Patch Neointima Technique in Acute Type A Aortic Dissection: Midterm Results of 147 Cases

Surgical management of the aortic root in acute type A aortic dissection: A comparative analysis

BACKGROUND

This study aimed to assess the early- and mid-term outcomes of aortic root repair and replacement, and to provide evidence to improve root management in acute type A aortic dissection (AAAD).

METHODS

This study enrolled 455 patients who underwent AAAD root repair (n = 307) or replacement (n = 148) between January 2016 and December 2017. Inverse probability of treatment weighting (IPTW) method was used to control for treatment selection bias. The primary outcomes were in-hospital mortality, mid-term survival, and proximal aortic reintervention.

RESULTS

The success rate of root repair was 99.7%. The in-hospital mortality in the conservative root repair (CRR) and aggressive root replacement (ARR) were 8.1% and 10.8%. The median follow-up time was 67.76 months (IQR, 67-72 months). After adjusting for baseline factors, there was no significant differences in mid-term survival (p = .750) or the proximal aortic reintervention rate (p = .550) between the two groups. According to Cox analysis, age, hypertension, severe aortic regurgitation, CPB time, and concomitant CABG were all factors associated with mid-term mortality. Regarding reintervention, multivariate analysis identified renal insufficiency, bicuspid aortic valve, root diameter ≥ 45 mm, and severe aortic regurgitation as risk factors, while CRR did not increase the risk of reintervention. The subgroup analysis revealed heterogeneity in the effects of surgical treatment across diverse populations based on a variety of risk factors.

CONCLUSIONS

For patients with AAAD, both CRR and ARR are appropriate operations with promising early and mid-term outcomes. The effects of treatment show heterogeneity across diverse populations based on various risk factors.

Mid-term outcomes of total neointima implantation in surgical repair of acute type A aortic dissection

Total neointima implantation (patch neointima technique + triple-branched stent graft placement) has been performed in proximal aortic repair for acute type A aortic dissection (ATAAD) for more than 10 years at a center. However, there is no report on the mid-term outcomes with a control group of the surgical procedure. Consequently, the authors aimed to evaluate the safety and efficacy of this technique in this study. Patients who underwent the total neointima implantation were classified as Group A, and those who underwent the conventional aortic root reconstruction with the "sandwich" technique and the total aortic arch replacement were classified as Group B. Furthermore, the authors described the preoperative characteristics, operative data, and patient outcomes. Group A patients experienced a shorter surgery duration, lower volumes of perioperative bleeding, and fewer red blood cell transfusions. The incidence of neurological complications was significantly reduced in Group A. All patients maintained a normal range of proximal aortic sizes after surgery. Kaplan-Meier analysis revealed no significant differences between the patients in the two groups regarding cumulative mortality and the incidence of moderate-to-severe aortic insufficiency. In well-selected patients, total neointima implantation is an alternative procedure for the surgical repair of ATAAD.

Time-of-day discrepancy for the long-term surgical outcome of patients with aortic dissection

OBJECTIVES

It has been suggested that the time of day when cardiovascular surgery is performed may affect the surgery outcomes. This study investigated whether there was a difference in risk-adjusted mortality and morbidity outcomes between patients undergoing acute aortic dissection (AAD) during the day or the night.

METHODS

Consecutive patients who had undergone Stanford A AAD surgery were enrolled between 2016 and 2020. In the daytime group, surgery was performed between 08:00 and 20:00, and in the nighttime group between 20:00 and 8:00. The primary outcome was in-hospital overall mortality, and the secondary outcomes were overall mortality within a median follow-up time of 35.2 (17.0, 53.5) months and the occurrence of re-entry tears and major bleeding.

RESULTS

A total of 925 patients were enrolled. The primary outcome of in-hospital overall mortality did not differ significantly between patients who received daytime or nighttime surgery. Similarly, the secondary outcomes of overall mortality during the follow-up and incidence of re-entry tears and major bleeding did not differ significantly between the groups. Subgroup analysis was also performed according to the surgery type (modified triple-branched stent graft implantation or frozen elephant trunk implantation) and surgical approach (partial upper sternotomy or full median sternotomy) confirming that the time of surgery did not significantly influence the outcomes. Cox regression analysis showed that time from onset to admission (P = 0.036) and time from the onset to surgery (P = 0.045) were significant risk factors for increased mortality during follow-up.

