Should we operate on patients with acute type A aortic dissection who present with cardiopulmonary resuscitation?

OBJECTIVES: Acute aortic dissection type A (AADA) is a life-threatening medical emergency. Emergent surgical repair is the gold standard but mortality remains high. Mortality is even higher in patients who arrive at the hospital in poor condition, especially after cardiopulmonary resuscitation (CPR). This study was designed to analyse the outcome of patients who underwent surgery for AADA and who require preoperative CPR. METHODS: Between 2000 and 2023, 810 patients underwent emergent surgery for AADA at our centre. Of these, 63 had preoperative CPR. We performed a retrospective analysis with follow-up. RESULTS: Mean age was 64 ± 13 years and 37 (59%) patients were male. Further, 50 (79%) patients had preoperative intubation, and 54 (86%) had pericardial effusion. Twenty-four (38%) patients had out-of-hospital CPR, 19 (30%) required CPR in hospital and 20 (32%) needed CPR in the operating room. Successful CPR with return of spontaneous circulation was achieved in 41 (65%) patients, and 22 (35%) underwent emergent surgery under ongoing CPR. The median time of CPR was 10 (interquartile range 12) min, and the median time from onset of symptoms to start of the operation was 5.5 (interquartile range 4.8) h. The majority of patients underwent ascending aortic replacement with hemiarch repair (n = 37, 59%). Further, 26 (41%) patients underwent full root replacement. Another 15 (24%) patients underwent total arch repair with or without (frozen) elephant trunk repair. Postoperative stroke was present in 8 (13%) patients. The 30-day mortality was 29 (46%). The 30-day mortality of patients with preoperative intubation was not significantly higher (n = 15/28, 54%, P = 0.446). The 1-, 5- and 10-year survival rates of the entire group were 42, 39 and 36%. CONCLUSIONS: Early mortality for patients undergoing surgery for AADA with preoperative CPR is extremely high (almost 50%). However, this means that also ∼50% of patients benefit from surgery despite poor preoperative prognosis. Patients with preoperative intubation after CPR and unknown neurological condition should also undergo surgery. Patients who survive the initial operation for AADA have acceptable long-term survival. Emergent surgery should be offered for all patients with AADA regardless of the preoperative condition, even after CPR.

Acute Aortic Dissection Type A in Younger Patients (< 60 Years Old) - Does Full Arch Replacement Provide Benefits Compared to Limited Approach?

ABSTRACT Introduction: Acute aortic dissection Stanford type A (AADA) is a surgical emergency associated with high morbidity and mortality. Although surgical management has improved, the optimal therapy is a matter of debate. Different surgical strategies have been proposed for patients under 60 years old. This paper evaluates the postoperative outcome and the need for secondary aortic operation after a limited surgical approach (proximal arch replacement) vs. extended arch repair. Methods: Between January 2000 and January 2018, 530 patients received surgical treatment for AADA at our hospital; 182 were under 60 years old and were enrolled in this study - Group A (n=68), limited arch repair (proximal arch replacement), and group B (n=114), extended arch repair (> proximal arch replacement). Results: More pericardial tamponade (P=0.005) and preoperative mechanical resuscitation (P=0.014) were seen in Group A. More need for renal replacement therapy (P=0.047) was seen in the full arch group. Mechanical ventilation time (P=0.022) and intensive care unit stay (P<0.001) were shorter in the limited repair group. Thirty-day mortality was comparable (P=0.117). New onset of postoperative stroke was comparable (Group A four patients [5.9%] vs. Group B 15 patients [13.2%]; P=0.120). Long-term follow-up did not differ significantly for secondary aortic surgery. Conclusion: Even though young patients received only limited arch repair, the outcome was comparable. Full-arch replacement was not beneficial in the long-time follow-up. A limited approach is justified in the cohort of young AADA patients. Exemptions, like known Marfan syndrome and the presence of an intimal tear in the arch, should be considered.

Acute Aortic Dissection Type A in Younger Patients (< 60 Years Old) - Does Full Arch Replacement Provide Benefits Compared to Limited Approach?

