Outcomes of patients with active cancer after transcatheter aortic valve replacement: an updated meta-analysis.

BACKGROUND: Patients with active cancer and aortic stenosis may be under-referred for valve interventions due to concerns over a prohibitive risk. However, whether active cancer impacts outcomes after transcatheter aortic valve replacement (TAVR) remains unknown. METHODS: We searched PubMed, Embase, and Cochrane Library in December 2023 for studies comparing the post-TAVR outcomes of patients with versus without active cancer. We pooled odds ratios (OR) and adjusted hazard ratios (aHR) with 95% confidence intervals (CI) applying a random-effects model. Statistical analyses were performed in R version 4.3.2. RESULTS: We included nine observational studies analyzing 133,906 patients, of whom 9,792 (7.3%) had active cancer. Compared with patients without cancer, patients with active cancer had higher short- (OR 1.33; 95% CI 1.15-1.55; p < 0.001) and long-term mortality (OR 2.29; 95% CI 1.80-2.91; p < 0.001) rates, not driven by cardiovascular mortality (OR 1.30; 95% CI 0.70-2.40; p = 0.40), and higher major bleeding rates (OR 1.66; 95% CI 1.15-2.42; p = 0.008). The higher mortality rate was sustained in an adjusted analysis (aHR 1.77; 95% CI 1.34-2.35; p < 0.001). There was no significant difference in cardiac, renal, and cerebral complications at a follow-up ranging from 180 days to 10 years. CONCLUSION: Patients with active cancer undergoing TAVR had higher non-cardiovascular mortality and bleeding rates, with comparable incidences of other complications. This highlights the need for a shared decision and appropriate patient selection considering cancer type, staging, bleeding risk, and optimal timing for intervention.

Direct visualization of postoperative aortobronchial fistula on computed tomography.

BACKGROUND: Postoperative aortobronchial fistula (ABF) is a rare complication that can occur in 0.3%-5.0% of patients over an extended period of time after thoracic aortic surgery. Direct visualization of the fistula via imaging is rare. AIM: To investigate the relationship between computed tomography (CT) findings and the clinical signs/symptoms of ABF after thoracic aortic surgery. METHODS: Six patients (mean age 71 years, including 4 men and 2 women) with suspected ABF on CT (air around the graft) at our hospital were included in this retrospective study between January 2004 and September 2022. Chest CT findings included direct confirmation of ABF, peri-graft fluid, ring enhancement, dirty fat sign, atelectasis, pulmonary hemorrhage, and bronchodilation, and the clinical course were retrospectively reviewed. The proportion of each type of CT finding was calculated. RESULTS: ABF detection after surgery was found to have a mean and median of 14 and 13 years, respectively. Initial signs and symptoms were asymptomatic in 4 patients, bloody sputum was found in 1 patient, and fever was present in 1 patient. The complications of ABF included graft infection in 2 patients and graft infection with hemoptysis in 2 patients. Of the 6 patients, 3 survived, 2 died, and 1 was lost to follow-up. The locations of the ABFs were as follows: 1 in the ascending aorta; 1 in the aortic arch; 2 in the aortic arch leading to the descending aorta; and 2 in the descending aorta. ABFs were directly confirmed by CT in 4/6 (67%) patients. Peri-graft dirty fat (4/6, 67%) and peri-graft ring enhancement (3/6, 50%) were associated with graft infection, endoleaks and pseudoaneurysms were associated with hemoptysis (2/6, 33%). CONCLUSION: Asymptomatic ABF after thoracic aortic surgery can be confirmed on chest CT. CT is useful for the diagnosis of ABF and its complications.

Case report: membranoproliferative glomerulonephritis associated with Q fever causing chronic endocarditis.

BACKGROUND: Membranoproliferative glomerulonephritis is a rare entity which can be a result from autoimmune diseases, caused by various medications and infections. CASE PRESENTATION: We herein present the case of a 62-year-old male patient who presented with fatigue and was found to have severe anemia, impaired renal function, and nephrotic syndrome. A renal biopsy revealed membranoproliferative glomerulonephritis (MPGN) of the immune complex type with activation of the classical complement pathway. Further investigations led to the diagnosis of a chronic Coxiella burnetii-infection (Q fever), likely acquired during cycling trips in a region known for intensive sheep farming. Additionally, the patient was found to have a post endocarditic destructive bicuspid aortic valve caused by this pathogen. Treatment with hydroxychloroquine and doxycycline was administered for a duration of 24 months. The aortic valve was replaced successfully and the patient recovered completely. CONCLUSIONS: Early detection and targeted treatment of this life-threatening disease is crucial for complete recovery of the patient.

