Aortic Root In Acute Type Research Articles

The mid-term outcomes of aortic-root repair is not inferior to Bentall procedure in acute type-A aortic dissection

ObjectiveBentall procedure used to be standard operation for involved aortic root in acute type A aortic dissection (ATAAD). But aortic root repair for preserving valve is still controversial in ATAAD. This study aimed to evaluate the midterm outcomes of aortic root repair by comparing with Bentall approach. MethodsA retrospective analysis of 1075 ATAAD patients with aortic root involvement was conducted. The patients were divided into aortic root repair group (n = 447) and Bentall group (n = 628). The propensity score matching analysis (PSMA) was used to adjust the baseline. ResultsThe median follow-up was 44 months (interquartile range, 17–65 months; range, 1–130 months). The 30-day mortality in the repair and replacement groups was 15.0 % and 12.9 % (P = 0.327) respectively; the late overall mortality was 15.9 % and 14.0 % (P = 0.394) respectively. The Kaplan-Meier 10-year survival and free-from-reoperation was 86.0 % and 92.5 % respectively in the repair group. After PSMA, the cumulative survival rate [Hazard Ratio (HR) 0.685; 95 % Confidence Interval (CI) 0.457–1.027; P = 0.747]) and reoperation rate (HR 0.308; 95 % CI 0.070–1.355; P = 0.157) was not significantly higher in the repair group than in the Bentall group. ConclusionThe mid-term outcome of aortic root repair is probably not inferior to Bentall procedure. Therefore, root repair is an alternative approach in ATAAD with the advantage of preserving native valve.

The Aortic Root in Acute Type A Dissection: Repair or Replace?

BackgroundThe effect of an “aggressive” approach on the aortic root in acute type A aortic dissection (ATAAD) remains insufficiently explored. MethodsRetrospective analysis was conducted between 1992 and 2020 of a single-center, prospective cohort of consecutive patients aged ≥18 years diagnosed with ATAAD. Patients were divided into 2 groups: aortic root replacement (ARR; prosthetic or valve-sparing root replacement, n = 141) and conservative root approach (CRA; root sparing of partially dissected root, n = 90; and supracoronary ascending replacement in nondissected root, n = 68). Inverse probability weighting was used to compare patients with different preoperative characteristics. Mean follow-up was 5.1 (0-21) years in ARR and 7.1 (0-25) years in CRA. ResultsThe frequency of ARR increased over the years, with 19% and 78% of patients undergoing ARR in the earliest and most recent periods, respectively. Early mortality decreased over the years, despite a more aggressive approach, and remained lower in ARR. CRA was associated with a higher hazard of late mortality (hazard ratio, 1.38; 95% CI, 1.12-1.68; P = .001) and reintervention (hazard ratio, 2.08; 95% CI, 1.44-3.56; P = .001). After CRA, new-onset aortic valve insufficiency was a common cause of reintervention. ConclusionsOver the years, there was a gradual increase in the root replacement approach in ATAAD. Root replacement was associated with better long-term survival and fewer reinterventions compared with the conservative approach, whereas the in-hospital mortality decreased during these years. Hence, aggressive root replacement is safe and may be applied in ATAAD with good long-term clinical results, without increased hospital mortality.

Perioperative and Short-Term Outcomes of Sinus Replacement and Conservative Repair for Aortic Root in Acute Type A Aortic Dissection: A Prospective Cohort Study.

BackgroundTo compare outcomes between sinus replacement (SR) and conservative repair (CR) for dissected roots with normal size.MethodsFrom October 2018 to April 2021, a prospective cohort study was carried out. Patients were assigned to two groups (SR group and CR group) according to whether they underwent sinus replacement. Propensity score matching was applied to adjust preoperative variables and Kaplan–Meier method was used for survival analysis.ResultsThree hundred and eighty-seven patients were enrolled. In the whole cohort, 18 patients (4.7%) died postoperatively. The operative mortality of SR group was comparable to CR group (3.2% vs. 6.0%, p = 0.192 before matching; 3.5% vs. 7.0%, p = 0.267 after matching) and the incidence of hemostasis management under restarted cardiopulmonary bypass for root bleeding was lower in SR group (1.6% vs. 7.0%, p = 0.002 before matching; 2.1% vs. 8.5%, p = 0.03 after matching). The median follow-up duration was 12 months. There were 3 reoperations in the CR group. The estimated cumulative event rate of reoperation was 1.1 % at 12 months and 1.6% at 24 months in CR group, with a trend of a lower rate in the SR group (log-rank p = 0.089 before matching, p = 0.075 after matching). There was one late death in each group. The estimated cumulative event rate of death was 3.8% at 12 months and 24 months in the SR group, and was 6.6% in the CR group with no significant difference (log-rank p = 0.218 before matching, p = 0.120 after matching). Aortic regurgitation significantly improved postoperatively and remained stable during follow-up.ConclusionsSinus replacement is a simple, safe, and effective technique for repairing severely dissected sinus with a comparable time spent in operation and excellent immediate and short-term results. It had the advantages of eliminating false lumen and avoiding aortic root bleeding.

Progression of aortic root based on long-term imaging studies after acute type A dissection repair.

