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BACKGROUND: We aimed to determine the effect of aortic annular enlargement on the mid-term 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, 1,328 patients underwent isolated aortic valve replacement-1,163 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 parameters 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 and 23 in the AVR+AAE and AVR groups, respectively. The AVR+AAE group had longer cardiopulmonary bypass (143 vs 111 mins) and cross-clamp (115 vs 82 mins) times. Incidences of perioperative complications including operative mortality (1.8% AVR+AAE vs 3.6% AVR) were similar between groups. 6-year survival was 98% in the AVR+AAE group and 74% in the AVR group (p=0.016). Aortic annular enlargement was an independent protective factor for mid-term mortality with a hazard ratio of 0.19 (p=0.006). The rate of moderate/severe patient-prosthesis mismatch was 19% in the AVR+AAE group and 31% in the AVR group (p=0.16). CONCLUSIONS: Patients with small native aortic annuli (≤23 mm) undergoing isolated aortic valve replacement may benefit from aortic annular enlargement.
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BACKGROUND: Over the past 25 years, diagnosis and therapy for acute aortic dissection (AAD) have evolved. We aimed to study the effects of these iterative changes in care. METHODS: Patients with nontraumatic AAD enrolled in the International Registry of Acute Aortic Dissection (61 centers; 15 countries) were divided into time-based tertiles (groups) from 1996 to 2022. The impact of changes in diagnostics, therapeutic care, and in-hospital and 3-year mortality was assessed. Cochran-Armitage trend and Jonckheere-Terpstra tests were conducted to test for any temporal trend. RESULTS: Each group consisted of 3785 patients (mean age, ≈62 years old; ≈65.5% males); nearly two-thirds had type A AAD. Over time, the rates of hypertension increased from 77.8% to 80.4% (P=0.002), while smoking (34.1% to 30.6%, P=0.033) and atherosclerosis decreased (25.6%-16.6%; P<0.001). Across groups, the percentage of surgical repair of type A AAD increased from 89.1% to 92.5% (P<0.001) and was associated with decreased hospital mortality (from 24.1% in group 1 to 16.7% in group 3; P<0.001). There was no difference in 3-year survival (P=0.296). For type B AAD, stent graft therapy (thoracic endovascular aortic repair) was used more frequently (22.3%-35.9%; P<0.001), with a corresponding decrease in open surgery. Endovascular in-hospital mortality decreased from 9.9% to 6.2% (P=0.003). As seen with the type A AAD cohort, overall 3-year mortality for patients with type B AAD was consistent over time (P=0.084). CONCLUSIONS: Over 25 years, substantial improvements in-hospital survival were associated with a more aggressive surgical approach for patients with type A AAD. Open surgery has been partially supplanted by thoracic endovascular aortic repair for complicated type B AAD, and in-hospital mortality has decreased over the time period studied. Postdischarge survival for up to 3 years was similar over time.
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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.
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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.
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OBJECTIVES: Traditional criterion for intervention on an asymptomatic ascending aortic aneurysm has been a maximal aortic diameter of 5.5 cm or more. The 2022 American College of Cardiology/American Heart Association aortic guidelines adopted cross-sectional aortic area/height ratio, aortic size index, and aortic height index as alternate parameters for surgical intervention. The objective of this study was to evaluate the impact of using these newer indices on patient eligibility for surgical intervention in a prospective, multicenter cohort with moderate-sized ascending aortic aneurysms between 5.0 and 5.4 cm. METHODS: Patients enrolled from 2018 to 2023 in the randomization or registry arms of the multicenter trial, Treatment In Thoracic Aortic aNeurysm: Surgery versus Surveillance, were included in the study. Clinical data were captured prospectively in an online database. Imaging data were derived from a core computed laboratory. RESULTS: Among the 329 included patients, 20% were female. Mean age was 65.0 ± 11.6 years, and mean maximal aortic diameter was 50.8 ± 3.9 mm. In the one-third of all patients (n = 109) who met any 1 of the 3 criteria (ie, aortic size index ≥3.08 cm/m2, aortic height index ≥3.21 cm/m, or cross-sectional aortic area/height ≥ 10 cm2/m), their mean maximal aortic diameter was 52.5 ± 0.52 mm. Alternate criteria were most commonly met in women compared with men: 20% versus 2% for aortic size index (P < .001), 39% versus 5% for aortic height index (P < .001), and 39% versus 21% for cross-sectional aortic area/height (P = .002), respectively. CONCLUSIONS: One-third of patients in Treatment In Thoracic Aortic aNeurysm: Surgery versus Surveillance would meet criteria for surgical intervention based on novel parameters versus the classic definition of diameter 5.5 cm or more. Surgical thresholds for aortic size index, aortic height index, or cross-sectional aortic area/height ratio are more likely to be met in female patients compared with male patients.
