Acute Aortic Dissection Type A in Younger Patients (< 60 Years Old) - Does Full Arch Replacement Provide Benefits Compared to Limited Approach?

ABSTRACT Introduction: Acute aortic dissection Stanford type A (AADA) is a surgical emergency associated with high morbidity and mortality. Although surgical management has improved, the optimal therapy is a matter of debate. Different surgical strategies have been proposed for patients under 60 years old. This paper evaluates the postoperative outcome and the need for secondary aortic operation after a limited surgical approach (proximal arch replacement) vs. extended arch repair. Methods: Between January 2000 and January 2018, 530 patients received surgical treatment for AADA at our hospital; 182 were under 60 years old and were enrolled in this study - Group A (n=68), limited arch repair (proximal arch replacement), and group B (n=114), extended arch repair (> proximal arch replacement). Results: More pericardial tamponade (P=0.005) and preoperative mechanical resuscitation (P=0.014) were seen in Group A. More need for renal replacement therapy (P=0.047) was seen in the full arch group. Mechanical ventilation time (P=0.022) and intensive care unit stay (P<0.001) were shorter in the limited repair group. Thirty-day mortality was comparable (P=0.117). New onset of postoperative stroke was comparable (Group A four patients [5.9%] vs. Group B 15 patients [13.2%]; P=0.120). Long-term follow-up did not differ significantly for secondary aortic surgery. Conclusion: Even though young patients received only limited arch repair, the outcome was comparable. Full-arch replacement was not beneficial in the long-time follow-up. A limited approach is justified in the cohort of young AADA patients. Exemptions, like known Marfan syndrome and the presence of an intimal tear in the arch, should be considered.

Acute Aortic Dissection Type A in Younger Patients (< 60 Years Old) - Does Full Arch Replacement Provide Benefits Compared to Limited Approach?

INTRODUCTION: Acute aortic dissection Stanford type A (AADA) is a surgical emergency associated with high morbidity and mortality. Although surgical management has improved, the optimal therapy is a matter of debate. Different surgical strategies have been proposed for patients under 60 years old. This paper evaluates the postoperative outcome and the need for secondary aortic operation after a limited surgical approach (proximal arch replacement) vs. extended arch repair. METHODS: Between January 2000 and January 2018, 530 patients received surgical treatment for AADA at our hospital; 182 were under 60 years old and were enrolled in this study - Group A (n=68), limited arch repair (proximal arch replacement), and group B (n=114), extended arch repair (> proximal arch replacement). RESULTS: More pericardial tamponade (P=0.005) and preoperative mechanical resuscitation (P=0.014) were seen in Group A. More need for renal replacement therapy (P=0.047) was seen in the full arch group. Mechanical ventilation time (P=0.022) and intensive care unit stay (P<0.001) were shorter in the limited repair group. Thirty-day mortality was comparable (P=0.117). New onset of postoperative stroke was comparable (Group A four patients [5.9%] vs. Group B 15 patients [13.2%]; P=0.120). Long-term follow-up did not differ significantly for secondary aortic surgery. CONCLUSION: Even though young patients received only limited arch repair, the outcome was comparable. Full-arch replacement was not beneficial in the long-time follow-up. A limited approach is justified in the cohort of young AADA patients. Exemptions, like known Marfan syndrome and the presence of an intimal tear in the arch, should be considered.

Open surgical replacement of the descending aorta: single-center experience.

