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. 2023 Jun 1;63(6):ezad122.
doi: 10.1093/ejcts/ezad122.

The modified frozen elephant trunk may outperform limited and extended-classic repair in acute type I dissection

Eric E Roselli  1   2 , Benjamin Kramer  2 , Emidio Germano  2 , Andrew Toth  3 , Patrick R Vargo  1   2 , Faisal Bakaeen  1   2 , Venu Menon  1   4 , Eugene H Blackstone  2   3 ; Collaborators from Cleveland Clinic Aorta Center
Collaborators, Affiliations

The modified frozen elephant trunk may outperform limited and extended-classic repair in acute type I dissection

Eric E Roselli et al. Eur J Cardiothorac Surg. .

Abstract

Objectives: A better surgical approach for acute DeBakey type I dissection has been sought for decades. We compare operative trends, complications, reinterventions and survival after limited versus extended-classic versus modified frozen elephant trunk (mFET) repair for this condition.

Methods: From 1 January 1978 to 1 January 2018, 879 patients underwent surgery for acute DeBakey type I dissection at Cleveland Clinic. Repairs were limited to the ascending aorta/hemiarch (701.79%) or extended through the arch [extended classic (88.10%) or mFET (90.10%)]. Weighted propensity score matched established comparable groups.

Results: Among weighted propensity-matched patients, mFET repair had similar circulatory arrest times and postoperative complications to limited repair, except for postoperative renal failure, which was twice as high in the limited group [25% (n = 19) vs 12% (n = 9), P = 0.006]. Lower in-hospital mortality was observed following limited compared to extended-classic repair [9.1% (n = 7) vs 19% (n = 16), P = 0.03], but not after mFET repair [12% (n = 9) vs 9.5% (n = 8), P = 0.6]. Extended-classic repair had higher risk of early death than limited repair (P = 0.0005) with no difference between limited and mFET repair groups (P = 0.9); 7-year survival following mFET repair was 89% compared to 65% after limited repair. Most reinterventions following limited or extended-classic repair underwent open reintervention. All reinterventions following mFET repair were completed endovascularly.

Conclusions: Without increasing in-hospital mortality or complications, less renal failure and a trend towards improved intermediate survival, mFET may be superior to limited or extended-classic repair for acute DeBakey type I dissections. mFET repair facilitates endovascular reintervention, potentially reducing future invasive reoperations and warranting continued study.

Keywords: Acute aortic dissection; DeBakey type I; Hybrid repair; Renal failure.

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Figures

Figure 1:
Figure 1:
Operative repair techniques. Consort diagram. Representative images of limited, extended-classic and mFET repair techniques. Propensity score matching generated comparable groups including 83/88 (94%) of extended-classic versus limited repairs, 83/90 (92%) of mFET versus limited repairs and 32/90 (36%) of mFET versus extended-classic repairs. mFET: modified frozen elephant trunk.
Figure 2:
Figure 2:
Propensity score matching. Mirror histogram of distribution of propensity scores between 2 groups before and after adjusting for matching weight (MW). Coloured areas represent patient contributions after applying MW. Unshaded areas represent non-weighted patients. Covariable balance plots for selected variables before (triangles) and after (squares) matching, contrasting characteristics of operative approach. Values on horizontal axis represent standardized difference. MV Regurg: mitral regurgitation; BMI: body mass index; HCT: haematocrit; AV Regurg: aortic valve regurgitation; mFET: modified frozen elephant trunk. (A) Limited (N = 80) and extended-classic (N = 83) repairs. Blue—limited, yellow—extended classic. Black triangles left of zero (negative) represent limited-like characteristics; triangles right of zero (positive) represent extended-classic-like characteristics. Pink squares represent the characteristics of the matched cohort. (B) Limited (N = 80) and mFET (N = 83) repair. Blue—limited, red—mFET. Grey triangles left of zero (negative) represent limited-like characteristics; triangles right of zero (positive) represent mFET-like characteristics. Light blue squares represent the characteristics of the matched cohort. (C) mFET (N = 32) and extended-classic (N = 33) repair. Red—mFET, yellow—extended classic. Purple triangles left of zero (negative) represent limited-like characteristics; triangles right of zero (positive) represent extended-classic-like characteristics. Turquoise squares represent the characteristics of the matched cohort.
Figure 3:
Figure 3:
Aortic dissection trends. Total case volume, operative techniques and operative mortality over time, stratified by repair technique. (A) Cumulative case volume. Blue—limited, yellow—extended classic, red—mFET. (B) Percentage of total case volume. Each dot represents percentage of repair type in that year. Blue—limited, yellow—extended classic, red—mFET. (C) Operative mortality. Dotted line is at 10% operative mortality. Curves are modelled LOESS smoothed tracings. Black—overall, blue—limited, yellow—extended-classic, red—mFET. mFET: modified frozen elephant trunk.
Figure 4:
Figure 4:
Weighted survival comparison. Survival stratified by repair type before and after adjusting for matching weights. Each symbol represents a death positioned on a vertical axis by Kaplan–Meier estimator; vertical bars are confidence limits equivalent to 1 standard error (SE). Solid lines are parametric survival estimates enclosed within dashed 68% confidence bands. mFET: modified frozen elephant trunk. (A) Overall survival in cohort before propensity score matching. Squares—limited, triangles—extended classic, circles—mFET. (B) After matching, limited versus extended-classic repair. Squares—limited, triangles—extended classic. (C) After matching, limited versus mFET repair. Squares—limited, circles—mFET. (D) After matching, mFET versus extended-classic repair. Circles—mFET, triangles—extended classic.
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