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Background/Objectives: Heart failure (HF) remains a major therapeutic and diagnostic challenge nowadays. Albeit, acute decompensated HF is associated with several clinical signs such as dyspnea or edema, it remains a challenge to use easy accessible and suitable tools, such as biomarkers, to distinguish between patients at risk for an acute decompensation of their heart failure and compensated, stable HF patients. Existing biomarkers, such as natriuretic peptides or troponin, are not specific and can be elevated due to several other disease conditions, such as myocardial infarction, atrial fibrillation, or valve diseases. Therefore, the aim of this study was to analyze the predictive potential of four novel cardiovascular biomarkers—the soluble urokinase-type plasminogen activator receptor (suPAR), heart-type fatty acid binding protein (H-FABP), vascular cell adhesion molecule 1 (VCAM-1), and growth/differentiation factor 15 (GDF-15) for the detection of cardiac decompensation in patients with HF. Methods: In this study, 146 patients were prospectively enrolled and the serum biomarker concentrations were analyzed using Enzyme Linked Immunosorbent Assay (ELISA). We correlated the biomarker concentrations with clinical and biochemical parameters of all patients and the predictive value for detection of cardiac decompensation was assessed. Results: A significant increase in the levels of suPAR (1.6-fold-change, p < 0.0001), H-FABP (2.2-fold-change, p = 0.0458), VCAM-1 (1.6-fold-change, p < 0.0001), and GDF-15 (1.7-fold-change, p = 0.0009) was detected in all patients with acute decompensated HF in comparison to patients with compensated HF. Univariate logistic regression analysis revealed a significant association of biomarker plasma concentration with the risk for a cardiac decompensation (suPAR: p < 0.0001; VCAM-1: p < 0.0001, H-FABP: p = 0.0458; GDF-15: p = 0.0009). Conclusions: In conclusion, the investigated novel cardiovascular biomarkers suPAR, GDF-15, VCAM-1, and H-FABP could be a valuable tool to facilitate therapeutic decisions in patients with heart failure and suspicion of a cardiac decompensation. Parameters such as renal function should be taken into account. Further studies on novel biomarkers are required to find reliable, sensitive, and specific tools that will enable the early detection of patients with acute decompensation. [ABSTRACT FROM AUTHOR]

Large-scale analyses of surgical outcomes after surgical pulmonary valve replacement (sPVR) as part of re-do surgery in adults with congenital heart disease (ACHD) are rare. Therefore, we present our outcomes of sPVR in ACHD patients over the last decade and demonstrate our standardized surgical approach. All ACHD patients who underwent sPVR between January 2013 and August 2022 were included. Primary diagnoses, peri-operative data, post-operative echocardiography, pre- and post-operative RV MRI and in-hospital mortality were examined. Pre- and postoperative MRI parameters were compared using paired testing. Standardized surgery was documented. Normality of continuous variables was tested using Shapiro-Wilk test. 79 patients (male 59.5% (n = 47), 71 re-operations (89.9%)) at a median age of 41.7 (52.2–28.8) years were included. Main underlying disease was Tetralogy of Fallot (TOF; n = 47, 59.5%). After removal of degenerated valve/conduit parts, right ventricular outflow tract (RVOT) patch augmentation and implantation of a larger stented bioprosthesis (25mm in 78.5%) were conducted. In 57% of cases, concomitant surgery was performed (mainly tricuspid valve surgery: n = 28, 35.4%). 25 patients (31.6%) were operated with beating heart technique. Echocardiographic outcomes showed no moderate or severe insufficiency (median Vmax of 2 m/s (2.3–1.77 m/s)) upon discharge. Available MRI data showed significantly lower indexed RV-EDV (p = 0.0006) and RV-ESV (P = 0.0017) after surgery. In-hospital mortality was 5.1% (n = 4). SPVR is a safe therapeutic option with low surgical risk and satisfying post-operative results. It can serve as a solid therapeutic option for patients who need future valve-in-valve interventions. [ABSTRACT FROM AUTHOR]

