Outcome comparison of different approaches to aortic root aneurysm.

BACKGROUND: The treatment of aortic root aneurysm remains challenging for both cardiac surgeons and cardiologists. AIMS: This study aimed to assess and compare the long-term outcomes of different approaches to aortic root replacement (ARR). METHODS: All elective patients operated for aortic root aneurysm with or without aortic regurgitation at our institution over a 10-year period were included. We excluded patients with any degree of aortic stenosis and with active endocarditis. We assessed mortality, freedom from reoperation, freedom from aortic valve regurgitation, and the rate of hemorrhagic and thromboembolic complications. RESULTS: Two hundred and four patients underwent elective aortic root replacement: 107 (53%) valve-sparing aortic root replacement (VSARR), 35 (17%) mechanical Bentall procedure (MB), and 62 (30%) Bio-Bentall procedure (BB). Early mortality for VSARR, BB, and MB group was 2.8%, 4.8%, and 0%, respectively (P = 0.40). Estimated 5-year survival was: 90.2% vs. 78.4% vs. 94.2%, respectively (P = 0.12), 5-year freedom from reoperation: 97.8%, 96.6%, and 96.8%, respectively (P = 0.99). Estimat-ed 5-year freedom from complications was: 94.2%, 83.1% and 57.3% in the VSARR, BB and MB group, respectively (P <0.001). On last follow-up echocardiography, 90.5%, 98.4%, and 97.1% (P = 0.08) of patients were free from aortic regurgitation grade 2 or higher. The median (IQR) aortic valve peak gradient was 9 (6-12) mm Hg, 12 (10-18) mm Hg and 16 (14-22) mm Hg, respectively (P <0.001). Complications were predicted by mechanical Bentall (hazard ratio, 6.70 [2.54-17.63]; P <0.001). CONCLUSION: With the same mortality, freedom from reoperation, and a minimal late complication rate in comparison with mechanical Bentall and Bio-Bentall, VSARR might be the preferred approach to aortic root aneurysm.

Open aortic arch surgery: 10 years' single-center experience.

INTRODUCTION: Open aortic arch surgery is a complex cardiac surgical procedure. AIM: We reviewed the 10-year outcomes of elective aortic arch aneurysm surgery in a single cardiac surgical center. MATERIAL AND METHODS: The analysis includes all patients who underwent elective aortic arch surgery at our institution between January 2010 and December 2020. The study population was divided into group A consisting of patients operated on during the first 5 years, and group B, including patients operated on during the subsequent 5 years. The groups were compared with regard to baseline characteristics, scope of the surgery, operative and postoperative data as well as morbidity and mortality. RESULTS: Eighty-six elective aortic arch procedures were performed during the analyzed period, including 25 (29%) patients in group A and 61 (71%) patients in group B. The hemiarch procedure was more frequently performed in group A (17 patients, 68%) in comparison to group B (21 patients, 34%) (p = 0.008). Stroke was recorded in 6 (20%) patients from group A and 5 (8.2%) patients from group B (p = 0.002). Five-year survival was 60 ±9.8% for group A, and 81 ±6.2% for group B (log-rank test, p = 0.003). CONCLUSIONS: After completion of the learning curve, open aortic arch surgery is associated with acceptable early mortality, low incidence of stroke, and a high 5-year survival rate.

The Role of Deep Hypothermia in Cardiac Surgery.

Hypothermia is defined as a decrease in body core temperature to below 35 °C. In cardiac surgery, four stages of hypothermia are distinguished: mild, moderate, deep, and profound. The organ protection offered by deep hypothermia (DH) enables safe circulatory arrest as a prerequisite to carrying out cardiac surgical intervention. In adult cardiac surgery, DH is mainly used in aortic arch surgery, surgical treatment of pulmonary embolism, and acute type-A aortic dissection interventions. In surgery treating congenital defects, DH is used to assist aortic arch reconstructions, hypoplastic left heart syndrome interventions, and for multi-stage treatment of infants with a single heart ventricle during the neonatal period. However, it should be noted that a safe duration of circulatory arrest in DH for the central nervous system is 30 to 40 min at most and should not be exceeded to prevent severe neurological adverse events. Personalized therapy for the patient and adequate blood temperature monitoring, glycemia, hematocrit, pH, and cerebral oxygenation is a prerequisite and indispensable part of DH.

