Extended Arch Research Articles

Aortic arch registry of type a aortic dissection (AoArch) - rationale, design and definition criteria

BackgroundType A acute aortic dissection (TAAAD) is a deadly condition that demands immediate surgery, because it involves a critically. The mortality and morbidity associated with it are significant, and it is vital that the patient’s conditions and treatment strategies are fully understood to ensure the appropriate management of TAAAD. This study aims to ascertain whether hemiarch repair (HAR) versus extended arch repair (EAR) with or without descending aortic intervention results in better perioperative and late outcomes for patients with TAAAD.MethodsFour leading centers of cardiac surgery from two European countries have joined forces to create a groundbreaking multicenter observational registry (AoArch). This study was approved by the institutional review board (IRB 202201173). We conducted a retrospective review (NCT 0591263) of our prospectively maintained database for patients who underwent operative repair of DeBakey type I or type II dissection from January 1, 2005 to March 2024 (NCT 05927090). We will analyze how patient co-morbidities, referral conditions, and surgical strategies involving hemi-arch repair (HAR) and extended arch repair (EAR) impact early and late adverse events. We have developed a procedure urgency algorithm based on the severity of preoperative hemodynamic conditions and malperfusion due to TAAAD, and we will use it to assess the primary clinical outcomes: in-hospital mortality, late mortality, and reoperations on the aorta. We will define secondary outcomes as permanent neurologic deficit, the need for new dialysis, respiratory failure, a composite of major adverse events (myocardial infarction, cerebrovascular accidents, the need for dialysis, or the need for tracheostomy), and a composite of major adverse pulmonary events (intubation over 48 h, pneumonia, reintubation, tracheostomy), and reoperation due to bleeding.DiscussionThis multicenter registry will definitively determine the prognostic significance of critical preoperative conditions and the efficacy of extended arch interventions and hemiarch repair in reducing the risk of early adverse events after surgery for TAAAD. This registry will provide insights into the long-term durability of different strategies of surgical repair for TAAAD.

Reoperative extended arch repair for acute type A aortic dissection after previous cardiac surgery: insights from a relatively young redo series.

To evaluate the impact of previous cardiac surgery (PCS) on clinical outcomes after reoperative extended arch repair for acute type A aortic dissection. This study included 37 acute type A aortic dissection patients with PCS (PCS group) and 992 without PCS (no-PCS group). Propensity score-matching yielded a subgroup of 36 pairs (1:1). In-hospital outcomes and mid-term survival were compared between the 2 groups. The PCS group was older (56.7 ± 14.2 vs 52.2 ± 12.6 years, P = 0.036) and underwent a longer cardiopulmonary bypass (median, 212 vs 183 min, P < 0.001) compared with the no-PCS group. Operative death occurred in 88 (8.6%) patients, exhibiting no significant difference between groups (13.5% vs 8.4%, P = 0.237). Major postoperative morbidity was observed in 431 (41.9%) patients, also showing no difference between groups (45.9% vs 41.7%, P = 0.615). Moreover, the multivariable logistic regression analysis revealed that PCS was not significantly associated with operative mortality (adjusted odds ratio 2.58, 95% confidence interval 0.91-7.29, P = 0.075) or major morbidity (adjusted odds ratio 1.92, 95% confidence interval 0.88-4.18, P = 0.101). The 3-year cumulative survival rates were 71.1% for the PCS group and 83.9% for the no-PCS group (log-rank P = 0.071). Additionally, Cox regression indicated that PCS was not significantly associated with midterm mortality (adjusted hazard ratio 1.40, 95% confidence interval 0.44-4.41, P = 0.566). After matching, no significant differences were found between groups in terms of operative mortality (P > 0.999), major morbidity (P > 0.999) and midterm survival (P = 0.564). No significant differences were found between acute type A aortic dissection patients with PCS and those without PCS regarding in-hospital outcomes and midterm survival after extended arch repair.

Acute Aortic Dissection Type A in Younger Patients (< 60 Years Old) - Does Full Arch Replacement Provide Benefits Compared to Limited Approach?

