Cerebral protection during surgery of the thoracic aorta

The brain is an organ with a high energy demand. Over 90% of the energy produced by mitochondria in the brain is derived from oxygen and glucose carried by the circulation. Any decrease in oxygen causes a prompt fall in energy production and results in severe ischemic brain damage. Since surgery of the aortic arch requires manipulation and exclusion of the cerebral vascularization the utilisation of optimal methods of cerebral function preservation is necessary to avoid ischemic brain injuries. Current brain protection strategies, involving reduction of cerebral oxygen consumption and/or maintenance of cerebral blood flow, include: Deep Hypothermic Circulatory Arrest (DHCA), Retrograde Cerebral Perfusion (RCP), Antegrade Selective Cerebral Perfusion (ASCP). Since 1995, at the St Antonius Hospital (Nieuwegein, Netherlands), ASCP is, for the following reasons the method of choice for brain protection when aortic reconstruction is anticipated to require a period of circulatory arrest longer than 30 minutes: ? As compared to DHCA with or without RCP, ASCP provides a much longer period of safe circulatory arrest. We have demonstrated that the extent of the aortic replacement and an ASCP time of longer than 90 minutes are not associated with an increased risk of hospital mortality and adverse neurologic outcome intended as the postoperative occurrence of permanent and transient neurologic dysfunctions ? ASCP can be used with moderate (instead of deep) hypothermia. Cooling down the patients core temperature to only 22°-25°C instead of 10°-18°C, is supposed to have various advantages such as the reduction of the duration of extracorporeal circulation with improved survival and reduced coagulative complications. ? the entire experimental literature, comparatively investigating the effects of ASCP, DHCA and RCP on brain energy metabolism, supports the idea that ASCP is superior to the other methods in maintaining an aerobic brain metabolism even after a prolonged period of circulatory arrest as demonstrated by morphologic, histopathologic and biochemical findings as well as by behavioural and clinical examinations Aim of the present thesis was: 1) to review our experience with ASCP during surgery of the thoracic aorta, 2) to determine the predictive risk factors for hospital mortality and adverse neurologic outcome, 3) to compare survival, neurologic outcome and systemic morbidity in patients undergoing aortic procedures requiring short periods of circulatory arrest with ASCP and DHCA, 4) to compare survival and neurologic outcome in patients receiving 2 different technique for arch vessels reimplantation to the aortic arch: the separated graft technique and the en bloc technique. Our findings were as follows: The hospital mortality rate ranged from to, permanent and transient neurological dysfunction occurred in of patients. Duration of cerebral perfusion and the extent of the aortic replacement were not indicated as predictive risk factor for hospital mortality and adverse neurologic outcome. Among the preoperative variables, type A dissection, urgency and history of stroke/TIA, emerged as the most important risk factors for hospital mortality and adverse neurologic outcome. The duration of CPB was the only intraoperative factor indicated as a risk factor for hospital mortality and neurologic outcome by our statistical analysis. Patients undergoing ascending aorta/hemiarch replacement with ASCP had similar survival and neurological outcome of those receiving DHCA as a method of brain protection but presented a better postoperative pulmonary and renal function recovery. As compared to the en bloc technique , the separated graft technique may result in several technical advantages and in reduced durations of extracorporeal circulation and myocardial ischemia. In our experience, ASCP has been demonstrated to be a safe and reliable method of brain protection allowing complex aortic procedures to be performed with acceptable results in terms of hospital mortality and adverse neurologic outcome

