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Treatment of aortic valve disease has become less and less invasive during the last years, thanks to progress in anesthesiology, surgical techniques, and perfusion management. In fact, it has been demonstrated that shorter skin incision, combined with ultra-fast-track anesthesia and minimized extracorporeal circuit could improve clinical outcomes. Current evidence shows that minimally invasive extracorporeal circulation system is associated with reduced red blood cells’ transfusion rate, improved end-organ perfusion, decreased incidence of postoperative atrial fibrillation, air embolism leakage, and so less cerebral accidents with better neurological outcomes. Moreover, the use of a closed circuit seems to be more physiologic for the patients, reducing systemic inflammatory response due to less air–blood contact and the use of biocompatible surfaces. In the literature, the benefits of minimally invasive extracorporeal circulation are described mostly for coronary surgery but few data are nowadays available for minimally invasive extracorporeal circulation during aortic valve replacement. In this article, we describe our perfusion protocol in minimally invasive aortic valve replacement.

Staged replacement of the aortic arch and thoraco-abdominal aorta (TAA) with a frozen elephant trunk followed by TAA repair is a valuable treatment for patients with chronic TAA dissection. However, in patients with an unclampable descending thoracic aorta, the retrieval of the trunk can be problematic and the proximal stent graft-to-graft anastomosis technically challenging. Here we present our ‘double layer’ frozen elephant trunk technique to treat patients with TAA dissection.

Despite minimally-invasive aortic valve replacement (MI-AVR) having gained interest within the cardiac surgeons’ community, patient requests for interventions associated with minimized trauma and faster recovery often remains unfulfilled (1). In our center, we believe that a MI-AVR program (2) may benefit from a multidisciplinary approach that combines reduced incisions with an increasing use of rapid deployment valves (RD), minimal invasive extracorporeal circulation system (MiECC) (3) and fast-track anesthetic (UFT) management. Our experience with the MI trans-axillary direct approach in mitral valve surgery (MVS) (4) led us to consider that the aortic valve could be nicely exposed from the same approach. As a result, we recently initiated the use of trans-axillary incisions for MI-AVR in selected patients. In this setting, RD valves may help with reducing technical complexity and operative times. The aim of this video is to share our approach in a step-by-step fashion.

Objectives Infective endocarditis (IE) with extensive peri-annular abscesses and aortic root involvement is a life-threatening disease. Aortic root replacement with a valved conduit is the most common intervention in this setting and represents a serious challenge for the surgeon. In the present two-center study we analyzed early and midterm outcomes of a high-risk series of IE patients undergoing aortic root reconstruction with a sub-annular implantation of a totally biological valved conduit at our centers. Methods The series comprised 29 patients (18 males, mean age: 72.3 ± 10.1 years) operated at "Lancisi Cardiovascular Center" of Ancona and "Pasquinucci Heart Hospital" of Massa, Italy, between May 2016 and October 2019. All patients had undergone a previous cardiac surgery. Median Euroscore-II was 12.6%. Following aggressive debridement, a Bioconduit was implanted using a sub-annular implantation technique in all cases. Results Thirty-day mortality was 13.8% (n = 4). Multiorgan failure was cause of death in all cases. Respiratory complications occurred in eight patients (27.6%). Renal complications requiring temporary or permanent dialysis occurred in six (20.7%) and two (6.9%) patients, respectively. Mortality and morbidity were not related to the surgical approach. At 1-year follow-up three patients died and no patients underwent reoperation neither reported endocarditis of the biological conduit. Conclusion Considered the high-risk profile of the study cohort, our results suggest safety and efficacy of our approach at 1-year. Indeed, we contend that our subannular implantation of a 100% pericardial valved conduit, allowing an effective abscess exclusion and a conduit anchoring to healthy tissues, can reduce the risk of reinfection and dehiscence.

