<pre style="background: #222222; color: #eeeeee; padding: 18px; border-radius: 8px; overflow-x: auto;">Objectives: Open surgery remains the gold standard for the treatment of the thoracoabdominal aorta (TAA). The rising number of endovascularly treated patients comes with an increase in the number of patients who require secondary open interventions due to the complex nature of the aortic disease or to treat endovascular complications.
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Methods: We describe our current approach to secondary open extent II TAA repair in patients with prior endovascular repair. We also describe our experience with this cohort of patients in our institution between 2017 and 2022 (n = 22).

Results: We routinely use left heart bypass with mild passive hypothermia (34 &deg;C), cerebrospinal fluid drainage, sequential aortic cross-clamping, motor evoked potentials monitoring, oxygen saturations and selective visceral perfusion with blood and renal protection with Custodiol. We advocate for reimplantation of intercostal arteries.
Between September 2017 and August 2022 a total of 22 patients underwent secondary open TAA repair after previous endovascular therapy in our institution.
Mean age was 56.5 years (20&ndash;78), and 77% were male.
Previous endovascular treatment consisted of TEVAR (16, 73%), EVAR/FEVAR (5, 23%) and FET (1, 4%). Indications included aneurysmal expansion (12, 54%), endoleak (4, 18%), stent misplacement (3, 14%) and infection (3, 14%).
Extent of the open TAA repair included: DTA (6, 27%), Crawford I (1, 4%), II (11, 50%), III (3, 14%) and IV (1, 4%). 14 patients (64%) were elective, while 8 cases (36%) were urgent/emergencies.
Median time to open TAA surgery from endovascular treatment was 31 months (0.5&ndash;264 months). In-hospital mortality was 32% (7 patients). Postoperative complications include haemofiltration (11, 50%), tracheostomy (3, 14%) and paraplegia (3, 14%).
Conclusions: Favourable early outcomes and a durable repair can be achieved at experienced high-volume centers, with pre-operative selection and multidisciplinary team based intraoperative and postoperative management of these patients.
Objectives: Retrograde type A aortic dissection (RTAAD) can be spontaneous or secondary to instrumentation of the descending and thoracoabdominal aorta. It has anatomical differences compared to antegrade TAAD that impact of the management and prognosis. Treatment is not standardised.
Methods: We report our current approach to spontaneous RTAAD, and describe our experience with this cohort of patients in our institution between 2018 and 2022 (n = 15).
Results: A total of 15 patients experienced a spontaneous RTAAD in our centre between January 2018 and July 2022. Mean age was 60.1 years (30&ndash;82) and 93% were male (14/15). In 80% of the cases valve, coronary arteries and supra-aortic trunks were spared by the dissection. Antegrade distal extension to iliacs was common and lower limb malperfusion was present in four cases (27%). The ascending aorta was dilated (> 40 mm) at presentation in 60% of the cases. Emergency surgery with arch/FET replacement was offered to 11 patients (73%); 3 patients (20%) received a limited proximal aortic repair (ascending and hemiarch replacement); and one patient was treated conservatively due to short life expectancy. In all cases, aorta was explored with deep hypothermic cardiac arrest and antegrade cerebral perfusion was used. Overall mortality was 47% (7 patients). Respectively, 100% mortality for cases treated with limited proximal repair and 22% for those who received arch/FET replacement. Other postoperative complications included stroke n = 3 (20%), spinal cord injury n = 2 (13%), tracheostomy n = 7 (47%), hemofiltration for renal failure n = 5 (33%). All eight survivors (53%) remain alive with median follow-up 4.8 months (3.7&ndash;11.2 months).
Conclusions: Based on our experience, we advocate for aggressive treatment of RTAAD excluding the primary entry tear to prevent immediate and mid-term complications.
Objectives: Evaluate early and long-term outcomes in treatment of NANB AAD in a single centre.
Methods: Retrospective observational study between 1/01/2016 and 30/06/2022. Early and long-term morbidity and mortality of a strategy of best medical treatment with early symptoms-based intervention was analyzed.
Results: Out of 514 AAS (n311, 60.5% type A AAD; n164, 31.9% type B AAD; n19, 3.7% IMH/PAU and n3, 0.6% iatrogenic dissection), n17 (3.3%) NANB were detected (n13, 76.5% men, mean age 64y, range 41&ndash;87). Best medical treatment was immediately successful in 90% of cases. Emergent/urgent operation was needed in 47.1% of patients and consisted in FET.
At a mean follow-up of 14 months, the overall survival rate was 94.1%; 17.6% of patients needed an aortic reintervention. CTA showed FL thrombosis in 85.7% of operated vs 64.7% medically treated patients. Patients underwent intervention had significantly higher preoperative diameter of zone 3&ndash;4 (mean 33.01 vs. 43.23 mm, p.005) and 5&ndash;6 (mean 29.51 vs. 35.04 mm, p.046).
Conclusions: There is a continuing controversy over the best treatment for NANB AAD. The benefit to patients of medical/surgical treatment depends critically upon selection criteria. Higher preoperative diameter of DTA seems to be related to a higher need for immediate intervention.
Objectives: During aortic surgery, the intended extent of aortic replacement is often confirmed intraoperatively by inspection of the aortic arch. The ambuscope is a single use bronchoscope which we have used to accurately and more extensively inspect the arch and proximal descending aorta during circulatory arrest. We describe our initial experience of ambuscope to assist decision making during major aortic surgery.
Methods: All patients undergoing aortic surgery at a single institution from Oct 2020 until September 2022 we analysed. Those in whom ambuscope was used were included. Operation notes and imaging was reviewed for demographics, diagnosis, findings and outcomes. Primary outcomes were the use of ambuscope and its impact on intraoperative decision making.
Results: From October 2020 until September 2022 the ambuscope was used in 39 major aortic cases. Mean age was 61 years (21&ndash;82) and 28 (72%) were male. Thirteen (33%) were elective, 5 (13%) urgent and 21 (54%) emergency. Thirteen (33%) had aneurysm, 18 (46%) Type A dissection and 8 (21%) retrograde Type B dissection. All cases underwent circulatory arrest with ambuscope inspection of the arch and proximal descending aorta. Utilisation of ambuscope included measuring length of frozen elephant trunk required 21 (54%), expansion of ascyrus medical dissection stent (AMDS) 6 (15%), confirming no further tears in arch or descending aorta 9 (23%), unexpected arch tear requiring frozen elephant trunk (FET) 3(8%). Recording of images may be useful for documentation and subsequent review.
Conclusions: We describe novel use of ambuscope and its benefits in decision making during major aortic surgery.
Objectives: Patients suffering Type A Aortic dissection (TAAD) can develop severe coagulopathy, particularly in the post-operative period. Antifibrinolytics such as Aprotinin have been shown to reduce blood loss and reduce the transfusion burden in cardiac surgical patients. We aim to identify the benefit of Aprotinin over Tranexamic acid (TXA) by investigating patients undergoing surgery for TAAD.
Methods: Patients undergoing TAAD repair were retrospectively identified using a hospital database. 32 patients were identified receiving aprotinin and 105 patients received TXA. Patients undergoing complete arch replacement and those requiring mechanical support for excluded from our study. The volume of blood product transfusion in both theatre and in the intensive care unit after surgery was compared as our primary outcome.
