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BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation.METHODS: EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing.FINDINGS: Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms.INTERPRETATION: Patient's age, timing of cannulation (FUNDING: None.

We investigated if the occurrence of preoperative right ventricular dysfunction is capable of influencing heart transplant results in terms of in-hospital mortality, incidence of primary graft dysfunction, and follow-up mortality.We retrospectively analyzed 517 patients who underwent heart transplant between January 2000 and December 2020. We defined right ventricular dysfunction (RVD), as central venous pressure (CVP)15 mm Hg and CVP/pulmonary capillary wedge pressure ratio0.63. We identified 2 subgroups in our population: 33 patients with preoperative RVD and 484 patients without RVD.In-hospital mortality was 7.9%. Severe early graft failure occurred in 6.6% of patients, with 26 patients (5.1%) needing intra-aortic balloon pump and 17 patients (3.3%) needing extracorporeal membrane oxygenation support. Clinical variables that significantly influenced in-hospital mortality were age, peripheral artery disease, and bilirubin1.5 mg/dL, while hemodynamic variables influencing in-hospital mortality were CVP (odds ratio [OR], 1.09 [confidence interval {CI}, 1.03-1.15], P = .004], pulmonary artery systolic pressure (OR, 1.02 [CI, 1.00-1.04], P = .05), CVP/pulmonary capillary wedge pressure ratio (OR, 2.78 [CI, 1.14-6.80], P = .025), pulmonary vascular resistance (OR, 1.15 [CI, 1.01-1.32], P = .042), transpulmonary gradient (TPG) (OR, 1.11 [CI, 1.03-1.18], P = .003) , diastolic transpulmonary gradient (OR, 1.10 [CI, 1.02-1.20], P = .015], together with right ventricular dysfunction (OR, 3.56 [CI, 1.44-8.80], P = .011). On the other hand, clinical variables influencing the incidence of early graft failure were body mass index (calculated as weight in kilograms divided by height in meters squared)30, peripheral artery disease, bilirubin1.5 mg/dL, Model for End-Stage Liver Disease score excluding international normalized ratio before transplant, and preoperative extracorporeal membrane oxygenation support, while hemodynamic variables were pulmonary arterial systolic pressure (OR, 1.03 [CI, 1.00-1.05], P = .016), TPG (OR, 1.08 [1.01-1.17], P = .03), and right ventricular dysfunction (OR, 3.00 [CI, 1.07-8.40] P = .046). On the multivariable analysis, RVD and TPG were independent predictors of in-hospital mortality, while only TPG was a predictor of early graft failure. Follow-up mortality was 38.7% and was influenced by recipient age, recipient body mass index, and preoperative diabetes. Moreover, 1-, 5-, and 10-year survival of patients with preoperative RVD was significantly worse than patients without RVD (log-rank = 0.001).In our population, RVD influenced both in-hospital and long-term results after heart transplant. For these reasons, it appears crucially important to optimize preoperative right ventricular function to improve these patients' outcomes.

Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for thoracic aorta diseases including penetrating aortic ulcer (PAU). The objective of this study was to analyze the results of TEVAR for the treatment of PAU in our population.From January 1999 to January 2019, 830 patients with type B aortic syndromes were treated with TEVAR in our institution. Of these we selected 73 patients treated for a PAU. Clinical and radiologic follow-up was performed in all patients.Mean age of our population was 72 ± 8 years. Fifteen patients (20.5%) were treated in an emergency setting. The proximal landing zone was in arch zone 2 in 22 patients (30.1%). In-hospital mortality was 6.8% and was associated with acute presentation (The use of TEVAR for treatment of aortic PAU is a safe procedure in an elective setting despite necessity of arch stent grafting. An early intervention performed at smaller aortic diameters of55 mm might be beneficial in selected patients to improve late survival.

Currently, guidelines for appropriate donor sizing in recipients mostly focuses on donor-recipient body weight matching. The purpose is to retrospectively determine the impact of predicted heart mass (pHM)-based size matching on heart transplant (HT) outcomes.According to our institutional registry, 512 consecutive adult patients underwent HT between January 2000 and August 2020. For each patient, pHM and donor-recipient pHM ratio were calculated. Patients were partitioned into quintiles in terms of pHM ratio: undersizing 2, undersizing 1, reference, oversizing 1, and oversizing 2, with mean pHM donor-recipient ratio of 0.81, 0.96, 1.04, 1.12, and 1.28, respectively. Severe early graft failure and 30-day, 90-day, 1-year, and 10-year mortality were analyzed as outcomes.Recipients of the most oversized group were mostly female (P.001), had higher preoperative pulmonary vascular resistance (P = .009), had higher rate of mechanical circulatory support (P.05), and showed a lower United Network for Organ Sharing score (P = .041); the respective donors were younger and more frequently male (P = .001). Ischemic time was similar in all groups (P = .358). Pulmonary vascular resistance (P = .023; odds ratio [OR], 2.38), preoperative mechanical circulatory support (P = .05; OR, 3.06), and United Network for Organ Sharing score (P = .033; OR, 1.76) were identified as risk factors for early mortality. Donor-recipient pHM ratio did not impact early graft failure (P = .871) and early mortality (P = .526). Survival analysis after adjustment for pHM ratio subgroups did not show any difference in outcomes.A wide range of pHM ratios seems to be safe. A careful allocation of organs, by considering a pHM ratio mismatch, may balance rescue preoperative clinical profiles and preserve HT outcomes.

