Exeporfinium chloride (XF-73) nasal gel dosed over 24 hours prior to surgery significantly reduced Staphylococcus aureus nasal carriage in cardiac surgery patients: Safety and efficacy results from a randomized placebo-controlled phase 2 study.

We studied 83 cardiac-surgery patients with nasal S. aureus carriage who received 4 intranasal administrations of XF-73 nasal gel or placebo <24 hours before surgery. One hour before surgery, patients exhibited a S. aureus nasal carriage reduction of 2.5 log10 with XF-73 compared to 0.4 log10 CFU/mL for those who received placebo (95% CI, -2.7 to -1.5; P < .0001).

One and Five-Year Mortality Risk Prediction in Patients with Moderate and Severe Aortic Stenosis.

(1) Background: Our goal was to develop a risk prediction model for mortality in patients with moderate and severe aortic stenosis (AS). (2) Methods: All patients aged 40−95 years, with echocardiographic evidence of moderate and severe AS at a single institution, were studied over a median of 2.8 (1.5−4.8) years, between 2013−2018. Patient characteristics and mortality were compared using Chi-squares, t-tests, and Kaplan−Meier (KM) curves, as appropriate. The risk calculation for mortality was derived using the Cox proportional hazards model. A risk score was calculated for each parameter, and the total sum of scores predicted the individualized risks of 1-and 5-year mortality. (3) Results: A total of 1991 patients with severe and 2212 with moderate AS were included. Severe AS patients were older, had a lower ejection fraction %, were more likely to be Caucasian, and had lower rates of obesity and smoking, but had higher rates of cardiac comorbidities and AVR (49.3% vs. 2.8%, p < 0.0001). The unadjusted overall mortality was 41.7% vs. 41%, p = 0.6530, and was not different using KM curves (log rank, p = 0.0853). The models included only patients with complete follow-up (3966 in the 1-year, and 816 in the 5-year model) and included 13 variables related to patient characteristics, degree of AS, and AVR. The C-statistic was 0.75 and 0.72 for the 1-year and the 5-year models, respectively. (4) Conclusions: Patients with moderate and severe AS experience high morbidity and mortality. The usage of a risk prediction model may provide guidance for clinical decision making in complex patients.

Midterm outcomes and durability of sinus segment preservation compared with root replacement for acute type A aortic dissection.

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

Midterm outcomes of emergency surgery for acute type A aortic dissection in octogenarians.

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

Recurrent aortic insufficiency after emergency surgery for acute type A aortic dissection with aortic root preservation.

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

Fate of the Preserved Sinuses of Valsalva After Emergency Repair for Acute Type A Aortic Dissection.

BACKGROUND: Patients with acute type A aortic dissection (ATAAD) present with heterogeneous involvement of the aortic root complex. Despite this variation, the aortic root can usually be preserved the majority of the time by Teflon (WL Gore, Newark, DE) inlay patch reconstruction of the dissected sinuses of Valsalva (SOV). In this study, we report the long term anatomic, functional, and clinical outcomes associated with the preserved SOV after surgery for ATAAD. METHODS: From 2002-2017, of 776 emergency ATAAD operations at a single institution, 558 (71.9%) underwent valve resuspension with SOV preservation. Echocardiography reports were reviewed to obtain postoperative SOV dimensions. Cumulative incidence of SOV dilation ≥ 4 5mm was calculated using the Fine-Gray method with death as a competing risk. Repeated-measures linear mixed effects model was used to determine risk factors for SOV growth over time. RESULTS: During the follow-up period, 62 of 558 (11.1%) patients developed SOV diameter ≥ 45 mm. Cumulative incidence of SOV dilation ≥ 45 mm at 1, 5, and 10 years was 5.5%, 12.4%, and 18.9% respectively. In a multivariable Cox regression model, preoperative SOV diameter ≥ 45 mm was associated with a hazard ratio of 14.11 (95% confidence interval 7.03-31.62) for postoperative SOV dilation ≥ 45 mm. In a repeated-measures linear mixed effects model, preoperative and discharge SOV diameter were significant predictors of SOV dilation. Postoperative time course was also identified as significant indicating growth over time. CONCLUSIONS: The preserved sinuses of Valsalva after surgery for ATAAD may be prone to progressive dilatation over time. Closer echocardiographic surveillance may be warranted in these patients.

