Re-hospital admission, morbidity and mortality rate in patients undergoing tunnelled catheter implantation for haemodialysis.

OBJECTIVE: Despite the effort to increase the proportion of patients starting dialysis on native accesses, many of them are still dialyzed on tunnelled catheter. Catheter-related complications are often serious and responsible for re-hospital admission, high morbidity and mortality. Several multicenter trials have reported results in the use of tunnelled dialysis catheter (TDC). However, few single-center studies have been published to verify the outcome from real-world experience. This study presents our center's experience in managing such patients in the context of relevant literature. METHODS: Demographics and operative data were retrospectively collected from medical charts. A prospective follow-up was performed to investigate complications, number of re-hospitalizations and mortality. Kaplan-Meier estimate was used to evaluate catheter primary patency and patients' overall survival. RESULTS: Among a total 298 haemodialysis accesses interventions, 105 patients (56 men, 53.3% and 49 women, 46.7%) with a median age of 65 years (range 32-88 years) were included in the study. All insertions were successful with an optimal blood flow achieved during the first session of dialysis in all cases. A catheter-related complication was detected in 33.3% (n=35) patients (48.6% infections; 28.6% TDC dysfunction; 14.3% local complications; 5.7% accidental catheter retractions; 2.8% catheter migrations). At a median follow-up of 10.5±8.5 months, a total of 85 patients (80.9%) was re-hospitalized, in 28 cases (26.7%) for a catheter-related cause. The median catheter patency rate was 122 days. At the last follow-up, 39 patients (37.1%) were still dialyzed on catheter, 30(28.6%) were dialyzed on an arteriovenous fistula and 7(6.7%) received a kidney transplantation. Two patients (2%) were transferred to peritoneal dialysis and two patients (2%) recover from renal insufficiency. Mortality rate was 23.8% (25 patients). Causes of death were myocardial infarction (n=13, 52%), sepsis (n=9, 36%); one patient (4%) died from pneumonia, one (4%) from uremic encephalopathy and one (4%) from massive hematemesis. CONCLUSION: TDCs may represent the only possible access in some patients, however they are burned with a high rate of complications, re-hospital admission and mortality. Results from this institutional experience are in line with previously published literature data in terms of morbidity and mortality. The present results reiterate once more that TDC must be regarded as a temporary solution while permanent access creation should be prioritized. Strict surveillance should be held in patients having TDC for the early identification of complications allowing the prompt treatment and modifying the catheter insertion site whenever needed.

Treatment outlines for the management of primary leiomyosarcoma of the inferior vena cava.

Primary venous Leiomyosarcoma (LMSs) are extremely rare tumours with poor survival rates. Surgery is currently the only potentially curative therapy in non-metastatic disease, but it consists in challenging interventions. The authors report the experience of one single centre in the treatment of LMS and a literature overview focusing on the diverse methods of vessels repair. Outcomes achieved are also outlined.

Aortic valve repair versus mechanical valve replacement for root aneurysm: the CAVIAAR multicentric study.

OBJECTIVES: Despite growing evidence that aortic valve repair improves long-term patient outcomes and quality of life, aortic valves are mostly replaced. We evaluate the effect of aortic valve repair versus replacement in patients with dystrophic aortic root aneurysm up to 4 years. METHODS: The multicentric CAVIAAR (Conservation Aortique Valvulaire dans les Insuffisances Aortiques et les Anévrismes de la Racine aortique) prospective cohort study enrolled 261 patients: 130 underwent standardized aortic valve repair (REPAIR) consisting of remodelling root repair with expansible aortic ring annuloplasty, and 131 received mechanical composite valve and graft replacement (REPLACE). Primary outcome was a composite criterion of mortality, reoperation, thromboembolic or major bleeding events, endocarditis or operating site infections, pacemaker implantation and heart failure, analysed with propensity score-weighted Cox model analysis. Secondary outcomes included major adverse valve-related events and components of primary outcome. RESULTS: The mean age was 56.1 years, and valve was bicuspid in 115 patients (44.7%). Up to 4 years, REPAIR did not significantly differ from REPLACE in terms of primary outcome [Hazard Ratio (HR) 0.66 (0.39; 1.12)] but showed significantly less valve-related deaths (HR 0.09 [0.02; 0.34]) and major bleeding events (HR 0.37 [0.16; 0.85]) without an increased risk of valve-related reoperation (HR 2.10 [0.64; 6.96]). When accounting for the occurrence of multiple events in a single patient, the REPAIR group had half the occurrence of major adverse valve-related events (HR 0.51 [0.31; 0.86]). CONCLUSIONS: Although the primary outcome did not significantly differ between the REPAIR and REPLACE groups, the trend is in favour of REPAIR by a significant reduction of valve-related deaths and major bleeding events. Long-term follow-up beyond 4 years is needed to confirm these findings.

