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Aortic aneurysms are a significant cause of mortality, and the presence of multiple aneurysms may affect treatment plans. The purpose of this study was to determine the frequency of abdominal aortic aneurysms (AAAs) in patients with thoracic aortic aneurysms (TAAs) and to establish whether patient specific factors, such as gender and comorbidities, influenced the frequency of AAAs, thereby indicating if and when abdominal aortic evaluation is justified. Electronic medical records were reviewed from 1000 patients with a computed tomography (CT) angiogram of the chest and abdomen and a clinical diagnosis of TAA from Cardiac Surgery clinic between 2008 and 2013. 538 patients with history of aortic intervention, dissection, rupture or trauma were excluded. The frequency of AAAs among the 462 remaining patients was established, and statistical analysis was used to elucidate differences in frequency based on age, gender, comorbidities, and TAA location. Overall, 104 of 462 (22.5 %) patients with a TAA also had an AAA. There were significant differences in the frequency of AAA based on TAA location, age, and comorbidities. The following comorbidities showed positive associations with AAA using logistic regression analysis: age ≥65 (P 0.0001; OR 30.1; CI 7.14-126.61), smoking history (P 0.0001; OR 4.1; 2.35-7.30), and hypertension (P = 0.024; OR 2.1; CI 1.11-4.16). Aneurysms in the proximal/mid descending (P 0.0001; OR 4.96; CI 2.32-10.61) and diaphragm level (P 0.0001; OR 38.4; CI 14.71-100.15) of the aorta also showed a positive association with AAAs when adjusted for age and gender. AAA screening in patients with TAA is a reasonable, evidence-based option regardless of the TAA location, with the strongest support in patientsage 55, with systemic hypertension, a smoking history and/or a TAA in the descending thoracic aorta.

Although transcatheter aortic valve replacement (TAVR) has expanded the proportion of patients with aortic stenosis (AS) who are candidates for valve replacement, some patients remain untreated, and their outcomes are not clear. We evaluated 172 consecutive patients with severe symptomatic AS referred for TAVR who declined (n = 55) or were not candidates for (n = 117) intervention. We examined clinical and echocardiographic variables associated with mortality. There were 77 deaths, and mean follow-up was 17.9 ± 10.9 months for survivors. Mortality rate at 1 and 2 years was 39.2% and 52.6%, respectively. There was a significant difference in mortality rate between patients who declined the procedure and those who were not candidates (p = 0.001), with 1-year mortality rates of 20.6% and 48.4%, respectively. On multivariate analysis, 4 variables were independently associated with all-cause mortality: New York Heart Association Class IV heart failure (hazard ratio [HR] 2.6, 95% confidence interval [CI] 1.6 to 4.2, p

Background Presenting systolic blood pressure (SBP) is a powerful predictor of mortality in many cardiovascular settings, including acute coronary syndromes, cardiogenic shock, and acute heart failure. Objectives This study evaluated the association of presenting SBP with in-hospital outcomes, specifically all-cause mortality, in acute aortic dissection (AAD). Methods The study included 6,238 consecutive patients (4,167 with type A and 2,071 with type B AAD) enrolled in the International Registry of Acute Aortic Dissection. Patients were stratified in 4 groups according to presenting SBP: SBP >150, SBP 101 to 150, SBP 81 to 100, or SBP ≤80 mm Hg. Results The relationship between presenting SBP and in-hospital mortality displayed a J-curve association, with significantly higher mortality rates in patients with very high SBP (26.3% for SBP >180 mm Hg in type A AAD, 13.3% for SBP >200 mm Hg in type B AAD; p = 0.005 and p = 0.018, respectively) as well as in those with SBP ≤100 mm Hg (29.9% in type A, 22.4% in type B; p = 0.033 and p = 0.015, respectively). This relationship was mainly from increased rates of in-hospital complications (acute renal failure, coma, and mesenteric ischemia/infarction in patients with SBP >150 mm Hg; stroke, coma, cardiac tamponade, myocardial ischemia/infarction, and acute renal failure in patients with SBP ≤80 mm Hg). Notably, presenting SBP ≤80 mm Hg was independently associated with in-hospital mortality in both type A (p = 0.001) and type B AAD (p = 0.003). Conclusions Presenting SBP showed a clear J-curve relationship with in-hospital mortality in patients with AAD. Although this association was related to increased rates of comorbid conditions at the edges of the curve, SBP ≤80 mm Hg was an independent correlate of in-hospital mortality.

Limited data are available regarding outcomes for stentless aortic valve reoperation. The reported reoperative mortality has been unacceptably high.Between 1997 and 2017, a retrospective analysis was performed on 143 patients who underwent open aortic valve reoperations for failed stentless aortic valve bioprostheses. We evaluated both short-term and long-term outcomes on this cohort of patients.Bicuspid aortic valve was present in 107 of 143 patients (75%) at the time of the initial Freestyle (Medtronic, Minneapolis, MN) procedure, and 120 of 143 patients (84%) underwent a modified inclusion aortic root replacement procedure. The interval from first operation to reoperation was 9 years (range, 5.4 to 11.8), which was significantly shorter for patients with infectious endocarditis (4.1 years; range, 1.8 to 7.1) compared with patients with structural valvular deterioration (10.4 years; range, 8.1 to 12.4, p0.001). The median age at the time of reoperation was 59 years (range, 50 to 67). Aortic valve reoperation was performed for structural valve deterioration in 68% cases compared with 32% for infectious prosthetic valve endocarditis. Concomitant surgery included coronary artery bypass (13%), mitral valve surgery (4%), and ascending aorta and arch replacement (42%). The 30-day and inhospital mortality was 1% and 2%, respectively. The composite outcome including myocardial infarction, stroke, new-onset renal failure on hemodialysis, and operative mortality was 4%. The 5-year and 10-year Kaplan-Meier survival after reoperation for failed stentless valve was 83% (95% confidence interval: 73% to 89%) and 57% (95% confidence interval: 36% to 74%).Aortic valve reoperation after stentless valve implantation can be performed with low operative mortality and favorable long-term survival.

