Longitudinal Outcomes of Thoracic Endovascular Aortic Repair for Ruptured Thoracic Aortic Aneurysms.

OBJECTIVES: Limited data exist on long-term mortality and reintervention rates of emergent thoracic endovascular aortic repair (TEVAR) for ruptured thoracic aortic aneurysm (rTAA). This study aimed to characterize the long-term outcomes of emergent TEVAR for rTAA. METHODS: This study reviewed all TEVARs for emergent rTAA and elective intact thoracic aortic aneurysms (iTAA) from August 2005 to March 2022 at a large academic medical center. Outcomes, including overall survival and reinterventions, were considered over eight years. RESULTS: Of 321 patients, 65 received TEVAR for rTAA (34 hemodynamically stable) and 256 for iTAA. Respective mean (SD) ages were 74.4 (11.9) and 74.7 (9.1) years. Median follow-up was 5.1 years. rTAA patients had lower 30-day survival (69.2% vs 96.9%, P < .001) and higher rates of stroke, pneumonia, and prolonged ventilation (all P ≤ .01). Survival was significantly worse for rTAA at 1 year (46% vs 86%), 5 years (27% vs 48%), and 8 years (20% vs 32%; all P < .001). For patients surviving at least 90 days, the long-term survival difference narrowed to statistical insignificance. Ruptured aneurysms required more reinterventions within 30 days, but comparable long-term reintervention rates. Indications for reintervention were similar, with type I endoleak as the leading cause. Long-term survival for hemodynamically stable rTAA patients did not differ significantly from iTAA patients (49% vs 48% at 5 years). CONCLUSIONS: Short-to-medium-term outcomes are worse for ruptured aneurysms. However, long-term survival of hemodynamically stable rTAA patients and rTAA patients who survive the first 90 days are comparable to iTAA patients.

The non to moderately dilated root in acute type A aortic dissection: outcomes of the PENN-BERN registry in young, non-syndromic patients.

OBJECTIVES: There is an ongoing debate regarding whether patients benefit more from root replacement compared to a reconstruction of the sinuses of Valsalva in acute type A aortic dissection (aTAAD). In those with known or suspected connective tissue disorders, root replacement is considered appropriate. However, there are currently no diameter-based guidelines regarding the best approach in patients with minimally to moderately dilated root and no connective tissue disorders. METHODS: From January 2005 to December 2022, a two-centre registry of aTAAD was created. Patients were included based on their age (≤60 years), the absence of root entry and dilatation >50 mm and the absence of syndromic hereditable aortic disease. Patients were divided into 2 groups based on the proximal procedure, root reconstruction and root replacement. Propensity score pair matching was performed based on preoperative characteristics. RESULTS: Cumulative incidence of reintervention at 10 years was slightly higher after root reconstruction 13% vs 3.9% in the matched group (P = 0.040). Survival at 10 years was not affected by the procedure independently of the matching 72.1% vs 71.4% (P = 0.2). Uni- and multivariate Cox regressions showed that a root diameter of >40 mm was associated with a hazard ratio of 7.7 (95% confidence interval 2.6-23) and 5.4 (7-17), respectively, for reoperation for aneurysm and pseudoaneurysm. CONCLUSIONS: Rate of reoperation due to proximal pseudoaneurysm and aneurysm could be significantly reduced with a lower threshold of 40 mm to replace the aortic root in aTAAD than in elective cases.

Validation of the GERAADA score to predict 30-day mortality in acute type A aortic dissection in a single high-volume aortic centre.

OBJECTIVES: This study aimed to evaluate employing the German Registry of Acute Aortic Dissection Type A (GERAADA) score to predict 30-day mortality in an aortic centre in the USA. METHODS: Between January 2010 and June 2021, 689 consecutive patients underwent surgery for acute type A dissection at a single institution. Excluded were patients with missing clinical data (N = 4). The GERAADA risk score was retrospectively calculated via a web-based application. Model discrimination power was calculated with c-statistics from logistic regression and reported as the area under the receiver operating characteristic curve with 95% confidence intervals. The calibration was measured by calculating the observed versus estimated mortality ratio. The Brier score was used for the overall model evaluation. RESULTS: Included were 685 patients [mean age 60.6 years (SD: 13.5), 64.8% male] who underwent surgery for acute type A aortic dissection. The 30-day mortality rate was 12.0%. The GERAADA score demonstrated very good discrimination power with an area under the receiver operating characteristic curve of 0.762 (95% confidence interval 0.703-0.821). The entire cohort's observed versus estimated mortality ratio was 0.543 (0.439-0.648), indicating an overestimation of the model-calculated risk. The Brier score was 0.010, thus revealing the model's acceptable overall performance. CONCLUSIONS: The GERAADA score is a practical and easily accessible tool for reliably estimating the 30-day mortality risk of patients undergoing surgery for acute type A aortic dissection. This model may naturally overestimate risk in patients undergoing surgery in experienced aortic centres.

Custodiol HTK versus Plegisol: in-vitro comparison with the use of immature (H9C2) and mature (HCM) cardiomyocytes cultures.

