Impact of concomitant replacement of the ascending aorta in patients undergoing aortic valve replacement on operative morbidity and mortality.

OBJECTIVES: The aim of this study was to evaluate the impact of concomitant ascending aortic replacement on operative morbidity and mortality in patients undergoing aortic valve replacement (AVR). METHODS: We retrospectively analysed our institutional database for all patients undergoing elective isolated AVR and AVR with concomitant replacement of the ascending aorta between January 2009 and May 2020. Patients undergoing surgery for infective endocarditis or requiring hypothermic circulatory arrest were excluded. A 3:1 propensity matching was performed for 688 patients to compare isolated AVR (120 patients) with AVR + ascending aortic replacement (40 patients). RESULTS: There were significant differences in median cardiopulmonary bypass (CPB) time [92.5 (75-114) vs 118.5 (104-131) min; P < 0.001], median aortic cross-clamp time [65.0 (51.5-78.5) vs 84.5 (77-94) min; P < 0.001] and median intensive care unit stay [1 (1-3) vs 2 (1-6) days; P < 0.01]. There was no significant difference in the use of intraoperative and postoperative blood products, re-exploration for bleeding, postoperative atrial fibrillation, acute renal failure, incidence of stroke, perioperative myocardial infarction and 30-day mortality. CONCLUSIONS: Concomitant replacement of the ascending aorta significantly prolongs CPB and aortic clamp times but does not increase operative morbidity and mortality. Therefore, replacement of a dilated ascending aorta appears to be the most durable and safest treatment option in patients undergoing AVR with an aneurysmatic ascending aorta.

Effect of electrical stimulation therapy of the lower esophageal sphincter in GERD patients with ineffective esophageal motility.

BACKGROUND: Electrical stimulation therapy (EST) of the lower esophageal sphincter (LES) is a novel technique in antireflux surgery. Due to the minimal alteration at the LES during surgery, LES-EST is meant to be ideal for patients with gastroesophageal reflux disease (GERD) and ineffective esophageal motility (IEM). The aim of this prospective trial (NCT03476265) is to evaluate health-related quality of life and esophageal acid exposure after LES-EST in patients with GERD and IEM. METHODS: This is a prospective non-randomized open-label study. Patients with GERD and IEM undergoing LES-EST were included. Follow-up (FUP) at 12 months after surgery included health-related quality of life (HRQL) assessment with standardized questionnaires (GERD-HRQL) and esophageal functional testing. RESULTS: According to the study protocol, 17 patients fulfilled eligibility criteria. HRQL score for heartburn and regurgitation improved from 21 (interquartile range (IQR) 15-27) to 7.5 (1.25-19), p = 0.001 and from 17 (11-23.5) to 4 (0-12), p = 0.003, respectively. There was neither significant improvement of esophageal acid exposure nor reduction of number of reflux events in pH impedance measurement. Distal contractile integral improved from 64 (11.5-301) to 115 (IQR 10-363) mmHg s cm, p = 0.249. None of the patients showed any sign of dysphagia after LES-EST. One patient needed re-do surgery and re-implantation of the LES-EST due to breaking of the lead after one year. CONCLUSION: Although patient satisfaction improved significantly after surgery, this study fails to demonstrate normalization or significant improvement of acid exposure in the distal esophagus after LES-EST.

Aortic Root Pressurizing Device: Aortic Valve Evaluation During Cardioplegic Arrest.

PURPOSE: The aortic root pressurizing device was developed for aortic valve repair surgery. It allows echocardiographic evaluation of the aortic valve during cardioplegic arrest by mimicking diastolic afterload. DESCRIPTION: This polyoxymethylene or polyether ether ketone-based device consists of a sealing cap nut, a sealing ring, a plug screw, and both a filling and a ventilation line. It can be easily connected to any size of aortic Dacron grafts. EVALUATION: The device was tested in 15 porcine hearts using a beating heart biosimulator including hemodynamic and echocardiographic monitoring. Valve competence was analyzed on both the beating and resting heart at 60 and 45 mm Hg root pressure. Aortic insufficiency was surgically induced by leaflet manipulation. Native aortic valves showed either none or trivial aortic insufficiency. After leaflet manipulation echocardiographic proof of valve insufficiency was possible in all specimen. Jet direction was identic in all cases at 60 mm Hg and 93% at 45 mm Hg root pressure. CONCLUSIONS: The aortic root pressurizing device shows highly comparable results of echocardiographic aortic valve evaluation between static and dynamic settings under experimental conditions.

Comparison of the conventional frozen elephant trunk implantation technique with a modified implantation technique in zone 1.

