Ascending Aortic Replacement Research Articles

Breaking the Limit of Cardiovascular Regenerative Medicine: Successful 6-Month Goat Implant in World's First Ascending Aortic Replacement Using Biotube Blood Vessels.

This study investigated six-month outcomes of first models of ascending aortic replacement. The molds used to produce the Biotube were implanted subcutaneously in goats. After 2-3 months, the molds were explanted to obtain the Biotubes (inner diameter, 12 mm; wall thickness, 1.5 mm). Next, we performed ascending aortic replacement using the Biotube in five allogenic goats. At 6 months, the animals underwent computed tomography (CT) and histologic evaluation. As a comparison, we performed similar surgeries using glutaraldehyde-fixed autologous pericardial rolls or pig-derived heterogenous Biotubes. At 6 months, CT revealed no aneurysmalization of the Biotube or pseudoaneurysm formation. The histologic evaluation showed development of endothelial cells, smooth muscle cells, and elastic fibers along the Biotube. In the autologous pericardium group, there was no evidence of new cell development, but there was calcification. The histologic changes observed in the heterologous Biotube group were similar to those in the allogenic Biotube group. However, there was inflammatory cell infiltration in some heterologous Biotubes. Based on the above, we could successfully create the world's first Biotube-based ascending aortic replacement models. The present results indicate that the Biotube may serve as a scaffold for aortic tissue regeneration.

Isolated or Combined Ascending Aortic Replacement through a Partial Sternotomy: Early and Midterm Outcomes

Abstract Background We aimed to investigate the in-hospital and midterm outcomes of patients undergoing ascending aortic replacement (AAR) through a partial or a full sternotomy approach through a propensity matching analysis. Methods We retrospectively included all patients (n = 167) who underwent elective AAR in our institution between 2013 and 2020. The study population was divided into two groups according to the surgical access (40 patient in the partial sternotomy or “PS” group and 127 in the full sternotomy or “FS” group). Due to the significant differences between the groups, a propensity matching of 1:3 was applied. In-hospital complications, survival, and reoperation at follow-up were investigated. Results The PS group showed higher cross-clamp and cardiopulmonary bypass times than the FS group (94.2 vs. 83 minutes and 164.2 vs. 126.8 minutes, respectively). Moreover, the postoperative ventilation time was significantly higher in the PS group, but it did not affect the length of stay in the intensive care unit (ICU). The incidences of bleeding, stroke, and mortality were comparable between the two groups (11 vs. 3%, 3 vs. 6%, and 5 vs. 3%, respectively). After a median follow-up of 2 ± 1.98 years, the Kaplan–Meier analysis showed no significant differences between the two groups (log-rank, p = 0.17) in terms of survival. Conclusion The surgical ascending aorta replacement through a partial sternotomy is associated with longer operative times, but this does not affect the early as well as the long-term follow-up.

Strategy for acute DeBakey type I aortic dissection considering midterm results: a retrospective cohort study comparing ascending aortic replacement and total arch replacement with frozen elephant trunk technique

BackgroundAcute type A aortic dissection is treated with an emergency procedure that uses ascending aortic replacement (AAR). However, to avoid a residual dissected aorta with a false lumen, total arch replacement (TAR) is required. The frozen elephant trunk (FET) technique is a promising surgical approach that promotes false lumen obliteration in a single step. Therefore, this retrospective single-center study aimed to evaluate the operative outcomes of AAR and TAR with FET.MethodsBetween 2007 and 2021, 143 patients with acute DeBakey type I aortic dissection underwent a central repair using AAR (n = 95) or TAR with FET (n = 43). All perioperative variables, the duration of all-cause mortality, and aortic events defined as dilatation of the distal aorta > 5 cm, new occurrences of aortic dissection, distal aortic surgery, and distal aortic rupture were recorded. We compared these perioperative variables and mid-term results with an additional focus on distal aortic events.ResultsPatient background data did not differ between the two groups. Perioperative results for the TAR with FET group vs the AAR group showed similar operative times (306 vs 298 min, P = 0.862), but the TAR group had longer cardiopulmonary bypass times (154 vs 179 min, P < 0.001). The freedom from all-cause death for the TAR vs AAR groups using the Kaplan–Meier method was 81.9% vs 85.4% and 78.0% vs 85.4% (P = 0.407) at 1 and 3 years, respectively. Freedom from aorta-related events was 90.6% vs 97.6% and 69.3% vs 87.0% (P = 0.034) at 1 and 3 years, respectively.ConclusionsTAR with FET had comparable perioperative results to AAR in acute DeBakey type I aortic dissection and was considered a valuable method to avoid aorta-related events in the midterm.

