Histopathological findings of diseased ascending aortae with clinicopathological correlation - A single-centre study of 160 cases.

The most common reason for ascending aorta resection is an aneurysm or dissection. Aortic dissection is a life-threatening condition in which an aneurysm is a crucial risk factor. The essential criteria for aneurysm resection include the diameter, genetic predisposition, and aortic valve disease. This study aimed to compare the histological findings in aneurysms and dissections and correlate them with clinical parameters to determine whether histopathological findings correspond with the current clinical approach. A total of 160 ascending aorta surgical specimens, separate or with an aortic valve, were collected and divided into four groups: aneurysm-tricuspid (n = 40; median 67 y), aneurysm-malformed (n = 68; median 50 y), dissection-tricuspid (n = 48; median 65.5 y), and dissection-malformed (n = 4; median 52.5 y). Male preponderance was observed in all groups; the youngest patients were in the aneurysm-malformed group. None of the specimens showed normal aortic histology. The most common finding in the aortic samples was medial degeneration, which was the most severe and most common in dissection. The mildest findings were found in the aneurysm-malformed group. Atherosclerosis was predominant and most severe in the aneurysm-tricuspid group, while only mild in both dissection groups, suggesting its protective effect against this complication. Chronic aortitis was the least common pathology, found only in the aneurysm-tricuspid group. The aortic valve was resected and examined simultaneously with the ascending aorta in 76 cases, most commonly in the aneurysm-malformed group (n = 53). Myxoid degeneration was the major finding in the tricuspid aortic valves, with calcifications in the malformed. Comparing the histopathological results with the clinical aspects, aneurysms with a malformed aortic valve seem to be managed appropriately, with the findings not reaching the severity as in patients with a tricuspid valve. In contrast, in patients with a tricuspid valve, there were more dissections than aneurysms, with a significant subset of aneurysms showing histological findings almost identical to those of dissections. Supported by histological findings, patients with a diseased ascending aorta and tricuspid aortic valve represent an underdiagnosed risk group that would benefit from earlier diagnosis and intervention to prevent dissection. There is a need to find a marker for dissection risk other than the aortic diameter.

Case report: Robotic repair of unroofed coronary sinus.

Unroofed coronary sinus is a rare congenital heart disease caused by the partial or complete absence of the common wall between the coronary sinus and left atrium. When indicated for repair, it is done either percutaneously or surgically. Repair using a totally endoscopic robotic procedure is rarely performed nor reported in the literature. We report a case of a 47-year-old male who underwent a successful totally endoscopic robotic repair of this anomaly.

Robot-assisted vs. conventional MIDCAB: A propensity-matched analysis.

Background: Robotic assistance (RA) in the harvesting of internal thoracic artery during minimally invasive direct coronary artery bypass grafting (MIDCAB) provides several potential benefits for surgeon and patient in comparison with conventional MIDCAB. The two technical options have not been thoroughly compared in the literature yet. We aimed to perform this in our cohort with the use of propensity-score matching (PSM). Methods: This was a retrospective comparison of all consecutive patients undergoing conventional MIDCAB (2005-2021) and RA-MIDCAB (2018-2021) at our institution with the use of PSM with 27 preoperative covariates. Results: Throughout the study period 603 patients underwent conventional and 132 patients underwent RA-MIDCAB. One hundred and thirty matched pairs were selected for further comparison. PSM successfully eliminated all preoperative differences. Patients after RA-MIDCAB had lower 24 h blood loss post-operatively (300 vs. 450 ml, p = 0.002). They had shorter artificial ventilation time (6 vs. 7 h, p = 0.018) and hospital stay (6 vs. 8 days, p < 0.001). There was no difference in the risk of perioperative complications, short-term and mid-term mortality between the groups. Conclusions: RA-MIDCAB is an attractive alternative to conventional MIDCAB. It is associated with lower post-operative blood loss and potentially faster rehabilitation after surgery. The mortality and the risk of perioperative complications are comparable among the groups.

Comparison of bicuspidization and Ross procedure in the treatment of unicuspid aortic valve disease in adults - Insight from the AVIATOR registry.

