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Objectives: To investigate the long-term durability of aortic valves, we reviewed the outcomes of patients who underwent valve-sparing root replacement with acute Type A aortic dissection., Methods: We included patients who underwent emergent aortic repair for acute Type A aortic dissection at our university hospital between 2000 and 2016. We identified patients who underwent valve-sparing root replacement from the included cohort and assessed their survival and long-term valve durability., Results: We identified 24 of 328 patients who underwent valve-sparing root replacement (age: mean ± SD 49 ± 11 years; 17 men). All patients underwent reimplantation procedures and 2 had concomitant cusp repairs (central plication). Prolapsed cusps caused by detached commissures in 12 cases were noted and reattached with buttress sutures with or without glue. There was no in-hospital mortality. Median follow-up period was 84 months (range 1-202 months) and survival was 100% at 5 and 10 years. Freedom from moderate or greater aortic insufficiency was 82% ± 10% at 5 years and 65% ± 13% at 10 years. Freedom from aortic valve reoperation was 83% ± 9% at 5 years and 69% ± 12% at 10 years. Valve reoperations were indicated for endocarditis in 1 patient, perforation of the aortic cusp in 1 patient and redetachment of commissures that had been attached with gelatin-resorcinol-formaldehyde glue at the initial operations in 3 patients., Conclusions: The durability of valve-sparing root replacement in acute aortic dissection was suboptimal. The major cause of late failure was commissure detachment after primary repair with buttress sutures and glue. Gelatin-resorcinol-formaldehyde glue should be avoided for commissural resuspension in patients with acute aortic dissection.

Aortic aneurysms and aortic dissection represent a significant health risk due to the demographic developments and current life styles. The mortality of ruptured aortic aneurysms is up to 80 % and the prevalence of aneurysms varies depending on the localization (thoracic or abdominal). Most commonly affected is the infrarenal abdominal aorta; however, there is evidence that the prevalence is diminishing but in contrast the incidence of thoracic aortic aneurysms is increasing. Aortic dissection is often fatal and is the most common acute aortic disease but the incidence is presumed to be underestimated. The pathogenesis of aortic aneurysms is manifold and is based on an interplay between degenerative, proteolytic and inflammatory processes. An aortic dissection arises from a tear in the intima which results in a separation of the aortic wall layers with infiltration of bleeding and the danger of aortic rupture. Various genetic disorders of connective tissue promote degeneration of the aortic media, most notably Marfan syndrome. Risk factors for aortic aneurysms and aortic dissection are nicotine abuse, arterial hypertension, age and male gender. Aortic aneurysms initially have an uneventful course and as a consequence are mostly discovered incidentally. The clinical course and symptoms of aortic dissection are very much dependent on the section of the aorta affected and the manifestations are manifold. Acute aortic dissection is in 80 % of cases first manifested as sudden extremely severe pain. The diagnostics and subsequent course control can be achieved by a variety of imaging procedures but the modality of choice is computed tomography.

The aim of this study was to evaluate the short-term operative results of patients with Marfan syndrome who underwent thoracic or abdominal aortic surgery in a 4-year period in Japan. Data were collected from the Japan Cardiovascular Surgery Database (JCVSD). We retrospectively analyzed the data of 845 patients with Marfan syndrome who underwent cardiovascular surgery between January 2008 and January 2011. Logistic regression was used to generate risk models. The early mortality rate was 4.4% (37/845). Odds ratios (OR), 95% confidence intervals (CI), and P values for structures and processes in the mortality prediction model were as follows: renal insufficiency (OR, 11.37; CI, 3.7234.66; P < 0.001); respiratory disorder (OR, 11.12; CI, 3.20-38.67; P < 0.001); aortic dissection (OR, 13.02; CI, 2.8060.60; P = 0.001); pseudoaneurysm (OR, 11.23; CI, 1.38-91.66; P = 0.024); thoracoabdominal aneurysm (OR, 2.67; CI, 1.22-5.84; P = 0.014); and aorticrupure (OR, 4.23; CI, 1.26-14.23; P = 0.002). The mortality prediction model had a Cindex of 0.82 and a Hosmer-Lemeshow P value of 0.56. In conclusion, this study demonstrated that renal insufficiency and respiratory disorder had great impact on the operative mortality of Marfan patients undergoing cardiovascular surgery. Because patients with aortic dissection or aortic rupture showed high operative mortality, close follow-up to avoid emergency operation is mandatory to improve the operative results. Achieving good results from surgery of the thoracoabdominal aorta was quite challenging, also in Marfan patients.

