Aortic Root Enlargement during Aortic Valve Replacement in Adults

Aortic valve replacement is a gold standard in the treatment of patients with severe aortic stenosis or combined aortic pathology. However, aortic valve pathology is often associated with a narrow aortic orifice, particularly in patients with severe aortic stenosis. In 1978, Rahimtoola first described the term of prosthesis-patient mismatch. He noted that effective orifice area of the prosthesis is smaller than that of the native valve. To minimize this complication, there are several surgical strategies: aortic root enlargement (ARE), implantation of a frameless biological prosthesis in the native position, neocuspidalization procedure, Ross procedure, aortic root replacement with xenograft or homograft. ARE is an excellent option, however, some authors outline additional perioperative risks. The aim. To analyze immediate results of ARE during isolated aortic valve replacement and in cases when it is combined with other heart pathologies. Materials and methods. Our study included 63 patients who underwent ARE. Isolated aortic valve replacement was performed in the majority of cases, but often aortic root replacement procedure was combined with coronary artery bypass grafting. Results and discussion. One of 63 patients died (hospital mortality 1.6%) at an early hospital stage (30 postoperative days). Measurement of the aortic valve ring was performed by two methods, through preoperative echocardiography and perioperative measurement using a valve sizer. However, perioperative dimension was chosen as the basis for the calculations. In 62 patients, the perioperative diameter of the aortic valve ring ranged from 19 to 23 mm, only one patient had a diameter of 24 mm. According to our findings, ARE enabled to achieve an average aortic ring size increase of 2.68 cm2 (from 1.5 to 3.4 cm2) and to prevent prosthesis-patient mismatch in 42 (66.7%) cases. Conclusions. Prosthesis-patient mismatch is considered a serious complication in the postoperative period. Narrow aortic root is a common pathology that should be considered during surgery. ARE is a safe procedure and is not associated with an increased risk of mortality and complications.

Transposition of Isolated Left Vertebral Artery in Hybrid Thoracic Endovascular Aortic Repair

Objectives: The aim of this study was to present our experience with the management of isolated left vertebral artery (ILVA) during complex thoracic aortic pathology treated with the hybrid thoracic endovascular aortic repair.Methods: This is a single-center, respective cohort study. Between June 2016 and June 2020, 13 patients (12 men; median age 60 years old, range 42–72 years old) who underwent hybrid procedures were identified with ILVA in our center. Demographics, imaging features, operation details, and follow-up in these patients were collected and analyzed.Results: In this study, all patients received the hybrid procedure, and the primary technical success rate was 100%. There were no in-hospital deaths. Complication occurred in two (15.4%) patients. One patient suffered from contrast-induced acute kidney injury (CI-AKI) and recovered before discharge. Another patient required reintervention for acute left-lower-limb ischemia, which was successfully treated using Fogarty catheter embolectomy. Immediate vagus/recurrent laryngeal never palsy, lymphocele, and chylothorax were not observed. The median duration of follow-up was 22 months (range, 13–29 months). No neurologic deficits, bypass occlusion, or ILVA occlusion or stenosis were observed during the follow-up. No aortic rupture, cerebrovascular accident, or spinal cord ischemia was observed during the follow-up period.Conclusions: Our limited experience reveals that hybrid procedures [thoracic endovascular aortic repair (TEVAR), ILVA transposition, and left common carotid artery-left subclavian artery (LCCA-LSA) bypass] are relatively safe, feasible, and durable for the treatment of thoracic aortic pathology with ILVA. However, further technique durability and larger studies with long-term follow-up periods are warranted.