Background: This study presents a single center's experience and analyzes clinical outcomes following elective open surgical descending aortic replacement. Methods: Between January 2000 and August 2019, 96 patients with mean age 64 years (range, 49.5-71 years) (62.5% (n=60) male) underwent elective descending aortic replacement due to aneurysm (n=60) or chronic dissection (n=36). Marfan syndrome was present in 12 patients (12.5%). Results: In-hospital mortality rate was 3.1% (n= 3. 2 in the aneurysm group, 1 in the dissection group). New-onset renal insufficiency postoperatively with (creatinine ≥ 2.5 mg/dl) manifested in 10 patients (10.8%). One patient (1%) suffered from stroke, and paraplegia developed in 1 pts (1%). The median follow-up time was 7 years (IQR: 2.5-13 years). The 5- and 10-year survival rates were 70.8% and 50.7% respectively. We did not observe any early or late prosthetic graft infection. The Cox proportional hazards regression analysis identified age (HR: 1.044, 95% CI: 1.009-1.080, p-value: 0.014), diabetes (HR: 2.544, 95% CI: 1.009-6.413, p-value: 0.048), and chronic obstructive pulmonary disease (COPD) (HR: 2.259, 95% CI: 1.044-4.890, p-value: 0.039) as risk factors for late mortality. Conclusions: This study showed that the elective open surgical replacement of the descending aorta can be achieved with excellent outcomes in terms of perioperative mortality and morbidity. Prosthetic graft is not a problem with open surgical descending aortic replacement, even in the long term. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-022-01443-x.

Is aortic valve-sparing root reimplantation (David-I) justified in cardiac redo surgery?

OBJECTIVES: Aortic valve-sparing root reimplantation (AVSRR) is a complex procedure, which offers the benefit of preserving the native aortic valve. Cardiac redo surgery is complex and time-consuming, and it is not known if David procedure is safe or beneficial in this context. METHODS: Between 1993 and 2019, we performed a total of 544 elective AVSRR operations at our centre. Patients were assigned to either group A (n = 30, redo) or group B (n = 514, first-time sternotomy). RESULTS: Aortic cross-clamp time was higher in the redo group (173[62] vs 125[31], P < 0.001). Cardiopulmonary bypass time was higher in the redo group as well (250[78] vs 179[51], P < 0.001). There were significantly more concomitant total arch replacements in the redo group (43.3% vs 5.8%, P < 0.001) using the 'beating heart' technique (20.0% vs 1.9%, P < 0.001). In-hospital mortality was comparable in both groups (3.3% vs 1.8%, P = 0.44). The rates for perioperative complications in terms of permanent neurological deficit and rethoracotomy were comparable between the 2 groups, too. Follow-up was complete for 99.6% of all patients and comprised a total of 584 patient-years. The 1-, 5-, 10- and 15-year survival rates were 90%, 81%, 60% and 55%, in group A (redo) and 96%, 90%, 78% and 67% in group B (native, P = 0.16), respectively. The rates for freedom from valve-related reoperation at 1, 5, 10 and 15 years after initial surgery were 96%, 92%, 92% and 92% in group A (redo) and 97%, 92%, 87% and 84% in group B (native, P = 0.52), respectively. CONCLUSIONS: Despite significantly more concomitant total arch replacements in the redo group, early mortality was comparable in both groups. We conclude that AVSRR can be performed in redo cardiac surgery without compromising the early postoperative outcome. Careful patient assessment and selection are mandatory when evaluating patients with a history of previous cardiac surgery for David procedure.

Aortic valve-sparing root replacement with Tirone E. David's reimplantation technique: single-centre 25-year experience.

OBJECTIVES: Tirone E. David described aortic valve-sparing root reimplantion (AVSRR) almost 30 years ago. At our centre, we adopted this operation in 1993, and since then, we have performed >700 operations over a time period of >25 years. In this report, we present our single-centre experience. METHODS: Between 1993 and 2019, a total of 732 patients underwent AVSRR at our centre. The mean age was 53 ± 15 and 522 (71%) were male. Marfan syndrome was present in 117 (16%) patients and bicuspid aortic valve in 81 (11%). The indication for surgery was aortic root aneurysm in 588 (80%) patients and acute aortic dissection in 144 (20%) patients. RESULTS: Mini-sternotomy was performed in 74 (10%) patients. A straight tube graft (David I) was used in 677 (92%) and a Valsalva-graft in 55 (8%) patients. Cusp plasty was done in 83 (11%) patients. Concomitant cardiac procedures were performed in 438 (60%) patients. Overall in-hospital mortality was 3.8% (n = 29) and 1.9% (n = 11) in elective cases. Postoperative echocardiography was available for 671 patients and showed aortic insufficiency (AI) ≤I° in 647 (96%) patients. The mean follow-up time was 10 ± 6.7 years and comprised a total of 7307 patient-years. The 1-, 5-, 10- and 15-year survival rates were: 93%, 88%, 77% and 65%, respectively. The rates for freedom from valve-related reoperation at 1, 5, 10 and 15 years after initial surgery were 97%, 93%, 88% and 85%, respectively. Cox regression analysis identified age [odds ratio (OR) = 0.975, 95% confidence interval (CI) = 0.955-0.995, P = 0.016], hyperlipidaemia (OR = 1.980, 95% CI = 1.175-3.335, P = 0.010), preoperative level of left ventricular ejection function (OR = 1.749, 95% CI = 1.024-2.987, P = 0.041) and postoperative degree of AI (OR = 1.880, 95% CI = 1.532-2.308, P ≤ 0.001) as risk factors for the future AI or reoperation. CONCLUSIONS: David procedure can be performed extremely safely, with low risks for perioperative morbidity and mortality, both in elective situations via minimally invasive access and in emergent settings for acute aortic type A dissection. Regarding long-term outcome, David's AVSRR seems to provide excellent clinical results and sustainable function of the aortic valve in the majority of patients almost 3 decades after its introduction.