Acute aortic dissection Stanford type A (AADA) is a surgical emergency associated with high morbidity and mortality. Although surgical management has improved, the optimal therapy is a matter of debate. Different surgical strategies have been proposed for patients under 60 years old. This paper evaluates the postoperative outcome and the need for secondary aortic operation after a limited surgical approach (proximal arch replacement) vs. extended arch repair. Between January 2000 and January 2018, 530 patients received surgical treatment for AADA at our hospital; 182 were under 60 years old and were enrolled in this study - Group A (n=68), limited arch repair (proximal arch replacement), and group B (n=114), extended arch repair (> proximal arch replacement). More pericardial tamponade (P=0.005) and preoperative mechanical resuscitation (P=0.014) were seen in Group A. More need for renal replacement therapy (P=0.047) was seen in the full arch group. Mechanical ventilation time (P=0.022) and intensive care unit stay (P<0.001) were shorter in the limited repair group. Thirty-day mortality was comparable (P=0.117). New onset of postoperative stroke was comparable (Group A four patients [5.9%] vs. Group B 15 patients [13.2%]; P=0.120). Long-term follow-up did not differ significantly for secondary aortic surgery. Even though young patients received only limited arch repair, the outcome was comparable. Full-arch replacement was not beneficial in the long-time follow-up. A limited approach is justified in the cohort of young AADA patients. Exemptions, like known Marfan syndrome and the presence of an intimal tear in the arch, should be considered.

No sex-based differences exist in clinical outcomes of extended aortic arch repair for acute type A aortic dissection.

Reports regarding the association between sex and clinical outcomes following surgical repair of acute type A aortic dissection (ATAAD) are not exhaustive and in part even conflicting. A total of 786 eligible adult patients with ATAAD undergoing extended arch repair between January 2015 and December 2021 were included. They were entered into a female group (n=161) or a male group (n=625). In-hospital outcomes (surgical mortality and major postoperative morbidity) and midterm outcomes (survival and aortic reintervention) between the two groups were compared before and after propensity score (PS) matching (1:1). Compared with male subjects, female patients were more likely to be older (median [interquartile range], 57 [46-67] vs. 50 [42-59] years, p<0.001) and to have a lower body mass index, but were less likely to be current smokers. Operative death occurred in 66 patients (6.8% for female vs. 8.8% for male), without significant differences between groups before and after matching (p=0.422 and p>0.999, respectively). Major postoperative morbidity was observed in 313 (39.8%) patients, including 57 (35.4%) female and 256 (41.0%) male patients (p=0.199). Sex-based grouping was not significantly associated with operative mortality or major postoperative morbidity. The 5-year cumulative survival and incidence of aortic reintervention among females were 90.6% and 6.0%, respectively, which were not statistically different from those observed in males before and after matching. No sex-based differences were found in terms of in-hospital and midterm outcomes of extended arch repair for ATAAD.

Septuagenarians with acute type A aortic dissection undergoing extended aortic arch repair: a retrospective cohort study.

Extended arch repair in elderly patients with acute type A aortic dissection (ATAAD) remains challenging for cardiac surgeons. Data on extended arch repair for ATAAD in septuagenarians are scarce. Consecutive adult patients with ATAAD undergoing extended arch repair from January 2015 to December 2021 were identified. According to age at presentation, 714 eligible patients were entered into either an elderly group (septuagenarians, n =65) or a control group (patients aged less than 70, n =649). Using propensity score matching, 60 pairs of patients were successfully established at a 1:1 ratio. In-hospital outcomes (operative death and major postoperative morbidity) and midterm outcomes (survival and aortic reintervention) were compared before and after matching. Operative death occurred in 64 patients (9.0%), including seven septuagenarians (10.8%) and 57 (8.8%) from the control group, without significant differences between groups before and after matching ( P =0.593 and 0.774, respectively). Major postoperative morbidity was observed in 298 patients (41.7%), including 29 (44.6%) in the elderly group and 269 (41.4%) in the control group ( P =0.622). Age-based grouping was not significantly associated with operative mortality or major postoperative morbidity in the crude, multivariable, and propensity score analyses. The 5-year cumulative survival and cumulative aortic reintervention rates in the elderly group were 83.5 and 4.6%, respectively, which were not statistically different from those in the control group before and after matching. Extended arch repair may be safely and effectively performed in septuagenarians with ATAAD, with in-hospital and midterm outcomes comparable to those obtained in patients aged less than 70 years.

