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Background : Type A aortic dissection (TAAD) is a life-threatening condition which requires prompt diagnosis and surgical treatment. When TAAD involves the aortic root, aortic valve-sparing or Bentall procedures are the main surgical treatment options. Method: The subjects of this analysis were 3735 patients included in the European Registry of Type A Aortic Dissection (ERTAAD). Propensity score matching was performed by estimating a propensity score from being treated with the Bentall or the David procedure using multilevel mixed-effects logistics, considering the cluster effect of the participating hospitals. Results: A Bentall procedure was performed in 862 patients, while a David operation was performed in 139 patients. The proportion of aortic root replacement, as well as the different techniques of aortic root replacement, varied significantly between the participating hospitals ( p < 0.001). After propensity score matching, we obtained two groups of 115 patients each, and no statistical differences were reported in terms of postoperative outcomes, except for the rate of dialysis, which was higher in the patients requiring a Bentall procedure (17.4% vs. 7.0%, p -value 0.016). In the unmatched cohorts, the David procedure was associated with a lower 10-year mortality rate compared to the Bentall procedure (30.1% vs. 45.6%, p -value 0.004), but no difference was observed after matching (30.0% vs. 43.9%, p -value 0.082). After 10 years, no differences were observed in terms of proximal aortic reoperation (3.9% vs. 4.1%, p -value 0.954), even after propensity score matching (2.8% vs. 1.8%, p -value 0.994). Conclusions: The David and Bentall procedures are durable treatment methods for TAAD. When feasible, it is advisable that the David procedure is performed for acute TAAD by surgeons with experience with this demanding surgical technique.

Background: The current study aims to report the presentation of the malperfusion syndrome in patients with acute type A aortic dissection admitted to surgery and its impact on mortality., Methods: Data were retrieved from the multicenter European Registry of Type A Aortic Dissection. The Penn classification was used to categorize malperfusion syndromes. A machine-learning algorithm was applied to assess the multivariate interaction's importance regarding in-hospital mortality., Results: A total of 3902 consecutive patients underwent repair for acute type A aortic dissection. Local malperfusion syndrome occurred in 1584 (40.59%) patients. Multiorgan involvement occurred in 582 patients (36.74%) whereas 1002 patients (63.26%) had single-organ malperfusion. The prevalence was the greatest for cerebral (21.27%) followed by peripheral (13.94%), myocardial (9.7%), renal (9.33%), mesenteric (4.15%), and spinal malperfusion (2.10%). Multiorgan involvement predominantly occurred in organs perfused by the downstream aorta. Malperfusion significantly increased the risk of mortality (P < .001; odds ratio, 1.94 ± 0.29). The Boruta machine-learning algorithm identified the Penn classification as significantly associated with in-hospital mortality (P < .0001, variable importance = 7.91); however, 8 other variables yielded greater prediction importance. According to the Penn classification, mortality rates were 12.38% for Penn A, 20.71% for Penn B, 28.90% for Penn C, and 31.84% for Penn BC, respectively., Conclusions: Nearly one half of the examined cohort presented with signs of malperfusion syndrome predominantly attributable to local involvement. More than one third of patients with local malperfusion syndrome had a multivessel involvement. Furthermore, different levels of Penn classification can be used only as a first tool for preliminary stratification of early mortality risk., Competing Interests: Conflict of Interest Statement E.Q. receives payment or honoraria from Cardiva SL, AtriCure, Medtronic, and Edwards. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Due to the discrepancy between patients awaiting a heart transplant and the availability of donor hearts, strategies to expand the donor pool and improve the transplant's success are crucial. This review aims to summarize current knowledge on the ex vivo heart preservation (EVHP) experience as an alternative to standard cold static storage (CSS). EVHP techniques can improve the preservation of the donor's heart before transplantation and allow for pre-transplant organ evaluation., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: Gender difference in the outcome after type A aortic dissection (TAAD) surgery remains an issue of ongoing debate. In this study, we aimed to evaluate the impact of gender on the short- and long-term outcome after surgery for TAAD., Methods: A multicentre European registry retrospectively included all consecutive TAAD surgery patients between 2005 and 2021 from 18 hospitals across 8 European countries. Early and late mortality, and cumulative incidence of aortic reoperation were compared between genders., Results: A total