Background: Unicuspid aortic valve (UAV) is the second most common underlying cause of aortic valve dysfunction in young adults after the bicuspid valve. The valve may be replaced (for example by pulmonary autograft) or repaired using the bicuspidization technique. The aim of our study was to compare short- and mid-term outcomes of Ross procedure with bicuspidization in patients with severe UAV dysfunction. Methods: This was a multi-center retrospective observational cohort study comparing data from two dedicated Ross centers in the Czech Republic with bicuspidization outcomes provided by AVIATOR registry. As for the Ross group, only the patients with UAV were included. Primary endpoint was mid-term freedom from reintervention. Secondary endpoints were mid-term freedom from major adverse events, endocarditis and pacemaker implantation. Results: Throughout the study period, 114 patients underwent the Ross procedure (years 2009-2020) and 126 patients underwent bicuspidization (years 2006-2019). The bicuspidization group was significantly younger and presented with a higher degree of dyspnea, a lower degree of aortic valve stenosis and more often with pure regurgitation. The primary endpoint occurred more frequently in the bicuspidization group than in the Ross group - 77.9 vs. 97.9 % at 5 years and 68.4 vs. 75.2 % at 10 years (p < 0.001). There was no difference in secondary endpoints. Conclusion: Ross procedure might offer a significantly lower mid-term risk of reintervention than bicuspidization in patients with UAV. Both procedures have comparable survival and risk of other short- and mid-term complications postoperatively.

Transforming growth factor serum concentrations in patients with proven non-syndromic aortopathy.

Background: The mechanism underlying aortic dilatation is still unknown. Vascular dilatation is thought to be the result of progressive aortic media degeneration caused by defective vascular matrix hemostasis, including TGF-ß1 dysregulation. The goal of this study is to draw attention to the potential utility of TGF-ß1 as a diagnostic marker in non-syndromic patients with aortic dilatation. Methods: TGF-ß1 levels in plasma were measured in 50 patients who had undergone surgery and had a tricuspid or bicuspid aortic valve as well as a normal or dilated ascending aorta. A pathologist also examined thirty resected aorta samples. To specify the reference range of TGF-ß1, a control group of 40 volunteers was enrolled in this study. Results: We discovered a significant difference in TGF-ß1 levels between patients with aortic dilatation and the control group (32.5 vs. 63.92; P < 0.001), as well as between patients with non-dilated aorta but with aortic valve disease, and the control group (27.68 vs. 63.92; P < 0.001). There was no difference between the dilated ascending aorta group and the non-dilated ascending aorta group. We found a poor correlation between TGF-ß1 levels and ascending aorta diameter as well as the grade of ascending aorta histopathological abnormalities. Conclusion: TGF-ß1 concentration does not meet the criteria to be a specific marker of aortic dilatation, but it is sensitive to aortic valvulopathy-aortopathy. A larger patient cohort study is needed to confirm these findings.

Medial degeneration and atherosclerosis show discrete variance around the circumference of ascending aorta aneurysms.

Medial degeneration is the most common histological finding in ascending aortic aneurysms with lesser but significant involvement by atherosclerosis. The overall extent and severity can be potentially underrated because of their uneven distribution and macroscopic inconspicuousness of medial degeneration. This study aims to compare the distribution of degenerative and atherosclerotic lesions around ascending aorta circumference, also considering aortic valve cuspidity. We evaluated 88 cases of resected ascending aortae, 25 with a tricuspid aortic valve and 63 with a malformed aortic valve, oriented by a cardiac surgeon and sent for pathological examination. We applied the consensus documents from 2015 and 2016 for microscopic evaluation of aortic specimens. The medial degeneration and atherosclerosis were graded semi-quantitatively for each aortic quadrant: convexity, anterior wall, concavity, and posterior wall. Nearly all quadrants showed at least mild medial degeneration; more severe findings of medial degeneration and atherosclerosis were in the aneurysms associated with the tricuspid valve. In the aneurysms with the tricuspid aortic valve, there was more frequent and more severe atherosclerosis at the concavity than at the anterior wall (p = .046); the frequency and severity of medial degeneration did not differ significantly. The aneurysms with a malformed aortic valve showed more severe medial degeneration at the concavity compared to the convexity (p = .011); atherosclerosis was less common and did not show any significant differences. More than half of the samples also revealed at least a one-grade (mostly one-grade) difference among the quadrants in individual cases for both atherosclerosis and medial degeneration. Extreme differences were rare except for atherosclerosis in the tricuspid group. The results revealed only slight overall differences around the aortic circumference, with concavity being the most susceptible. Still, thanks to occurring inter- and intraindividual variability, the examination of all quadrants seems meaningful not to miss the most severe changes and to underscore the findings.

Minimally invasive or sternotomy approach in mitral valve surgery: a propensity-matched comparison.

