Thursday, April 25, 2024: 5:38 PM - 7:00 PM
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Presentations
Objective: Describe the short and long-term outcomes of aortic valve-sparing root replacement procedures in a referral center in Bogota D.C, Colombia
Methods: We included all patients who underwent the David procedure from January 2002 to September 2023 at our institution. We identified patients using the institutional cardiac surgery database that follows the coding guidelines of the Society of Thoracic Surgeons (STS). We collected demographics, clinical and imaging data from pre-, intra- and post-operative periods. Patient follow-up was done through outpatient clinic, government databases and telephone interviews. Our main outcomes were survival rate, valve regurgitation recurrence and freedom from reoperation, estimated by the Kaplan-Meier method. The bivariate analyses were done using the Mann-Whitney U test and the Chi-square or Fisher´s exact test according to the nature and distribution of each variable
Results: A total of 170 patients between 14 and 72 years of age were identified in 21 years of experience. Median age was 51 years (IQR 39-59), 82% of the patients were male and the most frequent comorbidity was hypertension (39%). Marfan´s syndrome was present in 14% of patients and 38% had bicuspid aortic valve. The indication of the procedure was an aortic aneurism in 84% of cases and aortic dissection in 12%. Preoperative aortic regurgitation (AVR) was grade IV in 52% of patients, grade III in 13% and grade II in 6%. Most patients underwent elective surgery (57%), followed by urgent priority (38%) and 4% were emergencies. The concomitant procedures were aortic valve repair in 20 patients, aortic arch repair in 22 patients, mitral valve repair in 12 patients and Maze procedure in 3 patients. There were 2 perioperative deaths. At a mean follow-up of 3 years, 95% of patients were free of significant aortic regurgitation. Freedom from hemodynamically significant AVR (Grade III or higher) was estimated at 96% at 108 months. Freedom from reoperation was 95% at 13 years and there was a total of 7 valve related reoperations. Survival estimate was 83% after 15 years of follow-up.
Conclusions: Aortic valve-sparing root replacement is a safe procedure providing excellent short and long-term outcomes. The improvement of AVR was remarkable and maintainable in the long term. In our setting, the David procedure shows excellent outcomes comparable to the reported in high-volume income centers.
Authors
Julian Senosiain (1), Jaime Camacho (2), Juan Umaña (3), Nicolas Nunez-Ordonez (1), Juan David Niño (4), Carlos Villa (5), TOMAS Chalela (6), NESTOR SANDOVAL (7), Carlos Obando (8)
Institutions
(1) N/A, N/A, (2) Fundacion Cardioinfantil, Bogota, NA, (3) Cleveland Clinic, Ohio, USA, (4) Universidad del Rosario, Bogota, NA, (5) Fundacion Cardioinfantil, Bogota, Colombia, (6) N/A, bogota, Colombia, (7) FUNDACION CARDIOINFANTIL, BOGOTA, DC, (8) N/A, Bogota, Colombia
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Poster Presenter
Julian Senosiain, Fundacion Cardioinfantil
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Bogota DC
Colombia
Objectives: To evaluate the role of 4D analysis using multiphase computed tomography (MCCT) in the description of the aortic annulus (AA) of the bicuspid aortic valves (BAV) with regards to the latest expert consensus classification and to describe the morphometrics of the different types of BAV.
Methods: 15 ECG-gated MCCT of patients with normal BAV were analyzed using an in-house software. The AA border was pinpointed on 9 reconstructed planes and the 3D coordinates of the 18 consecutive points were interpolated into a 3D curve using a cubic spline to calculate 3D areas, perimeters, all diameters, eccentricity indexes and global height. Three additional planes were generated at the level of the left ventricular outflow tract (LVOT), the level of the Valsalva sinuses and the level of the sinotubular junction (STJ). This procedure was repeated for all the 10 temporal phases of the RR interval. 15 additional ECG-gated MCCT of patients with normal tricuspid aortic valve (TAV) were analyzed for comparison.
Results: The annulus was significantly larger in BAV than in TAV in terms of area, perimeter, diameters, and height. The Valsalva sinuses and the STJ were also significantly larger in BAV compared to TAV (mean area in end-diastole of 6.06±1 cm² vs 4.69±1 cm², p<0.001 and 5.13±1.62 cm² vs 3.62+/ 0.99 cm², p= 0.001 respectively). In BAV, 3D AA shape analysis helps to distinguish the 3 types of BAV: the 2-sinus type (symmetrical), the fused type, and the partial-fusion type or form fruste (both asymmetrical). It also allows to determine the position and the height of the nonfunctional commissure. In symmetrical BAV, the non-functional commissure was significantly lower than the other commissures (6.01±4.27 mm vs 18.24±3.2 mm vs 17.15±3.6 mm, p <0.001) whereas in asymmetrical BAV, the 3 commissures had comparable heights (16.38±0.86 mm vs 15.88±1.69 mm vs 15.37±0.88 mm, p=0.316). There was no difference in the AA eccentricity indexes between TAV and BAV at all phases of the cardiac cycle. However, there was a spectrum of ellipticity of the other components of the aortic root between the different types of valves: at end-diastole, going from TAV to asymmetrical BAV to symmetrical BAV, the LVOT became more circular, and the Valsalva sinuses became more elliptical (Figure).
Conclusion: 3D morphometric analysis of the BAV using MCCT allows to identify the type of BAV, and to describe the position and height of the nonfunctional commissure. There are significan
Authors
amine fikani (1), Damian Craiem (2), cyrille boulogne (3), Gilles Soulat (4), Elie Mousseaux (4), Jerome Jouan (1)
Institutions
(1) Limoges University Hospital, France, (2) Favaloro University, Instituto de Medicina Traslacional, Trasplante y Bioingeniería, CONICET, Buenos Aires, NA, (3) Limoges University Hospital, Limoges, Haute Vienne, (4) Department of Radiology, Georges Pompidou European Hospital, Paris, NA
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Poster Presenter
Amine Fikani
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Limoges
France
Objective: The last few decades have seen a steady rise in incidence of reoperations in cardiac surgery, such that redo cardiac surgery has become an integral part of cardiac surgery. Redo aortic surgeries are complex procedures known to be associated with increased morbidity and mortality compared to primary aortic procedures. We aimed to report on the early outcomes and 5-year outcome following redo aortic surgeries in our centre.
Methods: Of the 348 patients who had redo-cardiac surgery in our centre from January 1st, 2018, to August 30th, 2023, 77 (22.1%) patients underwent redo aortic surgery and were included in this study. The primary outcome of interest was in-hospital mortality, and secondary outcomes of interest included overall mortality, 30-day mortality, prolonged intensive care unit stay (>72hours), and prolonged length of hospital stay (>10days), and other adverse events such as re-entry injury, need for re-exploration, need for mechanical circulatory support, prolonged mechanical ventilation (>48hours), need for permanent pace maker, stroke, renal dysfunction requiring renal replacement therapy, arrhythmia, and wound infection. Survival analysis was used to determine the association between demographics and perioperative variables of interest and rate of occurrence of outcomes of interest. Univariate and multivariate Cox- proportional hazard (Cox-PH) regression models were fitted to explore their relationship. Kaplan-Meir plots were fitted to visualise the probability of overall survival and freedom from adverse outcomes of interest.
Results: The mean age of the total cohort of redo aortic patients was 64.22 ± 12.22. Majority of the patients were males (n= 57, 69.3%) and underwent elective redo-aortic surgeries (n= 48, 62.3%). The mean Logistic Euroscore and Euroscore II were 33.25 ± 19.52 and 24.15 ± 20.89 respectively. The mean duration between redo surgeries was higher in females (12.45 ± 13.28) years compared to males (8.72 ± 7.93) years but this difference was not found to be statistically significant (p=0.243). The most common indication for redo surgery was aortic dilatation (n=41, 53.2%). Majority of the patients had a first redo-operation (n=69, 89.6%), while only one patient (0.3%) had a fourth redo. The most common surgery type was aortic arch surgery (frozen elephant trunk) with ascending aortic replacement (n=34, 44.1%). The mean duration of follow-up was 2.0 ± 1.7. The rate of freedom from in-hospital mortality was 63.1% (95% CI 35.4 – 100%). Overall survival rate at the end of the 5-year follow-up period was 73.1% (95% CI 62.6 – 85.4%). The factors found to be predictive of overall mortality were priority of surgery (HR 3.48, 95% CI 1.20-10.05, p=0.02), time to re-operation (HR 0.89, 95% CI 0.81–0.99, p=0.025), pre-op chronic kidney disease (HR 3.16, 95% CI 1.18-8.43, p=0.022), need for mechanical circulatory support (HR 12.7, 95% CI 4.23-38.12, p<0.001), post operative renal dysfunction (HR 4.03, 95% CI 1.50-10.79, p=0.006), and post op re-exploration (HR 47.82, 95% CI 13.9–164.4, p<0.001). Need for mechanical circulatory support (HR 7.74, 95% CI 2.09 – 28.69, p=0.002) was found to be predictive of in-hospital mortality.
Conclusion: Survival rates following redo aortic surgery in our centre are comparable with those gotten in other studies with immediate and 5-year outcomes shown to be favourable. In addition, several independent risk factors have been shown to be predictors of mortality.
Authors
Oluwanifemi Akintoye (1), Namrata Mishra (2), RAVI DE SILVA (1)
Institutions
(1) Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom, (2) New Vision University Medical Student, Tbilisi, Georgia
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Poster Presenter
Oluwanifemi Akintoye, Royal Papworth Hospital
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Cambridge
United Kingdom
Objective: Retrograde type A aortic dissection is a challenging surgical emergency associated with high morbidity and mortality. The aim of this study was to describe our experience with retrograde type A aortic dissection (RAAD) following thoracic endovascular aortic repair (TEVAR) and its surgical management strategy.
Methods: Our study was conducted between January 2011 and January 2021 at Cairo University Hospitals, and included 100 patients undergoing (TEVAR) , of them 8 patients developed retrograde dissection at time interval ranging from 2 weeks to 6 months . The mean age was 55 ± 9 years and 76% of patients were males. All retrograde dissection patients underwent emergency surgical repair under hypothermic circulatory arrest to excise the stent induced new entry and perform hemi arch replacement..
Results: The mean cross clamp time was 93±17 minutes and circulatory arrest time was 25±6 minutes. One patient suffered from acute renal failure requiring hemodialysis during the postoperative hospital stay and one patient developed paraparesis of lower limbs that improved after insertion of spinal drain. In-hospital mortality occurred in one patient(12%) who suffered from fatal hematemesis postoperatively.
Conclusions : Retrograde type A aortic dissection post TEVAR is an uncommon but potentially catastrophic complication of TEVAR. Surgical replacement of ascending aorta and segment of aortic arch involving the entry tear offers an efficient strategy for the management and proved to be safe and durable technique with good early results.
Authors
ahmed elsharkawy (1), saidabdelaziz badr (2)
Institutions
(1) Kasr Alaini Cairo university Hospital, cairo, cairo, (2) DR, CAIRO, CAIRO
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Poster Presenter
ahmed elsharkawy, Cairo University hospital
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cairo, cairo
Egypt
Objective: In the treatment of thoracic aortic aneurysms, one-stage total thoracic aortic replacement presents risks in older and frail patients, and two-staged descending aortic replacement using the elephant trunk is also considered very invasive. Currently, thoracic endovascular aortic repair (TEVAR) is performed as a two-staged procedure of the elephant trunk technique. However, two-staged TEVAR is difficult to perform in cases of intravascular atheroma, intramural thrombus, rupture, or imminent rupture conditions.
Methods: The invasiveness of surgery can be minimized by performing an ascending arch replacement through a median sternotomy, inserting the elephant trunk during circulatory arrest, and performing TEVAR while maintaining circulatory arrest. Blood can be pumped through the sheath from the femoral artery to blow off the debris in the aorta upon resumption of circulation, reducing the risk of peripheral emboli.
Results: In this study, we report the case of a 67-year-old man with a giant aneurysm from the arch to the descending aorta who underwent a one-stage frozen elephant trunk and TEVAR procedure which covered the aortic aneurysm without paraplegia. The patient presented with a 2-year history of cough, exertional shortness of breath, significant weight loss, and an imminent rupture risk. The patient's recovery was uneventful, and he was transferred on postoperative day 64 for rehabilitation in preparation for discharge.
Conclusions: This method allows for minimally invasive surgery as it allows for the replacement of the ascending and descending aorta in a single-stage procedure through median sternotomy. However, the risk of paraplegia should be considered because the descending aorta is covered in one stage.
Authors
Takanori Hishikawa (1), Takeki Ohashi (1), Soichiro Kageyama (1), Akinori Kojima (1)
Institutions
(1) Nagoya Tokushu-kai general hospital, Kasugai city Aichi, Japan
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Poster Presenter
Takanori Hishikawa
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Department of cardiovascular surgery, Na
Japan
Objective:
Aorto-pulmonary fistulas carry a high risk of morbidity and mortality given the potential for spontaneous massive bleeding events, and the high risk of associated infection. Patients are typically complex, and either present primarily such as in the setting of congenital aortopathy, and/or after previous aortic intervention. Management remains sparsely described given their rarity. We describe three patients who presented with aorto-pulmonary fistula at our institution and subsequent management and an algorithm for treatment.
Methods:
Included were three patients who presented with aorto-pulmonary fistulas from 2017 to 2023. We review their relevant history, presentation, and subsequent management.
Results:
All three patients presented with symptoms of hemoptysis related to the aorto-pulmonary fistula. All three patients had histories of prior aortic intervention, with two patients having a history of congenital aortopathy. One patient had multiple prior presentations for aorto-pulmonary fistula, previously undergoing both open and endovascular therapy at outside institutions over the course of 15 years. All three patients were successfully managed with endovascular therapy, with uncomplicated post-operative courses.
Patients were maintained on lifelong antimicrobial suppression therapy and underwent frequent surveillance with imaging and serial inflammatory markers including ESR and CRP. Two patients developed new findings on surveillance imaging: one patient developed in-stent thrombus while undergoing treatment for colorectal cancer and was started on a DOAC, and the patient with prior recurrent fistulas developed a slight increase in perigraft air, however, he was asymptomatic with normal inflammatory markers, and the multidisciplinary team assessed the perigraft air that was present was likely a residual abscess cavity. The patient was closely surveilled, with stability for over a year following.
Conclusion:
Aorto-pulmonary fistulas remains a rare, but challenging pathology that carries high risk of morbidity and mortality, exacerbated by potential hemodynamic instability and a contaminated, inflammatory, and often re-operative surgical field. Although typically amenable to endovascular repair in stable patients, when necessary open repair should be performed promptly, as any delays carry a high risk of mortality. Close surveillance imaging is of paramount importance, however, although there is no clear evidence, given the high risk of mortality patients are routinely placed on anticoagulation with monitoring of inflammatory markers. Given the potential for antimicrobial resistance, and the unclear benefit and potential distress of inflammatory markers, it is vital to continue to gather evidence to determine the best practice for these patients.
Authors
Adam Carroll (1), Tylor Thai (1), Elizabeth Devine (1), Donald Jacobs (1), Rafael Malgor (1), T. Brett Reece (1), Muhammad Aftab (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Tylor Thai, University of Colorado
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Denver, CO
United States
Objectives: A consensus on surveillance for the thoracoabdominal aortic aneurysm (TAAA) in patients with Marfan syndrome (MFS) has not been established. This study aimed to compare the perioperative and long-term outcomes after open TAAA repair in patients with and without MFS.
Methods: This retrospective study included 230 consecutive patients who underwent TAAA repair from 2012 to 2022. We compared 69 MFS patients with 161 non-MFS patients. The primary endpoints were composite adverse events and long-term survival, encompassing 30-day mortality, persistent stroke, persistent paraplegia, and acute renal failure requiring continuous dialysis. The secondary outcome was the re-operation rate. Multivariate analysis was used to identify factors associated with major adverse events and reoperation.
Results: MFS patients were younger than non-MFS patients (31.9±8.5 vs 44.8±12.3 years; P<0.001) and underwent more Crawford extent III repairs (56.5% vs 34.8%; P=0.002). No significant difference in major adverse events was found between groups (10.1% in MFS vs 13.0% in non-MFS; P=0.538). The reoperation rate was significantly higher in the MFS group than in the non-MFS group (18.8% vs 5.0%; P<0.001). Overall survival was significantly superior in the MFS group than in the non-MFS group (Log-rank P=0.046). Multivariable analysis revealed age ≥50 years (OR 4.08, 95%CI: 1.62-10.27; P=0.003), Crawford II repair (OR 5.68, 95%CI: 1.12-28.78; P=0.036), and Crawford III repair (OR 9.76, 95%CI: 2.01-47.27; P=0.005) were associated with major adverse events, while MFS was not.
Conclusions: Open TAAA repair in MFS patients, despite different risk profiles, can achieve similar or even superior operative outcomes compared to non-MFS patients. Surgical approaches and adjunctive techniques should be individualized to meet the specific needs of each patient to optimize outcomes.
Authors
Luchen Wang (1), Yanxiang Liu (1), Xiaogang Sun (1)
Institutions
(1) Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Xicheng
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Poster Presenter
Luchen Wang, Fuwai Hospital, National Center for Cardiovascular Diseases
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Beijing, Beijing
China
A Computational Analysis of Annuloplasty in Bicuspid Aortic Valve Regurgitation
Jiayi Ju1, Tianyang Yang2, Shengzhang Wang1
1 Fudan University, Shanghai, China; 2 Shanghai Chest Hospital, Shanghai, China
Objective: To evaluate the impact of annuloplasty ring sizes on treating bicuspid aortic valve regurgitation through numerical simulation, which may provide insights into determining an optimal annuloplasty range for surgical procedures.
Method: CT images of a patient diagnosed with bicuspid aortic valve regurgitation and underwent annuloplasty surgery were utilized to establish patient-specific models in preoperative and postoperative conditions. The postoperative model was preprocessed to expand the annulus to align with the preoperative model, obtaining a model after procedures such as raphe relaxation and the free margin plication. Subsequently, elastic rings with diameters of 19,21,23,25 and 27 mm were generated, and the annular plane was remolded and constrained by these rings to simulate surgical annuloplasty process. After applying the physiological transvalvular pressure on the leaflets for finite element analysis, computational fluid dynamics method was employed to obtain hemodynamic information of the annuloplasty models at peak systole.
Results: As the annuloplasty ring size decreased, the leaflet coaptation area during early-diastole enhanced from 139 mm² preoperatively to a range of 247-416 mm² post-annuloplasty, concomitant with a reduction in stress at that location. Besides, annuloplasty led to a slight decrease in transvalvular pressure gradient and had minimal effect on the wall shear stress at the aorta. However, when reducing the annuloplasty ring diameter to less than 23 mm, folds manifested at the root of the leaflets, with the most significant folding occurring in case of 19 mm, reaching a ring area of 100 mm². Moreover, with an increased degree of annular remodeling, the annular plane exhibited stress concentration, accompanied by a significant elevation in wall shear stress in the adjacent region.
Conclusion: The computational analysis conducted on the selected patient indicates that annuloplasty by smaller-sized ring have both benefit on improving leaflet coaptation area and the mitigating of leaflet stress and transvalvular pressure gradient. Nevertheless, the use of excessively small ring may result in leaflet folding at the root and wall shear stress increasement at the annular plane region. Personalized annuloplasty simulation may be a valuable tool to provide the optimal size threshold for individual patients before surgery.
Authors
Jiayi Ju (1), Tianyang Yang (2), Shengzhang Wang (1)
Institutions
(1) Fudan University, Shanghai, China, (2) Shanghai Chest Hospital, Shanghai, China
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Poster Presenter
Tianyang Yang, Shanghai Chest Hospital Affiliated to Shanghai Jiaotong University
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Shanghai, Shanghai
China
Objective:
Given limited epidemiological data on Acute Type A aortic dissection (ATAAD), the objective was to ascertain if there existed any correlation between the occurrence of ATAAD and indices of multiple deprivation (IMD), a comprehensive measure of the socio-economic landscape of a given area.
Methods:
Ten year data (2010-2020) from a single-center encompassing emergency or urgent surgeries for ATAAD and their corresponding postcodes were gathered. IMDs were derived from statistical data procured from the Office for National Statistics. IMD for population range from 1(most deprived 10%) to 10(least deprived 10%). Our analysis encompassed calculating the center's incidence of ATAAD, exploring demographic variables such as age and gender, identifying prevalent risk factors, and assessing survival rates in relation to IMD. Data analysis was performed using Python version 3.10.12.
Results:
A total of 279 patients were included. The calculated incidence of ATAAD stood at 5.5 per 100000 inhabitants, notably higher in IMD 3 and lower in IMD 8. The mean age (standard deviation) of the population affected was 63.28 (13.79) years, with median age of patients surpassing that of the general population per IMD. Predominant risk factors comprised age (p= <0.005), male gender 67.4% (188/279)(p= 0.92) and hypertension(p= 0.66). IMD 3 exhibited the highest 30-day and 5-year mortality rates. Survival rates beyond 30 days post-operation were superior in the least deprived population subset.
Conclusions:
ATAAD stands as a critical and life-threatening cardiovascular emergency mandating urgent surgical intervention. IMD serve as vital socio-economic indicators, offering insights into the relative deprivation experienced by different regions or populations within a country. The observed burden of ATAAD cases at our center, coupled with the scarcity of extensive epidemiological data, prompted this exploration into the potential correlation between ATAAD incidence and socio-economic deprivation as indicated by IMD. These findings shed light on the intricate interplay between socio-economic factors and the incidence and outcomes of ATAAD, potentially informing future research directions and targeted interventions for at-risk populations.
Authors
ANCHAL JAIN (1), Rushmi Purmessur (1), RAVI DE SILVA (1)
Institutions
(1) Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
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Poster Presenter
ANCHAL JAIN, Royal Papworth Hospital
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CAMBRIDGE
United Kingdom
Objective: The inverse relationship between operative volume and outcome of surgical procedures has been indisputably shown in a variety of disease entities. Nonetheless, surgery for acute type-A aortic dissection (ATAAD) – a typical complex surgical emergency – is mainly performed by non-dedicated surgeons. This is often due to logistic reasons, including a high on-call burden. In this study, we report the observed consequences of dedicated surgical care for ATAAD in our high-volume thoracic aortic center.
Methods: From 2020, ATAAD surgery was preferably performed by two young, albeit experienced, aortic surgeons, supervised by a senior when deemed necessary. Early surgical outcome of the patients as well as the experienced work-life balance impact of the surgeons was retrospectively studied.
Results: Since January 2020, a total of 53 ATAAD patients were operated by the two dedicated surgeons. The mean age of the studied population was 62 11 years, 72% were males (n=38). The proximal repair consisted of composite aortic root replacement in 42% (n=22); 58% of patients (n=31) underwent resuspension of the aortic valve with reconstruction of the aortic root and supracoronary ascending aorta replacement. The distal repair consisted of hemi-arch repair in 64% (n=34), zone 1 arch replacement in 4% (n=2), zone 2 arch replacement with proximalization of brachiocephalic trunk and left common carotid in 24% (n=13), total arch replacement in 8% (n=4), including 2 with the Frozen Elephant Trunk technique. The mean cardiopulmonary bypass time was 261 81 min; the mean cross clamp time 160 49 min. Arterial cannulation was performed in the femoral artery in 81% (n=43), in the right axillary artery in 8% (n=4), and direct aortic cannulation was performed in 11% (n=6). Bilateral antegrade cerebral perfusion was used in 98% of cases (n=52). No operative mortality occurred, and only one in-hospital mortality (1.8%) was observed on post-operative day +16 due to late vein graft thrombosis in a patient who experienced iatrogenic ATAAD after PCI of the left mainstem in whom the left coronary ostium had to be sacrificed and the left coronary territory was grafted. Re-exploration due to bleeding was performed in 15% (n=8) of patients. New cerebral neurological deficits were observed in 8% (n=4) of patients. No paraplegia occurred. Renal function replacement therapy was temporarily used in 2 patients; no need for long-term dialysis was observed. Despite the positive motivation to maintain the effort given the obtained surgical results, both surgeons experienced an undesirable high burden of the dedicated on-call frequency to their work-life balance during the investigated period, resulting in early termination of this tight dedication trial.
Conclusions: Very favorable results of extensive, complex ATAAD repair are observed in this limited cohort of patient operated by two dedicated aortic surgeons only. However, both surgeons experienced an undesirably high burden of the on-call frequency to their work-life balance. It is conceivable that optimal care for ATAAD lies between the two extremes of generalized and highly specialized surgical teams to be maintained sustainable. One of the potential solutions may be cooperation within regional networks, aiming at providing the best surgical care for our patients and sustainability for our surgical teams.
Authors
Tim Smith (1), Guillaume Geuzebroek (1), Wilson Li (1), Michel Verkroost (1), Robin Heijmen (1)
Institutions
(1) Radboudumc, Nijmegen, the Netherlands
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Poster Presenter
Tim Smith, St. Antonius Hospital
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Rotterdam
Netherlands
Objectives: A new approach for the Frozen Elephant Trunk (Simplified Delivery FET) procedure allows distal suturing on a perfused and loaded aorta in normothermia with shorter circulatory arrest time. This study compares outcomes with the conventional technique in patients treated for Acute Aortic Dissection (AAD).
Methods: A non-randomised, multicentre, retrospective study of all patients who underwent total arch replacement for AAD using either the simplified (SD-FET) or conventional FET (control) techniques. In-hospital mortality, stroke, and spinal cord injury were primary endpoints.
Results: Of the 153 patients (n=90 SD-FET; n=63 control FET), 26.8% were female and the mean age was 62±11 years. Circulatory arrest time was significantly shorter in the SD-FET group (5±3 vs 40±16 min; P <0.001). The lowest core temperature was significantly lower in the SD-FET group (34.6 ± 1 vs 25.3 ± 3 °C, P <0.001). Total operative time, CPB, and cross clamp times were significantly shorter in the SD-FET group (P <0.001), despite the significantly higher rate of concomitant procedures associated with this technique (P <0.001).
Overall, in-hospital mortality was 13.3% (n=20), 10.5% (n=9) in the SD-FET group vs 17.5% (n=11) in the control FET group (P=0.206). The rate of postoperative stroke was higher in the conventional group (12.4% vs 23.8%; P =0.065) but did not reach significance, similarly the spinal cord injury rate was lower in the SD-FET group but did not reach significance (2.2% vs 4.8%, P =0.385). SD-FET was protective for combined outcome (death and/or neurological event) with a corresponding population-average percentage of events of 17.8% (5.3–27.7) in the SD-FET group versus 30.7% (16.5–52.8) in the FET group [significant difference of -12.9% (-0.3 to -26)].
After a median follow-up of 21.4 months (range 0-81), 7 patients died during follow-up, with no difference between groups (4(4.5%) in the SD-FET group versus 3(5%) in the FET group; P=0.886). Of these deaths, 3 were due to the aorta (P =0.376). The incidence of early distal reinterventions during the first hospitalisation was not significant (7(7.8%) in the SD-FET group versus 7(11.1%) in the FET group; P=0.482), but this incidence was significantly higher in the conventional group during follow-up (3(3.3%) in the SD-FET group versus 7(14.5%) in the FET group; P =0.012).The Kaplan-Meier showed a survival rate at 12 and 24 months of 87% in the SD-FET group versus 83% in the FET group and 86% in the SD-FET group versus 80% FET (P = 0.625).
Conclusions: The SD-FET technique reduces circulatory arrest time and allows hybrid arch surgery to be performed without cooling. This approach is associated with a lower incidence of the combined criteria of death and/or neurological event.
Authors
Guillaume Guimbretiere (1), Olivier Fouquet (2), charles-henri david (3), Stéphane Kermen (4), Yohann Foucher (5), Aurelien Vallée (6), Thibaut Schoell (7), Sébastien Gonthier (8), Julien Guihaire (9), Thierry BOURGUIGNON (10), Jean Christian Roussel (11), Eric braunberger (12), Nicolas Bonnet (13), Thomas Sénage (14)
Institutions
(1) N/A, N/A, (2) Department of Thoracic and Cardiovascular Surgery, University Hospital, Angers, NA, (3) Cardio-thoracic and vascular surgery unit, CHU Nantes, nantes, NA, (4) CHU Tours, Tours, NA, (5) CIC 1402, CHU de Poitiers, Poitiers, NA, (6) Department of Cardiovascular Surgery, Marie Lannelongue Hospital, Le Plesis Robinson, NA, (7) Centre cardiologique du Nord, Saint-Denis, NA, (8) Department of Thoracic and Cardiovascular Surgery, Univsersity hospital Felix Guyon, Saint-Denis de la Réunion, France, (9) N/A, Rennes, France, (10) N/A, TOURS, France, (11) Nantes Hospital University, Nantes, France, (12) CHU Felix Guyon, Saint-Denis, NA, (13) Centre Cardiologique du Nord, Paris, France, (14) CHU Nantes, Nantes, NA
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Poster Presenter
Guillaume Guimbretiere, Nantes Hospital University
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NANTES
France
Objective: Valve sparing aortic root repair for the treatment of aortic root dilation with or without aortic dissection has increased recently with studies reporting better outcomes with valve sparing aortic root repair mostly among patients with tricuspid aortic valve. Considering bicuspid aortic valve being an independent risk factor, the role of valve sparing aortic root repair in patients with bicuspid valve is controversial with minimal data. We aim to perform a meta-analysis comparing outcomes of valve sparing aortic root repair in bicuspid as compared with tricuspid aortic valve.
Methods: A systematic, comprehensive search across PUBMED/Medline, SCOPUS, EMBASE, and web of sciences databases was conducted from the inception of the respective database through March 30th, 2023. After screening the retrieved list for duplicates, 2 independent reviewers selected studies meeting our inclusion criteria. The Mantel-Haenszel method with the Paule-Mandel estimator of Tau2 and Hartung-Knapp adjustment for random effect model was utilized to account for interstudy variability and small size effect was utilized to calculate pooled risk ratios (RR) and 95% confidence interval (CI).
Results: A total of 2204 studies were retrieved from our search. Of which, 7 studies were included in our final analysis comprising of 478 patients with bicuspid valve and 715 patients with tricuspid valve. Bicuspid valve as compare with tricuspid was found to have lower risk of short-term outcomes of in-hospital mortality [RR: 0.26, 95% CI 0.13; 0.53] (Figure 1; Panel A) and renal failure [0.49, 95% CI 0.33; 0.73] (Figure 1; Panel E). Bicuspid as compared with tricuspid was found to have similar short outcomes of re-operation for bleeding [0.77, 95% CI 0.44; 1.35] (Figure 1; Panel B), new onset atrial fibrillation [1.10, 95% CI 0.89; 1.36] (Figure 1; Panel C), permanent pacemaker implantation [1.18, 95% CI 0.60; 2.29] (Figure 1; Panel D) and long-term outcomes of overall mortality [0.35, 95% CI 0.10; 1.21], re-operation [1.68, 95% CI 0.74; 3.80] and aortic insufficiency [1.04, 95%CI 0.31; 3.48].
Conclusion: Based on the current results valve sparing aortic repairs in bicuspid as compared with tricuspid aortic valve are associated with comparable short and long outcomes, with indirect evidence suggesting valve sparing aortic valve repair as a feasible option for bicuspid aortic valve.
Authors
Mariam Shariff (1), Ashish Kumar (2), John Stulak (3), Gabor Bagameri (3)
Institutions
(1) Mayo Clinic, United States, (2) Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, (3) Mayo Clinic, Rochester, MN
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Poster Presenter
Mariam Shariff, Mayo Clinic - Rochester
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Rochester, MN
United States
Objective: Aberrant left subclavian artery (ALSCA) with Kommerell diverticulum (KD) in adults with right aortic arch is a rare clinical entity, and consequently, data regarding indications for repair and optimal surgical approach are limited. We describe a minimally invasive staged approach for resection of KD and ALSCA revascularization without use of cardiopulmonary or prosthetic material.
Case Video Summary: After induction, the patient is intubated with a single-lumen endotracheal tube and placed in the left lateral decubitus position. Next, a right posterolateral thoracotomy is performed, sparing both the serratus anterior and latissimus dorsi muscles. As necessary, the 3rd or 4th rib is shingled to facilitate exposure. After the aortic arch is mobilized, the stump of the ALSCA and KD is identified and dissected down to the base, taking care to identify and avoid injury to surrounding structures. A side-biting clamp is applied, the stump is resected at its base, then closed with two layers of running 5-0 polypropylene suture and buttressed with bovine pericardium. After hemostasis, the thoracotomy is closed in usual fashion. All patients survived to discharge without major adverse event, transfusion, or re-exploration for bleeding. Median mechanical ventilation time was 6 hours. One patient had chylothorax requiring prolonged chest drainage and was discharged home on very low fat diet.
Conclusions: Advantages of this technique include avoidance of cardiopulmonary bypass and hypothermic circulatory arrest along with introduction of prosthetic material in young adults at lifetime risk of thromboembolic events and infection, yielding excellent early outcomes and durable relief of compressive esophageal and tracheobronchial symptoms.
Authors
William Frankel (1), Matthew Thompson (2), Siva Raja (3), Michael Tong (4), Eric Roselli (4)
Institutions
(1) Cleveland Clinic Foundation, Cleveland, OH, (2) Cleveland Clinic, Lakewood, OH, (3) Cleveland Clinic Foundation, Cleveland Ohio, OH, (4) Cleveland Clinic, Cleveland, OH
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Poster Presenter
William Frankel, Cleveland Clinic
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Cleveland, OH
United States
Objective
The Ascyrus Medical Dissection Stent (AMDS) is an uncovered aortic arch hybrid graft developed to promote true lumen expansion and enhance aortic remodelling in patients undergoing type A aortic dissection repair. The first implantation in the United Kingdom was performed in early 2021. The objective of this study was to report the short and mid-term outcomes in patients treated with the AMDS.
Methods
This was a multi-centre retrospective analysis of prospectively collected routine clinical data. All patients who presented with an acute type A aortic dissection and received an AMDS stent between January 2021 and September 2023 were included. Anonymised clinical data were transferred to the lead centre for analysis.
Results
A total of 46 patients across four centres were included. The majority (40, 87.0%) were operated as an emergency with six salvage procedures included. Most patients (33, 71.7%) were male and the mean age at operation was 64.4 (SD 12.0). The mean EuroSCORE II was 19.8 (SD 16.4) and 12 (26.1%) of patients presented with malperfusion. The in-hospital mortality rate was 21.7% (10/46) and 15.0% (6/40), overall and for non-salvage patients respectively. The mean duration of follow-up was 10 months with a maximum follow up of 30 months. There were no post-discharge deaths during follow-up with one patient requiring further aortic intervention. False lumen thrombosis was demonstrated on latest follow-up CT scan in 70% (23/33) of patients however there was evidence of descending aortic growth in 27.2% (9/32).
Conclusions
This study demonstrates that the AMDS can be used safely and effectively in patients with acute type A aortic dissection who present with or without malperfusion. No patients died during follow-up after discharge and positive remodelling of the false lumen was seen in the majority of patients. Further studies are required to demonstrate the long-term outcomes of the AMDS device and further define its role in the treatment of acute type A aortic dissection.
Authors
Stuart Grant (1), Mohamed Allam (2), Cha Rajakaruna (3), Eltayeb Mohamed Ahmed (4), David Zicho (5), Mazyar Kanani (2), Andrew Owens (2)
Institutions
(1) South Tees NHS Foundation Trust, Middlesbrough, NA, (2) South Tees Hospitals NHS Foundation Trust, Middlesbrough, NA, (3) Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK, Bristol, NA, (4) Bristol Heart Institute, Bristol, NA, (5) Hull University NHS Foundation Trust, Hull, NA
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Poster Presenter
Stuart Grant
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Bowdon
United Kingdom
Background
Valve-sparing aortic root replacement (VSARR) is an effective technique to treat aortic root aneurysm or aortic regurgitation (AR) in cases with pliable cusps. However, it remains underutilized due to perceived procedural complexity and difficulty in standardization. To address these concerns, we developed a novel device consisting of a rigid three-dimensional (3D) coronet-shaped aortic annular skeleton assembled with a woven polyester graft (Figure A). This reinforcing 3D frame is designed to attach to the basal ring of the aortic valve (AV) by a single-layer hemostatic line (Figure-B, C) to obviate the need for basal layer stitches typically required in conventional root reimplantation. In this study, we studied the hemodynamic profiles of VSARR performed by this novel device as compared to conventional reimplantation and remodeling techniques.
Methods
Using 5 normal porcine aortic roots (median annular diameter=25mm), the novel (Novel), reimplantation (David) and remodeling (Yacoub) techniques were implemented in each of the 5 roots in a randomized fashion. A 28mm-straight graft was used for all. Hemodynamic data were acquired using a custom 3D-printed ex-vivo left heart simulator. AR fraction was the primary endpoint. Secondary endpoints included other hemodynamic parameters and procedural times.
Results
AR fraction was 1.6±0.8%, 3.3±2.6% and 7.1±3.1% in the Novel, David and Yacoub groups, respectively (P=0.006), with Novel and David groups being significantly lower than Yacoub group (Figure-D). Trans-AV mean pressure gradient was 6.0±2.2mmHg, 9.4±4.0mmHg and 4.2±1.3mmHg in the Novel, David and Yacoub groups, respectively (P=0.032), with David group being higher than other two groups (Figure-E). Energy losses across the AV demonstrated the Novel group having significantly less forward energy loss than the David group (P=0.033), and significantly less closing (P=0.025) and regurgitation (P=0.023) energy losses than the Yacoub group. Finally, the mean procedural times were 23.2±6.2min, 37.8±8.5min and 15.2±2.3min in the Novel, David and Yacoub groups, respectively (P<0.001) with the Novel and Yacoub groups being significantly shorter than the David group (P=0.008 and <0.001, respectively).
Conclusion
VSARR performed using the novel 3D reinforced graft showed short procedural time and favorable hemodynamic profiles that are non-inferior to conventional VSARR techniques suggesting its potential clinical utilities.
Authors
Joon Bum Kim (1), Matthew Park (2), Yuanjia Zhu (2), SHIN YAJIMA (2), Stefan Elde (2), Perry Choi (2), Michael Paulsen (2), Y. Joseph Woo (2)
Institutions
(1) Asan Medical Center, Stanford University School of Medicine, Seoul, Korea; Stanford, CA, (2) Stanford University School of Medicine, Stanford, CA
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Poster Presenter
*Joon Bum Kim, Asan Medical Center
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Seoul, NA
South Korea
This retrospective study was conducted by collecting data from 176 consecutive patients (105 men, mean age 52.54±12.38 years) with TAAD from October 2019 to December 2020. Cerebral and body perfusion were provided by the same pump of CPB. The right axillary artery, femoral artery, superior and inferior vena cava were disassociated for cannulation. The right axillary artery and the left common carotid artery were used for antegrade-selective cerebral perfusion. Once the balloon was deployed into the stent graft, perfusion of the lower body was resumed through the femoral artery. Antegrade-selective cerebral perfusion and lower body perfusion were provided by the same pump. The CPB flow was gradually returned to 1.6-1.9 L.min-1.
Oxygen saturation of superior and inferior vena cava was monitor and used for regulating the perfusion flow during cerebral-body separate. In brief, detect the superior vena cava oxygen saturation before CPB, 5 minutes during CPB, 10, 20 and 30 minutes during cerebral-body separate perfursion. Increase the perfusion flow if superior vena cava oxygen saturation lower than 65% or 10% of the oxygen saturation before CPB.
The operation was performed by the same surgeon in all patients. All the operations were successfully completed with no intra-operative death. The mean hypothermic circulatory arrest time was 5.79±0.6 minutes, cerebral perfusion flow was 800-1000 L.min-1, cerebral-body separate perfursion time was 40.07±8.78 min,
aortic cross-clamp time was 110.8±21.7, cardiopulmonary
bypass time was 141.8±19.3 min. Rectal
temperature at circulatory arrest
was 34.43±0.75℃.Minimum temperature at
circulatory arrest was 32.33±0.76 ℃.
There was 11 death in hospital. Consciousness recovery time was 4.85±1.97 h. Mechanical ventilation time was 23.8±24.46 h. There are 19 patients need CRRT. Neurological events especially transient consciousness disorder occurred in 4 patients, permanent consciousness disorder occurred in 2 patients. There were no early events, such as paraplegia, cerebral infarction, and limb ischemia. (Table 3)
Oxygen saturation of superior vena cava at 10, 20, 30, 40 minutes during cerebral-body separate was 70.95%, 71.30%, 72.03% and 72.9%. Inferior vena oxygen saturation was 63.95%, 62.94%, 63.92% and 69.1%. The perfusion flow was 1.73, 1.83, 1.82, 1.79 L.min-1.
Authors
kexiang liu (1), weitie wang (2)
Institutions
(1) N/A, Jilin, Jilin, (2) Department of Cardiovascular Surgery, The Second Hospital of Jilin University, Changchun, CA
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Poster Presenter
Kexiang Liu, Second Hospital of Jilin University
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Jilin, Jilin
China
Objectives: Various prevention and treatment options exist to prevent paraplegia during thoracic aortic surgery. Postoperative cerebrospinal fluid drainage (CSFD) is one treatment option when paraplegia occurs. To evaluate the neurological efficacy of postoperative cerebrospinal fluid drainage (CSFD) in patients undergoing thoracic and thoracoabdominal aortic surgery. In addition, we will use Machine Learning to analyze how many hours postoperatively inserted CSFD is effective.
Methods: This retrospective study included 85 patients who underwent perioperative CSFD in thoracic and thoracoabdominal aortic surgery from January 1, 2006 to December 12, 2022.A total of 61 patients (72%) underwent preoperative CSFD and 24 (28%) postoperative CSFD. Perioperative neurological data were analyzed with a focus on perioperative changes. Machine learning by Prediction One (Sony Network Communications Inc., Tokyo, Japan) was also used to analyze the effect of CSFD placement by how many hours postoperatively.
Results: In the postoperative CSFD group, the manual muscle testing (MMT) score before CSFD was 0.8,2.4 immediately after CSFD, and 3.0 at discharge. Thus, postoperative CSFD was associated with improved MMT scores. Scores improved compared to preoperative scores. Once surgery was completed, the postoperative CSFD was conducted after mean 9.8 hours. Machine learning analysis showed that postoperative CSFD was more effective in patients who had a tendency to improving paraplegia at 2 to 3 hours after surgery and who had a CSFD implanted. The area under curve and the accuracy of the model in the validation data were 0.956 and 96%, respectively. Six of the patients (25%) who underwent early postoperative CSFD remained paralyzed without improvement.
Conclusions: Machine learning analysis showed that patients with postoperative paraplegia after thoracic and thoracoabdominal aortic aneurysm surgery could avoid postoperative paraplegia if the CSFD could be implanted by 3 hours after surgery. Based on these results, we recommend early awakening to improve postoperative paraplegia and placement of a CSFD within 3 hours in patients who need it.
Authors
Tomohiro Nakajima (1), Tsuyoshi Shibata (1), Kei Mukawa (1), Keitaro Nakanishi (1), Takakimi Mizuno (1), Ayaka Arihara (1), Shuhei Miura (1), JUNJI NAKAZAWA (1), Yutaka Iba (1), Nobuyoshi Kawaharada (1)
Institutions
(1) Sapporo Medical University CardioVascular Sugery, Sapporo, Hokkaido,Japan
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Poster Presenter
Tomohiro Nakajima, Department of Cardiovascular Surgery, Sapporo Medical University
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Sapporo, Hokkaido
Japan
Objective: This case report details the diagnosis, management, and outcome of a rare case of ascending aortic aneurysm in a pediatric patient. Ascending aortic aneurysms are uncommon in children, such diagnosis and treatment pose unique challenges compared to adults.
Methods: One male child at 2 year of age presented with shortness of breath and failure to thrive. Due to severe aortic regurgitation and signs of heart failure, the patient was admitted to pediatric intensive care unit.
Further investigation revealed a large aneurysm of the aortic root and ascending aorta and the aortic valve was deemed tri-valvular at initial evaluation.
Despite maximal medical treatment, it was not possible to compensate the patient and surgical intervention was recommended. Complete correction was undertaken performing a Bentall-de Bonno operation. It was implanted a biological pericardial prostheses INSPIRIS number 23 (Edwards LifeSciences), mounted on a 30 mm dacron graft. The procedure was uneventful, and the patient was extubated the following day.
On post operative day 4 it was done a surgical re-exploration due to cardiac tamponade. No further complications occurred and the patient was discharged home on post operative day 14. Late follow-up at 6 months shows good surgical result.
Results / conclusions: Biopsy of the aorta revealed Cowden Syndrome, which is a mutation on the PTEN gene (phosphatase and tensin homologue).
Although PTEN mutations are related to vascular anomalies, we were unable to locate literature that correlates this finding with aneurysm of the aorta. Due to the limited number of cases, it is not possible to draw more accurate conclusions about such genetic disorder. In this particular case it was possible to implant an adult-size prostheses to ensure adequate growth to the patient. In a future intervention we expect to replace the biological valve for a mechanical one.
Authors
Stevan Martins (1), Frederico Carlos Cordeiro de Mendonça (1), Daniel Ortuno (1), Flavia Miasuguku Samos (2), Maria Elisa Albrecht (2), Paul Alejandro Salvador Morales (3), Lucio Walfrido Aleixo da Silveira (4)
Institutions
(1) Sirius Cardiovascular, São Paulo, Brazil, (2) Hospital São Luiz Jabaquara, São Paulo, Brazil, (3) Hospital Sao Luiz Jabaquara, São Paulo, Brazil, (4) Hospital Sao Luiz Jabaquara, Sao Paulo, Brazil
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Poster Presenter
Stevan Martins, HCor - Hospital do Coração
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Sao Paulo, São Paulo
Brazil
Ascending aortic aneurysms concern 3 to 4% of the population aged from 65 years old and older. One of the major issues is to detect and evaluate aneurysms at high risk of growth or rupture. As many aortic dissections can appear below the admitted 50mm cut-off limit of diameter. New parameters should be found to improve characterization of individual risk. In the present study, we present a workflow to obtain new metrics of interest.
We studied a cohort of ninety-one patients with a follow-up of ascending aortic aneurysm using CT-scan. For each patient, we evaluated with semi-automated method diameter but also less often used measurements such as centerline, external and internal curvature, surface and volume. We also implemented original metrics helped by "morphing process" : strain over time and local growth area using a computer-helped method.
In this study, we propose a method to compute a set of local shape features that, in addition to the maximum diameter D, are intended to improve the classification performances for the ascending aortic aneurysm growth risk assessment. Apart from D, these are the ratio DCR between D and the length of the ascending aorta centerline, the ratio EILR between the length of the external and the internal lines and the tortuosity T. 50 patients with two 3D acquisitions at least 6 months apart were segmented and the growth rate (GR) with the shape features related to the first exam computed. The correlation between them has been investigated. After, the dataset was divided into two classes according to the growth rate value. We used six different classifiers with input data exclusively from the first exam to predict the class to which each patient belonged. A first classification was performed using only D and a second with all the shape features together. The performances have been evaluated by computing accuracy, sensitivity, specificity, area under the receiver operating characteristic curve (AUROC) and positive (negative) likelihood ratio LHR+ (LHR-). A positive correlation was observed between growth rate and DCR (r = 0.511, p = 1.3e-4) and between GR and EILR (r = 0.472, p = 2.7e-4). Overall, the classifiers based on the four metrics outperformed the same ones based only on D. Among the diameter-based classifiers, k-nearest neighbours (KNN) reported the best accuracy (86%), sensitivity (55.6%), AUROC (0.74), LHR+ (7.62) and LHR- (0.48). Concerning the classifiers based on the four shape features, we obtained the best accuracy (94%), sensitivity (66.7%), specificity (100%), AUROC (0.94), LHR+ (+∞) and LHR- (0.33) with support vector machine (SVM).
Our method provided for each patient diameter along centerline but also lenghts of external, internal curvatures, surface, and volume. Strain and local growth area were obtained for four patients. These different parameters seem to increase with aneurysmal dilatation.
The workflow presented enables to obtain metrics of interests which seem correlated to aneurysmal evolution. Further studies are needed to assess correlation of these metrics with risk of acute complications such as rupture or aortic dissection. Also these parameters does not take into account for now the arterial pressure that can have potential effect in aneurysm evolution.
Authors
Jacques Tomasi (1), Pierre Flores (2), Leonardo Geronzi (3), Albadi Waleed (2), Pascal Haigron (4), Jean-Philippe Verhoye (5)
Institutions
(1) Universtity Hospital of Rennes, Rennes, France, (2) University Hospital of Rennes, Rennes, France, (3) University of Roma, Roma, Italy, (4) University of Rennes, Rennes, France, (5) University hospital of Rennes, Rennes, France
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Poster Presenter
Jacques Tomasi, Universtity Hospital of Rennes
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Rennes, Bretagne
France
Objective: Acute type A aortic dissection is a life-threatening cardiovascular emergency and remains a challenge in cardiac surgery with immediate and late complications. The Elephant Trunk technique was developed as a 1-stage repair of the aortic arch and descending aorta and evolved into the Frozen Elephant Trunk (FET), which promotes early thrombosis of the false lumen and positive remodeling of the aorta in 90% of dissection patients . FET, in turn, has benefited from numerous modifications and simplifications as well as incremental improvements in devices. However, most patients still require hypothermic circulatory arrest (HCA) of 40-60 min duration. Many postoperative complications are-directly or indirectly related-to hypothermia. In order to avoid the disadvantages of hypothermia, we propose a simplified delivery FET technique (SD-FET) that is characterized by FEt proximalisation in aortic arch zone 0 (or 1) with a very short curculatory arrest of the lower body, allowing normothermia.
Case video summary: The SD-FET surgical technique essentially involves the placement of two surgical sealing tourniquets. Operation is performed through median sternotomy. Right axillary canulation for arterial reinjection and atriocaval for venous drainage. The supra aortic vessels were put on tourniquet. During the dissection and release of the aortic arch, it is important not to dissect the arch extensively to keep the attachment tissue, especially posteriorly, for the effectiveness of the "sealing tourniquets". The key point of the technique is the placement of these two tourniquets with a blunt dissector around the aortic arch between the innominate artery and the left common carotid artery. The preparation of the prosthesis must be imperatively done before the start of the CA. The Innominate artery is disconnected, and Circulatory arrest is initiated, the cross clamp is removed. The 3 U-stitches are passed through the aorta (to improve the apposition between the aortic tissue and the sewing collar). Insertion of the thoraflex and 3 U stitches passage in the collar. Arterial line reconnection and CPB is restarted via fourth branch at full flow to expand the stent. The two sealing tourniquets are gradually tightened on the aortic arch facing the stent until a zone 0 or 1 seal is achieved. Tourniquets should be tightened gently under the pressure of the antegrade arterial blood flow of the cardiopulmonary bypass (CPB). Complete apposition of the stent to the aortic wall in the tourniquets area allows for a near complete seal. Distal anastomosis could then be performed on a loaded aorta in normothermia.
Conclusion: SD-FET significantly reduces circulatory arrest time and allows the FET procedure to be carried out in moderate hypothermia-and or even without cooling with experience and mastery of the technique. SD-FET is feasible, reproducible, and safe and is associated with a lower occurrence of death and/or neurological events, even in patients requiring combined root surgery.
Authors
Guillaume Guimbretiere (1), charles-henri david (2), Sébastien Gonthier (3), Antoine Buschiazzo (4), Thibaut Schoell (5), Blandine Morel (6), Eric braunberger (7), Nicolas Bonnet (8), Jean Christian Roussel (9), Thomas Sénage (10)
Institutions
(1) N/A, N/A, (2) Cardio-thoracic and vascular surgery unit, CHU Nantes, nantes, NA, (3) Department of Thoracic and Cardiovascular Surgery, Univsersity hospital Felix Guyon, Saint-Denis de la Réunion, France, (4) L'institut du thorax, NANTES, NA, (5) Centre cardiologique du Nord, Saint-Denis, NA, (6) L’Institut du Thorax, Cardiac and Vascular surgery department, Nantes, NA, (7) CHU Felix Guyon, Saint-Denis, NA, (8) Centre Cardiologique du Nord, Paris, France, (9) Nantes Hospital University, Nantes, France, (10) CHU Nantes, Nantes, NA
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Poster Presenter
Guillaume Guimbretiere, Nantes Hospital University
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NANTES
France
Objective: Aortic root replacement with a stentless valve has become an effective treatment for patients with aortic root pathology, including dissection, aneurysm, and endocarditis of the aortic valve, allowing for a greater effective orifice area for the implanted valve and increased hemodynamic stability compared to conventional stented aortic valves. However, candidates for aortic root replacements tend to be severely comorbid populations that are at high risk of mortality. The purpose of this study is to evaluate the outcomes of patients who underwent aortic root replacement with the Medtronic Freestyle prosthesis (Medtronic, Minneapolis, MN, USA).
Methods: We performed a single-center retrospective review of adult patients (≥18 years) who underwent aortic root replacement with a Medtronic Freestyle prosthesis from July 1, 2014, to May 15, 2023. Descriptive statistics were performed. Continuous variables are reported as mean ± standard deviation or median (interquartile range [IQR]), and categorical variables are reported as frequency and percentage. The Kaplan-Meier method was used to estimate longitudinal survival.
Results: During the study period, 127 patients underwent a Freestyle aortic root replacement. Most patients were male (61.4%, n=78), and mean age was 60.1±15.2 years. Many patients had at least one prior sternotomy (80.3%, n=102). Other comorbidities included hypertension in 74.8% (n=95), diabetes in 33.9% (n=43), preoperative acute kidney injury in 8.7% (n=11), chronic kidney disease in 18.9% (n=24), and history of stroke in 26.0% (n=33). The majority of patients were indicated for aortic root replacement due to endocarditis (47.2%, n=60). Mean valve size implanted was 26.0±2.2 mm. Cardiopulmonary bypass time was 312.5±103.4 minutes, and cross-clamp time was 220.5±70.7 minutes. Postoperatively, 6.3% (n=8) required permanent dialysis, 9.5% (n=12) had pneumonia, 5.5% (n=7) had a stroke, and 37.0% (n=47) required a new permanent pacemaker. Ten (7.9%) patients died before hospital discharge. During follow-up, 3 (2.4%) patients developed root pseudoaneurysms. Follow-up echocardiography was available in 54 (42.5%) patients at a median follow-up time of 213 (IQR 49.3-525) days. Peak gradient was 21.8±9.8 mmHg, and mean gradient was 9.5±4.5 mmHg. Longitudinal survival is shown in Figure 1.
Conclusions: Among high-risk patients undergoing aortic root replacement at a single center, the Freestyle prosthesis is associated with limited rates of postoperative morbidity.
Authors
Iverson Williams (1), Omar Sharaf (2), Zaid Abu-Mowis (3), William Ricks (4), Eric Jeng (5), John Spratt (6), Tomas Martin (7), Thomas Beaver (8)
Institutions
(1) N/A, N/A, (2) N/A, Berlin, CT, (3) University of Florida College of Medicine, Gainesville, FL, (4) The University of Florida, N/A, (5) University of Florida- Shands, Gainesville, FL, (6) University of Florida, Gainesville, FL, (7) Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL, (8) Shands, Gainesville, FL
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Poster Presenter
Iverson Williams
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Gainesville, FL
United States
Objective
Open repair of aortic coarctation has excellent short-term outcomes, but restenosis at the repair site is a long-term complication observed in up to 50% of patients. We hypothesized that residual hemodynamic abnormalities at the repair site may contribute to pathologic aortic remodeling and restenosis.
Methods
Six patients who underwent resection with end-to-end anastomosis for aortic coarctation underwent postoperative MRI angiography. Anatomically accurate models were generated for each patient. They were each compared to age- and sex-matched healthy control patients. Computational fluid dynamics (CFD) simulations were performed of the baseline geometries. Stenoses of 10%, 50%, and 80% were introduced at the repair site in each patient and control. Measured outcomes included blood flow and velocity, vorticity, time-averaged wall shear stress (TAWSS) and oscillatory shear index (OSI).
Results
Significant differences in TAWSS persist following CoA repair (Figure). Additionally, these differences increase significantly and nonlinearly with restenosis angle.
Conclusions
Significant hemodynamic differences persist following aortic coarctation repair. The nonlinear association of these differences with restenosis angle suggests a positive feedback mechanism. CFD investigations may be able to provide additional insight on patient-specific pathologic remodeling following CoA repair.
Authors
Christopher Jensen (1), Arash Ghorbannia (2), David Urick (2), G. Chad Hughes (1), Amanda Randles (2)
Institutions
(1) Duke University Medical Center, Durham, NC, (2) Duke University, Durham, NC
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Poster Presenter
Christopher Jensen, Duke University Medical Center
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Durham, NC
United States
Background: The modality of thoracoabdominal aortic repair (TAAR) is mainly based on left heart bypass (LHB) in western countries, while in our team, it is mainly based on a unique technique, off-pump aortic self-bypass, and there is a lack of systematic reports and long-term results. To describe the operative technique and summarize the patient characteristics and outcomes of TAAR with off-pump aortic self-bypass technique in our team in the last decade. Meanwhile, to explore the influence of different previous surgical history on prognosis.
Methods: 137 consecutive patients who received TAAR with off-pump aortic self-bypass technique by single surgeon from 2012 to 2022 were retrospectively analyzed. Operative details were described and data were grouped according to previous surgical history. Early operative mortality and adverse events were summarized. Survival over time was estimated by the Kaplan–Meier curve.
Results: The average age of the cohort was 42.39±11.76 years old, 70.07% were male. 63 (46%) patients had no previous surgery, 53 (39%) patients had total arch replacement with frozen elephant trunk (TAR_FET), and 21 (15%) patients had thoracic endovascular aortic repair (TEVAR). Operative mortality was 4.38%, the incidence of early paraplegia was 6.57%, and previous surgery had no significant effect on prognosis (p=0.294). Cumulative survival was 92.1% at 3 years and 90.8% at 5 years.
Conclusions: The off-pump aortic self-bypass technique for TAAR is feasible regardless of previous surgery, as long as there are no complicating factors. And the early outcomes are satisfactory and the long-term outcomes are reliable.
Authors
Jian Song (1), Cuntao Yu (2), Juntao Qiu (3)
Institutions
(1) N/A, N/A, (2) Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, NA, (3) Fuwai Hospital, Beijing, China
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Objective:
While it is well-established that severe acute kidney injury (AKI) after aortic arch surgery increases morbidity and mortality, the impact of less severe kidney injury conflicts in the literature. Current STS criteria encompasses only the most severe kidney injury, which as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria, only encapsulates Stage 3 AKI. Given the prolonged operative time required for total arch replacement (TAR), we believe that even mild kidney injury could be reflective of greater whole-body injury. We sought to investigate the spectrum of kidney injury in total arch replacement and its impact on post-operative morbidity and mortality.
Methods:
We performed a single-center retrospective review of patients who underwent TAR from 2014-2023. Patients were stratified into three cohorts based on KDIGO criteria: no AKI, KDIGO stage 1 and stage 2/3 to optimize study power. Multivariable logistic regression was performed for pre-operative and operative variables for development of AKI, with subsequent additional analysis for significant variables and correlation with in-hospital major adverse cardiovascular events (MACE, defined as stroke, myocardial infarction, and death). Adjusted Cox regression analysis was performed for post-operative mortality, as stratified by degree of kidney injury.
Results:
Any degree of AKI occurred in 95/235 (40.4%) of the cohort, with twenty-seven stage 2/3 patients requiring renal replacement therapy. There was no significant difference between the three cohorts regarding pre-operative variables. Regarding operative data, procedural urgency (p < 0.001), and cardiopulmonary bypass time (p<0.001) were significantly associated with AKI development. Any degree of AKI, with progression depending on severity, was associated with increased postoperative ICU morbidity, mortality, and MACE. Adjusted Cox regression analysis confirmed that AKI based on KDIGO criteria (1, 2/3) was an independent predictor of 30-day mortality (p<0.001, Hazard ratio = 2.63, 11.07).
Conclusions:
Acute kidney injury occurs across a spectrum in total arch surgery, with even mild kidney injury carrying the potential to increase post-operative morbidity and mortality. To further investigate outcomes of mild AKI, quality guidelines should be adjusted to capture kidney injury across its full spectrum.
Authors
Adam Carroll (1), Michael Kirsch (1), Nicolas Chanes (1), Bo Chang Wu (1), Michal Schafer (1), William Riley Keeler (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective:
Acute type A aortic dissection is an extremely rare complication in a patient with previously undiagnosed giant cell arteritis (GCA). There has been only scarce data exist regarding giant cell arteritis related acute type A aortic dissection. Wie present a successful repair of acute type A aortic dissection complicated cerebral malperfusion in a patient with undiagnosed giant cell arteritis.
Methods:
A 73-year-old male with unknown past medical history presented to outside hospital with back pain and altered mental status. Subsequent computed tomography angiogram demonstrated type A aortic dissection with an occluded innominate artery. The diameter of the ascending aorta was 40 mm.
Results:
The patient was transferred to our institution, directly to the operating room from. Doppler ultrasound of the right carotid arteries revealed s decimal flow, necessitating immediate surgical intervention. Cardiopulmonary bypass was established via cannulation of the ascending aorta and bicaval drainage. Under moderate hypothermia with retrograde cerebral perfusion, the circulation was arrested. Graft replacement of the ascending and proximal transverse Zone 1 arch with a bypass to the innominate artery was performed using a Dacron graft. Circulatory arrest time was 28 minutes and lowest temperature was 21.6 ℃. Postoperatively, the patient experienced prolonged altered mental status and required reintubation due to pneumonia. Histopathological analysis revealed diffuse transmural lymphoplasmacytic infiltration with giant cells, consistent with GCA, alongside marked medial elastin fiber degradation, intimal fibrosis, and severe atherosclerosis. Subsequent CT imaging uncovered multiple cerebral aneurysms, prompting the initiation of steroid therapy.
Conclusions:
The surgical outcome of giant cell arteritis related acute type A aortic dissection was acceptable, even though the patient was complicated with cerebral malperfusion. It also highlights the necessity of vigilant assessment for large vessel complications, including cerebral aneurysms, in GCA patients, and the importance of early steroid therapy in this unique patient population.
Authors
Yuki Ikeno (1), Lucas Ribe (1), Anthony Estrera (1), Akiko Tanaka (1)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX
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Poster Presenter
Yuki Ikeno, University of Texas - Houston
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Houston, TX
United States
Objective:
Takayasu arteritis (TA) is an uncommon chronic inflammatory disorder, characterized by granulomatous panarteritis primarily affecting the large vessels, particularly the aorta and its branches, leading to stenosis, occlusion, and aneurysm formation. Aortic dissection, a catastrophic complication associated with TA, occasionally presents as an initial manifestation in an even more extraordinarily rare subset, occurring in less than 1% of patients with TA.
Methods:
In this report, we present a case of TA complicated by acute aortic dissection, an event that occurred during the remission phase and notably in the absence of aortic dilation and inflammation.
Results:
A 64-year-old female patient with a prolonged history of Takayasu arteritis (TA) presented with the sudden onset of back pain. She had previously been prescribed steroids for her condition; however, steroid treatment had been discontinued over the past two years due to the development of osteoporosis. Notably, her TA had been effectively managed without recurrences. During outpatient visits, her systolic blood pressure had consistently measured around 110 mmHg. Approximately one month prior to her current presentation, the patient had undergone routine TA follow-up evaluation, including computed tomography (CT) imaging. The CT scan from that evaluation had revealed no signs of inflammatory response surrounding the aorta and indicated no significant dilatation of the aortic structure (Figure 1). The diameter of the descending aorta was measured at 30 mm. However, upon her recent presentation, a follow-up CT scan revealed an acute Stanford type B aortic dissection with an exclusively thrombosed false lumen that extended from Zone 4 to Zone 9, type III anatomic classification of aortitis (Figure 2). Importantly, there were no discernible indications of organ malperfusion or aortic rupture. The patient's aortic dissection was managed conservatively, and she was discharged home without experiencing any complications. Stress-dose steroids were gradually tapered off over the course of eight weeks following the dissection event.
Conclusions:
We encountered a case of acute type B aortic dissection in a patient with TA, despite the absence of aortic dilation during remission. This underscores the critical need for proactive risk factor modification and regular aortic monitoring as indispensable components of long-term management for
Authors
Yuki Ikeno (1), Francesco Brandini (1), Lucas Ribe (1), Anthony Estrera (1), Akiko Tanaka (1)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX
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Poster Presenter
Yuki Ikeno, University of Texas - Houston
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Houston, TX
United States
Objective: Outcomes after frozen elephant trunk (FET) stent-grafts are mainly focused on the perioperative results. Recently, concerns have been raised regarding the rates of late stent-graft induced complications such as thromboembolic events, 'septal injury new entry' tear (SINE) and type Ib endoleak.
Methods: The COOK FET graft, in addition to facilitate the FET procedure owing to its versatility in terms of arch zone anastomosis and endovascular management of the left subclavian, may also be customized by adapting the stent length, the proximal and distal diameters, the graft tapering and the distal radial stent strength to the patient's aortic diameter and pathology possibly allowing to decrease stent-graft related complications. To assess the mid-term stent-graft related complications of the COOK FET graft, results of 56 consecutive patients treated with the COOK FET were reviewed.
Results: Mean age was 64.511.2years; 35.7% (20pts) of female gender. Aortic pathology was aneurysmal disease in 15 (26.8%) pts, acute aortic dissection in 20 (35.7%) pts, chronic dissection in 11 (19.6%) pts and other aortic pathologies in 10 (17.9%) pts. Distal anastomosis was performed in zone 0 or 1 in 33 pts(59.0%), zone 2 in 21 pts(37.5%) and zone 3 in 2 pts(3.6%). Mean stent-graft length was 12055mm. Mean follow-up was 32.923.3 months; patients followed prospectively in a dedicated aortic clinic. Five-year survival was 80.2% with a 5-year freedom from aortic related death of 94.2%. Two patients presented a type Ib endoleak (93.5% 5-year freedom of type Ib); one patient with planned second stage stent-graft extension at 3 months post FET and one patient at 30 months post FET owing to progression of disease and currently treated medically. Two patients initially treated for dissection without low radial strength stents distally, presented SINE at respectively 8- and 25-months post FET; 5-year freedom from SINE of 93.6%. No patients with low-radial strength distal stents presented SINE at follow-up. Two patients required stent graft extension (one distal type Ib and one SINE case); 5-year freedom from aortic reintervention of 94.2%. No patient suffered a thrombo-embolic complication; all patients were treated long-term with 80mg of aspirin daily. No FET graft foreshortening, stent-graft collapse or fracture were observed at follow-up.
Conclusions: Late stent-graft related complications with FET stent-grafts are not uncommon and mandate long-term follow-up. The initial experience with the COOK FET demonstrates low stent-graft related complications at mid-term. Hence, the present study suggests that adapting stent-graft design to the patient's disease and anatomy may be beneficial.
Authors
Francois Dagenais (1), Rim Abdelli (2), Eric Dumont (2)
Institutions
(1) Quebec Heart and Lung Insitute, Quebec, Quebec, (2) Quebec Heart and Lung Institute, Quebec, Quebec
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Poster Presenter
*Francois Dagenais, Quebec Heart & Lung University Institut, Division of Cardiac Surgery
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Quebec, QC
Canada
Objective:
Valve sparing root replacement (VSRR) has seen increasing usage at large aortic centers for root pathology, with the benefit of preserving the native valve, and in younger patients avoiding lifelong anticoagulation. A common cause of failure of valve sparing root replacement VSRR is graft slippage resulting in aortic insufficiency. This is often due to insufficient depth of dissection, preventing fixation of the VSRR. While some advocate for additional subannular stitches to prevent slippage, we developed a novel method of concomitant ring annuloplasty and VSRR to prevent graft malposition and present our initial results.
Methods:
Using our institutional aortic database, six patients were identified who underwent VSRR with concomitant ring annuloplasty. We discuss their presentation, operative management, and initial follow-up.
Results:
All patients were male, with 3 patients having trileaflet morphology, and three patients having bicuspid Sievers I RL morphology. All patients had concomitant arch dilation requiring adjunctive hemiarch. Full pre-operative valve, root and aortic characteristics are described in Table 1. For all patients, 6 subannular stitches were used, with 5 patients also having leaflet plication performed at the time of the procedure. A 25mm HAART annuloplasty ring with a 30mm Valsalva graft was used in all cases. Intra-operative course was uncomplicated for all patients, with no or trace aortic insufficiency on TEE intra-operatively after repair. One patient required a return to the operating room after persistent hypoxia and post-operative echo found a new ASD that was not seen on pre-operative or intra-operative echo, after which his symptoms of hypoxia improved. Otherwise, post-operative course was uncomplicated for all patients. At three-month follow-up, all patients had no or trace aortic insufficiency and were otherwise doing well.
Conclusion:
Our novel method of concomitant ring annuloplasty at the time of VSRR demonstrated excellent results at short-term follow-up. Ring annuloplasty prevents slippage of VSRR, providing both internal and external support to the repair. Furthermore, given the failure of VSRR is usually due to aortic insufficiency, an internal rigid prosthesis may facilitate TAVR salvage therapy if necessary.
Authors
Adam Carroll (1), Bo Chang Wu (1), Michael Kirsch (1), Nicolas Chanes (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective: Thoracoabdominal aortic aneurysm (TAAA) repair is a highly complex, morbid surgery with up to 10% reported operative mortality requiring integrated expertise from multiple disciplines for successful completion. The use of left heart bypass (LHB) may reduce complications including mortality and spinal cord injury compared to circulatory arrest or full cardiopulmonary bypass, but its use remains confined primarily to specific, experienced centers.z Here, we report the results of extensive TAAA repair after the implementation of routine LHB at a new institution by an experienced surgeon.
Methods: All patients undergoing extensive TAAA repair at our institution from November 2022 to May 2023 were included. Patient characteristics and their operative outcomes were collected via direct chart review and our institutional STS database data. All patients were managed via a standardized perioperative protocol, including routine use of left heart bypass and passive intraoperative hypothermia.
Results: A total of seven cases were performed over the course of six months. The median age was 38 years, 4/7 were female, 5/7 were White. All had prior Stanford Type A (4/7) or B (3/7) aortic dissections resulting in descending aortic aneurysm (6 Extent II, 1 Extent III) with a median diameter of 5.0 cm. All patients had a spinal drain placed preoperatively and were transfused to a goal hemoglobin of 10.0 g/dL intraoperatively. LHB was initiated after the placement of venous and arterial cannulas at the left pulmonary vein/left atrial junction and the descending aorta, respectively; the median LHB time was 65 minutes. The descending and abdominal aorta was replaced with a four-branch Coselli graft in all patients with bypass performed to the celiac, superior mesenteric, and bilateral renal arteries. The intercostal arteries were routinely revascularized, with re-implantation in six patients and graft-intercostal artery bypass with PTFE performed in the other. Significant postoperative complications included one return to the operating room for bleeding, 3 patients with prolonged ventilation with 1 requiring a tracheostomy (decannulated before discharge), 4 patients with renal failure (none dialysis-dependent at discharge), and one patient with persistent lower extremity weakness secondary to a retroperitoneal hematoma. The median length of stay was 18 days. At the time of reporting, all patients were alive and living independently.
Conclusions: Our experience demonstrates that the use of LHB during extensive TAAA repair can be effectively and safely implemented under the guidance of an experienced expert. Elements critical to implementation success include a standardized protocol for perioperative management as well as collaborative, interdisciplinary work between the surgeon, anesthesiologist, and perfusionist during each case.
Authors
Jake Awtry (1), Thais Faggion Vinholo (2), Ajami Gikandi (3), Michael Gilfeather (2), Trevor Smith (2), Douglas Shook (4), Mohamad Hussain (2), Kim de la Cruz (5)
Institutions
(1) Brigham and Women's Hospital, United States, (2) Brigham and Women's Hospital, Boston, MA, (3) Harvard Medical School, Boston, MA, (4) Brigham and Women's Hospital, Newton, MA, (5) Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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Poster Presenter
Jake Awtry, Brigham and Women's Hospital
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Jamaica Plain, MA
United States
Objective:
Post-operative blood transfusion in cardiac surgery has been linked to adverse outcomes including acute kidney injury and post-operative mortality. Machine learning models for post-operative red blood cell (RBC) transfusion have not been applied to aortic surgery specifically, despite the risk of bleeding in arch surgery. We sought to develop a machine learning model to predict the need for post-operative transfusion of RBC in aortic surgery.
Methods:
We identified all adult patients who underwent elective aortic surgery between June 2009 to October 2022 (n = 543) from our single institution prospectively maintained database. Patients were randomly divided into training (70%) and testing (30%) sets with various eXtreme gradient boosting (XGBoost) models constructed to predict postoperative RBC transfusion in the cardiothoracic intensive care unit (CTICU). From the index hospitalization, we extracted 64 input parameters, including 24 demographic characteristics as well as 8 preoperative and 32 intraoperative variables. To assess model performance, we employed various evaluation metrics, including accuracy, area under the receiver operating characteristic curve (AUC-ROC), and area under the precision-recall curve (AUC-PR, mean average precision). Additionally, we assessed model performance on various subsets within the broader study population, including root, hemiarch, and total arch procedures.
Results:
Postoperative RBC transfusion was required in 48.8% of patients (265 cases) following aortic surgery. The final XGBoost model demonstrated a 77% cross-validation accuracy and a 77% test accuracy, achieving an AUC-ROC of 0.79 and an AUC-PR of 0.56. When stratifying by aortic procedure, the model attained an AUC-ROC of 0.73 for root procedures, 0.82 for hemiarch cases, and 0.72 for total arch surgeries. Prominent factors associated with an increased risk of postoperative RBC transfusion included extended periods of circulatory arrest, SACP via innominate or axillary cannulation, low nadir hemoglobin, higher intraoperative blood product transfusion, low preoperative hemoglobin, and a history of prior sternotomy. Comparatively, baseline thrombocytopenia, extended cardiopulmonary bypass time, and lower nadir bladder temperature had significantly less effect on need for post-operative transfusion.
Conclusions:
The machine learning model developed had a strong performance in the overall cohort for predicting post-operative transfusion for all aortic surgery, and for specific procedure subsets. Extended periods of circulatory arrest, antegrade cerebral perfusion, baseline anemia and intraoperative bleeding were the strongest predictors of need for post-operative transfusion, while nadir temperature, baseline platelets, and extended cardiopulmonary bypass time did not have as significant of a model impact.
Authors
Adam Carroll (1), Nicolas Chanes (1), Michael Kirsch (1), Ananya Shah (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective
Advanced age is a risk factor for poor prognosis after cardiac surgical procedures. This study sought to report age related morbidity and mortality outcomes of patients with Type B aortic dissections.
Methods
This was an observational study of patients with type B aortic dissections using the National Inpatient Sample (NIS) from 2016 to 2020. Patients were stratified into three age groups: <65 years, 66-75 years, and >75 years. Multivariable regression analysis was performed to identify variables associated with in-hospital mortality after a Type B aortic dissection.
Results
A total of 16,781 patients with Type B dissections were identified with 51.4% (8632) patients in the < 65 group, 23.2% (3888) in the 65-75 group, and 26% (4361) in the >75 group. Women comprised 39.8% (6677) of the patient population and were more likely to present at a later age (55.9% [2440] comprised >75 group, p<0.001). Patients above 75 years were more likely to have coronary artery disease (39.6% [1730], p<0.001), congestive heart failure (30.7% [1338], p<0.001), peripheral vascular disease (16.5% [720], p=0.009), and chronic kidney disease (27.6% [1204], p<0.001).
The in-hospital mortality for patients above 75 years of age was 16.7% [729] (p< 0.001). This group also had the lowest proportion of patients routinely discharged (23.69% [1033], p<0.001). Patients >75 years also had higher incidences of post-treatment heart failure (15.6% [679], p<0.001) and arrhythmia (31.3% [1364], p<0.001; however, rates of stroke (2% [171], p<0.0174) and spinal cord ischemia (2.1% [178], p<0.01) were highest in the <65 group. The median length of hospital stay was 6 days (3-11).
On multivariable mixed-model regression, age >75 was associated with odds of in-hospital mortality (OR: 2.729, [95%CI: 2.2-3.4], p<0.001). Other predictors included age 65-75 years (OR: 1.614 [1.347-1.933], p<0.001), non-elective procedure (OR: 3.090 [2.422-3.942], p<0.001), cerebrovascular disease (OR: 2.593 [2.203-3.052], p<0.001) and peripheral vascular disease (OR: 1.314 [1.175-1.470], p<0.001). Age as a continuous variable was also associated with mortality (OR:1.04 [1.01-1.03], p<0.001) (Figure).
Conclusions
Increase in age is associated with increased morbidity and mortality in patients with Type B aortic dissections likely due to baseline comorbidity burden. Preoperative conversations with patients and support members regarding outcomes may help adjudicate appropriate candidates for surgery.
Authors
Mahnoor Imran (1), Danial Ahmad (2), Derek Serna-Gallegos (3), James Brown (2), Sarah Yousef (4), Floyd Thoma (2), Yisi Wang (2), David West (2), Danny Chu (5), Pyongsoo Yoon (2), Johannes Bonatti (6), David Kaczorowski (7), Francis Ferdinand (8), Ibrahim Sultan (3)
Institutions
(1) N/A, United States, (2) UPMC, Pittsburgh, PA, (3) University of Pittsburgh Medical Center, Pittsburgh, PA, (4) University of Pittsburgh, Pittsburgh, PA, (5) Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, (6) UPMC Heart and Vascular Institute, Pittsburgh, PA, (7) University of Pittsburgh Medical Center, Venetia, PA, (8) UPMC, Erie, PA
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Poster Presenter
Mahnoor Imran, UPMC medical center
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Pittsburgh, PA
United States
Objectives:
Brain malperfusion secondary to acute aortic dissection results in higher in-hospital mortality. Some patients develop permanent neurological deficit even after central aortic repair. We evaluated surgical results of direct perfusion to the carotid artery during acute type A aortic dissection (AAAD) repair complicated with brain malperfusion.
Methods: Among 175 patients who underwent aortic repair for AAAD from 2014 to 2022, brain malperfusion was recognized in 21(12%) patients. Brain malperfusion was defined as stenosis or occlusion of the unilateral or bilateral carotid artery on computed tomography. Age at surgery was 70 years (53-89) and nine (42.9%) patients were male. Preoperative consciousness level was alert in four (19.0%) patients, drowsy in four (19.0%), and coma in two (9.5%). Thirteen (61.9%) patients had preoperative hemiplegia, six (28.6%) had dysarthria, and five (23.8%) conjugate deviations. Four of eighteen patients undergoing preoperative computed tomography already showed developed cerebral infarction. Eight (38.1%) patients had direct perfusion of unilateral or bilateral carotid arteries before starting systemic cardiopulmonary bypass. Conventional antegrade cerebral perfusion under circulatory arrest was applied in thirteen (61.9%) patients. Of eight patients with direct cannulation, total arch replacement was performed in two (25.0%) patients, partial arch in four (50.0%), and hemiarch in two (25.0%).
Results: There was no in-hospital mortality. Seven (87.5%) of eight patients undergoing direct cannulation and 11 (84.6%) of patients with conventional cerebral perfusion showed improvement of neurological signs (p=0.43). Six (75.0%) of eight patients with direct cannulation discharged ambulatory (1 in conventional cerebral perfusion, p=0.0019). One of four patients with cerebral infarction detected on preoperative computed tomography completely recovered after decompressive craniectomy, however, remaining three patients resulted in coma even after AAAD repair (1 in direct cannulation and two in conventional cerebral perfusion).
Conclusion: Aggressive direct reperfusion of the carotid artery before the aortic repair may reduce neurological complications during AAAD repair in patients with brain malperfusion. However, further investigation would be required in patients with established infarction before AAAD repair.
Authors
Kyokun Uehara (1), Taku Shirakami (1), Junpei Kobiki (1), Takashi Tsuji (1), Manabu Morishima (1), Yoshio Arai (1)
Institutions
(1) Tenri Hospital, Tenri, Nara
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Poster Presenter
Kyokun Uehara, National cerebral and cardiovascular center
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Tenri, Osaka
Japan
Objective
Patients who are unable to accept blood products may require alternative interventions, particularly for complex cardiac surgeries such as a frozen elephant trunk (FET) procedure. We described the case of a patient with an aortic root aneurysm and distal aortic arch pseudoaneurysm for which a FET procedure would be standard management, but instead an alternative course of treatment was chosen as the patient was a Jehovah's witness.
Methods:
We discuss the case of a 46-year-old male Jehovah's witness with a history of congenital aortic coarctation involving the distal transverse arch and descending thoracic aorta. The coarctation was repaired via left thoracotomy when the patient was an infant, however, patient was lost to follow-up until July 2022, at which point an echo showed a dilated root with a bicuspid aortic valve (BAV) and a 5.7 cm aneurysm proximal to the site of the coarctation repair.
Results:
The patient's situation was evaluated, and it was determined that while a FET procedure with a root replacement would be the standard treatment, a staged approach would be better in this scenario as the patient could not accept blood products. The patient's first procedure would repair the pseudoaneurysm and would be followed by an aortic root replacement one month later. For the first procedure, the patient was managed with an endovascular therapy using a GORE-TAG thoracic branched endograft (TBE) with left common carotid artery (LCCA) stent extension of the side portal branch. Access was first established via the left common femoral and left radial arteries, and the GORE-TAG TBE device was then properly positioned and deployed, with good seal proximal and distal in the aorta. No endoleak was noted, and there was no filling of the aneurysm, indicating full exclusion. The patient had an uncomplicated post-operative stay and was discharged on hospital day 3. The patient underwent the subsequent planned bio-Bentall aortic root replacement one month later. Post-op course was notable for atrial fibrillation, but was otherwise uncomplicated, and the patient was discharged on post-op day 8. CTA performed 6 months post-operatively showed stable post-operative thoracic aorta without recurrent aneurysm.
Conclusion:
For patients who are unable to receive blood products alternative management, such as staged surgeries, may be optimal to reduce operative risk. Consideration of patient values is paramount, and developing endovascular technologies allows for new opportunities in complex aortic pathology.
Authors
Adam Carroll (1), Ananya Shah (1), Muhammad Aftab (1), Donald Jacobs (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Ananya Shah, University of Colorado Anschutz
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Fort Collins, CO
United States
Objective
Aortic tortuosity can pose significant difficulties in endovascular management of aortic disease. In addition to the operative difficulty of navigating a tortuous aorta, ensuring an ideal aortic position for successful stent-graft placement is paramount. We describe a case of a patient who required a complex, modified TEVAR technique for treatment of a descending thoracic aorta (DTA) aneurysm in a severely tortuous aorta.
Methods:
We discuss the case of a 73-year-old male with a severely tortuous aorta and a history of prior infrarenal EVAR who presented with an extensive large descending thoracic and abdominal aortic aneurysm for a planned TEVAR and 4v-PMEG.
Results:
After obtaining bilateral femoral access, bilateral Lunderquist wires were advanced to the thoracic aorta, and a 18Fr Dryseal was placed on the left and a 22Fr Dryseal on the right. His aorta had 3 significant angulations, the most substantial of which was 62 degrees above the diaphragm. For the initial TEVAR, in order to advance the 40-36 x 250 mm relay Pro thoracic stent-graft, a 22Fr 65cm dryseal sheath was exchanged to straighten out the aorta. This was then cut at the proximal end to allow for retraction and full release of the endograft which was placed just distal to the left subclavian.
After defining the visceral aorta anatomy through aortogram, the Treo PMEG was oriented. The second thoracic stent graft, a 36-32 x 150 mm relay Pro thoracic stent graft, was then advanced and deployed just superior to the celiac fenestration. Due to the tortuosity of the thoracic aorta, this graft lost seal with the PMEG graft when deployed. A trilobe balloon was used to cover the overlap between the two thoracic stent grafts, which caused the more distal graft to move even further away from the proximal one. A 34 x 100 mm Gore C TAG thoracic stent graft was then required to bridge the distal thoracic graft with the PMEG graft. A trilobed balloon was again used for the overlaps, this time resulting in a good seal without coverage of the celiac fenestration. The celiac artery, superior mesenteric artery (SMA), and right renal artery (RRA) were then cannulated, and the Treo graft was fully deployed. Following the placement of visceral fenestration and iliac stents, final angiography was done showing patency of all stented vessels, and no type I, 2, or 3 endoleak from the thoracic aorta through to the iliac arteries.
Conclusion:
Management of severely tortuous aortas can be challenging and complex, potentially requiring immediate modification of existing techniques in the operating room. Multidisciplinary collaboration at high volume aortic centers is necessary when severe tortuosity is present.
Authors
Adam Carroll (1), Ananya Shah (1), Robert King (1), Donald Jacobs (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Ananya Shah, University of Colorado Anschutz
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Fort Collins, CO
United States
Objective: Following acute type A aortic dissection (ATAAD) repair, distal aortic dilation may occur. False lumen (FL) communications at the head vessels and visceral vessels are thought to contribute to this growth. We sought to identify operative and anatomical factors predictive of distal aortic growth following ATAAD repair.
Methods: Patients that underwent ATAAD repair from 2017-2021 were included. This study included 48 patients who underwent ATAAD repair with supra-aortic vessel involvement and at least one year of follow-up imaging. Patients were divided into groups based on surgical repair and dissection type: supraaortic vessel dissection (SAVD), SAVD with head vessel FL communication (SAVD+FL), and those that received hemiarch or extended arch repair. Preoperative and postoperative measurements were taken at zone 1 and at the level of the tracheal bifurcation. Aortic measurements were compared between groups using paired t-tests.
Results: 22 patients received isolated hemiarch repairs, 17 hemiarch with arch stent implantations, and 9 total arch repairs. Measurements of zone 1 did not show significant growth for any group during the follow-up period. Measurements taken at the level of the tracheal bifurcation demonstrated that patients with more false lumen communications at the visceral level experienced a larger degree of distal aortic growth at greater than one year of follow-up.
Conclusions: This study has demonstrated an association of distal aortic expansion with increased visceral FL communications. While extended arch repair may address FL communications at the head vessels, they do not address communications distally. These visceral communications may contribute to distal aortic growth.
Authors
Ryaan EL-Andari (1), Sabin Bozso (1), Nicholas Fialka (1), Michael Moon (1)
Institutions
(1) University of Alberta, Edmonton, AB
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Poster Presenter
Ryaan EL-Andari
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Edmonton, AB
Canada
Objective: Total aortic arch replacement using the Frozen Elephant Technique (FET) remains a technically challenging and time-consuming procedure and the reinsertion of the supraaortic vessels occasionally difficult. In 2017, our group published a stent bridging technique to simply the reinsertion and to transpose the distal anastomosis to Zone 2. To move the distal anastomosis yet further to Zone 0, however avoiding any debranching or rerouting techniques, we developed a new custom-made hybrid prosthesis, which employs established endovascular methods to allow anatomical reconstruction of the arch. The prosthesis holds a classical "standard" outer side branch for the brachiocephalic trunk in front of the sewing collar and two inner branches beyond. The latter allow the reconnection of left common carotid and left subclavian artery by placing bridging stents from inside the main graft through the inner branches to the recipient vessel. In 2022, we reported the first-in-man implantation and presented the technique. Here, the first clinical experience and technical challenges are presented.
Methods: Seven patients underwent total arch replacement using the custom-made prosthesis, median age was 56 years (range 42-76). Six patients suffered from acute aortic dissection type-A, one from aortic arch aneurysm with subacute type-B dissection. Median follow-up including CT scan was 833 days (563-1182).
Results: The median graft size (body and stent–a non-tapered design) was 26mm (24-33). The length of the stented portion was 160mm (152-180). Median diameter of the bridging stents to the left common carotid artery and left subclavia artery were 9mm (8-9) and 11mm (10-13), respectively. Circulatory arrest times dropped from 60 minutes (38-97) in a historical SAVSTEB cohort to 37 minutes (23-61).
All patients survived the index procedure and are still alive at follow-up (100% completed). One patient underwent reexploration due to bleeding. No strokes, renal or cardiac complications were observed perioperatively or during follow-up.
The main prosthesis showed 100% technical success. However, two patients required FET extension due to distal progression of disease during follow-up.
Regarding the supraaortic vessel reconnection, two major technical failures were observed. One subclavian stent dislocated during placement unnoticed into the descending aorta and the upper extremity perfusion had to be secondarily secured by a carotid-subclavian bypass. One stent was misplaced into the vertebral artery without clinical consequences. Again, a carotid-subclavian bypass was performed. Two minor issues were observed: one type Ib endoleak in the carotid artery due to a short stent graft and one Ia endoleak due to inadequate ballooning of the stent. Both were solved by endovascular techniques - extension and relining.
Conclusions: Combining endovascular and conventional surgical techniques may improve the overall strategy in open surgery by reducing the HCA time, reducing invasiveness and improving safety. The anatomical reconstruction of the aortic arch from zone 0 is feasible and reproducible and avoids extensive debranching and rerouting techniques. Sutureless attachment of the supraaortic vessels from inside the main graft has now been proven feasible. However, a learning curve and new potential pitfalls have to be overcome. Nevertheless, the custom-made Zone 0 prosthesis felt to be the next logical developmental step for anatomic reconstruction.
Authors
Sven Peterss (1), Nikolaos Tsilimparis (1), Joscha Buech (1), Caroline Radner (1), Linda Grefen (1), Thomas G. Fabry (1), Simon Rutkowski (1), Christian Hagl (1), Maximilian Pichlmaier (1)
Institutions
(1) LMU University Hospital, Munich, Germany
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Poster Presenter
Sven Peterss, University Hospital Munich
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Munich
Germany
Objective: Antegrade selective cerebral perfusion (ASCP) is one of the strategies employed for cerebral protection during aortic arch surgery. The aim of this study is to establish the relationship between ASCP average flow and cerebral damage, considering both transient (TND) and permanent (PND) neurological deficits.
Methods: The cohort of this retrospective study includes patients from two centers: Cardiac Surgery Department of Policlinico Sant'Orsola, Bologna, and Columbia Irving Medical Center, New York. Data collected include patients who underwent aortic arch surgery using ASCP and moderate hypothermia from January 2015 to August 2023. Patients have been divided into two groups according to ASCP flow rate: low-flow (LF) with a flow <10ml/kg/min and high-flow (HF) with a flow 10ml/kg/min. Neurological complications have been distinguished into PND and TND analyzing both clinical and radiological aspects. Early postoperative outcomes were evaluated. Late mortality has been compared through Kaplan-Meier survival curves.
Results: A total of 712 patients were included in a retrospective study, LF 67(9.4%) and HF 645(90.6%). The mean age was 62.412.7 in LF and 63.512.5 in HF. The analysis of risk factors showed that HTN was significantly higher in LF (55, 82.1%) than in HF (465, 72.1%), p=0.042. Preoperative data showed a higher rate in HF of bicuspid aortic valve (LF 3(4.5%), HF 67(10.0%), p= 0.034) and reintervention (LF 10(14.9%), HF 174(27.0%), p=0.010). Aneurysm was the main indication for surgery in HF (LF 18(26.9%), HF 325(50.4%), p<0.001), while Acute Type A aortic dissection (ATAAD) was more frequent in LF (LF 40(59.7%), HF 226(35.0%), p<0.001). The main site of arterial cannulation was femoral artery in LF (LF 24(35.8%), HF 142(22.0%), p=0.031), and brachiocephalic trunk in HF (LF 8(11.9%), HF 163(25.3%), p=0.009). Concerning neurological complications, no significant differences were found between the two groups: TND was higher in LF (LF 13(19.4%), HF 96 (14.9%), p=0.270), PND and ischemic stroke were similar (respectively LF 6(9.0%), HF 61(9.5%), p= 0.865 and LF 4(7.5%), HF 31(8.8%), p= 0.680) and hemorrhagic stroke was lower in LF (LF 1(20.0%), HF 24 (42.1%), p=0.175). No significant differences were found in survival rate at 60 months.
Conclusions: Despite the limitations of the study, related to different characteristics of the groups, short period of analysis and absence of the exact mean flow for each patient, with our data we have been able to correlate neurological damage to ASCP flow. Although it is not statistically significant, hemorrhagic stroke rate was higher in those patients who received a higher flow.
Authors
Giacomo Murana (1), Sabrina Castagnini (1), Kavya Rajesh (2), Costanza Fiaschini (1), Francesco Campanini (1), Edoardo Bianco (1), Yu Hohri (2), Dov Levine (2), Hiroo Takayama (3), Davide Pacini (1)
Institutions
(1) IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum Università di Bologna, Bologna, Italy, (2) Columbia University Irving Medical Center, New York, NY, (3) NewYork- Presbyterian/Columbia University Medical Center, New York, NY
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Poster Presenter
Giacomo Murana, S. Orsola Hospital
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Bologna, Bologna
Italy
Objective: To determine the prevalence of psychological distress in thoracic aortic aneurysm patients, examine whether these factors impacted patient beliefs about their longevity, and determine if results differ by surgical status (surgical vs. non-surgical/surveillance).
Methods: During a yearly follow-up visit for thoracic aortic aneurysm surveillance or post-operative monitoring after thoracic aortic aneurysm repair, 45 patients in a rural-serving cardiac surgery clinic were administered measures that assess mental health symptomatology and beliefs about their longevity. The Depression, Anxiety, and Stress Scale (DASS-21) assessed for the presence of depressive, anxiety, and stress symptoms, while a screening item asked patients how long they expected to live, and how long they expected healthy peers would live. Patients were grouped by history of aortic surgical intervention and tested for group differences.
Results: Overall, 26% of patients reported depressive symptoms, 33% reported elevated stress levels, and 53% indicated the experience of elevated anxiety. No significant differences emerged in reported mental health symptoms between surgically treated and non-surgical/surveillance patient groups. A moderate relationship was observed between stress and life expectancy for surgically treated patients, with increased stress being associated with decreased life expectancy (r = -0.43). In addition, those who had undergone surgical repair believed that they would live longer than their healthy peers (81.3 vs. 77.7 years, respectively), while the non-surgical/surveillance group believed they had a shorter life expectancy than their healthy peers (81.7 vs. 84.8 years, respectively).
Conclusions: Mental health distress is highly prevalent in thoracic aortic aneurysm patients. However, mental health symptomatology did not differ by a proxy for disease severity (as indicated by surgical status). For surgically treated patients, the presence of stress resulted in reduced appraisals of life expectancy. Our results also suggest that surgically treated patients may perceive a sense of security for having undergone aortic repair. These results further highlight the psychological impact of aortic disease and the need for routine clinical psychology attention in cardiac surgery clinics.
Authors
Elizabeth Jordan (1), Caroline Miller (1), Maeve M. Sargeant (1), Phoebe Jollay-Castelblanco (1), Samuel F. Sears (1), Benjamin Degner (1)
Institutions
(1) East Carolina University, Greenville, NC
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Poster Presenter
Benjamin Degner, East Carolina University
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Greenville, NC
United States
Objective: Hemiarch replacement with open stent graft has been used for acute Stanford A aortic dissection could be useful for descending aorta remodeling. However, the aortic arch is left as native aorta and could dilate later. We investigated the cause and frequency of aortic arch dilation.
Methods: We analyzed the clinical data of patients who underwent hemiarch and open stent graft for acute Stanford A aortic dissection between 2008 and 2017. Results: A total of 145 patients [Male:82(57%) Femal:63(43%)] were included in this study. Median age was 68 years old. In-hospital mortality was 4 patients (3%). New stroke occurred in 10 patients (7%). Paraplegia in one patient (0.7%). During a follow-up (Median 3 years), out of 141 patients who were discharged alive, 14 patients (10%) had larger than 5 cm of aortic arch or more than 1 cm dilation compared to the one in preoperative CT scan. Out of those 14 patients, arch branch vessels were preoperatively dissected in 12 patients (86%) compared with 64 patients (50%) out of 127 patients who did not meet the criteria above (P<0.05). 7 patients required reintervention for dilated aortic arch. One patient whose arch branch vessels were dissected preoperatively had 4.4 cm of aortic ach and died due to aortic arch rupture 2.6 years after the index surgery. Complete descending aorta remodeling was accomplished in 83 patients (59%). 14 patients (10%) needed an intervention for descending aorta. Conclusions: Hemiarch replacement with open stent could rescue the patients with a low mortality rate and acceptable perioperative adverse events' rate. Some patients required aortic arch intervention later. Preoperative aortic arch branch vessels dissection could increase aortic arch adverse events such as aortic arch dilation or rupture as the residual dissection in the arch branch vessels become re-entry site.
Authors
Shinichiro Ikeda (1), Tomomi Nakajima (1), Takayuki Gyoten (1), Osamu Kinoshita (1), Toshihisa Asakura (1), Akihiro Yoshitake (1)
Institutions
(1) Saitama Medical University International Medical Center, Hidaka, Japan
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Poster Presenter
Shinichiro Ikeda, Saitama medical university International medical center
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Japan
• Objective:
Conventional approach to aortic arch surgery requires hypothermic cardiopulmonary bypass (CPB) and lower body circulatory arrest. Prolonged CPB and lower body ischemia have negative impact on outcomes in patients with visceral abnormalities and ongoing infection.Arch replacement under uninterrupted perfusion can minimize organic injury. The objective of this submission is to demonstrate the feasibility of open aortic arch replacement without circulatory arrest in specific patient conditions with appropriate anatomy.
• Case Video Summary:
Open arch repair with a distal anastomosis performed in zone 2 under mild hypothermia (34-35ºC) and uninterrupted perfusion. The patient is cannulated in the right axillary artery and right femoral artery. Under full CPB fow the aortic balloon in the descending aorta (inserted through the left femoral artery) is inflated, the proximal brachiocephalic trunk is clamped and the left carotid artery snared. The aorta is opened and retrograde cold blood cardioplegia administered while maintain unilateral cerebral perfusion (right axillary) and distal body perfusion (right femoral artery). A cerebral perfusion cannula is inserted in the left carotid artery while the left subclavian is back bleeding is blocked with a Foley catheter. Distal anastomosis is performed with a polyester graft and 4/0 monofilament in zone 2. The graft is deaired and occluded reestablishing left subclavian artery perfusion. The proximal anastomosis is performed and the heart reperfused. The operation continues with separate head vessel reconstruction (brachiocephalic trunk and left carotid artery) with a bifurcated polyester graft. CPB time 177 min Cardiac ischemic time were 62 min. The patient was extubated within the first 24 h and discharged without complications. After 9 months there is no evidence of relapse and the patient has no physical restriction.
• Conclusions:
Aortic arch replacement avoiding moderate/deep hypothermia and circulatory arrest is
feasible, provided that there is no precluding thoracoabdominal aorta or peripheral disease. It provides a bloodless and comfortable aortic arch operative [eld, ensuring thorough and unrushed tissue debridement. There is potential to minimize coagulopathy and end organ damage. The downsides of this approach are the need for additional femoral artery manipulation and endoclamping of the descending aorta. Similar anatomies could be safely tackled under normothermic CPB.
Authors
Eduard Quintana (1), Elena Sandoval (2), Robert Pruna-Guillen (2), Maria Ascaso Arbona (2)
Institutions
(1) Hospital Clínic Barcelona Cardiovascular Surgery Department. University of Barcelona, Barcelona, Barcelona, (2) Hospital Clínic Barcelona Cardiovascular Surgery Department, Barcelona, Barcelona
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Poster Presenter
Eduard Quintana, Hospital Clínic Barcelona Cardiovascular Surgery Department
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Barcelona, barcelona
Spain
Objectives: The size of the aorta is a significant contributor and predictor for complications and by virtue, the size serves as an important parameter for intervention. There is insufficient literature on population-based studies concerning the normal size of the aorta and is well-recognized that age, gender, and ethnicity may play a role in its size. We thus sought to determine the normal dimensions of the aorta amongst our population.
Methods: Seven hundred and four patients admitted to our center due to polytrauma between January 2018 to December 2022 underwent protocolized non-contrast cardiac CT of the chest and abdomen. Images were used to measure the diameter of the aorta at the established reference levels. Patients below 18 years of age(N=50), individuals not confirming Asian ethnicity(N=6), and patients with images with excessive motion artifacts resulting in difficulty in assessing their diameters(N=135) were excluded.
Results: There were 513 patients with a mean age of 34.7+14.6 (range 18-86) and 382 (74.5%) males. The dimensions of the aorta at sinus, ascending aorta, arch, descending aorta, supra and infrarenal aorta were 30.7 + 3.8, 29.3 + 4.5, 24.9 + 3.3, 20.1 + 3.0, 19.4 + 2.9 and 15.3 + 2.2 respectively. The age of patients demonstrated a positive correlation to the diameter at the ascending aorta, descending aorta, and infrarenal aorta {(r=0.58, p<0.01 [CI95%. 0.519; 0.634]; r=0.69, p<0.01 [CI 0.642; 0.733]; r=0.571, p<0.01 [CI 0.509; 0.626])} along with the length of the ascending aorta to the above reference diameters {(r=0.420, p < 0.01 [CI95% = 0.346; 0.488]; (r = 0.536, p < 0.01; [CI95% = 0.47; 0.595]; (r = 0.476, p < 0.01; [CI95% = 0.407; 0.541]} respectively. Females had a smaller dimension of the aorta at the majority of reference points without any statistical significance. There were 50 (9.8%) patients with bovine aortic arch and 10 (1.9%) patients with separate origin of vertebral artery from the arch of the aorta. The dimension of the distal descending aorta, suprarenal, and infrarenal abdominal aorta appears markedly smaller in our population compared to what is elucidated in literature amongst the Western population.
Conclusion: Normal values of the diameter of the aorta are provided and are affected by age and length of the ascending aorta. The study suggest that the aorta size is much smaller in Asians, more significantly for distal descending and abdominal aorta, and that ethnicity may have a prominent role in determining indication for intervention.
Authors
Bijoy Rajbanshi (1), Bhuwan Kayastha (2), Gangaram Biswakarma (3), Sangam KC (4), Pralaya Khadka (4), Dharmendra Joshi (5), Ram Kumar Ghimire (2)
Institutions
(1) Department of Cardio Vascular and Thoracic Surgery, Nepal Mediciti, Nepal, (2) Department of Radiology, Nepal Mediciti, Lalitpur, Bagmati, (3) Tribhuwan University, Kathmandu, Bagmati, (4) Nepal Mediciti, Lalitpur, NA, (5) Department of Cardio Vascular and Thoracic Surgery, Nepal Mediciti, Lalitpur, Bagmati
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Poster Presenter
Bijoy Rajbanshi, Nepal Mediciti
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Kathmandu
Nepal
Objective:
In the setting of Acute Aortic Syndromes, timely access to definitive surgical repair is of paramount importance. Older patients, primarily septuagenarians and octogenarians, undergoing emergent Ascending Arch Repair experience higher rates of mortality compared to younger patients. Despite this risk, studies show that surgical management is still superior to medical management for this patient population. The objective of this study is to determine if older age impacts the time from presentation to start of surgery for patients with Acute Aortic Syndromes undergoing surgical repair.
Methods: This retrospective review included all patients with Acute Aortic Syndromes who underwent emergent Ascending Aortic Arch Repair from January 2018 to May 2023 at a single academic institution. Our analysis compared outcomes for older patients (age 70 years and older) with younger patients (age less than 70 years). Primary outcomes included time from Emergency Department presentation to the start of surgery and time from diagnosis with Computerized Tomography to start of surgery. Secondary outcomes included intraoperative and 30-Day mortality, postoperative stay, and complications. Outcomes were analyzed using Chi-squared, Fisher's Exact, and t-tests, with significance set at p<0.05.
Results:
Of 107 patients included, 71 (66%) were under the age of 70 and 36 (34%) were 70 years of age or older. The younger cohort had more male and non-White patients, with no differences in rates of hypertension, dyslipidemia, and smoking history. With no difference in the rate of transfers from outside hospitals, we observed longer times from presentation to start of surgery for older patients compared to younger patients (7 hours and 13 minutes vs. 6 hours 25 minutes; p=0.02), and also for time of diagnosis to start of surgery (4 hours 22 minutes vs. 3 hours 54 minutes (p= 0.006). Older patients had higher rates of intraoperative (0% vs. 17%, p<0.001) and 30-day (7% vs. 44 %, p<0.001) mortality. There were no differences in length of stay, or in rates of postoperative complications and surgery-related Emergency Department visits.
Conclusions:
Patients aged 70 and older experienced delays from time of presentation to start of surgery and from time of diagnosis to start of surgery. Age should not delay an individual from receiving timely transfer to a tertiary center for higher level of care to better assess the patient's operative candidacy and determine appropriate treatment.
Authors
Anthony Lemaire (1), Sorasicha Nithikasem (1), Abhishek Chakraborty (2), George Hung (1), Hirohisa Ikegami (1), Manabu Takebe (1), Mark Russo (3), Leonard Lee (4)
Institutions
(1) Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, (2) Rutgers Robert Wood Johnson Medical School, New Brunswick,NJ, (3) Robert Wood Johnson University Hospital, Green Village, NJ, (4) Robert Wood Johnson University Hospital, New Brunswick, NJ
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Poster Presenter
*Anthony Lemaire, Rutgers Robert Wood Johnson Medical School
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New Brunswick, NJ
United States
Objective: Aortic valve repair techniques are still evolving with better understanding of aortic root and leaflet imaging. This study seeks to present results of an additional new technique in aortic valve repair. The technique entails remodeling of the leaflet by peeling off the fibrous tissue of thickened leaflets (on the ventricular side of the aortic valve along with thinning and plication of the central region of the leaflets). Other repair techniques are added to complete the repair.
Methods: A retrospective chart analysis of 10 patients that underwent aortic valve remodeling for aortic regurgitation and received advanced imaging pre-operative assessment from January 2022 to November 2023. Institutional review board approval was obtained under expedited review for retrospective studies.
Results: All patients with a wide range of congenital pathologies, underwent leaflet remodeling, five patients underwent additional valve-sparing root replacement and four had subaortic annuloplasty. Nine patients had moderate or severe aortic insufficiency at the time of presentation. Mean clinical follow-up was 166 days (range: 8, 538). At follow-up, 6 patients did not have aortic regurgitation on echocardiogram and the remaining four had mild regurgitation. All patients assessed for LVEF at follow-up had their EF>50%. None of the patients required re-operation.
Conclusions: Leaflet remodeling expands leaflet dimensions by freeing tethered portions and improves mobility. This additional technique will preserve more valves from replacement. However, further follow up is needed.
Authors
Lama Dakik (1), Hani Najm (1), Lama Dakik (1), John Costello (2), Munir Ahmad (1), Justin Tretter (1)
Institutions
(1) Cleveland Clinic, Cleveland, OH, (2) Cleveland Clinic Foundation, United States
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Poster Presenter
Lama Dakik, Cleveland Clinic Foundation
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Cleveland, OH
United States
Aims: Hybrid treatment of acute DeBakey I aortic dissection (AD) using a conventional ascending replacement in combination with an uncovered nitinol Ascyrus Medical Dissection Stent (AMDS) enables a timesaving stabilization of the aortic wall with good clinical results. Despite proper use and stent sizing, considering D1 and D2 aortic diameters (figure 1), different stages of aortic remodeling – reaching from complete thrombosis to total patency of the false lumen (FL) at the level of the aortic arch and descending aorta – are seen in the follow-up. We aimed to determine the influence of aortic arch morphopathology on aortic remodeling.
Methods: Pre- and postoperative angiographic computed tomography (CT) data of 20 patients (20.4 ± 11.2 EuroSCORE II; 17.8 ± 7.1GERAADA score) who received a hybrid arch repair for DeBakey I AD between 04/2021 and 03/2023 were analyzed. Morphologic aortic arch types (type I, II and III) were defined according to the ratio between the LCCA-diameter and the distance from the horizontal line through the top of the arch to the horizontal line through the orifice of the innominate artery (figure 1). Volumetric measurements of the true (TL) and FL as well as the degree of FL thrombosis were assessed. Aortic remodeling was defined according to the FL volume index = FL volume/ (TL volume + FL volume). Finally, the degree of aortic remodeling was analyzed considering the morphologic aortic arch type. Primary endpoint was the degree of aortic remodeling after six month. Secondary endpoints were incidence of stroke, spinal cord ischemia and mortality.
Results: One permanent stroke (5%), one spinal cord ischemia (5%) but no malperfusion occurred postoperatively. The 30-day and 6-month mortality rates were 0% and 5%. The 6-month follow-up analysis of the remaining 19 patients revealed a 74% remodeling in the AMDS-covered part of the aorta: complete FL thrombosis in nine, and a partial FL thrombosis in five patients. Distal the AMDS a remodeling was seen in only 42%. Regarding the arch morphology, type I arches (n=10) showed a FL volume index decrease from 0.7 preoperatively to 0.08 postoperatively, with a remodeling in 80%. In type II arches (n=4) a complete remodeling was seen in 67%, whereas no reliable remodeling was seen in type III arches (n=6).
Conclusion: Indication for AMDS in DeBakey I AD should consider not only D1 and D2 aortic measurements for sizing, but also the aortic arch morphopathology for therapy decision. Although the significance of the present study is limited due to the small sample sizes, it seems that dissected type I arches may result with a complete aortic remodeling, whereas dissected type III arches are not best treated with AMDS.
Authors
Peter-Lukas Haldenwang (1), Markus Schlömicher (1), Chiara Bonnemann (2), Justus Strauch (1)
Institutions
(1) Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany, Bochum, Germany, (2) Departement of Radiology and Nuclear Medicine, University Hospital Bergmannsheil Bochum, Bochum, Germany
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Poster Presenter
Peter-Lukas Haldenwang, Ruhr University of Bochum
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Bochum, NRW
Germany
Objective:
Aortic root replacement (ARR) is performed in 20-30% of patients who present with acute type A aortic dissection in many aortic centers. We reviewed our two-decade experience to evaluate for the results of root conservation approach in acute type A aortic dissection ATAD.
Methods:
All open ATAD repairs performed at our institution from December 1999 to December 2023 were reviewed. Perioperative data were reviewed and patients who did not have ARR was compared with ARR.
Results:
Total of 770 patients had type A aortic repair during the study period. 75 (9%) patients had ARR, and modiced Bentall was the most common procedure (63%). Patients with ARR were younger (43 yo vs. 59 yo, P<0.001), more commonly male (87% vs. 69%, P<0.001), had hereditary thoracic aortic disease (53% vs. 6%, <0.0001), and had fewer comorbidities (COPD, CKD Stage greater than 3b, diabetes, coronary artery disease; all P<0.002). Median aortic root diameter prior to procedure was 40(IQR 36-44)mm in non-ARR group while that of ARR group was 54(IQR 48-65)mm. Aortic clamp time (95min vs 151min, P<0.001) and cardiopulmonary bypass time (150min vs. 198min, P<0.001) were shorter in non-ARR group but circulatory arrest time were longer (27min vs. 20min, P<0.001). Operative mortality was similar in 2 groups (non-ARR 13% vs. ARR 14%, P<0.804). Re-exploration for bleeding was significantly less in non-ARR (3% vs. 11%, P<0.008). In non-ARR group, 9 patients developed severe aortic insuhciency during follow-up and 12 patients had dilation of aortic root >50mm (of 12, 6 had severe AI) All the 9 severe AI underwent proximal re-intervention. There were 8 patients who did not have severe AI underwent proximal intervention at the time of redo total arch replacement with elephant trunk to prepare for distal intervention. There was no aortic root rupture. Reintervention-free survival was similar in 2 groups (10-year, non-ARR 52.2% ± 3.3% vs. ARR 59.1% ± 10.6% vs.).
Conclusions:
Patients without ARR were older and had more comorbidities. In acute type A aortic
dissection, aortic root conservation may be performed with reasonable early and late result.
Authors
Yuki Ikeno (1), Akiko Tanaka (1), Alexander Mills (1), Lucas Ribe (1), Harleen Sandhu (1), Charles Miller (1), VIACHESLAV BOBOVNIKOV (1), steven eisenberg (1), Anthony Estrera (1)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX
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Poster Presenter
Akiko Tanaka, Memorial Hermann Heart and Vascular Institute
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Houston, TX
United States
Objective:
Acute Type A aortic dissections remain a devastating and life limiting pathology. Although modifications in surgical technique and perioperative care have significantly improved short-term morbidity and mortality, patients remain at high risk of long-term complications related to residual dissection, with up to 47% of patients requiring procedural re-intervention. Furthermore, there is significant variability in both index operative management and post-operative surveillance due to the heterogenous pathologic spectrum of disease. Management of the aortic root exemplifies this variability. Depending on patient and surgeon specific factors, preferences range from conservative preservation of the native root, to complete replacement of both the valve and aortic root (in addition to the myriad of options in between). Current literature suggests that both provide viable short-term outcomes, and further suggests that replacing a root decreases likelihood of future replacement. However, it is unknown if it provides any benefit in avoiding degeneration of distal pathology. Our goal was to evaluate freedom from all re-operation, including distal intervention, of patients who were treated for type A dissection based on index root treatment.
Methods: We performed a single center retrospective review of patients who presented with initial type A dissection without previous aortic pathology at our institution. Patient records were reviewed to determine freedom from re-operation, with re-operation defined as repeat aortic root, arch, or distal intervention, or if no re-operation occurred, furthest stable imaging from initial surgery. Aortic root replacement procedures included Davids, Bentalls, Biobentalls, and Freestyle grafts, while non-root replacement consisted of aortic valve resuspension. The freedom from re-operation analysis between the two groups was performed with Kaplan-Meier analysis with corresponding log-rank test and corresponding hazard ratios.
Results: 200 patients from 2009-2021 were included in our analysis, with median follow-up time of 390 days. Patients who underwent root replacement at the time of index surgery had higher freedom from re-operation with 2-year and 4-year freedom of 95% and 91% respectively, when compared to those who did not have root replacement (Plog-rank = 0.005, HR = 2.8 (95%CI: 1.2 – 6.3)) with 2- and 4-year freedom from re-operation of 71% and 60% respectively (Figure 1A). Considering re-operation requiring only arch-distal re-intervention as the clinical event, patients who underwent root replacement at the time of index surgery had higher freedom from re-operation with 2-year and 4-year freedom of 97% and 92% respectively, when compared to those who did not have root replacement (Plog-rank = 0.014, HR = 2.8 (95%Ci 1.3 – 5.6)) with 2- and 4-year freedom from re-operation of 77% and 67% respectively (Figure 1B).
Conclusion
Our findings suggest that aortic root replacement is protective from re-operation for arch and distal aortic pathology. This finding advocates for a more aggressive approach to the aortic root at initial intervention when possible. Further investigation is required to understand changes in pathology and physiologic alterations in flow that may contribute to this finding.
Authors
Adam Carroll (1), Michal Schafer (1), Robert King (1), Zihan Feng (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective: While use of stentless aortic bioprosthesis has become increasingly common particularly in an academic setting, there has been no comprehensive analysis of the outcomes in a large volume community hospital. Through this study, we hope to provide insight into outcomes of this procedure in a non-academic medical center setting.
Methods: This study included all patients at least 18 years of age, undergoing aortic root replacement using stentless valve from 1985 to 2021. Data were retrospectively extracted from a prospectively maintained cardiac surgical database. Stentless aortic root replacement was performed via standard median sternotomy. Baseline characteristics and operative characteristics are presented as means ± standard deviation for continuous and parametric variables, and percentage (frequency) for categorical variables. Primary outcome is 30-day mortality. Secondary outcome includes complications such as stroke, deep sternal wound infection, re-exploration for mediastinal bleeding, postoperative sepsis, pulmonary ventilation > 24 hours, pneumonia, renal failure requiring dialysis, new-onset atrial fibrillation, new pacemaker and blood products transfused. Patients were followed immediate postoperative, then 1 month, 3 month, 6 month and yearly up to 17 years with echocardiography. Logistic regression analysis was performed to assess the impact of various factors on 30-day mortality, utilizing a stepwise model to select only the variables that significant impact death rate (p < 0.2).
Results: A total of 326 patients who underwent aortic root replacement using the stentless valve were included in the study. 69 patients (21.17%) had prior cardiac or valve surgery. 132 operations (40.49%) were performed with urgent or emergent status. The mean cardiopulmonary bypass time for all patients was 227.88 ± 92.85 minutes. The mean cross-clamp time for all patients was 169.12 ± 64.72 minutes. The overall 30-day mortality was 14.72%, but that for elective case was 7.22%. For patients who underwent root replacement only without concomitant procedures, the overall 30-day mortality was 6.45% and that for elective cases was 4.55%. The most common postoperative morbidity was atrial fibrillation, with an incidence of 35.28% in overall group and 33.51% in elective group. Immediate postoperative, 1 month, 3 month, 6 month, then yearly follow-up transvalvular mean gradients were 10.11, 7.36, 6.83, 5.49, 7.59 mmHg respectively. Logistic regression analysis performed to assess the impact of various factors on 30-day mortality showed that cardiopulmonary bypass time, cross-clamp time, re-exploration for mediastinal bleeding, renal failure requiring dialysis, new-onset atrial fibrillation and concomitant Cabrol procedure placed a significant role in affecting the 30-day mortality.
Conclusions: Aortic root replacement with stentless xenografts represents a significant advancement in cardiac surgery. Their superior hemodynamic performance, favorable clinical outcomes, long-term durability, and expanding applications make them a valuable option for patients requiring aortic root replacement despite the increased technical aspects of the operation. Favorable outcomes can be achieved even in non-academic community hospitals with aortic root replacement.
Authors
Jinman Cai (1), Mamata Tokala (1), W. Scott Arnold (1), Joseph Baker (1), David Wyatt (1), Joseph Rowe (1), Cynthia Choate (1), Mark Joseph (1)
Institutions
(1) Virginia Tech Carilion School of Medicine, Roanoke, VA
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Poster Presenter
Jinman Cai, Carilion Roanoke Memorial Hospital
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VA
United States
BACKGROUND: Right anterolateral thoracotomy, known for being a minimally invasive surgical approach, has been effectively and safely used for isolated aortic valve replacement. However, its application in aortic root surgery is not as common, with limited cases reported in medical literature. The purpose of this study is to evaluate the immediate outcomes of aortic root surgeries performed using the right anterolateral minithoracotomy approach.
METHODS: This observational descriptive study analyzed seven patients with aortic root pathologies who underwent surgery through right anterolateral minithoracotomy at our institution from 2021 to 2022. Each patient's results were evaluated sequentially.
RESULTS: The cohort included two women (28.6%) and five men (71.4%), aged 25 to 67 years (mean = 33.6 ± 13.09). Surgeries performed included aortic valve reimplantation (David procedure) in four patients, aortic valve and root replacement (Bentall de Bono operation) in two patients (one with a biological valve prosthesis), and a combination of aortic valve replacement and supracoronary aortic replacement in one patient. Two patients had a hemiarch prosthesis with open distal anastomosis and antegrade bilateral brain perfusion. Aortic occlusion times ranged from 110 to 228 minutes (mean = 166.5 ± 36.70), cardiopulmonary bypass from 155 to 470 minutes (mean = 252.7 ± 102.94), ICU stays from 1 to 6 days (mean = 2.2 ± 1.94), and hospital stays from 7 to 27 days (mean = 17.2 ± 7.05). Complications included a left-sided pneumothorax in one patient, bilateral polysegmental pneumonia in another, and one early postoperative death due to intraoperative right coronary artery dissection.
CONCLUSIONS: This case series suggests that aortic root reconstruction via right anterolateral minithoracotomy can be safely and effectively performed. However, this approach requires a longer learning curve and preparation time for surgeons. Further studies with a larger patient sample and a control group using standard or minimally invasive sternotomy are recommended for more comprehensive evaluations.
Authors
Anastasiia Karadzha (1), Alexander Bogachev-Prokophiev (1), Ravil Sharifulin (1)
Institutions
(1) E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
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Poster Presenter
Anastasiia Karadzha, Mayo Clinic (Rochester, MN)
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Rochester, MN
United States
Objective
Aortic surgery is a complex and critical procedure that requires specialized skills, advanced technology, and a well-equipped healthcare system. While developed countries have established centers of excellence for aortic surgery, the situation is different in developing countries. Limited resources, inadequate infrastructure, and a lack of trained professionals pose significant challenges in providing high-quality aortic surgery. However, private hospitals in developing countries can play a crucial role in bridging this gap and improving access to aortic surgery for patients in need.
Case Video Summary
In almost 2 years, we have dealt with a total of 15 cases of aortic disease, undergoing aortic surgery and endovascular procedures. We collaborate with our cardiologist and emergency department to diagnose the aortic disease. With the support of our radiologists and their imaging technology, we can identify cases like aortic aneurysms, aortic dissection type A and B, penetrating aortic ulcer, intramural hematoma, and pericardial effusion with acute aortic dissection. Our team tried to give the best they could to perform aortic surgery even though they lacked knowledge at the beginning but after a lot of discussion and learning together we became a solid team. We have performed 12 cases of aortic surgery, including Bentall procedure, total arch replacement, hemiarch replacement, root sparing, and ascending replacement. The remaining 3 cases undergoing endovascular procedure was aortic aneurysm and aortic dissection type B with symptom.
Conclusion
Aortic surgery in developing countries faces significant challenges, but private hospitals can play a crucial role in overcoming these obstacles. By investing in infrastructure, attracting skilled professionals, forming collaborations, and improving access and affordability, private hospitals can contribute to the development of aortic surgery services. Through these efforts, patients in developing countries can receive timely and high-quality care, reducing morbidity and mortality rates associated with aortic conditions. It is imperative that governments, healthcare organizations, and international stakeholders recognize the potential of private hospitals and work together to strengthen aortic surgery services in developing countries.
