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The frozen elephant trunk technique has revolutionized aortic arch repair to enable more extensive arch and descending thoracic aortic treatment in a single setting. We review the current evidence supporting the use of the Thoraflex Hybrid (Terumo Aortic, FL, USA) device and discuss advantages, pitfalls and future design considerations.Lay abstract Disease of the aorta, the biggest blood vessel in the body, is challenging. In recent years, new technologies such as the frozen elephant trunk (FET) have improved the treatment of patients with these complicated diseases. The FET is a hybrid device, made of medical fabrics and a covered metal stent (a tube inserted into the blood vessel to keep it open). In this paper, we provide an in-depth review of a FET device known as Thoraflex Hybrid (Terumo Aortic, FL, USA). We discuss its advantages and pitfalls as well as future areas of research.

Background: To explore evolving surgical techniques and outcomes for aortic arch surgery. Methods: A total of 2435 consecutive patients underwent aortic arch repair with hypothermic circulatory arrest between 2008 and 2018 in 12 institutions across Canada. Trends in patient characteristics, surgical techniques, and in-hospital outcomes, including major morbidity or mortality, were examined. Results: From 2008 to 2018, the age of patients (62.3 ± 13.2 years) and the proportion of women (30.2%) undergoing arch surgery did not change significantly. Aortic diameters at operation decreased (2008: 58 ± 13 mm; 2018: 53 ± 11 mm; P < 0.01). Surgeons performed more valve-sparing root replacements (2008: 0%; 2018: 15%; P < 0.001) and fewer Bentall procedures (2008: 27%; 2018: 20%; P < 0.01). Total arch replacement rates were similar (P = 0.18); however, elephant trunk (2008: 9.5%; 2018: 19%; P < 0.001) and frozen elephant trunk (2008: 3.1%; 2018: 15%; P < 0.001) repair rates have increased. Over time, higher nadir temperatures (2008: 18 [17-21]°C; 2018: 25 [23-28]°C; P < 0.001), and more frequent antegrade cerebral perfusion (2008: 61%; 2018: 83%; P < 0.001) were used. For elective cases, in-hospital mortality rates declined (2008: 6.8%; 2018: 1.2%; P = < 0.01), as did major morbidity or mortality (2008: 24%; 2018: 13%; P < 0.001) and transfusion rates (2008: 61%; 2018: 41%; P < 0.001), but stroke rates remained constant (2008: 6.8%; 2018: 5.3%; P = 0.12). Outcomes remained the same over time for urgent or emergent cases. Conclusions: Outcomes have improved over the past decade in Canada for elective aortic arch surgery, in the context of operating on smaller aortas, and more frequent use of moderate hypothermia and antegrade cerebral perfusion. Further research is needed to improve stroke rates and outcomes in the emergency setting. Résumé: Introduction: Examiner l’évolution des techniques chirurgicales et les résultats de l'intervention chirurgicale de l'arc aortique. Méthodes: Un total de 2 435 patients consécutifs ont subi une réparation de l'arc aortique en arrêt circulatoire en hypothermie entre 2008 et 2018 dans 12 établissements du Canada. Nous avons examiné les tendances en ce qui concerne les caractéristiques des patients, les techniques chirurgicales et les résultats cliniques intrahospitaliers, y compris les principales causes de morbidité ou de mortalité. Résultats: De 2008 à 2018, l’âge des patients (62,3 ± 13,2 ans) et la proportion de femmes (30,2 %) subissant l'intervention chirurgicale de l'arc n'a pas montré de changement significatif. Les diamètres aortiques à l'opération ont diminué (2008 : 58 ± 13 mm; 2018 : 53 ± 11 mm; P

AIMS The aim of this study was to evaluate the impact of rheumatic heart disease (RHD) on the long-term outcomes of the Ross operation when compared to patients with bicuspid aortic valves (BAV). METHODS AND RESULTS We analysed patients with rheumatic disease and BAV who underwent a Ross operation between 1995 and 2020. The primary outcomes were late survival and reoperations on the pulmonary autograft and the right ventricular allograft. We also performed a propensity score analysis to adjust for differences in baseline characteristics. The cumulative incidence of the events in the matched cohorts was compared using the Fine–Gray model. There were 147 patients with rheumatic disease and 314 with bicuspid valves. In the unmatched population, patients with rheumatic disease were younger, more symptomatic, had worse left ventricular function and were more likely to present a preoperative diagnosis of aortic insufficiency. Propensity matching resulted in 86 pairs with similar baseline characteristics. Compared with those with bicuspid valves, rheumatic patients had similar 20-year survival both in the unmatched (RHD = 67.8% vs BAV = 79.7%, P = 0.27] and matched cohorts (RHD = 72.5% vs BAV = 82.9%, P = 0.46). Cumulative incidence of reoperations on the pulmonary autograft after 20 years was also comparable between them in the unmatched (RHD 13.4% vs BAV 14.4%, P = 0.67) and matched patients (RHD 11.6% vs BAV 21.1%, P = 0.47). Pulmonary autograft dysfunction due to rheumatic involvement was detected in only three occasions. Cumulative incidence of reoperations on the right-sided allograft was higher in the unmatched cohort (RHD = 5.5% vs BAV = 16.7%, P = 0.035) but became nonsignificant after propensity score matching (RHD = 9.9% vs BAV = 32.3%, P = 0.051). The cumulative incidence of all Ross-related reoperations was similar in both groups. CONCLUSIONS Among patients undergoing Ross operation, patients with RHD had similar long-term survival and rates of reoperations, when compared to patients with BAV.