Native and prosthetic graft infections of the thoracic aorta: surgical management.

OBJECTIVES: Infection of the native aorta or after previous open or endovascular repair of the thoracic aorta is associated with high risks for morbidity and mortality. We analysed the outcome after surgical management of a native mycotic aneurysm or of prosthetic graft infection of the descending aorta. METHODS: From June 2000 to May 2019, a total of 39 patients underwent surgery in our centre for infection of the native descending aorta (n = 19 [49%], group A) or a prosthetic descending aorta [n = 20 (51%), group B]. In the 20 patients in group B, a total of 8 patients had prior open aortic repair with a prosthesis and 12 patients had a previous endovascular graft repair. RESULTS: The cohort patients had a mean age of 57 ± 14; 62% were men (n = 24). The most common symptoms at the time of presentation included fever, thoracic or abdominal pain and active bleeding. Emergency surgery was performed in 11 patients (28%); 3 patients had emergency endovascular stent grafts implanted during thoracic endovascular aortic repair for aortic rupture before further open repair. The 30-day mortality was 42% in group A and 35% in group B. The 90-day mortality was 47% in group A and 45% in group B. Pathogens could be identified in approximately half of the patients (46%). The most commonly identified pathogens were Staphylococcus aureus in 6 patients (15%) and Staphylococcus epidermidis in 4 patients (10%). Survival of the entire group (including patients with both native and prosthetic graft infections) was 44 ± 8%, 39 ± 8% and 39 ± 8% at 1, 2 and 3 years after surgery. The percentage of patients who survived the initial perioperative period was 81 ± 9%, 71 ± 9% and 71 ± 10% at 1, 2 and 3 years after surgery. CONCLUSIONS: Patients with infection of the descending aorta, either native or prosthetic, are associated with both high morbidity and mortality. However, patients who survive the initial perioperative period have an acceptable long-term prognosis. In emergency situations, thoracic endovascular aortic repair may help to stabilize patients and serve as bridge to open repair.

Aortic Valve-Sparing Root Replacement (David I Procedure) in Adolescents: Long-Term Outcome.

INTRODUCTION: Aortic valve-sparing root replacement (David's procedure) is an especially appealing treatment option for young patients. Here, we present the short-, mid, and long-term outcomes of this operation in adolescent patients. METHODS: Between September 1994 and March 2014, 29 patients aged 6 to 21 years underwent the David-I procedure at our center. We conducted a retrospective study with follow-up. RESULTS: The mean age was 16.8 ± 3.4 years and 90% (n = 26) were male. Marfan's syndrome was present in 86% (n = 25) of cases. Ninety-seven percent (n = 28) of cases were performed electively, and one case (3%) was performed emergently for acute aortic dissection type A. There were no early perioperative deaths (0%). Follow-up, which was completed on 100% of patients, comprised a total of 394 patient years and a mean follow-up time of 13.6 ± 5.4 years. The estimates for survival at 1, 5, and 10 years after initial surgery were 100, 97, and 93%, respectively. During follow-up, there were four (14%) late deaths and five (17%) aortic valve-related reoperations. The 1-, 5-, and 10-year estimates for freedom from valve-related reoperation were 100, 86, and 83%, respectively. The perioperative mortality for these five reoperations was 0%. DISCUSSION: Aortic valve-sparing root replacement can be performed in adolescents with a very low perioperative risk. Long-term survival seems to be affected by connective tissue diseases.

