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We study plasma transport at a thin magnetopause (MP), described hereafter as a thin current sheet (TCS), observed by Cluster at the southern cusp on 13 February 2001 around 20:01 UT. The Cluster observations generally agree with the predictions of the Gas Dynamic Convection Field (GDCF) model in the magnetosheath (MSH) up to the MSH boundary layer, where significant differences are seen. We find for the MP a normal roughly along the GSE x-axis, which implies a clear departure from the local average MP normal, a ~90 km thickness and an outward speed of 35 km/s. Two populations are identified in the MSH boundary layer: the first one roughly perpendicular to the MSH magnetic field, which we interpret as the "incident" MSH plasma, the second one mostly parallel to B. Just after the MP crossing a velocity jet is observed with a peak speed of 240 km/s, perpendicular to B, with MA=3 and β>10 (peak value 23). The magnetic field clock angle rotates by 70° across the MP. Ex is the main electric field component on both sides of the MP, displaying a bipolar signature, positive on the MSH side and negative on the opposite side, corresponding to a ~300 V electric potential jump across the TCS. The E×B velocity generally coincides with the perpendicular velocity measured by CIS; however, in the speed jet a difference between the two is observed, which suggests the need for an extra flow source. We propose that the MP TCS can act locally as an obstacle for low-energy ions (

Proceeding with the analysis of Amata et al. (2005), we suggest that the general feature for the local transport at a thin magnetopause (MP) consists of the penetration of ions from the magnetosheath with gyroradius larger than the MP width, and that, in crossing it, the transverse potential difference at the thin current sheet (TCS) is acquired by these ions, providing a field-particle energy exchange without parallel electric fields. It is suggested that a part of the surface charge is self-consistently produced by deflection of ions in the course of inertial drift in the non-uniform electric field at MP. Consideration of the partial moments of ions with different energies demonstrates that the protons having gyroradii of roughly the same size or larger than the MP width carry fluxes normal to MP that are about 20% of the total flow in the plasma jet under MP. This is close to the excess of the ion transverse velocity over the cross-field drift speed in the plasma flow just inside MP (Amata et al., 2005), which conforms to the contribution of the finite-gyroradius inflow across MP. A linkage through the TCS between different plasmas results from the momentum conservation of the higher-energy ions. If the finite-gyroradius penetration occurs along the MP over ~1.5 RE from the observation site, then it can completely account for the formation of the jet under the MP. To provide the downstream acceleration of the flow near the MP via the cross-field drift, the weak magnetic field is suggested to rotate from its nearly parallel direction to the unperturbed flow toward being almost perpendicular to the accelerated flow near the MP. We discuss a deceleration of the higher-energy ions in the MP normal direction due to the interaction with finite-scale electric field bursts in the magnetosheath flow frame, equivalent to collisions, providing a charge separation. These effective collisions, with a nonlinear frequency proxy of the order of the proton cyclotron one, in extended turbulent zones are a promising alternative in place of the usual parallel electric fields invoked in the macro-reconnection scenarios. Further cascading towards electron scales is supposed to be due to unstable parallel electron currents, which neutralize the potential differences, either resulted from the ion- burst interactions or from the inertial drift. The complicated MP shape suggests its systematic velocity departure from the local normal towards the average one, inferring domination for the MP movement of the non-local processes over the small-scale local ones. The measured Poynting vector indicates energy transmission from the MP into the upstream region with the waves triggering impulsive downstream flows, providing an input into the local flow balance and the outward movement of the MP. Equating the transverse electric field inside the MP TCS by the Hall term in the Ohm's law implies a separation of the different plasmas primarily by the Hall current, driven by the respective part of the TCS surface charge. The Hall dynamics of TCS can operate either without or as a part of a macro-reconnection with the magnetic field annihilation.

