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Surgical treatment strategies for acute type A aortic dissection continue to evolve. Proximal reconstruction typically involves aortic valve resuspension with preservation of the aortic root, unless the tear site extends into the aortic root. Although there is strong consensus on proximal aortic reconstruction strategy, open distal aortic reconstruction as a transverse hemiarch replacement under circulatory arrest is still not adopted by many groups, even though evidence supports for this distal reconstructive strategy. In addition to proximal and distal aortic stabilization, one of the essential aspects of repair remains reapposition of the dissection flap in the aortic root and the ascending aorta. To this effect, there is literature supporting for many techniques, including placement of adhesives into the dissection flap and/or placement of felt material in the dissection flap to reappose the intima, media and the adventia of the dissected aorta. But overall, there is no clear consensus on the ideal technique for apposition of the dissection flap.

ObjectivePreviously, we showed that antegrade stent grafting of the descending thoracic aorta during DeBakey type I dissection repair improves distal aortic remodeling. We assessed midterm outcomes of this reconstructive strategy compared with standard open repair.MethodsDeBakey type I dissections (non-Marfan, nontotal arch cases only) from 2005 to 2012 were retrospectively reviewed. One hundred eighty patients underwent standard open repair (standard group), and 62 patients underwent open repair plus stenting (stented group). Open repair entailed ascending aorta plus transverse hemiarch reconstruction under circulatory arrest, with variable aortic root work. Data was prospectively maintained.ResultsPreoperative parameters were similar. Patients in the stented group had longer circulatory arrest time and higher utility of antegrade cerebral perfusion (P

Data on acute type A aortic dissection in patients with bicuspid aortic valve (BAV) syndrome are limited. This investigation evaluated the clinical details in patients with type A dissection stratified according to aortic valve morphology.Between 1993 and 2013, 629 patients (median age 61 years [50; 73], 64% men) underwent surgical procedures for type A dissection. Forty-one patients with BAV were compared with 588 patients with tricuspid aortic valve (TAV).The BAV patients were younger (55 years [46; 67] vs 61 years [51; 73] years; p0.001), presented more frequently with moderate or severe aortic insufficiency (51% vs 34%; p = 0.039), cardiogenic shock (37 vs 21%; p = 0.029), and had larger ascending aorta diameters (5.5 cm [5.1; 6.4] vs 4.8 cm [4.4; 5.5] cm; p0.001). The BAV patients more frequently required aortic root replacement (81% vs 14%; p0.001). Total arch replacement was performed in 5% of the BAV patients and 4% of the TAV patients. In-hospital mortality (14.6% vs 13.1%; p = 1.0) and survival at 5, 10, and 15 years (56% ± 8%, 46% ± 10%, and 37% ± 11% vs 68% ± 2%, 49% ± 3%, and 36% ± 4%; log rank, p = 0.4) were similar in the BAV and TAV patients. Twenty (3%) TAV and no BAV patients underwent proximal reoperations (p = 0.6) at a median follow-up time of 4.1 years (range, 0.8 to 6.9 years).BAV patients experience dissection at a younger age and at a greater ascending aortic diameter. Extensive aortic root repair in BAV patients is not associated with higher in-hospital mortality and prevents the need for later proximal redo operation.