Clinical profile, microbiology and outcomes in infective endocarditis treated with aortic valve replacement: a multicenter case-control study.

BACKGROUND: Aortic valve infective endocarditis (IE) is associated with significant morbidity and mortality. We aimed to describe the clinical profile, risk factors and predictors of short- and long-term mortality in patients with aortic valve IE treated with aortic valve replacement (AVR) compared with a control group undergoing AVR for non-infectious valvular heart disease. METHODS: Between January 2008 and December 2013, a total of 170 cases with IE treated with AVR (exposed cohort) and 677 randomly selected non-infectious AVR-treated patients with degenerative aortic valve disease (controls) were recruited from three tertiary hospitals with cardiothoracic facilities across Scandinavia. Crude and adjusted hazard ratios (HR) were estimated using Cox regression models. RESULTS: The mean age of the IE cohort was 58.5 ± 15.1 years (80.0% men). During a mean follow-up of 7.8 years (IQR 5.1-10.8 years), 373 (44.0%) deaths occurred: 81 (47.6%) in the IE group and 292 (43.1%) among controls. Independent risk factors associated with IE were male gender, previous heart surgery, underweight, positive hepatitis C serology, renal failure, previous wound infection and dental treatment (all p < 0.05). IE was associated with an increased risk of both short-term (≤ 30 days) (HR 2.86, [1.36-5.98], p = 0.005) and long-term mortality (HR 2.03, [1.43-2.88], p < 0.001). In patients with IE, chronic obstructive pulmonary disease (HR 2.13), underweight (HR 4.47), renal failure (HR 2.05), concomitant mitral valve involvement (HR 2.37) and mediastinitis (HR 3.98) were independent predictors of long-term mortality. Staphylococcus aureus was the most prevalent microbe (21.8%) and associated with a 5.2-fold increased risk of early mortality, while enterococci were associated with the risk of long-term mortality (HR 1.78). CONCLUSIONS: In this multicenter case-control study, IE was associated with an increased risk of both short- and long-term mortality compared to controls. Efforts should be made to identify, and timely treat modifiable risk factors associated with contracting IE, and mitigate the predictors of poor survival in IE.

Inflammatory signature-based theranostics for acute lung injury in acute type A aortic dissection.

Acute lung injury (ALI) is a serious adverse event in the management of acute type A aortic dissection (ATAAD). Using a large-scale cohort, we applied artificial intelligence-driven approach to stratify patients with different outcomes and treatment responses. A total of 2,499 patients from China 5A study database (2016-2022) from 10 cardiovascular centers were divided into 70% for derivation cohort and 30% for validation cohort, in which extreme gradient boosting algorithm was used to develop ALI risk model. Logistic regression was used to assess the risk under anti-inflammatory strategies in different risk probability. Eight top features of importance (leukocyte, platelet, hemoglobin, base excess, age, creatinine, glucose, and left ventricular end-diastolic dimension) were used to develop and validate an ALI risk model, with adequate discrimination ability regarding area under the receiver operating characteristic curve of 0.844 and 0.799 in the derivation and validation cohort, respectively. By the individualized treatment effect prediction, ulinastatin use was significantly associated with significantly lower risk of developing ALI (odds ratio [OR] 0.623 [95% CI 0.456, 0.851]; P = 0.003) in patients with a predicted ALI risk of 32.5-73.0%, rather than in pooled patients with a risk of <32.5 and >73.0% (OR 0.929 [0.682, 1.267], P = 0.642) (Pinteraction = 0.075). An artificial intelligence-driven risk stratification of ALI following ATAAD surgery were developed and validated, and subgroup analysis showed the heterogeneity of anti-inflammatory pharmacotherapy, which suggested individualized anti-inflammatory strategies in different risk probability of ALI.

The optimal management of blunt aortic injury in the young.

BACKGROUND: Blunt aortic injury (BAI) is relatively uncommon in the pediatric population. The goal of this study was to examine the management of BAI in both children and adolescents, using a large national dataset. METHODS: Patients (1-19 years of age) with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 14-years. Patients were stratified by age group (children [ages 1-9] and adolescents [ages 10-19]) and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in adolescents with BAI. RESULTS: Adolescents undergoing TEVAR had similar morbidity (16.8 vs 12.6 â€‹%, p â€‹= â€‹0.057) and significantly reduced mortality (2.1 vs 14.4 â€‹%, p â€‹< â€‹0.0001) compared to those adolescents managed non-operatively. MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (OR 0.138; 95%CI 0.059-0.324, p â€‹< â€‹0.0001). CONCLUSIONS: BAI leads to significant morbidity and mortality for both children and adolescents. For pediatric patients with BAI, children may be safely managed non-operatively, while an endovascular repair may improve outcomes for adolescents.