OBJECTIVES Root reimplantation has been the favoured approach for patients with heritable aortic disorder requiring valve-sparring root replacement. In the past few years, root remodelling with annuloplasty has emerged as an alternative to root reimplantation in the general population. The aim of this study was to examine the late outcomes of patients with heritable aortic disorder undergoing valve-sparring root replacement and compare different techniques. METHODS Using the AVIATOR registry (Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry), data were collected from 5 North American and European centres. Patients were divided into 4 groups according to the technique of valve-sparing used (root reimplantation, root remodelling with ring annuloplasty, root remodelling with suture annuloplasty and root remodelling alone). The primary endpoints were freedom from aortic regurgitation (AR) ≥2 and freedom from reintervention on the aortic valve. Secondary endpoints were survival and changes in annular dimensions over time. RESULTS A total of 237 patients were included in the study (reimplantation = 100, remodelling + ring annuloplasty = 76, remodelling + suture annuloplasty = 34, remodelling alone = 27). The majority of patients had Marfan syndrome (83%). Preoperative AR ≥2 was present in 41% of the patients. Operative mortality was 0.4% (n = 1). No differences were found between techniques in terms of postoperative AR ≥2 (P = 0.58), reintervention (P = 0.52) and survival (P = 0.59). Changes in aortic annulus dimension were significantly different at 10 years (P CONCLUSIONS Overall, valve-sparring root replacement is a safe and durable procedure in patients with heritable aortic disorder. Nevertheless, root remodelling alone is associated with late annular dilatation. The addition of an annuloplasty, however, results in similar freedom from AR, reintervention, survival and changes in annulus size compared to reimplantation.

The study objective was to evaluate the clinical and radiographic outcomes of the Ascyrus Medical Dissection Stent in a prospective, nonrandomized, international study (Dissected Aorta Repair Through Stent Implantation) of patients with acute DeBakey type I aortic dissection.The Ascyrus Medical Dissection Stent was used in combination with the standard surgical management of acute DeBakey type I aortic dissection I to treat patients with (56.5%, 26/46) and without (43.5%, 20/46) preoperative clinical and radiographic malperfusion. All patients had a primary entry tear in the ascending aorta, and 97.8% (45/46) were treated with a hemiarch repair. Median follow-up was 3 years.All 47 patients underwent emergency surgical repair with successful Ascyrus Medical Dissection Stent implantation. One patient was excluded from analysis due to use in iatrogenic dissection. Overall mortality at 30 days and 3 years was 13.0% (6/46) and 21.7% (10/46), respectively. Overall new stroke rate at 30 days was 15.2% (7/46). No devices were explanted at any time during the 3-year median follow-up. At 3 years, the total aortic diameter in zones 0, 1, and 2 decreased or remained stable in 91.7%, 72.7%, and 75.0%, respectively. The false lumen was completely or partially thrombosed in 90.5% in zone 0, 60.0% in zone 1, and 68.2% in zone 2 at 3 years.The use of the Ascyrus Medical Dissection Stent in the treatment of acute DeBakey type I aortic dissection I holds promise as a simple technology that enables repair of the aortic arch and proximal descending aorta, while promoting positive aortic remodeling. Ongoing follow-up of the Dissected Aorta Repair Through Stent Implantation trial will provide long-term, prospective, clinical outcomes and radiographic data on positive remodeling of the aortic arch.

The Ross procedure is the best operation to treat aortic stenosis (AS) in young and middle-aged adults. However, its role in non-repairable aortic regurgitation (AR) remains debated since many historical series have reported an increased risk of pulmonary autograft dilatation and subsequent need for reintervention in these patients. Some have attributed these findings to an unrecognized and poorly characterized inherited genetic defect that prevents adaptive remodelling of the pulmonary autograft. Herein, we review the contemporary evidence surrounding the use of the Ross procedure in young adults with AR and put forth the argument that with proper technical refinements, the Ross procedure may still be the best operation to treat these patients. We believe that by tailoring the operation to the patient's anatomy and ensuring strict postoperative blood pressure control, one can achieve excellent results with the Ross procedure, including in this challenging patient population.

Objective: In complex and high-risk aortic root disease, the porcine Freestyle stentless bioprosthesis (Medtronic Inc, Minneapolis, Minn) is an important surgical treatment option. We aimed to determine prevalence and clinical effect of structural and functional abnormalities after full-root Freestyle implantation.Methods: Our cross-sectional 2-center study combined with clinical follow-up included 253 patients with full-root Freestyle bioprostheses implanted from 1999 to 2017. Patients underwent transthoracic echocardiography (TTE) and contrast-enhanced, electrocardiogram-gated 4-dimensional cardiac computed tomography (4DCT) at median age 70 (interquartile range, 62-75) years. After 4DCT, clinical follow-up continued throughout 2018. Median follow-up was 3.3 years before 4DCT and 1.4 years after.Results: We identified abnormalities in 46% of patients, including pseudoaneurysms (n = 32; 13%), moderate or severe coronary ostial stenosis (n = 54; 21%), and moderate-severe leaflet thickening or reduced leaflet motion (n = 51; 20%). TTE only identified 1 patient with pseudoaneurysm. After 4DCT, the unadjusted hazard ratio for surgical reintervention among patients with abnormal 4DCT was 4.2 (95% confidence interval, 1.2-15.3), in all, 10% required a reintervention. 4DCT abnormalities were associated with a statistically nonsignificant increased risk of death, stroke, or myocardial infarction (hazard ratio obtained using Cox proportional hazards regression analysis, 2.4; 95% confidence interval, 0.7-7.6). In all, 4.0% died, 3.6% had a myocardial infarction, and 2.0% had a stroke.Conclusions: Structural and functional abnormalities of the aortic root are frequent after Freestyle implantation and TTE appears to be insufficient for follow-up. Abnormalities might be associated with increased risk of reintervention and potentially adverse clinical outcomes. Longer follow-up and larger study populations are needed to further clarify the clinical implications of abnormalities identified with 4DCT. Objective: In complex and high-risk aortic root disease, the porcine Freestyle stentless bioprosthesis (Medtronic Inc, Minneapolis, Minn) is an important surgical treatment option. We aimed to determine prevalence and clinical effect of structural and functional abnormalities after full-root Freestyle implantation.Methods: Our cross-sectional 2-center study combined with clinical follow-up included 253 patients with full-root Freestyle bioprostheses implanted from 1999 to 2017. Patients underwent transthoracic echocardiography (TTE) and contrast-enhanced, electrocardiogram-gated 4-dimensional cardiac computed tomography (4DCT) at median age 70 (interquartile range, 62-75) years. After 4DCT, clinical follow-up continued throughout 2018. Median follow-up was 3.3 years before 4DCT and 1.4 years after.Results: We identified abnormalities in 46% of patients, including pseudoaneurysms (n = 32; 13%), moderate or severe coronary ostial stenosis (n = 54; 21%), and moderate-severe leaflet thickening or reduced leaflet motion (n = 51; 20%). TTE only identified 1 patient with pseudoaneurysm. After 4DCT, the unadjusted hazard ratio for surgical reintervention among patients with abnormal 4DCT was 4.2 (95% confidence interval, 1.2-15.3), in all, 10% required a reintervention. 4DCT abnormalities were associated with a statistically nonsignificant increased risk of death, stroke, or myocardial infarction (hazard ratio obtained using Cox proportional hazards regression analysis, 2.4; 95% confidence interval, 0.7-7.6). In all, 4.0% died, 3.6% had a myocardial infarction, and 2.0% had a stroke.Conclusions: Structural and functional abnormalities of the aortic root are frequent after Freestyle implantation and TTE appears to be insufficient for follow-up. Abnormalities might be associated with increased risk of reintervention and potentially adverse clinical outcomes. Longer follow-up and larger study populations are needed to further clarify the clinical implications of abnormalities identified with 4DCT.

