The effect of high-dose selenium on mortality and postoperative organ dysfunction in post-cardiotomy cardiogenic shock patients supported with mechanical circulatory support - A post-hoc analysis of the SUSTAIN CSX trial.

PURPOSE: Cardiac surgery, post-cardiotomy cardiogenic shock (PCCS), and temporary mechanical circulatory support (tMCS) provoke substantial inflammation. We therefore investigated whether a selenium-based, anti-inflammatory strategy would benefit PCCS patients treated with tMCS in a post-hoc analysis of the sustain CSX trial. METHODS: Post-hoc analysis of patients receiving tMCS for PCCS in the Sustain CSX trial, which investigated the effects of high-dose selenium on postoperative organ dysfunction in cardiac surgery patients. PRIMARY OUTCOME: duration of tMCS therapy. SECONDARY OUTCOMES: postoperative organ dysfunction and 30-day mortality. RESULTS: Thirty-nine patients were treated with tMCS for PCCS. There was no difference in the median duration of tMCS between the selenium and the placebo group (3 days [IQR: 1-6] vs. 2 days [IQR: 1-7], p = 0.52). Median dialysis duration was longer in the selenium group (1.5 days [0-21.8] vs. 0 days [0-1.8], p = 0.048). There was no difference in 30-day mortality (53% vs. 41%, OR 1.44, 95% CI 0.32-6.47, p = 0.62). CONCLUSION: In this explorative study, a perioperative high-dose selenium-supplementation did not show beneficial effects on organ dysfunctions and mortality rates in patients with PCCS receiving tMCS.

The impact of onset-to-cut time in surgery for stable acute type a aortic dissection-a single-center retrospective cohort study.

OBJECTIVES: The study aim is to investigate the impact of onset-to-cut time on mortality in patients undergoing surgery for stable acute type A aortic dissection. METHODS: Patients who underwent surgery for acute type A aortic dissection between 01/2006 and 12/2021 and available onset-to-cut times were included. Patients with unstable aortic dissection (preoperative shock, intubation, resuscitation, coma, pericardial tamponade and local/systemic malperfusion syndromes) were excluded. After descriptive analysis, a multivariable binary logistic regression for thirty-day mortality was performed. A receiver operating characteristic curve for onset-to-cut time and thirty-day mortality was calculated. Restricted cubic splines were designed to investigate the association between onset-to-cut time and survival. RESULTS: The final cohort consisted of 362 patients. The median onset-to-cut time was 543 (376-1155) min. Thirty-day mortality was 9%. Only previous myocardial infarction (p = 0.018) and prolonged cardiopulmonary bypass time (p < 0.001) were identified as independent risk factors for thirty-day mortality. The corresponding area under the receiver operating characteristic curve showed a value of 0.49. Restricted cubic splines did not indicate an association between onset-to-cut time and survival (p = 0.316). CONCLUSIONS: Onset-to-cut time in the setting of stable acute type A aortic dissection does not seem to be a valid predictor of thirty-day mortality in patients undergoing surgery and stayed stable during the preoperative course.

The role of concomitant coronary artery bypass grafting in acute type A aortic dissection complicated by coronary malperfusion.

