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Type A acute aortic dissection are associated with significant morbidity and mortality with prompt referral imaging and management to tertiary referral centres needed urgently. Surgery is usually needed emergently but the choice of surgery often varies depending on the patient and presentation. Staff and center expertise also play a major role in determining the surgical strategy employed The aim of this study is to compare early and medium term outcomes of patient across 3 European referral centers. We also identified risk factors for poorer outcomes irrespective of surgical strategy employed. A retrospective study was conducted across 3 sites between January 2008 and December 2021. 601 patients were included within the study of which 30% were female and the median age was 64.4 years. The most common operation was ascending aorta replacement (n= 246, 40.9%). The aortic repair was extended proximally (i.e., root n= 105; 17,5%) and distally (i.e., arch n = 250; 41,6%). A more extensive approach, extending from the root to the arch, was employed in 24 patients (4.0%). Operative mortality occurred in 146 patients (24.3%), and the most common morbidity was stroke (75, 12.6%). An increased length of ICU admission was noted in the extensive surgery group who were younger and more frequently male No significant differences were noted in surgical mortality from patients managed with extensive surgery vs those managed conservatively. However, age, arterial lactate levels, “intubated/sedated” status on arrival, and “emergency or salvage” status at presentation were independent predictors of mortality both within the index hospitalization and also during follow-up. Overall survival was similar between the groups.

An inclusive contemporary analysis of spinal cord injury (SCI) rates in patients undergoing aneurysm repair and the factors associated with complications has not been performed.Following a systematic literature search, studies from 2008 to 2018 on repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) were pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was permanent SCI. Secondary outcomes were temporary SCI, operative mortality, long-term mortality, postoperative stroke, and cerebrospinal fluid (CSF) drain-related complications.One-hundred sixty-nine studies (22,634 patients) were included. The pooled rate of permanent SCI was 4.5% (95% confidence interval [CI], 3.8-5.4); 3.5% (95% CI, 1.8-6.7) for DTA and 7.6% (96% CI, 6.2-9.3) for TAAA repair (P for subgroups = .02), 5.7% (95% CI, 4.3-7.5) for open repair and 3.9% (95% CI, 3.1-4.8) for endovascular repair (P for subgroups = .03). Rates for Crawford extents I, II, III, IV, and V aneurysms were 4.0% (95% CI, 3.0-5.0), 15.0% (95% CI, 10.0-22.0), 7.0% (95% CI, 6.0-9.0), 2.0% (95% CI, 2.0-4.0), and 7.0% (95% CI, 2.0-23.0) respectively (P for subgroups.001). The pooled rates for operative mortality, late mortality at a mean follow-up of 5.0 years, stroke, and temporary SCI were 7.4% (95% CI, 6.1-9.4), 1.0% (95% CI, 0.0-1.0), 4.2% (95% CI, 3.6-4.8), and 3.7% (95% CI, 3.0-4.6), respectively. The pooled rates for severe, moderate, and minor CSF-drain related complications were 5.1% (95% CI, 2.23-11.1), 4.1% (95% CI, 0.6-22.0), and 3.6% (95% CI, 1.2-8.0) respectively.Despite improvement, both open and endovascular aneurysm repair remain associated with a substantial risk of permanent SCI. The risk is greater for TAAA repair, especially extent II, III, and V.

To discern the impact of diabetes mellitus (DM) on spinal cord injury (SCI) after open descending thoracic and thoraco-abdominal aneurysm repair (DTAAAR).Compared to euglycemia, hyperglycemia and ketosis make neurons respectively more vulnerable and more resilient to ischemia.During the study period (1997-2021), patient who underwent DTAAAR were dichotomized according to the presence/absence of DM. The latter was investigated as predictor of our primary (SCI) and secondary (operative mortality, myocardial infarction, stroke, need for tracheostomy, de-novo dialysis, and survival) endpoints. Two-level risk-adjustment employed maximum likelihood conditional regression after 1:2 propensity-score matching.DTAAAR was performed in 934 patients. Ninety-two diabetics were matched to 184 non-diabetics. All preoperative variables had a standardized mean difference0.1 between the matched groups. Patients with DM had higher SCI (6.5% vs. 1.6%, P 0.03) and operative mortality (14.1% vs. 6.0%, P 0.01), while the other secondary endpoints were similar between groups in the matched sample. DM was an independent predictor for SCI in the matched sample (OR 5.05, 95% CI 1.17 to 21.71). Matched patients with DM presented decreased survival at 1 (70.2% vs. 86.2%), 5 (50.4% vas 67.5%), 10 years (31.7% vs. 36.7%) (P 0.03). The results are summarized in the graphical abstract.DM is associated to increased operative mortality and decreased survival, and it is an independent predictor of SCI after open DTAAAR. Strict perioperative glycemic control should be implemented, and exogenous ketones should be investigated as neuroprotective agents to reduce such adverse events.

This cross-sectional study examines the readability, accuracy, content, quality, and suitability of online health information on coronary artery bypass grafting or percutaneous coronary intervention for patients.

To evaluate the neuroprotection exerted by ketosis against acute damage of the mammalian central nervous system (CNS). Search engines were interrogated to identify experimental studies comparing the mitigating effect of ketosis (intervention) vs non‐ketosis (control) on acute CNS damage. Primary endpoint was a reduction in mortality. Secondary endpoints were a reduction in neuronal damage and dysfunction, and an “aggregated advantage” (composite of all primary and secondary endpoints). Hedge’s g was the effect measure. Subgroup analyses evaluated the modulatory effect of age, insult type, and injury site. Meta‐regression evaluated timing, type, and magnitude of intervention as predictors of neuroprotection. The selected publications were 49 experimental murine studies (period 1979‐2020). The intervention reduced mortality (g 2.45, SE 0.48, p

