Correction: Hlavicka et al. Long-Term Outcomes after Aortic Valve and Root Replacement in a Very High-Risk Population. J. Cardiovasc. Dev. Dis. 2022, 9, 197.

The authors would like to make the following corrections to the published paper [...].

Early and midterm results of frozen elephant trunk operation with Evita open stent-graft in patients with Marfan syndrome: results of a multicentre study.

BACKGROUND: Endovascular treatment of patients with Marfan syndrome (MFS) is not recommended. Hybrid procedures such as frozen elephant trunk (FET), which combines stent-graft deployment with an integrated non-stented fabric graft for proximal grafting and suturing, have not been previously evaluated. The aim of this study was to assess the safety and feasibility of FET operation in patients with MFS. METHODS: Patients enrolled in the International E-vita Open Registry (IEOR) who underwent FET procedure between January 2001 and February 2020 meeting Ghent criteria for MFS were included in the study. Early and midterm results were retrospectively analyzed. Preoperative, postoperative and follow-up computed tomography angiography scans were analysed. RESULTS: We analyzed 37 patients [mean age 38 ± 11 years, 65% men]. Acute or chronic aortic dissection was present in 35 (95%) patients (14 and 21 patients respectively). Two (5%) patients had an aneurysm without dissection. Malperfusion syndrome was present in 4 patients. Twenty-nine (78%) patients had history of aortic surgical interventions. The 30-day and in-hospital mortality amounted to 8 and 14% respectively. False lumen exclusion was present in 73% in stented segment in last postoperative CT. The overall 5-year survival was 71% and freedom from reintervention downstream was 58% at 5 years. Of the nine patients who required reintervention for distal aortic disease, one patient died. CONCLUSIONS: FET operation for patients with MFS can be performed with acceptable mortality and morbidity. In long-term follow-up no reinterventions on the aortic arch were required. FET allows for easier second stage operations providing platform for surgical and endovascular reinterventions.

Long-Term Outcomes after Aortic Valve and Root Replacement in a Very High-Risk Population.

Background: Aortic valve and root replacement (AVRR) is a standardised procedure to treat patients with aortic valve and root disease. In centres with a well-established aortic valve and root repair program (valve repairs and Ross operations), only patients with very complex conditions receive AVRR; this procedure uses a mechanical or biological composite valve graft (modified Bentall-de Bono procedure). The aim of the study was to evaluate the short- and long-term results after AVRR in a high-risk population with complex pathologies. Methods: Between 2005 and 2018, a total of 273 consecutive patients (mean age 64 ± 12.8 years; 23% female) received AVRR. The indication for surgery was an acute type A aortic dissection in 18%, infective endocarditis in 36% and other pathologies in 46% patients; 39% were redo procedures. The median EuroSCORE II was 11.65% (range 1.48-95.63%). Concomitant surgery was required in 157 patients (58%). Results: The follow-up extended to 5.2 years (range 0.1-15 years) and it was complete in 96% of the patients. The 30-day mortality was 17%. The overall estimated survival at 5 and 10 years was 65% ± 3% and 49% ± 4%, respectively. Univariate and multivariate logistic regression analyses revealed the following risk factors for survival: perioperative neurological dysfunction (OR 5.45), peripheral artery disease (OR 4.4) and re-exploration for bleeding (OR 3.37). Conclusions: AVRR can be performed with acceptable short- and long-term results in a sick patient population. The Bentall-De Bono procedure may be determined to be suitable for only elderly or high-risk patients. Any other patients should receive an AV repair or the Ross procedure in well-established centres.

Reply to Jasinski M et al.: "Indeed, there is still room for improvement in long-term durability of BAV repair".

We read the letter to the editor by Dr Jasinski et al. entitled "Long-term durability of valve-sparing or repair procedures in BAV-Is there room for improvement?" with great interest.

Modified transventricular and transaortic mitral valve edge-to-edge repair mimicking MitraClip overcorrection.

