William Moser

Long-term comparison of thoracic endovascular aortic repair (TEVAR) to open surgery for the treatment of thoracic aortic aneurysms

OBJECTIVE Thoracic endovascular aortic repair (TEVAR) has become a widely established treatment for a variety of thoracic aortic pathologic diseases despite limited long-term data to support its use. We compared the long-term outcomes of TEVAR with the 3 commercially available stents grafts for thoracic aortic aneurysms to results in control subjects undergoing open surgery. METHODS Demographic, clinical radiographic parameters were collected prospectively on patients enrolled in trials assessing the Gore TAG (55), Medtronic Talent (36) and Cook TX2 (15) devices. Outcomes were compared with 45 contemporaneous open controls. Detailed clinical and radiographic information was available for analysis. Standard univariate, survival, and regression methods were used. RESULTS During the study period (1995-2007) 106 patients were enrolled in TEVAR trials and there were 45 open controls. TEVAR patients were older and had significantly more comorbidities including diabetes and renal failure. TEVAR patients had 2.3 ± 1.3 devices implanted. Mortality (2.6% TEVAR, 6.7% open; P = .1), paralysis/paraparesis (3.9% TEVAR, 7.1% open; P = .2), and prolonged intubation more than 24 hours (9% TEVAR, 24% open; P = .02) tended to be more common in the open controls. Overall survival at 10 years was similar between groups (log rank P = .5). Multivariate predictors of late mortality included age, chronic obstructive pulmonary disease, diabetes, and chronic renal failure. Use of TEVAR versus open surgery did not influence mortality (hazard ratio, 0.9 95% confidence interval, 0.4-1.6). Over 5 years of radiographic follow-up in the TEVAR group, mean aortic diameter decreased from 61 to 55 mm. Freedom from reintervention on the treated segment was 85% in TEVAR patients at 10 years. CONCLUSIONS TEVAR is a safe and effective procedure to treat thoracic aortic aneurysms with improved perioperative and similar long-term results as open thoracic aortic repair. TEVAR-treated aneurysm diameters initially decrease and then stabilize over time.

Transapical Deployment of Endovascular Thoracic Aortic Stent Graft for an Ascending Aortic Pseudoaneurysm

We report a case of a patient with a history of previous coronary artery bypass grafting undergoing endovascular aortic repair of a large pseudoaneurysm in the ascending aorta. Due to the limitations of the current technology, the endograft was deployed through a left ventricular transapical approach by using a left mini-thoracotomy.

Long-term results of aggressive hemiarch replacement in 534 patients with type A aortic dissection

OBJECTIVE To present the outcomes of routinely performed hemiarch replacement in patients with acute type A aortic dissection. METHODS From 1993 to 2013, among 629 patients with acute type A dissection, 534 patients (85%) underwent hemiarch, 63 patients (10%) underwent hemiarch and antegrade thoracic stent grafting, 26 patients (4%) underwent total arch, and 6 patients (1%) underwent isolated ascending replacement. Patients with hemiarch replacement comprised the study population. Median follow-up was 4.1 years (first quartile, 1.9; third quartile, 7.8) (2462 patient years). RESULTS In-hospital mortality was 12% (66 out of 534 patients). Survival was 80% ± 2%, 68% ± 3%, and 51% ± 3%, and 84% ± 3%, 65% ± 4%, and 41% ± 6% in DeBakey type I and II patients at 1, 5, and 10 years, respectively (log rank P = .375). Freedom from distal aortic reintervention was 97% ± 1%, 90% ± 2%, and 85% ± 3% and 99% ± 1%, 97% ± 2%, and 90% ± 5% in DeBakey type I and II patients at 1, 5, and 10 years, respectively (log rank P = .046). Seven patients (1.3%) required reintervention for aortic arch aneurysm and 25 patients (5%) required reintervention for descending aortopathy. The success rate for distal reintervention performed electively or urgently was 92% (24 out of 26 patients). Marfan syndrome (odds ratio, 3.43; P = .046) and DeBakey type I dissection (odds ratio, 2.49; P = .048) were independent predictors of distal aortic reintervention. CONCLUSIONS Aggressive hemiarch replacement in acute type A dissection can be performed with low mortality and low aortic arch reoperation rate. Resection of all dissected aortic wall tissue decreases, but does not eliminate, the risk of later adverse aortic events.

