Roberto Di Bartolomeo

Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection

Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.

Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the Vascular Domain of EACTS

The implementation of new surgical techniques offers chances but carries risks. Usually, several years pass before a critical appraisal and a balanced opinion of a new treatment method are available and rely on the evidence from the literature and experts opinion. The frozen elephant trunk (FET) technique has been increasingly used to treat complex pathologies of the aortic arch and the descending aorta, but there still is an ongoing discussion within the surgical community about the optimal indications. This paper represents a common effort of the Vascular Domain of EACTS together with several surgeons with particular expertise in aortic surgery, and summarizes the current knowledge and the state of the art about the FET technique. The majority of the information about the FET technique has been extracted from 97 focused publications already available in the PubMed database (cohort studies, case reports, reviews, small series, meta-analyses and best evidence topics) published in English.

Clinical and hemodynamic outcomes of ''all-comers'' undergoing transapical aortic valve implantation: Results from the Italian Registry of Trans-Apical Aortic Valve Implantation (I-TA)

OBJECTIVE The aim of this study was to assess clinical and hemodynamic outcomes of transapical aortic valve implantation (TA-TAVI) in patients enrolled in the Italian Registry of Trans-Apical Aortic Valve Implantation (I-TA). METHODS From April 2008 until November 2010, 504 patients from 20 Italian centers were enrolled in the I-TA registry. Mean logistic EuroSCORE and Society of Thoracic Surgeons score were 24% ± 16% and 11% ± 4%, respectively. Mean follow-up was 9.2 ± 6.5 months (range, 1-26 months). Outcomes were analyzed according to intraoperative complications, procedural volume (high-volume centers, >20 cases; low-volume centers, < 20 cases) and learning curve (first 50% cases vs second 50% cases of each center). RESULTS All-cause overall mortality was 8.3% (42 patients). Device success was 99% (500/504 patients). Intraoperative severe complications occurred in 24 (4.8%) patients. Overall 2-year survival was 71.5% ± 6.2%. At discharge, peak and mean gradients were 16.4 ± 11.2 and 8.7 ± 4.1 mm Hg, respectively, and effective orifice area was 1.67 cm(2). These values remained stable at 3, 6, and 12 months after surgery. Independent risk factors for mortality after TA-TAVI were as follows: New York Heart Association class III and IV (odds ratio [OR], 4.43; 95% confidence intervals [CI], 1.28-15.40; P = .02); logistic EuroSCORE greater than 20 (OR, 1.83; 95% CI, 1.02-3.29; P = .04); creatinine concentration greater than 200 μmol/L (OR, 2.56; 95% CI, 1.07-6.15; P = .03), and intraoperative complications (OR, 5.80; 95% CI, 2.68-12.55; P < .001). There were no significant differences in outcomes between high- and low-volume centers and between the first and the second 50% of cases. CONCLUSIONS TA-TAVI represents a safe and effective alternative treatment for patients who are inoperable or at high risk for surgery. The occurrence of an intraoperative complication significantly affects survival. Procedural volume and learning curve have no impact on patient survival.

Arch replacement and downstream stent grafting in complex aortic dissection: first results of an international registry.

OBJECTIVES Arch replacement combined with antegrade stent grafting of the descending aorta represents a hybrid surgical approach for extensive thoracic aortic disease. This multicentre study evaluates the early results of this method in complex aortic dissection (AD). METHODS Retrospective data acquisition was achieved by institution of an international registry. A hybrid stent graft with integrated vascular prosthesis for arch replacement (E-vita open®) was used. From January 2005 to March 2009, 106 patients (mean age 57; 77% male) with complex AD (55 acute, 51 chronic) were studied. RESULTS As many as 49/106 (46%) patients underwent emergency surgery. Stent-graft deployment and arch replacement (95 total, 11 subtotal) were performed under hypothermic circulatory arrest (HCA (8±6min) and selective antegrade cerebral perfusion (SACP) (74±23min). Stent-graft placement into the true lumen was successful in all but one case (99%). Ascending aortic replacement was performed in 91/106 (86%), aortic valve repair/replacement in 49/106 (46%), coronary artery bypass grafting (CABG) in 17/106 (16%) and mitral valve repair in 2/106 (2%). Cardiopulmonary bypass (CPB) and cardiac arrest times were 242±64 and 144±44min, respectively. In-hospital mortality was 12% (13/106; six acute, seven chronic AD) and new strokes observed in 5/106 (5%). The false lumen (FL) was evaluated in 96/106 (91%) patients postoperatively. At first follow-up computed tomography (CT)-examination, thoracic FL thrombosis was 93% (76 complete, 13 partial) and 58% (31 complete, 25 partial) in the thoraco-abdominal aorta. CONCLUSIONS By combining arch replacement with downstream stent grafting, one-stage repair of complex aortic dissection with almost unanimous thoracic FL thrombosis can be achieved at acceptable perioperative risk.

Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery

Ischaemic spinal cord injury (SCI) remains the Achilles heel of open and endovascular descending thoracic and thoracoabdominal repair. Neurological outcomes have improved coincidentially with the introduction of neuroprotective measures. However, SCI (paraplegia and paraparesis) remains the most devastating complication. The aim of this position paper is to provide physicians with broad information regarding spinal cord blood supply, to share strategies for shortening intraprocedural spinal cord ischaemia and to increase spinal cord tolerance to transitory ischaemia through detection of ischaemia and augmentation of spinal cord blood perfusion. This study is meant to support physicians caring for patients in need of any kind of thoracic or thoracoabdominal aortic repair in decision-making algorithms in order to understand, prevent or reverse ischaemic SCI. Information has been extracted from focused publications available in the PubMed database, which are cohort studies, experimental research reports, case reports, reviews, short series and meta-analyses. Individual chapters of this position paper were assigned and after delivery harmonized by Christian D. Etz, Ernst Weigang and Martin Czerny. Consequently, further writing assignments were distributed within the group and delivered in August 2014. The final version was submitted to the EJCTS for review in September 2014.

Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation?

Thoracic endovascular aortic repair (TEVAR) has emerged as a promising therapeutic alternative to conventional open aortic replacement but it requires suitable proximal and distal landing zones for stent-graft anchoring. Many aortic pathologies affect in the immediate proximity of the left subclavian artery (LSA) limiting the proximal landing zone site without proximal vessel coverage. In patients in whom the distance between the LSA and aortic lesion is too short, extension of the landing zone can be obtained by covering the LSAs origin with the endovascular stent graft (ESG). This manoeuvre has the potential for immediate and delayed neurological and vascular symptoms. Some authors, therefore, propose prophylactic revascularisation of the LSA by transposition or bypass, while others suggest prophylactic revascularisation only under certain conditions, and still others see no requirement for prophylactic revascularisation in anticipation of LSA ostium coverage. In this review about LSA revascularisation in TEVAR patients with coverage of the LSA, we searched the electronic databases MEDLINE and EMBASE historically until the end date of May 2010 with the search terms left subclavian artery, covering, endovascular, revascularisation and thoracic aorta. We have gathered the most complete scientific evidence available used to support the various concepts to deal with this issue. After a review of the current available literature, 23 relevant articles were found, where we have identified and analysed three basic treatment concepts for LSA revascularisation in TEVAR patients (prophylactic, conditional prophylactic and no prophylactic LSA revascularisation). The available evidence supports prophylactic revascularisation of the LSA before ESG LSA coverage when preoperative imaging reveals abnormal supra-aortic vascular anatomy or pathology. We further conclude that elective patients undergoing planned coverage of the LSA during TEVAR should receive prophylactic LSA transposition or LSA-to-left-common-carotid-artery (LCCA) bypass surgery to prevent severe neurological complications, such as paraplegia or brain stem infarction.

Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients: A 5-year multi-institutional experience

BACKGROUND Acute fulminant myocarditis (AFM) may represent a life-threatening event, characterized by rapidly progressive cardiac compromise that ultimately leads to refractory cardiogenic shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in this circumstance, but few clinical series are available about early and long-term results. Data from a multicenter study group are reported which analyzed subjects affected by AFM and treated with VA-ECMO during a 5-year period. METHOD From hospital databases, 57 patients with diagnoses of AFM treated with VA-ECMO in the past 5 years were found and analyzed. Mean age was 37.6 ± 11.8 years; 37 patients were women. At VA-ECMO implantation, cardiogenic shock was present in 38 patients, cardiac arrest in 12, and severe hemodynamic instability in 7. A peripheral approach was used with 47 patients, whereas 10 patients had a central implantation or other access. RESULTS Mean VA-ECMO support was 9.9 ± 19 days (range, 2 to 24 days). Cardiac recovery with ECMO weaning was achieved in 43 patients (75.5%), major complications were observed in 40 patients (70.1%), and survival to hospital discharge occurred in 41 patients (71.9%). After hospital discharge (median follow-up, 15 months) there were 2 late deaths. The 5-year actual survival was 65.2% ± 7.9%, with recurrent self-recovering myocarditis observed in 2 patients (at 6 and 12 months from the first AFM event), and 1 heart transplantation. CONCLUSIONS Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of AFM, although major complications may characterize the hospital course. Long-term outcome appears favorable with rare episodes of recurrent myocarditis or cardiac-related events.

Extracorporeal membrane oxygenation support in refractory cardiogenic shock: treatment strategies and analysis of risk factors.