Objective: In the current study, we present our mid-term experience with modified edge-to-edge repair technique through a transventricular and transaortic route in patients requiring left ventricular remodeling or aortic root/valve surgery. Methods: From December 2006 through April 2015, 49 high-risk patients (median age: 69 years; median European System for Cardiac Operative Risk Evaluation II: 11.4 [6.54-14.9]) underwent transventricular (N = 7; 14%) or transaortic (N = 42; 86%) edge-to-edge mitral valve repair. The Alfieri stitch technique was modified by MitraClip type overcorrection and solid buttressing behind the posterior leaflet. Indication was grade 2+ functional mitral valve incompetence and dilated or impaired left ventricle (N = 25; 52%), or grade 3+ (N = 22; 45%) and grade 4+ functional mitral valve regurgitation (N = 2; 4%). Surgical procedure included aortic root surgery in 65%, aortic valve replacement with surgical revascularization in 18%, and Dor-plasty with surgical revascularization in 14%. Results: Intraoperative mortality and early neurologic complications were absent in our series. Ninety-day mortality was 12.2% (N = 6). Median clinical and echocardiographic follow-up-time was 50.7 (21.5-44.1) and 39.2 (33.7-44.1) months, respectively. Median postoperative transvalvular gradient was low (2.72 [1.91-4.22] mm Hg) and did not increase during follow-up (P = .268), although peak gradient rose slightly from 7.41 to 8.12 mm Hg (P = .071). The actuarial reoperation free rate at the index valve was 96.8%. Conclusions: Transventricular or transaortic Alfieri mitral repair mimicking mitral clip overcorrection represents a quick and safe technique in the setting of high-risk patients undergoing left ventricular remodeling or aortic root/valve surgery and can be performed with low risk of creating mitral stenosis at midterm. The technique is straightforward, with reliable identification of the center of the valve leaflets being the limitation.

Early- and longer-term outcomes of David versus Florida sleeve procedure: propensity-matched comparison.

OBJECTIVES: The aim of this study was to compare short- and longer-term outcomes of David (DV) versus Florida sleeve (FS) procedure in patients requiring valve-sparing aortic root replacement. METHODS: Between January 1996 and December 2020 285 patients received a DV procedure (median age 60 years; 26% females) and 57 patients underwent an FS procedure (median age 64 years; 19% females) in our department. Propensity score matching using patient characteristics led to 58 (DV) versus 57 (FS) patients. End points were defined as primary: freedom from aortic valve and/or aortic root-related reoperation and freedom from aortic regurgitation ≥moderate and secondary: early and late survival. RESULTS: Thirty-day mortality was 2% (DV) and 0% (FS) (P = 0.319). There was 1 early stroke in each group (P = 0.990). Follow-up was complete in 99% with only 1 patient (FS) lost. The 5- and 10-year freedom from aortic valve and/or aortic root related reoperation was 98 ± 2% and 96 ± 3% in the DV group and 92 ± 5% and 84 ± 9% in the FS group, respectively (P = 0.095). The 5- and 10-year freedom from aortic regurgitation ≥moderate was 88 ± 5% and 80 ± 8% in the DV group and 92 ± 5% and 78 ± 1% in the FS group, respectively (P = 0.782). The 5- and 10-year survival rates were 93 ± 4% and 82 ± 6% (DV) vs 75 ± 7% and 67 ± 10% (FS), respectively (P = 0.058). No case of endocarditis (DV) and 3 cases of endocarditis (FS) (P = 0.055) were observed during follow-up. CONCLUSIONS: Both DV and FS resulted in similar early and longer-term outcomes with a trend to slightly better performance and survival in the DV group. Florida sleeve procedure might be an alternative approach for patients with higher-risk profiles requiring valve-sparing aortic root replacement.

Integrative analysis reveals early and distinct genetic and epigenetic changes in intraductal papillary and tubulopapillary cholangiocarcinogenesis.

