Root replacement in acute dissection type A—A superior procedure?

Schäfers, Hans‐Joachim

doi:10.1016/j.jtcvs.2017.09.038

Cited by 4 publications

(5 citation statements)

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“…These instances require more aggressive primary surgery, such as root replacement. 26 This is a generally accepted strategy for connective…”

Section: Discussionmentioning

confidence: 99%

“…These instances require more aggressive primary surgery, such as root replacement. 26 This is a generally accepted strategy for connective tissue disease, such as Marfan's syndrome 27 ; it may also apply to patients with preexistent root dilatation. 8 In these cases, primary aortic root replacement appears reasonable to decrease the potential risk of future proximal reoperation.…”

Section: Discussionmentioning

confidence: 99%

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Aortic Root Remodeling in Acute Aortic Dissection

Ehrlich

Karliova

Froede

et al. 2020

Thorac Cardiovasc Surg

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Objectives To evaluate the long-term results of remodeling in acute aortic dissection type A (AADA) to define operative risk and root and valve stability. Methods Between October 1995 and December 2018, a total of 352 patients were treated surgically for AADA. Of these, 90 patients with AADA (<2 weeks from onset; age: 57 ± 15 years; 70 males) with a root diameter of >43 to 45 mm (depending on patient size) (48 ± 4.1 mm) underwent aortic root remodeling and were analyzed further. As the control group, we chose the patients with normally sized aortic roots who had been treated by tubular replacement only (n = 227). Other procedures were performed in 35 cases. Results Early mortality was 9% in the remodeling group versus 15% in the tubular ascending aortic replacement (TAR). Actuarial survival at 10 and 15 years was 68 ± 5% and 58.3 ± 6.4%, respectively, in the root remodeling group versus 68 ± 4% and 66 ± 4% in the TAR group (p = 0.99). Freedom from reoperation on the aortic valve or root was 95 ± 3% at 10 years and at 89 ± 6% at 15 years. Freedom from proximal reoperation after TAR at 10 and 15 years was 93 ± 3% and 91 ± 3% (n = 31 patients at risk), respectively, not statistically different from that after remodeling (p = 0.75). Conclusions The long-term stability of aortic root remodeling for enlarged roots with AADA was comparable to TAR preserving a normal aortic root.

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“…These instances require more aggressive primary surgery, such as root replacement. 26 This is a generally accepted strategy for connective…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Aortic Root Remodeling in Acute Aortic Dissection

Ehrlich

Karliova

Froede

et al. 2020

Thorac Cardiovasc Surg

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“…The debate about the optimal approach to addressing the root in ATAD is analogous to the debate about arch extent. The conservative approach (root repair with reapproximation of the aortic wall, valve resuspension, and reconstruction of the sinotubular junction) is the most expeditious and reproducible in inexperienced hands but is least durable in the long-term (67,68). High volume centers have demonstrated that root replacement with prosthetic valve and valve sparing root replacement can safely be performed with excellent long-term outcomes (69)(70)(71)(72).…”

Section: Arch Extent and Proximal Repairmentioning

confidence: 99%

Cerebral protection in type A aortic dissection

Ghincea¹,

Aftab²,

Ikeno³

et al. 2021

J Vis Surg

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Acute type A aortic dissection (ATAD) carries extremely high morbidity and mortality with a significantly increased risk of cerebrovascular injury following repair compared to elective arch operations.Advancement in operative and neuroprotective strategies have led to a temporal improvement in outcomes, but the incidence of cerebrovascular injury remains high and warrants continued innovation. In the setting of ATAD, stroke can occur due to malperfusion resulting from true lumen compression and compromised cerebral inflow, malperfusion from cardiogenic shock, or embolization. Therefore, stroke mitigation strategies must address vascular obstructions, hemodynamic compromise, and reduce risk of embolization. This article reviews contemporary strategies for cerebral protection in ATAD including preoperative patient evaluation, perfusion and temperature management, extent of aortic repair, utility of cerebral oximetry and neuromonitoring, and pharmacological adjuncts. In summary, patients should be evaluated preoperatively with contrast imaging to fully characterize their dissection to facilitate well-informed operative planning.Cannulation for cardiopulmonary bypass (CPB) can be safely achieved through multiple routes, but should consider patient pathology and the intended approach to cerebral perfusion. Central cannulation is feasible in most patients and allows for the most expeditious initiation of CPB. Although both deep hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP) and moderate HCA with antegrade cerebral perfusion (ACP) have been shown to provide adequate cerebral protection, targeting moderate hypothermic temperatures reduces CPB times. The combination of a brief period of RCP followed by ACP during moderate HCA allows for the potential flushing of emboli from the cerebral arterial system with the superior metabolic protection of antegrade perfusion. The proximal and distal extent of arch repair should be individually tailored to patient pathology and surgeon experience, making sure to completely resect disease to prevent acute neurological complications. Cerebral oximetry and neuromonitoring are useful adjuncts, providing real-time information about the adequacy of neuroprotection. Finally, co-management by anesthesiologists and perfusionists with administration of neuroprotective agents, appropriate pH management, and maintenance of normal metabolic hemostasis and hemodynamic stability will further minimize cerebrovascular complications. Optimal cerebral protection requires a comprehensive, interdisciplinary approach and implementation of multimodal strategies.

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“…Proponents of aortic repair suggest that hospital mortality is of paramount importance and hence a more conservative repair may be preferrable in most cases. 4,17 However, it is increasingly been shown that more extensive root replacement techniques do not increase the risk of early mortality. [18][19][20][21] However, it must be borne in mind that most of these series are reported from high-volume centers and whether the results seen in these studies are reproducible at all institutions remain questionable.…”

mentioning

confidence: 99%

“…If it leads to a more durable repair, can increased early mortality be an acceptable trade‐off? Proponents of aortic repair suggest that hospital mortality is of paramount importance and hence a more conservative repair may be preferrable in most cases 4,17 . However, it is increasingly been shown that more extensive root replacement techniques do not increase the risk of early mortality 18–21 .…”

mentioning

confidence: 99%

To repair or replace‐the root dilemma in aortic dissections

Narayan

Angelini

2022

Journal of Cardiac Surgery

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Significant dilemma exists regarding the management of the aortic root pathology in acute aortic dissections. Several strategies for both repair and replacement exist and there is a lack of clarity on the superiority of one over the other. Important factors that influence management strategies include involvement of the sinuses, the competence of the aortic valve, the presence of Marfans syndrome, and connective tissue disorders, as well as availability of surgical expertise. The wide variability in these factors makes it unlikely for any one technique to be suitable for the management of all aortic roots pathology.

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Root replacement in acute dissection type A—A superior procedure?

Abstract: Primary root replacement repeatedly has been proposed for acute aortic dissection. Nonetheless, the need for reoperation after lessinvasive root procedures is low, at least over a 10-year period.

Cited by 4 publications

References 5 publications

Aortic Root Remodeling in Acute Aortic Dissection

Aortic Root Remodeling in Acute Aortic Dissection

Cerebral protection in type A aortic dissection

To repair or replace‐the root dilemma in aortic dissections

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