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Karianna Milewski RC, Habertheuer A, Bavaria JE, Suhail M, Siki M, Hu R, Freas MA, Ram C, Nanduri A, Szeto WY, Vallabhajosyula P. Long-term outcomes of aortic root procedures for heterogenous ascending aneurysm disease in bicuspid aortic valve syndrome. J Thorac Cardiovasc Surg 2024; 167:2063-2075.e4. [PMID: 36631305 DOI: 10.1016/j.jtcvs.2022.09.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/13/2022] [Accepted: 09/17/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Surgery for ascending aneurysms in bicuspid aortic valve syndrome primarily includes Bentall root replacement, aortic valve replacement with supracoronary ascending aorta replacement (AVRSCAAR), and valve-sparing root reimplantation (VSRR). Comparative analysis of long-term clinical and functional outcomes of these procedures is detailed. METHODS From 1997 to 2017, 635 patients with bicuspid aortic valve undergoing root complex-focused procedures electively were stratified by valvulopathy (ie, aortic stenosis vs aortic insufficiency) and substratified into ascending or root aneurysm phenotype. Inverse probability weights were calculated to adjust for baseline differences. RESULTS Kaplan-Meier curves for all-cause mortality demonstrated no difference between Bentall versus AVRSCAAR for aortic stenosis and aortic insufficiency presentations (log-rank P > .05). In patients with aortic stenosis, multivariable Cox regression showed significantly decreased risk of stroke for biologic AVRSCAAR (hazard ratio, 0.04; P = .013). Aortic reoperation rates were similar for biologic versus mechanical valves (P = .353). In patients with aortic insufficiency, similar long-term mortality (hazard ratio, 0.95; P = .93), but lower stroke risk in biologic AVRSCAAR group by Cox regression, and lower aortic reoperation rate was noted (coefficient < 0.01; P < .001). Comparing Bentall to VSRR, mortality (hazard ratio, 0.12; P = .022) was significantly improved in patients undergoing VSRR, but recurrence of moderate or greater aortic insufficiency was higher in VSRR by multistate model (beta coefficient 2.63; P < .001). CONCLUSIONS A tailored approach to heterogeneous ascending aneurysm pathologies in bicuspid aortic valve syndrome utilizing Bentall, AVRSCAAR, and VSRR procedures renders excellent long-term clinical and functional outcomes, with biologic conduits showing equivalent to improved clinical outcomes.
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Affiliation(s)
- Rita Carrie Karianna Milewski
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Conn; Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Andreas Habertheuer
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa; Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Maham Suhail
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Mary Siki
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Robert Hu
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Melanie A Freas
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Chirag Ram
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Ananya Nanduri
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Conn; Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa.
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Ogami T, Serna-Gallegos D, Yousef S, Brown JA, Thoma FW, Subramaniam K, Gelzinis TA, Bonatti JO, Kaczorowski DJ, Yoon PD, Chu D, Sultan I. The Clinical Significance of Unplanned Coronary Artery Bypass Grafting in Aortic Root Replacement. J Cardiothorac Vasc Anesth 2024; 38:918-923. [PMID: 38307738 DOI: 10.1053/j.jvca.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/24/2023] [Accepted: 01/01/2024] [Indexed: 02/04/2024]
Abstract
OBJECTIVES Unexpected coronary artery bypass grafting (CABG) is occasionally required during aortic root replacement (ARR). However, the impact of unplanned CABG remains unknown. DESIGN A single-center, retrospective observational study. SETTING At university-affiliated tertiary hospital. PARTICIPANTS All patients who underwent ARR from 2011 through 2022. INTERVENTIONS Aortic root replacement with or without unplanned CABG. MEASUREMENTS AND MAIN RESULTS A total of 795 patients underwent ARR. Among them, 131 (16.5%) underwent planned concomitant CABG, and 34 (4.3%) required unplanned CABG. The most common indication of unplanned CABG was ventricular dysfunction (33.3%), followed by disease pathology (25.6%), anatomy (15.4%), and surgical complications (10.3%). A vein graft to the right coronary artery was the most commonly performed bypass. Infective endocarditis and aortic dissection were observed in 27.8% and 12.8%, respectively. Prior cardiac surgery was seen in 40.3%. The median follow-up period was 4.3 years. Unplanned CABG was not associated with operative mortality (odds ratio [OR] 1.54, 95% CI 0.33-7.16, p = 0.58) or long-term mortality (hazard ratio 0.91, 95% CI 0.44-1.89, p = 0.81). Body surface area smaller than 1.7 was independently associated with an increased risk of unplanned CABG (OR 4.51, 95% CI 1.85-11.0, p < 0.001). CONCLUSIONS Unplanned CABG occurred in 4.3% of patients during ARR, but was not associated with operative mortality or long-term mortality. A small body surface area was a factor associated with unplanned CABG.
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Affiliation(s)
- Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Floyd W Thoma
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kathirvel Subramaniam
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Theresa A Gelzinis
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Johannes O Bonatti
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Pyongsoo D Yoon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA.
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3
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024:S0003-4975(24)00077-8. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
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4
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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Haider Jeoffrey SM, Zafar MA, Velasco J, Khattak A, Ellauzi H, Nasir A, Kalyanasundaram A, Ziganshin BA, Elefteriades JA. Midterm follow-up of composite graft replacement of the aortic root (30-year experience)-remarkably safe, effective, and durable. JTCVS OPEN 2024; 17:1-13. [PMID: 38420531 PMCID: PMC10897671 DOI: 10.1016/j.xjon.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 10/26/2023] [Accepted: 11/09/2023] [Indexed: 03/02/2024]
Abstract
Objectives Contemporary operative choices for aortic root disease include aortic root replacement (ARR) and a variety of valve-sparing and aortic root-repair procedures. We evaluate ultra-long-term outcomes of ARR, focusing on survival, freedom from late reoperation, and adverse events. Methods Prospectively kept records were used to accomplish long-term follow-up of patients who underwent ARR (4-pronged Yale survival assessment paradigm). Results Between 1990 and 2020, 564 patients underwent ARR (mean 56 years, 84% male). A modified Cabrol procedure (Dacron coronary graft) was employed in 9.0% (51/564) and concomitant coronary artery bypass grafting in 9.4% (53/564). There were 12.8% (72/564) urgent/emergent and 7.4% (42/564) redo procedures. Operative mortality occurred in 12 patients (2.1%) overall, or 1.4% (8/554) of nondissection and 1.3% (6/468) of elective first-time operations. Six of the 12 deaths presented with acute type A dissection, urgent operation, or reoperative states. Operative mortality dropped to 0.6% during the past 10 years. In total, 11 patients developed endocarditis. Stroke occurred in 11 of 564 patients (2.0%), 4 of whom had presented with type A dissection. Late events included bleeding in 2.8% (16/564), thromboembolism in 1.4% (8/564), and reoperation of the root in 5 of 564 (0.9%) at 15 years and more distal aortic segments in 16/564 (2.8%). Survival was no different from age/sex-matched controls. Conclusions This ultra-long-term experience finds ARR to be extraordinarily safe, effective, and durable, with minimal long-term bleeding, thromboembolism, or graft failure. This experience provides a standard of durability for ARR against which ultra-long-term outcomes with alternate procedures (valve-sparing, Ross, other) may be compared.
