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OBJECTIVES Volume concentration of complex noncardiac operations to high-volume centers has been observed, but whether this is also occurring in cardiac surgery is unknown. We examined the relationship between volume concentration and mortality rates for valve surgery and coronary artery bypass grafting (CABG) between 2005 and 2016 in New York State. METHODS We analyzed publicly available, hospital-level case volume and risk-adjusted mortality rates (RAMRs) from 2005 to 2016 for isolated CABG and isolated or concomitant valve operations performed in New York. We identified hospitals in the top- and bottom-volume quartiles for each procedure type and compared changes in percent market share and outcomes. Bivariate and univariate longitudinal analysis was used to evaluate the statistical significance of the temporal trend. RESULTS Among 36 centers, percent market share of the top-volume quartile increased for valve cases from 54.4% to 59.4%, whereas CABG share increased from 41.4% to 44.3%. No significant changes were noted in market share for the bottom quartile. The top-volume quartile demonstrated significant trends in improving outcomes over the study period for both valve procedures (RAMR: -0.261%/year, P

The study objective was to evaluate the safety and effectiveness of the second-generation, low-profile RelayPro (Terumo Aortic) thoracic endograft for the treatment of descending thoracic aortic aneurysm or penetrating atherosclerotic ulcer.A prospective, international, nonblinded, nonrandomized, pivotal trial analyzed a primary safety end point of major adverse events at 30 days (death, myocardial infarction, stroke, renal/respiratory failure, paralysis, bowel ischemia, procedural blood loss) and a primary effectiveness end point of treatment success at 1 year (technical success, patency, absence of aneurysm rupture, type I/III endoleaks, stent fractures, reinterventions, aneurysm expansion, and migration) compared with performance goals from the previous generation Relay pivotal study. The study was conducted in 36 centers in the United States and Japan and enrolled participants between 2017 and 2019.The study population of 110 patients had a median (interquartile range) age of 76 (70-81) years, 69 (62.7%) were male, and 43 (39.1%) were Asian. Patients were treated for 76 fusiform aneurysms (69%), 24 saccular aneurysms (22%), and 10 penetrating atherosclerotic ulcers (9%). Most patients (82.7%) were treated with a non-bare stent configuration. Technical success was 100%. The median (interquartile range) procedure time was 91 (64-131) minutes, and the deployment time was 16 (10-25) minutes. A total of 50 patients (73.5%) in the US cohort had percutaneous access, whereas centers in Japan used only surgical cutdown. The 30-day composite major adverse events rate was 6.4% (95% upper confidence interval, 11.6%; P = .0002): 2 strokes, 2 procedural blood losses greater than 1000 mL requiring transfusion, 2 paralysis events, and 1 renal failure. Primary effectiveness was 89.2% (lower 95% confidence interval, 81.8%; P = .0185). Nine subjects experienced 11 events (1 aneurysm expansion, 6 secondary interventions, and 4 type I endoleaks). There was no loss of stent-graft patency, no rupture, no fractures, and no migration.The low-profile RelayPro thoracic endograft met the study primary end points and demonstrated satisfactory 30-day safety and 1-year effectiveness for the treatment of patients with aneurysms of the descending thoracic aorta or penetrating atherosclerotic ulcers. Follow-up is ongoing to evaluate longer-term outcomes and durability.

Objective The best method of aortic root repair in older patients remains unknown given a lack of comparative effectiveness of long-term outcomes data. The objective of this study was to compare long-term outcomes of different surgical approaches for aortic root repair in Medicare patients using The Society of Thoracic Surgeons Adult Cardiac Surgery Database-Centers for Medicare & Medicaid Services–linked data. Methods A retrospective cohort study was performed by querying the Society of Thoracic Surgeons Adult Cardiac Surgery Database for patients aged 65 years or more who underwent elective aortic root repair with or without aortic valve replacement. Primary long-term end points were mortality, any stroke, and aortic valve reintervention. Short-term outcomes and long-term survival were compared among each root repair strategy. Additional risk factors for mortality after aortic root repair were assessed with a multivariable Cox proportional hazards model. Results A total of 4173 patients aged 65 years or more underwent elective aortic root repair. Patients were stratified by operative strategy: mechanical Bentall, stented bioprosthetic Bentall, stentless bioprosthetic Bentall, or valve-sparing root replacement. Mean follow-up was 5.0 (±4.6) years. Relative to mechanical Bentall, stented bioprosthetic Bentall (adjusted hazard ratio, 0.80; confidence interval, 0.66-0.97) and stentless bioprosthetic Bentall (adjusted hazard ratio, 0.70; confidence interval, 0.59-0.84) were associated with better long-term survival. In addition, stentless bioprosthetic Bentall (adjusted hazard ratio, 0.64; confidence interval, 0.47-0.80) and valve-sparing root replacement (adjusted hazard ratio, 0.51; confidence interval, 0.29-0.90) were associated with lower long-term risk of stroke. Aortic valve reintervention risk was 2-fold higher after valve-sparing root replacement compared with other operative strategies. Conclusions In the Medicare population, there was poorer late survival and greater late stroke risk for patients undergoing mechanical Bentall and a higher rate of reintervention for valve-sparing root replacement. Bioprosthetic Bentall may be the procedure of choice in older patients undergoing aortic root repair, particularly in the era of transcatheter aortic valve replacement.

