Annals of cardiothoracic surgery最新文献

This keynote lecture and corresponding presentation discuss the anatomy and pathophysiology surrounding spinal cord injury in aortic surgery. This article will discuss risk factors and mechanisms for spinal cord injury, including loss of direct and collateral spinal cord perfusion and ischemia-reperfusion injury. This review will examine these elements in both the laboratory and clinical setting, in addition to other neuroprotective strategies applied in clinical practice. Addressing spinal cord injury requires an integrated and considerate approach to simultaneously optimize spinal cord blood flow, promote collateralization and improve ischemic tolerance. Given the catastrophic clinical consequences for both the patient and their caregivers, continuing to investigate and examine spinal cord injury is of the utmost importance.

Background: Valve-sparing aortic procedures, including the David and Yacoub procedures, have emerged as the dominant approaches in aortic aneurysm surgery, preserving the native aortic valve and thereby conferring significant prognostic benefits to the patient. Over the years, these procedures have also shown promise in patients with bicuspid valve-related aortopathy. This systematic review and meta-analysis presents the most up-to-date data on perioperative outcomes, freedom from secondary reoperation, and freedom from mortality for bicuspid valve patients undergoing valve-sparing aortic operations.

Methods: The methods for this systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Four databases were searched, ultimately yielding 19 papers for inclusion, using appropriate search terminology. Meta-analysis using proportions or means, as appropriate, were applied. Kaplan-Meier curves were digitized and aggregated using previously validated techniques.

Results: A total of 1,159 patients were included. Males accounted for 87.4% of the cohort. The mean age of the cohort was 44.9 years. The mean aortic root diameter was estimated to be 46.3 mm, with an estimated range from 38 to 54 mm. Thirty-day mortality rate was estimated to be 1.7%. Eighty-five percent of patients in this series received the David approach, with the remainder receiving the Yacoub approach. Overall, there was low heterogeneity observed for the mean length of intensive care stay, while high heterogeneity was observed for the other remaining variables of interest. Kaplan-Meier survival estimation at 5, 10, and 15 years was 96%, 90%, and 87%, respectively. Kaplan-Meier freedom from secondary reoperation at 5, 10, and 15 years was 96%, 91%, and 88%, respectively.

Conclusions: This review demonstrates the durability and safety of the David and Yacoub valve-sparing procedures across long-term follow-up in bicuspid aortic valve patients. These procedures offer significant freedom from mortality and secondary reoperations on the aorta and valve and will likely continue to demonstrate excellent results into the future. There is a clear transition towards the David procedure, with the bulk of contemporary literature publishing on this technique.

Background: Debate still persists on whether valve-sparing root reimplantation (VSRR) of a very asymmetric bicuspid aortic valve (BAV) should be completed such that the asymmetry of the native commissural orientation is retained, or if it should be made symmetric (180°-180°). Herein, we present our approach, in which the native asymmetry is preserved, and the valve is reimplanted in a 210°-150° orientation.

Methods: A retrospective review was performed of 130 patients with BAV who underwent VSRR between January 1, 2004 and March 1, 2023 at a single institution. Of this total, 37 were reimplanted asymmetrically (210°-150°). The primary outcome was > moderate aortic insufficiency (AI). Secondary outcomes included severe aortic stenosis (AS), reintervention, and survival.

Results: The included 37 patients were mostly male [94.6% (35/37)] with mean age of 46.3 years, and with low rates of comorbidities. At least moderate AI was present in 40.5% (15/37) prior to surgery. All BAV in this series were Sievers Type 1 with a mean commissural angle of 128.2°. Leaflet repair was required in 81.1% (30/37), most commonly involving central plication of the conjoined cusp [96.7% (29/30)] and raphe release [73.3% (22/30)]. There was no 30-day mortality or stroke. At 10 years, the cumulative incidences of > moderate AI, severe AS, and reintervention were 7.6% (0-17.2%), 7.1% (0-19.7%), and 5.3% (0.3-22%), respectively. There was no mortality for the entire duration of the study period.

Conclusions: This series demonstrates excellent 10-year outcomes of maintaining commissural orientation in asymmetric BAV reimplantation procedures. However, further study with additional patients, longer follow-up, and direct comparison to symmetric reimplantation for similar BAV morphology is required.

Cardiac computed tomography (CT) and magnetic resonance (CMR) supplement echocardiography in the evaluation of those with aortic root and ascending aortic dilation, determining timing for intervention, guiding pre-surgical planning and post-operative surveillance. The dynamic, three-dimensional complexity of the aortic root and how it relates to the base of the left ventricle must be understood in any surgical approach addressing the aneurysmal aortic root. With improved imaging technology and the importance for proper patient counseling, it is no longer acceptable to enter the operating theater without a detailed blue print of what the problem is, and how best to address it. In addition, reliance on surgical expertise alone for intraoperative evaluation and decision making could be suboptimal due to the unloaded condition of the aortic root and the variance of experience of the surgeons to successfully repair the aortic valve. This is exemplified by the selective surgeons and centers who have the ability to tackle these aortic valve and root pathologies, compared to mitral valve repair techniques that have been codified and are generalizable. This review discusses a multimodality imaging approach in the patient with aortic root aneurysm, focusing on the precision added with pre-surgical CT assessment to guide aortic-valve sparing operations. This precision is afforded with a detailed understanding of the anatomy of the aortic root and underlying support, and its accurate evaluation by standard two- and three-dimensional imaging. Furthermore, we describe the evolving ability to predict the location of ventricular components of the atrioventricular conduction axis with further clinical imaging to personalize surgical strategies.

Background: Several conduit configurations, such as straight graft (SG), Valsalva graft (VG), anticommissural plication (ACP), and the Stanford modification (SMOD) technique, have been described for the valve-sparing aortic root replacement (VSARR) procedure. Prior ex vivo studies have evaluated the impact of conduit configurations on root biomechanics, but the mock coronary artery circuits used could not replicate the physical properties of native coronary arteries. Moreover, the individual leaflet's biomechanics, including the fluttering phenomenon, were unclear.

Methods: Porcine aortic roots with coronary arteries were explanted (n=5) and underwent VSARR using SG, VG, ACP, and SMOD for evaluation in an ex vivo left heart flow loop simulator. Additionally, 762 patients who underwent VSARR from 1993 through 2022 at our center were retrospectively reviewed. Analysis of variance was performed to evaluate differences between different conduit configurations, with post hoc Tukey's correction for pairwise testing.

Results: SG demonstrated lower rapid leaflet opening velocity compared with VG (P=0.001) and SMOD (P=0.045) in the left coronary cusp (LCC), lower rapid leaflet closing velocity compared with VG (P=0.04) in the right coronary cusp (RCC), and lower relative opening force compared with ACP (P=0.04) in the RCC. The flutter frequency was lower in baseline compared with VG (P=0.02) and in VG compared with ACP (P=0.03) in the LCC. Left coronary artery mean flow was higher in SG compared with SMOD (P=0.02) and ACP (P=0.05). Clinically, operations using SG compared with sinus-containing graft was associated with shorter aortic cross-clamp and cardiopulmonary bypass time (P<0.001, <0.001).

Conclusions: SG demonstrated hemodynamics and biomechanics most closely recapitulating those from the native root with significantly shorter intraoperative times compared with repair using sinus-containing graft. Future in vivo validation studies as well as correlation with comprehensive, comparative clinical study outcomes may provide additional invaluable insights regarding strategies to further enhance repair durability.