Two different geometric orientations for aortic neoroot creation in bicuspid aortic valve repair with root reimplantation.

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

Open Thoracoabdominal Aortic Repair in Patients With Heritable Aortic Disease in the GenTAC Registry.

BACKGROUND: Although patients with various types of heritable aortopathy often require distal aortic repair, data are limited regarding the most extensive operations-open thoracoabdominal aortic aneurysm (TAAA) repairs. The objective of this multicenter registry study was to characterize TAAA repairs in a large cohort of patients with different heritable aortic diseases. METHODS: From the 3699 patients enrolled at 8 participating centers in the Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) Registry, we identified 155 open TAAA repairs in 142 unique patients. We examined data related to clinical characteristics, surgical techniques, and outcomes. RESULTS: The primary diagnoses included Marfan syndrome (n = 76; 54%), familial thoracic aortic aneurysm and dissections (n = 31; 22%), and Loeys-Dietz syndrome (n = 10; 7%). Most repairs were performed for aneurysms associated with aortic dissection (n = 110; 71%). The most common repairs involved the entire descending thoracic aorta with distal extension (21% Crawford extent I and 36% extent II). Adjuncts used during repair varied substantially. The operative mortality rate was 1.3%. Other complications included paraplegia (4%), acute renal failure (5%), and vocal cord paralysis (21%). Reoperation after TAAA repair was required in a subset of cases for early bleeding (n = 15; 10%) and late repair failure (n = 7; 5%). CONCLUSIONS: Open TAAA repairs are necessary in a variety of heritable aortic diseases. These patients often require extensive surgical repair, and a variety of adjunctive techniques are utilized. The risk of repair failure and the need for reoperation in a subset of patients support the need for vigilant long-term surveillance after repair.

Aortic Dilatation Associated With Bicuspid Aortic Valve: Relation to Sex, Hemodynamics, and Valve Morphology (the National Heart Lung and Blood Institute-Sponsored National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions).

This study analyzed the impact of sex, hemodynamic profile, and valve fusion pattern on aortopathy associated with bicuspid aortic valve (BAV). The National Heart Lung and Blood Institute-sponsored National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) provided comprehensive information on a large population of well-characterized patients with BAV. Of 969 enrolled patients with BAV, 551 (57%, 77% male) had already undergone valvular and/or aortic surgery. Echocardiographic imaging data were available on 339 unoperated or preoperative participants who formed the basis of this study. BAV function was normal in 45 (14%), with a predominant aortic regurgitation (AR) in 127 (41%) and a predominant aortic stenosis (AS) in 76 (22%). Moderate-severe AR was associated with larger sinus of Valsalva (SOV) diameters compared with normal function and AS (all p <0.01). Moderate-severe AS was associated with a larger ascending aortic (AscAo) diameter compared with normal function (p = 0.003) but not with AR. The SOV diameter was larger in men than in women (3.7 ± 0.7 vs 3.3 ± 0.6 cm, p <0.0001), whereas AscAo diameters were comparable (3.9 ± 0.9 vs 3.7 ± 0.9 cm, p = 0.08). Right-left commissural fusion was associated with a larger SOV diameter (3.7 ± 0.7 vs 3.3 ± 0.6 cm, p <0.0001) compared with a right-noncoronary fusion pattern. Predominant AR was more common in men (45% vs 27%, p = 0.004), whereas AS was more common in women (29% vs 18%, p = 0.04). In conclusion, in the GenTAC Registry, AR was associated with diffuse (annular, SOV, and AscAo) enlargement, whereas moderate-severe AS was only associated with AscAo enlargement. Male sex and right-left cusp pattern of cusp fusion were associated with larger SOV diameters and a greater likelihood of AR, whereas women had a higher prevalence of AS.

Outcomes of Elective Aortic Hemiarch Reconstruction for Aneurysmal Disease in the Elderly.

