The impact of onset-to-cut time in surgery for stable acute type A aortic dissection-a single-centre retrospective cohort study.

OBJECTIVES: The goal of this study was to investigate the impact of onset-to-cut time on mortality in patients undergoing surgery for stable acute type A aortic dissection. METHODS: Patients who underwent surgery for acute type A aortic dissection between January 2006 and December 2021 and available onset-to-cut times were included. Patients with unstable aortic dissection (preoperative shock, intubation, resuscitation, coma, pericardial tamponade and local/systemic malperfusion syndromes) were excluded. After descriptive analysis, a multivariable binary logistic regression for 30-day mortality was performed. A receiver operating characteristic curve for onset-to-cut time and 30-day mortality was calculated. Restricted cubic splines were designed to investigate the association between onset-to-cut time and survival. RESULTS: The final cohort comprised 362 patients. The median onset-to-cut time was 543 (376-1155) min. The 30-day mortality was 9%. Only previous myocardial infarction (P = 0.018) and prolonged cardiopulmonary bypass time (P < 0.001) were identified as independent risk factors for 30-day mortality. The corresponding area under the receiver operating characteristic curve showed a value of 0.49. Restricted cubic splines did not indicate an association between onset-to-cut time and survival (P = 0.316). CONCLUSIONS: Onset-to-cut time in the setting of stable acute type A aortic dissection does not seem to be a valid predictor of 30-day mortality in patients undergoing surgery and stayed stable during the preoperative course.

The role of concomitant coronary artery bypass grafting in acute type A aortic dissection complicated by coronary malperfusion.

OBJECTIVES: Managing acute type A aortic dissection with coronary malperfusion is challenging. This study outlines our revascularization strategy for these patients. METHODS: Patients undergoing surgery for acute type A aortic dissection with coronary malperfusion and aortic root involvement from January 2000 to December 2021 were included. Patients were classified using the Neri classification for coronary dissection, including a novel 'Neri -' class (no coronary dissection). Patients undergoing revascularization either as a planned or as a bailout strategy due to persisting low cardiac output were compared additionally. RESULTS: The cohort comprised 195 patients: 43 (22%) Neri -, 43 (22%) Neri A, 74 (38%) Neri B and 35 (18%) Neri C. Aortic root replacement was mainly performed in 25 Neri C patients (71%; P < 0.001). Concomitant bypass surgery was performed in 4 (9%) of Neri -, 5 (12%) of Neri A, 21 (28%) of Neri B and 32 (91%) of Neri C patients (P < 0.001). Thirty-day mortality was 42% with 21 (49%) Neri -, 12 (28%) Neri A, 30 (41%) Neri B and 19 (54%) Neri C patients (P = 0.087). Bailout revascularization was primarily performed in 11 Neri B patients (69%; P = 0.001) and associated with a higher 30-day mortality of 81% compared to 48% for planned revascularization (P = 0.042). CONCLUSIONS: Postoperative outcomes in case of coronary malperfusion are poor, irrespective of the anatomic dissection pattern. The decision for concomitant bypass surgery is crucial but may be considered in Neri C patients combined with aortic root replacement. Bailout revascularization was most common in Neri B and showed dismal outcome.

The Ascyrus Medical Dissection Stent: A One-Fits-All Strategy for the Treatment of Acute Type A Aortic Dissection?

The treatment of DeBakey type I aortic dissection remains a major challenge in the field of aortic surgery. To upgrade the standard of care hemiarch replacement, a novel device called an "Ascyrus Medical Dissection Stent" (AMDS) is now available. This hybrid device composed of a proximal polytetrafluoroethylene cuff and a distal non-covered nitinol stent is inserted into the aortic arch and the descending thoracic aorta during hypothermic circulatory arrest in addition to hemiarch replacement. Due to its specific design, it may result in a reduced risk for distal anastomotic new entries, the effective restoration of branch vessel malperfusion and positive aortic remodeling. In this narrative review, we provide an overview about the indications and the technical use of the AMDS. Additionally, we summarize the current available literature and discuss potential pitfalls in the application of the AMDS regarding device failure and aortic re-intervention.

