Sergey Leontyev

Aortic Valve Replacement in Octogenarians: Utility of Risk Stratification With EuroSCORE

BACKGROUND With the advent of percutaneous valve implantation, an increasing amount of interest is being expressed in outcomes of conventional aortic valve replacement (AVR) in elderly patients. We evaluated characteristics and outcomes of elderly patients undergoing isolated AVR with a particular focus on the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk stratification. METHODS All patients aged 80 years or older (n = 282) undergoing isolated AVR between November 1995 and June 2006 at our institution were reviewed according to logistic EuroSCORE (ES(log)) risk stratification. Surgical risk was defined as low risk (ES(log) < or = 10% [n = 107]), moderate risk (10% < ES(log) < 20% [n = 103]), and high risk (ES(log) > or = 20% [n = 72]). Patient age was 82 +/- 2 years (low risk), 82.7 +/- 2.7 years (moderate risk), and 83.6 +/- 3.1 years (high risk), respectively (p < 0.05). Mean ES(log) predicted risk of mortality was 7.3% +/- 1.4% (low risk), 13.7% +/- 2.5% (moderate risk), and 33.0% +/- 11.5% (high risk; p < 0.05). Follow-up was 99.7% complete. RESULTS In-hospital mortality was 7.5% (low risk), 12.6% (moderate risk), and 12.5% (high risk; p = 0.4). One-year survival was 90%, 78%, and 69% (p = 0.002); 5-year survival was 70%, 53%, and 38% (p = 0.05); and 8-year survival was 38%, 33%, and 21% (p = 0.017), for low-, moderate-, and high-risk patients, respectively. Independent predictors for in-hospital mortality were pulmonary hypertension and urgent indication for surgery. Cox regression predictors of medium-term survival were congestive heart failure, urgent timing, previous stroke or transient ischemic attack, and EuroSCORE stratum. CONCLUSIONS Aortic valve replacement can be performed in the elderly population with acceptable outcomes. EuroSCORE risk stratification is imprecise for prediction of perioperative mortality among octogenarian AVR patients, but may be useful for predicting mortality during medium-term follow-up.

What Is the Best Strategy for Brain Protection in Patients Undergoing Aortic Arch Surgery? A Single Center Experience of 636 Patients

BACKGROUND Cerebral protection during aortic arch surgery can be performed using various surgical strategies. We retrospectively analyzed our results of different brain protection modalities during aortic arch surgery. METHODS Between January 2003 and November 2009, 636 consecutive patients underwent aortic arch replacement surgery using unilateral antegrade cerebral perfusion (UACP [n=123]), bilateral antegrade cerebral perfusion (BACP [n=242]), retrograde cerebral perfusion (RCP [n=51]), or deep hypothermia and circulatory arrest (DHCA [n=220]). Mean age of patients was 62±14 years, 64% were male, 15% were reoperations, and 37% were performed for acute type A dissections. Mean follow-up was 4.9±0.1 years and was 97% complete. RESULTS Circulatory arrest time was 22±17 minutes UACP, 23±21 minutes BACP, 18±12 minutes RCP, and 15±13 minutes DHCA; p<0.001). Early mortality was 11% (n=72) and was not different between the surgical groups. Stroke rate was 9% for ACP patients (n=33) versus 15% (n=39) for patients who did not receive ACP (p=0.035). Independent predictors of stroke were type A aortic dissection (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3 to 3.2; p<0.001), age (OR, 1.04; 95% CI, 1.01 to 1.06; p=0.001), duration of circulatory arrest (OR, 1.01, 95% CI, 1.002 to 1.03; p=0.02), and total aortic arch replacement (OR, 2.7; 95% CI, 1.3 to 5.7; p=0.005). Five year survival was 68%±4% and was not significantly different between groups. CONCLUSIONS Antegrade cerebral perfusion is associated with significantly less neurologic complications than RCP and DHCA, despite longer circulatory arrest times. Medium-term survival is worse for patients with postoperative permanent neurologic deficit and preoperative type A aortic dissection.

