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1.
Rita Karianna Milewski Andreas Habertheuer Joseph E. Bavaria Stephanie Fuller Nimesh D. Desai Wilson Y. Szeto Varun Korutla Prashanth Vallabhajosyula 《The Journal of thoracic and cardiovascular surgery》2019,157(2):714-725
Objective
Long-term outcomes of prosthetic aortic valve/root replacement in patients aged 30 years or younger are not well understood. We report our single institutional experience in this young cohort.Methods
From 1998 to 2016, 99 patients (age range, 16-30 years) underwent aortic valve replacement (n = 57), aortic valve replacement and supracoronary ascending aorta replacement (n = 6), or aortic root replacement (n = 36). A prospectively maintained aortic valve database was retrospectively reviewed to complete longitudinal functional and clinical data. Total follow-up was 493 patient years.Results
Surgical indications included primary stenosis/insufficiency (52% [n = 51]), Marfan syndrome (10% [n = 10]), and endocarditis (33.3% [n = 33]). Fifty-eight patients (59%) underwent mechanical valve replacement, with 41 patients (41%) receiving a biologic/bioprosthetic valve. Twenty-five patients underwent aortic valve reoperation after index procedure with following indications: prosthesis–patient mismatch 1.0% (n = 1), prosthetic valve degeneration/dysfunction 10% (n = 10), connective tissue 2% (n = 2), and endocarditis 12% (n = 12). Mortality (30-day/in-hospital) and stroke rate were 3.0% (n = 3) and 1% (n = 1), respectively. One-, 5-, and 10-year actuarial freedom from aortic valve reoperation by valve type was 89.1%, 84.6%, and 69.4% for the Mechanical Valve group and 89.6%, 70.9%, and 57.6% for the Biologic/Bioprosthetic Valve group, respectively (log rank P = .279). Replacement valve size ≤21 mm was a significant risk factor for reoperation, and was associated with progression of mean aortic valve transvalvular gradients over follow-up. Valve type had no effect.Conclusions
The choice of mechanical versus biologic/bioprosthetic valve does not affect freedom from reoperation or survival rates in this young cohort during mid- to long-term follow-up. Smaller aortic valve replacement size (≤21 mm) is a significant risk factor for reoperation and progression of mean aortic valve gradients. 相似文献2.
Peter Chiu Jeffrey Trojan Sarah Tsou Andrew B. Goldstone Y. Joseph Woo Michael P. Fischbein 《The Journal of thoracic and cardiovascular surgery》2018,155(1):1-7.e1
Objective
Management of the aortic root is a challenge for surgeons treating acute type A aortic dissection.Methods
We performed a retrospective review of the acute type A aortic dissection experience at Stanford Hospital between 2005 and 2015 and identified patients who underwent either limited root repair or aortic root replacement. Differences in baseline characteristics were balanced with inverse probability weighting to estimate the average treatment effect on the controls. Weighted logistic regression was used to evaluate in-hospital mortality. Weighted Cox proportional hazards regression was used to evaluate differences in the hazard for mid-term death. Reoperation was evaluated with death as a competing risk with the Fine-Gray subdistribution hazard.Results
After we excluded patients managed either nonoperatively or with definitive endovascular repair, there were 293 patients without connective tissue disease who underwent either limited root repair or aortic root replacement. There was no difference in weighted perioperative mortality, odds ratio 0.89 (95% confidence interval [CI], 0.44-1.76, P = .7), and there was no difference in weighted survival, hazard ratio 1.12 (95% CI, 0.54-2.31, P = .8). Risk of reoperation was greater in limited root repair (11.8%, 95% CI, 0.0%-23.8%) than for root replacement (0%), P < .001.Conclusions
Limited root repair was associated with increased risk of late reoperation after repair of acute type A aortic dissection. Surgeons with adequate experience may consider aortic root replacement in well-selected patients. However, given good outcomes after limited root repair, surgeons should not feel compelled to perform this more-complex operation. 相似文献3.
