Comparison of HTK-Custodiol and St-Thomas solution as cardiac preservation solutions on early and midterm outcomes following heart transplantation.

OBJECTIVES: The choice of the cardiac preservation solution for myocardial protection at time of heart procurement remains controversial and uncertainties persist regarding its effect on the early and midterm heart transplantation (HTx) outcomes. We retrospectively compared our adult HTx performed with 2 different solutions, in terms of hospital mortality, mid-term survival, inotropic score, primary graft dysfunction and rejection score. METHODS: From January 2009 to December 2020, 154 consecutive HTx of adult patients, followed up in pre- and post-transplantation by 2 different tertiary centres, were performed at the University Hospital of Lausanne, Switzerland. From 2009 to 2015, the cardiac preservation solution used was exclusively St-Thomas, whereafter an institutional decision was made to use HTK-Custodiol only. Patients were classified in 2 groups accordingly. RESULTS: There were 75 patients in the St-Thomas group and 79 patients in the HTK-Custodiol group. The 2 groups were comparable in terms of preoperative and intraoperative characteristics. Postoperatively, compared to the St-Thomas group, the Custodiol group patients showed significantly lower inotropic scores [median (interquartile range): 35.7 (17.5-60.2) vs 71.8 (31.8-127), P < 0.001], rejection scores [0.08 (0.0-0.25) vs 0.14 (0.05-0.5), P = 0.036] and 30-day mortality rate (2.5% vs 14.7%, P = 0.007) even after adjusting for potential confounders. Microscopic analysis of the endomyocardial biopsies also showed less specific histological features of subendothelial ischaemia (3.8% vs 17.3%, P = 0.006). There was no difference in primary graft dysfunction requiring postoperative extracorporeal membrane oxygenation. The use of HTK-Custodiol solution significantly improved midterm survival (Custodiol versus St-Thomas: hazard ratio = 0.20, 95% confidence interval: 0.069-0.60, P = 0.004). CONCLUSIONS: This retrospective study comparing St-Thomas solution and HTK-Custodiol as myocardial protection during heart procurement showed that Custodiol improves outcomes after HTx, including postoperative inotropic score, rejection score, 30-day mortality and midterm survival.

Risk of embolic events before and after antibiotic treatment initiation among patients with left-side infective endocarditis.

PURPOSE: Embolic events (EEs) are a common complication of left-side infective endocarditis (IE). The aim of the present study was to identify risk factors for the occurrence of EEs before or after antibiotic treatment instauration among patients with definite or possible IE. METHODS: This retro-prospective study was conducted at the Lausanne University Hospital, Lausanne, Switzerland, from January 2014 to June 2022. EEs and IE were defined according to modified Duke criteria. RESULTS: A total of 441 left-side IE episodes were included (334: 76% were definite and 107; 24% possible IE). EE were diagnosed in 260 (59%) episodes; in 190 (43%) before antibiotic treatment initiation and 148 (34%) after. Central nervous system (184; 42%) was the most common site of EE. Multivariable analysis identified S. aureus (P 0.022), immunological phenomena (P < 0.001), sepsis (P 0.027), vegetation size ≥ 10 mm (P 0.003) and intracardiac abscess (P 0.022) as predictors of EEs before antibiotic treatment initiation. For EEs after antibiotic treatment initiation, multivariable analysis revealed vegetation size ≥ 10 mm (P < 0.001), intracardiac abscess (P 0.035) and prior EE (P 0.042), as independent predictors of EEs, while valve surgery (P < 0.001) was associated with lower risk for EEs. CONCLUSIONS: We reported a high percentage of EEs among patients with left-side IE; vegetation size, intracardiac abscess, S. aureus and sepsis were independently associated with the occurrence of EEs. In addition to antibiotic treatment, early surgery led to further decrease in EEs incidence.

Role of Cerebral Imaging on Diagnosis and Management in Patients With Suspected Infective Endocarditis.

