Haemoadsorption in infective endocarditis: a systematic review.

Infective endocarditis surgical patients suffer from high rates of severe complications such as systemic inflammatory response, septic shock, and multi-organ failure leading to high mortality. Systemic inflammatory response based on cytokines as messengers plays an important role in these patients. The concept of intraoperative haemoadsorption has been proposed to remove such elevated cytokines in patients undergoing cardiac surgery for infective endocarditis. Haemoadsorption offers the possibility to stabilise haemodynamics, reduce sepsis-related mortality, and protect organ function. However, until now, there has been no general opinion and consensus regarding the clinical effectiveness of adjunctive intraoperative haemoadsorption in infective endocarditis. Therefore, we reviewed the current literature evaluating haemoadsorption in infective endocarditis patients undergoing cardiac surgery. The review was registered at PROSPERO (CRD42023457632). Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-024-01701-0.

E-vita OPEN NEO in the treatment of acute or chronic aortic pathologies: first interim results of the NEOS study.

OBJECTIVES: The aim of this multicentre study was to demonstrate the safety and clinical performance of E-vita OPEN NEO Stent Graft System (Artivion, Inc.) in the treatment of aneurysm or dissection, both acute and chronic, in the ascending aorta, aortic arch and descending thoracic aorta. METHODS: In this observational study of 12 centres performed in Europe and in Asia patients were enrolled between December 2020 and March 2022. All patients underwent frozen elephant trunk using E-vita OPEN NEO Stent Graft System. Primary end point was the rate of all-cause mortality at 30 days and secondary end points included further clinical and safety data are reported up to 3-6 months postoperatively. RESULTS: A total of 100 patients (66.7% male; mean age, 57.7 years) were enrolled at 12 sites. A total of 99 patients underwent surgery using the E-vita OPEN NEO for acute or subacute type A aortic dissection (n = 37), chronic type A aortic dissection (n = 33) or thoracic aortic aneurysm (n = 29), while 1 patient did not undergo surgery. Device technical success at 24 h was achieved in 97.0%. At discharge, new disabling stroke occurred in 4.4%, while new paraplegia and new paraparesis was reported in 2.2% and 2.2%, respectively. Renal failure requiring permanent (>90 days) dialysis or hemofiltration at discharge was observed in 3.3% of patients. Between discharge and the 3-6 months visit, no patients experienced new disabling stroke, new paraplegia or new paraparesis. The 30-day mortality was 5.1% and the estimated 6-month survival rate was 91.6% (standard deviation: 2.9). CONCLUSIONS: Total arch replacement with the E-vita OPEN NEO can be performed with excellent results in both the acute and chronic setting. This indicates that E-vita OPEN NEO can be used safely, including in the setting of acute type A aortic dissection.

Three-Dimensional-Evaluation of Aortic Changes after Frozen Elephant Trunk (FET) in Zone 0 vs. Zone 2 in Acute Type A Aortic Dissection.

