Valve-sparing root replacement in type A dissection: Age and experience matter

Levy, Gal; DeAnda, Abelardo

doi:10.1016/j.jtcvs.2018.10.043

Cited by 2 publications

(1 citation statement)

References 10 publications

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“…That being said, the most prudent approach is likely an individualized one that takes into account surgeon expertise, patient anatomy and pathology (presence of root entry tear, extent of root dissection, extent of valve disruption, root dilation, connective tissue disorder), and patient stability (73)(74)(75)(76).…”

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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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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The David Versus the Bentall Procedure for Acute Type A Aortic Dissection

Biancari,

Mastroiacovo,

Rinaldi

et al. 2024

JCDD

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Background: Type A aortic dissection (TAAD) is a life-threatening condition which requires prompt diagnosis and surgical treatment. When TAAD involves the aortic root, aortic valve-sparing or Bentall procedures are the main surgical treatment options. Method: The subjects of this analysis were 3735 patients included in the European Registry of Type A Aortic Dissection (ERTAAD). Propensity score matching was performed by estimating a propensity score from being treated with the Bentall or the David procedure using multilevel mixed-effects logistics, considering the cluster effect of the participating hospitals. Results: A Bentall procedure was performed in 862 patients, while a David operation was performed in 139 patients. The proportion of aortic root replacement, as well as the different techniques of aortic root replacement, varied significantly between the participating hospitals (p < 0.001). After propensity score matching, we obtained two groups of 115 patients each, and no statistical differences were reported in terms of postoperative outcomes, except for the rate of dialysis, which was higher in the patients requiring a Bentall procedure (17.4% vs. 7.0%, p-value 0.016). In the unmatched cohorts, the David procedure was associated with a lower 10-year mortality rate compared to the Bentall procedure (30.1% vs. 45.6%, p-value 0.004), but no difference was observed after matching (30.0% vs. 43.9%, p-value 0.082). After 10 years, no differences were observed in terms of proximal aortic reoperation (3.9% vs. 4.1%, p-value 0.954), even after propensity score matching (2.8% vs. 1.8%, p-value 0.994). Conclusions: The David and Bentall procedures are durable treatment methods for TAAD. When feasible, it is advisable that the David procedure is performed for acute TAAD by surgeons with experience with this demanding surgical technique.

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Valve-sparing root replacement in type A dissection: Age and experience matter

Abstract: Acute Stanford type A aortic dissection. Central MessageSurgical treatment of acute type A aortic dissection requires experience, and coupling this procedure with a complex valve-sparing operation increases the required expertise.

Cited by 2 publications

References 10 publications

Cerebral protection in type A aortic dissection

Cerebral protection in type A aortic dissection

The David Versus the Bentall Procedure for Acute Type A Aortic Dissection

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