Aortic stenosis is a common valvular condition with increasing prevalence in aging populations. When severe and symptomatic, the downstream prognosis is poor without surgical or transcatheter aortic valve replacement. Transcatheter aortic valve replacement is now considered a viable alternative to surgical aortic valve replacement in patients considered high and intermediate risk for surgery. Pre-intervention imaging with echocardiography and CT are essential for procedure planning and device selection to help optimize clinical outcomes with MR angiography playing largely a complementary role. Modern 3-D cross-sectional imaging has consistently shown to help reduce procedural complications from vascular access injury to paravalvular regurgitation and coronary obstruction. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Objectives: The study objectives were to evaluate the safety, effectiveness, and hemodynamic performance of a new stented bovine pericardial aortic valve. Methods: This trial enrolled patients with symptomatic moderate or severe aortic stenosis or chronic, severe aortic regurgitation. We assessed death, valve-related adverse events, functional recovery, and hemodynamic performance at discharge, 3 to 6 months, and 1 year, as required by the US Food and Drug Administration for regulatory approval. The primary analysis compared late linearized rates of valve-related adverse events after implantation with Food and Drug Administration–specified objective performance criteria to determine whether the adverse event rates associated with the valve are within acceptable limits. Adverse events included thromboembolism, thrombosis, all and major hemorrhage, all and major paravalvular leak, and endocarditis. Results: The primary analysis included 864 patients who received an implant and 904.1 valve-years of follow-up. A total of 577 patients completed the 1-year evaluation. The primary end point was met for death, thromboembolism, thrombosis, all and major paravalvular leak, and endocarditis, but not for all and major hemorrhage. At 1 year, freedom from all death and from valve-related death was 96.4% and 99.7%, respectively. From baseline to 1 year, New York Heart Association class changed as follows: I, 10.8% to 73.7%; II, 48.9% to 22.6%; III, 38.0% to 3.5%; and IV, 2.3% to 0.2%. Effective orifice area increased from 0.9 ± 0.5 to 1.5 ± 0.4 (P

Background To examine short-term and midterm outcomes after the David and Bentall procedures in patients with an acute type A aortic dissection. Methods Between 2001 and 2017, patients (n = 135) with acute type A aortic dissection underwent an aortic root replacement with either the David (n = 40) or Bentall (n = 95) procedure. Perioperative outcome, reoperation rate, aortic valve function, and long-term survival were evaluated. Results The median age of the entire cohort was 56 years. Rates of malperfusion (21%), shock (16%), history of renal failure (4%), and extent of surgery were similar between David and Bentall groups. However, the David group was significantly younger (45 versus 61 years) with less hypertension (45% versus 66%), coronary artery disease (0% versus 17%), valvulopathy (5% versus 19%), and prior cardiac surgery (5% versus 21%). Overall operative mortality was 9.6% (David 3% and Bentall 13%). Composite outcome comprising myocardial infarction, stroke, new-onset renal failure, and operative mortality was 18% in the entire cohort (David 5% and Bentall 23%). In the David group, the freedom of moderate aortic insufficiency was 95% at 10 years. The rate of reoperation for pathology of the proximal aorta or aortic valve was 0% and 2% for the David and Bentall groups, respectively. Ten-year Kaplan-Meier survival was 66% (95% confidence interval: 51% to 77%) for the entire cohort, with 98% (95% confidence interval: 84% to 99%) survival in the David group and 57% (95% confidence interval: 42% to 70%) survival in the Bentall group. Conclusions Both the David and Bentall procedures are appropriate surgical approaches for aortic root replacement in select patients with an acute type A aortic dissection.

OBJECTIVES The recommended extent of surgical resection and reconstruction of the arch in acute DeBakey Type I aortic dissection is an ongoing controversy. However, several recent reports indicate a trend towards a more extensive arch operation in several institutions. We have analysed the recent data from the International Registry of Acute Aortic Dissection to assess the choice of procedure over time and to evaluate the surgical outcome in a 'real-world' database. Our aim was to compare short- and mid-term outcomes of limited repairs versus complete arch surgery. METHODS Of the 1241 patients included in the 'Interventional Cohort' of the International Registry of Acute Aortic Dissection from March 1996 to March 2015, 907 underwent ascending aortic or hemiarch replacement (Group A) and 334 had extended arch replacement (Group B). An extended resection was a surgeon's 'judgement call'. Logistic regression analysis, propensity-adjusted multivariable comparisons and Kaplan-Meier curves were used for analyses. RESULTS Overall in-hospital mortality was 14.2% with no difference between groups (Group A 13.1%, Group B 17.1%). Coma/altered consciousness (odds ratio 3.16, 95% confidence interval 1.60-6.25, P = 0.001), hypotension, tamponade or shock (2.03, 1.11-3.73, P = 0.022) and any pulse deficit (1.92, 1.04-3.54, P = 0.038) were predictors of in-hospital mortality in a propensity score-adjusted multivariable analysis. Overall 5-year survival was 69.4% in the ascending group and 73.1% in the total arch group (P = 0.83 by Kaplan-Meier analysis). For survivors of the index hospitalization, the 5-year freedom from death, aortic rupture and reintervention were 71.1% in Group A and 76.4% in Group B (P = 0.54 by Kaplan-Meier analysis). CONCLUSIONS Selective, or 'surgeon's choice', extended arch replacement had no discernible acute downside compared with less extensive surgery. Whether extended arch replacement improves the prognosis beyond 5 years remains to be settled.

