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This article compares the long-term outcomes of two surgical techniques, neomedia implantation and two-component glue, for sinus preservation in patients under 65 with acute type A aortic dissection. The study found that neomedia resulted in lower rates of reintervention compared to glue, indicating a more durable reconstruction of the aortic root layers. While early postoperative outcomes were similar, neomedia showed promise in reducing the need for proximal reoperation. [Extracted from the article]

Objective: The aim of this study was to determine the indication and optimal timing for performing a hemiarch procedure in patients undergoing valve-sparing root replacement (VSRR)., Methods: We conducted a retrospective study on 986 patients undergoing VSRR at three tertiary care centres. Inclusion criteria were all patients undergoing elective VSRR. Exclusion criteria were age <18 years, Stanford type A dissection, dissection in the arch, total aortic arch replacement or previous aortic arch replacement. We performed propensity score matching in a 1:1 ratio. The primary end-point is a composite outcome that includes mortality, aortic arch reintervention, new aortic dissection during follow-up and cerebrovascular incidents within the first 30 days., Results: A total of 401 patients (41%) had a hemiarch replacement, while 585 (59%) did not. Root phenotype was present in 565 (57%). The mean follow-up time was 4.7 years (SD ± 4.6). In the matched population, there was no significant difference in the 10-year freedom from the composite outcome between the non-hemiarch and hemiarch groups (87.3% vs 85.0%, P > 0.999). Similarly, no difference was found for aortic reinterventions (P = 0.13) or survival (P = 0.5). This was also true for patients with heritable thoracic aortic disease. However, in patients with a bicuspid aortic valve, the intervention rate was significantly higher in the hemiarch group (10.8% vs 0%, P = 0.016). There was no significant difference in the 30-day incidence of cerebrovascular accidents between the groups (5% vs 2.7% in the hemiarch group, P = 0.117). Only the distal ascending diameter showed a tendency with better outcome over 45 mm for the hemiarch procedure; otherwise, we found no reliable cut-off values based on ascending length, diameter-to-height index or ascending length-to-height index., Conclusions: Our findings conclusively demonstrate that concomitant hemiarch replacement does not increase the perioperative risk in young patients undergoing VSRR. However, concomitant replacement does not seem to protect from aortic reinterventions during medium-term follow-up., (© The Author(s) 2025. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: We aim to evaluate the impact of antegrade stenting of the distal arch and proximal descending aorta combined with non-total arch procedures in acute type A aortic dissection., Methods: From 2005 to 2022, 733 nonsyndromic patients presented with acute DeBakey type I aortic dissection and underwent non-total arch procedure. Ninety-five patients underwent antegrade stenting and 638 did not. Propensity-score analysis was performed, and 95 optimal pairs were created. Survival was estimated using the Kaplan-Meier method and cumulative incidence of reintervention with death as a competing event was calculated and compared using Gray's method., Results: Survival estimates at 10 years after propensity score matching were similar between both groups, 58.9% (95% CI, 46.5%-74.5%) vs 58.4% (95% CI, 48.3%-70.6%) (P = .6) in the non-stented vs stented group. Cumulative incidence of reintervention with competing risk of death at 10 years after propensity matching was 27% (95% CI, 17%-37%) vs 22% (95% CI, 14%-32%) (P = .44), respectively., Conclusions: Antegrade thoracic endovascular aortic repair may be beneficial for remodeling and facilitating future endovascular reinterventions and reduces the occurrence of reintervention for malperfusion., Competing Interests: Disclosures Joseph E. Bavaria reports a relationship with WL Gore and Associates that includes: consulting or advisory; with Abbott that includes: consulting or advisory; with Edwards Lifesciences Corporation that includes: consulting or advisory; with Medtronic Inc that includes: consulting or advisory; and with Terumo Aortic that includes: consulting or advisory. Wilson Y. Szeto reports a relationship with Terumo Aortic that includes: consulting or advisory and speaking and lecture fees; with Medtronic Inc that includes: consulting or advisory and speaking and lecture fees; with Edwards Lifesciences Corporation that includes: consulting or advisory and speaking and lecture fees; and with Artivion, Inc. that includes: consulting or advisory and speaking and lecture fees. Nimesh D. Desai reports a relationship with Terumo Aortic that includes: consulting or advisory. