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Objectives: To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on acute and elective thoracic and abdominal aortic procedures., Methods: Forty departments shared their data on acute and elective thoracic and abdominal aortic procedures between January and May 2020 and January and May 2019 in Europe, Asia and the USA. Admission rates as well as delay from onset of symptoms to referral were compared., Results: No differences in the number of acute thoracic and abdominal aortic procedures were observed between 2020 and the reference period in 2019 [incidence rates ratio (IRR): 0.96, confidence interval (CI) 0.89-1.04; P = 0.39]. Also, no difference in the time interval from acute onset of symptoms to referral was recorded (<12 h 32% vs > 12 h 68% in 2020, < 12 h 34% vs > 12 h 66% in 2019 P = 0.29). Conversely, a decline of 35% in elective procedures was seen (IRR: 0.81, CI 0.76-0.87; P < 0.001) with substantial differences between countries and the most pronounced decline in Italy (-40%, P < 0.001). Interestingly, in Switzerland, an increase in the number of elective cases was observed (+35%, P = 0.02)., Conclusions: There was no change in the number of acute thoracic and abdominal aortic cases and procedures during the initial wave of the COVID-19 pandemic, whereas the case load of elective operations and procedures decreased significantly. Patients with acute aortic syndromes presented despite COVID-19 and were managed according to current guidelines. Further analysis is required to prove that deferral of elective cases had no impact on premature mortality., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Since its clinical implementation in the late nineties, thoracic endovascular aortic repair (TEVAR) has become the standard treatment of several acute and chronic diseases of the thoracic aorta. While TEVAR has been embraced by many, this disruptive technology has also stimulated the continuing evolution of open surgery, which became even more important as late TEVAR failures do need open surgical correction justifying the need to unite both treatment options under one umbrella. This fact shows the importance of-in analogy to the heart team-aortic centre formation and centralization of care, which stimulates continuing development and improves outcome . The next frontier to be explored is the most proximal component of the aorta-the aortic root, in particular in acute type A aortic dissection-which remains the main challenge for the years to come. The aim of this document is to provide the reader with a synopsis of current evidence regarding the use or non-use of TEVAR in acute and chronic thoracic aortic disease, to share latest recommendations for a modified terminology and for reporting standards and finally to provide a glimpse into future developments., (© The Author(s). Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Introduction: One of the main challenges in cardiac surgery is effective postoperative analgesia. Erector spinae-plane block (ESP block) is a novel regional technique, introduced by Forero in 2016 for neuropathic chest pain, then used successfully for mastectomy., Aim: To establish the efficacy of the ESP block in patients undergoing mitral and/or tricuspid valve repair through a right mini-thoracotomy., Material and Methods: It is a prospective observational cohort study performed in a tertiary health center. In the treatment group, a single-shot ESP block was performed before anesthetic induction. General anesthesia was induced with etomidate, remifentanil, and rocuronium, and continued with sevoflurane and remifentanil. Remifentanil infusion was continued for 2 h post-operatively, then stopped, and the patient's trachea was extubated. Patient-controlled analgesia was started with oxycodone immediately. Total oxycodone consumption and pain severity on the visual analog scale during the first 24 h were analyzed. In the control group, no regional block was performed. Instead of remifentanil, fentanyl was used. Patients were extubated on the second day. Pain was treated with morphine, administered according to nurses' discretion. Pain intensity was evaluated on the numerical rating scale., Results: Nineteen patients were evaluated in the ESP and 25 in the control group. Mechanical ventilation time was shorter in the ESP group (0.6 (0.4-1.1) h) than in the control one (10 (8-17) h, p = 0.00001). Moreover, patients in the ESP group spent fewer days in the intensive care unit (1 (1-1) vs. (2 (2-2), p = 0.0001)., Conclusions: The ESP block seems to be safe and efficient for pain control in patients undergoing right mini-thoracotomy for mitral and/or tricuspid valve repair., Competing Interests: The authors declare no conflict of interest., (Copyright: © 2019 Fundacja Videochirurgii.)