Background Bicuspid pulmonic valves are quite uncommon, being described in only 0.1% of donor hearts, while pulmonary artery aneurysms are even more rare, having been found in 8 out of 109,571 autopsies. This rarity makes it difficult to characterize the relationship between them. Materials & Methods We describe the case of a 66-year-old female who was found to have a bicuspid pulmonic valve and pulmonary artery aneurysm (5.1cm) on imaging by her cardiologist. Discussion & Conclusion This case raises the question of whether the association between bicuspid semilunar valve disease and vascular wall anomalies are more genetic or hemodynamic. Even on the aortic side, despite the robust association between bicuspid aortic valves and thoracic aortic aneurysms, the mechanism still remains unclear. In our patient there was no significant gradient across the bicuspid pulmonic valve, suggesting that hemodynamics are not the primum mobile of this association.

Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).

Background The intimal flap at the distal aortic anastomosis after standard aortic dissection repair creates distal anastomotic new entry, leading to false lumen (FL) pressurization and true lumen (TL) collapse and resulting in increased mortality, malperfusion, aortic growth, and reinterventions. The Ascyrus Medical Dissection Stent (AMDS; Ascyrus Medical, Boca Raton, FL) is a hybrid prosthesis that seals and depressurizes the FL at the distal anastomosis while expanding and pressurizing the TL. Methods The Dissected Aorta Repair Through Stent Implantation trial is a prospective, nonrandomized, international type A dissection trial where patients with acute DeBakey I dissections were enrolled between March 2017 and January 2019. Forty-seven patients were enrolled (median age, 62.5; 67.4% men) with a median follow-up of 631 days. Results All patients underwent emergent surgical repair with successful AMDS implantation. One patient was excluded because of use in iatrogenic dissection. Overall mortality at 30 days and 1 year was 13.0% (6/46) and 19.6% (9/46), whereas new strokes occurred in 6.5% (3/46). Over 95% of vessel malperfusions resolved because of AMDS-induced TL expansion, including 3 patients with preoperative paralysis. Positive remodeling of the aortic arch occurred in 100% of cases with complete obliteration or thrombosis of the FL in 74%. In the proximal descending thoracic aorta positive remodeling occurred in 77% and complete obliteration or FL thrombosis in 53% of cases. Conclusions AMDS facilitates single-stage management of malperfusion and induces positive remodeling of the aortic arch through effective sealing of the distal anastomotic FL, depressurization of the FL with expansion, and pressurization of the TL. Importantly the use of AMDS is safe and reproducible.

Cardiac surgery lacks a method for quantifying postoperative morbidities. The Clavien-Dindo Complications Classification (CDCC) and the Comprehensive Complication Index (CCI) were successfully implemented as outcome reporting methods in other surgical specialties. This study aims to validate these complication scales in cardiac surgery. Between 2010 and 2019, we prospectively collected data on 41,218 adult patients (73% men, mean age 67 ± 11 years) undergoing cardiac surgery at 6 university hospitals. Complications were graded using the CDCC based on the complication's treatment invasiveness with adaptations for common treatments in cardiac surgery. CCI were calculated, representing multiple complications on a scale of 0 (no complication) to 100 (death). Associations with predictors of poor outcome were assessed using mixed-effects models accounting for center as a random effect. CDCC grade was 0 in 23.0%, I in 11.4%, II in 35.3%, IIIa in 6.4%, IIIb in 2.6%, IVa in 16.1%, IVb in 2.1%, and V in 3.1%. Median CCI was 23 (9, 40). A change from lowest to highest observed CDCC grade was associated with an increase in the Society of Thoracic Surgeons mortality score from 1.1% to 4.7%, surgery duration from 177 to 233 minutes, and hospital stay from 5.2 to 17 days (all P0.0001). The CCI also increased with greater procedure complexity (P0.0001). Increase in CDCC/CCI is associated with greater comorbidities, surgery durations, lengths of stay, and procedure complexity, accurately reflecting the nuances of the adult cardiac surgery postoperative course. These have great potential for uniform outcome reporting and quality improvement initiatives.

