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OBJECTIVE: Female sex is a known risk factor in most cardiac surgery, including coronary and valve surgery, but unknown in acute type A aortic dissection repair. METHODS: From 1996 to 2018, 650 patients underwent acute type A aortic dissection repair; 206 (32%) were female, and 444 (68%) were male. Data were collected through the Cardiac Surgery Data Warehouse, medical record review, and National Death Index database. RESULTS: Compared with men, women were significantly older (65 vs 57 years, P < .0001). The proportion of women and men inverted with increasing age, with 23% of patients aged less than 50 years and 65% of patients aged more than 80 years being female. Women had significantly less chronic renal failure (2.0% vs 5.4%, P = .04), acute myocardial infarction (1.0% vs 3.8%, P = .04), and severe aortic insufficiency. Women underwent significantly fewer aortic root replacements with similar aortic arch procedures, shorter cardiopulmonary bypass times (211 vs 229 minutes, P = .0001), and aortic crossclamp times (132 vs 164 minutes, P < .0001), but required more intraoperative blood transfusion (4 vs 3 units) compared with men. Women had significantly lower operative mortality (4.9% vs 9.5%, P = .04), especially in those aged more than 70 years (4.4% vs 16%, P = .02). The significant risk factors for operative mortality were male sex (odds ratio, 2.2), chronic renal failure (odds ratio, 3.4), and cardiogenic shock (odds ratio, 6.8). The 10-year survival was similar between sexes. CONCLUSIONS: Physicians and women should be cognizant of the risk of acute type A aortic dissection later in life in women. Surgeons should strongly consider operations for acute type A aortic dissection in women, especially in patients aged 70 years or more.

We performed a contemporary assessment of clinical and radiographic factors of stroke after thoracic endovascular aortic repair (TEVAR). Patients undergoing TEVAR from 2006 to 2017 were identified. We assessed clinical and radiographic data, including preoperative head and neck computed tomography, Doppler ultrasonography, and intraoperative angiography. Our primary outcome was stroke after TEVAR. Four hundred seventy-nine patients underwent TEVAR, mean age 68.1 ± 19.5 years, 52.6% male. Indications for TEVAR included aneurysms (n = 238, 49.7%) or dissections (n = 152, 31.7%). Ishimaru landing zones were Zone 2 (n = 225, 47.0%), Zone 3 (n = 151, 31.5%), or Zone 4 (n = 103, 21.5%). Stroke occurred in 3.8% (n = 18) of patients, with 1.9% (8) major events (modified Rankin Scale3). Pathophysiology was predominantly embolic (n = 14), and occurred in posterior (n = 6), anterior (n = 6), or combined circulation (n = 4), and in the left hemisphere (n = 10) or bilateral (n = 6). Univariate analysis suggested use of lumbar drain (33.3% versus 57.2%, P = 0.04), inability to revascularize the left subclavian artery (16.7% vs 5.2%, P = 0.04) and number of implanted components (2.5 ± 1.2 vs 2.0 ± 0.97, P = 0.03) were associated with stroke. Multivariable analysis identified number of implanted components (OR 1.7, 95%CI 1.17-2.67 P = 0.00) and inability to revascularize the left subclavian artery as independent predictors of stroke. Stroke was associated with a higher perioperative mortality (27.8% vs 3.9%, P0.01). Stroke after TEVAR is primarily embolic in nature and related to both anatomic and procedural factors. This may have important implications for device development in the era of endovascular arch repair.

Left bundle branch block (LBBB) and atrioventricular (AV) conduction abnormalities requiring permanent pacemaker (PPM) implantation occur frequently following transcatheter aortic valve replacement (TAVR). The resultant left ventricular (LV) dyssynchrony may be associated with adverse clinical events.The purpose of this study was to assess the adverse outcomes associated with LV dyssynchrony due to high-burden right ventricular (RV) pacing or permanent LBBB following TAVR in patients with preserved left ventricular ejection fraction (LVEF).Consecutive TAVR patients at the University of Michigan from January 2012 to June 2017 were included. Pre-existing cardiac implantable electronic device, previous LBBB, LVEF50%, or follow-up period1 year were excluded. The primary outcome was all-cause mortality. Secondary outcomes included cardiomyopathy (defined as LVEF ≤45%), a composite endpoint of cardiomyopathy or all-cause mortality, and the change in LVEF at 1-year follow-up.A total of 362 patients were analyzed (mean age 77 years). LV dyssynchrony group (n = 91 [25.1%]) included 56 permanent LBBB patients, 12 permanent LBBB patients with PPM, and 23 non-LBBB patients with PPM and high-burden RV pacing. Remaining patients served as control (n = 271 [74.9%]). After adjusted analysis, LV dyssynchrony had significantly higher all-cause mortality (adjusted hazard ratio [HR] 2.16; 95% confidence interval [CI] 1.07-4.37) and cardiomyopathy (adjusted HR 14.80; 95% CI 6.31-14.69). The LV dyssynchrony group had mean LVEF decline of 10.5% ± 10.2% compared to a small increase (0.5% ± 7.7%) in control.Among TAVR patients with preserved LVEF and normal AV conduction, development of postprocedural LV dyssynchrony secondary to high-burden RV pacing or permanent LBBB was associated with significantly higher risk of death and cardiomyopathy at 1-year follow-up.

