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The Bentall procedure, using a composite valve graft, has become one of the standard therapies for aortic root disease. Patients with Marfan syndrome are prone to aortic annular dilatation and dissection and often undergo aortic root replacement, including the Bentall procedure. Therefore, this study aimed to compare the long-term outcomes of the Bentall procedure between Japanese patients with and without Marfan syndrome. Data from 294 patients who underwent the Bentall procedure over 37 years were retrospectively analyzed. The study compared the data of patients with Marfan syndrome (n = 94) and those without it (n = 200). Patient characteristics, surgical techniques, and postoperative outcomes were evaluated. Statistical analyses were performed to identify risk factors associated with early mortality, late mortality, reoperation, and aortic root reoperation. The early mortality rate was 4.1%, with no significant difference between patients with and without Marfan syndrome. The long-term survival rates at 10, 20, and 30 years were 81.0%, 66.5%, and 49.1%, respectively, with no significant between-group differences. Aortic reoperations were more frequent in patients with Marfan syndrome; however, the number did not differ significantly between the groups. Risk factors for late mortality included diabetes and coronary reimplantation with an inclusion technique. Aortic dissection, Marfan syndrome, and smoking were risk factors for aortic reoperation. Late mortality after the Bentall procedure was comparable between Japanese patients with and without Marfan syndrome although aortic reoperation was significantly frequent in patients with Marfan syndrome. Continuous monitoring and management, including the prevention of aortic dissection and dilation of residual aorta, are crucial for patients with Marfan syndrome undergoing the Bentall procedure., (© 2024. Springer Nature Japan KK, part of Springer Nature.)

Rationale: A U-shaped relationship should exist between lung volume and pulmonary vascular resistance (PVR), with minimal PVR at FRC. Thus, positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS) should increase PVR if it induces significant lung distension compared with recruitment. However, this has never been proved in patients. Objectives: To study the effects of PEEP on PVR according to lung recruitability, evaluated by the recruitment-to-inflation (R/I) ratio. Methods: In patients with ARDS, we measured hemodynamic (pulmonary artery catheter), echocardiographic, and ventilatory variables (including esophageal pressure) at both low PEEP and higher PEEP by 10 cm H2O. Preload responsiveness was assessed by the passive leg-raising test at high PEEP. Measurements and Main Results: We enrolled 23 patients, including 10 low recruiters (R/I <0.5) and 13 high recruiters (R/I ⩾0.5). Raising PEEP from 4 (2–5) to 14 (12–15) cm H2O increased PVR in low recruiters (from 160 [120–297] to 243 [166–380] dyn·s/cm5; P < 0.01), whereas PVR was unchanged in high recruiters (from 224 [185–289] to 235 [168–300] dyn·s/cm5; P = 0.55). Right-to-left ventricular end-diastolic area ratio simultaneously increased in low recruiters (from 0.54 [0.50–0.59] to 0.64 [0.56–0.70]; P < 0.01) while remaining stable in high recruiters (from 0.70 [0.65–0.79] to 0.68 [0.58–0.80]; P = 0.48). Raising PEEP decreased cardiac index only in preload responsive patients. Conclusions: PEEP increases PVR only when it induces significant lung distension compared with recruitment according to the R/I ratio. Tailoring PEEP on this recruitability index should mitigate its hemodynamic effects. [ABSTRACT FROM AUTHOR]

Background: Right ventricle impairment (RVI) is common during acute respiratory distress syndrome (ARDS) in adults and children, possibly mediated by the level of transpulmonary pressure (PL). We sought to investigate the impact of the level of PL on ARDS-associated right ventricle impairment (RVI). Methods: Adults and children (> 72 h of life) were included in this two centers prospective study if they were ventilated for a new-onset ARDS or pediatric ARDS, without spontaneous breathing and contra-indication to esophageal catheter. Serial measures of static lung, chest wall, and respiratory mechanics were coupled to critical care echocardiography (CCE) for 3 days. Mixed-effect logistic regression models tested the impact of lung stress (ΔPL) along with age, lung injury severity, and carbon dioxide partial pressure, on RVI using two definitions: acute cor pulmonale (ACP), and RV dysfunction (RVD). ACP was defined as a dilated RV with septal dyskinesia; RVD was defined as a composite criterion using tricuspid annular plane systolic excursion, S wave velocity, and fractional area change. Results: 46 patients were included (16 children, 30 adults) with 106 CCE (median of 2 CCE/patient). At day one, 19% of adults and 4/7 children > 1 year exhibited ACP, while 59% of adults and 44% of children exhibited RVD. In the entire population, ACP was present on 17/75 (23%) CCE. ACP was associated with an increased lung stress (mean ΔPL of 16.2 ± 6.6 cmH2O in ACP vs 11.3 ± 3.6 cmH2O, adjusted OR of 1.33, CI95% [1.11–1.59], p = 0.002) and being a child. RVD was present in 59/102 (58%) CCE and associated with lung stress. In children > 1 year, PEEP was significantly lower in case of ACP (9.3 [8.6; 10.0] cmH2O in ACP vs 15.0 [11.9; 16.3] cmH2O, p = 0.03). Conclusion: Lung stress was associated with RVI in adults and children with ARDS, children being particularly susceptible to RVI. Trial registration Clinical trials identifier: NCT0418467. [ABSTRACT FROM AUTHOR]