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OBJECTIVES: The objective of this analysis was to assess the normal haemodynamic performance of contemporary surgical aortic valves at 1 year postimplant in patients undergoing surgical aortic valve replacement for significant valvular dysfunction. By pooling data from 4 multicentre studies, this study will contribute to a better understanding of the effectiveness of surgical aortic valve replacement procedures, aiding clinicians and researchers in making informed decisions regarding valve selection and patient management. METHODS: Echocardiograms were assessed by a single core laboratory. Effective orifice area, dimensionless velocity index, mean aortic gradient, peak aortic velocity and stroke volume were evaluated. RESULTS: The cohort included 2958 patients. Baseline age in the studies ranged from 70.1 ± 9.0 to 83.3 ± 6.4 years, and Society of Thoracic Surgeons risk of mortality was 1.9 ± 0.7 to 7.5 ± 3.4%. Twenty patients who had received a valve model implanted in fewer than 10 cases were excluded. Ten valve models (all tissue valves; n = 2938 patients) were analysed. At 1 year, population mean effective orifice area ranged from 1.46 ± 0.34 to 2.12 ± 0.59 cm2, and dimensionless velocity index, from 0.39 ± 0.07 to 0.56 ± 0.15. The mean gradient ranged from 8.6 ± 3.4 to 16.1 ± 6.2 mmHg with peak aortic velocity of 1.96 ± 0.39 to 2.65 ± 0.47 m/s. Stroke volume was 75.3 ± 19.6 to 89.8 ± 24.3 ml. CONCLUSIONS: This pooled cohort is the largest to date of contemporary surgical aortic valves with echocardiograms analysed by a single core lab. Overall haemodynamic performance at 1 year ranged from good to excellent. These data can serve as a benchmark for other studies and may be useful to evaluate the performance of bioprosthetic surgical valves over time. CLINICAL TRIAL REGISTRATION NUMBER: NCT02088554, NCT02701283, NCT01586910 and NCT01531374.
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Valve aortique , Bioprothèse , Implantation de valve prothétique cardiaque , Prothèse valvulaire cardiaque , Hémodynamique , Humains , Hémodynamique/physiologie , Valve aortique/chirurgie , Valve aortique/imagerie diagnostique , Sujet âgé , Femelle , Mâle , Sujet âgé de 80 ans ou plus , Implantation de valve prothétique cardiaque/méthodes , Échocardiographie , Adulte d'âge moyen , Conception de prothèseRÉSUMÉ
OBJECTIVE: With an aging population and advancements in imaging, recurrence of thoracic aortic dissection is becoming more common. METHODS: All patients enrolled in the International Registry of Aortic Dissection from 1996 to 2023 with type A and type B acute aortic dissection were identified. Among them, initial dissection and recurrent dissection were discerned. The study period was categorized into 3 eras: historic era, 1996 to 2005; middle era, 2006 to 2015; most recent era, 2016 to 2023. Propensity score matching was applied between initial dissection and recurrent dissection. Outcome of interests included long-term survival and cumulative incidence of major aortic events defined by the composite of reintervention, aortic rupture, and new dissection. RESULTS: The proportion of recurrent dissection increased from 5.9% in the historic era to 8.0% in the most recent era in the entire dissection cohort. In patients with type A dissection, propensity score matching between initial dissection and recurrent dissection yielded 326 matched pairs. Kaplan-Meier curves showed similar long-term survival between the 2 groups. However, the cumulative incidence of major aortic events was significantly higher in the recurrent dissection group (40.3% ± 6.2% vs 17.8% ± 5.1% at 4 years in the initial dissection group, P = .02). For type B dissection, 316 matched pairs were observed after propensity score matching. Long-term survival and the incidence of major aortic events were equivalent between the 2 groups. CONCLUSIONS: The case volume of recurrent dissection or the ability to detect recurrent dissection has increased over time. Acute type A recurrent dissection was associated with a higher risk of major aortic events than initial dissection. Further judicious follow-up may be crucial after type A recurrent dissection.