In the present study, we sought to discern the effects of splanchnic occlusive disease (SOD; renal, superior mesenteric, and/or celiac axis arteries) on spinal cord injury (SCI; paraparesis or paraplegia) and major adverse events (MAE) after descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) open repair.Patients who had undergone DTA/TAAA repair at our institution were dichotomized according to the presence of SOD, which was investigated as a predictive factor of our primary (SCI) and secondary (operative mortality, myocardial infarction, stroke, tracheostomy, de novo dialysis, MAE, survival) endpoints. Risk adjustment used both propensity score matching and multivariable logistic regression.From July 1997 to October 2019, 888 patients had undergone DTA/TAAA repair, of whom 19 were excluded from our analysis for missing data. SOD was absent in 712 patients and present in 157 patients. The patients with SOD had presented with a greater incidence of preoperative renal impairment (61 [38.9%] vs 175 [24.6%]; P .01) and peripheral arterial disease (60 [38.2%] vs 162 [22.8%]; P .01] and decreased left ventricular ejection fraction (45%; interquartile range, 10%; vs 50%; interquartile range, 4%; P .01). The etiology of aortic disease was more frequently dissection in the SOD group (56.1% vs 43.7%) and more frequently nondissecting aneurysm in the non-SOD group (56.3% vs 43.9%; P .01). Patients without SOD had presented with aneurysms more cranially located (DTA, 34.0% vs 7.6%; extent I TAAA, 44.0% vs 7.6%). In contrast, patients with SOD had presented with aneurysms more caudally located (extent II TAAA, 36.9% vs 8.6%; extent III TAAA, 30.6% vs 11.0%; extent IV TAAA, 17.2% vs 2.5%; P .01). Propensity score matching led to 144 pairs, with SOD significantly associated with SCI (10 [6.9%] vs 2 [1.4%]; P = .03) and MAE (47 [32.6%] vs 26 [15%]; P .01). Ten-year survival was reduced in those with SOD (31.5% vs 45.2%; P .01). Conditional multivariable regression confirmed SOD to be a predictor of SCI in the matched sample (odds ratio, 6.60; P = .02).Our results have shown that SOD is a significant predictor of SCI in patients undergoing open DTA/TAAA repair. The investigation of measures to prolong neuronal ischemia tolerance (eg, hypothermia) is warranted for such patients.

Background We sought to evaluate the impact of surgical approach (thoracophrenolaparotomy vs thoracotomy crura splitting) on the outcomes of extent I thoracoabdominal aortic aneurysm repair. Methods Patient data were extracted from our aortic surgery database. The primary endpoint was need for tracheostomy, and secondary endpoints were operative mortality, myocardial infarction, stroke, spinal cord injury, de novo dialysis, and major adverse events (composite of secondary endpoints and tracheostomy). Freedom from death and reoperation during follow-up were calculated. Risk adjustment was obtained with propensity score matching and multivariable regression. Results Three hundred twenty-five patients underwent extent I repair. Compared with thoracophrenolaparotomy patients (n = 226), thoracotomy crura-splitting patients (n = 99) had a higher rate of previous coronary revascularization (27.3% vs 14.2%, P = .005), valvular disease (64.6% vs 50.4%, P = .018), and chronic obstructive pulmonary disease (61.6% vs 28.3%, P = .000) and a lower forced expiratory volume in 1 second (46% vs 69%, P = .000). In a matched sample thoracotomy crura splitting was associated with a decreased need for tracheostomy (4.0% vs 13.1%, P = .035). The need for tracheostomy was predicted by female gender (odds ratio, 3.11; 95% confidence interval, 1.17-8.30; P = .023), forced expiratory volume in 1 second (odds ratio, 0.95; 95% confidence interval, 0.91-0.98; P = .003), and thoracophrenolaparotomy (odds ratio, 3.66; 95% confidence interval, 1.14-11.73; P = .029). Five-year freedom from mortality and reoperation were similar. Conclusions In patients undergoing extent I thoracoabdominal aortic aneurysm repair, thoracotomy crura splitting was associated with decreased need for tracheostomy.

Triple valve surgery (TVS) remains a challenging procedure with limited existing literature. We aim to evaluate the prevalence, in-hospital outcomes, and prognostic determinants of TVS in the current era.We reviewed the Nationwide Inpatient Sample database from 2003 to 2012 and included all patients who underwent aortic valve replacement (AVR) combined with mitral valve replacement (MVR) or repair (MVRep) and tricuspid valve replacement (TVR) or repair (TVRep). Logistic regression analysis was used to identify independent predictors of in-hospital mortality and propensity score matching was adopted to compare groups receiving different operations.Overall, 5234 patients were included. In-hospital mortality was 13.9%. Major adverse events occurred in 42.9% of the cases (44.9%, 40.3%, 44.4% and 74.2% in the AVR + MVR + TVR, AVR + MVR + TVRep, AVR + MVRep + TVRep and AVR + MVRep + TVR groups respectively, p 0.05 for all intergroup comparisons). In-hospital mortality in the AVR + MVR + TVR, AVR + MVR + TVRep, AVR + MVRep + TVRep and AVR + MVRep + TVR groups was 19.9%, 13.3%, 12.9% and 0% respectively (p 0.05 for all intergroup comparisons). At regression analysis, age, reoperation, and urgent/emergent operation were independent predictors of in-hospital mortality. Patients submitted to tricuspid valve repair and mitral and tricuspid repair had a 62% and 63% mortality risk reduction (OR:0.380, CI:0.19-0.76 p = 0.006 and OR:0.37, CI:0.18-0.78 p = 0.009 respectively). In the propensity matched comparisons, in-hospital mortality was statistically similar (p = 0.08 for AVR + MVR + TVR vs. AVR + MVR + TVRep comparison and p = 0.06 for AVR + MVR + TVR vs. AVR + MVRep + TVRep comparison).TVS is associated with significant in-hospital mortality and morbidity. The use of valve repair strategies for the mitral and tricuspid valves can positively impact postoperative outcomes.