Long-Term Clinical Outcomes and Carotid Ultrasound Follow-Up of Transcarotid TAVI. Prospective Single-Center Registry.

This study aimed to prospectively evaluate the safety and long-term clinical outcomes of cerebral-oximetry-guided transcarotid transcatheter aortic valve implantation (TC-TAVI) with systematic follow-up with carotid ultrasound. Thirty-three TCTAVI procedures were performed in our center from 2017 to 2019. Our analysis includes in-hospital outcomes and long-term follow-up data on mortality, echocardiographic parameters, carotid Doppler ultrasound, and VARC-2 defined clinical events. Intraoperatively, one patient died, and one had a transient ischemic attack (TIA). The following events occurred in-hospital postoperatively: myocardial infarction (3.0%), cardiac tamponade (3.0%), new-onset atrial fibrillation (6.3%), need for temporary pacing (27.3%) and need for pacemaker implantation (15%). The mean follow-up was 19.5 ± 9.52 months. In the long-term follow-up, the two-year survival rate was 83% ± 14. The echocardiographic parameters did not differ significantly from the postprocedural values, and the ultrasound did not show any cases of significant vessel narrowing. The mean peak systolic velocity (PSV) was 71.6 cm/s in the left common carotid artery and 70.6 cm/s in the right common carotid artery. In conclusion, cerebral oximetry-guided TC access is safe, has a favorable long-term outcome, and does not increase the risk of plaque formation in the carotid artery. In a carefully selected group of patients, it might be considered as a first-choice alternative to TF access.

Aortic Root Reconstruction with TachoSil Fibrin Sealant Patch in Acute Type A Aortic Dissection.

PURPOSE: We propose a novel technique for reconstruction of the dissected aortic root with the use of TachoSil fibrin sealant patch. METHODS: Patients with acute type A aortic dissection involving the aortic root were included. Appropriately prepared TachoSil fibrin sealant patch was placed between the dissected layers of the aortic root to achieve their durable fusion. Thus, the false lumen was eliminated, and the anatomical and functional structure of the aortic wall was restored. RESULTS: In all, 13 patients mean aged 57 ± 10.3 years underwent surgery for acute type A aortic dissection with the use of TachoSil fibrin sealant patch. All patients survived the surgery. The mean follow-up time was 30.8 ± 16.4 months. Follow-up computed tomography angiography (CTA) scans confirmed no aortic root dissection in all patients. CONCLUSIONS: This technique ensures durable restoration of the aortic wall structure, eliminates the secondary aortic valve regurgitation, and allows for the preservation of patients' native aortic valve.

Comparison of bicuspid and tricuspid aortic valve repair.

OBJECTIVES: The aim of this study was to compare the outcomes of tricuspid aortic valve (TAV) and bicuspid aortic valve (BAV) repair. METHODS: We assessed mortality, freedom from reoperation and the rate of aortic valve regurgitation recurrence. Mortality in both groups was compared with expected survival, and risk factors for reoperation were identified. RESULTS: From January 2010 to April 2020, a total of 368 elective aortic valve repair procedures were performed, including 223 (60.6%) in patients with TAV. The perioperative mortality was 0.7% in the BAV group and 3.6% in the TAV group (P = 0.079). Estimated survival at 5 years in the BAV versus TAV group was 97 ± 3% vs 80 ± 6%, respectively (P < 0.001). Freedom from reoperation at 5 years in the TAV versus BAV group was 96 ± 3% vs 93 ± 4%, respectively (P = 0.28). Grade 2 or more aortic valve regurgitation was noted in 9.9% of BAV patients and 11% of TAV patients (P = 0.66). Reoperation was predicted by cusp perforation [hazard ratio 15.86 (4.44-56.61); P < 0.001], the use of pericardial patch [hazard ratio 8.58 (1.96-37.53); P = 0.004] and aortic valve annulus diameter >27.5 mm [hazard ratio 3.07 (0.99-9.58); P = 0.053]. CONCLUSIONS: BAV repair is as durable as TAV repair. BAV is not a predictor of a higher rate of reoperations. BAV repair yields survival comparable to expected. Cusp perforation, aortic valve annulus diameter >27.5 mm and the use of pericardial patch adversely impact long-term outcome of aortic valve repair.