OBJECTIVES: The aim of the study was to compare the conventional frozen elephant trunk implantation technique with a modified implantation technique with an aortic anastomosis in zone 1 and extra-anatomic revascularization of the left subclavian artery during reperfusion. METHODS: Between May 2014 and March 2018, 40 patients (26 male; mean age 60.2 ± 11.2 years) underwent complete aortic arch replacement with the Thoraflex Hybrid prosthesis™ (Vascutek, Inchinnan, Scotland) at our institution. Seventeen patients underwent conventional arch replacement (group 1) and 23 patients the modified procedure (group 2). Indication for arch replacement included all types of acute and chronic diseases. RESULTS: Cardiopulmonary bypass time (213.1 ± 53.5 vs 243.8 ± 67.0 min, P = 0.13) and aortic cross-clamp time (114.4 ± 40.7 vs 117.3 ± 56.6 min, P = 0.86) did not differ significantly between group 1 and 2. There was a trend towards a shorter circulatory arrest time (50.72 ± 9.6 vs 44.7 ± 15.5 min; P = 0.20) in group 2. Perioperative mortality was 10% (5.9% vs 13%; P = 0.62). Stroke occurred in 10% (5.9% vs 13%; P = 0.62) of patients. Spinal cord injury occurred in 7.5% of patients (11.8% vs 4.3% P = 0.57). Due to the a proximal aortic anastomosis, there was a significantly shorter coverage of the descending aorta with the prosthesis ending at vertebral level Th7.5 (6.75-8) in group 1 versus Th6.0 (5.0-6.0) in group 2 (P-value = 0.004). CONCLUSIONS: Implantation of the frozen elephant trunk prosthesis in zone 1 allows for a more proximal aortic anastomosis that could make the procedure more feasible especially in patients with difficult anatomies or in an acute setting.

An Alternative Approach to Build a "Biologic Bentall" From a Pericardial Tube and a Sutureless Valve.

This report describes a technique to create a biologic Bentall from a pericardial tube and a rapid deployment valve. This technique facilitates reimplantation of the coronary arteries because the proximal anastomosis is sewn before valve implantation and allows suturing of the coronary ostia from inside and outside, given that there is no interference with the implanted valve. Indications for this technique include complex redo cases and patients with contraindications to a conventional Bentall procedure. This technique has been used in 2 patients with good results.

Evidence-based Surgery of Aortic Regurgitation: Results of a Questionnaire in German-speaking Countries.

BACKGROUND: evidence-based medicine (EBM) approaches have reached broad acceptance, both in conservative and surgical disciplines. The aim of this study is to clarify the role of EBM in a rare condition of aortic regurgitation (AR) with surgical indication. METHODS: A purpose-built Internet-based questionnaire was sent to 607 cardiovascular surgeons in Germany, Austria, and Switzerland. A virtual 64-year-old patient's medical history was presented, including two ultrasound images and one computed tomography scan, showing a 58-mm aortic root aneurysm and a severe trileaflet regurgitant aortic valve. Participants had to choose their preferred therapeutic strategy from a list. Additionally, demographics including nationality, the center size, and the frequency of similar types of patients referred to their departments were collected. RESULTS: Of 607 questionnaires, 100 were returned (16%). One participant was excluded due to conflicting answers. Most surgeons (n = 84; 84%) chose a valve-sparing root replacement (VSRR). A Bentall procedure was preferred by 13 surgeons (13%). Two surgeons voted for aortic valve replacement combined with partial root resection. The decision-making process was not significantly influenced by center size, nationality, or frequency of patients. CONCLUSION: Applying the current guidelines to our virtual study patient, 84% of participants acted accordingly choosing VSRR. Remarkably, 14% of these surgeons see less than 10 and 43% see not more than 20 comparable patients per year. Since the guidelines reserve VSRR for competent centers, those numbers as well as the guidelines themselves should be further discussed.

First Experiences with Incisional Negative Pressure Wound Therapy in a High-Risk Poststernotomy Patient Population treated with Pectoralis Major Muscle Flap for Deep Sternal Wound Infection.

BACKGROUND: Radical debridement and wound closure with vascularized flaps has become a standard procedure in the treatment of deep sternal wound infections. Negative pressure incision management systems have been proven to diminish wound infections after sternotomy. In this study, the utility of Prevena Incision Management System (KCI Licensing Inc.) was evaluated in obese patients who received unilateral pectoralis major flap for the treatment of deep sternal wound infections. METHODS: The outcome and wound-related complication rates of 19 obese patients (mean body mass index, 33.7) treated for deep sternal wound infection with pectoralis major muscle flap in combination with Prevena between 2011 and 2016 were compared with 28 obese patients treated with conventional wound dressing only between 2000 and 2010. RESULTS: In patients additionally treated with Prevena, significantly fewer surgical revisions due to wound-related complications were necessary as compared with patients who received conventional wound dressing (5.3 vs. 32.1%, p = 0.034). A significantly shorter ICU length of stay (median 0 vs. 3.5 days, p < 0.001) and a trend toward shorter length of hospitalization (median 14 vs. 19.5 days after pectoralis major flap) could be observed. CONCLUSION: The application of Prevena significantly reduced revision surgery rates in obese patients treated with unilateral pectoralis major flap for deep sternal wound infections.

Silane-Acrylate Chemistry for Regulating Network Formation in Radical Photopolymerization.