Hoda Javadikasgari Eric E. Roselli Muhammad Aftab Rakesh M. Suri Milind Y. Desai Mitra Khosravi Frank Cikach Monica Isabella Jay J. Idrees Sajjad Raza Bassman Tappuni Brian P. Griffin Lars G. Svensson A. Marc Gillinov 《The Journal of thoracic and cardiovascular surgery》2017,153(5):1023-1030.e1
Objectives
Coexisting aortic root and mitral valve pathology is increasingly recognized among patients undergoing surgery. We characterized the pathology and surgical outcomes of patients with combined aortic root and mitral disease.Methods
From 1987 to 2016, 118 patients (age 52.40 ± 17.71 years) underwent concomitant aortic root and mitral procedures (excluding aortic stenosis, endocarditis, and reoperations). Aortic root pathologies included degenerative aneurysm (94%) and aortic dissection (6%). The aortic valve was bicuspid in 15% of patients and had normally functioning tricuspid leaflets in 23% of patients. Marfan syndrome was present in 34 patients (29%). Degenerative mitral disease predominated (78%). Mitral procedures were repair (86%) and replacement (14%), and root procedures were valve-preserving root reimplantation (36%), Bentall procedure (47%), and homograft root replacement (17%). In the last 10 years, the combination of valve-preserving root reimplantation and mitral repair has increased to 50%. Kaplan–Meier and competing risk analyses were used to estimate survival and reoperation.Results
There were 2 (1.7%) operative deaths with survival of 79% and 71% at 10 and 15 years, respectively, and reoperation rates of 4.7% and 12% after 5 and 10 years, respectively. There were no operative deaths in patients with combined valve-preserving root reimplantation and mitral repair, with survival of 89% and reoperation rate of 7.8% at 10 years. Among patients with Bentall/homograft and mitral operation, survival was 73% and reoperation was 9.8% at 10 years.Conclusions
In patients with aortic root and mitral pathology, combined surgical risk is low and valve durability is high. When possible, valve-preserving root reimplantation and mitral repair should be considered to avoid prosthesis degeneration, anticoagulation, and lifestyle limitations. 相似文献4.
Tirone E. David Maral Ouzounian Carolyn M. David Myriam Lafreniere-Roula Cedric Manlhiot 《The Journal of thoracic and cardiovascular surgery》2019,157(1):201-208
Objective
The study objective was to examine the long-term results of the Ross procedure in a cohort of patients followed prospectively for more than 2 decades.Methods
From 1990 to 2004, 212 consecutive patients with a median age (interquartile range) of 34 years (28-41) underwent the Ross procedure; 82% had congenital aortic valve disease. The technique of aortic root replacement was used in one half of the patients. Patients have been followed prospectively for a median (interquartile range) of 18.0 (14.6-21.2) years. Valve function was assessed by echocardiography.Results
Cumulative mortality at 20 years was 10.8% (95% confidence interval, 6.5-17.8). Thirty patients required Ross-related reoperations and 3 for coronary artery disease. The cumulative probability of Ross-related reoperations at 20 years was 16.8% (95% confidence interval, 11.3-24.5), on the pulmonary autograft was 11.5% (95% confidence interval, 7.2-18.0), and on the pulmonary homograft was 8.2% (4.6-14.7). The implantation technique was not associated with the cumulative incidence of reoperations on the pulmonary autograft. The development of moderate or severe aortic insufficiency and pulmonary homograft dysfunction increased with time. At 20 years, the probability of aortic insufficiency was 13% (95% confidence interval, 8.0-20.3) and of pulmonary homograft dysfunction was 19.7% (95% confidence interval, 13.9-27.2). Preoperative aortic insufficiency was associated with increased odds of postoperative aortic insufficiency.Conclusions
The long-term results of the Ross procedure are excellent regardless of the implantation technique, but there is a progressive deterioration of function of both semilunar valves. 相似文献5.
Joshua M. Rosenblum Bradley G. Leshnower Rena C. Moon Yi Lasanajak Jose Binongo LaRonica McPherson Edward P. Chen 《The Journal of thoracic and cardiovascular surgery》2019,157(1):14-23.e1
Background
Valve-sparing root replacement (VSRR) is an attractive option in type A aortic dissection (TAAD) repair for a young patient with normal cusp anatomy, but conventional root replacement using a composite valved-conduit (ROOT) remains the gold standard in this emergent clinical setting. We examine the long-term safety and durability of the David V VSRR compared with ROOT in TAAD repair.Methods
From March 2004 to April 2017, 136 patients underwent repair of acute TAAD using either ROOT (n = 77; 56.6%) or VSRR (n = 59; 43.4%). Annual echocardiograms were performed for follow-up in VSRR patients. Univariable regression, Kaplan–Meier, and competing risk analyses were performed.Results
Preoperative characteristics were similar between groups, except that VSRR patients were younger (mean age 43.5 ± 11.4 years VSRR vs 50.4 ± 3.0 years ROOT; P = .001). Both groups had similar rates of preoperative malperfusion or shock (29.3% VSRR vs 37.0% ROOT; P = .35) and ≥3+ aortic insufficiency (63% VSRR vs 76.8% ROOT). Thirty-day mortality in the VSRR group was 2/59 (3.4%) and 11/77 in the ROOT group (14.3%; P < .001). All-cause survival at 9 years was 92% (VSRR) and 59% (ROOT; P = .002). The incidence of aortic reintervention was similar between groups (20%-23% at 5 years; P = .81). At 9 years of follow-up, 5/52 (9.6%) VSRR patients had ≥2+ aortic insufficiency, and 1 patient required valve reintervention.Conclusions
In highly-selected patients, the David V VSRR provides a safe repair of acute TAAD with concomitant root pathology and valve insufficiency. In our center, the incidence of valve-related reintervention at long-term follow-up is low after emergent repair. 相似文献6.
