Long Term Results of the Modified Bentall Procedure With Mechanical and Biological Composite Valve Grafts.

Objectives: Despite the evident shift toward biological prostheses, the optimal choice of valve remains controversial in composite valve graft (CVG) replacement. We investigated long-term morbidity and mortality after CVG implantation in an all-comer cohort with a subgroup analysis of patients aged 50-70 years stratified after valve type. Methods: A total of 507 patients underwent the Bentall procedure with either a mechanical (MCVG, n = 299) or a biological (BCVG n = 208) CVG replacement between 2000 and 2020. A single-center analysis comprising clinical and telephone follow-up was conducted to investigate late mortality and morbidity. Results: The 30-day mortality in all patients [age 56 ± 14 years, 78.1% male, EuroSCORE II 3.12 (1.7; 7.1)] was 5.9%. Patients who were electively operated on had a 30-day mortality of 1.5% (n = 5) while it remained higher in urgent/emergent procedures (n = 25, 15.4%). Survival at 10 and 15 years was 78.19 ± 2.26% and 72.6 ± 3.2%, respectively. In patients aged 50-70 years (n = 261; MCVG = 151, BCVG = 110), survival did not differ significantly between the valve groups (p = 0.419). Multivariable analysis showed no significant impact of valve type on survival (p = 0.069). A time-varying relation with survival was notable, showing a higher risk in the MCVG group in the early postoperative phase, which declined compared to the BCVG group in the course of follow-up. Conclusions: The Bentall technique presents with excellent mortality when performed electively. The type of valve prosthesis showed no statistically significant effect on mortality in patients aged 50-70 years. However, a time-varying relation showing an initially higher risk with MCVG which decreased compared to BCVG at long-term follow-up was notable. Further studies with even longer follow-up of BCVGs will clarify the ideal choice of prosthesis in this patient subset.

Arrhythmia Caused by a Giant Coronary Artery Aneurysm.

Giant coronary artery aneurysms (GCAAs) are rare cardiovascular malformations that necessitate a multimodal, interdisciplinary diagnostic and individualized interventional approach. This report describes the case of a young, healthy patient with an idiopathic GCAA with pseudoaneurysmal protrusion into the right atrium that caused syncope, cardiac decompensation, and arrhythmia, which subsided postoperatively.

Anterior Right Thoracotomy for Rapid-Deployment Aortic Valve Replacement.

BACKGROUND: Minimally invasive aortic valve replacement through anterior right thoracotomy (ART) has shown to be safe and feasible. However, acceptance within the surgical community is low. Rapid-deployment aortic valves may be a game changer due to simplified surgical technique and shorter operative times. Therefore, the combination of advanced surgical techniques like the ART access with rapid-deployment aortic valves was assessed in this study. METHODS: We retrospectively analyzed all patients undergoing ART with the Edwards Intuity Elite (Edwards Lifesciences, Irvine, CA) valve system between 2011 and 2018. Patient data were collected prospectively in an ongoing, single-center registry. Data analysis regarding valve outcome was performed according to current guidelines. RESULTS: In all, 165 patients underwent aortic valve replacement through ART access with the Edwards Intuity valve system (age 73 ± 9 years, 49% female, median European System for Cardiac Operative Risk Evaluation II score 1.6 [range, 0.6 to 10.6]). Median cardiopulmonary bypass time was 114 minutes (range, 61 to 310) and median aortic cross-clamp time was 80 minutes (range, 45 to 230). Thirty-day as well as inhospital mortality was 0.6% (n = 1). Postoperative neurologic events occurred in 3%, resulting in major neurologic deficit in 1 patient. Intermediate and long-term survival was 99%, 98%, and 93% after 6 months, 1 year, and 3 years, respectively. CONCLUSIONS: Implantation of the Edwards Intuity valve system through ART is safe, feasible, and reproducible. The overall results of this single center experience are excellent compared with contemporary series of both surgical and transcatheter aortic valve replacements.

Bilateral or unilateral antegrade cerebral perfusion during surgery for acute type A dissection.