Various surgical options have been described for the treatment of aberrant subclavian arteries and an associated Kommerell diverticulum.Between 1999 and 2019, 43 patients underwent a repair, comprising 26 (61%) endovascular and 17 (39%) open approaches. The endovascular approach consisted of initial subclavian revascularization followed by thoracic endovascular aortic repair. The open approach included total arch replacement (12%) and reverse hemiarch repair with left thoracotomy (53%) or right thoracotomy (35%). The perioperative and long-term outcomes were retrospectively reviewed.No mortality occurred in the endovascular group, whereas there was 1 (6%) in the open approach group. Patients in the endovascular group demonstrated a shorter hospital stay (3.5 days vs 10.0 days; P = .001) and less frequent prolonged mechanical ventilation (0% vs 24%; P = .019), with a lower occurrence of pneumonia (0% vs 24%; P = .019). Among patients who had the endovascular approach, shrinkage of Kommerell diverticulum or aberrant vessel origin was seen in 96%. Furthermore, relief of dysphagia was confirmed in 92% (12/13), including patients without Kommerell diverticulum (n = 3) after endovascular repair. The cumulative incidence of treatment failure or aortic reintervention at 7 years was 21% and 14 % in the endovascular and open approach groups, respectively (P = .62). Two (8%) patients in the endovascular group required an open reintervention. One reintervention was performed for persistent dysphagia in the setting of an untreated complete vascular ring, and the other was for persistent false lumen flow associated with aortic dissection.The treatment approach should be individualized on the basis of the aortic disease and comorbidities. The endovascular approach is a viable and effective alternative in the presence of suitable landing zones.

Aortic aneurysms involving aortic arch vessels are anatomically unsuitable for standard thoracic endovascular repair (TEVAR) without cervical debranching of the arch vessels. Three year outcomes of a single branched thoracic endograft following previous publication of peri-operative and one year outcomes are reported.This was a multicentre feasibility trial of the GORE TAG Thoracic Branch Endoprosthesis (TBE), a thoracic endovascular graft incorporating a single retrograde branch for aortic arch vessel perfusion. The first study arm enrolled patients with an intact descending thoracic aortic aneurysm extending to the distal arch with left subclavian artery (LSA) incorporation (zone 2). The second arm enrolled patients with arch aneurysms requiring incorporation of the left carotid or innominate artery (zone 0/1) and extra-anatomic surgical revascularisation of the remaining aortic arch vessels. Outcomes at three years are reported.The cohort comprised 40 patients (31 zone 2, nine zone 0/1). The majority were male (52%). Mean follow up was 1 408 ± 552 days in the zone 2 and 1 187 ± 766 days in the zone 0/1 cohort. During three year follow up there was no device migration, fracture, or aortic rupture in either arm. In the zone 2 arm, freedom from re-intervention was 97% at one and three years but there were two side branch occlusions. Two patients had aneurysm enlargement5 mm without documented endoleak or re-intervention. Freedom from death at one and three years was 90% and 84%. In the zone 0/1 arm there were no re-interventions, loss of branch patency, or aneurysm enlargement at three years. Cerebrovascular events occurred in three patients during follow up: two unrelated to the device or procedure, and one of unknown relationship. Two patients in this arm died during the follow up period, both unrelated to the procedure or the aneurysm.Initial three year results of the TBE device for endovascular repair of arch aneurysms show favourable patency and durability with low rates of graft related complications.

To compare perioperative and midterm outcomes in thoracic and thoraco-abdominal aortic aneurysm (TAA and TAAA) repair using hypothermic circulatory arrest (HCA) or aortic clamping (AC) with mild hypothermia.From 2012 to 2021 there were 180 open repairs of a TAA or TAAA, of which 90 (50%) were done with HCA and 90 (50%) with aortic clamping with mild hypothermia. The indications for HCA were arch aneurysm, TAA from chronic aortic dissection, and inability to clamp the aorta for proximal anastomosis.Compared to AC, the HCA group had less prior descending aorta replacement/repair (9.1% vs. 32%, p = 0.0001). Intraoperatively, the HCA group had more TAAs (70% vs. 20%, p 0.0001) while the AC group had more TAAAs (80% vs. 30%, p 0.0001). HCA group had longer cardiopulmonary bypass times (242 vs. 181 min, p 0.0001) but shorter cross-clamp time (39 vs. 120 min, p 0.0001) and lower temperatures (18°C vs. 34°C, p 0.0001). Postoperatively, the HCA group had longer intubation times (31 vs. 26 h, p = 0.002), but all other postoperative outcomes including paralysis (2.2% vs. 8.9%, p = 0.08), and operative mortality (4.4% vs. 2.2%, p = 0.68) were similar between HCA and AC groups. Patient age was an independent risk factor for postoperative paralysis (OR 1.07, p = 0.03) while HCA was not significant (OR 0.37, p = 0.21). Five-year survival was similar between HCA and AC groups (85% vs. 80%, p = 0.36).Postoperative outcomes and midterm survival were acceptable in thoracic and thoracoabdominal aneurysm patients after HCA or AC. Both HCA and AC with mild hypothermia were valid approaches in TAA/A repair.

The aorta is in constant motion due to the combination of cyclic loading and unloading with its mechanical coupling to the contractile left ventricle (LV) myocardium. This aortic root motion has been proposed as a marker for aortic disease progression. Aortic root motion extraction techniques have been mostly based on 2D image analysis and have thus lacked a rigorous description of the different components of aortic root motion (e.g., axial versus in-plane). In this study, we utilized a novel technique termed vascular deformation mapping (VDM(D)) to extract 3D aortic root motion from dynamic computed tomography angiography images. Aortic root displacement (axial and in-plane), area ratio and distensibility, axial tilt, aortic rotation, and LV/Ao angles were extracted and compared for four different subject groups: non-aneurysmal, TAA, Marfan, and repair. The repair group showed smaller aortic root displacement, aortic rotation, and distensibility than the other groups. The repair group was also the only group that showed a larger relative in-plane displacement than relative axial displacement. The Marfan group showed the largest heterogeneity in aortic root displacement, distensibility, and age. The non-aneurysmal group showed a negative correlation between age and distensibility, consistent with previous studies. Our results revealed a strong positive correlation between LV/Ao angle and relative axial displacement and a strong negative correlation between LV/Ao angle and relative in-plane displacement. VDM(D)-derived 3D aortic root motion can be used in future studies to define improved boundary conditions for aortic wall stress analysis.

