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Purpose To evaluate the impact of individual institutions on the outcome after surgery for Stanford type A aortic dissection (TAAD). Methods This is an observational, multicenter, retrospective cohort study including 3902 patients who underwent surgery for TAAD at 18 university and non-university hospitals. Results Logistic regression showed that four hospitals had increased risk of in-hospital mortality, while two hospitals were associated with decreased risk of in-hospital mortality. Risk-adjusted in-hospital mortality rates were lower in four hospitals and higher in other four hospitals compared to the overall in-hospital mortality rate (17.7%). Participating hospitals were classified as overperforming or underperforming if their risk-adjusted in-hospital mortality rate was lower or higher than the in-hospital mortality rate of the overall series, respectively. Propensity score matching yielded 1729 pairs of patients operated at over- or underperforming hospitals. Overperforming hospitals had a significantly lower in-hospital mortality (12.8% vs. 22.2%, p p = 0.009) compared to underperforming hospitals. Aggregate data meta-regression of the results of participating hospitals showed that hospital volume was inversely associated with in-hospital mortality (p = 0.043). Hospitals with an annual volume of less than 15 cases had an increased risk of in-hospital mortality (adjusted OR, 1.345, 95% CI 1.126–1.607). Conclusion The present findings indicate that there are significant differences between hospitals in terms of early outcome after surgery for TAAD. Low hospital volume may be a determinant of poor outcome of TAAD. Trial registration ClinicalTrials.gov Identifier: NCT04831073.

Objective We sought to report our experience of repairing acute type A aortic dissection (ATAAD) over 21 years during in-hours versus out-of-hours before and after the establishment of specialized aortic service and rota. Methods A retrospective analysis of all patients who had ATAAD repair between November 1998 and December 2019 in our center. In-hours were defined as 08:00 to 19:59 hours and out of hours were defined as 20:00 to 07:59 hours. Results A total of 286 patients underwent repair of ATAAD. Eighty operations took place during the prerota period (43 operations in hours, 37 out of hours) and 206 operations during the specialized rota period (110 in hours, 96 out of hours). There was no difference in 30-day mortality between the in-hours and out-of-hours groups in either the prerota (23.3% vs 32.4%; P = .36) or specialized rota periods (11.6% vs 11.5%; P = .94). Mean number of cases per year increased by 83% between the prerota and specialized rota periods. Thirty-day mortality reduced in both the in-hours (23.3% vs 11.6%) and out-of-hours (32.4% vs 11.5%) groups since introduction of the specialized aortic rota. Conclusions Outcomes in repair of ATAAD during in-hours and out-of-hours periods are similar when operated on in a specialized unit with a dedicated aortic team. This emphasizes the current global trend of service centralization without particular attention to time of day to operate on such critical cohort patients.

Aortovascular medicine and surgery in relation to vascular health of the population requires input from a broad range of specialists and institutions throughout a patient life as well as integration with allied health care providers. This paper presents the essence of the novel clinical concept of the ‘Aortovascular Hub’ .

Background Acute Stanford type A aortic dissection (TAAD) is a life-threatening condition. Surgery is usually performed as a salvage procedure and is associated with significant postoperative early mortality and morbidity. Understanding the patient’s conditions and treatment strategies which are associated with these adverse events is essential for an appropriate management of acute TAAD. Methods Nineteen centers of cardiac surgery from seven European countries have collaborated to create a multicentre observational registry (ERTAAD), which will enroll consecutive patients who underwent surgery for acute TAAD from January 2005 to March 2021. Analysis of the impact of patient’s comorbidities, conditions at referral, surgical strategies and perioperative treatment on the early and late adverse events will be performed. The investigators have developed a classification of the urgency of the procedure based on the severity of preoperative hemodynamic conditions and malperfusion secondary to acute TAAD. The primary clinical outcomes will be in-hospital mortality, late mortality and reoperations on the aorta. Secondary outcomes will be stroke, acute kidney injury, surgical site infection, reoperation for bleeding, blood transfusion and length of stay in the intensive care unit. Discussion The analysis of this multicentre registry will allow conclusive results on the prognostic importance of critical preoperative conditions and the value of different treatment strategies to reduce the risk of early adverse events after surgery for acute TAAD. This registry is expected to provide insights into the long-term durability of different strategies of surgical repair for TAAD. Trial registration ClinicalTrials.gov Identifier: NCT04831073.

Objectives Management of infected prosthetic aortic grafts in the ascending and or root is complex and multifaceted. We report our diagnostic pathway, management and outcomes, identifying successful strategies. Methods This was a retrospective, single center, observational study. Consecutive patients who underwent management of infected aortic grafts in the ascending and/or root at our institution between October 1998 and December 2019 were included. The main outcome measures were: discharge from hospital alive with at least 1 year survival, operative mortality and success of primary treatment strategy. Results Twenty‐six patients presented with infection of proximal aortic grafts and were managed through a number of strategies with an overall hospital‐survival of 81% and 1 year survival of 69%. Twenty of them ultimately underwent redo surgery with 25% operative mortality (within 24 h of surgery). Five patients underwent washout and irrigation of which two were successfully treated and cured with adjunctive antibiotics and two went on to have staged explant and definitive surgery. Interval between surgery and infection was 42.5 ± 35.8 months. All patients had at least one major criterion and three minor criterions with no diagnostic uncertainty. The commonest primary strategy was 3a (definitive surgery), (13/26, 50%). Conclusions Adopting a systematic and flexible patient specific approach to the diagnosis and management of patients with proximal aortic graft infections results in reasonable overall 1 year survival. In the majority of patients surgery is ultimately required in an attempt to achieve a curative treatment; however this comes with high operative mortality risk.