Hemiarch versus extended arch repair for acute type A dissection: Results from a multicenter national registry

ObjectiveWe compared perioperative outcomes of patients with acute type A aortic dissection undergoing hemiarch (HA) versus extended arch (EA) repair with or without descending aortic intervention. MethodsNine hundred twenty-nine patients underwent acute type A aortic dissection repair (2002-2021, 9 centers) including open distal repair (HA) with or without additional EA repair. EA with intervention on the descending aorta (EAD) included elephant trunk, antegrade thoracic endovascular aortic replacement, or uncovered dissection stent. EA with no descending intervention (EAND), included unstented suture-only methods. Primary outcomes were in-hospital mortality, permanent neurologic deficit, computed tomography malperfusion resolution, and a composite. Multivariable logistic regression was also performed. ResultsMean age was 66 ± 18 years, 30% (278 out of 929) were women, and HA was performed more frequently (75% [n = 695]) than EA (25% [n = 234]). EAD techniques included: dissection stent (39 out of 234 [17%]), thoracic endovascular aortic replacement (18 out of 234 [7.7%]), and elephant trunk (87 out of 234 [37%]). In-hospital mortality (EA: n = 49 [21%] and HA: n = 129 [19%]; P = .42), and neurological deficit (EA: n = 43 [18%] and HA: n = 121 [17%]; P = .74) were similar. EA was not independently associated with death (EA vs HA odds ratio, 1.09; 95% CI, 0.77-1.54; P = .63) or neurologic deficit (EA vs HA odds ratio, 0.85; 95% CI, 0.47-1.55; P = .59). Composite adverse events differed significantly (EA vs HA odds ratio, 1.47; 95% CI, 1.16-1.87; P = .001). Malperfusion resolved more frequently after EAD (EAD: n = 32 [80%], EAND: n = 18 [56%], HA: n = 71 [50%]; P = .004), although multivariable analysis was not significant (EAD vs HA odds ratio, 2.17; 95% CI, 0.83-5.66; P = .10). ConclusionsExtended arch interventions pose similar perioperative mortality and neurologic risks as Hemiarch. Descending aortic reinforcement may promote malperfusion restoration. Extended techniques should be approached with caution in acute dissection due to increased risk of adverse events.

AORTIC REMODELLING FOLLOWING HEMIARCH VERSUS EXTENDED ARCH REPAIR FOR ACUTE TYPE A AORTIC DISSECTION

AORTIC REMODELLING FOLLOWING HEMIARCH VERSUS EXTENDED ARCH REPAIR FOR ACUTE TYPE A AORTIC DISSECTION

A Clinical Analysis of Thirty-Five Patients Undergoing Aortic Reoperation.

IntroductionAt present, there are few reports regarding the issue of aortic reoperation due to its complexity and high risk and individual differences among patients.MethodsFrom November 2016 to December 2017, the data from 35 cases of aortic reoperation at our institution, out of 212 consecutive aortic repairs, were reviewed. We retrospectively summarized and analyzed their surgical indications, operative data, time interval from previous aortic repair, and outcomes. The time intervals until reoperation were analyzed for differences.ResultsPatients’ mean age was 40.9±14.5 years, and 25 of them were men (71.4%). The indications for reoperation were aortic valvular problem (14.3%), aneurysmal dilatation (25.7%), pseudoaneurysm formation due to anastomotic leakage (43.2%), and aortic dissection (17.1%). For patients who had underwent primarily emergency operations due to aortic dissection, the time interval until reoperation (4.8±3.2 years) was significantly shorter than that of the whole group (5.5±3.6 years, P<0.01). Among the 35 reoperations, Sun’s procedure was selected for 16 patients (45.7%) with total aortic arch reconstruction. The average follow-up was 12 months (range 9-15 months). Hospital mortality was 5.7% (two patients). Among the hospital survivors there were no cases of death, rupture of residual dissection, paraplegia, or central nervous system complications during the follow-up period.ConclusionPatients with acute aortic dissection required repeat surgery significantly earlier compared to other diseases. As to reoperation strategy, we recommend Sun’s procedure as the choice for extended arch reconstruction since minimal effect on overall mortality and complication rates were found.

Surgical strategy for inflammatory thoracic aortic aneurysms in the endovascular surgery era.

