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Primary graft dysfunction (PGD) is a common complication after lung transplantation. A plethora of contributing factors are known and assessment of donor lung function prior to organ retrieval is mandatory for determination of lung quality. Specialized centers increasingly perform ex vivo lung perfusion (EVLP) to further assess lung functionality and improve and extend lung preservation with the aim to increase lung utilization. EVLP can be performed following different protocols. The impact of the individual EVLP parameters on PGD development, organ function and postoperative outcome remains to be fully investigated. The variables relate to the engineering and function of the respective perfusion devices, such as the type of pump used, functional, like ventilation modes or physiological (e.g. perfusion solutions). This review reflects on the individual technical and fluid components relevant to EVLP and their respective impact on inflammatory response and outcome. We discuss key components of EVLP protocols and options for further improvement of EVLP in regard to PGD. This review offers an overview of available options for centers establishing an EVLP program and for researchers looking for ways to adapt existing protocols., 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., (Copyright © 2024 Ponholzer, Dumfarth, Krapf, Pircher, Hautz, Wolf, Augustin and Schneeberger.)

Heritable thoracic aortic diseases (HTAD) are rare pathologies associated with thoracic aortic aneurysms and dissection, which can be syndromic or non-syndromic. They may result from genetic defects. Associated genes identified to date are classified into those encoding components of the (a) extracellular matrix (b) TGFβ pathway and (c) smooth muscle contractile mechanism. Timely diagnosis allows for prompt aortic surveillance and prophylactic surgery, hence improving life expectancy and reducing maternal complications as well as providing reassurance to family members when a diagnosis is ruled out. This document is an expert opinion reflecting strategies put forward by medical experts and patient representatives involved in the HTAD Rare Disease Working Group of VASCERN. It aims to provide a patient pathway that improves patient care by diminishing time to diagnosis, facilitating the establishment of a correct diagnosis using molecular genetics when possible, excluding the diagnosis in unaffected persons through appropriate family screening and avoiding overuse of resources. It is being recommended that patients are referred to an expert centre for further evaluation if they meet at least one of the following criteria: (1) thoracic aortic dissection (<70 years if hypertensive; all ages if non-hypertensive), (2) thoracic aortic aneurysm (all adults with Z score >3.5 or 2.5-3.5 if non-hypertensive or hypertensive and <60 years; all children with Z score >3), (3) family history of HTAD with/without a pathogenic variant in a gene linked to HTAD, (4) ectopia lentis without other obvious explanation and (5) a systemic score of >5 in adults and >3 in children. Aortic imaging primarily relies on transthoracic echocardiography with magnetic resonance imaging or computed tomography as needed. Genetic testing should be considered in those with a high suspicion of underlying genetic aortopathy. Though panels vary among centers, for patients with thoracic aortic aneurysm or dissection or systemic features these should include genes with a definitive or strong association to HTAD. Genetic cascade screening and serial aortic imaging should be considered for family screening and follow-up. In conclusion, the implementation of these strategies should help standardise the diagnostic work-up and follow-up of patients with suspected HTAD and the screening of their relatives., (Copyright © 2022 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Objectives: The aim of this study was to evaluate gender differences in the pre- and postoperative course in patients with acute aortic dissection type A., Methods: Of all patients undergoing surgery from 2000 to 2020, data on symptoms at presentation, operative strategy and postoperative course were analyzed. Long-term follow-up was obtained through visits at our outpatient clinic or via telephone interviews., Results: Out of 394 patients, 32% (n = 126) were female. Women suffered from aortic dissection type A at an older age (women 67.5 years vs men 57 years; P > 0.001) and experienced a more aggressive preoperative course leading to critical presentation or even lethal rupture [women 7.9% (n = 10) vs men 2.2% (n = 6); P = 0.008]. Chest pain as initial symptom was more common in men [women 59.5% (n = 75) vs men 73.5% (n = 197); P = 0.005]. Perfusion of the right carotid was impaired more often [women 22.5% (n = 27) vs men 13.7% (n = 36); P = 0.031] and preoperative rate of neurological dysfunction was higher in women [women 23% (n = 29) vs men 14.2% (n = 38); P = 0.028]. Time from symptom onset to surgery did not differ between gender. Surgical repair was less extensive and faster in women. Female patients were more likely to suffer from postoperative neurological injury [women 23.8% (n = 30) vs men 10.2% (n = 40); P = 0.023]. We detected impaired 30-day and long-term survival in women., Conclusions: Women represent an older and sicker patient collective. Preoperative course of aortic dissection type A is more aggressive and complicated in women. While time from onset of symptoms to surgery did not differ between gender, neurological outcome and survival were impaired in women., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Diagnosis and management of low-flow/low-gradient aortic stenosis are very challenging. Resting echocardiography is not capable of differentiating between different types and origins of low-flow and low-gradient state in aortic valve stenosis. Therefore, dobutamine stress echocardiography (DSE) and cardiac computed tomography (CCT) are necessary. This case report should illustrate the importance of these assessments., Case Summary: A 73-year-old woman presented to our emergency department with New York Heart Association III symptoms of exertional dyspnoea. In addition, the patient complained of fatigue and low resilience. On physical examination, auscultation revealed a systolic murmur over the aortic valve. Further diagnostic steps revealed a low-flow/low-gradient aortic valve stenosis (LF/LGAS) without contractile reserve (CR) in DSE and massive valve calcification in CCT., Discussion: In this case, we demonstrate the importance of different assessments and workflow. The prognosis of LF/LGAS has been re-evaluated during the last decade and the current guidelines recommend the treatment of such patients even in the absence of CR. Furthermore, we are discussing the results of LF/LGAS., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Transaortic (TAo) transcatheter aortic valve implantation has become a valid alternative access route in patients with unsuitable femoral arteries. The current literature does not allow to clearly favor one of the alternative access routes. Every approach has its specific advantages. Transaortic (TAo) access is of particular importance in the case of calcifications of the supra-aortic branches and the aortic arch, as under these circumstances other alternative access routes, such as transaxillary or transcarotid, are not feasible. The purpose of this minireview is to give an overview and update on TAo transcatheter aortic valve implantation focusing on indication, technical aspects, and recent clinical data., 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., (Copyright © 2022 Stastny, Krapf, Dumfarth, Gasser, Bauer, Friedrich, Metzler, Feuchtner, Mayr, Grimm and Bonaros.)