Results: The demographics and pre-operative risk factors between the two groups are well matched. There were significantly more patients in the Aprotinin group undergoing deep hypothermic circulatory arrest (p = 0.034). There was a significant difference between the groups in intra-operative platelet transfusion, with TXA patients needing 1.48 (&plusmn; 1.28) units vs those on aprotinin needing 0.94 (&plusmn; 0.96) units (p = 0.012). This increased platelet transfusion in the TXA group was not replicated in the ICU or in composite transfusion data. When comparing bleeding rates, there was no significant difference in 12-h blood loss and return to theatre between the groups.
There were no differences in incidence of renal replacement therapy. There were also no differences in incidence of stroke, ICU and hospital stays or 30d and 1 year mortality.
Conclusions: Based on the current findings&mdash;within the limits of a retrospective observational study&mdash;aprotinin does not appear to confer any benefit when used during acute Type A aortic dissection repair.
1St. Bartholomew's Hospital; 2St. Bartholomew's Hospital and Barts Heart Centre and Ortus I-Health, London, UK; 3St. Bartholomew's Hospital and William Harvey Research Institute, Centre for Cardiovascular Medicine and Devices, London, UK; 4Barts BP Centre of Excellence, William Harvey Research Institute, Centre for Cardiovascular Medicine and Devices, London, UK; 5St. Bartholomew's Hospital and University College London Department of Surgical and Interventional Sciences, London, UK
Objectives: Aortic dissection impacts 4.5/100,000 in the UK, and blood pressure [BP] control is critical. There has been no reliable method for monitoring patients&rsquo; BP after discharge to assess adherence to MDT developed antihypertensive guidelines. We describe the implementation and use of a novel digital remote monitoring tool for the post-discharge dissection patient.
Methods: From September to November 2022 all patients presenting with aortic dissection were enrolled onto a virtual ward. The pathway was developed with the expertise of vascular surgery, cardiothoracic surgery, a clinical hypertension specialist and nursing. Enrolment involved nursing delivered education, and daily monitoring by the clinical team. Adjustment of medications is based on antihypertensive guidelines and are communicated through both phone appointments and correspondence.
Results: To date, 22 patients have enrolled. Twelve patients underwent proximal surgery prior to enrolment, and 10 were monitored for distal dissection with or without endovascular intervention. Four enrolled patients did not engage, and four did not initiate registration. Six patients used the tool to communicate with the clinical team and four required hypertension intervention. Overall, 597 BP measurements were recorded; the average systolic BP was 128 mmHg (SD 20.36 mmHg). On average, patients recorded their BP 40 times (range 3&ndash;151 recordings); the longest enrolment was for three months.
Conclusions: After three months use of a digital tool for remote BP monitoring, we have found high patient uptake, engagement and an impact on antihypertensive management. Implementation of this tool requires a multidisciplinary effort to be successful, but has potential to change the management of dissection.
1Royal Sussex County Hospital, Brighton, UK; 2St Bartholomew's Hospital, London, UK
Objectives: Open surgery to the aortic arch is associated with a significant stroke risk. Neurological injury can occur from inadequate cerebral blood flow (CBF) during deep hypothermic circulatory arrest (DHCA). By directly measuring flow in the middle cerebral artery (MCA), robotic transcranial doppler (TCD) provides a more accurate and real time assessment of CBF than currently established monitoring of cerebral oxygen saturations. The routine use of robotic-TCD for aortic arch surgery has yet to be described in the scientific literature. We describe our early experience of its use.
Methods: Over a 4-week period commencing in February 2022, robotic-TCD was used in all patients undergoing elective aortic arch surgery. Robotic-TCD was used to measure cerebral blood flow (CBF) during deep hypothermic circulatory arrest (DHCA). The rate of CBF just prior to commencing DHCA was set as the minimal therapeutic target (MTT) to be achieved during antegrade cerebral perfusion (ACP). ACP flow rates at the MTT were recorded.
Results: Seven patients underwent aortic arch surgery with robotic-TCD over the study period. Once the flow in the MCA had been acquired by the robotic-TCD machine, the signal strength remained reliable throughout all seven cases. MTT flows within the MCA were achieved at significantly lower pump flow rates (mean of 5.62 ml/kg/min) compared to standard ACP flow rates (8&ndash;10 mls/kg/min). In addition, TCD allowed early identification of any issues with ACP cannula position and increased the use of a singular cannula for ACP as it was often possible to demonstrate good bilateral flow. No post-operative stokes were seen in any of the 7 patients.
Conclusions: Robotic-TCD was able to reliably provide continuous monitoring of cerebral blood flow for the duration of an aortic arch surgery case. Its use resulted in a significant reduction in ACP flow rates when compared to standard protocols.
Objective: Cerebrospinal fluid (CSF) drainage reduces spinal cord ischemia associated with distal aortic surgery. CSF drainage is an invasive technique that poses complications. This study aims to report the complication rate associated with CSF drainage in patients undergoing open surgery of the distal thoracic (DTA) and thoracoabdominal aorta (TAA).
Methods: A retrospective single-centre study of prospectively collected data from the local aortic database from 2017 to 2022. Patients who died in the perioperative period (< 24 h) were excluded. The primary outcome was CSF drainage complications; secondary outcomes included spinal drain insertion success rate and duration of drainage. The population was grouped into DTA and TAA groups. Data were analyzed using SPSS and statistical significance was checked using Fisher&rsquo;s Exact and Mann&ndash;Whitney tests.
Results: Median age was 56 years with 31% of the cohort having connective tissue disease (CTD). Over 60% of patients underwent TAA surgery. 124 out of 126 patients (98%) had successful spinal drain insertion with an average attempt of 1.47 &plusmn; 0.94 and a median drainage duration of 4 days. Drainage duration was significantly shorter in the DTA group (P = 0.011). The overall complication rate was 28.6%, including the following: Non-functional drain or fractured drain (42.9%), CSF leak (31.4%), spinal headache (11.4%), intraventricular hemorrhage (2.9%), retained catheter tip (2.9%), site infection (5.7%). Three patients (8.6%) had more than one complication. 41% of CTD patients had complications as compared to 23% in those with no CTD (p = 0.05). 22 (17.9%) patients had post-operative spinal ischemia with 17.3% in TAAA and 17.8% in the DTA group.
Conclusions: CSF drainage is a relatively safe procedure if done by a trained expert with a standardized protocol. Its importance in reducing the rate of spinal cord ischemia cannot be overemphasized (Fig. 1).
Complication of cerebrospinal fluid drainage in aortic surgery from a single center database collected retrospectively over a 5-year period. The success rate of insertion was 98% with a median drain duration of 4 days. Patients who had surgery for DTA had more complications and non-functional drain was the most complication recorded
Objectives: Acute type A aortic dissection is a surgical emergency requiring highly complex surgical repair with high mortality and morbidity rates. We report early results of single-centre experience using the Ascyrus Medical Dissection Stent (AMDS) hybrid prosthesis and its effect on aortic remodelling.
Materials & Methods: This retrospective study includes 10 patients with AMDS prostheses between June 2021 to July 2022. Aortic measurements (overall diameter, true lumen, false lumen, false lumen thrombosis) were obtained using computed tomography (CT) two-dimensional multiplanar reconstruction (MPR) from preoperative, postoperative and follow-up scans at 4&ndash;6 months. Statistical analysis was performed using IBM SPSS version 28.0.
Results: In-hospital mortality was 22.2% (n = 2/9), excluding one salvage procedure. The AMDS-mediated true lumen expansion is significant in the postoperative CT (zone 5; 20.7 &plusmn; 3.1 mm, p = 0.017) and follow-up CT (zone 5; 21.5 &plusmn; 3.3 mm, p = 0.046) compared to the preoperative CT (zone 5; 15.5 &plusmn; 3.4 mm). The descending aortic diameter remains stable during the follow-up period without further expansion of the false lumen.
