Search

Various surgical options have been described for the treatment of aberrant subclavian arteries and an associated Kommerell diverticulum.Between 1999 and 2019, 43 patients underwent a repair, comprising 26 (61%) endovascular and 17 (39%) open approaches. The endovascular approach consisted of initial subclavian revascularization followed by thoracic endovascular aortic repair. The open approach included total arch replacement (12%) and reverse hemiarch repair with left thoracotomy (53%) or right thoracotomy (35%). The perioperative and long-term outcomes were retrospectively reviewed.No mortality occurred in the endovascular group, whereas there was 1 (6%) in the open approach group. Patients in the endovascular group demonstrated a shorter hospital stay (3.5 days vs 10.0 days; P = .001) and less frequent prolonged mechanical ventilation (0% vs 24%; P = .019), with a lower occurrence of pneumonia (0% vs 24%; P = .019). Among patients who had the endovascular approach, shrinkage of Kommerell diverticulum or aberrant vessel origin was seen in 96%. Furthermore, relief of dysphagia was confirmed in 92% (12/13), including patients without Kommerell diverticulum (n = 3) after endovascular repair. The cumulative incidence of treatment failure or aortic reintervention at 7 years was 21% and 14 % in the endovascular and open approach groups, respectively (P = .62). Two (8%) patients in the endovascular group required an open reintervention. One reintervention was performed for persistent dysphagia in the setting of an untreated complete vascular ring, and the other was for persistent false lumen flow associated with aortic dissection.The treatment approach should be individualized on the basis of the aortic disease and comorbidities. The endovascular approach is a viable and effective alternative in the presence of suitable landing zones.

To compare perioperative and midterm outcomes in thoracic and thoraco-abdominal aortic aneurysm (TAA and TAAA) repair using hypothermic circulatory arrest (HCA) or aortic clamping (AC) with mild hypothermia.From 2012 to 2021 there were 180 open repairs of a TAA or TAAA, of which 90 (50%) were done with HCA and 90 (50%) with aortic clamping with mild hypothermia. The indications for HCA were arch aneurysm, TAA from chronic aortic dissection, and inability to clamp the aorta for proximal anastomosis.Compared to AC, the HCA group had less prior descending aorta replacement/repair (9.1% vs. 32%, p = 0.0001). Intraoperatively, the HCA group had more TAAs (70% vs. 20%, p 0.0001) while the AC group had more TAAAs (80% vs. 30%, p 0.0001). HCA group had longer cardiopulmonary bypass times (242 vs. 181 min, p 0.0001) but shorter cross-clamp time (39 vs. 120 min, p 0.0001) and lower temperatures (18°C vs. 34°C, p 0.0001). Postoperatively, the HCA group had longer intubation times (31 vs. 26 h, p = 0.002), but all other postoperative outcomes including paralysis (2.2% vs. 8.9%, p = 0.08), and operative mortality (4.4% vs. 2.2%, p = 0.68) were similar between HCA and AC groups. Patient age was an independent risk factor for postoperative paralysis (OR 1.07, p = 0.03) while HCA was not significant (OR 0.37, p = 0.21). Five-year survival was similar between HCA and AC groups (85% vs. 80%, p = 0.36).Postoperative outcomes and midterm survival were acceptable in thoracic and thoracoabdominal aneurysm patients after HCA or AC. Both HCA and AC with mild hypothermia were valid approaches in TAA/A repair.

OBJECTIVES Malperfusion syndrome accompanying aortic dissection is an independent predictor of death with in-hospital mortality rates >60%. Asymmetrically decreased renal enhancement on computed tomography angiography is often considered evidence of renal malperfusion. We investigated the associations between renal enhancement, baseline laboratory values and the diagnosis of renal malperfusion, as defined by invasive manometry, among patients with aortic dissection. METHODS In this retrospective cohort study, we included all patients who were referred to our institution with acute dissection and suspected visceral malperfusion between 2010 and 2020. We determined asymmetric renal enhancement by visual assessment and quantitative density measurements of the renal cortex. We collected invasive renal artery pressures during invasive angiography at the aortic root and in the renal arteries. Logistic regression was performed to evaluate independent predictors of renal malperfusion. RESULTS Among the 161 patients analysed, the majority of patients were male (78%) and had type A dissection (52%). Invasive angiography confirmed suspected renal malperfusion in 83% of patients. Global asymmetric renal enhancement was seen in 42% of patients who did not have renal malperfusion during invasive angiography. Asymmetrically decreased renal enhancement was 65% sensitive and 58% specific for renal malperfusion. Both global [odds ratio (OR) 4.43; 1.20–16.41, P = 0.03] and focal (OR 11.23; 1.12–112.90, P = 0.04) enhancement defects were independent predictors for renal malperfusion. CONCLUSIONS In patients with aortic dissection, we found that differential enhancement of the kidney as seen on the computed tomography angiography is predictive, but not prescriptive for renal malperfusion. While detection of renal malperfusion is aided by computed tomography angiography, its diagnosis requires close monitoring and often invasive assessment.

OBJECTIVES We sought to examine management and outcomes of (Stanford) type A aortic dissection (TAAAD) in patients aged >70 years. METHODS All patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection database (1996–2018) were studied (n = 5553). Patients were stratified by age and therapeutic strategy. Outcomes for octogenarians were compared with those for septuagenarians. Variables associated with in-hospital mortality were identified by multivariable logistic regression. RESULTS In-hospital mortality for all patients (all ages) was 19.7% (1167 deaths), 16.1% after surgical intervention vs 52.1% for medical management (P 80 years. Fewer octogenarians underwent surgery versus septuagenarians (68.1% vs 85.9%, P CONCLUSIONS When compared with septuagenarians, a smaller percentage of octogenarians undergo surgical repair for TAAAD, even though postoperative outcomes are similar. Age alone should not preclude consideration for surgery in appropriately selected patients with TAAAD.

Aortic valve replacement (AVR) is common in the setting of type A aortic dissection (TAAD) repair. Here, we evaluated the association between prosthesis choice and patient outcomes in an international patient cohort. We reviewed data from the International Registry of Acute Aortic Dissection (IRAD) interventional cohort to examine the relationship between valve choice and short- and mid-term patient outcomes. Between January 1996 and March 2016, 1290 surgically treated patients with TAAD were entered into the IRAD interventional cohort. Of those, 364 patients undergoing TAAD repair underwent aortic valve replacement (AVR; mean age, 57 years). The mechanical valve cohort consisted of 189 patients, of which 151 (79.9%) had a root replacement. The nonmechanical valve cohort consisted of 5 patients who received homografts and 160 patients who received a biologic AVR, with a total of 118 (71.5%) patients who underwent root replacements. The mean follow-up time was 2.92 ± 1.75 years overall (2.46 ± 1.69 years for the mechanical valve cohort and 3.48 ± 1.8 years for the nonmechanical valve cohort). After propensity matching, Kaplan-Meier estimates of 4-year survival rates after surgery were 64.8% in the mechanical valve group compared with 74.7% in the nonmechanical valve group (p = 0.921). A stratified Cox model for 4-year mortality showed no difference in hazard between valve types after adjusting for the propensity score (p = 0.854). A biologic valve is a reasonable option in patients with TAAD who require AVR. Although this option avoids the potential risks of anticoagulation, long-term follow up is necessary to assess the effect of reoperations or transcatheter interventions for structural valve degeneration.

Despite the rapid adoption of transcatheter aortic replacement (TAVR), surgical TAVR valve explantation (TAVR-explant) and the clinical impact of explanted TAVR device type are not well described.TAVR-explant from 2016 to 2019 was queried using the Society of Thoracic Surgeons (STS) National Database. A total of 483 patients with documented explanted valve type, consisting of 330 (68%) patients with balloon-expandable and 153 (32%) patients with self-expandable devices, were identified. The primary outcome was 30-day mortality. The secondary outcome was the need for any simultaneous procedures with TAVR-explant.The mean age was 72.8 years, 38% of the patients were female, and 51% demonstrated New York Heart Association functional class III to IV symptoms. During TAVR-explant, 63% of patients required other simultaneous procedures, including aortic repair (27%), mitral procedures (22%), coronary artery bypass grafting (15%), and tricuspid procedures (7%). Patients with a self-expandable device underwent more frequent ascending aortic replacement (22% vs 9%; P.001) than those with a balloon-expandable device, whereas the aortic root replacement rate was similar (19% vs 24%; P = .22). The overall 30-day mortality was 18% without differences in the mortality or other major complications between the groups. Of the 157 patients with isolated surgical aortic valve replacement and available STS predicted risk of mortality score, the observed-to-expected (O/E) mortality ratio was 2.2.The TAVR-explant outcomes were comparable between patients with balloon-expandable devices and patients with self-expandable devices, whereas ascending aortic replacement was observed more frequently in patients with self-expandable devices. Younger patients undergoing TAVR should be informed of the future TAVR-explant risk that may accompany a higher O/E ratio and frequent morbid concurrent procedures.

