Frozen elephant trunk technique using hybrid grafts: 15-year outcomes from a single-centre experience.

OBJECTIVES: The purpose of the study is to compare the short- and long-term outcomes of the frozen elephant trunk (FET) technique based on 2 different hybrid grafts implanted from January 2007 to July 2022. METHODS: The study includes patients who underwent an elective or emergency FET procedure. Short-term, long-term mortality and freedom from thoracic endovascular aortic repair (TEVAR) were the primary end points. Analyses were carried out separately for the periods 2007-2012 and 2013-2022. RESULTS: Of the 367 enrolled, 49.3% received E-Vita Open implantation and 50.7% received Thoraflex Hybrid implants. Overall mean age was 61 years [standard deviation (SD) = 11] and 80.7% were male. The average annual volume of FET procedures was 22.7 cases/year. Compared to E-Vita Open, patients implanted with Thoraflex Hybrid grafts were more likely to receive distal anastomosis in zone 2 (68.3% vs 11.6%, P < 0.001) with a shorter stent portion, mean = 103mm (SD = 11.3) vs mean = 149 mm (SD = 12.7; P < 0.001) and they underwent a reduced visceral ischaemia time, mean = 42.5 (SD = 14.2) vs mean= 61.0 (SD = 20.2) min, P < 0.001. In the period 2013-2022, overall survival at 1, 2 and 5 years was 74.8%, 72.5% and 63.2% for Thoraflex and 73.2%, 70.7% and 64.1% for E-Vita, without significant differences between groups (log-rank test = 0.01, P = 0.907). Overall freedom from TEVAR at 1, 2 and 5 years was 66.7%, 57.6% and 39.3% for Thoraflex and 79%, 69.7% and 66% for E-Vita, with significant differences between groups (log-rank test = 5.28, P = 0.029). In a competing risk analysis adjusted for chronic/residual aortic syndromes and stent diameter, the Thoraflex group was more likely to receive TEVAR during follow-up (subdistribution hazard ratio SHR = 2.12, 95% confidence interval 1.06-4.22). CONCLUSIONS: The FET technique addresses acute and chronic arch disease with acceptable morbidity and mortality. Downstream endovascular reinterventions are very common during follow-up.

Biological versus mechanical Bentall procedure for aortic root replacement: a propensity score analysis of a consecutive series of 1112 patients.

OBJECTIVES: In this study, a propensity-matching analysis was used to compare biological versus mechanical composite valve graft implantation for early mortality and morbidities and for late complications including the need for aortic reintervention. METHODS: Between 1978 and 2011, 1112 consecutive patients underwent a complete aortic root replacement using either a biological Bentall (BB, n = 356) or a mechanical Bentall (MB, n = 756) valve conduit. Preoperative data were stratified according to the type of valve graft, and treatment bias was addressed by propensity score analysis. RESULTS: Two homogeneous groups of 138 patients were obtained. Hospital mortality between them was comparable (MB = 7.2% and BB = 5.8%, P = 0.6). They also had similar results after a mean follow-up time of 40 ± 38 months. Propensity-adjusted Cox-regression analysis showed no relationship between the type of prosthesis and all-cause mortality at follow-up (hazards ratio: 0.88; 95% confidence interval: 0.50-2.14; P = 0.4). Freedom from proximal aortic reintervention at 1, 5 and 7 years was 99.1 ± 0.9% in the MB group compared with 98.4 ± 1.1%, 93.0 ± 3.2% and 93.0 ± 3.2% in the BB group (long-rank P = 0.07). CONCLUSIONS: The Bentall procedure is a safe and reproducible treatment for ascending aorta pathologies. The choice of either a mechanical or a biological valve graft seems to have no influence on early and late midterm adverse outcomes including need for aortic reinterventions.

Long-Term Outcomes of Open Arch Repair After a Prior Aortic Operation: Our Experience in 154 Patients.

BACKGROUND: This study assessed the early and long-term results of arch operations performed after a prior aortic operation. METHODS: From 1994 to 2014, 154 consecutive patients (mean age, 59.7 years) underwent an aortic arch repair, after a previous aortic operation, at our institution. Antegrade selective cerebral perfusion was used in all cases. Chronic postdissection aortic aneurysm (87 [56.5%]) and degenerative aneurysm (43 [27.9%]) represented the most common indications for surgical intervention. A complete arch replacement was performed in 119 patients (77.3%), an associated root repair in 70 (45.5%), and the frozen elephant trunk technique was used in 55 (35.7%). RESULTS: Hospital mortality was 11.7% (n = 18). Postoperative permanent neurologic dysfunction occurred in 10 patients (6.4%). On multivariate analysis, cardiopulmonary bypass time (odds ratio, 1.02 per minute; p = 0.005) emerged as the only independent predictor of hospital death. Follow-up was 100% complete. The estimated survival at 1, 5, and 10 years was 79.6%, 69.9%, and 46.8%, respectively. Freedom from reoperation was 75.6% at 5 years and 54.6% at 10 years. Cox regression identified chronic postdissection aortic aneurysm (odds ratio, 4.2; p = 0.006) to be the only independent predictor of aortic reintervention. Late survival was comparable between degenerative aneurysm patients and the Italian population matched for age and sex (standardized mortality ratio, 1.9; p = 0.1). Longevity was reduced in patients operated on for chronic postdissection aortic aneurysm (standardized mortality ratio, 6.3; p < 0.001). CONCLUSIONS: Arch operations after a previous open aortic repair can be performed with acceptable mortality and good long-term outcomes. Complete aortic resection did not increase hospital deaths and was associated with a low need for aortic reinterventions at follow-up.

