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Selective antegrade cerebral perfusion technique is a method of cerebral protection used worldwide during aortic arch surgery. This study was designed to identify a potential correlation between perfusion flows and the development of postoperative transient neurological dysfunctions.From January 2015 to May 2020, 175 patients underwent elective surgical replacement of the aortic arch using selective antegrade cerebral perfusion at the Cardiac Surgery Unit of Sant'Orsola Hospital in Bologna. Considering that patients who developed a permanent neurological dysfunction and those who died before a possible evaluation of neurological status were excluded, the study population included 160 patients. The perfusion flows were collected and analyzed. Univariate and multivariate analyses were performed to identify the statistical risk factors involved in the onset of transient neurological dysfunctions.The study population was divided into two groups: 138 patients (86.3%) without and 22 (13.8%) with postoperative transient neurological complications. Among the intra-operative parameters collected in the study, the univariate analysis showed that the indexed medium perfusion flow of selective antegrade cerebral perfusion was significantly lower in the transient neurological dysfunctions group (11.63 ± 2.41 ml/kg/min vs 12.62 ± 2.39 ml/kg/min, P -value = 0.03). The multivariate logistic regression analysis showed that the female gender ( P = 0.004, OR = 4.816, IC = 1.636-14.174) was predictor of transient neurological dysfunctions.The results of the study showed that lower perfusion flows seem to be related to a higher probability of developing transient neurological dysfunctions. However, the analysis of a wider population is required to confirm these preliminary data.

Background The aims of this study were to analyse the incidence of visceral malperfusion syndrome (MPS) following Frozen Elephant trunk operations in patients affected by chronic aortic dissection and the associated risk factors. Methods Between January 2007 and February 2019, 165 patients underwent surgery with FET for chronic aortic dissection. Post-operative computer tomography angiogram parameters (diameters, early post-operative false lumen enhancement and involving of aortic branches by the dissection) were collected and analysed to evaluate their impact on the occurrence of visceral malperfusion. Results Visceral (renal and mesenteric) MPS (with both clinical and radiological signs of MPS) was detected in 10 cases (6.1%). Post-operative visceral malperfusion was strongly related with in hospital mortality. The involvement of the visceral branches in the dissection was not a risk factor for visceral malperfusion occurrence, while a larger post-operative total aortic diameter at level of the coeliac trunk increased the risk of visceral MPS (OR 1.05; CI 1.002–1.102, p-value = 0.04). Furthermore, visceral MPS was associated to a complete thrombosis of the false lumen at level of the distal descending thoracic aorta. Conclusions The development of post-operative MPS in frozen elephant trunk is strongly related to in-hospital mortality. The involvement of aortic branches by the dissection does not represent a real predictive risk factor for MPS, while early larger aortic diameters and false lumen thrombosis represent independent risk factors for MPS and in-hospital mortality.

We describe our institutional sternal-sparing approach for Jarvik 2000 (Jarvik Heart, Inc., NY, USA) intraventricular axial flow left ventricular assist device (LVAD) (1-5) implantation and further heart transplantation surgery with details on pedestal cable removal.

In patients with operated type A aortic dissections, irreversible spinal cord injury (SCI) may result from several factors: prolonged circulatory arrest, extension of replacement, and hypoperfusion of segmental arteries secondary to aortic false lumen thrombosis. Careful neuroprotective strategies and shorter operative times are crucial to reduce SCI incidence. Despite optimal perioperative management, delayed-onset SCI occurs in rare cases in response to subacute aortic remodeling. This report describes the case of a 77-year-old woman who underwent ascending aorta and hemiarch replacement for type A aortic dissection and had delayed paraplegia that developed on postoperative day 12.