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BACKGROUND: Endovascular repair of blunt thoracic aortic injury (BTAI) has dramatically reduced the morbidity and mortality of intervention. Injuries requiring zone 2 coverage of the aorta traditionally require left subclavian artery (LSA) sacrifice or open revascularization. Furthermore, these injuries are associated with an increased risk of in-hospital mortality and long-term morbidity. Here we report 1-year outcomes of total endovascular repair of BTAI with the GORE® TAG® Thoracic Branch Endoprosthesis for LSA preservation. METHODS: Across 34 investigative sites, 9 patients with BTAI requiring LSA coverage were enrolled in a nonrandomized, prospective study of a single-branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for LSA perfusion. RESULTS: This initial cohort included 8 male and 1 female patient with a median age of 43 (22, 76) and 12 months of follow-up. Five total years of follow-up are planned. All participants had grade 3 BTAI. All procedures took place between 2018 and 2019. The median injury severity score was 2 (0, 66). The median procedure time was 109 min (78, 162). All aortic injuries were repaired under general anesthesia and with heparinization. A spinal drain was used in one patient. Post-deployment balloon angioplasty was conducted in one case at the distal landing zone. There was one asymptomatic LSA branch occlusion 6 months after repair. It was attributed to the purposeful proximal deployment of the branch stent to accommodate an early vertebral takeoff. The occlusion did not require revascularization. There were no strokes, mortalities, or aortic adverse events (migration, endoleak, native aortic expansion, dissection, or thrombosis) through 12 months of follow-up. CONCLUSIONS: Initial cohort outcomes suggest that endovascular repair of zone 2 BTAI is feasible and has favorable outcomes using the thoracic branch device with LSA preservation. Additional cases and longer-term follow-up are required for a definitive assessment of the device's safety and durability in traumatic aortic injuries.
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Aorte thoracique , Implantation de prothèses vasculaires , Prothèse vasculaire , Procédures endovasculaires , Conception de prothèse , Lésions du système vasculaire , Plaies non pénétrantes , Humains , Mâle , Plaies non pénétrantes/chirurgie , Plaies non pénétrantes/imagerie diagnostique , Femelle , Lésions du système vasculaire/chirurgie , Lésions du système vasculaire/imagerie diagnostique , Lésions du système vasculaire/mortalité , Lésions du système vasculaire/étiologie , Implantation de prothèses vasculaires/instrumentation , Implantation de prothèses vasculaires/effets indésirables , Implantation de prothèses vasculaires/mortalité , Aorte thoracique/chirurgie , Aorte thoracique/imagerie diagnostique , Aorte thoracique/traumatismes , Procédures endovasculaires/instrumentation , Procédures endovasculaires/effets indésirables , Procédures endovasculaires/mortalité , Adulte , Résultat thérapeutique , Adulte d'âge moyen , Facteurs temps , Études prospectives , Jeune adulte , Sujet âgé , Blessures du thorax/chirurgie , Blessures du thorax/imagerie diagnostique , Blessures du thorax/mortalité , États-Unis , Endoprothèses , Facteurs de risqueRÉSUMÉ