Authors
Maulidya Ayudika Dandanah (1), Dicky Aligheri Wartono (2), Budhi Adhiwidjaja (3)
Institutions
(1) Siloam Lippo Village, UPN Medical Faculty, Jakarta, Indonesia, (2) Siloam Lippo Village, Harapan Kita National Cardiovascular Center, Jakarta, Indonesia, (3) Siloam Lippo Village, Jakarta, Indonesia
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Poster Presenter
Maulidya Ayudika Dandanah
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Kabupaten tangerang, banten
Indonesia
Objective: Valve-preserving root replacement aims at normalizing valve form through restoration of root dimensions. In patients with aortic root aneurysm, the cusps may change in size and shape due to stress imposed by root dilatation. The purpose of this study was to quantify the differences in cusp size and shape in patients with normal and dilated tricuspid aortic roots and in dilated roots with or without aortic regurgitation.
Methods: Retrospective analysis of computed tomography studies in patients with normal and dilated tricuspid aortic roots was performed. Normal root size was defined as sinuses of Valsalva diameter less than 40 mm, dilated root as diameter equal or larger than 45 mm. Aortic root and aortic valve cusp measurements were analyzed to assess the size. Root measurements normalized to basal ring diameter and cusp measurements normalized to geometric height were analyzed to assess the shape of the root and the cusps. Additionally, comparison of dilated roots with or without aortic regurgitation was made.
Results: We analyzed 146 normal and 104 dilated aortic roots and 73 propensity-matched pairs. Dilated roots were larger in all measured dimensions and had a different shape, with increased ratio between commissural and basal ring diameter (1.58 (SD 0.23) vs. 1.11 (SD 0.10), p<0.001) and higher normalized root height (0.92 (SD 0.11) vs. 0.79 (SD 0.07), p<0.001). Cusps in dilated roots were bigger in all measured dimensions (cusp insertion, geometric height, estimated free margin length). The shape of the cusps was elongated with increased normalized cusp insertion length (3.64 (SD 0.39) vs. 3.26 (SD 0.20), p<0.001) and normalized free margin length (2.53 (SD 0.30) vs. 2.16 (SD 0.19), p<0.001). The effective cusp height was higher in dilated roots (13.6 mm (IQR 2.9 mm) vs. 8.7 mm (IQR 1.6 mm), p<0.001). Multivariable linear regression model with geometric height as the dependent variable was constructed using all (unmatched) patient data (adjusted R2 = 0.847). Commissural diameter was the strongest positive predictor of cusp geometric height, followed by basal ring diameter, body height and male gender. Age had a small negative correlation with geometric height. In the dilated root group, we selected patients without any cusp prolapse (n = 83) and compared patients with no or mild (grade 0-1) versus moderate to severe (grade 2-4) aortic regurgitation. The commissural diameter and effective cusp height were significantly larger in patients with aortic regurgitation, however the cusp dimensions were similar in both groups.
Conclusions: In the dilated roots most of the dilatation occurred at the level of the sinuses of Valsalva and the commissures, and it was associated with mild root elongation. The cusps in dilated roots were elongated transversely (increasing free margin lengths and cusp insertion length) and to a lesser degree radially (increasing the cusp geometric height). The most important predictor of cusp geometric height was commissural diameter, which was significantly larger in dilated roots. In patients with dilated roots and no cusp prolapse the functional aortic regurgitation was caused by extensive commissural dilatation and not by inadequate cusp growth. Thus, marked changes of cusp dimensions exist in correlation with root size which will have to be accommodated in valve-preserving surgery to produce normal aortic valve form.
Authors
Matija Jelenc (1), Blaž Jelenc (2), Sara Habjan (1), Thomas Foley (3), Peter Fries (4), Hector Michelena (3), Hans-Joachim Schäfers (4)
Institutions
(1) University Medical Center Ljubljana, Slovenia, (2) University of Ljubljana, Slovenia, (3) Mayo Clinic, Rochester, Minnesota, United States, (4) Saarland University Medical Centre, Homburg/Saar, Germany
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Poster Presenter
Matija Jelenc
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Ljubljana
Slovenia
Objectives: Identify factors associated with selection of bioprosthetic or mechanical aortic valve replacement (AVR) at the time of acute type A dissection repair, risk factors for long-term outcomes, and differentiating risk factors of late mortality.
Methods: From 2000 to 2022, 1,311 patients underwent acute type A dissection repair, with 345 (26%) requiring AVR with either a bioprosthetic (N=289, 84%; age 64±14 years) or mechanical (N=56, 16%; age 47±12 years) valve. Multivariable logistic regression identified factors associated with bioprosthetic versus mechanical AVR selection. Risk factors for time-related all-cause mortality were identified by multiphase hazard modeling for each AVR group.
Results: Frequency of mechanical AVR decreased over time while bioprosthetic replacement increased. Factors associated with bioprosthetic valve selection were older age, more recent surgery, total arch replacement, DeBakey type I dissection, concomitant coronary artery bypass grafting (CABG), diabetes, hypertension, and heart failure. Mechanical valve selection was associated with bicuspid aortic valve, Marfan syndrome, aortic root aneurysm, and concomitant root replacement (Figure 1A). Freedom from reoperation after bioprosthetic AVR at 1, 5, and 10 years was 92%, 82%, and 67% respectively; survival was 67%, 47%, and 24% at 5, 10, and 15 years. Freedom from reoperation after mechanical valve AVR at 1, 5, and 10 years was 95%, 81%, and 70%; survival was 83%, 66%, and 60% at 5, 10, and 15 years (Figure 1B). Among those receiving bioprosthetic valves, malperfusion (P<.001) and greater number of surgical components (P<.01) were risk factors for early mortality; older age (P<.001) and preoperative kidney injury (P<.0001) for late mortality. Among those who received mechanical valves, greater number of surgical components (P<.001), concomitant CABG (P<.01), and chronic pulmonary disease (P=.02) were risk factors for late mortality.
Conclusion: Survival is primarily influenced by age, preoperative complications, and preexisting comorbidities. Factors guiding valve selection in the setting of acute type A dissection are distinct. Mechanical valves have been reserved for patients under age 50 years and those with genetic aortopathies; bioprosthetic valve replacement has been favored for all others. This valve choice should be made preoperatively, with consideration for shared decision making, without concern for valve-associated mortality.
Authors
Brad Rosinski (1), Benjamin Kramer (2), Ashley Lowry (3), Matthew Thompson (4), Rohun Bhagat (1), Marijan koprivanac (5), Patrick Vargo (6), Faisal Bakaeen (1), Eugene Blackstone (1), Lars Svensson (1), Eric Roselli (1)
Institutions
(1) Cleveland Clinic, Cleveland, OH, (2) Cleveland Clinic, United States, (3) Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, OH, (4) Cleveland Clinic, Lakewood, OH, (5) N/A, cleveland heights, OH, (6) Cleveland Clinic, Cleveland, Ohio
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Poster Presenter
Bradley Rosinski, Cleveland Clinic
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Avon, OH
United States
Objective: Despite a voluminous literature on the aorta in health and disease, relatively little has been written about the lamellar architecture constituting the aortic wall. In this study, we provide a histological overview of the lamellar organization of the developing aorta in individuals with a tricuspid aortic valve (TAV). We further have undertaken literature review to elucidate (1) the number of aortic wall lamellae in various animals, as well (2) in (adult) humans, the number of aortic lamellar layers, and the decrement in lamellar layers in proceeding distally along the course of the aorta.
Methods: Non-dilated (n=60) ascending aortic wall samples were collected (embryonic–70 years of age), categorized in eight age groups. On PubMed we queried the following search terms: "aortic lamellar layers", "lamellar layers in ascending aorta", "lamellar layers in descending aorta", "extracellular matrix", "elastin", "vascular smooth muscle cells". This yielded 287 articles pertinent to our quest, which were reviewed in detail. Only five of these articles contained estimations of lamellar counts.
Results: Our study demonstrated that in the premature aorta, the medial layer consists of neatly organized elastic lamellae without pathological features such as elastic fiber thinning, fragmentation, or degeneration, whereas in the adult aorta progressive elastic fiber pathology is seen resulting in decreased aortic wall strength. A significant difference in the number of lamellae is further seen between the various age categories (figure 1). The neonate group contains the lowest number of lamellae, which increases significantly till the age of 6 years (p<0.01). In adolescence a slight decrease in the number of lamellae is observed (p = 0.049), and a further decrease is seen in the adult group (p=0.018) (figure 1).
Our literature review revealed: (A) Animals The number of lamellar units in mammals is closely proportional to the aortic radius, which itself is proportional to the animal body size: The smaller the mammal, the fewer the lamellar layers. (B) Humans The first published studies in humans estimated a thickness of 53 to 78 lamellar layers in the ascending thoracic segment of the aorta. Additional studies reported thoracic aortic lamellar counts ranging from 45 to 56. For the abdominal aorta, recent studies have disclosed about 28 layers. Thus, the lamellar count decreases as one descends the human aorta.
Conclusion: Dedicated studies on lamellar number in phylogeny is scant. Dedicated studies on number and progression of aortic lamellar layers with aging are also scant. Nonetheless, our study on the lamellar architecture in human aortic tissue and literature review supports the following conclusions: (1) In phylogeny, number of aortic layers increases proportionately with animal body size. (2) In human children, the number of lamellae increases progressively until age 6. (3) Adult human aortas carry approximately 50 to 75 lamellar layers. (4) In humans, lamellar layers decrease slowly but progressively from adulthood to old age, which in combination with progressive lamellar pathology likely contributes to the enhanced adverse event rate in the elderly.
Authors
Mohammad Zafar (1), Nicole Kargin (2), Bulat Ziganshin (1), Nimrat Grewal (3), John Elefteriades (1)
Institutions
(1) Yale New Haven Hospital, New Haven, CT, (2) Aortic Institute, New Haven, CT, (3) Amsterdam UMC, Amsterdam, NA
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Poster Presenter
Nicole Kargin, Yale University
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Trumbull, CT
United States
Objective
Perioperative stroke is one of the most important complications of acute type A dissection surgery. We have been performing extra-anatomical aorto-carotid bypass in selected patients with static obstruction of the carotid artery with clinical signs of neurological deficit or marked intraoperative cerebral hypoxia without signs of cerebral edema. Mainly two situations, preoperative transient ischemic attack and intra-operative drop of regional oxygen saturation of the brain fit the principle.
Case Video Summary
The presented case was a 67 year old female. She was brought to our hospital 2 hours after the onset of backpain and weakness in the left lower limb. She opened her eyes and was able to tell her name. Computed tomography images showed 90% of static obstruction of the right catotid artery. The left external iliac artery was blocked.
Since this patient was neurologically intact, we planned usual central repair with exposure of the right neck in case. Pre-sternotomy carotid artery echo showed forward blood flow in the narrow true lumen. We did usual arch replacement with selective cerebral perfusion via the callulae for three vessels, which is the routine ajunctive methods in our institution. After completing the anastomosis to the brachiocepharic artery, there was a marked drop of regional oxygen saturation (RSO2) on the right forehead. The right carotid artery was exposed and echo showed that true lumen was completely blocked. We cut the adventitia and evacuated thrombus from the false lumen. There was some forward blood flow detected by echo. However, the saturation did not improve. We then cut the true lumen and confirmed the forward flow. We replaced a short part of the carotid artery. The saturation did not improve. We finally decided to do extra-anatomical bypass. After the completion the brain saturation markedly improved in the right side as well as some improvement in the left side.
We have been doing this procedure for five cases until the end of 2021 and having good results.
Conclusion
We consider Aorto-carotid bypass at the time of Central repair of Acute type A dissection may be useful to prevent perioperative stroke in some cases.
Authors
Tomonobu Abe (1), Wataru Tatsuishi (2), Yasunobu Konishi (2), Atsushi Oi (2), Yuya Nozawa (2)
Institutions
(1) Gunma University, Japan, (2) Gunma University, Maebashi, NA
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Poster Presenter
Tomonobu Abe
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Maebashi, Gunma
Japan
Approaching a Brachiocephalic Artery Aneurysm with Porcelain Aorta: How I do it
German J. Chaud; Joaquín Gundelach; Marcos Durand; Pablo Filippa; Jaime Horta; Carolina González; Gustavo Merino
Hospital Las Higueras, Talcahuano, Concepcion, Chile.
Objective: To show our institutional approach for patients with brachiocephalic aneurysm and porcelain aorta.
Case Video Summary: A 51-year-old male patient was transferred to our clinic from a rural area because of a pulsatile mass in the neck. Personal background includes a severe smoking habit and a STEMI event a few months before treated with a drug eluting stent in the main trunk. CT angiogram revealed a 48 mm aneurysm of the brachiocephalic arterial trunk partially thrombosed and a porcelain aorta including ascending and aortic arch portions. Aortic root was measured at 44 mm. TTE demonstrated good LVEF and severe aortic insufficiency with central jet due to annular dilatation. Coronary angiogram revealed severe main trunk stenosis because of calcium progression.
How I Do It:
●Cannulation strategy: A right supraclavicular incision with exposure of the right subclavian and the common right carotid artery was performed, and the latter was cannulated with a 12 Fr arterial cannula (Quebec method). After full sternotomy, central arterial cannulation was performed in zones 1.
●CPB and cerebral perfusion strategy: After CPB was initiated, patient was cooled at 26°C. Meanwhile, left carotid artery was ligated and an end-to-end anastomosis was carried out with a trifurcated Dacron graft. ●Aortic replacement: At 26°C, antegrade Del Nido cardioplegia was infused by retroplegia and completed in the right coronary ostia. Once in circulatory arrest, the brain was perfused by both carotids, the braquicephalic trunk was resected leaving a common trunk for a later anastomosis. The aorta was also resected from zone 1 in the arch until de sinotubular junction proximally. After aortic resection, significant amount of calcium protrudes like cauliflower from the intima. The aorta was then replaced distally with a 30 mm straight dacron graft, with 4-0 pledgeted suture and "U" reinforcements in the back wall. Subsequently, an aortic cannula was placed in the graft, systemic CPB and rewarming was started.
●Root treatment: Because of moderate dilatation mainly in the non-coronary sinus and severe calcification of both coronary ostiums, aortic root was preserved and a standard AVR with a 25 mm Magna Ease was executed.
●Completion of Aortic replacement: Proximal aortic graft anastomosis was accomplished with a 4-0 running prolene and was reinforced with teflon felt. Once the Aortic cross clamp was released we performed an end-to-end anastomosis of our now bifurcated graft with the remaining brachiocephalic arterial trunk. Finally, by partially clamping the straight aortic tube, proximal anastomosis of the bifurcated graft was constructed, concluding the procedure once the cerebral circulation was unclamped through the carotid artery.
●Coronary artery stenosis: while rewarming, severe anterolateral ventricular hypokinesia was found in TEE. An internal saphenous vein was harvested and a coronary bypass was performed to the left anterior descending artery, showing resolution of wall abnormality. Conclusion: This case represents several challenges in decision making, cannulation strategy, cerebral as well as myocardial protection, and root treatment in a in a patient with porcelain aorta.
Authors
German Chaud (1), JOAQUIN GUNDELACH (2), Pablo Filippa (3), Jaime Horta (4), gustavo Meriño (4), Marcos Durand (4), carolina gonzalez (4)
Institutions
(1) Hospital las higueras, Tacahuano, Concepcion, (2) LAS HIGUERAS, CONCEPCION, Chile, (3) CHU Sainte Justine, Montréal, QC, (4) Hospital las Higueras, Talcahuano, concepcion, BI
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Poster Presenter
German Chaud, Hospital Las Higueras
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Concepcion
Chile
Objective: The aim of this study was to summarize our experience with a systematic approach to reduce blood transfusions in acute type A aortic dissection (ATAAD) surgery.
Methods: From August 2016 to June 2020, 326 patients underwent ATAAD surgery in our center using a systematic approach, which mainly included the following: Liu's aortic root repair technique, Liu's aortic arch inclusion technique with frozen elephant trunk, moderate to mild hypothermia circulatory arrest, and application of centrifugal pump in cardiopulmonary bypass circuit. Patients were divided into two groups according to whether they had blood product transfusion during their hospital stay: transfusion group and bloodless group. Perioperative outcomes were compared between two groups.
Results: 152 patients were included in the transfusion group and 174 patients in the bloodless group; the bloodless rate was 53.37%. Overall in-hospital mortality was 5.21% (17/326), with 3 mortalities (1.72%) in the bloodless group and 14 mortalities (9.21%) in the transfusion group (P=0.0025). The transfusion group had significantly more MODS, sepsis and tracheotomy, and longer intensive care unit stays. Hb levels of patients between the two groups were similar at tested time points.
Conclusions: With the implementation of systematic approach, bloodless ATAAD surgery can be achieved and safely applied in ATAAD patients.
Authors
kexiang liu (1), Cuilin Zhu (2)
Institutions
(1) N/A, Jilin, Jilin, (2) the Second Hospital of Jilin University, China, Jilin Province
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Poster Presenter
Kexiang Liu, Second Hospital of Jilin University
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Jilin, Jilin
China
OBJECTIVES: The optimal method for arterial cannulation in acute type A aortic dissection (TAAD) remains controversial. This study aimed to conduct a network meta-analysis to compare the clinical outcomes of the four most common cannulation strategies: single cannulation of the femoral artery (FA), axillary/subclavian artery (ASA), ascending aorta (AA), or dual arterial cannulation (DAC) with FA and ASA cannulations.
METHODS: Medline was searched in October 2023 to identify comparative studies reporting the clinical outcomes of different arterial cannulation strategies for TAAD. The outcomes of interest were perioperative mortality, stroke, spinal cord injury, reoperation for bleeding, renal failure requiring hemodialysis, and visceral malperfusion. Sensitivity analysis was conducted by limiting the studies with adjusted outcomes.
RESULTS: Overall, a total of 26 observational studies were identified, including 8,555 patients who underwent surgery for TAAD via AA (n =2,185), DAC (n =954), ASA (n=3425), and FA (n =1,991) cannulations. Propensity-score matching was used in 6 studies and inverse probability weighting in 2 studies. No adjustment methods were used in 18 studies. AA and ASA cannulations were associated with a significantly lower risk of perioperative mortality than FF cannulation (risk ratio [RR] [95% confidence interval [CI]] = 0.51 [0.38-0.69] and 0.69 [0.52-0.90], respectively). AA cannulation was also associated with a significantly reduced risk of reoperation for bleeding and renal failure requiring hemodialysis compared with ASA and FA cannulations. No significant differences in the rates of stroke, spinal cord injury, or visceral malperfusion were observed among the different cannulation strategies. Sensitivity analysis by limiting the studies with adjusted outcomes showed that AA cannulation was associated with decreased perioperative mortality compared to all other cannulation strategies (vs. DAC; RR [95% CI] =0.44 [0.25-0.78], vs. ASA; RR [95% CI] =0.44 [0.28-0.69], vs. FA; RR [95% CI] =0.40 [0.24-0.66]). Furthermore, ASA cannulation was associated with increased rates of spinal cord injury compared with all other cannulation strategies. The other outcomes of the sensitivity analysis were similar to the main outcomes.
CONCLUSIONS: The present network meta-analysis demonstrated that AA cannulation might be associated with favorable outcomes in terms of perioperative mortality and morbidity compared to other cannulation strategies.
Authors
Yujiro Yokoyama (1), Minami Watanabe (2), Tomohiro Fujisaki (3), Hisato Takagi (4), Toshiki Kuno (5), Shinichi Fukuhara (1)
Institutions
(1) University of Michigan, Ann Arbor, MI, (2) Leigh Valley Health Network, Allentown, PA, (3) Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, NA, (4) Shizuoka Medical Center, Shizuoka, Shizuoka, (5) Montefiore Medical Center, Bronx, NY
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Poster Presenter
Yujiro Yokoyama, University Of Michigan
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Ann Arbor, MI
United States
Background:
The 2022 AATS Aortic Guidelines indicate that for ascending aortic intramural hematoma (IMH) branch vessel involvement is an appropriate indication for surgical intervention. Not recalling branch vessel involvement by this entity, we investigated its true prevalence.
Methods:
We reviewed scans of 3055 patients in our aortic database to identify patients with ascending IMH. IMH was defined as concentric intramural hemorrhage without dissection flap or ulceration. We excluded patients with penetrating aortic ulcers (PAU) in addition to the ascending IMH. Of 628 patients with acute aortic syndromes, 22 patients with ascending IMH were identified. 19 patients with available scans meeting these criteria were identified. Their CT/MRI scans were reviewed in detail by a multi-member team with experience in interpreting such images. On contrast and non-contrast CT scans, IMH was identified as a hyper dense circular zone forming a rim around the main aortic lumen, and without a dissection flap appearing across the aortic lumen. The scans were reviewed to determine the frequency and degree of arch branch vessel occlusion.
Results:
Among the 19 patients, there were 10 females and 9 males aged 50-84 (mean age 70.3, median 71.5). The maximum ascending aortic diameter at presentation ranged from 42.7 to 59.6mm, with a mean of 50.6mm. All patients were treated with anti-impulse therapy (beta blocker and after load reduction) in an ICU setting. The IMH was limited to the ascending aorta in 5 cases and extended to the descending aorta in 14. 13 patients required surgery during the initial hospitalization, and the remainder were treated solely medically. Of those who were operated, 12 (92.3%) survived hospitalization and 1 (7.7%) died within 1 month post-operatively. Patient follow-up was 100% complete (0.1 to 22.3 years, mean 7.0). 11 patients died during follow-up. It was confirmed that 0 patients died directly of rupture. Of the IMHs in the discharged patients, 3 resolved spontaneously within 1.5-4 months and 0 progressed to typical aortic dissection. 0 of the total 19 patients manifested involvement of the great vessels, including innominate, left carotid, left subclavian. For all observed cases, blood flow to the great vessels was unimpaired.
Conclusion:
Branch vessel involvement from ascending IMH seems a rare phenomenon. If experience from other institutions is found to be similar, the surgical stipulation in the Guidelines may not be necessary.
Authors
Sanya Abbasey (1), Asanish Kalyanasundaram (2), John Elefteriades (2), Mohammad Zafar (2)
Institutions
(1) Yale University, New Haven, CT, (2) Yale New Haven Hospital, New Haven, CT
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Poster Presenter
Sanya Abbasey
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CT
United States
Objective: To evaluate outcomes of patients presenting with Type-A aortic dissection and identify patient characteristics associated with better or worse outcomes.
Methods: Cases over the past 10 years in our database of all patients who presented with Type-A aortic dissection were reviewed and stratified by treatment: Surgical vs non-surgical. Comorbidities, presenting symptoms, and treatment outcomes were assessed. Data are hazard ratio (HR) and 95% confidence interval (CI), mean±SEM, or count[%]. P-values were determined by Chi-squared or Fischer's exact, 2-way independent T-tests, 2-way ANOVA with Tukey's post-hoc tests, and uni- and multivariable regression modeling with propensity-matched analysis.
Results: 242 (157 Males/85 Females) patients presented with Type-A aortic dissection. Of these, 50 patients had prohibitive risks, and surgery was not offered. 192 patients underwent surgery and 174[91%] patients achieved 30-day survival (9% mortality). Within the surgical cohort, patient's age ≥72 years, history of prior cardiac surgery, chronic kidney disease, anticoagulant use, and myocardial infarction at time of presentation were all associated with increased mortality. Intraoperatively, shorter X-clamp time (≤121±4.3min) and cerebral perfusion time (≤36.4±1.7min) promoted better survival. Conversely, intraoperative transfusion of >2units pRBC carried a 44% increased risk of mortality. Post-operatively, patients experiencing bleeding had worse outcomes, and patients experiencing cardiogenic shock carried a 2.4 times increased risk of mortality. Within the non-surgical cohort, 14[28%] patients achieved 30-day survival (72% mortality). Non-surgical patients presenting with a stroke or history of heart failure demonstrated greater 30-day mortality. Notably, male sex was protective as males had lower mortality (36% mortality) vs female patients (64% mortality, p=0.053).
Conclusions: Emergent surgery is a life-saving treatment for Type-A aortic dissection in select patients, decreasing risk of mortality with excellent outcomes. Pre-operative comorbidities and post-operative complications of bleeding and cardiogenic shock increase the risk of mortality. Overall, mortality without surgery remains very high.
Authors
Kathy Nguyen (1), Bryan Mouser (1), Arun Singhal (2), Anthony Panos (2), Kalpaj Parekh (2), Mohammad Bashir (2)
Institutions
(1) University of Iowa Carver College of Medicine, Iowa City, IA, (2) University of Iowa Hospitals and Clinics, Iowa City, IA
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Poster Presenter
Kathy Nguyen, University of Iowa Hospitals
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Tiffin, IA
United States
Purpose:
Surgical site infection carries a significant risk of increased mortality and cost. In the context of aortic surgery, there is elevated risk due to the potential necessity for multiple debridements in the case of sternal wound infection and potential graft material. We utilized logistic regression algorithms in hemiarch surgery to predict patients at risk for infection and to elucidate specific risk factors.
Methods:
We identified a total of 602 adult patients who underwent hemiarch replacement between June 2009 and October 2022 from our single institution prospectively maintained database. These patients were randomly divided into training (70%) and testing sets (30%) with various logistic regression models constructed to predict post-operative infection in the cardiothoracic intensive care unit (CTICU). From the index hospitalization data, we extracted 17 demographic and pre-operative characteristics. To assess model performance, we used multiple evaluation metrics, including accuracy, Brier score, and area under the receiver-operating characteristic curve (AUC-ROC). Furthermore, we calculated odds ratios and confidence intervals derived from the logistic regression model.
Results:
Development of post-operative infection in the CTICU was noted in 40 patients (6.64%) who underwent hemiarch replacement. The final logistic regression model demonstrated a cross-validation accuracy of 94% and was well-calibrated as evidenced by the low Brier score of 0.06. The predictor also demonstrated strong performance on the testing set, achieving an accuracy of 89%. Our best performing CTICU post-operative infection prediction model achieved an AUC-ROC of 0.71. Increased infection risk was associated with most comorbidities, particularly diabetes, a prior history of CT surgery, concomitant root replacement, and urgent/emergent procedures. Protective factors included undergoing hemiarch surgery without concomitant root replacement and elective procedures.
Conclusions:
Fine-tuned logistic regression models have the potential to provide excellent prognostic accuracy for those at risk for wound infection. Specific features elucidated by the algorithm may help to better predict those at risk for infection, which may in turn affect clinical decision making.
Authors
Adam Carroll (1), Nicolas Chanes (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective: The environmental contributions to the development of aortic aneurysms or aortic dissection are poorly understood, though emerging evidence suggests a correlation between air pollution and increased risks of various cardiovascular diseases. This study utilized a validated population-level air pollution exposure model and a national clinical database to assess the associations between long-term exposures to fine particulate matter (PM2.5), ozone, and nitrogen dioxide (NO2) - key air pollutants regulated by the US Environmental Protection Agency - and hospitalizations related to aortic aneurysms or dissections.
Methods: Annual concentration levels of PM2.5, warm-season ozone, and NO2 at 1 km2 grid cells were estimated based on three machine-learning models combined with geographically weighted regressions. Predictors encompassed satellite data, land use, meteorological, and ancillary variables. Data were aggregated from 1 km2 grid cells to ZIP codes to match the spatial resolution of hospitalization records. Hospitalization records for residents of 14 U.S. states (2000-2016) were obtained from the State Inpatient Databases (SIDs). ICD-9 (441) and ICD-10 (I-71) codes were used to identify aortic aneurysm and aortic dissection-related hospitalizations. Hospitalization rates were calculated at the ZIP code level. A multivariable linear regression model was built to estimate associations between annual air pollutant levels and hospitalization rates, adjusting for patient demographics, neighborhood-level covariates, and seasonal temperatures during summer and winter. Penalized cubic splines with up to nine degrees of freedom were used for all three pollutants to estimate nonlinear exposure-response relationships.
Results: Analysis included 338, 381 hospitalizations related to aortic aneurysm or dissection (mean age 70.8 years, 71.8% male, and 70.0% Caucasian). Average annual PM2.5, warm-season ozone, and NO2 levels were 9.2 µg/m3, 44.7 parts per billion (ppb), and 17.1 ppb, respectively. All three pollutants were associated with increased hospitalization rates, with the effects of PM2.5 and NO2 being statistically significant. PM2.5 displayed a more pronounced effect, demonstrating that each unit increase in annual exposure correlated with 16.7 additional hospitalizations (95% confidence interval: 10.5, 22.9, p < 0.001) per ten million person-years, followed by NO2, which exhibited 1.85 additional hospitalizations (95% confidence interval: 0.03-3.7, p < 0.05) per ten million person-years. A clear exposure-effect relationship was observed for PM2.5 and NO2 (Figure 1).
Conclusions: Long-term exposures to PM2.5 and NO2 are independently associated with an elevated risk of hospitalization related to aortic aneurysm or aortic dissection, with PM2.5 being a more deleterious pollutant. This study underscores the potential role of air pollution in the development or progression of aortic aneurysm/dissection.
Authors
Kanhua Yin (1), Yaguang Wei (2), Joel Schwartz (2)
Institutions
(1) Department of Surgery, University of Missouri-Kansas City, Kansas City, MO, (2) Harvard T.H. Chan School of Public Health, Boston, MA
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Poster Presenter
Kanhua Yin, University of Missouri-Kansas City School of Medicine
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Kansas City, MO
United States
Objective – Quaternary referral centers perform metachronous operations on the same (reoperations) or on different (reinterventions) aortic segments. We aimed to discern the association of metachrony to operative mortality (OM) and survival after thoracic aortic surgery.
Methods – Our cohort was our institutional series (07/1996 - 10/2023). Aortic segment classification: segment I (ascending aorta ± root), segment II (segment I + total/hemi arch), segment III (descending thoraco-abdominal aorta). In survival analysis, index operations (the 1st aortic procedures performed) were dichotomized in proximal (segment I + II) and distal (segment III). Kaplan-Meier with Log Rank test survival analysis was performed.
Results – Relevant information was available on 4500 patients (655, 14% previously operated elsewhere), who underwent 5013 aortic procedures: 2284 (45.6%) on segment I, 1642 (32.7%) on segment II, 1087 (21.7%) on segment III. OM for segment I: initial operation 10/2129 (0.5%); 1st reoperation 2/136 (1.5%), 2nd reoperation 0/18 (0.0%), 3rd reoperation 0/1 (0.0%). OM for segment II: initial operation 42/1485 (2.9%), 1st reoperation 6/131 (4.6%), 2nd reoperation 0/26 (0.0%). OM for segment III: initial operation 35/775 (4.5%), 1st reoperation 11/277 (3.8%), 2nd reoperation 0/31 (0.0%), 3rd reoperation 0/2 (0.0%), 4th reoperation 0/2 (0.0%). Of the 2473 patients undergone a segment I index operation, subsequently 4 (0.2%) had segment II, 23 (0.9%) had segments III, and 32 (1.3%) had segments II and III procedures. Of the 1301 patients undergone a segment II index operation, subsequently 5 (0.4%) had segment I and 92 (7.1%) had segment III procedures. Of the 726 patients undergone a segment III index operation, subsequently 21 (2.9%) had segment I, 52 (7.2%) had segment III, and 1 (0.1%) had segment I and II procedures. Reoperations on the proximal aorta were not associated to survival (p 0.12). Reoperations on the distal aorta were associated to decreased survival (p < 0.01). After proximal index procedure, distal reinterventions were associated to decreased survival (p < 0.01). After distal index procedure, patients who underwent proximal reintervention had an increased survival (p < 0.01).
Conclusion – Metachronous aortic procedures can be performed with low OM in a quaternary center. Of all metachronous procedures, only reinterventions on the proximal aorta after distal index operation are associated to a survival benefit.
Authors
Ivancarmine Gambardella (1), berhane worku (2), Christopher Lau (3), Robert Tranbaugh (4), Sandhya Balaram (5), Leonard Girardi (4)
Institutions
(1) Weill Cornell Medical Center, New York, NY, (2) Weil Cornell Medical College, Brooklyn, NY, (3) New York Presbyterian-Weill Cornell, New York, NY, (4) Weill Cornell Medicine, New York, NY, (5) Mount Sinai, New York, United States
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Poster Presenter
Ivancarmine Gambardella, Weill Cornell Medical Center
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New York, NY
United States
Objective: Previous studies have shown that patients with preoperative anemia undergoing cardiac surgery more commonly experience postoperative complications. We sought to determine the association of preoperative hemoglobin level with postoperative outcomes following elective aortic arch reconstruction with hemiarch replacement.
Methods: We performed a retrospective review of prospectively collected clinical data from all patients undergoing elective aortic arch reconstruction with a hemiarch replacement at a single tertiary care center from February 2010 to October 2023. Data were retrieved from the electronic medical record. Postoperative complications were defined as either the presence of Society of Thoracic Surgeons ICU morbidity or postoperative death during their index hospitalization.
Results: Four-hundred and twenty-seven patients met the inclusion criteria. Three-hundred and twenty-seven (76.6%) were male and the median age was 62.1 (IQR 50.5 – 69.6) years. Median body mass index was 27.5 (IQR 24.4 – 31.9) and 50 (11.7%) patients had a history of diabetes. Thirty-nine (9.1%) patients had a history of previous aortic surgery.
Preoperative baseline hemoglobin was 13.7 (±1.84) g/dL, platelets were 221 (±64.0) 109/L, and international normalized ratio was 1.11 (±0.202).
Postoperative outcomes are shown in Table 1.
On univariate analysis, age 65 or greater (OR 1.94, 95% CI [1.31–2.88], p = 0.001), history of diabetes (OR 2.31, 95% CI [1.26–4.39], p = 0.008), history of coronary artery disease (OR 2.06, 95% CI [1.26–3.43], p = 0.004), and a history of chronic kidney disease (OR 2.10, 95% CI [1.03–4.50], p = 0.046) were independent predictors of postoperative complications. Baseline hemoglobin (OR 0.75, 95% CI [0.66–0.85], p < 0.001), baseline platelets (OR 1.00, 95% CI [0.99–1.00], p = 0.021), age 65 or greater (OR 3.73, 95% CI [2.34–6.10], p < 0.001), diabetes (OR 2.64, 95% CI [1.26–6.21], p = 0.016), history of stroke (OR 4.58, 95% CI [1.30–29.00], p = 0.043), and a history of aortic surgery (OR 2.71, 95% CI [1.18–7.32], p = 0.029) were independent predictors of intraoperative blood product transfusion.
On multivariate analysis adjusting for baseline hemoglobin, history of renal disease, diabetes, pulmonary disease, and coronary artery disease, only age 65 or greater (OR 1.55, 95% CI [1.01–2.36], p = 0.043) remained a significant predictor of complications. Preoperative baseline hemoglobin was not a statistically significant predictor of complications (p = 0.117). On multivariate analysis, adjusting for diabetes, coronary artery disease, and stroke, only baseline hemoglobin (OR 0.80, 95% CI [0.70–0.92], p = 0.002), baseline platelets (OR 1.00, 95% CI [0.99–1.00], p = 0.041), age 65 or greater (OR 3.27, 95% CI [1.96–5.60], p < 0.001), and history of aortic surgery (OR 2.68, 95% CI [1.12–7.48], p = 0.039) were significant predictors of intraoperative transfusion.
Conclusions: Preoperative hemoglobin is not associated with postoperative complications, but is associated with intraoperative blood transfusion. This suggests that our institutional practice of optimizing intraoperative delivery of oxygen may mitigate the risks associated with anemia.
Authors
Michael Kirsch (1), Adam Carroll (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Michael Kirsch, University of Colorado Anschutz Medical Center
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Aurora, CO
United States
Objective: Previous studies have shown that patients with preoperative anemia undergoing cardiac surgery more commonly experience postoperative complications. We sought to determine the association of preoperative hemoglobin level with postoperative outcomes following elective aortic arch reconstruction with total arch replacement.
Methods: We performed a retrospective review of prospectively collected clinical data from all patients undergoing elective aortic arch reconstruction with a total arch replacement at a single tertiary care center from August 2009 to October 2023. Data were retrieved from the electronic medical record. Postoperative complications were defined as either the presence of Society of Thoracic Surgeons ICU morbidity or postoperative death during their index hospitalization.
Results: One-hundred and forty patients met the inclusion criteria and underwent elective aortic arch reconstruction with total arch replacement. Ten (7.0%) underwent Ishimaru Zone 1 replacement, 29 (20.4%) underwent Zone 2 replacement, 2 (1.4%) underwent Zone 3 replacement, 3 (2.1%) underwent Zone 4 replacement, and 97 (68.3%) underwent frozen elephant trunk replacement. 92 patients (64.8%) were male, with a median age of 61.8 (IQR 51.9 – 70.0) years. Median BMI was 27.8 (IQR 24.3 – 31.5).
Preoperative baseline hemoglobin was 13.0 (±2.01) g/dL, platelets were 209 (±61.1) 109/L, and international normalized ratio was 1.16 (±0.247).
Postoperative outcomes are shown in Table 1.
On univariate analysis, age 65 or greater (OR 3.99, 95% CI [1.87–9.10], p = 0.001), coronary artery disease (OR 6.28, 95% CI [2.05–27.45], p = 0.012), and history of pulmonary disease (OR 2.48, 95% CI [1.07–6.30], p = 0.042) were associated with postoperative complications. No preoperative factors were statistically significant predictors of intraoperative transfusion.
On multivariate analysis, adjusting for preoperative platelet count, gender, diabetes, coronary artery disease, pulmonary disease, chronic kidney disease, and history of aortic surgery, only age 65 or greater (OR 3.44, 95% CI [1.32–9.69], p = 0.014) remained a statistically significant predictor of postoperative complications.
Conclusions: Our findings indicate that preoperative hemoglobin levels were not associated with intraoperative transfusion or postoperative complications, suggesting that optimizing intraoperative oxygen delivery may mitigate the risks associated with anemia. This contrasts with previously published data, potentially due to our institution's specific practices in oxygen delivery optimization.
Authors
Michael Kirsch (1), Adam Carroll (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Michael Kirsch, University of Colorado Anschutz Medical Center
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Aurora, CO
United States
Bentall operation using Aortic homograft
Brief Summary of the video:
This video demonstrates a Bentall operation using an aortic valve homograft conduit.
The operation helps cost cutting and avoiding lifelong anticoagulation. It provides excellent haemodynamic correction with little or no bleeding problems. A homograft valve bank with sufficient supply of aortic homografts is required.
Authors
Arkalgud Sampath Kumar (1), devagourou velayoudam (2)
Institutions
(1) Retd. Prof and head, Dept of CTVS, AIIMS, Max superspeciality hospital, New Delhi, India, (2) AIIMS, New Delhi, NA
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Poster Presenter
*Arkalgud Sampath Kumar, All india institute of medical sciences, New Delhi
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NEW DELHI, Delhi
India
Objective: Bicuspid aortic valve occurs in 1-2% of the population and has been associated with aortopathy in addition to valve pathology. Guidelines regarding surgical management of bicuspid aortopathy has remained controversial with some advocating for surgical intervention earlier compared to those with tricuspid aortic valves due to an increase risk of dissection in the BAV patient. The purpose of this study is to characterize the indications and incidence of aortic dissection in BAV patients.
Methods: Over four years, 634 patients underwent either an aortic root and/or ascending replacement at a single institution. Patients were stratified based on aortic valve morphology to bicuspid aortic valve (BAV, n=190) or tricuspid aortic valve (TAV, n=444) groups. Further analysis was performed of the BAV group based on aortic indication (aneurysm vs dissection). Data was obtained from the institutional STS Adult Cardiac Surgery database and supplemented with medical record review.
Results: Patients with BAVs comprised 30% of all patients undergoing aortic root and/or ascending replacement. Patients with BAVs were younger (56 vs 61 years, p<0.0001) and had less comorbidities including hypertension, stroke, myocardial infarction, and less prior cardiac surgery. Moderate-to-severe aortic insufficiency was similar between BAV and TAV groups, while the BAV group had significantly more moderate-to-severe aortic stenosis. The primary indication for surgery differed significantly between BAV and TAV groups with the BAV group having more operations for primary valve pathology (BAV 20% vs TAV 8%, p< 0.05) while the TAV group had more operations for primary aortic pathology (BAV 51% vs TAV 72%, p< 0.05). Among the aortic indication for root/ascending replacement, the BAV group had significantly more elective cases for thoracic aortic aneurysm vs urgent/emergent cases for aortic dissections compared to the TAV group. Only 5.8% (11/190) of the BAV group had surgery for a type A aortic dissection compared to 40% (176/444) of the TAV group (p<0.0001). The BAV group did undergo surgery at smaller thoracic aortic diameters compared to the TAV group (50 vs 52 mm, p=0.001). Postoperatively, patients with BAV had better postoperative outcomes including lower in-hospital mortality (3.2% vs 7.7%, p=0.03) compared to patients with TAVs. Among BAVs, patients undergoing surgery for a type A aortic dissection had worse outcomes than those for a thoracic aortic aneurysm, including higher in-hospital mortality (27% vs 2%, p=0.003). Long-term survival was greater among the BAV group compared to the TAV group (12-year: 81% [69%, 88%] vs 58% [47%, 68%].
Conclusions: Despite only representing 1-2% of the population, patients with bicuspid aortic valves comprise almost one-third of patients undergoing root/ascending aortic replacement in a high-volume aortic center, and rarely present with acute aortic dissection. These data suggest that BAV aortopathy may not be more prone to aortic dissection than TAV patients, and do not require a lower size threshold for surgical intervention.
Authors
Elizabeth Norton (1), Ryon Arrington (2), Alan Amedi (2), Woodrow Farrington (2), Brent Keeling (2), Bradley Leshnower (3)
Institutions
(1) Emory University, Atlanta, GA, (2) Emory University School of Medicine, Atlanta, GA, (3) Emory University Hospital, Atlanta, GA
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Poster Presenter
Elizabeth Norton, Emory University School of Medicine
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Atlanta, GA
United States
Objective: We present a case of minimal access valve sparing root in one of the last victims of Polio syndrome in the USA. This 69 year old male had significant issues with mobility and muscle wasting. In view of this, he was offered minimal access surgery.
Video summary: In this video we give technical tips & tricks on how to obtain excellent exposure, and then perform a valve sparing root through a small incision.
Conclusion: At the end of the video we show the patient mobilising without issue on day 1, which was a clear benefit of the sternal sparing approach.
Authors
Omar Jarral (1), Stevan Pupovac (2), Jui-Chuan Tseng (1), Chad Kliger (1), JONATHAN HEMLI (1), Nirav Patel (1), S.Jacob Scheinerman (1), Alan Hartman (2), Derek Brinster (3)
Institutions
(1) Lenox Hill Hospital, Northwell Cardiovascular Institute, New York, NY, (2) Northshore University Hospital, Northwell Cardiovascular Institute, New York, NY, (3) Northwell Health, Lenox Hill Hospital, New York, NY
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Poster Presenter
Omar Jarral, Lenox Hill Hospital
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New York, NY
United States
Objective: We aimed to explore the utility of blood speckle imaging in assessing changes in systolic antegrade flow characteristics in a patient undergoing aortic valve-remodeling procedure.
Methods: A 20-year old patient with history of partial atrioventricular septal defect and subaortic membrane stenosis status post atrioventricular septal defect repair and subaortic membrane resection in infancy presented with progression to severe aortic root and ascending aortic dilation with moderate aortic valve regurgitation. The aortic valve was trileaflet, however, with subcommissural nodular fusion of both commissures related to the left coronary leaflet and mild leaflet thickening causing leaflet restriction. This restriction in combination with annular and sinutubular junction dilation resulted in moderate regurgitation related to the free edge of the left coronary leaflet. The patient underwent a valve-remodeling aortic root and ascending aortic replacement with 28-mm Dacron graft, including resection of subcommissural nodular fusion and leaflet thinning. Pre- and post-operative transesophageal echocardiography, including blood speckle imaging, was obtained. Hemodynamic parameters, time-averaged wall shear stress, and oscillatory shear index were derived from blood speckle imaging and compared between pre- and post-operative conditions.
Results: Pre-operative blood speckle imaging evaluation depicted an uneven jet pattern during systole across the aortic valve directed anteriorly toward the right coronary sinus wall. Postoperative blood speckle imaging evaluation demonstrated aligned laminar blood flow during systole in the left ventricular outflow tract and through the aortic valve (Figure 1). In addition, there was reduced oscillatory shear index, indicating diminished endothelial alterations in the aortic wall structure. Color Doppler evaluation demonstrated improvement from moderate to trivial regurgitation.
Conclusions: This case study highlights the additive value of blood speckle imaging in illuminating detailed flow characteristics in those undergoing aortic valve-remodeling procedures. Blood speckle imaging provides additional insights into the spatiotemporally varying flow in the left ventricular outflow tract and aorta. This may offer valuable insight into the short and long-term durability of repair beyond traditional echocardiographic parameters. Larger studies are necessary to validate these findings and determine their insight into predicting long-term durable repair.
Authors
Justin Tretter (1), Elias Sundstrom (2), Lama Dakik (1), Debkalpa Goswami (1), Hani Najm (1)
Institutions
(1) Cleveland Clinic, Cleveland, OH, (2) KTH Royal Institute of Technology, Stockholm, NA
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Poster Presenter
Lama Dakik, Cleveland Clinic Foundation
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Cleveland, OH
United States
Objective: To evaluate whether branch first aortic arch replacement leads to improved outcomes in patients undergoing emergency or elective surgery for acute or chronic aortic pathology. This technique avoids total body circulatory arrest and profound hypothermia, resulting in excellent long-term survival, lower neurological and other end organ complications/dysfunction.
Methods: A single surgeon experience of branch first aortic arch replacement from December 2014 to December 2023 at a cardiothoracic unit in Wellington, New Zealand. Branch first arch replacement was introduced in Wellington in 2014. Total of 84 cases was performed by one surgeon in this period. The first four years a total of 62 patients underwent branch first aortic arch replacement in the unit with one surgeon performing 49 of those. The next 5 years saw the unit performing 78 branch first cases with one surgeon performing 35 of those. This highlights the safety and reproducibility of the technique as it was widely adopted in the unit by other surgeons. Each case is performed in an identical manner with establishing central or peripheral CPB and performing sequential disconnection and reconstruction of arch vessels from innominate artery to the left subclavian artery using a modified trifurcation dacron graft with a perfusing side arm port which is used for antegrade cerebral perfusion. During this sequential debranching, perfusion to the heart and distal organs is maintained. Once the proximal and distal aortic anastomosis is completed, the common stem of the trifurcation graft is anastomosed to the neo ascending aorta. In this series, the mean age was 61.9 (range 19- 84 years). Fourty five cases (53.6%) were of an urgent/emergency status for acute aortic syndrome, the remaining cases were performed for enlarging aneurysms or for chronic type B dissections that required debranching of the arch to allow for a safe TEVAR landing zone. Fifteen patients (17.8%) underwent a redo operation.
Results: There were six mortalities (7.1%), all in the emergency group with no elective mortality. 2 patients (2.3%) had a post operative stroke. Six patients (7.1%) returned to theatre for either bleeding, wound closure or pleural space wash out. One patient (1.1%) required an intra-aortic balloon pump and six patients (7.1%) required haemo-filtration for renal support.
Conclusion: The branch first aortic arch replacement enables us to treat the full extent of the diseased aorta. By maintaining continuous antegrade cerebral perfusion, shortening the distal body circulatory arrest time, cardiac ischaemic time and by avoiding profound hypothermia, the patient outcomes are close to being comparable to results of ascending aorta and root surgery. It has excellent long term outcomes and is a durable, reproducible and safe technique.
Authors
Nikhil Chandra (1), Kamaraj Radhakrishnan (1), Sean Galvin (2)
Institutions
(1) Wellington Regional Hospital, Wellington, New Zealand, (2) Victoria University / University Otago, Wellington, New Zealand
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Poster Presenter
Nikhil Chandra, Wellington Hospital
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New Zealand
Objectives
This abstract provides a roadmap for launching a successful Ross procedure surgical program with focus on the logistics of team building and streamlining patient management to mitigate the impact of a steep learning curve on surgical outcomes.
Methods
This is a narrative description of a division's experience with the initiation of a surgical program dedicated to performing Ross procedure. We describe the process and provide tips that we believe have contributed to the success of the program.
Results
Surgical Training: The program was initiated by two experienced surgeons with experience in aortic root surgery and with defined goals for a successful program. A list of potential patients was developed. The surgeons attended a formal training course at a center of excellence in Ross procedures. This course was comprised of dedicated lectures, wet lab sessions, and live surgery observation. Surgeons participated in other wet labs, including one on the morning before performing their first case, aided by a proctoring surgeon with Ross procedure expertise. Two attending surgeons worked together in all cases and three other surgeons were added as the program grew to form a core group.
Patient Selection: A patient selection pathway with specific eligibility criteria was established and distributed among all cardiac surgeons and referring cardiologists to ensure the capture of potential Ross procedure candidates.
Standardized Procedure: Efforts were made to standardize all aspects of the surgery. On the day of surgery, team members (including surgeons, anaesthesiologists, scrub nurses, and perfusionist) participated in a comprehensive team huddle to discuss the technical details of the planned procedure and any potential variations.
Postoperative Care: An internal standardized order set was used to ensure that all members of the intensive care team managed these patients in a cohesive manner. This included specific instructions on fluid management, inotropic/vasopressor support, and target blood pressure in the immediate postoperative period.
Follow-up: All Ross patients are captured in an institutional database, including clinical and radiological parameters for all patients. A dedicated nurse practitioner was designated to provide regular contact with patients after discharge to ensure full adherence to strict blood pressure targets for the first 6 months after surgery.
Monitoring Outcomes: A standardized quality process was utilized to continually review surgical outcomes and detailed multidisciplinary team discussions were held to review any serious complications.
Program growth timeline: The program was launched in July 2022. During the planning phase (0-2 months), surgeons attended preparatory courses and wet labs. The following phase lasted for the next 6-8 months, during which, surgeons performed their first cases where they double scrubbed with each other for support and to gain more exposure to the procedure. After that, three more experience surgeons from the team started performing the procedure under the proctorship of the two lead surgeons. The detailed program structure is presented in Figure 1.
Conclusions
Building a successful program for Ross procedure requires meticulous planning, team building, and a standardized perioperative care pathway. These factors contribute to the program development and the achievement of excellent surgical results.
Authors
Mohammad El Diasty (1), Travis Wilder (1), Yasir Abu-Omar (1), Rakesh Arora (1), Cristian Baeza (1), Kelsey Gray (1), Igo Ribeiro (1), Pablo Ruda Vega (1), Gregory Rushing (1), Marc Pelletier (1), Joseph Sabik (1), Yakov Elgudin (1)
Institutions
(1) University Hospitals Cleveland Medical Center, Cleveland, OH
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Poster Presenter
Mohammad El Diasty
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Cleveland, OH
United States
Objective: PEARS is a relatively new surgical option for aneurysms of the aortic root and
ascending aorta with less than 900 completed worldwide to date. Its proposed advantages over
aortic root replacement include a shorter operation time, retention of the normal aortic valve
leaflets and function and, as there is no prosthetic tissue in contact with the bloodstream, a
reduced lifetime risk of endocarditis. Although in most cases cardiopulmonary bypass (CPB) is not
required, it remains a technically challenging operation that carries a risk of coronary artery
ischaemia requiring emergency intervention. We hypothesised that the incidence of coronary
injury may be reduced by the use of 3D printed models of the coronary artery anatomy as a guide
to the surgeon during dissection and carried out a pilot study.
Methods: A retrospective study was carried out on the first 14 patients in our PEARS programme.
Major complications and duration of follow-up were recorded. A prospective pilot study was
performed using 3D-printed models of the coronary artery anatomy used to guide dissection in 6
consecutive patients.
Results: There was a combined total of 20 patients in the two studies. Their mean age was 37
years (range 17 to 62) and 4 were female. The diagnosis was Marfan syndrome (MS) in 10, Loeys-
Dietz in 3, autosomal dominant connective tissue disorder in 3 and idiopathic in 4. All operations
were completed without the use of CPB, bar two with concomitant mitral valve repair.
All patients survived surgery and there was 1 late death at 41 months post-op in an alcoholic
cocaine addict with schizophrenia. No dissection or rupture occurred at a median follow-up of 48
months. Three patients in the retrospective study had peri-operative complications. One with MS
had VF during the closure of the sternum. After defibrillation, the integrity of the origins of the
coronary arteries was confirmed and closure of the chest was completed without incident. A
patient with Loeys-Dietz syndrome developed an asymptomatic but enlarging pseudoaneurysm of
the right coronary artery detected on a routine CT scan and this was successfully repaired. One
patient with MS undergoing mitral valve repair in addition to PEARS had a cardiac arrest on
closure of the sternum. This did not respond to defibrillation and following emergency reinstitution
of CPB, CABG was performed to the circumflex artery and the patient remains well at
follow-up 52 months later. To further investigate the cause of coronary artery injury, a 3D model of
the patient's coronary anatomy was subsequently printed (https://sketchfab.com/3d-models/
p03028-67a0caf20b674d1d8e3cea4b78c2ed46) and compared to the post-operative angiogram
(see image) and confirmed that the main circumflex artery had been occluded by the PEARS graft.
In the pilot study, similar 3D models were created for 6 PEARS patients and used to guide
dissection. All operations were completed with no peri-operative complications and feedback
from the surgeon confirmed the utility of the model.
Conclusions: This pilot study confirms the feasibility of using 3D models of coronary anatomy as
a guide during PEARS surgery and this warrants further study. As some complications such as
coronary artery pseudoaneurysm may be asymptomatic, we recommend routine CT angiograms
be performed within 48 hours of PEARS.
Authors
Alastair Graham (1), Harvey Graham (2)
Institutions
(1) Blackrock Clinic, Dublin, Ireland, (2) University of Galway, Galway, Ireland
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Poster Presenter
Alastair Graham
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Belfast
United Kingdom
Objectives: To address disease of the aortic arch or proximal descending aorta, total arch replacement (TAR or zone 3 arch replacement) remains a challenging procedure. With advances in endovascular therapy, Zone 2 Arch Replacement (Z2R) may be increasingly utilized to treat arch pathologies. Herein we compare outcomes between patients undergoing Z2R and TAR at our institution.
Methods: This is a retrospective study of patients undergoing Z2R and TAR from 2006 to 2023 at a single institution. Propensity score matching was used to compare in-hospital outcomes, long-term survival, and the cumulative incidence of aortic reintervention between groups. Long-term survival was analyzed by the method of Kaplan and Meier and compared using the log rank test. Competing risks regression and multivariable Fine-Gray analysis identified factors associated with distal aortic reintervention for disease progression.
Results: Of 218 patients, 46.3% (n=101) underwent Z2R and 53.7% (n=117) underwent TAR. There were no differences in baseline characteristics. Median [IQR] age was 63 [53, 70] years, 67.4% were male, and 13.3% (n=29) had a connective tissue disorder. The most common surgical indication was chronic dissection in 42.7% (n=93), followed by aneurysm (30.7%, n=67) and acute dissection (26.6%, n=58). Aortic cannulation was more common in Z2R, and axillary was more common in TAR (p<0.001); other intraoperative details including procedure times and blood products were similar. Propensity score matching created well-matched groups of 86 patients each. There were no differences in operative mortality (Z2R: n=3, 3.5%; TAR: n=7, 8.1%; p=0.33), stroke (Z2R: n=11, 12.8%; TAR: n=13, 15.1%, p=0.83) or any other postoperative complication rates. Survival at 10 years was 57.6% (95% CI 41.4%-80.1%) after Z2R and 71.6% (61.4%-83.4%) after TAR (log-rank p=0.91) (Figure 1A). The cumulative incidence of at least one distal aortic intervention, including staged and endovascular procedures, was 64.4% (45.2%-63.8%) after Z2R and 39.1% (24.9%-53.4%) after TAR at 10 years (p=0.03) (Figure 1B). When excluding staged procedures, the cumulative incidence of at least one distal aortic reintervention for disease progression was 22.2% (0%-57.1%) after Z2R and 17.8% (2.5%-33.1%) after TAR (p=0.41) (Figure 1C). In all patients, acute (HR 2.69, 95% CI 1.04-6.99; p=0.04) and chronic dissection (HR 3.53; 95% CI 1.38-9.05, p=0.009) were associated with distal aortic reinterventions due to disease progression. Staged aortic reinterventions were well-tolerated, particularly when endovascular with a 2.1% operative mortality rate (1/47) and 4.2% in-hospital complication rate (2/47).
Conclusion: Z2R resulted in comparable operative and 10-year survival when compared to TAR. Z2R had higher rates of distal reinterventions when including staged and endovascular procedures; staged reinterventions were well tolerated. There was no difference in long-term reintervention rate for distal disease progression when excluding staged procedures. For aortic arch disease, Z2R is a viable alternative to TAR.
Authors
Megan Chung (1), Patra Childress (1), Michael Salna (1), David Blitzer (1), Adedeji Adeniyi (1), Yanling Zhao (1), Dov Levine (1), Yu Hohri (1), Christian Pearsall (1), Thomas O'Donnell (1), Paul Kurlansky, MD (1), Virendra Patel (1), Hiroo Takayama (1)
Institutions
(1) Columbia University Irving Medical Center, New York, NY
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Poster Presenter
Megan Chung, NewYork- Presbyterian/Columbia University Medical Center
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NY
United States
We will present our techniques of the Cabrol and Hemi-Cabrol's Modification, and with each case highlight technical pearls that will allow salvage of a difficult operation.
Authors
Nina Delavari (1), Tyler Holm (1), Adam Protos (1), Athanasios Tsiouris (1), Ashok Kumar Coimbatore Jeyakumar (1)
Institutions
(1) University of Mississippi Medical Center, Jackson, MS
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Poster Presenter
Nina Delavari, University of Mississippi Medical Center
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Madison, MS
United States
Objective: Pathology of the descending aorta is commonly perceived to be less dangerous compared to ascending and root disease, sometimes resulting in less aggressive surgical management. However, in some cases, complications are fatal. In this study, we aimed to describe characteristics of descending aortic conditions leading to aortic rupture and death.
Methods: We reviewed autopsy reports of a consecutive series of 30 patients who died due to rupture of the descending aorta before receiving surgical treatment. Post-mortem examinations were performed at our institution from 1994 to 2022, and autopsy data were supplemented with available clinical information.
Results: Pathologic examination revealed that the underlying causes of aortic rupture were atherosclerotic aneurysms in 18 patients (60%), aortic dissection in 10 patients (33.3%), penetrating ulcer in 1 patient (3.3%), and 1 case (3.3%) of intramural hematoma. The most common initial symptom for atherosclerotic aneurysm patients was collapse (n=6, 33.3%), whereas back pain (n=5, 50%) was prominent in the dissection group. The median interval between the onset of symptoms and death was 6 (1-96) hours for atherosclerotic aneurysm patients and 3 (1-48) hours for those with dissection (p=NS). Among all patients, 9 (30%) were found dead at home with an unknown time of death, 7 patients (23.3%) received unsuccessful resuscitation out of the hospital, 5 (16.7%) expired enroute to the hospital, and 9 (30%) died in the emergency room. From available clinical information, 20 patients (66.7%) had a history of hypertension. In patients with type B aortic dissection, 5 (50%) had acute dissection, 3 had chronic dissection with aneurysm formation, and 2 (20%) had chronic dissection without aneurysmal enlargement (surgery was not indicated). Among the 18 patients with rupture of an atherosclerotic aneurysm, the median aortic diameter was 6.0 cm (5.4-7.8 cm). The atherosclerotic aneurysm was limited to the descending aorta in 55.6% of patients, and (44.4%) had thoracoabdominal aneurysms. The distribution of thoracoabdominal aortic aneurysms was Crawford Type I - 1 patient, Type II - 3 patients, and Type III and Type IV - 2 patients each. Among the 20 patients who died because of aneurysm rupture, 7 had not been diagnosed with aneurysm antemortem; 2 of them declined surgery due to the high risk of the procedure. Eleven patients had aneurysms >5.5cm identified on imaging but did not have surgical referral in a timely fashion.
Conclusions: In this study, an atherosclerotic aneurysm was the most frequent descending aortic pathology that led to death. While not all cases of descending aortic aneurysms require emergent intervention, it is extremely important to schedule surgical intervention soon after guidelines thresholds are met especially in view of the availability of endovascular therapy for the majority of patients with descending aortic pathology.
Authors
Anastasiia Karadzha (1), Hartzell Schaff, MD (1), Robert Frye (1), Melanie Bois (1), Malakh Shrestha (1)
Institutions
(1) Mayo Clinic, Rochester, MN
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Poster Presenter
Anastasiia Karadzha, Mayo Clinic (Rochester, MN)
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Rochester, MN
United States
Objective:
Although significant advances have been made in cerebral protection, embolic stroke remains a significant complication in aortic surgery. We developed the "Shaggy Aorta" protocol which combines the metabolic benefits of antegrade cerebral perfusion (ACP) with a period of under 10 minutes of retrograde cerebral perfusion (RCP) to flush out embolic debris, with a transition to ACP if the circulatory arrest time exceeds 10 minutes. We discuss the outcomes of our "Shaggy Aorta" protocol in open aortic surgery and discuss our institutional protocol for cerebral protection.
Methods: A single center prospective database was used to retrospectively evaluate patients who underwent aortic surgery with circulatory arrest. In total, 229 patients were identified since the initiation of the Shaggy protocol in December 2018. We describe pre-operative and operative characteristics, and post-operative outcomes. Furthermore, we compare the Shaggy protocol to non-Shaggy procedures in the same time period, with additional multiple logistic regression to control for potential confounds.
Results:
For the 229 patients identified, the majority were male (71.6%) and the majority of procedures were elective (80.8%). The Shaggy protocol was employed in both hemiarch and more extensive arch replacement, with most patients undergoing hemiarch (69.0%). Average circulatory arrest time was 11.1 8.5. When ACP was needed, average time was 10.9 8.8. RCP only was utilized in 107 (46.7%) of cases, with an average RCP time of 5.3 2.5. Post-operative stroke occurred in 9 patients (3.9%), with the majority occurring as a non-disabling stroke (6, 2.6%). All disabling strokes occurred in urgent/emergent procedures (3, 1.3%). When comparing to 215 non-Shaggy cases, Shaggy protocol demonstrated decreased stroke risk in univariate analysis (p<0.001), and in multiple logistic regression accounting for urgency and extent of arch replacement (OR 0.3989, CI [0.167,0.8853], p=0.0293).
Conclusions:
The "Shaggy Aorta" protocol developed by our institution significantly reduces stroke risk. When stroke did occur, it was typically non-disabling, with disabling stroke only occurring in urgent or emergent procedures. Based on our experiences with our Shaggy protocol and managing stroke, we propose a protocol for mitigating stroke risk in aortic arch surgery.
Authors
Adam Carroll (1), Nicolas Chanes (1), Mohamed Eldeiry (1), Michael Kirsch (1), Bo Chang Wu (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
OBJECTIVE: Stroke after total arch replacement (TAR) remains a serious complication. To prevent it, deep hypothermia has been used during TAR. We evaluate cerebral protection with deep hypothermic circulatory arrest (DHCA) during TAR, particularly for patients with acute aortic dissection (AAD).
METHODS: Between October 2009 and July 2022, 109 consecutive patients with AAD underwent TAR using DHCA on an emergency basis and 147 patients with aneurysm underwent scheduled TAR also using DHCA. We reviewed retrospectively these patients by looking at stroke and 30-day mortality after TAR. We also analyzed the effects of clinical variables and anatomical features on stroke after TAR for AAD.
RESULTS: Stroke after TAR occurred in 11 (10.1%) patients with AAD. The stroke was due to embolism in eight patients, malperfusion in two patients including one who had been in a comatose state, and low output syndrome in one patient. Stroke occurred in 3 (2.0%) patients with aneurysm, due in all three to embolism (P = 0.005). The DHCA time for patients with AAD was 37 ± 7 minutes, and for patients with aneurysm it was 36 ± 6 minutes (P = 0.122). Mortality within 30 days occurred in 10 (9.2%) patients with AAD, and in 2 (1.4%) patients with aneurysm (P = 0.003). In the multivariable analysis, double-barreled dissection in the arch vessels (odds ratio 33.02, confidence interval (4.33 – 252.1), P < 0.001) was the only significant predictor of stroke after TAR for AAD.
CONCLUSIONS: Cerebral protection with DHCA during TAR continues to be an option, particularly for patients with aneurysm. Perioperative stroke in patients undergoing TAR for AAD appears to be associated with air emboli deriving from the double-barreled dissection in the repaired arch vessels.
Authors
Yasunori Cho (1), Sohsyu Kotani (2), kimiaki okada (2), Keisuke Ozawa (2), Goro Kishinami (2), Akiyoshi Yamamoto (2), Toshihiko Ueda (2)
Institutions
(1) Tokai University School of Medicine, Kanagawa, Japan, (2) Tokai University School of Medicine, Kanagawa, Japan
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Poster Presenter
Yasunori Cho, Tokai University School of Medicine
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Kanagawa
Japan
Objectives
The mortality rate of patients with an untreated acute type A aortic dissection (ATAAD) is 1-2% per hour for the first 24-48 hours. Various aortic cannulation strategies for ATAAD surgery have been described in literature, with the principle of each strategy being safe and expeditious cannulation of the true lumen. We review our experience with aortic arch branch vessel cannulation (axillary vs innominate artery) to assess operative outcomes.
Methods
From January 2016 to January 2022, all patients who underwent surgery for ATAAD at our institution were included (N=106). These patients were divided into 2 groups: axillary artery cannulation (N=65, 61%) and innominate artery cannulation (N=41, 39%). Baseline characteristics and outcomes of both groups were compared. Categorical variables were compared using Chi square testing. Continuous variable comparison was conducted using Wilcoxon signed-rank test.
Results
The baseline patient characteristics were identical in both groups and are described in Table 1. The reason for selecting one artery over the other for initial cannulation during ATAAD included the extent of dissection, surgeon preference, and hemodynamic instability. No difference in time on cardiopulmonary bypass was observed between the axillary artery group and the innominate artery group (213 minutes vs 198 minutes, P=0.08), nor was there a change in cross clamp times (123 minutes vs 105 minutes, P=0.2). Similar percentages of both groups underwent circulatory arrest (89% vs 92%, P=0.55) with antegrade cerebral perfusion (95% vs 84%, P=0.08). The operative mortality was also consistent across both groups (12% axillary vs 10% innominate, P=0.71). Other post-operative complications such as stroke (11% vs 10%, P=0.86), bleeding (15% vs 5%, P=0.09), renal failure (26% vs 12%, P=0.08) and prolonged ventilation (61% vs 49%, P=0.19) were similar across the groups.
Conclusions
Both axillary and innominate artery as options for initial cannulation in ATAAD surgery are safe and effective strategies and can be used in the appropriate clinical setting. No difference was noted in operative metrics, including time on CBP and cross-clamp time. Similarly, patient outcomes did not differ based on axillary vs innominate artery cannulation.
Authors
Juliana Cobb (1), Priyadarshini Chandrashekhar (1), Erin Schumer (2), Michele Gallo (2), Mark Slaughter (3), Brian Ganzel (2), Jaimin Trivedi (2), Siddharth Pahwa (2)
Institutions
(1) University of Louisville School of Medicine, Louisville, KY, (2) University of Louisville, Louisville, KY, (3) University of Louisville/Jewish Hospital, Louisville, KY
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Poster Presenter
Juliana Cobb, University of Louisville School of Medicine
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Louisville, KY
United States
Objective:
Acute aortic dissection of the ascending aorta is a life-threatening disease that poses a challenge for cardiovascular surgeons. Surgical repair involves the use of hypothermic circulatory arrest (HCA) for proximal aortic repair. The impact of circulatory arrest duration on postoperative outcomes is unclear. The purpose of this study is to determine the pivotal circulatory arrest time that increases surgical complications.
Methods: This retrospective review of prospectively collected data included patients who underwent Aortic Dissection Repair from 2016- 2022 at a single academic institution. Circulatory arrest time groups were stratified by above and below 30 minutes. Outcomes were compared across cerebral perfusion modalities and hypothermic temperatures with confounds controlled to ascertain independent effect. Primary outcomes included 30-Day mortality, and postoperative length of stay. Outcomes were analyzed using Pearson's Chi-squared, Fisher's Exact, Multiple Regression Analysis and Pooled T-Tests, with significance set at p<0.05.
Results: A total of 142 patients were included, 117 of whom (82%) had arrest times below 30 minutes and 25 (18%) had arrest times above 30 minutes. There were no differences in preoperative baseline characteristics. There were differences in Cardiopulmonary Bypass Time (P < .001) and Cross Clamp Time (P = .036). Patients with circulatory arrest times less than 30 minutes had less cerebrovascular accident (CVA) (P < .001) and less 30 Day (P < .001) and 12 Month Mortality (P = .002). Confound controlled multifactorial regression (CCMR) confirmed continuous circulatory arrest time as the sole independent effect on CVA (P=.002) in a model with cerebral perfusion modality, circulatory arrest time and hypothermic temperature. CCMR found no independent effect of neuroprotectant deep hypothermic temperature (P=.360) or cerebral perfusion technique (no perfusion vs retrograde vs anterograde) (P=.321) during circulatory arrest on incidence of CVA. CCMR did find that circulatory arrest time (P< .001) and use of retrograde cerebral perfusion (P=.040) to be independently predictive of 30 Day and 12 Month Mortality (Both | P=.003). Retrograde cerebral perfusion (P=.012) was additionally found predictive of postoperative pericardial and pleural effusions.
Conclusions: Longer circulatory arrest duration greater than 30 minutes leads to worse outcomes despite cooling temperature and method of neuroprotection.
Authors
Anthony Lemaire (1), Sorasicha Nithikasem (2), Abhishek Chakraborty (3), Alex Rahimi (1), Mark Russo (4), Leonard Lee (5)
Institutions
(1) Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, (2) Rutgers Robert Wood Johnson Medical School, United States, (3) Le Bonheur Children's Hospital, Memphis, TN, (4) Robert Wood Johnson University Hospital, Green Village, NJ, (5) Robert Wood Johnson University Hospital, New Brunswick, NJ
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Poster Presenter
*Anthony Lemaire, Rutgers Robert Wood Johnson Medical School
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New Brunswick, NJ
United States
Objective
Achievements of secure anastomosis and complete hemostasis are essential in the surgical treatment for type A acute aortic dissection (TAAD). In the present paper, we assessed the clinical feasibility of our tailored stand-up collar (TSC) technique, a simple technique for construction of the distal stump by pre-gluing felt strip with Hydrofit® during systemic cooling.
Methods
We enrolled 57 cases of isolated ascending aortic repair out of 143 cases of surgically repaired TAAD at our institution in the last decade. Patients were divided into three groups according to the technique for the distal stump construction; conventional (C) group in which only felt strip was used for reinforcement of the stump, 24 cases; post-aortotomy Hydrofit®️-felt (P) group in which a Hydrofit®️-applied felt strip was attached to the aorta after aortotomy, 18 cases; tailored stand-up collar technique (TSC) group in which a Hydrofit®️-applied felt strip was circumferentially placed on the aorta during systemic cooling, 15 cases. Pre-operative characteristics, procedural profiles, and post-operative outcomes were evaluated between these three groups.
Results
Pre-operative characteristics, such as age, gender, comorbidities, and complications associated with TAAD were identical between the groups. In the P and TSC group, distal-first anastomosis and utilization of retrograde cardioplegia were more frequent compared with the C group. Duration of the open distal, cardiopulmonary bypass, hemostasis, and operation in the P and TSC group were significantly short compared with the C group. Furthermore, duration of the open distal in the TSC group (20 min) was significantly shorter compared with the P group (26 min). Post-operative transfusion volume of the packed red blood cells was significantly less in the TSC group. Post-operative additional procedure was less necessary in the TSC group. Post-operative hospital stay of the TSC group was significantly short and 40% of the patients were discharged within 2 weeks after operation.
Conclusions
Our tailored stand-up collar technique were feasible to reduce open distal and operation time, post-operative transfusion volume, additional procedure, and post-operative hospital stay.
Authors
Yukio Umeda (1), Shohei Mitta (2), Yukihiro Matsuno (2)
Institutions
(1) Gifu Prefectural General Medical Center, Gifu, Gifu, (2) Gifu Prefectural General Medical Center, Gifu, NA
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Poster Presenter
Yukio Umeda, Gifu Prefectural General Medical Center
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Gifu, Gifu
Japan
Objective: We retrospectively evaluated the clinical outcomes and economics of Zone 2 aortic arch reconstruction in DeBakey Type 1 and 2 acute and chronic aortic dissections.
Methods: Between April 2018 and June 2022, n=140 patients with DeBakey Type 1 or 2 aortic dissection underwent Zone 2 repair at the University of Florida Health. Patients were categorized into two groups; the Acute group (n=83) and the chronic group (n=57). The Kaplan-Meier (KM) method was used to evaluate longitudinal survival.
Results: The Acute group was younger (54.5±13.0 vs. 59.3±11.1 years, p=0.031) and less frequently had hypertension (83.1% vs. 98.2%, p= 0.004), cerebrovascular disease (13.3% vs. 36.8%, p=0.002), and history of prior sternotomy (21.7% vs. 64.9%, p<0.0001). The Acute group had a longer total corporeal circulatory arrest time (66.1±15.4 vs. 59.7± 8.4 minutes, p=0.023), deep hypothermic cerebral circulatory arrest (DHCA) time (22.4±7.5 vs. 19.4±8.6 minutes, p=0.007), and lower minimum temperature (16.3±3.7 vs. 18.3±2.8 °C, p=0.0003) during DHCA. Postoperatively, the Acute group had a higher rate of postoperative acute kidney injury (21.7% vs. 7.0%, p=0.020); however, there was no difference between groups in the new requirement for dialysis (3.6% vs. 1.8%, p=0.646.) Morbidity included cerebrovascular accident in 7 (5.0%) patients, respiratory failure requiring tracheostomy in 15 (10.7%) patients, pneumonia in 19 (13.6%) patients, and sepsis in 13 (9.3%) patients. Thirty-day mortality was low at 2.3% (n=3). There is no difference in longitudinal KM-estimated survival by dissection timing (log-rank p=0.1).The Acute group had a lower operating room cost ($24,900±10,900 vs. $28,200±11,500, p=0.036), anesthesia cost ($3,300±1,300 vs. $4,200±1,600, p=<0.0001), and implant device costs ($12,100±12,000 vs. $16,700±11,000, p=0.003.) However, total hospital costs did not differ between Acute and Chronic groups ($108,000±50,500 vs. $117,000±54,900, p=0.285.)
Conclusions: Patients undergoing Zone 2 arch reconstruction for aortic dissections in our center are associated with a low postoperative complication rate and excellent long-term survival. While patients with chronic dissection presented older with higher comorbidity burden, there were no differences in most postoperative outcomes, mortality, and economics of dissection repair when evaluated by dissection timing.
Authors
Lauren Pixley (1), Omar Sharaf (2), Dan Neal (3), Kevin Reilly (4), Aidan Charles (4), John Spratt (4), Thomas Beaver (5), Tomas Martin (6), Eric Jeng (7)
Institutions
(1) N/A, N/A, (2) N/A, Berlin, CT, (3) University of Florida Health, Gainesville, FL, (4) University of Florida, Gainesville, FL, (5) Shands, Gainesville, FL, (6) Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL, (7) University of Florida- Shands, Gainesville, FL
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Poster Presenter
Lauren Pixley, University of Florida
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Gainesville, FL
United States
Objective: To evaluate clinical risk factors contributing to five-year all cause death in a veteran population who have dilated ascending aorta or ascending thoracic aortic aneurysm (aTAA) and who did not undergo repair within five years.
Methods: 451 patients with ascending thoracic aortic size of at least 4.0cm or greater were identified. Fifty-eight pertinent risk factors (including social, genetic, cardiac risk factors, comorbidities, date of diagnosis and aneurysm size, date of most recent CT scan and aneurysm size, etc.) that may contribute to adverse outcomes were evaluated. Patients who died before repair within 5 years of aTAA identification or had 5 years of follow-up without repair were further analyzed. Statistical analysis used logistic regression for the outcome of five-year all-cause mortality with stepwise variable selection based on the Akaike information criterion. P<0.05 was considered statistically significant.
Results: Of 451 patients, 179 had ≥5 years follow-up without aTAA surgical repair. 46 out of the 179 patients (26%) died within 5 years. The variable selection process retained 21 of 58 covariates. Variables of clinical interest and statistical significance in the adjusted model were age (odds ratio 1.22 per year, p<0.001), history of prior open or endovascular procedures (OR 5.18, p=0.003), history of angiotensin receptor blocker (ARB) use (OR 0.13, p=0.008), and aneurysm size (OR 3.13 per cm, p=0.037).
Conclusion: Age, history of prior open or endovascular procedures, and aneurysm size increased the risk of all-cause death at 5 years. Among modifiable risk factors, only the use of ARB was protective in preventing five-year mortality. Although prior clinical trials of ARB use in patients with Marfan Syndrome did not find beneficial effects in humans, ARB use in the overall aneurysm population may be beneficial in reducing 5-year mortality and should be further investigated.
Authors
Vidur Kailash (1), Sally Tu (1), Siavash Zamirpour (1), Tiffany Cao (1), William Pace (1), Marko Boskovski (1), Liang Ge (1), Elaine Tseng (2)
Institutions
(1) University of California, San Francisco, San Francisco, CA, (2) UCSF and SFVA, South San Francisco, CA
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Poster Presenter
Vidur Kailash
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Santa Rosa, CA
United States
Objective: Open thoraco-abdominal aortic aneurysm repair (TAAR) is a complex procedure with high mortality and complication rates. Different perfusion strategies have been developed to mitigate this risk of surgery. We evaluate and compare outcomes of deep hypothermic circulatory arrest (DHCA) and left heart bypass (LHB) in a decade of our experience as aortic referral centre.
Methods: Retrospective analysis of data included all consecutive patients who underwent TAAR from 2013 to September 2023. The analysed data includes demographics, pre-morbid clinical state, degree of aortic disease, perfusion strategy and post-operative complications. Primary outcomes measured were 30-day mortality and major complications including stroke, permanent neurologic deficit, renal dysfunction requiring dialysis and bowel ischemia.
Results: 120 consecutive adult patients who underwent thoracic or thoracoabdominal aorta repair were included with an average age of 60 years (range 22-84) with a male predominance (80.8%, 127). 17 (14.1%) patients had Marfan's syndrome and 3 (0.2%) had Loeys-Dietz syndrome. The average aneurysm size was 6.8 cm. 50% (60) of patients required cardio-pulmonary bypass, whereas 25% (30) required LHB. The average LHB time was 187.79 minutes (range 107-401) and the average DHCA time was 26 minutes (range 10-31). 30-day survival rate was 93.3% (112). The complication rate was 20.8% (25) with the most common being stroke (11, 9.2%), followed by paraplegia (9, 7.5%), post-operative dialysis (5, 4.2%) and bowel ischaemia (4, 3.3%). There was no significant difference between 30-day mortality (p=0.627, CI 95%) or complication rates (p=0.899, CI 95%) between our LHB and DHCA cohorts. No significant difference was identified for individual complications such as stroke, paraplegia, bowel ischaemia and post-operative dialysis in LHB and DHCA cohorts. Prolonged DHCA time was associated with an increase in complications (p=0.038, CI 95%). The most significant association of 30-day mortality was with poor pre-operative kidney function of Stage 3 or worse (rank correlation, p=0.032, CI95%, ρ (118) = 0.195).
Conclusion: Our study supports that DHCA is not inferior to LHB with no increase in 30-day mortality or complications between groups. Prolonged DHCA times increase the risk of complications; however, it had no effect on 30-day mortality. Pre-operative kidney dysfunction is a key risk factor in consideration of eligibility for surgery.
Authors
Ali Shan (1), Victoria Rizzo (1), Franziska Gorke (1), Muhammad Ashraf (1), Jason Kho (1), Michael M Sabetai (1), Morad Sallam (1), Amit Chawla (1), Roxanne Noces (1), Sunaina Mathapati (2)
Institutions
(1) Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom, (2) Kings College London, London, United Kingdom
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Poster Presenter
Ali Shan
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Dartford
United Kingdom
Objective: To report the comparative accuracy of dedicated preoperative 4D cardiac computed tomography angiogram (CTA), real-time 3D transesophageal echocardiography (TEE) and intraoperative techniques in aortic valve (AV) measurement and phenotype determination using the de Kerchove repair-oriented classification, in patients with trileaflet or bicuspid aortic valves undergoing surgery for predominant aortic insufficiency and/or root aneurysm.
Methods: This is a prospective, non-randomized, observational study of preoperative AV imaging for AV repair surgery. A total of 22 patients were accrued over a period of 12 months and followed for a minimum of 3 years postoperatively. Preoperative TEE and CTA were obtained and measurements provided by dedicated imaging cardiologists. Intraoperative measurements were obtained from the arrested heart and reported by the surgeon prior to repair. CTA was considered the comparative standard of AV phenotype and commissural orientation while intraoperative measurement was considered the standard for heights. Cohen's kappa (κ), Spearman's rank (rs) and Pearson (r) correlation coefficients were used to describe agreement of phenotype and measurements, as appropriate. Continuous variables are reported as a median with interquartile range or a mean with standard deviation if normally distributed.
Results: Assessment of AV phenotype and measurements of commissural orientation (CO), geometric height (gH) and functional commissural heights (fcH) are reported (Table 1). TEE (κ=0.902, p<0.01) was more likely to agree with CTA for AV phenotype than intraoperative assessment (κ=0.729, p<0.01), however both were likely to agree with CTA. TEE was thus more accurate than intraoperative measurement at predicting CO (rs=0.79, p<0.01 vs rs=0.58, p=0.01). Both CTA and TEE were unlikely to predict and measured shorter than intraoperative gH measurement. There was a low positive correlation of gH within CTA and TEE; neither tended to over or underestimate the other. Measurements of fcH by CTA did not agree with and were shorter than intraoperative measurement.
Conclusions: TEE appears more accurate than intraoperative assessment in predicting AV phenotype by measurement of CO compared to the gold standard of CTA. CTA and TEE did not agree with and predicted shorter gH and fcH than intraoperative measurement.
Authors
Kyle McCullough (1), Zuyue Wang (2), John Eisenga (1), Ghadi Moubarak (1), Tsung-Wei Ma (1), Amro Alsaid (2), J. Michael DiMaio (2), William Brinkman (2)
Institutions
(1) Baylor Scott & White Research Institute, Plano, TX, (2) Baylor Scott & White Health - The Heart Hospital, Plano, TX
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Poster Presenter
Kyle McCullough, Baylor Scott & White Research Institute
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Dallas, TX
United States
Background: Aortic dissection (AD) is a potential complication of pregnancy in Marfan Syndrome (MFS) which is life-threatening for both the pregnant woman and the baby, survival rate is reported to be 20-30%. Aortic root dilation in MFS and peripartum hormonal and hemodynamic changes of pregnancy, which peak at the third trimester, are risk factors for AD. We present a case of a patient with MFS that highlights the need for more research into MFS and pregnancy and improvement aortic root screening guidelines to reduce risk of AD.
Case: A 42-year-old female with history of bilateral lens dislocation, aortic root dilation (4cm), and family history of MFS but normal body habitus presented at 37-weeks gestation after in-vitro-fertilization (IVF) with hours of constant mid back pain. Blood pressure was 160/80, decelerations noted on fetal monitoring prompted an emergent cesarean section for suspected abruption causing the pain. Patient with continued back pain after delivery, a post-op echocardiogram revealed type-A dissection with aortic regurgitation.
Decision‐making: CT angio confirmed AD from the right coronary artery ostium, involving the arch, and extending down the descending aorta to the proximal left common iliac artery. After stabilization with IV labetalol, a multidisciplinary team proceeded with urgent median sternotomy with modified Bentall procedure with mechanical valve, single coronary artery bypass graft and descending thoracic aortic stent. She was discharged on warfarin and metoprolol.
Conclusion: A careful history is crucial to make a diagnosis of MFS as women may not have typical skeletal features. It is crucial to have a high index of suspicion at presentation when MFS characteristics are present and to have pre-pregnancy counseling, use a multidisciplinary team, and have early prophylactic intervention when needed to avoid catastrophe. We suggest research to determine the role of fertility drugs and age in AD risk, and the consideration of the use of aortic root Z-scores and of moving the cut off for pre pregnancy prophylactic aortic replacement, which is currently at 4.5cm, to 4.0 cm in MFS.
Authors
Sara Hazaveh (1), Vladimir Joseph (2), Elie Elmann (2), Marian Vandyck-Acquah (2)
Institutions
(1) Hackensack Meridian University Medical Center, Hackensack, NJ, (2) Hackensack Meridian University Medical Center, Hackensack , NJ
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Poster Presenter
Sara Hazaveh, Hackensack Meridian Health Network and Hackensack Meridian School of Medicine
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Hackensack, NJ
United States
Objective: Aortic arch pathology in patients with congenital heart disease and prior aortic arch interventions can be complex. Repairs are technically demanding and require high-risk intraprocedural adjustments. Here, we present the case of a 15-year-old girl born with hypoplastic left heart syndrome, who had undergone four previous open-heart surgeries for single ventricle palliation, most recently an intra/extracardiac fenestrated Fontan procedure. The patient was found to have Fontan baffle narrowing along with extensive coral-reef-like reactive calcifications of the bovine jugular vein graft used for reconstruction of the ascending aorta and aortic arch. The patient underwent successful arch repair and Damus-Kay-Stansel (DKS) revision.
Methods: Given the Fontan baffle narrowing, along with significant arch obstruction from calcification as demonstrated by chest CT (Figure 1A), a stepwise procedural plan was developed including stenting of the Fontan conduit prior to arch replacement. Virtual and printed 3D models of the aorta were utilized to assist with surgical planning (Figure 1B). Right femoral vein cannulation was performed under fluoroscopy guidance and the right axillary artery was exposed for bypass cannulation. A fifth median sternotomy was undertaken, and cardiopulmonary bypass was initiated via femoral vein and axillary artery. The entire mediastinal dissection was performed with aortic no-touch technique to minimize risk of embolization. A period of antegrade cerebral perfusion was started by clamping the distal innominate artery. The left carotid and left subclavian arteries were clamped. The ascending aorta was transected at the level of the DKS, and myocardial arrest was achieved via direct ostial administration of cardioplegia. The ascending aorta was near-totally obstructed, with only a minimal (3-4mm) residual lumen (Figure 1C). The ascending aorta and base of the arch were resected en bloc with the calcified matter (Figure 1D). The arch was reconstructed with a Gelweave graft, and the DKS was re-anastomosed.
Results: Intraoperative transesophageal echocardiogram demonstrated a patent arch and DKS. No neo-aortic valve regurgitation was observed. The procedure was performed successfully with avoidance of any neurologic event. Her post-operative course was complicated by a hoarse voice and video swallow study revealing aspiration with thin liquids. She was last seen in outpatient clinic on post-operative day 50 continuing her work with speech therapy and progressing appropriately.
Conclusions: Aortic pathology in patients with congenital heart disease and prior arch interventions represent a complex surgical problem and requires careful preoperative planning. A hybrid approach with preoperative catheter intervention for optimization and minimization of surgical repair is recommended when feasible. This approach can mitigate the risk for perioperative complications and increase procedural success.
Authors
Cathlyn Medina (1), Berk Aykut (2), Lauren Parker (3), Lindsey Reynolds (4), Stephen Miller (4), Joseph Cao (4), Joseph Turek (5), Douglas Overbey (6), Ziv Beckerman (3)
Institutions
(1) N/A, N/A, (2) Duke Univ Med Ctr, Dept. of Surgery, N/A, (3) Duke University Medical Center, Durham, NC, (4) Duke University, Durham, NC, (5) Duke Children's Hospital, Durham, NC, (6) Duke University, United States
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Poster Presenter
Cathlyn Medina, Duke University
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Durham, NC
United States
Objective: Endoleak arises as a specific set of complications from endovascular treatments in complex aortic pathologies, that warrants the longer-term surveillance and technical challenges in salvage scenarios. A case of symptomatic concealed rupture of descending aorta with previous endovascular stents demonstrated the importance of endoleak identification and open descending repair techniques.
Case Video Summary: A 67-year-old patient with previous complex thoracic aortic interventions involved staged endovascular treatments and total aortic arch replacement, found to have a symptomatic concealed descending aortic rupture. Preoperative imaging showed no active extravasation or definite endoleak, with only a suspicious of migration previous stent graft components. Open descending surgery was offered for severe back pain and persistent anaemia, confirmed a type III endoleak as the major culprit. Routine left thoracotomy approach of descending aortic surgery exposed the ruptured aortic wall. Upon stent graft components exposure and examination of endoleak, the culprit type III endoleak was treated with direct surgical repair and reinforcements. Furthermore, type II and IV endoleaks were also identified and treated, distal sealing of the stent graft to native aorta was reinforced. Patient recovered well and was discharged 12 days postoperatively with resolved back pain and no neurological complication.
Conclusions: Endovascular treatments expanded the treatment options for aortic pathologies, it arises a specific set of complications and treatment challenges. The current case showed the indispensable role of open repair in descending aortic treatments. The importance of surveillance after aortic interventions and timely endoleak management is demonstrated.
Authors
Jacky Yan Kit Ho (1), Kevin Lim (1), Chi Ying Simon Chow (1), Takuya Fujikawa (1), Randolph Wong (1)
Institutions
(1) Prince of Wales Hospital, Hong Kong SAR, Hong Kong SAR
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Poster Presenter
Jacky Yan Kit Ho, The Chinese University of Hong Kong, Prince of Wales Hospital
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Hong Kong SAR, Hong Kong
China
OBJECTIVE: This single-center retrospective study aims to 1) ascertain the added risk of performing coronary artery bypass graft (CABG) when the primary indication for open surgery is aortic aneurysm repair and 2) determine the difference in outcomes when the primary indication for combined surgery is aortic versus coronary artery disease (CAD).
METHODS: Patients who underwent open thoracic aortic replacement with or without concomitant CABG from 2005-2020 were included. Cases of emergent CABG were excluded. In the first analysis, 1391 patients for whom the primary indication for surgery was aortic disease alone were split into two groups: 1) those who underwent aortic replacement alone (aneurysm, n=1210) and 2) those who underwent aortic replacement with concomitant CABG (aneurysm/CABG, n=181) (Figure 1A). Inverse probability treatment weighting (IPTW) was performed to adjust for baseline differences between groups. Multivariable regression using the IPTW cohort was used to study postoperative complications, including stroke, respiratory failure, renal failure, and reoperation for bleeding. Kaplan-Meier (KM) analysis was used to study long-term mortality in the matched cohort. In our secondary analysis, all patients undergoing both aortic replacement and CABG (n=220) were split by primary indication for operation, aortic disease (n=181) or CAD (n=39). Similarly, perioperative complications and long-term mortality were studied.
RESULTS: After IPTW, compared to the group that had aortic replacement alone, the CABG/aneurysm group had increased stroke rate (OR: 2.36, 1.23-4.27, p=.006), post operative respiratory failure (OR: 2.83, 1.79-4.40, p<.0001), and operative mortality (OR: 2.59, 1.18-5.28, p=.001). Both groups had similar extent of aortic replacement (root, ascending, or arch, p = 0.4). KM curve for the matched cohort censored at 9 years showed decreased survival probability for aneurysm/CABG group (p = 0.002) . In the secondary analysis in aneurysm/CABG group, indication (aneurysm (n=181) vs CAD (n=39)) was not significant for postoperative morbidity or mortality with no significant difference in 9-year mortality (p = 0.8).
CONCLUSION: When performing open thoracic aortic replacement, the addition of CABG confers an added risk of stroke, post operative respiratory failure, and long-term mortality. Outcomes for combined surgery are similar regardless of primary indication.
Authors
Yaagnik Kosuri (1), Kavya Rajesh (2), Morgan Moroi (3), Krushang Patel (2), Pengchen Wang (4), Yu Hohri (5), Paul Kurlansky, MD (6), Craig Smith (7), Hiroo Takayama (8)
Institutions
(1) New York Presbyterian/Columbia, New York, NY, (2) N/A, N/A, (3) N/A, United States, (4) Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, NY, (5) Columbia University Irving Medical Center, New York, NY, (6) Columbia University Medical Center, New York, NY, (7) Columbia University Irving Medical Center of New York Presbyterian Hospital, New York, NY, (8) NewYork- Presbyterian/Columbia University Medical Center, New York, NY
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Poster Presenter
Yaagnik Kosuri, New York Presbyterian/Columbia
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New York, NY
United States
Objective: Q fever is a zoonosis caused by Coxiella burnetii. Aortitis by Coxiella burnetii remains rare and can mimic large vessel giant arteritis. 18FDG-PET/CT provides anatomic characterization and inflammatory activity assessment. Treatment of complicated lesions requires open surgery, which allows for definitive diagnosis.
72-year-old male presented with a 2-month history of fever, malaise and intermittent chest and lumbar pain. CT-scan showed distal arch penetrating ulcer with mural thrombus. TEE ruled out cardiac valve involvement. PET/CT revealed intense FDG uptake on zone 2-3 aortic segment. Serologies suggested active Coxiella burnetii infection. Coronary angiogram confirmed LAD stent re-stenosis (FFR 0.80). Concomitant CABG and aortic replacement through left thoracotomy was indicated.
Methods: 5th intercostal space left thoracotomy access was used. Left internal mammary artery was harvested. The descending thoracic aorta was cannulated using echo guidance (20Fr EOPA) with the cannula tip placed at the level of the proximal arch to reduce the risk of mural thrombus embolization with pump flow. LIMA-LAD was performed while cooling down and the affected aorta was replaced with a 26 mm Ante-Flo graft under deep hypothermic circulatory arrest at 18ºC with whole body retrograde perfusion (HCA-RBP). Surgical video available.
Results: HCA-RBP time was 40 minutes and 317, for cardiopulmonary bypass time. Patient was extubated on postoperative day (POD) 1. Uneventful post-operatory course with no neuro/renal/respiratory complications, discharged on POD 10. Intraoperative cultures and 16S were negative with positive IgG and IgM Coxiella burnetii antibodies. 6 months of Doxycycline 100mg/12h and Levofloxacin 500 mg/24h was completed, then switched to Doxycycline in monotherapy until negative antibodies (total: 18 months). 2 years after, patient is in good health, with no clinical or serological relapses and stable aorta reconstruction
Conclusions: Severe periaortic inflammatory reaction is seen in aortitis and complicates dissection, potentially increasing the iatrogenic risk (phrenic, vagus and esophagus injury). Thorough debridement, along with prolonged antibiotics, are a potentially curative option for complicated Coxiella burnetii aortitis. Whole body retrograde perfusion at the time of arch surgery with proximal open anastomosis allows washout of debris from head vessels and aortic root. CABG can be pursued concomitantly thought the same access
Authors
Maria Ascaso Arbona (1), Robert Pruna-Guillen (2), Jorge Alcocer Dieguez (2), Marta Hernandez-Meneses (3), Eduard Quintana (4)
Institutions
(1) N/A, Canada, (2) N/A, N/A, (3) Infectious Disease - Hospital Clinic, Barcelona, Spain, (4) Hospital Clínic Barcelona Cardiovascular Surgery Department, Barcelona, barcelona
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Poster Presenter
Maria Ascaso
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Barcelona
Spain
Objective: Aortic dissection (AD) is an acute event characterized by an intimomedial tear with the formation of a false lumen inside the aortic wall. In this study, we sought to determine whether a more aggressive surgical approach for acute type I AD results in improved distal aortic remodeling.
Methods: In this study of patients who underwent surgery for acute type I AD between 2013 and 2022, we conducted retrospective chart review of health records and reviewed cross sectional scans at three distinct anatomical locations: aortic zone 3, at the pulmonary artery bifurcation, and at the aortic hiatus. Patients were stratified into hybrid and traditional repair groups. Aortic remodeling was defined by aortic growth rate, true lumen diameter (TLD), and total aortic diameter (TAD) to TLD ratio difference.
Results: Fifty eight patients were included. Nineteen patients (33%) underwent hybrid repair and 39 (67%) underwent traditional repair. Analysis revealed a significant discrepancy in descending aortic growth rate at the level of the pulmonary artery bifurcation between the hybrid group and traditional group with median aortic growth of -0.15 mm/month and +0.12 mm/month respectively (p=0.047). At aortic zone 3 TAD/TLD ratio difference was significantly different with a ratio difference of -0.42 and +0.12 in the hybrid and traditional groups, respectively (p=0.003). and at the level of the pulmonary artery bifurcation, the ratio difference was found to be -0.79 for the hybrid group and +0.13 for the traditional group (p=0.010). Additionally, significant positive changes in TLD were observed at zone 3, with the hybrid repair group showing TLD growth from 19.4 mm at baseline to 27.1 mm at follow up (p< 0.001) and the traditional group showing no significant change in size from 18 mm at baseline (p>0.9). At the pulmonary artery bifurcation, the TLD grew from 17 mm at baseline to 28 mm at follow up (p< 0.001) in the hybrid group, while the traditional group showed no change from 14 mm (p>0.9).
Conclusions: Hybrid repair has been suggested to induce favorable remodeling profile in patients with type I AD. Our study showed that an aggressive hybrid repair led to less aortic growth rate, increased true lumen size, and decreased TAD/TLD ratio difference indicating positive aortic remodeling.
Authors
Bjarki Leó Snorrason (1), Katrín Hólmgrímsdóttir (1), Birta Rakel Óskarsdóttir (1), Syed Usman Bin Mahmood (2), Roland Assi (2), Arnar Geirsson (3)
Institutions
(1) University of Iceland, Reykjavík, Iceland, (2) Yale University School of Medicine, New Haven, CT, (3) Columbia University, New York, NY
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Poster Presenter
Bjarki Leó Snorrason
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Reykjavík
Iceland
Objective
Type A aortic dissection (TAAD) repair produces a significant coagulopathy. Blood product administration, especially fresh frozen plasma (FFP) and platelets, is associated with dose-dependent pulmonary complications, stroke, and mortality. We compared intraoperative blood product usage/waste in TAAD repair before and after implementation of a contemporary patient blood management (PBM) program.
Methods
Single-center retrospective review of adults (≥18 years) with acute TAAD repair between April 4, 2018 and December 29, 2019 (controls) and June 2, 2021 and June 19, 2022 (PBM group). The PBM program included point-of-care viscoelastic testing, education to reduce transfusion, guided concentrated fibrinogen administration and monitoring to reduce blood product waste (ordered but not administered). Statistical analysis included Chi-Square tests for categorical variables and Wilcoxon two-sample tests for continuous variables.
Results
There were 142 patients with blood product data available, including 74 (52%) historical control patients and 68 (48%) PBM patients. Mean age for cohort was 59.0±13.7 years. PBM patients had higher body mass index (31.3±6.9 versus 29.3±5.6, p=0.055), lower preoperative hemoglobin (12.5±2.3 versus 13.2±1.8, p=0.040), and less peripheral vascular disease (26.8% [n=15] versus 46.4% [n=32], p=0.025). PBM group had more complex operations with more zone 2 debranchings (50.0% [n=34] versus 27.0% [n=20], p=0.005) and fewer hemi-arch procedures (39.7% [n=27] versus 63.5% [n=47], p=0.005). Fewer patients in the PBM group had intraoperative FFP transfusions (1.5% [n=1] versus 18.9% [n=14], p<0.001) and Factor 7 transfusions (0% [n=0] versus 8.1% [n=6], p=0.016) with more prothrombin complex concentrate (PCC) (41.2% [n=28] versus 18.9% [n=14], p=0.004) and more fibrinogen concentrate (5.9% [n=4] versus 0% [n=0], p=0.034). Despite higher surgical complexity in the PBM cohort, there were no differences in major complications (stroke, tracheostomy, dialysis) or mortality and no differences in the percentage of patients transfused with red blood cells (RBCs), cryoprecipitate, platelets, or cell salvage blood. Blood product waste was lower in the PBM group for the four principal blood products (RBCs, FFP, platelets, cryoprecipitate).
Conclusions
A contemporary Patient Blood Management program in acute TAAD with point-of-care viscoelastic testing reduced FFP transfusion and blood product waste without any adverse effects on postoperative outcomes.
Authors
Omar Sharaf (1), Patrick Kohtz (1), Alexis Oglesby (1), Mary Michael (1), Cynthia Garvan (1), Bruce Spiess (1), Melissa Burger (1), George Arnaoutakis (2), Daniel Demos (1), Eric Jeng (1), Tomas Martin (1), Thomas Beaver (1)
Institutions
(1) University of Florida Health, Gainesville, FL, (2) University of Texas at Austin, Austin, TX
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Poster Presenter
Omar Sharaf, University of Florida Health System
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Gainesville, FL
United States
Objective: The use of a frozen elephant trunk has been reported to improve the long-term outcomes of acute type A aortic dissection. The fenestrated elephant trunk operation has recently been introduced to simplify arch vessel reconstruction. We employ the tear-oriented replacement strategy and use the frozen elephant trunk selectively. The aim of this study was to review the early and long-term outcomes of surgical treatment for acute type A aortic dissection in our hospital.
Methods: One hundred and forty-two patients who underwent emergent surgery for acute type A aortic dissection from January 2010 to November 2023 were included in this study. All the operations were performed using selective antegrade cerebral perfusion under moderate hypothermia. To prevent anastomotic leakage into the false lumen, we reinforced the aortic stump with a Dacron strip internally and a Teflon felt externally, and glued the false lumen using the Bioglue. Frozen elephant trunk was used for younger patients and those with dynamic malperfusion of the lower torso since November 2017. Patient characteristics and surgical outcomes were retrospectively evaluated. The median observation period was 77 months (0.2 - 170).
Results: Mean age was 68±13 (range 32-91) years. Seventy-three (51%) were male. Preoperative cardiopulmonary resuscitation (CPR) was required in 7 patients (5%). There were 128 classical dissection (90%). Thirty-two patients (23%) had cardiac tamponade and 44 (31%) had organ malperfusion (coronary 5; brain 16; mesenteric 3; renal 7; lower limb 20). Surgical procedures included 59 ascending or hemiarch replacement (5 with aortic root replacement), 40 partial arch replacement (1 or 2 separate tube grafts for arch vessel reconstruction; 1 with aortic root replacement), and 28 total arch replacement (7 with root replacement). Frozen elephant trunk was used in 28 (20%). Distal aortic anastomosis was created at zone-2 in 20 and zone-3 in 8. The trunk was fenestrated in 11. In-hospital mortality was 4.2% (6 of 142). Multivariable analysis revealed that preoperative CPR was an independent predictor of hospital death. The survival rate including in-hospital mortality was 91% at 1 year, 89% at 3 years, and 86% at 5 years. There were 13 late deaths including 4 aorta-related deaths (1 month, 2 months, 5 years, and 10 years). Freedom from reoperation rate was 98% at 1 year, 97% at 3 years, and 93% at 5 years. There were 7 reoperations. The causes of reoperations included 2 proximal pseudoaneurysms at 5 and 7 years, 1 distal pseudoaneurysm at 4 years, 1 distal aortic dilatation at 6 years, 1 SINE at 4 months, graft infection (Salmonella) at 2 years, and 1 endoleak of fenestrated frozen elephant trunk at 6 months. There was no mortality after reoperation.
Conclusions: Contemporary early and long-term surgical outcome of acute type A aortic dissection was excellent. Our tear-oriented strategy and selective use of the frozen elephant trunk seem justified.
Authors
Daisuke Takahashi (1), Norihiko Shiiya (1), Naoki Washiyama (1), Kazumasa Tsuda (1)
Institutions
(1) Hamamatsu University Hospital, Hamamatsu, Japan
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Poster Presenter
Daisuke Takahashi, Hamamatsu Univercity School of Medicine
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Hamamatsu
Japan
Objective:
Although hemiarch surgery is associated with reduced cardiopulmonary bypass (CPB), aortic cross clamp, and circulatory arrest times relative to total arch surgery, acute kidney injury remains a significant complication that contributes to in-hospital morbidity and mortality. Prior studies have investigated long-term survival after acute kidney injury in type A aortic dissection, however, these studies have included different methods of arch management. We evaluated hemiarch patients for pre-operative and operative characteristics that place patients at risk for developing acute kidney injury, any corresponding in-hospital outcomes, and subsequent long-term mortality after acute kidney injury.
Methods:
We performed a retrospective review of 616 patients who underwent hemiarch replacement at our institution from 2011-2023. AKI was categorized based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria which accounts for change from preoperative renal function. Pre-operative and operative characteristics, as well as post-operative outcomes were analyzed for relationship to AKI development. A multivariate logistic regression model was used to identify risk factors associated with AKI. Adjusted Cox proportional hazard regression was used to determine long-term mortality after acute kidney injury, using time to last documented follow-up with any provider or date of mortality to determine duration.
Results:
Any degree of AKI occurred in 198/616 (32.1%) of cases. On univariate analysis, multiple pre-operative variables were associated with acute kidney injury, including age (p=0.020), BMI (0.018), baseline CKD (0.011), and procedural urgency (p<0.001). Regarding operative variables, prolonged CPB (p<0.001), aortic cross-clamp (p=0.015), circulatory arrest (p<0.001) were associated with worsening AKI. Lower nadir bladder temperature was associated with worsening AKI (p<0.001), however, temperature ranges were in the range for moderate hypothermia. Rates of intraoperative transfusion of packed red blood cells, fresh frozen plasma, platelets, and post-operative open chest were higher for more severe AKI (p<0.001). Length of stay, ICU length of stay, coagulopathy, delirium, prolonged ventilation, infection, need for adjunctive mechanical circulatory support, and mortality were all significantly higher in Stage 3 kidney injury (p<0.001).
Multivariate logistic regression of significant pre-operative and operative variables demonstrated a significant relationship with development of any AKI (AUC 0.738, p<0.001). Significant predictor variables included BMI (p=0.007) and procedural urgency (0.004).
All cohorts had excellent post-discharge follow-up, with median follow-up for all groups exceeding 1000 days. Post-discharge mortality was significantly higher in the stage 3 KDIGO group (p=0.048), with adjusted Cox proportional hazard demonstrating a significant increase in mortality for patients with stage 3 AKI (p<0.001).
Conclusions:
AKI after hemiarch surgery of any degree is common, with more severe AKI increasing risk for short-term morbidity and mortality. Hemiarch patients with severe stage 3 AKI face not only the greatest risk of in-hospital mortality, but significantly increased risk of post-discharge mortality.
Authors
Adam Carroll (1), Michal Schafer (1), William Riley Keeler (1), Jintong Liu (1), Nicolas Chanes (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective:
Deep hypothermic circulatory arrest (DHCA) in patients undergoing descending (DTA) or thoracoabdominal aortic aneurysm (TAAA) repair is associated with increased morbidity, particularly pulmonary complications, and mortality. We present our outcomes after open DTA and TAAA repair with and without DHCA.
Methods:
We performed a retrospective review of a prospectively maintained aortic database. From 1998 to 2022, 267 patients underwent open DTA or TAAA repair by a single surgeon. Of these, 81 (30.3%) patients required DHCA because proximal cross-clamping was not feasible or aneurysmal pathology extended into the arch. The other 135 (50.6%) patients required either atrial-femoral bypass or femoral-femoral bypass. Of those that used atrial-femoral bypass, 30 (41.7%) patients had DTA repair and 42 (58.3%) patients had TAAA repair. Of those that used femoral-femoral bypass, 21 (31.3%) patients had DTA repair and 46 (68.6%) patients had TAAA repair. There were 59 (72.8%) DHCA patients and 86 (63.7%) non-DHCA patients with DTA or Crawford extent I TAAAs. The 51 (19.1%) patients who underwent surgery with the clamp-and-sew technique were excluded. Because of intrinsic pathological differences in patients requiring DHCA, confidence intervals were used to compare groups in lieu of p-values.
Results:
DHCA patients had more chronic dissections (64.2% vs 42.2%, 95% CI for difference: 0.08 - 0.36) and higher BMIs (29.5 ± 6.8 vs 27.3 ± 6.7, CI: 0.12 - 4.07). More non-DHCA patients had medial degeneration (9.9% vs 31.1%, CI: -0.33 - -0.07) and diabetes (11% vs 23%, CI: -0.23 - -0.01). There were 10 (12.4%) in-hospital deaths for the DHCA and 10 (7.4%) for the non-DHCA group (CI: -0.04 - 0.14). There were 4 (4.9%) in the DHCA and 5 (3.7%) in the non-DHCA group that developed stroke (CI: -0.05 - 0.08). Two (2.5%) patients in the DHCA group and two (1.5%) patients in the non-DHCA group developed permanent paraplegia (CI: -0.04 - 0.06). Three (3.7%) in the DHCA and nine (6.7%) in the non-DHCA group developed renal failure requiring dialysis (CI: -0.10 - 0.04). There were no differences in the incidence of pulmonary complications, particularly prolonged ventilation (>48 hours) (46.3% vs 36.3%, CI: -0.04 - 0.25), pneumonia (17.3% vs 12.9%, CI: -0.05 - 0.16), or tracheostomy (12.4% vs 13.3%, CI: -0.11 - 0.09) between DHCA and non-DHCA, respectively. The only meaningful differences in postoperative outcomes were ICU (5.5 (IQR: 3-19.75) days vs 6 (IQR: 4-10) days, CI: 0.43-9.0) and hospital length of stays (19 (IQR: 11-29) days vs 12 (IQR: 10-19) days, CI: 2.4-14.2), which were both longer in the DHCA group (Table 1).
Conclusions:
Despite longer ICU and hospital length of stays, DHCA is safe and effective with comparable morbidity and mortality to non-DHCA in open DTA and TAAA repair.
Authors
joshua chen (1), Vishal Shah (1), Scott Koeneman (2), Jacqueline McGee (1), Megary McCoy (1), Colin King (1), Jeffrey Zucker (1), Konstadinos Plestis (1)
Institutions
(1) Thomas Jefferson University Hospital, Philadelphia, PA, (2) Sidney Kimmel Medical College, Division of Biostatistics, Philadelphia, PA
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Poster Presenter
joshua chen, Thomas Jefferson University Hospital
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philadelphia, PA
United States
Objective: Immediate versus delayed treatment of acute type A aortic dissection (ATAAD) with concurrent stroke in the absence of severe aortic insufficiency (AI) or aortic rupture is controversial. We report 2 cases of successful delayed repair of ATAAD with concurrent stroke.
Patient 1:
A 60-year-old hypertensive male presented in an unresponsive state with right gaze deviation.
Computerized tomography angiography (CTA) revealed an ATAAD extending from the sinotubular junction into the bilateral carotid arteries with decreased perfusion to the frontoparietal regions of the brain (Figure 1A). MRI demonstrated acute infarcts in the left hippocampus, cerebellum, and basal ganglia.
Because of the patient's significant neurological deficits, risk for hemorrhagic conversion and absence of severe AI or pericardial effusion on echocardiogram, a decision was made to delay surgical repair and treat the patient medically with strict blood pressure control and anticoagulants. Although the patient had residual left-sided hemiplegia, the patient was discharged approximately 2 months after admission with significant improvement in his neurological status. Two months later, the patient was taken for proximal aortic repair with bypasses to the bilateral carotid arteries using a trifurcated graft. Operative management included femoral artery cannulation, deep hypothermic circulatory arrest (DHCA) and retrograde cerebral perfusion.
Patient 2:
A 63-year-old hypertensive male with recurrent strokes and bicuspid aortopathy requiring aortic valve replacement 15 years ago presented with altered mental status, aphasia, and right-sided hemiplegia.
CTA revealed ATAAD originating from the aortic root with dissection flaps extending into the innominate and left carotid and subclavian arteries (Figure 1B). Echocardiogram showed no severe AI or pericardial effusion. Brain MRI revealed several ischemic infarcts in the left cerebral hemisphere. Immediate surgical repair was delayed due to the patient's significant neurological deficits. Strict blood pressure control was maintained, and the patient was monitored for symptom progression. Three days later, computed tomography of the head revealed new watershed infarcts in the left hemisphere.
Repeat CTA 4 days later demonstrated partial false lumen thrombosis of the proximal root dissection and a decision was made to further delay surgery. The patient was subsequently discharged to a rehab facility. Five months later, the patient had complete resolution of his stroke symptoms. Interval CTA showed aortic dilation from 5.0 to 6.5 cm. The patient underwent proximal aortic repair and left carotid artery bypass with reoperative sternotomy, right subclavian cannulation, DHCA, and bilateral antegrade cerebral perfusion.
Results:
Patients 1 and 2 were discharged on PODs #21 and #11, respectively. On discharge, Patient 1 had residual, but improved left-sided hemiplegia from his initial stroke. Patient 2 had no significant neurological deficits or other complications on discharge.
Conclusions: When the risks of surgery, such as permanent neurological damage or hemorrhagic conversion outweigh the benefits, delayed repair of ATAAD with concurrent stroke is a feasible and safe approach.
Authors
Siddharth Vemuri (1), joshua chen (1), Vishal Shah (1), Colin King (1), Megary McCoy (1), Jacqueline McGee (1), Konstadinos Plestis (1)
Institutions
(1) Thomas Jefferson University Hospital, Philadelphia, PA
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Poster Presenter
joshua chen, Thomas Jefferson University Hospital
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philadelphia, PA
United States
Objective
Advances in aortic root replacement substitutes and surgical technique have significantly improved outcomes. However, re-implantation of the coronaries can carry significant risk when the coronary buttons are of poor quality, potentially compromising cardiac function due to malperfusion. Prior studies have suggested that when re-do root replacement is performed, unplanned CABG increases mortality, but no study has focused solely on comparing the two groups regardless of prior procedure. We compared patients who underwent aortic root replacement with concomitant coronary artery bypass grafting (CABG) at our institution, reviewing their pre-operative and operative characteristics, and subsequent outcomes.
Methods
We reviewed aortic root replacements with simultaneous CABG at our institution from 2011-2023 using our prospectively maintained retrospective database. Patients were stratified into two cohorts based on whether the CABG was unplanned or planned. In total, 33 patients were identified that underwent root replacement with concomitant CABG.
Results
In total, 11 CABG were unplanned, and 22 were planned. In all unplanned cases, the CABG was performed due to poor quality of the coronary button. Seven unplanned patients required mechanical circulatory support, compared to one planned patient (p=0.006). Cardiopulmonary bypass (p=0.001) and circulatory arrest (p=0.33) when an adjunctive aortic procedure was performed were significantly higher in the unplanned group. Intraoperative RBC (p=0.039) and FFP (p=0.007) administration was higher in the unplanned group, with most patients left with an open chest (p<0.001). Post-operatively, unplanned CABG patients required prolonged ventilation (p=0.003), and most patients died during their hospitalization (p=0.018).
Conclusion
Unplanned CABG in aortic root replacement due to non-viable coronary buttons significantly increases patient morbidity and mortality, with the majority of patients left open, needing significant blood product transfusion, requiring adjunctive mechanical circulatory support, and ultimately leading to in-hospital mortality.
Authors
Adam Carroll (1), Michael Kirsch (1), Nicolas Chanes (1), Bo Chang Wu (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective
Severe coarctation of the aorta can be challenging to treat. Intravascular stent graft therapy is a well-established therapeutic option; however, proper positioning and shape of the graft is critical. We describe the case of a pediatric patient who likely developed a pseudoaneurysm, requiring re-operation, due to the angulation created by the initial stent graft.
Methods:
We discuss the case of a 14-year-old male who was found to have a near complete interruption of his aorta at the site of a coarctation involving the distal transverse arch and descending thoracic aorta. The patient previously had a stent graft placed across this interruption, but the placement of the graft created an angulation with the patient's distal arch. The patient developed bacteremia and was found to have developed a multilobular pseudoaneurysm proximal to the previously placed stent graft.
Results:
The patient described above was taken to the OR for resection of the infected stent graft, resection of the pseudoaneurysm, and interposition graft repair of the coarctation. The pseudoaneurysm may have developed due to the graft causing erosion into the aorta or due to the angulation created between the graft and the patient's distal arch leading to stasis of blood flow; however, both are the result of the stent graft not being congruent with the patient's coarctation anatomy. Due to the complication, a higher risk procedure needed to be performed, and a distal arch replacement was required. Intraoperatively, the patient was found to have severe inflammation around the stent graft that also involved the vagus nerve and the recurrent laryngeal nerve. The aorta was opened, and the inflammatory tissue, pseudoaneurysmal tissue, and stent graft were removed. An 18mm antibiotic-soaked dacryon graft, was then sized and inserted. An anastomosis of this graft was carried out to the proximal aorta with a small incision created up onto the left carotid artery to enlarge the anastomosis to treat the hypoplastic transverse arch. Enlarging the anastomosis helped ensure that the new graft would create less of an angulation with the transverse arch, thereby decreasing the potential for static blood flow to prevent development of another pseudoaneurysm. Next, the subclavian artery was anastomosed onto the graft, completing the reconstruction. Post-procedure echo demonstrated a mildly increased velocity of 2.1 m/s at anastomosis, proximal to the left common carotid, with otherwise normal aortic flow pattern and normal left ventricular (LV) systolic function. The patient's post-operative course was otherwise uncomplicated, and the patient was discharged with oral antibiotics on hospital day 12 at baseline neurologic status.
Conclusion:
For patients with distal aortic arch coarctation, consideration of aortic shape and angulation is critical in treatment, given the potential for disruptions in laminar flow. Although managed successfully in this case report, therapies such as thoracic branched endografts or more novel technologies suited for the transition from the arch to the descending aorta, should be considered. These therapies may provide more coverage and create a better landing zone, thus reducing angulation and optimizing blood flow.
Authors
Adam Carroll (1), Ananya Shah (1), Muhammad Aftab (1), James Jaggers (2), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO, (2) Children's Hospital Colorado, Aurora, CO
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Poster Presenter
Ananya Shah, University of Colorado Anschutz
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Fort Collins, CO
United States
Objective: The primary objective of this study was to develop an advanced predictive model for acute kidney injury (AKI) in patients diagnosed with acute type A aortic dissection (ATAAD) by novel machine learning (ML) algorithms to timely intervention and improving prognosis.
Methods: From January 2014 to December 2019, a total of 640 patients diagnosed with ATAAD was enrolled in. The study leveraged the Scikit-learn toolkit and employed one-way analysis of variance (ANOVA) to identify and select pertinent risk factors that exhibited significant associations with the occurrence of AKI. A Synthetic Minority Over-sampling Technique was subsequently employed to address data imbalances. For the construction of the predictive model, a set of ML algorithms, comprising Logistic Regression (LR), XGBoost, and LightGBM, was utilized. The performance of these models was assessed in terms of the area under the curve (AUC) and accuracy (ACC). The Shapley Additive Explanations (SHAP) interpreter was implemented to provide insights into the key risk factors contributing to AKI.
Results: Among the ATAAD patients considered in the study, 74 individuals (11.56%) developed AKI during the post-operative phase of hospitalization. Fifteen highly relevant and statistically significant variables were identified for inclusion in the predictive model. These variables encompassed factors such as the duration of cardiopulmonary bypass (CPB), pre-operative AST levels, the presence of limb syndrome, involvement of the right coronary artery, pre-operative and post-operative creatinine levels, creatine kinase-MB (CK-MB) levels, aortic clamping duration, combined CABG surgery, pre-operative and post-operative WBC counts, lactate dehydrogenase (LDH) levels, the neutrophil-lymphocyte ratio, ALT levels, and neutrophil counts. The predictive models, including LR, XGBoost, and LightGBM, exhibited AUC values of 0.843, 0.879, and 0.887, along with ACC values of 0.801, 0.845, and 0.867, respectively. Notably, the LightGBM model emerged as the most promising model with the highest predictive performance, demonstrating its clinical applicability.
Conclusions: Machine learning models have demonstrated substantial predictive capabilities for identifying postoperative AKI in patients with ATAAD. This study has highlighted a set of variables that can be considered as independent risk factors,offering opportunities for early intervention and improved patient outcomes.
Authors
Yuan Li (1), Shuai Zhang (2), Yi Chang (3), Xiangyang Qian (4)
Institutions
(1) N/A, N/A, (2) Department of Cardiovascular Surgery, Fuwai Hospital, CAMS&PUMC, Beijing, Beijing, (3) N/A, Beijing, China, (4) Fuwai hospital, Beijing, NA
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Poster Presenter
Yuan Li, Fuwai Hospital, CAMS & PUMC
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Beijing
China
Objective
An aortic aneurysm is a life-threatening condition that can cause aortic dissection or rupture and most often requires surgical treatment. In order to successfully perform operations on the thoracic aorta, it is necessary to have a specialized Aortic team that allows to perform complex reconstructive operations with minimal complications. Another option is direct contact to experts or telemedicine. In emergency situations, it is not always possible to use such assistance, experts cannot be available around the clock. Thus, one of the solutions to this problem is the use of an expert system based on artificial intelligence technologies.
The aim of study: Analysis of the development of the EXPERT AI System for the examination of thoracic aortic pathology.
Methods
Currently, work is underway to develop the EXPERT AI System. A team of cardiac surgeons and cardiologists from the Saint Petersburg State University Hospital and Data Science specialists from St. Petersburg State University are involved in the development. The system is based on the use of an ensemble of neural networks and the analysis of a large amount of data, including anthropometry, clinical indicators, computed tomography and transthoracic echocardiography. The main technology used in the work is modern models of convolutional neural networks and transfer learning, which are used in the task of segmentation, including medical images. In particular, the work conducted an experiment to assess the quality of three neural network models: a model based on the U-Net architecture with a ResNet-50 encoder, TransUnet and SWIN transformers. The models under study were implemented in the Python 3 programming language, and PyTorch was chosen as the framework. To analyze the images of the aorta and the learning process of neural networks, both data from existing labeled datasets and computed tomography data of the chest and aorta organs of the patients selected and labeled by us were used.
