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Clinical cases referring to the EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ aim to assist physicians in selecting the best management strategies for individual patients with a given condition. These expert opinions consider the impact on patient outcomes as well as the risk-benefit ratio of different diagnostic or therapeutic methods. These cases serve as a vital tool to aid physicians in making decisions in their daily practice. However, in essence, although these recommendations serve as a valuable resource to guide clinical practice, their application should be tailored to the needs of the individual patient. Each patient's case is unique, presenting its own set of variables and circumstances. This editorial is a tool designed to support, but not supersede, the decision-making process of physicians, based on their knowledge, expertise and understanding of their patients' individual situations. Furthermore, these clinical cases are based on the EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ but should not be interpreted as legally binding documents. The legal responsibilities of healthcare professionals remain firmly grounded in applicable laws and regulations, and the guidelines and the clinical cases presented in this document do not alter these obligations., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Several short-term analyses from German Registry for Acute Aortic Dissection Type A (GERAADA) have been published. This study investigated whether short-term risk factors are transferable to the long-term prognosis of patients., Methods: Thirty-three centres with 2686 patients participated in the long-term follow-up. A total of 1164 patients died, 1063 survived and 459 were lost to follow-up during the follow-up timeframe (mean duration: 10.2 years). Long-term mortality of the cohort was compared with an age-stratified, German population., Results: One, 5 and 10 years after initial surgery, the survival of the GERAADA patient cohort was 71.4%, 63.4% and 51%, respectively. Without the early deaths (90-day mortality 25.4%), survival was calculated after 1, 5 and 10 years: 95.6%, 83.5% and 68.3%. Higher age, longer extracorporeal circulation time, shorter perioperative ventilation time and postoperative neurologic deficits were predictive of long-term prognosis. In an age-divided landmark analysis, the mortality of aortic dissection surgery survivors was found to be similar to that of the general German population. If patients are sorted in risk groups according to the GERAADA score, long-term survival differs between the risk groups., Conclusions: If patients have survived an acute postoperative period of 90 days, life expectancy comparable to that of the general German population can be assumed in lower- and medium-risk patients. Whether the GERAADA score can provide valuable insights into the long-term prognosis of patients undergoing surgery for acute aortic dissection type A is still unclear., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of this study was to analyse the indications, surgical extent and results of treatment, as well as determine the risk factors for adverse outcomes after redo arch surgery., Methods: Between January 1996 and December 2022, 120 patients underwent aortic arch reoperations after primary proximal aortic surgery. We retrospectively analysed perioperative data, as well as early and mid-term outcomes in these patients., Results: Indications for arch reintervention included new aortic aneurysm in 34 patients (28.3%), expanding post-dissection aneurysm in 36 (30.0%), aortic graft infection in 39 (32.5%) and new aortic dissection in 9 cases. Two patients underwent reoperation due to iatrogenic complications. Thirty-one patients (25.8%) had concomitant endocarditis. In-hospital and 30-day mortality rates were 11.7% and 15.0%, respectively. Stroke was observed in 11 (9.2%) and paraplegia in 1 patient. Prior surgery due to aneurysm [odds ratio 4.5; 95% confidence interval (CI) 1.4-17.3] and critical preoperative state (odds ratio 5.9; 95% CI 1.5-23.7) were independent predictors of 30-day mortality. Overall 1- and 5-year survival was 65.8 ± 8.8% and 51.2 ± 10.6%, respectively. Diabetes mellitus (hazard ratio 2.4; 95% CI 1.0-5.1) and peripheral arterial disease (hazard ratio 4.7; 95% CI 1.1-14.3) were independent predictors of late death. The cumulative incidence of reoperations was 12.6% (95% CI 6.7-20.4%) at 5 years. Accounting for mortality as a competing event, connective tissue disorders (subdistribution hazard ratio 4.5; 95% CI 1.6-15.7) and interval between primary and redo surgery (subdistribution hazard ratio 1.04; 95% CI 1.02-1.06) were independent predictors of reoperations after redo arch surgery., Conclusions: Despite being technically demanding, aortic arch reoperations are feasible and can be performed with acceptable results., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Age-related atherosclerosis has been shown to cause aortic stiffness and wall rigidification. This analysis aimed to correlate age and dissection extension length in a large contemporary multicentre study. We hypothesize that younger patients suffer more extensive DeBakey type I dissection due to aortic wall integrity, allowing unhindered extension within the layers., Methods: The perioperative data of 3385 patients from the German Registry for Acute Aortic Dissection Type A were retrospectively analyzed with regard to postoperative outcomes and dissection extension. Patients with DeBakey type I aortic dissection (n = 2510) were retrospectively identified and divided into 2 age groups for comparison: ≤69 years (n = 1741) and ≥70 years (n = 769). Patients with DeBakey type II dissection or connective tissue disease were excluded from the analysis., Results: In younger patients (≤69 years), aortic dissection involved the supra-aortic vessels significantly more often (52.0% vs 40.1%; P < 0.001) and extended significantly further downstream the aorta: descending aorta (68.4% vs 57.1%; P < 0.001), abdominal aorta (54.6% vs 42.1%; P < 0.001) and iliac bifurcation (36.6% vs 26.0%; P < 0.001). Consequently, younger patients also presented with significantly higher incidences of preoperative cerebral (P < 0.001), spinal (P < 0.001), visceral (P < 0.001), renal (P = 0.013) and peripheral (P < 0.001) malperfusion. In older patients (≥70 years), dissection extent was significantly more often limited to the level of the aortic arch (40.9% vs 29.2%; P < 0.001). No significant difference was found with regard to 30-day mortality (20.7% vs 23.6%; P = 0.114)., Conclusions: Extensive DeBakey type I aortic dissection is less frequent in older patients ≥70 years than in younger patients. In contrast, younger patients suffer more often from preoperative organ malperfusion and associated complications. Postoperative mortality remains high irrespective of age groups., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The Bentall procedure is the gold standard for patients with combined aortic root dilation and valve dysfunction. Over the past decade, fast-track (FT) perioperative anaesthetic management protocols have progressively evolved. We reviewed our results for selected patients undergoing Bentall surgery under an FT protocol., Methods: We retrospectively analysed a consecutive cohort of patients who underwent elective Bentall procedures at our institution between 2000 and 2018. Complex aortic root repair (i.e. David and Ross procedure, redo surgery, major concomitant procedures, emergency repair for acute dissections) was excluded. Patients who underwent conventional perioperative treatment and those treated according to our institutional FT concept were compared following 1:1 propensity score matching., Results: Of 772 patients who fit the in- and exclusion criteria, 565 were treated conventionally post-surgery, while 207 were treated using the FT protocol. Propensity score matching resulted in 197 pairs, with no differences in baseline characteristics after matching. In-house mortality, 30-day mortality and overall all-cause long-term mortality were comparable between the FT and the conventionally treated cohort. Postoperative anaesthetic care unit/intensive care unit length-of-stay (6.2 vs 20.6 h, P = 0.03) and postoperative ventilation times (158.9 vs 465.5 min, P < 0.001) were significantly shorter in the FT cohort. There were no differences in rates of postoperative adverse events., Conclusions: In centres with experienced anaesthesiologists, perioperative FT management is non-inferior to conventionally treated patients undergoing elective Bentall procedures without compromising patient safety., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Aortic steal is an underestimated risk factor for intraoperative spinal cord ischaemia. A negative effect on spinal cord perfusion in thoraco-abdominal aneurysm repair has been suspected if blood drains away from the cord initiated by a reversal of the arterial pressure gradient. The amount of blood and pressure loss via back-bleeding of segmental arteries and the impact of distal aortic perfusion (DaP) have not been analysed yet. The aim of our study was to quantify 'segmental steal' in vivo during simulated thoraco-abdominal aneurysm repair and to determine the impact of DaP on steal and spinal cord perfusion., Methods: Ten juvenile pigs were put on cardiopulmonary bypass with DaP and visceral arteries were ligated. 'Segmental steal' was quantified by draining against gravity with/without DaP. Blood volume of 'segmental steal' was quantified and microspheres were injected for Post mortem spinal cord perfusion analysis. 