Commentary: Aortic valve annuloplasty: The true and the false

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Commentary: Novel interventions in complex aortic disease: A perfect storm to “B-SAFER”

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Minimally invasive aortic valve surgery

Aortic valve disease is a prevalent disorder that affects approximately 2% of the general adult population. Surgical aortic valve replacement is the gold standard treatment for symptomatic patients. This treatment has demonstrably proven to be both safe and effective. Over the last few decades, in an attempt to reduce surgical trauma, different minimally invasive approaches for aortic valve replacement have been developed and are now being increasingly utilized. A narrative review of the literature was carried out to describe the surgical techniques for minimally invasive aortic valve surgery and report the results from different experienced centers. Minimally invasive aortic valve replacement is associated with low perioperative morbidity, mortality and a low conversion rate to full sternotomy. Long-term survival appears to be at least comparable to that reported for conventional full sternotomy. Minimally invasive aortic valve surgery, either with a partial upper sternotomy or a right anterior minithoracotomy provides early- and long-term benefits. Given these benefits, it may be considered the standard of care for isolated aortic valve disease

Endovascular treatment of penetrating atherosclerotic ulcers of the arch and thoracic aorta: In-hospital and 5-year outcomes

Objective: Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for thoracic aorta diseases including penetrating aortic ulcer (PAU). The objective of this study was to analyze the results of TEVAR for the treatment of PAU in our population. Methods: From January 1999 to January 2019, 830 patients with type B aortic syndromes were treated with TEVAR in our institution. Of these we selected 73 patients treated for a PAU. Clinical and radiologic follow-up was performed in all patients. Results: Mean age of our population was 72 ± 8 years. Fifteen patients (20.5%) were treated in an emergency setting. The proximal landing zone was in arch zone 2 in 22 patients (30.1%). In-hospital mortality was 6.8% and was associated with acute presentation (P = .005). Distal arch delivery of the endograft was unrelated to mortality (Fisher exact test, P = .157). Survival at 1 and 5 years was 81.7% and 67.3%, respectively. Sixteen patients underwent reintervention of the thoracic aorta. Patients who underwent emergency surgery and older patients had a shorter survival (log rank test, P < .001). No difference in survival was shown according to the proximal landing zone (log rank P = .292) or the dimension of the thoracic aorta (log rank P = .067). In multivariable Cox regression analysis, only age older than 75 years was associated with 5-year mortality (hazard ratio, 6.60; 95% CI, 2.12-20.56); P < .001). Conclusions: The use of TEVAR for treatment of aortic PAU is a safe procedure in an elective setting despite necessity of arch stent grafting. An early intervention performed at smaller aortic diameters of <55 mm might be beneficial in selected patients to improve late survival

BioGlue® is not associated with polypropylene suture breakage after aortic surgery

Objective: We have encountered broken or damaged polypropylene sutures (Prolene®) at the anastomotic sites during aortic reoperations. Because a surgical sealant, bovine serum albumin-glutaraldehyde (BioGlue®), was used in previous aortic surgery in some of these cases, we undertook this in vitro study to evaluate whether the use of BioGlue® was associated with breakage of polypropylene sutures at the aortic anastomosis. Materials and methods: The broken polypropylene sutures, anastomotic sites and aortic tissue at the location of suture breakage were visually inspected and evaluated intraoperatively. Six human cadaveric aortic samples were incised circumferentially and anastomosed proximally to a valved conduit with running 4–0 polypropylene sutures (Prolene®). In the test group (n = 3), BioGlue® was applied directly to the Prolene® sutures at the anastomotic sites, while in the control group (n = 3) the anastomoses were not sealed with any surgical adhesive. The six samples were immersed in Dulbecco's phosphate buffered saline solution and mounted on a M-6 Six Position Heart Valve Durability Testing System and tested up to 120 million cycles for a 2-year period. During and upon completion of the testing, the integrity of Prolene® sutures, the anastomosis and aortic tissues was regularly assessed by visual inspection. Results: Intraoperative findings included a stretched and thin aortic wall (some with thrombus), a small cleft between the aortic tissue and the Dacron vascular graft. An excessive amount of BioGlue® was often found around the anastomosis, with cracking material, but no signs of mechanical damage were observed in these cases. Upon visual inspection during and after in vitro testing, there was no apparent damage to the polypropylene sutures on the interior or exterior of the aortic anastomoses in any of the samples. No difference was observed in the physical integrity of the polypropylene sutures at anastomotic lines, the anastomoses and aortic tissues between the test and control samples. Conclusions: The results of this study suggest that the use of BioGlue® was not associated with breakage of the polypropylene sutures at the anastomotic sites after aortic dissection repair

Use of the frozen elephant trunk technique for type B aortic dissection and aberrant right subclavian artery: an anatomic repair of the “arteria lusoria”

