Search

Background: The current study aims to report the presentation of the malperfusion syndrome in patients with acute Type A aortic dissection admitted to surgery and its impact on mortality., Methods: Data were retrieved from the multicenter European Registry of Type A Aortic Dissection (ERTAAD). The Penn classification was utilized to categorize malperfusion syndromes. A machine learning algorithm was applied to assess the multivariate interaction's importance regarding in-hospital mortality., Results: A total of 3,902 consecutive patients underwent repair for Acute Type A Aortic Dissection. Local malperfusion syndrome occurred in 1,584 (40.58%) patients. Multi-organ involvement occurred in 582 patients (36.74%) whereas 1,002 patients (63.26%) had single-organ malperfusion. The prevalence was the highest for cerebral (21.27%) followed by peripheral (13.94%), myocardial (9.7%), renal (9.33%), mesenteric (4.15%), and spinal malperfusion (2.10%). Multi-organ involvement predominantly occurred in organs perfused by the downstream aorta. Malperfusion significantly increased mortality risk (p < 0.001, OR 1.95 ± 0.29). The Boruta machine learning algorithm identified the Penn classification as significantly associated with in-hospital mortality (p< 0.0001, variable importance = 7.91), however, 8 other variables yielded higher prediction importance. According to the Penn classification mortality rates were for Penn A = 12.38%, Penn B = 20.71% Penn C = 28.90%, and Penn BC = 31.84% respectively., Conclusions: Nearly half of the examined cohort presented with signs of malperfusion syndrome predominantly due to local involvement. More than one-third of patients with local malperfusion syndrome had a multivessel involvement. Furthermore, different levels of Penn classification can be used only as a first tool for preliminary stratification of early mortality risk., (Copyright © 2024. Published by Elsevier Inc.)

Background: In international guidelines, risk estimation for thoracic ascending aortic aneurysm (TAAA) is based on aortic diameter. We previously introduced the aortic size index (ASI), defined as aortic size/body surface area (BSA), as a predictor of aortic dissection, rupture, and death. However, weight might not contribute substantially to aortic size and growth. We seek to evaluate the height-based aortic height index (AHI) versus ASI for risk estimation and revisit our natural history calculations., Methods: Aortic diameters and long-term complications of 780 patients with TAAA were analyzed. Growth rate estimates, yearly complication rates, and survival were assessed. Risk stratification was performed using regression models. The predictive value of AHI and ASI was compared., Results: Patients were stratified into 4 categories of yearly risk of complications based on their ASI and AHI. ASIs (cm/m 2 ) of ≤2.05, 2.08 to 2.95, 3.00 to 3.95 and ≥4, and AHIs (cm/m) of ≤2.43, 2.44 to 3.17, 3.21 to 4.06, and ≥4.1 were associated with a 4%, 7%, 12%, and 18% average yearly risk of complications, respectively. Five-year complication-free survival was progressively worse with increasing ASI and AHI. Both ASI and AHI were shown to be significant predictors of complications (P < .05). AHI categories 3.05 to 3.69, 3.70 to 4.34, and ≥4.35 cm/m were associated with a significantly increased risk of complications (P < .05). The overall fit of the model using AHI was modestly superior according to the concordance statistic., Conclusions: Compared with indices including weight, the simpler height-based ratio (excluding weight and BSA calculations) yields satisfactory results for evaluating the risk of natural complications in patients with TAAA., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Surgical and cerebral protection strategies in aortic arch surgery remain under debate. Perioperative results using deep hypothermic circulatory arrest (DHCA) have been associated with favorable short-term mortality and stroke rates. The present study focuses on late survival in patients undergoing aortic surgery using DHCA., Methods: A total of 613 patients (mean age, 63.7 years) underwent aortic surgery between January 2003 and December 2015 using DHCA, with 77.3% undergoing hemiarch replacement and 20.4% undergoing arch replacement, with a mean DHCA duration of 29.7 ± 8.5 minutes (range, 10-62 minutes). We examined follow-up extending up to a mean of 3.8 ± 3.4 years (range, 0-14.1 