Composite valve graft implantation for the treatment of aortic valve and root disease: Results in 1045 patients.

OBJECTIVES: Aortic root replacement using a composite graft is the treatment of choice for a large variety of aortic root conditions with a diseased aortic valve. The objective of the current study was to evaluate the long-term results of this procedure. METHODS: Between 1978 and 2010, 1045 patients aged 58.7 ± 13.6 years underwent aortic root composite graft replacement using the following techniques: 95 Bentall operation; 926 the "button technique;" 24 the Cabrol technique. A mechanical composite valve graft was implanted in 69.6% of the patients. Six-hundred and thirty-five patients (62.3%) had annuloaortic ectasia and 162 (15.5%) had aortic dissection. RESULTS: Early mortality was 5.3% (55/1045). Independent risk factors for early mortality at logistic regression analysis were age ≥70 years (P = .051; odds ratio [OR], 2.97), New York Heart Association III-IV (P = .052; OR, 1.88), reoperation (P = .021; OR, 2.36), urgency/emergency (P = .003; OR, 3.09), mitral valve replacement (P = .001; OR, 6.01), or coronary artery bypass grafting (CABG) (P < .001; OR, 4.39); while bicuspid aortic valve (BAV) (P = .013; OR, 0.21), and time of operation 2001-2011 (P = .025; OR, 0.60) were protective predictors for early mortality. Overall survival at 5, 10, and 20 years was 84.1% ± 1.3%, 65.5% ± 2.6%, and 40.7% ± 4.6%, respectively. Multivariate analysis revealed chronic renal insufficiency (P = .001; hazard ratio [HR], 3.48), chronic obstructive pulmonary disease (P = .027; HR, 1.94), aortic dissection (P = .001; HR, 2.63), Cabrol technique (P = .009; HR, 15.34), and CABG (P = .016; HR, 2.02) to be significant predictors of late death, and BAV (P = .010; HR, 0.43) to be a significant protective predictor. Freedom from thromboembolism, bleeding complications, and endocarditis was 93.7% ± 2.6%, 90.3% ± 3.1%, and 98.4% ± 1% at 20 years, respectively. Freedom from aortic reoperation was 91.8% ± 2.1% at 20 years and was significantly lower in patients with aortic dissection. CONCLUSIONS: Within the limitations of this retrospective study, we can conclude that aortic root replacement for aortic root aneurysms can be performed with low morbidity and mortality and with satisfactory long-term results. Few late serious complications were related to the need for long-term anticoagulation or a prosthetic valve. Reoperation on the proximal or in the distal aorta was most commonly performed in patients with aortic dissection.

Risk factors for acute kidney injury after surgery of the thoracic aorta using antegrade selective cerebral perfusion and moderate hypothermia.

BACKGROUND: The development of acute kidney injury (AKI) in cardiac surgery is associated with increased morbidity and mortality. The aim of the study was to assess the incidence and risk factors for AKI after thoracic aorta surgery, using antegrade selective cerebral perfusion (ASCP) and moderate hypothermia. METHODS: We reviewed 641 patients undergoing thoracic aortic surgery, using ASCP and moderate hypothermia, from November 1996 to December 2012. Patient preoperative, intraoperative, and postoperative variables were evaluated for association with AKI with logistic regression analysis. Models including all variables and models, after the sequential removal of postoperative, and both postoperative and intraoperative variables, were assessed using receiver operating characteristic analysis. RESULTS: The mean age of the patients was 62.9 years, and 194 patients (30%) were women. The overall incidence of AKI was 19.0%. In-hospital mortality was significantly higher in the AKI group (33.6% vs 6.7%; P < .001). Logistic regression analysis identified 8 predictors of AKI: 4 of them were preoperative (priority, diabetes, preoperative glomerular filtration rate, and weight); 2 intraoperative (mitral valve and aortic valve replacement); and 2 postoperative (overall neurologic complication and reoperation for bleeding). Model-discrimination performance improved from an area under the curve (AUC) of 0.737, for the model including only preoperative variables, to an AUC of 0.798 for the model including all variables (P = .012). CONCLUSIONS: The incidence of AKI after thoracic aorta surgery is fairly common, and its occurrence strongly affects outcomes. Preoperative renal status and preoperative conditions are the main influences on AKI development. Predictive models can be improved by adding intraoperative and postoperative variables.

