Contemporary surgical management of infective endocarditis of the aortic root.

Infective endocarditis involving the aortic root is associated with a high degree of morbidity and mortality. Native aortic root infections can develop from aggressive organisms or from delays in diagnosis or definitive care, whereas prosthetic valve infections commonly result in extensive destruction of the aortic root and neighboring structures. Early detection, tailored antibiotic therapy, thoughtful pre-operative planning, and multidisciplinary heart team management are the keys to optimizing patient outcomes. Aggressive and complete surgical debridement are mandatory prior to aortic root reconstruction. Surgical experience and patient-centered decision making are critical in selecting the optimal reconstructive strategy for the aortic root and adjacent structures. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01604-6.

A Novel Technique for Thoracic Endovascular Graft Explantation.

Thoracic endovascular aortic repair (TEVAR) explantation remains a challenge due to endovascular graft ingrowth into the aortic wall with time. Surgical access into the aortic arch can be difficult either via sternotomy or thoracotomy, and proximal barbs become engaged firmly into the aortic wall. Explantation often requires extensive thoracic aortic resection, sometimes from the distal aortic arch to the abdominal aorta, followed by reconstruction, risking injury to surrounding neurovascular structures and even death. In cases of blunt thoracic aortic injury, the original injury is often healed, and failed TEVAR could theoretically be removed when thrombotic complications occur. We present a novel technique to facilitate TEVAR recapture with limited distal thoracic aorta replacement.

Simulation-based assessment of robotic cardiac surgery skills: An international multicenter, cross-specialty trial.

Objective: This study aimed to investigate the validity of simulation-based assessment of robotic-assisted cardiac surgery skills using a wet lab model, focusing on the use of a time-based score (TBS) and modified Global Evaluative Assessment of Robotic Skills (mGEARS) score. Methods: We tested 3 wet lab tasks (atrial closure, mitral annular stitches, and internal thoracic artery [ITA] dissection) with both experienced robotic cardiac surgeons and novices from multiple European centers. The tasks were assessed using 2 tools: TBS and mGEARS score. Reliability, internal consistency, and the ability to discriminate between different levels of competence were evaluated. Results: The results demonstrated a high internal consistency for all 3 tasks using mGEARS assessment tool. The mGEARS score and TBS could reliably discriminate between different levels of competence for the atrial closure and mitral stitches tasks but not for the ITA harvesting task. A generalizability study also revealed that it was feasible to assess competency of the atrial closure and mitral stitches tasks using mGEARS but not the ITA dissection task. Pass/fail scores were established for each task using both TBS and mGEARS assessment tools. Conclusions: The study provides sufficient evidence for using TBS and mGEARS scores in evaluating robotic-assisted cardiac surgery skills in wet lab settings for intracardiac tasks. Combining both assessment tools enhances the evaluation of proficiency in robotic cardiac surgery, paving the way for standardized, evidence-based preclinical training and credentialing. Clinical trial registry number: NCT05043064.

Malperfusion syndrome in acute type A aortic dissection: Thinking beyond the proximal repair.

BACKGROUND AND OBJECTIVE: Malperfusion syndrome (MPS) is associated with the highest mortality and major morbidity risk in patients with acute Type A aortic dissection (TAAD). The timing of the open proximal aortic repair in the presence of MPS remains debatable given variability in clinical presentation and different local treatment algorithms. This paper provides an up to date and comprehensive overview of published outcomes and available techniques for addressing malperfusion in the setting of acute TAAD. METHODS: We have reviewed published data from the major aortic dissection registries including the International Registry of Acute Aortic Dissection, the German Registry for Acute Aortic Dissection In Type A, and the Nordic Consortium for Acute Type A Aortic Dissection, as well as the most up to date literature involving malperfusion in the setting of acute TAAD. This data highlights unique strategies that have been adopted at aortic centers internationally to address malperfusion in this setting pre-, intra-, and postoperatively, which are summarized here and may be of great clinical benefit to other centers treating this disease with more traditional methods. RESULTS: The review of the available data has definitively shown an increased mortality up to 43% and morbidity in patients presenting with MPS in the setting of acute TAAD. More specifically, preoperative MPS has been shown to be an independent predictor of mortality with mesenteric malperfusion associated with the worst mortality outcomes from 70% to 100%. Addressing MPS pre or intraoperatively is associated with significantly reduced mortality outcomes down to 4%-13%. CONCLUSION: Adapting a dynamic and easily accessible diagnostic method for the comprehensive assessment of different forms of malperfusion (dynamic/static) and incorporating it within the surgical plan is the first step toward early diagnosis and prevention of malperfusion related complications.

