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Background : Type A aortic dissection (TAAD) is a life-threatening condition which requires prompt diagnosis and surgical treatment. When TAAD involves the aortic root, aortic valve-sparing or Bentall procedures are the main surgical treatment options. Method: The subjects of this analysis were 3735 patients included in the European Registry of Type A Aortic Dissection (ERTAAD). Propensity score matching was performed by estimating a propensity score from being treated with the Bentall or the David procedure using multilevel mixed-effects logistics, considering the cluster effect of the participating hospitals. Results: A Bentall procedure was performed in 862 patients, while a David operation was performed in 139 patients. The proportion of aortic root replacement, as well as the different techniques of aortic root replacement, varied significantly between the participating hospitals ( p < 0.001). After propensity score matching, we obtained two groups of 115 patients each, and no statistical differences were reported in terms of postoperative outcomes, except for the rate of dialysis, which was higher in the patients requiring a Bentall procedure (17.4% vs. 7.0%, p -value 0.016). In the unmatched cohorts, the David procedure was associated with a lower 10-year mortality rate compared to the Bentall procedure (30.1% vs. 45.6%, p -value 0.004), but no difference was observed after matching (30.0% vs. 43.9%, p -value 0.082). After 10 years, no differences were observed in terms of proximal aortic reoperation (3.9% vs. 4.1%, p -value 0.954), even after propensity score matching (2.8% vs. 1.8%, p -value 0.994). Conclusions: The David and Bentall procedures are durable treatment methods for TAAD. When feasible, it is advisable that the David procedure is performed for acute TAAD by surgeons with experience with this demanding surgical technique.

Aortic valve replacement improves and prolongs lives of patients with aortic valve disease, but requires significant healthcare resources, which are mainly determined by the length of associated hospital stays. Therefore, this study aims to identify risk factors for extended length of stay after surgical aortic valve replacement. Between 2018 and 2023, 458 consecutive patients underwent isolated surgical aortic valve replacement at our center and were included in our analysis. To identify independent predictors for hospital and intensive care unit stay, multivariable linear regression analysis using backward elimination process was performed. Upon multivariable linear regression, endocarditis [regression coefficient (β) 2.98; 95% confidence interval (CI) 1.51, 4.45; p<0.001)] and prior aortic valve surgery (β 1.72; 95% CI 0.18, 3.26; p=0.029) were associated with prolonged hospital stay. Prior aortic valve surgery was associated with prolonged intensive care unit stay (β 0.99; 95% CI 0.39, 1.59; p=0.001) as well as chronic obstructive pulmonary disease (β 1.61; 95% CI 0.66, 2.55; p=0.001), smaller prosthetic valve sizes (β -0.18; 95% CI -0.30, -0.06; p=0.003), preoperative atrial fibrillation (β 1.06; 95% CI 0.32, 1.79; p=0.005), and reduced left ventricular ejection fraction (β -0.03; 95% CI -0.05, -0.01; p=0.006). Pending further validation, structured programs aiming to accelerate intensive care unit and hospital discharge after surgical aortic valve replacement should focus on patients with prior cardiac surgery, atrial fibrillation, and chronic obstructive pulmonary disease. Surgeons should aim to implant large-diameter valves. Furthermore, the identified predictors should be used to discuss surgical versus transcatheter procedures in the interdisciplinary heart team., Competing Interests: CONFLICT OF INTEREST: AS received lecture fees/travel support from Abbott, Boston Scientific, and Edwards Lifesciences. AS is a proctor for Abbott. FUNDING: Till Demal was funded by the Clinician Scientist Programme of the German Center for Cardiovascular Research (Grant number DZHK; FKZ 81X3710109)., (Thieme. All rights reserved.)