The Bologna experience with the Thoraflex™ hybrid frozen elephant trunk device.

BACKGROUND: We present our initial experience with the frozen elephant trunk using a Thoraflex™ hybrid device for the treatment of the complex thoracic aorta lesions. MATERIALS & METHODS: Between March 2013 and March 2014, ten patients underwent thoracic aorta surgery using the frozen elephant trunk approach with the Thoraflex hybrid device. Indications for surgery were: residual type A chronic dissection (eight patients), degenerative aneurysm (one patient) and type B chronic aortic dissection (one patient). Selective antegrade cerebral perfusion and moderate hypothermia were used in all cases. RESULTS: In-hospital mortality was 0% and no patients presented with paraplegia, paraparesis or major neurological events. One patient experienced transient ischemic attack. Two patients underwent reoperation for bleeding. All postoperative angiography CT scans confirmed the desired results. CONCLUSION: Our initial experience demonstrated excellent early results. The Thoraflex hybrid prosthesis with the four-branched arch graft increases the spectrum of techniques available for the surgeon in the treatment of complex diseases of the thoracic aorta.

The frozen elephant trunk technique for the treatment of complicated type B aortic dissection with involvement of the aortic arch: multicentre early experience.

OBJECTIVES: Providing effective treatment for complicated type B aortic dissection (AD) with concomitant pathologies of the aortic arch or ascending aorta is challenging, especially if the aortic anatomy is contraindicated for thoracic endovascular aortic repair (TEVAR). We present the early results of a multicentre study using the frozen elephant trunk (FET) technique for type B AD. METHODS: From January 2005 to March 2013, data from 465 patients who had undergone treatment with the FET technique were collected in the database of the International E-vita Open Registry. From this cohort, 57 patients who had a primary indication for surgery for type B AD were included in the present study. Their mean age was 58±12 years, and 72% had a chronic dissection. All operations were performed in circulatory arrest and bilateral antegrade cerebral perfusion. Computed aortic imaging was performed for false lumen (FL) evaluation during the follow-up. RESULTS: The in-hospital mortality rate was 14% (8/57). Stroke and spinal cord injury occurred in 6 (10%) and 2 patients (4%), respectively. The rate of immediate FL thrombosis at the level of the stent graft was 75% (40/53) and increased to 97% (41/42) during the follow-up period (23±19 months). Distally, at the level of the abdominal aorta, the FL remained patent in 50% (21/42) of patients. The 1- and 3-year survival was 81 and 75%, respectively. CONCLUSION: The FET technique is a feasible therapeutic option for complicated type B AD with involvement of the aortic arch if TEVAR is contraindicated. In contrast to conventional aortic surgery via a lateral thoracotomy, the FET procedure can provide simultaneous treatment of the ascending aorta and aortic arch.

Visceral organ protection in aortic arch surgery: safety of moderate hypothermia.

OBJECTIVES: Although antegrade selective cerebral perfusion (ASCP) provides good brain protection during aortic arch surgery, the issue of distal organ protection during circulatory arrest remains to be clarified. The aim of the study was to retrospectively evaluate the outcome of aortic arch surgery using ASCP at different temperatures, focusing on visceral functions (VFs). METHODS: Three hundred and thirty-four patients underwent elective aortic arch surgery using ASCP from November 1996 to March 2011. Those patients without early postoperative low cardiac output syndrome were included. VFs were evaluated by comparing preoperative and postoperative creatinine, aspartate amino transferase, alanine amino transferase and bilirubin. Univariate and multivariate analysis were performed. RESULTS: Three hundred and four patients represent the cohort of the study. Deeper systemic hypothermia (≤25°C) (Group A) was used in 194 patients (63.8%) and moderate hypothermia (>25°C) (Group B) in 110 patients (36.2%). The 30-day mortality rate was 3.6% in Group B and 5.2% in Group A (P = NS). Permanent neurological deficits occurred in 4 (3.6%) and in 14 patients (7.2%) of Group A and Group B, respectively (P = NS). Postoperative renal insufficiency requiring dialysis occurred in 6 patients (5.4%) in Group A and in 15 patients (7.7%) in Group B, the differences were not statistically significant. Biochemical markers of VFs increased in the postoperative period without differences between groups. At the multivariate analysis, cardiopulmonary bypass time >180 min (odds ratio (OR) = 2.16) was the only significant risk factor for renal dysfunction with or without liver dysfunction, while cardiopulmonary bypass time longer than 180 min (OR = 2.28) and hypothermia higher than 25°C (OR = 0.54) were found to be independently related to liver dysfunction. CONCLUSIONS: Our results confirmed that ASCP with moderate hypothermia at 26°C is a safe method for brain protection. Moreover, during circulatory arrest, moderate hypothermia also offers good protection of visceral organs and it should be preferred for limited periods (<60 min) of visceral ischaemia because it may reduce the systemic inflammatory response and the reperfusion organ injury.