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Objective: To evaluate the long-term incidence and outcome of aortic interventions for medically managed uncomplicated thoracic aortic dissections., Methods: Between January 2012 and December 2018, 91 patients were discharged home with an uncomplicated, medically treated aortic dissection (involving the descending aorta with or without aortic arch involvement, no ascending involvement). After a median period of 4 (first quartile: 2, third quartile: 11) months, 30 patients (33%) required an aortic intervention. Patient characteristics, radiographic, treatment, and follow-up data were compared for patients with and without aortic interventions. A competing risk regression model was analyzed to identify independent predictors of aortic intervention and to predict the risk for intervention., Results: Patients who underwent aortic interventions had significantly larger thoracic (P = .041) and abdominal (P = .015) aortic diameters, the dissection was significantly longer (P = .035), there were more communications between both lumina (P = .040), and the first communication was significantly closer to the left subclavian artery (P = .049). A descending thoracic aortic diameter exceeding 45 mm was predictive for an aortic intervention (P = .001; subdistribution hazard ratio: 3.51). The risk for aortic intervention was 27% ± 10% and 36% ± 11% after 1 and 3 years, respectively. Fourteen patients (47%) underwent thoracic endovascular aortic repair, 11 patients (37%) thoracic endovascular aortic repair and left carotid to subclavian bypass, 3 patients (10%) total arch replacement with the frozen elephant trunk technique, and 2 patients (7%) thoracoabdominal aortic replacement. We observed no in-hospital mortality., Conclusions: The need for secondary aortic interventions in patients with initially medically managed, uncomplicated descending aortic dissections is substantial. The full spectrum of aortic treatment options (endovascular, hybrid, conventional open surgical) is required in these patients., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The frozen elephant trunk (FET) procedure has emerged as a potential single-step treatment for pathologies of the thoracic aorta, but the procedure's true potential to be a single-step treatment remains unclear. The aim of this study was to evaluate the need and outcomes of aortic reinterventions after previous FET implantation., Methods: Patient characteristics and follow-up data of 107 patients following the FET procedure were evaluated and compared between patients with and without aortic reinterventions. A competing risk regression model was analyzed to identify independent predictors of aortic reintervention and to predict the risk for reintervention., Results: Intended completion, anticipated reinterventions, and unexpected reinterventions were performed in 35 patients (33%). There was no difference in the underlying pathology between patients with or without aortic reintervention. An endovascular reintervention was performed in 24 patients (69%), open surgery in 7 patients (20%) and a hybrid approach in 4 patients (11%). No stroke or permanent spinal cord injuries were observed. In-hospital mortality after reintervention was 14% (5 patients), but there was no difference in survival during follow-up after FET implantation (log rank test, P = .58). No risk factors for aortic reinterventions were identified. The risk for aortic reintervention was 31% (95% confidence interval [CI], 21%-42%), 49% (95% CI, 35%-62%), and 64% (95% CI, 44%-79%) after 12, 24, and 36 months, respectively., Conclusions: Aortic reinterventions are common and likely after FET implantation, but this study did not identify independent predictors. Reinterventions are associated with acceptable morbidity and mortality. Close follow-up of all patients undergoing FET procedure is paramount., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The study objective was to screen patients with acute type A aortic dissection for anatomic feasibility of ascending aortic endovascular treatment with a valve-carrying conduit., Methods: High-quality computed tomography scans of 167 patients were available for screening. Aortic dimensions were measured using multiplanar reconstruction in the plane perpendicular to the manually corrected aortic center line. The simulated stent-graft 10-mm-long landing zones were measured starting at the sinotubular junction (proximal landing zone) and ending at the brachiocephalic trunk (distal landing zone). Exclusion criterion was an entry within the aortic root or the landing zone., Results: In 113 patients (68%), the entry was in a coverable zone in the ascending aorta with sufficient proximal and distal landing zone or in more distal aortic segments. In these patients, the median distance between the proximal and distal landing zone was 89.1 (first quartile: 80.0 mm; third quartile: 101.2 mm) and the median diameter difference was 5.0 mm (2.0; 10.1) (12.3 [4.9; 23.0] %). The diameter difference was less than 2 mm in 32 patients (28%), between 6 mm and 10 mm in 20 patients (18%), between 10 mm and 14 mm in 11 patients (10%), and 14 mm or greater in 10 patients (9%)., Conclusions: Two thirds of all patients who present with type A dissections are potential candidates for treatment with endovascular valve-carrying conduits, but most patients