Abstract Background In 2020, the WHO-approved Molbio Truenat platform and MTB assays to detect Mycobacterium tuberculosis complex (MTB) and resistance to rifampicin directly on sputum specimens. This primary health care center-based trial in Mozambique and Tanzania investigates the effect of Truenat platform/MTB assays (intervention arm) combined with rapid communication of results compared to standard of care on TB diagnosis and treatment initiation for microbiologically confirmed TB at 7 days from enrolment. Methods The Tuberculosis Close the Gap, Increase Access, and Provide Adequate Therapy (TB-CAPT) CORE trial employs a pragmatic cluster randomized controlled design to evaluate the impact of a streamlined strategy for delivery of Truenat platform/MTB assays testing at primary health centers. Twenty-nine centers equipped with TB microscopy units were selected to participate in the trial. Among them, fifteen health centers were randomized to the intervention arm (which involves onsite molecular testing using Truenat platform/MTB assays, process process optimization to enable same-day TB diagnosis and treatment initiation, and feedback on Molbio platform performance) or the control arm (which follows routine care, including on-site sputum smear microscopy and the referral of sputum samples to off-site Xpert testing sites). The primary outcome of the study is the absolute number and proportion of participants with TB microbiological confirmation starting TB treatment within 7 days of their first visit. Secondary outcomes include time to bacteriological confirmation, health outcomes up to 60 days from first visit, as well as user preferences, direct cost, and productivity analyses. Ethics and dissemination TB-CAPT CORE trial has been approved by regulatory and ethical committees in Mozambique and Tanzania, as well as by each partner organization. Consent is informed and voluntary, and confidentiality of participants is maintained throughout. Study findings will be presented at scientific conferences and published in peer-reviewed international journals. Trial Registration US National Institutes of Health’s ClinicalTrials.gov, NCT04568954. Registered 23 September 2020.

We present multi spacecraft measurements in the magnetosheath (MSH) and in the solar wind (SW) by Interball, Cluster and Polar, demonstrating that coherent structures with magnetosonic Mach number up to 3 – Supermagnetosonic Plasma Streams (SPS) – generate transient and anomalous boundary dynamics, which may cause substantial displacements of the magnetospheric boundaries and the riddling of peripheral boundary layers. In this regard, for the first time, we describe a direct plasma penetration into the flank boundary layers, which is a candidate for being the dominant transport mechanism for disturbed MSH periods. Typically SPS's have a ram pressure exceeding by several times that of the SW and lead to long-range correlations between processes at the bow shock (BS) and at the magnetopause (MP) on one side and between MSH and MP boundary layers on the other side. We demonstrate that SPS's can be observed both near the BS and near the MP and argue that they are often triggered by hot flow anomalies (HFA), which represent local obstacles to the SW flow and can induce the SPS generation as a means for achieving a local flow balance. Finally, we also discuss other causes of SPS's, both SW-induced and intrinsic to the MSH. SPS's appear to be universal means for establishing a new equilibrium between flowing plasmas and may also prove to be important for astrophysical and fusion applications.

Itaconic acid (IA) is considered as an important intermediate in the synthesis of bio-based chemicals and fuels. It can be produced under nitrogen-limited conditions from glucose by aerobic fermentation with the fungus Ustilago maydis (U. maydis). A metabolic model of this organism is developed to identify optimal operating conditions for a continuous fermentation which maximizes the overall itaconic acid yield. Experimental studies show that IA is only produced under nitrogen limitation. In order to capture this behaviour, the model should not only include the common metabolic pathways such as glycolysis, the pentose phosphate pathway and the tricarbonic acid cycle, but it should also comprise the amino acid metabolism as well as nucleotide and chitin synthesis. Since it has been shown experimentally that nitrogen limitation leads to changes in the elemental composition of the biomass, this effect must also be considered in the model. In this contribution, we will present a metabolic model accounting for these phenomena and compare model predictions with experimental results. A metabolic flux analysis carried out with the model clearly shows that nitrogen-free compounds such as IA acid are expressed by an overflow metabolism as soon as a nitrogen limitation occurs.