Background: The benefits and harms associated with femoral artery cannulation over other sites of arterial cannulation for surgical repair of acute Stanford type A aortic dissection (TAAD) are not conclusively established. Methods: We evaluated the outcomes after surgery for TAAD using femoral artery cannulation, supra‐aortic arterial cannulation (i.e., innominate/subclavian/axillary artery cannulation), and direct aortic cannulation. Results: 3751 (96.1%) patients were eligible for this analysis. In‐hospital mortality using supra‐aortic arterial cannulation was comparable to femoral artery cannulation (17.8% vs. 18.4%; adjusted OR 0.846, 95% CI 0.799–1.202). This finding was confirmed in 1028 propensity score‐matched pairs of patients with supra‐aortic arterial cannulation or femoral artery cannulation (17.5% vs. 17.0%, p = 0.770). In‐hospital mortality after direct aortic cannulation was lower compared to femoral artery cannulation (14.0% vs. 18.4%, adjusted OR 0.703, 95% CI 0.529–0.934). Among 583 propensity score‐matched pairs of patients, direct aortic cannulation was associated with lower rates of in‐hospital mortality (13.4% vs. 19.6%, p = 0.004) compared to femoral artery cannulation. Switching of the primary site of arterial cannulation was associated with increased rate of in‐hospital mortality (36.5% vs. 17.0%; adjusted OR 2.730, 95% CI 1.564–4.765). Ten‐year mortality was similar in the study cohorts. Conclusions: In this study, the outcomes of surgery for TAAD using femoral arterial cannulation were comparable to those using supra‐aortic arterial cannulation. However, femoral arterial cannulation was associated with higher in‐hospital mortality than direct aortic cannulation. Trial registration: ClinicalTrials.gov registration code: NCT04831073. [ABSTRACT FROM AUTHOR]

OBJECTIVES Gender difference in the outcome after type A aortic dissection (TAAD) surgery remains an issue of ongoing debate. In this study, we aimed to evaluate the impact of gender on the short- and long-term outcome after surgery for TAAD. METHODS A multicentre European registry retrospectively included all consecutive TAAD surgery patients between 2005 and 2021 from 18 hospitals across 8 European countries. Early and late mortality, and cumulative incidence of aortic reoperation were compared between genders. RESULTS A total of 3902 patients underwent TAAD surgery, with 1185 (30.4%) being females. After propensity score matching, 766 pairs of males and females were compared. No statistical differences were detected in the early postoperative outcome between genders. Ten-year survival was comparable between genders (47.8% vs 47.1%; log-rank test, P  = 0.679), as well as cumulative incidences of distal or proximal aortic reoperations. Ten-year relative survival compared to country-, year-, age- and sex-matched general population was higher among males (0.65) compared to females (0.58). The time-period subanalysis revealed advancements in surgical techniques in both genders over the years. However, an increase in stroke was observed over time for both populations, particularly among females. CONCLUSIONS The past 16 years have witnessed marked advancements in surgical techniques for TAAD in both males and females, achieving comparable early and late mortality rates. Despite these findings, late relative survival was still in favour of males. [ABSTRACT FROM AUTHOR]

