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OBJECTIVE To analyse the results after elective open total aortic arch replacement. METHODS We analysed 39 patients (median age 63 years, median logistic EuroSCORE 18.4) who underwent elective open total arch replacement between 2005 and 2012. RESULTS In-hospital mortality was 5.1% (n = 2) and perioperative neurological injury was 12.8% (n = 5). The indication for surgery was degenerative aneurysmal disease in 59% (n = 23) and late aneurysmal formation following previous surgery of type A aortic dissection in 35.9% (n = 14); 5.1% (n = 2) were due to anastomotical aneurysms after prior ascending repair. Fifty-nine percent (n = 23) of the patients had already undergone previous proximal thoracic aortic surgery. In 30.8% (n = 12) of them, a conventional elephant trunk was added to total arch replacement, in 28.2% (n = 11), root replacement was additionally performed. Median hypothermic circulatory arrest time was 42 min (21-54 min). Selective antegrade cerebral perfusion was used in 95% (n = 37) of patients. Median follow-up was 11 months [interquartile range (IQR) 1-20 months]. There was no late death and no need for reoperation during this period. CONCLUSIONS Open total aortic arch replacement shows very satisfying results. The number of patients undergoing total arch replacement as a redo procedure and as a part of a complex multisegmental aortic pathology is high. Future strategies will have to emphasize neurological protection in extensive simultaneous replacement of the aortic arch and adjacent segments.

This joint position paper gives a concise overview of the pre-, intra- and postoperative issues and management of pacemaker and de­fibrillator carriers in the setting of electrocautery used for surgery.

OBJECTIVES: The treatment of massive pulmonary embolism (PE) is a matter of debate. We present our institutional experience of patients suffering from massive PE with the aim of comparing the early results, the outcome and quality of life (QoL) between patients primarily assigned to either pulmonary surgical embolectomy (SE) or thrombolytic therapy (TL). A subgroup of patients (TS) with failed responses to TL requiring SE was separately analysed. METHODS: All consecutive patients (January 2001–December 2007) with computed tomography (CT)-scan-confirmed massive bilateral central or paracentral PE were reviewed. All clinical data were retrieved from our patients’ registry and completed by the evaluation of the CT-scan-derived right ventricle/left ventricle ratio (RV/LV ratio). Follow-up focused on clinical outcome and QoL was obtained. RESULTS: Eighty patients were analysed including 28 SE (35%) and 52 TL (65%), of whom 11 (21%) required TS. Demographics and preoperative characteristics were similar between SE and TL. Analysis of the RV/LV ratio revealed a ratio of 1.66 for SE and 1.44 for TL. The early mortality rate was not significantly different between the two groups (SE: 3.6% versus TL: 13.5%), whereas early mortality was 27% in those patients treated initially with thrombolysis and subsequently requiring SE (TS-group). Severe bleeding complications were lower in the SE-group (3.6% versus 26.5% P = 0.013). Intracerebral bleeding rates and neurological events were not statistically different. After a mean follow-up of 63 ± 21 months, the mortality rate was 17.9% in the SE-group and 23.1% in the TL-group. CONCLUSIONS: SE is an excellent treatment option in massive PE with comparable early mortality rates and significantly less bleeding complications than TL. Patients having surgery after inefficient thrombolysis have the worst early outcome. The RV/LV CT-scan ratio might serve as a predictor to differentiate patients, who could profit from direct surgical intervention than thrombolytic treatment attempts. Further studies are required to confirm these results.

Stroke due to hypoperfusion or emboli is a devastating adverse event of cardiac surgery, but early detection and treatment could protect patients from an unfavorable postoperative course. Hypoperfusion and emboli can be detected with transcranial Doppler of the middle cerebral artery (MCA). The measured blood flow velocity correlates with cerebral oxygenation determined clinically by near-infrared spectroscopy (NIRS) of the frontal cortex. We tested the potential advantage of a spatially extended NIRS in detecting critical events in three cardiac surgery patients with a whole-head fiber holder of the FOIRE-3000 continuous-wave NIRS system. Principle components analysis was performed to differentiate between global and localized hypoperfusion or ischemic territories of the middle and anterior cerebral arteries. In one patient, we detected a critical hypoperfusion of the right MCA, which was not apparent in the frontal channels but was accompanied by intra- and postoperative neurological correlates of ischemia. We conclude that spatially extended NIRS of temporal and parietal vascular territories could improve the detection of critically low cerebral perfusion. Even in severe hemispheric stroke, NIRS of the frontal lobe may remain normal because the anterior cerebral artery can be supplied by the contralateral side directly or via the anterior communicating artery.