BACKGROUND: This study evaluated outcomes of elective aortic hemiarch reconstruction for aneurysmal disease in the elderly. METHODS: Patients undergoing elective aortic hemiarch reconstruction for aneurysmal disease at a single institution between 2009 and 2014 were retrospectively reviewed. Patients were stratified into nonelderly (aged less than 75 years) versus elderly (aged 75 years or more). Outcomes included operative mortality and morbidity. RESULTS: In all, 629 patients (95 elderly; 15%) were included. Elderly patients had a greater comorbidity burden. Concomitant aortic valve replacement and coronary artery bypass were performed more frequently whereas root replacement was performed less frequently in the elderly. The overall stroke rate was 1.8% and was higher among the elderly (4.2% versus 1.3%, p = 0.05), although this difference no longer persisted after risk adjustment (odds ratio 2.54, p = 0.17). Median length of intensive care unit and hospital stay were longer in the elderly (64 versus 41 hours and 9 versus 7 days, respectively; each p < 0.001). Unadjusted and risk-adjusted operative mortality were similar (2.1% elderly versus 0.9% nonelderly, p = 0.32). Elderly patients were less frequently discharged to home (65% versus 95%, p < 0.001). Propensity matched analysis confirmed these findings. Moderate hypothermic circulatory arrest with antegrade cerebral perfusion was a safe strategy for the elderly patients, with stroke and operative mortality rates of 0% each. CONCLUSIONS: Although elderly patients have a more prolonged recovery after elective aortic hemiarch reconstruction for aneurysmal disease, outcomes are acceptable with low operative mortality and with the majority being discharged home. Moderate hypothermic circulatory arrest with antegrade cerebral perfusion is a safe strategy for this cohort. Advanced age alone should not be viewed as a contraindication in these cases.

Bicuspid Aortic Insufficiency With Aortic Root Aneurysm: Root Reimplantation Versus Bentall Root Replacement.

BACKGROUND: In patients with a bicuspid aortic valve presenting with aortic insufficiency (AI) and root aneurysm, we assessed whether outcomes with primary cusp repair with root reimplantation were equivalent to the gold standard Bentall procedures. METHODS: From 2002 to 2014, 710 patients with bicuspid aortic valve underwent aortic root procedures. Of these, only patients presenting with noncalcified type I bicuspid aortic valve with AI (n = 165) were included to maintain anatomic and physiologic homogeneity between the groups. Aortic stenosis, endocarditis, redo root, and emergency cases were excluded. Patients undergoing valve-sparing root reimplantation (VSRR group, n = 45) were retrospectively compared with those undergoing Bentall root replacement (Bentall group, n = 120). RESULTS: Patients in the Bentall group were older (52 ± 13 vs 46 ± 12 years; p ≤ 0.01) and had a lower ejection fraction (0.53 ± 0.12 versus 0.58 ± 0.08; p < 0.01), but left ventricular diastolic diameter was similar (58 ± 10 mm versus 57 ± 9 mm; p = 0.5). Thirty-day and in-hospital mortality was zero; in-hospital stroke rate was 0.8% (n = 1) in the Bentall group (0 in the VSRR group; p = 0.54). Permanent pacemaker rate was 6% (n = 7) in the Bentall group (0 in the VSRR group; p = 0.2). On discharge echocardiography, AI grade ≤ 1+ (100%; p = 1) and transvalvular gradients (mean gradient 7 ± 3 versus 6 ± 3 mm Hg; p = 0.14) were similar. Mean follow-up was 7.5 ± 3.2 and 3.4 ± 2.9 years (p < 0.001). There were 14 transient ischemic attacks or stroke events in the Bentall group, and none in the VSRR group. One patient in each group exhibited AI ≥ 3+. Five-year actuarial survival (100% versus 98% ± 2%; p = 0.8) and freedom from aortic reoperation (98% ± 2% versus 100%; p = 0.8) were similar. CONCLUSIONS: In patients with bicuspid aortic valve AI with root aneurysm, primary cusp repair with root reimplantation achieves equivalent midterm outcomes compared with Bentall root replacement.

The Impact of Deep Versus Moderate Hypothermia on Postoperative Kidney Function After Elective Aortic Hemiarch Repair.