Objective The incidence of elderly patients with acute type A aortic dissection is increasing. A recent analysis of the International Registry of Acute Aortic Dissection failed to show a mortality benefit with surgery compared with medical management in octogenarians. Therefore, we compared our institutional outcomes of emergency surgery for acute type A aortic dissection in octogenarians versus septuagenarians to understand the outcomes of surgical intervention in elderly patients. Methods From 2002 to 2017, 70 octogenarians (aged ≥80 years) and 165 septuagenarians (70-79 years) underwent surgery for acute type A aortic dissection (N = 235, total). Quality of life was assessed by the RAND Short Form-36 quality of life survey. Midterm clinical and functional data were obtained retrospectively. Results At baseline, septuagenarians had a higher prevalence of diabetes (20.6% vs 5.7%, P = .01). The prevalence of cardiopulmonary resuscitation was 4.8% versus 10.0% (P = .24) in septuagenarians and octogenarians. The prevalence of cardiogenic shock was 18.2% versus 27.1% (P = .17). Thirty-day/in-hospital mortality was 21.2% versus 28.6% (P = .29). Multivariable logistic regression identified cardiogenic shock as an independent risk factor for in-hospital mortality (odds ratio, 10.07; 95% confidence interval, 2.30-44.03) in octogenarians. Survival at 5 years was 49.7% (42.1%-58.6%) versus 34.2% (23.9%-48.8%) in septuagenarians and octogenarians, respectively. Responses to the quality of life survey were no different between septuagenarians and octogenarians across all 8 quality of life categories. Conclusions Clinical outcomes after surgery for acute type A aortic dissection are similar in octogenarians and septuagenarians. For discharged survivors, quality of life remains favorable and does not differ between the 2 groups.

Objective In patients presenting with aortic valvulopathy with concomitant ascending aortic aneurysm, surgical management of the sinus of Valsalva segment remains undefined, especially for moderately dilated aortic roots. In patients with this pathology undergoing aortic valve replacement with supracoronary ascending aorta replacement, we assessed the fate of the remnant preserved sinus of Valsalva segment stratified by aortic valve morphology and pathology. Methods From 2002 to 2015, 428 patients underwent elective aortic valve replacement with supracoronary ascending aorta replacement. Patients were stratified on the basis of valvular morphology (bicuspid aortic valve [n = 254] and tricuspid aortic valve [n = 174]), valvular pathology (bicuspid aortic valve with aortic stenosis [n = 178], bicuspid aortic valve with aortic insufficiency [n = 76], tricuspid aortic valve with aortic stenosis [n = 61], tricuspid aortic valve with aortic insufficiency [n = 113]), and preoperative sinus of Valsalva dimensions ( 45 mm). Results Kaplan–Meier analysis revealed no significant difference in freedom from reoperation in tricuspid aortic valve versus bicuspid aortic valve ( P = .576). Multivariable Cox regression model performed with sinus of Valsalva dimensions at baseline and follow-up as time-varying covariates did not adversely affect survival. A repeated-measure, mixed-effects model constructed to assess longitudinal sinus of Valsalva trends revealed that the retained sinus of Valsalva dimensions remain stable over long-term follow-up (discharge to ≥10 years), irrespective of valvular morphology/pathology (bicuspid aortic valve with aortic insufficiency, tricuspid aortic valve with aortic insufficiency, tricuspid aortic valve with aortic stenosis) and preoperative sinus of Valsalva groups ( 45 mm). Conclusions In patients with nonaneurysmal sinuses of Valsalva undergoing aortic valve replacement with supracoronary ascending aorta replacement, the sinus segment can be preserved irrespective of the type of valvular pathology (aortic stenosis vs aortic insufficiency) or valvular morphology (bicuspid aortic valve vs tricuspid aortic valve). Aortic valve replacement with supracoronary ascending aorta replacement may have a stabilizing effect on the sinus segment over long-term follow-up in patients with tricuspid aortic valves or bicuspid aortic valves.