OBJECTIVE: A detailed understanding of the molecular alterations in different forms of cholangiocarcinogenesis is crucial for a better understanding of cholangiocarcinoma (CCA) and may pave the way to early diagnosis and better treatment options. DESIGN: We analysed a clinicopathologically well-characterised patient cohort (n=54) with high-grade intraductal papillary (IPNB) or tubulopapillary (ITPN) neoplastic precursor lesions of the biliary tract and correlated the results with an independent non-IPNB/ITPN associated CCA cohort (n=294). The triplet sample set of non-neoplastic biliary epithelium, precursor and invasive CCA was analysed by next generation sequencing, DNA copy number and genome-wide methylation profiling. RESULTS: Patients with invasive CCA arising from IPNB/ITPN had better prognosis than patients with CCA not associated with IPNB/ITPN. ITPN was localised mostly intrahepatic, whereas IPNB was mostly of extrahepatic origin. IPNB/ITPN were equally associated with small-duct and large-duct type intrahepatic CCA. IPNB exhibited mutational profiles of extrahepatic CCA, while ITPN had significantly fewer mutations. Most mutations were shared between precursor lesions and corresponding invasive CCA but ROBO2 mutations occurred exclusively in invasive CCA and CTNNB1 mutations were mainly present in precursor lesions. In addition, IPNB and ITPN differed in their DNA methylation profiles and analyses of latent methylation components suggested that IPNB and ITPN may have different cells-of-origin. CONCLUSION: Integrative analysis revealed that IPNB and ITPN harbour distinct early genetic alterations, IPNB are enriched in mutations typical for extrahepatic CCA, whereas ITPN exhibited few genetic alterations and showed distinct epigenetic profiles. In conclusion, IPNB/ITPN may represent a distinctive, intermediate form of intrahepatic and extrahepatic cholangiocarcinogenesis.

Mitral Valve Surgery via Upper Ministernotomy: Single-Centre Experience in More than 400 Patients.

Background: Minimally invasive mitral valve (MV) surgery has emerged as an alternative to conventional sternotomy aiming to decrease surgical trauma. The aim of the study was to describe our experience with minimally invasive MV surgery through partial upper sternotomy (PUS) regarding short- and long-term outcomes. Methods: From January 2004 through March 2014, 419 patients with a median age of 58.9 years (interquartile range 18.7; 31.7% females) underwent isolated primary MV surgery using PUS. Myxomatous degenerative MV disease was the predominant pathology (77%). The patients' mean EuroSCORE II risk profile was 3.9 ± 3.6%. Results: Mitral valve repair was performed in 384 patients (91.6%) and replacement in 35 patients (8.4%). Thirty-day mortality was 3.1%. In total, 29 (6.9%) deaths occurred during the follow-up. The overall estimated survival at 1, 5, and 10 years was 93.1 ± 1.3%, 87.1 ± 1.9%, and 81.1 ± 3.4%. Reoperation was necessary in 14 (3.3%) patients. The overall freedom from MV reoperation at 1, 5, and 10 years was 98.2 ± 0.7%, 96.1 ± 1.2%, and 86.7 ± 6.7% and the overall freedom from recurrent MV regurgitation > grade 2 in repaired valves at 1, 5, and 10 years was 98.8 ± 0.6%, 98.8 ± 0.6%, and 94.6 ± 3.3%. Conclusions: Minimally invasive MV surgery via PUS can be performed with particularly good early and late results. Thus, the PUS approach with the use of standard surgical instruments and cannulation techniques can be a valuable option for the MV surgery either in patients contraindicated or not suitable to minithoracotomy.

Reoperative Aortic Arch Surgery under Mild Systemic Hypothermia: Two-Center Experience.

BACKGROUND: The aim of the study was to assess the indications, surgical strategies, and outcomes after reoperative aortic arch surgery performed generally under mild hypothermia. METHODS: Ninety consecutive patients (60 males, mean age, 55 ± 16 years) underwent open reoperative aortic arch surgery after previous cardiac aortic surgery. The indications included chronic-progressive arch aneurysm (55.5%), chronic aortic dissection (17.8%), contained arch rupture (16.7%), and graft infection (10%). The reoperation was performed through a repeat sternotomy (96%) or clamshell thoracotomy (4%) using antegrade cerebral perfusion under mild systemic hypothermia (28.9 ± 2.5°C) in all except three patients. RESULTS: The surgery comprised hemiarch or total arch replacement in 41 (46%) and 49 (54%) patients, respectively. The distal extension included classic or frozen elephant trunk technique, each in 12 patients, and total descending aorta replacement in 4 patients. Operative mortality was 6 (6.7%) among all patients, with age identified as the only independent predictor of operative mortality (p = 0.05). Permanent and transient neurologic deficits occurred in 1% and 9% of the patients, respectively. Estimated survival at 8 years was 59 ± 8% with advanced heart failure predictive for late mortality (p = 0.014). Freedom from second reoperation or intervention on the aorta was 78 ± 6% at 8 years, with most of these events occurring downstream in patients with chronic degenerative aneurysms. CONCLUSION: Aortic arch reoperations performed using antegrade cerebral perfusion under mild systemic hypothermia offer favorable operative outcomes with an exceptionally low rate of neurologic morbidity without any difference between hemiarch and complex arch procedures.