The Fate of Hemodialysis Vascular Access After Kidney Transplantation: Why Ligation Should Not Be Systematically Performed?

BACKGROUND: After renal transplant, the haemodialysis (HD) vascular access (VA) is often maintained in the event of graft failure but evidence to recommend the systematic ligation/maintenance are lacking. We investigate the effects of VA preservation/ligation in successfully transplanted patients. METHODS: A retrospective analysis of all patients undergoing successful renal transplantation after HD were conducted. Patients with a functioning VA, those undergoing ligation or presenting with post-transplantation spontaneous thrombosis were included. Demographics, comorbidities, reasons for ligation, need for secondary interventions, complications and return in dialysis were assessed. RESULTS: Out of 542 HD patients, 114 (76, 66.7% male, median age 50 years, range 20-70) were included. Eight (7%) accesses thrombosed in a mean of 1.4 days (range 1-3) after transplant; 42 (36.8%) fistulas were ligated and 64 (56.1%) preserved. The reasons for ligation were patient's request (35, 83.3%), steal syndrome (5, 11.9%), heart failure (1, 2.4%) and aneurysmal degeneration (1, 2.4%).During a mean follow-up of 724.9 days (range 80-1082) 25 patients developed complications over the maintained access (40% of stenosis; 32% high flow and 28% thrombosis); 18 (15.8%) needed reoperation; 17 (15%) required further HD. Multivariate analysis showed that coronary artery disease (OR= 12.566 [2.056-76.805], P < 0.06) or age >60 years (OR=0.181 [0.044-0.735], P = 0.017) were risk factor for complications over unused VA. CONCLUSIONS: The ligation of a functioning VA after renal transplant should evaluated on an individualized basis. Patients with pre-existing cardiovascular disease or aged >60 years should be monitored closely up as they are at higher risk of complications.

Late onset infection of covered and bare metal arterial stents.

OBJECTIVE: The objective was to present the case of a late covered iliac stent late infection and report a comprehensive literature review on diagnosis and outcomes in this setting. METHODS: A comprehensive review of the literature was performed through MedLine by two independent reviewers from 1990 to 2020 on reported cases of arterial stent late onset infection over arterial stents. The data about on the risk factors, clinical presentation, treatment and outcomes were collected. RESULTS: Twenty-two studies were selected as pertinent for the analysis, totalling 24 patients including the indexed case. Infection occurred at a median of 22 months postoperatively (range 2-120 months) over a bare metal stent in 66.7% (n 16) of cases versus 33.3% (n 8) over a covered stent. Clinical presentation included local symptoms (local pain, oedema, petechiae or skin rash) in 21 (87.5%) cases and non-specific systemic symptoms (fever, sepsis, chills and leucocytosis) in 8 cases (33.3%). In 4 cases (16.7%), patients presented with haemorrhagic shock upon arterial rupture. The bacteria most frequently encountered were S. aureus (54.2% of cases). Several factors were supposed to be responsible for the infection including among which procedure-related (non-aseptic technique, lack of prophylactic antibiotics and repetitive punctures at the access site) or related to pre-existing patient's clinical conditions (immunosuppression, diabetes and concurrent infection) have been considered responsible for the infection. Treatment consisted in antibiotics alone (2 patients, 8.3%) or in association with surgical explant, both with or and without revascularization (n 21, 87.5%). In one case, an endovascular coiling was performed. Complications occurred in 29.2% (n 7) of cases and included the need for amputation, bowel resection, endocarditis, pulmonary failure or pneumonia. Overall, three patients (12.5%) died from a septic shock or multi-organ failure. CONCLUSIONS: Intravascular stent infection is a rare but fearsome condition associated with high morbidity and mortality.

Surgical Treatment of Carotid Webs in Symptomatic Young Adults.