The durability of root repair for acute type A aortic dissection is not well studied in the context of aortic insufficiency and stability of the sinuses of Valsalva. We compared clinical and functional outcomes in patients undergoing root repair and replacement for acute type A aortic dissection.Of 716 patients undergoing surgery for acute type A aortic dissection, 585 (81.7%) underwent root repair and 131 (18.3%) underwent root replacement. Survival, cumulative incidence of reoperation, aortic insufficiency, and sinuses of Valsalva dilation were compared between the 2 groups.Survival at 1, 5, and 10 years was 84.1% versus 77.3%, 70.8% versus 69.2%, 57.6% versus 58.0% in the root repair and replacement groups, respectively (P = .69). Cumulative incidence of reoperation at 1, 5, and 10 years was 0.0% versus 0.8%, 1.4% versus 3.8%, and 3.4% versus 8.6% in the root repair and root replacement groups, respectively (P = .011). Multivariable Cox regression identified sinuses of Valsalva diameter 45 mm or more as a risk factor for proximal aortic reoperation (hazard ratio, 9.06; 95% confidence interval, 1.26-65.24). In a repeated-measures, linear, mixed-effects model, root replacement was associated with smaller follow-up of sinuses of Valsalva dimensions (β = -0.66, P .001). In an ordinal longitudinal mixed model, root replacement was associated with lower severity of postoperative aortic insufficiency (β = -3.10, P .001).Survival is similar, but the incidence of aortic insufficiency and root dilation may be greater after root repair compared with root replacement for acute type A aortic dissection.

A 43 year-old man with past history of an extent I thoracoabdominal aortic aneurysm (TAAA) repair presented with an enlarging pseudoaneurysm involving an intercostal limb of a branched descending thoracic aortic graft. Right brachial artery and right common femoral artery were used to access the proximal and distal portions of the intercostal limb graft respectively, and a snare was used to establish access across the entire length of the tortuous graft. Under somatosensory evoked potential monitoring (SSEP), angioplasty balloons were used to occlude the distal and proximal ends of the limb graft. After observing no change in signals, two 16mm Amplatzer vascular plugs were used to occlude the distal and proximal portions of the intercostal limb graft thereby excluding the source of the enlarging pseudoaneurysm and redirecting flow through the main descending thoracic aortic graft. This case demonstrates that endovascular options should be considered in patients presenting with late complications such as pseudoaneurysms after previous open thoracic aortic surgery.

Objective Patients with acute type A aortic dissection demonstrate a wide range of aortic insufficiency. Outcomes after valve resuspension and root repair are not well studied in the long term. We evaluated the long-term effects of preoperative aortic insufficiency in patients undergoing emergency root-preserving surgery for acute type A aortic dissection. Methods From 2002 to 2017, 558 of 776 patients with acute type A aortic dissection underwent native aortic valve resuspension and root reconstruction. Patients were stratified into 4 groups by preoperative aortic insufficiency grade (n = 539): aortic insufficiency less than 2+ (n = 348), aortic insufficiency = 2+ (n = 72), aortic insufficiency = 3+ (n = 49), and aortic insufficiency = 4+ (n = 70). Multivariable ordinal longitudinal mixed effects and multi-state transition models were used to assess risk factors for recurrent aortic insufficiency. Results The prevalence of cardiogenic shock in patients presenting with preoperative aortic insufficiency less than 2+, 2+, 3+, and 4+ was 53 of 348 (15.2%), 12 of 72 (16.7%), 10 of 49 (20.4%), and 24 of 70 (34.3%), respectively (P = .002). Postoperatively, 94.0% of patients had aortic insufficiency 1+ or less at discharge. Operative mortality was 34 of 348 (9.8%), 10 of 72 (13.9%), 6 of 49 (12.2%), and 12 of 70 (17.1%) (P = .303). In an ordinal mixed effects model, preoperative aortic insufficiency was associated with more severe postoperative aortic insufficiency. The multi-state transition model demonstrated that severe aortic insufficiency was associated with progression from no to mild aortic insufficiency (hazard ratio, 2.14; 95% confidence interval, 1.35-3.38), and progression from mild to moderate aortic insufficiency (hazard ratio, 5.70; 95% confidence interval, 1.88-17.30). Conclusions Preoperative aortic insufficiency is an important predictor of recurrent aortic insufficiency in patients undergoing valve resuspension with root reconstruction for emergency acute type A aortic dissection repair. Increased echocardiographic surveillance for recurrent aortic insufficiency may be warranted in this cohort.