Introduction: Tuberculosis (TB) is an important cause of morbidity and mortality among people living with HIV (PLHIV). Current WHO-recommended strategies for diagnosing TB among hospitalized PLHIV rely on symptom screening and disease severity to assess eligibility for urine lipoarabinomannan lateral flow (LF-LAM) and molecular testing. Despite these recommendations, autopsy studies show a large burden of undiagnosed TB among admitted PLHIV. The EXULTANT trial aims to assess the impact of an expanded screening strategy using three specimens (sputum, stool, and urine) for TB diagnosis among PLHIV admitted to hospitals in two high HIV and TB burden African countries., Methods: This is a multicenter, pragmatic, individually randomized controlled trial conducted across eleven hospitals in Tanzania and Mozambique. Participants in the intervention arm will be tested with Xpert MTB/RIF Ultra® from expectorated sputum, stool, and urine samples, with additional urine LF-LAM testing in the first 24 h after hospital admission, irrespective of the presence of the symptoms. The control arm will implement the WHO standard of care recommendations. Hospitalized adults (≥ 18 years) with a confirmed HIV-diagnosis, irrespective of antiretroviral (ART) therapy status or presence of TB symptoms will be assessed for eligibility at admission. Patients with a pre-existing TB diagnosis, those receiving anti-tuberculosis therapy or tuberculosis preventive treatment in the 6 months prior to enrolment, and those transferred from other hospitals will not be eligible. Also, participants admitted for traumatic reasons such as acute abdomen, maternal conditions, scheduled surgery, having a positive SARS-CoV2 test will be ineligible. The primary endpoint is the proportion of participants with microbiologically confirmed TB starting treatment within 3 days of enrolment., Discussion: The EXULTANT trial investigates rapid implementation after admission of a new diagnostic algorithm using Xpert MTB/RIF Ultra® in several non-invasive specimens, in addition to LF-LAM, in hospitalized PLHIV regardless of TB symptoms. This enhanced strategy is anticipated to detect frequently missed TB cases in this population and is being evaluated as an implementable and scalable intervention., Trial Registration: Trial reference number: NCT04568967 (ClinicalTrials.gov) registered on 2020-09-29., (© 2024. The Author(s).)

Objectives: To analyze Heart Team decisions and outcomes following failure of surgical aortic valve replacement (SAVR) prostheses. Methods: Patients undergoing re-operations following index SAVR (Redo-SAVR) and those undergoing valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) following SAVR were included in this study. Patients who underwent index SAVR and/or Redo-SAVR for endocarditis were excluded. Data are presented as medians and 25th-75th percentiles, or absolute numbers and percentages. Outcomes were analyzed in accordance to the VARC-3 criteria. Results: Between 01/2015 and 03/2021, 53 patients underwent Redo-SAVR, 103 patients ViV-TAVR. Mean EuroSCORE II was 5.7% (3.5-8.5) in the Redo-SAVR group and 9.2% (5.4-13.6) in the ViV group. In the Redo-SAVR group, 12 patients received aortic root enlargement (22.6%). Length of hospital and ICU stay was longer in the Redo-SAVR group ( p < 0.001; p < 0.001), PGmax and PGmean were lower in the Redo-SAVR group as compared to the ViV-TAVR group (18 mmHg (10-30) vs. 26 mmHg (19-38), p < 0.001) (9 mmHg (6-15) vs. 15 mmHg (9-21), p < 0.001). A higher rate of paravalvular leakage was seen in the ViV-TAVR group ( p = 0.013). VARC-3 Early Safety were comparable between the two populations ( p = 0.343). Survival at 1 year and 5 years was 82% and 36% in the ViV-TAVR cohort and 84% and 77% in the Redo-SAVR cohort. The variables were patient age (OR 1.061; [95% CI 1.020-1.104], p = 0.004), coronary heart disease (OR 2.648; [95% CI 1.160-6.048], p = 0.021), and chronic renal insufficiency (OR 2.711; [95% CI 1.160-6.048], p = 0.021) showed a significant correlation to ViV-TAVR. Conclusions: Heart Team decisions are crucial in the treatment of patients with degenerated aortic bioprostheses and lead to a low mortality in both treatment paths thanks to patient-specific therapy planning. ViV-TAVR offers a treatment for elderly or intermediate-risk profile patients with comparable short-term mortality. However, this therapy is associated with increased pressure gradients and a high prevalence of paravalvular leakage. Redo-SAVR enables the surgical treatment of concomitant cardiac pathologies and allows anticipation for later VIV-TAVR by implanting the largest possible valve prostheses.

