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1.
Artigo em Inglês | MEDLINE | ID: mdl-38058148

RESUMO

Our goal was to replace the previous composite graft with a bioprosthesis. The approach involved axillary artery and femoral vein cannulation and cardiopulmonary bypass with moderate hypothermia for re-entry of the chest and deep hypothermia with circulatory arrest to get control of and to clamp the aorta when entering the pseudoaneurysm. The myocardial protection strategy was general cooling and retrograde cardioplegia through direct coronary sinus cannulation and antegrade cardioplegia in the coronary ostia when possible. After the pseudoaneurysm was entered, the graft was divided in the middle, and the distal end was dissected out under circulatory arrest sufficiently to allow clamping and to resume systemic circulation. The graft was not dissected out beyond the previous anastomosis. Under another period of circulatory arrest, the distal graft was removed to the mid-arch, and a new graft was attached with a hemiarch anastomosis. Then the root was dissected out, and both coronary ostia were mobilized. The mechanical aortic valve and previous graft material were explanted. A new bioprosthetic valved conduit was used to replace the aortic root, and the coronary buttons were re-implanted directly in the new graft.


Assuntos
Falso Aneurisma , Aorta Torácica , Humanos , Aorta Torácica/cirurgia , Falso Aneurisma/etiologia , Falso Aneurisma/cirurgia , Aorta/cirurgia , Ponte Cardiopulmonar , Cateterismo , Reoperação
2.
Artigo em Inglês | MEDLINE | ID: mdl-38154501

RESUMO

OBJECTIVES: Bicuspid aortic valve (BAV) aortopathy is defined by 3 phenotypes-root, ascending, and diffuse-based on region of maximal aortic dilation. We sought to determine the association between aortic mechanical behavior and aortopathy phenotype versus other clinical variables. METHODS: From August 1, 2016, to March 1, 2023, 375 aortic specimens were collected from 105 patients undergoing elective ascending aortic aneurysm repair for BAV aortopathy. Planar biaxial data (191 specimens) informed constitutive descriptors of the arterial wall that were combined with in vivo geometry and hemodynamics to predict stiffness, stress, and energy density under physiologic loads. Uniaxial testing (184 specimens) evaluated failure stretch and failure Cauchy stress. Boosting regression was implemented to model the association between clinical variables and mechanical metrics. RESULTS: There were no significant differences in mechanical metrics between the root phenotype (N = 33, 31%) and ascending/diffuse phenotypes (N = 72, 69%). Biaxial testing demonstrated older age was associated with increased circumferential stiffness, decreased stress, and decreased energy density. On uniaxial testing, longitudinally versus circumferentially oriented specimens failed at significantly lower Cauchy stress (50th [15th, 85th percentiles]: 1.0 [0.7, 1.6] MPa vs 1.9 [1.3, 3.1] MPa; P < .001). Age was associated with decreased failure stretch and stress. Elongated ascending aortas were also associated with decreased failure stress. CONCLUSIONS: Aortic mechanical function under physiologic and failure conditions in BAV aortopathy is robustly associated with age and poorly associated with aortopathy phenotype. Data suggesting that the root phenotype of BAV aortopathy portends worse outcomes are unlikely to be related to aberrant, phenotype-specific tissue mechanics.

4.
Artigo em Inglês | MEDLINE | ID: mdl-37716653

RESUMO

OBJECTIVES: We evaluate the independent effects of patient and aortic tissue characteristics on biaxial physiologic mechanical metrics in aneurysmal and nonaneurysmal tissues, and uniaxial failure metrics in aneurysmal tissue, comparing longitudinal and circumferential behavior. METHODS: From February 2017 to October 2022, 382 aortic specimens were collected from 134 patients; 268 specimens underwent biaxial testing, and 114 specimens underwent uniaxial testing. Biaxial testing evaluated Green-Lagrange transition strain and low and high tangent moduli. Uniaxial testing evaluated failure stretch, Cauchy stress, and low and high tangent moduli. Longitudinal gradient boosting models were implemented to estimate mechanical metrics and covariates of importance. RESULTS: On biaxial testing, nonaneurysmal tissue was less deformable and exhibited a lower transition strain than aneurysmal tissue in the longitudinal (0.18 vs 0.30, P < .001) and circumferential (0.25 vs 0.30, P = .01) directions. Older age and increasing ascending aortic length contributed most to predicting transition strain. On uniaxial testing, longitudinal specimens failed at lower stretch (1.4 vs 1.5, P = .003) and Cauchy stress (1.0 vs 1.9 kPa, P < .001) than circumferential specimens. Failure stretch and Cauchy stress were most strongly associated with tissue orientation and decreased sharply with older age. Age, ascending aortic length, and tissue thickness were the most frequent covariates predicting mechanical metrics across 10 prediction models. CONCLUSIONS: Age was the strongest predictor of mechanical behavior. After adjusting for age, nonaneurysmal tissue was less deformable than aneurysmal tissue. Differences in longitudinal and circumferential mechanics contribute to tissue dysfunction and failure in ascending aneurysms. This highlights the need to better understand the effects of age, ascending aortic length, and thickness on clinical aortic behavior.