To evaluate the results of reoperation on descending thoracic and thoracoabdominal aneurysms.Sixty-nine consecutive patients undergoing reoperative aneurysm repair (20 descending thoracic and 49 thoracoabdominal) were compared to 602 contemporary primary repairs. Propensity matching was used to reduce observable differences in preoperative characteristics.The reoperation group was younger (60.2 vs 65.3 years, P = 0.005) and less were extent I or II (28.6% vs 76%, P 0.001). In the reoperation group, 82.6% were repaired with clamp-and-sew, 14.5% circulatory arrest and 2.9% partial bypass versus the primary surgery group 62.1%, 8.1% and 29.7%, respectively (P 0.001). In the reoperation versus primary surgery group, respectively, spinal drainage was used in 73.9% vs 83.7% (P = 0.05), intercostal reimplantation in 11.6% vs 44.2% (P 0.001), and cold renal perfusion in 36.2% vs 19.8% (P = 0.001). Operative mortality was comparable (8.7% vs 5.3% primary, P = 0.25) but the reoperative extent I subgroup had higher mortality (20% vs 3.1%; P = 0.04). Incidence of major complications was comparable (stroke 0 vs 0.9%, tracheostomy 5.8% vs 8%, renal failure 7.2% vs 5%, spinal cord injury 4.3% vs 2.7%; P 0.05 for all variables), with the exception of myocardial infarction (2.9% vs 0.5%, P = 0.028). Five-year survival was 57.6% in reoperations and 58% in the primary surgery group (P = 0.878). No differences in the in-hospital and follow-up outcomes were found in the propensity matched comparison.Reoperative repair of descending thoracic and thoracoabdominal aneurysms can be safely performed with reasonable in-hospital and follow-up outcomes compared to primary aneurysm repair.

Objectives Our goal was to report on early and midterm outcomes of hemiarch replacement performed in a high-volume centre. Methods We extrapolated hemiarch replacements from our institutional aortic database. We also analysed the impact of aortic disease (dissection vs aneurysm) on the outcomes of de novo hemiarch replacement. Results A total of 756 patients underwent hemiarch replacement between 1997 and 2016. After elimination of cases involving the aortic root/valve and redo cases, we identified 426 cases of de novo -isolated hemiarch replacement (369 aneurysms and 57 dissections). Overall operative mortality was 3.1% (13 of 426). The most frequent complications were respiratory failure requiring tracheostomy (11 of 426, 2.6%) and renal failure requiring dialysis (7 of 426, 1.6%). On regression analysis, previous myocardial infarction was the only independent predictor of major adverse events (odds ratio 3.14; 95% confidence interval 1.36-7.22; P = 0.007). Operative mortality was 5.3% (3 of 57) for dissections and 2.7% (10 of 369) for aneurysms ( P = 0.29). The postoperative need for tracheostomy and for new dialysis was more frequent in the dissection group (4 of 57 vs 7 of 369; P = 0.02 and 3 of 57 vs 4 of 369; P = 0.02, respectively). At 5 years, the overall survival rate was 72.5% (95% confidence interval 66.4-78.6%), and there was no difference in survival and risk of reoperation between the 2 groups ( P = 0.97). Conclusions In high-volume centres, aortic hemiarch replacement can be performed with excellent results. The aortic disease only partially affects the early and midterm outcomes.

Background Patients undergoing consideration for venoarterial extracorporeal membrane oxygenation (VA-ECMO) require an immediate risk profile assessment in the setting of incomplete information. A number of survival prediction models for critically ill patients and patients undergoing elective cardiac surgery or institution of VA-ECMO support have been designed. We assess the ability of these models to predict outcomes in a cohort of patients undergoing institution of VA-ECMO for cardiogenic shock or cardiac arrest. Methods Fifty-one patients undergoing institution of VA-ECMO support were retrospectively analyzed. APACHE II, SOFA, SAPS II, Encourage, SAVE, and ACEF scores were calculated. Their ability to predict outcomes were assessed. Results Indications for ECMO support included postcardiotomy shock (25%), ischemic etiologies (39%), and other etiologies (36%). Pre-ECMO arrest occurred in 73% and 41% of patients underwent cannulation during arrest. Survival to discharge was 39%. Three survival prediction model scores were significantly higher in nonsurvivors to discharge than surivors; the Encourage score (25.4 vs 20; p = .04), the APACHE II score (23.6 vs 19.2; p = .05), and the ACEF score (3.1 vs 1.8; p = .03). In ROC analysis, the ACEF score demonstrated the greatest predictive ability with an AUC of 0.7. Conclusions A variety of survival prediction model scores designed for critically ill ICU and VA-ECMO patients demonstrated modest discriminatory ability in the current cohort of patients. The ACEF score, while not designed to predict survival in critically ill patients, demonstrated the best discriminatory ability. Furthermore, it is the simplest to calculate, an advantage in the emergent setting.

Objectives Cardiac tumors and their associated outcomes are poorly characterized. This study sought to comprehensively assess the epidemiology and natural history of primary and secondary malignant cardiac tumors (PMCT and SMCT), a well as establish predictors of mortality. Methods A comprehensive literature review was performed to identify articles reporting on PMCTs and SMCTs. The prevalence of important cardiac tumor (CT) subtypes was evaluated and further stratified based on the continental region. Outcomes of interest included short- and long-term mortality and utilization of heart transplantation (HTX). A random effect model was adopted, and a meta-regression was performed to determine predictors of the prevalence of CTs as well as predictors of operative mortality. Results Of the 1,226 retrieved articles, 74 were included in our study (n = 8,849 patients). The mean follow-up was 2.27 years, mean age was 42.9 years, and 55% of the patients were females. There was a total number of 7,484 benign primary cardiac tumors (PCTs) (5,140 were myxoma), 862 (9.7%) malignant PCTs, and 355 secondary cardiac tumors. The prevalence of PMCTs among PCTs was 10.83% [95%CI = 09.11; 12.83%] with a trend towards being lower in South America compared to other continents (Prevalence = 5.80%). The prevalence of HTX among all patients was 2.45% [1.36; 4.38%]. The pooled short-term mortality was 5.90% [4.70; 7.39%] and the incidence of late mortality in all CTs, benign CT and PMCTs was 2.55% [1.76; 3.72%], 0.79% [0.46; 1.37%] and 14.77% [9.32; 23.40%], respectively. On meta-regression, the annual volume of cardiac tumor cases per center was the only predictor of lower early mortality (Beta = −0.14 ± 0.03, P Conclusions PMCTs represent the minority of PCT (~10%) and have a higher prevalence in Europe and North America. Survival is higher in benign pathology and is significantly improved by treatment in specialized high-volume centers. Approximately 2% of patients with CTs undergo heart transplantation.