Introduction: The management of aortic dissection has evolved significantly over the decades, with the frozen elephant trunk (FET) procedure emerging as a key technique for treating complex aortic pathologies. Recent practices involve deploying the FET prosthesis more proximally in the aorta (Zone 0) to reduce complications, leading to questions about its impact on long-term aortic remodeling compared to traditional Zone 2 deployment. Methods: This retrospective analysis utilized 3D segmentation software to assess the volumetric changes in aortic remodeling after acute Type A aortic dissections, comparing FET stent graft deployment in Zone 0 and Zone 2. The study included 27 patients operated on between 2020 and 2022, with volumetric measurements taken from postoperative and 6-month follow-up CT scans. Statistical analyses were performed to evaluate the differences in the aortic true lumen (TL) and the perfused false lumen (PFL) between the two groups. Results: Both Zone 0 and Zone 2 deployments resulted in significant true lumen (TL) increases (Z0 p = 0.001, Z2 p < 0.001) and perfused false lumen (PFL) decreases (Z0 p = 0.02, Z2 p = 0.04), with no significant differences in volumetric changes between the groups (p = 0.7 post op and p = 0.9 after 6 months). The distal anastomosis in Zone 0 did not compromise the aortic remodeling outcomes and was associated with reduced distal ischemia and cerebral perfusion times (p = 0.041). The angle measurements in Zone 0 did not show any significant changes after the 6-month control (p = 0.2). However, in Zone 2, a significant change was detected. (p = 0.022). The part comparison analyses did not indicate significant differences in aortic deviation between the groups (p = 0.62), suggesting comparable effectiveness in aortic remodeling. Conclusions: Performing the distal anastomosis more proximally in Zone 0 offers technical advantages without compromising the effectiveness of aortic remodeling compared to the traditional Zone 2 deployment. This finding supports the continued recommendation of Zone 0 deployment in the management of acute Type A aortic dissections, with ongoing studies being needed to confirm the long-term outcomes and survival benefits.

Sex Differences in Short- and Long-Term Survival after Acute Type A Aortic Dissection.

Background and Objectives: Acute type A aortic dissection (AAD) is a life-threatening disease. No differences between men and women have been made in the treatment of AAD so far and knowledge about sex differences regarding long-term outcomes is limited. Materials and Methods: Between 01/2004 and 12/2021, 874 patients were operated on for AAD, including 313 (35.8%) women and 561 (64.2%) men. Clinical and surgical records, including long-term follow-up information, were obtained and analyzed retrospectively. To account for differences in the outcome determined by different preoperative life expectancies, a subgroup analysis for a set of patients matched according to their remaining life expectancy was performed. Results: At the time of AAD, women were older than men (69.1 ± 13.0 vs. 61.8 ± 13.3 years, p < 0.001) and had a shorter remaining statistical life expectancy (18.6 ± 10.8 vs. 21.4 ± 10.4 years, p < 0.001). Significantly more DeBakey type II AAD was found in women (37.1% vs. 25.7%, p < 0.001). Comorbidities and preoperative status at the time of presentation were similar in women and men. More hemiarch procedures (63.3% vs. 52.0%, p < 0.001) and less arch replacements (8.6% vs. 16.6%, p < 0.001) were performed in women, resulting in shorter cross-clamp times for women (92 ± 39 vs. 102 ± 49 min, p < 0.001). The in-hospital mortality was similar in women and men (11.5% vs. 12.7%, p = 0.618). Long-term survival was significantly shorter in women compared to men (9.8 [8.1-11.5] vs. 15.1 [11.9-18.4] years, p = 0.011). A matched subgroup analysis revealed that when comparing groups with a similar remaining life expectancy, the long-term survival showed no significant differences between women and men (9.8 [7.9-11.6] vs. 12.4 [10.1-14.7] years, p = 0.487). Conclusions: There are sex differences in AAD, with DeBakey type II dissection being more frequent in women. The seemingly worse long-term outcome can mostly be attributed to the shorter remaining statistical life expectancy at the time of presentation.

Surgery for Infective Endocarditis after Primary Transcatheter Aortic-Valve Replacement-A Retrospective Single-Center Analysis.

Transcatheter aortic-valve replacement (TAVR) is increasingly being used for the treatment of aortic-valve stenosis. Therefore, the total number of patients with an aortic-valve prosthesis is increasing, causing the incidence of prosthetic-valve endocarditis to increase. METHODS: Between March 2016 and July 2019, ten patients underwent surgery due to prosthetic-valve endocarditis after TAVR. They were identified in our institutional database and analyzed. RESULTS: Infective endocarditis was diagnosed 17 ± 16 month after TAVR. Mean age was 79 ± 4.4 years. Microbiological detection showed 6/10 positive blood cultures for enterococcus faecalis. Median EuroScore II was 24.64%. The mean size of the surgically replaced aortic prosthesis was 23.6 ± 1.3 and that of the TAVR was 28.4 ± 2.3 mm. The surgically implanted aortic valves had a mean gradient of 8.5 ± 2.2 mmHg. One patient died in hospital due to septic multiorgan failure. After discharge, all patients survived with a mean follow-up of 9 ± 8 month. CONCLUSIONS: With a rising number of patients after TAVR, prosthetic-valve endocarditis will increasingly occur in patients who were previously considered high or intermediate risk. Our results show that patients with TAVR infective endocarditis can be operated on with good results. Surgical therapy should not be withheld from TAVR patients with infective endocarditis.