Background Aortic diameter measurements in patients with a thoracic aortic aneurysm (TAA) show wide variation. There is no technique to quantify aortic growth in a three-dimensional (3D) manner. Purpose To validate a CT-based technique for quantification of 3D growth based on deformable registration in patients with TAA. Materials and Methods Patients with ascending and descending TAA with two or more CT angiography studies between 2006 and 2020 were retrospectively identified. The 3D aortic growth was quantified using vascular deformation mapping (VDM), a technique that uses deformable registration to warp a mesh constructed from baseline aortic anatomy. Growth assessments between VDM and clinical CT diameter measurements were compared. Aortic growth was quantified as the ratio of change in surface area at each mesh element (area ratio). Manual segmentations were performed by independent raters to assess interrater reproducibility. Registration error was assessed using manually placed landmarks. Agreement between VDM and clinical diameter measurements was assessed using Pearson correlation and Cohen κ coefficients. Results A total of 38 patients (68 surveillance intervals) were evaluated (mean age, 69 years ± 9 [standard deviation]; 21 women), with TAA involving the ascending aorta (n = 26), descending aorta (n = 10), or both (n = 2). VDM was technically successful in 35 of 38 (92%) patients and 58 of 68 intervals (85%). Median registration error was 0.77 mm (interquartile range, 0.54-1.10 mm). Interrater agreement was high for aortic segmentation (Dice similarity coefficient = 0.97 ± 0.02) and VDM-derived area ratio (bias = 0.0, limits of agreement: -0.03 to 0.03). There was strong agreement (r = 0.85, P < .001) between peak area ratio values and diameter change. VDM detected growth in 14 of 58 (24%) intervals. VDM revealed growth outside the maximally dilated segment in six of 14 (36%) growth intervals, none of which were detected with diameter measurements. Conclusion Vascular deformation mapping provided reliable and comprehensive quantitative assessment of three-dimensional aortic growth and growth patterns in patients with thoracic aortic aneurysms undergoing CT surveillance. Published under a CC BY 4.0 license Online supplemental material is available for this article. See also the editorial by Wieben in this issue.

Institution of extracorporeal membrane oxygenation (ECMO) results in unique blood flow characteristics to the end-organ vascular beds. We studied the interplay between cardiac-driven and extracorporeal membrane oxygenation (ECMO)-driven flow to vascular beds in different ECMO configurations using a patient-specific computational fluid dynamics (CFD) analysis. A computational ECMO model (femoral artery cannulation [FAC]) was constructed using patient-specific imaging and hemodynamic data. Following model calibration, we augmented the 3D geometrical model to represent alternative ECMO configurations (ascending aorta cannulation [AAC] and subclavian artery cannulation [SAC]). We performed CFD analyses, including a novel virtual color-dye analysis to compare global and regional blood flow and pressure characteristics as well as contributions of cardiac and ECMO-derived flow to the various vascular beds. Flow waveforms at all the aortic branch vessels were pulsatile, despite low cardiac output and predominant nonpulsatile ECMO-driven hemodynamics. Virtual color-dye analysis revealed differential contribution of cardiac and ECMO-derived flow to the end-organ vascular beds in the FAC model, while this was more evenly distributed in the AAC and SAC models. While global hemodynamics were relatively similar between various ECMO configurations, several distinct hemodynamic indices, in particular wall shear stress and oscillatory shear patterns, as well as differential contribution of ECMO-derived flow to various vascular beds, showed remarkable differences. The clinical impact of this study highlighting the relevance of CFD modeling in assessment of complex hemodynamics in ECMO warrants further evaluation.

Background Management of type A aortic dissection with cerebral malperfusion poses a significant challenge. Although involvement of craniocervical vessels is undoubtedly critical, it is not well investigated in the surgical literature. Methods Between 1997 and 2019, 775 patients presented with acute type A aortic dissection and 80 (10%) with cerebral malperfusion. All patients were transferred from outside institutions. Medical records and imaging studies were retrospectively reviewed. Results Fifty-nine patients (74%) underwent an open repair, 2 (3%) had an endovascular aortic repair, 2 (3%) had carotid stenting, and 18 (23%) received nonoperative management. In-hospital mortality of all comers was 40.0%, and 81.3% were neurology related. Among the 45 patients (56%) in whom cerebrocervical imaging studies were available, 11 (24%) had an internal carotid artery (ICA) occlusion and 28 (62%) had a common carotid artery (CCA) occlusion without ICA involvement as the culprit lesion. Six comatose patients (55%) were in the ICA group and 10 comatose patients (36%) in the CCA group (P = .28). All patients with ICA occlusion developed cerebral edema and herniation syndrome regardless of the management and died. In contrast 79% of patients with unilateral or bilateral CCA occlusion survived to hospital discharge (P Conclusions ICA occlusion in the presence of type A aortic dissection may be a surrogate marker for dismal neurologic outcomes regardless of the surgical approach, whereas CCA occlusion or comatose state should not preclude surgical candidacy. A prompt neck computed tomography angiography may be warranted in patients with cerebral malperfusion.

Background: Hybrid debranching repair of pararenal and thoracoabdominal aortic aneurysms was initially designed as a better alternative to standard open repair, addressing the limitations of endovascular repair involving the visceral aorta. We reviewed the collective outcomes of hybrid debranching repairs using extra-anatomic, open surgical debranching of the renal-mesenteric arteries, followed by endovascular aortic stenting. Methods: Data from patients who underwent hybrid repair in 14 North American institutions during 10 years were retrospectively reviewed. Society of Vascular Surgery scores were used to assess comorbidity risk. Early and late outcomes, including mortality, morbidity, reintervention, and patency were analyzed. Results: A total of 208 patients (118 male; mean age, 71±8 years old) were treated by hybrid repair with extraanatomic reconstruction of 657 renal and mesenteric arteries (mean 3.2 vessels/patient). Mean aneurysm diameter was 6.6±1.3 cm. Thoracoabdominal aortic aneurysms were identified in 163 (78%) patients and pararenal aneurysms in 45 (22%). A single-stage repair was performed in 92 (44%) patients. The iliac arteries were the most common source of inflow (n=132; 63%), and most (n=150; 72%) had 3 or more bypasses. There were 30 (14%) early deaths, ranging widely across sites (0%–21%). A Society of Vascular Surgery comorbidity score >15 was the primary predictor of early mortality ( P P Conclusions: Mortality after hybrid repair and visceral debranching is highly variable by center, but strongly affected by preoperative comorbidities and the centers’ experience with the technique. With excellent graft patency at 5 years, the outcomes of hybrid repair done at centers of excellence and in carefully selected patients may be comparable (or better) than traditional open or even totally endovascular approaches. However, in patients already considered as high-risk for surgery, it may not offer better outcomes.

Background Aortic stenosis (AS) is the most common form of valvular heart disease with an increasing prevalence. Management of AS has changed dramatically with the introduction of transcatheter aortic valve replacement (AVR). The shift in management of AS, combined with an aging population, may increase the cost of patients with AS in the US health care system. Methods and Results We performed a retrospective cohort study, using inpatient, carrier, and outpatient data from a 20% Medicare fee‐for‐service beneficiaries' sample from 2008 to 2019 and included beneficiaries, aged ≥65 years. We identified beneficiaries with a diagnosis of AS and stratified the sample into 3 age groups: 66 to 74, 75 to 84, and ≥85 years. We evaluated the crude and adjusted changes in annual Medicare payments (total and component) per beneficiary. We identified 1 887 340 (1.6%) Medicare beneficiaries diagnosed with AS. The average annual spending for Medicare beneficiaries with AS was $19 241 in 2010 and increased annually by $301 to $23 174 in 2019 ( P 1.7 billion dollars. Inpatient spending increased 1.1% per year, with the highest increase in patients aged ≥85 years (1.9%). The percentage of beneficiaries undergoing surgical AVR decreased from 3.7% to 1.6%, and annual spending on surgical AVR decreased an average of 7.2% per year. The percentage of beneficiaries undergoing transcatheter AVR increased from 0% in 2010 to 3.8% in 2019, and annual spending for transcatheter AVR increased by 458.7% per year. Conclusions Although average annual Medicare spending per beneficiary modestly increased over the study period, the increase in the prevalence of AS and the proportion of beneficiaries undergoing (transcatheter) interventions for AS led to a substantial increase in overall Medicare spending among patients with AS.

