Background Cerebral protection during aortic arch surgery can be performed using various surgical strategies. We retrospectively analyzed our results of different brain protection modalities during ...aortic arch surgery. Methods Between January 2003 and November 2009, 636 consecutive patients underwent aortic arch replacement surgery using unilateral antegrade cerebral perfusion (UACP n = 123), bilateral antegrade cerebral perfusion (BACP n = 242), retrograde cerebral perfusion (RCP n = 51), or deep hypothermia and circulatory arrest (DHCA n = 220). Mean age of patients was 62 ± 14 years, 64% were male, 15% were reoperations, and 37% were performed for acute type A dissections. Mean follow-up was 4.9 ± 0.1 years and was 97% complete. Results Circulatory arrest time was 22 ± 17 minutes UACP, 23 ± 21 minutes BACP, 18 ± 12 minutes RCP, and 15 ± 13 minutes DHCA; p < 0.001). Early mortality was 11% (n = 72) and was not different between the surgical groups. Stroke rate was 9% for ACP patients (n = 33) versus 15% (n = 39) for patients who did not receive ACP ( p = 0.035). Independent predictors of stroke were type A aortic dissection (odds ratio OR, 1.9; 95% confidence interval CI, 1.3 to 3.2; p < 0.001), age (OR, 1.04; 95% CI, 1.01 to 1.06; p = 0.001), duration of circulatory arrest (OR, 1.01, 95% CI, 1.002 to 1.03; p = 0.02), and total aortic arch replacement (OR, 2.7; 95% CI, 1.3 to 5.7; p = 0.005). Five year survival was 68% ± 4% and was not significantly different between groups. Conclusions Antegrade cerebral perfusion is associated with significantly less neurologic complications than RCP and DHCA, despite longer circulatory arrest times. Medium-term survival is worse for patients with postoperative permanent neurologic deficit and preoperative type A aortic dissection.
Abstract
OBJECTIVES: The frozen elephant trunk (FET) technique allows one-stage hybrid repair approach in aortic dissection (AoD). Even if the effect of the FET technique on promoting false lumen ...(FL) thrombosis has been proved in the past, the relative importance of FL thrombosis on aortic remodelling at different levels of the distal aorta and the magnitude of this effect is not well known. The aim of the study was to evaluate aortic remodelling following a FET technique for AoD.
METHODS: A multicentre international registry database was searched to identify all patients who underwent a FET procedure for an AoD. A total of 383 patients with AoD were operated on between January 2005 and March 2014 with the FET technique; 137 patients (65 acute AoD and 72 chronic AoD) who survived the initial repair with at least a 1-year follow-up CT scan were included in the study.
RESULTS: The rate of FL thrombosis was higher in the mid-descending thoracic aorta (99.3%) and lower in the distal abdominal aorta (13.9%) but similar between acute and chronic AoDs. The negative remodelling rate was similar between acute and chronic AoDs in the abdominal aorta, but chronic AoD exhibited a higher rate of negative remodelling in the descending thoracic aorta (33% vs 17.5%, P = 0.040).
CONCLUSIONS: The FET technique provides an effective treatment for AoD, promoting FL thrombosis and remodelling in the descending thoracic aorta. Changes in the diameter of the aortic lumen depend mainly on the status of the FL and are similar between acute and chronic AoD. Changes in the diameter of true lumen are affected by both the FL status and the timing of the presentation. However, increased FL thrombosis and positive remodelling rates are not maintained at the level of the abdominal aorta, and strict follow-up is mandatory to detect early changes in the aortic dimensions, which may warrant further interventions.
In a multivariate binary logistic regression analysis, chronic hemodialysis (hazard ratio HR: 8.37; 95% confidence interval CI: 2.54 to 27.63; p < 0.001) and peripheral artery disease (HR: 3.77; 95% ...CI: 1.88 to 7.58; p < 0.001) remained the only independent predictors for developing IE. Negative imaging 15/47 (31.9) Total patients with affected prosthetic valve 22/47 (46.8) Vegetation only on prosthetic valve 12/47 (25.5) Vegetation on prosthetic valve and other valve 7/47 (14.9) Vegetation on prosthetic valve and PM/ICD lead 1/47 (2.1) Vegetation on prosthetic valve, PM/ICD lead and other valve 2/47 (4.3) Paravalvular abscess 9/47 (19.1) Vegetation on other valve than prosthetic valve 4/47 (8.5) Vegetation on PM/ICD lead 3/47 (6.4) Vegetation on PM/ICD lead and other valve 3/47 (6.4) Table 1 Characteristics of Patients Without and With Development of Infective Endocarditis Values are mean ± SD, median (interquartile range), or n (%).AR = aortic regurgitation; CKD = chronic kidney disease stage; COPD = chronic obstructive lung disease; ICD = implantable cardioverter-defibrillator; IE = infective endocarditis; PAD = peripheral artery disease; PM = pacemaker; STS = Society of Thoracic Surgeons; TOE = transesophageal echocardiography; ViV = valve-in-valve.
