Unilateral versus bilateral cerebral perfusion during aortic surgery for acute type A aortic dissection: a multicentre study.

OBJECTIVES: The aim of this retrospective multicentre study was to investigate and compare clinical outcomes of unilateral and bilateral antegrade cerebral perfusion (ACP) strategies on cerebral protection during surgery for type A aortic dissection. METHODS: Data from 646 patients who underwent surgical repair of thoracic type A aortic dissection using unilateral and bilateral ACP with moderate hypothermic circulatory arrest in 3 cardiac surgical institutions between 2008 and 2018 were analysed. Propensity matching was performed to assess which technique ensured better outcomes. RESULTS: Unilateral and bilateral ACP techniques were performed in 250 (39%) and in 396 (61%) patients, respectively. Propensity score analysis identified 189 matched pairs. In the matched cohort, the lowest core temperature was 27.5°C and 28°C in the bilateral and unilateral groups, respectively (P < 0.001). The unilateral technique required significantly shorter aortic cross-clamp and cardiopulmonary bypass times than bilateral technique [82 min vs 100 min (P < 0.001); 170 min vs 195 min (P < 0.001)]. The 30-day mortality was comparable (P = 0.325). The bilateral group reported a significantly higher incidence of permanent neurologic deficits (P < 0.001), left brain hemisphere stroke (P = 0.007) and all-combined complications (P < 0.001). Ten-year survival was comparable (P = 0.45). CONCLUSIONS: Unilateral and bilateral ACP are both valid brain protection strategies in the landscape of aortic arch surgery. While admitting all the study limitations, unilateral technique could offer some clinical advantages. CLINICAL REGISTRATION NUMBER: 76049.

Left ventricle reconstruction and heartmate3 implantation. The "double patch technique".

BACKGROUND: HeartMate 3 is a left ventricular assist device, composed of a centrifugal pump. It can be applied as a myocardial recovery, a bridge to transplant, or a destination therapy, in the treatment of patients with left ventricular heart failure. METHODS: Herein we describe a technique applied against a giant aneurysmal dilatation, which combines a surgical device implantation and a left ventricular reconstruction using a double patch. RESULTS: The patch minimizes thrombotic risk thanks to its internal bovine pericardium layer, which is in contact with blood. CONCLUSIONS: The outlined technique is relatively reproducible and safe in a selected group of patients, as it employs a high-quality device and enables the restoration of an appropriate ventricular geometry.

Rapid-deployment aortic valve replacement in high-risk patients with severe endocarditis.

BACKGROUND: Surgical management of aortic valve endocarditis in high risk patients is controversial and the ideal treatment has not been found yet. We describe a selected series of eight patients treated with rapid-deployment aortic valve prosthesis as a therapeutic solution for minimizing the risks associated with annulus manipulation in case of severe aortic infective endocarditis. METHODS: Eight consecutive patients (five men and three women) with a mean age of 74.3±7.2 years, mean logistic EuroSCORE II of 16.0%±0.1%, affected by aortic native (1 patient), or prosthetic valve endocarditis (7 patients), were treated with Edwards Intuity Elite implantation. Hemodynamic performance and infective data were collected pre-, intra-, and postoperatively with a mean follow-up of 2.7±0.7 years. RESULTS: One case of in-hospital mortality was noted. None of the patients had any embolic or infective complication postoperatively. The cardiopulmonary bypass and aortic cross-clamp times were 148.4±41.6 and 90.5±25.3 min, respectively. The postoperative echocardiographic controls indicated a mean transvalvular gradient of 16.7±3.0 mmHg and one case of paravalvular leaks (2 +). Two patients underwent epigastric permanent pacemaker implantation. During the follow-up, seven patients were alive, with no evidence of symptoms or recurrences of endocarditis or embolic episodes. No new paravalvular leaks were noted, and the mean gradient on the valves was 12.4±3.4 mmHg. CONCLUSIONS: Rapid deployment aortic valve replacement in selected very high-risk patients affected by infective endocarditis could be a reasonable choice with acceptable results. However, further studies are needed to confirm these results.

Comparison of Transcarotid vs. Transfemoral Transcatheter Aortic Valve Implantation.

