Lactate-Based Difference as a Determinant of Outcomes following Surgery for Type A Acute Aortic Dissection: A Multi-Centre Study.

Type A acute aortic dissection (TAAAD) is a serious condition within the acute aortic syndromes that demands immediate treatment. Despite advancements in diagnostic and referral pathways, the survival rate post-surgery currently sits at almost 20%. Our objective was to pinpoint clinical indicators for mortality and morbidity, particularly raised arterial lactate as a key factor for negative outcomes. METHODS: All patients referred to the three cardiovascular centres between January 2005 and December 2022 were included in the study. The inclusion criteria required the presence of a lesion involving the ascending aorta, symptoms within 7 days of surgery, and referral for primary surgical repair of TAAAD based on recommendations, with consideration for other concomitant major cardiac surgical procedures needed during TAAAD and retrograde extension of TAAAD. We conducted an analysis of both continuous and categorical variables and utilised predictive mean matching to fill in missing numeric features. For missing binary variables, we used logistic regression to impute values. We specifically targeted early postoperative mortality and employed LASSO regression to minimise potential collinearity of over-fitting variables and variables measured from the same patient. RESULTS: A total of 633 patients were recruited for the study, out of which 449 patients had complete preoperative arterial lactate data. The average age of the patients was 64 years, and 304 patients were male (67.6%). The crude early postoperative mortality rate was 24.5% (110 out of 449 patients). The mortality rate did not show any significant difference when comparing conservative and extensive surgeries. However, malperfusion had a significant impact on mortality [48/131 (36.6%) vs. 62/318 (19.5%), p < 0.001]. Preoperative arterial lactates were significantly elevated in patients with malperfusion. The optimal prognostic threshold of arterial lactate for predicting early postoperative mortality in our cohort was ≥2.6 mmol/L. CONCLUSION: The arterial lactate concentration in patients referred for TAAAD is an independent factor for both operative mortality and postoperative complications. In addition to mortality, patients with an upper arterial lactate cut-off of ≥2.6 mmol/L face significant risks of VA ECMO and the need for dialysis within the first 48 h after surgery. To improve recognition and facilitate rapid transfer and surgical treatment protocol, more diligent efforts are required in the management of malperfusion in TAAAD.

A Literature Review on the Use of Aortic Allografts in Modern Cardiac Surgery for the Treatment of Infective Endocarditis: Is There Clear Evidence or Is It Merely a Perception?

Infective valve endocarditis is caused by different pathogens and 60% of those involve the aortic valve with valve failure. Although S. aureus is recognized as the most frequently isolated causative bacterium associated with IE in high-income countries, Gram-positive cocci nevertheless play a crucial role in promoting infection in relation to their adhesive matrix molecules. The presence of pili on the surface of Gram-positive bacteria such as in different strains of Enterococcus faecalis and Streptococcus spp., grants these causative pathogens a great offensive capacity due to the formation of biofilms and resistance to antibiotics. The indications and timing of surgery in endocarditis are debated as well as the choice of the ideal valve substitute to replace the diseased valve(s) when repair is not possible. We reviewed the literature and elaborated a systematic approach to endocarditis management based on clinical, microbiological, and anatomopathological variables known to affect postoperative outcomes with the aim to stratify the patients and orient decision making. From this review emerges significant findings on the risk of infection in the allograft used in patients with endocarditis and no endocarditis etiology suggesting that the use of allografts has proved safety and effectiveness in patients with both pathologies.

The Roles of microRNAs in the Cardiovascular System.

The discovery of miRNAs and their role in disease represent a significant breakthrough that has stimulated and propelled research on miRNAs as targets for diagnosis and therapy. Cardiovascular disease is an area where the restrictions of early diagnosis and conventional pharmacotherapy are evident and deserve attention. Therefore, miRNA-based drugs have significant potential for development. Research and its application can make considerable progress, as seen in preclinical and clinical trials. The use of miRNAs is still experimental but has a promising role in diagnosing and predicting a variety of acute coronary syndrome presentations. Its use, either alone or in combination with currently available biomarkers, might be adopted soon, particularly if there is diagnostic ambiguity. In this review, we examine the current understanding of miRNAs as possible targets for diagnosis and treatment in the cardiovascular system. We report on recent advances in recognising and characterising miRNAs with a focus on clinical translation. The latest challenges and perspectives towards clinical application are discussed.