Abstract 15941: Efficacy of Frozen Elephant Trunk for Acute Type A Aortic Dissection

Objectives: There are various treatment strategies for acute type A aortic dissection (ATAAD). In our department, total arch replacement (TAR) using the Frozen Elephant Trunk (FET) is the standard technique for DeBakey type I, which has a patent false lumen, and we assessed the outcomes and postoperative complications. Methods: Of 71 consecutive patients who underwent surgical treatment for ATAAD at our department from October 2020 to May 2023, 42 patients were included, excluding 29 patients whose the descending aorta was thrombosed or not dissected. Results: Age 64±11 years, 30 male patients (71.4%). Preoperatively, cardiac tamponade was observed in 5 cases, malperfusion in 5 cases of head, 2 cases of coronary artery, 3 cases of celiac artery, 3 cases of superior mesenteric artery, 13 cases of renal artery, and 13 cases of lower limbs. The surgical procedures were ascending aortic replacement (AAR) in 6 cases (14.2%), partial arch replacement (PAR) in 2 cases (4.8%), TAR in 5 cases (11.9%), and TAR with FET in 29 cases (69.0%). The mean operation time was 304±70 minutes, the mean cardiopulmonary bypass time 168±45 minutes, the mean cardiac arrest time 100±26 minutes, the mean circulatory arrest time 42±8 minutes, and the mean minimum bladder temperature 26.1±1.4°C. There was no hospital death, and complications included new stroke in 2 patients (4.8%). The residual dissection was AAR5/6 (83.3%), PAR1/2 (50.0%), TAR5/5 (100%), and TAR with FET24/29 (82.8%), of which AAR5/5 (100%), PAR1/1 (100%), TAR2/5 (40.0%), and TAR with FET1/24 (4.2%) had residual dissection in the proximal descending aorta. There were 3 deaths (meningitis, cerebral hemorrhage, gastrointestinal hemorrhage) with a mean follow-up of 8.9±6.7 months. The only additional treatment was preemptive TEVAR in 1 case (2.4%) for residual dissection of proximal descending aorta of TAR with FET. There was no case of stent induced new entry. Conclusions: We consider the early results for ATAAD to be favorable. Furthermore, TAR with FET promotes good thrombosis and remodeling down to the proximal descending level, suggesting that FET may contribute to improved outcomes during follow-up period. Further clinical research on mid-term outcomes is needed.

Ascending Aortic Surgery for Small Aneurysms in Men and Women.

According to recent data, thoracic aortic surgery has reduced morbidity and mortality including ascending aortic aneurysm treatment; however, women are at increased postoperative risk of adverse outcomes. Our aim was to evaluate early and late outcomes in male and female patients who underwent pre-emptive ascending aortic replacement (AAR). From January 2013 to September 2021, 91 patients (56 [61.5%] men and 35 [38.5%] women) underwent AAR for small (ranged from 5.0 to 5.5 cm) non-syndromic aneurysms. A propensity score-based adjustment of the groups was performed. We compared clinical outcomes between males and females. Preoperative normalized aortic diameters were significantly larger in females (2.9 [2.7; 3.2] cm/m2) than in males (2.5 [2.3; 2.6] cm/m2, P<0.001), without differences in absolute values (51 [49; 53] mm vs. 52 [50; 53] mm, P=0.356). There were no significant differences in neurological, cardiac, pulmonary, and renal complications in both groups before and after matching. In-hospital mortality was 1 (1.8%) and 2 (5.7%) (P=0.307) in male and female patients in unmatched groups and 1 (2.9%) and 2 (5.7%) (P=0.553) in matched groups, respectively. Univariate logistic regression analysis revealed that the only risk factor for in-hospital mortality was age (odds ratio 1.117, 95% confidence interval 1.003-1.244; P=0.04). The overall survival rate was 83.5±0.06% in men and 94.3±0.04% in women at 36 months (P=0.404). Ascending aortic surgery for aneurysms ranged from 5.0 to 5.5 cm seems to have tolerable early and late outcomes in men and women.