Background Extended aortic repair is considered a key issue for the long-term durability of surgery for DeBakey type 1 aortic dissection. The risk of aortic degeneration may be higher in young patients due to their long life expectancy. The early outcome and durability of aortic surgery in these patients were investigated in the present study. Methods The subjects of the present analysis were patients under 60 years old who underwent surgical repair for acute DeBakey type 1 aortic dissection at 18 cardiac surgery centres across Europe between 2005 and 2021. Patients underwent ascending aortic repair or total aortic arch repair using the conventional technique or the frozen elephant trunk technique. The primary outcome was 5-year cumulative incidence of reoperation on the distal aorta. Results Overall, 915 patients underwent surgical ascending aortic repair and 284 patients underwent surgical total aortic arch repair. The frozen elephant trunk procedure was performed in 128 patients. Among 245 propensity score–matched pairs, total aortic arch repair did not decrease the rate of distal aortic reoperation compared to ascending aortic repair (5-year cumulative incidence, 6.7% versus 6.7%, subdistributional hazard ratio 1.127, 95% c.i. 0.523 to 2.427). Total aortic arch repair increased the incidence of postoperative stroke/global brain ischaemia (25.7% versus 18.4%, P = 0.050) and dialysis (19.6% versus 12.7%, P = 0.003). Five-year mortality was comparable after ascending aortic repair and total aortic arch repair (22.8% versus 27.3%, P = 0.172). Conclusions In patients under 60 years old with DeBakey type 1 aortic dissection, total aortic arch replacement compared with ascending aortic repair did not reduce the incidence of distal aortic operations at 5 years. When feasible, ascending aortic repair for DeBakey type 1 aortic dissection is associated with satisfactory early and mid-term outcomes. Trial registration ClinicalTrials.gov Identifier: NCT04831073. [ABSTRACT FROM AUTHOR]

(1) Background: Acute Stanford type A aortic dissection (TAAD) may complicate the outcome of cardiovascular procedures. Data on the outcome after surgery for iatrogenic acute TAAD is scarce. (2) Methods: The European Registry of Type A Aortic Dissection (ERTAAD) is a multicenter, retrospective study including patients who underwent surgery for acute TAAD at 18 hospitals from eight European countries. The primary outcomes were in-hospital mortality and 5-year mortality. Twenty-seven secondary outcomes were evaluated. (3) Results: Out of 3902 consecutive patients who underwent surgery for acute TAAD, 103 (2.6%) had iatrogenic TAAD. Cardiac surgery (37.8%) and percutaneous coronary intervention (36.9%) were the most frequent causes leading to iatrogenic TAAD, followed by diagnostic coronary angiography (13.6%), transcatheter aortic valve replacement (10.7%) and peripheral endovascular procedure (1.0%). In hospital mortality was 20.5% after cardiac surgery, 31.6% after percutaneous coronary intervention, 42.9% after diagnostic coronary angiography, 45.5% after transcatheter aortic valve replacement and nihil after peripheral endovascular procedure (p = 0.092), with similar 5-year mortality between different subgroups of iatrogenic TAAD (p = 0.710). Among 102 propensity score matched pairs, in-hospital mortality was significantly higher among patients with iatrogenic TAAD (30.4% vs. 15.7%, p = 0.013) compared to those with spontaneous TAAD. This finding was likely related to higher risk of postoperative heart failure (35.3% vs. 10.8%, p < 0.0001) among iatrogenic TAAD patients. Five-year mortality was comparable between patients with iatrogenic and spontaneous TAAD (46.2% vs. 39.4%, p = 0.163). (4) Conclusions: Iatrogenic origin of acute TAAD is quite uncommon but carries a significantly increased risk of in-hospital mortality compared to spontaneous TAAD. [ABSTRACT FROM AUTHOR]

