Objective To evaluate long-term results of aortic root procedures combined with ascending aorta replacement for aneurysms, using 4 surgical strategies. Methods From January 1995 to January 2011, 957 patients underwent 1 of 4 aortic root procedures: valve preservation (remodeling or modified reimplantation, n = 261); composite biologic graft (n = 297); composite mechanical graft (n = 156); or allograft root (n = 243). Results Seven deaths occurred (0.73%), none after valve-preserving procedures, and 13 strokes (1.4%). Composite grafts exhibited higher gradients than allografts or valve preservation, but the latter 2 exhibited more aortic regurgitation (2.7% biologic and 0% mechanical composite grafts vs 24% valve-preserving and 19%allografts at 10 years). Within 2 to 5 years, valve preservation exhibited the least left ventricular hypertrophy, allograft replacement the greatest; however, valve preservation had the highest early risk of reoperation, allograft replacement the lowest. Patients receiving allografts had the highest risk of late reoperation (P<05), and those receiving composite mechanical grafts and valve preservation had the lowest. Composite bioprosthesis patients had the highest risk of late death (57%at 15 years vs 14%-26%for the remaining procedures, P<.0001), because they were substantially older and had more comorbidities (P<.0001). Conclusions These 4 aortic root procedures, combined with ascending aorta replacement, provide excellent survival and good durability. Valve-preserving and allograft procedures have the lowest gradients and best ventricular remodeling, but they have more late regurgitation, and likely, less risk of valve-related complications, such as bleeding, hemorrhage, and endocarditis. Despite the early risk of reoperation, we recommend valve-preserving procedures for young patients when possible. Composite bioprostheses are preferable for the elderly.

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Radical resection and in situ reconstruction with CPA avoids placing prosthetic material in an infected field and provides good early and midterm outcomes. However, early postoperative imaging is necessary given the risk of pseudoaneurysm formation.

Key findings: A total of 4993 patients considered at high risk for renal complications (estimated glomerular filtration rate ¼ 15-44.9 mL/min/1.73 m 2 body surface area or 45-59.9 in diabetics) who were scheduled for coronary and noncoronary arteriography were randomly assigned to receive intravenous (IV) sodium bicarbonate or IV 0.9% sodium chloride (normal saline [NS]) and 5 days of oral acetylcysteine or oral placebo. The median volume of contrast material administered was 85 mL (range, 55-137 mL). Each of the four groups (bicarb + acetylcysteine; bicarb + placebo; NS + acetylcysteine; NS + placebo) suffered approximately a 4.5% incidence of composite death, need for dialysis, and persistent >50% increase in baseline serum creatinine (primary end point) at 90 days.Conclusion: Among patients at high risk for renal complications who underwent arteriography, there was no benefit of IV sodium bicarbonate vs IV normal saline or oral acetylcysteine vs. oral placebo to prevent death, dialysis, or persistent decline in kidney function at 90 days.Commentary: The periprocedural administration of IV NS has been the standard intervention to prevent acute kidney injury from contrast material during arteriography. Urinary alkalinization with IV bicarb and scavenging of reactive oxygen species using oral acetylcysteine may help prevent renal tubular epithelial-cell injury from the use of iodinated contrast material, but use of these agents has yielded inconsistent results. This study confirms that using good-old IV normal saline hydration without other adjuncts before, during, and after arteriography continues to be the best, and simplest, intervention to prevent kidney injury.