The electrocardiogram (ECG) is often used in the diagnosis of patients presenting with chest pain to emergency departments. Because chest pain is a common manifestation of type A acute aortic dissection (TAAAD), ECGs are obtained in much of this population. We evaluated the effect of particular ECG patterns on the diagnosis and treatment of TAAAD.TAAAD patients (N = 2,765) enrolled in the International Registry of Acute Aortic Dissection were stratified based on normal (n = 1,094 [39.6%]) and abnormal (n = 1,671 [60.4%]) findings on presenting ECGs and further subdivided according to specific ECG findings. Time data are presented in hours as medians (quartile 1 to quartile 3).Patients with ECGs with abnormal findings presented to the hospital sooner after symptom onset than those with ECGs with normal findings (1.4 [0.8 to 3.3] vs 2.0 [1.0 to 3.3]; p = 0.005). Specifically, this was seen in patients with infarction with new Q waves or ST elevation (1.3 [0.6 to 2.7] vs 1.5 [0.8 to 3.3]; p = 0.049). Interestingly, the time between symptom onset and diagnosis was longer with infarction with old Q waves (6.7 [3.2 to 18.4] vs 5.0 [2.9 to 11.8]; p = 0.034) and nonspecific ST-T changes (5.8 [3.0 to 13.8] vs 4.5 [2.8 to 10.5]; p = 0.002). Surgical mortality was higher in patients with abnormal ECG findings (20.6% vs 11.9%, p0.001), especially in those with ischemia by ECG (25.7% vs 16.8%, p0.001) and infarction with new Q waves or ST elevation (30.1% vs 17.1%, p0.001).TAAAD patients presenting with abnormal ECG results are sicker, have more in-hospital complications, and are more likely to die. The frequency of nonspecific ST-T abnormalities and its association with delay in diagnosis and treatment presents an opportunity for practice improvement.

OBJECTIVE: A number of factors limit the effectiveness of current aortic arch studies in assessing optimal neuroprotection strategies, including insufficient patient numbers, heterogenous definitions of clinical variables, multiple technical strategies, inadequate reporting of surgical outcomes and a lack of collaborative effort. We have formed an international coalition of centres to provide more robust investigations into this topic. METHODS: High-volume aortic arch centres were identified from the literature and contacted for recruitment. A Research Steering Committee of expert arch surgeons was convened to oversee the direction of the research. RESULTS: The International Aortic Arch Surgery Study Group has been formed by 41 arch surgeons from 10 countries to better evaluate patient outcomes after aortic arch surgery. Several projects, including the establishment of a multi-institutional retrospective database, randomized controlled trials and a prospectively collected database, are currently underway. CONCLUSIONS: Such a collaborative effort will herald a turning point in the surgical management of aortic arch pathologies and will provide better powered analyses to assess the impact of varying surgical techniques on mortality and morbidity, identify predictors for neurological and operative risk, formulate and validate risk predictor models and review long-term survival outcomes and quality-of-life after arch surgery.

Expanding therapies for aortic stenosis have focused on high-risk and inoperable patients, suggesting that an evaluation of outcomes of conventional aortic valve replacement (AVR) or AVR and coronary artery bypass grafting (CABG) is timely and warranted.Outcomes for 6,270 AVR (3,487) or AVR/CABG (2,783) procedures performed in Michigan (2008-2011) were analyzed using a statewide cardiothoracic surgical database. Hospital and surgeon volume-outcome relationships were assessed.Independent predictors of early mortality (all p0.05) included age, female sex, predicted risk of mortality, and hospital volume, with a hinge point of a 4-year volume of 390 procedures (high-volume hospital [HVH], 2.41% versus low-volume hospital [LVH], 4.34%; p0.001). At this hinge point, observed to expected ratio (O/E) for operative mortality after AVR was lower in HVHs for patients with a predicted risk of mortality (PRoM) greater than 4.7%. In contrast, no surgeon-volume outcome relationship was identified, even when stratified by preoperative patient-risk profile. With respect to other measures, HVHs reported lower rates of prolonged ventilation (24.9% versus LVH, 30.9%; p0.001), postoperative transfusion (46.1% versus LVH, 59.0%; p0.001), pneumonia (6.6% versus LVH, 9.0%; p = 0.01), and multisystem organ failure (0.7% versus LVH, 1.8%; p = 0.012).This population-based analysis suggests that volume-outcome relationships exist for AVR. The predominant effect on mortality appears based on the setting of the procedure and occurs primarily in the high-risk patient. These results provide an opportunity to review approaches for high-risk patients undergoing AVR, including resource availability and system experience as the spectrum of treatment options expands to transcatheter therapies.

The impact of left subclavian artery (LSA) revascularization before thoracic endovascular aortic repair (TEVAR) on cerebrovascular flow is not well described. We studied bilateral vertebral and carotid artery flow characteristics before and after TEVAR to evaluate the hemodynamic effects of LSA revascularization.Seventy-four patients with mixed etiologies (mean age 70.9 ± 10.5 years) underwent LSA revascularization and TEVAR (2006-2016) and had available preoperative and postoperative carotid duplex study available. Data from patient demographics, procedures, preoperative, and postoperative carotid duplex studies were gathered. Revascularization was by left common carotid artery (LCCA) to LSA bypass (n = 70, 94.6%) or LSA to LCCA transposition (n = 4, 5.4%).Duplex confirmation of antegrade left vertebral artery (LVA) flow decreased significantly after TEVAR with LSA revascularization (100.0% vs. 77.9%, P 0.001). Incidence of retrograde LVA flow increased from 0.0% to 8.3% (P = 0.063). Postoperatively, LVA bidirectional flow was observed in 3 patients (4.4%). Flow directions in the right vertebral artery (RVA) did not change significantly. Peak systolic velocity (PSV) in the LVA decreased significantly after TEVAR from 55.1 ± 22.0 cm/s to 35.9 ± 26.3 cm/s (P 0.001). In contrast, PSV increased in the RVA and the right internal carotid artery (ICA; 52.2 ± 21.7 cm/s to 63.2 ± 23.3 cm/s, P = 0.012 and 95.3 ± 46.8 cm/s to 102.8 ± 42.9 cm/s, P = 0.011). PSV did not change significantly in the left ICA. At mean follow-up of 36.6 ± 26.8 months, primary bypass patency was 100.0%. Postoperatively, one case of temporary spinal cord ischemia was seen (1.4%). Stroke rate was 6.9% (n = 5, 100.0% embolic), all without permanent disabilities. Stroke circulation distribution was 60.0% posterior, 20.0% anterior, and 20.0% mixed. Location of stroke was left sided (n = 2) or in both hemispheres (n = 3). There were no deaths at 30 days. Neurological events during follow-up included 3 new strokes. All-cause mortality rate during follow-up was 12.2% (n = 9).Adjunctive LSA revascularization in the setting of zone 2 TEVAR coverage is associated with hemodynamic vertebral artery changes. Future studies in larger sample sizes should evaluate whether these novel findings are an important determinant of postoperative neurologic events.