Stanford type A aortic dissection in patients with previous cardiac surgery (PCS) is a catastrophic disease. This investigation evaluates the results of a standardized integrated approach to type A dissection after PCS.Between 1993 and 2013, 629 patients with acute type A dissection (median age 61 [50 to 73] years, 64% males) underwent aortic repair utilizing a standardized integrated approach. Of these, 56 (9%) patients had PCS. Median follow-up was 4.1 (1.9 to 7.4) years (2,812 patient-years).Patients with PCS were older (70 [60 to 75] vs 60 [50 to 72] years, p0.001), fivefold more likely to have coronary artery disease (p0.001), and threefold less likely to have cardiac tamponade (p0.001). They had higher in-hospital mortality rate (25% vs 12%, p=0.011), similar postoperative stroke rate (4% vs 5%, p=0.821), and lower survival (60%±7%, 50%±7%, 38%±8% vs 84%±2%, 69%±2%, 50%±3%) at 1, 5, and 10 years, respectively (log rank, p=0.003). Among PCS patients, the lowest in-hospital mortality was in those without prior myocardial revascularization (11% vs 32%, p=0.185). Coronary malperfusion (odds ratio, 9.47; p=0.034) and cardiac tamponade (odds ratio, 5.01; p=0.076) were independent in-hospital mortality risk factors in PCS patients.Standardized integrated approach to acute type A aortic dissection in PCS patients results in acceptable postoperative mortality. Previous cardiac surgery should not be a reason to deny surgical repair in patients with type A dissection.

Background: Patients with a very low ejection fraction (EF) have been excluded from major TAVR trials. As a consequence, the safety and efficacy of TAVR in this cohort remains uncertain. In this study, patients with pre-TAVR EF≤20% were analyzed to determine survival and effects on cardiac

Direct transaortic (TAo) approach for transcatheter aortic valve replacement (TAVR) in patients with symptomatic, severe aortic stenosis (AS) with prohibitive transfemoral access is being increasingly performed. Furthermore, concomitant catheter-based procedures such as percutaneous coronary intervention (PCI) are also being increasingly performed during TAVR. We report a single-stage, catheter-based treatment of both critical AS and descending thoracic aortic aneurysm (DTA) by performing TAVR with concomitant thoracic aortic endovascular repair (TEVAR) through direct TAo access via a minimally invasive partial sternotomy approach. To our knowledge, this is the first report of a "hybrid" TAVR + TEVAR.

Transcatheter aortic valve replacement (TAVR) has become the standard of care for high risk and inoperable patients with severe symptomatic aortic stenosis. We sought to assess rates of paravalvular regurgitation (PVR) following TAVR in a large cohort of patients having undergone TAVR post approval

Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Philadelphia, PA, USA *These authors contributed equally to this work. Correspondence to: Wilson Y. Szeto. Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Penn Presbyterian Medical Center, 51 N 39th St, Heart & Vascular Pavilion 2A, Philadelphia, PA 19104, USA. Email: wilson.szeto@uphs.upenn.edu.

removed; however, the contaminated needle puncture may be associated with subsequent mediastinal infection, so empirical antimicrobial therapy is suggested in selected cases. In conclusion, surgeons could consider EBUS-TBNA as an effective and alternative option in the diagnosis, subsequent surgical intervention, and identification of the causative agent of mediastinal infections in patients who are unable to undergo surgery.

Background The combined open surgical and endovascular approach for the treatment of aortic arch aneurysms has emerged as a safe treatment modality. This platform may have an especially important role in treating patients of old age and with a greater comorbid burden. We describe our institutional experience with the hybrid aortic arch approach, with midterm outcomes. Methods From 2005 to the present, 685 patients have undergone thoracic endovascular repair (TEVAR); 104 had a hybrid arch repair (open plus endovascular approach). Of these, 47 patients had treatment for an aortic arch aneurysm with or without a proximal ascending aortic aneurysm. All these patients had a median sternotomy approach for arch vessel debranching and antegrade with or without retrograde TEVAR stent grafting of the arch. Results from a prospectively maintained database are reported. Results Twenty-eight patients had type I repair, 8 patients had type II repair, and 11 patients had type III arch hybrid repair. Those with type III repair were excluded from the analysis. Stent graft deployment rate was 100% after arch vessel debranching. Mean age was 71 ± 8 years. Fourteen percent of cases involved a redo sternotomy. Average cardiopulmonary bypass time was 215 ± 64 minutes, with a crossclamp time of 70 ± 55 minutes and a circulatory arrest time of 19 ± 10 minutes. The paraplegia rate was 5.5% (n = 2), with a stroke rate of 8% (n = 3). In-hospital mortality was 8% (n = 3). There were no postoperative endoleaks. The mean length of stay was 17.2 ± 14 days. The median follow-up was 30 ± 21 months. Freedom from all-cause mortality was 71%, 60%, and 48% at 1, 3, and 5 years, respectively. The aortic reoperation rate was 2.7% (n = 1). No patient has a type 1 or 3 endoleak at latest follow-up. Conclusions The hybrid approach to aortic arch aneurysm involving a zone 0 stent graft landing can be safely adopted with good midterm results in a cohort of old patients with significant comorbidity. This procedure can be performed with no type 1 or 3 endoleaks and may represent a technical advancement in the field of aortic arch surgery.