OBJECTIVES Differential luminal enhancement [between true lumen (TL) and false lumen (FL)] results from differential flow patterns, most likely due to outflow restriction in the FL. We aimed to assess the impact of differential luminal enhancement at baseline computed tomography angiography on the risk of adverse events in patients with acute type B aortic dissection (TBAD). METHODS Baseline computed tomography angiographies of patients with acute TBAD between 2007 and 2016 (n = 48) were analysed using three-dimensional software at multiple sites along the descending thoraco-abdominal aorta. At each location, we measured contrast density in TL and FL [Houndsfield unit (HU)], maximal diameter (cm) and circumferential FL extent (°). Outcome data were collected via retrospective chart review. Multivariable logistic regression models were employed to determine the independent risk of TL–FL differential luminal enhancement on aneurysm formation (maximal diameter ≥55 mm) and medical treatment failure. RESULTS Patients were predominately male (75%) and 52.8±12.9 years at diagnosis. The mean follow-up was 5.9±2.6 years, and 42% (n = 20/48) patients were diagnosed with thoraco-abdominal aortic aneurysm. The baseline absolute difference between FL and TL contrast density measured at 2 cm distal to primary entry tear (TL–FLabs-Tear) was significantly higher among patients who developed aneurysm (26 HU, IQR: 15–53 vs 13 HU, IQR: 4–24, P = 0.001). Aneurysm development during follow-up was predicted by TL–FLabs-Tear (odds ratio 1.07, P = 0.012) and baseline maximal aortic diameter (odds ratio 1.90, P CONCLUSIONS Differential luminal enhancement may be a novel predictor of aneurysm formation among patients with acute TBAD.

OBJECTIVES Confident growth assessment during imaging follow-up is often limited by substantial variability of diameter measurements and the fact that growth does not always occur at standard measurement locations. There is a need for imaging-based techniques to more accurately assess growth. In this study, we investigated the feasibility of a three-dimensional aortic growth assessment technique to quantify aortic growth in patients following open aortic repair. METHODS Three-dimensional aortic growth was measured using vascular deformation mapping (VDM), a technique which quantifies the localized rate of volumetric growth at the aortic wall, expressed in units of Jacobian (J) per year. We included 16 patients and analysed 6 aortic segments per patient (96 total segments). Growth was assessed by 3 metrics: clinically reported diameters, Jacobian determinant and targeted diameter re-measurements. RESULTS VDM was able to clearly depict the presence or absence of localized aortic growth and allows for an assessment of the distribution of growth and its relation to anatomic landmarks (e.g. anastomoses, branch arteries). Targeted diameter change showed a stronger and significant correlation with J (r = 0.20, P = 0.047) compared to clinical diameter change (r = 0.15, P = 0.141). Among 20/96 (21%) segments with growth identified by VDM, growth was confirmed by clinical measurements in 7 and targeted re-measurements in 11. Agreement of growth assessments between VDM and diameter measurements was slightly higher for targeted re-measurements (kappa = 0.38) compared to clinical measurements (kappa = 0.25). CONCLUSIONS Aortic growth is often uncertain and underappreciated when assessed via standard diameter measurements. Three-dimensional growth assessment with VDM offers a more comprehensive assessment of growth, allows for targeted diameter measurements and could be an additional tool to determine which post-surgical patients at high and low risk for future complications.

BACKGROUND. Patients with acute type A aortic dissection with a previous cardiac surgery (PCS) and malperfusion syndrome (MPS) are extremely difficult to manage and have poor outcomes. METHODS. From 1996 to 2018, 668 patients underwent emergent open aortic repair or endovascular fenestration/stenting for MPS for an acute type A aortic dissection, including those with PCS (PCS, n = 64) and those without PCS (No-PCS, n = 604). The groups were further divided into PCS+MPS, PCS+No-MPS, No-PCS+MPS, and No-PCS+No-MPS. RESULTS. Compared with the No-PCS group, the PCS group had significantly more coronary artery disease, acute renal failure, and mesenteric and renal MPS. Forty-two percent of patients with PCS underwent upfront endovascular fenestration/stenting for endovascular-amendable MPS. The in-hospital mortality was significantly higher in patients with PCS+MPS (40%) compared with PCS+No-MPS (5.9%), No-PCS+MPS (30%) and No-PCS+No-MPS (6.7%). Multivariable logistic regression showed cardiogenic shock (odds ratio, 7.3) and MPS (odds ratio, 6.6) were risk factors for in-hospital mortality (P < .0001). After recovering from MPS the PCS group (n = 54) had similar rates of postoperative complications, including 30-day mortality (7.4% vs 6.3%, P = .77), compared with the No-PCS group (n = 557). The 5-year survival was significantly lower in the PCS group compared with the No-PCS group (60% vs 72%, P = .004) and was lowest in those with PCS+MPS (46%). PCS was not a significant risk factor for in-hospital (odds ratio, 1.2; P = .63) or late (hazard ratio, 1.3; P = .27) mortality. CONCLUSIONS. Because of severe preoperative comorbidities and the complexity of open aortic repair, in acute type A aortic dissection patients with PCS and MPS, endovascular fenestration and stenting first with delayed redo sternotomy and central aortic repair was a valid approach.

The longevity of a stentless valve in a younger population (20-60 years old) is unknown.From 1992 to 2015, 1947 patients underwent aortic valve/root replacement for aortic stenosis, insufficiency, root aneurysm, or aortic dissection with stentless bioprostheses (median size, 26 mm). At operation 105 patients were40 years old, 528 were 40 to 59, 860 were 60 to 74, and 454 were ≥75 years. The data were obtained through chart review, administered surveys, and the National Death Index.The 30-day mortality rate was 2.6%. During follow-up 807 patients (41%) died before reoperation, 993 (51%) were alive without reoperations because of deterioration, and 113 patients (5.8%) underwent reoperation for structural valve deterioration. After adjusting death and reoperation for non-structural valve deterioration causes as competing risks, the cumulative incidence of reoperation was significantly different between the younger groups (40, 40-59) and the older groups (60-74, ≥75; P.0001) but not inside the younger (40 vs 40-59) or older (60-74 vs ≥75) group. The significant hazard ratio of reoperation for40 versus ≥75 years of age was 12,40 versus 60 to 74 was 4, 40 to 59 versus 60 to 74 was 3, and 40 to 59 versus ≥75 was 9 (P ≤ .01). The 10- and 15-year survival in the entire cohort was 53% and 29%, respectively.The stentless aortic valve provides satisfactory durability as a conduit for aortic valve/root replacement for patients who prefer a bioprosthesis. However it should be judiciously considered for patients younger than 60 years because of an increased incidence of reoperation for structural valve deterioration.

OBJECTIVES To improve haemodynamic performance, design modifications of prosthetic valves have been proposed with each new generation of valves. These different designs also impact the amount of mechanical wear, because mechanical stresses are distributed differently. Because long-term evidence for new prosthetic valves is lacking, this in vitro study compared hydrodynamic performance and durability among 3 currently available bioprosthetic valves with internally (IMLV) or externally mounted leaflets (EMLV). METHODS Prostheses of the internally mounted Medtronic Avalus and Carpentier-Edwards Perimount Magna Ease valves were compared to prostheses of the externally mounted Abbott Trifecta valve. For each labelled size (e.g. 19, 21 and 23) of the 3 types, 3 valves underwent accelerated wear testing for up to 600 million cycles, corresponding to ∼15 years of simulated wear. The valves underwent hydrodynamic testing and visual inspection. RESULTS EMLV had the largest effective orifice area and lowest pressure gradient for each labelled size at baseline and 600 million cycles; the effective orifice area and the pressure gradient were equivalent for the 2 types of IMLV. Five of 9 EMLVs had at least 1 hole or tear in the leaflet tissue around the stent posts, which resulted in severe regurgitation at 500 million cycles in 2 cases. All IMLVs were intact at 600 million cycles with minimal tissue wear. CONCLUSIONS EMLV showed superior hydrodynamic performance but inferior mechanical durability compared to IMLV after 600 million cycles of testing. The primary failures were because of significant mechanical abrasion in the commissural region, which may warrant close monitoring of EMLV during long-term follow-up.

There are limited data on cardiopulmonary exercise testing (CPX) and cardiorespiratory fitness (CRF), following open repair for a proximal thoracic aortic aneurysm or dissection. The aim was to evaluate serious adverse events, abnormal CPX event rate, CRF (peak oxygen uptake, (Equation is included in full-text article.)O2peak), and blood pressure.Patients were retrospectively identified from cardiac rehabilitation participation or prospectively enrolled in a research study and grouped by phenotype: (1) bicuspid aortic valve/thoracic aortic aneurysm, (2) tricuspid aortic valve/thoracic aortic aneurysm, and (3) acute type A aortic dissection.Patients (n = 128) completed a CPX a median of 2.9 mo (interquartile range: 1.8, 3.5) following repair. No serious adverse events were reported, although 3 abnormal exercise tests (2% event rate) were observed. Eighty-one percent of CPX studies were considered peak effort (defined as respiratory exchange ratio of ≥1.05). Median measured (Equation is included in full-text article.)O2peak was36% predicted normative values (19.2 mL·kgmin vs 29.3 mLkgmin, P.0001); the most marked impairment in (Equation is included in full-text article.)O2peak was observed in the acute type A aortic dissection group (40% normative values), which was significantly different from other groups (P.05). Peak exercise systolic and diastolic blood pressures were 160 mm Hg (144, 172) and 70 mm Hg (62, 80), with no differences noted between groups.We observed no serious adverse events with an abnormal CPX event rate of only 2% 3 mo following repair for a proximal thoracic aortic aneurysm or dissection. (Equation is included in full-text article.)O2peak was reduced among all patient groups, especially the acute type A aortic dissection group, which may be clinically significant, given the well-established prognostic importance of reduced cardiorespiratory fitness.