Normothermic frozen elephant trunk: our experience and literature review

none6Background and Objective: The frozen elephant trunk (FET) technique has undoubtable advantages in treating complex and extensive disease of the aortic arch and the thoracic descending aorta. Despite several improvements in cardiopulmonary bypass conduction and surgical strategy, operative times and the institution of systemic circulatory arrest remain the main determinants of early mortality, cerebral/spinal cord injury and visceral organs dysfunction. We have conducted this review to highlight the recent technical advances in arch and FET surgery aiming at the reduction/avoidance of systemic circulatory arrest, and their impact on early outcomes. Methods: A literature search (from origin to January 2022), limited to publications in English, was performed on online platforms and database (PubMed, Google, ResearchGate). After a further review of associated or similar papers, we found 4 experiences, described by 11 peer-reviewed published papers, which focused on minimising or avoiding systemic circulatory arrest during total arch replacement plus stenting of the descending thoracic aorta. Key Content and Findings: Recent experiences reported the use of an antegrade endoaortic balloon, advanced and inflated into the stent graft, to provide an early systemic reperfusion soon after the deployment of the stented portion of the FET prosthesis and minimize the circulatory arrest time (down to a mean of 5 minutes), thus avoiding the need of moderate or deep hypothermia (mean systemic temperature 28-30 ???) while allowing a complete arch and FET repair. Our approach, based on off-pump retrograde vascular stent graft deployment in distal arch/descending thoracic aorta, and the use of a retrograde endoballoon, allows the repair of extensive aortic pathologies during uninterrupted normothermic cerebral and lower body perfusion. Conclusions: The use of endoballoon occlusion has emerged in recent years as a safe and effective strategy to allow distal perfusion during FET repair. This technique minimizes or avoids the detrimental effects of hypothermia and systemic circulatory arrest and significantly reduces the operative times.Malvindi, PG; Alfonsi, J; Berretta, P; Cefarelli, M; Gatta, E; Di Eusanio, MMalvindi, Pg; Alfonsi, J; Berretta, P; Cefarelli, M; Gatta, E; Di Eusanio,

Transcatheter valve-in-valve implantation versus reoperative conventional aortic valve replacement: a systematic review

none6siTranscatheter valve-in-valve (VIV) implantation for degenerated aortic bioprostheses has emerged as a promising alternative to redo conventional aortic valve replacement (cAVR). However there are concerns surrounding the efficacy and safety of VIV. This systematic review aims to compare the outcomes and safety of transcatheter VIV implantation with redoes cAVR. Six databases were systematically searched. A total of 18 relevant studies (823 patients) were included. Pooled analysis demonstrated VIV achieved significant improvements in mean gradient (38 mmHg preoperatively to 15.2 mmHg postoperatively, P<0.001) and peak gradient (59.2 to 23.2 mmHg, P=0.0003). These improvements were similar to the outcomes achieved by cAVR. The incidence of moderate paravalvular leaks (PVL) were significantly higher for VIV compared to cAVR (3.3% vs. 0.4%, P=0.022). In terms of morbidity, VIV had a significantly lower incidence of stroke and bleeding compared to redo cAVR (1.9% vs. 8.8%, P=0.002 & 6.9% vs. 9.1%, P=0.014, respectively). Perioperative mortality rates were similar for VIV (7.9%) and redo cAVR (6.1%, P=0.35). In conclusion, transcatheter VIV implantation achieves similar haemodynamic outcomes, with lower risk of strokes and bleeding but higher PVL rates compared to redo cAVR. Future randomized studies and prospective registries are essential to compare the effectiveness of transcatheter VIV with cAVR, and clarify the rates of PVLs.openPhan, Kevin; Zhao, Dong-Fang; Wang, Nelson; Huo, Ya Ruth; Di Eusanio, Marco; Yan, Tristan DPhan, Kevin; Zhao, Dong-Fang; Wang, Nelson; Huo, Ya Ruth; Di Eusanio, Marco; Yan, Tristan

