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1.
Ann Thorac Surg ; 2024 Aug 03.
Artículo en Inglés | MEDLINE | ID: mdl-39102933

RESUMEN

BACKGROUND: We aimed to determine the effect of aortic annular enlargement on the midterm outcomes of aortic valve replacement surgery by comparing patients with the same-sized (≤23 mm) native aortic annuli. METHODS: From January 2011 to June 2022, 1328 patients underwent isolated aortic valve replacement-1163 without aortic annular enlargement (AVR group) and 165 with aortic annular enlargement (AVR+AAE group). Propensity score matching identified 112 pairs, controlling for native aortic annulus diameter, age, sex, diabetes, chronic lung disease, dialysis, ejection fraction, prior cardiac surgery, indication, hypertension, dyslipidemia, valve type, prior stroke, prior myocardial infarction, and case status. RESULTS: Demographic and preoperative variables were similar, except body surface area was larger in the AVR+AAE group (2.1 m2 vs 1.9 m2). Median native aortic annulus diameter was 23 mm in both groups. Median prosthesis size was 25 in the AVR+AAE group and 23 in the AVR group. The AVR+AAE group had longer cardiopulmonary bypass (143 vs 111 minutes) and cross-clamp (115 vs 82 minutes) times. Incidences of perioperative complications, including operative mortality (1.8% AVR+AAE vs 3.6% AVR) were similar between groups. Survival at 6 years was 98% in the AVR+AAE group and 74% in the AVR group (P = .016). Aortic annular enlargement was an independent protective factor for midterm mortality, with a hazard ratio of 0.19 (P = .006). The rate of moderate/severe patient-prosthesis mismatch was 19% in the AVR+AAE group and 31% in the AVR group (P = .16). CONCLUSIONS: Patients with small native aortic annuli (≤23 mm) undergoing isolated aortic valve replacement may benefit from aortic annular enlargement.

2.
Ann Thorac Surg ; 2024 Jul 20.
Artículo en Inglés | MEDLINE | ID: mdl-39033902

RESUMEN

BACKGROUND: There are limited data comparing the outcomes of aortic valve replacement surgery between patients with bicuspid aortic valve (BAV) vs tricuspid aortic valve (TAV) morphology. METHODS: From January 2000 to June 2022, 1122 patients with TAV (n = 562) or BAV (n = 560) underwent surgical aortic valve replacement for aortic stenosis with the same type of bovine pericardial stented bioprosthesis. Propensity score matching identified 350 pairs by matching for age, sex, operative status, chronic lung disease, prior stroke, diabetes, ejection fraction, renal failure on dialysis, coronary artery disease, prior cardiac surgery, and concomitant procedures. The primary end points were long-term survival and reoperation. RESULTS: Perioperative outcomes, including reoperation for bleeding, atrial fibrillation, heart block requiring pacemaker, stroke, need for dialysis, and operative mortality, were similar between the matched groups. Survival at 10 years was 67% (95% CI, 59%-74%) in the BAV group and 54% (95% CI, 46%-61%) in the TAV group (P = .001). BAV valve was a significant protective factor for late mortality, with a hazard ratio of 0.60 (95% CI, 0.45-0.81; P < .001). Risk factors for late mortality included age, chronic lung disease, low ejection fraction, and renal failure on dialysis. Cumulative incidence of aortic valve reintervention at 10 years was similar between the groups at 10% in the BAV group and 4.9% in the TAV group (P = .55). CONCLUSIONS: Patients with BAV likely could not be considered the same as patients with TAV when deciding on the approach of aortic valve intervention.