Objective: To describe our experience of nine patients with extra-anatomical bypass for clinically ischemic distal limb during repair of acute Type A aortic dissection (ATAAD). Methods: We retrospectively examined a series of nine patients who underwent surgery for ATAAD. We identified a subset of the patients who presented with concomitant radiographic and clinical signs of lower limb ischemia. All but one patient (axillobifemoral bypass) underwent femorofemoral crossover grafting by the cardiac surgeon during cooling. Results: One hundred eighty-one cases of ATAAD underwent surgery during the study period with a mortality of 19.3%. Nine patients had persistent clinical evidence of lower limb ischemia (4.9%) and underwent extra-anatomical bypass during cooling. Two patients underwent additional fasciotomies. Mean delay from symptoms to surgery in these nine patients was 9.5 hours. Two patients had bilateral amputations despite revascularisation and, of note, had long delays in presentation for surgery (> 12 hours). There were no mortalities during these inpatient episodes. Outpatient radiographic follow-up at the first opportunity demonstrated 100% patency. Conclusion: Our experience suggests that, during complicated aortic dissection, limb ischemia may have a devastating outcome including amputation when diagnosis and referral are delayed. Early diagnosis and surgery are crucial in preventing this potentially devastating complication.

Diseases of the thoracic aorta are increasing in prevalence worldwide. Recent data indicated wide regional variation in the volume and complexity of aortic cases undertaken in United Kingdom cardiac centers, especially in case of acute type A aortic dissection (ATAAD) conditions. Patients treated in high-volume centers with a specific multidisciplinary aortic program had a significant reduction in ATAAD mortality when compared with low-volume centers. Following the initial phase of a national aortic center reorganization, the current study reflects the initial experience of a national collective of cardiothoracic surgeons with expertise in complex aortic surgery, using frozen elephant trunk as standard technique for the surgical treatment of patients affected by ATAAD. Between June 2013 and October 2017, 66 ATAAD patients (45% women) underwent hybrid aortic arch and frozen elephant trunk repair with the Thoraflex hybrid graft at 8 UK high-volume aortic centers. The in-hospital mortality accounted for 8 patients (12%). Postoperative temporary or permanent neurologic events and temporary renal replacement therapy occurred in 17% and 20% of patients, respectively. No spinal cord injury events were documented. Our data were similar to those reported in literature in the 2 largest experiences with the use of frozen elephant technique in ATAAD condition (in-hospital/30-day mortality: 11-12%). This initial experience demonstrated that frozen elephant technique can potentially be adopted as standard approach in life-threatening aortic diseases, with acceptable complication and mortality rates.

The emergence of severe acute respiratory syndrome coronavirus 2 in December 2019, presumed from the city of Wuhan, Hubei province in China, and the subsequent declaration of the disease as a pandemic by the World Health Organization as coronavirus disease 2019 (COVID‐19) in March 2020, had a significant impact on health care systems globally. Each country responded to this disease in different ways, however this was done broadly by fortifying and prioritizing health care provision as well as introducing social lockdown aiming to contain the infection and minimizing the risk of transmission. In the United Kingdom, a lockdown was introduced by the government on March 23, 2020 and all health care services were focussed to challenge the impact of COVID‐19. To do so, the United Kingdom National Health Service had to undergo widespread service reconfigurations and the so‐called “Nightingale Hospitals” were created de novo to bolster bed provision, and industries were asked to direct efforts to the production of ventilators. A government‐led public health campaign was publicized under the slogan of: “Stay home, Protect the NHS (National Health Service), Save lives.” The approach had a significant impact on the delivery of all surgical services but particularly cardiac surgery with its inherent critical care bed capacity. This paper describes the impact on provision for elective and emergency cardiac surgery in the United Kingdom, with a focus on aortovascular disease. We describe our aortovascular activity and outcomes during the period of UK lockdown and present a patient survey of attitudes to aortic surgery during COVID‐19 pandemic.

OBJECTIVES Pre-emptive strategies to manage the aortic complications of Marfan syndrome have resulted in improved life expectancy yet, secondary to the variation of phenotypic expression, anticipating the risk and nature of future aortic events is challenging. We examine rates of new aortic events and reinterventions in a Marfan cohort following initial aortic presentation. METHODS Retrospective cohort study of Marfan patients with aortic pathology presenting to our institution 1998–2018. Patients were grouped according to index event: aortic dissection or root aneurysm. Patients with aortic dissection were classified according to Debakey criteria. Incidence of new aortic events and frequency of reintervention were analysed. RESULTS One hundred and twenty-six aortic procedures were performed in 74 Marfan patients with a median follow-up of 7 years. Forty-seven patients had an index event of root aneurysm and 27 had aortic dissection. Following operative intervention in the aneurysm group, 7 patients developed Debakey III dissections raising the overall number of patients who developed dissection within this cohort to 34. Reinterventions were more frequent in the dissection group with full replacement of the native aorta in 5 patients. CONCLUSIONS After operative intervention on the proximal aorta, a proportion will develop distal pathology. A greater focus on factors contributing to future events, such as mapping genotypes to clinical course, may lead the way for targeted operative techniques and surveillance.

Correction to:Journal of Cardiothoracic Surgery (2021) 16:171 - https://doi.org/10.1186/s13019-021-01536-5

We describe a case of dynamic obstruction of the mesenteric arteries caused by aortic dissection. The flow pattern demonstrates a periodic flow variation, during which peak systolic velocity varied fourfold.

