Assessment of continuous low-dose and high-dose burst of inhaled nitric oxide in spontaneously breathing COVID-19 patients: A randomized controlled trial.

BACKGROUND: Inhaled nitric oxide (iNO) showed to improve oxygenation at low doses by reducing intrapulmonary shunt and to display antiviral properties at high doses. To assess the safety and potential benefits, we designed an exploratory clinical trial comparing low-dose with intermittent high-dose iNO to only intermittent high-dose iNO in hypoxemic COVID-19 patients. METHODS: In this single-center interventional non-inferiority randomized trial (ClinicalTrials.gov, NCT04476992), twenty oxygen-dependent COVID-19 patients were randomly assigned to the high-dose (200 ppm for 30 min) + continuous low-dose (20 ppm) iNO group (iNO200/20) or the high-dose iNO group (iNO200). Methemoglobinemia (MetHb) assessed 48 h after iNO initiation was the primary endpoint. Reverse-transcription polymerase chain reaction for SARS-CoV-2, inflammatory markers during hospitalization, and heart ultrasounds during the iNO200 treatments were evaluated. RESULTS: MetHb difference between iNO groups remained within the non-inferiority limit of 3 %, indicating comparable treatments despite being statistically different (p-value<0.01). Both groups presented similar SpO2/FiO2 ratio at 48 h (iNO200 vs. iNO200/20 341[334-356] vs. 359 [331-380], respectively, p-value = 0.436). Both groups showed the same time to SARS-CoV-2 negativization, hospital length of stay, and recovery time. iNO-treated patients showed quicker SARS-CoV-2 negativization compared to a similar group of non-iNO patients (HR 2.57, 95%CI 1.04-6.33). During the 228 treatments, iNO200 and iNO200/20 groups were comparable for safety, hemodynamic stability, and respiratory function improvement. CONCLUSIONS: iNO200/20 and iNO200 are equally safe in non-intubated patients with COVID-19-induced respiratory failure with regards to MetHb and NO2. Larger studies should investigate whether iNO200/20 leads to better outcomes compared to non-iNO treated patients.

Identification of Variants of Uncertain Significance in the Genes Associated with Thoracic Aortic Disease in Russian Patients with Nonsyndromic Sporadic Subtypes of the Disorder.

Nonsyndromic sporadic thoracic aortic aneurysm (nssTAA) is characterized by diverse genetic variants that may vary in different populations. Our aim was to identify clinically relevant variants in genes implicated in hereditary aneurysms in Russian patients with nssTAA. Forty-one patients with nssTAA without dissection were analyzed. Using massive parallel sequencing, we searched for variants in exons of 53 known disease-causing genes. Patients were found to have no (likely) pathogenic variants in the genes of hereditary TAA. Six variants of uncertain significance (VUSs) were identified in four (9.8%) patients. Three VUSs [FBN1 c.7841C>T (p.Ala2614Val), COL3A1 c.2498A>T (p.Lys833Ile), and MYH11 c.4993C>T (p.Arg1665Cys)] are located in genes with "definitive" disease association (ClinGen). The remaining variants are in "potentially diagnostic" genes or genes with experimental evidence of disease association [NOTCH1 c.964G>A (p.Val322Met), COL4A5 c.953C>G (p.Pro318Arg), and PLOD3 c.833G>A (p.Gly278Asp)]. Russian patients with nssTAA without dissection examined in this study have ≥1 VUSs in six known genes of hereditary TAA (FBN1, COL3A1, MYH11, NOTCH1, COL4A5, or PLOD3). Experimental studies expanded genetic testing, and clinical examination of patients and first/second-degree relatives may shift VUSs to the pathogenic (benign) category or to a new class of rare "predisposing" low-penetrance variants causing the pathology if combined with other risk factors.

Effect of Implantation of a new Domestic Prosthesis in the Aortic Position on the Quality of Life of Patients With Degenerative Aortic Stenose, Survival Assessment and Development of Complications 1 Year Post-Surgery.

