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Does profound hypothermic circulatory arrest improve survival in patients with acute type A aortic dissection?
Results: Actuarial survival estimates for all patients at 30days, 1-year and 5-years were 81⫾2%, 74⫾3% and 63⫾3%, respectively. Survival rates and actual freedom from distal aortic reoperation was similar between PHCA and no-PHCA groups in the entire patient cohort as well as in the matched patients in quintiles III–V. Similarly, no significant differences in early major complications, late survival or distal aortic reoperation rates in the entire patient sample or in quintiles III–V were noted in the two treatment groups. Conclusions: Aortic repair with or without PHCA was associated with comparable early complications, survival, and distal aortic reoperation rates in patients with acute type A aortic dissection. Perspective: The small number of patients in the different propensity quintiles in this study does not allow firm conclusions to be drawn regarding the relative merits of the two methods of surgical repair for type A dissection. Nevertheless, many cardiothoracic surgeons use PHCA regularly because of its practical technical advantages and theoretical potential merit. RM
gust 1995 and September 2000 using two different techniques (the “remodeling” technique, described by Yacoub in 1983 [n⫽8] and the “reimplantation” technique, pioneered by David and Feindel, in 1992 [n⫽22]) were evaluated for early and late mortality, and aortic valve-related complications and reoperations. Results: The 30-day mortality was 17% and the late mortality 4% at 22.6⫾15.4 months of follow-up. Three of 8 patients in the remodeling group (all for acute aortic regurgitation) compared to only 1 of 22 patients in the reimplantation group (for acute aortic valve endocarditis) had reoperation for aortic valve replacement. In the 3 patients with acute aortic valve regurgitation in the reimplantation group, symptoms occurred 44, 24, and 17 months after the initial operation and was related to the prolapse of aortic leaflets because of commissural detachment in all 3 cases. All remaining patients had grade one of no aortic regurgitation on their follow-up echocardiograms. Conclusions: Compared to the reimplantation technique, aortic root remodeling in patients with acute type A aortic dissection is associated with greater need for reoperation for acute aortic regurgitation secondary to commissural detachment. Thus, the investigators recommend consideration of the reimplantation technique for surgical treatment of patients with acute type A aortic dissection rather than the remodeling technique, which at many centers is aortic valve replacement. Perspective: Large numbers of patients need to be studied with the two techniques before making any firm recommendations as to the relative merits of the two techniques. In the meantime, local experience should guide the choice of the preferred operative technique. RM
Hemodynamic Performance at Rest and During Exercise After Aortic Valve Replacement: Comparison of Pulmonary Autografts vs. Aortic Homografts Laforest I, Dumesnil JG, Briand M, Cartier PC, Pibarot P. Circulation 2002;106:I-57– 62. Study Question: Is there a difference in hemodynamic performance after aortic valve replacement with the Ross procedure or aortic homograft? Methods: Following aortic valve replacement with the Ross procedure (n⫽132) or with aortic homograft (AH, n⫽111) sequential Doppler echocardiograms were performed up to 5 years postoperatively to assess valvular regurgitation and valve effective orifice area (EOA) and mean transvalvular gradients. The same measurements were also performed during maximum exercise in 20 Ross patients and 14 AH patients. Results: Aortic valve hemodynamics were stable during follow-up for both procedures. However, at 1 year Ross was associated with larger EOAs (1.77⫾0.45 vs. 1.42⫾0.35 cm2/m2 p⬍0.001) and lower gradients (2⫾3 vs. 4⫾3 mm Hg) than AH. Similar findings were also observed during exercise favoring Ross (EOAs 1.99⫾0.44 vs. 1.36⫾0.39 cm2/m2, p⬍0.001 and gradients 7⫾3 vs. 17⫾11 mm Hg, p⬍0.001). Four patients (1 Ross, 3 AH) underwent a second operation for significant aortic regurgitation. Pulmonary homograft stenosis of varying severity was found in 20% of Ross patients, requiring surgery in four of these patients. Conclusion: Excellent long-term hemodynamics of the aortic valve are achieved with both Ross and AH. The Ross procedure appeared to have a slightly favorable hemodynamic
Does Profound Hypothermic Circulatory Arrest Improve Survival in Patients With Acute Type A Aortic Dissection? Lai DT, Robbins RC, Mitchell RS, et al. Circulation 2002;106:I218 –28. Study Question: Does Profound Hypothermic Circulatory Arrest (PHCA) improve survival in patients with acute type A aortic dissection undergoing surgical repair? Methods: Data on patients with acute type A aortic dissection undergoing surgical repair from 1967 to 1999 (n⫽307) were collected retrospectively and analyzed to assess the influence of repair using PHCA (n⫽121) vs. without PHCA (n⫽186) on death and freedom from distal aortic reoperation using multivariable Cox regression models. Propensity scores were calculated for each individual patient who were then divided into 5 propensity-matched quintiles. Patients in quintile I and II were not analyzed as they had very low propensity to undergo PHCA. Because of the small number of patients in the remaining three quintiles (n⫽152), these patients were analyzed together to evaluate the effects of PHCA (n⫽113) vs. no PHCA (n⫽39).