P. Michel , M. Arnold, H.-J. Hungerbuhler, F. Muller, C. Staedler, R. W. Baumgartner, D. Georgiadis, P. Lyrer, H. P. Mattle, R. Sztajzel, B. Weder, B. Tettenborn, K. Nedeltchev, S. Engelter, S. A. Weber, R. Basciani, J. Fandino, F. Fluri, R. Stocker, E. Keller, M. Wasner, M. Hanggi, Y. Gasche, R. Paganoni, L. Regli, for the Swiss Working Group of Cerebrovascular Diseases with the Swiss Society of Neurosurgery and the Swiss Society of Intensive Care Medicine

Objectives The aim of this study was to quantify potential differences in count, frequency and pattern of high-intensity transient signals (HITS) during transapical transcatheter aortic valve implantation (TA-TAVI), by comparing the Symetis Acurate TA (SA) with the balloon-expandable Edwards Sapien XT (ES) system. Background Recently, the Symetis Acurate TA revalving system has been introduced for TA-TAVI. The Symetis Acurate TA aortic bioprosthesis is self-expanding and is deployed by a specific two-step implantation technique. Whether this novel method increases the load of intraprocedural emboli, detected by transcranial Doppler ultrasound (TCD) as HITS, or not is not clear. Methods Twenty-two patients (n = 11 in each study arm, median logistic EuroScore 20%, median STS score 7%) displayed continuous TCD signals of good quality throughout the entire TA-TAVI procedure and were included in the final analysis. Data are presented as median with interquartile ranges. Results No significant differences were detected in total procedural or interval-related HITS load (SA: 303 [200; 594], ES: 499 [285; 941]; p = 0.16). With both devices, HITS peaked during prosthesis deployment (PD), whereas significantly fewer HITS occurred during instrumentation (SA: p = 0.002; ES

OBJECTIVE To analyse our results of using a double arterial perfusion strategy to avoid lower body hypothermic circulatory arrest after extensive thoracic aortic surgery. METHODS We analysed the intra- and perioperative courses of 10 patients (median age 58 years, median logistic EuroSCORE 14.6) who underwent extensive thoracic aortic surgery with a double arterial perfusion strategy. The main goal of double arterial perfusion is to separate myocardial and supra-aortic from systemic perfusion. Aortic repair starts at the most distal level of the descending aorta, followed by reinsertion of the supra-aortic vessels, and ends with completion of the proximal anastomosis or by any kind of root repair as needed. RESULTS Seven of 10 patients had prior surgery of the thoracic aorta. Indications for surgery were post-dissection aneurysm in 4 patients, true aneurysm in 3, anastomotic aneurysms in 2 and Type B aortic dissection with pseudo-coarctation in 1. Surgical access was performed through median sternotomy with left hemi-clamshell extension in all cases. There was no in-hospital mortality, but perioperative neurological symptoms occurred in 2 patients. These 2 patients developed delayed stroke (after awaking) after an initial uneventful clinical course, and in 1 of them, neurological symptoms resolved completely during follow-up. The median follow-up was 7 (±13) months. There was no death and no need for additional redo surgery during this observational period. CONCLUSIONS Extensive surgery of the thoracic aorta using a double arterial perfusion technique in order to avoid lower body hypothermic circulatory arrest is an attractive option. Further refinements of this technique may enable the safe and effective simultaneous multisegmental treatment of thoracic aortic pathology in patients who would otherwise have to undergo a two-step surgical approach.