would require tapered stent-grafts., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: In patients with acute type A aortic dissection involving the innominate artery, it is unclear whether right axillary artery cannulation for arterial inflow is safe. We evaluated the surgical outcomes of patients with dissected innominate artery according to different arterial cannulation sites., Methods: From 2005 to 2014, of 416 patients with acute type A aortic dissection and preoperative computed tomography angiography in 2 centers, 186 (aged 63 ± 13 years; 43% were female; 95% with DeBakey type I) had dissected innominate artery (84%, 9%, and 7% involving its entire length or more or less than half of its length, respectively). Neurologic complications, in-hospital mortality, and survival were compared between patients with right axillary (N = 84) and non-right axillary (N = 102) cannulation sites. Median follow-up was 30 months (range, 0-130 months)., Results: In-hospital mortality was 9.5% and 10.8% (P = .97) for patients with right and non-right axillary cannulation, respectively. Seven patients (8.3%) with right axillary cannulation and 9 patients (8.8%; P = .89) with non-right axillary cannulation had a new-onset postoperative stroke. The axillary artery was cannulated (although dissected) in 8 patients. None of them had a new-onset stroke or died perioperatively. The innominate artery remodeling was observed on follow-up computed tomography in 12% of right axillary cases and 14% of non-right axillary cases (P = .82). Survival did not differ between right axillary and non-right axillary cases, and measured 92% ± 3% versus 87% ± 4% and 85% ± 5% versus 73% ± 9% at 1 and 5 years, respectively (log rank, P = .29)., Conclusions: The right axillary artery is safe to cannulate for arterial inflow in patients with type A aortic dissection with dissected innominate artery., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Thoracic endovascular aortic repair has broadened the spectrum of treatment options for various acute and chronic thoracic aortic diseases. In clinical practice, aneurysms of the descending aorta are rarely limited to 1 segment. Thus, various surgical and endovascular options have been developed to offer treatment to those patients with more extended descending thoracic aortic disease. We have summarized the most common methods of arch rerouting, depending on the aortic involvement, emphasizing that these techniques should be used very selectively by experienced cardiovascular surgery teams., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Aortic valve replacement using a tissue valve is controversial for patients younger than 60 years old. The long-term survival in this age group, the expected event rates during long-term follow-up, and valve-related complications are not clearly determined., Methods: From January 2000 to December 2009, overall survival, valve-related events, and echocardiographic outcomes were analyzed in all patients younger than 60 years of age, who underwent biologic aortic valve replacement. Patients who received a Perimount Carpentier-Edwards pericardial tissue valve (n = 103) were selected and compared with a propensity matched group of 103 patients who received aortic valve replacement using a mechanical bileaflet valve. The mean follow-up was 33 ± 24 months (range, 2-120), and the mean age at implantation was 50.6 ± 8.8 years (bioprosthesis, 55 ± 8.9 years; mechanical valve, 50 ± 8.6 years; P = .03)., Results: Survival was significantly reduced in patients after biologic aortic valve replacement (90.3% vs 98%; P = .038). Freedom from all valve-related complications (bioprosthesis, 54.5%; mechanical valve, 51.6%; P = NS) and freedom from reoperation (bioprostheses, 100%; mechanical valve, 98%; P = NS) were comparable in both groups. The average transvalvular mean (11.2 ± 4.2 mm Hg vs 10.5 ± 6.0 mm Hg, P = .05) and peak (19.9 ± 6.7 mm Hg vs 16.7 ± 8.0 mm Hg, P = .03) gradients were greater after biologic aortic valve replacement. Regression of the left ventricular mass index was more pronounced after mechanical valve replacement (118.5 ± 24.9 g/m(2) vs 126.5 ± 38.5 g/m(2); P = NS). The echocardiographic patient-prosthesis mismatch was greater at follow-up after biological aortic valve replacement (0.876 ± 0.2 cm(2)/m(2) vs 1.11 ± 0.4 cm(2)/m(2); P = .01). Oral anticoagulation was a protective factor for survival among the bioprosthetic valve patients (P = .024)., Conclusions: In the present limited cohort of patients younger than 60 years old, biologic aortic valve replacement was associated with reduced mid-term survival compared with survival after mechanical aortic valve replacement. Despite similar valve-related event rates in both groups, the better hemodynamic performance of the mechanical valves and/or protective effect of oral anticoagulation seemed to improve the outcome. The transcatheter valve-in-valve intervention as potential treatment of tissue valve degeneration should not be considered the sole bailout strategy for younger patients because no evidence is available that this would improve the outcome., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Endovascular stent grafting represents a novel concept for type B aortic dissection both in the acute and subacute/chronic setting, with an unknown effect on outcomes., Methods: In a prospective trial 140 patients with