Antegrade cerebral perfusion via the right subclavian artery during open distal arch or proximal descending aortic repair from left thoracotomy.

In the current endovascular era, open surgery through left posterolateral thoracotomy with moderate to deep hypothermic circulatory arrest remains an alternative for treating chronic distal arch or proximal descending aortic diseases, allowing cardiovascular surgeons to definitively repair the aorta in a single stage. When utilizing this approach, this report illustrates an alternative surgical technique for antegrade body perfusion during cooling, antegrade selective cerebral perfusion and rewarming, through a prosthetic graft on the right subclavian artery. This report shows the safety and feasibility of this technique during open distal arch and/or proximal descending aortic surgery through left posterolateral thoracotomy, after shifting the patient from a supine to the right lateral decubitus position.

Lithotripsy of Calcified Aortic Valve Leaflets by a Novel Ultrasound Transcatheter-Based Device.

The increasing incidence of calcific aortic valve disease necessitates the elaboration of new strategies to retard the progression of the pathology with an innovative solution. While the increasing diffusion of the transcatheter aortic valve replacements (TAVRs) allows a mini-invasive approach to aortic valve substitution as an alternative to conventional surgical replacement (SAVR) in an always larger patient population, TAVR implantation still has contraindications for young patients. In addition, it is liable to undergo calcification with the consequent necessity of re-intervention with conventional valve surgery or repeated implantation in the so-called TAVR-in-TAVR procedure. Inspired by applications for non-cardiac pathologies or for vascular decalcification before stenting (i.e., coronary lithotripsy), in the present study, we show the feasibility of human valve treatment with a mini-invasive device tailored to deliver shockwaves to the calcific leaflets. We provide evidence of efficient calcium deposit ruptures in human calcified leaflets treated ex vivo and the safety of the treatment in pigs. The use of this device could be helpful to perform shockwaves valvuloplasty as an option to retard TAVR/SAVR, or as a pretreatment to facilitate prosthesis implantation and minimize the occurrence of paravalvular leak.

Commissural repositioning in bicuspid aortic valve repair: an in vitro acute model to explore and explain different results.

OBJECTIVES: Commissural orientation <160° is a recognized risk factor for bicuspid aortic valve repair failure. Based on this observation, repairing this subtype of aortic valve by reorienting the 2 commissures at 180° has recently been proposed. METHODS: Nine porcine hearts with aortic annulus diameters of 25 mm were selected. A pathological model of a Sievers 1 bicuspid aortic valve was obtained by suturing the coaptation line between the left and right leaflets. Each heart underwent reimplantation procedures both in the native (120°) and the reoriented (180°) configuration. After the operation, each sample was tested on a pulse duplicator at rest (heart rate 60 beats per min) and with mild exercise (heart rate 90 beats per min) conditions. RESULTS: No statistically significant difference was noted in mean and peak transvalvular aortic gradients between the 2 configurations at rest (18.6 ± 5 vs 17.5 ± 4 for the mean aortic gradient; 42.8 ± 12.7 vs 36.3 ± 5.8 for the peak aortic gradient) but the group with the 120°-oriented commissures had significantly higher mean transaortic gradients compared to the group with the 180°-oriented commissures at initial exercise stress conditions (30.1 ± 9.1 vs 24.9 ± 3.8; p value 0.002). CONCLUSIONS: The 180° commissural reorientation of the asymmetrical bicuspid aortic valve does not improve the transvalvular aortic gradient in an acute model at rest conditions, but it could do so under stress situations. Even if it is surgically more complex and time-consuming, this approach could be a good strategy to improve long-term results, particularly in young patients.

Hybrid Surgery to Manage Aortic Arch Pathology.

