Root Replacement In Acute Type Research Articles

Hemostatic Properties of Aortic Root Preservation versus Root Replacement for Acute Type A Aortic Dissection: A Pooled Analysis.

We reviewed the available literature on patients undergoing aortic repair for acute type A aortic dissection (ATAAD) with either aortic root preservation (RP) or root replacement (RR). Original research studies that evaluated short- and mid-term hemostatic properties of RP versus RR groups were identified, from 2000 to 2024. Intraoperative transfusions of red blood cells (RBCs), reoperation for bleeding, strategy of hemostatic sealing of the anastomosis in root repair following the reapproximation of the dissected layers of the aortic wall (with/without biological glue), and operative mortality were the primary endpoints. Postoperative morbidity and overall and reoperation-free survival at one and five years were the secondary endpoints. A sensitivity analysis was performed using the leave-one-out method. Ten studies were included in the qualitative and quantitative synthesis, incorporating data from 6850 patients (RP: 4389 patients; RR: 2461 patients). Root preservation demonstrated a lower median transfusion of RBCs (WMD: -1.00; 95% CI: -1.41, -0.59; p < 0.01) and incidence of reoperation for bleeding compared to root replacement (OR: 0.67; 95% CI: 0.58, 0.77; p < 0.01). The majority of studies did not use biological glue in root repair to avoid the risk of an anastomotic pseudoaneurysm. No difference was found regarding postoperative morbidity, along with mid-term overall and reoperation-free survival. Root preservation without the use of biological glue during aortic repair is associated with enhanced hemostatic traits compared to the root replacement approach. A future well-designed Randomized Controlled Trial should further validate our outcomes.

Long-term Results of Valve-Sparing Aortic Root Replacement in Acute Type A Aortic Dissection

BackgroundValve preservation in acute type A aortic dissection (ATAAD) can be accomplished with root repair or replacement. Long-term valve durability with root repair has been established, but limited data exist regarding long-term durability of valve-sparing root replacement (VSRR). In this study, long-term results of VSRR were compared with root repair in ATAAD. MethodsFrom 2005 to 2023, 866 patients underwent ATAAD repair, of which 675 underwent root repair and 191 underwent root replacement (VSRR, n = 65; Bentall, n =126). VSRR patients were compared with 123 patients who underwent valve resuspension and root repair with postoperative echocardiograms ≥1 year. ResultsVSRR patients were younger (VSRR, 44 ± 11 years vs root repair, 55 ± 13 years; P < .001). Preoperatively, 57% of VSRR and 35% of root repair patients had moderate or more aortic insufficiency. Cardiopulmonary bypass and myocardial ischemia times were significantly longer in VSRR (P < .001). Postoperative echocardiograms with ≥1 year follow-up were analyzed in 58 VSRR patients with median follow-up of 4.8 years (interquartile range, 3-12 years) and in 123 root repair patients with median follow-up of 3.6 years (interquartile range, 3-8 years). At 10 years, VSRR patients had superior freedom from more than mild aortic insufficiency (VSRR, 91% vs root repair, 49%; P < .001). At 10 years, freedom from aortic valve replacement was equivalent (VSRR, 98% vs root repair, 92%; P = .269). ConclusionsVSRR provides equivalent long-term valve durability as root repair in ATAAD, even in patients with moderate or severe aortic insufficiency. In select young patients who require root replacement during ATAAD repair, VSRR represents an ideal therapy.

Short- and mid-term outcomes of the aortic root repair versus root replacement in acute type A aortic dissection.

