Preservation of the Aortic Root During Type A Aortic Dissection Surgery: An Effective Strategy?

BACKGROUND: Management of the aortic root during acute Type A aortic dissection (TAAD) repair remains controversial in term of long-term evolution and reoperation. The aim of this study was to assess the long-term outcomes of the aortic root after conservative management during primary surgery. METHODS: One hundred sixty-four consecutive patients were included in this monocentric retrospective study. The primary endpoint was reoperation on the aortic root during long-term follow-up. Forty-six patients had aortic root replacement (ARR) and 118 had supracoronary aortic replacement (SCR). The 10-year survival, occurrence of significant aortic regurgitation, and radiologic aortic root dilatation in each group were assessed during follow-up. RESULTS: Patients from ARR group were younger than those from SCR group (p < 0.0001). Median follow-ups of ARR group and SCR group are 4.4 (interquartile range [IR]: 2.6-8.3) and 6.15 (IR: 2.8-10.53) years, respectively. Reoperation of the aortic root during long-term follow-up was similar in both groups (ARR group: 5.1%, SCR group: 3.3%, p = 0.636). The 10-year survivals of ARR and SCR groups were 64.8 ± 12.3% and 46.3 ± 5.8% (p = 0.012), respectively. Long-term significant aortic regurgitation occurred in one patient (1.7%) and seven patients (7.6%) of the ARR and SCR groups (p = 0.176), respectively. Radiologic aortic root diameters in the SCR group were similar between postoperative period and follow-up studies (p = 0.58). Reoperation on the distal aorta (p = 0.012) and patent radiologic false lumen of the descending aorta (p = 0.043) were independent risk factors of late death. CONCLUSION: SCR is an effective technique for primary TAAD surgery and does not increase the rate of late reoperation on the aortic root.

Author's reply (in reference to letter to editor proposed by Etem Caliskan, Catherine J. Pachuk, Louis P. Perrault, Maximilian Y Emmert and entitled: preservation solutions to improve graft patency: The devil is in the detail).

Not applicable.

Cardiopulmonary bypass and internal thoracic artery: Can roller or centrifugal pumps change vascular reactivity of the graft? The IPITA study: A randomized controlled clinical trial.

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory response (SIRS) and affects the organ vascular bed. Experimentally, the lack of pulsatility alters myogenic tone of resistance arteries and increases the parietal inflammatory response. The purpose of this study was to compare the vascular reactivity of the internal thoracic arteries (ITAs) due to the inflammatory response between patients undergoing coronary artery bypass grafting (CABG) under CPB with a roller pump or with a centrifugal pump. METHODS: Eighty elective male patients undergoing CABG were selected using one or two internal thoracic arteries under CPB with a roller pump (RP group) or centrifugal pump (CFP group). ITA samples were collected before starting CPB (Time 1) and before the last coronary anastomosis during aortic cross clamping (Time 2). The primary endpoint was the endothelium-dependent relaxation of ITAs investigated using wire-myography. The secondary endpoint was the parietal inflammatory response of arteries defined by the measurements of superoxide levels, leukocytes and lymphocytes rate and gene expression of inflammatory proteins using. Terminal complement complex activation (SC5b-9) and neutrophil activation (elastase) analysis were performed on arterial blood at the same times. RESULTS: Exposure time of ITAs to the pump flow was respectively 43.3 minutes in the RP group and 45.7 minutes in the CFP group. Acetylcholine-dependent relaxation was conserved in the two groups whatever the time. Gene expression of C3 and C4a in the artery wall decreased from Time 1 to Time 2. No oxidative stress was observed in the graft. There was no difference between the groups concerning the leukocytes and lymphocytes rate. SC5b-9 and elastase increased between Time 1 and Time 2. CONCLUSION: Endothelium-dependent relaxation of the internal thoracic arteries was preserved during CPB whatever the type of pump used. The inflammatory response observed in the blood was not found in the graft wall within this time frame. TRIAL REGISTRATION: Name of trial study protocol: IPITA Registration number (ClinicalTrials.gov): NCT04168853.

