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Objective: In heritable aortic diseases, different vascular involvement may occur with potential variable implications in aortic dilation/dissection risk. This study aimed to analyze the aortic anatomy of individuals with Marfan syndrome and Loeys-Dietz syndrome to identify possible morphological differences. Methods: Computed tomography and magnetic resonance imaging of the thoracoabdominal aorta from the proximal supra-aortic vessels to the femoral bifurcation level of 114 patients with Marfan and Loeys-Dietz syndromes and 20 matched control subjects were examined. Aortic diameters, areas, length, and tortuosity were measured in different aortic segments using specific vessel analysis software. Results: Patients with Marfan syndrome showed a higher prevalence of ascending aorta and aortic root dilation (P = .011), larger and longer aortic roots (P = .013) with pear-shaped phenotype, larger isthmus/descending aorta diameter ratio (P = .015), and larger suprarenal aorta and iliac arteries. Patients with Loeys-Dietz syndrome showed longer indexed segments and a significantly longer arch (P = .006) with type 2/3 arch prevalence (P = .097). Measurement ratios analysis provided cut-off values (aortic root to ascending aorta length/aortic root diameter, aortic root/sinotubular junction, aortic root/ascending aorta diameter) differentiating patients with Marfan syndrome from patients with Loeys-Dietz syndrome, even in the early stage of the disease. Conclusions: Both syndromes show peculiar anatomic patterns at different aortic levels irrespective of aortic dilation and disease severity. These features may represent the expression of different genetic mutations on aortic development, with a potential impact on prognosis and possibly contributing to better management of the diseases. The systematic adoption of whole body imaging with magnetic resonance or computed tomography should always be considered, because they allow a complete vascular assessment with practical indicators of differential diagnosis.

Objective: Randomized evidence suggests a high risk of pacemaker implantation for patients undergoing mitral valve (MV) surgery with concomitant tricuspid valve repair (cTVR). We investigated the impact of cTVR on outcomes in the Mini-Mitral International Registry. Methods: From 2015 to 2021, 7513 patients underwent minimally invasive MV with or without cTVR in 17 international centers (MV: n = 5609, cTVR: n = 1113). Propensity matching generated 1110 well-balanced pairs. Multivariable analysis was applied. Results: Patients with cTVR were older and had more comorbidities. Propensity matching eliminated most differences except for more TR in patients who underwent cTVR (77.2% vs 22.1% MV, P

Introduction The treatment of patients with cardiogenic shock (CS) encompasses several health technologies including Impella pumps and venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, while they are widely used in clinical practice, information on resource use and quality of life (QoL) associated with these devices is scarce. The aim of this study is, therefore, to collect and comparatively assess clinical and socioeconomic data of Impella versus VA-ECMO for the treatment of patients with severe CS, to ultimately conduct both a cost-effectiveness (CEA) and budget impact (BIA) analyses.Methods and analysis This is a prospective plus retrospective, multicentre study conducted under the scientific coordination of the Center for Research on Health and Social Care Management of SDA Bocconi School of Management and clinical coordination of Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute in Milan. The Impella Network stemmed for the purposes of this study and comprises 17 Italian clinical centres from Northern to Southern Regions in Italy. The Italian network qualifies as a subgroup of the international Impella Cardiac Surgery Registry. Patients with CS treated with Impella pumps (CP, 5.0 or 5.5) will be prospectively recruited, and information on clinical outcomes, resource use and QoL collected. Economic data will be retrospectively matched with data from comparable patients treated with VA-ECMO. Both CEA and BIA will be conducted adopting the societal perspective in Italy. This study will contribute to generate new socioeconomic evidence to inform future coverage decisions.Ethics and dissemination As of May 2024, most of the clinical centres submitted the documentation to their ethical committee (N=13; 76%), six centres received ethical approval and two centres started to enrol patients. Study results will be published in peer-reviewed publications and disseminated through conference presentations.