of 3902 patients underwent TAAD surgery, with 1185 (30.4%) being females. After propensity score matching, 766 pairs of males and females were compared. No statistical differences were detected in the early postoperative outcome between genders. Ten-year survival was comparable between genders (47.8% vs 47.1%; log-rank test, P = 0.679), as well as cumulative incidences of distal or proximal aortic reoperations. Ten-year relative survival compared to country-, year-, age- and sex-matched general population was higher among males (0.65) compared to females (0.58). The time-period subanalysis revealed advancements in surgical techniques in both genders over the years. However, an increase in stroke was observed over time for both populations, particularly among females., Conclusions: The past 16 years have witnessed marked advancements in surgical techniques for TAAD in both males and females, achieving comparable early and late mortality rates. Despite these findings, late relative survival was still in favour of males., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The outcomes after prolonged treatment in the intensive care unit (ICU) after surgery for Stanford type A aortic dissection (TAAD) have not been previously investigated., Methods: This analysis included 3538 patients from a multicenter study who underwent surgery for acute TAAD and were admitted to the cardiac surgical ICU., Results: The mean length of stay in the cardiac surgical ICU was 9.9±9.5 days. The mean overall costs of treatment in the cardiac surgical ICU 24086±32084 €. In-hospital mortality was 14.8% and 5-year mortality was 30.5%. Adjusted analyses showed that prolonged ICU stay was associated with significantly lower risk of in-hospital mortality (adjusted OR 0.971, 95%CI 0.959-0.982), and of five-year mortality (adjusted OR 0.970, 95%CI 0.962-0.977), respectively. Propensity score matching analysis yielded 870 pairs of patients with short ICU stay (2-5 days) and long ICU stay (>5 days) with balanced baseline, operative and postoperative variables. Patients with prolonged ICU stay (>5 days) had significantly lower in-hospital mortality (8.9% vs. 17.4%, <0.001) and 5-year mortality (28.2% vs. 30.7%, P=0.007) compared to patients with short ICU-stay (2-5 days)., Conclusions: Prolonged ICU stay was common after surgery for acute TAAD. However, when adjusted for multiple baseline and operative variables as well as adverse postoperative events and the cluster effect of hospitals, it was associated with favorable survival up to 5 years after surgery.

Background: The benefits and harms associated with femoral artery cannulation over other sites of arterial cannulation for surgical repair of acute Stanford type A aortic dissection (TAAD) are not conclusively established., Methods: We evaluated the outcomes after surgery for TAAD using femoral artery cannulation, supra-aortic arterial cannulation (i.e., innominate/subclavian/axillary artery cannulation), and direct aortic cannulation., Results: 3751 (96.1%) patients were eligible for this analysis. In-hospital mortality using supra-aortic arterial cannulation was comparable to femoral artery cannulation (17.8% vs. 18.4%; adjusted OR 0.846, 95% CI 0.799-1.202). This finding was confirmed in 1028 propensity score-matched pairs of patients with supra-aortic arterial cannulation or femoral artery cannulation (17.5% vs. 17.0%, p = 0.770). In-hospital mortality after direct aortic cannulation was lower compared to femoral artery cannulation (14.0% vs. 18.4%, adjusted OR 0.703, 95% CI 0.529-0.934). Among 583 propensity score-matched pairs of patients, direct aortic cannulation was associated with lower rates of in-hospital mortality (13.4% vs. 19.6%, p = 0.004) compared to femoral artery cannulation. Switching of the primary site of arterial cannulation was associated with increased rate of in-hospital mortality (36.5% vs. 17.0%; adjusted OR 2.730, 95% CI 1.564-4.765). Ten-year mortality was similar in the study cohorts., Conclusions: In this study, the outcomes of surgery for TAAD using femoral arterial cannulation were comparable to those using supra-aortic arterial cannulation. However, femoral arterial cannulation was associated with higher in-hospital mortality than direct aortic cannulation., Trial Registration: ClinicalTrials.gov registration code: NCT04831073., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Background: Surgery for Stanford type A aortic dissection (TAAD) is associated with an increased risk of late aortic reoperations due to degeneration of the dissected aorta., Methods: The subjects of this analysis were 990 TAAD patients who survived surgery for acute TAAD and had complete data on the diameter and dissection status of all aortic segments., Results: After a mean follow-up of 4.2 ± 3.6 years, 60 patients underwent 85 distal aortic reoperations. Ten-year cumulative incidence of distal aortic reoperation was 9.6%. Multivariable competing risk analysis showed that the maximum preoperative diameter of the abdominal aorta (SHR 1.041, 95%CI 