The Ross procedure consists in replacing the diseased aortic valve with the patient’s own pulmonary valve and simultaneous replacement of the pulmonary valve (and root) with a pulmonary homograft (or in some cases a xenograft). Pulmonary autograft in aortic position is a viable valve with excellent haemodynamics, low thromboembolic risk, resistance to infection and growth potential. These features make this procedure an ideal solution in paediatric aortic valve surgery. In adult patients, Ross procedure has been a subject to controversial debate over decades, with concerns raised over its complexity and for the two valves at potential risk in the long term. Current data, however, document superior long-term results, physiological haemodynamics and high quality of life without need of anticoagulation. In the light of these results, Ross procedure is an optimal option for young adults, women planning pregnancy and individuals with adherence to active life-style. A prerequisite for these beneficial outcomes is a meticulous surgical technique, the important details of which are discussed in the chapter.

Patients with a bicuspid aortic valve (BAV) frequently require surgical intervention for aortic regurgitation (AR) and/or aneurysm. Valve-preserving surgery and repair of regurgitant BAVs have evolved into an increasingly used alternative to replacement. Anatomic predictors of possible repair failures have been identified and solutions developed. Using current techniques most non-calcified BAVs can be preserved or repaired. Excellent repair durability and freedom from valve-related complications can be achieved if all pathologic components of aortic valve and root including annular dilatation are corrected. Anatomic variations must be addressed using tailored approaches.

Aortic valve-sparing operations theoretically have fewer stroke and bleeding complications but may increase late reoperation risk versus composite valve grafts.We meta-analyzed all studies comparing aortic valve-sparing (reimplantation and remodelling) and composite valve-grafting (bioprosthetic and mechanical) procedures. Early outcomes were all-cause mortality, reoperation for bleeding, myocardial infarction, and thromboembolism/stroke. Long-term outcomes included all-cause mortality, reintervention, bleeding, and thromboembolism/stroke. Studies exclusively investigating dissection or pediatric populations were excluded.A total of 3794 patients who underwent composite valve grafting and 2424 who underwent aortic valve-sparing procedures were included from 9 adjusted and 17 unadjusted observational studies. Mean follow-up was 5.8 ± 3.0 years. Aortic valve sparing was not associated with any difference in early mortality, bleeding, myocardial infarction, or thromboembolic complications. Late mortality was significantly lower after valve sparing (incident risk ratio, 0.68; 95% confidence interval [CI], 0.54-0.87; P.01). Late thromboembolism/stroke (incident rate ratio, 0.36; 95% CI, 0.22-0.60; P.01) and bleeding (incident rate ratio, 0.21; 95% CI, 0.11-0.42; P .01) risks were lower after valve sparing. Procedure type did not affect late reintervention.Aortic valve sparing appears to be safe and associated with reduced late mortality, thromboembolism/stroke, and bleeding compared with composite valve grafting. Late durability is equivalent. Aortic valve sparing should be considered in patients with favorable aortic valve morphology.

Background The bicuspid aortic valve (BAV) frequently requires surgical intervention for aortic regurgitation (AR) and aneurysm. Valve-preserving surgery for BAV has evolved over the last 25 years. Methods This review summarized experience in BAV repair with a special focus on predictors of failure and specific surgical techniques addressing them. Results Excellent repair stability can be achieved if a standardized approach addressing all pathologic components of aortic valve and root is used. Anatomic variations must be addressed with special approaches. Conclusions Today, BAV repair leads to excellent stability if an anatomy-oriented concept is used. Further improvements of cinical results and reproducibility can be anticipated.

OBJECTIVES Surgical treatment of infective endocarditis (IE) remains a challenge. The Ross procedure offers the benefit of a living substitute in the aortic position but it is a more complex operation which may lead to increased operative risk. The aim of this study was to assess the safety and late outcomes of the Ross procedure for the treatment of active IE. METHODS From 2000 to 2019, a total of 31 consecutive patients underwent a Ross procedure to treat active IE (mean age 43 ± 12 years, 84% male). All patients were followed up prospectively. Four patients (13%) were intravenous (IV) drug users and 6 patients (19%) had prosthetic IE. The most common infective organism was Streptococcus (58%). Median follow-up was 3.5 (0.9–4.5) years and 100% complete. RESULTS There were no in-hospital deaths. One patient suffered a postoperative stroke (3%) and 1 patient (3%) required reintervention for bleeding. Three patients had a new occurrence endocarditis: 2 patients were limited to the pulmonary homograft and successfully managed with IV antibiotics, whereas 1 IV drug user patient developed concomitant autograft and homograft endocarditis. Overall, cumulative incidence of IE recurrence was 13 ± 8% at 8 years. The cumulative incidence for autograft endocarditis was 5 ± 4% at 8 years. Two patients (6%) died during follow-up, both from drug overdoses. At 8 years, actuarial survival was 88 ± 8%. CONCLUSIONS In selected patients with IE, the Ross procedure is a safe and reasonable alternative with good mid-term outcomes. Freedom from recurrent infection on the pulmonary autograft is excellent, labelporting the notion that a living valve in the aortic position provides good resistance to infection. Nevertheless, in IV drug user patients, pulmonary homograft endocarditis remains a challenge. Continued follow-up is needed to ascertain the long-term benefits of this approach.

The Ross procedure represents a valid option for aortic valve replacement in young adults and was repeatedly shown to restore survival to that of the age- and sex-matched general population. However, its major drawback relies in the risk of pulmonary autograft (PA) dilation, negative histological remodeling and need for reoperation. Several techniques and materials to reinforce the PA have been proposed. They mainly include Dacron, personalized external aortic root support with a polyethylene terephthalate mesh system, autologous aortic tissue and bioresorbable materials. Synthetic materials, despite widely used in cardiac surgery, have significant biocompatibility issues with the PA and their interaction with this living structure translates into negative remodeling phenomena and disadvantageous biomechanical behaviors. Conversely, biomaterials with tailored degradable profiles might be able to reinforce while integrating with the PA and enhance its remodeling capabilities. The recent advancement in this field are here discussed.