Transcatheter Structural Heart Disease Interventions and Concomitant Left Atrial Appendage Occlusion: A State-of-the-Art Review.

Atrial fibrillation (AF) is the most common arrhythmia in patients with valvular heart disease, and it can be associated with adverse patient outcomes. However, the need of anticoagulation to counterbalance AF-associated stroke risk may further lead to suboptimal outcomes via increasing bleeding events, especially in high-risk individuals. Currently, the option to perform a concomitant to the index procedure for limiting stroke risk is emerging, in accordance to usual practice in cardiac surgery. In specific, as the vast majority of thrombi occur in the left atrial appendage, left atrial appendage occlusion (LAAO) is an established procedure for preventing ischemic stroke in patients with AF, while limiting anticoagulation-related bleeding events. Thus, the concept of combining an index procedure for a structural heart disease (SHD) with LAAO seems promising for preventing future stroke events. A combined procedure has been described in aortic stenosis (TAVI+LAAO), mitral regurgitation (TEER+LAAO) and atrial septal defects (PFO/ASD+LAAO). Evidence shows that a combined procedure can be safely performed in a "one-stop shop" fashion, without increased rates of procedural adverse events, with the potential to limit bleeding risk and provide prophylaxis against stroke events. Thus, this review is going to analyze indications and clinical evidence regarding the safety and efficacy of combined SHD+LAAO procedure, while also providing insights in gaps in knowledge and future directions for the evolvement of this field.

Volume Measurements for Surveillance after Endovascular Aneurysm Repair using Artificial Intelligence.

OBJECTIVE: Surveillance after endovascular aneurysm repair (EVAR) is suboptimal due to limited compliance and relatively large variability in measurement methods of abdominal aortic aneurysm (AAA) sac size after treatment. Measuring volume offers a more sensitive early indicator of aneurysm sac growth or regression/stability, but is more time consuming and thus less practical than measuring maximum diameter. This study evaluated the accuracy and consistency of the artificial intelligence (AI) driven software PRAEVAorta 2 and compared it with an established semi-automated segmentation method. METHODS: Post-EVAR aneurysm sac volumes measured by AI were compared with a semi-automated segmentation method (3mensio software) in patients with infrarenal AAA, focusing on absolute aneurysm volume and volume evolution over time. The clinical impact of both methods was evaluated by categorising patients as showing either AAA sac regression, stabilisation, or growth comparing the 30 day and one year post-EVAR computed tomography angiography (CTA) images. Intermethod and intramethod agreement were assessed using Bland-Altman analysis, the intraclass correlation coefficient (ICC) and Cohen's κ statistic. RESULTS: Forty nine patients (98 CTA images) were analysed, after excluding 15 patients due to segmentation errors by AI owing to low quality CT scans. Aneurysm sac volume measurements showed excellent correlation (ICC = 0.94, 95% confidence interval [CI] 0.88 - 0.99) with good to excellent correlation for volume evolution over time (ICC = 0.85, 95% CI 0.75 - 0.91). Categorisation of AAA sac evolution showed fair correlation (Cohen's κ = 0.33), with 12 discrepancies (24%) between methods. The intramethod agreement for the AI software demonstrated perfect consistency (bias = -0.01 cc), indicating that it is more reliable compared with the semi-automated method. CONCLUSION: Despite some differences in AAA sac volume measurements, the highly consistent AI driven software accurately measured AAA sac volume evolution. AAA sac evolution classification appears to be more reliable than existing methods and may therefore improve risk stratification post-EVAR. It could facilitate AI driven personalised surveillance programmes. While high quality CTA images are crucial, considering radiation exposure is important, validating the software with non-contrast CT scans might reduce the radiation burden.

The cardioprotective effects of adenosine-induced cardioplegic arrest versus saline in aortic valve replacement patients: A randomized controlled trial.