Cross-Entropy Learning for Aortic Pathology Classification of Artificial Multi-Sensor Impedance Cardiography Signals

An aortic dissection, a particular aortic pathology, occurs when blood pushes through a tear between the layers of the aorta and forms a so-called false lumen. Aortic dissection has a low incidence compared to other diseases, but a relatively high mortality that increases with disease progression. An early identification and treatment increases patients’ chances of survival. State-of-the-art medical imaging techniques have several disadvantages; therefore, we propose the detection of aortic dissections through their signatures in impedance cardiography signals. These signatures arise due to pathological blood flow characteristics and a blood conductivity that strongly depends on the flow field, i.e., the proposed method is, in principle, applicable to any aortic pathology that changes the blood flow characteristics. For the signal classification, we trained a convolutional neural network (CNN) with artificial impedance cardiography data based on a simulation model for a healthy virtual patient and a virtual patient with an aortic dissection. The network architecture was tailored to a multi-sensor, multi-channel time-series classification with a categorical cross-entropy loss function as the training objective. The trained network typically yielded a specificity of (93.9±0.1)% and a sensitivity of (97.5±0.1)%. A study of the accuracy as a function of the size of an aortic dissection yielded better results for a small false lumen with larger noise, which emphasizes the question of the feasibility of detecting aortic dissections in an early state.

Role of Extra-anatomic Ascending to Descending Bypass in Complex Thoracic Aortic Pathology

Complex pathology of the distal arch and proximal descending thoracic aorta is usually approached by stent endografting or in situ graft replacement. Oftentimes, these options are not feasible due to unfavorable anatomy, multiple previous procedures, active infection, or presence of concomitant cardiac disease. Thoracic aortic extra-anatomic bypass, as part of an open surgical strategy, is a useful and often the only curative option left for the treatment in these patients. Herein, we describe two cases that illustrate the utility of extra-anatomic thoracic aortic bypass for complex aortic disease.

Thoracic aortic aneurysm in pregnancy: morphological analysis of 6 cases

Aortic dissection is rare but life-threatening complication in pregnancy, causing significant maternal and perinatal losses. Pregnancy may influence the integrity of the vessel wall and is a risk factor for dissection. There are very few data in the literature on structural changes in the aortic walls during pregnancy complicated by aortic dissection. Aim. Study of pathological features in the wall of ascending aorta (AA) during or immediately after pregnancy is presented in the article. Materials and methods. Material after surgical correction of AA in patients during pregnancy and in the early postpartum period was studied. Frozen sections were made from one part of the sample, followed by hematoxylin and eosin (H&E) staining, as well as Sudan III–IV staining to detect lipids. Paraffin sections were stained with H&E and picrofuchsin (van Gieson’s stain) for differentiation of collagen and muscle fibers, as well as fuchselin (Weigert’s elastic stain). Results. Six cases of aortic surgery during pregnancy (n = 1) and postpartum period (n = 5) were included: severe aortopathy caused by Marfan syndrome (MS) (n = 3), aortic coarctation with bicuspid aortic valve (n = 1), renal hypertension (n = 1), and pregnancy-induced hypertension (n = 1). Pathohistological studies showed that in all patients who underwent aortic surgery at the end of the third trimester in the early postpartum period changes in aortic wall collagen structure were observed. In contrast, in a pregnant woman with MS and severe aortopathy, who underwent preventive aortic surgery at 19 weeks of gestation, there were no such changes, the morphologic samples showed areas of scarring. In all 6 cases signs of lipoidosis in the AA wall were observed. All these data require further theoretical study, but clinicians are already faced with the question of the feasibility of preventive surgery in women with severe aortopathy on the preconception stage or during pregnancy. Conclusions. The specific effect of pregnancy on the AA wall leads to collagen disruption and the appearance of lipoidosis in late pregnancy, which is an important pathomorphological substrate for the occurrence of acute aortic pathology.

