Beckmann, Erik

Abstract Background Valve-sparing aortic root replacement has increasingly been performed in Marfan patients. However, there is ongoing debate on whether the non-aneurysmal sized aortic arch should be prophylactically replaced during the index operation. The aim of our retrospective single-centre study was to investigate the long-term status of the aortic arch in these patients. Methods Between 1993 and 2021, a total of 723 patients underwent valve-sparing aortic root replacement with a straight tube graft (David I reimplantation) at our institution; 119 patients had confirmed Marfan disease. Of these 119 Marfan patients, 67 patients had isolated aortic root aneurysm with no aortic arch pathology. These 67 patients underwent isolated David I procedure in an elective setting (only aortic root and ascending aortic replacement) without any concomitant procedures and were included in the present study. Results This study includes 67 patients with Marfan syndrome who underwent isolated elective valve-sparing aortic root replacement. The median age of patients was 30 years (20-41), and 47 were male (70%). The cardiopulmonary time was 157.5 (145.8-178.3) min, and aortic clamp time was 117.0 ± 19.8 min. The in-hospital mortality and stroke rates were both 0%. Follow-up was 100% complete. Survival at 1, 5, 10, 15, and 20 years were 100%, 100%, 93%, 89%, and 85%, respectively. Freedom from aortic arch reoperation due to aneurysm at 1, 5, 10, 15, and 20 years was 100%, 100%, 100%, 100%, and 95%, respectively. In follow-up, no patient required aortic arch replacement due to aortic arch aneurysm. A total of 3 patients underwent aortic arch replacement for type B aortic dissection. Of these 3 patients, 1 had chronic type B dissection with aortic aneurysm, and 2 had acute type B dissection. Conclusions The long-term results after valve-sparing aortic root replacement with a straight tube graft (David I procedure) in Marfan patients are excellent. Our study shows that the risk for future aortic arch intervention after elective valve sparing aortic root replacement in Marfan patients is extremely low. Hence, our study supports the idea that concomitant prophylactic aortic arch replacement during elective valve sparing aortic root replacement in Marfan patients with non-aneurysmal aortic arch is not necessary.

Objective Acute aortic dissection type A (AADA) is a condition that affects both genders and requires urgent surgical intervention as non-operative treatment is often associated with a poor prognosis. Studies have proven that less aggressive surgical treatments influence the outcome for female patients in the fields of several diseases. The purpose of this study was to report and analyze our results in the selective cohort of female patients with AADA to detect differences in the treatment of this group of patients. Methods Between January 2000 and July 2018, 141 adult female patients with acute aortic dissection (AAD) underwent repair of the aorta in our department. A total of 75 patients received a proximal arch. replacement (group A), and 66 patients received a subtotal (replacement of the brachiocephalic trunk) and/or total arch. replacement with elephant trunk or frozen elephant trunk (group B). Results The median age in group A was 70.7 years (range 60.7–74.7 years) and in group B 66.3 years (range 55.6–71.3 years). Operation times were significantly longer in group B (total operation time: A = 286.9 min (range 225.0–341.0 min), B = 341 min (range 266.0–392 min), p = .003; cardiopulmonary bypass time: A = 189.0 min (range 139.0–138 min), B = 238 min (range 176.8–300.5 min), p < .001; circulatory arrest time: A = 27.0 min (range 21.0–37.0 min), B = 42.0 min (range 32.0–56.3 min), p < .001). There were no significant differences between the groups regarding 30-day mortality (A = 24% ( n = 18), B = 19.7% ( n = 13), p = .538) and rate of reoperation (A = 13.3% ( n = 10), B = 15.2% ( n = 10), p = .757) or the preoperative characteristics. Conclusion Our study showed no significant difference in mortality rate depending on the type of operation. Based on these results, a proximal arch. replacement should be considered as the first line of operation technique if the individual situation allows. For inexperienced clinics and surgeons in particular, we recommend limited aortic repair in patients with AADA. Finally, location of the intimal tear remains the essential factor for the evaluation of the surgical treat.