Ourania Preventza Joseph S. Coselli Andrea Garcia Shahab Akvan Sarang Kashyap Katherine H. Simpson Matt D. Price Kim I. de la Cruz Konstantinos Spiliotopoulos Lorraine D. Cornwell Faisal G. Bakaeen Shuab Omer Denton A. Cooley 《The Journal of thoracic and cardiovascular surgery》2017,153(3):511-518
Objective
Little is known about the outcomes of aortic root operations that involve inducing hypothermic circulatory arrest for relatively extensive proximal aortic surgery. We attempted to identify predictors of postoperative hospital length of stay (LOS) and factors that affect postoperative recovery.Methods
During 2006-2014, 247 of 265 patients (93.2%) with disease extending into the aortic arch survived aortic root operations (206 elective, 41 urgent/emergent) in which hypothermic circulatory arrest with moderate hypothermia was used. Stepwise multivariate regression analysis was performed to identify predictors of LOS (as a continuous variable) and prolonged LOS (defined as LOS >9 days, the median for the cohort). By this definition, 111 patients (45%) had prolonged LOS and 136 (55%) did not.Results
Preoperative factors that independently predicted longer LOS in the entire cohort included age (P = .0014), redo sternotomy (P = .0047), and intraoperative packed red blood cell (PRBC) transfusion (P = .0007). Redo sternotomy and intraoperative PRBC transfusion also predicted longer LOS in 3 subgroup analyses: one of elective cases, one from which total arch replacement procedures were excluded, and one limited to patients who were discharged home. Age predicted longer LOS in the non-total arch (hemiarch) replacement patients. Ventilator support >48 hours (P < .0001) was associated with longer LOS. Elective aortic valve?sparing root replacement predicted a shorter LOS than valve replacement in multivariate regression analysis (P = .028).Conclusions
In patients undergoing aortic root surgery with hypothermic circulatory arrest for disease extending into the aortic arch, reducing intraoperative PRBC transfusion except when absolutely necessary may reduce postoperative LOS and expedite recovery. Performing aortic valve–sparing root replacement, when feasible, may also reduce LOS. 相似文献7.
Scott Johnson Martha R. Stroud John M. Kratz Scott M. Bradley Fred A. Crawford John S. Ikonomidis 《The Journal of thoracic and cardiovascular surgery》2019,157(1):213-222
Background
The objective was to evaluate the long-term outcomes of the St Jude Medical (Saint Paul, Minn) mechanical valve prosthesis implantation.Methods
Since 1979, every patient receiving this prosthesis has been followed annually.Results
From January 1979 to December 2014, 1023 patients were accrued. Patients' ages ranged from 18 to 85 years. Aortic valve replacement was performed in 584 patients, and mitral valve replacement was performed in 439 patients. Follow-up was 95% complete. Operative mortality was 3% (17/584, aortic valve replacement) and 4% (18/439, mitral valve replacement). In patients undergoing aortic valve replacement, late actuarial survival was 62% ± 2%, 32% ± 2%, and 14% ± 3% at 10, 20, and 30 years, respectively. Thirty-year freedom from reoperation, thromboembolism, valve thrombosis, bleeding, and endocarditis was 92% ± 2%, 79% ± 3%, 96% ± 1%, 56% ± 5%, and 92% ± 2%, respectively. In patients undergoing mitral valve replacement, late actuarial survival was 64% ± 3%, 28% ± 3%, and 14% ± 3% at 10, 20, and 30 years, respectively. Thirty-year freedom from reoperation, thromboembolism, valve thrombosis, bleeding, and endocarditis was 85% ± 5%, 55% ± 6%, 99% ± 1%, 57% ± 6%, and 95% ± 2%, respectively. The incidence of bleeding was 2.5% and 2.0% per patient-year for aortic valve replacement and mitral valve replacement, respectively. The incidence of thromboembolism was 1.6% and 2.9% per patient-year for aortic valve replacement and mitral valve replacement, respectively.Conclusions
Annual follow-up of all of our patients receiving a St Jude Medical mechanical valves prosthesis has allowed better identification valve-related issues and events. After 3 decades of observation with close follow-up, the St Jude Medical mechanical valve continues to be a reliable prosthesis. 相似文献8.
