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Objectives Current evidence on TAVI has been generated exclusively by cardiology studies and no operative data from cardiac surgeons are available. Here we describe the development of our TAVI program and report the results of transfemoral TAVI done by cardiac surgeons on their own. Methods This study included all the TAVI procedures on native valve performed at Cardiac Surgery Unit, Ospedali Riuniti di Ancona, during the period October 2018 – July 2022. Relevant prospectively collected preoperative, intraprocedural and postoperative data were retrieved from the Institutional database. Results A total of 413 patients were included in the study. Mean patients’ age was 82 years and among them 44% (180/413) were male. STS score was 3.1% (2.2 – 4.4). Eighty patients underwent transapical TAVI and 333 patients had a transfemoral approach. We progressively moved from trans-apical TAVI towards trans-femoral procedures that are now routinely performed on conscious sedation and using a fully percutaneous approach. After trans-femoral TAVI, 30-day mortality rate was 1%, cerebral stroke occurred in 2% of the cases, permanent pacemaker implantation was necessary in 23% of the patients and in 6% of the cases there was a moderate/severe degree of aortic regurgitation. There was no association between operators performing TAVI and 30-day mortality. Conclusions The acquisition of catheter-based skills and an adequate training allowed cardiac surgeons to perform on their own awake and fully percutaneous trans-femoral TAVI with similar results when compared with major randomized clinical trials and registries’ experiences.

BACKGROUND AND OBJECTIVE: The frozen elephant trunk (FET) technique has undoubtable advantages in treating complex and extensive disease of the aortic arch and the thoracic descending aorta. Despite several improvements in cardiopulmonary bypass conduction and surgical strategy, operative times and the institution of systemic circulatory arrest remain the main determinants of early mortality, cerebral/spinal cord injury and visceral organs dysfunction. We have conducted this review to highlight the recent technical advances in arch and FET surgery aiming at the reduction/avoidance of systemic circulatory arrest, and their impact on early outcomes. METHODS: A literature search (from origin to January 2022), limited to publications in English, was performed on online platforms and database (PubMed, Google, ResearchGate). After a further review of associated or similar papers, we found 4 experiences, described by 11 peer-reviewed published papers, which focused on minimising or avoiding systemic circulatory arrest during total arch replacement plus stenting of the descending thoracic aorta. KEY CONTENT AND FINDINGS: Recent experiences reported the use of an antegrade endoaortic balloon, advanced and inflated into the stent graft, to provide an early systemic reperfusion soon after the deployment of the stented portion of the FET prosthesis and minimize the circulatory arrest time (down to a mean of 5 minutes), thus avoiding the need of moderate or deep hypothermia (mean systemic temperature 28–30 °C) while allowing a complete arch and FET repair. Our approach, based on off-pump retrograde vascular stent graft deployment in distal arch/descending thoracic aorta, and the use of a retrograde endoballoon, allows the repair of extensive aortic pathologies during uninterrupted normothermic cerebral and lower body perfusion. CONCLUSIONS: The use of endoballoon occlusion has emerged in recent years as a safe and effective strategy to allow distal perfusion during FET repair. This technique minimizes or avoids the detrimental effects of hypothermia and systemic circulatory arrest and significantly reduces the operative times.

Median sternotomy incision has shown to be a safe and efficacious approach in patients who require thoracic aortic interventions and still represents the gold-standard access. Nevertheless, over the last decade, less invasive techniques have gained wider clinical application in cardiac surgery becoming the first-choice approach to treat heart valve diseases, in experienced centers. The popularization of less invasive techniques coupled with an increased patient demand for less invasive therapies has motivated aortic surgeons to apply minimally invasive approaches to more challenging procedures, such as aortic root replacement and arch repair. However, technical demands and the paucity of available clinical data have still limited the widespread adoption of minimally invasive thoracic aortic interventions. This review aimed to assess and comment on the surgical techniques and the current evidence on mini thoracic aortic surgery.The online version contains supplementary material available at 10.1007/s12055-021-01258-2.

Treatment of aortic valve disease has become less and less invasive during the last years, thanks to progress in anesthesiology, surgical techniques, and perfusion management. In fact, it has been demonstrated that shorter skin incision, combined with ultra-fast-track anesthesia and minimized extracorporeal circuit could improve clinical outcomes. Current evidence shows that minimally invasive extracorporeal circulation system is associated with reduced red blood cells’ transfusion rate, improved end-organ perfusion, decreased incidence of postoperative atrial fibrillation, air embolism leakage, and so less cerebral accidents with better neurological outcomes. Moreover, the use of a closed circuit seems to be more physiologic for the patients, reducing systemic inflammatory response due to less air–blood contact and the use of biocompatible surfaces. In the literature, the benefits of minimally invasive extracorporeal circulation are described mostly for coronary surgery but few data are nowadays available for minimally invasive extracorporeal circulation during aortic valve replacement. In this article, we describe our perfusion protocol in minimally invasive aortic valve replacement.