Background and Objectives: Aortic arch disease is still a high-risk surgical challenge despite major advances both in surgical and anesthesiological management. A combined surgical and endovascular approach has been proposed for aortic arch disease treatment to avoid hypothermia and circulatory arrest in high-risk patients. Materials and Methods: Between June 2004 and June 2021, 112 patients were referred to our department for aortic arch surgery; 38 (33.9%) patients underwent supra-aortic debranching and endovascular treatment. Of these, 21 (55%) patients underwent type I aortic arch hybrid debranching procedure and in 17 (45%) patients a type II aortic arch hybrid debranching procedure was performed. None of the patients were emergent. Results: No intra-operative deaths were recorded. In the type I aortic arch hybrid debranching patients' group, one patient died at home waiting the endovascular step, one developed ascending aortic dissection and another one developed a pseudoaneurysm at the site of the debranching at follow-up. In the type II aortic arch hybrid debranching patients' group, left carotid artery branch closure was detected at follow-up in one patient. Thirty day/in-hospital rates of adverse neurological events for both the surgical and endovascular procedures were 3% for minor stroke, with no permanent neurological deficit and 0% for permanent paraplegia/paraparesis. In 100% of the cases, the endovascular step succeeded and the type Ia endoleak rate was 0%. Conclusions: Hybrid arch surgery is a valuable option for aortic arch aneurysm treatment in patients with high surgical risk. The choice of aortic arch debranching between type I or type II is crucial and depends on anatomic and clinical patient characteristics. Further larger scale studies are needed to better define the advantages of these techniques.

Open supra-aortic revascularization and arch reconstruction after previous TEVAR in a complex arch anatomy.

We propose a technique to minimize the neurological and systemic risks involved in rerouting the blood flow toward the brain in a "single remaining vessel" configuration with a 90% stenosis by means of complete hypothermic cerebral protection associated with normothermic systemic blood flow with a "restitutio ad integrum" of the supra-aortic trunks flow. The perfusion of the brain and the arms was almost completely separated from the systemic perfusion by the deployment 1 year before of a thoracic endoprosthesis in association with complete chronic occlusion of the brachiocephalic trunk and a functioning carotid-subclavian bypass. The Free Flow of the prosthesis, which acted as a hook, moved the calcium toward the left carotid ostium, creating a 90% stenosis with intermittent acute cerebral hypoperfusion and amaurosis. We achieved an optimal result: The patient was discharged on postoperative day 7 with no neurological problems and with patency and direct blood flow in all the supra-aortic trunks.

Hybrid endovascular/surgical Kommerrell's diverticulum treatment.

Kommerrell's diverticulum of the right aberrant subclavian artery is a rare disease, its treatment is still controversial. We report the case of a patient with a six cm aneurysmal dilation successfully treated in a hybrid surgical/endovascular way.

Hybrid repair of extensive thoracic aortic aneurysms.

OBJECTIVES: Our goal was to report the midterm results of hybrid treatment of extensive thoracic aortic aneurysm (ETAA) with the completion of thoracic endovascular aortic repair after proximal ascending-arch graft replacement. METHODS: This was a multicentre, observational study. Data were collected prospectively between January 2002 and March 2019 and analysed retrospectively. Inclusion criteria for the final analysis were the treatment of elective or urgent ETAA performed in a single-stage or a planned two-stage approach. Early and late survival rates were the primary outcomes. RESULTS: Indications for repair were degenerative ETAA in 27 (64.3%) patients and dissection-related ETAA in 15 (35.7%). The mean aortic diameter was 68 ± 16 mm (interquartile range 60-75). Five (11.9%) patients had a single-stage repair; and 37 underwent a two-stage approach. Three (7.1%) patients died in-hospital. The median follow-up was 49 months (range 0-204). During the follow-up period, 4 (9.5%) patients underwent aortic reintervention after a median of 32 months; however, no aortic rupture of the treated segment occurred. Overall, the estimated survival rate was 85% ± 6% [95% confidence interval (CI) 70.8-93] at 12 and 36 months and 69.5% ± 9% (95% CI 49.7-84) at 60 months. CONCLUSIONS: Hybrid repair of ETAA had satisfactory early results in this cohort of patients. At the midterm follow-up, the aneurysm-related mortality rate was acceptable with the reconstruction proving to be durable and safe with few distal aortic events.