years)., Results: Operative mortality was 2.9%, and the stroke rate was 2%. Survival was 92.2% at 1 year and 81.5% at 5 years, significantly lower than the values in an age- and sex-matched reference population. In elective, nondissection first-time surgeries (n = 424), survival was similar to that of the reference group. Acute type A aortic dissection (hazard ratio [HR], 4.84; P = .000), redo (HR, 4.12; P = .000), and descending aortic pathology (HR, 5.54: P = .000) were independently associated with reduced 1-year survival. Beyond 1 year, age (HR, 1.07; P = .000), major complications (HR, 3.11; P = .000), and atrial fibrillation (HR, 2.47; P = .006) were independently associated with poor survival. DHCA time was not significantly associated with survival in multivariable analysis., Conclusions: Aortic surgery with DHCA can be performed with favorable late survival, with the duration of DHCA period having only a limited impact. However, these results cannot be generalized for very long durations of DHCA (>50 minutes), when perfusion methods may be preferable. In elective, nondissection first-time surgeries, a late survival comparable to that in a reference population can be achieved. Early survival is adversely affected by aortic dissection, redo status, and disease extent., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The study objective was to describe our initial experience performing a V-shaped single sinus remodeling procedure in patients with ascending aortic aneurysm and moderate aortic root ectasia., Methods: Twelve consecutive patients underwent supracoronary ascending aortic replacement with V-shaped noncoronary sinus remodeling (median age, 63 years [range, 56-77]; 10 patients [83%] were male). All patients had an ascending aortic aneurysm (median diameter 48 mm [range, 42-53]) and aortic root ectasia (median root diameter, 43 mm [range, 38-49.7 mm]). A deep V-shaped (triangular) portion of the noncoronary sinus was excised, and the wall was directly reapproximated in 2 layers, 1 everting mattress suture layer followed by a running over-and-over layer., Results: No technical complication due to root remodeling was observed. All patients survived the initial hospitalization. Only 1 patient required reexploration for bleeding, unrelated to the V-shaped repair. On postoperative computed tomography, every patient showed reduction in maximal aortic root diameter and cross-sectional area. Mean aortic root diameter was reduced from 4.30 cm (range, 3.82-4.97) to 3.81 cm (range, 3.58-3.96) (P < .0006). Mean aortic root cross-sectional area was reduced from 1452 mm 2 (range, 1327-1615) to 1180 mm 2 (range, 961-1328) (P < .0002). Mean wall tension decreased postoperatively by 12%., Conclusions: The V-shaped resection of the noncoronary sinus is a viable option for patients with moderate aortic root enlargement. This technique reduces aortic root diameter, cross-sectional area, and wall tension. We offer this technique as another option in the surgeon's armamentarium., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of the study was to assess the anticipated incremental risk of a concomitant aortic resection performed with an aortic valve replacement., Methods: Patients who underwent aortic valve replacement with root-sparing ascending replacement were compared with those who underwent isolated aortic valve replacement using propensity score matching (81 pairs; mean age, 63 ± 11 years [root-sparing ascending replacement] vs 64 ± 14 years). To evaluate the impact of the technique at distal site, 71 pairs of those undergoing root-sparing ascending replacement also were matched by propensity score according to distal anastomosis performed clamped and open under deep hypothermic circulatory arrest., Results: Operative mortality was equal between the root-sparing ascending replacement and isolated aortic valve replacement groups. No significant difference was found regarding postoperative morbidities, such as bleeding, renal failure, stroke, and length of stay, except prolonged ventilation was found after root-sparing procedures (P = .028). Survival estimation showed no difference between the groups. Comparing the patients undergoing root-sparing ascending replacement with clamped and opened distal anastomosis revealed a prolonged ventilation requirement (7% vs 3%; P = not significant) in the open group. Operative mortality was 0% in both groups, and midterm