Introduction Thoracic aortic stent grafts are orders of magnitude stiffer than the native aorta. These devices have been associated with acute hypertension, elevated pulse pressure, cardiac remodelling and reduced coronary perfusion. However, a systematic assessment of such cardiovascular effects of thoracic endovascular aortic repair (TEVAR) is missing. The C ardi O vascular R emodelling following E ndovascular aortic repair (CORE) study aims to (1) quantify cardiovascular remodelling following TEVAR and compare echocardiography against MRI, the reference method; (2) validate computational modelling of cardiovascular haemodynamics following TEVAR using clinical measurements, and virtually assess the impact of more compliant stent grafts on cardiovascular haemodynamics; and (3) investigate diagnostic accuracy of ECG and serum biomarkers for cardiac remodelling compared to MRI. Methods and analysis This is a prospective, nonrandomised, observational cohort study. We will use MRI, CT, echocardiography, intraluminal pressures, ECG, computational modelling and serum biomarkers to assess cardiovascular remodelling in two groups of patients with degenerative thoracic aneurysms or penetrating aortic ulcers: (1) patients managed with TEVAR and (2) control patients managed with medical therapy alone. Power analysis revealed a minimum total sample size of 20 patients (α=0.05, power=0.97) to observe significant left ventricular mass increase following TEVAR after 1 year. Consequently, we will include 12 patients in both groups. Advanced MRI sequences will be used to assess myocardial and aortic strain and distensibility, myocardial perfusion and aortic flow. ECG, echocardiography and serum biomarkers will be collected and compared against the imaging data. Computational models will be constructed from each patient imaging data, analysed and validated. All measurements will be collected at baseline (prior to TEVAR) and 1-year follow-up. The expected study period is 3 years. Ethics and dissemination This study has been approved by the University of Michigan IRB. The results will be disseminated through scientific journals and conference presentations. Trial registration number NCT02735720.

To provide data on the management and outcomes of patients with acute retrograde aortic dissection (AD) originating from a tear in the descending aorta with extension into the aortic arch or ascending aorta. All patients enrolled in the International Registry of Acute Aortic Dissection from 1996-2015 were reviewed. Retrograde AD was defined by primary tear in the descending aorta with proximal extension into the arch or ascending aorta. Primary end points were in-hospital management strategy and mortality. We identified 101 patients with retrograde AD (67 men; 63.2 ± 14.0 years). During index hospitalization, medical (MED), open surgical (SURG), and endovascular (ENDO) therapies were undertaken in 44, 33, and 22 patients, respectively. The SURG group presented with larger ascending aorta (P = 0.04) and more frequent ascending aortic involvement (81.8% [27/33] vs 22.7% [15/66], P < 0.001) compared with the MED and ENDO groups. Early mortality rate was 9.1% (4/44), 18.2% (6/33), and 13.6% (3/22), for the MED, SURG, and ENDO groups (P = 0.51), respectively. A favorable early mortality rate was observed in patients with retrograde extension limited to the arch (8.6% [5/58]) vs into the ascending aorta (18.6% [8/43], P = 0.14). Early mortality rate of patients with retrograde AD with primary tear in the descending aorta (12.9% [13/101]) was significantly lower than those with classic type A AD presenting with primary tear in the ascending aorta (20.0% [195/977], P = 0.001). A subset of patients with acute retrograde AD originating from primary tear in the descending aorta might be managed less invasively with acceptable early results, particularly among those with proximal extension limited to the arch.

BackgroundThe TRANSFORM (Multicenter Experience With Rapid Deployment Edwards INTUITY Valve System for Aortic Valve Replacement) trial (NCT01700439) evaluated the performance of the INTUITY rapid deployment aortic valve replacement (RDAVR) system in patients with severe aortic stenosis.MethodsTRANSFORM was a prospective, nonrandomized, multicenter (n = 29), single-arm trial. INTUITY is comprised of a cloth-covered balloon-expandable frame attached to a Carpentier-Edwards PERIMOUNT Magna Ease aortic valve. Primary and effectiveness endpoints were evaluated at 1 year.ResultsBetween 2012 and 2015, 839 patients underwent RDAVR. Mean age was 73.5 ± 8.3 years. Full sternotomy (FS) was used in 59% and minimally invasive surgical incisions in 41%. Technical success rate was 95%. For isolated RDAVR, mean crossclamp and cardiopulmonary bypass times for FS were 49.3 ± 26.9 minutes and 69.2 ± 34.7 minutes, respectively, and for minimally invasive surgical 63.1 ± 25.4 minutes and 84.6 ± 33.5 minutes, respectively. These times were favorable compared with Society of Thoracic Surgeons database comparators for FS: 76.3 minutes and 104.2 minutes, respectively, and for minimally invasive surgical, 82.9 minutes and 111.4 minutes, respectively (P

We present the possible utility of computational fluid dynamics in the assessment of thrombus formation and virtual surgical planning illustrated in a patient with aortic thrombus in a kinked ascending aortic graft following thoracic endovascular aortic repair.A patient-specific three-dimensional model was built from computed tomography. Additionally, we modeled 3 virtual aortic interventions to assess their effect on thrombosis potential: (1) open surgical repair, (2) conformable endografting, and (3) single-branched endografting. Flow waveforms were extracted from echocardiography and used for the simulations. We used the computational index termed platelet activation potential (PLAP) representing accumulated shear rates of fluid particles within a fluid domain to assess thrombosis potential.The baseline model revealed high PLAP in the entire arch (119.8 ± 42.5), with significantly larger PLAP at the thrombus location (125.4 ± 41.2, p0.001). Surgical repair showed a 37% PLAP reduction at the thrombus location (78.6 ± 25.3, p0.001) and a 24% reduction in the arch (91.6 ± 28.9, p0.001). Single-branched endografting reduced PLAP in the thrombus region by 20% (99.7 ± 24.6, p0.001) and by 14% in the arch (103.8 ± 26.1, p0.001), whereas a more conformable endograft did not have a profound effect, resulting in a modest 4% PLAP increase (130.6 ± 43.7, p0.001) in the thrombus region relative to the baseline case.Regions of high PLAP were associated with aortic thrombus. Aortic repair resolved pathologic flow patterns, reducing PLAP. Branched endografting also relieved complex flow patterns reducing PLAP. Computational fluid dynamics may assist in the prediction of aortic thrombus formation in hemodynamically complex cases and help guide repair strategies.

