Aortic root rotation: morphological analysis of the aortic root with three-dimensional computed tomography.

OBJECTIVES: The aortic root (AoR) rotation and its spatial morphology at the base of the heart were postulated but not described in every detail. AoR rotation modalities may play an important role in decision-making during AoR surgery and its outcome. The aim was to provide a detailed spatial anatomy of the AoR rotation and its relation to the vital surrounding structure. METHODS: The AoR rotation and its relation to the surrounding structure were assessed in 104 patients with tricuspid aortic valve. The interatrial septum was chosen as a reference to describe AoR rotation that marked the midline of the heart base as a landmark for the AoR rotation direction. Intermediate, clockwise and counterclockwise AoR rotations were defined based on the mentioned reference structures. RESULTS: The AoR rotation was successfully assessed in 104 patients undergoing ascending aorta and or AoR intervention by multidetector row computed tomography. AoR was positioned normally in 53.8% of cases (n = 56) and rotated counterclockwise in 5.8% (n = 6) and clockwise in 40.4% (n = 42) of cases. In clockwise AoR rotation, the right coronary sinus was positioned in proximity to the right atrium and of the tricuspid valve, whereas in a counterclockwise rotation, the noncoronary sinus was placed over the tricuspid valve just over the membranous septum. CONCLUSIONS: The AoR's rotation can be diagnosed using multidetector row computed tomography. Understanding the anatomy of the aortic valve related to rotational position helps guide surgical decision-making in performing AoR reconstruction.

Combining Minimally Invasive Direct Coronary Artery Bypass Grafting with Transapical Aortic Valve Implantation-The Next Level Heart Team Approach.

We present the results of a combined approach for transapical aortic valve replacement and minimally invasive coronary artery bypass grafting (taTAVI-MIDCAB) in patients with combined aortic stenosis and coronary artery disease. BACKGROUND: For patients presenting with aortic stenosis and coronary artery disease, a simultaneous procedure addressing both diseases is recommended to reduce operative risk. In high-risk patients with hostile femoral or coronary axis, taTAVI-MIDCAB can be an alternative minimally invasive approach, offering the benefits of left interior mammary artery to left anterior descending coronary artery (LIMA-LAD) grafting. METHODS: From 2014 to 2022, 10 patients underwent taTAVI-MIDCAB for combined coronary and severe aortic stenosis in the hybrid operation theater at our institution. We assessed perioperative outcomes and follow-up outcomes. RESULTS: The median age was 83 years (81 to 86). The procedure was successfully performed in all patients without conversion to sternotomy. The median length of hospital and intensive care unit stay was 9 days (7 to 16) and 2.5 days (1 to 5), respectively. The median flow over the coronary artery bypass was 31 (22 to 44) mL/min, with a pulsatility index (PI) of 2.4 (2.1 to 3.2). Mild paravalvular leak occurred in 2 patients (10%). There were no neurological events nor acute kidney injury. Pacemaker implantation was required in 1 patient (10%). CONCLUSIONS: Simultaneous surgical coronary revascularization and interventional valve implantation in the setting of a hostile femoral and coronary axis appears to be safe and beneficial.

Sex differences in readmission rate after cardiac surgery.

Introduction: The impact of sex on hospital readmission rate after cardiac surgery is unclear. Therefore, we aimed to analyse sex-specific differences and underlying factors in 30-day readmission rate after cardiac surgery. Methods: We conducted a single center study including all patients after major cardiac surgery (excluding aortic dissection and left ventricular assist device implantation) from January 2012 to September 2020. Reasons for readmission were adjudicated according to all available medical records. We calculated incidence rate ratios (IRR) with 95% confidence intervals (CI) for female sex with re-admission crude and adjusted for plausible confounding factors using negative binomial regression. Results: 4,868 patients were included in the analysis. The median [Interquartile range] age was 68 [60 to 74] years and 24% (n = 1,149) of the patients were female. Female patients were significantly older (median [IQR] age 70 (63 to 76) vs. 67 (59 to 74), p < 0.001) and had lower body mass index and fewer cardiovascular risk factors compared to men. Isolated valve surgery was more frequent in female while coronary artery bypass grafting was more often in men. 30-day readmission was comparable between both sexes (7.0% [n = 81] in female vs. 8.7% [n = 322] in men; p = 0.078). Cardiac related readmissions and infections were the most common reasons for readmission in both groups. The overall incidence rate ratios of female sex with readmission (0.80, 95% CI 0.63 to 1.03, p = 0.078) remained robust after adjustment for EuroSCORE 2 (0.78, CI 0.61 to 1.0, p = 0.051). Conclusion: Readmission rate and reasons for 30-day readmission after major cardiac surgery were similar between men and women.