OBJECTIVE: The study objective was to investigate outcomes associated with the application of bilateral or unilateral antegrade cerebral perfusion during surgery for acute type A dissection. METHODS: Patients who underwent surgery for type A dissection with the application of antegrade cerebral perfusion between 2009 and 2017 at the Division of Cardiac Surgery, Medical University of Vienna were analyzed retrospectively (bilateral antegrade cerebral perfusion: n = 91, 49.5%; unilateral antegrade cerebral perfusion: n = 93, 50.5%). The primary outcome variable was overall survival. Subgroup analyses were performed in patients requiring antegrade cerebral perfusion durations of 50 minutes or more and less than 50 minutes. Secondary outcome variables were 30-day mortality, adverse outcome, permanent and temporary neurologic deficits, renal replacement therapy, prolonged ventilation, intensive care unit stay, and hospital stay. RESULTS: Multivariable Cox proportional hazards analysis demonstrated no significant association of bilateral antegrade cerebral perfusion with overall survival (hazard ratio, 0.63; 95% confidence interval, 0.34-1.14, P = .126). Propensity score modeling using the method of inverse probability of treatment weighting confirmed this result (hazard ratio, 0.73; 95% confidence interval, 0.33-1.60, P = .428). Bilateral antegrade cerebral perfusion was associated with significantly improved overall survival in patients requiring antegrade cerebral perfusion durations of 50 minutes or more (P = .017). The bilateral antegrade cerebral perfusion and unilateral antegrade cerebral perfusion groups showed comparable rates of secondary outcome variables. CONCLUSIONS: In the present study, bilateral antegrade cerebral perfusion and unilateral antegrade cerebral perfusion are associated with comparable outcomes after surgery for type A dissection. Subgroup analyses suggest that bilateral antegrade cerebral perfusion is associated with superior overall survival in patients requiring antegrade cerebral perfusion durations of 50 minutes or more. An adequately powered prospective randomized controlled trial is required to validate these results.

Thoracic endovascular repair for acute complicated type B aortic dissections.

OBJECTIVE: This study retrospectively assessed in-hospital mortality and long-term results of emergency thoracic endovascular aortic repair (TEVAR) for patients with life-threatening acute complicated type B aortic dissection (acTBD). METHODS: Between March 2001 and December 2016, there were 55 patients (40 male; median age, 52 ± 13 years) with an acTBD who were treated with TEVAR for malperfusion (58%), aortic rupture (18%), or persistent untreatable pain with true lumen reduction or rapid aortic diameter enlargement (24%) as a sign of disease progression. The patients were categorized according to clinical appearance into two groups: group A, malperfusion, pending rupture, or rupture; and group B, persistent ongoing pain, rapid enlargement of aortic diameter, or significant changes in the true to false lumen ratio. Four patients (7%) had undergone previous aortic surgery. RESULTS: Technical success (coverage of the primary intimal tear) was achieved in 50 patients (91%). The overall in-hospital mortality rate was 9% (n = 5), and there was a statistically significant difference in early mortality between group A and group B (7% vs 2%; P < .02). Causes of in-hospital death were all aorta related, including a rupture during the procedure and on the first postinterventional day in two patients and redissection (ascending aorta, n = 2; descending aorta, n = 1) with a consequent aortic rupture after TEVAR in the remaining three. Permanent neurologic dysfunction occurred in five patients (stroke, n = 2; paraplegia, n = 3). Overall, 19 patients (34%) developed early endoleaks (type IA, n = 5; type IB, n = 11; type II, n = 2; type IB plus type II, n = 1). Therefore, 5 patients needed early (within 30 days) endovascular intervention because of a type IA (n = 2), type IB (n = 3), or type II endoleak (n = 1) and the rapid progression of aortic diameter, persistent signs of ischemia (n = 2), or rupture (n = 1), whereas the remaining 14 patients were treated conservatively and followed up by computed tomography angiography. Seven patients with early endoleaks needed an endovascular intervention (n = 3) or conventional surgery (n = 4) because of aortic progression in the follow-up period (mean interval after procedure, 92 ± 56 months). The actual survival rates were 87%, 85%, and 75% at 1 year, 2 years, and 5 years, respectively, and freedom from aorta-related death was 87%, 87%, and 77% at 1 year, 2 years, and 5 years, respectively. Freedom from reintervention for any cause using a Kaplan-Meier analysis was 70%, 68%, 68%, and 63% at 6 months, 1 year, 2 years, and 5 years, respectively. CONCLUSIONS: TEVAR of acTBD has been proven to be an excellent treatment modality in this cohort of high-risk patients, with promising midterm and long-term results.