Background Treatment of ischemic mitral regurgitation (IMR) is in evolution, as percutaneous procedures and complex surgical repair have been recently investigated in randomized clinical trials and matched studies. This study aims to review and compare the current treatment options for IMR. Methods A comprehensive literature search was conducted using electronic databases. The primary outcome was all-cause long-term mortality. The secondary outcomes were perioperative mortality, unplanned rehospitalization, reoperation, and composite end points as defined in the original articles. Results A total of 12 articles met the inclusion criteria and were included in the final meta-analysis. The MitraClip procedure did not confer a significant benefit in mortality and repeated hospitalization compared with medical therapy alone. In patients with moderate IMR, the adjunct of mitral procedure over coronary artery bypass graft is not associated with clinical improvements. When evaluating mitral valve (MV) replacement versus repair, hospital mortality was greater among patients undergoing replacement (odds ratio [OR], 1.91; P = .009), but both reoperation and readmission rates were lower (OR, 0.60, P = .05; and OR, 0.45, P < .02, respectively). Comparing restrictive annuloplasty alone with adjunctive subvalvular repair, subvalvular procedures resulted in fewer readmissions (OR, 0.50; P = .06) and adverse composite end points (P = .009). Conclusions MitraClip procedure is not associated with improved outcomes compared with medical therapy. MV replacement is associated with increased early mortality but reduced reoperation rate and readmission rate compared with MV repair using annuloplasty in moderate-to-severe IMR. Despite no significant benefit in isolated outcomes comparing annular and adjunct subvalvular procedures, the adjunct of subvalvular procedures reduces the risk of major postoperative adverse events.

Introduction Extracorporeal membrane oxygenation (ECMO) is a life saving modality increasingly used in the management cardiopulmonary failure. However, ECMO itself is not without major complications. Mortality remains high, and morbidity such as stroke, renal failure, and acute threatening limb ischemia (ALI) are common among surviving patients. We analyzed the effect of one of these complications, ALI, on the survival of patients receiving veno-arterial ECMO (VA ECMO) with femoral cannulation. Methods Patients with cardiopulmonary failure supported by VA ECMO inserted through femoral cannulation at two institutions from December 2010 to December 2017 were enrolled in this study. Data were collected retrospectively. Our primary outcome was ALI and its effect on hospital mortality. Secondary outcomes included six-month mortality, length of hospital stay, as well as other complications (stroke and renal failure) multivariate logistic regression analysis was used to identify predictors of ALI and hospital mortality. Results There were 71 patients included in this study. The overall VA ECMO hospital mortality was 53.5%. ALI was seen in 14 (19.7%) patients. Of these, four (5.6%) patients had fasciotomy, four patients (5.6%) had thrombectomy, and one underwent arterial repair (1.4%). Five additional patients (7.0%) with ALI expired and had no vascular intervention. None of the demographic and clinical characteristics significantly correlated with ALI except for stroke and renal failure requiring new onset hemodialysis (HD). The rate of hospital and 6-month mortality in patients with and without vascular complications were 78.6%, 92.3% and 47.4%, 57.4% respectively (p=0.042 and p=0.023). Multivariate analysis correlated hospital and six month mortality with ALI, stroke, and new onset HD. Conclusions ALI correlates with higher mortality in VA ECMO patients with femoral cannulation. Although, some of the contributing factors to mortality in these patients are related to the consequences of cardiopulmonary failure, strong efforts should be made to avoid ALI after femoral VA ECMO cannulation.

OBJECTIVES Valve-sparing operations and root replacement with a biologic composite conduit are viable options in aortic root aneurysm. This study was conceived to compare the early and mid-term results of these 2 procedures. METHODS From September 2002 to November 2015, 749 consecutive patients underwent either a valve-sparing operation or a root replacement with a biologic composite conduit at 2 institutions. Propensity score matching was used to compare similar cohorts of patients in the overall population and in the ≤ 55 and ≥ 65-year age groups. RESULTS Overall operative mortality was 0.4%, mean age 57.4 ± 14.3 years, 84.6% were male. Individuals in the biologic composite conduit group were older and had worse preoperative risk profiles [chronic pulmonary disease (5.5% vs 0.9%; P = 0.001), diabetes (6.4% vs 1.5%; P = 0.001) and NYHA > 2 (25.2% vs 5.2%; P

OBJECTIVES To evaluate surgical outcomes in open repair of thoracoabdominal aortic (TAAA) and descending thoracic aortic aneurysms (DTA) in patients with preoperative renal failure (PRF). METHODS Our database was examined for all patients undergoing open TAAA/DTA repair. Patients with a creatinine greater than or equal to 1.5 gm/dl or on haemodialysis were defined as having PRF and were compared to those having normal preoperative renal function. Logistic and Cox regression analysis were used to identify independent determinants of in-hospital outcomes and long-term survival. RESULTS From 1997 to 2015, 711 patients underwent open TAAA/DTA repair. Two hundred and two were categorized as having PRF, of which, 22 where on preoperative haemodialysis. PRF patients had significantly worse comorbidities; smoking (95.5% vs 69.0%; P

A previously developed poly-l-lactide scaffold releasing granulocyte colony-stimulating factor (PLLA/GCSF) was tested in a rabbit chronic model of myocardial infarction (MI) as a ventricular patch. Control groups were constituted by healthy, chronic MI and nonfunctionalized PLLA scaffold. PLLA-based electrospun scaffold efficiently integrated into a chronic infarcted myocardium. Functionalization of the biopolymer with GCSF led to increased fibroblast-like vimentin-positive cellular colonization and reduced inflammatory cell infiltration within the micrometric fiber mesh in comparison to nonfunctionalized scaffold; PLLA/GCSF polymer induced an angiogenetic process with a statistically significant increase in the number of neovessels compared to the nonfunctionalized scaffold; PLLA/GCSF implanted at the infarcted zone induced a reorganization of the ECM architecture leading to connective tissue deposition and scar remodeling. These findings were coupled with a reduction in end-systolic and end-diastolic volumes, indicating a preventive effect of the scaffold on ventricular dilation, and an improvement in cardiac performance.