Aortic Root Replacement With Biological Valved Conduits

none9The execution of Bentall procedures using biological valved conduits is expanding owing to the increased incidence of aortic valve and root diseases in the aging population. To review the available data, a systematic search identified 29 studies with a total of 3,298 patients. Although evidence on short-term results suggested favorable outcomes after biological Bentall operations, data beyond 5 years are limited and highlight the urgent need for further investigations with longer follow-up.openCastrovinci, Sebastiano; Tian, David H; Murana, Giacomo; Cefarelli, Mariano; Berretta, Paolo; Alfonsi, Jacopo; Yan, Tristan D; Di Bartolomeo, Roberto; Di Eusanio, MarcoCastrovinci, Sebastiano; Tian, David H; Murana, Giacomo; Cefarelli, Mariano; Berretta, Paolo; Alfonsi, Jacopo; Yan, Tristan D; Di Bartolomeo, Roberto; Di Eusanio, Marc

Survival After Endovascular Therapy in Patients With Type B Aortic Dissection A Report From the International Registry of Acute Aortic Dissection (IRAD)

ObjectivesThis study sought to evaluate long-term survival in type B aortic dissection patients treated with thoracic endovascular aortic repair (TEVAR) therapy.BackgroundHistorical data have supported medical therapy in type B acute aortic dissection (TBAAD) patients. Recent advances in TEVAR appear to improve in-hospital mortality.MethodsWe examined 1,129 consecutive patients with TBAAD enrolled in IRAD (International Registry of Acute Aortic Dissection) between 1995 and 2012 who received medical (n = 853, 75.6%) or TEVAR (n = 276, 24.4%) therapy.ResultsClinical history was similar between groups. TEVAR patients were more likely to present with a pulse deficit (28.3% vs. 13.4%, p < 0.001) and lower extremity ischemia (16.8% vs. 3.6%, p < 0.001), and to characterize their pain as the “worst pain ever” (27.5% vs. 15.7%, p < 0.001). TEVAR patients were also most likely to present with complicated acute aortic dissection, defined as shock, periaortic hematoma, signs of malperfusion, stroke, spinal cord ischemia, mesenteric ischemia, and/or renal failure (61.7% vs. 37.2%). In-hospital mortality was similar in patients managed with endovascular repair (10.9 % vs. 8.7%, p = 0.273) compared with medically managed patients. One-year mortality was also similar in both groups (8.1% endovascular vs. 9.8% medical, p = 0.604). Among adverse events during follow-up, aortic growth/new aneurysm was most common, occurring in 73.3% of patients with medical therapy and in 62.7% of patients after TEVAR, based on 5-year Kaplan-Meier estimates. Kaplan-Meier survival estimates showed that patients undergoing TEVAR had a lower death rate (15.5% vs. 29.0%, p = 0.018) at 5 years.ConclusionsResults from IRAD show that TEVAR is associated with lower mortality over a 5-year period than medical therapy for TBAAD. Further randomized trials with long-term follow-up are needed

PREDICTORS OF SUBSEQUENT INTERVENTION AFTER INITIAL TREATMENT FOR ACUTE AORTIC DISSECTION

none15siopenLettinga, Mark; Patel, Himanshu; Peterson, Mark; Ehrlich, Marek; Myrmel, Truls; Conklin, Lori; Mussa, Firas; Bavaria, Joseph; Gleason, Thomas; Di Eusanio, Marco; Montgomery, Daniel; Eagle, Kim; Isselbacher, Eric; Nienaber, Christoph; Trimarchi, SantiLettinga, Mark; Patel, Himanshu; Peterson, Mark; Ehrlich, Marek; Myrmel, Truls; Conklin, Lori; Mussa, Firas; Bavaria, Joseph; Gleason, Thomas; Di Eusanio, Marco; Montgomery, Daniel; Eagle, Kim; Isselbacher, Eric; Nienaber, Christoph; Trimarchi, Sant

Prognostic role of endocarditis in isolated tricuspid valve surgery. A propensity-weighted study

