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Purpose: To evaluate the safety and effectiveness of total percutaneous implantation of the Zenith Alpha Thoracic (ZTA) endograft in the treatment of diseases of the descending thoracic aorta. Materials and Methods: A retrospective cohort study of 56 consecutive patients undergoing total percutaneous ZTA implantation between 2018 and 2020 was performed in a single center. Patients’ demographics, clinical characteristics, anatomical parameters, operative details, device features, and postoperative outcomes were assessed. The primary endpoint was ongoing clinical success. A Cox regression model was used to determine the predictive factors of worse postoperative outcomes. Results: Eighty-three ZTA endografts were implanted in 35 men and 21 women with a mean age of 69±11 years for the treatment of 26 degenerative aneurysms, 15 type B dissections, and 8 penetrating ulcers, among others. Primary technical success was 100%, with a 30-day ongoing clinical success rate of 94.6%. The 1-year ongoing clinical success rate was 91.1% (51 patients), and freedoms from all-cause mortality, type 1 and 3 endoleaks, and any unplanned reintervention were, respectively, 95.3%, 91.4%, and 88.2% at 1 year. During follow-up, there was one case of surgical conversion for an aorto-esophageal fistula. On the contrary, neither aneurysmal rupture nor significant aneurysmal expansion was recorded. Repair of ruptured thoracic aorta and a high ratio of sheath outer diameter to external iliac artery diameter were found to be independently associated with worse outcomes, with adjusted odds ratios of 4.4 [1.5-15.3] and 4.9 [1.1-23.9], respectively. Conclusion: The outcomes of total percutaneous implantation of ZTA endograft show excellent primary technical success and favorable midterm ongoing clinical success. Factors associated with worse outcomes include the repair of ruptured aorta and a high sheath to access vessel ratio.

ZusammenfassungPathologien im Bereich des Aortenbogens können isoliert auftreten, weit häufiger jedoch sind auch benachbarte Abschnitte der thorakalen Aorta – die Aorta ascendens oder Aorta descendens – mit betroffen. Die ersten operativen Eingriffe zur Behandlung des Aortenbogens wurden vor knapp 6 Jahrzehnten vorgenommen. Trotz zahlreicher Verbesserungen und Innovationen während des 20. und Anfang des 21. Jahrhunderts bleiben diese Eingriffe mit einer relevanten operativen Mortalität und neurologischen Komplikationsrate vergesellschaftet. Endovaskuläre Techniken sowie moderne Hybridverfahren erweitern das therapeutische Spektrum im Bereich des Aortenbogens zunehmend, auch wenn das offene operative Vorgehen aktuell noch der Goldstandard ist. Die endovaskuläre Behandlung eines Aortenaneurysmas wurde erstmals im Bereich der infrarenalen Aorta abdominalis in den frühen 1990er-Jahren durchgeführt. Es dauerte nicht lange, bis die ersten endovaskulären Therapieversuche zur Behandlung des Aortenbogens unternommen wurden. Schon 1996 berichteten Inoue et al. über den Einsatz der ersten gebranchten Endoprothese zur Behandlung von Aneurysmen im Aortenbogen. Fortwährende Verbesserungen und Verfeinerungen der Implantationstechniken und auch des implantierten Materials führten dazu, dass heutzutage im Bereich der deszendierenden thorakalen und abdominellen Aorta die endovaskuläre Therapie eine immer bedeutsamere Option im Vergleich zu den offenen chirurgischen Verfahren darstellt und diese teils als Goldstandard abgelöst hat. Diese Übersichtsarbeit soll einen Überblick über Voraussetzungen, Ergebnisse, aber auch Grenzen der endovaskulären Chirurgie des Aortenbogens geben.

Background We analyzed the short-term and mid-term outcomes as well as the health-related quality of life (HRQOL) of octogenarians undergoing elective and urgent cardiac surgery. Patients and Methods We retrospectively identified 688 consecutive octogenarians who underwent cardiac surgery at our center between January 2012 and December 2019. A propensity score matching was performed which resulted in the formation of 80 matched pairs. The patients were interviewed and the Short Form-36 survey was used to assess the HRQOL of survivors. Multivariable analysis incorporated binary logistic regression using a forward stepwise (conditional) model. Results The median age of the matched cohort was 82 years (p = 0.937), among whom, 38.8% of patients were female (p = 0.196). The median EuroSCORE II of the matched cohort was 19.4% (10.1–39.1%). The duration of postoperative mechanical ventilation was found to be independently associated with in-hospital mortality (odds ratio: 1.01 [95% confidence interval: 1.0–1.02], p = 0.038). The survival rates at 1, 2, and 5 years was 75.0, 72.0, and 46.0%, respectively. There was no difference in the total survival between the groups (p = 0.080). The physical health summary score was 41 (30–51) for the elective patients and 42 (35–49) for the nonelective octogenarians (p = 0.581). The median mental health summary scores were 56 (48–60) and 58 (52–60), respectively (p = 0.351). Conclusion Cardiac surgery can be performed in octogenarians with good results and survivors enjoy a good quality of life; however, the indication for surgery or especially for escalation of therapy should always be made prudently, reserved, and in consideration of patient expectations.