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Affiliation(s)
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Juan Velasco
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Ahad Khattak
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Hesham Ellauzi
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Afsheen Nasir
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Asanish Kalyanasundaram
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
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6
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Werner P, Kuscu BS, Coti I, Puchner S, Loewe C, Schmaranzer F, Ad N, Laufer G, Andreas M, Ehrlich M. Aortic root geometry following composite valve graft implantation: Implications for future valve-in-valve procedures. J Thorac Cardiovasc Surg 2023; 166:1635-1643.e1. [PMID: 37263524 DOI: 10.1016/j.jtcvs.2023.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/28/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Biological composite valve grafts (CVGs) are being performed more frequently, which increases the need for interventions treating bioprosthetic valve failure. The feasibility of valve-in-valve procedures in this population is uncertain. This study aimed to assess changes in aortic root geometry and coronary height following CVG implantation to better understand future interventions. METHODS We retrospectively identified 64 patients following bioprosthetic CVG replacement with pre- and postoperative computed tomography angiography. Root assessment was conducted as in preprocedural transcatheter aortic valve evaluation using a virtual valve simulation. RESULTS In 64 patients (age, 67.6 ± 9.3 years; 76.6% men) the preoperative coronary height was 14.3 ± 6.8 mm for the left coronary artery (LCA) and 17.9 ± 5.9 mm for the right coronary artery (RCA), which significantly decreased after CVG implantation, with 8.7 ± 4.4 mm for the LCA and 11.3 ± 4.4 mm for the RCA (P < .001). The virtual valve-to-coronary distances measured 4.0 ± 1.3 mm (LCA) and 4.6 ± 1.4 mm (RCA). Overall, 59.4% (n = 38) of patients with bio-CVGs would have been at risk for coronary obstruction, 29.7% (n = 19) for LCA, 10.9% (n = 7) for RCA, and 18.8% (n = 12) for combined LCA and RCA. CONCLUSIONS Coronary height significantly decreased following CVG implantation. The majority of patients after bio-CVG were at a potential risk for coronary obstruction in future valve-in-valve procedures. Further studies are needed to identify the best possible technique for coronary reimplantation and other measures to diminish the risk for future coronary obstruction in this population.
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Affiliation(s)
- Paul Werner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
| | - Begüm Sena Kuscu
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Iuliana Coti
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Puchner
- Division of Interventional Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Division of Interventional Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Florian Schmaranzer
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital Bern, University of Bern, Bern, Switzerland
| | - Niv Ad
- Department of Surgery, Johns Hopkins University, Baltimore, Md
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Marek Ehrlich
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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7
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Brega C, Albertini A. Aortic Root Surgery in Adults: An Unsolved Problem. AORTA (STAMFORD, CONN.) 2023; 11:29-35. [PMID: 36848909 PMCID: PMC9970757 DOI: 10.1055/s-0042-1757949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Nowadays, despite the rapid advancements in interventional cardiology, open surgery still deals with aortic root diseases, to assure the best "ad hoc" treatment. In case of middle-aged adult patients, the optimal operation still represents a matter of debate. A review of the last 10-year literature was conducted, focusing on patients below 65 to 70 years of age. Because of the small sample and the heterogeneity of the papers, no metanalysis was possible. Bentall-de Bono procedure, valve sparing, and Ross operations are the surgical options currently available. The main issues in the Bentall - de Bono operation are lifelong anticoagulation therapy and cavitation in case of mechanical prosthesis implantation and structural valve degeneration in case of biological Bentall. As transcatheter procedures are currently performed as valve in valve, biological prosthesis may be preferable, if the diameter may prevent postoperative high gradients. Conservative techniques, such as remodeling and reimplantation, preferred in the young, guarantee physiologic aortic root dynamics and impose surgical analysis of the aortic root structures to get a durable result. The Ross operation, which shows excellent performance, involves autologous pulmonary valve implantation and is performed only in experienced and high-volume centers. Due to its technical difficulty, it requires a steep learning curve and presents some limitations in specific aortic valve diseases. All three have advantages and downsides, and no ideal solution has still been reported.
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Affiliation(s)
- Carlotta Brega
- Department of Cardiovascular Surgery, GVM Care and Research, Cotignola, RA, Italy,Address for correspondence Carlotta Brega, MD Maria Cecilia Hospital, GVM Care and ResearchVia Corriera 1, 48033 Cotignola, RAItaly
| | - Alberto Albertini
- Department of Cardiovascular Surgery, GVM Care and Research, Cotignola, RA, Italy
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8
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Nardi P, Pisano C, Bassano C, Bertoldo F, Salvati AC, Buioni D, Trombetti D, Asta L, Scognamiglio M, Altieri C, Ruvolo G. Bentall Operation: Early Surgical Results, Seven-Year Outcomes, and Risk Factors Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:212. [PMID: 36612535 PMCID: PMC9820033 DOI: 10.3390/ijerph20010212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 06/17/2023]
Abstract
Aim: To analyze early and mid-term outcomes of the Bentall operation. Methods: Two hundred and seventeen patients (mean age 65.6 ± 15.9 years, males/females 172/45) underwent Bentall operation in a 7-year period (January 2015−December 2021), on average, 30 Bentall operations occurred per year, using biological (n = 104) or mechanical (n = 113) valved conduits for the treatment of ascending aorta−aortic root aneurysms. Associate procedures were performed in 58 patients (26.7%); coronary artery bypass grafting (CABG) in 35 (16%). Mean follow-up was 55.2 ± 24 (median 60.2) months. Cox model analysis was used to assess risk factors, Kaplan−Meier and log-rank tests were used to assess different survival rates. Results: Operative mortality was 1.38%. At 7 years, survival, freedom from cardiac death, and event-free survival were 93% ± 2%, 99% ± 1%, and 81% ± 5%. NYHA class (p < 0.0001), trans-aortic valve mean (p < 0.0001) and maximum (p < 0.000) gradients, left ventricular hypertrophy (p < 0.05), and pulmonary arterial pressure (p = 0.002) significantly improved vs. preoperative values. Concomitant CABG during Bentall operation independently affected late outcomes (HR 1.9−2.3; p-values < 0.05). Late survival was affected by concomitant CABG (84% ± 8% vs. 95% ± 2%, p = 0.04), preoperative myocardial infarction (91% ± 9% vs. 97% ± 2%, p = 0.02), and biological vs. mechanical prostheses valved conduits (91% ± 9% vs. 95% ± 3%, p = 0.02). Event-free survival also was affected by concomitant CABG (62% ± 14% vs. 85% ± 5%, p = 0.005) and biological prostheses (78% ± 8% vs. 84% ± 6%, p = 0.06). Freedom from endocarditis−redo operation was 83% ± 9% for biological prostheses vs. 89% ± 6% for mechanical prostheses (p = 0.49). Conclusions: Low rates of operative mortality and late complications make Bentall operation the gold standard for the treatment of ascending aorta−aortic root aneurysms. Coronary ischemic disease affects late outcomes. Biological prostheses should be preferred for the elderly.