The aim of this study was to compare the mortality rates, re-intervention rates, and volumetric changes in aortas following surgery, in terms of the true lumen and false lumen changes, using conventional hemi-arch repair (CET) and frozen elephant trunk (FET) techniques. During the period from 2015 to 2018, 66 patients underwent surgical treatment for acute aortic dissection (Debakey type 1). Demographic and procedure-related data were evaluated. We measured volumetric change before surgical treatment, at discharge, and at 12- and 24-month time points based on computed tomography angiography. The study cohort was divided into two groups (FET vs. CET). The mean age of the patients was 56.9 ± 9.4 years in the FET group versus 63.6 ± 11 years in the CET group (p = 0.063). The mean follow-up time was 24 ± 6 and 25 ± 5 months for the FET and CET groups, respectively. There were no significant differences between the two groups in terms of the medical histories of the cohorts. The results showed a significant increase in true lumen volume after the FET procedure (within 24 months postoperatively; p = 0.005), and no significant changes in total (p = 0.392) or false lumen (p = 0.659) volumes were noted. After the CET procedure, there were significant increases in total and false lumen volumes (p = 0.013, p = 0.042), while no significant change in true lumen was observed (p = 0.219). The volume increase in true lumen after the FET procedure was higher compared to the CET group at all postoperative time points (at discharge, 12 months, and 24 months) without significant evidence (p = 0.416, p = 0.422, p = 0.268). At two years, the volume increase in false lumen was significantly higher among the CET group compared to the FET group (p = 0.02). The Kaplan–Meier curve analysis showed that patients who underwent the CET procedure underwent significantly more re-interventions due to false lumen expansion of the descending aorta (p = 0.047). Present study results indicate that the true and false lumen changes in the aorta following the FET and CET procedures were different. FET led to a significant increase in true lumen volume, while false lumen volume remained stable; however, after the CET procedure, significant false lumen enlargement was noted at mid-term follow-up time points. The re-intervention rate after CET was higher due to false lumen expansion. [ABSTRACT FROM AUTHOR]

(1) Aim: The primary endpoint of this study was to evaluate the impact of frozen elephant trunk (FET) and conventional elephant trunk (CET) on aortic mural thrombus. The secondary endpoint was to investigate the incidence of persistent inflammatory response (IR) in the form of post-implantation syndrome (PIS) or persistent fever without infection focus after FET and CET, respectively, as well as the risk factors associated with its occurrence. (2) Methods: A single-center, retrospective, observational study of 57 consecutive patients treated with FET and CET between April 2015 and June 2020 was performed. Demographics, procedural data, perioperative laboratory exams as well as vital parameters were recorded. Pre- and postoperative computer tomography angiography (CTA) scans were analyzed with a dedicated software. IR was defined as the presence of continuous fever (>38°, lasting > 24 h) and leukocytosis (white blood cell count > 12 × 1000/µL) developing after surgery in the absence of an infection focus. (3) Results: Fifty-seven consecutive patients (mean age 58.4 ± 12.6 years, 36.8% females) treated with FET (66.6%) or CET (33.3%) for acute aortic dissection (56.1%), post-dissection-aneurysm (19.2%) or aortic aneurysm (24.5%) were included. The median thrombus volume on CTA preoperatively was 10.1 cm3 (range 2–408 cm3). After surgery, the median new-onset mural thrombus was 9.7 cm3 (range 0.2–376 cm3). Nineteen (33.3%) patients developed IR; patients with IR were significantly younger (p = 0.027), less frequently of female gender (p = 0.003) and more frequently affected from acute dissection (p = 0.002) and stayed in the intensive care unit (ICU) significantly longer (p = 0.033) than those without IR. Postoperatively, the volume of new-onset thrombus was significantly greater in the IR group (84.4 vs. 3.2 cm3, p < 0.001). (4) Conclusions: In the context of CET and FET, the persistent inflammatory response occurred in 33.3% of the patients with persistent fever without infection focus. IR was associated with a higher volume of new-onset thrombus and significantly prolonged ICU stay. Further studies to investigate these observations are needed. [ABSTRACT FROM AUTHOR]