In patients with acute acute type A aortic dissection (ATAAD) requiring emergency surgery, the use of aortic root repair or replacement remains a topic of controversy. The purpose of this study was to evaluate the early and mid-term clinical outcomes after aortic root repair or replacement, and to provide a theoretical basis for such patients. The study included 442 consecutive patients with ATAAD who underwent aortic root repair [n=227, repair group (RG)] or the Bentall procedure [n=215, Bentall group (BG)] at our hospital between December 2018 and December 2021. The indications for aortic root replacement were aortic root sinus diameter of ≥4.5 cm, severe sinotubular junction involvement, unrepairable aortic valvulopathy, severe coronary ostium involvement, connective tissue disease, intimal tear at the aortic root, or dissection involving three aortic sinuses. The primary outcome was the survival rate and incidence of reoperation between the two groups. The in-hospital and 30-day mortality rates in the RG and BG were 10.1% and 11.6%, respectively. The two groups had no significant difference (P=0.613). Multivariate logistic analysis showed that aortic root surgery did not influence the in-hospital or 30-day mortality rates. The mean follow-up time was 36.8±11.6 months (median, 33.4 months; interquartile range, 27.0-45.2 months). The 5-year survival rates for the RG and BG were 88.1% and 85.9%, respectively (P=0.650). During the follow-up period, only one patient in the BG group underwent proximal aortic reoperation. Continuous improvement of aortic root repair technology and identification of its indications may help reduce reoperation rates. Aortic root repair can be considered safe and feasible.

Short-term outcomes of a novel modified Bentall procedure in acute type A aortic dissection.

The Bentall procedure is a common surgical treatment for aortic root replacement in acute type A aortic dissection (ATAAD) with some complications which affect postoperative efficacy. We innovatively modified the Bentall procedure and investigated its short-term efficacy. From March 2017 to March 2019, 77 cases with ATAAD in our department underwent total arch replacement and frozen elephant trunk technique following prior Bentall procedure. They were divided into three groups. In modified-Bentall group, 20 patients underwent a modified Bentall surgery. In Bentall-inclusion group, coronary ostia inclusion anastomosis and Cabrol shunt were performed in 32 patients. In Bentall-button group, coronary ostia button anastomosis was used to 25 cases. No intraoperative deaths occurred in three groups. Operation time, CPB time, and aortic cross-clamp time in modified-Bentall group was longer than those in Bentall-inclusion group (P<0.05), but the number of RBC transfusion and postoperative drainage volume decreased compared with Bentall-button group (P<0.05). One patient with mesenteric malperfusion syndrome died after surgery in modified-Bentall group, 2 patients died in Bentall-inclusion group, and 1 patient died in Bentall-button group. No coronary anastomotic leak and vena cava-right atrium shunt signal occurred in modified-Bentall group, and there was no contrast extravasation and no pseudoaneurysm formation in the aortic root. The cardiac function of patients was grade I-II. This novel modified procedure is feasible and can significantly reduce postoperative complications with satisfactory short-term efficacy in ATAAD.

Midterm outcomes and durability of sinus segment preservation compared with root replacement for acute type A aortic dissection

ObjectiveThe durability of root repair for acute type A aortic dissection is not well studied in the context of aortic insufficiency and stability of the sinuses of Valsalva. We compared clinical and functional outcomes in patients undergoing root repair and replacement for acute type A aortic dissection. MethodsOf 716 patients undergoing surgery for acute type A aortic dissection, 585 (81.7%) underwent root repair and 131 (18.3%) underwent root replacement. Survival, cumulative incidence of reoperation, aortic insufficiency, and sinuses of Valsalva dilation were compared between the 2 groups. ResultsSurvival at 1, 5, and 10 years was 84.1% versus 77.3%, 70.8% versus 69.2%, 57.6% versus 58.0% in the root repair and replacement groups, respectively (P = .69). Cumulative incidence of reoperation at 1, 5, and 10 years was 0.0% versus 0.8%, 1.4% versus 3.8%, and 3.4% versus 8.6% in the root repair and root replacement groups, respectively (P = .011). Multivariable Cox regression identified sinuses of Valsalva diameter 45 mm or more as a risk factor for proximal aortic reoperation (hazard ratio, 9.06; 95% confidence interval, 1.26-65.24). In a repeated-measures, linear, mixed-effects model, root replacement was associated with smaller follow-up of sinuses of Valsalva dimensions (β = −0.66, P < .001). In an ordinal longitudinal mixed model, root replacement was associated with lower severity of postoperative aortic insufficiency (β = −3.10, P < .001). ConclusionsSurvival is similar, but the incidence of aortic insufficiency and root dilation may be greater after root repair compared with root replacement for acute type A aortic dissection.