It is controversial if extension of aortic dissection into arch branches should be an indication for replacement of the arch and its branches in acute type A aortic dissection.From 2008 to April 2018, 399 patients underwent open repair for an acute type A aortic dissection, and 190 patients had known innominate and/or left common carotid artery dissection without malperfusion syndrome, including no arch procedure (n = 1)/hemiarch replacement (n = 109) and zone 1/2/3 arch replacement (n = 80) with replacement of 1 to 4 arch branch vessels.Median patient age was 58 years. Preoperative comorbidities were similar between groups, except the hemiarch group had more coronary artery disease (22% vs 3%, P = .0002). Both groups underwent similar aortic root procedures and other concomitant procedures with equivalent cardiopulmonary bypass and aortic cross-clamp times. The zone 1/2/3 group had longer hypothermic circulatory arrest times with greater use of antegrade cerebral perfusion (all P.05). The perioperative and midterm outcomes were similar between the hemiarch and zone 1/2/3 arch groups, including 30-day mortality (7% vs 5%), rates of transient ischemic attack and stroke, incidence rates of reoperation for distal aortic pathology with a mean follow-up time of 3.5 years, and 5-year survival (79% [95% confidence interval, 69%-87%] vs 85% [95% confidence interval, 71%-93%]). However the hemiarch group had a trend of increased cumulative incidence of reoperation (8-year, 23% vs 9%; P = .33).In acute type A aortic dissection, dissection of arch branches alone should not be an indication for routine zone 1/2/3 arch replacement; however zone 1/2/3 arch replacement could be considered to prevent future reoperations in select patients.

OBJECTIVES Maximal aortic diameter is commonly used to assess aortic risk but poorly predicts the timing and location of dissection events in patients with connective tissue disease who undergo regular imaging surveillance. Hence, we aimed to use available surveillance computed tomography angiography (CTA) scans to investigate the correlation between 3-dimensional (3D) growth and cyclic transmural wall stress with the location of intimal tear formation. METHODS Three type B aortic dissection patients with 2 available electrocardiogram (ECG)-gated pre-dissection CTA scans and without surgical repair during the pre-dissection interval were retrospectively identified at our institution. Vascular deformation mapping was used to measure 3D aortic growth between 2 pre-dissection clinical CTA studies. In addition, we performed a computational analysis to estimate cyclic transmural wall stress in patient-specific baseline CTA geometries. RESULTS In all 3 connective tissue disease patients, the site of type B aortic intimal tear co-localized with areas of peak 3D aortic wall growth. Aortic growth was detected by clinical radiological assessment in only 1 case. Co-localization of peak transmural stress and the site of intimal tear formation were found in all cases. CONCLUSIONS Focal areas of growth and transmural wall stress co-localized with the site of intimal tear formation. These hypothesis-generating results suggest a possible new analytic pathway for a more sophisticated assessment of the factors leading to the initiation of dissection in patients with connective tissue disease. These methods could improve on current risk-stratification techniques.

Historically, a variety of non–dissection proximal aortic pathologies with suitable anatomy have been treated with thoracic endovascular aortic repair (TEVAR) with high technical success rates. However, TEVAR use for acute type A aortic dissection has been extremely limited due to the unique challenging anatomic and clinical features and the lack of specifically-designed endoprostheses. These features include: proximity of the aortic valve, coronary arteries, and supra-aortic vessels, related aortic insufficiency, diffusely dilated aorta diameter, entry tear extension into the aortic root and/or aortic arch, the dissection involvement of supra-aortic vessels, high degrees of ascending aortic curvature and notable length discrepancies between the greater and lesser curvatures, and tissue fragility at prosthesis-tissue transition zones. Additionally, the presence of patent coronary artery bypass grafting conduits on the ascending aorta is another factor precluding endovascular options and hybrid surgical and endovascular approaches may be considered. In contrast, early feasibility clinical trials of investigational devices specifically designed to treat type A aortic dissections have been currently underway. In our opinion, the location and extent of intimal tears are quite variable and only a minority of patients with type A aortic dissection are deemed suitable candidates for ascending TEVAR. On the contrary, combined application of aortic arch endograft, as demonstrated in the present report, likely increases TEVAR candidacy as well as procedural success rates.

Thoracic endovascular aortic repair has emerged as the dominant paradigm for treatment of patients with descending thoracic aortic aneurysms. For aneurysms involving the aortic arch in the region of the left subclavian artery (LSA), branch vessel preservation to maintain blood flow to the LSA is recommended. Branched aortic endografts are an alternative to surgical revascularization of the LSA.Across 34 investigative sites, 84 patients with zone 2 aneurysms were enrolled in a nonrandomized, prospective study of a single branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for left subclavian perfusion.More than one-half of the patients were male (63%). Their average age was 70 ± 11 years. The aneurysm morphology was fusiform in 43 and saccular in 41 patients. The mean aneurysm diameter at screening was 56.2 mm. The mean follow-up was 30 months (range, 2.6-50.7 months). Reported here are the patient outcomes at 1 and 12 months. Predefined technical success with implantation of the device in landing zone 2 was achieved in 92% of patients (n = 77). There were no cases of aortic rupture, lesion-related mortality, or new-onset renal failure. There was no perioperative (30-day) mortality. A single case each of permanent paraplegia and paraparesis occurred. Three patients experienced a procedure-related stroke. Through 12 months, four patients died; none of the deaths were adjudicated as related to the device or procedure. One aortic reintervention was required. A single case of aortic enlargement (core laboratory) was reported at 6 months. Type I (n = 3) and III (n = 5) endoleaks occurred in 9.8% of patients, of which one (type III) required reintervention.Results from this device study in patients with zone 2 aneurysms demonstrate that early safety and efficacy outcomes are maintained up to 12 months after the endovascular procedure with low mortality and reintervention rates and an acceptable frequency of procedural complications, including neurologic complications.

OBJECTIVES Current risk assessment strategies in type B aortic dissection are focused on anatomic parameters, although haemodynamic abnormalities that result in false lumen (FL) pressurization are thought to play a significant role in aortic growth. The objective of this study was to evaluate blood flow of the FL using 4D flow magnetic resonance imaging (MRI) and identify haemodynamic and anatomic factors that independently predict the rate of aortic growth. METHODS Patients with dissection of the descending thoraco-abdominal aorta (n = 18) were enrolled in a prospective observational study and underwent 4D flow MRI for haemodynamic assessment of the entry tear and FL. Anatomic parameters were obtained by magnetic resonance angiography and baseline computed tomography. False lumen ejection fraction (FL EF) was defined the ratio of retrograde flow rate at the dominant entry tear during diastole over the antegrade systolic flow rate. RESULTS The median aortic growth rate was 3.5 mm/year (interquartile range 0.5–8.1 mm/year). Entry tear peak velocity was lower in patients with enlarging aortic dimensions (95.5 ± 24.1 vs 128.1 ± 37.4 cm/s, P = 0.039). After adjusting for co-variates FL EF (β = 0.15, P = 0.004), baseline maximal aortic diameter (β = 0.37, P = 0.001) and the entry tear distance from the left subclavian artery (β = 0.07, P = 0.016) were significant predictors of aortic growth rate. CONCLUSIONS Beyond standard anatomic risk factors, FL EF is an independent predictor of aortic growth rate and may represent an intuitive, non-invasive method to estimate FL pressurization and improve patient-specific risk assessment in patients with type B aortic dissection.

As surgical mortality decreases and endovascular utilization increases, it is unknown whether volume-outcome relationships exist in thoracic aortic dissection repair. We characterized volume-outcome relationships for surgical and endovascular management of thoracic aortic dissection.Patients aged more than 18 years undergoing repair of thoracic aortic dissection in the United States between 2010 and 2014 were identified in seven all-payer state inpatient administrative databases. Patients were divided into groups based on type of repair: surgical repair of type A dissection (TAAD), surgical repair of type B dissection (TBAD), and endovascular repair (TEVAR). Hierarchical logistic regression models evaluated the association between hospital volume and in-hospital mortality.Overall in-hospital mortality rate was 13.4% (890 of 6650), highest after TAAD (463 of 2918, 15.9%), followed by TBAD (270 of 1934, 14.0%) and TEVAR (157 of 1798, 8.7%). Volume-outcome relationships for adjusted in-hospital mortality were demonstrated for TAAD and TBAD (P-trend.001), but not TEVAR (P-trend = .11). Adjusted in-hospital mortality differed most for TAAD (fewer than 3 cases per year: 21%, 95% confidence interval, 18% to 24%; vs 11 or more cases per year: 12%, 95% confidence interval, 8% to 16%; P.001) and TBAD (fewer than 2 cases per year: 18%, 95% confidence interval, 15% to 22%; vs 11 or more cases per year: 9%, 95% confidence interval, 5% to 12%; P.001), whereas TEVAR did not differ between quartiles. Adjusted mortality was lower at centers with 26 or more overall annual thoracic dissection repairs, compared with any of the three lower-volume quartiles (P.001).This study demonstrated lower mortality at high-volume hospitals for overall repair of aortic dissection, persisting separately for surgical repair of TAAD and TBAD, but not TEVAR. As endovascular technology advances and practice patterns consequently change, analyses should focus on understanding the balance between procedural volume, mortality, and access to care for thoracic aortic dissection.

