this relatively new approach on current clinical practice and its effect on surgical . . .
The frozen elephant trunk (FET) procedure has emerged as a potential single-step treatment for pathologies of the thoracic aorta, but the procedure's true potential to be a single-step treatment ...remains unclear. The aim of this study was to evaluate the need and outcomes of aortic reinterventions after previous FET implantation.
Patient characteristics and follow-up data of 107 patients following the FET procedure were evaluated and compared between patients with and without aortic reinterventions. A competing risk regression model was analyzed to identify independent predictors of aortic reintervention and to predict the risk for reintervention.
Intended completion, anticipated reinterventions, and unexpected reinterventions were performed in 35 patients (33%). There was no difference in the underlying pathology between patients with or without aortic reintervention. An endovascular reintervention was performed in 24 patients (69%), open surgery in 7 patients (20%) and a hybrid approach in 4 patients (11%). No stroke or permanent spinal cord injuries were observed. In-hospital mortality after reintervention was 14% (5 patients), but there was no difference in survival during follow-up after FET implantation (log rank test, P = .58). No risk factors for aortic reinterventions were identified. The risk for aortic reintervention was 31% (95% confidence interval CI, 21%-42%), 49% (95% CI, 35%-62%), and 64% (95% CI, 44%-79%) after 12, 24, and 36 months, respectively.
Aortic reinterventions are common and likely after FET implantation, but this study did not identify independent predictors. Reinterventions are associated with acceptable morbidity and mortality. Close follow-up of all patients undergoing FET procedure is paramount.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective The aim of our study was to delineate the effect of aortic arch surgery extension on the outcomes in acute type A dissection extending beyond the ascending aorta. Methods From 2001 to 2013, ...of 197 patients with type A dissection, 153 (78%) with dissection extending beyond the ascending aorta (age, 61 years; first quartile, 50; third quartile, 69; 67% men) were identified. Aortic repair involved isolated ascending replacement (n = 102), hemiarch (n = 37), and total arch replacement (n = 14). The median follow-up period was 4.9 years (first quartile, 2.5; third quartile, 7.6; 733 patient-years). Results In-hospital mortality was 9.8%, 21.6%, and 28.6% ( P = .122) for patients with no, hemiarch, and total arch replacement. Age > 80 years (odds ratio OR, 9.37; P = .006), malperfusion syndrome (OR, 4.74; P = .004), and total arch replacement (OR, 6.47; P = .016) were independent predictors of perioperative mortality. Freedom from distal reintervention was 93% ± 3%, 97% ± 3%, and 100% at 1 year and 89% ± 3%, 97% ± 3%, and 100% at 5 years for the no, hemiarch, and total arch replacement groups, respectively (log-rank, P = .440). Marfan syndrome (OR, 12.40; P = .038) and dissection of all aortic segments (OR, 10.68; P = .007) predicted distal aortic reintervention. In-hospital mortality for elective reintervention was 0%. Conclusions Limiting the extent of surgery for type A aortic dissection to ascending aortic replacement was associated with low perioperative mortality. Thus, aortic arch repair can be deferred, because it can be performed electively with a lower mortality risk.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract
OBJECTIVES
The goal was to develop a scoring system to predict the 30-day mortality rate for patients undergoing surgery for acute type A aortic dissection on the basis of the German ...Registry for Acute Type A Aortic Dissection (GERAADA) data set and to provide a Web-based application for standard use.
METHODS
A total of 2537 patients enrolled in GERAADA who underwent surgery between 2006 and 2015 were analysed. Variable selection was performed using the R-package FAMoS. The robustness of the results was confirmed via the bootstrap procedure. The coefficients of the final model were used to calculate the risk score in a Web-based application.
RESULTS
Age odds ratio (OR) 1.018, 95% confidence interval (CI) 1.009–1.026; P < 0.001; 5-year OR: 1.093, need for catecholamines at referral (OR 1.732, 95% CI 1.340–2.232; P < 0.001), preoperative resuscitation (OR 3.051, 95% CI 2.099–4.441; P < 0.001), need for intubation before surgery (OR 1.949, 95% CI 1.465–2.585; P < 0.001), preoperative hemiparesis (OR 1.442, 95% CI 0.996–2.065; P = 0.049), coronary malperfusion (OR 1.870, 95% CI 1.386–2.509; P < 0.001), visceral malperfusion (OR 1.748, 95% CI 1.198–2.530; P = 0.003), dissection extension to the descending aorta (OR 1.443, 95% CI 1.120–1.864; P = 0.005) and previous cardiac surgery (OR 1.772, 95% CI 1.048–2.903; P = 0.027) were independent predictors of the 30-day mortality rate. The Web application based on the final model can be found at https://www.dgthg.de/de/GERAADA_Score.
CONCLUSIONS
The GERAADA score is a simple, effective tool to predict the 30-day mortality rate for patients undergoing surgery for acute type A aortic dissection. We recommend the widespread use of this Web-based application for standard use.
This study sought to evaluate the incidence of and identify risk factors for distal stent graft–induced new entries (dSINEs) after the frozen elephant trunk (FET) procedure.