INTRODUCTION: Acute aortic dissection Stanford type A (AADA) is a surgical emergency associated with high morbidity and mortality. Although surgical management has improved, the optimal therapy is a matter of debate. Different surgical strategies have been proposed for patients under 60 years old. This paper evaluates the postoperative outcome and the need for secondary aortic operation after a limited surgical approach (proximal arch replacement) vs. extended arch repair. METHODS: Between January 2000 and January 2018, 530 patients received surgical treatment for AADA at our hospital; 182 were under 60 years old and were enrolled in this study - Group A (n=68), limited arch repair (proximal arch replacement), and group B (n=114), extended arch repair (> proximal arch replacement). RESULTS: More pericardial tamponade (P=0.005) and preoperative mechanical resuscitation (P=0.014) were seen in Group A. More need for renal replacement therapy (P=0.047) was seen in the full arch group. Mechanical ventilation time (P=0.022) and intensive care unit stay (P<0.001) were shorter in the limited repair group. Thirty-day mortality was comparable (P=0.117). New onset of postoperative stroke was comparable (Group A four patients [5.9%] vs. Group B 15 patients [13.2%]; P=0.120). Long-term follow-up did not differ significantly for secondary aortic surgery. CONCLUSION: Even though young patients received only limited arch repair, the outcome was comparable. Full-arch replacement was not beneficial in the long-time follow-up. A limited approach is justified in the cohort of young AADA patients. Exemptions, like known Marfan syndrome and the presence of an intimal tear in the arch, should be considered.

Features and risk factors of early intraluminal thrombus formation within the frozen elephant trunk stent graft.

OBJECTIVE: The frozen elephant trunk is a standard treatment method for aortic arch pathologies extending into the descending aorta. We previously described the phenomenon of early postoperative intraluminal thrombosis within the frozen elephant trunk. We investigated the features and predictors of intraluminal thrombosis. METHODS: A total of 281 patients (66% male, mean age 60 ± 12 years) underwent frozen elephant trunk implantation between May 2010 and November 2019. In 268 patients (95%), early postoperative computed tomography angiography was available to assess intraluminal thrombosis. RESULTS: The incidence of intraluminal thrombosis after frozen elephant trunk implantation was 8.2%. Intraluminal thrombosis was diagnosed early after the procedure (4.6 ± 2.9 days) and could be successfully treated with anticoagulation in 55% of patients. A total of 27% developed embolic complications. Mortality (27% vs 11%, P = .044) and morbidity were significantly higher in patients with intraluminal thrombosis. Our data showed a significant association of intraluminal thrombosis with prothrombotic medical conditions and anatomic slow flow features. The incidence of heparin-induced thrombopenia was higher in patients with intraluminal thrombosis (18% vs 3.3%, P = .011). Stent-graft diameter index, anticipated endoleak Ib, and degenerative aneurysm were significant independent predictors of intraluminal thrombosis. Therapeutic anticoagulation was a protective factor. Glomerular filtration rate, extracorporeal circulation time, postoperative rethoracotomy, and intraluminal thrombosis (odds ratio, 3.19, P = .047) were independent predictors of perioperative mortality. CONCLUSIONS: Intraluminal thrombosis is an underrecognized complication after frozen elephant trunk implantation. In patients with risk factors of intraluminal thrombosis indication for frozen elephant trunk should be carefully evaluated and postoperative anticoagulation considered. Early thoracic endovascular aortic repair extension should be considered in patients with intraluminal thrombosis to prevent embolic complications. Stent-graft designs should be improved to prevent intraluminal thrombosis after frozen elephant trunk implantation.

Elucidation of the genetic causes of bicuspid aortic valve disease.

AIMS: The present study aims to characterize the genetic risk architecture of bicuspid aortic valve (BAV) disease, the most common congenital heart defect. METHODS AND RESULTS: We carried out a genome-wide association study (GWAS) including 2236 BAV patients and 11 604 controls. This led to the identification of a new risk locus for BAV on chromosome 3q29. The single nucleotide polymorphism rs2550262 was genome-wide significant BAV associated (P = 3.49 × 10-08) and was replicated in an independent case-control sample. The risk locus encodes a deleterious missense variant in MUC4 (p.Ala4821Ser), a gene that is involved in epithelial-to-mesenchymal transformation. Mechanistical studies in zebrafish revealed that loss of Muc4 led to a delay in cardiac valvular development suggesting that loss of MUC4 may also play a role in aortic valve malformation. The GWAS also confirmed previously reported BAV risk loci at PALMD (P = 3.97 × 10-16), GATA4 (P = 1.61 × 10-09), and TEX41 (P = 7.68 × 10-04). In addition, the genetic BAV architecture was examined beyond the single-marker level revealing that a substantial fraction of BAV heritability is polygenic and ∼20% of the observed heritability can be explained by our GWAS data. Furthermore, we used the largest human single-cell atlas for foetal gene expression and show that the transcriptome profile in endothelial cells is a major source contributing to BAV pathology. CONCLUSION: Our study provides a deeper understanding of the genetic risk architecture of BAV formation on the single marker and polygenic level.

