Long-term outcomes after aortic root repair using selective sinus replacement.

OBJECTIVES: The study aim was to evaluate long-term results after anatomic restoration of the aortic root. METHODS: During an 18-year period, a total of 669 patients underwent valve-sparing root repair (aneurysm 554, dissection 115) using selective sinus replacement. None/trivial, mild, moderate, and severe (grades 3+ and 4+) insufficiency were present in 57, 146, 204, and 262 patients, respectively. RESULTS: The anatomic repair was adjusted to the existing aortic annulus diameter, which was 27.0 ± 3.0 mm on average. Replacement of 1, 2, or 3 sinuses of Valsalva was performed in 209, 234, and 226 patients, respectively. Altogether, 454 additional procedures on the cusps were performed, mostly as cusp patch plasty with pericardium (210). Thirty-day mortality was 0.6%. The mean follow-up duration was 7.1 ± 4.1 years (range, 0.01-19.1 years). The estimated freedom from relevant aortic insufficiency grade 3+ or greater (15 events) was 98% ± 1%, 97% ± 1%, and 94% ± 3% at 5, 10, and 15 years, respectively. On echocardiogram, no patient revealed a considerable change of the form or size of the repaired root, which was confirmed radiologically in 160 patients who received computed tomography angiography for any reason. Multivariate logistic regression analysis identified cusp prolapse/pseudo-prolapse as the only independent risk factor for the development of recurrent insufficiency grade 2+ or greater (41 occurrences), with a hazard ratio of 3.258 (95% confidence interval, 1.658-6.403; P = .001). An association between aortic annulus size and functional results could not be demonstrated. CONCLUSIONS: Patient-tailored root repair using isolated sinus replacement offers excellent functional long-term results regardless of underlying root pathology or annulus size. Aortic cusp pathology was decisive for long-term valve function.

Selective sinus replacement for aortic root repair in bicuspid aortopathy.

OBJECTIVES: To evaluate the results after selective sinus replacement (SSR) for aortic root remodeling in bicuspid aortopathy. METHODS: Among 662 patients who underwent root repair using SSR between 2005 and 2020, there were 114 with bicuspid aortopathy. SSR was performed either as an isolated procedure (31) or as an adjunct to aortic valve repair (83) and was adjusted to the existing aortic annulus diameter rather than a downsized diameter. In valves with asymmetrical commissural orientation, the repair aimed for the achievement of a 180°-commissural orientation. RESULTS: Abolishment of aortic insufficiency (AI) ≥2+ using root repair alone was only possible in 2 patients with acute-dissection-related AI, yet isolated root repair was also performed in 29 further patients with no/mild AI. All remaining patients with AI ≥2+ presented cusp-related regurgitation and necessitated an additional valve repair. During the mean follow-up of 91 months (range, 13-196), a relevant valve defect (AI ≥3+ in 8, stenosis in 2) occurred in 10 patients (all after combined repair) resulting in an estimated freedom from a relevant aortic valve defect and/or reoperation of 96 ± 2%, 89 ± 4%, and 82 ± 6% at 5, 10, and 12 years, respectively. Echocardiographically, no patient revealed a considerable change of form or size of the repaired root nor was any root reintervention necessary. CONCLUSIONS: Patient-tailored root repair using SSR is a very effective and durable valve-sparing approach for bicuspid aortopathy. Aortic cusp repair is decisive for both abolishment of AI in bicuspid aortopathy and for the functional durability of the repaired aortic valve.

Complete closure of coronary fistula communicating with the descending aorta.

We report a rare case of complex coronary fistula that contained two aneurysms and was connected to the descending aorta. The fistula was also associated with further aortic pathologies necessitating surgery. Preoperative computed tomography angiography, which revealed an abnormal vessel communication, was crucial for choosing the appropriate operative strategy. During a one-stage procedure comprising closure of both arterial (aortic and coronary) fistula origins and repair of the aortic valve and thoracic aorta, the coronary origin of the fistula was ligated and the frozen elephant trunk technique was used to close the aortic origin.

Reoperative Aortic Arch Surgery under Mild Systemic Hypothermia: Two-Center Experience.

