Faculty Bibliography

OBJECTIVES/UNASSIGNED:Type A acute aortic dissection can cause preoperative myocardial infarction due to coronary malperfusion or hemodynamic collapse. This study aims to characterize the presentation, management, and outcomes of patients with concomitant dissection and myocardial infarction. METHODS/UNASSIGNED:A total of 5762 patients with type A dissection were evaluated from the International Registry of Acute Aortic Dissection from 1996 to 2024. Patients with endovascular management, iatrogenic dissection, or insufficient data were excluded. Patients with preoperative myocardial infarction (n = 662, 10.8%) were compared with those without preoperative myocardial infarction (n = 5140, 89.2%). RESULTS/UNASSIGNED:.0001). CONCLUSIONS/UNASSIGNED:Patients with type A acute aortic dissection and preoperative myocardial infarction experienced higher complication and in-hospital mortality rates. Earlier recognition and targeted surgical strategies may improve outcomes.

OBJECTIVE/UNASSIGNED:Prolonged intubation is associated with worse outcomes and longer intensive care unit (ICU) and hospital length of stay (LOS). Extubation in the operating room for patients undergoing isolated coronary artery bypass grafting is feasible, safe, and decreases ICU and hospital LOS. Aortic root and arch procedures are lengthy and often require circulatory arrest. Here, we present our experience with the safety and feasibility of operating room extubation following simple and complex aortic surgery. METHODS/UNASSIGNED:All consecutive patients who underwent aortic surgery from August 2023 to April 2025 were included in this descriptive study. We evaluated 30-day postoperative outcomes for patients who were extubated in the operating room and those in the ICU. Outcomes of interest were time to chair, ICU and hospital LOS, as well as reintubation and reoperation rates. RESULTS/UNASSIGNED:< .001). Thirty-day outcomes were excellent and comparable in both groups with no deaths or myocardial infarctions for operating room extubation compared with ICU extubation, respectively: atrial fibrillation (n = 49 [21.9%] vs n = 9 [60%]), stroke (n = 1 [0.4%]) vs n = 0), reoperation for bleeding (n = 1 vs n = 0), reintubation for respiratory failure (n = 0 vs n = 1), and 30-day readmission (n = 11 [4.9%] vs n = 2 [11.8%]). CONCLUSIONS/UNASSIGNED:Routine extubation in the operating room is safe and feasible for a wide variety of patients undergoing both simple and complex aortic surgery, even when most of them undergo circulatory arrest. Operating room extubation may accelerate recovery and early ICU and hospital discharge, without increasing readmission or morbidity.

OBJECTIVE:To analyze the in-hospital outcomes of patients undergoing re-operative aortic arch repair and identify risk factors for mortality and morbidity using data from a multicenter, national registry. METHODS:We collected data on patients undergoing aortic arch repair (hemiarch or total arch replacement with or without elephant trunk/frozen elephant trunk) under circulatory arrest between 2002 and 2021, including those with acute aortic dissection. Patients with a history of previous open-heart surgery were defined as the redo cases (aortic-redo group and other-redo group). The primary outcomes were operative mortality and a modified Society of Thoracic Surgeons composite endpoint for mortality and major morbidity (MMOM). The MMOM composite endpoint was defined as: operative mortality, stroke, dialysis-dependent renal failure, deep sternal wound infection, reoperation, prolonged ventilation of >40 hours. Blood transfusion rates were also analyzed. RESULTS:Overall, 374 (15%) of 2481 patients were in the redo cohort. The overall operative mortality of aortic arch reoperations was 12%. Although redo patients had a significantly higher comorbidity burden, no significant difference was identified for the operative mortality among primary, aortic-redo and other-redo groups (9.3% vs. 11% vs. 14%, p = 0.132), and for the MMOM incidence (30% vs. 34% vs. 39%, p = 0.075). Additionally, transfusion requirements and ICU/hospital stays were higher in both redo groups (p < 0.001). To further analyze the redo group, all patients were divided into four groups: Primary hemi-arch group (n = 1800), primary total-arch group (n = 307), redo hemi-arch group (n = 266) and redo total-arch group (n = 108). Operative mortality was significantly higher in the redo hemi-arch group (p = 0.014). In contrast, there was no significant difference in mortality or MMOM between primary and redo total-arch groups (p > 0.05). Multivariable analyses identified older age, acute aortic dissection, and prolonged CPB time (log-transformed) as independent predictors of both operative mortality and MMOM in reoperative arch repair. CONCLUSIONS:This study of a national registry demonstrated that selected aortic arch reoperations can be performed with acceptable safety. Older age, acute aortic dissection, and prolonged CPB time are associated with worse operative outcomes. Further studies are needed to optimize surgical techniques and perioperative care, in addition to selecting patients who would benefit most from reoperative open arch surgery.