Introduction In the last decade, del Nido cardioplegia has been embedded in adult cardiac surgery involving CABG and aortic valve surgical procedures. We reviewed our early experience with del Nido cardioplegia in the setting of minimally invasive mitral valve surgery. Methods Data on 120 consecutive patients operated between 03/2021 and 06/2022 were retrieved from our internal database (infective endocarditis and urgent operations were excluded). Patients were divided into two groups according to the use of Histidine-Tryptophan-Ketoglutarate or del Nido cardioplegia. A propensity match analysis was performed using thirteen preoperative and intraoperative variables. Several intraoperative data and early postoperative outcomes were investigated, including cardiac enzymes (Troponin I HS and CK-MB) measured upon arrival in the Intensive Care Unit (ICU), after 12 hours and everyday thereafter. Results There was no difference in preoperative characteristics and surgical techniques between both unmatched and matched Histidine-Tryptophan-Ketoglutarate and del Nido populations. Patients in the del Nido group received a lower volume of cardioplegia ( p < 0.001) and ultrafiltration during CPB ( p < 0.001). Histidine-Tryptophan-Ketoglutarate was associated with a lower rate of post cross-clamp spontaneous defibrillation ( p < 0.001) and showed a lower level of blood sodium after CPB ( p < 0.001). The release of cardiac enzymes was similar between the two groups ( p = 0.72). There was no difference in terms of postoperative morbidity and 30 day mortality. Conclusions del Nido cardioplegia in the setting of minimally invasive mitral valve surgery seemed safe with acceptable myocardial protection and excellent early outcomes.

Staged replacement of the aortic arch and thoraco-abdominal aorta (TAA) with a frozen elephant trunk followed by TAA repair is a valuable treatment for patients with chronic TAA dissection. However, in patients with an unclampable descending thoracic aorta, the retrieval of the trunk can be problematic and the proximal stent graft-to-graft anastomosis technically challenging. Here we present our ‘double layer’ frozen elephant trunk technique to treat patients with TAA dissection.

Despite minimally-invasive aortic valve replacement (MI-AVR) having gained interest within the cardiac surgeons’ community, patient requests for interventions associated with minimized trauma and faster recovery often remains unfulfilled (1). In our center, we believe that a MI-AVR program (2) may benefit from a multidisciplinary approach that combines reduced incisions with an increasing use of rapid deployment valves (RD), minimal invasive extracorporeal circulation system (MiECC) (3) and fast-track anesthetic (UFT) management. Our experience with the MI trans-axillary direct approach in mitral valve surgery (MVS) (4) led us to consider that the aortic valve could be nicely exposed from the same approach. As a result, we recently initiated the use of trans-axillary incisions for MI-AVR in selected patients. In this setting, RD valves may help with reducing technical complexity and operative times. The aim of this video is to share our approach in a step-by-step fashion.

Objectives Infective endocarditis (IE) with extensive peri-annular abscesses and aortic root involvement is a life-threatening disease. Aortic root replacement with a valved conduit is the most common intervention in this setting and represents a serious challenge for the surgeon. In the present two-center study we analyzed early and midterm outcomes of a high-risk series of IE patients undergoing aortic root reconstruction with a sub-annular implantation of a totally biological valved conduit at our centers. Methods The series comprised 29 patients (18 males, mean age: 72.3 ± 10.1 years) operated at "Lancisi Cardiovascular Center" of Ancona and "Pasquinucci Heart Hospital" of Massa, Italy, between May 2016 and October 2019. All patients had undergone a previous cardiac surgery. Median Euroscore-II was 12.6%. Following aggressive debridement, a Bioconduit was implanted using a sub-annular implantation technique in all cases. Results Thirty-day mortality was 13.8% (n = 4). Multiorgan failure was cause of death in all cases. Respiratory complications occurred in eight patients (27.6%). Renal complications requiring temporary or permanent dialysis occurred in six (20.7%) and two (6.9%) patients, respectively. Mortality and morbidity were not related to the surgical approach. At 1-year follow-up three patients died and no patients underwent reoperation neither reported endocarditis of the biological conduit. Conclusion Considered the high-risk profile of the study cohort, our results suggest safety and efficacy of our approach at 1-year. Indeed, we contend that our subannular implantation of a 100% pericardial valved conduit, allowing an effective abscess exclusion and a conduit anchoring to healthy tissues, can reduce the risk of reinfection and dehiscence.

Italy has been hard hit by SarV CO2 infection with more than 240,000 cases and 35,000 deaths. During the acute phase of the pandemic the italian government decided on the lockdown which lasted about 2 months. During this period all surgical activities were limited to non-deferable procedures only. The sudden closure posed problems with the management of the heart surgery waiting which at that time included 135 patients. Among these were selected cases with the worst clinical characteristics that were progressively operated on. Compared with a similar period in 2019, the cardiac surgery activity of the “Lancisi Cardiovascular Center” in Ancona has been reduced by 65%. With pandemic mitigation, heart surgery activity has gradually resumed but many open questions remain. Above all, there is the problem of living with a low but persistent level of presence of the virus with the need to organize the activity in order to ensure patients and staff safety and an optimal level of performance.