The correlation of age and extension length in DeBakey type I aortic dissection: are older patients over 70 years at a lower risk?

OBJECTIVES: Age-related atherosclerosis has been shown to cause aortic stiffness and wall rigidification. This analysis aimed to correlate age and dissection extension length in a large contemporary multicentre study. We hypothesize that younger patients suffer more extensive DeBakey type I dissection due to aortic wall integrity, allowing unhindered extension within the layers. METHODS: The perioperative data of 3385 patients from the German Registry for Acute Aortic Dissection Type A were retrospectively analyzed with regard to postoperative outcomes and dissection extension. Patients with DeBakey type I aortic dissection (n = 2510) were retrospectively identified and divided into 2 age groups for comparison: ≤69 years (n = 1741) and ≥70 years (n = 769). Patients with DeBakey type II dissection or connective tissue disease were excluded from the analysis. RESULTS: In younger patients (≤69 years), aortic dissection involved the supra-aortic vessels significantly more often (52.0% vs 40.1%; P < 0.001) and extended significantly further downstream the aorta: descending aorta (68.4% vs 57.1%; P < 0.001), abdominal aorta (54.6% vs 42.1%; P < 0.001) and iliac bifurcation (36.6% vs 26.0%; P < 0.001). Consequently, younger patients also presented with significantly higher incidences of preoperative cerebral (P < 0.001), spinal (P < 0.001), visceral (P < 0.001), renal (P = 0.013) and peripheral (P < 0.001) malperfusion. In older patients (≥70 years), dissection extent was significantly more often limited to the level of the aortic arch (40.9% vs 29.2%; P < 0.001). No significant difference was found with regard to 30-day mortality (20.7% vs 23.6%; P = 0.114). CONCLUSIONS: Extensive DeBakey type I aortic dissection is less frequent in older patients ≥70 years than in younger patients. In contrast, younger patients suffer more often from preoperative organ malperfusion and associated complications. Postoperative mortality remains high irrespective of age groups.

Acute type A aortic dissection in adolescents and young adults under 30 years of age: demographics, aetiology and postoperative outcomes of 139 cases.

OBJECTIVES: The prevalence and aetiology of acute aortic dissection type A (AADA) in patients ≤30 years is unknown. The aims of this clinical study were to determine the prevalence and potential aetiology of AADA in surgically treated patients ≤30 years and to evaluate the respective postoperative outcomes in this selective group of patients in a large multicentre study. METHODS: Retrospective data collection was performed at 16 participating international aortic institutions. All patients ≤30 years at the time of dissection onset were included. The postoperative results were analysed with regard to connective tissue disease (CTD). RESULTS: The overall prevalence of AADA ≤30 years was 1.8% (139 out of 7914 patients), including 51 (36.7%) patients who were retrospectively diagnosed with CTD. Cumulative postoperative mortality was 8.6%, 2.2% and 1.4%. Actuarial survival was 80% at 10 years postoperatively. Non-CTD patients (n = 88) had a significantly higher incidence of arterial hypertension (46.6% vs 9.8%; P < 0.001) while AADA affected the aortic root (P < 0.001) and arch (P = 0.029) significantly more often in the CTD group. A positive family history of aortic disease was present in 9.4% of the study cohort (n = 13). CONCLUSIONS: The prevalence of AADA in surgically treated patients ≤30 years is <2% with CTD and arterial hypertension as the 2 most prevalent triggers of AADA. Open surgery may be performed with good early results and excellent mid- to long-term outcomes.

