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Previously we have shown that epicardial shock-wave therapy improves left ventricular ejection fraction (LVEF) in a rat model of myocardial infarction. In the present experiments we aimed to address the safety and efficacy of epicardial shock-wave therapy in a preclinical large animal model and to further evaluate mechanisms of action of this novel therapy. Four weeks after left anterior descending (LAD) artery ligation in pigs, the animals underwent re-thoracotomy with (shock-wave group, n = 6) or without (control group, n = 5) epicardial shock waves (300 impulses at 0.38 mJ/mm

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

Introduction: Minimally invasive techniques for valve surgery have emerged as a safe and efficient approach in many institutions. Based on data and growing experience of minimally invasive mitral valve procedures, the technique was extended to double valve surgery. Aim of this study was to evaluate [for full text, please go to the a.m. URL], 130. Kongress der Deutschen Gesellschaft für Chirurgie

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

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

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

In the management of type B acute aortic dissection, most recent benchmarking has been proposed by the Investigation of Stent Grafts in Aortic Dissection (INSTEAD) trial [1]. In the case of uncomplicated dissection with optimal medical therapy alone, only 22% of these particular patients had to undergo secondary intervention or surgery at 2 years. This indicates that, in a benchmark trial, 78% of patients did well without developing the need for secondary reinterventions. However, per definition, the INSTEAD trial deals with chronic dissection, since the time delay from event to randomization was 6 weeks in average and >2 weeks in all patients. So, there is still a window of uncertainty about treatment modality in the early, acute period of dissection. For this early time frame, the data from the International Registry of Acute Aortic Dissection (IRAD) indicate that 24% of 515 patients with acute Type B dissection require emergent intervention for early complications within the acute phase of 14 days [2]. However, we still miss clear predictive parameters identifying patients at risk of a complicated course. The merit of the manuscript by Weiss et al. [3] in this issue is the fact that they provide a potential tool for further classification of patients into a higher risk group in the acute phase of dissection. They report that a primary entry tear at the concavity of the aortic arch and short distance between the primary entry tear and the left subclavian artery are frequently associated with the development of acute complications. Most promising is the fact that the authors postulate that this discrimination can be drawn at the first, diagnostic imaging study. When the entry tear was located at the convexity of the aortic arch, subsequent complications, needing intervention, developed in 20% of the patients. In contrast, when entry tear was located at the concavity of the arch, an impressive 89% of the patients required acute intervention. This potentially important information is somewhat confused by the fact that in total 56% of all studied patients finally developed complicated acute dissection. Remarkably, under the assumption of comparable definitions of complications, this is twice the incidence when compared with IRAD and by this weakens the broader applicability of the given decisive algorithm in daily routine. The pathophysiological background is that the supra-aortic branches on the convexity of the aortic arch serve as a natural anatomic barrier against retrograde propagation of the dissection process. A similar protective structure is missing at the concavity of the arch. In a porcine model of aortic dissection, this theory has been confirmed: when the entry was at the concavity of the aortic arch the retrograde propagation reached the ascending aorta in 16%, whereas the dissection stopped at the origin of the left subclavian artery when the entry was at the convexity of the aortic arch [4]. One might speculate, together with the authors, to deliberately go for an intervention in patients with an entry localized at the concavity of the aorta. Nevertheless, in the present paper, there remain two major concerns. First, if we start with endovascular intervention in otherwise uncomplicated Type B aortic dissections, in this specific high-risk group with an entry close to the left subclavian artery, we inevitably end up in the landing zones 1 or 2 of the aortic arch. This in turn carries a certain risk of stentgraft-induced retrograde type A aortic dissection [5]. For this particular mechanism, it will be a matter for future studies to show whether completely covered stentgrafts might reduce the risk of retrograde aortic dissection by avoiding bare springs. Secondly, the entry localization was analysed retrospectively when the patients were already classified as complicated or uncomplicated course, which carries the risk of bias in retrospective analysis. Despite a relatively large number of acute aortic syndromes referred to our interdisciplinary aortic centre and despite sophisticated imaging techniques, in many cases we are still uncertain about the exact localization of the primary entry tear. This decision, to accurately allocate the entry tear and, by this. Guide acute therapeutic strategy, may become even more difficult in the setting of clinical routine for less-experienced radiologists/surgeons on call. In conclusion, we appreciate the effort by Weiss et al. to identify the entry localization at the concavity of the aorta as a new risk factor for complication of acute type B aortic dissection. It initiates structured decision-making in the very early phase of a potentially devastating disease. Nevertheless, two questions have to be answered in the future. First, is prospective detection of the primary entry tear localization accurate and reproducible in broad clinical application? Secondly, is the risk of aggressive endovascular treatment of the distal aortic arch in otherwise uncomplicated dissections really justified?

