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Hartzell V Schaff - One of the best experts on this subject based on the ideXlab platform.
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Aortic Root Surgery in marfan syndrome medium term outcome in a single center experience
Journal of Heart Valve Disease, 2017Co-Authors: Christine Attenhofer H Jost, Heidi M Connolly, Christopher G Scott, Naser M Ammash, Juan M Bowen, Hartzell V SchaffAbstract:BACKGROUND The study aim was to analyze the authors' experience with Aortic Root Surgery in Marfan syndrome (MFS), and to expand the surgical outcome data of patients meeting the Ghent criteria (Marfan registry). METHODS Analyses were performed of data acquired from MFS patients (who met the Ghent criteria), including an Aortic Root Surgery and Kaplan-Meier survival. RESULTS Between April 2004 and February 2012, a total of 59 MFS patients (mean age at Surgery 36 ± 13 years) underwent 67 operations for Aortic Root aneurysm (n = 52), Aortic valve (AV) regurgitation (n = 15), acute Aortic dissection (n = 2), and/or mitral valve (MV) regurgitation resulting from MV prolapse (n = 7). Of 59 initial operations, 21 (36%) involved AV-replacing Root Surgery, 38 (64%) AV-sparing Root Surgery, seven (12%) Aortic arch or hemi-arch repair, and five (8%) simultaneous MV Surgery. There were no early mortalities. The mean follow up was 6.8 ± 1.2 years, with five deaths (8%) and a relatively low reoperation rate (10 reoperations in nine patients; 14%). Seven reoperations involved AV or Aortic Root Surgery (including four for AV regurgitation following failed AV-sparing Surgery), two MV repair/replacements, and one coronary artery bypass graft. Eight patients (21%) with AV-sparing Surgery had moderate/severe AV regurgitation at the last follow up before re-intervention. The mean five-year freedom from postoperative death was 91.2 ± 8.8%, from cardiac reoperation 86.3 ± 4.5%, and more-than-moderate AV regurgitation 90.3 ± 4.8%. CONCLUSIONS Prophylactic Aortic Surgery in MFS patients with AV-replacing Root or AV-sparing Root Surgery carries a low risk of operative morbidity and death when performed at an experienced center. AV-sparing Root Surgery increases the risk of AV regurgitation and, possibly, of re-intervention. Regular clinical follow up is important after any Aortic Root Surgery in MFS patients, with a delineation of risk factors for AV regurgitation after AV Rootsparing Surgery.
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long term outcomes of survival and freedom from reoperation on the Aortic Root or valve after Surgery for acute ascending aorta dissection
The Journal of Thoracic and Cardiovascular Surgery, 2014Co-Authors: Hartzell V Schaff, Rakesh M Suri, Zhengjun Wang, Kevin L Greason, Alberto Pochettino, John M Stulak, Joseph A DearaniAbstract:Objective Limited long-term outcome data are available on survival and the need for Aortic Root or valve reoperation after Surgery for acute ascending aorta dissection. We report our 42-year experience. Methods We reviewed the records of 269 patients who had undergone Surgery for acute ascending aorta dissection from July 1969 to June 2011. The mean age at Surgery was 62.1 ± 15.2 years, and 181 were men (67.3%). The distal operation was limited to hemiarch replacement. The proximal Aortic operation groups included a composite valve conduit in 66 patients (24.5%), Aortic Root repair in 112 (41.6%), and isolated supracoronary ascending aorta replacement in 91 (33.8%). Results Operative morbidity occurred in 224 patients (83.3%) and mortality in 44 (16.4%), with similar rates among the groups ( P = .894 and P = .466, respectively). The mean follow-up was 9.7 ± 7.5 years. The Kaplan-Meier survival estimate at 10 and 20 years was 65.5% ± 3.6% and 28.7% ± 4.3%, respectively, and was similar among the groups ( P = .227). Reoperation on the Aortic Root or valve occurred in 20 patients (8.9%) at a median of 6.8 years (range, 0.2-20.3). The freedom from reoperation rate at 10 and 20 years was 91.5% ± 2.3% and 79.3% ± 6.1%, respectively, with no difference among the groups ( P = .605). Conclusions Operative morbidity and mortality rates are significant after repair of acute ascending aorta dissection. Aortic Root Surgery can be performed without an apparent increase in the prevalence of operative morbidity or mortality; however, patients remain at risk of subsequent Aortic Root or valve Surgery.