1.008-1.075), abdominal aorta dissection (SHR 2.133, 95%CI 1.156-3.937) and genetic syndromes (SHR 2.840, 95%CI 1.001-8.060) were independent predictors of distal aortic reoperation. Patients with a maximum diameter of the abdominal aorta >30 mm and/or abdominal aortic dissection had a cumulative incidence of 10-year distal aortic reoperation of 12.0% compared to 5.7% in those without these risk factors (adjusted SHR 2.076, 95%CI 1.062-4.060)., Conclusion: TAAD patients with genetic syndromes, and increased size and dissection of the abdominal aorta have an increased the risk of distal aortic reoperations. A policy of extensive surgical or hybrid primary aortic repair, completion endovascular procedures for aortic remodeling and tight surveillance may be justified in these patients., Trial Registration: ClinicalTrials.gov Identifier: NCT04831073., Competing Interests: Conflict of interest statement None declared., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Surgery for type A aortic dissection (TAAD) is frequently complicated by neurologic complications. The prognostic impact of neurologic complications of different nature has been investigated in this study. The subjects of this analysis were 3,902 patients who underwent surgery for acute TAAD from the multicenter European Registry of Type A Aortic Dissection (ERTAAD). During the index hospitalization, 722 patients (18.5%) experienced stroke/global brain ischemia. Ischemic stroke was detected in 539 patients (13.8%), hemorrhagic stroke in 76 patients (1.9%) and global brain ischemia in 177 patients (4.5%), with a few patients having had findings of more than 1 of these conditions. In-hospital mortality was increased significantly in patients with postoperative ischemic stroke (25.6%, adjusted odds ratio [OR] 2.422, 95% confidence interval [CI] 1.825 to 3.216), hemorrhagic stroke (48.7%, adjusted OR 4.641, 95% CI 2.524 to 8.533), and global brain ischemia (74.0%, adjusted OR 22.275, 95% CI 14.537 to 35.524) compared with patients without neurologic complications (13.5%). Similarly, patients who experienced ischemic stroke (46.3%, adjusted hazard ratio [HR] 1.719, 95% CI 1.434 to 2.059), hemorrhagic stroke (62.8%, adjusted HR 3.236, 95% CI 2.314 to 4.525), and global brain ischemia (83.9%, adjusted HR 12.777, 95% CI 10.325 to 15.810) had significantly higher 5-year mortality than patients without postoperative neurologic complications (27.5%). The negative prognostic effect of neurologic complications on survival vanished about 1 year after surgery. In conclusion, postoperative ischemic stroke, hemorrhagic stroke, and global cerebral ischemia increased early and midterm mortality after surgery for acute TAAD. The magnitude of risk of mortality increased with the severity of the neurologic complications, with postoperative hemorrhagic stroke and global brain ischemia being highly lethal complications., Competing Interests: Declaration of competing interest The authors have no competing interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Extended aortic repair is considered a key issue for the long-term durability of surgery for DeBakey type 1 aortic dissection. The risk of aortic degeneration may be higher in young patients due to their long life expectancy. The early outcome and durability of aortic surgery in these patients were investigated in the present study., Methods: The subjects of the present analysis were patients under 60 years old who underwent surgical repair for acute DeBakey type 1 aortic dissection at 18 cardiac surgery centres across Europe between 2005 and 2021. Patients underwent ascending aortic repair or total aortic arch repair using the conventional technique or the frozen elephant trunk technique. The primary outcome was 5-year cumulative incidence of reoperation on the distal aorta., Results: Overall, 915 patients underwent surgical ascending aortic repair and 284 patients underwent surgical total aortic arch repair. The frozen elephant trunk procedure was performed in 128 patients. Among 245 propensity score-matched pairs, total aortic arch repair did not decrease the rate of distal aortic reoperation compared to ascending aortic repair (5-year cumulative incidence, 6.7% versus 6.7%, subdistributional hazard ratio 1.127, 95% c.i. 0.523 to 2.427). Total aortic arch repair increased the incidence of postoperative stroke/global brain ischaemia (25.7% versus 18.4%, P = 0.050) and dialysis (19.6% versus 12.7%, P = 0.003). Five-year mortality was comparable after ascending aortic repair and total aortic arch repair (22.8% versus 27.3%, P = 0.172)., Conclusions: In patients under 60 years old with DeBakey type 1 aortic dissection, total aortic arch replacement compared with ascending aortic repair did not reduce the incidence of distal aortic operations at 5 years. When feasible, ascending aortic repair for DeBakey type 1 aortic dissection is associated with satisfactory early and mid-term outcomes., Trial Registration: ClinicalTrials.gov Identifier: NCT04831073., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd.)