Root reconstruction for proximal repair in acute type A aortic dissection.

Retrospective compared the results of root reconstruction and root replacement for acute type A aortic dissection (ATAAD) patients and observed the rate of aortic insufficiency (AI) and aortic root dilation in the midterm follow-up period. From 2008-2016, 427 ATAAD patients received surgical therapy in our center. There were 328 male and 99 female patients, aging from 22 to 83 years with a mean age of (51.1±12.5) years. These patients were divided into two major groups: 298 cases with root reinforcement reconstruction (Root Reconstruction), 129 cases with Bentall procedure (Root Replacement). The 30-day mortality was 7.7% (33/427), while no difference between the 2 procedures (8.1% and 7.0%, P=0.844). Cross-clamp, cardiopulmonary bypass, and circulatory arrest times of all the patients were 252.5±78.1, 173.6±68.9, 30.7±9.5 minutes, respectively. In the average follow-up time of (34.5±26.1) months, midterm survival rates were similar between the 2 procedures (86.2% and 86.0%, P=0.957). Only one patient received redo Bentall procedure because of severe aortic regurgitation and dilated aortic root (50 mm) in the Root Reconstruction Group. The indication of root management of ATAAD is based on the diameter of aortic root, structure of aortic root, and the dissection involvement. For most ATAAD patients, aortic root reinforcement reconstruction is a feasible and safe method.

Durability and safety of David V valve-sparing root replacement in acute type A aortic dissection

BackgroundValve-sparing root replacement (VSRR) is an attractive option in type A aortic dissection (TAAD) repair for a young patient with normal cusp anatomy, but conventional root replacement using a composite valved-conduit (ROOT) remains the gold standard in this emergent clinical setting. We examine the long-term safety and durability of the David V VSRR compared with ROOT in TAAD repair. MethodsFrom March 2004 to April 2017, 136 patients underwent repair of acute TAAD using either ROOT (n = 77; 56.6%) or VSRR (n = 59; 43.4%). Annual echocardiograms were performed for follow-up in VSRR patients. Univariable regression, Kaplan–Meier, and competing risk analyses were performed. ResultsPreoperative characteristics were similar between groups, except that VSRR patients were younger (mean age 43.5 ± 11.4 years VSRR vs 50.4 ± 3.0 years ROOT; P = .001). Both groups had similar rates of preoperative malperfusion or shock (29.3% VSRR vs 37.0% ROOT; P = .35) and ≥3+ aortic insufficiency (63% VSRR vs 76.8% ROOT). Thirty-day mortality in the VSRR group was 2/59 (3.4%) and 11/77 in the ROOT group (14.3%; P < .001). All-cause survival at 9 years was 92% (VSRR) and 59% (ROOT; P = .002). The incidence of aortic reintervention was similar between groups (20%-23% at 5 years; P = .81). At 9 years of follow-up, 5/52 (9.6%) VSRR patients had ≥2+ aortic insufficiency, and 1 patient required valve reintervention. ConclusionsIn highly-selected patients, the David V VSRR provides a safe repair of acute TAAD with concomitant root pathology and valve insufficiency. In our center, the incidence of valve-related reintervention at long-term follow-up is low after emergent repair.

Outcomes of valve-sparing root replacement in acute Type A aortic dissection.