OBJECTIVE The COVID-19 Pandemic posed challenges to healthcare services across the world. There has been a significant restructuring of healthcare resources to protect services for patients with COVID-related illness and to maintain emergency and urgent medical and surgical activity. This study assess access to emergency treatment, logistical challenges and outcomes of patients with acute aortic syndrome during early months of COVID-19 Pandemic in the United Kingdom. METHODS A multicentre study participated by 19 cardiac centres from 1st March to 20th May 2020. A retrospective analysis of prospectively collected data obtained from individual centres’ national cardiac surgical database. Demographic details, choice of treatment, operative details and outcomes were collected. COVID screening, timing of surgery and outcomes of COVID positive and negative patients were also analysed. RESULTS 88 patients presented with acute aortic syndrome to participating centres from 1st March to 20th May 2020. There were 79 aortic dissections (89.8%), 7 intramural haematomas (7.9%) and 2 penetrating aortic ulcers (2.3%). Seventy-nine patients (89.8%) underwent surgery. In-hospital mortality was 25.3% (n= 20). Postoperative complications included: 13.9% postoperative stroke – 11.4% permanent and 2.3% temporary, 16.5% rate of haemofiltration and 10.1% rate of tracheostomy. 9 patients were treated conservatively with mortality of 60%. 7 patients were diagnosed with COVID and there was no associated mortality. CONCLUSION Despite of extensive restructuring of healthcare resources, access to emergency and urgent treatment for acute aortic syndrome patients was maintained in the early months of COVID-19 Pandemic in the UK. Clinical outcomes were similar to pre-pandemic period., Graphical abstract

ObjectivesTo date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore ‘real-world’ practice.DesignRetrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants’ demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed.Setting27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis.Participants31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG.ResultsIn-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: 75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes.ConclusionsSurgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease.

Background: While short-term outcomes for patients undergoing transcatheter aortic valve implantation (TAVI) have long been studied, there is very little data on their predictors. We aimed to identify the predictors of outcomes, such as intensive care unit (ICU) and in-hospital length of stay (LOS), duration of postoperative intubation and in-hospital mortality, after TAVI procedures. Methods: We conducted a retrospective cohort study of 162 consecutive patients with aortic valve disease, who were admitted to a tertiary hospital of Liverpool for TAVI, during a five-year period. The data was collected using of the hospital’s structured database on November 2014. Results: By using a multivariate analysis we found that any postoperative bleeding [odds ratio (OR) 2.71; 95% confidence interval (CI): 1.41–5.24] was the independent predictor of prolonged ICU-LOS, while older age (OR 1.11; 95% CI: 1.05–1.17) and transapical TAVI (OR 4.11; 95% CI: 1.94–8.71) were the predictors of prolonged in-hospital LOS. Additionally, patients treated with oral inotropic agents, preoperatively (OR 5.77; 95% CI: 2.21–15.01), non-diabetics (OR 3.07; 95% CI: 1.12–8.42) and those with any postoperative bleeding (OR 3.53; 95% CI: 1.68–7.43) had a significantly greater probability in remaining intubated postoperatively. The multivariate analysis did not reveal any predictor of in-hospital mortality. Conclusions: The above predictors permit the early identification of TAVI patients at high risk for longer hospitalization and increased mechanical ventilation. This piece of information is crucial for clinicians and administrators contributing to more efficient patient care planning and better allocation of healthcare resources.

OBJECTIVES Biological valves are the most commonly used prostheses for aortic valve replacement (AVR) surgery in the UK. The aim of this retrospective observational study was to compare 10-year outcomes of Perimount Magna and Mitroflow bioprosthesis implanted in a single center. METHODS The medical records of patients undergoing AVR in Liverpool Heart and Chest Hospital between 1999 and 2014 were examined. All data were collected retrospectively, and a propensity match analysis was performed with a ratio 3:1 to analyze 10-year outcomes. The primary outcomes were all-cause mortality rates and aortic valve reintervention rates. RESULTS A total of 2608 patients were included; Mitroflow bioprosthesis was used in 352 patients while Perimount Magna was used in 2256 patients. Median (interquartile range [IQR]) follow-up for the entire data set was 6.95 (4.99, 9.69) years. After 10 years, the all-cause mortality rate was higher in Mitroflow cohort 34.8% vs 14.7% (P

Type B aortic dissection, whether acute or chronic, is a challenging disease to manage successfully. The acute disease often presents as a complex range of pathologies, described as the acute aortic syndrome, often occurring as acute on chronic thoracoabdominal disease. This complexity makes acute Type B aortic dissection a challenging and rewarding condition to manage. Unlike acute Type A dissection, the primary objective of acute Type B aortic dissection is to steward or shepherd the patient into a chronic state with good medical management.

Acute Type A aortic dissection is a lethal condition requiring immediate surgery. This chapter discusses strategies for improving diagnosis, early medical management, transfer and operative approaches. The experience is based largely on our practice in the Liverpool Heart and Chest Hospital and is a practical guide to achieving a series of marginal gains in every step of the pathway to create a system that is more than the sum of its parts, providing better outcomes for patients. In addition, we describe a series of Key Quality Indicators that may be used to monitor and improve a service.

OBJECTIVE To report our outcomes and identify predictors of mortality after open descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) repair in a specialist aortic center. METHODS This retrospective observational cohort study included consecutive patients who underwent surgery at our institution between October 1998 and December 2019. The main outcome measures were mortality and major morbidities. A multivariate analysis was used to identify predictors of mortality. RESULTS There were 430 patients who underwent DTA (n = 157) and TAA (n = 273) repair; 151 underwent surgery nonelectively. Forty-eight patients (11%) died within 30 days of surgery. The 30-day mortality was lower after elective surgery (3.1% after DTA repair and 9.9% after TAAA repair), whereas nonelective surgery had a 30-day mortality of 17.9%. Fourteen additional patients died in hospital after 30 days, one after nonelective DTA repair and 13 after TAAA repair (10 elective), all but one extent II. In-hospital mortality for the whole cohort improved over time, as the activity volume increased, except for patients undergoing extent II TAAA repair. Predictors of in-hospital mortality were age ≥70 years (odds ratio [OR], 3.36; 95% confidence interval [CI], 1.79-6.32; P < .001), extent II repair (OR, 4.39; 95% CI, 2.34-8.21; P < .001), nonelective surgery (OR, 2.72; 95% CI, 1.44, 5.12; P = .002), out-of-hours surgery (OR, 8.17; 95% CI, 2.16-30.95; P = .002), a left ventricular ejection fraction of