Traumatic brain injury (TBI) and blunt thoracic aortic injury (BTAI) are the top two leading causes of death after blunt force trauma. Patients presenting with concomitant BTAI and TBI pose a specific challenge with respect to management strategy, because the optimal hemodynamic parameters are conflicting between the two pathologies. Early thoracic endovascular aortic repair (TEVAR) is often performed, even for minimal aortic injuries, to allow for the higher blood pressure parameters required for TBI management. However, the optimal timing of TEVAR for the treatment of BTAI in patients with concomitant TBI remains an active matter of controversy.The Aortic Trauma Foundation international prospective multicenter registry was used to identify all patients who had undergone TEVAR for BTAI in the setting of TBI from 2015 to 2020. The primary outcomes included delayed ischemic or hemorrhagic stroke, in-hospital mortality, and aortic-related mortality. The outcomes were examined among patients who had undergone TEVAR at emergent (6 vs ≥6 hours) or urgent (24 vs ≥24 hours) intervals.A total of 100 patients (median age, 43 years; 79% men; median injury severity score, 41) with BTAI (Society for Vascular Surgery BTAI grade 1, 3%; grade 2, 10%; grade 3, 78%; grade 4, 9%) and concomitant TBI who had undergone TEVAR were identified. Emergent repair was performed for 51 patients (51%). Comparing emergent repair (6 hours) to urgent repair (≥6 hours), no difference was found in delayed cerebral ischemic events (2.0% vs 4.1%; P = .614), in-hospital mortality (15.7% vs 22.4%; P = .389), or aortic-related mortality (2.0% vs 2.0%; P = .996) and no patient had experienced delayed hemorrhagic stroke. Likewise, repairs conducted in an urgent (24 hours) setting showed no differences compared with those completed in an emergent (≥24 hours) setting regarding delayed ischemic stroke (2.6% vs 4.3%; P = .548), in-hospital mortality (18.2% vs 21.7%; P = .764), or aortic-related mortality (1.3% vs 4.3%; P = .654), and no patient had experienced delayed hemorrhagic stroke.In contrast to prior retrospective efforts, results from the Aortic Trauma Foundation international prospective multicenter registry have demonstrated that neither emergent nor urgent TEVAR for patients with concomitant BTAI and TBI was associated with delayed stroke, in-hospital mortality, or aortic-related mortality. In these patients, the timing of TEVAR did not have an effect on the outcomes. Therefore, the decision to intervene should be guided by individual patient factors rather than surgical timing.

Aim of this retrospective, multicenter study was to evaluate early and mid-term clinical and hemodynamic results of patients who underwent surgical aortic valve replacement (SAVR) with Intuity rapid-deployment bioprostheses (RDB) (Edwards Lifesciences, Irvine, CA). We analyzed data from the Italian Registry of Intuity Valve (INTU-ITA registry) that is a national, real-world and independent from the industry registry. Preoperative variables were defined according to EuroSCORE and postoperative outcomes according to Valve Academic Research Consortium (VARC). Survival distribution was evaluated using the Kaplan-Meier approach. A Cox-Proportional Hazard Model was employed to assess the effect of the covariates on patients’ survival. The registry included 1687 patients from 23 centers (June 2012-September 2019). Aortic cross clamp time for isolated SAVR was 55 minutes (IQR: 45–70 minute). Postoperative pace-maker rate was 6.3%. At discharge transaortic peak and mean gradients were: 18 mm Hg (IQR: 14–23 mm Hg) and 10 mmHg (IQR: 8–13 mm Hg), respectively. Indexed effective orifice area was 1.10 cm2/m2 (IQR: 0.91–1.31 cm2/m2) and the incidence of severe patient-prosthesis mismatch was 0.6%. Hemodynamic data for all valve sizes remained stable during follow-up. Thirty-day overall mortality was 1.8% (30 patients), and at follow-up it was 5.3% (89 patients). Kaplan-Meier overall survival was 95.5% (94.3–96.7%); 90.7% (88.3–93.1%); 86.4% (82.6–90.4%) at 1, 3, and 5 years, respectively. Serum creatinine (HR: 1.36; 95%CI: 1.04–1.81; p = 0.0397) and cross-clamp time (HR: 1.01; 95%CI: 1.002–1.017; p = 0.0077) were identified as independent predictors of mortality. According to our data from the INTU-ITA registry, SAVR with RDB provides good early clinical and hemodynamic results that are confirmed at follow-up.

Postinfarction ventricular septal rupture (VSR) represents a well-known mechanical complication of myocardial infarction, determining cardiogenic shock with high mortality rates. Surgical correction requires significant expertise to avoid cardiac rupture, uncontrollable bleeding, residual shunts, heart failure, and death. In the last year, we observed a substantial increase of VSR at our hospital, related to the delayed presentation of people with acute chest pain to the emergency departments during the coronavirus disease 2019 pandemic. We discuss our innovative triple-layer patch technique in a recent consecutive series of 8 patients. This technique proved effective in all patients, with no residual shunt or cardiac rupture.

Aberrant right subclavian artery (ARSA) is a relatively rare congenital anomaly of the aortic arch. A 74-year-old woman was referred to our Cardiac Surgery Department for chest pain. Angio-CT scan showed an acute aortic dissection and revealed an ARSA routed behind the trachea. We performed supra-coronary ascending aorta and total arch replacement with Frozen Elephant Trunk (FET) technique. The ARSA was then termino-terminal anastomosed to one branch of the Thoraflex arch graft. Postoperative CT-scan indicated a successful reconstruction of the aortic arch, proving the open stent-grafting technique as a useful and effective approach for aortic disease with ARSA.

A 57-year-old man with severe aortic valve stenosis at high surgical risk underwent transcatheter valve replacement with a 29-mm Edwards Sapien-3 valve (Edwards Lifesciences). The valve was successfully implanted using the right femoral access, but at the end of the deployment the balloon ruptured (Videos 1 and 2) and could not be retrieved from the e-Sheath. The Commander delivery system was then readvanced in the aorta over the wire (Video 3), which was snared and externalized using a 25-mm AndraSnare (Andramed GmbH) inserted through the left femoral artery using a 25-cm-long 22-F Cook sheath (Cook Medical) (Figure 1). Then, the Commander was pushed over the wire, across the aortic bifurcation, making the ruptured balloon get into the Cook sheath (Figure 2). The Commander was then truncated (Figure 3), and the ruptured balloon proximal part attached to the pusher/balloon catheter unit was retrieved through the eSheath (Figure 4). Then, the ruptured balloon distal part attached to the inner balloon shaft was pushed forward such that it could be externalized through the left femoral sheath, cut (Figure 5), and finally pulled back with the wire through the eSheath (Figure 6).

Background The aims of this study were to analyse the incidence of visceral malperfusion syndrome (MPS) following Frozen Elephant trunk operations in patients affected by chronic aortic dissection and the associated risk factors. Methods Between January 2007 and February 2019, 165 patients underwent surgery with FET for chronic aortic dissection. Post-operative computer tomography angiogram parameters (diameters, early post-operative false lumen enhancement and involving of aortic branches by the dissection) were collected and analysed to evaluate their impact on the occurrence of visceral malperfusion. Results Visceral (renal and mesenteric) MPS (with both clinical and radiological signs of MPS) was detected in 10 cases (6.1%). Post-operative visceral malperfusion was strongly related with in hospital mortality. The involvement of the visceral branches in the dissection was not a risk factor for visceral malperfusion occurrence, while a larger post-operative total aortic diameter at level of the coeliac trunk increased the risk of visceral MPS (OR 1.05; CI 1.002–1.102, p-value = 0.04). Furthermore, visceral MPS was associated to a complete thrombosis of the false lumen at level of the distal descending thoracic aorta. Conclusions The development of post-operative MPS in frozen elephant trunk is strongly related to in-hospital mortality. The involvement of aortic branches by the dissection does not represent a real predictive risk factor for MPS, while early larger aortic diameters and false lumen thrombosis represent independent risk factors for MPS and in-hospital mortality.