Malperfusion is a common lethal complication of acute aortic dissection following rupture, for which the optimal management strategy has yet to be clearly established. The objective of this study was to reassess the management of acute type A aortic dissection (Type A-AAD) with malperfusion. We retrospectively analyzed the outcomes of all patients with Type A-AAD with malperfusion at the University of Michigan and compared the results from patients that directly underwent open surgical repair versus those who had percutaneous reperfusion prior to open surgical repair. Based on the results, we developed a patient care protocol for the treatment of all patients with acute type A dissection. We later re-analyzed the long-term outcomes for patients using the protocol. The present study demonstrated that, although the outcomes for patients with acute type A aortic dissection with malperfusion syndrome treated with initial percutaneous reperfusion and delayed open surgical intervention are not as good as the results for patients with uncomplicated Type A-AAD that undergo immediate surgical repair, their outcomes continue the long-term outcomes of the former group are superior. To outdo patients with acute type A aortic dissection with malperfusion syndrome treated with immediate open surgical intervention. In conclusion, at the University of Michigan we continue to use our patient care protocol to treat patients with Type A-AAD.

Advancements in cardiothoracic surgery prompted investigation into changes in operative management for acute type A aortic dissections over time.One thousand seven hundred thirty-two patients undergoing surgery for type A aortic dissection were identified from the International Registry of Acute Aortic Dissection Interventional Cohort Database. Patients were divided into time tertiles (T) (T1: 1996-2003, T2: 2004-2010, and T3: 2011-2016).Frequency of valve sparing procures increased (T1: 3.9%, T2: 18.6%, and T3: 26.7%; trend P .001). Biologic valves were increasingly utilized (T1: 35.6%, T2; 40.6%, and T3: 52.0%; trend P = .009), whereas mechanical valve use decreased (T1: 57.6%, T2: 58.0%, and T3: 45.4%; trend P = .027) for aortic valve replacement. Adjunctive cerebral perfusion use increased (T1: 67.1%, T2: 89.5%, and T3: 84.8%; trend P .001), with increase in antegrade cerebral techniques (T1: 55.9%, T2: 58.8%, and T3: 66.1%; trend P = .005) and hypothermic circulatory arrest (T1: 80.1%, T2: 85.9%, and T3: 86.8%; trend P = .030). Arterial perfusion through axillary cannulation increased (T1: 18.0%, T2: 33.2%, and T3: 55.7%), whereas perfusion via a femoral approach diminished (T1: 76.0%, T2: 53.3%, and T3: 30.1%) (both P values .001). Hemiarch replacement was utilized more frequently (T1: 27.0%, T2: 63.3%, and T3: 51.7%; trend P = .001) and partial arch was utilized less frequently (T1: 20.7%, T2: 12.0%, and T3: 8.4%; trend P .001), whereas complete arch replacement was used similarly (P = .131). In-hospital mortality significantly decreased (T1: 17.5%, T2: 15.8%, and T3: 12.2%; trend P = .017).There have been significant changes in operative strategy over time in the management of type A aortic dissection, with more frequent use of valve-sparing procedures, bioprosthetic aortic valve substitutes, antegrade cerebral perfusion strategies, and hypothermic circulatory arrest. Most importantly, a significant decrease of in-hospital mortality was observed during the 20-year timespan.

Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.

BackgroundIncreasing aortic diameter is thought to be an important risk factor for acute type B aortic dissection (ABAD). However, some patients develop ABAD in the absence of aortic dilatation. In this report, we sought to characterize ABAD patients who presented with a descending thoracic aortic diameter

Summary written by: Fred Morady, MD, FACC Large Scale Replication and Meta-Analysis ofVariants on Chromosome 4q25 Associated WithAtrial Fibrillation Kaab S, Darbar D, van Noord C, et al. Eur Heart J 2009;Jan 13:[Epub ahead of print].Study Design: Is the association between genetic variation onchromosome 4q25 and atrial fibrillation (AF) reproduciblewhen applied to other cohorts? Methods: This association was analyzed in four independentcohorts, including 12,173 patients. The Framingham HeartStudy and Rotterdam Study are community-based longitudi-nal studies. The Vanderbilt AF Registry and German AFNetwork (AFNet) are case-control studies. Journal of the American College of Cardiology© 2009 by the American College of Cardiology FoundationPublished by Elsevier Inc.Vol. 53, No. 9, 2009ISSN 0735-1097/09/$36.00doi:10.1016/j.jacc.2009.02.002 SCANNING THE LITERATURE Summaries of Key Journal Articles Kim A. Eagle, MD, FACC, Editor-in-Chief, Journal Scan, Ann Arbor, MI Christopher P. Cannon, MD, FACC, Editor-in-Chief, Cardiosource

Valvular regurgitation is a recognized complication of aortic and mitral valve procedures, with paravalvular leak the primary mechanism and transvalvular leak less common. The Cor-Knot automated fastener (LSI Solutions, Victor, NY) has been shown to be a safe, viable alternative to knot pushers or manual tying for use in these procedures. Here we present two patients in whom the orientation of the Cor-Knot fastener appeared to result in transvalvular regurgitation necessitating a redo operation. With adjunctive use of Cor-Knot devices, fastener orientation relative to valve geometry must be assessed for optimal results.