BACKGROUND: There remains concern that moderate hypothermic circulatory arrest (MHCA) with antegrade cerebral perfusion (ACP) may provide suboptimal distal organ protection compared with deep hypothermic circulatory arrest (DHCA) with retrograde cerebral perfusion (RCP). We compared postoperative acute kidney injury (AKI) in in patients who underwent elective hemiarch repair with either DHCA/RCP or MHCA/ACP. METHODS: This was a retrospective review of all patients undergoing elective aortic hemiarch reconstruction for aneurysmal disease between 2009 and 2014. Patients were stratified according to the use of DHCA/RCP versus MHCA/ACP. The primary outcome was the occurrence of AKI at 48 hours, as defined by the Risk, Injury, Failure, Loss, End-Stage (RIFLE ) criteria. A multivariable logistic regression identified risk factors for AKI. RESULTS: One hundred eighteen patients who underwent ACP and 471 patients who underwent RCP were included. The mean lowest temperature was 26.4°C in patients who underwent MHCA/ACP and 17.5°C in patients who underwent DHCA/RCP. Baseline demographics were similar except that patients who underwent DHCA/RCP were more likely to have peripheral arterial disease or bicuspid aortic valves. Cardiopulmonary bypass and aortic cross-clamp times were shorter in the MHCA/ACP group. AKI occurred in 19 (16.2%) patients who underwent MHCA/ACP and 67 (14.3%) patients who underwent DHCA/RCP. Four (0.8%) patients who underwent DHCA/RCP required postoperative dialysis. In-hospital mortality tended to increase with increasing RIFLE classification (RIFLE class-0 (No AKI) = 0.41%; Risk = 1.35%, and Injury = 10.0%; p = 0.09). On multivariable analysis, the lowest temperature and cerebral perfusion strategy were not significant predictors of AKI. Lower baseline glomerular filtration rate (GFR), lower preoperative ejection fraction, and longer cardiopulmonary bypass (CPB) time were independently associated with higher AKI. CONCLUSIONS: We applied the sensitive RIFLE criteria to examine AKI in patients undergoing elective aortic hemiarch replacement for aneurysmal disease. Baseline renal dysfunction, lower ejection fraction, and longer CPB time are independent predictors of AKI. Compared with DHCA/RCP, our data suggest that an MHCA/ACP cerebral protection strategy does not appear to be associated with worse postoperative renal outcomes.

Direct innominate artery cannulation: An alternate technique for antegrade cerebral perfusion during aortic hemiarch reconstruction.

OBJECTIVE: We describe an alternate technique for establishing antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest via direct, central cannulation of the innominate artery. METHODS: From 2009 to 2015, 100 elective hemiarch reconstructions for proximal aortic aneurysms were performed under moderate hypothermic circulatory arrest (MHCA). Cerebral perfusion was instituted with ACP via direct cannulation of the innominate artery. RESULTS: Mean patient age was 63 ± 13 years (72 men; 72%). Mean MHCA temperature was 27.3°C ± 1.0°C (median, 28°C). Mean ACP time was 17 ± 4 minutes and mean crossclamp time was 134 ± 42 minutes. Proximal reconstruction included root replacement with composite valved graft (n = 47), valve sparing root reimplantation (n = 16), and aortic valve replacement (n = 19). In-hospital 30-day mortality (n = 1; 1%), stroke (1; 1%), reversible ischemic neurologic deficit (n = 1; 1%), coma (n = 0), and renal failure (n = 1; 1%) rates were low. There was no incidence of injury or dissection of the innominate artery. CONCLUSIONS: Direct, central innominate artery cannulation for ACP yields excellent outcomes. This technique is safe, provides excellent cerebral protection during circulatory arrest and simplifies the circulatory management strategy for elective ascending aortic and hemiarch reconstruction.

Bicuspid Aortic Valve Resuspension in Acute Type A Aortic Dissection Patients.