Objectives: The authors evaluated the outcome of adult patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) requiring the use of extracorporeal membrane oxygenation (ECMO). Design: Multicenter retrospective, observational study. Setting: Ten tertiary referral university and community hospitals. Participants: Patients with confirmed severe COVID-19-related ARDS. Interventions: Venovenous or venoarterial ECMO. Measurements and Main Results: One hundred thirty-two patients (mean age 51.1 +/- 9.7 years, female 17.4%) were treated with ECMO for confirmed severe COVID-19-related ARDS. Before ECMO, the mean Sequential Organ Failure Assessment score was 10.1 +/- 4.4, mean pH was 7.23 +/- 0.09, and mean PaO2/fraction of inspired oxygen ratio was 77 +/- 50 mmHg. Venovenous ECMO was adopted in 122 patients (92.4%) and venoarterial ECMO in ten patients (7.6%) (mean duration, 14.6 +/- 11.0 days). Sixty-three (47.7%) patients died on ECMO and 70 (53.0%) during the index hospitalization. Six-month all-cause mortality was 53.0%. Advanced age (per year, hazard ratio [HR] 1.026, 95% CI 1.000-1-052) and low arterial pH (per unit, HR 0.006, 95% CI 0.000-0.083) before ECMO were the only baseline variables associated with increased risk of six-month mortality. Conclusions: The present findings suggested that about half of adult patients with severe COVID-19 -related ARDS can be managed successfully with ECMO with sustained results at six months. Decreased arterial pH before ECMO was associated significantly with early mortality. Therefore, the authors hypothesized that initiation of ECMO therapy before severe metabolic derangements subset may improve survival rates significantly in these patients. These results should be viewed in the light of a strict patient selection policy and may not be replicated in patients with advanced age or multiple comorbidities. (C) 2021 The Authors. Published by Elsevier Inc.

Approximately one-quarter of patients with acute type A aortic dissection (TAAD) present with concomitant malperfusion of coronary arteries, mesenteric circulation, lower extremities, kidneys, brain, and/or coma. It is generally accepted that TAAD patients who present with malperfusion experience higher mortality rates than patients without, although how specific malperfusion syndromes, alone or in combination, affect mortality is not well described.The International Registry of Acute Aortic Dissection database was queried for patients who underwent surgical repair of TAAD. Patients were stratified according to the presence/absence of malperfusion at presentation. Multivariable logistic regression was used to evaluate in-hospital mortality according to malperfusion type. Kaplan-Meier estimates were used to estimate 30-day postoperative survival.Six thousand four hundred thirty-seven patients underwent surgical repair of acute TAAD, of whom 2642 (41%) had 1 or more preoperative malperfusion syndromes. Mesenteric malperfusion (adjusted odds ratio [AOR], 4.84; P .001) was associated with the highest odds of in-hospital mortality, followed by coma (AOR, 1.88; P = .007), limb ischemia (AOR, 1.73; P = .008), and coronary malperfusion (AOR, 1.51; P = .02). Renal malperfusion (AOR, 1.37; P = .24) and neurologic deficit (AOR, 1.35; P = .28) were not associated with increased in-hospital mortality. In patients who survived to discharge, there was no difference in 1-year postdischarge survival in the malperfusion and no malperfusion cohorts (P = .36).Survival during the index admission after TAAD repair varies according to the presence and type of malperfusion syndromes, with mesenteric malperfusion being associated with the highest odds of in-hospital death. Not only the presence of malperfusion but rather specific malperfusion syndromes should be considered when assessing a patient's risk of undergoing TAAD repair.

Background The aim of the present study was to evaluate early results of thoracic endovascular aortic repair (TEVAR) using the Valiant Navion™ stent graft in a “real-world” scenario. Methods All patients who underwent TEVAR with the Valiant Navion™ endograft between November 2018 and November 2019 were included in this retrospective multicenter study (six European centers). The primary endpoints were technical success, incidence of major adverse events (MAEs), access failure, deployment failure, deployment accuracy, and rate of intraoperative endoleaks (ELs). Results One hundred-sixteen patients with varying thoracic aortic diseases were included. Eighteen patients (15.5%) were treated for an off-label condition. The technical success rate was 100%, without any access or deployment failures. The proximal and distal deployment accuracy rates were 99.1% and 97.4%, respectively. There were no intraoperative MAEs, including death. Two (1.7%) type Ib ELs were detected at the first postoperative CTA, all of which were in off-label procedures and related to the short length of the sealing neck. No type III ELs were detected. The median hospitalization time was 8 days (IQR 4–12), including a median intensive care unit stay of 1 day (IQR 1–2). The in-hospital mortality rate was 4.3%. At a median follow-up time of 98 days (IQR 39–187), there were no aortic-related mortalities or new onset of endoleaks. Conclusion Our initial experience with the Valiant Navion™ endograft in a wide variety of aortic diseases showed safe early outcomes, especially for on-label procedures.

The study objective was to analyze the outcomes of reoperative thoracic aortic surgery at our institution from January 1986 to December 2018 to identify specific risk factors for early and late mortality.Two groups of patients were identified: aortic root or ascending aorta repair (group 1: proximal repair, 218 patients, 48%) and arch surgery or descending thoracic aorta repair (group 2: distal repair, 235 patients, 52%). Primary end points were 30-day mortality, 10-year survival, and freedom from aortic reoperations.The 30-day mortality (6.4% vs 8.1%) and in-hospital mortality (8.3% vs 11.9%) were similar (P .05) in the 2 groups. Multivariable analysis identified female gender (odds ratio, 8.60, P .01), endocarditis (odds ratio, 2.96, P = .04), and cardiopulmonary bypass time (odds ratio, 1.02, P .01) as risk factors for 30-day mortality. Mean follow-up time was 163 months (confidence interval, 147-179). Long-term survival at 1, 5, and 10 years was 91.2%, 79.4%, and 66.3% in the proximal repair group and 80.7%, 68.8%, the and 55.3% in distal repair group, respectively (P = .03). According to the indication, 1-, 5-, and 10-year survivals were 92.1%, 82.3%, and 68.8% in degenerative aneurysms; 82.7%, 72.4%, and 56.3% in residual dissections; 80.9%, 65.4%, and 50.3% in endocarditis and pseudoaneurysms; 69.2%, 52.7%, and 42.2% in acute type A aortic dissections, respectively (P .01). Competing risk analysis showed a significantly different cumulative incidence of reoperation at 1, 5, and 10 years between the 2 groups: 0.50%, 0.50%, and 0.90%, respectively, for the proximal repair group, and 0.40%, 4.30%, and 7.70%, respectively, the for distal repair group (P .01).In our experience, short- and long-term results of reoperative thoracic aortic surgery were satisfactory in chronic aneurysms but poor in aortic dissections, pseudoaneurysms, and active endocarditis. Reoperative aortic surgery carries a high risk, regardless of the anatomic extension of the procedure.