BACKGROUND: Cannulation strategy in acute type A dissection (ATAD) varies widely without known gold standards. This study compared ATAD outcomes of axillary vs femoral artery cannulation in a large cohort from the International Registry of Acute Aortic Dissection (IRAD). METHODS: The study retrospectively reviewed 2145 patients from the IRAD Interventional Cohort (1996-2021) who underwent ATAD repair with axillary or femoral cannulation (axillary group: n = 1106 [52%]; femoral group: n = 1039 [48%]). End points included the following: early mortality; neurologic, respiratory, and renal complications; malperfusion; and tamponade. All outcomes are presented as axillary with respect to femoral. RESULTS: The proportion of patients younger than 70 years in both groups was similar (n = 1577 [74%]), as were bicuspid aortic valve, Marfan syndrome, and previous dissection. Patients with femoral cannulation had slightly more aortic insufficiency (408 [55%] vs 429 [60%]; P = .058) and coronary involvement (48 [8%] vs 70 [13%]; P = .022]. Patients with axillary cannulation underwent more total aortic arch (156 [15%] vs 106 [11%]; P = .02) and valve-sparing root replacements (220 [22%] vs 112 [12%]; P < .001). More patients with femoral cannulation underwent commissural resuspension (269 [30.9%] vs 324 [35.3%]; P = .05). Valve replacement rates were not different. The mean duration of cardiopulmonary bypass was longer in the femoral group (190 [149-237] minutes vs 196 [159-247] minutes; P = .037). In-hospital mortality was similar between the axillary (n = 165 [15%]) and femoral (n = 149 [14%]) groups (P = .7). Furthermore, there were no differences in stroke, visceral ischemia, tamponade, respiratory insufficiency, coma, or spinal cord ischemia. CONCLUSIONS: Axillary cannulation is associated with a more stable ATAD presentation, but it is a more extensive intervention compared with femoral cannulation. Both procedures have equivalent early mortality, stroke, tamponade, and malperfusion outcomes after statistical adjustment.
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, Artère axillaire , Artère fémorale , Humains , /chirurgie , /mortalité , Femelle , Mâle , Études rétrospectives , Adulte d'âge moyen , Sujet âgé , Anévrysme de l'aorte thoracique/chirurgie , Anévrysme de l'aorte thoracique/mortalité , Cathétérisme périphérique/méthodes , Maladie aigüe , Enregistrements , Résultat thérapeutiqueRÉSUMÉ
Background: The use of rapid-deployment valves (RDVs) has been shown to reduce the operative time for surgical aortic valve replacement (AVR). Long-term core laboratory-adjudicated data are scarce, however. Here we report final 7-year data on RDV use. Methods: TRANSFORM was a prospective, nonrandomized, multicenter, single-arm trial implanting a stented bovine pericardial valve with an incorporated balloon-expandable sealing frame. A prior published 1-year analysis included 839 patients from 29 centers. An additional 46 patients were enrolled and implanted, for a total of 885 patients. Annual clinical and core laboratory-adjudicated echocardiographic outcomes were collected through 8 years. Primary endpoints were structural valve deterioration (SVD), all-cause reintervention, all-cause valve explantation, and all-cause mortality. Secondary endpoints included hemodynamic performance assessed by echocardiography. The mean duration of follow-up was 5.0 ± 2.0 years. Results: The mean patient age was 73.3 ± 8.2 years. Isolated AVR was performed in 62.1% of the patients, and AVR with concomitant procedures was performed in 37.9%. Freedom from all-cause mortality at 7 years was 76.0% for isolated AVR and 68.2% for concomitant AVR. Freedom from SVD, all-cause reintervention, and valve explantation at 7 years was 97.5%, 95.7%, and 97.8%, respectively. The mean gradient and effective orifice area at 7 years were 11.1 ± 5.3 mm Hg and 1.6 ± 0.3 cm2, respectively. Paravalvular leak at 7 years was none/trace in 88.6% and mild in 11.4%. In patients undergoing isolated AVR, the cumulative probability of pacemaker implantation was 13.9% at 30 days, 15.5% at 1 year, and 21.8% at 7 years. Conclusions: AVR for aortic stenosis using an RDV is associated with low rates of late adverse events. This surgical pericardial tissue platform provides excellent and stable hemodynamic performance through 7 years.