Inflammatory thoracic aortic aneurysms (TAAs) are very rare aortic conditions. Resection and replacement of the inflammatory aorta is the first-line treatment, and thoracic endovascular aortic repair (TEVAR) has recently been reported as a less invasive alternative even for this aortic cohort. In the present study, we reviewed our experience with inflammatory TAAs and assessed the preoperative management, surgical procedures, and outcomes. From 2006 to 2019, 21 surgeries were performed for inflammatory TAAs in 17 of 2583 patients (0.7%) who had undergone cardiovascular surgery at our institution. The etiologies were Takayasu's arteritis in 13 patients, giant cell arteritis in 2, antineutrophil cytoplasmic antibody-associated vasculitis in 1, and unknown in 1. The mean follow-up period was 66.2± 50.2months (range, 19-186months). Three patients had undergone multiple surgeries. The aorta was replaced in 14 patients (ascending aorta in 9, aortic arch in 4, and thoracoabdominal aorta in 1). Three isolated TEVARs were performed in two patients and single-stage hybrid aortic repair (ascending aorta and partial arch replacement combined with zone 0 TEVAR) in four patients for extended arch and descending thoracic aortic aneurysms. Stent grafts were deployed on the native aorta in five of the seven TEVARs. The perioperative inflammation was well-controlled with prednisolone (mean dose, 7.4± 9.4mg) in all patients except for one who had required two surgeries under inflammation-uncontrolled situations. No aorta-related complications, including anastomotic aneurysms and TEVAR-related aortic dissection, developed during the follow-up period, and the 5-year freedom from all-cause death was 92.9%. The mid-term outcomes of surgery for inflammatory TAAs were acceptable. Although replacement remains the standard procedure for inflammatory TAAs, TEVAR is a less invasive acceptable alternative when the inflammation is properly managed.

Abstract 11778: Comparison of Prenatal Diagnosis Rates and Cardiac Morphometry in Fetal Coarctation by Ultimate Surgical Repair Type

Background: Fetal diagnosis of coarctation of aorta is challenging, with limited data examining prenatal detection rates in patients requiring simple vs. extensive arch reconstruction. This study aims to evaluate prenatal detection rate s and fetal cardiac morphometric differences in neonates requiring simple vs. complex coarctation repair. Methods: Pre- and postnatal records of neonates with isolated coarctation repair from the Society of Thoracic Surgeons database from Jan 2010 - Dec 2020 at our center were reviewed. Patients were classified as requiring discrete (Group 1) or extended arch repair (Group 2). Fetal echocardiograms were measured by a single observer blinded to repair type. Results: Of 228 neonates requiring repair, 67 (29%) had a prenatal diagnosis. The proportion with prenatal diagnosis was not different in group 1 (28%) vs. group 2 (32%) (χ2 = 0.45, p = 0.5). At the first fetal echo (median gestational age (GA) of 21.9 wks in group 1 vs 23.6 wks in group 2, p = 0.2), there were no differences between groups when comparing right ventricular (RV) and left ventricular (LV) dimensions, valvular dimensions, or aortic arch dimensions. At the final fetal echo (median GA of 33.7 wks in both groups, p = 0.6), there were statistical differences between group 1 and 2 in RV geometry with ratio of RV minor to major axis (0.72 vs 0.83, p = 0.03) and ratio of LV to RV minor axis (0.68 vs 0.59, p = 0.02), ascending aorta Z score (-2.6 vs -3.4, p = 0.03), distal arch Z score (-3.9 vs -4.6, p = 0.048), and ratio of isthmus to distal arch dimension (0.88 vs 1.02, p = 0.045) (Figure). Conclusion: The rate of prenatal diagnosis in fetuses requiring neonatal coarctation repair remains low, regardless of ultimate surgical repair type. Fetuses ultimately requiring extensive arch repair have smaller aortic sizes, and greater RV/LV size disproportion in the third trimester. This data may be useful in counseling families with regard to postnatal surgical management in fetuses with suspected coarctation.

Different hypothermic and cerebral perfusion strategies in extended arch replacement for acute type a aortic dissection: a retrospective comparative study