Public demand for Transcatheter Aortic Valve Replacement (TAVR) 2.5 years post approval continues to be strong. However institutions are still perplexed on how to decrease cost and improve efficiency. This discussion addresses these challenges with the TAVR population and methods which may increase

Transcatheter aortic valve implantation (TAVI) is an emerging and promising modality to treat severe aortic stenosis in a select group of patients who are poor surgical candidates. Despite the lesser degree of invasiveness of TAVI compared to open aortic valve replacement (AVR), TAVI is associated with a significant potential for serious life-threatening complications, both intraoperatively and postoperatively. These include vascular injuries, stroke, structural injury to the aorta and the heart and its valves, aortic root or annulus injury, conduction tissue injury, paravalvular leak, valve malposition, coronary complications such as obstruction or ischemia, pericardial effusion and tamponade, and procedural cardiac depression requiring immediate cardiopulmonary bypass for resuscitation. The prevention, detection, and treatment of these complications demands a skill set requiring the services of a cardiovascular surgeon with endovascular skills, an interventional cardiologist, a cardiac perfusion team, and cardiac anesthesia. Therefore, the optimal care of TAVI patients requires a multidisciplinary approach involving these services. The range of serious complications associated with TAVI, and the management strategies utilized in their treatment, are discussed.

We have previously reported that transplantation (Tx) of prevascularized donor islets as composite islet-kidneys (IK) reverses diabetic hyperglycemia in miniature swine. In order to test the potential clinical applicability of this strategy, we have extended it to a fully allogeneic nonhuman primate model. IKs were prepared in baboons by isolating islets from 50% to 70% partial pancreatectomies and injecting them under the autologous renal capsule, allowing vascularization before allogeneic Tx. Baboons with diabetes induced by stereptozotocin or total pancreatectomy, received composite IKs (n = 3) or free islets under the renal capsule or intraportally (n = 3), across fully allogeneic barriers with an immunosuppressive regimen consisting of ATG followed by MMF and tacrolimus. FBS of two of IK recipients decreased immediately after Tx and no insulin therapy was required throughout the experimental period (225 and 301 days). In contrast, all recipients of allogeneic free islets showed unstable FBS levels and required insulin within 2 months. We conclude that in addition to maintaining creatinine in the normal range, fully allogeneic IKs from single primate donors can achieve glucose regulation without insulin therapy, while free islets do not. These results support the feasibility of composite allogeneic IK Tx as a potential cure for end-stage diabetic nephropathy.