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BACKGROUND: Transcatheter aortic valve replacement (TAVR) has changed the landscape of aortic stenosis (AS) management. AIM: To describe and evaluate geographic variation in AS treatment and outcomes among a sample of Medicare beneficiaries. METHODS: A retrospective analysis of administrative claims data was conducted on a 20% sample of Medicare fee-for-service beneficiaries aged 65 and older with a diagnosis of AS (2015-2018). Estimates of demographic, comorbidity, and healthcare resources were obtained from Medicare claims and the Dartmouth Atlas of Health Care at the hospital referral region (HRR), which represents regional tertiary medical care markets. Linear regression was used to explain HRR-level variation in rates of surgical aortic valve replacement (SAVR) and TAVR, and 1-year mortality and readmission rates. RESULTS: A total of 740,899 beneficiaries with AS were identified with a median prevalence of AS of 39.9 per 1000 Medicare beneficiary years. The average HRR-level rate of SAVR was 26.3 procedures per 1000 beneficiary years and the rate of TAVR was 20.3 procedures per 1000 beneficiary years. HRR-level comorbidities and number of TAVR centers were associated with a lower SAVR rate. Demographics and comorbidities explained most of the variation in HRR-level 1-year mortality (15.2% and 18.8%) and hospitalization rates (20.5% and 16.9%), but over half of the variation remained unexplained. CONCLUSION: Wide regional variation in the treatment and outcomes of AS was observed but were largely unexplained by patient factors and healthcare utilization. Understanding the determinants of AS treatment and outcomes can inform population health efforts for these patients.
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Sténose aortique , Implantation de valve prothétique cardiaque , Remplacement valvulaire aortique par cathéter , Humains , Sujet âgé , États-Unis/épidémiologie , Medicare (USA) , Études rétrospectives , Résultat thérapeutique , Sténose aortique/imagerie diagnostique , Sténose aortique/chirurgie , Sténose aortique/étiologie , Valve aortique/imagerie diagnostique , Valve aortique/chirurgie , Implantation de valve prothétique cardiaque/effets indésirables , Sténose pathologique , Facteurs de risqueRÉSUMÉ
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.
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Atteinte rénale aigüe , , Implantation de prothèses vasculaires , Mâle , Femelle , Humains , Sortie du patient , Études rétrospectives , /chirurgie , Dialyse rénale , Facteurs de risque , Atteinte rénale aigüe/étiologie , Atteinte rénale aigüe/thérapie , Résultat thérapeutiqueRÉSUMÉ
PURPOSE: Patients with complicated ascending aortic pathology, including patients with acute type A aortic dissection may be at extreme risk for open repair. Thoracic endovascular aortic repair (TEVAR), infrequently used for the ascending aorta, may be considered an alternative in this setting. We describe early results for emergency and compassionate (E&C) use of a novel endograft, specifically designed for use to treat pathology of the ascending aorta. MATERIALS AND METHODS: This case series evaluated 19 patients (mean age, 68.84±13.12 years; 57.9% female) treated with ascending TEVAR for acute and chronic acute (4), subacute (1), or chronic (1) aortic dissection or pseudoaneurysm (13). Six of the 19 patients (31.5%) were treated under compassionate use and 13 patients (68.4%) were treated under the emergency use exemption. Ten patients (52.6%) received additional devices to extend treatment into the arch and descending aorta. RESULTS: Device delivery was achieved in all patients (100%). Thirty-day mortality and stroke occurred in 3 patients (15.8%) and in 1 patient (5.3%), respectively. In 1 patient (5.3%), with an Unanticipated Adverse Device Event, the aorta ruptured when the endograft eroded into the adventitial portion of dissection site at the posterior aspect of the ascending wall. Devices were explanted in 2 patients (10.5%), 353 and 610 days after the index procedure, respectively. Six patients had endoleaks (31.6%), including type I (n=2, 10.5%), type II endoleaks (n=3, 15.8%), and indeterminate endoleak (n=1, 5.3%). CONCLUSIONS: Delivery and deployment of a novel ascending thoracic stent graft with or without an additional branched arch extension is feasible in patients with complex anatomy and pathology, including acute aortic dissection and pseudoaneurysm. Additional experience with this novel device will further refine the patient population most suitable for endovascular ascending aortic repair for these pathologies. CLINICAL IMPACT: This study describes a novel stent graft specifically designed for treatment of ascending aortic pathology, including acute type A dissection. The patients described in this series constituted a group outside the formal US FDA sponsored clinical trial, and were those accepted as part of an emergency and compassionate use basis.