To compare outcomes of single (intervention group: del Nido [DN], and histamine-tryptophan-ketoglutarate) versus multidose (control group) cardioplegia in the adult cardiac surgery patients.Medical search engines were interrogated to identify relevant randomized controlled trials and propensity-score matched cohorts. Meta-analysis was conducted for primary (in-hospital/30-day mortality) and secondary (ischemic and cardiopulmonary bypass [CPB] times, reperfusion fibrillation, peak of cardiac enzymes, myocardial infarction) endpoints. Subgroup analyses were conducted for study design and type of intervention, and meta-regression for primary outcome included type of surgery and left ventricular ejection fraction as moderators.Ten randomized controlled trials and 13 propensity-score matched cohorts were included, reporting on 5516 patients. Estimates are expressed as (parameter value [OR, odds ratio; MD, mean difference; SMD, standardized mean difference]/unit of measure [95% confidence interval], P value). DN reduced ischemic time (MD, -7.18 minutes [-12.52 to -1.84], P .01), CPB time (MD, -10.44 minutes [-18.99 to -1.88], P .01), reperfusion fibrillation (OR, 0.16 [0.05-0.54], P .01), and cardiac enzymes (SMD -0.17 [-0.29, 0.05], P .01) compared with multidose cardioplegia. None of these beneficial effects were reproduced by histamine-tryptophan-ketoglutarate, which instead increased CPB time (MD, 2.04 minutes [0.73-3.37], P .01) and reperfusion fibrillation (OR, 1.80 [1.20-2.70], P .01). There was no difference in mortality and myocardial infarction between single and multidose, independently of type of surgery or left ventricular ejection fraction.DN decreases operative times, reperfusion fibrillation, and surge of cardiac enzymes compared with multidose cardioplegia.

The aim was to compare peri-operative and late outcomes of patients with acute and subacute uncomplicated type B aortic dissection (uTBAD) treated by thoracic endovascular aortic repair (TEVAR) or best medical therapy (BMT).This was a Systematic review and meta-analysis of observational studies and randomised controlled trials (RCTs). The review was undertaken according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered with the International Prospective Register of Systematic Reviews (number: CRD42018094607). Multiple electronic databases were searched to identify relevant articles. The methodological quality of the included studies was assessed. The primary outcome measures were early mortality and re-intervention, late all cause and aorta related mortality, and re-intervention. Meta-analysis was used to produce pooled odds ratios (OR) or risk difference (RD) for peri-operative outcomes. Random effects models were applied. For late outcomes a time to event meta-analysis was conducted using the inverse variance model, reporting the results as hazard ratios (HR).Eight original articles from six studies encompassing 14 706 patients (1 066 TEVARs) were eligible for inclusion. There were no statistically significant differences between TEVAR and BMT with regards to inpatient mortality (RD 0.01, 95% CI -0.01-0.02, p = .46), early re-intervention by TEVAR (RD 0.02, 95% CI -0.01-0.04, p = .19) or surgery (RD 0.00, 95% CI -0.01-0.01, p = 1.0). BMT was associated with a significantly lower risk of early stroke (OR 0.64, 95% CI 0.48-0.85, p = .002), whereas the risk of late all cause (HR 1.54, 95% CI 1.27-1.86, p .001) and aorta related mortality (HR 2.71, 95% CI 1.49-4.94, p = .001) was significantly higher than with TEVAR. No suitable data regarding late aortic re-intervention was found for meta-analysis.Given the limited number and quality of suitable studies it remains uncertain whether TEVAR is beneficial in the management of acute/subacute uTBAD. Further research is required to understand which dissections would benefit from pre-emptive treatment.

Background Secondary open aortic procedures (SOAP) treat complications of endovascular aneurysm repair, when further endovascular options are exhausted. We aimed at depicting the state of the art of SOAP with high-level evidence. Methods A systematic review of the SOAP literature, with a meta-analysis of its outcomes (primary outcome operative mortality; secondary outcome major morbidity) and metaregression of risk factors for mortality (PROSPERO 42017075631). Results Twenty-eight studies (1093 patients) were elected for analysis. SOAP was performed within the same hospitalization of or 30 days from domestic endovascular aneurysm repair (early SOAP) in 0.2% of the patients (85/40,256), and in a nonelective setting in 24.3% (95% confidence interval, 21.8-26.9). Most frequent indications were endoleak (44.4%; 95% confidence interval, 41.4-47.3) and rupture (12.7%; 95% confidence interval, 10.4-15.1). The most common procedures were infrarenal aortic replacement (85.2%; 95% confidence interval, 82.6-87.7) with high use of supravisceral clamping (suprarenal, 25% [95% confidence interval, 21.9-28.1] and supraceliac, 20.7% [95% confidence interval, 17.8-23.6]), and axillobifemoral bypass with stent explant (6.9%; 95% confidence interval, 5.1-8.7). Operative mortality (in-hospital or 30-day) was 10.9% (95% confidence interval, 8.7-13.5). The most frequent morbidities were respiratory (11.4%; 95% confidence interval, 8.1-15.9) and renal (9.5%; 95% confidence interval, 8.1-15.9). Risk factors for mortality were supravisceral clamping (Z = 3.007; Q = 9.044; P = .003) and nonelective status (Z = 3.382; Q = 11.440; P = .001). Conclusions Endoleak is the main indication for SOAP, which mostly consists of infrarenal aortic replacement. Risk factors for operative mortality are nonelective status and supravisceral clamping.