Background: Despite recent advances in aortic surgery, acute type A aortic dissection remains a surgical emergency associated with high mortality and morbidity. Appropriate management is crucial to achieve satisfactory outcomes but the optimal surgical approach is controversial. The present systematic review and meta-analysis sought to access cumulative data from comparative studies between hemiarch and total aortic arch replacement in patients with acute type A aortic dissection. Methods: A systematic review of the literature using six databases. Eligible studies include comparative studies on hemiarch versus total arch replacement reporting short, medium and long term outcomes. A meta-analysis was performed on eligible studies reporting outcome of interest to quantify the effects of hemiarch replacement on mortality and morbidity risk compared to total arch replacement. Result: Fourteen retrospective studies met the inclusion criteria and 2,221 patients were included in the final analysis. Pooled analysis showed that hemiarch replacement was associated with a lower risk of post-operative renal dialysis [risk ratio (RR) =0.72; 95% confidence interval (CI): 0.56–0.94; P=0.02; I 2 =0%]. There was no significant difference in terms of in-hospital mortality between the two groups (RR =0.84; 95% CI: 0.65–1.09; P=0.20; I 2 =0%). Cardiopulmonary bypass, aortic cross clamp and circulatory arrest times were significantly longer in total arch replacement. During follow up, no significant difference was reported from current studies between the two operative approaches in terms of aortic re-intervention and freedom from aortic reoperation. Conclusions: Within the context of publication bias by high volume aortic centres and non-randomized data sets, there was no difference in mortality outcomes between the two groups. This analysis serves to demonstrate that for those centers doing sufficient total aortic arch activity to allow for publication, excellent and equivalent outcomes are achievable. Conclusions on differences in longer term outcome data are required. We do not, however, advocate total arch as a primary approach by all centers and surgeons irrespective of patient characteristics, but rather, a tailored approach based on surgeon and center experience and patient presentation.

We introduced a new algorithm utilizing a patient's own platelet rich plasma and factor concentrates to better manage coagulopathy in aortic surgery under circulatory arrest. This study compares the outcomes of the patients treated with a new algorithm with those of patients managed with our traditional approach.The data of 247 consecutive patients who had aortic surgery were analyzed. The 158 patients (group 1) who were managed with our usual algorithm were compared with the 89 patients (group 2) who were treated with the novel algorithm consisting of utilization of the patient's own platelet rich plasma, fibrinogen, and prothrombin cell concentrates. Differences in transfusion and intensive care unit stay were analyzed. Univariate and multivariable robust regression analyses were performed.In comparison with group 1, patients in group 2 had significantly reduced need for transfusion of red cells (7.9 ± 8.6 vs 3.5 ± 3.8 units, P.001). Postoperative intubation time was reduced from a mean of 42 hours to a mean of 12 hours (P.001). The time to medical discharge from the intensive care unit was reduced from a mean of 7 days to a mean of 5 days (P.001), favoring the new algorithm. After adjustment for demographics and comorbidities, the novel algorithm remained significantly associated with a reduction in units of red blood cells transfused (robust parameter estimate, -1.14; P = .027) and blood products transfused (robust parameter estimate, -5.11; P.001).Using autologous plasma and factor concentrates to reverse coagulopathy in aortic surgery significantly reduces blood product transfusion.

Vasileios Patris,1 Konstantinos Giakoumidakis,1 Mihalis Argiriou,1 Katerina K Naka,2 Efstratios Apostolakis,3 Mark Field,4 Manoj Kuduvalli,4 Aung Oo,4 Stavros Siminelakis3 1Department of Cardiac Surgery, “Evangelismos” General Hospital of Athens, Athens, Greece; 2Department of Cardiology, Medical School, University of Ioannina, Ioannina, Greece; 3Department of Cardiothoracic Surgery, University of Ioannina, Ioannina, Greece; 4Department of Cardiothoracic Surgery, Heart and Chest Hospital of Liverpool, Liverpool, UK Purpose: To estimate the incidence of postprocedural early cardiac complications among patients undergoing transcatheter aortic valve implantation, through transapical approach (TA-TAVI), and to identify factors independently associated with the occurrence of them. Patients and methods: A retrospective cohort study of 90 patients, who had undergone TA-TAVI in a tertiary hospital of Liverpool, UK, during a 5-year period (September 2008–October 2013), was conducted. Data on patient demographics, periprocedural characteristics and cardiac complications presented within 30-day post TA-TAVI were collected, retrospectively, using the hospital’s electronic database. Results: The overall 30-day incidence of cardiac complications was estimated at 18.9% (n=17/90). The rate of new onset of atrial fibrillation (AF), atrioventricular block requiring permanent pacemaker implantation, shockable cardiac arrest rhythm and cardiac tamponade was 11.1%, 3.3%, 2.2% and 2.2%, respectively. Bivariate analysis found that absence of preoperative AF (p=0.01), receiving of oral inotropes preprocedurally (p=0.01), intravenous inotropic support postprocedurally (p=0.01) and requirement for postprocedural tracheal intubation (p=0.001) were the main factors associated with increased probability for patient cardiac morbidity. Conclusion: It seems that patients with absence of AF and oral inotropic support preprocedurally and those with post TA-TAVI mechanical ventilatory and intravenous inotropic support have greater probability to develop cardiac complications. This knowledge allows the early identification of high-risk patients and supports clinicians to apply both preventive and therapeutic interventions for the optimum patient management and care. In addition, administrators could allocate the health care system resources effectively. Keywords: aortic valve stenosis, complications, retrospective studies, transcatheter aortic valve replacement