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The aorta is in constant motion due to the combination of cyclic loading and unloading with its mechanical coupling to the contractile left ventricle (LV) myocardium. This aortic root motion has been proposed as a marker for aortic disease progression. Aortic root motion extraction techniques have been mostly based on 2D image analysis and have thus lacked a rigorous description of the different components of aortic root motion (e.g., axial versus in-plane). In this study, we utilized a novel technique termed vascular deformation mapping (VDM(D)) to extract 3D aortic root motion from dynamic computed tomography angiography images. Aortic root displacement (axial and in-plane), area ratio and distensibility, axial tilt, aortic rotation, and LV/Ao angles were extracted and compared for four different subject groups: non-aneurysmal, TAA, Marfan, and repair. The repair group showed smaller aortic root displacement, aortic rotation, and distensibility than the other groups. The repair group was also the only group that showed a larger relative in-plane displacement than relative axial displacement. The Marfan group showed the largest heterogeneity in aortic root displacement, distensibility, and age. The non-aneurysmal group showed a negative correlation between age and distensibility, consistent with previous studies. Our results revealed a strong positive correlation between LV/Ao angle and relative axial displacement and a strong negative correlation between LV/Ao angle and relative in-plane displacement. VDM(D)-derived 3D aortic root motion can be used in future studies to define improved boundary conditions for aortic wall stress analysis.
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OBJECTIVE: The International Registry of Acute Aortic Dissection (IRAD) celebrated its 25th anniversary in January 2021. This study evaluated IRAD's role in promoting the understanding and management of acute aortic dissection (AD) over these years. METHODS: IRAD studies were identified, analyzed, and ranked according to their citations per year (c/y) to determine the most-cited IRAD studies and topics. A systematic search of the literature identified cardiovascular guidelines on the diagnosis and management of acute AD. Consequently, IRAD's presence and impact were quantified using these documents. RESULTS: Ninety-seven IRAD studies were identified, of which 82 obtained more than 10 cumulative citations. The median c/y index was 7.33 (25th-75th percentile, 4.01-16.65). Forty-two studies had a greater than median c/y index and were considered most impactful. Of these studies, most investigated both type A and type B AD (n = 17, 40.5%) and short-term outcomes (n = 26, 61.9%). Nineteen guideline documents were identified from 26 cardiovascular societies located in Northern America, Europe, and Japan. Sixty-nine IRAD studies were cited by these guidelines, including 38 of the 42 most-impactful IRAD studies. Among them, partial thrombosis of the false lumen as a predictor of postdischarge mortality and aortic diameters as a predictor of type A occurrence were determined as most-impactful specific IRAD topics by their c/y index. CONCLUSIONS: IRAD has had and continues to have an important role in providing observations, credible knowledge, and research questions to improve the outcomes of patients with acute AD.