Results
At the moment, 3 neural network models ("U-Net+ResNet-50", TransUnet and SWIN) have been developed and trained for automatic detection of the aorta of the heart on CT scans and methods for constructing its digital 3D model in full size. The resulting digital model of the aorta is planned to be used as a preparatory data processing procedure for neural network methods for segmenting the diameter of the aorta, searching and detailing pathological abnormalities/disorders in the aorta.
Conclusions
The widespread use of artificial intelligence in cardiac surgery is just beginning. However, our team is one of the leaders in this area. The lack of a sufficient number of experts in the field of aortic surgery, as well as the need for assistance in decision-making, is a key problem that can be solved through the use of an expert system.
Authors
Gleb Kim (1), Ivan Blekanov (2), Murad Dadashov (3)
Institutions
(1) N/A, Russia, (2) Saint Petersburg State University, Saint Petersburg , NA, (3) Saint Petersburg State University, Saint Petersburg, NA
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Poster Presenter
Gleb Kim, Saint Petersburg University
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Saint Petersburg
Russia
Objective: Guidelines for intervention on ascending aortic aneurysm repair are based on data from retrospective studies with no evidence from prospective trials. TITAN: SvS (Treatment in Thoracic Aortic aNeurysm: Surgery versus Surveillance) is the largest prospective multi-center study of patients with ascending aortic aneurysms between 5.0-5.4 cm with aim to randomize patients to initial surgery versus surveillance. For patients not randomized, they are enrolled into either an operative registry (surgery as initial treatment), or a surveillance registry (surveillance as initial strategy). We compare patient characteristics for subjects in the randomized and the registry arms of the TITAN:SvS study to understand factors behind patient selection for each strategy.
Methods: Demographic characteristics of 615 patients prospectively enrolled at 22 sites into the TITAN study (9/2018-12/2023) were analyzed and compared between randomized (n=210) and registry arms (operative registry n=147; surveillance registry n= 258). Preoperative characteristics, aortic size, indexed aortic parameters and country and site wise distribution of patients were compared. Categorical variables were compared with chi-square or Fischer's exact test. Continuous variables were compared with one-way ANOVA or Wilcoxon rank-sum test where appropriate.
Results: Patients in the surveillance registry have the most co-morbidities: older, more HTN, dyslipidemia, CAD, Afib, DM, CVA, pHTN and PVD (Table 1). No significant difference was noted in maximal ascending aortic diameter (5.1±0.3, 5.0±0.3, 5.1±0.5cm, p=0.2) or indexed aortic size in the randomized, operative or surveillance registry groups respectively. There was no significant difference in groups in the number of patients above the indexed aortic size, indexed aortic height or indexed aortic area thresholds for intervention suggested in the 2022 ACC/AHA aortic guidelines. Despite similar number of enrolling centers in the USA (n=11) and Canada (n=12), 91% (191/210) of patients in the randomized arm were enrolled in Canada. Of Canadian patients (n=332), 58% were randomized, 9% enrolled in the operative registry, 34% enrolled in the surveillance registry. Of US patients (n=283), 7% were randomized, 42% enrolled in the operative registry, 51% enrolled in the surveillance registry.
Conclusions: Early data from the largest ever prospective multicenter study on ascending aortic aneurysms reveals that patient characteristics rather than ascending aortic size seem to be the main factor driving decision making regarding initial treatment strategy, with younger healthier patients being offered surgery more often. These data suggest that the published outcomes of operative registries cannot be universally applied, as sicker patients may have been excluded. There is a geographic difference in enrollment with Canadian sites contributing heavily to the Randomized arm and US sites contributing heavily to the Registry arms. Reasons for this are likely multifactorial, but may include differences in patient preferences, surgeon perspectives, referral patterns and insurance/healthcare system structures. US vs. Canadian differences in participation has implications both for completion of Titan:SvS and for future randomized trials comparing surgical to conservative therapies. Future trials may consider a strategy of having a parallel registry to an RCT to interpret RCT data alongside contemporary real-world insights.
Authors
Sarah Brownlee (1), Munir Boodhwani (2), Jehangir Appoo (3), Ming Hao Guo (2), Adham Makarem (4), Philippe Demers (5), Michael Chu (6), Rony Atoui (7), William Brinkman (8), John Bozinovski (9), Francois Dagenais (10), Nimesh Desai (11), Ismail El-Hamamsy (12), Juan Grau (13), G. Chad Hughes (14), Kevin Lachapelle (15), Maral Ouzounian (16), Himanshu Patel (17), Zlatko Pozeg (18), Richard Whitlock (19), Arminder Jassar (1)
Institutions
(1) Massachusetts General Hospital, Boston, MA, (2) University of Ottawa Heart Institute, Ottawa, ON, (3) Libin Cardiovascular Institute, University of Calgary, Calgary, AB, (4) Massachusetts General Hospital, BOSTON, MA, (5) Montreal Heart Institute, Montreal, QC, (6) University Hospital, London Health Sciences Centre, London, Canada, (7) Northern Ontario School of Medicine, Sudbury, ON, (8) Baylor Scott & White Health, TX, (9) Ohio State University Wexner Medical Center, Columbus, OH, (10) Quebec Heart and Lung Insitute, Quebec, Quebec, (11) University of Pennsylvania, United States, (12) Mount Sinai Hospital, New York, NY, (13) The Valley Hospital, Ridgewood, NJ, (14) Duke University Medical Center, Durham, NC, (15) Division of Cardiac Surgery, McGill University Health Centre, Montreal, QC, (16) Toronto General Hospital, Toronto, ON, (17) University of Michigan Hospital, Ann Arbor, MI, (18) New Brunswick Heart Centre, Saint John, New Brunswick, (19) Population Health Research Institute, Hamilton, Canada
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Poster Presenter
Adham Makarem, Massachusetts General Hospital
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Boston, MA
United States
Objective
Cardiac tamponade is associated with fatal outcomes for patients with acute type A aortic dissection (AAAD), and the presence of cardiac tamponade should prompt urgent aortic repair. Many centers report performing pericardiocentesis in critical cardiac tamponade to release prolonged hypotension and low cardiac output and maintain the patient's condition before doing an urgent aortic repair. However, the treatment of the patient with moderate cardiac tamponade remains unclear whether we choose pericardiocentesis first or urgent aortic repair without pericardiocentesis. We report our experience with immediate aortic repair of AAAD.
Methods
A 54-year-old female patient was transferred from another hospital with the main complaint of shortness of breath. She also experienced chest pain and epigastric pain. Echocardiography showed moderate pericardial effusion, EF 63%, TAPSE 3.1 cm, anteroseptal hypokinetic and other segments are normal-kinetic. A computed tomography (CT) scan revealed aortic dissection Stanford A DeBakey type 1 and fluid accumulation around the heart.
Intraoperative findings: 400 cc of pericardial blood, entry tear on the ascending aorta, AoX time of 81 minutes, CPB time of 120 minutes, ASCP of 22.47 minutes, and circulatory arrest of 29.28 minutes. The lowest temperature during CPB was 26°C. Cannulation technique: femoral artery and right atrium. We performed ascending replacement + extended hemiarch procedure. The patient was discharged after 10 days in a stable condition.
Results
In this case, we preferred to perform urgent aortic repair without pericardiocentesis because the hemodynamics were still stable. If we had performed pericardiocentesis first, the procedure would have only provide temporary relief by reducing the pressure on the heart, but it would not have prevent the progression of AAAD, resulting in a higher mortality rate.
Conclusion
The choice between these two options may depend on the patient's overall condition, the severity of the tamponade, and the availability of resources and expertise to perform urgent aortic surgery. If we are in an aortic center and adequately prepared preoperatively, open aortic repair is a treatment option.
Authors
Maulidya Ayudika Dandanah (1), Budhi Adhiwidjaja (2), Dicky Aligheri Wartono (3)
Institutions
(1) Siloam Lippo Village, UPN Medical Faculty, Jakarta, Indonesia, (2) Siloam Lippo Village, Jakarta, Indonesia, (3) Siloam Lippo Village, Harapan Kita National Cardiovascular Center, Jakarta, Indonesia
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Poster Presenter
Maulidya Ayudika Dandanah
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Kabupaten tangerang, banten
Indonesia
Objectives
The right axillary artery is a common alternative arterial cannulation site for certain cases requiring cardiopulmonary bypass. Previous studies have found direct axillary artery cannulation (AAC) associated with an increased risk of stroke and cannulation-related complications compared to cannulation with a side graft. We sought to analyze our institutional experience and hypothesized that there would be no difference in stroke rates by the AAC method.
Methods
We identified all patients who underwent AAC between January 2011 and June 2022 using our institutional Society of Thoracic Surgeons adult cardiac surgery database. The cannulation technique was based on the surgeons' discretion. A chart review was performed to confirm the AAC method, measure the axillary artery diameter, and to obtain additional outcomes of axillary artery cannulation-related complications. Patients were divided into two cohorts based on the cannulation technique: direct cannulation (n=131) vs. cannulation using a side graft (n=333). The primary outcome was stroke, and secondary outcomes included operative mortality, axillary artery cannulation related complications, blood product use, reoperation, and new dialysis requirement. Baseline demographics, operative characteristics, and outcomes were compared using Wilcoxon rank sum test or Fisher's exact test as appropriate.
Results
There was no difference in sex, age, race, BMI, diabetes, preoperative creatinine, lung disease, peripheral vascular disease, immunocompromised, cerebrovascular disease, cardiogenic shock, heart failure, connective tissue disorder, aortic pathology (acute dissection, aneurysm, degenerative aneurysm), urgent/emergent status, reoperation, cardiopulmonary bypass or cross clamp time between the groups. Direct axillary artery cannulation cohort had a higher proportion of hypertension (88.5% vs 79.0%, p=0.02), a slightly larger median axillary artery diameter (8.1 mm vs 7.8 mm, p<0.01), a higher proportion of patients with previous aortic operation (26.0% vs 17.1%, p=0.04), and underwent more partial arch replacements (19.8% vs 8.7%, p<0.01) and cases requiring circulatory arrest (83.2% vs 71.2%, p=0.01). The side graft cohort had a longer median procedure time (428.2 minutes vs 404.1, p=0.04). Outcomes are presented in Table 1. There was no difference in the primary outcome of stroke between the groups (9.9% direct vs 8.4% side graft, p=0.59). In addition, there was no difference in the secondary outcomes of operative mortality, axillary cannulation related complications, blood products used, reoperation, or new dialysis requirements.
Conclusions
Overall complications from axillary artery cannulation were low. There was no difference in stroke rate or cannulation-related complications between direct versus side graft AAC in our institutional cohort. Direct axillary artery cannulation had a shorter median procedure time. These findings suggest that direct axillary artery cannulation is a safe technique for arterial cannulation.
Authors
Dane Paneitz (1), Duc Giao (2), Fernando Ramirez Del Val (3), George Tolis Jr (4), Motahar Hosseini (3), Jordan Bloom (3), Asishana Osho (3), Nathaniel Langer (3), Eriberto Michel (3), Serguei Melnitchouk (3), David D'Alessandro (3), Thoralf Sundt (3), Arminder Jassar (3)
Institutions
(1) Johns Hopkins Hospital, Baltimore, MD, (2) Harvard Medical School, Boston, MA, (3) Massachusetts General Hospital, Boston, MA, (4) Brigham and Women's Hospital, Boston, MA
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Poster Presenter
Dane Paneitz, The Johns Hopkins Hospital
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Baltimore, MD
United States
Objective: Thoracic aortopathy (TAAD) often occurs with aortic valve pathology (stenosis, AS or regurgitation, AR) which may impact TAAD phenotype and severity. We compared proteomic and phosphoproteomic profiles of TAAD aortas with AS, AR, mixed (AS+AR), and normal valves to determine whether valve disease-associated aortopathy is phenotypically distinct.
Methods: 176 aortic samples (root, ascending, and arch) were collected prospectively from TAAD and dissection individuals with various aortic valve phenotypes (Figure 1A). All samples were analyzed using a novel deep-coverage protocol for mass spectrometry proteomics (data independent acquisition) and double enrichment technique to identify phosphorylation sites in detected proteins. Proteomic and phosphoproteomic data were directly compared by valve morphology (p<0.05 considered significant) to determine impact of valve function on aortopathy biochemical profile.
Results: Samples included N=123 males (74%) and mean age was 58±16. Among samples derived from individuals with concomitant valve disease, N=70 were AR-associated, N=41 were AS-associated, and N=11 were AS+AR. Considering the entire cohort, we quantified 6094 proteins and 2125 phosphorylation sites. At the proteomic level, when AS+AR was compared to normal valve-associated aortopathy, 721 proteins were differentially expressed (174 up in AS+AR, 547 down in AS+AR Figure 1B). Additionally, AR-associated aortopathy was associated with substantial phenotypic differences in both proteomic (total proteins 651; up in AR: 216; down in AR: 435) and phosphoproteomic data sets (total sites 210; hyperphosphorylated in AR: 96; hypophosphorylated in AR: 114 Figure 1B). Examining proteomic profiles in more detail, cytoskeletal proteins were predominantly decreased in AR-associated aortopathy while both hyper- and hypo-phosphorylation of cytoskeletal proteins was observed in AR (Figure 1C).
Conclusion: We performed the first multiproteomic analysis of aortopathy by aortic valve function on a large cohort of human samples using a novel protocol. Valve dysfunction, especially AR, is associated with altered aortic tissue biochemistry which suggests differences in mechanism and progression of aortopathy.
Authors
Malak Elbatarny (1), Uros Kuzmanov (2), Daniella Eliathamby (3), Jennifer Chung (4), Craig Simmons (5), Anthony Gramolini (2), Maral Ouzounian (3)
Institutions
(1) TGH / St Michael's, Toronto, ON, (2) University of Toronto, Toronto, NA, (3) Toronto General Hospital, Toronto, ON, (4) Toronto General Hospital, Toronto, Ontario, (5) University of Toronto, Toronto, Ontario
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Poster Presenter
Malak Elbatarny, University of Toronto
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Toronto, ON
Canada
Do Collagen Impregnated Frozen Elephant Trunk Stent Grafts Bleed Less Than Non-Collagen Impregnated Grafts?
Ravi J De Silva, Shiu Chung Tam, Martin Muir, Aravinda Page, Ismail Vokshi, Fouad J Taghavi, Shakil Farid, Florian Falter
Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
Objectives
Aortic arch surgery is complex and prone to bleeding. There are several manufacturers of stent-graft prostheses which are used to perform a frozen elephant trunk (FET) procedure. The greatest international experience is with a collagen impregnated vascular graft attached to a nitinol reinforced stent (FET-C). A similar prosthesis with some unique features has been introduced which has a non-collagen impregnated vascular graft (FET-NC). Anecdotal experiences report these new grafts to be more porous and prone to bleed, presumably due to a lack of the collagen in the vascular graft. We reviewed our experience of these two prostheses to better understand if collagen impregnation of the vascular graft has any impact on post-operative bleeding or transfusion requirements.
Methods
We have performed more than 200 FET operations, but retrospectively reviewed our last 50 consecutive FET procedures including emergency cases. This case series included the introduction of the newer non-collagen impregnated graft (FET-NC). Electronic medical records were used to ascertain patient demographic and operative details, post operative bleeding and transfusion requirements.
Results
Of the last 50 consecutive frozen elephant trunk procedures, 33 used the FET-C prosthesis (table 1). 22 of these were elective, 7 were redo cardiac, and 7 needed additional concomitant cardiac surgery. Of the 17 FET-NC cases, 13 were elective, 3 redo cardiac, and 2 required additional concomitant cardiac surgery. There was no statistical difference in age (FET-C 70.5 years, FET-NS 74.0 years, p=0.07) and sex (FET-C 52% male, FET-NC 57% male, p=0.51) of the two groups. There was no difference in cardiopulmonary bypass time (FET-C 243', FET-NC 198', p=0.33) or lower body ischemic time (FET-C 35', FET-NC 28', p=0.28). All patients were cooled to a core temperature of 250C.
Average chest drain output after 24 hours was similar in both groups (FET-C 550ml, FET-NC 552 ml, p=0.43). There was no statistical difference in average chest tube drainage in the second 24 hours after surgery (FET-C 450ml, FET-NC 425ml, p=0.60).
With respect to post operative transfusion requirements there was no difference in average requirement for packed red blood cells (FET-C 5 units, FET-NC 6 units, p=0.27), fresh frozen plasma (FET-C 4 units, FET-NC 4 units, p=0.98), platelets (FET-C 2 units, FET-NC 2 units, p=0.31) or cryoprecipitate (FET-C 1 unit, FET-NC 2 units, p=0.40).
Conclusions
In our series of 50 consecutive cases, we find no evidence to suggest non-collagen impregnated frozen elephant trunk prostheses are more likely to bleed or require increased post-operative transfusion.
Authors
RAVI DE SILVA (1), Shiu Tam (1), Martin Muir (1), Aravinda Page (1), Ismail Vokshi (1), Fouad Taghavi (1), Shakil Farid (1), Florian Falter (1)
Institutions
(1) Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire
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Poster Presenter
RAVI DE SILVA, Royal Papworth Hospital
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CAMBRIDGE, Cambridgeshire
United Kingdom
Does the distal ascending aorta and arch grow following aortic root and ascending aorta replacement?
Krishna Mani, Rajdeep Bilkhu, Frank Schroeder, Marjan Jahangiri
Objective: We aim to assess the growth of distal ascending aorta and arch following aortic root replacement (ARR) and aortic valve replacement (AVR) + ascending aorta replacement (AAR).
Methods: A retrospective analysis of 184 consecutive patients who underwent ARR and AVR+AAR, between 2016 and 2022 was carried out (significant reduced activity during COVID). Patients with dissection and arch surgery were excluded. All patients underwent pre-operative CT scanning and follow-up at 6 months, 1 year and then annually.
Results: Of 184 patients, 60 had bicuspid aortic valve. 121 (66%) had ARR and 63 (34%) had AAR + AVR. Mean age was 60, 70% were male. Median cross-clamp and bypass times were 80 (range, 31-169) and 97 (range, 40-180) minutes, respectively. There were 2 (1.1%) in-hospital deaths. 3 (1.6%) patients had transient ischemic attacks/strokes and 3 (1.6%) had resternotomy for bleeding. Median ICU and hospital stays were 2 and 8 days, respectively. Median follow-up was of 4.3 years (1-82 months). The preoperative median ascending aorta and aortic arch diameters were 48.2 (range, 23-99) mm and 32.2 (range, 23-99) mm, respectively. The latest follow-up diameters of the distal ascending aorta were 32.4 (range, 23-41) mm and arch of 30.8 (range, 20-54) mm, respectively. No patients required surgery to the residual aorta.
In the bicuspid aortic valve subgroup, 54 (90%) had ARR and 6 (10%) had AAR + AVR. Mean age was 56 years and 90% were male. There was 1 (1.7%) in-hospital death and 1 (1.7%) patient had a TIA/stroke. The preoperative ascending aorta and aortic arch diameters were 48.2 (range, 26-65) mm and 31.2 (range, 23-49) mm respectively. The latest follow-up diameters of the distal ascending aorta were 32 (range, 27-45) mm and arch of 29.3 (range, 23-43) mm.
Conclusion: Our data does not support the practice of prophylactic arch replacement in patients undergoing ARR and AAR. The remainder of the aorta doesn't seem to grow in non-syndromic patients at four years follow-up and therefore there may not be a need for prolonged surveillance.
Authors
Krishna Mani (1), Rajdeep Bilkhu (1), Frank Schroeder (1), Marjan Jahangiri (2)
Institutions
(1) St. George's Hospital, London, NA, (2) St. George's Hospital, London, United Kingdom
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Poster Presenter
Krishna Mani, St George’s University Hospital NHS Foundation Trust London
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London
United Kingdom
Objective
This study aims to assess the effectiveness of the Ross procedure in reversing cardiac damage among patients who have previously undergone a prosthetic aortic valve replacement (pAVR) and are presenting with a stenotic dysfunctional prosthesis.
Methods
Patients aged between 18 and 65, who underwent either a Ross procedure (n=32) or a redo pAVR (n=23) due to stenotic structural prosthesis dysfunction, were identified. Those who had undergone other valvular interventions (n=6), coronary artery bypass surgery (n=7), or an AVR using a homograft (n=8) were excluded. In our institutional Ross database, echocardiographic data from the Ross procedure group were prospectively gathered. Echocardiographic data for patients who underwent a redo pAVR were collected retrospectively. The primary endpoint is the assessment of cardiac damage on echocardiogram overtime, categorized into five stages based on the definition by Généreux et al.1 Secondary endpoints included the aortic valve area (AVA), mean aortic gradient (MAG), and left ventricular (LV) mass overtime. The median follow-up duration was 4.7±1.9 years and 70 follow-up echocardiograms were included in the analysis. Echocardiographic data were analyzed using mixed effect models.
Results
A total of 32 Ross procedures and 23 patients with a redo pAVR were included. Of the Ross patients, 17 (53.1%%) had previously undergone a mechanical AVR and had 15 (46.9%) a biological AVR. In the pAVR group, 17 (73.9%) patients had a mechanical prosthesis and 6 (26.1%%) a bioprosthesis implanted. The Ross group was significantly younger (43±12 years vs AVR 58±7 years, p<0.01). Women represented 49% (n=17) of Ross patients and 35% (n=8) of redo-AVR patients (p=0.42). The preoperative LVEF was similar between groups (p=0.45). In both groups, there is a regression of cardiac damage over 5 years (Figure). In the Ross procedure group, n=15 (48.4%) of patients were in stage 0 of cardiac damage, n=4 (12.9%) in stage 1, (n=7) 22.6% in stage 2, n=4 (12.9%) in stage 3 and n=1 (3.2%) in stage 4. At 5 years, 54.5% (n=6) were in stage 0, 27.3% (n=3) in stage 1, 18.2% (n=2) in stage 2 and none in stages 3 and 4. At 5 years, there was no difference in terms of cardiac damage between groups (p=0.23). The post-operative MAG showed a significantly greater change over time in the pAVR group when compared to the Ross group (4±2 mmHg to 3±2 mmHg versus 15±4 to 17±-6 mmHg at 1 and 5 years respectively, p<0.01). Similarly, the AVA demonstrated a significantly greater increase in the pAVR group compared to the Ross group (3.4±0.4 to 3.3±0.7 cm2versus 2.0±0.4 to 1.8±0.4 cm2 at 1 and 5 years respectively, p<0.01). There was no difference observed in the rate of change in LV mass over time (p=0.66).
Conclusions
The pulmonary autograft proves successful in reversing acquired cardiac damage among young patients experiencing prosthetic valve dysfunction. Within this patient group, the Ross procedure demonstrates superior hemodynamic performance compared to prosthetic AVR for up to 5 years postoperatively. However, the long-term clinical implications of this hemodynamic advantage are yet to be established.
Authors
Eliza Calin (1), Vincent Chauvette (1), Jawad Falih (2), Nabil Dib (3), Philippe Demers (1), Nancy Poirier (4), Pierre-Luc Bernier (4), Ismail Bouhout (1)
Institutions
(1) Montreal Heart Institute, Montreal, QC, (2) Université de Sherbrooke, Sherbrooke, QC, (3) Marie Lannelongue, Paris, france, (4) CHU Sainte-Justine, Montreal, QC
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Poster Presenter
Eliza Calin, Université de Montreal
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Roxboro, QC
Canada
Objectives
Aortic arch surgery is complex and associated with neurovascular complications. Cerebral protection and spinal cord preservation are vital parts of the operation, having significant bearing on the clinical outcome. Replacement of the arch with a Frozen Elephant Trunk (FET) procedure usually involves sequential anastomoses of the arch branches, of which the left subclavian artery is the most surgically inaccessible and often the most fragile. It is also intimately related to the recurrent laryngeal nerve (RLN). Incidences of RLN injury, permanent stroke and paraplegia following aortic arch surgery in adults have been reported to be as high as 25%, 20% and 7% respectively. The axillary artery is a continuation of the subclavian artery, branches of which include the vertebral and thyrocervical arteries. These supply the brain and spinal cord. We suggest that using both axillary arteries as arterial return for cardiopulmonary bypass (CPB) during aortic arch surgery will increase perfusion of the brain and spinal cord and reduce instrumentation in the proximity of the left recurrent laryngeal nerve, thereby reducing the complications previously described.
Methods
Electronic medical records were used to ascertain patient demographic and operative details and outcome data. Our surgical protocol starts with exposing both axillary arteries and then anastomosing a 10mm vascular graft to each. An arterial perfusion line from the bypass machine is connected to each of the grafts. After establishing venous return and CPB (perfusing both axillary arteries) the patient is cooled to a core temperature of 25 0C. At this temperature the left subclavian artery (LSA) is ligated proximally, and the other arch branches transected. The arch replacement proceeds with deployment of the FET prosthesis during a short period of lower body ischaemia, during which time perfusion of both axillary arteries continues. After anastomosing the FET to the aorta, lower body perfusion recommences using the arterial line supplying the left axillary artery. The graft attached to the left axillary is tunnelled through the second intercostal space and delivered into the mediastinum where it is easily anastomosed to the third branch of the FET prosthesis. Sequential anastomosis of the remaining arch branches continues with relative ease, and finally the proximal graft section of the FET is attached to the native aorta.
Results
We have performed 109 FET cases using the bilateral axillary artery approach as described. We have had one case of RLN palsy (0.9%), no cases of paraplegia and 12 cases of permanent stroke (11.0%).
Conclusions
In our series using both axillary arteries for perfusion, the incidence of RLN injury, permanent stroke and paraplegia are very low in comparison to other published large volume series. Additionally, the extra-anatomic bypass of the LSA is technically far easier than anastomosing directly to the LSA, especially in cases of acute aortic dissection when this vessel can be fragile. We advocate using bi-axillary arterial cannulation for CPB in FET surgery. Larger, multi-centre series or controlled trials are desirable to validate this technique.
Authors
RAVI DE SILVA (1), Rushmi Purmessur (2), Morgan Quinn (3), Ismail Vokshi (3), Florian Falter (4), Shakil Farid (5)
Institutions
(1) Royal Papworth Hospital NHS Foundation Trust, Leicester, Cambridgeshire, (2) Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, (3) Royal Papworth Hospital NHS Foundation Trust, Cambridge, NA, (4) Royal Papworth NHS Foundation Trust, Cambridge, NA, (5) Royal Papworth Hospital NHS Trust, Cambridge, NA
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Poster Presenter
RAVI DE SILVA, Royal Papworth Hospital
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CAMBRIDGE, Cambridgeshire
United Kingdom
Objective: This study aimed to evaluate the impact of double (axillary and femoral) versus single (axillary) arterial cannulation on outcomes of surgery for acute type A aortic dissection (ATAAD)
Methods: The PubMed/MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were searched until August 23, 2023, to conduct a meta-analysis. Primary endpoints of the study were operative mortality and postoperative stroke. Secondary endpoints were cardiopulmonary bypass time, myocardial ischemic time, hypothermic circulatory arrest time, postoperative re-exploration for bleeding, spinal cord injury, renal replacement therapy, and intensive care unit length of stay. A random-effect model was used to estimate the pooled effect size.
Results: Five retrospective propensity score-matched studies met our eligibility criteria, including a total of 3607 patients. Although operative mortality was not significantly different between the groups, double arterial cannulation was associated with an increased incidence of postoperative stroke (pooled odds ratio: 1.69, 95% confidence interval: 1.19-2.39) compared to single axillary cannulation. Double arterial cannulation was also associated with a higher incidence of renal replacement therapy requirement (pooled odds ratio: 1.35, 95% confidence interval: 1.13-1.60)
Conclusions: Double arterial cannulation is associated with higher incidence of postoperative stroke and renal replacement therapy compared to single arterial cannulation.
Authors
Yoshiyuki Yamashita (1), Serge Sicouri (2), Basel Ramlawi (3)
Institutions
(1) Lankenau Institute for Medical Research, Wynnewood, PA, (2) Lankenau Institute for Medical Research, Wynnewood, PAX, (3) Lankenau Heart Institute, Wynnewood, PA
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Poster Presenter
Yoshiyuki Yamashita, Lankenau Institute for Medical Research
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Wynnewood, PA
United States
Objective: A new described wrapping method for root reconstruction with prosthetic vessel in acute type A aortic dissection.
Case Video Summary: The new described method was as follows: the root was dissected and left the coronary artery in situ, a handmade shaped Dacron patch/prosthetic vessel was inserted into the media level between inner and outer layer. After continuous suture with the new ″sandwich" root, a prosthetic vessel with one size bigger was wrapped outside the new root above the coronary artery ostium.
Conclusions: The new described root reconstruction method can provide a feasible support for root hemostasis and fixation for avoiding dilation.
Authors
Yunxing Xue (1), Dongjin Wang (2)
Institutions
(1) N/A, China, (2) Nanjing Drum Tower Hospital, Nnajing, Jiangsu
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Poster Presenter
Yunxing Xue, Affiliated Drum Tower Hospital of Nanjing University Medical School
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China, Jiangsu
China
Objective: This study aimed to evaluate the results of emergency operations for acute type A aortic dissection, especially in octogenarians. Our surgical approach for octogenarians aims to conclude with the least invasive procedure possible, with Hemiarch replacement being the primary choice whenever feasible.
Methods: From March 2012 to November 2023, 449 consecutive patients underwent surgical repair for acute type A aortic dissection at our institution. 113 patients aged 80 years or older were included in this retrospective study. The primary endpoint was early mortality, and the secondary endpoint was long-term mortality. The mean age of the cohort was 84.8 years.
Results: Of the 113 octogenarians with AAD (A), isolated Hemiarch replacement was performed in 105 (93%), total arch replacement in 5 (4.4%), and Bentall procedure in 3 (2.7%). Five patients (4.4%) died within 30 days, and 12 (10.6) died in the hospital more than 30 days after surgery. Ten (8.8%) had a new stroke and 7 (6.2%) had mediastinitis. The overall postoperative survival was 76%, 74%, and 50% at 1, 3, and 5 years, respectively.
Conclusions: The results of emergency surgery for octogenarians were acceptable. Octogenarians should not be refused this life-saving emergency operation.
Authors
Masaaki Kobayashi (1), Satoshi Kuroyanagi (1), Onichi Furuya (1)
Institutions
(1) Kishiwada Tokushukai hospital, Kishiwada, NA
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Poster Presenter
Masaaki Kobayashi, Kishiwada Tokusyukai hospital
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Osaka
Japan
Title: Early and long-term outcomes of conventional and valve-sparing aortic root replacement
Objective: We aim to determine the early and long-term outcomes of conventional aortic root (ARR) and valve sparing root replacement (VSRR). VSRR were performed using the remodeling technique.
Methods: We present prospectively collected data of 641 consecutive patients undergoing elective and urgent aortic root surgery (498 ARR, 143 VSRR) between 2006 and 2022. All patients underwent pre-operative echocardiogram and CT scanning and follow-up at 6 months, 1 year and then annually. Younger patients with syndromes underwent genetic analysis. Patients with aortic diameters of >4.5 cm were referred for surgery. Primary outcomes were operative mortality and incidence of postoperative complications. Secondary outcomes were long-term survival and requirement for re-intervention. Median follow-up was 7.8 years (range, 0.5–14.5).
Results: 203 (32%) patients had bicuspid aortic valves, 143 (22%) had a connective tissue disease and 18 (2.8%) underwent redo procedures. Median cross-clamp time was 88 (ARR 71, VSRR 115; [range 54–208]) minutes with cardiopulmonary bypass of 107 (ARR 82, VSRR 137; [range 75–296]) minutes. In the patients undergoing ARR, 314 (63%) patients had tissue ARR, 181 (36%) had mechanical ARR, 3 (0.6%) had ARR with a homograft and 84 (17%) had a concomitant procedure. In-hospital mortality was 11 (1.7%) (ARR [2.0%]; VSRR [0.7%]), with transient ischemic attacks/strokes occurring in 7 ARR patients (1.1%). 13 (2.0%) (ARR [2.4%]; VSRR [0.7%]) required a re-sternotomy for bleeding and 14 (2.8%) received hemofiltration. 6 (0.9%) (ARR [1.0%]; VSRR [2.0%]) required permanent pacemaker implantation. Intensive care unit and hospital stays were 1.7 and 7.0 days respectively. During follow-up, redo surgery for native aortic valve replacement was required in 2 (1.4%) of the VSRR group due to greater than moderate aortic valve incompetence.
Conclusions: ARR and VSRR can be performed with low mortality and morbidity as well as a low rate of re-intervention during long-term follow-up, if performed by an experienced team with a consistent perioperative approach. This series provides contemporary evidence of how to balance the risks of aortic aneurysms and the risk of rupture at diameters of 4.5 cm against the risks and benefits of surgery.
Authors
Krishna Mani (1), Robert Morgan (1), Mark Edsell (1), Maria Teresa Tome Esteban (1), Frank Schroeder (1), Marjan Jahangiri (2)
Institutions
(1) St George's, University of London, London, United Kingdom, (2) St. George's Hospital, London, United Kingdom
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Poster Presenter
Krishna Mani, St George’s University Hospital NHS Foundation Trust London
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London
United Kingdom
Objective:
The overall incidence of acute kidney injury (AKI) after aortic surgery is well documented, but its impact on the outcome of acute type A aortic dissection (ATAAD) has not been thoroughly investigated.
The aim of this study was to determine the significance of AKI in predicting postoperative morbidity and mortality in ATAAD patients.
Methods:
We performed a retrospective review of a prospectively collected database including 520 patients who underwent aortic surgery for TA-AAD from September 2004 to February 2023. AKI was classified according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. We used a risk-adjusted Cox proportional hazards regression model to assess long-term survival.
Results:
Of 520 patients, 270 (51.9%) were diagnosed with AKI. The in-hospital mortality rates of AKI and non-AKI patients were significantly different (11.5% vs. 2.0%, respectively; P < 0.0001). Major risk factors for the development of AKI include male gender, visceral malperfusion, extended duration of cardiopulmonary bypass, and lower body temperature. Mean follow-up period was 51.3 ± 44.2 months. Long-term survival was significantly lower in patients with AKI (75.5% vs. 83.3% at 5 years, P = 0.0003). The Cox proportional hazards model identified AKI as an independent risk factor for increased long-term mortality (hazard ratio 1.61, P=0.04).
Conclusions:
Following surgery for acute aortic dissection, the development of acute kidney injury significantly increases the risk of in-hospital death and is an indicator of poor long-term prognosis.
Authors
Toshihito Gomibuchi (1), Tatsuichiro Seto (1)
Institutions
(1) Shinshu University, Matsumoto, Japan
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Poster Presenter
Toshihito Gomibuchi, Suwa red cross hospital
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Matsumoto
Japan
Objective: Evaluate the early postoperative morbidity, mortality, and prosthetic valve function of patients who underwent aortic root replacement using a prefabricated bioprosthetic aortic valved conduit.
Methods: Single-center retrospective review of 89 consecutive adult patients who underwent aortic root replacement with a prefabricated bioprosthetic aortic valved conduit from 2021 to August of 2023, this included patients with urgent operative status (19), re-do cardiac operations (25), and endocarditis (12).
Results: Most patients were male (71), mean age was 69.1 (±7.7) years. Indications for operation were thoracic aortic aneurysms in 51 patients, endocarditis in 12, structural valve deterioration of prior prosthetics in eight, and aortic dissection in six patients. Isolated aortic root replacement was performed in 57 patients, concomitant CABG in 11, concomitant valve operations in 11, and other combinations in 10 patients.
Implanted valve sizes were 29 mm (29/89), 27 mm (26/89), 25 mm (24/89), and 23 mm (9/89). The extent of aortic repair included the aortic root and ascending aorta in 28 patients, hemi-arch in 58, and total arch with elephant trunk in three patients. Mean cardiopulmonary bypass time was 256 (±135.2) min, mean cross-clamp time was 195 (±83.2) min, circulatory arrest was used for 58 patients with a mean duration of 20 (±8.3) min. 30-day mortality occurred in four patients of whom four were re-do operations, and one was due to endocarditis, postoperative ECMO support was required in eight patients, and intra-aortic balloon pump in three patients, re-operation for bleeding was necessary in three patients, of which two were complex reoperative cases. Postoperative renal failure requiring dialysis occurred in 13 patients, no patients developed postoperative strokes.
Discharge echocardiogram was obtained in 85 patients, and follow-up assessment was available in 35 patients with a median follow-up time of 4.1 months. Prosthetic aortic valve gradient, effective orifice area, and doppler velocity index remained within normal limits (Table), importantly, no patient prosthesis mismatch was noted.
Conclusions: The prefabricated bioprosthetic aortic valved conduit was used in all patients with root repairs including complex re-operative scenarios and endocarditis with acceptable short-term morbidity and mortality. The hemodynamic performance of the valve within the studied period was normal, the long-term durability is yet to be proven.
Authors
Rolando Calderon (1), Alberto Pochettino (2), Juan Crestanello (2), Arman Arghami (2), Phillip Rowse (2), Molly Klanderman (3), Gabor Bagameri (2), Nishant Saran (1), Philip Spencer (4), Richard Daly (2), Joseph Dearani (5), Malakh Shrestha (6)
Institutions
(1) N/A, Rochester, MN, (2) Mayo Clinic, Rochester, MN, (3) Mayo Clinic, Phoenix, AZ, (4) Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, (5) Mayo Clinic, United States, (6) Mayo Clinic (Rochester, MN), Rochester, MN
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Poster Presenter
Rolando Calderon
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Rochester, MN
United States
Objective
In young patients with severe aortic valve regurgitation (AR), Aortic valve repair (AVr) is the ideal surgical option. Different techniques for AVr have evolved to address both cusp pathology and annular dilatation. To address the aortic annulus, different annuloplasty devices and techniques have been developed, including an internal ring. With the internal ring, concerns have been raised about the safety and efficacy. Here, we present two cases illustrative of early failure after internal ring placement.
Case Summary
Case 1: A 25-year-old patient with severe symptomatic bicuspid AR underwent AVr consisting of cusp plication, implantation of the HAART internal ring, and hemi-Yacoub root replacement at another institution. The patient now presented with severe recurrent AR requiring reintervention secondary to severe symptoms as well as a severely dilated left ventricle (indexed left ventricular end-diastolic volume of 177 mL/m2. On direct inspection in the operating room, there was a large perforation in the body of the aortic valve secondary to a ring suture as well as a dehiscence of the HAART ring along half the basal ring circumference. The patient underwent a successful prosthetic aortic valve replacement.
Case 2: A 55-year-old male with a history of bicuspid aortic valve who underwent AVr with an internal ring 1 year prior presented to our institution with severe recurrent AR. Workup revealed not only severe AR with a dilated left ventricle (indexed left ventricular end-systolic volume of 57 ml/m2) but also with moderate aortic stenosis. On inspection, there was a large hole at the base of the fused cusp, which was likely a result of the ring damaging the valve once dehisced. Additionally, the internal ring was partially dehisced from the left ventricular outflow tract. The patient then underwent a successful Ross procedure to correct their aortic valve disease.
Conclusions
The internal annuloplasty ring is quite appealing as it allows for basal ring stabilization without the need for deep external aortic root dissection. The device downsizes the annulus by pulling it inwards toward the ring. By the nature of this mechanism of action, it creates an inherent risk of dehiscence due to the large amount of stress on each suture that pulls the basal ring inwards. This effect is intensified in larger annuli. These cases are both illustrative of this mechanism of failure and raises questions of safety in the wide application of this device before longer follow-up is reported.
Authors
Elbert Williams (1), Busra Cangut (1), Charles Laurin (1), Lilyanne Chen (1), Ismail El-Hamamsy (1)
Institutions
(1) Mount Sinai Hospital, New York, NY
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Poster Presenter
Elbert Williams
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New York, NY
United States
Objective: Open surgical repair of pararenal aortic aneurysms (PRAAs) or thoracoabdominal aortic aneurysms (TAAAs) in high-surgical-risk patients is associated with significant morbidity and mortality. This study aims to present the early outcomes of physician-modified inner branched endovascular repair (PMiBEVAR) for PRAAs and TAAAs in patients at high surgical risk.
Methods: We conducted a comprehensive review of clinical data and outcomes from consecutive patients treated at six centers with PMiBEVAR for PRAA or TAAA from December 2020 to September 2023. Key endpoints included technical success, 30-day mortality, major adverse events (MAE), patient survival, freedom from aneurysm-related mortality, and freedom from reintervention. Patient eligibility for PMiBEVAR adhered to the following criteria: (1) American Society of Anesthesiologists (ASA) score of ≥ 3 or inapplicability of conventional open repair due to anatomical reasons or comorbidities; and (2) considerable involvement of visceral vessels. Protocol and informed consent were approved by the Institutional Review Boards.
Results: Among the patients, there were 7 PRAAs and 27 TAAAs, involving 82 renal-mesenteric arteries incorporated through 10 fenestrations or 72 inner branches. Seven cases (20.6%) presented with rupture, including five impending rupture. 67.6% of patients had an ASA score of 3 or higher and 58.8% had a history of previous aortic surgery. The technical success rate per patient was 94.1%. Mean operative time was 364.8 min, mean contrast volume was 178.9 ml, and mean fluoroscopy time was 139.5 min. The 30-day mortality rate was 17.6% (6 patients). MAE occurred in 9 patients (26.5%), including acute kidney injury in 3 patients (8.8%), respiratory failure in 3 patients (8.8%), bowel ischemia in one patient (2.9%), and spinal cord injury in 4 patients (11.8%). No type I endoleaks occurred at postoperatively. The mean follow-up was 16.6 months. At 2 years, the survival rate, freedom from aneurysm-related mortality, and freedom from reintervention were 57.7%, 82.4%, and 80.9%, respectively.
Conclusions: PMiBEVAR proves to be a viable approach for treating PRAA or TAAAs in patients at high surgical risk, demonstrating acceptable outcomes at the 2-year mark. This technology enables surgeons to customize surgery to a patient's specific anatomy without geographical restrictions and manufacturing time delays. However, the long-term durability of this approach remains uncertain, necessitating further large-scale and long-term studies.
Authors
Tsuyoshi Shibata (1), Yutaka Iba (1), Kiyomitsu Yasuhara (2), Noriaki Kuwada (3), Yoshiaki Katada (4), Hitoki Hashiguchi (5), Takeshi Uzuka (6), Tomohiro Nakajima (1), Junji Nakazawa (1), Shuhei Miura (1), Ayaka Arihara (1), Keitaro Nakanishi (1), Takakimi Mizuno (1), Kei Mukawa (1), Nobuyoshi Kawaharada (1)
Institutions
(1) Sapporo Medical University, Sapporo, Japan, (2) Isesaki Municipal Hospital, Isesaki, Japan, (3) Kawasaki Medical School, Kurashiki, Japan, (4) Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan, (5) Hokkaido Prefectural Kitami Hospital, Kitami, Japan, (6) Sunagawa City Medical Center, Sunagawa, Japan
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Poster Presenter
Tsuyoshi Shibata, Sapporo Medical University
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Sapporo
Japan
Objectives: To investigate if FET implantation leads to negative cardiac remodeling in dissection and non-dissection patients and to determine whether there are differences when FET is implanted as an aortic re-do procedure or initially.
Methods: Between March 2013 and April 2022 three hundred twenty-five patients underwent aortic arch replacement surgery using the FET technique at the XXX. To reduce bias regarding the frozen elephant trunk´s effect on cardiac remodeling preoperative moderate and severe valve stenosis or regurgitation as well as concomitant valve, root or cardiac procedures were excluded. Therefore, one-hundred-forty-eight (consisting of 104 dissection and 44 non-dissection) patients formed our cohort. Data was collected retrospectively using our centre´s dedicated aortic database. Echocardiographic data was extracted from transthoracic echocardiographic reports done by the in-house cardiologists before and after surgery as well as during follow-up
Results: Dissection patients show in the immediate postoperative phase after FET implantation a significant decrease of ejection fraction and increase of mild valvular insufficiencies. After the first postoperative year following FET implantation, non-dissection patients show a significant increase of ejection fraction and a decrease of septal diameter. Patients who receive FET as an aortic redo procedure tend to have significant larger left ventricular enddiastolic diameters and higher left ventricular masses – even after correction for body surface area. During longitudinal analysis there were no long-term negative effects, neither in patients who received FET initially, nor in patients who received it as an aortic redo procedure.
Conclusions: With strict treatment of cardiovascular risk factors including blood pressure control to normal values, the implantation of a FET hybrid prosthesis has no negative effect on cardiac remodeling. FET also has no measurable effect regarding negative cardiac remodeling independently of the fact if it is implanted initially or as aortic redo procedure in the first two years after implantation.
Authors
Tim Berger (1), Domenic Meissl (1), Maximilian Kreibich (1), Martin Czerny (1), Joseph Kletzer (1), Matthias Eschenhagen (2), Bartosz Rylski (1), Roman Gottardi (1)
Institutions
(1) Department of Cardiovascular Surgery, University Hospital Freiburg Heart Centre, Freiburg, Germany,, Freiburg, Germany, (2) Department of Cardiovascular Surgery, University Hospital Freiburg Heart Centre, Freiburg, GermanN/A, Freiburg, Germany
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Objective: Ultraviolet light (UV) irradiation in the presence of riboflavin is known to enhance mechanical strength and stiffness of collagen-based tissues through photochemical crosslinking of collagen fibers. We investigated the effect of combined riboflavin treatment and UV irradiation on both delamination and biaxial mechanical parameters in ex vivo human ascending aortic aneurysmal tissue.
Methods: Aortic specimens from patients undergoing ascending aortic replacement were collected for mechanical testing. Each specimen provided two sample sets from proximal and distal regions, which were randomized to treatment or control groups in a 1:1 ratio. Treated samples were soaked with 0.1% riboflavin solution for 30 minutes and then exposed to an irradiance of 45 mW/cm2 at 365nm for 10 minutes. Delamination testing simulates dissection and assesses the delamination strength of the tissue. Biaxial mechanical testing assesses stretch, stiffness, stress, or strain-energy density of the tissue. Linear mixed-effect models were used to assess the effect of treatment on mechanical outcomes. Correlation of determination (R2) was used to evaluate the relationship between delamination strength and biaxial mechanical outcomes. Gradient boosting models were implemented to assess the independent effect of treatment on mechanical outcomes.
Results: From 8/2023 to 11/2023, 27 adults were enrolled; 19 patients (mean age±SD: 63.7±11.1, 17 males) yielded 114 samples with complete biomechanical outcomes; delamination testing (76 samples [38 circumferential, 38 longitudinal], 66%) and biaxial mechanical testing (38 samples, 33%). There was no observed difference between the treated and control tissue with respect to delamination strength (β=0.8, P=.8), stretch (β=0.01, P=.1), stiffness (β=319, P=.2), stress (β=12, P=.2) or strain-energy density (β=0.8, P=.7). After adjustment for tissue and patient characteristics, we found several significant associations; delamination strength was inversely associated with age (β=-0.7, P=.01); biaxial stretch was lower in the longitudinal direction (β=-0.05, P<.001) and inversely associated with age (β=-0.006, P<.001); biaxial stiffness was lower in the longitudinal direction (β=-916, P<.001) and in the distal region (β=616, P<.001); biaxial strain-energy density was higher in the proximal region (β=7.1, P<.001) and inversely associated with age (β=-1.5, P<.001); biaxial stress was lower in the longitudinal direction (β=-45, P<.001), higher in the proximal region (β=57, P<.001), and inversely associated with age (β=-3.8, P<.01). Delamination strength was most well correlated with stretch in the longitudinal direction (R2=0.56 treatment, R2=0.11 control) (Figure 1A) and strain-energy density (R2=0.39 treatment, R2=0.11 control) (Figure 1B). Gradient boosting models were underpowered but demonstrated similar non-linear relationships, with age being the predominant covariate driving mechanical outcomes.
Conclusions: We did not observe a treatment effect on ascending aortic aneurysmal tissue using UV irradiation and riboflavin. Predictors of tissue mechanics were age, orientation, and region. Correlation between delamination strength and strain-energy density suggests that tissue with greater efficiency in storing energy requires more force to propagate a dissection plane. This finding, which has not been previously demonstrated, may be useful when evaluating the effectiveness of tissue-modifying therapies.
Authors
Richard Ramsingh (1), Benjamin Kramer (1), Abigail Snyder (1), Aaron Tipton (1), Erik Waldorff (1), Callan Gillespie (1), Samar Tarraf (2), Robb Colbrunn (1), Betty Hamilton (1), William Dupps Jr. (1), Marijan Kopravanac (1), Patrick Vargo (1), Eric Roselli (1), Faisal Bakaeen (1)
Institutions
(1) Cleveland Clinic, Cleveland, OH, (2) Northeastern Univeristy, Boston, MA
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Poster Presenter
Richard Ramsingh, Cleveland Clinic
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Cleveland, OH
United States
Objective:
Acute kidney injury (AKI) after aortic arch surgery remains common, causing significant increases in other morbidity and mortality and length of hospital stay. Despite this, even in severe cases of AKI requiring dialysis, some patients will have renal recovery. However, approximately how many patients will have renal recovery, contributing factors to whether patients will have renal recovery, and subsequent impact on long-term mortality are unknown. We sought to further investigate patients who suffer AKI requiring hemodialysis after aortic arch surgery who survive their initial hospital stay, and to determine how many patients have renal recovery, any contributing factors, and the impact of renal recovery or lack thereof on long term mortality.
Methods:
A single center retrospective aortic database was reviewed for all aortic arch procedures from 2011-2023, totally 944 aortic procedures. Patients were filtered for whether they developed acute renal failure post-operatively requiring hemodialysis. Patients that suffered in-hospital mortality were not included in subsequent analysis.
Among surviving patients, they were split into two cohorts: no renal recovery (NR) or renal recovery (RR). Between groups analysis was performed for pre-operative, operative, and post-operative variables, including long term mortality. Additionally, an adjusted Cox proportional hazard model for post-discharge mortality was performed between the two groups.
Results:
In total, 49 patients were identified who had renal failure requiring hemodialysis after aortic arch surgery. Of these patients, 24 (49.0%) suffered in-hospital mortality. Of the remaining 25 patients, 20 (80.0%) patients had subsequent renal recovery. 11 (55.0%) had renal recovery prior to discharge, with the remaining 9 having renal recovery within 3 months of discharge.
Analysis between the NR and RR cohorts of pre-operative, operative and in-hospital postoperative variables demonstrated no significant differences, apart from notably a lower pre-operative creatinine in the NR cohort (p=0.014), although the sample size was small. Notably, after discharge all patients in the NR recovery cohort died within one year (median 177, IQR 146-225), with only one death in the RR cohort (p<0.001).
Conclusions:
In-hospital mortality is common among patients who require renal replacement therapy after aortic arch surgery. If able to survive their post-operative course, most patients will have recovery of their kidney function. However, patients that do not recover kidney function have an absolute risk of mortality within the first year. These findings may help to guide patients who suffer severe acute kidney failure on their overall prognosis after initial surgical recovery.
Authors
Adam Carroll (1), Nicolas Chanes (1), Ananya Shah (1), William Riley Keeler (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective: We assessed the long-term outcomes after aortic valve resuspension for aortic regurgitation (AR) following dissection of aortic root in patients with acute type A aortic dissection (ATAAD).
Methods: A total of 168 first supracoronary aortic replacement for ATAAD were performed from January 2006 to December 2021. We excluded six patients without preoperative CT, three patients who had no aortic root dissection by preoperative CT but underwent aortic valve resuspension depending on the intraoperative findings, and 32 patients who had aortic root dissection by CT but did not undergo aortic valve resuspension. Regarding surgical technique, adhesion of proximal false lumen in dissected aortic root or dissected ascending aorta were basically performed using surgical adjuncts (gelatin-resorcin-formalin glue, BioGlue or fibrin glue). If all of three Valsalva sinuses were affected by the dissection and there was no significant aortic valve leaflet pathology, aortic valve resuspension was performed using a pledgeted U-stitch just above each top of aortic valve commissures. If Valsalva sinuses were affected only partially or were not affected by the dissection, just adhesion of proximal false lumen was performed using surgical adjuncts. The patients, who had no aortic root dissection by CT and underwent just adhesion of proximal false lumen, were included in the non-dissection group (N=54) and the patients, who had aortic root dissection by CT and underwent aortic valve resuspension adding to proximal adhesion, were dissection group (N=73).
Results: The rate of preoperative moderate or severe AR in the dissection group was significantly higher than that in non-dissection group (21.2% vs. 2.9%, P=0.007%). However, the rates of moderate or severe AR after surgical repair for ATAAD in both groups were comparable (3.0% vs. 0%, P=0.19). The cumulative 10-year incidence of all-cause death was similar between non-dissection group and dissection group (41.5% vs. 41.5%, log-rank P=0.66). The cumulative 10-year incidence of a composite of cardiac death / heart failure / aortic valve replacement (AVR) for deterioration of AR was also comparable between both groups (17.3% vs. 17.0%, log-rank P=0.64). The cumulative 10-year incidence of a composite of moderate or severe AR deteriorating during follow-up or AVR for deterioration of AR in dissection group was significantly higher than that in non-dissection group (70.9% and 20.8%, log-rank P=0.04). After adjustment with confounders, there was no difference between both groups in risk for all-cause death (HR 1.12, 95%CI 0.52 to 2.37, P=0.78), and in risk for a composite of cardiac death / heart failure / AVR for deterioration of AR (HR 1.32, 95%CI 0.41 to 4.21, P=0.64), while higher risk of a composite of moderate or severe AR deteriorating during follow-up or AVR for deterioration of AR in dissection group was significant in comparison with non-dissection group (HR 20.7, 95%CI 1.99 to 214, P=0.01).
Conclusions: Aortic valve resuspension for AR following aortic root dissection could improve valve competency in short-term and overall long-term survival rate is comparable with that in patients without aortic root dissection. However, aortic root dissection repaired with aortic valve resuspension is associated with significant higher risk of deterioration of AR in long-term follow-up. Aortic valve resuspension seemed an acceptable option for selected patients with AR following aortic root dissection.
Authors
Hiroyuki Hara (1), Naoki Kanemitsu (1), Yosuke Sugita (1), Keita Yano (1), Shinya Takimoto (1), Kenji Minatoya (2)
Institutions
(1) Division of Cardiovascular Surgery, Japan Red Cross Society Wakayama Medical Center, Wakayama City, Japan, (2) Kyoto University Hospital, Kyoto, outside of US
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Poster Presenter
Hiroyuki Hara
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Wakayama City, Wakayama
Japan
Objective: We identified the specific character of the aortic root morphology after reimplantation by analyzing cardiac computed tomography, and the formula to determine basal ring diameter (target basal ring radius = intraoperatively measured minimum cusp height – target effective height) was suggested. We investigated the efficacy of the controlled approach of basal ring reduction using the formula in reimplantation for valve durability in patients with greater than moderate aortic regurgitation (AR).
Methods: From January 2018 to August 2023, 46 patients underwent reimplantation. Of them, 39 had preoperative greater than moderate aortic regurgitation. Those patients were included in this study. Twenty-one had reimplantation without the formula (Group A) and 18 had with the formula (Group B). We reviewed those patients and compared the mid-term valve durability between two groups.
Results: Age was 61 (37-77) in Group A and 64 (43-75) in Group B. AR classification was 16 and 7 in type I (annular dilation), 4 and 9 in type II (cusp prolapse with cusp bending), and 1 and 2 in Type III (cusp restriction or retraction) in Group A and Group B, respectively. Ten (45%) had severe AR in Group A, whereas 15 (83%) had severe AR in Group B (p<0.05). Follow-up period was 24 (5-47) months in Group A and 15 (3-41) in Group B. Mean graft diameter was 28mm in Group A and 26.7mm in Group B. Regarding cusp repair techniques, only central plication was used in 10 of Group A, whereas central plication was used in 7, free margin resuspension in 6, and subcommissural annuloplasty in 1 of Group B. Freedom from AR greater than moderate at 3 years was 67±12% in Group A and 94±6% in Group B (p<0.05).
Conslusions: The controlled approach of basal ring reduction using the formula in reimplantation had positive effect for mid-term aortic valve durability in patients with aortic regurgitation.
Authors
Hiroshi Tanaka (1), Yoshikatsu Nomura (2), Toshihito Sakamoto (2)
Institutions
(1) N/A, N/A, (2) Harima Himeji General Medical Center, Himeji, NA
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Poster Presenter
Hiroshi Tanaka
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Himeji, Hyogo
Japan
Objective: Thoracic endovascular aortic repair (TEVAR) in patients with connective tissue disorders remains controversial given the relative paucity of follow-up data and concern for durability. We report our mid-term outcomes in endovascular thoracic aortic repair in patients with connective tissue disorders.
Methods: A single institution, retrospective review of patients with connective tissue disorders who underwent TEVAR between February 2017 and June 2023. Peri-operative outcomes (cerebrovascular accident (CVA), spinal ischemia, acute kidney injury, 30-day readmission, 30-day mortality) and mid-term follow-up data (mortality, presence of endoleak, and re-intervention rate) were collected and analyzed.
Results: Six patients with connective tissue disorders underwent TEVAR at our institution during the study period. Median age was 39 [IQR: 32.5-58.25] and the majority were male (4/6, 66.7%). Four patients had Marfan Syndrome (66.7%) and two had Loeys-Dietz Syndrome (33.3%). Pre-operative indications for repair included degenerative aneurysmal disease (1/6, 16.7%) and type B dissection (5/6, 83.3%). Half of the cohort had prior aortic surgery (3/6, 50%). First, we evaluated early post-operative outcomes which identified no peri-operative CVA (0/6, 0%), acute kidney injury (0/6, 0%), evidence of spinal ischemia (0/6, 0%), or 30-day mortalities. The average post-operative length of stay was 3.67 days (0.816). Median follow-up interval was 2.47 years (0.96-5.35). Surveillance imaging revealed no graft endoleaks (0/6, 0%), no patients required re-intervention (0/6, 0%), and there were no mortalities (0/6, 0%).
Conclusions: Endovascular therapy for thoracic aorta pathologies in patients with connective tissue disorders is safe and durable based on our institutional experience. TEVAR can be an effective modality in select cases within this patient population. This case series demonstrates success in the midterm time interval, however continued follow-up is necessary to evaluate the long-term durability of this approach.
Authors
John Iguidbashian (1), Adam Carroll (2), Michael Kirsch (3), T. Brett Reece (4), Muhammad Aftab (5)
Institutions
(1) University of Colorado, United States, (2) University of Colorado Anschutz, Denver, CO, (3) University of Colorado, Aurora, CO, (4) University of Colorado Hospital, Aurora, CO, (5) University of Colorado, Anschutz Medical Center, Aurora, Colorado, Aurora, CO
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Poster Presenter
John Iguidbashian, University of Colorado
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Aurora, CO
United States
Objectives
The Frozen Elephant Trunk (FET) can be used to treat acute type A aortic dissections and is described in conjunction with a hemiarch repair. However, inadvertent placement or maldeployment of elephant trunk can have severe patient complications. We describe a case of a FET placed across the origins of the arch vessels during hemiarch repair for dissection at a referring hospital. This was revised through laser fenestration and stenting to restore adequate flow to the left subclavian (SCA) and left common carotid artery (CCA).
Methods
A 69-year-old man with history of acute TAAD in 2018, status post hemiarch repair with frozen elephant trunk (FET) across his great vessels, presented with progressive dizziness and syncope. A computed tomography scan revealed stent graft coverage of the brachiocephalic, L CCA, and L SCA, with retrograde flow through a false lumen fed by a fenestration of the dissection flap near aortic bifurcation. He had reverse coarctation physiology, with lower extremity blood pressures at 200s/90s, and upper extremity blood pressures at 130s/60s. He was unable to tolerate anti-hypertensives due to cerebral hypoperfusion. Carotid duplex demonstrated flow reversal in the left internal carotid and bilateral vertebral arteries. Given lifestyle limiting symptoms and an elevated peri-operative death/stroke risk with a redo open arch repair, we performed an endovascular intervention via in-situ laser fenestration of his FET with L CCA and L SCA stenting.
Results
An initial aortogram revealed the stent graft was covering the great vessels, which were supplied only through false lumen flow (fig 1a). A 7 French sheath was placed into the left radial artery and a laser atherectomy catheter was inserted into the left SCA origin, but fenestration attempts were unsuccessful. Thus, we placed a steerable sheath via right femoral access into graft, and laser fenestrated through the graft into the false lumen near the left SCA origin. A wire was advanced into both the left SCA and left CCA, followed by kissing balloon dilation. Using the Culotte technique, balloon expandable bare-metal stents was placed in the L CCA and L SCA through the fenestration (fig 1b). Post-operatively, blood pressure in his left arm and legs equalized, his dizziness resolved, and he was able to maintain normotension without symptoms. His stents remain open several months after his procedure.
Conclusion
We present a novel case report where laser fenestration is used to salvage a misplaced FET. Laser fenestration is frequently used at our institution in complex endovascular aortic aneurysm repair and can be a minimally invasive alternative for salvaging FET deployed across the arch.
Authors
Richard Shi (1), Sanford Zeigler (1), Mathew Wooster (1)
Institutions
(1) Medical University of South Carolina, Charleston, SC
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Poster Presenter
Richard Shi, Medical University of South Carolina
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Charleston, SC
United States
Objective:
With the development of machine learning comes the opportunity to better predict risk factors for postoperative morbidity. Although surgical and cerebral perfusion techniques have improved, postoperative stroke remains a devastating outcome after hemiarch surgery. To better predict at risk patients, we developed a machine learning algorithm to assess preoperative and operative risk factors associated with postoperative stroke following hemiarch surgery.
Methods:
We identified a total of 602 adult patients who underwent hemiarch surgery between June 2009 to October 2022 from our single institution prospectively maintained database. These patients were randomly divided into training (70%) and testing (30%) sets and various eXtreme gradient boosting (XGBoost) models were constructed to predict postoperative stroke in the cardiothoracic intensive care unit (CTICU). We considered 64 input parameters from the index hospitalization which were comprised of 24 demographic characteristics as well as 8 preoperative and 32 intraoperative variables. Our model underwent hyperparameter fine-tuning with 10-fold cross-validation at each iteration, leading to the development of the final model. We employed various evaluation metrics to assess model performance, including accuracy, Brier score, and area under the receiver operating characteristic curve (AUC-ROC). Additionally, we employed a SHapley Additive exPlanation (SHAP) beeswarm plot to elucidate the impact of individual features on the predictions generated by the XGBoost model.
Results:
Postoperative stroke occurred in 5.1% of patients (31 cases) following hemiarch surgery. The final XGBoost model showcased a cross-validation accuracy of 96% and exhibited excellent calibration, indicated by the low Brier score of 0.04. The predictor also displayed robust performance on the test dataset, attaining an accuracy rate of 96%. Our best performing postoperative stroke prediction model achieved an AUC-ROC of 0.80 on the training set and an AUC-ROC of 0.81 on the testing set. The SHAP beeswarm plot helped explain the complex decision-making process of our XGBoost model and provided insights into 20 of the key features that significantly influence model prediction. Elevated stroke risk was linked to factors such as female sex, higher intraoperative cryoprecipitate administration, older age, reduced nadir bladder temperature, and a history of CT surgery. Patients at a reduced risk of postoperative stroke exhibited characteristics such as aortic aneurysm at presentation, lower BMI, and underwent elective aortic surgery.
Conclusions:
Our model demonstrated excellent accuracy in predicting postoperative stroke after hemiarch surgery. Reduced stroke occurrences at higher nadir bladder temperatures could imply improved myocardial protection with normothermic cardioplegia in certain patients undergoing aortic procedures. Further research using a broader machine learning model is necessary to understand specific risk factors, including why females exhibit a higher incidence of stroke. Additionally, the apparent protective effect of aortic aneurysms without dissection warrants investigation, which may be due to a diminished inflammatory response stemming from less extensive intraoperative tissue handling.
Authors
Nicolas Chanes (1), Adam Carroll (1), Michael Kirsch (1), Bo Chang Wu (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Nicolas Chanes, University of Colorado, Anschutz Medical Center, Aurora, CO
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Denver, CO
United States
Objective:
Previously, we have demonstrated the impact of ethnicity in aortic surgery, with under-representation and greater acuity of minority patients, concerning for a lack of access to care. The CDC's social vulnerability index (SVI) measure is increasingly used to quantify patient socioeconomic and demographic factors. We sought to expand on our prior study, by incorporating both the individual and cumulative effects of SVI as well as ethnicity to better define presentation and subsequent outcomes in patients undergoing aortic arch surgery.
Methods:
We use a single-institution database of patients who underwent total arch replacement (TAR) or hemiarch repair between 2009 and 2022. A total of 837 patients were placed into five cohorts based on their self-reported race: African American, Asian, Caucasian, Hispanic, and Other, with further subdivision based on SVI (high social vulnerability, ≥75%, normal social vulnerability <75%). Additional analysis was performed excluding race with grouping solely by SVI. We compared patient presentation, operative variables and subsequent outcomes based on the above cohorts.
Results:
Demographic city data compared to included patients was 16.6% vs. 9.7% for the African American cohort, 6.6% vs. 2.4% for the Asian cohort, 43.5% vs. 76% for the Caucasian cohort, 12% vs 8.7% for the Hispanic cohort, and 22% vs. 2.6% for the Other cohort. Regardless of SVI, African American and Hispanic presented at a younger age (p=0.001), with high SVI patients in general more likely to present at a younger age (p=0.007). African American and high SVI Asian patients presented with higher baseline systolic and diastolic blood pressures (p=0.002). African American and high SVI patients regardless of race were significantly more likely to present urgently or emergently (p<0.001) with aortic dissection pathology (p=0.006).
Intraoperatively, significant differences were seen in cardiopulmonary bypass (p=0.018) and aortic cross-clamp times (p=0.020), with notably higher circulatory arrest times across high SVI groups (p=0.002), despite a decreased likelihood in the performance of adjunctive structural procedures in high SVI groups (p=0.018). Possibly contributing was a greater performance of total arch replacement in high SVI patients (p=0.048). Postoperatively, high SVI patients were significantly more likely to require mechanical circulatory support (p=0.025), otherwise, no difference was seen in length of stay, or ICU morbidity or mortality. After discharge, significant differences were seen in number of procedure-related emergency department presentations within one year (p<0.001), with notably high usage among African Americans and low usage among high SVI Asian patients, although no differences were seen in rates of re-admission, or follow-up with a cardiovascular provider.
Conclusions:
Clear lack of access to care exists for under-represented groups as demonstrated by a patient population not reflective of city demographics, higher surgical acuity in socially vulnerable patients, and trends in emergency department usage after discharge. Furthermore, the ethnicity-only dataset hid significant differences within ethnicities between normal and high SVI groups. Most importantly, approaches to expanding care need to be both geared towards high SVI groups and be racially sensitive, and must be applied at all levels of care.
Authors
Adam Carroll (1), Kyndall Hadley (1), Nicolas Chanes (1), Ananya Shah (2), Alejandro Suarez-Pierre (1), Jessica Rove (1), Catherine Velopulos (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO, (2) University of Colorado Anschutz, Aurora, CO
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Poster Presenter
Kyndall Hadley, University of Colorado Anschutz Medical Center
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Denver, CO
United States
Objective: Recent studies have analysed the anatomical relationships between the aortic root components (sino-tubular junction, ventricular-arterial junction and virtual basal ring), to improve results of root reconstruction and valve competence over time. In a previous work from our group, we analysed the in vivo anatomy of the aortic root after a with the Valsalva graft. The aim of this study is to evaluate the in vivo evolution over time of the anatomical features after reimplantation procedure with sinuses reconstruction
Methods: Ten patients with tricuspid aortic valve underwent a reimplantation procedure with Valsalva graft, between March 2019 and April 2020. At the time of procedure, surgical haemoclips were applied at the level of proximal annular knots and at the distal reimplanted commissures on the neo-sinutubular junction, as radiopaque markers. All patients underwent an ECG-gated heart CT scan before discharge and at follow-up. Images were reconstructed with 3D software and aortic root features were measured in both series and compared. We analyzed the annular dimensions and the distance between annular knots haemoclip and virtual basal ring, both as height from the annular plane and as distance (thickness) from the annular lumen.
Results: The mean follow-up time was 50 ± 4 months. There were no deaths, nor reoperation or recurrence of moderate-to-severe aortic regurgitation. We found no significant differences in annular dimensions after 4 years. Post-operative measures vs. follow-up measures were: mean major diameter 25.3 ± 1.1 vs. 27.6 ± 0.9 mm (p: 0.024), mean minor diameter 22.9 ± 0.9 vs. 23.6 ± 0.5 mm (p: 0.09), mean perimeter 77.9 ± 2.5 vs. 80.7 ± 2.3 mm (p: 0.05), mean area 478.6 ± 38.9 vs. 504.3 ± 22.2 mm2 (p: 0.15), mean ellipticity index (major diameter / minor diameter) 1.10 ± 0.04 vs. 1.13 ± 0.04 (p: 0.23). The mean heights of Dacron graft basal landmarks from virtual basal ring were also not significantly modified form post-operative values to follow-up's: Right-Left commissure 6.6 ± 2.0 vs. 5.2 ± 1.1 mm (p: 0.16); Right sinus 6.1 ± 1.9 vs. 5.6 ± 1.3 mm (p: 0.53); Right-Non Coronary commissure 6.1 ± 1.6 vs. 5.3 ± 2.1 mm (p: 0.45); Non Coronary sinus 2.1 ± 1.7 vs. 2.1 ± 1.2 mm (p: 1); Left-Non Coronary commissure 2.4 ± 1.5 vs. 1.3 ± 0.9 mm (p: 0.11); Left sinus 2.7 ± 1.4 vs. 1.8 ± 1.1 mm (p: 0.22). The mean planar distances of basal Dacron graft landmarks from virtual basal ring (thickness) were: Right-Left commissure 5.1 ± 1.3 vs. 4.6 ± 1.3 mm (p:0.43); Right sinus 4.9 ± 1.6 vs. 5.1 ± 1.3 mm (p: 0.72); Right-Non Coronary commissure 3.7 ± 0.5 vs. 3.1 ± 1.1 mm (p: 0.22); Non Coronary sinus 4.0 ± 0.8 vs. 3.1 ± 0.7 mm (p: 0.05); Left-Non Coronary commissure 3.1 ± 0.7 vs. 2.8 ± 0.7 mm (p: 0.45); Left sinus 3.3 ± 1.1 vs. 3.4 ± 0.8 mm (p: 0.78).
Conclusions: After a 4-year mean follow up, no significant modification of the relationships in aortic root components occurred. The proximal edge of the Dacron graft lies at the ventricular-arterial junction at a slightly different thickness and height along the annular circumference, especially at the level of right sinus and left-right commissure. This feature persists at follow-up. Annular stabilization appears unaffected. A minimal, not significant, reduction of the tissue thickness all along the annulus and a minimal, not significant, increase in annular dimensions were noted.
Authors
Francesco Giosuè Irace (1), Giulio Folino (2), Ilaria Chirichilli (1), Andrea Salica (2), Raffaele Scaffa (2), Luca Paolo Weltert (2), Ruggero De Paulis (2)
Institutions
(1) Department of Cardiac Surgery, Ospedale San Camillo-Forlanini, Rome, Italy, (2) Department of Cardiac Surgery, European Hospital, Rome, Italy
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Poster Presenter
Francesco Giosuè Irace, Sapienza University of Rome
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Rome, Rome
Italy
Background
Acute aortic syndrome is a catastrophic event still characterized by high mortality even in case of successful prompt surgical treatment. Many authors evaluated biomechanical properties of aortic wall from "ex vivo" specimens in order to better clarify the physiopathology of aortic diseases and identify potential predictor risk factors for acute aortic complications. Significant limitation, so far, has been the lack of a "control group", being the majority of specimens harvested during scheduled aortic surgery. In this study we report our extensive experience in evaluation of biomechanical properties of aortic wall including specimens from patients experiencing acute aortic dissection and patients without aortic diseases
Materials and Methods
Aortic wall specimens were obtained in 113 patients who underwent ascending aorta replacement for chronic aortic aneurysm (NDAA: 73pts-64%), genetic aortic disease (GEN: 9pts–8%), acute aortic dissection (AAD: 11pts-10%) or heart transplantation (CG: 20pts- 17%). Mechanical uniaxial tensile ultimate stress test were performed on the fresh "ex vivo" sample within 24 hours from the harvesting measuring 3 parameters: Peek strain (Pstr: marker of aortic wall elasticity); Peek Stress (PS:marker of aortic wall strength) and Maximum elastic modulus (MEM: marker of aortic wall stiffness or resistance to deformation).
Results
Comparative analysis of overall mechnaical properties showed no significant differences between non dissected and dissected aorta. Control group, on other hands showed more preserved elasticity and strength (Fig 1A). Preserved mechanical properties of aortic wall in acute dissection compared to non-dissected disease was confirmed regardless aortic region and direction of mechanical stress (Fig 1B). Both Elasticity and Strenght of aortic wall were overall improved in specimens from control group (red square) especially in posterior wall (Fig 1C).
Conclusions
Our study on mechanical properties included patients with acute dissection and a control group without aortic dilatation. Control group showed indeed the better elasticity and strength of aortic wall thus confirming that impaired mechanical properties are characteristics of dilated aorta. Preserved mechanical properties in undamaged wall of dissected patients showed, however, that acute dissection is characterized by a focal fragility more than a diffuse impaired mechanical properties of aortic wall.
Authors
Pasquale Totaro (1), Ferdinando Auricchio (2), Simone Morganti (2), Stefano Pelenghi (1)
Institutions
(1) IRCCS Foundation Hospital San Matteo, Pavia, PV, (2) University of Pavia, Pavia, PV
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Poster Presenter
Pasquale Totaro, IRCCS Foundation Hospital "San Matteo"-Pavia-Italy
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Milano, Milan
Italy
Objective: Rapid deployment aortic valve replacement (RD[AVR]) has been widely used for the treatment of aortic valve stenosis. However, there is limited evidence on the use of the RD valve in aortic valve diseases other than aortic stenosis. This study evaluated the 5-year outcomes of RDAVR for various aortic valve diseases in a single center.
Methods: Overall 344 patients who underwent AVR using INTUITY valve in our institution between 2016 and 2023 were included. Early clinical outcomes, mid-term clinical outcomes and hemodynamic outcomes from early postoperative period to postoperative 5 years were also investigated. Median follow-up duration was 28.6 months (maximum 86.4 months).
Results: Mean age was 68.9 ± 9.8 years, and 46.2% were female. There were 176 bicuspid valves (51.2%), 20 pure aortic regurgitations (5.8%), and 4 infective endocarditis (1.2%). Isolated RDAVR was performed in 90 patients (26.2%), and concomitant procedures were performed in 254 patients (73.8%), including aorta surgery (48.8%), mitral valve surgery (20.3%), arrhythmia surgery (9.0%), tricuspid valve surgery (7.0%), and coronary artery bypass grafting (5.5%). Operative mortality was observed in 11 patients (3.2%), and permanent pacemaker implantation was required in 5 patients (1.5%) during the early postoperative period. The 1-year and 5-year survival rates were 94.2% and 84.0%, respectively, and freedom from aortic valve-related events were 89.0% and 77.9% in 1 year and 5 years, respectively. No deterioration of valve hemodynamics in every size of the prostheses was observed up to 5-year echocardiographic evaluation. Mean pressure gradients of the prostheses were 9.9 ± 4.3 mmHg and 9.4 ± 3.8 mmHg at 1 year and 5 years, respectively.
Conclusions: The RD valve can serve as a reliable bioprosthesis for both isolated and concomitant AVRs for various aortic valve diseases, including bicuspid valve, pure aortic regurgitation, and infective endocarditis. Excellent clinical and hemodynamic results would be guaranteed up to 5 years.
Authors
SEON YONG BAE (1), Kyung Hwan Kim (1), Suk Ho Sohn (1), Yongwoo Chung (1), Yoonjin Kang (1), Ji Seong Kim (1), Jae Woong Choi (1)
Institutions
(1) Seoul National University Hospital, Seoul, Seoul
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Poster Presenter
Seon Yong Bae, Seoul National University Hospital
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Seoul
South Korea
Objective
Over the last decade, the minimally invasive access has become more and more the standard approach for aortic valve and aortic root replacement. As the next logical step, minimally invasive approaches for more complex operations of the supracommissural ascending aorta and proximal aortic arch have currently moved into the center of attention. While there is a broad evidence basis for minimally invasive aortic root and aortic valve replacements, currently available evidence focusing on the supracommissural aorta and the proximal aortic arch is still scarce to date.
Methods
We present our single center experience of 86 consecutive patients who underwent supracommissural ascending aorta replacement with or without proximal aortic arch replacement via an upper J-shaped hemisternotomy between June 2009 and April 2023. Data regarding patient characteristics, surgical procedures, postoperative outcome, and overall survival was collected prospectively in our institutional database and analyzed retrospectively.
Results
Mean patient age was 65.4 ± 13.6 years, 42% (n=36) were male. In 40 cases (45.5%), proximal aortic arch replacement was performed while in the remaining cases, patients received isolated replacement of the supracommissural aorta. Mean operation time was 202.9 ± 50 minutes and cross-clamp time was 52.2 ± 18.9 minutes. Conversion to full sternotomy was necessary in one case (1.2%). One patient required re-thoracotomy due to bleeding after proximal aortic arch repair. Re-operation rate was 0%. In-hospital mortality was 1.2% (n=1) and 30-day mortality was 2.3% due to two early deaths (one after isolated ascending aortic repair and one after proximal arch replacement). With a mean follow-up time of 5.7 years, Kaplan-Meier analysis revealed an overall survival of 90.5% with no statistically significant differences between patients undergoing isolated supracommissural ascending aorta replacement and cases with additional proximal arch replacement (93.2% vs. 87.5%, p = 0.45).
Conclusions
Supracommissural ascending aortic replacement as well as proximal aortic arch repair can be safely performed via a minimally invasive approach with a low conversion rate. Short- and long-term survival are comparable to results previously reported for complete sternotomy. Expanding the indication for the minimally invasive access towards the proximal aortic arch did not impair short- and long-term survival.
Authors
Florian Helms (1), Heike Krueger (1), Ruslan Natanov (1), Andreas Martens (1), Alina Zubarevich (1), Bastian Schmack (1), Alexander Weymann (1), Arjang Ruhparwar (1), Aron Popov (1)
Institutions
(1) Hannover Medical School, Hannover, Lower Saxony, Germany
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Poster Presenter
Florian Helms, Hannover Medical School(MHH)
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Hannover
Germany
Objective:
Previously, we observed various presentations between two Social Vulnerability Index (SVI) cohorts, demonstrating that high SVI patients tended to present more urgently or emergently for aortic arch/valvular surgery. To further understand the healthcare accessibility and dynamics, this study aims to explore the role of SVI in surgical outcomes among the referred patients who required elective aortic arch/valvular surgery.
Methods:
We used a single-institution database of patients who underwent aortic valve repair/replacement with total arch or hemiarch replacement for aortic root and/or arch aneurysms between 2009 and 2023. A total of 280 patients were reviewed and 227 patients were placed into two cohorts – high social vulnerability (SVI ≥75%, N=32) and normal social vulnerability (SVI < 75%, N=195) after excluding those receiving surgery for other indications. We compared patient characteristics and presentations (i.e. prevalence of severe valvular disease), operative variables and subsequent outcomes based on the two cohorts.
Results:
There was significant difference in body mass index (BMI), with the high SVI cohort having a higher BMI (median 28.5) than the normal SVI cohort (p = 0.05). Patients in the high SVI cohort tended to be younger, with a median age of 59.2, in contrast to the normal SVI cohort with a median age of 64.9 (p = 0.06). Additionally, a higher proportion of individuals in the high SVI group had a history of smoking (37.5% vs. 22.6%, p = 0.078). However, no significant differences were observed between the two cohorts in terms of gender or medical history, including hypertension, hyperlipidemia, diabetes, chronic kidney disease, pulmonary disease, coronary artery disease, or severe aortic stenosis or aortic insufficiency. The analysis of operative variables revealed no significant differences in the operative types (aortic root or arch replacement), cardiopulmonary bypass time, and aortic cross-clamping time. Postoperatively, both cohorts exhibited comparable outcomes with no significant differences noted in adverse events such as length of stay, ICU days, acute kidney injury requiring hemodialysis, stroke, prolonged ventilation, postoperative infection, need for mechanical circulatory support, or mortality.
Conclusions:
Among elective patients, high SVI did not appear to affect the pre-operative presentation except that the high SVI cohort had higher BMI, tended to be younger and have smoking history. Referred patients regardless of SVI had similar pre-operative presentations and post-operative outcomes compared to high SVI patients. Our results suggest that disparities in care do not occur at the time of seeing a specialist, rather they either occur at two levels: either in obtaining initial access to primary care, or in failure to appropriately see a referred specialist.
Authors
Adam Carroll (1), Bo Chang Wu (1), Nicolas Chanes (1), Michael Kirsch (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Bo Chang Wu, University of Colorado Anschutz
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Aurora, CO
United States
Objective: Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) continues to be a debilitating complication occurring in 10% of patients. Studies have shown that extended aortic coverage is a risk factor for SCI. This study evaluates if extended aortic length coverage is a significant risk factor for spinal cord ischemia.
Methods: This study retrospectively reviewed 277 consecutive patients who underwent TEVAR successfully between 2006 and 2021 at a single institution. Patients with TEVAR were classified into two groups: greater or less than 205mm of thoracic aortic coverage. Analysis of variance was conducted comparing these variables and associated aortic coverage.
Results: A total of 269 patients underwent successful TEVAR. Of those, 127 (47.2%) had greater than 205mm of thoracic aorta covered while 142 (52.8%) did not. Patients who had greater aortic coverage were more likely to be smokers (p< 0.01) and have previous strokes (p< 0.05). Patients who received extended coverage were more likely to receive a pre-operative lumbar drain (p< 0.01). Extended aortic coverage was not associated with higher risk of spinal cord ischemia compared to standard aortic coverage (4.7% vs 4.2%, p=0.84). On sub-analysis of descending thoracic aneurysms, rapid growth (>10mm/yr) [9.15% vs 23.62%, p=0.0012] and urgency (24-48 hrs of presentation) [23.94% vs 35.43%, p=0.038] were noted to be statistically higher in the extended aortic cohort group Type II endoleaks were seen more in extended aortic coverage (p< 0.01).
Conclusion: Extended aortic coverage (compared with the standard approach) was not associated with higher risk of spinal cord ischemia; however, this may have been mitigated by this population's higher prevalence of prophylactic lumbar drainage.
Authors
George Chachati (1), James Brown (2), Sarah Yousef (3), Nishant Agrawal (2), Shwetabh Tarun (3), Kristian Punu (4), Derek Serna-Gallegos (5), Ibrahim Sultan (5)
Institutions
(1) UPMC Central PA, Harrisburg, PA, (2) UPMC, Pittsburgh, PA, (3) University of Pittsburgh, Pittsburgh, PA, (4) N/A, N/A, (5) University of Pittsburgh Medical Center, Pittsburgh, PA
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Poster Presenter
George Chachati, UPMC Pinnacle Harrisburgh Hospital
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Camp Hill, PA
United States
Objective
Patients presenting with acute type A aortic dissection require urgent, resource-intensive interventions, and there is significant variation in cost of caring for these patients. The purpose of this study was to identify the preoperative and operative factors that contribute to high healthcare costs in patients undergoing surgical management for type A aortic dissection.
Methods
All patients at a single institution who underwent urgent or emergent operative repair of type A aortic dissection from 2017-2022 were evaluated for study inclusion. One patient with iatrogenic dissection and five patients who died within two days following surgery were excluded. Data were obtained from the Society of Thoracic Surgeons Adult Cardiac Surgery database and hospital financial records. Patients were grouped by total index encounter cost: with the high cost group consisting of patients with costs >70th percentile and the standard cost group consisting of patients with costs ≤70th percentile. Detailed cost data allowed for classification of costs into exclusive categories including operating room costs, intensive care unit costs, room charges, etc. Patient demographics and comorbidities, disease presentation factors, operative characteristics, and clinical outcomes were compared between groups using univariate and multivariable logistic regression analyses. P-values less than 0.05 were considered statistically significant.
Results
A total of 105 patients were included in this study, 32 in the high cost group and 73 in the standard cost group. The median total encounter cost was $46,234 in the standard cost group and $132,084 in the high cost group. See Figure 1 for a breakdown of costs by category for each group. Factors at presentation that were associated with high cost were male sex (OR 4.3 [95% CI 1.3, 14.8]), aortic root involvement requiring Bentall procedure (OR 5.9 [95% CI 1.6, 21.8]), and aortic arch involvement requiring total arch repair (OR 8.4 [95% CI 2.0, 35.7]). Malperfusion, rupture, and lower extremity neurologic deficits were not associated with increased cost. See Table 1 for all patient presentation factors. Unsurprisingly, patients in the high cost group were more likely to have a complex operative experience, including increased blood product usage, longer operative times, and increased operating room costs. High cost was also associated with postoperative complications including stroke, acute kidney injury, unplanned reoperation, and operative mortality. Post-discharge costs are also expected to be higher as high cost patients were significantly more likely to be discharged to a rehabilitation facility compared with standard cost patients.
Conclusions
Management of acute type A aortic dissection requires extensive resources, often associated with high cost. Males and patients requiring aortic root or aortic arch procedures are associated with the highest cost. Surprisingly, presenting with malperfusion, rupture, or lower extremity neurological deficits was not associated with increased cost. While more extensive repair is sometimes necessary in acute type A dissection, based on this study, it appears financially and clinically beneficial to limit surgery to relatively more straightforward procedures such as an ascending aorta/aortic hemiarch repair whenever possible. Further investigation using a larger, national patient database will be necessary to better understand this relationship.
Authors
Brandon Peine (1), Yuanyuan Fu (2), William Irish (2), Linda Kindell (1), Shahab Akhter (1), Benjamin Degner (1)
Institutions
(1) Dept. of Cardiovascular Sciences, East Carolina University, Greenville, NC, (2) Dept. of Surgery, East Carolina University, Greenville, NC
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Poster Presenter
Brandon Peine, East Carolina University
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Winterville, NC
United States
Objective: To evaluate the fate of the aortic root after surgery for acute aortic dissection and clarify the events of the aortic root after aortic repair for acute aortic dissection.
Methods: We studied 119 of 134 consecutive patients with Stanford type A aortic dissection who underwent emergency surgery at our hospital. We excluded two patients who had already undergone aortic root replacement at the time of initial surgery and 13 patients whose postoperative evaluation by contrast-enhanced computed tomography was not possible due to deterioration in their postoperative condition. All patients underwent proximal anastomosis with felt strips and biologic glue reinforcement. There were no patients with connective tissue disease. The primary endpoint is all-cause mortality, and the second endpoint is open aortic reintervention.
Results: Of the 119 patients, 14 patients showed residual dissection in the aortic root and four patients showed pseudoaneurysm in the aortic root. In total, four patients died and nine patients required open aortic reintervention, during follow-up. Cases with residual root dissection were detected from postoperative computed tomography, within one week postoperatively; however, all cases were followed conservatively. All cases of pseudoaneurysm, which were detected between 45 to 792 days postoperatively, underwent redo surgery with patch repair to the pseudoaneurysm. At reopening, the anastomosis appeared completely detached and almost ruptured in all cases. In one case, pathologically complete necrosis of the aortic wall was detected and this may have been caused by the biologic glue. There was no significant difference in all-cause mortality (p = 0.51) between the 18 cases with aortic root events and 101 cases without; however, there was a significant difference (p =0.0015) in open aortic reintervention in these groups.
Conclusions: Although the residual aortic root dissections may have been due to inadequate repair of the proximal anastomoses, these can be followed conservatively without any aortic root events. Alternatively, in cases with aortic root pseudoaneurysms due to necrosis of the aortic wall, prompt surgical intervention is recommended. Although felt strips and biologic glue are useful in controlling anastomotic bleeding in aortic dissections, in essence, they do not cure the dissection and should be deployed with the appropriate amount of use.
Authors
Kayo Sugiyama (1), Hirotaka Watanuki (2), Masato Tochii (3), Daisuke Koiwa (2), Katsuhiko Matsuyama (4)
Institutions
(1) N/A, Japan, (2) Aichi Medical University Hospital, Nagakute, NA, (3) Fujita Health University, Toyoake, Japan, (4) N/A, Tokyo, Japan
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Poster Presenter
Kayo Sugiyama, Aichi Medical University
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Nagakute city, Aichi prefecture
Japan
Objective: Aim of this retrospective, multicenter study was to assess feasibility of endovascular repair of the aortic arch (Ar-TEVAR), with proximal landing in zone 0, in patients with a history of surgery for type A acute aortic dissection (TAAAD) and to identify reasons for infeasibility, particularly those modifiable during the first operation (e.g. short ascending graft) in order to enhance Ar-TEVAR feasibility rate.
Methods: We analyzed data from patients who underwent surgery for TAAAD at two centers from 1/2012 to 9/2023. Study devices were: a single-branch, off-the-shelf, dual module system (SB) and a double-branch, custom-made device (DB). Inclusion criteria were: ascending and/or hemiarch replacement (with no reimplantation of any supra-aortic vessel) at first operation; pre-discharge angio-CT scan available and of good quality, showing residual dissection of the aortic arch. Primary endpoint was the evaluation of Ar-TEVAR feasibility with the study devices; secondary endpoint was the identification of the causes of infeasibility overall and separately for the two study devices. Feasibility was assessed according to the anatomical requirements of each device provided by the manufacturers.
Results: Study population included 119 patients. Overall, Ar-TEVAR feasibility was 49.6% (59 patients). Ar-TEVAR with SB and DB devices was feasible in 38 (31.9%) and in 42 (35.3%), respectively (Figure 1). Reasons for infeasibility with the SB devices were: unsuitable proximal landing zone and unsuitable supra-aortic vessels in 39 (48.1%) and in 45 (55.6%) patients, respectively. Reasons for infeasibility with the DB devices were: unsuitable proximal landing zone and unsuitable supra-aortic vessels in 53 (68.8%) and in 45 (58.4%) patients, respectively. Notably, a short ascending graft was the reason for infeasibility in 33 (27.7%) and in 37 (31.1%) patients with the SB and the DB grafts, respectively. If these patients had received a longer ascending graft, overall feasibility would have been as high as 70.6% (84 patients).
Conclusions: Ar-TEVAR with SB and DB devices is feasible in nearly half of patients with a history of surgery for TAAAD. A short ascending graft made one third of patients unsuitable. With an appropriate ascending graft, feasibility would have increased to two thirds of patients. Lifetime management of patients with TAAAD commences at the time of the first operation with appropriate operative planning and optimal surgical strategy
Authors
Augusto D'Onofrio (1), Raphael Caraffa (2), Giorgia Cibin (3), Domenico Crea (4), Alberto Bortolato (5), Domenico Mangino (6), Michele Antonello (7), Michele Piazza (4), Gino Gerosa (8)
Institutions
(1) Padova, Padova, -, (2) N/A, N/A, (3) Policlinico Universitario, Rovigo, Italy, (4) University of Padova, PADOVA, NA, (5) Azienda Università Ospedale Padova, Padova, VA, (6) Azienda ULSS 3 Serenissima, Mogliano Veneto, Italy, (7) University of Padova, Padova, AL, (8) N/A, Padova, Italy
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Poster Presenter
Augusto D'Onofrio, "Tor Vergata" University of Rome, Rome, Italy
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Roma, Rome
Italy
Objective:
In many cases of acute aortic dissection, the dissection extends beyond the left subclavian artery. Initial aortic repair leaves the downstream aorta untouched. The residually dissected aorta carries the risk of aneurysm formation requiring secondary intervention. The aim of this study was to evaluate the outcome of patients undergoing aortic arch replacement employing the frozen elephant trunk (FET) technique after surgery for acute dissection.
Methods:
Sixty-six consecutive patients (60% men, mean age: 57±12 years, ES II: 7.29±5.21) underwent open redo aortic arch replacement at two Austrian centers. The reoperation was performed through a repeat sternotomy using selective antegrade cerebral perfusion (bilateral n=48, 72.7%, unilateral n=18, 27.3%) under moderate- to- mild hypothermic circulatory arrest (28°C bladder temperature) in all patients. Intraoperative details, clinical outcomes and follow-up data were evaluated.
Results:
Redo FET was performed using either a conventional technique with the distal anastomosis in Ishimaru zone 3 (n=25, 37.9%) or a simplified technique with an anastomosis in zone 2 (n=41, 62.1%). Cardiopulmonary bypass time totaled 208±50 min and myocardial ischemic time was 102±33 min. Mean duration of selective antegrade cerebral perfusion (ACP) was 57±19 min. In-hospital mortality was 3% (n=2). Postoperative neurological complications comprised stroke (n=6, 9.1%) and spinal cord injury (temporary n=1, 1.5%; permanent n=2, 3%). Postoperative renal failure occurred in 10 patients (15%), necessitating temporary or permanent dialysis in 9 (13.6%) and 1 (1.5%) patients, respectively. Median intensive care unit stay was 3 days. Survival rates after 1, 3 and 5 years were 95%, 88% and 85%, respectively. A multivariate analysis, using a Cox regression model, identified older age, new dialysis and stroke as predictors of mortality (HR = 1.0909, 95% CI, 1.05 – 1.12, HR = 2.37, 95% CI, 1.53 - . 3.65, HR = 1.58, 95% CI, 1.15 – 2.16, respectively).
Conclusions:
Our data suggest that redo FET following previous aortic surgery for acute aortic dissection performed by a dedicated aortic team shows an excellent safety profile. Survival rates are very promising despite the high-risk nature of the surgery. Nonetheless, stroke and renal failure are concerns that can influence late outcome. Furthermore, successful redo aortic arch surgery employing the FET technique serves as an ideal platform for distal aortic interventions.
Authors
Florian Huber (1), Zsuzsanna Arnold (2), Bruno Schachner (1), Jessica Gottsberger (3), Armin Kai Schöberl (1), Sandra Folkmann (4), Daniela Geisler (4), Gabriel Weiss (4), Martin Grabenwoger (2), Andreas Zierer (1)
Institutions
(1) Department of Thoracic and Cardiovascular Surgery, Kepler University Hospital, JKU, Linz, Austria, (2) Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Vienna, (3) Department of Thoracic and Cardiovascular Surgery, Kepler University Hospital, JKU, Linz, Linz, (4) Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
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Poster Presenter
Florian Huber
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Linz
Austria
Objective: The GORE TAG Thoracic Branched Endoprosthesis (TBE, WL Gore & Associates, Flagstaff AZ) received FDA approval in May 2023 and remains the only branched thoracic stent graft available in the US. As the use of TBE expands it can be expected that management of complications from this device will become increasingly important. We present here the first reported case of explantation of an infected TBE.
Methods: A 67-year-old male underwent placement of a TBE for contained rupture of the distal aortic arch and thoracic aorta. Two weeks following his initial presentation he re-developed chest pain and was found to have a type 1a endoleak prompting proximal extension of his endograft. Following this re-intervention he developed imaging evidence concerning for a mycotic aneurysm which had not been noted at the time of his initial surgery. The mycotic portion of the aneurysm eroded into the left lower lobe that resulted in hemoptysis. This required resection of his left upper lobe and ultimately prompting transfer to a quaternary care aortic center.
Results: In order to remove the TBE a left common carotid to subclavian artery bypass was performed. The patient was then repositioned into the right lateral decubitus position, cannulated for cardiopulmonary bypass and placed in deep hypothermic circulatory arrest. The patient's aneurysm was explored and the main aortic component was removed (Figure 1). A large abscess involving the distal arch, at base of the left subclavian artery, was explored and the subclavian stent component was explanted. The aorta was reconstructed with a 28 mm rifampin-soaked dacron graft with anastomoses in zone 2 and zone 5. The subclavian artery was ligated. Two additional washouts were required before an omental flap was used to obtain coverage of the aortic graft on post-operative day (POD) 6. As operative cultures grew methicillin-resistant Staphylococcus aureus the patient was treated with a course of vancomycin followed by suppressive doxycycline. After an otherwise uncomplicated course the patient was discharged on POD 18.
Conclusions: Explantation of an infected TBE is feasible with multidisciplinary care at an experienced aortic center.
Authors
Fabian Jimenez Contreras (1), Griffin Stinson (1), Patrick Kohtz (1), Brian Gilmore (2), Gilbert Upchurch (2), Tomas Martin (1)
Institutions
(1) Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, FL, (2) Department of Surgery, Division of Vascular Surgery, University of Florida, Gainesville, FL
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Poster Presenter
Fabian Jimenez Contreras
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Gainesville, FL
United States
Objective
To report functional outcome of type A aortic dissection (TAAD) after 1 year as well as morbidity and mortality.
Methods
Retrospective analysis including 642 patients with TAAD from 01/2005 –12/2021. Patients were followed in the aortic disease clinic at 3, 6, and 12 months after the event. Permission was sought to contact health care providers outside of our institution. Stroke was defined as any impairment of neurological function. Follow-up at 12 months was 90% complete.
Results
Mean age at TAAD was 62y (95% CI: 61-63y) and 30% of the population was female. One year after surgery for TAAD, 75% of patients were living at home in NYHA functional class I. No patients were observed with NYHA stage IV. Less than 2% were residing in an assisted living facility. 85% of non-retired patients had returned to work. 212 (33%) patients were retired after 1 year at a mean age of 73y (95% CI: 72-74y). Stroke occurred in 148 (23%) patients and was the cause of death in 33 patients. Among the 148 patients, 66 (45%) exhibited preoperative neurological disabilities, while four patients (3%), initially without any neurological impairments postoperatively, experienced a postoperative stroke. Of the remaining (alive) patients with stroke (115) 30% had no residual limitations 1 year after TAAD. Pericardial effusion in the patients with neurological disability was present in 60 patients (41%) of which 25 were hemodynamically impaired (17%).
The cross-clamp time was significantly higher in patients with stroke (98min 95% CI: 94.0-101.1 in patients without stroke vs. 106min 95% CI: 98.5-114.1 in patients with stroke, p-value: 0.026). 69% of patients with stroke live at home, 28% at home with support and 3% in an assisted living facility. One year after stroke, 77% of the patients achieved a Rankin Scale ≤2, while no patient had a Rankin Scale of 5. There was no significant correlation between gender and recovery rate (p-value: 0.48). However, experiencing a stroke significantly increased the likelihood of residing in an assisted living facility or receiving support at home one year after TAAD (OR = 9.44, 95% CI: 4.85-18.77, p-value:<0.001). Thirty-day mortality was 11.8% and 92 patients (14%) died within 1st year after TAAD. There was no significant gender difference in mortality (p-value: 0.101).
Conclusions
After surgery for acute type A aortic dissection, 3 out of 4 patients live at home unassisted 1 year after surgery. Stroke survivors have a favorable outcome with the majority having mild or no residual neurological deficits at 1 year. Nevertheless, experiencing stroke is a risk factor for living in an assisted living facility 1 year after the event. There were no gender differences in suffering from a stroke, living in an assisted living facility, or mortality.
Authors
Murat Yildiz (1), Maria Nucera (1), Selim Mosbahi (1), Cem Kapkin (1), Silvan Jungi (1), Matthias Siepe (1), Florian Schoenhoff (1)
Institutions
(1) Inselspital, Bern, Switzerland
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Poster Presenter
Murat Yildiz, Hopsital of the University of Pennsylvania
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Philadelphia, PA
United States
Objective:
Delayed extubation causes significant patient harm, with the potential for increased ventilator associated pneumonia, delirium associated with sedation, and prolonged recovery. Furthermore, delayed extubation places a significant burden on the health care system, with increased in-hospital costs and length of stay. Aortic surgery carries high risk for prolonged ventilation given its comorbid population and the potential for hemodynamic instability. To better predict those at risk for prolonged ventilation, we applied a machine learning model to all aortic surgeries at our institution.
Methods:
All adult patients undergoing aortic surgery from June 2009 to October 2022 (n = 875) were identified from our single institution prospectively maintained database. Patients were randomized 4:1 into training and testing cohorts to develop various eXtreme gradient boosting (XGBoost) models that predicted postoperative prolonged intubation (>24 hours) in the cardiothoracic intensive care unit (CTICU). We identified 64 input parameters from the index hospitalization, including 24 demographic characteristics, 8 preoperative variables, and 32 intraoperative parameters. To achieve the final model, we conducted hyperparameter fine-tuning involving 10-fold cross-validation at each iteration. Model performance was evaluated using multiple measures including accuracy, Brier score, area under the receiver operating characteristic curve (AUC-ROC), and area under the precision-recall curve (AUC-PR, mean average precision). We also utilized a SHapley Additive exPlanation (SHAP) violin plot to identify and interpret the impact of individual features on the predictions of the XGBoost model.
Results:
Postoperative prolonged intubation in the CTICU was noted in 81 patients (9.3%) who underwent aortic surgery. The final XGBoost model demonstrated a cross-validation accuracy of 89% and was well-calibrated as evidenced by the low Brier score of 0.09. The predictor also displayed robust performance on the test dataset, achieving an accuracy of 90%. Our best performing postoperative prolonged intubation prediction model achieved an AUC-ROC of 0.82 and an AUC-PR of 0.39. Upon stratification by aortic procedure, the model attained an AUC-ROC of 0.75 for root surgeries, 0.76 for hemiarch cases, and 0.74 for total arch procedures. The SHAP violin plot helped explain the complex decision-making process of our XGBoost model and provided insights into the top 25 key features that significantly influence model prediction. Key factors associated with an increased risk of postoperative prolonged intubation included extended durations of cardiopulmonary bypass and circulatory arrest, increased intraoperative blood product transfusion, advanced age, and a prior history of stroke.
Conclusions:
Our machine learning model accurately predicted those at most risk for prolonged ventilation. More complex surgeries and hemodynamic instability, as reflected by longer intraoperative cardiopulmonary bypass and circulatory arrest times as well as increased intraoperative transfusion, significantly augment the risk of prolonged ventilation. Machine learning empowers clinicians to have better, data-driven discussions with patients, offering personalized insights that allow further optimizations to improve outcomes.
Authors
Nicolas Chanes (1), Adam Carroll (1), Michael Kirsch (1), Bo Chang Wu (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Nicolas Chanes, University of Colorado, Anschutz Medical Center, Aurora, CO
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Denver, CO
United States
Objective: Although recent reports indicate a trend towards a more extensive arch operation, the recommended extent of graft replacement in acute aortic dissection (AAD) is an ongoing controversy. Thus, this study compared early and late outcomes of hemi-arch versus total arch replacement for DeBakey type I communicating AAD.
Methods: From 2004 to 2022, 221 patients with AAD underwent emergent surgery at our institution. A total of 39 patients were excluded, including those with DeBakey type II AAD, non-communicating aortic dissection, chronic type B dissection, previous thoracic aortic surgery, and those who had undergone surgery more than 14 days after onset. The remaining 182 patients were included in this study. Eighty patients received hemi-arch and 102 received total arch replacement. We compared the early and late outcomes between the two procedures retrospectively.
Results: There were no significant differences in preoperative characteristics between the two procedures, except age. Patients over 80 years of age were more likely to have undergone hemi-arch replacement. No significant differences were observed in postoperative complications, and in-hospital mortality was statistically similar in both procedures (4/80 (5.0%) vs 3/102 (2.9%); p=.368). The mean follow-up period was 6.4 years (0-19.7 years). At 5 years, mortality was 15.0% after hemi-arch replacement and 8.5% after total arch replacement (p=.558). The cumulative incidence of aortic reoperation was 8.8% (11 reoperations in 7 patients) in the hemi-arch replacement and 9.8% (11 reoperations in 10 patients) in the total arch replacement (p=.443). Though both procedures required aortic reoperations, multiple reoperations were more likely in patients undergoing hemi-arch replacement (3cases vs 1case). In multivariate analysis, aortic reoperation was significantly common in patients under 60 years of age (OR, 2.85; 95% CI, 1.01-8.05) and in patients with residual entry in the distal aortic arch (OR, 3.40; 95% CI, 1.20-9.62).
Conclusion: While hemi-arch replacement is adequate to achieve the primary goal of saving the AAD patient, total arch replacement is also a feasible approach with similar results to hemi-arch replacement. Total arch replacement might be useful for patients with a younger age. The main limitation of this study was its retrospective approach to the analysis, thus selection bias of patients could not be eliminated.
Authors
Masahiro Daimon (1), Yuki Asada (1), Takurou Makiura (1), Tatsuya Suzuki (1), Hiroaki Uchida (1), Junko Okamoto (1), Sachiko Kanki (1), Hideki Ozawa (1), Takahiro Katsumata (1)
Institutions
(1) Osaka Medical and Pharmaceutical University, Osaka, Japan
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Poster Presenter
Masahiro Daimon, Osaka Medical College
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Kyoto
Japan
Objective: Hemiarch reconstruction for pathology of the ascending thoracic aorta has increased in recent years, owing to improvements in neuroprotection and surgical techniques. This has mitigated some of the additional morbidity inherent to longer cardiopulmonary bypass time and the need for circulatory arrest in performing hemiarch reconstruction, and reducing further pathological degeneration of the remaining proximal aortic arch. We sought to present our institutional experience with elective hemiarch reconstruction.
Methods: We performed a retrospective review of prospectively collected clinical data from all patients undergoing elective aortic arch reconstruction with a hemiarch reconstruction at a single tertiary care center from February 2011 to October 2023. Data were retrieved from the electronic medical record.
Results: Four-hundred and twenty-seven patients met the inclusion criteria. Three-hundred and twenty-seven (76.6%) were male and the median age was 62.1 (IQR 50.5 – 69.6) years. Median body mass index was 27.5 (IQR 24.4 – 31.9) and 50 (11.7%) patients had a history of diabetes. Thirty-nine (9.1%) patients had a history of previous aortic surgery. Complete patient demographic data is shown in Table 1.
Mean cardiopulmonary bypass, aortic cross clamp, and circulatory arrest time were 148 (±55.1), 104 (±47.8), and 9.97 (±6.53) minutes, respectively. Mean total length of stay was 8.32 (±5.20) days and mean intensive care unit length of stay was 3.49 (±4.18) days.
Twenty-eight (6.6%) patients experienced postoperative delirium, 11 (2.6%) experienced postoperative stroke, and 7 (1.6%) experienced postoperative seizure. Eighty-seven (20.4%) patients experienced KDIGO Grade 1 acute kidney injury (AKI) and 13 (3.0%) experienced Grade 2 or greater AKI. Ninety-six (22.5%) patients had a postoperative arrhythmia. Seven (1.6%) patients died during their postoperative hospitalization.
Conclusions: Hemiarch reconstruction is a safe and routinely performed procedure at our institution, with minimal postoperative mortality. Surgical risk should be weighed against the annual risk of complications in determining the true size criteria for elective repair.
Authors
Michael Kirsch (1), Adam Carroll (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Michael Kirsch, University of Colorado Anschutz Medical Center
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Aurora, CO
United States
Objective:
Optimal repair technique for DeBakey type I acute aortic dissection (AAD) is controversial. The purpose of this study is to compare the clinical outcomes and distal aortic remodeling in patients who had hemiarch repair versus those with an extended arch replacement in patients with DeBakey I AAD. All patients were managed post-operatively in a multidisciplinary aortic disease clinic with post-operative imaging surveillance at 1-, 6-, and 12-months, and yearly thereafter.
Methods:
All patients undergoing repair of DeBakey type I AAD between January 1, 2000, and January 1, 2021, were retrospectively analyzed. Patients were separated into hemiarch repair and extended arch replacement groups which included zones 1, 2, or 3 arch replacements with or without elephant trunks. Distal aortic remodeling was evaluated by assessing growth of the residual aorta as well as false lumen thrombosis on follow-up ECG-gated computed tomography angiography imaging. Linear mixed models were used to compare both aortic measurements and follow up year with subject and year follow up included as random effects.
Results:
One hundred and seventy-four patients had a hemiarch repair alone and twenty-one had an extended arch replacement. No significant differences in demographics were observed between groups. Mean age was 60 years, 27.2% (n=53) were female, 61.5% (n=120) were current or former smokers, and 46.7% (n=91) presented with neurologic, visceral, and/or peripheral malperfusion. Patients undergoing extended arch replacement had longer cross-clamp, cardiopulmonary bypass, and circulatory arrest times. Postoperatively there was no significant difference in rate of stroke, paralysis, renal failure, or death within 30 days. Overall, 30-day mortality was 11.9% (n=23). Mortality at 1 and 5 years was 16.7% (n=29), and 24.1% (n=42), in the hemiarch group, respectively, versus 14.3% (n=3) and 14.3% (n=3) in the extended arch replacement group (p=0.23). Rate of aortic reintervention at 1, 5, and 10 years was 1.1% (n=2), 3.4% (n=6), and 4.0% (n=7) in the hemiarch group; in the arch replacement group it was 9.5%, (n=2), and 14.3% (n=3) at 1 and 5 years (p=0.29). Follow up imaging was available for 91% (n=176) of patients Complete false lumen thrombosis of the descending aorta occurred in 7.2% (n=11) of hemiarch patients and 11.1% (n=2) of extended arch replacement patients (p=0.631). In the linear mixed models, no interaction between group and year of follow-up was significant. There was no significant difference in the measurements for each year of follow up for extended arch repair compared to hemiarch.
Conclusions:
In the setting of DeBakey type I AAD aggressive arch replacement can be safely accomplished despite increased technical complexity compared to hemiarch repair only. A lower-than-expected reintervention rate was observed in both groups, possibly due to post-operative surveillance and management in a specialty aortic disease clinic. Linear mixed models demonstrated progressive distal aortic growth but no difference in rate between groups.
Authors
Stephen Thorp (1), Caleb Weissman (2), Tomasz Timek (1), Stephane Leung (1)
Institutions
(1) Corewell Health, Grand Rapids, MI, (2) Michigan State University College of Human Medicine, Lansing, MI
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Poster Presenter
Stephen Thorp, Corewell Health
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Grand Rapids, MI
United States
Objective
To prevent the abuse and misuse of antibiotic therapy, C-reactive protein (CRP) has been widely used as a marker for the diagnosis and treatment of infectious diseases. However, there are limited studies on this subject in the mycotic aneurysms. We investigated the prognosis based on serum CRP levels after surgery and antibiotic therapy in mycotic aneurysms.
Methods
The retrospective study, conducted at a single center, involved 56 patients treated for mycotic aneurysm of the ascending aorta and aortic arch (n=18), descending thoracic aorta (n=25), and thoracoabdominal aorta (n=13) from March 2003 to June 2023. Patients were considered responsive to antibiotic treatment based on clinical improvement, including the resolution of symptoms, a decrease in serum infectious markers, and the absence of microbial growth in blood after the control of infection. The duration of postoperative antibiotics was determined by the causative bacterial strain. CRP levels were measured at the discontinuation of antibiotic therapy after surgery. Clinical outcomes, including mortality and recurrent infection, underwent meticulous examination during the follow-up period. The relationship between CRP levels and the recurrence of aortic infection was assessed using the area under the curve (AUC) of the receiver operating characteristic.
Results
The mean age of the participants was 69.8 ± 8.2 years, and 40 (71.4%) were male. Complications, such as stent graft infection or aortoesophageal fistula, occurred in 8 (14.3%) patients after endovascular repair. Emergency operations were performed in 8 (14.3%) patients who presented with a rupture of the aorta or massive bleeding. The causative microorganism was identified in all but 10 patients, with staphylococcus and enterococcus being the prevalent bacteria. Most patients underwent in-situ replacement, and 10 utilized the aorta homograft. The median follow-up duration was 34 months. Early mortality occurred in 4 patients (7.1%), and late mortality in 2 patients (3.6%). Without early mortality cases and tuberculosis patients (n=48), 43 patients finally discontinued the antibiotics. Among them, 8 patients (18%) experienced a recurrence of infection. An elevated CRP level at the time of antibiotic discontinuation was identified as a risk factor for recurrence in multivariable analysis (hazard ratio 3.23, p=0.041). The area under the curve (AUC) of the receiver operating characteristic was 0.73, with a cut-off value of 2.64 mg/dL. The five-year recurrence-free survival for patients with CRP levels under 2 mg/dL was 73.2%, whereas for those with CRP levels exceeding 2 mg/dL, it was 21.8% (p<0.001).
Conclusion
CRP levels at the time of antibiotic discontinuation post-aortic surgery could be a predictor of infection recurrence. Monitoring CRP levels postoperatively offers a valuable clinical tool for risk assessment.
Authors
Siwon Oh (1), muhyung Heo (1), Seyeon Jeon (1), suryeun chung (1), Yang Hyun Cho (1), Dong Seop Jeong (1), Wook Sung Kim (1), Kiick Sung (1)
Institutions
(1) Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University, Seoul, NA
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Poster Presenter
Siwon Oh, Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University
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Seoul, NA
South Korea
Objective: To demonstrate an efficient, single-stage approach for treating retrograde type A aortic dissections with an entry tear in the descending aorta.
Case Video Summary: A 38-year-old man presents with chest pain, hemodynamic stability, and no signs of malperfusion. CTA shows an acute retrograde type A dissection extending to the renal arteries with high-risk features: an entry tear in the descending aorta and a 360° dissection flap.
The aorta is cannulated over a guidewire. The right atrium and superior vena cava are cannulated for venous return and to enable retrograde perfusion. Retrograde cardioplegia is given. Cardiopulmonary bypass is initiated. The aorta is cross-clamped and transected.
Characteristically for a retrograde type A with an entry tear in the descending aorta, the intimal flap is filled with clot. A dissection flap extends from the ascending aorta and root into the right- and non-coronary sinuses with detachment of the non-coronary commissure. The aortic valve is trileaflet with no major defects.
The media of the right- and non-coronary sinuses is reconstructed with a felt insert and 5-0 prolene. Additional pledgeted suture is placed in the middle of the noncoronary sinus due to redundancy and to improve remodeling. All aortic valve commissures are re-suspended with pledgeted 4-0 prolene.
After deep cooling, circulation is arrested and retrograde perfusion is given. The arch is inspected revealing no unexpected tears.
Given the location of a primary intimal tear in the descending aorta, the absence of tears in the arch, and lack of dissection in the head vessels, the decision is made to perform a hybrid arch replacement with subclavian artery stenting.
A 15 cm frozen elephant trunk is deployed in the true lumen with a proximal landing zone in zone 2. A subclavian artery stent graft is advanced. A suture is placed on the lesser curvature to prevent stent dislodgment. A hole is made in the stent graft. A 13.5 mm stent is advanced over a guidewire into the left subclavian artery. The frozen elephant trunk is fixed in zone 2 with 4-0 prolene. The distal anastomosis is created with a 30 mm single-branched tubular graft using 4-0 prolene. De-airing is performed, circulation resumed, and rewarming is initiated. True lumen stent positioning is confirmed on echocardiogram.
The supracoronary proximal anastomosis is created, bypass is weaned, and the patient is decannulated. True lumen flow is again confirmed on echocardiogram.
Circulatory arrest time is 36 minutes. The patient is extubated on postoperative day 2 and discharged on day 8. CTA four months postoperatively reveals stable aortic dimensions, no endoleak, and a patent left subclavian artery stent.
Conclusions: Hybrid arch replacement with subclavian artery stenting for retrograde acute type A dissections is a simple, efficient way to treat the primary tear – a goal of every acute dissection surgery. This technique allows for single-stage, multi-segment aortic repairs in patients with risk factors for fast dissection propagation and growth. Fixating the frozen elephant trunk in zone 2 rather than zone 3 may reduce circulatory arrest time, bleeding complications, and left recurrent laryngeal nerve injury risk. Stenting the left subclavian artery is simpler then debranching, promotes remodeling, and reduces the risk of retrograde perfusion from the subclavian into an aortic false lumen if only covered by the main stent.
Authors
Noah Weingarten (1), Patrick Vargo (1), Xiaoying LOU (1), Eric Roselli (1), Faisal Bakaeen (1), Edward Soltesz (1), Michael Tong (1), Shinya Unai (1), Haytham Elgharably (1), Benjamin Kramer (1), Anibal Ibanez (1), Francis Caputo (1), Jon Quatromoni (1), Ali Khalifeh (1), Lars Svensson (1), Marijan koprivanac (1)
Institutions
(1) Cleveland Clinic, Cleveland, OH
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Poster Presenter
Noah Weingarten, Cleveland Clinic
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Cleveland, OH
United States
CASE REPORT
Hybrid Arch Type II Repair for Acute Type A-on-Chronic Type B Aortic Dissection with Paraplegia and Acute Aortic Occlusion at the Aortic Bifurcation
Phasakorn Noiniyom, Sunthorn Muangsug
ABSTRACT
Background
Acute Type A dissection (ATAAD) remains a serious condition with high morbidity and mortality rates. Aortic dissection involving the ascending aorta may lead to various complications, ranging from malperfusion to aortic rupture, requiring immediate surgical repair. Surgical intervention in each patient will differ depending on the size of the aorta, location of the intimal tear, re-entry size, and the specific complications that necessitate tailored treatment.
Case presentation
A 46-year-old male presented with chest pain, numbness and weakness in both legs. Femoral pulse could not be palpated, and motor power was graded as 2 in both legs. One year prior to this admission, he had experienced chest pain and was diagnosed with aortic dissection type B. He had been treated solely with medication to control hypertension. After being discharged from the hospital, he lost follow-up and stopped taking all medications. Computed tomography angiography of the entire aorta revealed Stanford Type A aortic dissection with a complex triple lumen acute-on-chronic aortic dissection in the descending aorta and severe narrowing of the true lumen. Total occlusion of the aorta at the aortic bifurcation and reconstitution at both common iliac arteries were observed.Emergency surgery was performed, including Hemiarch replacement at zone 2 and total arch debranching with a branch-first technique. After weaning off cardiopulmonary bypass, both femoral pulses still could not be palpated, and arterial-line monitoring in the leg did not demonstrate an arterial waveform. TEVAR was performed, restoring arterial pressure and the arterial waveform. Following the operation, motor power improved to grade 4 and gradually continued to improve. The patient stayed in the hospital for one week and was able to walk before being discharged.
Conclusion
Hemiarch or total arch replacement plus total arch debranching with a branch-first technique are good choices for patients with aortic dissection type A, especially for young patients who still have a high risk of aortic progression. Staged TEVAR can be considered in these patients to promote better aortic remodeling. Hybrid arch type 2 procedures can also be considered if hemiarch or total arch replacement alone
Authors
Phasakorn Noiniyom (1), Sunthorn Muangsuk (2), surin woragidpoonpol (3)
Institutions
(1) Yala Hospital, Yala, Thailand, (2) Endovastec, Bangkok, Bangkok, (3) N/A, Chiang Mai
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Poster Presenter
Phasakorn Noiniyom, Yala Hospital
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Yala, Thailand
Thailand
Objective:
We report a hybrid repair of a right-sided aortic arch and an aberrant left subclavian artery associated with a Kommerell diverticulum.
Methods:
A 58- year- old was evaluated for acute-onset chest pain and shortness of breath. A computed tomographic angiography (CTA) of the chest, abdomen, and pelvis revealed a right-sided aortic arch and an aberrant left subclavian artery (ALSA) associated with a Kommerell diverticulum measuring 3.6 cm. Aneurysmal degeneration of the descending aorta measured 6.0 cm. An acute type B (zones 2-10) aortic dissection was identified.
Results:
The patient underwent open repair with explantation of the infected TEVAR, extensive periaortic debridement, graft replacement with a dacron graft, and complete coverage with a latissimus dorsi muscle flap.
In the second stage, we performed a thoracic endovascular aneurysm repair (TEVAR), which was deployed in the elephant trunk with a 4-cm proximal overlap.
At 1-year follow-up, he demonstrated symptoms of left upper extremity and vertebrobasilar ischemia. Therefore, a left common carotid to subclavian artery bypass was performed.
CT scan during follow-up shows no aneurysmal growth, with an aortic size over the past 3 years unchanged, at 2.9 cm.
Conclusions:
Our patient's successful management after hybrid repair of a right aortic arch and ALSA depended on meticulous preoperative planning with a multidisciplinary team. Careful evaluation of individual's unique anatomy and presenting symptoms is essential.
Authors
Lucas Ribe (1), Regina Husman (2), Yuki Ikeno (1), Madiha hassan (3), Rana Afifi (4), Anthony Estrera (5)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX, (2) Memorial Hermann Hospital. UTHealth., Houston, TX, (3) Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Houston, TX, (4) Memorial Hermann, Houston, TX, (5) Memorial Hermann Heart and Vascular Institute, Houston, TX
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Poster Presenter
Lucas Ribe, McGovern Medical School at UTHealth
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Houston, TX
United States
Objective
Dysphagia lusoria is a rare condition causing compression of the esophagus by an aberrant subclavian artery. When combined with connective tissue disorders, it poses unique surgical challenges.
The aim of this study is to present the case of a patient with Loeys-Dietz syndrome who underwent a two-stage procedure encompassing the ligation and resection of the aberrant right subclavian artery. We additionally report a bailout technique for an intraoperative unexpected complication, surgical bailout solutions, and postoperative outcome.
Methods
A 47-year-old Caucasian woman was transferred to our institution with a thirty-year history of dysphagia secondary to an ARSA (figure 1). Past medical history was significant for LDS, Hashimoto's disease, hypothyroidism, and hypertension. Pre-operative CTA demonstrated an ARSA with a retroesophageal course, and a 2 cm Kommerell diverticulum (figure 2).
Results
A two-stage elective procedure was planned considering the risks and technical challenges associated with LDS. The first stage was an ARSA transposition to the RCCA via a supra-clavicular approach Following this, the proximal and distal RCCA was clamped. Immediately after clamping the RCCA, we noticed discoloration of the arterial wall with a blueish colour, consistent with dissection. A RCCA-to-RSCA bypass was performed using an 8-mm interposition Dacron graft. To further reinforce the suture line and avoid future dilatation of the RCCA we placed a 12-mm Dacron graft over the previous Dacron graft across the proximal anastomosis. A separate 8-mm Dacron graft was connected to the distal ARSA to the carotid graft.