Aortic valve-sparing root replacement in patients with bicuspid aortic valve: long-term outcome with the David I procedure over 20 years.

OBJECTIVES: Aortic valve-sparing root replacement is an excellent treatment option for patients with intact tricuspid aortic valves. However, the durability in patients with bicuspid aortic valves is still a matter of debate. The aim of this study was to analyse the short- and long-term outcomes in patients with bicuspid aortic valves. METHODS: Between July 1993 and October 2015, a total of 582 patients underwent the David I procedure, 50 of whom had a bicuspid aortic valve. In these patients, the mean age was 46 ± 13 years, and 80% (n = 40) were men. Follow-up was complete for 100% of patients and comprised a total of 552 patient-years with a mean follow-up time of 11 ± 5.2 years. RESULTS: In addition to the David procedure, cusp plication was performed in 34% (n = 17) of patients and commissure repair in 8% (n = 4) of patients. There were no in-hospital deaths, and 1 patient (2%) had a perioperative stroke. The 1-, 5-, 10- and 20-year survival rates of patients after discharge were 98%, 94%, 88% and 84%, respectively. The rates for freedom from valve-related reoperation at 1, 5, 10 and 20 years after initial surgery were 98%, 88%, 79% and 74%, respectively. Long-term freedom from reoperation was comparable to that of patients with tricuspid aortic valves (P = 0.2). CONCLUSIONS: The David procedure has excellent short-term results in patients with a bicuspid aortic valve. In this study, the long-term durability of reimplanted bicuspid aortic valves was comparable to that of tricuspid valves. However, careful patient selection might have contributed to this, and further studies might be needed to definitely clarify this issue.

Aortic valve-sparing root replacement (David): learning curve and impact on outcome.

OBJECTIVES: Aortic valve-sparing root replacement (David procedure) offers the benefit of preserving the native aortic valve but is often criticized for being technically challenging and time-consuming. We analysed whether the surgeon's level of experience affects the early and long-term outcome after the David procedure. METHODS: From July 1993 to October 2015, a total of 582 patients underwent aortic valve-sparing David I procedure at our institution. A retrospective review with follow-up (mean follow-up time 8.6 ± 5.6 years) was performed. Statistical analysis of the surgeon's level of experience was performed as a categorical variable, after patients were chronologically assigned to groups of tens. Study end points assessing the surgeon's learning curve included both measures of patient outcome and measures of task efficiency. Study end points included both short- and long-term outcomes. RESULTS: Analysis of task efficiency showed that there was a statistically significant inverse correlation between the surgeon's level of experience and both cardiopulmonary bypass time (P = 0.026) and aortic cross-clamp time (P = 0.017). Analysis of patient outcome revealed that the incidence of aortic valve-related reoperation during follow-up showed a significant inverse correlation with the surgeon's level of experience (P = 0.048). Cox regression analysis found that the surgeon's level of experience (odds ratio 0.802, 95% confidence interval 0.673-0.957; P = 0.014) was a significant risk factor for aortic valve-related reoperation-free survival during follow-up. CONCLUSIONS: There is a surgeon's learning curve for aortic valve-sparing David procedure. The surgeon's experience has a direct impact on both the perioperative outcome and the long-term performance of the aortic valve.

Comparison of Two Strategies for Aortic Valve-Sparing Root Replacement.