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AIM: The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS: A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Maladies de l'aorte , Maladie de la valve aortique bicuspide , Cardiologie , Femelle , Grossesse , États-Unis , Humains , Association américaine du coeur , Maladies de l'aorte/diagnostic , Maladies de l'aorte/thérapie , AorteRÉSUMÉ
BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has evolved as the standard for treating complicated acute type B aortic dissection (ATBAD). Acute kidney injury (AKI) is a common complication in critically ill patients and is commonly observed in patients with ATBAD. The purpose of the study was to characterize AKI after TEVAR. METHODS: All patients who underwent TEVAR for ATBAD from 2011 through 2021 were identified using the International Registry of Acute Aortic Dissection. The primary end point was AKI. A generalized linear model analysis was performed to identify a factor associated with postoperative AKI. RESULTS: A total of 630 patients presented with ATBAD and underwent TEVAR. The indication for TEVAR was complicated ATBAD in 64.3%, high-risk uncomplicated ATBAD in 27.6%, and uncomplicated ATBAD in 8.1%. Of 630 patients, 102 (16.2%) developed postoperative AKI (AKI group) and 528 patients (83.8%) did not (non-AKI group). The most common indication for TEVAR was malperfusion (37.5%). In-hospital mortality was significantly higher in the AKI group (18.6% vs 4%; P < .001). Postoperatively, cerebrovascular accident, spinal cord ischemia, limb ischemia, and prolonged ventilation were more commonly observed in the AKI group. The expected mortality was similar at 2 years between the two groups (P = .51). Overall, the preoperative AKI was observed in 95 (15.7%) in the entire cohort consisting of 60 (64.5%) in the AKI group and 35 (6.8%) in the non-AKI group. A history of CKD (odds ratio, 4.6; 95% confidence interval, 1.5-14.1; P = .01) and preoperative AKI (odds ratio, 24.1; 95% confidence interval, 10.6-55.0; P < .001) were independently associated with postoperative AKI. CONCLUSIONS: The incidence of postoperative AKI was 16.2% in patients undergoing TEVAR for ATBAD. Patients with postoperative AKI had a higher rate of in-hospital morbidities and mortality than those without. A history of CKD and preoperative AKI were independently associated with postoperative AKI.
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Atteinte rénale aigüe , Anévrysme de l'aorte thoracique , , Implantation de prothèses vasculaires , Procédures endovasculaires , Insuffisance rénale chronique , Humains , Réparation endovasculaire d'anévrysme , Implantation de prothèses vasculaires/effets indésirables , Résultat thérapeutique , Anévrysme de l'aorte thoracique/imagerie diagnostique , Anévrysme de l'aorte thoracique/chirurgie , Anévrysme de l'aorte thoracique/complications , Procédures endovasculaires/effets indésirables , Études rétrospectives , /imagerie diagnostique , /chirurgie , Atteinte rénale aigüe/diagnostic , Atteinte rénale aigüe/épidémiologie , Atteinte rénale aigüe/étiologie , Insuffisance rénale chronique/complications , Facteurs de risque , Complications postopératoires/étiologie , Complications postopératoires/chirurgieRÉSUMÉ
OBJECTIVE: Use of transcatheter aortic valve replacement (TAVR) has demonstrated dramatic growth in the past decade. This study aims to investigate implications of post-TAVR reoperation from our 10-year experience. METHODS: Between 2011 and 2022, 66 post-TAVR patients underwent a reoperation, consisting of 42 (63.6%) patients with native TAVR and 24 (36.4%) patients with valve-in-valve TAVR (VIV-TAVR) after surgical aortic valve replacement. RESULTS: The aggregate proportion of patients belonging to the low-/intermediate-risk group at the time of TAVR exceeded that of the high-/extreme-risk cohort in 2021. The native TAVR group received a larger TAVR valve, whereas more frequent low-risk status at the time of TAVR than the VIV-TAVR group. Concurrent procedures were highly common during reoperation and isolated surgical aortic valve replacement represented only 18.2% of the entire cohort. The native TAVR group demonstrated significantly higher TAVR explant difficulty index score (2.0 vs 1.0 points; P < .001) and operative mortality (14.2% vs 0%; P = .079) compared with the VIV-TAVR group. The 8-year cumulative incidence of reoperation was 1.9% and 14.1% (subdistribution hazard ratio, 8.0; 95% CI, 4.1-15.9; P < .001) in the native and VIV-TAVR group, respectively. Furthermore, cumulative incidence of valve reintervention, combining reoperations and redo TAVRs, was 3.3% and 19.0% (subdistribution hazard ratio, 6.2; 95% CI, 3.6-10.9; P < .001). CONCLUSIONS: Low-/intermediate-risk patients are emerging as the predominant group necessitating reoperations. Native TAVR was associated with lower postimplant reintervention rates, albeit with higher reoperative technical difficulty and mortality. Conversely, VIV-TAVR was associated with higher reintervention, but demonstrated lower technical difficulty and mortality for reoperation.