Intermediate-term outcome of 500 consecutive rapid-deployment surgical aortic valve procedures†.

OBJECTIVES: The Edwards INTUITY Valve System is a balloon-expandable bioprosthesis, inspired from the Edwards Magna valve and transcatheter technology, with a subvalvular stent frame to enable rapid deployment. We report a single-centre experience of aortic valve replacement with this novel bioprosthesis. METHODS: Five hundred consecutive patients, of whom 45.6% were female with a mean age of 73.5 [standard deviation (SD) 7.9 years], with severe aortic stenosis who received a rapid deployment aortic valve between May 2010 and July 2017 were included in a prospective and ongoing database. The median follow-up time was 12 months, and the total accumulated follow-up time was 818 patient years. Preoperative characteristics, operative parameters, survival, valve-related adverse events and valve haemodynamics were assessed. RESULTS: Thirty-day mortality was 0.8% (4/500), and overall survival at 1, 3 and 5 years was 94%, 89% and 81%, respectively. A minimally invasive surgical approach was chosen in 236 patients (47%), of which 122 (24%) were operated on through an anterior right thoracotomy. Cross-clamp and cardiopulmonary bypass times for isolated aortic valve replacement were 53 (SD 17) and 89 (SD 29) min for full sternotomy as well as 75 (SD 23) and 110 (SD 31) min for minimally invasive surgery approaches (P < 0.001). Mean gradients at discharge, 1, 3 and 5 years were 13 (SD 5), 11 (SD 4), 12 (SD 5) and 11 (SD 3) mmHg, respectively. New pacemaker implantation was necessary in 8.6% of patients. A single case (0.2%) of structural degeneration was registered after 6 years. Valve explantation for non-structural dysfunction or endocarditis occurred in 9 patients (1.8%). CONCLUSIONS: This rapid deployment aortic valve has shown excellent results concerning haemodynamic performance, durability and safety. Implantation requires specific training, and the rate of pacemaker implantation remains a matter of concern. This novel valve also facilitates minimally invasive approaches and may be beneficial in complex combined procedures.

Extracorporeal membrane oxygenation support for right ventricular failure after left ventricular assist device implantation.

OBJECTIVES: Right ventricular (RV) failure complicating left ventricular assist device implantation is associated with increased mortality. Despite a lack of supporting evidence, venoarterial extracorporeal membrane oxygenation (ECMO) support is increasingly being used as an alternative to traditional temporary RV support. We report our institutional experience with ECMO-facilitated RV support after left ventricular assist device implantation. METHODS: We retrospectively reviewed the concept of temporary ECMO support for perioperative RV failure in 32 consecutive left ventricular assist device (mean age 52 ± 14 years; male 84.4%; ischaemic cardiomyopathy 40.6%; INTERMACS Level I 71.8%; INTERMACS Level II 6.3%; INTERMACS Level III 12.5%; INTERMACS Level IV-VII 9.4%; HeartWare ventricular assist device 75%; HeartMate II: 25%) from May 2009 to April 2014. The study end points were RV recovery during ECMO support, mortality and causes of death. RESULTS: Twenty-nine (90.6%) patients were successfully weaned from ECMO support after RV recovery. Three (9.4%) patients expired during ECMO support. ECMO support improved RV function and haemodynamic parameters (central venous pressure 13 mmHg vs 10 mmHg, P < 0.01; mean pulmonary artery pressure 28 mmHg vs 21 mmHg, P < 0.01; cardiac output 5.1 l/min vs 5.9 l/min, P = 0.09) over a median period of 3 (range 1-15) days. Thirty-day and in-hospital mortality were 18.8% and 25%, respectively. One-year survival was 75%, causes of death were multiorgan dysfunction syndrome (50%), sepsis (25%), haemorrhagic stroke (12.5%) and ischaemic stroke (12.5%). Causes of death during ECMO support were ischaemic stroke, sepsis and multiorgan dysfunction syndrome. CONCLUSIONS: Temporary ECMO-facilitated RV support is associated with good long-term outcomes and high rates of RV recovery.