Aim of this study was to elucidate if postoperative neurocognitive function after biological aortic valve replacement (AVR) can be influenced by temperature management during cardiopulmonary bypass (CPB).In this prospective randomized study, we measured the effect of mild hypothermic (32 °C, N.=30) vs. normothermic (37 °C, N.=30) CPB on neurocognitive function. All patients underwent elective isolated biological AVR (mean age 67 ± 8 years, mean additional EuroSCORE 5.6 ± 2.4). Neurocognitive function was objectively measured by means of objective P300 auditory-evoked potentials before surgery, one week and four months after surgery. Clinical data and outcome were monitored.P300 evoked potentials were comparable between patients operated with mild hypothermic (370 ± 30 ms) and normothermic CPB (373 ± 32 ms) before surgery (P=0.85). P300 peak latencies were prolonged (=impaired) in patients operated with normothermic (402 ± 29, P0.0001) as well as with mild hypothermic CPB (405 ± 30 ms, P0.0001) one week after surgery. Even four months after surgery, still impairment of P300 peak latencies could be documented in either patients operated with normothermic (394 ± 28 ms) and mild hypothermic CPB (400 ± 33 ms,) in repeated measures analysis of variance (P=0.042). Group comparison revealed no difference between patients operated with normothermic and mild hypothermic CPB at one week (P=0.54) and four months (P=0.67) after surgery. Clinical data as well as postoperative adverse events were comparable between the two groups.Normothermic temperature management during CPB is non-inferior to hypothermic in means of neuroprotection. Since patients after biological aortic valve replacement show a subclinical but measurable cognitive deficit up to four months after surgery, other factors have to be addressed to add further benefit to the extremely good results of open biological AVR.

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

Background We evaluated mechanisms of failure and outcome of secondary surgical interventions after thoracic endovascular aortic repair (TEVAR). Methods Between 1996 and 2009, 421 patients underwent TEVAR for the following indications: atherosclerotic aneurysms, type B dissections, penetrating ulcers and traumatic lesions. Results Twenty-one patients underwent secondary surgical interventions. Indications were type I endoleak formation, retrograde type A dissection, distal aneurysm formation as well as infection. Retrospectively, by analysing referral computed tomography scans and by current knowledge, failure could have been foreseen in 72% of patients. Median interval to secondary surgical intervention was 24 months (IQR 8-40). Sixteen patients underwent thoracic or thoracoabdominal repair and five patients underwent ascending and hemiarch replacement. In-hospital mortality was 19%. Cause of death was multiorgan failure in all cases. Conclusions The need for secondary surgical intervention after TEVAR is low but carries risk. By analysing mechanisms of failure, the majority of these events could have been avoided by a more strict indication. Thereby, further critical evaluation and respecting limitations of TEVAR will help to reduce the need for these operations.

Background The purpose of this study was to assess the efficacy and midterm results of endovascular treatment of acute, complicated type B aortic dissection. Methods Between January 2001 and February 2010, 32 patients (7 women, 25 men) with acute, complicated type B aortic dissection (mean age, 56 years; range, 35 to 83 years), defined as either aortic rupture, malperfusion, intractable pain, or uncontrolled hypertension, underwent endovascular stent graft placement with either the Gore Excluder/TAG device (n = 11), Medtronic Talent/Valiant device (n = 16), Bolton Relay (n = 2), or a combination of these stents (n = 3). Follow-up was 94% complete and averaged 26 ± 23 months. Results Technical feasibility and success with deployment proximal to the entry tear was 87%, requiring partial or total coverage of the left subclavian artery (LSA) in 9 patients (28%). Hospital mortality was 12% ± 11% (95% confidence limit) with 2 late deaths (17 and 98 months after implant). Causes of hospital death included rupture in 2, retrograde type A dissection in 1, and multiorgan failure in 1 patient. Three patients (11%) experienced new neurologic complications (2 paraparesis and 1 hemiparesis). Six patients with malperfusion required branch vessel stenting. Furthermore, 2 had an early type Ia endoleak. Actuarial survival at 1 and 5 years was 81% and 76%, respectively. Freedom from treatment failure at 1 and 5 years (including reintervention, aortic rupture, device-related complication, and aortic related death) was 78% and 61%, respectively. Conclusions Endovascular stent-graft placement in acute, complicated type B aortic dissection proves to be a promising alternative therapeutic treatment modality in this relatively difficult patient cohort. Refinements, especially in stent design and application, may further improve the prognosis of patients in this life-threatening situation.