OBJECTIVES: Managing acute type A aortic dissection with coronary malperfusion is challenging. This study outlines our revascularization strategy for these patients. METHODS: Patients undergoing surgery for acute type A aortic dissection with coronary malperfusion and aortic root involvement from January 2000 to December 2021 were included. Patients were classified using the Neri classification for coronary dissection, including a novel 'Neri -' class (no coronary dissection). Patients undergoing revascularization either as a planned or as a bailout strategy due to persisting low cardiac output were compared additionally. RESULTS: The cohort comprised 195 patients: 43 (22%) Neri -, 43 (22%) Neri A, 74 (38%) Neri B and 35 (18%) Neri C. Aortic root replacement was mainly performed in 25 Neri C patients (71%; P < 0.001). Concomitant bypass surgery was performed in 4 (9%) of Neri -, 5 (12%) of Neri A, 21 (28%) of Neri B and 32 (91%) of Neri C patients (P < 0.001). Thirty-day mortality was 42% with 21 (49%) Neri -, 12 (28%) Neri A, 30 (41%) Neri B and 19 (54%) Neri C patients (P = 0.087). Bailout revascularization was primarily performed in 11 Neri B patients (69%; P = 0.001) and associated with a higher 30-day mortality of 81% compared to 48% for planned revascularization (P = 0.042). CONCLUSIONS: Postoperative outcomes in case of coronary malperfusion are poor, irrespective of the anatomic dissection pattern. The decision for concomitant bypass surgery is crucial but may be considered in Neri C patients combined with aortic root replacement. Bailout revascularization was most common in Neri B and showed dismal outcome.

Infectious mass debulking in lead-associated endocarditis with a percutaneous aspiration system.

AIMS: Debulking of infective mass to reduce the burden if infective material is a fundamental principle in the surgical management of infection. The aim of this study was to investigate the validity of this principle in patients undergoing transvenous lead extraction in the context of bloodstream infection (BSI). METHODS AND RESULTS: We performed an observational single-centre study on patients that underwent transvenous lead extraction due to a BSI, with or without lead-associated vegetations, in combination with a percutaneous aspiration system during the study period 2015-22. One hundred thirty-seven patients were included in the final analysis. In patients with an active BSI at the time of intervention, the use of a percutaneous aspiration system had a significant impact on survival (log-rank: P = 0.0082), while for patients with a suppressed BSI at the time of intervention, the use of a percutaneous aspiration system had no significant impact on survival (log-rank: P = 0.25). CONCLUSION: A reduction of the infective burden by percutaneous debulking of lead vegetations might improve survival in patients with an active BSI.

Mediastinal transposition of the greater omentum for treatment of infected prostheses of the ascending aorta and aortic arch.

OBJECTIVES: The aim of this study was to evaluate the outcomes of transposition of the omentum into the mediastinum to support the replacement of infected aortic grafts or to cover infected aortic grafts that are not amenable for surgical replacement. METHODS: All patients with thoracic aortic graft infections who underwent mediastinal transposition of the omentum at our institution between 2005 and 2023 were included in this study. Mediastinal transposition of the omentum was performed either after replacement of the infected graft ('curative concept') or solely as bailout procedure by wrapping the infected graft ('palliative concept'). The diagnosis, including computed tomography scans during follow-up, was made according to the criteria of the Management of Aortic Graft Infection Collaboration. RESULTS: The patient cohort consisted of 31 patients. Both in-hospital and 1-year mortality were 0% (n = 0) for the curative concept (n = 9) compared to 23% (n = 5) and 41% (n = 9) for the palliative concept (n = 22), respectively. There was no graft infection-associated death or recurrence of infection after 3 years in the curative group. Survival was 52% at 3 years in the palliative group, with freedom of infection in 59% of the patients (n = 13). CONCLUSIONS: Transposition of the omentum and wrapping of the infected aortic prosthetic graft is a useful bailout strategy for patients who are ineligible for replacement of an infected aortic graft. However, mortality stays high. For radical treatment of aortic graft infections, it may prove an effective supportive therapy and represents an important tool in the armamentarium of cardiac surgeons.

The Ascyrus Medical Dissection Stent: A One-Fits-All Strategy for the Treatment of Acute Type A Aortic Dissection?

The treatment of DeBakey type I aortic dissection remains a major challenge in the field of aortic surgery. To upgrade the standard of care hemiarch replacement, a novel device called an "Ascyrus Medical Dissection Stent" (AMDS) is now available. This hybrid device composed of a proximal polytetrafluoroethylene cuff and a distal non-covered nitinol stent is inserted into the aortic arch and the descending thoracic aorta during hypothermic circulatory arrest in addition to hemiarch replacement. Due to its specific design, it may result in a reduced risk for distal anastomotic new entries, the effective restoration of branch vessel malperfusion and positive aortic remodeling. In this narrative review, we provide an overview about the indications and the technical use of the AMDS. Additionally, we summarize the current available literature and discuss potential pitfalls in the application of the AMDS regarding device failure and aortic re-intervention.