Redo Aortic Valve Surgery: Early and Late Outcomes

BACKGROUND Repeat aortic valve surgery (rAVS) is usually associated with an increased risk profile due to advanced patient age and comorbidities. We analyzed the current early and late results for isolated rAVS. METHODS One hundred fifty-five patients underwent isolated rAVS from November 1994 to April 2008, of which, 86 received isolated redo aortic valve surgery (rAVS without root) and 69 received aortic root replacement (rAVS with root) as the second operation. RESULTS Patient age was 58 ± 16 years; 23% were female. The indications for redo surgery were infective endocarditis (27.1%, n = 42), bioprosthetic structural valve dysfunction and degeneration (23.8%, n = 37), mechanical valve nonstructural dysfunction (7.2%, n = 11), paravalvular leak (18.1%, n = 28), aortic dissection (2.6%, n = 4), and aortic aneurysm (7.1%, n = 11). Early mortality was 4.5% (n = 7) for all patients (3.5% for rAVS without root and 5.8% for rAVS with root, p = 0.5). Left ventricular ejection fraction less than 0.30 (odds ratio 9.2, 95% confidence interval [CI] 1.1 to 80.3) and preoperative neurologic dysfunction (odds ratio 22.1, 95% CI 2.3 to 197.4) were found to be the independent predictors for in-hospital mortality according to multivariate analysis. Follow-up was 100% complete with a mean duration of 2.7 ± 2.8 years for all patients. Five-year and eight-year survival was 66% ± 5% and 61% ± 6% for all patients and did not significantly differ between surgical groups. Cox regression analysis revealed the following independent predictors of long-term survival: preoperative New York Heart Association functional class IV (hazard ratio 2.2, 95% CI 1.5 to 3.2, p < 0.01) and infective endocarditis (hazard ratio 2.2, 95% CI 1.4 to 3.1, p < 0.01). CONCLUSIONS Repeat isolated aortic valve surgery is associated with respectable outcomes. Follow-up results reveal good long-term survival for this group.

Experience with the conventional and frozen elephant trunk techniques: a single-centre study

OBJECTIVES The treatment of patients with extensive thoracic aortic disease involving the arch and descending/thoracoabdominal aorta is often performed using an elephant trunk procedure. We retrospectively analysed our results comparing two different techniques: the conventional elephant trunk (cET) and the frozen elephant trunk (FET) operation. METHODS Between January 2003 and December 2011, 171 consecutive patients underwent total aortic arch replacement with either a cET (n = 125) or FET (n = 46) technique. The mean age was 64 ± 13 years and was significantly higher in the FET group (P < 0.01). Acute Type A aortic dissection was the indication for surgery in 53.6% of cET and 17.4% of FET patients, and degenerative or atherosclerotic aneurysm accounted for 33.6% of cET and 58.7% of FET patients. The remaining patients were operated on for chronic Type A or acute or chronic Type B dissections with arch involvement. RESULTS In-hospital mortality was 21.6 vs 8.7% for cET and FET patients, respectively (P = 0.1). Logistic regression analysis revealed Type A aortic dissection (odds ratio (OR) 3.1, P = 0.01) as the only independent predictor of hospital mortality. Stroke occurred in 16 vs 13% of cET vs FET patients (P = 0.4). Type A aortic dissection was an independent predictor of stroke by multivariable analysis (OR 2.6, P = 0.03), and axillary arterial cannulation was protective against stroke (OR 0.4, P = 0.04). The occurrence of new-onset paraplegia was significantly higher in the FET group (21.7 vs 4.0%, P < 0.001), and aortic repair with the FET technique was an independent predictor for paraplegia (OR 6.6, P = 0.001). Among patients receiving FET, a body core temperature during circulatory arrest of ≥ 28 °C in combination with a prolonged circulatory arrest time of >40 min was an independent predictor for permanent spinal cord injury (OR 5.0, 95% CI 1.1-20, P = 0.038). The estimated 1-, 3- and 5-year survival were 70 ± 4, 70 ± 4 and 68 ± 4% (cET) and 4 ± 7 and 60 ± 9, 40 ± 1% (FET), with mean survival time 5.2 ± 0.3 vs 3.8 ± 0.5 years (cET vs FET, log-rank P = 0.9). CONCLUSIONS The FET procedure for extensive thoracic aortic disease is associated with an acceptable mortality rate, but with a higher incidence of perioperative spinal cord injury than cET. Arch replacement with a cET technique should be strongly considered in patients with expected prolonged circulatory arrest times, particularly if operated on under mild or moderate hypothermia. Axillary cannulation is associated with superior neurological outcomes and Type A acute aortic dissection is a risk factor for mortality and poor neurological outcomes in this patient population.