We evaluated whether volume-based, rather than time-based, annual reporting of center outcomes for coronary artery bypass grafting may improve inference of quality, assuming that large center-level year-to-year outcome variability is related to statistical noise.We analyzed 2012 to 2016 data on isolated coronary artery bypass grafting using statewide outcome reports from New York and California. Annual changes in center-level observed-to-expected mortality ratio represented stability of year-to-year outcomes. Cubic spline fit related the annual observed-to-expected ratio change and center volume. Volume above the inflection point of the spline curve indicated centers with low year-to-year change in outcome. We compared observed-to-expected ratio changes between centers below and above the volume threshold and observed-to-expected ratio changes between consecutive annual and biennial measurements.There were 155 centers with median annual volume of 89 (interquartile range, 55-160) for isolated coronary artery bypass grafting. The inflection point of observed-to-expected ratio variability was observed at 111 cases/year. Median year-to-year observed-to-expected ratio change for centers performing less than 111 cases (62 centers) was greater at 0.83 (0.26-1.59) compared with centers performing 111 cases or more (93 centers) at 0.49 (022-0.87) (P .001). By aggregating the outcome over 2 years, centers above the 111-case threshold increased from 93 centers (60%) to 118 centers (76%), but the median observed-to-expected change for all centers was similar between annual aggregates at 0.70 (0.26-1.22) compared with observed-to-expected change between biennial aggregates at 0.54 (0.23-1.02) (P = .095).Center-level, risk-adjusted coronary artery bypass grafting mortality varies significantly from one year to the next. Reporting outcomes by specific case volume may complement annual reports.

Objective Patients undergoing emergency peripheral arteriovenous extracorporeal life support were evaluated for lower-extremity complications on the basis of the ipsilateral limb perfusion strategy. Methods In a retrospective review of patients receiving extracorporeal life support (2008-2013), 105 of 250 underwent femoral extracorporeal life support. For ipsilateral lower-extremity perfusion, patients underwent no superficial femoral artery cannulation (n = 35), percutaneous superficial femoral artery cannulation (n = 23), or open superficial femoral artery cannulation (n = 47). Results Patients' mean age was 50 ± 16 years, and 63% (n = 67) were male. A total of 92 patients (88%) had primary cardiac emergency, and 13 patients (12%) had cardiopulmonary emergency. The 30-day in-hospital mortality was 65% (n = 68), with an overall lower-extremity complication rate of 13% (n = 14). Lower-extremity complications were highest in the percutaneous superficial femoral artery (n = 6, 26%) and no superficial femoral artery (n = 7, 20%) groups (n = 1 [2%] in open superficial femoral artery group). In 2 group comparisons, the open superficial femoral artery group had significantly lower lower-extremity complications than the no superficial femoral artery ( P = .02) and percutaneous superficial femoral artery ( P = .004) groups. There was no difference between the no superficial femoral artery and percutaneous superficial femoral artery groups ( P = .7). In the no superficial femoral artery group, emergency thromboembolectomy (n = 2), fasciotomy (n = 3), and emergency superficial femoral artery cannula placement (n = 2) were required. In the percutaneous superficial femoral artery group, thromboembolectomy with superficial femoral artery repair (n = 2), fasciotomy (n = 1), below-knee amputation (n = 1), open superficial femoral artery cannula revision (n = 1), and loss of distal signals from multiorgan failure (n = 1) were noted. In the open superficial femoral artery group, 1 patient had loss of signals from multiorgan failure. Conclusions No superficial femoral artery perfusion strategy is associated with a high lower-extremity complication rate. If percutaneous cannulation is performed, then angiographic confirmation of superficial femoral artery run-off is highly recommended. The open superficial femoral artery approach remains a safe alternative to the other strategies.