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early and 1 year outcomes of Aortic Root Surgery in patients with marfan syndrome a prospective multicenter comparative study
The Journal of Thoracic and Cardiovascular Surgery, 2014Co-Authors: Joseph S Coselli, Heidi M Connolly, Hartzell V Schaff, Scott A Lemaire, Thoralf M Sundt, Irina V Volguina, Elizabeth H Stephens, Dianna M Milewicz, Luca A Vricella, Harry C DietzAbstract:Objective To compare the 1-year results after Aortic valve-sparing (AVS) or valve-replacing (AVR) Aortic Root replacement from a prospective, international registry of 316 patients with Marfan syndrome (MFS). Methods Patients underwent AVS (n = 239, 76%) or AVR (n = 77, 24%) Aortic Root replacement at 19 participating centers from 2005 to 2010. One-year follow-up data were complete for 312 patients (99%), with imaging findings available for 293 (94%). The time-to-events were compared between groups using Kaplan-Meier curves and Cox proportional hazards models. Results Two patients (0.6%)—1 in each group—died within 30 days. No significant differences were found in early major adverse valve-related events (MAVRE; P = .6). Two AVS patients required early reoperation for coronary artery complications. The 1-year survival rates were similar in the AVR (97%) and AVS (98%) groups; the procedure type was not significantly associated with any valve-related events. At 1 year and beyond, Aortic regurgitation of at least moderate severity (≥2+) was present in 16 patients in the AVS group (7%) but in no patients in the AVR group ( P = .02). One AVS patient required late AVR. Conclusions AVS Aortic Root replacement was not associated with greater 30-day mortality or morbidity rates than AVR Root replacement. At 1 year, no differences were found in survival, valve-related morbidity, or MAVRE between the AVS and AVR groups. Of concern, 7% of AVS patients developed grade ≥2+ Aortic regurgitation, emphasizing the importance of 5 to 10 years of follow-up to learn the long-term durability of AVS versus AVR Root replacement in patients with MFS.
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abstract 17960 Aortic Root Surgery in patients with marfan syndrome in the current era analysis of surgical technique and outcome in 59 patients
Circulation, 2012Co-Authors: Christine Attenhofer H Jost, Heidi M Connolly, Christopher G Scott, Juan M Bowen, Hartzell V SchaffAbstract:Background: There are few data on outcome of Aortic Root Surgery in patients (pts) meeting strict diagnostic criteria for Marfan syndrome (MFS) in the current era. Methods: Pts with MFS referred fo...
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Surgery for aneurysms of the Aortic Root a 30 year experience
Circulation, 2004Co-Authors: Kenton J Zehr, Thomas A Orszulak, Charles J Mullany, Alireza Matloobi, Richard C Daly, Joseph A Dearani, Thoralf M Sundt, Francisco J Puga, Gordon K Danielson, Hartzell V SchaffAbstract:Background— This study evaluated long-term results of Aortic Root replacement and valve-preserving Aortic Root reconstruction for patients with aneurysms involving the Aortic Root. Methods and Results— Two-hundred three patients aged 53±16 years (mean±SD; 153 male, 50 female) underwent elective or urgent Aortic Root Surgery from 1971 to 2000 for an Aortic Root aneurysm: 149 patients underwent a composite valve conduit reconstruction, and 54 patients underwent valve-preserving Aortic Root reconstruction. Fifty patients had Marfan syndrome. In-hospital and 30-day mortality was 4.0% (8/203) overall: for a composite valve conduit procedure, the corresponding value was 4.0% (6/149) and for valve-preserving procedure, 3.7% (2/54) (P=NS). Morbidity included 3 strokes (1%), 10 perioperative myocardial infarctions (5%), and 8 reoperations for bleeding (4%). Actuarial survival at 5, 10, 15, and 20 years was 93% (95% confidence interval [CI] = 88% to 97%), 79% (95% CI = 71% to 87%), 67% (95% CI = 57% to 79%), and 52...
Martin Misfeld - One of the best experts on this subject based on the ideXlab platform.