Valve-Sparing Root Reconstruction Does Not Compromise Survival in Acute Type A Aortic Dissection

BACKGROUND The optimal management of the dissected aortic root remains unclear. The purpose of this study was to determine whether aortic valve-sparing root replacement (VSRR) compromises survival in aortic dissection repair and to evaluate the comparative efficacy of 2 types of VSRR procedures. METHODS The Heart Center database (Leipzig, Germany) was reviewed to identify patients who underwent a VSRR for acute type A aortic dissection (AAAD) repair. Patients were classified into 3 groups: Bentall (biological or mechanical valved conduit), Yacoub VSRR, and David VSRR. Intergroup comparisons were performed using the t test and analysis of variance as appropriate. RESULTS From March 1995 to April 2010, 208/374 patients (56%) undergoing AAAD repair received an aortic root procedure. Group 1 (n=130) underwent a Bentall operation, group 2 (n=51) underwent a modified Yacoub procedure, and group 3 (n=27) underwent a modified David procedure. Age and logistic European system for cardiac operative risk evaluation (EuroSCORE) as well as cross-clamp, cardiopulmonary bypass, and circulatory arrest times were similar among the groups. Hospital mortality among all 3 groups was similar (group 1, 27%; group 2, 16%; group 3, 15%). At a mean follow-up of 44 months for group 2 and 27 months for group 3, there was no difference in the need for aortic valve replacement for moderate to severe aortic insufficiency (AI) (2/37 survivors in group 2 versus 1/23 survivors in group 3; z score=-0.279; p>0.05). Five-year survival estimates were 66% for group 1, 65% for group 2, and 80% for group 3 (log rank p=0.2). CONCLUSIONS Both the David and Yacoub techniques have similar midterm durability in AAAD repair. When compared with the Bentall procedure, neither technique compromises short-term or midterm survival after AAAD repair.

Iatrogenic type A aortic dissection during cardiac procedures: early and late outcome in 48 patients

OBJECTIVE Iatrogenic aortic dissection (IAD) is a rare complication of cardiac procedures. We herein describe our management and results of this complication. METHODS A total of 55 279 patients underwent open heart surgery at our centre from 1995 to 2010, and 135 262 patients underwent cardiac catheterization over the same time period. We identified 48 patients from this cohort who underwent emergency surgery for IAD that occurred either during or shortly after cardiac surgery, or following cardiac catheterization. RESULTS The incidence of IAD was 0.06% (n = 36) for cardiac surgical procedures and 0.01% (n = 12) for cardiac catheterization procedures. The mean patient age was 66 ± 14 years and 50% were female. Intraoperative IAD occurred during aortic cannulation in 12 patients, insertion of the cardioplegia cannula in 7 patients, manipulation of the aortic crossclamp in 4 patients or during other events in 8 patients. IAD occurred early postcardiac surgery in 5 patients, and during cardiac catheterization in the remaining 12 patients. IAD was treated by emergent replacement of the ascending aorta and the aortic arch (when involved), as well as aortic root replacement or repair as indicated. Early mortality was 41.7: 35.5% for intraoperative IAD, 60.0% for postoperative IAD and 50.0% for cardiac catheterization-associated IAD (P = 0.5). Histological investigation revealed atherosclerosis in 61.2% of patients, cystic medial necrosis in 22.2%, aortitis in 2.8% and other pathologies in 13.8%. Follow-up was 100% complete with a 5-year survival of 40 ± 0.4%. CONCLUSION IAD is a rare but dangerous complication of cardiac surgery and cardiac catheterization, and is frequently associated with pre-existing aortic pathology.

The outcome after aortic valve-sparing (David) operation in 179 patients: a single-centre experience.