stable type B dissection were randomly subjected to elective stent-graft placement in addition to optimal medical therapy (n = 72) or to optimal medical therapy (n = 68) with surveillance (arterial pressure according to World Health Organization guidelines ≤ 120/80 mm Hg). The primary end point was 1-year all-cause mortality, whereas aorta-related mortality, progression (with need for conversion or additional endovascular or open surgical intervention), and aortic remodeling were secondary end points., Results: There was no difference in all-cause mortality: cumulative survival was 97.0% ± 3.4% with optimal medical therapy versus 91.3% ± 2.1% with thoracic endovascular aortic repair (P = .16). Moreover, aorta-related mortality was not different (P = .42), and the risk for the combined end point of aorta-related death (rupture) and progression (including conversion or additional endovascular or open surgical intervention) was similar (P = .86). Three neurologic adverse events occurred in the thoracic endovascular aortic repair group (1 paraplegia, 1 stroke, and 1 transient paraparesis) versus 1 episode of paraparesis with medical treatment. Finally, aortic remodeling (with true-lumen recovery and thoracic false-lumen thrombosis) occurred in 91.3% with thoracic endovascular aortic repair versus 19.4% with medical treatment (P < .001), which is suggestive of continued remodeling., Conclusions: In survivors of uncomplicated type B aortic dissection, elective stent-graft placement does not improve 1-year survival and adverse events, despite favorable aortic remodeling., (Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: This study evaluated long-term results of thoracic endovascular aortic repair for atherosclerotic aneurysms involving descending aorta., Methods: One hundred thirteen patients underwent thoracic endovascular aortic repair for this indication from 1996 to 2009. Mean follow-up was 54 ± 38 months (5-144 months). In-hospital mortality, neurologic injury, need for rerouting, occurrence of endoleaks and their treatment, and survival were recorded., Results: In-hospital mortality was 5.3%. Transient neurologic injury rate was 2.6%. Previous rerouting was performed in 51%. Assisted early and late type I and III endoleak rates were 7.9% and 5.7%, respectively. Five percent of patients required late surgical conversion. Actuarial survivals were 86%, 60%, and 42% at 1, 5, and 10 years, respectively. Aorta-related actuarial survivals were 94%, 90%, and 83% at 1, 5, and 10 years, respectively. Cox regression analysis revealed higher number of prostheses as independent risk factor for early (hazard ratio, 5.38; 95% confidence interval, 1.68-42.37) and late (hazard ratio, 8.49; 95% confidence interval, 1.09-66.06) endoleak formation. Female sex (hazard ratio, 0.35; 95% confidence interval, 0.13-0.99), no arch involvement (hazard ratio, 0.21; 95% confidence interval, 0.05-0.08), and higher number of prostheses (hazard ratio, 7.95; 95% confidence interval, 1.36-46.58) affected survival., Conclusions: Aorta-related survival is excellent among patients undergoing thoracic endovascular aortic repair for atherosclerotic aneurysms involving the descending aorta. Life-long surveillance remains mandatory, with early and late failure uncommon but still needing consideration. Thoracic endovascular aortic repair in this group of patients remains attractive and has now proven durability., (Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: Direct application of low-energy unfocused shock waves induces angiogenesis in ischemic soft tissue. The potential effects of epicardial shock wave therapy applied in direct contact to ischemic myocardium are uncertain., Methods: For induction of ischemic heart failure in a rodent model, a left anterior descending artery ligation was performed in adult Sprague-Dawley rats. After 4 weeks, reoperation with (treatment group, n = 60) or without (control group, n = 60) epicardial shock wave therapy was performed. Low-energy shock waves were applied in direct contact with the infarcted myocardium (300 impulses at 0.38 mJ/m(2)). Additionally, healthy animals (n = 30) with normal myocardium were studied. Angiogenesis, ventricular function upregulation of growth factors, and brain natriuretic peptide levels were analyzed., Results: Histologic analysis revealed significant angiogenesis 6 weeks (treatment group: 8.2 +/- 3.7 vs control group: 2.9 +/- 1.9 vessels per field, P = .016) and 14 weeks (treatment group: 7.1 +/- 3.1 vs control group: 3.2 +/- 1.8 vessels per field, P = .011) after shock wave treatment. In the treatment group ventricular function improved throughout the follow-up period (6 weeks: 37.4% +/- 9% [P < .001] and 14 weeks: 39.5% +/- 9% [P < .001]). No improvement of ventricular function was observed in the control group (6 weeks: 28.6% +/- 5% and 14 weeks: 21.4% +/- 5%). Rat brain natriuretic peptide 45 levels were lower in the treatment group compared with those in the control group 6 and 14 weeks after treatment. Vascular endothelial growth factor, Fms-related tyrosine kinase 1, and placental growth factor levels were upregulated after 24 and 48 hours and 7 days in the treatment group. No effects on healthy myocardium were observed., Conclusion: Direct epicardial low-energy shock wave therapy induces angiogenesis and improves ventricular function in a rodent model of ischemic heart failure.