3.
Ann Cardiothorac Surg ; 13(3): 255-265, 2024 May 31.
Artículo en Inglés | MEDLINE | ID: mdl-38841083

RESUMEN

Background: The short-term efficacy and safety of the Y-incision technique of aortic annular enlargement (AAE) has been established. We aimed to determine how the short-term outcomes of the Y-incision technique compared to traditional AAE techniques. Methods: From February 2011 to June 2022, 380 patients at the University of Michigan Hospital underwent aortic valve replacement (AVR) with AAE using either traditional annular enlargement techniques (Traditional group, n=270), including Nicks [63% (171/270)], Manouguian [34% (91/270)], and others [3% (8/270)], or the Y-incision technique (Y-incision group, n=110). Propensity score matching was performed by controlling for age, sex, body surface area (BSA), hypertension, diabetes, dialysis, chronic lung disease, stroke, prior cardiac surgery, primary indication, operative status, concomitant procedures, and prosthesis type, to generate a balanced cohort of 103 pairs. Results: There were no differences in demographics, comorbidities, primary indications of the operations, or concomitant procedures between the matched groups. The median native aortic annulus diameter, measured in the operating room, was 21 mm for both groups. Median prosthesis size was 23 in the Traditional group, and 27 in the Y-incision group (P<0.001). There were no differences in perioperative complications/outcomes between the matched groups, including operative mortality, which was 3.9% (8/206) overall. Short-term survival was similar between the groups on Kaplan-Meier analysis; one-year survival was 95% in the Traditional group, and 97% in the Y-incision group (P=0.54). The Y-incision group had significantly lower mean aortic valve gradients (7 vs. 10 mmHg, P<0.001), larger aortic valve areas (2.2 vs. 1.8 cm2, P=0.007), and less moderate/severe patient-prosthesis mismatch (PPM) (5.5% vs. 23%, P=0.039) on one-year follow-up echocardiography. Conclusions: The Y-incision technique was as safe and more effective in enlarging the aortic annulus and upsizing the prosthetic valve than the traditional techniques of AAE in AVR for small aortic annuli.

5.
Artículo en Inglés | MEDLINE | ID: mdl-38522868

RESUMEN

The Y-incision aortic annular enlargement (AAE), first performed in August 2020, offers a safe and more effective alternative for management of a small aortic annulus/root without need for violation of the left ventricular outflow tract, mitral valve geometry, or left/right atria in both first-time aortic valve replacement (AVR) and reoperative AVR. In the first consecutive 119 patients with Y-incision AAE, the median age was 65 (59, 71), 67% female, 28% had previous cardiac surgery, and 2 cases had endocarditis. The preoperative mean gradient was 36 (30, 47), and the native aortic valve area was 0.9 (0.7, 1.0). After aortic annular enlargement, the median prosthesis size was 29 (27, 29) with 63% of patients having a size 29 or the largest sized valve. The median increment of annulus enlargement was 3 (3, 4) valve sizes. Postoperative complications included 1 operative mortality, 1 stroke exacerbation, and 2 pacemaker implantations (including one case of endocarditis with Gerbode fistula). There was no renal failure requiring permanent dialysis, mediastinitis, or reoperation for bleeding. Postoperative computed tomography aortogram showed the aortic root was enlarged from 27 (24, 30) to 40 (37, 42) mm without aortic pseudoaneurysm. The postoperative mean gradient was 6 (5, 9) mm Hg and valve area was 2.2 (1.8, 2.6) cm2 at 24 months. Mitral and tricuspid valve functions were significantly improved. This report describes the Y-incision technique with the most up-to-date modifications and short-term outcomes.


Asunto(s)
Estenosis de la Válvula Aórtica , Endocarditis , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Anciano , Femenino , Humanos , Masculino , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Endocarditis/cirugía , Diálisis Renal , Persona de Mediana Edad
6.
J Surg Res ; 296: 472-480, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-38320367