5.
J Thorac Cardiovasc Surg ; 166(3): 701-712.e7, 2023 09.
Artigo em Inglês | MEDLINE | ID: mdl-35219518

RESUMO

OBJECTIVES: We hypothesized that tissue characteristics vary significantly along zone zero, which may be reflected by regional differences in stored elastic energy. Our objectives were to (1) characterize the regional variation in stored elastic energy within tissues of the aortic zone zero and (2) identify the association between this variation and patient characteristics. METHODS: From February 2018 to January 2021, 123 aortic tissue samples were obtained from the aortic root and proximal and distal ascending aortas of 65 adults undergoing elective ascending aorta replacement. Biaxial biomechanics testing was performed to obtain tissue elastic energy at the inflection point and compared with patient demographics and preoperative computed tomography imaging. Coefficient models were fit using B-spline to interrogate the relationship among elastic energy, region, and patient characteristics. RESULTS: Mean elastic energy at inflection point was 24.3 ± 15.6 kJ/m3. Elastic energy increased significantly between the root and proximal, and root and distal ascending aorta and decreased with increasing age. Differences due to history of connective tissue disorder and bicuspid aortic valve were significant but diminished when controlled for other patient characteristics. Among covariates, age and region were found to be the most important predictors for elastic energy. CONCLUSIONS: Aortic tissue biomechanical metrics varied across regions and with patient characteristics within the aortic zone zero. Assessment of endovascular outcomes in the ascending aorta must closely consider the region of deployment and variable tissue qualities along the length of the landing zone. Regional variation in tissue characteristics should be incorporated into existing patient-specific models of aortic mechanics.


Assuntos
Aorta , Doença da Válvula Aórtica Bicúspide , Adulto , Humanos , Fenômenos Biomecânicos , Aorta/diagnóstico por imagem , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia
6.
Indian J Thorac Cardiovasc Surg ; 38(Suppl 1): 7-13, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35463697

RESUMO

The ascending aorta has a unique microstructure and biomechanical properties that allow it to absorb energy during systole and return energy during diastole (Windkessel effect). Derangements in aortic architecture can result in changes to biomechanics and inefficiencies in function. Ultimately biomechanical failure may occur resulting in aortic dissection or rupture. By measuring aortic biomechanics with either in vivo or ex vivo methods, one may be able to predict tissue failure in patients with aortic disease such as aneurysms. An understanding of the biomechanical changes that lead to these tissue-level failures may help guide therapy, disease surveillance, surgical intervention, and aid in the development of new treatments for this deadly condition.

7.
J Thorac Cardiovasc Surg ; 157(2): 439-450.e5, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30669217

RESUMO

OBJECTIVES: Loeys-Dietz syndrome (LDS) is an aggressive connective tissue disorder associated with increased risk of aortic dissection and aneurysm rupture at an early age and smaller aortic diameters. We report our experience with LDS to better understand its natural history and treatment outcomes and help establish treatment guidelines. METHODS: We retrospectively reviewed all patients with LDS who underwent medical or surgical treatment at Cleveland Clinic before April 27, 2017. Primary endpoints were postoperative in-hospital morbidity and mortality. Secondary endpoints were aorta-related reoperations and short- and long-term mortality. RESULTS: We identified 53 patients with LDS. Of these, 33 (62%) underwent aortic surgery. Mean age was 39 ± 14 years, and mean maximum aortic diameter was 4.3 cm. There were 2 (6%) deaths after urgent or emergency surgery. Twenty-two patients (67%) required no aortic reoperation; 20 of these had prophylactic surgery. Multiple aortic operations were performed on 11 (33%) patients, 9 of whom experienced aortic dissections. Six patients (18%) required total aortic replacement. Among 19 patients with modified root reimplantation, no aorta- or valve-related complications occurred. Overall, 33 patients underwent 58 aortic and 81 cardiovascular operations, with 1 late death. Kaplan-Meier survival of the aortic-surgery cohort was 89% at 10 years (median follow-up 5.2 years). There were no late deaths in the non-aortic surgery group (20/53; 38%). CONCLUSIONS: Prophylactic aortic surgical outcomes in LDS are excellent. Surgical reintervention remains high, particularly after aortic dissections. Close surveillance of medically managed and postoperative patients and early prophylactic surgery are crucial to avoid aortic catastrophe and achieve a good long-term prognosis.