TCTAP C-091 Unexpected Coronary Involvement After Emergent Ascending Aortic Replacement

TCTAP C-091 Unexpected Coronary Involvement After Emergent Ascending Aortic Replacement

No Shame in Sole Ascending Aortic Replacement for Acute Type A Aortic Dissection

No Shame in Sole Ascending Aortic Replacement for Acute Type A Aortic Dissection

A Comparative Study of the Early and Short-Term Outcomes of Aortic Replacement in Patients with Stanford type A Aortic Dissection and Ascending Aortic Aneurysm.

Ascending aortic replacement is a challenging and complex surgery. The mortality, morbidity, and outcomes depend on the causes of the ascending aortic pathology and the type of operation. The research was conducted in a single-center, prospective, observational cohort study of patients undergoing ascending aortic replacement due to dissection or aneurysm. In the hospital, mortality, morbidity, and short-term outcomes were measured. A total of 85 patients were included in this study. Of them, 65.9% were male, and 34.1% were female. Thirty-three patients had Stanford type A aortic dissection (STAAD), whereas 52 had ascending aortic aneurysm (ASAA). Early mortality was (21.21% and 1.9%) for STAAD and ASAA, respectively, while the survival rate after one year was (75.8% and 96.15 %) for ascending dissection and aneurysm, respectively. The results of our study show higher early surgical mortality and morbidity and a lower short-term survival rate for STAAD surgery compared with ASAA surgery.

Long-term risk of arch complications in Loeys Dietz syndrome patients undergoing proximal ascending aortic replacement.

Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder. In LDS patients with normal arch morphology, whether the arch should be prophylactically replaced at the time of proximal aortic replacement remains unknown. We evaluated the risk of long-term arch complications in genetically confirmed LDS patients who underwent proximal ascending aortic replacement. We retrospectively reviewed the records of patients with LDS who have been followed at our institution between 1994 and 2020. Patients were only included if whole exome genetic testing confirmed a mutation in an LDS-causing gene (TGFBR1, TGFBR2, SMAD3, TGFB2, or TGFB3). Mutations were categorized as pathogenic, benign, or of unknown significance. We collected demographic information, aortic dimensions, comorbidities, mortality, and operative course from patients' charts. Descriptive statistics and freedom from reoperation plots were generated. Of the 18 patients with a mutation in an LDS-causing gene, 15 had known pathogenic variants, two had mutations of unknown significance, and one had a benign genetic variant. For the 15 patients with confirmed pathogenic variants of LDS the median follow-up duration was 5 years (interquartile range [IQR]: 4-8). Eleven patients underwent ascending aortic replacements (AAR) ± aortic valve replacement. Two patients required an additional operation; one required arch and staged elephant trunk for a dissection 18 years post-AAR and the other patient required an isolated descending aortic replacement for dissection 5 years post-AAR. Among patients who underwent surgery, the median ascending aortic diameter at intervention was 5.0 cm (IQR: 4.3-5.3). There was no surgical or late follow-up mortality observed for any of the 18 patients in the study. LDS patients who underwent proximal aortic replacement appeared to have low long-term risk of arch complications. While our study is somewhat limited by its sample size and follow-up duration, it suggests that routine prophylactic total arch replacement may not be warranted in LDS patients with nonaneurysmal aortic arches.

A Case of Redo Ascending Aortic Replacement for Anastomotic Pseudoaneurysm through Right Thoracotomy in a Patient with Severe Coagulation Disorder

A Case of Redo Ascending Aortic Replacement for Anastomotic Pseudoaneurysm through Right Thoracotomy in a Patient with Severe Coagulation Disorder

Theoretical Feasibility of Using Arch Branched Endograft Devices for Repair of Post Type A Aortic Dissection in Patients With Prior Ascending Aortic Replacement