Bicuspid aortic valve (BAV) represents 2 cusps oriented along a spectrum of equal (180°/180°) or unequal (150°/210°) leaflet surface area distribution along the aortic annular plane. We have taken the approach of respecting the native geometric orientation of the repaired BAV leaflets when creating the aortic neoroot during valve-sparing root reimplantation (VSRR) procedures. We investigated midterm outcomes with this 2-prong approach for VSRR in BAV syndrome.Of 72 patients in a prospectively maintained BAV repair database, 68 met inclusion criteria: 36 patients had 180°/180° neoroot geometry, and 32 patients had 150°/210° orientation. A multivariate ordinal logistic mixed effects model was performed to study parameters associated with recurrent AI greater than 2+.Preoperative parameters were similar between 180°/180° and 150°/210° groups, except for greater incidence of AI 4+ in the latter (50.0% [n = 16] vs 8.3% [n = 3]; P .001). Postoperatively, stroke, renal failure, reoperation for bleeding, and pacemaker rates were 0 in the entire cohort. In-hospital/30-day mortality in the entire cohort was 1.5% (n = 1). Multivariate ordinal logistic mixed effects model showed that preoperative AI greater than 3+ (odds ratio, 0.4; P = .46) and geometric orientation of the aortic neoroot (odds ratio, 3.8; P = .25) were not significantly associated with recurrence of AI greater than 2+.Respecting BAV geometry for VSRR neoroot creation yields excellent midterm outcomes and may minimize conjoint cusp leaflet stress that may occur in "forcing" a 150°/210° type I BAV into a 180°/180° neoroot.

The optimal method for arterial cannulation in acute aortic dissection type A (ADA) remains controversial. The aim of this study was to compare central ascending aortic, axillary, and femoral cannulation in patients who underwent surgery for acute ADA.Between 2006 and 2017, 584 patients were operated on for acute ADA. Of those, 355 (61%) underwent ascending aortic, 101 (17%) right axillary, and 128 (22%) femoral cannulation for arterial inflow. Clinical features and outcomes were compared after inverse probability weighting.After inverse probability weighting there were no statistical differences in preoperative characteristics. Operative details differed significantly among the 3 groups: hemiarch replacement was performed more often in the central aortic and the femoral group (P .001), whereas total arch replacement was performed more often in the axillary group (P .001). Cardiopulmonary bypass (P = .022) and aortic cross-clamp (P = .021) times were shortest in the aortic cannulation group and longest in the femoral cannulation group. Postoperative morbidities were similar; procedure-related stroke (P = .783) and the need for renal replacement therapy (P = .446). In-hospital mortality (P = .680) and long-term survival were similar (log rank, P = .704). Multilevel multivariate mixed effect logistic regression showed that the cannulation strategy was not associated with in-hospital mortality.Central ascending aortic cannulation in patients with ADA can be used as safely as axillary or femoral cannulation, providing another option for quick and easy establishment of cardiopulmonary bypass.

Objective In heart transplantation, there is a critical need for development of biomarkers to noninvasively monitor cardiac allografts for immunologic rejection or injury. Exosomes are tissue-specific nanovesicles released into circulation by many cell types. Their profiles are dynamic, reflecting conditional changes imposed on their tissue counterparts. We proposed that a transplanted heart releases donor-specific exosomes into the recipient's circulation that are conditionally altered during immunologic rejection. We investigated this novel concept in a rodent heterotopic heart transplantation model. Materials and Methods Full major histocompatibility mismatch (BALB/c [H2-K d ] into C57BL/6 [H2-K b ]) heterotopic heart transplantation was performed in 2 study arms: Rejection (n = 64) and Maintenance (n = 28). In the Rejection arm, immunocompetent recipients fully rejected the donor heart, whereas in the Maintenance arm, immunodeficient recipients (C57BL/6 Prkdc SCID ) accepted the allograft. Recipient plasma exosomes were isolated and a donor heart-specific exosome signal was characterized on the nanoparticle detector for time-specific profile changes using anti-H2-K d antibody quantum dot. Results In the Maintenance arm, allografts were viable throughout follow-up of 30 days, with histology confirming absence of rejection or injury. Time course analysis (days 1, 2, 3, 4, 5, 7, 9, 11, 15, and 30) showed that total plasma exosome concentration ( P = .157) and donor heart exosome signal ( P = .538) was similar between time points. In the Rejection arm, allografts were universally rejected (median, day 11). Total plasma exosome quantity and size distribution were similar between follow-up time points ( P = .278). Donor heart exosome signals peaked on day 1, but significantly decreased by day 2 ( P = 2 × 10 −4 ) and day 3 ( P = 3.3 × 10 −6 ), when histology showed grade 0R rejection. The receiver operating characteristic curve for a binary separation of the 2 study arms (Maintenance vs Rejection) demonstrated that a donor heart exosome signal threshold Conclusions Transplant heart exosome profiling enables noninvasive monitoring of early acute rejection with high accuracy. Translation of this concept to clinical settings might enable development of a novel biomarker platform for allograft monitoring in transplantation diagnostics.