BACKGROUND: Cerebral embolic events (CEEs) are common complications of infective endocarditis (IE), and their presence can modify diagnosis and therapeutic plans. The aim of the present study was to assess the role of cerebral imaging (Cer-Im) on diagnosis and management of patients with suspected IE. METHODS: This study was conducted at the Lausanne University Hospital, Lausanne, Switzerland, from January 2014 to June 2022. CEEs and IE were defined according to modified Duke criteria of the European Society of Cardiology (ESC) guidelines. RESULTS: Among 573 patients with IE suspicion and Cer-Im, 239 (42%) patients had neurological symptoms. At least 1 CEE was found in 254 (44%) episodes. Based on Cer-Im findings, episodes were reclassified from rejected to possible or from possible to definite IE in 3 (1%) and 25 (4%) patients, respectively (0% and 2% in asymptomatic patients, respectively). Among the 330 patients with possible or definite IE, at least 1 CEE was found in 187 (57%) episodes. A new surgical indication (in association with left-side vegetation >10 mm) was established in 74/330 (22%) IE patients and 30/155 (19%) asymptomatic IE patients, respectively. CONCLUSIONS: Cer-Im in asymptomatic patients with IE suspicion showed limited potential for improving the diagnosis of IE. In contrast, performing Cer-Im in asymptomatic patients with IE may be useful for decision making, because Cer-Im findings led to the establishment of new operative indication for valvular surgery in one fifth of patients according to ESC guidelines.

Percutaneous reduction of septal-to-lateral mitral annular distance to increase mitral leaflet coaptation length: Preclinical study results.

Objectives: Percutaneous indirect annuloplasty has emerged as a treatment strategy for functional/ischemic mitral regurgitation. This study sought to evaluate the feasibility of percutaneous indirect annuloplasty technique using a new device. Methods: The device has 3 components: the "saddle" inserted into the great cardiac vein, the "plug" positioned in the left ventricular outflow tract, and the "bridge," a transatrial suture connecting the 2 holding elements. The aim was to shorten the septal-to-lateral distance of the mitral annulus by pulling on the saddle element. The procedure was performed through venous access in healthy adult sheep. A dedicated catheter holding a needle was used to deploy the saddle into the great cardiac vein and pierce its wall toward the left atrium to deploy the expanded polytetrafluoroethylene suture that is part of the bridge. A catheter for transseptal puncture was inserted for crossing the interatrial septum and piercing the aortic-mitral curtain, thereby allowing the plug to be deployed. The plug was held in place by the second part of the expanded polytetrafluoroethylene bridge. The 2 parts of the bridge were then joined to reduce the septal-to-lateral mitral annular distance. The septal-to-lateral distance and the coaptation length at P2 level were measured before and after the procedure using echocardiography. Results: Overall, 10 animals were treated, 7 successfully. The mean procedure duration was 110 ± 81 minutes. Septal-to-lateral distance decreased from 3.8 mm to 2.6 mm (30%), and maximum increase of mitral leaflet coaptation was 4 mm. Conclusions: This new approach seems promising for percutaneous treatment of functional mitral regurgitation.

