Short-term outcomes of a simple and effective approach to aortic root and arch repair in acute type A aortic dissection

Yang, Bo; Malik, Aroosa; Waidley, Victoria; Kleeman, Kellianne C.; Wu, Xiaoting; Norton, Elizabeth L.; Williams, David M.; Khaja, Minhaj S.; Hornsby, Whitney E.

doi:10.1016/j.jtcvs.2017.11.089

Cited by 53 publications

(61 citation statements)

References 18 publications

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“…Besides, persistent blood flow in the aortic root false lumen after surgical repair can compress coronary artery origins, which may cause myocardial ischemia. 12) Therefore, aortic root reinforcement is critical in ATAAD treatment, and despite efforts to reduce complications, aortic root management remains a challenge for cardiac sur-NEW TECHNIQUE FOR AORTIC ROOT REINFORCEMENT geons.…”

Section: Discussionmentioning

confidence: 99%

A New Aortic Root Reinforcement Technique for Acute Type A Aortic Dissection Surgery

et al. 2019

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Reinforcing the dissected and fragile aortic root is critical in acute type A aortic dissection (ATAAD) surgery. This study introduces our new aortic root reinforcement technique and reports our early operative results and midterm follow-up results. A retrospective analysis study was performed on 235 patients (aged 53.2 ±15.5 years) who were admitted to our hospital for ATAAD surgery and underwent the procedure with our new technique between October 2011 and June 2016. Two vascular graft rings were placed inside and outside aortic root, followed by a running horizontal mattress suture, placed just above the coronary artery ostiums and aortic valve commissures, with another horizontal suture at distal end of the aortic root stump, to reinforce the inner vascular graft, aortic wall, and outside vascular graft. Then additional 3-5 vertical mattress sutures were placed for further reinforcement within the reconstructed aortic root. Computed tomography angiography was performed at discharge and annually during follow-up. The patients' 30-day mortality was 5.1% (12/235). There was no uncontrollable intraoperative bleeding from the aortic root, and re-exploration for bleeding occurred in 0.79% (2/235). The survival rate was 90.2% during follow-up of 4.2 ± 2.1 years. There were no requests for aortic root reoperations during follow-up. All patients were free from aortic root disruptions, proximal anastomosis complications, and re-dissections of the reconstructed aortic root. Our new aortic root reinforcement technique provides a safe and effective technique for aortic root in ATAAD surgery, by reinforcing friable aortic root tissues and minimizing aortic root complications.

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Section: Discussionmentioning

confidence: 99%

A New Aortic Root Reinforcement Technique for Acute Type A Aortic Dissection Surgery

et al. 2019

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“…Yang et al 5 reported a set of contrasting results from their single center study, compared to various other articles as seen in Table A1.…”

Section: Replacing the Root A Burden On Mid To Long Term Outcomes?mentioning

confidence: 99%

“…Surgical intervention on the aortic root remains controversial and debatable. [4][5][6][7] Acute aortic dissection repair can necessitate a variety of operations, from simple replacement of the ascending aorta to aortic root replacement or a version of total arch replacement. There are differing opinions regarding what constitutes the "appropriate" repair of the acutely dissected aorta, [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] a tear tailored approach is a trend that we normally follow; however, this is not generalizable across many different centers.…”

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confidence: 99%

Does adding a root replacement in type A aortic dissection repair provide better outcomes?