Conclusions: The AMDS hybrid prosthesis offers effective, reproducible repair in acute type A aortic dissection, and provides early positive remodelling of the aorta. However, long-term follow-up data is required for determination of its role in aortic dissection surgery.
Objectives: The use of the Hospital Episode Statistics (HES) dataset allows us to access information on patients typically underrepresented in research and examine whether there are variations in care associated with age, sex, social deprivation or geography in patients with thoracic aortic dissection (TAD).
Methods: Patients with a TAD diagnosis between 2013 and 2017 were identified from HES. Survival models were fitted adjusted for patient demographics and comorbidities with all-cause mortality as the outcome. An additional survival model was fitted to investigate the effect of receiving a TAD procedure on all-cause mortality with TAD procedure as a time varying covariate. A logistic regression model was fitted with patient demographics and comorbidities as explanatory variables to calculate the standardised TAD procedure rate by postcode area.
Results: The final cohort was 33,793 patients. There was an increased risk of death for women with HR: 1.09 (CI: 1.05&ndash;1.14) and an increasing trend in social deprivation quintiles with the most socially deprived having HR: 1.15 (CI: 1.08&ndash;1.22) compared to the least socially deprived. Asian patients showed a decrease in risk compared to White patients HR: 0.85 (CI: 0.75&ndash;0.97), with Black patients showing no significant difference. Emergency rather than elective admission had the greatest effect on all-cause mortality with HR: 2.52 (CI: 2.40&ndash;2.64). There was no significant difference in the effect of TAD procedure on survival after adjustment for patient level characteristics. 12 out of 98 postcode areas had a standardised ratio outside the 99.8% limits.
Conclusions: Being a woman and social deprivation are both associated with poorer survival, however an emergency admission provided the greatest increase in risk. There is variability in standardised revascularisation rates by postcode area not explained by patient level characteristics.
Objectives: As the population ages, the proportion of octogenarians experiencing acute aortic dissection will inevitably rise. We aimed to assess the peri-operative morbidity, mortality and long-term survival outcomes in octogenarians undergoing acute type A aortic dissection repair.
Methods: This was a single centre retrospective study (2007&ndash;2021). Demographic data and operative strategies of open versus closed distal anastomosis repair were compared including 26 variables. Univariate and multivariate logistic regression analysis was used for predictors of inpatient mortality. Kaplan&ndash;Meier and Cox proportional hazards methods were used to compare long-term survival.
Results: A total of 50 octogenarians underwent surgery for spontaneous Type A aortic dissection (22: open anastomosis; 28: closed anastomosis). The mean age was 82.3 &plusmn; 1.6 years. In-patient mortality was 18% (open; 14.2% versus closed; 22.7%, p = 0.44) and post-operative cerebrovascular accident (CVA) was 32% (open; 39.3% versus closed; 22.7%, p = 0.21). There was no difference in operative strategies for composite endpoint of hemofiltration, CVA, length of stay (LOS) &ge; 30 days, re-exploration, and inpatient mortality (open 45.5% versus closed 50.0%, p = 0.75). LVEF < 30, NHYA Class 3/4, cross-clamp time, LOS, pre-operative creatinine, cardiopulmonary bypass time, concomitant cardiac procedure and gender were independent predictors of inpatient mortality on univariate regression but not multivariate regression. Survival was similar for both open and closed strategies (open: 7.2 &plusmn; 1.3 years versus closed: 10.6 &plusmn; 3.1 years, p = 0.35; Fig. 1). Composite end point (HR: 3.65 95%, CI: 1.47&ndash;13.9, p = 0.008) and hypertension (HR 0.24, 95% CI: 0.08&ndash;0.78, p = 0.02) were predictors for long-term survival.
Conclusions: Aortic dissection repair in octogenarians is associated with high morbidity and mortality. Our study suggests there is no difference between open versus closed anastomosis strategies.
Objectives: To present a percutaneous approach in the management of an early postoperative ascending aortic pseudoaneurysm (AAP) from cardioplegia cannula site, an aetiology that was not previously suggested for the development of AAPs.
Methods: We present a case of symptomatic AAP from cardioplegia cannulla that was closed endovasculary with an occluder device in patient post mechanical aortic root replacement, ascending aorta and hemiarch replacement for type A aortic dissection.
Case presentation: A 52-year male patient complained of three days history of intermittent chest pain and attended local A&E department 5 weeks after emergency repair of Type A aortic dissection with mechanical aortic root replacement (25 mm St Jude Medical Master Valsalva conduit), ascending aorta and hemiarch replacement. CT scan raised possibility of pseudoaneurysm at the distal anastomosis site. Patient was transferred urgently to our tertiary care centre for further investigation and management. Gated CT aortogram confirmed contrast leak from aortic graft anteriorly with otherwise stable appearances of aortic repair. A multidisciplinary meeting consensus was in favour of percutaneous closure of the pseudoaneurysm.
Results: Via radial approach, an AVP4 5 mm device was deployed to occlude the neck of the AAP and an aortogram confirmed the isolation of pseudoaneurysm. The patient was discharged home the same day and a follow up call confirmed that patient is asymptomatic.
Conclusions: We have presented a case of an early pseudoaneurysm formation from what we believe was cardioplegia site that was treated successfully with a percutaneously deployed occluder, which is a reasonable approach in highly dedicated centres. It is important that we acknowledge that the insertion and removal of the cardioplegia cannula can be a cause for pseudoaneurysm development. Therefore, we recommend meticulous closure after cardioplegia cannula is removed by reinforcement sutures if needed.
Patient gave informed consent for their information to be published in an Open access journal.
1Glenfield Hospital, Leicester, UK; 2Campus Bio-Medica University of Rome, Rome, Italy; 3Helsinki University Hospital, Helsinki, Finland
Objectives: We compare the early and late outcomes of a modified aortic root remodelling (ARR) technique for aortic root replacement without mobilisation or reimplantation of the coronary ostia, with those of the modified Bentall-de Bono procedure.
Methods: A retrospective observational study was performed comprising 181 consecutive patients who underwent aortic root replacement with a modified Bentall-de Bono procedure (104 patients) or ARR (77 patients) between January 2013 and December 2019. Primary endpoints included hospital mortality and late survival. Secondary endpoints included incidence of post-operative complications and freedom from late re-operation.
Results: ARR procedures were performed with shorter cross-clamp times and comparable cardiopulmonary bypass times to modified Bentall-de Bono procedures. The incidence of early post-complications was comparable between groups. 30-day mortality was numerically lower with ARR than the modified Bentall-de Bono procedure. Over 7-year follow-up, 4 patients (3.8%) required repeat aortic surgery after a modified Bentall-de Bono procedure, and none after ARR. Long-term mortality after ARR and after modified Bentall-de Bono procedures was 17.1% and 22.7%, respectively. The cumulative incidence of reintervention on the aortic root/valve was 3.2% after a modified Bentall-de Bono procedure and 0% after ARR. When adjusted for other independent risk factors, late mortality was not influenced by the procedure performed, although competing risk adjusted for age showed that the modified Bentall-de Bono procedure was associated with an increased risk of aortic root/aortic valve re-operation.
Conclusions: The modified ARR technique is associated with reduced myocardial ischaemia time, lower post-operative mortality and aortic re-intervention rates compared to a modified Bentall-de Bono procedure. It may be considered a safe and feasible procedure for aortic root/ascending aortic replacement offering good long-term outcomes.