OBJECTIVES Malperfusion syndrome accompanying aortic dissection is an independent predictor of death with in-hospital mortality rates >60%. Asymmetrically decreased renal enhancement on computed tomography angiography is often considered evidence of renal malperfusion. We investigated the associations between renal enhancement, baseline laboratory values and the diagnosis of renal malperfusion, as defined by invasive manometry, among patients with aortic dissection. METHODS In this retrospective cohort study, we included all patients who were referred to our institution with acute dissection and suspected visceral malperfusion between 2010 and 2020. We determined asymmetric renal enhancement by visual assessment and quantitative density measurements of the renal cortex. We collected invasive renal artery pressures during invasive angiography at the aortic root and in the renal arteries. Logistic regression was performed to evaluate independent predictors of renal malperfusion. RESULTS Among the 161 patients analysed, the majority of patients were male (78%) and had type A dissection (52%). Invasive angiography confirmed suspected renal malperfusion in 83% of patients. Global asymmetric renal enhancement was seen in 42% of patients who did not have renal malperfusion during invasive angiography. Asymmetrically decreased renal enhancement was 65% sensitive and 58% specific for renal malperfusion. Both global [odds ratio (OR) 4.43; 1.20–16.41, P = 0.03] and focal (OR 11.23; 1.12–112.90, P = 0.04) enhancement defects were independent predictors for renal malperfusion. CONCLUSIONS In patients with aortic dissection, we found that differential enhancement of the kidney as seen on the computed tomography angiography is predictive, but not prescriptive for renal malperfusion. While detection of renal malperfusion is aided by computed tomography angiography, its diagnosis requires close monitoring and often invasive assessment.

OBJECTIVES We sought to examine management and outcomes of (Stanford) type A aortic dissection (TAAAD) in patients aged >70 years. METHODS All patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection database (1996–2018) were studied (n = 5553). Patients were stratified by age and therapeutic strategy. Outcomes for octogenarians were compared with those for septuagenarians. Variables associated with in-hospital mortality were identified by multivariable logistic regression. RESULTS In-hospital mortality for all patients (all ages) was 19.7% (1167 deaths), 16.1% after surgical intervention vs 52.1% for medical management (P 80 years. Fewer octogenarians underwent surgery versus septuagenarians (68.1% vs 85.9%, P CONCLUSIONS When compared with septuagenarians, a smaller percentage of octogenarians undergo surgical repair for TAAAD, even though postoperative outcomes are similar. Age alone should not preclude consideration for surgery in appropriately selected patients with TAAAD.

Aortic valve replacement (AVR) is common in the setting of type A aortic dissection (TAAD) repair. Here, we evaluated the association between prosthesis choice and patient outcomes in an international patient cohort. We reviewed data from the International Registry of Acute Aortic Dissection (IRAD) interventional cohort to examine the relationship between valve choice and short- and mid-term patient outcomes. Between January 1996 and March 2016, 1290 surgically treated patients with TAAD were entered into the IRAD interventional cohort. Of those, 364 patients undergoing TAAD repair underwent aortic valve replacement (AVR; mean age, 57 years). The mechanical valve cohort consisted of 189 patients, of which 151 (79.9%) had a root replacement. The nonmechanical valve cohort consisted of 5 patients who received homografts and 160 patients who received a biologic AVR, with a total of 118 (71.5%) patients who underwent root replacements. The mean follow-up time was 2.92 ± 1.75 years overall (2.46 ± 1.69 years for the mechanical valve cohort and 3.48 ± 1.8 years for the nonmechanical valve cohort). After propensity matching, Kaplan-Meier estimates of 4-year survival rates after surgery were 64.8% in the mechanical valve group compared with 74.7% in the nonmechanical valve group (p = 0.921). A stratified Cox model for 4-year mortality showed no difference in hazard between valve types after adjusting for the propensity score (p = 0.854). A biologic valve is a reasonable option in patients with TAAD who require AVR. Although this option avoids the potential risks of anticoagulation, long-term follow up is necessary to assess the effect of reoperations or transcatheter interventions for structural valve degeneration.

Despite the rapid adoption of transcatheter aortic replacement (TAVR), surgical TAVR valve explantation (TAVR-explant) and the clinical impact of explanted TAVR device type are not well described.TAVR-explant from 2016 to 2019 was queried using the Society of Thoracic Surgeons (STS) National Database. A total of 483 patients with documented explanted valve type, consisting of 330 (68%) patients with balloon-expandable and 153 (32%) patients with self-expandable devices, were identified. The primary outcome was 30-day mortality. The secondary outcome was the need for any simultaneous procedures with TAVR-explant.The mean age was 72.8 years, 38% of the patients were female, and 51% demonstrated New York Heart Association functional class III to IV symptoms. During TAVR-explant, 63% of patients required other simultaneous procedures, including aortic repair (27%), mitral procedures (22%), coronary artery bypass grafting (15%), and tricuspid procedures (7%). Patients with a self-expandable device underwent more frequent ascending aortic replacement (22% vs 9%; P.001) than those with a balloon-expandable device, whereas the aortic root replacement rate was similar (19% vs 24%; P = .22). The overall 30-day mortality was 18% without differences in the mortality or other major complications between the groups. Of the 157 patients with isolated surgical aortic valve replacement and available STS predicted risk of mortality score, the observed-to-expected (O/E) mortality ratio was 2.2.The TAVR-explant outcomes were comparable between patients with balloon-expandable devices and patients with self-expandable devices, whereas ascending aortic replacement was observed more frequently in patients with self-expandable devices. Younger patients undergoing TAVR should be informed of the future TAVR-explant risk that may accompany a higher O/E ratio and frequent morbid concurrent procedures.

