Descending thoracic aorta dissection and aortic trauma

none2noopenFattori R.; Di Eusanio M.Fattori, R.; Di Eusanio, M

Cerebral protection during surgery of the thoracic aorta

The brain is an organ with a high energy demand. Over 90% of the energy produced by mitochondria in the brain is derived from oxygen and glucose carried by the circulation. Any decrease in oxygen causes a prompt fall in energy production and results in severe ischemic brain damage. Since surgery of the aortic arch requires manipulation and exclusion of the cerebral vascularization the utilisation of optimal methods of cerebral function preservation is necessary to avoid ischemic brain injuries. Current brain protection strategies, involving reduction of cerebral oxygen consumption and/or maintenance of cerebral blood flow, include: Deep Hypothermic Circulatory Arrest (DHCA), Retrograde Cerebral Perfusion (RCP), Antegrade Selective Cerebral Perfusion (ASCP). Since 1995, at the St Antonius Hospital (Nieuwegein, Netherlands), ASCP is, for the following reasons the method of choice for brain protection when aortic reconstruction is anticipated to require a period of circulatory arrest longer than 30 minutes: ? As compared to DHCA with or without RCP, ASCP provides a much longer period of safe circulatory arrest. We have demonstrated that the extent of the aortic replacement and an ASCP time of longer than 90 minutes are not associated with an increased risk of hospital mortality and adverse neurologic outcome intended as the postoperative occurrence of permanent and transient neurologic dysfunctions ? ASCP can be used with moderate (instead of deep) hypothermia. Cooling down the patients core temperature to only 22°-25°C instead of 10°-18°C, is supposed to have various advantages such as the reduction of the duration of extracorporeal circulation with improved survival and reduced coagulative complications. ? the entire experimental literature, comparatively investigating the effects of ASCP, DHCA and RCP on brain energy metabolism, supports the idea that ASCP is superior to the other methods in maintaining an aerobic brain metabolism even after a prolonged period of circulatory arrest as demonstrated by morphologic, histopathologic and biochemical findings as well as by behavioural and clinical examinations Aim of the present thesis was: 1) to review our experience with ASCP during surgery of the thoracic aorta, 2) to determine the predictive risk factors for hospital mortality and adverse neurologic outcome, 3) to compare survival, neurologic outcome and systemic morbidity in patients undergoing aortic procedures requiring short periods of circulatory arrest with ASCP and DHCA, 4) to compare survival and neurologic outcome in patients receiving 2 different technique for arch vessels reimplantation to the aortic arch: the separated graft technique and the en bloc technique. Our findings were as follows: The hospital mortality rate ranged from to, permanent and transient neurological dysfunction occurred in of patients. Duration of cerebral perfusion and the extent of the aortic replacement were not indicated as predictive risk factor for hospital mortality and adverse neurologic outcome. Among the preoperative variables, type A dissection, urgency and history of stroke/TIA, emerged as the most important risk factors for hospital mortality and adverse neurologic outcome. The duration of CPB was the only intraoperative factor indicated as a risk factor for hospital mortality and neurologic outcome by our statistical analysis. Patients undergoing ascending aorta/hemiarch replacement with ASCP had similar survival and neurological outcome of those receiving DHCA as a method of brain protection but presented a better postoperative pulmonary and renal function recovery. As compared to the en bloc technique , the separated graft technique may result in several technical advantages and in reduced durations of extracorporeal circulation and myocardial ischemia. In our experience, ASCP has been demonstrated to be a safe and reliable method of brain protection allowing complex aortic procedures to be performed with acceptable results in terms of hospital mortality and adverse neurologic outcome

Type B aortic dissection complicating an isthmic coarctation in a Turner patient

none4openDi Eusanio, Marco; Pilato, Emanuele; Pantaleo, Antonio; Di Bartolomeo, RobertoDi Eusanio, Marco; Pilato, Emanuele; Pantaleo, Antonio; Di Bartolomeo, Robert