Abstract OBJECTIVES Acute aortic dissection type A (AADA) is a life-threatening medical emergency. Emergent surgical repair is the gold standard but mortality remains high. Mortality is even higher in patients who arrive at the hospital in poor condition, especially after cardiopulmonary resuscitation (CPR). This study was designed to analyse the outcome of patients who underwent surgery for AADA and who require preoperative CPR. METHODS Between 2000 and 2023, 810 patients underwent emergent surgery for AADA at our centre. Of these, 63 had preoperative CPR. We performed a retrospective analysis with follow-up. RESULTS Mean age was 64 ± 13 years and 37 (59%) patients were male. Further, 50 (79%) patients had preoperative intubation, and 54 (86%) had pericardial effusion. Twenty-four (38%) patients had out-of-hospital CPR, 19 (30%) required CPR in hospital and 20 (32%) needed CPR in the operating room. Successful CPR with return of spontaneous circulation was achieved in 41 (65%) patients, and 22 (35%) underwent emergent surgery under ongoing CPR. The median time of CPR was 10 (interquartile range 12) min, and the median time from onset of symptoms to start of the operation was 5.5 (interquartile range 4.8) h. The majority of patients underwent ascending aortic replacement with hemiarch repair (n = 37, 59%). Further, 26 (41%) patients underwent full root replacement. Another 15 (24%) patients underwent total arch repair with or without (frozen) elephant trunk repair. Postoperative stroke was present in 8 (13%) patients. The 30-day mortality was 29 (46%). The 30-day mortality of patients with preoperative intubation was not significantly higher (n = 15/28, 54%, P = 0.446). The 1-, 5- and 10-year survival rates of the entire group were 42, 39 and 36%. CONCLUSIONS Early mortality for patients undergoing surgery for AADA with preoperative CPR is extremely high (almost 50%). However, this means that also ∼50% of patients benefit from surgery despite poor preoperative prognosis. Patients with preoperative intubation after CPR and unknown neurological condition should also undergo surgery. Patients who survive the initial operation for AADA have acceptable long-term survival. Emergent surgery should be offered for all patients with AADA regardless of the preoperative condition, even after CPR.

Introduction Acute type A aortic dissection (ATAAD) is one of the most critical emergencies in cardiovascular surgery. Additional complications such as organ malperfusion can significantly decrease the chances of survival. Despite promptly performed surgical treatment, impaired organ perfusion may persist, thus close postoperative monitoring is recommended. But, is there a surgical consequence due to the existence of a preoperatively known malperfusion and is there a correlation between pre-, peri- and postoperative levels of serum lactate and proven malperfusion? Methods Between 2011 and 2018, 200 patients (66% male; median age: 62.5 years; interquartile range: +/−12.4 years) that received surgical treatment at our institution for an acute dissection DeBakey type I were enrolled in this study. The cohort was divided into two groups according to the preoperative existence of malperfusion and non-malperfusion. At least one kind of malperfusion occurred in 74 patients (Group A: 37%), while 126 patients (Group B: 63%) showed no evidence of malperfusion. Furthermore, lactate levels of both cohorts were differentiated into four periods: preoperative, intraoperative, 24 hours after surgery, and 2–4 days after surgery. Results The patients’ status differed significantly prior to surgery. Group A (malperfusion) showed an elevated requirement for mechanical resuscitation (A: 10.8%; B: 5.6%; p: 0.173), were significantly more often admitted in an intubated state (A: 14.9%; B: 2.4%; p: 0.001) and showed higher incidences of stroke (A: 18.9% ( n = 149); B: 3.2% ( n = 4); p: 0.001). Levels of serum lactate from the preoperative period until days 2–4 were significantly increased in the malperfusion cohort at all times. Conclusions Preexisting malperfusion due to ATAAD may significantly increase the chance of early mortality in patients with ATAAD. Serum lactate levels were a reliable marker for inadequate perfusion from admission until day 4 after surgery. Despite this, early intervention survival in this cohort remains limited.