Management of left subclavian artery in type B aortic dissection treated with thoracic endovascular aorta repair.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has been the favored approach for the treatment of type B aortic dissection (TBAD). To obtain an adequate proximal landing zone, coverage of the left subclavian artery (LSA) will often be necessary. The occurrence of possible neurologic complications has continued to be debated. We investigated the management of the LSA in patients with TBAD undergoing endovascular repair. METHODS: We searched the PubMed and MEDLINE databases to October 2020 for studies of TEVAR for TBAD. Data on the study design, demographics, endograft details, LSA coverage and revascularization, mortality, complications, and follow-up were extracted and analyzed. The effects of LSA coverage and revascularization on neurologic complications and outcomes were investigated. RESULTS: A total of 26 reports (24 retrospective and 2 prospective) were deemed eligible for our study. A total of 1483 patients (mean age, 56.9 ± 6.2 years) had undergone TEVAR for acute (n = 932; 62.9%), subacute (n = 36; 2.4%), or chronic (n = 515; 34.7%) TBAD, with a success rate of 97.8% and hospital mortality of 4.9%. The LSA origin had been covered for 707 patients (47.7%), and 326 had undergone LSA revascularization (surgical, n = 96; endovascular, n = 170; unspecified or not reported, n = 60). LSA revascularization was concomitant for 68.1% of cases, after TEVAR for 1.8%, and not reported for 30.1%. Of 1146 patients, 10 (0.9%) had experienced left arm claudication, and the overall stroke rate was 3.3% (2.7% for the LSA group and 1% for the uncovered LSA group; P = .0815). Of the patients with stroke and a covered LSA, 1% (2 of 203) had undergone LSA revascularization and 4.8% (5 of 105) had not (P = .0478). Twenty-six patients (1.9%) had developed paraplegia: 0.7% (3 of 433) with a covered LSA, 1.4% (7 of 491) with an uncovered LSA (P = .3508), and not reported for 16 patients. Endoleak was present in 138 patients (13.4%) at a mean follow-up of 32.1 ± 25.6 months. CONCLUSIONS: Our review has shown that LSA coverage during endovascular repair for complicated TBAD will does not significantly increase the risk of neurologic complications; however, revascularization of the LSA should be always recommended.

Aspergillus tubingensis Endocarditis: A Case Report and Review of the Literature.

Aspergillus endocarditis is a rare infection that may affect immunocompetent patients following heart valve replacement or heart surgery. We report the case of a 39 year old woman with a history of intravenous drug use who developed endocarditis with direct examination of the resected valve and vegetation showing the presence of mycelia. Cultures were positive for an Aspergillus of section Nigri, which was subsequently identified as Aspergillus tubingensis by sequencing. The clinical course was favorable following surgery and prolonged antifungal therapy (8 months in total). Antifungal susceptibility testing showed good in vitro activity of amphotericin B, voriconazole and echinocandins against planktonic cells of this A. tubingensis isolate. However, only amphotericin B displayed significant activity against biofilms. In vitro combinations of voriconazole or amphotericin B with echinocandins did not meet the criteria of synergism. Our review of the literature identified 17 other cases of endocarditis attributed to Aspergillus of section Nigri with an overall mortality rate of 57% (100% in the absence of surgery). Endocarditis caused by Aspergillus niger and related cryptic species are rare events, for which surgical management appears to be crucial for outcome. While amphotericin B was the only antifungal drug displaying significant anti-biofilm activity, the type and duration of antifungal therapy remain to be determined.

A Heart Surgery Simulator With an Integrated Supervision System for Self-Learning the Key Steps and Pitfalls of the Mitral Valve Repair: Initial Investigation.

INTRODUCTION: Over the years, surgical education has dramatically improved and has become increasingly innovative. Almost all educational programs in surgery now rely on sophisticated training boxes and simulators that enable surgical instruments to be handled and surgical procedures to be trained in a safe environment. However, simulators need constant feedback from supervising senior surgeons, who only have limited teaching time available. We describe a cardiac surgery simulator with an integrated supervision system for self-learning how to repair a mitral valve. METHODS: We developed a mitral surgery simulator with integrated sensors to generate, record, and display quantitative data on trainee performance in relation with the mitral valve repair procedure. A team of experienced cardiac surgeons defined critical areas of the model and an algorithm to identify inconsistent movements, in terms of error types and out-of-bound actions. The device provided real-time feedback on the accuracy of the stitches placed. Four experienced cardiac surgeons and 3 advanced cardiac-surgery used the simulator and were asked to evaluate specific parameters of the system on a scale ranging from 1 to 10. RESULTS: All surgeons completed a P2 resection, followed by implanting a 32-mm mitral ring. The simulator detected 2 stitches that were placed in dangerous zones and another stitch that was placed in an inappropriate position. Users scored the real tissue feeling and interactivity of the model 9.5/10. CONCLUSIONS: This heart-surgery simulator offers a real-life model for learning about and training in mitral valve surgery, which could potentially replace the experienced surgeon's teaching role.