Objectives: The aim of this study was to identify predictors of periprocedural success and safety in minimally invasive mitral valve surgery and to determine the impact of pathology localization and repair technique on reoperation-free survival., Methods: We isolated 686 patients (mean age 60.5, standard deviation 12.3 years, 69.4% male) who underwent surgery for mitral valve prolapse between 2002 and 2020 in a single institution. Patients with concomitant disease, redo or mitral pathology other than degenerative mitral disease were excluded from the analysis. Periprocedural safety was defined as: freedom from perioperative death, myocardial infarction, stroke, use of extracorporeal membrane oxygenation or reoperation for bleeding. Operative success was defined as: successful primary mitral repair without conversion to replacement or to larger thoracic incisions, without residual mitral regurgitation > mild at discharge or reoperation within 30 days. Predictors for perioperative success and safety were identified using univariable and multivariable analyses. The impact of prolapse localization and repair technique on reoperation-free survival was assessed by Cox regression., Results: The mitral repair rate and the need for concomitant tricuspid repair were 94.6% and 16.5%, respectively. Perioperative mortality occurred in 5 patients (0.7%). The criteria for perioperative safety and success were met in 646/686 (94.2%) and 648/686 (94.5%) patients, respectively. The absence of tricuspid disease requiring repair was the only independent predictor of safety in this cohort [hazard ratio (HR) 0.460 (0.225-0.941), P = 0.033]. The only independent predictor of operative success was the use of chordal replacement [0.27 (0.09-0.83), P = 0.022]. Reoperation-free survival was 98.5%, 94.5% and 86.9% at 1, 5 and 10 years, respectively. Posterior leaflet pathology demonstrated a higher reoperation-free survival as compared to other localizations (log-rank P = 0.002). The localization of leaflet pathology but not the repair method was an independent predictor for reoperation-free survival (HR 1.455, 95% confidence interval 1.098-1.930; P = 0.009)., Conclusions: In minimally invasive mitral surgery for degenerative disease, chordal replacement yields higher rates of periprocedural success than leaflet resection. Posterior leaflet pathology is an independent predictor of reoperation-free survival., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of this study was to externally validate a lab-based risk score (lactate, creatinine, aspartate aminotransferase, alanine aminotransferase or bilirubin) by Ghoreishi et al. to predict perioperative mortality in patients undergoing surgical repair for acute type A aortic dissection., Methods: The risk score to predict operative mortality was applied to a large and homogenous validation cohort that consisted of 632 patients undergoing surgery for acute type A aortic dissection in 2 centres. Multivariable regression analysis was performed to determine the impact on survival. Receiver operating characteristics with deduced area under the curve were used to assess the ability to predict perioperative mortality., Results: A total of 632 patients (54% male, mean age 62 ± 14 years) were assigned to 3 different risk groups according to the calculated mortality score [low risk <7 (31.2%), moderate risk 7-20 (36.1%) and high >20 (32.7%)]. Perioperative mortality was 8% in the low-risk group, 10% in the moderate-risk group and 24% in the high-risk group (P < 0.0001). Receiver operating characteristic analysis of this new score revealed an area under the curve of 0.69 with adequate calibration. In addition, multivariable analysis revealed an independet assocation with perioperative mortality (odds ratio 1.509; 95% confidence interval 1.042-2.185). While overall survival differed between the risk groups (P < 0.0001), the score does not serve as an independent predictor of long-term mortality when adjusted for relevant covariates., Conclusions: The external validation process confirmed that a newly proposed risk score offers clinicians a helpful and reliable tool to improve the preoperative risk assessment of acute type A aortic dissection patients based on easily accessible and broadly available laboratory parameters., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Aim: Due to improved therapy in childhood, many patients with congenital heart disease reach adulthood and are termed adults with congenital heart disease (ACHD). ACHD often develop heart failure (HF) as a consequence of initial palliative surgery or complex anatomy and subsequently require advanced HF therapy. ACHD are usually excluded from trials evaluating heart failure therapies, and in this context, more data about heart failure trajectories in ACHD are needed to guide the management of ACHD suffering from HF., Methods and Results: The pAtients pResenTing with cOngenital heaRt dIseAse Register (ARTORIA-R) will collect data from ACHD evaluated or listed for heart or heart-combined organ transplantation from 16 countries in Europe and the Asia/Pacific region. We plan retrospective collection of data from 1989-2020 and will include patients prospectively. Additional organizations and hospitals in charge of transplantation of ACHD will be asked in the future to contribute data to the register. The primary outcome is the combined endpoint of delisting due to clinical worsening or death on the waiting list. The secondary outcome is delisting due to clinical improvement while on the waiting list. All-cause mortality following transplantation will also be assessed. The data will be entered into an electronic database with access to the investigators participating in the register. All variables of the register reflect key components important for listing of the patients or assessing current HF treatment., Conclusion: The ARTORIA-R will provide robust information on current management and outcomes of adults with congenital heart disease suffering from advanced heart failure., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Objectives: Transit-time flow measurement is a recognized method for graft evaluation in coronary surgery. However, single flow measurement has been associated with a low specificity for detecting graft dysfunction. The goal of this study was to assess the value of transit-time flow measurement for assessing in situ internal mammary artery grafts during non-existent native coronary circulation and the relevance of collateral blood flow in target vessels., Methods: Between 2014 and 2018, a total of 134 patients undergoing on-pump coronary artery bypass grafting were evaluated using transit-time flow measurement. We analysed 111 single left internal mammary artery and 57 single right internal mammary artery bypasses. Correlations between coronary relevant parameters were calculated using Spearman's ρ coefficient. Risk factors for decreased flow with an arrested heart (FAH) <30 ml/min and an increased pulsatility index (PI) >3.0 as well as flow reduction >30% were calculated., Results: FAH correlated with the diameter of the target vessel (Spearman's ρ = 0.32; P < 0.001), the amount of blood distribution (Spearman's ρ = 0.34; P < 0.001), the PI (Spearman's ρ = 0.19; P = 0.019) and the degree of stenosis (Spearman's ρ = -0.17; P = 0.042). The percentage of flow change was found to correlate with the PI (Spearman's ρ = -0.47; P < 0.0001), the degree of stenosis (Spearman's ρ = 0.42; P < 0.001), the diameter of the target vessel (Spearman's ρ = -0.22; P = 0.008) and the area of blood distribution (Spearman's ρ = -0.19; P = 0.018). A small blood distribution area was the only risk factor for decreased FAH [odds ratio (OR) 8.43, confidence interval (CI) 95% (3.04-23.41); P < 0.001]. Binary logistic regression identified PI [OR 2.05, CI 95% (1.36-3.10); P = 0.001], FAH [OR 0.98, CI 95% (0.97-0.99); P = 0.005] and degree of stenosis [OR 0.95, CI 95% (0.92-0.99); P = 0.011] as risk factors for decreased flow after cardiopulmonary bypass (<30 ml/min). An increased PI (>3) was mainly influenced