BACKGROUND AND AIMS: Adenosine is a widely used potent cardioprotective drug, but the effect of an adenosine bolus in initial cardioplegia on cardioprotection in aortic valve replacement (AVR) patients has not been demonstrated. The aim of this double-blind randomized clinical trial was to compare intra-aortic adenosine bolus with saline on the postoperative myocardial function in patients undergoing AVR. METHODS: Aortic valve stenosis patients scheduled for elective or urgent AVR surgery were randomized to receive either a 20 mg (4 mL) single dose of adenosine or a saline into the ascending aorta during the first cardioplegia infusion. The primary outcome was cardiac index (CI (L/min/m2) at four timepoints (before incision, after weaning from cardiopulmonary bypass (CPB), at 7 p.m. on the operation day, and at 6 a.m. the next morning). Secondary outcomes included left ventricular stroke work index, right ventricular stroke work index, and myocardial biomarkers at the same timepoints. RESULTS: Between November 2015 and March 2018, 45 patients were recruited, 23 in the adenosine group and 22 in the placebo group. The last follow-up date was 17 March 2018. There were no statistically significant differences in CI (mean differences with 95% confidence interval (95% CI): 0.09 L/min/m2 at baseline (-0.20 to 0.38), -1.39 L/min/m2 (-3.47 to 0.70) at post-CPB, -0.39 L/min/m2 (-0.78 to 0.004) at 7 p.m., and -0.32 L/min/m2 (-0.68 to 0.05) at 6 a.m., (p = 0.066)), right ventricular stroke work index, (p = 0.24), or cardiac biomarkers between the groups. Left ventricular stroke work index was lower in the adenosine group (-3.66 gm/m2 (-11.13 to 3.81) at baseline, -17.42 gm/m2 (-37.81 to 2.98) at post-CPB, -3.36 gm/m2 (-11.10 to 4.38) at 7 p.m., and -3.77 gm/m2 (-10.19 to 2.66) at 6 a.m. (p = 0.021)). CONCLUSIONS: There were no differences between 20 mg adenosine bolus and saline in the first cardioplegia infusion in CI improvement in AVR surgery for aortic valve stenosis.EudraCT number: 2014-001382-26.

Comparison of mouse models of heart failure with reduced ejection fraction.

AIMS: Heart failure with reduced ejection fraction (HFrEF) is a leading cause of death worldwide; thus, therapeutic improvements are needed. In vivo preclinical models are essential to identify molecular drug targets for future therapies. Transverse aortic constriction (TAC) is a well-established model of HFrEF; however, highly experienced personnel are needed for the surgery, and several weeks of follow-up are necessary to develop HFrEF. To this end, we aimed (i) to develop an easy-to-perform mouse model of HFrEF by treating Balb/c mice with angiotensin-II (Ang-II) for 2 weeks by minipump and (ii) to compare its cardiac phenotype and transcriptome to the well-established TAC model of HFrEF in C57BL/6J mice. METHODS: Mortality and gross pathological data, cardiac structural and functional characteristics assessed by echocardiography and immunohistochemistry and differential gene expression obtained by RNA-sequencing and gene-ontology analyses were used to characterize and compare the two models. To achieve statistical comparability between the two models, changes in treatment groups related to the corresponding control were compared (ΔTAC vs. ΔAng-II). RESULTS: Compared with the well-established TAC model, chronic Ang-II treatment of Balb/c mice shares similarities in cardiac systolic functional decline (left ventricular ejection fraction: -57.25 ± 7.17% vs. -43.68 ± 5.31% in ΔTAC vs. ΔAng-II; P = 0.1794) but shows a lesser degree of left ventricular dilation (left ventricular end-systolic volume: 190.81 ± 44.13 vs. 57.37 ± 10.18 mL in ΔTAC vs. ΔAng-II; P = 0.0252) and hypertrophy (cell surface area: 58.44 ± 6.1 vs. 10.24 ± 2.87 µm2 in ΔTAC vs. ΔAng-II; P < 0.001); nevertheless, transcriptomic changes in the two HFrEF models show strong correlation (Spearman's r = 0.727; P < 0.001). In return, Ang-II treatment in Balb/c mice needs significantly less procedural time [38 min, interquartile range (IQR): 31-46 min in TAC vs. 6 min, IQR: 6-7 min in Ang-II; P < 0.001] and surgical expertise, is less of an object for peri-procedural mortality (15.8% in TAC vs. 0% in Ang-II; P = 0.105) and needs significantly shorter follow-up for developing HFrEF. CONCLUSIONS: Here, we demonstrate for the first time that chronic Ang-II treatment of Balb/c mice is also a relevant, reliable but significantly easier-to-perform preclinical model to identify novel pathomechanisms and targets in future HFrEF research.