Island remodelling in acute and chronic aortic dissection treated with frozen elephant trunk.

OBJECTIVES: The island technique for reimplantation of supra-aortic vessels in frozen elephant surgery is commonly used but might be questioned for dissected vessels. This study analyses the remodelling of reimplanted supra-aortic vessels after FET in acute and chronic aortic dissection (CAD). METHODS: Between June 2017 and April 2021, 133 patients were operated for acute and CAD using the frozen elephant technique. The island technique for reimplantation of the supra-aortic vessels was used in 94/133 patients. In 68 acute and 21 chronic patients, the total vessel lumen (VL), true lumen, false lumen (FL) and perfused FL area were measured in the innominate, right common carotid and left common carotid artery. Relative luminal changes were compared. RESULTS: In acute aortic dissection, 80% innominate, 40% right carotid and 59% left carotid arteries were dissected preoperatively, but postoperatively FL was only patent in 29%, 12% and 10% (P < 0.001). FL disappearance resulted in >20% total VL reduction in innominate, right carotid and left carotid artery (P < 0.01). In CAD, only 38% innominate, 14% right carotid and 43% left carotid arteries were dissected preoperatively, but postoperatively FL was patent in 19% (ns), 10% (ns) and 5% (P = 0.009). CONCLUSION: Vascular remodelling is frequently found after the island technique. In acute aortic dissection, the island technique frequently initiates FL disappearance associated with VL decrease. Continuously dissected head vessels show positive remodelling with true lumen increase without VL increase. FL disappearance is frequently found in CAD.

Early outcomes of patients with Marfan syndrome and acute aortic type A dissection.

BACKGROUND: Acute aortic Stanford type A dissection remains a frequent and life-limiting event for patients with Marfan syndrome. Outcome results in this high-risk group are limited. METHODS: The German Registry for Acute Aortic Dissection Type A collected the data of 56 centers between July 2006 and June 2015. Of 3385 patients undergoing operations for acute aortic Stanford type A dissection, 117 (3.5%) were diagnosed with Marfan syndrome. We performed a propensity score match comparing patients with Marfan syndrome with patients without Marfan syndrome in a 1:2 fashion. RESULTS: Patients with Marfan syndrome were significantly younger (42.9 vs 62.2 years; P < .001), predominantly male (76.9% vs 62.9%; P = .002), and less catecholamine dependent (9.4% vs 20.3%; P = .002) compared with the unmatched cohort. They presented with aortic regurgitation (41.6% vs 23.0%; P < .001) and involvement of the supra-aortic vessels (50.4% vs 39.5%; P = .017) more often. Propensity matching revealed 82 patients with Marfan syndrome (21 female) with no significant differences in baseline characteristics compared with patients without Marfan syndrome (n = 159, 36 female; P = .607). Although root preservation was more frequent in patients with Marfan syndrome, procedure types did not differ significantly (18.3% vs 10.7%; P = .256). Aortic arch surgery was performed more frequently in matched patients (87.5% vs 97.8%; P = .014). Thirty-day mortality did not differ between patients with and without Marfan syndrome (19.5% vs 20.1%; P = .910). Multivariate regression showed no influence of Marfan syndrome on 30-day mortality (odds ratio, 0.928; 95% confidence interval, 0.346-2.332; P = .876). CONCLUSIONS: Marfan syndrome does not adversely affect 30-day outcomes after surgical repair for acute aortic Stanford type A dissection compared with a matched cohort. Long-term outcome analysis is needed to account for the influence of further downstream interventions.

Elevated lactate levels and impaired lactate clearance during extracorporeal life support (ECLS) are associated with poor outcome in cardiac surgery patients.