BackgroundThe optimal hypothermic level in total arch replacement with stented elephant trunk implantation for acute type A aortic dissection (aTAAD) has not been established, and the superiority of unilateral or bilateral cerebral perfusion remains a controversial issue. Therefore, we evaluated the application of moderate hypothermic circulatory arrest (MHCA) with a core temperature of 29 °C and bilateral selective antegrade cerebral perfusion in aTAAD treated by total arch replacement with stented elephant trunk implantation.MethodsFrom July 2019 to January 2020, 25 aTAAD patients underwent total arch replacement with stented elephant trunk implantation via MHCA (29 °C) and bilateral selective antegrade cerebral perfusion (modified group). Thirty-six patients treated by the same procedure with MHCA (25 °C) and unilateral selective antegrade cerebral perfusion during this period were selected as controls.ResultsThere were no differences between the two groups of patients in terms of age, sex, incidence of hypertension, malperfusion, and pericardial effusion, although the incidence of cardiac tamponade was higher in the modified group (control 2.8%, modified 20%; P = 0.038). The lowest mean circulatory arrest temperature was 24.6 ± 0.9 °C in the control group, and 29 ± 0.8 °C in the modified group (P < 0.001). In-hospital mortality was 4.9% (3/61) for the entire cohort (control 8.3%, modified 0; P = 0.262). The incidence of permanent neurologic deficit was 4.9% (control 8.3%, modified 0; P = 0.262). There were no significant differences in the occurrence of temporary neurological deficit, renal failure, and paraplegia between groups. The rate of major adverse events in the modified group was lower (30.6% vs. 4%, P = 0.019). A shorter duration of ventilation and ICU stay was identified in the modified group, as well as a reduced volume of drainage within the first 48 h and red blood cell transfusion.ConclusionsThe early results of MHCA (29 °C) and bilateral selective antegrade cerebral perfusion applied in total arch replacement with stented elephant trunk implantation for aTAAD were acceptable, providing similar inferior cerebral and visceral protection compared with that of the conventional strategy. A higher core temperature may account for the shorter duration of ventilation and ICU stay, as well as a reduced volume of drainage and red blood cell transfusion.

Single-Stage Hybrid Arch Repair for Patients with Shaggy Aorta.

Operating on extended arch aneurysms that contain severe atherosclerotic plaques is difficult. In such cases, the incidence of intraoperative multiple embolization is very high. We applied single-stage hybrid arch repair, which involved ascending aorta replacement and debranching of arch vessels, consecutively with endovascular repair for two patients. This technique was developed to prevent embolization of atherosclerotic plaques during cardiopulmonary bypass, and abrasion of the plaques during thoracic endovascular repair. Both patients recovered without embolic complications.

Dynamics and connectivity of an extended arch filament system

Aims.In this study, we analyzed a filament system, which expanded between moving magnetic features (MMFs) of a decaying sunspot and opposite flux outside of the active region from the nearby quiet-Sun network. This configuration deviated from a classical arch filament system (AFS), which typically connects two pores in an emerging flux region. Thus, we called this system an extended AFS. We contrasted classical and extended AFSs with an emphasis on the complex magnetic structure of the latter. Furthermore, we examined the physical properties of the extended AFS and described its dynamics and connectivity.Methods.The extended AFS was observed with two instruments at the Dunn Solar Telescope (DST). The Rapid Oscillations in the Solar Atmosphere (ROSA) imager provided images in three different wavelength regions, which covered the dynamics of the extended AFS at different atmospheric heights. The Interferometric Bidimensional Spectropolarimeter (IBIS) provided spectroscopic Hαdata and spectropolarimetric data that was obtained in the near-infrared (NIR) Ca IIλ8542 Å line. We derived the corresponding line-of-sight (LOS) velocities and used He IIλ304 Å extreme ultraviolet (EUV) images of the Atmospheric Imaging Assembly (AIA) and LOS magnetograms of the Helioseismic and Magnetic Imager (HMI) on board the Solar Dynamics Observatory (SDO) as context data.Results.The NIR Ca IIStokes-Vmaps are not suitable to definitively define a clear polarity inversion line and to classify this chromospheric structure. Nevertheless, this unusual AFS connects the MMFs of a decaying sunspot with the network field. At the southern footpoint, we measured that the flux decreases over time. We find strong downflow velocities at the footpoints of the extended AFS, which increase in a time period of 30 min. The velocities are asymmetric at both footpoints with higher velocities at the southern footpoint. An EUV brigthening appears in one of the arch filaments, which migrates from the northern footpoint toward the southern one. This activation likely influences the increasing redshift at the southern footpoint.Conclusions.The extended AFS exhibits a similar morphology as classical AFSs, for example, threaded filaments of comparable length and width. Major differences concern the connection from MMFs around the sunspot with the flux of the neighboring quiet-Sun network, converging footpoint motions, and longer lifetimes of individual arch filaments of about one hour, while the extended AFS is still very dynamic.