'Segmental steal' was quantified with/without DaP-and with stopped DaP., Results: Quantification revealed a significantly higher steal on cardiopulmonary bypass with DaP with a mean difference of 24(11) ml/min. In all spinal cord segments, blood flow was diminished during steal drainage on DaP, compared to 'no steal'. The least perfused region was the low thoracic to upper lumbar segment., Conclusions: 'Segmental steal' is a relevant threat to spinal cord perfusion-even with the utilization of DaP-diminishing spinal cord perfusion. The blood volume lost by back-bleeding of segmental arteries is not to be underestimated and occlusion of segmental arteries should be considered in thoraco-abdominal aneurysm repair., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Full sternotomy (FS) is the common surgical access for patients undergoing open aortic valve replacement (AVR) with concomitant supracommissural replacement of the tubular ascending aorta. Since minimally invasive approaches are being used with increasing frequency in cardiac surgery, the aim of this study was to compare outcomes of patients undergoing AVR with supracommissural replacement of the tubular ascending aorta via FS versus partial upper sternotomy (PS)., Methods: We included all patients who underwent elective AVR with concomitant supracommissural replacement of the tubular ascending aorta at our institution between 2000 and 2015. Exclusion criteria were emergency surgery, other major concomitant procedures and reoperations. After 2:1 propensity score matching, outcomes of patients with PS and FS were compared., Results: A total of 652 consecutive patients were included, 117 patients operated via PS and 234 patients operated via FS. Cardiopulmonary bypass time and aortic cross-clamp time of the PS and FS groups were 89 vs 92 min (P = 0.2) and 65 vs 70 min (P = 0.3), respectively. Postoperative morbidity was low and there were no significant differences in postoperative outcomes between patient groups. In-hospital mortality was 1.7% in the PS vs 0.4% in the FS group (P = 0.3). Kaplan-Meier analysis revealed no difference in mid-term survival (P = 0.3). Reoperation rates for valve or aortic complications were very low with no significant difference between groups., Conclusions: In a high-volume centre with extensive experience in minimally invasive cardiac surgery, AVR with concomitant supracommissural replacement of the tubular ascending aorta via PS results in similar outcomes with regard to safety and longevity when compared to conventional FS., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Reoperative tricuspid valve (TV) surgery is considered high risk even in the absence of additional concomitant cardiac procedures. The purpose of this study was to evaluate preoperative clinical parameters as predictors for survival after isolated reoperative TV surgery., Methods: From January 2005 to January 2019, 85 patients (mean age: 66.7 ± 10.3 years, 34 male) with severe isolated TV regurgitation and prior cardiac surgery were referred to our centre for elective or urgent TV repair/replacement; patients with endocarditis were excluded. We retrospectively analysed preoperative hepatorenal function [reflected by widely used clinical and laboratory parameters and the Model of End-stage-Liver Disease excluding International Normalized Ratio (MELD-XI) score] as a predictor for postoperative survival., Results: At hospital admission, the patients' average preoperative New York Heart Association class was 2.9 ± 0.6, left ventricular ejection fraction 52.5 ± 10.6%, mean pulmonary artery pressure 24.7 ± 8.0 mmHg, creatinine 115.4 ± 66.6 μmol/l, bilirubin 20.0 ± 19.6 μmol/l and the mean MELD-XI score was 13.3 ± 4.0 μmol/l. The mean follow-up was 5.4 ± 4.2 years. Thirty-day mortality was 5%, 5-year survival was 60.6 ± 5.4% and 10-year survival was 42.9 ± 6.5%. The multivariable Cox regression analysis evaluated the MELD-XI score [hazard ratio (HR 1.144, confidence interval 95% 1.0-1.3, P = 0.005] and diabetes mellitus (HR 2.27, confidence interval 95% 1.0-5.0, P = 0.04) as significant predictors for excess mortality while age and mean pulmonary artery pressure did not reliably predict clinical outcome., Conclusions: Hepatorenal dysfunction was one main factor accounting for limited postoperative survival in our patient cohort. The MELD-XI score is easy to calculate and seems to reliably predict the perioperative risk in patients with prior cardiac surgery and indication for TV surgery., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Distal aortic perfusion (DaP) is a widely accepted protective adjunct facilitating early reinstitution of visceral perfusion during extended thoracic and thoraco-abdominal aortic repair. DaP has also been suggested to secure distal inflow to the paraspinal collateral network via the hypogastric arteries and thereby reduce the risk of spinal cord ischaemia. However, an increase in cerebrospinal fluid (CSF) pressure is frequently observed during thoracoabdominal aortic aneurysm repair. The aim of this study was to evaluate the effects of DaP on regional spinal cord blood flow (SCBF) during descending aortic cross-clamping and iatrogenic elevation of cerebrospinal fluid pressure., Methods: Eight juvenile pigs underwent central cannulation for cardiopulmonary bypass according to our established experimental protocol followed by aortic cross-clamping of the descending thoracic and abdominal aorta-mimicking sequential aortic clamping-with the initiation of DaP. Thereafter, CSF pressure elevation was induced by the infusion of blood plasma until baseline CSF pressure was tripled. At each time-point, microspheres of different colours were injected allowing for regional SCBF analysis., Results: DaP led to a pronounced hyperperfusion of the distal spinal cord [SCBF up to 480%, standard deviation (SD): 313%, compared to baseline]. However, DaP provided no or only limited additional flow to the upper and middle segments of the spinal cord (C1-Th7: 5% of baseline, SD: 5%; Th8-L2: 24%, SD: 39%), which was compensated by proximal flow only at C1-Th7 level. Furthermore, DaP could not counteract an experimental CSF pressure elevation, which led to a further decrease in regional SCBF most pronounced in the mid-thoracic spinal cord segment., Conclusions: Protective DaP during thoraco-abdominal aortic repair may be associated with inadequate spinal protection particularly at the mid-thoracic spinal cord level ('watershed area') and result in the adverse effect of a potentially dangerous hyperperfusion of the distal spinal cord segments., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The goal of therapy of proximal aortic aneurysms is to prevent an aortic catastrophe, e.g. acute dissection or rupture. The decision to intervene is currently based on maximum aortic diameter complemented by known risk factors like bicuspid aortic valve, positive family history or rapid growth rate. When applying Laplace's law, wall tension is determined by pressure × radius divided by aortic wall thickness. Because current imaging modalities lack precision, wall thickness is currently neglected. The purpose of our study was therefore to correlate maximum aortic diameter with aortic wall thickness and known indices for adverse aortic events., Methods: Aortic samples from 292 patients were collected during cardiac surgery, of whom 158 presented with a bicuspid aortic valve and 134, with a tricuspid aortic valve. Aortic specimens were obtained during the operation and stored in 4% formaldehyde. Histological staining and analysis were performed to determine the thickness of the aortic wall., Results: Patients were 62 ± 13 years old at the time of the operation; 77% were men. The mean aortic dimensions were 44 mm, 41 mm and 51 mm at the aortic root, sinotubular junction and ascending aorta, respectively. Aortic valve stenosis was the most frequent (49%) valvular dysfunction, followed by aortic valve regurgitation (33%) and combined dysfunction (10%). The maximum aortic diameter at the ascending level did not correlate with the thickness of the media (R = 0.07) or the intima (R = 0.28) at the convex sample site. There was also no correlation of the ascending aortic diameter with age (R = -0.18) or body surface area (R = 0.07). The thickness of the intima (r = 0.31) and the media (R = 0.035) did not correlate with the Svensson index of aortic risk. Similarly, there was a low (R = 0.29) or absent (R = -0.04) correlation between the aortic size index and the intima or media thickness, respectively. There was a similar relationship of median thickness of the intima in the 4 aortic height index risk categories (P < 0.001)., Conclusions: Aortic diameter and conventional indices of aortic risk do not correlate with aortic wall thickness. Other indices may be required in order to identify patients at high risk for aortic complications., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Minimally invasive staged segmental artery (SA) coil- and plug embolization is a new method for paraplegia prevention associated with extensive aortic procedures. Near-infrared spectroscopy of the paraspinal collateral network (cnNIRS) has emerged as a non-invasive method for spinal cord monitoring. The aim of this study was to evaluate cnNIRS to guide minimally invasive SA occlusion., Methods: In a chronic large animal experiment, 18 juvenile pigs underwent two-stage minimally invasive staged SA coil- and plug embolization for complete SA occlusion. Coil-embolization was performed either by SA main stem occlusion (characteristic of pig anatomy) or separately for the left- and right SA. Lumbar cnNIRS was recorded during and after the procedure. Neurological status was assessed up to 3 days after complete SA occlusion., Results: Mean time from SA coil embolization to minimum cnNIRS values was 11 ± 5 min with an average decrease from 101 ± 2% to 78 ± 8% of baseline (difference: -23 ± 9, P < 0.001). Lumbar cnNIRS demonstrated significant differences between left and right when SAs were occluded separately in all cases (-7 ± 4%, 1 min after first SA occlusion; P = 0.001). Permanent paraplegia occurred in 2 (11%) and any kind of neurological deficit-temporary or permanent-in 7 animals (39%). Association between lumbar cnNIRS and neurological outcome after minimally invasive staged SA coil- and plug embolization suggests positive