Cardiac troponin I Ser44 is a downstream target for protein kinase C. The current studies show heightened phosphorylation develops during contractile dysfunction in failing human myocardium and in rat models of pressure overload and aging with contractile dysfunction., Increases in protein kinase C (PKC) are associated with diminished cardiac function, but the contribution of downstream myofilament phosphorylation is debated in human and animal models of heart failure. The current experiments evaluated PKC isoform expression, downstream cardiac troponin I (cTnI) S44 phosphorylation (p-S44), and contractile function in failing (F) human myocardium, and in rat models of cardiac dysfunction caused by pressure overload and aging. In F human myocardium, elevated PKCα expression and cTnI p-S44 developed before ventricular assist device implantation. Circulatory support partially reduced PKCα expression and cTnI p-S44 levels and improved cellular contractile function. Gene transfer of dominant negative PKCα (PKCαDN) into F human myocytes also improved contractile function and reduced cTnI p-S44. Heightened cTnI phosphorylation of the analogous residue accompanied reduced myocyte contractile function in a rat model of pressure overload and in aged Fischer 344 × Brown Norway F1 rats (≥26 mo). Together, these results indicate PKC-targeted cTnI p-S44 accompanies cardiac cellular dysfunction in human and animal models. Interfering with PKCα activity reduces downstream cTnI p-S44 levels and partially restores function, suggesting cTnI p-S44 may be a useful target to improve contractile function in the future.

Background Heart block requiring a pacemaker is common after self-expandable transcatheter aortic valve replacement (SE-TAVR); however, conduction abnormalities may improve over time. Optimal device management in these patients is unknown. Objective To evaluate the long-term, natural history of conduction disturbances in patients undergoing pacemaker implantation following SE-TAVR. Methods All patients who underwent new cardiac implantable electronic device (CIED) implantation at Michigan Medicine following SE-TAVR placement between January 1, 2012 and September 25, 2017 were identified. Electrocardiogram and device interrogation data were examined during follow-up to identify patients with recovery of conduction. Logistic regression analysis was used to compare clinical and procedural variables to predict conduction recovery. Results Following SE-TAVR, 17.5% of patients underwent device placement for new atrioventricular (AV) block. Among 40 patients with an average follow-up time of 17.1 ± 8.1 months, 20 (50%) patients had durable recovery of AV conduction. Among 20 patients without long-term recovery, four (20%) had transient recovery. The time to transient conduction recovery was 2.2 ± 0.2 months with repeat loss of conduction at 8.2 ± 0.9 months. On multivariate analysis, larger aortic annular size (odds ratio: 0.53 [0.28-0.86]/mm, P = 0.02) predicted lack of conduction recovery. Conclusions Half of the patients undergoing CIED placement for heart block following SE-TAVR recovered AV conduction within several months and maintained this over an extended follow-up period. Some patients demonstrated transient recovery of conduction before recurrence of conduction loss. Larger aortic annulus diameter was negatively associated with conduction recovery.

Mechanisms contributing to acute kidney injury (AKI) after acute type B aortic dissection (ABAD) include renal malperfusion or underlying renal dysfunction. We characterized AKI after ABAD and evaluated its potential for adverse clinical and aortic outcomes.Between 1995 and 2016, 478 patients without prior dialysis requirement (mean age, 62.1 years; 60.5% male) presented with ABAD. Renal malperfusion was identified in 87 (18.2%). AKI was assessed by the Kidney Disease: Improving Global Outcomes criteria.AKI was seen in 252 (52.7%; stage 1 in 130, stage 2 in 71, stage 3 in 51) and was associated with increased hospitalization (11 days vs 7 days with no AKI, p = 0.008). Independent predictors of AKI included hypertension (odds ratio [OR], 1.69), chronic kidney disease (OR, 3.98), congestive heart failure (OR, 2.36), and visceral (OR, 2.19), renal (OR, 3.18), or limb malperfusion (OR, 2.18, all p0.05). Early mortality occurred in 44 (9.2%) and was independently predicted by stages 2 (OR, 4.38) and 3 AKI (OR, 6.30; both p0.03). The 10-year survival was 46.5%, and independent predictors of late death included aortic diameter (OR, 1.02), chronic obstructive pulmonary disease (OR, 2.02), chronic kidney disease (OR, 3.51), and stages 2 (OR, 2.74) and 3 AKI (OR, 2.26, all p0.01). The 10-year freedom from aortic rupture, repeat dissection, or need for reintervention was 39.8%. Independent predictors of late aortic events included hyperlipidemia (OR, 1.55), diabetes (OR, 0.38), aortic diameter (OR, 1.03), and connective tissue disease (OR, 2.54, all p0.03), but not AKI (p = 0.149).AKI is common after ABAD and increases early mortality and hospital stay and diminishes late survival. Despite its adverse effect on survival, AKI is not associated with late aortic events.

To analyze presentation, management, and outcomes of acute aortic dissections with proximal entry tear in the arch.Patients enrolled in the International Registry of Acute Aortic Dissection and entry tear in the arch were classified into 2 groups: arch A (retrograde extension into the ascending aorta with or without antegrade extension) and arch B (only antegrade extension into the descending aorta or further distally). Presentation, management, and in-hospital outcomes of the 2 groups were compared.The arch A (n = 228) and arch B (n = 140) groups were similar concerning the presence of any preoperative complication (68.4% vs 60.0%; P = .115), but the types of complication were different. Arch A presented more commonly with shock, neurologic complications, cardiac tamponade, and grade 3 or 4 aortic valve insufficiency and less frequently with refractory hypertension, visceral ischemia, extension of dissection, and aortic rupture. Management for both groups were open surgery (77.6% vs 18.6%; P .001), endovascular treatment (3.5% vs 25.0%; P .001), and medical management (16.2% vs 51.4%; P .001). Overall in-hospital mortality was similar (16.7% vs 19.3%; P = .574), but mortality tended to be lower in the arch A group after open surgery (15.3% vs 30.8%; P = .090), and higher after endovascular (25.0% vs 14.3%; P = .597) or medical treatment (24.3% vs 13.9%; P = .191), although the differences were not significant.Acute aortic dissection patients with primary entry tear in the arch are currently managed by a patient-specific approach. In choosing the management type of these patients, it may be advisable to stratify them based on retrograde or only antegrade extension of the dissection.

As emergency repair for acute type A aortic dissection is improving, the reintervention rate increases. Over 10% of cases require an aortic reintervention, which should ideally be performed in an early stage to allow for positive aortic remodeling and to prevent limitations by the stiffened aortic flap. These reinterventions remain a surgical challenge and may come with complications. We provide a comprehensive overview of different management strategies and their success in treating aortic adverse remodelling, based on current evidence of the literature. Two meta-analyses and an additional literature search yielded comparable mortality rates between limited repair and extensive repair. Cardiopulmonary bypass time, cross clamping time and cardiac arrest time were significantly shorter in limited repairs. Reintervention rate was generally lower in extensive repair, although not always significant. In conclusion, the early aggressive approach may be useful to lower reintervention rates. However, it has not yet been proven to be more beneficial. It will be imperative to develop a patient-specific early stage prediction model for residual aortic reintervention.

The long-term survival and reoperation rate in chronic renal failure (CRF) on hemodialysis (HD) patients after aortic valve/root replacement (AVR/ARR) with a stentless bioprosthesis is unknown. From 1992-2015, 1941 patients underwent AVR/ARR with stentless valve for primary indications of aortic stenosis/insufficiency, root aneurysm, and acute type A aortic dissection, including 93 CRF-HD (64 new-onset postoperative HD, and 29 preoperative HD) and 1848 non-CRF-HD. Data was obtained from the STS database, retrospective chart review, administered surveys and national death index data. Compared to the non-CRF-HD group, the CRF-HD group had significantly higher incidence of diabetes mellitus (28 vs 18%), CAD (49 vs 38%), COPD (31 vs 16%), NYHA class IV (12 vs 4%), atrial fibrillation (24 vs 12%), and previous cardiac surgery (27 vs 16%). Postoperatively, CRF-HD group had a higher reoperation for bleeding (10 vs 4%), length of hospital stays (20 vs 7 days), and operative mortality (23 vs 2.3%), all p0.01. The odds ratio of CRF-HD for operative mortality was 8.97. The long-term survival was worse in CRF-HD group than that in non-CRF-HD group [8-year survival: 31% vs 70%, p0.0001]. The hazard ratio of CRF-HD for long-term mortality was 2.4. The 10-year cumulative reoperation rate for structural valve deterioration in the CRF-HD group was 6.0% vs 5.0% in the non-CRF-HD group, p = 0.74. Surgeons should consider poor short- and long-term outcomes of patients with high risk of being on dialysis when offering aortic valve/root replacement. Bioprosthesis could be a good option in this patient population.

