Supracoronary Aortic Replacement Research Articles

Well-functioning bicuspid aortic valves should be preserved during aortic replacement for the ascending aortopathy phenotype

ObjectivesConsensus has not been reached on whether or not to replace or preserve a well-functioning bicuspid aortic valve (BAV) in patients undergoing aortic replacement for the ascending phenotype of BAV aortopathy. We characterize morphology, evaluate progression of aortic regurgitation or aortic stenosis, and investigate the need for aortic valve replacement in patients whose well-functioning BAV was preserved during ascending aortic replacement ≥10 years prior. MethodsFrom January 1991 to August 2011, 191 patients with a well-functioning BAV underwent supracoronary aortic replacement (113 valves were minimally repaired). Aortic morphology was evaluated, aortic regurgitation grade and transvalvular aortic gradient modeled parametrically, and survival assessed by the Kaplan-Meier method. Median follow-up was 10 years. ResultsMean aortic diameter was 2.9 ± 0.53 cm at the annulus and 4.2 ± 0.55 cm at the sinuses. Mean maximum ascending diameter was 5.1 ± 0.49 cm. All patients exhibited a cusp-fusion BAV phenotype. Fifteen-year progression to severe aortic regurgitation was 3.2%. Mean aortic valve gradient began to rise 5 years postoperatively to 27 mm Hg by 14 years. Freedom from aortic valve replacement at 1, 5, 10, and 15 years was 100%, 95%, 83%, and 63%, respectively. Minimal valve repair was not associated with late aortic valve replacement. Fifteen-year survival was 74%. ConclusionsPreserving a well-functioning BAV should be considered in carefully selected patients undergoing aortic replacement for the ascending phenotype of BAV aortopathy. The valves remain durable in the long term, with slow progression of regurgitation or stenosis, and low probability of aortic valve replacement through 10 years.

Anatomy of the retrograde type A aortic dissection after endovascular repair of type B aortic dissection: a case report

Aortic dissection requires immediate medical attention. The optimal treatment approach of Type B aortic dissection is still a matter of debate. Possible options include open surgery, endovascular aortic repair (EVAR), and hybrid procedure. The indication for surgery is the dissection that involves the ascending aorta and the aortic arch (Type A Stanford, Types I and II DeBakey). Hybrid or endovascular procedures seem to be an attractive alternative treatment for patients with the complex aortic disease and a high risk of surgery. Endovascular treatment of acute Type B aortic dissections is designed to prevent the retrograde dissection of the ascending aorta and the aortic arch. The occurrence of retrograde Type A aortic dissection (RTAD) is rare, but the mortality rate is high. We report a case of a 55-year-old gentleman who had undergone thoracic EVAR. Thirty months after the given procedure he presented with RTAD and underwent supracoronary aortic replacement. The article is intended to remind the clinicians of the importance of early detection of the possible complications when performing EVAR, and the significance of a rapid response.

Preservation of the Aortic Root During Type A Aortic Dissection Surgery: An Effective Strategy?

Background Management of the aortic root during acute Type A aortic dissection (TAAD) repair remains controversial in term of long-term evolution and reoperation. The aim of this study was to assess the long-term outcomes of the aortic root after conservative management during primary surgery. Methods One hundred sixty-four consecutive patients were included in this monocentric retrospective study. The primary endpoint was reoperation on the aortic root during long-term follow-up. Forty-six patients had aortic root replacement (ARR) and 118 had supracoronary aortic replacement (SCR). The 10-year survival, occurrence of significant aortic regurgitation, and radiologic aortic root dilatation in each group were assessed during follow-up. Results Patients from ARR group were younger than those from SCR group ( p < 0.0001). Median follow-ups of ARR group and SCR group are 4.4 (interquartile range [IR]: 2.6–8.3) and 6.15 (IR: 2.8–10.53) years, respectively. Reoperation of the aortic root during long-term follow-up was similar in both groups (ARR group: 5.1%, SCR group: 3.3%, p = 0.636). The 10-year survivals of ARR and SCR groups were 64.8 ± 12.3% and 46.3 ± 5.8% ( p = 0.012), respectively. Long-term significant aortic regurgitation occurred in one patient (1.7%) and seven patients (7.6%) of the ARR and SCR groups ( p = 0.176), respectively. Radiologic aortic root diameters in the SCR group were similar between postoperative period and follow-up studies ( p = 0.58). Reoperation on the distal aorta ( p = 0.012) and patent radiologic false lumen of the descending aorta ( p = 0.043) were independent risk factors of late death. Conclusion SCR is an effective technique for primary TAAD surgery and does not increase the rate of late reoperation on the aortic root.