Comparison of the short-term safety and efficacy of transcarotid and transfemoral access routes for transcatheter aortic valve implantation.

BACKGROUND: Transfemoral access is the preferred approach for transcatheter aortic valve implantation (TAVI), as it is characterized by the lowest complication rate. In the majority of patients ineligible for transfemoral access, the transcarotid approach can be used. AIMS: This study aimed to compare short­term outcomes in 2 groups of patients treated with transcarotid or transfemoral TAVI. METHODS: A retrospective comparison included 265 patients in whom the TAVI procedure was performed between 2017 and 2019 (transcarotid TAVI, n = 33; transfemoral TAVI, n = 232). Preoperative characteristics, procedural and postprocedural outcomes, as well as 30­day mortality were assessed. RESULTS: Compared with the transfemoral TAVI group,patients undergoing transcarotid TAVI presented with a higher New York Heart Association (NYHA) functional class (median [interquartile range (IQR)], 3 [3-3] vs 2 [2-3]; P <0.001), a higher surgical risk (median [IQR] EuroSCORE II, 6 [4.8-10.7] vs 4.8 [2.8-7.9]; P = 0.003), and a higher incidence of peripheral artery disease (36.4% vs 18.1%; P = 0.035). The median (IQR) procedure duration in the transcarotid TAVI group was shorter than in patients undergoing transfemoral TAVI (65 [60-80] min vs 90 [80-110] min; P <0.001, respectively). In both study groups, we noted a high percentage of procedural success (transcarotid vs transfemoral TAVI, 96.9% vs 97.2%; P = 0.66). We found no significant differences between transcarotid TAVI and transfemoral TAVI in terms of periprocedural and 30­day mortality as well as the number of strokes. Regardless of the access route chosen, echocardiographic parameters and the NYHA class similarly improved compared with preprocedural data. CONCLUSIONS: Despite posing a higher baseline risk and presenting a greater anatomic complexity, transcarotid access is safe and associated with 30­day outcomes similar to those observed for transfemoral access. Importantly, procedural time was short and no periprocedural strokes or vascular complications were reported.

Aneurysm of the aortic root and valve­sparing aortic root replacement: long-term outcomes from a single Polish center.

BACKGROUND: Valve-sparing aortic root replacement (VSARR) techniques are an alternative to the classic Bentall procedure when aortic root aneurysm is not accompanied by aortic valve stenosis, and the regurgitant aortic valve is amenable to repair. AIMS: The aim of the study was to assess long -term outcomes of valve sparing aortic root replacement using the David technique and the Yacoub technique. METHODS: A total of 101 consecutive, elective VSARR procedures were performed from January 2010 to April 2020 including 52 David procedures (51.5%) and 49 Yacoub procedures (48.5%). We analyzed mortality, freedom from reoperation, and freedom from aortic valve regurgitation. The analysis was performed for the entire study cohort and for 2 subgroups: the David technique and the Yacoub technique. RESULTS: The mean (SD) age was 50.2 (16.1) years; 90 (89.1%) patients were male. The median (interquartile range [IQR]) EuroScore II was 3.7 (2.7‒5.8). At 1, 5, and 8 years after surgery, survival (SE) was 98% (3%), 91.8% (8%), and 91.8% (8%), respectively, whereas freedom from reoperation (SE) was 100%, 97% (3%), and 97% (3%), respectively. Follow­up echocardiography performed at a median (IQR) of 18.7 (2.5‒36.7) months postsurgery revealed freedom from aortic valve regurgitation in 90.8% of patients. No significant differences in mortality, freedom from reoperation, and freedom from aortic valve regurgitation were noted between the David and Yacoub subgroups. CONCLUSIONS: VSARR is a safe and effective surgical technique in patients with aortic root aneurysm, as the associated mortality, reoperation rate, and aortic valve regurgitation recurrence are low.