Jacopo Alfonsi

Long-term outcomes after aortic arch surgery: results of a study involving 623 patients.

OBJECTIVES To assess early and long-term outcomes in a large cohort of patients undergoing open aortic arch surgery. METHODS From 1996 to 2012, 623 consecutive patients (mean age: 62.8 years) underwent aortic arch interventions in our institution. Of these, 208 (33.4%) presented with an acute aortic syndrome (AAS) and 415 (66.6%) with a chronic aortic pathology (CAP). During the study period, our surgical strategy involved extensive resections of the diseased aortic tissue at elective interventions, and a tear-oriented aortic replacement in patients with acute dissection. More extensive interventions were often performed in younger patients, and in those with connective tissue diseases and bicuspid aortic valves. A total arch replacement was frequently performed (53.3%). Antegrade selective cerebral perfusion was used in all cases. RESULTS Overall in-hospital mortality was 23.1% in patients with AAS and 11.1% in patients with a CAP; in the same groups, postoperative permanent neurological dysfunction (PND) occurred in 9.6 and 5.6%, respectively. The follow-up was 94.4% complete. For in-hospital survivors, 5- and 10-year survival (%) were 79.4 ± 2.1 and 60.9 ± 3.2, respectively, not influenced by the underlying aortic disease. Cox regression identified age (hazard ratio [HR]: 1.048; P < 0.001), preoperative renal failure (HR: 2.3; P = 0.003), diabetes (HR: 1.805; P = 0.005) and PND (HR: 2.4; P = 0.03) to be independent predictors for the follow-up mortality. Overall, 109 (59% endovascular) aortic reinterventions were performed: 18.3% were proximal and 81.7% distal to the aortic arch. Five- and 10-year freedom from aortic redo (%) were 82.8 ± 1.9 and 77.7 ± 2.6, respectively. Aortic dissection (HR: 1.7; P = 0.03) was the only independent predictor of reoperative surgery at the follow-up. CONCLUSIONS Aortic arch surgery was associated with satisfactory early and long-term outcomes. Survival was largely determined by patient comorbidities and postoperative PND. While the underlying aortic disease did not affect long-term mortality, chronic dissection was associated with increased need for aortic reinterventions.

Surgical management of aortic root in type A acute aortic dissection: a propensity-score analysis

OBJECTIVES Surgical management of the aortic root in type A acute aortic dissection (TAAAD) is controversial. This study compares short- and long-term outcomes of root replacement (RR) versus conservative root management (CR). METHODS Between 1999 and 2014, 296 patients with TAAAD were treated in our department. The mean age was 63.7 years. Of the total, 69% were male. Ten patients (3%) presented with Marfan syndrome or bicuspid aortic valve. RR was performed in 119 (40%) patients, whereas CR in 177 (60%). Pre- and intraoperative data were stratified according to root management, and treatment bias was addressed by propensity-score (PS) analysis. Independent predictors of hospital and long-term mortality and proximal aortic reoperation were identified using multivariable logistic and Cox regression models. RESULTS Using PS analysis, we obtain two groups of 82 patients. The matched cohort hospital mortality rate was 21% in the CR group and 26% in the RR group (P = 0.45). The unadjusted comparison showed no statistical difference in early and long-term mortality between the groups. This result was confirmed after standard logistic regression and propensity-adjusted logistic regression. Freedom from proximal aortic reintervention was higher in the RR group (at 7 years RR: 96 ± 3% vs CR: 80 ± 6%, log-rank P = 0.02) and remained high in the matched cohort of patients (at 7 years RR: 98 ± 2 vs CR: 86 ± 6, log-rank P = 0.06). CONCLUSIONS Conservative and aggressive root management in acute aortic dissection provided similar results for early and late mortality. Nevertheless, a more extensive root intervention appeared to be protective against aortic reintervention.

Aortic Root Replacement With Biological Valved Conduits.

The execution of Bentall procedures using biological valved conduits is expanding owing to the increased incidence of aortic valve and root diseases in the aging population. To review the available data, a systematic search identified 29 studies with a total of 3,298 patients. Although evidence on short-term results suggested favorable outcomes after biological Bentall operations, data beyond 5 years are limited and highlight the urgent need for further investigations with longer follow-up.

Frozen versus conventional elephant trunk technique: application in clinical practice

Summary Treating complex aortic arch disease with proximal and distal aortic segment involvement is challenging. In recent years, different surgical and endovascular techniques have been applied in a single or multiple-stage approach with the aim to cure and simplify these conditions. The first procedure available for this purpose was the conventional elephant trunk technique. Its recent evolution is the frozen elephant trunk, which treats the descending thoracic aorta using the antegrade release of a self-expandable stent graft. In the following review article, we analyse the advantages and drawbacks of both techniques from clinical and practical perspectives.