Frozen elephant trunk in acute aortic type a dissection: risk analysis of concomitant root replacement.

OBJECTIVES: To analyse whether full root replacement increases perioperative risks in patients who undergo frozen elephant trunk for acute aortic dissection. METHODS: Between March 2013 and December 2019, 115 patients underwent emergency frozen elephant trunk for acute dissection. Patients without root replacement were assigned to group A, while patients with concomitant full root replacement to group B. RESULTS: Mean age was 50.8 (12.5) years and 85 (73.9%) patients were male. Preoperative malperfusion was present in 49 (42.6%) patients. In group B, 27 (41.5%) patients received composite root replacement and 38 (33.0%) aortic valve-sparing David procedure. Cardiopulmonary-bypass and cross-clamp times were 252.5 (208.5-293.0) and 96.0 (40.5-148.0) min in group A, and 310.0 (274.0-346.5) and 121.0 (89.0-182.0) in group B (P < 0.001). Continuous myocardial perfusion was used in 40 (80.0%) patients of group A and 59 (90.8%) of group B (P = 0.098). Disabling stroke was present in 10 (20.0%) patients in group A and 12 (18.5%) in group B (P = 0.835). Thirty-day mortality was 12.0% (n = 6) in group A and 9.2% (n = 6) in group B (P = 0.630). The 1- and 5-year survival rates were 80% and 62% in group A, and 81% and 79% in group B. Logistic regression analysis identified age (odds ratio = 1.117, 95% confidence interval = 1.004-1.242, P = 0.041), cardiopulmonary-bypass time (odds ratio = 1.012, 95% confidence interval = 1.001-1.022, P = 0.029) and abdominal malperfusion (odds ratio = 17.394, 95% confidence interval = 2.030-149.013, P = 0.009) to be associated with 30-day mortality. CONCLUSIONS: Full root replacement does not increase the perioperative risk in patients who undergo frozen elephant trunk for acute dissection. Careful patient selection is important for such complex procedures. Continuous myocardial perfusion can help reducing the risk for intraoperative complications during such complex operations.

Is total aortic arch replacement with the frozen elephant trunk procedure reasonable in elderly patients?

OBJECTIVES: Total aortic arch replacement is an invasive procedure with significant risks for complications. These risks are even higher in older, multimorbid patients. The current trends in demographic changes in western countries with an ageing population will aggravate this issue. In this study, we present our experience with total aortic arch replacement using the frozen elephant trunk (FET) technique in septuagenarians. We compared the results of septuagenarians with those of younger patients and analysed if there was an improvement in outcome over time. METHODS: Between August 2001 and March 2020, 225 patients underwent non-urgent FET procedure at our institution. There were 75 patients aged ≥70 years (mean age 74 ± 4) who were assigned to group A, and 150 patients aged <70 years (mean age of 57 ± 11) who were assigned to group B. In groups A and B, the indications for surgery were chronic dissection (21% vs 53%), aortic aneurysm (78% vs 45%) and penetrating atherosclerotic ulcer (1% vs 2%). RESULTS: The rate for temporary dialysis was significantly higher in group A than in group B (29% vs 13%, P = 0.003), although the majority recovered kidney function. Rates for re-exploration for bleeding and stroke were comparable in both groups. In-hospital mortality was significantly higher in group A than in group B (24% vs 13%, P = 0.037). Logistic regression analysis showed that age >70 years was an independent statistically significant risk factor for in-hospital mortality (odds ratio = 2.513, 95% confidence interval = 1.197-5.278, P-value = 0.015). Follow-up was complete for 100% of patients and comprised a total of 1073 patient-years with a mean follow-up time of 4.8 ± 4.5 years. The 1- and 5-year survival rates were 68% and 49% in group A, and 85% and 71% in group B, respectively (log rank, P < 0.001). Survival did not significantly improve over time. DISCUSSION: Total aortic arch replacement using the FET technique has a significantly higher risk for perioperative morbidity and mortality in septuagenarians than in younger patients. Long-term survival is significantly impaired in older patients. We recommend thorough patient selection of those who require total aortic arch replacement, and optimization of perioperative management to improve outcomes.