Background Aortic diameter measurements in patients with a thoracic aortic aneurysm (TAA) show wide variation. There is no technique to quantify aortic growth in a three-dimensional (3D) manner. Purpose To validate a CT-based technique for quantification of 3D growth based on deformable registration in patients with TAA. Materials and Methods Patients with ascending and descending TAA with two or more CT angiography studies between 2006 and 2020 were retrospectively identified. The 3D aortic growth was quantified using vascular deformation mapping (VDM), a technique that uses deformable registration to warp a mesh constructed from baseline aortic anatomy. Growth assessments between VDM and clinical CT diameter measurements were compared. Aortic growth was quantified as the ratio of change in surface area at each mesh element (area ratio). Manual segmentations were performed by independent raters to assess interrater reproducibility. Registration error was assessed using manually placed landmarks. Agreement between VDM and clinical diameter measurements was assessed using Pearson correlation and Cohen κ coefficients. Results A total of 38 patients (68 surveillance intervals) were evaluated (mean age, 69 years ± 9 [standard deviation]; 21 women), with TAA involving the ascending aorta (n = 26), descending aorta (n = 10), or both (n = 2). VDM was technically successful in 35 of 38 (92%) patients and 58 of 68 intervals (85%). Median registration error was 0.77 mm (interquartile range, 0.54-1.10 mm). Interrater agreement was high for aortic segmentation (Dice similarity coefficient = 0.97 ± 0.02) and VDM-derived area ratio (bias = 0.0, limits of agreement: -0.03 to 0.03). There was strong agreement (r = 0.85, P < .001) between peak area ratio values and diameter change. VDM detected growth in 14 of 58 (24%) intervals. VDM revealed growth outside the maximally dilated segment in six of 14 (36%) growth intervals, none of which were detected with diameter measurements. Conclusion Vascular deformation mapping provided reliable and comprehensive quantitative assessment of three-dimensional aortic growth and growth patterns in patients with thoracic aortic aneurysms undergoing CT surveillance. Published under a CC BY 4.0 license Online supplemental material is available for this article. See also the editorial by Wieben in this issue.

Background: This study aims to determine the long-term outcomes and rate of reoperation among BAV patients with aortic diameter of 5–5.5cm who underwent immediate surgical repair versus surveillance. Methods: A total of 148 BAV patients with aortic aneurysm measuring 5–5.5cm were identified between 1993 to 2019. Patients were categorized into two groups: immediately operated (n=89), versus watched group (n=59) i.e., monitored until either symptomatic, aortic diameter ≥ 5.5 cm or operated at surgeons’ discretion/patient preference. Results: Compared to the immediately operated group the watched group had significantly lower proportion of proximal aorta replacement (86% vs 100%). The mean size of proximal thoracic aorta at initial encounter, including aortic root, ascending, and arch, for the watched group was 52.1 ± 1.62mm and 52.6 ± 1.81mm in the immediately operated group, p=0.06. There was no significant difference in 10-year survival between the watched group 94% (95% CI: 79%, 99%) vs immediately operated group 96.5% (95% CI: 86%, 99%), p=0.90. Initial operation rate for the watched group during 10-year follow-up was 85%. The operative mortality in both groups was 0%. The 10-year reoperation rate between groups was similar: 3.5% (95% CI: 0.9%, 9.1%) in the immediately operated group vs 7.7% (95% CI: 2.4%, 17.1%) in the patients who eventually had surgery in the watched group, p= 0.30. Conclusions Our study showed that the rate of reoperation was similar between groups and survival outcomes were acceptable in observed asymptomatic BAV patients without significant family history and with proximal aortic diameter of 5–5.5cm.

To determine long-term survival and reoperation rate in patients with a bicuspid aortic valve (BAV) and patients with a tricuspid aortic valve (TAV) after stentless aortic valve replacement (AVR)/aortic root replacement (ARR).Between 1992 and 2014, 1293 patients underwent first AVR/ARR with a stentless aortic valve using the modified inclusion operating technique, including 741 patients with a TAV and 552 with a BAV. Using propensity scoring with 26 variables, 330 matched pairs were identified with AVR with or without ascending aorta/arch replacement. Data were obtained through chart review, surveys, and the National Death Index.Patient demographics were similar in the propensity score-matched groups. Both groups had similar cardiopulmonary bypass, cross-clamp, and hypothermia circulatory arrest times, cerebral protection strategies, and rate of aortic arch replacement. The median size of implanted valves was similar (BAV: 27 mm [range, 25-29 mm] vs TAV: 27 mm [range, 25-27 mm]). Compared with the TAV group, the BAV group had a shorter hospital stay (6 days vs 7 days;The BAV patients had better long-term survival but a higher reoperation rate compared with TAV patients after stentless AVR. Our findings suggest caution in the use of bioprostheses for BAV patients.