Analysis of factors affecting outcome in acute type A aortic dissection complicated by preoperative cardiopulmonary resuscitation.

OBJECTIVES: Cardiopulmonary resuscitation (CPR) aggravates the pre-existing dismal prognosis of patients suffering from acute type A aortic dissection (ATAAD). We aimed to identify factors affecting survival and outcome in ATAAD patients requiring CPR at presentation at 2 European aortic centres. METHODS: Data on 112 surgical candidates and undergoing preoperative CPR were retrospectively evaluated. Patients were divided into 2 groups according to 30-day mortality. A multivariable model identified predictors for 30-day mortality. RESULTS: Preoperative death occurred in 23 patients (20.5%). In the remaining 89 surgical patients (79.5%) circulatory arrest time (41 ± 20 min in 30-day non-survivors vs 30 ± 13 min in 30-day survivor, P = 0.003) as well as cardiopulmonary bypass time (320 ± 132 min in 30-day non-survivors vs 252 ± 140 min in 30-day survivor, P = 0.020) time was significantly longer in patients with worse outcome. Thirty-day mortality of the total cohort was 61.6% (n = 69) with cardiac failure in 48% and aortic rupture or haemorrhagic shock (28%) as predominant reasons of death. Age [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.09, P = 0.034], preoperative coronary (OR 3.42, 95% CI 1.34-9.26, p = 0.012) and spinal malperfusion (OR 12.49, 95% CI 1.83-225.02, P = 0.028) emerged as independent predictors for 30-day mortality while CPR due to tamponade was associated with improved early survival (OR 0.29, 95% CI 0.091-0.81, P = 0.023). CONCLUSIONS: Assessment of underlying cause for CPR is mandatory. Pericardial tamponade, rapidly resolved with pericardial drainage, is a predictor for improved survival, while age and presence of coronary and spinal malperfusion are associated with dismal outcome in this high-risk patient group.

Case Report: Successful endovascular treatment of acute type A aortic dissection.

Introduction: Open surgical repair remains the current gold standard for the treatment of acute type A aortic dissection. However, especially elderly patients with relevant comorbidities who are deemed unfit for open surgery may benefit from a minimally invasive endovascular approach. Methods: We report a case of an 80-year-old male with retrograde acute type A aortic dissection and peripheral malperfusion after receiving thoracic endovascular aortic repair due to thoracic aortic aneurysm. Our individualized endovascular approach consisted of left carotid-subclavian bypass, proximal extension of thoracic endovascular aortic repair using a covered stent graft and a single covered stent graft for the ascending aorta in combination with an uncovered stent for the aortic arch. Results: Postoperative computed tomographic angiography demonstrated excellent outcome with no signs of endoleak or patent false lumen. Follow-up after 3.5 years showed a stable result with no signs of stent failure or dissection progress. No aortic re-interventions were needed in the further course. Discussion: An individualized endovascular approach may be justified for acute type A aortic dissection in elderly patients with high surgical risk if performed in specialized aortic centers. Additional short-length stent graft devices are needed to address the anatomical challenges of the ascending aorta. For enhanced remodeling of the dissected aorta, the use of an additional uncovered stent may be advisable.

The impact of malperfusion patterns in elderly patients undergoing surgery for acute type A aortic dissection.

OBJECTIVES: The aim of this study is to investigate the outcome of elderly patients with surgically treated acute type A aortic dissection (ATAAD) complicated by malperfusion. METHODS: Patients ≥70 years old who underwent surgical treatment for ATAAD between January 2000 and December 2020 were enrolled in this study and stratified by their specific Penn Classification into 4 different subgroups, where Penn Abc was defined as multilevel malperfusion. Short- and long-term outcomes were investigated. Multivariable binary logistic regression was performed to identify risk factors for 1-year mortality. RESULTS: Four hundred elderly patients underwent surgical treatment for ATAAD. A total of 204 (51%) patients had no evidence of malperfusion (Penn Aa), 106 (26.5%) had localized organic malperfusion (Penn Ab), 44 (11%) patients had systemic malperfusion (Penn Ac) and 46 (11.5%) suffered from multilevel malperfusion (Penn Abc). For the latter, in-hospital mortality was 70% (P < 0.001). Age (P < 0.006) and multilevel malperfusion (P < 0.001) were independent risk factors for 1-year mortality. Patients with multilevel malperfusion showed the worst 1-year survival (P < 0.001). In the case of Penn Aa, in-hospital mortality was 13% (P < 0.001). CONCLUSIONS: Surgery may lead to satisfactory results in the absence of malperfusion, even in octogenarians. Elderly patients with multilevel malperfusion show very poor surgical outcome. In these patients, the decision for surgery should be taken with caution. Operation, if performed, should be carried out by experienced teams only.

