Abstracts from the 72nd Congress of the ESCVS, the European Society of CardioVascular and Endovascular Surgery ^†

Abstract

The 72nd Annual International Congress of the European Society for Cardiovascular and Endovascular Surgery (ESCVS) 2024 in Istanbul, Turkey, marks a significant milestone in the advancement of cardiovascular surgery. As the main event in the cardiovascular surgery community calendar, this congress serves as a platform for leading experts, clinicians, and researchers to exchange information on the latest innovations, research results, and clinical procedures. This dedicated supplement to Proceedings provides a curated collection of abstracts presented at the congress, highlighting breakthrough contributions and fostering collaboration across the European and global cardiovascular surgery communities. The topics presented in this supplement represent a wide range of innovative advances in the fields of both cardiovascular and endovascular surgery. These include novel and minimally invasive surgical techniques, technological innovations, updates to clinical recommendations and guidelines, and new therapeutic strategies and procedures. Through the knowledge conveyed in these abstracts, the congress aims to advance the continuous evolution of patient care and outcomes in cardiac and vascular surgery. By showcasing the vibrant research and collaborative spirit of the ESCVS, this supplement provides valuable insights into the future directions of the field, emphasizing the importance of interdisciplinary approaches and innovation in addressing the complexities of cardiovascular disease. As cardiovascular care continues to evolve, the research and discussions presented at this congress will play a critical role in shaping the next generation of cardiac and vascular surgeons, promoting better patient outcomes, and improving the overall quality of cardiovascular health in Europe and worldwide.

1. Selected Oral Abstracts

1.1. CARDIAC » Adult Congenital

1.1.1. Surgical Correction of Tetralogy of Fallot in Adults: A Retrospective Analysis of Recent Experience

• Kamran Ahmadov, Kamran Musayev, Ilkin Osmanov, Fahreddin Alekberov and Murad Bayramli
  Department of Cardiovascular Surgery, Merkezi Klinika, Baku, Azerbaijan

BACKGROUND AND AIM: To report our experience with surgical correction of Tetralogy of Fallot (TOF) in adults.

METHOD: We retrospectively analyzed our results of adults with TOF who underwent surgical correction between 2020 and 2024. The cohort consisted of 15 patients, with a mean age of 28 years (range: 17–48 years). Mean cardiopulmonary bypass and aortic cross-clamp times were 103 and 66 min, respectively. Mean ICU was 3 days (range 2–4 days).

RESULTS: No mortality was observed during the study period. Mean hospital stay was 6 days (range 5–8 days). Additionally, there were no cases with major adverse cardiac and cerebrovascular events (MACCE).

CONCLUSIONS: Surgical correction of TOF can be safely performed in adults, with favorable outcomes in terms of mortality and MACCE. Our experience highlights the feasibility and safety of this procedure in the adult population.

• Keywords: Tetralogy of Fallot; GUCH

1.1.2. The First Cone Surgery Performed in Adult Ebstein Anomaly in Turkey

• Erdoğan Ibrişim, Kadir Burhan Karadem and Dinçer Uysal
  Department of Cardiovascular Surgery, Suleyman Demirel University, Isparta, Turkey

Ebstein’s disease is a rare congenital anomaly that occurs in one in 200.00 live births. Treatment of disease, repair, or replacement of the tricuspid valve prevents advanced insufficiency of the tricuspid valve. Plication of the atrialized ventricle, annular construction of tricuspid valve, closure of the defect to eliminate the right-left shunt. Cone operation is the most physiological and reliable of all methods. Valvular replacement and not using ring provide an advantage. Cone adulthood the first operation carried out with success in Turkey. We think that the frequent use of Cone method will have a positive effect to decrease the mortality, morbidity, and survival time in these cases.

• Keywords: Cone; Ebstein’s anomaly

1.1.3. Incidental Finding of Undiagnosed Aortic Coarctation in a 63-Year-Old Man Revealed by a Poly-Trauma

• Wafa Id El Mouden, Wassim Beladel, Mehdi Barrajaa and Mohamed El Minaoui
  Department of Cardiology, University Hospital Agadir, Medical School of Medicine & Pharmacy Ibn Zohr University, Agadir, Morocco

Aortic Coarctation is a narrowing of the aorta beyond the left subclavian artery, with an incidence ranging from 5% to 8% of all congenital cardiac defects. This anomaly is usually detected at birth by systematic palpation of the femoral pulses, but can also be diagnosed later, in both older children and adults.

We illustrate this fact with a case of a 63-year-old patient undergoing treatment for hypertension for four years. The diagnosis of coarctation of the aorta was established following a thoracic CT scan as part of the lesion assessment for poly-trauma following a road traffic accident.

While Coarctation of the Aorta is uncommon in adults, it should be included in the diagnostic evaluation for secondary hypertension, especially in individuals with a history of congenital heart disease. Better control of blood pressure, earlier repair and trans-catheter intervention may provide good results in this case.

No case of coarctation of the aorta in the context of poly-trauma has been cited in the literature, adult and elderly patients with uncorrected coarctation generally have a low survival rate, and the management strategies for such cases are controversial, especially when it is associated to other pathologies.

In the light of our findings, we recommend a thorough physical examination for all patients with suspected coarctation of the aorta, including upper and lower extremities blood pressure measurements.

• Keywords: Aortic Coarctation; secondary hypertension; incidental finding; poly-trauma

1.1.4. Modified Central Shunt (Aasim’s Shunt) Procedure via Upper Mini Sternotomy in Teenage Patients with Complex Cyanotic Congenital Heart Disease and Hypoplastic Pulmonary Vasculature

• Muhammad Aasim
  Department of Cardiac Surgery, Hayatabad Medical Complex, Peshawar, Pakistan

BACKGROUND: Grown up children with complex cyanotic congenital heart disease and hypoplastic pulmonary vasculature are not amenable to biventricular total correction surgery in our setup. In this study we present our experience with such patients undergoing modified central shunt (Aasim’s Shunt) via upper ministernotomy access.

METHODS: We studied 6 patients (4 males, 2 females), 13 years to 19 years of age, with hypoplastic pulmonary arteries who underwent modified central shunt procedure between 2018 and 2023. Patient’s preoperative, operative, postoperative and demographic data were recorded.

RESULTS: Patients were operated as the first-step palliation. No mortality was observed. The median follow-up after the procedure is 12 months (range 6 months to 18 months).

CONCLUSIONS: The central shunts increase oxygen saturation and improve quality of life with potential for pulmonary arteries development. Low morbidity, low mortality, good survival rate and less technical difficulty of this procedure make it a better option for treatment of complex cyanotic congenital heart disease patients, having hypoplastic pulmonary vasculature.

• Keywords: Complex cyanotic congenital heart disease; hypoplastic pulmonary arteries; modified central shunt (Aasim’s Shunt)

1.1.5. Perioperative Management and Hemostatic Control of Antiphospholipid Syndrome in Cardiac Valvular and Septal Defect Surgery

• Tanees Akhter, Ahson Memon, Malik Shafqat Hasan and Imran Ali
  Department of cardiothoracic surgery, Tabba heart institute, Karachi, Pakistan

BACKGROUND: Individuals with Antiphospholipid syndrome (APS) often have heart valve anomalies, however, experience with valve replacement in such individuals with a considerably large ASD is limited. We offer a case of a mitral valve replacement and an ASD closure in a patient with this disease at our institute.

CASE PRESENTATION: A 29 year old female, married, APS positive, with no other comorbids, presented in the OPD for an elective ASD (Atrial Septal Defect) repair and mitral valve replacement. Her TEE (Transesophageal echocardiography) showed a bileaflet mitral valve prolapse causing severe eccentric mid to late systolic mitral regurgitation with multiple regurgitation jets and systolic flow reversal in left upper and left lower pulmonary veins. Mitral annulus measured 33 mm and a large ASD measuring 48 mm in diameter with predominantly left to right shunt was detected.

She was given clearance for surgery after being reviewed by a multidisciplinary team and successfully operated on, on the 23rd of November 2023, via a median sternotomy, on cardiopulmonary bypass and with an intricately managed anticoagulation process.

CONCLUSIONS: This case highlights the special perioperative difficulties that APS patients undergoing on pump cardiac surgery face, especially with regard to ASD closure. We have demonstrated, that although rare, such a condition may arise in some patients that have APS and can be, through correct risk assessment and management, surgically corrected.

• Keywords: antiphospholipid syndrome; cardiopulmonary bypass; Mitral Valve replacement; large atrial septal defect; anticoagulation; perioperative management

1.1.6. Application of Reimplantation Technique in the Patient Who Had Anomalous Aortic Origin of the Right Coronary Artery and Aberrant Right Subclavian Artery

• Ebubekir Sönmez, Izatullah Jalalzai, Eyüp Serhat Çalık and Ümit Arslan
  Department of Cardiovascular Surgery, Atatürk University Medical Faculty, Erzurum, Türkiye

BACKGROUND: A rare congenital cardiac anomaly known as Anomalous Aortic Origin of the Right Coronary Artery (AAORCA) usually affects the right coronary artery (RCA) originating from the left sinüs of valsalva. Although AAORCA can cause angina, syncope, palpitations, and sudden cardiac death, most patients remain asymptomatic. Here, we present a rare case of a 42 year-old man who had AAORCA with an aberrant right subclavian artery. As a treatment, he underwent reimplantation of the right coronary artery to the aorta and right subclavien artery to right common carotid artery.

CASE PRESENTATION: A 42-year-old man presented with a history of angina. Beside blood tests and holter effor, to exclude any possibaly ischemic heart disease, coronary CT was ordered which reported that the RCA originated from the left sinus of Valsalva, indicating AAORCA. The RCA passed through the pulmonary artery and ascending aorta. At the same time aberrant right subclavian artery (ARCA) existence is revealed in the CT. ARCA is traveled posterior of esophagus. Operation was planned and we performed a reimplantation of the RCA and ARCA.

AAORCA, a rare congenital abnormality, can cause sudden cardiac death. Symptomatic patients should be treated surgically, while asymptomatic patients should be managed clinically, with secondary prevention through platelet antiaggregants and cholesterol reducers.

• Keywords: Aberrant right subclavian artery; reimplantation; right coronary artery anomaly

1.1.7. Retroaortic Innominate Vein with Right Aortic Arch in an Adult Patient with Previous Tetralogy of Fallot Repair

• David C. Cistulli, Mathew Doyle and Benjamin M. Robinson
  Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia

BACKGROUND: Retroaortic innominate vein is a very rare congenital abnormality, with only a few case reports in the literature. When combined with right aortic arch and Tetralogy of Fallot, there is just one previous case report of this abnormality. We present a such case in a patient undergoing redo cardiac surgery.

CASE: A 43 year old female was referred to our Cardiothoracic Surgery service for tricuspid valve replacement and closure of patent foramen ovale in the context of worsening right ventricular function. This was on a background of previous Tetralogy of Fallot repair at 11 months old, which involved several revisions including Melody pulmonary valve insertion 10 years prior to referral. Pre-operative imaging demonstrated the unique combination of retroaortic innominate vein with a right aortic arch. Intra-operatively, special care was taken to identify where the innominate vein joined the right brachiocephalic vein. This was important for insertion and snaring the superior vena cava cannula below this junction, to ensure sufficient drainage of the innominate vein.

• Keywords: Adult congenital; imaging; right aortic arch; retroaortic innominate vein

1.1.8. Unrepaired Persistent Truncus Arteriosus Typ4 in a 52 Years Old Woman Patient

• Laman Eyvazli
  Kapaz Hospital, Baku, Azerbaijan

INTRODUCTION: Truncus arteriosus (PAVSD) is a congenital defect that occurs as a result of incomplete septasia of great arteries and VSD. The common coronal arteria provides systemic, pulmonary and coronary perfusion. This pathology presents with severe heart failure, arrhythmia and right heart failure.

CLINICAL CASE: A 52-year-old woman applied to our clinic with chest pain, abdominal ascites, and arrhytmmia (NYHA III f.s). He has a physical work limitation since his childhood. She was not under regular cardiologist monitoring and did not receive regular treatment.

Physical examination: On the right, the breath sounds decrease on the lungs, on the left, wet wheezing is heard in the lower denominator. Core tones: increased, holosystolic sound is heard. Jugular venous distention+ and grade II ascites are observed in the abdomen. Their fingers are rod-shaped, and cyanosis is observed at the fingertips and around the mouth.

Hb-15.2, HCT-52.3, RBC-7,09, WBC-7.44, PLT-250

creatine—0.9 mg/dL, urea—54 mg/dL, TSH—10.84 mIU/mL, CRP—7.7 mg/L,

ECG: Atrial fibrillation, taxisystolic form.

ECHO: Biventrikulyar dilatation and hypertrophy, biatrial dilatation

PSAX: Pulmonary valve and artery could not be visualized

A5C: Overriding aorta, perimembranous VSD (−20 mm)

Primary Diagnosis: Pulmonary atresia? Truncus arteriosus? Heart Failure NHYA III. Atrial Fibrillation. Hypothyreoidism.

CT Angiography: CAT, which appeared by overriding IVS. RCA—originates from the right anterior part of the truncal sinus, LCA—originates from the left posterior part of the truncal sinus. Mapcas 4 mm on the right, 9 mm, 14 mm on the left.

CT: Undercirculation on the right side, Overcirculation on the left side

Clinical diagnosis:

• Truncus Arteriorosus type4.
• Right heart failure.
• Atrial Fibrillation.
• Hypothyreoidism

A consultation was held with the cardiosurgeon. It was deemed inoperable and conservative treatment was prescribed.

Medical treatment: Rivaroxaban 20 mq × 1, Diqoksin 0.25 mq × 1, Verospirone 50 mg × 2, Furosemide 2 mL/20 mq × 2

RESULT: The patient was clinically relatively stabilized and conservative treatment was recommended, with subsequent follow-up checks recommended.

• Keywords: Truncal arteria; Major aortopulmonar collateral arteries; Ventricular septal defect

1.2. CARDIAC » AF and CABG

1.2.1. AI-Atria Oracle—An Artificial Intelligence Sentinel for Precision Prognostication of Atrial Fibrillation Risks in Post-Cardiac Surgery Care-Pilot Study

• Anandshankar Soundararajan
  Institute of Cardiovascular and Thoracic surgery, RGGGH, Chennai, India

BACKGROUND AND AIM: This study introduces an AI system for post-cardiac surgery atrial fibrillation (AF) risk prediction, reshaping preoperative assessment in cardiac care. ChatGPT crafts a robust tool, potentially revolutionizing risk assessment in cardiac surgical interventions.

AIM: Leveraging insights from globally recognized articles on Post-Operative Atrial Fibrillation (POAF), the study aims to anticipate complications before thoracic surgery through an advanced AI-driven system.

METHODS: The research entails a comprehensive examination and synthesis of existing scoring methodologies related to AF complications post cardiac surgery. Leveraging state-of-the-art machine learning techniques, ChatGPT engineers a robust scoring system, enhancing the accuracy of preoperative assessments and facilitating early identification of individuals at higher risk for postoperative atrial fibrillation.

VALIDATION: In a retrospective cohort study spanning January to July 2023, 100 consecutive patients (18 years and above) undergoing various cardiac surgical procedures are evaluated. The focus is on atrial fibrillation occurrence within 30 days post-surgery. The AI-derived scoring system exhibits compelling performance metrics, with an Area Under the Curve (AUC) of 0.85 in derivation and 0.77 in validation, affirming its efficacy in predicting atrial fibrillation risks.

RESULTS: Out of the 100 patients studied over a 7-month period, 18.5% developed postoperative atrial fibrillation. Key predictors identified include Age, Transischemic attack/stroke, Ejection fraction, Left Atrial Size, and Surgical Procedure Type. The study acknowledges potential limitations related to sample size, impacting generalizability. Additionally, inherent biases associated with retrospective study designs are duly recognized.

CONCLUSIONS: This study introduces a cutting-edge AI model-based scoring system for the proactive assessment of atrial fibrillation risk post cardiac surgery. With strong predictive accuracy and calibration, the developed system holds promise for optimizing preoperative risk stratification and subsequent management strategies in the context of cardiac surgical interventions.

• Keywords: AI-driven Atrial fibrillation Cardiac surgery Preoperative assessment Machine learning Retrospective cohort study

1.2.2. Coronary Artery Bypass Grafting in Patients Having Impaired LV on Echocardiography and Preoperative Myocardial Viability Assessed by Cardiac Magnetic Resonance (CMR) Imaging

• Muhammad Aasim
  Department of Cardiac Surgery, Hayatabad Medical Complex, Peshawar, Pakistan

BACKGROUND AND AIM: Patients with impaired left ventricular (LV) systolic function and Coronary Artery Disease (CAD) undergoing coronary artery bypass grafting are more prone to peri-operative complications and poor outcomes as compared to patients with good left ventricular systolic function. Cardiac magnetic resonance (CMR) imaging is a useful investigation to know about the myocardial viability and can identify patients with impaired LV systolic function and significant CAD likely to benefit from revascularization. In this study we aimed to determine the relationship between impaired left ventricular systolic functions on echocardiography and preoperative myocardial viability assessed on cardiac magnetic resonance imaging and subsequently short term surgical outcomes in those patients undergoing coronary artery bypass grafting (CABG) for treatment of significant CAD.

METHOD: This study included the patients with impaired left ventricular systolic function on echocardiogram and diagnosed with significant coronary artery disease (CAD) on Coronary Angiogram. Cardiac magnetic resonance imaging was carried out after Echocardiogram in these patients, for assessment of the myocardial viability before subjecting them to CABG surgery. After assessment of the myocardial viability these patients underwent CABG surgery in our department.

RESULTS: Total 36 cases studied. All patients successfully underwent CABG surgery.

CONCLUSIONS: We recommend that Cardiac Magnetic Resonance imaging is a good tool for preoperative assessment of myocardial viability in patients having CAD with impaired left ventricular systolic function undergoing CABG.

• Keywords: Impaired LV; Coronary Artery Disease; Cardiac MRI; Coronary Artery Bypass Grafting

1.2.3. Posterior Pericardiotomy in Coronary Arter Bypass Surgery

• Ahmet Ozan Koyuncu ¹, Faruk Gençoğlu ² and Tolunay Toy ¹

1

Department of Cardiovascular Surgery, Istanbul University—Cerrahpasa, Institute of Cardiology, Istanbul, Turkey

2

Department of Cardiovascular Surgery, Hisar Intercontinental Hospital, Istanbul, Turkey

BACKGROUND AND AIM: Posterior pericardiotomy (PP) is a surgical maneuver that drains the pericardial space into the left pleural cavity to reduce the incidence of atrial fibrillation (AF) after cardiac surgery. Atrial fibrillation is one of the most common complications after coronary artery bypass surgery (CABG). Its prevalence is 20–45% and is associated with increased adverse outcomes, including death, stroke, and hemorrhage due to anticoagulation. This study evaluates the efficacy of PP in reducing AF and overall adverse outcomes in patients undergoing elective on-pump CABG.

METHOD: We conducted a retrospective analysis of 821 patients who underwent cardiac surgery in between January 2017 and December 2022, selecting 278 adult patients who underwent elective on-pump CABG with PP. We have focused on the incidence of AF, surgical revisions, pericardial effusion, pleural effusion, myocardial infarction (MI), stroke, intensive care unit and hospital stay lengths and 30 days mortality.

RESULTS: 230 of the patients were men, 48 of them were women with mean age of 60.8 years. 23 (8.2%) of them have low ejection fraction (EF < 40%). Out of the 278 patients who underwent PP, 36 (12.9%) developed AF, 10 (3.5%) required surgical revision, 10 (3.5%) developed pericardial effusion, 31 (11.1%) had pleural effusion, 14 (5%) experienced MI, and 10 (3%) suffered a stroke. The average ICU stay was 3 days, and the average hospital stay was 6.8 days. The one-month mortality rate was 3.5%.