OBJECTIVES In acute aortic dissection type A various components of the diagnostic and logistic pathways may affect the time to definitive treatment. This study aimed to characterize these components and to identify factors delaying the optimal management within our institutional referral network. METHODS Between January 2017 and January 2020, 96 consecutive patients with classical aortic dissection type A were admitted (28%) or referred (72%) to our tertiary care centre and analysed retrospectively. Data are presented as medians (25th–75th quartile). RESULTS Median age was 66 years (56–74), 63% were male. Most of the patients were primarily admitted to a cardiology department (40%), whereas about a fourth were admitted to departments for internal medicine (26%) and general surgery (27%). The median interval from the onset of symptoms to hospital admission was 2.1 (1–4.4) h. From admission to confirmed diagnosis it took 2.1 (0.6–9.5) h and the median interval from confirmed diagnosis to admission at our specialized tertiary care aortic centre was 1.5 (0.9–2.4) h. Following admission to our centre, 1.1 (0.5–1.9) h passed until the induction of anaesthesia and 0.8 (0.0–1.1) h until the start of surgery. The total interval from the onset of symptoms to the start of surgery was 7.6 h (5.1–12.3). CONCLUSIONS The marked variability of the time from symptoms to diagnosis at any medical facility demonstrates the importance of awareness in the optimization of the treatment of acute aortic dissection type A.

Purpose To present a novel technique to successfully cross a mechanical aortic valve prosthesis. Technique A 55-year-old female patient with genetically verified Marfan syndrome presented with a 5-cm anastomotic aneurysm of the proximal aortic arch after previous ascending aortic replacement due to a type A aortic dissection in 2007. The patient also underwent mechanical aortic valve replacement in 1991. A 3-stage hybrid repair was planned. The first 2 steps included debranching of the supra-aortic vessels. In the third procedure, a custom-made double branched endovascular stent-graft with a short 35-mm introducer tip was implanted. The mechanical valve was passed with the tip of the dilator on the lateral site of the leaflet, without destructing the valve and with only mild symptoms of aortic insufficiency, as one leaflet continued to work. This allowed the implantation of the stent-graft directly distally of the coronary arteries. Postoperative computed tomography angiography showed no endoleaks and patent coronary and supra-aortic vessels. Conclusion Passing a mechanical aortic valve prosthesis at the proper position is feasible and allows adequate endovascular treatment in complex arch anatomy. However, caution should be taken during positioning of the endovascular graft as the tip may potentially damage the valve prosthesis.

Treatment with extracorporeal life support (ECLS) in acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) fell short of improving myocardial recovery measured by 30 day ejection fraction in the ECLS-SHOCK trial. However, to date, no data regarding impact of ECLS on long-term outcomes exist. In this randomized, controlled, prospective, open-label trial, 42 patients with CS complicating AMI were randomly assigned to ECLS (ECLS group, n = 21) or no ECLS (control group, n = 21). The primary endpoint was left ventricular ejection fraction (LVEF) after 30 days. Secondary endpoints included mortality and neurological outcome after 12 months. Evaluation of neurological outcome used the modified Rankin Scale. The 12-month all-cause mortality was 19% in the ECLS group versus 38% in the control group (p = 0.31). Only one patient (control group) died after the initial 30 days. Three patients underwent elective percutaneous coronary intervention (PCI) during follow-up (one in the control and two in the ECLS group). Favorable neurological outcome (modified Rankin Score ≤ 2) was seen in 61.9% of patients in the ECLS group versus 57.1% in the control group (p = 1). This pilot study showed that randomized studies with ECLS in CS patients are feasible and safe. Small numbers of included patients impede meaningful conclusions about mortality and neurological outcome. Our findings of numerical differences in mortality and survival with severe neurological impairment give an urgent call for larger multi-centric randomized trials assessing the endpoint of all-cause mortality but also considering the effects on neurological outcome measures.

ZusammenfassungFünf Jahre nach der ersten endovaskulären Aortenrekonstruktion (EVAR) berichten Park et al. über die erste Implantation einer fenestrierten Endoprothese. In der Zwischenzeit wurden mehrere fortgeschrittene Generationen von fenestrierten und gebranchten Prothesen entwickelt. Diese können in den meisten Fällen in 2 Gruppen unterteilt werden. Zur 1. Gruppe gehören die „custom-made“-Prothesen, die für elektive Operationen individuell für Patienten mit spezifischer Anatomie hergestellt werden. Eine 2. Gruppe bilden die sog. „off-the-shelf“-Prothesen, die sich durch vom Hersteller vergebene Charakteristika im Sinne von Länge, Breite und Durchmesser auszeichnen und bei allen Prothesen gleich sind. Die offene gefäßchirurgische Therapie der thorakoabdominellen Aortenaneurysmen ist selbst bei elektiven Eingriffen mit relevanter Mortalität und Morbidität assoziiert. Die Entwicklung von endovaskulären Modalitäten wie z. B. fenestrierte oder gebranchte endovaskuläre Aortenrekonstruktionen (F-EVAR, B-EVAR) ermöglichten die Nutzung weniger invasiver Prozeduren für die Behandlung der komplexen Aortenpathologien sowohl im thorakoabdominalen Abschnitt als auch im Aortenbogen. Eine umfassende Behandlung aller Segmente der Aorta mit endovaskulären Techniken wurde noch nicht vollständig evaluiert. Das Ziel dieses Artikels ist die Präsentation eines Überblicks der zurzeit verfügbaren endovaskulären Möglichkeiten der Behandlung von komplexen abdominellen und thorakoabdominellen Aortenaneurysmen, die sowohl eine komplexe thorakale als auch komplexe abdominale Versorgung benötigen.