N.D.

Background: To assess early and late mortality in patients with isolated acute tricuspid valve infective endocarditis (TVIE) using data from a multicenter registry.Methods: From 1983 to 2018, isolated acute TVIE was surgically treated in 157 (3.8%) patients [mean age 47 +/- 16 years (range 15-86 years), 25% females]. Of these, 142 (90%) had native tricuspid regurgitation, 7 (5%) native tricuspid valve (TV) steno-regurgitation, and 8 (5%) prosthetic TVIE. Intravenous drug use (IVDU) was recorded in 38% of patients, infection involved cardiac implantable electronic device leads in 21%, and vascular catheters for dialysis in 1%; in the remaining cases, the cause was unknown. The primary endpoint was in-hospital outcome, long-term freedom from recurrence and overall survival.Results: Overall, 77 (49%) patients underwent TV repair, 72 (46%) TV replacement, and 8 (5%) prosthetic TV replacement. Early mortality was 11% (n = 17). Expected early mortality according to EndoSCORE was 12%, with age (odds ratio 1.06) and redo (odds ratio 6.64) as risk factors. Late deaths occurred in 31 patients and TVIE recurrences in 4. Survival rates at 10, 20, and 25 years were 66%, 60%, and 44%, respectively. Risk factors were age [hazard ratio (HR) 1.06], mycotic TVIE (HR 4.2), IVDU (HR 4.90), infected prosthesis replacement (HR 4.4), and presence of cardiac implantable electronic device leads (HR 3.0). No significant difference was found in valve repair vs. replacement and in IVDUs vs. non-IVDUs.Conclusions: Patients with isolated acute TVIE undergoing surgical treatment show acceptable early and late outcomes. TVIE recurrence was low, and repair of the affected valve does not seem to confer any advantage either at early or long term up to 25 years. (C) 2019 Elsevier B.V. All rights reserved.

The decision-making process is crucial for the surgery of acute type A aortic dissection (AAAD). Often surgeons have to face different challenges, taking prompt decisions in emergency setting, during the pre- and intraoperative phase. Choosing if operate or not a patients with AAAD as well as the management of the dissected aortic arch can be challenging. Different factors need to be evaluated as: the patients age, the presence of organ malperfusion, the intimal tear location, and last but not least the surgeon personal experience in aortic surgery. During the last decade, different milestone steps have been achieved in aortic surgery as the antegrade perfusion of the aorta through different cannulation sites, open distal repair, antegrade selective cerebral perfusion, and systematic resection of the proximal intimal tear, allowing complex repair for dedicated team as well as simpler repair for not dedicated surgeons. We reviewed different scenarios and techniques used for the aortic arch replacement in patients with AAAD, taking into consideration that the aim of surgery is to save patients life.

N.A.

Objectives The aim of this study was to assess the clinical course and outcomes of all heart transplant recipients affected by coronavirus disease-2019 (COVID-19) who were followed at the leading heart transplant centers of Northern Italy. Background The worldwide severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic has created unprecedented challenges for public health, demanding exceptional efforts for the successful management and treatment of affected patients. Heart transplant patients represent a unique cohort of chronically immunosuppressed subjects in which SARS-CoV-2 may stimulate an unpredictable clinical course of infection. Methods Since February 2020, we enrolled all 47 cases (79% male) in a first cohort of patients, with a mean age of 61.8 ± 14.5 years, who tested positive for SARS-CoV-2, out of 2,676 heart transplant recipients alive before the onset of the COVID-19 pandemic at 7 heart transplant centers in Northern Italy. Results To date, 38 patients required hospitalization while 9 remained self-home quarantined and 14 died. Compared to the general population, prevalence (18 vs. 7 cases per 1,000) and related case fatality rate (29.7% vs. 15.4%) in heart transplant recipients were doubled. Univariable analysis showed older age (p = 0.002), diabetes mellitus (p = 0.040), extracardiac arteriopathy (p = 0.040), previous PCI (p = 0.040), CAV score (p = 0.039), lower GFR (p = 0.004), and higher NYHA functional classes (p = 0.023) were all significantly associated with in-hospital mortality. During the follow-up two patients died and a third patient has prolonged viral-shedding alternating positive and negative swabs. Since July 1st, 2020, we had 6 new patients who tested positive for SARS-CoV-2, 5 patients asymptomatic were self-quarantined, while 1 is still hospitalized for pneumonia. A standard therapy was maintained for all, except for the hospitalized patient. Conclusions The prevalence and mortality of SARS-CoV-2 should spur clinicians to immediately refer heart transplant recipients suspected as having SARS-CoV2 infection to centers specializing in the care of this vulnerable population.

OBJECTIVE: The dissemination of mitral valve repair as the first line treatment and the introduction of MitraClip for patients who have a prohibitive risk for surgery has changed the landscape of mitral valve intervention. The aim of this study is to provide current and generalizable data regarding the trend of mitral valve interventions and outcomes from 2000-2016. METHODS: Patients ≥18 years of age who underwent mitral valve interventions were identified using the National Inpatient Sample database. National estimates were generated by means of discharge weights; comorbid conditions were identified using Elixhauser methods. All trends were analyzed with JoinPoint software. RESULTS: A total of 656,030 mitral valve interventions (298,102 mitral valve replacement, 349,053 mitral valve repair, and 8,875 MitraClip) were assessed. No changes in rate of procedures (per 100,000 people in the US) were observed over this period (annual percent change=−0.4, 95% CL −1.1 to 0.3, P=0.3). From 2000-2010, the number of replacements decreased by 5.6% per year (P