Background: Extended aortic repair is considered a key issue for the long-term durability of surgery for DeBakey type 1 aortic dissection. The risk of aortic degeneration may be higher in young patients due to their long life expectancy. The early outcome and durability of aortic surgery in these patients were investigated in the present study., Methods: The subjects of the present analysis were patients under 60 years old who underwent surgical repair for acute DeBakey type 1 aortic dissection at 18 cardiac surgery centres across Europe between 2005 and 2021. Patients underwent ascending aortic repair or total aortic arch repair using the conventional technique or the frozen elephant trunk technique. The primary outcome was 5-year cumulative incidence of reoperation on the distal aorta., Results: Overall, 915 patients underwent surgical ascending aortic repair and 284 patients underwent surgical total aortic arch repair. The frozen elephant trunk procedure was performed in 128 patients. Among 245 propensity score-matched pairs, total aortic arch repair did not decrease the rate of distal aortic reoperation compared to ascending aortic repair (5-year cumulative incidence, 6.7% versus 6.7%, subdistributional hazard ratio 1.127, 95% c.i. 0.523 to 2.427). Total aortic arch repair increased the incidence of postoperative stroke/global brain ischaemia (25.7% versus 18.4%, P = 0.050) and dialysis (19.6% versus 12.7%, P = 0.003). Five-year mortality was comparable after ascending aortic repair and total aortic arch repair (22.8% versus 27.3%, P = 0.172)., Conclusions: In patients under 60 years old with DeBakey type 1 aortic dissection, total aortic arch replacement compared with ascending aortic repair did not reduce the incidence of distal aortic operations at 5 years. When feasible, ascending aortic repair for DeBakey type 1 aortic dissection is associated with satisfactory early and mid-term outcomes., Trial Registration: ClinicalTrials.gov Identifier: NCT04831073., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd.)

Addressing proximal complications that arise after endovascular aortic repair for type B aortic dissection, such as type Ia endoleaks, "bird-beaking" of the thoracic endovascular aortic repair (TEVAR) stent, retrograde type A dissection, and postdissection aneurysms, bears considerable complexities. We present a novel and safe method for open arch repair that can ensure a secure and efficient approach for TEVAR complications. The key element of the operative technique is approximating the grafted stent portion to the aortic wall and the arch prosthesis. The technique has successfully been implemented in 11 patients, who received secondary open arch repair from 2019 to 2022 after TEVAR for type B dissection. Our objective is not only to introduce this reliable concept but also to provide a comprehensive demonstration of its advantages and disadvantages compared with currently used open treatment methods and discuss patient outcomes after secondary open arch repair., Competing Interests: None., (© 2024 Published by Elsevier Inc. on behalf of Society for Vascular Surgery.)

Background: In 2020, the WHO-approved Molbio Truenat platform and MTB assays to detect Mycobacterium tuberculosis complex (MTB) and resistance to rifampicin directly on sputum specimens. This primary health care center-based trial in Mozambique and Tanzania investigates the effect of Truenat platform/MTB assays (intervention arm) combined with rapid communication of results compared to standard of care on TB diagnosis and treatment initiation for microbiologically confirmed TB at 7 days from enrolment., Methods: The Tuberculosis Close the Gap, Increase Access, and Provide Adequate Therapy (TB-CAPT) CORE trial employs a pragmatic cluster randomized controlled design to evaluate the impact of a streamlined strategy for delivery of Truenat platform/MTB assays testing at primary health centers. Twenty-nine centers equipped with TB microscopy units were selected to participate in the trial. Among them, fifteen health centers were randomized to the intervention arm (which involves onsite molecular testing using Truenat platform/MTB assays, process process optimization to enable same-day TB diagnosis and treatment initiation, and feedback on Molbio platform performance) or the control arm (which follows routine care, including on-site sputum smear microscopy and the referral of sputum samples to off-site Xpert testing sites). The primary outcome of the study is the absolute number and proportion of participants with TB microbiological confirmation starting TB treatment within 7 days of their first visit. Secondary outcomes include time to bacteriological confirmation, health outcomes up to 60 days from first visit, as well as user preferences, direct cost, and productivity analyses., Ethics and Dissemination: TB-CAPT CORE trial has been approved by regulatory and ethical committees in Mozambique and Tanzania, as well as by each partner organization. Consent is informed and voluntary, and confidentiality of participants is maintained throughout. Study findings will be presented at scientific conferences and published in peer-reviewed international journals., Trial Registration: US National Institutes of Health's ClinicalTrials.gov, NCT04568954. Registered 23 September 2020., (© 2024. The Author(s).)