Introduction: Acute aortic dissection (AAD) is a serious disease of the aorta with high mortality and morbidity, which requires emergency surgical treatment in order to close the site of the dissection and direct blood flow into the true lumen. Improvements in surgical technique have led to better management of patients with reduced operative mortality, although it still remains high. The aim of this study is to evaluate early and late outcomes of the surgical treatment of acute type A aortic dissection at the hospital of Lecce between 1998 and 2007. We also aim to establish a correlation between these outcomes and pre-operative conditions, surgical procedures and location of the site of the tear., Methods: From 1998 to 2007, 100 patients (69 males and 31 females, average age 62.2 +/- 12.3 years, range 22-85 years) underwent surgery for acute AAD at the center. Surgical techniques included replacement of the ascending aorta (Asc Ao) with or without valve replacement (including five patients who underwent the Bentall/De Bono procedure) and replacement of the Asc Ao with or without arch or hemiarch replacement., Results: In-hospital mortality was 22%, with different results between surgery for replacement of the aorta and for aorta with valve replacement (respectively, 16% and 23%). Different mortality rates were found between the distal surgical treatments, with rates of 20.8% and 18.2% respectively between replacements of the Asc Ao and of Asc Ao with arch/hemiarch, although they were not statistically significant. A different mortality rate that was subject to the patient's preoperative condition has also been found (33.3% of mortality in patients in unstable or high-risk condition vs 13.8% in patients in stable condition). The peak reached 43.5% mortality in patients taken to the operating room while in shock or cardiac tamponade. The location of the site of the tear is another factor that distinguishes mortality rates, which are 17.8% if localized at the proximal ascending aorta and 22.2% in the aortic arch. Assessment of the outcome (10 years after surgery), has shown that four patients died several years later but for reasons unrelated to the surgery., Conclusions: The surgery of dissection is still an intervention with a relatively high in-hospital mortality risk, and whose outcome, which has been steady in the last 20 years, can be predicted according to the preoperative condition of the patient. This underlines the need to reduce the time of diagnosis indicating immediate surgical treatment.

Objective: Although rare, aortic dissection is one of the most devastating, but least studied, intraoperative complications. The objective of this study was to assess risk factors of aortic dissection and assess outcomes in patients with aortic dissection experience., Methods: A study from a 10-year hospitalization cohort (N = 12,907) with prospective data collection was conducted. Patients without aortic dissection were matched to 33 aortic dissection patients 3:1 on the type of procedure. The study examined 24 potential confounding risk factors and 12 outcome variables., Results: Univariate analysis on potential confounding risk factors revealed two significant risk factors. There was a significant difference between aortic dissection and nonaortic dissection patients with New York Heart Association (NYHA) functional class (p = 0.03). Patients with aortic dissection were more likely to be in Class I or II. Patients with aortic dissection had significantly longer perfusion time (p = 0.008). There was a significant difference between patients with and without aortic dissection on four outcome variables. Patients with an aortic dissection were more likely to need prolonged ventilation (p = 0.046), have renal failure (p = 0.005), require intraaortic balloon pump (IABP) (0.043), and have a higher mortality rate (p < 0.001)., Conclusion: Aortic dissection occurs infrequently during coronary artery bypass grafting, but is a devastating complication and greatly increases morbidity. Although few patients dissect intraoperatively, this study attempted to identify predictors that may label a patient as high risk for possible aortic dissection. Although two factors in this study were statistically significant, they are not reliable preoperative predictors of high-risk patients that can be used to screen patients and help prevent aortic dissection and its sequela.