Postoperative stroke after cardiac surgery is an ominous complication. Clinical manifestations range from cognitive disturbances and altered states of consciousness to focal neurological deficits. Stroke is also a well-documented risk of catheter-based cardiac interventions. Recently, the growth of transcatheter procedures has led to the increasing development of devices that are designed to minimize neurological events during valve implantation. In this video tutorial we demonstrate how to transfer a catheter-based cerebral protection technology into an open cardiac surgical intervention. The operation shown in this tutorial was an aortic valve replacement and the cerebral protection device implanted was the Sentinel Cerebral Protection System (Boston Scientific, Marlborough, MA, USA).

Type Ia endoleak after thoracic endovascular aortic repair is an ominous complication that requires an aggressive treatment. Total arch replacement with a distal suture taking the native distal aorta, the stent graft, and the arch graft, by allowing a perfect closure of the proximal endoleak, represents the most common treatment in this setting. Nevertheless, such intervention continues to carry significant mortality and morbidity that are mostly related to prolonged extracorporeal circulation time and hypothermic circulatory arrest. Here, we present a technique for total arch replacement that, with the use of stent graft balloon endoclamping, avoids both hypothermia and circulatory arrest.

Introduction: Type B aortic dissection (TBAD) is a threatening event that may lead to death for aortic rupture or multivisceral malperfusion in the acute phase and offers a poor prognosis for long term survivors. Thoracic endovascular aortic repair (TEVAR) has become the preferential therapy in acute and chronic complicated cases for its less invasivity compared to open surgery. However TEVAR is still encumbered by a significant number of reinterventions, caused by aortic neck aneurysmal degeneration, endoleaks and stent-graft induced new entry (SINE). This is even more true in patients with particularly fragile aortic wall like Marfan Syndrome (MS) in contrast to the excellent results of elective open surgery. Areas covered: This review analyzes the current available TEVAR devices and techniques in TBAD and their technological advancements, especially those most suitable to TBAD anatomy, according to current literature. Expert opinion: The continuous technological evolution of materials and device solutions ensures solid results of TEVAR in acute TBAD and may also potentially overcome some of the limitations of endovascular devices in this setting, paving the way for safer and more durable results and allowing for expanded indications in the future, even in the delicate population of collagenopathies, especially in MS.

Novel coronavirus disease-2019 (COVID-19) is an ominous infectious disease that seems capable to attack any organ system, leading in the most severe cases to patient death. COVID-19 has been associated with multiple cardiovascular complications of inflammatory and immune origin, leading to a wide spectrum of vascular damage, myocardial injury, stroke, and pulmonary obstruction. We report the case of a patient with COVID-19 infection who developed an acute aortic syndrome with the characteristics of aortic intramural hematoma.

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

OBJECTIVES The impact of minimally invasive extracorporeal circulation (MiECC) systems on the clinical outcomes of patients undergoing minimally invasive aortic valve replacement (MI-AVR) has still to be defined. This study compared in-hospital and 1 year outcomes of MI-AVR interventions using MiECC systems versus conventional extracorporeal circulation (c-ECC). METHODS Data from 288 consecutive patients undergoing primary isolated MI-AVR using MiECC (n = 102) or c-ECC (n = 186) were prospectively collected. Treatment selection bias was addressed by the use of propensity score matching (MiECC vs c-ECC). After propensity score matching, 2 groups of 93 patients each were created. RESULTS Compared with c-ECC, MiECC was associated with a higher rate of autologous priming (82.4% vs 0%; P CONCLUSIONS MiECC systems were a safe and effective tool in patients who had MI-AVR. Compared with c-ECC, MiECC promotes ultra-fast-track management and provides better clinical outcomes as regards bleeding, blood transfusions and postoperative AF. Thus, by reducing surgical injury and promoting faster recovery, MiECC may further validate MI-AVR interventions.

Background: Although sutureless and rapid deployment aortic valve replacement (SURD-AVR) has been associated with an increased rate of permanent pacemaker (PPM) implantation compared to conventional AVR (c-AVR), the predictors of new conduction abnormalities remain to be clarified. This study aimed to identify risk factors for conduction disorders in patients undergoing AVR surgery. Methods: Data from 243 patients receiving minimally invasive AVR were prospectively collected. SURD-AVR was performed in 103 (42.4%) patients and c-AVR in 140 (57.6%). The primary endpoint was the occurrence of new-onset conduction disorders, defined as first degree atrioventricular (AV) block, advanced AV block requiring PPM implantation, left anterior fascicular block (LAFB), left bundle branch block (LBBB) and right bundle branch block (RBBB). Results: The unadjusted comparison revealed that SURD-AVR was associated with a higher rate of advanced AV block requiring PPM when compared with c-AVR (10.5% vs. 2.1%, P=0.01). After adjusting for other measured covariates (OR: 1.6, P=0.58) and for the estimated propensity of SURD-AVR (OR: 5.1, P=0.1), no significant relationship between type of AVR and PPM implantation emerged. On multivariable analysis, preoperative first-degree AV block (OR: 6.9, P=0.04) and RBBB (OR: 6.9, P=0.03) were independent risk factors for PPM. Subgroup analysis of patients with normal preoperative conduction revealed similar incidence of PPM between SURD-AVR and c-AVR (1.3% vs. 1.9%, P=0.6). When compared with c-AVR, SURD-AVR was associated with a greater incidence of postoperative new onset LBBB (18.1% vs. 3.2%, P