Prolonged cardiopulmonary bypass time as predictive factor for bloodstream infection.

Objectives: To evaluate the correlation between patient characteristics, operative variables and the risk of blood stream infection as well as the association of primary blood stream infection and adverse outcomes. Methods: Clinical records of 6500 adult patients who underwent open heart surgery between February 2008 and October 2020 were analyzed. The microbiological pattern of the primary BSI and its association with adverse events, such as mortality and major cardiovascular events, were evaluated. Results: Primary bloodstream infection was diagnosed in 1.7% (n = 108) of patients following cardiac surgery with the application of cardiopulmonary bypass. Most isolated bacteria were gram-negative bacillus groups, such as the Enterobacteriaceae family with Serrata marcescens in 26.26%, followed by the Enterococcaceae family with the Enterococcus faecalis in 7.39% and Enterococcus faecium in 9.14% as the most frequently identified bacteria. The postprocedural mortality, stroke rate p < 0.001, the incidence of postoperative new renal failure p < 0.001, and the renal replacement therapy p < 0.001 were significantly higher in the primary BSI group. Aortic cross-clamp time >120 min, OR 2.31 95%CI 1.34 to 3.98, perfusion time >120 min, OR 2.45 95%CI 1.63 to 3.67, and duration of the intervention >300min, OR 2.78 95%CI 1.47 to 5.28, were significantly related to the primary BSI. Conclusion: The gram-negative bacillus was the most common microorganism identified in BSI after cardiovascular operations using cardiopulmonary bypass. Patients on dialysis prior to cardiac surgery are at higher risk for having BSI. Enteric bacterial translocation after prolonged cardiopulmonary bypass is a possible mechanism of early primary bloodstream infection in these patients. In patients at high risk, prophylactic use of an antibiotic regimen with broader gram-negative bacteria coverage should be considered, especially in those with prolonged cardiopulmonary bypass and intervention time.

Minimally Invasive Nonresectional Mitral Valve Repair Long-term Results.

BACKGROUND: We aimed to assess the outcomes of the minimally invasive nonresectional technique over 10 years in patients with severe mitral valve insufficiency. METHODS: A retrospective analysis of 365 patients undergoing a minimally invasive complete endoscopic mitral valve repair for mitral valve insufficiency was conducted between May 2009 and September 2021. All patients underwent the nonresectional repair approach using artificial neochordae implantation or ring annuloplasty. Clinical and echocardiographic follow-ups were performed. RESULTS: The minimal invasive procedure was successfully performed in all patients. The mean age was 61 ± 11, and 36% were female patients. The surgical success was 99.7%, with no conversion to sternotomy or to mitral valve replacement at 30 days. In 1 case (0.27%), mitral valve related reoperation was performed during the hospital stay. The procedural safety was 92%, with in-hospital mortality in 0.55% (n = 2), stroke in 0.55% (n = 2), and perioperative myocardial infarction in 0.82% (n = 3) patients. The mean follow up was 5.3 ± 2.9 years. Survival at 5 and 10 years was 96% (95% confidence interval [CI], 94%-98%) and 83% (95% CI, 72%-90%). Freedom of myocardial infarction, stroke, and congestive heart failure at 10 years was 95% (95% CI, 88%-98%), 86% (95% CI, 75%-92%), and 93% (95% CI, 89%-96%), respectively. Recurrent mitral valve insufficiency ≥ + 2 was diagnosed in 4.9% of cases. CONCLUSIONS: Minimally invasive nonresectional mitral valve repair technique can be performed for severe mitral valve regurgitation with excellent long-term results. The procedure is safe, with minimal risk of reoperation and recurrent mitral valve insufficiency at long term.

Five-Year Survival of Patients Treated with Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Compared with the General Swiss Population.

