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BACKGROUND: Surgical approach to type A acute aortic dissection (AADA) is usually dictated by the presenting anatomy. We compared long-term outcomes of AADA repaired with a root replacement versus a supracoronary tube graft, regardless of the proximal extent of the intimal tear. METHODS: A single-centre, retrospective cohort of consecutive patients undergoing repair of AADA between December 1999 and March 2012 were stratified based on the proximal surgical procedure performed: supracoronary tube graft or root replacement. Imaging, chart reviews and clinical follow-ups were analyzed to identify the presenting anatomy and clinical outcomes. RESULTS: We included the cases of 75 patients in our analysis: 54 received a supracoronary tube graft and 21 received a root replacement. The proximal tear was identified below the sinotubular junction in all patients in the root group and in 61% of patients in the supracoronary group. We detected no differences between the groups for in-hospital mortality, length of stay, or complications. However, the root group had significantly increased renal failure (0% v. 9.5%, p = 0.018), cardiopulmonary bypass time (198.4 ± 80.0 min v. 316.5 ± 102.5 min, p < 0.001), cross-clamp time (91.6 ± 34.9 min v. 191.3 ± 52.8 min, p < 0.001), duration of surgery (457.5 ± 129.9 min v. 611.6 ± 197.8 min, p < 0.001), and platelet transfusions (8.1 ± 7.6 v. 12.8 ± 8.7 units, p = 0.021) than the supracoronary group. Long-term follow-up demonstrated a greater incidence of 2+ aortic regurgitation among patients in the supracoronary group than the root group (29.7% v. 0.0%, p = 0.006); however, there was no difference between the groups in symptoms or reoperation. CONCLUSION: In AADA, aortic root replacement involves a longer procedure with increased risk of early renal impairment. Long-term follow-up identified significantly more aortic regurgitation and root dilation in the supracoronary group than the root group, with a trend toward worse long-term survival. However, we found no difference between the groups in mortality, reoperation or New York Heart Association class.

BACKGROUND: Reoperative mitral valve (MV) surgery is associated with significant morbidity and mortality; however, endoscopic minimally invasive surgical techniques may preserve the surgical benefits of conventional mitral operations while potentially reducing perioperative risk and length of stay (LOS) in hospital. METHODS: We compared the outcomes of consecutive patients who underwent reoperative MV surgery between 2000 and 2014 using a minimally invasive endoscopic approach (MINI) with those of patients who underwent a conventional sternotomy (STERN). The primary outcome was in-hospital/30-day mortality. Secondary outcomes included blood product transfusion, LOS in hospital and in the intensive care unit (ICU), and postoperative complications. RESULTS: We included 132 patients in our study: 40 (mean age 68 ± 14 yr, 70% men) underwent MINI and 92 (62 ± 13 yr, 40% men) underwent STERN. The MINI group had significantly more comorbidities than the STERN group. While there were no significant differences in complications, all point estimates suggested lower mortality and morbidity in the MINI than the STERN group (in-hospital/ 30-day mortality 5% v. 11%, p = 0.35; composite any of 10 complications 28% v. 41%, p = 0.13). Individual complication rates were similar between the MINI and STERN groups, except for intra-aortic balloon pump requirement (IABP; 0% v. 12%, p = 0.034). MINI significantly reduced the need for any blood transfusion (68% v. 84%, p = 0.036) or packed red blood cells (63% v. 79%, p = 0.042), fresh frozen plasma (35% v. 59%, p = 0.012) and platelets (20% v. 40%, p = 0.024). It also significantly reduced median hospital LOS (8 v. 12 d, p = 0.014). An exploratory propensity score analysis similarly demonstrated a significantly reduced need for IABP (p < 0.001) and a shorter mean LOS in the ICU (p = 0.046) and in hospital (p = 0.047) in the MINI group. CONCLUSION: A MINI approach for reoperative MV surgery reduces blood product utilization and hospital LOS. Possible clinically relevant differences in perioperative complications require assessment in randomized clinical trials.

The frozen elephant trunk technique has revolutionized aortic arch repair to enable more extensive arch and descending thoracic aortic treatment in a single setting. We review the current evidence supporting the use of the Thoraflex Hybrid (Terumo Aortic, FL, USA) device and discuss advantages, pitfalls and future design considerations. [ABSTRACT FROM AUTHOR]