Photoinitiated silane-ene chemistry has the potential to pave the way toward spatially resolved organosilicon compounds, which might find application in biomedicine, microelectronics, and other advanced fields. Moreover, this approach could serve as a viable alternative to the popular photoinitiated thiol-ene chemistry, which gives access to defined and functional photopolymer networks. A difunctional bis(trimethylsilyl)silane with abstractable hydrogens (DSiH) was successfully synthesized in a simple one-pot procedure. The radical reactivity of DSiH with various homopolymerizable monomers (i.e., (meth)acrylate, vinyl ester, acrylamide) was assessed via 1H NMR spectroscopic studies. DSiH shows good reactivity with acrylates and vinyl esters. The most promising silane-acrylate system was further investigated in cross-linking formulations toward its reactivity (e.g., heat of polymerization, curing time, occurrence of gelation, double-bond conversion) and compared to state-of-the-art thiol-acrylate resins. The storage stability of prepared resin formulations is greatly improved for silane-acrylate systems vs thiol-ene resins. Double-bond conversion at the gel point (DBCgel) and overall DBC were increased, and polymerization-induced shrinkage stress has been significantly reduced with the introduction of silane-acrylate chemistry. Resulting photopolymer networks exhibit a homogeneous network architecture (indicated by a narrow glass transition) that can be tuned by varying silane concentration, and this confirms the postulated regulation of radical network formation. Similar to thiol-acrylate networks, this leads to more flexible photopolymer networks with increased elongation at break and improved impact resistance. Additionally, swelling tests indicate a high gel fraction for silane-acrylate photopolymers.

Concomitant femoro-femoral bypass graft during surgery for acute type A dissection to treat lower limb malperfusion.

We report the case of a 69-year-old male patient who was admitted to our department with an acute type A dissection complicated by ischemia of the left lower limb. During surgery for acute type A dissection, the patient underwent concomitant femoro-femoral crossover bypass graft placement to ensure blood supply of the left lower limb during surgery and minimize ischemia-reperfusion injury. The patient underwent supracoronary replacement of the ascending aorta while in deep circulatory arrest with a deepest core temperature of 25°C. Postoperative computed tomography showed antegrade perfusion and patency of the crossover bypass. Postoperative course was eventless without sequelae, especially of the left lower limb. We conclude that concomitant crossover bypass graft reduces the risk of ischemia-reperfusion injury in lower limb ischemia in patients undergoing surgery for acute type A dissection.

Establishment of Extracorporeal Circulation under Local Anesthesia in a Patient with an Acute Type A Aortic Dissection Complicated by Cardiac Tamponade.

We report the case of an 82-year-old female who presented in a hemodynamically unstable condition to the emergency department of our institution. Transthoracic echo showed a hemodynamically relevant pericardial effusion and the suspicion of an intimal flap in the ascending aorta. The subsequent computed tomography scan revealed a Type A dissection that was limited to the ascending aorta. To prevent hemodynamic deterioration the patient was prepped and draped awake and underwent femoral cannulation for extracorporeal circulation under local anesthesia. After commencing extracorporeal circulation the patient was anesthetized and intubated. During this whole time period no relevant drop in mean arterial pressure was observed. The patient underwent routine replacement of the ascending aorta and was extubated the day after surgery without any neurologic sequelae. Awake cannulation and inception of extracorporeal circulation can prevent the hemodynamic deterioration and cardiac arrest often seen during induction of anesthesia in patients with cardiac tamponade.

Serum glutathione S-transferase P1 1 in prediction of cardiac function.

BACKGROUND: Glutathione S-transferase P1 1 (GSTP1) belongs to the multigene isozyme family involved in cellular response to oxidative stress and apoptosis. Our initial retrospective proteomic analysis suggested that GSTP1 is associated with heart failure (HF). Although pro-B-type natriuretic peptide (proBNP) serves currently as a surrogate diagnostic and prognostic parameter in HF patients, its specificity remains uncertain. We hypothesized that GSTP1 might be a useful serum marker in the monitoring of HF patients. METHODS AND RESULTS: Serum GSTP1 and proBNP were prospectively measured in 193 patients subdivided based on their ejection fraction (EF) either in equal-sized quintiles or predefined EF groups >52%, 43%-52%, 33%-42%, 23%-32% and ≤22%. At a cutoff of ≥231 ng/mL, GSTP1 identified HF patients with EF ≤22% with 81% sensitivity and 83% specificity, and at a cutoff of ≥655 pg/mL, proBNP identified the same patient group with 84% sensitivity and 22% specificity. GSTP1 at a ≥126 ng/mL cutoff identified EF ≤42% with 90% sensitivity and 95% specificity, or proBNP at a ≥396 pg/mL cutoff had 97% sensitivity and 20% specificity. In regression analyses, GSTP1, but not proBNP, discriminated between EF ≤42% and EF >42% in HF patients. CONCLUSIONS: These results suggest that GSTP1 is strongly associated with HF and could serve as a sensitive and specific marker to predict the ventricular function in HF patients.