BACKGROUND: Carotid webs are possibly responsible for ischemic stroke in young adults. We aim to report a case series study about surgical treatment of this uncommon condition. METHODS: We performed a retrospective analysis on clinical, imaging, pathological, operative data, and outcomes about consecutive patients affected with carotid ischemic stroke due to carotid webs in a single institution. RESULTS: During a three-year period, a total of 123 patients were treated for carotid stroke, in five cases (4%) (median age 48.4 years, range 44-53, 2 men and 3 women, median NIHSS score 8.4, range 4-17) due to a carotid web. Patients were all Caucasian excepting for one. No severe comorbidities were detected. Preoperatively thrombectomy of middle cerebral artery was needed in three cases. Surgical treatment consisted in web resection and carotid end-to-end anastomosis (3 cases) or web excision and patch angioplasty (2 cases). In-hospital NIHSS score improved postoperatively of more than 2 points (median 3.6, range 2-7) in all cases. No major complications were detected. One patient experienced a local hematoma treated conservatively. At a mean follow-up of 18 months (range 1-35 months), no recurrent stroke nor myocardial infarction nor death were remarked. CONCLUSIONS: In young patients presenting with ischemic stroke without neither conventional stroke risk factors nor other possible sources of embolism, a carotid web should be suspected. Surgery guarantees excellent results in prevention of recurrences.

True Aneurysm of Ovarian and Uterine Arteries:a Comprehensive Review.

BACKGROUND: Gonadal artery aneurysm represents an extremely rare condition often unrecognized until rupture. METHODS: A literature review was undertaken on Pubmed from 1990 to 2020 to identify reported cases of ovarian and uterine artery aneurysms, including the index case presented here. Data about the clinical presentation, diagnostic approach, and treatment were collected. RESULTS: Twenty-one articles reporting on data about 22 patients, including the index case, were included. The patients's median age was 46.7 years (range 30-80) and aneurysm maximal diameter 2.6 cm (range 0.75-5 cm). Except for one asymptomatic patient, the aneurysm's clinical presentation was abdominal/back pain in the majority of cases (n = 20, 90.9%). Rupture with retroperitoneal hematoma occurred in 16 cases (72.7%) and hemorrhagic shock in one case (4.5%). No history of vaginal bleeding was reported in any case. The majority of the aneurysms were diagnosed in women of childbearing age: in 50% (n = 11) of cases during the peripartum period and in 22.7% (n = 5) of cases during the postmenstruation period. The remaining cases (n = 6, 27.3%) were detected during the postmenopausal period. The majority of patients (n = 15, 68.2%) were emergently treated with an endovascular approach by embolization, achieving the total exclusion of the aneurysm in 86.7% of cases (13 patients). In 7 cases (31.8%), surgical ligation was performed, of which 2 (9.1%) were for the failure of a primarily attempted coils embolization. The spontaneous thrombosis of the uterine aneurysm was noted 3 months after the initial diagnosis in one patient. CONCLUSIONS: The Gonadal artery aneurysms are unrecognized entities until an acute rupture occurs. Endovascular treatment by embolization is progressively becoming the first-line treatment with satisfactory results.

Puncture Site Necrosis Over Hemodialysis Native and Prosthetic Vascular Accesses.

BACKGROUND: The aim of this study was to detail our experience in the management of skin necrosis/ulceration over hemodialysis vascular accesses. METHODS: We collected demographics and operative data about patients undergoing surgery for skin necrosis over native or prosthetic vascular accesses. The different procedural techniques used and outcomes achieved were analyzed. RESULTS: Over a six-year period (2013-2019), 593 hemodialysis accesses were created and 16 patients (50%, 8 male; median age 63.6 years, range 42-87; 12 native and 4 prosthetic accesses) were emergently/urgently treated for skin necrosis with danger of rupture (n 9), minor active bleeding (n 4) or life-threatening hemorrhage (n 3). Underlying causes were local infection, aneurysm/pseudo-aneurysm formation and venous stenosis. Most accesses were preserved. Rescue procedures consisted in excision of skin necrosis in association with aneurysmorrhaphy (n 1, 6.3%), simple closure of the venous breach (n 2, 12.5%) or resection and direct re-anastomosis (n 7, 43.8%). Concomitant endoluminal dilatation of venous outflow was needed in 7 (43.8%) cases. No intraoperative complications were observed. At a median of 13 months (range 1-39), 90% of rescued accesses were still functional. CONCLUSIONS: Skin necrosis/ulceration over vascular access requires prompt surgical intervention ahead the risk of life-threatening hemorrhage. The rescue of a functional access is possible in most patients and provides an efficient dialysis in postoperative period.