Background: Effective postoperative pain control remains a challenge for patients undergoing cardiac surgery. Novel regional blocks may improve pain management for such patients and can shorten their length of stay in the hospital. To compare postoperative pain intensity in patients undergoing cardiac surgery with either erector spinae plane (ESP) block or combined ESP and pectoralis nerve (PECS) blocks., Methods: This was a prospective, randomized, controlled, double-blinded study done in a tertiary hospital. Thirty patients undergoing mitral/tricuspid valve repair via mini-thoracotomy were included. Patients were randomly allocated to one of two groups: ESP or PECS + ESP group (1:1 randomization). Patients in both groups received a single-shot, ultrasound-guided ESP block. Participants in PECS + ESP group received additional PECS blocks. Each patient had to be extubated within 2 h from the end of the surgery. Pain was treated via a patient-controlled analgesia (PCA) pump. The primary outcome was the total oxycodone consumption via PCA during the first postoperative day. The secondary outcomes included pain intensity measured on the visual analog scale (VAS), patient satisfaction, Prince Henry Hospital Pain Score (PHHPS), and spirometry., Results: Patients in the PECS + ESP group used significantly less oxycodone than those in the ESP group: median 12 [interquartile range (IQR): 6-16] mg vs. 20 [IQR: 18-29] mg (p = 0.0004). Moreover, pain intensity was significantly lower in the PECS + ESP group at each of the five measurements during the first postoperative day. Patients in the PECS + ESP group were more satisfied with pain management. No difference was noticed between both groups in PHHPS and spirometry., Conclusions: The addition of PECS blocks to ESP reduced consumption of oxycodone via PCA, reduced pain intensity on the VAS, and increased patient satisfaction with pain management in patients undergoing mitral/tricuspid valve repair via mini-thoracotomy., Trial Registration: The study was registered on the 19th July 2018 (first posted) on the ClinicalTrials.gov identifier: NCT03592485.

The aim of this study was to evaluate the volume of air released from Relay Pro NBS thoracic stent grafts using different de-airing methods. The gas volume was measured in an in vitro experimental setting. Stent grafts were de-aired via (i) standard saline flushing (40 ml), (ii) increased volume saline flushing (120 ml), (iii) carbon dioxide followed by 40 ml saline flushing and (iv) de-airing with 40 ml of saline in an ultrasound bath. The volume of gas released was measured separately while introducing the folded stent graft in the delivery device into the simulated aorta (step 1) and while deploying it outside the delivery device (step 2). Median air volumes released during steps 1 and 2 after flushing with 40 ml of saline were 0.09 (1st-3rd quartile 0.06-0.21) and 0.14 (0.11-0.15) ml, respectively. The volume of air released during step 2 was significantly less [0.09 (0.08-0.10) ml] after de-airing with 120 ml saline (P = 0.049). Neither de-airing with carbon dioxide nor in an ultrasonic bath led to a reduction in the volume of gas released during step 2. Air remaining after de-airing with a standard 40 ml of saline was released partially during stent graft introduction into the aorta and partially during final deployment. The most effective method of reducing air volume was de-airing with increased saline volume., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: There is neither consensus regarding which methods of neuromonitoring are adequate and reliable for assessing cerebral cross-perfusion during unilateral cerebral perfusion (UCP) nor are any threshold values defined. The aim of the study was to evaluate the usefulness of near-infrared spectroscopy (NIRS) for the neuromonitoring of right-sided UCP, which is increasingly used for cerebral protection as a consequence of the recent rise in supra-aortic cannulation methods., Methods: For the purpose of the study, 122 patients (mean age 67 ± 12 years) who underwent open aortic arch surgery between August 2007 and July 2011 using right-sided UCP with a duration time exceeding 20 min were evaluated. The neuromonitoring consisted of NIRS and pressure measurement in both radial arteries in all patients. Forty-four (36%) patients suffered acute aortic dissection (3 having cerebral malperfusion), and 89 (73%) underwent total or subtotal arch replacement. Logistic regression analysis was used to model neurological adverse outcome (permanent and temporary neurological dysfunctions) as a function of cerebral oxygen saturation and other covariates., Results: During UCP (mean duration 38 ± 18 min) performed at a constant blood temperature of 28°C, the mean brain oxygen saturation dropped on the non-direct perfused side from 66 to 61% on average, corresponding to 92% of the baseline. In only 1 patient, an insufficient cross-over perfusion was presumed due to an intense drop of the saturation to 15% and was treated by employment of bilateral perfusion. In all remaining patients, the drop was not below 40% and/or 70% of the baseline. In the adjusted analysis, acute aortic dissection could be found as an independent predictor of an adverse neurological outcome (5 permanent, all in acute dissections, and 9 temporary dysfunctions), while there was no association between the occurrence of adverse neurological outcome and the values of regional cerebral oxygen saturation during UCP., Conclusions: NIRS seems to be a reliable instrument to recognize a relevant disruption of cerebral cross-perfusion during UCP. A drop of brain oxygen saturation to 40% and/or 70% of the baseline can be considered a threshold value for sufficient cerebral cross-perfusion, at least under the flow and temperature management presented.

