Too big to fail?-An aggressive strategy for a dire problem.

Tracheo-innominate fistula (TIF) is a reported complication of tracheostomy that typically presents with a herald bleed. The phenomenon of an aortotracheal fistula has similar pathology and presentation to TIF, but no standard surgical repair. In the manuscript by Musgrove et al. in the Journal of Cardiac Surgery, the authors propose a surgical treatment that is reproducible for the correct anatomic configuration-an ascending and aortic arch replacement, pericardial patch of the tracheal defect, and omental flap coverage. While this intervention is a large undertaking for a small defect, it is a safe and durable repair.

Aortic arch replacement and autologous pericardial tracheal patch for an aorto-tracheal fistula.

Aorto-tracheal fistulas are rare and highly lethal, with few reports of successful surgical intervention. We present a 48-year-old man with an aorto-tracheal fistula induced by radiation therapy for tracheal squamous cell carcinoma. He presented with hemoptysis and chest pain and workup revealed the aorta-tracheal fistula between the posterior aortic arch and anterior distal trachea. He was emergently taken to surgery. To our knowledge, this is the first report of an aorto-tracheal fistula successfully treated with a transverse aortic arch replacement and complex tracheal repair using autologous pericardium with an omental buttress.

Aortic annulus elevation for aortic valve and root replacement.

Aortic valve and root replacements require an in-depth understanding of the aortic root and annulus. Both structures can be asymmetric at times, and this needs to be recognized and taken into consideration when performing valve-sparing operations or other root-replacement procedures. Moreover, the geometry of the aortic annulus can be altered, and when performing an aortic root replacement this can distort the geometry of a neoaortic valve for instance, and lead to valve dysfunction, which is difficult to reverse. We are describing an altered aortic annulus, which required modification through annulus elevation before proceeding with aortic root replacement with a graft-reinforced pulmonary-autograft.

Precise endoballoon positioning for High-Risk sternal re-entry in an ascending aortic pseudoaneurysm with patent coronary grafts.

Redo cardiac surgery can present a unique set of challenges even to the experienced surgeon. Although outcomes have steadily improved in the modern era; if an intraoperative adverse event occurs, there is a 5% incidence of mortality and 19% incidence of myocardial infarction, stroke or death. Overall, the modern incidence of mortality at reoperation varies but be segregated into low and higher risk cohorts depending on the planning computed tomography imaging and risk to substernal structures on re-entry. Patients with ascending aortic or root pseudoaneurysms represent a particularly difficult subset of high-risk patients requiring reoperative cardiac surgery due to the danger of exsanguination and air embolization. The gold standard for management of such cases remains the use of deep hypothermic circulatory arrest (DHCA) to achieve safe re-entry in such cases however this can result in unpredictable DHCA duration depending on the degree of pericardial adhesions. We report a case of aortic pseudoaneurysm in a patient with patent coronary grafts managed using an endoballoon precisely positioned relative to the proximal anastomoses resulting in a safe surgical re-entry and shorter DHCA time.

Is open triple-branched stent graft the next stage?

Due to the pathology of acute type A aortic dissection (AAD), including fragile dissected aortic wall and visceral malperfusions, surgical procedures are still in development. This commentary is a review of a report by Bin and Yang et al. published in the Journal of Cardiac Surgery that reported similar effectiveness of the open triple-branched stent graft for acute type AAD and total arch replacement with the frozen elephant trunk technique.

Sex-based outcomes after surgery for acute type A aortic dissection.