Tailoring Hemodialysis Vascular Access in Diabetic Patients.

BACKGROUND: The objective of the study was to investigate which kind of native arterious-venous fistula guaranteed the best results in diabetic patients. METHODS: A retrospective case-control study with prospective follow-up was conducted on all consecutive patients undergoing creation of the first native vascular access (VA) at our Institution between January 2011 and December 2016. Patients were divided into 2 groups: diabetics (group A) and nondiabetics (group B), and results were evaluated in accordance with site chosen for VA creation. Primary outcomes were maturation and primary patency rate. Secondary outcomes were complications, rate of functional fistulas, and mortality. RESULTS: A total of 410 patients (n 155, 37.8% female; n 255, 62.2% male; mean age 64.21 ± 14.85 years, range 58-78) were divided into 2 nonstatistically different groups (group A: n 170, 41.5% and group B: n 240, 58.5%). Maturation and primary patency were statistically different for antebrachial (P = 0,038 and P = 0.044, respectively), but not for brachial access (P = 1 and P = 0.080, respectively) at 3 years. Hyperflow and steal syndrome rate did not differ between the 2 sites and groups. At a mean follow-up of 42.86 months (range 1-72), 5 patients died. Diabetics demonstrated the higher rate of overall complications at the long-term follow-up. CONCLUSIONS: Diabetes mellitus plays a detrimental role in maturation and primary patency of antebrachial fistula; however, brachial fistula results do not differ between diabetic and nondiabetic patients. More robust data and longer-term results from randomized studies are needed to affirm brachial fistula as preferential access in diabetic patients.

Symptomatic Aortic Mural Thrombus Treatment and Outcomes.

BACKGROUND: To report results achieved in treatment of symptomatic aortic mural thrombus in a single institution. MATERIALS AND METHODS: A retrospective analysis of data about 97 patients presenting with acute onset lower limb ischemia (Rutherford stage II-III), upper limb ischemia, and mesenteric ischemia surgically treated between January 2011 and December 2018 in the Vascular and Endovascular Unit of Foch Hospital (Suresnes, France) was conducted. Only patients affected with primary aortic mural thrombus (PAMT) as source of embolism were included. RESULTS: A total of 9 patients (mean age 51 years, range 28-69; 55.5%, n 5 men and 44.5% n 4 women) were affected with PAMT. Three (33.3%) patients presented a concomitant renal embolism (22.2% of acute renal failure). Thrombus was located at the level of thoracic aorta (4 patients), visceral aorta (2 patients), or infrarenal aorta (3 patients). PAMT was sessile or pedunculated in 5 (55.5%) and 4 (44.4%) patients, respectively. Treatment consisted of anticoagulation in all patients in association with surgical exclusion of the PAMT, distal thrombectomy alone, or in addition to distal bypass. At a median follow-up of 22 months (range 1-57 months) no patients died, 4 patients (44.4%) recovered well, and 5 patients (55.5%) experienced recurrence/thrombus persistency and needed secondary interventions. The best results and absence of recurrences were achieved in patients undergoing immediate exclusion of the PAMT. CONCLUSIONS: PAMT is an uncommon source of embolism, and no guidelines are at disposal in its management. An aggressive approach with anticoagulation and exclusion of thrombus seems to be efficacious in preventing recurrences limiting complications and optimizing outcomes.

Isolated aortic insufficiency valve repair with external ring annuloplasty: a standardized approach.

OBJECTIVES: Aortic valve (AV) insufficiency with normal root and ascending aorta is most frequently treated by valve replacement with significant prosthetic-related complications and reduced life expectancy. We compared the outcomes of a new standardized isolated AV repair approach using an external aortic annuloplasty ring at the subvalvular level (single ring annuloplasty) and the role of an additional supravalvular ring at the sinotubular junction (double ring annuloplasty). METHODS: Single centre data were collected from the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR) between 2003 and 2017. A total of 93 patients (56 single ring and 37 double ring) underwent isolated AV repair. RESULTS: The overall 30-day mortality rate and the need for a permanent pacemaker were 1% and 2%, respectively. The overall survival rate at 6 years was similar for sex- and age-matched members of the general population (89% vs 95%; P = 0.1) and did not differ between the double and single ring groups (82% vs 93%; P = 0.4) at 6 years. There were no thromboembolic or bleeding events in the entire cohort. However, at 6 years, the cumulative incidence of valve-related reintervention was 26% in the single ring annuloplasty group compared to 3% in the double ring annuloplasty (P = 0.02) group. Similarly, at 6 years, the cumulative incidence of moderate-to-severe (>2) aortic insufficiency was 30% in the single ring annuloplasty group compared to 0% in the double ring annuloplasty group (P = 0.007). CONCLUSIONS: Standardized AV repair with external ring annuloplasty has a survival rate similar to that of the general population. The additional stabilization of the sinotubular junction with a second supravalvular ring (double ring annuloplasty) is associated with better outcomes compared to single subvalvular annuloplasty. It can be considered as a first line intervention for patients with isolated aortic insufficiency and pliable leaflets.

