Aortic Arch Management During Acute and Subacute Type A Aortic Syndromes

Total Arch Replacement is Safe as Hemiarch Repair in Acute Type A Aortic Dissection in a Middle-Income Country Setting

OBJECTIVER

The aim of this study was to determine the clinical outcomes of patients with acute type A aortic dissection comparing proximal aortic repair vs. total arch replacement.

METHODS

This was a retrospective cohort study. We included all acute type A aortic dissection procedures from January 2002 to November 2022. Groups were defined according to the extent of aortic replacement (hemiarch repair vs. total arch replacement). We collected data from pre, intra, and postoperative variables. Our main endpoints were stroke rate, spinal cord injury, and in-hospital mortality. We performed a statistical analysis for between-group comparisons according to the nature and distribution of variables. Bivariate analyses were done using the Mann-Whitney U test and for categorical variables, the Chi-square test or Fisher's exact test. Significance was established at alpha level of 0.05.

RESULTS

We identified 107 acute type A aortic dissection procedures (69 hemiarch repairs vs. 38 total arch replacements). There were no differences in postoperative outcomes such as surgical site infection or acute kidney injury. Bleeding reoperation was more frequent in the hemiarch group (30% vs. 11 %). We did not find statistically significant differences in stroke rate, spinal cord injury, or in-hospital mortality.

CONCLUSION

Acute type A aortic dissection treatment is still a challenge. Total arch replacement does not increase the risk of major early postoperative complications in comparison to hemiarch repair. The extended repair seems to provide benefits such as a lower risk of reoperation. Total arch replacement should be performed in selected patients, as it may improve long-term outcomes.

Valve-sparing aortic root replacement in resternotomy settings

OBJECTIVES

Although valve-sparing aortic root replacement (VSRR) has demonstrated satisfactory outcomes, its utility in reoperative sternotomy settings remains uncertain. This study evaluates the perioperative safety and long-term durability of reoperative sternotomy VSRR.

METHODS

All consecutive VSRR procedures at 2 centers from 2005 to 2020 were included. Reoperative VSRR was defined as prior sternotomy for any reason. Time-dependent outcomes were compared between groups after balancing of covariates with inverse probability of treatment weighting. Multivariable Cox regression and the Fine-Gray subdistribution hazard model were used to identify factors associated with 10-year survival and aortic valve reintervention, respectively.

RESULTS

Of 778 VSRR procedures, 69 (8.9%) were reoperative sternotomies. Compared with primary, patients undergoing reoperative VSRR were younger (age 43 years [range, 34-54 years] vs age 51 years [range, 39-61 years]; P < .001) and had less aortic insufficiency (33.3% vs 48.5%; P = .02). Cardiopulmonary bypass times were longer in reoperative VSRR with similar rates of circulatory arrest. Reoperative VSRR had a higher incidence of postoperative acute kidney injury (10.1% vs 3.2%; P = .01) and prolonged ventilation (24.6% vs 9.9%; P < .001); operative mortality was higher in reoperative VSRR (2.9% [2 out of 69] vs 1.4% [10 out of 709]) although not significantly (P = .66). Ten-year survival was 82.0% (range, 70.0%-96.0%) and aortic valve reintervention rate was 11.8% (range, 2.3%-19.4%) after reoperative VSRR. After inverse probability of treatment weighting adjustment, survival and aortic valve reintervention rates were not different. Reoperative sternotomy was not associated with long-term mortality (P = .13) or aortic valve reintervention (P = .77) on multivariable analysis.

CONCLUSIONS

Although complex, reoperative sternotomy VSRR can be performed with low operative mortality in carefully selected patients. Ten-year survival and aortic valve reintervention rates were acceptable and comparable to primary VSRR.

Outcomes of hemi- vs. total arch replacement in acute type A aortic dissection: A systematic review and meta-analysis

Background

Acute type A aortic dissections (ATAAD) pose a challenge to surgeons due to high mortality, and decision making regarding the appropriate procedure is controversial. This study compared the outcomes of hemiarch and total arch replacement for ATAAD.

Methods

The PubMed, Web of Science, Embase and Cochrane databases were searched for comparative studies on hemiarch versus total arch replacement that were published before May 1, 2022.

Results

We included 23 observational studies with a total of 4,576 patients. Combined data analysis showed that early mortality (RR = 0.82; 95% CI: 0.70–0.97; P = 0.02), incidence of postoperative permanent neurological dysfunction (RR = 0.72; 95%CI:0.54∼0.94; P = 0.02), and incidence of renal failure and dialysis (RR = 0.82; 95%CI:0.71∼0.96; P = 0.01) were all lower for hemiarch than for total arch replacement. However, hemiarch replacement had a higher rate of late mortality (RR = 1.37; 95%CI:1.10∼1.71; P = 0.005). There were no statistically significant differences between the two groups in terms of re-operation for bleeding, aortic re-operation, or postoperative pneumonia.

Conclusion

In this study, hemiarch replacement had better early outcomes but a higher late mortality rate than total arch replacement. Decisions regarding the extent of arch repair should be made according to location and extent of ATAAD and the experience of surgeons to ensure the most favorable prognosis.

Systematic review registration:

[INPLASY.COM], identifier [INPLASY202250088].

Acute renal failure after acute type A aortic dissection repair. Insidious postoperative complication with poor short- and long-term prognosis

Acute type A aortic dissection (ATAAD) is a life-threatening aortic disease. Many systems and organs are affected by malperfusion which presents preoperatively and postoperatively. Postoperative acute renal failure after ATAAD constitutes a severe and insidious complication. Acute renal damage is observed in many patients with ATAAD preoperatively and it burdens the renal function postoperatively. Renal replacement therapy represents an additional risk factor for short-, mid-, and long-term outcomes after ATAAD repair. Brown et al.'s present study highlight the clinical significance of this complication. Also, they remind us of the importance of optimizing perioperative renal protective strategies in patients undergoing ATAAD repair.