Purpose: Ascending aortic replacement is a common emergency procedure for treating acute type A aortic dissection. Secondary open or endovascular interventions for residual arch pathologies is difficult because of adhesions, short prosthetic grafts, and distorted anatomies. Aortic arch branched stent grafts have emerged as a potential solution for these patients if they have suitable anatomical conditions. This study aimed to evaluate the theoretical anatomical and technical feasibility of 2 currently used aortic arch branch endografts in patients who had prior replacement of the ascending aorta. Materials and Methods: All patients who had a prosthetic ascending aortic or hemiarch replacement for acute type A dissection in a single institution between January 2013 and December 2018 were included. Contrast computed tomography images on the most recent follow-up were analyzed on a 3-dimensional workstation. Morphological parameters were measured individually for the ascending aorta, aortic arch, supra-aortic branches, and access iliac arteries. The computed tomography scan of each patient was individually evaluated for anatomical suitability for the arch branched and double-branch devices according to set selection criteria. Results: Computed tomography images of 56 patients (median age of 57 years, 45 males) were reviewed. Based on our evaluation, 26 patients (46.4%) were good candidates for an endovascular arch branched device. It would be feasible for 13 patients (23.2%), but prudent preoperative planning was required due to complicated anatomy. The other 17 patients (30.4%) were unsuitable because they met at least 1 exclusion criterion. Short prosthetic grafts, extreme graft angulations, and extensive dissections in the supra-aortic branches were the main reasons for exclusion. Conclusion: Endovascular repair using arch branched endografts is feasible in patients with prior ascending aortic arch or hemiarch replacement for acute type A aortic dissection. The most common anatomical conditions that may influence the feasibility of the arch branched endograft procedure include insufficient proximal seal length, severe angulation of the graft, and extensive aortic dissection within the supra-aortic vessels.

Outcomes Following Supracoronary Ascending Aortic Replacement with Aortic Valve Resuspension versus Modified Bentall's Operation for Acute Type A Aortic Dissection.

IntroductionType A acute aortic dissection (AAD) remains a challenging cardiac emergency despite the availability of various management strategies. This study compared the outcomes of supracoronary ascending aortic replacement (SCAAR) with aortic valve (AV) resuspension with those of modified Bentall's operation for type A AAD and the progression of aortic regurgitation (AR), long-term dilatation of aortic root and proximal arch, and long-term mortality in SCAAR patients.MethodsSixty patients underwent surgery for type A AAD (January 2005 to December 2015). Forty-three patients underwent SCAAR with AV resuspension and 17 underwent modified Bentall's operation. All patients were followed up.ResultsUpon follow-up of SCAAR patients (n=40), there was significant reduction in aortic root size (preoperative 39.3 mm [9.4] vs. postoperative 33.1 mm [9.1]; P<0.001). Three of these patients worsened to severe AR while others had similar or lesser degree of AR. On comparison between preoperative and postoperative dimensions of all patients (n=53), there was no significant difference in distal ascending aorta size (35.7 mm [8.1] vs. 34.4 mm [8.9]; P=0.52). However, an increase in descending thoracic aorta size (28.8 mm [7.8] vs. 33.7 mm [9.9]; P<0.001) was observed. In-hospital and late mortalities for SCAAR vs. modified Bentall's procedure were 11.7% (seven patients) (7% [3] vs. 23.5% [4]) and 28% (15 patients) (15% [6] vs. 69% [9]), respectively.ConclusionSCAAR with AV resuspension is a safe surgical option for type A AAD. Preservation of AV is associated with better long-term outcomes and reduced mortality. Modified Bentall's operation may be associated with long-term mortality.

Integrated Aortic-Valve-And-Ascending-Aortic Replacement vs. Partial Replacement in Bicuspid Aortic Valve-Related Aortopathy.

Objective: We sought to evaluate the outcomes of integrated aortic-valve and ascending-aortic replacement (IR) vs. partial replacement (PR) in patients with bicuspid aortic valve (BAV)-related aortopathy.Methods: We compared long-term mortality, reoperation incidence, and the cumulative incidence of stroke, bleeding, significant native valve or prosthetic valve dysfunction, and the New York Heart Association (NYHA) functional classes II-IV between inverse probability-weighted cohorts of patients who underwent IR or PR for BAV-related aortopathy in a single center from 2002 to 2019. Patients were stratified into different aortic diameter groups (“valve type” vs. “aorta type”).Results: Among patients with “valve type,” aortic valve replacement in patients with an aortic diameter > 40 mm was associated with significantly higher 10-year mortality than IR compared with diameter 35–40 mm [17.49 vs. 5.28% at 10 years; hazard ratio (HR), 3.22; 95% CI, 1.52 to 6.85; p = 0.002]. Among patients with “aorta type,” ascending aortic replacement in patients with an aortic diameter 52–60 mm was associated with significantly higher 10-year mortality than IR compared with diameter 45–52 mm (14.49 vs. 1.85% at 10 years; HR, 0.04; 95% CI, 1.06 to 85.24; p = 0.03).Conclusion: The long-term mortality and reoperation benefit that were associated with IR, as compared with PR, minimizing to 40 mm of the aortic diameter among patients with “valve type” and minimizing to 52 mm of the aortic diameter among patients with “aorta type.”Trial Registration: Treatment to Bicuspid Aortic Valve Related Aortopathy (BAVAo Registry): ChiCTR.org.cn no: ChiCTR2000039867.