Background: The extent of aortic replacement for aneurysms of the distal ascending aorta remains controversial and opinions vary between standard cross-clamp resection and open hemiarch anastomosis in circulatory arrest and selective cerebral perfusion. As the deleterious effects of extended circulatory arrest are well-known, borderline indication for distal ascending aorta aneurysm repair must be outweighed against the potential risk of complications related to the open anastomosis. In the present study, we describe our own approach consisting of "transversal arch clamping" for exhaustive resection of aneurysms of the distal ascending aorta without open anastomosis and we present the postoperative outcomes. Methods: Between May 2017 and December 2019, 35 patients with aneurysm of the ascending aorta (20 male, 15 female) underwent replacement with repair of the lesser curvature without circulatory arrest. Pre-operative, intraoperative, and postoperative clinical outcomes were retrospectively withdrawn from our institutional database and analyzed. Results: Maximal diameter of distal ascending aorta was 47.5 mm. Patient median age was 66 years (IQR 14) (range 42–86). Preoperative logistic median EuroSCORE II was 17% (IQR 11.3). Median duration of cardiopulmonary bypass and cardiac arrest were 137 (IQR 64) and 93 (IQR 59) min, respectively. In-hospital and 30-day mortality were 0%. There were no cases with acute low output syndrome, surgical re-exploration for bleeding, kidney injury requiring dialysis, or wound infection. Disabling stroke was observed in one patient (2.9%). There was one case of major ventricular arrhythmia (2.9%). Conclusions: Our institutional experience suggests that this novel technique is safe and feasible. It facilitates complete resection of the aortic ascending aneurysm avoiding circulatory arrest, antegrade cerebral perfusion, additional peripheral cannulation, and all related complications. [ABSTRACT FROM AUTHOR]

Abstract Background Secondary mitral insufficiency (SMI) is an indicator of a poor prognosis in patients with ischemic and dilated cardiomyopathies. Numerous studies corroborated that mitral valve (MV) surgery improves survival and may be an alternative to heart transplantation in this group of patients. The aim of the study was to retrospectively analyze the early and mid-term clinical results after MV repair resp. replacement in patients with moderate-severe to severe SMI and left ventricular ejection fraction (LVEF) below 35%. Methods We investigated 40 patients with poor LVEF (mean, 28 ± 5%) and SMI who underwent MV repair (n = 26) resp. replacement (n = 14) at the University Hospital Muenster from January 1994 to December 2005. All patients were on maximized heart failure medication. 6 pts. had prior coronary artery bypass grafts (CABG). Twenty-seven patients were in New York Heart Association (NYHA) class III and 13 were in class IV. Eight patients were initially considered for transplantation. During the operation, 14 pts had CABG for incidental disease and 8 had tricuspid valve repair. Follow-up included echocardiography, ECG, and physician's examination and was completed in 90% among survivors. Additionally, the late results were compared with the survival after orthotope heart transplantation (oHTX) in adults with ischemic or dilated cardiomyopathies matched to the same age and time period (148 patients). Results Three operative deaths (7.5%) occurred as a result of left ventricular failure in one and multiorgan failure in two patients. There were 14 late deaths, 2 to 67 months after MV procedure. Progress of heart failure was the main cause of death. 18 patients who were still alive took part on the follow-up examination. At a mean follow-up of 50 ± 34 (2–112) months the NYHA class improved significantly from 3.2 ± 0.5 to 2.2 ± 0.4 (p < 0.001). The LVEF improved significantly from 29 ± 5% to 39 ± 16 (p < 0.05). There were no differences in survival after MV repair or replacement. The 1-, 3-, 5-year survival rates in the study group were 80%, 58% and 55% respectively. In the group of patients after oHTX the survival was accordingly 72%, 68%, 66% (p > 0.05). Conclusion High risk mitral valve surgery in patients with cardiomyopathy and SMI offers a real mid-term alternative method of treatment of patients in drug refractory heart failure with similar survival in comparison to heart transplantation.