Objectives: Aortic arch surgery is traditionally performed on circulatory arrest with or without cerebral perfusion and mild to deep hypothermia. Normothermic cardiopulmonary bypass (NCPB) for arch surgery can reduce operating time, associated coagulopathy, systemic inflammatory response, multi-organ dysfunction and cerebro-spinal injuries.
We present the technique and results of performing aortic arch procedures using NCPB without circulatory arrest.
Methods: Four consecutive patients underwent normothermic aortic arch procedures at our Institution by a single aortic surgeon, over 12 months. CPB was established via right (1) or bilateral (3) axillary artery and right atrium. Transcutaneous cerebral oximetry was used. One patient had sickle cell anaemia.
The aortic cross clamp was applied obliquely from zone-I to the proximal descending aorta (pDTA) and separately at the base of the innominate artery. Systemic and left carotid antegrade perfusion was maintained via the left axillary artery and right carotid antegrade cerebral perfusion via right axillary artery. In 1 case a single aortic arch cross-clamp was applied obliquely from zone-0 to pDTA and a full hemi-arch replacement was performed, with the right axillary artery used for both systemic and cerebral perfusion. No circulatory arrest was required.
Results: The patients had a mean age of 58.2(36&ndash;68), 3 were male and 1 female. Mean CPB time was 142.7 min, cross-clamp 107.5 min. Two were extubated within 6 h and two had prolonged intubation (> 48 h). No patient required re-exploration for bleeding. Mean blood loss was 512.5 ml/12 h. Mean peak blood lactate was 3.3 mmol/L. One patient developed non-oliguric acute kidney injury. One patient (with chronic thrombus in the innominate artery &ndash; intraoperative finding) had a stroke from which recovered fully.
Conclusions: Normothermic arch replacement can be safely performed without circulatory arrest, in selected cases and by a dedicated, specialist Aortic Team.
Objectives: We assess the impact of time of operation (in-hours vs out-of-hours) on post operative outcomes in patients undergoing surgery for Type A acute aortic dissection (TAAD) in a single, tertiary cardiothoracic referral centre. Comparison is also made with published results from a specialised aortic centre in UK1.
Methods: Patients who underwent surgery for TAAD between Jan 2012 and Dec 2021 at a single generalised cardiothoracic centre were included. Data was collected prospectively. Retrospective subgroup analysis was performed where patients were grouped according to surgery in-hours (IH) or out-of-hours (OOH), defined as 08:00&ndash;17:59 and 18:00&ndash;07:59 respectively. Primary outcomes were mortality and cerebrovascular accident (CVA). Statistical significance was determined by Chi-squared and T-tests and defined at p < 0.05.
Results: 49 (38.6%) cases were operated IH and 78 (61.4%) cases OOH. The results are tabulated (Table 1). In the IH group, 47 (95.9%) had interposition grafts, 14 (28.6%) had aortic root procedures, and 7 (14.3%) had aortic arch interventions compared to the OOH group 76 (97.9%), 26 (33.3%), 16 (20.5%) (p = 0.47, p = 0.57, p = 0.38) respectively. The in-hospital mortality for IH group was 11 (22.4%) compared to 16 (20.5%) for the OOH group (p = 0.8). Postoperative CVA occurred in 6 (12.2%) patients IH compared to 18 (23%) patients OOH (p = 0.13). At a mean follow up of 5.7 years, 33 (67.3%) patients are alive in the IH group vs 47 (60.3%) in the OOH group (p = 0.42).
Conclusions: The neurological and mortality outcomes and the extent of the operation seem unaffected by the time of the day when the operation is undertaken. The outcomes in this tertiary cardiothoracic centre appear similar to the ones reported from a specialist aortic centre in the UK.
1Harky A, Mason S, Othman A et al. Outcomes of acute type A aortic dissection repair: Daytime versus nighttime. JTCVS Open. 2021;7:12&ndash;20.
Objectives: Acute aortic dissection (AAD) is a time-critical condition with multiple disease factors and clinical processes surrounding its management. Patients are referred to specialist centres with varying symptom severity, malperfusion syndromes and overall critical illness. Additionally, logistical parameters, includingavailability of cross-sectional imaging and transport availability, play an important role for the time-to-treatment.
We aimed to develop an algorithm to improve efficiency and ensure a timely and safe handover from the peripheral hospital to accepting tertiary centre.
Methods: Two clinical tools were implemented: (1) handover sheet, and (2) survive-dissection-mini-pathway, that are available online or as hard copy for the on-call cardiothoracic registrar.
The content has been approved by senior staff physicians to be used routinely for every AAD referral and uploaded on the patients&rsquo; electronic chart.
Conclusions: This Quality Improvement intervention aims to establish standardised good practice and minimise delay for critically sick patients. Data collection and analysis will identify gaps in the task-specific processes of patient management and help improve patient safety and outcome.
1University of Southampton NHS Foundation Trust, Southampton, UK; 2Royal Brompton and Harefield Hospitals, Harefield, UK; 3University of Ljubljana, Slovenia, EU, Ljubljana, Slovenia
Objectives: There is growing evidence that minimal access cardiac surgery can reduce postoperative morbidity with no difference in mortality. This stimulated enthusiasm in the use of upper ministernotomy for valve-sparing aortic root replacement. We aimed to present our initial experience with David procedure via upper ministernotomy, and a review of all the available literature on this topic.
Methods: We reviewed 16 patients (12 male) with isolated aortic root aneurysm selected for minimally invasive David procedure over a 4-year period at our tertiary cardiac centre. A comprehensive literature search from 1992 to 2022 was performed on David procedure via upper ministernotomy.
Results: No conversion to full sternotomy or re-exploration due to bleeding was observed. 30-day postoperative mortality and stroke were 0%. Simultaneous aortic valve repair was performed in 8/16 (50%) and coronary artery bypass graft in one patient. Literature search identified 6 retrospective nonrandomized studies (NRSIs) from five different centers, including a total of 250 patients operated via minimal access. Recent NRSIs and comparative studies demonstrated excellent clinical outcomes of minimally invasive David procedure in selected patients with comparable perioperative mortality to the conventional technique.
Conclusions: David procedure via upper ministernotomy can be performed with excellent early postoperative results. Meticulous hemostasis is of paramount importance during minimal access David procedure. This approach is particularly beneficial for younger patients as it allows faster recovery with improved cosmesis. Further large randomized studies with long-term follow-up are still required to confirm durability of minimal access approach (Fig. 1).
1University Hospitals Birmingham/Queen Elizabeth Hospital, Birmingham, UK; 2Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
Introduction: Infection remains a rare cause of thoracic aortic aneurysms, with mycobacterium tuberculosis being one of the least commonly reported causative organisms. We present a case of a 31-year-old patient who was diagnosed with tuberculous mycotic aortic aneurysm affecting the aortic arch.
Case presentation: A 31-years-old man, previously diagnosed with, and treated for, tuberculous cervical lymphadenopathy in 2014, was investigated for a new onset hoarseness of voice, when a CT scan of the thorax revealed a necrotic nodal mass likely secondary to TB in the AP window/left hilum, involving the aortic arch with evidence of a pseudoaneurysm measuring 7.6 cm &times; 4 cm.
Multiple serial CT angiograms taken afterwards showed gradual increase in the size of the haematoma surrounding the aneurysmal sac. Echocardiogram studies showed an unaffected aortic valve and normal biventricular function.