Comparison of Hybrid Vascular Grafts and Standard Grafts in Terms of Kidney Injury for the Treatment of Thoraco-Abdominal Aortic Aneurysm.

BACKGROUND: We present a comparison of renal function outcomes during HTAR with the use of a new hybrid vascular graft (GHVG) or standard graft. METHODS: It is a multicenter, retrospective, observational study. Between January 2015 and March 2019, 36 patients were treated with HTAR. We compared HTAR performed with the use of the GHVG and with the use of standard bypass graft. Primary outcome measures were hospital mortality, acute kidney injury (AKI) at 30 days and GHVG patency. RESULTS: Mean GHVG ischemia time was significantly lower for both renal arteries (right: GHVG, 4 ± 2 vs. standard graft, 15 ± 7 min; 95% CI 2.23-6.69, P < 0.001; left: GHVG, 3 ± 2 vs. standard graft, 13 ± 7 min; 95% CI 2.44-5.03, P < 0.001). Hospital mortality was 17% (6/36); while mortality did not differ between the two groups, postoperative acute kidney injury rate was 30.5% (11/36 patients) and was more common in the standard graft group (7% vs. 29%; OR 3.2, P = 0.074). Estimated primary patency was 92% ± 2 (95% CI 79.5-97%) at 36 months and was not different between the two groups (GHVG 94% ± 6 vs. standard graft 91% ± 6; log-rank χ2 = 0.260, P = 0.610). CONCLUSIONS: In our experience of HTAR, ischemia time was significantly shorter and postoperative AKI occurrence was lower with GHVG if compared to standard graft bypass, with satisfactory midterm patency rate comparable to that of standard graft bypass.

Transposition of the left vertebral artery during endovascular stent-graft repair of the aortic arch.

OBJECTIVES: The aim of this study was to present our experience with the management of isolated left vertebral artery during hybrid aortic arch repairs with thoracic endovascular aortic repair completion. METHODS: This is a single-center, observational, cohort study. Between January 2007 and December 2018, 9 patients (4.5%) of 200 who underwent thoracic endovascular aortic repair were identified with isolated left vertebral artery. The isolated left vertebral artery was the dominant vertebral artery in 4 cases and entered the Circle of Willis to form the basilar artery in all cases. Isolated left vertebral artery transposition was performed in 2 patients during open ascending/arch repair before thoracic endovascular aortic repair completion. In 4 patients, isolated left vertebral artery transposition was performed concomitant with carotid-subclavian bypass during thoracic endovascular aortic repair completion ("zone 2" thoracic endovascular aortic repair). Primary outcomes were early (<30 days) and late survival, freedom from aortic-related mortality, and isolated left vertebral artery patency. RESULTS: Primary technical success was achieved in all cases. Isolated left vertebral artery-related complication occurred in 1 patient (Horner syndrome). Immediate thrombosis, vagus/recurrent laryngeal nerve palsy, lymphocele, and chylothorax were never observed. Postoperative cerebrovascular accident or spinal cord injury was not observed. Median follow-up was 15 months (range, 3-72). We did not observe aortic-related mortality during the follow-up. Aortic-related intervention was never required. Both isolated left vertebral artery and carotid-subclavian bypass are still patent in all patients with no sign of anastomotic pseudoaneurysm or stenosis. CONCLUSIONS: Although isolated left vertebral artery is not a frequent occurrence, it is not so rare. It may pose additional difficulties during hybrid aortic arch surgical repairs, but isolated left vertebral artery transposition was feasible, safe, and a durable reconstruction.

Surgical Treatment of Synchronous Type B Acute Aortic Dissection and Abdominal Aortic Aneurysm.