Longer-term outcomes after bicuspid aortic valve repair in 142 patients.

BACKGROUND: The aim of this study was to evaluate the longer-term results of bicuspid aortic valve (BAV) repair with or without aortic root replacement. METHODS: From 1999 to 2017, 142 patients with or without aortic root dilatation who underwent repair of a regurgitant BAV were included in the study. Ninety-four patients underwent isolated BAV repair (Group 1; median age 43 years) and 48 patients underwent valve-sparing aortic root replacement plus BAV repair (aortic valve reimplantation-Group 2; median age 48 years). Median clinical follow-up time was 5.9 years (range 0.5-15) in Group 1 and 3 years (range 0.5-16) in Group 2, respectively. RESULTS: In-hospital mortality was 1% in Group 1, and 2% in Group 2 (p = .6). The 5- and 10-year survival was 93 ± 2.9% and 81 ± 5.8% in Group 1 and 96 ± 3.1% and 96 ± 3.1% in Group 2, respectively (p = .31). Eleven patients of Group 1 (1.7%/patient-year) and five patients of Group 2 (2.2%/patient-year) underwent reoperation of the aortic valve (p = .5). The 5- and 10-year freedom from reoperation were 93.0 ± 2.1% and 77.1 ± 7.1% in Group 1 and 93.0 ± 5.0% and 76.7 ± 9.6% in Group 2 (p = .83), respectively. At the latest follow-up, only two patients of Group 1 and 1 patient of Group 2 had AV regurgitation = 2° (p = .7). The cumulative linearized incidence of all valve-related complications (bleeding, stroke, endocarditis, and reoperation) was 2.9%/patient-year in Group 1% and 4%/patient-year in Group 2, respectively (p = .6). CONCLUSIONS: Isolated BAV repair and combined aortic valve reimplantation plus BAV repair provide good clinical longer-term outcomes with relatively low reoperation rate and durable valve function.

Long-term outcomes after the paediatric Ross and Ross-Konno procedures.

OBJECTIVES: The Ross procedure is an attractive option for the management of aortic valve disease in paediatric patients. We reviewed our experience with the paediatric Ross procedure to determine survival and freedom from reoperation in the third decade after surgery. METHODS: We reviewed the data of 124 paediatric patients [71% male, median age at time of surgery 11.1 years (interquartile range 6-14.8 years); 63.7% bicuspid aortic valve], who underwent the Ross procedure at 2 tertiary centres from April 1991 to April 2020. The Ross-Konno procedures were performed on 14 (11.3%) patients. Deaths were cross-checked with the national health insurance database, and survival status was available for 96.8% of the patients. The median follow-up time was 12.1 years (interquartile range 3-18 years). RESULTS: There were 3 early and 6 late deaths. All early deaths occurred in patients aged <1 year at the time of surgery. The 25-year survival was 90.3%. Actuarial freedom from reoperation (linearized rates in parentheses) was as follows: Autograft reoperation was 90.8% (0.48%/patient-year) and right ventricular outflow tract (RVOT) reoperation was 67% (2.07%/patient year) at 25 years. The univariable Cox-proportional hazard analysis revealed younger age at time of surgery (P < 0.001), smaller implanted valve size (P < 0.001) and the use of a xenograft rather than a homograft (P < 0.001) as predictors of RVOT reoperation. At multivariable Cox-proportional hazard analysis, only age was an independent risk factor for RVOT reoperation (P = 0.041). CONCLUSIONS: The Ross and the Ross-Konno procedures are associated with good outcomes in paediatric patients. Reoperation of the RVOT is frequent and associated with younger age.

Long-Term Outcomes of Patients Undergoing the Ross Procedure.