Surgical Strategy for the Repair of Acute Type A Aortic Dissection: A Multicenter Study.

Type A acute aortic dissection is associated with significant morbidity and mortality, with prompt referral imaging and management to tertiary referral centers needed urgently. Surgery is usually needed emergently, but the choice of surgery often varies depending on the patient and the presentation. Staff and center expertise also play a major role in determining the surgical strategy employed. The aim of this study was to compare the early- and medium-term outcomes of patients undergoing a conservative approach extended only to the ascending aorta and the hemiarch to those of patients subjected to extensive surgery (total arch reconstruction and root replacement) across three European referral centers. A retrospective study was conducted across three sites between January 2008 and December 2021. In total, 601 patients were included within the study, of which 30% were female, and the median age was 64.4 years. The most common operation was ascending aorta replacement (n = 246, 40.9%). The aortic repair was extended proximally (i.e., root n = 105; 17.5%) and distally (i.e., arch n = 250; 41.6%). A more extensive approach, extending from the root to the arch, was employed in 24 patients (4.0%). Operative mortality occurred in 146 patients (24.3%), and the most common morbidity was stroke (75, 12.6%). An increased length of ICU admission was noted in the extensive surgery group, which comprised younger and more frequently male patients. No significant differences were noted in surgical mortality between patients managed with extensive surgery and those managed conservatively. However, age, arterial lactate levels, "intubated/sedated" status on arrival, and "emergency or salvage" status at presentation were independent predictors of mortality both within the index hospitalization and during the follow-up. The overall survival was similar between the groups.

Association Between Shock Etiology and 5-Year Outcomes After Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: Outcomes of patients requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) vary greatly by etiology, but large studies that incorporate the spectrum of shock supported with ECMO are rare. OBJECTIVES: The purpose of this study was to describe the etiology-related outcome of patients with shock supported with peripheral VA-ECMO. METHODS: All consecutive adults with peripheral VA-ECMO between January 2015 and August 2018 at Pitié-Salpêtrière Hospital (Paris, France) were included in this retrospective observational study. The indication for VA-ECMO was cardiogenic shock. Rates of hospital death and neurological, renal, and pulmonary complications were evaluated according to etiology. RESULTS: Among 1,253 patients, hospital and 5-year survival rates were, respectively, 73.3% and 57.3% for primary graft failure, 58.6% and 54.0% for drug overdose, 53.2% and 45.3% for dilated cardiomyopathy, 51.6% and 50.0% for arrhythmic storm, 46.8% and 38.3% for massive pulmonary embolism, 44.4% and 42.4% for sepsis-induced cardiogenic shock, 37.9% and 32.9% for fulminant myocarditis, 37.3% and 31.5% for acute myocardial infarction, 34.6% and 33.3% for postcardiotomy excluding primary graft failure, 25.7% and 22.8% for other/unknown etiology, and 11.1% and 0.0% for refractory vasoplegia shock. Renal failure requiring hemodialysis developed in 50.0%, neurological complications in 16.0%, and hydrostatic pulmonary edema in 9.0%. CONCLUSIONS: Although the outcome differs depending on etiology, this difference is related more to the severity of the situation associated with the cause rather than the cause of the shock per se. Survival to 5 years varied by cause, which may reflect the natural course of the chronic disease and illustrates the need for long-term follow-up.

Atrio-oesophageal fistula following atrial fibrillation ablation: how to manage this dreaded complication?

OBJECTIVES: Atrio-oesophageal fistula is a rare but serious complication of radiofrequency catheter ablation of atrial fibrillation. Therapeutic options are surgery, oesophageal stenting and conservative treatment (antibiotics and anticoagulation). However, there are no guidelines available. Since no article dwells on the technical considerations of this surgery, we aim to present here our experience and share our surgical approach. METHODS: Between January 2012 and March 2020, all consecutive patients treated for atrio-oesophageal fistula following radiofrequency catheter ablation of atrial fibrillation at our institution were analysed retrospectively. The diagnosis was made on a set of clinical and radiological signs. All patients benefitted from a combined approach involving both digestive and cardiac surgeons. Femoro-femoral peripheral cardiopulmonary by-pass was used. The surgical approach was a right posterolateral thoracotomy. Atrial repair was done on fibrillating heart without cross-clamping, using a left atriotomy. Digestive management consisted of a total oesophagectomy. RESULTS: We identified 6 patients with this complication. The median age was 53 [34-72] years. Symptoms were neurological symptoms, fever and chest pain. Diagnostic modalities were cerebral imaging, chest CT and transthoracic echocardiogram. Atrial repair consisted in a suture of the atrium or by using a pericardial patch. With a median follow-up of 3.1 [0.1-7.7] years, only one patient died during the follow-up. CONCLUSIONS: Our experience shows that an aggressive surgery with a large resection of the oesophagus and left atrial repair by right thoracotomy in the same time provides good results. The ability to involve simultaneously both experienced digestive and cardiac surgical teams is the key for this strategy.