RESUMEN

INTRODUCTION: We aimed to investigate the association between renal dysfunction at discharge and long-term survival in acute type A aortic dissection (ATAAD) patients following surgery. METHODS: From 2000 to 2021, 784 patients underwent aortic repair for an ATAAD. Patients were stratified based on creatinine (Cr) level at discharge alive or dead: normal Cr (n = 582) and elevated Cr defined as >1.3 mg/dL for males and >1.0 mg/dL for females or on dialysis at discharge (n = 202). RESULTS: Preoperatively, both groups had similar rates of comorbidities except for the elevated-Cr group which had more diabetes, chronic obstructive pulmonary disease, and chronic and acute renal insufficiency. Both groups had similar open ATAAD repair procedures. Postoperative outcomes in the elevated-Cr group were significantly worse, including six times higher operative mortality (20% versus 3.4%, P < 0.0001). The landmark long-term survival after discharge alive was significantly worse in the elevated-Cr group than the normal-Cr group (10-y survival: 48% versus 69%, P = 0.0009). The elevated Cr on dialysis at discharge group had significantly worse five-year survival (40%) than the elevated Cr not on dialysis at discharge group (80%, P = 0.02) and the normal-Cr group (87%, P < 0.0001). Additionally, the elevated Cr not on dialysis had a worse five-year survival than the normal-Cr group (80% versus 87%, P = 0.02). Elevated Cr at discharge on dialysis was a significant risk factor for late mortality (hazard ratio = 4.22, 95% confidence interval: [2.07, 8.61], P < 0.0001). CONCLUSIONS: Renal dysfunction at discharge was associated with significantly decreased short-term and long-term survival following open ATAAD repair. Surgeons should aggressively prevent renal dysfunction, especially new-onset dialysis, at discharge as it is correlated with significantly worse short-term and long-term outcomes.


Asunto(s)
Lesión Renal Aguda , Disección Aórtica , Implantación de Prótesis Vascular , Masculino , Femenino , Humanos , Alta del Paciente , Estudios Retrospectivos , Disección Aórtica/cirugía , Diálisis Renal , Factores de Riesgo , Lesión Renal Aguda/etiología , Lesión Renal Aguda/terapia , Resultado del Tratamiento
7.
Indian J Thorac Cardiovasc Surg ; 39(Suppl 2): 341-343, 2023 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-38093919

RESUMEN

A small aortic root and annulus would need extensive aortic annular enlargement during valve replacement in adult patients to avoid patient-prosthesis mismatch. This report describes a technique that enlarges the aortic annulus by 4-5 valve sizes as well as a modification of the aortotomy with the roof technique to make the aortotomy closure easier and more hemostatic while enlarging the sinotubular junction and proximal ascending aorta effectively for future transcatheter valve-in-valve replacement. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01606-4.

8.
JTCVS Open ; 14: 1-13, 2023 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-37425443

RESUMEN

Objective: The study objective was to evaluate the progression of dissected distal aorta in patients with acute type A aortic dissection with malperfusion syndrome treated with endovascular fenestration/stenting and delayed open aortic repair. Methods: From 1996 to 2021, 927 patients presented with acute type A aortic dissection. Of these, 534 had DeBakey I dissection with no malperfusion syndrome and underwent emergency open aortic repair (no malperfusion syndrome group), whereas 97 patients with malperfusion syndrome underwent fenestration/stenting and delayed open aortic repair (malperfusion syndrome group). Sixty-three patients with malperfusion syndrome treated with fenestration/stenting were excluded due to no open aortic repair, including death from organ failure (n = 31), death from aortic rupture (n = 16), and discharged alive (n = 16). Results: Compared with the no malperfusion syndrome group, the malperfusion syndrome group had more patients with acute renal failure (60% vs 4.3%, P < .001). Both groups had similar aortic root and arch procedures. Postoperatively, the malperfusion syndrome group had similar operative mortality (5.2% vs 7.9%, P = .35) and permanent dialysis (4.7% vs 2.9%, P = .50), but more new-onset dialysis (22% vs 7.7%, P < .001) and prolonged ventilation (72% vs 49%, P < .001). The growth rate of the aortic arch (0.38 vs 0.35 mm/year, P = .81) was similar between the malperfusion syndrome and no malperfusion syndrome groups. The descending thoracic aorta growth rate (1.03 vs 0.68 mm/year, P = .001) and abdominal aorta growth rate (0.76 vs 0.59 mm/year, P = .02) were significantly higher in the malperfusion syndrome group. The cumulative incidence of reoperation over 10 years (18% vs 18%, P = .81) and 15-year survival outcome (50% vs 48%, P = .43) were similar between the malperfusion syndrome and no malperfusion syndrome groups. Conclusions: Endovascular fenestration/stenting followed by delayed open aortic repair was a valid approach for patients with malperfusion syndrome.