Background: Surgery for type A aortic dissection (TAAD) is associated with high risk of mortality. Current risk scoring methods have a limited predictive accuracy., Methods: Subjects were patients who underwent surgery for acute TAAD at 18 European centers of cardiac surgery from the European Registry of Type A Aortic Dissection (ERTAAD)., Results: Out of 3,902 patients included in the ERTAAD, 2,477 fulfilled the inclusion criteria. In the validation dataset (2,229 patients), the rate of in-hospital mortality was 18.4%. The rate of composite outcome (in-hospital death, stroke/global ischemia, dialysis, and/or acute heart failure) was 41.2%, and 10-year mortality rate was 47.0%. Logistic regression identified the following patient-related variables associated with an increased risk of in-hospital mortality [area under the curve (AUC), 0.755, 95% confidence interval (CI), 0.729-0.780; Brier score 0.128]: age; estimated glomerular filtration rate; arterial lactate; iatrogenic dissection; left ventricular ejection fraction ≤50%; invasive mechanical ventilation; cardiopulmonary resuscitation immediately before surgery; and cerebral, mesenteric, and peripheral malperfusion. The estimated risk score was associated with an increased risk of composite outcome (AUC, 0.689, 95% CI, 0.667-0.711) and of late mortality [hazard ratio (HR), 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403]. In the validation dataset (248 patients), the in-hospital mortality rate was 16.1%, the composite outcome rate was 41.5%, and the 10-year mortality rate was 49.1%. The estimated risk score was predictive of in-hospital mortality (AUC, 0.703, 95% CI, 0.613-0.793; Brier score 0.121; slope 0.905) and of composite outcome (AUC, 0.682, 95% CI, 0.614-0.749). The estimated risk score was predictive of late mortality (HR, 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403), also when hospital deaths were excluded from the analysis (HR, 1.024, 95% CI, 1.018-1.031; Harrell's C 0.630; Somer's D 0.261)., Conclusions: The present analysis identified several baseline clinical risk factors, along with preoperative estimated glomerular filtration rate and arterial lactate, which are predictive of in-hospital mortality and major postoperative adverse events after surgical repair of acute TAAD. These risk factors may be valuable components for risk adjustment in the evaluation of surgical and anesthesiological strategies aiming to improve the results of surgery for TAAD., Clinical Trial Registration: https://clinicaltrials.gov, identifier NCT04831073., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The authors declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (© 2024 Biancari, Demal, Nappi, Onorati, Francica, Peterss, Buech, Fiore, Folliguet, Perrotti, Hervé, Conradi, Rukosujew, Pinto, Lega, Pol, Rocek, Kacer, Wisniewski, Mazzaro, Vendramin, Piani, Ferrante, Rinaldi, Quintana, Pruna-Guillen, Gerelli, Di Perna, Acharya, Mariscalco, Field, Kuduvalli, Pettinari, Rosato, D'Errigo, Jormalainen, Mustonen, Mäkikallio, Dell'aquila, Juvonen and Gatti.)