CONCLUSIONS: PP in elective on-pump CABG surgery shows potential in reducing the incidence of AF and contributing to reducing overall adverse outcomes. A comparative study with larger numbers is likely to redound stronger results.

• Keywords: Atrial Fibrillation; POAF; CABG; Posterior Pericardiotomy; Prevention

1.2.4. Can Systemic Immune-Inflammation Index Predict Postoperative Atrial Fibrillation Risk in Low Ejection Fraction CABG Patients?

• Isa Civelek
  Etlik City Hospital, Cardiovascular Surgery, Ankara, Türkiye

BACKGROUND AND AIM: Recent studies have reported a correlation between elevated Systemic Immune-Inflammation (SII) Index levels and the severity of illness or adverse prognostic outcomes in cardiac patients. SII index, derived solely from existing hematological markers, is deemed appealing. However, its clinical significance remains to be established, and research in this direction is progressively expanding.

In our study, we aimed to examine the potential association between the preoperative calculation of the SII index based on complete blood count parameters and the occurrence of postoperative atrial fibrillation (PoAF) specifically in coronary artery bypass grafting (CABG) patients with low ejection fraction (EF).

METHOD: In our study, we aimed to investigate whether there is a relationship between the SII index and the development of PoAF. To this end, we included patients undergoing CABG with low EF in our study, as these individuals have a relatively higher risk of PoAF among CABG patients.

Data from all patients with low EF who underwent isolated CABG surgery at our clinic were reviewed starting from the first case onwards. Patients with EF < 35% were recorded as having low EF. Patients who underwent emergency surgery and those who underwent concomitant valvular or other surgical procedures in addition to CABG were excluded from the study.

RESULTS: The results showed that out of 102 patients, 10 (9.8%) developed new-onset atrial fibrillation during follow-up. These patients demonstrated higher levels of SII index compared to those who did not develop atrial fibrillation (p < 0.05). additional analysis revealed that the elevated SII index levels correlates wtih elevated CHADVASC scores. Upon examination of patients with unresolved PoAF during follow-ups, lower SII index levels were noted compared to those with persistent PoAF.

CONCLUSIONS: Preoperative SII index appears to serve as a non-invasive and readily accessible marker, demonstrating significant predictive value for the risk of PoAF in CABG patients with low EF.

• Keywords: Coronary Artery Bypass; Atrial Fibrillation; Inflammation; Postoperative Complications

1.3. CARDIAC » Anesthesia Techniques and New Developments

Tietze Syndrome Treatment with Transverse Thoracic Muscle Plane Block After Coronary Artery Bypass Grafting

• Erman Şen ¹, Mehmet Cihangir Ağca ¹, Esra Adıyeke ¹, Yusuf Çakmak ¹ and Hilmi Tokmakoğlu ²

1

Department of Anesthesiology, Sancaktepe Şehit İlhan Varank Education and Research Hospital, Istanbul, Türkiye

2

Department of Cardiovascular Surgery, Sancaktepe Şehit İlhan Varank Education and Research Hospital, Istanbul, Türkiye

CASE: 45-year-old male patient, one month after coronary-artery-bypass-grafting (CABG), had pain on the left sternoclavicular-joint (SCJ), and was started non-steroidal + opioid analgesic-treatment. At the second control, he was hospitalized because of persistant pain. In our first examination; was revealed severe pain in the left SCJ and midclavicular line, increased temperature, and tenderness over the joint. Also there was an inability for turning the head to the left and raising the left arm upwards. Cardiac causes, septic arthritis and rheumatologic diseases were excluded. According to MRI results (significant increased effusion on the left SCJ) Tietze-syndrome (TS) was considered. With this diagnosis, after two-days intravenous tramadol infusion (12.5 mg/h) we managed to apply transverse thoracic muscle plan block (TTMPB). After site confirmation with USG from the 2nd intercostal space, a 5 cm block-needle was inserted and 15 mL local-anesthesic (10 mL 0.5% bupivacaine, 5 mL 2% lidocaine) was administered. The patient’s fifth-minute visual-analogue-score (VAS) decreased rapidly from 8 to 3. The first-hour and 24th-hour VAS was 2. Neck and arm movement limitations disappeared within 24-h. 24 h after TTMPB, 40 mg Triamcinolone Acetonide +40 mg lidocaine were administered into left SCJ. Before the discharge in the third day after TTMPB, the patients VAS was 1.

DISCUSSION: Postoperative pain after open heart surgery can be severe. In some cases, may be prolonged and become chronic. As in our case, a rare chronic pain cause TS; is a non-suppurative, seronegative costochondritis of the upper parasternal region, usually unilateral, with symptoms such as pain, redness and swelling on the anterior chest wall, of unknown etiology. In a few cases, it may develop after the CABG procedure, as in ours. In our case, postoperative severe pain due to TS, which restricted daily physical activity and for which medical treatment was inadequate, was treated with TTMPB + intra-articular corticosteroid injection. Peripheral block applications are becoming increasingly common in the treatment of TS.

Conclusions: It should be kept in mind that TTMPB which we used in our case as an effective example of this, can be used both in the pain treatment of TS and postoperative open-heart-surgery pain.

• Keywords: transverse thoracic muscle plane block; Tietze syndrome; coronary artery bypass grafting; chronic pain

1.4. CARDIAC » Aortic Valve and Aortic Root Surgery

1.4.1. Aortic Stone Wars in a Case of Familial Hypercholesterolemia

• Zied Ben Ayed ¹, Imen Gabsi ¹, Aiman Ghrab ¹, Rahma Kallel ², Walid Trigui ¹ and Imed Frikha ¹

1

Department of CardioVascular and Thoracic Surgery, Habib Bourguiba University Hospital, Sfax, Tunisia

2

Department of Cardiology, Mohamed Ben Sassi Hospital, Gabes, Tunisia

BACKGROUND AND AIM: Familial hypercholesterolemia (FH) is a genetic disorder characterized by high levels of low-density lipoprotein cholesterol (LDL-C) that predispose affected individuals to early-onset atherosclerotic cardiovascular disease (ASCVD).

This case report describes a patient with FH who presented with severe ASCVD.

METHOD: A 28-year-old male with a medical history of familial hypercholesterolemia, treated with atorvastatin and ezetimibe, and type 2 diabetes mellitus, treated with insulin, came to the emergency department with dyspnea and chest pain.

The patient had a family history of FH, and his older brother also had FH and early-onset CAD.

The examination revealed a harsh systolic ejection murmur, best heard at the right second intercostal space, radiating to the carotids, and a mild diastolic murmur.

Additionally, xanthomas on the elbows and knees were noted.

The patient had LVH and left ventricular dysfunction with an ejection fraction (LVEF) of 45%.

Coronary angiography revealed significant stenosis in all three major coronary arteries, and the CT-Scan showed a porcelain aorta with significant stenosis in its initial part.

RESULTS: The patient underwent a complex surgery that consisted of several components, including aortic valve replacement, aortic annulus enlargement, aortic root enlargement, and triple CABG.

The patient’s condition improved significantly following surgery, as indicated by an echocardiogram that showed a 65% increase in LVEF, no wall-motion abnormalities, and successful surgical intervention.

The patient had a smooth postoperative recovery, and subsequent CT scans revealed good flow in the coronary bypass grafts without any signs of residual stenosis in the aorta.

CONCLUSIONS: The challenges of managing FH are highlighted in this case report, which describes a complex surgical procedure performed on a 28-year-old male with FH who presented with multiple cardiovascular complications.

This case emphasizes the importance of genetic counseling and screening of family members of affected individuals to facilitate early diagnosis and treatment of FH.

• Keywords: aorta; CABG; aortic valve; familial hypercholesterolemia

1.4.2. Does Thrombocytopenia Exist Following Sutureless Aortic Valve Replacement (SU-AVR): An Institutional Experience of 178 Patients

• Mustafa Mert Ozgur ¹, Halil Ibrahim Bulut ², Barıs Gurel ¹, Mehmet Aksut ¹, Tanıl Ozer ¹, Ahmet Mirza Ozdemir ¹, Hakan Hancer ¹ and Kaan Kirali ¹

1

Department of Cardiovascular Surgery, Koşuyolu High Specialization Training and Research Hospital, Istanbul, Türkiye

2

Cerrahpasa School of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey

BACKGROUND AND AIM: Sutureless Aortic Valves (Su-AVR) have been intricately designed to optimize the effectiveness of valve replacement surgery, placing a primary emphasis on minimizing invasiveness and shortening implantation time. Despite advancements, thrombocytopenia following sutureless aortic valve replacement remains a relatively obscure concern that requires further clarification. This study stands as the most extensive and largest registered assessment of thrombocytopenia following Su-AVR within the Turkish patient population, known for its tendency towards anemia in comparison to Western populations.

METHOD: From January 2015 to July 2023, a total of 178 individuals meeting the inclusion criteria were included in the analysis. The platelet count for each patient was evaluated one year post-operation at the same hospital.

RESULTS: The cohort, with a mean age of 70.1 ± 10.7 years, displayed minimal variations in valvular functions among individuals. Remarkably, there were no instances of aortic complications, structural heart complications, or prolonged bleeding within the cohort. Despite relatively high average EuroScore II values at 9.6 ± 3.5%, the 30-day survival rate stood at 94.4%, the 1-year survival rate at 80%, and the overall mortality rate at 60 months reached 66%. Additionally, complications associated with expandable valves, including paravalvular leak, stroke, and transient ischemic attack (TIA), were observed to be less than 5% at the 1-year clinical follow-up. The mean platelet count preoperatively was 236.7 ± 81.5, and at the postoperative 12th month, it was 222.2 ± 88.6, with this difference not reaching statistical significance (p = 0.109). Importantly, there was no occurrence of new-onset thrombocytopenia in any of the patients.

CONCLUSIONS: In conclusion, SU-AVR emerges as a safe procedure with respect to thrombocytopenia, and it yields satisfactory clinical results in the examined parameters.

• Keywords: aortic valve replacement; sutureless aortic valve prosthesis; complications and safety

1.4.3. Sex-Related Differences in Outcomes After Bioprosthetic and Mechanical Aortic Valve Replacement: A Report from the National Registry

• Milos Matkovic ¹, Igor Zivkovic ², Slobodan Micovic ², Ilija Bilbija¹, Petar Milacic ², Nemanja Aleksic ¹, Nemanja Milosevic ², Svetozar Putnik ¹

1

Department for Cardiac Surgery, University Clinical Centre of Serbia, Belgrade, Serbia

2

Department for Cardiac Surgery, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia

BACKGROUND AND AIM: Limited data are available for SAVR gender-based procedural and outcome differences. This study aimed to determine whether there are baseline, practice patterns and outcomes differences of SAVR by sex.

METHOD: An observational study with data derived from the National SAVR Registry. All consecutive patients with isolated AVR with at least 3 years follow-up were divided into 4 groups according to their sex and the type of implanted prosthesis. According to the statistical analysis plan, the primary outcome of the present study was all-cause mortality at 3 years. The prespecified subgroup analyses were (1) the EACTS Guideline age-defined threshold for a mechanical prosthesis (<65 years of age) and (2) the presence of patient-prosthesis mismatch (PPM).

RESULTS: Female patients (n = 517) were older (67.2 + 9.3 vs. 64.4 + 12.2 years, p < 0.001) and had greater body mass index (2.23 + 7.2 vs. 2.01 + 0.2 m², p < 0.005) than male patients (n = 732). Also, they had higher EUROscore values (1.85 + 1.5 vs. 1.78 + 1.9 p < 0.005) and lower EF (51.8 + 13.5 vs. 57.7 + 10.8%, p < 0.001). In subgroup of patients who received mechanical prosthesis females had a higher rate of PPM than male patents (9.1 vs. 2.2%, p < 0.001). No significant difference was seen between males and females for 3-year mortality risk (14.6% vs. 14.1%, p = 0.87). Males who underwent bioprosthetic SAVR had a significantly higher mortality risk than those who received mechanical valve prostheses HR = 0.54 (95% CI 0.36–0.81, p = 0.003). The mortality difference favoring mechanical prostheses was particularly observed in patients aged <65, HR 0.25 (95% CI 0.11–0.68, p = 0.005).

CONCLUSIONS: Females were older and had worse clinical risk profiles at index hospitalization for SAVR. No significant difference was seen between males and females for 3-year mortality risk. Further prospective studies, including international data-sharing, are needed to comprehensively assess sex-related differences in SAVR.

• Keywords: SAVR; sex; outcome; PPM; prosthesis type

1.4.4. Patient-Prosthesis Mismatch After Surgical Aortic Valve Replacement with Biological Prosthesis—Sutureless vs. Non-Sutureless Valve

• Milos Matkovic ¹ and Igor Zivkovic ²

1

Department for Cardiac Surgery, University Clinical Center of Serbia, Belgrade, Serbia

2

Department for Cardiac Surgery, Institute for cardiovascular diseases ‘’Dedinje”, Belgrade, Serbia

BACKGROUND AND AIM: Patient-prosthesis mismatch (PPM) may impair functional capacity and survival after aortic valve replacement. The aim was to investigate the impact of PPMon survival in mid-term follow-up (up to 36 months) in patients who underwent surgical AVR with implantation of biological valves (sutureless and other stented bioprosthesis).

METHOD: An observational study was performed using the data derived from the national registry of surgical AVR. All patients with isolated AVR and biological prosthesis implanted have been enrolled in the study and were divided into two groups, according to the type of prosthesis implanted into sutureless and non-sutureless group. All groups were than divided into PPM and no-PPM groups according to the presence of PPM.

RESULTS: The total of 426 patients who underwent surgical AVR have been enrolled in the study (96 patients in sutureless and 330 patients in the non-sutureless group). In the sutureless group female gender was much more frequent compared to the other group (63 (67.1%) vs. 126 (38.6%), p = 0.001). The rate of PPM was also similar between groups 52 (55.3%) vs. 208 (63.8%) pts, p = 0.136. Survival compared for overall AVR cohort with biological valves with and without PPM was lower in the PPM group (81.1% vs. 90.7%, p = 0.001, HR 2.11 (95% CI 1.18–3.75)). Further analysis within the sutureless group revealed lower survival in the PPM group compared to non-PPM group (25.5 months vs. 34.5 months, p = 0.002, HR 7.09 (95% CI 1.62–31.25)). However, in the non-sutureless group the difference in survival in PPM and non-PPM group was not observed (30.6 months vs. 32.2 months, p = 0.219, HR 1.49 (95% CI 0.78–2.89)).

CONCLUSIONS: If the risk of PPM after the implantation of a sutureless biological prosthesis is suspected, prospective strategies to avoid PPM at the time of the operation are warranted. Aortic root enlargement with other type of biological prosthesis may be considered as alternative.

• Keywords: Patient-prosthesis mismatch; biological valve; sutureless valve; survival

1.4.5. Evaluation of Short and Mid-Term Results of Patients Who Had Aortic Valve Neocuspidization with the Ozaki Technique

• Elgin Hacızade ¹, Kubilay Karabacak ², Murat Kadan ², Emre Kubat ², Gökhan Erol ², Tayfun Özdem ² and Tuna Demirkıran ²

1

Gülhane Training and Research Hospital, Main Clinical Hospital of the Ministry of Defense of Azerbaijan

2

Gülhane Training and Research Hospital

BACKGROUND AND AIM: The gold standard treatment for severe AVD has always been aortic valve replacement (AVR), which involves the substitution of the native aortic valve with a biological or mechanical prosthesis. The Ozaki procedure is now gaining popularity in cardiac surgery centers around the world. This study aimed to present the first 85 patients with midterm experience of the AVNeo procedure of a single center.

METHOD: Pre- and post-operative data of patients who were surgically treated with aortic valve neocuspidization technique in our clinic due to aortic valve stenosis and insufficiency were obtained by scanning retrospectively from the file or automation system. In our research, the data of the series of 85 patients who applied this technique in our clinic from November 2019 until January 2023 will be evaluated. Preoperative data of patients, operative and postoperative data were collected and evaluated.

RESULTS: The mean age of patients was 58.9 ± 13.4 aged years and 48 (56.5) of them were men. The mean follow-up period of 85 patients who underwent the AVNeo technique was 19.3 ± 10.5 months. Preoperative echocardiographic findings showed us Peak aortic gradient (mmHg) was 87.32 ± 27.6, the Mean aortic gradient was 54.4 ± 18.3, and the aortic valve area (mm²) was 1.13 ± 0.33. The mean aortic cross-clamp time in our clinical series was 118.3 ± 32.3, while the cardiopulmonary bypass time was 154.5 ± 45.4 min.

CONCLUSIONS: In conclusion, the AVNeo procedure is a feasible technique for all kinds of aortic pathologies. In the AVNeo procedure, there is no prosthetic stent ring, and the glutaraldehyde-fixed autologous pericardium is directly sutured into the native aortic annulus. This technique also has much better hemodynamic results as it does not change the anatomical structure of the annulus and the commissures thus allowing normal physiological annular movements and Dynamics without reducing the valve’s functional area.

• Keywords: Aortic valve; Aortic valve noecuspidisation (AVNeo); Ozaki procedure

1.4.6. Medium Term Outcomes from Perceval Aortic Valve Replacement in Aotearoa New Zealand

• Navneet Singh and Parma Nand
• Department of Cardiothoracic Surgery, Auckland City Hospital, Auckland, New Zealand

BACKGROUND AND AIM: The Perceval bioprosthesis is a contemporary sutureless technology utilised for surgical aortic valve replacement (AVR). Perceval valves allow for AVR with reduced cross-clamp and cardiopulmonary bypass times, which correlates with improved postoperative patient morbidity and mortality. However, there is a paucity of literature reporting the medium-term outcomes from Perceval AVR in indigenous populations. We aimed to investigate the mid-term outcomes from Perceval AVR at our single centre with a significant indigenous population (Maori/Pacific).

METHOD: All consecutive patients undergoing Perceval AVR (during isolated or combined procedures) at our unit from March 2011 to August 2021 were retrospectively analysed from a prospectively-collected database. Data are presented as mean +/− standard deviation.

RESULTS: Across the 10-year study period, 145 patients (mean age: 73.2 years; males: 71.7%; indigenous Maori/Pacific ethnicity: 18.3%; mean EuroSCORE II: 3.78%) underwent Perceval AVR. The most common indication for surgery was aortic stenosis (82.5%). The operative caseload was complex, with only 27.6% of patients undergoing first-time isolated AVR. The mean cross-clamp and cardiopulmonary bypass times were 74.7 +/− 40.6 and 111.3 +/− 63.6 min respectively. Latest follow-up transthoracic echocardiography (performed at a mean of 2.2 +/− 1.7 years postoperatively) revealed that 96% of patients had either none or only trivial paravalvular/transvalvular leaks. 30-day mortality and stroke rates were 6.2% and 2.1% respectively. Medium-term survival rates across 5 year and 9.5 year follow-up were 70% and 55% respectively. There was only one reoperation on the aortic valve.

CONCLUSIONS: Across an older indigenous patient population undergoing complex cardiac surgery, Perceval AVR facilitates short cross-clamp times with excellent medium-term prosthetic valvular function. Medium-term (5-year) survival is acceptable.

• Keywords: Perceval; indigenous population; aortic valve replacement

1.4.7. Single Center Experience in the Aortic Valve Sparing Procedure

• Stefan Stankovic, Igor Zivkovic, Petar Milacic, Petar Vukovic and Slobodan Micovic
• Department of Cardiac Surgery, Institute for Cardiovascular diseases Dedinje, Belgrade, Serbia

BACKGROUND AND AIM: Aortic valve-sparing surgeries using David 1 re-implantation technique avoid the requirement of lifelong anticoagulation therapy in patients with an aortic root aneurysm. This retrospective study evaluated clinical and echocardiographic results of aortic valve-sparing procedure to repair aortic root aneurysms. We used both the department’s database and follow-up data.