James C. Witten Syed T. Hussain Nabin K. Shrestha Steven M. Gordon Penny L. Houghtaling Faisal G. Bakaeen Brian Griffin Eugene H. Blackstone Gösta B. Pettersson 《The Journal of thoracic and cardiovascular surgery》2019,157(4):1418-1427.e14
Objective
Right-sided infective endocarditis is increasing because of increasing prevalence of predisposing conditions, and the role and outcomes of surgery are unclear. We therefore investigated the surgical outcomes for right-sided infective endocarditis.Methods
From January 2002 to January 2015, 134 adults underwent surgery for right-sided infective endocarditis. Patients were grouped according to predisposing condition. Hospital outcomes, time-related death, and reoperation for infective endocarditis were analyzed.Results
A total of 127 patients (95%) had tricuspid valve and 7 patients (5%) pulmonary valve infective endocarditis; 66 patients (49%) had isolated right-sided infective endocarditis, and 68 patients (51%) had right- and left-sided infective endocarditis. Predisposing conditions included injection drug use (30%), cardiac implantable devices (26%), chronic vascular access (19%), and other/none (25%). One native tricuspid valve was excised, 76% were repaired or reconstructed, and 23% were replaced. Intensive care unit and postoperative hospital stays were similar among groups. Injection drug users had the best early survival (no hospital mortality), and patients with chronic vascular access had the worst late survival (18% at 5 years). Survival was worst for concomitant mitral valve versus isolated right-sided infective endocarditis or concomitant aortic valve infective endocarditis. Survival after tricuspid valve replacement was worse than after repair/reconstruction. Estimated glomerular filtration rate was the strongest risk factor for death, not predisposing condition. Eleven patients underwent 12 reoperations for infective endocarditis; more reoperations occurred in injection drug users (P = .03).Conclusions
Overall outcomes after surgery are variable and affected by patient condition, not predisposing condition. Injection drug use carries a higher risk of reoperation for infective endocarditis. Earlier surgery may permit more valve repairs and improve outcomes. Whenever possible, tricuspid valve replacement should be avoided. 相似文献9.
Ulrich Schneider Susanne K. Feldner Christopher Hofmann Jakob Schöpe Stefan Wagenpfeil Christian Giebels Hans-Joachim Schäfers 《The Journal of thoracic and cardiovascular surgery》2017,153(4):S65-S71
Objective
Bicuspid aortic valve anatomy is associated with ascending aortic aneurysm in approximately 50% of individuals and may lead to severe aortic regurgitation with aortic dilatation. Both entities may be treated by valve repair and root remodeling. The objective was to review the cumulative experience of 20 years.Methods
Between November 1995 and December 2015, 357 patients (324 male; age 10-80 years; mean, 49 ± 13 years) underwent combined bicuspid aortic valve repair and root remodeling. Aortic regurgitation was relevant in 265 cases; the main indications for surgery were aortic regurgitation (n = 241), aortic aneurysm (n = 102), and acute dissection (n = 9). In 225 instances, a suture annuloplasty was added. Cusp calcification was present beyond the raphe in 52 cases, and an autologous pericardial patch was implanted for partial cusp replacement in 39 cases. All patients were followed. Follow-up was 97.8% complete with a mean of 57 ± 51 months (median, 39 months).Results
Two patients died (hospital mortality 0.6%), and survival at 15 years was 81%. Reoperation became necessary for recurrent aortic regurgitation in 24 patients; 6 patients underwent reoperation for stenosis. Cumulative incidence of reoperation at 15 years was 21.7%. Cusp calcification and the use of a pericardial patch for cusp reconstruction were associated with time to reoperation (P = .002).Conclusions
Repair of the bicuspid aortic valve combined with root remodeling leads to excellent 10- and 15-year results. Cusp calcification and the need for partial cusp replacement are associated with valve failure. 相似文献10.
