Acute-on-Chronic Aortic Dissection: Management and Outcomes of the Unstable "Triple-Lumen" Aorta.

BACKGROUND: The impact of acute aortic dissection of the chronically dissected distal aorta is unknown. This study sought to describe the incidence and characteristics of the triple-lumen aortic dissection and its impact on survival. METHODS: From 2010 to 2021, a query of a single-institution aortic database identified 1149 patients with chronic distal aortic dissection. Thirty-three (2.9%) patients with at least 3 distinct lumens and 2 separate "primary" intimal tears were identified by analysis of contrast-enhanced cross-sectional imaging. Triple-lumen patients were exactly matched with a cohort of double-lumen patients on a 1:1 ratio using 5 preoperative variables, and outcomes between the groups were assessed. RESULTS: The median age at time of initial dissection in patients with a triple-lumen dissection was 46 years. Initial dissection was a type A in 33% and a type B in 67% of patients. The median time from initial dissection to triple-lumen diagnosis was 4.2 years. On diagnosis of the triple-lumen aorta, 85% of patients required urgent aortic repair for rapid growth (36%), aortic diameter ≥55 mm (30%), malperfusion (6%), intractable pain (6%), and rupture/type A (6%). Thirty-day mortality after triple lumen dissection was 12%. CONCLUSIONS: Acute-on-chronic distal dissection resulting in a triple-lumen aorta should be classified as a "complicated" type B dissection as these patients typically have large aneurysms and a high incidence of rapid false lumen expansion requiring urgent surgical repair.

Bentall versus valve-sparing aortic root replacement for root pathology with moderate-to-severe aortic insufficiency: a propensity-matched analysis.

OBJECTIVES: To examine short- and long-term outcomes of patients with moderate-to-severe aortic insufficiency (AI) undergoing either a Bentall aortic root replacement (ARR) or valve-sparing root replacement (VSRR). METHODS: A two-centre retrospective database of patients undergoing ARR from 2004 to 2021 was reviewed. Patients <18 years old were excluded. A total of 1527 adult patients underwent Bentall ARR (n = 1150, 75%) or VSRR (n = 377, 25%). Propensity score matching based on preoperative comorbidities was used and 195 matched pairs were identified. Perioperative outcomes, reoperation rates, recurrence of AI and long-term survival were evaluated. RESULTS: ARR patients had more concomitant ascending aortic replacement (35% vs 20%, P = 0.002) and shorter cardiopulmonary bypass (189 vs 233 min, P < 0.0001) and aortic cross-clamp (170 vs 204 min, P < 0.0001) times than the VSRR group. Postoperatively, outcomes were similar between groups, including stroke (3% vs 2%) and in-hospital mortality (1.5% vs 2.1%), all P > 0.05. Indications for and rates of reoperation (4% vs 5%, P = 0.62) of the aortic valve and proximal aorta were similar between ARR and VSRR groups with reoperations occurring a mean of 3.2 years after initial root replacement. The ARR group had less moderate-to-severe AI than the VSRR group (1.6% vs 14%, P = 0.002) a mean of 3 years after surgery. Ten-year survival was similar between ARR (84%) and VSRR (82%) (P = 0.69) groups. CONCLUSIONS: Both ARR and VSRR can be performed with acceptable short- and long-term outcomes in patients with moderate-to-severe AI.

Redo aortic surgery: Does one versus multiple affect outcomes?

Objective: Redo aortic surgery has a higher risk of morbidity and mortality because it is technically complex due to mediastinal adhesions, infection, and previously implanted prostheses. In this study, we sought to benchmark our single-center experience comparing outcomes in patients undergoing aortic surgery after 1 versus multiple previous cardiac operations. Methods: Between 2004 and 2019, 429 patients underwent redo aortic surgery. They were classified as aortic surgery after 1 previous surgery (first redo surgery, n = 360) and aortic surgery after 2 or more (multiple) previous surgeries (multiple redo surgery, n = 69). Postoperative outcomes and long-term survival were compared, and risk factors for mortality were identified. Results: Thirty-day mortality was lower in first redo surgery compared with multiple redo surgery (12.3% vs 21.7%, P = .03). Age, cardiopulmonary bypass time, intra-aortic balloon pump use, postoperative cerebrovascular accident, absence of postoperative atrial fibrillation, intra-aortic balloon pump, and multiple redo surgery were independent predictors of 30-day mortality. Long-term survival was similar at 15 years. Patients who received first redo surgery were older (57.9 ± 14.0 years vs 50.3 ± 15.8 years, P = .0001) and had a higher incidence of hypertension (84.7% vs 73.9%, P = .02), whereas patients who received multiple redo surgery had a higher incidence of cerebrovascular disease (31.9% vs 20.3%, P = .03). Aortic valve replacement was the most common previous operation with higher incidence in multiple redo surgery. Incidence of previous aortic surgery was similar. Cardiopulmonary bypass (246 ± 67.3 minutes vs 219.9 ± 57.5 minutes, P = .009) and crossclamp times (208.2 ± 51.8 vs 181.9 ± 50.8 minutes, P = .004) were longer in multiple redo surgery. Incidence of reentry injury and balloon pump insertion were similar. Extracorporeal membrane oxygenation use was higher in multiple redo surgery. Postoperative complications occurred at similar rates, except for higher incidence of dialysis in multiple redo surgery (14.5% vs 7.2%, P = .04). Conclusions: Multiple redo aortic procedures have a higher morbidity and mortality compared with first redo aortic procedures, with linearly increasing short-term mortality risk but similar long-term survival with the number of redo procedures.