Aim      To evaluate quality of life (QoL), general survival, and development of complications in patents one year after surgical aortic valve (AV) replacement with a MedInzh-BIO xenopericardial carcass prosthesis.Material and methods  Degenerative AV disease is one of the most common cardiovascular diseases that gives place only to ischemic heart disease. Surgical correction of the AV defect should be aimed not only at hemodynamic outcomes but also at improvement of QoL. This study included 91 patients (48 women and 43 men), who were implanted with a MedInzh-BIO biological xenopericardial prosthesis in aortic position from January 2017 through March 2020. Mean age of patients was 69.96±4.4 years. QoL was evaluated with a standard SF-36 questionnaire. Also, survival and complications were analyzed one year after surgery.Results Data analysis before and one year after surgery showed a significant improvement of QoL. Postoperative one-year survival was 95.4 %, and major valve-associated complications were absent in 94.5% of cases. During one year, four patients died after 1, 6, 8, and 10 months of follow-up, respectively.Conclusion      The improvement of QoL following the AV replacement with a novel xenopericardial carcass prosthesis with the "easy change" system indicates the clinical and functional effectiveness of the used method. The results of the study demonstrated improvements of both the physical health component and the subjective emotional assessment. Postoperative one-year survival was 95.4 %, and major valve-associated complications were absent in 94.5% of cases.

Effect of inhaled nitric oxide on intestinal integrity in cardiopulmonary bypass and circulatory arrest simulation: An experimental study.

Background and Aims: Cardiopulmonary bypass (CPB) and circulatory arrest (CA) can induce intestinal injury and consequently lead to multiple organ dysfunction. Nitric oxide (NO) has protective effects, but its effect on the intestine has not been studied. The study aimed to investigate intestinal injury variables and prove the intestinal protective effects of exogenous nitric oxide when modelling CPB and CA in an experiment. Methods: The study was performed on sheep (n = 24). There were four groups: CPB, CPB + NO, CPB + CA and CPB + CA + NO. Sheep in NO groups received intraoperative inhalation of NO at a dose of 80 ppm. Groups without NO underwent CPB and CA without NO delivery. Defaecation rate, dynamics of intestinal fatty acid binding protein (i-FABP), coefficient of microviscosity and polarity in the areas of lipid-lipid and protein-lipid interactions of erythrocyte membranes were assessed. One hour after CPB, the intestinal tissue was collected and assessed for tissue concentrations of adenosine triphosphate (ATP) and lactate. Results: The defaecation rate after CPB was higher in the CPB + NO group than in the CPB group. The concentration of i-FABP after CPB was lower in the CPB + NO and CPB + CA + NO groups than in the CPB and CPB + CA groups. Erythrocyte deformability before and after CPB revealed no significant dynamics in groups with NO. The ATP concentration 1 h after CPB was higher in the CPB + NO group than in the CPB group. The morphological picture in groups with NO was better. Conclusion: When modelling CPB and CA, NO had a positive effect on the functional and structural state of the intestine and also maintained erythrocyte deformability.

Insights into ascending aortic aneurysm: Interactions between biomechanical properties of the aortic wall and tissue biomarkers.

Background: It remains difficult to understand the association between the local mechanical properties of ascending thoracic aorta aneurysm (asTAA), its tissue, and its cellular and molecular changes. The purpose of our study was to investigate the relationship between biomechanical properties, histopathological findings, and tissue biomarkers of asTAA. Methods: Intraoperative asTAA samples from 30 patients were studied. All samples were examined histologically and underwent a tensile test. We determined the tensile strength (σв, MPa), the strain (ε, mm/mm˟%), and the area under the strength-strain curve (S) along with the concentrations of tissue matrix metalloproteinases (MMP-1 et al.) and their inhibitors, their interleukins (IL) -6 -10, and their tumor necrosis factor (TNF) -α. Results: It was found that 43.3 % of asTAA patients had atherosclerosis, 3.3 % had aortitis, and 53.3 % of patients had connective tissue dysplasia. Differences in the studied parameters between these subgroups were not found. Age correlated with ε (r = -0.49) and S (r = -0.54). ε was also associated with media fibrosis degree (r = -0.5), collagen/elastin ratio (r = -0.61), and IL-10 (r = 0.52). IL-10 correlated with collagen/elastin ratio (r = -0.58), TNF-α (r = 0.77), and MMP-1 (r = 0.71). Conclusion: Tissue IL-10 has a protective effect on the elastic structures of the aortic wall and is positively associated with the activity of MMP-1 and pro-inflammatory cytokines. IL-6 is associated with media fibrosis degree, and negatively affects strength-strain parameters of asTAA samples.

The Nephroprotective Effect of Nitric Oxide during Extracorporeal Circulation: An Experimental Study.