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systematic review and meta analysis of surgical outcomes in marfan patients undergoing Aortic Root Surgery by composite valve graft or valve sparing Root replacement
Annals of cardiothoracic surgery, 2017Co-Authors: Campbell D Flynn, Martin Misfeld, Tirone E David, David H Tian, Ashley Wilsonsmith, George Matalanis, Stefano Mastrobuoni, Gebrine El Khoury, Tristan D YanAbstract:Background: A major, life-limiting feature of Marfan syndrome (MFS) is the presence of aneurysmal disease. Cardiovascular intervention has dramatically improved the life expectancy of Marfan patients. Traditionally, the management of Aortic Root disease has been undertaken with composite-valve graft replacing the Aortic valve and proximal aorta; more recently, valve sparing procedures have been developed to avoid the need for anticoagulation. This meta-analysis assesses the important surgical outcomes of the two surgical techniques. Methods: A systematic review and meta-analysis of 23 studies reporting the outcomes of Aortic Root Surgery in Marfan patients with data extracted for outcomes of early and late mortality, thromboembolic events, late bleeding complications and surgical reintervention rates. Results: The outcomes of 2,976 Marfan patients undergoing Aortic Root Surgery were analysed, 1,624 patients were treated with composite valve graft (CVG) and 1,352 patients were treated with valve sparing Root replacement (VSRR). When compared against CVG, VSRR was associated with reduced risk of thromboembolism (OR =0.32; 95% CI, 0.16–0.62, P=0.0008), late hemorrhagic complications (OR =0.18; 95% CI, 0.07–0.45; P=0.0003) and endocarditis (OR =0.27; 95% CI, 0.10–0.68; P=0.006). Importantly there was no significant difference in reintervention rates between VSRR and CVG (OR =0.89; 95% CI, 0.35–2.24; P=0.80). Conclusions: There is an increasing body of evidence that VSRR can be reliably performed in Marfan patients, resulting in a durable repair with no increased risk of re-operation compared to CVG, thus avoiding the need for systemic anticoagulation in selected patients.
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early and late outcomes of complex Aortic Root Surgery in patients with Aortic Root abscesses
European Journal of Cardio-Thoracic Surgery, 2016Co-Authors: Sergey Leontyev, Piroze Davierwala, Gunther Krogh, Stefan Feder, Andreas Oberbach, Farhad Bakhtiary, Martin Misfeld, Michael A Borger, Friedrich W MohrAbstract:OBJECTIVES: To evaluate the early and long-term outcomes in patients undergoing complex Aortic Root reconstructions for complicated Aortic Root abscesses. METHODS: A total of 1199 patients underwent Aortic valve Surgery for Aortic valve endocarditis between July 1999 and June 2012. Of these, 150 patients, who underwent complex isolated Aortic Root operations for Aortic Root abscesses, were included in this study. Radical resection of the abscess was performed in all patients followed by an Aortic Root replacement (ARR) in 91 (61.7%) or an Aortic valve replacement with patch reconstruction of the Aortic Root in 59 (39.3%) patients. Prosthetic valve endocarditis was observed in 74 patients (49.3%). Logistic regression analysis identified the predictors of 30-day mortality. Estimated mean follow-up was 7.0 ± 0.5 years (range 0–12.6 years). RESULTS: Mean age was 62 ± 15 years and 87% (n= 130) were male. The majority of patients (91%; n= 137) underwent urgent or emergent Surgery. Overall 30-day mortality was 19% (n= 29; ARR 21%; AVR 17%; P= 0.4). Postoperative low cardiac output, stroke and dialysis developed in 10.7, 4.7 and 25.3% of patients, respectively. Sepsis was the only independent predictor of 30-day mortality (odds ratio: 2.8; 95% confidence interval: 1.1–7.3; P= 0.03). The 1-, 5- and 10-year survival was 66 ± 5, 54 ± 5 and 51 ± 6%, respectively. Overall, 9% of surviving patients required a reoperation for recurrent endocarditis resulting in a 1-, 5- and 10-year freedom from reoperation of 93 ± 2, 91 ± 3 and 85 ± 5%, respectively, which was not influenced by surgical technique used (ARR vs AVR with patch reconstruction; log rank P= 0.9). CONCLUSIONS: The surgical treatment of Aortic Root abscess is a challenging operation and is associated with a high early morbidity and mortality. However, the long-term survival and freedom from reoperation is satisfactory.