Paul P. Urbanski Atanas Jankulowski Aleksandra Morka Vadim Irimie Xiaochun Zhan Michael Zacher Anno Diegeler 《The Journal of thoracic and cardiovascular surgery》2018,155(1):43-51.e1
Objective
The aim of the study was to evaluate the operative and functional results after individual, patient-tailored aortic root repair in marfanoid patients.Methods
Among 518 patients who underwent operation between 2002 and January 2016, using patient-tailored aortic root repair with isolated sinus replacement, 42 patients fulfilled the original Ghent criteria. None/trivial, mild, moderate, and severe insufficiency grades were present in 5, 16, 10, and 11 patients, respectively.Results
The repair was adjusted to the existing aortic annulus diameter. Replacement of 1, 2, or 3 sinuses of Valsalva was performed in 1, 14, and 27 patients, respectively. Concomitant cusp repair was performed in 17 patients (40.5%), and 10 patients (23.8%) underwent arch repair (total in 3). All patients survived surgery, and the follow-up (mean, 6.1 ± 3.1; range, 0.8-14.2 years) was 100% complete. No patient had a change in the form or size of the aortic neo-root, especially the size of aortic annulus and sinotubular junction during the follow-up time. No and trivial/mild insufficiency were present in 22 and 18 patients, respectively, and 2 patients with recurrent aortic insufficiency caused by cusp pathology underwent aortic valve replacement 43 and 66 months after the primary surgery, respectively. Thus, the estimated survival free from aortic valve/root reoperation for any reason at 5 and 8 years was 96.8% ± 3.2% and 91.4% ± 6.0%, respectively.Conclusions
Patient-tailored root repair using isolated sinus replacement is an effective and durable method of valve-sparing repair in select marfanoid patients with a satisfactory quality of aortic cusps, which seems to be decisive for long-term valve function. 相似文献11.
Shigeyuki Ozaki Isamu Kawase Hiromasa Yamashita Shin Uchida Mikio Takatoh Nagaki Kiyohara 《The Journal of thoracic and cardiovascular surgery》2018,155(6):2379-2387
Objective
We had previously reported the short-term results of the aortic valve neocuspidization (AVNeo) procedure. We have now evaluated the midterm results with the longest follow-up of 118 months.Methods
From April 2007 through December 2015, 850 patients were treated with AVNeo using autologous pericardium. Medical records of these patients were retrospectively reviewed. The procedure was on the basis of independent tricuspid replacement using autologous pericardium. The distances between the commissures were measured with an original sizing device, the pericardial cusp was trimmed using an original template, and then sutured to the annulus.Results
There were 534 patients with aortic stenosis, 254 with aortic regurgitation, 61 with aortic stenoregurgitation, 19 with infective endocarditis, and 5 with a previous aortic valve procedure. Besides 596 patients with tricuspid aortic valve, 224 patients had bicuspid valve, 28 had unicuspid valve, and 2 had quadricuspid valve. There were 444 male and 406 female patients. The median age was 71 (range, 13-90) years old. Preoperative echocardiography revealed a peak pressure gradient average of 68.9 ± 36.3 mm Hg with aortic stenosis. Surgical annular diameter was 20.9 ± 3.3 mm. There was no conversion to a prosthetic valve replacement. There were 16 in-hospital mortalities. Postoperative echocardiography revealed a peak pressure gradient average of 19.5 ± 10.3 mm Hg 1 week after surgery and 15.2 ± 6.3 mm Hg 8 years after surgery. Fifteen patients needed reoperation (13 infective endocarditis, 1 break of thread, and 1 tear of cusp case). The mean follow-up period was 53.7 ± 28.2 months. Actuarial freedom from death, cumulative incidence of reoperation, and that of recurrent moderate aortic regurgitation or greater was 85.9%, 4.2%, and 7.3%, respectively, with the longest follow-up of 118 months.Conclusions
The midterm outcomes of AVNeo using autologous pericardium were satisfactory in 850 patients with various aortic valve diseases. However, further randomized, multicenter prospective studies are needed to confirm the results of the current study. 相似文献12.