BACKGROUND: While prior data have suggested worse outcomes in women after acute type A aortic dissection (ATAAD) repair when compared to men, results have been inconsistent across studies over time. This study sought to evaluate the impact of sex on short- and long-term outcomes after ATAAD repair. METHODS: This was a retrospective study utilizing an institutional database of ATAAD repairs from 2007 to 2021. Patients were stratified according to sex. Kaplan-Meier survival estimation and multivariable Cox regression were performed. Supplementary analysis using propensity score matching was also performed. RESULTS: Of the 601 patients who underwent ATAAD repair, 361 were males (60.1%) and 240 (39.9%) were females. Females were significantly older, more likely to have hypertension, and more likely to have chronic lung disease. Females were also significantly more likely than males to undergo hemiarch replacement, while males were significantly more likely than females to undergo total arch replacement and frozen elephant trunk. Operative mortality was 9.4% among males and 13.8% among females, though this was not a statistically significant difference (p = .098). Postoperative complications were comparable between groups. Kaplan-Meier survival estimates were similar for men and women, and, on multivariable Cox regression, sex was not significantly associated with long-term survival (hazard ratio: 1.00, 95% confidence interval: 0.73, 1.37, p = .986). Outcomes remained comparable after supplementary propensity score matched analysis. CONCLUSION: ATAAD repair can be performed with comparable short-term and long-term outcomes in both men and women.

BioGlue and E-Vita Open NEO graft oozing: Long-term solution or band aid?

BACKGROUND: The introduction of the single-step total arch replacement (TAR) with frozen elephant trunk (FET) has revolutionised the field of aortic surgery. TAR is indicated when the aortic arch is involved in aortic pathologies such as Type A aortic dissection and thoracic aortic aneurysms. Several FET devices are available commercially for global use, and example is the E-Vita Open NEO hybrid prosthesis (HP) developed by CryoLife-JOTEC. Unlike other FET devices available, this HP in particular features a design that puts it at a disadvantage as it does not incorporate gelatine or collagen in its structure, which makes it permeable to blood. Several studies have reported incidence of post-anastomotic blood oozing through the E-Vita Open NEO right after weaning from cardiopulmonary bypass. AIMS: This commentary aims to discuss the recent study by Tan et al. which investigated E-Vita NEO device oozing as well as the implications of using BioGlue to overcome this serious complications. METHODS: We carried out a literature search on multiple electronic databases including PUBMED and Scopus in order to collate research evidence on E-Vita NEO device oozing, BioGlue health risks, and other commercially available and globally used FET devices such as Thoraflex Hybrid. RESULTS: It is proven fact that the E-Vita NEO excessively oozes blood, and while BioGlue is a safe and effective agent when used in small amounts, the amount needed to coat the E-Vita Open NEO and achieve haemostasis exceeds this by a wide margin which poses patients to great potential health risks. The Thoraflex Hybrid Prosthesis developed by Terumo Aortic is a commercially available and globally used FET device with long-standing favourable outcomes. DISCUSSION: Tan et al. recently conducted an interesting study which proved that the E-Vita NEO HP does excessively ooze blood and tackled the issue of pre-emptive BioGlue use to tackle this complication as suggested by Ho et al. This leads on to the main question, is the use of BioGlue with E-Vita Open NEO to overcome oozing a long-term sustainable solution or is it merely a band aid? CONCLUSION: In the face of fierce commercial competition, the choice of design and material of the E-Vita Open NEO HP would benefit from reconsideration.

Successive surgical repair of a progressive aortic dissection in a case of Loeys-Dietz Syndrome.

INTRODUCTION: The Frozen Elephant Trunk technique is a well-established treatment for aortic dissections (Stanford Type A) involving the aortic arch and descending aorta. The Thoraflex™ Hybrid prosthesis (Vascutek Ltd.), consisting of a proximal flexible conduit and a distal self-expanding covered stent, has consistently shown positive results in the treatment of this condition. CASE DESCRIPTION: The following is a description of such a staged reconstruction using the Thoraflex™ Hybrid Ante-Flo™ device, performed in a patient previously diagnosed with Loeys-Dietz Syndrome. After clamping the aorta proximally, an incision was taken at the distal end of the stent. Here, the distal end of the new prosthesis was inserted into the true lumen of the descending aorta and the stent was deployed. Following this, a bypass was established via the left atrium, and blood was returned to the lower body using the perfusion arm of the prosthesis with the proximal part of the descending aorta clamped. The collar of the prosthesis was sutured proximally to the aorta near the inlying previous stent. Air was removed via the perfusion arm of the prosthesis, which was then oversewn. DISCUSSION: To date, hybrid prostheses have only been used on the proximal aorta in patients with aortic aneurysms and aortic dissections (Stanford Type A). CONCLUSION: Using the described technique, it is possible to reconstruct the aortic anatomy using the available prostheses with accuracy and minimal complications.