Objective We seek to assess the safety of total arch replacement with frozen elephant trunk for acute type A aortic dissection in respect to the risks of operative mortality, stroke, and paraplegia using an international multicenter registry (ARCH). Methods The ARCH Registry database from 37 participating centers was analyzed between 2000 and 2015. Patients who underwent emergency surgery for acute type A aortic dissection treated by total arch replacement with or without frozen elephant trunk were included. Operative mortality, permanent neurologic deficits, and spinal cord injury were primary end points. These end points were analyzed using univariate and hierarchical multivariate regression analyses, as well as conditional logistic regression analysis and post hoc propensity-score stratification. Results A total of 11,928 patients were enrolled in the ARCH database, of which 6180 were managed with total arch replacement. A comprehensive analysis was performed for 978 patients who underwent total aortic arch replacement for acute type A aortic dissection with or without frozen elephant trunk placement. In propensity-score matching, there were no significant differences between total arch replacement and frozen elephant trunk in terms of permanent neurologic deficits (11.9% vs 10.1%, P = .59) and spinal cord injury (4.0% vs 6.3%, P = .52) For patients included in the post hoc propensity-score stratification, frozen elephant trunk was associated with a statistically significantly lower mortality risk (odds ratio, 0.47; P = .03). Conclusions The use of frozen elephant trunk for acute type A aortic dissection does not appear to increase the risk of paraplegia in appropriately selected patients at experienced centers. The exact risk factors for paraplegia remain to be determined.

Purpose: The purpose of this study is to compare the perioperative total prostate specific antigen (tPSA) levels among coronary artery bypass grafting (CABG) patients with and without extracorporeal circulation (ECC), to investigate the changes overtime of tPSA in each group separately and to determine the effect of body core temperature on tPSA levels. Materials and Methods: A prospective study was conducted. Our sample was allocated to: (a) Seven patients who underwent off pump CABG (Group I) and (b) 16 CABG patients with ECC (Group II). The levels of tPSA were measured preoperatively (baseline), intra-operatively and at the 4 th postoperative day. We compared the two groups on their tPSA levels and we investigated the changes of tPSA overtime in each group separately. Results: Intra-operative serum samples were obtained in significantly lower body temperature in patients of Group II than in those of Group I (31°C vs. 36.9°C, P < 0.001). In each group separately , postoperative tPSA levels were increased significantly compared to the baseline values (2.55 ng/ml vs. 0.39 ng/ml for Group I, P = 0.005 and 4.36 ng/ml vs. 0.77 for Group II, P < 0.001). CABG patients with ECC had significantly lower intra-operative tPSA levels than the baseline values (0.67 ng/ml vs. 0.77 ng/ml, P = 0.008). We did not observe significant differences of tPSA levels between the two groups. Conclusions: CABG surgery affects similarly the perioperative tPSA independently the involvement of ECC. Although all patients had significantly higher early postoperative tPSA levels, only those who underwent CABG with ECC had exceeded normal values and significantly decreased intra-operative tPSA. Hypothermia seems to be the causal factor of tPSA reduction.

Background Thoracic aortic disease has a high mortality. We sought to establish the contribution of unwarranted variation in care to regional differences in outcomes observed in patients with thoracic aortic disease in England. Methods and Results Data from the Hospital Episode Statistics ( HES ) and the National Adult Cardiac Surgery Audit ( NACSA ) were extracted. A parallel systematic review/meta‐analysis through December 2015, and structure and process questionnaire of English cardiac surgery units were also accomplished. Treatment and mortality rates were investigated. A total of 24 548 adult patients in the HES study, 8058 in the NACSA study, and 103 543 from a total of 33 studies in the systematic review were obtained. Treatment rates for thoracic aortic disease within 6 months of index admission ranged from 7.6% to 31.5% between English counties. Risk‐adjusted 6‐month mortality in untreated patients ranged from 19.4% to 36.3%. Regional variation persisted after adjustment for disease or patient factors. Regional cardiac units with higher case volumes treated more‐complex patients and had significantly lower risk‐adjusted mortality relative to low‐volume units. The results of the systematic review indicated that the delivery of care by multidisciplinary teams in high‐volume units resulted in better outcomes. The observational analyses and the online survey indicated that this is not how services are configured in most units in England. Conclusions Changes in the organization of services that address unwarranted variation in the provision of care for patients with thoracic aortic disease in England may result in more‐equitable access to treatment and improved outcomes.

Objectives: It is now well established by many groups that surgery on the aortic arch may be achieved with consistently low morbidity and mortality along with relatively good survival compared to estimated natural history for a number of aortic arch pathologies. The objectives of this study were to: 1) report, compare, and analyze our morbidity and mortality outcomes for hemiarch and total aortic arch surgery; 2) examine the survival benefit of hemiarch and total aortic arch surgery compared to age- and sex-matched controls; and 3) define factors which influence survival in these two groups and, in particular, identify those that are modifiable and potentially actionable. Methods: Outcomes from patients undergoing surgical resection of both hemiarch and total aortic arch at the Liverpool Heart and Chest Hospital between June 1999 and December 2012 were examined in a retrospective analysis of data collected for The Society for Cardiothoracic Surgeons (UK). Results: Over the period studied, a total of 1240 patients underwent aortic surgery, from which 287 were identified as having undergone hemi to total aortic arch surgery under deep or moderate hypothermic circulatory arrest. Twenty three percent of patients' surgeries were nonelective. The median age at the time of patients undergoing elective hemiarch was 64.3 years and total arch was 65.3 years (P = 0.25), with 40.1% being female in the entire group. A total of 140 patients underwent elective hemiarch replacement, while 81 underwent elective total arch replacement. Etiology of the aortic pathology was degenerative in 51.2% of the two groups, with 87.1% requiring aortic valve repair in the elective hemiarch group and 64.2% in the elective total arch group (P < 0.001). Elective in-hospital mortality was 2.1% in the hemiarch group and 6.2% (P = 0.15) in the total arch group with corresponding rates of stroke (2.9% versus 4.9%, P = 0.47), renal failure (4.3% versus 6.2%, P = 0.54), reexploration for bleeding (4.3% versus 4.9%, P > 0.99), and prolonged ventilation (8.6% versus 16.1%, P = 0.09). Overall mortality was 20.9% at 5 years, while it was 15.7% in the elective hemiarch and 25.9% in the total arch group (P = 0.065). Process control charts demonstrated stability of annualized mortality outcomes over the study period. Survival curve was flat and parallel compared to age- and sex-matched controls beyond 2 years. Multivariate analysis demonstrated the following independent factors associated with survival: renal dysfunction [hazard ratio (HR) = 3.11; 95% confidence interval (CI) = 1.44-6.73], New York Heart Association (NYHA) class ≥ III (HR = 2.25; 95% CI = 1.38-3.67), circulatory arrest time > 100 minutes (HR = 2.92; 95% CI = 1.57-5.43), peripheral vascular disease (HR = 2.44; 95% CI = 1.25-4.74), and concomitant coronary artery bypass graft operation (HR = 2.14; 95% CI = 1.20-3.80). Conclusions: Morbidity, mortality, and medium-term survival were not statistically different for patients undergoing elective hemi-aortic arch and total aortic arch surgery. The survival curve in this group of patients is flat and parallel to sex- and age-matched controls beyond 2 years. Multivariate analysis identified independent influences on survival as renal dysfunction, NYHA class ≥ III, circulatory arrest time (> 100 min), peripheral vascular disease, and concomitant coronary artery bypass grafting. Focus on preoperative optimization of some of these variables may positively influence long-term survival.

