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Open Surgery

Aortic Root Replacement

Influence of Left Ventricular Ejection Fraction

The NewYork-Presbyterian/Columbia University Aortic Center focuses on comprehensive care for high risk patients with aortic diseases through a multidisciplinary approach using the best available cutting- edge technologies. While several studies have identified general risk factors associated with outcomes of aortic root replacement, the impact of left ventricular ejection fraction (LVEF) on outcomes has not been specifically examined. The Aortic Center team, based on the strong track record of treating patients with decreased heart function in collaboration with the Columbia heart failure team, reviewed their own experience in approximately 600 patients to better understand early postoperative outcomes in patients with low LVEF undergoing aortic root replacement. Their findings, first published online in the November 16, 2018, issue of The Journal of Thoracic and Cardiovascular Surgery, showed that patients with a reduced LVEF who underwent aortic root replacement had satisifactory outcomes yet significantly increased mid-term and in-hospital mortality, major perioperative morbidity, as well as longer hospital and ICU lengths of stay compared to patients with a LVEF >50 percent. The increased risk likely reflected the inherent risk of performing cardiac surgery in patients with pre-existing left ventricular dysfunction. The researchers concluded that these significantly higher mid-term outcomes should be discussed when counseling patients with low LVEF who need aortic root replacement. These patients certainly benefit from receiving their care at aortic centers, where a multidisciplinary approach is applied.

Aortic Procedures


Volume
2013 - 2017


Aortic Procedures Volume Bar Graph

Source: NewYork-Presbyterian

Procedure Volume by Type
2017


Procedure Volume by Type Pie Chart

Source: NewYork-Presbyterian

Procedure by Location Distribution
2017


Procedure by Location Distribution Graph

Source: NewYork-Presbyterian

NewYork-Presbyterian had a 100% survival rate for aortic valve-sparing procedures for three consecutive years, 2015 to 2017.

Open Thoracic Aortic Repair


Volume
2013 - 2017


Open Thoracic Aortic Repair Volume Bar Graph

Source: NewYork-Presbyterian

Valve-Sparing In-Hospital Mortality
2017


Valve-Sparing In-Hospital Mortality Bar Graph

*Expected mortality was determined using Vizient risk-adjustment methodology. Source: Vizient Clinical Data Base/Resource Manager™ used by permission of Vizient. All rights reserved.

Root, Ascending Aorta, and Aortic Arch In-Hospital Mortality
2017


Root, Ascending Aorta, and Aortic Arch In-Hospital Mortality Bar Graph

**All = Root, Ascending Aorta, and Aortic Arch *Expected mortality was determined using Vizient risk-adjustment methodology. Source: Vizient Clinical Data Base/Resource Manager™ used by permission of Vizient. All rights reserved.

Root, Ascending Aorta, and Aortic Arch In-Hospital Complications
2017


Root, Ascending Aorta, and Aortic Arch In-Hospital Complications Graph

*Based on NYSDOH data Source: NewYork-Presbyterian

Complex Aortic Repair


In-Hospital Complications
2017


Complex Aortic Repair In-Hospital Complications Graph

Source: NewYork-Presbyterian

In-Hospital Mortality
2017


Complex Aortic Repair In-Hospital Mortality Bar Graph

*Expected mortality was determined using Vizient risk-adjustment methodology. Source: Vizient Clinical Data Base/Resource ManagerTM used by permission of Vizient. All rights reserved.

Aortic Blood Flow After Valve-Sparing Root Reimplantation

In 2018, Weill Cornell researchers and their colleagues with the European Hospital in Rome looked at 4D flow characterization of aortic blood flow after valve-sparing root reimplantation. This procedure is an effective alternative for young patients with dilated roots and preserved cusps, which avoids the risks of lifelong anticoagulation or valve degeneration. New grafts with anatomically shaped sinuses have been developed in order to preserve aortic root physiology, which could decrease complication rates and improve durability. Controversy remains regarding the effect of recreation of the sinuses of Valsalva on long-term outcomes.

With its unique ability to combine anatomical evaluation of the root with fluid-dynamic assessment of aortic flow, the novel 4D flow technique enables integrated analysis of the close interaction between graft design, valvular morphology, and 3D flow characteristics greatly facilitating patient-tailored surgical planning. Their findings were published in the Journal of Visualized Surgery in January 2018.

Weill Cornell researchers also used 4D flow imaging to elucidate vascular flow characteristics in patients who had undergone valve-sparing root replacement and the corresponding mechanical loads acting on the aortic wall as measured via MRI-derived computational analysis. The researchers determined that “recreation of the sinuses of Valsalva during valve-sparing root replacement is associated with significantly lower wall shear stress and organized vortical flows at the level of the sinus that are not evident using the straight tube graft.These findings need confirmation in larger studies and could have important implications in terms of aortic valve durability.” The results of the study were published in Interactive CardioVascular and Thoracic Surgery in February 2018.

4D flow MRI image

4D flow MRI images of a patient with bicuspid aortic valve who underwent valve-sparing root reimplantation with reconstruction of neo-sinuses

With its unique ability to combine anatomical evaluation of the root with fluid-dynamic assessment of aortic flow, the novel 4D flow technique enables integrated analysis of the close interaction between graft design, valvular morphology, and 3D flow characteristics greatly facilitating patient-tailored surgical planning. Their findings were published in the Journal of Visualized Surgery in January 2018.