Background While patients with uncomplicated acute Type B aortic syndromes (ATBAS) are usually managed with optimal medical therapy, complicated ATBAS require a quick intervention to prevent life-threatening complications. If anatomical features are favorable, TEVAR is the preferred treatment option. Nevertheless, open surgery still plays a significant role in selected cases. The optimal approach to complicated ATBAS remains matter of debate. Purpose We retrospectively evaluated our seventeen-years' experience as regional referral center for acute aortic syndromes to analyze the outcomes of TEVAR and open surgery in cases of complicated ATBAS. Methods Between January 2000 and December 2016, 199 patients with ATBAS were referred to our hospital: 133 aortic dissections, 53 intramural hematomas, 13 penetrating ulcers. All patients were evaluated by a multidisciplinary aortic team. 113 patients (56.8%) received the optimal medical therapy being uncomplicated, while 86 (43.2%) patients admitted with or developing a complicated form of ATBAS underwent TEVAR or open surgery during the same hospital admission. Open surgical repair was performed in cases of unsuitable anatomy for TEVAR, retrograde involvement of the arch, ascending aorta ectasia or aneurysm. In-hospital outcomes, long term survival and freedom from reoperation were analyzed and compared between the groups. Results No differences were observed in terms of in-hospital mortality between uncomplicated and complicated ATBAS (13.3% versus 14.0% respectively [p=0.890]). Complicated ATBAS were treated for unstable anatomical evolution (34 patients), refractory pain or uncontrollable hypertension (19 patients), visceral or peripheral malperfusion (18 patients) or impending rupture in 15 patients. Sixty-eight patients (79%) underwent TEVAR while 18 underwent open surgery (16 frozen elephant trunk [FET] and 2 descending thoracic aorta replacement). Operative timing from the onset of symptoms did not differ between two groups (9+10 (TEVAR) versus 14+16 (Open) days [p=0.233]). In-hospital mortality was 13.2% in TEVAR group versus 16.7% in open surgery (p=0.709). Postoperative myocardial infarction, visceral and peripheral ischemia and neurological outcomes were similar in two groups (p>0.05), but acute kidney injury was higher in open surgery cohort (p=0.027). One, 5 and 10-years survival of uncomplicated ATBAS (medical therapy) were 75%, 58%, 34% vs. 76%, 65%, 58% in TEVAR and 83%, 76%, 76% in open surgery groups (Log rank p=0.329). Comparing TEVAR and open surgery, freedom from endovascular reoperation at 1 and 5 years was 86%, 78% vs. 66%, 60% respectively (Log rank p=0.091). Conclusions Surgical treatment options (open and TEVAR) modify the natural history of complicated acute type B aortic syndromes. Open surgery represents a good option in selected cases with in-hospital and long-term survival at least comparable to TEVAR. Funding Acknowledgement Type of funding source: None

The decision-making process is crucial for the surgery of acute type A aortic dissection (AAAD). Often surgeons have to face different challenges, taking prompt decisions in emergency setting, during the pre- and intraoperative phase. Choosing if operate or not a patients with AAAD as well as the management of the dissected aortic arch can be challenging. Different factors need to be evaluated as: the patients age, the presence of organ malperfusion, the intimal tear location, and last but not least the surgeon personal experience in aortic surgery. During the last decade, different milestone steps have been achieved in aortic surgery as the antegrade perfusion of the aorta through different cannulation sites, open distal repair, antegrade selective cerebral perfusion, and systematic resection of the proximal intimal tear, allowing complex repair for dedicated team as well as simpler repair for not dedicated surgeons. We reviewed different scenarios and techniques used for the aortic arch replacement in patients with AAAD, taking into consideration that the aim of surgery is to save patients life.