CONCLUSIONS

The time of day when thoracotomy was performed did not significantly affect the clinical outcome and is therefore not a consideration for the improvement of outcome in Stanford A AAD patients.

Surgical outcomes associated with partial upper sternotomy in obese aortic disease patients

Background

Excellent partial upper sternotomy outcomes have been reported for patients undergoing aortic surgery, but whether this approach is particularly beneficial to obese patients remains to be established. This study was developed to explore the outcomes of aortic surgical procedures conducted via a partial upper sternotomy or a full median sternotomy approach in obese patients.

Methods

We retrospectively examined consecutive acute type A aortic dissection patients who underwent aortic surgery in our hospital between January 2015 to January 2021. Patients were divided into two groups based on body mass index: ‘non-obese’ and ‘obese’. We then further stratified patients in the obese and non-obese groups into partial upper sternotomy and full median sternotomy groups, with outcomes between these two sternotomy groups then being compared within and between these two body mass index groups.

Results

In total, records for 493 patients that had undergone aortic surgery were retrospectively reviewed, leading to the identification of 158 consecutive obese patients and 335 non-obese patients. Overall, 88 and 70 obese patients underwent full median sternotomy and partial upper sternotomy, respectively, while 180 and 155 non-obese patients underwent these respective procedures. There were no differences between the full median sternotomy and partial upper sternotomy groups within either BMI cohort with respect to preoperative baseline indicators and postoperative complications. Among non-obese individuals, the partial upper sternotomy approach was associated with reduced ventilation time (P = 0.003), shorter intensive care unit stay (P = 0.017), shorter duration of hospitalization (P = 0.001), and decreased transfusion requirements (Packed red blood cells: P < 0.001; Fresh frozen plasma: P < 0.001). Comparable findings were also evident among obese patients.

Conclusions

Obese aortic disease patients exhibited beneficial outcomes similar to those achieved for non-obese patients via a partial upper sternotomy approach which was associated with significant reductions in the duration of intensive care unit residency, duration of hospitalization, ventilator use, and transfusion requirements. This surgical approach should thus be offered to aortic disease patients irrespective of their body mass index.

Mid-term outcomes of modified valve-sparing aortic root replacement versus the Bentall procedure for middle-aged Chinese patients with acute DeBakey I aortic dissection: a single-center retrospective study

Background

The mid-term and long-term efficacies of valve preservation in acute DeBakey I aortic dissection (AD) are controversial. Thus, it is unclear whether middle-aged patients with acute DeBakey I AD should undergo modified valve-sparing procedures or the Bentall procedure in an emergency setting.

Methods

This study included 213 middle-aged Chinese patients (under 60 years old) who were treated for acute DeBakey I AD between January 2009 and June 2015. The treatments involved modified valve-sparing aortic root replacement (VSARR) (117 patients) or the Bentall procedure (96 patients). Preoperative, intraoperative, postoperative, and follow-up data were analyzed. Echocardiography and thoracoabdominal computed tomography angiography (CTA) findings were reviewed at 3 months, 1 year, and then annually after surgery.

Results

No significant differences were observed in terms of the preoperative, intraoperative, in-hospital mortality, and postoperative parameters. There were also no significant differences in aortic regurgitation (AR). However, follow-up examinations using CTA revealed that 6 patients had endoleakage at the distal end of the triple-branched stent (0/110 patients [0.0%] vs. 6/90 patients [6.7%], P = 0.022). The anticoagulation-related thromboembolism/bleeding events was significantly lower in group A than in group B (0/110 patients [0.0%] vs. 11/90 patients [11.1%], P = 0.001). And postoperative aortic valve re-operation rate was significantly lower in group A (1/110 patients [0.9%] vs. 8/90 patients [8.9%], P = 0.020). There was no significant difference in survival during the follow-up period (log-rank P > 0.05).

Conclusion

For middle-aged patients with acute DeBakey I AD, VSARR were associated with a lower rate of endoleakage at the distal end of the triple-branched stent, thromboembolism/bleeding events and aortic valve re-operation (vs. the Bentall procedure).