Weill Cornell researchers also used 4D flow imaging to elucidate vascular flow characteristics in patients who had undergone valve-sparing root replacement and the corresponding mechanical loads acting on the aortic wall as measured via MRI-derived computational analysis. The researchers determined that “recreation of the sinuses of Valsalva during valve-sparing root replacement is associated with significantly lower wall shear stress and organized vortical flows at the level of the sinus that are not evident using the straight tube graft.These findings need confirmation in larger studies and could have important implications in terms of aortic valve durability.” The results of the study were published in Interactive CardioVascular and Thoracic Surgery in February 2018.

Thoracic and Thoracoabdominal Aortic Aneurysms

Durability of Open Surgical Repair

The NewYork-Presbyterian/Columbia University Aortic Center team is recognized as one of the experienced centers in treating thoracoabdominal aneurysms, and participated in a study investigating durability of open surgical repair of type IV thoracoabdominal aortic aneurysm to help identify the risk of late graft and subsequent aortic events. The research group noted that this data is becoming increasingly important with the introduction of endovascular repair as a potential alternative. To better understand the long-term outcomes, they reviewed 233 patients who underwent open surgical repair of type IV TAAA during a 27-year period. Surviving patients were monitored for late aortic or graft-related events, defined as native aortic disease unrelated to the prior reconstruction leading to death or further intervention. Graft-related complications included anastomotic aneurysm, graft infection, and branch occlusion. The results, published in the January 2, 2019, online issue of the Journal of Vascular Surgery showed that late aortic and graft-related events were uncommon after open type IV TAAA repair. Additionally, the need for reintervention was infrequent, and aortic-related mortality was low. The researchers concluded that these findings verify durability of open type IV TAAA repair and serve as long-term comparative results for endovascular repair.

Open Repair in Octogenarians

Despite improved outcomes for open repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA), these operations remain challenging in octogenarians. Patients unsuitable for thoracic endovascular aortic repair require open surgery to avoid catastrophic rupture. Weill Cornell faculty recently undertook a study of the open repair of DTA and TAAA in octogenarians, the results of which were published in the November 2018 issue of the Journal of Vascular Surgery. Reviewing the Weill Cornell aortic database from 1997 to 2017, the researchers found that octogenarians were more likely to be female, with chronic pulmonary disease, severe peripheral vascular disease, and hypertension. Degenerative aneurysms were more common among octogenarians, whereas chronic and acute dissections were more common among those younger than 80 years. The operative mortality was 5.6 percent and was not negatively affected by advanced age, and there were no significant differences in the incidence of major postoperative complications. In conclusion, the researchers noted that in select octogenarians, open repair of DTA/TAAA can be performed with acceptable risk.

Novel Therapeutics
Management of Thoracoabdominal Aortic Aneurysm

In the July 2018 issue of Seminars in Thoracic and Cardiovascular Surgery, Weill Cornell faculty provide a review of open and endovascular therapies for three highly lethal thoracoabdominal aortic emergencies in order to highlight expectations for both short- and long-term outcomes.

Thoracoabdominal aortic aneurysms are most commonly asymptomatic until there is either an impending aortic catastrophe or one that has already occurred. Acute emergencies such as rupture, infection, or complicated dissection require expedient surgical treatment for optimal outcomes. Open surgical repair remains the gold standard treatment modality and thoracic endovascular aneurysm repair is evolving as a viable alternative. NewYork-Presbyterian cardiothoracic surgeons have extraordinary expertise and experience in treating acute aortic emergencies associated with thoracoabdominal aneurysms that require rapid diagnosis and treatment to avoid a fatal outcome.

in procedure repair photo

Repair of mycotic thoracoabdominal aortic aneurysm with a Dacron graft and omental flap

Open repair of ruptured thoracoabdominal aortic aneurysms is associated with a dramatic increase in all postoperative complications, even in specialized aortic surgery centers. Mycotic thoracic aortic aneurysms are highly lethal if surgical treatment is not initiated quickly as they have a propensity toward rapid growth and fatal rupture. Endovascular techniques have evolved as a viable alternative therapy for acute complicated Type B aortic dissection or as a bridge to more definitive repair in the setting of infection or rupture.

Novel Therapeutics
Facilitating Coronary Reconstruction

NewYork-Presbyterian/Columbia University Aortic Center surgeons receive referrals from other cardiovascular surgeons/specialists for extremely complex cases. Upon treating these difficult cases, they have developed a novel technique using the side branch of an aortic graft for difficult coronary reconstruction during complex aortic root replacement. The new technique and its successful application in six patient cases are described in a study published in the October 4, 2018, issue of Seminars in Thoracic and Cardiovascular Surgery.

The researchers retrospectively reviewed 234 patient charts of those who underwent aortic root replacement between January 2013 and November 2017. Within this group, six patients required coronary reconstruction with branches of aortic graft and were included in this study. All patients underwent complex surgery: All were reoperative cases, three of which were for acute type A aortic dissection. All patients survived to discharge with a median hospital stay of 20.5 days.


image of Side branch of aortic graft

Side branch of aortic graft facilitates coronary reconstruction with satisfactory outcomes

During a median follow-up of 221 days no patients experienced major adverse cardiovascular events. Four patients underwent radiographic follow-up, which confirmed patent interposition grafts (5/5). The researchers concluded that use of branches from the aortic graft for coronary reconstruction is feasible with satisfactory outcomes. They note that the key to the new technique is the use of branch(es) of the main aortic graft to restore the coronary perfusion when direct reimplantation is risky. The ascending aorta is reconstructed using a graft with one or more branches when the use of this technique is anticipated. Otherwise, an existing side branch of the main graft can be utilized after converting the arterial perfusion line from the side branch to an alternative access.