Surgical intervention was done via a median sternotomy and involved a total arch and frozen elephant trunk replacement to reduce the risk of rupture.
Comments: TB mycotic aortic aneurysms are extremely rare, fatal, and can present with variable clinical features. The incidence of mycotic aortic aneurysms has been reported as 0.6&ndash;2% of all aortic aneurysms, with Mycobacteria accounting for only 2% of that [1].
Literature recommends that deterioration of patients already diagnosed with TB should prompt an emergent investigation of the aorta. [2] Treatment options include open-surgical or endovascular interventions, usually in combination with anti-TB therapy.
[1] Chen, M., Chung, C., Ke, H., Peng, C., Chien, W. and Shen, C., 2021. Risk of Aortic Aneurysm and Dissection in Patients with Tuberculosis: A Nationwide Population-Based Cohort Study. International Journal of Environmental Research and Public Health, 18(21), p.11075.
[2] Choudhary, S., Bhan, A., Talwar, S., Goyal, M., Sharma, S. and Venugopal, P., 2001. Tubercular pseudoaneurysms of aorta. The Annals of Thoracic Surgery.
*The patient has consented to this information being published in an open access journal.
Objectives: There is limited data on the clinical outcomes of redo root replacement (rARR) and the clinical predictors for adverse outcomes. We report contemporary series from a single institution of rARR over the past decade.
Methods: In the period 2011&ndash;2022, 81 patients underwent rARR. Salvage procedures were excluded. Continuous variables were summarised as mean and standard deviation (SD) or median and interquartile range. A backward stepwise regression approach was used to select 8 final predictors which were included in the logistic regression model for mortality (Table 1).
Results: Median age was 54 (IQR: 34, 67) years and 59 (27%) patients were female. Urgent and emergency procedures were made up 39(48%) and 6 (7.4%) patients respectively. LV function was impaired in 26 (33%) cases. The indications were root aneurysm 36(44.4%), pseudoaneurysm 17 (20.9%), endocarditis 16 (19.5%), Chronic dissection 3 (3.7%), Valve failure 3(3.7%), PAU 1(1.2%) and acute aortic dissection 1 (1.2%). Median CPB and cross clamp time was 226(IQR: 177, 320) mins & 158 (IQR: 124,184) mins respectively. Types of operations were Composite ARR, Valve sparing ARR and homograft ARR in 72%, 12% and 16% cases respectively. In-hospital morality was 12(15%) patients. Aortic cross clamp time (OR: 1.02, CI 1.00&ndash;1.03, P = 0.025) was an independent predictor for in-hospital mortality (Table 1).
Conclusions: Redo aortic root replacement is associated with significant in-hospital mortality. In our analysis the only predictor for hospital morality was the prolonged aortic cross clamp time. Long term outcomes need to be described.
Objectives: This study reports our initial single-centre experience with total aortic arch replacement.
Methods: Consecutive patients undergoing elective and emergency total arch replacement were included. Demographic, perioperative data, 30-day and 1-year mortality alongside postoperative complications were retrospectively analysed.
Results: Between July 2018 and July 2022, 36 consecutive patients underwent total arch replacement in our institution. Indication for surgery was chronic type B dissection (14 patients), chronic type A (7 patients), arch aneurysms (11 patients) and acute aortic syndromes (4 patients). 6 patients (17%) had emergency surgery and 10 (28%) had concomitant aortic root surgery. Selective antegrade cerebral perfusion was used in 35 patients (97%). 10 patients (28%) had redo surgery. Frozen elephant trunk grafts were used in 28 patients (78%), while the conventional elephant trunk was used in 7 (19%). In-hospital or 30-day mortality in the entire cohort was 8.3% (3 patients) and 1-year survival was 78%.
Chest infections were the most common complication affecting 16 patients (44%) followed by atrial fibrillation in 10 (28%) and CVA/TIA in 5 (14%). Reoperation for bleeding occurred in 7 patients (19%). 5 patients (14%) required temporary haemofiltration or dialysis. The median LOS was 14.5 (IQR 9&ndash;21) days.
20 patients (56%) subsequently underwent a 2nd stage operation for the descending aorta (8 TEVAR and 12 open repairs). The median time between the 1st and 2nd stage procedure was 187 days (IQR:73&ndash;294). Overall survival at 3.5 years was 66%. Survival curves did not differ between chronic dissection vs aneurysms (p = 0.86) (Fig. 1), emergency vs elective surgery (p = 0.549) or redo vs first-time surgery (p = 0.132).
Conclusions: Our initial experience shows comparable results with those reported in the literature for early and mid-term survival after total aortic arch replacement. Long-term follow-up and dedicated aorto-vascular MDT surveillance is needed.
Objectives: Valve sparing aortic root replacement became widely accepted and even favoured above the standard aortic root replacement for the treatment of Aortic root dilatation with healthy valve leaflets.
Methods: We are presenting our early experience of valve sparing root replacement in a low flow centre. Patients&rsquo; data was retrospectively collected and analysed. Operative data, post-operative complications and mortality were also included. All patients had immediate post-operative, 6 month, 1-year and 2-year follow up echocardiogram.
Pre-operative EF ranged 23%-60% (53% &plusmn; 7.7%), Aortic annulus measurement ranged 18&ndash;45 mm (31 &plusmn; 5.3), Sinuses of Valsalva were 34&ndash;74 mm (49.8 &plusmn; 9.1 mm), STJ measured at 27-61 mm (42 &plusmn; 8.1 mm) and ascending aorta ranged 28-79 mm (46.8 &plusmn; 10.9). Circulatory arrest was used in 2 patients (5.8%). 14 patients had Bicuspid aortic valve while 20 patients had Tricuspid valve. Aortic valve leaflets height ranged 25&ndash;36 mm (30 &plusmn; 2.5), Coaptation length ranged 6&ndash;11 mm (8.3 &plusmn; 1.6 mm) and tubes used ranged 28&ndash;34 mm (30.5 &plusmn; 1.7 mm). Bypass time was between 143 and 487 min. (279.7 &plusmn; 77.3), Aortic clamp ranged 121&ndash;360 min (231.9 &plusmn; 55.5).
One patient died in ITU and 1 patient died 3 months post discharge.
Post-operative ventilation time ranged 2&ndash;39 h (9.7 &plusmn; 7.4 h).
ITU stay 10&ndash;980 h (78.3 with the exception of one patient who spent 147 days and died in ITU.
Post-operative complications included Multi-organ failure in 2 patients, 1 patient reopened for bleeding, 1 patient had stroke and 6 patients had PPM.
Follow up at 6-month one patient had severe AR another patient had moderate AR, 1-year echo showed severe AR in one patient with EF of 31% who needed redo AVR.
Objectives: Our goal is to describe our outcomes of urgent and emergency thoracic and thoracoabdominal aortic replacements from 1998 to 2022.
Methods: We retrospectively reviewed 516 patients. Our database was analysed for anyone who underwent a descending thoracic (DTA) or thoracoabdominal (TAAA) repair on urgent and emergency basis. Variables associated with 30-day mortality were identified among preoperative factors (age > 70, Female gender, NYHA class > 3, smoking, diabetes, hypercholesterolemia, hypertension, previous stroke, respiratory disease, TAAA Extent 2, peripheral artery disease, chronic renal disease, poor ejection fraction, previous aortic intervention, emergency surgery, use of CPB), on univariate analysis first, then on multivariate analysis.