The Influence of Audiovisual Distraction on Pain Reduction During Transcatheter Aortic Valve Implantation Under Monitored Anesthesia Care: A Prospective Randomized Trial.

OBJECTIVES: To investigate the effect of an audiovisual distraction system on the dose of remifentanil for perioperative sedation during transcatheter aortic valve implantation under monitored anesthesia care. DESIGN: Single-center prospective randomized nonblinded study. SETTING: Tertiary referral academic hospital. PARTICIPANTS: Ninety patients who underwent transfemoral transcatheter aortic valve implantation between July 2019 and July 2021. INTERVENTIONS: Patients were randomized to use either a novel audiovisual distraction system during the intervention (n = 45) or standard care without an audiovisual distraction system (n = 45). MEASUREMENTS AND MAIN RESULTS: Standardized questionnaires were given to each patient at admission and before and after the intervention to assess their levels of anxiety. Primary endpoints were the average and peak infusion rates of remifentanil. All patients were considered for the final analysis according to an intention-to-treat design. No relevant differences in pre- and postinterventional anxiety status were observed between the groups. Similarly, there were no significant differences in reported pain scores (p = 0.364). The average infusion rate (p = 0.028) and peak infusion rate (p = 0.025) of remifentanil were lower in the group with an audiovisual distraction system. CONCLUSIONS: Audiovisual distraction is a useful adjunct to reduce the dose of remifentanil under monitored anesthesia care during transcatheter aortic valve implantation. Larger studies are needed to evaluate potential positive effects on patient satisfaction, incidence of delirium, and possible economic benefits.

Transcatheter management of pure native aortic valve regurgitation in patients with left ventricular assist device.

OBJECTIVES: Aortic valve regurgitation (AR) frequently complicates the clinical course after left ventricular assist device (LVAD) implantation. Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement (SAVR) in this cohort with a mostly high surgical risk profile. The unique challenges in LVAD patients, such as presence of non-calcified aortic valves and annular dilatation, raise concerns about device migration and paravalvular leakage (PVL) leading to missing device success. This study evaluates procedural outcomes and survival rates in LVAD patients who underwent TAVI, emphasizing strategies to enhance device success. METHODS: Between January 2017 and April 2023, 27 LVAD patients with clinically significant AR underwent elective or urgent TAVI at our centre. Primary end-points were procedural success rates, without the need for a second transcatheter heart valve (THV) and postprocedural AR/PVL. Secondary outcomes included survival rates and adverse events. RESULTS: Among the cohort, 14.8% received AR-dedicated TAVI devices, with none requiring a second THV. There was no intraprocedural AR, and 1 patient (25%) had AR > 'trace' at discharge. Additionally, 25.9% underwent device landing zone (DLZ) pre-stenting with a standard TAVI device, all without needing a second THV. There was no intraprocedural AR, and none to trace AR at discharge. Among the 59.3% receiving standard TAVI devices, 37.5% required a second THV. In this subgroup, intraprocedural AR > 'trace' occurred in 12.5%, decreasing to 6.25% at discharge. In-hospital mortality was 3.7%, and median follow-up survival was 388 days (interquartile range 208-1167 days). CONCLUSIONS: TAVI yields promising procedural outcomes and early survival rates in LVAD patients with AR. Tailored TAVI devices and pre-stenting techniques enhance procedural success. Continued research into these strategies is essential to optimize outcomes in this complex patient cohort.

Analysis of factors affecting outcome in acute type A aortic dissection complicated by preoperative cardiopulmonary resuscitation.

