Systematic total arch replacement with thoraflex hybrid graft in acute type A aortic dissection: A single centre experience.

Introduction: In the last two decades, a more aggressive approach has been encouraged to treat patients with acute type A aortic dissection (ATAAD), extending the repair to the aortic arch and proximal descending thoracic aorta with the frozen elephant trunk (FET) implantation. Here, we report our single-centre experience with the FET technique for the systematic treatment of emergency type A aortic dissection. Materials and methods: Between December 2017 and January 2022, 69 consecutive patients were admitted with ATAAD; of those, 66 patients (62.9 ± 10.2 years of age, 81.8% men) underwent emergency hybrid aortic arch and FET repair with the multibranched Thoraflex hybrid graft and were enrolled in the study. Primary endpoints were 30 days- and in-hospital mortality. Secondary endpoints were postoperative morbidity and follow-up survival. To better clarify the impact of age on surgical outcomes, we have divided the study population into two groups: group A for patients <70 years of age (47 patients), and group B for patients ≥70 years (19 patients). Time-to-event analysis has been conducted using the Log-rank test and is displayed with Kaplan-Meier curves. A multiple Cox proportional Hazard model was developed to identify predictors of long-term survival with a stepwise backward/forward selection process. Results: 30-days- and in-hospital mortality were 10.6 and 13.6%, respectively. Stroke occurred in three (4.5%) patients. Two (3.0%) patients experienced spinal cord ischemia. We did not find any statistically significant difference between the two groups in terms of main post-operative outcomes. The multivariable Cox proportional hazard model showed left ventricular ejection fraction (HR: 0.83, 95% CI: 0.79-0.92, p < 0.01), peripheral vascular disease (HR: 15.8, 95% CI: 3.9-62.9, p < 0.01), coronary malperfusion (HR: 0.10, 95% CI: 0.01-0.77, p =0.03), lower limbs malperfusion (HR: 5.1, 95% CI: 1.10-23.4, p = 0.04), and cardiopulmonary bypass time (HR: 1.02, 95% CI: 1-1.04, p = 0.01) as independent predictors of long term mortality. Conclusions: Frozen elephant trunk repair to treat emergency type A aortic dissection appears to be associated with good early and mid-term clinical outcomes even in the elderly.

The need for custom made frozen elephant trunk: when and where.

The frozen elephant trunk (FET) technique is an increasingly common procedure to treat complex extensive aortic disease both in elective and emergency setting. In a contemporary era, several prostheses are available to be used by surgeons performing such procedures, merging the advantages of endovascular and conventional surgery and preparing a more useful landing zone for second-stage downstream endovascular or open repair. Thoraflex hybrid (Terumo Aortic, Scotland) is a largely used hybrid vascular device merging a conventional surgical vascular graft made of gelatin-sealed woven polyester graft with a nitinol self-expanding stent graft. Since its release in 2012, this prosthesis has gained a large consensus, mainly for the plexus version, which allows for single reimplantation of the epiaortic vessels. In the last few years, new devices have come out to offer new specific weapons to be used by the surgical team in different clinical scenarios. In this context, the need of making the supra-aortic vessel debranching easier and more functional to our surgical technique has pushed our demand for a customization of a conventional Thoraflex hybrid. Here we report a modification to its standard design, the concept beyond the "Custom device" and its potential advantages with regards to our peculiar implantation technique and intraoperative cerebral perfusion during circulatory arrest time.

Surgical removal of an exceedingly rare papillary fibroelastoma of the aortic wall causing unstable angina.

Difficult diagnosis is due to rarity of the case. TT or TE echocardiography is sufficient to make a correct diagnosis. The risk of embolism or coronary ostia occlusion should guide the decision for surgery.

"Pac-Man Heart" and Mitral Valve Prolapse: An Unreported Liaison.

A 50-year-old man accessed the echo laboratory for dyspnea. His medical history was unremarkable. Transthoracic two-dimensional echocardiogram showed a posterior leaflet of the mitral valve prolapse associated with eccentric regurgitant jet. An excavation of the medium interventricular septum, in the absence of left-right interventricular shunt, was detected as an incidental finding and considered as partial ventricular septum defect. Owing to the absence of acute myocardial infarction and thrombolysis in patient's medical history, this finding has been considered "pac-man heart" of the congenital origin. Of note, the association of this deformity with mitral valve prolapse is reported for the first time.

Caged-Ball Mitral Prosthesis Explanted After 50 Years.

We report a unique case of a Starr-Edwards prosthesis (model 6310, cloth covered) implanted in the mitral position by Christian Barnard that was successfully explanted and replaced after 50 years, the longest period free from valve dysfunction ever reported. Reoperation also included replacement of the native aortic valve combined with tricuspid valve annuloplasty. (Level of Difficulty: Beginner.).

Effects of glucagon-like peptide-1 receptor agonists on major cardiovascular events in patients with Type 2 diabetes mellitus with or without established cardiovascular disease: a meta-analysis of randomized controlled trials.

AIMS: Glucose-lowering, glucagon-like peptide-1 (GLP-1) receptor agonists reduce incidence of major cardiovascular (CV) events in patients with Type 2 diabetes mellitus (DM). However, randomized clinical trials reported inconsistent effects on myocardial infarction (MI) and stroke, and limited data in DM patients without established CV disease (CVD). Very recently, new relevant evidence was available from additional CV outcome trials (CVOTs) that also included large subgroups of patients with DM without established CVD. Thus, the aim of this meta-analysis was to investigate the effects of GLP-1 receptor agonists on major CV events and safety in DM patients with and without established CVD. METHODS AND RESULTS: In this trial-level meta-analysis, we analysed data from randomized placebo-controlled CVOTs assessing efficacy and safety of GLP-1 receptor agonists in adult patients with Type 2 DM. We searched PubMed, Embase, Cochrane, ISI Web of Science, SCOPUS, and clinicaltrial.gov databases for eligible trials. Of 360 articles identified and screened for eligibility, seven CVOTs were included, with an overall of 56 004 patients included. The difference in efficacy with respect to the major adverse cardiovascular events (MACE) primary endpoint (including CV mortality, non-fatal MI, and non-fatal stroke) between patients with established CVD and patients with CV risk factors only was not significant [pooled interaction effect, expressed as ratio of hazard ratio (HR) 1.06, 95% confidence interval (CI) 0.85-1.34]. In the analysis of the whole population of DM patients, GLP-1 receptor agonists showed a significant 12% reduction in the hazard of the three-point MACE composite endpoint (HR 0.88, 95% CI 0.80-0.96) and a significant reduction in the risk of CV mortality (HR 0.88, 95% CI 0.79-0.98), all-cause mortality (HR 0.89, 95% CI 0.81-0.97), fatal and non-fatal stroke (HR 0.84, 95% CI 0.76-0.94), and heart failure (HF) hospitalization (HR 0.92, 95% CI 0.86-0.97). No significant effect was observed for fatal and non-fatal MI (HR 0.91, 95% CI 0.82-1.02), although in a sensitivity analysis, based on a less conservative statistical approach, the pooled HR become statistically significant (HR 0.91, 95% CI 0.83-1.00; P = 0.039). No excess of hypoglycaemia, pancreatitis, and pancreatic cancer was observed between GLP-1 receptor agonists and placebo. CONCLUSION: Glucagon-like peptide-1 receptor agonists significantly reduce MACE, CV and total mortality stroke, and hospitalization for HF, with a trend for reduction of MI, in patients with Type 2 DM with and without established CVD.