Transplantation of vascularized donor thymic tissue along with a kidney transplant has markedly improved graft survival across the discordant pig-to-baboon xenogeneic barrier. To quantify the production of baboon T cells by the porcine thymic tissue, we recently developed an assay to measure the excised DNA products of baboon T-cell receptor (TCR) gene rearrangement (signal-joining TCR excision circles, sjTREC).Initial polymerase chain reaction (PCR) analysis documented that TCR δREC-ψJα rearrangement occurs in baboons. Primers, specific to baboon sjTREC sequence were designed and used to quantify sjTREC molecules in peripheral blood mononuclear cells and thymic tissue using a quantitative PCR assay.sjTREC levels were higher in phenotypically naïve (CD3CD45RA) T cells (650 copies/100,000 cells) than in phenotypically memory (CD3CD45RA) T cells, with sjTREC below the limit of detection (40 copies/100,000 cells). Surgical removal of the native thymus in two baboons led to a significant decrease of sjTREC in peripheral blood (from 1104 and 920 copies to 184 and 190 copies/100,000 cells, respectively), confirming the role of the thymus in maintaining the peripheral T-cell pool. In two thymectomized baboons that received porcine thymokidney xenografts, sjTREC levels remained low in the peripheral blood (40 copies/100,000 cells), but increased to 52 and 192 copies/100,000 cells in thymic biopsies, implying that baboon thymopoiesis had begun to occur in the porcine thymic xenografts.Baboon sjTREC can be quantified by quantitative PCR using primers specific to baboon sequence. Initial results suggest that baboon thymopoiesis occurs in vascularized porcine thymus xenografts.

[Figure][1] [Video 1][2] TTE With Contrast Demonstrating the Presence of the LV Pseudoaneurysm LV = left ventricular; TTE = transthoracic echocardiography. ![Figure][1] [Video 2][3] TEE with Color Doppler Demonstrating Flow Into the LV Pseudoaneurysm LV = left ventricular; TEE

Considerable progress has been made in identifying the transcription factors involved in the early specification of the B-lymphocyte lineage. However, little is known about factors that control the transition of mature activated B cells to antibody-secreting plasma cells. Here we report that the transcription factor XBP-1 is required for the generation of plasma cells. XBP-1 transcripts were rapidly upregulated in vitro by stimuli that induce plasma-cell differentiation, and were found at high levels in plasma cells from rheumatoid synovium. When introduced into B-lineage cells, XBP-1 initiated plasma-cell differentiation. Mouse lymphoid chimaeras deficient in XBP-1 possessed normal numbers of activated B lymphocytes that proliferated, secreted cytokines and formed normal germinal centres. However, they secreted very little immunoglobulin of any isotype and failed to control infection with the B-cell-dependent polyoma virus, because plasma cells were markedly absent. XBP-1 is the only transcription factor known to be selectively and specifically required for the terminal differentiation of B lymphocytes to plasma cells.

Background: Severe left ventricular hypertrophy (LVH) has a well documented severe negative impact on early mortality in patients undergoing surgical aortic valve replacement. This effect is particularly pronounced in patients with elevated relative wall thickness, an indicator of extreme hypertrophy with small ventricular cavity(suicide ventricle). It is not clear whether similar mortality risk is present in transcatheter aortic valve replacement(TAVR), which avoids issues regarding myocardial protection and hyperdynamic post-bypass physiology. The purpose of this study is to analyze the impact of LVH on patients undergoing TAVR. Methods: From 2008-2011, a retrospective review of patients undergoing TAVR was performed, comparing patients without severe LVH (n 59) to those with severe LVH (group 2, n 89). LVH was defined as a relative wall thickness (2xPosterior wall Thickness/LVEDD) of greater than 0.5. Data was abstracted from a prospectively kept database with robust echocardiograhpic and clinical follow-up. Results: Preoperative age, STS score, and aortic valve area did not differ (age: 81 vs. 84 years; STS score 12 vs. 12; AVA 0.61 vs. 0.61cm2, no LVH versus severe LVH groups respectively). Peak gradient (PG) was higher in severe LVH group (PG 79 vs. 84mmHg, p 0.0001) but mean gradient (MG) did not differ (MG: 47 vs. 49mmHG, p NS). The severe LVH group had a higher LV ejection fraction(p 0.001), higher preoperative pulmonary artery pressures(p 0.001), worse mitral and tricuspid regurgitation(p 0.01). There was no difference in peri-procedural mortality (6.8% vs. 7.8%, p 0.5). There were not differences in ventilation time, inotrope use or overall length of stay between groups. At 1 year follow up, mortality rates did not differ (29 vs. 25%, p 0.3). PG and MG did not differ (PG: 23 vs. 24mmH, MG: 12 vs. 12mmHg). LV mass regression did not differ between groups. The severe LVH group continued to have a higher ejection fraction (59 vs. 67%, p 0.001). Conclusions: Unlike surgical AVR patients, the presence of severe left ventricular hypertrophy in patients undergoing TAVR was not correlated with adverse outcomes at 1 year.

