Nonusefulness of Antithrombotic Therapy After Surgical Bioprosthetic Aortic Valve Replacement.

Controversy persists regarding the advisability of anticoagulation for the early period after biological surgical aortic valve replacement (AVR). We aim to examine the impact of various antithrombotic regimens on outcomes in a large cohort of biological AVR patients. Records of 1,111 consecutive adult patients who underwent surgical biological AVR at our institution between 2013 and 2017 were reviewed. Outcomes included stroke, bleeding, and death at 3 and 12 months. Treatment regimens included (1) no therapy, (2) anticoagulants (warfarin or Factor Xa inhibitors), (2) antiplateles (various), and (4) anticoagulants + antiplatelets. Kaplan-Meier analysis was used to track outcomes, and Cox-proportional hazards regression models were conducted to analyze effects of different therapies on adverse events. At 3 months, thromboembolic events were low and not significantly different between the no therapy group (2.2%) and anticoagulation (2.8%) or anticoagulation + antiplatelet (3.6%) or all groups (3.7%). The antiplatelet group was just significantly lower, at 2.2%. However, this was driven by non-stroke cardiovascular events in patients with coronary artery disease. The incidence of death at 3 months was low and not significantly different between all groups. At 12 months, there were no thromboembolic benefits between groups, but bleeding events were significantly higher in the anticoagulation group (no therapy (1.4%), anticoagulation (8.4%), antiplatelet (4.5%), anticoagulation + antiplatelet (7.9%)). In conclusion, none of the antithrombotic regimens showed benefits in stroke or survival at 3 or 12 months after biological AVR. Anticoagulation increased bleeding events. Routine anticoagulation after biological AVR appears to be unnecessary and potentially harmful.

Natural history and management of Kommerell's diverticulum in a single tertiary referral center.

OBJECTIVE: The Kommerell diverticulum (KD) is an extremely rare developmental abnormality of the aorta related to an aberrant subclavian artery (ASCA). The objective of our study was to review the natural history of KD and ASCA using our single-center experience in diagnosing and managing KD and ASCA. METHODS: A retrospective review of the Yale radiological database from January 1999 to December 2016 was performed. Only patients with KD/ASCA and a computed tomography (CT) scan of the chest were selected for review. The primary goal was to examine the natural history of KD and ASCA and the secondary goals were to review the management and outcomes of those patients treated for KD and ASCA. RESULTS: There were 75 patients with KD/ASCA identified, with a mean age of 63 ± 19 years; 49 were female (65%). On CT scans, left- and right-sided aortas were present in 47 (63%) and 28 (37%) patients. A right ASCA or a left ASCA were present in 47 (63%) and 28 (37%) patients. Six patients were symptomatic on presentation. Symptoms included dysphagia, chest or back pain, and emboli to the fingers. The mean KD diameter was 21.8 ± 6.0 mm and the distance to the opposite aortic wall (DAW) was 48.3 ± 10.8 mm. Sixty-six patients were followed for a mean of 31.7 ± 32.5 months. One patient ruptured without repair. Nine patients underwent operative intervention, including eight open and one endovascular repair. Complications from operative intervention included ischemic stroke with hemorrhagic transformation, deep vein thrombosis and pneumonia. The mean growth rate for KD and DAW was 1.45 ± 0.39 mm/year and 2.29 ± 0.47 mm/year, respectively. On multivariable regression analysis, hypertension was a predictor of growth of DAW (P = .03). CONCLUSIONS: KD is uncommon and shows a female predominance. The diverticulum grows, albeit slowly (KD and DAW growth rates of 1.45 ± 0.39 mm/year and 2.29 ± 0.47 mm/year). Most patients are asymptomatic, but dysphagia, chest/back pain, and distal emboli may occur. Rupture is rare. Symptomatic patients should be operated. Asymptomatic patients can be followed with serial CT scans.

Ascending Aortic Length and Risk of Aortic Adverse Events: The Neglected Dimension.

BACKGROUND: Little information is available regarding the longitudinal changes of the aneurysmal ascending aorta. OBJECTIVES: This study sought to outline the natural history of ascending thoracic aortic aneurysm (ATAA) based on ascending aortic length (AAL) and develop novel predictive tools to better aid risk stratification. METHODS: The ascending aortic diameters and lengths, and long-term aortic adverse events (AAEs) (rupture, dissection, and death) of 522 ATAA patients were evaluated using comprehensive statistical approaches. RESULTS: An AAL of ≥13 cm was associated with an almost 5-fold higher average yearly rate of AAEs compared with an AAL of <9 cm. Two AAL "hinge points" with a sharp increase in the estimated probability of AAEs were detected between 11.5 and 12.0 cm, and between 12.5 and 13.0 cm. The mean estimated annual aortic elongation rate was 0.18 cm/year, and aortic elongation was age dependent. Aortic diameter increased 18% due to dissection while AAL only increased by 2.7%. There was a noticeable improvement in the discrimination of the logistic regression model (area under the receiver-operating characteristic curve: 0.810) due to the introduction of aortic height index (AHI) (diameter height index + length height index). The AHIs <9.33, 9.38 to 10.81, 10.86 to 12.50, and ≥12.57 cm/m were associated with a âˆ¼4%, ∼7%, ∼12%, and ∼18% average yearly risk of AAEs, respectively. CONCLUSIONS: An aortic elongation of 11 cm serves as a potential intervention criterion for ATAA, which is even more reliable than diameter due to its relative immunity to dissection. AHI (including both length and diameter) is more powerful than any single parameter in this study.