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

Background: Nowadays, less invasive endovascular procedures have been employed in high risk patients for thoracoabdominal aortic aneurysm (TAAA) in order to try to reduce the risk of major complications. The aim of the study was to analyze the results of our hybrid 2-stage approach for TAAA repair. Methods: Between July 2011 and September 2016, 17 consecutive high-risk patients received a hybrid 2-stage procedure for TAAA repair. Mean age of the population was 58.9 ± 9.0 years and 16 (94.1%) were male. Of them, 7 (41.2%) suffered of chronic obstructive pulmonary disease and 15 (88.2%) had a previous history of aortic operation. Three patients had Marfan syndrome (17.6%). The preoperative anatomy of the aneurysms was classified according to “Crawford classification” in type II (n = 6, 35.3%), type III (n = 10, 58.8%) and type IV (n = 1, 5.9%). All patients were followed up with an angio CT-scan at 1, 3 months and yearly thereafter. Results: In-hospital mortality was 11.8% (2 patient). None of the patients experienced paraplegia and paraparesis. Major post-operative complications were pancreatitis 17.6% (3/17). At follow-up (mean time of 23.3 ± 21.7 months) 2 patient died (12.5%) waiting for the second stage endovascular completion. Median interval time between the 2 steps was 35 days. Overall survival at 1- and 3-years was 75.6 ± 1.0. One type Ib and 1 type III endoleak were noted and successfully treated with an additional stent graft. Conclusions: The results of hybrid 2-stage TAAA repair on high-risk patients are satisfactory and therefore encouraging. The extremely low incidence of spinal cord injury could make this technique the technique of choice for this type of pathology in selected high-risk patients. At follow-up, residual endoleaks occur although surgical reoperations are not often needed. © 2018 Elsevier B.V.

Our results confirm the diagnostic role of CTPA in evaluating patients with CTEPH and in addition open a new horizon in assessing hemodynamic changes in patients with CTEPH, only employing a CTPA, especially when RHC is contraindicated or not possible. Purpose: The aim of this study was to retrospectively assess the relationship between radiological and hemodynamic parameters in patients with chronic thromboembolic pulmonary hypertension (CTEPH). We introduced a new CT-score to evaluate hemodynamic changes, only employing CT-pulmonary angiography (CTPA). Materials and methods: 145 patients affected by CTEPH underwent hemodynamic and CTPA evaluation. Among these 145 patients, 69 underwent pulmonary endarterectomy (PEA) and performed a CTPA evaluation even after surgery. Hemodynamic assessment considered the values of mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR), obtained through right heart catheterization (RHC). Radiological evaluation included CTPA signs of pulmonary hypertension. Results: A highly significant statistical correlation was observed between the new CT-score and both mPAP and PVR (p < 0.000) in the whole sample and also in the subgroup who underwent PEA. In addition, mPAP and PVR showed an important association with the severity of mosaic perfusion (p < 0.000). mPAP also correlated with main pulmonary artery diameter (p < 0.01); a significant association was found in both between PVR and tricuspid regurgitation(p < 0.000) and with PVR and presence of unilateral or bilateral pulmonary thromboembolic occlusion (p < 0.05). Conclusion: Our results confirm the diagnostic role of CTPA in evaluating patients with CTEPH and in addition open a new horizon in assessing hemodynamic changes in patients with CTEPH, only employing a CTPA, especially when RHC is contraindicated or not possible.