Case report of Double Valve Replacement with Coronary Artery Bypass Grafting with Supracoronary Ascending Aortic Replacement in a Single Patient - A Chimera

Double valve replacement is now-a-days a common procedure to treat diseased cardiac valves and the primary aim of prophylactic aortic replacement during concomitant valve replacement is to prevent dreadful complication like dissection, aortic rupture and even death. Although aortic surgeries are complex and have high morbidity and mortality rates, additional double valve procedure with coronary surgery can make it even worse. But for these patients, surgery remains the one and only treatment option for symptom relieve and prolongation of life. We herein present a case of severe aortic stenosis (AS) with severe aortic regurgitation (AR) with severe mitral regurgitation (MR) with coronary artery disease (CAD) and aortic aneurysm treated successfully by us at Square Hospitals; and to our best knowledge and according to the published articles, this is probably the first time, this type of combined cardiac procedure has been accomplished along with aortic surgery, in our country. We recommend that surgeons should perform bypass grafting along with aortic replacement and valve replacement surgery when indicated, without worrying that adding such a procedure will escalate post-operative adverse effect. Cardiovasc j 2021; 14(1): 82-87

Feasibility and Outcome of Cardiovascular Surgeries Combined with Ozaki Procedure; Single Center Single Surgeon Experience

Objective: Considering aortic valve surgeries, use of prosthetic valves is associated with issues of quality, technology, availability and affordability in developing countries like Sri Lanka. In such setting, Ozaki procedure can be used to treat spectrum of aortic valve diseases, and can be combined with other cardiac surgeries. This study focused on recapitulating the current practice of Ozaki procedure combined with other cardiac surgeries. Methods: This retrospective cross sectional study was carried out from October 2019 to October 2020 at National Hospital Kandy. All patients were operated by a single surgeon. Total number of patients were 10 (6 males, 4 females) with mean age 52 years. Severe aortic stenosis 6, severe aortic regurgitation 3, combination of both 1, were assigned for Ozaki procedure and combined as follows. One patient had undergone isolated Ozaki procedure following aortic valve vegetectomy. Results: All patients were successfully weaned from CPB. Intra-operative echocardiogram showed no significant aortic or mitral regurgitation. Ejection fraction was preserved at 50 ±10%. Mean cross-clamp time for AV reconstruction only was 92 ± 18 minutes and mean length of stay on the intensive care unit was 70 ± 18 hours and hospital stay was 6 ± 1.5 days after combined procedures. No pacemaker implanted after all procedure. No reoperation done. Conclusions: In our experience, this technique can be mastered after a relatively short training period, can be used for variety of aortic valvular pathology, can combined successfully with other surgeries and even with aortic conduits. Ozaki procedure remains a very attractive strategy with excellent haemodynamics and may have the potential to overcome the structural disadvantages of prosthetic valves including use of warfarin. Combined procedure No of cases Coronary artery bypass grafting 5 Mitral valve ring annuloplasty 1 Coronary artery bypass grafting/ Mitral valve ring annuloplasty 1 Ascending aortic replacement 2

Does the 45 mm Size Cutoff for Ascending Aortic Replacement Predict Better Early Outcomes in Bicuspid Aortic Valve?