OBJECTIVES: Conventional mitral valve surgery through median sternotomy improves long-term survival with acceptable morbidity and mortality. However, less-invasive approaches to mitral valve surgery are now increasingly employed. Whether minimally invasive mitral valve surgery is superior to conventional surgery is uncertain. METHODS: A retrospective analysis of patients who underwent mitral valve surgery via minithoracotomy or median sternotomy between 2012 and 2018. A propensity score-matched analysis was generated to eliminate differences in relevant preoperative risk factors between the two groups. RESULTS: Data from 525 patients were evaluated, 189 underwent minithoracotomy and 336 underwent median sternotomy. The 30 day mortality was similar between the minithoracotomy and conventional surgery groups (1 and 3%, respectively; p = 0.25). No differences were seen in the incidence of stroke (p = 1.00), surgical site infections (p = 0.09), or myocardial infarction (p = 0.23), or in total hospital cost (p = 0.48). However, the minimally invasive approach was associated with fewer patients receiving transfusions (59% versus 76% in the conventional group; p = 0.001) or requiring reoperation for bleeding (3% versus 9%, respectively; p = 0.03). There were no significant differences in 5 year survival between the minithoracotomy and conventional surgery groups (93% versus 86%, respectively; p = 0.21) and freedom from mitral valve reoperation (95% versus 94%, respectively; p = 0.79). CONCLUSIONS: In patients undergoing mitral valve surgery, a minimally invasive approach is feasible, safe, and reproducible with excellent short-term outcomes; mid-term outcomes and efficacy were also seen to be comparable to conventional sternotomy.

Ascending aorta dissection in a new classification system: Clinicopathological features of 62 cases.

Herein we present a single institution 5-year experience with ascending aorta dissection biopsies depicting the clinicopathological features of 62 cases. To detect microscopic abnormalities in the aortic wall beside the dissection itself, we applied a new histopathological classification scheme from the consensus documents issued by The Society for Cardiovascular Pathology and The Association for the European Cardiovascular Pathology in 2015 and 2016. The most common finding was medial degeneration (MD) - 61 cases (98.4%); atherosclerosis (AS) was found in 19 aortae (30.6%), and chronic aortitis- giant cell pattern described in one aorta (1.6%). The medial degeneration constituents included mucoid matrix accumulation, smooth muscle cells and elastic fibers abnormalities, and medial fibrosis. The consensus document application led to increased MD reporting compared to older studies and to our previous experience, probably due to assessing more subtle and focal changes such as intralamellar fibrosis, intralamellar mucoid matrix accumulation, and loss of smooth muscle cell nuclei- these changes being also the most common MD abnormalities we are reporting. We have compared the results in patients with bicuspid (n = 7; 11.3%) versus tricuspid (n = 55; 88.7%) aortic valve, suggesting no significant differences except for translamellar fibrosis, which appeared to be more severe in the bicuspid valve group (p = 0.0397). The results might imply similar histopathological findings regardless of the aortic valve cuspidity in aortic dissection. These findings are in contrast to ascending aorta dilation (aneurysm), where more severe medial degeneration changes have been described in patients with the tricuspid aortic valve.

Histopathological changes in dilated ascending aorta associated with aortic valve cuspidity.

OBJECTIVES: Patients with a bicuspid aortic valve (BAV) often present with a dilated ascending aorta. However, the underlying pathogenesis for the observed changes in the aortic wall and the resulting aneurysmal dilation remains a subject of debate. This study aims to compare the histological abnormalities of the ascending aorta in BAV and tricuspid aortic valve (TAV) patients and their correlation with aortic diameter and patient age. METHODS: A total of 376 patients from our institution's clinical database were included in the retrospective analysis. These patients underwent either elective surgery for ascending aorta dilation or emergency surgery for aortic dissection, either isolated or with a structurally diseased aortic valve. After excision, the ascending aorta samples were analysed by a pathologist. RESULTS: On histological examination, a higher degree of elastic fibre fragmentation and loss and mucoid extracellular matrix accumulation was present in the samples from TAV patients when compared with that from BAV patients (P < 0.001). However, correlation was poor for all variables when considering aortic diameter and histological abnormalities or age and histological abnormalities in both BAV and TAV patients. CONCLUSIONS: Our study demonstrates a greater incidence of severe histological abnormalities in TAV patients when compared with BAV patients.

Lung Collapse during Mini-Thoracotomy Reduces Penetration of Cefuroxime to the Tissue: Interstitial Microdialysis Study in Animal Models.