Abstract Background The diagnosis of periprocedural myocardial infarction (PMI) after coronary artery bypass graft (CABG) is based on biochemical markers along with clinical and instrumental findings. However, there is not a clear cutoff value of high-sensitivity cardiac troponin (hs-cTn) to identify PMI. We hypothesized that isolated hs-cTn concentrations in the first 24 h following CABG could predict cardiac adverse events (in-hospital death and PMI) and/or left ventricular ejection fraction (LVEF) decrease. Methods We retrospectively enrolled all consecutive adult patients undergoing CABG, alone or in association with other cardiac surgery procedures, over 1 year. Hs-cTn I concentrations (Access, Beckman Coulter) were serially measured in the post-operative period and analyzed according to post-operative outcomes. Results 300 patients were enrolled; 71.3% underwent CABG alone, 33.7% for acute coronary syndrome. Most patients showed hs-cTn I values superior to the limit required by the latest guidelines for the diagnosis of PMI. Five patients (1.7%) died, 8% developed a PMI, 10.6% showed a LVEF decrease ≥ 10%. Hs-cTn I concentrations did not significantly differ with respect to death and/or PMI whereas they were associated with LVEF decrease ≥ 10% (p value

Despite the withdrawal of the HeartWare Ventricular Assist Device (HVAD), hundreds of patients are still supported with this continuous-flow pump, and the long-term management of these patients is still under debate. This study aims to analyse 5 years survival and freedom from major adverse events in patients supported by HVAD and HeartMate3 (HM3). From 2010 to 2022, the MIRAMACS Italian Registry enrolled all-comer patients receiving a LVAD support at seven Cardiac Surgery Centres. Out of 447 LVAD implantation, 214 (47.9%) received HM3 and 233 (52.1%) received HVAD. Cox-regression analysis adjusted for major confounders showed an increased risk for mortality (HR 1.5 [1.2–1.9]; p = 0.031), for both ischemic stroke (HR 2.08 [1.06–4.08]; p = 0.033) and haemorrhagic stroke (HR 2.6 [1.3–4.9]; p = 0.005), and for pump thrombosis (HR 25.7 [3.5–188.9]; p < 0.001) in HVAD patients. The propensity-score matching analysis (130 pairs of HVAD vs. HM3) confirmed a significantly lower 5 years survival (41.7% vs. 64.1%; p 0.02), freedom from haemorrhagic stroke (90.5% vs. 70.1%; p < 0.001) and from pump thrombosis (98.5% vs. 74.7%; p < 0.001) in HVAD cohort. Although similar perioperative outcome, patients implanted with HVAD developed a higher risk for mortality, haemorrhagic stroke and thrombosis during 5 years of follow-up compared to HM3 patients.

Abstract Background Endovascular treatment of patients with Marfan syndrome (MFS) is not recommended. Hybrid procedures such as frozen elephant trunk (FET), which combines stent-graft deployment with an integrated non-stented fabric graft for proximal grafting and suturing, have not been previously evaluated. The aim of this study was to assess the safety and feasibility of FET operation in patients with MFS. Methods Patients enrolled in the International E-vita Open Registry (IEOR) who underwent FET procedure between January 2001 and February 2020 meeting Ghent criteria for MFS were included in the study. Early and midterm results were retrospectively analyzed. Preoperative, postoperative and follow-up computed tomography angiography scans were analysed. Results We analyzed 37 patients [mean age 38 ± 11 years, 65% men]. Acute or chronic aortic dissection was present in 35 (95%) patients (14 and 21 patients respectively). Two (5%) patients had an aneurysm without dissection. Malperfusion syndrome was present in 4 patients. Twenty-nine (78%) patients had history of aortic surgical interventions. The 30-day and in-hospital mortality amounted to 8 and 14% respectively. False lumen exclusion was present in 73% in stented segment in last postoperative CT. The overall 5-year survival was 71% and freedom from reintervention downstream was 58% at 5 years. Of the nine patients who required reintervention for distal aortic disease, one patient died. Conclusions FET operation for patients with MFS can be performed with acceptable mortality and morbidity. In long-term follow-up no reinterventions on the aortic arch were required. FET allows for easier second stage operations providing platform for surgical and endovascular reinterventions.