Results: Out of 516 patients, 174 underwent emergency or urgent operation. Mean age was 58 years (&plusmn; 14.52) and 37.9% (N = 66) patients were women. 58 patients underwent DTA replacement, 45 Extent 2 TAAA replacement and 29 Extent 1 TAAA replacement. 30-day mortality for urgent cases was: isolated DTA replacement&mdash;urgent 3.3% (n = 1) and emergency 31.6% (n = 6). For those with Extent 2 repairs, 30-day mortality was 28.1% (n = 10) for urgent patients and 50% (n = 4) for emergency operations. Patients operated on due to Extent 1 TAAA on urgent basis had survival with 0% 30-day mortality and those who were operated on emergency basis had mortality rate of 25% (n = 3).
Predictors of mortality were extent 2 replacement (OR of 4.0 [CI 1.6&ndash;10.0]), respiratory disease (OR 4.0 [1.2&ndash;13] and poor LVEF OR 24 [2.17&ndash;270.0]) and emergency status (OR 5.4 [CI 1.8&ndash;15.9]).
Conclusions: In selected cases urgent and emergency thoracoabdominal aortic repairs can be performed with acceptable risk. Extent of repair and its urgency along cardiovascular and pulmonary condition should be taken into consideration in the preoperative patient selection and decision-making process.
Introduction: Acute Aortic dissection with intramural hematoma (ADD-IMH) and impending rupture needs emergency surgery. Reporting a rare case of surgery of ADD-IMH with complex vascular ring and highlighting crucial perioperative strategies.
Case report: A 79-year-old patient had chest and back pain, CT aorta revealed acute intramural hematoma from ascending aorta to renal arteries with dissection flap, aberrant right subclavian arising from distal arch coursing retro-tracheal and common carotid trunk with an anomalous course of a right common carotid artery (RCCA) (Fig. 1).
ECHO revealed pericardial effusion, moderate AR & MR. Preoperatively developed paraplegia. Comorbidities: Hypertension, AAA repair, Permanent pacemaker.
Intraoperative findings: dilated ascending aorta 7 cm, contained hematoma partially ruptured, dissection tear at mid ascending aorta with adherent LA & RA, tricuspid aortic valve & root morphology preserved.
Procedure: CPB with right common carotid artery (arterial) with 8 mm graft and RA (Venous) while cooling to 23 &ordm;C, aorta cross-clamped. Ante-grade cardioplegia given. Dissection flap, intramural hematoma in the ascending aorta and root removed. Ascending Aorta and proximal arch replaced with Valsalva graft. With DHCA continuous ante-grade cerebral perfusion. The distal anastomosis was performed on the proximal arch.
Patient had persistent paraplegia postoperatively and was referred to the regional spine center. Post-op CT scan and followed up 6 months satisfactory.
Conclusions: Rare case of type A acute aortic dissection repair with intramural haematoma in the context of the complex vascular ring so far not reported in literature. We recommend continuous antegrade cerebral perfusion strategy through arch vessels. Recent onset paraplegia is not a contraindication for this life-threatening condition.
The patient gave informed consent for their information to be published in an Open access journal.
This poster was possible because of the work of the cardiothoracic team at University Hospital Coventry and Warwickshire NHS Trust.
Objectives: To report the early and mid-term outcomes of open (OSR) and complex endovascular repair (cEVAR) for extent I-III TAAA in a UK aortic centre.
Methods: Single-centre retrospective study of consecutive patients with extent I-III TAAA treated between January 2009 and December 2021. Primary endpoint was 30-day/in-hospital mortality. Secondary end point was Kaplan&ndash;Meier estimates of mid-term survival. Data are presented as median (IQR). A P-value of < 0.05 was considered significant.
Results: 296 patients [176 men; median age 71 (65&ndash;76) years; median diameter 66 (61&ndash;75) mm] underwent elective (n = 222) or non-elective (n = 74) repair. OSR patients (n = 66) were significantly younger with a higher incidence of heritable thoracic aortic disease and chronic dissection, while cEVAR patients (n = 230) had a significantly higher incidence of coronary, pulmonary and kidney disease. Overall, in-hospital mortality after elective and non-elective repair was 3.2% (n = 7/222) and 23% (n = 17/74) with no significant difference comparing treatment modalities after elective [OSR 6.5% vs. cEVAR 2.3%; p = 0.142] or non-elective repair [OSR 25% vs. cEVAR 20.3%; p = 0.801]. Major non-fatal complications occurred in 15.7% (43 of 274) of operative survivors [OSR 39.7% vs. cEVAR 9.3%; p < 0.0001]. Median follow-up was 52 months (23&ndash;78). Estimated (&plusmn; SE) survival at 1, 3 and 5 years was 89.6% (&plusmn; 2.0%), 76.6% (&plusmn; 2.9%) and 69.0% (&plusmn; 3.2%) after elective repair, and 67.6% (&plusmn; 5.4%), 52.1% (&plusmn; 6.0%) and 41.0% (&plusmn; 6.2%) after non-elective repair. 5-year survival after elective and non-elective repair in patients < 70 years was 85.6% (&plusmn; 3.9%) and 65.4% (&plusmn; 9.2%) compared to 58.0% (&plusmn; 4.9%) and 23.7% (&plusmn; 7.0%) in those aged > 70 years.
Conclusions: A multi-disciplinary team offering both OSR and cEVAR can deliver comprehensive care for extent I&ndash;III TAAAs with low early mortality and good mid-term survival. Further studies are required to determine the optimal relative roles of the treatment modalities.
Objectives: Major aortic surgery is one of the most complex challenges a cardiac surgeon can undertake. High mortality is a feature of both elective and emergent cases with the elderly patient considered to be at higher risk than their younger counterpart.
Methods: We performed a retrospective analysis of all patients undergoing major aortic surgery between October 2014 and September 2016 inclusive. The patients were divided into 2 groups, those under the age of 70 years (group A), and those 70 years and above (group B). Demographic, admission length, complication and mortality data was collected for each group and statistically analysed.
Results: The 22 patients in group A had an average additive EuroSCORE of 7.45, with those is group B having a significantly higher score of 11.21 (P < 0.001). Similar number of patients underwent emergent surgery in each group (32% in group A vs 35% in group B). Group B had more complex aortic surgery with four patients requiring deep hypothermic circulatory arrest for aortic arch surgery compared to no patients in group A (P = 0.019). There was no significant difference between, mortality, major complication rates or length of admission between the 2 groups. Mortality in group B was actually lower than that of group A at 4% and 18% respectively but no statistical significance could be attributed to this.
Conclusions: There was no significant difference in post-operative outcomes for patients aged over 70 compared with their younger counterparts, despite this group having more complex aortic surgery and having higher predictive risk. Both elective and emergent major aortic surgery should be considered in the older patient, and age itself should not be used as the sole exclusion criteria.
1University Hospitals Birmingham (UHB), Birmingham, UK; 2Liverpool Heart and Chest Hospital, Liverpool, UK; 3Liverpool University Hospitals, Liverpool, UK
Methods: Two-centre retrospective study of consecutive patients treated between January 2010 and December 2019. Primary endpoint was 30-day/in-hospital mortality. Secondary end point was Kaplan&ndash;Meier estimates (&plusmn; SE) of mid-term survival. Data are presented as median (IQR). A P-value of < 0.05 was considered significant.