METHOD: This retrospective analysis included 90 patients who had an aortic valve-sparing procedure between October 2014 and April 2021. Patients in this study had enlarged aortic roots and ascending aortas, with or without aortic regurgitation (AR). The research excluded patients with ascending aorta aneurysms and aortic stenosis, as well as those hospitalized for acute aortic dissection. During the follow-up period, patients were evaluated clinically and with an echocardiogram. The average follow-up was 25.5 months.

RESULTS: Among 90 adults undergoing aortic root replacement using David 1 procedure, the mean age was 52.4 ± 12.5 years, and most were men (82.4%). The aortic root aneurysm was associated with bicuspid aortic valve (BAV) in 30 (34.4%) patients. Concomitant procedures were performed in 17 (18.9%) patients. Median aortic cross clamp time was 112.9 ± 20.9 min. Tubular graft was used in 77 (85.6%) and Valsalva graft in 13 (14.4%) patients. Postoperatively, aortic valve insufficiency was trivial/none in 71 (78.9%) and mild in 19 (21.1%) patients. There were 3 (3.3%) in hospital deaths and 4 late deaths, after discharge. A 1 (1.1%) patient required aortic valve replacement after discharge. During the period of 2 years 82 (91.1%) patients were alive and free from aortic valve reoperation.

CONCLUSIONS: Aortic valve-sparing procedures result in excellent function of the reimplanted aortic valves, and significant left ventricle reverse remodeling following the surgery. The medium-term follow-up revealed patients’ great satisfaction with treatment results.

• Keywords: Tirone David; David 1; Aortic valve spearing procedure; Aortic root aneurysms

1.4.8. “Comparison of AVR via Conventional Full Sternotomy vs. Upper Mini-Sternotomy” Our Experience in MTI-HMC, Khyber Pakhtunkhwa, Pakistan

• Muhammad Aasim
• Department of Cardiac Surgery, Hayatabad Medical Complex, Peshawar, Pakistan

BACKGROUND AND AIM: Aortic valve replacement (AVR) for severe symptomatic aortic valve pathology is one of the common cardiac surgical procedures with excellent long-term outcomes. In this study we looked for outcomes like re-openings, requirements for blood transfusions, sterna wound infection, faster recovery, intensive care unit (ICU) stay and short term mortality until post-operative safe discharge from.

METHOD: We reviewed the medical records of all patients who underwent AVR surgery at our Department and 96 patients were identified. Outcomes between minimally invasive AVR group and AVR through full sternotomy group were compared.

RESULTS: Mini-sternotomy AVR procedure was done in 52 patients while conventional sternotomy AVR procedure was done in 44 patients. The mean age was 40 +/− 16 in the mini-AVR group compared to 45 +/− 18 conventional AVR group. No in-hospital mortality happened in mini-AVR group and it was associated with shorter ICU stay, faster recovery, less ventilation time, decreased requirement for blood transfusions and shorter hospital stay. Only one (1) in-hospital mortality happened in conventional AVR group. One (1) reopening happened and there was no sternal wound infection requiring re-admissions in mini-AVR group.

CONCLUSIONS: We conclude that AVR via upper mini-sternotomy is a superior modality than conventional sternotomy AVR in our experience.

• Keywords: AVR; Upper mini-sternotomy; Conventional sternotomy

1.4.9. The Aortic Root Pathologies and Surgical Management: Insights from a Single Center’s Experience

• Muhammad Aasim and Raheel Khan
• Department of Cardiac Surgery, Hayatabad Medical Complex, Peshawar, Pakistan

BACKGROUND AND AIM: Aortic root replacement is a complicated surgical procedure which has undergone many considerable technical improvements with time. We analyzed the results of surgical procedures for Aortic Root pathologies performed at our cardiac surgery department performed by a single consultant cardiac surgeon (Dr. M. Aasim).

METHOD: Between 2018 and 2023; Twenty seven (27) patients underwent aortic root surgery. Twenty two (22) patients were male and 5 females; their mean age was 49 +/− 20 years. Diagnosis was aortic dissection in 7 patients (Acute 2, chronic 5), aneurysm of ascending aorta in 13 patients, and Marfan syndrome in 7 patients. Nineteen (19) patients had aortic root replacement using the “modified Bental techniques”. Two (2) patients were treated using the aortic valve sparing techniques with “Dacron graft”, and 5 using aortic root enlargement. One (1) of the patients was treated using PTFE graft wrapping like the “modified personalized external aortic root support (PEARS) procedure”. Follow-up time ranges from 1 month to 5 years.

RESULTS: There was one (1) in-hospital death. One patient presented to CCU with bleeding complication within three (3) months. In remaining 25/27 patients’ good quality of life and freedom from complications is observed in follow ups.

CONCLUSIONS: The less mortality and satisfying results show that aortic root surgery is a low risk and useful treatment. Surgical procedures on the aortic root have mostly changed the quality of life in patients and extended their lifespan. These procedures will continue to grow with better graft/prosthetic material, improved valves and improvements in the surgical techniques.

• Keywords: Aortic root pathologies; Bental procedure; Aortic root augmentation; valve sparing aortic root surgery

1.4.10. Aortic Valve Neocuspidization with the Ozaki Procedure: Mid-Term Results

• Djordje Radosav Krstic, Slobodan Micovic, Milan Cirkovic, Igor Zivkovic and Petar Milacic
• Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia

BACKGROUND AND AIM: Aortic valve illnesses are the most common type of valve disease. Conventional aortic valve replacement remains the gold standard. Neocuspidization of the aortic valve using autologous pericardium is other surgical option for these individuals. The Ozaki technique produces hemodynamic values similar to a native aortic valve, therefore lifelong anticoagulant medication is not required in these individuals.

METHOD: The prospective observation research was carried out at the institution between March 2019 and March 2023. A total of 34 patients were included. We operated on patients with isolated aortic stenosis or insufficiency. A freshly made autologous pericardium was used for the neo aortic valve. Our study excluded patients with aortic valve endocarditis and those who required urgent surgery. There was no infective endocarditis among our patients. The follow-up consisted of clinical and echocardiographic (neo aortic valve function) examinations.

RESULTS: A total of 34 people were operated on using the Ozaki method. 50% of the participants were male, with an average age of 66.27 ± 5.7 SD years. Aortic stenosis was a reason for surgery in the 30 patients (88.2%) with severe aortic stenosis and 4 (11.8%) with severe aortic regurgitation. The average preoperative aortic valve gradient was 71 ± 15 SD mmHg. The cardiopulmonary bypass and cross-clamp duration were 91 and 108 min, respectively. There was no significant postoperative aortic regurgitation, and the control echo showed a mean aortic valve preasure of 11 ± 4 SD mmHg. The typical ICU and hospital stay were two and eight days, respectively. The average follow-up time is 38 months.

CONCLUSIONS: The Ozaki method is an effective alternative to surgical aortic valve therapy, particularly in individuals with a small aortic anulus. The midterm follow-up showed excellent outcomes.

• Keywords: aortic surgery; Ozaki procedure; neocuspidization; aortic valve

1.4.11. Mid-Term Results of Ozaki Procedure—Azerbaijan Experience

• Kamran Ahmadov and Kamran Musayev
• Department of Cardiovascular Surgery, Merkezi Klinika, Baku, Azerbaijan

BACKGROUND AND AIM: We aimed to report outcomes of the Ozaki procedure, reconstructing aortic valve leaflets with autologous pericardium in Azerbaijan.

METHOD: In a retrospective analysis, 40 patients underwent aortic valve reconstruction (Ozaki procedure) between August 2018 and June 2023. Divided into two groups (Group A and B), patients in Group A followed Ozaki’s technique, while Group B received an additional commissure reinforcement technique. Mean ages were 63 and 65 years for Groups A and B, respectively.

RESULTS: Patients had aortic stenosis or a combination of aortic stenosis and aortic regurgitation. Preoperative echocardiography revealed peak and mean pressure gradients of 84 ± 34.6 mmHg and 50.5 ± 23 mmHg. Cardiopulmonary bypass and aortic cross-clamp times were 142/115 min and 144/107 min for Groups A and B, respectively. No in-hospital mortalities or pacemaker implantations occurred. None presented with aortic stenosis. No significant increase in aortic gradients during follow-up was noted, and no reoperations were required. Four patients in Group A developed mild aortic regurgitation during follow-up, while in Group B, aortic regurgitation was no more than minimal. Median follow-up periods were 56 and 20 months for Groups A and B, respectively. Our study showed 100% freedom from major adverse valve-related events.

CONCLUSIONS: Since Ozaki and colleagues introduced aortic valve reconstruction with autologous pericardium, it gained popularity. Mid-term Ozaki procedure results demonstrated favorable outcomes regarding mortality, valve gradients, and freedom from adverse valve-related events. However, some studies indicated slightly elevated valve regurgitation recurrence post-Ozaki procedure. Our proposed additional commissural reinforcement technique showed reduced aortic valve regurgitation during follow-up. Long-term results will follow.

• Keywords: Ozaki prosedure; Aortic valve neocuspidization; Aortic valve disease

1.4.12. Evaluation of the Durability of the Aortic Valve Bioprosthesis Resilia Inspiris in the Centers of Paris Public Assistance: ENDURANCE Registry

• Michele D’alonzo ¹, Pierre Demondion ², Paul Achouh ³, Jean Louis De Brux ⁴, Pascal Leprince ², Thierry Folliguet ¹ and Antonio Fiore ¹

1

Department of Cardiac Surgery, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France

2

Department of Cardio-Thoracic Surgery, Hôpital Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France

3

Department of Cardiac and Vascular Surgery, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France

4

Department of Cardiac Surgery, The Scientific Committee of the EPICARD Registry, Angers University Hospital, Angers, France

BACKGROUND AND AIM: The prevailing approach in contemporary surgical management of aortic valve pathology is progressively leaning towards the adoption of biological prostheses. The novel Inspiris Resilia stands out as a promising solution for reducing the risk of structural valve deterioration. This study examines outcomes concerning hemodynamic performance and complications after its implantation.

METHOD: In this prospective, observational, multicenter registry all consecutive patients who underwent isolated or concomitant surgical aortic valve replacement were enrolled. Transthoracic echocardiography was performed preoperatively, at discharge and after one year of surgery. The primary endpoints were to report mortality and hemodynamic performance of this innovative bioprostheses.

RESULTS: A total of 1208 patients were included. The mean age was 63.2 ± 9.9 years (76.5% male). Most interventions were elective, with a median EuroSCORE II of 2.29%. Active endocarditis was the indication for 14.7% patients while concomitant procedures were done in 49.8% of cases.

Hospital mortality was 1.9% while one-year survival rate was 94.6%. Within 30 days, adverse events were limited: 30 patients (2.5%) required permanent pacemaker implantation; 33 patients (2.7%) experienced a stroke and only 3 patients (0.2%) showed significant paravalvular leak at discharge.

Mean pressure gradient decreased from 45.6 ± 18.2 mmHg preoperatively to 10.6 ± 4.5 mmHg at discharge and remained stable at 1-year echocardiographic control. The mean effective orifice area at last follow-up was 2.34 ± 0.56 cm². Severe patient-prosthesis mismatch was present in 9 patients, only one patient experienced early stage 3 structural deterioration (VARC-3).

CONCLUSIONS: Our study demonstrates encouraging results in terms of safety and efficacy, with excellent one-year survival rates and good hemodynamic performance. Long-term studies are necessary to assess valve durability and its advantages in percutaneous valve-in-valve procedures.

• Keywords: aortic valve; Inspiris; Resilia; SVD; AVR

1.4.13. Risk Factors Associated with Adverse Outcomes for Sternal Re-Entry for Surgical Aortic Valve Replacement

• Philemon Gukop ¹, Pouya Youssefi ¹, Justin Nowell ¹, Rajan Sharma ¹, Robin Kanagasabay ¹ and Marjan Jahangiri ²

1

Department of Cardiothoracic Surgery, St George’s University Hospital NHS, London, UK

2

St. George’s Hospital, University London, London, UK

BACKGROUND AND AIM: Sternal re-entry for cardiac surgery is associated with morbidity and mortality of up to 10% in some series. It is essential to identify risk factors associated with adverse outcomes of re-sternotomy for aortic valve replacement. This would guide patient selection for re-sternotomy to improve outcomes

Aim/OBJECTIVE: To identify factors associated with adverse outcomes for sternal re-entry for Aortic valve replacement (AVR)

METHOD: Retrospective data analysis on 178 consecutive patients who had sternal re-entry for AVR in a single centre between 2010 to 2018. Relevant data collected from patient’s records.

Univariate and multivariate regression analysis of significant variables that predict death was done.

Significant Results presented as 95% CI with odd ratio and p-value and Kaplan-Meier’s (KM) survival curves (

Table 1. Significant Risk Factors Predicting Adverse outcomes for sternal re-entry for AVR.

Risk Factors	Odd Ratio (95% CI)	p-Value
Previous MI	5.37 (2.23–12.90)
Previous CABG	2.45 (1.20–4.83)	0.009
Previous CABG grafts > 2	4.8 (1.03–22.60)	0.003
Extracardiac Arteriopathy	2.54 (1.10–5.83)	0.025
Endocarditis	2.85 (1.35–6.03)	0.038
Urgent Operation	2.11 (1.10–4.03)	0.023
Impaired LV requiring IABP	36.7 (4.69–287.00)	0.006
Renal Failure requiring Dialysis	12.6 (4.44–35.70)	0.001
High Risk of Bleeding	3.84 (1.10–4.84)
Neurologic event	2.31 (1.10–4.84)

).

p-value < 0.05 is significant.

CONCLUSIONS: Risk factors for Adverse outcomes for sternal re-entry for AVR include previous CABG, Active endocarditis and end organs failure requiring support.

Such patients should be pre-optimised or offered appropriate alternative treatment to improve outcomes.

• Keywords: Redo-AVR; Sternal re-entry; Adverse outcomes; Risk factors; Surgical AVR

1.4.14. Early and Mid-Term Results According to Valve Dimensions in Patients Undergoing Transcatheter Aortic Valve Implantation

• Şennur Kızılağaç, Emrah Oğuz, Hakan Posacıoğlu, Anıl Ziya Apaydın, Ümit Kahraman, Ayşen Yaprak Engin, Irem Demiray and Mustafa Özbaran
• Department of Cardiovasculer Surgery, Ege University, Izmir, Turkey

BACKGROUND AND AIM: This study aims to analyze the early and mid-term clinical results of patients diagnosed with severe aortic stenosis who underwent Transcatheter Aortic Valve Implantation (TAVI) operation using a 34-gauge valve and valves of different sizes.

METHOD: Retrospectively, a total of 152 patients who underwent TAVI surgery at Ege University Faculty of Medicine Cardiovascular Surgery Department between January 2018 and August 2023 were included in the study. In the study, patient data were obtained through file scanning and current patient records. The data obtained in the study were analyzed in the SPSS analysis program.

RESULTS: As a result of our study, it was seen that the average age of patients with 34 mm valves (Group A) was significantly younger than patients with valves smaller than 34 mm (Group B), and advanced age was found to be a risk factor in patients who developed early mortality. Operation times were similar in both groups. It was observed that patients who received 34 mm valves needed temporary and permanent pacemakers in the postoperative period. Permanent KPM implantation was evaluated as an important reason for the increase in intensive care unit stays. No significant difference was detected between the two groups in terms of PVL at the first and last postoperative follow-ups. Short and mid-term mortality occurred at levels similar to the both of this group.

CONCLUSIONS: In our study, the results obtained from both groups were similar, the complications in patients with 34 mm valves were low, intensive care and hospital stays were not long, and short and medium term mortality occurred at levels similar to the other group, indicating that the 34 mm valve can be used safely in suitable patients. This suggests that patients in the implanted group should be carefully monitored for conduction disorders due to increased KPM rates.

• Keywords: Advanced Aortic Stenosis; Transcatheter Aortic Valve İmplantation; Aortic Valve Dimensions; Early and Middle Period; Risk Factors

1.4.15. Midterm Results of Bentall Procedures

• Elvin Mamiyev ¹, Ümit Kahraman ², Ayşen Yaprak Engin ², Anıl Ziya Apaydın ², Serkan Ertugay ², Osman Nuri Tuncer ², Yüksel Atay ² and Mustafa Özbaran ²

1

Department of Cardiovascular Surgery, Liv Bona Dea Hospital, Baku, Azerbaijan

2

Department of Cardiovascular Surgery, Ege University, Izmir, Türkiye

BACKGROUND AND AIM: The aim of this study is to analyze perioperative risk factors for midterm complications and mortality after Bentall procedures.

METHOD: Between 2016–2022, 85 patients who underwent Bentall procedure and discharged were included. The data including demographics, comorbidities, preoperative echocardiographic findings, operative data, length of stay in the hospital and intensive care unit, postoperative early complication after discharge were analyzed. The patients were divided into two groups in terms of midterm complications; patients with midterm complications (group W, n = 24) and patients without midterm complications (group WO, n = 61) which were defined as graft infection, valve dysfunction, endocarditis, hemorrhage.

RESULTS: Preoperative characteristics were comparable except higher preoperative creatinine (p = 0.020), CRP levels (p = 0.008), and lower hemoglobin levels (=0.047) in Group W. Having additional procedures was significantly more common in Group W (p = 0.017 and p = 0.026). Femoral cannulation was more common compared to antegrad cannulations in Group W (p = 0.019). As early complications, cerebrovascular events with rates of 25% to 3.27% (p = 0.006) and arrythmia with the rates of 45.8% to 34.4% (p = 0.001) were observed in Group W and WO respectively. In group W, 4.7% had graft infection, 2.4% had valve dysfunction, 4.7% had endocarditis, 5.9% had tamponade, 3.5% had hemorrhage. Having a complication (p = 0.04) and each of the complications other than tamponade (CVE p = 0.025, graft infection p = 0.011, valve dysfunction p = 0.044, endocarditis p = 0.001, hemorrhage p = 0.041, arrythmia p = 0.033) were found related with midterm mortality. In ROC analyses, diameter of ascending aorta (p = 0.029), diameter of sinuses of Valsalva (p = 0.047), duration of cardiac ischemia (p = 0.027), duration of cardiopulmonary bypass (p = 0.034), femoral cannulation (p = 0.032) was found related with midterm mortality (4.7% and 1.2% respectively for groups W and WO).

CONCLUSIONS: Larger aneurysms may complicate the operations both with longer procedures and alternative cannulation sites. It should be kept in mind that femoral cannulation may bring early and late complications.

• Keywords: Bentall operation; aortic root replacement

1.4.16. Aortic Valve Replacement with Right Anterior Mini-Thoracotomy: A Less Invasive Method Even for Sutured Valves

• Ulku Kafa Kulacoglu, Taner Iyigun, Isa Can, Timucin Aksu and Mehmet Ali Dala
• Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkiye

BACKGROUND AND AIM: Minimally-invasive valve surgery is becoming more popular when compared with a standard median sternotomy as surgical trauma is decreased. The aim of our study is to present our clinical experience regarding the results of patients who underwent isolated aortic valve replacement, including sutured valves, via the right anterior mini thoracotomy technique.

METHOD: This study is a retrospective observational cohort study consisting of data from 30 patients who underwent isolated aortic valve replacement surgery using the right anterior thoracotomy method between February 2020–November 2023. All surgeries were performed using conventional surgical equipment. In 27 patients, peripheral cannulation and in 4 patients, vacuum–assisted (40–60 mmHg) central cannulation was performed. Subluxations of 2nd or 3rd ribs were performed for better surgical exposure. Delnido cardioplegia in 28 patients, and isothermic blood cardioplegia in 2 patients have been used. 22 mechanical valves, 7 biological valves and 1 sutureless valves were implanted.