Patient characteristics ...and radiographic and follow-up data on 126 patients treated for aortic dissections with the Thoraflex (Vascutek Ltd, Inchinnan, United Kingdom) FET device in 2 centers between November 2013 and December 2018 were evaluated. Stress-strain behavior and load-displacement curves of the Thoraflex and the E-Vita Open (Jotec Inc, Hechingen, Germany) FET prosthesis were evaluated by applying axial load to the most distal ring of the prostheses.
dSINEs were diagnosed in 16 patients (13%). There was no difference in the underlying disease, aortic features, or FET stent graft dimension between patients with and without dSINEs. No predictors for dSINE occurrence in patients treated with the Thoraflex device were identified. The risk for dSINE development was 14% (95% confidence interval CI, 0% to 22%), 16% (95% CI, 0% to 24%), and 25% (95% CI, 0% to 45%) after 12, 24, and 36 months, respectively. When prostheses were loaded axially to 2-mm maximal displacement, the Thoraflex prosthesis exhibited strongly nonlinear behavior with maximal stiffness for minimal displacements, whereas the E-Vita prosthesis showed nearly constant stiffness. In addition, the Thoraflex prosthesis showed an increase in stiffness when confined.
dSINEs may develop at any time after the FET procedure, and the risk for dSINE development is high. No clinical or patient-specific risk factors were identified in this study. The design of the Thoraflex graft with a stiff distal ring may be a potential reason for the occurrence of dSINEs.
Abstract
OBJECTIVES
Our aim was to report outcome of patients with acute non-A non-B aortic dissection involving the aortic arch but not the ascending aorta.
METHODS
Dissection extension and entry ...location were analysed in patients with acute aortic dissection admitted between 2001 and 2016 at a tertiary centre. Non-A non-B dissection was classified as descending-entry type with entry distal to the left subclavian artery and dissection extending into the aortic arch, and arch-entry type with entry between the innominate and left subclavian arteries. We compared these 2 groups’ clinical presentation, treatment and outcome.
RESULTS
Among 396 acute aortic dissection patients, 43 (median age 60 ± 12 years, 81% males) had non-A non-B dissection (descending-entry n = 21, arch-entry n = 22). The overwhelming majority of aortic segments were not dilated in all these patients. The 2 groups’ cardiovascular risk profiles did not differ. Emergency open or endovascular aortic repair were necessary due to malperfusion or aortic rupture in 29% descending-entry and 36% arch-entry (in-hospital mortality was 1/6 and 3/8, respectively). Aortic repair within 2 weeks due to new organ malperfusion, rapid aortic growth, aortic rupture or persisting pain was performed in 43% descending-entry and 36% arch-entry patients (0% in-hospital mortality). All others (except for 1 diagnosed in 2014) required aortic repair for aneurysm at follow-up.
CONCLUSIONS
Acute non-A non-B aortic dissection frequently requires emergency aortic repair due to organ malperfusion or aortic rupture. Most descending-entry and arch-entry non-A non-B dissection patients undergo aortic repair within 2 weeks after dissection onset.
Prolonged normothermic cardiac arrest is associated with a high incidence of neurological morbidity and mortality. Whole body temperature-controlled perfusion has been applied to limit reperfusion ...injury and minimize ischemia. We describe the full recovery of a patient after the application of rapid hypothermia following an intraoperative aortic rupture with ten minutes of absent cerebral blood flow.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Aortic dissection is complex. Imaging and treatment modalities are evolving, demanding a more differentiated but pragmatic dissection classification. Our goal was to provide a new practical ...classification system including Type of dissection, location of the tear of the primary Entry and Malperfusion (TEM).
We extended the Stanford dissection classification (A and B) by adding non-A non-B aortic dissection, the location of the primary entry tear (E) and malperfusion (M). A 0 was added if the primary entry tear was not visible; 1, if it was in the ascending aorta; 2, if it was in the arch; and 3, if it was in the descending aorta (E0, E1, E2, E3). We added 0 if malperfusion was absent; 1, if coronary arteries; 2, if supra-aortic vessels; and 3, if visceral/renal and/or a lower extremity was affected (M0, M1, M2, M3). Plus (+) was added if malperfusion was clinically present and minus (-) if it was a radiological finding.
The new classification system was analysed in 357 patients retrospectively; distribution was 59%, 31% and 10% for A, B and non-A non-B dissections. The in-hospital mortality rate was 16%, 5% and 8% (P = 0.01). Postoperative stroke occurred in 14%, 1% and 3% (P < 0.001). The in-hospital mortality rate was 22%, 14%, 40% and 0% in A E0, E1, E2 and E3 (P = 0.023), respectively. Two years after the onset of dissection, the lowest survival rate was observed in A, followed by non-A non-B and B (83 ± 3% vs 88 ± 6% vs 93 ± 3%; P = 0.019).
The new practical TEM aortic dissection classification system adds clarity regarding the extent of the disease process, enhances awareness of the disease mechanism, aids in decision-making regarding the extent of repair and helps in anticipating outcome.
To evaluate the fate of a dissected aortic arch after limited surgical repair of type A aortic dissection.
Of the 271 patients operated for acute type A dissection between 2001 and 2015, 86 (age 57 ± ...13 years, 74% men) with predischarge computed tomographic (CT) scans had a residual dissection in the arch. Aortic diameters, lengths, ellipticity and communications between lumina were assessed using predischarge and follow-up CT scans. The median CT scan follow-up was 31 months (first quartile 15, third quartile 52).
The largest increase in the total aortic diameter at follow-up was 20 mm distal to the left subclavian artery (median +4.0 mm; first quartile +1.5, third quartile +9.2 mm; P = 0.004), with an average growth rate of 1.5 mm/year (first quartile 0.6, third quartile 3.9 mm). The true lumen diameter was unchanged at follow-up. At least 1 communication between the true and the false lumina was observed in 80% of patients on the predischarge CT scan, and 70% had communications at the distal aorta-graft anastomosis. Accelerated increase in the diameter of the dissected aorta was associated with the number of communications between the lumina, communication at the distal anastomosis and false lumen perfusion (all, P < 0.001).
Dissection of the residual aortic arch leads to aortic growth that may result in an aneurysm requiring treatment. The number of communications between the lumina, communication at the distal anastomosis and false lumen perfusion are associated with the accelerated aortic growth. Endovascular repair may be difficult due to the small true lumen and the presence of many communications between the lumina.
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