Background The impact of antegrade versus retrograde perfusion during cardiopulmonary bypass on short- and long-term outcome after repair for acute type A aortic dissection is controversial. Methods ...We reviewed 401 consecutive patients (age, 59.2 ± 14 years) with acute type A aortic dissection who underwent aggressive resection of the intimal tear and aortic replacement (March 1995 through July 2011). Arterial perfusion was antegrade in 78% (n = 311), either by means of the right axillary artery (n = 297) or through direct aortic cannulation (n = 15). Retrograde perfusion through the femoral artery was used in 22% (n = 90). Results Of the 401 patients with acute type A aortic dissection, 16% (n = 64) presented in critical condition and 10% (n = 39) entered the operating room under cardiopulmonary resuscitation. In 14% (n = 54) the dissection did not extend beyond the ascending aorta (DeBakey II); 82% of dissections did involve at least the aortic arch (n = 326, DeBakey I+III). Mean age was not significantly different between patients undergoing antegrade (59.4 ± 14 years) versus retrograde (59.2 ± 13 years; p = 0.489) perfusion. Operative mortality was 20% and did not differ significantly between the groups ( p = 0.766); postoperative stroke occurred also with a similar prevalence (antegrade, 15% versus retrograde, 18%; p = 0.623). Patients undergoing antegrade perfusion had a better long-term survival. Survival at 10 years after discharge was 71% versus 51% ( p = 0.025) in favor of antegrade perfusion. Retrograde perfusion was identified to be an independent risk factor for late mortality in multivariate analysis (hazard ratio = 2; p = 0.009). Conclusions Survival during the initial perioperative period was equivalent comparing antegrade and retrograde perfusion. Antegrade perfusion to the true lumen, however, appears to be associated with superior long-term survival after hospital discharge.
Background The Trifecta valve (St. Jude Medical, St. Paul, MN) is a stented bovine pericardial bioprosthesis for aortic valve replacement (AVR). Implantation experience and midterm follow-up of this ...valve have not yet been reported from a large single-center cohort. Methods We retrospectively analyzed data from 918 patients (73.2 ± 6.5 years; logistic European System for Cardiac Operative Risk Evaluation EuroSCORE, 13.2 ± 14.3) who underwent AVR. Analyses addressed implantation safety, short- and long-term survival, and hemodynamic valve performance. Results Concomitant procedures were performed in 54.9% of the patients. Low cardiac output syndrome, postoperative bleeding requiring transfusion or reoperation, and acute renal failure requiring temporary hemodialysis occurred at rates of 4.3%, 7.0%, and 11.7%, respectively. At discharge, 44 patients (4.8%) were identified with moderate prosthesis-patient mismatch (PPM) and none was identified with severe PPM. Mean follow-up was 2.7 ± 1.6 years (maximum, 7.4 years). Survival at 30 days was 88.7% and 92.0% for all patients and patients with isolated AVR, respectively; 5-year overall survival for these groups was 73.4% and 82.2%, respectively. Myocardial infarction (odds ratio OR, 78; 95% confidence interval CI, 20.8–294) and inotropic medication (OR, 6.8; 95% CI, 3.2–14.5) were the strongest independent predictors for long-term mortality. Five-year freedom from structural valve deterioration (SVD) was 97.9% ± 1.5%. Left ventricular ejection fraction (LVEF) after implantation was similar to baseline and was stable over time (range, 58.9%–62.3%). The mean gradient improved substantially (39.3 mm Hg at baseline versus 9.4 mm Hg at 6 months). Conclusions This large single-center cohort shows the easy and safe implantation, adequate hemodynamic performance, and satisfactory durability of the Trifecta valve at midterm follow-up.