Completion angiography revealed residual dissection just distal to the carotid graft anastomosis extending into the RCCA, stopping just proximal to the origin of RICA. The RCCA was stented using a 14 x 60 mm self-expandable stent proximally and a 7 x 30 mm self-expandable stent distally (figure 3).
The procedure was well tolerated, and post-operative CTA (figure 4) confirmed the patency of the vasculature and resolution of the extrinsic esophageal compression.
Conclusions
The presented case highlights the importance of a multidisciplinary approach and meticulous surgical planning when treating dysphagia lusoria in patients with underlying connective tissue disorders such as Loeys-Dietz syndrome.
Authors
Lucas Ribe (1), Yuki Ikeno (1), Lucas Ruiter (2), Thanila Macedo (3), Rana Afifi (4), Akiko Tanaka (5), Gustavo Oderich (1)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX, (2) McGovern Medical School UTHealth, Houston, TX, (3) Memorial Hermann Hospital. UTHealth., Houston, TX, (4) Memorial Hermann, Houston, TX, (5) Memorial Hermann Heart and Vascular Institute, Houston, TX
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Poster Presenter
Lucas Ribe, McGovern Medical School at UTHealth
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Houston, TX
United States
Introduction: Postoperative hemorrhage is one of the leading causes of mortality and reoperation following Stanford type A aortic dissection (TAAD) repair. However, factors associated with postoperative hemorrhage in TAAD remain unclear. This study aimed to use the National Inpatient Sample (NIS), the largest all-payer inpatient care database in the United States, to provide a comprehensive assessment of the preoperative factors for hemorrhage after TAAD.
Methods: Patients who underwent TAAD repair between the last quarter of 2015-2020 were selected from the National Inpatient Sample (NIS) database. Multivariable logistic regression was employed to select preoperative variables that were either predictive or protective of post-operative hemorrhage in TAAD. Multicollinearity tests were examined to confirm independency for the selected factors.
Results: Among 4,282 TAAD cases, there were 3,302 (77.11%) incidences of hemorrhage. The preoperative risk factors for hemorrhage include thrombocytopenia (aOR 3.090, p<0.01), depression (aOR 1.560, p<0.01), renal malperfusion (aOR 1.543, p<0.01), transferred in from a different acute care hospital (aOR 1.285, p<0.01). In contrast, White race (aOR 0.787, p<0.01), elective surgery (aOR 0.768, p=0.02), age < 45 years old (aOR 0.729, p<0.01), drug abuse (aOR 0.669, p=0.02), and coronary malperfusion (aOR 0.591, p<0.01) were protective for hemorrhage following TAAD repair.
Conclusion: The study identified preoperative factors associated with postoperative hemorrhage after TAAD repair. These findings can be insightful for preoperative risk assessment and perioperative management in patients undergoing TAAD repair.
Authors
Qianyun Luo (1), Renxi Li (1), Stephen Huddleston (1)
Institutions
(1) N/A, N/A
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Poster Presenter
Stephen Huddleston
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Minneapolis, MN
United States
Objective
Bilateral selective antegrade cerebral perfusion (ACP) has been proven safe in aortic arch surgery. However, there is a paucity of literature on the relationship between ACP time and in-hospital outcomes. The aim of this study is to evaluate the association between ACP time and major postoperative outcomes of patients who have undergone arch surgery with bilateral selective ACP.
Methods
This is a multi-center retrospective study of patients who underwent arch surgery with bilateral SACP and deep or moderate HCA (21.1-28.0°C) between 2005 and 2021. Logistic analysis was performed to determine the relationship of SACP time on the major postoperative outcomes of in-hospital mortality, stroke, renal failure, and prolonged ventilation. SACP time was used as a continuous and categorical variable. It was categorized into four groups at 30-minute intervals (SACP<30min (n=191), 31min91min (n=233)). Cubic spline interpolation was used to estimate the relationship between SACP time and the adjusted odds ratio of these complications.
Results
Among a total of 990 patients, 410 (41.4%) underwent hemiarch and 580 (58.6%) underwent total arch replacement with bilateral SACP and MHCA. The median (IQR) age was 65.5 (56.0-72.0) and the surgical indication was acute aortic dissection in 407 patients (41.1%). The median SACP time was 61.0 (35.0-89.0) min, the median cardiopulmonary bypass (CPB) time was 200.0 (166.0-244.0) min, and the median lower body ischemia (LBI) time was 43.0 (33.0-54.0) min. By cubic spline curve, the adjusted odds ratio of renal failure and prolonged intubation increased as SACP time increased; in contrast, in-hospital mortality and stroke did not increase (Figure 1). As a continuous variable, SACP time was not associated with any major outcome in multivariate analysis (mortality, OR=0.996 [0.99–1.003], p=0.28; stroke, OR=0.99 [0.98-1.00], p=0.06; renal failure, OR=1.00 [0.99-1.01], p=0.92; prolonged ventilation, OR=0.999 [0.99-1.004], p=0.78). Increased CPB time was associated with in-hospital mortality and prolonged ventilation (mortality, OR=1.01 [1.00–1.01], p<0.01; prolonged intubation, OR=1.01 [1.005-1.01], p<0.001), as was LBI time for renal failure (OR=1.01 [1.00–1.02], p=0.04). As a categorial variable, SACP time, even over 90 minutes, was not associated with any major outcomes (mortality, OR=1.25 [0.40–3.88], p=0.70; stroke, OR=0.26 [0.07-0.91], p=0.03; renal failure, OR=1.19 [0.47-3.04], p=0.72; prolonged ventilation, OR=1.22 [0.39-3.78], p=0.73).
Conclusion
In aortic arch surgery with ACP, ACP time, even with extended duration, was not associated with major in-hospital complications. ACP time may not be a suitable variable to address surgical impact of arch surgery.
Authors
Yu Hohri (1), Megan Chung (1), Giacomo Murana (2), Yanling Zhao (1), Sabrina Castagnini (2), Edoardo Bianco (2), Paul Kurlansky, MD (1), Davide Pacini (2), Hiroo Takayama (1)
Institutions
(1) NewYork- Presbyterian/Columbia University Medical Center, New York, NY, (2) S.Orsola Hospital, Bologna, Italy
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Poster Presenter
Yu Hohri, Columbia Univeristy Irving Medical Center
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New York, NY
United States
Objective: Aortic valve-sparing aortic root replacement (VSARR) is accepted as an excellent option for patients with isolated aortic root pathology. This study aims to compare outcomes between patients undergoing isolated VSARR and those undergoing VSARR with associated procedures.
Methods: We conducted a retrospective analysis of 171 patients who underwent VSARR, with 115 patients in the isolated procedure (IP) group and 56 patients in the associated procedures (AP) group. A propensity score matching (PSM) was employed to create 40 well-matched pairs. Patient characteristics, including sex, age, comorbidities, and clinical parameters were used to calculate propensity scores. Outcome measures were compared before and after PSM. The Kaplan-Meier method was used to establish long-term survival and freedom from valve-related reintervention.
Results: Prior to PSM, AP patients had a higher proportion of preoperative myocardial infarction (0% vs. 10.7%; p=0.001), atrial fibrillation (0.9% vs. 7.1%; p=0.04), higher EuroSCORE (median 4% vs. 5%; p=0.002), and worse NYHA functional class (8.7% vs. 21.5% in functional class III and IV; p=0.019). After PSM, a homogeneous sample was obtained. Postoperatively, statistically significant differences were found for the duration of cardiopulmonary bypass (median 190 min vs. 220 min; p=0.001), aortic cross-clamp (median 166 min vs. 193 min; p=0.005), length of ICU stay (median, days: 1 vs. 2.8; p=0.003), and postoperative hospital stay (median, days: 5 vs. 6.5; p=0.032), all greater in AP patients. The overall follow-up time median was 7.2 years. No significant differences were found in short- and long-term outcomes such as mortality, reoperation for bleeding, clinical stroke, cardiac arrest, and atrial fibrillation, both before and after PSM. Moreover, we found no difference in valve-related reintervention (Log Rank=0.932) and survival (Log Rank=0.259) at long-term follow-up.
Conclusion: In patients undergoing VSARR, the addition of associated procedures appears to be associated with increased surgical complexity and longer recovery times. However, these differences do not translate into increased postoperative morbidity and mortality. Further research is needed to explore the long-term outcomes in this patient population.
Authors
Andres Jimenez (1), Carlos Villa (2), Lina Ramírez (3), Ivonne Pineda (3), Julian Senosiain (4), Carlos Obando (5), TOMAS Chalela (6), NESTOR SANDOVAL (7), Jaime Camacho (8), Juan Umaña (9)
Institutions
(1) Fundacion Cardioinfantil / La Cardio - Universidad del Rosario, Bogota, DC, (2) Fundacion Cardioinfantil, Bogota, Colombia, (3) La Cardio, Bogota, NA, (4) N/A, N/A, (5) N/A, Bogota, Colombia, (6) N/A, bogota, Colombia, (7) FUNDACION CARDIOINFANTIL, BOGOTA, DC, (8) Fundación CardioInfantil, Bogota, NA, (9) La Cardio, Bogota
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Poster Presenter
Andres Jimenez, Fundacion Cardioinfantil
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Bogota, DC
Colombia
Objective: Stanford Type A aortic dissection (TAAD) is a life-threatening cardiovascular emergency necessitating immediate intervention; however, the correlation between travel distance to healthcare facilities offering surgical repair and clinical outcomes has not been examined. This study aims to investigate whether geographical proximity to medical care significantly affects patient survival.
Methods: Patients with TAAD who underwent surgical repair between 2011 and the second quarter of 2023 were identified in this single-center observational study. Patients were categorized into groups based on the distance from their residential zip code to the university hospital. Survival analysis employed the Kaplan-Meier method, and the influence of distance was assessed using the Cox proportional hazard model. Log rank test was done for multiple comparison to evaluate survival difference between the groups.
Results: 240 patients with TAAD who underwent surgical repair were identified. Median age was 61.1 (IQR 51.2-72.2), with 32.4% female. Median distance from patient's residential zip code to the university hospital is 25.4 miles (IQR 10.4-121.6 miles). Discharge mortality was 5.3%, 4.3%, 4.2%, 5.8% for patients who reside within 25 miles, 25-50 miles, 50-100 miles, and more than 100 miles from the hospital (p = 0.99). Log rank multiple comparison test revealed no difference between the four groups with all p-value greater than 0.50. Similarly, 30-day mortality for patients who reside within 25 miles, 25-50 miles, 50-100 miles, and more than 100 miles from the hospital was 7.3%, 12.5%, 3.8%, 6.3% respectively (p = 0.68). No difference was found from the log rank multiple comparison test (p> 0.46).
Conclusions: This study found no significant association between geographical proximity to the medical facility providing surgical repair and patient survival outcomes in cases of TAAD undergoing surgical repair. These results suggest that although access to timely medical care is important, it is not a limiting factor in achieving favorable clinical outcomes in this single-center setting.
Authors
Qianyun Luo (1), Stephen Huddleston (1), Qianyun Luo (1), Renxi Li (2), Ranjit John (1), Sara Shumway (3), Matthew Soule (1), K. Joshua Wong (1), Rochus Voeller (4), Andrew Shaffer (1), Rosemary Kelly (1)
Institutions
(1) University of Minnesota Medical Center, Minneapolis, MN, (2) N/A, N/A, (3) Univ of Minnesota Medical Center, Minneapolis, MN, (4) University of Minnesota Medical Center, United States
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Poster Presenter
Stephen Huddleston
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Minneapolis, MN
United States
Objectives:
In this study, we sought to assess the impact of a hospital's teaching status on survival and outcomes of patients presenting with type B aortic dissections (TBAD) across the United States. Additionally, we attempted to assess whether patient outcomes differed by TBAD management strategy.
Methods:
We reviewed The National Readmissions Database (NRD) to identify all TBAD between 2016 and 2020. Patients were stratified by hospital teaching status provided in the NRD. Subgroup analysis of open surgical repair (OSR) versus thoracic endovascular aortic repair (TEVAR) was undertaken. Mixed effects and logistic models were created for 30-day readmission and in-hospital mortality.
Results:
A total of 44,981 patients with a diagnosis of type B aortic dissection were included of which 12 % (5,421) received care at a metropolitan non-teaching (NT) hospital while 88% (39,470) were treated at a metropolitan teaching (T) hospital.
Younger patients (65 years (54-76) vs. 69 years (58-80), p<0.001) with TBAD presented at teaching hospitals and had longer durations of stay (6 days (3-12) vs. 5 days (2-9), p<0.01). The total adjusted charges were expectedly higher at teaching hospitals ($32,300 (12.3-70.2) vs. $16,900 (8.4-44.1), p<0.001). More females were treated at non-teaching hospitals compared to teaching hospitals (43.8% (2376) vs. 39.7% (15,653), p<0.001).
In-hospital mortality was higher at non-teaching hospitals (12.8% (694) vs 11.1% (4391), p<0.001). 30-day readmission rates were comparable between hospital types (NT: 23.2% (996) vs. T: 22% (6977), p=0.07). On both multivariable logistic regression for in-hospital death and multivariable mixed model for readmission, teaching status was not associated with the odds of the respective outcome.
On subgroup analysis, in-hospital death was comparable (NT: 3.8% (11) vs T: 5.5% (210), p=0.22) between hospital types in the TEVAR subgroup as were the 30-day readmission rates (NT: 27.3% (70) vs T: 22.8% (745), p=0.1). However, in the OSR subgroup, in-hospital death rate was lower at teaching hospitals (12.1% (275) vs. 17.8% (32), p=0.027). 30-day readmission rates were comparable in the OSR subgroup.
Conclusion:
Type B aortic dissections continue to be primarily managed by teaching hospitals, with superior in-hospital survival at teaching hospitals. Further, surgical management seems to yield better in-hospital survival at teaching hospitals while no such benefit is seen in TEVAR for TBAD at either type of institution.
Authors
Danial Ahmad (1), James Brown (1), Sarah Yousef (2), Derek Serna-Gallegos (3), Yisi Wang (1), David West (1), Pyongsoo Yoon (1), David Kaczorowski (4), Johannes Bonatti (5), Danny Chu (6), Francis Ferdinand (7), Julie Phillippi (8), Ibrahim Sultan (3)
Institutions
(1) UPMC, Pittsburgh, PA, (2) University of Pittsburgh, Pittsburgh, PA, (3) University of Pittsburgh Medical Center, Pittsburgh, PA, (4) University of Pittsburgh Medical Center, Venetia, PA, (5) UPMC Heart and Vascular Institute, Pittsburgh, PA, (6) Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, (7) UPMC, Erie, PA, (8) N/A, Pittsburgh, PA
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Poster Presenter
Danial Ahmad, UPMC
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Pittsburgh, PA
United States
Objective: Left thoracotomy for aortic repair often causes unbearable pain post-surgery. Nevertheless, various analgesics are used. The efficacy of intercostal nerve cryoablation for pain management after pectoris excavatum repair and lung resection has been reported. In this study, the impact of intercostal nerve cryoablation after aortic repair with thoracotomy was evaluated.
Methods: From January 2017 to July 2023, 72 patients underwent aortic repair with thoracotomy in our facility. After excluding emergency or infected aneurysm cases, 62 patients participated in this study. The primary outcome was the mean pain score during the first 5 days post-surgery using a numerical rating scale (1–10). Secondary outcomes were the rate of opioid use and the lung volume ratio assessed by computed tomography at 1 week post-surgery. These variables were compared between the two groups: thoracotomy with cryoablation for intercostal nerve block (cryoablation group) and thoracotomy without cryoablation (non-cryoablation group).
Results: The cryoablation group had 32 patients, and the non-cryoablation group had 30 patients. The mean age was 64.3 and 61.2 years, respectively, and other patients' characteristics, which were sex, physique, comorbidities, and operation time, were not significantly different. The mean pain score was lower in the cryoablation group (1.7 ± 0.9) than in the non-cryoablation group (2.4 ± 0.8; p < 0.01). The rate of opioid use was also lower in the cryoablation group (6.2%) than in the non-cryoablation group (56.6%; p < 0.01). The left lung volume ratio at 1 week post-surgery to preoperative value was larger in the cryoablation group (72.3%) than in the non-cryoablation group (62.4%; p = 0.05).
Conclusion: Intercostal nerve cryoablation showed good pain management. Furthermore, this procedure decreased opioid use and encouraged lung expansion post-surgery.
Authors
JUNJI NAKAZAWA (1), Yutaka Iba (1), Tomohiro Nakajima (1), Tsuyoshi Shibata (1), Shuhei Miura (1), Ayaka Arihara (1), Keitaro Nakanishi (1), Takatakimi Mizuno (1), Kei Mukawa (1), Nobuyoshi Kawaharada (1)
Institutions
(1) Department of Cardiovascular Surgery, Sapporo Medical University, Sapporo, Hokkaido
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Poster Presenter
Junji Nakazawa, Sapporo Medical University
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Sapporo, Hokkaido
Japan
Objective: Obesity has been reported to have variable effects on outcomes after surgery. In aortic operations, obesity may increase technical complexity, heating/cooling duration, duration of circulatory arrest, and impair recovery, however evidence is lacking. We therefore sought to the determine impact of overweight and obesity on perioperative risk of patients undergoing surgery with circulatory arrest.
Methods: We retrospectively reviewed all patients undergoing aortic arch repair with circulatory arrest (N=2256) from 9 centers (2002-2021). After excluding those without available BMI data, those undergoing thoracoabdominal incisions, and a minority of underweight patients, 2128 individuals remained. Subgroup analyses were performed for patients undergoing elective and acute type A dissection repairs. Primary outcomes were in hospital death and hospital length of stay. Secondary outcomes included perioperative complications. Linear regression was performed to determine the association of weight parameters with perfusion parameters. Multivariable logistic regression was also performed for death and prolonged hospital length of stay (defined as >15 days, 3rd quartile).
Results: Considering the total cohort, 27% patients were of ideal weight (BMI 18.5-24.9, n=571), 42% were overweight (BMI 25-29.9, n=885), and 31% were obese (BMI ≥ 30, n=672). Significant differences were observed in age [ideal: 64.0±14, overweight: 63.8±13, obese: 61.2±12.3 years p<0.001] and proportion of males [ideal: 59% (n=336), overweight: 76% (n=668), obese: 74% (n=495) years p<0.001]. Additionally, obese patients had the smallest proportion of acute dissections [ideal: 35% (n=197), overweight: 35% (n=307), obese: 28% (n=189), p=0.012]. No differences were observed in proportion of patients undergoing concomitant aortic valve replacement, Bentall procedure, valve sparing, extended arch procedures, or overall aortic cross clamp durations. Modest but statistically significant correlations were observed between weight and total CPB [weight vs total CPB: R=0.2, P<0.001]. In the unadjusted comparison of the overall cohort, no differences were observed in risk of death, stroke, re-exploration for bleeding, ventilation ≥ 40h, sepsis, or mediastinitis. However, hospital length of stay was significantly greater among ideal weight patients [ideal: 9 [IQR:6-16] overweight: 8 [IQR:6-14] obese: 8 [IQR:6-13] p<0.001, Figure 1A]. After adjusting for baseline differences, death remained similar between groups, and hospital length of stay remained significantly in favor of increased weight [overweight OR: 0.75 (95%CI: 0.61-0.93) p= 0.03; obese OR: 0.74 (95%CI: 0.58-0.93) p= 0.03; Figure 1B-C]. Adjusted risk of death was significantly higher among obese individuals in the type A dissection subgroup [OR: 2.55 (1.56 – 4.18, p=0.002, Figure 1B].
Conclusions: Most aortic surgery patients are overweight or obese. Similar complexity of operations as ideal weight patients are performed. While perioperative risk of death among obese and overweight patients is similar to that of ideal weight patients, obesity is independently associated with reduced hospital length of stay. These data suggest that the obesity paradox may prevail in aortic surgery for all comers. Obese patients have excess mortality from type A dissection. Obesity should not preclude patients from aortic surgery with circulatory arrest, however caution should be taken in type A dissection.
Authors
Malak Elbatarny (1), Areeba Zubair (2), Maral Ouzounian (3), Jennifer Chung (4), John Bozinovski (5), Michael Moon (6), Bindu Bittira (7), Rony Atoui (8), Kevin Lachapelle (9), Munir Boodhwani (10), Francois Dagenais (11), Jonathan Hong (12), Matthew Valdis (13), Michael Chu (14), Canadian Thoracic Aortic Collaborative Investigators (15)
Institutions
(1) TGH / St Michael's, Toronto, ON, (2) St. Michael's Hospital, University of Toronto, Toronto, Ontario, (3) Toronto General Hospital, Toronto, ON, (4) Toronto General Hospital, Toronto, Ontario, (5) Ohio State University Wexner Medical Center, Columbus, OH, (6) University of Alberta, Edmonton, NA, (7) N/A, N/A, (8) Northern Ontario School of Medicine, Sudbury, ON, (9) Division of Cardiac Surgery, McGill University Health Centre, Montreal, QC, (10) N/A, Ottawa, ON, (11) Quebec Heart and Lung Insitute, Quebec, Quebec, (12) Max Rady College of Medicine, University of Manitoba, Winnipeg, NA, (13) N/A, London, ON, (14) University Hospital, London Health Sciences Centre, London, Canada, (15) Western University, London, NA
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Poster Presenter
Malak Elbatarny, University of Toronto
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Toronto, ON
Canada
Objective: Our research aims to explore the impact of preoperative hyperuricemia on the prognosis of patients with acute type A aortic dissection.
Method: Between January 2015 and December 2017, 485 patients with acute type A aortic dissection who underwent surgery were included in our study. Based on preoperative blood uric acid tests, the patients were divided into a hyperuricemia group (N=118) and a normal uric acid group (N=367). Cox regression model was used to determine predictors of mortality. Multivariable adjustment and stabilized inverse probability of treatment weighting (IPTWs) were used to adjust for confounders.
Result: 118 patients (24.3%) developed hyperuricemia before surgery, and after using IPTWs to adjust baseline data, all variables in both groups had good balance (SMD<0.1). The 30-day mortality (19.4% vs 6.2%, P<0.001), ICU time (2.5d vs 1.9d, P=0.024), and ventilator time (76.0h vs 42.0h, P=0.004) in the hyperuricemia group were significantly higher than those in the normal uric acid group. Univariate and multivariate COX regression revealed that preoperative hyperuricemia was an independent risk factor for 30-day mortality in patients (HR, 2.2; 95% CI, 1.2-4.1; P=0.016). In subgroup analysis based on different age, gender, smoking, hypertension, ascending aorta replacement, and root replacement, the trend of increased mortality in the preoperative hyperuricemia group was consistent, and no interaction was found. In a median follow-up time of 6.2 years (IQR, 5.6-6.9 years), Landmark analysis using postoperative 1 month as the threshold showed that the mortality of the hyperuricemia group mainly increased significantly within 1 month after surgery (Log rank P<0.001), and there was no significant difference in survival between the two groups after 1 month (Log rank P=0.506).
Conclusion: Preoperative hyperuricemia was an independent risk factor for early mortality in patients with acute type A aortic dissection, but it did not affect the mid-term survival in patients who survived the early postoperative period.
Authors
Songhao Jia (1), Wenjian Jiang (1), Hongjia Zhang (1)
Institutions
(1) Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Poster Presenter
Songhao Jia, Beijing Anzhen Hospital Capital Medical University
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Beijing
China
Abstract:
Although preoperative nutritional status is used to predict morbidity and mortality, its effect on the outcomes of acute type A aortic dissection (ATAAD) has not been examined. Thus, the objective was to evaluate the role of preoperative nutritional status in predicting postoperative morbidity and mortality in ATAAD.
Method:
A retrospective analysis of a prospectively maintained database was undertaken for all patients (580) undergoing emergency aortic surgery between May 2004 and February 2023. Preoperative nutritional status was evaluated using Geriatric Nutritional Risk Index (GNRI= 14.89 x serum albumin (g/dL) + 41.7 x body weight (kg) / ideal body weight (kg)). We classified into two groups, GNRI≧92 (group A), GNRI< 92 (group B).
Results:
Of all patients, 410 (70.5%), 170 (29.5%) were classified into group A, group B, respectively. In-hospital mortality rates were not significantly different (8.7% vs. 7.1%, respectively; P=0.69). About incidence of postoperative major morbidities were also not statistically different.
As for 5-year survival rates, 82.4%, 68.9%, were found in groups A and B, respectively, showing a significant difference between the groups (p=0.001). Independent risk factors of late mortality were preoperative nutritional status, preoperative cardiopulmonary resuscitation, previous cardiac surgery, elderly (>80 years), preoperative shock status, myocardial malperfusion, visceral malperfusion.
Conclusion:
Preoperative assessment of nutritional status using GNRI is an independent factor in the long-term prognosis of acute aortic dissection. This assessment method is simple to perform preoperatively and may provide useful information for predicting the postoperative mortality and morbidity in elderly patients.
Authors
Takagi Yuki (1), Toshihito Gomibuchi (2), Tatsuichiro Seto (3)
Institutions
(1) N/A, N/A, (2) Suwa red cross hospital, Matsumoto, Japan, (3) PhD, Matsumoto, NA
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Poster Presenter
Takagi Yuki
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Nagano prefecture Matsumoto city
Japan
Objective:
We reviewed our near two-decade experience to evaluate for the impact of resternotomy in acute type A aortic dissection (ATAD).
Methods:
All open ATAD repairs performed at our institution from December 1999 to December 2022 were reviewed. Perioperative data were reviewed. Patients who had re-sternotomy was compared with first time sternotomy group.
Results:
Total of 697 patients had type A aortic repair during the study period. 49 patients had previous sternotomy procedures. Patients with re-sternotomy were older (67 yo vs. 57 yo, P<0.001) and had frequently had hypertension (82% vs. 64%, P=0.011), advanced chronic kidney disease (greater than stage IIIb), and previous infrarenal abdominal aortic aneurysm repair (10% vs. 1%, <0.001). Re-sternotomy patients required larger amount of transfusion including, cell saved units, packed red blood cell, and platelet (all P<0.001). Aortic clamp time (100 min vs. 96 min, P=0.137) and circulatory arrest time (27 min vs. 26 min, P=0.294) were similar in two groups, and performed concomitant procedures, but cardiopulmonary bypass time (178 min vs. 153 min, P=0.002) were longer in the re-sternotomy group. Postoperative complications were more frequently observed in re-sternotomy group, including ARDS (27% vs. 13%, P=0.008), postoperative dialysis (24% vs. 14%, P<0.001), and operative mortality (39% vs. 12%, P<0.001).
Conclusions:
ATAD patients with previous sternotomy had more comorbidities compared to first time sternotomy patients. Outcomes after ATAD patients remain challenging despite the advancement of perioperative care in ATAD.
Authors
Yuki Ikeno (1), Akiko Tanaka (1), Alexander Mills (1), Lucas Ribe (1), Harleen Sandhu (1), Charles Miller (1), steven eisenberg (1), Anthony Estrera (1)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX
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Poster Presenter
Akiko Tanaka, Memorial Hermann Heart and Vascular Institute
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Houston, TX
United States
Objective
Acute type A aortic dissection (ATAAD) is associated with significant mortality and morbidity, especially in cases complicated by malperfusion. However, the impact of symptom-to-surgery time on operative mortality in ATAAD is unclear. This study aims to determine the impact of symptom-to-surgery time on operative and mid-term mortality in ATAAD patients with and without malperfusion.
Methods:
A retrospective analysis included 288 ATAAD patients treated between January 2016 and December 2020. Patients were separated into early and late intervention groups by symptom-to-surgery time (Median: 10 hours, IQR: 6-21.25). Baseline characteristics, including malperfusion (late [n=46, 33%] vs. early [n=61, 41%], p=0.198), were comparable between groups, except for male gender (late [n=91, 66%] vs. early [n=121, 81%], p=0.005) and prior aortic dissection (late [n=11, 8%] vs. early [n=2, 1%], p=0.007). Malperfusion was further classified into specific organ systems (cerebral: n=34, 12%; cardiac: n=53, 18%; renal: n=35, 12%; mesenteric: n=5, 2%; limb: n=22, 8%; Spinal: n=1, 0%; Tamponade: n=21, 7%), number of malperfused organs (one organ: n=59, 20%; two organs: n=29, 10%; three organs: n=11, 4%), and the Penn classification system (Penn B: n=86, 30%, Penn C: n=8, 3%, Penn B-C: n=13, 5%). Follow-up data were complete for all patients (236/236) over a mean period of 4.3 ± 1.6 years, with 19 patients undergoing re-intervention at a median of 1.7 years (IQR 1.4-4.4).
Results:
Operative death (52 [18%]) and late death (14 [6%]) were not significantly different between the late and early intervention groups, along with other perioperative variables. Multivariable analysis identified age (OR 1.09, 95% CI 1.06-1.14, p<0.001), extracorporeal membrane oxygenation (ECMO) (OR 10.61, 95% CI 2.50-51.61, p=0.002), and malperfusion (OR 7.06, 95% CI 3.11-17.19, p<0.001) as predictors for operative death, when malperfusion was used as a binary variable (model 1). When stratified by organ systems (model 2), cerebral (OR 3.18, 95% CI 1.08-9.11, p=0.032), cardiac (OR 6.13, 95% CI 1.33-27.43, p=0.018), limb (OR 6.41, 95% CI 1.79-22.76, p=0.004) malperfusion were significant predictors for operative mortality. When divided into malperfused organ numbers, one organ (OR 6.48, 95% CI 2.51-17.58, p<0.001), two organs (OR 13.46, 95% CI 3.08-67.22, p=0.001), and three organs (OR 49.09, 95% CI 8.23-322.71, p<0.001) were all significant predictors for operative mortality (model 3). When using the Penn classification system for malperfusion (model 4), Penn B (OR 8.26, 95% CI 3.28-22.32, p<0.001) and Penn B-C (OR 13.26, 95% CI 2.81-63.75, p=0.001) significantly predicted operative mortality. Survival comparison revealed significant differences between the malperfusion and without malperfusion groups (Log-rank p<0.001), but not between the late and early groups (Log-rank p=0.187). Within late and early surgery groups, malperfusion still significantly increased both operative (late: OR 12.54, 95% CI 3.07-70.85, p=0.001; early: OR 5.40, 95% CI 1.77-18.31, p=0.004; p=0.189 for interaction) and mid-term mortality (late: HR 4.16, 95% CI 1.77-9.81, p=0.001; early: HR 4.07, 95% CI 1.84-8.98, p<0.001; p=0.342 for interaction), after adjusting for covariates.
Conclusions:
In this series of ATAAD patients, preoperative malperfusion status rather than symptom-to-surgery time determines both operative and mid-term mortality.
Authors
Xun Zhang (1), Chao Fu (1), Jun Shao (1), Bo Wang (1), Changming Niu (1), Hao Yao (1), Qing-Guo Li (1)
Institutions
(1) The 2nd Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Poster Presenter
Xun Zhang
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Nanjing, Jiangsu
China
Objective: Aortic dissection is a surgical emergency mandating expedient surgical repair. However, many dissections are repaired at low volume centers, possibly due to concerns of delay in care associated with transfer to experienced aortic centers. We hypothesized that interfacility transfer and distance travelled by the patient would not adversely impact outcomes after repair of acute type A aortic dissection (ATAAD).
Methods: The Texas State Inpatient Database was queried for patients who underwent emergent surgical repair for ATAAD from 2018-2021. Distance travelled to hospital was determined by extracting latitude and longitude from patient home and hospital zip codes. Patients and outcomes were stratified by transfer status and hospital ATAAD repair volume. High volume hospitals were defined as those in the top surgical volume quartile. Adjusted logistic regression models were used to assess the independent effect of distance on in-hospital mortality and major morbidity (stroke, renal failure, reoperation, prolonged ventilation, and DSWI).
Results: A total of 1036 patients underwent ATAAD repair at 69 hospitals, of which 56.0% (n=580) underwent transfer prior to surgery. Top quartile ATAAD volume centers performed a median 7 [IQR:5.1-14.1] repairs/year, with the five highest volume centers performing 27 [16-38] dissections/year. Transferred patients traveled greater distances (median [IQR] 26.0 [12.1-78.6]) miles) compared to non-transferred patients (10.8 [4.7-26.7] miles, p<0.001) and were more frequently (92%[537/580] vs. 72.8%[332/456] operated on at high-volume hospitals (p<0.001). Transferred patients had similar mortality (16.6%[96/580] vs. 19.5%[89/456], p=0.25) and major morbidity (41.7%[242/580] vs. 39.5%[180/456], p=0.39) compared to non-transferred patients. When comparing the outcomes of the five highest volume centers to all other centers, there was a signal towards lower observed mortality in the highest volume centers (15.7%[86/546] vs. 20.2%[99/490], p=0.07). After multivariate risk adjustment, distance travelled (OR [95% CI]: 0.998 [0.996-1.0004]) and transfer status (OR 0.783 [0.551-1.112]) did not increase operative mortality, whereas undergoing surgery at high-volume centers demonstrated a protective effect (OR 0.409 [0.283-0.591]). Prior cardiac surgery (OR 2.46 [1.43-4.20] and pre-operative hemodynamic instability (OR 2.10 [1.31-3.36]) represented the greatest risk factors for operative mortality.
Conclusion: Interfacility transfer and distance travelled do not adversely impact outcomes for ATAAD repair. Travel distance alone should not preclude transfer of stable patients with ATAAD to experienced aortic centers. Regionalization of aortic dissection management is safe and has the potential to improve outcomes.
Authors
Travis Miles (1), Robert Seniors (2), Vicente Orozco (3), Todd Rosengart (3), Marc Moon (3), Joseph Coselli (3), Subhasis Chatterjee (3), Ravi Ghanta (3)
Institutions
(1) Baylor College of Medicine, Houston, TX, (2) University of Texas Health Science Center, Houston, TX, (3) Baylor College of Medicine / Texas Heart Institute, Houston, TX
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Poster Presenter
Travis Miles, Baylor College of Medicine
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Houston, TX
United States
Introduction: Type A Aortic Dissection (TAAD) is a life-threatening disease that requires emergency surgical treatment. With a mortality rate reported as high as 1-2% per hour, the time to admission to hospital represent a crucial point in the management of these patients. We aimed to investigate the impact of time to admission on postoperative outcomes after TAAD repair.
Methods: From January 2011 to January 2020, 1406 consecutive patients underwent TAAD repair at our centre. After removing patients with no data on the timing of admission and patients admitted more than 72 hours from the onset of pain, the final dataset included 1228 patients which were divided in two groups: 867 patients were in the early( ≤12 hours) and 361 were in the late (> 12 hours) admission group.
Results: The median age was 53 years (IQR: 44 - 63) and 25% of the patients were female. Hypotension (11% vs 1.9%, p < 0.01) and bradycardia on admission (11% vs 1.9%, p < 0.01) were more common in the early group. This group also had an higher incidence of preoperative limb ischemia (17% vs 11%, p <0.01) and higher rates of rescue surgeries (16% vs 11%, p = 0.05). Despite prompt intervention, the postoperative mortality rate was higher in the early group (15% vs 9.4%, p = 0.01). Postoperative stroke rates were also higher in the early group (5.8% vs 2.8%, p = 0.03). The early group also had a significant higher incidence of postoperative kidney failure (29% vs 21%, p < 0.01) When adjusted for age and gender, the early group was an independent predictor of mortality (p < 0.01 vs late).
Conclusion: Our analysis confirms the results of previous studies showing that TAAD patients with a quicker admission present with more severe symptoms and ischemic signs and, despite early treatment, they have increased rates of complications and mortality emphasizing the importance of the clinical status on admission, rather than the time, as the main driver for postoperative complications.
Authors
Yunxing Xue (1), Vito Domenico Bruno (2), Fudong Fan (1), JUN PAN (1), Qing Zhou (1), Dongjin Wang (1)
Institutions
(1) Nanjing Drum Tower Hospital, Nanjing, China, (2) IRCCS Galeazzi – Sant’Ambrogio Hospital, Milan, Italy
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Poster Presenter
Yunxing Xue, Affiliated Drum Tower Hospital of Nanjing University Medical School
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China, Jiangsu
China
Objective: Total aortic arch replacement (TAR) necessitates hypothermic circulatory arrest (CA). Stroke and spinal cord injury are major complications following TAR with FET technique, which is performed typically with antegrade selective cerebral perfusion (ACP) omitting left subclavian artery (LSA) and additionally requires commercial hybrid grafts. However, left vertebral artery (VA) is dominant in 60% of population, whereas right VA dominance is only 15%. Considering VAs are the sole source of blood flow to spinal cord during ACP, a complete circle of Willis is seen in only 20-25% of population, and 1/3 of cases have hypoplastic posterior communicating arteries; varying degrees of neurologic impairments could be explained if not a major stroke after extended periods of ACP. Herein, we describe a novel modified FET technique that not only eliminates CA but also provides more complete cerebral and spinal cord perfusion using standard grafts thanks to left axillary artery (LAxA) cannulation in patients with acute type A aortic dissection.
Methods: A home-made debranching graft is constructed and consists of one large branch for innominate artery (IA) and 2 smaller branches, one for LCCA and another for LAxA with a perfusion limb. The LAxA branch is passed through a tunnel to infraclavicular fossa and anastomosed to LAxA, and cardiopulmonary bypass is initiated through perfusion limb at 32 °C, followed by debranching of IA and LCCA. The rest of the operation is performed with complete cerebral perfusion. Following replacement of ascending aorta±root, cardiac reperfusion is started using a 16F root cannula connected to arterial line, and the rest of the operation is completed with the heart empty and beating with full antegrade cardiac perfusion. Distal arch anastomosis is performed clamp-on, allowing lower body perfusion via LSA. If a modified FET is planned, a 3-4 cm length of the rest of the aortic graft is invaginated and the folded edge is sutured to distal stump of arch. For modified FET, lower body perfusion is interrupted for 5 to 8 minutes to push the invaginated part of aortic graft to distal aorta to create a classic elephant trunk, and a standard TEVAR is deployed started 2 cm proximal of anastomosis, so the inner surface of anastomosis is covered by endograft. Following cannulation of the distal arch graft, perfusion of distal aorta and rewarming are restarted, and all three grafts are incorporated with full body perfusion to construct a neo-ascending aorta and arch.
Results: Between December 2018 and May 2022, 38 patients underwent TAR without operative mortality. Hospital mortality was %15.7 (6/38), and spinal cord ischemia and stroke were not encountered in surviving patients. The mean lower body interruption of perfusion time was 7.2± 2.8 minutes.
Conclusions: Usage of LAxA for arterial perfusion provides more complete cerebral and spinal cord perfusion with a potential to lower stroke and spinal cord injury following TAR with FET technique. Performing TAR with complete cerebral, cardiac, and lower body perfusion could decrease the need for hypothermia, protect cerebral autoregulation, and may lower mortality and morbidity following TAR. To perform a FET, only a short interruption of lower body circulation is sufficient to deploy an endograft, also improving hemostasis of distal anastomosis. Further studies with a higher number of patients are required to evaluate the efficiency of this novel technique.
Authors
Ugursay Kiziltepe (1), Ilker Ince (2), Suleyman Surer (3), IBRAHIM DUVAN (4), Omer Delibalta (5), Melike Senkal (6), Ozgur Ersoy (7), Kasim Karapinar (8)
Institutions
(1) Diskapi YBEA Hospital, Çankaya, Select State, (2) Etlik Sehir Hastanesi, ANKARA, NA, (3) Etlik Sehir Hastanesi, Ankara, NA, (4) Ankara Etlik Sehir Hastanesi, ANKARA, NA, (5) Diskapi YBEA Hospital, ANKARA, NA, (6) N/A, N/A, (7) Etlik Sehir Hastanesi, ANKARA, Ankara, (8) Ankara EA Hastanesi, ANKARA, Ankara
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Poster Presenter
Ugursay Kiziltepe, Diskapi YBEA Hospital
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Cankaya, Select State
Turkey
Objective: Aortic root replacement (ARR), particularly valve-sparing root replacement (VSRR) is a challenging procedure requiring technical proficiency. This study aims to examine the influence of surgeon volume on practicing VSRR.
Methods: This is retrospective study of 1607 patients from two large aortic centers who underwent ARR from 2004 to 2021 and were potentially eligible for VSRR. Patients with moderate/severe aortic stenosis, prior aortic valve procedure, surgical indication for endocarditis or valvular dysfunction, and Ross/Homograft root replacements were excluded. Surgeons were classified as having performed <5 ARR or ≥5 ARR annually. Multivariable logistic regression was used to examine the independent association of surgeon volume and performing VSRR. Inverse probability treatment weighting (IPTW) was used to match patients who were operated on by <5 ARR or ≥5 ARR surgeons to determine their differences in postoperative clinical outcomes. Cumulative incidence curves with mortality as a competing risk were plotted to compare the rate of aortic valve reoperation in <5 ARR or ≥5 ARR surgeons.
Results: Of 1607 patients who met inclusion criteria, 884 patients underwent composite-valved conduit and 723 underwent VSRR. The median age of our cohort was 57 [45-66] years old and 257 (16.0%) were female. Aortic insufficiency was present in 1020 (63.5%) of patients and 188 (11.7%) of cases were a reoperation. Surgical indication was aneurysm in 1413 (87.9%) and dissection in 194 (12.1%) of patients. Among VSRR operations, 666 patients were operated on by ≥5 ARR surgeons and 57 patients were operated on by <5 ARR surgeons (Figure 1a). Of 57 VSRR performed by <5 ARR surgeons, 23 (40%) were assisted by an ≥5 ARR surgeon. In multivariable logistic regression, ≥5 ARR (OR: 3.48, 95% CI: 2.42-5.00, p <0.001) was associated with VSRR as a procedure of choice. Following IPTW, there was no significant difference in outcomes after VSRR between <5 ARR and ≥5 ARR surgeons (p = 0.8) (Figure 1b). There was also no significant difference in the rate of aortic valve reoperation between the two groups (p = 0.7).
Conclusions: In the context of a high-volume aortic center, patients who undergo ARR are less likely to receive VSRR if operated on by a <5 ARR surgeon; however, VSRR may be safely performed by a <5 ARR surgeon.
Authors
Kavya Rajesh (1), Megan Chung (2), Dov Levine (3), Elizabeth Norton (4), Parth Patel (4), Yu Hohri (5), Christopher He (1), Paridhi Agarwal (4), Yanling Zhao (6), Pengchen Wang (7), Paul Kurlansky, MD (8), Edward Chen (9), Hiroo Takayama (10)
Institutions
(1) N/A, N/A, (2) Columbia University Irving Medical Center, N/A, (3) Columbia University, New York, NY, (4) Emory University, Atlanta, GA, (5) Columbia University Irving Medical Center, New York, NY, (6) NewYork-Presbyterian Columbia University Irving Medical Center, New York, NY, (7) Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, NY, (8) Columbia University Medical Center, New York, NY, (9) Duke University Medical Center, Durham, NC, (10) NewYork- Presbyterian/Columbia University Medical Center, New York, NY
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Poster Presenter
Kavya Rajesh, NYPH-Columbia University Medical Center
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New York, NY
United States
Objective: We reviewed our experience with total arch replacement (TAR) to understand the impact of surgical methods on short- and long-term outcomes.
Methods: We analyzed all adult patients (n=334) undergoing TAR at our institution from 1/1993 through 6/2023; the median age was 64.8 years (Interquartile range [IQR], 55.6-73.4), and 214 (64.1 %) were males. Patients who underwent endovascular arch repair were not included.
Results: The number of patients undergoing TAR significantly increased with each successive decade (1993-2002, n=16, 4.8 %, 2003-2012, n=90, 26.9 %, 2013-2023: n=228, 68.3 %; p<0.001) (Figure 1). The majority had previous cardiac surgery and underwent a repeat sternotomy (n=204, 61.1 %) for TAR. Among patients undergoing repeat sternotomy, the most common indication for operation was dissecting aneurysm (n=97, 51.5%), followed by aneurysmal degeneration (n=70, 37.2 %); aneurysmal degeneration (n=120, 92.3%) followed by Type A dissection (n=78, 23.3 %) were the most common indications in patients having TAR as a primary procedure. Frozen elephant trunk was used in 118 patients (35.2 %), and classic elephant trunk in 116 (34.7 %). All 3 arch vessels were re-implanted in 241 (72.2 %) patients, while 2 and single vessel reimplantations were done in 77 (23.1 %) and 16 (4.8 %), respectively. Deep hypothermia was used in 316 (94.6 %) cases, and moderate in 18 (5.4 %). The most common cerebral protection strategy was combined retrograde cerebral perfusion (RCP) and antegrade cerebral perfusion (ACP) (n=183, 64.4 %). The typical sequence involved a median RCP time of 8.0 minutes (IQR, 6.0-10.0), followed by a median ACP time of 41.0 minutes (IQR, 33.8-49.2). The median cardiopulmonary bypass, cross-clamp, and circulatory arrest times were 275.0 min. (IQR, 231.5-317.0), 183.0 mins (IQR, 134.0-238.0), and 47.0 mins (IQR, 37.0-60.0), respectively. Postoperative stroke occurred in 11 (3.2 %) patients; all were observed in re-operative cases (p<0.001), and it was not associated with any specific cerebral protection strategy (p=0.109). Overall, early mortality was 9.3 % (n=30), which improved with each successive decade (1993-2002, n=4, 26.7 % vs 2003-2012, n=11, 12.2 % vs 2013-2023, n=15, 6.6 %). In the univariate analysis, years (2013-2023) were associated with lower early mortality (OR 0.21; 95 % CI 0.06-0.83). Use of ACP alone (OR 3.14; 95 % CI 1.27-7.99) and RCP alone (OR 9.67; 95 % CI 2.59-34.04) were associated with higher early mortality compared to the combined perfusion strategy. Median follow-up was 5.7 (IQR, 2.8-10.2) years, and survival at 5 and 10 years was 70.8 % (95% CI 65.5 % - 76.5 %) and 54.1% (95% CI 47 %- 62.2 %), respectively. Older age was the only factor independently associated with poorer long-term survival (HR 1.05; 95 % CI 1.03-1.06). Freedom from reoperation was 96 % (95 % CI 93.1%-99 %) at 5 years and 92 % (95 % CI 86 %- 98.3 %) at 10 years.
Conclusion: Over the last three decades, early outcomes of TAR have improved with declining early mortality rates. Improved results may relate to the use of a combined cerebral protection strategy utilizing RCP and ACP.
Authors
Defne Ergi (1), Alberto Pochettino (1), Austin Todd (1), Gabor Bagameri (1), Juan Crestanello (1), Kevin Greason (1), Hartzell Schaff, MD (1), Joseph Dearani (2), Nishant Saran (3)
Institutions
(1) Mayo Clinic, Rochester, MN, (2) Mayo Clinic, United States, (3) N/A, Rochester, MN
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Poster Presenter
Defne Gunes Ergi, Mayo Clinic - Rochester
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Rochester Minnesota, MN
United States
Objectives: This retrospective study aimed to investigate factors influencing aortic remodeling outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR) with the Proximal ExTension to Induce COmplete ATtachment (PETTICOAT) concept for acute complicated Type B aortic dissection (TBAD). The primary objective was to enhance predictability and consistency in aortic dissection therapy by identifying patient-related variables impacting remodeling outcomes.
Methods: The study included 60 "Full PETTICOAT" cases, employing extended bare-metal stents for complete aortic coverage, from a cohort of 299 patients undergoing TEVAR for complicated aortic dissections. The PETTICOAT concept was introduced in March 2015, and patient selection criteria excluded certain endoleaks and cases with short follow-up durations. The study utilized multivariate logistic regression for a detailed analysis of predictors for favorable aortic remodeling.
Results: Among the 60 patients subjected to the full PETTICOAT technique, 37 exhibited stable to good aortic remodeling (favorable remodeling group), while 23 demonstrated poor aortic remodeling (unfavorable remodeling group). The favorable remodeling group had a higher proportion of elderly patients (p=0.012) and a greater frequency of emergent cases (p=0.046). Multivariate analysis pinpointed several independent predictors of favorable aortic remodeling, including age over 60 (OR 9.02, p=0.007), preoperative aortic lumen area under 450mm² (OR 5.74, p=0.035), stent oversizing exceeding 75% of the total aortic lumen (OR 12.72, p=0.041), and oral administration of angiotensin II receptor blockers (ARB) (OR 6.55, p=0.015).
Conclusion: The PETTICOAT concept, utilizing bare-metal stents in conjunction with traditional covered stent grafts, proves highly effective in managing aortic dissections, particularly in elderly patients and those with smaller aortic dimensions. Over a 47.5-month follow-up, it demonstrates positive survival outcomes and comparable aortic event-free survival rates, mitigating risks associated with untreated aortic segments. Age, stent sizing, aortic diameter, and ARB therapy emerge as pivotal predictors of favorable aortic remodeling. Despite promising outcomes, prospective studies are imperative to refine patient selection and optimize technique application for aortic dissection therapy, reinforcing the clinical promise of the PETTICOAT concept in the evolving landscape of aortic interventions.
Authors
Mio Kasai (1), Kenichi Hashizume (1), Mitsuharu Mori (1), Toshiaki Yagami (1), Tadashi Matsuoka (2), Kiyoshi Koizumi (3), Hiroaki Kanayama (3), Yuika Kameda (1), Tsutomu Nara (1), Mayu Nishida (1), Misato Tokioka (1), Hideyuki Shimizu (4)
Institutions
(1) Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, (2) Keio University, Shinjyuku, Tokyo, (3) Ashikaga Red Cross Hospital, Ashikaga, Tochigi, (4) Keio University Hospital, Tokyo, Tokyo
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Poster Presenter
Mio Kasai
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shinjuku-ku
Japan
Objective:
Acute type A aortic dissection (ATAD) repair is a complex and high-risk procedure, often associated with a significant in-hospital mortality rate. We sought to evaluate the impact of implementing an aortic-specialist On-call Rota within our department on the outcomes of ATAD repair.
Methods:
Between January 2015 and October 2023, a total of 406 ATAD surgical repairs were performed. In September 2020, we introduced an aortic-specialist On-call Rota, which required surgeons to have a minimum of 10 major aortic cases per year and 4 ATAD repair cases per year. We compared outcomes between two groups: the pre-specialist Rota group (Group A) and the post-specialist Rota group (Group B).
Results:
There were no significant differences in preoperative patient characteristics between the two groups. The mean age was 59 years (18-89), and 68% of the patients were male.
The overall in-hospital mortality rate was 21.6% (88 out of 406 patients). Notably, we observed a significant decrease in mortality in the post-specialist Rota group (B), with a rate of 16.4% (28 out of 170) compared to 25.4% (60 out of 236) in the pre-specialist Rota group (A) (p-value = 0.03).
While there were no significant differences in operative techniques between the two groups, we noted a trend toward more complex repairs since the introduction of the Rota. Aortic root replacement was performed in 44% of Group B cases compared to 35% in Group A, and total arch replacement using a frozen elephant trunk (FET) technique was employed in 20% of Group B cases compared to 14% in Group A. Inversely, interposition graft alone was used in 38% of Group B cases compared to 45% in Group A. Consequently, longer cardiopulmonary bypass (CPB), cross-clamp, and circulatory arrest times were observed in Group B.
There were no significant differences in postoperative complications between the two groups, but lower incidence of permanent stroke (11% vs 15%), tracheostomy (14% vs 20%), or temporary dialysis (25% vs 31%) was observed in post-specialist Rota group B vs pre-specialist Rota group A, respectively.
Conclusion:
The implementation of an aortic-specialist On-call Rota for the surgical treatment of ATAD has a positive impact on in-hospital mortality and morbidity outcomes. Additionally, there is a discernible trend toward more complex repairs following the introduction of a specialist aortic Rota.
Authors
Robert Pruna-Guillen (1), Mehmet Alagoz (2), Benjamin Adams (3), Carmelo Di Salvo (4), Kulvinder Lall (5), John Yap (5), Rakesh Uppal (5), Aung Oo (3), Ana Lopez-Marco (4)
Institutions
(1) Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK., (2) University of Texas Health Science at Houston, 0, United States, (3) Department of Cardiothoracic Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, UK., London, NA, (4) St Bartholomew's Hospital, London, London, (5) St Bartholomew hospital, London, NA
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Poster Presenter
Robert Pruna-Guillen
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Barcelona/Spain
Spain
Objectives: Aortic biomechanics reflect material properties of aortic tissue including fragility in patients with ascending thoracic aortic aneurysms (ATAA). However, clinical translation requires robust methods for in vivo quantification of aorta biomechanics. This study validates, for the first time, in vivo MRI-based aortic biomechanical parameters against patient-specific ex vivo aortic biomechanical testing.
Methods: Preoperative MRI (including MR angiogram, 2D phase contrast and 4D flow sequences) was acquired in 17 patients with ATAA undergoing surgery and 4 healthy volunteers. In vivo aortic biomechanical parameters derived included strain, distensibility, compliance, arterial stiffness index (ASI), aortic pulse wave velocity (aPWV) and kinetic energy loss (KEL). Aortic tissue from ATAA patients was excised during surgery and ex vivo mechanical tests were performed to derive biomechanical properties including energy loss (effciency in performing the Windkessel function) and delamination strength (strength between tissue layers). Linear regression was used to compare the in vivo and ex vivo aortic biomechanical parameters.
Results: Strain, distensibility and compliance were not significantly different between aneurysm and control, and they also correlated poorly with ex vivo biomechanical parameters. In vivo ASI demonstrated a positive correlation with energy loss (R2 = 0.61, p<0.001), and a negative correlation with delamination strength (R2 = 0.53, p<0.011). In vivo aPWV was significantly lower in healthy controls compared to ATAA patients (p=0.01) and demonstrated a positive correlation with energy loss (R2 = 0.77, p<0.001), and a negative correlation with delamination strength (R2 = 0.52, p=0.002). In vivo KEL was significantly lower in healthy controls compared to ATAA patients (p<0.001) and demonstrated a positive correlation with energy loss (R2 = 0.31, p=0.04), and a negative correlation with delamination strength (R2 = 0.69, p<0.001).
Conclusions: MRI-based measurements of ASI, aPWV and KEL correlate strongly with ex vivo aortic biomechanical properties including energy loss and delamination strength. These imaging parameters are measurable in clinic to determine quality of aortic tissue. Future work includes multivariable analysis to improve accuracy of in vivo measurements of aortic biomechanics.
Authors
Jennifer Chung (1), Hijun Seo (2), Nitish Bhatt (3), Farshad Tajeddini (4), Maral Ouzounian (5), Kate Hanneman (6), Rifat Islam (2), Craig Simmons (2)
Institutions
(1) Toronto General Hospital, Toronto, Ontario, (2) University of Toronto, Toronto, Ontario, (3) University of Toronto, Toronto, NA, (4) N/A, N/A, (5) Toronto General Hospital, Toronto, ON, (6) University of Toronto, Toronto, Canada
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Poster Presenter
Jennifer Chung, Division of Cardiac Surgery, University of Toronto
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Toronto, ON
Canada
Objective
Due to the improvement in morbidity and mortality after aortic arch replacement, as well as an aging population, concomitant need for coronary revascularization has increased in aortic patients. This subgroup of patients has the potential to have more baseline comorbidities, and it remains unclear whether the potential of revascularization outweighs any risks of MACE in the perioperative period. We sought to clarify the characteristics and risk of morbidity, mortality and MACE in elective aortic arch patients undergoing adjunctive coronary artery bypass grafting.
Methods
We reviewed our single institution prospectively maintained database for patients who underwent elective aortic arch replacement from April 2009 to May 2023. In total, 564 patients were included in our analysis. Patients were stratified into two cohorts based on whether planned concomitant CABG was performed. Between groups comparisons were performed for pre-operative, operative and post-operative variables, as dictated by distribution of data, and nature of variable. The primary endpoint assessed was perioperative MACE defined as MI, stroke or mortality with subsequent multiple logistic regression analysis performed based on significant pre-operative and operative risk factors.
Results
41 patients underwent aortic arch replacement with adjunctive CABG, and 523 patients without a CABG. Patients who had a CABG were significantly older (p<0.001), more likely to be male (p=0.003), have a higher BMI (p=0.049) and have more comorbidities including HLD (p<0.001), HTN (p<0.001), DM2 (p<0.001), atrial fibrillation (p=0.009) and pulmonary disease (p=0.050). Most patients in both cohorts underwent hemiarch replacement, however, CABG patients were significantly more likely to undergo a hemiarch (p=0.015), and less likely undergo total arch replacement (p=0.050). Despite undergoing less extensive arch replacement, CABG patients had longer cardiopulmonary bypass times (p=0.001) and aortic cross-clamp times (p=0.005), but not circulatory arrest times. CABG patients were also more likely to undergo adjunctive atrial fibrillation procedures (p=0.008) and required more intraoperative platelet transfusion (p=0.008). CABG patients had higher rates of post-operative infection (p=0.02), prolonged ventilation (>48 hours, p=0.031), mechanical circulatory support (p=0.050), and post-operative arrhythmias (p<.001). CABG patients were more likely to have post-operative MACE (p=0.022). Multiple logistic regression demonstrated excellent fit (AUC=0.786, p<0.001), however, neither performance of any CABG (p=0.071) or number of vessels revascularized were independently significant.
Conclusion
Despite undergoing less extensive arch intervention, aortic surgery patients who require concomitant CABG face an increased risk of morbidity and perioperative MACE. Our results suggest this is not due to the performance of the CABG itself or the number of bypassed vessels, but rather due to the conglomeration of increased risk factors in patients requiring CABG. Adjunctive CABG should be performed when clinically indicated, although caution should be taken given the more comorbid population requiring coronary intervention.
Authors
Adam Carroll (1), Michael Kirsch (1), Nicolas Chanes (1), Joseph Cleveland (1), Jessica Rove (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
A 63year old female was referred to our department with a pulsatile left supra-clavicular tumor for further diagnostic and treatment. Medical history included Marfan syndrom, replacement of the aortic valve and the ascending aorta well as open thoracoabdominal aortic replacement.
Methods:
Contrast enhanced Computed Tomography (CT) revealed a giant aneurysm of the proximal and middle left subclavian artery with a maximum diameter of 5.5cm. Due to the proximal extent of the aneurysm open surgical repair would have required a re-re sternotomy approach which was considered technically very high risk.
Likewise complete endovascular exclosure was deemed uncertain due to the large size and proximal extent of the aneurysm without an adequate proximal landing zone.
We opted therefore for an alternative indirect hybrid approach combining a thoracic aortic stent graft (TEVAR) covering the aortic origin left subclavian artery and left carotid-subclavian bypass as well as transposition of the left vertebral artery into the left common carotid artery for aneurysm exclusion. First a 28x40mm Relay Pro aortic stent graft (Terumo Aortic, UK) was implanted in the distal aortic arch for proximal closure of the aneurysm. Next the left common carotid as well as the left vertebral artery were exposed via a left cervical incision and transposition of the left vertebral artery into the left common carotid artery was performed, facilitating save ligation of the proximal left vertebral artery arising from the aneurysm. Finally the distal left subclavian artery was exposed via a separate infraclavicular incision. A 8 mm Dacron prosthesis was anastomosed in an end-to-end fashion to the distal subclavian artery creating a carotid-subclavian bypass. The distal end of the mid left subclavian artery was ligated thereby completing aneurysm exclusion.
Results:
The patient had an uneventful postoperative course and was discharged at post-operative day six. A control CT prior hospital discharge showed sufficient exclosure of the subclavian aneurysm and unobstructed perfusion of the transposed left vertebral artery as well as the distal left subclavian artery.
Conclusion:
Our case demonstrates that combining established endovascular and open surgical procedures facilitates safe and efficient treatment facilitates the safe and efficient treatment even of anatomically challenging vascular pathology such as large intrathoracic subclavian artery aneurysms. Although endovascular procedures should always be considered carefully when treating aneurysmal disease in Marfan patients, we believe that in case like ours with a high technical risk of complete open surgical repair the use of a routine endovascular procedure like TEVAR in combination with a tailored open surgical part for a less invasive and still reliable aneurysm treatment is justified.
Authors
Peter Donndorf (1), Clemens Schafmayer (2), Justus Gross (2)
Institutions
(1) Department of General-, Visceral-, Thoracic-, Vascular- and Transplant Surgery, Rostock, (2) Department of General-, Visceral-, Thoracic-, Vascular- and Transplant Surgery, Rostock, NA
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Poster Presenter
Peter Donndorf
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Rostock
Germany
Objective
Recently, a newly designed frozen elephant trunk (FET) for the surgical treatment of aortic arch lesions has been developed. This FET, named "partial FET", has a 6 cm stent portion and a 2 cm distal non-stented portion. It is designed to reduce the stent induced new entry(SINE) by reducing springback force by 43% and radial force by 29%, and to facilitate anastomosis between the unstented portion and the new graft in the second stage of surgery through a left thoracotomy. We aim to determine the perioperative and short-term clinical outcomes of total arch replacement with the partial FET.
Methods
Between August and December of 2023, a total of 16 patients with aortic arch pathology were treated with partial FET in 6 institutions enrolled in this study. The primary endpoint is the technical success of partial FET implantation. The secondary endpoint is death and aortic events including the occurrence of distal stent graft induced new entry. Numerical values were expressed mean±standard deviation.
Results
Age was 62±10 and 8 were female. The operation is indicated for acute aortic dissection in 10, chronic aortic dissection in 5 and anastomotic pseudoaneurysm in 1 patient. The re-do were 2 cases. The preoperative malprefusion existed in 2 patients( 1 coronary and 1 cerebral with symptom). The total arch replacement with the partial frozen elephant trunk was technically successfully performed in all the patients. The concomitant procedures were valve-sparing aortic root replacement in 2, Bentall operation in 1 and CABG in 1 patient. The circulatory arrest time, the aortic cross-clamp time and the cardiopulmonary bypass time were 62±17, 176±66, 271±65 min, respectively. No postoperative pressure gradient between upper and lower extremities were observed, except one case of chronic dissection whose true lumen was severely stenosed and the cause of pressure gradient was not the presence of unstented portion of partial FET. The 30-day and in-hospital mortality was 0%. The postoperative new stroke, paraplegia, paraparesis were not observed. There were no aorta-related complications such as distal stent graft-induced new entry.
Conclusions
The early outcomes of total arch replacement with the partial frozen elephant trunk procedure were acceptable. Care must be taken for the use in chronic aortic dissection because of its decent radial and spring back force.
Authors
Takeshi Shimamoto (1), Kenji Minatoya (2), Tatsuhiko Komiya (3), Nobuhisa Ohno (4), Nobushige Tamura (5), Naoki Kanemitsu (6), Yoshio Arai (7), Hiroshi Tsuneyoshi (8), Jiro Esaki (9)
Institutions
(1) Hamamatsu Rosai Hospital, Hamamatsu, (2) Kyoto University Hospital, Kyoto, (3) Kurashiki Central Hospital, Kurashiki, (4) Kokura Memorial Hospital, Kokura, (5) Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, (6) Japan Red Cross Society Wakayama Medical Center, Wakayama, (7) Tenri Hospital, Tenri, (8) Shizuoka General Hospital, Shizuoka, (9) Kobe Central Municipal Hospital, Kobe
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Poster Presenter
Takeshi Shimamoto
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Chuo-ku, Hamamatsu-shi
Japan
Objective
Pulmonary thromboendarterectomy (PTE) is the curative treatment for chronic thromboembolic pulmonary hypertension (CTEPH). A subset of CTEPH patients present with concomitant cardiac and aortic pathology.
Deep hypothermic circulatory arrest (DHCA) is the standard cerebral protection strategy during PTE given the short intervals of circulatory arrest, and the benefit of a bloodless field. However, the risks posed by coagulopathy caused by DHCA, combined with the need for post-operative anticoagulation, limit the ability to address co-occurring aortic pathology simultaneously, and to our knowledge prior literature has only discussed staged intervention of concomitant aortic pathology. Moderate hypothermia with selective antegrade cerebral perfusion (SACP) has also been applied to PTE, however, the standard remains DHCA given the above and prior trials demonstrating similar outcomes between the two cooling strategies.
We present a series of patients where PTE was performed simultaneously to ascending and hemiarch repair using both DHCA and moderate hypothermia, with additional retrograde cerebral perfusion (RCP) for both groups.
Methods
Using our retrospective database, we reviewed PTE performed at our institution, and identified four patients who underwent PTE with ascending and hemiarch replacement. Patient presentation, operative, and post-operative course was reviewed.
Results
All four patients underwent bilateral PTE, with ascending and hemiarch replacement. Three of the four patients underwent additional cardiac procedures. All patients received RCP via the superior vena cava, with three of the four receiving moderate hypothermia. During circulatory arrest time, cerebral oxygenation was monitored in addition to intraoperative neuromonitoring. Aortic replacement was performed prior to PTE for all cases. One patient underwent two periods of circulatory arrest, with aortic repair during circulatory arrest period for the right PTE. Three of the four patients underwent three periods of circulatory arrest, with separate periods for right and left PTE, and aorta (median 6 min, IQR 6-6). All periods of PTE circulatory arrest did not exceed 22 minutes (median 19 min, IQR 14.75-19.5). Three of four patients were extubated within 24 hours. One patient had a prolonged intubation of 92 hours. All patients were started on low dose heparin infusion within 6 hours of surgery, with gradual up-titration. One patient had a prolonged hospital course due to an unrelated complication of colonic perforation due to diverticulitis the day prior to planned discharge. All patients were discharged at baseline neurologic status with home oxygen on therapeutic warfarin with appropriate follow-up.
Conclusion
Our initial experience demonstrates that simultaneous PTE and ascending and hemiarch replacement can be safely performed. Performing aortic repair has the added benefit of improving operative view, particularly of the right pulmonary artery, by removing the aneurysmal aorta prior to PTE. Applying RCP has the added benefit of additional cerebral protection under moderate hypothermia while maintaining a bloodless field. Careful consideration must be placed perioperatively on balancing adequate resuscitation and anticoagulation initiation with the risks of reperfusion injury and bleeding.
Authors
Adam Carroll (1), Michael Cain (1), T. Brett Reece (1), Jordan Hoffman (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective: Acute type A aortic dissection is generally indicated for emergency surgery. However, Japanese guidelines propose medical treatment as an option for acute type A intramural hematoma (ATAIMH) characterized by thrombosed false lumen in the ascending aorta, provided certain criteria are met. The diameter of the ascending aorta is <50 mm, the diameter of the false lumen is <11 mm, and there is no cardiac tamponade or vital organ malperfusion. The choice of treatment for ATAIMH is still controversial. This study aimed to compare outcomes between emergency surgery and conservative (medical) treatment for ATAIMH and identify factors leading to surgical intervention after medical management.
Methods: From January 2013 to December 2023, 46 consecutive patients with ATAIMH who were urgently admitted to our hospital were included in the study. 25 patients in the emergency surgery group (S group) and 21 patients in the medical treatment group (M group) were compared.
Results: The mean age of the patients was 71.5±9.4 years, with 54% females, showing no significant difference between the groups.10 (40%) patients in the S group experienced hemodynamic instability due to cardiac tamponade and 15 (60%) had a false lumen diameter >11 mm in the ascending aorta, prompting surgical intervention. The false lumen diameter was significantly larger in the S group than in the M group (14.3±8.1 mm vs. 7.8±1.8 mm, P<0.001). The range of aortic replacement was only ascending aorta (AR) in 6 cases, partial arch (PAR) in 16 cases, total arch (TAR) in 2 cases, and aortic root replacement (ARR) in 1 case. Preoperative enhanced computed tomography (CT) showed ulcer-like projection (ULP) in 21 patients (84%), which was consistent with surgical findings. One patient (4%) with preoperative cardiopulmonary arrest in the S group died on the 5th postoperative day from cerebral infarction. In the medical group, 18 patients (86%) completed rehabilitation and were discharged. However, 14% required surgical conversion during initial medical treatment, and 19% underwent surgical intervention after discharge due to various factors. Re-canalization occurred in 2 cases, enlargement of false lumen in 2 cases, enlargement of ULP in 1 case, new tear in the aortic root in 1 case, and enlargement of aortic root in 1 case. The median duration to surgical intervention was 38 days (5-330 days), all cases were within 1 year. The range of replacement was AR in 1 case, PAR in 2 cases, TAR+ frozen elephant trunk in 2 cases, and ARR in 2 cases. There were 6 late deaths in the S group and none in the M group. Kaplan-Meier curves showed that the overall survival rate of the S group was 96% at 1 year and 70% at 5 years, which was significantly lower than that of the M group (P=0.016). Among patients in the M group who required surgical intervention after medical treatment, the initial aortic diameter of the ascending aorta was significantly larger than patient without surgical intervention (47.7±7.5mm vs 42.3±4.6mm, P<0.05) and the reduction rate of false lumen diameter was significantly smaller (-41.1±35.8% vs +0.1±30.5%, P=0 .017).
Conclusions: As the initial treatment of ATAIMH, the course of medical treatment followed by guidelines was excellent. Close CT monitoring during the acute phase is crucial ,.Surgical intervention, considering patient background and condition, can significantly improve prognosis upon exacerbation despite initial medical management.
Authors
Shuji Setozaki (1), Hiroshi Tsuneyoshi (1)
Institutions
(1) Shizuoka General Hospital, Japan, Shizuoka
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Poster Presenter
Shuji Setozaki, Shizuoka General Hospital
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Shizuoka
Japan
Introduction. I had a vision, applied scholarship with leader ship regarding endogenous, neurologic
Spinal cord ischemia, paresis, paraparesis, paralysis, while rare, are all major problems fraught with support structure Most work has focused on exogenous means to protect the spinal cord. No data exists on ENDOGENOUS heat shock proteins to protect against spinal cord ischemia .
Our lab has extensive experience with hsp70i induction in various animal models. We have previously induced myocardial hsp70i resulting in doubling recovery of myocardial function preload recruitable work area after stunning. Also we induced coronary artery hsp70i result in improved coronary artery peak flow and coronary relaxation. This was also predominantly due to induction in the nuclear fraction in both the myocardium as well as coronary artery.
(Figure.)
No one has previously examined if HSP 70 can be induced in the descending aorta. The descending aorta and multiple factors affect spinal cord. Often times in the clinical scenario, spinal cord paresis or paralysis, are not necessarily evident until 24 to 48 hours after the insult and having heat shock protein present during this time period is more ideal.
In order to achieve this, dogs underwent hyperthermic or normothermic bypass and aortic hsp70 was examined at either 12 or 24 hours after hyperthermia. After either 12 or 24 hours, the descending aorta was harvested and frozen at -70° until further analysis was performed. Once sufficient number of aorta were obtained at 12 hours and 24 hours and subject to western blot analysis. The HSP 70 anybody was obtained from Stressgen.
AIM
Through vision leadership and scholarship, we proposed HSP 70 could be induced in the descending aorta with heat stress for potential protection against paralysis.
Results
Experimentation reveals that hyperthermia can induce hsp 70 within the descending aorta. Hsp70 is greater at 24 hours after hyperthermia than at 12 hours. The relative amounts of nuclear to cytoplasmic fraction is also greater at 24 hours than 12 hours. This is clinically important given that the sequelae resulting in spinal cord ischemia after any aortic procedure generally presents at 24 to 48 hours after aortic ischemia.
Discussion
All humans make endogenous hsps.There a paucity research on aortic hsps and spinal cord protection. Were the first to demonstrate that aorta hsp70 can be upregulated and at different time points with increased nuclear to cytoplasmic fractions. This has significant clinical sequelae as later increase in hsps has clinical benefit when potential spinal cord is most likely to occur after aortic surgery or stentibg.
Further mechanisms of hsp70 protection, remain to be investigated; this may involve antiapoptotic mechanisms such as mitochondria protection. Recent rapid advances in nanotechnology and newer agents, such as geranylgeranyl acetone, offer new opportunities for therapy against the aging diseased aorta.
Authors
Barbara Robinson (1), Hartzell Schaff, MD (2)
Institutions
(1) Your Health Llc, Lake Barrington, IL, (2) Mayo Clinic, Rochester, MN
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Poster Presenter
Barbara Robinson, Mayo
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Lake Barrington, IL
United States
Objective:
Aortic root pseudoaneurysms (PSA) are recognized complications after arch surgery for type A dissection, often related to the dehiscence of suture lines and cannulation sites. Management of PSA is complex due to the necessity to operate in a prior surgical field and the potential proximity of the pseudoaneurysm to the posterior sternal table. While open repair allows for definitive treatment, endovascular repair has been employed as an alternative. Furthermore, in our experience, surveillance may be a viable strategy in select patients. We describe our institutional experience with post-dissection aortic root pseudoaneurysms and propose an algorithm for treatment.
Methods:
A prospectively maintained institutional database was used to identify patients over the last 10 years who presented with aortic root pseudoaneurysms after arch surgery for aortic dissection. We describe the temporal relationship of their presentation to their index surgery, subsequent management strategy and outcomes. Based on our institutional experience we developed an algorithm for treatment.
Results:
In total, 31 patients were identified who had a root pseudoaneurysm post aortic-dissection repair. The majority of these patients underwent open surgical repair (27, 87.1%), with two having recurrence of their pseudoaneurysms following. In most cases open repair was selected due to concomitant pathology, with the majority of patients undergoing adjunct hemiarch (3, 11.1%), or total arch (18, 66,7%). Given the significant scar tissue present, pulmonary artery repair after iatrogenic injury was frequently required (7, 25.9%), with high rates of open chest (7, 25.9%) post-operatively due to coagulopathy (7, 25.9%). Notable post-operative complications included stroke (4, 14.8%), prolonged ventilation (4, 14.8%), and mortality (3, 11.1%).
Six patients were selected for endovascular management; three patients with a remote history of dissection, and three patients with a prior root replacement within the year prior to intervention, two of whom were from the above cohort. Four patients underwent successful endovascular repair; two with a transfemoral approach, and two with a transapical approach. In both unsuccessful attempts, the PSA tract was unable to accessed via either approach. Following successful endovascular repair, post-operative course was uncomplicated with minimal hospital stay. One procedure was converted to open and underwent successful open root replacement, and the other had a stable PSA at two years until he was lost to follow-up. Currently one patient is being surveyed for their PSA, who wanted to avoid further intervention and had a small root PSA, with stable imaging at three years. Based on our experience we developed an algorithm for treatment of aortic root pseudoaneurysm post aortic-dissection (Figure 1).
Conclusions:
Management of aortic root PSA carries a high risk of morbidity and mortality. Patients are typically complex, and due to a re-operative field are at high risk of bleeding and coagulopathy. In general, in the setting of isolated root pseudoaneurysm, we recommend an endovascular approach first to minimize morbidity. If unsuccessful, or in the setting of other pathology that can not be managed with an endovascular approach, open root replacement can be performed in suitable candidates. In select patients with stable, small pseudoaneurysms, close surveillance may be considered.
Authors
Adam Carroll (1), Michael Kirsch (1), Nicolas Chanes (1), Elizabeth Devine (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective:
There is a lack of prospective evidence around the risk profile of ascending thoracic aortic aneurysms (ATAA). Current societal guidelines rely heavily on maximal aortic diameter to guide intervention. Using data from the largest ever prospective multi-center study of ATAA, we assess the degree of inter-observer variability in assessing maximal aortic diameters as reported by 22 sites (real-world) to core lab data.
Methods:
TITAN: SvS (Treatment In Thoracic Aortic aNeurysm: Surgery versus Surveillance) is a multi-center trial randomizing patients with ATAA between 5.0-5.4 cm to an initial strategy of surgery versus surveillance. A parallel registry enrolls patients who are not randomized. To assess accuracy, aortic measures of site-reported CTs were compared to the core lab reported measurements of the same CTs. Along with comparing maximal aortic diameter, note was also made when measurements deviated by ≥2mm, and how often measurement differences resulted in whether patients were surgical candidates or not.
Results:
CT reports of 458 patients from 22 sites were available (mean age 67.9 +/-9.8; 18.6% female). The mean maximum ATAA diameter reported by sites was higher than core lab (51.05mm +/-5.1 vs 50.48mm +/-7.06; p<0.05). In 97/264 (36.74%) patients, maximal aortic diameters differed by ≥2mm between site-reported vs. core-lab (23 lower; 74 higher). The discrepancy for CT measurements was site-dependent; some site reports had 0 such differences, while others had as many as 44% reports incongruent by ≥2mm. According to core lab measurements, 93/458 (20.3%) patients reviewed did not meet criteria for intervention (92 had aortas under 5cm; 1 was over 5.4cm). In fact, 64/264 (24.2%) patients who met criteria for surgery based on site CT reports, no longer met criteria based on core lab measurements. Two orthogonal measurements for each aortic site, as recommended by imaging guidelines, were not provided in 120/458 (26.2%).
Conclusion:
Based on contemporary data from the largest ever prospective study on ATAA, significant variability exists between site reported aortic diameters on CT scans compared to diameters reported by an imaging core lab. Up to 20% of patients are diagnosed as meeting a surgical threshold before they actually reach it. The significant difference in inter-observer variability superimposed on lack of prospective evidence on risk profile of ascending aortic aneurysms, suggests need for more nuanced reproducible risk profiling of the ascending aorta. When completed, the Titan:SvS trial may provide further evidence on the risk profile of ATAA.
Authors
Saurabh Gupta (1), Ayse Hafsa (2), Jehangir Appoo (3), Eric Herget (4), Ming Hao Guo (5), Philippe Demers (6), Michael Chu (7), Rony Atoui (8), William Brinkman (9), John Bozinovski (10), Francois Dagenais (11), Nimesh Desai (12), Ismail El-Hamamsy (13), Juan Grau (14), G. Chad Hughes (15), Arminder Jassar (16), Kevin Lachapelle (17), Maral Ouzounian (18), Himanshu Patel (19), Zlatko Pozeg (20), Richard Whitlock (21), Munir Boodhwani (22)
Institutions
(1) N/A, Canada, (2) University of Ottawa Heart Institute, Ottawa, Ontario, (3) Libin Cardiovascular Institute, University of Calgary, Calgary, AB, (4) University of Calgary, Calgary, NA, (5) University of Ottawa Heart Institute, Ottawa, ON, (6) Montreal Heart Institute, Montreal, QC, (7) University Hospital, London Health Sciences Centre, London, Canada, (8) Northern Ontario School of Medicine, Sudbury, ON, (9) Baylor Scott & White Health, TX, (10) Ohio State University Wexner Medical Center, Columbus, OH, (11) Quebec Heart and Lung Insitute, Quebec, Quebec, (12) University of Pennsylvania, Philadelphia, PA, (13) Mount Sinai Hospital, New York, NY, (14) The Valley Hospital, Ridgewood, NJ, (15) Duke University Medical Center, Durham, NC, (16) Massachusetts General Hospital, Boston, MA, (17) Division of Cardiac Surgery, McGill University Health Centre, Montreal, QC, (18) Toronto General Hospital, Toronto, ON, (19) University of Michigan Hospital, Ann Arbor, MI, (20) New Brunswick Heart Centre, Saint John, New Brunswick, (21) Population Health Research Institute, Hamilton, Canada, (22) N/A, Ottawa, ON
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Poster Presenter
Saurabh Gupta, University of Ottawa Heart Institute
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Ottawa, ON
Canada
Objective. Red blood cell (RBC) transfusion has been associated with adverse outcomes in cardiac surgery procedures. However, outcomes in patients having intraoperative/perioperative nonautologous RBC transfusion in patients in Stanford Type A Aortic Dissection (TAAD) repair were less established. This study aimed to conduct a population-based examination of the effect of intraoperative/perioperative nonautologous RBC transfusion on the in-hospital outcomes after TAAD using the National/Nationwide Inpatient Sample (NIS) database.
Methods. Patients who underwent TAAD repair were identified in NIS from the last quarter of 2015-2020. Patients with preoperative RBC transfusion were excluded. Patients with and without intraoperative/perioperative nonautologous RBC transfusion were stratified into two groups. Multivariable logistic regressions, adjusting for demographics, comorbidities, hospital characteristics, primary payer status, and transfer status, were used to compare in-hospital outcomes.
Results. Among all patients who underwent TAAD repair, 1048 (25.28%) patients were included in the transfusion cohort. The transfusion group were more likely to be female, Hispanic, Asian, and have older age, diabetes, depression, renal malperfusion, anemia, thrombocytopenia, and under emergent admission. Patients with and without nonautologous RBC transfusion had comparable in-hospital mortality (16.32% vs 14.47%, aOR=1.113, 95 CI=0.906-1.367, p=0.31). The transfusion group had higher risks of myocardial infarction (7.25% vs 4.91%, aOR=1.492, 95 CI=1.118-1.990, p<0.01), respiratory complications (25.67% vs 20.99%, aOR=1.268, 95 CI=1.073-1.499, p<0.01), mechanical ventilation (39.22% vs 29.93%, aOR=1.448, 95 CI=1.237-1.689, p<0.01), and acute kidney injury (51.81% vs 47.56%, aOR=1.191, 95 CI=1.023-1.386, p=0.02). All other in-hospital complications, hospital length of stay (LOS), and total hospital charge were all comparable between the two groups.
Conclusions. While intraoperative/perioperative nonautologous RBC transfusion was not associated with in-hospital mortality, it was linked to higher risks of major organ system complications. While the causal relationships cannot be established, these findings might be insightful for postoperative management in patients receiving intraoperative/perioperative nonautologous RBC transfusion in TAAD repair.
Authors
Qianyun Luo (1), Renxi Li (2), Stephen Huddleston (1)
Institutions
(1) University of Minnesota, Minneapolis, MN, (2) The George Washington University, Washington, DC
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Poster Presenter
Stephen Huddleston
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Minneapolis, MN
United States
Objective: During thoracic endovascular aortic repair (TEVAR), it is crucial to deploy the stent into the true lumen of the aorta. Intravascular ultrasound (IVUS) can be used as an adjunct to or independent of transesophageal echocardiogram (TEE), as it allows for visualization of wire placement from insertion site to the distal extent of the wire. We describe a case in which we use intravascular ultrasound (IVUS) to confirm wire positioning within the true lumen prior to placement of the TEVAR stent.
Methods: A 76-year-old male with a history of Stanford Type A aortic dissection status post aortic valve resuspension and arch replacement presented with aneurysmal degeneration and Type B dissection. The patient underwent aortic debranching and vertebral artery transposition, followed by TEVAR with a thoracic branched endograft.
Results: The intraoperative decision algorithm is shown in Figure 1. After reviewing the preoperative imaging to delineate the surgical anatomy, we accessed the patient's left common femoral artery (CFA) and placed a glidewire and glide-catheter into the ascending aorta. We advanced the IVUS over the glidewire and confirmed positioning in the true lumen from access site to the ascending aorta. We positioned a 40mm x 15cm Gore TAG TBE with 12mm portal within the aortic arch, with the portal at the distal edge of the left subclavian artery origin, and deployed the stent graft. We used left subclavian artery angiography to confirm graft position and then placed a 12mm x 40mm armada balloon within the subclavian artery portal to provide endograft stability while the proximal endograft was advanced.
We performed an arch aortogram to identify the coronary arteries and determine the proximal landing zone of the endograft. A 40mm x 40mm x 10cm Gore TAG conformable was advanced into the ascending aorta and deployed with the proximal aspect at the sinotubular junction. Aortogram demonstrated patent coronary arteries. We advanced a 15mm x 12mm x 6cm Gore TAG TBE from the CFA and positioned it into the left subclavian artery, ensuring accurate overlap in the portal. This stent was deployed, post-dilated with the 12mm x 40mm armada balloon, and the stent overlap was stented. Angiography demonstrated good filling of the extracranial circulation and the right subclavian artery from the left subclavian artery, as well as good filling of the visceral vessels and predominant filling of the true lumen of the aorta.
Conclusions: IVUS is an easy and well-established way to confirm appropriate wire position in TEVAR. After stent deployment, a pull-back can be performed and recorded for future reference. Concerning changes in blood flow can be re-evaluated with repeat IVUS to determine need for extension of graft coverage. However, it's important to note the increased risk associated with upsizing the groin sheath from 6 Fr to 9 Fr when using IVUS. Therefore, in cases where TEE provides adequate visualization, the additional risk of sheath upsizing may not be justified. This is particularly pertinent in patients with previous ascending aortic replacement, who may not have a strong indication for TEE or have contraindications for it. In such scenarios, IVUS obviates the need for TEE in TEVAR deployment, but careful consideration should be given to the risks and benefits of sheath upsizing.
Authors
Michael Kirsch (1), Adam Carroll (1), Donald Jacobs (1), Rafael Malgor (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Michael Kirsch, University of Colorado Anschutz Medical Center
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Aurora, CO
United States
Objective: Currently, the 1st line therapy for acute uncomplicated type B aortic dissection (AUTBAD) is optimal medical therapy (OMT), providing excellent short-term results but a high rate of failure in the chronic phase. Thoracic endovascular aortic repair (TEVAR) is highly effective for remodeling the aorta in the acute phase, but less effective in the chronic phase. Ideally, patients with AUTBAD who fail OMT could be identified based upon data from non-invasive imaging modalities in the acute phase and undergo TEVAR. In this case study of a patient with an AUTBAD who failed OMT, we examine anatomic characteristics from the computed tomography angiogram (CTA) and hemodynamic metrics derived from 4D flow magnetic resonance imaging (MRI) before and after TEVAR.
Methods: The patient is a 48 year old male who presented with an AUTBAD and treated with OMT and discharged home. During his index hospitalization he underwent both CTA and 4D flow MRI exams. He returned for a surveillance visit at 3 months and a CTA demonstrated a rapid 1.6 cm growth of his descending thoracic aorta (DTA) to a size of 5.8 cm. He underwent TEVAR and had repeat CTA and 4D flow MRI scans 1 month post-TEVAR.
Maximum aortic diameters, primary tear area, and distance from the left subclavian artery (LSA) were measured from the CTAs. From the 4D flow MRI, we investigated primary tear and false lumen flow, wall shear stress, and pulse wave velocity (PWV) which is used as a stiffness index. After segmenting the true (TL) and false lumen (FL), a plane was placed perpendicular to the tear flow and in the FL to accurately measure peak velocity and assess FL flow (Materialise Mimics; Ansys EnSight). Wall shear stress (WSS) vectors were calculated using a previously developed method that multiplies blood viscosity, the rate of deformation tensor, and normal vector over the cardiac cycle. We estimated PWV by using a cross correlation method to measure lag time between flow waveforms at evenly spaced planes (4 mm) throughout the aorta compared to one reference plane at the aortic root.
Results: The index CTA maximum aortic diameter was 4.2 cm, with a primary intimal tear in Zone 3 (5.5 cm distal to LSA) measuring 22 mm in diameter and total area 380 mm2. The maximum FL diameter was 25 mm. At 3 months, there was proximal DTA growth (5.8 cm; Figure 1a). TEVAR resulted in complete FL thrombosis throughout the entire DTA.
The index 4D flow MRI revealed a peak velocity through the primary intimal tear of 180 cm/s, which is the highest recorded velocity in our 4D flow MRI database of AUTBAD (Figure 1b). There was substantial retrograde flow in the pre-tear region (net flow = -20.5 ml/cycle). The WSS opposite the tear in the FL was in the top 5% of estimated WSS (> 1 Pa) in the aorta (Figure 1c). PWV on the index 4D flow MRI was 3.6 m/s, and increased to 13.3 m/s following TEVAR, indicating a significant increase in aortic stiffness (Figure 1d).
Conclusions: This case study demonstrates the feasibility of collecting in vivo flow from AUTBAD patients using 4D flow MRI. This hemodynamic information may provide important prognostic data regarding patients at high risk for OMT failure. Furthermore, there is a significant increase in aortic stiffness following TEVAR, which may have significant implications on blood pressure and adverse cardiac remodeling. These adverse effects of thoracic aortic stents must be considered when deciding on optimal therapy for AUTBAD patients.
Authors
Hannah Cebull (1), Minliang Liu (2), Hai Dong (2), John Elefteriades (3), Rudolph Gleason (2), Marina Piccinelli (4), John Oshinski (5), Bradley Leshnower (6)
Institutions
(1) Emory University, United States, (2) Georgia Institute of Technology, Atlanta, GA, (3) Yale New Haven Hospital, New Haven, CT, (4) Emory University, Atlanta, GA, (5) Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, (6) Emory University Hospital, Atlanta, GA
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Poster Presenter
Hannah Cebull
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Atlanta, GA
United States
[Objective] Total arch replacement is the first-choice treatment for aortic arch aneurysms; however, total arch replacement is a high-risk procedure, and endovascular repair may be the treatment of choice in elderly patients. We investigated the risk factors associated with each technique and treatment outcomes of aortic arch aneurysm repair in elderly patients (age >80 years).
[Methods] The study included 54 octogenarians who underwent aortic arch aneurysm repair between 2007 and 2021. Patients were categorized into the total arch replacement (TAR) group (23 patients) and the thoracic endovascular aortic repair (TEVAR) group (31 patients). Early and mid-term outcomes and risk factors associated with mortality were investigated in each group. TAR was the preferred therapy; however, TEVAR was performed in patients who were unable to tolerate TAR owing to frailty and comorbidities. True aneurysms were included and dissected aneurysms and emergency cases secondary to aneurysm rupture or other causes were excluded from the analysis to ensure evaluation of timely surgical outcomes.
[Results] Patients' mean age was 82 years in both groups (TAR [81-84 years], TEVAR [81-83 years]), without a significant intergroup difference. The incidence of stroke and spinal cord ischemia, the 30-day mortality (TAR [0.0%], TEVAR [5.4%]), and in-hospital mortality (TAR [7.7%], TEVAR [8.1%]) did not show significant intergroup differences. The 5-year survival rates (TAR [82.0%], TEVAR [65.0%], p=0.24), aorta-related mortality averted (TAR [91.0%], TEVAR [81.0%], p=0.13), and the freedom from aortic events (p=0.05) did not show significant intergroup differences. On analysis of risk factors for all-cause mortality for each procedure, a history of ischemic heart disease was identified as a significant risk factor in the TAR group. No significant risk factors were identified in the TEVAR group in this study.
[Conclusions] The choice of procedure in this study was reasonable considering patients' frailty. Endovascular repair is a good option for patients with a history of ischemic heart disease.
Authors
Tomoki Cho (1), Keiji Uchida (2), Shota Yasuda (3), Tomoyuki Minami (4), aya saito (3)
Institutions
(1) Yokohama city university medical center, Yokohama, Kanagawa, (2) Yokohama City University Medical Center, Yokohama, Kanagawa, (3) N/A, N/A, (4) N/A, Yokohama, Japan
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Poster Presenter
Tomoki Cho, Yokohama city university medical center
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Yokohama, Kanagawa
Japan
Objective: To evaluate the impact of prior cardiac surgery on outcomes in patients undergoing repair of acute type A aortic dissection (ATAAD).
Methods: Retrospective, single-center center cohort study of patients undergoing surgery for ATAAD from January 1997 to August 2023. The primary outcome was operative mortality. The secondary outcome was major postoperative adverse events (MAE), defined as the composite outcome of perioperative mortality, myocardial infarction, stroke, tracheostomy, and dialysis.
Results: Of 403 patients included in our database, 69 (17.1%) had a prior cardiac surgery. Patients with prior cardiac surgery had a higher preoperative incidence of diabetes (26.1% vs 13.2%; P=0.012), previous myocardial infarction (33.3% vs 12.3%; P<0.001), connective tissue disorders (17.4% vs 4.2%; P<0.001) and a reduced ejection fraction (median 45.00, interquartile range (IQR) [40.00, 50.00] vs median 50.00, IQR [45.00, 50.00]; P<0.001) when compared with patients with no prior cardiac surgery. Intraoperatively, patients with prior cardiac surgery had longer cardiopulmonary bypass time (median 162.00 min, IQR [138.00, 190.00] vs median 140.00 min, IQR [127.00, 163.00]; P<0.001). Circulatory arrest time (CA) was the same in both groups (24.00 [20.00, 30.00] vs 25.00 [20.00, 33.75]; P=0.285). When stratified by the type of previous surgery, patients who had previous ascending aorta interventions had a significantly longer circulatory arrest time (49.50 [23.75, 59.00]; P=0.048) compared to patients who had other previous cardiac surgery procedures. Also, patients with a prior history of ascending aorta interventions were more likely to undergo to total arch repair during ATAAD surgery compared to the other groups (44.4%; P=0.017) Overall, patients with prior cardiac surgery had significantly higher operative mortality (13.0% vs 3.6%; P=0.004) compared with patients with no previous cardiac surgery. Mortality was 11.1% (1/9) in patients with previous ascending aorta interventions, 17.4% (4/23) in patients with previous valve surgery, 12% (3/25) in patients with previous CABG and 16.7% (1/6) for patients who had combined valve surgery and CABG. There was a significantly higher incidence of MAE in the reoperation group (21.7% vs 10.5%; P=0.017). However, on multivariable analysis, prior cardiac surgery was not associated with MAE (odds ratio 1.48, 95% confidence interval [0.76-2.8]; P= 0.25).
Conclusions: Patients with prior cardiac surgery undergoing ATAAD repair had higher operative mortality and incidence of MAE than those patients with no prior cardiac surgery, although in the fully adjusted analysis the difference did not reach statistical significance. Future research focusing on new strategies and techniques to improve outcomes in these high-risk patients is warranted.
Authors
Charles Mack (1), Gianmarco Cancelli (1), Lamia Harik (1), Mohamed Rahouma (1), Giovanni Jr Soletti (1), Camilla Rossi (1), Michele Dell'Aquila (1), Kevin R. An (1), Jordan Leith (1), Tulio Caldonazo (1), Christopher Lau (1), Mario Gaudino (1), Leonard Girardi (1)
Institutions
(1) Weill Cornell Medicine, New York, NY
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Poster Presenter
♦Charles Mack, Weill Cornell Medical College, Cornell University
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Manhasset, NY
United States
Isolated Cerebral Perfusion To Protect The Brain During Complex Cardiac Operations
Objective: To demonstrate that single vessel cannulation of the innominate artery or either carotid, prior to and until the cessation of systemic cardiopulmonary bypass, prevents neurological injury in complex cardiac cases.
Methods:
We used separate perfusion circuits for the body and the brain in 41 consecutive patients (Age range 48-82 years) between 2020-2022.
The technique:
• Direct single vessel cannulation of the innominate or either carotid artery with a 12 or 14 F catheter.
• Flow of 1 L/m via this catheter provides adequate brain perfusion at temperatures between 200 and 370C.
• Perfusion of the brain is begun before perfusion of the body and maintained until after cessation of systemic CPB.
• A vascular clamp placed below the cannula assures that all flow goes cephalad.
• We have learned that when we maintain cerebral flow at 1L/minute, flow up the other vessels is negligible and irrelevant.
• This approach essentially isolates the cerebral circulation from the rest of the body and thereby deters antegrade cerebral embolism.
• We manage systemic circulation with standard cannulation (central or peripheral as required).
• We use separate heat exchangers for each circulation to meet the separate metabolic requirements of body and brain.
For instance, in a typical Type A dissection, we begin brain perfusion first. A minute later we start systemic perfusion. The isolated brain perfusion prevents embolization of debris from the layers of the dissected aorta. We then cool the brain to 20-240C the body to 320C.
When we restart systemic circulation, we are rewarming from 320C. Compared to cooling the body to 18-200 C, our technique saves 60-90 minutes of CPB rewarming time and decreases bypass hematological perturbations. We continue cerebral perfusion until CPB to the body is discontinued.
In some of our cases the brain required protection but not hypothermia. The commonest reasons were proximal arch aneurysm repair where the clamp is placed between the innominate and left carotid artery (n=18). Another reason is dangerous sternal re-entry (n=4) where the aorta was adherent to the back of the sternum. Cannulating either carotid artery in the neck and perfusing the brain at 1L/min before opening the sternum eliminates the danger of cerebral injury. In patients with grade 5 atheromata in the arch (n=5) using this technique the brain is protected.
Our case mix is listed in Table below.
Underlying Diagnosis #patients
Acute Type A Dissection 7
Total Arch Reconstruction 6
Dangerous Re-entry Operations 4
Grade V Arch Atheromata 5
Proximal Arch Aneurysm 18
Aortic cannulation error 1
Results:
We have used this technique in 41 consecutive patients in the past three years. There were no strokes, encephalopathy or need for mechanical circulatory support.
There were two late deaths due to respiratory failure and failure to thrive.
Conclusion:
In this cohort, isolated single vessel brain perfusion begun before cardiopulmonary bypass to the body and extended until the operation is complete, provides excellent neurological protection and shortens overall cardiopul
Authors
Salim Aziz (1), Vincent Gaudiani (2), Pei Tsau (3), Keith Korver (4), Paul Shuttleworth (5), Jenna Aziz (6), Salim Aziz (7)
Institutions
(1) George Washington University Hospital, Washington, DC, (2) El Camino Hospital, Mountain View, CA, (3) El Camino Health, Mountain View, CA, (4) N/A, N/A, (5) N/A, San Francisco, (6) Ohio State Wexner Medical Center, Columbus, OH, (7) N/A, United States
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Poster Presenter
Salim Aziz, The George Washington University
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Washington, DC
United States
Objective: While postoperative atrial fibrillation (POAF) has been shown to be associated with worse survival after cardiac surgery, its effect on outcomes independent from other postoperative complications after thoracic aortic aneurysm repair is not well understood.
Methods: This is a single-center retrospective study of patients who underwent thoracic aortic aneurysm repair between March 2005 and March 2021. POAF was defined as new-onset atrial fibrillation (AF) that developed during the index hospital stay. Postoperative complications included reoperation for bleeding, respiratory failure, acute renal failure, and stroke. Factors associated with POAF were identified with multivariable regression. In patients without postoperative complications, propensity score matching for baseline and intraoperative characteristics was used to create well-matched groups of patients with and without POAF. Long-term survival was analyzed by the method of Kaplan and Meier and compared using the log rank test. Factors associated with 10-year survival were assessed using Cox regression.
Results: Of 1,454 patients, 520 (35.8%) had POAF. Patients with POAF had a higher rate of postoperative complications than those without AF (20.2% vs. 12.2%, p<0.001). Multivariable logistic regression revealed that age (OR 1.05, p<0.001), lowest body temperature (OR 1.06, p=0.001), intra-aortic balloon pump use (OR 22.5, p=0.004), and postoperative complications (OR 1.63, p=0.003) were independently associated with POAF. On a median of 7.1 year follow-up, unadjusted 10-year survival was lower in patients with POAF (82.0% [95% CI: 78.0%-86.1%] vs. 87.0% [84.4%-89.8%], p=0.008) (Figure A). In the matched cohort of patients without postoperative complications, 10-year survival was similar between patients with (83.6% [79.3%-88.2%]) and without POAF (83.8% [79.4%-88.6%], p=0.75) (Figure B). Postoperative complications but not POAF were independently associated with 10-year mortality on multivariable cox regression together with age, chronic obstructive pulmonary disease, peripheral vascular disease, prior myocardial infarction, preoperative ejection fraction, and use of circulatory arrest.
Conclusions: POAF is common after open proximal thoracic aortic aneurysm repair. Patients with POAF have higher rates of postoperative complications than patients without AF; however, patients with POAF in the absence of other major complications have equivalent long-term survival when compared to patients who do not have POAF. This data could suggest that POAF may be a marker of overall sickness rather than an independent contributor to mortality and morbidity.
Authors
Megan Chung (1), Cheryl Pan (1), Hideyuki Hayashi (1), Viswajit Kandula (1), Yanling Zhao (1), Dov Levine (1), Patra Childress (1), Lauren Sutherland (1), Syed Raza (1), Paul Kurlansky, MD (1), Craig Smith (1), Hiroo Takayama (1)
Institutions
(1) Columbia University Irving Medical Center, New York, NY
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Poster Presenter
Megan Chung, NewYork- Presbyterian/Columbia University Medical Center
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NY
United States
Objective
To outline patterns, prevalence and outcomes of aortic reinterventions at least 10 years after surgical repair for acute type A aortic dissection (ATAAD) and to identify factors associated with aortic reinterventions.
Methods
All patients who underwent surgical repair for ATAAD at a single center between January 1 2005 and December 31 2013 were included. All aortic reinterventions were reported. Cox regression analysis, including a Fine-Gray model treating death as a competing risk to reintervention, was used to investigate factors associated with aortic reintervention and mortality.
Results
225 patients underwent surgical repair for ATAAD. 195 patients (87%) underwent surgery with an open distal anastomosis, 33 patients (15%) had a root replacement, and 18 patients (8.0%) underwent an arch repair at the time of the index repair, with 30-day mortality of 13.0%. 37 patients (16%) underwent an aortic reintervention at a median time of 8 years (range up to 15 years) after the index procedure. The most common indications for aortic reintervention were aortic dilatation (84%) and aortic regurgitation (27%). 30-day mortality after aortic reintervention was 0%. Factors associated with proximal aortic reintervention was root diameter >45 mm at the time of initial ATAAD repair if no root replacement was performed (SHR 5.4, 95% CI 1.3-22, p=0.02) and age (SHR 0.9, 95% CI 0.9-0.96, p=0.001). Factors associated with distal aortic reintervention were descending aortic diameter at the time of index repair (per mm increase) (SHR 1.1, 95% CI 1.0-1.2, p=0.005), dissection of the right renal artery (SHR 2.9, 95% CI 1.7-2.3, p=0.03) and failure to completely resect the primary tear (SHR 2.3, 95% CI 1.0-5.5, p=0.05). With a mean follow-up of 9 years (median 10 years), event-free survival at 1, 5, 10 and 15 years was 82% (95% CI 77-87), 72% (65-77), 48% (41-54) and 33% (26-40), respectively.
Conclusion
Aortic reoperations are not uncommon after surgery for ATAAD, predominantly due to progressive aortic dilatation which may develop very late after the original repair. This warrants lifelong aortic imaging surveillance for most patients who have undergone a surgical repair for ATAAD and should be reflected properly in reporting long-term outcomes. In selected patients, aortic reinterventions can be done with limited surgical risk. At the time of the index repair, replacing a moderately dilated aortic root and ensuring complete resection of the primary tear may decrease the need for future aortic reinterventions.
Authors
Markus Bjurbom (1), Kristina Ma (1), Magnus Dalén (1), Anders Franco-Cereceda (1), Christian Olsson (1)
Institutions
(1) Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
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Poster Presenter
Markus Bjurbom, Karolinska Institute
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Stockholm
Sweden
Objective:
We report a case of open repair of an infected thoracic endovascular aneurysm repair (TEVAR), executed through a thoracoabdominal exposure and subsequent coverage with Latissimus dorsi muscle flap.
Methods:
A 70- year- old male with a past medical history of stroke, paroxysmal atrial fibrillation, and hyperlipidaemia was referred to our institution for an infected TEVAR. He had a history of a Stanford type A aortic dissection necessitating emergent open ascending repair in 2013, followed by TEVAR in 2015 due to a 6- cm post-dissection aneurysm in the descending thoracic aorta (DTA). Persistent symptoms of fever, chills, muscle pain, and fatigue prompted further investigation, revealing a PET scan highly suggestive of an infected aortic stent graft. Following a multidisciplinary team meeting (MDT), the decision was made to proceed with open aortic repair.
Results:
A left posterolateral thoracotomy incision was performed through the sixth intercostal space, and the sixth rib was preserved. The latissimus dorsi and trapezius muscles were dissected and mobilized for retraction. Following one-lung ventilation, the chest was entered. The latissimus flap was harvested preserving its pedicle.
Due to significant inflammation, the placement of a proximal clamp was deemed unfeasible. Consequently, full cardiopulmonary bypass was performed, incorporating profound hypothermic circulatory arrest after systemic heparinization. The removal of the infected thoracic stent-graft was executed, accompanied by extensive debridement of periaortic tissues. Subsequently, a replacement of the descending thoracic graft was performed, employing a 28-mm dacron graft (Hemashield TM). The newly placed dacron graft received complete coverage with a latissimus dorsi muscle flap. Throughout the hospitalization, the patient received treatment from the infectious disease team, involving intravenous daptomycin, micafungin, and meropenem. Tissue cultures obtained during surgery revealed Clostridium species. Discharge occurred on the 18th postoperative day with a prescription for long-term ampicillin/sulbactam. A postoperative CT scan indicated no aneurysmal dilatation or recurrence of infection.
Conclusions:
Open surgery with Latissimus muscle- flap coverage is an achievable option for infected TEVAR repair.
Authors
Lucas Ribe (1), Yuki Ikeno (1), Rana Afifi (2), Akiko Tanaka (3), Alexander Mills (4), Gustavo Oderich (1), Anthony Estrera (3)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX, (2) Memorial Hermann, Houston, TX, (3) Memorial Hermann Heart and Vascular Institute, Houston, TX, (4) University of Texas Health Science Center at Houston (UTHealth Houston), N/A
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Poster Presenter
Lucas Ribe, McGovern Medical School at UTHealth
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Houston, TX
United States
Background. The frozen elephant trunk has increasingly been used for acute type A aortic dissection. The trunk is frequently secured at zone 2, which may compromise left subclavian artery reconstruction. To facilitate reconstruction, the frozen elephant trunk may be fenestrated or bypass grafting to the left axillary artery has been employed. In the latter case, however, adhesion between the lung and the bypass graft may cause a problem during subsequent downstream aortic repair. We perform stress-free left subclavian artery reconstruction through a straight median sternotomy incision by dissecting the left common carotid artery and dividing the left anterior cervical muscles, which provides sufficient exposure of the left subclavian artery up to the vertebral artery take-off.
Objectives. We report our technique of left subclavian artery exposure and compare the outcomes between those treated by fenestrated frozen elephant trunk and those treated by anatomical left subclavian artery reconstruction.
Patients and Methods. Twenty-three patients who underwent frozen elephant trunk operation for acute type A aortic dissection between September 2019 and October 2023 were retrospectively analyzed. Patients requiring preoperative cardiopulmonary resuscitation were excluded. Anatomical reconstruction was performed in 11 patients (A group) and fenestrated frozen elephant trunk in 13 patients (F group; 8 patients with left subclavian fenestration and 5 patients with combined left carotid and subclavian fenestration). No patients underwent bypass grafting to the left axillary artery. Patient characteristics, concomitant procedures, cardiopulmonary bypass (CPB) time, aortic crossclamp (AXC) time, selective cerebral perfusion (SCP) time, circulatory arrest (CA) time of the lower torso, in-hospital death, and postoperative descending aortic false lumen status were evaluated. Data were shown as mean ±standard deviation.
Results. Patient age was 57 ± 12 (A) and 61 ± 7 years (F). Body weight was 73 ± 14 (A) and 71 ± 18 kg (F), and height was 170 ± 13 (A) and 169 ± 8 cm (F), respectively. Concomitant procedures included 3 Bentall in group T, 2 Bentall and 1 mitral valve repair in group F. CPB time was 274 ± 80 (A) and 251 ± 81 min (F), AXC time was 144 ± 48 (A) and 164 ± 73 minutes (F), SCP time was 180 ± 41 min (A) and 159 ± 65 min (F), CA time was 56 ± 15 (A) and 65 ± 8 minutes, respectively. There were no in-hospital deaths in both groups. In the A group, false lumen thrombosis was obtained around the trunk except for one case with 3-channel dissection. In the F group, there was one case with residual blood flow from the re-entry in the left subclavian artery and 1 case requiring additional TEVAR due to residual false lumen blood flow from fenestration.
Authors
Naoki Washiyama (1), Norihiko Shiiya (2), Daisuke Takahashi (3), Kazumasa Tsuda (4)
Institutions
(1) N/A, N/A, (2) Hamamatsu University Hospital, Hamamatsu, Japan, (3) MD, Hamamatsu, NA, (4) N/A, Hamamatsu, Shizuoka
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Poster Presenter
Naoki Washiyama, Hamamatsu University Hosipital
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Hamamatsu
Japan
Objective: Several studies have demonstrated better survival after aortic valve replacement (AVR) with a pulmonary autograft (Ross procedure) compared with a mechanical prosthesis. This study aims to compare resting and peak exercise left ventricle (LV) strain by cardiovascular magnetic resonance (CMR) in patients who underwent a Ross procedure versus a mechanical AVR.
Methods: A total of 40 patients were enrolled (20 with a previous Ross procedure and 20 with a previous mechanical AVR). Participants were previously screened and matched in a 1:1 ratio based on several preoperative characteristics. All patients underwent exercise stress CMR examination (MR ergometer, Lode, Netherlands). Measurements of LV strain were calculated using a dedicated software (Circle: Cardiovascular Imaging, Calgary, Alberta, Canada).
Results: Baseline characteristics were similar between both groups, with a mean age of 54±11 and 52±11 years in the Ross and mechanical AVR groups, respectively (p=0.60). There were 3 females in the Ross group and 2 in the mechanical AVR group (p=0.99). The time interval between CMR and surgery did not differ between the groups (4±2 years in both cases, p=0.50). LV strain measurements were obtained from all except 1 patient (mechanical AVR) who had suboptimal image quality. Resting LVEF (57±6% vs 59±8%, p=0.22), heart rate (68±13 bpm vs 67±9 bpm, p= 0.98), indexed end-systolic volumes (35±11 mL/m2 vs 34±11 mL/m2, p=0.38), and end-diastolic volumes (80±22 mL/m2 vs 81±14 mL/m2, p=0.43) did not differ between groups. Peak exercise was similar between the Ross and mechanical AVR groups (6.6±1.8 kcal/kg/h vs 6.8±1.7 kcal/kg/h, p=0.77). Global longitudinal strain (GLS) was similar at rest (-14±2% vs -14±2%, p=0.75) but was significantly improved in the Ross group at peak exercise (Figure 1, p= 0.03 for difference in slopes). Furthermore, the proportion of patients reaching normal GLS values at peak exercise was greater in the Ross group (Figure1, from 10% to 65%, p<0.01) when compared with mechanical AVR (from 10% to 35%, p=0.07). Similar findings were observed in analyzing radial long-axis ([Ross: 15% to 80%, p<0.01] vs [mechanical AVR: 30% to 45%, p=0.45]) and radial short-axis strain ([Ross: 60% to 95%, p<0.01] vs [mechanical AVR: 65% to 70%, p=0.13]). Peak exercise circumferential strain was similar between the 2 groups. There was no statistical difference in the number of patients reaching normal circumferential strain values at peak exercise ([Ross: 10% to 25%, p=0.25] vs [mechanical AVR: 20% to 25%, p=0.99]) between the 2 groups.
Conclusions: The Ross procedure results in greater GLS improvements at peak exercise stress CMR when compared with mechanical AVR. Similarly, the Ross procedure provides normal peak exercise strain values in a larger proportion of patients than mechanical AVR. These findings suggest a physiological explanation for the difference in long-term outcomes observed between these aortic valve replacement options.
Authors
Vincent Chauvette (1), Pierre-Emmanuel Noly (2), Mohamad Mansour (3), Ismail Bouhout (4), Nabil Dib (5), Mathieu Gayda (3), Christine Henri (6), François-Pierre Mongeon (3), Ismail El-Hamamsy (7)
Institutions
(1) Montreal Heart Institute, Montréal, QC, (2) Montreal Heart Institute, Montreal, QC, (3) Montreal Heart Institute, Montreal, Quebec, (4) NewYork-Presbyterian/Columbia University Medical Center, Montréal, QC, (5) Marie Lannelongue, Paris, france, (6) Montreal Heart Institute, Montreal, UT, (7) Mount Sinai Hospital, New York, NY
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Poster Presenter
Vincent Chauvette, Mount Sinai Hospital
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New York, NY
United States
Objective: Sodium-glucose cotransporter-2 inhibitors (SGLTIs, such as canagliflozin) are anti-diabetic medications that primarily have acquired significance in the field of cardiothoracic surgery as a result of their capacity to reduce the incidence of adverse cardiovascular events regardless of diabetic status. SGLT-2 receptors are expressed in the aorta, and SGLTIs have been extensively studied in the context of abdominal aortic aneurysmal disease, where they have been found to interrupt pathogenesis by reducing aortic inflammation and oxidative stress, improving endothelial cell survival and flow-mediated dilation, and improving hemodynamics. The potential of SGLTIs to affect ascending aortic pathology, however, has not been investigated. Given that our group studies the use of SGLTIs in a clinically relevant, large animal model of myocardial ischemia with metabolic syndrome, and given the relevance of metabolic syndrome to the pathogenesis of aortic aneurysms, we set out to determine whether administration of canagliflozin would also modulate parameters associated with ascending aortic aneurysmal/dissection pathogenesis.
Methods: Twenty-one Yorkshire swine aged 5-6 weeks arrived at our facility and were fed a high-fat diet for 12 weeks, as this has been validated to induce metabolic syndrome in experimental animals. At week 6, an ameroid constrictor device is placed around the left circumflex coronary artery to induce chronic myocardial ischemia. Beginning on the second postoperative week and extending for five weeks thereafter, animals were administered either 300 mg oral canagliflozin (high-fat canagliflozin group, or HCAN, n=10) or a drug-free vehicle (high-fat control group, or HFC, n=10). After 5 weeks of treatment, all animals underwent a terminal harvest procedure entailing the acquisition of hemodynamic parameters and collection of myocardial and ascending aortic tissue. Tissue sections were snap-frozen in liquid nitrogen. Tissue lysates were made using proteolytic digestion, and immunoblotting for proteins demonstrated to be associated with ascending aortic aneurysmal pathogenesis was performed. T-tests or nonparametric analogs were used to compare the relative expression of proteins between groups after normalization to a loading control; t-tests were also used to compare hemodynamics.
Results: Precise intra-arterial quantification using femoral arterial and direct myocardial puncture and catheterization yielded no significant difference in mean arterial pressure (p>0.8), a significant increase in heart rate (p=0.01), and no change in left ventricular dP/dt (p>0.4) in the HCAN treatment group compared with the HFC control group. Immunoblotting for proteins related to oxidative stress (eNOS, NOX-1, catalase, SOD-1, and GPX-1), inflammation (IL-1ß, IL-17, and IL-6), and TGF-ß signaling (TGF-ß, SMAD 2/3) did not demonstrate consistently significant differences between groups (p>0.05 for all but IL-6).
Conclusions: Despite the pleiotropic salubrious effects demonstrated following SGLTI administration on the myocardium and the abdominal aorta, our results indicate that these benefits do not extend to the ascending aorta. This provides further evidence of the biological heterogeneity between thoracic and abdominal aortic signaling and suggests that the administration of SGLTI therapy is unlikely to affect thoracic aortic disease processes.
Authors
Christopher Stone (1), Dwight Harris (2), Meghamsh Kanuparthy (3), Mark Broadwin (4), Jad Hamze (5), M. Ruhul Abid (6), Frank Sellke (7)
Institutions
(1) Brown University, N/A, (2) Beth Israel Deaconess Medical Center, United States, (3) Division of Cardiac Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, (4) Lehigh Valley Health Network/University of South Florida, Allentown, PA, (5) Brown University, Providence, RI, (6) Cardiovascular Research Center, Rhode Island Hospital, Providence, RI; Division of Cardiothoracic S, Providence, RI, (7) Rhode Island Hospital, Providence, RI
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Poster Presenter
Christopher Stone, Brown University
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Providence, RI
United States
Objective: We report the successful open surgical management of thoracoabdominal aneurysms (TAAAs) in a father and daughter with Loeys-Dietz Syndrome after failed endovascular repair.
Methods:
Patient 1:
A 36-year-old woman with Loeys-Dietz syndrome and a past history of postpartum type A aortic dissection requiring stage 1 elephant trunk and chronic type B aortic dissection with left carotid to subclavian bypass and subsequent TEVAR all performed at an outside hospital presented with chest pain. The CT scan demonstrated type 1B endoleak and a 9 cm Crawford extent II TAAA (Figure 1).
The patient was taken for open repair. After femoral-femoral cannulation, cardiopulmonary bypass (CPB) was initiated. Under deep hypothermic circulatory arrest (DHCA), the aorta was transected and the stent was explanted. A 26-mm graft was anastomosed proximally to the previous elephant trunk graft and distally to the infrarenal aorta. The renovisceral vessels were reattached using a trifurcated graft.
The patient was extubated after 36 hours. After surgery, the patient developed renal failure requiring temporary dialysis. She was discharged home on POD #16.
Patient 2:
A 62-year-old man with Loeys-Dietz syndrome, who incidentally was the father of Patient 1, presented with back pain. The patient had a prior CABG and AVR and hybrid aortic arch repair with TEVAR performed at an outside hospital. The CT scan demonstrated a type 1B endoleak and a 6.9 cm Crawford extent III TAAA (Figure 1).
After femoral-femoral cannulation, CPB was initiated. Under DHCA, the aorta was transected at the level of the distal stent and a 30-mm graft was anastomosed proximally at the level of the distal stent and then distally at the level of the aortoiliac bifurcation. The renovisceral vessels were selectively perfused and then reattached.
Postoperatively, the patient required a sigmoid colon resection for bowel ischemia. He also developed cholecystitis requiring a percutaneous cholecystostomy drain, renal failure requiring temporary dialysis, and tracheostomy. He was discharged to a rehabilitation facility on POD #57.
Results:
Both cases demonstrate the successful open surgical management of TAAAs in a father and daughter with Loeys-Dietz syndrome after failed endovascular repair.
Conclusions: Young patients with Loeys-Dietz syndrome should undergo open surgical repair of TAAAs to avoid stent-related complications. Early recognition and meticulous surveillance in families with Loeys-Dietz syndrome are absolutely essential.
Authors
joshua chen (1), Vishal Shah (1), Colin King (1), Jacqueline McGee (1), Megary McCoy (1), Jeffrey Zucker (1), Konstadinos Plestis (1)
Institutions
(1) Thomas Jefferson University Hospital, Philadelphia, PA
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Poster Presenter
joshua chen, Thomas Jefferson University Hospital
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philadelphia, PA
United States
Objective: To compare the early and late outcomes of thoracic endovascular aortic repair (TEVAR) under local anesthesia (LA) vs general anesthesia (GA) in acute type B dissection (ATBAD).
Methods: Of 247 patients (mean age 52.9±12.6 years; 195 men [78.9%]) receiving TEVAR for ABTAD from 2016-2021, 44 underwent GA and 203 received LA (lidocaine infiltration + dexmedetomidine sedation + butorphanol analgesia). Two groups were compared in respect to intraprocedural and early and late outcomes. Risk factors were identified for all-cause death and late adverse events (a composite of endoleak, retrograde type A dissection [RTAD], and distal aortic dilation).
Results: Baseline and pre-anesthesia data were comparable between 2 groups. At anesthesia start, LA group showed higher systolic blood pressure (SBP) (134 vs 123 mmHg, P<.001) and diastolic BP (DBP) (76 vs 72 mmHg, P=.044) and faster heart rate (HR) (77 vs 73 bpm, P=.026). During anesthesia, HR (74 vs 71 bpm, P=.186) and SBP (123 vs 119 mmHg) were similar between 2 groups, while LA group showed higher DBP (69 vs 65, P=.024). Technical success was 100%. The stent graft was 19 cm long and 33 mm in diameter, covering 3-5 zones in 58 (23.5%) and ≤2 zones in 189 patients (76.5%), similar between LA and GA. Upon anesthesia completion, LA group had a visual analog scale of 1.2±0.4 and Ramsay sedation scale of 3.2±0.5 (Table). Compared to GA group, LA group showed significantly shorter anesthesia (84 vs 136 min, P=.001) and procedure times (66 vs 115 min, P=.002), and less blood loss (20 vs 53 mL, P<.001) and fluid infusion (515 vs 1032 mL, P<.001).
Ten endoleaks (4%) were detected intraoperatively, including type I in 9 and type II in 1. Complications included stroke in 3 patients (1.2%), spinal cord ischemia in 2 (0.8%), acute kidney injury in 2 (0.8%) and limb ischemia in 4 (1.6%). In LA group, 2 patients underwent reintervention (0.8%) for access site injury, and 1 required exploratory laparostomy for visceral trauma. Despite similar morbidities in 2 groups (all P>.05), early mortality was significantly lower in LA group (1% [2/203] vs 6.8% [3/44], P=.041), who also had shorter lengths of ICU (3 vs 31 hours, P=.001) and hospital stay (23 vs 28 days, P=.040).
Follow-up was 100% complete (242/242) at mean 3.2±1.8 years. Ten patients died at 2.0±1.3 years, distal aortic dilation occurred in 11 at mean 2.6±0.9 years, endoleak in 4 at 2.0±0.6 years, and RTAD in 4 at 3.0±1.6 years, all similar between 2 groups. Reoperation was done in 5 patients at 2.6±1.5 years for RTAD in 4 and proximal aortic ulcer in 1, which was more common in LA group (1.6% vs 7.3%, P=.035). Despite similar survival at 5 years (93.6% vs 87.9%, P=.125), freedom from late adverse events (LAE) was significantly higher in the LA group (89% vs 62.4%, P=.015).
In Cox regression, 3-5 zones covered (vs ≤2) was a predictor of all-cause death (hazard ratio [HR] 3.54; 95% confidence interval [CI] 1.24-10.13, P=.018) and LAE (HR 2.96; 95% CI 1.03-8.52; P=.044), while LA was associated lower risk of LAE (HR 0.24; 95% CI 0.09-0.66; P=.005).
Conclusion: In this series of TEVAR for ATBAD, LA has achieved less physiological disturbance and blood loss, shorter anesthesia and procedure times, lower early mortality, shorter length of ICU and hospital stay, and fewer late reinterventions and adverse events compared to GA. These results argue favorably for more frequent use of local anesthesia in TEVAR for patients with ATBAD.