Surgery for type A aortic dissection (TAAD) is associated with a high risk of early mortality. The prognostic impact of a new classification of the urgency of the procedure was evaluated in this multicenter cohort study. Data on consecutive patients who underwent surgery for acute TAAD were retrospectively collected in the multicenter, retrospective European Registry of TAAD (ERTAAD). The rates of in-hospital mortality of 3,902 consecutive patients increased along with the ERTAAD procedure urgency grades: urgent procedure 10.0%, emergency procedure grade 1 13.3%, emergency procedure grade 2 22.1%, salvage procedure grade 1 45.6%, and salvage procedure grade 2 57.1% (p <0.0001). Preoperative arterial lactate correlated with the urgency grades. Inclusion of the ERTAAD procedure urgency classification significantly improved the area under the receiver operating characteristics curves of the regression model and the integrated discrimination indexes and the net reclassification indexes. The risk of postoperative stroke/global brain ischemia, mesenteric ischemia, lower limb ischemia, dialysis, and acute heart failure increased along with the urgency grades. In conclusion, the urgency of surgical repair of acute TAAD, which seems to have a significant impact on the risk of in-hospital mortality, may be useful to improve the stratification of the operative risk of these critically ill patients. This study showed that salvage surgery for TAAD is justified because half of the patients may survive to discharge., Competing Interests: Declaration of competing interest Dr. Biancari reports financial support was provided by Sigrid Jusélius Foundation and Finnish Heart Association. The remaining authors have no competing interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Surgery for type A aortic dissection (TAAD) is associated with high risk of mortality. Current risk scoring methods have a limited predictive accuracy., Methods: Subjects were patients who underwent surgery for acute TAAD at 18 European centers of cardiac surgery from the European Registry of Type A Aortic Dissection (ERTAAD)., Results: Out of 3,902 patients included in the ERTAAD, 2,477 fulfilled the inclusion criteria. In the validation dataset (2,229 patients), the rate of in-hospital mortality was 18.4%. The rate of composite outcome (in-hospital death, stroke/global ischemia, dialysis, and/or acute heart failure) was 41.2%, and 10-year mortality rate was 47.0%. Logistic regression identified the following patient-related variables associated with an increased risk of in-hospital mortality [area under the curve (AUC), 0.755, 95% confidence interval (CI), 0.729-0.780; Brier score 0.128]: age; estimated glomerular filtration rate; arterial lactate; iatrogenic dissection; left ventricular ejection fraction ≤50%; invasive mechanical ventilation; cardiopulmonary resuscitation immediately before surgery; and cerebral, mesenteric, and peripheral malperfusion. The estimated risk score was associated with an increased risk of composite outcome (AUC, 0.689, 95% CI, 0.667-0.711) and of late mortality [hazard ratio (HR), 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403]. In the validation dataset (248 patients), the in-hospital mortality rate was 16.1%, the composite outcome rate was 41.5%, and the 10-year mortality rate was 49.1%. The estimated risk score was predictive of in-hospital mortality (AUC, 0.703, 95% CI, 0.613-0.793; Brier score 0.121; slope 0.905) and of composite outcome (AUC, 0.682, 95% CI, 0.614-0.749). The estimated risk score was predictive of late mortality (HR, 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403), also when hospital deaths were excluded from the analysis (HR, 1.024, 95% CI, 1.018-1.031; Harrell's C 0.630; Somer's D 0.261)., Conclusions: The present analysis identified several baseline clinical risk factors, along with preoperative estimated glomerular filtration rate and arterial lactate, which are predictive of in-hospital mortality and major postoperative adverse events after surgical repair of acute TAAD. These risk factors may be valuable components for risk adjustment in the evaluation