BACKGROUND: We report the results of the operative treatment of synchronous type B acute aortic dissection (TBAAD) and infrarenal abdominal aortic aneurysm (AAA). METHODS: It is an observational, descriptive multicenter case series. Inclusion criterion was patients with diagnosis of TBAAD and AAA detected synchronously for the first time at clinical onset of dissection. Follow-up imaging protocol included triple-phase spiral/computed tomography angiography performed at 1, 6, and 12 months after thoracic endovascular aortic repair (TEVAR), and annually thereafter. Major end points were perioperative mortality and long-term survival, freedom from aortic events, and freedom from reintervention. RESULTS: We identified and treated 15 cases. All TBAADs were treated by TEVAR in the acute phase: infrarenal aortic repair was performed with stent graft (SG) in 10 (66.7%) patients, with open repair in 5 (33.3%). Overall, staged repair was used in 11 (73.3%) patients. Mean descending aortic endovascular length coverage was 21 cm ± 7 (range, 10-35; interquartile range [IQR], 150-265). Overall, early perioperative mortality occurred in 1 (6.7%) patient. Median radiologic follow-up was 48 months (range, 6-120; IQR, 36-67). During the follow-up, TEVAR-related mortality was not observed. Aortic remodeling after TEVAR was obtained in 12 (85.7%) patients; abdominal sac shrinkage after SG was obtained in 8 (80.0%) patients. Freedom from aortic event rate was 79% ± 10 (95% confidence interval [CI]: 53.1-92.6) at 1 year and 64% ± 13 (95% CI: 38.1-83.5) at 5 year. Freedom from reintervention rate at 1 and 5 year was 85% ± 10 (95% CI: 57.8-95.7). CONCLUSIONS: In our experience, the association of TBAAD and AAA was a rare finding. Because of the lack of available evidence to opt for a single intervention or a staged approach, selective approach with TEVAR and endovascular/open conventional treatment of the abdominal aorta yielded satisfactory results at midterm follow-up.

MitraClip removal: surgical techniques to preserve native mitral valve leaflets.

Transcatheter valve procedures are wide-spreading techniques for the treatment of heart valves pathologies. In case of implantation failure, the transcatheter device often needs to be removed. This procedure, which can alter the biological structure integrity, can limit the option available for the subsequent traditional surgery. One of the most popular devices for transcatheter mitral valve repair is the MitraClip system. In this work, we describe 2 different techniques for the surgical removal of MitraClip. These techniques aim to preserve the valve leaflets integrity, to allow for subsequent mitral valve surgical repair.

A novel system for the treatment of aortic annular dilation: an ex vivo investigation.

OBJECTIVES: The main reason for aortic repair failures is recurrent annular dilatation. The fibrous portion of left ventricular outflow tract dilates. A novel device was designed to tackle this problem. METHODS: The device consists of an internal ring applied at the aortic annulus plus an external flexible band at the level of the aortic root. The internal ring has a semi-rigid portion (40%, placed at ventriculo-arterial junction) and a flexible portion to allow it to conform along the curves of the non-coronary/right coronary leaflet and right coronary/left coronary leaflet commissures. The external band acts as a reinforcement to the internal ring. A pulsatile mock loop capable of housing porcine aortic valve was used. Working conditions were 60 bpm of heart rate, 75 of stroke volumes and 120-80 mmHg of simulated pressure. Mean gradient, effective orifice area, annular diameter, coaptation height and length were recorded on 11 aortic root units (ARUs). High-speed video and standard echocardiographic images were also recorded. All data were acquired in the following conditions: (i) basal (untreated ARU); (ii) pathological condition (left coronary/non-coronary triangle was dilated by suturing an aortic patch); and (iii) ARU treated with the device. RESULTS: Gradients and effective orifice area were respectively 0.9 ± 0.64 mmHg and 3.1 ± 0.7cm2 (pathological) and 3.7 ± 1.1 mmHg and 1.5 ± 0.2cm2 (treated, P < 0.05). Left coronary/non-coronary diameter decreased from 2.4 ± 0.2 cm (pathological) to 2.0 ± 0.2 (treated, P < 0.05). Coaptation length and height were fully restored to basal values following treatment. Visual inspection showed proper dynamics of the leaflet, confirmed by high-speed video and echocardiography. CONCLUSIONS: The device allowed for restoring physiologic-like coaptation in the experimental model, without inducing clinically relevant worsening of the haemodynamics of the treated ARU.