Paraplegia is a complication that may occur following surgery or endovascular stenting of thoracic and thoracoabdominal aortic pathology. Measuring transcranial motor evoked potentials (tcMEPs) has been shown to provide a reliable measure of spinal cord function during such procedures allowing interventions to protect cord function. In the spirit of sharing experience and eliminating the learning curve for others, this manuscript describes our experience of setting up a service for tcMEP monitoring as well as the documents and algorithms for measuring, recording and acting on the patient data, the so-called 'MEP Pathway'.Recording and interpretation of tcMEP during thoracoabdominal aortic intervention requires training of staff and close team working in the operating theatre and postoperative intensive care unit. Providing consistent, reliable, specific and sensitive information on spinal cord function and its safe and effective use to alter patient outcomes requires a protocol. The MEP pathway was developed by medical and paramedical staff at our institution based on clinical experience and literature reviews over a 1-year period (2012-2013).The tcMEP pathway comprises six documents that guide staff in: (a) assessing suitability of patients, (b) setting up hardware, (c) preparing algorithms for management, (d) documenting intervention (left heart bypass, cardiopulmonary bypass or endovascular stenting) as well as (e) documenting postoperative intensive care processes.The tcMEP pathway acts as a guide for safe introduction and use of tcMEPs in thoracoabdominal aortic interventions. tcMEP-led guidance of intraoperative and postoperative management in thoracic aortic surgery is an important adjunct in caring for this patient group.

Introduction: Readmission in the intensive care unit (ICU) is a significant morbidity index, which has been related to poor patient outcomes Aim: To identify the preoperative and intraoperative risk factors for readmission in the cardiac surgery ICU. Methods: We conducted a retrospective cohort study of 595 consecutive patients who were admitted to the cardiac surgery ICU of a tertiary hospital of Athens - Greece during the one-year period (September 2011-September 2012). Data collection was carried out, retrospectively, by the use of a short questionnaire and based on the review of medical and nursing patient records at December 2012. Results: The incidence of ICU readmission was 3.7% (22/595). Respiratory disorders were the main reason for readmission (45.4%). Readmitted patients had a significantly higher in-hospital mortality compared to those requiring no readmission (P < 0.001). Multivariate analysis revealed that female gender [for males odds ratio (OR) 0.37, 95% confidence interval (CI) 0.15-0.89], high logistic EuroSCORE (OR 1.02, 95% CI 1.00-1.04), prolonged cardiopulmonary (CPB) duration (OR 1.01, 95% CI 1.00-1.02) and preoperative renal failure (OR 1.02, 95% CI 1.00-1.05) were the independent risk factors for readmission to the cardiac surgery ICU. Conclusions: One intraoperative and three preoperative variables are associated strongly with higher probability for ICU readmission. Shorter CPB duration could contribute to lower ICU readmission incidence. In addition, the early identification of high risk patients for readmission in the cardiac surgery ICU could encourage both the more efficient healthcare planning and resources allocation.

OBJECTIVES: Paraplegia is a rare but devastating complication, which may follow thoracoabdominal aortic surgery. Many adjuncts have been developed to reduce this risk including cerebrospinal fluid (CSF) drainage. Acetazolamide (carbonic anhydrase inhibitor) is a drug used to counteract mountain sickness and one of its effects is to reduce CSF production. Here, we report its first postoperative application in thoracoabdominal surgery with the aim of reducing cerebrospinal cord perfusion pressure and reducing risk of paraplegia. METHODS: We retrospectively reviewed 6 patients who have been treated with this drug between 2011 and 2012 who were undergoing thoracoabdominal aortic surgery. Our indications were decided to include: (i) patients in whom a spinal drain could not be positioned; (ii) patients with blood-stained CSF; (iii) patients in whom the volume of CSF drained was outside guidelines; (iv) patients in whom CSF pressure was elevated; (v) patients with excessive vasopressor usage and (vi) patients with postoperative neurological dysfunction as measured by motor-evoked potentials or clinical examination. All were given 500 mg intravenous acetazolamide, not more than eight hourly, for a duration dependent on response. RESULTS: In the 6 patients, 2 received a single dose of the drug and responded by an immediate drop in intracranial pressure (ICP) pressure. Of the 4 who received multiple doses of the drug, 1 had an immediate decline in ICP after each of the first six doses, while 3 had no discernable response. CONCLUSIONS: This is the first report of the efficacy of acetazolamide in reducing CSF production and lowering ICP during thoracoabdominal aortic surgery. We believe that its use will be beneficial in the 6 patient groups described. Our experience suggests there are ‘responders’ and ‘non-responders’, the characteristics of whom are yet to be defined. Its efficacy in reducing not just CSF volume and ICP but also clinically relevant morbidity such as paraplegia, is the subject of a planned randomized controlled trial. This report serves to raise awareness of the possible efficacy of this drug when normal management strategies are limited or exhausted.