The intention of this study was to explore the efficacy and feasibility for Acid Yellow 17 adsorption onto fixed bed column of Tamarind Seed Powder. The effect of various parameters like flow rate, initial concentration of dye, bed height, and pH were exploited in this study. The Thomas, Yoon–Nelson, Bed Depth Service Time (BDST), and Adams and Bohart model were analysed to evaluate the column adsorption performance. The adsorption capacity, rate constant and correlation coefficient associated to each model for column adsorption was calculated and mentioned. The adsorption capacity increases with increasing initial dye concentration and bed height and decreasing flow rate. The maximum adsorption capacity related to Adams and Bohart model was found to be 978.5 mg/g at initial concentration of 50 ppm at constant flow rate of 15 mL/min, bed height of 15 cm, and pH 7. Le but de cette etude etait d'explorer l'efficacite et la faisabilite de l'Acid Yellow 17 adsorption sur colonne a lit fixe de Tamarind Seed Powder. L'effet de differents parametres comme le debit, la concentration initiale de colorant, la hauteur du lit et le pH ont ete exploitees dans cette etude. Le Thomas, Yoon-Nelson, BDST et Adams et le modele Bohart ont ete analysees pour evaluer les performances d'adsorption colonne. La capacite d'adsorption, constante de vitesse et coefficient de correlation associe a chaque modele de la colonne d'adsorption a ete calcule et mentionne. Les augmentations de capacite d'adsorption avec une concentration croissante de colorant initial et un lit en hauteur et le debit diminue. La capacite maximale d'adsorption liees au modele Adams et Bohart a ete trouve a 978,5 mg/g a la concentration initiale de 50 ppm a debit constant de 15 ml/min, la hauteur du lit de 15 cm et un pH de 7.

BackgroundPrevious studies have focused on early outcomes of open (descending thoracic aortic repair [DTAR]) and endovascular (thoracic endovascular aneurysm repair [TEVAR]) repair of blunt aortic injury (blunt thoracic aortic injury [BTAI]). Late results remain ill-defined and are the focus of this study.MethodsOne hundred nine patients (1992-2010) underwent repair for BTAI. Mean age was 39.0 years (73.4% male). DTAR was performed in 90, with left heart bypass (85) or hypothermic arrest (5). TEVAR was used in 19 of 45 patients treated since 2002. A strategy of selective delayed repair has been used since 1997, with 54 of 75 patients treated with delayed repair in this interval. The primary outcome was vital status (100% follow-up; mean, 103.9 months).ResultsMean Injury Severity Score was 39.5. Thirty-day mortality was 4.6% (n = 5). Early morbidity included permanent spinal cord ischemia (SCI, 1.8%), stroke (2.8%), and need for permanent dialysis (1.8%). Independent predictors of a composite outcome of early mortality and these morbidities included age >60 years (odds ratio [OR], 8.4; P = .015), increasing preoperative creatinine (OR, 7.9; P = .017), and occurrence of postoperative sepsis (OR, 9.6; P = .021). Fifteen-year Kaplan-Meier survival was 81.3%. Independent predictors of late mortality included age >60 years (Cox hazard ratio [HR], 4.1; P = .01), increasing creatinine (HR, 9.1; P < .001), or occurrence of postoperative SCI (HR, 20.6; P < .001), but not repair type (P = .73). Endograft collapse occurred in one patient, necessitating reintervention. Freedom from aortic reintervention at 4 years was higher after open repair (DTAR 100% vs TEVAR 94%; P = .03).ConclusionsWith careful selection, open or endovascular repair of BTAI has excellent early and late results. Although TEVAR has an increased risk for reintervention, factors other than treatment strategy impact late survival. These data support the growing role of an endoluminal approach for BTAI in anatomically appropriate patients.

Patients presenting with type A acute aortic dissection (TAAD) complicated by malperfusion syndromes represent one of the highest surgical risk cohorts for cardiovascular surgeons. In the setting of aortic dissection, end-organ ischemia may involve any of the major arterial side branches resulting in myocardial, cerebral, spinal cord, visceral and/or limb ischemia. In TAAD patients with malperfusion, notwithstanding continuous improvement in diagnostic and management strategies, surgical and clinical outcomes remain poor and the optimal therapy is controversial. The present review aimed to assess current evidence on TAAD patients with the complication of malperfusion, as enunciated by the International Registry of Acute Aortic Dissection (IRAD) investigators.

Rationnelle Nous souhaitions analyser notre experience du traitement hybride des anevrysmes aortiques englobant les arteres renales et viscerales. Methodes Nous avons mene une revue retrospective de 36 patients consecutifs qui avaient eu des pontages renaux/visceraux suivis par la mise en place d’endoprotheses aortiques. Les donnees demographiques des patients, l’histoire medicale, les interventions, les complications, la permeabilite prothetique, et la survie des patients etaient recueillies. Une analyse observationnelle et comparative etait realisee. Resultats L’âge moyen des patients etait de 71 ans. Le diametre anevrysmal moyen etait de 6,3 cm (range 4,1-9,4 cm). Selon la classification de Crawford, il y avait 1 type I, 10 type II, 12 type III, 10 type IV, et 3 anevrysmes pararenaux. Quatre patients etaient symptomatiques. Cent vingt-trois pontages etaient realises (mediane: 3/patient), dont 62 arteres renales, 32 arteres mesenteriques superieures, et 29 troncs cœliaques. Une revascularisation retrograde (via les arteres iliaques, l’aorte, ou un jambage de prothese aorto-bi-femorale) etait utilisee chez 30 patients et une revascularisation anterograde etait utilise chez six patients (trois a partir de l’aorte supracœliaque, et trois pontages renaux a partir de branches de tronc cœliaque). La mortalite hospitaliere etait de 8,3% (3 patients). Avec un suivi moyen de 6 mois, la survie etait de 80%. Une complication morbide majeure survenait chez 17 patients (47%), dont la necessite de dialyse (5), l’ischemie colique (3), l’alteration de l’etat general (5), la paraparesie temporaire (1), et la reintervention (7). Aucun patient n’a presente de paraplegie permanente. La duree moyenne de sejour etait de 26 jours (range 8-100 jours). La permeabilite primaire des pontages reno-visceraux etait de 93% a 8 mois. Au cours du suivi, 14 patients developpaient au moins une endofuite, 2 patients necessitaient une intervention percutanee, et les autres restaient en observation. Au dernier suivi, quatre endofuites de type 2 et une endofuite de type 3 etaient notees avec un anevrysme stable ou en diminution. Conclusion Le traitement hybride des anevrysmes aortiques englobant les arteres renales et viscerales est faisable avec une mortalite raisonnable et des taux de permeabilite satisfaisants a court terme concernant les pontages reno-visceraux. Cependant la morbidite des procedures de deroutage est elevee. Une selection plus stricte des patients pourrait ameliorer ces resultats.