Background: Acute type A aortic dissection (TAAD) is associated with significant mortality and morbidity. In this study we evaluated the prognostic significance of preoperative arterial lactate concentration on the outcome after surgery for TAAD., Methods: The ERTAAD registry included consecutive patients who underwent surgery for acute type A aortic dissection (TAAD) at 18 European centers of cardiac surgery., Results: Data on arterial lactate concentration immediately before surgery were available in 2798 (71.7 %) patients. Preoperative concentration of arterial lactate was an independent predictor of in-hospital mortality (mean, 3.5 ± 3.2 vs 2.1 ± 1.8 mmol/L, adjusted OR 1.181, 95%CI 1.129-1.235). The best cutoff value preoperative arterial lactate concentration was 1.8 mmol/L (in-hospital mortality, 12.0 %, vs. 26.6 %, p < 0.0001). The rates of in-hospital mortality increased along increasing quintiles of arterial lactate and it was 12.1 % in the lowest quintile and 33.6 % in the highest quintile (p < 0.0001). The difference between multivariable models with and without preoperative arterial lactate was statistically significant (p = 0.0002). The NRI was 0.296 (95%CI 0.200-0.391) (p < 0.0001) with -17 % of events correctly reclassified (p = 0.0002) and 46 % of non-events correctly reclassified (p < 0.0001). The IDI was 0.025 (95%CI 0.016-0.034) (p < 0.0001). Six studies from a systematic review plus the present one provided data for a pooled analysis which showed that the mean difference of preoperative arterial lactate between 30-day/in-hospital deaths and survivors was 1.85 mmol/L (95%CI 1.22-2.47, p < 0.0001, I 2 64 %)., Conclusions: Hyperlactatemia significantly increased the risk of mortality after surgery for acute TAAD and should be considered in the clinical assessment of these critically ill patients., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Fausto Biancari reports financial support was provided by 10.13039/501100005633Finnish Foundation for Cardiovascular Research. Fausto Biancari reports financial support was provided by Sigrid Jusélius Foundation., (© 2023 The Authors.)

Objectives: Severe mitral regurgitation (MR) and tricuspid regurgitation (TR) aggravate haemodynamic stress leading to congestive heart failure with impaired hepatic function, also known as cardiohepatic syndrome (CHS). Current perioperative risk calculators do not sufficiently consider CHS and serum liver function parameters lack sensitivity to diagnose CHS. Indocyanine green and its elimination (measured by the LIMON® test) represent a dynamic and non-invasive test which correlates with the hepatic function. Nevertheless, its utility in the setting of transcatheter valve repair/replacement (TVR) to predict CHS and outcome remains unknown., Methods: We analysed liver function and outcomes of patients undergoing TVR for MR or TR between August 2020 and May 2021 at the Munich University Hospital., Results: Out of a total of 44 patients treated at the University Hospital of Munich, 21 (48%) were treated for severe MR, 20 (46%) for severe TR and 3 (7%) for both diseases. Procedural success defined as MR/TR ≤2+ was 94% among MR patients and 92% among TR patients. While classical serum liver function parameters did not change after TVR, there was a significant improvement in liver function as assessed by the LIMON® test (P ≤ 0.001). Patients with baseline indocyanine green plasma disappearance rate <12.95%/min showed significantly increased 1-year mortality (hazard ratio: 1.54, 95% confidence interval: 1.05-2.25, P = 0.027) and lower New York Hear Association class improvement (P = 0.05)., Conclusions: Especially in the context of the recently stressed importance of a careful patient selection prior to the interdisciplinary treatment of valvular heart disease, the LIMON® test may provide further real-time information on the patients' cardiohepatic injury and prognosis., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

(1) Background: Acute Stanford type A aortic dissection (TAAD) may complicate the outcome of cardiovascular procedures. Data on the outcome after surgery for iatrogenic acute TAAD is scarce. (2) Methods: The European Registry of Type A Aortic Dissection (ERTAAD) is a multicenter, retrospective study including patients who underwent surgery for acute TAAD at 18 hospitals from eight European countries. The primary outcomes were in-hospital mortality and 5-year mortality. Twenty-seven secondary outcomes were evaluated. (3) Results: Out of 3902 consecutive patients who underwent surgery for acute TAAD, 103 (2.6%) had iatrogenic TAAD. Cardiac surgery (37.8%) and percutaneous coronary intervention (36.9%) were the most frequent causes leading to iatrogenic TAAD, followed by diagnostic coronary angiography (13.6%), transcatheter aortic valve replacement (10.7%) and peripheral endovascular procedure (1.0%). In hospital mortality was 20.5% after cardiac surgery, 31.6% after percutaneous coronary intervention, 42.9% after diagnostic coronary angiography, 45.5% after transcatheter aortic valve replacement and nihil after peripheral endovascular procedure (p = 0.092), with similar 5-year mortality between different subgroups of iatrogenic TAAD (p = 0.710). Among 102 propensity score matched pairs, in-hospital mortality was significantly higher among patients with iatrogenic TAAD (30.4% vs. 15.7%, p = 0.013) compared to those with spontaneous TAAD. This finding was likely related to higher risk of postoperative heart failure (35.3% vs. 10.8%, p < 0.0001) among iatrogenic TAAD patients. Five-year mortality was comparable between patients with iatrogenic and spontaneous TAAD (46.2% vs. 39.4%, p = 0.163). (4) Conclusions: Iatrogenic origin of acute TAAD is quite uncommon but carries a significantly increased risk of in-hospital mortality compared to spontaneous TAAD.