Background: Nowadays, less invasive endovascular procedures have been employed in high risk patients for thoracoabdominal aortic aneurysm (TAAA) in order to try to reduce the risk of major complications. The aim of the study was to analyze the results of our hybrid 2-stage approach for TAAA repair. Methods: Between July 2011 and September 2016, 17 consecutive high-risk patients received a hybrid 2-stage procedure for TAAA repair. Mean age of the population was 58.9 ± 9.0 years and 16 (94.1%) were male. Of them, 7 (41.2%) suffered of chronic obstructive pulmonary disease and 15 (88.2%) had a previous history of aortic operation. Three patients had Marfan syndrome (17.6%). The preoperative anatomy of the aneurysms was classified according to “Crawford classification” in type II (n = 6, 35.3%), type III (n = 10, 58.8%) and type IV (n = 1, 5.9%). All patients were followed up with an angio CT-scan at 1, 3 months and yearly thereafter. Results: In-hospital mortality was 11.8% (2 patient). None of the patients experienced paraplegia and paraparesis. Major post-operative complications were pancreatitis 17.6% (3/17). At follow-up (mean time of 23.3 ± 21.7 months) 2 patient died (12.5%) waiting for the second stage endovascular completion. Median interval time between the 2 steps was 35 days. Overall survival at 1- and 3-years was 75.6 ± 1.0. One type Ib and 1 type III endoleak were noted and successfully treated with an additional stent graft. Conclusions: The results of hybrid 2-stage TAAA repair on high-risk patients are satisfactory and therefore encouraging. The extremely low incidence of spinal cord injury could make this technique the technique of choice for this type of pathology in selected high-risk patients. At follow-up, residual endoleaks occur although surgical reoperations are not often needed. © 2018 Elsevier B.V.

Purpose The Multicenter Italian study on RAdial Mechanically Assisted Circulatory Support (MIRAMACS) represent the first national observational registry, gathering continuous-flow (CF) left ventricular (LVAD) and biventricular assist device (BiVAD) implantation performed in adult patients by high-volume, mechanical circulatory support (MCS) dedicated, Italian centres. Methods Seven participating hospitals contributed pre-, peri- and long-term postoperative data on LVAD implants to the registry. Data for all implants in adult patients (>18 years of age) performed between January 2000 to September 2020 were analysed. BiVADs were excluded in this preliminary analysis. This initial report focuses on patient demographics, survival, device types, adverse events and competing outcomes. Results A total of 515 patients received a CF LVAD. The mean age of LVAD recipients was 60±10 years. The majority of patients were male (89.3%). The adopted systems were: HeartWare HVAD (n=213), HeartMate III (n=140), HeartMate II (n=89), Jarvik 2000 (n=50), Berlin Heart Incor (n=19) and other brands (n=4). In 6.6% of patients the LVAD implantation was performed by usage of less invasive surgical approaches. Mortality at 30- and 90-days was 6.1% and 11.1%, respectively. A temporary right ventricular assist device (RVAD) support was necessary in 3.1% of patients. Mean follow-up time was 57±15 months. Heart transplantation was performed in 99 patients (19.2%). Survival at 1-year, 3-years, and 5-years of BTT cohort was 82.1%, 60.4% and 41.8%, respectively. Survival at 1-year, 3-years, and 5-years of DT cohort was 69.8%, 45.6% and 30.1%, respectively. Major bleeding, major infection, neurological events and device malfunction were reported in 40 (7.7%), 143 (27.7%), 97 (18.8%) and 36 (6.9%) patients, respectively. Conclusion This first MIRAMACS report reveals frequencies and results comparable with other registries. Overall success rate of CF LVAD patients seems to be satisfactory. Detailed prospective data collection, additional participating centres and further analyses may provide additional robust scientific contributions.

Purpose Chronic thromboembolic pulmonary hypertension (CTEPH) is the only type of pulmonary hypertension (PH) with a surgical resolution which is the Pulmonary Thrombo-Endarterectomy (PTE) operation. Fibrotic thrombus extraction allows pulmonary vascular resistances (PVR) reduction until normalisation in most of cases. However, this sentence might be controversial since results are conditioned by the center experience on patients's selection, operation's timing, skills and management of such complex pathology. Seventeen years performing PTE and our multidisciplinary approach allowed us to obtain very good results. In here we report our data progress and results of PTE for CTEPH. Methods A total of 177 patients underwent PTE from 2003 until 2020. From 2003 to 2012 (Group 1) 96 patients were operated avoiding Deep Hypothermic Circulatory Arrest (DHCA) being applied only when blood bronchial flow ruled out a complete endarterectomy. Group 2, included 81 patients operated rom 2012 until the present, when DHCA was routinely adopted. Furthermore, the event of the Balloon Pulmonary Angioplasty (BPA) in 2015, conceded us a therapeutic alternative in high risk or unsuitable PTE patients. The impact of these and other variables in patients population profile and results of both groups have been retrospectively compare and analysed. Results Most relevant preoperative differences were related to worst clinical status and associated pathologies in Group 1 and wider use of specific pulmonary vasodilator in Group 2. Cross clamp time as well as time of cardiopulmonary bypass were significantly shorter in Group 2 in spite of a mean DHCA time of 33 minutes. In-hospital mortality and need of postoperative ECMO was respectively 15.6% vs 3.7% and 15.6% vs 8.6% in group 1 and 2 (p 0.001). Pulmonary hemodynamic as well as long term outcome equally and significantly improved in both groups. Conclusion Our reported results demonstrate that, DHCA is the best approach to perform PTE for CTEPH. Certainly experience, protocols and a multidisciplinary approach contribute to obtain the best hemodynamics, surgical and clinical outcomes.

Purpose To investigate the predictive value of Acute Physiology, Age and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology (SAPS) II and Sequential Organ Failure Assessment (SOFA) scores for patient selection and timing to Extracorporeal Life Support (ECLS) as treatment of refractory cardiogenic shock. Methods Retrospective analysis of a prospectively-maintained operative dataset. Results Our study population included 185 patients receiving ECLS at our department between 2006 and 2018. Patient median age was 50.6 years; 62% were male. The most frequent reason for ECLS need, in our subset of patients, was post-cardiotomy syndrome (52.4%) followed by acute decompensation of chronic heart failure (17.5%), isolated right ventricular dysfunction (16.2%), acute myocardial infarction (10.2%) and myocarditis (3.7%). Median duration of ECLS was 8.9 days. Forty-one patients (22.2%) received heart transplantation. In-hospital mortality was 34.6% on ECLS running and 25.9% after ECLS removal. Multivariate regression analysis showed patient age, ECLS duration and bridge to transplantation (BTT) category as indipendent predictors of death (p Conclusion This study confirms the poor prognosis of critically ill patients receiving ECLS support. The APACHE II and SOFA scores, mainly, proved to be a reproducible evaluation tool with high prognostic abilities. In our population, age >65 years, ECLS duration >10 days and BTT ECLS intention appear to impact negatively.

