Is the classical elephant trunk better than the frozen elephant trunk?

Aortic diseases located in the ascending aorta, aortic arch or proximal descending aorta often require more than one surgical intervention depending on the type of pathology and its extent as well as future anticipated aortic problems. These obstacles were tackled in 1983 by Hans Borst with the introduction of the classic elephant trunk (cET). This was an outstanding and straightforward procedure. Since then, the cET was very often the first surgical approach for patients with extensive aortic pathology of the ascending aorta and arch extending into the downstream aorta. Thirteen years later, Suto and Kato introduced the frozen elephant trunk (fET) which was later on perfectionized by industry and applied in various ways by many surgical groups worldwide. Comparing the cET with the fET raises a lot of difficulties. The lack of randomization and the presence of procedural and complication-related limitations for each technique do not allow for definitive conclusions about the ideal procedure to treat complex aortic pathology. It would be very short-sighted to close all future discussions about the subject with this statement of the Hannover group made in 2011. Since both techniques and its results cannot be compared statistically due to the heterogeneity of patient groups, the lack of randomization, the difference in type and extent of pathology, the differences in surgical techniques, the learning curve in gaining experience in both techniques, and the lack of reporting standards, no scientific conclusion can be drawn as to which technique is most successful. Comparisons may even be considered futile. It is the purpose of this paper merely to make a descriptive observation of both techniques, to discuss some important elements of interest and to give some constructive and useful criticism.

Perspective: options in managing aortic graft infections.

Thoracic aortic graft infections are infrequent, but are associated with high mortality and morbidity risk. To prevent these life-threatening infections, one must be aware of pathogenesis. When it occurs, a multidisciplinary (surgeon, radiologist, microbiologist, nuclear specialist, infectiologist, anesthesiologist, intensive care specialist) cascade must be initiated. A fast and accurate diagnosis using diagnostic criteria is vital. The appropriate treatment consists of a combination of antibiotics and surgery. Whether or not the vascular prosthesis is preserved depends on a case-by-case basis (tailor-made). Several graft preservation strategies have proven their effectiveness.

Aortic valve replacement using the Freedom SOLO stentless bioprosthesis: clinical and haemodynamic performance in 625 patients at medium-term follow-up.

OBJECTIVES: Our goal was to analyse the haemodynamic and clinical results after implantation of the Freedom SOLO stentless aortic valve replacement by assessing the immediate postoperative results regarding mortality, discharge echocardiographic gradients and reoperation rates and by evaluating these results in the medium term. METHODS: This study was designed as a single-centre retrospective observational trial. Clinical and echocardiographic data were collected retrospectively from 625 patients undergoing an aortic valve replacement using the Freedom Solo stentless valve (LivaNova, London, UK) at the Sint-Jan Hospital, Bruges, between May 2009 and May 2017. RESULTS: The mean age of the patient was 76 ± 6.9 years. Early operative (30-day) mortality was 3.5% overall and 0.8% (n = 2) in patients having isolated aortic valve replacement. Early reinterventions were necessary in 3% of patients (n = 19). Permanent pacemaker implantation was performed in 3%. The mean postoperative peak gradient was 14.3 ± 8.14 mmHg, and the mean gradient was 7.5 ± 4.46 mmHg. Fourteen patients underwent explantation, 2 of which were for structural valve deterioration and 8 for endocarditis. Overall survival at 7 years was 55% [95% confidence interval (CI) 47-62]. At 7 years, freedom from reoperation overall, freedom from operation for endocarditis and freedom from operation for structural valve deterioration were 94% (95% CI 88-97), 97% (95% CI 94-99) and 98% (95% CI 90-99), respectively. CONCLUSIONS: The Freedom Solo stentless aortic valve has proved to be safe, with excellent clinical and haemodynamic results. Structural valve degeneration and explantation occur infrequently, illustrating good durability in the medium term.