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E. M. Ahmed and E. P. Chen
of the aortic root is a viable option [52]. Regardless to whether reimplantation or
remodelling with ring stabilization is used, the technical aspects pertinent in the
setting of TAAAD are shared.
The technical aspects of cardiopulmonary bypass in TAAAD repair are discussed
elsewhere in this book. At Emory, we use the right axillary artery or the ascending
aorta for arterial return, and the right atrium is used for drainage through a threestage venous cannula inserted through the right atrial appendage. At a bladder temperature of 24–28 °C, the innominate artery is clamped and unilateral antegrade
cerebral perfusion initiated. The aortic arch is reconstructed, using the neo-intima
technique, and repaired as indicated. Following completion of distal reconstruction,
the distal tube graft is clamped and total body perfusion is resumed through the right
axillary artery.
At this stage the aortic root and valve are assessed for indication for root intervention and suitability of the aortic valve for preservation. With regard to the aortic
valve, particular attention is paid to leaets tissue quality, thickening, calcication,
leaet fenestration, leaet prolapse and valve conguration. If the valve is suitable
for preservation, the aortic root tissue is excised, leaving a 4–5mm rim of aortic
tissue, and the coronary buttons created. Subsequently, the aortic root is dissected
free from surrounding structures 2mm below the nadir of each cusp; the dissection
is limited in the non-coronary/right coronary commissure because of the natural
limitation imposed by the membranous septum and the muscular septum; the left
atrium forms the lower limit of left coronary sinus dissection.
It is important to note that in cases of TAAAD tissue planes are more challenging
to identify because of the haematoma and the swelling induced by the dissection
(Fig.3). It is worthwhile to invest in careful dissection to avoid inadvertent injury to
the right ventricular outow tract (RVOT), pulmonary artery (PA), and coronary
vessels. Should an injury be identied, it should be repaired immediately.
Once the dissection is carried to the lowest point desired, 2-0 Polyester sutures are
placed from within the LVOT and used to anchor the aortic prosthesis. We do not use
pledgeted subannular sutures, as we believe pledgets can potentially interfere with
Fig. 3 TAAAD with
haematoma extension into
the pulmonary artery,
dissection of tissue planes
for VSRR can be
challenging
ab
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Fig. 4 (a) The aortic root is dissected leaving a 3–4mm of tissue. (b) The valve is telescoped
within the graft and sutured with 5-0 Polypropylene to the prosthesis prior to implantation of the
coronary buttons
275
the undersurface of the leaet. The proximal end of the graft is anchored to the subannular sutures with the valve and remnants of the aortic root telescoped within the
graft. Subsequently, we assess the height of the commissures and suspend them to the
graft with 5/0 Polypropylene under tension. It is important to maintain tension on the
commissures at this stage. The aortic root rim is sutured to the graft with 5/0
Polypropylene sutures (Fig.4); we assess leaet coaptation, and should leaet repair
be required, it is performed at this stage. The coronary buttons are then anastomosed
to the graft, starting with the left coronary artery. If the there is doubt regarding the
integrity of the tissue of the coronary button, Cabrol modication of the original
Bentall procedure, using a conduit to anastomose the coronary arteries to the graft is
a sound strategy that we occasionally employ, as it helps avoid disappointment caused
by a bleeding coronary button at the end of a long operation [6, 53]. We administer
cardioplegia into the root and assess its’ competency prior to releasing the cross clamp.
It is of paramount importance to carefully assess the TEE images after discontinuing CPB for evidence of AI.Should AI be identied, it is helpful to identify the
aetiology and mechanism from TEE, as that would shorten the second clamp time
required to address AI.It is our strategy to reclamp should AI>+1 be detected on TEE.
Regarding the sizing of the graft, we used David’s formula of a graft
size=[2*(C
*2/3)]+6 to 10mm to select a prosthesis appropriately. The height
usp
of the NC/RC commissure as proposed by El Khoury, or a Hegar dilator can also be
used as guide prosthesis size [54]. We do not perform complex cusp repair in
patients with TAAAD, as a second clamp may prove to be costly in this critically ill
cohort of patients.
Results ofVSRR inTAAAD
Sir Magdi Yacoub reported the results of remodelling in 158 patients, 31% had
acute aortic dissection, with a mortality of 4.6% for the whole cohort; the mortality
of patients with acute type A aortic dissection was 18%. However, a third of patients
developed moderate aortic insufciency, during a mean follow-up of 5years [55].
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E. M. Ahmed and E. P. Chen
The partial root replacement, including Uni-Yacoub and Bi-Yacoub, technique
has been adopted by other groups, with a reported freedom from reintervention of
100–90% at 10years or more [3, 56, 57]. Urbanski used a similar strategy in 46
patients with TAAAD with no valve related reintervention at mean follow-up of
4.5years [58]. However, the selective sinus repair excellent results have not bee
replicated by other group; in Chiu series 11% of patients who had unisinus or bisinus repair had a reintervention, while 0% of the Bentall group [27]. A study from
Japan reported repair of AAAD in 19 patients, using the remodelling technique with
VAJ ring stabilisation; the perioperative mortality was 5.6% and one patient needed
reoperation for AI during a follow-up of 56months [52]. The experience with this
strategy in TAAAD is still its infancy, and we would be curious for long-term results
and larger series to be reported.