Hospital and Surgeon Surgical Valvar Volume and Survival after Multi-Valve Cardiac Surgery in Medicare Beneficiaries.

OBJECTIVE: Long-term outcomes after multi-valve cardiac surgery remain under-evaluated. METHODS: Medicare administrative claims from 2008-2019 identified beneficiaries undergoing multi-valve surgery. Operative characteristics were doubly-adjudicated using International Classification of Diseases and Current Procedural Technology codes. A multivariable flexible parametric model evaluated predictors of survival; regression standardization was performed to predict standardized survival probabilities (SSP) at varying percentiles of annual valvar volume. RESULTS: Of 476,092 cardiac surgeries involving the aortic (AVS), mitral (MVS), or tricuspid (TVS) valve, 63,083 (13.3%) were identified as involving multi-valve surgery: 22,884 MVS+TVS, 30,697 AVS+MVS, 3,443 AVS+TVS and 6,059 AVS+MVS+TVS. Surgery occurred at 1,157 hospitals by 2,922 surgeons. Annual valvar volume (total AVS+MVS+TVS) was tallied for surgeons and hospitals. Median survival varied substantially by type of multi-valve surgery: 8.09 [7.90-8.24] years in MVS/TVS, 6.65 [6.49-6.81] years in AVS/MVS, 5.77 [5.37-6.13] in AVS/TVS, and 6.02 [5.64-6.38] in AVS/MVS/TVS. SSPs were calculated across combined hospital/surgeon volume percentiles; the median SSP increased with increasing percentile of combined hospital/surgeon volume: 5%tile: 5.77 [5.58,5.98], 25%tile: 6.18 [6.07,6.28], 50%tile: 6.56 [6.44,6.68], 75%tile: 6.86 [6.75,6.97], and 95%tile: 7.58 [7.34,7.83] years, respectively. CONCLUSIONS: Survival varied significantly by type of multi-valve surgery, worsened with addition of concomitant interventions and improved substantially with increasing annual hospital and surgeon volume. Hospital volume was associated with an improved early hazard for death that abated beyond 3 months post-surgery), while surgeon volume was associated with an improved hazard for death that persisted even beyond the first post-operative year. Consideration should be given to referring multi-valve cases to high-volume hospitals and surgeons.

IL-6 signaling accelerates iron overload by upregulating DMT1 in endothelial cells to promote aortic dissection.

Aortic dissection (AD), caused by tearing of the intima and avulsion of the aortic media, is a severe threat to patient life and organ function. Iron is closely related to dissection formation and organ injury, but the mechanism of iron ion transport disorder in endothelial cells (ECs) remains unclear. We identified the characteristic EC of dissection with iron overload by single-cell RNA sequencing data. After intersecting iron homeostasis and differentially expressed genes, it was found that hypoxia-inducible factor-1α (HIF-1α) and divalent metal transporter 1 (DMT1) are key genes for iron ion disorder. Subsequently, IL-6R was identified as an essential reason for the JAK-STAT activation, a classical iron regulation pathway, through further intersection and validation. In in vivo and in vitro, both high IL-6 receptor expression and elevated IL-6 levels promote JAK1-STAT3 phosphorylation, leading to increased HIF-1α protein levels. Elevated HIF-1α binds explicitly to the 5'-UTR sequence of the DMT1 gene and transcriptionally promotes DMT1 expression, thereby increasing Fe2+ accumulation and endoplasmic reticulum stress (ERS). Blocking IL-6R and free iron with deferoxamine and tocilizumab significantly prolonged survival and reduced aortic and organ damage in dissection mice. A comparison of perioperative data between AD patients and others revealed that high free iron, IL-6, and ERS levels are characteristics of AD patients and are correlated with prognosis. In conclusion, activated IL-6/JAK1/STAT3 signaling axis up-regulates DMT1 expression by increasing HIF-1α, thereby increasing intracellular Fe2+ accumulation and tissue injury, which suggests a potential therapeutic target for AD.

Sealing Zone Failure Decreases the Long Term Durability of Endovascular Aneurysm Repair.

