Femoral arterial cannulation for surgical repair of stanford type A aortic dissection.

BACKGROUND: The benefits and harms associated with femoral artery cannulation over other sites of arterial cannulation for surgical repair of acute Stanford type A aortic dissection (TAAD) are not conclusively established. METHODS: We evaluated the outcomes after surgery for TAAD using femoral artery cannulation, supra-aortic arterial cannulation (i.e., innominate/subclavian/axillary artery cannulation), and direct aortic cannulation. RESULTS: 3751 (96.1%) patients were eligible for this analysis. In-hospital mortality using supra-aortic arterial cannulation was comparable to femoral artery cannulation (17.8% vs. 18.4%; adjusted OR 0.846, 95% CI 0.799-1.202). This finding was confirmed in 1028 propensity score-matched pairs of patients with supra-aortic arterial cannulation or femoral artery cannulation (17.5% vs. 17.0%, p = 0.770). In-hospital mortality after direct aortic cannulation was lower compared to femoral artery cannulation (14.0% vs. 18.4%, adjusted OR 0.703, 95% CI 0.529-0.934). Among 583 propensity score-matched pairs of patients, direct aortic cannulation was associated with lower rates of in-hospital mortality (13.4% vs. 19.6%, p = 0.004) compared to femoral artery cannulation. Switching of the primary site of arterial cannulation was associated with increased rate of in-hospital mortality (36.5% vs. 17.0%; adjusted OR 2.730, 95% CI 1.564-4.765). Ten-year mortality was similar in the study cohorts. CONCLUSIONS: In this study, the outcomes of surgery for TAAD using femoral arterial cannulation were comparable to those using supra-aortic arterial cannulation. However, femoral arterial cannulation was associated with higher in-hospital mortality than direct aortic cannulation. TRIAL REGISTRATION: ClinicalTrials.gov registration code: NCT04831073.

Current Outcome after Surgery for Type A Aortic Dissection.

OBJECTIVE: The aim of this study was to evaluate the outcomes of different surgical strategies for acute Stanford type A aortic dissection (TAAD). SUMMARY BACKGROUND DATA: The optimal extent of aortic resection during surgery for acute TAAD is controversial. METHODS: This is a multicenter, retrospective cohort study of patients who underwent surgery for acute TAAD at 18 European hospitals. RESULTS: Out of 3902 consecutive patients, 689 (17.7%) died during the index hospitalization. Among 2855 patients who survived 3 months after surgery, 10-year observed survival was 65.3%, while country-adjusted, age-adjusted, and sex-adjusted expected survival was 81.3%, yielding a relative survival of 80.4%. Among 558 propensity score-matched pairs, total aortic arch replacement increased the risk of in-hospital (21.0% vs. 14.9%, P =0.008) and 10-year mortality (47.1% vs. 40.1%, P =0.001), without decreasing the incidence of distal aortic reoperation (10-year: 8.9% vs. 7.4%, P =0.690) compared with ascending aortic replacement. Among 933 propensity score-matched pairs, in-hospital mortality (18.5% vs. 18.0%, P =0.765), late mortality (at 10-year: 44.6% vs. 41.9%, P =0.824), and cumulative incidence of proximal aortic reoperation (at 10-year: 4.4% vs. 5.9%, P =0.190) after aortic root replacement was comparable to supracoronary aortic replacement. CONCLUSIONS: Replacement of the aortic root and aortic arch did not decrease the risk of aortic reoperation in patients with TAAD and should be performed only in the presence of local aortic injury or aneurysm. The relative survival of TAAD patients is poor and suggests that the causes underlying aortic dissection may also impact late mortality despite surgical repair of the dissected aorta.

Direct Aortic Versus Supra-Aortic Arterial Cannulation During Surgery for Acute Type A Aortic Dissection.