BACKGROUND: The aim of the study was to assess the indications, surgical strategies, and outcomes after reoperative aortic arch surgery performed generally under mild hypothermia. METHODS: Ninety consecutive patients (60 males, mean age, 55 ± 16 years) underwent open reoperative aortic arch surgery after previous cardiac aortic surgery. The indications included chronic-progressive arch aneurysm (55.5%), chronic aortic dissection (17.8%), contained arch rupture (16.7%), and graft infection (10%). The reoperation was performed through a repeat sternotomy (96%) or clamshell thoracotomy (4%) using antegrade cerebral perfusion under mild systemic hypothermia (28.9 ± 2.5°C) in all except three patients. RESULTS: The surgery comprised hemiarch or total arch replacement in 41 (46%) and 49 (54%) patients, respectively. The distal extension included classic or frozen elephant trunk technique, each in 12 patients, and total descending aorta replacement in 4 patients. Operative mortality was 6 (6.7%) among all patients, with age identified as the only independent predictor of operative mortality (p = 0.05). Permanent and transient neurologic deficits occurred in 1% and 9% of the patients, respectively. Estimated survival at 8 years was 59 ± 8% with advanced heart failure predictive for late mortality (p = 0.014). Freedom from second reoperation or intervention on the aorta was 78 ± 6% at 8 years, with most of these events occurring downstream in patients with chronic degenerative aneurysms. CONCLUSION: Aortic arch reoperations performed using antegrade cerebral perfusion under mild systemic hypothermia offer favorable operative outcomes with an exceptionally low rate of neurologic morbidity without any difference between hemiarch and complex arch procedures.

Ascending aorta replacement in patients with coronary ostia localized above the sinotubular junction.

OBJECTIVES: The study objective was to describe the technique and outcomes of original coronary ostial slide plasty in patients with anomalous coronary artery origin (ACAO) localized in the aneurysmal ascending aorta (AA) being replaced because of its isolated pathology and otherwise non-pathological aortic root. METHODS: A total of 23 patients (median age 52 years) with the ascending phenotype of proximal aorta aneurysm and ACAO of at least 1 coronary artery localized in the AA being replaced underwent ostial slide plasty to transpose the ACAO to the respective sinus of Valsalva and, consequently, to allow an AA replacement with placement of the proximal anastomosis at the level of the sinotubular junction (STJ). In 15 patients, the aortic valve was bicuspid, and all but 3 patients presented with a relevant valve defect. In addition to remodelling the STJs (all patients), valve-sparing repair or replacement was performed in 12 and 8 patients, respectively. RESULTS: No patient died during the entire follow-up (median 72, range 3-183 months). One patient required replacement of a recurrently insufficient valve that was repaired primarily using cusp patch plasty, but there were no further cardiac reoperations nor any re-interventions on the proximal aorta, aortic valve and/or coronary artery ostia. Two patients received peripheral coronary stents (8 and 7 years after surgery, respectively) due to coronary heart disease. CONCLUSIONS: Transposition of the ACAO from the replaced AA into the normal sinus of Valsalva using the ostial slide plasty offers a simple and safe surgical option enabling a recreation of a durable STJ at the level of the anastomosis between the root and the aortic graft.

Root repair in patient with huge sinus Valsalva aneurysm and severe aortic regurgitation.

Anatomical aortic root restoration in a patient with a giant aneurysm of the right Sinus of Valsalva accompanied by severe AI and compression of the right-ventricular outflow is described and the entire case series (5) is reported.

Long-term outcomes after valve-sparing anatomical aortic root reconstruction in acute dissection involving the root.