Single-stage hybrid total arch replacement for extended arch aneurysms

ObjectiveThe therapeutic strategy for extended aortic arch aneurysms remains controversial and has changed substantially since thoracic endovascular aortic repair was introduced. We applied single-stage hybrid (s-hybrid) total arch replacement (TAR), which involved ascending aorta replacement and debranching of arch vessels, consecutively performed with thoracic endovascular aortic repair for extended arch aneurysms. The aim of this study was to investigate the short-term results of s-hybrid TAR and to clarify the benefit of this method. MethodsWe reviewed the operative results of 62 patients who underwent elective s-hybrid TAR or conventional TAR (c-TAR) through the median approach from 2008 to 2017. We used the s-hybrid approach in 15 patients and the c-TAR approach in 47 patients. In both groups, axillary arterial perfusion and selective antegrade cerebral perfusion under moderate hypothermia were applied for brain protection. We compared the perioperative outcomes of the two groups. ResultsWe completed s-hybrid TAR in all 15 patients with extended aneurysms. The s-hybrid group required shorter times for myocardial ischemia, selective antegrade cerebral perfusion, and circulatory arrest of the lower body compared with the c-TAR group. The patients with complicated recurrent laryngeal nerve palsy and long ventilation support times were fewer in the s-hybrid group. No patient had substantial endoleaks or permanent paraplegia. The in-hospital mortality rates were 6.7% in the s-hybrid group and 0% in the c-TAR group. ConclusionsThe s-hybrid TAR has the same or better perioperative outcomes compared with the c-TAR approach. For extended aneurysms, this technique could resolve the problem of respiratory failure induced by left thoracotomy and also resolve the problem of rupture during the waiting period in staged surgery.

WHAT IS THE LONG-TERM AORTIC REMODELING OUTCOME AFTER HEMI-ARCH REPAIR FOR ACUTE TYPE A DISSECTION? AN 11-YEAR STUDY

Controversy is emerging regarding the optimal extent of arch replacement in acute Type A aortic dissection (ATAAD). Advocates for total arch as opposed to hemi-arch repair suggest improved long term aortic remodeling with extended arch technique due to distal true lumen expansion and false lumen obliteration. However, the data on imaging follow-up after hemi-arch repair in the current era is not robust. Purpose of this study is to determine long term survival and assess aortic remodeling of the descending thoracic aorta following hemi-arch repair for ATAAD. From 2005 to 2017, 133 patients with a mean age of 60 ± 13 years underwent hemi-arch repair for ATAAD. Long term survival was followed through a provincial database. Double oblique cross sectional reconstructions were used to measure aortic diameters and areas at 3 levels on patients presenting with a dissection flap in the descending aorta (DeBakey Type I). Clinical follow-up was 98% complete. Thirty-day mortality was 9.7% (n=13). Kaplan Meier analysis revealed 8-year estimated survival of 69%. Aortic re-intervention occurred in 26 patients for an estimated 5-year re-intervention rate of 24%. The primary indication for re-intervention was in the arch/descending in 81% (n=21), valve/root 12% (n=3), and abdominal aorta 8% (n=2). Median imaging follow-up time was 4.3 ± 2.6 years. Average aortic diameter increased 6.46 ± 3.31 mm in proximal descending aorta, 5.48 ± 3.58 mm in mid descending aorta, and 3.05 ± 1.77 mm at distal descending aorta. The descending aorta grew at >2 mm/year in 46% of patients with 16% growing >4 mm/year. False lumen obliteration at the proximal descending aorta was achieved in 18% of patients. Kaplan Meier estimated survival after hemi-arch surgery for ATAAD appears to be compromised in a relatively young patient population. Aortic re-intervention is more common than previously appreciated. Distal aortic growth and lack of false lumen obliteration occurs in a significant number of patients suggesting adverse aortic remodeling after hemi-arch repair of DeBakey Type I dissections. This survival and imaging data establishes the benchmark for comparison with emerging therapies.

Extended versus limited arch replacement in acute Type A aortic dissection.