Objective: Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for thoracic aorta diseases including penetrating aortic ulcer (PAU). The objective of this study was to analyze the results of TEVAR for the treatment of PAU in our population. Methods: From January 1999 to January 2019, 830 patients with type B aortic syndromes were treated with TEVAR in our institution. Of these we selected 73 patients treated for a PAU. Clinical and radiologic follow-up was performed in all patients. Results: Mean age of our population was 72 ± 8 years. Fifteen patients (20.5%) were treated in an emergency setting. The proximal landing zone was in arch zone 2 in 22 patients (30.1%). In-hospital mortality was 6.8% and was associated with acute presentation (P = .005). Distal arch delivery of the endograft was unrelated to mortality (Fisher exact test, P = .157). Survival at 1 and 5 years was 81.7% and 67.3%, respectively. Sixteen patients underwent reintervention of the thoracic aorta. Patients who underwent emergency surgery and older patients had a shorter survival (log rank test, P

Objective: The study objective was to evaluate the surgical results in patients with acute type A aortic dissection and cerebral malperfusion. Methods: From 2000 to 2019, 234 patients with type A aortic dissection and cerebral malperfusion were stratified into 3 groups: 50 (21%) with syncope (group 1), 152 (65%) with persistent loss of focal neurological function (group 2), and 32 (14%) with coma (group 3). Results were evaluated and compared by univariable and multivariable analyses. Results: Median age was higher in group 1, and incidence of cardiogenic shock was higher in group 3. The femoral artery was the most common cannulation site, whereas the axillary artery was used in 18% of group 1, 30% of group 2, and 25% of group 3 patients (P = .337). Antegrade cerebral perfusion was performed in more than 80% of patients, and ascending aorta/arch replacement was performed in 40% of group 1, 27% of group 2, and 31% of group 3 (P = .21). In-hospital mortality was 18% in group 1, 27% in group 2, and 56% in group 3 (P = .001). Survival at 5 years is 57.0% in group 1, 57.7% in group 2, and 38.7% in group 3 (P = .0005). On multivariable analysis, age, cardiopulmonary bypass time, and group 3 versus group 2 were independent risk factors for mortality, whereas axillary cannulation was a protective factor. Conclusions: Patients with aortic dissection and cerebral malperfusion without preoperative coma showed acceptable mortality, and those with coma had a high in-hospital mortality regardless of the type of brain protection. Overall axillary artery cannulation appeared to be a protective factor.

Angiosarcomas (ASs) are rare malignant vascular entities that can affect several regions in our body, including the heart. Cardiac ASs comprise 25–40% of cardiac sarcomas and can cause death within months of diagnosis. Thus, our aim was to identify potential differences and/or similarities between cardiac and extra-cardiac ASs to enhance targeted therapies and, consequently, patients’ prognosis. Whole-transcriptome analysis of three cardiac and eleven extra-cardiac non-cutaneous samples was performed to investigate differential gene expression and mutational events between the two groups. The gene signature of cardiac and extra-cardiac non-cutaneous ASs was also compared to that of cutaneous angiosarcomas (n = 9). H/N/K-RAS and TP53 alterations were more recurrent in extra-cardiac ASs, while POTE-gene family overexpression was peculiar to cardiac ASs. Additionally, in vitro functional analyses showed that POTEH upregulation conferred a growth advantage to recipient cells, partly supporting the cardiac AS aggressive phenotype and patients’ scarce survival rate. These features should be considered when investigating alternative treatments.

Sternal wound complications following cardiac surgery, including sternal dehiscence, mediastinitis, and osteomyelitis, pose significant challenges in terms of management and patient outcomes. We present a case report highlighting the complex management of a patient who underwent open heart surgery for severe aortic valve stenosis, followed by sternal wound dehiscence and sternum osteomyelitis due to extended spectrum beta lactamase (ESBL) producing Klebsiella aerogenes. A multiple myeloma diagnosis was also suspected at the positron emission tomography (PET) scan and confirmed with bone marrow biopsy. Multidisciplinary evaluation of the case led to a comprehensive treatment plan. To control the sternal osteomyelitis, total sternectomy was performed followed by immediate reconstruction with a bone (tibia) graft from the tissue bank and fixation with the minimal hardware possible. A microsurgical latissimus dorsi free flap was required to reconstruct the soft tissue defect. After 6 weeks of antibiotic treatment with ertapenem and fosfomycin based on a culture of intraoperative material, no clinical, imaging, or laboratory signs of infection were seen. Multiple myeloma treatment was then started. At 1 year of follow up, no recurrence of infection occurred, and the reconstruction was stable and closed. Multiple myeloma is under chronic treatment with novel agent combination, with an excellent haematological response.