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OBJECTIVE: To describe the trends in management and outcomes of patients with acute type B aortic dissection in the International Registry of Acute Aortic Dissection. METHODS: From 1996 - 2022, 3 908 patients were divided into similar sized quartiles (T1, T2, T3, and T4). In hospital outcomes were analysed for each quartile. Survival rates following admission were compared using Kaplan-Meier analyses with Mantel-Cox Log rank tests. RESULTS: Endovascular treatment increased from 19.1% in T1 to 37.2% in T4 (ptrend < .001). Correspondingly, medical therapy decreased from 65.7% in T1 to 54.0% in T4 (ptrend < .001), and open surgery from 14.8% in T1 to 7.0% in T4 (ptrend < .001). In hospital mortality decreased in the overall cohort from 10.7% in T1 to 6.1% in T4 (ptrend < .001), as well as in medically, endovascularly and surgically treated patients (ptrend = .017, .033, and .011, respectively). Overall post-admission survival at three years increased (T1: 74.8% vs. T4: 77.3%; p = .006). CONCLUSION: Considerable changes in the management of acute type B aortic dissection were observed over time, with a significant increase in the use of endovascular treatment and a corresponding reduction in open surgery and medical management. These changes were associated with a decreased overall in hospital and three year post-admission mortality rate among quartiles.
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BACKGROUND: Aortic stenosis treatment should consider risks and benefits for lifetime management. Although the feasibility of redo transcatheter aortic valve replacement (TAVR) remains unclear, concerns are emerging regarding reoperation after TAVR. OBJECTIVES: The authors sought to define comparative risk of surgical aortic valve replacement (SAVR) after prior TAVR or SAVR. METHODS: Data on patients undergoing bioprosthetic SAVR after TAVR and/or SAVR were extracted from the Society of Thoracic Surgeons Database (2011-2021). Overall and isolated SAVR cohorts were analyzed. The primary outcome was operative mortality. Risk adjustment using hierarchical logistic regression as well as propensity score matching for isolated SAVR cases were performed. RESULTS: Of 31,106 SAVR patients, 1,126 had prior TAVR (TAVR-SAVR), 674 had prior SAVR and TAVR (SAVR-TAVR-SAVR), and 29,306 had prior SAVR (SAVR-SAVR). Yearly rates of TAVR-SAVR and SAVR-TAVR-SAVR increased over time, whereas SAVR-SAVR was stable. The TAVR-SAVR patients were older, with higher acuity, and with greater comorbidities than other cohorts. The unadjusted operative mortality was highest in the TAVR-SAVR group (17% vs 12% vs 9%, respectively; P < 0.001). Compared with SAVR-SAVR, risk-adjusted operative mortality was significantly higher for TAVR-SAVR (OR: 1.53; P = 0.004), but not SAVR-TAVR-SAVR (OR: 1.02; P = 0.927). After propensity score matching, operative mortality of isolated SAVR was 1.74 times higher for TAVR-SAVR than SAVR-SAVR patients (P = 0.020). CONCLUSIONS: The number of post-TAVR reoperations is increasing and represent a high-risk population. Yet even in isolated SAVR cases, SAVR after TAVR is independently associated with increased risk of mortality. Patients with life expectancy beyond a TAVR valve and unsuitable anatomy for redo-TAVR should consider a SAVR-first approach.