The natural history of an intramural hematoma (IMH) has not been completely defined. This is a case report of a 63-year-old woman, in whom imaging reveals intercostal artery rupture during the process of expansion of an IMH in a Type B acute aortic syndrome. This case demonstrates that intercostal artery rupture may act as a precursor for the transformation of IMH to a classical dissection. Interestingly, complete resolution of this condition is achieved through medical management.

To report an initial experience of concomitant endovascular repair of abdominal aortic aneurysms (AAA) and cardiac surgery.Records for 10 consecutive patients (all men; median age 68 years, range 60-79) with AAA treated by a multidisciplinary team at a tertiary specialist center were retrospectively reviewed. Each patient had independent indications for surgical correction of their cardiac disease and AAAs. The patients underwent endovascular aneurysm repair (EVAR) followed by cardiac surgery under the same anesthesia. Eight patients had concomitant coronary artery bypass grafting (CABG; 4 off-pump), 1 patient had CABG and left ventricular aneurysmectomy, and 1 patient required aortic root replacement.All combined procedures were performed successfully under a single general anesthesia and took a median of 508 minutes (range 425-625). Median intensive care stay was 3 days (range 2-4), while hospital stay was 8 days (range 7-21) days. There were no deaths in-hospital or within 30 days. Complications were minor and self-limiting; there were no instances of renal failure. At a median follow-up of 29 months (range 14-38), no EVAR-related secondary interventions were required.Concomitant EVAR and cardiac surgery delivered by a multidisciplinary team is feasible, appears safe, and eliminates the risk associated with staged operations. Improved patient satisfaction and efficient use of resources are potential advantages.

We present a case of blunt traumatic aortic laceration following a motor vehicle crash. The aortic laceration was 4.5 cm above the coeliac axis and occurred because of an unstable tenth thoracic vertebral body. Open surgery was considered high risk, whereas an endovascular approach with an endoprosthesis placed at the exact anatomic location of the laceration was advocated.

Despite recent advances in aortic surgery, acute type A aortic dissection remains a surgical emergency associated with high mortality and morbidity. Appropriate management is crucial to achieve satisfactory outcomes but the optimal surgical approach is controversial. The present systematic review and meta-analysis sought to access cumulative data from comparative studies between hemiarch and total aortic arch replacement in patients with acute type A aortic dissection.A systematic review of the literature using six databases. Eligible studies include comparative studies on hemiarch versus total arch replacement reporting short, medium and long term outcomes. A meta-analysis was performed on eligible studies reporting outcome of interest to quantify the effects of hemiarch replacement on mortality and morbidity risk compared to total arch replacement.Fourteen retrospective studies met the inclusion criteria and 2,221 patients were included in the final analysis. Pooled analysis showed that hemiarch replacement was associated with a lower risk of post-operative renal dialysis [risk ratio (RR) =0.72; 95% confidence interval (CI): 0.56-0.94; P=0.02; I(2)=0%]. There was no significant difference in terms of in-hospital mortality between the two groups (RR =0.84; 95% CI: 0.65-1.09; P=0.20; I(2)=0%). Cardiopulmonary bypass, aortic cross clamp and circulatory arrest times were significantly longer in total arch replacement. During follow up, no significant difference was reported from current studies between the two operative approaches in terms of aortic re-intervention and freedom from aortic reoperation.Within the context of publication bias by high volume aortic centres and non-randomized data sets, there was no difference in mortality outcomes between the two groups. This analysis serves to demonstrate that for those centers doing sufficient total aortic arch activity to allow for publication, excellent and equivalent outcomes are achievable. Conclusions on differences in longer term outcome data are required. We do not, however, advocate total arch as a primary approach by all centers and surgeons irrespective of patient characteristics, but rather, a tailored approach based on surgeon and center experience and patient presentation.

Background: Acute type A aortic dissection repair is a surgical emergency associated with high mortality. In 2007, Liverpool Heart & Chest Hospital was the first institution in the United Kingdom to implement a thoracic aortic on-call dissection rota. We set out to investigate whether the dissection rota improved hospital quality outcomes and long-term survival. Methods: Data from a prospectively collected database was analysed following case note validation. Two hundred patients underwent acute type A aortic dissection repair between October 1998 and November 2015. To assess the effect of the post-dissection rota on operative and postoperative outcomes, propensity matching of pre- and post-dissection rota patients was used. Results: Eighty patients were identified from the pre-dissection rota era and 120 from the post-dissection rota era. Sixty patients from each era were then propensity matched. Comparative analyses showed that patients who underwent acute type A dissection repair in the post-dissection rota period were less likely to suffer in-hospital mortality in both the matched and unmatched groups (30% vs . 13.3%; P=0.004 and 28.3% vs . 11.7%; P=0.055, respectively). A similar improvement was shown in acute renal failure (26.3% vs . 14.2%; P=0.033 and 31.7% vs . 15.0%; P=0.044, respectively). However, cardiopulmonary bypass times and aortic cross clamp times were still significantly longer in the matched post–dissection rota cohort. There was a significant improvement in 5-year survival for the pre- and post-dissection rota in both the matched and unmatched patients (P=0.004 and P=0.034). Conclusions: Reorganization of surgical expertise, activity and implementation of a dissection rota within our hospital have resulted in lower in-hospital mortality and better survival outcomes in this group of patients.