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Affiliation(s)
- Paolo Nardi
- Cardiac Surgery Division, Tor Vergata University Hospital, Tor Vergata University, 00133 Rome, Italy
| | - Calogera Pisano
- Cardiac Surgery Division, Tor Vergata University Hospital, Tor Vergata University, 00133 Rome, Italy
| | - Carlo Bassano
- Cardiac Surgery Division, Tor Vergata University Hospital, Tor Vergata University, 00133 Rome, Italy
| | - Fabio Bertoldo
- Cardiac Surgery Division, Tor Vergata University Hospital, Tor Vergata University, 00133 Rome, Italy
| | | | - Dario Buioni
- Cardiac Surgery Division, Tor Vergata University Hospital, Tor Vergata University, 00133 Rome, Italy
| | - Daniele Trombetti
- Cardiac Surgery Division, Tor Vergata University Hospital, Tor Vergata University, 00133 Rome, Italy
| | - Laura Asta
- Cardiac Surgery Division, Tor Vergata University Hospital, Tor Vergata University, 00133 Rome, Italy
| | - Mattia Scognamiglio
- Cardiac Surgery Division, Tor Vergata University Hospital, Tor Vergata University, 00133 Rome, Italy
| | - Claudia Altieri
- Cardiology Unit of the Cardiac Surgery Division, Tor Vergata University Hospital, Tor Vergata University, 00133 Rome, Italy
| | - Giovanni Ruvolo
- Cardiac Surgery Division, Tor Vergata University Hospital, Tor Vergata University, 00133 Rome, Italy
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Hlavicka J, Antonov K, Salem R, Hecker F, Marinos S, Radwan M, Emrich F, Van Linden A, Moritz A, Walther T, Holubec T. Long-Term Outcomes after Aortic Valve and Root Replacement in a Very High-Risk Population. J Cardiovasc Dev Dis 2022; 9:197. [PMID: 35735826 PMCID: PMC9225355 DOI: 10.3390/jcdd9060197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/12/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Aortic valve and root replacement (AVRR) is a standardised procedure to treat patients with aortic valve and root disease. In centres with a well-established aortic valve and root repair program (valve repairs and Ross operations), only patients with very complex conditions receive AVRR; this procedure uses a mechanical or biological composite valve graft (modified Bentall-de Bono procedure). The aim of the study was to evaluate the short- and long-term results after AVRR in a high-risk population with complex pathologies. Methods: Between 2005 and 2018, a total of 273 consecutive patients (mean age 64 ± 12.8 years; 23% female) received AVRR. The indication for surgery was an acute type A aortic dissection in 18%, infective endocarditis in 36% and other pathologies in 46% patients; 39% were redo procedures. The median EuroSCORE II was 11.65% (range 1.48-95.63%). Concomitant surgery was required in 157 patients (58%). Results: The follow-up extended to 5.2 years (range 0.1-15 years) and it was complete in 96% of the patients. The 30-day mortality was 17%. The overall estimated survival at 5 and 10 years was 65% ± 3% and 49% ± 4%, respectively. Univariate and multivariate logistic regression analyses revealed the following risk factors for survival: perioperative neurological dysfunction (OR 5.45), peripheral artery disease (OR 4.4) and re-exploration for bleeding (OR 3.37). Conclusions: AVRR can be performed with acceptable short- and long-term results in a sick patient population. The Bentall-De Bono procedure may be determined to be suitable for only elderly or high-risk patients. Any other patients should receive an AV repair or the Ross procedure in well-established centres.
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Affiliation(s)
- Jan Hlavicka
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60590 Frankfurt/Main, Germany; (J.H.); (K.A.); (R.S.); (F.H.); (F.E.); (A.V.L.); (A.M.); (T.W.)
| | - Kiril Antonov
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60590 Frankfurt/Main, Germany; (J.H.); (K.A.); (R.S.); (F.H.); (F.E.); (A.V.L.); (A.M.); (T.W.)
| | - Razan Salem
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60590 Frankfurt/Main, Germany; (J.H.); (K.A.); (R.S.); (F.H.); (F.E.); (A.V.L.); (A.M.); (T.W.)
| | - Florian Hecker
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60590 Frankfurt/Main, Germany; (J.H.); (K.A.); (R.S.); (F.H.); (F.E.); (A.V.L.); (A.M.); (T.W.)
| | - Spiros Marinos
- Division of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, 72076 Tübingen, Germany; (S.M.); (M.R.)
| | - Medhat Radwan
- Division of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, 72076 Tübingen, Germany; (S.M.); (M.R.)
| | - Fabian Emrich
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60590 Frankfurt/Main, Germany; (J.H.); (K.A.); (R.S.); (F.H.); (F.E.); (A.V.L.); (A.M.); (T.W.)
| | - Arnaud Van Linden
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60590 Frankfurt/Main, Germany; (J.H.); (K.A.); (R.S.); (F.H.); (F.E.); (A.V.L.); (A.M.); (T.W.)
| | - Anton Moritz
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60590 Frankfurt/Main, Germany; (J.H.); (K.A.); (R.S.); (F.H.); (F.E.); (A.V.L.); (A.M.); (T.W.)
| | - Thomas Walther
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60590 Frankfurt/Main, Germany; (J.H.); (K.A.); (R.S.); (F.H.); (F.E.); (A.V.L.); (A.M.); (T.W.)
| | - Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60590 Frankfurt/Main, Germany; (J.H.); (K.A.); (R.S.); (F.H.); (F.E.); (A.V.L.); (A.M.); (T.W.)