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the everyday used nomenclature of the Aortic Root components the tower of babel
European Journal of Cardio-Thoracic Surgery, 2012Co-Authors: Hanshinrich Sievers, Martin Misfeld, W Hemmer, Friedhelm Beyersdorf, A Moritz, Rainer Moosdorf, Artur Lichtenberg, Efstratios I CharitosAbstract:Modern analyses of data for scientific reporting and healthcare management purposes require standardized and consistent definitions, something which also holds true for Aortic Root Surgery, as part of the cardiovascular Surgery spectrum. The aim of the present study was to investigate the currently employed nomenclature of the Aortic Root components. A questionnaire was constructed on the terminology of Aortic Root components, providing a list of common definitions including anatomical descriptions, as well as fields for custom responses. Responses were received from 534 cardiothoracic surgeons registered at www.ctsnet.org. Remarkable variations in definitions were detected. The most unanimously accepted terms were: 'Aortic leaflets', the freely moving parts (52.6% of responses); 'commissures', the distal part of the leaflet attachments plus the peripheral area of the free edges of the leaflets (52.2%); 'semi-lunar leaflet attachment', the anatomic site of leaflet attachment (58%); 'annulus', the circular line defined by the nadirs of the leaflets (38%); 'interleaflet triangle', the tissue between two leaflets and annulus (23%); 'Aortic valve', the three leaflets only (55%); 'Aortic Root' as composed of sinuses, tissue between the leaflets, sinutubular junction, leaflets and their wall attachment (63%). The remarkable variability on the everyday-used definitions of the Aortic Root components can potentially lead to misinterpretation of data. More stringent adoption of consistent, standardized definitions of Aortic Root components is necessary in the modern era of data collection and management.
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factors associated with the development of Aortic valve regurgitation over time after two different techniques of valve sparing Aortic Root Surgery
The Journal of Thoracic and Cardiovascular Surgery, 2009Co-Authors: Thorsten Hanke, Efstratios I Charitos, U Stierle, Derek R Robinson, Armin Gorski, H H Sievers, Martin MisfeldAbstract:Objective Early results after Aortic valve-sparing Root reconstruction are excellent. Longer-term follow-up, especially with regard to Aortic valve function, is required for further judgment of these techniques. Methods Between July of 1993 and September of 2006, 108 consecutive patients (mean age 53.0 ± 15.8 years) underwent the Yacoub operation (group Y) and 83 patients underwent the David operation (group D). Innovative multilevel hierarchic modeling methods were used to analyze Aortic regurgitation over time. Results In general, Aortic regurgitation increased with time in both groups. Factors associated with the development of a significant increase in Aortic regurgitation were Marfan syndrome, concomitant cusp intervention, and preoperative Aortic anulus dimension. In Marfan syndrome, the initial Aortic regurgitation was higher in group Y versus group D (0.56 Aortic regurgitation vs 0.29 Aortic regurgitation, P = .049), whereas the mean annual progression rate of Aortic regurgitation was marginally higher in group Y (0.132 Aortic regurgitation vs 0.075 Aortic regurgitation, P = .1). Concomitant cusp intervention was associated with a significant Aortic regurgitation increase in both groups (P < .0001). There was a trend that smaller preoperative Aortic annulus diameters in group D and larger diameters in group Y were associated with increased Aortic regurgitation over time. Conclusion In regard to Aortic regurgitation grade over time, patients with Marfan syndrome and a large preoperative Aortic annulus diameter were better treated with the reimplantation technique, whereas those with a smaller diameter were better treated with the remodeling technique. Concomitant free-edge plication of prolapsing cusps was disadvantageous in both groups. Considering these factors may serve to improve the Aortic valve longevity after valve-sparing Aortic Root Surgery.
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remodeling or reimplantation for valve sparing Aortic Root Surgery
The Annals of Thoracic Surgery, 2007Co-Authors: Armin W Erasmi, Thorsten Hanke, U Stierle, H H Sievers, J Matthias F Bechtel, Martin MisfeldAbstract:Background Valve-sparing operations are gaining increasing acceptance; however, there is an ongoing discussion about the technique-specific indications. We present our experience with a follow-up of 123 months. Methods Between July 1993 and July 2005, 164 consecutive patients were operated on using the remodeling (group A, n=96) or reimplantation technique (group B, n=68). Fifty-seven patients presented with acute type A dissection. Aortic regurgitation was present in 84%. Follow-up was 54.7 ± 28 in group A and 48.4 ± 37.3 months in group B. Results After urgent operations, 4 patients died in each group, but none died after elective Surgery. Late mortality was 8% in group A and 4% in group B. Seven patients of group A and 1 in group B required reoperation. Echocardiographic follow-up of reoperation-free survivors showed that 3 patients (all group A, 1.3%) had Aortic regurgitation of more than grade II. Root diameter, valve pressure gradient, and valve orifice area were comparable. No gross thromboembolic or bleeding events occurred. Conclusions Aortic valve–sparing operations can provide acceptable long-term results in both techniques. Particular care to the annulus in the remodeling technique and different prosthesis designs in the reimplantation technique may overcome the intrinsic problems of each procedure.