Retrograde extension into the aortic arch occurs in 16.5% of patients with type B aortic dissection (TBAD) (1). This cohort of patients may be eligible for a radical repair using the frozen elephant trunk (FET) technique. The combination of surgical replacement of the aortic arch and deployment of the stent graft allows complete exclusion of the false lumen in aortic dissections. In the case of aneurysm or residual dissection, patients undergoing FET are ready for subsequent endovascular or surgical treatment (2)

Survival and reoperation in acute aortic syndromes - a single-centre experience of 912 patients

OBJECTIVES: Acute aortic syndromes are associated with poor outcomes, despite diagnostic and therapeutic advances. We analysed trends in volumes and outcomes from 2000 to 2021. METHODS: The study population includes 494 type A acute aortic syndromes (TAAAS) (54.2%) and 418 type B acute aortic syndromes (TBAAS) (45.8%). Primary outcomes were in-hospital mortality, long-term survival and freedom from aortic reoperation. RESULTS: Regardless the type of acute aortic syndrome, patient volumes increased over time. Patients with TBAAS were older, more likely to have comorbid conditions and previous cardiac surgery (P < 0.001), while cerebrovascular accidents were more frequent in TAAAS (P < 0.05). Among TAAAS, 143 (28.9%) required total arch and 351 (71.1%) hemiarch replacement. TBAAS management was medical therapy in 182 (43.5%), endovascular in 198 (47.4%) and surgical in 38 (9.1%) cases. Overall in-hospital mortality was 14.6% [18.2% in TAAAS (95% confidence interval (CI) 14.4-21.2%) vs 10.7% in TBAAS (95% CI 7.8%-13.7%); P = 0.0027]. After propensity score adjustment, in-hospital mortality exhibited a significantly decreasing trend from 2000 to 2021 (P < 0.001) in TAAAS and TBAAS. 1-, 5- and 10-year survival was 74.2%, 62.2% and 45.5% in TAAAS and 75.4%, 60.7% and 41.0% in TBAAS (P = 0.975), with no differences among treatment strategies. The adjusted cumulative reoperation risk at 10 years was more than two-fold in TBAAS versus TAAAS (9.5% vs 20.5%, hazard ratio (HR) = 2.30, 95% I 1.31-4.04). CONCLUSIONS: In the last decades, better patient triage and surgical/endovascular techniques led to substantial improvements in the management of acute aortic syndrome, with reduction in early mortality and reoperation rate. However, long-term mortality is still >50%

Transcatheter Mitral Valve-in-Valve Dislocation: A Rescue Strategy

In the transcatheter aortic valve replacement era, transapical valve-in-valve mitral valve implantation is considered an alternative treatment for high-risk patients with degenerated mitral bioprosthesis. We report an unusual strategy to remedy the potentially fatal complication of the mitral prosthesis migration into the aortic arch. The dislocated prosthesis was successfully stabilized in the aortic arch with a bare aortic stent, ensuring adequate perfusion of epiaortic vessels. \ua9 2018 The Society of Thoracic Surgeon

Probable Mud Volcanoes in Chyse Planitia, Mars: Updates on Morphological, Sedimentrogical and Spectral Studies

We update on our study of small edifice features in Chryse Planitia, Mars, which have been proposed to be mud volcanoes

Restructuring surgical training after COVID-19 pandemic: A nationwide survey on the Italian scenario on behalf of the Italian polyspecialistic young surgeons society (SPIGC)

Introduction: The COVID-19 pandemic has led to the disruption of surgical training. Lack of communication, guidelines for managing clinical activity as well as concerns for safety in the workplace appeared to be relevant issues. This study aims to investigate how surgical training has been reorganized in Italy, almost 2 years after the outbreak of COVID-19 pandemic. Materials and methods: A 16-item-electronic anonymous questionnaire was designed through SurveyMonkey© web application. This survey was composed of different sections concerning demographic characteristics and impacts of the second COVID-19 pandemic wave on surgical and research/didactic activities. Changes applied in the training programme and activities carried out were also investigated. The survey was carried out in the period between June and October 2021. Results: Four hundred and thirty responses were collected, and 399 were considered eligible to be included in the study analysis. Three hundred and thirty-five respondents continued working in Surgical Units, with a significant reduction (less than one surgical session per week) of surgical sessions in 49.6% of them. With concern to didactic and research activities, 140 residents maintained their usual activity, while 116 reported a reduction. A sub-group analysis on resident moved to COVID-19 departments showed a reduction of research activities in 35% of them. During the period considered in this survey, the surgical training program was not substantially modified for most of participants (74.6%). Conclusion: Our survey demonstrated that surgical residency programs haven't improved 2 years after the beginning of the pandemic. Further improvements are needed to guarantee completeness of surgical training, even in emergency conditions