Background The optimal management of the dissected aortic root remains unclear. The purpose of this study was to determine whether aortic valve-sparing root replacement (VSRR) compromises survival in ...aortic dissection repair and to evaluate the comparative efficacy of 2 types of VSRR procedures. Methods The Heart Center database (Leipzig, Germany) was reviewed to identify patients who underwent a VSRR for acute type A aortic dissection (AAAD) repair. Patients were classified into 3 groups: Bentall (biological or mechanical valved conduit), Yacoub VSRR, and David VSRR. Intergroup comparisons were performed using the t test and analysis of variance as appropriate. Results From March 1995 to April 2010, 208/374 patients (56%) undergoing AAAD repair received an aortic root procedure. Group 1 (n = 130) underwent a Bentall operation, group 2 (n = 51) underwent a modified Yacoub procedure, and group 3 (n = 27) underwent a modified David procedure. Age and logistic European system for cardiac operative risk evaluation (EuroSCORE) as well as cross-clamp, cardiopulmonary bypass, and circulatory arrest times were similar among the groups. Hospital mortality among all 3 groups was similar (group 1, 27%; group 2, 16%; group 3, 15%). At a mean follow-up of 44 months for group 2 and 27 months for group 3, there was no difference in the need for aortic valve replacement for moderate to severe aortic insufficiency (AI) (2/37 survivors in group 2 versus 1/23 survivors in group 3; z score = −0.279; p > 0.05). Five-year survival estimates were 66% for group 1, 65% for group 2, and 80% for group 3 (log rank p = 0.2). Conclusions Both the David and Yacoub techniques have similar midterm durability in AAAD repair. When compared with the Bentall procedure, neither technique compromises short-term or midterm survival after AAAD repair.
Redo Aortic Valve Surgery: Early and Late Outcomes Leontyev, Sergey, MD; Borger, Michael A., MD, PhD; Davierwala, Piroze, MD ...
The Annals of thoracic surgery,
04/2011, Letnik:
91, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Background Repeat aortic valve surgery (rAVS) is usually associated with an increased risk profile due to advanced patient age and comorbidities. We analyzed the current early and late results for ...isolated rAVS. Methods One hundred fifty-five patients underwent isolated rAVS from November 1994 to April 2008, of which, 86 received isolated redo aortic valve surgery (rAVS without root) and 69 received aortic root replacement (rAVS with root) as the second operation. Results Patient age was 58 ± 16 years; 23% were female. The indications for redo surgery were infective endocarditis (27.1%, n = 42), bioprosthetic structural valve dysfunction and degeneration (23.8%, n = 37), mechanical valve nonstructural dysfunction (7.2%, n = 11), paravalvular leak (18.1%, n = 28), aortic dissection (2.6%, n = 4), and aortic aneurysm (7.1%, n = 11). Early mortality was 4.5% (n = 7) for all patients (3.5% for rAVS without root and 5.8% for rAVS with root, p = 0.5). Left ventricular ejection fraction less than 0.30 (odds ratio 9.2, 95% confidence interval CI 1.1 to 80.3) and preoperative neurologic dysfunction (odds ratio 22.1, 95% CI 2.3 to 197.4) were found to be the independent predictors for in-hospital mortality according to multivariate analysis. Follow-up was 100% complete with a mean duration of 2.7 ± 2.8 years for all patients. Five-year and eight-year survival was 66% ± 5% and 61% ± 6% for all patients and did not significantly differ between surgical groups. Cox regression analysis revealed the following independent predictors of long-term survival: preoperative New York Heart Association functional class IV (hazard ratio 2.2, 95% CI 1.5 to 3.2, p < 0.01) and infective endocarditis (hazard ratio 2.2, 95% CI 1.4 to 3.1, p < 0.01). Conclusions Repeat isolated aortic valve surgery is associated with respectable outcomes. Follow-up results reveal good long-term survival for this group.
Background This study evaluated preoperative predictors of in-hospital death for the surgical treatment of patients with acute type A aortic dissection (Type A) and created an easy-to-use scorecard ...to predict in-hospital death. Methods We reviewed retrospectively all consecutive patients who underwent operations for acute Type A between 1996 and 2011 at 2 tertiary care institutions. A logistic regression model was created to identify independent preoperative predictors of in-hospital death. The results were used to create a scorecard predicting operative risk. Results Emergency operations were performed in 534 consecutive patients for acute Type A. Mean age was 61 ± 14 years and 36.3% were women. Critical preoperative state was present in 31% of patients and malperfusion of one or more end organs in 36%. Unadjusted in-hospital mortality was 18.7% and not significantly different between institutions. Independent predictors of in-hospital death were age 50 to 70 years (odds ratio OR, 3.8; p = 0.001), age older than 70 years (OR, 2.8; p = 0.03), critical preoperative state (OR, 3.2; p < 0.001), visceral malperfusion (OR, 3.0; p = 0.003), and coronary artery disease (OR, 2.2; p = 0.006). Age younger than 50 years (OR, 0.3; p = 0.01) was protective for early survival. Using this information, we created an easily usable mortality risk score based on these variables. The patients were stratified into four risk categories predicting in-hospital death: less than 10%, 10% to 25%, 25% to 50%, and more than 50%. Conclusions This represents one of the largest series of patients with Type A in which a risk model was created. Using our approach, we have shown that age, critical preoperative state, and malperfusion syndrome were strong independent risk factors for early death and could be used for the preoperative risk assessment.
