Feasibility and Durability of the Modified Cabrol Coronary Artery Reattachment Technique

Redo aortic root - complexity vs simplicity with choice of device selected

INTRODUCTION

The field of cardiac surgery continues to evolve significantly and one such example of advancement is aortic root replacement. In the setting of prior cardiac surgery, operative complexity increases due to adhesions, surgically-altered anatomy, and previously implanted prosthetic graft material. Device choice plays a significant role in balancing operative complexity with achieving simplicity and optimal clinical outcomes.

AREAS COVERED

This review explores the critical considerations necessary in performing redo aortic root surgery and the impact that device selection can have on the procedural complexity and clinical outcomes. This review was formulated by a systematic identification of published and unpublished laboratory and clinical studies evaluating these technologies.

EXPERT OPINION

Redo aortic root surgery represents one of the most challenging procedures in cardiac surgery, and the choice of both surgical technique and prosthetic device used are critical factors which influence the clinical success of the operation and the long-term outcomes for patients. By understanding the unique challenges of root replacement in a reoperative setting and the characteristics of different prosthetic devices, a tailored approach must be employed toward the best possible outcomes.

Cabrol procedure and its modifications: a systematic review and meta-analysis

BACKGROUND

The Cabrol procedure has undergone various modifications and developments since its invention. However, there is a notable gap in the literature regarding meta-analyses assessing it.

METHODS

A systematic review and meta-analysis was conducted to evaluate the effectiveness and long-term outcomes of the Cabrol procedure and its modifications. Pooling was conducted using random effects model. Outcome events were reported as linearized occurrence rates (percentage per patient-year) with 95% confidence intervals.

RESULTS

A total of 14 studies involving 833 patients (mean age: 50.8 years; 68.0% male) were included in this meta-analysis. The pooled all-cause early mortality was 9.0% (66 patients), and the combined rate of reoperation due to bleeding was 4.9% (17 patients). During the average 4.4-year follow-up (3,727.3 patient-years), the annual occurrence rates (linearized) for complications were as follows: 3.63% (2.79-4.73) for late mortality, 0.64% (0.35-1.16) for aortic root reoperation, 0.57% (0.25-1.31) for hemorrhage events, 0.66% (0.16-2.74) for thromboembolism, 0.60% (0.29-1.26) for endocarditis, 2.32% (1.04-5.16) for major valve-related adverse events, and 0.58% (0.34-1.00) for Cabrol-related coronary graft complications.

CONCLUSION

This systematic review provides evidence that the outcomes of the Cabrol procedure and its modifications are acceptable in terms of mortality, reoperation, anticoagulation, and valve-related complications, especially in Cabrol-related coronary graft complications. Notably, the majority of Cabrol procedures were performed in reoperations and complex cases. Furthermore, the design and anastomosis of the Dacron interposition graft for coronary reimplantation, considering natural anatomy and physiological hemodynamics, may promise future advancements in this field.

Outcomes of Reoperative Aortic Root Replacement After Previous Acute Type A Dissection Repair

Limited aortic root repair for acute type A dissection is associated with greater risk of proximal reoperations compared to full aortic root replacement. Surgical outcomes for patients undergoing reoperative root replacement after previous dissection repair are unknown. This study seeks to determine outcomes for these patients to further inform the debate surrounding optimal upfront management of the aortic root in acute dissection. Retrospective record review of all patients who underwent full aortic root replacement after a previous type A dissection repair operation at a tertiary academic referral center from 2004-2020 was performed. Among 57 cases of reoperative root replacement after type A repair, 35 cases included concomitant aortic arch replacements, and 21 cases involved coronary reconstruction (unilateral or bilateral modified Cabrol grafts). There were 3 acute postoperative strokes and 4 operative mortalities (composite 30-day and in-hospital deaths, 7.0%). Mid-term outcomes were equivalent for patients who required arch replacement compared to isolated proximal repairs (81.8% vs 80.6% estimated 5-year survival, median follow-up 5.53 years. Reoperative root replacement after index type A dissection repairs, including those with concomitant aortic arch replacement and/or coronary reconstruction is achievable with acceptable outcomes at an experienced aortic center.