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

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

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

Mitral valve prolapse (MVP) is common among heart valve disease patients, causing severe mitral regurgitation (MR). Although complications such as cardiac arrhythmias and sudden cardiac death are rare, the high prevalence of the condition leads to a significant number of such events. Through next-generation gene sequencing approaches, predisposing genetic components have been shown to play a crucial role in the development of MVP. After the discovery of the X-linked inheritance of filamin A, autosomal inherited genes were identified. In addition, the study of sporadic MVP identified several genes, including DZIP1, TNS1, LMCD1, GLIS1, PTPRJ, FLYWCH, and MMP2. The early screening of these genetic predispositions may help to determine the patient population at risk for severe complications of MVP and impact the timing of reconstructive surgery. Surgical mitral valve repair is an effective treatment option for MVP, resulting in excellent short- and long-term outcomes. Repair rates in excess of 95% and low complication rates have been consistently reported for minimally invasive mitral valve repair performed in high-volume centers. We therefore conceptualize a potential preventive surgical strategy for the treatment of MVP in patients with genetic predisposition, which is currently not considered in guideline recommendations. Further genetic studies on MVP pathology and large prospective clinical trials will be required to support such an approach. [ABSTRACT FROM AUTHOR]

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

Open in new tab Download slide OBJECTIVES Annuloplasty rings are routinely used in mitral valve repair (MVr). However, accurate annuloplasty ring size selection is essential to obtain a favourable outcome. Moreover, ring sizing can be challenging in some patients and is highly influenced by surgeons' experience. This study investigated the utility of three-dimensional mitral valve (3D-MV) reconstruction models to predict annuloplasty ring size for MVr. METHODS A total of 150 patients undergoing minimally invasive MVr with annuloplasty ring due to Carpentier type II pathology and who were discharged with none/trace residual mitral regurgitation were included. 3D-MV reconstruction models were created with a semi-automated software package (4D MV Analysis) to quantitate mitral valve geometry. To predict the ring size, univariable and multivariable linear regression analyses were performed. RESULTS Between 3D-MV reconstruction values and implanted ring sizes, the highest correlation coefficients were provided by commissural width (CW) (0.839; P  < 0.001), intertrigonal distance (ITD) (0.796; P  < 0.001), annulus area (0.782; P  < 0.001), anterior mitral leaflet area (0.767; P  < 0.001), anterior–posterior diameter (0.679; P  < 0.001) and anterior mitral leaflet length (0.515; P  < 0.001). In multivariable regression analysis, only CW and ITD were found to be independent predictors of annuloplasty ring size (R 2 = 0.743; P  < 0.001). The highest level of agreement was achieved with CW and ITD, and 76.6% of patients received a ring with no >1 ring size difference from the predicted ring sizes. CONCLUSIONS 3D-MV reconstruction models can support surgeons in the decision-making process for annuloplasty ring sizing. The present study may be a first step towards accurate annuloplasty ring size prediction using multimodal machine learning decision support. [ABSTRACT FROM AUTHOR]