Objectives The role of the underlying etiology in isolated tricuspid valve surgery has not been investigated extensively in current literature. Aim of this study was to analyse outcomes of patients undergoing surgery due to endocarditis compared to other pathologies. Methods The SURTRI study is a multicenter study enrolling adult patients who underwent isolated tricuspid valve surgery (n = 406, 55 ± 16 y.o.; 56% female) at 13 international sites. Propensity weighted analysis was performed to compare groups (IE group n = 107 vs Not-IE group n = 299). Results No difference was found regarding the 30-day mortality (Group IE: 2.8% vs Group Not-IE = 6.8%; OR = 0.45) and major adverse events. Weighted cumulative incidence of cardiac death was significantly higher for patients with endocarditis (p = 0.01). The composite endpoint of cardiac death and reoperation at 6 years was reduced in the Group IE (63.2 ± 6.8% vs 78.9 ± 3.1%; p = 0.022). Repair strategy resulted in an increased late survival even in IE cases. Conclusions Data from SURTRI study report acceptable 30-day results but significantly reduced late survival in the setting of endocarditis of the tricuspid valve. Multi-disciplinary approach, repair strategy and earlier treatment may improve outcomes. © 2022 The Author

AORTIC DISSECTION IN THE ELDERLY: COMPARING SEPTUAGENARIANS AND OCTOGENARIANS

none15siopenJabara, Justin; Peterson, Mark; Trimarchi, Santi; Myrmel, Truls; Reece, T. Brett; Bossone, Eduardo; Hutchison, Stuart; Gilon, Dan; Appoo, Jehangir; Di Eusanio, Marco; Montgomery, Daniel; Isselbacher, Eric; Nienaber, Christoph; Eagle, Kim; Patel, HimanshuJabara, Justin; Peterson, Mark; Trimarchi, Santi; Myrmel, Truls; Reece, T. Brett; Bossone, Eduardo; Hutchison, Stuart; Gilon, Dan; Appoo, Jehangir; Di Eusanio, Marco; Montgomery, Daniel; Isselbacher, Eric; Nienaber, Christoph; Eagle, Kim; Patel, Himansh

STUDY OF ACUTE TYPE A AORTIC DISSECTION PATIENTS WITH UNDILATED AORTAS

none15siopenFroehlich, Benjamin; Trimarchi, Santi; Bossone, Eduardo; Suzuki, Toru; Braverman, Alan; Kline-Rogers, Eva; Appoo, Jehangir; Di Eusanio, Marco; Gleason, Thomas; Abdul-Nour, Khaled; Lee, Teng; Montgomery, Daniel; Isselbacher, Eric; Nienaber, Christoph; Eagle, KimFroehlich, Benjamin; Trimarchi, Santi; Bossone, Eduardo; Suzuki, Toru; Braverman, Alan; Kline-Rogers, Eva; Appoo, Jehangir; Di Eusanio, Marco; Gleason, Thomas; Abdul-Nour, Khaled; Lee, Teng; Montgomery, Daniel; Isselbacher, Eric; Nienaber, Christoph; Eagle, Ki

Multi-valve Libman-Sacks’s endocarditis-related multiple, massive and fatal systemic embolization. A case report and a review of diagnostic work-up

We reported a case of non-bacterial thrombotic endocarditis (NBTE) in a 37-year-old woman who presented with signs and symptoms of cardio-embolic cerebral stroke caused by a prothrombotic state due to underlying advanced uterine cancer. Multimodal imaging, including 3D-ecocardiography, as well as laboratory and cultural tests, were critical in making the diagnosis. After starting anticoagulation therapy with low molecular weight heparin (LMWH), the patient underwent surgical aortic valve replacement due to worsening aortic valve function, initial left ventricle enlargement, increasing dimensions, and mobility of vegetations. Unfortunately, vegetations relapsed on the aortic valve bio-prosthesis as well as the mitral leaflets, resulting in a final picture of multi-valve NBTE. The fatal outcome was due to a massive multiple limb embolism, which resulted in leg amputations and septical complications. Starting with the case, we present a brief overview of the pathology's presentation, treatment, management, and prognosis, as well as the diagnostic work-up