Background: The optimal technique for brain perfusion during circulatory arrest remains controversial. Concern exists that retrograde cerebral perfusion (RCP) via the superior vena cava (SVC) is unable to perfuse the brain. We evaluated whether RCP blood circulates through the brain parenchyma in humans during deep hypothermic circulatory arrest (DHCA). We hypothesized that a significant difference in the levels of S-100β (a protein with very high neuro-sensitivity) between the blood infused in the SVC and the effluent blood returning in the left carotid artery (CA) during RCP, should be regarded as a sign of the circulation of RCP blood through the brain parenchyma. Methods: We enrolled 10 non-consecutive patients undergoing elective arch-surgery using DHCA and RCP. Circulating S-100β levels were measured at baseline and immediately before DHCA. During DHCA and RCP the difference in S-100β between the SVC and the CA was evaluated after 10 minutes of arrest and immediately before resumption of the circulation. S-100β levels were evaluated using enzyme-linked immunosorbent assay (ELISA). Results: Mean DHCA duration was 22.4±7.9 minutes. Mean S-100β level at baseline was 92.5±54.9 µg/L. After 10 minutes of DHCA the level of S-100β in the CA was significantly higher than in the SVC (936.9±326.3 vs . 810.9±307.4 µg/L, P=0.0021). This difference was enhanced at the second DHCA sample (1113.8±334.2 vs . 920.5±340.0 µg/L, P=0.0002). There was a statistically significant correlation between the duration of DHCA and the percent difference in S-100β level between the SVC and the CA (Pearson’s correlation coefficient =0.902). Conclusions: RCP is able to perfuse the brain parenchyma in humans during DHCA.

Female sex has been associated with greater morbidity and mortality for a variety of major cardiovascular procedures. We sought to determine the influence of female sex on early and late outcomes after open descending thoracic aortic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) repair.We searched our aortic surgery database to identify patients having open DTA or TAAA repair. Logistic regression and Cox regression analyses were used to assess the effect of sex on perioperative and long-term outcomes.From 1997 until 2017, there were 783 patients who underwent DTA or TAAA repair. There were 462 male patients and 321 female patients. Female patients were significantly older (67.6 ± 13.9 years vs 62.6 ± 14.7 years; P .001), had more chronic pulmonary disease (47.0% vs 35.7%; P = .001) and forced expiratory volume in 1 second 50% (28.3% vs 18.2%; P .001), and were more likely to have degenerative aneurysms (61.7% vs 41.6%; P .001). Operative mortality was not different between women and men (5.6% vs 6.2%; P = .536). However, women were more likely to require a tracheostomy after surgery (10.6% vs 5.0%; P = .003) despite a reduced incidence of left recurrent nerve palsy (3.4% vs 7.8%; P = .012). Logistic regression found female sex to be an independent risk factor for a composite of major adverse events (odds ratio, 2.68; confidence interval, 1.41-5.11) and need for tracheostomy (odds ratio, 3.73; confidence interval, 1.53-9.10). Women also had significantly lower 5-year survival.Women undergoing open DTA or TAAA repair are not at greater risk for operative mortality than their male counterparts are. Reduced preoperative pulmonary function may contribute to an increased risk for respiratory failure in the perioperative period.

Aims The aim of this study was to evaluate the clinical and echocardiographic results and the predictors of outcomes in patients undergoing valve-sparing operation (VSO) at two aortic centers. In addition, we sought to evaluate the potential effect of recreation of the sinuses of Valsalva (SV) on the outcome of valve-sparing procedures. Methods During a 14-year period, 328 patients underwent aortic valve-sparing root replacement at two institutions. Clinical and echo evaluation was performed 6 months after surgery and every year thereafter or in case of clinical symptoms. Propensity weighting and propensity-weighted risk competing analysis were used. Results No operative mortality was reported; the most common complication was revision for bleeding, occurring in 15 patients (4.6%). At a mean follow-up of 30.0 ± 33.9 months, two patients died (0.6%). Recurrent aortic insufficiency (AI) >2+ was found in 11 patients (3.3%); five (1.5%) underwent reoperation. Recreation of the SV did not affect clinical outcome and aortic valve status. Need for aortic valve repair was the only independent predictor of recurrent AI, whereas a bicuspid aortic valve was a protective factor. Conclusions Re-creation of the SV does not affect short-term outcomes following VSO.

Objective The most efficient surgical approach to severe aortic valve disease in the young adult is still debated: cryopreserved aortic allograft offers excellent hemodynamic and avoid anticoagulation, but long-term durability is influenced by structural valve deterioration (SVD). This study aimed to describe long-term results of aortic allografts and to identify factors influencing long-term durability. Methods From January 1993 to August 2010, 210 patients underwent aortic allograft replacement via the free-hand subcoronary implantation technique (N = 55) or root replacement with coronary reimplantation (N = 155). Clinic and echocardiographic follow-up was updated to April 2016. Results Overall mortality and cardiac mortality occurred in 80 (38.1%) and 64 (30.5%) patients, respectively. Reoperation was required in 69 cases (32.8%), whereas SVD required reoperation in 57 cases (27.1%). No early endocarditis occurred, whereas late endocarditis occurred in 4 patients. The free-hand technique seems to be associated with improved left ventricular remodeling compared with the root-replacement technique, and smaller allograft size represents a predictor of reoperation independently on the surgical technique used. In the overall population, there were 44 women of childbearing age, and 37 patients remained pregnant during the follow-up of the study. No differences were found in the clinical outcomes among women who had children and who did not. Conclusions Cryopreserved allograft is a valid option, especially in complex infective endocarditis and in women of childbearing age. A careful choice of allograft size and implantation technique can reduce the risk of SVD.