correlation (R = 0.5, P = 0.052)., Conclusions: Lumbar cnNIRS independently reacts to unilateral SA occlusion. cnNIRS-guided SA occlusion is feasible and may become a useful adjunct facilitating adequate and complete vessel occlusion., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Spinal cord ischaemia (SCI) remains the most devastating complication after thoraco-abdominal aortic aneurysm (TAAA) repair. Its early detection is crucial if therapeutic interventions are to be successful. Cerebrospinal fluid (CSF) is readily available and accessible to microdialysis (MD) capable of detecting metabolites involved in SCI [i.e. lactate, pyruvate, the lactate/pyruvate ratio (LPR), glucose and glycerol] in real time. Our aim was to evaluate the feasibility of CSF MD for the real-time detection of SCI metabolites., Methods: In a combined experimental and translational approach, CSF MD was evaluated (i) in an established experimental large animal model of SCI with 2 arms: (a) after aortic cross-clamping (AXC, N = 4), simulating open TAAA repair and (b) after total segmental artery sacrifice (Th4-L5, N = 8) simulating thoracic endovascular aortic repair. The CSF was analysed utilizing MD every 15 min. Additionally, CSF was collected hourly from 6 patients undergoing open TAAA repair in a high-volume aortic reference centre and analysed using CSF MD., Results: In the experimental AXC group, CSF lactate increased 3-fold after 10 min and 10-fold after 60 min of SCI. Analogously, the LPR increased 5-fold by the end of the main AXC period. Average glucose levels demonstrated a 1.5-fold increase at the end of the first (preconditioning) AXC period (0.60±0.14 vs 0.97±0.32 mmol/l); however, they decreased below (to 1/3 of) baseline levels (0.60±0.14 vs 0.19±0.13 mmol/l) by the end of the experiment (after simulated distal arrest). In the experimental segmental artery sacrifice group, lactate levels doubled and the LPR increased 3.3-fold within 30 min and continued to increase steadily almost 5-fold 180 min after total segmental artery sacrifice (P < 0.05). In patients undergoing TAAA repair, lactate similarly increased 5-fold during ischaemia, reaching a maximum at 6 h postoperatively. In 2 patients with intraoperative SCI, indicated by a decrease in the motor evoked potential of >50%, the LPR increased by 200%., Conclusions: CSF is widely available during and after TAAA repair, and CSF MD is feasible for detection of early anaerobic metabolites of SCI. CSF MD is a promising new tool combining bedside availability and real-time capacity to potentially enable rapid detection of imminent SCI, thereby maximizing chances to prevent permanent paraplegia in patients with TAAA., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Cerebrospinal fluid (CSF) drainage is routinely utilized to mitigate perioperative and postoperative spinal cord ischaemia in open and endovascular thoraco-abdominal aortic aneurysm repair to prevent permanent paraplegia. Clinical decision-making in the vulnerable perioperative period, however, is still based on limited clinical and experimental data. Our aim was to investigate the isolated effect of CSF pressure elevation on spinal cord perfusion in an established large animal model., Methods: Ten juvenile pigs with normal (native) arterial inflow (patent segmental arteries and collaterals) underwent iatrogenic CSF pressure elevation (×2, ×3, ×4 from their individual baseline pressure). Each pressure level was maintained for 30 min to mimic clinical response time. After the quadrupling of CSF pressure, the dural sac was slowly depressurized against gravity allowing CSF pressure to passively return to baseline values. Measurements were taken 30 and 60 min after normalization, and microspheres for regional blood flow analysis were injected at each time point., Results: Spinal cord perfusion decreased significantly at all mid-thoracic to lumbar cord segments at the doubling of CSF pressure and declined to values <53% compared to baseline when pressure was quadrupled. Normalizing CSF pressure led to an intense hyperperfusion of up to 186% at the cervical level and 151% within the lumbar region., Conclusions: CSF pressure elevation results in a relevant impairment of spinal cord blood supply. Close perioperative and postoperative monitoring of CSF pressure is crucial for maintaining sufficient spinal cord perfusion. Radical and rapid withdrawal of CSF is followed by significant hyperperfusion in all spinal cord segments and may lead to 'drainage-related' iatrogenic reperfusion injury-aggravating the risk of delayed spinal cord injury-and should therefore be avoided., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Elective treatment of aortic valve disease by transcatheter aortic valve replacement (TAVR) is becoming increasingly popular, even in patients with low risk and intermediate risk. Even patients with a bicuspid aortic valve (BAV) are increasingly considered eligible for TAVR. Permanent pacemaker implantation (PMI) is a known-frequently understated-complication of TAVR affecting 9-15% of TAVR patients with a potentially significant impact on longevity and quality of life. BAV patients are affected by the highest PMI rates, although they are frequently younger compared to their tricuspid peers. The aim of the study is to report benchmark data-from a high-volume centre (with a competitive TAVR programme) on PMI after isolated surgical aortic valve replacement (SAVR) in patients with BAV and tricuspid aortic valve (TAV)., Methods: We performed a retrospective single-centre analysis on 4154 patients receiving isolated SAVRs (w/o concomitant procedures), between 2000 and 2019, of whom 1108 had BAV (27%). PMI rate and early- and long-term outcomes were analysed. For better comparability of these demographically unequal cohorts, 1:1 nearest neighbour matching was performed., Results: At the time of SAVR, BAV patients were on average 10 years younger than their TAV peers (59.7 ± 12 vs 69.3 ± 9; P < 0.001) and had less comorbidities; all relevant characteristics were equally balanced after statistical matching. Overall PMI rate was significantly higher in BAV patients (5.4% vs 3.8%; P = 0.03). BAV required PMI exclusively (100%) and TAV required predominately (96%) for persistent postoperative high-degree atrioventricular block. After matching, the PMI rate was similar (5.1% vs 4.4%, P = 0.5). In-hospital mortality in the matched cohort was 1% in both groups. Long-term survival was more favourable in BAV patients (94% vs 90% in TAV at 5 years; 89% vs 82% in TAV at 9 years; P = 0.013)., Conclusions: With SAVR, the overall incidence of PMI among BAV patients seems significantly higher; however, after propensity matching, no difference in PMI rates between BAV and TAV is evident. The PMI rate was remarkably lower among BAV patients after SAVR compared to the reported incidence after TAVR., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Patients with a bicuspid aortic valve (BAV) have an increased risk for developing thoracic aortic aneurysm, which is characterized by the destruction of the elastic media of the aortic wall. Several important enzymes have been characterized to play key roles in extracellular matrix homeostasis, namely matrix metalloproteinases (MMPs). In this study, we investigated MMP-2 levels and their epigenetic regulation via the miR-29 family., Methods: Aortic tissue samples from 58 patients were collected during cardiac surgery, of which 30 presented with a BAV and 28 with a tricuspid aortic valve. Polymerase chain reaction, western blot analysis and immunohistochemistry were performed to analyse MMP-2. In addition, enzyme-linked immunosorbent assay measurements were carried out to investigate both MMP-2 and tissue inhibitor of metalloproteinase-2 levels. To examine the epigenetic regulation of aortic extracellular matrix homeostasis, we furthermore studied the expression levels of miR-29 via qRT-PCR., Results: Patients with a BAV were significantly younger at the time of surgery, presented significantly less frequently with arterial hypertension and displayed more often with an additional valvular disease. On a molecular level, we found that MMP-2 is increased on gene and protein level in BAV patients. Tissue inhibitor of metalloproteinase-2 levels do not differ between the groups. Interestingly, we also found that only miR-29A is significantly downregulated in BAVs., Conclusions: Our findings highlight the importance of MMP-2 in the context of extracellular matrix destruction in BAV patients. We present new evidence that miR-29A is a crucial epigenetic regulator of these pathomechanistic processes and might hold promise for future translational research., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Minimally invasive staged segmental artery coil- and plug embolization (MIS2ACE) has been introduced for spinal cord injury prevention prior to open or endovascular thoraco-abdominal aortic aneurysm repair. To date, no optimal pattern has been developed. The aim of this study was to identify the optimal MIS2ACE occlusion pattern., Methods: Twenty-five juvenile pigs were randomly assigned to 3 MIS2ACE occlusion patterns (2 stages) and a control group [single-stage segmental artery (SA) occlusion, N = 7]. The first pattern started with occlusion of all lumbar segmental arteries in the first stage and the remaining thoracic arteries in the second stage (regional pattern, N = 6). In group 2, an alternating approach with occlusion of every other SA in the first stage and the remainder in the second stage was used (alternating pattern, N = 6). The third pattern started with occluding the watershed area between thoracic level 12 and lumbar level 2 in the first stage and the remaining arteries in the second stage (watershed pattern, N = 6). Neurological assessment at 6-h intervals and spinal cord tissue perfusion measurements via microspheres at 6 time points were performed. At the end of the experiments, the spinal cord was histopathologically examined., Results: An average of 6 ± 2 coils were used per SA. In the control group a total of 57% (N = 4) of animals experienced permanent paraplegia, 1 animal (16%) of the alternating and watershed intervention group suffered from permanent paraplegia. Animals from the staged regional pattern did not experience permanent paraplegia. Furthermore, no evidence of significant tissue damage was observed (P < 0.05 vs control). Tissue perfusion of the lumbar spinal cord in the regional pattern group recovered within 3 days after the second stage to 89.2 ± 47 percent-of-baseline (P = 0.393), whereas mean perfusion of the other 2 intervention groups and the control remained significantly lower compared to the baseline (35.7 ± 16%, 30.2 ± 11% and 63.2 ± 19, P < 0.05)., Conclusions: This study provides evidence that MIS2ACE (minimally invasive staging) may result in less ischaemic spinal cord injury and favourable neurological outcomes compared to complete (1 stage) SA occlusion. A regional-based occlusion pattern (starting with the lumbar segmental arteries) seems to be the best 2-stage approach., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives:: Concomitant aortic root enlargement (ARE) at the time of surgical aortic valve replacement can be performed to avoid patient-prosthesis mismatch, an important predictor of adverse long-term outcome., Methods:: We performed a single-centre, retrospective analysis of 4120 patients receiving isolated aortic valve replacement, of whom 171 (4%) had concomitant ARE between January 2005 and December 2015. The analysis of postoperative outcome and early mortality was performed. Owing to inequality of the groups, patients were matched 1:1., Results:: The mean age of all 4120 patients was 68.8 ± 10.5 years, and comorbidities were equally balanced after matching. The mean aortic cross-clamp time, cardiopulmonary bypass time and total operative time were prolonged by 19, 20 and 27 min in the ARE group, respectively. Early mortality was not statistically significantly different with 1.4% in the surgical aortic valve replacement and 1.8% in the ARE group. Postoperative complications were <5% in all matched 338 patients: bleeding (3% vs 3%), pericardial effusion (3.0% vs 4.2%), sternal instability (1.8% vs 0%) and sternal wound infection (3.0% vs 1.2%). A significant higher number of patients had respiratory failure after ARE (unmatched: 17.1% vs 9.9%, P < 0.001; matched: 18.3% vs 9.5%, P = 0.028). Factors independently associated with overall mortality were age [hazard ratio (HR) 1.71], chronic obstructive pulmonary disease (HR 1.47), diabetes (HR 1.82), atrial fibrillation (HR 2.14) and postoperative respiratory failure (HR 2.84)., Conclusions:: ARE can be performed safely in experienced centres with no significant increase in the risk of early postoperative surgical complications and early mortality. However, the surgeon and the intensive care unit team should be aware of an increased risk for postoperative respiratory failure in ARE patients., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The true incidence of aortic events (AEs) and reoperations (REDO) following elective total aortic arch replacement remains unknown. The aim of this study was to review the incidence of AEs and surgical REDO, and its respective outcomes after 1232 elective arch repairs at 11 European aortic centres., Methods: Retrospective chart review (in the absence of prospective data collection) was performed for statistical analysis. Follow-up was conducted during routine clinical examination or in a telephone interview with patients and/or their respective physicians., Results: One hundred fifty-five (12.6%) patients were identified (median follow-up time 48.7 months). The recorded AEs comprised aortic dilatation (62.6%), rupture (15.5%), endoleak (11%), false aneurysm (3.9%), dissection (3.2%), infection (2.6%) and others (1.3%). REDO (open/endovascular) were performed in 85.8% of patients (n = 133). Intraoperative and in-hospital mortality in the REDO patients were 7.5% and 17.3%, respectively. Postoperative neurological complications comprised paraplegia (6.0%) and stroke (1.5%). Survival rates after REDO at 1, 3 and 5 years were 81.2%, 79.0% and 76.7%, respectively. Univariate analysis identified 'rupture' and 'diameter progression', 'older age at REDO' and the REDO strategies 'frozen elephant trunk' and 'no elephant trunk' as predictors of increased in-hospital mortality. Multivariate analysis identified 'older age at REDO' (P = 0.008) as the only independent risk factor for in-hospital mortality., Conclusions: AEs after elective arch surgery are not irrelevant and mostly involve the distal aspects of the adjoining aorta. In accordance with the underlying pathology, open or endovascular REDO may be performed with an acceptable outcome. Preparation of an adequate proximal landing zone at the time of primary arch surgery is advisable., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The treatment of patients with extensive thoracic aortic disease involving the arch and descending aorta is often performed using the frozen elephant trunk technique (FET). Spinal cord blood flow (SCBF) in cervical, thoracic and lumbar sections prior, during and after aortic arch surgery were compared in conventional elephant trunk (cET) and FET technique in a pig model., Methods: German Landrace pigs (75-85 kg) underwent aortic arch surgery using the FET (n = 8) or cET (n = 8) techniques. The E-vita Open hybrid stent graft was applied in all FET animals. Regional SCBF was measured 4 times: (i) before cardiopulmonary bypass, (ii) after 1 h, (iii) after 3 h, and (iv) after 6 h of reperfusion using fluorescence microspheres. Spinal cord segments were examined histopathologically and by immunohistochemistry., Results: SCBF in FET decreased significantly from 0.13 ± 0.03 to 0.05 ± 0.02 ml/min/g after 1 h (P = 0.047). While at 3 h of reperfusion, SCBF increased and was comparable to baseline (0.09 ± 0.01 ml/min/g), beyond this time SCBF decreased again (0.05 ± 0.02 ml/min/g). A similar trend was found for SCBF in the cET group (baseline: 0.16 ± 0.04 ml/min/g, 1 h reperfusion: 0.02 ± 0.01 ml/min/g, 3 h reperfusion: 0.03 ± 0.01 ml/min/g and 6 h reperfusion: 0.02 ± 0.01 ml/min/g, P = 0.019). Cervical, thoracic and lumbar SCBF were also comparable in both groups. Histological analyses of spinal cord showed no differences in necrosis between cET and FET, while no differences were found for hypoxia-inducible factor-1α and apoptosis-inducing factor. In contrast, oxidative stress and caspase-induced apoptosis were higher in cET versus FET., Conclusions: The SCBF changed significantly during extensive aortic arch surgery with circulatory arrest and moderate hypothermia, but such changes were comparable between the FET and cET groups. The implantation of hybrid stent graft did not influence SCBF in thoracic and lumbar segments of the spinal cord. The immunohistological examination showed no differences between cET and FET regarding ischaemic damage and hypoxia-induced effects in spinal cord segments., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Surgical therapy for acute aortic dissection type A (AADA) in octogenarians carries high morbidity and mortality. The role of isolated medical treatment in this setting is controversial. The aim of this study is to determine whether risk of surgery for AADA outweighs risk of death from medical treatment only., Methods: From 2002 to 2015, 90 consecutive octogenarians (mean age, 83.5 ± 3 years) were treated for AADA at three institutions: 67 patients underwent surgery, 23 patients received medical treatment. Analysis of early and late outcome was performed., Results: Patients in the medical treatment group were significantly older than in the surgical group (84.9 ± 3.7 vs 83 ± 2.5 years, P  = 0.008) and in a more critical state. In patients undergoing surgical repair, perioperative mortality was 14.9% ( n  = 10). Rate of prolonged ventilation (63.2% vs 5.9%; P  < 0.001) and renal failure (35.1% vs 5.9%, P  = 0.029) was significantly higher in the surgical group. Thirty-day survival was impaired in the medical treatment group (34.8% vs 61.2% in the surgical group; P  = 0.032). Coronary artery disease (OR 3.95, 95% CI 1.16-13.49; P  = 0.029) and complicated dissections (OR 5.28, 95% CI 1.48-18.88; P  = 0.010)-composite variable of preoperative resuscitation, neurological injury and malperfusion-emerged as independent risk factors for 30-day mortality in the surgical group. There was no difference in long-term survival., Conclusions: Emergency surgery for AADA in octogenarians is associated with relatively high intraoperative mortality and may reasonably be avoided in patient with complicated presentation. Despite better immediate survival after surgery, long-term survival does not differ between medical and surgical patients, reflecting the extremely advanced point in life cycle octogenarians., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Near-infrared spectroscopy of the collateral network (cnNIRS) has recently been trialled to monitor real-time tissue oxygenation of the paraspinous vasculature as a surrogate for spinal cord tissue oxygenation. This large animal study was designed to investigate the correlation between cnNIRS and spinal cord oxygenation by comparing it to laser Doppler flowmetry (LDF), a proven method for direct oxygenation and flow assessment., Methods: Measurements were performed in seven animals. Four paravertebral cnNIRS optodes were positioned bilaterally at thoracic and lumbar levels to assess tissue oxygenation of the paraspinous vasculature. Paravertebral muscle and spinal cord oxygenation and microcirculatory flow were measured directly using LDF probes. LDF and cnNIRS were compared during consecutive repeated periods of descending aortic cross-clamping for 8 min and recovery by clamp release., Results: Following aortic cross-clamping, lumbar cnNIRS signals instantaneously responded with a decrease to 85 ± 4% within 30 s, and to a minimum of 69 ± 6% after 8 min, returning to