Cerebral Protection Strategies and Stroke in Surgery for Acute Type A Aortic Dissection.

BACKGROUND: Perioperative stroke remains a devastating complication in the operative treatment of acute type A aortic dissection. To reduce the risk of perioperative stroke, different perfusion techniques can be applied. A consensus on the preferred cerebral protection strategy does not exist. METHODS: To provide an overview about the different cerebral protection strategies, literature research on Medline/PubMed was performed. All available original articles reporting on cerebral protection in surgery for acute type A aortic dissection and neurologic outcomes since 2010 were included. RESULTS: Antegrade and retrograde cerebral perfusion may provide similar neurological outcomes while outperforming deep hypothermic circulatory arrest. The choice of arterial cannulation site and chosen level of hypothermia are influencing factors for perioperative stroke. CONCLUSIONS: Deep hypothermic circulatory arrest is not recommended as the sole cerebral protection technique. Antegrade and retrograde cerebral perfusion are today's standard to provide cerebral protection during aortic surgery. Bilateral antegrade cerebral perfusion potentially leads to superior outcomes during prolonged circulatory arrest times between 30 and 50 min. Arterial cannulation sites with antegrade perfusion (axillary, central or carotid artery) in combination with moderate hypothermia seem to be advantageous. Every concept should be complemented by adequate intraoperative neuromonitoring.

HeartWare to HeartMate 3 left ventricular assist device exchange via a left lateral thoracotomy.

A continuous-flow left ventricular assist device implant is a well-established therapy for patients with end-stage heart failure. Currently, the HeartMate 3 device is the only commercially available durable left ventricular assist device. Therefore, patients on HeartWare HVAD support who require a pump exchange must have a HeartMate 3 implanted.

Aortic remodelling and late outcomes following thoracic endovascular repair with a bare-metal stent distal extension among patients with complicated type-B aortic dissection.

OBJECTIVES: The goal of this study was to describe the factors affecting mid and late aortic remodelling following thoracic endovascular aortic repair with the PETTICOAT (Provisional Extension To Induce Complete Attachment) technique among patients with complicated acute or subacute type B aortic dissection. METHODS: A retrospective single-centre study that evaluates clinical and morphological outcomes among 65 consecutive patients. The area and diameter of the true and false lumen, overall aortic diameter and false lumen perfusion were evaluated. RESULTS: Concomitant direct visceral artery stenting was successfully conducted in 32 (49%) patients. There was one (1.5%) postoperative stroke; three (4.6%) patients developed spinal cord ischaemia; two (3%) patients suffered retrograde type A dissection; and two (3%) patients had mesenteric ischaemia, despite successful reperfusion, that required a bowel resection. Median postoperative follow-up was 63.1 (interquartile range, 32.1- 91.8) months. The probability of survival was 96.9% [95% confidence interval (CI) 88.3%-99.2%] at 30 days, 93.9% (95% CI 84.4%-97.6%) at 1 year, 78.0 (95% CI 64.2%-87.0%) at 5 years and 72.8% (95% CI at 57.9%-83.2%) at 10 years postoperatively. There was a statistically significant postoperative increase in true-lumen area, diameter and true-lumen index in all five aortic levels measured. Complete false lumen (FL) thrombosis at the coeliac trunk, renal arteries and aortic bifurcation levels was observed in 47%, 15% and 24% of patients at midterm (6-15 months) and in 29%, 21% and 29% on late (later than 21 months) computed tomography angiograms (CTA). Persistent false lumen (FL) perfusion at the coeliac level on midterm CTA was associated with a larger extent of late aortic growth (P = 0.042) and was, in the majority of cases, caused by iliac re-entries either alone (28.57) or in combination with visceral and lumbar (28.57%) or distal aortic (10.71%) re-entries. A larger abdominal aortic diameter at midterm was associated with an increased probability of distal aortic reinterventions (hazard ratio 7.26, 95% CI 2.41-21.9, P < 0.001). CONCLUSIONS: Persistent FL perfusion of the distal aorta at midterm following TEVAR with the PETTICOAT technique among patients with acute and subacute type B dissection is caused mainly by iliac, visceral, lumber and distal aorta re-entries. Patients with persistent FL perfusion have an increased risk of aortic aneurysmal growth at late follow-up.