BACKGROUND: Recently, the carotid artery has been used as an alternative approach for transcatheter aortic valve implantation (TAVI). The aim of this study was to prove the safety and feasibility of transcarotid (TC) vs. transfemoral (TF) TAVI. Methods and Results: This retrospective study enrolled 726 consecutive patients with severe symptomatic aortic stenosis. All patients underwent TC-TAVI or TF-TAVI at Hôpital Haut-Lévèque, Bordeaux Heart University Hospital between September 2012 and October 2017. The TC-TAVI (n=83) and TF-TAVI (n=643) groups were compared statistically. The EuroSCORE II was significantly higher (8.2±6.7 vs. 6.4±5.5; P=0.007) and rates of current smoking, dyslipidemia and peripheral arterial disease were higher in the TC-TAVI than TF-TAVI group. All TC-TAVIs and 9.3% of TF-TAVIs were performed under general anesthesia. Radiation time was significantly shorter in the TC-TAVI than TF-TAVI group (14.5±6.0 vs. 23.0±10.8 min; P<0.001). Postimplant balloon valvuloplasty was performed more frequently in the TF-TAVI than TC-TAVI group (7.2% vs. 19.4%; P=0.006). Postoperative echocardiographic data were similar between the 2 groups, and there were no significant differences in 30-day mortality (8.4% vs. 5.0%; P=0.189) or stroke rate (1.2% vs. 2.6%; P=0.428) between the TF-TAVI and TC-TAVI groups. CONCLUSIONS: The feasibility and 30-day safety of TC-TAVI and TF-TAVI are similar. When TF-TAVI is not suitable anatomically for a particular patient, TC-TAVI is a preferable alternative.

Alternative access for transcatheter aortic valve replacement in older adults: A collaborative study from France and United States.

BACKGROUND: We examined the outcomes of older adults undergoing nontrans-femoral (non-TF) transcatheter aortic valve replacement (TAVR) procedures including trans-apical (TA), trans-aortic (TAo), trans-subclavian (TSub), and trans-carotid (TCa) techniques. METHODS AND RESULTS: This is an observational study of all consecutive older patients who underwent non-TF TAVR for symptomatic severe AS with Edwards Sapien (ES), Medtronic CoreValve, ES3 or Lotus Valve at three centers in France and the United States from 04/2008 to 02/2017. Baseline characteristics and clinical outcomes were defined according to VARC-2 criteria. Of 857 patients who received TAVR, 172 (20%) had an alternative access procedure. Of these, 45 (26%) were TA, 67 (39%) TAo, 17 (10%) TSub, and 43 (25%) TCa procedures. The preference for non-TF access site was different between the two countries (US: TA 39%, TAo 52%, TSub 9%; TCa 0% vs. France: TA 9%, TAo 23%, TSub 11%, and TCa 57%, P-value < .001). Most patients who underwent TAo TAVR were older women (median age: TA 82, TAo 84, TSub 81, TCa 81, P-value = 0.043; female gender: TA 32 (27%), TAo 30 (55%), TSub 10 (41%), TCa 27 (37%), P-value = .021). The predicted Society of Thoracic Surgery risk of mortality was similar among groups (TA 7%, TAo 7%, TSub 6%, TCa 7%, P-value= .738). No differences were observed in the frequency of para-valvular leak, intra-procedural bleeding, vascular complications, conversion to open-heart surgery, or development of acute kidney injury. The highest in-hospital mortality was observed in the TAo group (TA 2%, TAo 15%, TSub 0%, TCa 2%, P-value = .014). However, hospital length of stay, one-month, and one-year mortality were similar among non-TF techniques. CONCLUSION: Although regional differences exist in the choice of alternative access techniques, centers with high technical expertise can provide a safe alternative to traditional TF TAVR. TAo TAVR was associated with higher in-hospital mortality than other non-TF approaches, and this may have reflected patient rather than procedural factors. All alternative access techniques had similar mortality rates and clinical outcomes at one-year follow-up. Trans-carotid access is safe and feasible compared to other non-TF access techniques.

Planar cell polarity genes frizzled4 and frizzled6 exert patterning influence on arterial vessel morphogenesis.