The aim of this study was to retrospectively evaluate the incidence and surgical outcomes of patients with native infective endocarditis (IE) and prosthetic aortic valve endocarditis (PVE) over the past decade at a single institution.Between January 2005 and December 2015, 289 patients (mean age, 63.3 ± 14.2 years) suffering from native IE (n = 186) and PVE (n = 103) of the aortic valve underwent surgical procedures. Perioperative data were acquired retrospectively for statistical analysis.During the study period the mean incidence of endocarditis increased from 22.0 ± 4.2 (2005-2009) to 29.8 ± 10.1 (2010-2015) cases per year. In-hospital mortality was significantly increased in PVE (22.3%) versus IE (9.1%) patients (P.001). In elective cases in-hospital mortality between the 2 groups was comparable (2.2% vs 4.6%; P = .288). Multivariate analysis identified urgent surgery (odds ratio [OR], 6.461; 95% CI, 1.941-21.509; P = .002), mitral regurgitation II (OR, 4.230; 95% CI, 1.249-14.331; P = .021), previous homograft operation (OR, 66.096; 95% CI, 2.369-1844.272; P = .0.14), and left ventricular ejection fraction40% (OR, 8.267; 95% CI, 1.931-35.388; P = .004) as independent risk factors for in-hospital mortality, whereas pathogen identification by preoperative blood cultures (OR, .228; 95% CI, 0.063-0.817; P = .023) was found to be independently protective.Surgery for native IE and PVE of the aortic valve may be performed with satisfactorily results at experienced cardiac surgical centers. In comparison PVE patients suffer from a more than twice as high in-hospital mortality, more postoperative complications, and inferior long-term survival. However preoperative identification of causative pathogens in IE and PVE allows for improved in-hospital survival.

Endovascular repair of the ascending aorta and aortic arch has evolved at an astonishing pace in the past several decades. Results of endovascular arch repair in experienced centers have been improving and the technology evolving, and it has begun to challenge the current gold standard status of open surgery in some groups of patients. Hybrid strategies with adjunctive cervical debranching for distal arch lesions are being replaced by fenestrated arch repairs. Total endovascular repair for proximal aortic arch pathologies with the use of inner branches has achieved the best results; however, the main current limitations of endovascular arch repair are diameter-, length-, and angulation-related issues with the ascending aorta (proximal landing zone). Ascending aorta endovascular repair has allowed extending treatment further proximally in patients with post-surgical pseudoaneurysms of the ascending aorta or post-type A chronic aortic dissections. However, sufficient proximal landing zone is still needed in the proximal aorta for these repairs; in a significant number of patients, this is not feasible with simple proximal tubular grafts. Therefore, new technologies and techniques are being developed to deal with this limitation, including the endovascular Bentall concept, with incorporation of the aortic valve and coronary ostia. In this review, the current state and future directions of endovascular ascending and arch repairs and the motion towards an endovascular Bentall procedure are discussed.

OBJECTIVES The aim of this study was to determine the proportion of patients undergoing open arch repair who would be anatomically suitable for multi-branched endovascular arch repair. METHODS This study was a single-centre review of patients undergoing open arch repair between 2000 and 2020. Anatomical feasibility was determined by comparing arch measurements to the anatomical criteria of the Zenith® double and triple inner branched-arch endografts (Cook Medical) and the Relay® double arch branched device (Terumo-Aortic). RESULTS Ninety (90) patients were included in this study, with 43/90 presenting degenerative aneurysm. The distance between the sinotubular junction and the brachiocephalic trunk measured 114 ± 30 mm on the outer curvature, and the maximum diameter of the proximal landing zone (PLZ) was 41 ± 11mm. A total of 42/90 patients (47%) were anatomically suitable for at least 1 stent graft and 29/90 patients (32%) were eligible for a triple-branched endograft. The most important determinant factors of anatomical suitability were the PLZ diameter (Cramer’s V = 0.743, P CONCLUSIONS This study shows that the proportion of patients who may be anatomically suitable for branched-arch repair remains limited. The PLZ dimensions tend to be the most important anatomical limitations and should receive more emphasis in the development of branched-arch devices.