9.
JTCVS Open ; 16: 25-35, 2023 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-38204619

RESUMEN

Objective: The study objective was to evaluate the midterm outcome of thoracic endovascular aortic repair compared with open repair in patients with descending thoracic aortic aneurysm. Methods: From August 1993 to February 2023, 499 patients with descending thoracic aortic aneurysms underwent open repair (n = 221) or thoracic endovascular aortic repair (n = 278). Of these, 120 matched pairs were identified using propensity score matching based on age, sex, chronic lung disease, stroke, coronary artery disease, diabetes, ejection fraction, dialysis, peripheral vascular disease, prior cardiac surgery, connective tissue disease, and chronic dissection. Primary outcomes were postoperative paralysis, operative mortality, reoperation, and midterm survival. Results: After matching, the preoperative demographics and comorbidities were balanced in both groups. Intraoperatively, open repair had a lower temperature (18 °C vs 36 °C) and more patients required blood products (66% vs 8%), P < .001. Postoperatively, patients undergoing thoracic endovascular aortic repair had fewer strokes (2.5% vs 9.2%; P = .03), less dialysis (0% vs 3.3%; P = .04), and shorter length of stay (5 days vs 12 days, P < .001), but similar lower-extremity paralysis (2.5% vs 2.5%, P = 1.00) compared with open repair. Furthermore, thoracic endovascular aortic repair had higher 7-year incidence of first reoperation (16.1% vs 3.6%, P < .001) but similar operative mortality (0.8% vs 4.2%; P = .10) and 10-year survival outcome (56%; 95% CI, 43-72 vs 58%; 95% CI, 49-68; P = .55) compared with open aortic repair. The hazard ratio was 0.93 (P = .78) for thoracic endovascular aortic repair for midterm mortality and 6.87 (P < .001) for reoperation. Conclusions: Open repair could be the first option for patients with descending thoracic aortic aneurysms who were surgical candidates.

10.
JTCVS Open ; 12: 20-29, 2022 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-36590717

RESUMEN

Objective: To evaluate the effect of autologous blood use on blood product consumption and outcomes after acute type A aortic dissection repair. Methods: From 2010 to October 2020, 497 patients underwent open acute type A aortic dissection repair, including those with autologous blood harvesting before cardiopulmonary bypass and transfusion after cardiopulmonary bypass (autologous blood transfusion [ABT], n = 397) and without autologous blood harvesting and transfusion (No-ABT, n = 100). The median ABT volume was 900 mL. Using propensity score matching, 89 matched pairs were identified based on age, sex, body mass index, preoperative hemoglobin, acute preoperative stroke, previous cardiac surgery, and cardiogenic shock. Results: After propensity score matching, both groups were similar in demographic characteristics and aortic procedures. The ABT group required significantly less intraoperative transfusion of blood products (6 vs 11 units; P < .0001), including packed red blood cells (2 vs 4), fresh frozen plasma (2 vs 4), platelets (2 vs 2), and cryoprecipitate (0 vs 1); and combined intraoperative and postoperative transfusion (9 vs 13; P < .001). ABT was protective against intra- and postoperative blood product transfusion (odds ratio, 0.28; P = .01). The ABT group had significantly less sepsis, acute renal failure requiring dialysis, reintubation, and shorter intubation times and postoperative lengths of stay. Operative mortality was 6.7% in the ABT group versus 13% in the No-ABT group (P = .14). The midterm survival was similar between the 2 groups (5 year: 76% vs 74%). ABT had a hazard ratio of 0.81 for midterm mortality (P = .41). Conclusions: Autologous blood transfusion was associated with better short-term outcomes and could be used routinely for acute type A aortic dissection repair. External multicenter prospective validation would be warranted.

