Acute type A aortic syndromes: outcomes are independent of aortic root/valve management.

Purpose: Clinical outcomes following various surgical intervention strategies for aortic root and valve pathology during repair of acute type A aortic syndromes were studied and compared. Methods: From 2004 to 2019, 634 patients underwent acute type A aortic repair. Patients were divided into 4 groups: Valve Resuspension (n = 456), Isolated Valve Replacement (AVR) (n = 24), Valve and Root Replacement (ROOT) (n = 97), and Valve Sparing Root Replacement (VSRR) (n = 57). The primary endpoint was midterm survival and multivariable risk factor analysis was performed. Results: The mean age was 55.4 ± 13 years, 424 (67%) were male, and overall early mortality was 12%. Early mortality was 13%, 8%, 11%, and 7% for the Valve Resuspension, AVR, ROOT, and VSRR groups respectively, p = 0.43. Five-year survival was 74%, 86%, 73%, and 84% for the Valve Resuspension, AVR, ROOT, and VSRR groups respectively, p = 0.46. There was no difference in late stroke, renal failure, heart block, and late bleeding (p > 0.05 for all). At late follow-up, AVR and ROOT patients had a higher mean gradient versus Valve Resuspension and VSRR patients, p < 0.0001. For the total cohort, risk factors for late mortality included preoperative peripheral vascular disease (hazard ratio (HR) 2.3, 95% confidence interval (CI) 1.2-4.4, p = 0.009) and preoperative dialysis (HR 2.8, 95% CI 1.3-6.1, p = 0.01). Conclusion: Mid-term survival following repair of acute type A aortic dissection is not independently associated with a specific type of aortic valve intervention. Native valve preservation leads to acceptable mid-term valve hemodynamics and should be the preferred therapy in this emergent clinical setting. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01602-8.

Optimal brain protection in aortic arch surgery.

There is considerable debate with regard to the optimal cerebral protection strategy during aortic arch surgery. There are three contemporary techniques in use which include straight deep hypothermic circulatory arrest (DHCA), DHCA with retrograde cerebral perfusion (DHCA + RCP), and moderate hypothermic circulatory arrest with antegrade cerebral perfusion (MHCA + ACP). Appropriate application of these methods ensures appropriate cerebral, myocardial, and visceral protection. Each of these techniques has benefits and drawbacks and ensuring coordinated circulation management strategy is critical to safe performance of aortic arch surgery. In this report, we will review various cannulation strategies, review logistics of hypothermia, and review the relevant literature to outline the strengths and weaknesses of these various cerebral protection strategies.

Clinical Outcomes Using Freestyle Valve-Valsalva Graft Composite Conduit for Aortic Root Replacement.

BACKGROUND: We reviewed the clinical outcomes of a novel method of aortic root replacement using a self-constructed tissue valve conduit composed of a Freestyle subcoronary valve sewn into a Valsalva graft. METHODS: From 2005 to 2020, 523 patients had aortic root replacement operations using a self-constructed Freestyle subcoronary-Valsalva graft tissue valve conduit. Median patient age was 62 years (interquartile range [IQR] 54-70), and 430 (82%) were men. Primary outcomes were mortality and the need for reoperation. Multivariable regression analyses were performed to identify risk factors for mortality and reoperation. RESULTS: Urgent procedures comprised 48.37% of cases, and 29.26% were reoperative procedures. Concomitant ascending aorta replacement, hemiarch replacement, and total arch replacement were required in 348 (67%), 227 (44%), and 40 (8%) patients, respectively. Cardiopulmonary bypass and cross-clamp times were 189 minutes (IQR, 164-218) and 166 minutes (IQR, 145-191), respectively. Early mortality was 7.7% (40), and 5- and 10-year survival rates were 83% and 71%, respectively. At the last echocardiogram follow-up left ventricular ejection fraction, left ventricular end-diastolic diameter, degree of aortic insufficiency, and mean aortic valve gradient were significantly improved from baseline (P < .001). Increasing age, peripheral artery disease, tobacco use, increased preoperative creatinine, and prior aortic valve surgery were risk factors for both mortality and the composite outcome (P < .02). CONCLUSIONS: In a complex patient population aortic root replacement using a self-constructed composite tissue valve conduit comprising a Freestyle subcoronary valve-Valsalva graft can be performed with excellent operative and 10-year outcomes. Midterm survival was acceptable, and valve durability was outstanding with an exceedingly low incidence for valve reintervention.

Aortic Arch Management During Acute and Subacute Type A Aortic Syndromes.

BACKGROUND: The purpose of this study was to compare the outcomes of no arch intervention, hemiarch replacement, and total arch replacement during type A aortic syndromes in a contemporary series. METHODS: From 2004 to 2019, 634 patients have required acute type A dissection repair; these patients were divided into three groups based on type of arch intervention performed: no arch (n = 130), hemiarch (n = 397), and total arch (n = 107). The primary endpoint was mortality; a multivariable risk factor analysis was performed. Secondary endpoints were reoperation and early and late complications. RESULTS: Operative age was 55 ± 14 years for the cohort and was similar between groups (P = .34). The incidence of peripheral artery disease, heart failure, and prior coronary artery bypass graft surgery differed between the groups (P < .05). Median cardiopulmonary bypass time, aortic cross-clamp time, and length of stay were longest for the total arch group (P < .0001). Early mortality was 20%, 10%, and 10% for the no-arch, hemiarch, and total arch groups, respectively (P = .01). Ten-year survival was 54%, 66%, and 65% for the no-arch, hemiarch, and total arch groups, respectively (P = .01). There was no difference in incidence or timing of redo aortic interventions (P > .05). For the entire cohort, risk factors for late mortality included preoperative peripheral artery disease (hazard ratio 2.3; 95% confidence interval, 1.2 to 4.4; P = .009) and preoperative dialysis (hazard ratio 2.8; 95% confidence interval, 1.3 to 6.1; P = .01). CONCLUSIONS: Despite longer cardiopulmonary bypass and aortic cross-clamp times, arch intervention was not associated with worse operative or long-term outcome in this series. Patients with peripheral vascular disease and preoperative renal failure remain at highest risk for mortality after type A aortic dissection repair.