Item does not contain fulltext BACKGROUND: The aim of this study was to determine perioperative factors influencing neurologic outcome in a single-center cohort of patients undergoing elective aortic arch operations. METHODS: From January 2005 to June 2015, 791 consecutive patients received open aortic arch operations with either antegrade selective cerebral perfusion (ASCP) (636 patients [80.4%]) or deep hypothermic circulatory arrest (DHCA) (155 patients [19.6%]). Main indications were degenerative aneurysm (85%) and chronic postdissection aneurysm (9.1%). RESULTS: Hospital mortality (30 days) was 5.3%. Permanent neurologic dysfunction (PND) was observed in 42 patients (5.3%). Significant risk factors for PND appeared to be femoral artery cannulation (p = 0.003), progressive cardiopulmonary bypass (p = 0.001), circulatory arrest (p = 0.001), and ASCP time (p = 0.011). ASCP, in contrast to DHCA, was protective against PND (odds ratio [OR], 0.37; p = 0.003). Temporary neurologic dysfunction (TND) was observed in 49 patients (6.2%). Preoperative transient ischemic attack (TIA) (p = 0.001), progressive EuroSCORE (p = 0.001), left ventricular ejection fraction (LVEF) less than 50% (p = 0.003), and the use of femoral artery cannulation (p = 0.049) showed correlation in the univariate analysis. Stepwise logistic regression indicated TIA (p = 0.002; OR, 3.24) and the EuroSCORE (p = 0.003; OR, 1.23) as independent predictors of TND. CONCLUSIONS: Contemporary elective aortic arch repair can be achieved with low mortality and a low incidence of neurologic dysfunction. ASCP was confirmed to be the safest method of cerebral protection. The extent of aortic arch replacement (apart from the frozen elephant trunk [FET] procedure) was not related to increased rates of TND or PND.

Infective endocarditis (IE) with extensive annular disruption and aortic root involvement carries an ominous prognosis (1,2). The broad and severe impairment of the peri-annular tissues at the level of the interventricular septum and mitro-aortic continuity may hamper a successful surgical reconstruction, with dehiscence and retraction of the anterior mitral leaflet (AML) being a possible dreadful complication (3,4). Here we present our technique for root replacement (Bentall) that involves a sub-annular implantation of a 100% pericardial valved conduit (BioconduitTM, Biointegral Surgical, Inc., Ontario, Canada).

Despite increased use of arterial grafts, the greater saphenous vein remains the most commonly used conduit in coronary artery bypass grafting. The use of less invasive techniques for vessel harvesting has gained interest in recent years, and, many studies have reported that endoscopic vein-graft harvesting reduces postoperative pain, the incidence of wound complications, and the length of hospital stay, as well as eliminating the need for a large longitudinal incision. Over the past decade, our cardiac surgery department has gained considerable experience (>1000 cases) with this endoscopic approach. In this video tutorial, we demonstrate our endoscopic techniques for saphenous vein-graft harvesting using two widely used devices: the VirtuoSaph Endoscopic Vein Harvesting System from Terumo (Tokyo, Japan), an open tunnel system, and the VasoView System from Maquet Cardiovascular (Rastatt, Germany), a closed tunnel system.

In adult the patent ductus arteriosus is a rare condition associated sometimes with lethal complications. We describe the case of a 44-year-old woman with a history of systemic lupus erythematosus admitted to our hospital with hoarseness and severe dyspnea. Clinical imaging examinations indicated a saccular aneurysm within a persistent ductus arteriosus with signs of impending rupture. Patient was not considered suitable for transcatheter closure and therefore she underwent open aortic repair. The procedure was uneventful and any significant complications occurred during postoperative course.

Early graft failure (EGF) is a major risk factor for death after heart transplantation (Htx). We investigated the predictive risk factors for moderate-to-severe EGF requiring an intra-aortic balloon pump (IABP) or extracorporeal membrane oxygenation (ECMO) circulatory support as treatment after Htx. Between January 2000 and December 2014, 412 consecutive adult patients underwent isolated Htx at our institution. Moderate and severe EGF were defined as the need for IABP and ECMO support, respectively, within 24 h after Htx. All available recipient and donor variables were analyzed to assess the risk of EGF occurrence. Overall, moderate-to-severe EGF occurred in 46 (11.1%) patients. Twenty-nine (63.04%) patients required peripheral or central ECMO support in the treatment of severe EGF and 17 (36.9%) patients required IABP support for the treatment of moderate EGF. The predictive risk factors for moderate-to-severe EGF in recipients, as assessed by logistic regression analysis, were a preoperative transpulmonary gradient > 12 mm Hg (odds ratio [OR] 5.2; P = 0.023), a preoperative inotropic score > 10 (OR 8.5; P = 0.0001), and preoperative ECMO support (OR 4.2; P = 0.012). For donors, the predictive risk factor was a donor score ≥ 17 (OR 8.3; P = 0.006). The absence of EGF was correlated with improved long-term survival: 94% at 1 year and 81% at 5 years without EGF versus 76% and 36% at 1 year (P

Aortic valve surgery has been undergone continuous development over the last years, involving less invasive techniques and the use of new technologies to reduce the traumatic impact of the intervention and extend the operability toward increasingly high-risk patients. Minimally invasive aortic valve replacement (AVR) has gradually been recognized as a less traumatic technique compared to median sternotomy, becoming first choice approach in numerous experienced centers. Herein we present our multidisciplinary minimally invasive approach for AVR, involving: (I) reduced chest incision; (II) rapid deployment AVR; (III) minimally invasive extracorporeal circulation system; and (IV) ultra fast track (UFT) anaesthetic management.