Heart–lungs interactions are related to the interplay between the cardiovascular and the respiratory system. They result from the respiratory-induced changes in intrathoracic pressure, which are transmitted to the cardiac cavities and to the changes in alveolar pressure, which may impact the lung microvessels. In spontaneously breathing patients, consequences of heart–lungs interactions are during inspiration an increase in right ventricular preload and afterload, a decrease in left ventricular preload and an increase in left ventricular afterload. In mechanically ventilated patients, consequences of heart–lungs interactions are during mechanical insufflation a decrease in right ventricular preload, an increase in right ventricular afterload, an increase in left ventricular preload and a decrease in left ventricular afterload. Physiologically and during normal breathing, heart–lungs interactions do not lead to significant hemodynamic consequences. Nevertheless, in some clinical settings such as acute exacerbation of chronic obstructive pulmonary disease, acute left heart failure or acute respiratory distress syndrome, heart–lungs interactions may lead to significant hemodynamic consequences. These are linked to complex pathophysiological mechanisms, including a marked inspiratory negativity of intrathoracic pressure, a marked inspiratory increase in transpulmonary pressure and an increase in intra-abdominal pressure. The most recent application of heart–lungs interactions is the prediction of fluid responsiveness in mechanically ventilated patients. The first test to be developed using heart–lungs interactions was the respiratory variation of pulse pressure. Subsequently, many other dynamic fluid responsiveness tests using heart–lungs interactions have been developed, such as the respiratory variations of pulse contour-based stroke volume or the respiratory variations of the inferior or superior vena cava diameters. All these tests share the same limitations, the most frequent being low tidal volume ventilation, persistent spontaneous breathing activity and cardiac arrhythmia. Nevertheless, when their main limitations are properly addressed, all these tests can help intensivists in the decision-making process regarding fluid administration and fluid removal in critically ill patients. [ABSTRACT FROM AUTHOR]

Infective endocarditis involving the aortic root is associated with a high degree of morbidity and mortality. Native aortic root infections can develop from aggressive organisms or from delays in diagnosis or definitive care, whereas prosthetic valve infections commonly result in extensive destruction of the aortic root and neighboring structures. Early detection, tailored antibiotic therapy, thoughtful pre-operative planning, and multidisciplinary heart team management are the keys to optimizing patient outcomes. Aggressive and complete surgical debridement are mandatory prior to aortic root reconstruction. Surgical experience and patient-centered decision making are critical in selecting the optimal reconstructive strategy for the aortic root and adjacent structures. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vasodilators, including oxygen, have not shown consistent beneficial effects on pulmonary hypertension due to valvular heart disease (PH-VHD). Therefore, the study aimed to assess the effect of 100% fractional inspiration of oxygen (FiO2) on pulmonary and systemic hemodynamics in patients with combined pre- and post-capillary pulmonary hypertension (CpcPH) and isolated post-capillary pulmonary hypertension (IpcPH) due to PH-VHD. Methods: This prospective study was conducted among patients with PH-VHD undergoing mitral or aortic valve replacement or repair. The study was conducted after induction of anesthesia and pulmonary artery catheterization. Cardiac output was obtained using thermodilution and all direct, and derived hemodynamic variables were obtained at 30% and 100% FiO2. The patients were stratified a priori into responders {(≥10 mmHg fall in mean pulmonary artery pressure (MPAP)} and non-responders. Results: Fifty-seven patients completed the acute vasodilator test. The mean age and body mass index of the study population was 41.8 ± 14.1 years and 21.4 ± 4.6 kg/m2, respectively. There was a significant decrease in MPAP (40.77 ± 12.07 mmHg vs 36.74 ± 13.3 mmHg; P <.001) and pulmonary vascular resistance (PVR) {(median; Interquartile range (IQR); 388; 371 vs 323; 362 dynes sec.cm−5; P <.001) at 100% FiO2. Transpulmonary gradient (TPG) and diastolic pulmonary gradient (DPG) also decreased significantly (P <.001 and P <.001). Cardiac output did not change significantly. The magnitude of decrease in MPAP, PVR, TPG, DPG, and pulmonary artery compliance (PAC) between CpcPH and IpcPH was comparable. Responders did not show a significantly greater fall in MPAP, PVR, TPG, DPG, and PAC after surgery. Conclusion: Hyperoxia may lead to reduction in MPAP and PVR in both hemodynamic phenotypes of PH-VHD. A larger sample size is required to support or refute the findings of this study. [ABSTRACT FROM AUTHOR]