We dis-cuss a case of acute type-A aortic dissection requiringa complex repair of the aorta wherein an unexpectedanatomic variant of the innominate artery allowed imme-diate institution of bilateral antegrade cerebral perfusion(ACP).A previously healthy 57-yr-old man was admitted to adistrict hospital after he had suffered a syncopal episode ona ski run. He was found unconscious in the snow after anunknown time period had elapsed. After recovering con-sciousness, he complained to the rescue team of severechest pain. Transthoracic echocardiography revealed alarge pericardial effusion and moderate aortic regurgita-tion. This medical condition along with other clinical signs(syncope, pulse asymmetry, and chest pain) led to a ten-tative diagnosis of type-A aortic dissection. Withhemodynamics deteriorating and acute respiratory failureimminent, the computed tomography scan in the districtfacility was cancelled. While the patient was on high-dosevasoactive support, his trachea was intubated and his lungswere ventilated prior to urgent transfer to our centre. In theoperating room, a transesophageal echocardiographyexamination confirmed the diagnosis of type-A aortic dis-section. Extracorporeal circulation was established with thearterial inflow cannula inserted in the right axillary arteryand a two-stage venous drainage cannula inserted in theright atrium. On reaching the targeted nasopharyngealtemperature (20 C), hypothermic circulatory arrest wasinstituted. By cross-clamping the innominate artery at itsorigin, the surgeon sought to establish a continuous uni-lateral right axillary ACP via the right-sided carotid andvertebral artery. The exploration of the aortic arch revealeda circumferential dissection with multiple intimal tearsextending beyond the ostium of the innominate artery.However, only one additional arch vessel ostium could beidentified. Further preparation of the distal aortic archshowed that the second arch ostium did not, as previouslyassumed, represent the left common carotid artery, but

BACKGROUND: Measurement of partial pressure of oxygen (PO2) at high temporal resolution remains a technological challenge. This study introduces a novel PO2 sensing technology based on Multi-Frequency Phase Fluorimetry (MFPF). The aim was to validate MFPF against polarographic Clark-type electrode (CTE) PO2 measurements. METHODOLOGY/PRINCIPAL FINDINGS: MFPF technology was first investigated in N = 8 anaesthetised pigs at FIO2 of 0.21, 0.4, 0.6, 0.8 and 1.0. At each FIO2 level, blood samples were withdrawn and PO2 was measured in vitro with MFPF using two FOXY-AL300 probes immediately followed by CTE measurement. Secondly, MFPF-PO2 readings were compared to CTE in an artificial circulatory setup (human packed red blood cells, haematocrit of 30%). The impacts of temperature (20, 30, 40°C) and blood flow (0.8, 1.6, 2.4, 3.2, 4.0 L min(-1)) on MFPF-PO2 measurements were assessed. MFPF response time in the gas- and blood-phase was determined. Porcine MFPF-PO2 ranged from 63 to 749 mmHg; the corresponding CTE samples from 43 to 712 mmHg. Linear regression: CTE = 15.59+1.18*MFPF (R(2) = 0.93; P0.05). MFPF response-time (monoexponential) was 1.48±0.26 s for the gas-phase and 1.51±0.20 s for the blood-phase. CONCLUSIONS/SIGNIFICANCE: MFPF-derived PO2 readings were reproducible and showed excellent correlation and good agreement with Clark-type electrode-based PO2 measurements. There was no relevant impact of temperature and blood flow upon MFPF-PO2 measurements. The response time of the MFPF FOXY-AL300 probe was adequate for real-time sensing in the blood phase.

Somanetics 5100C was used to assess regional tissue oxygen saturation. DO2 and VO2 values to assess the oxygen delivery and consumption were also calculated. The association between cerebral and somatic rSO2 trends and mean arterial pressure, pump flow and blood gases were also studied. Results. it was found that prolonged episodes of decrease of somatic rSO2 during cardiopulmonary bypass with lower haemoglobin levels and DO2 values were strongly associated with occurrence of post-op organ disorders especially acute kidney injury. As the results of the correspondence analysis it was shown that for positive outcome without organ disorders greater importance have absolute values of DO2, VO2 and rSO2 (both cerebral and somatic), but for the poor outcome with complications the length of episodes of rSO2 decrease has the greater influence. It was also found that somatic rSO2 values are not strongly associated with pump flow or mean arterial pressure or arterial pO2. Discussion. the use of continuous monitoring of cerebral and even somatic rSO2 during cardiopulmonary bypass in adults may help the prefusionist to assess the adequacy of tissue oxygenation. To improve the somatic and cerebral rSO2 complex strategy is needed to be worked out because the routine increase of pump or gas flow was shown to be not enough and sometimes controversial [2].