OBJECTIVES: To evaluate long-term results after valve-sparing surgery of acutely dissected aortic root in which a restoration of root anatomy adjusted to the existing aortic annulus diameter, rather than any kind of downsizing, was performed. METHODS: Among 286 consecutive patients operated on because of type A aortic dissection during the last 17 years were 100 patients (35.0%), mean age 63 ± 13 years (range, 29-88 years), in whom an anatomical restoration of the involved root was performed. Twenty-eight patients presented with severe (3+ or 4+), 37 with mild to moderate (2+), and 24 with mild (1+) insufficiency. In 5 patients, the valve was bicuspid. In all patients, a curative root repair with replacement of all dissected aortic wall was performed, containing a selective replacement of pathologic/dissected aortic sinuses, which were 1, 2, or all 3 sinuses in 62, 32, and 6 patients, respectively. Concomitant cusp repair was necessary in 18 patients. RESULTS: Thirty-day mortality was 1.0%. Survival was estimated starting with surgery and was 89.4 ± 3.4% (95% confidence interval, 80.5-94.4) and 68.8 ± 6.4% (95% confidence interval, 54.4-79.5) at 5 and 12 years, respectively. No patient required reoperation on the aortic root and/or valve during the follow-up period of 70 ± 50 (range, 3-202) months. A freedom from any aortic valve/root reintervention and/or relevant (>2+) aortic insufficiency at 12 years was 100%. CONCLUSIONS: Selective replacement of pathologic sinuses offers an anatomophysiological albeit curative restoration of acutely dissected aortic root resulting in excellent and durable outcomes in selected patients with acute aortic dissection.

Efficacy of unilateral cerebral perfusion for brain protection in aortic arch surgery.

OBJECTIVES: The aim of the study was to evaluate the surgical and neurological outcomes after aortic arch surgery using unilateral cerebral perfusion. METHODS: Between June 2004 and February 2017, a total of 1000 patients (mean age 63 ± 12; range, 14-88 years) with nonacutely dissected aortic pathology (aneurysm, porcelain aorta, chronic dissection, infection, and injury in 89.1%, 4.9%, 4.1%, 1.6%, and 0.3%, respectively) underwent aortic arch surgery using unilateral cerebral perfusion for brain protection using mild hypothermia. A previous neurological event with residuals was documented in 3.6% of the patients and 12.2% had received previous cardiovascular surgery. The surgery comprised total/subtotal arch repair (with involvement of at least 1 supra-aortic artery) or hemiarch replacement in 346 and 654 patients, respectively. The aortic valve was replaced in 521 (including 190 valve composite grafts) and repaired in 380 patients (284 valve-sparing root repairs). RESULTS: The unilateral cerebral perfusion (mean duration 23.3 ± 17.2; range, 6-105 minutes) was performed via cannulated common carotid or innominate artery and aimed for a pressure-controlled (70-100 mm Hg) flow (mean flow, 1.4 ± 0.3 L/min; mean pressure, 90.1 ± 20.1 mm Hg) at a constant blood temperature of 28°C for ensuring the patency of collateral pathways. The circulatory arrest of the lower body (mean duration 18.4 ± 9.9 minutes) was performed at a rectal temperature of 31.2 ± 1.8°C. Early (30-day) and in-hospital mortality was 1.3% and 2.1%, respectively; the rates of permanent neurological deficit and transient neurological dysfunctions were 1.0% and 4.9%, respectively. CONCLUSIONS: Unilateral cerebral perfusion performed in the described conditions is highly effective for cerebral protection in aortic arch surgery.

Innominate artery pathology in the setting of aortic arch surgery: incidences, surgical considerations and operative outcomes.

OBJECTIVES: The aim of the study was to evaluate the incidences of innominate artery (IA) involvement in aortic arch pathology necessitating surgery, the surgical strategies and the operative results. METHODS: Among the 366 patients who underwent total/subtotal arch replacement because of non-acutely dissected aortic pathology between 2004 and June 2017, there were 46 (12.6%) patients (29 males; mean age 69 ± 10, range 35-84 years) with IA involvement. Pathologies necessitating replacement of the IA were chronic aneurysm including progression of chronic dissection, severe atherosclerosis with or without an aneurysmatic dilatation, and inflammatory vasculitis in 34, 11 and 1 patient, respectively. All data were collected prospectively, and intention-to-treat analysis was performed. RESULTS: All patients underwent total/subtotal aortic arch replacement using unilateral cerebral perfusion (mean duration 44.6 ± 15.7 min) under mild hypothermia (30.6 ± .4°C). In addition to arch and IA replacement, repair of one or two further supra-aortic arteries was performed in 20 and 23 patients, respectively. One patient underwent complete thoracic aorta replacement via clamshell thoracotomy. The aortic valve, which was the most frequent object of concomitant surgery, was replaced in 18 (including 3 valve composite-grafts) and repaired in 20 (18 valve-sparing root repairs) patients. Early (30-day and/or in-hospital) mortality was 0. The rate of permanent neurological deficit was 2.2% (1 patient with a huge, partially thrombosed arch and innominate aneurysm). Transient neurological dysfunctions such as agitation were observed in 6 patients. CONCLUSIONS: Involvement of the IA in aortic arch surgery is not infrequent, and its concomitant replacement using well-considered cannulation, perfusion and surgical strategy offers excellent operative outcomes.