BACKGROUND: Treatment of aortic-valve disease in young patients still poses challenges. The Ross procedure offers several potential advantages that may translate to improved long-term outcomes. OBJECTIVES: This study reports long-term outcomes after the Ross procedure. METHODS: Adult patients who were included in the Ross Registry between 1988 and 2018 were analyzed. Endpoints were overall survival, reintervention, and major adverse events at maximum follow-up. Multivariable regression analyses were performed to identify risk factors for survival and the need of Ross-related reintervention. RESULTS: There were 2,444 adult patients with a mean age of 44.1 ± 11.7 years identified. Early mortality was 1.0%. Estimated survival after 25 years was 75.8% and did not statistically differ from the general population (p = 0.189). The risk for autograft reintervention was 0.69% per patient-year and 0.62% per patient-year for right-ventricular outflow tract (RVOT) reintervention. Larger aortic annulus diameter (hazard ratio [HR]: 1.12/mm; 95% confidence interval [CI]: 1.05 to 1.19/mm; p < 0.001) and pre-operative presence of pure aortic insufficiency (HR: 1.74; 95% CI: 1.13 to 2.68; p = 0.01) were independent predictors for autograft reintervention, whereas the use of a biological valve (HR: 8.09; 95% CI: 5.01 to 13.08; p < 0.001) and patient age (HR: 0.97 per year; 95% CI: 0.96 to 0.99; p = 0.001) were independent predictors for RVOT reintervention. Major bleeding, valve thrombosis, permanent stroke, and endocarditis occurred with an incidence of 0.15% per patient-year, 0.07% per patient-year, 0.13%, and 0.36% per patient-year, respectively. CONCLUSIONS: The Ross procedure provides excellent survival over a follow-up period of up to 25 years. The rates of reintervention, anticoagulation-related morbidity, and endocarditis were very low. This procedure should therefore be considered as a very suitable treatment option in young patients suffering from aortic-valve disease. (Long-Term Follow-up After the Autograft Aortic Valve Procedure [Ross Operation]; NCT00708409).

Aortic Valve Repair for Aortic Insufficiency or Dilatation: Technical Evolution and Long-term Outcomes.

BACKGROUND: Aortic valve repair (AVR) is an attractive alternative to valve replacement for the treatment of aortic valve insufficiency. Here we report on the midterm outcomes after AVR for aortic valve insufficiency with an emphasis on durability of repair. METHODS: Between 1996 and 2017, 560 consecutive patients (mean age, 57 ± 16 years) underwent various AVR procedures on tricuspid (n = 415, 74%) and bicuspid (n = 145, 26%) aortic valves. In 313 patients (56%) the David procedure was performed, whereas in 247 patients (44%) cusp repair without aortic root procedure was conducted. Concomitant procedures were coronary artery bypass grafting in 82 patients (15%) and mitral valve repair in 47 patients (8%). Clinical and echocardiographic follow-up was complete in 97% of patients. Mean follow-up was 6.3 ± 4.6 years. RESULTS: Thirty-day mortality was 1.4% (n = 8). Late mortality was observed in 132 patients with cardiovascular events accounting for mortality in 13 patients: Survival at 10 years was 70%. Reoperation on the aortic valve was performed on 39 patients for recurrent insufficiency, isolated in 25, or combined with valve stenosis in 5 patients; endocarditis accounted for reoperation in 9 patients (0.2% per patient-year). Freedom from reoperation was 88% at 10 years. Cumulative linearized incidence of all valve-related complications was 2% per patient per year. CONCLUSIONS: AVR for insufficiency is a durable procedure with low valve-related morbidity and mortality in the midterm.

Propensity-Matched Comparison of Two Different Access Modes for Minimally Invasive Mitral Valve Surgery.