by percentage of flow change [OR 0.99, CI 95% (0.98-1.00); P = 0.031]., Conclusions: FAH and percentage of flow change are related to the dimensions of the target vessel and the degree of stenosis. The addition of flow measurements with the heart arrested provides additional information about the bypass graft, the quality of the anastomosis and the physiology of the coronary circulation., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on acute and elective thoracic and abdominal aortic procedures., Methods: Forty departments shared their data on acute and elective thoracic and abdominal aortic procedures between January and May 2020 and January and May 2019 in Europe, Asia and the USA. Admission rates as well as delay from onset of symptoms to referral were compared., Results: No differences in the number of acute thoracic and abdominal aortic procedures were observed between 2020 and the reference period in 2019 [incidence rates ratio (IRR): 0.96, confidence interval (CI) 0.89-1.04; P = 0.39]. Also, no difference in the time interval from acute onset of symptoms to referral was recorded (<12 h 32% vs > 12 h 68% in 2020, < 12 h 34% vs > 12 h 66% in 2019 P = 0.29). Conversely, a decline of 35% in elective procedures was seen (IRR: 0.81, CI 0.76-0.87; P < 0.001) with substantial differences between countries and the most pronounced decline in Italy (-40%, P < 0.001). Interestingly, in Switzerland, an increase in the number of elective cases was observed (+35%, P = 0.02)., Conclusions: There was no change in the number of acute thoracic and abdominal aortic cases and procedures during the initial wave of the COVID-19 pandemic, whereas the case load of elective operations and procedures decreased significantly. Patients with acute aortic syndromes presented despite COVID-19 and were managed according to current guidelines. Further analysis is required to prove that deferral of elective cases had no impact on premature mortality., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Immediate surgical repair for type A aortic dissection is gold standard and at most centres is performed by the surgeon on call during night-time and weekends. The objective was to evaluate whether emergency surgery during night-time or weekends has an influence on 30-day mortality., Methods: In 319 patients undergoing surgery for type A aortic dissection, skin incision was documented. Patients were divided into 2 groups according to the time point of skin incision (05:00 a.m. to 07:00 p.m. = daytime group; 07:01 p.m. to 04:59 a.m. = night-time group). We also noted whether their surgeries were started on weekdays (Monday 00:00 to Friday 23:59) or weekends (Saturday 00:00 to Sunday 23:59)., Results: The median age was 61 years (interquartile range 49-70) and 69.6% (n = 222) were male. Almost 50% (n = 149) of patients presented in a critical preoperative state. Forty-one percent of patients (n = 131) underwent night-time surgery. There were no differences in baseline data, time from onset of symptoms to surgery or surgical treatment between groups, except from preferred femoral access for arterial cannulation during night-time. Advanced age [odds ratio 1.042, 95% confidence interval (CI) 1.014-1.070], preoperative malperfusion syndrome (odds ratio 2.542, 95% CI 1.279-5.051) and preoperative tamponade (odds ratio 2.562, 95% CI 1.215-5.404) emerged as risk factors for 30-day mortality. Night-time or weekend surgery did not have any impact on 30-day mortality when covariates were considered., Conclusions: Based on the natural course of the disease and our results, surgery for type A aortic dissection should be performed as an emergency surgery regardless of time and day., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Neurologic dysfunction remains an ongoing challenge in the diagnosis of type A aortic dissection (AAD). Our study analyzed the impact of preoperative neurologic dysfunction (PND) on outcome and assessed a potential link between PND and specific patterns of postoperative neurologic injury., Methods: Medical records of 338 patients (70.1% men; mean age, 59.3 ± 13.7 years) undergoing surgical repair for AAD were screened for the presence of PND. Preoperative characteristics, surgical treatment, and hospital and neurologic outcomes were analyzed according to patients with PND (PND+) and without PND (PND-) RESULTS: There were 50 patients (14.8%) admitted with PND. PND+ patients showed significantly higher rates of postoperative neurologic injury (44.4%) than PND- patients (14.3%; P < .001) with a specific pattern of ischemic lesions in accordance with preoperative neurologic status. While PND+ patients suffered mainly from right hemispheric strokes (66.7% vs 32.4% in PND- patients, P = .024), PND- patients more frequently presented with bilateral cerebral ischemia (56.8% vs 13.3% in PND+ patients, P = .004). Multivariable analysis identified presence of PND (odds ratio, 2.977; 95% confidence interval, 1.357-6.545) as an independent predictor for new postoperative neurologic injury. PND was associated with impaired survival (P = .005)., Conclusions: This study identified an association of preoperative neurologic status and specific stroke patterns after surgical repair of AAD. Irrespective of timing of surgery and reperfusion strategies, preoperative neurologic dysfunction is strongly associated with impaired neurologic outcome., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Organ transplantation is undergoing profound changes. Contraindications for donation have been revised in order to better meet the organ demand. The use of lower-quality organs and organs with greater preoperative damage, including those from donation after cardiac death (DCD), has become an established routine but increases the risk of graft malfunction. This risk is further aggravated by ischemia and reperfusion injury (IRI) in the process of transplantation. These circumstances demand a preservation technology that ameliorates IRI and allows for assessment of viability and function prior to transplantation. Oxygenated hypothermic and normothermic machine perfusion (MP) have emerged as valid novel modalities for advanced organ preservation and conditioning. Ex vivo prolonged lung preservation has resulted in successful transplantation of high-risk donor lungs. Normothermic MP of hearts and livers has displayed safe (heart) and superior (liver) preservation in randomized controlled trials (RCT). Normothermic kidney preservation for 24 h was recently established. Early clinical outcomes beyond the market entry trials indicate bioenergetics reconditioning, improved preservation of structures subject to IRI, and significant prolongation of the preservation time. The monitoring of perfusion parameters, the biochemical investigation of preservation fluids, and the assessment of tissue viability and bioenergetics function now offer a comprehensive assessment of organ quality and function ex situ . Gene and protein expression profiling, investigation of passenger leukocytes, and advanced imaging may further enhance the understanding of the condition of an organ during MP. In addition, MP offers a platform for organ reconditioning and regeneration and hence catalyzes the clinical realization of tissue engineering. Organ modification may include immunological modification and the generation of chimeric organs. While these ideas are not conceptually new, MP now offers a platform for clinical realization. Defatting of steatotic livers, modulation of inflammation during preservation in lungs, vasodilatation of livers, and hepatitis C elimination have been successfully demonstrated in experimental and clinical trials. Targeted treatment of lesions and surgical treatment or graft modification have been attempted. In this review, we address the current state of MP and advanced organ monitoring and speculate about logical future steps and how this evolution of a novel technology can result in a medial revolution., (Copyright © 2020 Resch, Cardini, Oberhuber, Weissenbacher, Dumfarth, Krapf, Boesmueller, Oefner, Grimm and Schneeberger.)