Introduction: Type B aortic dissection (TBAD) is a threatening event that may lead to death for aortic rupture or multivisceral malperfusion in the acute phase and offers a poor prognosis for long term survivors. Thoracic endovascular aortic repair (TEVAR) has become the preferential therapy in acute and chronic complicated cases for its less invasivity compared to open surgery. However TEVAR is still encumbered by a significant number of reinterventions, caused by aortic neck aneurysmal degeneration, endoleaks and stent-graft induced new entry (SINE). This is even more true in patients with particularly fragile aortic wall like Marfan Syndrome (MS) in contrast to the excellent results of elective open surgery. Areas covered: This review analyzes the current available TEVAR devices and techniques in TBAD and their technological advancements, especially those most suitable to TBAD anatomy, according to current literature. Expert opinion: The continuous technological evolution of materials and device solutions ensures solid results of TEVAR in acute TBAD and may also potentially overcome some of the limitations of endovascular devices in this setting, paving the way for safer and more durable results and allowing for expanded indications in the future, even in the delicate population of collagenopathies, especially in MS.

OBJECTIVES The impact of minimally invasive extracorporeal circulation (MiECC) systems on the clinical outcomes of patients undergoing minimally invasive aortic valve replacement (MI-AVR) has still to be defined. This study compared in-hospital and 1 year outcomes of MI-AVR interventions using MiECC systems versus conventional extracorporeal circulation (c-ECC). METHODS Data from 288 consecutive patients undergoing primary isolated MI-AVR using MiECC (n = 102) or c-ECC (n = 186) were prospectively collected. Treatment selection bias was addressed by the use of propensity score matching (MiECC vs c-ECC). After propensity score matching, 2 groups of 93 patients each were created. RESULTS Compared with c-ECC, MiECC was associated with a higher rate of autologous priming (82.4% vs 0%; P CONCLUSIONS MiECC systems were a safe and effective tool in patients who had MI-AVR. Compared with c-ECC, MiECC promotes ultra-fast-track management and provides better clinical outcomes as regards bleeding, blood transfusions and postoperative AF. Thus, by reducing surgical injury and promoting faster recovery, MiECC may further validate MI-AVR interventions.

Background: Although sutureless and rapid deployment aortic valve replacement (SURD-AVR) has been associated with an increased rate of permanent pacemaker (PPM) implantation compared to conventional AVR (c-AVR), the predictors of new conduction abnormalities remain to be clarified. This study aimed to identify risk factors for conduction disorders in patients undergoing AVR surgery. Methods: Data from 243 patients receiving minimally invasive AVR were prospectively collected. SURD-AVR was performed in 103 (42.4%) patients and c-AVR in 140 (57.6%). The primary endpoint was the occurrence of new-onset conduction disorders, defined as first degree atrioventricular (AV) block, advanced AV block requiring PPM implantation, left anterior fascicular block (LAFB), left bundle branch block (LBBB) and right bundle branch block (RBBB). Results: The unadjusted comparison revealed that SURD-AVR was associated with a higher rate of advanced AV block requiring PPM when compared with c-AVR (10.5% vs. 2.1%, P=0.01). After adjusting for other measured covariates (OR: 1.6, P=0.58) and for the estimated propensity of SURD-AVR (OR: 5.1, P=0.1), no significant relationship between type of AVR and PPM implantation emerged. On multivariable analysis, preoperative first-degree AV block (OR: 6.9, P=0.04) and RBBB (OR: 6.9, P=0.03) were independent risk factors for PPM. Subgroup analysis of patients with normal preoperative conduction revealed similar incidence of PPM between SURD-AVR and c-AVR (1.3% vs. 1.9%, P=0.6). When compared with c-AVR, SURD-AVR was associated with a greater incidence of postoperative new onset LBBB (18.1% vs. 3.2%, P