Background: Single-lung ventilation facilitates surgical exposure during minimally invasive cardiac surgery. However, a deeper knowledge of antibiotic distribution within a collapsed lung is necessary for effective antibiotic prophylaxis of pneumonia. Patients and Methods: The pharmacokinetics/pharmacodynamics (PK/PD) of cefuroxime were compared between the plasma and interstitial fluid (ISF) of collapsed and ventilated lungs in 10 anesthetized pigs, which were ventilated through a double-lumen endotracheal cannula. Cefuroxime (20 mg/kg) was administered in single 30-minute intravenous infusion. Samples of blood and lung microdialysate were collected until six hours post-dose. Ultrafiltration, in vivo retrodialysis, and high-performance liquid chromatography-tandem mass spectrometry were used to determine plasma and ISF concentrations of free drug. The concentrations were examined with non-compartmental analysis and compartmental modeling. Results: The concentration of free cefuroxime in ISF was lower in the non-ventilated lung than the ventilated one, evidenced by a lung penetration factor of 47% versus 63% (p < 0.05), the ratio between maximum concentrations (65%, p < 0.05), and the ratio between the areas under the concentration-time curve (78%, p = 0.12). The time needed to reach a minimum inhibitory concentration (MIC) was 30%-40% longer for a collapsed lung than for a ventilated one. In addition, a delay of 10-40 minutes was observed for lung ISF compared with plasma. The mean residence time values (ISF collapsed lung > ISF ventilated lung > plasma) could explain the absence of practically important differences in the time interval with the concentration of cefuroxime exceeding the MICs of sensitive strains (≤4 mg/L). Conclusion: The concentration of cefuroxime in the ISF of a collapsed porcine lung is lower than in a ventilated one; furthermore, its equilibration with plasma is delayed. Administration of the first cefuroxime dose earlier or at a higher rate may be warranted, as well as dose intensification of the perioperative prophylaxis of pneumonia caused by pathogens with higher MICs.

Female sex as a risk factor in minimally invasive direct coronary artery bypass grafting.

Objectives. Female sex has been generally accepted as a risk factor for short-term mortality and adverse events in surgical myocardial revascularization. However, there have been no data published yet about sex differences in minimally invasive settings. The aim of our study was to analyse short- and long- term outcomes of minimally invasive direct coronary artery bypass grafting (MIDCAB) in terms of sex comparison. Design. We retrospectively analysed the in-hospital data of all patients (n = 384) undergoing MIDCAB at our department in years 2006-2016. Subsequently, the data were enriched by long-term outcomes from national registries. Results. There were 96 women in our group (25%). Females were significantly older (67.1 vs 63.8 years; p < .01) and were more often diabetic (43.8% vs. 31.8%; p < .01). Surgery time was longer in females (160 vs 155 min; p = .02), and also the need for blood transfusion (19.8% vs 10.4%; p = .02) and wound complications (15.6% vs 2.4%; p < .001) were more frequent in women. After multivariate analysis, the wound complications risk (p < .001) and longer surgery times (p < .01) remained associated with sex. All-cause in-hospital mortality (2.1% vs 0.7%; p = .26), long-term mortality (p = .73), and the risk of coronary intervention post-operatively (p = .16) were the same in both sexes. Higher incidence of cardiac cause of death in women was observed from long-term aspect (69.6% vs 38.7%; p = .01). However, after adjustment it lost its significance. Conclusions. Female sex is not connected with higher risk of mortality or other major events in MIDCAB. Wound healing complications remain the leading attribute associated with female sex.

Single-Center Experience with Minimally Invasive Mitral Operations through Right Minithoracotomy.

BACKGROUND: To report single-institution experience with minimally invasive mitral valve operations through the right minithoracotomy over a 5-year period. METHODS: Patients who underwent minimally invasive mitral valve surgery (MIMVS) between January 2012 and December 2016 were included. Clinical follow-up data were collected in a prospective database and analyzed retrospectively. RESULTS: Data from 151 patients were assessed (mean age, 63.4 ± 9.7 years; 55% were females). Overall 30-day mortality was 0.7% (n = 1). Mean operating time, cardiopulmonary bypass, and aortic cross-clamp times were 254.9 ± 48.7, 140.5 ± 36.1, and 94.8 ± 27.0 minutes, respectively. Associated procedures were tricuspid valve annuloplasty (37.1%, n = 56) and closure of atrial septal defect (6.0%, n = 9). Cryoablation was performed in 43.7% of patients (n = 66). One patient (0.7%) required conversion to median sternotomy and six patients (4.0%) underwent re-explorations due to bleeding. Median postoperative hospital stay was 12 days. Overall survival at 5 years was 94.1% ± 2.0%. Freedom from reoperation was 94.6% ± 2.9% at 5 years. CONCLUSIONS: MIMVS is a feasible, safe, and reproducible approach with low mortality and morbidity. Mitral valve surgery through a small thoracotomy is a good alternative to conventional surgical access.