The Ross procedure is the optimal solution for young adults with unrepairable aortic valve disease.

While aortic valve repair remains the ideal intervention to restore normal valvular function, the optimal aortic valve substitute for patients with a non-repairable aortic valve remains an ongoing subject for debate. In particular, younger patients with a non-repairable valve represent a unique challenge because of their active lifestyle and long life expectancy, which carries a higher cumulative risk of prosthesis-related complications. The Ross procedure, unlike prosthetic or homograft aortic valve replacement (AVR), provides an expected survival equivalent to that of the age and gender-matched general population. Contemporary data has shown that the Ross procedure can be performed safely in centers with expertise, and is associated with improved valvular durability, hemodynamics and quality of life.

Review of frozen elephant trunk repair with the Thoraflex Hybrid device.

The frozen elephant trunk technique has revolutionized aortic arch repair to enable more extensive arch and descending thoracic aortic treatment in a single setting. We review the current evidence supporting the use of the Thoraflex Hybrid (Terumo Aortic, FL, USA) device and discuss advantages, pitfalls and future design considerations.

Lay abstract Disease of the aorta, the biggest blood vessel in the body, is challenging. In recent years, new technologies such as the frozen elephant trunk (FET) have improved the treatment of patients with these complicated diseases. The FET is a hybrid device, made of medical fabrics and a covered metal stent (a tube inserted into the blood vessel to keep it open). In this paper, we provide an in-depth review of a FET device known as Thoraflex Hybrid (Terumo Aortic, FL, USA). We discuss its advantages and pitfalls as well as future areas of research.

Multimodal imaging of aortic annulus and root geometry after valve sparing root reconstruction.

BACKGROUND: Controversy exists regarding the optimal annular stabilization technique following valve sparing aortic root reconstruction (VSRR) with no comprehensive imaging data to evaluate the natural history of aortic root graft geometry, aortic valve competency and patient prognosis post-reconstruction. METHODS: Between 2008-2017, 70 consecutive patients (mean age 56.4±16.4 years, 19.7% females) underwent VSRR. All patients were prospectively evaluated annually with clinical follow-up, echocardiography and CT imaging. Patients were assessed for survival, freedom from reoperation, degree of regurgitation, New York Heart Association (NYHA) status and graft complications and followed up to nine years post-operatively (mean 36±21 months). RESULTS: The largest increase of the aortic annulus diameter observed during the surveillance period was 2.64%±5.4% which occurred between the second and third years of follow-up and the aortic sinuses, sinotubular junction and ascending aorta all remained relatively stable based on annual CT imaging. Echocardiographic data showed far more variability in measurements at each annual post-operative visit with far less precision compared to the CT measurements taken at the same time. Due to the large variability and greater standard deviations, no significant difference was detected between the more precise CT measurements and those from the echocardiogram images. The overall survival rate was 94.3% (66 patients) at one year. Freedom from reoperation was 98.6% (69 patients). Throughout the entire duration of follow-up, aortic insufficiency was identified as 0 in 46 (65.7%), 1+ in 19 (27.1%), 2+ in 4 (5.7%), 3+ in 0 (0%) and 4+ in 1 (1.4%). Mean NYHA status was 1.1±0.3 at most recent follow-up for all patients. CT evidence showed 97.0% (64 patients) freedom from graft complication including: endocarditis, thrombosis, embolism, aneurysm, pseudoaneurysm, dehiscence, dissection and kinking. CONCLUSIONS: The annual imaging data presented here demonstrates stability of the Dacron aortic annuloplasty reconstruction over time, without the need for internal or external annular stabilization. CT imaging proved to be far more reliable than echocardiographic images, however given the stability, annual CT imaging is of little benefit. This is the first prospective study to compare echocardiographic, CT and clinical data following VSRR.