Normothermic frozen elephant trunk: our experience and literature review

none6Background and Objective: The frozen elephant trunk (FET) technique has undoubtable advantages in treating complex and extensive disease of the aortic arch and the thoracic descending aorta. Despite several improvements in cardiopulmonary bypass conduction and surgical strategy, operative times and the institution of systemic circulatory arrest remain the main determinants of early mortality, cerebral/spinal cord injury and visceral organs dysfunction. We have conducted this review to highlight the recent technical advances in arch and FET surgery aiming at the reduction/avoidance of systemic circulatory arrest, and their impact on early outcomes. Methods: A literature search (from origin to January 2022), limited to publications in English, was performed on online platforms and database (PubMed, Google, ResearchGate). After a further review of associated or similar papers, we found 4 experiences, described by 11 peer-reviewed published papers, which focused on minimising or avoiding systemic circulatory arrest during total arch replacement plus stenting of the descending thoracic aorta. Key Content and Findings: Recent experiences reported the use of an antegrade endoaortic balloon, advanced and inflated into the stent graft, to provide an early systemic reperfusion soon after the deployment of the stented portion of the FET prosthesis and minimize the circulatory arrest time (down to a mean of 5 minutes), thus avoiding the need of moderate or deep hypothermia (mean systemic temperature 28-30 ???) while allowing a complete arch and FET repair. Our approach, based on off-pump retrograde vascular stent graft deployment in distal arch/descending thoracic aorta, and the use of a retrograde endoballoon, allows the repair of extensive aortic pathologies during uninterrupted normothermic cerebral and lower body perfusion. Conclusions: The use of endoballoon occlusion has emerged in recent years as a safe and effective strategy to allow distal perfusion during FET repair. This technique minimizes or avoids the detrimental effects of hypothermia and systemic circulatory arrest and significantly reduces the operative times.Malvindi, PG; Alfonsi, J; Berretta, P; Cefarelli, M; Gatta, E; Di Eusanio, MMalvindi, Pg; Alfonsi, J; Berretta, P; Cefarelli, M; Gatta, E; Di Eusanio,

Sutureless versus transcatheter valves in patients with aortic stenosis at intermediate risk: A multi-institutional European study

Background: Recent randomized controlled trials showed comparable short-term outcomes of transcatheter aortic valve implantation versus surgical aortic valve replacement in intermediate and low-risk patients. However, independent studies comparing transcatheter aortic valve implantation results versus surgical aortic valve replacement at 5 years showed worsening outcomes in patients treated with transcatheter aortic valve implantation. The aim of this study was to analyze mid- to long-term outcomes of patients with isolated aortic stenosis and an intermediate-risk profile who underwent aortic valve replacement using a sutureless valve versus transcatheter aortic valve implantation. Methods: This retrospective multi-institutional European study investigated 2,123 consecutive patients with isolated aortic stenosis at intermediate risk profile treated with sutureless aortic valve replacement (824 patients) or transcatheter aortic valve implantation (1,299 patients) from 2013 to 2020. After 1:1 propensity score matching, 2 balanced groups of 517 patients were obtained. Primary endpoints were as follows: 30 days, late all-cause, and cardiac-related mortality. Secondary endpoints included major adverse cardiocerebrovascular events (all-cause death, stroke/transient ischemic attack, endocarditis, reoperation, permanent pacemaker implantation, and paravalvular leak grade >= 2).Results: Median follow-up was 4.3 years (interquartile range 1.1-7.4 years). Primary endpoints were as follows-30-day mortality sutureless aortic valve replacement: 2.13% versus transcatheter aortic valve implantation: 4.64% (P = .026), all-cause mortality sutureless aortic valve replacement: 36.7% +/- 7.8% vs transcatheter aortic valve implantation: 41.8% +/- 8.2% (P = .023), and cardiac-related mortality sutureless aortic valve replacement: 10.2% +/- 2.8% vs transcatheter aortic valve implantation: 19.2% +/- 3.5%;(P = .00043) at follow-up. Secondary endpoints were as follows-major adverse cardiocerebrovascular events in the sutureless aortic valve replacement group: 47.2% +/- 9.0% versus transcatheter aortic valve implantation: 57.3% +/- 7.5% (P = 2 (sutureless aortic valve replacement: 0.97% versus transcatheter aortic valve implantation: 4.84% [P = .0011) was significantly higher in transcatheter aortic valve implantation group. At Multivariable Cox regression analysis, paravalvular leak >= 2 (hazard ratio: 1.63%; 95% confidence interval: 1.06-2.53, P = .042) and permanent pacemaker implantation (hazard ratio: 1.49%; 95% confidence interval: 1.02-2.20, P = .039) were identified as predictors of mortality.Conclusion: Sutureless aortic valve replacement showed a significantly lower incidence of all-cause mortality, cardiac-related death, permanent pacemaker implantation, and paravalvular leak than transcatheter aortic valve implantation. Moreover, permanent pacemaker implantation and paravalvular leak negatively affected survival in patients treated for isolated aortic stenosis.(c) 2023 Elsevier Inc. All rights reserved

