Background. In acute DeBakey I aortic dissection presenting with malperfusion syndromes, we assessed whether standard open repair with concomitant antegrade stent grafting (thoracic endovascular aneurysm repair; TEVAR) of the descending thoracic aorta (DTA) improves outcomes compared with standard repair alone.Methods. From 2005 to 2012, 277 patients with acute DeBakey I dissection underwent emergent operation. Of these, 104 patients (37%) presenting with end-organ malperfusion were divided into those undergoing standard distal repair entailing transverse hemiarch replacement (Standard group, n = 65) versus standard repair with concomitant DTA TEVAR during circulatory arrest (TEVAR group, n = 39). Prospectively maintained aortic dissection database was retrospectively reviewed.Results. Demographic characteristics and preoperative comorbidities were similar. Circulatory arrest (56 +/- 12 versus 34 +/- 14 minutes, p < 0.001) and cross-clamp (176 +/- 43 versus 119 +/- 80, p = 0.001) times were longer in the TEVAR group. Overall, postoperative stroke rate (5% [n= 2] versus 6% [n = 4], p = 1), paraplegia rate (5% [n = 2] versus 5% [n = 3], p = 1.0), and renal failure rate (10% [n = 4] versus 22% [n = 14], p = 0.2) were similar. In-hospital/30-day mortality rate was lower in the TEVAR group but was not significant (18% (n = 7) versus 34% [n = 22], p = 0.1). In patients presenting with malperfusion involving greater than one end-organ system, the mortality rate was significantly improved in the TEVAR group (28% [n = 6] versus 58% [n = 14], p = 0.05).Conclusions. Standard repair with antegrade TEVAR of the DTA for acute DeBakey I aortic dissection presenting with malperfusion syndromes can be safely performed. Further, true lumen stabilization achieved through DTA TEVAR may provide a survival benefit in patients with distal multiorgan malperfusion. (C) 2017 by The Society of Thoracic Surgeons

Background. In patients requiring a second-time or more operation on the mitral valve (MV), we assessed whether the outcomes of the minimally invasive port access approach (port access group) were equivalent to those of the traditional redo sternotomy approach (redo sternotomy group).Methods. In a retrospective review (1998-2011), 409 patients had previous MV operations requiring a second-time or more MV reintervention. Of those, 67 patients had the port access approach, and 342 had the redo sternotomy approach. Of the latter, 220 met the inclusion criteria because emergencies, patients with endocarditis, and those requiring concomitant procedures involving aortic valve and aorta were excluded.Results. New York Heart Association class 2 or above, age, atrial fibrillation, and surgical indications were similar in both groups. The port access group had more patients with previous MV repair (78% [n = 52] vs 41% [n = 90], p < 0.01) than with MV replacement (19% [n =13) vs 53% [n = 116], p < 0.01). Concomitant procedures were similar (20% [n = 14] vs 27% [n = 59], p = 0.4).The MV re-repair rates were similar (19% [n = 10] vs 22% [n [20], p = 1). The cardiopulmonary bypass times (153 +/- 42 minutes vs 172 +/- 83 minutes, p = 0.07) and aortic cross-clamping times (104 +/- 38 minutes versus 130 +/- 71 minutes, p < 0.01) were lower in the port access group. Mortality was lower in the port access group, although not significantly (3.0% [n = 2] vs 6.0% [n = 13], p = 0.5). The rates of postoperative stroke were similar (3.0% [n [ 2] vs 3.2% [n = 7], p = 1). On postoperative echocardiography, freedom from mitral regurgitation >2+ was 100% in the port access group and 99% in the redo sternotomy group. The mean hospital length of stay was 11 +/- 15 days versus 14 +/- 12 days (p = 0.07).Conclusions. The port access approach can be safely adopted for reoperations on the MV without compromising postoperative mortality or MV function. (C) 2015 by The Society of Thoracic Surgeons

Objective: Previously, we showed that antegrade stent grafting of the descending thoracic aorta during DeBakey type I dissection repair improves distal aortic remodeling. We assessed midterm outcomes of this reconstructive strategy compared with standard open repair.Methods: DeBakey type I dissections (non-Marfan, nontotal arch cases only) from 2005 to 2012 were retrospectively reviewed. One hundred eighty patients underwent standard open repair (standard group), and 62 patients underwent open repair plus stenting (stented group). Open repair entailed ascending aorta plus transverse hemiarch reconstruction under circulatory arrest, with variable aortic root work. Data was prospectively maintained.Results: Preoperative parameters were similar. Patients in the stented group had longer circulatory arrest time and higher utility of antegrade cerebral perfusion (P <. 001). In-hospital/30-day mortality (10% vs 14%; P = .51), stroke (5% vs 8%; P = .6), and paraplegia (0% vs 1%; P = 1) were similar in the stented versus standard groups. Mean follow-up was 2.7 +/- 2.3 and 2.2 +/- 2.1 years. Actuarial survival in stented versus standard groups at 1 and 7 years was 86% versus 81% and 76% versus 60%(P = .5). Thoracic aorta false lumen obliteration was improved in the stented group (82% vs 39%; P <. 001), along with improved freedom from open distal aortic reoperation rate (98% vs 90% at 6 years, P < .1). Endovascular distal aortic reintervention rate was higher in the stented group (18% vs 3%; P - .008), with zero mortality.Conclusions: Antegrade stent graft deployment during acute DeBakey type I dissection repair is safe method to promote distal aortic remodeling without increasing postoperative or midterm mortality. This technique provides increased freedom from open distal aortic reoperations compared with standard open repair.