Acute aortic dissection is associated with poor outcomes.1 Aortic dissection is classified as Stanford Type A when involving the ascending aorta and Type B when involving the descending aorta or arch.2 Stanford Type A has a well-accepted management algorithm with aggressive control of blood pressure and immediate transfer to a cardiac surgery unit for surgical intervention (American Heart Association Guidelines [AHA] and European Society of Cardiology3,4). Stanford Type B, however, has been shown to have significantly better outcomes when treated medically (International Registry Aortic Dissection [IRAD]1). As such simple uncomplicated acute Type B aortic dissection within the UK has for decades largely been treated in non-specialized departments with attempts to refer to cardiac services rebuffed. The incidence and prevalence of Type B aortic dissection in the UK is unknown and there has been no systematic collection of data on diagnosis, management or outcomes. These patients are commonly young and they are not served well by the current often indifferent attitude of concerned specialties. Type B aortic dissection is a complex dynamic disease with true and false lumens, rentry sites and malperfusion syndromes affecting multiple organs. Selected complicated cases with malperfusion syndromes are accepted into specialized units for intervention, either open, endovascular or hybrid approaches, however, the majority are managed medically. Managing blood pressure is complex in this setting and on occasions requires high-level care with invasive monitoring including arterial lines and spinal drainage. As thoracic aortic intervention in the UK enters a new era, it is incumbent on us to set standards for best care. Our suggestion is that it is no longer an acceptable standard of care to leave management of patients with acute Type B aortic dissections to non-specialized units. We review current relevant guidelines and develop a case for registration and or transfer of all Type B aortic dissections to centres which offer a subspecialized aortic service which is multidisciplinary team (MDT)-led and capable of offering a full range of interventional services whether open surgery, endovascular or a hybrid procedure.

In recent years there has been a convergence of approaches to the treatment of cardiovascular disease with combined cardiology, radiology and surgical multidisciplinary team (MDT) based management. This is particularly true with the advent of transcatheter (transfemoral and transapical) aortic valve replacement1 as well as the new combined open and endovascular approaches to thoraco‐abdominal aneurysms,2 including single stage combined coronary artery bypass grafting (CABG) and abdominal aortic endovascular aneurysm repair (EVAR).3 However, there has also been a more longstanding, and commonly although not exclusively, staged hybrid approach in the form of combining percutaneous coronary intervention (PCI) with surgical coronary revascularization and surgical valve repair or replacement in appropriate patients.4–6 As such, it is inevitable new operating enviroments have emerged in the form of so‐called ‘hybrid theatres’ allowing single stage, hybrid endovascular and open intervention for a range of morbidities in children and adults.7,8 This manuscript discusses briefly the design and function of a hybrid theatre, including its perceived advantages and disadvantages. By way of example we review our activity in this environment over the first year of opening. We discuss whether this resource is a nicety or necessity in adopting hybrid approaches. Design and function of the hybrid theatre As part of the development of a regional thoracic aortic aneurysm service a purpose‐built hybrid theatre was constructed (Philips) and opened in Liverpool in April 2007. A number of detailed descriptions of hybrid theatres exist8–10 and we therefore restrict the discussion here to a brief overview. Broken down into its basic structural components, the hybrid theatre is simply an operating theatre with built‐in radiological screening capabilities. In truth, however, the hybrid theatre is more than simply the sum of its parts. The bespoke C‐arm image intensifier is built into the ceiling of the operating room and able to move both longitudinally and rotate around the axis of the patient (Figures 1a and b). As such, the theatre complex is designed with ample space, allowing for dedicated cardiopulmonary bypass equipment as well as the paraphernalia associated with general anaesthesia. Other equipment, including transoesophageal echocardiography, cell salvage, electrocautery and pacing, are easily accommodated. Multiple monitors allow easy access to data at all points around the table. High quality overhead lights allow for good visibility. Consistent with a normal catheter laboratory the theatre is designed with a control/viewing room with dedicated image processing, as well as catheter store room, surgical scrub room and anteroom. Lead aprons are available. Other devices such as contrast injector and defibrillator are stored in theatre. It is not only the close proximity of this multidisciplinary equipment which makes this a unique environment, but the fact that it engenders a collaborative approach to the management of complex disease. Figure 1a and 1b Hybrid theatre showing the theatre table, roof-mounted C‐arm, perfusion, anaesthetic and surgical equipment Hybrid approaches to elective cardiovascular disease The hybrid activity in the theatre is coordinated by two MDT meetings attended regularly by consultant representation from cardiology and radiology, as well as both vascular surgery and cardiac surgery, and intensive care medicine. The specialization of these two groups centres on endovascular approaches to thoraco‐abdominal aortic disease and transfemoral/transapical aortic valve replacement. Hybrid thoracic endovascular aneurysm repair (TEVAR)/open procedures A team of three cardiac surgeons with an interest in thoraco‐abdominal aneurysms attend a weekly thoracic aneurysm clinic, with regional and supra regional referrals from the full range of medical specialties. Complex cases requiring endovascular solutions or combined endovascular/open approaches (hybrid or staged) are referred to a monthly MDT meeting attended by cardiac and vascular surgeons with input from both interventional and non-interventional radiologists. During the first year of coming online, a range of truly hybrid interventions have been performed. These include abdominal endovascular aneurysm repairs (EVAR) with simultaneous coronary artery bypass grafting (CABG), arch-related TEVAR with arch vessel bypass, TEVAR with femoral–femoral cross‐over graft, as well as a full range of isolated TEVAR procedures ( Table 1). Table 1 Surgical activity 2007–2008 Transfemoral and transapical aortic valve replacement A regular MDT comprising interventional cardiologists, cardiac surgeons and anaesthetists/intensivists discusses possible suitable patients for this approach. To date we have early experience with transfemoral and transpical aortic valve replacement and found the hybrid theatre exceptionally well suited for this activity.