Total arch replacement and frozen elephant trunk for type A aortic dissection after Bentall procedure in Marfan syndrome

Abstract

Background: We seek to report the long-term outcomes of the total arch replacement and frozen elephant trunk (TAR + FET) technique for type A aortic dissection (TAAD) following prior Bentall procedure in patients with Marfan syndrome (MFS). Methods: Between 2003 and 2015, we performed TAR + FET for 26 patients with MFS who developed TAAD following a prior Bentall procedure. Mean age at FET 36.9±9.7 years and 24 were males. TAAD was acute in 8 (30.8%, all new dissections from precious root aneurysm) and chronic in 18 (69.2%, 15 residual and 3 new). The interval from Bentall procedure to FET averaged 6.4±5.8 years, which was significantly longer in the acute group (10.3±6.3 vs. 4.6±4.9, P=0.021). The early and long-term outcomes were compared between two groups and risk factors identified for late adverse events.Results: Operative mortality was 11.5% (3/26). Stroke, lower limb ischemia and reexploration for bleeding occurred in 1 patient each (3.8%). Follow-up was complete in 100% (23/23) at mean 5.1±2.3 years (range, 0.9-11.2 years). The maximal diameter (DMax) of distal aorta in the chronic group was significantly greater at the unstented descending aorta [DA, (56.4±15.5 vs. 35.6±12.2 mm, P=0.006)] compared to acute patients. The false lumen was obliterated in 95.7% across the FET and 56.5% in the unstented DA. Distal aortic dilation occurred in 13 patients (11 chronic, 68.8%). Of those 11 patients, 4 underwent an open thoracoabdominal aortic repair and 3 died of distal aortic rupture. Late death occurred in 7 patients at mean 3.9±2.5 years. At 6 years, the incidence was 18% for death, 11% for distal aortic reoperation, and 71% for reoperationfree survival. Survival did not differ between two groups (75.0% vs. 71.3%, P=0.851), while acute patients had significantly higher freedom from late rupture and reoperation at 6 years (100% vs. 61.9%, P=0.046). Bentall procedure in patients with MFS. Early and late survival did not differ with acute and chronic dissections, while freedom from late rupture and reoperation is significantly higher in patients with acute TAAD. Patients with hypertension and aged <35 years are at higher risk for late distal aortic dilation, reoperation and death.

Is the frozen elephant trunk technique justified for chronic type A aortic dissection in Marfan syndrome?

“…According to the 2014 European Society of Cardiology guidelines, aortic dissection is divided into sub-acute (15-90 days) and chronic (>90 days) (1). Patients with cTAAD who had a history of proximal aortic surgery were excluded from this study (10,15). The diagnosis of cTAAD was confirmed by computed tomographic angiogram (CTA) in all patients.…”

“…Since 2003, we have been using the TAR and FET technique to repair TAAD for patients with MFS (8). Our experience has proven the benefits of the TAR and FET technique with respect to long-term survival and freedom from reoperation in such patients (7,(9)(10)(11)(12). In this study, we seek to assess the early and long-term outcomes of the TAR and FET technique for cTAAD in MFS, and to identify the risk factors for death and reoperation in such patients.…”

Efficacy of Total Aortic Arch Replacement Combined with Frozen Elephant Trunk in Aortic Reoperation

“…Although operation on the great artery can currently be done by many hospitals in China, primary hospitals conduct ascending aortic replacement or root replacement instead of more thorough surgical methods only for patients with acute type A aortic dissection, due to technical conditions and hardware factors, which will lead to reoperation in the future. The literature has reported that the 5-year survival rate for type A AD patients receiving simple ascending aortic replacement or root replacement for the first time is only 70–80%, the 10-year reoperation rate is more than 10% [6–9], and the average age of Chinese patients is around 45 years old. These results are unacceptable, since the average age of the patients in this study was 44.7 years old.…”

Decision-making at initial surgery for type A aortic dissection in patients with Marfan syndrome: proximal or extensive repair

“…The indication of TAR + FET for TAAD in MFS patients was DeBakey type I dissection, as well as DeBakey type II dissection with an enlarged arch or proximal descending aorta. The surgical technique of TAR + FET has been depicted in detail previously (6,10,11).…”