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10
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Kluckner M, Enzmann F, Gruber L, Wipper SH, Bonaros N, Schachner T. Risk of Permanent Pacemaker Implantation Following Bentall Operation. Semin Thorac Cardiovasc Surg 2022; 35:639-646. [PMID: 35709882 DOI: 10.1053/j.semtcvs.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/07/2022] [Indexed: 11/11/2022]
Abstract
Conduction disorders following cardiac surgery are common complications with incidences of permanent pacemaker dependency up to 5%. However, data on pacemaker implantation rates in the long-term follow-up after Bentall operations are scarce. In a retrospective study, a mixed cohort of 260 patients including endocarditis and aortic dissection undergoing Bentall operation between March 1996 and December 2015 was analyzed. Median follow-up time was 60 (12-107) months. Early and late rates of permanent pacemaker implantation and associated risk factors were investigated. In the postoperative course 31 (11.9%) permanent pacemakers were implanted. The 30-day incidence of pacemaker implantations was 7.7% with operations performed after a median of 6 (3-12) days after the Bentall operation. After ten years, 21% of the Bentall patients were permanent pacemaker dependent. The risk factors for permanent pacemaker dependency included age above 75 years (16.1% vs 5.7%; P < 0.001), preoperative cardiac conduction disturbance (32.3% vs 22.7%, P = 0.018), aortic valve stenosis (38.7% vs 23.1, P = 0.008), infective endocarditis (19.4% vs 7.4%, P = 0.004), tricuspid valve reconstruction (6.5% vs 0.9%, P = 0.033), sepsis (12.9% vs 4.4%, P < 0.001) and non-cardiac reoperation (19.4% vs 8.7%, P = 0.004). Pacemaker implantation significantly increased the length of initial hospitalization (13 [8-26] days vs 8 [7-13] days; P = 0.003). In the long-term follow-up, mortality was not different between the groups. Permanent pacemaker dependency is a frequent complication in the short- and long-term follow-up after Bentall operations. Screening for cardiac conduction disturbances in the short- and long-term follow-up is recommended.
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Affiliation(s)
- Michaela Kluckner
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Florian Enzmann
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Leonhard Gruber
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Sabine Helena Wipper
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Thomas Schachner
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria.
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11
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Werner P, Gritsch J, Kaider A, Coti I, Osorio E, Mahr S, Stelzmueller ME, Kocher A, Laufer G, Andreas M, Ehrlich M. Long Term Results of the Modified Bentall Procedure With Mechanical and Biological Composite Valve Grafts. Front Cardiovasc Med 2022; 9:867732. [PMID: 35463795 PMCID: PMC9019133 DOI: 10.3389/fcvm.2022.867732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/09/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesDespite the evident shift toward biological prostheses, the optimal choice of valve remains controversial in composite valve graft (CVG) replacement. We investigated long-term morbidity and mortality after CVG implantation in an all-comer cohort with a subgroup analysis of patients aged 50–70 years stratified after valve type.MethodsA total of 507 patients underwent the Bentall procedure with either a mechanical (MCVG, n = 299) or a biological (BCVG n = 208) CVG replacement between 2000 and 2020. A single-center analysis comprising clinical and telephone follow-up was conducted to investigate late mortality and morbidityResultsThe 30-day mortality in all patients [age 56 ± 14 years, 78.1% male, EuroSCORE II 3.12 (1.7; 7.1)] was 5.9%. Patients who were electively operated on had a 30-day mortality of 1.5% (n = 5) while it remained higher in urgent/emergent procedures (n = 25, 15.4%). Survival at 10 and 15 years was 78.19 ± 2.26% and 72.6 ± 3.2%, respectively. In patients aged 50–70 years (n = 261; MCVG = 151, BCVG = 110), survival did not differ significantly between the valve groups (p = 0.419). Multivariable analysis showed no significant impact of valve type on survival (p = 0.069). A time-varying relation with survival was notable, showing a higher risk in the MCVG group in the early postoperative phase, which declined compared to the BCVG group in the course of follow-up.ConclusionsThe Bentall technique presents with excellent mortality when performed electively. The type of valve prosthesis showed no statistically significant effect on mortality in patients aged 50–70 years. However, a time-varying relation showing an initially higher risk with MCVG which decreased compared to BCVG at long-term follow-up was notable. Further studies with even longer follow-up of BCVGs will clarify the ideal choice of prosthesis in this patient subset.
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Affiliation(s)
- Paul Werner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- *Correspondence: Paul Werner
| | - Jasmin Gritsch
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kaider
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Iuliana Coti
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Emilio Osorio
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Stephane Mahr
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Alfred Kocher
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Marek Ehrlich
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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12
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Van HD, Pham TB, Chau CL, Vuong NL. Modified Bentall procedure: A 15-year single-center clinical experience. Asian Cardiovasc Thorac Ann 2022; 30:779-787. [PMID: 35360960 DOI: 10.1177/02184923221090692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Bentall procedure is a standard technique for complete aortic root replacement but a huge challenge is postoperative bleeding. Many modifications have been proposed and the "button technique" is commonly used. With a 15-year experience, this study was to evaluate outcomes of this modified Bentall procedure. METHODS A retrospective study was performed with all patients who underwent the Bentall procedure with a button technique between 2005 and 2020. Commercially available composite grafts were used in 38 patients and self-assembled composite graft was used in 74 patients. Safety outcome was postoperative complications and long-term outcomes included overall and reoperation-free survivals. RESULTS Among 112 patients, the mean age was 46.3 years and 69.6% were men. Indications for the Bentall procedure were ascending aortic aneurysm and valve regurgitation (59.8%), aortic dissection (19.6%), Marfan syndrome (17%), and endocarditis (3.6%). Three patients (2.7%) died in hospital. During a median follow-up period of 42 months, 11 patients died and 7 patients required reoperation. Overall survival and reoperation-free survival were 86.1% and 83.4% at 5 years and 86.1% and 72.6% at 10 years, respectively. CONCLUSIONS The Bentall procedure with a button technique is safe and effective for aortic root replacement. Further investigations are required to improve the feasibility and effectiveness of the procedure.