Background We sought to analyze our experience with hybrid treatment of aortic aneurysms involving the renal and visceral arteries. Methods We conducted a retrospective review of 36 consecutive patients who underwent renal/visceral bypasses followed by aortic endografting. Patient demographics, medical history, operations, complications, graft patency, and patient survival were recorded. Observational and comparative analyses were performed. Results Mean patient age was 71 years. Mean aneurysm diameter was 6.3 cm (range 4.1-9.4 cm). Crawford aneurysm types included 1 type I, 10 type II, 12 type III, 10 type IV, and 3 pararenal aneurysms. Four patients were symptomatic. One hundred twenty-three bypasses were performed (median of three per patient), including 62 renal, 32 superior mesenteric, and 29 celiac arteries. Retrograde inflow (using the iliac arteries, aorta, or a limb of an aortobifemoral graft) was obtained in 30 patients and antegrade inflow was performed in six (three from the supraceliac aorta and three celiac branch to renal bypasses). In-hospital mortality occurred in 3 patients (8.3%). Patient survival was 80% at a mean follow-up of 6 months. Major morbidity occurred in 17 patients (47%) and included need for dialysis (5), ischemic colitis (3), failure to thrive (5), temporary paraparesis (1), and need for reoperation (7). No patient sustained permanent paraplegia. Mean length of stay was 26 days (range 8-100 days). Primary renovisceral bypass graft patency rate at 8 months was 93%. During follow-up, 14 patients developed at least one endoleak, 2 patients required percutaneous intervention, and the rest remained under observation. At last follow-up, four type 2 endoleaks and one type 3 endoleak with stable or decreasing aneurysm size. Conclusion Hybrid repair of aortic aneurysms involving the renal and visceral arteries is feasible with a reasonable mortality and satisfactory short-term visceral graft patency rate. However, the morbidity of the debranching procedures is high. More stringent patient selection may improve these results.

Thoracic aortic endovascular repair (TEVAR) holds great promise in the elderly population. We conducted a concurrent comparison of TEVAR with open descending thoracic aneurysm repair (DTAR) in elderly patients to determine the more appropriate therapeutic option.Since 1993, 93 patients aged 75 years and older have undergone open (n = 41) or endovascular (n = 52) descending aortic repair. Intervention indications included aneurysms, dissection, or traumatic injury. Mean maximum aortic diameter was 6.1 cm. Contained rupture was more frequent in TEVAR (p = 0.005); 52 needed arch repair, and 46 needed total descending repair.The mean age was 78.9 years (TEVAR, 80.6 vs DTAR, 76.9; p0.0001). The TEVAR patients had more significant comorbidities; 42 (80.8%) were prospectively identified as nonoperative candidates. Thirty-day mortality was higher in DTAR at 7 (17.1%) vs TEVAR at 3 (5.7%, p = 0.1). The composite end point of 30-day death, stroke, permanent paralysis, or dialysis requirement was similar (TEVAR, 9; DTAR, 10; p = 0.45). Median postoperative length of stay was shorter in TEVAR (6 days) vs DTAR (13 days; p = 0.003). Endoleaks were observed in 12. Actuarial survival at 48 months was similar (mean survival: TEVAR, 30.2 months vs DTAR, 33.7 months; p = 0.49).Despite more complex preoperative comorbidities, the TEVAR group had shorter hospitalization, a trend towards a reduction in early mortality, and similar late outcomes. This comparative analysis suggests that thoracic endovascular repair may be a more suitable therapeutic option in this complex elderly group.

Complications following thoracic aortic graft surgery are rare. They are not always clinically apparent and may occasionally be detected at computed tomography (CT) even in asymptomatic patients. Normal postoperative findings that may simulate complications include graft kinks, graft side branches, felt pledgets or rings, small amounts of low-attenuation perigraft material, native aortic wraps, and bovine pericardial wraps. Postoperative complications include anastomotic dehiscence and graft infection, which may lead to perigraft hematomas, pseudoaneurysms, abscesses, or fistulas. At CT, these complications may manifest as abnormally large collections of low-attenuation perigraft material, contrast material extravasation, perigraft gas collections, or fistulas to adjacent structures. Familiarity with both normal and abnormal postoperative CT findings and knowledge of the surgical technique used are essential to avoid misdiagnosing normal findings and to correctly diagnose potentially life-threatening complications. Following graft surgery, surveillance imaging may be needed, since the time of onset of complications seems highly variable.

Background: Presentations and outcomes of acute aortic dissection (AD) with an entry tear in the ascending aorta may differ from retrograde dissection with an entry tear in the descending aorta. However, guidelines recommend urgent surgical repair for both entities. Methods and Results: All patients with AD enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2014 were analyzed. We identified 99 patients (67 men; 63.2±14.0 years) with an entry tear in the descending aorta and retrograde extension into the arch or ascending aorta. Overall, independent predictors of retrograde type A AD were increasing age(OR 1.0; 95% CI, 1.0 to 1.0; P=0.004), history of cocaine abuse (OR 4.9; 95% CI, 1.7 to 13.6; P=0.003), back pain at presentation (OR 2.1; 95% CI, 1.3 to 3.3; P=0.002), and non-white race (OR 0.4; 95% CI, 0.2 to 0.6; P Conclusion: There is a subset of patients with acute retrograde type A AD who can be managed non-operatively with acceptable short and long-term results. This implies that a selective approach may be reasonable, particularly among those with proximal extension limited to the arch distal to the innominate artery.

Takayasu arteritis is a chronic, idiopathic, granulomatous vasculitis involving the aorta, its major branches, and occasionally the pulmonary arteries. Although rare in children, it is the third most common vasculitis in the paediatric population. Although aneurysmal disease has been reported in adults with Takayasu arteritis, it is a rare entity in children. We present the case of a 10-year-old boy with a giant ascending and arch aneurysm that necessitated follow-up surgery for a new aneurysm and occlusive disease. This is also the first published case involving endovascular aortic graft placement for the management of vascular sequela of Takayasu arteritis in a child.