The aim of this study is to test if the newly proposed 45 mm size criterion for ascending aortic replacement (AAR) in bicuspid aortic valve (BAV) patients undergoing aortic valve replacement (AVR) is predictive of improved early outcomes. Data of 306 BAV patients with an aortic diameter of ≥45 mm undergoing AVR alone or with AAR were retrospectively analyzed. Patients were divided into groups of AVR + AAR (n = 220) and AVR only (n = 86) based on if surgery was performed according to the 45 mm criterion. End point was early adverse events, including 30-day and in-hospital mortality, cardiac events, acute renal failure, stroke, and reoperation for bleeding. Cox regression was used to assess if conformance to 45 mm criterion could predict fewer early adverse events. AVR + AAR group had significantly higher postoperative left ventricular ejection fraction (LVEF) (0.59 ± 0.09 vs. 0.55 ± 0.11, p = 0.006) and longer cardiopulmonary bypass (CPB) time (128 vs. 111 minutes, p = 0.002). Early adverse events occurred in 45 patients (14.7%), which was more prevalent in the AVR-only group (22.1% vs. 11.8%, p = 0.020). Conformance to the 45 mm criterion predicted lower rate of early adverse events (hazard ratio [HR]: 0.53, 95% confidence interval [CI]: 0.28-0.98, p = 0.042). After adjustment for gender, age, AAo diameter, sinuses of Valsalva diameter, preoperative LVEF, Sievers subtypes, BAV valvulopathy, and CPB and cross-clamp times, conformance to the 45 mm size criterion still predicted lower incidence of early adverse events (HR: 0.37, 95% CI: 0.15-0.90, p = 0.028). This study shows that conformance to 45 mm size cutoff for preemptive AAR during aortic valve replacement in patients with BAV was not associated with increased risk for adverse events and may improve early surgical outcomes.

Technical Feasibility of Arch Branched Endograft Repair in Type A Aortic Dissection with Prior Ascending Aortic Replacement

Introduction - Ascending aortic replacement is a common emergency procedure for treatment of acute type A dissection. Secondary open or endovascular intervention for residual arch pathologies is however difficult due to adhesions, short prosthetic grafts, and distorted anatomy. Aortic arch branched stent graft has emerged as a potential solution for these patients. The aim of this study is to evaluate the technical feasibility of two current aortic arch branch stent grafts in patients who had prior ascending aortic replacement. Methods - All patients who had a prosthetic ascending aortic replacement for acute type A dissection in a single institution between January 2013 and December 2017 were included. Contrast CT images on follow up were analyzed on a 3D workstation. Morphologic parameters were measured individually including: (i) Ascending aorta: diameter, greater and lesser curvature length from the coronary origin, angulation of residual ascending aorta and prosthetic graft. (ii) aortic arch: width and height of the arch, tortuosity index. (iii) supra-aortic branches: diameter, separation, sealing length, dissection, and take-off clock positions. Each patient’s CT scan was individually evaluated for anatomical suitability for the Zenith arch branched device (Cook Medical) and Relay double-branch device (Bolton Medical) according to set selection criteria. Adverse anatomical factors were further identified including prosthetic aortic valve replacement, insufficient proximal landing length, incompatible landing zone diameter, severe angulation of prosthetic ascending aorta, hostile arch branches sealing zone, and insufficient innominate artery (IA) sealing zone. Results - CT images from 56 subjects (45 males, mean age 57±10.8 years) were reviewed. 45 patients had ascending aortic replacement alone, 7 had a Bentall procedure, and 4 underwent David procedure. Based on our evaluation results, 23 patients (41.1%) were good candidates for an endovascular arch branched device. It should be mentioned that two patients were suitable for Relay double-branch device but not for Zenith branched device because the former displays more accommodating for larger proximal landing diameter (<43mm) than the latter (<38mm). Eleven patients (19.6%) were deemed feasible, but prudent pre-operative planning is required due to complicated anatomy. The other 22 patients (39.3%) were unsuitable due to one or more exclusive criteria. Short prosthetic grafts (8), extreme graft angulations (11) and dissected supra-aortic branches (15) were the main reasons for exclusion. Conclusion - Endovascular repair is technically feasible in patients with prior ascending aortic replacement for type A dissection. Incompatible prosthetic ascending aorta and dissecting arch branches are the most common exclusive risk factors.

Surgical repair of the moderately dilated ascending aorta combined with bicuspid aortic valve replacement