OBJECTIVES The David aortic valve-sparing reimplantation (AVr-D) operation is increasingly being used in patients with aortic root aneurysmal disease and pliable aortic cusps. The objective of this study was to assess our early and medium-term outcomes with the AVr-D operation. METHODS Between 2003 and 2011, a total of 179 patients underwent AVr-D procedures. The mean patient age was 49.7 ± 15.1 years, and 23.5% (n = 42) were females. Marfan syndrome was present in 17.3% of patients (n = 31), and acute Type A aortic dissection in 15.6% (n = 28). Clinical follow-up was 100% complete and was 1.8 ± 1.6 years (0 days to 7.5 years) long. Echocardiographic follow-up was performed 2.2 ± 1.5 years (0 days to 7.5 years) postoperatively and was 77% complete. RESULTS Early mortality was 1.1% (n = 2), with both deaths occurring in patients with Type A dissection. Pre-discharge echocardiography revealed no patients with >2+ aortic insufficiency (AI), 19.6% of patients (n = 34) with 1+ or 2+ AI and 80.4% of patients (n = 145) with trace or no AI. Left ventricular end-diastolic diameters decreased significantly from 5.6 ± 0.9 to 5.1 ± 0.8 cm early postoperatively (P < 0.01). Transvalvular maximum gradients were similar before discharge and at last follow-up (10.6 ± 5.4 vs. 10.0 ± 8.2 mmHg, P = 0.4). AI grade increased significantly over time (0.3 ± 0.4 before discharge vs. 0.5 ± 0.6 at follow-up, P = 0.01), but remained less than moderate in 93.6% of patients. Four patients required aortic valve re-replacement during follow-up, two due to early endocarditis and two due to non-coronary leaflet prolapse in Marfan patients. Five-year freedom from aortic valve reoperation was 95.9 ± 2.0%. CONCLUSIONS AVr-D is associated with a low mortality and morbidity rate, even in patients with Type A aortic dissection. Although a slightly higher rate of recurrent AI may be present in patients with Marfan syndrome, freedom from recurrent AI and reoperation remains excellent during medium-term follow-up. The David operation should be considered the gold standard for patients with proximal aortic root pathology (aneurysm or dissection) and pliable aortic cusps.

Redo aortic valve surgery: Influence of prosthetic valve endocarditis on outcomes.

OBJECTIVE Compared with reoperative aortic valve replacement for nonendocarditic causes, the contemporary risk and long-term outcomes of reoperation for aortic prosthetic valve endocarditis are ill-defined. METHODS Between December 1994 and April 2008, 313 patients underwent reoperative aortic valve replacement, of whom 152 (48.6%) had prosthetic valve endocarditis. Mean follow-up was 6.5 ± 0.4 years and 97.4% complete. RESULTS Patients with prosthetic valve endocarditis were older with a higher risk profile. The overall hospital mortality was 15.3% (n = 48) (prosthetic valve endocarditis vs nonendocarditis: 24.3%, n = 37, vs 6.8%, n = 11; P < .001). Independent predictors of perioperative mortality for prosthetic valve endocarditis were sepsis (odds ratio [OR], 6.5; 95% confidence interval [CI], 2.0-21.0; P < .01), ejection fraction less than 30% (OR, 5.8; 95% CI, 1.3-25.0; P = .02), concomitant coronary artery bypass grafting (OR, 3.3; 95% CI, 1.1-9.8; P = .03), and aortic root abscess (OR, 2.7; 95% CI, 1.2-6.4; P = .02), and for the nonendocarditis group were concomitant coronary artery bypass grafting (OR, 8.1; 95% CI, 2.0-33.0; P < .01), and mitral valve surgery (OR, 4.8; 95% CI, 1.3-17.9; P = .02). The 1-, 3-, 5-, and 10-year survivals for patients with and without prosthetic valve endocarditis were 52% ± 4% versus 82% ± 3%, 43% ± 5% versus 73% ± 4%, 37% ± 5% versus 63% ± 5%, and 31% ± 7% versus 56% ± 8%, respectively (log rank < 0.001). Predictors of long-term mortality in prosthetic valve endocarditis were sepsis (OR, 3.1; 95% CI, 1.5-4.5; P < .01) and unstable preoperative status (OR, 1.8; 95% CI, 1.2-3.5; P = .04), whereas in nonendocarditis patients the only predictor was New York Heart Association class IV (OR, 2.5; 95% CI, 2.8-7.4; P < .01). Five-year actuarial freedom from endocarditis was 80% ± 0.3% versus 95% ± 0.6% (prosthetic valve endocarditis cersus nonendocarditis; P = .002). CONCLUSIONS Despite contemporary therapy, reoperation for aortic prosthetic valve endocarditis is still associated with relatively high perioperative mortality and limited long-term survival.