Background  Driveline infection is a serious complication in left ventricular assist device (LVAD) patients. We report the case of a patient who was successfully treated by combining instillation and vacuum-assisted closure (VAC) therapy. Case Description  A 65-year-old LVAD patient presented with recurrent driveline infection. Local therapy with VAC therapy in combination with instillation of polyhexanide was performed for 2 weeks. The patient remains free from infection for twelve months by now. Conclusion  This case is the first to present the combination of polyhexanide instillation with VAC as treatment for driveline infection. This therapy may thus be an option for patients who lack any other surgical option., Competing Interests: Conflict of Interest None declared.

Objectives: This study sought to assess the incremental prognostic value of the psoas muscle area in patients scheduled for transcatheter aortic valve implantation (TAVI)., Methods: A total of 1076 consecutive patients undergoing TAVI at 2 centres between 2010 and 2017 were prospectively included in this study. Computed tomography-derived cross-sectional area of the psoas muscle was measured at the superior border of the third (L3) and fourth (L4) lumbar vertebra and indexed to body surface area (PMAi) as well as stratified into tertiles. Multivariable logistic regression and Cox regression analyses were performed to investigate the value of PMAi as a predictor of 30-day and cumulative mortality. The incremental prognostic value of PMAi over the Society of Thoracic Surgeons (STS) score was assessed using a net reclassification analysis., Results: The rate of 30-day mortality was 5.8% (n = 62). PMAi at the level of L3 [odds ratio 0.082, 95% confidence interval (CI) 0.011-0.589; P = 0.013] and L4 (odds ratio 0.049, 95% CI 0.005-0.536; P = 0.013) was independently associated with 30-day mortality. During a median follow-up of 435 days (interquartile range 139-904), 292 patients (27.1%) died. PMAi of L3 (hazard ratio 0.200, 95% CI 0.083-0.482; P < 0.001) and L4 (hazard ratio 0.083, 95% CI 0.029-0.235; P < 0.001) was independently associated with mortality during follow-up. The addition of PMAi to the STS score led to a net reclassification improvement for 30-day and cumulative mortality., Conclusions: PMAi emerged as a valuable outcome predictor in patients undergoing TAVI. The addition of PMAi to the established STS score led to an increase in its prognostic ability.

Purpose: Thoracic aortic aneurysm/aortic dissection (TAAD) is a disorder with highly variable age of onset and phenotype. We sought to determine the prevalence of pathogenic variants in TAAD-associated genes in a mixed cohort of sporadic and familial TAAD patients and identify relevant genotype-phenotype relationships., Methods: We used a targeted polymerase chain reaction and next-generation sequencing-based panel for genetic analysis of 15 TAAD-associated genes in 1,025 unrelated TAAD cases., Results: We identified 49 pathogenic or likely pathogenic (P/LP) variants in 47 cases (4.9% of those successfully sequenced). Almost half of the variants were in nonsyndromic cases with no known family history of aortic disease. Twenty-five variants were within FBN1 and two patients were found to harbor two P/LP variants. Presence of a related syndrome, younger age at presentation, family history of aortic disease, and involvement of the ascending aorta increased the risk of carrying a P/LP variant., Conclusion: Given the poor prognosis of TAAD that is undiagnosed prior to acute rupture or dissection, genetic analysis of both familial and sporadic cases of TAAD will lead to new diagnoses, more informed management, and possibly reduced mortality through earlier, preclinical diagnosis in genetically determined cases and their family members.