Comparison of outcomes of root replacement procedures and supracoronary techniques for surgical repair of acute aortic dissection.

BACKGROUND: Surgical approach to type A acute aortic dissection (AADA) is usually dictated by the presenting anatomy. We compared long-term outcomes of AADA repaired with a root replacement versus a supracoronary tube graft, regardless of the proximal extent of the intimal tear. METHODS: A single-centre, retrospective cohort of consecutive patients undergoing repair of AADA between December 1999 and March 2012 were stratified based on the proximal surgical procedure performed: supracoronary tube graft or root replacement. Imaging, chart reviews and clinical follow-ups were analyzed to identify the presenting anatomy and clinical outcomes. RESULTS: We included the cases of 75 patients in our analysis: 54 received a supracoronary tube graft and 21 received a root replacement. The proximal tear was identified below the sinotubular junction in all patients in the root group and in 61% of patients in the supracoronary group. We detected no differences between the groups for in-hospital mortality, length of stay, or complications. However, the root group had significantly increased renal failure (0% v. 9.5%, p = 0.018), cardiopulmonary bypass time (198.4 ± 80.0 min v. 316.5 ± 102.5 min, p < 0.001), cross-clamp time (91.6 ± 34.9 min v. 191.3 ± 52.8 min, p < 0.001), duration of surgery (457.5 ± 129.9 min v. 611.6 ± 197.8 min, p < 0.001), and platelet transfusions (8.1 ± 7.6 v. 12.8 ± 8.7 units, p = 0.021) than the supracoronary group. Long-term follow-up demonstrated a greater incidence of 2+ aortic regurgitation among patients in the supracoronary group than the root group (29.7% v. 0.0%, p = 0.006); however, there was no difference between the groups in symptoms or reoperation. CONCLUSION: In AADA, aortic root replacement involves a longer procedure with increased risk of early renal impairment. Long-term follow-up identified significantly more aortic regurgitation and root dilation in the supracoronary group than the root group, with a trend toward worse long-term survival. However, we found no difference between the groups in mortality, reoperation or New York Heart Association class.

CONTEXTE: L'approche chirurgicale à la dissection aigüe de l'aorte de type A (DAAA) dépend habituellement de la présentation anatomique. Nous avons comparé les résultats à long terme d'une DAAA réparée par remplacement de la racine de l'aorte c. greffon supracoronarien artificiel, indépendamment de la portée proximale de la déchirure de l'intima. MÉTHODES: Une cohorte rétrospective monocentrique de patients consécutifs soumis à une réparation de DAAA entre décembre 1999 et mars 2012 a été stratifiée en fonction de l'intervention chirurgicale proximale effectuée : greffon supracoronarien artificiel ou remplacement de la racine de l'aorte. Les épreuves d'imagerie, résumés de dossiers et suivis cliniques ont été analysés pour cerner la présentation anatomique et les résultats cliniques. RÉSULTATS: Nous avons inclus 75 patients dans notre analyse : 54 ont reçu un greffon supracoronarien artificiel et 21 ont subi un remplacement de la racine de l'aorte. Une déchirure proximale a été identifiée sous la jonction sinotubulaire chez tous les patients du groupe racine de l'aorte et chez 61 % des patients du groupe greffon supracoronarien. Nous n'avons décelé aucune différence entre les groupes pour ce qui est de la mortalité en milieu hospitalier, de la durée de l'hospitalisation ou des complications. Mais, le groupe racine de l'aorte a présenté des augmentations significatives du nombre de cas d'insuffisance rénale (0 % c. 9,5 %, p = 0,018), de la durée de la circulation extracorporelle (198,4 ± 80,0 min c. 316,5 ± 102,5 min, p < 0,001), du clampage de l'aorte (91,6 ± 34,9 min c. 191,3 ± 52,8 min, p < 0,001) et de la chirurgie (457,5 ± 129,9 min c. 611,6 ± 197,8 min, p < 0,001), ainsi que du nombre de transfusions plaquettaires (8,1 ± 7,6 unités c. 12,8 ± 8,7 unités, p = 0,021) comparativement au groupe greffon supracoronarien. Le suivi à long terme a fait état d'une incidence plus élevée de régurgitation aortique 2+ chez les patients du groupe greffon supracoronarien comparativement au groupe racine de l'aorte (29,7 % c. 0,0 %, p = 0,006); toutefois, on n'a noté aucune différence entre les groupes pour ce qui est des symptômes ou du taux de réopération. CONCLUSION: Dans la DAAA, le remplacement de la racine de l'aorte suppose une intervention de plus longue durée qui s'accompagne d'un risque accru d'insuffisance rénale précoce. Un suivi à long terme a révélé un nombre significativement plus élevé de cas de régurgitation aortique et de dilatation de la racine de l'aorte dans le groupe greffon supracoronarien que dans le groupe racine de l'aorte, avec une tendance moins favorable au plan de la survie à long terme. Toutefois, nous n'avons trouvé aucune différence entre les groupes pour ce qui est de la mortalité, du taux de réopération ou de la classe de la New York Heart Association.

