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      Clinical outcomes and quality of life after surgery for dilated ascending aorta at the time of aortic valve replacement; wrapping versus graft replacement

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          ABSTRACT

          Wrapping and graft replacement are two optional procedures for the treatment of dilated ascending aorta at the time of aortic valve replacement (AVR). Wrapping is considered less invasive. The aim of this study was to compare the short- and long-term clinical outcomes as well as the long-term quality of life in patients undergoing these two procedures.This study enrolled 40 consecutive patients with dilated ascending aorta who had undergone either wrapping (WAA group, n=20) or replacement (RAA group, n=20) of the ascending aorta at the time of AVR. Short-term outcomes, long-term deaths, and aortic events were evaluated, as was quality of life using the SF-36 Short Form. Long-term maximal proximal aortic diameter was also obtained.There were no early deaths in either group. Pump time was shorter, and transfusion (55% vs. 95%, p=0.035) and postoperative atrial fibrillation (5% vs. 30%, p=0.036) rates were lower, in the WAA than in the RAA group. At a mean follow-up of 4.9 years, the overall 5 year survival rates in the WAA and RAA groups were 78.1% and 87.5%, respectively. There were no significant between group differences in SF-36 scores in any subcategory of this survey. Long-term maximal aortic diameter remained stable in both groups. Both surgical interventions for dilated ascending aorta at the time of AVR yield favorable and comparable results in patients with suitable anatomy. Furthermore, we found no differences in quality of life between these procedures.

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          Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease?

          The optimal diameter at which replacement of the ascending aorta should be performed in patients with bicuspid aortic valve disease is not known. We reviewed all patients with bicuspid aortic valves undergoing aortic valve replacement at our institution from 1979 through 1993 (n = 201). Patients undergoing concomitant replacement of the ascending aorta were excluded. Follow-up was obtained on 98% of patients and was 10.3 +/- 3.8 (mean +/- SD) years. The average patient age was 56 +/- 15 years, and 76% were male. The ascending aorta was normal ( 5.0 cm) underwent replacement of the ascending aorta and were therefore excluded. Fifteen-year survival was 67%. During follow-up, 44 patients required reoperation, predominantly for aortic valve prosthesis failure. Twenty-two patients had long-term complications related to the ascending aorta: 18 required an operative procedure to replace the ascending aorta (for aortic aneurysm), 1 had aortic dissection, and 3 experienced sudden cardiac death. Fifteen-year freedom from ascending aorta-related complications was 86%, 81%, and 43% in patients with an aortic diameter of less than 4.0 cm, 4.0 to 4.4 cm, and 4.5 to 4.9 cm, respectively ( P < .001). Patients undergoing operations for bicuspid aortic valve disease should be considered for concomitant replacement of the ascending aorta if the diameter is 4.5 cm or greater.
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            Management of dilated ascending aorta during aortic valve replacement: valve replacement alone versus aorta wrapping versus aorta replacement.

            The optimal management of dilated ascending aorta during aortic valve replacement (AVR) remains controversial. This study compared the outcomes among 3 different managements (AVR alone, aorta wrapping, and aorta replacement) for the dilated ascending aorta. The study enrolled 499 consecutive non-Marfan patients undergoing AVR in the presence of the ascending aorta dilatation (40 to 55 mm). We evaluated rates of death and aortic events; in addition, we evaluated the aortic expansion rate by serial echocardiography. The surgery involved AVR alone (n = 362), aorta wrapping (n = 67), or aorta replacement (n = 70). Early mortality occurred in 1.2% (n = 6, P = .61). Throughout 1590.0 patient-years of follow-up, 47 deaths occurred. The 5-year survival rates were 90.1% ± 2.0%, 91.8% ± 3.5%, and 82.2% ± 7.5% in the AVR alone, aorta wrapping, and aorta replacement groups, respectively (P = .64). One aortic event (acute type A dissection) occurred in the AVR alone group. For the AVR alone group, the median aortic expansion rate was -0.6 mm/y (interquartile range, -3.2 to 0.6 mm/y). The aortic expansion rates were affected neither by the morphology of aortic valves (bicuspid vs tricuspid; P = .10) nor by the initial aorta diameter (γ = -0.31, P = .61). Clinically relevant aortic expansion (≥5 mm/y) was observed only in 5 patients; of these patients, 2 showed the aortic diameter of 60 mm or greater at the end of follow-up. Compared with concomitant aortic wrapping or replacement, AVR alone achieved similar clinical outcomes, showing considerably low risks of adverse aortic events or relevant aortic expansion in dilated ascending aorta. These findings argue against routine aortic replacement at the time of AVR. Crown Copyright © 2013. Published by Mosby, Inc. All rights reserved.
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              A meta analysis and systematic review of wrapping of the ascending aorta.

               Tomasz Plonek (2014)
              One of the methods of dealing with a dilated ascending aorta is to decrease its diameter using external wrapping. This exovascular procedure is regarded by many surgeons as controversial. The aim of the study was to evaluate the safety and efficacy of external wrapping of the ascending aorta. A metaanalysis and systematic review of studies reporting mid-term and long-term results of wrapping of the ascending aorta were performed. The postoperative hospital mortality, aortic-related mortality, significant redilatation rate, and need for aortic reoperation were analyzed. 17 manuscripts were included in the final analysis and postoperative data of 722 patients were studied. The mean age of patients was 58 years and mean follow-up was 62 months. Hospital mortality was 1.5% (11 deaths). During the follow-up late aortic related mortality was noted in two patients (0.3%), there were 12 (1.7%) cases of significant redilatation of the ascending aorta, and 13 (1.8%) patients had to have their ascending aorta reoperated. All of the aortic complications were noted in patients who either did not have their external wrapping sutured to the aorta or who underwent concomitant aortoplasty. The results of the metaanalysis suggest that external aortic wrapping may be considered as a safe operative technique. In patients with a moderately dilated aorta it offers good mid-term and long-term outcome compared to replacement of the ascending aorta. © 2014 Wiley Periodicals, Inc.
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                Author and article information

                Journal
                Nagoya J Med Sci
                Nagoya J Med Sci
                Nagoya Journal of Medical Science
                Nagoya University
                0027-7622
                2186-3326
                November 2017
                : 79
                : 4
                : 443-451
                Affiliations
                [1 ]Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
                Author notes

                Corresponding author: Tomonobu Abe, M.D.

                Department of Cardiac Surgery, Nagoya University Graduate School of Medicine

                65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan

                Phone: +81-52-744-2376, fax: +81-52-744-2381, e-mail: tomonobuabe@med.nagoya-u.ac.jp

                Article
                10.18999/nagjms.79.4.443
                5719203

                This is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view the details of this license, please visit ( http://creativecommons.org/licenses/by-nc-nd/4.0/).

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