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Tissue necrosis from persistent mesenteric ischemia after aortic dissection may progress to sepsis and death without emergency laparotomy. However, the signs of mesenteric necrosis are common in patients experiencing nonsurvivable multisystem failure after aortic catastrophe. This study examined when and whether laparotomy offers a chance for meaningful survival in these patients., Methods: A total of 145 patients treated for acute type A or type B aortic dissection with mesenteric ischemia were identified from a single institution from 2006 to 2022. Of those patients, 29 underwent laparotomy, all for compelling clinical indications. Detailed clinical characteristics were studied with respect to short- and long-term outcomes in these patients., Results: Among the patients who underwent laparotomy, 45% (13 of 29) survived to discharge compared with 71% (103 of 145) of all patients with mesenteric malperfusion. Serum lactate and arterial pH were both very strongly associated with survival after laparotomy. Among survivors and nonsurvivors, the mean lactate level before laparotomy was 6.3 mmol/L vs 13.4 mmol/L (P = .024), and the mean pH was 7.39 vs 7.20 (P < .001). In particular, a lactate value higher than 8 mmol/L (odd ratio, 16.5; 95% CI, 2.0-192; P = .003) and a pH lower than 7.30 (odds ratio, 14.4; 95% CI, 1.87-128; P = .003) were highly predictive of mortality. Survival to discharge after laparotomy for patients with both severe lactatemia and severe acidosis (defined earlier) was 9% (1 of 11) compared with 90% (9 of 10) for patients with neither severe lactatemia nor acidosis., Conclusions: The degree of lactic acidosis can effectively identify patients for whom laparotomy is futile and those for whom it is not after aortic dissection with mesenteric ischemia., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: For patients with type A aortic dissection complicated by mesenteric malperfusion syndrome, some centers advocate a nontraditional approach based on up-front endovascular intervention and delayed open repair. However, the efficacy of this strategy cannot be understood without first understanding outcomes of the traditional open-first strategy in the same select patient population eligible for delayed repair, applying modern techniques of hybrid aortic surgery., Methods: Patients with acute type A aortic dissection and mesenteric malperfusion syndrome were queried from a single institution. Those presenting with aortic rupture, tamponade, or cardiogenic shock (ineligible for delayed repair) were excluded. Patients were managed with immediate open aortic repair. Short-term and long-term outcomes are reported., Results: A total of 1228 patients were treated for acute type A dissection in the study period, of whom 77 were included in the mesenteric malperfusion syndrome cohort. In-hospital mortality was 29% compared with 39% in an identically selected mesenteric malperfusion syndrome population undergoing delayed repair reported previously. Among patients with mesenteric malperfusion syndrome, 32% underwent additional procedures addressing distal malperfusion in a hybrid operating room during or after open repair. Concomitant proximal malperfusion (coronary, cerebral, or upper extremity) was common in the mesenteric malperfusion syndrome cohort, present in 35% of cases. Although early mortality was greater in the mesenteric malperfusion syndrome cohort compared with all acute type A dissections, 10-year survival among those discharged alive was similar (65% vs 59%, P = .18)., Conclusions: The traditional open-first repair strategy performs equal to or better than the delayed repair strategy for patients with mesenteric malperfusion syndrome eligible for delayed repair., Competing Interests: Conflict of Interest Statement J.E.B. and N.D.D.: consultants for Gore Medical and Terumo Aortic. W.Y.S.: speaker, investigator, and advisory board member for Edwards Lifesciences, Medtronic, Abbott Laboratories, Terumo Aortic, and Artivion Inc. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Limited data exist on long-term mortality and reintervention rates after emergent thoracic endovascular aortic repair (TEVAR) for ruptured thoracic aortic aneurysm (rTAA). This study aimed to characterize the long-term outcomes of emergent TEVAR for rTAA., Methods: All TEVARs for rTAA and elective intact thoracic aortic aneurysms (iTAAs) were reviewed at a large academic medical center from 2005 to 2022. Long-term clinical outcomes were considered over eight years., Results: Of 321 patients undergoing TEVAR for TAA, 20% (65/321) presented with rTAA. Median clinical follow-up was 5.1 years. rTAA patients had much lower 30-day survival (69.2% vs 96.9%; P < .001) and higher rates of stroke, pneumonia, and prolonged ventilation (all P ≤ .01). Long-term survival was worse for all rTAA patients compared to all iTAA patients at 1 year (46% vs 86%), 5 years (27% vs 48%), and 8 years (20% vs 32%; all P < .001), driven largely by frequent early mortality. However, for patients surviving at least 90 days, the long-term survival difference over 8 years was minimal (34% vs 33%, log-rank P = .43) among patients presenting with ruptured vs intact TAA. Ruptured aneurysms required more reinterventions within 30 days, but had comparable late reintervention rates, with type I endoleak as the leading cause., Conclusions: The present study is the largest to focus on long-term outcomes following TEVAR for rupture TAA. Unsuprisingly, short-term outcomes are worse in patients presenting with ruptured vs intact aneurysms. However, importantly, long-term survival in rTAA patients who do survive 90 days is comparable to that of iTAA patients., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: This study aimed to evaluate employing the German Registry of Acute Aortic Dissection Type A (GERAADA) score to predict 30-day mortality in an aortic centre in the USA., Methods: Between January 2010 and June 2021, 689 consecutive patients underwent surgery for acute type A dissection at a single institution. Excluded were patients with missing clinical data (N = 4). The GERAADA risk score was retrospectively calculated via a web-based application. Model discrimination power was calculated with c-statistics from logistic regression and reported as the area under the receiver operating characteristic curve with 95% confidence intervals. The calibration was measured by calculating the observed versus estimated mortality ratio. The Brier score was used for the overall model evaluation., Results: Included were 685 patients [mean age 60.6 years (SD: 13.5), 64.8% male] who underwent surgery for acute type A aortic dissection. The 30-day mortality rate was 12.0%. The GERAADA score demonstrated very good discrimination power with an area under the receiver operating characteristic curve of 0.762 (95% confidence interval 0.703-0.821). The entire cohort's observed versus estimated mortality ratio was 0.543 (0.439-0.648), indicating an overestimation of the model-calculated risk. The Brier score was 0.010, thus revealing the model's acceptable overall performance., Conclusions: The GERAADA score is a practical and easily accessible tool for reliably estimating the 30-day mortality risk of patients undergoing surgery for acute type A aortic dissection. This model may naturally overestimate risk in patients undergoing surgery in experienced aortic centres., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: There is an ongoing debate regarding whether patients benefit more from root replacement compared to a reconstruction of the sinuses of Valsalva in acute type A aortic dissection (aTAAD). In those with known or suspected connective tissue disorders, root replacement is considered appropriate. However, there are currently no diameter-based guidelines regarding the best approach in patients with minimally to moderately dilated root and no connective tissue disorders., Methods: From January 2005 to December 2022, a two-centre registry of aTAAD was created. Patients were included based on their age (≤60 years), the absence of root entry and dilatation >50 mm and the absence of syndromic hereditable aortic disease. Patients were divided into 2 groups based on the proximal procedure, root reconstruction and root replacement. Propensity score pair matching was performed based on preoperative characteristics., Results: Cumulative incidence of reintervention at 10 years was slightly higher after root reconstruction 13% vs 3.9% in the matched group (P = 0.040). Survival at 10 years was not affected by the procedure independently of the matching 72.1% vs 71.4% (P = 0.2). Uni- and multivariate Cox regressions showed that a root diameter of >40 mm was associated with a hazard ratio of 7.7 (95% confidence interval 2.6-23) and 5.4 (7-17), respectively, for reoperation for aneurysm and pseudoaneurysm., Conclusions: Rate of reoperation due to proximal pseudoaneurysm and aneurysm could be significantly reduced with a lower threshold of 40 mm to replace the aortic root in aTAAD than in elective cases., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)