Transcaval Versus Transaxillary TAVR in Contemporary Practice: A Propensity-Weighted Analysis.

OBJECTIVES: The aim of this study was to compare transcaval and transaxillary artery access for transcatheter aortic valve replacement (TAVR) at experienced medical centers in contemporary practice. BACKGROUND: There are no systematic comparisons of transcaval and transaxillary TAVR access routes. METHODS: Eight experienced centers contributed local data collected for the STS/ACC TVT Registry (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry) between 2017 and 2020. Outcomes after transcaval and axillary/subclavian (transaxillary) access were adjusted for baseline imbalances using doubly robust (inverse propensity weighting plus regression) estimation and compared. RESULTS: Transcaval access was used in 238 procedures and transaxillary access in 106; for comparison, transfemoral access was used in 7,132 procedures. Risk profiles were higher among patients selected for nonfemoral access but similar among patients requiring transcaval and transaxillary access. Stroke and transient ischemic attack were 5-fold less common after transcaval than transaxillary access (2.5% vs 13.2%; OR: 0.20; 95% CI: 0.06-0.72; P = 0.014) compared with transfemoral access (1.7%). Major and life-threatening bleeding (Valve Academic Research Consortium 3 ≥ type 2) were comparable (10.0% vs 13.2%; OR: 0.66; 95% CI: 0.26-1.66; P = 0.38) compared with transfemoral access (3.5%), as was blood transfusion (19.3% vs 21.7%; OR: 1.07; 95% CI: 0.49-2.33; P = 0.87) compared with transfemoral access (7.1%). Vascular complications, intensive care unit and hospital length of stay, and survival were similar between transcaval and transaxillary access. More patients were discharged directly home and without stroke or transient ischemic attack after transcaval than transaxillary access (87.8% vs 62.3%; OR: 5.19; 95% CI: 2.45-11.0; P < 0.001) compared with transfemoral access (90.3%). CONCLUSIONS: Patients undergoing transcaval TAVR had lower rates of stroke and similar bleeding compared with transaxillary access in a contemporary experience from 8 US centers. Both approaches had more complications than transfemoral access. Transcaval TAVR access may offer an attractive option.

Sex Differences in Failure-to-Rescue After Coronary Artery Bypass Grafting.

BACKGROUND: Female patients experience worse outcomes after coronary artery bypass grafting (CABG). We investigated whether rates of failure-to-rescue (FTR), a systems-based quality indicator, were greater in women who underwent CABG. METHODS: A retrospective review was conducted on 20 045 patients who underwent isolated, nonemergent CABG between January 2002 and August 2019 at a single academic center. FTR was defined as postoperative death within 30 days after stroke, renal failure, reoperation, and prolonged ventilation. Propensity score matching was performed utilizing preoperative variables, excluding sex. RESULTS: A total of 4980 propensity score-matched pairs were identified. In the matched analysis, women experienced higher rates of postoperative stroke (1.9% vs 1.2%; P = .008), prolonged ventilation (13.3% vs 10.0%, P < .001), and 30-day mortality (2.6% vs 1.8%; P = .01). Rates of FTR after stroke (P = .36), renal failure (P = .11), reoperation (P = .86), and prolonged ventilation (P = .48) were not statistically significant between female and male patients. CONCLUSIONS: Women who underwent isolated, nonemergent CABG had statistically similar frequencies of FTR compared with their male counterparts despite experiencing greater rates of morbidity and mortality. Further efforts to narrow the sex outcome gap after CABG should focus on preoperative and intraoperative phases of care instead of postoperative management.

Preoperative Lung Function Is Associated With Patient-Reported Outcomes After Lung Cancer Surgery.

BACKGROUND: Patient quality of life (QOL) is a critical outcomes measure in lung cancer surgery. Patient-reported outcomes (PROs) provide valuable insight into the patient experience and allow measurement of preoperative and postoperative QOL. Our objective was to determine which clinical factors predict differences in QOL, as measured by patient-reported physical function and pain intensity among patients undergoing minimally invasive lung cancer surgery. METHODS: PRO surveys assessing physical function and pain intensity were conducted using instruments from the National Institutes of Health Patient-Reported Outcomes Measurement Information System. PRO surveys were administered to patients undergoing minimally invasive lung cancer resections at preoperative, 1-month, and 6-month postoperative time points, in an academic institution. Linear mixed-effects regression models were constructed to assess the association between clinical variables on PRO scores over time. RESULTS: A total of 123 patients underwent a thoracoscopic lung resection for cancer. Mean age of the cohort was 67 ± 9.6 years, 43% were male, and 80% were White. When comparing clinical variables with PRO scores after surgery, lower diffusing capacity of the lungs for carbon monoxide (Dlco) was associated with significantly worse physical function (P < .01) and greater pain intensity scores (P < .01) at 6 months, with no differences identified at 1 month. No other studied clinical factor was associated with significant differences in PRO scores. CONCLUSIONS: Low preoperative Dlco was associated with significant decreases in PRO after minimally invasive lung cancer surgery. Dlco may be of utility in identifying patients who experience greater decline in QOL after surgery and for guiding surgical decision making.