Aortic Valve-Sparing Root Replacement (David I Procedure) in Adolescents: Long-Term Outcome.

INTRODUCTION: Aortic valve-sparing root replacement (David's procedure) is an especially appealing treatment option for young patients. Here, we present the short-, mid, and long-term outcomes of this operation in adolescent patients. METHODS: Between September 1994 and March 2014, 29 patients aged 6 to 21 years underwent the David-I procedure at our center. We conducted a retrospective study with follow-up. RESULTS: The mean age was 16.8 ± 3.4 years and 90% (n = 26) were male. Marfan's syndrome was present in 86% (n = 25) of cases. Ninety-seven percent (n = 28) of cases were performed electively, and one case (3%) was performed emergently for acute aortic dissection type A. There were no early perioperative deaths (0%). Follow-up, which was completed on 100% of patients, comprised a total of 394 patient years and a mean follow-up time of 13.6 ± 5.4 years. The estimates for survival at 1, 5, and 10 years after initial surgery were 100, 97, and 93%, respectively. During follow-up, there were four (14%) late deaths and five (17%) aortic valve-related reoperations. The 1-, 5-, and 10-year estimates for freedom from valve-related reoperation were 100, 86, and 83%, respectively. The perioperative mortality for these five reoperations was 0%. DISCUSSION: Aortic valve-sparing root replacement can be performed in adolescents with a very low perioperative risk. Long-term survival seems to be affected by connective tissue diseases.

Open total arch replacement with trifurcated graft and frozen elephant trunk.

BACKGROUND: The frozen elephant trunk (FET) technique was introduced in Hannover Medical School in 2001 to treat patients with complex aortic arch pathologies. Since 2012, we primarily use the trifurcated Thoraflex Hybrid FET graft. In this article, we report our experience with the trifurcated FET graft. METHODS: Between November 2012 and September 2018, 211 patients underwent FET implantation with the trifurcated Vascutek Thoraflex Hybrid graft. The indications for surgery were: degenerative aneurysms in 68 patients, acute aortic dissections (AD) in 96 patients, and chronic ADs in 47 patients. And, 18% of cases were sternal re-operations. RESULTS: Mean cardiopulmonary bypass time, aortic cross-clamp time, and myocardial ischemia time were 262±84, 115±71, 50±26 minutes, respectively. Incidence of re-thoracotomy for bleeding, stroke, permanent paraplegia/paraparesis, prolonged ventilatory support (>96 h), and long-term dialysis were 13%, 18%, 2%, 21%, and 5%, respectively. In-hospital mortality was 12%. Follow-up was complete for 100% of patients and comprised a total of 513 patient years. The mean follow-up time was 2.2 [0-6] years. During follow-up, there were 32 aortic re-interventions distal to the FET. The survival rate at 1 and 5 years was 84% and 81%, respectively. CONCLUSIONS: Total aortic arch replacements with trifurcated FET can be performed with positive results. The trifurcated graft allows selective anastomosis of the supra-aortic vessels, which might result in improved hemostasis.

Aortic valve-sparing root replacement (David): learning curve and impact on outcome.

OBJECTIVES: Aortic valve-sparing root replacement (David procedure) offers the benefit of preserving the native aortic valve but is often criticized for being technically challenging and time-consuming. We analysed whether the surgeon's level of experience affects the early and long-term outcome after the David procedure. METHODS: From July 1993 to October 2015, a total of 582 patients underwent aortic valve-sparing David I procedure at our institution. A retrospective review with follow-up (mean follow-up time 8.6 ± 5.6 years) was performed. Statistical analysis of the surgeon's level of experience was performed as a categorical variable, after patients were chronologically assigned to groups of tens. Study end points assessing the surgeon's learning curve included both measures of patient outcome and measures of task efficiency. Study end points included both short- and long-term outcomes. RESULTS: Analysis of task efficiency showed that there was a statistically significant inverse correlation between the surgeon's level of experience and both cardiopulmonary bypass time (P = 0.026) and aortic cross-clamp time (P = 0.017). Analysis of patient outcome revealed that the incidence of aortic valve-related reoperation during follow-up showed a significant inverse correlation with the surgeon's level of experience (P = 0.048). Cox regression analysis found that the surgeon's level of experience (odds ratio 0.802, 95% confidence interval 0.673-0.957; P = 0.014) was a significant risk factor for aortic valve-related reoperation-free survival during follow-up. CONCLUSIONS: There is a surgeon's learning curve for aortic valve-sparing David procedure. The surgeon's experience has a direct impact on both the perioperative outcome and the long-term performance of the aortic valve.