Do storage solutions protect endothelial function of arterialized vein graft in an experimental rat model?

BACKGROUND: This study aims to compare the effects of storage solutions commonly used in coronary artery bypass grafting on the vascular reactivity in vein graft interposed in arterial position in syngeneic rats. METHODS: Twenty-seven male Lewis rats were sacrified to sample a vein graft implanted 6 weeks ago into abdominal aorta position. The vein grafts were inferior venae cavae initially pretreated with heparinized saline solution (HS) or autologous heparinized blood (AHB) or our referent solution, GALA. The endothelial functionality, the in situ Reactive Oxygen Species (ROS) levels and the histological characteristics were conducted from segments of arterialized vein graft. RESULTS: At 6 weeks, graft thrombosis occurred respectively in 22% of AHB group, 62.5% in the HS group and 82.5% in the GALA group. In each group, significative intimal hyperplasia was observed. After 6 weeks, an endothelium-remodeling layer associated with an increase of wall thickness was observed in each group. Endothelium-dependent tone was reduced in the vein graft regardless of the group. No difference was observed concerning the ROS in vein graft between the different groups. In distal aortic sections, ROS levels were increased in HS and GALA groups. CONCLUSIONS: Storage solutions used in this experimental model of vein graft implanted in arterial position cause graft injury and a complete disappearance of vascular reactivity. GALA solution did not reduce intimal risk hyperplasia when the vein graft was exposed to arterial flow in a rat model.

Transesophageal echocardiography-guided chordal replacement for tricuspid regurgitation.

A 29-year-old man was referred to our institution for severe tricuspid regurgitation. Preoperative transesophageal echocardiography revealed dilation of the tricuspid annulus with prolapse of the anterior leaflet and progressive increase in right ventricular diameter. The anterior papillary muscle was elongated. Annuloplasty was completed by polytetrafluoroethylene artificial chordae implanted on the free margin of the anterior leaflet, and thereafter, tied outside the right ventricle, under echocardiography control to achieve appropriate length. The patient recovered well, and 6 months after surgery, repeat echocardiography revealed only mild tricuspid regurgitation with recovery of normal right ventricular dimensions.

A combined approach for improving cardiopulmonary bypass in coronary artery surgery: a pilot study.

BACKGROUND: This is a pilot study carried out to assess the feasibility and the clinical impact of a combined approach of cardiopulmonary bypass (CPB) with reduced anti-coagulation. METHODS: We used a retrospective, non-randomized analysis of 45 consecutive patients undergoing coronary artery bypass using standard CPB with full anticoagulation (activated clotting time, ACT, > 450 s) (Group 1; n = 23) or closed, heparin-coated CPB with low anticoagulation (ACT>250 s), precise heparin and protamine titration, controlled suction, and retrograde autologous prime (Group 2; n = 22). RESULTS: Patients were similar except for a higher incidence of three-vessel disease in Group 2 (77.3% versus 47.8%; p < 0.03). Heparin was reduced by 41% in Group 2 and protamine by 56% (p < 0.0001). Total postoperative blood loss was similar between Groups 1 and 2 (429 +/- 149 versus 435+/-168 ml, respectively). However, the operative hematocrit decrease was lower in Group 2 (-1.6 +/- 7.5% versus -6.9 +/- 4.8%; p = 0.007), although hemodilution was similar, as reflected by the blood protein level. The need for postoperative inotropic support was less frequent in Group 2 (36.4% versus 65.2%; p = 0.05). Within the subgroup of patients weaned from CPB without requiring inotropic support (n = 35), the cardiac index dropped significantly in Group 1 (p = 0.003) 6 h after the start of CPB, whereas it remained stable in Group 2 (p = 0.92). Using multivariate analyses, Group 2 was found to be more protected than Group 1 against myocardial cellular injury (p = 0.046) and need for postoperative inotropic support (p = 0.014). CONCLUSION: The pejorative postoperative outcome in coronary artery surgery was attenuated through a combined approach aimed at improving CPB.