To investigate the long-term durability of aortic valves, we reviewed the outcomes of patients who underwent valve-sparing root replacement with acute Type A aortic dissection. We included patients who underwent emergent aortic repair for acute Type A aortic dissection at our university hospital between 2000 and 2016. We identified patients who underwent valve-sparing root replacement from the included cohort and assessed their survival and long-term valve durability. We identified 24 of 328 patients who underwent valve-sparing root replacement (age: mean ± SD 49 ± 11 years; 17 men). All patients underwent reimplantation procedures and 2 had concomitant cusp repairs (central plication). Prolapsed cusps caused by detached commissures in 12 cases were noted and reattached with buttress sutures with or without glue. There was no in-hospital mortality. Median follow-up period was 84 months (range 1-202 months) and survival was 100% at 5 and 10 years. Freedom from moderate or greater aortic insufficiency was 82% ± 10% at 5 years and 65% ± 13% at 10 years. Freedom from aortic valve reoperation was 83% ± 9% at 5 years and 69% ± 12% at 10 years. Valve reoperations were indicated for endocarditis in 1 patient, perforation of the aortic cusp in 1 patient and redetachment of commissures that had been attached with gelatin-resorcinol-formaldehyde glue at the initial operations in 3 patients. The durability of valve-sparing root replacement in acute aortic dissection was suboptimal. The major cause of late failure was commissure detachment after primary repair with buttress sutures and glue. Gelatin-resorcinol-formaldehyde glue should be avoided for commissural resuspension in patients with acute aortic dissection.

Clinical outcomes of valve-sparing root replacement in acute type A aortic dissection

>Objectives. The early and late outcomes of valve-sparing root replacement (VSR) in type A aortic dissection (AAD) are unknown. The aim of this study was to review the outcomes of VSR in AAD. We also compared the outcomes of VSR with the Bentall operation, which served as a standard reference technique. Design. We retrospectively reviewed 52 patients who underwent surgery for AAD and concomitant root replacement between 1998 and 2013 at Samsung Medical Center. Patients were divided into two groups: Bentall (n = 34) and VSR (n = 18). Two out of six surgeons performed VSR. The mean follow-up duration was 62.3 ± 46.5 months. Results. Preoperative characteristics were similar between the two groups except age (Bentall, 48 ± 11 years; VSR, 37 ± 11 years, p = 0.011). The aortic cross-clamping time was longer in the VSR group (Bentall, 185.8 ± 63.8; VSR, 241.4 ± 44.3 min, p = 0.002). There was no early death in the VSR group, but there was one in the Bentall group (p = 1.000). Despite the higher reoperation rate for aortic valve in the VSR group (Three reoperations) than in the Bentall group (no reoperation), major valve-related events and overall mortality did not differ between the two groups(p = 0.876 and 0.119, respectively). In multivariable analysis, the root replacement technique was not a risk factor for major valve-related events. Conclusions. VSR seems to be equivalent to the Bentall procedure for AAD in terms of early and late outcomes. VSR can be considered as a viable option, particularly for young patients with favorable aortic valve leaflets undergoing surgery at an experienced center.

Midterm Results of David V Valve-Sparing Aortic Root Replacement in Acute Type A Aortic Dissection

The David V valve-sparing aortic root replacement (David V) has been shown to provide excellent long-term valve function and low rates of valve-related complications in the elective treatment of aortic root aneurysms. The safety and durability of the David V in the repair of acute type A aortic dissection (type A) are currently unclear. In this study, the midterm results of David V in the setting of type A aortic dissection were analyzed. From 2005 to 2013, 350 patients underwent surgical repair of type A aortic dissection. Outcomes were analyzed in 43 consecutive patients who received a David V during repair of type A aortic dissection. Patients were followed with annual postoperative echocardiograms. Follow-up was 85% complete, with a mean duration of 40 ± 31 months. The mean age of these patients was 46 ± 10 years. There were two operative deaths (4.7%), and 93% of patients required a hemiarch replacement (n= 32) or a total arch replacement (n= 8) using hypothermic circulatory arrest. Cusp repairs were performed in 6 (14%) patients; 51% of patients had 3+ or greater preoperative aortic insufficiency (AI), 83% of patients left the operatingroom with zero AI, and the remainder had 1+ AI or less. No patient in the follow-up period developed endocarditis or required aortic valve replacement. At midterm follow-up, freedom from 2+ AI was 94%, and freedom from aortic valve replacement was 100%. The David V can be performed with lowmorbidity and mortality in young patients presenting with type A aortic dissection who require aortic root replacement. At midterm follow-up, valve function is durable, and the incidence of valve-related complications is low.