Comparison of Two Strategies for Aortic Valve-Sparing Root Replacement.

BACKGROUND: Since its introduction in 1992, multiple variations of the aortic valve-sparing David procedure technique have been described. Here, we present the short- and midterm outcomes of 2 centers using the straight tube graft (David-I) and the Valsalva prosthesis in patients who underwent isolated David procedure. METHODS: Between March 2002 and October 2015, 232 patients underwent the David procedure at 2 European centers. Patients received either a straight tube graft (David-I, group A, n = 103, 74% men) or Valsalva graft (group B, n = 129, 85% men). Mean age was 47 ± 17 years in group A and 48 ± 17 years in group B (P = .916). RESULTS: There were significantly more cusp repairs in group B (n=28, 22%) compared with group A (n = 4, 4%, P < .001). The 30-day mortality rate was 1% (n = 1) in group A and 2% (n = 2, P = .698) in group B. Postoperative echocardiography showed aortic insufficiency ≥II in 0% (n = 0) of group A and 17% (n = 21) of group B (P < .001). Follow-up comprised 1530 patient-years, and survival was comparable between the 2 groups (P = .799). Follow-up echocardiography showed aortic insufficiency ≥II in 22% (n = 15) of group A and 39% (n = 33) of group B (P < .026). The rates for aortic valve-related reoperation were 8% (n = 8) in group A and 13% (n = 16) in group B (P = .241). Logistic Cox regression analysis identified bicuspid aortic valve (odds ratio, 3.435; 95% confidence interval, 1.459-8.083, P = .005) and postoperative aortic insufficiency ≥II (odds ratio, 5.988; 95% confidence interval, 2.545-14.088, P < .001) as risk factors for aortic valve-related reoperation. CONCLUSIONS: The aortic valve-sparing David procedure has acceptable midterm results. Our results show that the David-I procedure with straight tube graft is not inferior to those performed with Valsalva prosthesis.

Valve-sparing aortic root replacement (David I procedure) in Marfan disease: single-centre 20-year experience in more than 100 patients†.

OBJECTIVES: Valve-sparing aortic root replacement (VSARR) is recommended for patients with aortic root dilatation and preserved aortic valve cusp morphology. The durability of VSARR in Marfan patients has been questioned. The aim of our study was to establish the long-term outcomes of VSARR in Marfan patients. METHODS: Between 1993 and 2015, 582 patients underwent VSARR (David I reimplantation) at our institution. Of these patients, 104 had Marfan disease. Thirteen surgeons performed the procedures in this group. The mean follow-up time was 12 ± 5.4 years (1201 patient-years). RESULTS: Early mortality was 0.96%, and long-term survival was 91% at 10 years and 76% at 20 years in Marfan patients. Marfan patients had a significantly better survival compared to non-Marfan patients (P < 0.0001). Freedom from aortic-valve reoperation was 86% at 10 years and 80% at 20 years in Marfan patients. The reoperation rate was similar in Marfan and non-Marfan patients (P = 0.60). Morphological perioperative features (untreated prolapse, commissural plasty, cusp plasty and graft size mismatch) predicted long-term mortality (P = 0.0054). Graft size mismatch and untreated prolapse predicted structural valve deterioration (both P < 0.0001). Long-term valve function in event-free survivors was excellent [mean gradient 4.2 (2.9-6.9), 98% aortic regurgitation ≤ mild]. There were no valve-related thromboembolic or bleeding events. The endocarditis rate was 0.96%. Only 17% of the patients were on oral anticoagulants during the follow-up. CONCLUSIONS: VSARR using the David I reimplantation technique results in excellent long-term outcomes in Marfan patients. We present the longest follow-up period so far. The genetic disease does not affect long-term valve function. The durability of the repair is affected by morphological perioperative criteria depending on surgical expertise, and dedicated training is recommended.

Elective David I Procedure Has Excellent Long-Term Results: 20-Year Single-Center Experience.