Sutureless Aortic Valve Replacement vs. Transcatheter Aortic Valve Implantation in Patients with Small Aortic Annulus: Clinical and Hemodynamic Outcomes from a Multi-Institutional Study

Objective: This study aimed to compare hemodynamic performances and clinical outcomes of patients with small aortic annulus (SAA) who underwent aortic valve replacement by means of sutureless aortic valve replacement (SUAVR) or transcatheter aortic valve implantation (TAVI). Methods: From 2015 to 2020, 622 consecutive patients with SAA underwent either SUAVR or TAVI. Through a 1:1 propensity score matching analysis, two homogeneous groups of 146 patients were formed. Primary endpoint: all cause-death at 36 months. Secondary endpoints: incidence of moderate to severe patient-prosthesis mismatch (PPM) and incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) Results: All-cause death at three years was higher in the TAVI group (SUAVR 12.2% vs. TAVI 21.0%, P=0.058). Perioperatively, comparable hemodynamic performances were recorded in terms of indexed effective orifice area (SUAVR 1.12 +/- 0.23 cm(2)/m(2) vs. TAVI 1.17 +/- 0.28 cm(2)/m(2), P=0.265), mean transvalvular gradients (SUAVR 12.9 +/- 5.3 mmHg vs. TAVI 12.2 +/- 6.2 mmHg, P=0.332), and moderate-to-severe PPM (SUAVR 4.1% vs. TAVI 8.9%, P=0.096). TAVI group showed a higher cumulative incidence of MACCEs at 36 months (SUAVR 18.1% vs. TAVI 32.6%, P= 2 were significantly higher in TAVI group and identified as independent predictors of mortality (PMI: hazard ratio [HR] 3.05, 95% confidence interval [CI] 1.34-6.94, P =0.008; PPM: HR 2.72, 95% CI 1.25-5.94, P=0.012). Conclusion: In patients with SAA, SUAVR and TAVI showed comparable hemodynamic performances. Moreover, all-cause death and incidence of MACCEs at follow-up were significantly higher in TAVI group

Transcatheter valve-in-valve implantation versus reoperative conventional aortic valve replacement: a systematic review

none6siTranscatheter valve-in-valve (VIV) implantation for degenerated aortic bioprostheses has emerged as a promising alternative to redo conventional aortic valve replacement (cAVR). However there are concerns surrounding the efficacy and safety of VIV. This systematic review aims to compare the outcomes and safety of transcatheter VIV implantation with redoes cAVR. Six databases were systematically searched. A total of 18 relevant studies (823 patients) were included. Pooled analysis demonstrated VIV achieved significant improvements in mean gradient (38 mmHg preoperatively to 15.2 mmHg postoperatively, P<0.001) and peak gradient (59.2 to 23.2 mmHg, P=0.0003). These improvements were similar to the outcomes achieved by cAVR. The incidence of moderate paravalvular leaks (PVL) were significantly higher for VIV compared to cAVR (3.3% vs. 0.4%, P=0.022). In terms of morbidity, VIV had a significantly lower incidence of stroke and bleeding compared to redo cAVR (1.9% vs. 8.8%, P=0.002 & 6.9% vs. 9.1%, P=0.014, respectively). Perioperative mortality rates were similar for VIV (7.9%) and redo cAVR (6.1%, P=0.35). In conclusion, transcatheter VIV implantation achieves similar haemodynamic outcomes, with lower risk of strokes and bleeding but higher PVL rates compared to redo cAVR. Future randomized studies and prospective registries are essential to compare the effectiveness of transcatheter VIV with cAVR, and clarify the rates of PVLs.openPhan, Kevin; Zhao, Dong-Fang; Wang, Nelson; Huo, Ya Ruth; Di Eusanio, Marco; Yan, Tristan DPhan, Kevin; Zhao, Dong-Fang; Wang, Nelson; Huo, Ya Ruth; Di Eusanio, Marco; Yan, Tristan

Reliability of EuroSCORE II on Prediction of Thirty-Day Mortality and Long-Term Results in Patients Treated with Sutureless Valves