Quantitative analysis of the vascular network anatomy is critical for the understanding of the vasculature structure and function. In this study, we have combined microcomputed tomography (microCT) and computational analysis to provide quantitative three-dimensional geometrical and topological characterization of the normal kidney vasculature, and to investigate how 2 core genes of the Wnt/planar cell polarity, Frizzled4 and Frizzled6, affect vascular network morphogenesis. Experiments were performed on frizzled4 (Fzd4-/-) and frizzled6 (Fzd6-/-) deleted mice and littermate controls (WT) perfused with a contrast medium after euthanasia and exsanguination. The kidneys were scanned with a high-resolution (16 µm) microCT imaging system, followed by 3D reconstruction of the arterial vasculature. Computational treatment includes decomposition of 3D networks based on Diameter-Defined Strahler Order (DDSO). We have calculated quantitative (i) Global scale parameters, such as the volume of the vasculature and its fractal dimension (ii) Structural parameters depending on the DDSO hierarchical levels such as hierarchical ordering, diameter, length and branching angles of the vessel segments, and (iii) Functional parameters such as estimated resistance to blood flow alongside the vascular tree and average density of terminal arterioles. In normal kidneys, fractal dimension was 2.07±0.11 (n = 7), and was significantly lower in Fzd4-/- (1.71±0.04; n = 4), and Fzd6-/- (1.54±0.09; n = 3) kidneys. The DDSO number was 5 in WT and Fzd4-/-, and only 4 in Fzd6-/-. Scaling characteristics such as diameter and length of vessel segments were altered in mutants, whereas bifurcation angles were not different from WT. Fzd4 and Fzd6 deletion increased vessel resistance, calculated using the Hagen-Poiseuille equation, for each DDSO, and decreased the density and the homogeneity of the distal vessel segments. Our results show that our methodology is suitable for 3D quantitative characterization of vascular networks, and that Fzd4 and Fzd6 genes have a deep patterning effect on arterial vessel morphogenesis that may determine its functional efficiency.

Lethal Aorto-Right Ventricular Defect After Transcatheter Aortic Valve Implantation in a Patient With Radiation-Induced Porcelain Aorta: Notes of Caution.

A 47-year-old man with severe radiation-induced aortic stenosis was rejected for cardiac surgery because of porcelain aorta. We successfully implanted an Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA), but the patient was readmitted 3 weeks later for heart failure with a continuous murmur on auscultation. Echocardiography showed a small defect between the aorta and the infundibulum of the right ventricle, which was also confirmed with aortography and computed tomography. Medical therapy was optimized; however, he died unexpectedly a few weeks later. We concluded that irradiated tissues are particularly fragile and require specific attention during transcatheter aortic valve implantation. Furthermore, this case suggests that a more aggressive closure should have been applied.

Early to midterm results of total cavopulmonary connection in adult patients.

BACKGROUND: Total cavopulmonary connection (TCPC) has not been studied in adults. We investigated early and midterm morbidity and mortality in adults undergoing TCPC and assessed risk factors for mortality. METHODS: Between June 1994 and October 2010, 30 adults (21.3 ± 5.5 years) underwent TCPC (extracardiac conduit). Twenty-two patients who had palliated single ventricles underwent TCPC completions and 8 patients underwent TCPC conversions. Preoperative and perioperative data were reviewed retrospectively. RESULTS: Six of 9 patients with preoperative atrial flutter or fibrillation or intraatrial reentry tachycardia were treated in the catheterization room. An aortic cross-clamp was necessary in 12 patients, and 16 TCPCs were fenestrated. Mean follow-up was 51 months (range, 4-198 months). Early mortality was 10%: 2 of 8 conversions and 1 of 22 completions. There was 1 late conversion death (at 56 months postoperatively). Postoperatively, 4 patients required pacemakers and 1 patient required long-term antiarrhythmic medication, but no heart transplantations were necessary. Risk factors for early mortality were arrhythmia (p = 0.02), aortic cross-clamp (p = 0.054), and extracorporeal circulation in hypothermia (p = 0.03). Risk factors for overall mortality were conversion (p = 0.047), absence of fenestration (p = 0.036), surgery before January 2006 (p = 0.036), aortic cross-clamp (p = 0.018), extracorporeal circulation in hypothermia (p = 0.008), and arrhythmia (p = 0.005). New York Heart Association functional class had improved at the last follow-up: preoperatively, 17 patients were in class II and 12 patients were in class III versus 18 patients in class I and 9 patients in class II postoperatively (p < 0.001). At the last clinical visit, systemic ventricular function was maintained, and no late supraventricular arrhythmia was found. CONCLUSIONS: Early and midterm TCPC results for adults are encouraging for completion but are disappointing for conversion. Identified risk factors for mortality should improve patient selection for TCPC.