Humanoids for teaching and training coronary artery bypass surgery to the next generation of cardiac surgeons.

OBJECTIVES: Technical skills are an essential component of cardiac surgery, and the operating room is becoming an even more challenging environment for trainees who want to acquire such skills. Simulation, which partially overcomes this limitation, represents a valid adjunct to surgical education. We describe an original simulator and provide results in terms of trainees' evaluations and ratings. METHODS: We used a humanoid that is a silicone replica of the chest of an adult human that provides a complete anatomical platform for hands-on skin-to-skin practice of surgical techniques in arrested heart coronary artery bypass graft (CABG) surgery cases. Learners were residents in cardiac surgery. The teaching sessions included 2 full three-vessel CABG procedures using both mammary arteries and a hydrogel vein. Five board-certified cardiovascular surgeons scored the surgical activity of all trainees. The trainees were asked to complete an exit questionnaire to evaluate their course. RESULTS: Overall, 16 residents participated in the simulation, including 5 women and 11 men, with a mean age of 30 ± 4 years, all of whom had at least 2 years of cardiac surgery training. All participants completed the 2 CABG operations. Three mammary arteries (4.6%) were seriously damaged during harvesting. In 1 case (3.1%), an aortic tear occurred during aortic cannulation. Each trainee performed overall 6 distal and 2 proximal coronary anastomoses. All participants agreed that the 'humanoid reproduces real-life situations, the feeling is realistic, and they are now more confident in performing coronary anastomosis'. CONCLUSIONS: Trainees involved in this simulation curriculum acquired and refined technical skills that could be applied directly to human patients. In addition, we were able to foster a higher level of teamwork within the operating room team.

Usefulness of postoperative high-sensitive troponin T measurement and implications for defining type 5 infarction.

BACKGROUND AND AIM OF THE STUDY: Guidelines indicate for type 5 myocardial infarction (MI) that postoperative troponin need not be exclusively ischemic but may also be caused by epicardial injury. Complexity arises from the introduction of high-sensitive troponin. This study attempts to contribute to the understanding of postoperative high-sensitive cardiac troponin T (hs-cTnT) increase. METHODS: The median enzyme increase of different cardiac operations was compared. Linear regression analyses were used to determine correlations between enzyme rise and independent parameters. Receiver-operating characteristics (ROC) served to evaluate the discriminatory power of enzyme rise in detecting ischemia and to determine possible thresholds. RESULTS: Among 400 patients, 2.8% had intervention-related ischemia analogous to type 5 MI definition. The median postoperative hs-cTnT/creatine kinase myocardial band (CK-MB) increase varied according to types of surgery, with highest increase after mitral valve and lowest after off-pump coronary surgery. After ruling out patients with preoperatively elevated hs-cTnT, regression analysis confirmed Maze procedure (p < .001), intra-pericardial defibrillation (p = .002), emergency intervention (p = .01), blood transfusions (p = .02), and cardiopulmonary bypass time (p = .03) as significant factors associated with hs-cTnT increase. In addition, CK-MB increase was associated with mortality (p = .002). ROC confirmed good discriminatory power for hs-cTnT and CK-MB with ischemia-indicating thresholds of 1705.5 ng/L (hs-cTnT) and 113 U/L (CK-MB) considering different types of operations. CONCLUSIONS: The Influence of the type of surgery and intervention-related parameters on hs-cTnT increase was confirmed. Potential thresholds indicating perioperative ischemia appear to be significantly elevated for high sensitive markers.

Prediction of right ventricular failure after left ventricular assist device implantation in patients with heart failure: a meta-analysis comparing echocardiographic parameters.