Bo Yang Aroosa Malik Victoria Waidley Kellianne C. Kleeman Xiaoting Wu Elizabeth L. Norton David M. Williams Minhaj S. Khaja Whitney E. Hornsby 《The Journal of thoracic and cardiovascular surgery》2018,155(4):1360-1370.e1
Objective
To evaluate short-term outcomes following direct aortic root and arch repair in patients with acute type A aortic dissection (ATAAD) without technical adjuncts.Methods
Between 2012 and 2016, 94 consecutive patients with ATAAD underwent surgical repair, including aortic root repair (n = 45), root replacement (n = 39), or no root procedure (n = 10). Aortic root repair was achieved by running approximation of the dissected aortic wall circumferentially at the sinotubular junction and reinforcing the coronary ostia with 5-0 Prolene. The aortic root and arch were anastomosed to the Dacron graft with 5-0 Prolene without Teflon felt or biological glue.Results
Postoperative new-onset myocardial infarction, stroke, renal failure, and complete heart block occurred in 0%, 4%, 13%, and 0% of patients, respectively, whereas 30-day mortality was 4%. The incidences of permanent neurologic deficit and renal failure were 1% and 2%, respectively. Up to 5 years, the aortic root repair group was free from residual or recurrent aortic root dissection, major change in the aortic root diameter, and moderate to severe aortic regurgitation; the entire cohort was free of anastomotic pseudoaneurysm and reoperation for proximal aortic pathology or significant change in diameter of the aortic arch and descending thoracic aorta. Overall survival was 85% at 4 years and was significantly enhanced in the aortic root repair group compared with the Bentall group (n = 24) (93% vs 57%; P = .035).Conclusions
Direct aortic root and arch repair with approximation of the aortic wall without use of technical adjuncts is safe and effective for patients with ATAAD. If warranted, preservation of the native aortic valve should be considered for a potential survival benefit. 相似文献13.
Yuki Ikeno Koki Yokawa Takashi Matsueda Katsuhiro Yamanaka Takeshi Inoue Hiroshi Tanaka Yutaka Okita 《The Journal of thoracic and cardiovascular surgery》2019,157(1):75-85.e3
Objective
Our study evaluated the long-term outcomes of total arch replacement using a 4-branched graft.Methods
From October 1999 to December 2016, 655 patients underwent total arch replacement using a 4-branched graft (pathology in the 655 patients was distributed as 399 no dissection, 149 acute dissection, and 107 chronic dissection). Two hundred nine patients (31.9%) underwent nonelective surgery. Mean follow-up term was 5.0 ± 4.1 years and follow-up rate was 97.1%.Results
Of 655 patients who underwent total arch replacement using a 4-branched graft, operative mortality occurred in 34 patients (5.2%) and permanent neurologic deficit occurred in 24 patients (3.7%). One hundred ninety late deaths occurred, with 20 aortic event-related deaths. Overall survival was 73.1% ± 1.9% at 5 years and 54.8% ± 2.7% at 10 years. Multivariate Cox-hazard regression analysis demonstrated that older age, lower estimated glomerular filtration rate, concurrent procedures, permanent neurologic deficit, tracheostomy, and renal failure were significant risk factors for late death. Freedom from repeat operation on the aorta was 98.0% ± 0.7% at 5 years and 93.9% ± 1.8% at 10 years and freedom from additional aortic operation was 87.2% ± 1.5% at 5 years and 77.3% ± 2.7% at 10 years. The incidence of pseudoaneursym was 2.2%.Conclusions
The long-term outcomes for patients undergoing total arch replacement using 4-branched graft are favorable. However, even in the late phase, periodic follow-up is necessary to address subsequent aorta-related events. 相似文献14.
Kenji Minatoya Yosuke Inoue Hiroaki Sasaki Hiroshi Tanaka Yoshimasa Seike Tatsuya Oda Atsushi Omura Yutaka Iba Hitoshi Ogino Junjiro Kobayashi 《The Journal of thoracic and cardiovascular surgery》2019,157(4):1370-1378
Objective
Total arch replacement (TAR) is an established standard surgical procedure. We report >1000 cases of TAR using a 4-branched graft with antegrade cerebral perfusion (ACP) during a 15-year period.Methods
Since May 2001, 1005 patients who underwent total aortic replacement (mean age 69.8 ± 11.2 years; range, 9-92 years; 744 male) underwent TAR with a 4-branched graft. All surgeries were performed under hypothermia with ACP. There were 252 emergent operations for acute aortic dissection or aneurysm rupture. Concomitant operations included coronary arterial bypass grafting in 196 patients, aortic valve repair or replacement in 64, and aortic root replacements in 38.Results
The operation time was 482 ± 171 minutes, cardiopulmonary time was 254 ± 94 minutes, cardiac ischemia time was 145 ± 51 minutes, ACP time was 160 ± 47 minutes, and lower body circulatory arrest time was 62 ± 16 minutes. The hospital mortality rate was 5.2%. The permanent neurological dysfunction rate was 3.6% and temporary neurological dysfunction rate was 6.4%. There were no spinal cord complications. The 5-year survival rate was 80.7% and 10-year survival rate was 63.1%. Fifteen patients (1.5%) underwent reoperation for the arch grafts because of a pseudoaneurysm (11 patients), hemolysis (3 patients), and infection (1 patient).Conclusions
TAR using a 4-branched graft with ACP could be accomplished with acceptable short- and long-term results. 相似文献15.
