Aortic arch surgery for DeBakey type 1 aortic dissection in patients aged 60 years or younger.

BACKGROUND: Extended aortic repair is considered a key issue for the long-term durability of surgery for DeBakey type 1 aortic dissection. The risk of aortic degeneration may be higher in young patients due to their long life expectancy. The early outcome and durability of aortic surgery in these patients were investigated in the present study. METHODS: The subjects of the present analysis were patients under 60 years old who underwent surgical repair for acute DeBakey type 1 aortic dissection at 18 cardiac surgery centres across Europe between 2005 and 2021. Patients underwent ascending aortic repair or total aortic arch repair using the conventional technique or the frozen elephant trunk technique. The primary outcome was 5-year cumulative incidence of reoperation on the distal aorta. RESULTS: Overall, 915 patients underwent surgical ascending aortic repair and 284 patients underwent surgical total aortic arch repair. The frozen elephant trunk procedure was performed in 128 patients. Among 245 propensity score-matched pairs, total aortic arch repair did not decrease the rate of distal aortic reoperation compared to ascending aortic repair (5-year cumulative incidence, 6.7% versus 6.7%, subdistributional hazard ratio 1.127, 95% c.i. 0.523 to 2.427). Total aortic arch repair increased the incidence of postoperative stroke/global brain ischaemia (25.7% versus 18.4%, P = 0.050) and dialysis (19.6% versus 12.7%, P = 0.003). Five-year mortality was comparable after ascending aortic repair and total aortic arch repair (22.8% versus 27.3%, P = 0.172). CONCLUSIONS: In patients under 60 years old with DeBakey type 1 aortic dissection, total aortic arch replacement compared with ascending aortic repair did not reduce the incidence of distal aortic operations at 5 years. When feasible, ascending aortic repair for DeBakey type 1 aortic dissection is associated with satisfactory early and mid-term outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04831073.

The frozen elephant trunk procedure: indications, outcomes and future directions.

The treatment of complex multi-segment disease concomitantly affecting the aortic arch and descending thoracic aorta is technically challenging. Until the 1990s, such extensive pathology was addressed by median sternotomy for aortic arch replacement followed by a traumatic thoraco-abdominal incision for reconstruction of the descending aorta as a single- or two-stage procedure. The advent of the conventional elephant trunk procedure by Borst in 1983 simplified the second-stage of this procedure by eliminating the need for clamping of the descending thoracic aorta. However, graft-related complications and the considerable inter-stage mortality were significant limitations associated with the conventional elephant trunk procedure. The emergence of endovascular technology and availability of dedicated arch prostheses culminated in a major paradigm change with the introduction of the frozen elephant trunk (FET) concept by Kato and colleagues in the mid-1990s. This one-stage procedure permits concurrent total aortic arch replacement with antegrade delivery of a descending aortic stent-graft which itself functions as a proximal landing zone to facilitate prospective endovascular intervention to treat residual or de novo disease in the more distal aorta. The frozen elephant technique has been applied extensively in acute aortic dissection to restore true lumen patency, occlude descending aortic intimal tears and promote false lumen thrombosis, as well as for chronic degenerative arch aneurysms. The Thoraflex Hybrid and E-vita Open are the two most common commercially available hybrid FET prostheses. This review aims to discuss the development, indications, surgical technique, currently available prostheses, clinical outcomes and future directions regarding the FET procedure.

External or subcomissural annuloplasty in bicuspid aortic valve repair: Which is better?

Patients with a bicuspid aortic valve (BAV) are at increased risk of valvular regurgitation compared to their counterparts with a tri-leaflet aortic valve. There is now increasing emphasis to offer BAV repair to mitigate the risks of prosthesis-related complications, including thromboembolism, hemorrhage and endocarditis, as well as structural valve deterioration and future reoperation with conventional valve replacement, particularly in younger populations. Furthermore, over the preceding two decades, our greater understanding of the functional anatomy of the BAV, pathophysiological mechanisms of BAV insufficiency, and the development of a functional classification of aortic regurgitation have significantly contributed to the evolution of aortic valve reconstructive surgery. In this commentary, we discuss a recent article from the Journal of Cardiac Surgery comparing external annuloplasty and subcommissural annuloplasty as techniques for BAV repair.

Metachronous recurrent pediatric primary spontaneous pneumothorax: A case presentation and literature review.

INTRODUCTION: Pediatric primary spontaneous pneumothorax (PSP) is defined as the presence of air in the pleural cavity without underlying lung disease or thoracic trauma. Metachronous recurrence of PSP whether ipsilateral or contralateral is rare. Apical bullae and sub-pleural blebs are found in the majority of PSP patients. As in adults, surgery is indicated in cases with prolonged air leak. Video-assisted thoracoscopic surgery (VATS) is increasingly performed in children and has been reported to be both safe and effective. PRESENTATION OF THE CASE: An 11-years-old girl had bilateral attacks of PSP, the second attack happened one after the first one and this later was associated with her menarche. Chest CT scan detected bilateral apical blebs. DISCUSSION: Contralateral recurrence in pediatric PSP is a low probability. The decision for surgery in the pediatric age group is a matter of controversy as there are no strict pediatric guidelines for management of PSP. Currently, VATS is superior to open surgery. Pediatric Catamenial pneumothorax is not well described in the literature. CONCLUSIONS: Contralateral recurrence of PSP in children is rarer. No guidelines exist for the management of these cases. The association of pediatric PSP with menarche is not well described in the current literature.

Trans-thoracic versus trans-hiatal resection for oesophageal carcinoma: a retrospective comparative study of a single-centre case series.

Background: Oesophageal carcinoma (EC) is the eighth most common cancer. Surgery is the cornerstone of management for resectable EC. Trans-thoracic oesophagectomy (TTE) and trans-hiatal oesophagectomy (THE) are the two most widely practised procedures. Most of the related controversies are centred on both early and late post-operative complications and mortality (in terms of overall survival and cancer-free survival).This was a single-centre, retrospective, comparative study analysing the outcomes of two EC resection methods. All 87 patients underwent surgery by the same surgical team over 13 years. Consequently, 87 oesophagectomies with curative intent were performed and divided into the TTE group (group A = 47) and the THE group (group B = 40). Results: The mean patient age was 65.60 ± 6.30 years in the TTE group and 63.48 ± 9.34 years in the THE group. No significant difference was found in operative time, blood loss or duration of stay in the intensive care unit. The duration of hospital stay was significantly different between the THE and TTE groups (17.25 ± 5.92 vs. 12.93 ± 3.44, respectively; P ≤ 0.001). In-hospital mortality was higher in the TTE group (9/47, 19.14%) than in the THE group (5/40, 12.5%) (P = 0.400). The mean survival rate from our series showed the superiority of group A (TTE) (65.56 months) over group B (THE) (45.01 months), with P = 0.146. Conclusion: No high level of evidence suggests the superiority of one surgical procedure over another. The THE procedure is less time-consuming concerning care and follow-up, and most patients were more satisfied and experienced less pain than with the TTE procedure. Both THE and TTE have comparable post-operative anastomotic complications, and they have no significant long-term survival differences.