Periareolar endoscopic minimally invasive cardiac surgery: postoperative scar assessment analysis.

OBJECTIVES: The standard approach for minimally invasive cardiac surgery (MICS) for repair of the atrioventricular valves is a right lateral minithoracotomy. In this study, we report our experience with a periareolar endoscopic approach, which aims at an optimal cosmetic outcome while preserving optimal clinical outcomes. METHODS: All patients underwent periareolar endoscopic MICS using high-definition three-dimensional endoscopic visualization without additional rib-spreading. Patients presented with degenerative and/or functional mitral regurgitation. Patients undergoing concomitant tricuspid valve surgery, cryo-ablation, patent foramen ovale closure, left atrial appendage occlusion and/or left atrial myxoma extirpation were included. This descriptive article analysed the aesthetic and functional outcome of the periareolar scar using 5 most common and clinimetrically sound scar assessment scales. For statistical analysis of the scar assessment grading scales, box and whisker plots were calculated depicting median, interquartile range and high and low range data points. RESULTS: Median scar assessment scale scores for n = 100 male patients (response rate 100/109; 91.7%) were 2 [1, 4], 7.5 [6, 9], 11 [8, 14], 3 [2, 3] and 10 [9, 11] for the Vancouver scar scale, Manchester scar scale, patient scar assessment scale, Stony brook scar evaluation scale and Dermatology Quality of Life Index scale, respectively. Ninety-seven patients received mitral valve repair, 7 mitral valve replacement, whereas 5 had left atrial myxoma extirpation. Concomitant tricuspid annuloplasty, cryo-ablation, left atrial appendage occlusion and patent foramen ovale closure surgery were performed in 12, 29, 5 and 8 patients, respectively. Median procedure, cardiopulmonary bypass and cross-clamp times were 169.5 [154.3, 189.3], 111.5 [97, 127], and 68.5 [58.8, 81] min, respectively. CONCLUSIONS: Periareolar endoscopic MICS is safe and cosmetically appealing. It is feasible and allows for complex mitral valve repair, mitral valve replacement and concomitant surgery. Data from 5 scar assessment scales suggest that this technique delivers patient-satisfying results regarding functional and cosmetic outcomes.

The arch remodelling stent for DeBakey I acute aortic dissection: experience with 100 implantations.

OBJECTIVES: A novel hybrid non-covered stent was developed to treat malperfusion and prevent aneurysm formation following hemiarch procedure for DeBakey I acute aortic dissection (AAD). The present analysis investigates the performance of the device in 100 consecutive implantations. METHODS: Between 2018 and 2021, 100 patients underwent surgical repair of DeBakey I AAD with implantation of a non-covered stent in the arch and descending aorta. The primary entry tear was located in the root or the ascending aorta. Clinical and imaging data were collected and analysed retrospectively. The endpoints of the study were 30-day mortality, neurological outcome and need of additional procedures due to postoperative malperfusion. Technical success was assessed in the first postoperative computed tomography in regard to the induction of false lumen thrombosis in the descending aorta. RESULTS: The median age was 61 (54-73) years. Preoperative malperfusion was present in 46 (46%) patients. The primary arterial cannulation strategy was the right axillary artery and an open distal anastomosis was performed in a median caudal circulatory arrest of 40 (34-52) min. In 48% of cases, a 55-40 tapered stent was implanted. The 30-day mortality was 18%, and the operation-related new postoperative neurological deficit was present in 8%. Technical success was achieved in 76% of patients. CONCLUSIONS: The novel non-covered stent can be safely applied to complement aortic repair with the hemiarch procedure for DeBakey I AAD. The expansion of the true lumen through the device may prevent postoperative malperfusion and induces positive vascular remodelling with the thrombosis of the false lumen.