BACKGROUND: To evaluate the midterm follow-up and 5-year survival outcome of the minimally invasive direct coronary artery bypass (MIDCAB) procedure compared with the survival of the general Swiss population. METHODS: Retrospective study on preoperative data, intraoperative data, and postoperative outcome of patients who underwent MIDCAB surgery between June 2010 and February 2019. To assess validity of this surgical therapy, outcomes were compared with survival data of a gender- and age-matched cohort of the general Swiss population taken from the database of the Swiss Federal Statistical Office. RESULTS: A total of 88 patients were included. Median (interquartile range [IQR[) age was 66 (56-75) years, and 27% (n = 24) were female. The median (IQR) length of the in-hospital stay was 7 (6-8) days. No postoperative stroke occurred. The 30-day mortality was 1.1% (n = 1). Reintervention for failed left internal mammary artery was needed in 1.1% (n = 1). The median (IQR) ejection fraction was 58% (47-60) preoperatively and remained stable during follow-up. The median (IQR) follow-up period was 3 (1.1-5.2) years. Five years postoperatively, 83% (confidence interval, 69-91) of the patients were alive, showing an overlap with the range of survival of the matched subcohort of the general Swiss population (range, 84-100%). CONCLUSION: Though suffering from coronary heart disease, patients after MIDCAB show almost equal survival rates as an equivalent subcohort corresponding to the general Swiss population matched on age and gender. Thus, our data show this treatment to be safe and beneficial.

Management of left subclavian artery in type B aortic dissection treated with thoracic endovascular aorta repair.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has been the favored approach for the treatment of type B aortic dissection (TBAD). To obtain an adequate proximal landing zone, coverage of the left subclavian artery (LSA) will often be necessary. The occurrence of possible neurologic complications has continued to be debated. We investigated the management of the LSA in patients with TBAD undergoing endovascular repair. METHODS: We searched the PubMed and MEDLINE databases to October 2020 for studies of TEVAR for TBAD. Data on the study design, demographics, endograft details, LSA coverage and revascularization, mortality, complications, and follow-up were extracted and analyzed. The effects of LSA coverage and revascularization on neurologic complications and outcomes were investigated. RESULTS: A total of 26 reports (24 retrospective and 2 prospective) were deemed eligible for our study. A total of 1483 patients (mean age, 56.9 ± 6.2 years) had undergone TEVAR for acute (n = 932; 62.9%), subacute (n = 36; 2.4%), or chronic (n = 515; 34.7%) TBAD, with a success rate of 97.8% and hospital mortality of 4.9%. The LSA origin had been covered for 707 patients (47.7%), and 326 had undergone LSA revascularization (surgical, n = 96; endovascular, n = 170; unspecified or not reported, n = 60). LSA revascularization was concomitant for 68.1% of cases, after TEVAR for 1.8%, and not reported for 30.1%. Of 1146 patients, 10 (0.9%) had experienced left arm claudication, and the overall stroke rate was 3.3% (2.7% for the LSA group and 1% for the uncovered LSA group; P = .0815). Of the patients with stroke and a covered LSA, 1% (2 of 203) had undergone LSA revascularization and 4.8% (5 of 105) had not (P = .0478). Twenty-six patients (1.9%) had developed paraplegia: 0.7% (3 of 433) with a covered LSA, 1.4% (7 of 491) with an uncovered LSA (P = .3508), and not reported for 16 patients. Endoleak was present in 138 patients (13.4%) at a mean follow-up of 32.1 ± 25.6 months. CONCLUSIONS: Our review has shown that LSA coverage during endovascular repair for complicated TBAD will does not significantly increase the risk of neurologic complications; however, revascularization of the LSA should be always recommended.

Minimal Extracorporeal Circulation and Microplegia in the Setting of Urgent Coronary Artery Bypass Grafting.

Background: We aimed to analyse the performance of minimal invasive extracorporeal circulation (MiECC) concomitantly with Microplegia, in patients with recent myocardial infarction (MI) undergoing urgent coronary artery bypass grafting (CABG) surgery. Methods: We included patients with a recent MI (≤7 days) undergoing isolated CABG surgery using MiECC. The primary endpoint was a major cardiovascular or cerebrovascular event (MACCE). In a secondary analysis, we compared our institutional Microplegia concept with the use of a crystalloid single-shot cardioplegic solution. Results: In total, 139 patients (mean ± standard deviation (SD) age 66 ± 10 years) underwent urgent CABG surgery using Microplegia; 55% (n = 77) of the patients had an acute MI within 1−7 days preoperatively; 20% (n = 28) had an acute MI within 6−24 h; and 24% (n = 34) had an acute MI within <6 h preoperatively. The number of distal anastomoses was a geometric mean of 4 (95% confidence interval 3−4). The MACCE and in-hospital mortality were 7% (n = 10) and 1% (n = 2), respectively. The results were confirmed in a secondary analysis comparing Microplegia with crystalloid cardioplegic solution (n = 271). Conclusion: The use of MiECC with Microplegia in urgent CABG surgery is feasible and safe and provides a straight-forward intraoperative setting. Therefore, it can also be considered to retain the benefits of MiECC in urgent CABG surgery.