BACKGROUND: Although cardioplegia is used since the '70s of the last century, debate on cardioprotection during cardio-surgical procedures is still actual. The selection of a particular method depends mainly on the preferences and experience of a specific center or even surgeon. Crystalloid cardioplegia is an aqueous ion solution similar to intracellular (Custodiol HTK) or extracellular (Plegisol) fluid. The potensional clinical advantages of relatively new idea of cardioplegia solution based on intracellular composition (Custodiol HTK) justifies futher research, but only a few used cultured cells in laboratory conditions. METHODS: In this study, the authors sought to compare Custodiol HTK with Plegisol cardioplegia solutions using an in-vitro model simulating cardioplegic arrest. The efficacy of myocardial protection during ischemia was investigated with susceptible indicators like the appearance of the deleterious effect of reactive oxygen species and oxidative stress markers. Immersed human cardiomyocytes and rat cardiomyoblasts H9C2 in cardioplegia for 4 h were examined for expression of oxidative stress markers (MnSOD, iNOS, HSP27), cardioplegic solutions cytotoxicity, and peroxidation damage of the cell's lipids and proteins. All tests were performed after 0.5 h, 1 h, 2 h, and 4 h of incubation in identical physical and biological conditions, which is difficult to achieve in clinical trials. RESULTS: The lower cytotoxicity index performed on matured cells of human cardiomyocytes and highest dehydrogenase level showed after incubation with Custodiol HTK. This did not apply to tests on immature cells H9C2. Custodiol HTK induced significantly stronger iNOS expression. The decrease of HSP27 concentration has been instantaneous and maintained troughout the study only in both cultures incubated with Custodiol HTK. The other tests: lipid peroxidation, carbonyl groups concentration and MnSOD expression show no clear superiority evidence of used cardioplegic solutions. CONCLUSIONS: Considering proceeded examinations on cultured cardiomyocytes, Custodiol HTK appears to be safer than Plegisol.

Non-A non-B acute aortic dissection with entry tear in the aortic arch.

OBJECTIVES: Our aim was to describe the outcomes of the latest treatment options of acute non-A non-B aortic dissection involving an entry tear in the aortic arch. METHODS: Included were patients who presented between January 2001 and February 2020 with a non-A non-B aortic dissection involving the aortic arch but not the ascending aorta and with the most proximal entry tear located within the aortic arch between the innominate and left subclavian artery. Clinical data and operative details were retrieved from medical histories and surgical protocols. Preoperative, postoperative and follow-up computed tomography angiography scans were analysed. RESULTS: We analysed a total of 39 patients [median age 62 (52; 67) years, men 76.9%] with non-A non-B arch entry aortic dissections type. They underwent 15 thoracic endovascular aortic repairs, 20 frozen elephant trunk implantations, 1 hybrid arch replacement, or 1 conventional arch replacement. Two patients were managed conservatively. Twelve (31%) patients underwent emergent intervention, 12 (31%) were treated invasively within 2 weeks. Another 2 (5%) and 9 (23%) patients were treated 2 and 4 weeks after dissection occurred, respectively. Six (15%) patients presented with an impending aortic rupture, while 19 (49%) had at least one malperfused organ. Four patients (27%) died after thoracic endovascular aortic repair; the 30-day mortality following frozen elephant trunk was 0%. CONCLUSIONS: Non-A non-B acute aortic dissection reveals a frequently complicated course requiring emergency intervention. The majority of patients required aortic arch repair within the first 2 weeks. Total arch replacement with the frozen elephant trunk technique seems to be low procedural mortality, and may become the treatment of choice in arch entry non-A non-B aortic dissection.

Early aortic growth in acute descending aortic dissection.

OBJECTIVES: Acute aortic dissection leads to the destabilization of the aortic wall, followed by an immediate increase in aortic diameter. It remains unclear how the aortic diameter changes during the dissection's acute and subacute phases. The aim of this study was to evaluate the change in aortic geometry within 30 days after the onset of a descending aortic dissection. METHODS: Patients with acute type B and non-A non-B dissection who had at least 2 computed tomography angiography scans obtained within 30 days after the onset of dissection were evaluated. Exclusion criteria were a thrombosed false lumen, connective tissue disorders and endovascular or open aortic repair performed prior to the second computed tomography angiography. RESULTS: Among 190 patients with acute aortic dissection, 42 patients met our inclusion criteria. Their aortic geometry was analysed according to the computed tomography angiography scans obtained between 0-3 (N = 35), 4-7 (N = 9) and 8-30 (N = 12) days after the dissection onset. The highest aortic diameter growth rate was observed in the first quartile of the thoracic aorta and measured 0.66 (0.06; 1.03), 0.29 (-0.01; 0.41) and 0.06 (-0.13; 0.26) mm/day at 0-3, 4-7 and 8-30 days after the dissection, respectively. Proximal entry location (P = 0.037) and entry located at the arch concavity (P = 0.008) were associated with a higher aortic diameter increase. CONCLUSIONS: Early rapid growth occurs during the first week after the descending aortic dissection-most intensely over the first 3 days, and this is associated with the location of the dissection's entry.