Background: It is known that the use of a cardiopulmonary bypass (CPB) during cardiac surgery leads to leukocyte activation and may, among other causes, induce organ dysfunction due to increased leukocyte recruitment into different organs. Leukocyte extravasation occurs in a cascade-like fashion, including capturing, rolling, adhesion, and transmigration. However, the molecular mechanisms of increased leukocyte recruitment caused by CPB are not known. This clinical study was undertaken in order to investigate which steps of the leukocyte recruitment cascade are affected by the systemic inflammation during CPB. Methods: We investigated the effects of CPB on the different steps of the leukocyte recruitment cascade in whole blood from healthy volunteers (n = 9) and patients undergoing cardiac surgery with the use of cardiopulmonary bypass (n = 7) or in off-pump coronary artery bypass-technique (OPCAB, n = 9) by using flow chamber experiments, transmigration assays, and biochemical analysis. Results: CPB abrogated selectin-induced slow leukocyte rolling on E-selectin/ICAM-1 and P-selectin/ICAM-1. In contrast, chemokine-induced arrest and transmigration was significantly increased by CPB. Mechanistically, the abolishment of slow leukocyte rolling was due to disturbances in intracellular signaling with reduced phosphorylation of phospholipase C (PLC) γ2, Akt, and p38 MAP kinase. Furthermore, CPB induced an elevated transmigration which was caused by upregulation of Mac-1 on neutrophils. Conclusion: These data suggest that CPB abrogates selectin-mediated slow leukocyte rolling by disturbing intracellular signaling, but that the clinically observed increased leukocyte recruitment caused by CPB is due to increased chemokine-induced arrest and transmigration. A better understanding of the underlying molecular mechanisms causing systemic inflammation after CPB may aid in the development of new therapeutic approaches. [ABSTRACT FROM AUTHOR]

We present a case of surgical treatment of a pseudoaneurysm of the right-sided aortic arch after stent implantation for primary coarctation in a 36-year-old woman with a previous history of ventricle septal defect closure in early childhood. As a first step, she underwent a left carotid to subclavian artery bypass for an aberrant left subclavian artery and as a second step a 'beating heart' aortic arch and descending aorta replacement via resternotomy. The postoperative course was uneventful. [ABSTRACT FROM AUTHOR]

Background Neoaortic pseudoaneurysm after previous surgery is rare and life-threatening. Case Description We present a case of a 6th redo surgery in a 23-year-old male patient with a history of hypoplastic left heart syndrome presenting with transsternal penetration of aortic pseudoaneurysm. The previously implanted Dacron prosthesis showed semicircular dehiscence. It was exchanged by a Vascutek prosthesis during circulatory arrest and selective antegrade cerebral perfusion. Conclusion Control imaging at 1 year after surgery was unobtrusive. Three years after surgery, the patient is alive and doing well., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Fungal endocarditis is associated with high surgical mortality rates. Advanced expertise is required for surgical treatment of this serious condition. In the present report, we describe the homograft replacement in a beating heart during re-re-re-re-do in a 29-year-old female patient with fungal endocarditis. The previous operations included Fallot correction at the age of 1 year, Contegra graft implantation in the right ventricular outflow tract (RVOT) due to severe pulmonary insufficiency, homograft implantation in pulmonary position due to Contegra endocarditis, and on-pump pericardial defect closure after homograft injury during sternal rewiring following wound infection., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: This observational study aimed to evaluate the perioperative risk factors for spinal cord ischemia (SCI) in patients who underwent aortic repair with the frozen elephant trunk technique (FET) after acute aortic Stanford A dissection., Methods: From May 2015 to April 2019, 31 patients underwent aortic arch replacement with the FET technique, and spinal ischemia was observed in 4 patients. The risk factors for postoperative SCI were analyzed., Results: The mean age of patients with acute aortic dissection was 57.1 years, and 29.4% were female. Four patients developed SCI. There were no significant differences in characteristics such as age and body mass index. The female gender was associated with most of the SCI cases in the univariate analysis (75%, p = 0.016). Known perioperative and intraoperative risk factors were not related to postoperative SCI in our study. Patients who developed SCI had increased serum postoperative creatinine levels ( p = 0.03). Twenty-four patients showed complete false lumen thrombosis up to zones 3-4, five patients up to zones 5-6 and two patients up to zones 7-9, which correlates with the postoperative development of SCI ( p = 0.02). The total number of patent intercostal arteries was significantly reduced postoperatively in SCI patients ( p = 0.044)., Conclusions: Postoperative acute kidney injury, the reduction in patent intercostal arteries after surgery and the extension of false lumen thrombosis up to and beyond zone 5 may play a significant role in the development of clinically relevant spinal cord injury after FET.