Objective To present the outcomes of routinely performed hemiarch replacement in patients with acute type A aortic dissection. Methods From 1993 to 2013, among 629 patients with acute type A dissection, 534 patients (85%) underwent hemiarch, 63 patients (10%) underwent hemiarch and antegrade thoracic stent grafting, 26 patients (4%) underwent total arch, and 6 patients (1%) underwent isolated ascending replacement. Patients with hemiarch replacement comprised the study population. Median follow-up was 4.1 years (first quartile, 1.9; third quartile, 7.8) (2462 patient years). Results In-hospital mortality was 12% (66 out of 534 patients). Survival was 80% ± 2%, 68% ± 3%, and 51% ± 3%, and 84% ± 3%, 65% ± 4%, and 41% ± 6% in DeBakey type I and II patients at 1, 5, and 10 years, respectively (log rank P = .375). Freedom from distal aortic reintervention was 97% ± 1%, 90% ± 2%, and 85% ± 3% and 99% ± 1%, 97% ± 2%, and 90% ± 5% in DeBakey type I and II patients at 1, 5, and 10 years, respectively (log rank P = .046). Seven patients (1.3%) required reintervention for aortic arch aneurysm and 25 patients (5%) required reintervention for descending aortopathy. The success rate for distal reintervention performed electively or urgently was 92% (24 out of 26 patients). Marfan syndrome (odds ratio, 3.43; P = .046) and DeBakey type I dissection (odds ratio, 2.49; P = .048) were independent predictors of distal aortic reintervention. Conclusions Aggressive hemiarch replacement in acute type A dissection can be performed with low mortality and low aortic arch reoperation rate. Resection of all dissected aortic wall tissue decreases, but does not eliminate, the risk of later adverse aortic events.

An 88-year-old woman with a history of severe aortic stenosis presented for a transaortic valve replacement (TAVR). A pre-TAVR computed tomography angiogram showed an aortic annular area of 385 mm2 and an average diameter of 22.1 mm ([Figure 1A][1]). The patient underwent an uncomplicated

ObjectivesThe current guidelines for ascending aortic replacement were determined from already dissected aorta diameters. Previous computed tomography-based work on humans who underwent imaging before and directly after aortic dissection onset has shown an average 30% increase in the ascending aortic diameter with acute dissection. The present investigation evaluated the incidence of predissection ascending aortic dilatation in acute type A dissection.MethodsFrom 2002 to 2013, 495 patients presented with acute type A aortic dissection to 1 center. Of these cases, 343 were non-Marfan, nonbicuspid with spontaneous dissection etiology. In those with available preoperative computed tomography angiograms (n = 83) or transesophageal echocardiograms (n = 260), the predissection ascending aorta diameters were modeled from the dissected aorta diameters by subtraction of the average diameter increase rate.ResultsAltogether 343 patients were included (age, 62 years; range, 53-73; 64% men). The median modeled predissection ascending diameter was 3.7 cm (first quartile, 3.3; third quartile, −4.1). Of the 343 patients, 334 (97%) and 315 (92%) had an ascending diameter before dissection onset of

Transcatheter Aortic Valve Replacement (TAVR) has emerged as an alternative to high-risk surgery in patients with comorbid conditions. The role of TAVR in patients with liver disease has not been fully examined. We examined the procedural and intermediate to long-term follow-up outcomes of patients