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Comment on Da Li, Liqing Peng, Yi Wang, Jichun Zhao, Ding Yuan, Tinghui Zheng Predictor of false lumen thrombosis after thoracic endovascular aortic repair for type B dissection The Journal of Thoracic and Cardiovascular Surgery, Available online 25 August 2019

Purpose Heart transplantation (Htx) remains the gold standard as treatment of patients with advanced heart failure. Donor and recipient characteristics have changed dramatically in recent years, leading to more complex decision-making regarding organ acceptance and postoperative management. Primary aim of the study was to identify donor risk factors variables impacting on in-hospital mortality, early graft failure and follow-up mortality; secondary objective was to validate the available international donor risk scores. Methods Between January 2000 and December 2017, 461 adult patients underwent Htx. UNOS, RADIAL and Eurotransplant scores have been calculated. Clinical features and donor risk scores have been tested in order to identify pre-, intra- and post-operative risk variables and eventually validate the scores on our population. Results Post-Htx extracorporeal life support (ECLS) was used in 11.1% (51/461). Of the donor related factors, peak of troponine (p 240 minutes (p=0.037) influenced EGF occurrence. The Eurotransplant donor score didn't impact on outcomes, the RADIAL significantly influenced both on early (p=0.02) and late mortality (p=0.004) while the UNOS on late mortality only (p=0.03). On the multivariate model, after adjustment per cohort of scores, noradrenaline infusion resulted to be an independent predictor of in-hospital mortality in the Eurotransplant score >17 population, recipient pre-Htx ECLS and BMI >30 were independent predictors of EGF in the UNOS score >6 population, and recipient age >60 was predictor of late mortality in the RADIAL score >5 (figure 1). Conclusion Actual heart donor scoring systems do not fully behave as reliable predictors of transplant outcomes. Therefore, every transplant institution should consider developing a local donor scoring systemto provide their own standard graft selection thus preserving the outcomes.

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Purpose As Italy faced SARS-CoV-2 outbreak as first country outside China, and our hospital converted most of activities into the ones for COVID-19 patients (pts), we had to manage the need for continuing care of advanced heart failure (HF), heart transplant (HT) and LVAD pts. TM was a possible strategy, but its role in this very sick cohort is unknown. Methods During the lockdown (03-05/2020), we decided to make either a phone (PV) or an in presence (IV) visit, selecting for IV pts listed for HT, with LVAD, recently HT, scheduled for a biopsy within 6 months after HT or a RHC for listing eligibility. In PV, we assessed symptoms, blood pressure, drugs, and programmed a subsequent IV. All pts in IV group were triaged by phone for COVID-19 symptoms or contacts and if scheduled for RHC or biopsy received SARS-CoV-2 swab 48 h before the procedure. Study endpoints were: combined incidence at 6 months of MACE (HF hospitalization, CV death and need for anticipated IV) in HF/VAD group, and MACE, rejection and any cause- hospitalization in HT group. Results Among 448 pts (57±12y, 240 HT, 191 HF, 17 LVAD), 52% were managed by PV and a subsequent IV was scheduled after 3±2 months. Pts managed by PV were healthier: in HF-VAD group they were less frequently listed, had less Afib, LVAD (2/17) (p

Purpose Currently, guide for appropriate donor sizing in recipients mostly focuses on donor-recipient body weight matching. The purpose is to retrospectively determine the impact of predicted heart mass (pHM)-based size matching among recipients on heart transplantation (HT) outcomes. Methods According to our institutional registry, 512 consecutive adult patients underwent HT between January 2000 and August 2020. For each patient, pHM and donor-recipient pHM ratio have been calculated (4 patients were excluded for missing anthropometric data). Patients were partitioned into quintiles in terms of pHM ratio: Undersizing2 (n=101), Undersizing1 (n=102), Reference (n=102), Oversizing1 (n=102), Oversizing2 (n=101) with a mean pHM donor-recipient ratio of 0.81, 0.96, 1.04, 1.12, 1.28, respectively. Severe early graft failure, 30-day, 90-day and 1-year mortality were analyzed as early outcomes. Results Several characteristics were significantly different between groups. Recipients of the most oversized group were mostly male (p 0.05). Kaplan-Mayer and Cox-regression analysis after adjustment for pHM ratio subgroups did not show any difference in outcomes (p>0.05). Conclusion A wide range of pHM donor-recipient ratios seem to be safe (0.81-1.28). Providing a pHM-based oversized graft to more compromised patients may preserve good outcomes. Instead, low risk profile patients may have acceptable outcomes even in the presence of extremely undersized pHM ratio calculation. A careful allocation of organs, by considering a pHM ratio mismatch, may balance rescue preoperative clinical profiles and preserve HT outcomes.

Purpose Advanced Heart Failure (A-HF) is a clinical condition which interferes with patient identity and perception. Psychological reactions depend on the nature and severity of patient disease, personality and environmental factors. Our goal was to evaluate quality of life of outpatients with left ventricular assist device (LVAD), heart transplantation (HT) and optimal medical treatment (OMT) for heart failure (HF). We additionally analyzed two cohorts of patients resulting different in terms of objective disease severity, to assess eventual perceived quality of life differences. Methods We included all consecutive adult patients presenting at our outpatient clinic for routine follow-up between January and September 2019. Including criteria were: being subjected to right heart catheterization (RHC), presence of LVAD for at least 2 months, HT for at least 2 months. Clinical severity of HF has been stratified using RHC and 6-minute walk test. Psychological parameters were measured by Kellner Symptom Questionnaire, Brief-Illness Perception Questionnaire, and WHO Quality of Life -BREF. Results Overall population consisted of 179 patients (HT=90, LVAD=15, and OMT-HF =74). OMT-HF patients were stratified into advanced and non-advanced (A-HF/NA-HF). A-HF patients walked significant less meters (p 3 (p=0.89), walked meters (p=0.32), CI (p=0.82). In psychological well-being comparison between OMT, LVAD and HT, patients who underwent advanced surgical therapy showed better results in terms of anxiety (p=0.014), depression (p=0.003), anger (p=0.04) and illness perception (p Conclusion Patients undergoing a major surgical procedure, such as LVAD implantation or Heart Transplantation, showed overall better psychological parameters than patients with chronic heart failure treated with medical therapy.

