Single Low-Volume Center Experience with Frozen Elephant Trunk in Acute Type A Aortic Dissections.

BACKGROUND: Acute Type A aortic dissection (AAAD) is a surgical emergency. In patients with arch and descending aorta involvement (DeBakey Type I), a total aortic arch replacement with frozen elephant trunk (FET) could favor false lumen thrombosis and improve long-term results. The authors hereby present their experience with this technique in a single low-volume center, to assess whether the technique is feasible to treat such disease. METHODS: From January 2011 to December 2016, 43 patients with AAAD were operated on in the authors' institution, which carries out 300 to 350 annual procedures. Among these, 12 patients with an intimal tear in the aortic arch and/or proximal descending aorta received a FET procedure (10 males, age 57 years). Concomitant procedures were aortic valve replacement (42%), Bentall (25%), and aortic valve repair (17%). RESULTS: Cardiopulmonary bypass, cardiac arrest, and circulatory arrest times were 235 ± 43, 171 ± 33, and 75 ± 20 minutes, respectively. The operative mortality was 16.7% (n = 2). Stroke and re-thoracotomy for bleeding occurred in 8% (n = 1) and 8% (n = 1), respectively. There was no spinal cord injury. Follow-up was 36.1 months. During follow-up, no patients died or required a reoperation on the downstream aorta. CONCLUSION: Although all patients were operated on in a low-volume center, the results with FET in AAAD are acceptable. Even though this technique demands high technical skills, it is a promising approach in patients with acute aortic dissection.

Patient-prosthesis mismatch in aortic valve replacement: really tolerable?

OBJECTIVE: Several studies have demonstrated favorable results despite patient-prosthesis mismatch after aortic valve replacement with the use of third generation prostheses. Our aim was to determine whether this mismatch is always tolerable. METHODS: A clinical-echocardiographic study has been performed in 339 consecutive patients who underwent aortic valve replacement because of aortic stenosis. In-hospital outcome and left ventricular mass index regression (1st month-1st year) were analyzed in the presence or absence of mismatch (indexed effective orifice area < or =0.85cm(2)/m(2)). The influence of high degrees of preoperative left ventricular mass on in-hospital mortality has also been evaluated. Left ventricular mass index was considered increased if the calculated value was over the superior quartile of the frequency distribution of all the values observed in both sexes. RESULTS: Mismatch was found in 38% of the patients. In the absence of mismatch, the absolute mass regression was proportional to the preoperative left ventricular mass. This regression was higher in patients with increased left ventricular mass indexed (vs not increased): -38.0+/-7.8 vs -8.8+/-4.7g/m(2), p<0.01 (1st month) and -67.7+/-16.9vs -23.5+/-6.7g/m(2), p<0.05 (1st year). Mass regression was impaired in the presence of mismatch, particularly, in patients with previously increased left ventricular mass: -8.2+/-11.6 vs -5.6+/-6.3g/m(2) (p=0.83) and -24.6+/-12.6 vs -11.7+/-10.5g/m(2) (p=0.54). This worse regression was reflected on a 100% incidence of residual hypertrophy at follow-up (1st month-1st year). In the presence of mismatch, increased ventricular mass was associated with higher mortality: 14.7% vs 2.1% (p<0.01). In the absence of mismatch, ventricular mass was not associated with mortality: 4.1 vs 2.5% (p=0.55). CONCLUSIONS: In patients with severe ventricular hypertrophy it may be important to elude patient-prosthesis mismatch to avoid a significant increase in mortality and improve ventricular mass regression. Mismatch may be tolerable in those patients with lesser degree of hypertrophy.

Left ventricular mass index as a prognostic factor in patients with severe aortic stenosis and ventricular dysfunction.

Ventricular dysfunction and high hypertrophy may influence surgical outcome in aortic stenosis. Our aim was to determine whether an excessive left ventricular mass index (LVMI) discriminates different risk profiles in aortic stenosis with low ventricular ejection fraction (LVEF). Three hundred and thirty-nine patients with severe aortic stenosis underwent valve replacement (Mar-1994 and Nov-2001). LVMI values over the superior quartile were considered increased. Mortality models were constructed in global and LVEF