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Background. Over the years, with the introduction of minimally invasive techniques and technologies aimed at reducing surgical trauma, aortic valve surgery has considerably developed and improved. Our approach includes: reduced incisions (upper “J” ministernomy or anterior right minithoracotomy), “ultra fast-track” anesthesia protocols, sutureless and rapid deployment valve prostheses and miniaturized circuits of extracorporeal circulation. The aim of this study was to evaluate the clinical outcomes associated with this multidisciplinary approach. Methods. Between October 2016 and November 2018, 429 patients underwent isolated aortic valve replacement at the Cardiac Surgery Unit of the “Ospedali Riuniti” of Ancona, Italy. Overall, 91 patients (21.2%) were operated according to our minimally invasive approach. A severe aortic valve stenosis was the indication for surgery in 90.1% of patients, aortic valve insufficiency in the remaining 18.7%. Results. There were neither in-hospital deaths nor major or minor neurological events. Atrial fibrillation was the main postoperative complications (n=26, 28.6%). Four patients (4.4%) underwent permanent pacemaker implantation due to third-degree atrioventricular block, and a surgical bleeding revision was performed in 3.3%. No episodes of respiratory failure were reported. The median length of hospital stay was 6 days (5-8 days). Conclusions. Our initial experience with a 360° minimally invasive approach for the treatment of patients undergoing aortic valve replacement shows encouraging clinical outcomes; this approach may lead to an improved perception of surgery both by patients and their families. However, further clinical studies are needed to evaluate the long-term results.

Thoracic aortic aneurysm (TAA) is a silent disease that can become rapidly lethal once dissection or rupture occurs. To prevent aortic catastrophe, prophylactic aortic replacement is the mainstay of therapy in patients with TAA. Currently, surgical indications for TAA repair are predominantly based on the aortic size. However, the effectiveness of the diameter criterion to predict aortic rupture and dissection has been largely questioned over the last years. Growing evidence suggests that aortic size alone May not be sufficient to predict the risk in all TAAs. In this setting, other predictors such as genetic, environmental, biochemical and hemodynamic factors have been proposed. The aim of this paper is to review and discuss on current evidence, controversies and future directions for the treatment of patients with TAA.

The RotaFlow (Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany) and Levitronix CentriMag (Levitronix LCC, Waltham, MA, USA) veno-arterial extracorporeal membrane oxygenation (ECMO) support systems have been investigated as treatment for refractory cardiogenic shock. METHODS: Between 2004 and 2012, 119 consecutive adult patients were supported on RotaFlow (n=104) or CentriMag (n=15) ECMO at our Institution (79 men; mean age 57.3 ± 12.5 years, range 19-78 years). Indications for support were: failure to wean from cardiopulmonary bypass in the setting of postcardiotomy (n=47) and primary graft failure (n=26); post-acute myocardial infarction cardiogenic shock (n=11); acute myocarditis (n=3), and cardiogenic shock on chronic heart failure (n=32). RESULTS: A central ECMO setting was established in 64 (53.7%) patients while peripherally in 55 (46.2%). Overall mean support time was 10.9 ± 8.7 days (range 1-43 days). Forty-two (35.2%) patients died on ECMO. Overall success rate, in terms of survival on ECMO (n=77), weaning from mechanical support (n=51; 42.8%) and bridge to heart transplantation (n=26; 21.8%), was 64.7%. Sixty-eight (57.1%) patients were successfully discharged. Stepwise logistic regression identified blood lactate levels and creatine kinase-MB relative index at 72h after ECMO initiation, and number of packed red blood cells (PRBCs) transfused on ECMO as significant predictors of mortality. Central ECMO population had a higher rate of continuous veno-venous hemofiltration need and bleeding events compared with the peripheral setting. CONCLUSIONS: ECMO support provides encouraging results in different subsets of patients in cardiogenic shock. Blood lactate levels, creatine kinase-MB relative index and PRBCs transfused should be strictly monitored during veno-arterial ECMO running. Type of ECMO implantation, if peripheral or central, should be decided according to the specific patient subset.

Aim: Extensive thoracic aorta lesions represent a challenging pathology in cardiac surgery. In the last years, hybrid procedures have been introduced for the treatment of these complex aortic diseases. The frozen elephant trunk (FET) procedure, combining conventional surgery with endovascular techniques, allows single-stage treatment for such pathology. Here we present our initial experience with the single-stage FET procedure using the latest commercially available hybrid prosthesis: the Thoraflex hybrid device. Methods: Between March 2013 and March 2014,11 patients underwent thoracic aorta surgery using the FET approach with the Thoraflex hybrid device. Indications for surgery were residual type A chronic dissection in 8 patients, chronic aneurysm of the distal arch in 2 patients and type B chronic aortic dissection in 1 patient Eight patients had already undergone aortic interventions through a median sternotomy. Brain protection was achieved by means of antegrade selective cerebral perfusion (ASCP) and moderate hypothermia (26 °C) in all cases. Results: Overall, in-hospital mortality was 0%. No patient presented spinal cord injury or major neurological events. Only one patient experienced transient ischemic attack. Two patients underwent reoperation for bleeding. One patient had renal failure needing temporary dyalisis. All postoperative angio CT-Scans confirmed the desired results. Conclusion: Our initial experience, although based on only eleven patients, showed excellent survival at 30 days with absence of paraplegia and major neurological events. 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.

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.

Background. The introduction of transcatheter aortic valve replacement (AVR) mandates attention to outcomes after surgical AVR (SAVR). The aim of this study was to assess 1-year outcomes in a contemporary large cohort of patients undergoing AVR. Methods. Data from 520 patients who underwent isolated SAVR between October 2016 and April 2019 were prospectively collected. Results. The mean age of the study population was 72.8 ± 10.1 years and the average EuroSCORE II was 1.8 ± 1.5%. SAVR was performed using minimally invasive approaches (MI-AVR) in 306 patients (58.9%). However, the rate of MI-AVR considerably increased over the observational period from 47.9% to 86.7% (p

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: Neurological events after cardiac surgery or transcatheter aortic valve implantation (TAVI) have a dramatic effect on patients' prognosis. Recent development of transcatheter cerebral protection systems aims to reduce their incidence, even if their use is currently limited to TAVI. Here we report our initial experience with transcatheter cerebral protection devices used in patients at high brain embolic risk undergoing cardiac surgery. METHODS: Between December 2018 and March 2020, at the Cardiac Surgery Unit of Lancisi Cardiovascular Center in Ancona, Italy, 9 patients (mean age 77 years; median EuroSCORE II: 2.2%) underwent cardiac surgery using a transcatheter cerebral protection system (Sentinel, Claret Medical, Santa Rosa, CA, USA). In all cases, a preoperative computed tomography scan highlighted the presence of severely calcified ascending aorta. RESULTS: The brain protection system was successfully implanted in all patients. Total time for device implantation and removal was less than 10 min in all cases. Four patients underwent aortic valve replacement, 2 mitral surgery, whereas 3 received combined valve surgery. Calcified debris were found within filters in 100% of patients. Postoperatively, there were neither neurological events nor major complications. CONCLUSIONS: In our experience, transferring transcatheter brain protection techniques and technologies to cardiac surgery allowed us (with excellent results) to avoid palliative percutaneous or medical management in patients with severe aortic calcifications. Waiting for more solid evidence, we believe that our example supports the concept of hybrid surgery as a therapeutic approach capable of extending traditional surgical indications with improved patients' outcomes.

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.