Two centrifugal pumps, the RotaFlow (Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany) and Levitronix CentriMag (Levitronix LCC, Waltham, MA, USA), used in central or peripheral veno-arterial extracorporeal membrane oxygenation (ECMO) support systems have been investigated, in terms of double-center experience, as treatment for patients with refractory cardiogenic shock (CS). Between January 2006 and December 2012, 228 consecutive adult patients were supported on RotaFlow (n=213) or CentriMag (n=15) ECMO, at our institutions (155 men; age 58.3±10.5 years, range: 19-84 years). Indications for support were: failure to wean from cardiopulmonary bypass in the setting of postcardiotomy (n=118) and primary donor graft failure (n=37); postacute myocardial infarction CS (n=27); acute myocarditis (n=6); and CS on chronic heart failure (n=40). A peripheral ECMO setting was established in 126 (55.2%) patients while it was established centrally in 102 (44.7%). Overall mean support time was 10.9±9.7 days (range: 1-43 days). Eighty-four (36.8%) patients died on ECMO. Overall success rate, in terms of survival on ECMO (n=144), weaning from mechanical support (n=107; 46.9%), bridge to mid-long-term ventricular assist device (n=6; 2.6%), and bridge to heart transplantation (n=31; 13.5%), was 63.1%. One hundred twenty-two (53.5%) patients were successfully discharged. Stepwise logistic regression identified blood lactate level and MB isoenzyme of creatine kinase (CK-MB) relative index at 72 h after ECMO initiation, and number of packed red blood cells (PRBCs) transfused on ECMO as significant predictors of mortality on ECMO (P=0.010, odds ratio [OR]=2.94; 95% confidence interval [CI]=1.10-3.14; P=0.010, OR=2.82, 95% CI=1.014-3.721; and P=0.011, OR=2.69; 95% CI=1.06-4.16, respectively). Central ECMO population had significantly higher rate of continuous veno-venous hemofiltration need and bleeding requiring surgery events compared with the peripheral ECMO setting population. No significant differences were seen by comparing the RotaFlow and CentriMag populations in terms of device performance. At follow-up, persistent heart failure with left ventricle ejection fraction (LVEF)≤40% was a risk factor after hospital discharge. Patients with a poor hemodynamic status may benefit from rapid central or peripheral insertion of ECMO. The blood lactate level, CK-MB relative index, and PRBCs transfused should be strictly monitored during ECMO support. In addition, early ventricular assist device placement or urgent listing for heart transplant should be considered in patients with persistent impaired LVEF after ECMO.

Role of endovascular repair in the management of late pseudo-aneurysms following open surgery for aortic coarctation

BACKGROUND Coarctation of the aorta accounts for almost 5% of all congenital cardiac malformations, and it is usually treated by open surgical procedures. Despite the excellent primary results, many patients may develop anastomotic pseudo-aneurysms, associated with considerable morbidity and mortality rates. We investigated the role of endovascular repair as an alternative to open re-do surgery on the descending aorta. METHODS We retrospectively collected data of 11 consecutive patients who presented with pseudo-aneurysms of the descending aorta following previous surgical repair of congenital aortic coarctation. Nine patients developed a pseudo-aneurysm after patch aortoplasty, while an interposition graft repair was performed in two cases. Seven patients underwent an endovascular repair (26.9 years after the previous open surgery). Four patients with a pseudo-aneurysm after coarctation repair associated with arch hypoplasia underwent conventional open re-operation. RESULTS No complications or death were observed in the conventional surgical group. Technical success was obtained in all patients who received a stent-graft procedure. More than one stent graft was necessary only in one case. A left carotid-left subclavian artery bypass was performed in three patients. Type II endoleak was detected by angiography in one patient who had previously undergone subclavian re-vascularisation. The median follow-up (FU) was 44.5 months and was 100% complete. Neither re-operations nor complications or deaths occurred during FU. CONCLUSIONS Endovascular repair of pseudo-aneurysms following open surgery for aortic coarctation is feasible and safe. However, more patients and longer follow-up are necessary to assess the efficacy of this promising less-invasive alternative to open re-do surgery.

The frozen elephant trunk technique for the treatment of complicated type B aortic dissection with involvement of the aortic arch: multicentre early experience

OBJECTIVES Providing effective treatment for complicated type B aortic dissection (AD) with concomitant pathologies of the aortic arch or ascending aorta is challenging, especially if the aortic anatomy is contraindicated for thoracic endovascular aortic repair (TEVAR). We present the early results of a multicentre study using the frozen elephant trunk (FET) technique for type B AD. METHODS From January 2005 to March 2013, data from 465 patients who had undergone treatment with the FET technique were collected in the database of the International E-vita Open Registry. From this cohort, 57 patients who had a primary indication for surgery for type B AD were included in the present study. Their mean age was 58±12 years, and 72% had a chronic dissection. All operations were performed in circulatory arrest and bilateral antegrade cerebral perfusion. Computed aortic imaging was performed for false lumen (FL) evaluation during the follow-up. RESULTS The in-hospital mortality rate was 14% (8/57). Stroke and spinal cord injury occurred in 6 (10%) and 2 patients (4%), respectively. The rate of immediate FL thrombosis at the level of the stent graft was 75% (40/53) and increased to 97% (41/42) during the follow-up period (23±19 months). Distally, at the level of the abdominal aorta, the FL remained patent in 50% (21/42) of patients. The 1- and 3-year survival was 81 and 75%, respectively. CONCLUSION The FET technique is a feasible therapeutic option for complicated type B AD with involvement of the aortic arch if TEVAR is contraindicated. In contrast to conventional aortic surgery via a lateral thoracotomy, the FET procedure can provide simultaneous treatment of the ascending aorta and aortic arch.