Thrombus formation in the noncoronary sinus of Valsalva following primary graft dysfunction.

We hereby present a case of thrombus formation in the noncoronary sinus of Valsalva following primary graft dysfunction. The case highlights that stagnant and nonpulsatile flow can form thrombi in the noncoronary sinus since this sinus does not have a natural distal runoff.

Surgical management of giant pulmonary artery aneurysms in patients with severe pulmonary arterial hypertension.

BACKGROUND AND AIM: Giant aneurysm of the pulmonary artery (PAA) is an extremely rare condition that may develop in patients with pulmonary arterial hypertension (PAH) which may be complicated by rupture, dissection or intravascular thrombus formation. The aim of this study was to examine available literature with regard to surgical strategies in patients undergoing transplantation for PAH with PAA. RESULTS: These patients were traditionally considered for heart-lung transplantation but more recently, there have been reports of successful lung transplantation with reconstruction of the pulmonary artery. CONCLUSIONS: Unless there is a mandatory indication for heart-lung transplantation, patients with PAH and PAA can undergo lung transplantation and reconstruction of the pulmonary artery without compromising the outcome.

Transapical cannulation for surgical repair of chronic type B aortic dissection.

Open surgery for chronic type B aortic dissection has been shown to have considerable risks of cerebrovascular complications. Because retrograde perfusion is a potential cause of intraoperative cerebrovascular events, we report our transapical cannulation strategy for descending aorta replacement in chronic type B aortic dissection repair with circulatory arrest. This technique provides an easy and quick establishment of cardiopulmonary bypass by way of a left thoracotomy, and prevention of cerebrovascular event. Transapical cannula can be also used as a vent to ensure a bloodless field during proximal anastomosis and to prevent extension of left ventricle during rewarming. Transapical cannulation is a useful option in open repair of the descending aorta for chronic type B aortic dissection by way of left thoracotomy.

Intraoperative nadir hematocrit as a poor outcome predictor after acute type A aortic dissection surgey.

Acute type A aortic dissection is a life-threatening disease associated with high morbidity and mortality that requires urgent surgical intervention. Hemodilution is inevitable in cardiac operations performed with cardiopulmonary bypass, which leads to nadir hematocrit levels. Studies have shown that nadir hematocrit levels are associated with poor postoperative outcomes. The management strategy of intraoperative anemia in these operations is still controversial. Should we follow the patients with intraoperative low hematocrit values or should we transfuse them? In addition to intraoperative nadir hematocrit, cannulation strategies play an important role in early postoperative outcomes after aortic dissection surgery.

An alternate approach: Percutaneous axillary cannulation for minimally invasive cardiac surgery.

BACKGROUND: Percutaneous axillary artery cannulation for cardiopulmonary bypass (CPB) offers a novel alternate approach to mechanical circulatory support for patients with contraindications to femoral perfusion. To our knowledge, this has not yet been reported in minimally invasive cardiac surgery (MICS). AIM: We aim to highlight our experience using percutaneous axillary artery cannulation to safely facilitate CPB for minimally invasive cardiac surgery MICS. METHODS: Four patients who underwent robotic cardiac surgery utilizing the axillary artery for percutaneous cannulation between November 2019 and August 2021 at a single center were identified and included in the analysis. Preoperative, intraoperative, and postoperative data were collected and analyzed to support this case series. RESULTS: There were no perioperative hematomas, brachial plexus injuries, or neurovascular injuries. Within 30-days postoperatively there was no mortality, vessel injury, stroke, new onset atrial fibrillation, or other life-threatening bleeding. CONCLUSION: Percutaneous cannulation of the axillary artery is a novel and promising CPB modality for robotic cardiac surgery in patients with extensive peripheral and aortic atherosclerotic disease.