Authors
Wei-Guo Ma (1), Song Chen (2), Wen-Jing Guo (2), Tong-Xuan Wang (3), Zhi-Liang Song (3), Yang Liu (3), Xing-Peng Chen (2)
Institutions
(1) Yale New Haven Hospital, Connecticut, (2) Luoyang Central Hospital, Luoyang, NA, (3) Luoyang Central Hospital, Luoyang, China
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Poster Presenter
Song Chen, Zhengzhou University
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Luoyang, Henan
China
Purpose:
Logistic regression algorithms have shown the potential to predict surgical outcomes in cardiac surgery. Although they have been used in aortic surgery, their application has been constrained by the extensive data needed before and after surgery to effectively employ these models. Applying logistic regression to hemiarch surgery to assess mortality would be of particular benefit, especially given disagreements in weighing risks of surveillance versus operative intervention. We sought to apply and develop a logistic regression model to predict post-operative mortality following hemiarch surgery, utilizing only data from patient presentation and intra-operative procedures performed.
Methods:
From our single institution prospectively maintained database, we identified a total of 602 adult patients who underwent hemiarch replacement between June 2009 and October 2022. These patients were randomly divided into training (80%) and testing (20%) sets and various logistic regression models were constructed to predict overall post-operative mortality. We considered 17 input parameters from the index hospitalization which were comprised of demographic and pre-operative characteristics. To assess model performance, we employed multiple measures, including accuracy, Brier score, and area under the receiver-operating characteristic curve (AUC-ROC). Furthermore, we calculated odds ratios and confidence intervals derived from the logistic regression model.
Results:
Post-operative mortality was noted in 56 patients (9.30%) who underwent hemiarch replacement. The final logistic regression model demonstrated a cross-validation accuracy of 91% and was well-calibrated as evidenced by the low Brier score of 0.09. The predictor also demonstrated strong performance on the testing set, achieving an accuracy of 86%. Our best performing overall post-operative mortality prediction model achieved an AUC-ROC of 0.70 both on the training and testing sets. A heightened mortality risk was linked to factors such as aortic dissection with malperfusion, the urgency of the procedure, adjunctive valvular repair, and concomitant CABG or root replacement. Factors that reduced risk included aortic dissection without malperfusion, elective procedures, and the performance of hemiarch surgery without any adjunctive interventions.
Conclusions:
Logistic regression algorithms can accurately predict mortality after hemiarch surgery, specifying key intra-operative procedures that lead to higher rates of mortality. Given the absence of risk models available for aortic surgery, logistic regression models may have the potential to serve as an excellent clinical tool to predict surgical outcomes.
Authors
Adam Carroll (1), Nicolas Chanes (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective: Besides for the well known connective tissue disorderes the mechanism of aortic aneurysm formation is poorly understood. The presence and quantity of non-coding RNAs, in particular long non-coding RNA (lncRNA) may offer new opportunities in understanding aortic pathology. Here, we describe promising candidates from patients with different thoracic aortic disease and by comparing their presence in different areas with more or less wall shear stress and consecutive dilation.
Methods: Single-cell RNA sequencing was performed on samples of the wall of the outer (dilated) and inner (non-dilated) curvature of thoracic ascending aortic aneurysms (TAA) (n=4). To cluster the cells, a UMAP (Uniform Manifold Approximation and Projection) analysis was performed. In a second step, the 10 most deregulated lncRNAs in vascular smooth muscle cell (VSMC) clusters were identified. Two promising representatives with almost unique expression in VSMCs were further analysed by qPCR and life-cell-imaging.
Quantitativ expression was measured by qPCR in 110 samples of TAA and acute aortic dissection (AADA), comparing inner and outer curvature. In addition, analyses were performed according to aortic valve morphology (bicuspid - BAV, tricuspid - TAV) and valve pathology (stenosis - AS, regurgitation - AI). As a control, expression was validated in 7 aortic samples from healthy heart transplant donors. CT values of more than 40 were excluded. The results were expressed as multiples of the expression at the inner curvature, which was set to 1.
Functional analyses were performed using live-cell imaging. Migration, proliferation and apoptosis were evaluated after siRNA-mediated temporary knockdown of both lncRNAs in primary VSMCs extracted from thoracic aortic tissue. All cells and tissues were provided by the Aortic Biobank of the Department of Cardiac Surgery at the LMU University Hospital, Munich, Germany.
Results: UMAP analysis identified 17 different cell clusters, including 3 VSMC cluster. Examination in the VSMC clusters for the 10 most deregulated lncRNA revealed 25 representatives with differential expression along the inner and outer curvature, notably TMEM72-AS1 and LINC00632 with almost exclusive expression in VSMC. Quantitative expression analysis showed significantly higher expression of TMEM72-AS1 and LINC00632 in dilated areas (1.96, p<0.01; 2.1, p<0.001). LINC00632 showed increased expression particularly in tissues from BAV and AI (1.99, p<0.01; 2.16, p<0.01). However, there was no significant difference in samples from AADA tissue. Conversely, TMEM72-AS1 was highly expressed in AADA tissue (1.54, p<0.01), but showed no significant difference in AI tissue samples. No differences in expression was detected for either lncRNA in healthy aortic tissue.
SiRNA-mediated silencing of TMEM72-AS1 and LINC00632 in primary VSMCs showed reduced migration and proliferation at 48 and 72 hours compared to non-transfected VSMCs (99.37% vs. 62.54%, p<0.0001 and 88.39%, p=0.025, respectively). Conversely, apoptosis was activated with a peak at 120 hours (0.5% vs. 11.25%, p<0.0001 and 14.17% p<0.0001, respectively).
Conclusion: ScRNA sequencing supports the role of lncRNAs in the pathophysiological process of thoracic aortic aneurysm formation. Functional and quantitative expression analyses of TMEM72-AS1 and LINC00632 identify these lncRNAs as targets for potential diagnostic and therapeutic approaches.
Authors
Joscha Buech (1), Jessica Pauli (2), Caroline Radner (1), Zhaolong Li (2), Linda Grefen (1), Christian Hagl (1), Maximilian Pichlmaier (1), Lars Maegdefessel (2), Sven Peterss (1)
Institutions
(1) LMU University Hospital, Munich, Germany, (2) Institute for Molecular Vascular Medicine, Technical University Munich, Munich, Germany
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Poster Presenter
Joscha Buech, LMU KLINIKUM MUNICH
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Munich, NA
Germany
Title
Long-term outcome in patients undergoing aortic root replacement: the Bentall Procedure in Latin-American
Objective
In order to assess the early and long-term outcomes of the Bentall procedure in Latin America we compared the outcomes of patients undergoing Bentall procedure with biological vs mechanical valved conduits.
Methods
Between January 2008 and January 2023. 110 aortic root replacement operations were performed. The results were examined by univariate, multivariate and a Kaplan Meier analysis.
Results
Median age 64 ± 4 years, male 88 cases. The mean follow-up was 120 months. Median EuroSCORE II was 6 ± 3. Hospital mortality was 9,1% with 19 (17%) emergency cases. The most frequently found complication resulted in heart rhythm disorders in 33 (27%) patients. The incidence of perioperative neurological complications, respiratory complications, renal failure were 2 (1,8%), 4 (3,6%), 6 (5,5%) respectively. With a median of cardiopulmonary bypass (CPB) time 111 minutes, and cross clamp time 94 minutes. All patients were free from MACCE at 5 years post procedure, and 93.8% were the survival rate at 12 years.
Conclusions
In conclusion, the Bentall procedure offers acceptable early and long-term outcomes in Latin American.
Authors
Carlos Perez (1), Javier Maldonado (2), German Molina (2), Andres Motta (3), Alejandra Prada (3)
Institutions
(1) Universidad El Bosque, Bogota, Colombia, (2) Clinica Universitaria Colombia, Bogota, (3) Clinica Universitaria Colombia, Bogota,
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Poster Presenter
Carlos Perez, El Bosque University
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Bogota, Colombia
Colombia
Objective: Aberrant subclavian artery (aSA) and Kommerell's diverticulum (KD) have been reported to increase the risk of aortic rupture (4%-19%) and aortic dissection. However, limited studies have investigated the treatment of aortic dissection in patients with aSA and KD. This study aims to report the clinical characteristics, surgical treatment, and through standardized data reporting. This study aims to investigate clinical characters and long-term follow-up outcomes of patients with aortic dissection associated with aSA.
Methods: Between 2011 and 2021, a total of 48 patients with aSA anomalies underwent aortic dissection intervention. Among them, 20 (41.7%) had Stanford type A dissection, 9 (18.8%) had Stanford type B dissection, and 19 (39.6%) had non-A non-B dissection.
Results: The mean age of the patient population was 48.81±9.65 years. The operative mortality rate was 12.5%. The overall mortality rate was 20.8%, with a median follow-up time of 4.5 years (IQR: 2-8.75 years). Preoperative coronary artery atherosclerotic heart disease was identified as a factor associated with operative mortality (OR=2.57, P=0.017). The adjusted variables associated with a reduced risk of overall mortality were increased BMI (HR=0.73; 95%CI 0.56-0.96). Central nervous system complications occurred in 8 patients (16.7%), subclavian steal syndrome in 6 patients (12.5%), respiratory complications in 3 patients (6.2%), and peripheral nerve injury in 2 patients(4.2%). The incidence of respiratory complications in patients with the right aortic arch was significantly higher than that in patients with the left aortic arch (P=0.01). During the follow-up period, a total of 7 cases required reintervention for cardiovascular disease. The estimated Kaplan-Meier survival rates at 1 year, 3 years, 5 years, and 7 years after surgery were 87.0%, 82.5%, 79.7%, and 75.1%, respectively.
Conclusions: In patients with aSA and KD, the presence of aortic dissection is associated with increased early and long-term mortality rates, as well as a higher incidence of postoperative complications. Early intervention should be considered for patients with aSA and KD to prevent the occurrence of aortic dissection. Once aortic dissection occurs, individualized intervention strategies should be formulated based on preoperative characteristics, including age, general condition, type of dissection, and imaging characteristics.
Authors
Yangxue Sun (1), Hongwei Guo (2), Yuanrui Gu (3), Shuo dong (4), Haitao Xu (5), Chuhao Du (5), Jie Dong (6)
Institutions
(1) National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, Beijing, (2) Fuwai Hospital, Beijing, Beijing, (3) Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, (4) N/A, N/A, (5) Department of Pediatric Cardiac Surgery, National Center for Cardiovascular Disease and Fuwai Hospit, Beijing, Beijing, (6) N/A, Baltimore, MD
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Poster Presenter
Yangxue Sun, Fuwai Hospital, Chinese Academy of Medical Sciences
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Beijing, Beijing
China
Objective: Selective antegrade cerebral perfusion using trifurcated graft technique during aortic arch replacement is associated with low rate of adverse neurologic outcomes. We described clinical outcomes of total arch replacement using Trifurcated Graft Technique (modified Spielvogel technique).
Methods: From January 2007 to September 2022, overall 143 patients underwent non-emergent total arch replacement using trifurcated graft technique. The trifurcated graft was used for hypothermic selective cerebral perfusion. Median follow-up duration was 63.3 months. Primary outcomes were overall survival and aortic re-intervention.
Results: There were hospital death in 10 (7.0%) and postoperative stroke in 8 (5.6%) patients. However, only one patient (0.7%) had disabling stroke. Reoperation due to bleeding was present in 13 (9.1%) patients. There was no graft infection or mediastinitis. Twenty-two (15.4%) patients underwent prolonged intubation. Cardiopulmonary bypass time, aorta cross clamp time, and Mean selective cerebral perfusion were 228.0±56.9, 154.5±41.8, 79.3±23.6 minutes. Overall survival at 1 and 5 years was 94.3% and 83.1%, respectively. Freedom from aortic re-intervention at 1 and 5 years was 94.1% and 89.0%, respectively. There were no occlusion of trifurcated graft during the follow-up.
Conclusions: Use of a trifurcation graft to the brachiocephalic vessels with modified Spielvogel technique is a reliable and safe method for aortic arch replacement, yielding acceptable postoperative and long-term outcomes.
Authors
Yoonjin Kang (1), Ji Seong Kim (1), Jae Woong Choi (2), David Spielvogel (3), Kyung Hwan Kim (1)
Institutions
(1) Seoul National University Hospital, Seoul, (2) Seoul National University Hospital, Seoul, Seoul, (3) Westchester Medical Center, Valhalla, NY
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Poster Presenter
Yoonjin Kang, Seoul National University Hospital
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Seoul, Seoul
South Korea
Objective: Valve-sparing aortic root replacement (VSARR) is a favored method for repairing aortic root aneurysms in patients with suitable anatomy and a reasonable life expectancy, as numerous studies have demonstrated excellent long-term outcomes. Despite the increasing use of minimally invasive techniques in cardiac surgery, there is limited data on minimally invasive VSARR. This study aimed to compare the long-term survival and durability of repairs between VSARR performed via full sternotomy (FS) or ministernotomy (MS).
Methods: We gathered data prospectively of all VSARR procedures at two high-volume tertiary centers. Starting in 2014, one center adopted a MS approach for aortic root aneurysms below 65 mm. The primary endpoint was long-term mortality, while the secondary endpoint involved repair durability, measured by the degree of aortic insufficiency at the longest follow-up, perioperative complications, and the need for further intervention.
Results: Ninety-four patients were included in the study (21 in the MS group and 73 in the FS group). The median age [interquartile range, IQR] of patients was 46 [32-62], and the median EuroSCORE II was 2.48 [1.29-3,36]. The aortic cross clamp duration was 35 minutes longer in the MS group [median 160 (143-184) vs. 195 (171-212), p=0.011]. There were no differences in perioperative complications, including kidney failure requiring dialysis (p=0.399), re-exploration for bleeding (p=0.705), neurological complications (p>0.999), or ICU stay (p=0.700). The 30-day mortality was 4.1% (3 out of 73) in FS group and 0% in MS group (p>0.999). In a median clinical follow-up of 5.1 years, there were no differences in survival between the groups (logrank test, p=0.260). Four patients (5.4%) in the FS group and no patients in MS required re-intervention during follow-up (p=0.572). Similarly, in a median echocardiographic follow-up of 2.0 years, there were no differences in the progression to ≥moderate aortic regurgitation between the groups (p>0.999).
Conclusions: Minimally invasive VSARR appears to be safe and shows comparable survival and durability to the FS approach among patients with aortic root aneurysms below 65 mm.
Authors
Jakub Staromlynski (1), Adam Kowalowka (2), Radoslaw Gocol (2), Damian Hudziak (2), Damian Chudzik (2), Małgorzata Żurawska (1), Wojciech Nowak (1), Michal Pasierski (1), Wojciech Sarnowski (1), Radosław Smoczyński (1), Maciej Bartczak (1), Jakub Brączkowski (1), Sabina Sadecka (1), Dominik Drobiński (1), Marek Deja (2), Mariusz Kowalewski (3), Piotr Suwalski (1)
Institutions
(1) National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland, (2) Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland, (3) IRCCS-ISMETT, Palermo, Italy
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Poster Presenter
Jakub Staromlynski
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Warsaw
Poland
Objective
Although physician-modified fenestrated and branched endografts (PMEGs) has been proposed as an alternative endovascular solution for complex aortic aneurysm for decades, its usage is still limited by lack of long-term data in large series. This report marks the first comprehensive analysis focusing on the long-term outcomes of PMEGs in the endovascular repair of complex aortic diseases, drawing data from three aortic centers in southeast China.
Materials and methods Between 2017 and 2021, patients undergoing PMEGs in 3 southeast China academic centers were collected. Data of patients with PMEGs were retrospectively analyzed. Perioperative morbidity/mortality was assessed as early outcomes. Survival, freedom from reintervention (FFRs), and target vessels (TVs) patency and freedom from any instability were assessed as late follow-up outcomes.
Results Among 186 patients who underwent PMEGs for complex aortic disease (156 males; mean age 68.4±13.4 years), 151(81.2%) had extent thoracoabdominal aortic aneurysm (TAAAs) and 35 (18.8%) had complex abdominal aortic aneurysm (CAAAs, defined as short neck infrarenal, juxtarenal, and pararenal AAAs). A total of 618 TVs were incorporated by fenestrations or branches (3.3±0.9 vessel/patient). 89 patients with TAAAs had incidence of prior aortic repair, including thoracic EVAR (TEVAR, 41.0%), frozen elephant trunk (FET, 9.9%) or FET plus TEVAR (6.6%) procedures. 30-day or in hospital mortality occurred in 6 patients (3.2%). Morbidities included acute kidney injury in 11 (5.9%); new-onset dialysis in 6 (3.2%); and stroke, myocardial infarction, and limb ischemia in 5 (2.7%) patients each; respiratory failure requiring treatment in 7 (3.8%) patients, and bowel ischemia requiring resection in 3 (1.6%). Only one patient developed spinal cord injury with transient paresthesia. Independent predictors for all-cause mortality by multivariate cox regression analysis were age (+1 year, HR:1.104, 95% CI: 1.013 -1.203; p= .024), total operative time (HR:1.018, 95% CI: 1.010 -1.027; p≤ .001), largest aortic diameter (HR: 1.046, 95% CI: 1.006 -1.087; p= .025). After a mean follow-up of 3.5 ±1.1 years, there were 4 (2.2%) deaths. In the Kaplan-Meier analysis, the survival rates at 1, 3, and 5 years were 96.2%, 95.1%, and 93.9%, respectively. Freedom from any instability at 1, 3, and 5 years was 97.3% (95% CI, 93.7% - 98.9%), 92.2% (95% CI, 87.2% - 95.3%), and 87.4% (95% CI, 80.3% -92.1%), respectively. The secondary patency for all target vessel at 1, 3 and 5 years was 99.3% (95% CI, 98.4% - 99.7%), 98.5% (95% CI, 97.1% - 99.2%) and 98.5% (95% CI, 97.1% - 99.2%), respectively. Freedom from any reintervention at 1, 3, and 5 years was 96.2% (95% CI, 92.2%-98.2%), 90.4% (95% CI, 85.0%-93.9%) and 72.0% (95% CI, 51.1%-85.2%) for the entire cohort, respectively.
Conclusions FB-EVAR with PMEGs emerges as a safe technique with acceptable postoperative morbidity and mortality rates. PMEGs serve as a crucial bridging tool in the toolkit of aortic surgeons, particularly when manufactured devices are not immediately accessible. Although initial outcomes are promising, pooled data and continued surveillance is a crucial component of endovascular repair. With the continued evolution of endovascular technology, PMEGs stands to benefit from improved standardization of the endovascular procedure, with the hope of broader adoption in the f
Authors
Guangmin Yang (1), min zhou (2)
Institutions
(1) N/A, N/A, (2) N/A, jiangsu, China
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Poster Presenter
Guangmin Yang, Affiliated Drum Tower Hospital of Nanjing University Medical School
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Germany
Objective: The most effective surgical method for acute type A aortic dissection(ATAAD) involving the aortic arch is controversial. This article was first to explore the long-term outcomes of ATAAD using total arch replacement with frozen elephant trunk procedure (TAR with FET) with the largest cases in one center.
Methods: From 2007 to 2018, 1427 cases of ATAAD underwent surgical treatment in Fuwai Hospital. Among them, patients who underwent TAR with FET were selected to obtain clinical data and conduct long-term follow-ups. The follow-up deadline is November 2023. Long-term clinical outcomes were summarized by survival, freedom from aortic reoperation, and activity of daily living.
Results: A total of 1090 patients underwent TAR with FET, 80.18% (874/1090) of male patients, average age 46.6 ± 10.2 years. 290 (26.6%) patients underwent the Bentall procedure in aortic root management. The average CPB time was 191.2 ± 63.7min, cross-clamp time was 105.1 ± 33.4min, hypothermic circulatory arrest time was 19.6 ± 7.2min, and operative mortality was 7.34% (80/1090). By the end of follow-up, All causes of death is166(including 80 operative deaths), average follow-up time is 6.15±3.97 years, the longest follow-up time is more than 16 years, 83.86% of patients (847/1010) have complete self-care ability and can engage in general physical work. Overall survival was 89.21%, 87.52%, and 81.7% at 3, 5 and 10 years respectively. The 5-year and 10-year freedom from aortic reoperation rates for discharged patients (1010 cases) were 95.55% and 92.97%, respectively.
Conclusion: TAR with FET had acceptable operative mortality and encouraging long-term outcomes for ATAAD. TAR with FET should be given priority to recommend for ATAAD in experienced center for better long-term outcomes.
Authors
Juntao Qiu (1), Kai Zhang (2), Cuntao Yu (3)
Institutions
(1) N/A, China, (2) Fuwai Hospital, Beijing, Beijing, (3) Fuwai Hospital, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular, Beijing, Beijing
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Juntao Qiu, Fuwai
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Beijing, Beijing
China
Objective: The aim of this study was to investigate the long-term prognosis of the preserved, native aortic root after supra-coronary replacement in open repair for acute type A aortic dissection (ATAAD) and risk factors for root dilatation and aortic root re-operation.
Methods: Between 2001 and 2020, 238 consecutive patients (mean age, 62.6 ± 13.9 years) with ATAAD underwent supra-coronary replacement. The maximum diameter of aortic root was measured with computed tomography (CT) before-, immediate after surgery and every 1~2 years after surgery. The mean follow-up duration was 9.0 ± 5.9 years and the mean CT follow-up duration was 7.3 ± 5.02 years. End-points were aortic root re-operation, all-cause mortality and aortic root dilatation.
Results: There were 9 (3.8%) patients with Marfan syndrome and 1 (0.4%) with bicuspid aortic valve. The pre-operative mean aortic root diameter was 39.0 ± 5.4mm; 139 patients (58.4%) with <40mm, 66 patients (27.7%) with ≥40mm and <45mm, and 33 patients (13.9%) with ≥45mm. In-hospital mortality was 10.9%. The mean aortic root diameter increased from 48.6mm to 63.5mm in pre-operative aortic root ≥45mm patients, but it did not significantly increase (37.7mm to 38.9mm) in <45mm patients. Pre-operative aortic root ≥45mm patients showed significantly lower rates of 10-year aortic root re-operation free survival (73.5% vs. 99.4%, p<0.01) and overall survival (49.8% vs. 75.8%, p<0.01) than <45mm patients. The receiver operating characteristic curve showed aortic root re-operation was significantly corelated with pre-operative aortic root diameter (area under curve, 0.911; p<0.01) and optimal cut-off value was 45mm. Multivariate analysis showed that pre-operative aortic root ≥45mm was independent risk factor for aortic root re-operation (hazard ratio, 55.43 [6.79-452.80]; p<0.01) and all-cause death (hazard ratio, 3.41 [1.81-6.44]; p<0.01).
Conclusions: Pre-operative aortic root ≥45mm showed significantly higher risk of aortic root re-operation and late mortality because of the progressive aortic root dilatation.
Authors
Jung-Hwan Kim (1), Seung Hyun Lee (2), Sak Lee (3), Young-Nam Youn (2), Kyung-Jong Yoo (2), Hyun Chel Joo (4)
Institutions
(1) Severance hospital, Seoul, Seoul, (2) Severance Cardiovascular Hospital, Seoul, AK, (3) Severance Hospital, Seoul, none, (4) Severance hospital, Seoul, seoul
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Poster Presenter
Jung-Hwan Kim, Severance hospital
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Seoul, Seoul
South Korea
Objective: To propose a machine learning algorithm to detect aortic dissection on non-contrast-enhanced CT and evaluate the diagnostic ability of the algorithm compared with those of radiologists.
Methods: This study developed a machine learning algorithm using single-center data collected between January 1, 2022, and December 31, 2022. Included in the study were 130 patients (65 with AD and 65 without AD). An AD detection algorithm was developed using a 3D full-resolution U-net architecture. We have continuously trained and developed an algorithm based on machine learning to segment the true and false lumens of the aorta and then determine whether there is aortic dissection. The algorithm's efficacy in detecting dissections was evaluated using the receiver operating characteristic (ROC) curve, including the area under the curve (AUC), sensitivity, and specificity. Furthermore, a comparative analysis of the diagnostic capabilities between our algorithm and three radiologists was conducted.
Results: The developed algorithm achieved an accuracy of 94.8%, a sensitivity of 93.6%, and a specificity of 96.6%. For radiologists, accuracy, sensitivity, and specificity were 88.9%, 90.8%, and 94.6%, respectively. The algorithm's performance was not significantly different from the mean performance of radiologists in terms of accuracy, sensitivity, or specificity.
Conclusion: The proposed algorithm showed comparable diagnostic performance to radiologists for detecting AD on non-contrast-enhanced CT, which suggests that the proposed algorithm has the potential to reduce misdiagnosis of AD to improve clinical outcomes.
Authors
zhangbo cheng (1), Lei Yin (2), Jun Yan (2), Shengmei Lin (2)
Institutions
(1) N/A, China, (2) Fujian Medical School, Fuzhou, Fujian, China, Fuzhou, NA
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Poster Presenter
zhangbo cheng, Fujian medicine school
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Fuzhou, Fujian
China
Objective:
With progression of infectious endocarditis, destruction of the aortic annulus and root occurs, potentially resulting in aortic root pseudoaneurysms. The standard of care centers around aggressive debridement, reconstruction of any destroyed annulus, and replacement of any infected or necrotic tissue including the valve or root. The vast majority of literature surrounding the topic is related to case reports, and thus, we sought to evaluate our aortic center's institutional outcomes after root replacement for endocarditis-related aortic root pseudoaneurysms.
Methods:
A prospectively maintained institutional database was used to identify patients over the last 10 years who presented with endocarditis-related aortic root pseudoaneurysms. We describe any prior surgical history and temporal relationship to prior surgeries, and subsequent management strategy and outcomes.
Results:
A total of 15 patients with endocarditis-related aortic root pseudoaneurysms were identified. In addition to infectious symptoms, roughly half of the patients presented with additional cardiovascular symptoms, including stroke (2, 13.3%), pericardial effusion (2, 13.3%), and arrhythmia (complete heart block or new onset atrial fibrillation, 3, 20.0%). All but two of the patients had a prior aortic surgical history, except for two patients who presented primarily in the setting of bicuspid aortic valve disease. Most of the cohort had a previous aortic valve replacement (13, 86.7%), with a significant portion having an aortic or valve intervention within the past year (4, 26.7%). All patients underwent concomitant valve and root replacement including mechanical bentall, biobentall or homograft replacement. Roughly a third of patients required concomitant arch intervention of some form, with other adjunctive procedures including coronary artery bypass grafting, mitral valve replacement, and PFO closure. Approximately half of patients (7, 46.7%) were left open for either bleeding or serial washouts, with 2 (13.3%) requiring adjunctive mechanical circulatory support. Post-operatively, rates of coagulopathy were high (7, 46.7%), with a relatively high mortality rate (3, 20.0%).
Conclusions:
For endocarditis-related aortic root pseudoaneurysm to form, patients typically have severe enough progression in their disease that they can present with a number of additional life-threatening pathologies, furthermore, they are subject to increased morbidity and mortality due to their disease progression. Decisive surgical treatment with radical debridement, reconstruction of the annulus, and replacement of the valve and root is of paramount importance.
Authors
Adam Carroll (1), Michael Kirsch (1), Nicolas Chanes (1), Elizabeth Devine (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objectives: Pituitary apoplexy after cardiac surgery is a rare but described phenomenon that often requires operative intervention. We present a rare case of pituitary apoplexy following circulatory arrest and implantation of a mechanical aortic valve, requiring both post-operative anticoagulation and an acute neurosurgical resection.
Methods: A 54-year-old man with a bicuspid aortic valve with severe aortic stenosis and aortic dilation was recommended for mechanical root and ascending hemiarch replacement. During his preoperative evaluation, no neurologic symptoms were reported. The operation was an uncomplicated mechanical root and ascending hemiarch replacement performed under circulatory arrest with cooling to 18°C and retrograde cerebral perfusion. The procedure was uncomplicated, and the patient transferred to the ICU postoperatively.
Shortly after transfer, the patient was weaned off sedation and then noted to have ophthalmoplegia of the right eye and a fixed, dilated pupil. A stroke alert was called where the patient was evaluated by Neurology. An emergent non-contrast head CT and CT angiogram of the head and neck were negative for acute ischemic infarct or hemorrhage. However, a 3.0 cm mass was appreciated in the sellar/suprasellar cistern, with subsequent MRI demonstrating a cystic mass compressing the right optic nerve with extension into the right cavernous sinus.
ENT, Ophthalmology, Neurosurgery and Endocrinology were consulted. Initially, the patient trialed medical management with steroids and diuresis to address his cerebral edema. However, daily ophthalmic exams revealed worsening visual symptoms, prompting more urgent neurosurgical intervention. In the days leading up to his neurosurgical procedure, CT surgery and Neurosurgery worked together to balance the risks and benefits of anticoagulation for his recent mechanical valve with timing of operative intervention for his worsening intra-pituitary hemorrhage.
Results: The interdisciplinary team ultimately decided to initiate a heparin drip on post-operative day 4 and continue holding aspirin/coumadin. On post-operative day 9, he underwent a successful trans-sphenoidal neuro-endoscopic excision. Post-operatively, the patient developed intracranial hemorrhage in the operative bed, so anticoagulation continued to be held. Two days later, he developed a DVT in his left upper extremity, which prompted initiation of a heparin drip. Monitoring scans after heparin initiation demonstrated stability of the hemorrhage, and he was ultimately transitioned to warfarin on discharge. The patient recovered well and is currently living at home with some residual diplopia.
Conclusions: This case supports the idea that systemic anticoagulation can be temporarily held even in the acute period after mechanical valve replacement, when risk of a thromboembolic event is highest. It highlights the need for thoughtful multidisciplinary conversations when making decisions about anticoagulation and the optimal time for surgical intervention after intraoperative pituitary apoplexy. In this case, the patient's pituitary mass was successfully resected without major bleeding or thromboembolism complications.
Authors
Danielle Brown (1), Cecillia Lui (2), Yombe Fonkeu (3), Joseph Bavaria (2)
Institutions
(1) Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, (2) Hospital of the University of Pennsylvania, Philadelphia, PA, (3) Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA
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Poster Presenter
Danielle Brown
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Philadelphia, PA
United States
This video outlines the case of a 60-year-old male who underwent coronary artery bypass, experiencing complications in the form of a residual ascending aorta pseudoaneurysm. CT imaging revealed the presence of an ascending aorta pseudoaneurysm originating proximal to the innominate artery, with a neck measuring 9mm. The patient underwent endovascular repair using a 45 x 46mm Gore TAG stent for the ascending aortic pseudoaneurysm. A second stent was deployed with sufficient overlap. Subsequent follow-up imaging indicated complete coverage and resolution of the pseudoaneurysm. The patient was discharged in stable condition on postoperative day 1.
Authors
Dina Al Rameni (1), Robert Hooker (2), Scott Chicotka (3), Kenneth Fox (4), Tony Friday (5)
Institutions
(1) N/A, United States, (2) N/A, Tampa, FL, (3) N/A, Del Mar, CA, (4) N/A, Austin, TX, (5) University of Arizona, Tucson, AZ
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Poster Presenter
Dina Al Rameni, Banner/University of Arizona
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Tucson, AZ
United States
Objective:
The management of cardiac arrest whilst on femoro-femoral cardiopulmonary bypass (FF-CPB) during removal of an infected TEVAR can be challenging. We present our approach to this conundrum: change to dual site arterial cannulation CPB and use of deep hypothermia circulatory arrest (DHCA).
Methods:
A 66-year-old female four months previously presented with severe chest pain. CTA showed a large descending thoracic (DTA) aneurysm (6.4cm) and large penetrating ulcers. She had a history of chest pain, smoking, severe hypertension and a coronary stent. She underwent TEVAR placement. She now re-presented with hypertension and severe low back pain. A CTA was done and an endoleak was seen at the distal end of the TEVAR. A "relining" of the prior TEVAR was performed at an outside hospital. Twelve hours after discharge she was readmitted to an ER because of severe chest pains. A repeat CTA (Fig 1) showed extensive air around the TEVAR with a WBC of 25k. A diagnosis of an infected TEVAR (gram negative rods on blood culture) was made and she was transferred to our hospital. Her EF was approximately 40%. There was no esophageal leak on a swallow study. Plan: Urgent removal of infected TEVAR on femoro-femoral bypass (FF-CPB).
Operation: The thoraco-abdominal (TAA incision) and fem/fem access for CPB were done concurrently. On opening the chest there was extensive pus in the chest and she decompensated rapidly with global cardiac hypokinesis/distension, hypotension, arrhythmias requiring cardiac massage which persisted despite placement on FF-CPB. Action: A second arterial cannula was placed in the arch and Yed to the femoral cannula and the heart vented through the left superior pulmonary vein. Her hemodynamics and arrhythmias rapidly stabilized. The distal arch and DTA were densely adherent, and the aortic clamp could not be placed across the distal arch. The patient was rapidly cooled to 180C. Under DHCA, the infected TEVARs were removed, and a Rifampicin soaked 28 mm Hemashield graft interposed to above the celiac artery. Once the proximal anastomosis was completed a clamp was placed on the graft and patient rewarmed. Because of persistent LV dysfunction on weaning off CPB, she was transitioned to peripheral VAECMO (extracorporeal membrane oxygenation). The patients had severe coagulopathy requiring use of thoraco-abdominal wound vac and blood products. Her post-op course was complicated with poor wound healing requiring a wound vac, respiratory (ventilator) and renal support (dialysis). She was transferred to long-term care.
Summary:
Rapid conversion to dual site (central and peripheral) arterial cannulation with LV venting should be used for cardiac arrest on fem-fem CPB for TEVAR removal not responsive to standard measures. If the aorta cannot be cross-clamped DHCA can be used.
Authors
Salim Aziz (1), Jenna Aziz (2), Bao Nguyen (3), Shawn Sarin MD (3)
Institutions
(1) George Washington University Hospital, United States, (2) Ohio State Wexner Medical Center, Columbus, OH, (3) George Washington University Hospital, Washington, DC
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Poster Presenter
Jenna Aziz, Ohio State Wexner Medical Center
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Columbus, OH
United States
Objective:Summarize our center's 9-year surgical experience managing neonatal patients with Interrupted Aortic Arch (IAA)
Methods: We conducted a descriptive cross-sectional observational retrospective study, analyzing our tertiary care center's database of patients operated on for IAA between 2014 and 2023.Those with major congenital heart defects (CHD) other than the usual association with patent ductus arteriosus, left ventricular outflow tract obstruction (LVOTO), Ventricular Septal Defect (VSD) and aberrant right subclavian artery, were excluded.
Initial imaging used Doppler echocardiography for detailed assessment.
Results: Medical charts of 48 patients diagnosed with IAA were reviewed, 8 were excluded due to other associated major defects, leaving a total of 40 patients.
Most patients required surgery within the first weeks of life. The overall average age at the time of surgery was 20.3 days, with a median of 14 days [6 - 88]. There was a slight female predominance, being 52.6% of the sample (22/40). The average weight at the time of surgery was 3.15 kg [2 - 4.13 kg].
A strong association between IAA and 22q11 microdeletion, was confirmed in 62.3% of the sample (25/40).
Regarding interruption types, 79% were type B IAA and 21% type A. No type C cases were found.
Biventricular Repair was achieved in a single stage by end-to-end anastomosis with homograft patch enlargement in 85% of cases. In only one patient, due to prematurity and low weight, an hybrid procedure of pulmonary artery branch banding and ductal stenting was chosen, Delaying correction.
ninety-eight percent of patients had an associated VSD (n: 39), and it was successfully closed during the same surgical procedure in 89% of them.
Damus-Kaye-Stansel (DKS) surgery was the initial approach in 12.5% (5/40), and 60% of them later achieved biventricular correction in a second stage. Among those with complete repair (n: 34), 11% required a second surgery for LVOTO relief in the following 3 years
The mean aortic annulus size in the re-intervened group was 4.68 mm , with an average Z score of -3.6. The Sinotubular junction (STJ) was measured on average at 4.85 mm, with a mean Z score of -3.31. Measurements in the group of corrected patients without reintervention requirements showed an average aortic annulus of 5.05 mm with a Z score of -3.12. The mean STJ measurement was 5.38 mm with a -2.5 mean Z score.
There were no significant differences in the length of hospitalization between both groups after the first surgery [57.4 days for reintervention patients vs.56.4 days for non-reintervention].
The overall mortality was 14% among those who underwent corrective surgery in neonatal period (5/40), with 3 of these deaths associated with infectious complications during hospitalization.
Within the initial DKS-type palliation group, there was one late death related to complications during the Yasui procedure later on.
Conclusions: Interrupted aortic arch is a severe and low-incidence CHD whose management has significantly improved over the past 40 years.
In the last 9 years at our center, 85% of the patients achieved successful biventricular repair in a single stage and among those who underwent initial DKS-type palliation or Pulmonary artery banding (remaining 15%), 66% achieved biventricular repair in a second stage.
However, close post-surgical follow-up remains crucial considering the risk of progressive LVOTO development in the medium- and long-term evolution
Authors
Maria Zenobi (1), Julia Blando (2), Agustina San Pedro (3), Gustavo Sivori (4), Ignacio Berra (5), Pablo Garcia Delucis (6)
Institutions
(1) Hospital nacional de pediatria J.P.Garrahan, Buenos Aires, Argentina, ciudad autonoma de buenos aires, caba, (2) Hospital Nacional de Pediatría J.P. Garrahan, Ciudad Autónoma de Buenos, NA, (3) Hospital nacional de pediatria J.P.Garrahan, Buenos Aires, Argentina, Ciudad autónoma de Buenos Aires, Buenos Aires, (4) N/A, N/A, (5) Hospital nacional de pediatria J.P.Garrahan, Buenos Aires, Argentina, Morón, Buenos Aires, (6) Hospital nacional de pediatria J.P.Garrahan, Buenos Aires, Argentina, Buenos Aires
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Poster Presenter
Maria Zenobi, Hospital de Pediatria SAMIC Juan P Garrahan
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Ciudad autónoma de Buenos Aires, caba
Argentina
Objective: The cervical aortic arch (CAA) is an uncommon congenital anomaly in aortic development, characterized by an elongated aortic arch extending at or above the medial ends of the clavicles, and occasionally prominently into the neck. Our objective was to examine the clinical and surgical characteristics of this infrequent condition in the adult population.
Methods: PubMed, ScienceDirect, SciELO, DOAJ and Cochrane Library databases were searched until December 2023 for case reports describing the presence of a cervical aortic arch in the adult age. Case reports and series were included if the following criteria were met: 1) description of the cervical aortic arch; 2) age ≥18 years 3) English language. Exclusion criteria for analysis were all other forms of papers that did not have individual patient data.
Results: The literature search identified 2325 potentially eligible articles, 61 of which met our inclusion criteria with 71 patients. Mean age was 38.6 15.4 years, with a female prevalence of 67.1% (47/70). Two-thirds of the CAA were left-sided (48/71, 67.6%) and 62.0% (44/71) of patients presented a concomitant aneurysm. Asymptomatic patients were 45.7% (32/70), while among those symptomatic, symptoms related to vascular-induced compression of trachea and esophagus (coughing, dysphagia, wheezing, etc.), were present in 60.5% (23/38). Surgery was performed in 42 patients (62.7%) among 67 cases that reported the patient's treatment, and 5 patients (11.9%) among those surgically treated underwent the procedure through an endovascular approach. The intervention resolved compression symptoms in all surgically treated patients. Five patients (7.5%) rejected any invasive intervention despite being indicated and opted for a more conservative approach. Only one death was reported occurring in a critical patient presenting with a dissecting aneurysm and considered at inoperable risk.
Conclusion: Cervical aortic arch is an uncommon congenital heart condition that presents challenges in diagnosis and treatment due to its high anatomical variability, diverse clinical manifestations, and presence of concomitant diseases. Surgical intervention appears to be a safe and effective resolution for symptoms, albeit requiring an individualized approach.
Authors
Massimo Baudo (1), Serge Sicouri (1), Basel Ramlawi (2)
Institutions
(1) Lankenau Institute for Medical Research, Wynnewood, PA, (2) Lankenau Heart Institute, Wynnewood, PA
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Poster Presenter
Massimo Baudo, Lankenau Institute for Medical Research
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Wynnewood, PA
United States
A 64-year old gentleman underwent urgent replacement of aortic arch and proximal descending thoracic aorta for rapidly enlarging mycotic aneurysm of the aortic arch and proximal descending thoracic aorta.
The highly complex procedure involved extensive exposure to enable visualization of the entire aortic arch and descending aorta. The inflammatory process at the aortic arch made dissection and reconstruction extremely challenging.
This video will demonstrate and illustrate our team's approach and management of such a complex and challenging surgery.
Authors
Ali Alakhtar (1), Puja Kachroo (2)
Institutions
(1) N/A, United States, (2) Barnes Jewish Hospital, Saint Louis, MO
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Poster Presenter
Ali Alakhtar, Washington University in St Louis
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Pointe Claire, QC
Canada
Objective: Describe the characteristics and postoperative outcomes of patients with Marfan syndrome and aortic dissection in a referral hospital in Mexico.
Methods: retrospective study during the period from January 1, 2012 to March 31, 2022.
Results: We identified 74 patients with Marfan syndrome and similar pathologies who underwent surgery; 64 patients met more than two Ghent criteria for Marfan syndrome and 28 of them presented aortic dissection with a prevalence of 4.78%. Aneurysmal dilatation of the ascending aorta was present in 78% of patients with Marfan syndrome, aortic dissection in 44%(28). Acute aortic dissection was the most frequent type of dissection with 17%. The mean age at the time of dissection was 22 ± 3 years. The most frequently performed surgery was Bentall and de Bono in 22 of the patients. Complications occurred in 18 patients with aortic dissection. In-hospital death occurred in 11%.
Conclusions: The high mortality of aortic dissection demands for early diagnosis and comprehensive atention to assess the need for prophylactic intervention.
Working in new strategies for timely diagnosis, screening and decision-making pathways that lead to excellence in the care of patients with Marfan Syndrome is needed for the improvement of outcomes
Authors
Jesus Sanchez Pacheco (1), Benjamin Ivan Hernandez Mejia (2), Humberto Jorge Martinez Hernandez (2), María Elena Soto López (2)
Institutions
(1) N/A, N/A, (2) Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, NA
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Poster Presenter
Jesus Sanchez Pacheco, Instituto Nacional de Cardiologia Ignacio Chavez
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Ciudad de Mexico, Federal District
Mexico
Objective: To evaluate if concomitant CABG for coronary artery disease (CAD) during ascending aortic aneurysm (AsAA) repair is associated with worse early and mid-term outcomes compared to isolated AsAA repair.
Methods: A single-center, retrospective cohort study was performed with 69 patients out of 248 who underwent AsAA repair from February 2020 to December 2022. We analyzed clinical data and outcomes for a matched cohort of 35 patients who received a concomitant CABG for confirmed CAD (involving 1, 2, and 3 vessels in 17, 11, and 7 patients, respectively) and 34 who received isolated AsAA repair.
Results: Mean age was 64.8±7.7 years (59 male, 85.5%). Hypertension was seen in 53 patients (76.8%), bicuspid aortic valve in 29 (42%), dyslipidemia in 47 (68.1%), atrial fibrillation in 8 (11.6%), and chronic kidney injury in 7 (10.1%). AsAA involved the ascending aorta (AAo) in 25 patients (36.2%), root+AAo in 31 (44.9%), AAo+arch in 7 (10.1%), and root+AAo+arch in 4 (5.8%). Mean AsAA diameter was 47.1±4.9mm.
The two groups were similar at baseline except for lower triglyceride levels (109±47 vs 134±60 mg/dL, p=.053) and less antiplatelet use (35.3% vs 62.9%, p=.022) in isolated AsAA patients. Left internal mammary artery (LIMA) graft was used in 18 patients and saphenous vein graft in 30, while hypothermic circulatory arrest was used in 59 patients (85.5%). Although CABG significantly prolonged cardiopulmonary bypass (304 vs 259 m, p=.027) and cross-clamp times (230 vs 174 m, p=.003), no operative deaths occurred in either group (0 vs 0, p=1.000), nor did the two groups differ significantly in terms of intubation time, need for blood transfusion, IABP use, stroke, acute kidney injury, reexploration for bleeding, or length of ICU stay (Table 1).
There were 2 deaths and 3 reinterventions during follow-up, which was 100% complete at 2.3±0.9 years (range 0.3-4.1). In the CABG group, 1 patient died from sternal wound abscess at 4 months and another from COVID-19 pneumonia at 2 years. 3 patients in the isolated AsAA group underwent TEVAR for type B dissection at 3.3, 4.2, and 18.4 months. For the whole series, survival was 98.6% (95% confidence interval [CI], 91.2-99.8%) at 1 year and 96.4% (95% CI, 85.9-99.1%) at 3 years, and freedom from reintervention was 97.1% (95% CI, 88.9-99.3%) at 1 year and 93.6% (95% CI, 79.5-98.1%) at 3 years. Neither survival nor freedom from reintervention differed significantly between patients with and without CABG (93.1% vs 100%, p=.174; 94.3% vs 100%%, p=.101, respectively) (Figures 2 and 3).
Conclusion: In this series of patients with AsAA, a concomitant CABG for coexisting CAD was not associated with increased risks for operative mortality and morbidities and achieved mid-term survival and freedom from reoperation comparable to isolated AsAA repair. These results suggest that CABG can be safely performed during AsAA repair when necessary.
Authors
Shiv Verma (1), Wei-Guo Ma (1), Nupur Nagarkatti (2), Ely Erez (1), Adrian Acuna Higaki (2), Roland Assi (2), Prashanth Vallabhajosyula (1)
Institutions
(1) Yale New Haven Hospital, New Haven, CT, (2) Yale University School of Medicine, New Haven, CT
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Poster Presenter
Shiv Verma
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Aliso Viejo, CA
United States
Objective:
Patient prosthesis mismatch remains a significant problem following surgical aortic valve replacement in up to half the patients, affecting long-term valve durability and outcomes. The Y-incision root enlargement technique was recently proposed to enlarge the annulus by 3-4 valve sizes. We compare our early results using this technique with traditional root enlargement (Nicks or Manougian).
Methods:
From 2017-2023, we retrospectively reviewed our institutional cardiac surgery database, patient medical records, and internal surgical valve database to compare all patients undergoing root enlargement operations with or without other combined cardiac operations. Patients were categorized based on the operative techniques. Patient demographics, procedural characteristics, and operative outcomes were reported at 30 days and one year between the two groups. Multivariable Cox proportional hazards regression was used to investigate the association between one-year mortality and root enlargement techniques.
Results:
Among the 111 patients in our cohort, 60 underwent the traditional, and 51 underwent Y-incision root enlargement. The mean age was 64.7±11.8 years; 68% (76/111) were females, and (29/111) 26% had a prior surgical aortic valve replacement. Most operations (95%) employed a sternotomy, with 78% receiving a bioprosthetic valve and 22% a mechanical valve. Isolated AVR was performed in 69% (77/111) of the cohort. Patients undergoing Y-incision annuloplasty had a higher prevalence of endocarditis (18%(9/51) vs 2%(1/60), p<0.003), former sternotomy (33% (17/51) vs 23%(14/60)), and prior MI (16%(8/51) vs 5%(3/60)) compared to the traditional group. Compared to the traditional group, the increase in implanted valve size was significantly higher in the Y-incision group, 4.1mm compared to 2.6mm (p<0.001), an aortic cross-clamp time of 135 min versus 105 min (p:<0.001), and a cardiopulmonary bypass time of 182 min versus 130 minutes(p<0.001). Overall, 30-day post-operative complications were not statistically different between the two groups. The postoperative mean gradient across the aortic valve was 8.1mmHg in the traditional group and 10.1mmHg in the Y enlargement group (p=0.23). Similarly, the effective orifice area was 1.8cm2 in the Y-incision group compared to 1.6cm2 in the traditional group (p=0.05). Multivariable analysis, adjusting for age, gender, endocarditis, and prior MI, showed no significant difference in mortality hazards at 30 days (p:0.14) and one year (p:0.26) between the two procedures.
Conclusions:
Our experience with 51 patients undergoing Y root enlargement shows similar perioperative outcomes after adjusting for comorbidities compared to traditional root enlargement techniques. The Y enlargement cohort was associated with a longer operative time and a more significant increase in aortic valve size. Further investigations are warranted to validate these early results and assess long-term effects.
Authors
Fatima Qamar (1), Sahar Samimi (2), Marcel Gugala (2), Muskan Khan (2), Ahmed Ahmed (2), Taha Hatab (2), Rody Bou Chaaya (2), Neal Kleiman (2), Sachin Goel (3), Syed Zaid (4), Ross Reul (2), Mahesh Ramchandani (2), Michael Reardon (2), Marvin Atkins (2)
Institutions
(1) N/A, N/A, (2) Houston Methodist Hospital, Houston, TX, (3) Houston Methodist, N/A, (4) Houston Methodist Debakey Heart and Vascular Center, Houston, TX
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Poster Presenter
Fatima Qamar, Houston Methodist Hospital
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Houston, TX
United States
[Objective] For severe aortic valve regurgitation (AR), valve sparing root replacement, represented by David procedure, is performed in cases of severe root dilatation. However, there is no established surgical method for cases of mild to moderate dilatation. We performed Sleeve procedure and compared its efficacy with David procedure.
[Methods] We analyzed 55 cases of Sleeve procedure (S group) and 59 cases of David procedure (D group) performed at our hospital between 2012 and 2021. We considered the S group with mild to moderate root dilatation to potentially pose more challenges in cusp repair than the D group. The difficulty of the cusp repair technique was evaluated by scoring system as follows [non-prolapsed valve central plication (CP); 0.5 points, prolapsed cusp suspension with Neo-chord; 0.5 points, prolapsed valve or fusion cusp CP; 1 point, prolapsed reinforcement; 1 point, patch repair; 2 points, patch reconstruction around commissure; 3 points].
[Results] There were no significant differences in age at surgery (S group 62(46-71) years vs D group 59(42-69) years). The preoperative annular diameter (24.2(23.0-27.0) mm vs 24.0(22.0-27.0) mm, P=0.216) was equivalent, but Valsalva sinus diameter (38.0(35.0-41.5) mm vs48.5(43.0-54.0), P<.0001) and Sino tubular junction (STJ) diameter (31.0(27.0-34.0) mm vs 40.0(35.0-44.0) mm, P<.0001) were significantly larger in the D group. Although there was no statistically significant difference, the prevalence of AR beyond moderate to severe was higher in the S group than in the D group(44(80%) vs 38(66%), P=0.083). The percentage of cusp repair difficulty scores higher than 2.5 points were significantly higher in S group (30(54.6%) vs 11(18.6%), P<.0001). There were no in-hospital deaths in either group. The 6-year survival rate (100% vs 93%±5%), reoperation free rate (90±4% vs 95±4%), and more moderate to severe AR recurrence free rate (92%±4% vs 95%±4%) were equivalent between the two groups(S group(n=55), D group(n=59)). There were 7 cases of AR recurrence (5 in S group and 2 in D group), and in the S group, cases of recurrence had larger preoperative annular diameter (24.0(22.6-26.0) mm vs 31.0(27.0-35.8) mm).
[Conclusion] Sleeve procedure has been applied to cases with more complex valve repair, however its mid-term results are equivalent to David procedure and it is expected to be an excellent total root remodeling for severe AR with mild to moderate root dilatation.
Authors
Junichiro Eishi (1), Takashi Miura (2), Ichiro Matsumaru (3), Kikuko Obase (4), Kiyoyuki Eishi (5)
Institutions
(1) N/A, N/A, (2) N/A, Nagasaki, Japan, (3) Nagasaki University Hospital, Nagasaki, Japan, Nagasaki, Japan, (4) Nagasaki University Hospital, Nagasaki, N/A, (5) Hakujyuji Hospital, N/A
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Poster Presenter
Junichiro Eishi
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Fukuoka-shi
Japan
Background: Complications associated with treating aortic root aneurysm using the conventional Bentall technique necessitated the development of modified techniques to improve patient outcomes. This study aimed to describe a modified Bentall technique for aortic root replacement and report the middle- and long-term follow-up outcomes.
Methods: Eighty-eight patients (9 with Marfan syndrome), including 69 males (78.4%) and 19 females (21.6%), underwent aortic root replacement using the modified Bentall technique from 2011 to 2020 at our hospital. The patients' mean age was 43.4±11.7 years (range, 20–71 years). Data were collected on surgical time, aortic clamping time, cardiopulmonary bypass time, and computed tomography angiography before discharge.
Results: The patients' in-hospital mortality was 2.27%, with one case of multiple organ dysfunction syndrome and one of arrhythmia. The mean aortic cross-clamp time and cardiopulmonary bypass time were 120.9±27.1 mins and 159.2±37.9 mins, respectively. The follow-up rate was 94.2% (81/86) for 55±23 months (range, 6–120). Follow-up mortality occurred in three cases (3.7%), including one death due to a traffic accident, one death due to cerebral hemorrhage, and one sudden death of unknown reasons. No patients required aortic root re-operation during follow-up. The survival rate was 98.8%, 95.9%, and 95.9% after 48, 96, and 120 months, respectively.
Conclusions: Our modified Bentall technique can be performed easily and safely, with excellent middle- and long-term outcomes. Our technique can be an effective alternative method in aortic root aneurysm treatment.
Authors
kexiang liu (1), weitie wang (2)
Institutions
(1) N/A, Jilin, Jilin, (2) Department of Cardiovascular Surgery, The Second Hospital of Jilin University, Changchun, CA
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Poster Presenter
Kexiang Liu, Second Hospital of Jilin University
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Jilin, Jilin
China
Objective: The treatment of complex aortic arch pathologies demands the reconstruction (Endovascular or open) of one or multiple supra-aortic vessels to restore the blood flow of these vessels during thoracic endovascular aortic repair (TEVAR). However, the patency and fate of the endovascular bypass reminds unclear. This report aims to compare the midterm outcome of endovascular versus open bypass in TEVAR.
Methods: Between 2007 and 2015, 395 patients underwent TEVAR at our institution. Only TEVARs landing proximally at landing zones zero, one, and two were included (221/395). Endovascular bypass was selected only when a secure proximal landing zone of at least one centimeter existed. We recorded the type of bypass method that was used (Endovascular or open) and the number of supra-aortic vessels bypassed.
Results: The median follow-up was 4.1 years. Aortic dissection, thoracic aortic aneurysm, and traumatic aortic injury were the most common indication for TEVAR. Endovascular bypass was more commonly used in TEVAR landing proximally at zone 1. The thirty-day post-operative mortality was 11% (25 patients), but it was not different among both methods. Six patients (10.5%) in the endovascular group and 27 (16.5%) patients in the open bypass group needed reintervention. The late survival rate and adverse events were similar. Post-operative stroke happened in 15 (6.8%) of the patients. Bypass occlusion was the most common complications in both groups. Type Ia endoleak was more common after endovascular bypass (17 patients, 36.2%) but this was not statistically significant. Most of the type Ia endoleaks self-resolve within 3 months after TEVAR.
Conclusion: In our report, endovascular bypass of the supra-aortic vessels was not inferior to the open approach and had a good patency rate at mid follow-up with a low rate of complications after surgery. With appropriate patient selection, endovascular bypass can achieve acceptable outcomes.
Authors
Iván Alejandro De León Ayala (1), Kuo-Sheng Liu (1)
Institutions
(1) Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
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Poster Presenter
Iván De León Ayala
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Taiwan
Objective
The purpose of this study was to describe mid-term surgical outcomes in patients with thoraco-abdominal aortic aneurysms or dissections after complex endovascular procedures. Connective tissue disorders (CTDs) represent a unique group of patients with special features and medical problems. We conducted a retrospective review of our experience with complex endovascular aortic repair of thoracoabdominal aortic aneurysms (TAAAs) and dissections in patients with CTDs to evaluate complications and midterm outcomes.
Methods
Data were analysed by univariate methods, including contingency tables and logistic regression. Complications analysed included cardiovascular, stroke, renal, respiratory, gastrointestinal, and 30-day mortality.
Results
We conducted a review of 12 patients who underwent endovascular repair for confirmed connective tissue disorders (CTDs) and thoracoabdominal aortic aneurysms or dissections between 2018 and 2023. 10 patients were treated with Fenestrated-branched endovascular repair (FB-EVAR), and 2 with physician modified endovascular graft (PMEG). The median age was 72 years (IQR 63-81), with 5 females (42%) among them. Among these patients, six had previously been diagnosed with Marfan syndrome (50%), four had confirmed Loeys-Dietz syndrome (LDS) (33.3%), one (8.3%) had Ehlers-Danlos Syndrome (EDS), and one patient was diagnosed with an ACTA 2 mutation (8.3%).
Additionally, 11 patients (92%) had previously undergone open aortic surgery before the complex endovascular repair, and 9 patients (75%) had previously undergone some endovascular aortic procedures. Nine (75%) were treated for aortic dissections, and eleven (92%) for aortic aneurysmal disease. Four patients (33%) required re-intervention, and four patients (33%) had endoleaks, with 2 requiring intervention.
Conclusions
This study found that patients with CTDs undergoing complex FB-EVAR in complex aortic repairs had a low perioperative mortality rate, and elevated rate of early technical success. Mid-term survival may be similar to those previous publications of CTD patients following thoracoabdominal open repairs.
Authors
Lucas Ribe (1), Yuki Ikeno (1), Safa Savadi (2), Rana Afifi (3), Akiko Tanaka (4), Lucas Ruiter (5), Gustavo Oderich (1)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX, (2) McGovern Medical School UTHealth, HOUSTON, TX, (3) Memorial Hermann, Houston, TX, (4) Memorial Hermann Heart and Vascular Institute, Houston, TX, (5) McGovern Medical School UTHealth, Houston, TX
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Poster Presenter
Lucas Ribe, McGovern Medical School at UTHealth
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Houston, TX
United States
Objective
There has been growing interest in performing aortic surgery through a mini-sternotomy approach. There is limited evidence base, and studies are needed to establish its safety. The objective of this study was to assess our institutional outcomes for aortic surgery through a mini approach.
Methods
Institutional Database was used to retrospectively obtain characteristics for patients undergoing elective proximal aortic surgery (excluding redo's/chronic dissections) between 2015-2021. Multivariable logistic regression and propensity score adjustment was used to explore the influence of relevant variables on outcome.
Results
547 patients were included, of which 74 (13.5%) had a mini sternotomy. The mean age of the cohort was 61.6 (±14.5) years, and 121 (22.1%) were female. The mini group had significantly more females (32.4%, n=24 vs. 20.5%, n=97), BAV's (45.9%, n=34 vs. 30.6%, n=145), and a lower proportion with PVD (25.7%, n=19 vs 46.3%, n=219).
In terms of operative characteristics (mini vs. conventional), a total of 73 (13.3%, n=29 vs. 44) underwent ascending aorta (AA) replacement, 17 (3.1%, n=4 vs 13) underwent AV repair and AA, 198 (36.2%, n=35 vs. 163) underwent AV and AA replacement, 175 (32%, n=1 vs. 174) underwent root replacement, and 84 (15.4%, n=5 vs. 79) underwent VSRR. 307 patients (56.1%, n=70 vs. 237) required a arch procedure. The sternotomy group underwent significantly more root and VSRR (53.4% vs. 8.1%), and the mini group underwent significantly more arch procedures (94.6% vs. 50.1%).
Unadjusted outcomes were comparable between the mini and conventional group: 30-day mortality (2.8% vs. 1.3%), DSWI (2.8% vs. 1.1%), sepsis (4.1% vs. 2.1%), CVA (2.8% vs. 2.1%), ARF (2.8% vs. 1.7%), post-op length of stay (8.8 ± 5.9 vs. 7.9 ± 5.1 days), and ventilation time (40.3 ± 103.7 vs 27.2 ± 85.0 hours). However, re-op for bleeding (6.8% vs. 0.8%, p<0.001) and products transfused (9.6 ± 7.1 vs. 6.4 ± 7.4 units, p<0.001) were significantly higher in the mini group. On multivariable logistic regression and propensity score adjustment, the mini approach was not predictive of a composite outcome of death, CVA, ARF, or re-op for bleeding.
Conclusions
The mini approach is safe for performing aortic surgery in selected patients. It was associated with a higher rate of re-op for bleeding, which may be due to higher proportion of arch procedures. Further series are required to help establish outcomes for this procedure.
Authors
Omar Jarral (1), Stevan Pupovac (2), Kenenna Onyebeke (3), Adam Kiridly (2), Chad Kliger (1), Kush Dholakia (1), Nirav Patel (1), S.Jacob Scheinerman (1), Alan Hartman (2), Derek Brinster (4)
Institutions
(1) Lenox Hill Hospital, Northwell Cardiovascular Institute, New York, NY, (2) Northshore University Hospital, Northwell Cardiovascular Institute, New York, NY, (3) Zucker School of Medicine at Hofstra/Northwell, New York, NY, (4) Northwell Health, Lenox Hill Hospital, New York, NY
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Poster Presenter
Omar Jarral, Lenox Hill Hospital
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New York, NY
United States
Objectives: Valve-sparing aortic root replacement (VSARR) offers many advantages over complete root replacement by avoiding the systemic anticoagulation and the prosthetic-valve related complications. Root reimplantation, mostly widely accepted prototype procedure in VSARR, however, may entail some technical difficulties when the second-layer hemostatic stitches are made by conventional over-and-over continuous sutures within the woven-polyester graft especially for the beginning-level surgeons. We would like to show "Half Back Stitch" technique for the hemostatic suture line during the root reimplantation for VSARR.
Case Video Summary: The cardiac arrest is induced with cardioplegic solution infusion after an aortic clamp placement. The aorta wall is resected leaving its margin of around 3mm, coronary buttons are trimmed, and the root is completely mobilized. Graft diameter is determined, usually 28mm to 32mm, based on the length of free-edge of the cusp, in which the diameter should be shorter than the free-edge length so that the cusps can make coaptation point at the center of the graft. Non-pledgeted 6 sub-annular stitches with 2-0 braided polyester are placed using horizontal mattress sutures, which are then fixed at the bottom of graft. Standard manner, thereafter, is to make hemostatic layer stitches to reattach the native aortic valve (AV) annulus inside the tubular graft using continuous over-and-over sutures referred as "whip stitch technique" in the classic root reimplantation (Figure 1A). We, however, have adopted modified version of this attachment sutures-"half back stitch" (Figure 1B). At first, the inside-out suture is performed at the nadir of AV annulus, and it is tied down outside of the graft. The next suture proceeds outside-in manner 3mm proximal to the first suture. Then, the return suture goes inside-out way 10mm distal to the prior suture. After repeating this "half back stitch", the thread is tie down outside of the graft at the commissure level. By repeating the three sets of this continuous suture for each of the sinus, hemostatic layer is completed (Figure 2). When the leaflet prolapses, the central plication suture is added to elevate the coaptation of the corresponding leaflet. Thereafter, the coronary buttons are reattached to the graft. Finally, the distal part of the graft is anastomosed to the native aorta or another artificial graft depending on the extent of distal repair.
Conclusions: "Half back stitch" involves a straightforward penetration of each stitch as the suture line only exist in the overlapping area of native aortic rim and graft. It may offer more stable hemostasis as it makes reinforced layers of suture lines. By the addition of small backward stitch on each large forward stitch, it may also prevent purse-string effects of the suture lines. We believe that these advantages may shorten the cardiac ischemic time and may help construct the hemostatic suture lines. In summary, the "half back stitch" technique is technically easy and may be helpful for the timesaving and better hemostasis during the VSARR.
Authors
MInJung Ku (1), Joon Bum Kim (2), Wan Kee Kim (3), Hong Rae Kim (4)
Institutions
(1) N/A, N/A, (2) Asan Medical Center, Seoul, Na, (3) Yongin Severance Hospital, Yongin, Gyeonggi-do, (4) Asan Medical Center, Gangnamgu, Seoul
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Poster Presenter
MIN JUNG KU, Asan Medical Center
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Seoul
South Korea
Objective
Neurologic injury due to ischemia-reperfusion injury (IRI) is a severe outcome of aortic arch surgery, with no pharmacologic treatment available. Mitochondria (MT) play a key role IRI, with initial oxygen-glucose deprivation depleting adenosine triphosphate, and subsequent production of reactive oxygen and nitrogen species leading to cell death. MT transplantation (MTR) has shown promise in other tissue models. We sought to develop an in vitro model of MTR for neuronal cells with the goal of application to aortic surgery.
Methods
MT were harvested from male mice at four different tissue sites and homogenized. MT were isolated and resuspended in PBS. MT concentration was detected via BCA and adjusted to three concentrations (1mg/ml, 0.01mg/ml, and 0.0002mg/ml) and stained.
Ischemia-Reperfusion Model
HT-22, a mouse hippocampal cell line, was cultured in 96 well plates. Cells were pre-cultured for 24 hours prior to ischemia. Ischemia was simulated via an oxygen-glucose deprived (OGD) cell medium and placement into a hypoxia chamber for 18 hours resulting in 30-50% remaining cell viability. Control cells were placed in new culture medium and returned to the incubator. Following OGD exposure, cells were placed in new culture medium and returned to the incubator for a period of 24 hours. At 24 hours, cell viability was assessed via MTS assay.
Transplantation
MTR was performed at two time points: during the pre-culture phase and during reperfusion simultaneous to addition of culture medium. The above three concentrations of MT were added at ratios of 1:5, 1:20 or 1:100 (cells:MT).
Results
BCA demonstrated excellent MT yield from all tissues, with the highest yield from brain and liver tissues. Co-culture with stained neuronal cells demonstrated excellent exogenous MT incorporation.
Incorporation into IRI model
For both control and OGD cells MTR during the reperfusion phase resulted in a significant dose-dependent increase in both control and OGD cell death. MTR performed during the pre-culture phase increased OGD cell viability for the 1mg/ml concentration at 1:100, and for the 0.01mg/ml for all ratios depending on tissue selected. MTR performed at the higher concentrations resulted in an increase in cell death for both groups of cells.
Conclusion
MTR is feasible in a neuronal cell model. In an IRI model, MTR prior to ischemia can preserve cell viability at optimal concentrations. MTR performed during reperfusion results in a dose-dependent increase in cell death.
Authors
Adam Carroll (1), Linling Cheng (1), William Riley Keeler (1), Bo Chang Wu (1), Anastacia Garcia (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective
While the Bentall operation is regarded as the standard therapy for aortic root surgery, it poses challenges in cases of vulnerable aortic tissue, such as infective endocarditis, Behcet's disease, or acute aortic dissection. These conditions are associated with an increased risk of prosthesis detachment, leading to significant morbidity and mortality. In this study, we present a modified Bio-Bentall technique using a rapid deployment valve (RDV).
Case video summary
After establishing cardiopulmonary support and aortic cross-clamping, the aortic roots were resected to the level of the aortic valve annulus, and coronary buttons were mobilized. A 30-mm Valsalva graft was folded and inserted into the left ventricular outflow tract, followed by a double-layer continuous suture. The graft was withdrawn, and valve size was decided. After successfully anastomosing the left coronary artery, the RDV was introduced, guided by the suture, and carefully deployed to ensure the expandable frame was positioned below the proximal end of the graft.
Surgery was performed in 13 patients (median age 69 years, IQR 67-75) by a single surgeon between January 2018 and December 2022. The median cardiopulmonary bypass time and aortic cross-clamping time was 99.0 minutes (IQR 81-120), and 73.0 minutes (IQR 60-90), respectively. Among these, 5 (38.5%) required emergent or urgent operations. There were no early mortality. Over a 10-month period of echocardiographic follow-up (IQR 6-13), no prosthetic aortic valve insufficiency was observed.
Conclusions
Our initial experiences with the modified Bio-Bentall operation using a RDV have demonstrated positive early outcomes in high-risk candidates. However, these results should be further validated with larger datasets and long-term follow-up data.
Authors
Hyo Kyen Park (1), Hong Rae Kim (2), Byeong A Yoo (3), Joon Bum Kim (4)
Institutions
(1) Asan Medical Center, Seoul, (2) Asan Medical Center, Gangnamgu, Seoul, (3) Asan medical center, Seoul, Korea, Republic of, (4) Asan Medical Center, Seoul, Na
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Poster Presenter
Hyo Kyen Park, Asan Medical Center
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South Korea
Objective: Symptomatic multivessel arch branch ostial stenosis (MVABS) is a rare condition. Operative technique remains controversial and few reports assess long-term outcome. We propose a strategy incorporating the use of aorto-axillary extra-anatomical bypass (AAEAB) grafts in the management of patients with symptomatic MVABS. Early and late outcomes are reported.
Methods: Since 2015, 8 consecutive patients with symptomatic (>2) MVABS were referred for operative treatment. All operations were conducted without cardiopulmonary bypass. A multi-branch dacron graft with a 12 or 14mm main branch anastomosed to the ascending aorta was initially constructed. The AAEAB (es) was (were) initially performed to increase cerebral perfusion through the posterior circulation. Subsequently, the most severe carotid artery was revascularized in an end to end fashion followed by revascularization of the other arch branch vessels. Patients were followed prospectively in a dedicated aortic clinic
Results: Mean age was 63,6±3,4yrs; 87,5% female. A mean of 3,1±0,8 bypasses/pt were performed; with right and left AAEAB in respectively 6 and 7 patients. No stroke or hospital death were encountered. One patient required a tracheostomy for 4 days owing to partial bilateral recurrent nerve palsy. At a mean of 3,6±3,2yrs, two patients died of non-vascular causes (80% 5-yr survival). Patients remained free of recurrent symptoms. Among 27 grafts, one carotid graft showed a stenosis requiring stenting 3 years postoperatively (85,7% 5-yr bypass patency; 100% patency of AAEAB grafts)
Conclusion: Operative treatment of symptomatic multivessel arch branch ostial offers excellent symptom relief. Use of AAEAB bypass is safe, enhances cerebral perfusion through the posterior circulation before revascularizing the carotid arteries. Mid-term outcome shows excellent clinical outcome with excellent graft patency.
Authors
Francois Dagenais (1), Rim Abdelli (2), Roxanne St-Louis (3), Eric Dumont (4)
Institutions
(1) Quebec Heart and Lung Insitute, Quebec, Quebec, (2) Quebec Heart and Lung Institute, Quebec, Qc, (3) Quebec Heart and Lung Institute, Quebec City, QC, (4) Quebec Heart and Lung Institute, Quebec, QC
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Poster Presenter
*Francois Dagenais, Quebec Heart & Lung University Institut, Division of Cardiac Surgery
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Quebec, QC
Canada
Objective: Thoracic aortic aneurysms (TAAs) are associated with an increased risk of aortic rupture or dissection. However, the optimal timing for preemptive surgical intervention remains uncertain. Current societal guidelines rely on maximum aneurysm diameter to determine when to intervene, but this one-size-fits-all approach has limitations. Modern artificial intelligence (AI) enabled models have significant potential for characterizing disease patterns, but they require large datasets to achieve clinically useful performance. TAAs and their related complications are relatively uncommon within the general population, making it difficult for any single institution to achieve sufficient cohort size alone. Multi-institutional studies are traditionally time consuming, logistically challenging, and expensive to implement to ensure patient data security. Federated learning is an approach that allows for the training of a single AI prognostic model across multiple institutions without the need for sharing of protected patient data between the centers. We present a framework for a multi-institutional study to train an AI model capable of predicting a TAA patient-specific risk of aortic complication from computed tomography (CT) scans taken at multiple timepoints.
Methods: The data pre-processing can be distilled into the following steps: (1) patient cohort creation, (2) inclusion filtering, (3) study acquisition, (4) image series selection, (5) image resizing, and (6) aorta segmentation. The data pre-processing must be robust enough to remain highly accurate across many different CT acquisition protocols. These pre-processing steps are automated and can be run locally at each institution. The AI model can then be trained from the processed CT scans on a primary outcome of aortic annualized growth rate. Federated learning will be utilized in order to keep all patient sensitive data at each institution, decreasing costs and improving data security. Open-source segmentation models are utilized and all code is written in Python (Version 3.1).
Results: We performed retrospective review of our tertiary academic center patient population to identify patients with TAA via billing documentation. We next developed natural language processing (NLP) methods of identifying patients that have no history of prior aortic intervention and would be eligible for the study. Cross sectional imaging for eligible patients when available were collected in an automated fashion, and open-source algorithms were utilized for series selection, image pre-processing, and aortic segmentation. Aortic size was calculated from the raw images and cross referenced to the radiologist reported measurements. Data integrity and quality checks were incorporated throughout the process. The final dataset was found to be in the appropriate format and data structure to undergo subsequent AI model development.
Conclusions: This proof-of-concept study demonstrates the feasibility of the proposed study design to create a patient specific TAA prognostic AI model. The end result is an automated, repeatable and scalable process for the creation of an institution's TAA imaging dataset that is ready for collaborative multi-institutional AI model development via federated learning.
Authors
Brian Ayers (1), Aaron Aguirre (1), Michael Lu (1), Thoralf Sundt (1)
Institutions
(1) Massachusetts General Hospital, Boston, MA
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Poster Presenter
Brian Ayers, Massachusetts General Hospital
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Boston, MA
United States
Objective:
Genetic factors can play a significant role in the development of thoracic aortic disease (TAD). Around 20% of individuals with a TAD have a first-degree relative with aortic dilatation. One example is the TGFB2 gene, which is associated with Loeys-Dietz syndrome (LDS). Since the clinical presentation of these types of diseases can vary between patients, a multidisciplinary care team is important for proper management of the patient.
Methods:
The multidisciplinary approach is designed for complex aortic disease patients and developing a patient care plan from the expertise of a panel of specialists. In this report, we highlight the unique management of four individuals with distinct presentations of LDS in the context of aortic disease.
Results:
A 33-year-old female physician is evaluated after presenting to the emergent department (ED) with crushing substernal chest pain, visual changes, and lower extremity weakness. She was diagnosed with an acute Type A aortic dissection involving the root and proximal ascending aorta. Emergent valve-sparing root and ascending replacement (David procedure) was performed. At 18 weeks after surgery, a repeat computed tomography angiogram (CTA) demonstrated progressive dilation of the proximal descending thoracic aorta to 4.2 cm. Genetic tests identified a pathogenic variant in TGFB2 (p.Y126Sfs*19) that is consistent with LDS.
A 33-year-old man presented to the ED with chest tightness, neck pain, and moderate exertional dyspnea. CTA disclosed an acute Type A aortic dissection involving the root and proximal ascending aorta. He underwent emergent aortic mechanical valve replacement with a composite graft (modified Bentall procedure) and replacement of the ascending aorta and hemiarch. Within 3 years, the diameter of the brachiocephalic artery (2.9 cm), aortic arch (4.2 cm), and proximal descending thoracic aorta (5.4 cm) had significantly increased. Genetic tests identified a pathogenic variant in TGFB2 (p.R330C) that is consistent with LDS.
A 30-year-old female initially presented to the ED with chest pain and exertional dyspnea. CTA disclosed an acute Type A aortic dissection involving the aortic root, right coronary artery, and proximal ascending aorta, with her aortic root measuring 5.0 cm. She underwent aortic valve, root, and ascending replacement with a porcine bioprosthetic valve. Genetic testing revealed a pathogenic variant in TGFB2 (p.C380F), consistent with the diagnosis of LDS.
A 43-year-old female presented to the ED with dyspnea and chest pain. CTA revealed a Type A aortic dissection involving the aortic root, ascending aorta, transverse arch, extending to the descending thoracic aorta (DTA) and infrarenal aorta. Echocardiogram identified a moderately dilated aortic root aneurysm (4.6 cm) with severe aortic regurgitation. She underwent urgent modified Bentall repair with a mechanical aortic prosthesis. This patient is the sister of the patient described as the third case and carries the same pathogenic variant of TGFB2 (p.C380F). She is currently under close surveillance with annual imaging.
Conclusions:
These cases illustrate the various clinical manifestations of LDS and the high risk of developing subsequent arterial disease after the index event. LDS patients require lifelong management and follow-up to prevent deaths due to recurrent aortic events.
Authors
Lucas Ribe (1), Yuki Ikeno (1), Milan Jaiswal (2), Rana Afifi (3), Akiko Tanaka (4), Anthony Estrera (4), Siddharth Prakash (5)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX, (2) Memorial Hermann Hospital. UTHealth., Houston, TX, (3) Memorial Hermann, Houston, TX, (4) Memorial Hermann Heart and Vascular Institute, Houston, TX, (5) N/A, Houston, TX
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Poster Presenter
Lucas Ribe, McGovern Medical School at UTHealth
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Houston, TX
United States
Objective:
We report a case of open descending thoracic aortic aneurysm (DTAA) repair with muscle sparing left thoracotomy.
Methods:
A 47- year- old female with a past medical history of Raynaud syndrome, hypertension, smoking, and hyperlipidemia was referred to our institution for DTAA. The aneurysm was associated with severe aortic stenosis due to intraluminal calcific lesions. Because of the large calcified mass, the DTAA was not suitable for TEVAR. Thus, the decision was made to proceed with open aortic repair.
Results:
The patient underwent open repair and resection of the DTAA. The technique performed involves the following steps. A seven-inch-long incision was made from the inferior scapula border to anterior axillary line. The subcutaneous flaps were created and the auscultation triangle was identified. The latissimus dorsi and trapezius muscles were dissected and mobilized for retraction. The posterior border of the serratus anterior muscle was mobilized anteriorly. Following one-lung ventilation, the chest was entered through the sixth intercostal space. The proximal aortic clamp site was dissected distal to the subclavian artery. The diaphragm was retracted caudally using traction sutures around the aortic hilum to expose the distal clamp site. The left heart bypass was established using left inferior pulmonary vein drainage and left femoral artery return after systemic heparinization. The proximal aorta was clamped using a regular atraumatic clamp. The distal aorta was clamped using a flexible aortic clamp, which was inserted through a ninth intercostal space. DTAA repair was then performed in usual fashion after resecting the calcified mass en bloc with the aortic wall.
After surgery, the patient required pain management with acetaminophen and cyclobenzaprine. She was discharged home on the 9th postoperative day. CT scan after surgery showed no abnormalities. There was no chronic thoracic pain or infection during follow-up. Pathology demonstrated severe intimal atherosclerotic lesion with nodular calcification, and marked medial thinning with elastin fiber damage and loss by elastin stain.
Conclusions:
Muscle-sparing thoracotomy is a feasible option for open DTAA repair.
Authors
Lucas Ribe (1), Yuki Ikeno (1), Alexander Mills (2), Akiko Tanaka (3), Rana Afifi (4), Anthony Estrera (3)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX, (2) University of Texas Health Science Center at Houston (UTHealth Houston), N/A, (3) Memorial Hermann Heart and Vascular Institute, Houston, TX, (4) Memorial Hermann, Houston, TX
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Poster Presenter
Lucas Ribe, McGovern Medical School at UTHealth
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Houston, TX
United States
Objective: Aortic arch surgery using the frozen elephant trunk (FET) procedures is still a complex procedure and is associated with increased early mortality, especially when used in acute aortic dissections (AAD). Outcome after surgery may be dependent on the experience of the medical staff participating intra- as well as perioperatively. Thus, we aimed to evaluate the influence of nighttime and weekend surgery, where medical staff may not be the core aortic team.
Methods: Between 01/2010 and 11/2022, 222 consecutive patients underwent FET surgery at our center. Of these 76 underwent FET for AAD and were thus included in this analysis. We used a multivariable regression analysis to test whether surgery during normal working hours (group 1) vs nighttime and/or weekend (group 2) was associated with better 30-day survival rates.
Results: Mean age was 59.515.5 years (n=20 >70 years) with 73.7% (n=56/76) male patients. EuroSCORE II was 21.0±15.9. Nighttime and/or weekend surgery (group 2) was performed in 42.1% (n=32/76).
In group 1 vs group 2, 20.5% (n=9/44) vs 15.6% (n=5/32) suffered from heritable thoracic aortic disease (HTAD), respectively. Prior cardiac surgery had been performed in 9.1% (n=4/44) vs 0% (n=0/32). Surgery on the aortic root was necessary in 18.2% (n=8/44) vs 25.0% (n=8/32) and concomitant coronary artery bypass grafting (CABG) was necessary in 18.2% (n=8/44) vs 6.3% (n=2/32) of patients. Aortic cross clamp and selective antegrade cerebral perfusion times were 144±59 vs 151±60 and 81±32 vs 82±34 minutes, respectively.
30-day mortality was 15.9% (n=7/44) vs 31.3% (n=10/32) in group 1 vs group 2. In multivariable regression analysis, including 9 covariables (nighttime and /or weekend surgery, prior cardiac/aortic surgery, hereditable thoracic aortic disease, age >70y, surgery on the aortic root, distal landing zone 2 vs. 3, concomitant CABG, cerebral perfusion time >75 minutes and aortic cross clamp >140 minutes) surgery during nighttime and/or weekend was found to be an independent risk factor for 30-day mortality (OR 4.1; CI 1.1–15.8; p=0.037).
Conclusions: In our patient cohort FET surgery for AAD during nighttime and/or weekend was independently associated with an elevated 30-day mortality. Since the core aortic team, consisting of specialized surgeons, anaesthesiologists and ICU personnel are usually not present during these hours we suggest either reducing the complexity of the surgical procedure, or having a dedicated FET-team on call at all hours.
Authors
Lennart Bax (1), Till Demal (2), Jens Brickwedel (1), Hermann Reichenspurner (1), Christian Detter (3)
Institutions
(1) University Heart & Vascular Center Hamburg, Hamburg, Hamburg, (2) University Heart & Vascular Center Hamburg, Hamburg, Germany, (3) University Heart and Vascular Center Hamburg, Hamburg, Hamburg
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Poster Presenter
Lennart Bax, University Heart & Vascular Center Hamburg
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Hamburg, Hamburg
Germany
Objective: Acute type A aortic dissection remains a surgical challenge due to its inherited high risk for morbidity and mortality. Deep to moderate hypothermia is a standard for aortic surgery, such as aortic type A dissection. The current trend in aortic surgery is to avoid deep hypothermia due to possible deleterious effects. Early studies have shown the feasibility and safety of moderate to normothermic aortic surgery. Our institution has adopted normothermic surgery in type A aortic dissections. In this retrospective propensity score-matched analysis, we aim to set a new standard of care for patients undergoing surgery for acute type A aortic dissection.
Methods: A retrospective database analysis was performed for patients undergoing surgery for acute type A aortic dissections from January 2007 to January 2023 at a single center. Patients undergoing surgery in normothermia (> 35 °C) were matched with patients undergoing surgery in mild hypothermia (28 - 34 °C). Out of 218 patients, 20 propensity score-matched pairs were created. All patients were operated on using selective antegrade cerebral perfusion. Retrospective statistical analysis was performed regarding 30-day mortality, new neurological symptoms, and benefits in the intra and postoperative course (e.g., bypass time, need for transfusions).
Results: Our data shows very strong evidence favoring normothermia for lower extracorporeal bypass and cross-clamping times. Moreover, the normothermic group had a limited trend towards lower ICU stay (p = 0,59), intubation times (p = 0.4 ), and postoperative delirium (p = 0.1797). There was no evidence favoring hypothermia in terms of new neurological symptoms (n= 4 vs 6 in both groups; p =0.8), 30-day mortality (n = 3 vs. 1 patients, p = 0.6), blood transfusion (Erythrocytes and Thrombocytes) and Cell-Saver blood. A detailed breakdown of our results can be found on Table 1.
Conclusions: Normothermic surgery in acute type A aortic dissection reduces operation times, extracorporeal perfusion, and aortic cross-clamping that might be beneficial for the patients. Moreover, normothermic surgery is comparable to the current hypothermic standard in aortic dissection surgery, and does not affect early mortality.
Authors
Laura Rings (1), Rasha Boulos (2), Vasileios Ntinopoulos (1), Achim Haeussler (2), Petar Risteski (2), Hector Rodriguez Cetina Biefer (2), Omer Dzemali (2)
Institutions
(1) Department of Cardiac Surgery, City Hospital of Zurich – Site Triemli, Zurich, Switzerland, (2) Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
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Poster Presenter
Laura Rings, University Hospital Zurich
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Zurich, NA
Switzerland
Objective: To demonstrates that the implementation of our normothermic artery bypass and visceral-anastomosis-first strategy in the repair of thoracoabdominal aortic aneurysm represents a safe and reproducible treatment approach, which offers improved protection for visceral organs and the spinal cord, reduced reliance on blood products, and favorable clinical outcomes in terms of mortality, complications such as paraplegia and continuous renal replacement therapy (CRRT), as well as lower lactate levels.
Methods: From July 2019 to February 2022, a total of 26 patients with thoracoabdominal aortic aneurysm (18 males and 8 females) underwent the normothermic artery bypass and visceral-anastomosis-first strategy for TAAA repair at our institution. The surgical procedure involved a combined left thoracoabdominal incision. Initially, access to the artificial vessel was established through one of the four branches, providing entry into the proximal aorta. Subsequently, anastomoses were sequentially performed for the abdominal trunk, superior mesenteric artery, renal artery, and intercostal artery. Finally, the proximal and distal anastomoses were completed to ensure effective blood supply to the distal branches. This approach was designed to optimize normothermic iliac perfusion, with the primary objective of safeguarding the viscera and spinal cord, while minimizing blood damage and coagulation disorders.
Results: The mean age of the patients was 38.9±12.8 years (range,15.0-58.0 years), with 18 patients(69.2%)being female. The most common presentation was Crawford type II aneurysms, observed in 46.2% of patients. The procedure was successfully performed in all 26 patients. The mean operative time was 551.4±106.2 minutes. Typically, patients' lactate levels returned to normal within approximately 48 hours postoperatively. Prior to discharge, average creatinine levels were within the normal range. Only one patient required re-exploration due to bleeding; otherwise, there were no cases of postoperative paraplegia. The patients were discharged from the hospital with a median length of stay of 17.0 days. The mean follow-up time was 23.5±9.3 months, with a follow-up rate of 100%. No late deaths occurred, and none of the patients required further surgery for aortic valve or other aortic diseases.
Conclusions: Open surgical repair of thoracoabdominal aortic aneurysm remains a crucial therapeutic approach and continues to be challenging. The available data indicate that our normothermic artery bypass and visceral-anastomosis-first strategy represents a secure and replicable method, particularly when executed at an experienced center, can produce remarkable outcomes.
Authors
Shuai Zhang (1), Jing Sun (2)
Institutions
(1) Department of Cardiovascular Surgery, Fuwai Hospital, CAMS&PUMC, Beijing, Beijing, (2) Department of Cardiovascular Surgery, Fuwai Hospital, Beijing, Beijing
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Poster Presenter
Shuai Zhang, Fuwai Hospital, CAMS & PUMC
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Beijing, Beijing
China
Objective: Aortic arch operations involve long cardiopulmonary bypass runs with at least moderate hypothermia contributing to time-dependent myocardial ischemia if the heart is arrested. Normothermic myocardial perfusion reduces this myocardial ischemic period. The aim of this study was to compare the short-term outcomes of normothermic myocardial perfusion versus cardioplegia cardiac arrest in aortic arch reconstruction employing a hybrid frozen elephant trunk stent-graft.
Methods: Between July 2022 and October 2023, 28 consecutive patients (mean age: 61.5 +/- 9.8, 62% men) underwent hybrid frozen elephant trunk stent-graft implantation for arch surgery at a single center. In 15 patients, Del Nido cardioplegia was used to arrest the heart while in 13 patients the heart was continuously perfused with normothermic blood. In the latter patients, the cardioplegia circuit was used to deliver 36°C blood, without additives, at 250-450 ml/min into the ascending aorta which was clamped distally without aortic root pressure monitoring. The flow rate was adjusted to maintain a stable electrocardiogram with a narrow QRS. Antegrade cerebral perfusion and moderate hypothermia (23°C) were employed in all cases. The primary outcome was stroke, spinal cord ischemia, and changes in left ventricular ejection fraction. The secondary outcomes were cardiopulmonary bypass (CPB) and cross clamp time, total operative time, length of stay (LOS), and new dialysis requirements. Median follow-up was 140.5 days.
Results: The cardioplegia cardiac arrest cohort (n=15) were slightly older than the normothermic myocardial perfusion cohort (n=13) (63 +/- 11 vs 59 +/- 7.4) with no difference in sex (67% vs. 69%) and 47% of patients with previous sternotomy. Surgical indications included chronic dissection (13, 46.4%), acute dissection (8, 28.6%), aneurysm (4, 14.3%), and rupture (3, 10.7%). There were three (20%) strokes in the cardioplegia cardiac arrest cohort. There was one (7%) stroke (acute on chronic) and one (7%) spinal cord ischemic injury (temporary) in the normothermic myocardial perfusion cohort. There were no in-hospital or 30-day deaths in either group. Cross clamp times were shorter with normothermic myocardial perfusion (median minutes [IQR]: 150 [98-190] vs 48 [48-72.5]; p-value < 0.05). There was no significant different between pre-CPB and post-CPB left ventricular function in the cardioplegia cardiac arrest cohort (p=0.42) and the normothermic myocardial perfusion cohort (p=0.82) (Figure 1). There was no statistically significant difference in CPB time (median minutes [IQR]: 229 [211-272] vs 217 [201.5-240.5]; p=0.23) or total operative time (median minutes [IQR]: 495 [456-531] vs 463 [413.5-504]; p=0.17). There were no significant differences in hospital length of stay (median days [IQR]: 10 [8-14] vs 11 [8-23.5]; p=0.37) or ICU length of stay (median days [IQR]: 6 [5-7.5] vs 6 [4-10]; p-value 0.65). There were 3 (20%) new dialysis patients in the cardioplegia cardiac arrest cohort and no new dialysis requirements in the normothermic myocardial perfusion cohort (20% vs 7%).
Conclusion: Aortic arch repair with a hybrid frozen elephant trunk stent-graft using normothermic myocardial perfusion reduces cross-clamp times and provides equivalent myocardial protection while maintaining neurological outcomes compared to cardioplegic cardiac arrest.
Authors
Shruthi Nammalwar (1), Pedro Catarino (2), Dominick Megna (1), Michael Bowdish (3), Joanna Chikwe (4), Aziz Ghaly (5), Derrick Tam (6)
Institutions
(1) N/A, Los Angeles, CA, (2) Cedars-Sinai, Los Angeles, CA, (3) Cedars-Sinai Medical Center, La Canada, CA, (4) Cedars-Sinai Medical Center, Beverly Hills, CA, (5) N/A, New York, NY, (6) Cedars-Sinai Medical Center, Los Angeles, CA
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Poster Presenter
Shruthi Nammalwar
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Los Angeles, CA
United States
Objectives: The primary goal of this case series is to report two cases of aortic dissection during pregnancy, its sign of malperfusion during pregnancy and its outcomes after surgical treatment.
Methods: It is recognized that one of the most catastrophic conditions complicating pregnancies is aortic dissection. This case series will present two cases of aortic dissection during pregnancy and its outcomes.
Case A: A 36 year old Gravida 2 mother was admitted in the emergency department due to chest pain. On physical examination, the patient had loud systolic murmur at the second intercostal space parasternal line. Her CT Aortogram showed an intimal flap which originated at the aortic root extending at the infrarenal aorta. She had severe aortic regurgitation with good left ventricular function. With medications for tight blood pressure and heart rate control she was able to deliver a healthy baby girl at 37 weeks AOG via caesarean section. The patient underwent Modified Bentalls Procedure one month after her delivery with an uneventful postoperative course. Case B: A 31 year old hypertensive pregnant woman presented to the outpatient clinic with chest CT Scan of 7.32 x 9.40cm descending aorta dissection commencing at T5 down to T10, with a narrowed true lumen diameter supplying the ovarian artery distally. She was admitted for control of hypertension and heart rate. However, during the course of admission, her fetus developed intrauterine growth retardation. On the 28th week of gestation the patient underwent thoracic aortic endovascular repair. However, the fetus developed bradycardia and absence of fetal variability on fetal monitoring prompting delivery of a live preterm baby girl with APGAR 8,9 weighing 890 grams. The patient was discharged on the 8th postoperative day.
Results: The result of this case series is a good indication that aortic dissections during pregnancy can be managed conservatively. Fetal complications such as malperfusion in the fetal-maternal circulation may present with signs and symptoms culminating to intrauterine growth retardation.
Conclusion: In conclusion, aortic dissections during pregnancy can be managed medically during pregnancy. Tight control of heart rate, blood pressure and close monitoring of fetal growth should be strictly be monitored to avoid complications. We follow AHA and ESC guidelines for management of aortic dissections. Surgical repair through Modified Bentalls Procedure for type A dissections and endovascular repair for type B dissections produce favorable outcomes in terms of surgical management. We highly recommend that best efforts in completing the age of gestation or doing a procedure during the second trimester prevent adverse fetal outcomes. Lastly, malperfusion symptoms towards the developing baby maybe subtle but must be recognized with high degree of suspicion to prevent fetal loss in utero.
Authors
Chery Lou Cabanero (1), Aquileo Rico (2)
Institutions
(1) N/A, N/A, (2) N/A, Manila, Philippines
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Poster Presenter
Chery Lou Cabanero, Southern Philippines Medical Center
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Davao City
Philippines
Objective: The purpose of this case is to show a successful hybrid approach of the repair of an Ascending-Descending Aneurisms with relatively stable size arch in a high-risk patient. Approach provides efficient, simplified way of dealing with this pathology with minimal exposure to circulatory arrest.
Case Video Summary: The patient is an 83-year-old frail female on two liters of oxygen at home with significant medical history of Atrial Fibrillation, Coronary Artery Disease, Diabetes Mellitus, and obesity. Incidentally, an Ascending-Descending aortic aneurism is found after a total right knee replacement complicated by Deep Vein Thrombosis and Pulmonary Embolism.
CT angiogram showed the ascending and proximal descending aorta with 5.2 cm and 6.2 cm, respectively. Aortic arch of 3.5 cm.
Transthoracic Echocardiogram showed Normal Left and Right ventricular function/size.
Based on our assessment, we planned an Ascending and Total Aortic Arch Replacement, performing a fenestrated Frozen Elephant Trunk with stent to left subclavian and carotid arteries (BSAFER), in an octogenarian and high-risk patient.
Central cannulation is performed. Superior Vena Cava (SVC) is cannulated for retrograde brain perfusion. Head vessels and aortic root are dissected to maximize efficiency and diminish CPB exposure.
Patient is cooled to the level of deep hypothermia for about 30 min. Circulatory arrest is initiated and retrograde brain perfusion started. A 40 mm x 10 cm stent graft is delivered antegrade into the descending aorta under direct vision. Based on tissue quality assessment and arch disease the device is deployed and positioned in zone 1. A 13 mm x 2.5 cm branch vessel stent graft is delivered into the Left Subclavian (LSC) artery. Retrograde perfusion is stopped and antegrade perfusion is started through the innominate and LSC arteries. A 10 mm x 5 cm stent component is deployed into the Left Common Carotid and a Pruitt balloon catheter is placed to continue antegrade brain perfusion. The aortic stent graft is circumferentially sutured to the aortic wall. The suture line is continued behind the innominate artery. Distal anastomosis is done by suturing graft to stent and then as coming closer to innominate artery, transitioned to graft to aorta, leaving innominate orifice open and reimplanted. Proximal anastomosis is done in supracoronary fashion and excluding most of the noncoronary sinus.
A total of 24 minutes of Deep Hypothermic Circulatory Arrest with Retrograde and Antegrade Cerebral Perfusion were needed to repair the Total Arch and FET. Patient is extubated the following day and discharged to skilled nurse facility after 3 weeks. The post-operative CT angiogram showed the surgical graft of the ascending aorta and the arch that continues as a frozen elephant trunk to the level of the mid descending aorta without signs of endoleak or pseudoaneurysm formation.
Conclusions: The clinical importance of this case is to show that there is an efficient and effective treatment of the Ascending-Descending Aneurism in a high-risk patient. Brief time of Circulatory Arrest is a significant factor to take into consideration when we address a complex case in an older higher risk patient. A hybrid approach allows us to treat the whole pathology decreasing the circulatory arrest and overall surgical time and with good outcomes. Currently, our patient is doing well is at home and continues her following-up appointments with positive assessments.
Authors
Anibal Ibanez (1), Patrick Vargo (1), Xiaoying LOU (1), Eric Roselli (1), Faisal Bakaeen (1), Edward Soltesz (1), Michael Tong (1), Shinya Unai (1), Haytham Elgharably (1), Benjamin Kramer (1), Noah Weingarten (1), Francis Caputo (1), Jon Quatromoni (1), Ali Khalifeh (1), Lars Svensson (1), Marijan koprivanac (1)
Institutions
(1) Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
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Poster Presenter
Anibal Ibanez, Cleveland Clinic
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OH
United States
Objective:
Acute and chronic type B aortic dissection during pregnancy is a challenging cardiovascular disease. The best management for these patients is still unclear, and usually specific for each scenario. Therefore, guidelines are still required for this uncommon clinical situation.
Methods:
We present an unusual case of a 26-year-old pregnant woman who initially presented with chest pain and an enlarging post-dissection descending thoracic aortic (DTA) aneurysm. A computed tomography angiography (CTA) revealed a type B aortic dissection starting just distal to the origin of the left subclavian artery (LSA), extending to the superior mesenteric artery (SMA) origin (Fig. 1A). The descending thoracic aorta measured 5 cm in diameter. A large fenestration was seen in the proximal descending thoracic aorta (DTA) and at the origin of the celiac axis (Fig. 1B and Fig. 3). Transthoracic echocardiogram (TTE) displayed a dissection flap in the proximal DTA, with a compressed true lumen (Fig. 2A).
Results:
Due to non-reactive fetal tracings, after close management in the intensive care unit, she underwent cesarean section at 28- weeks of gestation.
Four months after the delivery and she had a successful open repair of the post- dissection descending thoracic aneurysm. Resection and graft replacement (reversed elephant trunk) of the descending thoracic aortic aneurysm, using a 30- mm woven dacron tube graft via a left modified thoracoabdominal incision (through the 6th intercostal space) was performed. The patient was discharged home 7 days after the procedure.
Conclusions:
Our case highlights the importance of a multidisciplinary team, including obstetrics and maternal-fetal-medicine (MFM) consultants, cardiothoracic and vascular surgery, intensive care physicians, and pediatric cardiologists, for a successful outcome of complex cases of chronic type B aortic dissection in pregnant women.
Authors
Lucas Ribe (1), Yuki Ikeno (1), Rana Afifi (2), Akiko Tanaka (3), Alexander Mills (4), Anthony Estrera (3)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX, (2) Memorial Hermann, Houston, TX, (3) Memorial Hermann Heart and Vascular Institute, Houston, TX, (4) University of Texas Health Science Center at Houston (UTHealth Houston), N/A
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Poster Presenter
Lucas Ribe, McGovern Medical School at UTHealth
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Houston, TX
United States
Objective
Minimally invasive approaches, such as partial-sternotomy (PS), could reduce the surgical trauma and were proven to be safe for valve-related procedures. We aimed to investigate the in-hospital and mid-term outcomes of patients undergoing ascending aortic surgery (AAS) through a partial or a full-sternotomy approach through a propensity matching analysis.
Methods
We retrospectively included all patients (n=167), who underwent elective AAS for aneurysm in our institution between 2013 and 2020. Patients, who received a surgical treatment in cases of emergency situations for aortic dissection were excluded. Study population was divided in two groups according to the surgical access (n=40 in partial sternotomy or "PS", and n=127 in full sternotomy, or "FS"). Due to the significant differences between the groups, a propensity matching 1:3 was applied. Age, BMI, gender and EuroSCORE II were used as covariate variables and the propensity score was computed based on the combined aortic valve operation. The Mahalanobis distance including the propensity score was used as distance calculation method. The order for matching was done at random. No maximum number of iterations were set for the optimization algorithm. After propensity matching, only the preoperative EF was significantly different between the two groups. In-hospital complications, survival and reoperation at follow-up were investigated.
Results
No operation started with a partial upper sternotomy had to be converted into a median full sternotomy during the operation. The majority of patients were operated with a brachiocephalic cannulation (PS=70% vs FS=61%, p=0.3) and selective cerebral perfusion (PS=65% vs FS=58%, p=0.3) in both groups. A combined aortic valve surgery was performed in the 92% of patients in the PS-group and 76% of patients in FS-group (p=0.06). PS group showed higher X-clamp and cardiopulmonary bypass times (94.2 min vs. 83 min and 164.2 min vs. 126.8 min). Moreover, the mean postoperative ventilation time was significantly higher in the PS group (41.5 hours±98.8 versus 22.5 hours±58.5), however not affecting the length of stay in ICU (3.6 days±4.7 versus 2.9 days±3.3; p=0.1). The incidence of bleeding, stroke and in-hospital mortality were similar between PS and FS group (11% vs. 3%, 3% vs. 6%, 5% vs 3%, respectively). After a median follow-up of 2±1.98 years, the Kaplan-Meier analysis showed not significant differences between the PS and FS group (log-rank, p=0.17) in term of survival. Cardiac reoperations were observed in 2 cases (6%) of the PS-group and in 8 (7%) of the FS-group. In the PS group the reason accounted for hemodynamic relevant pericardial effusion, that was successfully treated with a subxiphoidal drainage placement. In the FS-group patients were reoperated because of pericardial effusion (n=3), sternal complications (n=2), tricuspidal valve insufficiency (n=1), aortic valve replacement (n=1) or tube prosthesis endocarditis by Streptococcus gallolyticus (n=1).
Conclusions
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. Surgical ascending aorta replacement can be safely performed through a minimally invasive approach.
Authors
Francesco Pollari (1), Matthias Angerer (1), Wolfgang Hitzl (2), Lucia Weber (1), Joachim Sirch (1), Theodor (Teddy) Fischlein (3)
Institutions
(1) Klinikum Nürnberg – Paracelsus Medical University, Nuremberg, NA, (2) Research and Innovation Management (RIM), Team Biostatistics, Paracelsus Medical University, Salzburg, NA, (3) Klinikum Nürnberg – Paracelsus Medical University, Nuremberg, Bavaria
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Poster Presenter
*Theodor (Teddy) Fischlein, Klinikum Nürnberg
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Nuremberg, Bavaria
Germany
Objective: Transcatheter Aortic Valve Replacement (TAVR) has emerged as a safe and effective option for treatment of aortic valve disease in many patient populations. Although rare, aortic injury during TAVR can be devastating. Here, we present our center's experience with several cases of iatrogenic aortic complications that were successfully managed through both surgical and non-surgical intervention, all resulting in stabilization and ultimately hospital discharge.
Methods: We conducted a literature search to review the published literature on aortic complications of TAVR and retrospectively reviewed several patient electronic health records who underwent successful operative and non-operative management of a potentially devastating aortic complication of TAVR.
Results: Patient A suffered an annular rupture during pre-balloon dilation. Hemodynamic compromise suggested a complication which was then identified as annular rupture with pericardial effusion on an echocardiogram. After pericardiocentesis and stabilization of blood pressure, the patient was taken to the OR for successful surgical AVR with root repair. Patient B suffered an annular rupture during balloon-expansion of TAVR valve, resulting in effusion that was similarly identified on echocardiogram. After pericardiocentesis and injection of a hemostatic agent into the pericardial space, aortic root aortography demonstrated no further extravasation. The patient was observed closely with a temporary pericardial drain and discharged home with no further intervention. Patient C underwent TAVR that was complicated by a moderate paravalvular leak requiring post-balloon dilation. Shortly thereafter, an effusion was noted on echocardiogram. The patient underwent pericardiocentesis and pericardial drain placement, and surgical intervention was initially offered, however the patient's family declined intervention. The patient ultimately recovered from this and was discharged. Finally, Patient D suffered an acute ascending aortic dissection at the time of balloon expandable TAVR valve placement. Given that this procedure was performed under moderate sedation, neurologic deficits were able to be immediately identified by the heart team, prompting urgent imaging. The patient was then taken to the OR for successful hemiarch repair with antegrade and retrograde cerebral perfusion.
Conclusion: This case series emphasizes the importance of quick detection and effective management of aortic complications like dissection and annular rupture during TAVR. It highlights that prompt identification, coupled with a combination of surgical and non-surgical interventions can lead to successful patient outcomes. Finally, there are some proposed patient-related and procedural risk-factors for aortic injury during TAVR that are described in the literature, however further investigation is needed.
Authors
Shaelyn Cavanaugh (1), Hossein Amirjamshidi (1), Andrew Jones (1), Ariana Goodman (1), Kazuhiro Hisamoto (1)
Institutions
(1) University of Rochester, Rochester, NY
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Poster Presenter
Shaelyn Cavanaugh, University of Rochester Medical Center
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Rochester, NY
United States
Objective
Despite advances in technique and post-operative management, total arch replacement remains a procedure with significant clinical risk. It has been repeatedly demonstrated that elective patients have significantly lower rates of morbidity and mortality relative to emergent patients. However, it is unclear how "urgent" patients, patients who present acutely, but can undergo some degree of pre-operative resuscitation and optimization, fare compared to the other groups. Our goal was to clarify total arch outcomes in urgent patients compared to elective and emergent cases. We hypothesized that given the similar severity in pathology of urgent patients, often to the point of being symptomatic, they would have similar outcomes to emergent total arch replacements, despite pre-operative resuscitation.
Methods
We performed a retrospective review of our database for patients who underwent total arch replacement at our institution from 2009-2023. Patients were categorized based on operative urgency: elective, urgent (admitted due to pathology, operation occurred during same admission), and emergent (admitted and taken immediately to operating room due to pathology and/or hemodynamic instability). Between groups comparisons were performed for pre-operative, operative and post-operative variables, as dictated by distribution of data, and nature of variable. An adjusted cox proportional hazard model was performed with the primary endpoint of mortality, with cumulative survival stratified by procedure urgency.
Results
A total 243 patients from 2011-2023 were included in the analysis (Table 1). There was a higher incidence in coronary artery disease (p=0.011) among the elective and urgent group, otherwise, there were no differences in pre-operative characteristics. Cardiopulmonary bypass and cross-clamp time was significantly longer for emergent compared to elective and urgent procedures (p<0.001), but not circulatory arrest times (p=0.205). Usage of packed red blood cells (pRBC, p=0.001), and coagulation products (FFP, plasma, cryo, p=0.003), was significantly higher in emergent compared to elective and urgent procedures.
Length of stay between the urgent and emergent group were similar and higher than elective cases (p=0.003), however, this included the pre-operative optimization period, and ICU length of stay was significantly higher comparatively in the emergent cohort (p=0.001). Significant differences were found between groups for prolonged ventilation (p=0.025), new renal replacement therapy (p<0.001), stroke (p<0.001), and mortality (p=0.001), with higher rates in the emergent group. Adjusted cox proportional hazard with baseline as elective procedure demonstrated no significant difference in mortality compared to urgent (p=0.653), and a significant difference compared to emergent (p=0.010).
Conclusions
Our results did not support our hypothesis, as urgent total arch outcomes were significantly better than emergent cases and were similar to elective outcomes. Emergent procedures were associated with longer intraoperative CPB and XC times, more use of blood and coagulation products, and significant morbidity and mortality. Urgent cases did not have any significant difference in any operative or post-operative variables compared to elective cases. These results suggest that even during urgent aortic admissions, patients benefit from pre-operative optimization.
Authors
Adam Carroll (1), Michal Schafer (1), Nicolas Chanes (1), Michael Kirsch (1), Ananya Shah (1), Zihan Feng (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objectives:
Although management of extensive aortic aneurysmal disease has greatly improved, further techniques are warranted to optimize stent-graft landing zones. In particular, the stricture created by distal anastomosis in open arch replacement can compromise endovascular aortic extension. We describe a case where a short-stent cuff was placed to create a landing zone for a stent distal to a zone 2 arch anastomosis to facilitate extensive aortic coverage for aneurysmal disease.
Methods:
We discuss the case of a 63-year-old female with a history of prior mechanical Bentall and ascending aorta replacement, and Kommerell's diverticulum with an aberrant right subclavian artery who presented with aortic valve stenosis, as well as arch and descending thoracic aortic aneurysms. Prior to addressing her arch pathology, she underwent robotic ligation of her aberrant right subclavian artery, with transposition to her right common carotid and division of her vascular ring.
Results:
The patient was taken to the operating room to address her stenotic mechanical Bentall and her aneurysmal pathology. Following initiation of cardiopulmonary bypass, the proximal arch, innominate and left common carotid were dissected out. The innominate and left common carotid artery, respectively, were divided and sewn to the distal and proximal side arms of a Spielvogel graft and deaired, restoring cerebral perfusion. Following the initiation of circulatory arrest, the aorta was fashioned to underneath the left common carotid. The remaining aorta was resected to zone 2. Given the extent of her descending pathology, to optimize coverage the Bavaria graft was cut to length with 45mm of soft graft distal to the branch takeoffs, and a small 36x45mm Gore Aortic Extender Endoprosthesis was secured proximally and distally to optimize landing zone. The complex was placed in the true lumen of the aorta, and the marked line of the soft graft, the proximal edge of the stent, and the full thickness of the aortic wall were all sewn together, placing the anastomosis at zone 2 with the end of the stent just proximal to the left subclavian artery takeoff. Circulatory arrest was ended, and the prior stenotic Bentall was addressed. Post-operative course was uncomplicated, and the patient was discharged on day 8.
Three months following, the patient returned to the operating room for endovascular extension to address her descending pathology with a zone 2 thoracic branched endograft. After obtaining access, intravascular ultrasound was used to measure the proximal landing zone, which as planned was just proximal to the left subclavian artery and was 38mm and widely patent. Once appropriately positioned, a 40x15mm thoracic branched endograft was placed, which was extended with placement of an additional 45x15mm Gore cTAG. The left subclavian stent-graft was then deployed. Due to her short and tortuous arch, an additional stent-graft was placed proximal to the left vertebral artery, which remained patent. Convalescence thereafter was uncomplicated, and the patient was discharged on post-operative day 2. At one month follow-up, the patient was doing well, with no concerns on three-month surveillance imaging.
Conclusions
Our novel technique of using a short-stent cuff to optimize endovascular extension was successful and allowed for additional aortic coverage. This technique should be considered in select patients with extensive aortic disease at select aortic centers.
Authors
Adam Carroll (1), Michael Kirsch (1), Rafael Malgor (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective:
The optimal protocol for imaging following aortic hemiarch replacement remains a topic of debate. At our institution, pathology related to the repair typically occurs within the first three months postoperatively. We hypothesize surveillance CT scans performed at 3 months will identify any pathologies requiring re-intervention; additional imaging may be superfluous.
Methods:
Using our single institution-maintained database, 417 patients who underwent an elective aortic hemiarch repair between February of 2010 and December of 2022 were identified. Eight patients (1.9%) who had an in-hospital postoperative mortality were excluded from analysis. For the remaining 409, the stability of post-operative imaging and follow-up with cardiovascular providers was reviewed. Patients requiring re-intervention related to hemiarch replacement were identified, with additional focus on whether pathology was detected during routine post-operative surveillance imaging.
Results:
Of the 409 patients who underwent elective aortic hemiarch repair, 391 (95.4%) completed post-operative follow-up with a cardiovascular provider. A total of 21 patients required operative re-intervention after discharge (5.1%). Of those, 14 patients presented urgently or emergently with symptoms related to their pathology. Only 7 patients (1.7%) had pathology requiring re-intervention found on surveillance imaging. Of those, 4 patients required re-intervention based on their post-hemiarch surveillance imaging, with all pathology detected at three-months. Three patients required re-intervention for surveillance imaging related to other pathology: two patients had distal degeneration of known descending thoracic aortic aneurysms on annual surveillance imaging, and one patient required re-intervention at eight years required to stenosis of their mechanical aortic valve. The Kaplan-Meier survival curve (Figure 1) details duration of follow-up and expected freedom from re-intervention after elective hemiarch replacement.
Conclusions:
This data supports surveillance imaging completed at 3 months following hemiarch replacement is sufficient to identify pathology related to the repair. While other indications may dictate ongoing surveillance, for most patients, the need for further imaging is unnecessary.
Authors
Adam Carroll (1), Nicolas Chanes (1), Zihan Feng (1), Cenea Kemp (1), Austin Gronewold (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
We reviewed our outcomes of treatment for Stanford Type A acute aortic dissection (TAAD) in over 85 years old patients.
In January 2010- August 2019, 41 patients at over 85 years old had diagnosed TAAD. We compare the outcomes between the surgical treatment group (N=23) and the medical treatment group (N=18).
There were no significant differences in the patient's characteristics between each group. All operative procedure was ascending aorta graft replacement.
In the surgical treatment group, hospital mortality was 17% (4/23 cases). Only five patients were discharged without any complications (22%). The remaining 14 patients transferred to other hospital for any other complications or rehabilitation.
In the medical treatment group, hospital mortality was 28% (5/18 cases). Only four patients were discharged without any complications (22%). The remaining 9 patients transferred to other hospital.
The average follow-up period was 450 days and the follow up rate was 95.1%In Kaplan-Meier survival analysis, there was no significant difference in the overall survival. But 1-year survival rate of surgical treatment group was 71.5% and better than that of medical treatment group (55.0%)
We cannot say that the outcomes of surgical treatment for TAAD patients at over 85 years old was overwhelming better than that of medical treatment. Therefore, we should consider the treatment strategy more carefully for an individual patient.
Authors
Yuta Kanazawa (1), Hirotsugu Fukuda (2), Masahiko Ezure (3)
Institutions
(1) Dokkyo Medial University Hospital, Japan, (2) Dokkyo Medial University Hospital, Mibu,Tochigi, Japan, (3) Gunma Prefectural Cardiovasvular Center, Maebashi, Gunma
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Poster Presenter
Yuta Kanazawa
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Shimotsuga-gun
Japan
Objective: The optimal diameter at which concomitant aorta replacement should be done in borderline aortic dilation is not yet known. The purpose of this study was to evaluate the surgical outcomes of concomitant aorta replacement with rapid deployment aortic valve replacement (RDAVR) in borderline aortic dilation.
Methods: From September 2016 to June 2023, overall 124 patients underwent RDAVR with concomitant ascending aorta replacement due to borderline aorta dilation (4.0-4.5cm). Early outcomes including operative mortality and postoperative complication and mid-term outcomes including overall survival and freedom from aorta related events were evaluated. Multivariable analysis was performed to find the risk factors for mid-term all-cause mortality.
Results: Mean aorta diameter was 43.1± 4.0mm. Cardiopulmonary bypass time and aorta cross clamp time were 175± 44 and 126 ± 34 minutes, respectively. There was no operative mortality. The most common complication after operation was postoperative atrial fibrillation (N=51, 41.1%), followed by acute kidney injury (N=3, 12.9%). Median follow up duration was 27.8 ± 21.9 months. Overall survival at 1 year and 5 years were 98.3% and 98.3%, respectively. There were no aortic re-intervention during follow up. Multivariate analysis showed that risk factor associated with midterm all-cause mortality were COPD (HR 24.02 [2.177-265.000], P=0.009) and EuroScore (1.154 [1.067-1.247]. P<0.001).
Conclusions: Concomitant replacement of ascending aorta with RDAVR is a safe option in borderline aorta dilation.
Authors
Yoonjin Kang (1), Kyung Hwan Kim (1), Ji Seong Kim (2), Suk Ho Sohn (3), Jae Woong Choi (3)
Institutions
(1) Seoul National University Hospital, Seoul, Seoul, (2) Seoul National University Hospital, Seoul, Kyeongi-Do, (3) Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea, Seoul, NA
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Poster Presenter
Yoonjin Kang, Seoul National University Hospital
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Seoul, Seoul
South Korea
Objective:
The purpose of this study was to investigate the impact of cannabis consumption on the mid and long-term surgical outcomes of patients with aortic aneurysms or dissections.
Methods:
All individuals aged > 18 years with more than 6 months of cannabis use at the time of surgical repair for cardiovascular disease (aortic aneurysms or aortic dissection) between 2007 and 2023 were eligible. Patients were stratified into two groups based on their preoperative history of marijuana use: Cannabis-users and non-cannabis users. The primary endpoint was complications or death within 30 days of intervention. Secondary outcomes included late complications and re-interventions. Data were combined from our institution (the University of Texas Health Science) and inpatient records from Memorial Hermann Hospital (Houston, Texas).
Results:
During the study period, we identified 134 patients who met the inclusion criteria out of 1,543 treated patients (9%). Compared to the non-cannabis group, individuals in the Cannabis group were significantly younger (Cannabis: 48.3 ± 11.8 years vs. non-Cannabis: 58.5 ± 14.9 years, p < 0.001). The Cannabis group included significantly higher patients with Marfan syndrome (Cannabis: 11.2% vs. non-Cannabis: 4.4%, p<0.001). Furthermore, the Cannabis group showed significantly higher history of recreational drug use, including cocaine (25.4% vs. 1.6%, p<0.001), amphetamines (3.7% vs. 0.6%, p<0.001), opioids (8.2% vs. 0.5%, p<0.001), and intravenous drugs (6.7% vs. 0.6%, p<0.001). Emergency surgeries were significantly more frequent in the Cannabis group (Cannabis: 56.7% vs. non-cannabis: 36.2%, p<0.001). Surgical mortality was comparable between both groups (Cannabis: 9.7% vs. non-cannabis: 8.6%, p=0.662). Postoperative stroke was significantly higher in the Cannabis group (Cannabis: 14.9% vs. non-cannabis: 8.2%, p=0.009), and the rate of postoperative respiratory complications was also significantly higher in the Cannabis group (Cannabis: 32.1% vs. non-cannabis: 19.0%, p<0.001).
Conclusions:
The increased rates of postoperative cerebrovascular accidents and respiratory complications suggest that cannabis use is a significant risk factor in aortic surgery. Our study showed that young, healthy patients with prolonged cannabis use might be at a higher risk of requiring more emergency surgeries due to their background.
Authors
Lucas Ribe (1), Yuki Ikeno (1), Akiko Tanaka (2), Rana Afifi (3), Harleen Sandhu (4), Charles Miller (5), Anthony Estrera (2)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX, (2) Memorial Hermann Heart and Vascular Institute, Houston, TX, (3) Memorial Hermann, Houston, TX, (4) N/A, HOUSTON, TX, (5) Memorial Hermann Texas Medical Center, Houston, TX
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Poster Presenter
Lucas Ribe, McGovern Medical School at UTHealth
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Houston, TX
United States
Objective: Proximal aortic repair is often performed in patients with significant coronary artery disease that is addressed to mitigate prohibitive risk. We analyzed proximal aortic repair with and without concomitant coronary artery bypass grafting (CABG) to understand risk factors and operative outcomes.
Methods: We retrospectively reviewed 3916 patients (median age 62 years [38-70]) who underwent proximal aortic repair (1990-2022), including 717 (18.3%) who underwent concomitant CABG (+CABG). Propensity score matching was used to adjust for baseline differences between repairs with and without +CABG. Logistic regression aimed to identify predictors of operative death (death within 30 days or before final hospital discharge including transfer) and adverse events (a composite of operative death, persistent neurological deficit, or persistent renal failure necessitating hemodialysis). Kaplan-Meier analyzed survival was compared by log-rank.
Results: Patients in the +CABG group were older (67 years vs 60 years [p<.001]), more likely to be male (73.5% vs 66.5% [p=.002]), and more likely to have chronic kidney disease (36.9% vs 23.1% [p<.001]) than those without +CABG (Table 1). Overall, patients in the +CABG group had a higher occurrence of operative death and adverse events (13.4% vs 7.7% and 18.1% vs 10.9% [p<.001]); after matching (520 pairs), operative mortality was similar, although the +CABG group had higher rates of adverse events (16.5% vs 11.9% [p=.03]), including persistent renal failure (9.2% vs 5.6% [p=.02]). Concomitant CABG was an independent predictor of adverse events (OR=1.63, p=.009) in the overall cohort but lost significance after matching (p=.09). Late survival was significantly decreased in patients with concomitant CABG (overall cohort, 35.0% vs 54.1% at 10 years, p<.001; matched cohort, 35.3% vs 46.2% at 10 years, p=.006). Of interest, late survival was not affected by the number of bypasses performed (p=.3).
Conclusion: Patients who underwent concomitant CABG experienced adverse events more frequently than those who did not; however, +CABG was not an independent predictor of adverse events. Patients who required CABG were older and had more co-morbid conditions. Long-term survival was significantly decreased in +CABG patients. Findings suggest that patients who require concomitant CABG are more medically fragile, and they may benefit from close postoperative follow-up focused on the management of non-aortic related comorbidities.
Authors
Lauren Barron (1), Natalia Roa-Vidal (2), Kimberly Rebello (3), Qianzi Zhang (3), Susan Green (4), Scott A. LeMaire (5), Marc Moon (1), Joseph Coselli (6)
Institutions
(1) Baylor College of Medicine / Texas Heart Institute, Houston, TX, (2) School of Medicine, University of Puerto Rico Medical Science Campus, San Juan, PR, (3) Baylor College of Medicine, Houston, TX, (4) N/A, Houston, TX, (5) Geisinger Commonwealth School of Medicine, Scranton, PA, (6) Baylor College of Medicine, Texas Heart Institute, United States
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Poster Presenter
Lauren Barron, Baylor St Lukes/Texas Heart Institute
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Houston, TX
United States
Objective:
To describe short- and mid-term surgical outcomes of patients with Turner syndrome (TS) after cardiovascular interventions.
Methods:
All individuals aged 18 years or older at the time of surgical repair for cardiovascular diseases, including coarctation repairs, aortic disease and aortic dissection, between 2002 and 2022 were eligible. The primary endpoint focused on complications or death within 30 days of surgery. Secondary outcomes encompassed late complications within 6 months. The analysis incorporated data from the University of Texas Health Science Center at Houston and the Turner Syndrome Society of the United States.
Results:
We identified 22 patients who met the inclusion criterion. The median age was 46 years (range, 21-75). The most common medical condition was hypertension (77%), followed by hypothyroidism (59%). The most frequent indication for surgery was aortic root or ascending aortic aneurysms (68%), followed by symptomatic aortic stenosis in patients with bicuspid aortic valve (64%), coarctation of aorta (45%), and acute aortic dissection (18%). Respiratory complications were the most common (68%). Pleural effusions were the most frequent found sign on imaging studies (68%). Thoracentesis, or chest tube placement, was required in 33% (5/15).