The recommended extent of surgical resection and reconstruction of the arch in acute DeBakey Type I aortic dissection is an ongoing controversy. However, several recent reports indicate a trend towards a more extensive arch operation in several institutions. We have analysed the recent data from the International Registry of Acute Aortic Dissection to assess the choice of procedure over time and to evaluate the surgical outcome in a 'real-world' database. Our aim was to compare short- and mid-term outcomes of limited repairs versus complete arch surgery. Of the 1241 patients included in the 'Interventional Cohort' of the International Registry of Acute Aortic Dissection from March 1996 to March 2015, 907 underwent ascending aortic or hemiarch replacement (Group A) and 334 had extended arch replacement (Group B). An extended resection was a surgeon's 'judgement call'. Logistic regression analysis, propensity-adjusted multivariable comparisons and Kaplan-Meier curves were used for analyses. Overall in-hospital mortality was 14.2% with no difference between groups (Group A 13.1%, Group B 17.1%). Coma/altered consciousness (odds ratio 3.16, 95% confidence interval 1.60-6.25, P = 0.001), hypotension, tamponade or shock (2.03, 1.11-3.73, P = 0.022) and any pulse deficit (1.92, 1.04-3.54, P = 0.038) were predictors of in-hospital mortality in a propensity score-adjusted multivariable analysis. Overall 5-year survival was 69.4% in the ascending group and 73.1% in the total arch group (P = 0.83 by Kaplan-Meier analysis). For survivors of the index hospitalization, the 5-year freedom from death, aortic rupture and reintervention were 71.1% in Group A and 76.4% in Group B (P = 0.54 by Kaplan-Meier analysis). Selective, or 'surgeon's choice', extended arch replacement had no discernible acute downside compared with less extensive surgery. Whether extended arch replacement improves the prognosis beyond 5 years remains to be settled.

Classification and outcomes of extended arch repair for acute Type A aortic dissection: a systematic review and meta-analysis.

Distal extent of repair in patients undergoing surgery for acute Type A aortic dissection (ATAAD) is controversial. Emerging hybrid techniques involving open and endovascular surgery have been reported in small numbers by select individual centres. A systematic review and meta-analysis was performed to investigate the outcomes following extended arch repair for ATAAD. A classification system is proposed of the different techniques to facilitate discussion and further investigation. Using Ovid MEDLINE, 38 studies were identified reporting outcomes for 2140 patients. Studies were categorized into four groups on the basis of extent of surgical aortic resection and the method of descending thoracic aortic stent graft deployment; during circulatory arrest (frozen stented elephant trunk) or with normothermic perfusion and use of fluoroscopy (warm stent graft): (I) surgical total arch replacement, (II) total arch and frozen stented elephant trunk, (III) hemiarch and frozen stented elephant trunk and (IV) total arch and warm stent graft. Perioperative event rates were obtained for each of the four groups and the entire cohort using pooled summary estimates. Linearized rates of late mortality and reoperation were calculated. Overall pooled hospital mortality for extended arch techniques was 8.6% (95% CI 7.2-10.0). Pooled data categorized by surgical technique resulted in hospital mortality of 11.9% for total arch, 8.6% total arch and frozen stented elephant trunk, 6.3% hemiarch and frozen stented elephant trunk and 5.5% total arch and 'warm stent graft'. Overall incidence of stroke for the entire cohort was 5.7% (95% CI 3.6-8.2). Rate of spinal cord ischaemia was 2.0% (95% CI 1.2-3.0). Pooled linearized rate of late mortality was 1.66%/pt-yr (95% CI 1.34-2.07) with linearized rate of re-operation of 1.62%/pt-yr (95% CI 1.24-2.05). Perioperative results of extended arch procedures are encouraging. Further follow-up is required to see if long-term complications are reduced with these emerging techniques. The proposed classification system will facilitate future comparison of short- and long-term results of different techniques of extended arch repair for ATAAD.

CLASSIFICATION AND OUTCOMES OF EXTENDED ARCH REPAIR FOR ACUTE TYPE A AORTIC DISSECTION: A SYSTEMATIC REVIEW AND META-ANALYSIS

The debate around surgical technique for the repair of acute type A aortic dissection (ATAAD) has recently centered on whether aortic replacement should extend beyond the ascending aorta. Extended arch techniques involving arch replacement with or without descending aortic stent grafting are being reported in small numbers by select centres. Proposed benefits include resection of primary intimal tears beyond the ascending aorta, resection or exclusion of re-entry tears in the distal aorta, facilitation of re-expansion of the distal true lumen and promotion of false lumen obliteration. A systematic review and meta-analysis was conducted to investigate clinical outcomes of extended arch repair for ATAAD. A novel classification system of heterogeneous surgical techniques is proposed to facilitate discussion and further investigation.