Purpose Orthotopic heart transplantation (OHT) remains the gold standard for end-stage heart failure. The number of patients who have had at least one prior sternotomy while awaiting transplantation is increasing. Redo sternotomy before OHT may increase operative complexity thus affecting the outcomes. Methods We retrospectively analyzed patients who underwent OHT at our institution, during a 17-year period. All patients who underwent prior sternotomy were compared with those undergoing OHT with a virgin chest. Patients who underwent left ventricular assist device (LVAD) support as bridge to transplantation were excluded, in the study. Preoperative, intraoperative, and postoperative variables were analyzed. Short- and long-term outcomes/survival were studied. Primary and secondary graft failure after OHT were weighted. To account for bias in selection of patients a propensity score (PS) model was constructed and adopted. Kaplan-Meier survival estimates of overall and adverse events-free survival were compared using a paired analysis. Results A total of 461 adult patients underwent OHT, between 2000 and 2017. Unmatched population: No prior sternotomy OHT patients (n=343) vs. prior sternotomy OHT patients (n=118). PS matched population: No prior sternotomy OHT patients (n=118) vs. prior sternotomy OHT patients (n=118). Overall 30-day mortality was slightly lower in the prior sternotomy OHT group, but not significantly (13.3% vs 7.7%, p=0.14). The two groups showed similar perioperative outcomes. Long-term survival (5-year and 10-year) was similar in the two groups (80.9% vs. 75.7% and 72.5 vs. 67.4 %; log-rank, p=0.41). The subgroups analysis revealed prior valvular surgery associated with a coronary artery bypass grafting (CABG) procedure as risk factor for 30-day mortality (OR 6.2; p=0.01). Conclusion Redo sternotomy before OHT may increase operative complexity but not affecting the outcomes in terms of survival or allograft function.Type of prior surgical procedure should be properly weighted to preserve the outcomes at the time of OHT.

Background Aortic dissection is a major cardiovascular disease associated with a high mortality rate. In complicated type B dissection, with favorable anatomy, endovascular surgical repair (thoracic endovascular aortic repair [TEVAR]) is considered the treatment of choice. Intimomedial injury induced by stent graft, or stent graft-induced new entry (SINE), has a clinically significant incidence. SINE can occur at the proximal or distal level of the stent graft. The aim of this retrospective study was to investigate the incidence, mechanism, and predictive factors of late distal SINE. Methods We reviewed 139 discharged patients after TEVAR for type B or residual aortic dissection after type A surgery, from January 2007 to March 2013. Three intervals of computed tomography imaging were collected, including before and after primary TEVAR and with the first detection of distal SINE. Four accessible measurement methods for precise size selection of the stent graft before and after the procedure were analyzed at the distal end level of the primary stent graft. Results Among the 139 patients, only 108 had complete preoperative and follow-up imaging and were enrolled in the study. The mean age of the patients was 59.7 ± 11.7 years, and 92 patients (85.2%) were men. Seventy had type B aortic dissection, and 38 had residual aortic dissection after type A surgery. The mean follow-up period was 36.1 ± 25.7 months. During follow-up, distal SINE occurred in 30 patients (27.8%), and 18 of them (60%) underwent secondary TEVAR whereas the remaining 12 patients were medically treated. No statistically significant differences in demographic and clinical conditions were seen between patients with or patients without SINE. The incidence of SINE was lower for acute than for chronic dissection (16% versus 50%). At the multivariate analysis, the independent factors associated with SINE development were the oversizing ratio of the area (odds ratio 1.858; 95% confidence interval: 1.109 to 3.064; p = 0.018) and of the mean diameter (odds ratio 1.858; 95% confidence interval: 1.109 to 3.064; p = 0.018). Conclusions Type B aortic dissection can be treated effectively with TEVAR. The incidence of distal SINE is not negligible but is not associated with poor outcomes. The main determinant of SINE seems to be an excessive oversizing, which is particularly evident in the distal end. More accurate sizing can be obtained by evaluating the area of the true lumen.

Background Contemporary scores for estimating perioperative death have been proposed to also predict also long-term death. The aim of the study was to evaluate the performance of the updated European System for Cardiac Operative Risk Evaluation II, The Society of Thoracic Surgeons Predicted Risk of Mortality score, and the Age, Creatinine, Left Ventricular Ejection Fraction score for predicting long-term mortality in a contemporary cohort of isolated aortic valve replacement (AVR). We also sought to develop for each score a simple algorithm based on predicted perioperative risk to predict long-term survival. Methods Complete data on 1,444 patients who underwent isolated AVR in a 7-year period were retrieved from three prospective institutional databases and linked with the Italian Tax Register Information System. Data were evaluated with performance analyses and time-to-event semiparametric regression. Results Survival was 83.0% ± 1.1% at 5 years and 67.8 ± 1.9% at 8 years. Discrimination and calibration of all three scores both worsened for prediction of death at 1 year and 5 years. Nonetheless, a significant relationship was found between long-term survival and quartiles of scores (p < 0.0001). The estimated perioperative risk by each model was used to develop an algorithm to predict long-term death. The hazard ratios for death were 1.1 (95% confidence interval, 1.07 to 1.12) for European System for Cardiac Operative Risk Evaluation II, 1.34 (95% CI, 1.28 to 1.40) for the Society of Thoracic Surgeons score, and 1.08 (95% CI, 1.06 to 1.10) for the Age, Creatinine, Left Ventricular Ejection Fraction score. Conclusions The predicted risk generated by European System for Cardiac Operative Risk Evaluation II, The Society of Thoracic Surgeons score, and Age, Creatinine, Left Ventricular Ejection Fraction scores cannot also be considered a direct estimate of the long-term risk for death. Nonetheless, the three scores can be used to derive an estimate of long-term risk of death in patients who undergo isolated AVR with the use of a simple algorithm.

Purpose The prognostic impact of pulmonary hypertension (PH) is debated as well as the trend of pulmonary hemodynamic variables after heart transplantation (HTx). We investigated the impact of preoperative PH on postoperative survival and on the evolution of right heart hemodynamics (RHH) after HTx. Methods We reviewed the records of 431 consecutive HTx recipients, divided in a non-PH group (270 pts) and a PH group (161 pts).PH was defined as pulmonary vascular resistance ≥2.5 Wood units (WU) at right heat catheterization: mild (97 pts; PVR: 2.5-3.4WU), moderate (41 pts; PVR: 3.5-4.9WU) and severe PH (23 pts; PVR ≥5.0WU). RHH [systolic/mean/diastolic pulmonary artery-systolic-pressure (PAP), pulmonary-capillary-wedge-pressure (PCWP), transpulmonary gradient (TPG), cardiac output (CO), pulmonary vascular resistance (PVR), pulmonary-arterial-pulsatility-index (PAPi) and right-ventricle-stroke-work-index (RVSWI)] were measured before HTX and 3, 6, 12 months, 3, 5 years after HTX. Survival analysis was conducted using Kaplan-Meier curves. Results Preoperatively, patients with severe PH had significantly (P Conclusion Pre-transplant PH is an independent predictor of early mortality after HTx, not affecting long-term survival even when severe. After an early significant improvement of RHH, mean PAP, TPG and PVR increase while CO, PAPi and RVSWI decrease during follow-up. A rigorous monitoring of RHH must be scheduled during FU.