of surgical and anesthesiological strategies aiming to improve the results of surgery for TAAD., Clinical Trial Registration: https://clinicaltrials.gov, identifier NCT04831073., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The authors declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (© 2024 Biancari, Demal, Nappi, Onorati, Francica, Peterss, Buech, Fiore, Folliguet, Perrotti, Hervé, Conradi, Rukosujew, Pinto, Lega, Pol, Rocek, Kacer, Wisniewski, Mazzaro, Vendramin, Piani, Ferrante, Rinaldi, Quintana, Pruna-Guillen, Gerelli, Di Perna, Acharya, Mariscalco, Field, Kuduvalli, Pettinari, Rosato, D'Errigo, Jormalainen, Mustonen, Mäkikallio, Dell'aquila, Juvonen and Gatti.)

Aims: In this study we evaluated the impact of direct aortic cannulation versus innominate/subclavian/axillary artery cannulation on the outcome after surgery for type A aortic dissection., Methods: The outcomes of patients included in a multicenter European registry (ERTAAD) who underwent surgery for acute type A aortic dissection with direct aortic cannulation versus those with innominate/subclavian/axillary artery cannulation, i.e. supra-aortic arterial cannulation, were compared using propensity score matched analysis., Results: Out of 3902 consecutive patients included in the registry, 2478 (63.5%) patients were eligible for this analysis. Direct aortic cannulation was performed in 627 (25.3%) patients, while supra-aortic arterial cannulation in 1851 (74.7%) patients. Propensity score matching yielded 614 pairs of patients. Among them, patients who underwent surgery for TAAD with direct aortic cannulation had significantly decreased in-hospital mortality (12.7% vs. 18.1%, p = 0.009) compared to those who had supra-aortic arterial cannulation. Furthermore, direct aortic cannulation was associated with decreased postoperative rates of paraparesis/paraplegia (2.0 vs. 6.0%, p < 0.0001), mesenteric ischemia (1.8 vs. 5.1%, p = 0.002), sepsis (7.0 vs. 14.2%, p < 0.0001), heart failure (11.2 vs. 15.2%, p = 0.043), and major lower limb amputation (0 vs. 1.0%, p = 0.031). Direct aortic cannulation showed a trend toward decreased risk of postoperative dialysis (10.1 vs. 13.7%, p = 0.051)., Conclusions: This multicenter cohort study showed that direct aortic cannulation compared to supra-aortic arterial cannulation is associated with a significant reduction of the risk of in-hospital mortality after surgery for acute type A aortic dissection., Trial Registration: ClinicalTrials.gov Identifier: NCT04831073., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Background: Acute type A aortic dissection (TAAD) is associated with significant mortality and morbidity. In this study we evaluated the prognostic significance of preoperative arterial lactate concentration on the outcome after surgery for TAAD., Methods: The ERTAAD registry included consecutive patients who underwent surgery for acute type A aortic dissection (TAAD) at 18 European centers of cardiac surgery., Results: Data on arterial lactate concentration immediately before surgery were available in 2798 (71.7 %) patients. Preoperative concentration of arterial lactate was an independent predictor of in-hospital mortality (mean, 3.5 ± 3.2 vs 2.1 ± 1.8 mmol/L, adjusted OR 1.181, 95%CI 1.129-1.235). The best cutoff value preoperative arterial lactate concentration was 1.8 mmol/L (in-hospital mortality, 12.0 %, vs. 26.6 %, p < 0.0001). The rates of in-hospital mortality increased along increasing quintiles of arterial lactate and it was 12.1 % in the lowest quintile and 33.6 % in the highest quintile (p < 0.0001). The difference between multivariable models with and without preoperative arterial lactate was statistically significant (p = 0.0002). The NRI was 0.296 (95%CI 0.200-0.391) (p < 0.0001) with -17 % of events correctly reclassified (p = 0.0002) and 46 % of non-events correctly reclassified (p < 0.0001). The IDI was 0.025 (95%CI 0.016-0.034) (p < 0.0001). Six studies from a systematic review plus the present one provided data for a pooled analysis which showed that the mean difference of preoperative arterial lactate between 30-day/in-hospital deaths and survivors was 1.85 mmol/L (95%CI 1.22-2.47, p < 0.0001, I 2 64 %)., Conclusions: Hyperlactatemia significantly increased the risk of mortality after surgery for acute TAAD and should be considered in the clinical assessment of these critically ill patients., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Fausto Biancari reports financial support was provided by 10.13039/501100005633Finnish Foundation for Cardiovascular Research. Fausto Biancari reports financial support was provided by Sigrid Jusélius Foundation., (© 2023 The Authors.)