Bicuspid aortic valve sparing root replacement.

BACKGROUND AND AIM OF STUDY: Mid and long-term data regarding the durability of bicuspid aortic valve sparing root replacement is not completely understood. In this study, our institutional experience is reviewed regarding this procedure with special attention to the operative technique. METHODS: From 2004 to 2019, 1241 patients underwent aortic root replacement and of these 79 patients underwent bicuspid aortic valve sparing root replacement. Early and late outcomes along with echocardiographic data were reviewed. Univariate analysis was used to identify risk factors for mortality. RESULTS: Median age at operation was 43 (inner quartile range: 34.5-50.5) years, with 17% (14) being female. Median follow up time was 4 (inner quartile range: 1-8) years with 359 years of total follow up. Early mortality was 2.5% (2). Overall 10-year freedom from aortic valve intervention was 95.6%. Risk factor analysis did not demonstrate preoperative root diameter, aortic diameter, or aortic insufficiency to be risk factors for mortality. CONCLUSION: Bicuspid aortic valve sparing root replacement can be performed safely in the setting of aortic root pathology and valve insufficiency. With appropriate selection and excellent surgical technique, long-term durable valve function is observed without the need for repeat valve intervention.

Regurgitant Bicuspid Aortopathy: Is Valve-Sparing Root Replacement Equivalent to Bentall Procedure?

BACKGROUND: Repair of aortic root aneurysms with nonstenotic bicuspid valves (NS-BAVs) is achieved either with valve-sparing root replacement (VSRR) or conventional Bentall procedure (ROOT). Procedural and long-term outcomes comparing these 2 techniques are sparse and need investigation. METHODS: From March 2004 to January 2019, 158 patients with an aortic root aneurysm and NS-BAV underwent VSRR (n = 78, 49.3%) or ROOT (n = 80, 50.6%). VSRR involved optional aortic valve repair (n = 47, 60%), and ROOT was performed with bioprosthetic (81.3%) or mechanical valve replacement (18.7%). Procedural and postoperative outcomes were obtained, and univariate and Kaplan-Meier analyses were performed. RESULTS: VSRR patients were younger (42.7 ± 12.0 years of age) than ROOT (54.8 ± 13.6 years of age) (P < .001). Cardiopulmonary bypass (CPB) and cross-clamp duration were longer in VSRR (CPB: 228.0 ± 39.1 minutes; cross-clamp: 200.1 ± 36.2 minutes) compared with ROOT (CPB: 199.5 ± 55 minutes; cross-clamp: 170.3 ± 39.5 minutes) (P < .001). Postoperative stroke, renal failure, pneumonia, and reoperation for bleeding were similar, but postoperative atrial and ventricular arrhythmias was lower in VSRR (15% vs 42%; P < .001). Length of stay and 30-day mortality were similar. At discharge, none had greater than trivial aortic insufficiency. Long-term 10-year survival and incidence of moderate-severe aortic insufficiency, aortic stenosis, and reoperation were equivalent between groups. CONCLUSIONS: Surgery for aortopathy associated with NS-BAV is safe and effective with either VSRR or ROOT. Despite its complexity, VSRR should be considered in the surgical treatment of this population.

Association Between Patient Physical Function and Length of Stay After Thoracoscopic Lung Cancer Surgery.

Patient-reported outcomes (PRO) are an ideal method for measuring patient functional status. We sought to evaluate whether preoperative PRO were associated with resource utilization. We hypothesize that higher preoperative physical function PRO scores, measured via the NIH-sponsored Patient Reported Outcome Measurement Information System (PROMIS), are associated with shorter length of stay (LOS). Preoperative physical function scores were obtained using NIH PROMIS in a prospective observational study of patients undergoing minimally invasive surgery for lung cancer. Poisson regression models were constructed to estimate the association between the length of stay and PROMIS physical function T-score, adjusting for extent of resection, age, gender, and race. Due to the significant interaction between postoperative complications and physical function T-score, the relationship between physical function and LOS was described separately for each complication status. A total of 123 patients were included; 88 lobectomy, 35 sublobar resections. Mean age was 67 years, 35% were male, 65% were Caucasian. Among patients who had a postoperative complication, a lower preoperative physical function T-score was associated with progressively increasing LOS (P  value = 0.006). In particular, LOS decreased by 18% for every 10-point increase in physical function T-score. Among patients without complications, T-score was not associated with LOS (P = 0.86). Preoperative physical function measured via PRO identifies patients who are at risk for longer LOS following thoracoscopic lung cancer surgery. In addition to its utility for preoperative counseling and planning, these data may be useful in identifying patients who may benefit from risk-reduction measures.