The anatomic complexity of aortic dissection remains a challenge in endovascular treatment. The dissection flap may contain defects allowing accidental guidewire passage from one lumen into the other, and inadvertent device placement into the false lumen can occur. The description of this complication and its bail-out maneuvers are sparse in the literature. Herein, we describe seven patients with errant endoprosthesis re-routed with minimally invasive intervention into the true lumen.

Background: Hybrid debranching repair of pararenal and thoracoabdominal aortic aneurysms was initially designed as a better alternative to standard open repair, addressing the limitations of endovascular repair involving the visceral aorta. We reviewed the collective outcomes of hybrid debranching repairs using extra-anatomic, open surgical debranching of the renal-mesenteric arteries, followed by endovascular aortic stenting. Methods: Data from patients who underwent hybrid repair in 14 North American institutions during 10 years were retrospectively reviewed. Society of Vascular Surgery scores were used to assess comorbidity risk. Early and late outcomes, including mortality, morbidity, reintervention, and patency were analyzed. Results: A total of 208 patients (118 male; mean age, 71±8 years old) were treated by hybrid repair with extraanatomic reconstruction of 657 renal and mesenteric arteries (mean 3.2 vessels/patient). Mean aneurysm diameter was 6.6±1.3 cm. Thoracoabdominal aortic aneurysms were identified in 163 (78%) patients and pararenal aneurysms in 45 (22%). A single-stage repair was performed in 92 (44%) patients. The iliac arteries were the most common source of inflow (n=132; 63%), and most (n=150; 72%) had 3 or more bypasses. There were 30 (14%) early deaths, ranging widely across sites (0%–21%). A Society of Vascular Surgery comorbidity score >15 was the primary predictor of early mortality ( P P Conclusions: Mortality after hybrid repair and visceral debranching is highly variable by center, but strongly affected by preoperative comorbidities and the centers’ experience with the technique. With excellent graft patency at 5 years, the outcomes of hybrid repair done at centers of excellence and in carefully selected patients may be comparable (or better) than traditional open or even totally endovascular approaches. However, in patients already considered as high-risk for surgery, it may not offer better outcomes.

Approximately one-quarter of patients with acute type A aortic dissection (TAAD) present with concomitant malperfusion of coronary arteries, mesenteric circulation, lower extremities, kidneys, brain, and/or coma. It is generally accepted that TAAD patients who present with malperfusion experience higher mortality rates than patients without, although how specific malperfusion syndromes, alone or in combination, affect mortality is not well described.The International Registry of Acute Aortic Dissection database was queried for patients who underwent surgical repair of TAAD. Patients were stratified according to the presence/absence of malperfusion at presentation. Multivariable logistic regression was used to evaluate in-hospital mortality according to malperfusion type. Kaplan-Meier estimates were used to estimate 30-day postoperative survival.Six thousand four hundred thirty-seven patients underwent surgical repair of acute TAAD, of whom 2642 (41%) had 1 or more preoperative malperfusion syndromes. Mesenteric malperfusion (adjusted odds ratio [AOR], 4.84; P .001) was associated with the highest odds of in-hospital mortality, followed by coma (AOR, 1.88; P = .007), limb ischemia (AOR, 1.73; P = .008), and coronary malperfusion (AOR, 1.51; P = .02). Renal malperfusion (AOR, 1.37; P = .24) and neurologic deficit (AOR, 1.35; P = .28) were not associated with increased in-hospital mortality. In patients who survived to discharge, there was no difference in 1-year postdischarge survival in the malperfusion and no malperfusion cohorts (P = .36).Survival during the index admission after TAAD repair varies according to the presence and type of malperfusion syndromes, with mesenteric malperfusion being associated with the highest odds of in-hospital death. Not only the presence of malperfusion but rather specific malperfusion syndromes should be considered when assessing a patient's risk of undergoing TAAD repair.

Despite the rapid adoption of transcatheter aortic valve replacement (TAVR), the frequency and clinical outcomes of reoperation after TAVR are not well-described.Between 2011 and 2020, 1719 patients underwent a TAVR at our institution. Among these, 32 patients (2%) required a reoperation. Additionally, 16 patients who received a TAVR at another institution received a reoperation at our institution. We retrospectively reviewed these 48 patients. The median interval from TAVR to reoperation was 2.3 years.Primary reoperations included 37 TAVR valve explants (TAVR-explant; 77%) with surgical aortic valve replacement (SAVR), 8 mitral repairs/replacements (17%), 2 coronary artery bypass grafting procedures (4%), and 1 tricuspid valve replacement (2%). Forty-nine percent of nonaortic valve cardiac lesions were present at the time of TAVR. Furthermore, 18 TAVR-explant patients (49%) were deemed anatomically unsuitable for repeat TAVR based on the index TAVR imaging. During TAVR-explant, 6 patients (16%) with native TAVR sustained various degrees of aortic trauma. Patients with unplanned aortic repair demonstrated a smaller sinotubular junction diameter than those without unplanned repair. In contrast, no unplanned aortic repair was needed in the 14 patients with previous SAVR or the latest 20 consecutive patients. The overall in-hospital mortality was 15%, with an observed-to-expected morality ratio of 1.8.The clinical impact of post-TAVR reoperation remains substantial despite the lower frequency of unplanned aortic repair over time. The necessity of reoperations or unfavorable repeat TAVR anatomy appears predictable at the time of the index TAVR, and implanters must be mindful of "lifetime management" strategy during candidate selection.