Effects of angiotensin-converting-enzyme inhibitor therapy on the regulation of the plasma and cardiac tissue renin-angiotensin system in heart transplant patients.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors (ACEis) are beneficial in patients with heart failure, yet their role after heart transplantation (HTx) remains ambiguous. Particularly, the effects of ACEis on plasma and cardiac metabolites of the "classical" and "alternative" renin-angiotensin system (RAS) in HTx patients are unknown. METHODS: This cross-sectional study used a novel mass spectrometry-based approach to analyze plasma and tissue RAS regulation in homogenates of heart biopsy specimens from 10 stable HTx patients without RAS blockade and in 15 patients with ACEi therapy. Angiotensin (Ang) levels in plasma and Ang formation rates in biopsy tissue homogenates were measured. RESULTS: Plasma Ang II formation is exclusively ACE dependent, whereas cardiac Ang II formation is primarily chymase dependent in HTx patients. ACEi therapy substantially increased plasma Ang-(1-7), the key effector of the alternative RAS, leaving plasma Ang II largely intact. Importantly, neprilysin and prolyl-carboxypeptidase but not angiotensin converting enzyme 2 are essential for cardiac tissue Ang-(1-7) formation. CONCLUSION: ACE is the key enzyme for the generation of plasma Ang II, whereas chymase is responsible for cardiac tissue production of Ang II. Furthermore, our findings reveal that neprilysin and prolyl-carboxypeptidase are the essential cardiac enzymes for the alternative RAS after HTx. These novel insights into the versatile regulation of the RAS in HTx patients might affect future therapeutic avenues, such as chymase and neprilysin inhibition, beyond classical Ang II blockade.

Interaction of a Transapical Miniaturized Ventricular Assist Device With the Left Ventricle: Hemodynamic Evaluation and Visualization in an Isolated Heart Setup.

New left ventricular assist devices (LVADs) offer both important advantages and potential hazards. VAD development requires better and expeditious ways to identify these advantages and hazards. We validated in an isolated working heart the hemodynamic performance of an intraventricular LVAD and investigated how its outflow cannula interacted with the aortic valve. Hearts from six pigs were explanted and connected to an isolated working heart setup. A miniaturized LVAD was implanted within the left ventricle (tMVAD, HeartWare Inc., Miami Lakes, FL, USA). In four experiments blood was used to investigate hemodynamics under various loading conditions. In two experiments crystalloid perfusate was used, allowing visualization of the outflow cannula within the aortic valve. In all hearts the transapical miniaturized ventricular assist device (tMVAD) implantation was successful. In the blood experiments hemodynamics similar to those observed clinically were achieved. Pump speeds ranged from 9 to 22 krpm with a maximum of 7.6 L/min against a pressure difference between ventricle and aorta of ∼50 mm Hg. With crystalloid perfusate, central positioning of the outflow cannula in the aortic root was observed during full and partial support. With decreasing aortic pressures the cannula tended to drift toward the aortic root wall. The tMVAD could unload the ventricle similarly to LVADs under conventional cannulation. Aortic pressure influenced central positioning of the outflow cannula in the aortic root. The isolated heart is a simple, accessible evaluation platform unaffected by complex reactions within a whole, living animal. This platform allowed detection and visualization of potential hazards.

Off-pump HeartWare ventricular assist device implantation with outflow graft anastomosis to the left subclavian artery.

A novel, off-pump implantation technique for the HeartWare ventricular assist device with outflow graft anastomosis to the left subclavican artery is described. Cannulation of the left ventricular apex is performed through an incision in the left fourth or fifth intercostal space. The outflow graft is anastomosed to the left subclavian artery after tunneling through the left thoracic cavity and the first intercostal space. This technique is especially appealing in redo cases as well as in patients with significant calcifications of the ascending aorta or in destination-therapy patients.

Preoperative patient optimization using extracorporeal life support improves outcomes of INTERMACS Level I patients receiving a permanent ventricular assist device.