Objectives: Despite improvement in operative and cerebral perfusion techniques, cerebral malperfusion and neurological injury remain a dreaded complication of acute type A aortic dissection. We aimed to identify predictors for postoperative stroke and analyse the impact on morbidity, neurological recovery and mid-term survival., Methods: Between 2000 and 2017, 303 (71.9% men, mean age 58.9 ± 13.6 years) patients with acute type A aortic dissection underwent surgical repair. Clinical and imaging data were retrospectively evaluated. Patients were divided into 2 groups depending on the presence of postoperative stroke., Results: Postoperative stroke was detected in 15.8% (n = 48) of the patients. Patients with postoperative stroke showed higher rates of preoperative cardiopulmonary resuscitation (stroke: 18.8% vs no stroke: 3.5%, P < 0.001) and malperfusion syndrome (stroke: 47.9% vs no stroke: 22.4%, P < 0.001). Multivariable analysis identified the presence of bovine aortic arch [odds ratio (OR) 2.33, 95% confidence interval (CI) 1.086-4.998; P = 0.030], preoperative cardiopulmonary resuscitation (OR 6.483, 95% CI 1.522-27.616; P = 0.011) and preoperative malperfusion (OR 2.536, 95% CI 1.238-5.194; P = 0.011) as independent predictors for postoperative stroke. Postoperative stroke had a strong impact on morbidity and was associated with higher rates of postoperative complications and a significantly longer hospital stay (stroke: 23 ± 16 days vs no stroke: 17 ± 18 days, P = 0.021). Postoperative stroke was not independently associated with in-hospital mortality (adjusted OR 1.382, 95% CI 0.518-3.687; P = 0.518). There was no difference in mid-term survival between patients with stroke and patients without stroke., Conclusions: This study identified independent preoperative predictors for postoperative stroke. Although postoperative stroke was associated with significant morbidity and postoperative complications, significant impairment in mid-term survival could not be confirmed by the data.

Background: In international guidelines, risk estimation for thoracic ascending aortic aneurysm (TAAA) is based on aortic diameter. We previously introduced the aortic size index (ASI), defined as aortic size/body surface area (BSA), as a predictor of aortic dissection, rupture, and death. However, weight might not contribute substantially to aortic size and growth. We seek to evaluate the height-based aortic height index (AHI) versus ASI for risk estimation and revisit our natural history calculations., Methods: Aortic diameters and long-term complications of 780 patients with TAAA were analyzed. Growth rate estimates, yearly complication rates, and survival were assessed. Risk stratification was performed using regression models. The predictive value of AHI and ASI was compared., Results: Patients were stratified into 4 categories of yearly risk of complications based on their ASI and AHI. ASIs (cm/m 2 ) of ≤2.05, 2.08 to 2.95, 3.00 to 3.95 and ≥4, and AHIs (cm/m) of ≤2.43, 2.44 to 3.17, 3.21 to 4.06, and ≥4.1 were associated with a 4%, 7%, 12%, and 18% average yearly risk of complications, respectively. Five-year complication-free survival was progressively worse with increasing ASI and AHI. Both ASI and AHI were shown to be significant predictors of complications (P < .05). AHI categories 3.05 to 3.69, 3.70 to 4.34, and ≥4.35 cm/m were associated with a significantly increased risk of complications (P < .05). The overall fit of the model using AHI was modestly superior according to the concordance statistic., Conclusions: Compared with indices including weight, the simpler height-based ratio (excluding weight and BSA calculations) yields satisfactory results for evaluating the risk of natural complications in patients with TAAA., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) and the Society of Thoracic Surgeons (STS) score are currently used to estimate periprocedural risk of death in patients undergoing transcatheter aortic valve implantation (TAVI). However, data regarding the predictive ability and usefulness of these scores for TAVI are controversial, especially for different access sites., Methods: Between 2008 and 2016, 1192 consecutive patients undergoing TAVI [transfemoral (TF): n = 607 (51%); transapical (TA): n = 585 (49%)] at 2 centres were included. All-cause mortality was assessed at a median of 533 days (interquartile range 153-1036). The value of the EuroSCORE II and the STS score in terms of predicting 30-day and cumulative mortality according to access site was investigated., Results: The mean age was 83 (interquartile range 79-86) years. Overall, the 30-day mortality rate was 7.6% (n = 90), and the cumulative all-cause mortality rate was 35.1% (n = 418). The EuroSCORE II and the STS score were significantly increased in non-survivors compared with survivors (P < 0.001). The EuroSCORE II and the STS score emerged as independent predictors of 30-day mortality [EuroSCORE II: odds ratio (OR) 1.039, 95% confidence interval (CI) 1.013-1.065; P = 0.003; STS score: OR 1.055, 95% CI 1.023-1.088; P = 0.001] and cumulative all-cause mortality [EuroSCORE II: hazard ratio (HR) 1.026, 95% CI 1.013-1.038; P < 0.001; STS score: HR 1.05, 95% CI 1.03-1.06; P < 0.001]. In contrast to TF TAVI, the EuroSCORE II (OR 1.038, 95% CI 1.009-1.068; P = 0.010) and the STS score (OR: 1.063, 95% CI 1.025-1.102; P = 0.001) were independent predictors of 30-day mortality and cumulative mortality (EuroSCORE II: HR 1.023, 95% CI 1.009-1.037; P = 0.001; STS score: HR 1.055, 95% CI 1.037-1.073; P < 0.001) in patients undergoing TA TAVI., Conclusions: The EuroSCORE II and the STS score were independent predictors of 30-day and cumulative mortality rates in patients undergoing TAVI. The EuroSCORE II and the STS score were associated with 30-day mortality and mortality during follow-up period only in TA TAVI., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The study sought to evaluate if a bovine aortic arch (BAA) influences the location of the entry site in acute aortic dissection type A (AADA) and to identify the impact of BAA on postoperative outcome, especially stroke., Methods: A total of 315 patients underwent surgery due to AADA DeBakey type I (72.1% men, mean age 59.5 ± 13.4 years) between 2002 and 2015. Imaging studies and operative reports were screened for presence of BAA and location of the entry site. Patients were divided into 2 groups based on presence (BAA+) and absence (BAA-) of BAA (BAA+ n = 49, BAA- n = 264). Dissection patterns, surgical treatment, risk factors for postoperative complications, and long-term outcome were analyzed., Results: Prevalence of BAA in patients with AADA was 15.6%. Location of the entry site was more commonly in the aortic arch in patients with BAA (BAA+ 46.8% versus BAA- 14.3%; p < 0.001). Multivariable analysis identified BAA (odds ratio [OR], 5.9; 95% confidence interval [CI], 2.89 to 12.04; p < 0.001) and preoperative competent aortic valve (OR, 2.26; 95% CI, 1.19 to 4.31; p = 0.013) as independent predictors for an arch tear. Thirty-nine patients (12.4%) suffered from stroke. Patients with BAA had higher stroke rates (BAA+ 24.5% versus BAA- 10.2%; p = 0.009). BAA emerged as one risk factor for stroke in the setting of AADA (OR, 2.69; 95% CI, 1.2 to 6.0; p = 0.016). Long-term survival was comparable for patients with BAA and patients without congenital arch anomalies., Conclusions: BAA is an independent predictor for the distinctive location of the entry site in the aortic arch and risk factor for stroke., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Our basic understanding