Background Management of type A aortic dissection with cerebral malperfusion poses a significant challenge. Although involvement of craniocervical vessels is undoubtedly critical, it is not well investigated in the surgical literature. Methods Between 1997 and 2019, 775 patients presented with acute type A aortic dissection and 80 (10%) with cerebral malperfusion. All patients were transferred from outside institutions. Medical records and imaging studies were retrospectively reviewed. Results Fifty-nine patients (74%) underwent an open repair, 2 (3%) had an endovascular aortic repair, 2 (3%) had carotid stenting, and 18 (23%) received nonoperative management. In-hospital mortality of all comers was 40.0%, and 81.3% were neurology related. Among the 45 patients (56%) in whom cerebrocervical imaging studies were available, 11 (24%) had an internal carotid artery (ICA) occlusion and 28 (62%) had a common carotid artery (CCA) occlusion without ICA involvement as the culprit lesion. Six comatose patients (55%) were in the ICA group and 10 comatose patients (36%) in the CCA group (P = .28). All patients with ICA occlusion developed cerebral edema and herniation syndrome regardless of the management and died. In contrast 79% of patients with unilateral or bilateral CCA occlusion survived to hospital discharge (P Conclusions ICA occlusion in the presence of type A aortic dissection may be a surrogate marker for dismal neurologic outcomes regardless of the surgical approach, whereas CCA occlusion or comatose state should not preclude surgical candidacy. A prompt neck computed tomography angiography may be warranted in patients with cerebral malperfusion.

OBJECTIVES Differential luminal enhancement [between true lumen (TL) and false lumen (FL)] results from differential flow patterns, most likely due to outflow restriction in the FL. We aimed to assess the impact of differential luminal enhancement at baseline computed tomography angiography on the risk of adverse events in patients with acute type B aortic dissection (TBAD). METHODS Baseline computed tomography angiographies of patients with acute TBAD between 2007 and 2016 (n = 48) were analysed using three-dimensional software at multiple sites along the descending thoraco-abdominal aorta. At each location, we measured contrast density in TL and FL [Houndsfield unit (HU)], maximal diameter (cm) and circumferential FL extent (°). Outcome data were collected via retrospective chart review. Multivariable logistic regression models were employed to determine the independent risk of TL–FL differential luminal enhancement on aneurysm formation (maximal diameter ≥55 mm) and medical treatment failure. RESULTS Patients were predominately male (75%) and 52.8±12.9 years at diagnosis. The mean follow-up was 5.9±2.6 years, and 42% (n = 20/48) patients were diagnosed with thoraco-abdominal aortic aneurysm. The baseline absolute difference between FL and TL contrast density measured at 2 cm distal to primary entry tear (TL–FLabs-Tear) was significantly higher among patients who developed aneurysm (26 HU, IQR: 15–53 vs 13 HU, IQR: 4–24, P = 0.001). Aneurysm development during follow-up was predicted by TL–FLabs-Tear (odds ratio 1.07, P = 0.012) and baseline maximal aortic diameter (odds ratio 1.90, P CONCLUSIONS Differential luminal enhancement may be a novel predictor of aneurysm formation among patients with acute TBAD.

OBJECTIVES Confident growth assessment during imaging follow-up is often limited by substantial variability of diameter measurements and the fact that growth does not always occur at standard measurement locations. There is a need for imaging-based techniques to more accurately assess growth. In this study, we investigated the feasibility of a three-dimensional aortic growth assessment technique to quantify aortic growth in patients following open aortic repair. METHODS Three-dimensional aortic growth was measured using vascular deformation mapping (VDM), a technique which quantifies the localized rate of volumetric growth at the aortic wall, expressed in units of Jacobian (J) per year. We included 16 patients and analysed 6 aortic segments per patient (96 total segments). Growth was assessed by 3 metrics: clinically reported diameters, Jacobian determinant and targeted diameter re-measurements. RESULTS VDM was able to clearly depict the presence or absence of localized aortic growth and allows for an assessment of the distribution of growth and its relation to anatomic landmarks (e.g. anastomoses, branch arteries). Targeted diameter change showed a stronger and significant correlation with J (r = 0.20, P = 0.047) compared to clinical diameter change (r = 0.15, P = 0.141). Among 20/96 (21%) segments with growth identified by VDM, growth was confirmed by clinical measurements in 7 and targeted re-measurements in 11. Agreement of growth assessments between VDM and diameter measurements was slightly higher for targeted re-measurements (kappa = 0.38) compared to clinical measurements (kappa = 0.25). CONCLUSIONS Aortic growth is often uncertain and underappreciated when assessed via standard diameter measurements. Three-dimensional growth assessment with VDM offers a more comprehensive assessment of growth, allows for targeted diameter measurements and could be an additional tool to determine which post-surgical patients at high and low risk for future complications.

Present invention was indented for characterization and adsorptive (batch and column) treatment of sugar industry distillery spent wash to remove COD (chemical oxygen demand) and color using sugarcane industrial waste, bagasse fly ash (BFA). Distillery spent wash was extremely polluted including acidic pH and very high value of COD, BOD (biological oxygen demand) and color. Sophisticated techniques such as BET (Brunauer–Emmett–Teller) surface area, pore volume, pore diameter, particle size distribution, porosity, FTIR (Fourier-transform infrared spectroscopy), chemical composition by XRF (X-ray fluorescence) and SEM (scanning electron microscopy) were utilized to analyze BFA as an adsorbent and revealed that BFA surface was highly porous and consisted of various oxides. In batch treatment, different process parameters such as contact duration and temperature w.r.t adsorbent dose, thermodynamic studies and isotherms (Langmuir and Freundlich model) were analyzed. Column adsorption was performed using various variables (bed height, particle size distribution and flow rate), breakthrough parameters and isotherms (Thomas, Yoon–Nelson, BDST and Adams and Bohart model). Adsorption capacities were increased with increasing BFA dose, contact duration, temperature, bed height and decreasing flow rate and average particle size. The maximum adsorption capacity of Langmuir and Thomas model was achieved up to 124.5 mg g−1 and 0.1394 mg g−1, respectively, for COD and 109.8 (Hazen L) gm−1 and 0.2547 (Hazen L) gm−1, respectively, for color. Sugar Industry wastewater stream, i.e., distillery spent wash was shown to be feasible using own industrial solid waste, BFA.