Composite aortic root replacement in acute type A dissection: time to rethink the indications?

The indications for aortic root replacement in acute type A dissection are unclear. We reviewed the immediate and long-term outcome of consecutive patients in a series in which a low-threshold policy of composite aortic root replacement had evolved. From a prospectively compiled aortic surgery database, we identified 162 patients who had either supracoronary interposition grafting, Group A (n=89), or composite root replacement, Group B (n=73) for acute type A dissection. Patients receiving total arch replacements were excluded. Operative and clinical details were analyzed and patient survival was compared to an age and gender matched census cohort. Need for reoperation on the proximal or distal aorta was also noted. Follow-up totaled 795.5 patient-years. Hospital mortality rates were identical in both groups (12.3%: 11 deaths in group A; 9 in group B). Chronic pulmonary disease, diabetes, malperfusion, hemodynamic compromise and aortic root dilatation were independent risk factors for hospital death. Actuarial survival estimates at 1, 5 and 10 years were 79% (71-88%), 64% (53-75%), and 55% (41-68%) for group A, and 79% (70-86%), 73% (62-83%), and 65% (52-78%) for group B (P=0.48). Age and operative patency of the ascending false lumen were independent risk factors for death after hospital discharge. Proximal aortic reoperation was required for four patients in group A and none in group B (P=0.085). A strategy of replacement rather than repair of the dissected aortic root for specific indications in type A dissection yielded high survival and low proximal reoperation rates. These results support an aggressive policy of composite root replacement in acute type A dissection.

High failure rate after valve-sparing aortic root replacement using the “remodeling technique” in acute type A aortic dissection

Valve-sparing surgery including the replacement of the sinus of valsalvae were initially meant to be promising approaches in the treatment of acute type A aortic dissection. However, the long-term outcome after valve-sparing aortic root replacement in acute type A dissection is currently the subject of intense debate, and the evidence reported in the literature is sparse. Here we report on our experience on valve sparing aortic root replacement inpatients with acute type A dissection. From August 1995 to November 2000, 30 patients with acute type A dissection received valve-sparing aortic root replacement. Two different techniques were performed: the "remodeling" technique, first described by Yacoub in 1983 (8 patients) and the "reimplantation" technique, initially described by David and Feindel, in 1992 (22 patients). Endpoints of the study were early and late mortality, as well as aortic valve-related complications and reoperations. The mean follow-up time was 22.6+/-15.4 months. The overall 30 day mortality was 17% (5/29) and the late mortality 4% (1/24). During the observation period, 4 patients had to be reoperated (n=3) for acute aortic valve regurgitation after aortic root remodeling and for acute aortic valve endocarditis (n=1) after aortic root reimplantation. In the 3 patients with acute aortic valve regurgitation, symptoms occurred 44, 24, and 17 months after the initial operation in these patients. Intraoperatively prolapsing aortic leaflets because of commissural detachment was found in all 3 cases. In all other patients the latest echocardiographic follow-up examination revealed freedom from aortic regurgitation higher than grade 1. The high failure rate of aortic root remodeling inpatients with acute type A aortic dissection is discouraging. Whether this technique should be applied in acute type A aortic dissection is questionable. In contrast, aortic root reimplantation lead to favorable midterm outcome. Thus, we recommend consideration of this technique for surgical treatment of patients with acute type A aortic dissection.