Conclusions:
Patients with TS may be at an increased risk for postoperative complications after aortic surgery. Bicuspid aortic valve (59%) and coarctation of the aorta (45%) were the most common congenital malformations among our study group. Our study showed that respiratory complications were the most common, with thoracentesis or chest tube placement required in 33% of patients. This is the largest series presenting mid-term outcomes of adult-only Turner syndrome patients following aortic surgery repair.
Authors
Lucas Ribe (1), Yuki Ikeno (1), Rana Afifi (2), Akiko Tanaka (3), Ferial Shihadeh (4), Anthony Estrera (3), Siddharth Prakash (5)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX, (2) Memorial Hermann, Houston, TX, (3) Memorial Hermann Heart and Vascular Institute, Houston, TX, (4) McGovern Medical School UTHealth, Houston, TX, (5) N/A, Houston, TX
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Poster Presenter
Lucas Ribe, McGovern Medical School at UTHealth
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Houston, TX
United States
Objectives
Custodiol cardioplegia is well-established in routine and minimally invasive cardiac surgery with the advantage of prolonged myocardial protection with a single infusion without interrupting the operation flow. The aim of this study is to compare the efficacy of Custodiol against blood cardioplegia in patients undergoing major aortic surgery.
Methods
Retrospectively analysed prospectively collated data of patients who underwent major aortic surgery by two experienced aortic surgeons at a large specialist centre in the UK between April 2022 and November 2023.
Patients were 1:1 propensity score matched by age, gender and EuroScoreII (45 Custodiol, 45 blood).
All aortic operations were included, except for isolated aortic valve replacements.
Reported outcomes include operative data, changes in blood and biochemistry results, in-hospital mortality, length of ICU and hospital stay, and adverse postoperative events.
Continuous variables were described as median and Mann-Whitney U test utilised to calculate for statistical significance (p<0.05). Multivariable logistic regression model was employed after adjusting for covariates.
Results
Mean age was 59 years in both cohorts, 71% male (32/45 in each) with a high mean EuroscoreII (7.74% blood and 7.79% Custodiol).
No significant change was noted in pre to postoperative haemoglobin (p=0.14) and sodium (p=0.16) between cardioplegia.
There was no significant difference in postoperative outcomes between the two cohorts including: return to theatre for bleeding (p=0.50), postoperative stroke (p=0.69), new acute kidney injury (p=0.07), pacemaker (p=0.08) or 30-day mortality (2 deaths in Custodiol, 3 in Blood, p=0.65).
Cardiopulmonary bypass and circulatory arrest times were not statistically significant different between blood and custodial cohorts (225 vs 237 minutes, p=0.07; 59.5 and 58 minutes, p=0.42).
Cross-clamp time showed no significant difference between blood and custodial (163 vs 153 minutes, p=0.83). After adjusting for Euroscore II, urgency, redo surgery and operation type, a multivariable regression model reported no significant difference in cross clamp time (p=0.98). However for redo operation, it was associated with an average 44.3 minutes longer cross clamp time which was significant (p=0.002).
Sub-analysis of cross-clamp time between different operation types showed: 36 minutes significantly shorter for root replacement in Custodiol (147.5 vs 183.5 minutes, p=0.005); 16.5 minutes shorter for ascending and hemiarch in Custodiol (146.5 vs 163 minutes, p=0.28) but it did not reach statistical significance. Majority of patients who had arch repair via Custodial were redo operations compared to blood cohort so unable to draw a conclusion.
After adjusting for covariates, there was no statistically significant difference in duration of surgery (p=0.98), mechanical ventilation (p=0.28), ICU stay (p=0.68), and hospital stay (p=0.81).
Conclusions
Custodiol cardioplegic solution is a safe and effective myocardial protective agent compared to traditional blood cardioplegia in patients undergoing major aortic surgery.
The reduced cross-clamp time was most significantly noticeable in patients receiving Custodiol during aortic root replacements without affecting postoperative outcomes.
Authors
Vinci Naruka (1), Samuel Burton (1), Selina Tsai (1), Danielle Blackie (1), Ana Lopez-Marco (1), Benjamin Adams (1), Aung Oo (1)
Institutions
(1) Department of Cardiothoracic Surgery, Barts Heart Centre, St Bartholomew's Hospital, London (UK)
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Poster Presenter
Vinci Naruka, Barts Heart Centre, St Bartholomew's Hospital
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London
United Kingdom
Objectives: To evaluate the outcomes of transposition of the omentum into the mediastinum to support the replacement of infected aortic grafts or to cover infected aortic grafts that are not amenable for surgical replacement.
Methods: All patients with thoracic aortic graft infections who underwent mediastinal transposition of the omentum at our institution between 2000 and 2023 were included in this study. Mediastinal transposition of the omentum was performed either after replacement of the infected graft ("curative concept") or solely as bailout procedure by wrapping the infected graft ("palliative concept"). The diagnosis, including computed tomography scans during follow-up, was made according to the criteria of the Management of Aortic Graft Infection Collaboration.
Results: The patient cohort consisted of 31 patients. Both in-hospital and one-year mortality were 0% (n=0) for the curative concept (n=9) compared to 23% (n=5) and 41% (n=9) for the palliative concept (n=22), respectively. There was no graft infection-associated death or recurrence of infection after 3 years in the curative group. Survival was 52% at 3 years in the palliative group, with freedom of infection in 59% of the patients (n=13).
Conclusions: Transposition of the omentum and wrapping of the infected aortic prosthetic graft is a useful bailout strategy for patients who are ineligible for replacement of an infected aortic graft. For radical treatment of aortic graft infections, it may prove an effective supportive therapy.
Authors
Leonard Pitts (1), Miralem Pasic (1), Leonhard Wert (1), Gaik Nersesian (1), Julius Kaemmel (1), Semih Buz (1), Jörg Kempfert (1), Volkmar Falk (1)
Institutions
(1) German Heart Center Berlin, Berlin, Germany
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Poster Presenter
Leonard Pitts, Deutsches Herzzentrum der Charité
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Berlin, Germany
Germany
Objectives:
Cardiac surgery has seen a shift in the patient population with increasing disease severity. Some patients are unable to wean from cardiopulmonary bypass safely following surgery. The increased availability and reliability of ECMO has allowed mechanical circulatory support (MCS) to become a viable option for selected patients in this situation. Our objectives were to assess the outcomes of Post Cardiotomy Veno-Arterial Extra-Corporeal Membrane Oxygenation (PC VA-ECMO) at our institution following repair of acute aortic syndrome compared to other cardiac operations.
Methods:
This was a retrospective study of all patients that underwent cardiac surgery at our institution from January 2008 until July 2023. Patients initiated on ECMO prior to surgery, placed on VV-ECMO or VAD were excluded. Patients initiated onto VA-ECMO post cardiotomy were identified and their records analysed further. Categoric variables were presented as numbers and percentages and compared with two tailed chi-square tests. Continuous variables were expressed as median and standard deviation and compare with an unpaired t-test.
Results:
28310 general adult cardiac operations were performed, of which 172 (0.61%) patients fulfilled inclusion criteria, with a median age of 66.5years. A total of 22 (12.8%) of patient had repair of an acute aortic syndrome (Group A) and 150 (87.2%) patients underwent other cardiac operations (Group B). There was no significant difference in relation to gender; 12/22 males in group A vs 99/150 in group B (p=0.2943), or in the age of the two groups the mean age in group A was 62.3 ±11.75 vs 64.9 ±12.01 in group B (p=0.3434), with a mean EuroScore of 12.4% ± 3.1% vs 9.9% ±4.6% (p=0.0131)
Pre-operatively, there was no significant differences between the two groups with regards to redo-sternotomy 3/22 vs 25/150 (p= 0.7192), LVEF<30% 9/22 vs 50/150 (p=0.4845), pre-operative cardiogenic shock 5/22 vs 27/150 (p= 0.8432), pre-operative intubation 3/22 vs 25/150 (p= 0.7192), and pre-operative inotropes 4/22 vs 23/150 (p=0.7344).
The urgency of the index procedure was elective in 29.1% (50/172), urgent in 29.1% (50/1972) and emergency/salvage in 41.8% (72/172). VA-ECMO was instituted at the index operation in 20/22 in group A vs 87/150 in group B (p= 0.0029) with the mean number of days on ECMO in group A of 7.5 ± 8.2 vs 5.9 ± 6 in group B (p=0.2685). A total of 10 patients underwent further mechanical circulatory support, 3 in group A (2x RVAD and 1x BiVAD) and 7 in group B (1x LVAD, 4x RVAD and 2x BiVAD). Table 1 shows other complications, mortality, and survival outcomes.
Conclusion:
Post cardiotomy ECMO is a useful method of support following cardiac surgery, although utilised in a small percentage of patients. The use of PC VA-ECMO following repair of acute aortic syndrome has comparable outcomes to its use following other cardiac operations. In-hospital mortality was significantly lower in the acute aortic syndrome group, with a significantly higher number of patients discharged from hospital. Survival outcomes between the two groups was similar. Our results demonstrate that VA-ECMO can be utilised in patients following repair of acute aortic syndromes with similar outcomes compared to other cardiac operations.
Authors
Ahmed Mohamed Abdel Shafi (1), Jason Ali (1), Narain Moorjani (1), David Jenkins (1), Alain Vuylsteke (1), Stephen Large (1), Ismail Vokshi (1), Choo Ng (1), Muhammad Rafiq (1), Fouad Taghavi (1), Shakil Farid (1), Pradeep Kaul (1), Jo-Anne Fowles (1), Francis Wells (1), Marius Berman (1), STEVEN TSUI (1), Hassiba Smail (1), RAVI DE SILVA (1)
Institutions
(1) Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
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Poster Presenter
Ahmed Mohamed Abdel Shafi, Royal Papworth Hospital
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London, London
United Kingdom
Objective:
Patients with thoracoabdominal aortic aneurysms (TAAAs) may present with mildly enlarged abdominal segments. After TAAA repair limited to resect the aneurysmal lesion, patient may require completion extent II in the future, which may be more high-risk. We sought to examine our outcomes with staged-completion TAAA repair.
Methods:
We retrospectively reviewed patients who underwent primary and redo-completion extent II TAAA repairs between 1999 and 2019. Primary repair was defined as single-stage extent II TAAA repair at initial encounter. Completion repair was defined as staged-aortic repair with a prior distal aortic repair to replace the entire extent II TAAA in continuity. Preoperative patient characteristics and perioperative outcomes in the two repair groups were compared.
Results:
141 primary and 105 completion extent II TAAA repairs were performed during the study period. Patient baseline characteristics were similar except for more frequent hypertension in completion repair group and previous elephant trunk procedure in primary repair group. The extent of repairs performed to achieve the completion extent II repair included descending in 8%, extent I in 3 %, extent II in 18%, extent III in 34%, extent IV in 35%, and extent V in 2%. Paraplegia rate was twice as high in the primary repair compared to completion repair (14% vs. 7%, p=0.067); Permanent paraplegia rate was 9% and 6%, respectively (p=0.469) Pump time and clamp time were significantly longer in primary repairs compared to completion repairs, but 30-day mortality (11% vs. 14%, p=0.543), respiratory failure, dialysis requirement, and stroke rates did not differ in two groups.
Conclusions:
Outcomes after staged-completion extent II TAAA repairs were comparable to that of primary extent II repairs. Staging the repair may reduce the risk of paraplegia after extent II repairs. Without significant enlargement of the abdominal segment, a limited initial repair with expectant completion extent II repair is a reasonable approach.
Authors
Yuki Ikeno (1), Lucas Ribe (1), Alexander Mills (1), Harleen Sandhu (1), Rana Afifi (1), Charles Miller (1), Hazim Safi (1), Anthony Estrera (1), Akiko Tanaka (1)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX
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Poster Presenter
Yuki Ikeno, University of Texas - Houston
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Houston, TX
United States
Outcomes of Thoracoabdominal Aortic Aneurysm Repair in Patients with and without Peripheral Vascular Disease
Authors: Alexis Nichols, Veronica A. Glover, Lynna Nguyen, Ginger Etheridge, Susan Green, Subhasis Chatterjee, Marc Moon, Joseph Coselli
Author Institutions: Baylor College of Medicine/The Texas Heart Institute
Objective: Peripheral vascular disease (PVD) is closely associated with other atherosclerotic diseases that are common in patients with thoracoabdominal aortic aneurysms (TAAA); however, its association with TAAA repair is not well studied. This study aims to investigate the relationship between PVD and TAAA repair; specifically, how patients with and without PVD differ in terms of presentation, extent and details of TAAA repair, and early outcomes.
Methods: This retrospective, single-practice study analyzed 3,772 patients who underwent TAAA repair from 1990-2023. Included were 891 (23.6%) patients with PVD and 2,881 (76.4%) patients without PVD. Preoperative, perioperative, and postoperative factors were compared. Adverse events included operative mortality (within 30 days or final hospital discharge, including transfer) or persistent (ie, present at discharge or at time of death) stroke, paraplegia, paraparesis, or renal failure necessitating dialysis.
Results: The median age of patients who underwent TAAA repair was 69 [64-75, P<.001] in patients with PVD and 66 [56-73, P<.001] in patients without PVD. Patients without PVD had a higher prevalence of heritable aortic disorder (12.9 % vs 4.0%, P<.001). Patients with PVD had a higher prevalence of hypertension (90.8% vs 84.6%, P<.001), hyperlipidemia (42.8% vs 28.1%, P<.001), coronary artery disease (45.7% vs 32.0%, P<.001), cerebrovascular disease (29.3% vs 13.8%, P<.001), chronic kidney disease (49.9% vs 35.4%, P<.001), and chronic obstructive pulmonary disease (42.7% vs 56.5%, P<.001). Patients with PVD were more likely former tobacco users (59.0% vs 46.1%, P<.001), while those without PVD were more likely never tobacco users (22.6% vs 10.3%, P<.001). Patients with PVD underwent extent IV repairs more often (30.4% vs 16.8%, P<.001), while patients without PVD underwent extent I repair more often (29.4% vs 16.9%, P<.001). Management of visceral/renal arteries by endarterectomy, stenting, or bypass was required more often in PVD patients (55.8% vs 40.1%, P<.001). There was no difference in operative mortality between patients with and without PVD (9.2% vs 8.4%, P=.5). Adverse events were increased in PVD patients (17.6% vs 14.4%, P=.02), specifically persistent stroke (3.6% vs 2.0%, P=.009). Spinal cord deficit occurred more often in PVD patients (12.3% vs 9.1%, P=.004); however, much of this was transient with no difference in incidence of persistent paraplegia between patients with and without PVD (3.6% vs 2.7%, P=.2).
Conclusions:
Our data suggest that a history of PVD is associated with significant differences in preoperative, perioperative, and postoperative factors in patients presenting with TAAA. Patients with PVD more often had other comorbid atherosclerotic disease and were more likely to have used tobacco. Patients with PVD more often underwent extent IV repairs, while patients without PVD more often underwent extent I repairs. PVD was associated with higher rates of adverse outcomes after TAAA repair. Patients with PVD may experience higher rates of stroke and of spinal cord deficit, which may necessitate careful monitoring after repair.
Authors
Alexis Nichols (1), Veronica Glover (1), Lynna Nguyen (1), Ginger Etheridge (1), Susan Green (1), Subhasis Chatterjee (1), Marc Moon (2), Joseph Coselli (3)
Institutions
(1) Baylor College of Medicine, Houston, TX, (2) Baylor College of Medicine / Texas Heart Institute, Houston, TX, (3) Baylor College of Medicine, Texas Heart Institute, Houston, TX
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Poster Presenter
Alexis Nichols, Baylor College of Medicine
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Houston, TX
United States
Objective
Despite increasing reports of successful replacement of the aortic arch for acute aortic syndrome, arch surgery is nonetheless perceived with reverence. Extension of the aortic pathology, preoperative status and GERAADA score should be considered, if total arch replacement is to be decided. Here we present our single centre experience with the frozen elephant trunk (FET) procedure in patients with acute aortic syndrome.
Methods
All patients who underwent frozen elephant trunk (FET) implantation in a setting of acute aortic syndrome between March 2008 and March 2023 were included in this retrospective study. Perioperative data and follow-up data were acquired through patient records and surgery logs.
Results
Overall, 90 patients underwent FET implantation due to acute aortic syndrome, 81 of which were aortic dissections type A (AADA). Mean age was 60.0 (±11.6 sd) years, 74 patients (82%) were male. All had extensive aortic pathologies with involvement of the aortic arch, supraaortic vessels or descending aorta. 27 patients (30%) presented with neurological disorders, including aphasia, hemiparesis, paraparesis and coma. Predicted 30-day mortality by the GERAADA score was 23.9 % (SEM 0.148) on average. All patients were operated in mild to moderate hypothermia with antegrade cerebral perfusion. Several patients underwent concomitant procedures i.e., 32 patients (35%) underwent aortic valve procedure, 8 patients (9%) underwent CABG, 7 patients (8%) underwent TEVAR. In our cohort, we observed a 30-day mortality of 17.4 % (SEM 4.1). Following surgery, neurological disorders were observed in 34 patients (38%). Reexploration for bleeding was required in 13 patients (14%). Postoperative haemodialysis was required in 21 patients (23%). Considering long term outcomes, aortic redo surgery was required in 8 patients (9%) and 5-year survival rate was 78.5%.
Since 2017, favourable results and the introduction of a new type of prosthesis has led to an increased utilization of the approach. 26 patients (29%) received a FET before 2017 and 64 patients (71%) after that time point.
Several preoperative and intraoperative parameters were tested for prediction of 30-day survival. Preoperative lactate levels (p<0.001), preoperative hemiparesis (p=0.035) and preoperative resuscitation (p<0.001) served as significant predictors in a multivariate cox regression. Variables such as procedure time or concomitant procedures had no significant influence on survival.
Conclusions
The recent adaptation of a comprehensive treatment approach i.e., total arch replacement and frozen elephant trunk implantation in acute aortic syndrome led to an improved outcome. Overprediction trend of early mortality by the GERAADA score and a low rate of aortic redo surgery in the long-term course support this idea.
Authors
Fasolt Meinert (1), Jamila Kremer (1), Mina Farag (1), Anna Meyer (1), Bashar Dib (1), Matthias Karck (1), Rawa Arif (1)
Institutions
(1) Heidelberg University Hospital, Heidelberg, NA
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Poster Presenter
Fasolt Meinert
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Heidelberg
Germany
Objective: To describe the experience in thoracoabdominal aorta (TAA) repair using partial cardiopulmonary bypass (CPB) at a cardiac surgery referral center.
Methods: This single-center retrospective study included all patients undergoing open TAA surgery from 2002 to November 2023. The extension of the repair was defined according to the Crawford classification, including an additional extension 0 for isolated descending aorta surgery. Open repairs were performed using selective visceral perfusion and sequential clamping aided by CPB supported by femoral arterial and venous cannulation. Postoperative in-hospital follow-up information was recorded. Variables were described according to their nature and distribution.
Results: A total of 124 patients were included with a median age of 58 years. Hypertension (72%) and Chronic lung disease (97%) were the most common comorbidities; 7% of patients had diabetes and 4% were on preoperative dialysis. Patients presented with NYHA class I-II in 92% of cases. Median EuroScore II was 4. Repair distribution was as follows: 37 extent 0, 18 extent I, 23 extent II, 21 Extent III and 24 extent IV. Most patients (59%) were intervened as elective cases. The main postoperative outcomes are summarized in Table 1.
Conclusions: Our results show comparable mortality to other centers that use left-heart bypass (LHB), with relatively low rates of stroke, spinal cord injury, gastrointestinal ischemic events, and renal replacement therapy. Therefore, despite the evidence favoring the use of LHB, partial CPB can still be an adequate alternative for TAA surgery in low-volume centers. Based on our experience, it allows for easier operative team coordination due to the use of standard CPB equipment in a setting where the learning curve for LHB use can be limited. This ensures a better intraoperative volume control with minimized blood loss thus guaranteeing a clean operative field and adequate organ perfusion.
Authors
Julian Senosiain (1), Jaime Camacho (2), Nicolas Nunez-Ordonez (1), Carlos Villa (3), TOMAS Chalela (4), Carlos Obando (5), NESTOR SANDOVAL (6), Andres Jimenez (7)
Institutions
(1) N/A, N/A, (2) Fundación CardioInfantil, Bogota, NA, (3) Fundacion Cardioinfantil, Bogota, Colombia, (4) N/A, bogota, Colombia, (5) N/A, Bogota, Colombia, (6) FUNDACION CARDIOINFANTIL, BOGOTA, DC, (7) Fundacion Cardioinfantil / La Cardio - Universidad del Rosario, Bogota, DC
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Poster Presenter
Julian Senosiain, Fundacion Cardioinfantil
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Bogota DC
Colombia
Objective: The association between socioeconomic status and mortality has been studied in a subset of cardiac surgery patients, however, this association is poorly defined in open thoracic aortic aneurysm repair. This study investigates the relationship between The Distressed Communities Index (a composite socioeconomic metric) and long-term mortality in aortic aneurysm repair.
Methods: This is a single-center retrospective study with 1416 patients who underwent open thoracic aortic aneurysm repair between 2005 and 2021. The Distressed Communities Index (DCI), which encompasses education level, poverty rate, unemployment, housing vacancy rate, median income, and change in the number of businesses, was used as a metric for socioeconomic status. Each patient's zip code was given a distressed score, with a higher score indicating a more at-risk community. Based on the patients' scores, they were subsequently placed into two separate groups. Group 1 was the not-distressed group classified by a DCI score of <40, while Group 2 was the distressed group classified by a DCI score of ≥40. The primary outcome of this study was 10-year mortality. Kaplan-Meier landmark analysis was used to analyze long-term mortality. Landmark analysis was done at the 1-year mark due to a significant number of deaths occurring within the first year. Multivariable Cox regression, including patient demographics and operative characteristics, was used to assess the association between DCI and mortality.
Results:
Of 1416 patients analyzed, 38% (n=533) were from a distressed community. These communities were also found to have more patients with comorbidities such as hypertension (76.9% vs. 69.3; p<0.01) and prior cerebrovascular accidents (7.1% vs. 4.0%; p=0.01). Additionally, patients in the more distressed communities were found to have higher rates of in-hospital mortality (4.9% vs. 1.9%; p<0.01), longer median length of hospital stay (9 days vs. 7 days; p<0.001) and higher rates of postoperative respiratory failure (15.9% vs. 9.9%; p<0.01). When comparing 30-day mortality, re-operation for bleeding, and AKI, both groups did not demonstrate a statistical difference. Patients from a more distressed community were then found to have an increased risk of long-term mortality (HR: 1.68; p=0.01), as well as being of a Non-Hispanic Other race and ethnicity (HR: 1.83 p=0.04), having a prior myocardial infarction (HR: 3.35; p<0.01), being a former smoker (HR 1.55; p=0.03), and having heart failure (HR: 1.58; p=0.03) as seen in our multivariable analysis. Patients from distressed communities had decreased survival probability at 1 year (p < 0.001) and in landmark analysis at 10 years (p=0.046) as seen in our Figure 1.
Conclusion
Being from a distressed community, defined by an elevated DCI score, is independently associated with worse long-term outcomes after aortic aneurysm repair. As more research is conducted towards acknowledging external factors that affect survival, socioeconomic status can be considered a part of surgical planning for improving patient outcomes and dismantling healthcare disparities.
Authors
Gerardo Ramos-Lemos (1), Kavya Rajesh (2), Dov Levine (3), Yanling Zhao (4), Yu Hohri (5), Thomas O'Donnell (5), Virendra Patel (6), Paul Kurlansky, MD (7), Hiroo Takayama (8)
Institutions
(1) N/A, United States, (2) N/A, N/A, (3) Columbia University, New York, NY, (4) NewYork-Presbyterian Columbia University Irving Medical Center, New York, NY, (5) Columbia University Irving Medical Center, New York, NY, (6) New York Presbytarian/Columbia, New York, NY, (7) Columbia University Medical Center, New York, NY, (8) NewYork- Presbyterian/Columbia University Medical Center, New York, NY
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Poster Presenter
Gerardo Ramos-Lemos
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New York, NY
United States
Objective:
Despite key differences in pathological processes, both Intramural Hematomas and Aortic Dissections are Acute Aortic Syndromes repaired with similar surgical technique. The objective of this study was to determine differences in surgical outcomes between patients with Intramural Hematoma versus Type A Aortic Dissection undergoing Ascending Aortic and Hemiarch repair.
Methods: This retrospective review of prospectively collected data included all patients with acute Intramural Hematoma or Type A Aortic Dissection who underwent emergent Ascending Aortic and Hemiarch Repair from January 2018 to May 2023 at a single academic institution. Primary outcomes included intraoperative mortality, 30-Day mortality, and postoperative stay. Secondary outcomes included postoperative complications. Outcomes were analyzed using Chi-squared, Fisher's Exact, and t-tests, with significance set at p<0.05.
Results: A total of 107 patients were included, 27 of whom (25%) had Intramural Hematoma and 80 (75%) had Type A Aortic Dissection. There were no differences in preoperative characteristics such as age, gender, and comorbidities, and no differences in perioperative characteristics such as case length, cardiopulmonary bypass, aortic cross-clamp, and circulatory arrest times. When comparing postoperative outcomes, there was a higher rate of pericardial effusions requiring pericardial window in the Intramural Hematoma cohort compared to the Aortic Dissection cohort (15% [n=27] vs. 3% [n=80]; p=0.02). There were no differences in other primary outcomes such as intraoperative mortality, 30-Day mortality, and postoperative length of stay. There were also no differences in the rates of postoperative complications such as bleeding requiring reoperation, cerebrovascular accident, atrial fibrillation, pleural effusion requiring thoracentesis, and surgery-related Emergency Department visits.
Conclusions: Our analysis demonstrates similar outcomes for patients undergoing Ascending Aortic and Hemiarch repair between patients with Intramural Hematoma and Type A Aortic Dissection. Despite the higher rate of required postoperative pericardial windows in the Intramural Hematoma cohort, the overall primary outcomes remained comparable. These findings were surprising as we anticipated an improved outcome for patients with the Intramural hematoma. The results of this study will be further explored in additional studies.
Authors
Anthony Lemaire (1), Sorasicha Nithikasem (2), Abhishek Chakraborty (1), George Hung (1), Hirohisa Ikegami (1), Manabu Takebe (1), Gengo Sunagawa (1), Mark Russo (3), Leonard Lee (4)
Institutions
(1) Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, (2) Rutgers Robert Wood Johnson Medical School, United States, (3) Robert Wood Johnson University Hospital, Green Village, NJ, (4) Robert Wood Johnson University Hospital, New Brunswick, NJ
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Poster Presenter
*Anthony Lemaire, Rutgers Robert Wood Johnson Medical School
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New Brunswick, NJ
United States
Objectives
Although open surgical repair is gold standard in treatment of patients with arch disease, there are unfit patients for open repair. Current endovascular options are not widely available, have strict IFUs limiting their use widely, and are high-cost. Endovascular arch repair with modifications of standard stent grafts (SG) is attractive due to higher adaptation to anatomy, wider availability, and favorable costs. However, alignment of fenestrations/branches (F/B) with arch vessels is a formidable problem, precluding their widespread use. A reproducible and foolproof technique is needed for this purpose, and we devised the Anchor technique to ease the alignment of fenestrations to arch vessels without interfering with aortic flow and manipulating SGs to prevent cerebral embolization.
Methods:
Following creation of F/Bs on SGs at back table according to spatial relations of arch vessels, a through-and-through wire (TTW) between target and femoral arteries is acquired and used for precannulation of F/B corresponding target artery. After applying diameter-reducing sutures and resheating, SG is advanced to arch with the entrance of TTW to the nosecone and fenestration facing towards the outer curvature. Following partial deployment of the 1/3 of the SG, a non-compliant balloon is advanced through F/B and inflated with half of it in target artery and the rest in SG to create "anchoring" to align and stabilize SG, then the remainder of SG is deployed while diameter-reducing sutures were intact. Using the gap between SG and aorta, the rest of F/Bs were cannulated retrogradely from arch vessels or antegradely from femoral access. Precannulation of F/Bs with .018 nitinol wires extending from femoral access can also expedite antegrade cannulation to avoid carotid cut-down. Following advancing sheats into target arteries and broking diameter-reducing sutures with compliant balloon for full deployment of SG, covered bridging stents were deployed into F/Bs.
Results:
Between August 2020 and November 2023, thirty patients underwent physician-modified TEVAR using Anchor technique. It ensured alignment of F/Bs in all patients without difficulty. Two patients died (6%, 2/30) due to ipsilateral stroke due to a technical error and malperfusion. While LSA was targeted in 25 patients with single F/B, double fenestrated SGs were deployed in 5, in which LCCA+LSA were targeted in three, and IA+ LCCA and LSA+Aberrant RSA were targeted in one patient each. Type 1a endoleak was seen in one and resolved spontaneously in 1st postoperative month. One patient died in the 14th month postoperatively due to pancreatic carcinoma.
Conclusion:
Modifications of SGs allow endovascular treatment of a broad spectrum of arch anatomies provided that adequate landing zone at proximal extent. On the contrary to bypass procedures for arch vessels, F/B SGs preserve anatomic integrity of aortic arch to be used for future interventions. The anchor technique warrants the alignment of F/Bs to at least one of arch vessels, and manipulation of stent graft in the arch is unnecessary. Anchoring balloon fixes partially deployed SG in arch and creates a space to cannulate other arch vessels without interfering with blood flow and causing embolism. The technique is reproducible and can be performed by advanced endovascular specialists for single F/B endografts, while multiple inner and outer branches, in addition to fenestrations, can be created to repair complex arch diseas
Authors
Ugursay Kiziltepe (1), Melike Senkal (2), Ilker Ince (3), Suleyman Surer (4), Ozgur Ersoy (3), Omer Delibalta (5), IBRAHIM DUVAN (3), Kasim Karapinar (6)
Institutions
(1) Diskapi YBEA Hospital, Çankaya, Select State, (2) N/A, N/A, (3) Etlik Sehir Hastanesi, ANKARA, NA, (4) Etlik Sehir Hastanesi, Ankara, NA, (5) Diskapi YBEA Hospital, ANKARA, NA, (6) Ankara EA Hastanesi, ANKARA, NA
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Poster Presenter
Ugursay Kiziltepe, Diskapi YBEA Hospital
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Cankaya, Select State
Turkey
Objective: Thoracic endovascular aortic repair (TEVAR) has emerged as the primary therapeutic modality for thoracic aortic aneurysms in eligible candidates. Despite its widespread use, there have been limited reports on TEVAR application in cases involving aortic anomalies. This presentation highlights the successful simultaneous management of descending thoracic aortic aneurysm and right nondominant aortic arch coarctation in a patient with a left dominant double aortic arch anatomy and history of prior open coarctation repair. This was achieved through a combination of TEVAR and vascular plugging.
Case Video Summary: A 56-year-old Caucasian female, who had a history of hypertension, atrial fibrillation post-ablation, and aortic coarctation with left dominant double aortic arch/vascular ring with a remote open coarctation repair, was referred to the Cardiac Surgery Clinic due to asymptomatic aneurysmal dilatation of descending thoracic aorta and coarctation of right aortic arch. A recent echocardiogram showed mild mitral regurgitation and mildly dilated left atrium. She underwent an MR angiogram of the chest, ordered by her cardiologist for surveillance of the repaired aorta according to the guidelines, which reported symmetric aneurysmal dilatation up to 5.1cm at the anastomosis with the proximal descending aorta and distal right aortic arch of 1.3cm. She otherwise had normal cardiac anatomy.
The patient reported feeling well without any symptoms. A CT aortogram showed a double aortic arch with post coarctation dilatation up to 5cm. The right aortic arch gave off the right common carotid and right subclavian arteries, and traveled behind the esophagus, with relative stenosis of 1.2cm prior to joining the anastomosis. The left aortic arch gave off the left common carotid and left subclavian arteries. Given the size of the aneurysm and the coarctation, a TEVAR with vascular plugging was offered to the patient.
We began with a thoracic aortic angiogram. A TEVAR graft was deployed from distal to the left subclavian artery to exclude the aneurysm, followed by an Amplatzer vascular plug deploying to the narrowest portion of the previous coarctation. Postoperative CT angiogram demonstrated successful graft placement with no endoleak. At three years, she remained asymptomatic, doing well, with no degenerative pathology.
Conclusions: The successful utilization of TEVAR with vascular plugging for managing a descending thoracic aortic aneurysm within the context of a double aortic arch introduces a novel, alternative approach to open surgery in patients with such complex aortic anatomies. Considering the patient's asymptomatic presentation, our decision to proceed with TEVAR with concurrent vascular plugging aimed at achieving a comprehensive solution, preemptively preventing tracheal or esophageal compression by occluding the nondominant right aortic arch, and avoiding a redo open surgery. However, long-term follow-up and more cases are needed to further support the extended use of the technique.
Authors
Bo Chang Wu (1), Adam Carroll (1), Nicolas Chanes (1), Jessica Rove (2), Joseph Cleveland (3), Muhammad Aftab (4), T. Brett Reece (3)
Institutions
(1) University of Colorado Anschutz, Denver, CO, (2) University of Colorado Anschutz Medical Center and Rocky Mountain Regional VAMC, Aurora, CO, (3) University of Colorado Hospital, Aurora, CO, (4) University of Colorado, Anschutz Medical Center, Aurora, Colorado, Aurora, CO
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Poster Presenter
Bo Chang Wu, University of Colorado Anschutz
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Aurora, CO
United States
Objectives
Assess peri-operative outcomes and post-operative quality of life of octogenarians undergoing acute type A aortic dissection (TAAD) repair at our centre.
Method
We performed a retrospective analysis of prospectively collected operative and early outcome data between 2011 and 2022. We identified 543 patients who underwent TAAD, 56 patients were identified as being octogenarian. We report the baseline patient characteristics, intra-operative variables, and early postoperative outcomes for all octogenarians. We then assessed medium-term survival by generating Kaplan-Meier curves.
We contacted patients who were discharged and administered an SF-36 questionnaire to assess their quality of life at a median follow up of 58 months. Aggregate scores were calculated for each domain of the SF-36 questionnaire ranging from 0 to 100 compiled as percentages where the higher the score the more favourable the health.
Results
Amongst octogenarians undergoing TAAD repair, median age was 82 years (interquartile range 1 year), with a median Euroscore II of 13.9 (Interquartile range 13.4). 23 patients underwent isolated ascending aorta graft repair. 16 underwent aortic arch surgery (including 3 frozen elephant trunk procedures), 6 underwent ascending aorta replacement and valve replacement, 11 underwent aortic root surgery and 6 patients underwent concomitant CABG and 19 underwent concomitant valve replacement or repair. 16 patients underwent deep hypothermic circulatory arrest (DHCA), of this group 12 underwent DHCA and had cerebral antegrade perfusion, 4 underwent DHCA alone.
Median bypass time was 177 minutes (IQR 72.5 minutes) and cross clamp time was 90 minutes (IQR 36.8 minutes). 10 patients we re-explored for rebleeding or tamponade. Median ITU stay was 4 days (2-10), and median length of hospital stay was 14 days (9-18).
51 patients were discharged, 5 died prior to discharge representing 8.9% in house mortality. 30-day mortality was 19.6%, 6-month mortality was 26.7%- and 1-year mortality was 32.1%.
Of the 24 patients who were alive during 24th September 2023, 20 responded to the SF-36 questionnaire administered to assess various domains of quality of life. For the physical functioning domain (10 items) the average score was 48.1% ± 9.8%, for social functioning (2 domains), 62.1% ± 3.19 pain (2 domains) 86.7% ± 3.3%, general health (5 domains) 60.1% ±17.2 % and for the emotional well-being domain (5 domains) 75.5% ± 19.2%.
Conclusion
At our centre between 2011 and 2022, octogenarians operated on for Type A Aortic Dissection who survived past an initial period of increased mortality risk have SF36 scores comparable to octogenarians of a non-operated cohort. This suggests that ATAAD repair can successfully return octogenarians to a good quality of life.
Authors
Harry Smith (1), Fadi Al-Zubaidi (1), Shakil Farid (1), Ravi Joseph De Silva (1), Jason Ali (1)
Institutions
(1) Royal Papworth Hospital, Cambridge, Cambridgeshire
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Poster Presenter
Harry Smith, Royal Papworth Hospital
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Coventry
United Kingdom
Objective: The opioid epidemic in the US has been potentially exacerbated by prescription opioids. As aortic dissection is associated with severe pain, we intended to assess the impact of post-surgical opioid prescription on development of persistent opioid use (POU) in patients presenting with acute type A aortic dissections (ATAAD).
Methods: This was a retrospective review of clinical records of patients with a diagnosis of ATAAD presenting to our institution from 2010-2020. Patients' discharge opioid prescriptions were all converted to oral morphine equivalents (OME) for analysis. Only opioid-naïve patients were included, who were defined as having no history of opioid prescription in the six months prior to presentation. Patients with active cancers and no OME or refill information were excluded. POU was defined as any refilling of opioid prescription one week to one year after discharge. Patients were stratified on basis of POU into two groups: POU and no POU. Baseline characteristics and outcomes were compared between the groups. Univariable analysis was undertaken to assess factors associated with POU. Further, the non-linear relationship between total OME at discharge and POU was assessed using splines. P<0.05 was considered statistically significant.
Results: A total of 132 patients were included of which 10.6% (14/132) developed POU. Women comprised 34.9% (46/132) of the population which was 81.8% (108/132) white. Patients in the POU group trended towards being younger (51.5 years (44-63) vs. 61 years (49-70), p=0.07) and undergoing procedures in more recent years (2020: 28.6% (4/14) vs.8.5% (10/118) and 2021: 21.4% (3/14) vs. 2.5% (3/118), p=0.06). POU patients had greater prevalence of chronic pain (21.4% (3/14) vs. 4.2% (5/132), p=0.01).
The 30-day (1.52% (2/132)) and overall mortality rates (12.1% (16/132)) at a follow-up of 5.5 years (3.6-7) were comparable between the groups. Non-POU patients had longer lengths of stay during index admissions (7.3 days (5.6-10.5) vs. 5.3 days (4.8-6.8), p=0.05); however, they had lower overall readmission rates (50% (59/118) vs. 78.6% (11/14), p=0.04).
On univariable analysis (Table), only chronic pain (Odds Ratio (OR): 6.164 (95% confidence interval: 1.296-29.317), p=0.022) was significantly associated with odds of developing POU. Neither was total OME at discharge (OR: 0.996 (0.987-1.005), p=0.381), nor were OME categories associated with odds of developing POU. Analysis of non-linear relationship between total OME at discharge and POU showed a downward trend with increasing dosage of OME (Figure).
Conclusions: Postoperative opioid dosage was not associated with the development of POU; however, a history of chronic pain was associated with POU. This implies reasonable pain control regimens following ATAAD treatment. Nevertheless, individually tailored opioid regimens and close follow-up would be recommended for pain control in younger ATAAD patients with a history of chronic pain.
Authors
Danial Ahmad (1), Derek Serna-Gallegos (2), Sarah Yousef (3), James Brown (1), Carlos Diaz-Castrillon (4), Nidhi Iyanna (5), Yisi Wang (1), Floyd Thoma (1), Julie Phillippi (6), Michel Pompeu Sá (7), Johannes Bonatti (8), David Kaczorowski (9), Pyongsoo Yoon (1), Danny Chu (10), Ibrahim Sultan (2)
Institutions
(1) UPMC, Pittsburgh, PA, (2) University of Pittsburgh Medical Center, Pittsburgh, PA, (3) University of Pittsburgh, Pittsburgh, PA, (4) University of Pittsburgh, United States, (5) University of Pittsburgh Medical Center, N/A, (6) N/A, Pittsburgh, PA, (7) PROCAPE / University of Pernambuco, Recife, Pernambuco, (8) UPMC Heart and Vascular Institute, Pittsburgh, PA, (9) University of Pittsburgh Medical Center, Venetia, PA, (10) Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Poster Presenter
Danial Ahmad, UPMC
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Pittsburgh, PA
United States
Objective: Several techniques of aortic valve (AV) repair have, to date, shown safety and efficacy. One of the main contraindications to AV repair is still the presence of cusps calcification and this reduces the rate of patients eligible for this procedure. Piezoelectric surgery (PS) is based on the high frequency vibration of a metallic tip used to selectively cut calcium while sparing surrounding soft tissues. This technology can be considered a useful tool in addressing towards conservative techniques also complex valves with calcified cusps. CASE VIDEO Summary: This is a case of a 55-year-old woman with diagnosis of severe AV regurgitation and dilated ascending aorta who was suitable for aortic valve repair. The trans-esophageal echocardiography (TEE) showed a tricuspid AV with severe regurgitation and a partial fusion of right and non-coronary cusps with mild calcification of the raphe, which could compromise a successful repair. A full sternotomy is performed, and cardiopulmonary bypass established. The ascending aorta is opened, and the aortic valve exposed. AV cusps appear pliable except for the calcified raphe. The raphe is therefore opened with a sharp dissection and then calcium removed with a piezoelectric scalpel, until a pliable surface is obtained. Repair feasibility is then verified by measuring the effective height of all the three cusps with a dedicated calliper. HAART ring is sized with the dedicated spherical sizer and a 21 millimeters ring is selected. The post sutures are placed in the sub-commissural triangle with Cabrol-like configuration and the ring is lowered into the sub-valvular position. The sinus sections of the device are secured to the annulus with two interrupted looping sutures for each sinus. Ascending aorta is then replaced with a 30 mm Dacron graft. Post-procedural TEE shows a trivial residual AV regurgitation with a mean gradient of 10 mmHg. Conclusions: Nowadays, in high experienced centers, AV repair should be considered as first option in all comers with aortic regurgitation. Piezoelectric surgery helps surgeons to face also complex cases with cusps calcifications in patients otherwise considered not suitable for a conservative technique.
Authors
Antonio Spitaleri (1), Dario Brenna (1), Cristina Barbero (2), Marco Pocar (3), Giacomo Maraschioni (4), SERGIO TRICHIOLO (1), Michele La Torre (5), Mauro Rinaldi (6)
Institutions
(1) N/A, N/A, (2) AO Citta' della Salute e della Scienza di Torino, Torino, Italy, (3) Department of Cardiac Surgery, Città della Salute e della Scienza, University of Turin, Turin, Italy, Torino, NA, (4) Department of Surgical Sciences, University of Turin, Division of Cardiac Surgery, Turin, Italy., Turin, NA, (5) Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, Turin, Turin, (6) AO Citta' della Salute e della Scienza di Torino, Torino
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Poster Presenter
Antonio Spitaleri, A.O.U. Città della Salute e della Scienza di Torino
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Turin, Turin
Italy
Objective:
Patients undergoing total arch surgery are at high risk of acute kidney injury, increasing the risk of morbidity and mortality. Identifying patients at risk for severe acute kidney injury may help to improve patient outcomes. We developed a machine-learning model to identify patients at risk for new renal replacement therapy after total arch surgery.
Methods:
From our single institution prospectively maintained database, we identified a total of 235 patients who underwent total arch surgery between June 2009 and October 2022. These patients were randomly divided into training (70%) and testing (30%) sets and various eXtreme gradient boosting (XGBoost) models were constructed to predict the need for postoperative renal replacement therapy (RRT) in the cardiothoracic intensive care unit (CTICU). From the index hospitalization data, we extracted 64 input parameters including demographic information as well as preoperative and intraoperative characteristics. To assess model performance, we utilized multiple evaluation metrics, including accuracy, Brier score, area under the receiver operating characteristic curve (AUC-ROC), and area under the precision-recall curve (AUC-PR, mean average precision). We also employed a SHapley Additive exPlanation (SHAP) violin plot to discern the influence of individual features on the predictions generated by the XGBoost model.
Results:
Postoperative RRT in the CTICU was noted in 25 patients (10.6%) who underwent total arch surgery. The final XGBoost model demonstrated a cross-validation accuracy of 90% and exhibited strong calibration, as indicated by the low Brier score of 0.10. Additionally, the predictor displayed robust performance on the test dataset, achieving an accuracy of 92%. Our top-performing postoperative RRT prediction model attained an AUC-ROC of 0.78 on the training set and an AUC-ROC of 0.88 on the testing set. The SHAP violin plot assisted in elucidating the intricate decision-making process employed by our XGBoost model, offering insights into the top 10 features that exert significant influence on model predictions. Prominent risk factors linked to an elevated risk of postoperative RRT included low preoperative creatinine levels, increased intraoperative blood product transfusion, extended cardiopulmonary bypass durations, and reduced nadir hemoglobin levels.
Conclusions:
Our machine learning model provided insight into preoperative and operative factors associated with increased risk of need for post-operative renal replacement therapy. Lower creatinine, likely a byproduct of decreased muscle mass in a frail population, as well as longer cardiopulmonary bypass with more intraoperative transfusion likely reflecting lower intraoperative DO2 during the procedure were significant risk factors for developing severe kidney injury.
Authors
Adam Carroll (1), Nicolas Chanes (1), Michael Kirsch (1), Bo Chang Wu (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective:
To develop a machine learning algorithm for the precise prediction of 30-day mortality in patients presenting with acute type A aortic dissection (ATAAD).
Methods:
A retrospective analysis was conducted using data from the Michigan Medicine Aortic Dissection database, covering the period from January 1996 to February 2023. Data were retrieved from chart reviews, the Society of Thoracic Surgeons warehouse, the national death index, and the Michigan death index database.
A random forest (RF) machine learning model was used to predict 30-day mortality. Preprocessing involved addressing missing values through multiple imputation by chained equations. Continuous variables were normalized by linearly scaling each feature to a range of 0 and 1. The dataset was separated into an 80:20 ratio for the training set and held-out testing set. We performed 5-fold cross-validation and feature selection using the training set. A total of 42 features were utilized in constructing the original RF machine learning model.
Subsequently, the top 10 features, selected using the mean impurity decrease method from the original RF, were isolated. These features were then used to develop the new RF model, which was tested on the held-out testing set to mitigate overfitting. Evaluation metrics included the Area Under the Receiver Operating Characteristic curve (AUROC) and Brier Score.
Results:
Within the cohort of 1,067 patients with ATAAD, the original RF model, using 42 features, achieved a testing AUROC of 0.825 and a Brier score of 0.099. Key features, including DeBakey type 1 or 2, right upper extremity malperfusion, age, creatinine levels, glomerular filtration rate, inotrope usage, anticoagulant usage, innominate artery dissection presentation, left common carotid dissection presentation, and Body Mass Index, contributed to the RF model's predictive capacity. The new RF model, using the 10 selected features, achieved a testing AUROC of 0.841 and a Brier score of 0.101.
Conclusions:
Our study highlights the strong predictive capability of the RF model in predicting 30-day mortality among patients with ATAAD. Considering the high mortality rate in this patient group, integrating pre-operative mortality predictions could aid surgeons in their decision-making process; however, the prediction should not be the sole determinant for proceeding with surgery. Future external validation using larger cohorts ensures the generalization of our findings.
Authors
Bo Yang (1), Carol Ling (2), Alexander Shieh (3), Chi-Ching Huang (4)
Institutions
(1) University of Michigan, Ann Arbor, MI, (2) University of Michigan, Department of Cardiac Surgery, Ann Arbor, MI, (3) UT MD Anderson Cancer Center, Houston, TX, (4) N/A, Taipei, Taiwan
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Poster Presenter
Chi-Ching Huang, Michigan Medicine University of Michigan
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Taipei
Taiwan
Objectives:
Cerebral malperfusion due to acute type A aortic dissection can lead to severe neurologic deficits and even operative death. Early detection of risk for this sequela is imperative to optimize clinical decision-making and improve patient outcomes. Machine learning models have been shown to synthesize large, granular databases efficiently and accurately. We hypothesized that a machine learning model would be able to produce a novel predictive risk score for cerebral malperfusion to aid in early risk assessment.
Methods:
We retrospectively reviewed all patients undergoing surgical management for acute type A aortic dissection from 2001 to 2020 at our institution. We focused on readily available admission data that was retrieved upon initial assessment by the surgical team (i.e., prior medical/surgical history, admission laboratory values, admission imaging). Any missing data was imputed with a missRanger imputation model (RStudio). All data was then analyzed in a random forest regression machine learning model to identify key predictor variables for cerebral malperfusion (primary outcome). Risk scores were calculated for these variables using a generalized regression model. Predictive probabilities were then obtained, and the strength of the model was evaluated by the area under the curve, sensitivity/specificity, and negative/positive predictive values.
Results:
We identified 650 patients who underwent surgical repair for acute type A aortic dissection during the study period. Median age was 58.0 years old (interquartile range: 47.0-69.0). 183 (28.1%) were female. There were 119 patients (18.3%) who were diagnosed with cerebral malperfusion preoperatively. Our model determined 8 key predictor variables (score) for cerebral malperfusion: presenting comatose (2), presenting with altered mental status (2), hemiparesis on presentation (4), concomitant celiac malperfusion (1), concomitant renal malperfusion (1), prior history of stroke (1), prior history of transient ischemic attack (1), and dissection extending into either common carotid artery (1). This model had an area under the curve of 0.866 (0.798-0.933, p<0.001). For patients with a score of 1 or less, the sensitivity was 95.0%. With a score of 4 or more, the specificity was 97.0%. Table illustrates the sensitivities, specificities, positive predictive values, and negative predictive values for the different score ranges. Figure demonstrates the receiver operative curve for the model.
Conclusion:
A novel predictive risk score was developed using machine learning models to aid in the early detection of cerebral malperfusion. This model uses readily available information, is easy to calculate, and can aid the surgical team in clinical decision-making.
Authors
Alexander Mills (1), Akiko Tanaka (1), Yuki Ikeno (1), Lucas Ribe (1), Harleen Sandhu (1), Charles Miller (1), Charles Green (1), Danny Ramzy (1), Anthony Estrera (1)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX
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Poster Presenter
Alexander Mills, University of Texas Health Science Center at Houston (UTHealth Houston)
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Pearland, TX
United States
Objective: Rupture of thoracic aortic aneurysms (TAA) is a rare and life-threatening complication with high mortality rates. We sought to identify demographic and clinical predictors of aortic rupture in patients with TAA.
Methods: A retrospective review of medical records for all patients presenting to our institution with the diagnosis of TAA from 2010-2020 was conducted. Patients were stratified into two cohorts: rupture vs no rupture. Baseline characteristics, labs at admission, and post-treatment outcomes were compared between the groups. Univariate and multivariate stepwise logistic regression analysis were undertaken to identify statistically significant predictors of rupture. Imputation by median was performed If <15% data for any variable were missing. Survival was compared between the groups using Kaplan-Meier analysis.
Results: A total of 3902 TAA patients were included of which 3.7% (144/3902) had ruptured aneurysms. Median age was 71 years (61-80) and more women had ruptured TAA (55.6% (80/144) vs. 38.7% (1455/3758), p<0.001). End-stage renal disease (3.45% (3/87) vs. 0.76% (24/3144), p=0.007) was more prevalent in the rupture cohort.
Higher levels of C-reactive protein (CRP) (15.7mg/L (7.6-22.2) vs. 5mg/L (1.0 vs. 11.8), p=0.003), neutrophil-lymphocyte ratio (6.3 (3.1-12.6) vs. 4.5 (2.7 vs. 8.2), p=0.016), serum creatinine (1.06mg/dL (0.9-1.3) vs. 1.0mg/dL (0.8-1.16), p<0.001), and maximum TAA size (5.6cm (4.7-7.0) vs. 4.7cm (4.3-5.4), p<0.001) were observed in patients with ruptured aneurysms.
30-day mortality (51.4% (74/144 ) vs. 4.2% (158/3758), p<0.001) was higher in the rupture cohort. Overall mortality was 31.6% (1233/3902) at a followup of 3.6 years (1.4-6.8). Kaplan-Meier survival analysis further showed significantly worse survival in the rupture cohort (Logrank p=<0.001) (Figure).
The multivariable logistic regression model (C-statistic: 0.80) showed that white race (Odds Ratio (OR): 0.432 (95%CI: 0.216-0.866), p=0.018) was protective for risk of rupture while female sex (OR: 2.269 (1.036-4.971), p=0.041), increased neutrophil-lymphocyte ratio (OR: 1.023 (1.001-1.046), p=0.039) and maximum aneurysm size (OR: 1.703 (1.436-2.020), p<0.001) significantly increased the odds of rupture.
Conclusions: Non-white women with high neutrophil-lymphocyte ratios, CRP, and maximum aneurysm sizes were more predisposed to TAA rupture. Given the poor outcomes associated with aortic rupture, further validation of inflammatory markers and patient demographics as predictors of rupture is needed to define high-risk populations and initiate timely interventions.
Authors
Danial Ahmad (1), Derek Serna-Gallegos (2), Nidhi Iyanna (3), Jack Donohue (4), Yisi Wang (1), Floyd Thoma (1), Sarah Yousef (5), James Brown (1), Julie Phillippi (6), Michel Pompeu Sá (7), Johannes Bonatti (8), David Kaczorowski (9), Pyongsoo Yoon (1), Danny Chu (10), Ibrahim Sultan (2)
Institutions
(1) UPMC, Pittsburgh, PA, (2) University of Pittsburgh Medical Center, Pittsburgh, PA, (3) University of Pittsburgh Medical Center, N/A, (4) N/A, N/A, (5) University of Pittsburgh, Pittsburgh, PA, (6) N/A, Pittsburgh, PA, (7) PROCAPE / University of Pernambuco, Recife, Pernambuco, (8) UPMC Heart and Vascular Institute, Pittsburgh, PA, (9) University of Pittsburgh Medical Center, Venetia, PA, (10) Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Poster Presenter
Danial Ahmad, UPMC
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Pittsburgh, PA
United States
Objective: To determine the predictors and identify the impact of aneurysmal pathology on in-vivo aortic distensibility, ascending aortic global circumferential strain (GCS), and stiffness index (SI).
Methods: Patients with ascending aortic aneurysm undergoing aortic replacement and patients undergoing coronary artery bypass grafting (CABG) underwent intraoperative transesophageal and ascending epiaortic ultrasound; CABG patients were only enrolled if the maximum ascending aortic diameter was less than 4.0 cm and there was no evidence of aortic value disease on preoperative imaging. In-vivo biomechanical assessment was performed using 2D image speckle tracking of short axis images to evaluate mechanical outcomes (distensibility, GCS, and SI). Unadjusted and multivariable mixed-effects modeling, as well as machine learning gradient boosting models were implemented to characterize the relationships and independent effect of covariates on biomechanical outcomes.
Results: Between 7/2021-11/2023, a total of 369 short-axis images of the ascending aorta were acquired from 95 patients undergoing aneurysm repair. Additionally, 129 images were obtained from 39 patients undergoing CABG. Images were obtained from the aortic root (94 aTAA, 36 CABG), the proximal (91 aTAA, 31 CABG), mid (92 aTAA, 31 CABG), and distal (92 aTAA, 31 CABG) ascending aorta. The aneurysm cohort was younger (55 ± 15 years vs 67±10 years, P<.01), had a greater prevalence of bicuspid aortic valve (53 [56%] vs 0, P<.01), and were less likely to have hypertension (57 [60%] vs 39 [100%], P<.01). When comparing the aneurysm and CABG cohorts, patients with aneurysm demonstrated a higher distensibility (9.1 ± 6.9 mmHg-1 vs 6.2 ± 4.5 mmHg-1, P<.01, Figure 1A), higher GCS (6.4 ± 4.5% vs P<.01), and a lower SI (13.1 ± 9.3 vs 18.1 ± 9.7, P<.01). Multivariable mixed-effects and gradient boosting modeling of the aneurysm cohort demonstrated that distensibility was negatively associated with age (β= -.17, P<.01) and had the largest positive association with the root region (βRoot =8.4, βProx = 1.2, βMid =.2, P<.01, Figure 1B). Similar results were demonstrated for the GCS and SI. In the CABG cohort, region was similarly positively associated with distensibility (βRoot =5.6, βProx =.02, βMid =-.2, P<.01, Figure 1C) and GCS (βRoot =3.3, βProx =.3, βMid =-.3, P<.01). SI was negatively associated with region (βRoot =-11, βProx =-2.4, βMid =.9, P<.01) and ascending aortic length (β =-.1, P=.04) and positively associated with age (β=.2, P=.02). When examining both cohorts together the mixed effect model of distensibility demonstrates a negatively associated interaction term between age and the aortic area at the image location (β =-.006, P=.05), and positive association with the aortic area at the image location (β =.14, P=.04), the ascending aortic length (β =.05, P=.01), and aortic proximity (βRoot =7.5, βProx =.7, βMid =-.04, P<.01).
Conclusions: Across both cohorts, lengthwise regional variation consistently emerges as a significant predictor of in-vivo biomechanics. However, age had a more pronounced effect in the aneurysm cohort. The presence of an ascending aneurysm may exacerbate age related aortic tissue dysfunction. Clinical judgement is necessary to determine the optimal surgical timing balancing age and ascending aortic area.
Authors
Abigail Snyder (1), Benjamin Kramer (2), Matthew Thompson (3), Ashley Lowry (4), Eugene Blackstone (1), Jennifer Hargrave (1), Eric Roselli (1)
Institutions
(1) Cleveland Clinic, Cleveland, OH, (2) Cleveland Clinic, United States, (3) Cleveland Clinic, Lakewood, OH, (4) Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, OH
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Poster Presenter
Abigail Snyder, Cleveland Clinic
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Cleveland, OH
United States
Introduction
Preexisting comorbid severe lung disease present a unique challenge for patients who require elective or semi-elective aortic surgery. Intraoperative and post operative medical management can include methylpredinsone, inhaled pulmonary vasodilators, beta-2 agonists. In select cases mechanical circulatory support options, such as immediate venovenous extracorporeal membrane oxygenation (VV ECMO) can act as a bridge from cardiopulmonary bypass (CPB). Minimally invasive cardiac surgery, with peripheral drainage cannulation can be used initially for CPB and then for extracorporeal membrane oxygenation as a bridge to rapid recovery. Here we describe 3 cases of elective peripheral cannulation for CPB converted to VV ECMO in patients requiring aortic surgery with concomitant severe lung disease.
Methods
All patients had preoperative pulmonary function testing and CT chest imaging. Cannulation was performed using a 25 French Medtronic (Minneapolis, MN) femoral venous multiorifice drainage cannula and a 21 French Medtronic internal jugular drainage cannula. These two cannulas were Y-bifurcated together as inflow to CPB. At the conclusion of the case after weaning CPB and full reversal of heparin, the aortic cannula was removed and the y-connector in the venous was removed. The femoral cannula was then withdrawn into the IVC/RA junction. A Spectrum medical (Glouster, UK) CP22 pump head and Spectrum Medical Dual Chamber oxygenator were connected to establish VV ECMO. Anti-coagulation was not used for the duration of VV ECMO. VV ECMO flow was maintained at > 4.5 liters per minute and sweep and FiO2 gas flow as titrated as clinically indicated.
Results
Three patients had preoperative planning which included consent for for full VV ECMO support at the conclusion of CPB. The indication for AVR was endocarditis for case 1 and severe aortic regurgitation for case 2 and 3. All three patients had severely reduced lung function. The first case had severe COVID ARDS and was intubated semi-electively prior to the day of surgery. The patient had a restrictive pattern on PFT, with severely reduced FEV1 and severely reduced DLCO on PFTs. The second case had an FEV1 of 31.8% predicted. CT imaging revealed centrilobar lung destruction. The last patient had a predicted FEV1 of 62% with a 42 year smoking history and severe COPD. All 3 patients were successfully extubated from mechanical ventilation and VV ECMO was weaned on day 4, day 1, and day 1 respectively. No ECMO complications were noted. No post operative bleeding was encountered.
Conclusion
VV ECMO can be used as a bridging tool for patients with severe lung disease with high post operative STS risk for pulmonary complications and high risk for prolonged mechanical ventilator. With the advent of MIS aortic surgery, in situ cannulas can be used as a platform for conversion to VV ECMO post CPB. Preoperative planning is necessary to accomplish this transition. With high flow, low shear stress, anticoagulation free VV ECMO is possible, thus mitigating the risk for bleeding post operatively. If RA and or RCP isolation is needed then the cannulas will need to be positioned for correct caval snaring.
Authors
Asad Usman (1), Joyce Ho (1), Jamie Bloom (1), Vincent Sakks (1), Kendall Lawrence (1), Chase Brown (1), Audrey Spelde (1), Jacob Gutsche (1), Wilson Szeto (1), Joseph Bavaria (1)
Institutions
(1) Hospital of the University of Pennsylvania, Philadelphia, PA
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Poster Presenter
Asad Usman
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Philadelphia, PA
United States
Objective: Conflicting evidence exists regarding the impact of pregnancy on aortic aneurysm behavior. Here, we aim to assess the pattern of thoracic aortic size changes across pregnancy, to characterize incidence and timing of pregnancy-associated arterial complications and to analyze trends of management of high-risk pregnancies due to the presence of thoracic aortic aneurysm.
Methods: Electronic health record charts of thoracic aortic aneurysm patients with pregnancy and/or delivery at a single healthcare delivery network were reviewed.
Information was collected regarding demographics, aortic size from before, during and after pregnancy period where available, possible arterial complications, and clinical management of pregnancy.
Results: Twenty-seven patients with a total of 98 pregnancies (median per patient=3, IQR 2,4) were identified. Data were available for 42 pregnancies between 2011 and 2023.
At the time of the first index pregnancy, 7/27 mothers had no known diagnosis of thoracic aortic aneurysm despite 2 of the 7 patients known to have connective tissue disease. Rapid aortic size increase was observed in women with heritable thoracic aortic disease (HTAD) (N=14/22*) with an average growth rate of 0.1mm/ month (Fig. 01). No type A aortic dissection was noted in relation to pregnancy. Pregnancy-associated arterial complications (N=3, SCAD of LAD, IMH of descending aorta, rupture of the celiac artery) as well as maternal mortality (N=1) was observed in the peripartum period, solely in women with HTAD. Of the 20 patients that carried the diagnosis of thoracic aortic aneurysm prior to or during a total of 32 pregnancies, 25% (N=5/20) had received preconception counselling, 45% (N=9/20) received advice for strict blood pressure control, 80% (N=16/20) had aortic size monitoring during pregnancy via echocardiography and MRA imaging, and only 10% (N=2/20) required a CT surgeon on standby during delivery.
Conclusions: Pregnancy appears to impact growth rate of aortic aneurysm, particularly in heritable thoracic aortic disease. No acute aortic events were observed during pregnancy, however risk of pregnancy-related arterial complications is higher during peripartum period vs non-pregnancy period. Aortic surveillance during pregnancy is variable.
Authors
Afsheen Nasir (1), Christina Waldron (2), Prashanth Vallabhajosyula (1), Roland Assi (3)
Institutions
(1) Yale New Haven Hospital, New Haven, CT, (2) Yale School of Medicine, New Haven, CT, (3) Yale University School of Medicine, New Haven, CT
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Poster Presenter
Afsheen Nasir, Yale New Haven Hospital
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New Haven, CT
United States
Preoperative Cardiac Troponin I Predicts Early Outcomes in Surgery for Acute Type A Aortic Dissection
Sangyu Zhou1, Yanxiang Liu1, Xiaogang Sun1
1Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Objective: To explore the association between preoperative cardiac troponin I (cTnI) and early outcomes in patients with acute type A aortic dissection (ATAAD).
Methods: The medical records of patients with ATAAD who underwent aortic surgery from April 2018 to December 2022 were retrospectively reviewed. Logistic regression analysis and linear regression analysis were performed to determine the association between cTnI and early outcomes. Receiver-operating characteristic (ROC) curve was performed to estimate the cut-off value of cTnI in the prediction of adverse events.
Results: A total of 535 patients were enrolled, of whom 163 (30.5%) had elevated cTnI. Primary endpoint of in-hospital mortality was 6 (3.7%) for the cTnI-positive group and 5 (1.3%) for the cTnI-negative group. The cTnI-positive group had a higher incidence of concomitant coronary artery bypass grafting and postoperative acute kidney injury Grade Ⅲ, and underwent longer time of cardiopulmonary bypass, aortic cross-clamp time, and intensive care unit (ICU) stay. Multivariate logistic regression analysis identified that preoperative cTnI was an independent risk factor of in-hospital mortality. ROC curve revealed that the cut-off value of cTnI in predicting in-hospital mortality was 0.28 ng/mL. Multivariate linear regression analysis showed that preoperative cTnI was also significantly associated with ICU stay.
Conclusions: Preoperative cTnI was a robust risk predictor of in-hospital mortality in patients with ATAAD undergoing aortic surgery and the cut-off value was 0.28 ng/mL. It was also strongly associated with ICU stay. Preoperative cTnI helped identify patients with high risk and provided information about prognosis.
Authors
Sangyu Zhou (1), Xiaogang Sun (2), Yanxiang Liu (3)
Institutions
(1) Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and, Beijing, NA, (2) Fuwai Hospital, Beijing, Xicheng Distric, (3) Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Xicheng
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Poster Presenter
Sangyu Zhou, Fuwai Hospital, Peking Union Medical College
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Beijing, Beijing
China
Objective. Depression is highly prevalent in patients with aortic diseases. While depression has been shown to predispose patients to adverse outcomes after surgery, its impact on postoperative outcomes in Stanford Type A Aortic Dissection (TAAD) has not been established. This study aimed to conduct a population-based examination of the effect of preoperative depression on in-hospital outcomes after TAAD using the National/Nationwide Inpatient Sample (NIS) database, the largest all-layer database in the US.
Methods. Patients undergoing TAAD repair were identified in NIS from the last quarter of 2015-2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients with and without preoperative depression, adjusted for demographics, comorbidities, hospital characteristics, primary payer status, and transfer status.
Results. There were 321 (7.50%) patients with depression and 3,961 (92.50%) non-depressive patients who went under TAAD repair. Patients with and without depression had comparable in-hospital mortality (11.84% vs 15.37%, p=0.35). However, Patients with depression had a higher risk of hemorrhage/hematoma (83.49% vs 76.6%, aOR 1.593, 95 CI 1.161-2.184, p<0.01) and a higher rate of transfer out (40.81% vs 32.62%, aOR 1.396, 95 CI 1.077-1.81, p=0.01). All other in-hospital complications, hospital length of stay (LOS), and total hospital charge were all comparable between patients with and without depression.
Conclusion. Preoperative depression is associated with a higher risk of bleeding after TAAD repair. This may be due to anti-depression treatment, such as Selective Serotonin Reuptake Inhibitors (SSRIs), that can disrupt platelet function and lead to abnormal bleeding. While preoperative depression is not associated with other major outcomes, preoperative screening for depression before TAAD and corresponding preoperative blood management may be helpful in avoiding bleeding complications in patients with depression
Authors
Renxi Li (1), Qianyun Luo (2), Stephen Huddleston (2)
Institutions
(1) The George Washington University, Washington, DC, (2) University of Minnesota, Minneapolis, MN
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Poster Presenter
Stephen Huddleston
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Minneapolis, MN
United States
Objective
With improvements in management of aortic pathology, including type A dissection, patients are more likely to survive their index pathology and over time have degeneration of their arch that necessitates a re-do arch replacement. It remains unclear if prior arch surgery confers additional risk of neurologic or other adverse outcomes in patients undergoing total arch replacement. We sought to evaluate if prior arch surgery requiring circulatory arrest increased the risk of stroke, or other morbidity and mortality in patients undergoing elective total arch replacement.
Methods
Using our prospectively maintained retrospective institutional aortic database, we identified patients who were undergoing elective total arch replacement. The patients were stratified into two cohorts: those who had a previous arch replacement requiring circulatory arrest, and those who did not.
Results
In total, 113 patients were identified from 2011-2023 who underwent elective total arch replacement. Of these, 44 had no prior procedure requiring circulatory arrest, and 69 had a prior arch replacement requiring circulatory arrest. Regarding demographic characteristics, the only variable of significance was younger age (p=0.014) in repeat circulatory arrest patients. Cardiopulmonary bypass times (p=0.001), and intraoperative administration of FFP (p=0.023) and platelets (p=0.005) were higher in repeat circulatory arrest patients, with a trend towards increased circulatory arrest times (p=0.058). No differences were found in length of stay, ICU length of stay, or post-operative morbidity or mortality between the two cohorts.
Conclusion
Although there were increases in cardiopulmonary bypass time and in intra-operative administration of coagulation products, likely related to scar tissue from prior aortic surgery, there was no significant difference between the two cohorts in post-operative outcomes. Patients undergoing total arch replacement should be counseled that prior aortic arch surgery does not increase their risk of stroke or other adverse outcomes.
Authors
Adam Carroll (1), Nicolas Chanes (1), Michael Kirsch (1), Ananya Shah (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objectives:
Neutrophil-to-lymphocyte ratios (NLR) are an inexpensive and readily available biomarker that measures ongoing acute inflammation. We hypothesized that an elevated preoperative NLR was an independent predictor of worse outcomes following surgical repair of acute type A aortic dissection, especially if it continued to be elevated 24 hours from symptom onset.
Methods:
We retrospectively evaluated consecutive patients presenting with acute type A aortic dissection who underwent surgical repair from 2001 to 2020 at a single institution. Preoperative NLR values were calculated. Median and quartile values of NLR were used as cutoff points, which were evaluated by a receiver operating curve and area under the curve. A subgroup of patients who underwent repair 24 hours after symptom onset were evaluated to see if a persistently elevated NLR would portend worse outcomes. The primary outcome was in-hospital death. Secondary outcomes were stroke, atrial fibrillation, coagulopathy, acute renal failure, and unplanned reoperation. Univariate and multivariate logistic regression were used to evaluate preoperative NLR as a predictor variable for these postoperative outcomes in the overall cohort as well as the pre-identified subgroup.
Results:
613 of the 650 patients (94.3%) had preoperative NLR values. The median preoperative NLR value was 7.8 (interquartile range: 4.6-12.3). The primary outcome (in-hospital death) occurred in 94 patients (14.5%), and 317 (48.7%) underwent repair more than 24 hours from symptom onset. For all patients, the median preoperative NLR was slightly higher in the primary outcome group but not statistically significant (8.0 vs. 7.7, p=0.325). For those that presented after 24 hours from symptom onset, the preoperative NLR was much higher in the primary outcome group (8.6 vs. 6.8, p=0.037). Median NLR value of 7.8 was used as a cutoff point for predicting in-hospital death [AUC; 0.620 (0.471-0.769)]. In patients who underwent repair after 24 from onset of symptoms, NLR of 7.8 was a significant predictor of the primary outcome, coagulopathy, and acute renal failure following repair (Figure). On multivariate analysis, malperfusion and age >70 were the only predictors that remained significant for in-hospital death when combined with median preoperative NLR and emergent procedure (Figure).
Conclusions:
Preoperative NLR is an accessible and inexpensive inflammatory biomarker with prognostic implications in surgical repair of ATAAD. It appears most useful to predict postoperative complications in patients undergoing repair more than 24 hours from symptom onset, which might signify ongoing acuity in illness and portend worse postoperative outcomes.
Authors
Alexander Mills (1), Gregory Estrera (1), Akiko Tanaka (1), Lucas Ribe (1), Yuki Ikeno (1), Harleen Sandhu (1), Charles Miller (1), Anthony Estrera (1)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX
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Poster Presenter
Alexander Mills, University of Texas Health Science Center at Houston (UTHealth Houston)
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Pearland, TX
United States
Objective: The mechanical strength of the false lumen wall (FLW) prevents rupture in aneurysms secondary to Chronic Type B Aortic Dissection (CTBAD), despite having partial thickness. The FLW consists primarily of adventitia, a key component in the open repair of dissections. This study sought to elucidate mechanisms of FLW mechanical properties which remain unclear.
Methods: The FLW from 14 patients (9 CTBAD and 5 Acute Type A Aortic Dissection) who underwent open aortic replacement was analyzed, and compared to iatrogenically dissected, manually peeled FLW from 6 normal transplant donor descending aortas designated as a control group (C-FLW). Biaxial tension testing in the circumferential (Circ) and axial directions was performed on the CTBAD-FLW (n=9), Acute-A-FLW (n=5) and C-FLW (n=6) tissues. Stress-strain curves were created (Fig. 1a), and a lower and higher tangent modulus (LTM & HTM) was determined for each sample to assess tissue stiffness. A histologic analysis of the tissue microstructure was performed on the collagen and elastin fibers. Quantification of the composition of collagen and elastin fibers was performed by calculating the fibers' volume fraction (VF) from Z-Stack scans (n=106 locations in 15 FLW samples [5 per group], 4-9 locations per sample based on thickness).
Results: In Circ, both LTM and HTM of CTBAD-FLW were significantly larger than those of C-FLW and Acute-A-FLW (Fig. 1b, c). In axial, HTM of the FLW was also larger than that of C-FLW and Acute-A-FLW (Fig. 1c), and LTM of Acute-A-FLW was smaller than that of C-FLW (Fig. 1b). Histology demonstrated a higher concentration of organized collagen in CTBAD-FLW compared to C-FLW and Acute-A-FLW, and a lower concentration of elastin (Fig. 1d). Quantification of the collagen/elastin profile in the tissue demonstrated a significant increase in the VF of collagen fibers and a significant decrease in the VF of elastin fibers when comparing CTBAD-FLW versus Acute-A-FLW & control-FLW (Fig. 1e). The VF of collagen fiber is larger than that of elastic fibers within CTBAD-FLW, but smaller than that of elastic fibers within Acute-A-FLW & control-FLW (Fig. 1e).
Conclusions: The FLW is stiffer in CTBAD compared to either normal or acute aortic dissection tissue due to increased collagen and decreased elastin. This change in the composition of FLW extracellular matrix may be a protective adaption to prevent aortic rupture and explains the importance of the adventitia in the surgical repair of aortic dissection.
Authors
Hai Dong (1), Minliang Liu (1), Hannah Cebull (2), Marina Piccinelli (2), John Oshinski (3), John Elefteriades (4), Rudolph Gleason (1), Bradley Leshnower (5)
Institutions
(1) Georgia Institute of Technology, Atlanta, GA, (2) Emory University, Atlanta, GA, (3) Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, (4) Yale New Haven Hospital, New Haven, CT, (5) Emory University Hospital, Atlanta, GA
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Poster Presenter
Hai Dong
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GA
United States
Objectives: Ischemic stroke causes time-dependent neuronal injury and is a major public health burden. We developed a novel method for performing ischemic stroke protein signature discovery by analyzing plasma collected during aortic arch surgery with deep hypothermic circulatory arrest (DHCA). This work aims to increase our understanding of stroke during aortic arch surgery as well as identify candidate biomarkers that can be utilized for ischemic stroke diagnosis.
Methods: A total of 21 patients were enrolled (DHCA n=17 and CABG controls n=4). Blood samples were collected at various timepoints during the operation as well as the subsequent hospitalization. All patients underwent post-operative neurologic exam by a trained provider as well as brain MRI. Diffusion weighted imaging (DWI) lesions were volumetrically assessed. Plasma samples were then analyzed by a novel mass spectrometry (MS) technique called Mag-Net, which utilizes an extracellular vesicle enrichment strategy that captures membrane-bound particles from plasma.
Results: Two patients (12%) in the DHCA group had a clinical stroke compared to none of the CABG controls. Fourteen (82%) of DHCA patients had DWI lesions on post-operative MRI compared to 2 (50%) CABG patients. DWI infarct volume was significantly greater in the DHCA group (56 mm3 vs. 3 mm3, p=0.03). A total of 5,376 proteins were identified, 1,125 of which showed a significant difference between paired pre- and post-operative concentrations. Of these, 261 proteins had significantly greater expression among the infarct group as compared to the non-infarct group. Analysis of enrichment pathways of these 261 unique proteins revealed many known stroke pathways (interleukins, FAS, complement pathway, EGF, IGF-1, etc.), providing validation of this methodological approach.
Conclusions: We have developed a novel approach for ischemic stroke protein signature discovery utilizing plasma obtained from patients undergoing aortic arch surgery with DHCA. The results of this preliminary work reveal a distinctive proteomic expression when ischemic infarct occurs in patients undergoing DHCA. Further expansion of this work is needed to better define candidate biomarkers that may be predictive of presence and severity of ischemic stroke. This would increase our understanding of the safety of aortic arch surgery as well as potentially aid in diagnosis of ischemic stroke.
Authors
Chris Burke (1), Michael Levitt (1), Michael MacCoss (1), Andy Hoofnagle (1), Christine Wu (1), Theo Bammler (1), James MacDonald (1), Kate Carroll (1), Jonathan Weinstein (1), Scott DeRoo (1)
Institutions
(1) University of Washington, Seattle, WA
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Poster Presenter
Christopher Burke, University of Washington
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Seattle, WA
United States
Introduction: Data about proximal aortic reoperation after Type A dissection are mostly based on single center experience. We aimed to investigate the fate of proximal aorta after Type A dissection, utilizing a large international multicenter registry.
Methods: Data were extracted from an observational, multicenter, retrospective cohort study including 3902 patients who underwent surgery for TAAD at 18 tertiary hospitals. A total of 115 patients underwent a reoperation at the level if the proximal aorta. Freedom from reoperation was estimated with cumulative incidence survival and Fine-Gray competing risk regression model was used to identify independent risk factors for reoperation.
Results: Patients who had a proximal reoperation were younger (57 years vs 65 years, p<0.01), had higher incidence of Marfan syndrome (5.2% vs 1.8%, p 0.02). The median follow-up was 2.2 years (range, 0-17 years). Incidence of proximal reoperation at 5, 10 and 15 years was 2.9%, 4.4% and 6.5% respectively. Age, extension of the dissection in the left coronary were associated with proximal reoperation.
Conclusion: Type A aortic dissection repair was associated with a low proximal reoperation rate. Age and extension of the dissection were associated with reoperation.
Authors
Matteo Pettinari (1), Antonio Dell'Aquila (2), Giuseppe Gatti (3), Andrea Perrotti (4), Tatu Juvonen (5), Mikko Jormalainen (6), Mauro Rinaldi (7), Sven Peterss (8), Marek Pol (9), Igor Vendramin (10), Francesco Nappi (11), Antonio Fiore (12), Angel Pinto (13), Joscha Buech (14), Javier Rodriguez Lega (15), Fausto Biancari (16)
Institutions
(1) Universitaires Cliniques Saint Luc, Belgium, (2) South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Lappeenranta, NA, (3) Azienda Sanitaria Universitaria Giuliana Isontina, Trieste, NA, (4) N/A, Besancon, France, (5) Helsinki University Hospital, Helsinki, Finland, (6) HUS Meilahti Hospital, Helsinki, Finland, (7) AO Citta' della Salute e della Scienza di Torino, Torino, (8) University Hospital Munich, Munich, Germany, (9) Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital, Prague, NA, (10) University Hospital of Udine, Udine, italy, (11) Centre Cardiologique du Nord, Paris, France, (12) Hôpitaux Universitaires Henri Mondor, Creteil, NA, (13) N/A, Madrid, (14) LMU University Hospital, Munich, NA, (15) N/A, N/A, (16) Helsinki University Hospital and University of Helsinki, Helsinki, NA
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Poster Presenter
Matteo Pettinari, Catholic University of Louvain
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Lubbeek
Belgium
Objective: Re-intervention of the aorta poses a technical challenge and risk of iatrogenic injury to surrounding structures due to significant scar tissue. The pulmonary arteries (PA) are at particular risk for injury, especially in distal ascending interventions. We hypothesize that when a PA injury does occur, if recognized and repaired at the time of surgery, patients are not at risk for adverse postoperative outcomes.
Methods: All patients who underwent re-do sternotomy for aortic arch or root intervention in our single institution prospectively maintained database between February 2010 and December 2023 were reviewed. In total, 238 patients were identified for analysis. Patients were stratified into two cohorts based on whether PA injury occurred. Pre-, intra- and post-operative outcomes were analyzed.
Results: Of the 238 patients who underwent re-do sternotomy for aortic intervention, 34 (14.3%) required PA repair and 204 (85.7%) did not require PA repair. Patients who underwent PA repair were more likely to undergo more extensive aortic intervention (p<0.001), with the majority occurring in total arch replacement (70.6%). Notably, patients who required PA repair had significantly longer cardiopulmonary bypass time (p<0.001), cross clamp time (p=0.014) and circulatory arrest time (p<0.001). When separated by procedure type, significant differences remained in total arch cardiopulmonary bypass time and cross-clamp time, but not with circulatory arrest time. No significant difference was present in any of the three times for hemiarch repair, however, the total number of PA injuries in hemiarch was small (N=7). PA injury was associated with greater administration of intra-operative FFP, but not other blood products. PA injury was not associated with any significant difference in post-operative outcomes, including risk of open chest or take back for bleeding, blood product transfusion, hospital or ICU length of stay, and post operative morbidity or mortality.
Conclusions: PA injury in re-do sternotomy is a common injury, that is more likely to occur with more extensive & complex aortic reinterventions. PA injury is significantly associated with longer cardiopulmonary bypass times and aortic cross clamp times in total arches, but not hemiarches, likely reflective of the more extensive tissue dissection required in total arches. However, when PA injury occurs and is recognized it does not increase the risk of post-operative morbidity or mortality.
Authors
Adam Carroll (1), Nicolas Chanes (1), Ananya Shah (1), Zihan Feng (1), Michal Schafer (1), Kelly Higa (1), Jintong Liu (1), Jacob Edwards (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objectives
Determining the feasibility of valve-sparing aortic root replacement (VSRR) and achieving a successful repair requires a comprehensive understanding of the aortic root, which involves accurate preoperative measurements using currently available imaging modalities. Most relevant prior studies focused on parameters of the aorta, and only a few studies have evaluated the cusp parameters, which play a critical role in competent valve function. In this study, we examined whether the cusp profiles obtained from preoperative 3-D computed tomographic (CT) have acceptable degrees of agreement with actual intraoperative measurements.
Methods
In this prospective trial, we enrolled 32 consecutive patients (median 53.5 yrs, 29–79, 5 women) undergoing VSRR with a reimplantation technique from June 2021 to May 2022. The aortic cusp profiles, including the free-margin length and geometric height, were measured on preoperative cardiac CT. Comparisons between preoperative cardiac CT and intraoperative measurement of the aortic valve cusp were performed by Bland–Altman plots and the interclass-correlation method.
Results
Six patients had a bicuspid aortic valve, and 4 (12.5%) had Marfan syndrome. The degree of preoperative aortic insufficiency (AI) was non-to-trivial in 2 (6.3%), mild in 3 (9.4%), moderate in 5 (15.6%), and severe in 22 (68.8%). The mean differences in free-margin length between the two measurements were -3.29 mm (95% CI, -15.05–8.46 mm), -3.74 mm (95% CI, -16.47–8.98 mm), and -1.95 mm (95% CI, -11.96–8.06 mm) for the left, right, and non-coronary, respectively, with an acceptable strength of agreement (interclass correlation coefficient, 0.81, 0.80 and 1.87 for left-, right-, and non-coronary, respectively). The mean differences in geometric height were 0.31 mm (95% CI, -2.90–5.51 mm), 2.15 mm (95% CI, -3.73–8.02 mm,) and 1.93 mm (95% CI, -2.67–6.53 mm) for left, right, and non-coronary, respectively. There was a moderate strength of agreement (interclass correlation coefficient, 0.69, 0.44, and 0.60 for left-, right-, and non-coronary, respectively) for the cusp geometric height. During the VSRR, cusp plication was needed in 7 (21.9%) to correct the cusp asymmetry. Postoperative echocardiography showed none-to-mild AI in 31 (96.9%) patients, while 1 had mild-to-moderate AI.
Conclusions
The preoperative CT measurements of the aortic valve cusp showed reasonable predictive power for the free-margin length, albeit only limited accuracy for the geometric height measurement.
Authors
Hong Rae Kim (1), Joon Bum Kim (2)
Institutions
(1) Asan Medical Center, Seoul, (2) Asan Medical Center, Seoul
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Poster Presenter
Hong Rae Kim, Asan Medical Center
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Gangnamgu, Seoul
South Korea
Objective
Aortic root replacement is commonly performed to address root pathology and is overall associated with low rates of morbidity and mortality. However, some prosthetic roots will degenerate requiring re-do replacement, or the prosthetic root will be afflicted with another pathology such as endocarditis or thrombosis. Aortic re-do root operations pose a significant technical challenge, and previous studies have sought to clarify associated perioperative outcomes. Most previous analyses have compared re-do root operations with de novo chests undergoing root replacement that have not had a previous operation. Comparisons with de novo chests have shown similar perioperative mortality rates; however, re-do roots have been associated with longer cardiopulmonary bypass and cross clamp times, and significant short-term morbidity. However, we believe that further investigation is necessary to compare true re-do roots (TRR) with patients undergoing re-do sternotomy who have not had a previous root replacement (no previous root, NPR). We sought to clarify outcomes comparing the two groups.
Methods
We performed a retrospective review of our database for patients who underwent aortic root replacement at our institution from 2009-2023. In total, 18 patients had a previous root operation and were undergoing a repeat root operation (true re-do root), and 76 patients had a previous sternotomy for a non-root operation and were undergoing root replacement (no previous root). Root replacement technique included Davids, Bentalls, BioBentalls, and Homograft procedures. Concomitant aortic procedures were considered and included as part of the analysis.
Results
No significant difference was found between baseline patient demographics and comorbidities. The majority of TRRs were urgent or emergent (55.6%), however this difference was not statistically significant compared to NPRs (p=0.290). TRRs were more likely have connective tissue disease (p=0.024), however the number of patients in each cohort was small. No differences were found in cardiopulmonary bypass, cross clamp, or circulatory arrest time. There was no significant difference in perioperative blood product administration, post-operative pacemaker rate, ICU-related complications, or mortality. There was no significant difference in ICU length of stay, however, TRRs had a longer overall hospital length of stay (p=0.028).
Conclusion
In patients with a non-native chest, outside of total length of stay, there is no difference in perioperative morbidity and mortality between TRRs and NPRs. If root intervention is potentially indicated at index operation, it should be performed without concern that re-do root replacement poses additional risk.
Authors
Adam Carroll (1), Nicolas Chanes (1), Michal Schafer (1), Zihan Feng (1), Jintong Liu (1), Ananya Shah (1), Jacob Edwards (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objectives: There are few studies that have evaluated the outcomes of patients undergoing a re-operative aortic root replacement after initial aortic valve replacement (AVR), or root surgery. The objective of this study was to evaluate the characteristics and outcomes of patients undergoing re-operative root replacement.
Methods: We evaluated a single-center cardiac surgery database from January 2014 to June 2023 to identify patients undergoing re-operative root replacement who had prior aortic valve, aortic root, ascending aortic, or any combination of these surgeries. Patients undergoing other prior cardiac procedures such as other valve repair/replacement, coronary artery bypass grafting, descending thoracic aortic surgery, or aortic arch surgery were excluded. Patient characteristics and outcomes were evaluated using descriptive statistics.
Results: A total of 59 patients (median age 63 years, 61% male) underwent re-operative root replacement during the study period after index aortic surgery. 49% had prior AVR, and 51% had prior root replacement. The indication for reoperation was predominantly due to new-onset aneurysm/pseudoaneurysm formation (39%), followed by degeneration of the initial prosthesis (34%) and endocarditis (27%). The median time between index surgery and reoperation was 8 (5-14) years. History of hypertension, type 2 diabetes, and prior MI were present in 81%, 20%, and 20% of patients, respectively. Median left ventricular ejection fraction was 55% (50-60) and creatinine was 1.0 mg/dl (0.8-1.4). The operative mortality was 6.4%, and the incidence of complications such as stroke, reoperation for bleeding, and renal failure were 3.4%, 7.1%, and 3.4%, respectively. Of 59 patients, 43 were seen again at a 1-year follow-up (median follow-up 2.5 years). One patient did require a late pacemaker placement, and none required a cardiac re-operation.
Conclusions: This single-center experience shows that re-operative aortic root replacement after prior AVR or root replacement is associated with acceptable early and mid-term mortality. No patients required late re-reoperations for the ascending aorta. Re-operative aortic root replacement may be a safe procedure for a select group of patients. A larger collaborative cohort may identify risk factors for adverse operative outcomes.
Authors
Toyokazu Endo (1), Jaimin Trivedi (1), Priyadarshini Chandrashekhar (1), Michele Gallo (1), Erin Schumer (1), Brian Ganzel (1), Mark Slaughter (1), Siddharth Pahwa (1)
Institutions
(1) University of Louisville School of Medicine, Louisville, KY
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Poster Presenter
Toyokazu Endo
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Louisville, KY
United States
Objective
The purpose of this study was to characterize the impact of requiring a tracheostomy on readmission within 1-year and survival after surgical repair of acute type A aortic dissection.
Methods
Retrospective analysis of patients undergoing surgery for acute type A aortic dissection (ATAAD) from 2010 to 2020. Comparative analyses were performed between patients with and without postoperative tracheostomy. Resource utilization was defined by the number of readmissions during the first year after the index operation. Kaplan-Meier function and multivariable Cox regression analysis were used to evaluate longitudinal survival after discharge.
Results
552 patients underwent repair for ATAAD, with 9.4% (n=52) requiring tracheostomy. The median number of days from surgery to the need for tracheostomy was 12 days (IQR 8-17). There were no significant differences between the tracheostomy and non-tracheostomy cohorts in terms of age (63.6 vs. 61.3; p=0.23). However, patients with tracheostomy were more likely to have a higher BMI (32.1 vs 29.9; p=0.02), hypertension (88.5% vs 75.8%; p=0.03), diabetes mellitus (21.2% vs 9.6%; p=0.01), and mal perfusion syndrome (50% vs 29%; p=0.002).
The tracheostomy cohort experienced a greater rate of readmission within the first-year post-surgery (44.2% vs. 29.5%; p=0.03), with one-third of these patients needing ICU readmission (34.2% vs. 16.1%; p=0.001). While the difference in in-hospital mortality wasn't statistically significant (9.40% vs. 13.4%; p=0.34), after surviving the initial hospitalization, tracheostomy patients exhibited a lower 1-year survival rate (77.8%, 95% CI 64.6-88.6) as opposed to their non-tracheostomy counterparts (95.3%, 95% CI 93.2-97.8) (see Figure). Multivariable Cox regression analysis showed that requiring a tracheostomy after ATAAD surgery is associated with a 76% increased hazard of mortality after discharge (HR 1.76, 95% CI 1.03-3.00) (Table)
Conclusion
Requiring a tracheostomy after surgical repair of ATAAD has a significant impact on increased mortality during the first year. Moreover, the higher readmission burden in patients with tracheostomy highlights the substantial resource utilization associated with this patient population. These findings highlight the importance to optimize comprehensive postoperative protocols of care, aiming to enhance rehabilitation and manage resource utilization effectively for improved long-term survival after ATAAD surgery.
Authors
Carlos Diaz-Castrillon (1), Derek Serna-Gallegos (2), Pyongsoo Yoon (3), Johannes Bonatti (4), Danny Chu (5), David Kaczorowski (6), Jianhui Zhu (2), Julie Phillippi (7), Floyd Thoma (3), Danial Ahmad (3), Ibrahim Sultan (2)
Institutions
(1) University of Pittsburgh, United States, (2) University of Pittsburgh Medical Center, Pittsburgh, PA, (3) UPMC, Pittsburgh, PA, (4) UPMC Heart and Vascular Institute, Pittsburgh, PA, (5) Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, (6) University of Pittsburgh Medical Center, Venetia, PA, (7) N/A, Pittsburgh, PA
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Poster Presenter
Carlos Diaz-Castrillon, University of Pittsburgh
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Pittsburgh, PA
United States
Recurrent Laryngeal Nerve Injury in Aortic Arch Replacement.
Elizabeth Devine, PA-C, Matthew Clary, MD, Jessica AY Rove, MD, Muhammad Aftab, MD, T. Brett Reece, MD.
Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado, Aurora, CO.
Objective: Vocal cord dysfunction secondary to recurrent laryngeal nerve (RLN) injury following aortic arch surgery can cause significant morbidity and mortality. However, the incidence is unknown because aspiration is likely underrecognized. This study aims to identify the true incidence of RLN injury prior to and after operation to reduce the patient burden of silent aspiration and sequelae of complications through early identification and aggressive treatment.
Methods: Protocol was instituted in 2019 to include all elective and emergent patients getting aortic arch replacement (zone 1, zone 2 or FET). During this time, we evaluated 87 patients. On elective basis, pre and post operative direct laryngoscopy was requested to document bilateral vocal cord function. Emergent cases received post operative direct laryngoscopy only. Per Otolaryngology recommendations, patients could progress post operative diet and swallowing prior to direct laryngoscopy if asymptomatic per bedside nurse exam or speech language therapist evaluation.
Results: Due to COVID, coordination of full pre and post operative evaluations was limited. 63 patients had normal functioning vocal cords post operative. 12 patients had abnormal vocal cord function post operative but 6 of those did not have preoperative exam completed due to the emergent nature of their presentation. 4 patients had abnormal functioning vocal cord pre and post operative. 8 patients had normal preoperative exam but no post operative exam due to refusal or death.
Conclusions: RLN injury resulting in vocal cord dysfunction can be a source of morbidity and mortality. This data suggests both pre and postoperative vocal cord evaluations can be helpful and is relevant to surgical plan, clinical course and post operative recovery. The operative approach can be altered if unilateral vocal cord dysfunction is present preoperatively to avoid potential bilateral vocal cord dysfunction. Early recognition and treatment of vocal cord dysfunction post operative decreases mortality and morbidity. Understanding the injury can help to optimize patient's outcomes.
Authors
Elizabeth Devine (1), Matthew Clary (1), Jessica Rove (2), Muhammad Aftab (3), T. Brett Reece (4)
Institutions
(1) University of Colorado, Anschutz Medical Campus, Aurora, CO, (2) University of Colorado Anschutz Medical Center and Rocky Mountain Regional VAMC, Aurora, CO, (3) University of Colorado, Anschutz Medical Center, Aurora, Colorado, Aurora, CO, (4) University of Colorado Hospital, Aurora, CO
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Poster Presenter
Elizabeth Devine, University of Colorado Anschutz Medical Center
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Aurora, CO
United States
Objectives: To evaluate differences in biomechanical properties between the inner and outer curve of the ascending aorta. To correlate the extent of regional biomechanical differences with clinical markers including asymmetric dilation, age, sex, and bicuspid aortopathy (BAV).
Methods: Normal (n=25) and aneurysmal (n=102) whole aortic rings were collected intraoperatively, and inner (IC) and outer (OC) curvature regions were sectioned. Biaxial tensile tests were performed to derive tissue hysteresis (energy loss), stored elastic energy (EE), tissue stiffness, and stress and strain at onset of the transition zone (TZo). Delamination tests were performed to derive adhesive strength between aortic tissue layers. Higher energy loss and stiffness, and lower EE, stress/strain at the TZo zone, and delamination strength were previously shown to associate with aneurysmal aortic tissue. Preoperative computed tomography (CT) scans from the aneurysm group (n=39) were analyzed for IC, OC, and centerline length (annulus to innominate). Degree of asymmetric dilation was then defined as difference between OC and IC length normalized to centerline length.
Results: In normal aortas, energy loss was higher in the OC compared to the IC (OC: 0.06±0.02 vs. IC: 0.04±0.01, p<0.001), while EE (p=0.01), stiffness (p<0.001), and TZo stress (p<0.001) were lower. The aortic wall was thinner in the OC (OC:2.9±0.5 mm vs. IC: 3.1±0.8 mm, p=0.05), but delamination strength did not differ significantly between regions (p=0.5). In aneurysmal aortas, a similar pattern emerged. Energy loss was higher in the OC (OC: 0.06±0.03 vs. IC: 0.05±0.02, p<0.001), while EE (p<0.001), stiffness (p<0.001), and TZo stress (p<0.001) were lower than the IC. The aneurysmal aortic wall was thinner in the OC (p<0.001), with lower TZo strain (p<0.001) and delamination strength (OC: 29.5±15 mN/mm vs. IC: 32.3±17 mN/mm, p=0.003) compared to the IC. Aneurysmal aortas with greater differences between IC and OC biomechanics were then identified using the interquartile range method (n=15). These patients were not associated with greater asymmetric outer curvature dilation. Additionally, patients with greater biomechanical differences did not differ in age (p=0.06), sex (p>0.99), hypertension (p=0.76), or presence of BAV (p=0.18) from patients with minimal regional biomechanical differences. Correlations between IC and OC biomechanics were also evaluated by linear regression models. In normal aortas, IC biomechanical properties were positively correlated with their counterparts in the OC (0.77>r2>0.20, p<0.05), except for TZo strain (r2=0.02,p=0.56) and delamination strength (r2=0.09, p=0.17). In aneurysms, all biomechanical properties in the IC were positively correlated with their counterparts in the OC (0.67>r2>0.12, p<0.001).
Conclusion: Biomechanical differences between IC and OC regions were observed in both normal and aneurysmal aortas. Patients with greater regional biomechanical differences were not identifiable by clinical variables including asymmetric outer curvature dilation. However, biomechanical properties of the IC and OC regions were linearly correlated. Therefore, while regional biomechanical differences are present in the ascending aorta, these properties remain inter-related.
Authors
Daniella Eliathamby (1), Sachin Peterson (2), Hayley Yap (2), Malak Elbatarny (3), Maral Ouzounian (1), Melanie Keshishi (4), Rifat Islam (5), Chun-Po Steve Fan (6), Kongteng Tan (5), Craig Simmons (5), Jennifer C.-Y. Chung (7)
Institutions
(1) Toronto General Hospital, Toronto, ON, (2) University of Toronto, Toronto, NA, (3) TGH / St Michael's, Toronto, ON, (4) University of Toronto, Toronto, ON, (5) University of Toronto, Toronto, Ontario, (6) Toronto General Hospital, Toronto, Ontario, (7) Toronto General Hospital - Toronto, ON, Toronto, Ontario
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Poster Presenter
Daniella Eliathamby, Toronto General Hospital
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Toronto, ON
Canada
Objective: Repairing aortic regurgitation in cases involving calcified bicuspid valves remains a complex challenge. This presentation shows a successful repair of a calcified aortic valve through the reimplantation method using an ultrasound device, with the assistance of our developed endoscopic evaluation technique.
Case Video Summary: A 57-year-old male patient was diagnosed with moderate aortic valve regurgitation with fused and calcified right and left coronary cusps, a sinus of Valsalva measurement of 43 mm, and an enlarged ascending aorta measurement of 55 mm. After establishing cardiopulmonary bypass, distal anastomosis with a 28-mm Dacron woven graft right before the brachiocephalic artery and a patent foramen ovale closure via the right atrial were performed during circulatory arrest under hypothermia at a rectal temperature of 25°C. After trimming the aortic root and making coronary buttons, the raphe of the fused cusp was dissected and advanced calcifications were removed using an ultrasound device with attention not to perforate the cusps, which caused the mobility of the fused cusp to be improved. A 28-mm Dacron Valsalva-type graft was fixed to the ventriculo-aortic junction with twelve first-row sutures. After that, the commissure angle was fixed at 180 degrees to improve the mobility of the non-fused cusp, and the center of the fused cusp was resected in a triangular form to remove excess tissue. Our developed endoscopic evaluation method involved inserting a camera port with a balloon at the tip into the graft, inflating the balloon, and adding saline solution through a side tube to provide sufficient monitored pressure to the base. This allowed us to observe the aortic valve from the front using a camera. With a continuously monitored pressure of 70 mmHg applied to the valve, no regurgitation and great coaptation with matched free margins of the cusps were observed. Finally, the second-row suture was performed horizontally with polypropylene, and the shape of the aortic root was fixed. The total operation time was 5 hours and 40 minutes, aortic clamp time was 193 minutes, and circulation arrest time was 23 minutes, with no need for blood transfusion. The patient made a successful recovery and was discharged 10 days after the surgery, and follow-up echocardiography revealed no regurgitation.
Conclusions: In this case, we achieved optimal results by using our endoscopic evaluation method, which is particularly valuable for straightforward front-facing valve assessment under a continuously monitored pressure of 70 mmHg. Furthermore, when treating with bicuspid aortic valves, the cautious removal of calcifications using an ultrasound device can be advantageous in cases with a calcified valve, as calcified areas can impede mobility and complicate the reconstruction process. These techniques not only eliminate regurgitation in calcified valves but also improve valve patency and provide a sufficient effective orifice area.
Authors
Yuta Kitagata (1), Taro Nakatsu (1), ETSURO SUENAGA (1)
Institutions
(1) Kansai Electric power hospital, Osaka, Osaka
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Poster Presenter
Yuta Kitagata, Kokura Memorial Hospital
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Kitakyushu
Japan
Objective: Aortic root replacement (ARR) with a valve-replacing mechanical valve conduit is a longstanding cornerstone for treating aortic root aneurysm-emerging techniques include bioprosthetic and valve-sparing (VS) approaches. However, the durability of ARR may be compromised and failure of the valve or root complex can necessitate late repair in some patients. We describe our experience with reoperation in patients with prior ARR, emphasizing indications for reintervention, types of subsequent repair, and outcomes of reoperative repair.
Methods: In a retrospective analysis of patients undergoing elective reoperation related to previous ARR, we identified a final population of 193 such patients undergoing repair between 1991 and 2023. We divided patients into three intervention subgroups: true redo ARR (n=132), surgical aortic valve replacement (SAVR; n=40), and transcatheter aortic valve replacement (TAVR; n=21).
Results: The median patient age was 54 years (range, 41-62); patients undergoing TAVR were older (true redo ARR: 53 [39-61]; SAVR: 54 [43-67]; TAVR: 63 [52-73]; p=0.2). Few significant differences in baseline demographics were seen among the three subgroups such as the chronicity of symptoms at presentation. Indications for reintervention included prosthetic valve regurgitation (94/193), pseudoaneurysm (55/193), and graft infection (46/193). Prior ARR techniques included a mechanical composite valve graft (CVG) in 74 patients, of which 71 underwent a subsequent redo ARR (Figure). Additionally, 28 patients underwent an index aortic valve sparing root replacement and 91 patients had an index bioprosthetic root with many of these patients undergoing a true redo ARR (51/91) and the rest a valve replacement only (SAVR [n=18/91] and TAVR [n=19/91]). Repair was urgent or emergent in 39% (n=76). Aortic disease necessitated hemiarch or total arch replacement during reintervention in 92 patients (48%). Overall operative mortality was 14%, which differed with the approach to repair (true redo ARR: 19%; SAVR: 5%; TAVR: 0%; p=0.01). Persistent stroke occurred in only 5 patients (3%), although cardiac complications (including arrhythmia, cardiac failure, and pericardial effusion) were more common (n=81; 42%). The length of overall hospital stay was lower after TAVR (3 days [2-4.5]) compared to after true redo ARR (10 days [7-16]) and SAVR (10 days [7-20]; p<0.001). In late events, survival differed by approach (p=0.003); at 5 years, survival was 100% after TAVR, and at 10 years, was 48%±6% and 68%±10% after true redo ARR and SAVR, respectively. Recurrent repair failure was relatively uncommon; at 5 years, freedom from recurrent repair failure was 100% after TAVR and was 86%±7% and 73%±12% at 10 years after true redo ARR and SAVR, respectively.
Conclusions: In general, the approach to reintervention after prior ARR is dictated by the indication for repair, with true redo ARR indicated by complex reoperative scenarios (e.g., infection or pseudoaneurysm). Operative mortality trended higher with true redo ARR than with SAVR, which is not unexpected given the technical demands of redo aortic root intervention. When suitable, emerging TAVR techniques are beneficial to avoid redo sternotomy, with minimal operative mortality and a short length of stay.
Authors
Anna Xue (1), Lynna Nguyen (2), Susan Green (3), Ginger Etheridge (2), Subhasis Chatterjee (4), Lauren Barron (2), vicente Orozco Sevilla (5), Marc Moon (6), Joseph Coselli (7)
Institutions
(1) Baylor College of Medicine/Texas Heart Institute, Houston, TX, (2) Baylor College of Medicine, Houston, TX, (3) N/A, Houston, TX, (4) Baylor St. Luke's Medical Center, Houston, TX, (5) Baylor St Lukes/Texas Heart Institute, Houston, TX, (6) Baylor College of Medicine / Texas Heart Institute, Houston, TX, (7) Baylor College of Medicine, Texas Heart Institute, United States
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Poster Presenter
Anna Xue, Baylor College of Medicine
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Houston, TX
United States
Objective: Ruptured thoracic aortic aneurysms and reoperation on the proximal thoracic aorta remain a surgical challenge. Time to the operating room, surgical strategy, and cerebral protection play is essential for patients' survival. Additionally, an ascending aortic graft rupture, contained below the posterior sternal plate, complicates not only the reentry in the thorax but also endangers the organ protection. In this case report, we would like to present our surgical strategy during the reoperation of a thoracic-contained ruptured aneurysm after acute aortic dissection.
Methods: A 32-yo male patient presented in 2022 with an acute aortic dissection type A. He was urgently treated with a mechanical aortic valve replacement, replacement of the non-coronary sinus, ascending aorta, and aortic arch with a dacron prosthesis. Furthermore, the innominate and proximal 8 cm of his left common carotid artery were replaced with separate polyester grafts. 18 months later, he presented with fever, shivering, and sweating at the emergency department. Blood cultures and echocardiography remained negative for endocarditis, but a fluorodeoxyglucose-positron emissions tomography (FDG-PET) scan showed abnormal uptake in the aortic graft and contained graft rupture. Reoperation was carefully planned with bilateral cannulation of the carotid arteries and venous cannulation through the right femoral vein. Simultaneously and on the back table, two 14x9 cm xenologous pericardium blocks were used to construct two pericardial tubes. The patient was cooled to 26° C. During re-sternotomy, the contained rupture converted into an open rupture, which was controlled manually by one surgeon while the other surgeon kept preparing the scar tissue. After cardioplegic arrest, cerebral perfusion was initiated, and all prosthesis material, sutures, and felt were removed. The aortic arch showed necrotic and dissected tissue, which was resected. A xenologic self-made pericardial tube was anastomosed as a neo-aortic arch, clamped, and systemic perfusion started. After that, mobilization of the coronary ostia, implantation of a new mechanical aortic prosthesis and re-implantation of the coronary ostia into the pericardial tube graft. After reperfusion, the patient was weaned from the bypass properly and transferred to the ICU after the surgery. Extracorporeal circulation times were 341 min, Aortic clamp time 213 min, antegrade cerebral perfusion 41 min, and visceral ischemia time 41 min.
Results: The patient was extubated in the evening hours of the operation day and transferred to the ward on the second postoperative day. A postoperative initial LBBB could no longer be detected during the postoperative period. Postoperative echocardiography showed sufficient valve function without elevated gradients and an LVEF of 47 %. All intraoperative microbiological samples remained negative. He remained on antibiotic therapy with Ceftriaxon and Doxycyclin. The patient suffered from aphonia postoperative due to laryngeal nerve palsy with bilateral vocal fold paralysis.
Conclusions: Graft infection is a disastrous complication after aortic repair, with reported morbidity and mortality rates exceeding 35%. Surgeons confronted with the dare of exploring these aneurysms are facing the probability of numerous unwanted events during surgery. Experts' recommendations include radical explantation of the infected graft, extensive debridement followed by aortic reco
Authors
Laura Rings (1), Achim Haeussler (2), Mathias van Hemelrijck (2), Hector Rodriguez Cetina Biefer (2), Omer Dzemali (2), Petar Risteski (2)
Institutions
(1) Department of Cardiac Surgery, City Hospital of Zurich – Site Triemli, Zurich, Switzerland, (2) Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
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Laura Rings, University Hospital Zurich
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Zurich, NA
Switzerland
Objective: We present a case requiring neoaortic root, ascending, and arch replacement with Damus-Kaye-Stansel (DKS) reconstruction for massive neoaortic dilatation and severe neoaortic insufficiency after previous single ventricle palliation in the setting of depressed systemic ventricular function.
Case Video Summary: Our patient is a 20-year-old male with history hypoplastic left heart syndrome, who underwent 3-stage palliation, culminating in a fenestrated lateral tunnel Fontan. His cardiac MRI demonstrated rapid aortic enlargement, now 8.7cm, with severe neo-AI, and moderately reduced systemic ventricular function with a RVEF of 33%. He was initially referred for transplant evaluation, but given his functional status and moderate sensitization, he would likely spend several years of further decline on the waitlist. After consideration he was offered high-risk reoperative neoaortic root, ascending and arch replacement with DKS reconstruction to both prevent aortic complication, as well as eliminate neo-AI, and attendant further decline in systemic ventricular function. Reoperative sternotomy was performed using standard techniques. The innominate artery and left common carotid artery were mobilized for later snaring during periods of circulatory arrest with sACP. The DKS was identified, freed with a rim of healthy tissue, and cardioplegia administered with prompt arrest. The aneurysmal arch was resected to isolate the head vessels and remaining proximal descending aorta, to which we anastomosed a beveled 28mm graft. After mobilization and neoaortic valve excision, we secured a bioprosthetic valved conduit. After aneurysm excision and relief of previous distortion, it was clear that the graft-to-graft anastomosis would not be able to be completed with room for an aortic clamp, instead requiring another period of circulatory arrest to re-establish aortic continuity. A site on the Valsalva portion of the root graft was then chosen for reattachment of the DKS. He recovered well, has seen in follow-up, and is doing well without functional limitations, and stable mild-moderate systemic ventricular dysfunction.
Conclusions: Our case highlights the successful management of a complex neoaortic root and ascending aneurysm with severe neoaortic insufficiency after single ventricle palliation, treated with replacement and Damus-Kaye-Stansel reconstruction.
Authors
Alexander Nissen (1), Bradley Leshnower (2), Mani Daneshmand (2), Joshua Rosenblum (3)
Institutions
(1) Emory University, Atlanta, GA, (2) Emory University Hospital, Atlanta, GA, (3) Children's Healthcare of Atlanta, Atlanta, GA
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Poster Presenter
Alexander Nissen, Emory University School of Medicine
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Decatur, GA
United States
Objective: Repair of aortic root pseudo aneurysms can be challenging and necessitates careful surgical planning.
Case Video Summary: A 72 year old female patient underwent ascending aorta replacement with a hemashield graft 37 years ago and was found to have an incidentally discovered 6.5cm pseudo aneurysm likely arising from the proximal anastomosis and adherent to the undersurface of the sternum. The case illustrates the need to be on cardiopulmonary bypass with moderate hypothermia prior to performing the
sternotomy. The intraoperative TEE showed severe mitral regurgitation with a large P2/P3 cleft that necessitated adding a mitral valve repair procedure. The distal aorta was relatively normal and able to be cross-clamped. The cardioplegia strategy involved selective coronary antegrade delNido cardioplegia given after opening the pseudo aneurysm. There was a partial dehiscence of the proximal suture line and the entire aortic root was calcified which necessitated a full aortic root replacement with a porcine stentless aortic valve. The video shows the details of that procedure. The previous hemashield graft was intact and left in place to simplify the procedure and avoid deep hypothermic circulatory arrest.
Conclusions: Careful surgical planning and execution allows for safe completion of a complex repair of an aortic root pseudo aneurysm.
Authors
Charles Lutz (1), Mark Lutz (2), Ahmad Nazem (3), Gary Green (4), Anton Cherney (5), Krishna Patel (5), Karikehalli Dilip (6), Zhandong Zhou (7)
Institutions
(1) N/A, Syracuse, NY, (2) N/A, United States, (3) St. Joseph's Hospital, Syracuse, NY, (4) St Joseph's Health, Syracuse, NY, (5) N/A, N/A, (6) St Joseph's Hospital, Syracuse, NY, (7) N/A, NY
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Poster Presenter
Charles Lutz, St. Joseph Medical Center
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Syracuse, NY
United States
Repair of iatrogenic type A dissection following trans-catheter aortic valve replacement: Case Presentation
Krishna Mani, Alexander Smith, Adnan Charaf, David Smith, Marjan Jahangiri
Objective: Transcatheter aortic valve replacement (TAVR) has been established as an effective treatment for patients with severe aortic stenosis (AS) in patients with high and intermediate operative risk for surgical aortic valve replacement. Complications associated with this procedure, including aortic dissection, is rare. We present a case of an emergency repair of a type A aortic dissection following TAVR.
Case Video Summary: An 81-year-old woman presented with dyspnea, fatigue, and paroxysmal nocturnal dyspnea. She had a past medical history of a liver transplant 30 years prior. Her echocardiography revealed severe AS with a normal ejection fraction. Her coronary angiogram was normal. She underwent an elective TAVR which was complicated by femoral artery stent, drainage of a hemopericardium and an iatrogenic type A aortic dissection, which was detected 10 days later. She underwent an emergency repair of iatrogenic acute type A aortic dissection with TAVR explantation, tissue aortic valve replacement with a 21mm Magna Ease valve, and replacement of ascending aorta using a 28mm hemoshield vascular graft. Her operation was complicated by spontaneous rupture of the ascending aorta and changes in standard myocardial arrest and protection strategies, from antegrade to retrograde cardioplegia due to the TAVR struts. She had a prolonged intensive care unit stay requiring medical management with vasoconstrictors and inotropes. She was subsequently transferred to her local hospital for further rehabilitation.
Conclusions: We describe successful repair of an acute ascending aortic dissection following TAVR. It highlights the technical considerations for these patients, including possible damage to the aortic root and anterior mitral valve leaflet during explantation, spontaneous aortic rupture, and cardioplegia strategies.
Authors
Krishna Mani (1), Alexander Smith (2), Adnan Charaf (2), David Smith (2), Marjan Jahangiri (3)
Institutions
(1) St George's, University of London, United Kingdom, (2) St George's, University of London, London, NA, (3) St. George's Hospital and University of London, London, United Kingdom
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Poster Presenter
Krishna Mani, St George’s University Hospital NHS Foundation Trust London
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London
United Kingdom
Objective:
Aberrant subclavian artery is a rare congenital anomaly of the aortic arch, with reported incidence of left aortic arch with aberrant right subclavian artery (ARSA) in 0.7 to 2.0% of the population. Furthermore, the anomalous origin of left subclavian artery (AOLSA) in a left aortic arch is an extremely rare anomaly that only a few cases have been previously reported. This report details the successful surgical repair of an exceptionally uncommon case: a descending thoracic aortic aneurysm coinciding with a ARSA and an AOLSA, accompanied by a Kommerell's diverticulum.
Methods:
A 19-year-old female with no significant past medical history presented outside hospital with episodic chest and back pain. Computed tomography angiography (CTA) revealed an aneurysmal dilation extending from the distal arch to the proximal descending thoracic aorta, with a maximum diameter of 41 mm. Notably, the CTA also identified unique anatomical variations in the aortic arch: both right and left subclavian arteries originated anomalously from the proximal descending aorta.
Results:
Femorofemoral cardiopulmonary bypass was initiated for deep hypothermic circulatory arrest, aiming nasopharyngeal temperature of 20 °C. The thoracic aorta was clamped at the level of T6. The proximal descending aorta was opened and replaced with a branched 18-mm woven Dacron graft. Three separate 8-mm side-branches were hand-sewn to the main body before initiating cardiopulmonary bypass, and fashioned for reconstructions of bilateral subclavian arteries as well as arterial cannulation. The proximal anastomosis was constructed just distal to the left common carotid artery. The right subclavian artery was reconstructed to the second side-arm prior to the distal anastomosis. The 8-mm graft was anastomosed to a healthy portion of the ARSA to exclude the aneurysmal segment using inclusion technique. The distal anastomosis was then performed at the level of the T5. The AOLSA was bypassed with the last 8-mm Dacron graft. The circulatory arrest time was 22 minutes for proximal, and cardiopulmonary bypass time was 129 minutes. Postoperative course was complicated with chylothorax, which reslolved with low-fat diet. She was discharged at postoperative day 14th.
The pathology reported that aortic tissue has focal fibrocellular intimal thickening, dense adventitial fibrosis, and severe near-complete loss of medial elastic fibers on elastic stains, consistent with Kommerell's diverticulum.
Conclusion:
We presented a case of an extremely rare anatomical configuration comprised of an ARSA in left aortic arch, in the presence of Kommerell's diverticulum, an AOLSA and a descending thoracic aortic aneurysm. Open aneurysm repair with in situ reconstruction of subclavian arteries was satisfactory.
Authors
Yuki Ikeno (1), Francesco Brandini (1), Lucas Ribe (1), Anthony Estrera (1), Akiko Tanaka (1)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX
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Poster Presenter
Yuki Ikeno, University of Texas - Houston
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Houston, TX
United States
Objective
Aortic remodeling from elephant trunk (ET) surgery has emerged as a valuable tool treating further degeneration after thoracic aortic dissection. However, many patients still require unplanned endovascular extension after pathology further degenerates. Identifying which patients are at risk based on pre-operative and initial post-operative imaging features may optimize surveillance strategies.
Methods
A single-center retrospective review of 320 patients who underwent ET from 2015-2023 was performed. Patients with non-dissection pathology, connective tissue disease, or absent post-operative surveillance imaging were excluded. Two cohorts were created from patients meeting criteria: those who required endovascular extension after surgery, and those who did not. Between the two cohorts, pre-operative and first post-operative surveillance computed tomography (CT) scans were reviewed, with emphasis placed on dissection and post-surgical feature differences. To optimize imaging review, TeraRecon Aquarius software was used for three-dimensional analysis and multiplanar renderings.
Results
Among included ET patients, 25 required extension and 25 did not. No significant differences were found in aortic tortuosity, character of thoracic entry tears, dissection extent, arch or visceral vessel dissection, cross-sectional minimum true lumen percentage, or evidence of radiographic malperfusion. Extension patients had a trend towards larger aortic diameters at time of presentation (p=0.07). Extension patients had less total false lumen area thrombosis in the covered area (p=0.02), with less complete false lumen thrombosis (p=0.01), and greater maximal aortic diameters in covered areas (p=0.05).
Conclusion
Persistent false lumen flow and incomplete thrombosis in covered regions after elephant trunk surgery, with associated increased aneurysm size, places patients at risk for unplanned endovascular extension. Patients with persistent false lumen flow warrant closer surveillance given risk of further degeneration of pathology.
Authors
Adam Carroll (1), Rafael Malgor (1), T. Brett Reece (1), Pedro Furtado Neves (1), Muhammad Aftab (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
OBJECTIVE: The Ross procedure in patients with unicuspid aortic valve (UAV) disease is the only aortic valve replacement performed using a living valve substitute. We evaluated the efficacy of the pulmonary autograft in restoration of select aortic 3D hemodynamic parameters-ascending aorta (AAo) wall shear stress (WSS) and systolic peak velocity (PV)-in patients with UAV using 4D flow MRI. Our hypothesis was that patients would have restored aortic hemodynamics following pulmonary autograft replacement.
METHODS: Twenty-five patients with UAV disease who underwent pulmonary autograft replacement of their UAV between February 2020 and August 2023 were identified. Thirteen patients had pre- and post-operative 4D flow MRI exams between July 2018 and August 2023. All MRIs were performed using 1.5 or 3.0T systems (Siemens, Germany) and were retrospectively gated. Data were processed to correct for eddy currents, velocity noise, and aliasing, and to generate a 3D segmentation of the thoracic aorta. The systolic PV in the AAo was determined using a voxel-wise approach as the maximum velocity within the AAo segmentation at peak systole. The systolic peak WSS was calculated as the average of the top 5% of magnitude WSS values mapped on the AAo surface at peak systole. Normality was assessed with the Shapiro-Wilk test. Paired t-tests were utilized to analyze any differences in AAo hemodynamics before and after UAV replacement. Two-sample t-tests were used to compare UAV patients with healthy controls.
RESULTS: Thirteen patients (37.1±10.1 yrs, 11 males) who underwent pulmonary autograft replacement of UAV (11/13 (85%) primarily severe aortic stenosis; 2/13 (15%) primarily unicuspid aortic valve indication) with n=26 MRIs (2/patient, pre/post-Ross) acquired between 2018 to 2023 were included. Twelve of 13 patients demonstrated a reduction in their AAo systolic PV and 10 of 13 demonstrated a reduction in AAo WSS. Thirteen healthy controls were age (±2yrs) and gender matched and analyzed. Mean systolic PV and WSS of healthy controls were 1.51±0.25 m/s and 1.27±0.21 Pa. In the UAV cohort, mean systolic PV before and after pulmonary autograft replacement were 3.72±1.08 m/s and 1.86±0.34 m/s, respectively (p<0.01), and mean AAo WSS before and after pulmonary autograft replacement were 2.34±0.66 Pa and 1.56±0.36 Pa, respectively (p<0.01).
CONCLUSIONS: Ascending aorta systolic PV and WSS are significantly reduced in UAV patients after undergoing the Ross procedure and very closely resemble AAo hemodynamics of healthy controls. These preliminary results suggest that replacement of UAV with a pulmonary autograft can potentially restore AAo hemodynamics similar to that of healthy controls. Further restoration of normal hemodynamics to the level of healthy controls may occur after the perioperative period and warrants further investigation.
Authors
Andrew Zbihley (1), Anthony Maroun (1), Justin Baraboo (1), Bradley D. Allen (2), Michael Markl (1), S. Chris Malaisrie (2), Christopher Mehta (2), Meilynn Shi (3)
Institutions
(1) Northwestern University, Chicago, IL, (2) Northwestern Memorial Hospital, Chicago, IL, (3) N/A, United States
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Poster Presenter
Andrew Zbihley, Northwestern University Feinberg School of Medicine
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Chicago, IL
United States
Objective: In-situ fenestration technique for Zone 1 TEVAR can be an excellent alternative to open surgical repair. However, the surgical risk can be high in patients with a history of coronary arterial grafting (CABG) due to left internal mammary artery (LIMA) graft ischemia during the fenestration procedure. The two-debranching procedure can be an option, although insufficient brain perfusion and cosmetic problems remain. An extracorporeal circuit may be employed, though an embolic event can occur. We employed left subclavian-femoral arterial shunting using a high-flow vascular sheath to minimize the risk of LIMA graft ischemia during Zone 1 in-situ fenestration TEVAR.