Objective: Fixed pulmonary hypertension is a contraindication for cardiac transplantation because of the increased risk of donor heart failure. We sought to determine whether left ventricular assist devices improve fixed pulmonary hypertension in cardiac transplant candidates to enable safe cardiac transplantation., Methods: Thirty-five consecutive cardiac transplant candidates (age 56 +/- 6 years, 88.5% were men) with fixed pulmonary hypertension (5.1 +/- 2.6 Wood units) resistant to medical treatment received a left ventricular assist device as a bridge to transplantation. Three left ventricular assist device systems were used (pulsatile blood flow: Novacor [World Heart Inc, Oakland, Calif] n = 8; continuous blood flow: MicroMed DeBakey [MicroMed Technology Inc, Houston, Tex] n = 24, DuraHeart [Terumo Heart Inc, Ann Arbor, Mich] n = 3). Right-sided heart catheter data were obtained before left ventricular assist device implantation at 3-day and 6-week follow-ups. Clinical data and complications were recorded., Results: Before left ventricular assist device implantation, the pulmonary vascular resistance was 5.1 +/- 2.8 Wood units. Values were comparable in patients receiving pulsatile (5.1 +/- 3.4 Wood units) or continuous blood flow left ventricular assist devices (5.1 +/- 2.7 Wood units, P = .976). Left ventricular assist device implantation decreased pulmonary vascular resistance at 3-day (2.9 +/- 1.3 Wood units, P < .0001) and 6-week (2.0 +/- 0.8 Wood units, P < .0001) follow-ups compared with before implantation. This effect was independent of the type of left ventricular assist device system used (3-day follow-up: pulsatile flow: 3.2 +/- 1.3 Wood units vs continuous flow: 2.7 +/- 1.2 Wood units; P = .310 and 6-week follow-up: pulsatile flow: 1.9 +/- 0.9 Wood units vs continuous flow: 2.1 +/- 0.8 Wood units; P = .905). Twenty-four patients had successful bridges to transplantation (69%, mean time on left ventricular assist device 210 +/- 83 days), and 11 patients died before transplantation (31%, mean time on left ventricular assist device 67 +/- 30 days). The 1-year survival after transplantation was 95%., Conclusion: Left ventricular assist devices decrease fixed pulmonary hypertension in cardiac transplant candidates and allow patients to overcome a contraindication for cardiac transplantation. Therefore, left ventricular assist devices should be considered in all cardiac transplant candidates with fixed pulmonary hypertension.

Objective: The purpose of the study was to determine technical and clinical results in endovascular repair of thoracic aortic diseases necessitating stent-graft anchoring across the arch vessels., Methods: The causes for endovascular treatment in 58 patients (aged 20 to 84 years) were aneurysms (n = 32), acute type A (n = 2) and type B dissections (n = 17), posttraumatic transections (n = 4), iatrogenic dissection (n = 1), and penetrating ulcers with an intramural hematoma (n = 2). Surgical revascularization of arch vessels was performed in 26 patients before stent-graft implantation. Intentional overstenting of the left subclavian artery resulted in complete occlusion in 8 and was partial in 24 patients., Results: The 30-day mortality rate was 3.4%. Overall, 19 major postprocedural complications occurred in 14 (24%) patients. Among patients with left subclavian artery occlusion, 2 patients had major (1 paraplegia, 1 critical arm ischemia), and 3 minor (2 temporary vertebrobasilary symptoms, 1 transient arm claudication) complications. Fourteen (25%) patients had an early endoleak, of whom 5 were treated successfully with a secondary endovascular procedure, 2 necessitated open surgical conversion, and 7 were treated conservatively, with spontaneous sealing of the endoleak in 3. In 53 (91%) in whom computed tomographic follow-up was longer than 3 months (mean, 30.1 months, range, 3 to 85), the aortic diameter along the stented segment decreased in 24, was stable in 19, and increased in 10 patients., Conclusion: Fixation of the stent graft in the aortic arch can expand the applicability of endovascular repair. Intentional overstenting should be performed with caution to avoid ischemic problems after complete occlusion of left subclavian artery.