OBJECTIVE: Endovascular aneurysm repair (EVAR) has higher long term aneurysm related mortality compared with open surgery, mainly due to aneurysm rupture. Loss of stent graft-vessel apposition at the EVAR sealing zones is a potential cause of post-EVAR rupture. This study aimed to investigate sealing zone failure and its relation to post-EVAR rupture. METHODS: This was a retrospective structured review of pre-operative and post-operative computed tomography (CT) scans of 399 consecutive patients treated with standard bifurcated EVAR. The primary outcome was total loss of seal at last post-operative CT. Secondary outcomes were partial loss of seal, standard follow up detection, post-EVAR rupture, aneurysm sac development, and endoleaks. RESULTS: During a median follow up of 5.3 years, total and partial loss of seal occurred in 85 (21.3%) and 78 (19.5%) patients, respectively. Initial mean sealing zone lengths were within current recommendations but decreased over time, mainly due to vessel dilatation. Mean proximal sealing length at one month CT was 15.5 ± 10.5 mm (95% confidence interval [CI] 12.6 - 18.5 mm) in the group with total loss of seal, 14.3 ± 6.9 mm (95% CI 12.2 - 16.4 mm) with partial loss of seal, and 23.2 ± 7.4 mm (95% CI 22.3 - 24.0 mm) with preserved seal through follow up (p < .001). Mean iliac sealing lengths were 22.4 ± 12.1 mm (95% CI 18.9 - 25.8 mm) if total loss and 21.8 ± 10.0 mm (95% CI 19.6 - 24.0 mm) if partial loss of seal vs. 34.7 ± 12.4 mm (95% CI 33.8 - 35.7 mm) if preserved seal. Larger vessel diameters were associated with loss of seal both in proximal and distal sealing zones. During the study period, 13 post-EVAR ruptures occurred, all preceded by CT findings of total (n = 7) or partial (n = 6) loss of seal. Aneurysm sac expansion was seen in 40% of patients with total loss of seal, 18% with partial loss of seal, and 6.6% with preserved seal. CONCLUSION: Loss of seal after EVAR is frequent and associated with post-EVAR rupture. Increased recommended sealing zones lengths and focus on sealing zones in surveillance may reduce post-EVAR ruptures and aneurysm related mortality.

Extensive aortic replacement including aortic arch for a mega aorta with chronic aortic dissection via posterolateral thoracotomy.

BACKGROUND: Mega-aortic syndrome including aortic arch and descending aortic aneurysm is a challenging surgical case. Because the aorta continuously dilates, creating the distal anastomosis sites becomes an issue. Despite the developments in endovascular techniques including frozen elephant trunk, in the case of mega-aortic syndrome or mycotic aneurysm, extensive surgical repair is still a strong armamentarium. Our patient had a mega-aorta with chronic aortic dissection. Herein, we show tips regarding concurrent ascending, aortic arch, and descending aortic replacement via posterolateral thoracotomy for this relatively young patient. CASE PRESENTATION: A 46-year-old man with chronic kidney disease had chronic type A aortic dissection with an extensively dilated thoracic aorta from the distal ascending to the descending aorta measuring 63 mm in diameter and abdominal aorta measuring 50 mm. The short segment of the distal descending aorta was narrowed to 36 mm. The patient underwent a concurrent replacement of the distal ascending aorta, aortic arch, and descending aorta via a posterolateral thoracotomy. The patient was extubated on postoperative day (POD) 1 and discharged home without serious complications such as stroke, respiratory failure, or renal failure on POD 18. The 1-year follow-up computed tomography did not find issues in the anastomosis sites; however, the abdominal aorta enlarged from 50 to 58 mm. The patient underwent a thoracoabdominal aortic replacement and recovered well without any complications. CONCLUSIONS: Good exposure and meticulous organ protection methods are key to a safe concurrent replacement of the ascending, aortic arch, and descending aorta via posterolateral thoracotomy.

High proportion of undiagnosed diabetes in patients surgically treated for infrarenal abdominal aortic aneurysm: findings from the multicentre Norwegian Aortic Aneurysm and Diabetes (ABANDIA) Study.