We report a case of a 56-year-old male who underwent Frozen Elephant Trunk procedure for residual type A chronic aortic dissection, complicated by the release of the distal endovascular portion of the hybrid prosthesis in the false lumen. This complication was successfully treated with a totally endovascular approach.

ObjectiveWe have encountered broken or damaged polypropylene sutures (Prolene®) at the anastomotic sites during aortic reoperations. Because a surgical sealant, bovine serum albumin-glutaraldehyde (BioGlue®), was used in previous aortic surgery in some of these cases, we undertook this in vitro study to evaluate whether the use of BioGlue® was associated with breakage of polypropylene sutures at the aortic anastomosis.Materials and methodsThe broken polypropylene sutures, anastomotic sites and aortic tissue at the location of suture breakage were visually inspected and evaluated intraoperatively. Six human cadaveric aortic samples were incised circumferentially and anastomosed proximally to a valved conduit with running 4–0 polypropylene sutures (Prolene®). In the test group (n = 3), BioGlue® was applied directly to the Prolene® sutures at the anastomotic sites, while in the control group (n = 3) the anastomoses were not sealed with any surgical adhesive. The six samples were immersed in Dulbecco's phosphate buffered saline solution and mounted on a M-6 Six Position Heart Valve Durability Testing System and tested up to 120 million cycles for a 2-year period. During and upon completion of the testing, the integrity of Prolene® sutures, the anastomosis and aortic tissues was regularly assessed by visual inspection.ResultsIntraoperative findings included a stretched and thin aortic wall (some with thrombus), a small cleft between the aortic tissue and the Dacron vascular graft. An excessive amount of BioGlue® was often found around the anastomosis, with cracking material, but no signs of mechanical damage were observed in these cases. Upon visual inspection during and after in vitro testing, there was no apparent damage to the polypropylene sutures on the interior or exterior of the aortic anastomoses in any of the samples. No difference was observed in the physical integrity of the polypropylene sutures at anastomotic lines, the anastomoses and aortic tissues between the test and control samples.ConclusionsThe results of this study suggest that the use of BioGlue® was not associated with breakage of the polypropylene sutures at the anastomotic sites after aortic dissection repair.

Abstract Background Early treatment of aortic valve stenosis is recommended in eligible symptomatic patients with severe aortic valve stenosis who would otherwise have a poor prognosis. The sutureless aortic valve bioprosthesis offers an alternative to standard aortic valve replacement with a sutured valve, but limited data are available in patients who have undergone multiple valve procedures involving the new, sutureless technology. We sought to investigate outcomes in high operative risk patients with previous or concomitant valve surgery who were implanted with a sutureless valve. Methods SURE-AVR is an ongoing, prospective, multinational registry of patients undergoing aortic valve replacement. In-hospital and post-discharge outcomes up to 5 years were collected. Results The study population comprised 78 patients (mean ± SD: age 73.6 ± 7.6 years, logistic EuroSCORE 18.0 ± 17.5) enrolled at 13 sites who presented for concomitant or previous mitral valve repair (n = 45) or replacement (n = 33), with or without additional concomitant procedures, and were implanted with a sutureless valve. Mean ± SD overall aortic cross-clamp time was 109 ± 41 min and cardiopulmonary bypass time was 152 ± 49 min. Mean ± SD aortic pressure gradients decreased from 37.6 ± 17.7 mmHg preoperatively to 13.0 ± 5.7 mmHg at hospital discharge, and peak aortic pressure gradient from 61.5 ± 28.7 to 23.4 ± 10.6 mmHg. Early events included 1 death, 1 transient ischaemic attack, and 1 bleed (all 1.3%); a permanent pacemaker implantation was required in 6 patients (7.7%), and 2 reoperations (not valve related) (2.6%) took place. Over a median follow-up of 55.5 months (Q1 13.4, Q3 68.6), 12 patients died (6 cardiovascular and 6 non-cardiovascular, both 2.1% per patient-year). Five-year survival was 81.3%. Late paravalvular leak occurred in 2 patients (0.7% per patient-year) and permanent pacemaker implantation was required in 3 patients (0.1% per patient-year). There was no apparent rise in mean or peak aortic pressure gradient over the study. Conclusions These results suggest that the sutureless implant is a technically feasible procedure during mitral surgery and is associated with good clinical outcomes.