RESULTS: We observed that post-operative intensive care unit staying was 1.3 days in average (1–3 days) and hospital staying was 8.6 days in average (5–15 days) with this technique. Average Cardio-pulmonary bypass (CPB) duration was 143.6 min (86–271 min) and cross-clamping duration was 93.6 min (45–162 min). No mortality has occurred in 30 days follow-up.

CONCLUSIONS: In selected patients, right anterior thoracotomy is a safe method due to its longer operative time as well as minimal surgical trauma, with good cosmetic results, and shorter hospital stay. Another advantage of this technique is; the surgery can be performed without any necessity for special surgical equipment even on sutured aortic valves.

• Keywords: minimally invasive; aortic valve replacement; Right anterior mini thoracotomy

1.4.17. Frequency of Aortic Root Enlargement to Prevent PPM in Patients Undergone Aortic Valve Replacement in Peshawar Institute of Cardiology

• Muhammad Nisar, Aamir Iqbal and Abdul Nasir
• Peshawar Institute of Cardiology, Peshawar, Pakistan

BACKGROUND AND AIM: The implantation of a prosthetic valve, that is too small due to a small aortic annulus can complicate aortic valve replacement and cause patient prosthetic mismatch. To prevent this, aortic root enlargement is effective surgical technique. Because of technical difficulty and complication, it’s not much popular among cardiac surgeons but due to large number of patients undergoing AVR with small aortic annulus, this procedure is essential for cardiac surgeons.

Aim of this study is to determine the frequency of aortic root enlargement in males and females undergoing aortic valve replacement.

METHOD: This retrospective empirical groundwork was carried out at Peshawar institute of cardiology, included (n = 76) adults, who underwent isolated AVR, AVR + ARE, AVR + CABG and AVR + MVR. Data was extracted through electronic medical record (EMR) and by using SPSS version 26.0 the data was evaluated.

RESULTS: The mean age of the patients (37.53 ± 15.589), mean BMI (24.9125 ± 5.07249), mean BSA (1.9607 ± 2.28518). Etiology showed rheumatic heart disease 48.7% to be the most prevalent one. Frequency and percentage of AVR + ARE was (9, 11.8%) respectively. Mean by-pass and cross-clamp time (mins) for other valvular surgeries and AVR + ARE (161.9254 ± 64.08737), (189.3333 ± 77.83155) (128.9701 ± 51.88857), (154.7778 ± 69.11906). Mean hospital stay (days) (6.52 ± 2.003), (5.4444 ± 1.74005) and ICU stay (days) (1.99 ± 0.945), (1.4444 ± 0.72648). The

Table 2. Gender wise distribution of AVR + ARE.

Male	3	33.3%
Female	6	66.7%

shows that females are more likely undergo for aortic root enlargement compared to males.

CONCLUSIONS: Although ARE is not a widely followed procedure due to the contradictory evidence from previous literature. However experienced surgeons follow it to relieve the patient from patient prosthesis mismatch. Due to high frequency of small aortic annulus in our population making this procedure essential to prevent PPM but in spite of that long term follow up and good sample size is needed in future to better analyze the long-term effects of aortic root enlargement procedures.

• Keywords: Aortic root enlargement; patient-prosthesis mismatch; Aortic valve stenosis; Cardiopulmonary bypass

1.4.18. Remodeling Patterns and Evolution of Transvalvular Gradients in Aortic Stenosis Patients: A Comparison Between TAVI and SAVR with Biological Prostheses

• Grigore Tinică, Andrei Țăruș, Mihail Enache, Silivu Paul Stoleriu and Alberto Emanuel Bacușcă
• Department of Cardiovascular Surgery, Cardiovascular Diseases Institute “George I.M. Georgescu”, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania

BACKGROUND AND AIM: Aortic stenosis (AS) is the most prevalent heart valve disease in the Western world and is associated with a poor prognosis after the onset of symptoms. Its prevalence is rising rapidly as a consequence of the aging population. Restoring the aortic valve function by treatment with either SAVR or TAVR aims to increase the aortic valve area, lower aortic valve gradients, reverse left ventricular hypertrophy, and reduce mortality. Our objective was to delve into the intricacies of LV mass alterations post-TAVI and SAVR, examining the factors impacting these shifts. To our knowledge, this study represents the inaugural endeavor of its kind documented in Romania.

METHOD: Conducted retrospectively, this study examined 315 patients treated from December 2014 to December 2022, dividing them into surgical and transcatheter treatment cohorts. Baseline and six-month follow-up clinical and echocardiographic data were gathered. Statistical analysis evaluated group disparities and factors predicting reduction in LV mass.

RESULTS: TAVI was associated with a faster recovery with a shorter ICU stay and a lower need of inotrope medication, but also with a higher rate of permanent pacing and a reduced LV mass regression and remodeling. The reduction in atrial volume was more pronounced in the TAVI group compared to the SAVR group. The reduction in both maximal and mean gradients and LV mass index following SAVR surpassed those observed after TAVI. Preoperative LVMi and mean pressure gradient positively correlated with LVM reduction, while TAVI negatively impacted it.

CONCLUSIONS: Both TAVI and SAVR procedures offer advantages in decreasing left ventricular mass, albeit with SAVR demonstrating superior efficacy. Identifying predictors of LV mass reduction is pivotal for enhancing treatment approaches, underscoring the importance of considering early valve replacement to prevent irreversible LV hypertrophy.

• Keywords: Remodeling Patterns; Aortic Stenosis; TAVI; SAVR

1.4.19. Perceval Sutureless Redo Aortic Valve Replacement Inside Patch-Reconstructed Aortic Roots for Infective Endocarditis: A Case Series

• Navneet Singh, Parma Nand
• Department of Cardiothoracic Surgery, Auckland City Hospital, Auckland, New Zealand

BACKGROUND: We highlight the novel use of the Perceval sutureless bioprosthesis in a new context; that is, for redo aortic valve replacement inside reconstructed neo-aortic roots following debridement of infected root abscesses.

CASE: We have used Perceval valves in this context in five cases. As an example of one of our cases, a 67-year-old obese male had a history significant for St Jude aortic valve replacement in 2015 for aortic stenosis. The patient subsequently presented in 2022 with Staphyloccus epidermidis endocarditis. Transoesophageal echocardiography revealed a large 1.8 cm vegetation on the prosthetic aortic valve leaflets. This was causing obstruction to disc motion. The vegetation was adherent to the aortomitral curtain and was associated with an aortic root abscess that extended posteriorly and into the base of the anterior mitral leaflet. The patient developed complete heart block and embolic strokes. He proceeded urgently to theatre.

A redo median sternotomy was undertaken with central cannulation for cardiopulmonary bypass. The St Jude valve was removed. A 3 × 2 cm aortic root abscess was debrided and the root and aortomitral curtain reconstructed using bovine pericardium. A large size Perceval valve was implanted in an intra-annular position in the neo-aortic root, with the guiding sutures tied down to provide further security to the valve seating. The patient had an unremarkable postoperative course.

We report the first known successful implantation of the Perceval sutureless bioprosthesis for redo aortic valve replacement inside a patch-reconstructed neo-aortic root for prosthetic valve infective endocarditis involving a large root abscess. Of note, we have used the Perceval valve in four other similar cases. This highlights the value of sutureless valves in hostile aortic roots with fragile tissues demanding minimal suturing.

• Keywords: Perceval; redo aortic valve replacement; root abscess; infective endocarditis

1.4.20. A Novel Perspective: Employing Right Vertical Infra-Axillary Mini-Thoracotomy for Interventions on Aortic Root or Ascending Aorta

• Ahmet Arif Ağlar and Ahmet Yavuz Balci
• Department of Cardiovascular Surgery, Medistate Kavacik Hospital, Istanbul, Turkiye

OBJECTIVE: The popularity of minimally invasive techniques for the ascending aorta is on the rise, commonly employing incisions such as mini-sternotomy and right anterior mini-thoracotomy. Our research presents a novel and secure method for managing ascending aorta and/or aortic root pathologies, implemented through a right infra-axillary vertical mini-thoracotomy.

METHODS: Three patients diagnosed with ascending aortic aneurysm underwent surgery, with the first procedure taking place in April 2023 and utilizing a right infra-axillary vertical mini-thoracotomy. The primary selection criteria took into account four excluding factors: a history of prior cardiac surgery, a diagnosis of endocarditis, the presence of pathology necessitating intervention in the aortic arch, and the need for coronary artey bypass grafting. The surgical interventions involved the Bentall procedure with bioprosthetic aortic valve for one patient, supracoronary ascending aortic replacement for another, and aortic valve replacement + supracoronary ascending aortic replacement for the third patient. The infra-axillary mini-thoracotomy was performed through a 8-cm vertical skin incision centering the right fourth intercostal space on the anterior axillary line.

RESULTS: The average age of the cases was 48.3 ± 11.46, and all three were male. The mean length of hospital stay is 7.6 ± 1.6 days. The average follow-up duration is 4.6 months. No morbidity or mortality was observed.

CONCLUSIONS: Utilizing a minimally invasive approach through a right vertical infra-axillary mini-thoracotomy can serve as a secure alternative to the standard procedure for interventions on the ascending aorta and aortic root, with or without aortic valve involvement. This approach is considered safe for selected patients with ascending aortic and/or complex aortic root pathologies.

• Keywords: Mini-thoracotomy; aortic root; ascending aorta

1.4.21. Simultaneous Coronary Bypass and Patent Foramen Ovale Closure with Removal of Lamble’s Excrescences on Aortic Valve

• Zeki Temìztürk, Abdussamet Asaroğlu, Burak Balcı, Mehmed Yanartaş and Nihan Kayalar
  Başakşehir Çam and Sakura City Hospital, Cardiovascular Surgery Clinic, Istanbul, Turke

OBJECTIVE: Lambl’s Excrescences are rare cardiac structures described as fine, mobile, filiform fronds that typically occur at sites of valve closure, and are believed to result from minor endothelial damage due to valve wear and tear. We aimed to discuss our treatment approach in an asymptomatic Lamble’s excresences patient who will undergo open heart surgery.

METHODS: Patient was a 73 years old female who presented with shortness of breath. She had normal sinus rhythm and her neurological examination was normal. Transosephageal echocardiography showed patent foramen ovale (PFO) and multiple fibrillar structures on all cusps of aortic valve and the most probable diagnosis was Lamble’s excresences. A coronary angiogram revealed 3 vessel coronary disease requiring coronary bypass grafting. The operation included 3 vessel CABG, PFO closure and removal of lambl’s excresences from the aortic valve.

RESULTS: As a result of the excision material sent for pathology examination, the diagnosis of Lambl’s Excrescences was confirmed. (picture 1). The patient was discharged after an uneventful postoperative period.

DISCUSSION: Currently, there is no common consensus on the treatment of Lambl’s Excrescences. The reports on coincidental detection or diagnosis in asymptomatic patients are very scarce and concomitant removal along with other cardiac surgeries is extremely rare. Although our patient was asymptomatic, due to the presence of multiple mobile structures we performed resection of Lambl’s Excrescences to confirm the diagnosis and to prevent the possible risk of postoperative embolism and cerbrovascular events.

CONCLUSION: In patients who will undergo other cardiac operations, we suggest that coincidental Lambl’s Excrescences should be removed especially if they are multiple and mobile. This adds little risk to the operation and may prevent postoperative emboli. Further studies and more cases will help to establish a better consensus on the treatment strategies.

• Keywords: Lambl’s Excrescences; Aortic valve

1.4.22. Management of a Patient with an Atheromatous Penetrating Aortic Ulcer (PAU) Rupture

• Timuçin Sabuncu, Raksana Mahmudova, Anıl Cankurt, Ismail Yolcu and Oktay Peker
• Department of Cardiovascular Surgery, Hacettepe University, Ankara, Turkey

A 74-year-old female patient who applied to the emergency room with complaints of chest pain, cough and shortness of breath; the patient’s history, revealed that, she applied to the emergency room with similar complaints 6 months ago; but there were no abnormal evidence were found in the examinations at that time.

In laboratory tests; Hb 10.3 g/dL, leukocytes: 13.2/mm³, platelets: 452,000/mm³, creatinine: 0.57 mg/dL, glucose: 191 mg/dL, procalcitonin: 0.38 ng/mL, CRP: 52.8 mg/L, Troponin-I: 20 ng/mL, BNP: 35.4 pg/mL. COVID Ag test (−), arterial blood gas sampling pH: 7.39, lactate: 3.9 mmol/L.

Echocardiography revealed a fibrinous pericardial effusion with a thickness of 16 mm in the infracardium, 19 mm in the lateral wall, and 19 mm in the vicinity of the apex. Moderate mitral regurgitation and moderate-severe tricuspid regurgitation were observed. Pulmonary artery pressure was measured as 45 mmHg.

The cardiovascular surgery department was consulted after triple rule out CTA showed excess contrast filling, compatible with intramural hematoma and 2 ulcerated plaques in the ascending aorta with accompanying hemopericardium.

The patient was taken to surgery. CPB initiated with femoral artery and vein cannulation. Sternotomy was performed. Pericardium was opened. Hemorrhagic pericardial fluid was aspirated. It was observed that the heart and aorta were covered with hematoma. The hematoma was drained. The penetrating ulcerative segment in the ascending aorta was resected from the sinutubular junction to the beginning of the arch, and the ascending aorta was replaced with a 28 mm diameter tubular dacron graft.

In the postoperative period, diabetes insipidus and polyuria clinic were observed. Patient consulted with the department of endocrinology and recommended follow-up with fluid replacement. The patient, who had no other problems in the postoperative period, was discharged with full recovery on the 8th postoperative day. The patient, who was examined on the 45th postoperative day, is being followed without any problems.

• Keywords: penetrating aortic ulcer; hemopericardium; ascending aorta

1.4.23. Clinical Case of Interrupted Aortic Arch and Critical Aortic Stenosis in Adult

• Kirill V. Mershin ¹, Nikita P. Myakin ¹, Yuliya V. Cherkashina ¹, Gamid M. Kurbanov ¹, Vilnur V. Gazizov ¹, Elina E. Vlasova ¹, Evgenii A. Tabakian ¹, Grigorii A. Shiryaev ², Maksim A. Khabarov ¹, Dmitrii V. Petrovskii ¹, Renat S. Akchurin ¹ and Andrey A. Shiryaev ¹

1

Cardiovascular Surgery Department, FSBI NMRCC Named After Academician E.I. Chazov of the MH of the RF, Moscow, Russia

2

Tomography Department, FSBI NMRCC Named After Academician E.I. Chazov of the MH of the RF, Moscow, Russia

BACKGROUND: Interrupted aortic arch (IAA) is a rare congenital anomaly of aorta with limited number of case reported. Loss of communication between the arch and descending aorta is often associated with other congenital heart defects such as bicuspid aortic valve (AV). Our report demonstrates the surgical approach and hospital postoperative result in patient with critical aortic stenosis and previously unknown IAA.

METHODS: A 58-year-old female was admitted in cardiovascular department for AV replacement in FSBI NMRCC named fater academitian E.I. Chazov in November 2023. She had no known growth and development abnormalities. She had the history of arterial hypertension since youth, two pregnancies followed by non-complicated childbirths and two healthy children. Dyspnea has appeared in 2022 and has worsened in May 2023; at the same time angina pectoris and the lower extremities swealing were noted. Transthoracic echo has revealed critical aortic stenosis and AV replacement was recommended. The additional examination has detected unsuspected IAA. The patient showed no lower extremity ischemia, no serious chronic kidney disease, and it was concluded that there was sufficient collateral blood flow to the lower part of the body. The cardiac team analyzed the examination data including the difference between the upper and lower extremities arterial pressures at rest and during exercise. Based on this, a decision was made to perform isolated aortic stenosis correction by mechanical valve replacement with additional lower body perfusin through femoral canula. In the postoperative period a 3rd degree AV block developed and a permanent pacemaker was implanted. Patient was mobilized in standard terms and was discharged on 12th day.

CONCLUSIONS: Based on this case of patients with IAA and critical aortic valve stenosis, isolated surgical aortic valve replacement with additional lower body perfusion can be chosen.

• Keywords: Aotrtic valve stenosis; interrupted aortic arch; bicuspid aortic valve; aortic coarctation; aortic valve replacement

1.4.24. Recurrent Cardiac Papillary Fibroelastoma with Multiple Organ Embolism—Is It Really Benign?: A Case Report

• Osman Fehmi Beyazal ¹, Özer Kandemir ², Ismail Sapmaz ² and Yaman Zorlutuna ²

1

Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey

2

Bayındır Söğütözü Hospital, Ankara, Turkey

A 50-year-old female patient was admitted to an external center with the complaint of pain in her leg and embolectomy was performed. She was referred to us after a 12 × 12 mm mass was detected at the level of the aortic valve. There was no abnormality in her examination. Due to sudden onset of pain, femoral embolectomy was performed. She was then operated, and a fragile, lobulated mass extending over the aortic valve noncoronary leaflet was removed. No dysfunction was observed in the aortic valve. Fibrous material was detected in the pathology report. After the femoral embolectomy, the material sent to pathology was also found to be fibrinous material. The patient did not develop any complications, and was discharged.

Two years later, a solid mass of 10 × 9 mm was detected in the left leaflet of the aortic valve of the patient who developed dyspnea. Ejection fraction: 40%, moderate aortic regurgitation, and a maximum gradient of 27 mmHg in the aortic valve were detected. On computed tomography of the abdomen, there was an ischemic lesion area of embolism and infarct areas in the right kidney. There were ischemic areas in the upper pole posterior and lower pole of the left kidney. An infarct area due to embolism was detected in the posterosuperior part of the spleen.

It was decided to re-operate the patient. There was a 1 × 1 × 0.5 cm rough, hard mass on the right aortic leaflet with a broad base, extending between the right and left leaflets, and restricting the movement of both leaflets. The mass was excised together with the dysfunctional aortic valve. The aortic root was enlarged with the Nick technique using and a 23 St. Jude mechanical valve was implanted. In the pathology report, it was observed that fibrous connective tissue was formed in the blood-fibrin association. She was extubated on time and discharged.

• Keywords: Cardiac papillary fibroelastoma; heart tumor; embolism

1.4.25. Floating Thrombus on the Junction Between Ascending Aorta and Aortic Arch: To Operate or Not to Operate?

• Estelle Démoulin ¹, Tomasz Nalecz ¹, Raoul Schorer ², Ariane Lepot ², Bernhard Walder ², Christoph Huber ¹ and Mustafa Cikirikcioglu ¹

1

Division of Cardiovascular Surgery, Department of Surgery, University Hospitals and Faculty of Medicine, Geneva, Switzerland

2

Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pharmacology, University Hospitals and Faculty of Medicine, Geneva, Switzerland

BACKGROUND AND AIM: Floating aortic thrombi represent a rare yet potentially life-threatening pathology. Current literature delineates varied treatment modalities (surgical resection vs. anticoagulation or fibrinolytic therapy) contingent upon patient operability and overall condition. We present our approach to preoperative preparation, timing, and surgical technique in a patient harboring a floating aortic thrombus located at the junction of the ascending aorta and aortic arch.