OBJECTIVES: Between 10% and 40% of patients who receive a left ventricular assistance device (LVAD) suffer from right ventricular failure (RVF) shortly after the device is implanted. Patients with post-LVAD RVF tend to have poor outcomes. Only a few predictive factors concerning the right ventricle (RV) have been investigated. Our goal was to search for non-invasive variables that correlate with RV function, focusing on echocardiographic parameters of the RV. METHODS: We selected 3 parameters: tricuspid annular plane systolic excursion, right ventricular fractional area change and right ventricular global longitudinal strain. We searched the literature and pooled relevant studies in a meta-analysis. Finally, we performed a statistical analysis to confirm whether each parameter was a reliable predictor of RVF after LVAD implantation. RESULTS: We retained 19 articles involving a total of 1561 patients. We found a pooled standardized mean deviation of -0.13 cm for the tricuspid annular plane systolic excursion, with the lower and upper tails of -0.21 and -0.04 cm, respectively. Concerning the right ventricular fractional area change, the averaged standardized mean deviation was equal to -2.61%, with the lower and upper extremities of -4.12% and -1.09%, respectively. Finally, regarding the global longitudinal strain, the standardized mean deviation was equal to -2.06% with an uncertainty value between -3.23% and -0.88%. CONCLUSIONS: The tricuspid annular plane systolic excursion could be a reliable parameter in RVF prediction. The right ventricular fractional area change and global longitudinal strain are likely to be stronger predictors of RVF after LVAD implantation. Prospective studies should be carried out to confirm this observation.

Case Report: Are We Witnessing an Increase of Chronic Ascending Aortic Dissection as a Collateral Effect to the COVID-19 Pandemic?

Background: The COVID-19 (coronavirus disease 2019) pandemic is reducing health care accessibility to non-life-threatening diseases, thus hiding their real incidence. Moreover, the incidence of potentially fatal conditions such as acute type A aortic dissection seems to have decreased since the pandemic began, whereas the number of cases of chronic ascending aortic dissections dramatically increased. We present two patients whose management has been affected by the exceptional sanitary situation we are dealing with. Case report: A 70-year-old man with chest pain and an aortic regurgitation murmur had his cardiac workup delayed (4 months) because of sanitary restrictions. He was then diagnosed with chronic type A aortic dissection and underwent urgent replacement of ascending aorta and aortic root. The delay in surgical treatment made the intervention technically challenging because the ascending aorta grew up to 80 mm inducing strong adhesions and chronic inflammation. The second case report concerns a 68-year-old woman with right lower-limb pain who was diagnosed with deep vein thrombosis. However, a CT scan to exclude a pulmonary embolism could not be realized until 5 months later because of sanitary restrictions. When she eventually got the CT scan, it fortuitously showed a chronic dissection of the ascending aorta. She underwent urgent surgery, and the intervention was challenging because of adhesions and severe inflammation. Conclusion: Delayed treatment due to sanitary restrictions related to COVID-19 pandemic is having a significant impact on the management of potentially life-threatening conditions including type A aortic dissection. We should remain careful to avoid COVID-19 also hitting patients who are not infected with the virus.

[Sutureless and rapid-deployement valves for aortic valve replacement: the ideal compromise ?] / Les valves sutureless et à déploiement rapide dans le remplacement valvulaire aortique: le compromis idéal ?

For a decade, aortic valve replacement (AVR) surgery has been simplified thanks to the development of sutureless or rapid deployment valves (SU-RD valves), which offer an alternative to sutured valves. These SU-RD valves, inspired by the TAVI (Transcatheter Aortic Valve Implantation), allow significant operating time reduction and facilitate minimally invasive surgery. They are particularly indicated for patients that are more fragile and in combined procedures (for example AVR associated with coronary bypass surgery). Recent studies report high reliability and excellent outcomes with lower morbidity and mortality compared to other AVR modalities, including TAVI. Considering the constant technical improvement, SU-DR valves may become the new standard in AVR.