BACKGROUND: Since its introduction in 1992, multiple variations of the aortic valve-sparing David procedure technique have been described. Here, we present the short- and midterm outcomes of 2 centers using the straight tube graft (David-I) and the Valsalva prosthesis in patients who underwent isolated David procedure. METHODS: Between March 2002 and October 2015, 232 patients underwent the David procedure at 2 European centers. Patients received either a straight tube graft (David-I, group A, n = 103, 74% men) or Valsalva graft (group B, n = 129, 85% men). Mean age was 47 ± 17 years in group A and 48 ± 17 years in group B (P = .916). RESULTS: There were significantly more cusp repairs in group B (n=28, 22%) compared with group A (n = 4, 4%, P < .001). The 30-day mortality rate was 1% (n = 1) in group A and 2% (n = 2, P = .698) in group B. Postoperative echocardiography showed aortic insufficiency ≥II in 0% (n = 0) of group A and 17% (n = 21) of group B (P < .001). Follow-up comprised 1530 patient-years, and survival was comparable between the 2 groups (P = .799). Follow-up echocardiography showed aortic insufficiency ≥II in 22% (n = 15) of group A and 39% (n = 33) of group B (P < .026). The rates for aortic valve-related reoperation were 8% (n = 8) in group A and 13% (n = 16) in group B (P = .241). Logistic Cox regression analysis identified bicuspid aortic valve (odds ratio, 3.435; 95% confidence interval, 1.459-8.083, P = .005) and postoperative aortic insufficiency ≥II (odds ratio, 5.988; 95% confidence interval, 2.545-14.088, P < .001) as risk factors for aortic valve-related reoperation. CONCLUSIONS: The aortic valve-sparing David procedure has acceptable midterm results. Our results show that the David-I procedure with straight tube graft is not inferior to those performed with Valsalva prosthesis.

Novel mouse model of cardiopulmonary bypass.

OBJECTIVES: Cardiopulmonary bypass (CPB) is an essential component of many cardiac interventions, and therefore, there is an increasing critical demand to minimize organ damage resulting from prolonged extracorporeal circulation. Our goal was to develop the first clinically relevant mouse model of CPB and to examine the course of extracorporeal circulation by closely monitoring haemodynamic and oxygenation parameters. METHODS: Here, we report the optimization of device design, perfusion circuit and microsurgical techniques as well as validation of physiological functions during CPB in mice after circulatory arrest and reperfusion. Validation of the model required multiple blood gas analyses, and therefore, this initial report describes an acute model that is incompatible with survival due to the need of repetitive blood draws. RESULTS: Biochemical and histopathological assessment of organ damage revealed only mild changes in the heart and lungs and signs of the beginning of acute organ failure in the liver and kidneys. CONCLUSIONS: This new CPB mouse model will facilitate preclinical testing of therapeutic strategies in cardiovascular diseases and investigation of CPB in relation to different insults and pre-existing comorbidities. In combination with genetically modified mice, this model will be an important tool to dissect the molecular mechanisms involved in organ damage related to extracorporeal circulation.

Aortic events and reoperations after elective arch surgery: incidence, surgical strategies and outcomes.

OBJECTIVES: The true incidence of aortic events (AEs) and reoperations (REDO) following elective total aortic arch replacement remains unknown. The aim of this study was to review the incidence of AEs and surgical REDO, and its respective outcomes after 1232 elective arch repairs at 11 European aortic centres. METHODS: Retrospective chart review (in the absence of prospective data collection) was performed for statistical analysis. Follow-up was conducted during routine clinical examination or in a telephone interview with patients and/or their respective physicians. RESULTS: One hundred fifty-five (12.6%) patients were identified (median follow-up time 48.7 months). The recorded AEs comprised aortic dilatation (62.6%), rupture (15.5%), endoleak (11%), false aneurysm (3.9%), dissection (3.2%), infection (2.6%) and others (1.3%). REDO (open/endovascular) were performed in 85.8% of patients (n = 133). Intraoperative and in-hospital mortality in the REDO patients were 7.5% and 17.3%, respectively. Postoperative neurological complications comprised paraplegia (6.0%) and stroke (1.5%). Survival rates after REDO at 1, 3 and 5 years were 81.2%, 79.0% and 76.7%, respectively. Univariate analysis identified 'rupture' and 'diameter progression', 'older age at REDO' and the REDO strategies 'frozen elephant trunk' and 'no elephant trunk' as predictors of increased in-hospital mortality. Multivariate analysis identified 'older age at REDO' (P = 0.008) as the only independent risk factor for in-hospital mortality. CONCLUSIONS: AEs after elective arch surgery are not irrelevant and mostly involve the distal aspects of the adjoining aorta. In accordance with the underlying pathology, open or endovascular REDO may be performed with an acceptable outcome. Preparation of an adequate proximal landing zone at the time of primary arch surgery is advisable.