BACKGROUND: The aim was to investigate the total prevalence of known and undiagnosed diabetes mellitus (DM), and the association of DM with perioperative complications following elective, infrarenal, open surgical (OSR) or endovascular (EVAR), Abdominal Aortic Aneurysm (AAA) repair. METHODS: In this Norwegian prospective multicentre study, 877 patients underwent preoperative screening for DM by HbA1c measurements from November 2017 to December 2020. Diabetes was defined as screening detected HbA1c ≥ 48 mmol/mol (6.5%) or previously diagnosed diabetes. The association of DM with in-hospital complications, length of stay, and 30-day mortality rate were evaluated using adjusted and unadjusted logistic regression models. RESULTS: The total prevalence of DM was 15% (95% CI 13%,17%), of which 25% of the DM cases (95% CI 18%,33%) were undiagnosed upon admission for AAA surgery. The OSR to EVAR ratio was 52% versus 48%, with similar distribution among DM patients, and no differences in the prevalence of known and undiagnosed DM in the EVAR versus the OSR group. Total 30-day mortality rate was 0.6% (5/877). Sixty-six organ-related complications occurred in 58 (7%) of the patients. DM was not statistically significantly associated with a higher risk of in-hospital organ-related complications (OR 1.23, 95% CI 0.57,2.39, p = 0.57), procedure-related complications (OR 1.48, 95% CI 0.79,2.63, p = 0.20), 30-day mortality (p = 0.09) or length of stay (HR 1.06, 95% CI 0.88,1.28, p = 0.54). According to post-hoc-analyses, organ-related complications were more frequent in patients with newly diagnosed DM (n = 32) than in non-DM patients (OR 4.92; 95% CI 1.53,14.3, p = 0.005). CONCLUSION: Twenty-five percent of all DM cases were undiagnosed at the time of AAA surgery. Based on post-hoc analyses, undiagnosed DM seems to be associated with an increased risk of organ related complications following AAA surgery. This study suggests universal DM screening in AAA patients to reduce the number of DM patients being undiagnosed and to improve proactive diabetes care in this population. The results from post-hoc analyses should be confirmed in future studies.

Cerebral hypoperfusion resulting from improper cannulation positioning during aortic dissection surgery: a case report.

BACKGROUND: Selective antegrade cerebral perfusion (sACP) is a crucial cerebral protection technique employed during aortic dissection surgeries involving cardiopulmonary bypass. However, postoperative neurological complications, particularly those related to cannulation issues and perfusion problems, remain a significant concern. CASE PRESENTATION: This case report details an unusual instance where a 38-year-old male patient with Marfan syndrome experienced cerebral hypoperfusion during emergency surgery for Stanford Type A aortic dissection. Despite following standard protocols, a significant drop in regional cerebral oxygen saturation (rSO2) and abnormal blood pressure fluctuations were observed shortly after initiating sACP via the innominate artery. After initial attempts to optimize perfusion flow proved ineffective, the cannulation position was adjusted, leading to improvements. Nevertheless, the patient subsequently exhibited signs of cerebral hypoperfusion and was found to have suffered a new cerebral infarction. CONCLUSIONS: This case report underscores the importance of precise cannula placement during sACP procedures and the dire consequences that can arise from improper positioning. It emphasizes the need for continuous monitoring and prompt intervention in cases of abnormal cerebral oxygenation and blood pressure, as well as the value of considering cannulation-related issues as potential causes of postoperative neurological complications.

Carbon dioxide cone-beam computed tomography for the technical assessment of endovascular aortic intervention.

Cone-beam computed tomography (CBCT) is widely used for the technical assessment of standard and complex endovascular aortic interventions. Use of iodinated contrast in CBCT imaging might provide useful additional information; however, this also increases the procedural contrast dose, which may cause renal function deterioration, and the radiation exposure. We describe the technique and feasibility of carbon-dioxide (CO2)-enhanced CBCT for the technical assessment of standard and complex endovascular aortic repair. In our experience CO2-CBCT had no related adverse events and provided satisfactory imaging quality to assess endograft integrity, vessels patency, and was safely performed in case of severe chronic renal insufficiency.

A nomogram for individualized prediction of new-onset postoperative atrial fibrillation in acute type A aortic dissection patients: a retrospective study.