Rotational Thromboelastometry Values After On-Pump Cardiac Surgery - A Retrospective Cohort Study.

BACKGROUND: Viscoelastic coagulation monitoring is recommended for coagulation management after cardiac surgery, but optimum target values are poorly defined. AIMS: To determine "to-be-expected" values in rotational thromboelastometry (ROTEM) after heparin reversal, to correlate ROTEM parameters with fibrinogen levels and platelet count, and to estimate the effect of hemoglobin levels on these measurements. METHODS: We retrospectively analyzed 571 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass from 12/2018 to 08/2020. ROTEM and conventional laboratory measurements were performed 5 to 10 minutes after protamine administration. RESULTS: Clotting times in EXTEM, INTEM, and FIBTEM were significantly prolonged (72.6%, 96.1%, and 31.8% above reference ranges, respectively). Clot firmness parameters in EXTEM and INTEM were relevantly reduced (7.9% to 14.4% and 9.1% to 32.3% below the reference ranges, respectively). There was an excellent linear correlation of FIBTEM amplitude after 10 min (A10) and of maximal clot firmness (MCF) with fibrinogen concentrations (r = .81 and .80). Areas under receiver operating characteristic (AUROC) for identifying hypofibrinogenemia <1.5 g/L were between .80 and .87. No effect of hematocrit was observed. We also found a linear correlation of EXTEM, INTEM, and EXTEM-FIBTEM at both A10 and MCF with platelet counts (.32 to .68). The AUROCs for identifying thrombocytopenia (<100,000/µL) were .79 to .84, and were greater for A10 than for MCF measurements (P=.074, .001, and <.001, respectively). CONCLUSIONS: "To-be-expected" ROTEM values after CPB are different from the published reference ranges. ROTEM parameters might allow for reliable estimation of fibrinogen level and platelet count without being influenced by hematocrit.

Non-invasive evaluation of new-onset atrial fibrillation after cardiac surgery: a protocol for the BigMap study.

AIMS: New-onset atrial fibrillation (NOAF) is the most common complication after cardiac surgery, occurring in 25-50% of patients. It is associated with post-operative stroke, increased mortality, prolonged hospital length of stay, and higher treatment costs. Previous small observational studies have identified the left atrium as a source of the electrical rotors and foci maintaining NOAF, but confirmation by a large prospective clinical study is still missing. The aim of the proposed study is to investigate whether the source of NOAF lies in the left atrium. The correct identification of NOAF-maintaining structures in cardiac surgical patients might offer potential therapeutic targets for prophylactic perioperative ablation strategies. METHODS AND RESULTS: This is a prospective single-centre observational study of patients developing NOAF after cardiac surgery. The primary outcome is the description of NOAF-maintaining structures within the atria. Key secondary outcomes include overall mortality, intensive care unit length of stay, hospital-ventilator-free days, and proportion of persistent NOAF. In NOAF patients, the non-invasive electrophysiological mapping will be conducted using a 252-electrode electrocardiogram vest. After mapping, a low-dose computed tomography scan of the chest will be performed to integrate the electrophysiological mapping results into a 3D picture of the heart. The study will include approximately 570 patients, of whom 30% (n = 170) are expected to develop NOAF. Sample size calculation revealed that 157 NOAF patients are necessary to assess the primary outcome. Patients will be tracked for a total of 5 years. CONCLUSIONS: This is the largest prospective study to date describing the electrophysiological mechanisms of NOAF using non-invasive mapping.

Modified frozen elephant trunk procedure as standard approach in acute type A aortic dissection: A propensity-weighted analysis.