This study aims to determine the effectiveness of administering 80 ppm nitric oxide in reducing kidney injury, mitochondrial dysfunction and regulated cell death in kidneys during experimental perfusion. Twenty-four sheep were randomized into four groups: two groups received 80 ppm NO conditioning with 90 min of cardiopulmonary bypass (CPB + NO) or 90 min of CPB and hypothermic circulatory arrest (CPB + CA + NO), while two groups received sham protocols (CPB and CPB + CA). Kidney injury was assessed using laboratory (neutrophil gelatinase-associated lipocalin, an acute kidney injury biomarker) and morphological methods (morphometric histological changes in kidney biopsy specimens). A kidney biopsy was performed 60 min after weaning from mechanical perfusion. NO did not increase the concentrations of inhaled NO2 and methemoglobin significantly. The NO-conditioning groups showed less severe kidney injury and mitochondrial dysfunction, with statistical significance in the CPB + NO group and reduced tumor necrosis factor-α expression as a trigger of apoptosis and necroptosis in renal tissue in the CPB + CA + NO group compared to the CPB + CA group. The severity of mitochondrial dysfunction in renal tissue was insignificantly lower in the NO-conditioning groups. We conclude that NO administration is safe and effective at reducing kidney injury, mitochondrial dysfunction and regulated cell death in kidneys during experimental CPB.

Potential Mechanisms for Organoprotective Effects of Exogenous Nitric Oxide in an Experimental Study.

Performing cardiac surgery under cardiopulmonary bypass (CPB) and circulatory arrest (CA) provokes the development of complications caused by tissue metabolism, microcirculatory disorders, and endogenous nitric oxide (NO) deficiency. This study aimed to investigate the potential mechanisms for systemic organoprotective effects of exogenous NO during CPB and CA based on the assessment of dynamic changes in glycocalyx degradation markers, deformation properties of erythrocytes, and tissue metabolism in the experiment. A single-center prospective randomized controlled study was conducted on sheep, n = 24, comprising four groups of six in each. In two groups, NO was delivered at a dose of 80 ppm during CPB ("CPB + NO" group) or CPB and CA ("CPB + CA + NO"). In the "CPB" and "CPB + CA" groups, NO supply was not carried out. NO therapy prevented the deterioration of erythrocyte deformability. It was associated with improved tissue metabolism, lower lactate levels, and higher ATP levels in myocardial and lung tissues. The degree of glycocalyx degradation and endothelial dysfunction, assessed by the concentration of heparan sulfate proteoglycan and asymmetric dimethylarginine, did not change when exogenous NO was supplied. Intraoperative delivery of NO provides systemic organoprotection, which results in reducing the damaging effects of CPB on erythrocyte deformability and maintaining normal functioning of tissue metabolism.

Frozen Elephant Trunk Technique to Treat Extensive Thoracic Aortic Mural Thrombus.

We describe a case report of a 63-year-old man who presented with chronic left-hand weakness and the absence of a pulse in the left arm. Thoracoabdominal computed tomography (CT) revealed an extensive thoracic aortic mural thrombus. Initial anticoagulation therapy did not provide a positive result, so the patient was referred for surgery. Hybrid aortic arch surgery using the frozen elephant trunk technique was performed with excellent early outcomes. A CT performed in the early postoperative period showed that the thrombus was completely excluded from the aortic lumen by the hybrid graft. No thrombus dislodgment was detected. No thrombus recurrence was observed during 19 months of follow-up.

False lumen thrombosis after frozen elephant trunk procedure in acute and chronic aortic dissection.

BACKGROUND: The clinical significance of the false lumen (FL) thrombosis after the thoracic aortic surgery consists in the correlation with aortic remodeling. The aim of the study was to analyze the incidence of the FL thrombosis of the thoracoabdominal aorta after the frozen elephant trunk (FET) procedure in acute and chronic aortic dissection. METHODS: A total of 57 consecutive patients with type A and B aortic dissection (AD) underwent the FET procedure between March 2012 and December 2020 were included in a retrospective study. All of the patients were divided in two groups: acute (N.=18) and chronic (N.=39) AD. Early and 2-year outcomes were evaluated in both groups. Computed tomography scans were obtained along the entire aorta for the aortic status assessment. RESULTS: There were no statistically significant differences in early mortality and postoperative outcomes in both groups. The 2-year survival rate in acute and chronic AD was 74.7±10% vs. 71.4±7% (P=0.573), respectively. In the follow-up, the FL thrombosis rate, changes of the true lumen and total aortic diameters did not differ significantly between the analyzed groups of patients. The freedom from negative aortic remodeling was 62.2±26% in acute AD versus 76.2±11% in chronic AD (P=0.853). One (5.6%) and 4 (10.3%) distal aortic reinterventions were performed in acute and chronic AD, respectively. CONCLUSIONS: False lumen thrombosis rate after the FET procedure did not differ significantly in acute and chronic AD.