Case video summary
The patient was a 70-year-old male with a history of CABG and abdominal aortic replacement. LIMA was anastomosed to the left anterior descending artery. The computed tomography showed a thoracic aortic aneurysm lying from the aortic arch to the descending thoracic aorta with a maximum diameter of 60 mm. Zone 1 left common carotid artery (LCCA) in-situ fenestration TEVAR was planned. LCCA – left subclavian arterial bypass was performed prior to the stentgraft placement. A 6Fr high-flow vascular sheath was inserted into the neck bypass graft and was connected to the 22 Fr Dryseal sheath, which was inserted from the right femoral artery for the shunting. A 40mm-20cm main Gore cTAG was deployed from Zone 1. The needle puncture for the left common carotid in-situ fenestration was difficult because of the shallow angle between LCCA and the aorta(18°). LCCA was finally reconstructed (the time from Zone 1 landing to successful puncture was 16.5 minutes), and there was no ST-segment change or circulatory instability during the puncture. There was no myocardial ischemia and stroke, and no endoleak was shown in the postoperative CT scan.
Conclusion
The left subclavian-femoral arterial shunting using a high-flow vascular sheath was a reliable technique for safely performing Zone 1 in-situ fenestration TEVAR in a patient with a history of CABG.
Authors
Yoshiaki Saito (1), Kenyu Murata (1), Yuki Imamura (1), Rin Itokawa (1), Masahito Minakawa (1)
Institutions
(1) Hirosaki University School of Medicine, Hirosaki, NA
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Poster Presenter
Yoshiaki Saito
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Hirosaki
Japan
Objective
Ascending aortic dissection is a highly morbid condition that requires prompt surgical intervention. It frequently affects patients in their working years. The aim of this study is to quantify the socioeconomic impact of aortic surgery on our patient population by their ability to participate and return to work in this multi-center, single institution review.
Methods
After IRB approval, we conducted a retrospective review of a prospectively maintained database and included any patient who suffered an acute Type-A aortic dissection (TAAD) that was treated operatively. We then analyzed those who survived beyond thirty days. We then contacted each of these patients to enroll them in a voluntary survey to assess their pre-operative and post-operative occupation and associated salary and loss there-of from their operation and perioperative period. Statistical analysis was then performed.
Results
173 patients who underwent urgent or emergent repair of TAAD from 2012 to 2023 were attempted to be contacted. Out of 173 patients surveyed, 39 were willing to participate in the survey. Incomplete surveys due to requests for patient privacy were further excluded. The mean amount of missed days was 103 days and the average amount of direct missed income was $14,662.67 per patient. Additionally, only 40.7% (11 out of 27) of patients returned to full- or part-time work after aortic surgery. Our lower income patients (annual income less than $20,000 per annum) were noted to have a trend towards significance of not returning to work as compared to higher income earners (.333 vs .714, [p= 0.0883]).
Conclusions
Aortic surgery is a major undertaking that affects multiple aspects of our patient's life – including their ability to return to work. Many patients do not return to work after aortic surgery, and our lower income patients are potentially more vulnerable to this phenomenon. This negative impact to our patients, and our community should be better addressed with a multi-disciplinary approach to help patients return to work.
Authors
Matthew Billy (1), Salmaan Zafer (2), Christian Hailey Summa (2), Zachary Brennan (3), Jiatian Qu (1), Scott A. LeMaire (4), Tyler Wallen (5)
Institutions
(1) N/A, N/A, (2) Geisinger Health Systems, Wilkes-Barre, PA, (3) UF, Gainesville, FL, (4) Geisinger Commonwealth School of Medicine, Scranton, PA, (5) The University of Florida Health System, Newberry, FL
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Poster Presenter
Matthew Billy
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Scranton, PA
United States
Objective
For thoracoabdominal aortic repair, we routinely employ straight incision with rib-cross (SIRC) incision to ensure good visual field and deep hypothermic circulatory arrest (DHCA) to prevent cerebral and spinal cord complications. In this study, we investigated risk factors associated with the perioperative strokes in these combined procedures.
Methods
We reviewed records of patients who underwent repair for thoracoabdominal aorta related disease between 2016 to 2023. Sixty patients underwent Crawford extent I or II aortic repair using SIRC and DHCA (39 men, 21 women; mean age, 63.5 ± 15.9 years; consisted of 11 aneurysm cases and 49 dissection cases, of which 14 cases were accompanied by arch lesions and required total or partial arch replacement via SIRC view or via median sternotomy). The patients were divided into two groups, those who experienced perioperative stroke (Stroke group) [with obvious image findings and persistent or temporary neurological deficits], and those who did not (Non-stroke group). Perioperative and postoperative data from patients' record were collected retrospectively and the variables were compared between the 2 groups.
Results
Eleven (18.3%) patients experienced stroke. Stroke group included 2 cases of hemiplegia, 4 cases of impaired consciousness (major strokes), 3 cases of seizure and 2 cases of obvious image findings without symptoms (minor strokes). Operative mortality were 2 cases in Stroke group and 4 cases in Non-stroke group (18.0% vs 8.2%, p=0.302). The age tended to be higher in Stroke-group (Stroke: 70.5 ± 9.0 years, Non-stroke: 62.0 ± 16.7 years, p=0.069). While 4 of Stroke-group patients had undergone arch reconstruction via SIRC view using selective cerebral perfusion which was significantly different (Stroke: 4 cases, 36.4%, Non-stroke: 2 case, 4.1%, p=0.008) patients who underwent arch reconstruction through a median sternotomy did not develop stroke. There were no significant differences in operation time, cardiopulmonary bypass time, circulatory arrest time, minimum body temperature, or blood transfusion volume between the two groups. In addition, there were no significant differences in length of ICU/hospital stay, or incidence of perioperative complications (acute renal failure, pneumonia, and spinal cord injury) between the two groups. Univariate analysis revealed that a significant risk factor for perioperative stroke following Crawford extent I or II aortic repair using SIRC and DHCA were the age (odds ratio = 1.05, 95% confidence interval: 0.99-1.12, p = 0.033) and arch reconstruction via SIRC view (13.4, 2.06-87.47, p = 0.005).
Conclusions
Although not statistically significant, the occurrence of stroke may worsen the short-term prognosis. Higher age and performing arch reconstruction via SIRC view were found to be associated with the occurrence of strokes. Even if the procedure is performed under SIRC and DHCA, care should be taken or furthermore adding median sternotomy should be considered when performing arch repair.
Authors
Hiroaki Osada (1), Kenji Minatoya (1), Haruka Fujimoto (1), Yasuyuki Fujimoto (1), Hiromasa Kira (1), Kazuhiro Takatoku (1), Kazuyoshi Kanno (1), Masahide Kawatou (1), Fumie Takai (1), Takahide Takeda (1), Takehiko Matsuo (1), Tadashi Ikeda (1)
Institutions
(1) Kyoto University, Graduate School of Medicine, Kyoto, Japan
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Poster Presenter
Hiroaki Osada, Kyoto University, Graduate School of Medicine
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Kyoto
Japan
AVR with Pulmonary Autograft
Brief summary of the video:
In this video we demonstrate pulmonary autograft aortic valve replacement with modifications to reduce the problem of bleeding from the anastomotic sites.
The operation is a complex one and should be performed after acquiring sufficient experience in aortic valve surgery. This is suitable for patients with severe aortic stenosis not amenable to repair. It provides a living, autologous valve which can grow with the patients somatic growth. It avoids lifelong anticoagulation. Provides normal haemodynamics. With the use of a pulmonary homograft the likelihood of reoperation for replacement will be necessary in about 10 to 15 years depending on the age at first operation.
Authors
Arkalgud Sampath Kumar (1), devagourou velayoudam (2)
Institutions
(1) Retd. Prof and head, Dept of CTVS, AIIMS, Max superspeciality hospital, New Delhi, India, (2) AIIMS, New Delhi, NA
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Poster Presenter
*Arkalgud Sampath Kumar, All india institute of medical sciences, New Delhi
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NEW DELHI, Delhi
India
Rupture Sinus of Valsalva Repair Via a Mini-sternotomy
Osman Osama AL-Radi, MD, MSc, FRCSC1, Ragab Shehata Debis, MD1,
Ahmed Abdulrahman Elassal MD1.
(1) King Abdulaziz University, Department of surgery, Cardiac Surgery Unit, Jeddah, Saudi Arabia
Objective: Demonstration of a Ruptured sinus of Valsalva Repair via a mini-sternotomy by an intraoperative video
Case Video Summary:
A29-year-old male with a sub-arterial ventricular septal defect and rupture of sinus of Valsalva leading to an aortic to right ventricular fistula. He was admitted for urgent repair.
An upper mini-sternotomy was done. The pericardium was opened. The aorta and RA were cannulated. CPB was started. The aorta was clamped. Cardioplegia was given. A vent was placed in the RUPV to the LV. The aorta was incised. The aneurysmal tissue in the right sinus of Valsalva was excised. The VSD was closed with a patch of equine pericardium. Another equine patch was used to closed the aorta to RV fistula. The right cusp was resuspended with a commissural stich in the right to left commissure. A post operative echocardiogram showed a complete repair of the ventricular septal defect and a functioning aortic valve with trace insufficiency.
The patient had an uneventful hospital course and was discharge home on the 7th post operative day.
Conclusions:
Ruptured sinus of Valsalva can be repaired safely through a mini-sternotomy approach
Authors
Osman Al-Radi (1), ragab Debis (2), Ahmed Elassal (3)
Institutions
(1) King Abdulaziz University Hospital, Jeddah, Makkah, saudi arabia, (2) King Abdulaziz University, Jeddah, Makkah, saudi arabia, (3) King Abdulaziz University, Jeddah, Makkah, Saudi Arabia
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Poster Presenter
Osman Al-Radi, King Abdulaziz University
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Jeddah, CA
Saudi Arabia
Objective: To review a unique case presentation that began with a low pacemaker battery.
Case Video Summary: This is a case of a patient whose pacemaker battery became low, triggering symptoms that ultimately saved her life. The patient is a 78-year-old woman who previously underwent aortic valve replacement with coronary artery bypass grafting in 2005. This was complicated by heart block requiring a pacemaker. Over the subsequent years she suffered from structural valve degeneration and underwent a valve-in-valve femoral transcatheter aortic valve replacement (TAVR) in 2018. In 2023, the patient presented with dyspnea and malaise. Workup revealed that her pacemaker device had reached the elective replacement indicator (ERI). Device interrogation demonstrated that the onset of her symptoms matched the timing of ERI. Further imaging revealed that the patient had a large ascending aortic aneurysm, measuring 6.4 centimeters, which was increased from 5 centimeters the year prior.
The operative video demonstrates the finding of a complex chronic aortic dissection flap in her proximal ascending aorta, which was not recognized on preoperative imaging. A second chronic flap, presumably the re-entry tear was identified during hemiarch replacement. The timing of her dissection is unknown but occurred at some point after her transfemoral TAVR. She ultimately underwent uncomplicated revision sternotomy, explantation of surgical and valve-in-valve TAVR valves with tissue aortic valve replacement, and replacement of the ascending and hemi-aortic arch.
Conclusions: The constellation of symptoms prompting initial presentation may yield surprising findings when investigated thoroughly.
Authors
Margaret Connolly (1), Jordan Bloom (1)
Institutions
(1) Massachusetts General Hospital, Boston, MA
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Poster Presenter
Margaret Connolly, Massachusetts General Hospital
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Boston, MA
United States
Objective: Thoracic endovascular aortic repair (TEVAR) is becoming more widely used in aortic surgery due to its minimally invasive nature, which does not require thoracotomy. However, some patients require secondary open aortic repair for various reasons, so the surgical strategy and the management of endoprosthesis in such situation are still controversial.
Methods: From January 2012 to December 2022, twenty patients who underwent secondary open aortic repair for the same or adjacent site after TEVAR were included. Indications for secondary open aortic repair are aneurysmal dilatation due to endoleaks (type Ia: n=4, Type II: n=1, Type V: n=2), Infection of stentgraft (n=6), enlargement of distal aorta or false lumen (n=4), and retrograde type A aortic dissection (RTAD) (n=3). Six patients who required open conversion for type Ia endoleaks or RTAD received aortic arch replacement while its distal anastomosis was done to the fully or partially preserved prior stentgraft. Four patients underwent thoracoabdominal aortic repair for enlargement of distal aorta or the false lumen of chronic aortic dissection, and three of them were performed proximal anastomosis to the prior stentgraft. Six patients of stentgraft infection underwent the removal of stentgraft and descending thoracic aortic (DTA) replacement. In addition, three of such patients had aorto-esophageal fistula (AEF), and esophagectomy were simultaneously performed. One patient with chronic aortic dissection was required aortic arch and DTA replacement with full extraction of prior endoprosthesis due to the growth of the false lumen. Two patients with type V endoleak was received DTA replacement with partially or complete extraction of stentgraft, and the other with the dilatation of DTA aneurysm due to persistent type II endoleak underwent the ligation of intercostal artery and aneurysmorrhaphy with thoracotomy.
Results: There were two early mortality (10%). One died of sepsis from persistent infection in patient with stentgraft infection and AEF, the other from sudden arrhythmia. Stroke was observed in 2 cases (10%), paraplegia occurred in 2 cases (10%), and paraparesis also developed in 2 cases (10%). Tracheostomy was required in 3 cases (15%), all with AEF. Mean in-hospital day was 46 ± 25 days.
Conclusions: Secondary open aortic repair after TEVAR may be required for various reasons and pathologies, however, the operative outcomes of this open conversion surgery seem to be acceptable, except for those in AEF. Previous stent grafts may be available in some situations; therefore, it is necessary to consider the surgical strategy including how to manage the stentgraft according to each individual case.
Authors
Yutaka Iba (1), Tomohiro Nakajima (1), Junji Nakazawa (1), Tsuyoshi Shibata (1), Shuhei Miura (1), Ayaka Arihara (1), Takakimi Mizuno (1), Keitaro Nakanishi (1), Kei Mukawa (1), Nobuyoshi Kawaharada (1)
Institutions
(1) Department of Cardiovascular Surgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
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Poster Presenter
Yutaka Iba, Sapporo Medical University
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Sapporo
Japan
Separate Brain and Body Perfusion Shortens Operating Time in a Jehovah's Witness with Arch Dissection
Objective: Can separation of cerebral and systemic perfusion using separate circuits to cool the brain and body at different temperatures allow for successful surgery in a Jehovah's Witness with acute Type A aortic dissection?
Case Video Summary:
We performed aortic arch reconstruction in a 79-year-old Jehovah's Witness who presented with Type A dissection in an arch aneurysm and cardiac surgery not offered at an outside hospital. We initiated assiduous control of blood pressure and measures to enhance hematopoiesis (Epogen, iron infusion, multivitamins) and standard measures to reduce blood loss (pre and intraoperative) resulting in a hematocrit on day of operation of 40.
We completely separated cerebral and corporeal perfusion. The brain was cooled to 240C and body to 340C. We maintained cerebral perfusion prior to bypass and until after cessation of cardiopulmonary bypass. Systemic circulatory arrest was initiated at 340C for 20 minutes for the distal arch anastomosis.
Surgical strategy:
1. Median sternotomy. 2.Heparinize. 3. Cannulate innominate artery with 14 F cannula. 4 Cannulate mid-arch. 5. Clamp base of innominate artery and initiate cerebral circulation
1 L/min and cool to 240C. 6. 1 minute later initiate corporeal circulation (3L/min) and cool to 340C (separate heat/exchanger). 7. Start operation immediately as described in accompanying video.
Conclusions
1. Separate perfusion and cooling temperature strategy for the body and brain shortens operation time and therefore reduce coagulopathy and blood loss. This approach should be used when operating on a Jehovah's' Witness.
2. There were no intra- or post-op complications.
Authors
Salim Aziz (1), Vincent Gaudiani (2), Pei Tsau (3), Paul Shuttleworth (4), Jenna Aziz (5)
Institutions
(1) N/A, United States, (2) El Camino Hospital, Mountain View, CA, (3) El Camino Health, Mountain View, CA, (4) N/A, San Francisco, (5) Ohio State Wexner Medical Center, Columbus, OH
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Poster Presenter
Salim Aziz, The George Washington University
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Washington, DC
United States
Objective: Marfan syndrome (MFS) is the most common hereditary disorder causing lethal aortic syndrome by degradation of the aortic wall. The underlying mutation in the fibrillin-1 gene affects multiple organs and their function and the aorta's mechanical stability. Recently, neprilysin (NEP)/angiotensin II receptor blockers sacubitril/valsartan have been shown to improve cardiac function in heart failure and positively affect the aortic wall in mouse models of MFS. NEP degrades and inactivates apelin peptides, which have been reported to be protective in terms of aortic aneurysm formation. Here, we aimed to investigate possible correlations between NEP and MFS in aortic specimens and serum of patients with MFS.
Methods: We collected serum and aortic specimens from patients with MFS (age 19-64 years) in the outpatient MFS centre at the University Hospital Heidelberg and resected tissue from patients with MFS undergoing valve sparing aortic root replacement. Control samples were collected from the aortic tissue of patients undergoing routine coronary artery bypass grafting. Enzyme-linked immunosorbent assay (ELISA) was used to analyze blood serum soluble NEP (sNEP) and apelin levels. sNEP activity in the serum was assessed using a fluorogenic peptide substrate. Aortic tissue was examined using immunofluorescence microscopy.
Results: Soluble neprilysin activity was significantly higher in patients with MFS than in control individuals without a connective tissue disorder diagnosis (n=36-76, p=0.0047). We observed a positive correlation between aortic root diameter and sNEP activity (r=0.46, p=0.0137), predominantly driven by the male gender (r=0.5178, p=0.0399), whereas it was not relevant in female patients with MFS. Furthermore, elevated sNEP levels correlated negatively with apelin concentration in patients with MFS (r=0.4083, p=0.0251) compared to control individuals (r=0.3417, p=0.1023). Exemplary NEP immunofluorescent staining of aortic tissue derived from MFS patients (n=2) revealed a 47% higher NEP protein abundance in the AAo media than in control individuals (n=2). However, in MFS patients, sNEP plasma levels were 78% higher (p=0.004, n=24-29), independent of gender, age, aortic diameter, and clinical data such as pre-/ post-surgery.
Conclusions: Elevated serum neprilysin levels may play a pivotal role in developing and progressing aortic aneurysm formation in patients with MFS. The addition of neprilysin receptor blockers may influence the progression of aneurysm formation in patients with MFS, reducing the need for early aortic replacement surgery.
Authors
Rawa Arif (1), Elisa Krieg (2), Franziska Rehberg (2), Jasmin Soethoff (3), Marcin Zaradzki (3), Markus Hecker (2), Matthias Karck (4), Andreas H Wagner (2)
Institutions
(1) Department of Cardiac Surgery, Heidelberg, Germany, (2) Institute of Physiology and Pathophysiology, Heidelberg, NA, (3) Department of Cardiac Surgery, Heidelberg, NA, (4) N/A, Heidelberg
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Poster Presenter
Rawa Arif, University Hospital Heidelberg
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Heidelberg
Germany
Objective
Data on sex-related differences in presentation, management, and clinical outcome in acute aortic dissection (AAD) are scarce, especially for acute type A (AAAD) and acute type B (ABAD) subtypes.
The aim was to determine the effect of sex on AAD presentation, management and outcomes in a large cohort of patients from two major aortic surgery centers.
Methods
We retrospectively reviewed the two-institution clinical data of all consecutive patients treated for AAD from 2000 to 2023. Data were analyzed by univariate and multivariable methods for short- and long-term data. Cox multivariable analyses were restricted to 3 years' follow-up.
Results
Overall, 2,269 patients treated for AADs with 1,380 AAAD and 889 ABAD. Median age was 60 years (IQR:50-71); 779 (34%) were women. Women were older (63 vs 58 yrs; P<.001), had lower baseline renal function (39% vs 26%, p<.001) and more genetically triggered aortic disease (11% vs 7%, P=.008). Clinical presentation is shown in Table. Women had fewer renal (13% vs 18%; P=.004), bleeding (13% vs 19%; P=.001), and GI (24% vs 28%; P=.049) in-hospital complications. 30-day mortality was not different between groups (11% vs 13%; P=.134). There was no significant difference in mid or long-term survival by sex overall, but Kaplan Meir analysis suggest a possible difference in the type A group, notably in the first 3 years (Figure 1, p<.001). Among AAAD cases, risk factors for mid (3-years) and long-term mortality were examined to assess the independent effect of female sex. Absolute risk difference of midterm mortality attributable to COPD in stratified analysis was 15% in women (p<.01). Multivariable risk factors for midterm and long term mortality after AAAD were female (HR 1.4, p<.02), rupture (HR 2.0, p<.001), CAD (HR 1.7, p<.001), mesenteric MPS (HR 2.3, p<.001). After adjusting for these risk factors, midterm as well as long-term survival among women with AAAD was significantly lower compared to males (Figure 2, p<.017).
Conclusions
Women with AAD presented at an older age with poor baseline renal function and had higher prevalence of genetic disease and ABAD. 3-year adjusted survival for women with AAAD was worse than men; COPD may modify risk by sex. Independent risk factors for mid and long-term mortality after AAAD included rupture, mesenteric malperfusion, CAD, and female sex.
Authors
Lucas Ribe (1), Rana Afifi (2), Yuki Ikeno (1), Akiko Tanaka (3), Charles Miller (4), Harleen Sandhu (5), Gustavo Oderich (1), Anthony Estrera (3)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX, (2) Memorial Hermann, Houston, TX, (3) Memorial Hermann Heart and Vascular Institute, Houston, TX, (4) Memorial Hermann Texas Medical Center, Houston, TX, (5) N/A, HOUSTON, TX
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Poster Presenter
Lucas Ribe, McGovern Medical School at UTHealth
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Houston, TX
United States
Objective
Trauma is the leading cause of death in people younger than 45 years. Blunt traumatic aortic injury (BTAI) is the second most common cause of death after blunt trauma. There have been reports on the different response to trauma between men and women, as well as sex/gender disparities in aortic diseases, including aneurysms and dissections, in terms of outcomes. However, there is a gap in the literature regarding sex differences in patients with BTAI.
Methods
The Aortic Trauma Foundation international prospective multicenter registry was utilized to investigate sex differences in traumatic aortic injury characteristics, management, and outcomes from 2016 to 2023. Data were analyzed using contingency tables and stratified and multivariable regression.
Results
There were 781 patients with BTAI and complete injury grade information, of whom 182 patients (23%) were female. The mean age was 43.4 ± 18 years, and women were significantly older than men (48 ± 18.6 vs. 42.3 ± 17.6, p < 0.0001). Four hundred sixty-four patients (59%) underwent TEVAR, with no significant difference between men (61%, 364/599) and women (55%, 100/182). Injury severity score and Glasgow Coma Scale scores did not differ between women and men. Women more often had pelvic fractures (41% vs. 30%, p < 0.004), splenic injuries (31% vs. 23%, p < 0.05), renal injuries (22% vs. 14%, p < 0.02), sacral spine fractures (12% vs. 6%, p < 0.02), and sternal fractures (17% vs. 10%, p < 0.02), but these injury patterns were not associated with higher-grade aortic injuries. There were no sex differences in the distribution of aortic injury grade. In-hospital mortality was 12%, and aortic-related mortality was 4% for the entire cohort, with no differences between men and women. The presence of sternal fracture appeared to predict higher aortic mortality in women (10% with sternal fracture vs. 2% without, p = 0.05), but not in men (9% with sternal fracture vs. 10% without, p = 0.9).
Conclusions
Women with BTAI presented more frequently with intra-abdominal and pelvic injuries, and sternal fractures appeared to predict higher mortality in women with BTAI. No differences in mortality were found between men and women with BTAI.
Authors
Lucas Ribe (1), Yuki Ikeno (1), Rana Afifi (2), Akiko Tanaka (3), Christopher Rosa (4), Naveed Saqib (3), Harleen Sandhu (5), Charles Miller (6), Anthony Estrera (3), Gustavo Oderich (1)
Institutions
(1) McGovern Medical School at UTHealth, Houston, TX, (2) Memorial Hermann, Houston, TX, (3) Memorial Hermann Heart and Vascular Institute, Houston, TX, (4) Memorial Hermann Hospital. UTHealth., Houston, TX, (5) N/A, HOUSTON, TX, (6) Memorial Hermann Texas Medical Center, Houston, TX
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Poster Presenter
Lucas Ribe, McGovern Medical School at UTHealth
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Houston, TX
United States
Objective: Sex-specific intervention threshold guidelines exist for abdominal aortic aneurysms, but not for ascending thoracic aortic aneurysms. Maximum aortic diameter at time of acute type A dissection (ATAAD) was assessed to evaluate if absolute size threshold guidelines for ascending aneurysm disadvantage females.
Methods: All adult ATAAD surgical repairs at a single center from 7/2011-3/2023 were included. Patients excluded had previous cardiac surgery, known connective tissue disorder, poor quality CT or onset of symptoms >24 hours before index CT. Maximum ascending thoracic aortic aneurysm diameter was measured at the index CT using dedicated 3D analysis software in a double-oblique plane, orthogonal to the aortic centerline. Using Rylski criteria pre-dissection aortic diameter was estimated by reducing the maximal post-dissection diameter by 31%. A standard measurement protocol was used by 4 trained physicians with strong inter-rater agreement on a 30-case test-set (intra-class coefficient 0.76). Patient characteristics, median pre-dissection aortic diameter and cumulative distribution curves of pre-dissection aortic diameter were compared by sex. Multivariable linear regression was used to identify independent associations with pre-dissection aortic diameter.
Results: 566 patients underwent ATAAD repair. 383 patients (67%) with suitable index CT studies were analyzed, of these 138 (36%) were female. Hypertension incidence (83%) was similar by sex, though females were older [65 (IQR 55-74) vs 58 (IQR 48-66), p<0.001] and higher frequency of family history of aortic aneurysm/dissection/sudden death (8% vs 3%, p=0.049). Females had smaller estimated pre-dissection aortic diameter [38mm (IQR 35-43) vs 40mm (IQR 37-45), p=0.027] compared to males. Based on the recommended guideline threshold for ascending thoracic aortic aneurysm repair of ≥50 mm at experienced centers, 96% of females and 88% of males had an estimated pre-dissection aortic diameter below threshold size prior to onset of ATAAD (Figure). Adjusting for age and family history, female sex was an independent predictor of smaller pre-dissection aortic diameter at the time of dissection (β= -2.22; 95%CI -4.05 to -0.62, p=0.008). However, after controlling for body surface area in the regression, female sex was no longer predictive of smaller pre-dissection aortic diameter (β= -1.53; 95%CI -3.54 to 0.48, p=0.14).
Conclusions: Females have ATAAD at smaller aortic diameters compared to males, and females dissect prior to aneurysm repair size thresholds more than males. Sex-specific ascending thoracic aortic aneurysm criteria or criteria indexed to body surface area should be considered, and may decrease the incidence of ATAAD in females.
Authors
Catherine Wagner (1), Carlos Alberto Campello Jorge (2), Prabhvir Marway (2), Meganne Ferrel (2), Shinichi Fukuhara (2), Robert Hawkins (3), G. Michael Deeb (4), Himanshu Patel (5), Gorav Ailawadi (2), Bo Yang (2), Nicholas Burris (6), Barbara Hamilton (2)
Institutions
(1) Michigan Medicine, Ypsilanti, MI, (2) University of Michigan, Ann Arbor, MI, (3) University of Michigan, Department of Cardiac Surgery, Ann Arbor, MI, (4) Frankel Cardiovascular Center, Ann Arbor, MI, (5) University of Michigan Hospital, Ann Arbor, MI, (6) University of Michigan Heath System, Ann Arbor, MI
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Poster Presenter
Catherine Wagner, Michigan Medicine
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Ann Arbor, MI
United States
Objectives: Acute type A aortic dissection (TAAD) is a catastrophic disorder associated with high mortality rates. Current guidelines recommend a threshold diameter of 5.0-5.5 cm for surgery, irrespective of sex. Although men are more affected than women, the distribution of aortic diameters at the time of TAAD stratified by sex remains unknown.
Methods: Maximal ascending aortic size at the time of naturally occurring acute flap-type TAAD was measured in 258 patients with still-available radiographic images of sufficient quality to permit size measurement presenting between 1990-2023. Demographic and comorbidity data were extracted from electronic medical records. Aortic size was re-measured from CT or MRI images in a standardized method. We compared the ascending aortic diameter at time of dissection between men and women. Aortic diameters were indexed to height, and histograms were constructed to display the raw and indexed aortic size at time of dissection.
Results: Among 258 patients with measurable TAAD (median age 63 years [IQR 53, 73]; 33% (N=86) female), the average maximal ascending aortic diameter was 5.05 cm [4.6, 5.6]. Men were taller (178 cm vs 163 cm, p<0.001), had a higher BMI (28 kg/m2 vs. 26 kg/m2, p=0.005), and had lower rates of COPD than women (9.9% (N=15/172) vs. 20% (N=15/86), 0.04). Other comorbidities were comparable. Women had a smaller ascending aortic diameter (4.95 vs. 5.10 cm, p=0.014) and presented at an older age than men (69 vs. 60, p<0.001). Among women, a larger proportion of aortic diameters were below 5.5 cm (77% (N=66/86) vs. 66% (N=114/172), p=0.084) and 5.0 cm (51% (N=44/86) vs. 37% (N=63/172), p=0.025) compared to men. After normalizing the ascending aortic diameter to the patient's height, the difference in ascending aortic diameter between women and men diminished (3.03 cm/m vs. 2.87 cm/m, p=0.079, respectively).
Conclusions: Although overall aortic diameter at the time of TAAD is consistent with updated guideline recommendations for prophylactic surgery, more than half of female patients dissected below 5.0 cm. An earlier intervention criterion below 5.0 cm may prove to be appropriate for women. Indexing aortic diameter to patient height reduces the size disparity and risk for women, endorsing the use of aortic diameter indexing when determining patient risk for TAAD. Female patients were almost a decade older at presentation; the pathophysiologic reasons for this age difference remain to be clarified.
Authors
Christina Waldron (1), Mohammad Zafar (2), Zachary Perez (2), John Elefteriades (2)
Institutions
(1) Yale School of Medicine, New Haven, CT, (2) Yale New Haven Hospital, New Haven, CT
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Poster Presenter
Christina Waldron, Yale School of Medicine
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New Haven, CT
United States
Objective: Diagnosis of Marfan (MFS), Ehlers-Danlos (EDS), and Loeys-Dietz (LDS) syndromes often warrants specialized evaluation for screening and surveillance of aortic disease. This study aims to characterize the incidence of referral to cardiovascular medicine and cardiothoracic surgery between male and female patients within a large healthcare network for patients diagnosed with MFS, EDS, or LDS.
Methods: We conducted a retrospective review of patients with genetic or clinical diagnoses of MFS, EDS, or LDS from the electronic medical record database in a large healthcare delivery network between 2013-2022. We explored the referral pattern to cardiovascular medicine and cardiothoracic surgery based on connective tissue disease and sex.
Results: 995 patients were identified (74% (n=741) female). There were 242 (24%) patients with MFS (41% (n=99) female), 772 (73%) with EDS (87% (n=627) female), and 31 (3%) with LDS (48% (n=15) female). Overall, the referral rates to cardiovascular medicine and cardiothoracic surgery were 69% (n=687) and 14% (n=137), respectively, both with a significantly higher referral for men compared to women (77% (n=196/254) vs 66% (n=491/741), p=0.001 and 33% (n=83/254) vs 7.3% (n=54/741), p<0.001). Among referred patients, 74% (n=507) saw cardiovascular medicine at our institution, with the remaining 26% (n=180) going to outside institutions. Referral rates to cardiovascular medicine for MFS, EDS, and LDS were 90% (n=217), 61% (n=441), and 94% (n=29), respectively. There was no significant sex difference. Referral rates to cardiothoracic surgery for MFS, EDS, and LDS were 38% (n=92), 2.9% (n=21), and 48% (n=15), respectively. Men with EDS were more likely to be referred to cardiothoracic surgery than women (11% (n=10/95) vs 1.8% (n=11/627), p<0.001). Among patients with vascular EDS, 71% (n=25/35) and 11% (n=4) were referred to cardiovascular medicine and cardiothoracic surgery, respectively, with a higher rate for men compared to women (100% (n=10/10) vs 60% (n=15/25), p=0.03; 30% (n=3) vs. 4% (n=1), p=0.061, respectively). Among patients with EDS and aortic pathology (4.4%, n=32), men were more likely to be referred to cardiothoracic surgery than women (62% (n=8) vs. 32% (n=6), p=0.093).
Conclusions: Patients with MFS and LDS had appropriately high referral rates to cardiovascular medicine. Women with connective tissue diseases are less likely to be referred to cardiovascular medicine, particular women with vascular EDS.
Authors
Christina Waldron (1), Afsheen Nasir (2), Alan Chou (3), Roland Assi (3)
Institutions
(1) Yale School of Medicine, New Haven, CT, (2) Yale New Haven Hospital, New Haven, CT, (3) Yale University School of Medicine, New Haven, CT
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Poster Presenter
Christina Waldron, Yale School of Medicine
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New Haven, CT
United States
Objective:
Rupture and dissection are feared complications of ascending thoracic aortic aneurysms (ATAA). ATAA failure is a mechanical phenomenon, occurring when the stress in the wall exceeds the strength of the material. Unfortunately, there are no direct biomarkers to evaluate wall stress and strength, such that other predictors are needed to estimate the risk of failure. Currently, the largest aortic diameter is used as predictor, but since this criterion lacks accuracy, groups are advising a 'shift to the left' in terms of threshold value for surgery. Though this would reduce the number of ATAA failures, it will further increase the number of false positives.
Methods:
To identify better predictors, we performed a retrospective personalized failure risk analysis, including clinical, geometrical, histological and mechanical data of 33 patients. Uniaxial tensile tests until failure were performed to determine the wall strength. Material parameters were fitted against ex vivo planar biaxial data and in vivo pressure-diameter relationships at diastole and systole. Using the resulting material properties and in vivo data, the maximal in vivo stress at 110% systole was calculated, assuming a thin-walled axisymmetric geometry. The retrospective failure risk (RFR), defined as the ratio between the maximal stress and maximal strength in each direction (i.e. the circumferential and axial direction of the aneurysm), was correlated with prospective parameters to find the best failure risk predictor. A.o., the maximum diameter at systole (D_sys) and the volumetric distensibility coefficient (DC_V) were considered as predictors. This distensibility coefficient reflects the aneurysm's compliance and is calculated as the normalized aneurysm volume change between diastole and systole as measured on an ECG gated CT-scan, divided by the pulse pressure.
Results:
The results show that the volumetric distensibility coefficient (DC_V) outperforms other predictors, including maximum aneurysm diameter (D_sys), in terms of correlation to the retrospective failure risk of the aneurysm (RFR) in each direction. Indeed as shown in the figure, the Spearman correlation coefficient for the D_sys vs RFR correlation was ρ = 0,29 with a corresponding p-value of 0,35 in the axial direction, as compared to ρ = -0,80 and p < 0,01 for the DC_V vs RFR correlation. Also in the circumferential direction, D_sys vs RFR shows a ρ = 0,44 with a p-value of 0,07, whereas DC_V vs RFR shows ρ = -0,59 with p < 0,05.
Conclusion:
In contrast to the maximum aortic diameter, the volumetric distensibility coefficient significantly correlates to the retrospective personalized failure risk of 33 patients in our clinical study. This distensibility coefficient is easily calculated in a clinical setting provided an ECG gated CT-scan and BP measurement. Rather than shifting to the left in the diameter criterion, we propose further consideration of this mechanics-based predictor of ATAA failure risk.
Authors
Nele Famaey (1), Klaas Vander Linden (1), Amber Hendrickx (2), Emma Vanderveken (2), Lucas Van Hoof (2), Steven Dymarkowski (3), Filip Rega (2), Peter Verbrugghe (2), Bart Meuris (2)
Institutions
(1) Division of Biomechanics, KU Leuven, Leuven, Vlaams-Brabant, Belgium, (2) Cardiac Surgery, KU Leuven, Belgium, Leuven, Vlaams-Brabant, Belgium, (3) Department of Imaging & Pathology, UZ Leuven. Belgium, Leuven, Vlaams-Brabant, Belgium
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Poster Presenter
Amber Hendrickx
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Belgium
Objective: Ascending thoracic aortic aneurysms (ATAA) and acute dissections (ATAD) are associated with high risk of mortality. Because metabolic pathways can regulate cell phenotype and disease progression, we investigated the transcriptomic profile of glycolysis in smooth muscle cells (SMCs) in human aortic tissue and its potential involvement in promoting an inflammatory phenotype in SMCs of sporadic aortic aneurysms and acute dissections. Activation of STING pathway and subsequent activation of IRF3-mediated pro-inflammatory signaling has been shown to play a critical role in aortic degeneration. We hypothesized that glycolytic activity in SMCs is elevated in both ATAA and ATAD tissues compared to healthy control aortic tissues, and that this effect is mediated by the STING-IRF3 pro-inflammatory signaling pathway.
Methods: We performed single cell RNA sequencing (scRNA-seq) analysis of ascending aortic tissue from 9 patients with ATAA without dissection, 9 patients with ATAD (dissected and non-dissected areas collected separately), and 8 organ donor control subjects (Fig A). Within the SMC clusters analyzed (Fig B), we identified differentially expressed glycolytic genes between control, ATAA, and ATAD patients. Single-cell flux estimation analysis (scFEA) was performed to estimate metabolic flux variation in glycolytic activity in SMCs. Single-cell assay for transposase accessible chromatin using sequencing (scATAC-seq) (Fig C-D) and scRNA-seq analyses (Fig E) were performed in ascending aortic tissues from wild-type (WT) mice infused with angiotensin II (Ang II), WT mice infused with saline (control), and Sting-/- mice infused with Ang II.
Results: In human aortic tissues, glycolytic genes (e.g., ENO1, HK1) and predicted glycolytic activity in SMCs were progressively upregulated from control to ATAA to ATAD, especially in inflammatory SMCs (Fig F-G). We also observed progressive induction of lactate production gene LDHA from control to ATAA and ATAA to ATAD that was consistent with greater lactate accumulation in scFEA analysis (Fig F-G). In Ang II-infused mice, scATAC-seq analyses revealed slightly higher gene activity of glycolysis genes in inflammatory SMCs of AngII-infused mice (Fig H). Chromatin accessibility of glycolytic genes (e.g., Hk1, Ldha) in SMCs was elevated compared to saline-infused controls, suggesting potential regulation at the epigenetic level by chromatin remodeling (Fig I). Furthermore, the activity of most glycolytic genes (e.g., Ldha) were positively associated with the motif activity of Irf3 (Fig J), which is increased in the AngII infused mice (Fig K). This suggests Irf3 may be involved in the induction of chromatin remodeling and in the expression of glycolytic genes. Finally, Sting deficiency partially prevented Ang II-induced upregulation of glycolytic genes in SMCs (Fig L).
Conclusion: Our data suggest that glycolytic gene expression and lactate production in SMCs are progressively increased from control to ATAA to ATAD. The induction of glycolysis genes was partially controlled by chromatin remodeling. Activation of STING-IRF3 pro-inflammatory signaling may play a critical role in the epigenetic induction of glycolytic genes. Investigating the upstream and downstream regulators is key to understanding this metabolic shift in aortic disease progression.
Authors
Samantha Xu (1), Yanming Li (2), Chen Zhang (2), Hernan Vasquez (2), Robert Seniors (3), Kimberly Rebello (2), Joseph Coselli (4), Hong Lu (5), Alan Daugherty (5), Dianna Milewicz (6), Ying Shen (2), Scott LeMaire (7)
Institutions
(1) N/A, United States, (2) Baylor College of Medicine, Houston, TX, (3) Baylor College of Medicine/Texas Heart Institute, Houston, TX, (4) Baylor College of Medicine, Texas Heart Institute, United States, (5) University of Kentucky, Lexington, KY, (6) N/A, Houston, TX, (7) Geisinger, PA
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Poster Presenter
Samantha Xu, Case Western Reserve University
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Naperville, IL
United States
Objective: In the past decade, the Ross procedure has experienced a resurgence in popularity due to improved autograft longevity and potentially enhanced survival compared to current prosthetic valves. However, few studies have examined outcomes in patients older than 45 years old. In this study, perioperative outcomes after Ross procedure were compared between patients aged 45 (middle-aged) and patients < 45 (young).
Methods: From June 2020 to July 2023, 79 patients underwent a Ross procedure at one academic center. After excluding patients under age 18, 76 patients were stratified into cohorts of ages 18-44 (mean 32 ± 6.47 years, n=47) and ages 45 (mean 54.1± 5.23 years, n=29). Preoperative demographics, intraoperative characteristics, perioperative, and short-term outcomes were collected from the electronic health record. Normality of the variables was assessed using the Shapiro-Wilk test. Statistical comparisons were then performed using the t-test or the Mann-Whitney test for continuous variables, and Fisher's exact test for categorical variables.
Results: Mean age of the entire cohort was 40.4 ± 12.36 years, 72% of patients were male, and mean follow-up time was 10.8 months. 25% of patients (n=19) had prior cardiac surgery. Shortness of breath was the most common presenting symptom (47%, n=36), while 27% (n=21) were asymptomatic. 88% (n=67) had a preoperative EF of over 55%. The middle-aged cohort had higher rates of hypertension (48% vs 21%, p<0.05), hyperlipidemia (62% vs 6%, p=0.001), coronary artery disease (21% vs 2%, p=0.011) and a higher BMI (30.59 vs 25.72, p=0.002). Middle-aged patients had more isolated aortic stenosis, compared to a mixed pathology with an aortic stenosis predominance in the young cohort (69% vs 47%, p=0.002). Bypass time, cross-clamp time, and number of concomitant procedures performed were similar between cohorts. Post-operatively, the middle-aged cohort had a higher rate of atrial fibrillation (31% vs 11%, p <0.05), more frequently required prolonged inotropes (21% vs 2%, p<0.05), and had a longer median length of stay (8 days vs 7, p=0.02). There was one stroke in the middle-aged group, no in-hospital mortality in either group, and no significant difference in frequency of post-op pacemaker placement, reintervention, or readmission.
Conclusions: Peri-operative and short-term outcomes of the Ross procedure are similar when comparing cohorts of patients aged 18-44 and 45-60 years. It is reasonable to consider a Ross procedure in select middle-aged adults at an experienced Ross center.
Authors
Anne Reimann-Moody (1), Arjune Dhanekula (2), Michael Shang (2), Audrey Mossman (3), Rachel Flodin (2), David Mauchley (2), Chris Burke (2), Scott DeRoo (2)
Institutions
(1) University of Washington, Bozeman, MT, (2) University of Washington, Seattle, WA, (3) University of Washington, Laramie, WY
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Poster Presenter
Anne Reimann-Moody, University of Washington School of Medicine
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Missoula, MT
United States
Objective: to describe the simplified reimplantation technique, to discuss its range of application and report the early echocardiographic and computed tomography angiography (CTA) results of the technique.
Case Video Summary: 13 patients underwent the simplified reimplantation procedure between December 2022 and November 2023, 2 bicuspid and 11 tricuspid aortic valve patients. The technique was applied to cases of extremely diseased root wall where the aortic remnants were judged fragile and unsuitable for suturing to the Dacron.
The simplified reimplantation was performed as follows: the aortic wall remnants are completely removed. Twelve-pledgeted sutures are placed along the circumference of the virtual basal ring and then passed at the established level of the Valsalva graft (hemostatic suture). The commissures are fixed at the new sinotubular junction with a horizontal pledgeted suture. One pledgeted suture is added vertically within each interleaflet triangle to anchor the aortic valve to the graft. The rest of the procedure is carried out in the standard fashion.
Early echocardiographic results showed none or trivial AR in all patients, no significant gradient. Early postoperative CTA images showed a re-established morphology of the root with a preserved separation of the sinuses of Valsalva. The stabilization of the interleaflet triangles allows a better distribution of the hemodynamic stress along the whole commissure (not only on the tip of the commissure) and avoids blood flow between the commissure and the Dacron.
Conclusions: the simplified reimplantation technique is an excellent bailout strategy for valve sparing in patients with fragile and damaged aortic wall remnants. The early echocardiographic results are excellent. The CTA images show a re-established physiological root morphology and comparable to the standard technique. Longer follow up is needed to evaluate long term results.
Authors
Giulio Folino (1), Andrea Salica (1), Mario Torre (2), Raffaele Scaffa (1), Francesco Giosuè Irace (3), Paolo Ciancarella (4), Ilaria Chirichilli (3), Luca Paolo Weltert (1), Ruggero De Paulis (5)
Institutions
(1) Department of Cardiac Surgery, European Hospital, Rome, Italy, Rome, IT, (2) University of Naples Federico II, Naples, IT, (3) Department of Cardiac Surgery, Ospedale San Camillo-Forlanini, Rome, Italy, Rome, IT, (4) European Hospital, Rome, IT, (5) European Hospital, Unicamillus University, Rome, IT
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Poster Presenter
Giulio Folino, European Hospital (Rome)
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Rome, Rome
Italy
Objective: Clamshell or antero-lateral partial sternotomy is used for replacing extensive thoracic mega aorta. Here, we present our approach, left thoracotomy/posterolateral thoracotomy for this pathology.
Case Video Summary:
This is a 46-year-old male with a history of chronic kidney disease. The patient was incidentally diagnosed with chronic Stanford A aortic dissection aneurysm during an inguinal hernia work-up.
A CT scan showed type A aortic dissection starting from the distal ascending aorta to the iliac artery with 66 mm aortic arch and 63 mm descending aorta. The size of the distal descending aorta decreased to 35mm and the abdominal aorta was dilated to 50mm. The Adamkiewicz artery was identified at the level of Th8. We decided to perform total arch and descending aorta replacement simultaneously via left thoracotomy.
In the beginning, in supine position, the left femoral artery and vein were exposed for arterial and venous cannulation. The patient was positioned in right decubitus potion. The skin incision was made from the level of anterior axillary line to the tip of the scapula. The 4th intercostal space was opened, and posterior 4th rib and anterior 5th rib was divided for the further exposure. After systemic heparinization, venous and arterial cannulas were inserted via the left femoral vein and artery and cardiopulmonary bypass was initiated. The pericardium was opened to expose the heart and the ascending aorta. The left upper pulmonary vein was exposed outside of the pericardium. Left ventricular vent was inserted and advanced into the left ventricle while passing it along the left atrium wall. A transesophageal echocardiogram was used to confirm the position of the cannula in the left ventricle. A root cannula was placed in the ascending aorta. The ascending aorta was cross clamped to give antegrade cardioplegia. Then, mid descending aorta (Th7 level) was clamped, and upper body circulatory arrest was started at bladder temperature 25 ℃. The lower body was perfused from the femoral artery cannula. 15Fr, 12 Fr, 12Fr cannula were placed into the arch vessels for selective antegrade cerebral perfusion. First, the proximal anastomosis was performed at the distal ascending aorta where there was no dissection with a four-branched graft (J graft 26mm 4 branched, Japan lifeline, Tokyo). The graft was deaired via a perfusion from one of the branches. Rewarming was started. The head vessels were individually anastomosed to the branches of the graft from the innominate artery. The Adamkiewicz artery was reconstructed with a 10mm graft. The graft for the Adamkiewicz artery was attached the main graft. Finally, the distal anastomosis to the distal descending aorta was performed at the level of Th9. The heart was deaired from the root vent and left ventricular vent and weaned from the cardiopulmonary bypass. The distal anastomosis site was wrapped with a Gore-Tex sheet to prevent the adhesion for the future surgery of abdominal aortic aneurysm. Postoperatively, the patient recovered without any complications and was discharged home on the postoperative day 18. A post operative CT scan demonstrated the almost whole thoracic aorta was replaced with a graft without any anastomosis issues.
Conclusions: The left thoracotomy provides an excellent view of the whole thoracic aorta for simultaneous total arch and descending aorta replacement. A left ventricular vent can be inserted through the left upper pulmonary vein.
Authors
Shinichiro Ikeda (1), Tomomi Nakajima (1), Takayuki Gyoten (1), Osamu Kinoshita (1), Toshihisa Asakura (1), Akihiro Yoshitake (1)
Institutions
(1) Saitama Medical University International Medical Center, Hidaka, Japan
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Poster Presenter
Shinichiro Ikeda, Saitama medical university International medical center
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Japan
Objectives: Understanding thoracic cage morphology is essential for determining the optimal surgical incisions and approaches for thoracic aortic surgeries. We aimed to describe the size and morphological differences of the thoracic cage between Marfan and non-Marfan patients.
Methods: In this single-center retrospective cohort study, 58 Marfan patients and 1,535 non-Marfan patients diagnosed with aortic diseases were listed. Among these, 47 patients from each group were selected after exact matching to control for differences in sex and age categories. We compared physical data and computed tomography measurements of the thoracic cage between the two groups. Linear regression models were applied to estimate the effect size for Marfan syndrome patients in comparison to those without Marfan syndrome. The adjusted effect size was estimated using multiple linear regression models that accounted for sex, age, and body surface area.
Results: The Marfan group exhibited significantly greater height (Marfan: 177.1 ± 10.7 cm vs Non-Marfan: 166.3 ± 12.1 cm; P<0.001) and a significantly lower body mass index than the Non-Marfan group (Marfan: 22.3 ± 3.4 vs Non-Marfan: 20.0 ± 3.6; P=0.002). Angles between the ribs and the craniocaudal axis were significantly smaller in the Marfan group than in the non-Marfan group (45.0° vs 55.4° for the 4th rib; 42.2° vs 51.3° for the 5th rib; 39.7° vs 49.3° for the 6th rib; all P<0.001). At the level of the aortic valve, the adjusted analysis showed the Marfan group had significantly smaller anteroposterior distance, sternum-vertebra distance, transverse distance, and thoracic cavity area in comparison to the Non-Marfan group (Table). Furthermore, the angles between the ribs and the craniocaudal axis were significantly smaller in the Marfan group than in the Non-Marfan group in both crude and adjusted analyses. The angles between the ribs and the craniocaudal axis showed a mild correlation with the anteroposterior distance and the sternum-vertebra distance at the level of the aortic arch (R=0.22-0.34; all P<0.05), and a moderate correlation with those at the level of the aortic valve (R=0.46-0.54; all P<0.001).
Conclusions: Our findings implicate that patients with Marfan syndrome exhibit a flatter chest wall than those without Marfan syndrome. Better results may be obtained if these morphological differences are taken into account in the surgical strategy.
Authors
Yuki Kuroda (1), Takehiko Matsuo (1), Hiroaki Osada (1), Masahide Kawatou (1), Takahide Takeda (1), Fumie Takai (1), Kazuhiro Takatoku (1), Hiromasa Kira (1), Yasuyuki Fujimoto (1), Haruka Fujimoto (1), Kazuyoshi Kanno (1), Tadashi Ikeda (1), Kenji Minatoya (1)
Institutions
(1) Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Poster Presenter
Yuki Kuroda, Kyoto University, Graduate School of Medicine
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Kyoto-shi, Fukuoka
Japan
Objective: to analyze the early and mid-term results of urgent surgical procedures for shrapnell penetrating injuries of the thoracic and abdominal cavities with damage to the thoracic or abdominal part of the aorta.
To analyze the early results of endoprosthesis of the descending thoracic aorta in case of shrapnels pseudoaneurysms of the thoracic aorta.
Methods: patients with shrapnel penetrating wounds of the thoracic and abdominal cavity with damage to the thoracic or abdominal sections of the aorta, with profuse bleeding were studied in detail. Patients were brought to the operating room in the first two hours from the moment of the injury. Urgent surgical procedures^ thoracotomies and laparotomies were performed in patients with ongoing bleeding with an attempt to sew up damage to the thoracic or abdominal aorta. Mainly suturing of damage to the aorta on the lateral impression was performed with the help of U-shaped sutures on teflon pads. If necessary, the aorta was wrapped externally with a vascular prosthesis to achieve stable hemostasis. REBOA endovascular balloon was used during operations for damage to the abdominal part of the aorta to reduce bleeding and centralize blood circulation. Urgent thoracotomies and laparotomies were performed only under the condition of relative stabilization of the patient's condition and adequate replenishment of the volume of circulating blood.
Results: intraoperative and early postoperative mortality (during first 6 hours) was 59% in patients with srapnel injuries of the thoracic or abdominal part of the aorta who underwent emergency surgery. Patients with small aortic injuries (2-3 mm) or tangential injuries made up the majority of patients who successfully underwent surgical interventions. Among the patients who successfully underwent life-saving operations, 25% had complications in the form of pseudoaneurysms of the aorta and required endoprosthesis of the aorta in a timely manner.
Conclusions: gunshot penetrating shrapnel injuries with damage to the thoracic or abdominal aorta are life-threatening injuries and are accompanied by high mortality. Emergency thoracotomies and laparotomies with subsequent suturing of aortic injuries enable about 41% of patients to survive. In the future, patients need dynamic monitoring for 6 months for the purpose of timely diagnosis and hybrid or endovascular treatment of pseudoaneurysms of the aorta.
Authors
DMYTRO BESHLEY (1), Andriy Sobko (2), Roman Sobko (3), Uliana Pidvalna (4)
Institutions
(1) Lviv Regional Clinical Hospital, Mobile Military Hospital, Ukrainian-Polish Heart Center Lviv, Lviv, Ukraine, (2) MD., Surgeon, Lviv, --None--, (3) MD., Anestesiologist, Lviv, Ukraine, (4) MD., Radiologist, Lviv, Ukraine
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Poster Presenter
Dmytro Beshley, Lviv Clinical Regional Hospital
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Lviv
Ukraine
Objective
The incidence of re-entry injury is low in redo cardiac surgery, but it is associated with a significant increase in-hospital mortality. Hypothermic circulatory arrest with cardiopulmonary bypass (CPB) before resternotomy is often performed in these cases. However, in anticipation of a prolonged circulatory arrest period, lack of myocardial protection or left ventricular (LV) venting during cooling can pose great concern. Herein we describe a staged sternotomy strategy that facilitates insertion of an LV vent and retrograde cardioplegia cannula via a lower hemi-sternotomy, followed by upper sternotomy with circulatory arrest in complex redo aortic aneurysm repair and mitral valve replacement (MVR).
Case Video Summary
The case was a 42-year-old male who had undergone 4 prior open cardiac operations. The echocardiogram showed severe paravalvular leak of the mitral valve and reduced right ventricular function with a left ventricular ejection fraction of 55%. Computed tomography showed a proximal arch pseudoaneurysm with severe adhesions to the sternum. The patient was taken to the operating room for a planned MVR and proximal aortic repair. During surgery, a lower partial sternotomy was performed by transecting the sternum, and adhesions were taken down from around the heart. With femoral aortic and central venous cannulation, CPB was initiated with systemic cooling. An LV vent was inserted via the right upper pulmonary vein as well as a retrograde cardioplegia catheter into the coronary sinus. Once the target temperature was reached, circulatory arrest was induced, and an upper hemisternotomy was quickly performed with anticipated entry into the proximal aorta/graft. The heart was arrested with retrograde cardioplegia. Following aortic repair, MVR was performed with a Commando procedure. CPB time and aortic cross clamp time were 367 and 266 min, respectively. The patient was discharged on postoperative day 15 without any complications.
Conclusion
We reported a case of complex redo aortic aneurysm repair and MVR for which staged sternal opening was used. In redo cases where there is concern for aortic injury upon sternotomy and long myocardial ischemia, a staged sternal opening facilitates heart dissection, LV venting and coronary sinus cannulation prior to circulatory arrest.
Authors
Yu Hohri (1), Megan Chung (1), Hiroo Takayama (1)
Institutions
(1) NewYork- Presbyterian/Columbia University Medical Center, New York, NY
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Poster Presenter
Yu Hohri, Columbia Univeristy Irving Medical Center
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New York, NY
United States
Objective:
Cardiovascular manifestations of Marfan syndrome typically present as aortopathy or valvular disease. Rarely, they can present with peripheral aneurysms. Subclavian artery aneurysms (SCAA) are particularly rare, representing <1% of all peripheral aneurysms with connective tissue patients accounting for <10% of SAA. We discuss a familial case of Marfan syndrome in two patients with a history of extensive aortopathy that in turn developed subclavian artery aneurysms.
Methods:
We discuss two patients with Marfan syndrome and SCAA, a 37-year-old male (Patient 1) and his 57-year-old mother (Patient 2). We review their relevant prior history, presentation, and management.
Results:
Patient 1 presented to our institution at age 32, with a history of a previous aortic root and mitral valve replacement and an enlarging type B dissection involving the distal arch and left subclavian artery (LSCA) extending to his left iliacs. A staged repair was planned, including a left carotid-SCA bypass, ligation of the LSCA, and elephant trunk arch replacement. This was followed by an extent 2 thoracoabdominal aortic repair with aorto-bi-iliac bypasses.
Two years following, he developed enlargement of his bilateral axillary artery (AA) aneurysms (R 4.5[3.3]cm, L 2.3[0.8]cm), and enlargement of the LSCA (2.3[1.5]cm). He first underwent a right SCA to brachial artery bypass. His LSCAA appeared to include several branches, including the vertebral artery, placing the patient at risk for operative stroke. Coil embolization of the vertebral was performed. No other aneurysm branch vessels were able to be cannulated, and a vascular plug was placed at the neck. Angiography demonstrated sac thrombosis. However, post-operative imaging demonstrated ongoing flow to LSCAA, as well as a new large left AA/brachial aneurysm. He also developed left arm pain, with duplex showing minimal left arm flow. Open ligation of the LSCAA, with excision and bypass of the AA aneurysm was performed. The LSCAA was isolated, however, when clamped proximally significant bleeding occurred from the top of the LSCAA. The LSCAA was divided off the bypass and suture closed. The residual LSCA was unsuitable for bypass and was ligated. The residual carotid-SCA bypass was sutured to the AA-brachial graft, with improvement in left arm flow. He was discharged on post-operative day 2 without issue. Despite the extensive interventions above, the LSCAA stump remains with filling from the internal mammary and thyrocervical trunk. Pending approval of new embolic plugs, the patient will undergo further intervention.
Patient 2 presented to our institution at age 57, with a history of previous aortic valve, and ascending aortic, hemiarch, and abdominal aorta repair, with an expanding LSCA and AA aneurysm measuring 4.9 x 7.8cm, causing worsening nerve compression. To exclude collateral branches, she underwent LSCA and AA stenting, in addition to an AA to brachial bypass. The procedure was uncomplicated, however, a year following she presented with acute limb ischemia related to complete occlusion of the stents. She subsequently underwent failed endovascular thrombectomy and thrombolytic therapy, ultimately requiring open thrombectomy and grafting with resolution.
Conclusion:
Marfan patients with SCAA present a challenging clinical dilemma. Given their vasculopathy, they are at high risk of rapid expansion of pathology and require close surveillance and aggressive intervention.
Authors
Adam Carroll (1), Lance Dzubinski (1), Rafael Malgor (1), Donald Jacobs (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
LANCE DZUBINSKI, N/A
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Denver, CO
United States
Objective
Sinus of Valsalva aneurysms (SOVA) is a rare congenital or acquired condition of the aortic root. Ruptured SOVA typically involves another chamber of the heart. Free wall rupture of the SOVA is usually associated with sudden death due to tamponade. We report a case of blunt trauma resulting in the rupture of the non-coronary sinuses of Valsalva, which was successfully repaired.
Case Presentation
The patient is a 47-year-old male with a past medical history of sternotomy for penetrating trauma who recently sustained blunt chest trauma. Upon arrival, the patient complained of chest pain and shortness of breath. The transthoracic echocardiograph reveals a rupture of the sinus of Valsalva. The rupture is near the aortic root's non-coronary cusp (NCC). Axial view of chest CT showing disruption of the non-coronary sinus (NCC) with contained posterior hematoma within the mediastinum.
The patient underwent a redo sternotomy, revealing a rupture of the non-coronary aortic root sinuses. He received a biological aortic root reconstruction. After a prolonged hospital course, he was discharged to home and resumed all normal activities upon outpatient follow-up.
Conclusion
A literature search did not identify any reports of long-term survival following emergency surgical intervention for traumatic, free rupture of the Sinuses of Valsalva. We identified reports of non-traumatic ruptures of the SOVA into the pericardium causing tamponade.1 The unique feature of this case was the acute traumatic cause of the rupture, the distinct CT and TTE findings, and the successful aortic valve replacement. The history of sternotomy for penetrating trauma possibly contributed to the patient's survival.
Traumatic free wall ruptured sinus of Valsalva into the mediastinum can show specific radiological findings; rapid surgical correction should ensue.
Authors
Nicholas Ray (1), Philipos Gebremedhin (1), Sasha Adams (1), Michelle McNutt (1), Thanila Macedo (1), Anthony Estrera (1), steven eisenberg (1)
Institutions
(1) UTHealth Medical School, Houston, TX
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Poster Presenter
Nicholas Ray, McGovern Medical School at UTHealth
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Austin, TX
United States
Objective: Blunt force traumatic injuries to the aortic arch and great vessels are relatively rare, but are often fatal. The fact that they are encountered infrequently, coupled with their location, makes them a particular surgical challenge. Our objective is to present an unusual case of a traumatic pseudoaneurysm of the innominate artery, outline the options for repair, and discuss the technicalities of the operation in conjunction with intraoperative images.
Methods: A 17-years-old male was taken by ambulance to a district general hospital emergency room, having sustained polytrauma following a motorcycle collision. His primary injuries at presentation included a right forearm fracture with deformity, an open tibia/fibula fracture with distal neurovascular compromise, T4 & T5 fracture, craniofacial fractures and lung contusions. On transfer to our tertiary trauma centre, a repeat CT angiogram identified an expanding 23 x 15 x 7 mm pseudoaneurysm arising from the anterior surface of his innominate artery extending to the proximal right common carotid artery (figure 1). An ad hoc aortovascular MDT was held, and the patient was consented for repair of his innominate artery with or without aortic arch replacement under circulatory arrest
Results: In the operating room, a right total sternoclavicular joint dislocation was identified as the probable cause of the underlying vascular injury. On opening the chest, there was a frank hemopericardium and bruising to his innominate artery. After dissection of the great vessels, vascular clamps were applied to the right common carotid and right subclavian arteries beyond the point of injury, along with the base of the innominate artery at the take-off from the arch. It was deemed that injury could be repaired without arch surgery or circulatory arrest. The patient was placed on cardiopulmonary bypass. On opening the adventitia, a complete rupture of the innominate intima and media was identified. The artery was resected and a 10 mm Gelweave interposition graft implanted. Cerebral saturation monitoring was stable throughout. On waking, the patient was neurologically intact and post-operative imaging was satisfactory. He was discharged home 16 days later.
Conclusions: Innominate artery trauma is a rare presentation, but should be considered in high velocity blunt trauma leading to sternoclavicular joint dislocation. This case, along with radiological and intraoperative imaging, illustrates the decision making and surgical skills necessary for an aortovascular surgeon to manage such patients.
Authors
Luke Holland (1), Karim Brohi (2), John Yap (1), Benjamin Adams (1)
Institutions
(1) Department of Cardiothoracic Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, UK., London, NA, (2) Royal London Hospital, London, NA
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Poster Presenter
Luke Holland, Barts Heart Centre, St Bartholomew's Hospital
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London, NA
United Kingdom
Objective
Acute type A aortic dissection (ATAAD) is a life-threatening disease that requires emergent surgery. However, the surgical indication for ATAAD with preoperative cardiopulmonary resuscitation (CPR) remain controversial. This retrospective study aimed to compare the individual characteristics and short-term outcomes between survivors and deceased patients who underwent preoperative in-hospital CPR.
Methods
From Jan 2019 to Aug 2023, 174 consecutive patients underwent ATAAD repair; 22 (12.6%) of these patients underwent preoperative in-hospital CPR. Patients who underwent preoperative CPR were classified into the survival group (n=13) and non-survival group (n=9), based on whether they survived to hospital discharge. Clinical features, surgical information, and postoperative complications were analyzed. Cerebral performance category (CPC) scores at discharge are presented.
Results
The major cause of cardiovascular collapse requiring CPR was aortic rupture/cardiac tamponade (n = 13, [59%]), followed by coronary mal-perfusion (n =7, [32%]). When patients who had been planned for surgery requiring CPR without return of spontaneous circulation, ECMO was actively applied. There were 5 (38.5%) patients in the survivors group and 2 (22.2%) in the non-survivors group who required preoperative ECMO at the beginning of surgery (P= .735). Overall duration of CPR was similar in survivors (5.0 minutes [range, 4.0-6.5 minutes] vs 7.0 minutes [range, 4.5-10 minutes]; P= .453). There were no significant inter-group differences in preoperative demographics and intra-operative procedures. Among patients in the survival group, 61.5% (8/13) of patients were discharged home, and 92.3% (12/13) of patients had full cerebral performance at discharge.
Conclusion
Patients with ATAAD undergoing preoperative in-hospital CPR, a significant proportion of these patients survived and discharged home with full cerebral performance. The prognosis of patients could not be predicted based solely on the preoperative situation. Therefore, a transient in-hospital CPR issue with active treatment might not be an obstacle to aortic surgery.
Authors
MIHEE LIM (1), Chee-hoon Lee (2), Minho Ju (3), Hyung Gon Je (4)
Institutions
(1) Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedic, Yangsan, South Korea, (2) Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedic, Seoul, South Korea, (3) N/A, Seoul, South Korea, (4) N/A, Yangsan, Korea
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Poster Presenter
MIHEE LIM
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South Korea
Objectives:
Considering longer life expectancy of the population, octogenarians represent a new challenge in aortic surgery. Aortic surgery in elderly patients is associated with high rates of postoperative morbidity and mortality. Considering the current pressure on the national health system and the limited hospital resources, offering major aortic surgery to this group of patients remains controversial. One of the main preconceptions is the expected poor quality of life after surgery.
Methods:
We prospectively collected data of 800 consecutive patients who underwent major aortic surgery between 2011 and 2023. Forty-five patients (5.6%) were octogenarians. The median age was 82 years (80-87 years). Preoperative, operative, postoperative and follow-up data were prospectively collected in our hospital database. Quality of life at follow-up was assessed trough a telephone questionnaire.
Results:
Twenty-two patients (48.9%) required emergency surgery. The main indications for aortic surgery were ascending aortic aneurysm in 48.9%, acute aortic syndrome in 22.2% and chronic aortic syndrome in 6.7%. Five patients (11.1%) had surgery of the aortic root, 37 (82.2%) of the ascending aorta and 9 (20%) of the arch.
In-hospital mortality was 26.6%, incidence of stroke 11% and average length of hospital stay 21 days (7-139 days).
Overall survival at 1 and 3 years was 64.4% and 51.1%.
15 patients were alive at the time of QOL assessment and 10/15 completed the questionnaire. 80% of the patients had a full recover after surgery; less than 20% suffered a major complication after discharge, 70% graded their quality of life >4 in a scale 1 to 5; 80% had same or better quality of life compared to prior surgery and all the patients would have their aortic surgery again.
Conclusion:
Octogenarians undergoing aortic surgery have high incidence of post-operative complications with 26.6% mortality and 11% stroke. Despite high peri-operative mortality, the late survival was encouraging with a 3 years survival rate of 51.1% The patients who survived aortic surgery maintained a good quality of life. All the patients who completed the QOL questionnaire would have the aortic surgery again if they had the opportunity to go back in time.
Authors
Mohamed Shoeib (1), Sumit Das (2), Syed Sadeque (3), Govind Chetty (3), Stefano Forlani (4), Graham Cooper (5), Renata Greco (6)
Institutions
(1) Sheffield Teaching Hospitals, Sheffield, (2) Sheffield teaching Hospitals, Sheffield, NA, (3) Sheffield Teaching Hospitals, Sheffield, NA, (4) Sheffield Teaching Hospitals, Sheffield, United Kingdom, (5) Sheffield Teaching Hospitals Foundation NHS Trust, Sheffield, NA, (6) Sheffield Teaching Hospital, Sheffield
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Poster Presenter
Mohamed Shoeib, Sheffield Teaching Hospitals NHS Foundation Trust
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United Kingdom
Objectives: The management of acute type A aortic dissection complicated by coma remains controversial. This study evaluates the surgical results of patients presenting with acute type A aortic dissection complicated by preoperative coma.
Methods: Between January 2016 to December 2019, Our institution accepted 200 patients with acute type A aortic dissection. All 200 patients underwent immediate surgery without any patient selection. Coma was defined as Glasgow Coma Scale (GCS) score of less than 11 upon arrival. The study population was divided into 2 groups comprising those with preoperative coma (Coma＋) and those without preoperative coma (Coma−). The characteristics, neurological symptoms, computed tomographic or magnetic resonance imaging scans and echocardiographic studies, interval from symptom onset to operation, and operative details (procedure, arterial cannulation site, method of brain protection) were retrospectively reviewed and compared by univariable and multivariable analyses.
Results: There were 30 patients (15.0%, 30/200) admitted with coma. there were no significant differences except that males were significantly less prevalent in the Coma+ group and that the median interval from onset to the start of surgery was significantly shorter in the Coma+ group (2.8 hours, 2.9-5.1 vs. 3.7 hours, 2.0-4.5; P = .017). In terms of preoperative data related to aortic dissection, shock, cardiac tamponade, intubation upon arrival, cardiopulmonary arrest, and visceral malperfusion were significantly more prevalent in Coma＋ patients. Preoperative CT angiography revealed a significantly higher incidence of dissection involving supra-aortic vessels in Coma＋ patients. There were no significant differences in almost all operative data, except that femoral arterial cannulation was significantly more prevalent in the Coma+ group. When comparing postoperative data, there was a significantly higher incidence of postoperative neurologic injury (14/30, 46.7% vs. 23/170, 13.5%; P < .001) and multiple organ failure (6/30, 20.0% vs. 5/170, 2.9%; P = .002) in the Coma+ group. Postoperative stroke was significantly more prevalent in in the Coma+ group (14/30, 46.7% vs. 20/170, 11.8%; P < .001). However, 60.0% (18 of 30) experienced recovery of consciousness in the GCS score and 46.7% (14 of 30) experienced full recovery after surgery. Multivaribale analysis identified preoperative coma (odds ratio, 12.183; 95% confidence interval, 3.368-44.067) as an independent predictor for in-hospital mortality. Preoperative coma was associated with impaired survival (P < .001).
Conclusions: Coma was associated with high mortality after surgery. However, full recovery was observed in approximately half of the patients with preoperative coma. Immediate surgical repair is warranted even when acute type A aortic dissection is complicated by preoperative coma.
Authors
Junghun Lee (1), Noriyuki Takashima (2), Tomoaki Suzuki (3)
Institutions
(1) N/A, N/A, (2) N/A, Otsu, Shiga, Japan, (3) Shiga University of Medical Science, Otsu, Shiga
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Poster Presenter
Junghun Lee, Emory university
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Decatur, GA
United States
Objective: A substantial portion of patients diagnosed with aortic stenosis (AS) manifest mixed aortic valve pathology, which includes moderate to severe concurrent aortic regurgitation (AR). However, the clinical and echocardiographic consequences after aortic valve replacement (AVR) of these populations remain less comprehended.
Methods: The study enrolled patients undergoing isolated AVR (n=1,467) between Oct 2000 and Dec 2021. In the AS group (n=1,137, 66.3±9.5yrs, 47.4% female), individuals had mild or less AR combined with severe AS, whereas the mixed AS group (n=330, 64.6±10.8yrs, 39.1% female) presented concurrent moderate to severe AR alongside severe AS preoperatively. The primary and secondary endpoints were all-cause mortality with serial echocardiographic parameters and composite outcomes of death, valve-related adverse events including heart failure requiring hospitalization, reoperation and stroke independently.
Results: In preoperative echocardiography, the mixed AS group exhibited a lower prevalence of bicuspid AV (BAV) (31.5% vs. 49.2%, p<0.001), along with reduced ejection fraction (57.2±11.9% vs. 60.8±10.2%, p<0.001), and larger left ventricular systolic/diastolic dimensions (LVIDs/LVIDd) (37.2±9.1mm vs. 30.4±7.6mm / 55.6±7.7mm vs. 48.4±6.1mm, p<0.001). During a median follow-up of 6.3 years, both groups showed comparable survival rates (P=0.66). However, in patients with tricuspid AV (TAV), the mixed AS group exhibited significantly better survival rates (HR, 0.69, 95% CI, 0.49-0.97, P=0.031), whereas in those with BAV, although not statistically significant, the mixed AS group displayed higher mortality rates (HR, 1.44, 95% CI, 0.92-2.25, P=0.109) in subgroup analysis (P for interaction=0.008) (Figure 1). The composite outcome comprising death and valve-related adverse events, no significant difference was observed between the two groups (P=0.91). The mixed AS group demonstrated a progressive reduction in LVIDs/LVIDd during follow-up period, while the AS group exhibited a noteworthy increase, with statistical significance after AVR (p<0.001) (Figure 2).
Conclusions: The AS and mixed AS group, which underwent AVR, showed comparable survival rates; however, the mixed AS group exhibited more favorable survival rates in patients with TAV. Moreover, LVIDs/LVIDd showed a progressive reduction in mixed AS group in contrast to AS group after AVR. Further studies are required to understand the mechanisms of the study findings.
Authors
Soo Jin Park (1), Kitae Kim (1), Hong Rae Kim (2), Ho Jin Kim (2), Jae Suk Yoo (2), Sung-Ho Jung (2), cheol hyun chung (2), Joon Bum Kim (2)
Institutions
(1) Asan Medical Center, South Korea, (2) Asan Medical Center, Seoul, Korea
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Poster Presenter
Soo Jin Park, Ajou University Medical Center
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Suwon-si
South Korea
Objective: Traditional techniques of total arch replacement (TAR) with frozen elephant trunk (FET) deployment require the use of two separate grafts for the arch and descending thoracic aorta. The newly approved hybrid Thoraflex endoprosthesis treats the arch and descending aorta with a single continuous device. This eliminates the need for a graft-to-graft anastomosis which is prone to bleeding and extends circulatory arrest time. Preliminary studies in Europe and Asia have demonstrated the safety and feasibility of the Thoraflex device with favorable early and midterm results. However, no such results have been published in the United States due to the novelty of its authorization and small numbers of patients at individual hospitals. By combining data from multiple institutions, this study aims to describe the early results of the Thoraflex device among a larger cohort of patients in the United States.
Methods: Each participating institution obtained STS data on patients undergoing TAR/FET using the Thoraflex device. Data were shared and merged into a single database. Categorical variables were summarized as count (percent) and numerical variables were summarized as median (interquartile range). Baseline characteristics, operative details, and postoperative outcomes were compared across different aortic pathologies.
Results: A total of 77 patients underwent Thoraflex implantation across four institutions, of which 23/77 (30%) had acute type A aortic dissections, 17/77 (22%) had aneurysms, 13/77 (17%) had type B dissections with arch pathology, and 24/77 (31%) had previous type A repair with residual dissections or aneurysmal degeneration (Table 1). The median age was 64 years old. 39/77 (51%) patients underwent a redo sternotomy after previous cardiac surgery, 26/77 (34%) had urgent operations, and 17/77 (22%) had emergent surgery. The median lowest temperature was 28 degrees Celsius, and the median circulatory arrest time was 19 minutes. The most common site of Thoraflex deployment was in zone 2 of the aortic arch in 51/77 (66%) patients. The most common stent diameter was 32mm, and the most common stent length was 15cm. Cardiopulmonary bypass time, cross clamp time, circulatory arrest time, and intraoperative transfusions were similar across aortic pathologies. The overall in-hospital or 30-day mortality rate was 9/77 (12%). 15/77 (20%) patients suffered a stroke, and 9/77 (12%) developed renal failure. Operative mortality and stroke rates were 7/23 (30%) and 9/23 (39%) respectively among patients undergoing acute type A aortic dissection repair and were significantly higher than in patients with other aortic pathologies (p=0.005, and p=0.042).
Conclusions: In this study, we present multi-institutional early "real world" Thoraflex results in the United States that will improve with additional volume and experience. This cohort of patients demonstrates that the Thoraflex is an effective device for TAR/FET procedures across multiple aortic pathologies. Patients who underwent Thoraflex implantation for acute type A aortic dissections had the highest morbidity and mortality rates compared to other surgical indications. Notably, there were no deaths even in emergent cases of type B and residual type A dissections. The mortality rate was acceptable given the acuity of patient presentations, and these outcomes compare similarly to published results of Thoraflex implantation outside the United States.
Authors
Markian Bojko (1), Wililam Oslund (1), Michael Kirsch (2), Emma Longo (1), Kamso Okonkwo (1), Nithya Rajeev (1), T. Brett Reece (3), Chris Burke (4), Jason Glotzbach (5), FERNANDO FLEISCHMAN (1)
Institutions
(1) Division of Cardiac Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, (2) University of Colorado, Aurora, CO, (3) University of Colorado Hospital, Aurora, CO, (4) University of Washington, Seattle, WA, (5) University of Utah, Salt Lake City, UT
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*Fernando Fleischman, Keck Hospital of the University of Southern California
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los angeles, CA
United States
Objective
Redo-thoracotomy due to aneurysmal changes in the residual aorta post-surgery presents challenges such as lung adhesions and lesion dissection difficulties. This study aims to scrutinize the outcomes of patients undergoing thoracoabdominal aorta replacement surgery with a prior left thoracotomy approach.
Methods
As a retrospective study at a single center, 214 patients were enrolled undergoing thoracoabdominal aortic aneurysm surgery from 1996 to 2023. A comparative analysis was performed between 30 patients who underwent redo-thoracotomy (redo group) and 184 patients who had their initial surgery through a thoracotomy (control group). Clinical outcomes, including early mortality and postoperative complications, were meticulously examined.
Results
Compared to the control group, the redo group exhibited a significantly younger median age (49.1 years vs. 60.2 years, p=0.019). Connective tissue disease was more prevalent in the redo group (50% vs. 29.9%, p=0.049). In the control group, Crawford type 2 and type 3 distributions were 47.3% and 23.4%, respectively, while the redo group predominantly featured type 3 (83.3%) (p<0.001). Surgical parameters, including total surgical time, cardiopulmonary bypass (CPB) time, and aortic cross-clamp (ACC) time, did not exhibit statistically significant differences between the two groups.
Postoperative outcomes, such as 30-day mortality, showed no significant difference between the redo group (3.3%) and the control group (5.4%) (p>0.999). The incidence of postoperative complications did not differ significantly between the two groups; paraplegia (0% vs. 4.3%, p=0.589), postoperative bleeding (10.0% vs. 8.7%, p>0.999), continuous renal replacement therapy (CRRT) use (10.0% vs. 10.9%, p>0.999), pneumonia rates (3.3% vs. 2.6%, p=0.589), and median post-surgery ventilation time (14.0 hours vs. 15.9 hours, p=0.223), did not significantly differ between the redo and control groups.
Conclusion
The study suggests that outcomes following redo-thoracotomy for thoracoabdominal aorta replacement surgery are not significantly worse than anticipated.
Authors
muhyung Heo (1), Seyeon Jeon (1), Siwon Oh (1), suryeun chung (1), Yang Hyun Cho (1), Dong Seop Jeong (1), Wook Sung Kim (1), Kiick Sung (1)
Institutions
(1) Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University, Seoul, NA
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Poster Presenter
Suk Kyung Lim, Samsung Hospital
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seoul, NA
South Korea
Objective:
While thoracic endovascular aortic repair (TEVAR) offers a safe solution for type B aortic dissections, complications create complex surgical candidates. Here we describe a case of a TEVAR for acute-on-chronic type B3,10 aortic dissection that was complicated by type 1a endoleak three years after placement. This was treated with a thoracic branch endoprosthesis (TBE). One year later, the patient presented with retrograde type A dissection with pseudoaneurysm at the proximal seal zone, and underwent zone 2 aortic arch replacement. We believe this is the first reported case of an iatrogenic retrograde type A dissection following TBE.
Methods:
We conducted a retrospective chart review of this patient's clinical course.
Results:
A 62-year-old man with a history of hypertension, hyperlipidemia, and Graves' Disease, with a bovine arch presented with acute-on-chronic type B3,11 dissection. He was treated with two Conformable Thoracic Stent Grafts from zones 3 to 5. Three years later, CT angiogram demonstrated loss of seal and a penetrating ulcer at the proximal landing zone with interval growth of a dissection-associated aneurysm to 5.5cm. The proximal seal zone was extended using a TBE. One year later, he presented with chest pain and was found to have a retrograde type A aortic dissection, pericardial effusion, mediastinal fluid, an enlarging pseudoaneurysm at the proximal seal zone up to 1.1cm and a stably enlarged aortic root of 4.6cm. The patient was brought to the OR for zone 2 replacement of the aortic arch. Right axillary cannulation with an 8mm graft and right atrial venous cannulation was performed. Upon entering the pericardial space, 200cc of hemopericardium was evacuated. Both anterograde and retrograde cardioplegia were administered and the patient was cooled to 24°C. Upon opening the aorta, an intimal tear was noted just proximal to the TBE, extending proximally to the sinotubular junction. The left common carotid was cannulated for selective antegrade cerebral perfusion. Dissection into the proximal TEVAR was performed under circulatory arrest. The 32mm branched graft was inverted and inserted into the TEVAR graft to help facilitate the distal anastomosis. The proximal TEVAR stent was cut, and the anastomosis was reinforced with a felt strip. The branch graft was cannulated, the proximal graft cross-clamped, and full flow bypass was resumed. A 14mm and 8mm Y-graft was anastomosed to the innominate and left common carotid, respectively, and bilateral cerebral perfusion was resumed followed by completion of the proximal aortic anastomosis. Finally, the pre-made Y graft was anastomosed to the aortic graft, bypass was weaned, and the branched graft was closed. The patient recovered well without complications.
Conclusions:
We believe this to be the first case of a successful repair of iatrogenic retrograde type A dissection following TBE placement for type B dissection. This case represents successful surgical management of a rare complication with a favorable outcome. This complication demonstrates the importance of patient selection for TBE following type 1a endoleak after conventional TEVAR.
Authors
Andrew Jones (1), Shaelyn Cavanaugh (2), Hossein Amirjamshidi (2), Sarah Hoffman (1), Joshua Geiger (2), Daniel Lehane (1), Baqir Kedwai (1), Kazuhiro Hisamoto (2)
Institutions
(1) University of Rochester School of Medicine and Dentistry, Rochester, NY, (2) University of Rochester Medical Center, Rochester, NY
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Poster Presenter
Andrew Jones, University of Rochester
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Boston, NY
United States
Objective: The aim of this study was to evaluate the therapeutic efficacy of Liu's aortic root repair strategy for patients with a complicated aortic root in acute type A aortic dissection (ATAAD) .
Methods: From October 2011 to December 2019, 473 consecutive patients underwent surgical aortic repair of ATAAD at Second Hospital of Jilin University. We divided these patients into two groups: 162 patients with complicated aortic root (34.2%) and 311 patients without complicated aortic root (65.8%). Patients with complicated aortic root were divided into 4 types: 1, aortic sinus diameter < 4.5 cm, but sinotubular junction (STJ) diameter ≥ 4.5 cm, 24 patients; 2, coronary involvement, including Neri. type A, B and C8, 86 patients; 3, aortic sinus diameter ≥ 4.5 cm with significant dilatation in the non-coronary sinus only, 19 patients; 4, aortic sinus diameter ≥ 4.5 cm with Marfan syndrome or other hereditary thoracic aortic disorder, or aortic sinus diameter ≥ 5.0 cm and excessive dilatation of the aortic root involving two or three sinuses of Valsalva, 33 patients; respectively (Figure 1). We focused on assessing the therapeutic efficacy of Liu's aortic root repair strategy in the 162 patients.
Results: 33 patients received Modified Bentll procedure for aortic root aneurysm, and the remaining 129 patients were performed Liu's aortic root repair. In addition, 24 patients received coronary artery bypass surgery for Neri. type C coronary involvement. Overall in-hospital mortality was 5.6%. The 1-year, 3-year, and 5-year survival estimates were 90.7%, 84.5%, and 80.6%, respectively. At a median follow-up of 48.2 (interquartile range, 23.1-67.7) months, all patients were free from reoperation for aortic root disease, such as: recurrent aortic root dissections, residual false lumens in the aortic root, aortic root pseudoaneurysms, and severe aortic regurgitation.
Conclusions: In type A aortic dissection with complicated aortic root except aortic root aneurysm, Liu's aortic root repair is a safe and effective surgical strategy that achieves favorable outcomes.
Authors
kexiang liu (1), maoxun huang (2)
Institutions
(1) N/A, Jilin, Jilin, (2) Second Hospital of Jilin University, changchun, jilin province
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Poster Presenter
Kexiang Liu, Second Hospital of Jilin University
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Jilin, Jilin
China
Objectives Aortic graft infections are associated with high mortality and antibiotic treatment and excisional surgery are paramount. The aim of the study was to assess characteristics and treatment outcomes of infected aortic root, ascending aorta, and aortic arch prosthetic grafts after reoperative surgery with thorough debridement. Methods Retrospective analysis of prospectively collected data from an ongoing cohort of patients with vascular graft infections. Patients who had am infected aortic root, ascending aorta or aortic arch prosthesis and were reoperated were included in this analysis. Patients treated with a conservative approach and those with infected prosthesis in other anatomical locations were excluded. Results From November 2012 until February 2023, 22 patients had root, ascending or aortic arch graft infection and underwent reoperations. Thereof, 95% (21/22) were male, median age was 62.5 years (Interquartile range: 55.6–72.7), and median BMI was 27.4 kg/m2 (24.9 – 29.9). Upon presentation, 32% (7/22) had dyspnea, 68% (15/22) reported on fever episodes and median LVEF was 54.5% (46.7 – 70). Median time from index surgery to diagnosis/re-operative surgery was 54.5 months (18–99.5) and 91% (20/22) were late infections. Past surgical history included operations for acute Type A aortic dissection in 40.9% (9/22) and aortic aneurysm in 54.5% (12/22); and 59% (13/22) were performed on an urgent/emergency setting. Polyester grafts were used in 91% (20/22) and 59% (13/22) received a Bentall-deBono procedure or a modified procedure with a biological prosthesis. Median EuroSCORE II at reoperation was 32% (16.2 – 48.3). Operative findings included cutaneous abscesses in 18% (4/22), mediastinal abscesses in 54% (12/22), and root abscesses in 45% (10/22). Duration of surgery was 450min (327.5 – 540), aortic-cross-clamping time 130min (112 – 199); and ECC-time 247min (174.5 – 310.5). The aortic valve or aortic valve prosthesis was involved in 73% (16/22). Re-operative techniques included in 63% (14/22) re-Bentall procedures; in 36% (8/22) a biological aortic prosthesis was used (homograft or xenopericardial tube). Operative mortality was 13% (3/22) and Staphylococci 36% (8/22) were the most common microorganisms. There were no patients lost to follow-up. At 4.3 years, 73% (CI 95%, 49 – 97) were survivors.
Conclusion Root, ascending and aortic arch prosthetic vascular graft infections are complex pathologies with high mortality rates if untreated. Re-operative surgery in combination with antimicrobial therapy remains the gold standard with good results at 4 years.
Authors
Mathias Van Hemelrijck (1), Juri Sromicki (1), Petar Risteski (2), Michelle Frank (3), Bruno Ledergerber (4), Ronny R Buechel (5), Barbara Hasse (4), Hector Rodriguez Cetina Biefer (2), Omer Dzemali (2)
Institutions
(1) Department of Cardiac Surgery, University Hospital Zurich, Zurich, NA, (2) Department of Cardiac Surgery, University Hospital and City Hospital Triemli, Zurich, NA, (3) Department of Cardiology, University Hospital Zurich, Zurich, NA, (4) Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, NA, (5) Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, NA
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Poster Presenter
Mathias Van Hemelrijck, University Hospital Zurich
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Zurich, NA
Switzerland
Surveillance After Proximal Aortic Surgery: What are the data
Olaniran Omodara1,Sana Khan1,Massimo Capoccia1,Syed Sadeque1,Govind Chetty1,Graham Cooper1,Stefano Forlani1,Renata Greco1
1Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals Foundation NHS Trust, Sheffield, United Kingdom
BACKGROUND AND OBJECTIVE
Radiological surveillance after proximal thoracic aortic surgery is recommended by the current aortic guidelines based on level C evidence. The length and frequency of the follow-up are not specified, particularly for patents with no history of aortic dissection. Strict radiological surveillance following aortic surgery is challenging to organise. The objective of this study is to review our 20 years radiological surveillance data to identify the patients at risk for complications and progression of the thoracic aortic disease.
METHODS
We prospectively collected data on 565 patients with ascending aorta and/or aortic root surgery between 2003 and 2022. We excluded those with acute and chronic dissections. 48.5% of the patients underwent ascending aorta replacement and 52.5% aortic root replacement. 256 (45.3%) patients had a bicuspid aortic valve, 34 (6%) had confirmed Marfan's or Loeys-Dietz's syndrome and 23 (4%) had history of endocarditis/infection. CT/MRA of the aorta were performed within 6 months and annually after surgery. All the scans were reported by a vascular radiologist. For this study, we monitored clinical outcomes, compared the first post-operative and last follow-up scan to identify any signs of significant progression, defined as ≥5mm increase in the aortic diameter.
RESULTS
The first follow-up scan (at 6.8 ± 7.9 months) was available for 456(80.71%) patients. The scans showed no evidence of pseudo-aneurysm, a peri-graft collection in 26(5.7%) patients. Residual disease was present in 61(13.4%) patients: 14 had a root, 28 a distal ascending aorta and 31 a descending thoracic aorta ≥45mm. Four developed a pseudo-aneurysm during the follow-up. Two pseudo-aneurysms originated from the coronary re-implantation site, both occurred at an early stage of the follow-up(2.3 months and 11.1 months). Two delayed pseudo-aneurysm formations were observed in two patients at 2.5 and 6 years, both had residual descending thoracic disease. Six(1.06%) required a re-operation: 2 pseudo-aneurysm repair, 1 aortic root replacement for residual root aneurysm, 3 re-do AVRs. Two required thoracic and abdominal endovascular treatment. The surveillance scan (average follow-up 7.00 ± 7.08 years) was available for 442(78%) patients and showed peri-graft collection in 7(1.6%) and significant progression of the aortic disease in 28(6.2%): 2 of the root, 11 of the distal ascending, 17 of the descending thoracic aorta. 32 patients had an adverse combined outcome (4 pseudoaneurysm formations, 28 significant progression of the aortic disease). Residual aortic disease at first follow-up scan and peri-graft collection (p<0.001) were the two radiological signs associated with adverse outcome.
CONCLUSION
An early post-operative scan alone is not sufficient to exclude surgical complications. The two radiological factors associated with adverse outcome were the presence of peri-graft collection and residual aortic disease at early follow-up scan. Strict radiological follow-up should be recommended for the first 5 years after surgery, longer follow-up should be mandatory for patients with residual aortic disease.
Authors
Olaniran Omodara (1), Sana Khan (1), Massimo Capoccia (1), SYED SADEQUE (1), Govind Chetty (1), Stefano Forlani (1), Graham Cooper (1), Renata Greco (1)
Institutions
(1) Sheffield Teaching Hospitals Foundation NHS Trust, Sheffield, United Kingdom
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Poster Presenter
Renata Greco, Sheffield Teaching Hospitals NHS Foundation Trust
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Sheffield
United Kingdom
Objective
Acute type A aortic dissection (ATAAD) still carries a significant risk for mortality, despite evolutions in operative management and organ protection. During the last decade, preoperative malperfusion has been identified as a risk factor for mortality, and some centers even advocate treatment of the malperfusion as a first step. Therefore, we wanted to analyze whether the various types of malperfusion carry comparable operative risks and a sternotomy-first strategy is defendable.
Methods
A retrospective review of all ATAAD patients treated at a Belgian aortic referral center was performed. Preoperative malperfusion was categorized as cerebral, abdominal, limb or cardiac. Primary endpoints were in-hospital and overall mortality. All patients were treated as per protocol, with central open aortic surgery as the index procedure. Statistical analysis was achieved with SPSS version 29.
Results
Between 2016 and 2023, a total of 95 patients underwent aortic surgery for ATAAD. Sixty patients (63%) were male. The treated aortic segment varied in this cohort, with the majority of patients having hemi-arch or full arch replacement (n=47 or 49.5% ; n=28 or 29.5%) respectively. Malperfusion of any kind was seen in more than one third of patients (n=35 , 36.8%). Cerebral malperfusion was observed in 17 (17.9%), followed by limb (n=14 , 14.7%) , abdominal (n=6 , 6.3%) and cardiac (n=6 , 6.3%) ischemia. Seven patients (7.3%) were diagnosed with multi-organ involvement. Hospital survival was 80% (n=76), and overall survival 75.8% (n=72) at latest follow-up. In this cohort, age at presentation was not associated with survival. Cerebral malperfusion was significantly associated with mortality (p=0.002). Other types of malperfusion however were not identified as risk factors (limb p=0.385 , abdominal p=0.833 , cardiac p=0.058). Only two of 7 patients with malperfusion in 2 or more organs survived. In 6 of them there was cerebral malperfusion. One patient had abdominal and limb ischemia, and survived.
Conclusions
More than one third of patients with ATAAD present with some form of organ malperfusion. Int his cohort, cerebral malperfusion was a significant risk factor for mortality. Whether other forms of malperfusion are as equally a burden, has to be delineated in further research.
Authors
Thomas Martens (1), Joke Verlinden (2), Isabelle Claus (3), Jens Czapla (2), Tine Philipsen (2), Katrien François (4), Thierry Bové (5)
Institutions
(1) Ghent University Hospital, Belgium, (2) Department of Cardiac Surgery, Ghent University Hospital, Belgium, Ghent, NA, (3) Ghent University Hospital, Department of Cardiac Surgery, Ghent, NA, (4) University Hospital Ghent, Gent, NA, (5) Ghent University Hospital, Ghent, East Flanders
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Poster Presenter
Isabelle Claus, Ghent University Hospital, Department of Cardiac Surgery
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Lokeren, NA
Belgium
Objective
With the approval of TAVR for low-risk patients, surgical aortic valve replacement (AVR) has become primarily used for patients with bicuspid aortic valve disease, especially for younger patients given the limited durability of bioprosthetic TAVR valves. However, for younger patients, the need for lifelong anticoagulation after mechanical AVR places a significant burden on patients with increased risk of bleeding events. As data has emerged regarding the durability of ring annuloplasty, particularly in bicuspid aortic valve patients, our institution has adopted their use not just in bicuspid aortic valve patients, but also in patients without aberrant valve anatomy with increased surgeon experience. We sought to evaluate institutional temporal trends in AVR versus aortic valve repair (AVr), including the frequency of valve replacement in root replacement, and the trends in usage of ring annuloplasty.
Methods
Using our prospectively maintained institutional database, we identified patients who underwent aortic valve repair or replacement from 2016-2023 and whether any adjunct root replacement procedure was performed. Furthermore, we analyzed temporal trends annually in repair versus replacement and in valve sparing versus non-valve sparing root replacement. We looked at four-year trends (2016-2019 and 2020-2023) for repair versus replacement in bicuspid aortic valve (BAV) patients and in ring annuloplasty utilization in AVr.
Results
529 patients were identified who underwent aortic valve repair or replacement from 2016-2023, with 183 (34.6%) undergoing AVr, and 346 (65.4%) undergoing AVR. Among these patients, 295 (55.8%) had an adjunctive root replacement procedure. Annually, there was a significant increasing trend toward aortic valve repair (p<0.001), and a trend toward valve-sparing root replacement (p=0.009). Regarding four-year trends, there was a significant increase in the utilization of ring annuloplasty (p<0.001), and a significant increase in aortic valve repairs in BAV patients (p= 0.027). Prior to 2020, only 54 aortic valve repairs were performed, with a large increasing following.
Conclusions
A significant institutional trend in performing aortic valve repair and in preserving the aortic root was seen across an 8-year trend at our institution. Our data suggested that at least 50 aortic valve repairs, which can be more challenging to ensure a durable repair, particularly in bicuspid patients, are required to ensure adequate comfort in performing the procedure routinely. Thus, we advocate for the performance of aortic valve repairs at experienced centers.
Authors
Adam Carroll (1), Michael Kirsch (1), Jessica Rove (1), John Iguidbashian (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective:
Thoracic endovascular aortic repair (TEVAR) is well established for zone 2 aortic arch coverage, with maintenance of left subclavian perfusion through collateral vessels, or open or endovascular revascularization. Thoracic branched endografts (TBE) have been applied to zone 2 arch repair, allowing for subclavian revascularization with a comparable safety profile and a decreased length of stay. Proximal to zone 2, TBE has seen very limited application due to the high risk of neurologic complications. We discuss two cases of patients who underwent aortic debranching and subsequent zone 0 TBE.
Methods:
We discuss two patients with a history of previous type A aortic dissection and remote repair requiring intervention after further degeneration. We discuss presentation, operative details, and hospital course. Reconstruction of patient aortic pathology was performed using Slicer 3D software.
Results:
Four years prior, patient 1 underwent aortic valve resuspension and ascending aortic repair for his type A dissection. Observation of his pathology demonstrated aneurysmal degeneration of his aortic arch and descending thoracic aorta (Figure 1; 1A). He was admitted for elective aortic debranching and TBE. He underwent right carotid to left carotid to subclavian, carotid-carotid, and right carotid to subclavian bypass, right vertebral to carotid transposition, and ligation of the bilateral carotids and right subclavian artery (Figure 1; 1B). He developed right vocal cord paresis post-operatively, which resolved without intervention. He also developed a left neck chyle leak, and he was discharged on hospital day (HD) 10 with a left neck drain in place. He subsequently underwent staged TBE with proximal extension to the ascending aorta and stenting of the left subclavian without complication (Figure 1; 1C). The patient was discharged on HD 2 on aspirin, in addition to oral anticoagulation for history of atrial fibrillation.
Two years prior, patient 2 had a hemiarch replacement for type A dissection. She presented with symptoms of hemoptysis, with concern for contained rupture with aorto-pulmonary fistula, in addition to descending thoracic aneurysmal degeneration with dissection extending into the proximal left common carotid and subclavian arteries (Figure 1; 2A). She underwent aortic debranching with right to left carotid bypass, left carotid to subclavian bypass, with ligation of the left common carotid artery and amplatzer plug of the left subclavian artery (Figure 1; 2B). On hospital day (HD) two, the patient underwent thoracic branched endograft with stenting of the innominate artery (Figure 1; 2C). The procedure was uncomplicated, and the patient was started on aspirin monotherapy. Hospital course was prolonged due to left vocal cord paresis related to aortic debranching and resulting poor oral intake, which was treated with vocal cord injection and placement of a percutaneous endoscopic gastrostomy tube. The patient was discharged on HD 33 on aspirin and oral anticoagulation, without significant neurologic deficits.
Conclusion:
With careful patient selection at dedicated aortic centers, zone 0 TBE can be safely performed. Further experience is needed to mitigate the risks related to extensive aortic debranching.
Authors
Adam Carroll (1), Donald Jacobs (1), T. Brett Reece (1), Muhammad Aftab (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective: Smoking is a predominant risk factor associated with the incidence and progression of abdominal aortic aneurysm. However, gaps still exist in understanding the association between smoking history and early operative outcomes after open thoracoabdominal aortic aneurysm (TAAA) repair. We sought to identify potential differences in early operative outcomes between patients with or without a history of smoking undergoing open TAAA repair. We hypothesized that patients currently smoking would be at higher risk of early morbidity after open TAAA repair.
Methods: After excluding patients with unknown smoking status, we performed a retrospective analysis of 2,825 patients who underwent elective open TAAA repair (1986-2023) by a single practice. Patients were stratified into three groups based on self-reported smoking history; 746 (26.4%) reported currently smoking, 1530 (54.2%) were former smokers, and 549 (19.4%) never smoked. Current smoking was defined as having smoked in the last 4 weeks prior to admission, and former smoking referred to the cessation of smoking at least 4 weeks prior to surgery. Adverse event was defined as a composite of operative death or persistent renal failure requiring hemodialysis, stroke, paraplegia, or paraparesis.
Results: Please refer to the table for data and p-values. Patients who were never smokers were significantly younger (median age, 58 years) than current and former smoking patients (both 68 years, p<.001). While current and former smoking patients had similar rates of coronary artery disease and peripheral vascular disease, patients who were never smokers had lower rates. Current smoking patients presented with a markedly higher prevalence of COPD (63%) compared to former smoking (53%) and never smoking (13%, p<.001) patients. Patients who were never smokers were more likely to undergo extent I repair, while former and current smoking patients were more likely to undergo extents III and IV repair; extent II repairs were similar between groups. Although the operative mortality rate was lower in patients who were never smokers (4.9% [n=27]) compared to former and current smoking patients (7.6% [n=117] and 7.4% [n=55] respectively), the difference did not reach statistical significance. The rates of adverse event and specific complications-including persistent paraplegia (0.2% in never smoking patients vs. 2.5% in former and 3.9% in current smoking patients, p<.001), acute renal dysfunction, cardiac complication, and pulmonary complications-was markedly lower in patients who never smoked and similar between patients who were former or current smokers.
Conclusions: A history of smoking is associated with increased peri-operative morbidity after open TAAA repair. Of note, we found never smokers to rarely experience postoperative persistent paraplegia. Contrary to our hypothesis, we were unable to demonstrate a significant difference in outcomes between current and former smoking patients. Further investigation is needed to evaluate whether early outcome benefits may be more pronounced as the duration of smoking cessation increases from the time of surgery. Nevertheless, smoking cessation should be encouraged in all patients currently smoking upon diagnosis of a TAAA.
Authors
Robert Seniors (1), Lynna Nguyen (2), Veronica Glover (1), Susan Green (3), Marc Moon (4), Joseph Coselli (5), Samantha Xu (6), Subhasis Chatterjee (7), Scott A. LeMaire (8)
Institutions
(1) Baylor College of Medicine/Texas Heart Institute, Houston, TX, (2) Baylor College of Medicine, Houston, TX, (3) N/A, Houston, TX, (4) Baylor College of Medicine / Texas Heart Institute, Houston, TX, (5) Baylor College of Medicine, Texas Heart Institute, United States, (6) N/A, United States, (7) Baylor St. Luke's Medical Center, Houston, TX, (8) Geisinger Commonwealth School of Medicine, Scranton, PA
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Poster Presenter
Robert Seniors, Baylor College of Medicine/Texas Heart Institute
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Iowa Colony, TX
United States
Objective: Branch-first total aortic arch repair (BF-TAR) has been a paradigm shift in the technical approach to open aortic surgery. This technique is further modified to instigate hostile sternal re-entry in reoperative aortic surgery whilst assuring uninterrupted neuroprotection.
Methods: Intraoperative preparation and the illustrated operative technique of the cervical branch-first technique in complex resternotomy are described. An accompanying case series narrates the experiences and outcomes of four complex patients who underwent high-risk reoperative aortic surgery utilising this technique.
Results: The indications for resternotomy included (1) a sixth reoperation for recurrent mycotic aortic pseudoaneurysm; (2) a third reoperation for extensive infective endocarditis; (3) a reoperation for complete Bentall graft dehiscence with contained ascending aortic rupture; and (4) a third reoperation for residual Stanford Type B dissection. All patients had evidence of significant adhesion between the aorta, aortic graft, and/or pseudoaneurysm to the posterior sternal stable. Two patients were operated on in an emergency setting. Two patients separated from cardiopulmonary bypass with extracorporeal support. None experienced permanent neurological sequelae, gut ischaemia, peripheral arterial complications, or in-hospital mortality. One mortality due to decompensated heart failure was reported at six months postoperatively.
Conclusions: The cervical branch-first technique offers unparallel advantage in neuroprotection from an early stage of complex reoperative aortic surgery. It provides an independent circuit for complete antegrade cerebral perfusion, irrespective of suspension to circulatory flows to the rest of the body during re-entry into hostile chests. Our experience to date has demonstrated promising outcomes and further refinements will guide patient selection best suited for this technique.
Authors
Michelle Ng (1), George Matalanis (1)
Institutions
(1) Austin Health, Victoria, Australia
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Poster Presenter
Michelle Ng, Austin Health
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Melbourne, Victoria
Australia
Objective: Surgical skill and experience are known to be associated with improved outcomes in acute aortic syndrome (AAS). Aortic programs face the challenge of ensuring that new faculty are well prepared to take on such complex cases without compromising outcomes. Here we review the initial experience of a new faculty at a large aortic center in the context of processes in place to optimize results.
Methods: From January 13, 2022, to December 4, 2023, a total of 101 patients diagnosed with AAS underwent surgical repair by a single surgeon. Excluded from this study, were 5 patients (all >87 yrs and at nursing homes/assisted living) who were deemed unsuitable for surgery, and 3 patients who experienced mortality during hospital transfer. Mean age was 62 yrs and 61 were male. Average BMI was 31, 88 had hypertension, 7 recent drug use, 2 on dialysis, 11 with CKD, and 12 received antithrombotic therapy. The aortic center has an AAS volume of >100 cases/year and incorporates advanced logistics, transport and communications and multidisciplinary care including imaging, endovascular, and critical care services.The surgeon spent 6 months of additional aortic training after completing cardiothoracic residency and before starting independent practice.
Results: Among the 101 patients, 79 were DeBakey Type 1 and 16 were Type 2 dissections. Additionally, 3 patients presented with intramural hematoma, 2 with perforating ulcers in the ascending, and 1 with an arch mycotic pseudoaneurysm. Twelve cases were redo procedures. The distribution of entry tears was: ascending aorta (52), arch (36), descending (8), left subclavian artery (1), and femoral artery (1). For DeBakey Type 1 patients, 54 had supraaortic dissection, including 4 with complete occlusions of the right carotid artery and 1 with occlusion of the right subclavian artery. Forty eight patients exhibited dissections extending to the iliac vessels, with 15 experiencing lower extremity malperfusion due to static obstruction. Nineteen patients had compression of the superior mesenteric artery, 7 of which had static obstruction. Two patients had complete occlusions of the infrarenal abdominal aorta. Clinical presentations included 2 patients with bloody bowel movements, 8 with stroke, 2 withTIA, 10 with intubation prior to transfer, and 16 with lower extremity symptoms. Additionally, 5 patients required preoperative pressors, and 5 experienced cardiac arrest in the operating room. GERAADA score and UPenn classification are summarized in Table. Sixty-one patients underwent arch procedures with a frozen elephant trunk (B-SAFER), 3 had Zone 1 arch, 1 zone 2 and 1 total arch. Thirty-four patients received hemiarch replacement. Twenty-three patients underwent root replacement, with 20 receiving a biobentall, 2 undergoing valve-sparing root replacement, and 1 receiving a homograft. Direct aortic cannulation was performed in 93 patients, axillary in 6, innominate in 1, and Samurai cannulation in 1 patient. There were 4 (4%) perioperative deaths and 4 strokes. Nine patients required tracheostomy and 5 required dialysis.
Conclusions: In a setting of a cumulative institutional experience and culture of teamwork managing complex patients with AAS can be achieved with good outcomes by a junior surgeon. The modern take on managing these patients including multidisciplinary care and technical innovations allows safe operations on some patients who were previously deemed at prohibitive risk for surgery.
Authors
Marijan koprivanac (1), Filip Stembal (1), Patrick Vargo (1), Xiaoying LOU (1), Eric Roselli (1), Faisal Bakaeen (1), Marc Gillinov (1), Edward Soltesz (1), Michael Tong (1), Shinya Unai (1), Nicholas Smedira (1), Gosta Pettersson (1), Haytham Elgharably (1), Richard Ramsingh (1), Francis Caputo (1), Jon Quatromoni (1), Ali Khalifeh (1), Sean Lyden (1), Paul Schoenhagen (1), Vidyasagar Kalahasti (1), Marta Kelava (1), Venu Menon (1), Andrej Alfirevec (1), Mariya Geube (1), Lars Svensson (1), Mar
Institutions
(1) Cleveland Clinic, Cleveland, OH
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Poster Presenter
Marijan Koprivanac, Cleveland Clinic Foundation
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Chagrin Falls, OH, OH
United States
Objective: While, the Ross Procedure had seen decreased utilization due to concerns over long-term viability and operative risk, modern literature has demonstrated both the safety and efficacy of this surgery. As expert centers demonstrate the utility of this surgery in young patients with diseased aortic valves, the Ross procedure has seen a resurgence in popularity. Much has been written on the technical aspects and outcomes of the procedure, however little convention exists on preoperative imaging and assessment. As non-invasive imaging modalities have improved better information can be obtained regarding the right ventricular outflow tract. As a high-volume Ross center, we have established a preoperative imaging protocol for all patients being evaluated for Ross procedure to assess the RVOT for use as a homograft. We describe our novel approach to RVOT assessment below using four real world examples.
Methods: We have established a new institutional imaging protocol for patients being evaluated for the Ross procedure. Patients who are candidates for the procedure undergo preoperative 4D cardiac CTA. Optimal contrast timing is selected to allow simultaneous visualization (>220 HU) of the LVOT and RVOT. Contrast administration is visually inspected and the scan initiated once both sides have adequate attenuation or auto-triggered 5-6 seconds following the left atrium reaching the HU threshold. Reconstruction imaging of the aortic and pulmonic annulus are obtained and sized at peak systolic phases. Imaging reconstructions are performed and interpreted by a Level 3 Certified Advanced Cardiac Imaging Specialist. The aortic measurements include LVOT, aortic annulus (Diameters, area and perimeter), SOV, STJ and ascending aorta as well as coronary heights. The Pulmonic measurements include the PV annulus (diameter, perimeter and area) as well as the muscular cuff (3-5 mm below the PV annulus), and PA below the bifurcation.
Results: Patient ages were 36, 41, 48 and 61 years. Two patients were male and two were female. Average diameter of the pulmonic annulus in the four patients was 27.3 mm, 28.8 mm, 21.4 mm, and 25 mm. Perimeter of the pulmonic annulus was 90 mm, 93.1mm, 69.6 mm and 79.5 mm. Average diameter and perimeter of the aortic annulus were 23/73.8mm, 28.6/92.3 mm, 22.8/72.3mm, and 25.1/80.4 mm. Intraoperative measurement of the aortic annulus was obtained using a Freestyle sizer in each case. The annular measurements were 27 mm, 29 mm, 23 mm, and 27 mm. Three patients underwent a supported Ross, and one patient underwent tissue supported Ross procedure.
Conclusions: All four patients underwent successful Ross procedure. The pulmonary autograft was found to be properly sized and used successfully as an autograft in each of the four patients. Using 4D CTA reconstructions to assess the RVOT size during the evaluation for the Ross procedure is an easy adjunct to the process and appears to adequately size the RVOT for feasibility of use as an autograft. Being able to accurately and efficiently size the RVOT will likely provide a benefit for preoperative assessment and operative care for patients undergoing the Ross procedure. As this procedure experiences a resurgence of popularity it will be important to implement standardized quality measures and we believe 4D CTA with reconstructions can be an important part of the preoperative evaluation.
Authors
John Eisenga (1), William Brinkman (2), J. Michael DiMaio (3), Zuyue Wang (4), Kyle McCullough (5), Ghadi Moubarak (6), Sarah Hale (7), Justin Schaffer (8), Katherine Harrington (9), William Ryan (10), Amro Alsaid (4)
Institutions
(1) Baylor Scott & White Research Institute, Plano, TX, (2) Baylor Scott & White Health, TX, (3) The Heart Hospital Baylor Plano, Dallas, TX, (4) Baylor Scott & White - The Heart Hospital, Plano, TX, (5) Baylor Scott and White Research Institute, Plano, TX, (6) N/A, N/A, (7) BSWH Research Institute, Plano, TX, (8) The Heart Hospital Baylor Plano, Plano, TX, (9) N/A, Plano, TX, (10) Baylor Scott and White The Heart Hospital, Plano, TX
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Poster Presenter
John Eisenga, Baylor University Medical Center
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Dallas, TX
United States
Objective: We used advanced cardiac imaging studies to evaluate the effectiveness of aortic valve (AV) repair in tricuspid aortic valves and multiple de Kerchove bicuspid aortic valve phenotypes.
Methods: This is a prospective trial assessing the effectiveness of AV repair using advanced cardiac imaging studies. Patients underwent pre- and postoperative echocardiogram and CTA which were reviewed by specialized cardiac imaging cardiologists. For descriptive analyses, frequencies and percentages are used to present categorical variables. Median and Interquartile ranges are used to describe continuous variables with non-normal distribution, while mean and standard deviation are used to present normally distributed variables. Chi-square test, Fisher's exact test, Kruskal-Wallis test, and two-sample t-test were used as indicated. Statistical significance was determined as p<0.05.
Results: 22 patients underwent aortic valve repair surgery in this study. 20/22 (90.9%) patients were male, and the median age was 52 [47-58] years. 16 patients had a preoperative diagnosis of an aortic aneurysm. Zero patients had previous valve intervention. There were nine patients with tricuspid aortic valves (TAV) and 13 patients with bicuspid aortic valves. Of the bicuspid valves: 5 were type A (BAV-A), 5 were type B (BAV-B), and 3 were type C (BAV-C). Preoperative echocardiogram noted aortic insufficiency (AI) >1+ in 7/8 TAV, 4/5 in BAV-A, 5/5 in BAV-B, and 3/3 in BAV-C. Preoperative median mean and peak gradients were 4/6, 6/13, 6.2/11, and 5.5/10.5 in the groups respectively. Preoperative and postoperative CTA measurements of non-coronary cusp geometric, commissural, coaptation and effective heights are reported in the table below. Post-operative echocardiogram noted AI >1+ in 0/7 TAV, 0/5 in BAV-A, 0/5 in BAV-B, and 0/3 in BAV-C. Postoperative mean and peak AV gradients were 3.8/6.5, 6.5/12, 5.5/9, and 8/15 in the groups respectively.
Conclusion: Valve repair surgery in aortic insufficiency can be accomplished with satisfactory results in multiple phenotypes of AV. Our experience demonstrates resolution of AI in all patients in our series. However there appeared to be a non-significant trend for increased valve gradients in BAV-C patients, continued surveillance is ongoing.
Authors
John Eisenga (1), Zuyue Wang (2), Kyle McCullough (3), Ghadi Moubarak (4), Tsung-Wei Ma (1), Ambarish Gopal (5), J. Michael DiMaio (6), William Brinkman (7), Amro Alsaid (2)
Institutions
(1) Baylor Scott & White Research Institute, Plano, TX, (2) Baylor Scott & White - The Heart Hospital, Plano, TX, (3) Baylor Scott and White Research Institute, Plano, TX, (4) N/A, N/A, (5) Baylor Scott & White Health - The Heart Hospital, Plano, TX, (6) The Heart Hospital Baylor Plano, Dallas, TX, (7) Baylor Scott & White Health, TX
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Poster Presenter
John Eisenga, Baylor University Medical Center
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Dallas, TX
United States
Background: The indications and methods for preserving the aortic root in acute type A aortic dissection are not clear. We retrospectively reviewed the treatment strategies based on 20 years´ experiences in Drum Tower hospital and analyzed the fate of preserved aortic root in the long−term period. Methods: From Jan. 2002 to Dec. 2021, 1705 acute type A aortic dissection cases were underwent surgical treatment in Drum Tower hospital. We divided them into three group according to different treatment periods: Stage 1 (2002-2010, n=78), Stage 2(2011-2018, n=880) and Stage 3 (2019-2021, n=747). The clinical manifestations, surgical methods and outcomes were compared among three groups. The anatomy classification of aortic root in aTAAD was confirmed by preoperative CTA, echocardiology and intraoperative direct vision: A1-Not involved or slightly involved; A2-Partially involved; A3Seriously involved. Double Jacket Wrapping method has been the main root reconstruction method for aTAAD after 2018. Results: The average age was 53.9 years (21-88 years old), no differences among three groups. The distribution of the three types is basically the same in the three groups: A1-5.6%, A2-78.1%, A3-16.3%. Bentall procedure accounted for 62.0% in Stage 1, while the proportion in Stage 2 and Stage 3 decreased significantly (28.6%, 16.5%, p<0.001). Root reconstruction repair procedure accounted for 32.0% in Stage 1 and significantly increased in Stage 2 and Stage 3 (68.3%, 74.5%, p<0.001). The 30-day mortality rate was 12.6% (15.4% vs 13.5% vs 9.8%, p<0.001). The 5-year survival rate was 82.3%, and the 10-year survival rate was 69.4%. During the follow-up period, the incidence of aortic root events was 1.3% (0.9% in Bentall group vs 2.1% in root repair group). After adjustment for survival rate, the rate of freedom from aortic root events in 5 year was 95%, in 10 year was 86%; and the surgical mortality of redo aortic root surgery was 5%. Conclusions: The aortic root treatment strategy of aTAAD requires a comprehensive selection based on the clinical characteristics of the patient, the pathological anatomy of the aortic dissection, and the surgical ability of the surgeon. The follow-up results also proved that compared with the long-term survival rate of type A dissection, the secondary intervention of preserved aortic root has less impact on patients. Double Jacket Wrapping method for aortic root reconstruction can be used as the mainstream way of root treatment for TAAD.
Authors
Yunxing Xue (1), Dongjin Wang (1), Qing Zhou (1), JUN PAN (1), Fudong Fan (1)
Institutions
(1) Nanjing Drum Tower Hospital, Jiangsu, China
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Poster Presenter
Yunxing Xue, Affiliated Drum Tower Hospital of Nanjing University Medical School
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China, Jiangsu
China
Objective:
The spring back force of the frozen elephant trunk (FET) often leads to stent-induced new entry (SINE). However, limited knowledge exists regarding the morphological alterations in the aortic angle resulting from this spring-back force.
Methods:
Among 107 cases using the Frozenix ®(Japan lifeline©, Japan) from July 2014 to October 2023 at our institution, 32 cases underwent follow-up using 3D-CT. We assessed changes in the aortic angle between the proximal and distal edge of the FET from preoperative to 1-year postoperative follow-up.
Results:
The definition of the aortic angle, an example, and a graphical representation of the changes in the aortic angle are shown in the figure. The mean age of the cohort was 74.1 years, with 14 cases of aortic dissection and 18 cases of aortic aneurysm. The aortic angle increased in all patients postoperatively. The mean aortic angles at preoperative, discharge, 6 months, and 1 year were 78.9°, 99.3°, 106.2°, and 114.1°, respectively. The mean angle change at discharge compared to preoperative was 129.9%. The angle change was more pronounced in the aortic dissection group than in the aortic aneurysm group (153.1° for aortic dissection vs. 111.8° for aortic aneurysm, p=0.048). Distal SINE occurred in 2 cases demonstrating relatively substantial angular changes (135.3% and 146.3%, respectively). One case occurred immediately after the surgery, while the other manifested one year after surgery when the aortic angle significantly changed from 109° to 132°.
Conclusions:
The spring-back force induced by the FET results in substantial changes in the aortic angle. Particularly in cases of aortic dissection, these changes are prominently evident immediately after the operation. Meticulous follow-up should be needed to detect SINE associated with angle changes.
Authors
Takanobu Kimura (1), Hiroshi Tsuneyoshi (2)
Institutions
(1) Shizuoka general hospital, Shizuoka,Japan, (2) Shizuoka General Hospital, Shizuoka,Japan
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Poster Presenter
Takanobu Kimura, Shizuoka General Hospital
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Shizuoka city
Japan
Objective: The gold standard for repair of descending thoracic (DTA) and thoracoabdominal aortic aneurysms (TAAA) is open surgery. Common etiologies of DTAs and TAAAs include medial degeneration (MD) and chronic type B aortic dissection (cTBAD). A subset of aneurysms, termed atherosclerotic aneurysms (AA), have atherosclerotic changes in the vessel wall with various degrees of thrombus. We analyzed the impact of atherosclerosis on the short- and long-term outcomes of patients undergoing open DTA or TAAA repair.
Methods: We performed a retrospective analysis of a prospectively maintained aortic database. From 1999 to 2023, 281 patients underwent open DTA or TAAA repair by a single surgeon. We compared preoperative comorbidities, postoperative complications, and in-hospital and long-term mortality for patients with cTBAD vs AA vs MD. Patients who underwent repair for other etiologies (acute dissection, infection, pseudoaneurysm, trauma) were excluded.
Results: Of the 120 cTBAD patients, open DTA and TAAA repair was performed in 50 (42%) and 70 (58%) patients, respectively. Of the 60 AA patients, 6 (10%) and 54 (90%) patients had open DTA and TAAA repair, respectively. Of the 65 MD patients, 17 (27%) and 48 (73%) patients had open DTA and TAAA repair, respectively. Patients with AA were significantly older (cTBAD: 57 [53-64] vs AA: 71 [66.8-76] vs MD: 68 [63-75] years, p<0.01) and more likely to be female (cTBAD: 30%, AA: 53.3% vs MD: 36.9%, p=0.01). Patients with cTBAD were less likely to have COPD (cTBAD: 21.7% vs AA: 50% vs MD: 40%, p<0.01) and diabetes (cTBAD: 10.8% vs AA: 26.7% vs. MD: 21.7%, p<0.01). There were no significant differences in in-hospital mortality between cTBAD, AA, and MD patients (cTBAD: 7.5% vs AA: 16.7% vs MD: 6.2%, p=0.08) as well as rates of paraplegia (0.8% vs 3.3% vs. 1.5%, p = 0.23), stroke (4.2% vs 5% vs. 1.5%, p=0.54), new renal insufficiency (13.3% vs 10% vs. 6.2%, p=0.31) and reoperation for bleeding (6.7% vs 6.7% vs 6.2%, p=0.999). Overall survival at 1-, 5-, 10-, and 15-years for cTBAD vs AA vs MD patients was 90% vs 65% vs 86%, 79% vs 52% vs 66%, 59% vs 37% vs 47%, and 50% vs 23% vs 35% respectively, p<0.01 (Figure 1).