The largest series to date of VSRR in TAAAD is from Hannover; Beckmann
et al. reported their results of 109 patients who underwent David procedure for
TAAAD.The in-hospital mortality was 11%, despite 40% of patients undergoing
concomitant total arch replacement, which is below the mortality reported by IRAD,
with a 10-year freedom from reoperation of 85%. Freedom from AI<+1 was 96%.
Interestingly, when adjusted for perioperative mortality, the long-term survival of
patients treated with VSRR for TAAAD is no different from elective patients [59].
These excellent results should be evaluated bearing in mind that in Hannover, on
average, 22 VSRRR are performed electively every year; while in the USA the
median number of aortic root surgeries performed by a centre is 2, and only 5% of
centres performed more than 16 aortic root operations annually [60].
At Emory we published our experience in VSRR in TAAAD patients over
13years. Of the 132 patients, 52 had VSRR.The 30-day mortality was 3.4% and
14.3in the VSRR and root replacement groups respectively. The freedom from AI
+2 was 94% at midterm follow-up and no patient required AVR.Furthermore, longterm survival benet has been demonstrated following VSRR [31, 38, 61].
A comparative study of Bentall and David procedure in 135 TAAAD patients,
reported similar adjusted perioperative mortality, no reoperations in the David
group, and a better 10year survival in favour of VSRR, 98% vs. 57% at 10years.
The Leipzig group reported the results of 208 root replacement in TAAAD, 130
Bentall, 51 modied Yacoub, 21 David, with similar perioperative results, despite
the longer bypass time in the reimplantation group; the freedom from reoperation
was also similar and in excess of 80% in all groups at 5years [62]. Higher freedom
from reoperation rates were reported in smaller series [63]. It is likely that in selfselected institutions good results are obtainable [64]. However, the encouraging
results of VSRR in TAAAD are not consistent. Tanka etal. reported 24 VSRR, from
a total cohort of 328 TAAAD patients, with a freedom from reoperation and freedom from moderate AI of 65% [65]. Tanaka’s series is over a 16years period, which
may reect a small volume of VSRR, and may explain the discouraging results. On
the other hand, an element of publication bias is likely, as centres with good results
are more likely to publish them.
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A meta-analysis of valve sparing root replacement, 10% had TAAAD, reported
a linearized mortality rate of 1.5%, 0.4% thromboembolic events, and a rate of 1.7%
of major adverse valve related events [66]. Furthermore, a meta-analysis comparing
Bentall and VSRR, including 9 studies and 706 patients, reported an improvement
in early mortality and late mortality in the pooled VSRR group with an OR 0.77
(0.21–0.57 95% CI) for early mortality. The linearized late mortality was 4.1% and
19.8% for VSRR and Bentall respectively, OR 0.34 (95% CI 0.21–0.57) for later
mortality. However, reintervention rate was higher in the VSRR group. The number
of patients included in each study ranged from 52 to 295 patients, and all the studies
were cohort studies. It is likely that there is an element of selection bias in all the
reported studies based on surgeons’ experience and patents’ characteristic. Yet it is
safe to conclude that in the appropriately selected patient VSRR provides long term
benet, these ndings resonate with meta-analysis ndings in aneurysmal aortic
root disease [67, 68].
Aubin et al. reported a single surgeon experience of liberally employing the
reimplantation in 45 patients with TAAAD.All patients with root involvement, in
the absence of haemodynamic instability or serious organ dysfunction had reimplantation repair. Despite an increase in ischaemic time, cardiopulmonary bypass
time by an approximately 50min, the 30-day mortality of the reimplantation and
non-reimplantation groups was 17% and 23% respectively. No reoperations were
required for proximal disease, and the mean AI grade was 0.6 at 5years follow-up.
While Aubin’s series is relatively small, it is among the most recently published data
reecting an increase in experience with reimplantation, a trend of a more aggressive approach to the root. It highlights importance of the surgeon’s experience in
achieving a good outcome in this challenging condition [69].
Others have demonstrated the association between surgeons with aortic interest
and an aggressive approach towards the root, with a potential survival benet [70].
The trend towards a more radical root strategy is particularly evident in the light that
the University of Pennsylvania group published a series, just under a decade ago, of
“new paradigms” in TAAD in which under a quarter of patients had aortic root
replacement [71]. We have seen time and time again in cardiac surgery “the pendulum swing” and only more data would enable us to assess if swing in the other direction is needed.
277
Conclusion
In experienced centres VSRR should be considered if the valve morphology is
favourable and in the absence of increased perioperative mortality risk factors.