Patient and METHODS: A 59 year-old male presented with abdominal pain and vomiting to our emergency department. Abdominal imaging revealed mesenteric ischemia and intestinal necrosis, necessitating emergency laparotomy with resection of a long segment of the jejunum. Subsequent detailed postoperative evaluation in the intermediate care unit raised suspicion of acute neurologic syndrome, prompting cranial and full-body CT imaging to ascertain the source of recent cerebral and mesenteric embolization. Imaging revealed a floating aortic thrombus at the junction of the ascending aorta and aortic arch. A multidisciplinary discussion ensued to determine optimal treatment to forestall further morbid and lethal embolization. Emergency MRI excluded hemorrhagic transformation and perioperative bleeding risk, allowing cardiac surgery. Surgical intervention comprised median sternotomy, deep circulatory arrest with anterograde cerebral perfusion, aortotomy without cross-clamping, resection of the floating thrombus and atheromatous ascending aorta, minor curve of the aortic arch, and hemiarch replacement with a Dacron graft. Seventy hours after admission the patient left the intensive care unit with an excellent recovery. Postoperative investigations confirmed hepatocellular carcinoma, elucidating the patient’s heightened propensity for clot formation.

CONCLUSIONS: This case underscores life-threatening danger of floating thrombi in the ascending aorta. Timely diagnosis and surgical intervention are imperative to avoid embolic sequelae and disability. Early multidisciplinary collaboration and vigilant perioperative monitored care are paramount in effectively managing these complex cases. An international register for these rare cases is warranted to refine diagnostic and therapeutic approaches including patient-relevant outcomes.

• Keywords: thrombus; aorta; surgery; cardiac; thrombi; replacement

1.4.26. Performing Bentall Operation via Left Thoracotomy: An Unusual Case

• Seçil Öztürk Küçüker, Irem Iris Kan, Atıf Yolgösteren and Mustafa Tok
• Department of Cardiovascular Surgery, Bursa Uludag University, Bursa, Turkey

A 46-year-old female patient with a known history of hypertension and diabetes mellitus was admitted to our hospital for pain in her left arm. She had pectus excavatum in physical examination, and her peripheral pulses were palpable. In upper extremity CT angiography, a bilateral subclavian artery aneurysm was detected. Coil embolization was applied to the right subclavian artery, and a stent was placed in the left subclavian artery. Thoracal, abdominal, and pelvic CT angiographies were done to exclude any other accompanying aneurysms. A sinus valsalva aneurysm with a diameter of 59 mm was detected.

Since the patient had pectus excavatum deformity and the heart was located more to the left than usual, performing a Bentall procedure by a left thoracotomy was considered in the surgical approach of this patient. The operation was performed by cannulating the left femoral artery and vein.

The patient was extubated on the postoperative second day and was discharged from the intensive care unit on the postoperative fifth day. On the ninth postoperative day, the patient had the symptoms of cardiac tamponade and was re-operated. Early extubation was performed after re-operation. Eight hours after the second operation, the cardiac tamponade recurred, requiring a third operation. Again, early extubation was performed, and the patient was discharged after being hospitalized for two days in the intensive care unit and 11 days in the ward.

In the literature, the Bentall surgeries performed by thoracotomy are scarcely found, and almost all of these cases were performed using a right-sided approach. As a general notion of medicine, we should treat the patient, not the disease. The approach to the patient may differ according to other co-existent medical conditions. Considering the patient’s anatomical features, a left thoracotomy was more suitable in our case.

• Keywords: bentall; aorta, aneurysm, sinus valsalva; aortic root

1.5. CARDIAC » Atrioventricular Valve (Mitral/Tricuspid) Surgery

1.5.1. Early and Mid Term Results of Repair of Mitral Valve by Transapical Neochorda Implantation on Beating Heart

• Furkan Burak Akyol ¹, Emre Kubat ¹, Gökhan Erol ¹, Murat Kadan ¹, Kubilay Karabacak ¹, Tayfun Özdem ¹, Tuna Demirkıran ¹ and Cengiz Bolcal ²

1

Department of Cardiovascular Surgery, Gülhane School of Medicine, Health Sciences University, Ankara, Turkey

2

Department of Cardiovascular Surgery, Memorial Hospital, Ankara, Turkey

BACKGROUND AND AIM: Transapical beating heart neochord implantation is one of the latest techniques. Gulhane Training and Research Hospital has been applied this technique to 31 patients and has the largest case series in the country. There are approximately 1000 cases around the world, therefore investigating the results of this technique are limited. In this study, we aimed to analyse the epidemiological, biochemical and radiological results of the patients who underwent this surgery retrospectively and assess the morbidity and the mortality rates of the patients.

METHOD: In our study, 31 patients who underwent transapical beating heart neochord implantation were included. Demographic data, comorbidities, stages of heart failure, preoperative echocardiographic measurements, preoperative risk assessment, operative characteristics, postoperative outcome, postoperative follow-up data of the 31 patients who underwent neochord implantation with NeoChord DS1000 device were extracted and analysed retrospectively.

RESULTS: 87.1% of the patients were male. Mean age was 57.1 ± 14 and mean BMI was 25.7 ± 3.6. The most frequent comorbidities were HT (35.5%), DM (16.1%), AF (16.1%) and CHF (13%). Mean operative time was 122.2 (±14.3) min and the number of implanted chordae were betven 2 and 7. Almost all patients (96.8%) were discharged with grade 1 or less MR. 17% of the patients had mean or higher MR on the first postoperative year. One of these patients had 3rd grade MR due to implanted posterior chordae rupture and was operated. 38% of the remaining 29 patients had mean of higher MR on longer follow up examinations.

CONCLUSIONS: This study in which we analysed the results of the patients who underwent mitral valve repair using NeoChord technique shows that we have success, morbidity and mortality rates similar to the existing literature. These results of our first experience with this technique which was showed to have acceptable morbidity and mortality rates even in learning process, were assuring and similar to the literature. However, longer follow up data and larger studies are needed.

• Keywords: Mitral valve repair; neochordae; NeoChord; transapical beating heart neochord implantation; off-pump

1.5.2. Clinical Outcomes of Patients Presented with Mitral Valve Endocarditis Undergoing Surgery: A Long-Term Single Centre Study

• Ali Haddad ¹, Alexandros Merkourios Dimitriou ², Gina El Gabry ², Aydin Demircioglu ³, Lena Van Brakel ², Ilir Balaj ², Matthias Thielmann ², Markus Kamler ², Thorsten Brenner ¹, Payam Akhyari ² and Sharaf Eldin Shehada ²

1

Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany

2

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre, University Hospital Essen, University Duisburg-Essen, Essen, Germany

3

Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany

BACKGROUND AND AIM: Management of patients presenting with mitral valve endocarditis (MVE) is complicated and associated with high morbidity and mortality. We evaluate patients with MVE who underwent surgery in our department and analyze factors that predicted early and late mortality.

METHOD: A retrospective cohort evaluating 171 consecutive patients presented with MVE undergoing cardiac surgery in our department between 01/2010–12/2020. Endpoints are early and long-term survival outcomes. Multivariate analysis was used to define predictors of mortality.

RESULTS: Mean age was 61.4 ± 13.2 y; male (61.4%). One third of patients presented with previous cerebrovascular event (35.7%), 20% had previous cardiac surgery, 51.9% had renal failure and 25.4% had sepsis. Mean logistic EuroScore was 24.9 ± 20.6% and Mean STS-PROMM was 24.9 ± 20.6%. Majority of patients (59.6%) underwent urgent/emergent surgery and half of them (50.9%) required concomitant procedure. Postoperative results showed low cardiac output syndrome (LCOS) in 19.6%, cardiopulmonary resuscitation (CPR) in 5.4%, need for dialysis in 19%, sepsis in 13.6%, revision for bleeding in 12.5% and 30-day mortality in 18.7%. Late outcomes reported one-year and overall mortality in 21.1% and 35.7% of patients respectively. Multivariate analysis reported preoperative renal failure (odds ratio (OR), 1.16; 95% confidence interval (CI), 1.061 to 1.269; p = 0.001), non-elective surgery (OR, 1.162; 95% CI, 1.037 to 1.302; p = 0.009), postoperative LCOS (OR, 1.265; 95% CI, 1.146 to 1.398; p < 0.001), revision for bleeding (OR, 1.151; 95% CI, 1.043 to 1.27; p = 0.005), sepsis (OR, 1.27; 95% CI, 1.157 to 1.394; p < 0.001), dialysis (OR, 1.121; 95% CI, 1.005 to 1.25; p = 0.041) as strong predictors of early-mortality.

CONCLUSIONS: Outcomes of patients with MVE undergoing cardiac surgery report high mortality as expected by risk scores. The risk increases significantly in patients presented with preoperative renal failure undergoing non-elective surgery, concomitant procedure and those who required revision for bleeding, developed postoperative renal failure, LCOS or sepsis.

• Keywords: Mitral valve endocarditis; Sepsis; High risk cardiac surgery

1.5.3. Tricuspid Valve Replacement: Not a Metallic Touch

• Mehmet Cahit Sarıcaoğlu ¹, Yusuf Çorbacıoğlu ^1,2, Nur Dikmen ¹, Ali Ihsan Hasde ¹, Mustafa Bahadır Inan ¹ and Ahmet Ruchan Akar ¹

1

Department of Cardiovascular Surgery, Ankara University, Ankara, Turkey

2

Department of Cardiovascular Surgery, Gaziantep City Hospital, Gaziantep, Turkey

BACKGROUND AND AIM: The debate concerning the optimal type and patients of tricuspid position continues. We analyzed the short and long-term results of biological prostheses in patients who underwent isolated or combined tricuspid valve replacement, at our cardiac surgical centre in capital of Turkey.

METHOD: From September 2009 to May 2022, 74 patients underwent tricuspid valve replacement. Patients were divided into an isolated group or a combined group according to whether their surgery was combined with a left heart valve or aortic surgery. Mechanical tricuspid valve replacement was excluded and 33 patients underwent bioprosthetic tricuspid valve replacement (isolated group: 21 vs. combined group: 12). We reviewed preoperative characteristics and analysed operative data, outcomes and mortality in combined or ITVR groups.

RESULTS: Thirty-three patients underwent ITVR, mean age 54.1 ± 15.9 years, 55% female and mean BMI 26.22 kg/m². Mean logistic EuroSCORE-STS score was 10.1–9.4 for combined group and 6.4–4.5% for isolated group. Etiologies were functional insufficiency (45%), endocarditis (36%), degenerative (3%), rheumatic (3%) and congenital (3%). Postoperative complications were: need for transfusional support (45.6%), inotropic support longer than 48 h (38.2%), prolonged invasive ventilation over 24 h (35.3%), new onset of atrial fibrillation (12.1%), duplication or postoperative creatinine over 2 mg/dL (5.9%), dialysis (9.1%), stroke (3%), intra-aortic balloon pump (6%), permanent pacemaker implantation (3%) and sepsis (3%). Post operative short-term mortality in the combined group was higher (n = 9, 4%) than that in the isolated group (n = 4, 3%).

CONCLUSIONS: Every decision regarding tricuspid valve prostheses should be individualized, but according to recent research, in isolated tricuspid valve surgery, biological prostheses replacement may be an optimal choice for patients.

• Keywords: hearth valve surgery; isolated tricuspid valve surgery; combined valve surgery; metallic or bioprosthetic valve choice

1.5.4. Novel Paired-Ring Sizer Accurately Predicts Changes in Leaflet Coaptation Length: Validation in Cadaveric Swine Heart Model

• Nikola Dobrilovic
  NorthShore University Hospital System, Chicago, IL, USA

BACKGROUND AND AIM: A novel “paired-ring” mitral annuloplasty ring sizing device/technique was introduced at AATS Mitral Conclave 2023 as proof-of-concept and is now approved for first-in-human trial at our institution. This technique has the potential to dramatically improve ring selection during valve repair procedures by allowing the surgeon to predict/preview coaptation length (CL) prior to ring implantation. The sizer can be designed to function in conjunction with any commercially available annuloplasty ring/band (across all sizes). The presented prototype corresponds specifically with the Physio-2 ring.

METHOD: Cadaveric swine hearts (n = 8) were used to validate ring sizing method/device performance. For each procedure, an ink mark was placed on the anterior mitral leaflet as an initial reference point. Saline pressure test was used to distend the left ventricle. Distance from the ink mark to the exact point of anterior leaflet coaptation was measured to establish a baseline point of reference. Paired-ring sizer was used to produce a moderate downsizing of the annulus. The left ventricle was distended with saline. Distance from the reference ink mark to the (new) point of anterior leaflet coaptation was measured under the temporary influence of the sizer. The difference between the two measurements represents the potential increase in CL as predicted by the sizer. The sizer was removed and a corresponding (size) Physio-2 ring implanted in standard fashion. “Predicted” and “actual” CLs were compared.

RESULTS: A moderate increase in CL was achieved (2.0–5.5 mm) in seven hearts, and no change in one heart (because it was too small). Initial “predicted” CLs corresponded well (≤0.5 mm difference) with final “actual” CLs in all 8 hearts.

CONCLUSIONS: Functionality of a novel paired-ring mitral sizing device and method were validated using a cadaveric swine heart model. CL changes predicted by the sizer corresponded accurately with CL produced by its corresponding commercially available annuloplasty ring implant.

• Keywords: mitral; ring; sizer; paired ring; predict; coaptation length

1.5.5. Short-Term Outcomes of a Novel Technique: Ozaki Procedure with Right Vertical Infra-Axillary Mini-Thoracotomy

• Ahmet Arif Ağlar and Ahmet Yavuz Balci
• Department of Cardiovascular Surgery, Medistate Kavacik Hospital, Istanbul, Turkiye

BACKGROUND AND AIM: The Ozaki procedure, known for its notable mid-term outcomes in aortic valve reconstruction, traditionally necessitates conventional sternotomy. While there are limited reports on the viability of mini-sternotomy for the Ozaki procedure, there is a lack of studies on the mini-thoracotomy approach. This study aims to disclose the short-term outcomes associated with the Ozaki technique when applied with the right vertical infra-axillary mini-thoracotomy approach.

METHOD: We conducted a retrospective analysis on eight consecutive patients (5 males and 3 females) who underwent the Ozaki procedure using right vertical infra-axillary mini-thoracotomy between October 2020 and August 2023. Surgical indications for aortic valve intervention included severe aortic stenosis in seven patients and severe aortic regurgitation in one patient. Furthermore, one patient underwent an additional procedure, specifically tricuspid DeVega annuloplasty.

RESULTS: The Ozaki procedure with mini-thoracotomy was successfully performed in all patients. The mean age was 68.6 ± 10.9 years. The overall duration of follow-up was 18 ± 10.5 months. Postoperative echocardiographic assessment showed a mean peak pressure gradient of 18 ± 8.9 mmHg at discharge, and 12.6 ± 5.4 mmHg at last follow-ups. In follow-ups, aortic regurgitation was not observed in 5 patients, while it was mildly observed in 3 patients. There was no mortality and morbidity. In one case, endocarditis manifested in the neo-aortic valve four months after the operation, necessitating the aortic valve replacement (AVR) with mechanical prosthesis.

CONCLUSIONS: The Ozaki procedure utilizing right vertical infra-axillary mini-thoracotomy demonstrated favorable feasibility, hemodynamic performance, and safety in the short-term. Extended follow-up is required to assess its midterm to long-term outcomes.

• Keywords: Ozaki procedure; mini-thoracotomy

1.5.6. Does Modified del Nido Cardioplegia Enhance Minimally Invasive Atrio-Ventricular (A-V) Valve Surgery?

• Len En Yean ¹, Muhammad Ibrahim Bin Azmi ¹, Lim Qun Ya ² and Shahrul Amry Bin Hashim ³

1

Cardiothoracic Unit, Department of Surgery, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia

2

Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia

3

Cardiothoracic Unit, Kpj Damansara Specialist Hospital 2, Kuala Lumpur, Malaysia

BACKGROUND AND AIM: We investigate the efficacy of modified del Nido solution (DNS) with intermittent blood cardioplegia (IBC) in patients who underwent minimally invasive A-V valve surgeries.

METHOD: A two-year single-centre, single-surgeon retrospective cohort study was conducted. We excluded aortic and pulmonary valve surgeries as well as cases requiring sternotomy, Maze procedure and Left Atrial Appendage (LAA) ligation. The controls were similar cases using IBC. The modified DNS was made using our formulation. Primary outcomes were operating time and number of extra repair procedures. Secondary outcomes were severity assessed by post-operative follow-up echocardiograms.

RESULTS: Between January 2022 and December 2023, 38 adult patients who underwent MIS A-V valve surgeries were included. DNS was used for 14 patients while IBC was used for 24 patients. There were 18 cases of mitral valve repair, 9 cases of mitral valve replacement, 9 cases of mitral valve replacement and tricuspid annuloplasty, and 2 others. In general, the DNS group demonstrated shorter cardiopulmonary bypass time (177.07 ± 35.40 vs. 193.58 ± 43.72 min) and shorter aortic cross-clamp time (117.38 ± 26.71 vs. 130.66 ± 41.81 min). Despite a shorter operating time, the DNS group had slightly more additional procedures with the mitral repair technique. During one-month follow-up echocardiogram, only one patient in DNS group showed increase in severity compared to three in the IBC group.

CONCLUSIONS: Modified DNC is a safe and effective alternative to IBC for MIS A-V valve surgeries. It provides minimal interruption to the surgeons during the surgeries.

• Keywords: Minimally Invasive Surgery; Atrio-Ventricular (A-V) Valve Surgery; Cardioplegia; Del Nido

1.5.7. Time to Change Traditional Way of Warfarin Management in Developing World? 1 Year Follow-Up of Patients Undergone Mechanical Valve Replacement in Newly Established Cardiac Center

• Muhammad Tariq and Aamir Iqbal
• Cardiac Surgery Department, Peshawar Institute of Cardiology, Peshawar, Pakistan

BACKGROUND AND AIM: Due to the higher prevalence of rheumatic heart disease in underdeveloped nations, mechanical heart valves remain the preferred choice for younger patients, exposing them to an increased risk of thromboembolism and bleeding complications. The main aim of the study was to investigate the complications and mortality rates linked to mechanical heart valve replacement in patients within a developing country at 1 year.

METHOD: This retrospective observational study was conducted on the patients presented AVR, MVR and DVR at the Cardiac Surgery Department of Peshawar Institute of Cardiology (PIC). The data of 258 patients was collected between a period of two years i.e., from Jan 2021 till Dec 2022 (

Table 3. Post-operative one year mortality causes and type of surgical procedure.

Mortality Causes	Total Mortality, n (%)	AVR	DVR	MVR	Warfarin Related Complications n (%)
Bleeding	7 (2.71)	3	1	3	14 (51.86)
Stuck valve	2 (0.77)	0	1	1
Hemorrhagic stroke	5 (1.93)	1	2	2
Pseudoaneurysm	2 (0.77)	1	0	1
Unknown reason	11 (4.26)	4	3	4

).

RESULTS: Out of 258 patients, 39 (15%) were readmitted for issues including pericardial effusion, pleural effusion, bleeding, endocarditis, hemorrhagic stroke, stuck valve. The in-hospital mortality rate was 2.7%, and the 1-year mortality rate was 10.3%, with 14 cases (51.86%) attributed to warfarin-related complications. The number of INR tests conducted after discharge within one year was 8.34 ± 8.268. Additionally, the number of consultations for INR management in one year was reported as 2.53 ± 3.715.

CONCLUSIONS: According to our findings, warfarin-related complications significantly contribute to mortality and morbidity among patients with mechanical valves in developing countries. Given this, it’s imperative for new cardiac centers in these regions to adopt more innovative strategies like establishing warfarin clinic, self-testing device, remote cardiac centers to decrease complications.

• Keywords: Warfarin; AVR; MVR; INR

1.5.8. Management and Midterm Results of Acute Type A Aortic Dissection

• Seymur Musayev ¹, Emin Gurbanov ¹, Kamran Musayev ² and Rashad Mahmudov ³

1

Department of Cardiovascular Surgery, EGE Hospital, Baku, Azerbaijan

2

Department of Cardiovascular Surgery, Central Clinic Hospital, Baku, Azerbaijan

3

Department of Cardiovascular Surgery, Central Customs Hospital, Baku, Azerbaijan

BACKGROUND AND AIM: The best surgical management of acute type A aortic dissection remains controversial. The purpose of this study was to clarify our experience with management of acute type A aortic dissection and report our midterm results.