Background The aim of this study was to determine the preoperative predictors of in-hospital and medium-term mortality in patients with dialysis-dependent chronic renal failure (DD CRF) undergoing ...cardiac operations. Methods Between January 1996 and June 2014, 483 consecutive patients with DD CRF underwent cardiac surgical procedures. The mean age was 65 ± 11 years, and 32. 3% were women. Isolated coronary artery bypass grafting (CABG) or isolated valve operations were performed in 39.8% and 32.3%, of patients, respectively. Combined surgical procedures (CABG with valve operations) were necessary in 20.3% of patients. Endocarditis was an indication for surgical intervention in 11% of patients. Urgent or emergent operations were performed in 49.3% of patients. Results The in-hospital mortality was 15.3%. Postoperative respiratory failure, gastrointestinal complications, low cardiac output, stroke, and sepsis occurred in 25.7%, 12.4%, 11.8%, 5.6%, and 5.2% of patients, respectively. The independent predictors of in-hospital mortality were combined mitral and aortic valve pathologic conditions (odds ratio OR, 3.7, 95% CI, 1. 5–9; p = 0.003), chronic obstructive pulmonary disease (OR, 2.6; 95% CI, 1.1–5.9; p = 0. 03), peripheral vascular disease (OR, 2.3; 95% CI, 1.04–4; p = 0.003), left ventricular ejection fraction (LVEF) <30% (OR, 2.9; 95% CI, 1.3–6. 4; p = 0.008), and active endocarditis (OR, 2.2; 95% CI, 1.04–4.6; p = 0.04). The estimated 2-, 4-, and 6-year survival was 50.1% ± 2%, 34.3% ± 2%, and 20.3% ± 2%, respectively. Previous cerebrovascular accident, active endocarditis, previous cardiac operations, and combined aortic/mitral valve pathologic conditions were independent predictors of medium-term mortality. Conclusions Patients with DD CRF undergoing cardiac operations have high perioperative and medium-term mortality, particularly in the presence of combined aortic and mitral valve pathologic conditions, active endocarditis, and poor left ventricular function.
Background Iatrogenic coronary artery injuries during percutaneous coronary interventions ( PCI ) often require emergent surgical management. Our study evaluated the early and long-term outcomes in ...patients undergoing surgical treatment of iatrogenic PCI complications and identified the predictors of operative and long-term mortality. Methods and Results Pre-, intra- and post-operative data and hospital outcomes of 168 consecutive patients undergoing cardiac surgical procedures for iatrogenic complications following PCI between December 1999 and July 2015, were prospectively collected in our computerized database. Logistic and Cox regression analyses were used to identify the independent predictors of operative and long-term mortality. The mean age was 68.5±10.2 years and 35.7% were females. PCI complications included left anterior descending (38.7%), right coronary (29.2%), circumflex (13.1%), left main coronary artery injuries (19.0%), and acute myocardial infarction (66.7%), Type A aortic dissection (7.7%), cardiac tamponade (17.9%), and cardiogenic shock ( CS ) (46.4%). Operative mortality for corrective surgery was 20.8% and was independently predicted by critical preoperative state (odds ratio: 3.5; P=0.01). The 5- and 10-year survival for all patients was 63.9±4.0% and 49.6±5.0%, which improved remarkably in hospital survivors (79.0±4.0% and 64.0±6.0%). Risk factors for long-term mortality were critical preoperative state (hazard ratio: 3.5; P<0.0001) and coronary artery occlusion during PCI (hazard ratio: 2.6; P=0.002). The 5- and 10-year freedom from major adverse cardiac and cerebrovascular events was 59.7±4.0% and 41.9±5.0%. Conclusions Iatrogenic injuries after PCI or coronary angiography requiring surgical correction are associated with a high operative and long-term mortality. Patients developing acute coronary artery occlusion have a more guarded long-term prognosis. Hospital survivors, however, have a superior long-term survival.
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