David Procedure as Valve-Sparing Root Replacement.

Composite replacement of the aortic root and aortic valve is a valid surgical strategy in a case of annuloaortic ectasia. However, valve-sparing root replacement procedures have become the gold standard in cases with a morphologically intact or at least repairable aortic valve, and offer several advantages compared to conventional replacement techniques. Above all, the David procedure has become established as a well-known valve-sparing root replacement strategy with excellent short- and long-term outcomes, and it has been further applied to additional patient populations with characteristics like a bicuspid aortic valve or in the setting of acute type A aortic dissection. This narrative review offers an overview of the indications as well as the surgical steps of the T. David V procedure, and highlights important key points regarding the surgical feasibility and criteria of patient selection for valve-sparing root replacement.

Matched comparison of 3 cerebral perfusion strategies in open zone-0 anastomosis for acute type A aortic dissection.

OBJECTIVES: The present study aims to investigate outcomes after the surgical treatment of acute type A aortic dissection in regard to three available selective cerebral perfusion strategies. METHODS: From 2000 to 2019, patients were selected based on the employment of either retrograde cerebral perfusion (RCP), unilateral antegrade cerebral perfusion (uACP) or bilateral antegrade cerebral perfusion (bACP) during open zone-0 anastomosis. Propensity score TriMatch analysis considering several preoperative and intraoperative variables was used to identify well-balanced triplets. The primary end point of the study was a new cerebral operation-related neurologic deficit. RESULTS: Operative times (operation time, cardiopulmonary bypass time, reperfusion time) were significantly longer in the RCP group, in which deeper hypothermia was applied (27.5 [24-28], 28 [26-28] and 16 [16-17]°C for uACP, bACP and RCP, respectively, P-value <0.001). The RCP group showed higher red blood cell concentrates and fresh frozen plasma transfusion rates. No significant difference of new cerebral operation-related neurologic deficit was observed between the 3 groups (12.9% vs 12.9% vs 11.3% for RCP, uACP and bACP, P-value = 0.86). In addition, 30-day mortality showed similar distribution independently of the cerebral perfusion strategy adopted (17.7% vs 14.5% vs 17.7% for RCP, uACP and bACP, P-value = 0.86). CONCLUSIONS: However, based on a small sample size, the comparison showed no relevant differences in terms of neurologic outcome and 30-day mortality, confirming RCP, uACP and bACP as safe and reproducible selective cerebral perfusion strategies in surgery for acute type A aortic dissection.

Endoaortic balloon occlusion in minimally invasive mitral valve surgery.

Minimally invasive mitral valve surgery has become a standardized and well-established approach to treat mitral valve disease and is associated with limited procedural trauma. Nevertheless, it remains a technically demanding procedure with a steep learning curve, and new manual skills need to be acquired. Various technical solutions have been adopted and implemented to overcome the challenges associated with this surgical technique. Endoaortic balloon occlusion was introduced as an alternative to the conventional external transthoracic cross-clamping of the aorta. In this video tutorial, we provide detailed insights into and step-by-step guidance for the endoaortic balloon occlusion procedure in minimally invasive mitral valve surgery.

Validation of a novel risk score to predict mortality after surgery for acute type A dissection.