Impact of Perfusion Strategy on Outcome After Repair for Acute Type A Aortic Dissection

BACKGROUND The impact of antegrade versus retrograde perfusion during cardiopulmonary bypass on short- and long-term outcome after repair for acute type A aortic dissection is controversial. METHODS We reviewed 401 consecutive patients (age, 59.2 ± 14 years) with acute type A aortic dissection who underwent aggressive resection of the intimal tear and aortic replacement (March 1995 through July 2011). Arterial perfusion was antegrade in 78% (n = 311), either by means of the right axillary artery (n = 297) or through direct aortic cannulation (n = 15). Retrograde perfusion through the femoral artery was used in 22% (n = 90). RESULTS Of the 401 patients with acute type A aortic dissection, 16% (n = 64) presented in critical condition and 10% (n = 39) entered the operating room under cardiopulmonary resuscitation. In 14% (n = 54) the dissection did not extend beyond the ascending aorta (DeBakey II); 82% of dissections did involve at least the aortic arch (n = 326, DeBakey I+III). Mean age was not significantly different between patients undergoing antegrade (59.4 ± 14 years) versus retrograde (59.2 ± 13 years; p = 0.489) perfusion. Operative mortality was 20% and did not differ significantly between the groups (p = 0.766); postoperative stroke occurred also with a similar prevalence (antegrade, 15% versus retrograde, 18%; p = 0.623). Patients undergoing antegrade perfusion had a better long-term survival. Survival at 10 years after discharge was 71% versus 51% (p = 0.025) in favor of antegrade perfusion. Retrograde perfusion was identified to be an independent risk factor for late mortality in multivariate analysis (hazard ratio = 2; p = 0.009). CONCLUSIONS Survival during the initial perioperative period was equivalent comparing antegrade and retrograde perfusion. Antegrade perfusion to the true lumen, however, appears to be associated with superior long-term survival after hospital discharge.

Acute type A aortic dissection: characteristics and outcomes comparing patients with bicuspid versus tricuspid aortic valve

OBJECTIVES The aim of this study is to investigate the clinical characteristics and postoperative outcome of patients with a bicuspid aortic valve (BAV) suffering acute dissection in comparison with their tricuspid peers. METHODS Between 1995 and 2011, 460 consecutive patients underwent emergency repair for acute type A aortic dissection. In 379 patients without connective tissue disease, the aortic valve morphology could clearly be specified (91.6% tricuspid and 8.4% bicuspid). RESULTS At the time of dissection, patients with a bicuspid valve were younger (46.7 ± 13 vs 61.6 ± 12 years, P < 0.001) with the entry tear more often located in the root compared with those with a tricuspid valve (bicuspid: 31.3% vs tricuspid: 6.3%, P < 0.001). Consequently, surgical repair warranted root replacement in 93.8% of bicuspid vs 28.8% of tricuspid valve patients (P < 0.001). The leading pathology was medial necrosis/degeneration in bicuspid and atherosclerosis in tricuspid patients (P = 0.166). Hospital mortality was 20.3% and not significantly different between the two valve morphologies, even despite the younger age of bicuspid patients: 28.1% among bicuspids vs 19.6% among tricuspids (P = 0.255). Survival after discharge was 63.3% at 10 years for all patients. BAV patients had a significantly better survival with 100% at 10 years compared with 60.2% in tricuspid valve patients (P = 0.011). Mean follow-up among survivors was comparable for bicuspid and tricuspid patients (3.7 and 4.1 years, respectively). CONCLUSIONS Patients with BAV have a distinctive dissection pattern with the entry tear frequently located in the aortic root and-despite their younger age-are subject to substantial hospital mortality. For bicuspid patients suffering from dissection, composite root replacement yields an excellent outcome equal to an age- and gender-matched normal population.