Depuis une décennie, la chirurgie du remplacement valvulaire aortique (RVA) s'est simplifiée grâce à l'apparition de valves dites « sutureless ¼ ou à « déploiement rapide ¼ (valves SU-DR) qui offrent une alternative aux valves suturées. Ces valves SU-DR, inspirées du Transcatheter Aortic Valve Implantation (TAVI), permettent un gain de temps opératoire important et facilitent la chirurgie mini-invasive. Elles sont notamment indiquées chez les patients plus fragiles et lors de procédures combinées (par exemple, RVA et pontages coronariens associés). Des études récentes rapportent une grande fiabilité et d'excellents résultats avec une moindre morbi-mortalité par rapport aux autres modalités de RVA, y compris le TAVI. Considérant l'amélioration technique constante, les valves SU-RD pourraient bien devenir le nouveau standard dans le RVA.

Management of Atrial Fibrillation Following Cardiac Surgery: Observational Study and Development of a Standardized Protocol.

BACKGROUND: Postoperative atrial fibrillation (POAF) is the most common complication occurring after cardiac surgery. Guidelines for the management of this complication are scarce, often resulting in differences in treatment strategy use among patients. OBJECTIVE: To evaluate the management of POAF in a cardiac surgery department, characterize the extent of its variability, and develop a standardized protocol. METHODS: This was an observational retrospective study with data from patients who underwent cardiac surgeries with subsequent POAF between January 1, 2017, and June 1, 2018. We assessed the difference in the proportions of patients whose first POAF episodes were treated with a rate control (RaC) strategy, a rhythm control (RhC) strategy, and both among different hospital units. We also assessed the mean duration of POAF episodes, POAF recurrences, and the management of anticoagulation. RESULTS: Data from 97 patients were included in this study. The POAF management strategy differed significantly among the 3 types of hospital units (P = 0.001). Considering all POAF episodes (including all recurrences), 83 of the 97 patients (85.6%) received amiodarone as part of the RhC strategy. Anticoagulation was used in 58 (59.8%) patients and was suboptimal according to the study criteria in 29.5% of the patients included. Based on these results, a hospital working group developed a standardized protocol for POAF management. CONCLUSIONS AND RELEVANCE: POAF management was heterogeneous at our institution. This article highlights the need for clear practice guidelines based on large prospective studies to provide care according to best practices.

Type A aortic dissection in aneurysms having modelled pre-dissection maximum diameter below 45 mm: should we implement current guidelines to improve the survival benefit of prophylactic surgery?

OBJECTIVES: Current guidelines recommend prophylactic replacement of the ascending aorta at an aneurysmal diameter of >55 mm to prevent acute Type A aortic dissection (TAAD) in non-Marfan patients. Several publications have challenged this threshold, suggesting that surgery should be performed in smaller aneurysms to prevent this devastating disease. We reviewed our experience with measuring aortic size at the time of TAAD to validate the existing recommendation for prophylactic ascending aorta replacement. METHODS: All patients who had been admitted for TAAD to our emergency department from 2014 to 2019 and underwent ascending aorta replacement were included. Marfan patients were excluded. The maximum diameter of the dissected aorta was measured preoperatively using CT scan. We estimated the aortic diameter at the time of dissection to be 7 mm smaller than the measured maximum diameter of the dissected aorta (modelled pre-dissection diameter). RESULTS: Overall, 102 patients were included. Of these, 67 were male (65.6%) and 35 were female (34.4%), and the cohort's mean age was 65 ± 12.1 years. In addition, 66% were treated for arterial hypertension. The mean maximum modelled pre-dissection diameter was 39.6 ± 4.8 mm: 39.1 ± 5.1 mm in men and 40.7 ± 2.8 mm in women (P = 0.1). The cumulative 30-day mortality rate was 19.6% (20/102). CONCLUSIONS: TAAD occurred at a modelled aortic diameter below 45 mm in 87.7% of our patients. Therefore, the current aortic diameter threshold of 55 mm excludes ∼99% of patients with TAAD from prophylactic replacement of the ascending aorta. The maximum diameter of the ascending aorta warrants reappraisal and this parameter should be a distinct part of a personalized decision-making process that also takes into account age, gender and body surface area to establish the surgical indication for preventive aorta replacement aimed to improve the survival benefit of this procedure.