Ross, Hybrid Arch, and Frozen Elephant Trunk Reconstruction for Late Complications of Bicuspid Aortic Valve and Aortopathy.

Young patients with bicuspid aortic valve disease and aortopathy remain a clinical challenge, with many requiring multiple corrective operations throughout their lifetimes. Innovative surgical approaches are often required to address complex aortic pathologic conditions but leave patients at risk for reintervention, lifelong anticoagulation, and suboptimal hemodynamics. We describe an active 44-year-old female triathlete with recurrent bicuspid aortic stenosis, a small aortic root, a hypoplastic aortic arch and complex distal arch, and a descending aortic aneurysm, who underwent a single-stage reconstruction with a combined Ross procedure, hybrid arch, and frozen elephant trunk reconstruction.

Evaluation of robotic cardiac surgery simulation training: A randomized controlled trial.

OBJECTIVE: To compare the currently available simulation training modalities used to teach robotic surgery. METHODS: Forty surgical trainees completed a standardized robotic 10-cm dissection of the internal thoracic artery and placed 3 sutures of a mitral valve annuloplasty in porcine models and were then randomized to a wet lab, a dry lab, a virtual reality lab, or a control group that received no additional training. All groups trained to a level of proficiency determined by 2 expert robotic cardiac surgeons. All assessments were evaluated using the Global Evaluative Assessment of Robotic Skills in a blinded fashion. RESULTS: Wet lab trainees showed the greatest improvement in time-based scoring and the objective scoring tool compared with the experts (mean, 24.9 ± 1.7 vs 24.9 ± 2.6; P = .704). The virtual reality lab improved their scores and met the level of proficiency set by our experts for all primary outcomes (mean, 24.9 ± 1.7 vs 22.8 ± 3.7; P = .103). Only the control group trainees were not able to meet the expert level of proficiency for both time-based scores and the objective scoring tool (mean, 24.9 ± 1.7 vs 11.0 ± 4.5; P < .001). The average duration of training was shortest for the dry lab and longest for the virtual reality simulation (1.6 hours vs 9.3 hours; P < .001). CONCLUSIONS: We have completed the first randomized controlled trial to objectively compare the different training modalities of robotic surgery. Our data demonstrate the significant benefits of wet lab and virtual reality robotic simulation training and highlight key differences in current training methods. This study can help guide training programs in investing resources in cost-effective, high-yield simulation exercises.

Higher-risk mitral valve operations after previous sternotomy: endoscopic, minimally invasive approach improves patient outcomes.