OBJECTIVES: The aim of this study was to externally validate a lab-based risk score (lactate, creatinine, aspartate aminotransferase, alanine aminotransferase or bilirubin) by Ghoreishi et al. to predict perioperative mortality in patients undergoing surgical repair for acute type A aortic dissection. METHODS: The risk score to predict operative mortality was applied to a large and homogenous validation cohort that consisted of 632 patients undergoing surgery for acute type A aortic dissection in 2 centres. Multivariable regression analysis was performed to determine the impact on survival. Receiver operating characteristics with deduced area under the curve were used to assess the ability to predict perioperative mortality. RESULTS: A total of 632 patients (54% male, mean age 62 ± 14 years) were assigned to 3 different risk groups according to the calculated mortality score [low risk <7 (31.2%), moderate risk 7-20 (36.1%) and high >20 (32.7%)]. Perioperative mortality was 8% in the low-risk group, 10% in the moderate-risk group and 24% in the high-risk group (P < 0.0001). Receiver operating characteristic analysis of this new score revealed an area under the curve of 0.69 with adequate calibration. In addition, multivariable analysis revealed an independet assocation with perioperative mortality (odds ratio 1.509; 95% confidence interval 1.042-2.185). While overall survival differed between the risk groups (P < 0.0001), the score does not serve as an independent predictor of long-term mortality when adjusted for relevant covariates. CONCLUSIONS: The external validation process confirmed that a newly proposed risk score offers clinicians a helpful and reliable tool to improve the preoperative risk assessment of acute type A aortic dissection patients based on easily accessible and broadly available laboratory parameters.

Initial experience with the new type A arch dissection stent: restoration of supra-aortic vessel perfusion.

OBJECTIVES: The goal of the present study is to investigate changes in supra-aortic vessel perfusion after implantation of the non-covered Ascyrus Medical Dissection Stent (AMDS) for surgical treatment of acute type A aortic dissection. METHODS: From 2017 to 2020, 16 consecutive patients treated with AMDS and involvement (dissection to total occlusion) of at least 1 supra-aortic vessel were included in the study. Centre-line based computed tomography measurements of true, false and total lumen area using Terarecon software were performed before and after surgery. Changes in the true lumen area were indexed to the entire vessel area. The paired sample t-test was used to assess the significance of the observed differences. RESULTS: Analysis of supra-aortic vessels and the descending aorta showed significant improvement in true lumen perfusion after the AMDS was implanted. The indexed true lumen area increased postoperatively by 72%, 112% and 30% in the innominate, right and left common carotid arteries, respectively. Total occlusions of both common carotid arteries recovered completely after surgical treatment. The proximal- and the mid-descending aorta showed a 78% and 48% improvement of the indexed true lumen area, respectively. CONCLUSIONS: Arch repair using AMDS shows promising results in the treatment of acute type A aortic dissection. Quantitative measurements of true and false lumen perfusion demonstrated a significant increase in true lumen area and a 100% regression of totally occluded supra-aortic branches. Further examination in a larger cohort of patients and comparison with isolated hemiarch repair are needed to confirm positive vascular remodelling after an AMDS implant.

Single arterial access ECMELLA: A new concept and step-by-step procedure.

Therapy for cardiogenic shock using temporary mechanical circulatory support has improved significantly in the last decades, providing patients with new technologies for both acute phase stabilization and bridging to long-term therapies. A combination of a venoarterial extracorporeal life support system and the Impella left ventricular assist device (known as the ECMELLA approach) represents an effective therapy for severe cardiogenic shock that achieves high-flow circulatory support with simultaneous left-ventricular unloading. We present the new ECMELLA 2.0 concept, whereby a single arterial access technique is used to treat severe cardiogenic shock. The goal of this technique is to reduce access-related complications and make a bedside staged weaning from mechanical support possible.

State of the Art Review: Surgical Treatment of Acute Type A Aortic Dissection.

Acute type A aortic dissection (ATAAD) is a life-threatening event that requires immediate surgical treatment. Improvements in surgical treatment, graft technology, organ protection and imaging techniques have led to improved clinical outcomes. Individualized treatment concepts have emerged based on more advanced planning tools that allow for a tailored approach even in complex situations such as multi-level malperfusion. This review provides an overview of the current surgical treatment of ATAAD, focusing on new disease classifications, preoperative computed tomography angiography (CTA) assessment, new prosthesis and stent technologies, and organ-protection strategies.