Background Despite the rapid adoption of transcatheter aortic valve replacement (TAVR), there are scant data regarding aortic valve reintervention after initial TAVR. Methods Between 2011 and 2019, 1487 patients underwent a TAVR at the University of Michigan. Among these, 24 (1.6%) patients required an aortic valve reintervention. Additionally, 4 patients who received a TAVR at another institution underwent a valve reintervention at our institution. We retrospectively reviewed these 28 patients. Results The median age was 72 years, 36% were female and 86% of implanted TAVR devices were self-expandable. The leading indications for reintervention were structural valve degeneration (39%) and paravalvular leak (36%). The cumulative incidence of aortic valve reintervention was 4.6% at 8 years. Most (71%) were deemed unsuitable for repeat TAVR because of the need for concurrent cardiac procedures (50%), unfavorable anatomy (45%), or endocarditis (10%). TAVR valve explant was associated with frequent concurrent procedures, consisting of aortic repair (35%), mitral repair/replacement (35%), tricuspid repair (25%), and coronary artery bypass graft (20%). Seventy-one percent of aortic procedures were unplanned but proved necessary because of severe adhesion of the devices to the contacting tissue. There were 3 (15%) in-hospital mortalities in the TAVR valve explant group, whereas there was no mortality in the repeat TAVR group. Conclusions Repeat TAVR procedure was frequently not feasible because of unfavorable anatomy and/or the need for concurrent cardiac procedures. Careful assessment of TAVR procedure repeatability should be weighed at the initial TAVR workup especially in younger patients who are expected to require a valve reintervention.

BACKGROUND. Patients with acute type A aortic dissection with a previous cardiac surgery (PCS) and malperfusion syndrome (MPS) are extremely difficult to manage and have poor outcomes. METHODS. From 1996 to 2018, 668 patients underwent emergent open aortic repair or endovascular fenestration/stenting for MPS for an acute type A aortic dissection, including those with PCS (PCS, n = 64) and those without PCS (No-PCS, n = 604). The groups were further divided into PCS+MPS, PCS+No-MPS, No-PCS+MPS, and No-PCS+No-MPS. RESULTS. Compared with the No-PCS group, the PCS group had significantly more coronary artery disease, acute renal failure, and mesenteric and renal MPS. Forty-two percent of patients with PCS underwent upfront endovascular fenestration/stenting for endovascular-amendable MPS. The in-hospital mortality was significantly higher in patients with PCS+MPS (40%) compared with PCS+No-MPS (5.9%), No-PCS+MPS (30%) and No-PCS+No-MPS (6.7%). Multivariable logistic regression showed cardiogenic shock (odds ratio, 7.3) and MPS (odds ratio, 6.6) were risk factors for in-hospital mortality (P < .0001). After recovering from MPS the PCS group (n = 54) had similar rates of postoperative complications, including 30-day mortality (7.4% vs 6.3%, P = .77), compared with the No-PCS group (n = 557). The 5-year survival was significantly lower in the PCS group compared with the No-PCS group (60% vs 72%, P = .004) and was lowest in those with PCS+MPS (46%). PCS was not a significant risk factor for in-hospital (odds ratio, 1.2; P = .63) or late (hazard ratio, 1.3; P = .27) mortality. CONCLUSIONS. Because of severe preoperative comorbidities and the complexity of open aortic repair, in acute type A aortic dissection patients with PCS and MPS, endovascular fenestration and stenting first with delayed redo sternotomy and central aortic repair was a valid approach.

With increasing specialization within the field of cardiac surgery and a positive relationship between case volume and surgical outcomes in many areas, the concept of dedicated aortic surgeons performing acute type A aortic dissection (ATAAD) repair was investigated. From 1996 to 2014, 436 patients underwent open surgical repair of an ATAAD and were subsequently divided based on surgeon subspecialization, aortic-surgeon (AS, n = 401) vs non-aortic-surgeon (NAS, n = 35). Each aortic surgeon performed an average of 13 ATAAD repair operations per year. Preoperative comorbidities were similar between groups. Intraoperatively, the AS group had 36% aortic root replacement vs 23% in the NAS group, P = 0.12, and 36% zone 1/2/3 arch replacement vs 26% in the NAS group, P = 0.20). Postoperatively, the AS group had significantly better outcomes, including intraoperative mortality (1.2% vs 5.7%), 30-day mortality (6.5% vs 17%), and composite outcomes (23% vs 46%). Multivariable logistic regression showed NAS was a risk factor for 30-day mortality with an odds ratio (OR) of 4.4 (P = 0.03), as were COPD (OR = 4.0, P = 0.046) and cardiogenic shock (OR = 13.4, P0.0001). The 10-year survival was 66% in the AS group vs 46% in the NAS group, P = 0.02. NAS (HR = 2.2), Age (hazard ratio (HR) = 1.05), COPD (HR = 1.96), acute stroke (HR = 3.0), and New York Heart Association class III or IV (HR = 1.75) were significant risk factors for long-term mortality. Managing ATAAD by subspecialized aortic surgeons resulted in improved short- and long-term outcomes. Our specialty could consider ATAAD repair by high-volume aortic surgeons for better patient outcomes.