Harry C Dietz - One of the best experts on this subject based on the ideXlab platform.
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management of the Aortic arch in patients with loeys dietz syndrome
The Journal of Thoracic and Cardiovascular Surgery, 2020Co-Authors: Florian S. Schoenhoff, Harry C Dietz, Luca A Vricella, Diane E Alejo, James H Black, Todd C Crawford, Joshua C Grimm, J Magruder, Nishant D Patel, Allen YoungAbstract:Abstract Objectives We sought to develop strategies for management of the Aortic arch in patients with Loeys–Dietz syndrome (LDS) through a review of our clinical experience with these patients and a comparison with our experience in patients with Marfan syndrome (MFS). Methods We reviewed hospital and follow-up records of 79 patients with LDS and compared them with 256 patients with MFS who served as reference controls. Results In the LDS group, 16% of patients presented initially with acute Aortic dissection (AAD) (67% type A, 33% type B) or developed AAD during follow-up, compared with 10% of patients with MFS (95% type A, 5% type B). There was no difference between patients with LDS or MFS in need for subsequent arch interventions after Aortic Root Surgery (46% vs 50%, P = 1.0). Among the patients who never had AAD, the need for arch repair at initial Root Surgery was greater in patients with LDS (5% vs 0.4%, P = .04), as was the need for any subsequent Aortic Surgery (12% vs 1.3%, P = .0004). Late mortality in patients with LDS after arch repair was greater than in those patients who had no arch intervention (33% vs 6%, P = .007). Conclusions In the absence of dissection, patients with LDS have a greater rate of arch intervention after Root Surgery than patients with MFS. After a dissection, arch reintervention rates are similar in the 2 groups. Arch intervention portends greater late mortality in LDS.
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atenolol versus losartan in children and young adults with marfan s syndrome
The New England Journal of Medicine, 2014Co-Authors: Ronald V Lacro, Harry C Dietz, Lynn A Sleeper, Anji T Yetman, Timothy J Bradley, Steven D Colan, Gail D Pearson, Seda Selamet E Tierney, Jami C Levine, Andrew M AtzAbstract:BACKGROUND Aortic-Root dissection is the leading cause of death in Marfan’s syndrome. Studies suggest that with regard to slowing Aortic-Root enlargement, losartan may be more effective than beta-blockers, the current standard therapy in most centers. METHODS We conducted a randomized trial comparing losartan with atenolol in children and young adults with Marfan’s syndrome. The primary outcome was the rate of AorticRoot enlargement, expressed as the change in the maximum Aortic-Root-diameter z score indexed to body-surface area (hereafter, Aortic-Root z score) over a 3-year period. Secondary outcomes included the rate of change in the absolute diameter of the Aortic Root; the rate of change in Aortic regurgitation; the time to Aortic dissection, Aortic-Root Surgery, or death; somatic growth; and the incidence of adverse events. RESULTS From January 2007 through February 2011, a total of 21 clinical centers enrolled 608 participants, 6 months to 25 years of age (mean [±SD] age, 11.5±6.5 years in the atenolol group and 11.0±6.2 years in the losartan group), who had an AorticRoot z score greater than 3.0. The baseline-adjusted rate of change (±SE) in the Aortic-Root z score did not differ significantly between the atenolol group and the losartan group (−0.139±0.013 and −0.107±0.013 standard-deviation units per year, respectively; P = 0.08). Both slopes were significantly less than zero, indicating a decrease in the degree of Aortic-Root dilatation relative to body-surface area with either treatment. The 3-year rates of Aortic-Root Surgery, Aortic dissection, death, and a composite of these events did not differ significantly between the two treatment groups. CONCLUSIONS Among children and young adults with Marfan’s syndrome who were randomly assigned to losartan or atenolol, we found no significant difference in the rate of AorticRoot dilatation between the two treatment groups over a 3-year period. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT00429364.)
