E-vita OPEN NEO in the treatment of acute or chronic aortic pathologies: first interim results of the NEOS study.

OBJECTIVES: The aim of this multicentre study was to demonstrate the safety and clinical performance of E-vita OPEN NEO Stent Graft System (Artivion, Inc.) in the treatment of aneurysm or dissection, both acute and chronic, in the ascending aorta, aortic arch and descending thoracic aorta. METHODS: In this observational study of 12 centres performed in Europe and in Asia patients were enrolled between December 2020 and March 2022. All patients underwent frozen elephant trunk using E-vita OPEN NEO Stent Graft System. Primary end point was the rate of all-cause mortality at 30 days and secondary end points included further clinical and safety data are reported up to 3-6 months postoperatively. RESULTS: A total of 100 patients (66.7% male; mean age, 57.7 years) were enrolled at 12 sites. A total of 99 patients underwent surgery using the E-vita OPEN NEO for acute or subacute type A aortic dissection (n = 37), chronic type A aortic dissection (n = 33) or thoracic aortic aneurysm (n = 29), while 1 patient did not undergo surgery. Device technical success at 24 h was achieved in 97.0%. At discharge, new disabling stroke occurred in 4.4%, while new paraplegia and new paraparesis was reported in 2.2% and 2.2%, respectively. Renal failure requiring permanent (>90 days) dialysis or hemofiltration at discharge was observed in 3.3% of patients. Between discharge and the 3-6 months visit, no patients experienced new disabling stroke, new paraplegia or new paraparesis. The 30-day mortality was 5.1% and the estimated 6-month survival rate was 91.6% (standard deviation: 2.9). CONCLUSIONS: Total arch replacement with the E-vita OPEN NEO can be performed with excellent results in both the acute and chronic setting. This indicates that E-vita OPEN NEO can be used safely, including in the setting of acute type A aortic dissection.

Antiplatelet Resistance in Coronary Artery Bypass Grafting: A Systematic Review.

Background: This systematic review examines the occurrence and implications of resistance to primary antiplatelet agents, aspirin and clopidogrel, often utilised in patients undergoing coronary artery bypass grafting (CABG), alongside the methodologies for assessment of such resistance. Methods: An extensive literature search across various databases such as PubMed, MEDLINE via Ovid, Embase, and Cochrane CENTRAL until May 2024 was conducted to identify studies evaluating antiplatelet resistance in on-pump and off-pump CABG patients. Following quality assessment, only high-quality studies were incorporated into this review. Results: This review included 19 studies with 3,915 patients, four of which were randomised controlled trials and 15 were observational studies. Aspirin resistance incidence ranged from 11.0% to 51.5%, while clopidogrel resistance was 22%. Antiplatelet resistance, assessed through a wide variety of methods, was associated with a 13 times increase in the risk of vein graft occlusion and increased rates of mortality, myocardial infarction, and target vessel revascularisation in the case of clopidogrel resistance. The effect of cardiopulmonary bypass on antiplatelet resistance remains ambiguous. Conclusion: The academic literature lacks a standardised definition for antiplatelet resistance. Assessment methodologies greatly vary, leading to noninterchangeable outcomes. While aspirin resistance has a conflicting overall significant impact on adverse outcomes, clopidogrel resistance correlates with poorer clinical outcomes.

Patient-Specific Haemodynamic Analysis of Virtual Grafting Strategies in Type-B Aortic Dissection: Impact of Compliance Mismatch.

INTRODUCTION: Compliance mismatch between the aortic wall and Dacron Grafts is a clinical problem concerning aortic haemodynamics and morphological degeneration. The aortic stiffness introduced by grafts can lead to an increased left ventricular (LV) afterload. This study quantifies the impact of compliance mismatch by virtually testing different Type-B aortic dissection (TBAD) surgical grafting strategies in patient-specific, compliant computational fluid dynamics (CFD) simulations. MATERIALS AND METHODS: A post-operative case of TBAD was segmented from computed tomography angiography data. Three virtual surgeries were generated using different grafts; two additional cases with compliant grafts were assessed. Compliant CFD simulations were performed using a patient-specific inlet flow rate and three-element Windkessel outlet boundary conditions informed by 2D-Flow MRI data. The wall compliance was calibrated using Cine-MRI images. Pressure, wall shear stress (WSS) indices and energy loss (EL) were computed. RESULTS: Increased aortic stiffness and longer grafts increased aortic pressure and EL. Implementing a compliant graft matching the aortic compliance of the patient reduced the pulse pressure by 11% and EL by 4%. The endothelial cell activation potential (ECAP) differed the most within the aneurysm, where the maximum percentage difference between the reference case and the mid (MDA) and complete (CDA) descending aorta replacements increased by 16% and 20%, respectively. CONCLUSION: This study suggests that by minimising graft length and matching its compliance to the native aorta whilst aligning with surgical requirements, the risk of LV hypertrophy may be reduced. This provides evidence that compliance-matching grafts may enhance patient outcomes.