The use of extracorporeal life support (ECLS) as part of cardio-circulatory support has increased rapidly in recent years. Severe hyperlactatemia is not uncommon in this group of patients. Lactate peak concentrations and lactate clearance have already been identified as independent marker for mortality in critical ill patients without mechanical device support. The aim of this study was to determine a supposed correlation between the variables lactate peak concentration and clearance in the blood and mortality in the ECLS context. Therefore, a total of 51 cardiac surgery ICU patients with ECLS therapy were included in this retrospective, clinical observational study (survivors n = 23; non-survivors n = 28). Lactate measurement was performed before, during and after ECLS therapy. Further, common ICU scores (SAPSII, SOFA, TISS28), the rates of transfusion and the different vasopressor therapies will be compared. Significant elevated peak lactate levels and poor lactate clearance were associated with higher mortality during ECLS therapy (p < 0.001). Deceased patients had higher SAPSII scores (p < 0.001), received more transfusions (p < 0.001) and presented with higher rates of epinephrine (p < 0.001). In conclusion, hyperlactatemia during ECLS therapy is a time sensitive emergency. Lactate cannot be cleared in all patients. Reversible causes should be explored and treated. In cases where the cause is irreversible, the prognosis of elevated lactate concentrations and reduced clearance is very poor.

Treatment of the aortic root in acute aortic dissection type A: insights from the German Registry for Acute Aortic Dissection Type A.

OBJECTIVES: Surgery of the aortic root in acute aortic dissection type A (AADA) remains a topic of vague evidence since the extend of dissection and surgeons' capability and interpretation of the disease vary remarkably. We aimed to interpret root operation strategies in the German Registry for Acute Aortic Dissection cohort. METHODS: German Registry for Acute Aortic Dissection collected the data of 56 centres between July 2006 and June 2015. A total of 3382 patients undergoing operations for AADA were included and divided into 3 groups according to aortic root procedure types: supracommissural replacement (SCR), conduit replacement (CR) and valve sparing root replacement (VSRR). RESULTS: Patients in SCR (2425, 71.7%) were significantly older than CR (681, 20.1%) and VSRR (276, 8.2%) (63.4 vs 57.5 vs 54.2 years; P < 0.001), more female (38.9% vs 32.0% vs 26.1%; P < 0.001) and presented with less aortic regurgitation (26.3% vs 57.1% vs 56.5%; P < 0.001). VSRR presented with slightly less multiple organ malperfusion (11.6% vs 12.0% vs 10.9%; P = 0.045) and were more often diagnosed for Marfan syndrome (2.4% vs 5.1% vs 9.1%; P < 0.001). Thirty-day mortality was lower for VSRR (11.6%) compared to SCR (16.1%) and CR (19.8%; P = 0.010). Despite longer procedural times, multivariable regression showed no influence of total arch replacement for VSRR on mortality compared to CR (odds ratio 0.264; 95% confidence interval, 0.033-2.117; P = 0.21). CONCLUSIONS: SCR remains the procedure of choice in elderly and compromised patients. Extended root preservation techniques may be applied even in combination with extended aortic arch surgery for selected patients for AADA with promising early outcomes.

Treatment of the Aortic Root in Acute Aortic Dissection Type A: Insights from the German Registry for Acute Aortic Dissection Type A (GERAADA) Registry.