Young patients and patients with dilated aortic root or genetic aortic syndromes
would probably benet the most from valve conservation and preservation of native
valve function.
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E. M. Ahmed and E. P. Chen
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Basic Approaches fortheSurgical
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Management ofAcute Type AAortic
Dissection: Safe Management Strategies
fortheGeneral Cardiac Surgeon
TironeE.David
Surgery for acute type A aortic dissection is associated with high operative mortality and morbidity largely because of its heterogeneity in pathology, pathophysiology and clinical presentation. Many patients die before reaching an emergency
room whereas others walk in a doctors’ ofce complaining of vague chest discomfort or other symptom and are found to have acute type A aortic dissections. The
dissection may involve only the ascending aorta in some cases whereas in most
patients the entry tear is in the proximal ascending aorta and the false lumen extends
down to the thoracic, abdominal and even femoral arteries causing various degrees
of organ malperfusion. The faster the diagnosis is made and the faster the patient
can be taken to the operating the better for the patient, and probably for the surgeon
too. The mortality of acute type A aortic dissection during the rst 24h is very high
and referring these patients to an aortic center may be inappropriate because whatever might be gained in operative mortality if the operation is performed by an
experienced aortic surgeon the overall mortality might be higher by delaying surgery. In addition, even experienced aortic surgeons nd challenging to operate on
certain patients with acute type A aortic dissection. Thus, the general cardiac surgeon working somewhere distant from an “aortic center” is probably the best person
to save the patient’s life. This is an operation that every cardiac surgeon should be
able to perform, and if it is planned and executed well, the mortality and morbidity
rates can be reduced.
This chapter was written with the “general cardiac surgeon” in mind, the one
who sees only a few patients with acute type A dissection each year. Based on my
The contents of this chapter were largely based on an editorial written by the author and published
in the Journal of Thoracic and Cardiovascular Surgery in 2015; volume 150, pages 279–283.
Permission from Elsevier was obtained.
T. E. David (*)
University of Toronto, Toronto, ON, Canada
e-mail: tirone.david@uhn.ca
J. S. Coselli et al. (eds.), Aortic Dissection and Acute Aortic Syndromes,
https://doi.org/10.1007/978-3-030-66668-2_20
283© Springer Nature Switzerland AG 2021
284
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lifetime experience working in a teaching hospital, I will be describing techniques
that I know that are reproducible if only followed correctly and performed with care
and attention to the details I will enumerate. Although I already mentioned, I rmly
believe that prompt diagnosis and immediate surgery are crucial in this disease, and
the sooner you can get the patient on the operating table, the better the operative and
long-term outcomes will be.
T. E. David
The Hemodynamically Unstable Patient
Hemodynamic instability after acute type A aortic dissection occurs because acute
myocardial ischemia due to the dissection or ruptured of the false lumen into the
pericardial cavity with consequent pericardial tamponade or rupture into the chest
of abdominal cavities. It is difcult and sometimes impossible to save the patient
with acute rupture of the false lumen in the pleural or abdominal cavity. However, it
is relatively common to have to operate on patients with myocardial ischemia or
pericardial tamponade. Patients with acute type A dissection and myocardial ischemia may have been treated by emergency room doctors with drugs such as ticagrelol which immensely increases the risk of massive postoperative bleeding. I have
operated on only two such patients and one died as consequence of massive blood
transfusion after a correctly and expeditiously performed operation for acute type A
dissection.
An arterial line on the right radial or brachial artery, a central venous line, and a
good peripheral IV are indispensable in hemodynamically unstable patients.
Although transcutaneous cannulation of the femoral vessels can be performed, I
believe you should start the operation by making an incision in the inguinal area and
expose the anterior wall of the femoral vein and common femoral artery. If the
femoral artery has evidence of a false lumen, mobilize this vessel circumferentially
and put tapes around it. If there is no dissection, simply put a purse string suture on
the anterior wall of the common femoral artery. A purse string suture should also be
place on the femoral vein. Next, go to the chest and do a full median-sternotomy. If
the hemodynamic instability is due to tamponade the pericardial cavity will be tense
and blue. Don’t open it because if you do there is a risk of a hypertensive crisis and
the aorta may blow up and make things messy. Give heparin and insert perfusion
cannulas in the femoral vessels using the Seldinger technique. If the femoral artery
has a false lumen, clamp it and open it transversely and insert a cannular into the
true lumen. Both the arterial and venous cardiopulmonary bypass lines should have
a second arm of tubing 80–100cm long in case you need another venous cannula to
completely drain the right side of the heart, or another arterial cannula. Go on
bypass and start to cool the patient. Make a small incision in the pericardium and
begin to drain the uid slowly. Alert the anesthetist of possible hypertension and
reduce the doses of inotropes and vasopressors. The rupture that caused the tamponade is often sealed and there is no active bleeding in most patients. If this is the case,
carry on and you may want to insert a cannula in the right atrium for better venous
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