et al. 2020

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Background: Acute type A aortic dissection (ATAAD), is a surgical emergency often requiring intervention on the aortic root. There is much controversy regarding root management; aggressively pursuing a root replacement, versus more conservative approaches to preserve native structures. Methods: Electronic database search we performed through PubMed, Embase, SCOPUS, google scholar, and Cochrane identifying studies that reported on outcomes of surgical repair of ATAAD through either root preservation or replacement. The identified articles focused on short-and long-term mortalities, and rates of reoperation on the aortic root. Results: There remains controversy on replacing or preserving aortic root in ATAAD. Current evidence supports practice of both trends following an extensive decision-making framework, with conflicting series suggesting favorable results with both procedures as the approach that best defines higher survival rates and lower perioperative complications. Yet, the decision to perform either approach remains surgeon decision and bound to the extent of the dissection and tear entries in strong correlation with status of the aortic valve and involvement of coronaries in the dissection. Conclusions: There exists much controversy regarding fate of the aortic root in ATAAD. There are conflicting studies for impact of root replacement on mortality, whilst some study's report no significant results at all. There is strong evidence regarding risk of reoperation being greater when root is not replaced. Majority of these studies are limited by the single centered, retrospective nature of these small sample sized cohorts, further hindered by potential of treatment bias.

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“…Root replacement was performed as a total root (BioBentall with Freestyle ) (n=7), inclusion root with a Freestyle bioprosthesis (n=4), or David valve-sparing aortic root replacement (n=2); all of which are current practice in our group. If criteria were not met for aortic root replacement, aortic root repair was performed (n=52) by preserving the aortic valve and all sinuses of Valsalva based on surgeons' preference as previously described (20)(21)(22). With aortic valve pathology in the absence of aortic root pathology, an isolated aortic valve replacement was performed (n=1).…”

Section: Surgical Techniquesmentioning

confidence: 99%

Management of malperfusion syndrome in acute type A aortic intramural hematoma

Norton

Williams

Kim

et al. 2019

Ann. Cardiothorac. Surg.

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Background: We report the outcomes of acute type A aortic intramural hematoma (ATAAIMH) with malperfusion treated with endovascular intervention and delayed open aortic repair. Methods: Between April 1998 and April 2018, 644 patients were treated at our institution with an acute type A aortic dissection (ATAAD) or ATAAIMH, 82 (13%) had intramural hematomas (IMHs) including 12 (15%) with malperfusion syndrome (MPS) and 70 (85%) without MPS (no MPS). Data was obtained through medical record review, the Society of Thoracic Surgeons data elements, and the National Death Index database. Results: Both MPS and No MPS groups had similar comorbidities including coronary artery disease, hypertension, diabetes, and peripheral vascular disease; however, those with MPS were sicker on admission with higher rates of acute renal failure (50% vs. 1%, P<0.0001) and acute paralysis (17% vs. 0%, P=0.02). Patients with MPS amenable to endovascular reperfusion (n=10) underwent endovascular fenestration/ stenting and delayed aortic repair. Those with cerebral or coronary MPS (n=2) and those without MPS (n=70) underwent emergent open aortic repair. Of the ten patients undergoing fenestration/stenting, seven went on to aortic repair, one survived to discharge without aortic repair, one died from aortic rupture on hospital day 34, and one died from organ failure prior to aortic repair. Following endovascular fenestration/stenting or aortic repair, all patients with MPS had higher in-hospital mortality (17% vs. 0%), P=0.02. Following aortic repair, patients with MPS had more postoperative sepsis and longer postoperative length of stay (all P<0.05). However, both groups had a 0% operative mortality (including in-hospital and 30-day mortality following aortic repair). The 5-year survival of all ATAAIMH patients was 79%. The 2-year survival was significantly better in the No MPS group (94% vs. 62%, P=0.006). Conclusions: ATAAIMH with MPS can be effectively managed with upfront endovascular fenestration/ stenting followed by delayed aortic repair.

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Short-term outcomes of a simple and effective approach to aortic root and arch repair in acute type A aortic dissection

Abstract: Direct aortic root and arch repair with approximation of the aortic wall without use of technical adjuncts is safe and effective for patients with ATAAD. If warranted, preservation of the native aortic valve should be considered for a potential survival benefit.

Cited by 53 publications

References 18 publications

A New Aortic Root Reinforcement Technique for Acute Type A Aortic Dissection Surgery

A New Aortic Root Reinforcement Technique for Acute Type A Aortic Dissection Surgery

Does adding a root replacement in type A aortic dissection repair provide better outcomes?

Management of malperfusion syndrome in acute type A aortic intramural hematoma

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