AIMS: In this study we evaluated the impact of direct aortic cannulation versus innominate/subclavian/axillary artery cannulation on the outcome after surgery for type A aortic dissection. METHODS: The outcomes of patients included in a multicenter European registry (ERTAAD) who underwent surgery for acute type A aortic dissection with direct aortic cannulation versus those with innominate/subclavian/axillary artery cannulation, i.e. supra-aortic arterial cannulation, were compared using propensity score matched analysis. RESULTS: Out of 3902 consecutive patients included in the registry, 2478 (63.5%) patients were eligible for this analysis. Direct aortic cannulation was performed in 627 (25.3%) patients, while supra-aortic arterial cannulation in 1851 (74.7%) patients. Propensity score matching yielded 614 pairs of patients. Among them, patients who underwent surgery for TAAD with direct aortic cannulation had significantly decreased in-hospital mortality (12.7% vs. 18.1%, p = 0.009) compared to those who had supra-aortic arterial cannulation. Furthermore, direct aortic cannulation was associated with decreased postoperative rates of paraparesis/paraplegia (2.0 vs. 6.0%, p < 0.0001), mesenteric ischemia (1.8 vs. 5.1%, p = 0.002), sepsis (7.0 vs. 14.2%, p < 0.0001), heart failure (11.2 vs. 15.2%, p = 0.043), and major lower limb amputation (0 vs. 1.0%, p = 0.031). Direct aortic cannulation showed a trend toward decreased risk of postoperative dialysis (10.1 vs. 13.7%, p = 0.051). CONCLUSIONS: This multicenter cohort study showed that direct aortic cannulation compared to supra-aortic arterial cannulation is associated with a significant reduction of the risk of in-hospital mortality after surgery for acute type A aortic dissection. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04831073.

From the RELAY Family-A Story of Single-Branched International Outcomes.

BACKGROUND: Advances in surgery over the last few decades has led to the development and widespread utilization of thoracic endovascular aortic repair (TEVAR). TEVAR, due to its minimally invasive nature and potential superior outcomes, is now becoming a key focus of interest in treating pathologies of the aortic arch, which has traditionally been treated with open surgical repair. We present our findings of our international multicentre dataset documenting the efficacy of the single-branched RELAY™ endograft in terms of technical success, postoperative outcomes, and reintervention rates. METHODS: Prospective data were collected and retrospectively analyzed with descriptive and distributive analysis between January 2019 and January 2022 from 17 patients treated with RELAY single-branched endoprostheses from centers across Europe. Follow-up data from 30 days and 6 months, 12 months, and 24 months postoperatively was included. Patient follow-up was evaluated in terms of postoperative outcomes, target vessel patency, and reintervention rates. RESULTS: Technical success was achieved in all 17 patients (100%) and there were no postoperative disabling or nondisabling strokes in our single-branched RELAY cohort. The target vessel patency remained 100% during the first 30 days postoperatively; however, by the end of the follow-up period (24 months), target vessel patency was achieved in 93.7% of the patients. There were no reinterventions or deaths during the full study duration using the single-branched RELAY stent-graft. CONCLUSIONS: These results with the single-branched RELAY stent graft demonstrate favorable outcomes in comparison to the literature and demonstrate the feasibility of treatment of aortic pathology with this single-branched graft in the future. Further studies with larger patient cohorts will help us to accumulate evidence for the feasibility of the single-branched RELAY stent graft for aortic arch surgery in the future.

The role of the ADVanced Organ Support (ADVOS) system in critically ill patients with multiple organ failure.

BACKGROUND: Multi-organ failure characterized by acute kidney injury, liver dysfunction, and respiratory failure is a complex condition associated with high mortality, for which multiple individual support devices may be simultaneously required. This review aims to appraise the current evidence for the ADVanced Organ Support (ADVOS) system, a novel device integrating liver, lung, and kidney support with blood detoxification. METHODS: We performed a literature review of the PubMed database to identify human and animal studies evaluating the ADVOS system. RESULTS: In porcine models of acute liver injury and small clinical studies in humans, ADVOS significantly enhanced the elimination of water-soluble and protein-bound toxins and metabolites, including creatinine, ammonia, blood urea nitrogen, and lactate. Cardiovascular parameters (mean arterial pressure, cerebral perfusion pressure, and cardiac index) and renal function were improved. ADVOS clears carbon dioxide (CO2 ) effectively with rapid correction of pH abnormalities, achieving normalization of CO2 , and bicarbonate levels. In patients with COVID-19 infection, ADVOS enables rapid correction of acid-base disturbance and respiratory acidosis. ADVOS therapy reduces mortality in multi-organ failure and has been shown to be safe with minimal adverse events. CONCLUSIONS: From the small observational studies analyzed, ADVOS demonstrates excellent detoxification of water-soluble and protein-bound substances. In particular, ADVOS permits the correction of metabolic and respiratory acidosis through the fluid-based direct removal of acid and CO2 . ADVOS is associated with significant improvements in hemodynamic and biochemical parameters, a trend toward improved survival in multi-organ failure, and is well-tolerated. Larger randomized trials are now necessary to further validate these encouraging results.