Results: 158 patients [72 men, median age 70 (64&ndash;75), median descending thoracic aortic diameter 58 mm (46&ndash;68)] underwent elective (n = 107) or non-elective (n = 51) repair. Peri-operative mortality was 8.4% (n = 9) after elective, and 13.7% (n = 7) after non-elective repair. Median follow-up was 46 months (26&ndash;75). There were 7 early deaths in 74 (46.8%) patients with a primary distal seal, and 9 (13.4%) survivors underwent distal aortic repair at median 25 months (15&ndash;48). There were 9 early deaths in 84 patients with no primary distal seal, and 42 (56%) underwent distal repair at median 7 months (4&ndash;22). Of the remaining 33 patients, 23 reached size threshold: 7 were unfit, 8 were fit but died before repair, 1 declined repair, 4 were awaiting repair, and 3 were lost to follow-up. Survival at 1, 3 and 5 years was 89.7% (&plusmn; 2.9%), 80.0% (&plusmn; 3.9%) and 70.6% (&plusmn; 4.7%) after elective, and 58.8% (&plusmn; 6.9%), 46.1% (&plusmn; 7.1%) and 43.2% (&plusmn; 4.3%) after non-elective repair. There was no significant difference in survival comparing patients with or without a primary distal seal (p = 0.38); or those who had and did not have distal repair (p = 0.09).
1Cardiff University, Cardiff, UK; 2Cardiff and Vale University Health Board, Cardiff, UK
Objectives: Analyse 10-year survival for urgent and elective major aortic surgery at University Hospital of Wales from 2012 to 2022. Identify significant risk factors for post-operative all-cause mortality and evaluate their relevance over time.
Methods: 391 patients (237 male, 118 female) underwent open surgery (236 elective, 155 urgent) involving the ascending aorta (335/391), aortic root (207/391) and/or aortic arch (32/391) between 1st April 2012 and 31st March 2022. Kaplan&ndash;Meier survival curves were generated to calculate the probability of survival at various intervals post-operatively. Chi-squared tests identified significant risk factors for all-cause mortality in-hospital, at 30-days, 1-year, 3-years, 5-years, and 8-years.
Results: ​Overall non-risk adjusted survival at 10-years was 89.5%. Survival for elective procedures ranged from 98.3% (30-days) to 90.4% (10-years). Survival for urgent procedures ranged from 98.1% (30-days) to 87.4% (10-years). 14/32 factors were statistically significant (p < 0.05) at one or more intervals post-operatively. Short-term survival is not independent of previous cardiac surgery, hypertension, GI disease, VT/VF, heart rhythm, or infective endocarditis. Intermediate-term survival is not independent of angina, dyspnoea, heart failure, diabetes, previous cardiac surgery, renal impairment, or infective endocarditis. Long-term survival is not independent of angina, previous MI, heart failure, diabetes, previous DVT, or severity of aortic stenosis.
Conclusions: 89.5% survival at 10-years following urgent and elective major aortic surgery compares favourably with international publications of 68.7&ndash;80.9%. Risk of mortality is non-linear and is highest in the immediate post-operative period. Individual patient survival is multifactorial and influenced by presenting symptoms, established cardiac risk factors and disease severity. Further investigations can determine causal relationships and compare life expectancy to the general population.
Objectives: It is a common held belief that an interrupted suture technique is superior to a semi-continuous technique for valve implantation due to lower rates of para-valvular leak and reoperation. Our aim was to investigate whether one implantation suture technique was superior.
Methods: A retrospective cohort study was conducted using a prospectively maintained single institutional database. All patients undergoing aortic valve replacement, with or without coronary artery bypass were included. A propensity matched analysis was performed for the primary outcomes of re-operation rate for valvular dysfunction and in-hospital mortality, matched on baseline EuroSCORE II, age and procedure performed. A multivariate cox-proportional hazards model was constructed to explore long-term survival adjusted for age, procedure, EuroSCORE II and gender.
Results: Between July 2017 and September 2021, 1474, patients met the inclusion criteria. The mean age was 65 and 411 (28%) patients were female. 1016 (69%) underwent isolated aortic valve replacement and 458 (31%) concomitant coronary artery bypass grafts. An interrupted suture technique was used in 709 (48%) cases and semi-continuous in 765 (52%). In the propensity matched analysis there was no significant difference between the cohorts in re-operation rate for valvular dysfunction [semicontinuous n = 8, interrupted n = 5, p = 0.25]. Neither was there any significant difference seen in in-hospital mortality between the two cohorts [4.7% semicontinuous, 3.7% interrupted, p = 0.32]. However, mean cross-clamp duration and cardiopulmonary bypass duration were significantly reduced in the semi-continuous group. The adjusted cox-proportional hazards model showed no difference in overall long-term survival between the cohorts (p = 0.65).
Conclusions: A semi-continuous suture technique for aortic valve implantation is not associated with increased reoperation rates or reduced mortality compared to the commonly employed interrupted technique.
1Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, UK; 2Royal Victoria Hospital, Belfast, UK
Objectives: Recent data suggests 2nd generation rapid deployment aortic valves have superior haemodynamic profiles compared to conventional bioprostheses. The German Aortic Valve registry suggests post-operative haemodynamic profiles are comparable to transcatheter valves. We aimed to analyse the haemodynamic performance of three generations of aortic bioprosthetic valves including 1st generation conventional tissue prosthesis, 2nd generation rapid deployment valve, and 3rd generation bioprosthesis with advanced tissue technology.
Methods: Patients who underwent tissue aortic valve replacement from 2018 to 2020 for native valve aortic stenosis were identified. Pre and 1-year post-operative haemodynamic data including peak gradient (PG), mean gradient (MG), peak velocity (PVel), velocity time integral ratio (VTI) and aortic valve area (AVA) were collected. 1:1 propensity matching based on based on age, gender, body surface area, EuroSCORE II, pre-operative rhythm, left ventricular function was performed. Pre and post-operative haemodynamic data was compared via unpaired T-test and ANOVA.
Results: 234 cases were identified: Conventional bioprosthesis = 131, rapid deployment valve = 74 and bioprosthesis with advanced tissue technology = 29. Mean age was 69(&plusmn; 9.43); mean EuroSCORE II was 4.17(&plusmn; 0.42). Post-operative haemodynamics were significantly improved for all 3 valves at 1 year follow-up (p < 0.05). Propensity matched analysis showed significantly improved post-operative peak and mean gradients and peak velocities when comparing, 2nd generation rapid deployment valve to 1st generation (p < 0.001 PG; p < 0.001 MG; p < 0.001 PVel), and 3rd generation valves (p = 0.006 PG; p = 0.002 MG; p = 0.004 PVel). VTI and AVA were found to be significantly improved (p < 0.001 and 0.005) compared to 1st generation valves (Fig. 1).
Comparison of pre and post-operative haemodynamic profiles for 3 generation of tissue aortic valve in patients with isolated aortic stenosis. 2nd generation rapid deployement valve bioprosthesis shows the most marked improvement in haemodynamic profile at one year follow up for, aortic valve area (AVA), mean gradient (MG) and peak gradient (PG) (P < 0.05) when compared to 1st and 3rd generation
Conclusions: Rapid deployment aortic valves are shown to give the greatest post-operative haemodynamic performance at 1 year. This is likely due to sub-annular remodelling of the LVOT.
Objectives: Several recent series support the implant of sutureless valve for aortic valve stenosis treatment usually describing the outcome of one of the two most utilised sutureless valves. Our study aims at comparing early post-operative clinical outcomes and long-term follow up in patients undergoing aortic valve replacement (AVR) using conventional vs sutureless valves (Perceval-LivaNova or Edwards-Intuity).