Nitric oxide delivery during cardiopulmonary bypass reduces acute kidney injury: A randomized trial.

OBJECTIVE: Acute kidney injury (AKI) is a serious complication of cardiac surgery with cardiopulmonary bypass (CPB). The aim of this study was to evaluate the effects of nitric oxide (NO) supplementation to the CPB circuit on the development of cardiac surgery-associated AKI. METHODS: This prospective randomized controlled study included 96 patients with moderate risk of renal complications who underwent elective cardiac surgery with CPB. The study protocol was registered at ClinicalTrials.gov (identifier NCT03527381). Patients were randomly allocated to either NO supplementation to the CPB bypass circuit (NO treatment group; n = 48) or usual care (control group; n = 48). In the NO treatment group, 40-ppm NO was administered during the entire CPB period. The primary outcome was the incidence of AKI. RESULTS: NO treatment was associated with a significant decrease in AKI incidence (10 cases [20.8%] vs 20 cases [41.6%] in the control group; relative risk, 0.5; 95% confidence interval, 0.26-0.95; P = .023) and a higher median urine output during CPB (2.6 mL/kg/h [interquartile range (IQR), 2.1-5.08 mL/kg/h] vs 1.7 mL/kg/h [IQR, 0.80-2.50 mL/kg/h]; P = .0002). The median urinary neutrophil gelatinase-associated lipocalin level at 4 hours after surgery was significantly lower in the NO treatment group (1.12 ng/mL [IQR, 0.75-5.8 ng/mL] vs 4.62 ng/mL [IQR, 2.02-34.55 ng/mL]; P = .005). In the NO treatment group, concentrations of NO metabolites were significantly increased at 5 minutes postclamping, at 5 minutes after declamping, and at the end of the operation. Concentrations of proinflammatory and anti-inflammatory mediators and free plasma hemoglobin did not differ significantly between the 2 groups. CONCLUSIONS: NO administration in patients at moderate risk of renal complications undergoing elective cardiac surgery with CPB was associated with a lower incidence of AKI.

Existing and Emerging Approaches to Risk Assessment in Patients with Ascending Thoracic Aortic Dilatation.

Ascending thoracic aortic aneurysm is a life-threatening disease, which is difficult to detect prior to the occurrence of a catastrophe. Epidemiology patterns of ascending thoracic aortic dilations/aneurysms remain understudied, whereas the risk assessment of it may be improved. The electronic databases PubMed/Medline 1966-2022, Web of Science 1975-2022, Scopus 1975-2022, and RSCI 1994-2022 were searched. The current guidelines recommend a purely aortic diameter-based assessment of the thoracic aortic aneurysm risk, but over 80% of the ascending aorta dissections occur at a size that is lower than the recommended threshold of 55 mm. Moreover, a 55 mm diameter criterion could exclude a vast majority (up to 99%) of the patients from preventive surgery. The authors review several visualization-based and alternative approaches which are proposed to better predict the risk of dissection in patients with borderline dilated thoracic aorta. The imaging-based assessments of the biomechanical aortic properties, the Young's elastic modulus, the Windkessel function, compliance, distensibility, wall shear stress, pulse wave velocity, and some other parameters have been proposed to improve the risk assessment in patients with ascending thoracic aortic aneurysm. While the authors do not argue for shifting the diameter threshold to the left, they emphasize the need for more personalized solutions that integrate the imaging data with the patient's genotypes and phenotypes in this heterogeneous pathology.

Frozen elephant trunk technique with different proximal landing zone for aortic dissection.