Conclusions: There were no significant differences in postoperative complications between groups. Although there was a higher in-hospital mortality in the AA group, the difference did not reach statistical significance. The AA patients have a statistically significant decrease in long-term survival compared to cTBAD patients.
Authors
joshua chen (1), Christopher Pritting (1), Vishal Shah (1), Colin King (1), Jacqueline McGee (1), Megary McCoy (1), Konstadinos Plestis (1)
Institutions
(1) Thomas Jefferson University Hospital, Philadelphia, PA
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Poster Presenter
joshua chen, Thomas Jefferson University Hospital
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philadelphia, PA
United States
Objective: To determine the impact of multiple factors including birth weight and gestational age on neo-aortic root dilation in patients with transposition of the great arteries that underwent an arterial switch operation.
Methods: A retrospective review of electronic medical records was conducted to identify patients who underwent an arterial switch operation (ASO) at our center from March 2002 to July 2023. Data collected included demographic data, operative data, mortality, and longitudinal echocardiography follow up neo-aortic root measurements. Neo-aortic root diameter growth rate for the first year post-operatively was calculated for each patient by calculating the difference in root diameter between the first post-op echo and the echo closest to one year of age and dividing by the time period between the two echocardiograms (cm/year). Correlations between neo-aortic root growth rate and additional variables were performed and analyzed for statistical significance.
Results: During the study period 98 patients underwent ASO at our center. Of these, 42 met inclusion criteria, while others were excluded due to inadequate follow up echo data or severely delayed ASO performed at greater than 1 month of life. Demographic data for patients as well as the results of multivariate analysis is summarized in table 1. Birth weight and gestational age in isolation did not demonstrate correlation with neo-aortic root growth rate. However, when analyzed in tandem on a multiple linear regression model, birth weight and gestational age had a statistically significant correlation with neo-aortic root growth rate in the first year of life, with coefficients of 0.93 and -0.22 respectively.
Conclusions: In summary, birth weight and growth rate are directly correlated, while gestational age and growth rate are inversely correlated with neo-aortic root growth rate in the first year of life in patients with transposition of the great arteries status post arterial switch operation. Further studies are required to better understand the mechanism responsible for these correlations and to correlate the neo-aortic root growth rate in the first year of life and its impact on long term outcomes after arterial switch operation.
Authors
Matthew Purlee (1), Lindsey Brinkley (2), John-Anthony Coppola (1), Mark Bleiweis (3), Jeffrey Jacobs (4), Giles Peek (5), Dalia Lopez-Colon (1), Dipankar Gupta (1)
Institutions
(1) University of Florida, Gainesville, FL, (2) The University of Florida, N/A, (3) Shands Hospital, Gainesville, FL, (4) University of Florida Shands, Saint Petersburg, FL, (5) Congenital Heart Center, University of Florida, Gainesville, FL
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Poster Presenter
Matthew Purlee, University of Florida Shands Hospital
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Gainesville, FL
United States
Objectives:
Preoperative anemia is associated with increased morbidity and mortality after cardiac surgery. We sought to evaluate the impact of preoperative anemia in patients undergoing surgery for acute type A aortic dissection (ATAAD).
Methods:
This was a retrospective institutional study from 2010-2023 of patients undergoing treatment for ATAAD. Patients were stratified into propensity matched anemia (+) and anemia (-) groups based on standard gender-based cutoffs for anemia using hemoglobin (Hb) or hematocrit if Hb was unavailable.
Results:
A total of 579 patients were identified. Of those, 454 were included with 273 patients in the anemia (-) and 181 in the anemia (+) group. Patients with no Hb data, or those with aortic rupture, traumatic dissection/trauma, previous dissection, cancer, heart failure (NYHA 3-4), or no follow-up were excluded to avoid including secondary causes of anemia. Among women, more patients were non-anemic (44.7% vs.32.6%, p=0.01). Anemic patients were older at presentation (63 vs. 61 years, p=0.04) and had a higher incidence of diabetes (15.5% vs. 8.1%, p=0.0135). Further, these patients had lower total albumin (3.5 g/dL (3.1-3.8) vs. 3.8 (3.5-4), p<0.001) along with longer cardiopulmonary bypass (195 mins (158-229) vs. 178 mins (149-218), p=0.02) and cross clamp (128 mins (92.5-170) vs. 113 mins (92-151), p=0.05) times. Circulatory arrest times were however comparable among the groups (24.0 mins (20.0-33.0) vs.25.0 mins (19.0-32.0), p=0.672).
At a follow up of 4.8 years (1.6-8), overall mortality was comparable between the anemia (+) and (-) cohort (29.8% vs 22.7%, p=0.088). There was also no difference in operative mortality, 30-day readmission, and one-year survival between the groups.
Postoperative blood product utilization (60.8% vs. 46.5%, p=0.003) was higher in the anemia (+) group who also had a longer length of hospital stay (9 days (6-15) vs. 8 (6-14), = 0.04). On multivariable Cox proportional hazards regression for overall mortality, anemia was not associated with the outcome of mortality (HR: 1.11 (95%CI: 0.615-2.006), p=0.727). However, chronic obstructive pulmonary disease (HR:2.27 (1.48-3.51), p<0.0001) and perfusion time (HR: 1.013 (1.009-1.017), p<0.0001) were associated with overall mortality.
Unadjusted Kaplan-Meier survival analysis (Panel A) and the cumulative incidence of readmission or reintervention (Panel B) showed no significant difference between the groups. The nonlinear relationship between baseline Hb and overall survival for men (Panel C) and women (Panel D) is depicted in the figure.
Conclusions:
Preoperative anemia did not directly predispose ATAAD patients to worse survival. Anemia appears to be a bystander with other comorbidities that impact survival and outcomes after surgery for acute type A aortic dissection.
Authors
Danial Ahmad (1), James Brown (1), Sarah Yousef (2), Derek Serna-Gallegos (3), Yisi Wang (1), Floyd Thoma (1), Julie Phillippi (4), David Kaczorowski (5), David West (1), Pyongsoo Yoon (1), Johannes Bonatti (6), Danny Chu (7), Francis Ferdinand (8), Ibrahim Sultan (3)
Institutions
(1) UPMC, Pittsburgh, PA, (2) University of Pittsburgh, Pittsburgh, PA, (3) University of Pittsburgh Medical Center, Pittsburgh, PA, (4) N/A, Pittsburgh, PA, (5) University of Pittsburgh Medical Center, Venetia, PA, (6) UPMC Heart and Vascular Institute, Pittsburgh, PA, (7) Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, (8) UPMC, Erie, PA
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Poster Presenter
Danial Ahmad, UPMC
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Pittsburgh, PA
United States
Objective: Home health care (HHC) may help reduce the burden on patients and families after interventions and potentially reduce hospital length of stay (LOS). We sought to assess outcomes of patients undergoing Thoracic Endovascular Aortic Repair (TEVAR) who were discharged with or without HHC services.
Methods: This was a retrospective analysis, using the Nationwide Readmissions Database (NRD), of TEVAR patients (2010 to 2018) who were categorized based on disposition at discharge into either the HHC cohort or the routine cohort. Propensity matching was utilized to compare the cohorts in addition to stepwise-weighted logistic regression.
Results: Of the 9170 TEVAR patients included, 27.3% (2500/9170) were discharged to HHC. Median age was 71 years (62-78) and women comprised 45.9% of the population with no differences between the groups.
Post-TEVAR rates of heart failure (HF) (4.3% vs. 2.7%, p<0.01), pneumonia (7.2% vs. 5%, p<0.01), ileus (4% vs. 2.8%, p=0.02), sepsis (1.6% vs. 0.9%), and hemorrhage (26.4% vs. 23.7%, p=0.03) were higher in the HHC cohort. The LOS for the index admission was comparable (7 days [5-12] vs. 6 days [3-12], p=0.09) as were the 30-day readmission (21.3% vs.19.6%, p=0.07) and 30-day mortality (0.17% vs. 0.25%, p=0.53) rates.
On weighted stepwise logistic regression (Table), HHC status (Odds Ratio (OR): 1.21 [95% CI: 1.11-1.32], p<0.001), female gender (0.87 [0.80-0.94], p<0.001), resident status (1.78 [1.54-2.04], p<0.001), non-elective procedure (1.62 [1.49-1.77], p<0.001), myocardial infarction (1.31 [1.18-1.44], p<0.001), arrhythmia (1.13 [1.03-1.25], p=0.01), and spinal cord ischemia (1.98 [1.26-3.10], p<0.001) were associated with 30-day readmission. Following propensity matching, HHC status did not show statistically significant association with 30-day readmission (HHC vs not: OR=1.14, 0.98-1.31, P=0.07)
Conclusion: Post-TEVAR utilization of HHC services was likely due to higher in hospital complications and trended toward association with increased odds of 30-day readmissions after propensity matching. Therefore, priority should be given to reducing TEVAR-related in-hospital complications as that may reduce HHC utilization and improve overall outcomes.
Authors
Danial Ahmad (1), Sarah Yousef (2), James Brown (1), Derek Serna-Gallegos (3), Carlos Diaz-Castrillon (4), Floyd Thoma (1), Yisi Wang (1), Michel Pompeu Sá (5), Ibrahim Sultan (3)
Institutions
(1) UPMC, Pittsburgh, PA, (2) University of Pittsburgh, Pittsburgh, PA, (3) University of Pittsburgh Medical Center, Pittsburgh, PA, (4) University of Pittsburgh, United States, (5) PROCAPE / University of Pernambuco, Recife, Pernambuco
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Poster Presenter
Danial Ahmad, UPMC
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Pittsburgh, PA
United States
Objective: Type A aortic dissection (TAAD) is considered a time-critical condition. The time needed for diagnosis and transfer to surgery may affect survival. We analyzed the impact of geography and time from TAAD diagnosis to surgery on hospital mortality using a national registry.
Methods: All patients undergoing emergency TAAD repair in 3 centres between 2008 and 2022 were included. The primary endpoint was all-cause in-hospital mortality. Times from diagnostic scan to surgery (T1) and first imaging to surgery (T2) were recorded. We defined early (2008-2014) vs. recent (2015-2022) eras.
Results: 357 patients referred from 35 emergency departments across 12 distinct geographic health regions were included. 70% [249/357] were male. Males were younger than females [58±14 vs.64±14 years, p<0.001]. Median diagnosis-to-surgery (T1) and overall time (T2) were 5 hrs [IQR:3.7-6.7] and 7.4 hrs [IQR 5-21.5] respectively. Median T1 [4.5 vs. 5.8 hrs, p<0.001] and T2 [6.6 vs. 10.2 hrs, p<0.001] were significantly shorter in the recent era. Patients from health regions without a surgical centre [n=161, 47%] had significantly longer median T1 [5.5 vs.4.4 hrs, p<0.001] compared to patients in health regions with a surgical centre [n=185, 54%].
Hospital mortality was 26% [93/357], decreasing from 30% [33/109] to 24% [60/248], p=0.24 in the recent period. Comparing survivors with non-survivors, there were no differences in times to surgery: T1 [5 vs. 4.9 hrs, p=0.68] and T2 [7.4 vs. 7.1 hrs, p=0.72]. Mortality was similar 24.7% [47/143] vs. 27.5% [46/121], p=0.55 for patients referred from within vs. outside a surgical health region. Distances from home to a referring centre (7 [IQR 4-16] vs. 8 miles [IQR 4-18], p=0.2) or surgical centre (32 [IQR 14-58] vs. 36 miles [IQR 16-69], p=0.46) were similar for survivors and non-survivors. Age was associated with mortality, OR 1.05 [95%CI 1.03-1.07, p<0.001], while gender [OR 0.94 [95%CI 0.57-1.57, p=0.89] was not. 39% [139/357] of patients had pericardial effusion on diagnostic CT scan. This was associated with higher mortality [OR 1.80; 95%CI 1.11-2.90, p=0.02].
Conclusion: Over a 14 year-period, time from TAAD diagnosis to surgery decreased. Patients in regions with surgical centres had faster access to treatment. Hospital mortality was associated with patient and disease-specific factors, such as age and pericardial effusion at presentation, while geographical factors and time to surgery had no impact on the outcome.
Authors
George Gradinariu (1), Hussein El-Shafei (2), Renzo Pessotto (3), Mark Danton (4)
Institutions
(1) Golden Jubilee National Hospital, United Kingdom, (2) Aberdeen Royal Infirmary, Aberdeen, NA, (3) N/A, Edinburgh, (4) N/A, Glasgow, United Kingdom
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Poster Presenter
George Gradinariu, Liverpool Heart and Chest Hospital
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Glasgow
United Kingdom
Objective:
Bupropion is purported to effectively modulate two distinct pathways linked to the progression of aortic aneurysms. Notably, current literature indicates that bupropion demonstrates a capacity to inhibit the circulating levels of IL-6, MMP-2, and MMP-9, while concurrently increasing TIMP-1. This dual action aims to mitigate the advancement of aortic aneurysms. The principal objective of our study is to investigate the potential preventive impact of Bupropion on the progression of aortic aneurysms.
Methods:
Utilizing the Medicare Claims database (2007-2017), we identified a cohort of patients with major depressive disorder, seasonal affective disorder, and tobacco use-conditions for which Bupropion is FDA-approved. The comparative group included patients prescribed alternative medications (including SSRIs, SNRIs, mirtazapine, buspirone, nefazodone, trazodone, vilazodone, vortioxetine, varenicline, and nicotine) for the same diagnoses. Employing a comparative approach, we aimed to isolate the potential impact of Bupropion on aortic aneurysm progression. Throughout the study, patient aortic aneurysm development or interventions for repair were diligently tracked. The Kaplan-Meier method was employed for analysis.
Results:
In the database, we identified 916 patients treated with Bupropion and 46,052 treated with alternative medications. The median time to aneurysm diagnosis or repair was 29 months [IQR: 10, 60] in the Bupropion arm compared to 22 months [IQR: 8, 46] in the comparative arm (p<0.001).
Conclusions:
Our results generate the hypothesis that Bupropion might exhibit protective effects against aneurysm development and progression. This real-world data analysis aims to contribute valuable insights into the potential role of Bupropion in preventing the progression of aortic aneurysms, illuminating its broader cardiovascular implications beyond its well-established antidepressant properties.
Authors
Panagiotis Tasoudis (1), Christopher Agala (2), Kyle Alexander (3), John Blackwell (4), Elizabeth Collins (3), Yiwen Ding (3), Thomas Caranasos (5), John Ikonomidis (6), Adam Akerman (3)
Institutions
(1) University of North Carolina, Chapel Hill, NC, USA, (2) UNC Chapel Hill, Chapel Hill, NC, (3) University of North Carolina, Chapel Hill, NC, (4) UNC at Chapel Hill, Chapel Hill, NC, (5) N/A, Chapel Hill, United States, (6) UNC Medical Center, Chapel Hill, NC
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Poster Presenter
Panagiotis Tasoudis, University of North Carolina at Chapel Hill
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Chapel Hill, NC
United States
Objective: To evaluate sex differences in patients undergoing repair of acute type A aortic dissection (ATAAD).
Methods: Retrospective, sex-stratified, single-center cohort study of patients undergoing surgery for ATAAD from 1997-2022. The primary outcome was aortic diameter at time of presentation with ATAAD. Secondary outcomes were mortality, myocardial infraction, stroke, hemodialysis requirement, tracheostomy, re-exploration for bleeding, a composite of said major adverse events (MAE), and long-term survival.
Results: In 390 consecutive patients (150 women), men were younger than women (61.0 [interquartile range (IQR) 50-70] vs 70.5 [IQR 59-78]; p<0.001), had higher body mass index (BMI) (28.6 [IQR 25.1-32.3] vs 25.4 [IQR 21.9-29.2]; p<0.001), more frequent peripheral vascular disease (11.7% vs 4.7%; p=0.03), renal insufficiency (36.7% vs 22%; p=0.003), malperfusion (34.2% vs 18.7%; p=0.007), and smoking history (65% vs 44%; p<0.001). There was no sex difference in median aortic diameter at the time of ATAAD (men: 5.3cm [IQR 4.9-6.1], women: 5.2cm [IQR 4.6-5.9]; p=0.12) even when adjusted for BMI (men: 5.7cm [IQR 5.4-6.1], women: 5.4cm [IQR 5.4-6.1]; p=0.19). There was no sex difference in operative mortality (4.6% vs 6.0%; p=0.7), MAEs, or ten-year survival (61.7% vs 71.0%; p=0.11). On multivariable analysis, there was no interaction between aneurysm size and sex (p of interaction=0.62); and sex was not associated with MAEs (odds ratio 0.75, 95% confidence interval 0.07-7.39; p=0.806).
Conclusions: There was no difference in aneurysm size at the time of presentation of ATAAD between men and women, even after adjustment for BMI, and no interaction between aneurysm size and sex.
Authors
Christopher Lau (1), Lamia Harik (1), Arnaldo Dimagli (1), Mohamed Rahouma (1), Giovanni Jr Soletti (1), Gianmarco Cancelli (1), Jordan Leith (1), Eilon Ram (1), Charles Mack (1), Mario Gaudino (1), Leonard Girardi (1)
Institutions
(1) Weill Cornell Medicine, New York, NY
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Poster Presenter
*Christopher Lau, Weill Cornell Medicine
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New York, NY
United States
Objective:
Anatomically, the ascending aorta and pulmonary artery (PA) share a common adventitia. In acute ascending aortic dissection (AAD) blood can extravasate into the common aortopulmonary adventitia and cause pulmonary artery dissection or intramural hematoma. We describe our experience with the recognition and surgical management of associated pulmonary artery involvement in acute Type aortic dissection using bovine pericardium which enabled suitable hemostasis and successful separation from cardiopulmonary bypass.
Methods:
Case1.
A 40-year-old male presented to the ER with severe shortness of breath, left sided weakness and in extremis. He required urgent intubation. CT angiogram of the chest showed a Type 1 DeBakey dissection with extension into the innominate and right carotid artery, a pericardial effusion and blood around the pulmonary artery (PA) (Fig 1). He was emergently taken to the OR in extremis. TEE showed severe aortic regurgitation and pericardial tamponade. A bio-Bental procedure with Cabrol technique for the coronaries was performed using deep hypothermia circulatory arrest and antegrade perfusion. After coming off cardiopulmonary bypass and reversal of anticoagulation, persistent bleeding from the aorta and adjacent pulmonary artery near the root was noted. The patient was placed back on CPB and after cardioplegic arrest, a tear and hematoma in the PA adjacent to the ascending aorta near the root was identified. A patch of bovine pericardial was used to repair the involved area. He was transitioned to veno-arterial extracorporeal membrane oxygenation from which he was weaned successfully with recovery.
Case 2.
A 49-year-old hypertensive male presented with upper abdomen and chest pain. On CTA an AAD in an 8 cm ascending aortic aneurysm that was compressing the main PA was seen. In addition, there was a separate type B aortic dissection. Also present there was a small sinus tract leading from the dissected aortic aneurysm into the adjacent pulmonary artery. At operation an acute dissection in a chronic Type A aneurysmal dissection was seen which tracked into the wall of the adjacent main PA with a contained intramural hematoma. On preparing the ascending aorta for replacement the PA hematoma bled and required repair using a bovine pericardial patch. A Bio-Bental procedure was performed. The post-operative course was uneventful.
Results:
Bovine pericardial patch can be used to repair pulmonary artery dissection and a bleeding intramural hematoma associated with Type A aortic dissection.
Conclusion: Pulmonary artery dissection or intramural hematoma is infrequently seen in Type A dissection. CT scan findings can be variable. Use of bovine pericardium for repairing the involved pulmonary artery is advisable.
Authors
Salim Aziz (1), Jenna Aziz (2)
Institutions
(1) George Washington University Hospital, Washington, DC, (2) Ohio State Wexner Medical Center, Columbus, OH
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Poster Presenter
Jenna Aziz, Ohio State Wexner Medical Center
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Columbus, OH
United States
Objective:
Endovascular repair has become the standard of treatment for blunt thoracic aortic injury (BTAI). Aberrant right subclavian artery (ARSCA) complicates treatment of BTAI, with described cases excluding the ARSCA with extra-anatomic bypass when indicated. We describe a novel case of using thoracic branched endograft (TBE) in a patient with an ARSCA presenting with BTAI.
Methods:
We discuss the case of a 38 year old female admitted to our institution after a high speed motor vehicle collision. The patient presented with numerous injuries including multiple cervical spine, rib, and extremity fractures, abdominal solid organ injury, as well as a grade 3 BTAI with ARSCA.
Results:
The above patient was discussed at aortic conference, special consideration was taken to the retroesophageal passage of the ARSCA, however, the associated mediastinal hematoma displaced the esophagus from the ARSCA, and the patient was without symptoms related to the retroesophageal passage. After embolization of abdominal solid organ injuries, the patient was taken to the operating room for TBE. A GORE-TAG TBE device was successfully deployed via left common femoral access with corresponding access via the right brachial artery with a Jagwire. A POBA balloon expanded the profile of the ARSCA stent after deployment. The procedure was without complications and no endoleak was present. Post-procedure right upper extremity duplex demonstrated excellent, triphasic flow and CTA demonstrated a well-positioned stent graft without endoleak. Given the presence of concomitant blunt cerebrovascular injuries (BCVI), the patient was started on full dose aspirin post-procedure which was continued at discharge. The patient was discharged on hospital day 24 following recovery from other injuries, with no changes on one-month post-discharge CTA. At one-month post-operative clinic visit, given the resolution of BCVI the patient was transitioned to 81mg of aspirin with plan for yearly surveillance.
Conclusion:
With careful patient selection at dedicated aortic centers, TBE can be performed for BTAI in the presence of ARSCA. Important considerations are patient stability, presence of a Kommerell Diverticulum, vertebral artery anatomy, and the passage of the ARSCA relative to other anatomic structures.
Authors
Adam Carroll (1), Donald Jacobs (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Adam Carroll, University of Colorado Anschutz
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Denver, CO
United States
Objective: Thoracic branched endoprosthesis (TBE) gained FDA approval in May 2022, offering an alternative to surgical revascularization of left subclavian artery (LSCA) territory for patients undergoing thoracic endovascular aortic repair (TEVAR) for aortic pathology abutting or proximal to the take-off of the LSCA. Prior reports have described reduced total length of stay (LOS) without difference in outcomes. We sought to describe our institution's experience with TBEs during the first year of our institutional practice.
Methods: We performed a retrospective review of prospectively collected clinical data from all patients undergoing TBE at a single tertiary care center from September 2022 through October 2023. Data were retrieved from the electronic medical record. Patients whose primary indication for hospital admission was not related to aortic pathology were excluded.
Results: Twenty-seven patients met the inclusion criteria and underwent TBE during the study period. Twenty (74.1%) were male with a median age of 63.3 (IQR 53.3–73.9) years. Median BMI was 28.3 (IQR 26.0–30.5). Comorbidities and cardiac surgical history are shown in Table 1. Fifteen (55.6%) patients had an aortic aneurysm, 13 (48.1%) had an aortic dissection, and 6 (22.2%) had a penetrating aortic ulcer.
Twenty-three (85.2%) cases were performed electively and 4 (14.8%) were performed urgently. Two (7.4%) patients underwent Ishimaru zone 0 repair, 3 (11.1%) underwent zone 1 repair, and 22 (81.5%) underwent zone 2 repair. Twenty (74.1%) patients had native flow through their innominate artery and 16 (59.3%) through their left carotid artery (LCA). Six (22.2%) patients had extra-anatomic bypasses of their innominate, 11 (40.7%) of their LCA, and 1 (3.7%) of their LSCA.
Mean LOS was 3.6 ± 2.6 days and mean ICU LOS was 1.8 ± 1.5 days. No operations were converted to open operations. Two (7.4%) patients experienced postoperative access site hemorrhage and 1 (3.7%) experienced intraoperative lower extremity ischemia. No upper extremity access complications occurred. Two (7.4%) patients experienced an intraoperative Type II endoleak. One (3.7%) patient experienced an intraoperative cerebrovascular accident. One (3.7%) patient experienced postoperative acute kidney injury according to STS criteria but did not need renal replacement therapy. One (3.7%) patient has undergone reoperation with open arch replacement. There were no deaths during postoperative hospitalization.
Conclusions: The implementation of TBE at our institution aligns with initial proof-of-concept reports. TBE is a well-tolerated procedure with minimal operative and postoperative morbidity and shortened total LOS compared with traditional surgical revascularization and TEVAR.
Authors
Michael Kirsch (1), Adam Carroll (1), Donald Jacobs (1), Rafael Malgor (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Michael Kirsch, University of Colorado Anschutz Medical Center
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Aurora, CO
United States
Thoracic Endovascular Aortic Repair Outcomes in Octogenarians and Nonagenarians, a Single Center Experience
Raza Ahmad, MD1, Halim Yammine, MD1, John R. Frederick, MD1, Gregory Stanley, MD1, Charles S. Briggs, MD1, Garrett Clemons, PhD1, Hector Crespo-Soto, MD1, Tzvi Nussbaum, MD1, Jeko Madjarov, MD1, Frank R. Arko, III, MD1
1Atrium Health Sanger Heart and Vascular Institute, Charlotte, NC
Objective
The primary goal of this study is to evaluate outcomes of elderly patients who underwent Thoracic Endovascular Aortic Repair (TEVAR).
Methods
Retrospective study from a prospectively maintained single-center database. We identified 506 patients who underwent TEVAR. 50 patients were ≥ 80 years of age. Their data were analyzed to assess primary outcomes (survival and reintervention). Trends in patient demographics, aortic history, TEVAR indication, preoperative status, intraoperative details, and postoperative outcomes were evaluated as well.
Results
Average patient age was 83.6 years, and 60% were females in contrast to only 42.3% in patients younger than 80 (p=0.02). Most of the patients were white (86%) with the next highest reported ethnicity being Black (5%). 19/50 (38%) had coronary artery disease (CAD) compared to only 21% in the younger group (p=0.01). COPD and Hyperlipidemia were also more prevalent in patients older than 80 (p=0.05 for both). The most frequent indication for TEVAR was type B aortic dissection (TBAD) (28/50, 56%), followed by intact thoracic or thoracoabdominal aneurysm (21/50, 42%) with an average aortic diameter of 7.15 cm. A lone case of tumor erosion into the thoracic aorta represents the remainder of TEVAR indication (1/50, 2%).
Landing zones proximal to the left subclavian artery were in 24/50 (48%) (Zone 0 2/50, Zone 1 4/50, Zone 2 18/50) and 7 great vessel debranching procedures were performed. The 30-day stroke rate was 4% (2/50), and there were no instances of myocardial infarction (MI), bowel ischemia, extremity ischemia or spinal cord ischemia at 30- days. Retrograde Type A dissection (RTAD) was observed in 6% (3/50) of patients with one patient undergoing repair. The overall re-intervention rate was 16%. Aortic-related mortality was 10% (5/50). Kaplan Meier estimates for overall survival at 30 days, 1 year, 2 years, 3 years, 4 years, and 5 years were 84%, 67.4%, 55.1%, 47.7%, 40.9%, and 30.7% respectively.
Conclusions
TEVAR can be performed safely and efficiently in patients older than 80 years of age. Even though patients should not be denied a potentially lifesaving procedure based on age alone, careful consideration of all comorbidities is important to ensure the best outcomes. Also, a clear and honest conversation with the patients and their families is crucial to set expectations given the high overall mortality over time.
Authors
Halim Yammine (1), Raza Ahmad (1), John Frederick (1), Gregory Stanley (1), Charles Briggs (1), Garrett Clemons (1), Hector Crespo Soto (1), Tzvi Nussbaum (1), Jeko Madjarov (1), Frank Arko (1)
Institutions
(1) Sanger Heart and Vascular Institute, Charlotte, NC
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Poster Presenter
Halim Yammine, Sanger Heart and Vascular Institute
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NC
United States
Introduction
Two-dimensional (2D) TEE enables echocardiographers to dynamically evaluate the anatomy of an aortic dissection and assess blood flow through branch vessels.1 Mesenteric ischemia has an associated mortality rate of 63.2%. Abdominal pain, lactic acidosis, evidence of liver dysfunction, or findings of celiac trunk or superior mesenteric artery occlusion on imaging may prompt further evaluation for visceral malperfusion.2 The optimal timing of direct surgical or endovascular stabilization of mesenteric blood flow remains controversial,2 although preventing or reversing visceral malperfusion seems crucial to reducing postoperative morbidity and mortality.
TEE can be used to diagnose visceral malperfusion in the OR or at the bedside for patients who are too unstable for computed tomographic angiography (CTA).2,3 TEE has particular utility when visceral malperfusion is dynamic, due to intermittent occlusion of visceral lumina or changes in regional blood flow after blood pressure reduction.3 TEE findings indicating reduced blood flow to the celiac trunk or superior mesenteric artery should prompt intervention on the dissected portions of the descending thoracic or abdominal aorta.
Methods
Philips 7CVxi echocardiography machines and X8-2T transducers were used to obtain celiac, SMA and abdominal aortic imaging between 0 – 30 degrees in the transgastric view. The celiac trunk and superior mesenteric artery were interrogated for patency, origin from the true aortic lumen, and extension of any dissection into these arteries.
Results
3D images show dynamic aortic flap motion impacting the celiac trunk and SMA. Patency is assessed structurally and color doppler proves blood flow.
Conclusion
TEE assess blood flow to the celiac trunk and SMA. Though static obstruction physiology is better diagnosed on CTA, dynamic obstruction mechanistically explains up to 80% of malperfusion syndromes.3 The ability to consistently view the celiac trunk and superior mesenteric artery with TEE has been demonstrated in case reports and single center case series; the attempts to characterize the celiac trunk have a high reported success rate (99-100%), although there is greater reported variability in the success rate of visualization of the orifice of the SMA (may be as low as 66%).3,4
3D-TEE for assessment of cardiac function and valvular disease is recommended by the ASE/SCA/STS guidelines as an adjunct to 2D TEE for intraoperative imaging of the heart and aorta.5 Published benefits of 3D TEE in evaluation of aortic dissections include a superior illustration of a dissection flap's architecture if the dissection has a helical course, and superior evaluation of entry tear size, coronary involvement, or interface with the aortic valve.6,7,8 No direct comparative studies have assessed 3D vs 2D imaging of the celiac trunk or SMA, but the value of 3D images of abdominal aortic dissection anatomy is easily extrapolated.
We advocate for standardization of routine 3D TEE evaluation of mesenteric vascular involvement in the dissected aorta as a method to best assess the impact of the aortopathy on visceral perfusion dynamically.
Authors
Jamie Bloom (1), Audrey Spelde (1), Waseem Lutfi (2), Kendall Lawrence (2), Edward Percy (1), Chase Brown (3), Joseph Bavaria (1), Asad Usman (1)
Institutions
(1) Hospital of the University of Pennsylvania, Philadelphia, PA, (2) University of Pennsylvania, Philadelphia, PA, (3) University of Pennsylvania, PHILADELPHIA, PA
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Poster Presenter
Jamie Bloom
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Philadelphia, PA
United States
Objective: Comfort with total arch replacement has increased with the evolution of hybrid techniques. The frozen elephant trunk (FET) technique, has traditionally relied upon distinct open and endovascular grafts, joined intraoperatively. The ThoraflexTM Hybrid was FDA approved in May 2022 as the first commercially available hybrid device for FET. We sought to describe our institutional experience performing total arch replacement since its approval.
Methods: We performed a retrospective review of prospectively collected clinical data from all patients undergoing elective aortic arch reconstruction with a total arch replacement at a single tertiary care center from May 2022 to October 2023. Data were retrieved from the electronic medical record.
Results: Thirty-four patients met the inclusion criteria and underwent elective aortic arch reconstruction with total arch replacement during the study period. Twenty-two (64.7%) underwent traditional frozen elephant trunk (FET) replacement, while 12 (35.3%) underwent replacement using the Thoraflex. Sixteen (72.7%) FET and 9 (75.0%) Thoraflex patients were male (p = 0.508), with a median age of 56.7 (IQR 51.0–63.8) and 62.6 (IQR 55.6–71.8) years, respectively (p = 0.597). Nine (40.9%) of traditional FET patients had a prior aortic intervention, compared with 9 (75.0%) of Thoraflex patients, p = 0.184. There were no significant differences in demographics or comorbidities between patients undergoing FET and non-FET aortic arch replacement, including diabetes, hypertension, tobacco use, chronic lung disease, peripheral artery disease, previous stroke, coronary artery disease, or previous cardiac intervention.
There were no differences in median cardiopulmonary bypass time (p = 0.242), aortic cross clamp time (p = 0.135) or circulatory arrest time (p = 0.364) by type of aortic arch replacement. There were no differences in postoperative length of stay (p = 0.669) or ICU length of stay (p = 0.112). There were no differences in postoperative ICU morbidity, including new dialysis requirement, venous thromboembolus, paralysis, stroke, prolonged mechanical ventilation, surgical site infection, postoperative atrial fibrillation, or operative mortality.
Complete outcome data are shown in Table 1.
Conclusions: Elective total arch replacement for aortic arch pathology is not associated with differences in operative and postoperative outcomes based upon technique of replacement.
Authors
Michael Kirsch (1), Adam Carroll (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
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Poster Presenter
Michael Kirsch, University of Colorado Anschutz Medical Center
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Aurora, CO
United States
Objective:
After hemi-arch replacement for acute type A aortic dissection (ATAAD), enlargement of the residual aneurysm sometimes requires surgery. We investigated the long-term outcomes of total arch replacement through left thoracotomy in such cases.
Methods:
From October 1999 to September 2023, 445 patients underwent surgery because of ATAAD. Two hundreds patients had total arch replacement (TAR), 33 patients had semi-arch replacement（1-2 branch）, and 212 patients had hemi-arch replacement (ascending aorta). Nineteen patients (18 patients have had hemi-arch replacement, 1 patient have had semi-arch replacement) required redo TAR because of residual distal dissection. Fourteen patients had median sternotomy and TAR+ Free Elephant Trunk or Frozen Elephant Trunk installation (ET) as a redo surgery, while 5 patients (4 post hemi-arch replacement, 1 post semi-arch replacement) underwent left thoracotomy and TAR. Including these 4 patients, we had in total of 34 patients (30 patients have undergone hemi-arch replacement for ATAAD at other hospitals) undergoing extensive（aortic arch to descending aorta）arch replacement after previous surgery for ATAAD, using the left thoracotomy. The mean age of the patients was 62.1 ± 10.6 years (42-80 years), and the most enlarged aortic site was the aortic arch in 19 patients, descending aorta above the Th 6 level in 4 patients, and descending aorta below Th 6 in 11 patients. Three symptomatic patients were operated urgently, while the others underwent elective surgery. Left posterolateral thoracotomy approach was used in 31 patients, clam-shell approach was used in 1 patient, antero-lateral thoracotomy with partial sternotomy (ALPS) was used in 1 patient, and straight incision with rib cross approach was used in 1 patient. All patients underwent total arch replacement and replacement of descending aorta. As an additional procedure, 2 patients underwent aortic root replacement, 10 patients underwent thoracoabdominal aorta replacement, and 1 patient underwent CABG. The mean cardiopulmonary bypass time was 229 ± 60.1 minutes, cardiac ischemia time was 74.5 ± 33.5 minutes. Antegrade cerebral perfusion was used in all patients, and the cerebral perfusion time was 79.9 ± 23.8 minutes. The minimum tympanic temperature was 24.5 ± 2.67 ℃, the minimum rectal temperature was 26.1 ± 2.96 ℃.
Results:
There was one early death because of coronary embolism and multiple stroke 5 days after the surgery. The follow-up period varies from 2 months to 16.5 years. Kaplan-Meier survival at 5, 10 year was 89.7 ± 5.65 %, 64.2 ± 10.6 % respectively. Freedom from cardio-aortic event at 5, 10 year was 85.4 ± 6.82 %, 76.1 ± 8.67 %, and reoperation freedom at 5, 10 year was 92.0 ± 5.44 %. Of the 8 patients who died within 10 years, 3 died of cardiovascular events (2 for aortic aneurysm rupture, 1 for renal and heart failure).
Conclusion:
The early results of total arch replacement through left thoracotomy for residual aortic dissection after ATAAD repair were satisfactory. However, there have been some patients who had events in the distal aorta after reoperation.
Authors
Aya Tanaka (1), Yutaka Okita (2), Kenji Okada (3), takanori Oka (1), Kotaro Tsunemi (1), Atsushi Omura (4), Hiroyuki Hayashi (1)
Institutions
(1) Takatsuki General Hospital, Takatsuki, Osaka, (2) Takatsuki General Hospital, Kobe, Hyogo, (3) Kobe University Hospital, Kobe, Hyogo, (4) N/A, Kobe, Japan
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Poster Presenter
Aya Tanaka, Takatsuki general Hospital
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Narai city, Nara
Japan
Objective: Frozen Elephant Trunk (FET) along with total aortic arch replacement (TAR) is a viable surgical option for Acute Stanford Type A aortic dissection (TAAD) with distal dissection flap. The addition of FET to TAR has the advantage of providing a distal landing zone for subsequent TEVAR as well as potentially improving aortic remodeling by directing flow down the distal true lumen. However, there are concerns of complications with FET, such as risk of distal malperfusion. We thus sought to compare TAR+FET versus TAR alone.
Methods: The Society of Thoracic Surgeons (STS) database was queried for patients who had surgery for acute TAAD from January 2017 to December 2020 (n=18706). All patients with distal dissection extent beyond zone 2 were included while those with missing data or previous cardiac operations were excluded. This yielded 4066 eligible records. We excluded 1322 patients as they did not undergo arch repair leaving 2744 patients. From this dataset we specifically focused on those who underwent TAR ± FET (n= 237). Demographic, intraoperative, and post-operative data were analyzed using descriptive statistics. To minimize bias associated with baseline characteristics between those who did and did not undergo FET, we utilized multiple regression with prespecified variables to calculate risk adjusted odds ratio adjusted for age, sex, race, high volume center, and preoperative malperfusion.
Results: Of the 237 patients analyzed, 77 underwent TAR and 196 underwent TAR with FET. Baseline characteristics (Table 1) showed statistically significant differences in race and preoperative malperfusion was higher in the TAR+FET group. Intraoperatively there was a difference in arterial cannulation site and an increase in unplanned aortic valve replacement in the TAR+FET group. There was, however, no significant difference in cardiopulmonary bypass time and circulatory arrest time. Those who underwent TAR+FET had significantly lower 30-day mortality (OR=0.455 p=0.02) though more patients in this group presented with malperfusion. Those who underwent TAR+FET had similar length of stay and ICU time to those who had TAR alone. Although not statistically significant, there was a trend towards fewer 30-day readmissions in the TAR+FET cohort. There was no significant difference in complications between the two groups, specifically: renal failure, liver dysfunction, stroke, and spinal cord ischemia. After adjusting for multiple potential confounders, 30-day mortality remained significantly lower in those who underwent TAR+FET with an adjusted Odds Ratio (aOR) of 0.49 (CI= 0.25 to 0.98, p=0.04). Our risk adjusted logistical regression found that presentation with malperfusion (aOR=2.03 [CI:1.04-3.95], p=0.04), and presentation at a lower-volume center (fewer than 30 cases per year) (aOR=2.54 [CI:1.06-6.08], p=0.04) were shown to be significant risks for mortality within our model.
Conclusion: Total Arch Replacement with FET is associated with reduced early mortality compared to TAR alone in those presenting with greater than zone 2 TAAD despite a greater proportion of patients in the TAR+FET group presenting with malperfusion, which in our adjusted analysis increases mortality. With the theoretical benefits of decreased reintervention and promoting aortic remodeling, FET may be ideal for those presenting with TAAD, especially with clinical malperfusion.
Authors
Henry Kwon (1), George Divine (2), Kyle Miletic (1), Loay Kabbani (3)
Institutions
(1) N/A, United States, (2) Henry Ford Health, Detroit, MI, (3) N/A, Ann Arbor, MI
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Poster Presenter
Henry Kwon, Henry Ford Health
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Royal Oak, MI
United States
Objectives
Total endovascular repair of the aortic arch is an evolving field. In the last few years, several options, including fenestrated, branched or scalloped custom grafts have become available to adapt to the complex anatomy of the aortic arch. While open surgery is still the gold standard, endovascular arch replacement allows treatment in a wide cohort of patients with increased surgical risk and appropriate anatomy. Much of the literature available on the matter includes hybrid procedures with previous debranching of the supra-aortic trunks (SATs) or procedures with a zone 2 landing zone. Our aim is to focus on total endovascular aortic arch replacement with a zone 0 or zone 1 landing zone to describe its short- and long-term outcomes.
Methods
This is a single-center, retrospective study. From May 2017 to November 2023, 15 patients underwent total endovascular aortic arch repair with a zone 0 or zone 1 landing zone. We retrospectively collected patients' data. We performed a Kaplan-Meier analysis to evaluate survival and freedom from reintervention at follow-up.
Results
The study population was 15 patients. Mean age was 74.7 ± 7.8 years. All were elective cases. Indications were aortic aneurysms (6; 40%), followed by penetrating ulcers (5; 33.3%), dissections (2; 13.3%) and pseudoaneurysms (2; 13.3%). All patients were evaluated to have a prohibitive risk for open surgery. The main risk factors were hypertension (11; 73.3%), COPD (5,33.3%), renal failure (2; 13.3%) and coronary artery disease (1; 6.7%).
The most frequently performed procedure was aortic arch fenestrated EVAR (FEVAR) associated with a left carotid-subclavian bypass (LCSB) (6; 40%), followed by Double branched graft with LCSB (5; 33.3%) and Triple branched graft (2; 13.3%). In two cases a scalloped graft was used on the left carotid artery, associated with LCSB (2; 13.3%).
There was 1 in-hospital death, caused by an ischemic stroke with hemorrhagic transformation. Perioperative stroke occurred in 2 cases (both in the Double branched group, both showed patent SAT stents at the CT- scan). There was no occurrence of spinal cord injury or retrograde dissection.
Mean follow-up (FU) time was 16.4±15.1 months. There were 3 deaths at FU, all for non-cardiovascular causes, and 1 stroke at FU. One patient also required reintervention, which was performed by further stenting of the brachio-cephalic trunk for a type III endoleak. In our analysis, 12-month survival was 87.5% and freedom from reintervention was 85.7% (Figure 1).
Conclusions
Total endovascular aortic arch repair with custom-made prosthesis is a safe and effective procedure in the cohort of patients with prohibitive surgical risk, even though stroke remains the main complication with still significant rates. Our initial experience showed promising results.
Authors
Luca Di Marco (1), Chiara Nocera (1), Francesco Buia (2), Francesco Campanini (1), Domenico Attinà (2), Vincenzo Russo (2), Luigi Lovato (2), Davide Pacini (3)
Institutions
(1) IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum Università di Bologna, Bologna, Italy, (2) Division of Radiology. IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy., Bologna, Italy, (3) IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum Università di Bologna, Depa, Bologna, Italy
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Poster Presenter
Luca Di Marco
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Bologna, Bologna
Italy
Objective
We present the management of a ruptured thoracic aorta with total thoracic aorta replacement in a patient with a prior TEVAR.
Methods
A 56-year-old male presented with worsening left arm and chest pain. He has a history of a ruptured Type B aortic dissection complicated by PEA arrest which was emergently stented with a thoracic endograft 6 months ago. The patient also underwent a right to left femoral artery bypass due to malperfusion of his left leg. On presentation, his CTA chest revealed an 11.0 x 11.5 cm ruptured descending thoracic aorta with a massive left chest hemothorax and Type 1 endoleak at the distal aortic graft. Transesophageal echo revealed significant aortic insufficiency.
Results
The patient was taken to the operating room where a lumbar drain was placed and a left thoracotomy was performed through the 5th and 8th intercostal spaces with evidence of a large, contained rupture of the thoracic aorta. The lung was dissected with exposure of the diaphragm. The patient was then placed supine, a right axillary artery cutdown was performed, and cardiopulmonary bypass was initiated via the right axillary artery and right femoral vein. Through a median sternotomy, the aortic valve, ascending aorta, and aortic arch were replaced. Remaining on cardiopulmonary bypass, the patient was repositioned laterally, and the distal end of the aortic graft used to replace the aortic arch was pulled through the remaining native aorta and TEVAR graft down to the diaphragm. The distal graft was then sewn to a fenestrated aorta at the diaphragm and the patient was weaned from cardiopulmonary bypass. The patient was noted to have a significant air leak and became profoundly hypoxic with evidence of disruption of the posterior membranous portion of the left main stem bronchus. The patient was then placed on venoarterial ECMO via a sidearm of the aortic graft with repair of the bronchus. The chest was packed with chest closure the following day. The patient was weaned from ECMO and discharged home several weeks later.
Conclusions
This case represents the successful management of a ruptured descending thoracic aorta in the setting of a previous TEVAR with total replacement of the aorta from the sinotubular junction to the diaphragmatic hiatus. The total thoracic aorta was replaced due to poor substrate for sewing a proximal anastomosis in the left chest. A bronchial injury was identified and ECMO was immediately utilized for support. We demonstrate that replacement of the entire thoracic aorta is a reasonable approach when there are limited options for isolated repair of the descending aorta within the left chest and highlight the use of ECMO support to facilitate the management of complications.
Authors
Michael Bishop (1), Antone Tatooles (2), David Stern (3), Patroklos Pappas (4)
Institutions
(1) N/A, United States, (2) Rush University Medical Center, Chicago, IL, (3) RUSH University Medical Center, Chicago, IL, (4) N/A, N/A
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Poster Presenter
Michael Bishop, Rush University Medical Center
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Chicago, IL
United States
Objective:
To demonstrate a surgical technique employed in a child with a very unusual severe ascending, transverse arch and descending aortic aneurysm with a rare genetic disease.
Case Video Summary:
A 19-month child with a family history of aortic dilatation was referred to our center due to a severe ascending, transverse arch and descending aortic aneurysm. The dimensions showed a dilatation up to 45 mm in the aortic arch and preoperative echocardiogram showed aortic insufficiency secondary to the dilatation of the sinotubular junction.
A median sternotomy, cardiopulmonary bypass with arterial cannulation in the innominate artery, the descending aorta, and venous cannulation in the right atrium was initiated. Then, moderate hypothermia and selective antegrade cerebral perfusion at a rate of 50 cc/kg/minute was established. Near infrared spectroscopy (NIRS), and proximal and distal pressure monitoring was set.
The ascending aorta, transverse arch, and descending aorta was replaced up to where the dilatation was evidenced with a Dacron graft (22 mm) with independent reimplantation of the neck vessels.
The patient was weaned from cardiopulmonary bypass without complications.
Aortic cross clamp time was 77 minutes, cardiopulmonary bypass time was 130 minutes and selective antegrade cerebral perfusion was 24 minutes.
The patient was extubated 12 hours after the operation but due to vocal cord disfunction a traqueostomy was performed. The patient had an adequate evolution and was discharged home at day 23 with an angiotensin receptor antagonist. Genetic evaluation was made and the gene EFEMP2 was identified related to Autosomal Recessive Cutis Laxa Type 1B, a rare genetic disease that has various clinical manifestations including aortic aneurysms.
1 year follow up showed an adequate evolution, with no repercussions after surgery.
Conclusions:
Simple techniques with neck vessel reimplantation can be the solution for a very unusual case of thoracic aneurysm in a child. A thorough genetic evaluation should be done in these patients with infrequent presentations to identify further possible complications and establish a medical management for the future.
Authors
NESTOR SANDOVAL (1), Pablo Sandoval (2), TOMAS Chalela (3), Jaime Camacho (4), Carlos Villa (5), Juan Umaña (6), Carlos Obando (7)
Institutions
(1) FUNDACION CARDIOINFANTIL, BOGOTA, DC, (2) El Bosque University, Bogota, NA, (3) N/A, bogota, Colombia, (4) Fundación CardioInfantil, Bogota, NA, (5) Fundacion Cardioinfantil, Bogota, Colombia, (6) La Cardio, Bogota, (7) N/A, Bogota, Colombia
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Poster Presenter
Pablo Sandoval, El Bosque University
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Bogotá D.C., NA
Colombia
Objective: Acute type A aortic dissection (AAD) and the necessary surgical repair lead to a disruption of the physiological coagulation systems. Ensuring hemostasis is crucial, and routinely requires perioperative transfusions and substitution of coagulation factors. This retrospective study investigates the impact of various factors on the use of these products.
Methods: Patients operated for AAD between 2017 and 2022 were identified and demographics, comorbidities, clinical details, including the status at presentation and perioperative transfusions and administered coagulation factors, and postoperative details were obtained and stratified according to the Penn classification. 369 patients were included, consisting of 281 (76%) patients with DeBakey type I dissection and 88 (24%) patients with DeBakey type II dissection. Mean age was 65.5±13.1 years and 235 (64%) patients were male. Multivariable linear regression models for transfusions and coagulation factors were calculated including the variables age, gender, body-surface-are (BSA), preoperative oral anticoagulation, Penn classification, cardiopulmonary bypass (CPB) and distal ischemia times, lowest body temperature, and extent of surgery.
Results: The study collective, including comorbidities, prevalence of risk factors, and postoperative complications, is representative of AAD patients. Patients with preoperative shock and/or malperfusion required significantly more transfusions, prothrombin complex concentrates, and Fibrinogen both intraoperatively and in the early postoperative course (p≤0.007). Multivariable linear regression analysis revealed that shock, the duration of cardiopulmonary bypass, root replacement, the patient's size, and the preoperative use of oral anticoagulation were significant factors, while the other tested variables did not have a significant influence on transfusions and coagulation factor substitution.
Conclusions: Surgical repair for AAD remains major surgery requiring transfusions and coagulation factors in almost all patients. Significant factors that necessitate use of these products are shock, duration of CPB, and patient's size. With proper management, acceptable rethoracotomy and chest drain rates can be achieved with good clinical outcomes.
Authors
Philipp Pfeiffer (1), Vanessa Buchholz (1), Chris Probst (1), Ahmed Ghazy (1), Hendrik Treede (1), Daniel-Sebastian Dohle (1)
Institutions
(1) Univercity Medical Center Mainz, Mainz, Germany
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Poster Presenter
Philipp Pfeiffer
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Mainz
Germany
Objective: A 58-year-old male presented following a motor vehicle accident with loss of consciousness. He was found to have a traumatic type A aortic dissection and underwent a hemiarch repair with bioprosthetic aortic valve replacement at an outside hospital. On postoperative day three, the patient developed absent left upper extremity pulses and severe lethargy. Imaging revealed a residual dissection extending to all three arch branches. The patient was transferred to our institution for further surgical management. On further review of imaging, an intimal intussusception causing possible dynamic flow obstruction of the arch vessels was noted. Here, we present successful management of this complication through total aortic arch repair with frozen elephant trunk.
Methods: We conducted a retrospective chart review of this patient's preoperative, operative, and postoperative course as well as relevant literature review.
Results: The patient underwent peripheral cannulation via the right axillary artery using a 10mm graft and right femoral vein, followed by repeat sternotomy. After initiation of cardiopulmonary bypass, cooling, cross-clamping, and administration of antegrade and retrograde cardioplegia, the previous ascending aorta graft was cut. The bioprosthetic valve appeared normal on inspection. After cooling to below 26C, the innominate artery was clamped and antegrade selective cerebral perfusion was initiated through the right axillary artery graft. Next, the aorta was resected. A 13Fr cerebral perfusion cannula was inserted into the ostia of the left common carotid artery for additional cerebral perfusion. A four branched hybrid prosthesis was advanced to the descending aorta through left common femoral access. The stent was deployed followed by completion of an anastomosis between the device sewing cuff and the native aorta. Systemic circulation was then restored through the graft side branch. The proximal aortic graft-to-graft anastomosis was performed followed by removal of the aortic cross-clamp and anastomosis of the 8mm graft branch to the left common carotid artery and the 10mm graft branch to the innominate. Given the fragile tissue quality secondary to injuries sustained in the MVA, as well as the deep anatomic location of the subclavian, the decision was made to ligate the subclavian artery and anastomose the left internal mammary artery to the branched graft to restore perfusion to the left upper extremity. The patient was successfully weaned from cardiopulmonary bypass. The patient recovered from surgery well and discharged to rehabilitation facility with non-disabling stroke.
Conclusions: We describe a rare case of a traumatic type A dissection, initially treated with hemiarch repair with AVR. The patient developed symptoms of a residual dissection leading to possible dynamic flow obstruction of the arch vessels due to intimal intussusception. This catastrophic complication was successfully treated with total arch replacement with a frozen elephant trunk approach and resulted in a satisfactory patient outcome.
Authors
Sarah Hoffman (1), Shaelyn Cavanaugh (2), Andrew Jones (1), Hossein Amirjamshidi (2), Kazuhiro Hisamoto (2)
Institutions
(1) University of Rochester School of Medicine and Dentistry, Rochester, NY, (2) URMC Division of Cardiac Surgery, Rochester, NY
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Poster Presenter
Sarah Hoffman, URMC Strong Memorial
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Rochester, NY
United States
Objective: Acute aortic dissection with primary entries in the arch and extension to the distal descending aorta is infrequent and designated as type Arch B aortic dissection in the clinical situation. At present, the appropriate treatment of acute Arch B aortic dissection remains unclear. The aim of this study was to compare the outcomes of different treatments in patients with acute Arch B aortic dissection.
Methods: From 2001 to 2022, patients admitted emergently with a primary diagnosis of acute aortic dissection were screened, and a total of 57 candidates with Arch B aortic dissection were enrolled. The locations of the entries were determined by intraoperative inspection or angiography. Among these patients, 15 underwent total arch replacement (TAR) plus frozen elephant trunk, 14 underwent supra-arch debranching and retrograde stenting, and 28 underwent isolated endovascular intervention with fenestration or chimney technique. Baseline demographics, clinical outcomes including mortality and aortic reinterventions, and the computed tomography angiography-derived parameters of arch dimensions and remodeling, were compared across groups of different treatments. The median follow-up time was 55.5 months (interquartile range, 35-88 months).
Results: Overall mean age was 49.6 years (range, 26-80 years) with a male predominance (52/57, 91.2%). The in-hospital survival was comparable across 3 groups (14/15, 93.3% vs 13/14, 92.9% vs 28/28, 100%; log-rank P = 0.499), while there was a trend towards lower 5-year freedom from aortic reintervention in the TAR group (TAR vs non-TAR:100% vs 83.6% ± 6.8%, P = 0.057). At 5 years, the regressions of the arch and descending aorta were better in the TAR group than in non-TAR groups (aortic diameter at Zones 1-4: -1.2mm vs +0.01mm, P<0.001; -1.2mm vs +0.2mm, P<0.001; -1.6mm vs +0.14mm, P=0.001; and -0.6mm vs -0.10mm, P=0.121, respectively). The rate of complete descending aortic remodeling was also higher in the TAR group (66.7% vs 48.6%, P = 0.045).
Conclusions: In patients with acute Arch B aortic dissection, resection of the dissected arch may be beneficial with acceptable survival and superior freedom from aortic reintervention compared with non-resection treatments.
Authors
Jing Zhang (1), Wen-rui Ma (2), Xiaobin Zhang (1), Ye Kong (1), Jianfeng Zhang (1), dan zhu (3)
Institutions
(1) Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China, (2) Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China, SHANGHAI, NA, (3) Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, NA
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Poster Presenter
Jing Zhang
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SHANGHAI
China
OBJECTIVE: To evaluate the short and long-term results after treatment of aneurysm or aortic dissection using the FET technique using the E®vita-Open prosthesis.
METHODS: Medical records were analyzed and data was collected from a database of patients who underwent surgery using the Frozen Elephant Trunk (FET) technique using the E-vita Open® prosthesis (Jotec GmbH, Hechingen, Germany) between Jul/2009 and Jun/2023. The adverse effects evaluated were paraplegia, stroke and AKI. Bleeding, need for re-intervention to treat remaining segments of the aorta and mortality were also assessed. Statistical program used in this study was GraphPad Prism v.10.0.1(218). The test used to compare categorical or non-categorical variables between groups was the chi-square, with a significant "p" <0.05.
RESULTS: 158 patients who underwent FET using the E-vita Open® prosthesis were evaluated. Average age was 59.1 years, with 98 (62%) patients being male. The underlying diseases corrected surgically were Aortic Aneurysm (AA) with 26%, Acute Aortic Dissection (AAD) with 13% and Chronic Aortic Dissection (CAD) with 60.1% of cases; 40 (25%) of which were re-operations. The mean maximum aortic diameter was 65.6 (14.1; 41-130) mm; the mean Cardio Pulmonary Bypass (CPB), Anoxia and Selective Cerebral Perfusion (SCP) time being respectively: 160.6 (SD 32; 92-292); 127.5 (SD 33.7; 55-249) and 60.6 (SD 12.5; 39-111) minutes. Comparing CPB, Anoxia and SCP between the groups, there was a statistically significant difference with a "p" value of respectively: 0.003; 0.005 and 0.0001. The average follow-up was 3.1 (SD 2.6; 0.07-10.12) years. The prevalence of stroke/neurological deficit within 7 days after surgery was 8.02%, with a persistent deficit for up to a year in 3.6% of cases. Limb paresis and plegia accounted for 61% of the deficits, with the comatose state in second place at 30.76%. During the postoperative period of up to 7 days, we observed the need for dialysis renal replacement therapy in 10.6% and the occurrence of acute kidney injury/injury in 25.3% of the population. There was no statistical difference between the prevalence of re-intervention between the AA, AAD and CAD groups: p=0.24 (DF 2.84). General mortality within 30 days was 14.5%, between 30 days and one year 6.9% and between one year and 5 years 3.1%. When comparing mortality within 7 days and the occurrence of dialysis AKI, there was a statistically significant difference (p=0.01).
CONCLUSIONS: In this report we observed statistically significant differences regarding the time of CPB, Anoxia and PCS, however, without apparently contributing to an increase in short- or long-term mortality when comparing the AA, AAD and CAD groups. The prevalence of stroke, paraplegia and acute kidney injury due after FET operation remains low in this new series. In this study, mortality within 30 days was observed to be lower than that of other representative single-center series and in relation to an international multicenter registry¹ˈ²ʾ³. Retrospective nature and divergence between the size of the groups treated in this sample can also influence and limit interpretations; prospective and randomized studies are needed to test hypotheses. In this service, the treatment of complex aortic diseases using the FET technique proved to be safe, effective and with good long-term results, comparable with results from other centers of excellence.
Authors
Rômullo Santos (1), Jose Augusto Duncan Santiago (2), Vagner Madrini (3), Vinicius Correia (3), Fabio Fernandes (3), Felix Ramires (3), Fabio Jatene (2), Ricardo Dias (2)
Institutions
(1) Division of Cardiac Surgery of Heart Institute of University of Sao Paulo, Sao Paulo, SP, Brazil, São Paulo, Brazil, (2) Division of Cardiac Surgery of Heart Institute of University of Sao Paulo, Sao Paulo, SP, Brazil, Sao Paulo, Brazil, (3) Division of Cardiology of Heart Institute of University of Sao Paulo, Sao Paulo, SP, Brazil, Sao Paulo, Brazil
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Poster Presenter
Rômullo Santos, University of Sao Paulo
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Sao Paulo, São Paulo
Brazil
Objective: Novel surgical techniques for acute type A aortic dissection (ATAAD) have been continuously implemented but short term outcomes have been stagnating over the last decades. We investigated operative mortality and adverse outcomes after surgery for ATAAD over the course of 25 years in an all-comer, single-center collective.
Methods: Between 1998-2022, 500 patients underwent open surgical repair for ATAAD in a tertiary reference center. Retro- and prospective follow up was conducted and patients were included when sufficient documentation was available. Short term major adverse events were classified after the International Aortic Arch Surgery Study Group consensus statement.
Results: In the overall cohort (67.4% male, age 60±14 years), an open distal/ hemiarch was performed in 82.4% of cases (n=412), a partial or total arch replacement in 6.4% (n=32) and 5.4% (n=27) respectively and an elephant- and frozen elephant trunk procedure in 0.8% (n=4) and 3.2% (n=16) patients respectively. Neurological endpoints were observed in 25.2% (n=126) of patients. Operative mortality was 14.2% (n=71), based on a 11.8% (n=59) 30-day mortality and a 14.2% (n=71) in-hospital mortality. Age (1.01, 1.00-1.03) and cardiopulmonary bypass time (1.004, 1.00-1.007) were independent predictors of operative mortality in a multivariate analysis. Surgical volume has significantly increased (46%) between surgical eras of 1998-2010 and 2011-2022 from 203 to 297 cases. There was a statistically significant difference in axillary artery cannulation (42.3% vs 85.3%, p<0.001) and cerebral perfusion (CP) mode (antegrade CP 43.2% vs 96.2%, p<0.001) between eras of 1998-2010 (n=203, age 58±14 years) and 2011-2022 (n=297, age 60±14 years), yet, no significant differences in operative mortality (15.7% vs 14.2%, p=0.66) or neurological endpoints (23.2% vs 28.3%, p=0.219) were observed between those periods.
Conclusions: Surgical technique for operative repair of ATAAD has undergone significant changes with regards to performed procedures, arterial canulation and cerebral perfusion. No statistically significant difference of operative mortality was observed between the first and second half of a 25 year period. A significant increase in surgical volume was observed between the first and the second period, which might reflect that nowadays more patients receive surgical treatment for ATAAD with steady operative outcomes
Authors
Paul Werner (1), Iuliana Coti (2), Beguem Sena Kuscu (3), Philipp Angleitner, Dominik Wiedemann (5), Marie-Elisabeth Stelzmueller (6), Stephane Mahr (3), Guenther Laufer (7), Daniel Zimpfer (8), Marek Ehrlich (9)
Institutions
(1) General Hospital of Vienna, Vienna, Vienna, (2) General Hospital of Vienna, Austria, Vienna, Vienna, (3) Medical University of Vienna, Vienna, NA, (4) Department of Cardiac Surgery, Medical University of Vienna, Vienna, Vienna, (5) N/A, Vienna, Austria, (6) N/A, Austria, (7) Vienna General Hospital - AKH Wien, Vienna, Austria, (8) MUW/AKH Viena, Graz, IN, (9) AKH Vienna, Vienna, GA
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Poster Presenter
Paul Werner, Medical University of Vienna
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Vienna, Vienna
Austria
Objective：Valve-sparing root replacement is advantageous over the Bentall technique and provides excellent long-term results. Intraoperative aortic valve evaluation should be accurate in valve-sparing root replacement for longtime valve durability. We had published a technique to accurately evaluate aortic valve conformation using a balloon blunt-tip(BBT) system that enables aortic valve evaluation under the suitable pressure and without Valsalva deformation. The BBT system is a camera port used for laparoscopic surgery. With a balloon at the tip and a movable soft-gel cone, it is used for Valsalva graft closure with the endoscope placed at the center of the graft. This system has a stopcock that enables objective root pressure monitoring. Using this technique, we have 2 times chance to correct the aortic root, at first adjust commissure height, 2nd leaflet correction.
Case Video Summary: A 69-year-old man, diagnosed with severe aortic regurgitation (AR), was referred to our hospital for operation. Preoperative echocardiography revealed severer AR with Left Ventricular (LV) dilatation. Echocardiography revealed severe AR. A dilated aortic root and ascending aorta were observed on four-dimensional computed tomography angiography. After establishing cardiopulmonary bypass, an aortic cross-clamp was placed to induce cardiac arrest. A 26-mm J-graft Valsalva (Japan Lifeline, Tokyo, Japan) was selected. After ascending aortic replacement, the root reconstruction was resumed. After placing the Valsalva graft with first row stiches, we evaluated the aortic valve using the BBT system to determine the commissure height. The second BBT check was performed after 2nd raw running stitches. Saline was infused into the graft to achieve a 70-mmHg pressure. The aortic valve was corrected with central plication. Finally, intraoperative transesophageal echocardiography revealed no residual AR. The patient discharged hospital uneventfully 9dyas after the operation. Postoperative 4DCT revealed excellent results.
Conclusions: The BBT system facilitates simple and accurate physiological evaluation for valve-sparing root replacement. Using this technique, long-term durable aortic root replacement could be performed.
Authors
ETSURO SUENAGA (1), Taro Nakatsu (2), Yuta Kitagata (3)
Institutions
(1) Kansai Electric power hospital, Osaka, Osaka, (2) N/A, Japan, (3) N/A, N/A
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Poster Presenter
ETSURO SUENAGA, Kansai Electric power hospital
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Osaka, Osaka
Japan
Two-Year Outcomes of Endovascular Repair of Isolated Thoracic Aortic Lesions Using a Single-Branch Thoracic Endograft with Left Subclavian Artery Preservation
Hughes GC, Dake MD, Patel HJ, Matsumura JS, Panneton JM, Azizzadeh A, Lee JT, Brinkman WT, Lumsden AB, Long CA.
Objective. Thoracic endovascular aortic repair (TEVAR) has become the preferred management strategy for most pathologies (aneurysm, dissection, trauma, other) involving the descending thoracic aorta. When coverage of the left subclavian artery (LSA) is required during TEVAR to achieve adequate proximal landing zone (PLZ), revascularization of the LSA is recommended. Branched aortic endografts represent an alternative to surgical LSA revascularization.
Methods. Across 34 investigative sites, 13 adult patients with isolated lesions (non-aneurysm, non-dissection, non-trauma) of the descending thoracic aorta requiring zone 2 PLZ were enrolled in a nonrandomized, prospective study of a single-branched aortic endograft (Gore TAG Thoracic Branch Endoprosthesis (TBE), W.L. Gore and Associates, Flagstaff, AZ). The TBE device allows for zone 2 coverage and incorporates a single side branch for maintenance of LSA perfusion.
Results. Mean patient age was 65±13 years and 54% of patients were female. Pathologies treated included intramural hematoma (IMH) in 23% (n=3/13), penetrating aortic ulcer in 39% (n=5/13), and other isolated aortic lesion in 39% (n=5/13). Procedural technical success rate was 100%; 31% (n=4/13) of patients required distal thoracic endografting, in addition to the TBE device, for complete exclusion of their aortic pathology. Median procedure time was 142 [66,357] minutes. 30-day/in-hospital mortality, stroke, paraparesis/paraplegia, and new dialysis rates were all 0%. Through 24-month complete core laboratory adjudicated imaging follow-up, there have been no type I or III endoleaks, loss of LSA branch patency, or re-interventions. One (8%) patient, who underwent index intervention for an IMH, suffered a new acute type B dissection due to distal stent graft-induced new entry at 533 days postoperatively which resulted in aortic rupture and late death. An additional 3 (23%) patients suffered late deaths due to non-aorta related causes including cerebral hemorrhage (n=1; POD 129) and respiratory failure (n=2; POD 167 & 875). Through 24 months, no patients had aortic enlargement (>5mm) and there were no cases of wire fracture, migration, or compression.
Conclusions. Two-year results from a multi-center, prospective, non-randomized cohort study utilizing an investigational single-branched thoracic endograft for maintaining LSA perfusion in patients with isolated lesions of the descending thoracic aorta demonstrates excellent perioperative and early mid-term outcomes and avoids the need for concomitant surgical LSA revascularization in patients with appropriate anatomy. Longer-term follow up is needed to ensure continued branch graft patency and sustained protection from aortic events.
Authors
G. Chad Hughes (1), Michael Dake (2), Himanshu Patel (3), Jon Matsumura (4), Jean Panneton (5), Ali Azizzadeh (6), Jason Lee (7), William Brinkman (8), Alan Lumsden (9), Chandler Long (1)
Institutions
(1) Duke University Medical Center, Durham, NC, (2) University of Arizona Health Sciences, Tuscon, AZ, (3) University of Michigan Hospital, Ann Arbor, MI, (4) University of Colorado Health, Aurora, CO, (5) Sentara Vascular Specialists, Norfolk, VA, (6) Cedars-Sinai Medical Center, Los Angeles, CA, (7) Stanford University, STANFORD, CA, (8) Baylor Scott & White Health, TX, (9) Houston Methodist, Houston, TX
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Poster Presenter
*G. Chad Hughes, Duke University
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Durham, NC
United States
Introduction: Type A Aortic Dissection (TAAD) is a life-threatening disease and in rare cases is complicated by cardiac tamponade. We aimed to investigate the outcomes after TAAD surgery in the presence of pericardial effusion in a large tertiary centre.
Methods: From January 2011 to January 2020, 1406 consecutive patients underwent TAAD repair at our centre. After removing patients with no data on the presence of pericardial effusion, the final dataset included 1098 patients which were divided in two groups: 132 (12%) patients presented with signs of pericardial effusion and represented the study group.
Results: The median age was 52 years (IQR: 44 -62) and 26% of the patients were female. Compared with the non-effusion patients, the study group patients were older (median age 57 years vs 52, p <0.01) and presented with lower systolic blood pressure (median 116 vs 136 mmHg, p < 0.01) and higher heart rate (median HR 86 vs 80 bpm, p < 0.01). They also had more signs of peripheral malperfusion such as preoperative stroke (22% vs 8.3%), hemiplegia (4.5% vs 1%), limb ischaemia (22% vs 14%) and alterations of the consciousness (7.6% vs 1.1%). The postoperative outcomes were also worst in these patients with a higher in hospital mortality (29% vs 12%) and prolonged ventilations time (median 44 vs 27 hours).
Conclusion: Pericardial effusion and cardiac tamponade in the presence of TAAD represent life-threatening conditions with significant negative impact on the preoperative clinical status and increased postoperative complications and mortality rates.
Authors
Yunxing Xue (1), Vito Domenico Bruno (2), Fudong Fan (1), JUN PAN (1), Qing Zhou (1), Dongjin Wang (1)
Institutions
(1) Nanjing Drum Tower Hospital, Nanjing, China, (2) IRCCS Galeazzi – Sant’Ambrogio Hospital, Milan, Italy
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Poster Presenter
Yunxing Xue, Affiliated Drum Tower Hospital of Nanjing University Medical School
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China, Jiangsu
China
Objective: Aging is a well-known risk factor for aortic dilation, aneurysm formation, and dissection. Genetic aortopathies have also been shown to have an "early-aging" phenotype. Given the role of both mitochondrial dysfunction and senescence in age-related disease, we seek to better characterize the role of these processes in aortic pathology, and investigate the effect of therapeutics targeting these pathways in treating aortic disease.
Methods: Four model systems will be utilized. The first is a model of natural aging, comparing 24-month-old C57BL/6 mice to 3- to 8-month-old C57BL/6 mice. The second model will utilize 24-month-old C57BL/6 mice treated with four weeks of Angiotensin II to induce hypertensive aortic disease. The third model will utilize 4-week-old C57BL/6 mice treated with Beta-Aminoproprionitrile to induce connective tissue-related aortic disease via lysyl oxidase inhibition. The final model will utilize primary aortic smooth muscle cells cultured from patients undergoing cardiac surgery, from both diseased and non-diseased aortas. Each model will be treated with either standard saline/culture media or elamipretide, a mitochondrial targeted therapeutic that has been shown to improve mitochondrial function, senescence, and age-related dysfunction in multiple organ systems. After treatment endpoint, the mice will be euthanized and the aorta will be harvested. Mitochondrial function will be assessed using direct tissue respirometry and mitochondrial content assays. Senescence will be investigated via senescence-associated beta galactosidase staining along with immunoblotting and immunofluorescent assessment of the senescence markers p16/CDKN2a and p53. Histologic assessment of the aorta will be done to determine media thickness and frequency elastin breaks. Primary smooth muscle cells will be assessed for mitochondrial function and senescence as noted above.
Results: Data is currently being collected for this project. Available data reveals a non- statistically significant higher respiratory capacity in young wild type mouse aortas compared to older wild type aortas (p=0.46), and a significantly larger aorta in older wild type mice compared to young wild type mice (p=0.03). However, appropriate power numbers have not yet been reached for definitive analysis.
Conclusions: Based on early data, the aortas of wild type older C57BL/6 mice are on average larger and may have depressed mitochondrial function compared to young wild type C57BL/6 mice. Complete results for the first model (natural aging) will be analyzed and available by April of 2024.
Authors
Arjune Dhanekula (1), Scott DeRoo (2), Chris Burke (2), Billiana Hwang (2), Michael Mulligan (3), Jay Pal (4), David Marcinek (2)
Institutions
(1) University of Washington Medical Center, United States, (2) University of Washington, Seattle, WA, (3) UWMC, Seattle, WA, (4) UCHealth, Aurora, CO
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Poster Presenter
Arjune Dhanekula, University of Washington School of Medicine
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Seattle, WA
United States
Objectives: To compare the impact of unilateral antegrade cerebral perfusion (uni-ACP) and bilateral antegrade cerebral perfusion (bi-ACP) on perioperative complications and short-term follow-up outcomes in Asian patients of total arch replacement surgery.
Methods: We retrospectively collected clinical baseline characteristics and perioperative complications of 1052 patients who underwent total arch replacement surgery in China Cardiovascular Center-Fuwai Hospital from January 2019 to December 2022. Patients were separated into unilateral (n=448) and bilateral (n=604) antegrade cerebral perfusion groups We selected 372 pairs of patients for propensity score matching and evaluated baseline differences between the two groups and analyze perioperative and short-term postoperative complications such as bleeding, infection, redissection and organ damage, especially neurological injury such as cerebrovascular accident(CVA), delirium, etc.
Results: Perioperative mortality and postoperative complications such bleeding, infection, and redissection were similar between groups with a 30-day mortality of 8.5% for uni-ACP versus 9.2% for bi-ACP (P=0.46). Notably, the incidence of postoperative delirium was significantly lower in the uni-ACP group (5% vs. 12%, p=0.03). Between uni-ACP and bi-ACP groups, overall CVA rate (4.3% vs. 3.8%, p=0.4) were not significantly different. The short-term survival was similar between the two groups, p=0.27, (1-year:93.4% vs. 94.2%).
conclusions: In total arch replacement surgery, both uni-ACP and bi-ACP are considered valid strategies for brain protection. Notably, the use of bi-ACP demonstrates a significant reduction in the incidence of postoperative delirium.
Authors
Juntao Qiu (1), Yumeng Ji (2), Cuntao Yu (3)
Institutions
(1) N/A, China, (2) Fuwai Hospital, Beijing, Beijing, (3) Fuwai Hospital, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular, Beijing, Beijing
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Poster Presenter
Yumeng Ji, Fuwai Hospital, National Center for Cardiovascular Diseases
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beijing, Beijing
China
Objective: Coronary artery bypass graft (CABG) may unexpectedly become necessary in aortic root replacement (ARR) for a variety of reasons, such as geometry of root, tissue friability, extent of dissection, injury during mobilization, myocardial ischemia due to coronary button trouble, or coronary button bleeding. This study aims to elucidate the outcomes of such unplanned CABG during ARR.
Methods: This is retrospective study from two large aortic centers who underwent ARR from 2004 to 2021. Planned CABG for atherosclerotic coronary artery disease were excluded (n=285) while other concomitant CABG were defined as "unplanned". A total of 2416 patients were divided into 2 groups based on the need of unplanned CABG: ARR (n=2212) vs ARR + Unplanned CABG (n=204). Propensity score matching (PSM) was performed to compare patients who underwent ARR or ARR + Unplanned CABG alongside landmark analysis to study long-term mortality. Multivariable logistic regression was used to determine which variables were associated with need for unplanned CABG. Results: Reasons for unplanned CABG included: 81 (3.4%) for anatomy or friability of coronary button, 33 (1.4%) for involvement of coronary ostia in aortic dissection, 12 (0.5%) for coronary injury during mobilization, and 78 (3.3%) for suspected impaired coronary flow at button anastomosis. ARR + Unplanned CABG had much higher in-hospital mortality (43 (21.1%) vs ARR 87 (3.9%), p<0.001). After PSM, in hospital mortality (42 (20.8%) vs 15 (7.4%), p<0.001), respiratory failure (99 (49.0%) vs 68 (33.7%), p=0.002), and renal failure (36 (17.8%) vs 21 (10.4%), p=0.045) were greater in the ARR + Unplanned CABG group compared to the ARR group, respectively (Figure 1a). Need for unplanned CABG was associated with following factors: urgent status (OR: 2.25, 95% CI [1.70-2.98], p <0.001), CKD (OR: 1.55, 95% CI [1.08-2.20], p = 0.01), reoperation (OR: 2.44, 95% CI [1.73-3.45], p <0.001), concomitant hemiarch replacement (OR: 1.47, 95% CI [1.07-2.03], p = 0.02), and valve-sparing root replacement (OR: 0.48, 95% CI [0.28-0.80], p=0.005). Landmark analysis showed decreased in survival probability up to 1 year in patients with ARR + Unplanned CABG compared to ARR (p<0.001) while survival was comparable among groups during the rest of the follow-up period (p=0.11) (Figure 1b).
Conclusions: Unplanned CABG leads to higher operative mortality in ARR. Patients who undergo ARR + Unplanned CABG have decreased survival probability during the first year after operation.
Authors
Kavya Rajesh (1), Megan Chung (2), Dov Levine (3), Yu Hohri (4), Elizabeth Norton (5), Parth Patel (5), Yanling Zhao (6), Paul Kurlansky, MD (7), Edward Chen (8), Hiroo Takayama (9)
Institutions
(1) N/A, N/A, (2) Columbia University Irving Medical Center, N/A, (3) Columbia University, New York, NY, (4) Columbia University Irving Medical Center, New York, NY, (5) Emory University, Atlanta, GA, (6) NewYork-Presbyterian Columbia University Irving Medical Center, New York, NY, (7) Columbia University Medical Center, New York, NY, (8) Duke University Medical Center, Durham, NC, (9) NewYork- Presbyterian/Columbia University Medical Center, New York, NY
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Poster Presenter
Kavya Rajesh, NYPH-Columbia University Medical Center
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New York, NY
United States
Objective: Aortic thrombus formation is a potentially life threatening condition that is typically seen in patients with known risk factors for a hypercoagulable state such as certain genetic conditions, malignancy, and some infections (COVID-19). Thrombus associated with the aortic root is most commonly observed in patients with left ventricular assist devices (LVAD) secondary to changes in flow within the aortic root. We present a patient with an abnormality in the aortic root, thought to be a Type A aortic dissection, but was subsequently diagnosed with an unprovoked aortic root thrombus.
Case Video Summary: A 52 year old woman with past medical history of COPD, DM2, and unprovoked pulmonary embolism presented to a referring hospital with acute onset vomiting and chest pain. CTA chest showed a luminal irregularity in the ascending aorta at the level of the sinuses of Valsalva which was favored to represent an intimal flap vs angiosarcoma of the aortic wall. Review of the patient's prior imaging showed no proximal aortic pathology when the patient was diagnosed with her pulmonary embolism 6 months prior. The patient was transferred to our institution where an EKG gated CT scan failed to better characterize the proximal aorta. Given the presumptive diagnosis of a subtle Type A dissection, the patient was taken to the operating room where transesophageal echocardiogram (TEE) showed an 8 x 14 mm filamentous mobile mass arising from the right sino-tubular junction. No wall motion abnormalities or other pathology was identified. Given the size of the mass, acute onset, and unclear diagnosis, the decision was made to proceed with surgical exploration/resection. With a lower suspicion for an aortic dissection, axillary/femoral cannulation was not pursued and a median sternotomy was performed. An epi-aortic ultrasound corroborated the findings of the TEE showing a pedunculated mass arising from the wall of the aorta. The distal ascending aorta and right atrium were cannulated and the heart was arrested. A transverse aortotomy was performed and a 1 x 1 x 3 cm thrombus like mass was found arising from the middle of the right coronary sinus. (Figure 1) This was removed with gentle dissection and the underlying intima appeared intact. Of note, no ostium of the right coronary artery could be identified and with retrograde delivery of cardioplegia, efflux was only observed from the left main coronary artery. Given the lack of wall motion abnormalities and normal pre-operative serum troponin, the right coronary artery was not bypassed. The patient's post-operative course was uncomplicated and she was discharged on POD 5. A hematology consult was obtained prior to discharge and the recommendation was given to obtain a hypercoagulable work-up as an outpatient. The patient was seen at 2 weeks post-op in our clinic and was doing well, but unfortunately has since been lost to follow up. Pathology of the mass resulted as vascular tissue with organizing thrombus.
Conclusions: In patients presenting to the ED with acute onset chest pain, cross sectional imaging remains an important diagnostic modality to evaluate for potential life threatening conditions. In patients with equivocal cross sectional findings, especially in the root, TEE remains an important adjunct to defining the anatomy and guiding operative decision making. This case also highlights a rare case of an unprovoked aortic root thrombus not associated with the presence of an LVAD.
Authors
Timothy Guenther (1), SATORU OSAKI (1), Chris Rokkas (1), Andreas de Biasi (1)
Institutions
(1) Division of Cardiothoracic Surgery, University of Wisconsin Department of Surgery, Madison, Madison, WI
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Poster Presenter
Timothy Guenther, University of Wisconsin
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Madison, WI
United States
Stanford type A aortic dissection (TAAD) remains a life-threatening aortic event with high mortality rates. If the aortic arch is involved, either a hemiarch replacement (HAR) or a total replacement of the aortic arch (TAR) with implantation of a stent into the descending aorta (frozen elephant trunk -FET) is performed. Both HAR and TAR have their advantages and disadvantages. While TAR using FET is often considered to be the best way of sealing entry tears, perfusing arch vessels and supporting the expansion of the true lumen, it is a complex operation that involves a skilled, experienced team. On the other hand, HAR with an open distal anastomosis is technically simpler to perform and, therefore, within the repertoire of surgeons who do not have extensive experience of complex aortic arch surgery. However, some studies showed that HAR has an increased risk of aortic reintervention. Recently, there have been many attempts to address this problem, one of them is the Ascyrus Medical Dissection Stent (AMDS Hybrid Prothesis). This uncovered stent is intended to be implanted distal to an ascending aorta replacement and proximal to the brachiocephalic trunk (Zone 0) in cases of Type 1 acute aortic dissections. We present the early data of AMDS device in a single centre in the United Kingdom. We also present the results of propensity matched comparative analysis of AMDS and Ascending Aorta +/- Hemiarch replacement.
Data was collected retrospectively for a total of 20 patients who had AMDS device implanted for Type 1 Aortic Dissection in our centre from the period of March 1, 2022 – March 31, 2023, Data for 102 patients who underwent Ascending Aorta +/- Hemiarch replacement from 1 Jan 2018 – 31 March 2023, were also collected retrospectively to complete a propensity match analysis with the AMDS group.
During the period of 1 March 2022 – 31 March 2023, 66 patients had surgery for TAAD in our unit, out of which 20 patients (30.3%) had AMDS device. The 30-day mortality was 10% (n=2). This was comparable to the overall 30-day mortality of all dissection patients (N=66) during this time (13.64%, n=9). Postoperative CT scans were available in 17/20 patients (85%) and showed that the AMDS implantation and device expansion was successful in all patients (100%) with no device-related complications.
In the propensity matched analysis, there was no statistically significant difference between the overall mortality and 30-day mortality in between the AMDS & non-AMDS groups. There was also no statistically significant difference in length of ICU stay, prolonged respiratory support, post-operative AKI or need for CVVH or post-operative CVA/stroke between the AMDS group and non-AMDS group. However, there was a statistically significant difference in improvement in false lumen between the AMDS group and non-AMDS group (OR 2.13, 95% CI [0.69 – 3.78], P=0.006). Interpreted to mean that patients in the AMDS group had 2 times increase in improvement in false lumen compared to those in the control group. The 1-year survival rate in the AMDS group was 84.4% (95% CI 69.5% - 100%) compared to 85.0% (95% CI 70.7%-100%) in the non-AMDS group and this difference was not shown to be statistically significant (p=0.42)
Long term follow-up of patients with AMDS with serial imaging and comparative analysis is required to assess the long-term outcome, including any subsequent procedures required to treat the rest of the aorta and device-related complications.
Authors
Ruhina Alam (1), Oluwanifemi Akintoye (1), Simon Strohmeier (2), RAVI DE SILVA (3)
Institutions
(1) Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom, (2) Medizinische Universitat Graz, Graz, Austria, (3) Royal Papworth Hospital NHS Foundation Trust, Leicester, Cambridgeshire
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Poster Presenter
Ruhina Alam, Royal Papworth Hospital
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Cambridge
United Kingdom
Objective: Local anesthesia with conscious sedation (CS) has shown benefit over general anesthesia (GA) with many different endo-surgical procedures. The nationwide use of CS in thoracic endovascular aortic surgery (TEVAR) is low. We adopted the use of CS for TEVAR in 2016 and explored our institutional results with both approaches.
Methods: From January 2014 to December 2022, 109 patients underwent TEVAR at our institution. 68 (62%) and 41 (38%) cases were done under GA and CS with local, respectively. TEVARs were for the following indications: dissection (61, 56%), aneurysm (37, 34%), transection (5, 5%), penetrating ulcers (5,5%) and coarctation (1,1%). Status of the procedures included: emergent (42, 39%), urgent (26, 24%), elective (41, 38%).
Results: GA was used for 17 elective, 13 urgent, and 38 emergent cases, while for CS, there were 24 elective, 13 urgent, and 4 emergent cases. A femoral cutdown was performed in 9 cases (13%) within the GA group, whereas all cases in the CS group utilized percutaneous access, except for 1 (3%) that required a conversion to femoral cutdown. Preoperative malperfusion was noted in 11 (16%) and 1 (3%) case under GA and CS with local, respectively. Spinal drain usage included 31 (45%) and 30 (73%) within the GA and CS with local groups. Median total operative time (minutes) was 217 (±118) and 224(±65) in the GA and CS groups, respectively. In-hospital morality occurred in 10 (14%) GA and 0 CS patients (p=0.024). There were 18 patients that required prolonged ventilation (>48 hours) in the GA group. Postoperative renal failure was noted in 12 (18%) and 2 (5%) cases under GA and CS with local, respectively. Need for vasopressor use following TEVAR was noted in 26 (38%) and 6 (15%) cases under GA and CS with local. Hospital Length of stay was 7±13 and 7±9 days for GA and CS with local, respectively. Extensive TEVAR, defined as greater than 2 zones of aortic coverage, was done in 44 (65%) GA and 26 (63%) CS with local cases. The same increased in-hospital morality risk remained present in the extensive TEVAR subset with 7 (16%) GA and 0 CS patients (p=0.042). Use of CS in extensive TEVAR was associated with shorter OR times GA (285.3±121.3) vs CS (224.2.2±65.3) (p=0.024).
Conclusions: Most CS TEVAR cases were done in the elective setting. Those that underwent CS for extensive TEVAR at our institution were associated with improved mortality and shorter operative times. When feasible, CS with local for TEVAR is safe and has potential benefits related to outcomes and resource utilization for extensive TEVAR coverage.
Authors
Bogdan Kindzelski (1), Alexander Chen (1), Emanuela Peshel (1), Jeffrey Altshuler (1), O. William Brown (2), Graham Long (2), Paul Bove (2), Maciej Uzieblo (2), Kyle Markel (2), Alessandro Vivacqua (1)
Institutions
(1) Department of Cardiovascular Surgery, Corewell William Beaumont University Hospital, Royal Oak, MI, (2) Department of Vascular Surgery, Corewell William Beaumont University Hospital, Royal Oak, MI
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Poster Presenter
Bogdan Kindzelski, Beaumont Royal Oak Medical Center
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Royal Oak, MI
United States
Objective:
Stent graft infection (SGI) caused by a pathogen Burkholderia cepacia complex is rare. Its subsequent clinical course and surgical management are therefore of clinical value to future similar encounters, especially in multiple traumatic thoracic intervention cases.
Methods:
This investigation was conducted by reviewing the patient's clinical course and management. The patient's laboratory tests and imaging studies were presented alongside its clinical course, followed by the final reconstructed three-dimensional image showing the final vascular reconstruction result.
Results:
A 41-year-old man with a history of falling injury had multiple surgical interventions for left lung contusion and hemopneumothorax, right lung pneumothorax, traumatic aortic injury (TAI) grade III (pseudoaneurysm) without evidence of dissection or extravasation in computed tomography angiography, 1st to 12th rib fracture, left clavicle fracture, grade I liver laceration on left liver, right pubic ramus fracture, right sacral ala fracture, left iliac wing fracture, right L5 transverse process fracture, left facial bone, skull and skull base fracture, and left orbital wall fracture. This time, he was admitted due to hemoptysis. Chest CT and positron emission tomography–computed tomography (PET-CT) scan showed a ruptured pseudoaneurysm with a positive signal in the aortic stent graft and periaortic region. Blood culture showed positive finding of B. cepacia complex. Thoracic endovascular aortic repair (TEVAR) was performed, accompanied by ceftriaxone and vancomycin for six weeks, ertapenem and daptomycin for two weeks, and daptomycin and meropenem for four weeks. He was afebrile throughout this hospitalisation and his level of serum CRP was managed to less than 5 in the last week. The patient was then discharged with routine follow-up and an 8-day course of oral linezolid and levofloxacin. However, the patient's positive findings of B. cepacia complex bacteremia 4 months later and positive signal in PET-CT supported persistent infected aortic aneurysm and SGI. This prompted the surgical team to perform the following operation under cardiopulmonary bypass and cardioplegia: 1. The infected aorta from zone I to T8 and stent graft were removed. 2. Ascending-to-descending aortic bypass (ADAB) was performed with an 18-mm graft end-to-side anastomosed to the ascending aorta. The graft extended caudally, passed next to the right atrium, traversed between the right ventricle and the diaphragm, posteriorly passed through the posterior pericardium, and finally anastomosed to the thoracic descending aorta. 3. The left carotid artery was debranched with an 8-mm graft and anastomosed to the 18-mm graft. Finally, negative findings in the follow-up blood culture and diminished PET-CT signals achieved and clinical symptoms and signs improved. The patient was therefore discharged and recovered with no complications in the follow-up.
Conclusions:
This is the first case showing a patient with SGI caused by B. cepacia complex managed successfully through ADAB.
Authors
Shao-Wei Chen (1), Tsung-Han Cheng (2), Yu-Ting Cheng (3), Sung-Yu Chu (4), Chih-Chun Lee (5), Shao-Wei Chen (1)
Institutions
(1) Chang Gung Memorial Hospital, Linkou, Taoyuan, taiwan, (2) Department of Medical Education, Chang Gung Memorial Hospital, Taoyuan City, NA, (3) Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City, NA, (4) Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, NA, (5) Department of Medical Education, Chang Gung Memorial Hospital, Linkou, Taoyuan City, NA
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Poster Presenter
Tsung-Han Cheng, Department of Medical Education, Chang Gung Memorial Hospital
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Taoyuan City, NA
Taiwan
Objective:
Thoracic endovascular aortic repair (TEVAR) has emerged as an alternative to traditional open repair. However, neurologic complications remain a risk. Spinal cord ischemia (SCI) is the most devastating complication after TEVAR. Although motor evoked potential (MEP) monitoring is used to assess intraoperative spinal cord viability, it is not clear whether perioperative MEP monitoring decreases SCI. We retrospectively investigate patients who had undergone TEVAR in our institution to assess the association of intraoperative MEP monitoring with postoperative paraplegia.
Methods:
We retrospectively examined 81 patients (64 males, mean age of 74.2 ± 7.8 years old) who underwent TEVAR with MEP monitoring, excluding cases of emergency surgery, at Kurume University Hospital between 2015 and 2022. MEP was recorded on the skin overlying the abductor pollicis brevis muscle and tibialis anterior muscles. A significant reduction in MEP amplitude was defined as a decrease in the peak-to-peak amplitude of at least 10% relative to the baseline. MEP changes occurred in 11 patients (14%) during TEVAR. We compared the 11 patients with MEP changes to the 71 patients without MEP changes.
Results:
Underlying pathologies included descending thoracic aortic aneurysm in 41 (51%) patients, and type B aortic dissection in 20 (25%) patients. No significant differences in patient characteristics were observed between the two groups, except for males. The proportion of past abdominal aortic repair and bleeding during TEVAR were higher in patients with MEP changes than those in patients without MEP changes. The two groups had no differences in the proportion of artery of Adamkiewicz (AKA) coverage, left subclavian artery (LSCA) coverage, and internal iliac artery (IIA) occlusion. Three (3.7%) of the patients who underwent TEVAR had delayed paraplegia, and two of them had MEP changes. One of the patients without MEP changes had delayed paraplegia. Preoperative cerebrospinal fluid (CSF) drainage caused spinal cord compression by subdural hematoma. The incidence of SCI was significantly higher in patients with MEP changes than in patients without MEP changes (18% vs 1%, p=0.0293).
Six (17%) of the 36 patients who underwent TEVAR with AKA coverage had MEP changes, and one of them had delayed paraplegia. Five (11%) of 45 patients who underwent TEVAR without AKA coverage had MEP changes, one of which had delayed paraplegia. Nine (82%) of 11 patients who had MEP changes showed reduction of MEP after stent graft deployment, and two of them had delayed paraplegia. In all patients with MEP changes, raising blood pressure using dopamine and administration of blood transfusion resulted in spontaneous recovery of MEP.
Conclusions:
MEP changes during TEVAR had high sensitivity and specificity for SCI. Therefore, intraoperative MEP monitoring may be a useful tool in detecting spinal cord ischemia in TEVAR patients.
Authors
Shinichi Imai (1), Hiroyuki Otsuka (1), Seiji Onitsuka (1), Atsutoshi Tanaka (1), Ryo Kanamoto (1), Yusuke Shintani (1), Takahiro Shojima (1), Kazuyosi Takagi (1), Toru Takaseya (1), Shinichi Hiromatsu (1), Eiki Tayama (1)
Institutions
(1) Department of Surgery, Division of Cardiovascular Surgery, Kurume University School of Medicine, Kurume, 67 Asahi-machi
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Poster Presenter
Shinichi Imai
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Kurume
Japan
Objective: Renal dysfunction after thoracoabdominal aortic aneurysm (TAAA) repair remains a significant and common complication despite continuing research on and improvements in renal perfusion methods, surgical technique, and perioperative care. In the hope of reducing renal dysfunction rates after TAAA repair, we tested a novel technique of using hyperoxygenated blood to perfuse the downstream aorta with selective visceral perfusion during repair.
Methods: Since February 2023, we have provided intraoperative hyperoxygenated blood to 11 patients undergoing TAAA repair. This was done by adding an oxygenator to our left heart bypass (LHB) circuit to increase the partial pressure of oxygen (PaO2) in the blood as it is exposed to 100% fraction of inspired oxygen (FiO2) via the oxygenator before returning to the patient. A heat exchanger was also utilized to maintain normothermia. Heparin was administered for ACT ≥ 250. Separate return lines with balloon perfusion catheters provided hyperoxygenated blood to the celiac trunk, superior mesenteric artery, and bilateral renal arteries as part of selective visceral perfusion. No additional cold blood or perfusate was administered to the renal or visceral arteries. Postoperative complications including renal dysfunction and persistent paraplegia were evaluated.
Results: Among the patients (age range 37-77 years), baseline preoperative creatinine level was 0.86-3.34 mg/dL and eGFR was 24-111mL/min/1.73m2; 2 patients had non-dialysis-dependent chronic kidney disease at baseline. Most repairs were elective (n=9), and 7 patients underwent extent II TAAA repair. All patients received selective visceral perfusion and LHB during repair and 9 underwent cerebrospinal fluid drainage. Of the 11 patients, only 1 developed postoperative acute renal dysfunction (with creatinine elevation greater than 50% above baseline creatinine level within 10 operative days) but did not need dialysis. None of the patients had persistent renal failure on discharge. There was also no incidence of mesenteric ischemia, return to the operating room for bleeding, or persistent postoperative paraplegia. One patient died of cerebral herniation due to subarachnoid hemorrhage from an undiagnosed intracranial aneurysm on postoperative day 7 and another patient died suddenly on postoperative day 18 of unknown causes.
Conclusions: This preliminary work suggests that using LHB with hyperoxygenated blood to perfuse renal and visceral arteries during TAAA repair produces favorable results, even for patients with baseline chronic renal dysfunction and elevated serum creatinine levels. Future steps include conducting a formal clinical trial of hyperoxygenated blood as an LHB perfusate in patients undergoing TAAA repair to evaluate the utility and significance of this novel technique. LHB with hyperoxygenated blood should also be evaluated as a potential method to reduce spinal cord deficits and pulmonary complications in these patients.
Authors
Anna Xue (1), vicente Orozco Sevilla (2), Nguyen Le (2), Veronica Glover (1), Susan Green (2), Ginger Etheridge (3), Subhasis Chatterjee (4), Marc Moon (5), Joseph Coselli (6)
Institutions
(1) Baylor College of Medicine/Texas Heart Institute, Houston, TX, (2) Baylor St. Luke's/Texas Heart Institute, Houston, TX, (3) Baylor College of Medicine, Houston, TX, (4) Baylor St. Luke's Medical Center, Houston, TX, (5) Baylor College of Medicine / Texas Heart Institute, Houston, TX, (6) Baylor College of Medicine, Texas Heart Institute, Houston, TX
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Poster Presenter
Anna Xue, Baylor College of Medicine
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Houston, TX
United States
Objectives: Numerical computational simulations (CS) of thoracic endovascular aortic repair (TEVAR) can be integrated into the preoperative workflow when credible and reliable. For this, the methodological mechanical definition of endografts is essential. We explored the potential of TEVAR simulation in predicting technical outcomes and identifying potential adverse events.
Methods: In this process, four different steps were performed, including: 1) experimental test to characterize stent-graft materials and reconstruction of the anatomical conditions , 2) experimental test in 3D printed aortic models to assess deployment of the stent-grafts, 3) Finite Element Analysis (FEA) simulations and comparison with CT-scan experiments, and 4) pre-operative planning. In this study, two cases on preoperative CS before TEVAR are described.
Results: The first case involves an 82-year-old female, presenting with a penetrating atherosclerotic ulcer in the left hemiarch. The patient was submitted to TEVAR in zone 2, with previous left common carotid artery to left subclavian artery bypass. During the intervention, kinking of the distal thoracic stent graft occurred. The kinking was resolved by ballooning the area. The simulation was able to reproduce both the kinking and the situation after simulation of the ballooning (fig 1). Postoperative CT-scan was compared to the simulation and a less than 10% difference in opening area for the nitinol rings was found. The second case includes a 76-year-old patient presenting with a descending thoracic aneurysm, type III arch angulations with several aortic calcifications and a previous open thoraco-abdominal type IV repair. The CS showed both the proximal correct deployment without presence of bird-beak and a partial shrinkage of the last stent within the surgical graft (fig. 2).
Conclusion: This report highlights the potential and reliability of TEVAR simulations in predicting perioperative adverse events and short-term postoperative technical results.
Authors
Tim Mandigers (1), Jasper de Kort (1), Anna Ramella (2), Daniele Bissacco (3), Maurizio Domanin (3), Joost van Herwaarden (4), Giulia Luraghi (2), Francesco Migliavacca (2), Santi Trimarchi (5)
Institutions
(1) Policlinico di Milano, Milan, Utrecht, (2) Politecnico di Milano, Milan, (3) Policlinico di Milano, Milan, (4) University Medical Center Utrecht, Utrecht, (5) Policlinico di Milano, Milano
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Poster Presenter
Jasper de Kort
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Amersfoort
Netherlands
Objective:
Brain protection during ascending aortic replacement (AAR) for thoracic aortic aneurysms (TAA) and cooling temperatures is a critical issue. The usefulness of retrograde cerebral perfusion (RCP) has already been reported, but safety reports on moderately cooled RCP are lacking. We therefore compared early and mid-term results of AAR with aortic clamping and open-distal AAR with moderately cooled RCP.
Methods:
A single-center retrospective analysis was performed for all patients who underwent AAR, and not dissection, for only TAA. A total of 310 patients who underwent either clamped AAR (n=88, Group C) or non-clamped open-distal AAR (n=222, Group O) between April 2011 and May 2023 were included. Concomitant procedures were also included.
Primary endpoints were perioperative stroke and five-year survival, whereas secondary endpoints included 30-day mortality and remote arch re-intervention.
Results:
The mean age of all patients was 65±13 years. The lowest rectal temperature was 23.4±9℃, and circulatory arrest time was 17 minutes in Group O. One case of perioperative stroke was recorded in Group C, while there was none in Group O (P=0.284). Thirty-day mortality was observed in three and two patients (2% vs 1%, P=0.141) for Group C and Group O, respectively. Five-year survival was 90.8±3.3% and 88.7±3.4% (P=0.950) and avoidance rate of arch re-intervention was 94.6±3.1% and 97.5±2.5% (P=0.414) for Group C and Group O respectively.
Conclusion:
Ascending aortic replacement under moderate hypothermic circulatory arrest using retrograde cerebral perfusion in patients with ascending aortic aneurysms did not cause any permanent neurological dysfunction. Therefore, ascending aortic replacement may be safe and feasible under moderate hypothermic circulatory arrest with retrograde cerebral perfusion.
Authors
daiki saitoh (1), Naoya Sakoda (2), yuya yamazaki (3), Tatsunori Tsuji (4), Azuma Tabayashi (5), Kazuki Yakuwa (6), Junichi Koizumi (5), Hajime Kin (7)
Institutions
(1) N/A, N/A, (2) Okayama University Hospital, N/A, (3) Iwate Medical University, Iwate, iwate, (4) Iwate Medical University, yahaba, Iwate, (5) Iwate Medical University, Iwate, Iwate, (6) Iwate Medical University, iwate, iwate, (7) Iwate Medical University, Iwate, NA
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Poster Presenter
Daiki Saito
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yahaba
Japan
Objective
Valve-sparing aortic root replacement (VSRR) has been performed for over 40 years with excellent long-term outcomes for a range of pathologies reported in numerous studies. However, there is evidence that widespread standardized adoption of VSRR has been variable. The objective of this study was to assess trends in VSRR surgery activity and outcomes across England.
Methods
Data from the UK National Adult Cardiac Surgery Audit (NACSA) were obtained from the National Institute of Cardiovascular Outcomes Research (NICOR) central cardiac database. Patients who underwent aortic root surgery between March 2011 and March 2019 were included, and patients who underwent VSRR by any technique were identified. Geographical regions in England were defined with the Kruskal-Wallis test used to assess the rate of VSRR as a proportion of all aortic root surgery. The primary outcome of the study was in-hospital mortality.
Results
A total of 618 VSRR were performed during the study period across 40 centers by a total of 165 consultant surgeons. VSRR represented 8.3% of all aortic root surgery (618/7472). The majority of VSRR (78.1%, 483/618) were performed electively. The median age at operation was 51 (IQR 37-63), and most patients were male (68.6%, 424/618). The median EuroSCORE II was 0.86 (IQR 0.61, 1.67). The overall in-hospital mortality was 2.8% (17/618), with an elective mortality of 1.4% (7/483). The overall rate of permanent stroke was 2.6% (16/618), with a permanent stroke rate for elective patients of 1.7% (8/483). The mean number of cases performed per year was 68.66 (SD 24.61), and the mean number of cases per consultant surgeon per year was 4.61 (SD 7.54). The number of cases per year increased from 42 in 2011 to 72 in 2018. There was evidence of variation between geographical regions in the rate of VSRR as a proportion of all aortic root surgery.
Conclusions
This analysis of national registry data demonstrates a significantly lower overall rate of VSRR as a proportion of all aortic roots compared to other national series. Despite all included centers performing at least one VSRR during the study period, there was evidence of geographical variation in the rate of VSRR. Despite relatively low consultant and hospital volumes, short-term clinical outcomes were excellent. Further work is required to ensure equity of access to VSRR across England.
Authors
Stuart Grant (1), Daniel Fudulu (2), Tim Dong (2), Cha Rajakaruna (2), Gianni Angelini (2), Enoch Akowuah (1), Tirone David (3)
Institutions
(1) South Tees NHS Hospitals Foundation Trust, United Kingdom, (2) Bristol Heart Institute, United Kingdom, (3) Toronto General Hospital, Toronto, ON
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Poster Presenter
Stuart Grant
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Bowdon
United Kingdom
Objective : More than 60 years after its first description, the Ross procedure has demonstrated its high durability and excellent long term results. However, due to the young age of the patients undergoing this procedure, reintervention after a Ross procedure is frequent.
In this study, we describe our experience in Redo surgery after a previous Ross procedure, focusing on valve-sparing root replacement (VSRR) and its durability.
Methods : We searched in our database all patients who were referred to a Redo surgery interessing the aortic root, after a previous Ross procedure, between January 2001 and November 2023. The indication could relate to the aortic or the pulmonary root. The attitude (changing the pulmonary homograft when surgery is performed for aortic dilatation and making a David procedure when surgery is indicated for pulmonary dehiscence) is supported by the natural history after a Ross procedure, meaning an aortic root dilatation (generating a left ventricular dysfunction) when the aortic root was not included during the first surgery, and a pulmonary dehiscence. The follow-up for all of them was provided by local cardiologists, including regular trans-thoracic echocardiography (TTE).
Results : From 1998 to 2023, 171 patients underwent a Ross procedure in our Hospital. Twenty-two of them needed a Redo surgery for aortic root dilatation or pulmonary root stenosis, with a planned gesture on the aortic root. Eleven underwent a mechanical valve implantation (Bentall procedure or Aortic Valve Replacement with Aortic tube), and 11 underwent a VSRR (David procedure).
In the population "VSRR procedure", four of them were indicated for surgery because of an aortic root dilatation with arctic valve regurgitation, six of them because of a pulmonary tube dehiscence with stenosis, and one of them for an infectious endocarditis on the pulmonary autograft. The mean age was 15,8 years (SD = 10,06 years). Mean follow up was 4,5 years. All of them underwent a David procedure associated with a changing of the pulmonary homograft.
The median aortic leak was ¾ when surgery was indicated for aortic dilatation and ¼ when surgery was indicated for pulmonary dehiscence.
Mean cross-clamp time was 173 minutes (SD = 31, 44) and mean cardiopulmonary bypass was 259 minutes (SD = 77,17).
The median ICU stay length was 4,5 days (IQR = 3,25 ; 7,25) and the median hospital stay length was 14 days (IQR = 7,5 ; 18,5).
Cumulative survival was 100% at hospital discharge, at 1 year, 2 years and 5 years.
Freedom from reoperation at hospital discharge was 90,9% (10/11), and equal at 1, 2 and 5 years.
No aortic valve regurgitation or aneurysmal dilatation of the aortic root was observed at hospital discharge or during the follow up, except for the one patient that underwent a new surgery (Mechanical Bentall procedure), after a diagnosis of infectious endocarditis on the aortic valve. One patient needed a catheterism for right coronary stenting because of a coronary compression.
Conclusion : David procedure seems to present good mid term-results when performed as a Redo after a Ross procedure. In our opinion, this should be performed for both aortic and pulmonary indication, to prevent a new short- or mid-term surgery for the patients, and especially before left ventricular dysfunction. This approach is, when feasible, supported by the youngness of this population.
Authors
Pierre FLORES (1), OLIVIER BARON (2), Pierre Maminirina (3), Mohamedou LY (4)
Institutions
(1) Service de Chirurgie Thoracique et Cardio-Vasculaire, CHU de Rennes, Rennes, France, (2) N/A, Nantes Cedex, France, (3) N/A, Nantes, France, (4) Department of Pediatric and Congenital Heart Disease, Marie Lannelongue Hospital, M3C, GHPSJ, Un, Le Plessis Robinson, FRANCE
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Poster Presenter
Pierre FLORES, CHU, Rennes, France
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Aucamville
France
Objective: The approach to aortic root replacement (ARR) is multifaceted and complex, with valve selection being an integral part of any decision. In cases where traditional mechanical composite valve grafts (CVG), which necessitates a lifelong anticoagulation and potential for related bleeding complications, may not align with patient-specific needs and lifestyle, the selection of a tissue-based prosthesis avoids anticoagulation but at the expense of structural valve degeneration and risk of reoperation. We described our 32-year experience with ARR using mechanical CVGs and bioprosthetic roots and compared outcomes.
Methods: After excluding patients with infection, acute/subacute aortic dissection, and rupture, we retrospectively evaluated data regarding 1149 ARRs performed (1991-2023) in a single practice. Repairs included 581 (51%) using a mechanical CVG, and 568 (49%) using a bioprosthetic root. Bioprosthetic root group included composite CVG-tissue (n=136), homograft (n=98), porcine bioroot (n=333), and Ross procedure (n=1). We evaluated usage trends by decade and compared outcomes of ARRs with mechanical and bioprosthetic valves.
Results: Trends in usage have shifted from our earliest to most recent decade, with the use mechanical CVGs becoming less common over time (from 175/192 [91.1%] in Decade 1 to 100/310 [32.3%] in Decade 4). Compared to patients with a bioprosthetic root, those with mechanical CVG were younger (median age, 46 [Q1-Q3:37-56] vs 60 [49-67] years; P<.001) and had lower rates of prior proximal aortic repair (22.5% vs 56.7%, P=.046), but higher rates of genetic disorder (30.6% vs 14.1%, P<.001) and chronic aortic dissection (16.0% vs 11.6%, P=.03). Patients with a bioprosthetic root had longer cardiopulmonary bypass (175 [145-216] vs 163 [137-200] min; P=.002) and aortic clamp (105 [87-133] vs 94 [81-114] min; P<.001) times. The incidence of redo sternotomy was high but comparable across both groups (mechanical: 34.9% vs bioprosthetic: 38.9%; P=0.163). Operative mortality was similar between groups (mechanical: 8.6% vs bioprosthetic: 11.3%; P=.1); however, patients with a bioprosthetic root had higher rates of renal failure necessitating dialysis at discharge (7.7% vs 3.6%, P=.002) and cardiac failure (20.2% vs 11.9%, P<.001). Unadjusted survival differed by type of valve replacement (mechanical: 66.5%±2.5 vs bioprosthetic: 59.3%±2.8 at 10 years; P=.005). Freedom from repair failure (including late valve dysfunction and other factors) differed between groups (mechanical: 95.6%±1.1 vs bioprosthetic: 89.1%±2.4 at 10 years; P<.001); this was related to operative survivors with bioprosthetic root having higher rates of late valve dysfunction as compared to those with mechanical CVG (n=24/504 [4.8%] vs n=2/531 [0.8%], P=<.001).
Conclusions: Valve selection in ARR remains dependent on patient-specific needs including lifestyle. Descriptively evaluating usage trends can inform the selection process, including awareness regarding longer intra-operative times when using bioprosthetic roots. Operative mortality is similar between groups, although renal and cardiac complication are more pronounced in patients undergoing bioprosthetic ARR. Although late aortic regurgitation is more common in bioprosthetic roots, transcatheter repair is increasingly being used to address these concerns.
Authors
Ahmad Tabatabaeishoorijeh (1), Lynna Nguyen (1), Veronica Glover (1), Ginger Etheridge (1), Susan Green (1), Subhasis Chatterjee (1), Marc Moon (1), Joseph Coselli (1)
Institutions
(1) Baylor College of Medicine/Texas Heart Institute, Houston, TX
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Poster Presenter
Ahmad Tabatabaeishoorijeh, Baylor College of Medicine/Texas Heart Institute
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Houston, TX
United States
Objective:
Aortic regurgitation (AR) is a common coexisting anomaly, present in about one-third of ruptured or unruptured sinus of Valsalva aneurysms (SVA), which is related to the asymmetrical aortectasis of the aneurysm's origin, dilation of the corresponding annulus, and prolapse of the corresponding cusp. Simple cusp repair may not lead to a satisfactory long-term outcome due to the continuous dilation of the affected sinus and corresponding annulus. Therefore, aortic valve replacement may be necessary. Our aim was to characterize an alternative surgical strategy for SVA with AR.
Methods: From July 2016 to Mar 2023, 51 patients of SVA underwent surgical repair in our center, of whom 16 patients (31.4%) were associated with AR (2+-4+). All 16 patients underwent reimplantation valve-sparing aortic root replacement (VSR) for the repair of SVA and AR. In 7 cases, the sac of SVA was transected, through which the aorta was dissected down to the level below the annulus. Part of the SVA wall was retained and sutured to the tubular Dacron graft along with the remaining aortic wall. In the other 9 cases, the aorta was dissected to the level just above the sac of SVA and the sac was kept intact. The interrupted horizontal mattress sutures at the site of SVA were passed from inside the left ventricular outflow tract immediately below the aortic valve, through the sac of SVA, to outside the sac of SVA. And SVA was closed when the graft was attached to the annulus by tying the horizontal mattress sutures. Abnormalities of cusp were corrected by multiple techniques, until all cusps located at the same level with a coaptaion height >3-5mm. Coexisting VSDs were repaired using a Dacron patch through an additional transverse incision of the pulmonary artery.
Results: No aortic valve replacement was performed. The median graft size was 26 (24-28) mm. The cardiopulmonary bypass and cross-clamping time were 121.4±15.4 and 97.6±12.3 mins. There were no in-hospital deaths. At discharge, residual AR of 1+ was present in 5 patients, while no AR was in the other 11 patients. Fourteen patients were followed-up for 6-87 months, and the freedom from AR >2+ was 100%.
Conclusions: VSR combined with cusp repair for SVA with AR can simultaneously correct the aortectasis of the sinus, dilatation of the annulus, and prolapse of the cusp. This surgical approach indicates excellent short-term outcomes and mid-term durability.
Authors
Tianxiang Gu (1), Enyi Shi (1)
Institutions
(1) 1st Hospital, China Medical University, Shenyang, Liaoning
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Poster Presenter
Tianxiang Gu, First Affiliated Hospital of China Medical University
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Shenyang, Liaoning
China
Objective: Valve-sparing root replacement (VSRR) has been shown to have excellent short- and long-term outcomes and is performed in a wide range of age into the 8th decade of life, although more often in young patients. The specific clinical factors that limit the advantages of a VSRR; however, has been understudied. This study analyzed the impact of age and preoperative comorbidities on reoperation and survival following VSRR.
Methods: From 2004-2021, in an academic database, 780 patients underwent VSRR. VSRR was performed using the David V reimplantation technique. The majority of VSRRs were performed with tailored straight tube grafts or Gelweave Valsalva graft. A discriminating age cut-off for the effect of age was determined by Contal and O'Quigley methods and patients were then divided into two groups based on age at time of surgery. Median follow-up time was 7.1 (3.3, 10.5) years with a follow-up index of 0.84.
Results: The optimal cut-off for age among patients undergoing VSRR was found to be 65 years. Sixteen percent of patients undergoing VSRR were ≥65 years at time of surgery. Overall, in-hospital mortality was 1.5% [12/780] and significantly higher among the ≥65 group (4.1% [5/123]vs 1.1% [7/657], p=0.03). The cumulative incidence of reoperation of the aortic valve or proximal aorta was similar between ≥65 and <65 groups (5% [95% CI: 2%, 10%] vs 6% [95% CI: 4%, 9%] p=0.28) and reoperative indications were similar between groups. Recurrence of moderate-severe aortic insufficiency was similar between ≥65 and <65 groups (14% [15/106] vs 11% [61/564], p=0.32). Overall, 10-year survival was 89% [95% CI: 85%, 91%] and significantly worse among the ≥65 group (76% [95% CI: 66%, 83%] vs 92% [95% CI: 88%, 94%], p<0.0001). Age ≥65 was an independent risk factor for late mortality (HR=5.28 [95% CI: 2.17, 12.8], p<0.001) as was longer cardiopulmonary bypass times (HR=1.01 [95% CI: 1.00, 1.02], p=0.04) and postoperative acute renal failure (HR=7.99 [95% CI: 2.24, 28.5], p<0.01).
Conclusion: Valve-sparing root replacement can be performed with low operative mortality and excellent freedom from reoperation across age groups. In patients ≥65 years old, however, aortic root replacement using a composite valve-graft conduit (ie: Bentall) should be considered due to the complexity of VSRR operations as well as worse short- and long-term survival outcomes.
Authors
Elizabeth Norton (1), Yanhua Wang (1), Parth Patel (1), Dov Levine (2), Jose Binongo (3), Bradley Leshnower (4), Hiroo Takayama (5), Edward Chen (6)
Institutions
(1) Emory University, Atlanta, GA, (2) Columbia University, New York, NY, (3) Emory Rollins School of Public Health, Atlanta, GA, (4) Emory University Hospital, Atlanta, GA, (5) NewYork- Presbyterian/Columbia University Medical Center, New York, NY, (6) Duke University Medical Center, Durham, NC
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Poster Presenter
Elizabeth Norton, Emory University School of Medicine
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Atlanta, GA
United States
Objective: With recent ACC/AHA guidelines for thoracic ascending aortic aneurysm (TAA) lowering the threshold for surgery, accurate and consistent means of measuring TAA are critical for clinical decision-making. This study aimed to evaluate the difference in manual, radiology reported vs. computer algorithm-assisted measurements of TAA on computerized tomography (CT) scans.
Methods: A retrospective analysis of 250 patients with a history of TAA who received their follow-up CT scans at our institution between 2010 and 2020 was completed. Exclusion criteria were patients <18 years of age, prior history of aortic repair, and scans for which the algorithm was used to generate the radiology report. TAA measurements included the sinus of Valsalva (SOV) and maximum ascending diameter (MAD). The iNtuition TeraRecon imaging platform with advanced visualization capacities was used to complete SOV and MAD algorithm-assisted measurements. These measurements were compared to the manual SOV and MAD from the patient chart review. Statistical analysis was employed to assess the agreement between the two methods. A paired t-test was done to compare the two groups. A bland-Altman plot was generated for both SOV and MAD.
Results: The algorithm-assisted measurements were significantly greater than the manual measurements by paired t-test. The two method's measurement for the SOV had a significant p-value of p< 0.01. Likewise, paired t-test of MAD measurements had a significant p-value of p < 0.01. Further analysis showed a bias of 3.1mm when taking the difference between the algorithm assisted and the manual measurements of the MAD. The bias when taking the contrast of the algorithm-assisted and manual measurements of the SOV was 1.6mm (Figure)
Conclusion: The utilization of a standard algorithm to measure the diameter of the TAA perpendicular to blood flow shows a significant variance, with an average upsizing of 1.6 mm for SOV and 3.1 mm for MAD. This variance can prove significant in clinical decision-making using the current ACC/AHA guidelines, as this advanced imaging platform could standardize TAA measurements to decrease inter-observer dependent variation in aneurysm measurements.
Authors
Samuel Ajamu (1), Abdulrhman Elnaggar (2), Anna Tarren (2), Jonathan Tomasko (3), Behzad Soleimani (4)
Institutions
(1) Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA, (2) Penn State College of Medicine, Hershey, PA, (3) N/A, Hershey, PA, (4) N/A, N/A
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Poster Presenter
Samuel Ajamu
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Hershey, PA
United States
【Objective】
Trainees have limited opportunities to gain surgical experience with acute type A aortic dissection (AAD) due to the high degree of urgency and high surgical mortality rate. Since 2017, our institution has introduced Adventitia Inversion + Interrupted Double Pledgetted Suture (AIDPS) for the distal anastomosis of hemiarch replacement (HAR) for AAD, and we have assigned young trainees to the AAD surgeon. We compared trainee's and senior surgeon's result.
【Method】
There were 238 cases of AAD surgery in our center between February 2017 and September 2023. we examined the surgical outcomes of 102 HAR cases in which distal anastomosis was performed with AIDPS.
As a general rule, distal anastomosis of HAR was performed under circulatory arrest at a rectal temperature of 25 Celsius degree. For cerebral protection, antegrade cerebral perfusion was given to one or two branches. The distal portion of the ascending aorta was trimmed leaving the adventitial side 1 cm longer than the intimal side, and anastomosed with interrupted sutures using 12 stitches of 4-0 Poly Vinylidene Fluoride with pledgets. First, 7 stitches were applied from the 3 o'clock direction to the 9 o'clock direction while inverting the adventitia on the native posterior wall side. These needles were placed on the posterior wall of the one branched graft. Next, lower this graft and five stitches were applied to the anterior wall from 10 o'clock to 2 o'clock. Subsequently, all stitches were tied circumferentially and the distal anastomosis was completed.
【Result】
The surgery was performed by Senior surgeon in 60 cases (S group) and by Trainee in 42 cases (T group). Surgical mortality was (S vs T = 3 cases, 5.0% vs 2 cases, 4.8% p=0.96). The mean time of circulatory arrest was (S vs T = 53.3 min vs 51.4 min p = 0.58), cerebral infarction (S vs T = 2 patients 3.3% vs 0 patients 0%, p = 0.51), and no re-operation for bleeding was observed. Distal Anastomosis induced New Entry was confirmed in 13 cases (12.7%)(S vs T = 6 cases, 10.0% vs 7 cases, 16.7% p=0.51). No significant difference was found in the 3-year survival rate (S vs T=85.9% vs 95.1%, p=0.19). There was no aorta-related deaths. 5 cases required additional aortic intervention(S vs T=4 vs 1).
【Conclusion】
Distal anastomosis of HAR for AAD using AIDPS was performed safely and reliably even when it was performed by trainees.
Authors
Takuya Fujikawa (1), Micky Wai Ting Kwok (2), Jacky Ho (3), Chi Ying Simon Chow (4), Kevin Lim (4), Song Wan (5), Randolph Wong (6)
Institutions
(1) Prince of Wales Hospital, Shatin, New Territory, (2) N/A, Hong Kong,, (3) Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NA, (4) N/A, N/A, (5) Prince of Wales Hospital, Hong Kong, Hong Kong, Hong Kong SAR, (6) Prince of Wales Hospital, N/A
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Poster Presenter
Takuya Fujikawa, Prince of Wales Hospital
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Shatin, New Territory