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

Item does not contain fulltext BACKGROUND: The aim of this study was to determine perioperative factors influencing neurologic outcome in a single-center cohort of patients undergoing elective aortic arch operations. METHODS: From January 2005 to June 2015, 791 consecutive patients received open aortic arch operations with either antegrade selective cerebral perfusion (ASCP) (636 patients [80.4%]) or deep hypothermic circulatory arrest (DHCA) (155 patients [19.6%]). Main indications were degenerative aneurysm (85%) and chronic postdissection aneurysm (9.1%). RESULTS: Hospital mortality (30 days) was 5.3%. Permanent neurologic dysfunction (PND) was observed in 42 patients (5.3%). Significant risk factors for PND appeared to be femoral artery cannulation (p = 0.003), progressive cardiopulmonary bypass (p = 0.001), circulatory arrest (p = 0.001), and ASCP time (p = 0.011). ASCP, in contrast to DHCA, was protective against PND (odds ratio [OR], 0.37; p = 0.003). Temporary neurologic dysfunction (TND) was observed in 49 patients (6.2%). Preoperative transient ischemic attack (TIA) (p = 0.001), progressive EuroSCORE (p = 0.001), left ventricular ejection fraction (LVEF) less than 50% (p = 0.003), and the use of femoral artery cannulation (p = 0.049) showed correlation in the univariate analysis. Stepwise logistic regression indicated TIA (p = 0.002; OR, 3.24) and the EuroSCORE (p = 0.003; OR, 1.23) as independent predictors of TND. CONCLUSIONS: Contemporary elective aortic arch repair can be achieved with low mortality and a low incidence of neurologic dysfunction. ASCP was confirmed to be the safest method of cerebral protection. The extent of aortic arch replacement (apart from the frozen elephant trunk [FET] procedure) was not related to increased rates of TND or PND.

Infective endocarditis (IE) with extensive annular disruption and aortic root involvement carries an ominous prognosis (1,2). The broad and severe impairment of the peri-annular tissues at the level of the interventricular septum and mitro-aortic continuity may hamper a successful surgical reconstruction, with dehiscence and retraction of the anterior mitral leaflet (AML) being a possible dreadful complication (3,4). Here we present our technique for root replacement (Bentall) that involves a sub-annular implantation of a 100% pericardial valved conduit (BioconduitTM, Biointegral Surgical, Inc., Ontario, Canada).

OBJECTIVES: Few case studies have shown the feasibility of the prosthesis-sparing operation in patients requiring aortic root replacement after aortic valve replacement. Such technique allows the sparing of a well-functioning aortic valve prosthesis and facilitates the root substitution with only a vascular graft. The aim of the present study was to assess short- and mid-term outcomes of the patients who underwent such procedures at our institution. METHODS: Between 2004 and 2012, 26 patients (mean age: 59 ± 13.6 years; male: 21, 80.8%) underwent the prosthesis-sparing operation in our institution. The mean time from previous aortic intervention was 20.1 ± 6.9 years; two patients were operated for a Type A acute aortic dissection. RESULTS: Overall, two patients (7.7%) died during hospitalization: both were operated for a complicated Type A acute aortic dissection. None of the electively operated patients died or presented serious complications after surgery, except for one patient (3.8%) who required chest re-exploration for excessive bleeding due to coagulopathy. At follow-up (100% completed at 30 ± 24 months) two late deaths occurred: one due to lung cancer and one due to infective endocarditis. Kaplan-Meier estimates of 1- and 3-year survival were 92 and 85.4%, respectively. No late cardiac/aortic re-interventions were performed during follow-up, with a 5-year freedom from re-operation of 100%. CONCLUSIONS: Our favourable short- and mid-term results indicate that the prosthesis-sparing operation is a valid treatment option in selected re-operative aortic root procedures.

ABSTRACT Background: We present our initial experience with the frozen elephant trunk using a Thoraflex™ hybrid device for the treatment of the complex thoracic aorta lesions. Materials & methods: Between March 2013 and March 2014, ten patients underwent thoracic aorta surgery using the frozen elephant trunk approach with the Thoraflex hybrid device. Indications for surgery were: residual type A chronic dissection (eight patients), degenerative aneurysm (one patient) and type B chronic aortic dissection (one patient). Selective antegrade cerebral perfusion and moderate hypothermia were used in all cases. Results: In-hospital mortality was 0% and no patients presented with paraplegia, paraparesis or major neurological events. One patient experienced transient ischemic attack. Two patients underwent reoperation for bleeding. All postoperative angiography CT scans confirmed the desired results. Conclusion: Our initial experience demonstrated excellent early results. The Thoraflex hybrid prosthesis with the four-branched arch graft increases the spectrum of techniques available for the surgeon in the treatment of complex diseases of the thoracic aorta.