Background: Results of supraaortic transpositions and endovascular repair of aortic arch pathology remain to be determined. Methods: From 1996 through 2008, 73 patients presented with aortic arch pathology. Strategy for distal arch disease was subclavian-to-carotid transposition (n=24) or autologous double-vessel transposition through upper hemisternotomy (n=36). For entire arch disease, total supra-aortic rerouting with a reversed bifurcated prosthesis was applied (n=13). Endovascular stent graft placement was performed metachronously. Results: In-hospital mortality was 6.8% (n=5). Overall actuarial survival was 90%, 86%, and 72% at 1, 3, and 5 years. Mean follow-up is 37 months (range, 1 to 120). Early and late endoleak formation was independently predicted by the number of prostheses (early odds ratio [OR] 0.210, p=0.0003; late OR 0.216, p=0.012), whereas logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) reached borderline significance regarding late endoleaks (OR 2.1, p=0.095). An earlier year of implantation reached borderline significance predicting survival (OR 1.9, p=0.062). Furthermore, survival was independently predicted by higher logistic EuroSCORE levels (OR 1.8, p=0.020). Interestingly, type of arch rerouting did not influence endoleak formation and survival (OR 0.9, p=0.812). Conclusions: Results after supra-aortic transpositions in various extents followed by endovascular stent graft placement for treatment of aortic arch pathology are promising. Endoleak formation is directly related to the number of prostheses and may be reduced by longer devices. Extended applications of these combined treatment strategies substantially augment therapeutic options.

The aim of this study was to determine risk factors for mortality in different age groups after thoracic endovascular aortic repair (TEVAR).We retrospectively analyzed 226 consecutive patients undergoing TEVAR at our institution during a 12-year period (female 28%; median age 67 years). Fifty-six patients were more than 75 years of age at the time of TEVAR. Follow-up data were available in all patients.Patients more than 75 years old had a higher incidence of extracardiac arteriopathy (79% versus 58%; p = 0.006) and were more likely to be unsuitable for open surgery (84% versus 47%; p0.001). Multivariate logistic regression analysis revealed the combined endpoint of perioperative myocardial infarction and neurologic injury (p = 0.023, odds ratio 13.9, 95% confidence interval: 1.44 to 134.6) as well as persisting type I and III endovascular leaks (p = 0.042, odds ratio 2.81, 95% confidence interval: 1.04 to 7.58) as independent predictors of mortality in patients less than 75 years old. Emergency TEVAR was the only independent predictor of mortality among patients more than 75 years old (p = 0.041, odds ratio 3.65, 95% confidence interval: 1.06 to 12.64).Different age groups exhibit different risk factors after TEVAR. The prognosis for younger patients is substantially limited by perioperative myocardial infarction and neurologic injury as well as persisting endovascular leak formation, as these patients may be more likely to experience aortic-related complications. Emergency TEVAR-most often being associated with hemodynamic instability-is the limiting factor for elderly patients, reflecting their frail physiology. Adhering to strict indications and broad screening, thereby reducing the incidence of emergency procedures, will help to further improve outcome after TEVAR.

This is a report on the combined surgical and endovascular treatment of a very large aortic arch aneurysm. In the first step, total arch rerouting was performed with an inversed bifurcated Dacron prosthesis. Brachiocephalic trunk and left subclavian artery were inserted into the two branches of the prosthesis via an end-to-end anastomosis and left common carotid was reinserted into the branch to the left subclavian. In the second step, thoracic endovascular aortic repair was performed. By this combined concept a stable and durable result could be achieved.