Surveillance for moderate-sized thoracic aortic aneurysms: Equality is the goal.

Comprehensive clinical and imaging-based surveillance represents a fundamental aspect in the management of thoracic aortic aneurysms (TAAs), affording the opportunity to identify intermediate-sized TAAs before the onset of worrying symptoms or devastating acute aortic dissection/rupture. Currently, size-based indices are favored as the major determinants driving patient selection for surgery, as supported by aortic guidelines, although it is recognized that smaller subthreshold TAAs may still confer substantial risks. Prophylactic aortic surgery can be offered within set timeframes at dedicated aortic centers with excellent outcomes, to mitigate the threat of acute aortic complications associated with a repeatedly deferred intervention. In this commentary, we discuss a recent article from the Journal of Cardiac Surgery that highlights important socioeconomic disparities in TAA surveillance and follow-up.

Is it safe to perform total arterial grafting in elderly patients lacking vein grafts? A single surgeon comparison.

OBJECTIVES: The results of coronary artery bypass graft (CABG) surgery with total arterial revascularisation (TA-CABG) in elderly patients, who may have insufficient vein graft material for conventional CABG (CO-CABG), have not been fully established. We therefore sought to compare the short- and long-term outcomes of patients >70 years old undergoing CO-CABG and TA-CABG. METHODS: We performed a retrospective observational study analyzing all consecutive adult patients aged >70 years undergoing first-time CABG over the 15-year period from 2004 to 2020 under a single surgeon. Primary outcomes of interest were in-hospital mortality, long-term mortality, and re-intervention rate. Secondary outcomes of interest included operative durations and the incidence of peri-operative complications. RESULTS: There were 46 patients (age 76 ± 3 SD) in the TA-CABG group and 145 patients (age 76 ± 4 SD) in the CO-CABG group. Cardio-pulmonary bypass and cross-clamp durations were comparable between groups (p = .11 and p = .23, respectively). Stroke occurred in 1.0% undergoing CO-CABG compared to 0% in the TA-CABG group (p = .42). Hospital mortality was 3.0% with CO-CABG (EuroSCORE; mean [SD] 6.81 (5.81)) and 2.0% with TA-CABG (EuroSCORE; mean [SD] 6.38 (6.57)) (p = .93). On long-term follow-up, myocardial infarction occurred in 10.0% of CO-CABG patients compared to 4.0% of TA-CABG patients (p = .25). Re-intervention rates were 7% following CO-CABG, and 2% after TA-CABG (p = .23). There was no significant difference in long-term mortality between patients undergoing CO-CABG and TA-CABG (47% vs. 57%, p = .27). Long-term survival was comparable between grafting techniques (p = .27). CONCLUSIONS: There were no significant differences in major adverse cardiac and cerebrovascular events, re-intervention rate, hospital or long-term mortality between CO-CABG and TA-CABG. TA-CABG represents a safe and feasible alternative to CO-CABG in elderly patients offering good long-term outcomes.

External or subcomissural annuloplasty in bicuspid aortic valve repair: Which is better?

Patients with a bicuspid aortic valve (BAV) are at increased risk of valvular regurgitation compared to their counterparts with a tri-leaflet aortic valve. There is now increasing emphasis to offer BAV repair to mitigate the risks of prosthesis-related complications, including thromboembolism, hemorrhage and endocarditis, as well as structural valve deterioration and future reoperation with conventional valve replacement, particularly in younger populations. Furthermore, over the preceding two decades, our greater understanding of the functional anatomy of the BAV, pathophysiological mechanisms of BAV insufficiency, and the development of a functional classification of aortic regurgitation have significantly contributed to the evolution of aortic valve reconstructive surgery. In this commentary, we discuss a recent article from the Journal of Cardiac Surgery comparing external annuloplasty and subcommissural annuloplasty as techniques for BAV repair.