The present investigate was intended for adsorption of heavy metals i.e. Pb, Cu, Cr, Zn, Ni and Cd onto activated charcoal prepared from neem leaf powder (AC-NLP) using batch and column studies. Batch adsorption was performed using different variables like adsorbent dose, temperature and contact duration. Thermodynamic analysis of batch treatment concluded that adsorption is thermodynamically feasible and endothermic. This adsorption followed the Pseudo second-order kinetic model derived from correlation coefficient values of chemical kinetic studies. For column study, interpretation of breakthrough curves and parameters were conducted by varying flow rate, initial concentration and bed height; and reveal that optimum conditions were lower flow rate (5 mL/min) and lower initial concentration (5 mg/L) and higher bed height (20 cm). Comparisons of batch and column study through isotherm models were evaluated and column study is more preferred than batch treatment. Maximum Thomas adsorption capacity was achieved upto 205.6, 185.8, 154.5, 133.3, 120.6, 110.9 mg/g for Pb, Cu, Cd, Zn, Ni and Cr respectively. This removal pattern is elucidated by metal ionic properties. Various adsorbing agents such as acids and bases were utilized for adsorption–desorption of AC-NLP.

The longevity of a stentless valve in a younger population (20-60 years old) is unknown.From 1992 to 2015, 1947 patients underwent aortic valve/root replacement for aortic stenosis, insufficiency, root aneurysm, or aortic dissection with stentless bioprostheses (median size, 26 mm). At operation 105 patients were40 years old, 528 were 40 to 59, 860 were 60 to 74, and 454 were ≥75 years. The data were obtained through chart review, administered surveys, and the National Death Index.The 30-day mortality rate was 2.6%. During follow-up 807 patients (41%) died before reoperation, 993 (51%) were alive without reoperations because of deterioration, and 113 patients (5.8%) underwent reoperation for structural valve deterioration. After adjusting death and reoperation for non-structural valve deterioration causes as competing risks, the cumulative incidence of reoperation was significantly different between the younger groups (40, 40-59) and the older groups (60-74, ≥75; P.0001) but not inside the younger (40 vs 40-59) or older (60-74 vs ≥75) group. The significant hazard ratio of reoperation for40 versus ≥75 years of age was 12,40 versus 60 to 74 was 4, 40 to 59 versus 60 to 74 was 3, and 40 to 59 versus ≥75 was 9 (P ≤ .01). The 10- and 15-year survival in the entire cohort was 53% and 29%, respectively.The stentless aortic valve provides satisfactory durability as a conduit for aortic valve/root replacement for patients who prefer a bioprosthesis. However it should be judiciously considered for patients younger than 60 years because of an increased incidence of reoperation for structural valve deterioration.

OBJECTIVES To improve haemodynamic performance, design modifications of prosthetic valves have been proposed with each new generation of valves. These different designs also impact the amount of mechanical wear, because mechanical stresses are distributed differently. Because long-term evidence for new prosthetic valves is lacking, this in vitro study compared hydrodynamic performance and durability among 3 currently available bioprosthetic valves with internally (IMLV) or externally mounted leaflets (EMLV). METHODS Prostheses of the internally mounted Medtronic Avalus and Carpentier-Edwards Perimount Magna Ease valves were compared to prostheses of the externally mounted Abbott Trifecta valve. For each labelled size (e.g. 19, 21 and 23) of the 3 types, 3 valves underwent accelerated wear testing for up to 600 million cycles, corresponding to ∼15 years of simulated wear. The valves underwent hydrodynamic testing and visual inspection. RESULTS EMLV had the largest effective orifice area and lowest pressure gradient for each labelled size at baseline and 600 million cycles; the effective orifice area and the pressure gradient were equivalent for the 2 types of IMLV. Five of 9 EMLVs had at least 1 hole or tear in the leaflet tissue around the stent posts, which resulted in severe regurgitation at 500 million cycles in 2 cases. All IMLVs were intact at 600 million cycles with minimal tissue wear. CONCLUSIONS EMLV showed superior hydrodynamic performance but inferior mechanical durability compared to IMLV after 600 million cycles of testing. The primary failures were because of significant mechanical abrasion in the commissural region, which may warrant close monitoring of EMLV during long-term follow-up.

Background Structural valve degeneration (SVD) is a major flaw of bioprostheses. An apparent increase in the SVD rate has been observed among patients who received the Trifecta bioprosthesis (Abbott Vascular, Santa Clara, CA). Methods This study retrospectively reviewed 1058 consecutive patients who underwent aortic valve placement with a stented bioprosthesis between January 2011 and December 2015. Patients were grouped into a Trifecta group (508 [48.0%] patients with Trifecta bioprostheses) and a non-Trifecta group (550 [52.0%] patients with other bioprostheses). Results Patients in the Trifecta group were older (69.7 years vs 64.6 years; P = .001), were more likely female (40.4% vs 28.0%; P = .001), more often had aortic stenosis (85.1% vs 77.1%; P = .001), and received smaller valves (23.0 mm vs 25.0 mm; P Conclusions The SVD rate of the Trifecta bioprosthesis has been greater than expected, compared with other bioprostheses, particularly in younger patients. In view of the large number of Trifecta bioprostheses implanted worldwide, further investigation involving other institutions is warranted.