Abstract 18055: Induced Growth of Hypoplastic Cardiac Structures to Facilitate Repair of Congenital Defects

Introduction: Congenital heart defects (CHD) may include hypoplastic valves, ventricles and vessels which complicate repairs. Our hypotheses were that hypoplastic structures are developmental rather than primarily genetic in origin and the correct biomechanical signal would induce catch up growth. Our corollary hypothesis was that the growth signal is provided by flow, not pressure. First stage operations, therefore, were designed to increase flow and induce growth. Once growth was sufficient, a second operation would often complete the repair. We report our results using flow induced growth of hypoplastic structures to facilitate repair in 3 types of CHD. Methods: Three groups of CHD patients with associated hypoplastic structures: unbalanced atrioventricular canal defects (UAVC); pulmonary atresia with intact ventricular septum (PAIVS); and coarctation of the aorta (CoA) were reviewed. Operations increased flow through the hypoplastic structures, such as creating restrictive septal defects to increase flow through the hypoplastic AV valves and ventricles (UAVC, PAIVS) or relieving obstruction (CoA) to enhance aortic valve and arch flow. Results: On follow up, virtually all (85/90) hypoplastic structures reached normal size and the rest had nearly comparable growth (Table). Conclusions: 1) Operations designed to increase flow through hypoplastic structures reliably induced catch up growth of UAVC, PAIVS and CoA lesions. 2) The growth response supported underdevelopment as the cause of hypoplasia and flow as the growth signal to reverse it. 3) Growth induction allowed two ventricle repairs in UAVC and PAIVS patients and avoided extended arch repairs in CoA; all with decreased operative risk. 4) Following catch up growth of the hypoplastic lesions, the outlook improved to that of patients with balanced AVCs, normal sized RVs in pulmonary atresia and well repaired CoA. 5) Once normal size was reached growth continued, producing a durable result.

Curative replacement of the dissected aortic arch: a new insight to resolve an old question 'how extended should the arch repair be?'

I read with great interest the paper by Tsagakis et al. suggesting that the extent of dissection exactly reflects the late outcome after surgery of acute type A aortic dissection [1]. Almost 40% of their patients suffered aortic dissection limited to the ascending aorta and aortic arch. In 18% of them, classical-type DeBakey II dissection was diagnosed, and in 82% the aortic arch was involved in the dissection. However, the complete arch replacement was performed in only 36%, indicating that a complete resection of all the dissected aortic wall was not performed in all patients. Although there were no late aortic events during the follow-up of 5 years, distal complications like redissection or false aneurysm formation can occur beyond such a time range, especially when only a limited part of the dissected aortic wall remains in place. Nevertheless, the observations of Tsagakis et al. correspond with our experience in which a curative replacement of all dissected aorta was technically possible in almost 50% of patients with acute type A aortic dissection [2]. Besides the dissection of the proximal aorta in which the dissection does not extend beyond the aortic isthmus, isolated arch dissection or arch and descending aorta dissection without involvement of the ascending aorta can be observed, and therefore, as a surgical consequence of those pathologies, we proposed a classification that takes into consideration the extent of dissection (D) and the location of the intimal tear (E) in three main segments of the aorta (a—ascending aorta, b—aortic arch, c—descending aorta) [2]. Thus, there are several subgroups of type A dissection that are relevant from a surgical perspective. In the group (D-a; E-a), which corresponds to the DeBakey Type II classification and contains about 10–20% of patients, the dissection is limited exclusively to the ascending aorta and aortic arch replacement is not necessary unless there is another indication for doing it. About 20–30% of patients present aortic dissection that extends from the ascending aorta through the entire arch reaching approximately to the level of aortic isthmus (D-ab, mostly combined with E-a). In such cases, complete arch replacement ensures curative resection of all dissected aortic wall. Because during the follow-up time of up to 16 years no patient with this subtype of dissection suffered any aortic event after complete arch replacement in our experience, I am convinced that this approach is an appropriate one and should be the goal. Regarding Tsagakis’s paper, I would like to add that it is actually not the distal extent of dissection but, as a consequence of it, the extent of surgery that reflects the late outcome and the risk of distal aortic events. Given the continuing controversy on how extended arch repair should be performed, their paper supports again the need for dividing the aortic arch within common classifications, which can, by using meta-analyses, shed more light on the choice of proper surgery and prediction of results.