OBJECTIVES: The objective of the study was to evaluate early and midterm outcomes after the frozen elephant trunk (FET) procedure with different proximal landing zones in patients with aortic dissection. METHODS: Forty-four patients with type A and type B aortic dissection that extended down to the abdominal aorta were enrolled in the study. All of the patients had the FET procedure. The patients were divided in 2 groups according to the level of the proximal landing zone: the zone 2 (Z2) group and zone 3 (Z3) group. Early and midterm outcomes including the false lumen (FL) thrombosis rate were monitored in both groups. RESULTS: The incidence of stroke, delirium and spinal cord ischaemia was 5.9% vs 3.7% (P = 0.533), 5.9% vs 7.4% (P = 0.903) and 5.9% vs 0 (P = 0.533) in the Z2 and Z3 groups, respectively. The 30-day mortality was 9.1% in both groups. The mean distal landing zone was T7.5 (T7; T9) in the Z2 group vs T9 (T8; T10) in the Z3 group (P = 0.668). The 2-year overall survival was 62.2% with no significant difference in the Z2 and Z3 groups (61.6% vs 64.2%; P = 0.940). There were no aortic-related deaths during the follow-up period. Freedom from reintervention at 24 months was 73% and was comparable between Z2 and Z3 (74.1% vs 91.7%; P = 0.123). The rate of early complete FL thrombosis was comparable in the Z2 and Z3 groups. By 24 months of observation in the Z3 group, the rate of complete FL thrombosis was significantly higher (60% vs 77%; P = 0.046). CONCLUSIONS: No statistically significant differences were observed between landing zones 2 and 3 during the FET procedure with regard to early outcomes. Proximalization of the FET was associated with a shorter FL thrombosis in the midterm follow-up period that affected the distal aortic reintervention rate.

Results of reconstructive interventions in patients with ischemic cardiomyopathy.

BACKGROUND: Effective treatment of patients with ischemic cardiomyopathy is one of the most difficult issues in contemporary cardiac surgery. The aim of this study was to evaluate the long-term effectiveness of reconstructive interventions on the left ventricle during chronic heart failure in patients with ischemic cardiomyopathy. METHODS: Between March 2013 and December 2017, 178 patients underwent surgical treatment for ischemic cardiomyopathy. Isolated coronary artery bypass grafting was compared with coronary artery bypass grafting with left ventricular reconstruction, using propensity score matching analysis. The primary endpoints of the study were hospital mortality and long-term survival. RESULTS: After propensity score matching, 29 pairs of patients were compared. The 30-day hospital mortality was comparable (6.8% versus 6.8%, p = 0.952), the average follow-up was 37.4 ± 12.6 months, with no statistically significant difference in mortality from all causes (p = 0.352). After coronary artery bypass in combination with left ventricular reconstruction, patients showed a statistically significant decrease in clinical and functional indicators of chronic heart failure compared to those who had coronary artery bypass grafting alone, in terms of peak oxygen consumption (15.3 versus 13.5 mL·kg-1·min-1, p = 0.043) and N-terminal pro-brain natriuretic peptide concentrations (298.6 versus 461.1 pg·mL-1, p = 0.032). CONCLUSIONS: Compared to isolated coronary artery bypass, coronary artery bypass in combination with left ventricular reconstruction for the treatment of ischemic cardiomyopathy leads to a significant decrease in the clinical and functional parameters of chronic heart failure in the long-term postoperative period.

Human exome sequence data in support of somatic mosaicism in carotid atherosclerosis.

Understanding the mechanisms underlying the connection between somatic mosaicism and cardiovascular disease is likely essential for the future of personalized medicine. This article is aimed at providing data on somatic mosaicism in human carotid atherosclerosis. An advanced carotid atherosclerotic plaque and white blood cells were collected simultaneously from each patient (eight Slavic males, aged 67 ± 3.8 years [mean ± SD]) to assess the spectrum of germline and somatic genetic variants. Exome sequencing of DNA from the samples was performed with the SureSelect Clinical Research Exome Enrichment Kit (Agilent Technologies) and HiSeq 1500 (Illumina). The dataset contains germline and somatic single-nucleotide variants and small indels identified in the advanced carotid atherosclerotic plaque and white blood cells of each patient. This dataset does not include copy number variants owing to a lack of suitable tools for reliable calculation of copy numbers from exome sequencing data on cancer-unrelated samples. The dataset should help to understand somatic mosaicism in cardiovascular diseases and to identify copy number variants by means of more appropriate newer tools in the future.

Cardiovascular abnormalities in patient with Williams-Beuren syndrome.

We present a case of a 42-year-old male patient with severe supravalvular aortic stenosis associated with aortic and mitral valve stenosis as well as an anomalous origin of the right coronary ostium caused by deletion in the q11.23 region of the human chromosome 7 in a patient with Williams-Beuren syndrome.

Distal aortic remodelling after the standard and the elongated frozen elephant trunk procedure.