Long-Term Follow-Up of Survivors of Extracorporeal Life Support Therapy for Cardiogenic Shock: Are They Really Survivors?

Background and Objectives: Cardiogenic shock (CS) is a medical emergency associated with a high mortality rate. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has become an accepted therapy for CS. Despite widely available data for short-term survival rates, there are only limited data available regarding long-term outcomes following successful VA-ECMO therapy. Materials and Methods: We analyzed the demographics, past medical history, adverse events, and outcomes of survivors who received VA-ECMO support for CS at our center from January 2012 to December 2019. Post-cardiotomy cases were excluded. Results: A total of 578 VA-ECMO implantations on 564 consecutive patients due to CS were identified during the study period. Successful weaning was achieved in 207 (36.7%) patients. Among the survivors, 126 (63%) patients received VA-ECMO therapy without preceding cardiac surgery during their current admission. A follow-up exceeding 12 (mean: 36 ± 20.9) months was available in a total of 55 (43.7%) survivors. The mean VA-ECMO perfusion time was 10.9 (±7.7) days with a mean intensive care unit (ICU) stay of 38.2 (±29.9) days and a mean hospital stay of 49.9 (±30.5) days. A total of 3 deaths were recorded during long-term follow-up (mean survival of 26 ± 5.3 months). Conclusions: Despite the high mortality associated with VA-ECMO therapy, a long-term follow-up with an acceptably low rate of negative cardiac events can be achieved in many survivors. We observed an acceptable low rate of new cardiac events. Further evaluation, including a quality-of-life assessment and a close follow-up for rarer complications in these patients, is needed to elucidate the longer-term outcomes for survivors of invasive VA-ECMO therapy.

ECMO implantation training: Needle penetration in 3D printable materials and porcine aorta.

AIM: Patients with cardiogenic shock or ARDS, for example, in COVID-19/SARS-CoV-2, may require extracorporeal membrane oxygenation (ECMO). An ECLS/ECMO model simulating challenging vascular anatomy is desirable for cannula insertion training purposes. We assessed the ability of various 3D-printable materials to mimic the penetration properties of human tissue by using porcine aortae. METHODS: A test bench for needle penetration and piercing in sampled porcine aorta and preselected 3D-printable polymers was assembled. The 3D-printable materials had Shore A hardness of 10, 20, and 50. 17G Vygon 1.0 × 1.4 mm × 70 mm needles were used for penetration tests. RESULTS: For the porcine tissue and Shore A 10, Shore A 20, and Shore A 50 polymers, penetration forces of 0.9036 N, 0.9725 N, 1.0386 N, and 1.254 N were needed, respectively. For piercing through the porcine tissue and Shore A 10, Shore A 20, and Shore A 50 polymers, forces of 0.8399 N, 1.244 N, 1.475 N, and 1.482 N were needed, respectively. ANOVA showed different variances among the groups, and pairwise two-tailed t-tests showed significantly different needle penetration and piercing forces, except for penetration of Shore A 10 and 20 polymers (p = 0.234 and p = 0.0857). Significantly higher forces were required for all other materials. CONCLUSION: Shore A 10 and 20 polymers have similar needle penetration properties compared to the porcine tissue. Significantly more force is needed to pierce through the material fully. The most similar tested material to porcine aorta for needle penetration and piercing in ECMO-implantation is the silicon Shore A 10 polymer. This silicon could be a 3D-printable material in surgical training for ECMO-implantation.

Quality of Life Following Urgent LVAD Implantation for ECMO Therapy in Cardiogenic Shock: A Long-Term Follow-Up.