Patients with severe aortic valve stenosis are currently treated with 2 different interventional techniques: surgical aortic valve replacement or transcatheter aortic valve implantation (TAVI). Both have strengths and limitations. On the one hand, TAVI represents a valuable option in high- and intermediate-risk patients and is commonly preferred over surgical aortic valve replacement in subjects with porcelain or severely calcified aorta, on the other, the lack of data on valve durability raises concerns on its use in young, low-risk patients. We present herein the case of a low-risk 71-year-old patient with a severely calcified ascending aorta. We successfully combined our minimally invasive surgical approach with the use of a percutaneous cerebral protection system commonly employed during TAVI procedures. We believe that cardiac surgeons could adopt transcatheter technology to improve operative results.

Background Surgical management of aortic arch in type A acute dissection (TAAD) is controversial. This study compared short-term and long-term outcomes of total arch replacement (TAR) interventions versus more conservative arch management (CAM). Methods Between 1997 and 2012, 240 patients underwent TAAD surgery in our institution; 53 (22.1%) received TAR and 187 (77.9%) received CAM. Compared with CAM patients, those undergoing TAR were younger (59.1 vs 64.4 years, p = 0.004) and were less likely to present with cardiogenic shock (3.8 vs 14.4, p = 0.02). Distal site of intimal tear (arch or descending aorta) was predictive of TAR management (odds ratio [OR], 9.1; p Results Hospital mortality was similar in the groups (24.1% vs 22.6%; p = 0.45), and no other significant differences were observed in terms of major postoperative complications. Age (OR, 1.047; p = 0.007) and cardiopulmonary bypass time (OR, 1.005 per minute; p = 0.05) emerged as independent predictors of hospital death. The TAR management did not affect hospital mortality (propensity score [PS] adjusted OR: 1.51, p = 0.36). On Kaplan-Meier analysis, 7-year survival (TAR, 52.1% ± 0.9% vs CAM, 57.2% ± 4.2%, log-rank p = 0.9) and freedom from aortic re-intervention (TAR, 71.6% ± 1.3% vs CAM, 85.4% ± 3.9%, log-rank p = 0.3) were similar. The PS-adjusted Cox regression showed no relationship between type of arch management and follow-up survival (hazard ratio [HR], 1.001; p = 0.8) or need for re-intervention (HR, 1.507; p = 0.4). Conclusions In our experience TAR and CAM were associated with similar hospital mortality and morbidity rates. Nevertheless, the more extensive arch interventions were not protective for long-term survival and freedom from aortic re-intervention. Thus, in TAAD patients TAR remains indicated by site of intimal tear and patient-specific factors.

Objectives Acute aortic dissection is a catastrophic condition, for which emergency surgery is the mainstay of therapy. In approximately 70% of patients who survive surgery, a dissected distal aorta remains, posing a risk of late aneurysmal degeneration, rupture, and malperfusion, and secondary extensive interventions are often required. Methods In order to improve the long-term prognosis, a more extensive intervention, the frozen elephant trunk (FET) procedure, has been introduced. This involves the simultaneous replacement of the aortic arch and antegrade stenting of the descending thoracic aorta (DTA). Although FET is assumed to produce total thoracic aortic remodeling by inducing both coverage of secondary entry tears located in the proximal DTA and obliteration of the false lumen at the proximal DTA, its role in patients with acute dissection remains controversial mostly because of its technical complexity and increased risk of paraplegia. Results Data available in literature show that, after FET interventions, hospital death, stroke, and spinal cord injury occur in 10.0%, 4.8%, and 4.3% of patients with acute dissection, respectively. Available long-term data are sparse but suggest that aortic remodeling with partial or complete thrombosis of the persistent false lumen can be expected in approximately 90% of cases. Conclusions The FET technique is a promising approach in patients with acute dissection. Solid long-term data are warranted to validate the assumed short- and long-term benefits, but we believe that thoughtful patient selection criteria remain crucial.

Bentall operation via median sternotomy has been largely shown to be safe and long-term efficacious and currently represents the “gold standard” intervention in patients presenting with aortic valve and root disease. However, over the last years, minimally invasive techniques have gained wider clinical application in cardiac surgery. In particular, minimally invasive aortic valve replacement through ministernotomy has shown excellent outcomes and becomes the first choice approach in numerous experienced centers. Based on these favorable results, ministernotomy approach has also been proposed for complex cardiac procedures such as aortic root replacement and arch surgery. Herein, we present our technique for minimally invasive Bentall operation using a ministernotomy approach.