To determine the progression of aortic root in acute type A aortic dissection (ATAAD) patients after aortic root repair (ARr) or replacement (ARR) based on long-term follow-up imaging studies. From 1996 to 2019, 732 patients had ATAAD repair at our institution. Six hundred and seven of these patients had either ARr, (n = 383) or ARR (n = 224). Eighty-one patients were excluded due to a lack of postoperative imaging. Three hundred and thirty-two patients were included in the repair group and 194 patients in the replacement group for long-term follow-up imaging study. Compared to the ARR group, the ARr group was significantly older (60 years vs. 55 years) and had more patients with hypertension (79% vs. 63%) but less male patients (63% vs. 79%) and connective tissue disorder (1.8% vs 8%). The ARr group had more zone two arch replacement (22% vs. 11%), similar HCA time (35 min vs. 31 min), shorter cardiopulmonary bypass time (203 min vs. 266 min), aortic cross-clamp time (128 min vs. 214 min), and fewer concomitant coronary artery bypass (3.9% vs. 8.9%). The root growth rate over 12 years was similar between the repair and replacement group (0.20 mm/year vs. 0.18 mm/year, p = .75). Both the repair and replacement group had similar 15-year cumulative incidence of reoperation (6.9% vs. 5.9%; p = .67), operative mortality (7.8% vs. 8.5%; p = .78), and 15-year survival (51% vs. 52%; p = .40). There was minimal growth of the aortic root after root repair or replacement for ATAAD patients. Both aortic root repair and replacement were acceptable techniques for ATAAD surgery in select patients.

"Sleeve" Sinus of Valsalva Repair in Patients with Acute Type A Aortic Dissection.

The optimal surgical strategy of aortic root in acute type A aortic dissection (ATAAD) is controversial. The aim of this study was to evaluate the feasibility and safety of "Sleeve" Sinus of Valsalva repair for AAD limited to the non-coronary sinus or partial left and right coronary sinus without involvement coronary artery ostia. From September 2016 to March 2019, 20 patients with AAD involving non-coronary sinus or partial left and right coronary sinus Valsalva underwent "Sleeve" Sinus of Valsalva repair. A tailored Dacron patch was inserted into the dissected layers and two Dacron strips were placed inside and outside of the aorta, and the new five-layers root was sutured with 3/0 prolene continuous stitches. The artificial vessel was reversed about 1cm and anastomosed with the reconstructed root. Then, the reversed artificial vessel was pulled and anastomosed with the Dacron strip of the new proximal aorta. There was no early death in hospital and one death occurred during the 30-day postoperative period. Re-thoracotomy due to bleeding was necessary in only one patient and no bleeding was related to the proximal anastomosis. The postoperative drainage was 390.5 ± 229.3 mL. During follow up, the echocardiography showed the normal sinus of Valsalva and aortic valvular function. Computed tomography angiography showed normal aortic root without endovascular leak or dissection around the sinus of Valsalva. All patients were free from reoperation. "Sleeve" Sinus of Valsalva repair with Dacron patch for aortic dissection limited to the non-coronary sinus or partial left and right coronary sinus without involvement coronary artery ostia was technically feasible and safe.

Inner Coating for the Aortic Root in Acute Type A Dissection

In this issue of The Annals of Thoracic Surgery, Dai and colleagues1 report the midterm outcome of their original “patch neointima technique” for acute aortic dissection type A. For those patients with nonbicuspid, noninfected, and non–severely calcified aortic valve with insufficiency, they performed an aortic root repair using the patch neointima technique: three made-to-measure semicircular patches are sutured inside each sinus of Valsalva to provide a sturdy “inner coating” to the aortic root and support to the aortic valve.

Surgical Management and Outcomes of the Aortic Root in Acute Type A Aortic Dissection

This study evaluated the short- and middle-term outcomes of different aortic root managements in the setting of acute type A aortic dissection (ATAAD): aortic root repair (ARR group), untouched aortic root (UAR group), and Bentall procedure (Bentall group). The study enrolled 673 patients (512 men; age 48.8 ± 11.2 years) between 2010 and 2015. Survival, aortic growth, reintervention, and valve function were compared between the 3 groups. The ages were 50.6 ± 9.9, 49.8 ± 12.2, and 44.0 ± 12.0 years for ARR, UAR, and Bentall groups, respectively (P < .01). The mean follow-up time was 3.0 years (range, 0.5-6.8 years). The aortic root diameters in the groups were 39.0 ± 5.1 mm in ARR, 38.2 ± 4.4 mm in UAR, and 50.3 ± 6.2 mm in Bentall (P < .01). The overall 30-day mortality was 11.7% (79 of 673). There was no difference in 30-day mortality between the 3 groups (P= .58). The estimated aortic root growth rate was 0.60 ± 0.17 mm/y for ARR and 0.50 ± 0.14 mm/y for UAR. During follow-up, 28 patients (4.1%) died. Differences in 5-year survival between the 3 groups did not reach statistical significance (P= .82). Aortic insufficiency greater than grade 2+ developed in 15 patients (2.2%). There was no significant difference between ARR and UAR in freedom from aortic insufficiency greater than grade 2+ (P= .56). None of the patients experienced new dissection or underwent proximal reoperation during the follow-up period. Conservative techniques (ARR and UAR) and aggressive root replacement can both be performed with excellent short- and middle-term outcomes in ATAAD. Thus, an individualized approach in managing the aortic root for ATAAD is recommended based on the patient's general condition, root pathology, and the surgeon's preference.