Preoperative B-Type Natriuretic Peptides to Predict Postoperative Atrial Fibrillation in Cardiac Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Post-operative atrial fibrillation (AF) is the most common complication following cardiac surgery. There has been extensive exploration of clinical variables, imaging, and biomarkers to predict its occurrence after cardiac surgery. In this study, we examine the emerging biomarkers B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) to assess their pre-operative values and correlations with the occurrence of post-operative AF in patients undergoing cardiac surgery. METHODS: A comprehensive literature search was conducted using PubMed, EMBASE, MEDLINE via Ovid, ClinicalTrials.Gov, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify studies published until March 2023. The studies were included if they reported pre-operative BNP or NT-proBNP values and the development of post-operative AF in cardiac surgery patients. Subsequently, data were extracted, and a meta-analysis was performed using Review Manager 5.4 4 (The Cochrane Collaboration, 2020) and SPSS version 28 (IBM Corp, Armonk, NY, USA) to assess the difference between pre-operative BNP and NT-proBNP levels between patients with post-operative AF (AF group) and those without (No-AF group) using a random-effect model. Further analysis was performed in three subgroups: isolated coronary artery bypass grafting, isolated valve, and combined/mixed surgery group. RESULT: A total of 20 studies, including 9,079 participants were identified and included in the systematic review and meta-analysis. Pre-operative BNP levels were reported in 11 studies, and NT-proBNP levels were reported in 10 studies, of which one study reported both BNP and NT-proBNP levels. There is an overall significant difference between pre-operative levels of BNP (p=0.03, I2=95%) and NT-proBNP (p<0.001, I2=65%) when compared between AF and No-AF groups. Nonetheless, subgroup analysis showed there is no significant difference in pre-operative BNP levels, except in isolated valve surgery (p<0.001), whereas all subgroups showed significantly different pre-operative levels of NT-proBNP. CONCLUSIONS: Elevated levels of both BNP and NT-proBNP were observed in patients who developed post-operative AF after undergoing cardiac surgery. In particular, pre-operative NT-proBNP levels were elevated in all patients irrespective of the type of surgical procedure, but elevated pre-operative BNP was only seen in valve surgery patients. These findings suggest the potential usefulness of NT-proBNP as a promising biomarker for predicting the occurrence of post-operative AF following cardiac surgery.

The Impact of the Covid-19 Pandemic on Recovery from Cardiac Surgery Over Time: Results of the Cardiaccovid Study from three Uk National Lockdowns.

This prospective study (clinicaltrials.gov NCT04366167) explores health-related quality of life (EQ-5D-5L), event-related distress (IES-R) and depression (CES-D) after cardiac surgery during the three UK national COVID-19 lockdowns. Overall, 253 patients participated (lockdown one n = 196; two n = 45; three n = 12) completing the above-mentioned questionnaires at baseline, one week after discharge and six weeks, six and 12 months after surgery. While EQ-5D-5L values were similar across all cohorts, those having surgery in lockdowns two and three had higher IES-R scores at 1-year and higher IES-R and CES-D baseline scores, respectively. Generally, increased distress, worse depression and poorer HRQoL were observed in women.

The impact of the COVID-19 pandemic on recovery from cardiac surgery: 1-year outcomes.