Background and Objectives: Over the past decade, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has developed into a mainstream treatment for refractory cardiogenic shock (CS) to maximal conservative management. Successful weaning of VA-ECMO may not be possible, and bridging with further mechanical circulatory support (MCS), such as urgent implantation of a left ventricular assist device (LVAD), may represent the only means to sustain the patient haemodynamically. In the recovery phase, many survivors are not suitably prepared physically or psychologically for the novel issues encountered during daily life with an LVAD. Materials and Methods: A retrospective analysis of our institutional database between 2012 and 2019 was performed to identify patients treated with VA-ECMO for CS who underwent urgent LVAD implantation whilst on MCS. Post-cardiotomy cases were excluded. QoL was assessed prospectively during a routine follow-up visit using the EuroQol-5 dimensions-5 level (EQ-5D-5L) and the Patient Health Questionnaire (PHQ-9) surveys. Results: Among 126 in-hospital survivors of VA-ECMO therapy due to cardiogenic shock without prior cardiac surgery, 31 (24.6%) urgent LVAD recipients were identified. In 11 (36.7%) cases, cardiopulmonary resuscitation (CPR) was performed (median 10, range 1-60 min) before initiation of VA-ECMO, and in 5 (16.7%) cases, MCS was established under CPR. Mean age at LVAD implantation was 51.7 (+/-14) years and surgery was performed after a mean 12.1 (+/-8) days of VA-ECMO support. During follow-up of 46.9 (+/-25.5) months, there were 10 deaths after 20.4 (+/-12.1) months of LVAD support. Analysis of QoL questionnaires returned a mean EQ-5D-5L score of 66% (+/-21) of societal valuation for Germany and a mean PHQ-9 score of 5.7 (+/-5) corresponding to mild depression severity. When compared with 49 elective LVAD recipients without prior VA-ECMO therapy, there was no significant difference in QoL results. Conclusions: Patients requiring urgent LVAD implantation under VA-ECMO support due to CS are associated with comparable quality of life without a significant difference from elective LVAD recipients. Close follow-up is required to oversee patient rehabilitation after successful initial treatment.

Mechanical circulatory support for cardiovascular complications in a young COVID-19 patient.

BACKGROUND: The current coronavirus (COVID-19) pandemic is associated with severe pulmonary and cardiovascular complications. CASE PRESENTATION: This report describes a young patient with COVID-19 without any comorbidity presenting with severe cardiovascular complications, manifesting with pulmonary embolism, embolic stroke, and right heart failure. CONCLUSION: Management with short-term mechanical circulatory support, including different cannulation strategies, resulted in a successful outcome despite his critical cardiovascular status.

Is it Safe for Patients with Left Ventricular Assist Devices to Undergo Non-Cardiac Surgery?

Background and Objectives: Since the first use of ventricular assist devices (VADs) as bridge to recovery and bridge to cardiac transplantation in the early 1990s, significant technological advances have transformed VAD implantation into a routine destination therapy. With improved survival, many patients present for cardiac surgery for conditions not directly related to their permanent mechanical circulatory support. The aim of this study was to analyze the indications and outcomes of non-cardiac surgeries (NCSs) of left ventricular assist device (LVAD) patients in tertiary center. Material and Methods: We present a single-center experience after 151 LVAD implantations in 138 consecutive patients between 2012-2019 who had to undergo NCS during a follow-up period of 37 +/- 23.4 months on left ventricular assist device (LVAD). Results: A total of 105 procedures was performed in 63 LVAD recipients, resulting in peri-operative mortality of 3.8%. Twenty-five (39.7%) of patients underwent multiple surgeries. We found no significant difference in cumulative survival associated with the performed surgical interventions (p = 0.469). Conclusion: We demonstrated good overall clinical outcomes in LVAD patients undergoing NCS. With acceptable peri-operative mortality, NCS can be safely performed in LVAD patients on long-term support.

Role of gender in short- and long-term outcomes after surgery for type A aortic dissection: analysis of a multicentre European registry.