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Affiliation(s)
- Hung Dung Van
- Heart Institute of Ho Chi Minh City, Ho Chi Minh City, Vietnam.,Department of Thoracic and Cardiovascular Surgery, 384732Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Thanh Binh Pham
- Heart Institute of Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Chi Linh Chau
- Heart Institute of Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nguyen Lam Vuong
- Department of Medical Statistics and Informatics, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
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13
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Clinical Outcomes Using Freestyle Valve/Valsalva Graft Composite Conduit for Aortic Root Replacement. Ann Thorac Surg 2022; 114:643-649. [PMID: 35031292 DOI: 10.1016/j.athoracsur.2021.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 11/26/2021] [Accepted: 12/06/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND We review the clinical outcomes with a novel method of aortic root replacement using a self-constructed tissue valve-conduit comprised of a Freestyle subcoronary valve sewn into a Valsalva graft. METHODS From 2005 to 2020, 523 patients had aortic root replacement operations using a self-constructed Freestyle Subcoronary-Valsalva graft tissue valve-conduit. Median age was 62 years (IQR 54-70) and 430 (82%) were male patients. Primary outcomes were mortality and the need for reoperation. Multivariable regression analyses were performed to identify risk factors for mortality and reoperation. RESULTS Urgent procedures comprised 48.37% of the cases and 29.26% were reoperative procedures. Concomitant ascending aorta replacement, hemi-arch replacement, and total arch replacement were required in 348 (67%), 227 (44%), and 40 (8%) patients, respectively. Cardiopulmonary bypass and cross-clamp times were 189 minutes (IQR 164-218) and 166 minutes (IQR 145-191). Early mortality was 7.7% (40), five and ten-year survival was 83% and 71% respectively. At last echo follow-up, LVEF, LV end diastolic diameter, degree of AI, and mean aortic valve gradient were significantly improved from baseline, p<0.001. Increasing age, peripheral artery disease, tobacco use, increased preoperative creatinine, and prior aortic valve surgery were risk factors for both mortality and the composite outcome (p<0.02). CONCLUSIONS In a complex patient population, aortic root replacement using a self-constructed composite tissue valve-conduit comprised of a Freestyle Subcoronary Valve/Valsalva Graft can be performed with excellent operative and 10-year outcomes. Mid-term survival is acceptable and valve durability was outstanding with an exceedingly low incidence for valve reintervention.
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14
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6538731. [DOI: 10.1093/ejcts/ezac104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 01/17/2022] [Accepted: 01/31/2022] [Indexed: 11/14/2022] Open
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Igarashi T, Satokawa H, Sato Y, Takase S, Wakamatsu H, Seto Y, Kurosawa H, Iwai-Takano M, Fujimiya T, Shinjo H, Ishida K, Yokoyama H. Long-term results of modified bentall procedures: 18-year experience of the flanged technique. Fukushima J Med Sci 2021; 67:119-127. [PMID: 34744087 PMCID: PMC8784198 DOI: 10.5387/fms.2021-06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To evaluate the early and late outcomes of the modified Bentall procedure with the flanged technique. METHODS We reviewed the medical records of 63 patients who had undergone root replacement by the modified Bentall procedure at our institute between January 2001 and December 2018. In most cases, we adopted a composite graft constructed with a mechanical valve or bioprosthesis and a Dacron graft by the flanged technique. Since 2011, we have used Valsalva grafts. RESULTS Mean age 57 ± 16 years, range 16-80, male 43 cases. The mean follow-up was 75 ± 56 months (range 0-216). Through April 1, 2020, we could follow up on 61 cases (97%) within a six-month period. Hospital mortality was 7.9% (4.8% in elective cases). In late follow-up, eight deaths were observed. In the bio-Bentall group (n=26), no deaths or major adverse valve-related events (MARVEs) occurred. In the mechanical Bentall group (n=37), seven cases of MARVEs, including two cerebral hemorrhages and one cerebral embolism, were observed. All patients were free from MARVEs at 5 years post procedure in the bio-Bentall group, and 93.8% and 76.8% were event-free at 5 years and 10 years, respectively, in the mechanical Bentall group. CONCLUSIONS The 18-year results of the modified Bentall procedure were acceptable, providing excellent outcomes in the bio-Bentall group. The flanged technique enabled the use of a larger prosthesis, which may have resulted in good durability with the bio-Bentall procedure.
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Affiliation(s)
- Takashi Igarashi
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Hirono Satokawa
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Yoichi Sato
- Department of Cardiovascular Surgery, Yonezawa City Hospital
| | - Shinya Takase
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Hiroki Wakamatsu
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Yuki Seto
- Department of Cardiovascular Surgery, Fukushima Medical University
| | | | | | | | - Hiroharu Shinjo
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Keiichi Ishida
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Hitoshi Yokoyama
- Department of Cardiovascular Surgery, Fukushima Medical University
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Dagnegård HH, Bekke K, Kolseth SM, Glaser N, Wallén C, El-Hamamsy I, Vidisson KO, Lie AS, Valentin JB, Sartipy U, Haaverstad R, Vanky F, Lefebvre L, Gudbjartsson T, Johnsen SP, Søndergaard L, Thyregod GH, Lund JT, Ihlemann N, Smerup MH. Survival after aortic root replacement with a stentless xenograft is determined by patient characteristics. J Thorac Cardiovasc Surg 2021; 164:1712-1724.e10. [PMID: 34452760 DOI: 10.1016/j.jtcvs.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/08/2021] [Accepted: 07/01/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Our objective was to examine intermediate-term survival and reinterventions in unselected patients, stratified according to indication, who received a Freestyle (Medtronic Inc, Minneapolis, Minn) bioprosthesis as a full aortic root replacement. METHODS Data from medical records were retrospectively collected for patients who had aortic root replacement using Freestyle bioprostheses between 1999 and 2018 at 6 North-Atlantic centers. Survival status was extracted from national registries and results stratified according to indication for surgery. RESULTS We included 1030 implantations in 1008 patients with elective indications for surgery: aneurysm (39.8%), small root (8.3%), and other (13.8%), and urgent/emergent indications: endocarditis (26.7%) and Stanford type A aortic dissection (11.4%). Across indications, 46.3% were nonelective cases and 34.0% were reoperations. Median age was 66.0 (interquartile range, 58.0-71.8) years and median follow-up was 5.0 (interquartile range, 2.6-7.9) years. Thirty-day mortality varied from 2.9% to 27.4% depending on indication. Intermediate survival for 90-day survivors with elective indications were not different from the general population standardized for age and sex (P = .95, .83, and .16 for aneurysms, small roots, and other, respectively). In contrast, patients with endocarditis and type A dissection had excess mortality (P < .001). Freedom from valve reinterventions was 95.0% and 94.4% at 5 and 8 years, respectively. In all, 52 patients (5.2%) underwent reinterventions, most because of endocarditis. CONCLUSIONS At intermediate term follow-up this retrospective study provides further support for the use of the Freestyle bioprosthesis in the real-world setting of diverse, complex, and often high-risk aortic root replacement and suggests that outcome is determined by patient and disease, rather than by prosthesis, characteristics.