baseline values after clamp release within 40 s. Direct lumbar muscle and spinal cord oxygenation assessed by LDF responded analogously to cnNIRS (muscle and spinal cord oxygenation after cross-clamping 11.3 ± 6 and 37.6 ± 22% after 5 and 8 min, respectively). Comparison between lumbar cnNIRS and LDF muscle and spinal cord measurements showed a significant positive correlation (r = 0.51-0.52, P < 0.001). Thoracic cnNIRS signals remained relatively stable throughout the procedure. Lumbar paraspinous muscle oxygenation corresponded to direct spinal cord oxygenation (no significant difference, P = 0.296)., Conclusions: These experiments confirm that the paraspinous vasculature in the presented large animal model is directly linked to spinal cord microcirculation and that the regional paraspinous muscle oxygenation status reflects spinal cord tissue oxygenation. As lumbar cnNIRS reproducibly depicts tissue oxygenation of the paraspinous vasculature, it can be used for non-invasive spinal cord oxygenation monitoring in real-time., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The study was conducted to evaluate, on the basis of a multicentre analysis, current results of elective open aortic arch surgery performed during the last decade., Methods: Data of 1232 consecutive patients who underwent aortic arch repair with reimplantation of at least one supra-aortic artery between 2004 and 2013 were collected from 11 European cardiovascular centres, and retrospective statistical examination was performed using uni- and multi-variable analyses to identify predictors for 30-day mortality. Acute aortic dissections and arch surgeries not involving the supra-aortic arteries were not included., Results: Arch repair involving all 3 arch arteries (total), 2 arch arteries (subtotal) or 1 arch artery (partial) was performed in 956 (77.6%), 155 (12.6%) and 121 (9.8%) patients, respectively. The patients' characteristics as well as the surgical techniques, including the method of cannulation, perfusion and protection, varied considerably between the clinics participating in the study. The in-hospital and 30-day mortality rates were 11.4 and 8.8% for the entire cohort, respectively, ranging between 1.7 and 19.0% in the surgical centres. Multivariable logistic regression analysis identified surgical centre, patient's age, number of previous surgeries with sternotomy and concomitant surgeries as independent risk factors of 30-day mortality. The follow-up of the study group was 96.5% complete with an overall follow-up duration of 3.3 ± 2.9 years, resulting in 4020 patient-years. After hospital discharge, 176 (14.3%) patients died, yielding an overall mortality rate of 25.6%. The actuarial survival after 5 and 8 years was 72.0 ± 1.5% and 64.0 ± 2.0, respectively., Conclusions: The surgical risk in elective aortic arch surgery has remained high during the last decade despite the advance in surgical techniques. However, the patients' characteristics, numbers of surgeries, the techniques and the results varied considerably among the centres. The incompleteness of data gathered retrospectively was not effective enough to determine advantages of particular cannulation, perfusion, protection or surgical techniques; and therefore, we strongly recommend further prospective multicentre studies, preferably registries, in which all relevant data have to be clearly defined and collected., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of this study was to evaluate the results after stented porcine xenograft implantation with Linx™ anticalcification treatment in the aortic and/or mitral position in elderly patients., Methods: Over a decade, a total of 2544 patients receiving aortic (AVR = 1920), mitral (MVR = 347) or double valve (DVR = 277) replacement (between November 2001 and March 2012) were evaluated. The study was designed on an 'all comers' basis including all patients with elective, urgent or emergent need for valve replacement. Outcome was assessed by reviewing the prospectively acquired hospital database as well as regular follow-up information obtained by annual written interviews., Results: Mean patient age was 76.5 ± 6 (AVR), 73.8 ± 7 (MVR) and 74.2 ± 7 (DVR) years, respectively; 54.2%/41.9%/42.0% were male, and active endocarditis was diagnosed in 4.5%/19.9%/22.1%; indication for valve surgery and the logistic EUROSCORE I predicted risk for mortality was 15.4 ± 15%/19.9 ± 19%/22.3 ± 21%, respectively. Concomitant mitral valve repair was required in 196 (10.2%) (AVR) patients; coronary artery bypass graft surgery (CABG) in 840 (43.8%) (AVR), 82 (23.7%) (MVR) and 94 (34.1%) (DVR) patients; cryoablation in 232 (12.1%)/81 (23.4%)/67 (24.3%) patients and surgery on the thoracic aorta in 166 (8.7%)/12 (3.5%)/41 (14.9%) patients, respectively. The mean follow-up was 4.5 ± 3.5 years. The rate of freedom from endocarditis after 10 years was 98.3 ± 0.4%/97.5 ± 1.0%/97.4 ± 1.6% (P = n.s.). The rate of freedom from structural valve disease was 96.3 ± 0.6%/93.8 ± 2.4%/92.8 ± 2.2% (AVR versus DVR, P = 0.009), and from thromboembolic events was 94.8 ± 1.0%/91.5 ± 2.9%/97.9 ± 1.3%. The 30-day survival rate was 97.3 ± 0.4%/95.1 ± .1.2%/92.8 ± 1.6% and the 10-year survival rate was 42.1 ± 1.5%/33.9 ± 4.7%/22.1 ± 7.1%, respectively., Conclusions: The Epic™ stented porcine xenograft is associated with acceptable survival, with large proportions of patients free from valve-related complications and freedom from valve reintervention for all older, in-coming patients., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The purpose of this study is to retrospectively evaluate, with an 'all-comers' approach, the survival and outcome of patients following secondary surgical or interventional procedures after thoracic endovascular aortic repair (TEVAR)., Methods: Between October 2002 and December 2013, 371 patients with different aortic pathologies underwent primary TEVAR at our institution. Fifty-six out of the 371 patients (15.1%, 18 females, mean age 62.3 ± 13.7 years) required secondary procedures, either interventionally (N = 31; 55.4%) or surgically (N = 25; 44.6%), due to stent graft-related complications. After TEVAR complications comprised endoleaks (N = 28; 7.5%), organ malperfusion (N = 9; 2.4%), aorto-oesophageal/-bronchial fistulae (N = 9; 2.4%), stent graft infections (N = 4; 1.1%), aneurysm progression (N = 3; 0.8%), retrograde type A aortic dissection (N = 2; 0.5%) and aortic regurgitation (N = 1; 0.3%)., Results: The overall in-hospital mortality rate was 10.7% (N = 5): open surgery (N = 1; 4%) versus reintervention (N = 5; 16%; P = 0.14). The cumulative survival rates after secondary procedures at 6 months, 1 year and 3 years were 80.4, 73.5 and 69.3%, respectively. Postoperative complications either for open surgery or reintervention comprised stroke (8 vs 9.6%; P = 0.82), paraplegia (4 vs 6.4%; P = 0.68), renal failure (16 vs 3.2%; P = 0.09), respiratory failure (12 vs 0%; P = 0.04), sepsis (16 vs 3.2%; P = 0.87), organ malperfusion (4 vs 3.2%; P = 0.87) and need for a tertiary procedure (8 vs 6.4%; P = 0.82)., Conclusions: Stent graft complications after primary TEVAR were not infrequent and often required secondary procedures for definite treatment. Endoleaks (type Ia), organ malperfusion, stent graft infections, fistula formation and expanding aneurysm occurred predominantly during early and mid-term follow-up. Despite the high-risk nature of the complications, secondary open surgical or interventional procedures may be successfully performed with an acceptable outcome., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Acute aortic dissection type A (AADA) is an emergency with excessive mortality if surgery is delayed. Knowledge about independent predictors of mortality on surgically treated AADA patients is scarce. Therefore, this study was conducted to identify pre- and intraoperative risk factors for death., Methods: Between July 2006 and June 2010, 2137 surgically treated patients with AADA were enrolled in a multicentre, prospective German Registry for Acute Aortic Dissection type A (GERAADA), presenting perioperative status, operative strategies, postoperative outcomes and AADA-related risk factors for death. Multiple logistic regression analysis was performed to identify the influence of different parameters on 30-day mortality., Results: Overall 30-day mortality (16.9%) increased with age [adjusted odds ratio (OR) = 1.121] and among patients who were comatose (adjusted OR = 3.501) or those who underwent cardiopulmonary resuscitation (adjusted OR = 3.751; all P < 0.0001). The higher the number of organs that were malperfused, the risk for death was (adjusted OR for one organ = 1.651, two organs = 2.440, three organs or more = 3.393, P < 0.0001). Mortality increased with longer operating times (total, cardiopulmonary bypass, cardiac ischaemia and circulatory arrest; all P < 0.02). Arterial cannulation site for extracorporeal circulation, operative techniques and arch interventions had no significant impact on 30-day mortality (all P > 0.1). No significant risk factors, but relevant increases in mortality, were determined in patients suffering from hemiparesis pre- and postoperatively (each P < 0.01), and in patients experiencing paraparesis after surgery (P < 0.02)., Conclusions: GERAADA could detect significant disease- and surgery-related risk factors for death in AADA, influencing the outcome of surgically treated AADA patients. Comatose and resuscitated patients have the poorest outcome. Cannulation sites and operative techniques did not seem to affect mortality. Short operative times are associated with better outcomes., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Management of patients with acute aortic dissection type A (AADA) and cerebral malperfusion secondary to occlusion or stenosis of the left common carotid artery (LCCA) or right common carotid artery (RCCA) is a significant challenge. The aim of this study is to present our institutional strategy and postoperative results for this high-risk