OBJECTIVE:We performed an intention to treat analysis of initial cannulation strategy to assess impact on perioperative outcomes in acute type A dissection using multicenter data. METHODS:All patients undergoing surgical repair of acute type A dissection from a multicenter national registry of 9 high-volume aortic centers were analyzed. Cannulation strategies included in the analysis were: Axillary, Femoral, Direct Aortic, and Innominate. Among 950 patients, we excluded those with chronic, type B dissections, and unknown initial cannulation strategy. Patients with multiple cannulation strategies were included if the sequence in which strategies were initiated was known. The final cohort consisted of 936 patients. Primary outcomes were stroke and death. Multivariable logistic regression was performed to adjust for baseline differences. P values represent Tukey's post hoc comparisons. RESULTS:Among 936 patients, cannulation strategies in descending order included: Axillary (n=502, 53%), Femoral (n=268, 29%), Aortic (n=104, 11%), and Innominate (n=59, 6%). Of these 46 (5%) had a change in the initial cannulation strategy prior to initiating circulatory arrest, mainly for poor axillary flow or initial femoral cannulation for hemodynamic instability followed by axillary. Femoral patients were younger (61.3±13.8) than Aortic patients (66.4±12.52, p=0.01) and more likely to present with malperfusion (n=123, 45.9%) compared to Aortic, Axillary, or Innominate patients (p <0.01). Femoral patients also had the longest duration of cerebral ischemia (Femoral: 16.9±16min, Aortic: 11.5±11.8min; Axillary: 4.41±10.3min; Innominate: 2.53±6min, p<0.01 for all vs Femoral). Unadjusted risk of death, stroke, and prolonged ventilation was lowest among Axillary and Innominate patients (Figure 1A). Length of stay was also reduced among Innominate patients. Multivariable regression demonstrated Axillary [OR 0.52 (0.36-0.75), p=0.004] and Innominate [OR 0.19 (0.07-0.54), p=0.009] cannulation to be associated with significantly reduced risk of stroke (Figure 1C). A non-significant signal of reduced death in Axillary patients remained [OR 0.66 (0.45-0.96), p=0.07]. CONCLUSIONS:In high volume aortic centers, an initial cannulation strategy using Axillary access is associated with reduced risk of stroke compared to Femoral. Axillary cannulation should be the preferred strategy in experienced centers if anatomy and stability allow.

BACKGROUND:Transcatheter tricuspid valve replacement (TTVR) abolishes tricuspid regurgitation (TR) and has emerged as a definitive treatment for TR. OBJECTIVES/OBJECTIVE:The purpose of this multicenter, observational study was to determine the clinical characteristics and short-term outcomes of patients with TR screened for TTVR. METHODS:Patients underwent TTVR screening at 7 centers on a compassionate-use basis. The primary endpoints were NYHA functional class and TR grade at 30-day follow-up. Secondary endpoints included all-cause mortality, heart failure hospitalization, technical success, and reasons for TTVR screening failure. RESULTS:A total of 149 patients (median age 79 years [Q1-Q3: 72-84 years], 54% women) underwent TTVR screening. The TTVR screening failure rate was 74%, mainly related to large tricuspid annular diameter. Patients undergoing TTVR (n = 38) had significant functional improvements (NYHA functional class I or II from 21% to 68%; P < 0.001), with TR ≤1+ in 97% at 30-day follow-up (P < 0.001 from baseline). Technical success was achieved in 91%, with no intraprocedural mortality or conversion to surgery. At 30-day follow-up, mortality was 8%, heart failure hospitalization 5%, major bleeding 18%, and reintervention 9%. Patients who failed screening for TTVR and subsequently underwent "bailout" transcatheter edge-to-edge repair (n = 26) had favorable outcomes (NYHA functional class I or II from 27% to 58%; P < 0.001), with TR ≤1+ in 43% at 30-day follow-up (P < 0.001 from baseline). CONCLUSIONS:This first real-world report of TTVR screening demonstrated a high screening failure rate, mainly related to large tricuspid annular diameter. Patients undergoing TTVR had superior TR reduction and symptom alleviation compared with bailout tricuspid transcatheter edge-to-edge repair, at the cost of greater procedural complications.

Aortic root reconstruction operations have undergone substantial evolution with technical modifications, expanding indications, and the need for increasingly complex decision-making. The purpose of this state-of-the-art review is to detail our approach to contemporary aortic root reconstruction operations. First, we review the evolution of root reconstruction procedures over the years and discuss the approach to the aortic root patient for lifetime management of aneurysm and valvular disease in the modern context of management options. We also discuss state-of-the art technical considerations of valve-sparing root replacement, variations of the Ross operation, aortic valve repair principles and challenges in special populations, and considerations for complication-free coronary button reconstruction. We also discuss root reconstruction in high-risk subpopulations including acute type A aortic dissection, congenital, and reoperative patients. We briefly highlight future directions in transcatheter root replacement as well as the outlook for the next generation of aortic root surgeons.