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Affiliation(s)
- Hanna H Dagnegård
- Department of Cardiothoracic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark; Department of Cardiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark.
| | - Kirstine Bekke
- Department of Cardiothoracic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Solveig M Kolseth
- Department of Heart Disease, Haukeland University Hospital and University of Bergen, Bergen, Norway
| | - Natalie Glaser
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Christoffer Wallén
- Department of Cardiothoracic and Vascular Surgery, Heart Centre, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Ismail El-Hamamsy
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Kristjan O Vidisson
- Department of Cardiothoracic Surgery, Landspítali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Asbjørn S Lie
- Department of Heart Disease, Haukeland University Hospital and University of Bergen, Bergen, Norway
| | - Jan B Valentin
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Ulrik Sartipy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rune Haaverstad
- Department of Heart Disease, Haukeland University Hospital and University of Bergen, Bergen, Norway
| | - Farkas Vanky
- Department of Cardiothoracic and Vascular Surgery, Heart Centre, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Laurence Lefebvre
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspítali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Søren P Johnsen
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Lars Søndergaard
- Department of Cardiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Gustav H Thyregod
- Department of Cardiothoracic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Jens T Lund
- Cardio Thoracic Surgical Department, Green Lane Division, Auckland City Hospital, Auckland, New Zealand
| | - Nikolaj Ihlemann
- Department of Cardiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Morten H Smerup
- Department of Cardiothoracic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Abstract
Background The upper mini sternotomy Bentall (mini-Bentall) procedure may result in less trauma and earlier recovery compared with the full sternotomy Bentall procedure (full Bentall). This study compares immediate and 1- and 3-year survival rates after mini- and full Bentall procedures. Methods Between February 2009 and July 2019, 48 patients underwent a mini-Bentall and 49 underwent a full Bentall. Patients who required concomitant procedures, reoperations, or hypothermic circulatory arrest were excluded from our analysis. The mean patient age was 60.7 years in the mini-Bentall group and 59.0 years in the full Bentall group. Results There were no in-hospital mortalities. The median cardiopulmonary bypass time (mini-Bentall: 165 minutes [interquartile range (IQR), 155.5-183 minutes]; full Bentall: 164 minutes [IQR, 150-187 minutes]; P = .619) and aortic cross-clamp times (139 minutes [IQR, 128.5-153 minutes] vs 137 minutes [IQR, 125-156 minutes]; P = .948) were not significantly different between the 2 groups. The mini-Bentall group had a significantly shorter median ventilation time compared with the full Bentall group (5.5 hours [IQR, 3-14 hours] vs 17 hours [IQR, 11-23 hours]; P < .001). None of the patients in the mini-Bentall group had postoperative bleeding necessitating reoperation, whereas 4 patients (8.2%) underwent reoperation after full Bentall (P = .043). The mini-Bentall group also had a shorter median hospital length of stay (6 days [IQR, 5-8 days] vs 7 days [IQR, 6-8 days]; P = .086). Survival at 1 and 3 years was 100% in both cohorts. Conclusions Patients required significantly less ventilation time and reoperations for bleeding after the mini-Bentall procedure. There were no significant differences in cardiopulmonary bypass, aortic cross-clamp times, or intensive care unit and hospital length of stay between the mini-Bentall and full Bentall groups. The mini-Bentall approach is associated with low morbidity and mortality.
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Key Words
- ACC, aortic cross-clamp
- ARR, aortic root replacement
- CI, confidence interval
- CPB, cardiopulmonary bypass
- FS, full sternotomy
- ICS, intercostal space
- ICU, intensive care unit
- IQR, interquartile range
- LOS, length of stay
- PVS, prolonged ventilatory support
- TEE, transesophageal echocardiography
- UMS, upper mini-sternotomy
- aortic root replacement
- full sternotomy
- mini-Bentall
- upper mini-sternotomy
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Myocardial ischemia 10 years after a modified Cabrol procedure in a 42-year-old patient with Marfan syndrome. BMC Cardiovasc Disord 2020; 20:461. [PMID: 33109088 PMCID: PMC7590664 DOI: 10.1186/s12872-020-01740-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/12/2020] [Indexed: 11/10/2022] Open
Abstract
Background Marfan syndrome, a genetic disorder of the connective tissue, may cause aortic root dilation with aortic insufficiency, aortic dissection and mitral prolapse with mitral insufficiency. We present a case of a late complication of the modified Cabrol procedure that included replacing the ascending aorta with a composite graft. Case presentation In February 2019, a 42-year-old female patient with Marfan syndrome who presented with chest pain was sent to the Emergency Department. She had undergone the modified Cabrol procedure 10 years prior. Upon presenting, laboratory analysis revealed elevated troponin-I levels. Electrocardiogram showed new inverted T waves over lead I, aVL and V4 to V6. Contrast computed tomography (CT) revealed thrombosis in the Dacron graft. Percutaneous coronary angiography was conducted, and a large thrombus in the graft was noted. Thrombolytic therapy and percutaneous coronary intervention were performed, after which the patient had no more symptoms and was discharged without complications. Conclusions Aortic root surgery, including the Cabrol or modified Cabrol procedure, is necessary for complicated cases of aortic dilations, such as in patients with Marfan syndrome, even though the Cabrol or modified Cabrol procedure has a high complication rate. Regarding this case, we were surprised by the timing of the myocardial ischemia and the position of the thrombus, which differed from other cases. To better manage such a patient’s condition and to detect the formation of thrombus early, completeness of the graft and possible stenosis of the anastomosis site to avoid preventable myocardial ischemia, we suggest that patients should have regular image follow-up, even years after the Cabrol or modified Cabrol procedure.
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19
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Hardikar A, Marwick TH. An economic analysis of medical and surgical management of aortopathy associated with bicuspid aortic valve. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 5:380-387. [DOI: 10.1093/ehjqcco/qcz020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/22/2019] [Accepted: 04/29/2019] [Indexed: 11/14/2022]
Abstract
Abstract
Aims
To develop a cost-effectiveness model to address the outcome and economic implications of different thresholds for surgery in the management of aortopathy associated with bicuspid aortic valve disease.