Objective: The objective of this study is to explore the risk factors associated with new-onset postoperative atrial fibrillation (POAF) following Sun's surgery(total arch replacement using a tetrafurcate graft with stented elephant trunk implantation) for acute type A aortic dissection(AAAD) and to develop a predictive model for assessing the likelihood of new-onset POAF in patients undergoing Sun's surgery for AAAD. Methods: We reviewed the clinical parameters of patients diagnosed with AAAD who underwent Sun's surgery at Qilu Hospital between December 1, 2017 and December 31, 2022. The data was analyzed through univariable and multivariable logistic regression analysis. Variance inflation factor was used to investigate for variable collinearity. A nomogram for predicting new-onset POAF was developed and verified by bootstrap resampling. In addition, the calibration of our model was evaluated by the calibration curve and Hosmer-Lemeshow test. Furthermore, the clinical utility of our model was evaluated using the net benefit curve. Results: This study focused on a cohort of 242 patients with AAAD, among whom 42 experienced new-onset POAF, indicating an incidence rate of 17.36%. Age, left atrial diameter (LA), right atrial diameter (RA), preoperative red blood cells (RBC), and previous acute coronary syndrome (preACS) emerged as independent influences on new-onset POAF following Sun's surgery, as identified by univariable and multivariable logistic regression analysis. Collinearity analysis with demonstrated no collinearity among the variables. A user-friendly prediction nomogram for new onset POAF following Sun's surgery was formulated. The model demonstrated commendable diagnostic accuracy with an area under the curve (AUC) of 0.7852. Validation of the model through bootstrapping (1,000 repetitions) yielded an AUC of 0.8080 (95% CI: 0.8056-0.8104). affirming its robustness. Additionally, the model exhibited favorable fit, calibration, and positive net benefits in decision curve analysis. Conclusions: Drawing upon these findings, we have developed a predictive model for the occurrence of new-onset POAF. These results suggest the potential efficacy of this prediction model for identifying patients at risk of developing POAF. The visualization of this model empowers healthcare professionals to conveniently and promptly assess the risk of AF in patients, thereby facilitating the timely intervention implementation.

Successful percutaneous coronary intervention of left main coronary artery dissection following mechanical aortic valve replacement surgery: a case report and literature review.

Background: Iatrogenic left main coronary artery (LMCA) dissection resulting from cardiac surgery is a rare complication. Its early detection is challenging and often poses a significant threat to the patient's life. However, evidence regarding the most effective management strategy for this condition remains limited at present. Case presentation: We present a case of 65-year-old female patient who developed cardiogenic shock after mechanical aortic valve replacement surgery associated acute myocardial infraction. Despite concurrent coronary artery bypass graft (CABG) surgery, the patient's condition remained unimproved. Subsequent coronary angiography revealed extensive LMCA dissection involving the left circumflex (LCx) artery. Percutaneous coronary intervention (PCI) guided by intravascular ultrasound (IVUS) led to an immediate improvement in hemodynamic status. The patient was successfully discharged after 22 days of treatment. Conclusions: Iatrogenic LMCA dissection is an uncommon complication following cardiac surgery. It can manifest in a variety of ways, including as incidental findings, cardiogenic shock or sudden cardiac arrest. The precise prevalence rates of causes linked to cardiac surgery remain largely unknown due to the scarcity of reported cases and the absence of research on this issue. Currently, a definitive management strategy for this condition has not been established. However, previous reported clinical cases provide insight that CABG could be considered if coronary artery dissection is detected during cardiac surgery. Upon postoperative identification, diagnostic coronary angiography and PCI may be feasible alternatives.

Acute type A aortic dissection in patients with non-prior cardiac surgery vs. prior cardiac surgery: a systematic review and meta-analysis.

Background: Patients with prior cardiac surgery undergoing acute type A aortic dissection (ATAAD) are thought to have worse clinical outcomes as compared to the patients without prior cardiac surgery. Aim: To compare the safety and efficacy of ATAAD in patients with prior cardiac surgery. Methods: We systematically searched PubMed, Cochrane Library and Google Scholar from database inception until April 2024. We included nine studies which consisted of a population of 524 in the prior surgery group and 5,249 in the non-prior surgery group. Our primary outcome was mortality. Secondary outcomes included reoperation for bleeding, myocardial infarction, stroke, renal failure, sternal wound infection, cardiopulmonary bypass (CPB) time, cross-clamp time, hospital stay, and ICU stay. Results: Our pooled estimate shows a significantly lower rate of mortality in the non-prior cardiac surgery group compared to the prior cardiac surgery group (RR = 0.60, 95% CI = 0.48-0.74). Among the secondary outcomes, the rate of reoperation for bleeding was significantly lower in the non-prior cardiac surgery group (RR = 0.66, 95% CI = 0.50-0.88). Additionally, the non-prior cardiac surgery group had significantly shorter CPB time (MD = -31.06, 95% CI = -52.20 to -9.93) and cross-clamp time (MD = -21.95, 95% CI = -42.65 to -1.24). All other secondary outcomes were statistically insignificant. Conclusion: Patients with prior cardiac surgery have a higher mortality rate as compared to patients who have not undergone cardiac surgery previously. Patients with prior cardiac surgery have higher mortality and longer CPB and cross-clamp times. Tailored strategies are needed to improve outcomes in this high-risk group.