Objective Long-term outcomes of prosthetic aortic valve/root replacement in patients aged 30 years or younger are not well understood. We report our single institutional experience in this young cohort. Methods From 1998 to 2016, 99 patients (age range, 16-30 years) underwent aortic valve replacement (n = 57), aortic valve replacement and supracoronary ascending aorta replacement (n = 6), or aortic root replacement (n = 36). A prospectively maintained aortic valve database was retrospectively reviewed to complete longitudinal functional and clinical data. Total follow-up was 493 patient years. Results Surgical indications included primary stenosis/insufficiency (52% [n = 51]), Marfan syndrome (10% [n = 10]), and endocarditis (33.3% [n = 33]). Fifty-eight patients (59%) underwent mechanical valve replacement, with 41 patients (41%) receiving a biologic/bioprosthetic valve. Twenty-five patients underwent aortic valve reoperation after index procedure with following indications: prosthesis–patient mismatch 1.0% (n = 1), prosthetic valve degeneration/dysfunction 10% (n = 10), connective tissue 2% (n = 2), and endocarditis 12% (n = 12). Mortality (30-day/in-hospital) and stroke rate were 3.0% (n = 3) and 1% (n = 1), respectively. One-, 5-, and 10-year actuarial freedom from aortic valve reoperation by valve type was 89.1%, 84.6%, and 69.4% for the Mechanical Valve group and 89.6%, 70.9%, and 57.6% for the Biologic/Bioprosthetic Valve group, respectively (log rank P = .279). Replacement valve size ≤21 mm was a significant risk factor for reoperation, and was associated with progression of mean aortic valve transvalvular gradients over follow-up. Valve type had no effect. Conclusions The choice of mechanical versus biologic/bioprosthetic valve does not affect freedom from reoperation or survival rates in this young cohort during mid- to long-term follow-up. Smaller aortic valve replacement size (≤21 mm) is a significant risk factor for reoperation and progression of mean aortic valve gradients.

ObjectivesPatients often present for aortic root replacement surgery with concomitant mitral valve pathology. Moderate mitral regurgitation is the point of clinical equipoise where the benefits of intervention compared with observation are currently unknown. This study compares outcomes in patients undergoing aortic root replacement surgery who did or did not receive a mitral valve repair for their preoperative moderate mitral regurgitation.MethodsA total of 1316 patients who underwent aortic root replacement surgery between 2000 and 2011 were evaluated, with 104 patients meeting the inclusion criteria by presenting with moderate preoperative mitral regurgitation. A total of 73 patients (70%) received no mitral intervention, and 31 patients (30%) received a mitral repair. Patients underwent preoperative, postoperative, and greater than 6-month follow-up echocardiograms. Average clinical follow-up was 6.5 years.ResultsThe mitral repair group had increased preoperative New York Heart Association III/IV and heart failure, longer crossclamp times, and more postoperative renal failure (P = .0003, P = .04, P

From the Divisions of Cardiovascular Surgery and Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Dec 16, 2015; revisions received Feb 11, 2016; accepted for publicationMarch 14, 2016; available ahead of print May 11, 2016. Address for reprints: Prashanth Vallabhajosyula, MD, MS, Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein, Philadelphia, PA 19104 (E-mail: prashant. vallabhajosyula@uphs.upenn.edu). J Thorac Cardiovasc Surg 2016;152:622-3 0022-5223/$36.00 Copyright 2016 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.03.047