Cardiopulmonary Bypass in a Mouse Model: A Novel Approach.

As prolonged cardiopulmonary bypass becomes more essential during cardiac interventions, an increasing clinical demand arises for procedure optimization and for minimizing organ damage resulting from prolonged extracorporal circulation. The goal of this paper was to demonstrate a fully functional and clinically relevant model of cardiopulmonary bypass in a mouse. We report on the device design, perfusion circuit optimization, and microsurgical techniques. This model is an acute model, which is not compatible with survival due to the need for multiple blood drawings. Because of the range of tools available for mice (e.g., markers, knockouts, etc.), this model will facilitate investigation into the molecular mechanisms of organ damage and the effect of cardiopulmonary bypass in relation to other comorbidities.

Valve-sparing David I procedure in acute aortic type A dissection: a 20-year experience with more than 100 patients.

OBJECTIVES: The aortic valve-sparing David procedure has been applied to the elective treatment of patients with aortic aneurysms with excellent results. The use of this technique in patients with acute aortic dissection type A (AADA) is still a matter of debate. We present our long-term experience with 109 patients with AADA who had the valve-sparing David I procedure. METHODS: Between July 1993 and October 2015, 109 patients with AADA had the valve-sparing David I procedure at our centre. We conducted a retrospective review with follow-up. RESULTS: The mean age was 54 ± 12 years; 78 (72%) patients were men. Marfan syndrome was present in 6 (5%) patients and bicuspid aortic valve in 3 (3%). Only 4 (4%) patients received the isolated David procedure; 50 (46%) underwent additional proximal, 13 (12%) subtotal and 42 (39%) total aortic arch replacement. The in-hospital mortality rate was 11% ( n = 12). Intraoperative/discharge echocardiography showed aortic insufficiency ≤ I° in 93 of 97 patients (96%). Mean follow-up time was 8.3 ± 5.7 years. The survival rate after discharge at 1, 5 and 10 years was 94%, 90% and 78%, respectively. Thirteen percent ( n = 13) of patients underwent valve-related reoperation. Freedom from valve-related reoperation at 1, 5 and 10 years was 96%, 88% and 85%, respectively. Compared to patients who underwent the David I procedure for any reason other than AADA, there were no significant differences in long-term survival rates ( P = 0.29) and freedom from a valve-related reoperation ( P = 0.39). CONCLUSIONS: The valve-sparing David I procedure has acceptable long-term results even in emergent operations for AADA and is not inferior when performed in elective settings.

The Unplanned Postoperative Coronary Angiogram after CABG: Identifying the Patients at Risk.

Objectives Coronary artery bypass grafting (CABG) is the "gold standard" for patients with multiple vessel coronary artery disease (CAD). However, there is no "gold standard" to control bypass patency immediately postoperatively. "Post-completion" control angiogram (CA) is not routinely performed. We retrospectively analyzed the data of all patients undergoing urgent coronary angiogram post-CABG at our center. Methods Between January 2005 and June 2011, a total of 6,025 patients underwent CABG (isolated or combined) for CAD in our hospital. In patients who underwent urgent postoperative CA, high serum cardiac enzymes (>100 CK-MB), severe new ECG changes, or unexpected low left ventricular function were present. Results A total of 106 patients (1.8%) underwent post-CABG urgent coronary angiogram. Overall 30-day mortality in this cohort was 8.5%. The average time between the cardiac operation and the coronary angiogram in these patients was 3.41 ± 5.68 days. The rates for an urgent coronary angiogram were 1.3% (n = 25), 2% (n = 65), and 1.8% (n = 16) for total arterial, combined arterial, and venous and solely venous CABG, respectively. Twenty-four percent of patients underwent CABG bypass revision, while 32% of the patients underwent PTCA, stenting, or both. Younger patients, female patients, smaller patients, and patients receiving a combined arterial and venous revascularization were at a higher risk for an unplanned postoperative CA in the multivariate risk analysis. Conclusion This study shows that the necessity for urgent post-CABG coronary angiogram is low (1.8%). However, more than half of the patients undergoing postoperative coronary angiogram needed reintervention, and, in spite of it, had high mortality. "Completion" control angiogram is not always feasible, patients at higher risk (e.g., female patients) should be identified and post-CABG coronary angiogram performed as soon as possible without undue delay, or a primary hybrid approach with an intraoperative CA should be applied.