Several studies have shown that after DeBakey type 1 acute aortic dissection (DB1-AAD) surgery, 70% of the surviving patients still present with a dissected distal aorta that can eventually dilate, rupture, lead to distal malperfusion or require secondary extensive interventions. In order to minimize these complications, different surgeons have advocated total thoracic aorta remodelling procedures during primary aortic repair to promote false-lumen obliteration and distal thrombosis. Such management, which includes arch replacement and antegrade stenting of the dissected descending thoracic aorta (DTA), remains controversial due to its perceived increased operative mortality. Furthermore, the desired long-term benefits remain to be confirmed. The present article aimed to evaluate results of antegrade stenting of DTA during surgery for DB1-AAD, focusing on in-hospital mortality and morbidity, and long-term survival, occurrence of distal aortic remodelling and freedom from aortic reinterventions. Early results from the identified studies suggested that hybrid repair of DB1-AAD with antegrade DTA stenting was associated with satisfactory in-hospital mortality (10.0%) and stroke (4.8%) rates, while the risk of spinal cord injury appeared to be higher (4.3%) than that reported from historical controls. Furthermore, antegrade stenting of DTA was associated with promising rates of partial/complete thrombosis of the peristent DTA false lumen (88.9%), suggesting that aortic remodelling is highly probable with this approach. Evidence on long-term results after proximal acute dissection repair is still sparse, and mostly jeopardized by limited data beyond 5 years. Further investigations with longer term follow-up and with specifically designed protocols to assess long-term clinical outcomes (late aortic mortality and freedom from distal aortic reinterventions) of total thoracic aortic remodelling procedures vs more conservative management are warranted to reach more definitive conclusions.

OBJECTIVE: The objective of our study was to report our hospital and long-term results after reinterventions on the thoracic aorta. METHODS: Between 1986 and 2011, 224 reoperations on the proximal thoracic aorta after previous aortic surgery were performed in our institution. The number of reinterventions quadrupled during the course of the study period. Mean patient age was 58.1 years, and 174 patients (77.7%) were male. An urgent/emergency operation was performed in 39 patients (17.4%). Indications for surgery included degenerative and chronic postdissection aneurysm (n = 166), false aneurysm (n = 31), active prosthetic infection (n = 16), acute dissection (n = 10), and other (n = 1). Surgical procedures involved the aortic root in 40.6% of patients, the ascending aorta in 9.4%, the aortic arch in 24.6%, and the entire proximal thoracic aorta in 25.4%. RESULTS: Hospital mortality was 12.1%. On multivariate analysis, cardiopulmonary bypass time (odds ratio, 1.1023/minute; P < .001), and urgent/emergency status (odds ratio, 5.6; P < .001) emerged as independent predictors of hospital mortality. The follow-up was 98.7% complete. Estimated 1-, 5-, and 10-year survival rates were 84.4%, 72.5%, and 48.5%, respectively. Eighteen reinterventions were performed during follow-up-16 because of the progression of aortic disease at the proximal aorta (n = 2) and downstream aorta (n = 14). Freedom from reoperation at 1, 5, and 10 years was 95.6%, 90.2%, and 81.5%, respectively. CONCLUSIONS: Reoperative aortic surgery was associated with satisfactory short- and long-term results, especially if carried out on an elective basis. The extent of the aortic replacement did not impact survival and was associated with a reduced need for reintervention. The progressive nature of aortic disease and the favorable results of elective primary aortic interventions suggest favoring aggressive aortic resections at initial surgery.