Methods and results
A model was created from the perspective of an Australian healthcare funding agency. The index case was a 65-year-old with bicuspid aortic valve (BAV) and ascending aorta diameter of 5.0 cm. Health states were defined as: pre-operative with dilated aorta, post-operative without complications, post-complication, and death. The mean and variance of risks and transition probabilities were taken from a local surgical database and local costs and utilities of elective and urgent thoracic aortic surgery (AoS) with or without aortic valve replacement, with a sensitivity analysis based on a systematic review. Scenario analyses were provided for other aortic dimensions. Implications for survival, quality-adjusted life years (QALYs), and costs were calculated from healthcare delivery and economic perspectives. After 10 000 simulations for the reference case, the utility of watchful waiting (WW) exceeded that of elective AoS (13 ± 4 vs. 10 ± 5 QALY). The net monetary benefit was A$351 063 ± 304 965 with immediate AoS vs. 534 797 ± 198 570 with WW surveillance. The most important variables affecting effectiveness were utility value of survivors, rate of aortic growth, and probability of acute aortic event during WW.
Conclusions
This decision-analytic model informed by our practice, as well as a systematic analysis, shows that AoS in a BAV patient with aorta <5 cm diameter is costlier and less effective than WW.
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Affiliation(s)
- Ashutosh Hardikar
- Cardiovascular Imaging group, Menzies Institute for Medical research, 17 Liverpool Street, Hobart, Tasmania, Australia
- Department of Cardiothoracic Surgery, Royal Hobart Hospital, 48 Liverpool Street, Hobart, Tasmania, Australia
| | - Thomas H Marwick
- Cardiovascular Imaging group, Menzies Institute for Medical research, 17 Liverpool Street, Hobart, Tasmania, Australia
- Imaging Research, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, Victoria, Australia
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Kunihara T, Ichihara N, Miyata H, Motomura N, Sasaki K, Matsuhama M, Takamoto S. Valve-sparing root replacement and composite valve graft replacement in patients with aortic regurgitation: From the Japan Cardiovascular Surgery Database. J Thorac Cardiovasc Surg 2019; 158:1501-1511.e6. [PMID: 30952541 DOI: 10.1016/j.jtcvs.2019.01.122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 01/05/2019] [Accepted: 01/31/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The advantage of valve-sparing root replacement (VSRR) over aortic root replacement with a composite valve graft (CVG) remains unclear. We compared these 2 procedures with regard to early outcomes with propensity score matching using the Japan Cardiovascular Surgery Database. METHODS Of 5303 patients from the Japan Cardiovascular Surgery Database who had undergone aortic root replacement in 2008 to 2017, emergent/urgent or redo cases and those with infective endocarditis or aortic stenosis were excluded (included n = 3841). Two propensity score-matched groups treated with VSRR or CVG replacement (n = 1164 each) were established. RESULTS Overall, VSRR was more frequently performed for younger patients with Marfan syndrome with lower operative risk and aortic regurgitation grade compared with CVG replacement. After matching, a weaker but similar trend still existed in baseline characteristics. Although more concomitant procedures were performed in the CVG group, myocardial ischemia and cardiopulmonary bypass time was significantly longer in the VSRR group (median, 193 and 245 minutes) than the CVG group (172 and 223 minutes, both P < .01). The CVG group was associated with a significantly greater incidence of postoperative stroke (2.5% vs 1.1%, P = .01) and prolonged ventilation >72 hours (7.0% vs 4.6%, P = .02). In-hospital mortality rates were significantly greater in the CVG group (1.8%) than the VSRR group (0.8%, P = .02). CONCLUSIONS In overall Japanese institutions, VSRR was more frequently performed for patients at low risk and was associated with better morbidity and mortality rates than CVG replacement. After matching, VSRR was also associated with better morbidity and mortality rates despite longer procedure time.
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Affiliation(s)
- Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Nao Ichihara
- Department of Healthcare Quality Assessment, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | | | - Kenichi Sasaki
- Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Sayama, Japan
| | - Minoru Matsuhama
- Department of Cardiovascular Surgery, the Cardiovascular Institute, Tokyo, Japan
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21
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Waste not, want not: Bentall style. J Thorac Cardiovasc Surg 2018; 156:2087. [DOI: 10.1016/j.jtcvs.2018.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 06/19/2018] [Accepted: 06/21/2018] [Indexed: 11/23/2022]
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22
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Bilkhu R, Youssefi P, Soppa G, Theodoropoulos P, Phillips S, Liban B, Child A, Tome M, Nowell J, Sharma R, Edsell M, Jahangiri M. Fate of the Aortic Arch Following Surgery on the Aortic Root and Ascending Aorta in Bicuspid Aortic Valve. Ann Thorac Surg 2018; 106:771-776. [DOI: 10.1016/j.athoracsur.2018.03.052] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/28/2018] [Accepted: 03/19/2018] [Indexed: 01/16/2023]
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23
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Keeling WB, Hunting J, Leshnower BG, Stouffer C, Binongo J, Chen EP. Salvage Coronary Artery Bypass Predicts Increased Mortality During Aortic Root Operation. Ann Thorac Surg 2018; 106:1727-1734. [PMID: 30171853 DOI: 10.1016/j.athoracsur.2018.06.079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/18/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Aortic root replacement (ROOT) has been an established therapy, yet the impact of adding coronary artery bypass grafting (CABG) to ROOT (CABG-R) is unknown. The purpose of this research was to investigate the impact of CABG on the outcomes of ROOT. METHODS A retrospective review from 2004 to 2016 of patients undergoing nonemergent ROOT surgical procedure was performed. Cohorts were established based on the presence or absence of added CABG. A propensity-score weighted comparison of outcomes was then conducted. RESULTS A total of 867 patients met inclusion criteria and were analyzed (711 ROOT [72.0%], 156 CABG-R [18.0%]). CABG-R patients were older and had higher proportions of previous valve operation, hypertension, endocarditis, immunosuppressive therapy, renal insufficiency, and redo operation (all p < 0.01). Indications for CABG included anatomy (n = 48, 30.8%), coronary artery disease (80, 51.3%), and ventricular failure (28, 17.9%). The permanent stroke rate was not significantly increased with the addition of CABG-R (p = 0.06). Thirty-day mortality was 5.5% for the entire cohort but was substantially higher in patients who underwent concomitant CABG (3.4% ROOT, 15.4% CABG-R). Mortality rates were highest among patients with acute ventricular failure and CABG (28.8%) compared with patients who underwent CABG for coronary artery disease (6.3%) or patients for anatomy (22.9%; p = 0.003). CONCLUSIONS CABG-R results in increased postoperative morbidity or mortality compared with isolated ROOT. Outcomes, however, are influenced by the specific clinical indication. CABG for coronary artery disease was associated with similar outcomes compared with isolated ROOT. Patients undergoing unplanned CABG for acute ventricular failure had the worst outcomes, thus underscoring the importance of technical success during coronary reimplantation.