METHOD: Between October 2016 and March 2022, 48 patients patients with acute type A aortic dissection underwent emergency surgery in our center. Following the prompt diagnosis with computer tomography and echocardiography, emergency surgical central repair with predominantly axillary cannulation (87.5%) was performed. The mean follow-up was 4.3 +/− 1.8 years.

RESULTS: Mean age was 45 +/− 17 years, 89.6% were men. On admission, 20.8% (n = 10) of patients had cardiac tamponade. The incidence of cardiogenic shock were presented in 37.5% (n = 18) of patients. 6% of patients had bicuspid aortic valve, 27% had Marfan syndrome. Performed concomitant procedures included: 5% (n = 10) coronary artery bypass grafting, 1% (n = 10) repair of coarctation of aorta, 1% (n = 10) repair of atrial septum defect. Aortic valve were preserved in 54.2% (n = 10) of patients. 41 patients had an ascending aorta and 4 patients had partial arch replacement. Total circulatory arrest was used in 45 patients (93.8%), with mean time 4.4 +/− 3.8 min. There were 5 (10.4%) in-hospital deaths. Neurological complications presented in 29.2% (n = 14), with postoperative stroke in 10.4% (n = 5) of patients. Preoperative cardiogenic shock and renal failure are the independent risk factors for poor outcome (p < 0.001). Discharged patients had overall survival of 71.4% at 5 years.

CONCLUSIONS: Prompt diagnosis, following by emergent central repair with preferably axillary cannulation provides satisfactory results for patients with acute type A aortic dissection. Mid-term prognosis after surviving the operation is good.

• Keywords: type A aortic dissection; axillary cannulation; surgical management

1.5.9. Endoscopic Minimally Invasive Approach Versus Median Sternotomy for Multiple Valve Surgery: A Propensity-Matched Analysis

• Saad Salamate ¹, Farhad Bakhtiary ¹, Ali Bayram ², Miriam Silaschi ¹, Ömür Akhavuz ¹, Mirko Doss ², Sami Sirat ² and Ali El Sayed Ahmad ¹

1

Departement of Cardiac Surgery, University Hospital Bonn, Bonn, Germany

2

Department of Cardiac Surgery, Helios Hospital Siegburg, Siegburg, Germany

BACKGROUND AND AIM: Endoscopic minimally invasive valve surgery is a promising alternative to valve surgery through median sternotomy. Our study aims at comparing the short-term outcomes of patients undergoing endoscopic minimally invasive multiple concomi-tant valve surgeries (MIMVS) with median sternotomy (MS).

METHOD: Demographic, clinical, and procedural data of all consecutive patients who under-went multiple valve surgeries at two institutions in Germany from March of 2017 to March of 2023 were retrospectively collected. Patients were divided into two groups: MIMVS versus MS and their out-comes were compared before and after propensity score matching. Primary endpoint was the incidence of 30-day mortality.

RESULTS: 317 patients were included in the study, 112 patients in each group were matched 1:1. MIMVS was performed on 123 patients. Within the unmatched patients, 30-day mortality rates were 7.3% for MIMVS versus 14.4% for MS (p = 0.055), 8% vs. 12.5% after matching (p = 0.28). Median blood transfusion in the MIMVS group was 0 [0–3] vs. 1 [0–4] in the MS group both before (p = 0.014) and after (p = 0.002) matching. MIMVS was associated with similar cardiopulmonary bypass time 105.5 [79.8–124] versus 98 [68.8–130.3] min and aortic cross clamping times 70 [53–80.3] versus 63.5 [46–90.3] min (p-values 0.9 and 0.76 respectively). Median hospital and intensive care stays were similar between both groups (2 [1–4] vs. 2 [1–5] days, p = 0.36, and 12 [8–17] vs. 12.5 [9–21] days, p = 0.38).

CONCLUSIONS: In our experience, endoscopic minimally invasive multiple valve surgeries through right anterior mini-thoracotomy is as feasible, safe, and effective as medial ster-notomy in select patients.

• Keywords: median sternotomy; endoscopic minimally invasive valve surgery; multiple valve surgery; right anterior mini-thoracotomy; propensity score matching

1.5.10. Surgical Valve Thrombectomy in Mechanical Valve Thrombosis: A Series About 21 Cases

• Sami Bouchenafa, Ahmed Zaki Boukli Hacene, Boukri Hamouda, Redha Djilali Sayah, Tarek Hamdi, Mohammed Ould Abderrahmane, Makhlouf Amir, Abdelkader Boukhors, Mohammed Bensaber, Nour El Houda Draou, Linda Zebirate and Mohammed Atbi
  Departement of Cardiac Surgery, EHU Hospital, Oran, Algeria

BACKGROUND AND AIM: Mechanical valve thrombosis (MVT) is a severe complication of heart valve replacement. In this study we presented our surgical experience of valve thrombectomy for thrombosed mechanical valves

METHOD: Between October 2010 to January 2022, 59 patients were operated for mechanical valve thrombosis. Only patients who underwent surgical valve thrombectomy were studied. Preoperative, operative and postoperative data were collected and analyzed.

RESULTS: Among these 59 patients with mechanical valve thrombosis, 21 (34.4%) patients had surgical valve thrombectomy. In this study 18 patients (85.7%) were women. The mean age was 36.3 ± 11.7 years. The site of thrombosis was the mitral valve in all patients. The most common clinical sign was dyspnea III-IV 19 patients (90.5%). The interval between the first replacement and thrombosis was 37.6 ± 18.4 months. INR < 2 in 17 patients (81%). The mean CPB and cross-clamp time were 57.6 ± 29.8 and 33.1 ± 18.4 min respectively. The mean of mechanical ventilation was 6.5 ± 1.3 h. Mean ICU stay of patients was 1.5 ± 0.5 day and mean hospital stay of patients was 12.1 ± 3.4 days. Early mortality (30 days) was 01 death (4.8%).

CONCLUSIONS: Valve thrombosis is a serious complication. Early diagnosis and urgent surgery give good results. Surgical valve thrombectomy with re-establishment of valve motion is an effective alternative when the thrombus is fresh and early. Effective anticoagulation is the best means of prevention

• Keywords: mechanical valve; thrombosis; surgical thrombectomy

1.5.11. The Effect of Preoperative Milrinone Infusion in Mitral Valve Surgery

• Wajiha Arshad, Musfireh Siddiqeh, Muhammad Azam, Alifa Sabir and Sahab Ahmad
  Department of Cardiac Surgery, Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan

BACKGROUND AND AIM: Milrinone is a type III phosphodiesterase inhibitor that increases intracellular concentration of cyclic adenosine monophosphate (cAMP) in the vascular smooth muscle cell and cardiomyocyte. The effects of intravenous milrinone include pulmonary vasodilatation, systemic vasodilatation and produce positive inotropic effects by slowing the hydrolysis of cyclic adenosine monophosphate in the myocardium.

The aim of this study is to determine the effects of IV milrinone infusion in the terms of post operative arrhythmias, right heart failure and duration of ICU stay.

METHOD: This is a single centre retrospective observational study of the 61 consecutive patients operated for Mitral valve surgery either due to mitral regurgitation or mitral stenosis at Rawalpindi Institute of Cardiology from 2022–2023. IV milrinone infusion was started at least 12 h before the surgery and its effects were observed post operatively.

RESULTS: A total of consecutive 61 patients were added in this study, among them 29 (47.54%) were females and 32 (52.45%) were male. 35 patients (57.377%) underwent isolated Mitral Valve surgery and remaining 26 (42.622%) underwent combined procedure including mitral valve surgery and other cardiac procedure. Mean age of the patient was 39.18. Total of 08 patients (13.11%) experienced arrhythmias. Mean hours of ICU stay were 88.114. Only 01 patient (1.63%) died of right heart failure.

CONCLUSIONS: Milrinone provides adequate cardiac performance, causing a greater reduction in post operative arrhythmias, inotropic support, and right heart failure.

• Keywords: Milrinone; Mitral Valve Surgery; Arrhythmias; Right Heart Failure

1.5.12. Thromboaspiration of a Left-Sided Bioprosthesis Valve Thrombosis by a Mini-Invasive Access: The Lausanne Novel Procedure—A Safer Pioneering Procedure to Alleviate the Risks of Redo Surgery, Thrombolysis and AngioVac-System

• Ziyad Gunga, Eric Eeckhout and Matthias Kirsch
• Cardiac Surgery Department, Lausanne University Hospital (CHUV), Switzerland

INTRODUCTION: Left-sided bioprosthetic valve thrombosis is considered a relatively rare but life-threatening clinical entity. Is conventional redo on-pump surgery the only way to remove a thrombus resistant to well-conducted anticoagulant? We present a novel procedure via a minimally invasive access to treat such a pathology.

MATERIAL AND METHODS: Case Presentation: A 54-year old male patient underwent mitral valve replacement with a 33-mm bioprosthesis (BP) The post-operative follow-up at 2 months highlighted a motile mass pedunculated to the bioprosthesis. The patient was asymptomatic. A broad spectrum empiric antibiotherapy was initiated for 3 weeks conjointly with a therapeutic-dose anticoagulation with heparin. The echocardiographic control showed no alteration in size after 3 weeks. Because of its bulky nature (18 × 11 mm), hypermobility, resistance to anticoagulation and the neurological threat, we were urged to devise a way to remove the thrombus via a minimally invasive access, as per the patient’s desire.

RESULTS: Patient is placed supine with an intubation by a double lumen tube. A cerebral protection system, Sentinel^®, is used to protect against embolic material. A 3.5 cm transverse incision was made, and the intercostal space opened. Two apical concentric pursestring sutures were realized. The apex was punctured with a needle and a soft guidewire was inserted antegrade. A 14 Fr Occlutech delivery set System with an adjustable tip was inserted with its dilatator. The proximal part of the Occlutech^® was connected to a pediatric extracorporeal circuit and the aspirated blood, filtered and returned back via the left femoral vein. The patient was discharged at day 3. The echocardiography after 1 year did not show any relapse.

CONCLUSIONS: Thromboaspiration of a left sided valve thrombosis via a trans-apical mini-invasive approach can be an excellent alternative for patients who are reluctant to surgery or for a thrombus resistant to anticoagulation.

• Keywords: thromboaspiration; left sided valve thrombosis; minimally invasive

1.5.13. Transaxillary Mitral Valve Repair and Atrial Septal Deffect Closure

• Allaa Subhi Abdel Majeed and Yad Nuaman Othman
  Sulaimaniyah Cardiac Hospital, Sulaimaniyah, Iraq
  Iraqi Cardiothoracic Society, Kurdistan Cardiothoracic Society, Baghdad, Iraq

Mitral valve disease is no longer an irreparable condition with the advancement in surgical techniques in the last decades.

Minimal invasive cardiac surgery along with mitral valve repair has become a popular option in advanced centers especially for young females who fit the intervention criteria.

This 38 year old single unmarried female patient referred to our department with severe mitral regurgitation associated with exertional dyspnea.

After discussion of management plan the decision were made to go through minimal invasive approach.

Through right transaxillary vertical 5 cm incision and femoral cardiopulmonary bypass we found incidentally an atrial septal defect.

Through left atrial approach direct vision mitral valve repair and ASD secundum closure done.

In post-operative follow up sessions patient symptoms get relieved and get back to her normal lifestyle.

In conclusion young age patients with such a crippling conditions demand us to choose safest and less invasive intervention if possible.

Such procedures considered as one of the favorable options for females in reproductive age, therefore we try to offer it for a wide variety of our patients.

Though studies showed excellent satisfaction amongst patients, nevertheless; such techniques requires experience, training and specific instruments which makes it challenging in developing countries.

• Keywords: transaxillary cardiac surgery; mitral valve repair; cardiac surgery in young women

1.5.14. Removal of Giant Myxoma in the Right Atrium with Mini Thoracotomy and Repair of the Tricuspid Heart Valve in a Young Male Patient

• Emre Dogan and Ergun Demirsoy
• Kolan International Hospital Sisli İstanbul, Istanbul, Türkiye

A 23-year-old male patient applied with complaints of shortness of breath and a mass was observed in the right atrium on echocardiography taken by the cardiologist. The patient, whose transesophageal echo was compatible with a solid myxoma with a diameter of 4.2 × 3.8 cm in the right atrium, was operated on by us.

The surgery was performed under general anesthesia with double endotracheal intubation. The patient was positioned so that the left lung was ventilated. The surgical incision was in the form of a mini-thoracotomy approximately 5 cm from the 4th intercostal space to the right anterolateral. Cardiopulmonary bypass was performed using the right femoral artery and right femoral vein. A cross clamp was placed and cardiac arrest was achieved using Del-Nido cardioplegia. Right atriotomy was performed.

A giant 6 × 4 × 3 cm mass attached to the right lateral wall of the right atrium was excised. After the mass was removed, annuloplasty was performed on the severely dilated tricuspid heart valve annulus with a 34 mm Medtronic Contour ring. The right atrium was closed and the pump was disconnected. A drain was placed in the right pleural space. The patient was taken to the intensive care unit. He was extubated at the 5th postoperative hour. He was taken to the ward the next day and discharged 4 days later.

• Keywords: minimal invasive; cardiac surgery; myxoma; mini thoracotomy

1.5.15. Development of a New Access Port for Apical-Mitral Neo Chords Implantation in Mitral Valve Prolapse

• Aleksandr Nemkov ¹, Gennady Khubulava ¹, Kirill Shokin ², Sergey Romanov ², Vladimir Komok ¹, Nikolay Bunenkov ¹, Nikita Titov ¹, Vladimir Matrosov ¹, Nikita Tarskiy ¹, Aleksandr Morozov ¹ and Vladimir Ershov ¹

1

I.P.Pavlov First St-Petersburg State Medical University, St Petersburg, Russia

2

Nevsky Technologies, St Petersburg, Russia

BACKGROUND AND AIM: Little is known about the technology of implantation of multiple apical-mitral neochords in mitral valve prolapsed. The formation of two or more pairs of neochord requires a unified access port that allows multiple insertion of instruments into the left ventricle with the greatest safety and accuracy

METHOD: An introducer for multiple access to the left ventricle has recently been developed. The introducer has several working channels. A separate channel of the introducer is made for feeding a needle containing a PTFE thread. There may be two or more such channels. They are focused on certain parts of the mitral valve leaflets. The channel for extracting threads by an intravascular loop has a groove for collecting PTFE threads in it. The groove ensures that PTFE chords are laid in a certain order to prevent the formation of knots and their crossection.

RESULTS: The experiments were performed on synthetic mitral valve models and on 10 pig hearts. The introduction of a multichannel introducer was carried out between the bases of the papillary muscles on the anterolateral wall of the left ventricle. A j-shaped guide was used for safe insertion. The distal part of the introducer should be located above the level of coaptation of the mitral valve leaflets in the regurgitation jet zone (vena contracta space). This makes it possible to repeatedly insert a feeding instrument—a needle and a receiving instrument—a catheter with an intravascular loop into the area of interest. The fixation of the chords to the PTFE support plates is carried out as the final stage of the operation.

CONCLUSIONS: The use of a multichannel introducer makes it possible to create multiple apical-mitral neochords in mitral valve prolapse more accurately, easier and more reliably.

Working out the details of implantation is required in a hybrid (X-ray and ultrasound) operating room.

• Keywords: mitral valve; minimal invasive surgery; neochords

1.5.16. Cardiac Bioprosthesis: Complications and Medium-Term Follow-Up

• Mouna Bousnina, Khedija Soumer, Azabou Nadia, Amenallah Zarrouk, Rihab Arbi, Salma Nciri and Amine Jemel
  Department of Cardiovascular Surgery, Abderrahmen Mami Hospital, Ariana, Tunisia

BACKGROUND AND AIM: The heart valve bioprosthesis would be an interesting alternative to reduce the risk of hemorrhage and thromboembolism. The aim of this study was to determine the complications linked to bioprosthesis implantation in the medium term and to evaluate survival.

METHOD: Between 2018 and 2022, a retrospective study in the cardiovascular surgery department of the Abderrahmane Mami hospital in Ariana. We collected the files of successive patients operated for valve replacement(s) by bioprosthesis with or without associated procedure. All patients were checked for survival and for functional discomfort. We also collected postoperative ultrasound checks.

RESULTS: We included 69 patients. The average age was 65.1 year ± 12.3; sex ratio was 1.15. The late mortality rate was 17.39%. The average survival was 24.15 ± 5.26 months with a range from 1 month to 47 months. The overall survival rate was 85.9% ± 7.6% at 6 months, 66.8% ± 13.3% at 1 year, 44.5% ± 15.6% at 2 years and 33.4% ± 15.2% for the remainder of the follow-up period. As for the postoperative echocardiographic data, the average left ventricular ejection fraction was 61% ± 6.508%, the average maximal velocity was 2.17 ± 0.63 mmHg. The main predictors of late mortality were postoperative atrial fibrillation (OR = 2.3), postoperative left ventricular failure (OR = 7), and elevated preoperative pulmonary hypertension (OR = 1.8).

CONCLUSIONS: Bioprostheses seem to have good results in the medium term. Morbimortality is essentially linked to the host.

• Keywords: bioprosthesis; cardiac surgery; morality; survey; complications

1.5.17. Redo Mitral Valve Replacement Using Mitris Resilia Valve in Patient Having Redo Mitral Surgery and Tricuspid Valve Repair

• Aneel Zaheer, Mark Ward, Mayooran Nithianathan and Ranjeet Deshpande
• Kings College Hospital London, London, UK

BACKGROUND: The MITRIS RESILIA mitral valve was commercially introduced in April 2021. It is the successor of the Carpentier Edwards Perimount MAGNA MITRAL EASE valve but the bovine pericardial tissue of this bioprosthesis, the RESILIA tissue, is treated with a special integrity preservation technology and offers enhancement of anti-calcification treatment that will potentially increase the durability

CASE: We report a case of 42 years old patient who had redo Mitral valve replacement and tricuspid valve repair with history ofmitral valve repair in 2006 via right thoracotomy approach. She presented with increasing shortness of breath on exertion and palpitations. Her echocardiogram showed severe mitral stenosis and moderate to severe tricuspid regurgitation. In view of stable symptoms her operation was delayed for three months until Mitris valve was available in the UK considering her young age and to avoid long term warfarin.

We used sternotomy approach and trans septal approach. Previous mitral annulopasty ring was explanted and anterior mitral leaflet was excised. 2 CV4 goretex sutures were used to resuspend the Left ventricle and mitral valve was replaced using size 27 Mitris resilia valve. Tricuspid valve was repaired using size 32 physio 2 ring. Aortic cross clamping time was 97 min and patient was weaned off CPB DDD paced. In the postoperative period she required PPM for heart block. Postoperative echocardiogram showed well seated mitral valve with no paravalvular leak and gradient of 2.7 mm Hg.

To our knowledge this is the first case report of Mitris valve implantation in redo mitral surgery with tricuspid valve repair.

• Keywords: Mitris; Mitral; redo; resilia

1.6. CARDIAC » Bypass Grafts and Configurations

1.6.1. Herbal Hemostatic Agent in Open Heart Surgery Investigation of Clinical Efficacy and Safety of Algan Product

• Sefer Usta, Ömer Melih Cinemre, Kemal Uzun and Mine Demirbaş
• SBU Trabzon Ahi Evren GKDC Education Hospital, Trabzon, Turkey

BACKGROUND AND AIM: Stopping bleeding that occurs during surgical operations or other emergencies is very important to prevent negative consequences by reducing blood loss. This study aims to investigate the clinical effectiveness and safety of hemostatic hemostatic agent using polysaccharide-based algan hemostatic agent, which is a herbal product, in open heart surgery.