Symptoms Matter: A Symptomatic but Radiographically Elusive Ascending Aortic Dissection.

Symptoms attributable to a thoracic aortic aneurysm (TAA) are a separate indication for prophylactic repair, irrespective of aortic size. We present the case of a 56-year-old female with a history of a thoracic ascending aortic aneurysm (TAAA) and four other heart and arch vessel abnormalities who presented to us with chest pain radiating to her back. Computed Tomography and echocardiography showed no evidence of a dissection and revealed a maximal ascending aortic diameter of 4.2 cm. The patient subsequently underwent root-sparing ascending aortic and hemiarch replacement due to her threatening symptomatology. A focal dissection was discovered intraoperatively, resembling a similar case previously reported by our team.

Decision-making algorithm for ascending aortic aneurysm: Effectiveness in clinical application?

OBJECTIVE: The risk of rupture and dissection in ascending thoracic aortic aneurysms increases as the aortic diameter exceeds 5 cm. This study evaluates the clinical effectiveness of a specific algorithm based on size and symptoms for preemptive surgery to prevent complications. METHODS: A total of 781 patients with nondissecting ascending thoracic aortic aneurysms who presented electively for evaluation to our institution from 2011 to 2017 were triaged to surgery (n = 607, 77%) or medical observation (n = 181, 24%) based on a specific algorithm: surgery for large (>5 cm) or symptomatic aneurysms. A total of 309 of 781 patients did not undergo surgery. Of these, 128 (16%) had been triaged to prompt repair but did not undergo surgery for a variety of reasons ("surgery noncompliant and overwhelming comorbidities" group). Another 181 patients (24%) were triaged to medical management ("medical" group). RESULTS: In the "surgery noncompliant and overwhelming comorbidities" versus the "medical" group, mean aortic diameters were 5 ± 0.5 cm versus 4.45 ± 0.4 cm and aortic events (rupture/dissection) occurred in 17 patients (13.3%) versus 3 patients (1.7%), respectively (P < .001). Later elective surgeries (representing late compliance in the "surgery noncompliant and overwhelming comorbidities group" or onset of growth or symptoms in the "medical" group) were conducted in 21 patients (16.4%) versus 15 patients (8.3%) (P = .04), respectively. Death ensued in 20 patients (15.6%) versus 6 patients (3.3%) (P < .001), respectively. In the "surgery noncompliant and overwhelming comorbidities" group, 7 of 20 patients died of definite aortic causes compared with none in the "medical" group. CONCLUSIONS: Patients with ascending thoracic aortic aneurysms who did not follow surgical recommendations experienced substantially worse outcomes compared with medically triaged candidates. The specific algorithm based on size and symptoms functioned effectively in the clinical setting, correctly identifying both at-risk and safe patients.

Antithrombotic Therapy after Bioprosthetic Aortic Valve Replacement: A Therapeutic Morass.

Valvular heart disease is a common pathologic condition that affects 6 million people in the United States and more than 100 million worldwide. The most common valvular disorder is aortic stenosis. Current American and European guidelines recommend surgical management for symptomatic aortic stenosis with low risk of perioperative complications and endovascular intervention for high-risk patients with multiple comorbidities. Considering the increasing volume of aortic valve replacement (AVR) with biological valves, it is very important to select the appropriate anticoagulant after surgical AVR. In this article, we review the impact of anticoagulation on immediate and remote complications after AVR.

Height alone, rather than body surface area, suffices for risk estimation in ascending aortic aneurysm.

BACKGROUND: In international guidelines, risk estimation for thoracic ascending aortic aneurysm (TAAA) is based on aortic diameter. We previously introduced the aortic size index (ASI), defined as aortic size/body surface area (BSA), as a predictor of aortic dissection, rupture, and death. However, weight might not contribute substantially to aortic size and growth. We seek to evaluate the height-based aortic height index (AHI) versus ASI for risk estimation and revisit our natural history calculations. METHODS: Aortic diameters and long-term complications of 780 patients with TAAA were analyzed. Growth rate estimates, yearly complication rates, and survival were assessed. Risk stratification was performed using regression models. The predictive value of AHI and ASI was compared. RESULTS: Patients were stratified into 4 categories of yearly risk of complications based on their ASI and AHI. ASIs (cm/m2) of ≤2.05, 2.08 to 2.95, 3.00 to 3.95 and ≥4, and AHIs (cm/m) of ≤2.43, 2.44 to 3.17, 3.21 to 4.06, and ≥4.1 were associated with a 4%, 7%, 12%, and 18% average yearly risk of complications, respectively. Five-year complication-free survival was progressively worse with increasing ASI and AHI. Both ASI and AHI were shown to be significant predictors of complications (P < .05). AHI categories 3.05 to 3.69, 3.70 to 4.34, and ≥4.35 cm/m were associated with a significantly increased risk of complications (P < .05). The overall fit of the model using AHI was modestly superior according to the concordance statistic. CONCLUSIONS: Compared with indices including weight, the simpler height-based ratio (excluding weight and BSA calculations) yields satisfactory results for evaluating the risk of natural complications in patients with TAAA.