Objectives: The objective of this study was to compare the long-term outcomes and health-related quality of life (HRQOL) of patients following surgery for infective native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE)., Methods: We retrospectively identified 633 consecutive patients who had undergone surgery for infective endocarditis at our center between January 2005 and October 2018. The patients were interviewed, and the SF-36 survey was used to assess the HRQOL of survivors. Propensity score matching (2:1) was performed with data from a German reference population. Multivariable analysis incorporated binary logistic regression using a forward stepwise (conditional) model., Results: The median age of the cohort was 67 (55-74) years, and 75.6% were male. Operative mortality was 13.7% in the NVE group and 21.6% in the PVE group ( p = 0.010). The overall survival at 1 year was 88.0% and was comparable between the groups. The physical health summary scores were 49 (40-55) for the NVE patients and 45 (37-52) for the PVE patients ( p = 0.043). The median mental health summary scores were 52 (35-57) and 49 (41-56), respectively ( p = 0.961). On comparison of the HRQOL to the reference population, the physical health summary scores were comparable. However, significant differences were observed with regard to the mental health summary scores ( p = 0.005)., Conclusions: Our study shows that there are significant differences in the various domains of HRQOL, not only between NVE and PVE patients, but also in comparison to healthy individuals. In addition to preoperative health status, it is important to consider the patient's expectations regarding surgery. Further prospective studies are required.

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., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: We evaluated the outcome of patients in cardiogenic shock receiving a paracorporeal pulsatile biventricular assist device as a bridge to transplantation., Methods: We performed a retrospective single-centre analysis of all patients who received a Berlin Heart Excor® at our institution between 2004 and 2019., Results: A total of 97 patients (90 adults, 7 paediatric) were analysed. Eighty-four patients were in Interagency Registry for Mechanically Assisted Circulatory Support level 1 (80 adults, 4 paediatric). Diagnoses were dilated cardiomyopathy (n = 41), ischaemic cardiomyopathy (n = 17) or myocardial infarction (n = 4), myocarditis (n = 15), restrictive cardiomyopathy (n = 2), graft failure after heart transplant (n = 7), postcardiotomy heart failure (n = 5), postpartum cardiomyopathy (n = 3), congenital heart disease (n = 1), valvular cardiomyopathy (n = 1) and toxic cardiomyopathy (n = 1). All patients were in biventricular heart failure and had secondary organ dysfunction. The mean duration of support was 63 days (0-487 days). There was a significant decrease in creatinine values after assist device implantation (from 1.83 ± 0.79 to 1.12 ± 0.67 mg/dl, P = 0.001) as well as a decrease in bilirubin values (from 3.94 ± 4.58 to 2.65 ± 3.61 mg/dl, P = 0.084). Cerebral stroke occurred in 16 patients, bleeding in 15 and infection in 13 patients. Forty-eight patients died on support, while 49 patients could be successfully bridged to transplantation. Thirty-day survival and 1-year survival were 70.1% and 41.2%, respectively., Conclusions: A pulsatile biventricular assist device is a reasonable therapeutic option in cardiogenic shock, when immediate high cardiac output is necessary to rescue the already impaired kidney and liver function of the patient., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Despite the rapid increase in experience and technological improvement, the incidence of conduction disturbances in patients undergoing transcatheter aortic valve replacement (TAVR) with the self-expandable CoreValve Evolut valve remains high. Recently, a cusp-overlap view (COP) implantation technique has been proposed for TAVR with self-expandable valves offering an improved visualization during valve expansion compared to the three-cusp view (TCV). This study aims to systematically analyze procedural outcomes of TAVR patients treated with the CoreValve Evolut valve using a COP compared to TCV in a high-volume center. The primary endpoint was technical success according the 2021 VARC-3 criteria. A total of 122 consecutive patients (61 pts. TCV: April 2019 to November 2020; 61 pts. COP: December 2020 to October 2021) that underwent TAVR with the CoreValve Evolut prosthesis were included in this analysis. Although there was no difference in the primary endpoint technical success between TCV and COP patients (93.4% vs. 90.2%, OR 0.65, 95% CI 0.16, 2.4, p = 0.51), we observed a significantly lower risk for permanent pacemaker implantation (PPI) among COP patients (TCV: 27.9% vs. COP: 13.1%, OR 0.39, 95% CI 0.15, 0.97, p = 0.047). Implantation of the CoreValve Evolut prosthesis using the COP might help to reduce the rate of PPI following TAVR.