Implantable mechanical circulatory support (MCS) systems for ventricular assist device (VAD) therapy have emerged as an important strategy due to a shortage of donor organs for heart transplantation. A growing number of patients are receiving permanent assist devices, while fewer are undergoing heart transplantation (Htx). Continuous-flow (CF) pumps, as devices that can be permanently implanted, show promise for the treatment of both young and old patients with heart failure (HF). Further improvement of these devices will decrease adverse events, enable pulse modulation of continuous blood flow, and improve automatic remote monitoring. Ease of use for patients could also be improved. We herein report on the current state of the art regarding implantable CF pumps for use as MCS systems in the treatment of advanced refractory HF.

ABSTRACT Sinus of Valsalva aneurysm is a very uncommon clinical finding and often requires emergency surgery due to its high risk of rupture. This educational text reports the case of a 91-year-old Italian women who was incidentally discovered to have a huge double aneurysm of the sinuses of Valsalva.

Abstract Background Purulent pericarditis is an infectious disease, frequently caused by gram-positive bacteria, that is rarely observed in healthy individuals, and is often associated with predisposing conditions. Case presentation Here, we present the case of an Escherichia coli post-surgical localized purulent pericarditis complicated by transient constrictive pericarditis and its diagnostic and therapeutic management. Conclusions Our case report focuses on the importance of imaging-guided treatment of purulent pericardial diseases, in particular on the emerging role of 18 F-labelled 2-fluoro-2-deoxy-D-glucose Positron Emission Tomography/Computed Tomography in pericardial diseases and on the management of transient constrictive pericarditis, often seen after thoracic surgery.

Abstract Background This case represents the first report of malignant primary cardiac tumour in a patient with Lynch Syndrome associated with MSH2 pathogenic variant. Case presentation A 57-year-old woman with previous ovarian cystadenocarcinoma was admitted to the emergency room for hematic pericardial effusion. Multimodal diagnostic imaging revealed two solid pericardial vascularized masses. After pericardiectomy, the final histological diagnosis was poorly differentiated pleomorphic sarcomatoid carcinoma. During follow-up she developed an ampulla of Vater adenocarcinoma. Genetic analysis identified an MSH2 pathogenic variant. Conclusion This case contributes to expand the tumour spectrum of Lynch syndrome, suggesting that MSH2 pathogenic variants cause a more complex multi-tumour cancer syndrome than the classic Lynch Syndrome. In MSH2 variant carriers, symptoms such as dyspnoea and chest discomfort might alert for rare tumours and a focused cardiac evaluation should be considered.

Primary cardiac sarcomas are considered rare malignant entities associated with poor prognosis. In fact, knowledge regarding their gene signature and possible treatments is still limited. In our study, whole-transcriptome sequencing on formalin-fixed paraffin-embedded (FFPE) samples from one cardiac osteosarcoma and one cardiac leiomyosarcoma was performed, to investigate their mutational profiles and to highlight differences and/or similarities to other cardiac histotypes. Both cases have been deeply detailed from a pathological point of view. The osteosarcoma sample presented mutations involving ATRX, ERCC5, and COL1A1, while the leiomyosarcoma case showed EXT2, DNM2, and PSIP1 alterations. Altered genes, along with the most differentially expressed genes in the leiomyosarcoma or osteosarcoma sample versus the cardiac angiosarcomas and intimal sarcomas (e.g., YAF2, PAK5, and CRABP1), appeared to be associated with cell growth, proliferation, apoptosis, and the repair of DNA damage, which are key mechanisms involved in tumorigenesis. Moreover, a distinct gene expression profile was detected in the osteosarcoma sample when compared to other cardiac sarcomas. For instance, WIF1, a marker of osteoblastic differentiation, was upregulated in our bone tumor. These findings pave the way for further studies on these entities, in order to identify targeted therapies and, therefore, improve patients’ prognoses.