Background Chronic type B aortic dissection (TBAD) is associated with poor long-term outcome, and accurate risk stratification tools remain lacking. Pressurization of the false lumen (FL) has been recognized as central in promoting aortic growth. Several surrogate imaging-based metrics have been proposed to assess FL hemodynamics; however, their relationship to enlarging aortic dimensions remains unclear. We investigated the association between aortic growth and three cardiovascular magnetic resonance (CMR)-derived metrics of FL pressurization: false lumen ejection fraction (FLEF), maximum systolic deceleration rate (MSDR), and FL relative pressure (FL ΔPmax). Methods CMR/CMR angiography was performed in 12 patients with chronic dissection of the descending thoracoabdominal aorta, including contrast-enhanced CMR angiography and time-resolved three-dimensional phase-contrast CMR (4D Flow CMR). Aortic growth rate was calculated as the change in maximal aortic diameter between baseline and follow-up imaging studies over the time interval, with patients categorized as having either ‘stable’ (max: the difference in absolute pressure between aortic root and distal FL. Results FLEF was higher in enlarging TBAD (49.0 ± 17.9% vs. 10.0 ± 11.9%, p = 0.002), whereas FL ΔPmax was lower (32.2 ± 10.8 vs. 57.2 ± 12.5 mmHg/m, p = 0.017). MSDR and conventional anatomic variables did not differ significantly between groups. FLEF showed positive (r = 0.78, p = 0.003) correlation with aortic growth rate whereas FL ΔPmax showed negative correlation (r = − 0.64, p = 0.026). FLEF and FL ΔPmax remained as independent predictors of aortic growth rate after adjusting for baseline aortic diameter. Conclusion Comparative analysis of three 4D flow CMR metrics of TBAD FL pressurization demonstrated that those that focusing on retrograde flow (FLEF) and relative pressure (FL ΔPmax) independently correlated with growth and differentiated patients with enlarging and stable descending aortic dissections. These results emphasize the highly variable nature of aortic hemodynamics in TBAD patients, and suggest that 4D Flow CMR derived metrics of FL pressurization may be useful to separate patients at highest and lowest risk for progressive aortic growth and complications.

Summary Thoracic aortic aneurysm (TAA) is characterized by dilation of the aortic root or ascending/descending aorta. TAA is a heritable disease that can be potentially life threatening. While 10%–20% of TAA cases are caused by rare, pathogenic variants in single genes, the origin of the majority of TAA cases remains unknown. A previous study implicated common variants in FBN1 with TAA disease risk. Here, we report a genome-wide scan of 1,351 TAA-affected individuals and 18,295 control individuals from the Cardiovascular Health Improvement Project and Michigan Genomics Initiative at the University of Michigan. We identified a genome-wide significant association with TAA for variants within the third intron of TCF7L2 following replication with meta-analysis of four additional independent cohorts. Common variants in this locus are the strongest known genetic risk factor for type 2 diabetes. Although evidence indicates the presence of different causal variants for TAA and type 2 diabetes at this locus, we observed an opposite direction of effect. The genetic association for TAA colocalizes with an aortic eQTL of TCF7L2, suggesting a functional relationship. These analyses predict an association of higher expression of TCF7L2 with TAA disease risk. In vitro, we show that upregulation of TCF7L2 is associated with BCL2 repression promoting vascular smooth muscle cell apoptosis, a key driver of TAA disease.

Background Thoracic endovascular aortic repair has radically transformed the treatment of descending thoracic aortic aneurysms. However, when aneurysms involve the aortic arch in the region of the left subclavian artery, branch vessel preservation must be considered. Branched aortic endografts have provided a new option to maintain branch patency. Methods Six investigative sites enrolled 31 patients in a nonrandomized, prospective investigational device exemption feasibility trial of a single branched aortic endograft for the management of aneurysms that include the distal aortic arch. The Gore TAG thoracic branch endoprosthesis (W. L. Gore & Associates, Inc, Flagstaff, Ariz), an investigational device, allows for graft placement proximal to the left subclavian artery and incorporates a single side branch for left subclavian perfusion. Results All 31 patients (100%) had undergone successful implantation of the investigational device in landing zone 2. Men slightly outnumbered women (51.6%). Their average age was 74.1 ± 10.4 years. The aneurysm morphology was fusiform in 12 and saccular in 19 patients, with a mean maximum aortic diameter of 54.8 ± 10.9 mm. The mean follow-up period for the cohort was 25.2 ± 11.1 months. We have reported the patient outcomes at 1 month and 1 year. At 1 month, the side branch patency was 100% and the freedom from core laboratory-reported device-related endoleak (types I and III) was 96.7%, without 30-day death or permanent paraplegia. One patient experienced a procedure-related stroke. Through 1 year, five patients had died; none of the deaths were related to the device or procedure (clinical endpoint committee adjudicated). One thoracic reintervention was required. No conversions were required, and no aneurysm growth (core laboratory) was reported. One case of the loss of side branch patency was diagnosed in the left subclavian artery in an asymptomatic individual from computed tomography at 6 months, with no reported subsequent adverse events due to loss of patency. Endoleaks were reported by the core laboratory in five patients at 12 months (two, type II; and three, indeterminate). Conclusions The present investigational device exemption feasibility study has reported the preliminary results of the use of a single side branch endograft to treat patients with proximal descending thoracic aortic aneurysms.

Purpose Up to 10% of acute type A aortic dissection (TAAD) patients are deemed unfit for open surgical repair, exposing these patients to high mortality rates. In recent years, thoracic endovascular aortic repair has proven to be a promising alternative treatment modality in specific cases. This study presents a comprehensive overview of the current state of catheter-based interventions in the setting of primary TAAD. Methods A literature search was conducted, using MEDLINE and PubMed databases according to PRISMA guidelines, updated until January 2020. Articles were selected if they reported on the endovascular repair of DeBakey Type I and II aortic dissections. The exclusion criteria were retrograde type A dissection, hybrid procedures, and combined outcome reporting of mixed aortic pathologies (e.g., pseudoaneurysm and intramural hematoma). Results A total of 31 articles, out of which 19 were case reports and 12 case series, describing a total of 92 patients, were included. The median follow-up was 6 months for case reports and the average follow-up was 14 months for case series. Overall technical success was 95.6% and 30-day mortality of 9%. Stroke and early endoleak rates were 6% and 18%, respectively. Reintervention was required in 14 patients (15%). Conclusion This review not only demonstrates that endovascular repair in the setting of isolated TAAD is feasible with acceptable outcomes at short-term follow-up, but also underlines a lack of mid-late outcomes and reporting consistency. Studies with longer follow-up and careful consideration of patient selection are required before endovascular interventions can be widely introduced.

Worse outcomes have been reported for women with type A acute aortic dissection (TAAD). We sought to determine sex-specific operative approaches and outcomes for TAAD in the current era.The Interventional Cohort (IVC) of the International Registry of Acute Aortic Dissection (IRAD) database was queried to explore sex differences in presentation, operative approach, and outcomes. Multivariable logistic regression was performed to identify adjusted outcomes in relation to sex.Women constituted approximately one-third (34.3%) of the 2823 patients and were significantly older than men (65.4 vs 58.6 years, P.001). Women were more likely to present with intramural hematoma, periaortic hematoma, or complete or partial false lumen thrombosis (all P.05) and more commonly had hypotension or coma (P = .001). Men underwent a greater proportion of Bentall, complete arch, and elephant trunk procedures (all P.01). In-hospital mortality during the study period was higher in women (16.7% vs 13.8%, P = .039). After adjustment, female sex trended towards higher in-hospital mortality overall (odds ratio, 1.40; P = .053) but not in the last decade of enrollment (odds ratio, 0.93; P = .807). Five-year mortality and reintervention rates were not significantly different between the sexes.In-hospital mortality remains higher among women with TAAD but demonstrates improvement in the last decade. Significant differences in presentation were noted in women, including older age, distinct imaging findings, and greater evidence of malperfusion. Although no distinctions in 5-year mortality or reintervention were observed, a tailored surgical approach should be considered to reduce sex disparities in early mortality rates for TAAD.

Objective The study objective was to provide evidence for choosing a bioprosthesis in treating patients with active aortic valve endocarditis. Methods From 1998 to 2017, 265 patients with active aortic valve endocarditis underwent aortic valve replacement with a stented valve (n = 97, 37%) or a stentless valve (n = 168, 63%) with further breakdown into inclusion technique (n = 142, 85%) or total root replacement (n = 26, 15%). Data were obtained from the Society of Thoracic Surgeons database aided with chart review, surveys, and National Death Index data. Results The median age of patients was 53 years (43-56) in the stented group and 57 years (44-66) in the stentless group. The stented and stentless groups had high rates of heart failure (54% and 40%), liver disease (16% and 7.7%), prosthetic valve endocarditis (14% and 48%), root abscess (38% and 70%), and concomitant ascending aorta procedures (6.2% and 22%), respectively. The stentless group required permanent pacemakers in 11% of cases. Operative mortality was similar between groups (6.2% and 7.1%). The 5-year survival was 52% and 63% in the stented and stentless groups, respectively. Significant risk factors for long-term mortality included liver disease (hazard ratio, 2.38), previous myocardial infarction (hazard ratio, 1.64), congestive heart failure (hazard ratio, 1.63), and renal failure requiring dialysis (hazard ratio, 4.37). The 10-year cumulative incidence of reoperation was 12% and 3.4% for the stented and stentless groups, respectively. The 10-year freedom from reoccurrence of aortic valve endocarditis was 88% for the stented and 98% for the stentless groups. Conclusions Both stented and stentless aortic valves are appropriate conduits for replacement of active aortic valve endocarditis for select patients.