OBJECTIVES: Interagency Registry for Mechanical Assisted Circulatory Support (INTERMACS) Level I patients have the highest early mortality after ventricular assist device (VAD) implantation. This is determined by the exposure of patients in shock with acutely damaged end-organs and high catecholamine support to a significant surgical trauma. We report our experience with a bridge-to-bridge concept consisting of initial veno-arterial extracorporeal life support (ECLS) and deferral of VAD implantation to recovery of end-organ function in INTERMACS Level I patients. METHODS: We reviewed the concept of initial ECLS implantation and deferral of VAD implantation to end-organ recovery in 22 consecutive patients (mean age 54 ± 14 years; 72.2% males; 50% ischemic cardiomyopathy; 100% INTERMACS Level I; 18.2% Heartmate II, 68.2% Heartware HVAD, 4.5% Heartware BiVAD, 9.1% DeBakey LVAD) receiving a VAD for refractory cardiogenic shock between June 2004 and February 2013. Study endpoints were end-organ recovery during ECLS and survival. RESULTS: ECLS significantly improved renal (creatinine 1.86 ± 0.91 vs 1.32 ± 0.52 mg/dl, P = 0.02), hepatic (aspartate aminotransferase 1426 ± 2176 vs 277 ± 259 U/l, P = 0.04; alanine aminotransferase 982 ± 1466 vs 357 ± 447 U/l, P = 0.04) and pulmonary functions (fraction of inspired oxygen 52 ± 18 vs 26 ± 23%, P < 0.01; positive end-expiratory pressure 7 ± 3 vs 5 ± 4 mbar, P = 0.02) over a period of 8 ± 7 days. Catecholamines could be reduced during ECLS (levosimendan 0.056 ± 0.085 vs 0.010 ± 0.032 µg/kg/min, P = 0.06; dobutamine 4.362 ± 5.268 vs 0.056 ± 0.097 µg/kg/min, P = 0.06; noradrenaline 0.408 ± 0.355 vs 0.056 ± 0.097 µg/kg/min, P < 0.01). Thirty-day and in-hospital mortality after VAD implantation were 4.5 and 9.1%, respectively, and 1-year survival was 86.4%. CONCLUSIONS: Preoperative patient optimization using ECLS improves outcomes of INTERMACS Level I patients receiving a permanent VAD.

Viennese approach to minimize the invasiveness of ventricular assist device implantation†.

OBJECTIVE: Avoiding full sternotomy and cardiopulmonary bypass (CPB) could significantly reduce the invasiveness of left ventricular assist device (LVAD) implantation. Therefore, we developed minimally invasive implant strategies for the Heartware® VAD (HVAD) and the Thoratec® HeartMate II (HMII) covering isolated LVAD implantation as well as concomitant valve procedures (aortic/tricuspid). We present the surgical techniques and the initial clinical experience. METHODS: From February 2012 to March 2013, 27 patients (mean age 58 ± 8 years; male 85%; Ischemic Cardiomyopathy 63%; redo surgery 22%; Interagency Registry for Mechanically Assisted Circulatory Support Level I: 29%, II: 22%, III: 33%, IV-VII: 16%) underwent minimally invasive LVAD implantation at our department. Apical cannulation was performed via a left lateral minithoracotomy in HVAD patients (n = 20) or a left subcostal incision in HMII patients (n = 7). The outflow graft anastomosis was performed to the ascending aorta via a right minithoracotomy in the second intercostal space (n = 22) or the right subclavian artery (n = 2). If additional valve procedures (aortic/tricuspid) were necessary (n = 3), a hemisternotomy was performed to access the valve and perform the outflow graft anastomosis. Circulatory support for LVAD implantation was CPB (33%), extracorporeal membrane oxygenation (48%) or off-pump (19%). RESULTS: The minimally invasive approach was feasible in all patients with no need for conversions. Thirty-day and in-hospital mortality were 7.4 and 14.8%, respectively. In-hospital stay was 30.0 ± 22.5 days. One patient (4%) died during follow-up from pump thrombus formation. Three patients (11%) underwent surgical revision for bleeding. CONCLUSIONS: Minimally invasive LVAD implantation is feasible and safe. The very encouraging results obtained in this initial series justify a broad application of this technique.

Low-molecular-weight heparin for anti-coagulation after left ventricular assist device implantation.