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early and 1 year outcomes of Aortic Root Surgery in patients with marfan syndrome a prospective multicenter comparative study
The Journal of Thoracic and Cardiovascular Surgery, 2014Co-Authors: Joseph S Coselli, Heidi M Connolly, Hartzell V Schaff, Scott A Lemaire, Thoralf M Sundt, Irina V Volguina, Elizabeth H Stephens, Dianna M Milewicz, Luca A Vricella, Harry C DietzAbstract:Objective To compare the 1-year results after Aortic valve-sparing (AVS) or valve-replacing (AVR) Aortic Root replacement from a prospective, international registry of 316 patients with Marfan syndrome (MFS). Methods Patients underwent AVS (n = 239, 76%) or AVR (n = 77, 24%) Aortic Root replacement at 19 participating centers from 2005 to 2010. One-year follow-up data were complete for 312 patients (99%), with imaging findings available for 293 (94%). The time-to-events were compared between groups using Kaplan-Meier curves and Cox proportional hazards models. Results Two patients (0.6%)—1 in each group—died within 30 days. No significant differences were found in early major adverse valve-related events (MAVRE; P = .6). Two AVS patients required early reoperation for coronary artery complications. The 1-year survival rates were similar in the AVR (97%) and AVS (98%) groups; the procedure type was not significantly associated with any valve-related events. At 1 year and beyond, Aortic regurgitation of at least moderate severity (≥2+) was present in 16 patients in the AVS group (7%) but in no patients in the AVR group ( P = .02). One AVS patient required late AVR. Conclusions AVS Aortic Root replacement was not associated with greater 30-day mortality or morbidity rates than AVR Root replacement. At 1 year, no differences were found in survival, valve-related morbidity, or MAVRE between the AVS and AVR groups. Of concern, 7% of AVS patients developed grade ≥2+ Aortic regurgitation, emphasizing the importance of 5 to 10 years of follow-up to learn the long-term durability of AVS versus AVR Root replacement in patients with MFS.
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rationale and design of a randomized clinical trial of β blocker therapy atenolol versus angiotensin ii receptor blocker therapy losartan in individuals with marfan syndrome
American Heart Journal, 2007Co-Authors: Ronald V Lacro, Harry C Dietz, Timothy J Bradley, Steven D Colan, Lisa M Wruck, Richard B Devereux, Gloria L Klein, Jennifer S Li, Luann L Minich, Stephen M ParidonAbstract:Background Cardiovascular disease, including Aortic Root dilation, dissection, and rupture, is the leading cause of mortality in patients with Marfan syndrome (MFS). The maximal Aortic Root diameter at the sinuses of Valsalva is considered the best predictor of adverse cardiovascular outcome. Although advances in therapy have improved life expectancy, affected individuals continue to suffer cardiovascular morbidity and mortality. Recent studies in an FBN1 -targeted mouse model of MFS with Aortic disease similar to that seen in humans showed that treatment with losartan normalized Aortic Root growth and Aortic wall architecture. Methods The Pediatric Heart Network designed a randomized clinical trial to compare Aortic Root growth and other short-term cardiovascular outcomes in subjects with MFS receiving atenolol or losartan. Individuals 6 months to 25 years of age with a body surface area–adjusted Aortic Root z score >3.0 will be eligible for inclusion. The primary aim is to compare the effect of atenolol therapy with that of losartan therapy on the rate of Aortic Root growth over 3 years. Secondary end points include progression of Aortic regurgitation; incidence of Aortic dissection, Aortic Root Surgery, and death; progression of mitral regurgitation; left ventricular size and function; echocardiographically derived measures of central Aortic stiffness; skeletal and somatic growth; and incidence of adverse drug reactions. Conclusion This randomized trial should make a substantial contribution to the management of individuals with MFS and expand our understanding of the mechanisms responsible for the Aortic manifestations of this disorder.
Axel Haverich - One of the best experts on this subject based on the ideXlab platform.
