The Effect of Surgical Aortic Valve Replacement on Arterial Stiffness: Does the Valve Type Matter?

Background: Despite the increasing use of transcatheter aortic valve procedures, many patients still require surgical aortic valve replacement (SAVR). Assessing arterial properties in patients undergoing SAVR for aortic valve stenosis can be challenging, and the existing evidence is inconclusive. Our study aimed to investigate the impact of SAVR on vascular stiffness and the quality of life, as well as the different effects of valve type on arterial properties. Methods: We included 60 patients (mean age 70.25 ± 8.76 years, 65% men) with severe symptomatic aortic stenosis who underwent SAVR. Arterial stiffness (cfPWV, baPWV) and vascular parameters (AIx@75, central pressures, SEVR) were measured at baseline, pre-discharge, and 1-year post-operation. The QOL was assessed using the generic questionnaire-short-form health survey 36 (SF-36) pre-operatively and at 1 year. Results: Post-SAVR, cfPWV increased immediately (7.67 ± 1.70 m/s vs. 8.27 ± 1.92 m/s, p = 0.009) and persisted at 1 year (8.27 ± 1.92 m/s vs. 9.29 ± 2.59 m/s, p ≤ 0.001). Similarly, baPWV (n = 55) increased acutely (1633 ± 429 cm/s vs. 2014 ± 606 cm/s, p < 0.001) and remained elevated at 1 year (1633 ± 429 cm/s vs. 1867 ± 408 cm/s, p < 0.001). Acute decrease in Alx@75 (31.16 ± 10% vs. 22.48 ± 13%, p < 0.001) reversed at 1 year (31.16 ± 10% vs. 30.98 ± 9%, p = 0.71). SEVR improved (136.1 ± 30.4% vs. 149.2 ± 32.7%, p = 0.01) and persisted at 1 year (136.1 ± 30.4% vs. 147.5 ± 30.4%, p = 0.01). SV had a greater cfPWV increase at 1 year (p = 0.049). The QOL improved irrespective of arterial stiffness changes. Conclusions: After SAVR, arterial stiffness demonstrates a persistent increase at 1-year, with valve type having a slight influence on the outcomes. These findings remain consistent despite the perceived QOL.

Angiotensin Regulation of Vascular Homeostasis: Exploring the Role of ROS and RAS Blockers.

Extensive research has been conducted to elucidate and substantiate the crucial role of the Renin-Angiotensin System (RAS) in the pathogenesis of hypertension, cardiovascular disorders, and renal diseases. Furthermore, the role of oxidative stress in maintaining vascular balance has been well established. It has been observed that many of the cellular effects induced by Angiotensin II (Ang II) are facilitated by reactive oxygen species (ROS) produced by nicotinamide adenine dinucleotide phosphate (NADPH) oxidase. In this paper, we present a comprehensive overview of the role of ROS in the physiology of human blood vessels, specifically focusing on its interaction with RAS. Moreover, we delve into the mechanisms by which clinical interventions targeting RAS influence redox signaling in the vascular wall.

Mitral valve repair with the use of the "Memo 3D ReChord" ring.

BACKGROUND: From a variety of ring types, semirigid ring is more preferred for mitral annuloplasty during mitral valve repair particularly in patients whose native mitral saddle shape annulus is well maintained. During mitral annuloplasty artificial chord implantation with the appropriate neochord length is surgically challenging. We present our experience of using the Memo 3D ReChord, a semirigid ring with additional chordal guiding system for mitral valve repair. PATIENTS AND METHODS: From September 2018 to February 2020, we successfully treated ten patients with severe (4+/4+) degenerative mitral valve regurgitation due to posterior leaflet prolapse with chordal rupture with the implantation Memo 3D ReChord and neo-chords. RESULTS: We implanted from one to three neo-chords and always a ring in our patients. None of the patients had any residual mitral valve regurgitation at the end of the repair and on their discharge evaluated through transesophageal and transthoracic echocardiography respectively. There was no mortality at 30-days or on midterm follow-up. During the 3-month follow-up no regurgitation was noticed either. We included in our study only the patients successfully treated. We also used it in two patients, who underwent valve replacement during the same operation due to mild to moderate mitral valve regurgitation. CONCLUSIONS: This, in our knowledge, is the first Greek series of the implantation of the Memo 3D Rechord. The initial excellent results give us the enthusiasm to continue while long-term results and the durability of this technique are necessary to establish this semirigid annuloplastic ring in our every-day practice.

Treatment of aortic arch rupture grade III with hybrid arch replacement: the key role of perfusion preservation.

Hybrid arch replacement is a well-accepted method for the treatment of lesions involving the aortic arch, though its benefits compared to classic surgical techniques remain controversial. Multiple surgical approaches have been analyzed in the literature for the treatment of such a challenging pathology. In this case report, we describe the surgical management of a 72-year-old man presenting with a complicated aortic arch rupture. The patient was treated urgently with a type I hybrid arch replacement in two stages, with total preservation of cerebral and systemic perfusion. Our case shows that hybrid arch methods are applicable even in emergency cases.