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gust 1995 and September 2000 using two different techniques (the “remodeling” technique, described by Yacoub in 1983 [n⫽8] and the “reimplantation” technique, pioneered by David and Feindel, in 1992 [n⫽22]) were evaluated for early and late mortality, and aortic valve-related complications and reoperations. Results: The 30-day mortality was 17% and the late mortality 4% at 22.6⫾15.4 months of follow-up. Three of 8 patients in the remodeling group (all for acute aortic regurgitation) compared to only 1 of 22 patients in the reimplantation group (for acute aortic valve endocarditis) had reoperation for aortic valve replacement. In the 3 patients with acute aortic valve regurgitation in the reimplantation group, symptoms occurred 44, 24, and 17 months after the initial operation and was related to the prolapse of aortic leaflets because of commissural detachment in all 3 cases. All remaining patients had grade one of no aortic regurgitation on their follow-up echocardiograms. Conclusions: Compared to the reimplantation technique, aortic root remodeling in patients with acute type A aortic dissection is associated with greater need for reoperation for acute aortic regurgitation secondary to commissural detachment. Thus, the investigators recommend consideration of the reimplantation technique for surgical treatment of patients with acute type A aortic dissection rather than the remodeling technique, which at many centers is aortic valve replacement. Perspective: Large numbers of patients need to be studied with the two techniques before making any firm recommendations as to the relative merits of the two techniques. In the meantime, local experience should guide the choice of the preferred operative technique. RM
Hemodynamic Performance at Rest and During Exercise After Aortic Valve Replacement: Comparison of Pulmonary Autografts vs. Aortic Homografts Laforest I, Dumesnil JG, Briand M, Cartier PC, Pibarot P. Circulation 2002;106:I-57– 62. Study Question: Is there a difference in hemodynamic performance after aortic valve replacement with the Ross procedure or aortic homograft? Methods: Following aortic valve replacement with the Ross procedure (n⫽132) or with aortic homograft (AH, n⫽111) sequential Doppler echocardiograms were performed up to 5 years postoperatively to assess valvular regurgitation and valve effective orifice area (EOA) and mean transvalvular gradients. The same measurements were also performed during maximum exercise in 20 Ross patients and 14 AH patients. Results: Aortic valve hemodynamics were stable during follow-up for both procedures. However, at 1 year Ross was associated with larger EOAs (1.77⫾0.45 vs. 1.42⫾0.35 cm2/m2 p⬍0.001) and lower gradients (2⫾3 vs. 4⫾3 mm Hg) than AH. Similar findings were also observed during exercise favoring Ross (EOAs 1.99⫾0.44 vs. 1.36⫾0.39 cm2/m2, p⬍0.001 and gradients 7⫾3 vs. 17⫾11 mm Hg, p⬍0.001). Four patients (1 Ross, 3 AH) underwent a second operation for significant aortic regurgitation. Pulmonary homograft stenosis of varying severity was found in 20% of Ross patients, requiring surgery in four of these patients. Conclusion: Excellent long-term hemodynamics of the aortic valve are achieved with both Ross and AH. The Ross procedure appeared to have a slightly favorable hemodynamic
Does Profound Hypothermic Circulatory Arrest Improve Survival in Patients With Acute Type A Aortic Dissection? Lai DT, Robbins RC, Mitchell RS, et al. Circulation 2002;106:I218 –28. Study Question: Does Profound Hypothermic Circulatory Arrest (PHCA) improve survival in patients with acute type A aortic dissection undergoing surgical repair? Methods: Data on patients with acute type A aortic dissection undergoing surgical repair from 1967 to 1999 (n⫽307) were collected retrospectively and analyzed to assess the influence of repair using PHCA (n⫽121) vs. without PHCA (n⫽186) on death and freedom from distal aortic reoperation using multivariable Cox regression models. Propensity scores were calculated for each individual patient who were then divided into 5 propensity-matched quintiles. Patients in quintile I and II were not analyzed as they had very low propensity to undergo PHCA. Because of the small number of patients in the remaining three quintiles (n⫽152), these patients were analyzed together to evaluate the effects of PHCA (n⫽113) vs. no PHCA (n⫽39).
ACC CURRENT JOURNAL REVIEW Jan/Feb 2003
83