BACKGROUND: We present our results after elective, isolated David I procedures over the past 20 years. METHODS: Between 1993 and 2015, 197 patients (mean age 46 ± 17 years, 73% men) underwent isolated aortic valve reimplantation using straight tube grafts (David I procedure). Sixty patients (31%) had Marfan syndrome, and 24 (12%) had a bicuspid aortic valve. Twenty-four patients (12%) were operated through upper mini-sternotomy. RESULTS: There were no perioperative deaths. Stroke rate was 1% (2 of 197). Discharge echocardiography showed none to trivial aortic regurgitation (AR) in 71% (139 of 197 patients) and mild AR in 26% (51 of 197 patients). Thirty-two patients (16%) died during follow-up (9.0 ± 5.5 years after operation). One death was aortic valve related. Twenty-six patients (13%) underwent aortic valve reoperations during follow-up (5.5 ± 5.0 years after operation). Late endocarditis occurred in 2 patients (1.0%). More than trivial AR at discharge predicted a higher reoperation rate. In 144 non-reoperated survivors, echocardiography showed none to trivial AR in 56 (39%), mild AR in 53 (37%), moderate AR in 19 (6.3%), and severe AR in 4 (2.7%) of the patients after 12 ± 5.3 years. CONCLUSIONS: The valve-sparing David I procedure has excellent short- and long-term results. Erosion due to supposed leaflet contact with the straight tube graft was not observed in any patient, proving that using a straight graft has no negative impact on the leaflets. The "spared valve" (being native living tissue) seems to be more resistant to infection than prosthetic valves.

Single-centre experience with the frozen elephant trunk technique in 251 patients over 15 years.

OBJECTIVES: Our goal was to present our 15-year experience (2001-2015) with the frozen elephant trunk (FET) technique. METHODS: A total of 251 patients (82 with aortic aneurysms, 96 with acute aortic dissection type A, 4 with acute type B dissections, 52 with chronic aortic dissection type A, 17 with chronic type B dissection and 67 redo cases) underwent FET implantation with either the custom-made Chavan-Haverich (n = 66), the Jotec E-vita (n = 31) or the Vascutek Thoraflex hybrid (n = 154) prosthesis. The cases were assigned to an early period (2001-2011) and a contemporary period (2012-present). RESULTS: Mean cardiopulmonary bypass time, aortic cross-clamp time, circulatory arrest time and selective antegrade cerebral perfusion time were 241 ± 72, 125 ± 59, 56 ± 30 and 81 ± 34 min, respectively. Incidence of rethoracotomy for bleeding, stroke, spinal cord injury, prolonged ventilatory support (>96 h) and long-term dialysis were 18, 14, 2, 24 and 2%, respectively. The in-hospital mortality rate was 11% (in acute aortic dissection type A, 12%). Of the 2 patients with graft infections, 1 died and the other had a protracted hospital stay. There were 49 second-stage procedures in the downstream aorta: either open surgical [n = 25 (thoraco-abdominal, n = 15; descending, n = 6; infrarenal, n = 4)] or transfemoral endovascular (n = 23). Elective thoracic endovascular aneurysm repair R implantation was successful in all 23 cases. CONCLUSIONS: FET results are comparable with those of the published results of the conventional elephant trunk technique. FET is an ideal landing zone for subsequent transfemoral endovascular completion. Patients with graft infections may have dismal results.

Is the frozen elephant trunk procedure superior to the conventional elephant trunk procedure for completion of the second stage?

OBJECTIVES: Our goal was to compare the results and outcomes of second-stage completion in patients who had previously undergone the elephant trunk (ET) or the frozen elephant trunk (FET) procedure for the treatment of complex aortic arch and descending aortic disease. METHODS: Between August 2001 and December 2014, 53 patients [mean age 61 ± 13 years, 64% (n = 34) male] underwent a second-stage completion procedure. Of these patients, 32% (n = 17) had a previous ET procedure and 68% (n = 36) a previous FET procedure as a first-stage procedure. RESULTS: The median times to the second-stage procedure were 7 (0-78) months in the ET group and 8 (0-66) months in the FET group. The second-stage procedure included thoracic endovascular aortic repair in 53% (n = 28) of patients and open surgical repair in 47% (n = 25). More endovascular interventions were performed in FET patients (61%, n = 22) than in the ET group (35%, n = 6, P = 0.117). The in-hospital mortality rate was significantly lower in the FET (8%, n = 3) group compared with the ET group (29%, n = 5, P = 0.045). The median follow-up time after the second-stage operation for the entire cohort was 4.6 (0.4-10.4) years. The 5-year survival rate was 76% in the ET patients versus 89% in the FET patients (log-rank: P = 0.11). CONCLUSIONS: We observed a significantly lower in-hospital mortality rate in the FET group compared to the ET group. This result might be explained by the higher rate of endovascular completion in the FET group. We assume that the FET procedure offers the benefit of a more ideal landing zone, thus facilitating endovascular completion.