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Aortic Root Surgery in septuagenarians impact of different surgical techniques
Journal of Cardiothoracic Surgery, 2009Co-Authors: Nawid Khaladj, Rainer G Leyh, Malakh Shrestha, Sven Peterss, Axel Haverich, Christian HaglAbstract:Background: To evaluate the impact and safety of different surgical techniques for Aortic Root replacement (ARR) on early and late morbidity and mortality in septuagenarians undergoing ARR. Methods: Ninety-five patients (73.8 ± 3.2 years) were operated and divided into three groups according to the Aortic Root procedure; MECH-group (n = 51) patients with a mechanical composite graft, BIO-group (n = 22) patients with a customized biological composite graft, and REIMPL-group (n = 22) patients with a valve sparing Aortic Root reimplantation (David I). In 42.1% (40/95) of these patients the Aortic arch was replaced. Follow-up was completed in 95.2% (79/83) of in-hospital survivors. Results: Hospital mortality was 12.6% (12/95) in the entire population (MECH. 15.7% (8/51), BIO 19.7% (4/22), REIMPL 0% (0/22); p = 0.004). Two patients died intraoperatively. The most frequent postoperative complications were prolonged mechanical ventilation ((>48 h) in 16.8% (16/93) (MECH. 7% (7/51), BIO 36.4% (8/22), REIMPL 4.5% (1/22); p = 0.013) and rethoracotomy for postoperative bleeding in 12.6% (12/95) (MECH. 12% (6/51), BIO 22.7% (5/22), REIMPL 4.5% (1/ 22); p = 0.19). Nineteen late deaths (22.9%) (19/83) (MECH 34.8% (15/43), BIO 16.7% (3/18), REIMPL 4.5% (1/22); p = 0.012) occurred during a mean follow-up of 41 ± 42 months (MECH 48 ± 48 months, BIO 25 ± 37 months, REIMPL 40 ± 28 months, p = 0.028). Postoperative NYHA class decreased significantly (p = 0.017) and performance status (p = 0.027) increased for the entire group compared to preoperative values. Conclusion: Our data indicate that valve sparing Aortic Root reimplantation is safe and effective in septuagenarians, and is associated with low early and late morbidity and mortality.
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ascending Aortic cannulation in acute Aortic dissection type a the hannover experience
European Journal of Cardio-Thoracic Surgery, 2008Co-Authors: Nawid Khaladj, Malakh Shrestha, Sven Peterss, Axel Haverich, Matthias Karck, M Strueber, Maximilian Pichlmaier, Christian HaglAbstract:Objective: The incidence of embolic events and of cerebral malperfusion in Aortic dissection type A (AADA) must be viewed in the context of theexistenceof a numberof possiblecannulationtechniques. Sincefemoralcannulationis thoughtto beassociatedwith a higherriskofperfusion of the false lumen and retrograde embolization, techniques establishing antegrade flow may provide a better option. We describe herein our experience with ascending Aortic cannulation in this special patient population. Methods: Between November 1999 and February 2006, 122 patientsunderwentoperation forAADAwith arterialaccessviathedissectedascendingaorta.Theaortawas cannulated atthe siteofthe minimal distancesof thedissected layers.Doublepurse-stringsutureswere usedto supportthe cannula.Pressuremonitoring inboth radialarteries as well as bilateral cerebral oxygen saturation measurement helped to identify malperfusion after establishment of cardiopulmonary bypass. Aortic arch as well as Aortic Root Surgery was performed, as dictated by the pathology. Selective antegrade cerebral perfusion and moderate hypothermia were usedfor brainand bodyprotection.Results: Malperfusion occurred in threepatients (2.5%).Hospitalmortalitywas 15%for the entirecohort (18 patients). Permanent neurological dysfunction was detected in 15 patients (12%), whereas temporary neurological dysfunction occurred in 21 (17%). Total arch replacement was performed in 31 patients (25%). Conclusion: Direct cannulation of the ascending aorta is an easy and safe method in patients with AADA. This technique, which also avoids retrograde flow in the downstream aorta, is an alternative to time-consuming axillary artery access. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
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Aortic Root Surgery in marfan syndrome comparison of Aortic valve sparing reimplantation versus composite grafting
The Journal of Thoracic and Cardiovascular Surgery, 2004Co-Authors: Matthias Karck, Rainer G Leyh, Christian Hagl, Klaus Kallenbach, Christine Rhein, Axel HaverichAbstract:Abstract Objective The objective of this study was to compare the results of Aortic valve-sparing reimplantation and Aortic Root replacement with mechanical valve conduits in patients with Marfan syndrome undergoing operation for Aortic Root aneurysms. Patients and methods Between March 1979 and April 2002, 119 patients with clinical evidence of Marfan syndrome underwent composite graft replacement with mechanical valve conduits (n = 74) or Aortic valve-sparing reimplantation according to David (n = 45). The underlying causes were Aortic dissection type A (43 patients) and aneurysms (76 patients). Results Patients undergoing Aortic valve reimplantation were younger compared with patients undergoing composite grafting (28 vs 35 years, P = .002) and had longer intraoperative Aortic crossclamp times (125 vs 78 minutes, P P P = .15). Mean follow-up was 30 months for patients undergoing Aortic valve reimplantation and 114 months for patients undergoing composite grafting. Freedom from reoperation and death after 5 years postoperatively was 92% and 89% in patients undergoing composite grafting and 84% and 96% in patients undergoing Aortic valve reimplantation ( P = .31; P = .54), respectively. Thromboembolic complications or late postoperative bleeding occurred in 17 patients undergoing composite grafting, and an early postoperative event occurred in 1 patient undergoing Aortic valve reimplantation. Conclusions The results of Aortic valve reimplantation and composite grafting of the Aortic valve and ascending aorta with mechanical valve conduits are similar with regard to early and mid-term postoperative mortality and to the incidence of late reoperations in patients with Marfan syndrome. The low risk of thromboembolic or bleeding complications favors Aortic valve reimplantation in these patients.