11.
Cardiol Cardiovasc Med ; 5(6): 651-662, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34950856

RESUMEN

BACKGROUND: This study aims to determine the long-term outcomes and rate of reoperation among BAV patients with aortic diameter of 5-5.5cm who underwent immediate surgical repair versus surveillance. METHODS: A total of 148 BAV patients with aortic aneurysm measuring 5-5.5cm were identified between 1993 to 2019. Patients were categorized into two groups: immediately operated (n=89), versus watched group (n=59) i.e., monitored until either symptomatic, aortic diameter ≥ 5.5 cm or operated at surgeons' discretion/patient preference. RESULTS: Compared to the immediately operated group the watched group had significantly lower proportion of proximal aorta replacement (86% vs 100%). The mean size of proximal thoracic aorta at initial encounter, including aortic root, ascending, and arch, for the watched group was 52.1 ± 1.62mm and 52.6 ± 1.81mm in the immediately operated group, p=0.06. There was no significant difference in 10-year survival between the watched group 94% (95% CI: 79%, 99%) vs immediately operated group 96.5% (95% CI: 86%, 99%), p=0.90. Initial operation rate for the watched group during 10-year follow-up was 85%. The operative mortality in both groups was 0%. The 10-year reoperation rate between groups was similar: 3.5% (95% CI: 0.9%, 9.1%) in the immediately operated group vs 7.7% (95% CI: 2.4%, 17.1%) in the patients who eventually had surgery in the watched group, p= 0.30. CONCLUSIONS: Our study showed that the rate of reoperation was similar between groups and survival outcomes were acceptable in observed asymptomatic BAV patients without significant family history and with proximal aortic diameter of 5-5.5cm.

12.
JMIR Res Protoc ; 10(2): e21350, 2021 Feb 16.
Artículo en Inglés | MEDLINE | ID: mdl-33591291

RESUMEN

BACKGROUND: Despite pharmacological treatments, patients undergoing cardiac surgery experience severe anxiety and pain, which adversely affect outcomes. Previous work examining pediatric and nonsurgical adult patients has documented the effectiveness of inexpensive, nonpharmacological techniques to reduce anxiety and pain as well as health care costs and length of hospitalization. However, the impact of nonpharmacological interventions administered by a dedicated comfort coach has not been evaluated in an adult surgical setting. OBJECTIVE: This trial aims to assess whether nonpharmacological interventions administered by a trained comfort coach affect patient experience, opioid use, and health care utilization compared with usual care in adult cardiac surgery patients. This study has 3 specific aims: assess the effect of a comfort coach on patient experience, measure differences in inpatient and outpatient opioid use and postoperative health care utilization, and qualitatively evaluate the comfort coach intervention. METHODS: To address these aims, we will perform a prospective, randomized controlled trial of 154 adult cardiac surgery patients at Michigan Medicine. Opioid-naive patients undergoing first-time, elective cardiac surgery via sternotomy will be randomized to undergo targeted interventions from a comfort coach (intervention) versus usual care (control). The individualized comfort coach interventions will be administered at 6 points: preoperative outpatient clinic, preoperative care unit on the day of surgery, extubation, chest tube removal, hospital discharge, and 30-day clinic follow-up. To address aim 1, we will examine the effect of a comfort coach on perioperative anxiety, self-reported pain, functional status, and patient satisfaction through validated surveys administered at preoperative outpatient clinic, discharge, 30-day follow-up, and 90-day follow-up. For aim 2, we will record inpatient opioid use and collect postdischarge opioid use and pain-related outcomes through an 11-item questionnaire administered at the 30-day follow-up. Hospital length of stay, readmission, number of days in an extended care facility, emergency room, urgent care, and an unplanned doctor's office visit will be recorded as the primary composite endpoint defined as total days spent at home within the first 30 days after surgery. For aim 3, we will perform semistructured interviews with patients in the intervention arm to understand the comfort coach intervention through a thematic analysis. RESULTS: This trial, funded by Blue Cross Blue Shield of Michigan Foundation in 2019, is presently enrolling patients with anticipated manuscript submissions from our primary aims targeted for the end of 2020. CONCLUSIONS: Data generated from this mixed methods study will highlight effective nonpharmacological techniques and support a multidisciplinary approach to perioperative care during the adult cardiac surgery patient experience. This study's findings may serve as the foundation for a subsequent multicenter trial and broader dissemination of these techniques to other types of surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT04051021; https://clinicaltrials.gov/ct2/show/NCT04051021. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21350.

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