BACKGROUND: Anti-coagulation is required in patients with left ventricular assist devices (LVADs). We evaluated the feasibility of low-molecular-weight heparin (LMWH) for initiation of anti-coagulation and transitioning to oral anti-coagulation after LVAD implantation. METHODS: This single-center study included 78 consecutive patients who underwent either Thoratec HeartMate II LVAD (n = 27) or HeartWare ventricular assist device (HVAD, n = 51) implantation. The LMWHs enoxaparin (n = 50) and dalteparin (n = 28) were used. LMWH was started within 24 hours post-operatively in 79.5% of patients. No anti-coagulation was given before starting LMWH therapy. LMWH activity was monitored by determination of anti-factor Xa levels in plasma. RESULTS: The majority of patients (80.7%) had peak anti-Xa activity within the defined range of efficacy of 0.2 to 0.4 IU/ml by the second day of treatment. Mean effective peak anti-Xa activity was 0.28 ± 0.06 IU/ml. Mean duration of anti-coagulation with LMWH was 25.8 ± 18 days. Ischemic strokes were observed in 3 patients (3.8%), with a total of 4 events. Three events occurred while on LMWH, and 1 event occurred during follow-up on oral anti-coagulation. There was 1 fatal stroke. No pump thrombus was observed. Major bleeding was observed in 5 patients (6.4%), with a total of 6 events. Gastrointestinal bleeding was the most common complication (n = 3). There were no fatal bleeding events. CONCLUSIONS: LMWH in the setting of LVAD shows rapid and constant biologic efficacy. Anti-coagulation with LMWH appears feasible after LVAD implantation. These findings support further evaluation of LMWH as an alternative to unfractionated heparin in this patient cohort.

Investigation of hemodynamics in the assisted isolated porcine heart.

BACKGROUND: Currently, the interaction between rotary blood pumps (RBP) and the heart is investigated in silico, in vitro, and in animal models. Isolated and defined changes in hemodynamic parameters are unattainable in animal models, while the heart-pump interaction in its whole complexity cannot be modeled in vitro or in silico. AIM: The aim of this work was to develop an isolated heart setup to provide a realistic heart-pump interface with the possibility of easily adjusting hemodynamic parameters. METHODS: A mock circuit mimicking the systemic circulation was developed. Eight porcine hearts were harvested using a protocol similar to heart transplantation. Then, the hearts were resuscitated using Langendorff perfusion with rewarmed, oxygenated blood. An RBP was implanted and the setup was switched to the "working mode" with the left heart and the RBP working as under physiologic conditions. Both the unassisted and assisted hemodynamics were monitored. RESULTS: In the unassisted condition, cardiac output was up to 9.5 l/min and dP/dtmax ranged from 521 to 3621 mmHg/s at a preload of 15 mmHg and afterload of 70 mmHg. With the RBP turned on, hemodynamics similar to heart-failure patients were observed in each heart. Mean pump flow and flow pulsatility ranged from 0 to 11 l/min. We were able to reproduce conditions with an open and closed aortic valve as well as suction events. CONCLUSIONS: An isolated heart setup including an RBP was developed, which combines the advantages of in silico/vitro methods and animal experiments. This tool thus provides further insight into the interaction between the heart and an RBP.

Minimally invasive thoratec Heartmate II implantation in the setting of severe thoracic aortic calcification.

A minimally invasive approach for implantation of the Heart Mate II left ventricular assist device (LVAD) in the setting of severe thoracic aortic calcification is described. Cannulation of the left ventricular apex is performed through a left subcostal incision with preperitoneal creation of the pump pocket. To avoid outflow graft anastomosis to a severely calcified ascending or descending aorta, the outflow graft is tunneled through the diaphragm, the right thoracic cavity, and the second intercostal space, and is anastomosed to the right subclavian artery. This technique is especially appealing in patients with generalized aortic calcification undergoing LVAD implantation.

Thoracic endovascular aortic repair in 300 patients: long-term results.