Operative and Long-Term Outcomes After Curative Repair of Acute Dissection Involving the Proximal Aorta.

BACKGROUND: The aim of the study was to evaluate operative and long-term results after acute type A aorta dissection (AAAD) operation, in which complete resection of all dissected aortic segments (curative repair) was achieved. METHODS: Among 205 consecutive patients operated on between 2002 and 2014 because of AAAD were 88 patients (42.9%), in whom the dissection did not extend into the downstream aorta. The distal extension of the dissection ended before the origin of the innominate artery in 50 patients of the study cohort (56.8%) or extended throughout the arch, necessitating a total/subtotal arch replacement to achieve a curative distal repair in 38 remaining patients (43.2%). The aortic root was involved in 52 patients (59.1%) and was repaired using valve-sparing repair (31) or replacement with a valve composite graft (21). Combination of root and open arch surgery was reported in 46 patients (52.3%). RESULTS: Thirty-day and in-hospital mortalities were 3.4% and 5.7%, respectively. Survival was estimated starting with the operation and was 81.9% ± 4.5% and 56.6% ± 8.7% at 5 and 10 years, respectively. No patient required reoperation on the aortic root and/or distal thoracoabdominal aorta; however 2 cardiac reoperations were unrelated to the primary surgical procedure. Moreover, the freedom of aortic and/or sudden/unknown death was 100%. CONCLUSIONS: Curative aortic repair can be achieved in a relevant share of AAAD patients and is mostly limited by the distal extension of dissection. This kind of repair is advisable, whenever possible, because it can provide very low risk of aortic complications and/or reoperations over time.

Does anatomical completeness of the circle of Willis correlate with sufficient cross-perfusion during unilateral cerebral perfusion?

OBJECTIVES: The aim of the study was to evaluate the role of anatomical completeness of the circle of Willis for sufficient brain perfusion during unilateral cerebral perfusion and the methodology of the preoperative and intraoperative functional assessments of adequate cross-perfusion. METHODS: This prospective observational study included all elective patients (99) who underwent elective open arch surgery (hemiarch in 74 and arch replacement in 25 patients, respectively) at our institution between September 2004 and September 2006. Preoperative neuro-vascular evaluation included color-coded duplexsonography of the extracranial arteries, cranial CT angiography, and transcranial sonography. A functional test of cerebral cross-perfusion was performed during cross-clamping of the common carotid artery during cannulation by transcranial Doppler, electroencephalography and measurement of somatosensory evoked potentials. These examinations, which were completed through measurement of arterial pressure in both radial arteries, also served as an intraoperative assessment of cerebral perfusion during surgery. During mild hypothermic (30 degrees C) circulatory arrest with a mean duration of 18 min (range, 7-70) brain protection using unilateral cerebral perfusion was performed in all patients. RESULTS: As assessed in preoperative CT angiography, the circle of Willis was complete in only 59 patients. Eighteen patients showed a singular abnormal location within the circle of Willis, 13 patients presented with abnormalities within the posterior communicating arteries on both sides, and 9 patients within the anterior and posterior communicating arteries. Nevertheless, functional tests during carotid artery cross-clamping as well as intraoperative cerebral monitoring including transcranial Doppler showed no pathology in any patient, and only one patient with severe aortic valve calcification suffered from embolic minor stroke after surgery. CONCLUSIONS: The anatomical status of the circle of Willis assessed with cranial CT angiography does not correlate with functional and intraoperative tests examining the cerebral cross-perfusion. The authors do not recommend cranial CT angiography as a preoperative standard examination before open arch surgery in which unilateral cerebral perfusion is scheduled.

Importance of accurately locating the entry site for endovascular treatment of retrograde Type A acute aortic dissection.