Valve-sparing root reimplantation (VSRR) in tricuspid aortic valve (TAV) patients is well established, but in bicuspid aortic valve (BAV) patients, it has been less widely adopted. We assessed whether valve type affects midterm outcomes with VSRR.A retrospective review was performed of 186 patients who underwent an aortic valve-sparing root reimplantation operation between 2004 and 2013. Of these, 129 patients underwent elective VSRR with the David V technique. Outcomes were compared in this cohort by valve type: TAV (n = 89) versus BAV (n = 40).Demographics were similar in the 2 groups. BAV patients had a higher degree of aortic insufficiency (AI) at presentation (P .05), and an enlarged preoperative annulus (30 ± 4 vs 28 ± 6 mm, P = .06). All BAV patients required primary leaflet repair (6% in the TAV group; P .01). Postoperative mortality (0), stroke (0% vs 1%), and pacemaker requirement (0% vs 5%) were similar. Postoperative freedom from AI grade ≥2+ was 100% in the entire cohort, and transvalvular gradients were similar. At follow-up, a 1-year echocardiogram showed higher peak and mean transvalvular gradients in the BAV group (P .01). One TAV group patient died from an unknown cause. The 5-year actuarial freedom from aortic valve reoperation was 100% versus 97% ± 3% (P = .6). Three patients in the entire cohort have had AI grade2+ on follow-up (n = 1 in the BAV group; n = 2 in the TAV group).Even though BAV patients present with higher AI grade and require concomitant primary valve repair, the VSRR David V technique offers excellent midterm outcomes with both the BAV and TAV valve types.

Objective Although endovascular repair has been widely adopted for treatment of descending thoracic aortic pathologies, its role in ascending aortic pathologies remains undefined. We reviewed our experience with endovascular repair of ascending aortic pathologies in patients facing high or prohibitive risk with open surgical treatment. Methods From 2007 to 2013, 6 patients (aged 16-90 years) underwent endovascular repair (pseudoaneurysm, n = 4; acute type A aortic dissection, n = 2). Their records were retrospectively reviewed. Results All patients had extensive comorbidities or anatomic features making an open surgical approach high risk. Three cases were done on an emergency basis (aortic dissection, n = 2; ruptured pseudoaneurysm, n = 1). Ascending aortic access was obtained through transapical (n = 4), transfemoral (n = 1), and left common carotid artery (n = 1) approaches. Cook Zenith TX2 (n = 4), Cook EVAR iliac limb (n = 1), and Amplatzer occluder (n = 1) devices were used, with 3 patients requiring more than 1 stent-graft. Stent-graft lengths ranged from 55 to 81 mm; diameters ranged from 22 to 40 mm. Technical success was achieved in 5 cases (83%); 1 patient (type A dissection) had an intraoperative endoleak not amendable to further endovascular repair. In-hospital and 30-day mortalities were zero. One patient sustained a minor stroke, which reversed completely. Stay ranged from 5 to 15 days. On follow-up, 1 patient (type A dissection) had an endoleak at 12 months. Two patients died of nonaortic causes at 6 and 27 months after endovascular repair. Conclusions Endovascular repair of ascending aortic pathology is feasible in patients facing high risk with open surgery, with promising early results. Technical challenges remain in adapting current endovascular technology to ascending aortic pathologies, particularly type A aortic dissection.

ObjectivePreviously, we showed that antegrade stent grafting of the descending thoracic aorta during DeBakey type I dissection repair improves distal aortic remodeling. We assessed midterm outcomes of this reconstructive strategy compared with standard open repair.MethodsDeBakey type I dissections (non-Marfan, nontotal arch cases only) from 2005 to 2012 were retrospectively reviewed. One hundred eighty patients underwent standard open repair (standard group), and 62 patients underwent open repair plus stenting (stented group). Open repair entailed ascending aorta plus transverse hemiarch reconstruction under circulatory arrest, with variable aortic root work. Data was prospectively maintained.ResultsPreoperative parameters were similar. Patients in the stented group had longer circulatory arrest time and higher utility of antegrade cerebral perfusion (P

removed; however, the contaminated needle puncture may be associated with subsequent mediastinal infection, so empirical antimicrobial therapy is suggested in selected cases. In conclusion, surgeons could consider EBUS-TBNA as an effective and alternative option in the diagnosis, subsequent surgical intervention, and identification of the causative agent of mediastinal infections in patients who are unable to undergo surgery.