The optimal strategy for cerebral protection during repair of type A acute aortic dissection has yet to be determined. We sought to determine the impact of differing degrees of hypothermia in patients undergoing acute dissection repair.All patients in the International Registry of Acute Aortic Dissection Interventional Cohort database who underwent type A acute aortic dissection repair between 2010 and 2018 were identified. Data for operative temperature were available for 1962 patients subsequently divided into 2 groups according to lowest temperature: moderate hypothermic circulatory arrest (MHCA) (20-28°C) versus deep hypothermic circulatory arrest (DHCA) (20°C). We then propensity matched 362 pairs of patients and analyzed operative data and short-term outcomes.The median lowest temperature was 25.0°C in the matched MHCA group as compared with 18.0°C in the DHCA group. For the entire cohort of 1962 patients, in-hospital mortality was 14.2% (278 deaths) but was not significantly different between DHCA and MHCA. The perioperative stroke rate was comparable between groups, before and after propensity matching. Circulatory arrest times were significantly longer in the MHCA cohort, regardless of matching. Use of antegrade or retrograde cerebral perfusion was similar in matched groups. There were no differences in 30-day survival or in other major postoperative morbidity between the 2 matched cohorts.A surgical strategy of MHCA + antegrade cerebral perfusion is at least as safe as DHCA during repair of acute type A aortic dissection.

Introduction To identify patients with aneurysmal degeneration of the native aorta following type A aortic dissection (TAAD), reproducible serial measurements of aortic dimensions are critical. We used a systematic workflow for measuring aortic geometry following TAAD, using computed tomography angiography data, and test its reproducibility. Methods The workflow for aortic measurements included centerline generation, luminal diameter, and area measurement at six anatomically defined locations along the aorta and luminal volumetric measurements in the descending aorta. Two independent observers measured the aortic geometry in 20 surgically repaired TAAD patients, preoperatively and at 3 months follow‐up. To test reproducibility, intraobserver and interobserver agreement scores were analyzed using a concordance correlation coefficient (CCC). Results The interobserver agreement scores of the diameter, area, and volumetric measurements in the descending aorta were acceptable. The agreement scores of the area measurements were highest, with CCCs ranging from 0.909 to 0.984. Luminal diameter measurements scored lower than luminal area measurements and were least reproducible at the mid aortic arch (CCC

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has increased in volume as an alternative to surgical aortic valve replacement (SAVR). Comparisons of total episode expenditures, while largely ignored thus far, will be key to the value proposition for payers. METHODS: We evaluated 6,359 Blue Cross Blue Shield of Michigan and Medicare fee-for-service beneficiaries undergoing TAVR (17 hospitals, n=1,655) or SAVR (33 hospitals, n=4,704) in Michigan between 2012 and 2016. Payments through 90 post-discharge days between TAVR and SAVR were price-standardized and risk-adjusted. Centers were divided into terciles of procedural volume separately for TAVR and SAVR, and payments were compared between lowest and highest terciles. RESULTS: Payments (± standard deviation) were higher for TAVR than SAVR ($69,388 ± $22,259 vs. $66,683 ± $27,377, p

Background Expandable, rapid deployment aortic valves may interfere with the cardiac conduction system, which can lead to permanent pacemaker implantation (PPI). We sought to characterize PPI after rapid deployment aortic valve replacement with the Edwards Intuity valve system (Edwards Lifesciences, Irvine, CA) and investigate associated factors. Methods We analyzed 708 patients from 29 centers in the Multicenter Experience With Rapid Deployment Edwards Intuity Valve System for Aortic Valve Replacement (TRANSFORM) trial undergoing rapid deployment aortic valve replacement with or without coronary artery bypass graft surgery without preexisting pacemakers. Intrinsic conduction status was recorded as well as PPI incidence through 1 year. The PPI indications were categorized based on expert review of patient PPI source documents. Multivariate analysis was conducted to identify characteristics associated with PPI. Results After rapid deployment aortic valve replacement, the PPI incidence through 30 days (PPI30) was 13.6%, with 10.9% due to atrioventricular block. In the 423 of 708 patients (59.7%) without any baseline conduction abnormalities, all-cause PPI30 was 8%, 5% for atrioventricular block. For PPIs inserted before discharge, the median time to PPI was 5 days, with 22% placed within 48 hours. Independent predictors of PPI30 were baseline right bundle branch block (odds ratio 7.35, p Conclusions Patient factors associated with PPI after rapid deployment aortic valve replacement were right bundle branch block, atrioventricular block, female gender, and larger valve size. Interestingly, a strong center-level effect was associated with PPI. This effect may reflect differences in practice patterns, such as postoperative drug management or timing to PPI. These findings provide a deeper understanding of PPI after rapid deployment aortic valve replacement and help guide clinical practice and patient management.

Endovascular aortic repair (EVAR) has improved over the last two decades. Approximately 80% of the patients presenting with an abdominal aortic aneurysm (AAA) is nowadays primarily treated with EVAR.In this review, the differences between endovascular and open repair, the clinical characteristics needed for EVAR, the role of clinical imaging and the developments in EVAR technology will be discussed. Early mortality is lower in EVAR as compared to open repair, whereas this benefit is lost after 3 years postoperatively. EVAR comes with a high reintervention rate, with endoleak being the most important predictive factor for reintervention. Expanding technical possibilities have allowed surgeons to choose from a palate of endovascular approaches in aneurysm patients with challenging anatomies.Although EVAR has taken a giant leap forward in development, the new developments have seemed to surpass the long-term limitations with older devices. It is important to start focusing on the current limitations of EVAR, in particular the durability of devices in the human variable anatomic and dynamic environment.

Objectives Aortic arch repair remains a major surgical challenge. Multiple manufacturers are developing branched endografts for Zone 0 endovascular repair, extending the armamentarium for minimally invasive treatment of aortic arch pathologies. We hypothesize that the design of the Zone 0 endograft has a significant impact on the postoperative haemodynamic performance, particularly in the cervical arteries. The goal of our study was to compare the postoperative haemodynamic performance of different Zone 0 endograft designs. Methods Patient-specific, clinically validated, computational fluid dynamics simulations were performed in a 71-year-old woman with a 6.5-cm saccular aortic arch aneurysm. Additionally, 4 endovascular repair scenarios using different endograft designs were created. Haemodynamic performance was evaluated by calculation of postoperative changes in blood flow and platelet activation potential (PLAP) in the cervical arteries. Results Preoperative cervical blood flow and mean PLAP were 1080 ml/min and 151.75, respectively. Cervical blood flow decreased and PLAP increased following endovascular repair in all scenarios. Endografts with 2 antegrade inner branches performed better compared to single-branch endografts. Scenario 3 performed the worst with a decrease in the total cervical blood flow of 4.8%, a decrease in the left hemisphere flow of 6.7% and an increase in the mean PLAP of 74.3%. Conclusions Endograft design has a significant impact on haemodynamic performance following Zone 0 endovascular repair, potentially affecting cerebral blood flow during follow-up. Our results demonstrate the use of computational modelling for virtual testing of therapeutic interventions and underline the need to monitor the long-term outcomes in this cohort of patients.

Background Stroke is a feared complication of cardiac surgery. Modern clot-retrieval techniques provide effective treatment for large vessel occlusion (LVO) strokes. The purpose of this study was to 1) report the incidence of LVO stroke after cardiac surgery at a large academic center, and 2) describe outcomes of postoperative LVO strokes. Methods All patients experiencing stroke within 30 days after undergoing cardiac surgery at a single center in 2014-2018 were reviewed. LVOs were identified through review of imaging and medical records, and their characteristics and clinical courses were examined. Results Over the study period, 7,112 cardiac surgeries, including endovascular procedures, were performed. Acute ischemic stroke within 30 days after surgery was noted in 163 patients (2.3%). Among those with a stroke, 51/163 (31.3%) had a CTA or MRA, and 15/163 (9.2%) presented with LVO stroke. For all stroke patients, the median time from surgery to stroke was 2 days (interquartile range, IQR, 0–6 days), and for patients with LVO, the median time from surgery to stroke was 4 days (IQR 0–6 days). The overall rate of postoperative LVO was 0.2% (95% CI 0.1–0.4%), though only 6/15 received thrombectomy. LVO patients receiving thrombectomy were significantly more likely to return to independent living compared to those managed medically (n = 4/6, 66.6% for mechanical thrombectomy vs. n = 0/9, 0% for medical management, P = .01). Of the 9 patients who did not get thrombectomy, 6 may currently be candidates for thrombectomy given new expanded treatment windows. Conclusions The rate of LVO after cardiac surgery is low, though substantially elevated above the general population, and the majority do not receive thrombectomy currently. Patients receiving thrombectomy had improved neurologic outcomes compared to patients managed medically. Optimized postoperative care may increase the rate of LVO recognition, and cardiac surgery patients and their caregivers should be aware of this effective therapy.