Assuntos
Síndrome de Loeys-Dietz , Adulto , Aorta/cirurgia , Procedimentos Cirúrgicos Cardíacos , Procedimentos Endovasculares , Feminino , Humanos , Síndrome de Loeys-Dietz/epidemiologia , Síndrome de Loeys-Dietz/mortalidade , Síndrome de Loeys-Dietz/cirurgia , Masculino , Pessoa de Meia-Idade , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
8.
Ann Thorac Surg ; 104(6): 1960-1967, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28939200

RESUMO

BACKGROUND: Retrograde false lumen perfusion is a common mode of failure after stent grafting chronic aortic dissection. Open fenestration during the first-stage elephant trunk (ET) creates a landing zone for second-stage endovascular ET completion in patients with a false lumen aneurysm. Our objectives were to assess long-term safety and durability of this technique. METHODS: From 2007 to 2014, 56 patients with thoracoabdominal dissection and aneurysm underwent stage 1 ET and open fenestration. Fifteen (26.8%) patients had DeBakey type III dissection, and 41 (73%) had type I, 38 (68%) with previous ascending repair. Mean maximum diameter was 5.8 ± 1 cm. Imaging follow-up was complete in all survivors. RESULTS: Endovascular ET completion was performed in 49 patients (87.5%), urgently in 11 (22%). Operative mortality after the first stage was 1.8%. The ET in 8 patients was performed prophylactically. Complications after the first stage included transient ischemic attack in 1 patient (1.8%), subdural hemorrhage in 1 (1.8%), tracheostomy in 1 (1.8%), bleeding in 5 (8.9%), and paraplegia in 1 (1.8%). All 48 patients had false lumen thrombosis in the treated segment without endoleak or retrograde perfusion. The aneurysm sac shrunk in 67%, with a mean overall aortic diameter reduction of 1 ± 0.8 cm. Median follow-up was 33.8 months. Eight patients (16%) underwent 11 late reinterventions, comprising thoracic endovascular aortic repair extension in 4 patients (36%), thoracic endovascular aortic repair and false lumen embolization in 3 (27%), open thoracoabdominal aortic aneurysm completion repair in 2 (18%), and redo proximal repair for infection in 2 (18%). There were 6 late deaths. CONCLUSIONS: Open aortic fenestration to create a distal landing zone during stage 1 ET facilitates endovascular completion for chronic dissection with false lumen aneurysm. The technique is safe, effective, and durable. It promotes reverse aortic remodeling and eliminates retrograde false lumen flow.


Assuntos
Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Procedimentos Endovasculares/métodos , Complicações Pós-Operatórias/epidemiologia , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/mortalidade , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/mortalidade , Doença Crônica , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
9.
J Thorac Cardiovasc Surg ; 153(5): 1023-1030.e1, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28262292

RESUMO

OBJECTIVES: Coexisting aortic root and mitral valve pathology is increasingly recognized among patients undergoing surgery. We characterized the pathology and surgical outcomes of patients with combined aortic root and mitral disease. METHODS: From 1987 to 2016, 118 patients (age 52.40 ± 17.71 years) underwent concomitant aortic root and mitral procedures (excluding aortic stenosis, endocarditis, and reoperations). Aortic root pathologies included degenerative aneurysm (94%) and aortic dissection (6%). The aortic valve was bicuspid in 15% of patients and had normally functioning tricuspid leaflets in 23% of patients. Marfan syndrome was present in 34 patients (29%). Degenerative mitral disease predominated (78%). Mitral procedures were repair (86%) and replacement (14%), and root procedures were valve-preserving root reimplantation (36%), Bentall procedure (47%), and homograft root replacement (17%). In the last 10 years, the combination of valve-preserving root reimplantation and mitral repair has increased to 50%. Kaplan-Meier and competing risk analyses were used to estimate survival and reoperation. RESULTS: There were 2 (1.7%) operative deaths with survival of 79% and 71% at 10 and 15 years, respectively, and reoperation rates of 4.7% and 12% after 5 and 10 years, respectively. There were no operative deaths in patients with combined valve-preserving root reimplantation and mitral repair, with survival of 89% and reoperation rate of 7.8% at 10 years. Among patients with Bentall/homograft and mitral operation, survival was 73% and reoperation was 9.8% at 10 years. CONCLUSIONS: In patients with aortic root and mitral pathology, combined surgical risk is low and valve durability is high. When possible, valve-preserving root reimplantation and mitral repair should be considered to avoid prosthesis degeneration, anticoagulation, and lifestyle limitations.


Assuntos
Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Valva Aórtica/anormalidades , Implante de Prótese Vascular , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Mitral/cirurgia , Adulto , Idoso , Dissecção Aórtica/etiologia , Dissecção Aórtica/mortalidade , Dissecção Aórtica/fisiopatologia , Aneurisma Aórtico/etiologia , Aneurisma Aórtico/mortalidade , Aneurisma Aórtico/fisiopatologia , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Doença da Válvula Aórtica Bicúspide , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Tomada de Decisão Clínica , Feminino , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/fisiopatologia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Síndrome de Marfan/complicações , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/fisiopatologia , Recuperação de Função Fisiológica , Reimplante , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
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