Brain and lower body protection during aortic arch surgery.

BACKGROUND: Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (antegrade cerebral perfusion [ACP]), or retrograde. In recent years nadir temperature progressively increased to 26°C-28°C (moderately hypothermic circulatory arrest [MHCA]), adding ACP. Aim of this multicentric study is to evaluate early results of aortic arch surgery and if DHCA with 10 min of cold reperfusion at the same nadir temperature of the CA before rewarming (delayed rewarming [DR]) can provide a neuroprotection and a lower body protection similar to that provided by MHCA + ACP. METHODS: A total of 210 patients were included in the study. DHCA + DR was used in 59 patients and MHCA + ACP in 151. Primary endpoints were death, neurologic event (NE), temporary (TNE), or permanent (permanent neurologic deficit [PND]), and need of renal replacement therapy (RRT). RESULTS: Operative mortality occurred in 14 patients (6.7%), NEs in 17 (8.1%), and PNDs in 10 (4.8%). A total of 23 patients (10.9%) needed RRT. Death + PND occurred in 21 patients (10%) and composite endpoint in 35 (19.2%). Intergroup weighed logistic regression analysis showed similar prevalence of deaths, NDs, and death + PND, but need of RRT (odds ratio [OR]: 7.39, confidence interval [CI]: 1.37-79.1) and composite endpoint (OR: 8.97, CI: 1.95-35.3) were significantly lower in DHCA + DR group compared with MHCA + ACP group. CONCLUSIONS: The results of our study demonstrate that DHCA + DR has the same prevalence of operative mortality, NE and association of death+PND than MHCA + ACP. However, the data suggests that DHCA + DR when compared with MHCA + ACP provides better renal protection and reduced prevalence of composite endpoint.

The black root: Aortic valve sparing in alkaptonuria.

We report an unusual case of black discoloration of an aortic root aneurysm and aortic valve cusps due to homogentisic acid deposition in a patient suffering from alkaptonuria. The patient underwent a valve-sparing aortic root replacement after careful and objective evaluation of the valve cusps. Despite alkaptonuria is classically associated with aortic valve stenosis and replacement, in the present case, the affected valve cusps were suitable for repair. To our knowledge, this is the first reported case of aortic valve-sparing procedure performed in a patient with alkaptonuria.

Lactate levels: A reliable tool to predict mortality in acute type A aortic dissections?

Lactate levels are surrogate markers of malperfusion in patients presenting with type A aortic dissections. Lactate measurement is simple, easy to perform, universally available, and thus can be an important tool for predicting mortality. However, the discriminatory power varies between studies and no cut-off point has been defined that can determine outcomes in the most reliable fashion. The risk prediction based on lactate levels can be improved when combined with other clinical and laboratory prognostic factors. Further studies with a much larger sample size, need to be carried out using serial measurements at well-defined time points to try and identify a cut-off value. The addition of lactate values to existing risk prediction scores or developing a new score based on it should be the subject of future research.

Frozen elephant trunk procedure for complex aortic arch surgery: The Salerno experience with Thoraflex hybrid.