Background: Ascending aortic (AA) dilatation is common in patients with bicuspid aortic valve (BAV). In BAV replacement, surgery of the AA is indicated in the case if AA diameter exceeds 45 mm. Aortic valve replacement combined with an AA intervention is associated with increased risk of complications. The feasibility of the reduction ascending aortoplasty for correction of the dilated AA remains disputable.Aim: To analyze the results of BAV surgical replacement with simultaneous surgical correction of the borderline AA dilatation (45-50 mm) by the reduction aortoplasty (RAP) or supracoronary AA replacement (SPR).Materials and methods: This single center prospective non-randomized study included 53 patients with significant BAV stenosis and AA dilatation (45-50 mm), divided into 2 groups: BAV surgical replacement combined with RAP AA replacement (group 1, 36 patients) and BAV replacement with SPR (group 2, 17 patients). There were no significant differences between the patients of the two groups in their characteristics of the underlying disease, complications and comorbidities.Results: Hospital mortality was 0%. No between-group differences in the early postoperative course were found. At later term, 44 (81.5%) patients were assessed; median (dispersion) of the follow-up was 36 (25; 50) months. Two patients from the group 2 died during the follow-up. The long-term survival was better in the group 1 (p = 0.028). No differences in the combined adverse event rate were observed between the groups (p = 0.633). The median (dispersion) of the AA absolute increment and the rate of dilatation after RAP were 1.0 (0.0; 3.0) mm and 0.24 (0.00; 0.95) mm/year, respectively. The predictor of AA increment rate ≥ 2 mm/year was the baseline blood pressure level (odds ratio 1.321, 95% confidence interval 1.050-1.662; p=0.017). The threshold preoperative blood pressure value for the increased risk of the long-term AA expansion rate was 138 mmHg.Conclusion: The efficacy and safety of RAP and SRP combined with BAV replacement in AA borderline dilatation are similar. Combined BAV surgery and RAP is effective and safe in patients with systolic blood pressure level ≤ 135 mmHg. Combined BAV replacement with SRP seems reasonable in patients with arterial hypertension.

The fate of mild to moderate proximal aortic dilatation after isolated aortic valve replacement in tricuspid aortic valve patients.

Proximal aortic dilatation is frequently associated with aortic valve pathology. The treatment of mild to moderate proximal aortic dilatation (maximal diameter: 40-50 mm) at the time of aortic valve replacement (AVR) is still controversial. We retrospectively analyzed the fate and progression of the proximal dilated aorta after isolated AVR in tricuspid aortic valve (TAV) patients, to determine if ascending aortic replacement (AAR) is recommended at the time of the initial AVR. The review of our hospital database revealed a subgroup of 127 TAV disease patients with mild to moderate ascending aortic dilatation, who underwent isolated AVR (group I, n = 68) or AVR combined AAR (group II, n = 59) from January 2000 to December 2013. Follow-up was obtained through a telephone interview/outpatient interview. Adverse aortic events were defined as aortic dissection/ rupture, or diameter of proximal aorta ≥55 mm, or re-do aortic surgery contributable to the dilated aorta during follow-up. There were no differences in age, gender, heart function, hypertension, diabetes, smoking, chronic renal failure, and atrium fibrillation between two groups except for the maximum aortic diameter (group I 43.91 ± 2.0 vs group II 45.20 ± 2.63, P < .05). The cross-clamp time and cardiopulmonary bypass time was significantly less in group I than that in group II, owing to the replacement of the proximal aorta. A total of 126 patients were discharged home successfully, with 0.79% hospital mortality. There was no significant difference of hospital mortality and morbidity between the two groups. Follow-up was successfully obtained in 106 patients (84.13%). Mean follow-up time was (9.60 ± 3.47) years. The overall survival at 10-year follow-up was 72.46% ± 6.42% in group I versus 74.55% ± 6.87% in group II ( P = .73). The freedom from adverse aortic events at 10-year was 89.59% ± 4.02% in group I versus 96.88% ± 3.07% in group II ( P = .09). No significant difference in survival rate and freedom from adverse aortic events can be obtained between the two groups. Progression of proximal aorta leading to adverse aortic events after isolated AVR in TAV patients is infrequent. AVR alone is acceptable and reasonable in patients with mild to moderate proximal aortic dilatation if connective tissue disorders are not present.

Con: "Debate: does every ascending aorta repair require at least an open distal anastomosis at the innominate? Or not?"

Ascending aortic replacement is usually performed with a cross-clamp at the distal ascending aorta. This cross-clamping is one of the routine procedures in cardiac surgery, and the risk of the cross-clamping has been lowered to minimum in regular practice. Theoretically, the cross-clamp itself is a risk to apply and might lead to aortic dissection (1) or create a source of embolization in the aortic wall. However, when there is no atheroma, calcification, or other abnormal situations including aortic dissection in the aorta, the cross-clamp is applied very safely in modern cardiac surgery.