OBJECTIVES: The aim of this study was to evaluate the diagnostic possibilities of accurately locating the entry site in acute retrograde Type A aortic dissection and the results of the corresponding endovascular treatments. METHODS: Among 100 patients who underwent surgery for the treatment of spontaneous acute Type A aortic dissection between 2012 and June 2017, all but 1 patient had preoperative computed tomographic angiography. A total of 8 retrograde extensions originated from the descending aorta, in which 6 of them were diagnosed correctly using radiological imaging. The surgical team was unable to properly diagnose the entry site using radiological imaging in only 1 patient, and no preoperative computed tomographic-angiographic scans were available for 1 other patient. In the latter case, the retrograde dissection was diagnosed intraoperatively and confirmed by postoperative computed tomographic angiography. RESULTS: In 5 patients, a tear-oriented endovascular repair was performed based on preoperative radiological findings. In the remaining 3 patients, conventional surgery of the proximal aorta was performed because of the clinical situation (e.g. aortic insufficiency, pericardial effusion) and/or diagnostic uncertainty. One patient subsequently underwent an endograft successfully. All patients survived surgery and were alive at the last follow-up; however, complete remodelling of the thoracic aorta was evident in only patients with endovascular repair. CONCLUSIONS: Tear-oriented endovascular repair of acute Type A aortic dissection originating from the descending aorta seems to be a valuable and durable therapeutic option. However, the determination of the entry site in the descending aorta is a prerequisite for this type of treatment. Therefore, the surgical team should consider a diagnostics based on modern, sophisticated radiological methods.

Reconstructive aortic valve surgery in the elderly: Techniques and outcomes.

OBJECTIVES: The aim of the study was to evaluate operative techniques and long-term results after aortic valve or root repair in patients aged 75 years or more. METHODS: Between November 2002 and January 2016, a total of 815 patients underwent aortic valve or root repair. Among them were 100 patients aged 75 years or more (mean, 78 ± 3; range, 75-88 years), including 17 patients operated on an emergency basis because of acute aortic dissection. None/trivial, mild, moderate, and severe insufficiency grades were presented in 9, 23, 27, and 41 patients, respectively. The surgery comprised root repair, cusp repair, and a combination of both in 45, 16, and 39 patients, respectively. RESULTS: Early (30-day) mortality and the rate of permanent neurologic deficit were 2% for each. The follow-up was 99% complete, resulting in 427 patient/years. During the follow-up period (mean duration, 4.3 ± 3.2; range, 0.02-11.1 years), only 1 patient developed a relevant aortic insufficiency and required aortic valve reoperation. There were 24 late deaths, which occurred on average 50.0 ± 40.6 months (range, 2.4-135.0) after surgery at the average patient age of 82 ± 5 years (range, 75-90). Estimated survival at 5 and 8 years was 76.4% ± 5.1% and 71.3% ± 5.9%, respectively, and was similar to those of the sex- and age-matched general population. CONCLUSIONS: Reconstructive aortic valve surgery is a suitable and justifiable surgical option in selected elderly patients undergoing operation by surgeons with considerable experience in this kind of surgery. It offers low cardiac and valve-related mortality and morbidity, leading to life expectancy applicable to the patients' ages.

Patient-tailored aortic root repair in adult marfanoid patients: Surgical considerations and outcomes.

OBJECTIVE: The aim of the study was to evaluate the operative and functional results after individual, patient-tailored aortic root repair in marfanoid patients. METHODS: Among 518 patients who underwent operation between 2002 and January 2016, using patient-tailored aortic root repair with isolated sinus replacement, 42 patients fulfilled the original Ghent criteria. None/trivial, mild, moderate, and severe insufficiency grades were present in 5, 16, 10, and 11 patients, respectively. RESULTS: The repair was adjusted to the existing aortic annulus diameter. Replacement of 1, 2, or 3 sinuses of Valsalva was performed in 1, 14, and 27 patients, respectively. Concomitant cusp repair was performed in 17 patients (40.5%), and 10 patients (23.8%) underwent arch repair (total in 3). All patients survived surgery, and the follow-up (mean, 6.1 ± 3.1; range, 0.8-14.2 years) was 100% complete. No patient had a change in the form or size of the aortic neo-root, especially the size of aortic annulus and sinotubular junction during the follow-up time. No and trivial/mild insufficiency were present in 22 and 18 patients, respectively, and 2 patients with recurrent aortic insufficiency caused by cusp pathology underwent aortic valve replacement 43 and 66 months after the primary surgery, respectively. Thus, the estimated survival free from aortic valve/root reoperation for any reason at 5 and 8 years was 96.8% ± 3.2% and 91.4% ± 6.0%, respectively. CONCLUSIONS: Patient-tailored root repair using isolated sinus replacement is an effective and durable method of valve-sparing repair in select marfanoid patients with a satisfactory quality of aortic cusps, which seems to be decisive for long-term valve function.