Objectives Our objective was to examine intermediate-term survival and reinterventions in unselected patients, stratified by indication, who received a Freestyle® bioprosthesis as a full aortic root replacement. Methods Data from medical records were retrospectively collected for patients who had aortic root replacement using Freestyle® bioprostheses between 1999 and 2018 at six North-Atlantic centers. Survival status was extracted from national registries and results stratified for indication for surgery. Results We included 1030 implantations in 1008 patients with elective indications for surgery: aneurysm (39.8%), small root (8.3%) and other (13.8%), and urgent/emergent indications: endocarditis (26.7%) and Stanford type A aortic dissection (11.4%). Across indications, 46.3% were non-elective cases and 34.0% were reoperations. Median age was 66.0 years (IQR 58.0-71.8) and median follow-up was 5.0 years (IQR 2.6-7.9). Thirty-day mortality varied from 2.9% to 27.4% depending on indication. Intermediate survival for 90-day survivors with elective indications were not different from the general population standardized by age and sex (p-values 0.95, 0.83 and 0.16 for aneurysms, small roots and other, respectively). In contrast, patients with endocarditis and type A dissection had excess mortality (p-values Objectives: Our objective was to examine intermediate-term survival and reinterventions in unselected patients, stratified according to indication, who received a Freestyle (Medtronic Inc, Minneapolis, Minn) bioprosthesis as a full aortic root replacement. Methods: Data from medical records were retrospectively collected for patients who had aortic root replacement using Freestyle bioprostheses between 1999 and 2018 at 6 North-Atlantic centers. Survival status was extracted from national registries and results stratified according to indication for surgery. Results: We included 1030 implantations in 1008 patients with elective indications for surgery: aneurysm (39.8%), small root (8.3%), and other (13.8%), and urgent/emergent indications: endocarditis (26.7%) and Stanford type A aortic dissection (11.4%). Across indications, 46.3% were nonelective cases and 34.0% were reoperations. Median age was 66.0 (interquartile range, 58.0-71.8) years and median follow-up was 5.0 (interquartile range, 2.6-7.9) years. Thirty-day mortality varied from 2.9% to 27.4% depending on indication. Intermediate survival for 90-day survivors with elective indications were not different from the general population standardized for age and sex (P = .95, 83, and .16 for aneurysms, small roots, and other, respectively). In contrast, patients with endocarditis and type A dissection had excess mortality (P < .001). Freedom from valve reinterventions was 95.0% and 94.4% at 5 and 8 years, respectively. In all, 52 patients (5.2%) underwent reinterventions, most because of endocarditis. Conclusions: At intermediate term follow-up this retrospective study provides further support for the use of the Freestyle bioprosthesis in the real-world setting of diverse, complex, and often high-risk aortic root replacement and suggests that outcome is determined by patient and disease, rather than by prosthesis, characteristics.

Postoperative coronary vasospasm is a rare but potentially life-threatening complication after cardiac surgery. We present the case of a young patient with osteogenesis imperfecta who developed coronary vasospasm after each of his 2 aortic valve procedures. We believe this case provides new information about the presentation, potential for recurrence, and clinical progression of perioperative coronary vasospasm.

Background Cerebral protection remains the cornerstone of successful aortic surgery; however, there is no consensus as to the optimal strategy. Objective To compare the safety and efficacy of innominate to axillary artery cannulation for delivering antegrade cerebral protection during proximal aortic arch surgery. Methods This randomized controlled trial (The Aortic Surgery Cerebral Protection Evaluation CardioLink-3 Trial, ClinicalTrials.gov Identifier: NCT02554032 ), conducted across 6 Canadian centers between January 2015 and June 2018, allocated 111 individuals to innominate or axillary artery cannulation. The primary safety outcome was neuroprotection per the appearance of new severe ischemic lesions on the postoperative diffusion-weighted-magnetic resonance imaging. The primary efficacy outcome was the difference in total operative time. Secondary outcomes included 30-day all-cause mortality and postoperative stroke. Results One hundred two individuals (mean age, 63 ± 11 years) were in the primary safety per-protocol analysis. Baseline characteristics between the groups were similar. New severe ischemic lesions occurred in 19 participants (38.8%) in the axillary versus 18 (34%) in the innominate group (P for noninferiority = .0009). Total operative times were comparable (median, 293 minutes; interquartile range, 222-411 minutes) for axillary versus (298 minutes; interquartile range, 231-368 minutes) for innominate (P for superiority = .47). Stroke/transient ischemic attack occurred in 4 (7.1%) participants in the axillary versus 2 (3.6%) in the innominate group (P = .43). Thirty-day mortality, seizures, delirium, and duration of mechanical ventilation were similar in both groups. Conclusions diffusion-weighted magnetic resonance imaging assessments indicate that antegrade cerebral protection with innominate cannulation is safe and affords similar neuroprotection to axillary cannulation during aortic surgery, although the burden of new neurological lesions is high in both groups.