Background: Simulation-based training has gained distinction in cardiothoracic surgery as robotic-assisted cardiac procedures evolve. Despite the increasing use of wet lab simulators, the effectiveness of these training methods and skill acquisition rates remain poorly understood., Objectives: This study aimed to compare learning curves and assess the robotic cardiac surgical skill acquisition rate for cardiac and noncardiac surgeons who had no robotic experience in a wet lab simulation setting., Methods: In this prospective cohort study, participants practiced 3 robotic tasks in a porcine model: left atriotomy closure, internal thoracic artery harvesting and mitral annular suturing. Participants were novice robotic cardiac and noncardiac surgeons alongside experienced robotic cardiac surgeons who established performance benchmarks. Performance was evaluated using the time-based score and modified global evaluative assessment of robotic skills (mGEARS)., Results: The participants were 15 novice surgeons (7 cardiac; 8 noncardiac) and 4 experienced robotic surgeons. Most novices reached mastery in 52 (±22) min for atrial closure, 32 (±18) for internal thoracic artery harvesting and 34 (±12) for mitral stitches, with no significant differences between the cardiac and noncardiac surgeons. However, for mGEARS, noncardiac novices faced more challenges in internal thoracic artery harvesting. The Thurstone learning curve model indicated no significant difference in the learning rates between the groups., Conclusions: Wet lab simulation facilitates the rapid acquisition of robotic cardiac surgical skills to expert levels, irrespective of surgeons' experience in open cardiac surgery. These findings support the use of wet lab simulators for standardized, competency-based training in robotic cardiac surgery., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Aortic root reconstruction operations have undergone substantial evolution with technical modifications, expanding indications, and the need for increasingly complex decision-making. The purpose of this state-of-the-art review is to detail our approach to contemporary aortic root reconstruction operations. First, we review the evolution of root reconstruction procedures over the years and discuss the approach to the aortic root patient for lifetime management of aneurysm and valvular disease in the modern context of management options. We also discuss state-of-the art technical considerations of valve-sparing root replacement, variations of the Ross operation, aortic valve repair principles and challenges in special populations, and considerations for complication-free coronary button reconstruction. We also discuss root reconstruction in high-risk subpopulations including acute type A aortic dissection, congenital, and reoperative patients. We briefly highlight future directions in transcatheter root replacement as well as the outlook for the next generation of aortic root surgeons., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: M.W.C. is supported as the Ray and Elliott Chair in Surgical Innovation and has received speakers honoraria from Medtronic, Edwards Lifesciences, Terumo Aortic, and Artivion.

Thoracic endovascular aortic repair (TEVAR) explantation remains a challenge due to endovascular graft ingrowth into the aortic wall with time. Surgical access into the aortic arch can be difficult either via sternotomy or thoracotomy, and proximal barbs become engaged firmly into the aortic wall. Explantation often requires extensive thoracic aortic resection, sometimes from the distal aortic arch to the abdominal aorta, followed by reconstruction, risking injury to surrounding neurovascular structures and even death. In cases of blunt thoracic aortic injury, the original injury is often healed, and failed TEVAR could theoretically be removed when thrombotic complications occur. We present a novel technique to facilitate TEVAR recapture with limited distal thoracic aorta replacement.

Objective: Robotic cardiac surgery training has relied entirely on classical methods of surgical teaching. We sought to evaluate the impact of a virtual reality (VR) simulation curriculum to improve skill acquisition in robotic cardiac surgery., Methods: We randomly assigned 20 surgical trainees to undergo a 9-exercise VR curriculum on a robotic surgical simulator or a control group that received no additional training. The trainees were then evaluated in a blinded fashion by assessing their de-identified video recordings of the following: (1) standardized robotic internal thoracic artery harvest and (2) mitral valve annuloplasty performed in porcine models, using a validated time-based scoring system and an objective intraoperative scoring tool. Postintervention assessments were compared to baseline., Results: Trainees randomized to the VR group were faster than the control group for both the internal thoracic artery harvest (957.3 ± 98.9 vs. 749.1 ± 171.9; P = 0.004) and mitral annuloplasty (580.4 ± 14.4 vs. 463.8 ± 86.4; P < 0.001) and scored significantly higher with the intraoperative scoring tool (22.8 ± 2.7 vs. 11.0 ± 4.5; P < 0.001). Additionally, the VR group achieved a proficiency level similar to our experts for both time-based scores (P = 0.624 and P = 0.967), and the intraoperative assessment (P = 0.110), whereas the control group was not able to meet this level of proficiency for any of the primary outcomes. The average duration of training to successfully complete all required tasks was 9.3 hours., Conclusions: We have demonstrated that a VR simulation curriculum can significantly improve the efficiency and quality of learning in robotic cardiac surgery. Further evaluation of this curriculum is required for its widespread implementation in surgical training (ClinicalTrials.gov, NCT#02357056).

We describe the use of extracorporeal membrane oxygenation (ECMO) in a 30-year old woman at 37 weeks' gestation, following cardiac arrest from pulmonary embolism immediately post-partum from an emergent Caesarean section. In this case, ECMO was initiated though modified techniques with only the equipment available in a delivery room as a last resort to save a new mother after a significant downtime of 83 min. The patient received tissue plasminogen activator during the resuscitation resulting in significant blood loss. However, the patient was stabilized on ECMO and after 5 weeks in the intensive care unit achieved complete physical and neurologic recovery. To our knowledge, this is the first reported case where ECMO has been used in a resuscitation from massive pulmonary embolism immediately post-partum, after thombolytics were administered. Here, we discuss our strategies for emergent cannulation in a suboptimal environment, management of profound bleeding and oxygenation strategies in this hostile setting. Given the potential for success and the significant life-years gained, aggressive measures, such as ECMO, should be considered in such extreme life-threatening cases.