The learning curve effect on outcomes with frozen elephant trunk technique for extensive thoracic aorta disease

Abstract

Objective The purpose of this study was to analyze the learning curve effect on hospital mortality, postoperative outcomes, freedom from reintervention in the aorta and long‐term survival after frozen elephant trunk (FET) operation. Methods From July 2009 to June 2018, 79 patients underwent surgery with the FET technique. They had type A aortic dissection (acute 7.6%, chronic 33%), type B aortic dissection (acute 1.26%, chronic 34.2%), and complex thoracic aortic aneurysm (24%). 27.8% were reoperations and 43% received concomitant cardiac procedures. To compare the results, the sample was divided into group 1 (G1) (first half of the sample ‐ operations from 2009 to 2014) and group 2 (G2) (first half of the sample ‐ operations from 2015 to 2018). Results The in‐hospital mortality was 20.25%, 30.7% for G1 and 10% for G2 (P = .02). The mean cardiopulmonary bypass time, myocardial ischemia time, and selective cerebral perfusion at 25°C time were 154 ± 31, 118 ± 32, and 59 ± 12 minutes, respectively, similar for both groups. Stroke and spinal cord injury occurred in four and two patients, with no difference between groups (P = .61 and P = .24). The necessity for secondary intervention on the downstream aorta for both groups was also similar (P = .136). Five of sixty‐three surviving patients died during the follow‐up period and the estimated survival rate was different between groups 49% vs 88% (P = .007). Conclusion The learning curve with the FET procedure had a significant impact on hospital mortality and midterm survival over the follow‐up period, albeit did not influence the freedom from reintervention on the downstream aorta.

A Novel Sutureless Integrated Stented (SIS) Graft Prosthesis for Type A Aortic Dissection: A Pilot Study for a Prospective, Multicenter Clinical Trial

“…These wide variations in mortality may be attributed to differences in experience in addition to the aggressiveness of the procedure. Dinato and associates divided their patients into two groups according to the operative date distribution ( 25 ). The results showed that earlier in-hospital mortality (from 2009 to 2014) was significantly higher than that later (from 2015 to 2018) (30.7 vs. 10%; P = 0.02) and indicated that operative outcomes improved as experience accumulated.…”

Frozen elephant trunk in total arch replacement: A systematic review and meta‐analysis of outcomes and aortic proximalization

“…The complexity of the procedure for aortic dissection results in longer durations of operation and extracorporeal circulation, leading to postoperative renal failure in a significant proportion of patients 88 . The rate of acute renal failure after FET has been reported around 40% in some studies, 26,57 while it was identified in less than 10% in other reports 60,61 . In a meta‐analysis of 4178 patients, 8 the pooled estimate of acute renal failure was 15.5% (95% CI, 11.9–20.1).…”

“…Of 64 studies reporting outcomes of patients included in this report 13–76 . The proportions of studies from Asia, Europe, and North America were 54.7%, 31.3%, and 10.9%, respectively.…”

Commentary: The elephant in the room: Walking the walk and talking the talk after a frozen elephant trunk procedure

“…2,3 The prevalence of SCI is of particular importance, because the rates reported (4.7% in the current study of Preventza and colleagues, 1 5.1% in the study of Tian and colleagues, 2 and 5.0% in the report of Hanif and colleagues 3 ) are higher than those reported for the classic elephant trunk procedure, for 1-stage procedures performed without a stent graft, and for conventional aortic arch procedures. [3][4][5][6][7] Some important limitations of the current study that were acknowledged by Preventza and colleagues 1 deserve comment. Age of the patients was not analyzed separately.…”

“…These data may not reflect how the device will perform in lessexperienced centers as the procedure gains more widespread use, as the learning curve for FET can have a significant impact on hospital mortality and midterm survival. 6 FET may increase risk of spinal cord ischemia with extended stent coverage and should be used cautiously in acute type A dissection. RCTs are needed to guide best practice as FET gains widespread use.…”