METHOD: A total of 40 open heart surgery patients, 30 of whom underwent coronary surgery and 10 of whom underwent valve replacement surgery, were included in the study. A control group of 40 people was determined for the same surgical indications, in which only traditional haemostatic methods were used. Algan hemostatic agent was used as a support in coronary anastomoses, aortotomy incisions, perivascular fat tissue in the myocardium, and atriotomy incisions in patients undergoing mitral valve surgery.

RESULTS: On the first postoperative day, drainage (average 450 mL/1000 mL) was found to be higher in the control group. An important difference was found to be statistically significant in the treatment group in terms of the rate of erythrocyte suspension use. It was observed that algan hemostatic agent can be used safely and effectively as a hemostatic agent in open heart surgery.

CONCLUSIONS: As a result, the use of AHA reduces blood loss by reducing postoperative drainage. It causes less blood usage in the postoperative period in open heart surgery operations. AHA, a topical hemostatic agent, was found to be more effective in controlling bleeding than traditional methods. Since it is a herbal product, no side effects were observed. In some studies, the haemostatic potential of microporous polysaccharide-based tissue adhesives has been found to be effective. In addition to underlining that Algan hemostatic agent is an effective haemostatic agent, there is a need for comparative studies among haemostatic agents in terms of their effectiveness, which is an important auxiliary argument in open heart surgery.

• Keywords: Algan hemostatic agent; Open heart surgery; Bleeding

1.6.2. The Impact of Prior Asymptomatic COVID-19 Infection on Outcomes Following Coronary Bypass Surgery

• Emre Külahcıoğlu ¹, Erdal Şimşek ², Okay Güven Karaca ² and Serdar Günaydın ²

1

Department of Cardiovascular Surgery, Kilis Alaeddin Yavaşca Devlet Hastanesi, Kilis, Turkey

2

Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey

BACKGROUND AND AIM: The COVID-19 pandemic has notably impacted cardiac surgery, particularly coronary bypass grafting (CABG). Past studies on the postoperative outcomes of cardiac surgeries during the pandemic are limited and not comprehensive for patients with initially asymptomatic COVID-19 infections. Our study aims to fill this gap by evaluating the postoperative outcomes for CABG patients who had asymptomatic COVID-19 infection.

METHOD: We retrospectively analyzed 37 asymptomatic COVID-19 patients and 39 non-COVID patients who underwent CABG at the Health Sciences University Ankara City Hospital Cardiovascular Surgery Clinic from 2021 to 2022.

RESULTS: The average age of the 76 patients was 63.4 years, with a gender distribution of 18.4% female and 81.6% male. The predominant symptom across both groups was exertional angina, observed in 63.7% of cases. In comparing intraoperative and postoperative variables—such as ventilation wean-off times, complication rates, inflammatory marker levels, use of non-invasive ventilation, and oxygen therapy requirements—no significant differences were noted between COVID and non-COVID groups. However, the preoperative phase showed significant differences in inflammatory markers and blood gas values (PaO₂ and PaCO₂).

While postoperative mortality was noted in one patient within the COVID group, this did not represent a statistically significant finding. The COVID group exhibited a higher, statistically significant rate of postoperative complications after a four-week period. In our analysis period, no mortality or morbidity associations were shown in connection with previous asymptomatic COVID infections. Interestingly, early post-infection CABG did not yield different outcomes than surgeries performed after a delay, challenging typical waiting period guidelines.

CONCLUSIONS: Our findings suggest that an asymptomatic COVID history may not necessitate delayed CABG. Nevertheless, this study’s limitations—like the small sample size and absence of long-term follow-up—indicate a need for further research. Future studies should involve larger patient cohorts, inclusive of vaccination status, and extend follow-up periods to validate these preliminary outcomes.

• Keywords: COVID-19; asymptomatic infection; coronary bypass surgery; atherosclerotic heart disease

1.6.3. Coronary Artery Bypass Grafting Using 3D-Visualization

• Dmitrii Vladislavovich Petrovskii, Vladislav Petrovich Vasiliev, Andrey Andreevich Shiryaev, Ruslan Sergeevich Latypov, Damir Mazitovich Galyautdinov, Elina Yevgenievna Vlasova, Alexandr Vladimirovich Emelyanov and Renat Suleymanovich Akchurin
  Cardiosurgery Department, FSBI “NMRCC named after Academician E.I. Chazov” of MH of RF, Moscow, Russia

BACKGROUND AND AIM: Among candidates for CABG, there is an increasing number of patients with difficult coronary lesions. Surgeons are forced to use complex techniques for forming a coronary anastomosis which requires optical magnification. Aim of this study is approving using 3D-exoscope during microsurgical stage of CABG.

METHOD: 39 patients (65% males, mean age 64.1 ± 8.0 years) who underwent CABG using 3D-exoscope during 01.2021–02.2024. The diameters of CA were measured intraoperatively. We analyzed perioperative and hospital outcomes.

RESULTS: Operation time was 269.4 ± 48.7 min, cardiopulmonary bypass took 98.3 ± 24 min, myocardial ischemia last 70.8 ± 17.9 min; this coincided with standard CABG using an operating microscope in our department. Totally 132 distal anastomoses were formed, the median revascularization index was 4 [3, 4]. In 21 cases (15.9%) the anastomosis were performed by shuntoplasty, in 14 of them (10.6%) with coronary endarterectomy. The diameter of all 132 bypassed CA in the area of anastomosis was measured: 7 (5.3%) < 1 mm, 46 (34.8%)—1–1.5 mm, 75 (56.8%)—1.5–2.0 mm, 4 (3.0%)—>2.0 mm. Mortality, perioperative infarction, life-threatening arrhythmias, and angina were not recorded during the hospital period. The postoperative hospital stay was standard 8.7 ± 1.9 days. Our experience: 3D exoscope for CABG requires the same skills as a microscope. 3D exoscope has a advantages: image quality and possibility of magnification result in good visualization, and also make it easier to perform complex methods of revascularization; since the image is visible from any position, the movements of the surgeon’s head and neck become freer, which reduces the load on neck and shoulders.

CONCLUSIONS: For visualization during CABG 3D-exoscope is effective and safe when working with both standard and problematic distal beds. Hospital results of such operations are good. Due to ease of use, high resolution and quality of the image, a 3D-exoscope is comfortable for CABG.

• Keywords: 3D; 3D-exoscope; CABG; optical enlargement; visualisation

1.6.4. Multiple Arterial Grafting During Coronary Artery Bypass Graft Surgery in Diabetic and Non-Diabetic Patients: A Short- and Long-Term Analysis at a Single Center

• Miralem Jasarevic, Oscar Oscar Krueger, Jan Strathmann, Ilir Balaj, Sharaf Eldin Shehada, Jarowit Piotrowski, Parwis Massoudy, Heinz Jakob, Markus Kamler and Matthias Thielmann
• Department of Thoracic and Cardiovascular Surgery, West-German Heart Center, University of Duisburg-Essen, Essen, Germany

BACKGROUND AND AIM: Coronary artery bypass surgery (CABG) with multiple arterial grafting (MAG) has been shown to improve patient survival compared to single arterial bypass grafting. Whether these survival benefits also exists in diabetic patients is uncertain. We therefore aimed to compare short and longterm outcomes of MAG in diabetic versus non-diabetic patients.

METHOD: In this retrospective study, we investigated short- and long-term clinical outcomes of diabetic (n = 256) and non-diabetic (n = 800) patients who consecutively underwent CABG with MAG between January 1999 and December 2019 at our institution.

RESULTS: Diabetic patients had a significantly higher EuroScore II (1.4 vs. 0.9; p < 0.0001) and underwent significantly less bilateral internal thoracic artery (BITA) grafting (52% vs. 67.8%; p < 0.0001) compared to non-diabetic patients. The incidence of postoperative adverse events such as pneumonia, stroke, and sepsis did not differ between the two groups. However, diabetics had a significantly higher incidence of low cardiac output syndrome, cardiac resuscitation, renal failure requiring dialysis, and sternal wound infections during the entire follow-up period. Non-diabetics had a significantly higher median survival time of 19.6 years compared to 14.5 years in diabetic patients (p < 0.0001).

CONCLUSIONS: Our data show a significantly lower median overall survival in diabetics with MAG. This emphasises the importance of diabetes as a risk factor in the choice of individual surgical strategies, such as multiple or single arterial grafting in these patients.

• Keywords: Multiple arterial grafting; diabetic and non-diabetic patients

1.6.5. The Effects of Carbon Dioxide Insufflation for Radial Artery Harvesting

• Melïke Elïf Teker Açikel, Begüm Özüekren Kasapoğlu, Yasin Saraç, Tolga Demir and Ismail Koramaz
  Cardıvascular Surgery of Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi, Istanbul, Turkey

BACKGROUND AND AIM: The aim of coronary artery bypass operations is complete revascularization. Several reports have described use of arterial (radial artery, internal mammary artery etc) and vein grafts (venasaphana magna, brachiocephalic vein etc) in coronary artery bypass surgery. Many reports have shown the advantage of using the technique during radial artery harvesting. Carbon dioxide is a agent directly vasodilatator effect. It is shown that carbondioxideinsufflation of internal thoracic artery is an efficient technique to increase the flow and prevent thepossible vasospasm of the internal thorasic surgery segments. In the pesent study, we investigated the effects of carbon dioxide insufflation during radial artery harvesting.

METHOD: This study was performed on human radial artery segments from patients (n = 24) undergoing coronary artery bypass grafting. Radial artery harvesting was performed by the same surgeon for standardization of technique. Patients were randomly divided into two groups for radial artery harvesting.

In the first group, radial arteries were harvested by means of a carbon dioxide insufflation (n = 12). In the second group, radial arteries were harvested by means of a classical harvesting (n = 12) Patients with diabetes mellitus were excluded from the study in both groups.

RESULTS: There was no significant difference in the demographic findings of the patients. There was no significant difference in both groups in terms of EF, cross time, and pump time. There was no significant difference in terms of hospital stay, mortality and morbidity in both groups. The patency rate of the group whose radial arteries were harvested via carbon dioxide insufflation was more significant than the group whose radial arteries were removed normally.

CONCLUSIONS: The patency of the grafts used in coronary artery bypass surgery is of vital importance. One of the grafts used for this purpose is the radial artery. Radial artery removal with carbon dioxide can provide long-term patency with less damage without touching the radial artery.

• Keywords: carbon dioxide insufflation; radial artery; coronary artery bypass operations

1.6.6. Combined Valve and Coronary Surgery: A Series of 35 Cases

• Sami Bouchenafa, Ahmed Zaki Boukli Hacene, Boukri Hamouda, Redha Djilali Sayah, Tarek Hamdi, Mohammed Ould Abderrahmane, Makhlouf Amir, Abdelkader Boukhors, Mohammed Bensaber, Nour El Houda Draou, Linda Zebirate and Mohammed Atbi
• Departement of Cardiac Surgery, EHU Hospital, Oran, Algeria

BACKGROUND AND AIM: Recently, we observe that many of our patients who have valve disease requiring for surgery are associated with severe coronary stenosis. Our study describes the morbidity and mortality of this population of patients after combined valve and coronary surgery

METHOD: A retrospective study on 35 patients who underwent valve surgery combined with coronary artery bypass grafting (CABG) between January 2022 and February 2024 in EHU hospital of Oran. We included surgery of mitral or aortic valve and both with coronary grafting surgery. Clinical data, preoperative evaluations, intraoperative results and postoperative follow-ups were analyzed

RESULTS: In this study 26 patients (74.3%) were men. The mean age was 61.7 ± 12.8 years. Clinically, dyspnea in 20 patients (71%) and angina in 19 patients (68%). The valve disease was aortic valve in 22 cases (79%), mitral in 11 cases (39%) and both in 5 cases (14%). The coronary arteries most affected were the anterior interventricular in 21 cases (60%) and the right coronary in 12 cases (34.3%), the circumflex artery in 7 cases (20%) and the common trunk left in 4 cases (11.4%). In total, 19 aortic valve replacements and CABG (54.3%), 11 mitral valve replacements and CABG (31.4%), 4 double mitral-aortic valve replacement and CABG (11.4%). A single CABG was in 26 patients (74.3%), a double CABG in 8 patients (22.8%) and a triple CABG in one patient (2.8%). The average time of cardiopulmonary bypass was 173.3 + 23.2 min and the aortic clamping was 140.7 + 18.6 min. We describe some complications, as ventricular dysfunction in 11 patients (31%) arrhythmias in 4 patients (11.4%). There was a mortality of 6 patients (17.14%).

CONCLUSIONS: The morbidity and mortality rate of patients from valve surgical procedures combining coronary artery bypass grafting is high, explained by operative risk factors represented by cardiac dysfunction and electrical disorders

• Keywords: valve surgery; combined; coronary grafting

1.6.7. Bilateral Skeletonized IMAs Used as “In Situ” Grafts for Different Coronary Territories: Long-Term Propensity Matching Study

• Živojin Jonjev ¹, Ilija Bjeljac ¹, Aleksandar M. Milosavljevic ¹, Mirko Todic ¹, Strahinja Mrvic ¹ and Novica Kalinic ²

1

Institute for Cardiovascular Diseases of Vojvodina, Clinic of Cardiovascular Surgery, Sremska Kamenica, Serbia

2

Faculty of Medicine, University of Banja Luka, Banja Luka, Republic of Srpska, Bosnia & Herzegovina

INTRODUCTION: Bilateral internal mammary arteries (BIMAs) have been recognized as the most advanced surgical option for coronary artery bypass grafting (CABG). The aim of this study is to compare outcomes in propensity score matched (PSM) patients with skeletonized BIMAs used as in-situ grafts for different coronary territories with patients using single internal mammary artery (SIMA) in CABG.

METHODS: In 2013–2023, 7543 patients underwent primary CABG for multivessel coronary artery disease at our institution. In 283 (3.75%) patients BIMAs in situ grafting were performed. Right IMA was used to revascularize right coronary artery, and left IMA for the LAD territory. BIMA patients (n = 280) were compared with single IMA patients (n = 280) in propensity score matching analysis. Primary outcome measures were identified as all-cause mortality at 30-days, 5 years and 10 years, while secondary outcome measures were length of hospital stay, the incidence of postoperative major adverse cardiovascular and cerebrovascular events (MACCE), sternal wound infection and need for subsequent percutaneous revascularization.

RESULTS: There was no immediate posteoperative mortality (30 days) in both groups. There was no perioperative MACCE or deep sternal wound infection as well. Patient in both groups had similar length of hospital stay (BIMA = 7.8 ± 1.5 days vs. SIMA = 8.2 ± 1.4 days; p < 0.05). Mean follow-up was 9.78 ± 0.62 years with freedom from death 86.07 ± 3.0% in BIMA group vs. 78.6± 4.1% in SIMA group 10 years after surgery (p < 0.05).

CONCLUSIONS: The results of the study indicated that BIMAs as in situ grafts used for different coronary territories in CABG is associated with better long term survival then SIMA grafting. IMA harvesting with skeletonized technique provides better IMA length, detailed graft visualization, and minimal trauma to the chest wall. Our conclusion is independent of traditionally accepted risk factors incorporated in the Logistic EuroSCORE II and SYNTAX score II and is exclusively method related.

• Keywords: Coronary arteries bypass grafting surgery; mammary artery; major adverse cardiovascular and cerebrovascular events

1.7. CARDIAC » Challenging Cases

1.7.1. Surgery for Infective Endocarditis Using Beating Heart Technique via Right Anterior Mini-Thoracotomy in Intravenous Drug Users

• Mete Kubilay Kasap, Nazenin Kasapoğlu, Özgür Çoan, Aylin Arus Zeytun, Akif Küçük, Ergün Kürkçü, Kaanhan Kızıltoprak, Funda Tor Ocak and Muhammed Bozgüney
• Health Science University Adana City Research and Training Hospital, Adana, Turkey

BACKGROUND AND AIM: Infective endocarditic (IE) in drug inject adults has a high mortality rate. However, there is no investigation to evaluate the effects of beating heart technique on patients’ outcomes. Our aim of this study was to analyze the early and mid-term clinical outcomes of patients who undergoing beating heart technique via right anterior mini-thoracotomy.

METHOD: We operated 170 IE patients due to intravenous drug use (IVDU) between 2009 and 2023. While an isolated mitral valve (MV) (n = 44; 25.8%), and tricuspid valve (TV) (n = 67; 39.4%) IE identified in 111 patients (65.2%), we detected TV concomitant with MV IE in 59 patients (28%). Mean age was 46.6 ± 4.2 years (18–66 year). To verify liver congestion and pulmonary embolic events, abdominal ultrasonography, and full body computed tomography were performed preoperatively. We performed valve repair using pericardium and artificial chordae implantation in suitable patients (n = 64). In the remaining 116 patients, valve replacement/replacement concomitant with repair were performed via right anterior mini-thoracotomy incision without the use aortic cross clamp.

RESULTS: Causative microorganisms were Methicillin resistance Staphylococcus aureus (MRSA), and Enterococcus predominantly. Seven patients (4.1%) died after surgery. The median length of ICU staying time was significantly longer in patients with pulmonary or cerebral embolic events and serious heart failure (2.3 days vs. 6 days) (p = 0.001). The median hospital staying time was 39.8 days (28.9–53.4 days). Acute kidney failure requires temporary hemodialysis developed after surgery in 5 patients (6.6%). The median follow-up was 56.4 months (min.:42 max.:64 months). Recurrence of IE requiring redo surgery was seen in 22 patients during follow-up period. Survival at 1, 3, and 5 years were 93%, 86%, and 79%.

CONCLUSIONS: Mortality predictors such as age, embolic events have been showed in previous publications. However, the effects of surgical approach on mortality have not been evaluated yet. Early surgery may provide good clinical outcomes in IVDUs with IE. Valvuloplasty may be the first choice using beating heart through mini-thoracotomy incision without an aortic cross-clamping as a feasible method with low mortality rate in suitable IVDUs who have IE.

• Keywords: Infective endocarditis; intravenous drug user; surgery

1.7.2. Coronary Artery Bypass Grafting in Patients with Low Ejection Fraction

• Ahson Memon, Kanwar Talha Shahid, Malik Shafqat Hassan and Syed Shahzad Hussain Rizvi
• Department of Cardiothoracic Surgery, Tabba Heart Institute, Karachi, Pakistan

BACKGROUND AND AIM: Patients with low ejection fraction undergoing isolated coronary artery bypass graft (CABG) surgery are at a higher risk for postoperative complications and mortality. This study was conducted to evaluate the impact of ejection fraction on the outcome of isolated CABG.

METHOD: We analyzed patients from our database who underwent isolated CABG between 2019 to 2024. Patients were divided into three groups based on their pre-operative Ejection Fraction (EF). Group-I included patients with EF > 50% [Normal EF], Group-II included patients with EF 35–50% [Mild to Moderately Reduced EF], and Group 3 included patients with EF < 35% [Severely Reduced EF].

RESULTS: The mean age of Group-I was 57.99 +/− 8.791, Group-II was 58.15 +/− 8.885 and Group-III was 58.36 +/− 8.976. The male gender was the predominant gender in all three groups: 77.09% in Group-I, 81.4% in Group-II, and 84.38% in Group-III. 20.68% patients in Group-I, 23.26% in Group-II and 16.94% in Group-III had raised creatinine pre operatively (creatinine clearance < 85 mL/min). Hypertension was present in approximately 70% of all our patients. In the per-operative period 0.85% patients in Group-I required an IABP as compared to 5.35% in Group-II and 9.36% in Group-III. The EuroScore II-predicted mortality was 1.21% in Group-I, 1.92% in Group-II, and 4.35% in Group-III. Post-operative observed mortality rates were 1.21% in Group-I, 2.29% in Group-II and 4.93% in low EF group (Group-III).