Objective: The aim of this study was to evaluate the early and mid-term results after the frozen elephant trunk (FET) procedure for the treatment of complex arch and proximal descending aortic disease in a single-center institution., Methods: From April 2015 to July 2021, 72 patients (25 women, 60.4 ± 10.3 years) underwent Thoraflex™ Hybrid implantation at our institution. The indications were thoracic aortic aneurysm (TAA) ( n = 16, 22.2%), post-dissection aneurysm ( n = 21, 29.2%), and acute aortic dissection (AAD) ( n = 35, 48.6%). Antegrade cerebral perfusion under moderate hypothermia (28°C) was employed in all cases. Eighteen patients (25%) have already been operated due to heart or aortic disease., Results: Overall in-hospital mortality was 12.5% (9 patients). Rates of permanent neurological dysfunction and spinal cord injury were 9.7 and 5.5%, respectively. The in-hospital mortality rate among patients operated on AAD, TAA, and post-dissection aneurysm were 8.6, 6.2, and 23.8%, respectively. At a mean follow-up of 26 ± 20 months, mortality was 9.7%. Furthermore, 23 patients (31.9%) required a subsequent procedure in distal aorta: endovascular stentgraft extension in 19 patients (26.4%) and open aortic surgery in 4 patients (5.5%). The mid-term survival of patients with type A aortic dissection was 97%., Conclusions: Our experience with the Thoraflex Hybrid prosthesis demonstrates its surgical applicability for different types of aortic pathologies with promising outcomes during early and midterm follow-up. Our technique and perioperative management lead to comparable or even superior neurological outcomes and mortality in urgent cases considering other high-volume centers., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Wisniewski, Motekallemi, Dell'Aquila, Oberhuber, Schaefers, Ibrahim, Martens and Rukosujew.)

Background: Post-implantation syndrome (PIS) is defined as non-infectious continuous fever and a concomitant rise in inflammatory markers shortly after endovascular aortic repair. PIS occurrence after hybrid procedures, such as the frozen elephant trunk (FET) technique, has not been adequately investigated. The current study aims to define the incidence of PIS after the FET and to identify possible risk factors associated with its occurrence., Methods: The clinical charts of 59 patients undergoing the FET between February 2015 and April 2020 were reviewed retrospectively. The occurrence of PIS was defined as the presence of fever (>38 °C lasting longer than one day during the hospitalisation) and leucocytosis (white blood cell count >12,000/µL). Patients with concomitant conditions possibly leading to fever and/or leucocytosis were excluded. Beside demographic and procedure-related data, serum/plasma inflammatory markers were evaluated before surgery and daily up to seven days postoperatively. Computed tomography scans (CT) were examined to calculate the volume of pre-existent and new-onset mural thrombus after the FET., Results: Thirty-eight patients met the inclusion criteria. The study cohort was divided into two groups based on the occurrence of PIS (17 cases; 44.7%). Patients with PIS were significantly younger than those without PIS (53.5±8.9 vs. 62.5±9.6 years; P=0.005). Female patients were less likely to develop PIS (5.2% vs. 26.3%, P=0.018). Patients with PIS had a higher volume of new-onset thrombus in the postoperative CT (P<0.001). Patients treated for post-dissection aneurysm had, postoperatively, significantly more thrombus material developed in a false lumen (P=0.02). Among the PIS markers, CRP (C-reactive protein) levels on the third postoperative day were independently associated with the volume of new-onset thrombus (P=0.011). After multivariate analysis, the volume of new-onset thrombus (P=0.028) and age (P=0.036) remained the variable associated with a statistically significant increased incidence of PIS., Conclusions: PIS can occur after the frozen elephant trunk procedure. The volume of new-onset thrombus seems to be associated with an increased incidence of PIS. These findings need to be confirmed in larger patient cohorts., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/jtd-21-398). The authors have no conflicts of interest to declare., (2021 Journal of Thoracic Disease. All rights reserved.)