Transport Characteristics of Peptidomimetics. Effect of the Pyrrolinone Bioisostere on Transport Across Caco-2 Cell Monolayers

AbstractPurpose. To compare the permeation characteristics of amide bond-containing HIV-1 protease inhibitors and their pyrrolinone-containing counterparts across Caco-2 cell monolayers, a model of the intestinal mucosa. Methods. Transepithelial transport and cellular uptake of three pairs of amide bond-containing and pyrrolinone-based peptidomimetics were assessed in the presence and absence of cyclosporin A using the Caco-2 cell culture model. The potential of the peptidomimetics to interact with biological membranes was estimated by IAM chromatography. Results. In the absence of cyclosporin A, apical (AP) to basolateral (BL) flux of all compounds studied was less than the flux determined in the opposite direction (i.e., BL-to-AP). The ratio of the apparent permeability coefficients (Papp) calculated for the BL-to-AP and AP-to-BL transport (PBL⇒AP/PAP⇒BL) varied between 1.7 and 36.2. When individual pairs were compared, PBL⇒AP/PAP⇒BL ratios of the pyrrolinone-containing compounds were 1.5 to 11.5 times greater than those determined for the amide bond-containing analogs. Addition of 25 μM cyclosporin A to the transport buffer reduced the PBL⇒AP /PAP⇒BL ratios for all protease inhibitors to a value close to unity. Under these conditions, the amide bond-containing peptidomimetics were at least 1.6 to 2.8 times more able to permeate Caco-2 cell monolayers than were the pyrrolinone-containing compounds. The intrinsic uptake characteristics into Caco-2 cells determined in the presence of 25 μM cyclosporin A were slightly greater for the amide bond-containing protease inhibitors than for the pyrrolinone-containing analogs. These uptake results are consistent with the transepithelial transport results determined across this in vitro model of the intestinal mucosa. Conclusions. The amide bond-containing and pyrrolinone-based peptidomimetics are substrates for apically polarized efflux systems present in Caco-2 cell monolayers. The intrinsic permeabilities of the amide bond-containing protease inhibitors are slightly greater than the intrinsic permeabilities of the pyrrolinone-based analogs through Caco-2 cell monolayers.

Long-Term Results of Neomedia Sinus Valsalva Repair in 489 Patients With Type A Aortic Dissection

BACKGROUND Acute type A aortic dissection frequently occurs in patients with normally sized aortic roots. The aim of this investigation was to describe the durability of aortic valve resuspension and root repair with a novel technique of reconstruction in type A dissection. METHODS From 1993 to 2013, among 629 patients operated on for acute type A dissection 489 (62% male, median age 62 years (53; 73) underwent aortic valve resuspension and reinforcement of the sinus of Valsalva with a Teflon felt neomedia. The median follow-up time was 4.1 years (1.3; 6.8) (2075 patient-years). RESULTS In-hospital mortality was 11% (56/489). Survival was 69%±2%, 50%±3%, and 36%±5% at 5, 10, and 15 years, respectively. Freedom from moderate or severe aortic regurgitation was not influenced by the aortic regurgitation grade at the initial operation (p=0.131). Freedom from proximal aortic reoperation was 96%±1%, 92%±2%, and 89%±4% at 5, 10, and 15 years, respectively. Seventeen patients (3%) required proximal reoperation: 10 for aortic regurgitation, including 3 with concomitant pseudoaneurysm and 2 with root aneurysm; 6 for pseudoaneurysm; and 1 for graft infection. CONCLUSIONS Aortic root neomedia reconstruction and valve resuspension can be successfully performed in the majority of patients with type A dissection. The in-hospital mortality is low, and the results are durable.

Gender-related changes in aortic geometry throughout life †

OBJECTIVES Aortic geometry changes throughout life are not well defined. This investigation delineates aortic geometry across the adult age spectrum and determines the gender-related influence of aging on aortic morphometry. METHODS Contrast-enhanced computed tomography scans of all aortic segments in 195 subjects (94 women, 101 men, average age 57 ± 20 years) free of vascular disease were analysed. Lengths and diameters of each aortic segment as well as width, height and tortuosity of the thoracic aorta were compared between both genders. RESULTS Aortic diameters and lengths were larger in men than women (P < 0.001); however, after adjustment for body surface area (BSA), the ascending aorta and aortic arch revealed greater diameters in women than in men (P = 0.001 and P = 0.011, respectively). All aortic segment dimensions increased in a similar pattern with age for both genders, except the ascending aorta diameter, which increased +3.4% (P < 0.001) per decade in women and +2.6% (P < 0.001) per decade in men. Owing to more dynamic ascending aortic growth in women, absolute diameters were similar in both genders at an older age (>70 years old: 3.4 ± 0.3 vs 3.5 ± 0.3 cm, P = 0.241). CONCLUSIONS Female gender is associated with smaller aortic dimensions, but only at a young age. The dynamics of aortic growth throughout life are greater in women than in men. Gender-related changes in aortic geometry provide a hypothesis for the predominance of aortic dissection in young male patients, which normalizes between genders with increasing age.

Development of a Single Endovascular Device for Aortic Valve Replacement and Ascending Aortic Repair

Transcatheter aortic valve implantation (TAVI) is contraindicated in the presence of an ascending aortic aneurysm. Our aim was to design a composite endovascular device enabling ascending aortic repair and TAVI.