Discussion: Session 3—Dissection

Discussion: Session 3—Dissection

High Failure Rate After Valve-sparing Aortic Root Replacement Using the “Remodeling Technique” in Acute Type A Aortic Dissection

Background Valve-sparing surgery including the replacement of the sinus of valsalvae were initially meant to be promising approaches in the treatment of acute type A aortic dissection. However, the long-term outcome after valve-sparing aortic root replacement in acute type A dissection is currently the subject of intense debate, and the evidence reported in the literature is sparse. Here we report on our experience on valve sparing aortic root replacement inpatients with acute type A dissection. Methods From August 1995 to November 2000, 30 patients with acute type A dissection received valve-sparing aortic root replacement. Two different techniques were performed: the “remodeling” technique, first described by Yacoub in 1983 (8 patients) and the “reimplantation” technique, initially described by David and Feindel, in 1992 (22 patients). Endpoints of the study were early and late mortality, as well as aortic valve-related complications and reoperations. Results The mean follow-up time was 22.6±15.4 months. The overall 30 day mortality was 17% (5/29) and the late mortality 4% (1/24). During the observation period, 4 patients had to be reoperated (n=3) for acute aortic valve regurgitation after aortic root remodeling and for acute aortic valve endocarditis (n=1) after aortic root reimplantation. In the 3 patients with acute aortic valve regurgitation, symptoms occurred 44, 24, and 17 months after the initial operation in these patients. Intraoperatively prolapsing aortic leaflets because of commissural detachment was found in all 3 cases. In all other patients the latest echocardiographic follow-up examination revealed freedom from aortic regugitation higher than grade 1. Conclusions The high failure rate of aortic root remodeling inpatients with acute type A aortic dissection is discouraging. Whether this technique should be applied in acute type A aortic dissection is questionable. In contrast, aortic root reimplantation lead to favorable midterm outcome. Thus, we recommend consideration of this technique for surgical treatment of patients with acute type A aortic dissection.

Aortopulmonary fistula after aortic root replacement

This report describes a rare case of aortopulmonary fistula in pseudoaneurysm of the left coronary ostial button. A 66-year-old woman suddenly developed congestive heart failure 3 years after aortic root replacement for acute type A aortic dissection. The diagnosis of aortopulmonary fistula was confirmed preoperatively by aortography, heart catheterization, and spiral computed tomography. She was discharged in good condition after surgical treatment. This serious complication should be considered in patients who have severe congestive heart failure after aortic root replacement.

Valve-sparing aortic root replacement in patients after a previous operation for acute type A aortic dissection

T he list of long-term complications after surgical intervention for acute type A aortic dissection includes recurrent dissection, aneurysm formation, and aortic valve regurgitation. Ten years after the initial operation for acute type A dissection, the reoperation rate for these kinds of long-term complications is 13% to 30% in the literature.1 The diseased aortic root in these patients is commonly treated with the replacement of the aortic valve and ascending aorta with an artificial composite graft carrying a mechanical or biologic valve substitute. Recently, we have described the feasibility of valve-sparing aortic root replacement in acute type A dissection.2 However, no reports are available on the feasibility of valve-sparing aortic root replacement after a previous operation for acute type A dissection involving the aortic root. Here we report on 3 patients who underwent reoperation after an operation for acute type A dissection involving the aortic root, ascending aorta, and aortic arch. In all 3 cases we successfully performed valve-sparing aortic root replacement.

Stentless Xenograft Repair of the Dissected Aortic Root

We used a Freestyle (Medtronic, Minneapolis, MN) porcine root to replace a regurgitant aortic valve and repair acute type A dissection. A Hemashield (Meadox Medicals, Oakland, NJ) graft was used to replace the ascending aorta with the “open anastomosis” technique. This method is a valuable alternative to conventional root replacement in acute type A dissection.