With the incidence of thoracic aortic disease on the rise, total arch replacement (TAR) with frozen elephant trunk (FET) remains the gold-standard management strategy due to optimal results. Several FET devices exist commercially on the global market. However, the mainstay and most commonly used and reported device is the Thoraflex Hybrid Prosthesis (THP), with several recent reports suggesting its superiority. This review aims to collate and summarize the evidence in the literature on the clinical outcomes of TAR with FET using THP, with a focus on mortality, neurological complications, endoleak, distal stent-induced new entry (dSINE), aortic remodeling, coagulopathy, and graft kinking. In addition, the design features of THP is discussed, and an overview of market competitors is also highlighted. THP consistently demonstrates its effectiveness in treating complex thoracic aortic pathology through favorable clinical outcomes, which can be attributed to its unique and innovative design. Rates of early mortality ranged 0.6–14.2%, neurological complications 0–25%, endoleak 0–8.4% and dSINE 0–14.5%, with minimal incidence of graft kinking and coagulopathy. Aortic remodeling is favorable and comparable to competitors. All this evidence solidifies THP as the leading FET device, particularly when combined with appropriate patient selection and surgical planning. [ABSTRACT FROM AUTHOR]

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A patient in his late 30s presented with issues of retrosternal chest pain and palpitations. He had sustained a splinter injury to the left hemithorax a year ago for which he had been managed with a tube thoracostomy. During subsequent evaluations, he was found to have atrial fibrillations and a CT angiography revealed an arch of the aorta pseudoaneurysm with a fistulous communication with the innominate vein, which being a rare condition has no established treatment protocols. Endovascular salvage of the condition required an aortic Ishimaru zone 2 deployment of the thoracic endovascular aortic repair stent graft to provide an adequate landing zone. The elective left subclavian artery revascularisation was obtained by a left carotid artery to left subclavian artery bypass. Post procedure there was complete exclusion of the pseudoaneurysm sac, and the fistulous aorto-venous communication inflow tract. The patient recuperated well and has returned to full active duties. [ABSTRACT FROM AUTHOR]

Iatrogenic vascular air embolism is a relatively infrequent event but is associated with significant morbidity and mortality. These emboli can arise in many clinical settings such as neurosurgery, cardiac surgery, and liver transplantation, but more recently, endoscopy, hemodialysis, thoracentesis, tissue biopsy, angiography, and central and peripheral venous access and removal have overtaken surgery and trauma as significant causes of vascular air embolism. The true incidence may be greater since many of these air emboli are asymptomatic and frequently go undiagnosed or unreported. Due to the rarity of vascular air embolism and because of the many manifestations, diagnoses can be difficult and require immediate therapeutic intervention. An iatrogenic air embolism can result in both venous and arterial emboli whose anatomic locations dictate the clinical course. Most clinically significant iatrogenic air emboli are caused by arterial obstruction of small vessels because the pulmonary gas exchange filters the more frequent, smaller volume bubbles that gain access to the venous circulation. However, there is a subset of patients with venous air emboli caused by larger volumes of air who present withmore protean manifestations. There have been significant gains in the understanding of the interactions of fluid dynamics, hemostasis, and inflammation caused by air emboli due to in vitro and in vivo studies on flow dynamics of bubbles in small vessels. Intensive research regarding the thromboinflammatory changes at the level of the endothelium has been described recently. The obstruction of vessels by air emboli causes immediate pathoanatomic and immunologic and thromboinflammatory responses at the level of the endothelium. In this review, we describe those immunologic and thromboinflammatory responses at the level of the endothelium as well as evaluate traditional and novel forms of therapy for this rare and often unrecognized clinical condition. [ABSTRACT FROM AUTHOR]

Although tissue stiffness is known to play an important role in aortic dilatation, the current guidelines for offering preventative surgery in patients with Marfan syndrome rely solely on the aortic diameter. In this systematic review and meta-analysis, we analyze and compare literature on in vivo aortic stiffness measures in Marfan patients. Our aim is to assess the potential of these measurements as early indicators of aortic dilatation. Following the PRISMA guidelines, we collected literature on diameter and three in vivo stiffness measures: Pulse wave velocity (PWV), β -stiffness index (SI) and distensibility, at five different aortic locations in patients with Marfan syndrome. Results were reviewed and compared against each other. For meta-analysis, an augmented dataset was created by combining data from the literature. Regression with respect to age and statistical comparisons were performed. Thirty articles reporting data from 1925 patients with Marfan and 836 patients without Marfan were reviewed. PWV was found to be higher in Marfan, but only in dilated aortas. Distensibility was found to be lower even in non-dilated aortas, and its decrease was associated with higher chances of developing aortic dilatation. β -SI was higher in Marfan patients and was positively correlated with the rate of aortic dilatation, emphasizing its role as a valuable indicator. In our meta-analysis, all stiffness measures showed a significant variation with age. Distensibility and β -stiffness index were different in Marfan patients at all locations, and the difference was more pronounced after accounting for age-related variation. From the literature, β -SI and distensibility emerge as the best predictors of future aortic dilatation. Our meta-analysis quantifies age-related changes in aortic stiffness and highlights the importance of accounting for age in comparing these measurements. Missing diameter values in the literature limited our analysis. Further investigation of criteria combining stiffness and diameter is recommended to better assist clinical decisions for prophylactic surgery., (© 2024. The Author(s).)