The surgical treatment of aortic valve endocarditis (AVE) is generally performed using conventional mechanical or biological xenograft prosthesis, with limited use of aortic homograft (Ao-Homo) or pulmonary autograft (PA). Clinical evidence has demonstrated a clear contradiction between the proven benefits of Ao-Homo and PA in the context of infection and the very limited use of allogenic or autologous tissue in everyday clinical practice. This review aims to summarize the most recent and relevant literature in order to foster the scientific debate on the use of the use of allogenic and autologous tissue to treat AVE. The decisional process of the Heart Team should also include the preferences of the patient, his/her family, the general cardiologist or primary care physician. The use of allogenic or autologous valve substitute is beneficial if there is a high risk of recurrence of infection, avoiding extensive adhesiolysis and debridement of synthetic material. In any case, those procedures should be performed by highly trained centers to optimize outcomes.

Background The optimal brain protection strategy for prolonged periods of circulatory arrest is still controversial. This study evaluated whether retrograde cerebral perfusion (RCP) provides adequate brain protection for prolonged periods of deep hypothermic circulatory arrest (DHCA). Methods From January 1997 to December 2014, 1,043 patients underwent aortic arch operations using RCP and DHCA at 18°C. The DHCA time for 993 patients was 49 minutes or less and the DHCA time for the remaining 50 patients was 50 minutes or more. Propensity matching between the two groups was performed, taking into account the main preoperative and surgical variables and all the preoperative and intraoperative neurologic risk factors. Logistic regression analysis was performed to identify independent predictors of operative death and postoperative cerebral complications. Results In the unmatched population, mortality in the 50 minutes or more vs the 49 minutes or less group was 8% vs 3.8% ( p = 0.143), and the stroke rate was 2% vs 1.2% ( p = 0.623). Propensity matching resulted in 48 pairs. Operative death and incidence of transient and permanent neurologic deficit were similar and not statistically significant in the matched groups for all comparisons. No difference in the incidence of other major postoperative complications was found between the two groups. Midterm survival was similar. Regression analysis showed DHCA duration was not independently associated with operative death or postoperative neurologic deficits. Conclusions RCP is an effective adjunctive cerebral protection strategy for complex aortic arch aneurysm repair with prolonged DHCA and is not associated with increased death or neurologic complications.

To evaluate the impact of preoperative pulmonary function on outcomes after open repair of descending thoracic (DTA) and thoracoabdominal aortic (TAAA) aneurysms.The outcomes of patients undergoing open repair of DTA or TAAA were analyzed in relation to the results of preoperative pulmonary function tests. Receiver operating characteristic was adopted to assess the effect of forced expiratory volume in one second (FEV1) on the incidence of mortality. Logistic regression analysis and propensity score matching were used.Between 1997 and 2015, 726 patients underwent open DTA or TAAA repair. Pulmonary function tests were available in 711 (97.9%). Receiver operating characteristic analysis revealed the cutoff value of FEV1 to be 50%. Propensity score matching led to 149 pairs of patients with FEV1 below and above 50% with only limited residual imbalance. In the matched population operative mortality was 11.4% and 6.0% in patients with FEV1 ≤ 50% and FEV1 ≥ 51%, respectively (P = .10). The incidence of major adverse events was 33.1% in cases with FEV1 ≤ 50% and 19.5% in those with FEV1 ≥ 51% (P = .008). FEV1 ≤ 50% was associated with a 6.99× increase in the risk of major postoperative adverse events at logistic regression analysis.Preoperative FEV1 50% is strongly predictive of increased respiratory failure, tracheostomy, and operative mortality in patients undergoing open DTA/TAAA repair. For these very high-risk patients with either extensive TAAAs or anatomy unsuitable for endovascular repair, medical therapy may offer the best long-term survival.

Background We evaluated the results of open operation for the treatment of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) in patients with DeBakey type I versus type III chronic aortic dissection. Methods We reviewed our institutional aortic database and compared the results of open repair in patients with type I versus type III chronic aortic dissection. Between 1997 and 2015, 726 patients underwent open DTA or TAAA repair at our institution. The indication for this procedure was chronic dissection in 243 patients (101 type I and 142 type III). Propensity matching was used to neutralize differences in preoperative risk profile. Results Operative mortality was 4% (4 of 101) in type I and 9.2% (13 of 142) in type III ( p = 0.12). The incidence of major postoperative complications was similar between the two groups. Five-year Kaplan-Meyer survival was similar between the groups (68.3% for type I and 72% for type III patients, p 0.80). Five-year risk of reoperation was 3.5% in type I and 6.6% in type III ( p = 0.25). These results were confirmed in 76 propensity-matched pairs. Conclusions Perioperative and midterm results are similar for patients undergoing open TAAA/DTA repair for chronic type I and III dissection. There was a trend toward increased operative mortality and 5-year risk of reoperation in the type III group, but it did not reach statistical significance.

Introduction The aim of this study was to establish if an elevated triglyceride to high-density lipoprotein (HDL) ratio (THR) is not only a risk factor for cardiovascular and overall morbidity as the updated evidence shows, but could also be employed as a significant predictor for surgical adverse outcomes and hence be a valid tool for risk stratification of candidates undergoing abdominal aortic surgery. Methods This is a single-centre retrospective analysis of 2224 patients who underwent open abdominal aortic surgery between January 1996 and 2009. This cohort was divided into quartiles of THR. A list of covariates has been entered with THR into a multiple logistic model with forwards stepwise selection. The obtained result is an adjusted model, conceived to establish the association between THR and perioperative adverse events. Discrimination of the model so obtained and comparison with vascular-specific risk stratification scoring systems were evaluated using the area under the receiver operating characteristic (AUROC). Results THR had the highest predictive value for the outcomes of interest. The adjusted odds ratios (ORs) per every 0.1 augmentation of THR were 1.41 (1.08–1.88) for cardiac, 1.38 (1.09–1.84) for respiratory, 1.27 (1.06–1.54) for renal adverse events and 1.02 (0.84–1.23) for mortality. Regarding mortality, either of the scoring systems Vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and customised probability index (CPI) and the THR ranked as moderate discriminators, with THR performing the worst (AUROC 0.71) compared with Vascular POSSUM (AUROC 0.76) and CPI (AUROC 0.78). THR performed as a very strong predictor of morbidity (AUROC 0.86), ranking above Vascular POSSUM (AUROC 0.72). Conclusions THR is a significant predictor of perioperative morbidity and mortality. THR offers a broad outlook on the metabolic state of patients undergoing major abdominal aortic surgery and hence their propensity to adverse events, allowing us to risk-stratify the prognostic outcome of surgical intervention and possibly intervene preoperatively to optimise results.