Objective: The studies showing the superior characteristics of ITA graft and its impact on the clinical results of coronary artery surgery were performed with ITA harvested almost exclusively as a pedicle. This study assesses the impact of ITA skeletonization on its innervation and reactivity., Methods: Segments of skeletonized and non-skeletonized ITA were stained with antibodies against protein S-100 to look for the presence of sympathetic nerve fibers. The functional studies were performed on segments of discarded human pedicled ITA that were divided into two 3mm rings, one skeletonized and another non-skeletonized. We compared concentration-effect relationships for the contraction to norepinephrine and endothelium-dependent relaxation to acetylcholine and bradykinin, as well as endothelium-independent relaxation to sodium nitroprusside in skeletonized and non-skeletonized segments of the same ITA., Results: Skeletonized ITA was devoid of protein S-100 positive nerve fibers. It contracted stronger (maximal response 37.0+/-2.04 vs. 25.4+/-1.83mN (P<0.001)) and was twice as sensitive to norepinephrine: pD(2) 6.03+/-0.10 vs. 5.70+/-0.12 (P=0.035). The endothelium-dependent relaxation responses did not differ between skeletonized and non-skeletonized ITA rings. The skeletonized ITA rings appeared over 10 times more sensitive to sodium nitroprusside: pD(2) 6.66+/-0.20 vs. 5.59+/-0.37 (P=0.012)-potency ratio 11.61. The maximal responses did not differ significantly: 112.0+/-6.71 vs. 129.4+/-16.4% (P=0.33)., Conclusions: Skeletonization results in sympathectomy of ITA. It has no effect on endothelium-dependent relaxation but increases reactivity of ITA to norepinephrine. This augmented response to alpha-agonist is small, in comparison with over a ten-fold increase in sensitivity to sodium nitroprusside. Pedicled and skeletonized ITA are functionally significantly different vessels when studied in vitro.

Background: Diazoxide has been shown to confer significant myocardial protection in many experiments. This study was designed to assess its influence on the structural injury and functional recovery of human myocardium subjected to hypoxia/reoxygenation in vitro., Methods: The isolated electrically driven human right atrial trabeculae, obtained during cardiac surgery, were studied. The tissue bath was oxygenated with 95% oxygen and 5% carbon dioxide, hypoxia being obtained by replacing oxygen with argon. The influence of diazoxide on atrial contractility was studied first. Next, the two trabeculae from one atrial appendage were studied simultaneously, adding diazoxide to the tissue bath 10 minutes before hypoxia in one, with another serving as a control. We tested 10(-4.5) mol/L and 10(-4) mol/L diazoxide in three sets of experiments testing 30, 60, and 90 minutes of hypoxia. We continued reoxygenation for 120 minutes (in 60-minute and 90-minute hypoxia experiments) and subsequently tested reaction to 10(-4) mol/L norepinephrine. Apart from continuous recording of the contraction force, we measured the troponin I release into the tissue bath after ischemia and reoxygenation., Results: Diazoxide exerted a negative inotropic effect in human atrial muscle (pD(2)=3.96 +/- 0.18). Both concentrations of diazoxide studied resulted in better functional recovery of atrial trabeculae subjected to 30 minutes of hypoxia. With longer hypoxia, only the higher diazoxide concentration provided significant protection as assessed by contractility. After 120 minutes of reoxygenation, only diazoxide-treated muscle was viable enough to respond to norepinephrine. Only 10(-4) mol/L diazoxide resulted in lower troponin I release during hypoxia and reoxygenation., Conclusions: This study shows that diazoxide provides significant concentration-dependent protection against hypoxia/reoxygenation injury to human myocardium in vitro.