Malperfusion in acute aortic dissection is not uncommonly observed and associated with a highly significant increase in mortality and morbidity. Of the various malperfusion syndromes, visceral and renal involvement is the most challenging in terms of correct and timely diagnosis as well as the choice of management strategy. The aim of this study was to identify the pathology and associated fate of each visceral and renal vessel in acute type A dissections.Over a 12-year period, 167 consecutive patients with acute dissection type A extending into the thoracoabdominal aorta were included and radiographic images analyzed with a focus on individual branch vessel pathology and dependent organ perfusion.Sixty-five patients (39%) were diagnosed with radiological signs of malperfusion on the CT Images. Of those, 20% expired during the hospital stay, compared to 8% without malperfusion. The left renal artery was the most frequently affected by dissection (31%) or false lumen supply (28%). False lumen perfusion was more often associated with manifest malperfusion than an extension of the dissection flap into the branch vessel. During the study period, there was no preference of surgical procedure treating the malperfusion.Malperfusion of the visceral/renal branches of a dissected aorta represents a manifest indicator for postoperative mortality and morbidity. Neither clinical outcome, nor the fate of individual vessels can reliably be predicted prior to proximal reconstruction and thus, surgical strategy cannot generally be defined alone by radiological findings.

Purpose: To describe the transaxillary branch-to-branch-to-branch carotid catheterization technique (tranaxillary 3BRA-CCE IT) for cannulation of all supra-aortic vessels using only 1 femoral and 1 axillary access during triple-branch arch repair. Technique: After deployment of the triple-branch arch device, catheterization and bridging of the innominate artery (IA) should be performed through a right axillary access (cutdown or percutaneous). Then, the retrograde left subclavian (LSA) branch should be catheterized (if not preloaded) from a percutaneous femoral access, and a 12×90Fr sheath should be advanced to the outside of the endograft. Subsequently, catheterization of the left common carotid artery (LCCA) antegrade branch should be performed, followed by snaring of a wire in the ascending aorta which was inserted through the axillary access, creating a branch-to-branch-to-branch through-and-through guidewire. Over the axillary access, a 12×45Fr sheath should be inserted into the IA branch and looped in the ascending aorta using a push-and-pull technique so that it faces the LCCA branch, allowing for stable catheterization of the LCCA. The retrograde LSA branch should then be bridged following the standard fashion. Conclusions: This series of 5 patients demonstrates that triple-branch arch repair can be performed with the transaxillary 3BRA-CCE IT, allowing catheterization of the supra-aortic vessels without manipulation of the carotid arteries. Clinical Impact The transaxillary 3BRA-CCE IT allows catheterization and bridging of all supra-aortic vessels in triple-branch arch repair through only 2 vascular access points, the femoral artery and the right axillary artery. This technique avoids carotid surgical cutdown and manipulation during these procedures, reducing the risk of access site complications, including bleeding and reintervention, reintubation, cranial nerve lesions, increased operating time, and so on, and has the potential to change the current vascular access standard used during triple-branch arch repair.

Type Ia endoleaks due to failed sealing or loss of landing zone and the adequate management thereof remain crucial for long-term therapeutic success following TEVAR. This expert opinion summarizes our institutional experience with endovascular, open surgical, and hybrid techniques in the context of recent scientific publications. The rapid turnover of technical innovations, but most importantly outcome data demonstrate the requirement for increasingly patient-tailored treatment strategies and the need for specialized aortic centers. The latter should offer a complete range of treatment options, an adequate perioperative management, and the highest level of multidisciplinary expertise.

Сценарии политики Германии в области энергетики и климата предполагают, что к 2050 г. использование синтетических топлив будет значительно возрастать с ростом уровня устремлений по защите климата. В сценариях синтетические топлива используются также в применениях, в которых с точки зрения нынешних перспектив, будет возможна и электрификация в 2050 г. Действительно синтетические топлива используются также в областях, для которых имеются адекватные альтернативы топливу в виде возобновляемой энергии. Использован статический анализ на основе модели для создания кривых ранжирования для практического применения синтетических топлив с целью сравнения с традиционными ископаемыми топливами, а также с применениями электрификации. Это даст возможность провести начальную оценку реального экономически эффективного использования синтетических топлив. Анализ показывает, что с учетом нынешних тенденций цен на энергоресурсы для временного горизонта до 2050 г. синтетические топлива не будут экономически обоснованным вариантом, по сравнению с традиционными ископаемыми топливами. Однако сочетание синтетических топлив с высокоэффективными технологиями типа топливных элементов даст ценовые преимущества по сравнению с альтернативами в виде традиционных ископаемых топлив. Это можно наблюдать особенно в части транспортного сектора, в котором синтетические топлива могут оказать содействие экономически оптимальной стратегии снижения потребления ископаемых топлив. Однако при использовании синтетических топлив по сравнению с традиционной альтернативой появятся дополнительные затраты порядка 48 млрд. евро. Эти дополнительные затраты в 2 раза превышают субсидии, выделяемые в Германии в 2018 г. в соответствии Законом о возобновляемых источниках энергии. Если синтетические топлива и электрификацию сравнивать с точки зрения defossilization (снижения потребления ископаемых топлив)1, становится ясно, что имеются области, в которых синтетические топлива предпочтительнее для электрификации, с затратной точки зрения. В особенности в транспортном секторе имеются применения на основе синтетического топлива, которые можно экономически эффективно использовать для снижения потребления ископаемых топлив в энергетической системе. Кроме того, литературный обзор показал, что имеется 28% применений, когда технологии не апробированы, и может быть идентифицирован эффективный вариант электрификации для снижения потребления ископаемых топлив в энергетической системе. В транспортном секторе, в частности имеются применения на основе синтетического топлива, которые можно экономически эффективно использовать для снижения потребления ископаемых топлив в энергетической системе. Результатом применений с учетом количественно определенных затрат станут дополнительные затраты величиной 22 млрд. евро для использования синтетического топлива, по сравнению с электрификацией.