BİR ÜNİVERSİTE HASTANESİ KLİNİĞİNDE YAPILAN İLK 200 AÇIK KALP AMELİYATI SONUÇLARI: KIRIKKALE ÜNİVERSİTESİ, TIP FAKÜLTESİ, KALP-DAMAR CERRAHİSİ

Amaç: Çalışmanın amacı, kliniğimizde yapılan ilk 200 açık kalp ameliyatının sonuçlarını değerlendirmektir.Gereç ve Yöntemler: Yapılan 200 kalp ameliyatı hastane kayıt sistemi taranarak geriye dönük olarak incelendi. Hastaların yaş, cinsiyet, komorbiditeleri, ameliyat tipleri, hastane ve yoğun bakımda yatış süreleri, morbidite ve mortalite oranları değerlendirildi.Bulgular: Hastaların 128’i kadın,72’si erkekti. Yaşları 38-90 yıl arasında olup, ortalama 68±5 yıldı. Komorbit faktörleri olarak, kronik obstrüktif akciğer hastalığı, hipertansiyon, diabetes mellitus, hiperlipidemi, serebro-vasküler hastalık, periferik arter hastalığı ve kronik böbrek yetmezliği ve miyokart enfarktüsü görüldü. Toplam 162 koroner arter bypass grefti (KABG) yapıldı. Bunlardan 24 tanesi çalışan kalpte gerçekleştirildi. Eş zamanlı olarak 5 karotis endarterektomi ve 15 koroner endarterektomi yapıldı. Dört KABG ve mitral kapak replasmanı (MVR), 2 KABG ve aort kapak replasmanı (AVR), 6 AVR, 12 MVR, 4 AVR ve MVR, 3 MVR ve tricuspit anuloplasti yapıldı. İki hastaya aort diseksiyonu nedeniyle asenden aort replasmanı ve 3 hastanın asenden aort anevrizmasına supra koroner aort replasmanı yapıldı. İki hastaya kardiyak yaralanma nedeniyle sağ ventrikül tamiri yapıldı.Düşük kardiyak debi nedeniyle 10 hastaya intra-aortik balon pompası takıldı. Komplikasyon olarak 38 hastada atrial fibrilasyon, 4 hastada akut böbrek yetmezliği, 3 hastada serebrovaskuler olay gelişti. Hastaların 4’ünde postoperatif kanama ve 3’ünde sternal dehisens nedeniyle revizyon yapıldı. Bir hastada mediastinit görüldü. Yoğun bakımda kalış süresi ortalama 2,2±1,7 gün olup, hastanede kalış süresi 7,5±4 gündü. Hastane mortalitesi 8 hastada (%4) görüldü.Sonuç: Kırıkkale Üniversitesi Tıp Fakültesi Araştırma ve Uygulama Hastanesi kalp ve damar cerrahisi kliniği, açık kalp ameliyatlarının literatüre uygun morbidite ve mortalite oranları ile yapıldığı bir merkez olmuştur.