OBJECTIVES: Cardiopulmonary resuscitation (CPR) aggravates the pre-existing dismal prognosis of patients suffering from acute type A aortic dissection (ATAAD). We aimed to identify factors affecting survival and outcome in ATAAD patients requiring CPR at presentation at 2 European aortic centres. METHODS: Data on 112 surgical candidates and undergoing preoperative CPR were retrospectively evaluated. Patients were divided into 2 groups according to 30-day mortality. A multivariable model identified predictors for 30-day mortality. RESULTS: Preoperative death occurred in 23 patients (20.5%). In the remaining 89 surgical patients (79.5%) circulatory arrest time (41 ± 20 min in 30-day non-survivors vs 30 ± 13 min in 30-day survivor, P = 0.003) as well as cardiopulmonary bypass time (320 ± 132 min in 30-day non-survivors vs 252 ± 140 min in 30-day survivor, P = 0.020) time was significantly longer in patients with worse outcome. Thirty-day mortality of the total cohort was 61.6% (n = 69) with cardiac failure in 48% and aortic rupture or haemorrhagic shock (28%) as predominant reasons of death. Age [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.09, P = 0.034], preoperative coronary (OR 3.42, 95% CI 1.34-9.26, p = 0.012) and spinal malperfusion (OR 12.49, 95% CI 1.83-225.02, P = 0.028) emerged as independent predictors for 30-day mortality while CPR due to tamponade was associated with improved early survival (OR 0.29, 95% CI 0.091-0.81, P = 0.023). CONCLUSIONS: Assessment of underlying cause for CPR is mandatory. Pericardial tamponade, rapidly resolved with pericardial drainage, is a predictor for improved survival, while age and presence of coronary and spinal malperfusion are associated with dismal outcome in this high-risk patient group.

The Potential of Intertwining Gene Diagnostics and Surgery for Mitral Valve Prolapse.

Mitral valve prolapse (MVP) is common among heart valve disease patients, causing severe mitral regurgitation (MR). Although complications such as cardiac arrhythmias and sudden cardiac death are rare, the high prevalence of the condition leads to a significant number of such events. Through next-generation gene sequencing approaches, predisposing genetic components have been shown to play a crucial role in the development of MVP. After the discovery of the X-linked inheritance of filamin A, autosomal inherited genes were identified. In addition, the study of sporadic MVP identified several genes, including DZIP1, TNS1, LMCD1, GLIS1, PTPRJ, FLYWCH, and MMP2. The early screening of these genetic predispositions may help to determine the patient population at risk for severe complications of MVP and impact the timing of reconstructive surgery. Surgical mitral valve repair is an effective treatment option for MVP, resulting in excellent short- and long-term outcomes. Repair rates in excess of 95% and low complication rates have been consistently reported for minimally invasive mitral valve repair performed in high-volume centers. We therefore conceptualize a potential preventive surgical strategy for the treatment of MVP in patients with genetic predisposition, which is currently not considered in guideline recommendations. Further genetic studies on MVP pathology and large prospective clinical trials will be required to support such an approach.

Case Report: Successful endovascular treatment of acute type A aortic dissection.

Introduction: Open surgical repair remains the current gold standard for the treatment of acute type A aortic dissection. However, especially elderly patients with relevant comorbidities who are deemed unfit for open surgery may benefit from a minimally invasive endovascular approach. Methods: We report a case of an 80-year-old male with retrograde acute type A aortic dissection and peripheral malperfusion after receiving thoracic endovascular aortic repair due to thoracic aortic aneurysm. Our individualized endovascular approach consisted of left carotid-subclavian bypass, proximal extension of thoracic endovascular aortic repair using a covered stent graft and a single covered stent graft for the ascending aorta in combination with an uncovered stent for the aortic arch. Results: Postoperative computed tomographic angiography demonstrated excellent outcome with no signs of endoleak or patent false lumen. Follow-up after 3.5 years showed a stable result with no signs of stent failure or dissection progress. No aortic re-interventions were needed in the further course. Discussion: An individualized endovascular approach may be justified for acute type A aortic dissection in elderly patients with high surgical risk if performed in specialized aortic centers. Additional short-length stent graft devices are needed to address the anatomical challenges of the ascending aorta. For enhanced remodeling of the dissected aorta, the use of an additional uncovered stent may be advisable.