AIMS: The outbreak of COVID-19 was potentially stressful for everyone and possibly heightened in those having surgery. We sought to explore the impact of the pandemic on recovery from cardiac surgery. METHODS AND RESULTS: A prospective observational study of 196 patients who were ≥18years old undergoing cardiac surgery between March 23 and July 4, 2020 (UK lockdown) was conducted. Those too unwell or unable to give consent/complete the questionnaires were excluded. Participants completed (on paper or electronically) the impact of event [Impact of Events Scale-revised (IES-R)] (distress related to COVID-19), depression [Centre for Epidemiological Studies Depression Scale (CES-D)], and EQ-5D-5L [(quality of life, health-related quality of life (HRQoL)] questionnaires at baseline, 1 week after hospital discharge, and 6 weeks, 6 months and 1 year post-surgery. Questionnaire completion was >75.0% at all timepoints, except at 1 week (67.3%). Most participants were male [147 (75.0%)], white British [156 (79.6%)] with an average age 63.4years. No patients had COVID-19. IES-R sand CES-D were above average at baseline (indicating higher levels of anxiety and depression) decreasing over time. HRQoL pre-surgery was high, reducing at 1 week but increasing to almost pre-operative levels at 6 weeks and exceeding pre-operative levels at 6 months and 1 year. IES-R and CES-D scores were consistently higher in women and younger patients with women also having poorer HRQoL up to 1-year after surgery. CONCLUSIONS: High levels of distress were observed in patients undergoing cardiac surgery during the COVID-19 pandemic with women and younger participants particularly affected. Psychological support pre- and post-operatively in further crises or traumatic times should be considered to aid recovery. REGISTRATION: Clinicaltrials.gov ID:NCT04366167.

Fulminant Herpes Pneumonia Postaortic Surgery with Known Ankylosing Spondylitis.

Herpes simplex virus (HSV) pneumonitis is rare after cardiac surgery. A 36-year-old gentleman with ankylosing spondylitis underwent emergency surgery for a complex aortic aneurysmal disease. Preoperative treatment of aortitis with antitumor necrosis factor and steroid medication and surgical stress including cardiopulmonary bypass potentially created an immunosuppressive state and reactivation of undiagnosed HSV. Rapid HSV pneumonia ensued, culminating in fulminant organ failure and mortality. HSV pneumonia should be considered postoperatively in patients with severe respiratory distress, especially if immunocompromised.

Retrograde type A aortic dissection: a different evil.

Retrograde type A aortic dissection (RTAAD) can be spontaneous or secondary to the instrumentation of the descending and thoraco-abdominal aorta. It has anatomical differences compared to antegrade type A aortic dissection that impact the management and prognosis. Treatment is not standardized. We report our approach to spontaneous RTAAD in our institution between 2018 and 2022 (n = 15). The mean age was 60.1 years and 93% were male. Aortic valve, coronary arteries and supra-aortic trunks were spared by the dissection in 80% of the cases; distal extension to iliacs was common and lower limb malperfusion was present in 4 cases (27%). The ascending aorta was dilated at presentation in 60% of the cases. Emergency surgery with arch/FET replacement was offered to 11 patients (73%); 3 patients (20%) received a limited proximal aortic repair; 1 patient was treated conservatively. Overall mortality was 47% (100% for limited proximal repair and 22% for those who received arch/FET). We advocate for aggressive treatment of RTAAD excluding the primary entry tear to prevent immediate- and mid-term complications.

Surgical and endovascular treatment of late postcoarctation repair aortic aneurysms: Results from an international multicenter study.

OBJECTIVE: The formation of postaortic coarctation aneurysms (pCoAA) is well-described in the literature and carries a significant risk of rupture and death. Treatment strategies include open surgical, hybrid, and endovascular repair, depending on the clinical presentation, risk assessment, and anatomy. The aim of this study was to report the early and midterm results of open surgical and endovascular repair of pCoAA. METHODS: This is an international multicenter retrospective study including patients who underwent open surgical or endovascular repair for pCoAA between 2000 and 2021 at 14 highly specialized academic cardiovascular centers. The preoperative, intraoperative, and postoperative data were recorded and analyzed. RESULTS: A total of 74 patients (46 male; median age, 44 years; interquartile range [IQR], 35-53 years) underwent pCoAA repair. All patients had previously undergone surgical repair of aortic coarctation at a median age of 11 years for the index procedure (IQR, 7-17 years). The most common first surgical correction was synthetic patch aortoplasty in 48 patients, followed by graft interposition in 11. The median pCoAA diameter was 54 mm (IQR, 44-63 mm). The median time from the aortic coarctation repair to the pCoAA diagnosis was 33 years (IQR, 25-40 years). A total of 33 patients had symptoms at presentation, including thoracic or back pain in 8 patients. Open surgical repair was performed in 28 patients, including four frozen elephant trunk procedures and one Bentall. The remaining 46 patients underwent endovascular repair of the pCoAA. Two in-hospital deaths were observed (one frozen elephant trunk and one endovascular). After a median follow-up of 50 months (IQR, 14-127 months), there were a total of seven reinterventions. CONCLUSIONS: This international multicenter study demonstrates that patients with pCoAA can be safely treated with either open surgical or endovascular interventions. Because the median time between the coarctation repair and the aneurysm formation was more than 30 years, life-long surveillance of these patients is warranted.