BACKGROUND: Reoperative mitral valve (MV) surgery is associated with significant morbidity and mortality; however, endoscopic minimally invasive surgical techniques may preserve the surgical benefits of conventional mitral operations while potentially reducing perioperative risk and length of stay (LOS) in hospital. METHODS: We compared the outcomes of consecutive patients who underwent reoperative MV surgery between 2000 and 2014 using a minimally invasive endoscopic approach (MINI) with those of patients who underwent a conventional sternotomy (STERN). The primary outcome was in-hospital/30-day mortality. Secondary outcomes included blood product transfusion, LOS in hospital and in the intensive care unit (ICU), and postoperative complications. RESULTS: We included 132 patients in our study: 40 (mean age 68 ± 14 yr, 70% men) underwent MINI and 92 (62 ± 13 yr, 40% men) underwent STERN. The MINI group had significantly more comorbidities than the STERN group. While there were no significant differences in complications, all point estimates suggested lower mortality and morbidity in the MINI than the STERN group (in-hospital/ 30-day mortality 5% v. 11%, p = 0.35; composite any of 10 complications 28% v. 41%, p = 0.13). Individual complication rates were similar between the MINI and STERN groups, except for intra-aortic balloon pump requirement (IABP; 0% v. 12%, p = 0.034). MINI significantly reduced the need for any blood transfusion (68% v. 84%, p = 0.036) or packed red blood cells (63% v. 79%, p = 0.042), fresh frozen plasma (35% v. 59%, p = 0.012) and platelets (20% v. 40%, p = 0.024). It also significantly reduced median hospital LOS (8 v. 12 d, p = 0.014). An exploratory propensity score analysis similarly demonstrated a significantly reduced need for IABP (p < 0.001) and a shorter mean LOS in the ICU (p = 0.046) and in hospital (p = 0.047) in the MINI group. CONCLUSION: A MINI approach for reoperative MV surgery reduces blood product utilization and hospital LOS. Possible clinically relevant differences in perioperative complications require assessment in randomized clinical trials.

CONTEXTE: Les réopérations de la valve mitrale (VM) sont associées à une morbidité et à une mortalité importantes. Cependant, il semblerait que les techniques chirurgicales endoscopiques à effraction minimale préservent les avantages des opérations traditionnelles de la VM tout en réduisant potentiellement les risques périopératoires et la durée d'hospitalisation. MÉTHODES: Nous avons comparé les résultats de patients consécutifs ayant subi une réopération de la VM entre 2000 et 2014 selon une approche endoscopique à effraction minimale (groupe MINI) à ceux de patients ayant subi une sternotomie classique (groupe STERN). Le résultat primaire à l'étude était la mortalité intrahospitalière ou dans les 30 premiers jours, et les résultats secondaires, la transfusion de produits sanguins, la durée du séjour à l'hôpital et à l'unité des soins intensifs (USI), ainsi que les complications postopératoires. RÉSULTATS: Nous avons retenu 132 patients : 40 (âge moyen de 68 ± 14 ans, 70 % d'hommes) dans le groupe MINI et 92 (âge moyen de 62 ± 13 ans, 40 % d'hommes) dans le groupe STERN. Les patients du groupe MINI présentaient un nombre significativement plus élevé de comorbidités que ceux du groupe STERN. Aucune différence significative n'a été observée quant aux complications, mais toutes les estimations ponctuelles pointaient vers une mortalité et une morbidité moindres dans le groupe MINI (mortalité intrahospitalière ou dans les 30 premiers jours : 5 % c. 11 %, p = 0,35; morbidité combinée à la présence d'au moins une complication parmi 10 possibles : 28 % c. 41 %, p = 0,13). Les taux de complications individuels étaient semblables chez les patients des 2 groupes, sauf pour l'exigence de ballon de contrepulsion intra-aortique (BCIA; 0 % c. 12 %, p = 0,034). L'approche MINI a réduit significativement le taux de transfusion de sang (68 % c. 84 %, p = 0,036) ou de concentrés de globules rouges (63 % c. 79 %, p = 0,042), de plasma frais congelé (35 % c. 59 %, p = 0,012) et de plaquettes (20 % c. 40 %, p = 0,024), en plus de diminuer significativement la durée médiane d'hospitalisation (8 jours c. 12 jours, p = 0,014). En outre, une analyse exploratoire du score de propension a révélé une réduction significative du BCIA (p < 0,001) ainsi qu'une durée moyenne de séjour à l'USI (p = 0,046) et à l'hôpital (p = 0,047) plus courte dans le groupe MINI. CONCLUSION: Le recours à l'approche endoscopique à effraction minimale pour les réopérations de la VM diminuerait le recours aux produits sanguins et la durée d'hospitalisation. En ce qui a trait aux complications périopératoires, il faudra procéder à des essais cliniques aléatoires pour évaluer les différences possiblement pertinentes sur le plan clinique.