The impact of malperfusion patterns in elderly patients undergoing surgery for acute type A aortic dissection.

OBJECTIVES: The aim of this study is to investigate the outcome of elderly patients with surgically treated acute type A aortic dissection (ATAAD) complicated by malperfusion. METHODS: Patients ≥70 years old who underwent surgical treatment for ATAAD between January 2000 and December 2020 were enrolled in this study and stratified by their specific Penn Classification into 4 different subgroups, where Penn Abc was defined as multilevel malperfusion. Short- and long-term outcomes were investigated. Multivariable binary logistic regression was performed to identify risk factors for 1-year mortality. RESULTS: Four hundred elderly patients underwent surgical treatment for ATAAD. A total of 204 (51%) patients had no evidence of malperfusion (Penn Aa), 106 (26.5%) had localized organic malperfusion (Penn Ab), 44 (11%) patients had systemic malperfusion (Penn Ac) and 46 (11.5%) suffered from multilevel malperfusion (Penn Abc). For the latter, in-hospital mortality was 70% (P < 0.001). Age (P < 0.006) and multilevel malperfusion (P < 0.001) were independent risk factors for 1-year mortality. Patients with multilevel malperfusion showed the worst 1-year survival (P < 0.001). In the case of Penn Aa, in-hospital mortality was 13% (P < 0.001). CONCLUSIONS: Surgery may lead to satisfactory results in the absence of malperfusion, even in octogenarians. Elderly patients with multilevel malperfusion show very poor surgical outcome. In these patients, the decision for surgery should be taken with caution. Operation, if performed, should be carried out by experienced teams only.

Cerebral Protection Strategies and Stroke in Surgery for Acute Type A Aortic Dissection.

BACKGROUND: Perioperative stroke remains a devastating complication in the operative treatment of acute type A aortic dissection. To reduce the risk of perioperative stroke, different perfusion techniques can be applied. A consensus on the preferred cerebral protection strategy does not exist. METHODS: To provide an overview about the different cerebral protection strategies, literature research on Medline/PubMed was performed. All available original articles reporting on cerebral protection in surgery for acute type A aortic dissection and neurologic outcomes since 2010 were included. RESULTS: Antegrade and retrograde cerebral perfusion may provide similar neurological outcomes while outperforming deep hypothermic circulatory arrest. The choice of arterial cannulation site and chosen level of hypothermia are influencing factors for perioperative stroke. CONCLUSIONS: Deep hypothermic circulatory arrest is not recommended as the sole cerebral protection technique. Antegrade and retrograde cerebral perfusion are today's standard to provide cerebral protection during aortic surgery. Bilateral antegrade cerebral perfusion potentially leads to superior outcomes during prolonged circulatory arrest times between 30 and 50 min. Arterial cannulation sites with antegrade perfusion (axillary, central or carotid artery) in combination with moderate hypothermia seem to be advantageous. Every concept should be complemented by adequate intraoperative neuromonitoring.

The arch remodelling stent for DeBakey I acute aortic dissection: experience with 100 implantations.