OBJECTIVES: Gender difference in the outcome after type A aortic dissection (TAAD) surgery remains an issue of ongoing debate. In this study, we aimed to evaluate the impact of gender on the short- and long-term outcome after surgery for TAAD. METHODS: A multicentre European registry retrospectively included all consecutive TAAD surgery patients between 2005 and 2021 from 18 hospitals across 8 European countries. Early and late mortality, and cumulative incidence of aortic reoperation were compared between genders. RESULTS: A total of 3902 patients underwent TAAD surgery, with 1185 (30.4%) being females. After propensity score matching, 766 pairs of males and females were compared. No statistical differences were detected in the early postoperative outcome between genders. Ten-year survival was comparable between genders (47.8% vs 47.1%; log-rank test, P = 0.679), as well as cumulative incidences of distal or proximal aortic reoperations. Ten-year relative survival compared to country-, year-, age- and sex-matched general population was higher among males (0.65) compared to females (0.58). The time-period subanalysis revealed advancements in surgical techniques in both genders over the years. However, an increase in stroke was observed over time for both populations, particularly among females. CONCLUSIONS: The past 16 years have witnessed marked advancements in surgical techniques for TAAD in both males and females, achieving comparable early and late mortality rates. Despite these findings, late relative survival was still in favour of males.

Classification of the Urgency of the Procedure and Outcome of Acute Type A Aortic Dissection.

Surgery for type A aortic dissection (TAAD) is associated with a high risk of early mortality. The prognostic impact of a new classification of the urgency of the procedure was evaluated in this multicenter cohort study. Data on consecutive patients who underwent surgery for acute TAAD were retrospectively collected in the multicenter, retrospective European Registry of TAAD (ERTAAD). The rates of in-hospital mortality of 3,902 consecutive patients increased along with the ERTAAD procedure urgency grades: urgent procedure 10.0%, emergency procedure grade 1 13.3%, emergency procedure grade 2 22.1%, salvage procedure grade 1 45.6%, and salvage procedure grade 2 57.1% (p <0.0001). Preoperative arterial lactate correlated with the urgency grades. Inclusion of the ERTAAD procedure urgency classification significantly improved the area under the receiver operating characteristics curves of the regression model and the integrated discrimination indexes and the net reclassification indexes. The risk of postoperative stroke/global brain ischemia, mesenteric ischemia, lower limb ischemia, dialysis, and acute heart failure increased along with the urgency grades. In conclusion, the urgency of surgical repair of acute TAAD, which seems to have a significant impact on the risk of in-hospital mortality, may be useful to improve the stratification of the operative risk of these critically ill patients. This study showed that salvage surgery for TAAD is justified because half of the patients may survive to discharge.

Poorly-differentiated signet-ring cell carcinoma of the ampulla of Vater: report of a rare malignancy.

CONTEXT: Signet-ring cell carcinoma (SRCC) of the ampulla of Vater is a very rare clinical entity, which is infrequently reported in medical literature. CASE REPORT: A 78-year-old woman was admitted with jaundice, pruritus and postprandial vomiting. Abdominal ultrasound and computed tomography scanning demonstrated gross dilatation of the common bile and pancreatic ducts with gallbladder calculi. Endoscopic retrograde cholangiopancreatography suggested a duodenal tumour at the ampulla. The patient underwent Whipple's procedure with cholecystectomy. Immunohistopathological examination confirmed poorly-differentiated SRCC of the ampulla of Vater. The tumour had infiltrated the duodenal muscularis propria and pancreatic parenchyma, but local lymph nodes were clear (T3N0M0). The patient was disease-free at 6-month follow-up. CONCLUSIONS: We here report a case of poorly-differentiated SRCC of the Ampulla of Vater. The majority of patients with such tumours undergo pancreaticoduodenectomy, which affords good outcomes in early disease. However, owing to the rarity of cases, the exact prognosis of ampullary SRCC remains as yet undetermined.

Diagnosis and acute management of type A aortic dissection.

Acute type A aortic dissection is a devastating aortic disease associated with significant morbidity and mortality. Clinicians should maintain a high degree of suspicion in patients presenting with sudden-onset chest pain, although the diagnosis may be confounded by the broad spectrum of attendant symptoms and signs. Accurate and timely identification of the acute dissection is of paramount importance to ensure suitable patients are referred promptly for definitive surgical management. This review focuses on the diagnosis of acute type A aortic dissection and discusses the haematological tests, and electrocardiographic, echocardiographic and radiological investigations necessary to confirm the diagnosis and assess for associated complications. The acute medical management of patients with acute type A dissection is also reviewed.