Bentall procedure after previous aortic valve or complete root replacement: Usefulness of self-assembled aortic valve conduit.

OBJECTIVES: The aim of this study was to evaluate surgical results of complete aortic root replacement using self-assembled valve composite graft in the setting of destroyed aortic annulus after previous valve replacement. METHODS: Aortic root pathology being addressed by complete root replacement was combined with partial or complete absence of annular tissue in 112 consecutive patients. Eighty-eight had undergone a previous replacement of the aortic valve and 24 had undergone root replacement with a valved conduit. Altogether, 31 patients (27.7%) presented with acute endocarditis, which was the indication for surgery in 75% of patients with prior root replacement. In all patients, the root replacement or re-replacement was performed with a self-assembled valved conduit using mechanical (n = 74) or, in patients with an advanced age, biological (n = 38) valve prostheses. RESULTS: In-hospital mortality was 11.6%, including a 30-day mortality of 6.3%. Resternotomy for bleeding was necessary in 5.4% of patients and about one-quarter did not need any blood transfusion. Estimated survival at 1, 5, and 10 years was 84.8% ± 3.4%, 75.7% ± 4.3%, and 57.1% ± 6.5%, respectively. Freedom from any valve-related events at 10 years was 86.2% ± 4.1%. During the follow-up time (mean, 63 ± 47 months), there was only 1 reoperation necessary 9 years after surgery (replacement of deteriorated biological valve prosthesis within the vascular tube leaving the conduit untouched). CONCLUSIONS: A self-assembled composite graft allows safe proximal fixation of the conduit in patients with destroyed aortic annulus, resulting in sufficient proximal anastomosis and a very low incidence of aorta-related reoperations.

Aortic events and reoperations after elective arch surgery: incidence, surgical strategies and outcomes.

OBJECTIVES: The true incidence of aortic events (AEs) and reoperations (REDO) following elective total aortic arch replacement remains unknown. The aim of this study was to review the incidence of AEs and surgical REDO, and its respective outcomes after 1232 elective arch repairs at 11 European aortic centres. METHODS: Retrospective chart review (in the absence of prospective data collection) was performed for statistical analysis. Follow-up was conducted during routine clinical examination or in a telephone interview with patients and/or their respective physicians. RESULTS: One hundred fifty-five (12.6%) patients were identified (median follow-up time 48.7 months). The recorded AEs comprised aortic dilatation (62.6%), rupture (15.5%), endoleak (11%), false aneurysm (3.9%), dissection (3.2%), infection (2.6%) and others (1.3%). REDO (open/endovascular) were performed in 85.8% of patients (n = 133). Intraoperative and in-hospital mortality in the REDO patients were 7.5% and 17.3%, respectively. Postoperative neurological complications comprised paraplegia (6.0%) and stroke (1.5%). Survival rates after REDO at 1, 3 and 5 years were 81.2%, 79.0% and 76.7%, respectively. Univariate analysis identified 'rupture' and 'diameter progression', 'older age at REDO' and the REDO strategies 'frozen elephant trunk' and 'no elephant trunk' as predictors of increased in-hospital mortality. Multivariate analysis identified 'older age at REDO' (P = 0.008) as the only independent risk factor for in-hospital mortality. CONCLUSIONS: AEs after elective arch surgery are not irrelevant and mostly involve the distal aspects of the adjoining aorta. In accordance with the underlying pathology, open or endovascular REDO may be performed with an acceptable outcome. Preparation of an adequate proximal landing zone at the time of primary arch surgery is advisable.