Resumen: La hipertensión pulmonar tromboembólica crónica se considera el único tipo de hipertensión pulmonar con un tratamiento quirúrgico potencialmente curativo. Aun hoy está infradiagnosticada o con frecuencia diagnosticada tardíamente, comportando un empeoramiento del pronóstico. La hipertensión pulmonar tromboembólica crónica se presenta con síntomas poco específicos y los médicos de atención primaria pueden no ser conscientes de su presencia o del potencial tratamiento. El tratamiento médico actual es, en el mejor de los casos, paliativo. La endarterectomía pulmonar ofrece la única posibilidad de mejora sintomática y pronóstica, siendo curativa en la mayoría de los casos a corto y a largo plazo. Por lo tanto, no solo la identificación de la enfermedad puede ser difícil y tardía sino que incluso después de que el diagnóstico se haya establecido, la evaluación de la operabilidad puede ser un reto. La operabilidad se basa en la estimación preoperatoria de la clasificación quirúrgica y de la probable resistencia vascular pulmonar postoperatoria, las cuales determinan el riesgo de la intervención y el posible resultado. Este complejo procedimiento que va desde la caracterización de la enfermedad a la intervención quirúrgica pasando por todo el proceso decisional, requiere una colaboración multidisciplinar de expertos en hipertensión pulmonar, con un equipo quirúrgico dedicado a este campo y con protocolos bien precisos. En nuestro centro, hemos construido un equipo especializado que incluye radiólogos, cardiólogos, cirujanos cardiacos, anestesistas/intensivistas y fisioterapeutas, que no solo ha permitido obtener resultados quirúrgicos comparables a centros europeos de más alto volumen, sino que también ha permitido desarrollar e implementar otras opciones terapéuticas como la angioplastia pulmonar con balón, dedicadas a los pacientes de alto riesgo descartados para la cirugía.En el siguiente artículo presentamos una revisión sobre la actualidad en este campo y al mismo tiempo ponemos de ejemplo nuestra experiencia como centro en la gestión de la hipertensión pulmonar tromboembólica crónica a través de un equipo multidisciplinar especializado. Abstract: Chronic thromboembolic pulmonary hypertension is considered the only type of pulmonary hypertension with a potentially curative surgical treatment. Even today it is under-diagnosed or often diagnosed late with a worsening of the prognosis. Chronic thromboembolic pulmonary hypertension presents with nonspecific symptoms and general practitioners may not be aware of the condition or potential for treatment. Current medical treatment is, at best, palliative. Pulmonary endarterectomy offers the only possibility of symptomatic and prognostic improvement, being curative in most cases in the short and long term. Not only the identification of the pathology can be difficult and delayed, moreover after the diagnosis has been established, the estimation of operability can be challenging. The operability is based on the preoperative estimation of postoperative surgical classification and probable pulmonary vascular resistance, which determine the risk of intervention and the probable outcome. This complex procedure that includes, characterization of the pathology, the surgical intervention going through the whole decision process requires a multidisciplinary collaboration of experts in pulmonary hypertension, with a dedicated surgical team, and with very precise protocols. At our center, we have built a team of dedicated specialists including radiologists, cardiologists, cardiac surgeons, anesthesiologists and physiotherapists. Together, not only we have been able to obtain surgical results comparable to higher European centers, but also, to develop and implement other therapeutic options such as pulmonary angioplasty with balloon, dedicated to patients at high risk and discarded for surgery.In the present paper, we present a review of the pathology and, as an example, our single center experience with a multidisciplinary and dedicated management of chronic thromboembolic pulmonary hypertension patients, specifically diagnosis, pulmonary endarterectomy indication, protocols and results. Palabras clave: Hipertensión pulmonar, Parada de círculo hipotérmica, Endarterectomía, Keywords: Pulmonary hypertension, Deep hypothermic circulatory arrest, Endarterectomy