Thomas Sénage Florence Gillaizeau Thierry Le Tourneau Basile Marie Jean-Christian Roussel Yohann Foucher 《The Journal of thoracic and cardiovascular surgery》2019,157(4):1383-1390.e5
Objectives
Structural valve deterioration (SVD) remains a major bioprosthesis-related complication, as recently described for the Mitroflow valve (models LX and 12A) (LivaNova, London, United Kingdom). The real incidence of the SVD risk remains unclear, often due to methodologic pitfalls by systematically using the Kaplan-Meier estimator and/or the Cox model. In this report, we propose for the first time a precise statistical modeling of this issue.Methods
Five hundred sixty-one patients who underwent aortic valve replacement with the aortic Mitroflow valve between 2002 and 2007 were included. We used an illness–death model for interval-censored data. Median follow-up was 6.6 years; 103 cases of SVD were diagnosed.Results
The 4-year and 7-year SVD cumulative incidences after the first anniversary of surgery were 15.2% (95% confidence interval, 11.9-19.1) and 31.0% (95% confidence interval, 25.8-37.2), respectively. Female gender, dyslipidemia, chronic obstructive pulmonary disease, and severe patient-prosthesis mismatch were significant risk factors of SVD. The occurrence of SVD was associated with a 2-fold increase in the risk of death.Conclusions
Appropriate statistical models should be used to avoid underestimating the SVD complication associated with worse long-term survival. 相似文献16.
Yue Xuan Danny Dvir Zhongjie Wang Trek Mizoguchi Jian Ye Julius M. Guccione Liang Ge Elaine E. Tseng 《The Journal of thoracic and cardiovascular surgery》2019,157(2):528-536
Objectives
Transcatheter aortic valve replacement has proven successful in treating intermediate-risk, high-risk, and inoperable patients with severe aortic stenosis. Third-generation, balloon-expandable transcatheter aortic valves were developed with an outer sealing skirt to reduce paravalvular leakage. As transcatheter aortic valve replacement use expands, long-term durability questions remain. Valve design influences durability, where regions of increased leaflet stress are vulnerable to early degeneration. However, third-generation transcatheter aortic valve stresses are unknown. Our goals were to determine the stent and leaflet stresses of third-generation, balloon-expandable transcatheter aortic valves.Methods
The commercial 26-mm Edwards SAPIEN 3 valve (Edwards Lifesciences, Inc, Irvine, Calif) underwent high-resolution micro-computed tomography scanning to develop a precise 3-dimensional geometric mesh of the stent and valve. Leaflet material properties were obtained from surgical bioprostheses, and stent material properties were based on cobalt-chromium. Simulations of systemic pressure loading were performed, and stress was calculated using finite element analyses.Results
At diastole, maximum and minimum principal stresses on transcatheter aortic valve leaflets were 2.7 MPa and ?0.47 MPa, respectively. Peak leaflet stresses were observed at upper leaflet commissures, at their connection to the stent. Maximum and minimum principal stresses for the stent were 38.2 MPa and ?44.4 MPa, respectively, at 80 mm Hg and were located just below the commissural stent.Conclusions
Stress analysis of the 26-mm SAPIEN 3 valve using exact geometry from high-resolution scans demonstrated that peak stresses for both transcatheter aortic valve stent and leaflets were present at commissural tips where leaflets were attached. These regions would be most likely to initiate degeneration. The Dacron skirt had minimal effect on stresses on leaflets and stent. 相似文献17.
Ourania Preventza Joseph S. Coselli Matt D. Price Katherine H. Simpson Ouyang Yafei Kim I. de la Cruz Qianzi Zhang Susan Green 《The Journal of thoracic and cardiovascular surgery》2017,153(6):1402-1408
Objective
Excellent outcomes have been established for elective aortic root replacement (ARR). It is less clear whether extending the repair into the proximal aortic arch with hypothermic circulatory arrest increases risk. We examined the early outcomes of elective, primary ARR, with and without hemiarch replacement, in patients without previous cardiac surgery.Methods
Over a 4-year period, 140 non-redo patients (median age, 54 years) underwent elective, primary ARR for root aneurysms; 119 patients (85%) had hemiarch replacement, and 21 (15%) had only ascending aortic replacement. Valve-sparing ARR was performed in 41 cases (29.3%) and valve-replacing ARR in 99 (70.7%). Moderate hypothermic circulatory arrest and antegrade cerebral perfusion were used in 118 (99%) hemiarch repairs.Results
There were no operative deaths or permanent strokes. Complications included temporary renal dialysis (n = 1; 4.8%), transient neurologic deficit (n = 2; 9.5%), and tracheostomy (n = 2; 9.5%) after ascending aortic repair and bleeding requiring reoperation (n = 4; 3.4%), pericardial effusion requiring drainage (n = 9; 7.6%), and tracheostomy (n = 2; 1.7%) after hemiarch replacement. No stroke was observed in the hemiarch group (P = .022; univariate analysis). The extent of the repair into the proximal arch did not appear to be associated with any adverse effect.Conclusions
In non-redo patients, elective primary ARR has excellent early outcomes, regardless of whether repair extends into the proximal arch. Additional elective hemiarch replacement with moderate hypothermic circulatory arrest and antegrade cerebral perfusion has a low risk of neurologic complications and should be performed if necessary. Long-term data are needed to compare the rates of reintervention in the aortic arch in patients with or without proximal arch replacement. 相似文献18.