Background: Treatment of acute type A aortic dissection remains a surgical challenge because of prolonged operative times, bleeding complications, and a considerable risk of neurologic morbidity and mortality. The following study investigates clinical results after modification of perfusion technique for cardiopulmonary bypass as well as temperature management., Methods: Between January 2000 and August 2006, 120 consecutive patients underwent repair of acute type A dissection. Selective antegrade cerebral perfusion through the right subclavian artery combined with mild systemic hypothermia (30 degrees C) was used in all patients., Results: Mean cardiopulmonary bypass time was 144 +/- 53 minutes, and mean myocardial ischemic time was 98 +/- 49 minutes. Isolated cerebral perfusion was performed for 25 +/- 12 minutes. Mean core temperature amounted to 30.1 degrees +/- 2.2 degrees C. Chest tube drainage during the first 24 hours was 525 +/- 220 mL. Mean ventilation time was 54 +/- 22 hours. Elevation of serum lactate levels at 1, 12, and 24 hours postoperatively rose to 22 +/- 14, 18 +/- 11, and 19 +/- 8 mg/dL respectively. We observed new postoperative permanent neurologic deficits in 5 patients (4.2%) and TND in 3 patients (2.5%). The 30-day mortality rate was 5% (n = 6). After a mean follow-up period of 2.8 years, 104 patients (87%) were still alive., Conclusions: Antegrade cerebral perfusion in combination with mild hypothermia offered sufficient neurologic protection in our patient cohort, provided adequate distal organ protection, and reduced perioperative complications in surgery for type A dissection. This perfusion strategy may help in reducing perioperative complications in this particular patient population.

Introduction: A retrospective review was undertaken to evaluate the results after surgery of the thoracic aorta in Denmark 1997-2003 and to evaluate if the organisation of surgery was in accordance with recommendations from The National Health Service. All operations were performed at one of the five cardiothoracic surgical departments in Denmark according to the recommendations from the National Health Service. However, this review showed that 49 different surgeons performed 542 operations corresponding to 1.7 operation per surgeon per year., Materials and Methods: Discharge letters and operative notes on patients operated for aortic aneurysm or aortic dissection were collected from The National Patient Registry. The study comprises 542 patients at a mean age of 59 +/- 12 years of age of whom 366 (68%) were operated on acutely. 369 patients were operated for aortic dissection and 173 were operated for aortic aneurysm. The number of operations increased from 59 in 1997 to 100 in 2003., Results: 30 day mortality was 18% for aneurysms and 30% for dissections. The mean postoperative length of stay was 35 +/- 12 days. When comparing the operating hospitals, there was no difference in mortality or in postoperative length of stay. 345 patients (64%) developed one or more postoperative complications. Severe neurologic complications developed in 20% of the patients operated for aortic dissection and in 10% operated for aortic aneurysm. Reoperation for bleeding occurred in 19% of the patients operated for aortic dissection and in 10% operated for aortic aneurysm., Conclusion: This study has shown that mortality and complication rate are higher in Denmark compared with corresponding studies abroad and it should be possible to improve the results in the future.

Background: Valve-sparing operations are gaining increasing acceptance; however, there is an ongoing discussion about the technique-specific indications. We present our experience with a follow-up of 123 months., Methods: Between July 1993 and July 2005, 164 consecutive patients were operated on using the remodeling (group A, n = 96) or reimplantation technique (group B, n = 68). Fifty-seven patients presented with acute type A dissection. Aortic regurgitation was present in 84%. Follow-up was 54.7 +/- 28 in group A and 48.4 +/- 37.3 months in group B., Results: After urgent operations, 4 patients died in each group, but none died after elective surgery. Late mortality was 8% in group A and 4% in group B. Seven patients of group A and 1 in group B required reoperation. Echocardiographic follow-up of reoperation-free survivors showed that 3 patients (all group A, 1.3%) had aortic regurgitation of more than grade II. Root diameter, valve pressure gradient, and valve orifice area were comparable. No gross thromboembolic or bleeding events occurred., Conclusions: Aortic valve-sparing operations can provide acceptable long-term results in both techniques. Particular care to the annulus in the remodeling technique and different prosthesis designs in the reimplantation technique may overcome the intrinsic problems of each procedure.