patient cohort., Methods: Between November 2005 and July 2013, 23 of 354 consecutively operated AADA patients [median age: 66.3; interquartile range (IQR): 55.2-69.9] suffered from cerebral malperfusion due to bilateral (n = 1) or unilateral occlusion of the LCCA/RCCA (n = 22). AADA repair comprised hemi- (n = 14) or total (n = 9) arch replacement in combination with aortic valve repair (n = 7) or replacement (n = 11), root replacement (n = 15) and coronary bypass (n = 3). Extra-anatomic aorto-carotid bypass was performed in all patients. Aorto-carotid bypass was performed at the beginning of the procedure to allow for unilateral selective cerebral perfusion (n = 17; 73.9%) or during the procedure if persisting malperfusion was suspected by near-infrared spectroscopy (n = 6; 26.1%)., Results: The median follow-up was 15.2 months (IQR: 4.8-34.1) and 100% complete. Median hospital stay and ICU stay were 16.0 (IQR: 12.5-26.0) and 13.7 (IQR: 2.0-16.5) days, respectively. Rethoracotomy for haemorrhage or cardiac tamponade was performed in 6 (26.1%) patients. Other postoperative complications comprised low cardiac output with extracorporeal membrane oxygenation (n = 2; 8.7%), sepsis (n = 4; 17.4%), respiratory insufficiency (n = 10; 43.5%), renal failure with temporary dialysis (n = 7; 30.4%) and visceral malperfusion (n = 2; 8.7%) requiring stent grafting (n = 1) or laparotomy with intestinal resection (n = 1). New stroke with or without permanent sensory or motor deficit was diagnosed in 8 (34.8%) patients. Temporary neurological deficits were seen in 9 (39.1%) individuals. Hospital and 1-year mortality rates were 13.0 and 30.4%, respectively. Overall survival after 36 months of the 23 patients (Group I = Extra-anatomic bypass) versus the remaining 331 AADA patients without distal RCCA/LCCA occlusion (Group II = no extra-anatomic bypass) was 69.6% (n = 16) in Group I vs 72.5% (n = 240) in Group II (P = 0.90)., Conclusion: Extra-anatomic bypass for LCCA or RCCA occlusion allows for early selective cerebral perfusion during AADA repair, and may reduce the risk of neurological complications in patients with preoperative cerebral malperfusion., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of this study is to investigate the clinical characteristics and postoperative outcome of patients with a bicuspid aortic valve (BAV) suffering acute dissection in comparison with their tricuspid peers., Methods: Between 1995 and 2011, 460 consecutive patients underwent emergency repair for acute type A aortic dissection. In 379 patients without connective tissue disease, the aortic valve morphology could clearly be specified (91.6% tricuspid and 8.4% bicuspid)., Results: At the time of dissection, patients with a bicuspid valve were younger (46.7 ± 13 vs 61.6 ± 12 years, P < 0.001) with the entry tear more often located in the root compared with those with a tricuspid valve (bicuspid: 31.3% vs tricuspid: 6.3%, P < 0.001). Consequently, surgical repair warranted root replacement in 93.8% of bicuspid vs 28.8% of tricuspid valve patients (P < 0.001). The leading pathology was medial necrosis/degeneration in bicuspid and atherosclerosis in tricuspid patients (P = 0.166). Hospital mortality was 20.3% and not significantly different between the two valve morphologies, even despite the younger age of bicuspid patients: 28.1% among bicuspids vs 19.6% among tricuspids (P = 0.255). Survival after discharge was 63.3% at 10 years for all patients. BAV patients had a significantly better survival with 100% at 10 years compared with 60.2% in tricuspid valve patients (P = 0.011). Mean follow-up among survivors was comparable for bicuspid and tricuspid patients (3.7 and 4.1 years, respectively)., Conclusions: Patients with BAV have a distinctive dissection pattern with the entry tear frequently located in the aortic root and-despite their younger age-are subject to substantial hospital mortality. For bicuspid patients suffering from dissection, composite root replacement yields an excellent outcome equal to an age- and gender-matched normal population., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The implementation of new surgical techniques offers chances but carries risks. Usually, several years pass before a critical appraisal and a balanced opinion of a new treatment method are available and rely on the evidence from the literature and expert's opinion. The frozen elephant trunk (FET) technique has been increasingly used to treat complex pathologies of the aortic arch and the descending aorta, but there still is an ongoing discussion within the surgical community about the optimal indications. This paper represents a common effort of the Vascular Domain of EACTS together with several surgeons with particular expertise in aortic surgery, and summarizes the current knowledge and the state of the art about the FET technique. The majority of the information about the FET technique has been extracted from 97 focused publications already available in the PubMed database (cohort studies, case reports, reviews, small series, meta-analyses and best evidence topics) published in English., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Severe complications after thoracic endovascular aortic repair (TEVAR), such as secondary aorto-oesophageal (AOF) or aorto-bronchial fistulae (ABF), are most likely under-reported; however, once detected, emergent surgery becomes necessary., Methods: Between June 2002 and September 2013, 10 (2.6%) of 374 patients (8 males; mean age 68 years, range: 49-77) were admitted with AOF (n = 8) or ABF (n = 2) post-TEVAR during follow-up (mean 12.9 months, range 0.2-48.1). The respective Ishimaru landing zones were 0 (n = 1), 2 (n = 3), 3 (n = 4) and 4 (n = 2). Median interval between TEVAR and AOF/ABF formation was 18.1 months (range 0.1-65.1). Symptoms on admission included haematemesis (n = 4), haemoptysis (n = 2), melena (n = 1), elevated C-reactive protein (n = 10), new-onset fever (n = 3), positive blood cultures (n = 8), dysphagia (n = 1), chest pain (n = 4), previous syncope (n = 1) and vertigo (n = 1). In 6 patients with AOF, stent graft removal required ascending aortic (n = 1), aortic arch (n = 1), left hemiarch (n = 2) and descending aortic (n = 6) replacement with concomitant oesophagectomy (n = 4) and cervical oesophagostomy (n = 1) or oesophageal repair (n = 2); another patient with AOF underwent oesophagectomy and cervical oesophagostomy via posterolateral thoracotomy without stent graft removal as a first-stage operation. One patient with ABF was treated by stent graft removal, aortic arch and descending aortic replacement in combination with bronchial repair. Two patients were deemed inoperable and treated conservatively., Results: All patients survived the operation. Reoperation due to postoperative mediastinitis, haemorrhage, pericardial tamponade and wound infection was required in 4 (50%, 95% confidence interval [CI] [22, 78]) patients. In-hospital mortality was 25% (n = 2; 95% CI [7, 59]) due to mediastinitis with resulting multiorgan failure (n = 1) and aortic rupture with haemorrhagic shock (n = 1). One patient died due to unknown cause on postoperative day 158. No neurological complications occurred postoperatively. Postoperative complications comprised acute renal failure with temporary dependence on haemodialysis (n = 2) and respiratory insufficiency (n = 4) requiring percutaneous tracheostomy (n = 2). Both patients treated conservatively died after 4 and 81 days due to pulmonary haemorrhage and fulminant mediastinitis, respectively., Conclusions: AOF and ABF represent uncommon but fatal complications-if treated conservatively-after TEVAR that may occur during short- and mid-term follow-up. Surgery for AOF/ABF requires early diagnosis and should be performed promptly and in a radical fashion to totally excise all infected tissues in these high-risk patients., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Arch surgery is undoubtedly among the most technically and strategically challenging endeavours in aortic surgery, requiring thorough understanding not only of cardiovascular physiology, but also in particular, of neurophysiology (cerebral and spinal cord), and is still associated with significant mortality and morbidity. In the late 1980s, when deep hypothermic circulatory arrest (HCA) had gained widespread acceptance as the standard approach for arch surgery, antegrade selective cerebral perfusion (SCP), as an adjunct to deep HCA, began its triumphal march, offering excellent neuroprotection and improved overall outcome. This encouraged the use of antegrade SCP in combination with steadily increasing body core temperatures--a trend culminating in the progressive advocation of moderate-to-mild temperatures up to 35 °C, and even normothermia. The impetus for progressive temperature elevation was the limitation of adverse effects of profound hypothermia and the most welcome side effect of significantly shorter cooling and rewarming periods on cardiopulmonary bypass (CPB), and thereby, potentially, the alleviation of the systemic inflammatory response and, in particular, the risk of severe postoperative bleeding (and other organ dysfunctions). The safe limits of prolonged distal circulatory arrest, particularly with regard to the ischaemic tolerance of the viscera and the spinal cord, have not yet been clearly defined. Adverse outcomes due to inappropriate temperature management (core temperatures too high for the required duration of distal arrest) are probably highly underreported. Complications historically associated with hypothermia, namely excessive bleeding, are possibly overestimated. Trading effective neuroprotection and excellent outcomes for the risk of prolonged 'warm' distal ischaemia might constitute a significant step back, jeopardizing visceral and, in particular, spinal cord integrity, with unpredictable consequences for long-term outcome and quality of life, particularly affecting those in need of more complex surgery or with previous neurological deficits.