Takashi Kunihara - One of the best experts on this subject based on the ideXlab platform.
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Valve-sparing Aortic Root Surgery. CON: remodeling
General Thoracic and Cardiovascular Surgery, 2019Co-Authors: Takashi KuniharaAbstract:The two major valve-sparing Root replacement procedures, Aortic valve reimplantation (reimplantation) and Aortic Root remodeling (remodeling), have advantages and disadvantages, which are reviewed herein. The main advantage of reimplantation is the resulting annular support, and the disadvantages are the unfavorable hemodynamics and relatively long procedure time. The main advantages of remodeling are the physiological hemodynamics and decreased procedure time, and the disadvantage is the lack of annular support. With technical advances and modifications, however, the differences between these two procedures have narrowed. Application of a graft with sinuses for reimplantation improves the hemodynamics, and addition of annuloplasty to remodeling provides the necessary annular support. Nevertheless, remodeling has some advantages because less Root dissection is required and the procedure time is shorter and hemodynamically favorable. Thus, remodeling may be the procedure of choice for high-risk patients (such as those with acute Aortic dissection, of advanced age, with reduced ventricular function, or undergoing a concomitant operation). Remodeling may also be best for young athletes because of the hemodynamic advantage. Regardless of the advantages and disadvantages, both procedures provide excellent clinical results in terms of late valve durability. Surgeons should be familiar with both techniques and properly match patients to the appropriate treatment.
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preoperative Aortic Root geometry and postoperative cusp configuration primarily determine long term outcome after valve preserving Aortic Root repair
The Journal of Thoracic and Cardiovascular Surgery, 2012Co-Authors: Takashi Kunihara, Diana Aicher, Svetlana Rodionycheva, Heinrichvolker Groesdonk, Frank Langer, Fumihiro Sata, Hansjoachim SchafersAbstract:Objective Technical controversies exist in valve-preserving Aortic Root replacement. We sought to determine predictors of long-term stability of the Aortic valve. Methods A total of 430 patients (aged 57 ± 15 years, 323 male) underwent valve-preserving Aortic Root Surgery (remodeling in 401, reimplantation in 29) between 1995 and 2009 and were followed echocardiographically. Factors influencing late recurrence of Aortic valve regurgitation grade II or greater (n = 45) or need for reoperation on the Aortic valve (n = 25) were analyzed. Results Early mortality was 2.8% (1.9% for elective cases), and actuarial survival at 10 years was 83.5% ± 2.4%. Ten-year freedom from Aortic valve regurgitation grade II or greater was 85.0% ± 2.5%. Preoperative aortoventricular junction diameter greater than 28 mm and postoperative effective height of the Aortic cusp less than 9 mm were identified as significant predictors for late Aortic valve regurgitation grade II or greater in multivariate analysis (both P P P = .022), and effective height of the Aortic cusp less than 9 mm ( P = .049) were identified as significant predictors for reoperation in multivariate analysis. Operative technique (remodeling, reimplantation), Marfan syndrome, bicuspid valve anatomy, concomitant central cusp plication, size of prosthesis used, and acute dissection were not associated with an increased risk of late Aortic valve regurgitation grade II or greater or reoperation. In patients with preoperative aortoventricular junction diameter greater than 28 mm (n = 94), the addition of central cusp plication significantly improved freedom from Aortic valve regurgitation grade II or greater ( P = .006) regardless of Root procedures (remodeling, P = .011; reimplantation, P = .053). Conclusions Long-term stability of valve-preserving Aortic Root replacement was influenced not by the technique of Root repair but by the preoperative Aortic Root geometry and postoperative cusp configuration.