BACKGROUND: The aim of this analysis was to assess short and mid-term results of patients undergoing thoracic endovascular aortic repair (TEVAR) for 4 different indications. METHODS: From 1996 to 2010, 300 patients (80 female, 220 male, median age 67 years [20 to 88]) underwent TEVAR at our department. Among them were 137 descending thoracic aneurysms (DTA), 80 type B dissections (60 acute, 20 chronic), 59 perforating aortic ulcer (PAU), and 24 traumatic aortic transections (ATAT). Hospital mortality and mid-term survival among different indications for TEVAR were evaluated. RESULTS: Overall hospital mortality in our series was 5% (n = 15). Seven patients with DTA (5%), 4 patients with type B dissections (5%), 2 patients with PAU (3.4%), and 2 ATAT (8%) patients died during their hospital stay. Kaplan-Meier survival analysis revealed significant differences in survival rates according to the various indications for TEVAR (p < 0.001). Overall long-term mortality was 86%, 63%, and 44% at 1, 5, and 10 years. Early and late endoleak rate was 18% and 8%, respectively. CONCLUSIONS: The TEVAR has evolved into a safe and effective therapy for different aortic pathology resulting in promising long-term results. Nevertheless, the indication for TEVAR has direct impact on the success of the procedure. Patients with acute type B aortic dissections and acute traumatic aortic lesions seem to benefit the most from TEVAR.

Extraordinary branching pattern of the aortic arch.

A CT-scan of a 75-year-old patient showed an aneurysm of the descending aorta with a maximum diameter of 4.8 cm involving the left subclavian artery. Due to the fact that the patient had several comorbidities including a severe chronic obstructive pulmonary disease he was treated only conservatively. However, there were several interesting findings on the CT-scan: the branching pattern of the aortic arch revealed a left carotid artery arising as first side branch of the distal part of the ascending aorta. This vessel crosses the midline right in front of the trachea. Apart from that the patient did not have a brachiocephalic trunk: the right carotid artery arose as the first branch from the aortic arch and crossed the right subclavian artery anteriorly. Furthermore, the left subclavian seemed to arise from the descending aorta and not from the aortic arch.

Effect of cerebral protection strategy on outcome of patients with Stanford type A aortic dissection.

OBJECTIVE: The aim of the present study was to assess the efficacy and mid- to long-term results of different cerebral protection techniques in the treatment of acute type A aortic dissection. METHODS: Between April 1987 and January 2011, 329 patients (220 male patients; median age, 60 years; range, 16-87) with type A aortic dissection underwent replacement of the ascending aorta or aortic arch with an open distal anastomosis. Either hypothermic circulatory arrest alone at 18 °C (n = 116; 35%) or combined with retrograde cerebral perfusion (n = 122; 37%) or antegrade cerebral perfusion at 25 °C (n = 91; 28%) was used. RESULTS: The median circulatory arrest time was 30 minutes (range, 12-92). The overall 30-day mortality was 19% (62 of 329). The 30-day mortality stratified by group was 26% (30 patients) in the hypothermic circulatory arrest group, 16% in the retrograde cerebral perfusion group (20 patients), and 13% (12 patients) in the antegrade cerebral perfusion group (P = .047). Permanent neurologic dysfunction occurred in 53 patients (16%), with statistically significant differences among the 3 groups (23% for hypothermic circulatory arrest, 12% for retrograde cerebral perfusion, and 12% for antegrade cerebral perfusion; P = .033). Univariate analysis showed a significant effect of the brain protection strategy on 30-day mortality and neurologic outcome. Multivariate analysis revealed preoperative hemodynamic instability, preoperative resuscitation, age, and operative year as independent predictors of 30-day mortality. Regarding permanent neurologic dysfunction, the multivariate analysis could not identify any independent predictors. Kaplan-Meier analyses revealed statistically significant differences among the 3 groups with a 1-, 3-, and 5-year survival rate of 84%, 79%, and 77% with antegrade cerebral perfusion, 75%, 72%, and 66% with retrograde cerebral perfusion, and 66%, 62%, and 60% with hypothermic circulatory arrest alone. CONCLUSIONS: Patients in the antegrade cerebral perfusion group had the best short- and long-term survival rates. However, during the study period, several significant improvements in the treatment of patients with type A aortic dissection were achieved; therefore, independent predictors of mortality and permanent neurologic dysfunction were difficult to identify.