Background: The current study aims to report the presentation of the malperfusion syndrome in patients with acute type A aortic dissection admitted to surgery and its impact on mortality., Methods: Data were retrieved from the multicenter European Registry of Type A Aortic Dissection. The Penn classification was used to categorize malperfusion syndromes. A machine-learning algorithm was applied to assess the multivariate interaction's importance regarding in-hospital mortality., Results: A total of 3902 consecutive patients underwent repair for acute type A aortic dissection. Local malperfusion syndrome occurred in 1584 (40.59%) patients. Multiorgan involvement occurred in 582 patients (36.74%) whereas 1002 patients (63.26%) had single-organ malperfusion. The prevalence was the greatest for cerebral (21.27%) followed by peripheral (13.94%), myocardial (9.7%), renal (9.33%), mesenteric (4.15%), and spinal malperfusion (2.10%). Multiorgan involvement predominantly occurred in organs perfused by the downstream aorta. Malperfusion significantly increased the risk of mortality (P < .001; odds ratio, 1.94 ± 0.29). The Boruta machine-learning algorithm identified the Penn classification as significantly associated with in-hospital mortality (P < .0001, variable importance = 7.91); however, 8 other variables yielded greater prediction importance. According to the Penn classification, mortality rates were 12.38% for Penn A, 20.71% for Penn B, 28.90% for Penn C, and 31.84% for Penn BC, respectively., Conclusions: Nearly one half of the examined cohort presented with signs of malperfusion syndrome predominantly attributable to local involvement. More than one third of patients with local malperfusion syndrome had a multivessel involvement. Furthermore, different levels of Penn classification can be used only as a first tool for preliminary stratification of early mortality risk., Competing Interests: Conflict of Interest Statement E.Q. receives payment or honoraria from Cardiva SL, AtriCure, Medtronic, and Edwards. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Prosthesis-patient mismatch (PPM) is a common phenomenon after transcatheter aortic valve implantation (TAVI), especially in patients with small aortic annuli. Whether factors during implantation, such as the implantation depth, have an impact on the occurrence of PPM is currently unclear. The objectives of our study were to (1) investigate the influence of procedure planning- and implantation-related factors on the occurrence of PPM and (2) evaluate the impact of PPM on long-term mortality after TAVI. Data from 315 patients with small aortic annuli, defined as multidetector computed tomography-derived annulus area <400 mm 2 , treated with transfemoral TAVI between 2014 and 2021 were retrospectively analyzed. TAVI was performed with ballon-expandable valves (BEVs) in 113 and self-expanding valves (SEVs) in 202 cases. PPM was defined according to Valve Academic Research Consortium 3 and follow-up was obtained within 5 years after TAVI. Overall, PPM occurred in 121 patients (38.4%) and was significantly more frequent in patients treated with BEVs (54.9%) than with SEVs (29.2%, p <0.001). Evaluation of planning- and implantation-related factors found that deeper implantation of BEVs significantly increased the risk of PPM (p = 0.014), whereas no association was observed in SEVs. The overall mortality rates at 3 and 5 years were 25.5% and 43.1%, respectively, without significant differences between patients with and without PPM. In conclusion, PPM occurred frequently, especially after BEV implantation. In these patients, implantation depth was identified as a predictor of PPM, whereas no association was found for SEV implantation. In addition, there was no difference in longer-term mortality between patients with and without PPM., Competing Interests: Declaration of competing interest Dr. Voigtlaender-Buschmann reports a relation with German Center for Cardiovascular Research that includes funding grants. Dr. Schofer reports a relation with Edwards Lifesciences and St Jude Medical that includes travel reimbursement; and Boston Scientific that includes: speaking and lecture fees and travel reimbursement. Dr. Conradi reports a relation with Abbott, Medtronic, and JenaValve that includes board membership; Edwards Lifesciences, Boston Scientific, VenusMedtech, MicroPort, PiCardia, MicroInterventions, Neovasc, and Smartcanula Sarl that includes consulting or advisory. Dr. Seiffert reports a relation with JenaValve and Boston Scientific that includes: consulting or advisory; Edwards Lifesciences, JenaValve Technology Inc., Boston Scientific, and Biotronik that includes travel reimbursement; and Medtronic that includes speaking and lecture fees. The remaining authors