Validation of a Novel Virtual Reality Training Curriculum for Robotic Cardiac Surgery: A Randomized Trial.

OBJECTIVE: Robotic cardiac surgery training has relied entirely on classical methods of surgical teaching. We sought to evaluate the impact of a virtual reality (VR) simulation curriculum to improve skill acquisition in robotic cardiac surgery. METHODS: We randomly assigned 20 surgical trainees to undergo a 9-exercise VR curriculum on a robotic surgical simulator or a control group that received no additional training. The trainees were then evaluated in a blinded fashion by assessing their de-identified video recordings of the following: (1) standardized robotic internal thoracic artery harvest and (2) mitral valve annuloplasty performed in porcine models, using a validated time-based scoring system and an objective intraoperative scoring tool. Postintervention assessments were compared to baseline. RESULTS: Trainees randomized to the VR group were faster than the control group for both the internal thoracic artery harvest (957.3 ± 98.9 vs. 749.1 ± 171.9; P = 0.004) and mitral annuloplasty (580.4 ± 14.4 vs. 463.8 ± 86.4; P < 0.001) and scored significantly higher with the intraoperative scoring tool (22.8 ± 2.7 vs. 11.0 ± 4.5; P < 0.001). Additionally, the VR group achieved a proficiency level similar to our experts for both time-based scores (P = 0.624 and P = 0.967), and the intraoperative assessment (P = 0.110), whereas the control group was not able to meet this level of proficiency for any of the primary outcomes. The average duration of training to successfully complete all required tasks was 9.3 hours. CONCLUSIONS: We have demonstrated that a VR simulation curriculum can significantly improve the efficiency and quality of learning in robotic cardiac surgery. Further evaluation of this curriculum is required for its widespread implementation in surgical training (ClinicalTrials.gov, NCT#02357056).

Invasive Methicillin-Resistant Staphylococcus Aureus Endocarditis Resulting in Right Ventricular Pseudoaneurysm and Fistulation to Previous Bypass Graft.

We describe the case of a 73-year-old man with methicillin-resistant Staphyloccocus aureus (MRSA) endocarditis, which developed into a right ventricular pseudoaneurysm that fistulated into a previous saphenous vein graft to his distal right coronary artery (RCA). The patient was taken for a redo sternotomy, surgical evacuation of the abscess, bovine pericardial patch reconstruction of the right ventricular free wall, and tricuspid valve repair. Despite our best efforts and a repair that appeared sufficient at the time of operation, the patient died of ischemic colitis on postoperative day 5. This case report highlights some of the surgical considerations for such a rare and lethal condition.

Extracorporeal membrane oxygenation in the acute treatment of cardiovascular collapse immediately post-partum.

We describe the use of extracorporeal membrane oxygenation (ECMO) in a 30-year old woman at 37 weeks' gestation, following cardiac arrest from pulmonary embolism immediately post-partum from an emergent Caesarean section. In this case, ECMO was initiated though modified techniques with only the equipment available in a delivery room as a last resort to save a new mother after a significant downtime of 83 min. The patient received tissue plasminogen activator during the resuscitation resulting in significant blood loss. However, the patient was stabilized on ECMO and after 5 weeks in the intensive care unit achieved complete physical and neurologic recovery. To our knowledge, this is the first reported case where ECMO has been used in a resuscitation from massive pulmonary embolism immediately post-partum, after thombolytics were administered. Here, we discuss our strategies for emergent cannulation in a suboptimal environment, management of profound bleeding and oxygenation strategies in this hostile setting. Given the potential for success and the significant life-years gained, aggressive measures, such as ECMO, should be considered in such extreme life-threatening cases.