BACKGROUND AND AIM OF THE STUDY: To report early clinical outcomes of the frozen elephant trunk (FET) technique for the treatment of complex aortic diseases after transition from conventional elephant trunk. METHODS: A single-center, retrospective study of patients who underwent hybrid aortic arch and FET repair for aortic arch and/or proximal descending aortic aneurysms, acute and chronic Stanford type A aortic dissection with arch and/or proximal descending involvement, Stanford type B acute and chronic aortic dissections with retrograde aortic arch involvement. RESULTS: Between December 2017 and May 2020, 70 consecutive patients (62.7 ± 10.6 years, 59 male) were treated: 41 (58.6%) for emergent conditions and 29 (41.4%) for elective. Technical success was 100%. In-hospital mortality was 14.2% (n = 12, 17.1% emergent vs. 10.3% elective, P = NS); 2 (2.9%) major strokes; 1 (1.4%) spinal cord injury. Mean follow-up was 12.5 months (interquartile range, 3.7-22.3). Overall survival at 3, 6, 12, and 24 months was 90% (95% confidence interval [CI], 83.2-97.3), 85.6% (95% CI, 77.7-94.3), 79.1% (95% CI, 69.9-89.5), 75.6% (95% CI, 65.8-86.9) and 73.5% (95% CI, 63.3-85.3). There were no aortic re-interventions and no distal stent graft-induced new entry (dSINE); 5 patients with residual type B dissection underwent TEVAR completion. CONCLUSIONS: In a real-world setting, FET with Thoraflex Hybrid demonstrated feasibility and good clinical outcomes, even in emergent setting. Our implant technique optimize cerebral perfusion reporting good results in terms of neurological complications. Techniques to perfect the procedure and to reduce remaining risks, and consensus on considerations such as standardized cerebral protection need to be reported.

Is this the final answer for the aortopathy with bicuspid aortic valve.

There have been changes in the guidelines for surgical indications for aortopathy associated with bicuspid aortic valves over the last 10 years. Although the results of the last 3 years adhering to the latest guidelines have been shown to be good, careful follow-up and accumulation of new research findings are still required.

Long-term outcomes of patients undergoing mechanical versus bioprosthetic aortic root replacement.

BACKGROUND: We evaluated the impact of valve type (mechanical vs. bioprosthetic) on survival after aortic root replacement (ARR). METHODS: In a propensity-matched analysis, we evaluated consecutive operations from 2010 to 2018. Patients were identified using a prospectively maintained institutional database. Patients with infective endocarditis were excluded. Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed. Cox regression adjusted for age, sex, baseline comorbidities, and operative variables. Propensity score matching yielded 153 pairs of patients. RESULTS: A total of 893 patients were identified. We excluded 192 patients with endocarditis and evaluated 701 patients. Of these patients, 455 (64.9%) received a bioprosthetic valve, 246 (35.1%) received a mechanical valve. Median follow-up was 4.06 years. The proportion of aortic dissections and circulatory arrest as well as cardiopulmonary bypass and ischemic times were similar across groups (p = .207, p = .086, p = .668, p = .454, respectively). Operative mortality was significantly higher in the bioprosthetic valve group (7.9% vs. 2.4%, p = .004). Total length of hospital stay was longer (11.4 ± 11.0 vs. 9.5 ± 10.1, p < .001) and there was a higher proportion of prolonged postoperative ventilation >24 h (21.3% vs. 13.0%, p = .007) in the bioprosthetic group. Postoperative outcomes were similar, regarding stroke (p = .077), re-exploration for bleeding (p = .211), new dialysis requirement (p = .077), long-term bleeding complications (p = .561), and reoperations (p = .755). Mechanical valve replacement was associated with improved long-term survival (adjusted HR 0.42, 95% CI: 0.23-0.77, p = .005). CONCLUSIONS: These findings suggest that mechanical valves for ARRs may confer a survival benefit over bioprosthetic valves. Surgeon bias was likely to account for this survival advantage.

Hybrid off-pump debranching and thoracic endovascular arch repair in a high-risk surgical patient.

Management of aortic arch pathologies remains challenging. Open total arch replacements have been associated with significant morbidity and mortality owing to the need for cardiopulmonary bypass and circulatory arrest. On the other hand, aortic arch-branched stent grafts are not widely available. In this context, hybrid techniques combining open arch debranching with endovascular graft placement have been identified as an attractive option in select patients. However, there still is a paucity of literature on their application and outcomes. A case is presented of an elderly frail patient diagnosed with a pseudoaneurysm of the aortic arch and who was successfully treated by an off-pump arch debranching followed by endovascular arch repair. This case highlights (i) the feasibility of hybrid debranching techniques, (ii) their technical challenges, and (iii) the need for long-term follow-up data.