Ravil Sharifulin Alexander Bogachev-Prokophiev Sergey Zheleznev Igor Demin Alexey Pivkin Alexander Afanasyev Alexander Karaskov 《The Journal of thoracic and cardiovascular surgery》2019,157(1):134-141.e3
Objective
Although the Ross procedure provides excellent long-term survival and a high quality of life, its use has been limited to relatively few centers. In this study, we evaluated long-term Ross procedure results in adults to assess the predictors of pulmonary autograft durability.Methods
Between 1998 and 2015, 793 consecutive adult patients underwent the Ross procedure. The total root replacement technique was used in all patients.Results
The early mortality rate was 2.9%. The mean follow-up duration was 6.5 ± 3.2 years, and the 10-year survival rate was 90.4%. Longitudinal mixed-effects ordinal regression identified a combination of bicuspid aortic valve and aortic insufficiency (odds ratio, 2.19; P < .001) as predictors for progression of autograft valve insufficiency at follow-up. The cumulative incidence of autograft reoperations at 10 years was 8.6%. Competing risk regression identified bicuspid aortic valve insufficiency as the independent predictor of autograft reoperation (subdistribution hazard ratio, 2.16; P = .030). Moreover, patients with bicuspid aortic valve and aortic insufficiency had greater increases in annulus (P < .001), sinus (P < .001), and ascending aorta (P < .001) diameters over time.Conclusions
For patients undergoing the Ross procedure, a combination of bicuspid aortic valves and aortic insufficiency is the main risk factor for late autograft dilatation and dysfunction. 相似文献19.
Mathieu Vergnat Boulos Asfour Claudia Arenz Philipp Suchowerskyj Benjamin Bierbach Ehrenfried Schindler Martin Schneider Viktor Hraska 《The Journal of thoracic and cardiovascular surgery》2019,157(1):318-326.e1
Objectives
Because data for neonates are limited, optimal management of critical aortic stenosis remains controversial (balloon valvotomy [BV] or open valvoplasty [OV]). In a center with balanced experience in both methods, we hypothesized that OV can provide a better individualized approach than blunt BV and better serve long-term outcomes.Methods
A retrospective review of data and follow-up (survival, freedom from operation/replacement) of all neonates, suitable for biventricular repair, undergoing aortic valve procedure (1989-2015), was performed.Results
One hundred three patients were concomitantly treated (BV [n = 51], OV [n = 52). Median age was 8 days, median aortic annulus Z-score was ?1.3 for BV (range, ?3.9 to 2.0) and OV (?3.9 to 3.2) groups. Operative mortality after BV or OV was 8% (n = 4) and 4% (n = 2), respectively. With a 13-year median follow-up, 10-year freedom from operation was 36% and 66% after BV or OV, respectively. Valve replacement was ultimately required in 32 patients (n = 20 [39%] in the BV group; n = 12 [23%] in the OV group) within a 5.9-year median time. After OV, tricuspid arrangement of the repaired aortic valve provided a 10-year freedom from operation and replacement of 87% and 95%, respectively. In multivariate analysis, associated left heart malformations, BV, nontricuspid geometry, and inadequate post procedural result were predictive of operation and replacement.Conclusions
In neonates with critical aortic stenosis, both methods (BV and OV) offer excellent survival benefit. OV significantly minimizes the need for operation, whereas BV did not postpone age of replacement. Clearly superior results are achieved with OV when a post repair tricuspid arrangement is obtained. 相似文献20.
Muhammad Aftab Frank S. Cikach Yuanjia Zhu Jay J. Idrees Christina M. Rigelsky Vidyasagar Kalahasti Eric E. Roselli Lars G. Svensson 《The Journal of thoracic and cardiovascular surgery》2019,157(2):439-450.e5