BACKGROUND. Reports have associated nadir hematocrit (Hct) on cardiopulmonary bypass with the occurrence of renal dysfunction. Recent literature has suggested that women, although more often exposed to lower nadir Hct, have a lower risk of postoperative renal dysfunction. We assessed whether this relationship held across a large multicenter registry. METHODS. We undertook a prospective, observational study of 15,221 nondialysis-dependent patients (10,376 male, 68.2%; 4,845 female, 31.8%) undergoing cardiac surgery between 2010 and 2014 across 26 institutions in Michigan. We calculated crude and adjusted OR between nadir Hct during cardiopulmonary bypass and stage 2 or 3 acute kidney injury (AKI), and tested the interaction of sex and nadir Hct. The predicted probability of AKI was plotted separately for men and women. RESULTS. Nadir Hct less than 21% occurred among 16.6% of patients, although less commonly among men (9.5%) than women (31.9%; p < 0.001). Acute kidney injury occurred among 2.7% of patients, with small absolute differences between men and women (2.6% versus 3.0%, p = 0.20). There was a significant interaction between sex and nadir Hct (p [ 0.009). The effect of nadir Hct on AKI was stronger among male patients (adjusted odds ratio per 1 unit decrease in nadir Hct 1.10, 95% confidence interval: 1.05 to 1.13) than female patients (adjusted odds ratio 1.01, 95% CI: 0.96, 1.06). CONCLUSIONS. Lower nadir Hct was associated with an increased risk of AKI, and the effect appears to be stronger among men than women. Understanding of the mechanism underlying this association remains uncertain, although these results suggest the need to limit exposure to lower nadir Hct, especially for male patients.

Approximately 6% of all Type A dissection patients have no pain symptoms, making rapid diagnosis difficult. A better understanding of how painless patients present to the emergency room will help improve recognition of dissection in this subset of patients. Type A patients enrolled in the

Background Endovascular treatment for aortic arch aneurysms often requires adjunctive use of hybrid debranching procedures to maintain branch vessel perfusion. This study describes early results with a novel branched arch endograft for total endovascular repair of distal arch aneurysms. Methods This US feasibility multicenter clinical trial evaluated 22 patients (mean age, 74.1 ± 10.5 years; 54.5% male) undergoing branched thoracic endovascular aortic repair in Ishimaru zone 2. This endograft was designed with a single side branch designed to facilitate aortic coverage proximal to the left subclavian artery while maintaining branch vessel patency. The pathologic features treated included fusiform (n = 10) and saccular (n = 12) aneurysms, with a mean aortic diameter of 5.7 ± 1.1 cm. The mean preoperative left-to-right brachial index was 1.0 ± 0.1. Results The mean total treatment length was 17.6 ± 8.9 cm; 8 patients were treated with a single 10-cm graft for isolated arch disease. The primary endpoint of device delivery and branch vessel patency was achieved in 100% of patients, without 30-day death, stroke, or permanent paraplegia. The median duration of hospitalization was 4.0 days. Type I endoleaks at completion angiography were observed in 4 patients, and all resolved by 1 month without reintervention. All side branches were patent at 1 month. The Kaplan-Meier survival rate at 6 months was 94.7%. Conclusions Total endovascular repair of distal zone 2 arch aortic aneurysms can be achieved with a novel branched arch endograft. Future studies will evaluate the feasibility of this approach for aneurysms encompassing the brachiocephalic trunk and left carotid artery.

PURPOSE Small collections of contrast material are frequently seen within the otherwise thrombosed false lumen of an aortic dissection (AD). These collections can be divided into those without apparent communication with the aortic lumen (ie, pseudoaneurysms) and those with obvious communications (ie, ulcers). The present study was performed to test the hypotheses that pseudoaneurysms and ulcers differ in their distribution around the aorta and that the distribution of pseudoaneurysms is similar to that of small aortic branch arteries. MATERIALS AND METHODS Computed tomography (CT) scans in 187 patients with AD and thrombosed false lumens showed 335 intramural contrast medium collections, including 128 pseudoaneurysms and 207 ulcers. CT scans in 40 control individuals without AD were reviewed to localize small aortic branch arteries. The angular distributions around the circumference of the aorta of pseudoaneurysms and ulcers and the branch artery origins were tabulated and compared. The frequency of detection of small branch arteries arising from the contrast material collections was noted. RESULTS The angular distribution of pseudoaneurysms did not differ significantly from that of branch artery origins but did differ from that of ulcers. Pseudoaneurysms were found along the posterior, medial, and anterior walls of the aorta in the chest, sparing the lateral wall abutting the pleura. Ulcers tended to spare the arc containing branch artery origins. The composite distribution of ulcers and pseudoaneurysms appears uniform around the circumference of the aorta except at the T10–T12 levels. CONCLUSIONS Branch artery pseudoaneurysms spare the pleural surface of the aorta and have nearly the same distribution around the circumference of the aorta as the origins of small aortic branch arteries. In contrast, ulcers tend to spare branch artery origins. The characteristic appearance and distribution of pseudoaneurysms on CT can help differentiate them from ulcers.

During the diagnostic evaluation of a 31-year-old male with Marfan syndrome, an acute type B aortic dissection, and rising creatinine, the retrograde loop of our selective catheter inadvertently engaged the entry tear of the dissection in the mid-descending aorta. Traction on the catheter led to a full circumferential dehiscence of the remaining lumen, causing an intimointimal intussusception down to the level of the celiac artery with complete collapse of the true lumen and visceral and renal artery obstruction. Balloon fenestration and supramesenteric stenting of the true lumen decompressed the intussuscepted intimal flap and restored normal perfusion pressures.

Patient selection for left ventricular assist device (LVAD) therapy is the most important process in obtaining a successful outcome. Evaluation requires assessing the appropriateness for device implantation based on need and risk of LVAD implant to the patient. Appropriate patients can be selected without the need for invasive hemodynamic measurements and selection can be based on symptoms, appropriateness of medical therapy, and on the need for inotropic therapy. Assessing the risk of LVAD therapy to the patient requires evaluating the degree of organ dysfunction and technical factors. Patients should be offered the option of LVAD therapy if they meet criteria for need, possess the potential for organ recovery, and have appropriate operative risk.