Background: Frozen elephant trunk (FET) is an established approach to reduce late complications of type A aortic dissection (AADA) by diminishing false lumen perfusion. Currently, surface size of aortic lumina are evaluated using Computed tomography (CT). However, this 2D method is prone to error as it evaluates dissection progression slice by slice. Volume measurement on the other hand can overcome this limitation and deliver better insights in aortic remodeling. Therefore, the aim was to quantify volume changes of the descending and abdominal aorta at short- and mid-term follow-up after FET., Methods: Between April 2015 and March 2018, 20 patients who underwent surgical repair of AADA using the Thoraflex™ Hybrid Plexus (Vascutek, Terumo Aortic, Scotland) were included in this study. We measured volumetric change before surgical treatment, at discharge, at 12 and at 24 months based on CTAs (Computed tomography angiography). Surfaces and volumes have been analyzed using Aquarius iNtuition (TeraRecon Inc., Foster City, CA, USA)., Results: One hundred fifty-eight volumetric measures were obtained. The findings show a significant increase of volume of the true lumen (TL) while surface measurement of the TL did not show any significant change at other levels besides level C (diaphragm, P=0.00193). Variance analysis showed significant increase of volume, whereas no significant change was seen in false lumen. Post-hoc analysis revealed a significance at 24 months (P=0.047)., Conclusions: Although previous studies outline the clinical benefit of Thoraflex hybrid prosthesis on short-term follow up, this study provides a more precise understanding of aortic remodeling based on volumetric measurement. Thus, quantification of volume changes should be included for the assessment of optimal follow-up timing and consecutive procedure planning., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-20-2356). The authors have no conflicts of interest to declare., (2021 Journal of Thoracic Disease. All rights reserved.)

Background: Many patients with tetralogy of Fallot (TOF) who underwent surgical correction of their congenital cardiac malformation during infancy develop right ventricular dysfunction and exercise intolerance in the long term. The right ventricle (RV) dilates due to the development of severe pulmonary regurgitation (and secondary tricuspid insufficiency). To reduce RV dilation and improve exercise tolerance pulmonary valve replacement (PVR) is the common therapeutic strategy. Whether concomitant tricuspid valve repair (TVR) is beneficial in these pure volume-overload conditions is still unknown., Methods: Twenty-eight adults who received surgical PVR were included in the study and perioperative data including operative records, postoperative course and echocardiography before and after surgery was analyzed retrospectively., Results: Mean age of the patients was 41.1±13.5 years and PVR with Carpentier Edwards Perimount bioprostheses was performed 32.0±9.5 years after initial cardiac surgery. Preoperative echocardiography revealed moderate RV dilation in 60.7% of the patients and severe pulmonary valve regurgitation in 82.3%. Ten patients underwent additional TVR. Indication was purely based on annular dilation (>40 mm), independent from the degree of tricuspid insufficiency. Periprocedural data of both groups did not differ significantly. However, ICU stay was significantly increased in patients who underwent additional TVR (P=0.0420) and these patients developed more complications (P=0.0407) while postoperative echography showed the same recovery of the RV function and diameters, independent of concomitant TVR., Conclusions: In grown-ups with congenital heart disease surgical PVR with or without TVR is a safe procedure with good short-term outcomes. As the RV remodels after volume reduction, indication for concomitant TVR should be restrictive.

The patient was 62-year-old male who successfully underwent an anatomic repair of aortic coarctation at the age of 15 and an extra-anatomic ascending aorta- to-descending aorta bypass (graft size 20 mm) and an extra-anatomic ascending aorta to the left subclavian artery bypass (graft size 10 mm) at the age of 49. As he grew older he started presenting clinical symptoms of aortic stenosis. The echocardiogram showed a bicuspid aortic valve with severe stenosis and a mean gradient of 65 mm Hg. Despite the high surgical risk, we decided to perform an open valve replacement with installing the CPB prior to re-sternotomy with a simultaneous cannulation of the axillary and femoral arteries by reason of interrupted descending aorta. The postoperative course was uneventful.