Background The impact of different cannulation strategies on outcomes of aortic arch surgery remains controversial. This retrospective study sought to evaluate central cannulation (ascending aorta, right axillary, and innominate artery) compared with femoral artery cannulation for aortic arch surgery, and to identify among preoperative and intraoperative variables the independent predictors of death and permanent neurologic dysfunction (PND) in aortic arch surgery. Methods All patients were operated through a median sternotomy using antegrade selective cerebral perfusion with moderate hypothermia as a method of brain protection. Treatment bias was addressed by use of propensity-score matching and multivariate regression analysis. Logistic regression models were used to identify the independent predictors of hospital mortality and PND. Results Of the 473 patients undergoing aortic arch surgery, 273 (57.7%) underwent femoral cannulation (FC), and 200 (42.3%) underwent central cannulation (CC). The CC and FC cannulation were associated with similar risk of in-hospital death (absolute risk reduction [ARR]: 0.7%; p = 0.880) and PND (ARR:-2.6%, p = 0.361) in the overall cohort and after adjusting for propensity-based matching (ARR for hospital mortality: 2.2%, p = 0.589; ARR for PND: 3.4%, p = 0.271). Female gender (odds ratio [OR]:2.1, p = 0.030), type A acute dissection or intramural hematoma (OR: 2.2; p = 0.041), and CPB time (OR: 1.010/minute, p = 0.015) were independent predictors of in-hospital death. Female gender (OR: 2.4; p = 0.033), type A acute dissection or intramural hematoma (OR: 4.2; p = 0.005), and diabetes (OR: 6.6, p = 0.007) were independent predictors of PND. Conclusions During aortic arch surgery, CC and FC are associated with a similar risk of postoperative death and PND. Type A acute aortic dissection and cardiopulmonary bypass time remain strong risk factors for mortality and PND.

OBJECTIVES: Unresponsive pulmonary hypertension (PH) may contraindicate heart transplant since it implies poor early outcomes. The present study reports the effectiveness of oral perioperative sildenafil in allowing heart transplant candidacy and surgery in a selected group of patients initially deemed ineligible because of PH. METHODS: Between May 2005 and December 2009, 31 consecutive patients (5 females, 9 with a history of idiopatic cardiomyopathy and 16 with a history of coronary artery disease, 10 with previous sternotomies, 71.42 ± 27.69 ml/min/m 2 mean pre-operative epidermal growth factor receptor) were qualified for oral sildenafil because of unresponsive PH at baseline right heart catheterization (RHC). After a 12-week trial, RHC disclosed PH reversibility (mean pulmonary vascular resistance index: 9.57 ± 4.07 WU, mean transpulmonary gradient 14.47 ± 5.66 mmHg and mean systolic pulmonary artery pressure: 68.96 ± 15.15 mmHg), allowing listing despite a higher risk for early post-transplant RV failure. Transplant protocol included donor/recipient size matching ≥0.8 and inhaled nitric oxide in the early post-operative period followed by reinstitution of oral sildenafil. RESULTS: All patients underwent heart transplantation. Mean overall graft ischaemic time was 179 ± 47min; mean donor recipient weight ratio was 1.04 ± 0.17. Right ventricular failure developed in three patients (9.6%) and hospital mortality was 3.2%. Protocol RHC disclosed pulmonary haemodynamic profile normalization within the third post-operative month allowing weaning from sildenafi li n the 30 hospital survivors. One-year RHC confirmed PH reversal (n= 29 patients, all who survived up to 1year). CONCLUSIONS: This pilot prospective uncontrolled trial suggests that oral sildenafil is effective in allowing candidacy, safe transplantation and post-operative pulmonary profile normalization in potential recipients initially disqualified because of PH.

As originally described by Bentall and De Bono, aortic root replacement with reimplantation of the coronary arteries using a composite valved conduit represents the gold standard intervention in patients with aneurysmal disease or dissection involving the aortic root. Over the last decade, the number of Bentall procedures performed using biological valved conduit has dramatically expanded mainly due to the increased incidence of aortic disease in the aging population. Here, we sought to describe the commercially available biological composite grafts and the techniques that, to the best of our knowledge, are most frequently used in this setting.

Background Pulmonary endarterectomy (PEA) is recognized as the best surgical choice for treatment of chronic thromboembolic pulmonary hypertension caused by pulmonary vascular occlusion in eligible patients. This study aims to describe correlations between the daily walk (DW), and the demographic and clinical characteristics of patients undergoing pulmonary endarterectomy. Methods This was a cross-sectional study using data from 32 consecutive patients who had undergone PEA operations and were admitted to the cardiac ward to complete their post-operative rehabilitation. Results Those with a body mass index of ≥25 walked a greater distance during the post-operative rehabilitation phase after PEA compared with those with body mass index Conclusions The authors found that estimation of the DW was a simple, inexpensive, and reliable measure that can help professionals to evaluate patients' post-operative course after PEA.