Early Carotid Endarterectomy for Symptomatic Stenosis of Internal Carotid Artery in Patients Affected by Transient Ischemic Attack or Minor-to-Moderate Ischemic Acute Stroke: A Single-Center Experience.

BACKGROUND: In the setting of carotid transient ischemic attack (TIA) or minor/moderate ischemic stroke, early surgical endarterectomy (CEA) seems to decrease the number of recurrences. The aim of the present study was to report a single-center experience with early surgical carotid revascularization in patients affected by TIA and minor/moderate ischemic acute stroke. METHODS: A retrospective data collection was carried out on all consecutive patients surgically treated for an extracranial internal carotid artery (ICA) hemodynamic NASCET stenosis in the Vascular Unit of Foch Hospital, in Suresnes (France) between January 2011 and July 2016. All patients undergoing ICA endarterectomy for symptomatic carotid stenosis (SCS) within 48 hours and 14 days after the acute neurologic onset were included in the present study. Outcomes were evaluated by a prospective follow-up. Primary outcomes were the rate of postoperative ipsilateral stroke and myocardial infarction (MI) and the death/stroke/MI at 30-day and at the long-term follow-up. Secondary outcomes were local and systemic complications' rate. Outcomes were stratified according to NIHSS score and comorbidities, and a univariate analysis and multivariate analysis were performed to define any correlation between preoperative data and postoperative outcomes. RESULTS: A total of 249 consecutive patients (45.4%, 113 symptomatic vs. 54.6%, 136 asymptomatic) underwent CEA for hemodynamically significant ICA stenosis at our institution. According to inclusion criteria, 72 patients affected by SCS (27.7% women vs. 72.3% men; median age 71.9 years, range: 42-89; median preoperative NIHSS score 3, range 1-17) were enrolled in the present study. Median delay for surgery was 4 days (range: 2-14). No in-hospital stroke, nor myocardial infarction nor death were detected during in-hospital post-operative period. The combined death/stroke/MI rate was 0% and 5.5 % at 30-days at 6 years follow-up respectively. In-hospital NIHSS score improved post-operatively of more than 2 points (range 0-15) in 47.2% of cases. A total of 10 patients (13.8%) experienced a local complication (hematoma, permanent or regressive nerve injury). No systemic complications (renal/respiratory failure, urinary tract infection, pneumoniae) were registered. At long-term follow-up a total of four patients (5.5%) died and six patients (8.3%) were lost. The stratification of outcomes according to NIHSS status, sex, comorbidities and preoperative surgical procedure did not show any statistical relation neither at 30 days nor at the long term-follow up. Diabetes was statistically correlated to a higher rate of complication at the long-term follow-up (P 0.049). CONCLUSIONS: In properly selected patients affected by minor/moderate ischemic acute stroke and TIA early carotid endarterectomy can be performed without any worsening of neurological status.

Aortic valve opening and closure: the clover dynamics.