OBJECTIVES: If mitral valve repair is not feasible, mitral valve replacement remains the only option. Based on our overall experience with the On-X mitral valve, the aim of this study was to investigate early and late outcomes after mitral valve replacement using this latest generation prosthesis. METHODS: From 1998 to 2016, 600 patients received an On-X prosthesis in the mitral position. Of them, we excluded all patients who had combined aortic procedures and retrospectively analysed 318 consecutive patients who had a mitral valve replacement. Associated procedures (53.5%) were tricuspid valve repair, coronary artery bypass graft and the maze procedure. The mean follow-up time was 5.6 ± 4.0 years. RESULTS: The overall hospital mortality rate was 4.4%, including acute cases of ischaemic mitral regurgitation (9.4%) and infective endocarditis (9.4%). Survival rates at 1, 3, 5 and 10 years were 97.8 ± 1.0%, 92.4 ± 1.7%, 88.4 ± 2.2% and 70.9 ± 4.0%, respectively. Independent predictors of late mortality were hypertension [hazard ratio (HR) 1.91; P = 0.027], chronic obstructive pulmonary disease (HR 2.91; P = 0.003) and chronic renal failure (HR 5.27; P < 0.001). Freedom from reoperation was 99.3 ± 0.5%, 98.4 ± 0.8%, 97.2 ± 1.2% and 92.5 ± 2.4% at 1, 3, 5 and 10 years, respectively. At follow-up, 8.5% events were recognized as thromboembolic or haemorrhagic events; freedom from events related to anticoagulation therapy at 1, 3, 5 and 10 years was 99.0 ± 0.6%, 96.8 ± 1.1%, 93.7 ± 1.8% and 89.0 ± 2.7%, respectively. CONCLUSIONS: According to the results of this observational study, the unique design of the On-X valve works well with mitral valve diseases of various aetiologies, especially in cases with an unfavourable anatomy. This prosthesis also guarantees safe long-term durability associated with a low incidence of thromboembolism.

Purpose To investigate the predictive value of Acute Physiology, Age and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology (SAPS) II and Sequential Organ Failure Assessment (SOFA) scores for patient selection and timing to Extracorporeal Life Support (ECLS) as treatment of refractory cardiogenic shock. Methods Retrospective analysis of a prospectively-maintained operative dataset. Results Our study population included 185 patients receiving ECLS at our department between 2006 and 2018. Patient median age was 50.6 years; 62% were male. The most frequent reason for ECLS need, in our subset of patients, was post-cardiotomy syndrome (52.4%) followed by acute decompensation of chronic heart failure (17.5%), isolated right ventricular dysfunction (16.2%), acute myocardial infarction (10.2%) and myocarditis (3.7%). Median duration of ECLS was 8.9 days. Forty-one patients (22.2%) received heart transplantation. In-hospital mortality was 34.6% on ECLS running and 25.9% after ECLS removal. Multivariate regression analysis showed patient age, ECLS duration and bridge to transplantation (BTT) category as indipendent predictors of death (p Conclusion This study confirms the poor prognosis of critically ill patients receiving ECLS support. The APACHE II and SOFA scores, mainly, proved to be a reproducible evaluation tool with high prognostic abilities. In our population, age >65 years, ECLS duration >10 days and BTT ECLS intention appear to impact negatively.

The best surgical treatment for acute type A aortic dissection (AAAD) is still a strongly debated issue of every cardiac surgeon. The successful result is obtained by taking into consideration both the preoperative and intraoperative aspects, such as cerebral, visceral or coronary malperfusion before surgery. More conservative approaches or more aggressive treatments are different strategies with their pros and cons to face the same problem, especially for the aortic arch management. The expertise of the center, the perfect surgical timing and a dedicated aortic team composed of expert aortic surgeons, anesthesiologist, radiologist and cardiologist are important but not mandatory to achieve the best results in this type of surgery since is not possible to offer it in all the hospitals. The accurate assessment of the aortic anatomy has to be performed, including the extension of the dissection process, the exact location of the entry and re-entry tears, the aortic diameters, the distribution of visceral vessels between the true and the false lumen and the assessment of perfect size of the prosthesis to avoid the oversize since it may cause new entry site in the descending thoracic aorta. We reviewed and analyzed different scenarios and techniques used for the aortic arch replacement in patients with AAAD, taking into consideration that the aim of surgery is to save patients life.

Left ventricular assist device graft protection and its intraoperative orientation continues to be a major concern in bridge-to-transplant strategy. Different techniques have been described, including the adoption of a standard full sternotomy approach. We describe our institutional experience of placement of the with HeartWare HVAD® implantable continuous flow pump, with outflow graft tunnelling through the transverse sinus to prepare patients in need of eventual re-sternotomy. Surgical tips are provided in the tutorial videos both for HVAD® placement, and for explantation at the time of heart transplantation.