Objective: The aim of this study was to evaluate the outcomes of different surgical strategies for acute Stanford type A aortic dissection (TAAD)., Summary Background Data: The optimal extent of aortic resection during surgery for acute TAAD is controversial., Methods: This is a multicenter, retrospective cohort study of patients who underwent surgery for acute TAAD at 18 European hospitals., Results: Out of 3902 consecutive patients, 689 (17.7%) died during the index hospitalization. Among 2855 patients who survived 3 months after surgery, 10-year observed survival was 65.3%, while country-adjusted, age-adjusted, and sex-adjusted expected survival was 81.3%, yielding a relative survival of 80.4%. Among 558 propensity score-matched pairs, total aortic arch replacement increased the risk of in-hospital (21.0% vs. 14.9%, P =0.008) and 10-year mortality (47.1% vs. 40.1%, P =0.001), without decreasing the incidence of distal aortic reoperation (10-year: 8.9% vs. 7.4%, P =0.690) compared with ascending aortic replacement. Among 933 propensity score-matched pairs, in-hospital mortality (18.5% vs. 18.0%, P =0.765), late mortality (at 10-year: 44.6% vs. 41.9%, P =0.824), and cumulative incidence of proximal aortic reoperation (at 10-year: 4.4% vs. 5.9%, P =0.190) after aortic root replacement was comparable to supracoronary aortic replacement., Conclusions: Replacement of the aortic root and aortic arch did not decrease the risk of aortic reoperation in patients with TAAD and should be performed only in the presence of local aortic injury or aneurysm. The relative survival of TAAD patients is poor and suggests that the causes underlying aortic dissection may also impact late mortality despite surgical repair of the dissected aorta., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate the impact of individual institutions on the outcome after surgery for Stanford type A aortic dissection (TAAD)., Methods: This is an observational, multicenter, retrospective cohort study including 3902 patients who underwent surgery for TAAD at 18 university and non-university hospitals., Results: Logistic regression showed that four hospitals had increased risk of in-hospital mortality, while two hospitals were associated with decreased risk of in-hospital mortality. Risk-adjusted in-hospital mortality rates were lower in four hospitals and higher in other four hospitals compared to the overall in-hospital mortality rate (17.7%). Participating hospitals were classified as overperforming or underperforming if their risk-adjusted in-hospital mortality rate was lower or higher than the in-hospital mortality rate of the overall series, respectively. Propensity score matching yielded 1729 pairs of patients operated at over- or underperforming hospitals. Overperforming hospitals had a significantly lower in-hospital mortality (12.8% vs. 22.2%, p < 0.0001) along with decreased rate of stroke and/or global brain ischemia (16.5% vs. 19.9%, p = 0.009) compared to underperforming hospitals. Aggregate data meta-regression of the results of participating hospitals showed that hospital volume was inversely associated with in-hospital mortality (p = 0.043). Hospitals with an annual volume of less than 15 cases had an increased risk of in-hospital mortality (adjusted OR, 1.345, 95% CI 1.126-1.607)., Conclusion: The present findings indicate that there are significant differences between hospitals in terms of early outcome after surgery for TAAD. Low hospital volume may be a determinant of poor outcome of TAAD., Trial Registration: ClinicalTrials.gov Identifier: NCT04831073., (© 2023. The Author(s).)