Venous or arterial thromboses after venoarterial extracorporeal membrane oxygenation support: Frequency and risk factors.

BACKGROUND: Although venous thrombosis after venovenous-extracorporeal membrane oxygenation (ECMO) is well described, vascular complications occurring after venoarterial ECMO (VA-ECMO) removal have not yet been thoroughly described. Our aim was to evaluate the frequency of vascular (arterial and venous) complications after VA-ECMO removal and try to identify the risk factors associated with them. METHODS: Retrospective analysis of data prospectively collected in 2 intensive care units was performed. Consecutive patients successfully weaned off VA-ECMO during year 1 were screened for cannula-associated deep vein thrombosis (CaDVT) or arterial complications (arterial thrombosis/stenosis) using Doppler ultrasonography. RESULTS: From November 2018 to November 2019, a total of 107 patients with a median (interquartile range [IQR]) age of 54 (42-63) years and a median (IQR) ECMO support duration of 8 (2-5) days were successfully weaned off VA-ECMO and included. CaDVT occurred in 44 patients (41%), and arterial complications occurred in 15 (14%) (9 acute leg ischemia, 1 arteriovenous femoral fistula, and 5 late femoral stenosis). Multivariable analysis retained longer duration of ECMO support (odds ratio [OR]: 1.12 per day; 95% CI: 1.02-1.22) and infection occurring on ECMO (OR: 3.03; 95% CI: 1.14-8.03) as independent risk factors for CaDVT, whereas older age (OR: 0.97 per year; 95% CI: 0.94-0.99) and previous anti-coagulation use (OR: 0.21; 95% CI: 0.06-0.68) were protective factors for CaDVT. No risk factors for arterial complications were identified. CONCLUSIONS: In patients requiring VA-ECMO support, vascular complications occurred frequently after its removal, especially CaDVT. Arterial complications, either early leg ischemia or late arterial stenosis, were observed less often. Strategies aimed at preventing CaDVT after VA-ECMO remain to be determined.

Bilateral Internal Thoracic Artery Grafting in Women: A Word of Caution.

BACKGROUND: Despite the superior hemodynamic performance of internal thoracic arteries, total arterial revascularization with exclusive bilateral internal thoracic arteries (BITA) is less frequently used especially in specific subsets of patients, including females. We report our experience with total arterial revascularization with exclusive BITA regardless of sex and analyze the impact of female sex on the early and midterm outcomes. METHODS: Total arterial revascularization with exclusive BITA was performed with equal frequency in females (79/99, 80%) and males (392/477, 82%; P = .68) undergoing isolated CABG for 3-vessel disease. Pre, intra and postoperative data were compared between these two groups. RESULTS: Complete revascularization was achieved in 77% of females and 72% of males (P = .08). Early mortality did not differ between the groups (6.3% versus 4.6%, P = .7). The incidence of re-sternotomy for bleeding, postoperative stroke, myocardial infarction, new onset atrial fibrillation, and hemofiltration for renal failure did not differ between the two groups. However, there were significantly more wound revision for combined superficial and deep sternal wound infection in females (26.5% versus 5.1%, P = .0001). Nevertheless, midterm survival, freedom from repeat revascularization, myocardial infarction, stroke, and major adverse cardiovascular and cerebral events at five years were very good and compared favorably between females and males. CONCLUSIONS: Our findings suggest that total arterial myocardial revascularization with exclusive internal thoracic arteries in females carries the same midterm benefits as in males. Early outcomes are comparable except for a higher incidence of wound revision for combined superficial and deep sternal wound infections in females compared to males. Benefits of bilateral internal thoracic artery grafting in females should be weighed against increased risk of early wound revision.