Perceval S valve empire: healing the Achilles' heel of sutureless aortic valves.

Aortic valve replacement is the treatment of choice concerning aortic valve disease. Excellent short- and long-term clinical results are reported. Patients referred for aortic valve replacement are getting older and older, so bioprosthetic valves play a more central role worldwide. However, patient comorbidities are also increased more often rendering patients unsuitable for open conventional aortic valve replacement. As a result, transcatheter aortic valve implantation has become the treatment of choice in patients at very high surgical risk. However, the percutaneous technique is related to major disadvantages provided that the diseased native valve is left in place. Its durability is also uncertain. More recently, sutureless Perceval S valve bioprosthesis has gained ground in the field of aortic stenosis therapy filling the gap between conventional aortic valve replacement and transcatheter approach. Excellent hemodynamic and clinical results are reported. Its deployment is performed under direct view and ischemic and overall operative times are significantly decreased. Five-year follow-up results are also optimal. However, the "Achilles' heel" of sutureless technology is increased rates of postoperative permanent pacemaker implantation requirement compared to conventional approach. The incidence of this complication varies in literature. Patient-related factors such as preoperative conduction disorders, older age and short membranous septum are predictors of postoperative pacemaker requirement. However, several technical modifications regarding manufacturer recommendations can be adopted to mitigate this complication. Appropriate annular decalcification, higher guiding sutures placement, reduced balloon pressure and duration and avoiding of oversizing can contribute to prevent from this complication.

Does minimal invasive cardiac surgery reduce the incidence of post-operative atrial fibrillation?

Atrial fibrillation (AF) is the most common post-operative complication and tends to be the most common arrhythmia after cardiac surgery. The etiology and risk factors for post-operative AF are poorly understood, but older age, large left atrium, diffuse coronary artery disease, a history of AF paroxysms and in general, pre-existing cardiac conditions that cause restricting and susceptibility towards inflammation have been consistently linked with post-operative atrial fibrillation (POAF). It has been traditionally thought that post-operative AF is transient, well-tolerated, benign to the patient and self-limiting complication of cardiac surgery that was temporary and easily treated. However, recent evidence suggests that POAF may be more "malignant" than previously thought, associated with follow-up mortality and morbidity. Several minimally invasive approaches, including the right parasternal approach, upper and lower mini-sternotomy (MS), V-shaped, Z-shaped, inverse-T, J-, reverse-C and reverse-L partial MS, transverse sternotomy and right mini-thoracotomy, have been developed for cardiac surgery operations since 1993 and have been associated with better outcomes and lower perioperative morbidity compared to full sternotomy (FS). The common goal of several minimally invasive approaches is to reduce invasiveness and surgical trauma. According to a statement from the American Heart Association (AHA), the term "minimally invasive" refers to a small chest wall incision that does not include a FS. This review is aimed to evaluate the use of minimally invasive techniques like mini-sternotomy, mini-thoracotomy and hybrid techniques versus conventional techniques which are used in cardiac surgery and to compare the frequency of post-operative AF and its effect on post-operative complications, morbidity and mortality, after cardiac surgery operations with FS versus cardiac surgery operations with the use of minimally invasive techniques.

Aortic rupture during endovascular repair of a postoperative coarctation pseudoaneurysm in an adult: Emergency lifesaving stent graft implantation.

We present a case with aortic rupture during an operation of thoracic endovascular aortic repair of an anastomotic pseudoaneurysm. This happened after the use of a low-pressure remodeling balloon inside the covered part of the deployed endografts. It was successfully treated with a second more centrally in the aortic arch-implanted endograft with full coverage of the left subclavian artery orifice. This patient had a history of surgically operated aortic coarctation.

Frozen Elephant Trunk: An Alternative Surgical Weapon Against Extensive Thoracic Aorta Disease. A Three-Year Meta-Analysis.

BACKGROUND: Conventional open total arch replacement is the treatment of choice for surgical aortic arch pathologies. However, it is a two-stage procedure related to high cumulative and interval mortality rates. Hybrid type III aortic arch reconstruction, the so-called "frozen elephant trunk" is a one-stage alternative approach. METHODS: A meta-analysis and detailed review of the literature published from January 2013 until December 2016, concerning frozen elephant trunk hybrid approach was conducted and data for morbidity and mortality rates were extracted. RESULTS: Among 989 patients included, the pooled 30-day or in-hospital mortality rate was 5.04% (95%CI=1.13-10.74), stroke rate was 2.38% (95%CI=0.13-6.30), and the irreversible paraplegia due to spinal cord injury rate was 0.63% (95%CI=0.00-2.73). Finally, the pooled cumulative survival at 1year was remarkably high (86.7%, 95%CI=81.08-92.90). CONCLUSIONS: Frozen elephant trunk is a safe alternative to conventional elephant trunk repair for extensive aortic arch pathologies with acceptable short- and mid-term results, avoiding the interval mortality hazard.