of ascending thoracic aortic aneurysm (ATAA) pathogenesis is still very limited, hampering early diagnosis, risk prediction, and development of treatment options. "Omics"-technologies, ideal to reveal tissue alterations from the normal physiological state due to disease have hardly been applied in the field. Using a metabolomic approach, with this study the authors seek to define tissue differences between controls and various forms of ATAAs., Methods: Using a targeted FIA-MS/MS metabolomics approach, we analysed and compared the metabolic profiles of ascending thoracic aortic wall tissue of age-matched controls (n = 8), bicuspid aortic valve-associated aneurysms (BAV-A; n = 9), tricuspid aortic valve-associated aneurysms (TAV-A; n = 14), and tricuspid aortic valve-associated aortic dissections (TAV-Diss; n = 6)., Results: With sphingomyelin (SM) (OH) C22:2, SM C18:1, SM C22:1, and SM C24:1 only 4 out of 92 detectable metabolites differed significantly between controls and BAV-A samples. Between controls and TAV-Diss samples only phosphatidylcholine (PC) ae C32:1 differed. Importantly, our analyses revealed a general increase in the amount of total sphingomyelin levels in BAV-A and TAV-Diss samples compared to controls., Conclusions: Significantly increased levels of sphingomyelins in BAV-A and TAV-Diss samples compared to controls may argue for a repression of sphingomyelinase activity and the sphingomyelinase-ceramide pathway, which may result in an inhibition of tissue regeneration; a potential basis for disease initiation and progression.

Objectives: Surgical therapy for acute aortic dissection type A (AADA) in octogenarians carries high morbidity and mortality. The role of isolated medical treatment in this setting is controversial. The aim of this study is to determine whether risk of surgery for AADA outweighs risk of death from medical treatment only., Methods: From 2002 to 2015, 90 consecutive octogenarians (mean age, 83.5 ± 3 years) were treated for AADA at three institutions: 67 patients underwent surgery, 23 patients received medical treatment. Analysis of early and late outcome was performed., Results: Patients in the medical treatment group were significantly older than in the surgical group (84.9 ± 3.7 vs 83 ± 2.5 years, P  = 0.008) and in a more critical state. In patients undergoing surgical repair, perioperative mortality was 14.9% ( n  = 10). Rate of prolonged ventilation (63.2% vs 5.9%; P  < 0.001) and renal failure (35.1% vs 5.9%, P  = 0.029) was significantly higher in the surgical group. Thirty-day survival was impaired in the medical treatment group (34.8% vs 61.2% in the surgical group; P  = 0.032). Coronary artery disease (OR 3.95, 95% CI 1.16-13.49; P  = 0.029) and complicated dissections (OR 5.28, 95% CI 1.48-18.88; P  = 0.010)-composite variable of preoperative resuscitation, neurological injury and malperfusion-emerged as independent risk factors for 30-day mortality in the surgical group. There was no difference in long-term survival., Conclusions: Emergency surgery for AADA in octogenarians is associated with relatively high intraoperative mortality and may reasonably be avoided in patient with complicated presentation. Despite better immediate survival after surgery, long-term survival does not differ between medical and surgical patients, reflecting the extremely advanced point in life cycle octogenarians., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

We review current knowledge regarding the natural transition of aortic dissection from acute to chronic stages. As this is not well understood, we also bring to bear new data from our institution. Type A dissection rarely transitions naturally into the chronic state; consequently, information is limited. Type B dissections are routinely treated medically and indeed undergo substantial changes during their temporal course. General patterns include: 1) the aorta dilates and, absent surgical intervention, aortic enlargement may cause mortality; 2) continued false lumen patency, particularly with an only partially thrombosed false lumen, increases aortic growth, whereas calcium-channel blockers affect aortic dilation favorably; 3) aortic dilation manifests a temporal dynamic, with early rapid growth and deceleration during transition; 4) the intimal flap dynamically changes over time via thickening, straightening, and loss of mobility; and 5) temporal remodeling, on the cellular level, initially shows a high grade of wall destruction; subsequently, significant fibrosis ensues., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of the study was to assess the anticipated incremental risk of a concomitant aortic resection performed with an aortic valve replacement., Methods: Patients who underwent aortic valve replacement with root-sparing ascending replacement were compared with those who underwent isolated aortic valve replacement using propensity score matching (81 pairs; mean age, 63 ± 11 years [root-sparing ascending replacement] vs 64 ± 14 years). To evaluate the impact of the technique at distal site, 71 pairs of those undergoing root-sparing ascending replacement also were matched by propensity score according to distal anastomosis performed clamped and open under deep hypothermic circulatory arrest., Results: Operative mortality was equal between the root-sparing ascending replacement and isolated aortic valve replacement groups. No significant difference was found regarding postoperative morbidities, such as bleeding, renal failure, stroke, and length of stay, except prolonged ventilation was found after root-sparing procedures (P = .028). Survival estimation showed no difference between the groups. Comparing the patients undergoing root-sparing ascending replacement with clamped and opened distal anastomosis revealed a prolonged ventilation requirement (7% vs 3%; P = not significant) in the open group. Operative mortality was 0% in both groups, and midterm survival was comparable., Conclusions: The concomitant replacement of the aorta in root-sparing fashion is associated with an excellent operative outcome and adds no additional risk to aortic valve replacement in elective and non-high-risk patients. If the distal anastomosis is performed in an open fashion, while the operative mortality is still very low, morbidities are slightly higher, but midterm survival remains comparable., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of the study was to evaluate the operative outcome and the risk of retained proximal aortic tissue following the root-sparing (RS) technique in acute aortic dissection type A (AADA)., Methods: Between 2002 and 2014, 338 patients underwent repair of AADA; 74% of those were performed with the RS technique and 26% with root replacement (RR). The mean age was 62.4 ± 13.4 years (69% male) in the RS group and 56.1 ± 13.1 years (76% male) in the RR group (P < 0.001). Aortic insufficiency 2+ or higher was present in 35% (RS) and 72% (RR, P < 0.001), and bicuspid morphology in 1% (RS) and 16% (RR, P < 0.001)., Results: Cardiopulmonary bypass time and cross-clamp time were significantly lower in the RS group (199 ± 71 vs 274 ± 110 min; 108 ± 46 vs 169 ± 55 min; P < 0.001 each), while no difference was seen with regard to distal operative extent, the use of circulatory arrest and adjunct protection strategies. The postoperative incidence of bleeding (18 vs 34%; P = 0.003), low cardiac output (14 vs 29%; P = 0.002) and sepsis/systemic inflammatory response syndrome (5 vs 12%; P = 0.037) were higher after RR, whereas mortality and survival did not differ between the groups. The aortic root grows at 0.40 ± 0.13 mm/year after AADA and thus, the need for potential reoperation was estimated at greater than 40 years. Freedom from root events after 5 and 10 years of follow-up was 97 and 92% in the RS group, and 100% each in RR group, respectively., Conclusions: Both RS and RR procedures can be performed with an acceptable postoperative outcome and late survival in AADA. The RS approach can safely be performed with excellent results in acute survival and stabilizes the native root for a long period of time., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To analyse the clinical outcomes of surgical repair of DeBakey type I and III aortic dissection (AD) by using the frozen elephant trunk (FET) technique, and to evaluate the postoperative behaviour of the residual aorta., Methods: In total, 27 consecutive patients underwent treatment of the thoracic aorta for AD with the FET technique in a tertiary-care hospital in Vienna/Austria between 2005 and 2012, and were enrolled in this case series study. All operations were performed under circulatory arrest and bilateral antegrade cerebral perfusion. During the follow-up, a clinical examination was performed as well as aortic diameters and false lumen (FL) patency evaluated by computed tomography (CT) imaging at following levels: pulmonary bifurcation, diaphragm and coeliac trunk., Results: The mean age of the patient cohort was 56 ± 12 years; 21 patients were male. Twenty-two (82%) and 5 (18%) patients presented with DeBakey type I and type III AD, respectively. The hospital mortality rate was 7% (2/28); 2 patients died due to non-aortic-related reasons during a follow-up period of 48 ± 26 months. Three (11%) patients had a stroke, and 2 (7%) a spinal cord injury. The follow-up CT scans revealed FL thrombosis in 96% of the patients at the level of the pulmonary bifurcation (P < 0.001). Distal to the stent graft, at the level of the diaphragm and coeliac trunk, FL patency was observed in 52% (P = 0.1) and 78% (P = 0.6) of the patients, respectively. The true lumen of all analysed aortic segments increased significantly while the mean aortic diameter remained stable., Conclusions: Compared with conventional surgery for extensive ADs, the FET technique provides a high rate of FL thrombosis of the thoracic aorta., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: To examine the potential of aortic arch variants, specifically bovine aortic arch, isolated left vertebral artery, and aberrant right subclavian artery, as markers for thoracic aortic disease (TAD)., Methods: We screened imaging data of 556 patients undergoing surgery due to TAD for presence of aortic arch variations. Demographic data were collected during chart review and compared with a historical control group of 4617 patients., Results: Out of 556 patients with TAD, 33.5% (186 patients) demonstrated anomalies of the aortic arch, compared with 18.2% in the control group (P < .001). Three hundred seventy (66.5%) had no anomaly of the aortic arch. Bovine aortic arch emerged as the most common anomalous branch pattern with a prevalence of 24.6% (n = 137). Thirty-five patients (6.3%) had an isolated left vertebral artery, and 10 patients (1.8%) had an aberrant right subclavian artery. When compared with the control group, all 3 arch variations showed significant higher prevalence in patients with TAD (P < .001). Patients with aortic aneurysms and anomalous branch patterns had hypertension less frequently (73.5% vs 81.8%; P = .048), but had a higher rate of bicuspid aortic valve (40.8% vs 30.6%; P = .042) when compared with patients with aneurysms but normal aortic arch anatomy. Patients with aortic branch variations were significantly younger (58.6 ± 13.7 years vs 62.4 ± 12.9 years; P = .002) and needed intervention for the aortic arch more frequently than patients with normal arch anatomy (46% vs 34.6%; P = .023)., Conclusions: Aortic arch variations are significantly more common in patients with TAD than in the general population. Atypical branching variants may warrant consideration as potential anatomic markers for future development of TAD., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To review the current general concepts and understanding of the natural history of thoracic aortic aneurysm and their clinical implications., Methods: Data on the the normal thoracic aortas were derived from the database of the Multi-Ethnic Study of Atherosclerosis (n = 3573), representative of the general population. Data on diseased thoracic aorta were derived from the database of the Aortic Institute at Yale-New Haven Hospital (n = 3263), representative of patients with thoracic aortic aneurysm and dissection., Results: Our studies have shown that the normal aorta in the general population is small (3.2 cm for the ascending aorta). Aortas larger than 5 cm are rare in the real world. The aneurysmal aorta grows at a mean of 0.2 cm/y, and larger aneurysms grow faster than do smaller ones. The dissection size paradox (which shows some aortic dissections occurring at small aneurysm sizes) is explained by the huge number of patients with small aortas in the general population. Genetic testing of patients with thoracic aortic disease helps identify genes responsible for aortic aneurysm and dissection. New imaging techniques such as 4-dimensional magnetic resonance imaging may add engineering data to our decision making., Conclusions: Size continues to be a strong predictor of natural complications and a suitable parameter for intervention. As we enter the era of personalized aneurysm care, it is likely that specific genetic mutations will facilitate the determination of the appropriate size criterion for surgical intervention in individual cases., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to evaluate if the presence of a bovine aortic arch (BAA)- the most common aortic arch anomaly-influences the location of the primary entry tear, the surgical procedure, and the outcome of patients undergoing operation for type A acute aortic dissection (AAD)., Methods: A total of 157 patients underwent emergency operations because of AAD (71% men, mean age 59.5 ± 13 years). Preoperative computed tomographic scans were screened for the presence of BAA. Patients were separated into 2 groups: presenting with BAA (BAA+, n = 22) or not (BAA-, n = 135). Location of the primary tear, surgical treatment, outcome, and risk factors for postoperative neurologic injury and in-hospital mortality were analyzed., Results: Fourteen percent (22 of 157) of all patients operated on for AAD had a concomitant BAA. Location of the primary entry tear was predominantly in the aortic arch in patients with BAA (BAA+, 59.1% versus BAA-, 13.3%; p < 0.001). Multivariate analysis revealed the presence of a BAA to be an independent risk factor for having the primary tear in the aortic arch (odds ratio [OR], 14.79; 95% confidence interval [CI] 4.54-48.13; p < 0.001) but not for in-hospital mortality. Patients with BAA had a higher rate of postoperative neurologic injury (BAA+, 35% versus BAA-, 7.9%; p = 0.004). Multivariate analysis identified the presence of BAA as an independent risk factor for postoperative neurologic injury (OR, 4.9; 95% CI, 1.635-14.734; p = 0.005)., Conclusions: In type A AAD, the presence of a BAA predicts the location of the primary entry site in the aortic arch and is an independent risk factor for a poor neurologic outcome., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We present ten important specific tips regarding the natural history of Type B aortic dissection, which have a bearing on diagnosis and management decisions.