Transapical approach versus transcervical approach for transcatheter aortic valve replacement: a retrospective monocentric study.

OBJECTIVES: Transfemoral approach is the standard access-route for transcatheter aortic valve replacement (TAVR). However, alternative approaches are needed in a number of patients and accesses such as transapical (TA) TAVR or transcervical (TC) are used. We aimed to compare clinical and echocardiographic outcomes after TA-TAVR or TC-TAVR. METHODS: All patients who underwent TA- and TC-TAVR for severe aortic stenosis in our institution between 2008 and 2020 were retrospectively included. End points included 30-day all-cause mortality, procedural complications (according to the Valve Academic Research Consortium-2 criteria), procedure duration, intensive care unit (ICU) length of stay (LOS) and overall hospital LOS. For 30-day all-cause mortality, we furthermore used a Cox proportional-hazards model to adjust for significant between-group differences in baseline characteristics as well as difference in year of intervention. RESULTS: TAVR was performed in 176 patients, using a TA approach (n = 127) or a TC approach (n = 49). Baseline clinical and echocardiographic characteristics were comparable between the 2 groups, except age and peripheral artery disease. All-cause 30-day mortality rates were not significantly different (8.5% in the TA group vs 2.3% in the TC group, P = 0.124). TC approach was associated with significantly shorter procedure duration {71.0 [interquartile range (IQR) 52.5-101.0] vs 93 [IQR 80.0-120.0] min, P < 0.001}, shorter ICU LOS [0.0 (IQR 0.0-0.0) vs 1.0 (IQR 1.0-3.0) days, P < 0.001] and shorter hospital LOS [7.0 (IQR 5.0-9.5) vs 14.0 (IQR 10.0-22.0) days, P < 0.001]. CONCLUSIONS: The TC approach may be a good first-choice alternative in case of contraindications to transfemoral-TAVR.

A New Clinically Driven Classification for Acute Aortic Dissection.

Objectives: To report a new classification scheme for acute aortic dissection (AAD) that considers the aortic arch as a separate entity and integrates patterns of malperfusion syndrome (MPS). The proposed classification was evaluated retrospectively in a large population. Materials and Methods: We retrospectively reviewed pre-therapy CT angiograms of 226 consecutive patients (mean ± SD age: 64 ± 12 years) with AAD. AADs were reclassified with a new classification scheme that included three aortic dissection types (A, involving at least the ascending aorta; B, involving exclusively the descending aorta; and C, involving the aortic arch with/without the descending aorta) and four malperfusion grades (0: no MPS; 1: dynamic MPS; 2: static MPS; 3: static and dynamic MPS). AAD features were assessed and correlated to patient outcomes. Results: According to the new classification, we identified 152 type A dissections (92 A0, 11 A1, 38 A2, 11 A3); 50 type B (38 B0, 5 B1, 6 B2, 1 B3); and 24 type C (17 C0, 6 C2, 1 C3). Type C represented 11% of all AADs. MPS occurred in 39, 24, and 29% in type A, B, and C, respectively. Type C was treated with significantly more endovascular or hybrid interventions (37%) than in types A (3%) and B (20%) (p < 0.001). Conclusion: The new AAD classification was feasible, and type C was easily identified ("non-A, non-B"). Preliminary findings supported the usefulness of this classification for the decision-making process and subsequent treatments.

Heart procurement in a multi-organ donor.

The first orthotopic heart transplant was performed in 1967. Following on from this achievement, the first major evolution in heart transplantation was the transition from biatrial anastomosis to separate caval anastomoses, in 1991. Various strategies for myocardial protection have been used for this. This video tutorial describes heart procurement for a bicaval anastomosis technique in a case of multi-organ procurement.