Objectives: The treatment of patients with extensive thoracic aortic disease involving the arch and descending/thoracoabdominal aorta is often performed using an elephant trunk procedure. We retrospectively analysed our results comparing two different techniques: the conventional elephant trunk (cET) and the frozen elephant trunk (FET) operation., Methods: Between January 2003 and December 2011, 171 consecutive patients underwent total aortic arch replacement with either a cET (n = 125) or FET (n = 46) technique. The mean age was 64 ± 13 years and was significantly higher in the FET group (P < 0.01). Acute Type A aortic dissection was the indication for surgery in 53.6% of cET and 17.4% of FET patients, and degenerative or atherosclerotic aneurysm accounted for 33.6% of cET and 58.7% of FET patients. The remaining patients were operated on for chronic Type A or acute or chronic Type B dissections with arch involvement., Results: In-hospital mortality was 21.6 vs 8.7% for cET and FET patients, respectively (P = 0.1). Logistic regression analysis revealed Type A aortic dissection (odds ratio (OR) 3.1, P = 0.01) as the only independent predictor of hospital mortality. Stroke occurred in 16 vs 13% of cET vs FET patients (P = 0.4). Type A aortic dissection was an independent predictor of stroke by multivariable analysis (OR 2.6, P = 0.03), and axillary arterial cannulation was protective against stroke (OR 0.4, P = 0.04). The occurrence of new-onset paraplegia was significantly higher in the FET group (21.7 vs 4.0%, P < 0.001), and aortic repair with the FET technique was an independent predictor for paraplegia (OR 6.6, P = 0.001). Among patients receiving FET, a body core temperature during circulatory arrest of ≥ 28 °C in combination with a prolonged circulatory arrest time of >40 min was an independent predictor for permanent spinal cord injury (OR 5.0, 95% CI 1.1-20, P = 0.038). The estimated 1-, 3- and 5-year survival were 70 ± 4, 70 ± 4 and 68 ± 4% (cET) and 4 ± 7 and 60 ± 9, 40 ± 1% (FET), with mean survival time 5.2 ± 0.3 vs 3.8 ± 0.5 years (cET vs FET, log-rank P = 0.9)., Conclusions: The FET procedure for extensive thoracic aortic disease is associated with an acceptable mortality rate, but with a higher incidence of perioperative spinal cord injury than cET. Arch replacement with a cET technique should be strongly considered in patients with expected prolonged circulatory arrest times, particularly if operated on under mild or moderate hypothermia. Axillary cannulation is associated with superior neurological outcomes and Type A acute aortic dissection is a risk factor for mortality and poor neurological outcomes in this patient population.

Objectives: Hybrid endovascular procedures are rapidly evolving and have recently been adopted for high-risk patients deemed unsuitable for conventional aortic arch surgery. We describe here our initial experience with this technique, including the management of 2 patients who developed a retrograde type A aortic dissection post-de-branching., Methods: Between May 2010 and October 2012, 109 patients underwent conventional aortic arch repair at our institution. A further 9 high-risk patients with complex aortic arch pathology (median logistic EuroSCORE: 26, range: 11-41) were deemed unsuitable for conventional total aortic arch replacement and therefore underwent hybrid aortic arch repair. Complete supra-aortic de-branching, followed by endovascular stent-grafting (TEVAR) of the transverse arch and descending aorta, was performed in these high-risk patients., Results: In-hospital mortality was zero and no patient developed paraplegia/paraparesis due to spinal cord ischaemia. However, 2 patients (22%) developed retrograde type A aortic dissection on Days 10 and 12 post-TEVAR. Both patients had a dilated ascending aorta and received a stent graft containing bare metal springs at the proximal end. Emergency ascending aortic replacement was performed during moderate-to-mild hypothermia (28-34°C) and bilateral antegrade cerebral perfusion via cannulation of the de-branching prosthesis. A Hemashield prosthetic graft was anastomosed to the proximal stent graft in an elephant trunk technique. Both patients suffered from minor non-debilitating stroke, with 1 being discharged home and 1 transferred to a neurological rehabilitation centre 2 and 3 weeks after reoperation, respectively., Conclusions: Retrograde type A aortic dissection after hybrid endovascular treatment of the aortic arch represents a new-most likely under-reported-pathology that may be successfully treated with open surgical repair. The use of stent grafts with protruding proximal bare springs and the implementation of oversizing and post-deployment ballooning should be avoided in patients undergoing hybrid arch procedures, particularly if the ascending aorta is dilated.

Objectives: Congenital supravalvular aortic stenosis (SVAS) is a rare arteriopathy associated with the Williams-Beuren syndrome (WBS) and other elastin gene deletions. Our objective was to review the mid-term outcomes of SVAS repair with extended aortoplasty., Methods: Congenital SVAS repairs from 2001 to 2010 were retrospectively reviewed. The follow-up records, reintervention and reoperation data and most recent echocardiograms were obtained., Results: From 2001 to 2010, 21 patients (15 males) underwent surgical repair of SVAS by extended aortoplasty with autologous pretreated pericardium, which is a modification of the Doty technique. The mean age was 3.1 ± 4.2 years. WBS was diagnosed in 14 of the patients. There was no early mortality, but one late death was observed. At the latest follow-up (mean follow-up, 4.3 ± 2.9 years; range, 1-108 months), echocardiograms revealed a peak Doppler gradient across the aortic outflow tract of 15 ± 8 mmHg. The majority of the patients had minimal to mild aortic insufficiency. No reoperation or reintervention was required., Conclusions: Extended aortoplasty provides excellent mid-term relief of SVAS and, in addition, reshapes the aortic root geometry to a much more favourable anatomical configuration. It can be performed without any increase in operative risks. The mid-term results are excellent.

Objectives: Patients with chronic Stanford type B aortic dissections (TBAD) are traditionally treated medically, but some of the affected thoracic and thoracoabdominal aortic segments progress to large aneurysms with a significant risk of rupture. The purpose of this study is to retrospectively evaluate, with an 'all-comers' approach, the survival and the outcome of patients following thoracic endovascular aortic repair (TEVAR) or conventional open surgery for chronic TBAD as a first-line therapy or a secondary option after failed medical treatment., Methods: Between January 2000 and May 2010, 80 consecutive patients (59 males, median age 63, inter-quartile range (IQR) 55-69) suffering from chronic TBAD were treated at our institution. Thirty-three were treated medically (Group A, median age: 65, IQR: 58.5-71.5), 32 received TEVAR (Group B, median age: 62, IQR: 54-67.5) and 15 patients underwent conventional open surgery (Group C, median age: 61, IQR: 54-66). The median follow-up was 42 months (range: 0.1-124.7) and 100% complete., Results: There were no significant differences with regard to age, gender and associated comorbidities between the treatment groups. The overall hospital mortality for chronic TBAD was 6.3% (n = 5); in-hospital mortalities for Groups A, B and C were 3.0, 6.2 and 13.4%, respectively. The incidence of major complications, such as paraplegia, malperfusion, renal failure and cardiac arrhythmia, did not significantly differ between the three groups. Postoperative stroke occurred more often after conventional open surgery (Group C: 13.3%; P = 0.07). Reintervention for TBAD pathology was required in Groups A, B and C in 12.1, 28.1 and 0%, respectively (P = 0.03). Secondary open surgery post-TEVAR was required in 7 cases (21.8%) with no postoperative paraplegia., Conclusions: Open surgery for extensive thoracic and thoracoabdominal repair in chronic TBAD may be performed with acceptable early and mid-term outcomes. TEVAR for aortic complications in patients with chronic dissection may be successfully performed as a first-stage procedure in order to stabilize the patient and serve as a 'bridge' to secondary open surgery. However, close surveillance is mandatory for the timely detection of aneurysm enlargement, malperfusion or impending rupture after TEVAR.