Reoperations versus primary operation on the aortic root: a propensity score analysis

OBJECTIVES: Reported early outcomes for patients undergoing reoperations on the aortic root are worse than those for patients undergoing first-time surgery. The aim of this study was to review our experience with aortic root surgery by stratifying outcomes according to the type of intervention: reoperation versus primary operation on the aortic root. METHODS: Of the 1267 patients undergoing aortic root surgery, 180 underwent aortic reoperation with root replacement (ARR) and 1087 underwent primary root replacement (PRR). Treatment bias was addressed by the use of propensity score (PS) matching and multivariate regression analysis. After PS matching, two groups of 116 patients each were created (ARR versus PRR). The primary end-points were inhospital mortality and occurrence of postoperative complications. RESULTS: In the unmatched cohort, hospital mortality and postoperative complications rates were higher in the ARR group than in the PRR group (11.1 vs 4.1%, P < 0.001; 22.2 vs 15.1%, P = 0.02). Early results were greatly affected by the type of aortic disease. The in-hospital mortality rate was 3.1% for degenerative aneurysm, 13.3% for chronic dissection, 14% for acute dissection, 16.7% for active endocarditis and 25% for false aneurysm (P < 0.001). In the propensity-matched cohort, no significant differences were observed between the groups in terms of hospital mortality rate (ARR: 6%; PRR: 1.7%; P = 0.2) and postoperative complications (ARR: 16.4%; PRR: 14.7%; P = 0.9). Logistic regression analysis revealed cardiopulmonary bypass (CPB) time [odds ratio (OR): 1.03 per min; P < 0.001] and urgent/emergent status (OR: 6.4; P = 0.04) as independent risk factors for hospital deaths. Age (OR: 1.07 per year; P = 0.03) was the sole independent predictor of postoperative complications. CONCLUSIONS: During root surgery, reintervention did not affect early outcomes and was associated with satisfactory mortality and morbidity rates. In this setting, hospital results were heavily influenced by aortic pathology and the patient’s profile.

Open surgical repair of post-dissection thoraco-abdominal aortic aneurysms: early and late outcomes of a single-centre study involving over 200 patients

OBJECTIVES Chronic, post-dissection thoraco-abdominal aortic aneurysms (TAAAs) are increasingly being treated by (hybrid) endovascular means. Although it is less invasive, thoracic endovascular aortic repair is technically complex with the risk of incomplete aneurysm exclusion, necessitating frequent reinterventions with potentially reduced long-term outcomes. The aim of this study was to evaluate contemporary early and late outcomes after open surgical repair of post-dissection TAAA. METHODS At our centre, 633 patients underwent open repair for TAAA over a 20-year period (1994-2015), including 217 (34%) patients for post-dissection TAAA, who were included in this analysis. Circulatory support was obtained by either left heart bypass (173 patients, 79.7%), deep hypothermic circulatory arrest (41 patients, 18.9%) or simple aortic cross-clamping in 3 patients. We analysed all relevant perioperative and intraoperative variables with respect to adverse outcomes. Additionally, long-term survival and the need for aortic reinterventions were studied. RESULTS The mean age was 60.2 ± 11.9 years (men 68.2%). We identified 66 Type I (30.4%), 113 Type II (52.1%), 25 Type III (11.5%), 10 Type IV (4.6%) and 3 Type V (1.4%) TAAAs. Early mortality and spinal cord deficit were 5.9% and 5.5%, respectively. Follow-up was 100% complete (mean 6.0 ± 5.8 years), with long-term survival of 71.4% at 10 years, and freedom from death and reoperation was 68.2% at 10 years. CONCLUSIONS Although it is more invasive than current endovascular approaches for post-dissection TAAA, open surgical repair can be performed safely with acceptable rates of morbidity and mortality when it is done in a specialized aortic centre. Long-term survival and freedom from aortic reintervention are excellent and should also be taken into account when evaluating less invasive alternatives.

Hybrid two-stage repair of thoracoabdominal aortic aneurysm.

Thoracoabdominal aortic aneurysm is a challenging disease that often requires an invasive surgical repair. Recently, a less invasive hybrid approach has been proposed to improve postoperative outcomes in high-risk patients. It consists of an open first stage where arterial visceral rerouting is obtained, using a vascular graft followed by a second stage where the remaining thoracoabdominal aorta is covered with a stent graft. Initial results using this approach seem promising. Here, we sought to describe the hybrid two-stage technique that is most frequently used in this extensive aortic pathology.

Innominate artery cannulation during aortic surgery.

During aortic surgery, the cannulation of arteries preserving an antegrade flow in the thoracic aorta [ascending aorta, axillary artery, innominate artery (IA) and carotid artery] has been associated with superior survival and neurological outcomes compared with the cannulation of the femoral artery. However, the ideal site of cannulation for both cardiopulmonary bypass (CPB) and antegrade selective cerebral perfusion remains under debate. Here, we present our technique of IA cannulation for CPB and antegrade selective cerebral perfusion during surgery of the thoracic aorta.

Minimally invasive root surgery: a Bentall procedure through a J-ministernotomy.

A 43-year-old woman was referred to our hospital with a diagnosis of severe aortic regurgitation and ascending aorta aneurysm (Video 1). The patient was classified as New York Heart Association (NYHA) II. Upon admission, a transthoracic echocardiogram showed a bicuspid aortic valve associated with severe aortic regurgitation and normal left ventricular function [left ventricular ejection fraction (LVEF) =65%]. The computed tomography (CT) angiogram confirmed dilatation of the sinuses of Valsalva (42 mm) and ascending aorta (45 mm). Coronary angiography ruled out any significant coronary artery disease. The patient was scheduled for a Bentall procedure through an upper J-ministernotomy (1).

Is the frozen elephant trunk frozen

The elephant trunks, either conventional or frozen represent the major technical improvements in the treatment of complex thoracic aortic disease. In the last decades, these useful techniques progressively evolved along with the introduction of new devices to facilitate the procedure and ameliorate post-operative results. The latest multi-branched hybrid FET prostheses give us the opportunity to greatly facilitate graft implantation and reduce operative times. The following review will provide an overview of the FET technique throughout the current available devices, possible surgical indications and principal surgical steps.