Background: The International Registry of Aortic Dissections showed that 42% of the unoperated patients with type A acute aortic dissection were discharged from the hospital after intensive medical treatment. We analyzed our experience to identify a preoperative score for in-hospital mortality to propose an alternative strategy for type A acute aortic dissection., Methods: From 1980 to 2004, 616 consecutive patients with type A acute aortic dissection underwent surgery in our center. The preoperative univariate risk factors with a probability value less than 0.05 were entered into multivariate analysis. A risk equation was developed: predicted mortality = exp(beta 0 + sigma beta i X i)/[1 + exp(beta 0 + sigma beta i X i)]., Results: Early mortality was 25.1% (154 of 616 patients). Five risk factors were identified: age, coma, acute renal failure, shock, and redo operation. The beta i values are age 0.023, shock 0.771, reoperation 0.595, coma 1.162, acute renal failure 0.778; the constant (beta 0) is -2.986., Conclusions: Our large, single-center experience allowed us to develop a mathematical model to predict 30-day mortality for type A acute aortic dissection. When the expected mortality is 58% or less, surgery is always indicated. When the predicted mortality is greater than 58%, the possibility of survival is similar, according to International Registry of Aortic Dissections data, for surgery and medical treatment. In such cases surgery can no longer be considered mandatory, and a careful evaluation of the individual patient is recommended to choose the more suitable strategy.

Background: Risk of repairing aortic dissection after previous cardiovascular surgery has not been described clearly. This study assesses early and late outcomes of such reoperations., Methods: From January 1, 1990, to January 1, 2002, 108 patients with prior cardiovascular surgery (isolated coronary artery bypass grafting, 51%; isolated valve surgery, 21%; aortic aneurysm repair, 24%; and combinations of these in the remainder) underwent reoperation for aortic dissection (emergency operation for acute dissection in 24%). Mean age was 63 +/- 13 years, and 85% were men. The interval since prior surgery ranged from 10 days to 22 years (median, 3.8 years). This was the third operation for 8%. Ascending aortic repair with or without aortic arch or descending aortic repair was performed in 40%, aortic valve replacement (n = 15) or repair (n = 17) with ascending aortic repair in 30%, aortic root replacement with or without aortic arch or descending aortic repair in 30%, and aortic arch with or without descending aortic repair in 1%. Circulatory arrest was used in 78%, with retrograde brain perfusion in 58%., Results: Hospital mortality was 6%, stroke 4%, renal failure 2%, and respiratory failure 7%. Survival at 30 days and 1, 3, 5, and 7 years was 93%, 85%, 74%, 63%, and 53%, respectively. Aortic reoperation was performed in 7 patients, with freedom from this event at 30 days and 1, 3, 5, and 7 years of 98%, 95%, 93%, 91%, and 89%., respectively, Conclusions: Aortic dissection after cardiovascular surgery is rare and can be managed with acceptable operative risks and good long-term survival. Need for subsequent aortic reoperation is uncommon.

Objective: Aortic dissection is associated with significant mortality and morbidity. Effective methods to treat aortic disection are now available although these lesions still challenge the cardiovascular surgeon., Methods: From January 1994 to January 2000. 131 patients with DeBakey I, II type aortic dissection underwent surgical treatment. Operations were performed under cardiopulmonary bypass in 59 patients. Hypothermic circulatory arrest was used in 15 patients. Hypothermic circulatory arrest and selective cerebral perfusion was used in 57 patients. A graft replacement of ascending aorta and partial aortic arch was performed in 25 patients, ascending aorta and total aortic arch in 10. 83 patients underwent the Bentall procedure. The Bentall procedure and total aortic arch replacement were performed in 3 patients, the Wheats operation in 4. 4 patients underwent the elephant trunk techniques and 2 patients with the elephant trunk techniques and the Bentall procedures., Results: There were 4 deaths within 30 days after surgery with an operative mortality of 3.05%, and 3 neurological dysfunction undergone hypothermic circulatory arrest. They were recovered within 1 week., Conclusion: The operative technique is difficult. Selective cerebral perfusion can provide available protection during surgery of aortic dissection. It prolongs the time allowed to performed the aortic repair.