International Expert Consensus on Sutureless and Rapid Deployment Valves in Aortic Valve Replacement Using Minimally Invasive Approaches.

OBJECTIVE: To define the benefit of sutureless and rapid deployment valves in current minimally invasive approaches in isolated aortic valve replacement. METHODS: A panel of 28 international experts with expertise in both minimally invasive aortic valve replacement and rapid deployment valves was constituted. After thorough literature review, the experts rated evidence-based recommendations in a modified Delphi approach. RESULTS: No guideline could be retrieved. Thirty-three clinical trials and 9 systematic reviews could be identified for detailed text analysis to obtain a total of 24 recommendations. After rating by the experts 12, final recommendations were identified: preoperative computed tomographic scan as well as intraoperative transesophageal echocardiography are highly recommended. Suitable annular sizes are 19 to 27 mm. There is a contraindication for bicuspid valves only for type 0 and for annular abscess or destruction due to infective endocarditis. The use of sutureless and rapid deployment valves reduces extracorporeal circulation and aortic cross-clamp time and leads to less early complications as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions, paravalvular leakages and aortic regurgitation, and renal replacement therapy, respectively. These clinical outcomes result in reduced intensive care unit and hospital stay and reduced costs. The use of sutureless and rapid deployment valves will lead to a higher adoption rate of minimally invasive approaches in aortic valve replacement. Respect should be taken to a necessary short learning curve for both sutureless and minimally invasive programs. CONCLUSIONS: Sutureless and rapid deployment aortic valve replacement together with minimally invasive approaches offers an attractive option in aortic valve placement for patients requiring biological valve replacement.

Multicentre analysis of current strategies and outcomes in open aortic arch surgery: heterogeneity is still an issue.

OBJECTIVES: The study was conducted to evaluate, on the basis of a multicentre analysis, current results of elective open aortic arch surgery performed during the last decade. METHODS: Data of 1232 consecutive patients who underwent aortic arch repair with reimplantation of at least one supra-aortic artery between 2004 and 2013 were collected from 11 European cardiovascular centres, and retrospective statistical examination was performed using uni- and multi-variable analyses to identify predictors for 30-day mortality. Acute aortic dissections and arch surgeries not involving the supra-aortic arteries were not included. RESULTS: Arch repair involving all 3 arch arteries (total), 2 arch arteries (subtotal) or 1 arch artery (partial) was performed in 956 (77.6%), 155 (12.6%) and 121 (9.8%) patients, respectively. The patients' characteristics as well as the surgical techniques, including the method of cannulation, perfusion and protection, varied considerably between the clinics participating in the study. The in-hospital and 30-day mortality rates were 11.4 and 8.8% for the entire cohort, respectively, ranging between 1.7 and 19.0% in the surgical centres. Multivariable logistic regression analysis identified surgical centre, patient's age, number of previous surgeries with sternotomy and concomitant surgeries as independent risk factors of 30-day mortality. The follow-up of the study group was 96.5% complete with an overall follow-up duration of 3.3 ± 2.9 years, resulting in 4020 patient-years. After hospital discharge, 176 (14.3%) patients died, yielding an overall mortality rate of 25.6%. The actuarial survival after 5 and 8 years was 72.0 ± 1.5% and 64.0 ± 2.0, respectively. CONCLUSIONS: The surgical risk in elective aortic arch surgery has remained high during the last decade despite the advance in surgical techniques. However, the patients' characteristics, numbers of surgeries, the techniques and the results varied considerably among the centres. The incompleteness of data gathered retrospectively was not effective enough to determine advantages of particular cannulation, perfusion, protection or surgical techniques; and therefore, we strongly recommend further prospective multicentre studies, preferably registries, in which all relevant data have to be clearly defined and collected.