OBJECTIVES We compared the results of 2 groups of patients who underwent aortic arch replacement with the frozen elephant trunk technique. In the first group, the distal anastomosis was performed in arch zone 2; in the second control group, the distal anastomosis was performed in arch zone 3. METHODS Between January 2007 and April 2018, the frozen elephant trunk technique was used in 282 patients. The median age was 62 years (range 18–83 years), and 233 patients were men (82.6%). Two different frozen elephant trunk prostheses were used: the Jotec E-vita open prosthesis in 167 patients (59.2%) and the Vascutek Thoraflex hybrid prosthesis in 115 patients (40.8%). Patients were divided into 2 groups according to the distal anastomosis site: zone 2 group (69 patients) and zone 3 group (213 patients). The main indications were chronic aortic dissection (n = 164, 58.2%), degenerative aneurysm (n = 72, 25.5%) and acute aortic dissections (n = 45, 16%). RESULTS The overall in-hospital mortality rate was 17%: 20% for the zone 2 group and 16% for the zone 3 group, without significant differences, also in terms of cardiopulmonary bypass and myocardial ischaemia times. However, the visceral ischaemia time was significantly shorter for the zone 2 group, whereas the antegrade selective cerebral perfusion time was significantly longer for the same group. Recurrent laryngeal nerve injury rate was lower in the zone 2 group. The overall postoperative paraplegia rate was 3.5%, whereas the occurrence of permanent neurological dysfunction and dialysis was 9% and 19%, respectively, with no significant differences between the groups. CONCLUSIONS ‘Proximalization’ of the distal anastomosis can be used for arch reconstruction, especially in complex cases such as reoperations or acute aortic dissections. Furthermore, with the aid of branched hybrid grafts, a reduction of the visceral ischaemia time is achieved.

Stroke events are very common in acute type A aortic dissection. Cerebral malperfusion could manifest at presentation due to prolonged arch vessels hypoperfusion or develop after surgery for inadequate cerebral protection during arch repair. To reduce this detrimental complication there are several adjuncts that can be adopted for cerebral protection such as direct antegrade or retrograde cerebral perfusion (RCP) and use period of deep to moderate hypothermic circulatory arrest time; however, they are often insufficient as preoperative malperfusion already caused irreversible ischemic damages. The aim of the current review article is to analyze the principal series reporting on neurological injuries during type A aortic dissection to focus on the outcomes according to the type of surgical management and identify possible predictors to better manage this complication.

The aim of this study is to evaluate the mid-term clinical and functional outcomes of maze surgery in symptomatic refractory lone atrial fibrillation (AF) patients. Between March 2008 and January 2013, 39 highly symptomatic patients [mean age 51 +/- 10 (mean +/- standard deviation); 95% CI, European Heart Rhythm Association class III-IV] underwent maze surgery for lone AF. Biatrial ablations were performed with bipolar radiofrequency and cryoenergy, according to a maze III lesion set (modified by omitting the intercaval line in 5 of 39 patients). Mean ejection fraction was 51 +/- 9% (range 17-60), < 45% in 10 patients (26%). Seventeen of 39 patients (44%) had persistent, 22 of 39 patients (56%) long-standing persistent AF, and 35 of 39 patients (90%) had previous transvenous ablations (median = 2; range 0-8). No patient had concomitant structural heart disease. A minimally invasive approach was adopted in 22 patients (56%). Major complications were 1 mediastinitis, 1 re-exploration for bleeding and 2 pacemaker (5%) implantation. At a mean follow-up of 29.4 +/- 14.2 months, freedom from arrhythmias was 92 and 93% at 24 and 36 months, respectively. Freedom without antiarrhythmic drugs was 75 and 85% at 24 and 36 months, respectively. Ejection fraction normalized in all cases, from 51.3 +/- 9% to 61.1 +/- 3% (P < 0.001) overall, and from 37.0 +/- 10% to 60.3 +/- 3% (P < 0.001) when a parts per thousand currency sign45% preoperatively. AF-related symptoms score decreased to class I in 36 patients (93%). No early or late stroke occurred. Within a dedicated AF centre, maze surgery grants excellent outcomes, with symptoms relief and negligible risk. It provides a complete reversal of arrhythmia-related myocardial dysfunction and is therefore a convenient alternative to His bundle ablation and lifelong pacemaker dependency in symptomatic refractory patients.