We performed a meta-analysis of early and long-term outcomes after tricuspid repair to compare the results of suture-based and prosthetic ring annuloplasty with the employment of an algorithm that derives the original patient time-to-event data. There was an advantage in early but not in long-term survival with the use of the annuloplasty ring. The freedom from moderate tricuspid regurgitation was significantly better in patients with ring annuloplasty (78.9% ± 5.0% at 15 years vs 60.0% ± 4.2%, log-rank p = 0.0107). The ring annuloplasty is associated to better outcomes, being a protective factor for early mortality and long-term recurrence of tricuspid regurgitation after surgery. © 2014 The Society of Thoracic Surgeons.

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Indexed aortic diameters have shown improved stratification for prediction of adverse events among men and women with aortic disease; less is known about the prognostic value of these indices post-dissection. We evaluated whether indexed aortic diameters at time of Type B acute aortic dissection (

Turnersyndrome(TS)isawell-definedautosomaldominantgenetic syndrome caused by a partial or complete monosomy of the chromosome X(45,X0). Cardiovascular complications are mostly responsible forreducedlifeexpectancy.Themaincardiacabnormalitiesarebicuspid aortic valve and aortic coarctation in approximately 16% and 11% of the patients, respectively [1]. A dilatation of major vessels is also observed, above all of the aorta and of the carotid and the brachial arteries. Aortic disease in TS is characterizedbya “connective tissue disorder”similarto that seen in Marfansyndrome. Ascending aorta dilatation is observed in 33% of the cases, and the incidence of aortic dissection is much higher than for women in general, occurring in the third and fourth decades of life [2]. We present a case of TS with bicuspid aortic valve plus hypoplastic aortic arch and chronic aneurysm of the descending thoracic aorta. Informed consent was obtained by the patient. The patient, a 38-year-old woman (Body Surface Area: 1.34 m 2 ; Aortic Size Index: 2.6 cm/m 2 ) with 45,X0 karyotype diagnosed at birth, presented a bicuspid aortic valve, an aortic coarctation, a left superior vena cava and patent ductus arteriosus. At 11 months, she underwent surgical repair of isthmic coarctation and patent ductus closure. After that, she was followed by regular examinations until the age of six, when she was operated on for an excision of a supravalvular mitral stenosis. During the following years, the patient had a normal quality of life up to 38 years when an echocardiogram showed mild aortic regurgitation

Background: Little epidemiological information on acute aortic dissection (AAD) is available in the literature. The objective of the present study was to determine the incidence and mortality rates of AAD in the general population and to analyze its clinical features. Methods: Data from the Emilia-Romagna regional database of hospital admissions was analyzed. Urgent admissions with the diagnosis of dissection of the aorta, dissection of the thoracic aorta and dissection of the thoracoabdominal aorta were selected. Results: Between January 2000 and December 2008, 1499 Emilia-Romagna residents were hospitalized with a diagnosis of AAD. The patients were divided into three groups: Group A, 617 patients (41.2%) surgically treated for type A AAD; Group B, 93 complicated patients (6.2%) with type B AAD treated by endovascular stent-grafting and Group C, 789 patients (52.6%) suffering from any type of AAD medically treated. The overall annual incidence rate was 4.7%/100,000 people and was higher for men than for women (6.7% vs 2.9%).Two hundred ninety-six patients (19.8%) were 80 years of age or older.The overall in-hospital mortality rate was 27.7%, with mortality rates of 21.1%, 26.9% and 33% in Groups A, B and C, respectively. Conclusion: The incidence of AAD is not negligible and a notable rate of patients is ultra-octogenarian. A large number of patients with AAD had no surgery or interventional treatment. The results of surgical treatment for patients with type A dissection are acceptable but the results obtained in patients with complicated type B dissection who were treated with an endoprosthesis are dismal. © 2012 Elsevier Ireland Ltd.

Background: There is still a wide debate concerning the performance of commonly used risk prediction models in assessing the risk of patients undergoing isolated aortic valve surgery. This study was designed to compare the performances of European System for Cardiac Operative Risk Evaluation (EuroSCORE) II and age, creatinine, and ejection fraction (ACEF) score with those of The Society of Thoracic Surgeons (STS) score and logistic EuroSCORE in patients undergoing isolated aortic valve surgery. Methods: Data on 1,758 consecutive patients who underwent isolated aortic valve replacement in a 6-year period were retrieved from 3 prospective institutional databases. Discriminatory power was assessed using the c-index. Calibration was evaluated with calibration curves and associated statistics. Results: In-hospital mortality rate was 1.4%. The discriminatory power was similar in all algorithms (area under the curve 0.80, 95% confidence interval [CI] 0.72 to 0.88 for logistic EuroSCORE; 0.81, 95% CI 0.73 to -0.88 for EuroSCORE II; 0.78, 95% CI 0.68 to 0.88 for ACEF; 0.85, 95% CI 0.78-0.93 for STS score) and not significantly different (p values > 0.05 for all tests). The EuroSCORE II had a better calibration, being the only score with nonsignificant associated statistics (unreliability test, Hosmer-Lemeshow test, and Spiegelhalter Z-test for calibration accuracy). Nonetheless, EuroSCORE II calibration plot highlighted a trend over under-prediction. Conclusions: The EuroSCORE II is a good predictor of perioperative mortality in isolated aortic valve surgery, with lower discrimination if compared with STS and a better calibration when compared with logistic EuroSCORE, ACEF, and STS scores. Its performance is optimal in the lowest tertile of patients, whereas it under-predicts mortality afterward. None of these algorithms seems suitable for risk estimation in mid and high-risk patients that are the ones who might benefit most from transcatheter procedures. © 2013 The Society of Thoracic Surgeons.

Marfan syndrome is the most frequently inherited disorder of connective tissue and is strongly associated with aortic dilatation, dissection, and rupture; in these patients, type B dissection occurs substantially. It is not known whether stent grafting, which is now frequently used in type B aortic dissection and descending thoracic aneurysms in non-Marfan patients, is a valuable option in Marfan patients, and reports from the literature are sparse and sporadic. We performed a systematic review of studies reporting the early and late results of endovascular stent grafting in Marfan patients with type B dissection in the attempt to quantify possible benefits or potential drawbacks of this approach in these usually very sick patients. Although associated with a low operative risk (1.9%), endovascular stent grafting in patients with Marfan syndrome carries a substantial risk of early and late complications, mainly endoleaks and surgical conversions, and of death at midterm follow-up. Because these complications are relatively more frequent in patients undergoing endovascular stent grafting for chronic dissections, these data suggest caution against the routine use of endovascular stent grafting in Marfan patients. © 2013 The Society of Thoracic Surgeons.