OBJECTIVES: To evaluate whether the modified frozen elephant trunk (mFET) procedure provides comparable outcome compared with the standard approach for DeBakey type I aortic dissection. METHODS: From November 2008 to December 2018, 262 (mean age 62.7 ± 12.4 years) patients with acute DeBakey type I aortic dissection were included. mFET was performed in 100 (38.2%) patients and isolated ascending aorta and hemiarch replacement (iAoA) were performed in 162 (61.8%). Outcome analyses included in-hospital mortality, stroke rate, incidence of composite cardiovascular events, survival, freedom from aorta-related intervention, as well as freedom from neurologic event. Inverse probability of treatment weighting was applied. RESULTS: After inverse probability of treatment weighting, in-hospital mortality was greater in the iAoA group. The incidence of cardiac cause of death, new postoperative renal failure, as well as stroke rate were similar in both groups. The survival at 1 year, 3 years, and 4 years was 84%, 81%, and 77%, respectively, in the iAoA group and 91%, 86%, and 86%, P = .025, respectively, in the mFET group. Cause-specific HR for aortic reoperation 1.03 (confidence interval [CI], 0.43-2.48, P = .95) and neurovascular event 2.72 (CI, 0.62-11.93, P = .19) was similar in 2 groups. Subhazard ratio (sHR) for mortality as competing outcome for aorta-related reintervention sHR of 0.52 (CI, 0.32-0.86, P = .011) and neurologic event sHR of 0.45 (95% CI, 0.26-0.76, P = .003) was significantly lower in mFET. CONCLUSIONS: The mFET procedure as surgical treatment modality for DeBakey type I acute aortic dissection may be considered as viable alternative with beneficial mid-term outcome.

Outcome of right ventricular assist device implantation following left ventricular assist device implantation: Systematic review and meta-analysis.

OBJECTIVES: The main aim was a systematic evaluation of the current evidence on outcomes for patients undergoing right ventricular assist device (RVAD) implantation following left ventricular assist device (LVAD) implantation. METHODS: This systematic review was registered on PROSPERO (CRD42019130131). Reports evaluating in-hospital as well as follow-up outcome in LVAD and LVAD/RVAD implantation were identified through Ovid Medline, Web of Science and EMBASE. The primary endpoint was mortality at the hospital stay and at follow-up. Pooled incidence of defined endpoints was calculated by using random effects models. RESULTS: A total of 35 retrospective studies that included 3260 patients were analyzed. 30 days mortality was in favour of isolated LVAD implantation 6.74% (1.98-11.5%) versus 31.9% (19.78-44.02%) p = 0.001 in LVAD with temporary need for RVAD. During the hospital stay the incidence of major bleeding was 18.7% (18.2-19.4%) versus 40.0% (36.3-48.8%) and stroke rate was 5.6% (5.4-5.8%) versus 20.9% (16.8-28.3%) and was in favour of isolated LVAD implantation. Mortality reported at short-term as well at long-term was 19.66% (CI 15.73-23.59%) and 33.90% (CI 8.84-59.96%) in LVAD respectively versus 45.35% (CI 35.31-55.4%) p ⩽ 0.001 and 48.23% (CI 16.01-80.45%) p = 0.686 in LVAD/RVAD group respectively. CONCLUSION: Implantation of a temporary RVAD is allied with a worse outcome during the primary hospitalization and at follow-up. Compared to isolated LVAD support, biventricular mechanical circulatory support leads to an elevated mortality and higher incidence of adverse events such as bleeding and stroke.

Planning of graft size and 3D reconstruction using virtual reality technique in aortic valve reimplantation.

Objectives: To evaluate applicability and feasibility of the virtual imaging technology for diagnosis and planning of the aortic valve sparing procedure. Methods: Pre-operative electrocardiography-gated computed tomography images of 12 adult patients with aortic root pathology were used for 3D reconstruction of the aortic root geometry. The structural analysis was conducted with focusing on spatial architecture of key aortic root structures such as the three commissures, intervalvular triangles (IVT), as well as on morphology of the aortic root base (AoB) and of the sinotubular junction (STJ). Results: In all included patients, the 3D mapping of aortic root (AoR) morphology was successfully performed. The pre-operative diameter of the AoB was 30.6 ± 2.6 mm and of the STJ 46.5 ± 7.5 mm (p < 0.001). Based on measured AoB diameter, the mean size of prosthesis used was 28.3 ± 1.37 mm. The planar arrangement of the three commissures was similar to an equilateral triangle where the three commissures were at similar distance for each individual sinus with 39.8 ± 6.64 mm for right, 37.5 ± 7.10 mm for left, and 39.2 ± 7.52 mm for non-coronary sinus (p = 0.72) subsequently. The similar height of the three IVT's with 32.6 ± 5.87 mm for right, 33.6 ± 6.14 mm for anterior, and 31.7 ± 5.83 mm for left IVT (p = 0.73) was suggestive for all three commissures being positioned in the same plane. Consequently at reimplantation, the orientation of the three commissures followed the pattern of an equilateral triangle. Conclusion: The reconstructed images revealed a detailed 3D anatomy of the aortic root, with the spatial arrangement of the intervalvular triangles, planimetric orientation of the commissures, as well as determination of the AoB and STJ diameters. Obtained information was successfully applied to pre-operative surgical planning. The reimplantation technique, the height of the reimplanted intervalvular triangles, as well as their orientation are crucial for achieving adequate aortic valve function.