Was ist neu? Diagnostik Die CTA hat sich mit der kontinuierlichen Verbesserung der Qualität, Geschwindigkeit und Verfügbarkeit als optimales diagnostisches Verfahren für die thorakale Aorta etabliert. Daneben gewinnt die MRT zunehmend an Wichtigkeit, hauptsächlich wegen der exakten Darstellung von Wandveränderungen der Aorta und der Möglichkeit, durch innovative Protokolle dynamische Fluss-Phänomene abzubilden. Behandlungsstrategien Nachdem sich die TEVAR als Therapie der Wahl für die Versorgung von thorakalen Aortenpathologien durchgesetzt hat, fokussiert sich die Entwicklung dieser Technik nun auf den total endovaskulären Ansatz durch die Rekrutierung einer suffizienten proximalen Landezone im Aortenbogen, proximal der LSA mittels gebranchter oder fenestrierter Aortenbogen-Prothesen, die supraaortale Gefäße mit einbeziehen. Da neurologische Komplikationen wie der perioperative Schlaganfall oder die spinale Ischämie derzeit die größte Herausforderung bei endovaskulären Verfahren darstellen, ist intensive Forschung und stetige Optimierung der Techniken die Grundlage für eine sichere endovaskuläre Zukunft in der Versorgung thorakaler Aortenpathologien.

The “frozen elephant trunk” is a hybrid technique to treat aortic arch and proximal descending aortic pathologies in a single step. Despite its encouraging early and long-term results, some stent-graft-related adverse events have been reported. Here, we describe a possible treatment option to “re-freeze” the FET in case of loss of landing zone. We report a patient who developed significant kinking of the FET over the course of the first 2 postoperative years. The 1-year follow-up computed tomography angiography (CTA) showed significant kinking and proximal migration of the endograft portion of the FET, resulting in new thrombus formation. Due to kinking and thrombus progression in subsequent CTA follow-ups (2 years and 2½ years) with risk for peripheral embolization, a secondary endovascular repair was indicated. Transfemoral relining of the stent component with a thoracic aortic endovascular repair (Zenith®TX2®30142) stent-graft was performed. In the context of postoperative aneurysm sac shrinkage, the low radial force and lack of longitudinal stiffness of the hybrid graft may lead to proximal migration, thus secondary kinking, emphasizing the importance of an adequate degree of oversizing of the primary graft and an appropriate follow-up. Selection of a suitable graft for a particular pathology concerning the radial force and longitudinal stiffness is furthermore important.

The first-in-man implant of a custom-made branched frozen elephant trunk graft designed for an anastomosis in aortic arch zone 0 is reported. Combining endovascular technology with open surgical techniques has allowed for simplification of the open procedure with substantial reduction in circulatory arrest time and in the extent of the surgical preparations.

To synthesise and present all available evidence regarding the surgical treatment of patients with aberrant subclavian artery (aSA) pathologies during the last 30 years. The study also aimed to create a checklist of suggested reporting items to help increase reporting homogeneity.A systematic search of medical databases was performed to identify all studies published between 1990 and 2020 reporting on the outcomes of patients undergoing surgery for an aSA pathology. Patients were divided into two groups; Group A included patients undergoing open or hybrid surgery through sternotomy/thoracotomy and Group B included patients undergoing endovascular or hybrid treatment without chest access. The % crude rates (CR) of all variables of interest were calculated. A proportion meta-analysis was performed reporting pooled rates with 95% confidence intervals (CIs).Three hundred and fourteen studies were identified reporting on the surgical outcomes of 732 patients (60.1% males; 440/732). The quality of evidence was generally low, with 286 studies including fewer than four patients and 28 studies with five or more cases. Aberrant right subclavian artery (aRSA) in a left sided aortic arch was present in 71.4% of the patients and a Kommerell's diverticulum was present in 50.1% of the cases. A total of 68% of the patients were symptomatic on presentation, with the majority complaining of dysphagia (49.6%). Group A included 453 and Group B 279 patients. Studies reporting on five or more patients were included in the main meta-analysis. The pooled early mortality rate was 1.62% (95% CI 0.05% - 4.53%) in Group A and 1.96% (95% CI 0 - 6.34%) in Group B. Pooled rates of symptom relief were 99.52% (95% CI 92.05% - 100.00%) in Group A and 95.79% (95% CI 83.96% - 100.00%) in Group B.The surgical techniques used to treat aSA and aortic pathologies involving an aSA had remarkably low mortality rates and high clinical success, regardless of the technique used.