Total aortic arch repair: risk factor analysis and follow-up in 199 patients.

OBJECTIVES: Aortic arch surgery is associated with substantial perioperative risks. New prostheses as well as novel perfusion techniques have been developed to reduce the risks of these procedures. The routine application of these new techniques warrants reassessment of risk factors of aortic arch repair. METHODS: Between April 2010 and December 2015, 199 patients [61% male, median age 63 years (interquartile range 52-70 years)] underwent total aortic arch repair in our institution. Forty-four per cent of the patients presented with acute aortic dissections (ADs, 32% with malperfusion), 22% with chronic aortic dissections (CDs), 34% with degenerative aneurysms, 24% underwent reoperations. Our surgical technique involved cold blood cardioplegia for cardiac procedures, non-cardioplegic continuous myocardial blood perfusion during aortic arch repair and early lower body reperfusion after distal aortic arch reconstruction. Anastomosis of head vessels is performed at the end of the procedure. RESULTS: Forty-four per cent of patients underwent aortic root surgery, 90% received a classical elephant trunk (ET) or frozen elephant trunk (FET). Median (interquartile range) cardiopulmonary bypass time, cardiac ischaemia time, hypothermic circulatory arrest time and selective antegrade cerebral perfusion time were 248 min (204-302), 105 min (51-150), 47 min (35-61) and 93 min (72-115), respectively. Operative mortality was 16%, stroke occurred in 10%, dialysis in 21% and spinal cord injury in 5%. Independent risk factors for mortality were age, rethoracotomy for bleeding, postoperative dialysis, maximum lactate value and maximum creatinine kinase-MB (CK-MB) value. 'Beating heart' aortic arch surgery significantly reduced the risk of mortality. Malperfusion syndrome and coronary artery bypass grafting were preoperative predictors of stroke. CD, preoperative renal dysfunction, operation time, rethoracotomy for bleeding and low cardiac output syndrome were risk factors for postoperative dialysis. Freedom from aortic reoperation was 91% (AD), 66% (CD) and 70% (aneurysm) after 2 years. CONCLUSIONS: Aortic arch repair remains a high-risk procedure, especially in multisegment aortic disease. Several peri- and postoperative factors predicted adverse outcome, indicating the need to further improve perioperative management (e.g. organ protection). Indications for FET treatment have to be thoroughly investigated (e.g. FET in CDs).

Total aortic arch replacement with a novel 4-branched frozen elephant trunk prosthesis: Single-center results of the first 100 patients.

OBJECTIVE: Combined disease of the aortic arch and the proximal descending aorta remains a surgical challenge. The Thoraflex Hybrid graft (Vascutek, Inchinnan, United Kingdom) consists of a 4-branched graft with a stent graft at the distal end allowing a total aortic arch replacement, including the origins of the supra-aortic vessels combined with endoluminal treatment of the proximal descending aorta. We present the midterm results of our first 100 patients who were treated with this frozen elephant trunk prosthesis. METHODS: From April 2010 to October 2014, 100 patients (65 men aged 59 ± 14 years) underwent operation (37 acute dissections, 31 chronic dissections, and 32 aneurysms). Fifty-four percent of patients received concomitant cardiac procedures, and 28% were reoperations. RESULTS: The perioperative mortality was 7% (n = 7). Midterm survival after a follow-up of 3.1 ± 1.4 years was 81% (n = 81). Mean cardiopulmonary bypass time was 243 ± 61 minutes, cardiac ischemia time was 101 ± 65 minutes, and circulatory arrest time was 51 ± 20 minutes. Aortic root replacement was performed in 41 patients (n = 41; valve-sparing: 30% [n = 30]). Twenty-two percent of patients underwent secondary aortic reinterventions during follow-up (15% planned second stage operations). Sixty percent of reinterventions were performed via endovascular approach. Acute dissection patients needed significantly fewer reinterventions (n = 3; 8%). CONCLUSIONS: The Thoraflex Hybrid graft adds to the frozen elephant trunk concept for treating aortic arch and descending aortic disease. Implantation of the Thoraflex Hybrid graft resulted in excellent outcomes and beneficial aortic remodeling during follow-up. This graft increases surgeons' armamentarium in the treatment of complex and diverse aortic arch pathology.