Background The combined open surgical and endovascular approach for the treatment of aortic arch aneurysms has emerged as a safe treatment modality. This platform may have an especially important role in treating patients of old age and with a greater comorbid burden. We describe our institutional experience with the hybrid aortic arch approach, with midterm outcomes. Methods From 2005 to the present, 685 patients have undergone thoracic endovascular repair (TEVAR); 104 had a hybrid arch repair (open plus endovascular approach). Of these, 47 patients had treatment for an aortic arch aneurysm with or without a proximal ascending aortic aneurysm. All these patients had a median sternotomy approach for arch vessel debranching and antegrade with or without retrograde TEVAR stent grafting of the arch. Results from a prospectively maintained database are reported. Results Twenty-eight patients had type I repair, 8 patients had type II repair, and 11 patients had type III arch hybrid repair. Those with type III repair were excluded from the analysis. Stent graft deployment rate was 100% after arch vessel debranching. Mean age was 71 ± 8 years. Fourteen percent of cases involved a redo sternotomy. Average cardiopulmonary bypass time was 215 ± 64 minutes, with a crossclamp time of 70 ± 55 minutes and a circulatory arrest time of 19 ± 10 minutes. The paraplegia rate was 5.5% (n = 2), with a stroke rate of 8% (n = 3). In-hospital mortality was 8% (n = 3). There were no postoperative endoleaks. The mean length of stay was 17.2 ± 14 days. The median follow-up was 30 ± 21 months. Freedom from all-cause mortality was 71%, 60%, and 48% at 1, 3, and 5 years, respectively. The aortic reoperation rate was 2.7% (n = 1). No patient has a type 1 or 3 endoleak at latest follow-up. Conclusions The hybrid approach to aortic arch aneurysm involving a zone 0 stent graft landing can be safely adopted with good midterm results in a cohort of old patients with significant comorbidity. This procedure can be performed with no type 1 or 3 endoleaks and may represent a technical advancement in the field of aortic arch surgery.

Objective To present the outcomes of routinely performed hemiarch replacement in patients with acute type A aortic dissection. Methods From 1993 to 2013, among 629 patients with acute type A dissection, 534 patients (85%) underwent hemiarch, 63 patients (10%) underwent hemiarch and antegrade thoracic stent grafting, 26 patients (4%) underwent total arch, and 6 patients (1%) underwent isolated ascending replacement. Patients with hemiarch replacement comprised the study population. Median follow-up was 4.1 years (first quartile, 1.9; third quartile, 7.8) (2462 patient years). Results In-hospital mortality was 12% (66 out of 534 patients). Survival was 80% ± 2%, 68% ± 3%, and 51% ± 3%, and 84% ± 3%, 65% ± 4%, and 41% ± 6% in DeBakey type I and II patients at 1, 5, and 10 years, respectively (log rank P = .375). Freedom from distal aortic reintervention was 97% ± 1%, 90% ± 2%, and 85% ± 3% and 99% ± 1%, 97% ± 2%, and 90% ± 5% in DeBakey type I and II patients at 1, 5, and 10 years, respectively (log rank P = .046). Seven patients (1.3%) required reintervention for aortic arch aneurysm and 25 patients (5%) required reintervention for descending aortopathy. The success rate for distal reintervention performed electively or urgently was 92% (24 out of 26 patients). Marfan syndrome (odds ratio, 3.43; P = .046) and DeBakey type I dissection (odds ratio, 2.49; P = .048) were independent predictors of distal aortic reintervention. Conclusions Aggressive hemiarch replacement in acute type A dissection can be performed with low mortality and low aortic arch reoperation rate. Resection of all dissected aortic wall tissue decreases, but does not eliminate, the risk of later adverse aortic events.

ObjectivesThe current guidelines for ascending aortic replacement were determined from already dissected aorta diameters. Previous computed tomography-based work on humans who underwent imaging before and directly after aortic dissection onset has shown an average 30% increase in the ascending aortic diameter with acute dissection. The present investigation evaluated the incidence of predissection ascending aortic dilatation in acute type A dissection.MethodsFrom 2002 to 2013, 495 patients presented with acute type A aortic dissection to 1 center. Of these cases, 343 were non-Marfan, nonbicuspid with spontaneous dissection etiology. In those with available preoperative computed tomography angiograms (n = 83) or transesophageal echocardiograms (n = 260), the predissection ascending aorta diameters were modeled from the dissected aorta diameters by subtraction of the average diameter increase rate.ResultsAltogether 343 patients were included (age, 62 years; range, 53-73; 64% men). The median modeled predissection ascending diameter was 3.7 cm (first quartile, 3.3; third quartile, −4.1). Of the 343 patients, 334 (97%) and 315 (92%) had an ascending diameter before dissection onset of