Background: The outcome of FBEVAR in post-dissection thoracoabdominal aortic aneurysms has not been well established in the literature. The aim of this study was to compare midterm outcomes following FBEVAR in post-dissection aneurysms to degenerative aneurysms. (2) Methods: This was a retrospective review of all patients undergoing FBEVAR in a single center between 2017 and 2020. The baseline characteristics, intraoperative details, and postoperative outcomes of patients with post-dissection aneurysms were compared to those with degenerative outcomes. The primary end point was unplanned reinterventions. Cox regression analysis was performed to identify the determinants of worse outcomes. Results: A total of 137 subjects with a mean age of 70 ± 10 years were included in the study, out of which 30 presented post-dissection aneurysms (22%). Custom-made devices were employed in 119 patients, off-the-shelf devices in 13 and physician-modified endografts in 5, with incorporation in 505 target vessels. The technical success rate was comparable in both groups (97% vs. 98%, p = 0.21). However, the one-year freedom from unplanned reintervention was lower in the post-dissection group (67% vs. 89%, p = 0.011). Conclusion: FBEVAR in post-dissection aneurysms is associated with a favorable technical success rate, but reintervention rates remain high. Long procedural duration and the use of adjunctive techniques are associated with increased risk of reinterventions.

Background: Endovascular repair of the thoracic aorta (TEVAR) is the preferred option for the treatment of the distal arch and descending thoracic aorta. Fenestrated and branched TEVAR have become an option to treat pathologies of the aortic arch, avoiding sternotomy and cardiopulmonary arrest as well as total surgical debranching. We describe here the case of a symptomatic patient with an arteria lusoria aneurysm associated with Kommerel diverticulum who underwent total endovascular repair with a triple-branched TEVAR. Case Report: A 66-year-old male patient was treated for a symptomatic arteria lusoria artery associated with a Kommerel diverticulum, resulting in difficulty swallowing and choking. We used a custom-made triple inner-branch endograft (Cook Medical, Bloomington, Indiana) following implantation of a right-sided carotid-subclavian (C-S) bypass. The C-S bypass occluded in the interval time between the 2 procedures and required recanalization and stent-graft placement during the aortic arch procedure. The arteria lusoria was embolized with a vascular plug. No complications occurred and postoperative tomography showed exclusion and thrombosis of the Kommerel diverticulum and perfusion of the supra-aortic vessels. Conclusions: Treatment of arteria lusoria aneurysms can be performed with total endovascular arch inner-branch repair, avoiding increased risk of morbidity and mortality caused by open or hybrid procedures.

Background The supraaortic vessel anastomosis stent bridging (SAVSTEB) technique simplifies the reattachment of the supraaortic vessels in aortic arch surgery; however, follow-up data are limited. The study aimed to investigate the stent-related performance and complications. Methods Between February 2009 and September 2020, 112 patients underwent total arch replacement with a tetrabranched graft and using the SAVSTEB technique. Mean age was 59.3±12.7 years, and male gender prevailed. Nineteen percent of these patients had acute aortic dissection extending into the supraaortic vessels, 12% had chronically dissected vessels, and 70% had unaffected vessels. The left subclavian artery, left common carotid artery, and innominate artery were bridged in 88%, 75%, and 2%, respectively, and an aberrant right subclavian artery was bridged in 2%. Results Total stent experience was 341 stent-years, and stent patency was found in 98%. Technical success was achieved in all but 1 case. One percent of patients had major stent thrombosis requiring reintervention. Minor stent thrombosis was found in 2%. No endoleak was found, and the number of new-onset dissections distal to the stent was 4%. Freedom from stent-related events was estimated at 89.1% ± 0.5% at 3 years. The stroke rate was 10%, with the highest incidence among nondissected vessels. The vertebral artery was overstented in 15%, and 2% of these cases were associated radiographically with stroke. Conclusions SAVSTEB is a comparatively simple, safe, and efficacious technique to create the anastomosis between tetrabranched arch grafts and the supraaortic arteries in the short and intermediate term. Bleeding from the anastomoses, kinking, and scar-associated stenosis are negligible; however, vertebral overstenting remains a critical technical issue.

The objective was to provide initial data from our prospective valve-sparing aortic root replacement (V-SARR) registry and reasons for conversion to prosthetic aortic valve replacement.Six centers established an intention-to-treat-design V-SARR-registry (the German Aortic Root Repair Registry; first patient in October 2016); the main inclusion criterion was being scheduled for V-SARR as plan A. Clinical information, operative details, intraoperative valve/root measurements, and clinical and transthoracic echocardiography follow-up-data are documented.Of a total of 449 patients, we report data for 401 (81% male; mean age 51 ± 14 years). Overall, 350 patients underwent V-SARR as scheduled, group A (David variants I 55%, III 2%, IV 13%, V 24%, V-Stanford 2%, and Yacoub remodeling 2%); and 51 were converted to aortic valve replacement (group B). Median follow-up was 11 months (range, 0 to 2.6 years), cumulative follow-up was 279 patient-years. In group B, there were fewer connective tissue disorders (6% vs 16%), fewer patients had left ventricular ejection fraction greater than 50% (60% vs 90%), more had bicuspid aortic valves (45% vs 28%), and fewer patients had preoperative none/trace aortic regurgitation (2% vs 20%). Fewer patients in group B had rare types of bicuspid aortic valve (fused N/L, R/N, 10% vs 30%) and more had unbalanced roots (56% vs 40%). Immediate postoperative aortic regurgitation was none/trace in 79% and mild in 20%. At 30 days, the mean transvalvular pressure gradient was 7 ± 5 mm Hg. None of the patients died in hospital; two strokes occurred. One patient needed early aortic valve replacement as redo surgery.The main factors causing surgeons to convert a planned V-SARR to aortic valve replacement include asymmetry of aortic valve/root, severity of aortic regurgitation, safety reasons (left ventricular ejection fraction), and bicuspid aortic valves (but not rare types). The German Aortic Root Repair Registry will help us identify the impact on long-term outcomes of preoperative and postoperative valvular anatomy and various V-SARR types.