Transcatheter Edge-to-Edge Treatment of Functional Tricuspid Regurgitation in an Ex Vivo Pulsatile Heart Model.

BACKGROUND: Although associated with left heart pathologies, functional tricuspid regurgitation (FTR) is often left untreated during left heart surgery. Hence, owing to its degenerative character, reoperation is often needed, encompassing an impressive (25% to 35%) mortality rate. Thus transcatheter approaches to FTR are raising great interest. OBJECTIVES: The authors evaluated the post-treatment effectiveness of the edge-to-edge technique using the percutaneous mitral valve repair device in an ex vivo pulsatile model of FTR. METHODS: The devices were implanted in 11 porcine hearts simulating FTR. In each heart, single-clip treatments involved grasping leaflet pairs in the medial or commissural position (6 combinations). Two-clip treatments were then performed considering all possible 15 combinations of leaflet pairs and medial/commissural grasping. Cardiac output, mean pulmonary pressure, and mean diastolic valve pressure gradient were evaluated in physiological and simulated pathological conditions (FTR), and post-treatments. RESULTS: Grasping the septal and anterior leaflets allowed for the best post-procedural outcome, ensuring a complete re-establishment of physiological-like hemodynamics. Septal and posterior grasping induced a significant recovery from FTR, although less marked. Conversely, grasping the anterior and posterior leaflets did not reduce FTR, and was detrimental in some specific cases. CONCLUSIONS: This experimental work demonstrated that the transcatheter edge-to-edge repair technique is a feasible approach for FTR. The study investigated this approach to develop a selective, specific structural intervention methodology for treating FTR, considering the several biomechanical factors that alter proper functionality of valvular substructures. These results can be used to guide the development of edge-to-edge repair techniques in treatment of FTR.

A geometric approach to aortic root surgical anatomy.

OBJECTIVES: The aim of this study was the analysis of the geometrical relationships between the different structures constituting the aortic root, with particular attention to interleaflet triangles, haemodynamic ventriculo-arterial junction and functional aortic annulus in normal subjects. METHODS: Sixteen formol-fixed human hearts with normal aortic roots were studied. The aortic root was isolated, sectioned at the midpoint of the non-coronary sinus, spread apart and photographed by a high-resolution digital camera. After calibration and picture resizing, the software AutoCAD 2004 was used to identify and measure all the elements of the interleaflets triangles and of the aortic root that were objects of our analysis. Multiple comparisons were performed with one-way analysis of variance for continuous data and with Kruskal-Wallis analysis for non-continuous data. Linear regression and Pearson's product correlation were used to correlate root element dimensions when appropriate. Student's t-test was used to compare means for unpaired data. Heron's formula was applied to estimate the functional aortic annular diameters. RESULTS: The non coronary-left coronary interleaflets triangles were larger, followed by inter-coronary and right-non-coronary ones. The apical angle is <60° and its standard deviation can be considered an asymmetry index. The sinu-tubular junction was shown to be 10% larger than the virtual basal ring (VBR). The mathematical relationship between the haemodynamic ventriculo-arterial junction and the VBR calculated by linear regression and expressed in terms of the diameter was: haemodynamic ventriculo-arterial junction = 2.29 VBR (diameter) + 47. DISCUSSION: Conservative aortic surgery is based on a better understanding of aortic root anatomy and physiology. The relationships among its elements are of paramount importance during aortic valve repair/sparing procedures and they can be useful also in echocardiographic analysis and in computed tomography reconstruction.

Aortic valve repair: a ten-year single-centre experience†.

