Commentary: Management of mesenteric malperfusion syndrome in patients with type A aortic dissection:An unsettled issue

The modern treatment for type A aortic dissection requires careful planning, a wide range of expertise, and a multidisciplinary approach. Specialized aortic centers might be the solution

Impact of Isolated Tricuspid Valve Repair on Right Ventricular Remodelling in an Adult Congenital Heart Disease Population

BackgroundSurgical repair of isolated congenital tricuspid valve (TV) disease is rare with no well-defined indication and outcomes. Moreover, the role of right ventricle (RV) in this context has not yet been investigated.ObjectivesWe sought to assess the impact of congenital TV repair on cardiac remodelling and clinical–functional status and the importance of the RV function in an adult congenital heart disease (ACHD) population.Methods and resultsFrom January 2005 to December 2015, 304 patients underwent TV surgery in our centre. Of these, 27 (ACHD) patients had isolated TV repair. Patients were evaluated with preoperative and postoperative transthoracic echocardiogram. Survival rate has been investigated with a mean clinical follow-up (FU) of 3.7 ± 2.3 years, whereas the mean echocardiographic FU was 2.9 ± 1.8 years. The clinical and functional status of patients showed a statistically significant improvement after the surgical repair in terms of New York Heart Association class (66.7 vs 7.4%; p < 0.01), clinical signs of heart failure (29.6 vs 7.4%; p < 0.01), and left ventricular function (14.8 vs 7.4%; p < 0.01). The RV and right atrium diameter were significantly reduced after surgery (5.15 ± 1.21 vs 4.32 ± 1.16; p < 0.01) and (44.7 ± 16.7 vs 26.7 ± 9.2; p < 0.01), respectively. The degree of postoperative pulmonary hypertension was also significantly reduced (40.7 vs 7.4%; p < 0.01). The survival rate was 96.3% at 1 year and 93.7% at 5 years. One patient (3.7%) had early failure of the tricuspid repair requiring a reoperation.ConclusionIsolated TV repair for adult congenital disease significantly improved patients’ clinical and functional status and allowed right ventricular remodelling and functional improvement

Surgical repair of Stanford type A aortic dissection in elderly patients:a contemporary systematic review and meta-analysis

BACKGROUND: The results of surgical treatment of type A aortic dissection (AAD) in the elderly are controversial and aggravated by a higher operative mortality rate. The studies published in this subset of patients are mainly retrospective analyses or small samples from international registries. We sought to investigate this topic by conducting a contemporary meta-analysis of the most recent observational studies. METHODS: A systematic literature search was conducted for any study published in the last five years on aortic dissection treated surgically in patients 70 years and older. A pooled risk-ratio meta-analysis has been conducted three main post-operative outcomes: short-term mortality, stroke and acute kidney injury. RESULTS: A total of 11 retrospective observational studies have been included in the quantitative meta-analysis. Pooled meta-analysis showed an increased risk of short term mortality for the elderly population [relative risk (RR) =2.25; 95% CI, 1.79–2.83; I(2)=0%; P<0.0001], and this has been confirmed in a sub-analysis of patients 80 years and older. The risk of having stroke (RR =1.15; 95% CI, 0.89–1.5; I(2)=0%; P=0.28) and acute kidney injury (RR =0.79; 95% CI, 0.5–1.25, I(2)=14%, P=0.31) after surgery were comparable to the younger cohort of patients. CONCLUSIONS: Although affected by an increased risk of short-term mortality in the elderly, surgical repair remains the treatment of choice for AAD. The main post-operative outcomes are comparable to younger patients and the mid-term survival rates are acceptable

Postoperative acute kidney injury defined by RIFLE criteria predicts early health outcome and long-term survival in patients undergoing redo coronary artery bypass graft surgery

AbstractObjectiveTo investigate the impact of postoperative acute kidney injury (AKI) on early health outcome and on long-term survival in patients undergoing redo coronary artery bypass grafting (CABG).MethodsWe performed a Cox analysis with 398 consecutive patients undergoing redo CABG over a median follow-up of 7 years (interquartile range, 4-12.2 years). Renal function was assessed using baseline and peak postoperative levels of serum creatinine. AKI was defined according to the risk, injury, failure, loss, and end-stage (RIFLE) criteria. Health outcome measures included the rate of in-hospital AKI and all-cause 30-day and long-term mortality, using data from the United Kingdom's Office of National Statistics. Propensity score matching, as well as logistic regression analyses, were used. The impact of postoperative AKI at different time points was related to survival.ResultsIn patients with redo CABG, the occurrence of postoperative AKI was associated with in-hospital mortality (odds ratio [OR], 3.74; 95% confidence interval [CI], −1.3 to 10.5; P < .01], high Euroscore (OR, 1.27; 95% CI, 1.07-1.52; P < .01), use of IABP (OR, 6.9; 95% CI, 2.24-20.3; P < .01), and reduced long-term survival (hazard ratio [HR], 2.42; 95% CI, 1.63-3.6; P = .01). Overall survival at 5 and 10 years was lower in AKI patients with AKI compared with those without AKI (64% vs 85% at 5 years; 51% vs 68% at 10 years). On 1:1 propensity score matching analysis, postoperative AKI was independently associated with reduced long term survival (HR, 2.8; 95% CI, 1.15-6.7).ConclusionsIn patients undergoing redo CABG, the occurrence of postoperative AKI is associated with increased 30-day mortality and major complications and with reduced long-term survival

Enlightening the Association between Bicuspid Aortic Valve and Aortopathy

Bicuspid aortic valve (BAV) patients have an increased incidence of developing aortic dilation. Despite its importance, the pathogenesis of aortopathy in BAV is still largely undetermined. Nowadays, intense focus falls both on BAV morphology and progression of valvular dysfunction and on the development of aortic dilation. However, less is known about the relationship between aortic valve morphology and aortic dilation. A better understanding of the molecular pathways involved in the homeostasis of the aortic wall, including the extracellular matrix, the plasticity of the vascular smooth cells, TGF&beta; signaling, and epigenetic dysregulation, is key to enlighten the mechanisms underpinning BAV-aortopathy development and progression. To date, there are two main theories on this subject, i.e., the genetic and the hemodynamic theory, with an ongoing debate over the pathogenesis of BAV-aortopathy. Furthermore, the lack of early detection biomarkers leads to challenges in the management of patients affected by BAV-aortopathy. Here, we critically review the current knowledge on the driving mechanisms of BAV-aortopathy together with the current clinical management and lack of available biomarkers allowing for early detection and better treatment optimization