This article applies the Well-to-Wheels (WTW) methodology in order to evaluate to which extent alternative fuels and powertrains can contribute to GHG emissions reductions within the heavy-duty segment of the European Union (EU). The analysis compares the WTW chain of diesel as the fossil benchmark to biodiesel, bio-methane, Power-to-Liquid (PtL) and Power-to-Gas (PtG) fuels, as well as catenary electric vehicles (CEVs) in heavy-duty tractor-trailers. The WTW analysis found that fuel and powertrain combinations from renewable energy sources offer a high potential for reducing GHG emissions as compared to diesel, however, the magnitude of the reductions significantly varies depending on feedstock and fuel type. Taking feedstock availability into account, the direct use of electricity in CEVs was identified as the most promising option for decarbonizing the heavy-duty long-haul sector, although the performance of CEVs depends on the extent to which the required energy comes from non-fossil resources.

Fur eine aus Gesamtsystemsicht kosteneffiziente Reduktion der CO2-Intensitat der Energieversorgung, muss eine sektorubergreifende Betrachtung und Priorisierung von Transformationsschritten erfolgen. Energietechnologien, in denen konventionelle oder erneuerbare Gase anstelle von Ol oder Kohle eingesetzt werden, stellen dabei potenzielle Masnahmen zur Reduktion von CO2-Emissionen dar. In dieser Studie wurden resultierende Mehr- bzw. Minderkosten durch die Neuinvestition in gasbasierte anstelle von kohle- und erdolbasierten Technologien ermittelt. Die Untersuchungen wurden sowohl fur aktuelle als auch fur das Jahr 2030 erwartete Kostenstrukturen der Energietrager und Technologien durchgefuhrt. Zudem wurde zwischen resultierenden Kosten aus Akteurs- und Systemsicht unterschieden. Die Ergebnisse verdeutlichen, dass speziell im Bereich der Hochtemperatur-Prozesswarme und des Individualverkehrs sehr hohe CO2-Verminderungskosten vorliegen. Der Bereich der Niedertemperaturbereitstellung weist hingegen geringe CO2-Verminderungskosten auf, teilweise ist hier sogar mit einer Kostenersparnis durch den Einsatz gasbasierter Technologien zu rechnen. Bis zum Jahr 2030 ergibt sich aufgrund sinkender Kosten fur erneuerbare Gase sektorubergreifend eine Reduktion der CO2-Verminderungskosten.

BACKGROUND Survival rates of out-of-hospital cardiac arrest remain poor. Bystander cardiopulmonary resuscitation (CPR) is crucial for survival and feedback devices could improve its quality. OBJECTIVE We investigated quality of chest compression when using the Cardio First AngelTM (CFA) feedback device compared to standard basic life support (BLS). The analysis focused on laymen. METHODS Laymen without (n= 43) and with (n= 96) explanation of the device, medical students (n= 128) and medical staff (n= 27) performed 60 seconds of standard versus assisted chest compression using the CFA on a resuscitation manikin. Compression frequency, depth and position were analyzed according to current guidelines. RESULTS Laymen showed significantly better success rates regarding correct compression depth when using the CFA (23.3% vs. 55.8%, p= 0.004 and 25.0% vs. 52.1%, p< 0.001, laymen without and with explanation of the device, respectively). Medical students likewise improved (22.7% vs. 42.2%, p= 0.004). Hand positioning was 100% correct in all groups with the device. Improvement in frequency yielded by the CFA was more pronounced for probands with fears of contact (p= 0.02). The benefit of using the device did not differ significantly in laymen with or without explanation. CONCLUSIONS Chest compression as performed by laymen was significantly improved with regard to compression depth when using the CFA for guidance and feedback. With the device, no cases of incorrect hand positioning occurred in any group.

Aortic regurgitation secondary to aortic aneurysmal disease with subsequent long-term volume overload of the left ventricle is associated with left ventricular dysfunction. In Marfan syndrome, ventricular dysfunction may exist independent of valvular disease (Marfan cardiomyopathy). We report of a 20-year-old Marfan syndrome patient presenting with severe aortic regurgitation and severe heart failure. Aortic surgery with concurrent biventricular paracorporeal assist device implantation was performed to bridge the patient to heart transplantation, which was performed successfully 21 weeks after aortic surgery. While the optimal strategy for this situation has not been described, the approach applied here appears a valid option.