ObjectiveThe Ross procedure is an excellent option for children or young adults who need aortic valve replacement because it can restore survival to that of the normal aged-matched population. However, autograft remodeling can lead to aneurysmal formation and reoperation, and the biomechanics of this process is unknown.This study investigated postoperative autograft remodeling after the Ross procedure by examining patient-specific autograft wall stresses.MethodsPatients who have undergone the Ross procedure who had intraoperative pulmonary root and aortic specimens collected were recruited. Patient-specific models (n=16) were developed using patient-specific material property and their corresponding geometry from cine magnetic resonance imaging at 1-year follow-up. Autograft±Dacron for aneurysm repair and ascending aortic geometries were reconstructed to develop patient-specific finite element models, which incorporated material properties and wall thickness experimentally measured from biaxial stretching. A multiplicative approach was used to account for prestress geometry from invivo magnetic resonance imaging. Pressure loading to systemic pressure (120/80) was performed using LS-DYNA software (LSTC Inc, Livermore, Calif).ResultsAt systole, first principal stresses were 809kPa (25%-75% interquartile range, 691-1219kPa), 567kPa (485-675kPa), 637kPa (555-755kPa), and 382kPa (334-413kPa) at the autograft sinotubular junction, sinuses, annulus, and ascending aorta, respectively. Second principal stresses were 360kPa (310-426kPa), 355kPa (320-394kPa), 272kPa (252-319kPa), and 184kPa (147-222kPa) at the autograft sinotubular junction, sinuses, annulus, and ascending aorta, respectively. Mean autograft diameters were 29.9±2.7mm, 38.3±5.3mm, and 26.6±4.0mm at the sinotubular junction, sinuses, and annulus, respectively.ConclusionsPeak first principal stresses were mainly located at the sinotubular junction, particularly when Dacron reinforcement was used. Patient-specific simulations lay the foundation for predicting autograft dilatation in the future after understanding biomechanical behavior during long-term follow-up.

Introduction: Although the Ross procedure offers several advantages over standard prosthetic AVR, its use remains limited. The risk of pulmonary autograft dilatation requiring reintervention remains one of the main concerns. Consequently, multiple techniques have been developed in attempt to mitigate this complication.Areas covered: This article reviews the incidence of pulmonary autograft dilatation, its risk factors and pathophysiology. The techniques of external pulmonary autograft support are discussed along with their respective advantages and limitations. Finally, future areas of research and developments are examined.Expert opinion: The risk of autograft dilatation is mainly prevalent in patients with aortic regurgitation and a dilated aortic annulus. In these selected patients, an external support may prevent dilatation of the autograft. However, any permanent support potentially restricts autograft root motion, mitigating some of the advantages associated with the Ross procedure. A bioresorbable matrix that could support the root during its initial adaptative phase could alleviate this problem. In our opinion, aggressive blood pressure control during the first postoperative year along with annular and sino-tubular junction support in selected patients provides optimal stability of autograft root dimensions while preserving root dynamics. Serial imaging and clinical follow-up are necessary to define the role of these various strategies.

Aortic valve repair is the preferred approach for the treatment of severe aortic insufficiency (AI), as it allows patients to keep their native aortic valve, thus substantially reducing the risk of prosthesis-related complications. Several studies have documented excellent long-term outcomes of aortic valve repair. The major complication of this operation is AI recurrence, with ensuingneed for reoperation. The surgical experience accumulated over the last two decades has allowed for better understanding of the mechanisms of recurrent AI after aortic valve repair. Herein, we review the current state of knowledge on predictors of aortic valve repair failure. These include unaddressed annular dilation, residual cusp prolapse or retraction, commissural orientation, and use of patch material. This enhanced understanding has led to the development of increasingly refined techniques and improved patient outcomes. Continued follow-up and detailed data collection at the time of surgery, together with three-dimensional echo imaging, will allow further improvements in aortic valve repair.

Objectives We describe the Canadian results of the Ascyrus Medical Dissection Stent (AMDS), a novel partially uncovered aortic arch hybrid graft implanted antegrade during hypothermic circulatory arrest to promote true lumen expansion and enhance aortic remodeling. Methods From March 2017 to February 2018, 16 consecutive patients (66 ± 12 years; 38% female) presented with acute type A aortic dissections and underwent emergent surgical aortic repair with AMDS implantation. All patients presented with DeBakey I aortic dissection, with evidence of malperfusion in 50% (n = 8) of patients. All cases were performed under hypothermic circulatory arrest with an additional average duration for AMDS implantation time of 2.1 minutes. Results All 16 device implantations were successful. Overall 30-day mortality was 6.3% (n = 1) and stroke occurred in 6.3% (n = 1) of cases. There was no incidence of device-related aortic injury or aortic arch branch vessel occlusion. During the follow-up period, 12 patients had completed at least 1 postoperative computed tomography scan. At initial follow-up computed tomography scan, complete or partial thrombosis, and remodeling of the aortic arch occurred in 91.7% of cases (n = 11/12) and in the proximal descending thoracic aorta, complete or partial thrombosis, and remodeling occurred in 91.7% (n = 11/12). Conclusions Preliminary results suggest that the AMDS is a safe, feasible and reproducible adjunct to current surgical approaches for acute DeBakey I aortic dissection repair. Further, the AMDS manages malperfusion and promotes early positive remodeling in the aortic arch and distal dissected segments, with favorable FL closure rates at follow-up. Ongoing follow-up will provide additional insight into the long-term effects of the AMDS.

Background: Contemporary outcomes after surgical management of thoracic aortic disease have improved; however, the impact of sex-related differences is poorly understood. Methods: A total of 1653 patients (498 [30.1%] female) underwent thoracic aortic surgery with hypothermic circulatory arrest between 2002 and 2017 in 10 institutions of the Canadian Thoracic Aortic Collaborative. Outcomes of interest were in-hospital death, stroke, and a modified Society of Thoracic Surgeons–defined composite for mortality or major morbidity (stroke, renal failure, deep sternal wound infection, reoperation, prolonged ventilation). Multivariable logistic regression was used to determine independent predictors of these outcomes. Results: Women were older (mean±SD, 66±13 years versus 61±13 years; P P P =0.02), stroke (8.8% versus 5.5%; P =0.01), and Society of Thoracic Surgeons–defined composite end point for mortality or major morbidity (31% versus 27%; P =0.04). On multivariable analyses, female sex was an independent predictor of mortality (odds ratio, 1.81; P P P Conclusions: Women experience worse outcomes after thoracic aortic surgery with hypothermic circulatory arrest. Further investigation is required to better delineate which measures may reduce sex-related outcome differences after complex aortic surgery.