Objectives: In destructive aortic valve endocarditis with abscess formation in the root, homografts are used more often than xenografts. Because we had reliable perioperative results with Freestyle (Medtronic Inc, Minneapolis, Minn) xenograft root replacement in these complex patients, we analyzed the long-term outcome in this high-risk indication., Methods: Of 126 consecutive patients with aortic valve endocarditis treated by surgery from 1997 to 2012, 32 (25.4%) received a Freestyle aortic root replacement for severe, destructive valve endocarditis and were studied retrospectively with approval of the local ethical committee. Perioperative complications, recurrence of endocarditis, and long-term morbidity and mortality were analyzed. The follow-up period was 3 months to 11.5 years., Results: Indication for surgery was native (n = 9) and prosthetic valve endocarditis (n = 23). In 18 patients, concomitant procedures were performed: coronary bypass (n = 9), additional valve surgery (n = 6), and ascending aortic surgery (n = 7). Thirty-day mortality was 19.4% (n = 6). There were no instances of technical failure requiring modification of the surgical strategy or reoperation for anastomotic bleeding. Actuarial survival at 5 and 10 years was 61.9% and 54.2%, respectively. Freedom from death, reoperation for prostheses dysfunction, and recurrence of endocarditis as the composite end point at 5 and 10 years was 56.3% and 53.1%, respectively., Conclusions: The Freestyle root was used successfully with no technical complications in all patients with most severe destructive aortic root endocarditis. In view of this complex patient population, short- and long-term results make this conduit a reliable choice for treatment of this condition., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

We present the case of a 56-year-old patient suffering from an aorto-esophageal fistula after complex treatment of acute Type A dissection including thoracic endovascular aortic repair (TEVAR) of the descending aorta. Open surgical descending replacement using a pericardial patch, as well as esophagectomy, was performed. After a long and complicated hospital stay, the patient finally recovered and was discharged in stable condition. By choosing an aggressive surgical approach the patient survived this devastating complication of TEVAR, which is associated with high mortality.

Patients and Methods: 140 patients with aortic dissection type A were admitted for cardiac surgery. Seventy-seven patients experienced their dissection in the winter season (from November to April). We analyzed cases of ascending aortic dissection associated with alpine skiing., Results: In 17 patients we found skiing-related aortic dissections. Skiers were taller (180 (172-200) cm versus 175 (157-191) cm, P = 0.008) and heavier (90 (68-125) kg versus 80 (45-110) kg, P = 0.002) than nonskiers. An extension of aortic dissection into the aortic arch, the descending thoracic aorta, and the abdominal aorta was found in 91%, 74%, and 69%, respectively, with no significant difference between skiers and nonskiers. Skiers experienced RCA ostium dissection requiring CABG in 17.6% while this was true for 5% of nonskiers (P = 0.086). Hospital mortality of skiers was 6% versus 13% in nonskiers (P = 0.399). The skiers live at an altitude of 170 (0-853) m.a.s.l. and experience their dissection at 1602 (1185-3105; P < 0.001) m.a.s.l. In 82% symptom start was during recreational skiing without any trauma., Conclusion: Skiing associated aortic dissection type A is usually nontraumatic. The persons affected live at low altitudes and practice an outdoor sport at unusual high altitude at cold temperatures. Postoperative outcome is good.

Background: This study is to evaluate if different locations of the primary entry tear result in primary complicated, secondary complicated, or uncomplicated acute type B aortic dissection., Methods: Sixty-five patients were analyzed. Patients were stratified according to the location of the primary entry tear. Primary entry tears in axial computed tomographic scans at the upper circumference (180°) of the distal aortic arch were defined as convex (group A) and the remaining as concave (group B). Detailed morphometry was done and the clinical outcome, including need for thoracic endovascular aortic repair, was evaluated., Results: Forty-two patients (group A) had the primary entry tear at the convexity and 23 patients (group B) had the primary entry tear at the concavity of the distal aortic arch. There was a significant difference with regard to the incidence of primary complicated type B aortic dissection (group A 21% vs group B 61%, p = 0.003) and with regard to the development of complications in group A (9 days; 9 to 37) versus group B (0 days; 0 to 13, p = 0.03). Cox regression analysis revealed a primary entry tear at the concavity to be the only independent predictor of primary or secondary development of a complicated acute type B aortic dissection (hazard ratio, 1.8; 95% confidence interval, 1.0 to 3.2)., Conclusions: A primary entry tear at the concavity of the distal aortic arch is associated with a significant increase of the occurrence of complicated acute type B aortic dissection. Due to low procedural risk and high success rates, closure of the primary entry tear with thoracic endovascular aortic repair is strongly recommended in this newly defined high-risk subgroup of patients., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)