Background: Vasoplegic syndrome is associated with increased morbidity and mortality in patients undergoing cardiac surgery. This retrospective, single-center study aimed to evaluate the effect of early use of methylene blue (MB) on hemodynamics after an intraoperative diagnosis of vasoplegic syndrome (VS). Methods: Over a 10-year period, all patients diagnosed with intraoperative VS (hypotension despite treatment with norepinephrine ≥0.3 μg/kg/min and vasopressin ≥1 IE/h) while undergoing heart surgery and cardiopulmonary bypass were identified, and their data were examined. The intervention group received MB (2 mg/kg intravenous) within 15 min after the diagnosis of vasoplegia, while the control group received standard therapy. The two groups were matched using propensity scores. Results: Of the 1022 patients identified with VS, 221 received MB intraoperatively, and among them, 60 patients received MB within 15 min after the diagnosis of VS. After early MB application, mean arterial pressure was significantly higher, and vasopressor support was significantly lower within the first hour (p = 0.015) after the diagnosis of vasoplegia, resulting in a lower cumulative amount of norepinephrine (p = 0.018) and vasopressin (p = 0.003). The intraoperative need of fresh frozen plasma in the intervention group was lower compared to the control group (p = 0.015). Additionally, the intervention group had higher creatinine values in the first three postoperative days (p = 0.036) without changes in dialysis incidence. The 90-day survival did not differ significantly (p = 0.270). Conclusion: Our results indicate the additive effects of MB use during VS compared to standard vasopressor therapy only. Early MB administration for VS may significantly improve the patients’ hemodynamics with minor side effects.

Der konventionell therapierefraktare Herz-Kreislauf-Stillstand verlauft in aller Regel letal. Die „Extracorporeal Life Support“(ECLS)-Therapie hat das Potenzial der sofortigen, vollen kardiopulmonalen Unterstutzung und wird zunehmend im Rahmen der kardiopulmonalen Reanimation (Extracorporeal Cardiopulmonary Resuscitation, ECPR) eingesetzt. Diese Arbeit soll Einblicke in die aktuelle Studienlage und eine Ubersicht uber das Verfahren der ECPR geben. Es erfolgt ein systematischer Uberblick uber die vorhandenen Daten und Empfehlungen zur ECPR-Therapie in Kombination mit einer fokussierten Darstellung von Schlusselelementen des Verfahrens. Die ECPR kann im Fall der frustranen konventionellen CPR zur Etablierung einer suffizienten Zirkulation dienen. Daten aus prospektiven, randomisierten kontrollierten Studien sind bisher nicht verfugbar. Es handelt sich um ein hochinvasives Verfahren, das entsprechende Expertise erfordert. Parameter zur Patienten-Triage konnen Alter und Vorerkrankungen, den beobachteten Herz-Kreislauf-Stillstand, die Ischamiezeit, Qualitat und Dauer der Reanimation, einschlieslich Einsatz einer mechanischen Kompressionshilfe, umfassen. Vor Implantation liefern pH-Wert und Lactatkonzentration wertvolle Zusatzinformationen uber den metabolischen Zustand des Patienten und die Perfusion wahrend der Reanimation. Das Verfahren der ECPR sollte auf Zentren der Maximalversorgung beschrankt sein, die uber das volle Spektrum der modernen interdisziplinaren Herzmedizin verfugen, einschlieslich Kunstherzimplantation und thorakaler Organtransplantation. Randomisierte kontrollierte Studien und umfassende entsprechende Leitlinien sind dringend erforderlich. Die Definition minimaler Fallzahlen und die Etablierung von Kompetenzzentren werden zu diskutieren sein.

Genome studies of heart valve tissue (HVT) in patients with structural valvular heart disease (sVHD) and acute infective endocarditis (aIE) showed polymicrobial infections. Subject of this study is the quantification of bacterial DNA in HVT of sVHD in comparison to aIE. It will be examined whether the bacterial DNA concentration can be used as surrogate marker to differentiate chronic and acute infections. DNA was isolated from HVT of 100 patients with sVHD and 23 microbiologically positively tested patients with aIE. Selected pathogens (Cutibacterium acnes, Enterococcus faecalis, Enterococcus faecium, Staphylococcus aureus, Streptococcus pyogenes, Streptococcus agalactiae, Clostridium difficile, and Klebsiella pneumoniae) were quantified using TaqMan-qPCR. Polymicrobial infiltration of HVT was investigated by immunohistologic methods. Of 100 sVHD patients, 94 tested positive for bacteria by 16S-rDNA and 72 by TaqMan-qPCR. In 29% of the sVHD cohort and in 70% of the aIE cohort, a coinfection with more than 2 bacteria was observed as indication of a polymicrobial infection. The most common pathogens in the sVHD patients were C. acnes (59%; 5–4074 pg/mL), E. faecalis (16%, 174–2781 pg/mL), and S. aureus (15%, 8–105 pg/mL). The DNA concentration of E. faecalis (P = 0.0285) and S. aureus (P = 0.0149) is significantly lower in the sVHD cohort than in the aIE cohort. sVHD is associated with bacterial infection and infiltration of the HVT in a majority of cases. TaqMan-qPCR is a valid instrument for the specific detection of bacteria in HVT and allows discrimination between sVHD and aIE for E. faecalis and S. aureus.

Home non-invasive ventilation improves morbidity and mortality patients with respiratory insufficiency due to neuromuscular disease. Evidence-based information on adequate ventilator settings for paediatric patients is missing. In a single-centre retrospective study, we analysed ventilator settings for 128 patients aged 0-17 years with home non-invasive ventilation on account of respiratory insufficiency due to neuromuscular disease. In four defined age groups (