Aortic valve surgery in non-elderly patients represents a very challenging patient population. The younger the patient is at the point of aortic valve intervention, the longer their anticipated life expectancy will be, with longer exposure to valve-related complications and risk for re-operation. Although the latest international guidelines recommend aortic valve repair in patients with aortic valve insufficiency, what we see in the real world is that the vast majority of these aortic valves are replaced. However, current prosthetic valves has now been shown to lead to significant loss of life expectancy for non-elderly patients up to 50% for patients in their 40s undergoing mechanical aortic valve replacement. Bioprostheses carry an even worse long-term survival, with higher rates of re-intervention. The promise of trans-catheter valve-in-valve technology is accentuating the trend of bioprosthetic implantation in younger patients, without yet the appropriate evidence. In contrast, aortic valve repair has shown excellent outcomes in terms of quality of life, freedom from re-operation and freedom from major adverse valve-related events with similar life expectancy to general population as it is also found for the Ross procedure, the only available living valve substitute. We are at a time when the paradigm of aortic valve surgery needs to change for the better. To better serve our patients, we must acquire high quality real-world evidence from multiple centers globally - this is the vision of the AVIATOR registry and our common responsibility.

To examine the perioperative outcomes following aortic arch repair using frozen elephant trunk (FET) vs conventional elephant trunk (ET) techniques. Between 2002 and 2018, 390 patients underwent aortic repair with elephant trunk reconstruction at 9 centers: 172 patients received a FET (mean age: 65+/-13 years, 30% female, 37% aortic dissection) and 218 patients received an ET (mean age: 63+/-13 years, 37% female, 43% aortic dissection). Outcomes of interest included in-hospital mortality; stroke; and spinal cord injury (SCI). In-hospital mortality rate was 11% (n = 43) overall, 9% (n = 15) for FET and 13% (n = 28) for ET. Post-operative stroke occurred in 13% (n = 49) overall, 13% (n = 22) for FET and 12% (n = 27) for ET. The rate of post-operative SCI was 3% (n = 13) overall, 5.0% (n = 9) for FET and 2.0% (n = 4) for ET. When compared to ET, the propensity score analysis confirmed FET to be associated with lower mortality (adjusted risk difference -7.0% (95% CI -13.0 to -1.0), P = 0.02). There was no significant difference in the propensity score-adjusted risk difference for stroke between FET and ET (-0.7%, 95% CI -7.4% to 6.1%, P = 0.85), nor for SCI (3.3%, 95% CI -0.4% to 7.0%, P = 0.085) On multivariable analysis, FET was associated with lower odds of mortality (OR 0.44, 95% CI 0.21–0.95, P = 0.04), and had similar odds of stroke (OR 0.83, 95% CI 0.41–1.70, P = 0.62) and SCI (OR 2.83, 95% CI 0.83–9.60, P = 0.1). FET repair is associated with lower in-hospital mortality as compared to conventional ET, and results in similar risk of stroke and spinal cord injury. Further investigation is warranted.

BACKGROUND The Ross procedure offers several advantages in patients requiring aortic valve replacement (AVR). However, it is a more complex procedure than a standard AVR. Whether there is a risk associated with expanding its eligibility and having multiple surgeons performing this operation remains a matter of debate. METHODS AND RESULTS From 2011-2020, 568 Ross procedures were performed by 5 surgeons in 2 Canadian institutions. The cohort was divided in 5 periods of 100 patients (P1 through P5) per center to assess efficacy and safety throughout time. The efficacy endpoints were cross-clamp time, bypass time and aortic regurgitation (AR)>1 at discharge. Safety was assessed with a cumulative sum analysis (CUSUM) adjusted using the STS score. The mean age increased throughout the study period (P1: 45±13 years, P2: 47±12 years, P3: 47±12 years, P4: 48±11 years, P5: 53±10 years; p 1 (1 in P2 and 1 in P5; p=0.76). The CUSUM analysis showed that the risk of complications decreased after 100 cases (Figure 1). Three patients had a perioperative myocardial infarction (1 in P4 and 2 in P5; p=0.25) and 3 patients presented a transient ischemic attack (2 in P1 and 1 in P2; p=0.70). There was a non-statistically significant decrease in the need for temporary dialysis (P1: 5 patients, P2: 3 patients, P3: 0 patient, P4: 1 patient, P5: 1 patient; p=0.08). A similar trend was observed in terms of reintervention for bleeding (P1: 5 patients, P2: 1 patient, P3: 0 patient, P4: 2 patients, P5: 0 patient; p=0.10). The perioperative outcomes did not differ between centers. Two patients died within 30-days, both during P1 (p=0.20). There was no perioperative death in center 2. The overall mortality was 0.4%, (O/E ratio=0.24). CONCLUSION In dedicated programs, the learning curve for the Ross procedure is ≈70 cases. Following this initial phase, nor the addition of other experienced surgeon or increased patient comorbidities had a significant impact on safety and efficacy. Overall mortality remained lower than predicted.