have no competing interests to declare., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: The goal of this project was to assess the efficacy of a reoperative frozen elephant trunk (FET) operation for treating residual type A aortic dissections., Methods: Between April 2015 and October 2023, a total of 237 patients underwent elective redo surgical aortic arch replacement via the FET technique to treat residual type A aortic dissection in 11 European aortic centres. Data were pooled and analysed retrospectively., Results: The time between an acute type A dissection repair to an FET implant was 5 years. More than half of all patients (54%) presented with an entry within the aortic arch, and 174 patients (73%) presented residual dissections of supra-aortic vessels. During FET repair, the axillary artery was cannulated in 181 patients (76%), whereas 83 patients (35%) underwent additional cardiac procedures including 39 root replacements (16%) and 15 coronary bypass procedures (6%). Zone 2 was the most common arch anastomosis site (n = 163, 69%), and bilateral antegrade cerebral perfusion was most frequent (n = 159, 67%). Fifteen patients (6%) died in-hospital. Age in years (P < 0.001, odds ratio: 1.069) proved to be predictive for overall mortality in our Cox regression model., Conclusions: Elective redo surgical aortic arch replacement using the FET technique for treating residual type A aortic dissection following ascending aortic replacement revealed a favourable outcome. The decision to undertake stage two therapy of a residually dissected aortic arch should be made by an aortic team on a patient-by-patient basis., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Gender difference in the outcome after type A aortic dissection (TAAD) surgery remains an issue of ongoing debate. In this study, we aimed to evaluate the impact of gender on the short- and long-term outcome after surgery for TAAD., Methods: A multicentre European registry retrospectively included all consecutive TAAD surgery patients between 2005 and 2021 from 18 hospitals across 8 European countries. Early and late mortality, and cumulative incidence of aortic reoperation were compared between genders., Results: A total of 3902 patients underwent TAAD surgery, with 1185 (30.4%) being females. After propensity score matching, 766 pairs of males and females were compared. No statistical differences were detected in the early postoperative outcome between genders. Ten-year survival was comparable between genders (47.8% vs 47.1%; log-rank test, P = 0.679), as well as cumulative incidences of distal or proximal aortic reoperations. Ten-year relative survival compared to country-, year-, age- and sex-matched general population was higher among males (0.65) compared to females (0.58). The time-period subanalysis revealed advancements in surgical techniques in both genders over the years. However, an increase in stroke was observed over time for both populations, particularly among females., Conclusions: The past 16 years have witnessed marked advancements in surgical techniques for TAAD in both males and females, achieving comparable early and late mortality rates. Despite these findings, late relative survival was still in favour of males., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The outcomes after prolonged treatment in the intensive care unit (ICU) after surgery for Stanford type A aortic dissection (TAAD) have not been previously investigated., Methods: This analysis included 3538 patients from a multicenter study who underwent surgery for acute TAAD and were admitted to the cardiac surgical ICU., Results: The mean length of stay in the cardiac surgical ICU was 9.9±9.5 days. The mean overall costs of treatment in the cardiac surgical ICU 24086±32084 €. In-hospital mortality was 14.8% and 5-year mortality was 30.5%. Adjusted analyses showed that prolonged ICU stay was associated with significantly lower risk of in-hospital mortality (adjusted OR 0.971, 95%CI 0.959-0.982), and of five-year mortality (adjusted OR 0.970, 95%CI 0.962-0.977), respectively. Propensity score matching analysis yielded 870 pairs of patients with short ICU stay (2-5 days) and long ICU stay (>5 days) with balanced baseline, operative and postoperative variables. Patients with prolonged ICU stay (>5 days) had significantly lower in-hospital mortality (8.9% vs. 17.4%, <0.001) and 5-year mortality (28.2% vs. 30.7%, P=0.007) compared to patients with short ICU-stay (2-5 days)., Conclusions: Prolonged ICU stay was common after surgery for acute TAAD. However, when adjusted for multiple baseline and operative variables as well as adverse postoperative events and the cluster effect of hospitals, it was associated with favorable survival up to 5 years after surgery.