Mitral valve surgery is being performed routinely using minimally invasive operative techniques. We aimed comparing perioperative and long-term outcomes of minimally invasive mitral valve surgery using 2 different surgical approaches, partial upper sternotomy (PUS) vs right anterolateral minithoracotomy (RAT). From January 1998 through December 2015, 1006 patients underwent mitral valve surgery using a minimally invasive access in our institution. Logistic regression analysis was used to identify covariates among 18 patient variables including the type of mitral valve surgery. Using the significant regression coefficients, each patient's propensity score was calculated, allowing selectively matched subgroups of 243 patients each. Results are based on the matched cohorts between the 2 groups. The PUS approach was performed by 8 surgeons whereas the RAT approach by 2. PUS led to slightly longer duration of the cross-clamp time (100 ± 28 vs 88 ± 26 minutes, P < 0.001) whereas ventilation time (9 ± 37 vs 11 ± 66 hours, P < 0.001) was shorter in PUS than in RAT group. Besides the number of pacemaker implants (PUS: 6.6% vs RAT: 0.4, P = 0.0005) and postoperative chest tube drainage amount at 24 hours (PUS: 556 ± 557 mL/24 h vs RAT: 716 ± 580 mL/24 h, P < 0.001) no differences between the 2 groups regarding further perioperative outcome were observed. Long-term survival and freedom from mitral valve reintervention were comparable between the 2 groups at 6- and 8 years' follow-up. Minimally invasive mitral valve surgery can be performed safely using a PUS or RAT approach without any differences regarding perioperative and long-term morbidity and mortality. Although the RAT approach may be cosmetically more appealing in female patients, PUS may facilitate both safe performance of mitral valve surgery and resident training.

Thromboembolic infarction caused by an unknown patent foramen ovale 30 years after VA shunt insertion: a case report and review of the literature.

BACKGROUND: Ventriculoatrial shunt (VA) insertion is one of the possible surgical procedures to treat hydrocephalus. However, it is also associated with several complications such as obstruction and shunt infection as well as life-threatening complications like intraatrial thrombus or thrombosis on the distal catheter. In this case report, we share a rare case of a patient with a VA shunt, who was admitted to our hospital with a stroke. CASE DESCRIPTION: A 56-year-old female patient with suspected acute stroke was admitted to the stroke unit. CT and MRI scans showed multiple cerebral infarctions in both hemispheres. The transesophageal echocardiography (TEE) showed at the tip of the VA shunt catheter, which was implanted about 30 years ago due to aqueduct stenosis, also a thrombotic formation as the reason of stroke. Interestingly, the tip of the catheter was not in the right atrium as expected, but in the left atrium. Further evaluation showed a patent foramen ovale (PFO), through which the catheter migrated from the right to the left side. At first, conservative treatment with anticoagulation was started with the aim to dissolve the thrombotic formation; however, a control TEE showed an unchanged mass at the catheter tip. Therefore, a ventriculoperitoneal shunt was implanted and the proximal shunt catheter was removed with an additional closure of the PFO by our heart surgeons. Postoperatively, the patient was discharged 10 days later in good condition to a rehabilitation center. CONCLUSIONS: Thromboembolic events due to a PFO are rare but possible life-threatening complication after VA shunt insertion. Therefore, preoperative cardiac diagnostic might be clinically relevant prior to a VA shunt implantation to avoid such complications.

Age-related regulation and region-specific distribution of ion channel subunits promoting atrial fibrillation in human left and right atria.

AIMS: Age-induced changes and electrical remodelling are important components of the atrial fibrillation (AF) substrate. To study regional distribution and age-dependent changes in gene expression that may promote AF in human atria. METHODS AND RESULTS: Human left atrial (LA) and right atrial (RA) tissue samples were obtained from donor hearts unsuitable for transplantation and from patients undergoing mitral valve repair. Atrial fibrillation was mimicked in vitro by tachypacing of human atrial tissue slices. Ionic currents were studied by the whole-cell patch-clamp technique; gene expression was analysed by real-time qPCR and immunoblotting. Both healthy RA and RA from older patients showed greater CACNA1c mRNA and CaV1.2 protein expression than LA. No age-dependent changes of Kir2.1 expression in both atria were seen. Remodelling occurred in a qualitatively similar manner in RA and LA. IK1 and Kir2.1 protein expression increased with AF. MiR-1, miR-26a, and miR-26b were down-regulated with AF in both atria. ICa,L was decreased. CACNA1c and CACNA2b expression decreased and miR-328 increased in RA and LA during AF. Ex vivo tachypacing of human atrial slices replicated these findings. There were age-dependent increases in miR-1 and miR-328, while miR-26a decreased with age in atrial tissues from healthy human donor hearts. CONCLUSION: Features of electrical remodelling in man occur in a qualitatively similar manner in both human atria. Age-related miR-328 dysregulation and reduced ICa,L may contribute to increased AF susceptibility with age.