Objective: To shorten cooling/rewarming associated with hypothermic neuroprotection strategies during complex aortic arch surgery, selective cerebral perfusion (SCP) at 28 degrees C has recently been advocated, although its safe limits - especially with regard to the ischaemic tolerance of the spinal cord - have not been systematically examined., Methods: Twenty juvenile Yorkshire pigs (30.3+/-2.8kg) were randomly allocated to undergo circulatory arrest and SCP at 28 degrees C for 90 min (group A; N=12) or 120 min (group B; N=8) at 50 mmHg using alpha-stat pH management. Spinal cord blood flow (SCBF) was assessed using fluorescent microspheres at baseline (prior to SCP); at 5 and 80 min during SCP, and at 1, 5 and 48 h after cardiopulmonary bypass (CPB). A modified Tarlov score was used to evaluate neurobehavioural recovery in all survivors blindly from videotapes for 5 days postoperatively. Histological ischaemic spinal cord injury was scored after sacrifice., Results: All pigs could be weaned from CPB and ventilation, but seven pigs (58%) in group A and five (63%) in group B developed multi-organ failure and died within 24h. SCBF diminished immediately after initiation of SCP and was absent throughout SCP in all segments below T8/9, recovering to baseline 1h after SCP at all cord levels. All survivors suffered moderate-to-severe histological lumbar spinal cord damage, more severe in group B (p< or =0.049). Three of five group A pigs recovered normal function, but two suffered paraparesis. Group B survivors had a worse neurologic outcome (p<0.0001): all suffered paraplegia (one immediate, and two on day 2, after initial recovery)., Conclusion: SCP provides insufficient SCBF below T8/9 to sustain cord viability. At 28 degrees C, the ischaemic tolerance of the cord may be exceeded enough by 90 min to impair function; by 120 min, SCP at 28 degrees C invariably results in paraplegia.

Objectives: Repair of thoracic aneurysms (TA) involving the ascending, arch, and descending aorta results in substantial morbidity and mortality. This study evaluates outcomes with a two-stage elephant trunk (ET) technique., Methods: Two hundred and fifteen consecutive patients (pts) underwent total arch replacement using an ET (02/90-09/06). One hundred and thirty-nine pts (65%), group PC (planned completion; median age 68; 28-86 years), had extensive descending TA (Ø>/=5 cm) or dissections requiring complete repair. Seventy-six pts (35%), group CS (close surveillance; median age: 68; 20-87 years), had less severe distal dilatation (Ø

Objective: Pathological aortic flow patterns differ significantly from haemodynamics within the healthy aorta. Development and impact of pathological flow is largely unknown and might affect pathogenesis and the progression of thoracic aortic diseases. This study presents pathological blood-flow patterns within a series of six patients suffering from ascending aortic aneurysms investigated with high-detail flow-sensitive, four-dimensional (4D)-MRI and three-dimensional (3D) computer-aided flow-visualisation strategies., Methods: Data were acquired on a 3T magnetic resonance system (TRIO, Siemens, Erlangen, Germany) using a flow-sensitive 4D (time-resolved 3D) sequence protocol. Measurements were taken in synchrony with the cardiac cycle and under respiration control. After data pre-processing, blood-flow was visualised by means of systolic 3D streamlines and time-resolved 3D particle traces using the software EnSight (CEI, Apex, NC, USA) and homemade visualisation tools. We investigated six adult patients with ascending aortic aneurysms and one healthy individual and findings were compared to 3D-haemodynamics of the dilated ascending aorta described in current literature., Results: Normal blood-flow in the healthy volunteer resulted in highest velocities of up to 1 ms in the ascending and descending aorta, a right-handed helical flow pattern featuring 0.5-1.5 revolutions within the ascending aorta was present. Two atherosclerotic aneurysms presented either increased right-handed helical flow with flow acceleration along the great curvature, or multiple vortical flows in the sinuses and middle of the ascending aorta. One Marfan-associated aneurysm exhibited increased vortical flow in the dilated sinuses. One pseudo-aneurysm at the proximal anastomosis of an earlier supracoronary aortic replacement showed extensive vortex formation inside the aneurysm's lumen. An aneurysm in a patient with a bicuspid aortic valve revealed one major vortex formation directly above the aortic valve. One aneurysm following congenital valvular stenosis and commissurotomy in childhood was characterised by helical diastolic backflow in the central ascending aorta and a vortex at the small curvature., Conclusion: Patients with ascending aortic aneurysms reveal considerable differences in local flow patterns among themselves and compared to healthy individuals. Further investigations are necessary to identify flow patterns predisposing to aortic aneurysm development or adverse events in the course of aortic disease.

Objective: Spinal cord blood flow (SCBF) after sacrifice of thoracoabdominal aortic segmental arteries (TAASA) during thoracoabdominal aortic aneurysm (TAAA) repair remains poorly understood. This study explored SCBF for 72 h after sacrifice of all TAASA., Methods: Fourteen juvenile Yorkshire pigs underwent complete serial TAASA sacrifice (T4-L5). Six control pigs underwent anesthesia and cooling to 32 degrees C with no TAASA sacrifice. In the experimental animals, spinal cord function was continuously monitored using motor evoked potentials (MEPs) until 1h after clamping the last TAASA. Fluorescent microspheres enabled segmental measurement of SCBF along the entire spinal cord before, and 5 min, 1 h, 5 h, 24 h and 72 h after complete TAASA sacrifice. A modified Tarlov score was obtained for 3 days after surgery., Results: All the pigs with complete TAASA sacrifice retained normal cord function (MEP) until 1h after TAASA ligation. Seven pigs (50%) with complete TAASA sacrifice recovered after 72 h; seven pigs suffered paraparesis or paraplegia. Intraoperatively, and until 1h postoperatively, SCBF was similar among the three groups along the entire cord. Postoperatively, SCBF did not decrease in any group, but significant hyperemia occurred at 5h in controls and recovery animals, but did not occur in pigs that developed paraparesis or paraplegia in the T8-L2 segments (p=0.0002) and L3-S segments (p=0.0007). At 24h, SCBF remained marginally lower from T8 caudally; at 72h, SCBF was similar among all groups along the entire cord. SCBF in the segments T8-L2 at 5h predicted functional recovery (p=0.003)., Conclusions: This study suggests that critical spinal cord ischemia after complete TAASA sacrifice does not occur immediately (intraoperatively), but is delayed 1-5h or longer after clamping, and represents failure to mount a hyperemic response to rewarming and awakening. The short duration of low SCBF associated with spinal cord injury suggests that hemodynamic and metabolic manipulation lasting only 24-72 h may allow routine preservation of normal cord function despite sacrifice of all TAASA secondary to surgical or endovascular repair of large TAAA.

Objective: Understanding the ability of the paraspinal anastomotic network to provide adequate spinal cord perfusion pressure (SCPP) critical for both surgical and endovascular repair of thoracoabdominal aortic aneurysms (TAAA)., Methods: To monitor pressure in the collateral circulation, a catheter was inserted into the distal end of the divided first lumbar segmental artery (SA) of 10 juvenile Yorkshire pigs (28.9+/-3.8kg). SA pairs from T3 through L5 were serially sacrificed at 32 degrees C; SCPP and function - using motor-evoked potentials (MEPs) - were continuously monitored until 1h after clamping the last SA. Intermittent aortic and SCPP monitoring was continued for 5 days postoperatively, along with evaluation of motor function., Results: A mean of 14.4+/-0.7 SAs were sacrificed without loss of MEP. SCPP (mmHg) dropped from 68+/-7 before SA clamping (77% of aortic pressure) to 22+/-6 at end clamping, and 21+/-4 after 1h, reaching its lowest point - 19+/-4 - after 5h. Postoperatively, SCPP recovered to 33+/-6 at 24h; 42+/-10 at 48h; 56+/-14 at 72h; 62+/-15 at 96h, returning to baseline (63+/-20) at 120h. Despite comparable SCPP patterns, four pigs did not fully regain the ability to stand. Six animals recovered: two could stand and four could walk., Conclusions: Interruption of all SAs at 32 degrees C in this pig model results in a spectrum of cord injury, with normal function in a majority of pigs postoperatively. The short duration of low SCPP suggests that hemodynamic manipulation lasting only 24-48h may allow routine complete preservation of normal cord function despite sacrifice of all SAs.