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Affiliation(s)
- W Brent Keeling
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia.
| | - John Hunting
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Chad Stouffer
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Jose Binongo
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
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Treasure T, King A, Hidalgo Lemp L, Golesworthy T, Pepper J, Takkenberg JJM. Developing a shared decision support framework for aortic root surgery in Marfan syndrome. Heart 2018; 104:480-486. [PMID: 28780581 PMCID: PMC5861390 DOI: 10.1136/heartjnl-2017-311598] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/28/2017] [Accepted: 06/28/2017] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE The study is an early phase of development of a decision support framework for people with Marfan syndrome who are anticipating prophylactic aortic root surgery. Implications of the timing and the nature of the operation chosen were previously elicited in focus groups. In this step, we explored the range of relative values placed by individuals on the implications of decisions made about surgery. METHODS Following the principles of the Ottawa Decision Support Framework, eight questions in the general form 'How important is it to you …' were framed by a panel. Marfan people, families and specialist doctors answered online. Quantitative and qualitative analyses were performed. RESULTS Worldwide, 142 responses were received including 25 specialist doctors. Respondents were 55% female and 46% had previous aortic root surgery. Overall, active lifestyle was more important to males (p=0.03). Patients placed more importance than doctors on not deferring surgery (p=0.04) and on avoidance of anticoagulation in the interests of childbearing (p=0.009). Qualitative analysis showed differing but cogently reasoned values that were sometimes polarised, and mainly driven by the wish to maintain a good quality of life and active lifestyle. CONCLUSIONS Given the cogency of these viewpoints, people anticipating root replacement surgery should have ample opportunity to express them and to have them acknowledged ahead of a consultation when they can then be fully explored in a mutually informed forum. If they differ from local medical practice, they can then be discussed in the process of reaching shared and individualised decisions.
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Affiliation(s)
- Tom Treasure
- Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Annette King
- Centre for Health Services Studies, University of Kent, Canterbury, Kent, UK
| | | | | | - John Pepper
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
| | - Johanna JM Takkenberg
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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25
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Pantaleo A, Murana G, Di Marco L, Jafrancesco G, Barberio G, Berretta P, Leone A, Di Bartolomeo R, Pacini D. Biological versus mechanical Bentall procedure for aortic root replacement: a propensity score analysis of a consecutive series of 1112 patients†. Eur J Cardiothorac Surg 2017; 52:143-149. [DOI: 10.1093/ejcts/ezx070] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 02/15/2017] [Indexed: 12/11/2022] Open
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26
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Balsam LB, DeAnda A. Postoperative myocardial infarction after acute type A dissection: Another day, another database? J Thorac Cardiovasc Surg 2016; 153:528-529. [PMID: 28012696 DOI: 10.1016/j.jtcvs.2016.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 11/08/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Leora B Balsam
- Department of Cardiothoracic Surgery, New York University-Langone Medical Center, New York, NY.
| | - Abe DeAnda
- Division of Cardiothoracic Surgery, University of Texas Medical Branch-Galveston, Galveston, Tex
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27
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Mok SCM, Ma WG, Mansour A, Charilaou P, Chou AS, Peterss S, Tranquilli M, Ziganshin BA, Elefteriades JA. Twenty-five year outcomes following composite graft aortic root replacement. J Card Surg 2016; 32:99-109. [PMID: 27966257 DOI: 10.1111/jocs.12875] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Operative choices for aortic root disease include traditional root replacement with a composite valved graft as well as various valve-sparing and root repair procedures. OBJECTIVES To report our experience with traditional composite graft aortic root replacement by a single surgeon over a 25-year period in 449 patients, focusing on long-term survival and freedom from late reoperation and adverse events. METHODS The coronary button technique was used in all patients. Mean age was 56.1 ± 14.0 years (range 14-87) with 83% males (373/449). Valve prosthesis was mechanical in 343 (76%) and bioprosthetic in 106 (24%). A modified Cabrol procedure (Dacron coronary graft) was employed in 10% (45/449) and concomitant coronary artery bypass graft in 10.9% (49/449). There were 15.8% (71/449) urgent/emergent and 8.2% (37/449) redo procedures. Survival follow-up was 100%. Mean follow-up was 7.0 ± 5.1 years (range 0.1-24.8). RESULTS Operative mortality occurred in 14 patients (3.1%) and was 2.2% (9/418) in non-dissection and 1.9% (7/361) in elective first-time operations. Stroke and re-exploration for bleeding occurred in nine (2.0%) and 20 (4.5%) patients, respectively. Major late events included bleeding in 2.5% (11/435) and thromboembolism in 1.1% (5/435). At 5, 10, and 20 years, freedom from major events and reoperations on the root were 97.8, 95.4, and 94.39%, and 99.0, 99.0, and 97.9%, respectively. Survival in patients aged <60 years was 92.0, 90.1, and 79.8% at five, 10, and 20 years versus 88.4, 67.9, and 42.6% in patients aged ≥60 years (p = 0.001). Compared with age- and gender-matched controls, survival was not significantly different (p = 0.20). CONCLUSIONS Composite graft aortic root replacement is associated with low operative risk, excellent long-term survival, and low incidence of reoperation and late events.
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Affiliation(s)
- Salvior C M Mok
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Wei-Guo Ma
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.,Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Ahmed Mansour
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Paris Charilaou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Alan S Chou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Sven Peterss
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Maryann Tranquilli
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.,Department of Surgical Diseases #2, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
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28
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Composite graft aortic root reconstruction: Reproducible, durable, and uncomplicated. J Thorac Cardiovasc Surg 2016; 152:1049-51. [PMID: 27497732 DOI: 10.1016/j.jtcvs.2016.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 06/30/2016] [Indexed: 11/24/2022]
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29
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Coselli JS. Aortic root replacement, the "gold" standard: All that shines is not gold! J Thorac Cardiovasc Surg 2016; 152:956-7. [PMID: 27542627 DOI: 10.1016/j.jtcvs.2016.06.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex.
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