Aortic Root Thrombus Directly After Left Ventricular Assist Device Implantation.

A 70-year-old female heart failure patient could not be weaned from temporary left ventricular mechanical support with Impella CP (Abiomed Inc, Danvers, MA) after myocardial infarction; therefore, she underwent left ventricular assist device implantation (HeartMate 3; Abbott, Chicago, IL). After uneventful surgery, the patient had an early postoperative thrombus in the aortic root, and surgical thrombectomy on extracorporeal circulation was performed on the seventh postoperative day. The patient recovered well and presented in good condition with no neurologic symptoms at the 6-month follow-up visit. Surgical excision of aortic root thrombus is a feasible option even for frail patients with a left ventricular assist device.

Après un infarctus du myocarde, une patiente de 70 ans présentant une insuffisance cardiaque n'a pas pu être sevrée d'une assistance mécanique temporaire pour le ventricule gauche par dispositif Impella CP (Abiomed Inc, Danvers, MA); elle a donc subi l'implantation d'un dispositif d'assistance ventriculaire gauche (HeartMate 3; Abbott, Chicago, IL). Après une intervention sans incident, la patiente a présenté un thrombus postopératoire précoce dans l'anneau aortique, et une thrombectomie chirurgicale sous circulation extracorporelle a été réalisée le septième jour suivant l'intervention. La patiente s'est bien rétablie et semblait en bonne santé, sans symptômes neurologiques, au moment de la visite de suivi six mois plus tard. L'excision chirurgicale du thrombus de l'anneau aortique est une option réaliste même chez les patients fragiles ayant un dispositif d'assistance ventriculaire gauche.

Endovascular treatment of the dissected proximal aortic arch: a systematic review.

OBJECTIVES: Surgical repair of aortic dissection involving the proximal aortic arch is associated with higher morbidity and mortality, in particular when elderly high-risk patients are concerned. Endovascular treatments for this disease are under evaluation and some reports exist. We investigated the current use of catheter-based treatments for the dissected proximal aortic arch repair. METHODS: We searched in PubMed and MEDLINE databases up to the end of June 2020 for studies on endovascular treatment of the dissected proximal aortic arch. Data on demographic, procedure and stent graft (SG) details, access route, mortality with cause of death, complications and follow-up were extracted. A systematic review on the employed technology, procedure and outcome was performed. RESULTS: A total number of 15 articles (13 retrospective reports and 2 case reports) were deemed eligible and were included in the study. In total, 140 patients (mean age: 56.7 years in 106 cases) received endovascular treatments for the dissected proximal aortic arch (unspecific aortic dissection: 14; acute and subacute type A aortic dissection: 88; chronic type A aortic dissection: 23; type B aortic dissection with retrograde type A dissection: 15). The procedure strategy included unspecific thoracic endovascular aorta repair (TEVAR) (n = 8), TEVAR + supra-aortic debranching (n = 2), TEVAR + cervical bypass (n = 8), TEVAR + periscope SG (n = 12), TEVAR + chimney graft (n = 8), TEVAR + branched SG (n = 21) and TEVAR + fenestration (n = 81). Procedural success rate was 95.6% for 116 reported cases. Complications included endoleaks (postoperative: 2; late: 5), stroke (n = 4), late SG-induced new entry (n = 3) and new false lumen formation (n = 1). Hospital mortality was 5% (6 cases) in 13 reports (120 patients). The mean follow-up time was 26.2 ± 29.4 months and 2 patients died during follow-up. CONCLUSIONS: As an alternative to surgery for high-risk patients with a dissected proximal aortic arch, the endovascular treatment seems to be promising in highly selected cases. Further studies with long-term results and specifically designed devices are required to standardize this approach.