Surgical Management of Undiagnosed Laceration of Superior Vena Cava Caused by Blunt Trauma.

Intrapericardial rupture of the superior vena cava resulting from blunt thoracic trauma is a rare and life-threatening condition that has to be ruled out in the presence of signs of cardiac tamponade and a history of blunt thoracic trauma. We report the case of undiagnosed superior vena cava laceration caused by a high-speed road traffic accident in a 25 year-old patient revealed by cardiac tamponade. We highlight the need of urgent surgical exploration in all patients whose condition is unstable in the setting of blunt thoracic trauma regardless of imaging conclusions.

Surgery for secondary aorto-enteric fistula or erosion (SAEFE) complicating aortic graft replacement: a retrospective analysis of 32 patients with particular focus on digestive management.

BACKGROUND: Optimal management of patients with abdominal secondary aorto-enteric fistula or erosion (SAEFE) complicating aortic graft replacement is controversial. OBJECTIVE: The aim of the present study was to report on the postoperative and long-term outcomes of patients operated on for SAEFE. METHODS: From 2002 to 2012, consecutive patients operated on for SAEFE were identified. All were managed with in situ revascularization by cryopreserved allograft associated with the treatment of the digestive tract involved. Postoperative and long-term outcomes were collected prospectively and analysed retrospectively. RESULTS: A total of 32 patients (median age 65 years) underwent an aortic replacement for SAEFE after a median of 5 years after the initial aortic surgery. Fistula location was duodenal (n = 20), small bowel (n = 6), colonic (n = 5), or gastric (n = 1). Digestive treatment included suture (n = 16), resection with anastomosis (n = 13), and Hartmann's procedure (n = 3). An omentoplasty was performed in 18 patients (56 %), and 17 patients (53 %) had a feeding jejunostomy. Postoperative mortality was 25 %. Among perioperative risk factors, preoperative shock was associated with postoperative mortality (p = 0.009). Among the 24 patients who survived, 15 patients developed 27 postoperative complications (overall morbidity rate of 62.5 %), including six (25 %) patients with severe morbidity (Dindo III-IV). Reoperation was required in five (21 %) patients. During follow-up (median 31 months), no patient developed a recurrent aorto-enteric fistula. CONCLUSIONS: Surgery for SAEFE is a major undertaking, with high mortality and morbidity. Excision of the prosthetic graft with cryopreserved allograft replacement and management in a tertiary referral centre with expertise in both vascular and digestive surgery allows good long-term results.

[Abdominal secondary aorto-enteric fistulae complicating aortic graft replacement: postoperative and long-term outcomes in 32 patients]. / Fistules aorto-intestinales après remplacement prothétique de l'aorte abdominale : résultats chirurgicaux et suivi à long terme chez 32 patients.

Management of patients with abdominal secondary aorto-entericfistulae (SAEF) complicating aortic graft replacement is controversial. We retrospectively analyzed the postope- rative and long-term outcomes of all consecutive patients operated on for SAEF betwveen 2002 and2012. All were managed by in situ replacement with a cryopreserved allograft and treatment of the affected digestive tract. Thirty-two patients (median age 65 years) underwent aortic replacement for SAEFa median of 5 years after initial aortic surgery. The fistulae were located in the duodenum (n = 20), small bowel (n = 6), colon (n = 5) or stomach (n = 1). Treatment of the digestive tract included suture (n = 16), resection with anastomosis (n = 12) covered by a defunctioning stoma (n = 1), and Hartmann's procedure (n = 3). Omentoplasty was performed in 18 patients (56 %), and 17 patients (53 %) had afeedingjejunostomy. Eight patients (25 %) died post-operatively, 3 with a recurrent aorto-enteric fistula. Fifteen (62.5 %) of the remaining patients developed 27 complications, including 6 patients (19 %) with severe morbidity (Dindo III-IV). The reoperation rate was 21 %. The median hospital stay was 33 days. During follow-up (median 15 months), no further patients had a recurrent aorto-enteric fistula. We conclude that surgery for SAEF is a major procedure associated with high mortality and morbidity. Good long-term results can be obtained by excision of the prosthetic graft with cryopreserved allograft replacement, and by management in a tertialy referral center with expertise in both vascular and digestive surgery.