OBJECTIVES: Aortic valvuloplasty could represent an alternative to valve replacement resulting in optimal haemodynamic conditions, avoiding anticoagulation and allowing, in young people, normal aortic annulus growth. We analysed our results of aortic valve repair for incompetence due to leaflets and root pathology. METHODS: From January 2003 to January 2013, 235 patients affected by aortic valve regurgitation, pure or associated with aortic dilatation, were treated with a combination of the principal leaflet repair techniques and, when necessary, sparing procedures. Of these patients, 218 were considered eligible in this study. All of them were submitted to pre- and postoperative transthoracic echocardiography and pre- and post-repair transoesophageal echocardiography. Follow-up was achieved with periodic echocardiograms and clinical evaluations. RESULTS: Eight patients (3.40%) died before discharge. Median clinical and echocardiographic follow-up for all patients was 2.94 (1.41-5.41) years. Mean cross-clamping time was 101.94 ± 40.22 min and mean hospital stay was 10 ± 6.69 days. Kaplan-Meier freedom from aortic regurgitation >2 and freedom from aortic valve replacement were, respectively, 92.9 ± 2.8 and 94.5 ± 2.5% at 9.24 years: 6 patients (2.75%) were reoperated on with aortic valve replacement for severe aortic regurgitation. We also observed a good effect of aortic surgery on the left ventricle: the end-diastolic volume decreased from 137.89 ± 50.23 ml in the preop to 105.17 ± 31.19 ml at follow-up. CONCLUSIONS: Aortic valve leaflet repair seems to be a good and feasible option for selected patients, both alone or associated with an aortic sparing technique concerning long-term results.

Hybrid endovascular treatment of an aortic root and thoracoabdominal aneurysm in a high-risk patient with Marfan syndrome.

This report describes the hybrid endovascular treatment of an aortic root dilatation and a thoracoabdominal aneurysm in a high-risk patient with Marfan syndrome. A 50-year-old male, in hemodialysis for polycystic kidney and polycystic liver, was referred to our department for aortic root dilatation of 5 cm and a 6.3-cm thoracoabdominal aneurysm . He already underwent surgical repair of abdominal aortic aneurysm 10 years ago, complicated by pseudoaneurysm of the proximal anastomosis that had been treated in another center, with an endoprosthesis. The patient underwent aortic root replacement, aortic valve sparing operation, and rerouting of the superior mesenteric artery and celiac trunk to the ascending aorta. The thoracoabdominal aneurysm was excluded with an endoprosthesis few days after the surgical step. The 12-month computed tomography scan confirmed the complete exclusion of the thoracoabdominal aneurysm.

Predictors and outcomes of acute kidney injury after thoracic aortic endograft repair.

BACKGROUND: This study analyzed the incidence and the predictive factors of postoperative acute kidney injury (AKI) after thoracic endovascular aortic repair (TEVAR) and evaluated the effect of AKI on postoperative survival. METHODS: Between November 2000 and April 2011, all consecutive patients undergoing TEVAR of the descending thoracic or thoracoabdominal aorta were enrolled at four teaching hospitals. Estimated glomerular filtration rate (eGFR) was evaluated during the entire hospitalization. AKI was defined by the RIFLE (Risk, Injury, Failure, Loss of function, End-stage renal disease) consensus criteria. RESULTS: The study included 171 patients (80% men) who were a mean age of 69±14 years (range, 18-87 years). AKI occurred in 24 patients (14%). Independent predictors of postoperative AKI were preoperative depressed eGFR, thoracoabdominal extent, and postoperative transfusion. Patients with AKI experienced major postoperative complications (P=.001), longer hospitalization (P=.008), and higher hospital mortality (29% vs 4%; P<.001). Kaplan-Meier analysis showed a survival of 82%, 51%, and 51% at 1, 3, and 5 years for patients who developed AKI, which was significantly worse than the 99%, 89%, and 80% for patients who did not experience AKI (P=.001). CONCLUSIONS: Preoperative poor renal function, blood transfusions, and the thoracoabdominal extent of the aortic disease were the most important predictors for AKI.