Design optimization of bidirectional arterial perfusion cannula.

OBJECTIVES: Determine if shortening the covered section of a self-expanding bidirectional arterial cannula, can enhance retrograde flow and thus reduce the risk of lower limb ischemia. METHODS: Outlet pressure vs flow rate was determined for three cannulas types: a 15F self-expanding bidirectional cannula having a covered section of 90 mm, the same cannula but with a shorter covered section of 60 mm, and a Biomedicus cannula as control. The performances of all the cannulas were compared using a computerized flow-bench with calibrated sensors and a centrifugal pump. Water retrograde flow was determined using a tank timer technique. Anterograde and retrograde flow rate versus outlet pressure were determined at six different pump speed. RESULTS: For each of the six pump speed, both bidirectional cannulas, 60-mm covered and 90-mm covered respectively, showed higher performance than Biomedicus cannula control, as demonstrated by higher flow rate and lower pressure. We also observed that for the bidirectional cannula with shorter covered section, i.e. 60 mm coverage, provides enhanced performance as compared to a 90-mm coverage. Finally, the flow rate and the corresponding pressure can be consistently measured by our experimental set-up with low variability. CONCLUSIONS: The new configuration of a shorter covered section in a bidirectional self-expanding cannula design, may present an opportunity to overcome lower leg ischemia during extra-corporal life support with long term peripheral cannulation.

Simple endovascular thoracic aortic stenting rescues a wrongly deployed frozen elephant trunk during a modified procedure.

We report a bail out approach of endovascular thoracic aorta repair following incorrect deployment of a modified frozen elephant trunk stent graft into the false lumen. A 76-year-old patient was admitted to our Emergency Department. A computed tomography angiography scan showed type I DeBakey aortic dissection. An emergency modified frozen elephant trunk procedure was performed. Immediate postoperative computed tomography angiography showed that the distal segment of the stent was deployed in the false lumen, probably through a re-entry tear at the descending thoracic aorta. Emergency endovascular repair of the thoracic aorta, as well as angioplasty of the superior mesenteric artery and left iliac artery, were performed.

Early surgical aortic bioprosthesis failure caused by cusp tear: A word of caution.

Cusp tear is an increasingly described mode of failure of the Trifecta aortic bioprosthesis. Acute aortic regurgitation after implantation of a Trifecta in absence of endocarditis should suggest a cusp tear and be promptly treated with redo surgery.

Performance characteristics of the new Eurosets magnetically suspended centrifugal pump.

OBJECTIVE: The aim was to evaluate the performance of a newly developed magnetically suspended centrifugal pump head intended for use as a ventricular assistance device with a newly developed extracorporeal membrane oxygenator setup. METHODS: In an experimental setup, an extracorporeal membrane oxygenator circuit was established in three calves with a mean weight of 68.2 ± 2.0 kg. A magnetically levitated centrifugal pump was tested, along with a newly designed extracorporeal membrane oxygenator console, at three different flow ranges: (a) 0.0 to 5.2 L/min, (b) 0.0 to 7.1 L/min, and (c) 0.0 to 6.0 L/min. For each setup, the animals were supported by a circuit for 6 h. Blood samples were collected just before caridiopulmonary bypass (CPB) after 10 min on bypass and after 1, 2, 5, and 6 h of perfusion for hemolysis determination and biochemical tests. Values were recorded for blood pressure, mean flow, and pump rotational speed. Analysis of variance was used for repeated measurements. RESULTS: Mean pump flows achieved during the three 6 h pump runs for the three pump heads studied were as follows: (a) flow range 0.0 to 5.2 L/min, 3.6 ± 1.5 L/min, (b) flow range 0.0 to 7.1 L/min, 4.9 ± 1.3 L/min, and (c) flow range 0.0 to 6.0 L/min, 3.8 ± 1.5 L/min. Blood trauma, evaluated by plasma hemoglobin and lactate dehydrogenase levels, did not help in detecting any significant hemolysis. Thrombocytes and white blood cell count profiles showed no significant differences between the groups at the end of the 6 h perfusion. At the end of testing, no clot deposition was found in the oxygenator, and there was no evidence of peripheral emboli. CONCLUSION: The results suggest that the newly developed magnetically suspended centrifugal pump head provides satisfactory hydrodynamic performance in an acute perfusion scenario without increasing hemolysis.