OBJECTIVES: Surgery of the aortic root in acute aortic dissection type A (AADA) remains a topic of vague evidence since the extend of dissection and surgeons' capability and interpretation of the disease vary remarkably. We aimed to interpret root operation strategies in the German Registry for Acute Aortic Dissection (GERAADA) cohort. PATIENTS AND METHODS: GERAADA collected the data of 56 centers between July 2006 and June 2015. A total of 3382 patients undergoing operations for AADA were included and divided into three groups according to aortic root procedure types: supracommissural replacement (SCR), conduit replacement (CR) and valve sparing root replacement (VSRR). RESULTS: Patients in SCR (2425, 71.7%) were significantly older than CR (681, 20.1%) and VSRR (276, 8.2%) (63.4 vs 57.5 vs 54.2 yrs; p < 0.001), more female (38.9 vs 32.0 vs 26.1%; p < 0.001) and presented with less aortic regurgitation (26.3 vs 57.1 vs 56.5%; p < 0.001). VSRR presented with slightly less multiple organ malperfusion (11.6 vs 12.0 vs 10.9%; p = 0.045) and were more often diagnosed for Marfan syndrome (2.4 vs 5.1 vs 9.1%; p < 0.001). Thirty-day mortality was lower for VSRR (11.6%) compared to SCR (16.1%) and CR (19.8%; p = 0.010). Despite longer procedural times multivariable regression showed no influence of total arch replacement for VSRR on mortality compared to CR (OR 0.264; 95% CI, 0.033-2.117; p = 0.21). CONCLUSIONS: SCR remains the procedure of choice in elderly and compromised patients. Extended root preservation techniques may be applied even in combination with extended aortic arch surgery for selected patients for AADA with promising early outcomes.

Open redo thymectomy for a large recurrent thymoma in a patient with myasthenia gravis: a case report.

Thoracoscopic and robotic approaches are becoming increasingly popular for thymoma surgery. Yet open thymectomy must still be mastered today, as it may be the only viable option in challenging cases. In this study, we report a case of an extended local recurrence of myasthenia gravis associated thymoma and a history of previous sternotomy. The mediastinal mass infiltrated the left upper lobe of the lung, the pericardium, and presumably the aortic arch. Although the standard for thymoma resection at our institution is the robotic approach, we performed primary open redo thymectomy in standby of cardiopulmonary bypass in this case. Intraoperatively, bleeding from the aortic arch occurred, which was promptly controlled due to the open approach and due to immediate availability of cardiopulmonary bypass. The patient was transferred to the normal ward on the first postoperative day, was treated according to fast-track principles and recovered well. The pathology revealed a WHO B2:B1 thymoma with negative resection margins. Thymectomy is recommended as the principal treatment for thymoma and is also advised in the case of recurrence. However, there is no evidence regarding the optimal surgical approach. Our case indicates that in the era of minimally invasive thymectomy, the decision to conduct open surgery is wise when the risk of serious bleeding is anticipated or adherence to oncologic principles is challenged by tumor size or growth pattern.

Surgery for infective endocarditis following low-intermediate risk transcatheter aortic valve replacement-a multicentre experience.

OBJECTIVES: With the expansion of transcatheter aortic valve replacement (TAVR) into intermediate and low risk, the number of TAVR procedures is bound to rise and along with it the number of cases of infective endocarditis following TAVR (TIE). The aim of this study was to review a multicentre experience of patients undergoing surgical intervention for TIE and to analyse the underlying indications and operative results. METHODS: We retrospectively identified and analysed 69 patients who underwent cardiac surgery due to TIE at 9 cardiac surgical departments across Germany. The primary outcome was operative mortality, 6-month and 1-year survival. RESULTS: Median age was 78 years (72-81) and 48(69.6%) were male. The median time to surgical aortic valve replacement was 14 months (5-24) after TAVR, with 32 patients (46.4%) being diagnosed with early TIE. Cardiac reoperations were performed in 17% of patients and 33% underwent concomitant mitral valve surgery. The main causative organisms were: Enterococcus faecalis (31.9%), coagulase-negative Staphylococcus spp. (26.1%), Methicillin-sensitive Staphylococcus aureus (15.9%) and viridians group streptococci (14.5%). Extracorporeal life support was required in 2 patients (2.9%) for a median duration of 3 days. Postoperative adverse cerebrovascular events were observed in 13 patients (18.9%). Postoperatively, 9 patients (13.0%) required a pacemaker and 33 patients (47.8%) needed temporary renal replacement therapy. Survival to discharge was 88.4% and survival at 6 months and 1 year was found to be 68% and 53%, respectively. CONCLUSIONS: Our results suggest that TIE can be treated according to the guidelines for prosthetic valve endocarditis, namely with early surgery. Surgery for TIE is associated with acceptable morbidity and mortality rates. Surgery should be discussed liberally as a treatment option in patients with TIE by the 'endocarditis team' in referral centres.