Background This study assessed the early and long-term results of arch operations performed after a prior aortic operation. Methods From 1994 to 2014, 154 consecutive patients (mean age, 59.7 years) underwent an aortic arch repair, after a previous aortic operation, at our institution. Antegrade selective cerebral perfusion was used in all cases. Chronic postdissection aortic aneurysm (87 [56.5%]) and degenerative aneurysm (43 [27.9%]) represented the most common indications for surgical intervention. A complete arch replacement was performed in 119 patients (77.3%), an associated root repair in 70 (45.5%), and the frozen elephant trunk technique was used in 55 (35.7%). Results Hospital mortality was 11.7% (n = 18). Postoperative permanent neurologic dysfunction occurred in 10 patients (6.4%). On multivariate analysis, cardiopulmonary bypass time (odds ratio, 1.02 per minute; p = 0.005) emerged as the only independent predictor of hospital death. Follow-up was 100% complete. The estimated survival at 1, 5, and 10 years was 79.6%, 69.9%, and 46.8%, respectively. Freedom from reoperation was 75.6% at 5 years and 54.6% at 10 years. Cox regression identified chronic postdissection aortic aneurysm (odds ratio, 4.2; p = 0.006) to be the only independent predictor of aortic reintervention. Late survival was comparable between degenerative aneurysm patients and the Italian population matched for age and sex (standardized mortality ratio, 1.9; p = 0.1). Longevity was reduced in patients operated on for chronic postdissection aortic aneurysm (standardized mortality ratio, 6.3; p Conclusions Arch operations after a previous open aortic repair can be performed with acceptable mortality and good long-term outcomes. Complete aortic resection did not increase hospital deaths and was associated with a low need for aortic reinterventions at follow-up.

OBJECTIVES: Reported early outcomes for patients undergoing reoperations on the aortic root are worse than those for patients undergoing first-time surgery. The aim of this study was to review our experience with aortic root surgery by stratifying outcomes according to the type of intervention: reoperation versus primary operation on the aortic root. METHODS: Of the 1267 patients undergoing aortic root surgery, 180 underwent aortic reoperation with root replacement (ARR) and 1087 underwent primary root replacement (PRR). Treatment bias was addressed by the use of propensity score (PS) matching and multivariate regression analysis. After PS matching, two groups of 116 patients each were created (ARR versus PRR). The primary end-points were inhospital mortality and occurrence of postoperative complications. RESULTS: In the unmatched cohort, hospital mortality and postoperative complications rates were higher in the ARR group than in the PRR group (11.1 vs 4.1%, P < 0.001; 22.2 vs 15.1%, P = 0.02). Early results were greatly affected by the type of aortic disease. The in-hospital mortality rate was 3.1% for degenerative aneurysm, 13.3% for chronic dissection, 14% for acute dissection, 16.7% for active endocarditis and 25% for false aneurysm (P < 0.001). In the propensity-matched cohort, no significant differences were observed between the groups in terms of hospital mortality rate (ARR: 6%; PRR: 1.7%; P = 0.2) and postoperative complications (ARR: 16.4%; PRR: 14.7%; P = 0.9). Logistic regression analysis revealed cardiopulmonary bypass (CPB) time [odds ratio (OR): 1.03 per min; P < 0.001] and urgent/emergent status (OR: 6.4; P = 0.04) as independent risk factors for hospital deaths. Age (OR: 1.07 per year; P = 0.03) was the sole independent predictor of postoperative complications. CONCLUSIONS: During root surgery, reintervention did not affect early outcomes and was associated with satisfactory mortality and morbidity rates. In this setting, hospital results were heavily influenced by aortic pathology and the patient's profile.

OBJECTIVES: Few case studies have shown the feasibility of the prosthesis-sparing operation in patients requiring aortic root replacement after aortic valve replacement. Such technique allows the sparing of a well-functioning aortic valve prosthesis and facilitates the root substitution with only a vascular graft. The aim of the present study was to assess short- and mid-term outcomes of the patients who underwent such procedures at our institution. METHODS: Between 2004 and 2012, 26 patients (mean age: 59 ± 13.6 years; male: 21, 80.8%) underwent the prosthesis-sparing operation in our institution. The mean time from previous aortic intervention was 20.1 ± 6.9 years; two patients were operated for a Type A acute aortic dissection. RESULTS: Overall, two patients (7.7%) died during hospitalization: both were operated for a complicated Type A acute aortic dissection. None of the electively operated patients died or presented serious complications after surgery, except for one patient (3.8%) who required chest re-exploration for excessive bleeding due to coagulopathy. At follow-up (100% completed at 30 ± 24 months) two late deaths occurred: one due to lung cancer and one due to infective endocarditis. Kaplan-Meier estimates of 1- and 3-year survival were 92 and 85.4%, respectively. No late cardiac/aortic re-interventions were performed during follow-up, with a 5-year freedom from re-operation of 100%. CONCLUSIONS: Our favourable short- and mid-term results indicate that the prosthesis-sparing operation is a valid treatment option in selected re-operative aortic root procedures.