Approximately ¼ of patients with thoracic aortic aneurysms (TAAs) have concomitant abdominal aortic aneurysms (AAAs), thereby justifying the addition of an abdominal CT scan to a chest CT scan in patients with a newly diagnosed or suspected TAA. However, the prevalence of pelvic artery aneurysms (PAAs) in these patients is unknown. The purpose of this study was to determine the prevalence of PAAs in patients with TAAs and to assess what patient specific factors were associated with PAAs, thereby providing insight into the usefulness of pelvic imaging in TAA patients. Consecutive non-operated patients seen in Cardiac Surgery clinic between 2008 and 2013 with a TAA and a CT scan of the chest/abdomen/pelvis were included. Scans of 371 patients were evaluated for PAAs using threshold diameters of 20 and 15 mm for common iliac artery aneurysms (CIAs) and internal iliac artery aneurysms (IIAs), respectively, on 3D analysis. The prevalence of PAAs was determined and multiple logistic regression was used to identify associated risk factors. 41 of 371 (11.1%) patients with a TAA had at least one PAA. Factors showing positive associations with PAAs included increased age (p = 0.0004), male gender (p = 0.0007), descending TAA location (p = 0.0024) and presence of an AAA (p

Objectives This study evaluated the safety and effectiveness of self-expanding transcatheter aortic valve replacement (TAVR) in patients with surgical valve failure (SVF). Background Self-expanding TAVR is superior to medical therapy for patients with severe native aortic valve stenosis at increased surgical risk. Methods The CoreValve U.S. Expanded Use Study was a prospective, nonrandomized study that enrolled 233 patients with symptomatic SVF who were deemed unsuitable for reoperation. Patients were treated with self-expanding TAVR and evaluated for 30-day and 1-year outcomes after the procedure. An independent core laboratory was used to evaluate serial echocardiograms for valve hemodynamics and aortic regurgitation. Results SVF occurred through stenosis (56.4%), regurgitation (22.0%), or a combination (21.6%). A total of 227 patients underwent attempted TAVR and successful TAVR was achieved in 225 (99.1%) patients. Patients were elderly (76.7 ± 10.8 years), had a Society of Thoracic Surgeons Predicted Risk of Mortality score of 9.0 ± 6.7%, and were severely symptomatic (86.8% New York Heart Association functional class III or IV). The all-cause mortality rate was 2.2% at 30 days and 14.6% at 1 year; major stroke rate was 0.4% at 30 days and 1.8% at 1 year. Moderate aortic regurgitation occurred in 3.5% of patients at 30 days and 7.4% of patients at 1 year, with no severe aortic regurgitation. The rate of new permanent pacemaker implantation was 8.1% at 30 days and 11.0% at 1 year. The mean valve gradient was 17.0 ± 8.8 mm Hg at 30 days and 16.6 ± 8.9 mm Hg at 1 year. Factors significantly associated with higher discharge mean aortic gradients were surgical valve size, stenosis as modality of SVF, and presence of surgical valve prosthesis patient mismatch (all p Conclusions Self-expanding TAVR in patients with SVF at increased risk for surgery was associated with a low 1-year mortality and major stroke rate, significantly improved aortic valve hemodynamics, and low rates of moderate and no severe residual aortic regurgitation, with improved quality of life.

Background We aimed to identify predictors of stable aortic dimensions in medically managed type B aortic dissections (TBAD). Methods Medically managed TBAD patients from the International Registry of Acute Aortic Dissection with available aortic measurements at up to 24 months were included. Growth rate was calculated by dividing the largest descending diameter at the latest end point not influenced by intervention minus initial descending diameter, by the recorded time interval. Patients were split into 2 groups: without aortic growth ( 0.0 mm/year, group II). Results 219 patients had available data for our inclusion criteria and comprised group I (n = 89, 40.6%) and group II (n = 130, 59.4%). Mean expansion rate of the total cohort was 0.19 ± 0.81 cm, mean expansion rate in group I was −0.47 ± 0.54 cm, and in group II, it was +0.63 ± 0.64 cm. Patients in group I were more frequently of Asian descent (15.9% vs. 3.1%, P = 0.001), showed more often intramural hematoma on imaging (57.3% vs. 30.0%, P

To improve surgical pain control through cryoablation of intercostal nerves and reduce narcotic usage in patients undergoing open thoracic or thoracoabdominal aortic aneurysm (TAA or TAAA) repair. From 2012 to 2018, 117 patients underwent open repair of TAA or TAAA. Of those patients, 25 (21%) received cryoablation (2016-2018) of their intercostal nerves and 92 (79%) did not (2012-2018). The primary outcome was pain scores and narcotic usage from extubation day 1 to 10 or the day of discharge. The median age (57 years), demographics, and preoperative comorbidities were not significantly different between the 2 groups. The cryoablation group had significantly more incidences of thoracoabdominal incisions (52% vs 28%), urgent operations (32% vs 11%), and longer duration of chest tubes compared to the noncryoablation group (all P0.05). T9-T12 intercostal arteries were selectively reimplanted. Left intercostal nerves were cryoablated from T3 to T9 if 2 thoracotomies were used; or 2 intercostal spaces above and below the thoracotomy if 1 thoracotomy was used. There were no significant differences between the noncryoablation and cryoablation groups in postoperative stroke, paraplegia (5%), pneumonia, and in-hospital mortality (0.9%). However, the average usage of narcotics was significantly reduced in the cryoablation group by 28 measured morphine equivalents (equal to four 5 mg Oxycodone)/patient/day in 10 days after extubation, P = 0.005. With cryoablation of intercostal nerves, the postoperative surgical pain was well controlled and narcotic usage was significantly decreased after TAA or TAAA repair. Cryoablation of intercostal nerves was a safe and effective measure for postoperative pain control in TAA or TAAA repair.

Triggering events for acute aortic dissections are incompletely understood. We sought to investigate whether there is an association between admission for acute type A aortic dissection (ATAAD) to the University of Michigan Medical Center and the reported annual influenza activity by the Michigan Department of Health and Human Services. From 1996–2019 we had 758 patients admitted for ATAAD with 3.1 admissions per month during November-March and 2.5 admissions per month during April-October (p = 0.01). Influenza reporting data by the Michigan Department of Health and Human Services became available in 2009. ATAAD admissions for the period 2009–2019 (n = 455) were 4.8 cases/month during peak influenza months compared to 3.5 cases/month during non-peak influenza months (p = 0.001). ATAAD patients admitted during influenza season had increased in-hospital mortality (11.0% vs. 5.8%, p = 0.024) and increased 30-day mortality (9.7 vs. 5.4%, p = 0.048). The results point to higher admission rates for ATAAD during months with above average influenza rates. Future studies need to investigate whether influenza virus infection affects susceptibility for aortic dissection, and whether this risk can be attenuated with the annual influenza vaccine in this patient population.

Background The Clinical PeRformancE of the Valiant Thoracic Stent Graft with Capitvia Delivery System for the EndovaSCUlar treatment of Blunt Thoracic Aortic Injuries (RESCUE) study evaluating thoracic endovascular repair using the Valiant Captivia endograft for blunt thoracic aortic injury reported promising 30-day outcomes. We now describe 5 years of follow-up of this cohort. Methods Fifty patients (mean age 40.7 ± 17.4 years, 76% male, mean injury severity score 38 ± 14.4) were treated for blunt thoracic aortic injury (2010 to 2012) with this endograft. Seventy percent (n = 35) of blunt thoracic aortic injury extent was grade III or higher. Extent of arch repair required full (40%) or partial (18%) left subclavian artery coverage. At 5 years, clinical and imaging compliance was 90.3% (28 of 31) and 67.7% (21 of 31), respectively. Results Thirty-day mortality was 8%. Three additional patients died of non–device-related causes (respiratory failure, infection, metastatic cancer) through 5-year follow-up, yielding a Kaplan-Meier survival of 85.2% through 5 years. Neither stroke nor spinal cord ischemia was observed at 5 years. Two type II endoleaks seen at 30 days resolved spontaneously, and no additional endoleaks were described in the study cohort through 5 years. No secondary endovascular procedures or conversion to open surgery were reported through 5 years. Four subjects underwent left subclavian revascularization for symptomatic indications. Finally, complete exclusion of the traumatic injury was maintained with no incidences of stent graft kinking, fracture, loss of patency, or migration through 5 years in all patients. Conclusions This multicenter clinical trial describes excellent 5-year outcomes and durable exclusion of blunt thoracic aortic injury using a novel stent graft system. Thoracic endovascular repair with this endograft appears to be a safe and effective treatment option for patients with blunt thoracic aortic injury.