BACKGROUND: There are no data on the fate of the preserved bicuspid aortic valve (BAV) in patients with acute type A aortic dissection. We investigated surgical outcomes in BAV patients who had undergone aortic valve resuspension versus replacement for dissection type A. METHODS: Among 1,500 consecutive patients operated on for acute type A dissection between 1993 and 2013 at 3 tertiary centers, 66 had BAV (68% males, median age 60 ± 15 years). Thirteen BAV resuspension patients were compared with 53 BAV replacement patients. Median follow-up was 5.0 ± 4.7 years. RESULTS: The ages of both groups were similar (resuspension 62 ± 13 vs replacement 57 ± 15 years, p = 0.62), and both presented similar risk-factor profiles. Moderate-to-severe aortic valve regurgitation was observed in 15% of the resuspension and 45% of the replacement patients (p = 0.06). Resuspension patients required shorter cardiopulmonary bypass and cross-clamp times (153 ± 48 vs 224 ± 76 min, p < 0.01; 106 ± 33 vs 172 ± 57 min, p < 0.01, respectively). In-hospital mortality was observed in 15.4% of the resuspension and 15.1% of the replacement patients (p = 1). One replacement patient underwent a proximal reoperation. The resuspension group experienced no severe aortic regurgitation, nor any need for proximal reintervention. Overall survival was 68% ± 13% vs 65% ± 7% at 5 years in resuspension and replacement groups, respectively (log- rank, p = 0.97). CONCLUSIONS: The BAV resuspension in type A dissection patients showed good short- and mid-term results. It is doable with acceptable results, and full root replacement is not always necessary.

Outcomes of aortic root replacement after previous aortic root replacement: the "true" redo root.

BACKGROUND: Aortic reoperations are technically challenging. This study evaluated outcomes after "true" redo root replacement (previous full root replacement) stratified by cause of prosthesis failure. METHODS: Data were compared for 793 patients who underwent a first-time sternotomy (de novo group) and 120 patients who had previously undergone full aortic root replacement (redo group), of which 76 underwent reoperation due to structural valve deterioration (degenerative group), and 44 due to endocarditis (infection group). RESULTS: Overall mortality was 4% (n = 28) in the de novo group and 5% (n = 6) in the redo group (p = 0.43) (degenerative group, 3%, infection group, 9%; p = 0.19). The infection group had an increased incidence of renal failure, sternal infection, prolonged ventilation, reoperation for bleeding, multisystem failure, and sepsis, and an increased hospital length of stay. The degenerative group and the de novo group had a similar risk of perioperative death and major complications. The 5-year survival was 86.3% ± 1.3% for the de novo group and 77.3% ± 4.6% for the redo group (p ≤ 0.01; degenerative, 86.3% ± 5%; infection, 65.3% ± 7.7%; p < 0.01; p = 0.98 for de novo vs degenerative). Multivariate analysis demonstrated that reoperation for degenerative failure did not increase the risk of perioperative or late death. CONCLUSIONS: Redo aortic root replacement can be performed with low perioperative morbidity and death. The presence of infection increases the risk of complications and worsens survival. However, redo root replacement for degenerative failure can be performed with similar short-term complication risk and midterm survival as de novo root replacement.

Distal aortic reintervention after surgery for acute DeBakey type I or II aortic dissection: open versus endovascular repair.

OBJECTIVES: Aortic dissection DeBakey type I and II may require distal reinterventions after initial proximal repair. We evaluated outcomes following open versus endovascular approaches to distal aortic pathologies after surgery for acute dissection. METHODS: One hundred and forty-one consecutive patients underwent 152 distal reinterventions after previous type I or II dissection repair [63 (first quartile, 55; third quartile, 72) years old; initially 86% DeBakey type I; 54% hemiarch, 39% isolated ascending, 7% total arch replacement] at two tertiary centres in the USA and Europe over the last 14 years. Among them, 56 and 85 required reintervention for the aortic arch and the descending aorta, respectively. The median follow-up was 2.1 (first quartile, 0.8; third quartile, 5.8) years (439 patient-years). RESULTS: The median time between acute aortic dissection repair and descending aortic reintervention was longer in the open group (2.7 (first quartile, 0.8; third quartile, 6.7) vs 0.6 (first quartile, 0.1; third quartile, 3.5) years, P < 0.01). There was one irreversible spinal ischaemia in the open and one stroke in the endovascular group. Two patients in the open and none in the endovascular group required re-exploration for bleeding. Two open and 4 endovascular patients required more than 1 distal reintervention (6 vs 8%, P = 1). Descending aortic open-repair patients experienced higher in-hospital mortality (23 vs 0%, P < 0.01) and lower survival at 1 and 5 years (74 ± 8% vs 96 ± 3%, 65 ± 9% vs 92 ± 5%, P < 0.01, respectively). CONCLUSIONS: Endovascular intervention for descending aortic pathologies after DeBakey type I or II dissection surgical repair is associated with lower in-hospital mortality and better survival, and does not raise the likelihood of later reinterventions at the mid-term follow-up.