Comprehensive treatment of pathology of the ascending, arch and descending thoracic aorta by performing operations of the hybrid "elephant trunk"

The purpose of the study – study and demonstration of the possibilities of the technique of complete replacement of the ascending, arch, vessels of the arch and descending thoracic aorta "elephant trunk" surgery in patients with aortic arch aneurysms.Material and methods. The paper describes the technique and demonstrates the results of the first 29 operations of prosthetics of the ascending, arch, vessels of the arch and descending thoracic aorta, which were performed by the staff of the Department of Surgical Treatment of Aortic Pathology National M.Amosov ICVS of the NAMS of Ukraine" in 2016-2020. Results. Hospital mortality was 10.3%, three patients died. The causes of death were: the following acute cardiovascular failure, uncontrolled bleeding, and multiple organ failure in each case. In none of the operated patients the level of postoperative blood loss did not require rethoracotomies.Conclusions. The optimal way to correct aneurysms of the aortic arch is the operation of prosthetics of the ascending, arch and descending thoracic aorta - "elephant trunk". Improvement of preoperative diagnostics, surgical equipment, optimization of methods of protection of the brain, spinal cord and visceral organs, the possibility of using hybrid / endovascular techniques to treat patients with complex lesions of the aortic arch pool with hospital mortality within 10.3%.

Association of sleep apnoea risk and aortic enlargement in Marfan syndrome

BackgroundMarfan syndrome (MFS) is a connective tissue disorder characterised by complex aortic pathology and a high prevalence of obstructive sleep apnoea (OSA). OSA produces intrathoracic transmural stresses that may accelerate aortic injury. The current study was designed to examine the associations between OSA risk and markers of aortic enlargement in MFS.MethodConsecutive patients with MFS were recruited at Johns Hopkins if they completed a STOP-BANG survey. Composite survey scores were categorised into those with low OSA risk (STOP-BANG <3) and high OSA risk (STOP-BANG ≥3). Participants’ aortic data were collated to ascertain aortic root diameter, dilatation and prior aortic root replacement. Regression analyses were used to examine associations between OSA risk strata and these aortic parameters.ResultsOf the 89 participants studied, 28% had a high OSA risk and 32% had aortic grafts. Persons with high OSA risk had greater aortic root diameter (mm) (ß=4.13, SE=1.81, p=0.027) and aortic root dilatation (ß=2.80, SE=1.34, p=0.046) compared with those with low OSA risk . In addition, the odds of prior aortic root replacement was three times greater in those with high OSA risk compared with those with low OSA risk.ConclusionIn MFS, high OSA risk is associated with aortic enlargement and a threefold increased risk of having had prior aortic root replacement. These findings invite further exploration of the relationship between OSA and aortic disease in MFS, and studies to clarify whether targeted interventions for OSA might mitigate aortic disease progression in MFS.Registration numberIRB00157483.

Variability in surveillance practice for patients with diagnosis of bicuspid aortic valve syndrome

Background/Aim: In patients with bicuspid aortic valves, guidelines call for regular follow-up to monitor disease progression and guide timely intervention. We aimed to evaluate how closely these recommendations are followed at a tertiary care center. Methods: This was retrospective cohort study at a tertiary care center. Among 48,504 patients who received echocardiograms between 2013-2018, 245 patients were identified to have bicuspid aortic valve. Bivariate analyses compared patient and echocardiographic characteristics between patients who did and did not receive follow-up by a cardiovascular specialist. Results: The mean age of the cohort was 55.2  15.6 years and 30.2% were female. During a median follow-up of 3.5  2.2 years, 72.7% of patients had at least one visit with a cardiovascular specialist after diagnosis of bicuspid aortic valve by echocardiogram. Patients followed by specialists had a higher proportion of follow-up surveillance by echocardiogram (78.7% vs. 34.3%, p< .0001), or by CT or MRI (41.0% vs. 3.0%, p < .0001), and were more likely to undergo valve or aortic surgery compared with patients not followed by specialists. Patients with moderate to severe valvular or aortic pathology (aortic stenosis/regurgitation, dilated ascending aorta) were not more likely to be followed by a cardiovascular specialist or receive follow-up echocardiograms. Conclusions: Follow-up care for patients with bicuspid aortic valve was highly variable, and surveillance imaging was performed sparsely despite guidelines. There is an urgent need for surveillance and clinical follow-up mechanisms to monitor this patient population with increased risk of progressive valvulopathy and aortopathy.