Early graft failure (EGF) is a major risk factor for death after heart transplantation (Htx) accounting for >40% of deaths within 30 days postoperatively. According to the last International Society for Heart and Lung Transplantation (ISHLT) consensus state‐ ment, the graft dysfunction (GD) is to be classified into primary (PGD), in case of an unknown triggering factor or secondary (SGD) where there is a discernible cause such as acute rejection, pulmonary hypertension, or known surgical complications. The diagnosis of GD is to be made within 24 h after completion of Htx surgery and a severity scale for GD should include mild, moderate, or severe grades based on specified criteria. Mechanical circulatory support (MCS) for GD should be considered when medical management is not sufficient to support the newly transplanted graft. Currently, extra‐ corporeal membrane oxygenation (ECMO) is widely accepted as treatment of severe EGF, given its easy and quick setup, the system versatility, the optimal end‐organ perfusion provided, and the possibility of both biventricular and lung assistance by usage of a low‐cost single pump.

Thoracoabdominal aortic aneurysm is a challenging disease that often requires an invasive surgical repair. Recently, a less invasive hybrid approach has been proposed to improve postoperative outcomes in high-risk patients. It consists of an open first stage where arterial visceral rerouting is obtained, using a vascular graft followed by a second stage where the remaining thoracoabdominal aorta is covered with a stent graft. Initial results using this approach seem promising. Here, we sought to describe the hybrid two-stage technique that is most frequently used in this extensive aortic pathology.

Objectives Surgical management of the aortic root in type A acute aortic dissection (TAAAD) is controversial. This study compares short- and long-term outcomes of root replacement (RR) versus conservative root management (CR). Methods Between 1999 and 2014, 296 patients with TAAAD were treated in our department. The mean age was 63.7 years. Of the total, 69% were male. Ten patients (3%) presented with Marfan syndrome or bicuspid aortic valve. RR was performed in 119 (40%) patients, whereas CR in 177 (60%). Pre- and intraoperative data were stratified according to root management, and treatment bias was addressed by propensity-score (PS) analysis. Independent predictors of hospital and long-term mortality and proximal aortic reoperation were identified using multivariable logistic and Cox regression models. Results Using PS analysis, we obtain two groups of 82 patients. The matched cohort hospital mortality rate was 21% in the CR group and 26% in the RR group (P = 0.45). The unadjusted comparison showed no statistical difference in early and long-term mortality between the groups. This result was confirmed after standard logistic regression and propensity-adjusted logistic regression. Freedom from proximal aortic reintervention was higher in the RR group (at 7 years RR: 96 ± 3% vs CR: 80 ± 6%, log-rank P = 0.02) and remained high in the matched cohort of patients (at 7 years RR: 98 ± 2 vs CR: 86 ± 6, log-rank P = 0.06). Conclusions Conservative and aggressive root management in acute aortic dissection provided similar results for early and late mortality. Nevertheless, a more extensive root intervention appeared to be protective against aortic reintervention.

Early graft failure (EGF) is a major risk factor for death after heart transplantation (Htx). We investigated the predictive risk factors for moderate-to-severe EGF requiring an intra-aortic balloon pump (IABP) or extracorporeal membrane oxygenation (ECMO) circulatory support as treatment after Htx. Between January 2000 and December 2014, 412 consecutive adult patients underwent isolated Htx at our institution. Moderate and severe EGF were defined as the need for IABP and ECMO support, respectively, within 24 h after Htx. All available recipient and donor variables were analyzed to assess the risk of EGF occurrence. Overall, moderate-to-severe EGF occurred in 46 (11.1%) patients. Twenty-nine (63.04%) patients required peripheral or central ECMO support in the treatment of severe EGF and 17 (36.9%) patients required IABP support for the treatment of moderate EGF. The predictive risk factors for moderate-to-severe EGF in recipients, as assessed by logistic regression analysis, were a preoperative transpulmonary gradient > 12 mm Hg (odds ratio [OR] 5.2; P = 0.023), a preoperative inotropic score > 10 (OR 8.5; P = 0.0001), and preoperative ECMO support (OR 4.2; P = 0.012). For donors, the predictive risk factor was a donor score ≥ 17 (OR 8.3; P = 0.006). The absence of EGF was correlated with improved long-term survival: 94% at 1 year and 81% at 5 years without EGF versus 76% and 36% at 1 year (P

ABSTRACT Background: We present our initial experience with the frozen elephant trunk using a Thoraflex™ hybrid device for the treatment of the complex thoracic aorta lesions. Materials & methods: Between March 2013 and March 2014, ten patients underwent thoracic aorta surgery using the frozen elephant trunk approach with the Thoraflex hybrid device. Indications for surgery were: residual type A chronic dissection (eight patients), degenerative aneurysm (one patient) and type B chronic aortic dissection (one patient). Selective antegrade cerebral perfusion and moderate hypothermia were used in all cases. Results: In-hospital mortality was 0% and no patients presented with paraplegia, paraparesis or major neurological events. One patient experienced transient ischemic attack. Two patients underwent reoperation for bleeding. All postoperative angiography CT scans confirmed the desired results. Conclusion: Our initial experience demonstrated excellent early results. The Thoraflex hybrid prosthesis with the four-branched arch graft increases the spectrum of techniques available for the surgeon in the treatment of complex diseases of the thoracic aorta.