Outcomes of surgery for chronic type A aortic dissection.

BACKGROUND: Data on outcomes of surgery for chronic Stanford type A aortic dissection are limited. We investigated the primary surgery and long-term results in patients with chronic dissection of the native ascending aorta. METHODS: Between 1993 and 2013, among 696 patients (median age, 61 years [first quartile, 50; third quartile 73 years]; 64% males) who underwent surgery for type A dissection, 67 (10%) had chronic dissection by traditional criteria (>14 days). Median follow-up was 4.1 years (first quartile, 1.9; third quartile, 7.3 years; 3,105 patient-years). RESULTS: Patients with chronic dissection more frequently had undergone previous cardiac surgery (37% versus 9%; p < 0.001) and more frequently had bicuspid aortic valve syndrome (19% versus 7%; p < 0.001) and larger ascending aortic diameter (6.0 cm [first quartile 5.2; third quartile 7.2 cm] versus 4.9 cm [first quartile, 4.5; third quartile, 5.7 cm]; p < 0.001). Aortic dissection extended beyond the aortic arch less frequently in chronic dissection patients (27% versus 70%; p < 0.001). Moderate to severe aortic insufficiency rate was higher in chronic group (65% versus 36%; p < 0.001); they required aortic root replacement more frequently (42% versus 18%; p < 0.001) and had lower in-hospital mortality (4.5% versus 13.2%; p = 0.062). Resection of all dissected aortic tissue was achieved in 73% chronic and 30% acute dissection patients. Overall survival was better in the chronic group with 80% ± 5% versus 68% ± 2% at 5 years and 64% ± 13% versus 49% ± 3% at 10 years (log rank p = 0.021). CONCLUSIONS: Patients with chronic and acute type A dissection differ substantially in presentation, management, and outcome. Replacement of all dissected aortic tissue can be performed safely in the majority of patients with chronic type A dissection.

Valve-sparing aortic root replacement in patients with Marfan syndrome enrolled in the National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions.

BACKGROUND AND AIM OF THE STUDY: The long-term outcomes of aortic valve-sparing (AVS) root replacement in Marfan syndrome (MFS) patients remain uncertain. The study aim was to determine the utilization and outcomes of AVS root replacement in MFS patients enrolled in the Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC). METHODS: At the time of this analysis, 788 patients with MFS were enrolled in the GenTAC Registry, of whom 288 had undergone aortic root replacement. Patients who had undergone AVS procedures were compared to those who had undergone aortic valve replacement (AVR). RESULTS: AVS root replacement was performed in 43.5% of MFS patients, and the frequency of AVS was increased over the past five years. AVS patients were younger at the time of surgery (31.0 versus 36.3 years, p = 0.006) and more likely to have had elective rather than emergency surgery compared to AVR patients, in whom aortic valve dysfunction and aortic dissection was the more likely primary indication for surgery. After a mean follow up of 6.2 +/- 3.6 years, none of the 87 AVS patients had required reoperation; in contrast, after a mean follow up of 10.5 +/- 7.6 years, 11.5% of AVR patients required aortic root reoperation. Aortic valve function has been durable, with 95.8% of AVS patients having aortic insufficiency that was graded as mild or less. CONCLUSION: AVS root replacement is performed commonly among the MFS population, and the durability of the aortic repair and aortic valve function have been excellent to date. These results justify a continued use of the procedure in an elective setting. The GenTAC Registry will be a useful resource to assess the long-term durability of AVS root replacement in the future.

Long-term results of aggressive hemiarch replacement in 534 patients with type A aortic dissection.

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