BACKGROUND: Systolic aortic root expansion is reported to facilitate valve opening, but the precise dynamics remain unknown. A sonometric study with a high data sampling rate (200 to 800 Hz) was conducted in an acute ovine model to better understand the timing, mechanisms, and shape of aortic valve opening and closure. METHODS: Eighteen piezoelectric crystals were implanted in 8 sheep at each annular base, commissures, sinus of Valsalva, sinotubular junction, nodulus of Arantius, and ascending aorta (AA). Geometric changes were time related to pressures and flows. RESULTS: The aortic root was hemodynamically divided into left ventricular (LV) and aortic compartments situated, respectively, below and above the leaflets. During isovolumetric contraction (IVC), aortic root expansion started in the LV compartment, most likely due to volume redistribution in the LV outflow tract below the leaflets. This expansion initiated leaflet separation prior to ejection (2.1%±0.5% of total opening area). Aortic compartment expansion was delayed toward the end of IVC, likely related to volume redistribution above the leaflets due to accelerating aortic backflow toward the aortic valve and coronary flow reduction due to myocardial contraction. Maximum valve opening during the first third of ejection acquired a truncated cone shape [leaflet free edge area smaller than annular base area (-41.5%±5.5%)]. The distal orifice became clover shaped because the leaflet free edge area is larger than the commissural area by 16.3%±2.0%. CONCLUSIONS: Aortic valve opening is initiated prior to ejection related to delicate balance between LV, aortic root, and coronary dynamics. It is clover shaped at maximum opening in systole. A better understanding of these mechanisms should stimulate more physiological surgical approaches of valve repair and replacement.

Remodeling root repair with an external aortic ring annuloplasty.

OBJECTIVE: Although the remodeling technique provides the most dynamic valve-sparing root replacement, a dilated annulus (>25 mm) is a risk factor for failure. Aortic annuloplasty aims to reduce the annulus diameter, thus increasing coaptation height to protect the repair. The results of 177 patients with remodeling and external aortic ring annuloplasty were studied. METHODS: Data were collected from the Aortic Valve repair InternATiOnal Registry. Preoperative aortic insufficiency grade 3 or greater was present in 79 patients (44.7%). The valve was bicuspid in 59 patients (33.3%). External annuloplasty was performed through a homemade Dacron ring (56) or a dedicated expansible aortic ring (121). RESULTS: Thirty-day mortality was 2.9% (5). Mean follow-up was 41.1 ± 36.4 months. For the whole series, freedom from valve-related reoperation, aortic insufficiency grade 3 or greater, aortic insufficiency grade 2 or greater, and major adverse valve-related events were 89.5%, 90.5%, 77.4%, and 86.6% at 7 years, respectively, with similar results for tricuspid and bicuspid valves. Since 2007, systematic use of calibrated expansible ring annuloplasty, followed 1 year later by systematic cusp effective height assessment, significantly increased 7-year freedom from valve-related reoperation, aortic insufficiency grade 3 or greater, and major adverse valve-related events up to 99.1% ± 0.9% (P = .017), 100% (P = .026), and 96.3% ± 1.8% (P = .035), respectively, whereas freedom from aortic insufficiency grade 2 or greater remained unaffected (78.1% ± 7.6%). Calibrated annuloplasty and effective height assessment were identified as protective factors from reoperation: hazard ratio, 0.13; 95% confidence interval, 0.02-1.06; P = .057 and hazard ratio, 0.11; 95% confidence interval, 0.01-0.95; P = .044, respectively. CONCLUSIONS: The standardization of remodeling root repair with calibrated expansible aortic ring annuloplasty and cusp effective height assessment improves valve repair outcomes.

Long-term results of external aortic ring annuloplasty for aortic valve repair.

OBJECTIVES: An untreated dilated aortic annulus is a major risk factor for failure of aortic valve-sparing operations or repair of either bicuspid or tricuspid valve. Aortic annuloplasty efficiently reduces the annulus and increases the coaptation height, thus protecting the repair. This study analyses long-term results of 232 consecutive patients operated on with a standardized and physiological approach to aortic valve repair according to each phenotype of the dystrophic ascending aorta. Subvalvular aortic annuloplasty was systematically added using an external aortic ring to reduce annulus diameter when ≥25 mm. METHODS: Data were collected into the multicentric international AVIATOR registry (AorticValve repair InternATiOnal Registry): 149 patients with root aneurysm underwent remodelling with an external ring; 21 patients with tubular aortic aneurysm underwent supracoronary grafts with an external open ring and 62 patients with isolated aortic insufficiency (AI) underwent double sub- and/or supravalvular external open ring annuloplasty. Preoperative AI ≥ Grade III was present in 58.6% (133), and the valve was bicuspid in 37.9% (88). RESULTS: Cusp repair was performed in 75.4% (175) patients. The 30-day operative mortality rate was 1.4% (3). The mean follow-up was 40.1 ± 37.8 months (0-145.5). The actuarial survival rate at 7 years was 89.9%. The rate of freedom from reoperation at 7 years was similar among each phenotype, being 90.5% for root aneurysms, 100% for tubular aortic aneurysms and 97.5% for isolated AI with no difference between the bicuspid and tricuspid valve. The rates of freedom from AI ≥ Grade 2 and from AI ≥ Grade 3 at 7 years were, respectively, 76.0 and 93.1% for root aneurysms, 92.9 and 100% for tubular aortic aneurysms and 57.3 and 82.2% for isolated AI. Eye balling repair achieved suboptimal valve competency when compared with systematic cusp effective height assessment, which tended to improve the rate freedom from reoperation, respectively, from 85.8 ± 5.5% to 98.9 ± 1.1% and the rate of freedom from AI ≥ Grade 3 from 89.8 ± 4.9% to 100%. For isolated AI, an additional sinotubular junction ring (double sub- and supravalvular annuloplasty) tended to reduce recurrent AI when compared with single subvalvular annuloplasty. CONCLUSIONS: External aortic ring annuloplasty provides a reproducible technique for aortic valve repair with satisfactory long-term results for each ascending aorta phenotype with bicuspid or tricuspid valve. Longer follow-up is ongoing with the AVIATOR registry.