OBJECTIVES Transcatheter aortic valve implantation (TAVI) is an alternative to surgery for high risk patients with severe aortic valve stenosis. Periprocedural stroke is reported at an incidence up to 10. Magnetic resonance imaging studies have identified new onset of clinically silent ischaemic cerebral lesions more frequently (68 84). So far few data are available about cerebral embolism during TAVI. The aim of this study was to determine the frequency of high intensity transient signals (HITS) and to explore differences in the HITS pattern between transfemoral and transapical access and between self expanding (SE) and balloon expandable (BE) deployment technique. METHODS Transcranial Doppler (TCD) ultrasound recordings of 44 patients undergoing TAVI (age 78 ± 6 years; logistic EuroSCORE 28 ± 15; transfemoral access n = 32; transapical access n = 12; SE n = 27; BE n = 17) were analysed for HITS during the following intervals: (i) instrumentation prior to valvuloplasty (ii) balloon valvuloplasty (iii) prosthesis deployment (DP) and (iv) post implantation (PI) including any re dilatation episodes. The total procedural load of HITS and HITS frequency in procedural intervals were compared between different access routes and DP techniques. Periprocedural neurocognitive impairment was assessed clinically and by the confusion assessment method (CAM) prior to TAVI and on post procedural days 1 and 4 6. RESULTS TCD recordings demonstrated the occurrence of HITS in all patients. DP was associated with the highest load of HITS. Access route did not significantly influence the total burden of periprocedural HITS. During procedures using the SE type a slightly larger total load of HITS was observed than with the BE type (P = 0.024). This was mainly due to more HITS during the DP (P = 0.027) and the PI interval (P = 0.002). No incidence of delirium was detected by CAM ratings. Two patients suffered a new onset of stroke within the 2 weeks following the procedure. In hospital death and 30 day mortality were 0/44. CONCLUSIONS HITS are observed during all procedural intervals in TAVI. The embolic events appear to peak during DP. In our series the overall cerebral embolic load did not differ between the transfemoral and the transapical access route. TCD monitoring in TAVI is useful to identify periods and manipulations associated with an increased cerebral embolic load and may help to further enhance the safety of this procedure.

1Department of Anesthesiology and Pain Therapy; 2Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland Correspondence: Dr Gabor Erdoes, Department of Anesthesiology and Pain Therapy, Inselspital, University Hospital Bern, Freiburgstrasse, CH-3010 Bern, Switzerland. Telephone 41-316323965, fax 41-316320554, e-mail gabor.erdoes@insel.ch Received for publication November 23, 2009. Accepted December 8, 2009 A 76-year-old woman underwent redo aortic valve surgery because of failure of a stented porcine aortic valve bioprosthesis (Conforma, HeartLine Medical, United Kingdom; diameter 23 mm) that had been implanted 10 years earlier. Full-volume three-dimensional transesophageal echocardiography (Video 1) revealed severe transprosthetic regurgitation due to noncalcific structural valve deterioration with tears in two leaflets (Figure 1, black arrows) of the aortic valve bioprosthesis in the mid esophageal aortic valve short-axis view. In diastole, the cusps prolapsed into the left ventricle outflow tract, causing a large leakage in the prosthesis’ orifice (Figure 1, white star), corresponding to severe aortic regurgitation. A prosthetic cusp without a tear, closed in diastole, was also identifiable (Figure 1, white arrow). Intraoperatively, the deteriorated bioprosthesis was replaced (Carpentier-Edwards PERIMOUNT Magna, Edwards Lifesciences LLC, USA; diameter 23 mm) using standard cardiopulmonary bypass at mild hypothermia. The recovery was uncomplicated and the patient was discharged home on the 12th postoperative day. Structural valve deterioration is the most important adverse event of bioprosthetic valves and the major complication requiring reoperation. Cusp tears without calcification are related to direct mechanical damage to the collagen structure during functional opening and closure of the cusps. Because mortality for reoperative surgery for structural valve failure is high, various authors recommend periodic clinical and echocardiographic surveillance of the patients to avoid emergency surgery due to advanced ventricular and functional disease. images in caRdiology

The case of a 55-year-old woman is presented, whose clinical signs were initially suggestive of infective endocarditis. Transthoracic echocardiography (TTE) provided the diagnosis of a large left atrial myxoma attached to the anterior mitral leaflet. Perioperative transesophageal echocardiography (TEE) confirmed preoperative findings and assisted the surgical team in the assessment of tumour size, area of attachment, and mobility. Following tumour resection, TEE demonstrated residual moderate mitral valve regurgitation, which resulted in a change of surgical strategy. This report reinforces the importance of intraoperative TEE to facilitate and optimize surgical and anaesthesiological management of patients presenting with non-specific cardiorespiratory symptoms.