АНАТОМІЯ РОЗШАРУВАННЯ АОРТИ В ОПЕРОВАНОЇ ПАЦІЄНТКИ ЗІ СИНДРОМОМ МАРФАНА: ОПИС КЛІНІЧНОГО ВИПАДКУ

Introduction. Aortic dissection is the most common acute aortic pathology. Acute ascending aortic dissection is a life-threatening condition and a surgical emergency which requires prompt visualization of the aortic anatomy. Various types of classification and assessment of the aorta are described. Presentation of the case. Concurrent aortic dissection and Marfan syndrome (MS) followed by the aneurysm of aorta which required supracoronary aortic replacement (2012), Bentall procedure (2014) and urgent open thoracic descending aorta replacement (2017) are described in the case-report. Discussion. Patients with the aortic dissection may have certain underlying conditions, such as MS, which can predispose to dissection. The aortic pathology is registered in almost 65-100% of the patients with MS. The prevalence of type A aortic dissection among the patients with MS at the age of 60 is approximately 50%. The most common pattern of repair is the proximal ascending aortic repair followed by the descending thoracic aneurysm surgery. The open surgery technique as well as the aortic dissection or aneurysm repairs may be safely used in the patients with MS. Conclusion. Anatomical features of the aorta in the patients with MS are vitally important when carrying out the analysis of the computed tomography images; in particular, the schedule of the computed tomography follow-up for the patients with MS should be customized to each case.

The fate of aortic root and aortic regurgitation after supracoronary ascending aortic replacement for acute type A aortic dissection

BackgroundThe aim of this study was to evaluate the fate of the preserved aortic root after supracoronary aortic replacement for acute type A aortic dissection. MethodsBetween October 1999 and March 2018, 339 patients underwent supracoronary aortic replacement for acute type A aortic dissection at our institution. Late outcomes were evaluated, including overall survival, aortic-related death, and aortic root–related reoperation. The median follow-up was 3.7 years (1.4-8.4 years). ResultsOperative mortality was 46 patients (13.6%). The cumulative incidences at 5 years for aortic root–related reoperation, aortic-related death, and non–aortic related death were 2.5%, 14.5% and 12.4%, respectively. Multivariable Cox hazard regression analysis demonstrated greater sinus of Valsalva diameter and number of commissural detachments to be significant risk factors for a composite outcome consisting of aortic-related death or aortic root–related reoperation. Mixed-effects regression demonstrated that sinus of Valsalva diameter significantly increased with time (P < .001), and aortic regurgitation significantly worsened (P < .001). ConclusionsSinus of Valsalva diameter and commissural detachment were independent predictors of unfavorable outcomes after supracoronary aortic replacement. Close follow-up is particularly necessary for these patients, and aortic root replacement at the time of initial operation may lead to more favorable late outcomes.

Single coronary ostium in a patient with quadricuspid aortic valve combined with aneurysmal ascending aortic dilatation

BackgroundThe presence of a fourth aortic valve cusp (quadricupsid aortic valve) is a rare congenital malformation and is often accompanied by other anomalies of the adjacent cardiovascular structures. Among these concomitant anomalies, simultaneous association of both a single coronary ostium and aneurysmal ascending aortic dilation in combination with the quadricupsid aortic valve has not been reported yet.Case presentationWe experienced the case of a 56-year-old female patient presenting as aortic regurgitation resulted from malcoaptation of quadricupsid aortic valve. The patient had also accompanying aneurysmal ascending aortic dilatation and coronary ostial anomaly. Surgical correction (aortic valve replacement with mechanical devices and supracoronary aortic replacement with prosthetic graft) was performed without any complications.ConclusionsThe technological development of preoperative imaging studies enable the physician to encounter the quadricuspid aortic valve with other associated malformations more often unlike previous reports. With review on the quadricuspid aortic valve, we discussed a surgical considerations for the treatment of this anomaly.

Marfan syndrome with a giant noncoronary sinus of Valsalva aneurysm.