Ministernotomy repair of inadvertent proximal right subclavian artery injury following right internal jugular central venous catheter insertion.

A man in his 60s was referred for urgent coronary artery bypass grafting (CABG) procedure following acute coronary syndrome. After induction of general anaesthesia, right jugular venous catheterisation under two-dimensional ultrasound guidance was planned as part of perioperative management. While obtaining vascular access, the pulsatile flow was noted once the dilator was inserted, having to abandon the procedure and immediately apply manual pressure. CT angiogram showed proximal right subclavian artery injury with active contrast extravasation and resultant large haematoma in the neck. The patient underwent urgent exploration of the injured vessel through a J-shaped ministernotomy, and primary repair of the artery was performed. The patient recovered from the procedure without any complications. He continued to stay in the hospital for a few days, afterwards, he underwent the initially planned CABG surgery. He was discharged home on day 5 after surgery without further concerns.

High Wall Shear Stress can Predict Wall Degradation in Ascending Aortic Aneurysms: An Integrated Biomechanics Study.

Background: Blood flow patterns can alter material properties of ascending thoracic aortic aneurysms (ATAA) via vascular wall remodeling. This study examines the relationship between wall shear stress (WSS) obtained from image-based computational modelling with tissue-derived mechanical and microstructural properties of the ATAA wall using segmental analysis. Methods: Ten patients undergoing surgery for ATAA were recruited. Exclusions: bicuspid aortopathy, connective tissue disease. All patients had pre-operative 4-dimensional flow magnetic resonance imaging (4D-MRI), allowing for patient-specific computational fluid dynamics (CFD) analysis and anatomically precise WSS mapping of ATAA regions (6-12 segments per patient). ATAA samples were obtained from surgery and subjected to region-specific tensile and peel testing (matched to WSS segments). Computational pathology was used to characterize elastin/collagen abundance and smooth muscle cell (SMC) count. Results: Elevated values of WSS were predictive of: reduced wall thickness [coef -0.0489, 95% CI (-0.0905, -0.00727), p = 0.022] and dissection energy function (longitudinal) [-15,0, 95% CI (-33.00, -2.98), p = 0.048]. High WSS values also predicted higher ultimate tensile strength [coef 0.136, 95% CI (0 0.001, 0.270), p = 0.048]. Additionally, elevated WSS also predicted a reduction in elastin levels [coef -0.276, 95% (CI -0.531, -0.020), p = 0.035] and lower SMC count ([oef -6.19, 95% CI (-11.41, -0.98), p = 0.021]. WSS was found to have no effect on collagen abundance or circumferential mechanical properties. Conclusions: Our study suggests an association between elevated WSS values and aortic wall degradation in ATAA disease. Further studies might help identify threshold values to predict acute aortic events.

Cardiac surgery outcome during the COVID-19 pandemic: a retrospective review of the early experience in nine UK centres.