The frozen elephant trunk technique (FET) requires the use of a pre-assembled hybrid prosthesis consisting of a standard Dacron vascular portion to replace the aortic arch and a stent graft component, which is placed into the proximal descending thoracic aorta (DTA) anterogradely in the proximal descending thoracic aorta. In Europe, two hybrid prostheses are available: the E-evita Open Plus hybrid stent graft system provided by JOTEC (Hechingen, Germany) and the ThoraflexTM Hybrid (Vascutek, Inchinnan Scotland). Recommendations for use are extensive pathologies of the arch in case of acute and chronic aortic dissection, degenerative aneurysm and intramural hematoma. The FET approach allows the replacement of the whole arch in one stage with the option of direct treatment of the proximal descending thoracic aorta based on the stent component, creating a safe landing zone for further endovascular treatment more distally. The remarkable feature of this technique is the possibility to perform more proximally (from zone 3 to zone 0) the distal anastomosis in to the arch. This allows for an easier distal anastomosis, reduced hypothermic circulatory arrest time and decreased risk of paraplegia (

Complex lesions of the thoracic aorta are traditionally treated in 2 surgical steps with the elephant trunk technique. A relatively new approach is the frozen elephant trunk (FET) technique, which potentially allows combined lesions of the thoracic aorta to be treated in a 1-stage procedure combining endovascular treatment with conventional surgery using a hybrid prosthesis. These are very complex and time-consuming operations, and good results can be obtained only if appropriate strategies for myocardial, cerebral, and visceral protection are adopted. However, the FET technique is associated with a non-negligible incidence of spinal cord injury, due to the extensive coverage of the descending aorta with the excessive sacrifice of intercostal arteries. The indications for the FET technique include chronic thoracic aortic dissection, acute or chronic type B dissection when endovascular treatment is contraindicated, chronic aneurysm of the thoracic aorta, and chronic aneurysm o f the distal a rch. T he F ET t echnique i s also i ndicated i n acute type A a ortic dissection, especially when the tear is localized in the aortic arch; in cases of distal malperfusion; and in young patients. In light of the great interest in the FET technique, the Vascular Domain of the European Association for cardio-thoracic Surgery published a position paper reporting the current knowledge and the state of the art of the FET technique. Herein, we describe the surgical techniques involved in the FET technique a nd w e report o ur e xperience with the F ET t echnique f or t he t reatment o f complex aortic d isease of the thoracic aorta.

Extensive mitral annulus calcifications are considered a contraindication for valve surgery. We describe the case of a 76-year-old female with severe mitral and aortic stenosis associated with extensive calcifications of the heart. The patient underwent an open mitroaortic valve replacement using transcatheter aortic valve im-plantation with an Edwards SAPIEN XT valve (Edwards Lifesciences Corp., Irvine, CA, USA) in the mitral position. The aortic valve was replaced using a stentless valve prosthesis (LivaNova SOLO; LivaNova PLC, London, UK). Postoperative echocardiography showed that the prosthetic valve was in the correct position and there were no paravalvular leaks. A bailout open transcatheter valve implantation can be considered a safe and effective option in selected cases with an extensively calcified mitral valve.

Doctors are often faced with difficult decisions and uncertainty when patients need a certain treatment. They routinely rely on the scientific literature, in addition to their knowledge, experience, and patient preferences. Clinical practice guidelines are created with the intention of facilitating decision-making. They may offer concise instructions for the diagnosis, management (medical or surgical treatments), and prevention of specific diseases o r conditions. All information included in t he f inal v ersion a re the r esult of a s ystematic rev iew of scientific articles and an assessment of the benefits and costs of alternative care options. The final document attempts to meet the needs of most patients in most circumstances and clinicians, aware of these recommendations, should always make individualized treatment decisions. In this review, we attempted to define the intent and applicability of clinical practice guidelines, expert consensus documents, and registry studies, focusing on the management of patients with thoracic aortic disease.