Efficacy and safety of transvenous lead extraction in 108 consecutive patients: a single-centre experience.

OBJECTIVES: The number of cardiac implantable electronic devices is growing worldwide because they play a relevant role in improving the survival rate in patients with specific heart diseases. Cardiac implantable electronic devices complications including infection, dysfunction or venous stenosis increase the need for the least traumatic way to explant leads. Our goal was to report the successes and procedural complication rates of transvenous lead extraction (TLE) in a consecutive series of patients. METHODS: From 2010 to 2016, 108 patients underwent TLE of 227 leads due to endocarditis (n = 21; 19%), pocket infection (n = 58; 54%) or lead dysfunction (n = 29; 27%). In 98% (n = 106) of the patients, laser-assisted lead extraction was performed. In 2% (n = 2) of the patients, the application of a solitary locking stylet was sufficient. The patient mean age was 68 ± 14 years; 25% of the patients had previous cardiac surgery. TLE was performed a mean of 9 ± 6 years after the implantation of the existing device. RESULTS: Complete procedural success (removal of all lead material from the vascular space) was achieved in 98.7% (n = 224), and clinical success (achievement of all clinical goals associated with the indication for lead removal and absence of major complications) was achieved in 98% (n = 106). In 2 patients the procedure failed due to a vascular tear requiring a thoracotomy. In 1 patient, complete lead extraction was not possible due to heavy calcification (coronary-sinus lead). The 30-day mortality rate was 3.7% (n = 4); the patients died of multiorgan failure (n = 1), cardiac failure (n = 1) and septicaemia (n = 2). The procedure-related major complication rate was 2% (n = 2). CONCLUSIONS: Laser-assisted TLE seems to be a safe and effective procedure with an acceptable complication rate.

Moderate Hypothermic Circulatory Arrest (≥ 28°C) with Selective Antegrade Cerebral Perfusion for Total Arch Replacement with Frozen Elephant Trunk Technique.

OBJECTIVES: The optimal hypothermic level during circulatory arrest in aortic arch surgery remains controversial, particularly in frozen elephant trunk (FET) procedures. We describe herein our experience for total arch replacement with FET technique under moderate systemic hypothermic circulatory arrest (≥ 28°C) during selective antegrade cerebral perfusion. METHODS: Between January 2009 and January 2016, 38 consecutive patients underwent elective total arch replacement for various aortic arch pathologies with FET technique using the E-vita Open hybrid prosthesis (Jotec GmbH, Hechingen, Germany). Selective unilateral or bilateral cerebral perfusion under moderate systemic hypothermic circulatory arrest (28.7°C ± 0.5°C) was used in all patients. Minimally invasive total arch replacement with FET via partial upper sternotomy was performed in 15 patients (39%) and in the remaining 23 patients (61%) via full sternotomy. Mean late follow-up was 3 ± 2 years and was 98% complete. Clinical data were prospectively entered into our institutional database. RESULTS: Cardiopulmonary bypass time accounted for 198 ± 58 minutes and the myocardial ischemic time 109 ± 29 minutes. Selective antegrade cerebral perfusion time was 55 ± 6 minutes. Lower body circulatory arrest time was 39 ± 11 minutes. Unilateral cerebral perfusion was performed in 31 patients (82%), and bilateral in 7 patients (18%). Intensive care unit stay was 4 ± 3 days. Thirty-day mortality was 5% (n = 2). Late survival at 3 years was 87 ± 3%. Two patients (5%) required reexploration for bleeding. Patients were discharged after a hospital length of stay of 7 ± 2 days. Postoperative permanent neurologic complication occurred in two patients (5%). Three patients (8%) experienced a transient neurologic disorder. New transient renal replacement therapy was necessary in three patients (8%). No spinal cord injury was noted. CONCLUSIONS: Our data suggest that moderate systemic hypothermic circulatory arrest (≥ 28°C) in combination with antegrade cerebral perfusion can safely be applied for total aortic arch replacement with FET and offers sufficient neurologic and visceral organ protection.