Management of early graft infections in the ascending aorta and aortic arch: a comparison between graft replacement and graft preservation techniques.

OBJECTIVES: Treatment of infected thoracic aortic grafts is associated with considerable morbidity and mortality. The replacement of an infected graft is an effective strategy, yet a complex surgical endeavour, especially if the aortic root or aortic arch is involved. In situ graft-sparing surgical therapy with continuous mediastinal irrigation after surgical debridement might offer an alternative in the management of early graft infections in the thoracic aorta. METHODS: Between 1996 and August 2015, 25 patients were treated in our institution for early graft infection after thoracic aortic surgery via sternotomy. In 11 patients, the infected prosthesis was replaced by a cryopreserved homograft or a biological valved pericardial xenograft. In 14 patients, an attempt to salvage the graft was made by resternotomy, aggressive debridement and subsequent continuous mediastinal antibiotic irrigation over a course of 2 weeks, accompanied by systemic antibiotic therapy. RESULTS: In-hospital mortality was comparable (replacement group: 2/11 = 18%, graft-sparing group: 2/14 = 14%, P = ns). The time interval from the initial surgery was significantly shorter in the graft-sparing group (replacement group: 165 days [range 95-300 days] and graft-sparing group: 24 days [range 15-93 days], P = 0.004]. Two patients (14%), who were treated with the graft-sparing approach >100 days after the initial surgery, were retreated for infection, and 1 due to an intra-aortic infection of an aortic arch hybrid stent graft was not amenable to external irrigation (median follow-up: 1.5 years [range 1.1-2.1 years]). One patient in the replacement group (9%) was reoperated on due to homograft degeneration (median follow-up: 6.0 years [3.0-8.9 years]). CONCLUSIONS: In situ graft-sparing surgical therapy is safe and effective if diagnosis and treatment of aortic graft infection is initiated promptly and aggressively (ideally <1 month post-surgery). Our method produces good midterm results (3 years). For aortic graft infections that become clinically apparent >3-6 months after surgery, replacement of grafts with biological conduits (homografts or pericardial xenografts) most likely remains the best treatment option.

Outcomes of minimally invasive lung transplantation in a single centre: the routine approach for the future or do we still need clamshell incision?

OBJECTIVES: Minimally invasive lung transplantation (MILT) via bilateral anterior thoracotomies has emerged as a novel surgical strategy with potential patient benefits when compared with transverse thoracosternotomy (clamshell incision, CS). The aim of this study is to compare MILT with CS by focusing on operative characteristics, postoperative organ function and support and mid-term clinical outcomes at Harefield Hospital. METHODS: It was a retrospective observational study evaluating all bilateral sequential lung transplants between April 2010 and November 2013. RESULTS: CS was performed in 124 patients and MILT in 70 patients. Skin-to-skin surgical time was less in the MILT group [285 (265, 339) min] compared with CS [380 (306, 565) min] and MILT-cardiopulmonary bypass [426 (360, 478) min]. Ischaemic time was significantly longer (502 ± 116 vs 395 ± 145 min) in the MILT group compared with CS (P < 0.01). Early postoperative physiological variables were similar between groups. Patients in the MILT group required less blood [2 (0, 4) vs 3 (1, 5) units, P = 0.16] and platelet transfusion [0 (0, 1) vs 1 (0, 2) units, P < 0.01]. The median duration of mechanical ventilation was shorter (26 vs 44 h, P < 0.01) and intensive therapy unit stay was 2 days shorter (5 vs 7) in the MILT group. While overall survival was similar, fraction of expired volume in 1 s (FEV1) and forced vital capacity (FVC) were consistently higher in the MILT group compared with CS during mid-term follow-up after transplantation. Specifically, FEV1 and FVC were, respectively, 86 ± 21 and 88 ± 18% predicted in the MILT group compared with 74 ± 21 and 74 ± 19% predicted in the CS group (P < 0.01) at the 6-month follow-up. CONCLUSIONS: MILT was successfully introduced at our centre as a novel operative strategy. Despite longer ischaemic times and a more complex operation and management, MILT appears to offer early postoperative and mid-term clinical benefits compared with our traditional approach of clamshell operations. These observations warrant larger definite studies to further evaluate the impact of MILT on physiological, clinical and patient-reported outcomes.