Training Cardiac Surgeons: Safety and Requirements.

To analyze whether cardiac surgical residents can perform their first surgeries without compromising patients' safety or outcomes, by comparing their performance and results to those of senior surgeons. All documented CABGs conducted between 2002 and 2020 were included. Surgeries were divided according to the experience level of the main surgeon (defined by the number of CABG conducted by him/her) using the following thresholds: 1000; 150; 80 and 35. This resulted in 5 groups: senior surgeons (the reference group); attending surgeons; fellow surgeons; advanced residents and new residents. Primary endpoint was 30 day mortality. Secondary endpoints included a list of intra and post-operative parameters (including in-hospital complications). A multivariable analysis was conducted. 16,486 CABG were conducted by 66 different surgeons over a period of 18 years. Multivariable analysis did not find significant differences between both the primary and the secondary endpoints. Skin-to-skin time correlated significantly with experience level, as new residents needed almost 30% more time than senior surgeons (234 vs 180 minutes). With a suitable supervision by experienced surgeons, patient selection and sufficient resources (longer duration of surgery), surgical residents can perform CABGs with good results and without compromising the patient's outcome.

New 3-zone hybrid graft: First-in-man experience in acute type I dissection.

OBJECTIVE: Acute type I aortic dissection (AAD) represents a surgical emergency with time-dependent evolving complications. Frozen elephant trunk (FET) enables false lumen exclusion downstream but is still debated in AAD due to its greater dimension of surgery. To combine the benefits of fast proximal repair with the FET benefits, a 3-zone hybrid graft was developed consisting of an ascending polyester portion, an arch noncovered stent, and a descending stent graft. Mid-term results of this new technique are presented. METHODS: A total of 6 patients (age mean 69 years) with type I AAD in critical status (Penn classification B n = 5, BC n = 1) were operated between July 2016 and April 2018 using the 3-zone hybrid graft. The device was implanted on the basis of strict compassionate use. Operations were performed under distal hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP). RESULTS: Operative mortality was 17% (n = 1). Mean crossclamp and SACP time were 92 and 34 minutes, respectively, but came down in the last 2 cases to 75/65 crossclamp and 23/24 SACP minutes each. During follow up, mean 19 ± 12 months, one endovascular extension downstream was performed. Imaging control demonstrated no anastomotic-related proximal entry and no true lumen collapse downstream. CONCLUSIONS: The goal to achieve fast and reliable repair of complicated type I AAD down to midthoracic level seems to be achievable. Noncovered stenting of the head vessel's origin does not cause stenosis or obstruction. A multicenter studying of this concept is next.

Paving the way for E-vita open NEO hybrid prosthesis implantation for complex aortic arch disease in Asia-Pacific.

We report first in man implantations of the newly designed Evita-open-NEO hybrid prosthesis for complex aortic arch disease from three different countries in Asia-Pacific including instructions on how to proceed with perioperative coagulation management.

"Unlucky punch": unexpected annular rupture during TAVR and successful treatment.

Although rare, annular rupture in TAVR is a feared and often unpredictable complication with relevant impact on in-hospital prognosis. Severe annular calcification is a common risk factor for annular rupture. We report on a case of annular rupture during TAVR with a balloon-expanded prosthesis in the absence of any annular calcification in the planning CT scan and illustrate the proposed pathomechanism as well as its successful immediate surgical management.