Aortic root remodelling with external ring annuloplasty in acute type A aortic dissection.

OBJECTIVES: To investigate the early and mid-term results of aortic root remodelling with external ring annuloplasty in acute type A aortic dissection. METHODS: From January 2015 to April 2019, a total of 194 patients underwent emergency or urgent operation for acute type A aortic dissection in our hospital. Of these, outcomes in 18 patients who underwent valve-sparing aortic root remodelling with external ring annuloplasty were retrospectively evaluated. RESULTS: The mean age of the 18 patients was 49 ± 14 years. Fourteen patients (78%) were men. Five patients had Marfan syndrome and 2 patients had bicuspid aortic valve. Two patients had coronary malperfusion and 1 patient had cerebral malperfusion. All 18 patients underwent aortic root remodelling with external ring annuloplasty. Cusp repair using central cusp plication was required in 9 patients. Concomitant procedures were hemiarch replacement in 8 patients, total arch replacement in 7 patients, partial arch replacement in 1 patient and coronary artery bypass grafting to the right coronary artery in 3 patients. Thirty-day mortality rate was 5.6% (1 of 18). Postoperative echocardiography showed aortic regurgitation of <1+ in all patients. During follow-up (mean 56 ± 41 months), 1 case of recurrent aortic regurgitation required aortic valve replacement. CONCLUSIONS: Aortic root remodelling with external ring annuloplasty may be an appropriate treatment in middle-aged or younger patients presenting with acute type A aortic dissection.

Surgical embolectomy for high-risk acute pulmonary embolism is standard therapy.

OBJECTIVES: Acute massive pulmonary embolism (AMPE) is a life-threatening condition that often induces rapid haemodynamic deterioration. The mortality of surgical embolectomy is still poor in patients with preoperative cardiopulmonary arrest (CPA). We analysed the outcome of surgical pulmonary embolectomy for haemodynamically unstable patients. METHODS: Thirty-one patients underwent surgical embolectomy for haemodynamically unstable AMPE. The indications for surgical embolectomy were (i) <7 days from onset, (ii) haemodynamically unstable, (iii) massive clots in bilateral pulmonary arteries or unilateral pulmonary artery occlusion with a floating clot in the main pulmonary artery or right atrium and (iv) right ventricular dilatation in transthoracic echocardiography. Eight (25.8%) patients had cardiopulmonary arrest. Nine (29.0%) patients received preoperative percutaneous cardiopulmonary support (PCPS). The mean original Pulmonary Embolism Severity Index (PESI) and simplified PESI scores were 158 ± 51 and 2.4 ± 0.9, respectively. RESULTS: The hospital mortality rate was 12.9% (n = 4). Two patients died of hypoxia. Multiorgan failure occurred by sepsis and by right ventricular failure in 1 patient each. No hospital deaths occurred in patients with preoperative PCPS (n = 9). The mean follow-up period was 47.7 ± 35.9 months (range, 3 - 134 months) and the 5-year survival rate was 83.2 ± 6.9%. Postoperative pulmonary artery pressure significantly decreased from 52.7 to 25.8 mmHg. CONCLUSIONS: Surgical embolectomy for high-risk AMPE patients has an excellent operative mortality and long-term outcome. Preoperative PCPS may lead to an immediate stable haemodynamic state and improve surgical embolectomy results, especially in high-risk patients (e.g. those with preoperative CPA). Surgical embolectomy for AMPE is an established operation and considered as the first-line therapy.