Alexander the Great's Life-Threatening Thoracic Trauma.

Alexander the Great was a world-class leader with tremendous courage. He paid no heed to the dangers of the battlefield, so he was always in the front lines. However, his excessive courage put his life in danger. Herein, we present an analysis of the information contained in the chronicles about a very severe, life-threatening thoracic trauma that nearly killed the great stratelates. The detailed descriptions made by Arrianus allow us to conclude that Alexander the Great experienced a nearly fatal case of tension pneumothorax. Information on how he was managed is also presented.

Aortic Arch Reconstruction: Are Hybrid Debranching Procedures a Good Choice?

INTRODUCTION: Conventional open total arch replacement is the treatment of choice for surgical aortic arch pathologies. However, it is an invasive procedure, requiring cardiopulmonary bypass and deep hypothermic circulatory arrest leading to significant morbidity and mortality rates. Hybrid aortic arch debranching procedures without (type I) or with (type II) ascending aorta replacement seek to limit operative, bypass, and circulatory arrest times by making the arch repair procedure simpler and shorter. MATERIAL AND METHODS: A meta-analysis and detailed review of the literature published from January 2013 until December 2016, concerning hybrid aortic arch debranching procedures was conducted and data for morbidity and mortality rates were extracted. RESULTS: As far as type I hybrid aortic arch reconstruction is concerned, among the 122 patients included, the pooled endoleak rate was 10.78% (95%CI=1.94-23.40), 30-day or in-hospital mortality was 3.89% (95%CI=0.324-9.78), stroke rate was 3.79% (95%CI=0.25-9.77) and weighted permanent paraplegia rate was 2.4%. In terms of type II hybrid approach, among 40 patients, endoleak rate was 12.5%, 30-day or in-hospital mortality rate was 5.3%, stroke rate was 2.5%, no permanent paraplegia was noticed and late mortality rate was 12.5%. CONCLUSIONS: Hybrid aortic arch debranching procedures are a safe alternative to open repair with acceptable short- and mid-term results. They extend the envelope of intervention in aortic arch pathologies, particularly in high-risk patients who are suboptimal candidates for open surgery.

Coronary artery bypass grafting and paraparesis; is there a correlation?

Adult cardiac surgery is associated with significant perioperative morbidity and mortality rates, mainly in elderly patients with co-morbidities. A series of postoperative complications may arise and delay the recovery of patients undergoing cardiac surgery. Such complications also increase the burden of resource use and may affect late survival rates. Neurological complications appear mainly as stroke of varying degrees, with impairment of mobility and ability of the patient. We describe a rare case of progressive paraparesis after on-pump coronary artery bypass grafting, and review its aetiology, diagnosis and management.

Ascending Aorta Endovascular Repair of a Symptomatic Penetrating Atherosclerotic Ulcer with a Custom-Made Endograft.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has become lately the procedure of choice in the treatment of most pathologies of descending thoracic aorta. Aortic arch aneurysms also came to be treated by TEVAR with various hybrid techniques or custom-made scalloped/fenestrated stent grafts. Zone 0; ascending TEVAR is more challenging than TEVAR of the descending thoracic aorta or aortic arch because of the more complex pathology, hemodynamics, and anatomy. Ascending TEVAR can be a lifesaving treatment in selected high surgical risk patients. CASE REPORT: A 71-year-old male with known history of respiratory insufficiency, coronary artery disease, and low left ventricle ejection fraction, presented to emergency department with acute thoracic pain. As the initial laboratory tests and the electrocardiogram were negative for acute coronary syndrome, a computed tomography (CT) scan was performed that showed a 20 mm large and 17 mm depth penetrating atherosclerotic ulcer (PAU) in the middle portion of ascending thoracic aorta. After medical therapy administration, the thoracic pain was controlled, and due to the high surgical risk of the patient, high incidence of aortic rupture due to PAU, and favorable anatomic conditions was scheduled the implantation of a custom-made (due to short ascending aorta) stent graft (Bolton, Relay Plus). A pacemaker was implanted 1 week before the operation to induce rapid ventricular pacing during the stent-graft deployment. During the operation, the patient was under general anesthesia as it was our first case treated in this way. The delivery of the graft was achieved through a right femoral artery cut open by an extra-stiff guide wire (Lunderquist Cook) that was placed through an angio-catheter into the left ventricle of the heart. The final positioning and deployment of the graft was achieved under rapid ventricular pacing, and the final angiogram after the withdraw of the graft delivery system showed exclusion from circulation of PAU, patency of coronary arteries, and brachiocephalic trunk with competent aortic valve. CONCLUSIONS: TEVAR of the ascending aorta is a safe and feasible technique indicated mainly unfit for open surgery patients.