Background: EuroSCORE II (ES2) is a reliable tool for preoperative cardiac surgery mortality risk prediction; however, a patient's age, a surgical procedure's weight and the new devices available may cause its accuracy to drift. We sought to investigate ES2 performance related to the surgical risk and late mortality estimation in patients who underwent aortic valve replacement (AVR) with sutureless valves. Methods: Between 2012 and 2021, a total of 1126 patients with isolated aortic stenosis who underwent surgical AVR by means of sutureless valves were retrospectively collected from six European centers. Patients were stratified into three groups according to the EuroSCORE II risk classes (ES2 8%). The accuracy of ES2 in estimating mortality risk was assessed using the standardized mortality ratio (O/E ratio), ROC curves (AUC) and Hosmer-Lemeshow (HL) test for goodness-of-fit. Results: The overall observed mortality was 3.0% (predicted mortality ES2: 5.39%) with an observed/expected (O/E) ratio of 0.64 (confidential interval (CI): 0.49-0.89). In our population, ES2 showed a moderate discriminating power (AUC 0.65, 95%CI 0.56-0.72, p < 0.001; HL p = 0.798). Good accuracy was found in patients with ES2 < 4% (O/E ratio 0.54, 95%CI 0.23-1.20, AUC 0.75, p < 0.001, HL p = 0.999) and for patients with an age < 75 years (O/E ratio 0.98, 95%CI 0.45-1.96, AUC 0.76, p = 0.004, HL p = 0.762). Moderate discrimination was observed for ES2 in the estimation of long-term risk of mortality (AUC 0.64, 95%CI: 0.60-0.68, p < 0.001). Conclusions: EuroSCORE II showed good accuracy in patients with an age < 75 years and patients with ES2 < 4%, while overestimating risk in the other subgroups. A recalibration of the model should be taken into account based on the complexity of actual patients and impact of new technologies

Aortic Root Replacement With Biological Valved Conduits

none9The execution of Bentall procedures using biological valved conduits is expanding owing to the increased incidence of aortic valve and root diseases in the aging population. To review the available data, a systematic search identified 29 studies with a total of 3,298 patients. Although evidence on short-term results suggested favorable outcomes after biological Bentall operations, data beyond 5 years are limited and highlight the urgent need for further investigations with longer follow-up.openCastrovinci, Sebastiano; Tian, David H; Murana, Giacomo; Cefarelli, Mariano; Berretta, Paolo; Alfonsi, Jacopo; Yan, Tristan D; Di Bartolomeo, Roberto; Di Eusanio, MarcoCastrovinci, Sebastiano; Tian, David H; Murana, Giacomo; Cefarelli, Mariano; Berretta, Paolo; Alfonsi, Jacopo; Yan, Tristan D; Di Bartolomeo, Roberto; Di Eusanio, Marc

Transaxillary approach enhances postoperative recovery after mitral valve surgery

Objectives: Several thoracic incisions have been described and different techniques used for cardiopulmonary bypass, myocardial protection, and valve exposure in minimally invasive mitral valve surgery (MIMVS). Aim of this study is to compare the early outcomes of patients operated using a simplified minimally invasive approach through a right trans-axillary (TAxA) access with those achieved with conventional full sternotomy (FS) operations. Methods: Prospectively collected data of patients who underwent mitral valve surgery between 2017 and 2022 at two academic centres were reviewed. Among them, 454 patients were operated through MIMVS TAxA access and 667 patients through FS; associated aortic and CABG procedures, infective endocarditis, redo and urgent operations were excluded. A propensity match analysis was performed using seventeen preoperative variables. Results: Two well balanced cohorts including a total of 804 patients were analysed. The rate of mitral valve repair was similar in both groups. Operative times were shorter in FS group, nevertheless in patients operated with a minimally invasive approach there was a trend towards decreasing crossclamp time over the study period (p = 0.07). In TAxA group 30-day mortality was 0.25%, postoperative cerebral stroke rate was 0.7%. TAxA mitral surgery was associated with shorter intubation time (p &lt; 0.001) and ICU stay (p &lt; 0.001). After a median hospital stay of 8 days, 30% of patients who had TAxA surgery were discharged home vs. 5% in the FS group (p &lt; 0.001). Conclusions: When compared with FS access, TAxA approach provides at least similar excellent early outcomes in terms of perioperative morbidity and mortality and allows shorter mechanical ventilation time, ICU and postoperative hospital stay with a higher rate of patients able to be discharged home without any further period of cardiopulmonary rehabilitation