Background Endovascular aneurysm repair (EVAR) reduces the morbidity and mortality associated with abdominal aortic aneurysm repair, but in some patients endoleak or aneurysm expansion may necessitate secondary open conversion (SOC). We reviewed the outcomes after delayed SOC following EVAR in consecutive patients at a single center. Methods We retrospectively reviewed all patients undergoing EVAR to identify a cohort undergoing delayed SOC in a single center between 1998 and 2008. We analyzed delayed SOC patients for operative indications, technique, and early outcomes. We made specific comment on the surgical techniques used, with respect to partial or total endograft explantation. Results Delayed SOC was carried out in 10/285 (3.5%) consecutive patients implanted with the Zenith endograft; during this period, two further patients had SOC after initial EVAR in another center. Graft types were Zenith ( n = 10), Talent ( n = 1), and AneuRx ( n = 1). Indications for open conversion were infected graft ( n = 3), sac expansion ( n = 3), type 1 endoleak ( n = 2), type 2 endoleak ( n = 2), juxtarenal aneurysm ( n = 1), and rupture ( n = 1). Explantation techniques were partial explantation with in situ replacement ( n = 7), full explantation with axillobifemoral bypass ( n = 3), in situ replacement ( n = 1), and suturing ( n = 1)Complete stent explantation was required in 4 patients with axillo-bifemoral bypass in three of them. 7 patients had partial stent explantation and one patient stent was left insitu. Postoperative morbidities included myocardial infarction ( n = 1), renal dialysis ( n = 1), and chest infection ( n = 3). No 30-day mortality was noted, and all patients were discharged from hospital and remain well with median follow-up of 5 months (interquartile range 1.7-26.7). Conclusion SOC after EVAR is feasible in selected patients with low morbidity and mortality. Partial explantation with in situ replacement, in the absence of sepsis, may be the preferred revascularization option but may require long-term follow-up.

Objectif Le traitement endovasculaire des anevrysmes (EVAR) reduit la morbidite et la mortalite associees a la reparation des anevrysmes de l’aorte abdominale et certains patients presentant des endofuites ou une expansion anevrysmale peuvent necessiter une conversion ouverte secondaire (COS). Nous avons revu les resultats de la COS differee apres EVAR chez des patients consecutifs dans un centre unique. Methodes Nous avons revu retrospectivement tous les patients ayant une EVAR afin d’identifier une cohorte de patients ayant une COS differee dans une seule institution entre 1998 et 2008. Nous avons analyse les patients ayant une COS differee en fonction des indications operatoires, des techniques et des resultats precoces. Nous avons analyse de maniere specifique les details de la technique chirurgicale utilisee en fonction de l’explantation partielle ou totale de l’endoprothese. Resultats Une COS differee a ete effectuee chez 10/285 (3,5%) patients consecutifs ayant eu l’implantation d’une endoprothese Zenith. Au cours de cette periode, deux autres patients ont eu une COS apres une EVAR effectuee initialement dans un autre centre. Le type de prothese etait une Zenith (n = 10), une Talent (n = 1) et une AneuRx (n = 1). Les indications de conversion ouverte etaient une infection de prothese (n = 3), une expansion du sac anevrysmal (n = 3), une endofuite de type I (n = 2), une endofuite de type II (n = 2), un anevrysme juxta-renal (n = 1) et une rupture (n = 1). Les techniques d’explantation ont ete l’explantation partielle avec un remplacement in situ (n = 7), l’explantation complete avec pontage axillo-bifemoral (n = 3), le remplacement in situ (n = 1) et la suture (n = 1). L’explantation complete du stent a ete necessaire chez quatre patients dont trois ont recu un pontage axillo-bifemoral. Sept patients ont eu l’explantation partielle du stent et le stent a ete laisse in situ chez un patient. La morbidite post-operatoire a inclus un infarctus du myocarde (n = 1), une dialyse renale (n = 1) et trois infections pulmonaires (n = 3). Le taux de mortalite a 30 jours a ete nul. Tous les patients ont pu quitter l’hopital pour rester en bonne forme avec un suivi median de 5 mois (extremes 1,7 a 26,7). Conclusion Une COS est possible avec de faibles taux de morbidite et de mortalite apres une EVAR, chez des patients selectionnes. L’explantation partielle avec remplacement in situ, en l’absence de sepsis, pourrait etre l’option preferable de revascularisation mais un suivi a long terme doit etre obtenu.

Acute kidney injury (AKI) in cardiac surgery has traditionally been linked to reduced arterial perfusion. There is ongoing evidence that central venous pressure (CVP) has a pivotal role in precipitating acute renal dysfunction in cardiac medical and surgical settings. We can regard this AKI driven by systemic venous hypertension as 'kidney congestive failure'. In the cardiac surgery population as a whole, when the CVP value reaches the threshold of 14 mmHg in postoperative period, the risk of AKI increases 2-fold with an odds ratio (OR) of 1.99, 95% confidence interval (95% CI) of 1.16-3.40. In cardiac surgery subsets where venous hypertension is a hallmark feature, the incidence of AKI is higher (tricuspid disease 30%, carcinoid valve disease 22%). Even in the non-chronically congested coronary artery bypass population, CVP measured 6 h postoperatively showed significant association to renal failure: risk-adjusted OR for AKI was 5.5 (95% CI 1.93-15.5; P = 0.001) with every 5 mmHg rise in CVP for patients with CVP