Durability of Porcine Bioroots in Younger Patients With Aortic Root Pathology: A Propensity-Matched Comparison With Composite Mechanical Roots

BACKGROUND We present a comparison of porcine bioroot and composite mechanical root replacement in a large series of patients younger than 60 years who required full root replacement for true root pathology. METHODS Between 1997 and 2007, we performed 986 aortic root replacement procedures, including 391 porcine bioroots and 515 composite mechanical roots for true root indications. Of these, 504 patients were younger than 60 years old at time of the operation. Porcine bioroots were placed in 138 patients, including 38 St. Jude Toronto Root (St. Jude Inc, St. Paul, MN), 98 Medtronic Freestyle (Medtronic Inc, Minneapolis, MN), and 2 Edwards Prima (Edwards Lifesciences Inc, Irvine, CA). Standard univariate, logistic regression, Cox regression, and propensity matching techniques were used. RESULTS To adjust for baseline differences in risk factor profiles, propensity matching yielded a final matched data set of 128 matched pairs, with no differences in preoperative risk factor profile or indication for operation. Overall 30-day operative mortality was 2.3% for porcine bioroot patients vs 1.6% for mechanical root patients (p = 0.6). Root type did not influence early (odds ratio, 0.8; 96% confidence interval, 0.2 to 3.2) or late mortality (hazard risk, 1.4; 95% confidence interval, 0 0.5 to 3.8). Multivariate predictors of late mortality included (hazard ratio, 95% confidence interval) age in years (1.01; 1.01 to 1.03), chronic renal failure (3.6; 1.1 to 12.6), and preoperative bacterial endocarditis (3.6; 1.1 to 11.8). Freedom from reoperation was similar between groups; however, bleeding events were more common among mechanical root patients. CONCLUSIONS Porcine bioroots provide durable midterm to late-term outcomes after aortic root replacement for true root indications and are an appealing alternative in younger patients because they limit morbidity associated with anticoagulant-related bleeding.

Type A Aortic Dissection After Previous Cardiac Surgery: Results of an Integrated Surgical Approach

BACKGROUND Stanford type A aortic dissection in patients with previous cardiac surgery (PCS) is a catastrophic disease. This investigation evaluates the results of a standardized integrated approach to type A dissection after PCS. METHODS Between 1993 and 2013, 629 patients with acute type A dissection (median age 61 [50 to 73] years, 64% males) underwent aortic repair utilizing a standardized integrated approach. Of these, 56 (9%) patients had PCS. Median follow-up was 4.1 (1.9 to 7.4) years (2,812 patient-years). RESULTS Patients with PCS were older (70 [60 to 75] vs 60 [50 to 72] years, p<0.001), fivefold more likely to have coronary artery disease (p<0.001), and threefold less likely to have cardiac tamponade (p<0.001). They had higher in-hospital mortality rate (25% vs 12%, p=0.011), similar postoperative stroke rate (4% vs 5%, p=0.821), and lower survival (60%±7%, 50%±7%, 38%±8% vs 84%±2%, 69%±2%, 50%±3%) at 1, 5, and 10 years, respectively (log rank, p=0.003). Among PCS patients, the lowest in-hospital mortality was in those without prior myocardial revascularization (11% vs 32%, p=0.185). Coronary malperfusion (odds ratio, 9.47; p=0.034) and cardiac tamponade (odds ratio, 5.01; p=0.076) were independent in-hospital mortality risk factors in PCS patients. CONCLUSIONS Standardized integrated approach to acute type A aortic dissection in PCS patients results in acceptable postoperative mortality. Previous cardiac surgery should not be a reason to deny surgical repair in patients with type A dissection.

Transcatheter aortic valve implantation in patients with ascending aortic dilatation: safety of the procedure and mid-term follow-up

OBJECTIVES Transcatheter aortic valve implantation (TAVI) does not enable concomitant or simultaneous ascending aortic intervention. This investigation evaluates the safety of TAVI in patients with ascending aortic dilatation and demonstrates mid-term follow-up. METHODS From November 2007 to December 2012, among 1143 patients with severe aortic stenosis screened for TAVI, a cohort of 457 patients met the inclusion criteria. Of these, a total of 98 patients [71% males, median age 85.0 (9.0) years] were diagnosed with concomitant ascending aortic dilatation (4.0-5.0 cm). An additional 2 patients had an ascending aortic diameter of >5.0 cm. The mid-term follow-up (652.2 patient-years) was 100% complete. RESULTS There was no iatrogenic dissection in patients with dilatated ascending aorta. Intraoperative aortic rupture occurred in 1 patient with mildly dilatated ascending aorta. One-year survival rates in patients with dilatated and non-dilatated ascending aorta were 65 of 75 (87%) and 201 of 242 (83%, P = 0.573). The mean ascending aortic diameter remained stable at 4.1 (0.2) and 4.7 (0.2) cm in patients with mild and moderate dilatation, respectively, with a median follow-up of 14 months after TAVI. Two patients with an aortic diameter of over 5.0 cm survived the procedure and expired 7 and 20 months after TAVI due to tumour and heart failure, respectively. CONCLUSIONS Ascending aortic dilatation is diagnosed in almost one-fourth of patients treated with TAVI. Their intraprocedural risk of adverse aortic events is low. The ascending aortic dilatation does not affect mid-term survival in the TAVI population.