Composite aortic root replacement in acute type A dissection: time to rethink the indications?

Halstead, James C.; Spielvogel, David; Meier, D. Matthias; Rinke, Sindy; Bodian, Carol; Malekan, Ramin; Ergin, Mehmet; Griepp, Randall B.

doi:10.1016/j.ejcts.2004.12.059

Cited by 96 publications

(75 citation statements)

References 19 publications

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“…Operative mortality was 12.3% in each group, and the ten year survival was 65% in the ARR group and 55% in the CRR group (P=0.48). There was a trend towards a higher incidence of root reoperation in the repair group (CRR n=4 vs. ARR n=0; P=0.08) (18). The Hannover group reported similar results in their series of 295 patients with TAAD.…”

Section: Aortic Root Replacement (Arr)supporting

confidence: 66%

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When and how to replace the aortic root in type A aortic dissection

Leshnower

Chen

2016

Ann. Cardiothorac. Surg.

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Management of aortic root pathology during repair of acute type A aortic dissection (TAAD) requires a comprehensive evaluation of the patient's anatomy, demographics, comorbidities and physiologic status at the time of emergent operative intervention. Surgical options include conservative repair of the root (CRR) (with or without replacement of the aortic valve), replacement of the native valve and aortic root using a composite valve-conduit and valve sparing root replacement (VSRR). The primary objective of this review is to provide data for surgeons to aid in their decision-making process regarding management of the aortic root during repair of TAAD. No time or language restrictions were imposed and references of the selected studies were checked for additional relevant citations. Multiple retrospective reviews have demonstrated equivalent operative mortality between aortic root repair and replacement during TAAD. There is a higher incidence of aortic root reintervention with aortic root repair compared to aortic root replacement (ARR). Experienced, high-volume aortic centers have demonstrated the safety of VSRR in young, hemodynamically stable patients presenting with TAAD. In conclusion, aortic root repair can safely be performed in the vast majority of patients with TAAD. Despite the increased surgical complexity, ARR does not increase operative mortality and improves the freedom from root reintervention. VSRR can be performed in highly selected populations of patients with TAAD with durable mid-term valve function.

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Section: Aortic Root Replacement (Arr)supporting

confidence: 66%

“…Despite the increased risk associated with ARR, several large series comparing CRR to ARR have demonstrated equivalent operative mortality with a lower incidence of aortic root reoperation following ARR (8,18,19). The Mount Sinai group reviewed their experience with CRR compared to ARR in 162 patients with TAAD.…”

Section: Aortic Root Replacement (Arr)mentioning

confidence: 99%

When and how to replace the aortic root in type A aortic dissection

Leshnower

Chen

2016

Ann. Cardiothorac. Surg.

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“…This aggressive approach to the root was later advocated by Kouchoukos et (72,75), and it has since been revived again by Griepp's group at Mt. Sinai (76). The earlier practice at Stanford may have been overly conservative by saving the valve and sinuses in the vast majority of patients, but it appears to be the predominant treatment method in Japan where only 6.2% of AcA-AoD patients underwent root replacement in 2011 (77).…”

Section: Replacement Of the Valve And Rootmentioning

confidence: 99%

“…In the hands of expert thoracic aortic surgeons, the mortality risk may not be substantially elevated (76,78,80); however, the apparent safety of CVG root replacement may be due in part to publication bias as low risk has not been universally observed even among experienced surgeons (61,81). It is important to recall that the median number of proximal aortic operations among institutions performing at least one aortic operation per year in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) is only 12 per year per center (82).…”

Section: Replacement Of the Valve And Rootmentioning

confidence: 99%

Evolution of surgical therapy for Stanford acute type A aortic dissection

Chiu

Miller

2016

Ann. Cardiothorac. Surg.

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Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small?The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results.

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“…Previous extensive studies demonstrated the safety of root replacement at the time of AD when the root tissue was involved (5,6). Since these patients tend to be younger, they have the most benefit to gain from preserving the native aortic valve when possible at the time of Type A repair and root replacement.…”

mentioning

confidence: 99%