Methods: We report a single unit experience between 2015 and 2022 of a total of 1937 consecutive patients who underwent an AVR. To minimize bias, propensity score matching was conducted and two groups of 275 patients with similar preoperative characteristics were matched: Standard aortic valve replacement (AVR) and Sutureless (SUAVR). Early outcome assessed included: CVA, re-exploration for bleeding, low cardiac output, deep sternal wound infection, dialysis, length of hospital stay and long-term survival.
Results: Our cohort characteristics were: age (74.5 &plusmn; 6.4), gender (F: 56%), BMI (29.2 &plusmn; 5.32). AVR group showed increased time (minutes) of: CBP (107.5 &plusmn; 46.9 vs 92.91 &plusmn; 38.7; p < 0.001) and cross-clam time (75.7 &plusmn; 28.4 vs 56.3 &plusmn; 24.1; p < 0.001). In early outcome AVR shown higher incidence of: CVA (8, 2.9% vs. 1, 0.4%; p < 0.001), re-exploration for bleeding (20, 7.3%, vs 10, 3.6%; p = 0.05) and dialysis (16, 5.8% vs. 7, 2.5%; p = 0.05). Postoperative permanent pacemaker (PPM) implantation at 30 days was increased in SUAVR (20, 7.2% vs. 9, 3.3%; p = 0.03).
No difference between the groups were found in terms of: hospital length of stay, deep wound infection and in-hospital mortality as well as overall six years survival for both unmatched (p = 0.12) and matched (p = 0.42) population.
Conclusions: Our analysis in keeping with literature showed that SUAVR offering overall reduced surgical time and associated complications with no differences observed in length of stay, short- and long-term survival but is associated with increased rate of PPM implantation (Table 1).
Objectives: This study compared the early and ten-year outcomes of Trifecta and Perimount Magna Ease aortic prosthesis.
Methods: Patients who underwent aortic valve replacement using the Trifecta and Perimount Magna Ease valves between May 2011 and December 2021 in our centre were included. Patients with concomitant valvular/aortic procedures and reoperations were excluded. Propensity score based matching and comparison was done between the two groups. The primary endpoints were 10-year survival and reoperation rate and secondary endpoints were perioperative complications and 30-day mortality.
Results: Out of the 1684 patients (mean age, 72.5 &plusmn; 8.5 years; Males 65.3%), 438 received the Trifecta and 1246 received the Perimount valve. After propensity scoring, 406 patients in each group were matched. There was no significant difference in the survival rate at 10 years (50.3% for Perimount vs 43.9% for Trifecta, p = 0.73). At 10 years, the Trifecta cohort had a significantly higher risk of repeat aortic valve replacement for all cause (6.3% vs 0.5%, p = 0.011) and the median time to reoperation was 4.75 years (IQR-4.96) vs 3.66 years (IQR-3.12) for Perimount. The median time to reoperation for structural valve failure in the Trifecta group was 5.6 years (IQR-4.92). There were no instances of reoperation for structural valve failure in the Perimount group. The 30-day mortality was similar between both the groups (96.8%, p = 0.73). Patients receiving Trifecta had significantly shorter bypass (p = 0.04) and cross-clamp times (p < 0.001), less likely to need blood products (p = 0.04), more likely to develop atrial fibrillation and require a permanent pacemaker (p = 0.05).
Conclusions: The Trifecta valve is associated with a higher occurrence of repeat operation due to structural valve failure compared with the Perimount Magna Ease valve. Further comparative studies with echocardiographic data on structural valve deterioration are needed to confirm these findings.
1Royal Infirmary of Edinburgh, Edinburgh, UK; 2Golden Jubilee National Hospital, Glasgow, UK; 3Aberdeen Royal Infirmary, Aberdeen, UK; 4Nottingham University Hospitals, Nottingham, UK; 5University Hospital of Wales, Cardiff, UK; 6Freeman Hospital, Newcastle upon Tyne, UK
Objectives: The Cor-Knot automated knot fastener was designed as an adjunct to valve surgery to reduce cardio-pulmonary bypass (CBP) and cross clamp (XC) times and facilitate minimally invasive access. The aim of this study is to explore the safety of Cor-Knot in a large multi-centre real-life cohort of patients.
Methods: All patients undergoing valve interventions between January 2014 and February 2020 using the Cor-Knot device at four UK Cardiothoracic Units were included. Conventional sternotomy, minimal access, redo surgery and combined procedures (CABG, aortic surgery) were included. The primary outcome was severity of paravalvular leak (PVL) at discharge and during follow-up. Secondary outcomes were in-hospital and medium-term mortality and reoperations.
Results: 613 patients were included. 731 valves were operated using Cor-Knot: 404 (55%) aortic valves, 253 (35%) mitral valves (52 repairs with ring) and 73 (10%) tricuspid valves. 145 patients (20%) had concomitant CABG, 28 patients (5%) redo surgery, 57 (9%) surgery of the aorta and 34 patients (6%) had minimal-access surgery.
Pre-discharge echo was available for 416 patients (68%) and long-term follow-up data for 449 patients (73%). No cases of severe PVL pre-discharge were seen (Table 1). Median CBP and XC times for the entire cohort were 108 and 74 min. At a mean follow-up of 28 months, four mitral prostheses had severe PVL and three of them had subsequent reoperations. Endocarditis during follow-up was 2.9%. New permanent pacemaker rate was 5%. In-hospital mortality was 4.6% and medium-term survival at 28 months was 86%.
Conclusions: This is the largest study of Cor-Knot yet reported and its use appears safe with rates of PVL similar to those reported in the literature. Cor-Knot can be successfully used in complex multivalve procedures where a reduction in CPB and XC times may impact patient outcomes or when access is challenging and knot tying is technically difficult. Long term, prospective trials are required.
Results: The mean age of 68.8 years (61-77 years), mean EuroSCORE II of 10.6 (3.43&ndash;39.62), SD 8.5. Preoperative mean aortic valve area of 0.59 &plusmn; 0.30 cm2, a mean gradient of 60 &plusmn; 23 mmHg and peak gradient of 94 &plusmn; 35 mmHg. The mean aortic annulus size was 17 (15&ndash;20) mm.
The mean valve size implanted was 23 &plusmn; SD 1.15 (19&ndash;23). The mean bypass time and aortic clamp times were 138 (88&ndash;205) min, and 96 (70&ndash;132) min, respectively. All patients had improvement in the ejection fraction with mean EF of 58 &plusmn; 4.8.
There was a statistically significant increase in mean valve size post aortic root enlargement 5.3 mm (SD 1.9 mm) (p < 0.001). On postoperative echocardiography, there were statistically significant drops in mean pressure gradients across the aortic valve (MPG) (from 57 &plusmn; 21 mmHg to 9.8 &plusmn; 2.56 mmHg, (p < 0.001) and peak pressure gradient (from 92 &plusmn; 33 to 19.5 &plusmn; 4.4 mmHg, p < 0.001). No patients following ARE had moderate/severe PPM.
At up to two years follow-up, there is no mortality. The rate of the paravalvular leak 0%. Only one patient required a permanent pacemaker for a complete heart block. There were no cerebrovascular accidents or renal and respiratory failure.
Conclusions: Our series suggests that elective aortic root enlargement is safe.
Objectives: Infective endocarditis (IE) is now a recognised complication after transcatheter aortic valve implantation (TAVI). However, the data remains scarce. We have therefore conducted a retrospective analysis of its incidence, microbiological profile and the clinical outcomes at our centre over a 3-year period with the aim of formulating a contemporary profile of its