(1) Background: Acute Stanford type A aortic dissection (TAAD) may complicate the outcome of cardiovascular procedures. Data on the outcome after surgery for iatrogenic acute TAAD is scarce. (2) Methods: The European Registry of Type A Aortic Dissection (ERTAAD) is a multicenter, retrospective study including patients who underwent surgery for acute TAAD at 18 hospitals from eight European countries. The primary outcomes were in-hospital mortality and 5-year mortality. Twenty-seven secondary outcomes were evaluated. (3) Results: Out of 3902 consecutive patients who underwent surgery for acute TAAD, 103 (2.6%) had iatrogenic TAAD. Cardiac surgery (37.8%) and percutaneous coronary intervention (36.9%) were the most frequent causes leading to iatrogenic TAAD, followed by diagnostic coronary angiography (13.6%), transcatheter aortic valve replacement (10.7%) and peripheral endovascular procedure (1.0%). In hospital mortality was 20.5% after cardiac surgery, 31.6% after percutaneous coronary intervention, 42.9% after diagnostic coronary angiography, 45.5% after transcatheter aortic valve replacement and nihil after peripheral endovascular procedure (p = 0.092), with similar 5-year mortality between different subgroups of iatrogenic TAAD (p = 0.710). Among 102 propensity score matched pairs, in-hospital mortality was significantly higher among patients with iatrogenic TAAD (30.4% vs. 15.7%, p = 0.013) compared to those with spontaneous TAAD. This finding was likely related to higher risk of postoperative heart failure (35.3% vs. 10.8%, p < 0.0001) among iatrogenic TAAD patients. Five-year mortality was comparable between patients with iatrogenic and spontaneous TAAD (46.2% vs. 39.4%, p = 0.163). (4) Conclusions: Iatrogenic origin of acute TAAD is quite uncommon but carries a significantly increased risk of in-hospital mortality compared to spontaneous TAAD.

Objective: The optimal duration of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients affected by postcardiotomy cardiogenic shock (PCS) remains controversial. The present study was conducted to investigate the effect of VA-ECMO duration on hospital outcomes., Design: Retrospective analysis of an international registry., Setting: Multicenter study including 19 tertiary university hospitals., Participants: Between January 2010 and March 2018, data on PCS patients receiving VA-ECMO were retrieved from the multicenter PC-ECMO registry., Interventions: Patients were stratified according to the following different durations of VA-ECMO therapy: ≤three days, four-to-seven days, eight-to-ten days, and >ten days., Measurements and Main Results: A total of 725 patients, with a mean age of 62.9 ± 12.9 years, were included. The mean duration of VA-ECMO was 7.1 ± 6.3 days (range 0-39 d), and 39.4% of patients were supported for ≤three days, 29.1% for four-seven days, 15.3% for eight-ten days, and finally 20.7% for >ten days. A total of 391 (53.9%) patients were weaned from VA-ECMO successfully; however, 134 (34.3%) of those patients died before discharge. Multivariate logistic regression showed that prolonged duration of VA-ECMO therapy (four-seven days: adjusted rate 53.6%, odds ratio [OR] 0.28, 95% confidence interval [CI] 0.18-0.44; eight-ten days: adjusted rate 61.3%, OR 0.51, 95% CI 0.29-0.87; and >ten days: adjusted rate 59.3%, OR 0.49, 95% CI 0.31-0.81) was associated with lower risk of mortality compared with VA-ECMO lasting ≤three days (adjusted rate 78.3%). Patients requiring VA-ECMO therapy for eight-ten days (OR 1.96, 95% CI 1.15-3.33) and >10 days (OR 1.85, 95% CI 1.14-3.02) had significantly greater mortality compared with those on VA-ECMO for 4 to 7 days., Conclusions: PCS patients weaned from VA-ECMO after four-seven days of support had significantly less mortality compared with those with shorter or longer mechanical support., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Aims: Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiogenic shock (PCS) after adult cardiac surgery is associated with satisfactory hospital survival. However, data on long-term survival of these critically ill patients are scarce., Methods and Results: Between January 2010 and March 2018, 665 consecutive patients received VA-ECMO for PCS at 