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., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Transcatheter mitral valve repair (TMVR) has shown to improve symptoms and functional capacity in patients with severe mitral valve regurgitation (MR). Novel device developments provide the technology to treat patients with complex anatomies and large coaptation gaps. Nevertheless, the question of superiority of one device remains unanswered. We aimed to compare the MitraClip XTR and MitraClip NTR system in a real world setting., Hypothesis: TMVR with the MitraClip XTR system is equally effective, but associated with a higher risk of leaflet injury., Methods: We retrospectively analyzed peri-procedural and mid-term clinical and echocardiographic outcomes of 113 patients treated for severe MR between March 2018 and August 2019 at the University Hospital of Munich., Results: Postprocedural MR reduction to ≤2+ was comparable in both groups (XTR: 96.1% vs. NTR: 97.6%, p = .38). There was a significant difference in a composite safety endpoint of periprocedural Major adverse cardiac and cerebrovascular events (MACCE) including leaflet injury between groups (XTR 14.6% vs. NTR 1.7%, 95% CI [2.7, 24.6], p = .012). After a median follow-up of 8.5 (4.4, 14.0) months, durable reduction of MR was confirmed (XTR: in 91.9% vs. NTR: 96.8%, p = .31) and clinical and symptomatic improvement was comparable in both groups accordingly., Conclusion: While efficacy was comparable in both treatment groups, patients treated with the MitraClip XTR systems showed more events of acute leaflet tear and single leaflet device attachment (SLDA). A detailed echocardiographic assessment should be done to identify risk candidates for acute leaflet injury., (© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background: In specialized centers, percutaneous closure using specific occluders is the first-choice treatment in atrial septal defects (ASD). Late complications after this intervention, such as erosion of the aorta or the atria, are rare and have not been sufficiently approached and dealt with in literature. In our clinic we have been faced with the problematic situation of diagnosing and treating such cases. That is why, we have decided to share our experience with other colleagues., Case Presentation: We present two cases of severe late complications after percutaneous closure of atrial septal defects (ASD). In both cases, the atrial septal occluder (Amplatzer™ Atrial Septal Occluder Device, Abbott, Chicago USA) caused the erosion between the left atrium and the aortic root. The atrio-aortic erosion led to acute cardiac tamponade with upper venous congestion and shock. As the bleeding source remained undetectable for any imaging tools, a diagnostical sternotomy remained the only solution. The cause of the acute bleeding was discovered to be the erosion between the left atrium and the aortic root. The treatment consisted in the removal of the occluder, direct suturing of the perforated areas and the surgical closure of the remaining ASD. The patients fully recovered within the nine to fourteen days' hospital stay. Six months after surgery both patients were well and able to recover their daily routine., Conclusions: The atrio-aortic erosion after percutaneous closure of atrial septal defects is a surgical emergency. The more so, since it can be complicated by the absence of specific symptoms. A key-element in the diagnosis of this rare pathology remains the medical history of the patient, which the surgeon has to consider thoroughly and launch the diagnostic sternotomy without delay.