survival was comparable., Conclusions: The concomitant replacement of the aorta in root-sparing fashion is associated with an excellent operative outcome and adds no additional risk to aortic valve replacement in elective and non-high-risk patients. If the distal anastomosis is performed in an open fashion, while the operative mortality is still very low, morbidities are slightly higher, but midterm survival remains comparable., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the potential of aortic arch variants, specifically bovine aortic arch, isolated left vertebral artery, and aberrant right subclavian artery, as markers for thoracic aortic disease (TAD)., Methods: We screened imaging data of 556 patients undergoing surgery due to TAD for presence of aortic arch variations. Demographic data were collected during chart review and compared with a historical control group of 4617 patients., Results: Out of 556 patients with TAD, 33.5% (186 patients) demonstrated anomalies of the aortic arch, compared with 18.2% in the control group (P < .001). Three hundred seventy (66.5%) had no anomaly of the aortic arch. Bovine aortic arch emerged as the most common anomalous branch pattern with a prevalence of 24.6% (n = 137). Thirty-five patients (6.3%) had an isolated left vertebral artery, and 10 patients (1.8%) had an aberrant right subclavian artery. When compared with the control group, all 3 arch variations showed significant higher prevalence in patients with TAD (P < .001). Patients with aortic aneurysms and anomalous branch patterns had hypertension less frequently (73.5% vs 81.8%; P = .048), but had a higher rate of bicuspid aortic valve (40.8% vs 30.6%; P = .042) when compared with patients with aneurysms but normal aortic arch anatomy. Patients with aortic branch variations were significantly younger (58.6 ± 13.7 years vs 62.4 ± 12.9 years; P = .002) and needed intervention for the aortic arch more frequently than patients with normal arch anatomy (46% vs 34.6%; P = .023)., Conclusions: Aortic arch variations are significantly more common in patients with TAD than in the general population. Atypical branching variants may warrant consideration as potential anatomic markers for future development of TAD., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: This study was undertaken to identify preoperative and intraoperative risk factors influencing outcome after operations requiring hypothermic circulatory arrest with selective antegrade cerebral perfusion in a single center., Methods: Between November 1999 and March 2006, a total of 501 consecutive patients (median age 64 years, range 20-86 years, 320 male) underwent aortic arch surgery with moderate hypothermic circulatory arrest (25 degrees C +/- 2 degrees C) and additional selective antegrade cerebral perfusion (14 degrees C) at our institution for various indications (256 aneurysms, 153 acute and 23 chronic type A aortic dissections, 66 other). Of these, 181 were emergency operations. Statistical analysis was carried out to determine risk factors for 30-day mortality as well as for temporary and permanent neurologic dysfunction., Results: Overall mortality was 11.6%. Permanent neurologic dysfunction occurred in 48 patients (9.6%); temporary neurologic dysfunction was detected in 67 patients (13.4%). Multivariate analysis revealed age (P = .001, odds ratio 1.08), reoperation (P = .006, odds ratio 3.58), femoral arterial cannulation (P = .004, odds ratio 2.87), and cardiopulmonary bypass duration (P < .001, odds ratio 1.009) as risk factors for mortality. Permanent neurologic dysfunction was associated with preoperative renal insufficiency (P = .029, odds ratio 2.79) and operation time (P < .001, odds ratio 1.005), whereas temporary neurologic dysfunction occurred in patients with coronary artery disease (P = .04, odds ratio 2.29), emergency surgery (P = .001, odds ratio 4.09), and increasing hypothermic circulatory arrest duration (P = .01, odds ratio 1.015)., Conclusion: Moderate hypothermic circulatory arrest in combination with cold selective antegrade cerebral perfusion is an adequate tool for neuroprotection during aortic surgery. Nevertheless, the safety of this technique is limited for patients with long intraoperative durations, advanced age, and multiple comorbidities. This technique, which avoids profound core temperatures, has become an alternative to simple deep hypothermic circulatory arrest.