OBJECTIVES: The aim of this study was to evaluate abdominal aortic remodelling after the standard compared with the elongated frozen elephant trunk (FET) technique in patients with aortic dissection. METHODS: Twenty-six patients underwent surgery and were randomized into 2 groups. Fifteen patients were treated with the standard FET technique. Eleven patients were treated with the advanced FET technique using an additional thoracic stent graft implanted down to the coeliac artery, within 30 days after the first stent graft implantation. Preoperative and postoperative and 5-year follow-up computed tomography aortic scans were obtained along the stent graft (A), between the distal edge of the graft and the coeliac trunk (B) and at the abdominal aorta (C). RESULTS: In the standard FET group, positive and stable aortic remodelling occurred in segments A (100%), B (87%) and C (87%). Negative remodelling was found in 2/15 (13%) patients; 1 patient had an endovascular reintervention. In the elongated FET group, positive and stable remodelling were observed in segments A (100%), B (100%) and C (90.9%). Negative remodelling occurred in 1/11 (9.1%) patients. No reintervention was required. Cumulative survival, freedom from negative remodelling and distal aortic reintervention in the standard FET group and the elongated FET group were 72 vs 100% (P = 0.29); 67.5 vs 80% (P = 0.58) and 75 vs 100% (P = 0.61), respectively. CONCLUSIONS: The standard FET technique is an adequate measure to induce false lumen thrombosis and improve abdominal aortic remodelling. The elongated FET technique seems to be superior to the standard FET procedure in terms of freedom from aortic remodelling and the distal reintervention rate.

Nitric oxide provides myocardial protection when added to the cardiopulmonary bypass circuit during cardiac surgery: Randomized trial.

OBJECTIVES: The aim of this pilot study was to elucidate the effects of exogenous nitric oxide (NO) supply to the extracorporeal circulation circuit for cardioprotection against ischemia-reperfusion injury during coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). METHODS: A total of 60 patients with coronary artery disease scheduled for CABG with CPB were enrolled in a prospective randomized study. Patients were allocated randomly to receive treatment according to standard or modified CPB protocol where 40-ppm NO was added to the CPB circuit during cardiac surgery. The primary endpoint was the measurement of cardiac troponin I (cTnI). The secondary end points consisted in the measurements of creatine kinase-muscle/brain fraction (CK-MB) and vasoactive inotropic score (VIS). RESULTS: NO delivered into the CPB circuit had a cardioprotective effect. The level of cTnI was significantly lower in NO-treated group compared with the control group 6 hours after surgery: 1.79 ± 0.39 ng/mL versus 2.41 ± 0.55 ng/mL, respectively (P = .001). The CK-MB value was significantly lower in NO-treated group compared with the control group 24 hours after surgery: 47.69 ± 8.08 U/L versus 62.25 ± 9.78 U/L, respectively (P = .001); and the VIS was significantly lower in the NO-treated group 6 hours after the intervention. CONCLUSIONS: NO supply to the CPB circuit during CABG exerted a cardioprotective effect and was associated with lower levels of VIS and cardiospecific blood markers cTnI and CK-MB.

The risk of spinal cord injury during the frozen elephant trunk procedure in acute aortic dissection.

OBJECTIVES: The aim of the study was to access the extended occlusion of the intercostal arteries by a stent graft in the development of postoperative spinal cord injury during aortic arch surgery using the frozen elephant trunk technique. METHODS: A total of 37 consecutive patients underwent total aortic arch surgery using the frozen elephant trunk technique between March 2012 and July 2017. The mean age of the patients was 54.7 ± 10.5 years. Type A and Type B aortic dissections were the indications for surgery. Moderate hypothermia and antegrade cerebral perfusion via the innominate artery were utilized. The mean diameter of the implanted stent graft was 27.7 ± 2 mm (range 24-30 mm). RESULTS: No permanent spinal cord injuries occurred. The distal edge of the stent graft was in the T7-T12 range. Its lower edge was implanted at the T9-T12 level in 25 (67.6%) cases. Preoperatively, the mean number of intercostal arteries was 10 ± 1 on the left side and 10 ± 2 on the right side (P = 0.59). Postoperatively, the mean number of open segmental arteries was 3 ± 2 on the left and 4 ± 1 on the right (P = 0.003). CONCLUSIONS: The frozen elephant trunk procedure is associated with the occlusion of most (two-thirds) of the intercostal arteries. Maintenance of adequate blood flow in the subclavian and iliac arteries is an integral prerequisite for a favourable outcome. The level of the deployment of the distal edge of the stent graft does not play a defining role.

Hybrid treatment of aortic dissection associated with Kommerell's diverticulum.

This clinical case demonstrates a successful simultaneous approach for Type B aortic dissection in association with Kommerell's diverticulum using an E-vita OPEN PLUS Hybrid prosthesis. Computed tomography in the early postoperative period and after a 6-month follow-up showed favourable surgical outcomes.