ObjectivesDirect application of low-energy unfocused shock waves induces angiogenesis in ischemic soft tissue. The potential effects of epicardial shock wave therapy applied in direct contact to ischemic myocardium are uncertain.MethodsFor induction of ischemic heart failure in a rodent model, a left anterior descending artery ligation was performed in adult Sprague–Dawley rats. After 4 weeks, reoperation with (treatment group, n = 60) or without (control group, n = 60) epicardial shock wave therapy was performed. Low-energy shock waves were applied in direct contact with the infarcted myocardium (300 impulses at 0.38 mJ/m2). Additionally, healthy animals (n = 30) with normal myocardium were studied. Angiogenesis, ventricular function upregulation of growth factors, and brain natriuretic peptide levels were analyzed.ResultsHistologic analysis revealed significant angiogenesis 6 weeks (treatment group: 8.2 ± 3.7 vs control group: 2.9 ± 1.9 vessels per field, P = .016) and 14 weeks (treatment group: 7.1 ± 3.1 vs control group: 3.2 ± 1.8 vessels per field, P = .011) after shock wave treatment. In the treatment group ventricular function improved throughout the follow-up period (6 weeks: 37.4% ± 9% [P < .001] and 14 weeks: 39.5% ± 9% [P < .001]). No improvement of ventricular function was observed in the control group (6 weeks: 28.6% ± 5% and 14 weeks: 21.4% ± 5%). Rat brain natriuretic peptide 45 levels were lower in the treatment group compared with those in the control group 6 and 14 weeks after treatment. Vascular endothelial growth factor, Fms-related tyrosine kinase 1, and placental growth factor levels were upregulated after 24 and 48 hours and 7 days in the treatment group. No effects on healthy myocardium were observed.ConclusionDirect epicardial low-energy shock wave therapy induces angiogenesis and improves ventricular function in a rodent model of ischemic heart failure.

Background Wound healing disorders after vein harvesting for coronary artery bypass graft surgery increase morbidity and lower patient satisfaction. Low-energy shock wave therapy (SWT) reportedly improves healing of diabetic and vascular ulcers by overexpression of vascular endothelial growth fractor and downregulation of necrosis factor κB. In this study, we investigate whether prophylactic low-energy SWT improves wound healing after vein harvesting for coronary artery bypass graft surgery. Methods One hundred consecutive patients undergoing coronary artery bypass graft surgery were randomly assigned to either prophylactic low-energy SWT (n = 50) or control (n = 50). Low-energy SWT was applied to the site of vein harvesting after wound closure under sterile conditions using a commercially available SWT system (Dermagold; Tissue Regeneration Technologies, Woodstock, GA). A total of 25 impulses (0.1 mJ/mm 2 ; 5 Hz) were applied per centimeter wound length. Wound healing was evaluated and quantified using the ASEPSIS score. (ASEPSIS stands for Additional treatment, presence of Serous discharge, Erythema, Purulent exudate, Separation of the deep tissue, Isolation of bacteria, and duration of inpatient Stay). Patient demographics, operative data, and postoperative adverse events were monitored. Results Patient characteristics and operative data including wound length (SWT 39 ± 13 cm versus control 37 ± 11 cm, p = 0.342) were comparable between the two groups. We observed lower ASEPSIS scores indicating improved wound healing in the SWT group (4.4 ± 5.3) compared with the control group (11.6 ± 8.3, p = 0.0001). Interestingly, we observed a higher incidence of wound healing disorders necessitating antibiotic treatment in the control group (22%) as compared with the SWT group (4%, p = 0.015). No SWT-associated adverse events were observed in the treatment group. Conclusions As shown in this prospective randomized study, prophylactic application of low-energy SWT improves wound healing after vein harvesting for coronary artery bypass graft surgery.

Aims: Therapeutic options of ischemic heart failure are limited. Shock wave therapy (SWT) reportedly induces VEGF overexpression in ischemic myocardium. We hypothesized that epicardial SWT improves ventricular function in an experimental model of ischemic heart failure by inducing neoangiogenesis. Methods: Pigs were subdivided in 3 groups: unharmed myocardium with epicardial SWT (healthy control, n=2), infarcted myocardium with epicardial SWT (SWT-group, n=6) and infarcted myocardium without epicardial SWT (control, n=2). Four weeks following myocardial infarction (MI), epicardial SWT (300 impulses at 0.15 mJ/m2) was applied directly to the infarcted area in the healthy control and the SWT-group, controls were left untreated. Cardiac function was evaluated using echocardiography before MI, 4 weeks after MI and 4 weeks after SWT. Angiogenesis was evaluated 4 weeks after treatment by immunohistology with vonWillebrand Factor antibody, which was morphometried with Lucia software. Results: Compared to healthy controls (68±0.7%), left ventricular ejection fraction decreased in the SWT (43±2.5%, p

We report 2 patients who were referred for treatment of hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition (coral reef aorta) that was causing abdominal angina and intermittent claudication. Both patients underwent successful transfemoral endovascular stent-graft placement and are free of symptoms, with regular findings at 6-month follow-up completion computed tomography scan.