OBJECTIVES: A novel hybrid non-covered stent was developed to treat malperfusion and prevent aneurysm formation following hemiarch procedure for DeBakey I acute aortic dissection (AAD). The present analysis investigates the performance of the device in 100 consecutive implantations. METHODS: Between 2018 and 2021, 100 patients underwent surgical repair of DeBakey I AAD with implantation of a non-covered stent in the arch and descending aorta. The primary entry tear was located in the root or the ascending aorta. Clinical and imaging data were collected and analysed retrospectively. The endpoints of the study were 30-day mortality, neurological outcome and need of additional procedures due to postoperative malperfusion. Technical success was assessed in the first postoperative computed tomography in regard to the induction of false lumen thrombosis in the descending aorta. RESULTS: The median age was 61 (54-73) years. Preoperative malperfusion was present in 46 (46%) patients. The primary arterial cannulation strategy was the right axillary artery and an open distal anastomosis was performed in a median caudal circulatory arrest of 40 (34-52) min. In 48% of cases, a 55-40 tapered stent was implanted. The 30-day mortality was 18%, and the operation-related new postoperative neurological deficit was present in 8%. Technical success was achieved in 76% of patients. CONCLUSIONS: The novel non-covered stent can be safely applied to complement aortic repair with the hemiarch procedure for DeBakey I AAD. The expansion of the true lumen through the device may prevent postoperative malperfusion and induces positive vascular remodelling with the thrombosis of the false lumen.

David Procedure as Valve-Sparing Root Replacement.

Composite replacement of the aortic root and aortic valve is a valid surgical strategy in a case of annuloaortic ectasia. However, valve-sparing root replacement procedures have become the gold standard in cases with a morphologically intact or at least repairable aortic valve, and offer several advantages compared to conventional replacement techniques. Above all, the David procedure has become established as a well-known valve-sparing root replacement strategy with excellent short- and long-term outcomes, and it has been further applied to additional patient populations with characteristics like a bicuspid aortic valve or in the setting of acute type A aortic dissection. This narrative review offers an overview of the indications as well as the surgical steps of the T. David V procedure, and highlights important key points regarding the surgical feasibility and criteria of patient selection for valve-sparing root replacement.

Matched comparison of 3 cerebral perfusion strategies in open zone-0 anastomosis for acute type A aortic dissection.

OBJECTIVES: The present study aims to investigate outcomes after the surgical treatment of acute type A aortic dissection in regard to three available selective cerebral perfusion strategies. METHODS: From 2000 to 2019, patients were selected based on the employment of either retrograde cerebral perfusion (RCP), unilateral antegrade cerebral perfusion (uACP) or bilateral antegrade cerebral perfusion (bACP) during open zone-0 anastomosis. Propensity score TriMatch analysis considering several preoperative and intraoperative variables was used to identify well-balanced triplets. The primary end point of the study was a new cerebral operation-related neurologic deficit. RESULTS: Operative times (operation time, cardiopulmonary bypass time, reperfusion time) were significantly longer in the RCP group, in which deeper hypothermia was applied (27.5 [24-28], 28 [26-28] and 16 [16-17]°C for uACP, bACP and RCP, respectively, P-value <0.001). The RCP group showed higher red blood cell concentrates and fresh frozen plasma transfusion rates. No significant difference of new cerebral operation-related neurologic deficit was observed between the 3 groups (12.9% vs 12.9% vs 11.3% for RCP, uACP and bACP, P-value = 0.86). In addition, 30-day mortality showed similar distribution independently of the cerebral perfusion strategy adopted (17.7% vs 14.5% vs 17.7% for RCP, uACP and bACP, P-value = 0.86). CONCLUSIONS: However, based on a small sample size, the comparison showed no relevant differences in terms of neurologic outcome and 30-day mortality, confirming RCP, uACP and bACP as safe and reproducible selective cerebral perfusion strategies in surgery for acute type A aortic dissection.

State of the Art Review: Surgical Treatment of Acute Type A Aortic Dissection.

Acute type A aortic dissection (ATAAD) is a life-threatening event that requires immediate surgical treatment. Improvements in surgical treatment, graft technology, organ protection and imaging techniques have led to improved clinical outcomes. Individualized treatment concepts have emerged based on more advanced planning tools that allow for a tailored approach even in complex situations such as multi-level malperfusion. This review provides an overview of the current surgical treatment of ATAAD, focusing on new disease classifications, preoperative computed tomography angiography (CTA) assessment, new prosthesis and stent technologies, and organ-protection strategies.