Objective: The study objective was to investigate the long-term survival of patients undergoing xenograft versus homograft full root aortic valve replacement. Methods: A total of 166 patients requiring aortic valve surgery were randomized to undergo the Freestyle (Medtronic Inc, Minneapolis, Minn) bioprosthesis (N = 90) or a homograft (N = 76) full root aortic valve replacement between 1997 and 2005 in a single institution. Six patients randomly assigned to the homograft crossed over to the Freestyle bioprosthesis because of the unavailability of suitably sized homografts. All surgeons were required to adhere to the standard surgical technique for homograft root implantation previously described. Follow-up was 98.5% complete. Results: The mean age of the study population was 65 ± 8 years. Coronary artery bypass grafting was associated with root aortic valve replacement in 76 of 166 patients (46%, P = not significant between groups), and overall hospital mortality was 4.8% (8/166, P = not significant between groups). Median follow-up was 13.8 years (range, 0-21.8 years; 2033 patient-years). The Kaplan–Meier survival analysis showed that there was no significant difference in overall survival between the 2 arms at 5, 10, and 15 years. Twenty-year survival was 28.3% ± 5% for the Freestyle group versus 25.1% ± 5.7% for the homograft group (P =.90), which was comparable to the age- and sex-matched UK general population. The freedom from aortic valve reoperation at 20 years was comparable for the Freestyle group versus the homograft group (67.9% ± 8.8% vs 67.2% ± 10.3%, respectively; P =.74). Conclusions: This is the first study to investigate the long-term survival of xenograft versus homograft full root aortic valve replacement from a prospective randomized trial. The observed 20-year overall survival and freedom from aortic valve reoperation serve as a benchmark for future studies on interventions for aortic valve disease in the elderly.

Acute type A aortic dissection remains a high-risk surgical condition, and mortality among those presenting with malperfusion is up to 3-fold higher. Despite the added technical challenge of distal aortic arch interventions in the acute setting, it may be necessary to resolve distal malperfusion in patients with this disorder. The ideal arch intervention to address acute type A aortic dissection complicated by malperfusion should address the following objectives: (1) to relieve distal malperfusion by expanding the distal true lumen and depressurizing the false lumen; (2) to avoid compromising arch branches without requiring additional arch branch interventions; (3) to minimize the risk of spinal cord ischemia; and (4) to minimize the operative duration and circulatory arrest time. The use of an uncovered aortic arch stent that is delivered in an antegrade manner during circulatory arrest, concomitantly with hemiarch replacement, therefore represents an attractive solution in the management of acute type A aortic dissection complicated by malperfusion. This strategy does not require complex arch reconstruction and may thus be a feasible option among cardiac and vascular surgeons in lower volume aortic centers. Here we present a step-by-step approach to acute type A aortic dissection repair with hemiarch repair and delivery of an uncovered arch stent for a patient presenting with malperfusion.

Pulmonary homograft dysfunction is a limitation after the Ross procedure. Decellularized pulmonary homografts can potentially mitigate this complication. The aim of this study was to examine the incidence, predictors, progression, and morphology of pulmonary homograft dysfunction using data from the Canadian Ross Registry.From 2011 to 2019, 466 consecutive patients (mean age: 47 ± 12 years, 73% male) underwent a Ross procedure using a decellularized cryopreserved pulmonary homograft (SynerGraft SG; CryoKife, Kennesaw, Ga). Pulmonary homograft dysfunction was defined as any of the following: peak pulmonary gradient ≥30 mm Hg, pulmonary regurgitation2, or pulmonary homograft reintervention. Patients meeting ≥1 of these criteria (n = 30) were compared with the rest of the cohort (n = 436). Median follow-up is 2.2 years (maximum = 8.5 years) and 99% complete (1176 patient-years).The cumulative incidence of pulmonary homograft dysfunction was 11 ± 2% at 6 years. Pulmonary homograft stenosis was the most frequent presentation (n = 28 patients, 93%). Morphologically, stenosis occurred most often along the conduit (59%). Overall, 4 patients required homograft reintervention. At 6 years, the cumulative incidence of homograft reintervention was 3 ± 1%. The instantaneous risk was greatest in the first year after surgery (3.5%/year) and decreased to1%/year thereafter. Patient age45 years was the only independent risk factor associated with pulmonary homograft dysfunction (hazard ratio, 3.1, 95% confidence interval, 1.1-8.6, P = .03).The use of decellularized cryopreserved pulmonary homografts results in a low incidence of dysfunction and reintervention after the Ross procedure. The risk is greater in the first postoperative year. Younger age is the only independent risk factor for pulmonary homograft dysfunction.

Introduction: The Ross procedure is an excellent option for children and young adults who need aortic valve replacement as this surgery can restore patient survival to that of a normal sex and aged-matched population. However, some patients experience aneurysmal formation during autograft remodeling and require reoperation. As the underlying biomechanics of autograft remodeling are unknown, we investigated patient-specific wall stresses in pulmonary autografts one year post-operatively to better understand systemic pressure-driven early autograft wall stresses. Methods: Ross patients (n=16) who underwent intraoperative collection of pulmonary root/aortic specimen, and subsequent one-year MRI follow-up were recruited. Patient-specific material properties from their tissue were experimentally determined and incorporated into autograft ± Dacron and ascending aorta finite element models. A multiplicative approach was used to account for pre-stress geometry from in-vivo MRI. Physiologic pressure loading was simulated with LS-DYNA software. Results: At systemic systole, first principal stresses were 567kPa (25-75% IQR, 485-675kPa), 809kPa (691-1219kPa), and 382kPa (334-413kPa) at autograft sinuses, sinotubular junction (STJ), and ascending aorta, respectively. Second principal stresses were 355kPa (320-394kPa), 360kPa (310-426kPa), and 184kPa (147-222kPa) at autograft sinuses, STJ, and ascending aorta, respectively. Mean autograft diameters were 38.3±5.3mm, 29.9±2.7mm, and 26.6±4.0mm at sinuses, STJ, and annulus, respectively. Conclusions: First principal stresses were mainly located at STJ, particularly when Dacron reinforcement was applied to constrain STJ dilatation. However, at one-year after the Ross operation, autograft dilatation was not seen despite elevated autograft wall stresses compared to their internal controls, the lower wall stresses in corresponding native distal ascending aorta. In this group of patients, higher risk of dilatation is expected in the sinuses and STJ if not constrained by Dacron than the corresponding ascending aorta. Future follow-up will elucidate the biomechanics of long-term autograft remodeling to develop predictive models for autograft dilatation.