17 cardiac surgery centres and herein we evaluated their 5-year survival. The mean follow-up of this cohort was 1.7 ± 2.7 years (for hospital survivors, 4.6 ± 2.5 years). In this cohort, 240 (36.1%) patients survived to hospital discharge. Five-year survival of all patients was 27.7%. The PC-ECMO score was predictive of 5-year survival in these patients (0 point, 50.9%; 1 point, 44.9%; 2 points, 40.0%; 3 points, 34.7%; 4 points, 21.0%; 5 points, 17.6%; ≥6 points, 10.7%; P < 0.0001). Age was among factors independently associated with late survival, patients >70 years old having a remarkably poor 5-year survival (<60 years: 39.2%; 60-69 years: 29.9%; 70-79 years: 12.3%; ≥80 years: 13.0%, P < 0.0001). Implantation of a ventricular assist device or heart transplant was performed in 3.2% of patients and their 5-year survival was 42.9% (for heart transplant, 63.6%)., Conclusion: Veno-arterial extracorporeal membrane oxygenation for PCS is associated with satisfactory 5-year survival in young patients without critical pre-ECMO conditions. The use of VA-ECMO for PCS in patients >70 years should be considered only after a judicious scrutiny of patient's life expectancy. Future studies should evaluate whether satisfactory mid-term survival of these patients translates into a good functional outcome., Trial Registration: Clinicaltrials.gov-NCT03508505., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Background: Minimally invasive mitral valve repair or replacement (MIMVR) approaches have been increasingly adopted for the treatment of mitral regurgitation, allowing a shorter recovery time and improving postoperative quality of life. However, inadequate positioning of the right mini thoracotomy access (working port) translates into suboptimal exposure, prolonged operative times and, potentially, reduction in the quality of mitral repair. At present, we are missing tools to further improve the positioning of the working port in order to ameliorate surgical exposure in a patient- specific fashion., Methods and Evaluation of the Hypothesis: We hypothesized that computation of relevant anatomical measurements from preoperative CT scans in patients undergoing MIMVR may provide patient-specific information in order to propose the surgical access that best fits to the patient's morphology. We hypothesized that this may systematize optimal mitral valve exposure, facilitating the procedure and potentially ameliorating the outcomes. We also hypothesized that preoperative simulation of the working port site and surgical instruments' insertion using a three-dimensional virtual model of the patient is feasible and may help in the customization of ports positioning. The hypothesis was evaluated by a multidisciplinary team including cardiac surgeons, experts in medical image processing and biomedical engineers. CT scans of 14 patients undergoing MIMVR were segmented to visualize 3D chest bones and heart structures meshes. The mitral valve annulus is pointed manually by the expert or extracted automatically when contrast-enhanced CT scan was available. The valve plane was then calculated and the optimal incision location analyzed according to a) the perpendicularity and b) the distance between the intercostal spaces and the valve plane. An angle-chart representation for the 4th, 5th and 6th intercostal spaces and a color map illustrating the distance between the skin and the mitral valve were created. We started the development of a simulation tool for preoperative planning using 3D Slicer software., Conclusions: Several patient-specific factors (including the orientation of the mitral valve plane and the morphology of the chest cage) may influence the performance of a MIMVR procedure, but they are not quantitatively considered in the current planning strategy. We suggest that the clinical results of MIMVR can be improved through preoperative virtual simulation and computer-assisted surgery (through determination of working port and surgical instruments insertion positioning). Further research is justified and the development of a software tool for clinical evaluation is warranted to verify the current hypothesis., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019 Elsevier Ltd. All rights reserved.)