Once presented in 2011 by Dayi SU et al. our case is a 30-year-old woman with Marfan syndrome who had undergone aortic valve replacement due to severe aortic regurgitation secondary to dilatation of the aortic root in 2000 and supracoronary aortic replacement due to Stanford type A dissection in 2002 with subsequent dilatation of sinus of Valsalva. When described by Dayi SU et al. the size of the aneurysm was noted to be 6x6.5x6.5 cm in dimensions and it was formed from noncoronary sinus of Valsalva. At this time conservative followup was found to be the appropriate therapy because high risk of redo surgery. Three years later the same patient was observed in echocardiography laboratory with a rapid progression of the same aneurysm of sinus of Valsalva to 8.3x9.3x8.2 cm in size (Figure 1A). Moderate mitral and tricuspid regurgitation with prolapse of valves and normal function of mechanical aortic valve were observed. Computed tomography angiography also confirmed enlargement of the aneurysm to 91.9x91.8 in size (Figures 1B, C, and D). Herein, we would like to draw attention to the clinical presentation and progression of Marfan syndrome.

Supracoronary aortic replacement for acute type A aortic dissection: A risk-factor for developing a late aortic root aneurysm?

Supracoronary aortic replacement for acute type A aortic dissection: A risk-factor for developing a late aortic root aneurysm?

Re-dissection of the sinus of Valsalva: An underestimated complication after supracoronary aortic replacement in patients with Stanford type A aortic dissection

Re-dissection of the sinus of Valsalva: An underestimated complication after supracoronary aortic replacement in patients with Stanford type A aortic dissection

Flow-sensitive four-dimensional magnetic resonance imaging: flow patterns in ascending aortic aneurysms

Pathological aortic flow patterns differ significantly from haemodynamics within the healthy aorta. Development and impact of pathological flow is largely unknown and might affect pathogenesis and the progression of thoracic aortic diseases. This study presents pathological blood-flow patterns within a series of six patients suffering from ascending aortic aneurysms investigated with high-detail flow-sensitive, four-dimensional (4D)-MRI and three-dimensional (3D) computer-aided flow-visualisation strategies. Data were acquired on a 3T magnetic resonance system (TRIO, Siemens, Erlangen, Germany) using a flow-sensitive 4D (time-resolved 3D) sequence protocol. Measurements were taken in synchrony with the cardiac cycle and under respiration control. After data pre-processing, blood-flow was visualised by means of systolic 3D streamlines and time-resolved 3D particle traces using the software EnSight (CEI, Apex, NC, USA) and homemade visualisation tools. We investigated six adult patients with ascending aortic aneurysms and one healthy individual and findings were compared to 3D-haemodynamics of the dilated ascending aorta described in current literature. Normal blood-flow in the healthy volunteer resulted in highest velocities of up to 1 ms in the ascending and descending aorta, a right-handed helical flow pattern featuring 0.5-1.5 revolutions within the ascending aorta was present. Two atherosclerotic aneurysms presented either increased right-handed helical flow with flow acceleration along the great curvature, or multiple vortical flows in the sinuses and middle of the ascending aorta. One Marfan-associated aneurysm exhibited increased vortical flow in the dilated sinuses. One pseudo-aneurysm at the proximal anastomosis of an earlier supracoronary aortic replacement showed extensive vortex formation inside the aneurysm's lumen. An aneurysm in a patient with a bicuspid aortic valve revealed one major vortex formation directly above the aortic valve. One aneurysm following congenital valvular stenosis and commissurotomy in childhood was characterised by helical diastolic backflow in the central ascending aorta and a vortex at the small curvature. Patients with ascending aortic aneurysms reveal considerable differences in local flow patterns among themselves and compared to healthy individuals. Further investigations are necessary to identify flow patterns predisposing to aortic aneurysm development or adverse events in the course of aortic disease.

One-stage treatment of aortic coarctation associated with coronary heart disease, ascending aortic aneurysm, and aortic valve stenosis with an extra-anatomic ascending-descending aortic bypass

The surgical treatment for aortic coarctation associated with coronary artery disease and valvular disease is a difficult decision. We describe the case of a 64-year-old man with coronary heart disease, aortic coarctation, aneurysm of the ascending aorta, and bicuspid aortic valve. The surgical therapy included total arterial revascularization, placement of a mechanical valve, supracoronary aortic replacement, and extra-anatomic ascending aortic–to–descending aortic bypass in one session.