BACKGROUND: Early studies conclude patients with Covid-19 have a high risk of death, but no studies specifically explore cardiac surgery outcome. We investigate UK cardiac surgery outcomes during the early phase of the Covid-19 pandemic. METHODS: This retrospective observational study included all adult patients undergoing cardiac surgery between 1st March and 30th April 2020 in nine UK centres. Data was obtained and linked locally from the National Institute for Cardiovascular Outcomes Research Adult Cardiac Surgery database, the Intensive Care National Audit and Research Centre database and local electronic systems. The anonymised datasets were analysed by the lead centre. Statistical analysis included descriptive statistics, propensity score matching (PSM), conditional logistic regression and hierarchical quantile regression. RESULTS: Of 755 included individuals, 53 (7.0%) had Covid-19. Comparing those with and without Covid-19, those with Covid-19 had increased mortality (24.5% v 3.5%, p < 0.0001) and longer post-operative stay (11 days v 6 days, p = 0.001), both of which remained significant after PSM. Patients with a pre-operative Covid-19 diagnosis recovered in a similar way to non-Covid-19 patients. However, those with a post-operative Covid-19 diagnosis remained in hospital for an additional 5 days (12 days v 7 days, p = 0.024) and had a considerably higher mortality rate compared to those with a pre-operative diagnosis (37.1% v 0.0%, p = 0.005). CONCLUSIONS: To mitigate against the risks of Covid-19, particularly the post-operative burden, robust and effective pre-surgery diagnosis protocols alongside effective strategies to maintain a Covid-19 free environment are needed. Dedicated cardiac surgery hubs could be valuable in achieving safe and continual delivery of cardiac surgery.

Thoracoabdominal aneurysmectomy: Operative steps for Crawford extent II repair.

BACKGROUND: Open surgical repair remains the gold standard for treatment of thoracoabdominal aortic aneurysm (TAAA). Surgery aims to replace the whole length of the diseased distal aorta while protecting the spinal cord and the visceral organs to limit ischemia-related complications. The substantial associated surgical risks, including death, paraplegia, renal failure requiring permanent dialysis, and respiratory complications leading to prolonged intensive care unit stay, still outweigh the natural history of TAAA with conservative treatment. METHODS: We describe in detail our current approach to open extent II TAAA repair with a step-by-step illustration of the technique and the surgical adjuncts. RESULTS: We routinely perform left heart bypass with mild passive hypothermia (34°C), cerebrospinal fluid drainage, sequential aortic cross-clamping, monitoring of motor evoked potentials (MEPs) and cerebral, paraspinal, and lower limb oxygen saturation by near-infrared spectrometry, as well as selective visceral perfusion via the celiac and superior mesenteric arteries and renal protection with intermittent administration of Custodiol HTK (histidine-tryptophan-ketoglutarate) solution via the renal arteries. We advocate for individual branch reimplantation using a branched thoracoabdominal graft when possible, and we selectively reattach 1 or more pairs of the lower thoracic intercostal arteries and/or high lumbar arteries, even in the absence of a significant reduction in the MEPs signal. The distal anastomosis is usually constructed above the aortic bifurcation and occasionally to each iliac separately using a bifurcated graft. CONCLUSIONS: Favorable early outcomes and a durable TAAA repair can be achieved at experienced high-volume centers with standardized preoperative selection and multidisciplinary team-based intraoperative and postoperative management of these patients.

[Impact of smoking on the results of coronary artery bypass surgery]. / Einfluss des Rauchens auf die Ergebnisse der koronaren Bypasschirurgie.

BACKGROUND AND PURPOSE: The proportion of patients undergoing coronary artery bypass surgery (CABG) with a history of smoking is increasing. The aim of this study was to examine the effect of smoking on outcomes following CABG. PATIENTS AND METHODS: 6,367 consecutive patients who underwent CABG between April 1997 and March 2003 were analyzed retrospectively. Logistic regression was used to risk-adjust inhospital outcomes, while Cox proportional hazards analysis was used to risk-adjust Kaplan-Meier survival curves. Outcomes were adjusted for variables suggested by the American Heart Association and the American College of Cardiology. RESULTS: 947 patients (14.9%) were current smokers (smoking within 1 month of surgery), while 3,857 (60.6%) were ex-smokers and 1,563 (24.5%) nonsmokers. After adjusting for differences in case-mix, current smokers were more likely to develop chest infections (p < 0.001), atelectasis (p < 0.001), and require ventilation > 48 h (p = 0.003). Current smokers were also more likely to stay in intensive care for > 3 days (p < 0.001). There was no association between smoking status and in-hospital mortality. Ex-smokers were not associated with excess mortality (p = 0.11), while current smokers had significantly increased mortality during follow-up (p = 0.029). CONCLUSION: Current smokers are associated with increased respiratory complications, and prolonged stay on intensive care. Although not associated with in-hospital mortality, there appears to be a significant increase in mortality in smokers during a 4-year follow-up period. Patients should be encouraged to stop smoking to maximize the long-term benefits of CABG.