Bentall Procedure: A Systematic Review and Meta-Analysis.

BACKGROUND: The Bentall procedure is considered the gold standard in the treatment of patients requiring aortic root replacement. An up-to-date overview of outcomes after the Bentall procedure is lacking. METHODS: We conducted a systematic review and meta-analysis of characteristics of and long-term outcome after the Bentall procedure with a mechanical valve prosthesis. Pooling was performed using the inverse variance method within a random-effects model. Outcome events are reported as linearized occurrence rates (percentage per patient year) with 95% confidence intervals. RESULTS: In total, 46 studies with 7,629 patients (mean age, 50 years; 76% men) were selected. Pooled early mortality was 6% (422 patients). During a mean follow-up of 6 years (49,175 patient-years), the annual linearized occurrence rate for late mortality was 2.02% (1.77%- 2.31%; 892 patients), for aortic root reoperation it was 0.46% (0.36%-0.59%), for hemorrhage it was 0.64% (0.47%-0.87%), for thromboemboli it was 0.77% (0.60%-1.00%), for endocarditis it was 0.39% (0.33%-0.46%), and for major adverse valve-related events it was 2.66% (2.17%-3.24%). Operations performed in more recent years were associated with lower rates of aortic root reoperation (beta = -0.452; p = 0.015). CONCLUSIONS: This systematic review illustrates that rates of aortic root reoperation after the Bentall procedure have decreased over the years. However, late mortality, major bleeding, and thromboembolic complications remain a concern. This report may be used to benchmark the potential therapeutic benefit of novel surgical approaches, such as valve-sparing aortic root replacement.

Reported Outcome After Valve-Sparing Aortic Root Replacement for Aortic Root Aneurysm: A Systematic Review and Meta-Analysis.

Valve-sparing aortic root techniques have progressively gained ground in the treatment of aortic root aneurysm and aortic insufficiency. By avoiding anticoagulation therapy they offer a good alternative to composite graft replacement. This systematic review describes the reported outcome of valve-sparing aortic root replacement, focusing on the remodeling and reimplantation technique. A systematic literature search on the characteristics of and outcomes after valve-sparing aortic root replacement revealed 1,659 articles. The inclusion criteria were a focus on valve-sparing aortic root replacement in adults with aortic root aneurysm, presentation of survival data, and inclusion of at least 30 patients. Data were pooled by inverse variance weighting and analyzed by linear regression. Of 1,659 articles published between January 1, 2000, and January 1, 2014, 31 were included (n = 4,777 patients). The mean age at operation was 51 ± 14.7 years, and 14% of patients had a bicuspid aortic valve. The reimplantation technique was used in 72% and remodeling in 27% (1% other). No clinical advantage in terms of survival and reoperation of one technique over the other was found. Cusp repair was performed in 33%. Pooled early mortality was 2% (n = 103). During follow-up (21,716 patient-years), 262 patients died (survival 92%), and 228 (5%) underwent reoperation, mainly valve replacement. Major adverse valve-related events were low (1.66% patient-years). Preoperative severe aortic valve regurgitation showed a trend toward higher reoperation rate. Remodeling and reimplantation techniques show comparable survival and valve durability results, providing a valid alternative to composite valve replacement. The heterogeneity in the data underlines the need for a collaborative effort to standardize outcome reporting.