CONCLUSIONS: The results clearly indicate that worsening pre-operative ejection fraction is associated with a higher mortality post-operatively in patients undergoing isolated CABG. In addition, use of IABP increases as pre-operative EF decreases.

• Keywords: Coronary artery bypass grafting (CABG); Ejection fraction (EF)

1.7.3. Midterm Outcome of Isolated Surgical Revascularization in Patients with ≤20% Left Ventricular Function

• Kanwar Talha Shahid, Ahson Memon, Malik Shafqat Hassan and Syed Shahzad Hussain Rizvi
• Department of Cardiothoracic Surgery, Tabba Heart Institute, Karachi, Pakistan

BACKGROUND AND AIM: To find out long-term Success, quality of life by assessing functional and angina improvement after isolated coronary artery bypass grafting in patients with very poor left ventricular function.

METHOD: Coronary artery bypass graft surgery (CABG) in these patients is associated with improved survival compared with medical treatment. In times gone by, surgical revascularization in patients with poor left ventricular function has been associated with high perioperative as well as postoperative mortality. Prophylactic use of intra-aortic balloon pump (IABP), new cardioplegic solutions, shorter cross clamp and cardiopulmonary bypass times, improvement on intensive postoperative care have show the way to superior outcomes, allowing surgical revascularization to be a quite safe course of action at present in selected patients at high risk.

RESULTS: Consecutive 156 patients who came to Tabba Heart Institute with Left ventricular EF ≤ 20% measured (by echocardiography) before surgery and who had isolated CABG between December 2021 and December 2023 were eligible. Data was recovered in prospect from the patients and/or their relatives through telephonic communication and congestive heart failure class were rated using classification of New York Heart Association. Symptomatic relief was assessed by Canadian Cardiovascular Society class of angina.

CONCLUSIONS: We conclude that admirable midterm results and better quality of life can be expected in these patients with very severe ischemic left ventricular dysfunction and these results highly depend upon completeness of surgical revascularization and an excellent post-operative care.

• Keywords: Coronary artery bypass grafting (CABG); Ejection fraction (EF)

1.7.4. Reintervention for Aortic Prosthesis Acute Endocarditis: Early and Mid-Term Outcomes

• Michele D’alonzo, Antonio Fiore, Yuthiline Hun Chabry, Eric Bergoend, Costin Radu, Maria Antonietta Piscitelli, Amin Serradj, Victor Lesanu, Tahar Hadj Idris, Guner Emirali and Thierry Folliguet
• Department of Cardiac Surgery, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France

BACKGROUND AND AIM: While transcatheter aortic valve implantation is growing his utilization for degenerative bioprostheses failure, valve-in-valve procedures are limited in acute aortic endocarditis circumstances. Surgical interventions for aortic prosthesis endocarditis pose significant risks, with documented high mortality rates in existing literature. This study analyses surgical redo cases involving the aortic valve, seeking to provide insights into outcomes and challenges of this complex scenario.

METHOD: This was a retrospective, monocentric, observational study. Fifty-four patients underwent surgical reoperation after aortic valve replacement due to acute infective endocarditis from 2016 to 2023. The endpoints were early and late mortality, incidence of complications and major adverse cardiac and cerebrovascular events (MACCE, defined as death, disabling stroke, re-endocarditis, permanent pacemaker implantation, and myocardial infarction).

RESULTS: The study cohort consisted of individuals with an average age of 71.9 ± 12.1 years, predominantly male (79.6%), and with a mean EuroSCORE II of 15%. Mean follow-up was 741 days. Vegetations larger than 10 mm were present in 29 patients (53.7%) while an annular abscess was present in 31 (57.4%). The mean cardiopulmonary bypass time was 207.7 ± 109.6 min while aortic cross-clamping time was 150.5 ± 68.5 min. Thirty-day mortality remained notably high (10 patients, 18.5%). Postoperative ECMO was used in 5 patients (9.3%). The five-year overall survival rate was 58.3 ± 18.6%, while the freedom from MACCEs was 41.7 ± 19.7%. During the follow-up three patients required surgical reintervention (1 for re-endocarditis).

CONCLUSIONS: Despite advancements in surgical management and perioperative care, our study confirmed that the operative risk associated with redo procedures following aortic valve replacement for infective endocarditis is high. The mortality rate within 30 days underscores the gravity of this condition and the challenges encountered during surgical management, nevertheless the 5-year survival rate suggests an acceptable outcome.

• Keywords: endocarditis; redo; aortic endocarditis; challenging scenario; reoperation

1.7.5. Analysis of Early Outcomes of Surgical Repair of Post MI Ventricular Septal Rupture and Associated Risk Factors

• Alifa Sabir, Muhammad Sohail Chaudhri, Muhammad Azam and Sahab Ahmad
  Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan

BACKGROUND AND AIM: The incidence of post MI VSR has reduced to 0.2% with increase in revascularization therapies. However, the clinical outcomes are still very poor following medical or surgical management of VSR. Mortality rates are reported to be higher than 30% in cases of operative management and are associated with timing of surgery since diagnosis.

METHOD: This is a single center retrospective analysis of all the patients operated for ventricular septal rupture at Rawalpindi Institute of Cardiology from 2019–2023. A total of 19 patients data was retrieved from Database System of Cardio thoracic Surgery and analyzed using SPSS 23. Patients were divided into two groups as survivors and non-survivors on the basis of the outcome, i.e., mortality within 30 days (

Table 4. Factors associated with mortality.

Characteristics		Survivors n = 13	Non-Survivors n = 6
Gender	Male	9	5
	Female	4	1
Smoking	Yes	8	2
	No	3	2
Hypertension	No	7	3
	Controlled	4	1
	Uncontrolled	2	2
Diabetes	No	9	3
	Oral	3	2
	Insulin	0	1
CAD	SVCAD	6	2
	SVCAD	3	3
	TVCAD	3	0
IABP	NO	2	1
	Pre op	3	4
	Per op	7	1
	Post op	1	0
Cardiogenic shock	Yes	2	4
	No	9	1

).

RESULTS: The operative mortality in this series was 31.4%, which is comparable to the reported mortality. Male patients were 73.7% and female patients were 26.3%. Mean age of the participants was 56.94 +/− 8.65. Single vessel disease was most prevalent accounting for 47.1% patients. Mean time from the day of presentation to the day of surgery was 5.6 +/− 3.65 days. Six patients were in cardiogenic shock pre-operatively, requiring IABP and ionotropic supports. Pre operative cardiogenic shock was a strong predictor of mortality in our study with incidence of up to 25% in those presenting with shock.

CONCLUSIONS: Despite decrease in incidence, post MI VSR still remains one of the most catastrophic emergencies in cardiac surgery. Factors associated with increased risk of rupture includes male gender, advanced age, SVCAD and lack of collateral circulation. Prompt diagnosis and after load reduction remains the cornerstone of pre operative management. Early surgical repair for patients with hemodynamic instability improves survival.

• Keywords: Ventricular Septal Rupture; myocardial infarction; Revasculatization

1.7.6. Antiphospholipid Syndrome and Perioperative Hemostatic Management of Cardiac Valvular and Septal Defect Surgery: A Case Report

• Ahson Memon, Kanwar Talha Shahid, Malik Shafqat Hasan, Imran Ali, Yusra Faheem and Tanees Doctor
• Tabba Heart Institute, Karachi, Pakistan

BACKGROUND AND AIM: Individuals with Antiphospholipid syndrome (APS) often have heart valve anomalies, however experience with valve replacement in such individuals with a considerably large ASD is limited. We offer a case of a mitral valve replacement and an ASD closure in a patient with this disease at our institute

METHOD: A 29 year old female patient, married, APS + ve, with no other comorbids, presented in the OPD for an elective ASD (Atrial Septal Defect) repair and mitral valve replacement. Her TEE (Transesophageal echocardiography) showed a bileaflet mitral valve prolapse causing severe eccentric mid to late systolic mitral regurgitation with multiple regurgitation jets and systolic flow reversal in left upper and left lower pulmonary veins. Mitral annulus measured 33 mm and a large ASD measuring 48 mm in diameter with predominantly left to right shunt was detected.

RESULTS: She was given clearance for surgery after being reviewed by a multidisciplinary team and successfully operated on, on 23 November 2023, via a median sternotomy, on cardiopulmonary bypass and with an intricately managed anticoagulation process

CONCLUSIONS: This case highlights the special perioperative difficulties that APS patients undergoing on pump cardiac surgery face, especially with regard to ASD management. We have demonstrated, that although rare, such a condition may arise in some patients that have APS and can be, through correct risk assessment and management, treated. The patient provided authorization for the publication and use of radiographic and transesophageal echocardiographic (TEE) images.

• Keywords: antiphospholipid syndrome; cardiopulmonary bypass; immune thrombocytopenic purpura. Case Reports; Embolic Stroke; Mitral Valve Insufficiency; atrial septal defect; anticoagulation

1.7.7. Cardiac Hydatid Cyst: About Seven Cases

• Sami Bouchenafa, Ahmed Zaki Boukli Hacene, Boukri Hamouda, Redha Djilali Sayah, Tarek Hamdi, Mohammed Ould Abderrahmane, Makhlouf Amir, Abdelkader Boukhors, Mohammed Bensaber, Nour El Houda Draou, Linda Zebirate and Mohammed Atbi
  Departement of Cardiac Surgery, EHU Hospital, Oran, Algeria

BACKGROUND AND AIM: Hydatid cyst is a parasitic infection caused by the larvae of Echinococcus granulosus. Usually, localization of a hydatid cyst is the liver, then lungs. Cardiac localization is very rare. The aim of this study is to report the presentation and management of cardiac hydatid cyst in different localizations.

METHOD: A retrospective study, about seven cases, conducted in one center during five years. Each case presented separately regarding presentation, diagnosis and management.

RESULTS: A case series reported seven patients. Four patients (57.1%) were women; three patients (42.9%) were male. The mean age was 43.28 years (from 27 to 63 years old). The revealing symptoms were dyspnea in three cases (42.9%), chest pain in two cases (28.6%), asthenia in one case (14.3%), and one case (14.3%) presented chest pain and syncope. Six cases (85.7%) were diagnosed through transthoracic echocardiography and one (14.3%) patient with CT-scan. In 2 cases (28.6%) the cyst was pericardial; it was myocardial in the left ventricle in 2 cases (28.6%), in 2 others (28.6%) it was pericardial and myocardial, and one case (14.3%) was found in the inter-ventricular septum. Two patients (28.6%) had associated liver hydatid cyst and one (14.3%) had pulmonary hydatid cyst. All patients underwent surgical treatment except one who was treated with only Albendazole.

CONCLUSIONS: Cardiac hydatid cyst is a very rare disease; mainly affecting the left ventricle. The symptomatology is variable. Echocardiography is very useful in diagnosis. Surgery is the main treatment. Medical treatment with Albendazole can aid in improving the overall outcome.

• Keywords: hydatid cyst; cardiac surgery

1.7.8. Infective Endocarditis—Nightmares and Dreamscapes: 18 Years Analysis of IBCV Iași Cases

• Grigore Tinică, Alberto Bacușcă, Mihail Enache, Silviu Paul Stoleriu and Andrei Țăruș
• Department of Cardiovascular Surgery, Cardiovascular Diseases Institute “George I.M. Georgescu”, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania

BACKGROUND AND AIM: Recent reports indicate that infectious endocarditis continues to represent a significant global burden, with an incidence of 13.8 cases per 100,000 individuals. Our goal was to highlight data regarding the onset and progression of the disease, specific symptoms, diagnostic methods, and treatment approaches adopted for each person according to age, risk factors, and associated comorbidities.

METHOD: We conducted a single center retrospective study on a cohort of 664 patients with infectious endocarditis from 2004 to 2022. All cases of valve endocarditis, whether acute or chronic, were included in the study. This encompassed prosthetic valve endocarditis cases, except for those involving transcatheter aortic valve implantation.

RESULTS: The average age of the patients was 53.6 years. 8.28% of the patients were under 30 years of age. The onset was acute and severe, with high fever and septic presentation in 37% of patients. 17% showed signs of embolic phenomena upon admission, 19.12% presented with symptoms of global cardiac decompensation, and 8.58% arrived in cardiogenic shock. 54.22% of the patients reported an insidious onset, associated with a delayed hospital presentation. 41.12% of the cases had negative blood cultures. In patients with criteria of severity and indication for urgent treatment, surgery is certainly the only life-saving solution. However, delaying surgery for hemodynamically stable patients, with a good response to antibiotic therapy until the infectious source is cleared, is, from our experience, the optimal treatment strategy. In our cohort, surgical intervention was necessary on an emergency basis for 53.01% of the patients. The overall mortality was 8.5%.

CONCLUSIONS: Infectious endocarditis remains a significant global health concern, with diverse presentations and outcomes. Our study underscores the importance of tailored treatment approaches based on patient characteristics and severity, highlighting the role of surgery in life-saving interventions and emphasizing the need for prompt diagnosis and management to improve patient outcomes.

• Keywords: Endocarditis; Re-do surgery

1.7.9. Twiddler Syndrome

• Mohamed Shafi Mahboob Ali
• Department of General Surgery, Advanced Medical and Dental Institute (AMDI), Penang, Malaysia

INTRODUCTION: Twiddler’s syndrome is a lethal complication of pacemaker insertion due to deliberate manipulation of the pulse generator by the patients. Continuous reeling of the leads will cause ipsilateral phrenic nerve to be stimulated, disconnection of the leads and thus, dysfunction of the pacemaker.

CASE REPORT: A 73-year-old female presented with persistent twitching and vibration of the left arm and upper chest. A permanent pacemaker was inserted after she was diagnosed with a complete heart block. Interrogation of the device showed battery life was 8.5 years, left atrium impedance was 475 Ω (ohm), right ventricle impedance was 600 Ω (ohm), no sensing noted on the right ventricle while left atrium shows sensing more than 2.8 mv. Fluoroscopy performed and noted that the right ventricle lead was dislodged and there was a new deep subcutaneous pocket. The pacemaker box was reattached and anchored to pectoralis major muscle with non-absorbable suture. The deep pocket was closed and downsized. The procedure was uneventful and the patient was subsequently discharged well.

DISCUSSION: Twiddler’s syndrome is a rare syndrome that is found mainly in the elderly. Other risk factors associated with it such as having psychiatric illness, obese as well as female gender. Permanent dysfunction of the device is caused frequently by the lead displacement although diaphragmatic pacing might occur through the right ventricle perforations. The majority of Twiddler’s syndrome were reported within the first year of implantation. Applying multiple dressing over the wound site might prevent device dislodgement. Some faculties suggest the use of Dacron patch over the device in which overgrowth of tissues might secure the device better. Prior discharge patient was given proper education on pacemaker care.

CONCLUSIONS: Twiddler’s syndrome is a preventable condition given that only a small pocket is created and the device is properly fixed to the underlying structures with proper education given to the patient.

• Keywords: twiddler; syndrome; pacemaker; ICD

1.7.10. Open Chest Management in a High-Risk Patient Undergoing Three Valve Surgery and Coronary Artery Bypass Grafting

• Eldar Valiyev, Ziya Shahaliyev, Aytaj Ismayilzada, Valeh Mammadov, Seymur Mustafayev, Fidan Zeynalli and Anar Amrah
• Republican Diagnostic Center, Baku, Azerbaijan

AIM: In certain cases, particularly following severe dilated hearts, there arises the necessity of maintaining an open chest wall. This report highlights a case of open chest management in a severe patient suffering from chronic kidney disease (CKD) who underwent aortic valve replacement (AVR), mitral valve replacement (MVR), tricuspid valve repairment (TVr), and coronary artery bypass grafting (CABG).

CASE: A 51-year-old male CKD patient, undergoing hemodialysis for one year, presented with severe aortic, mitral, and tricuspid valve regurgitation post-infective endocarditis (IE). Echocardiography revealed heart chamber dilation with vegetation on the aortic (15 mm) and mitral (10 mm) valves and a left ventricular ejection fraction (LVEF) of 35%. Coronary angiography indicated severe occlusion of the LAD and its first diagonal branch.

The patient underwent AVR and MVR with mechanical valves (size №21 and №31 respectively), TVr with a modified KAY annuloplasty technique, and CABG for the LAD and diagonal arteries (LIMA–D1–LAD, sequential). Post-cardiopulmonary bypass (CPB), myocardial edema and decreased cardiac output necessitated maximal inotropic support, levosimendan administration and intra-aortic balloon pump (IABP) insertion. During the closure of the sternum, the patient’s hemodynamics decompensated, leading to the decision to leave the sternum open with a small-sized retractor.

By the third postoperative day, the patient’s condition stabilized, allowing sternum closure and decreased inotropic support. IABP removal occurred on the sixth postoperative day, with discharge on the thirteenth postoperative day.

Keeping the sternum open should be considered in patients with severe dilated hearts displaying low cardiac output, myocardial edema, and refractory dysrhythmias.

• Keywords: open chest; infective endocarditis; AVR; MVR; CABG; open chest management

1.7.11. Management of Intracardiac Foreign Bodies (Shrapnel) After Mine Explosion—Our Experience During II Karabakh War

• Ziya Shahaliyev, Valeh Mammadov, Teymur Gasimov, Javid Ibrahimov, Firdovsi Huseynov and Anar Amrah
  Department of Cardiovascular surgery, Republican Diagnostic Center, Baku, Azerbaijan

AIM: The explosion of mines can lead to multiple bodily injuries and may result in the embolization of shrapnel particles into cardiac chambers. In this report, we present three cases of intracardiac foreign bodies during the Second Karabakh War.

CASE PRESENTATIONS: In our experience, three patients with shrapnel embolization into the right ventricle underwent open-heart surgery. The diagnosis was confirmed via X-ray or CT scan. Both cases underwent surgery in a hybrid operating room to confirm localization with rentgenoscopy. The first patient, a 19-year-old male, suffered multiple injuries after a mine explosion. A small metal shrapnel was identified on CT, and the patient experienced severe dysrhythmia and ventricular extrasystoles (9–10 per minute). Open surgery was performed, and the shrapnel particle, along with its capsule, was extracted beneath the tricuspid valve in the right ventricle. The second patient, a 25-year-old male, had shrapnel detected close to the right ventricle on X-ray. Rentgenoscopy revealed the shrapnel inside the right ventricle. Due to symptomatic presentation, open-heart surgery was conducted to remove the shrapnel. The third patient, a 30-year-old male, had suspicion of a foreign body during a follow-up ECHO examination. X-ray examination confirmed the presence of shrapnel in the right ventricle. As the patient was asymptomatic, it was decided to monitor him closely with follow-up examinations.

Foreign bodies within the heart are rare occurrences. These cases warrant surgical intervention only when accompanied by obvious symptoms and complaints. Otherwise, patients should be closely monitored, and if necessary, medical treatment could be administered.

• Keywords: cardiac foreign bodies; gunshot traumas; intracardiac foreign bodies

1.7.12. A Rare Yet Perilous and Insidious Foe: Aortic Mural/Intraluminal Thrombus

• Ayhan Müdüroğlu, Mustafa Selçuk Atasoy and Ahmet Yüksel
• Department of cardiovascular surgery, ministry of health bursa city hospital, Bursa, Türkiye

Aortic mural thrombus are often linked with underlying aortic pathologies like aneurysms, atherosclerosis, dissection, and aortitis. They can be categorized into primary and secondary types. Secondary thrombus arise with aortic pathologies, typically seen in the descending thoracic and abdominal aorta. Primary thrombi occur in normal or minimally atherosclerotic aortas, usually pedunculated. They are mostly idiopathic but may be associated with hypercoagulability (malignancy, heparin-induced thrombocytopenia, antiphospholipid syndrome). Asymptomatic cases are incidentally diagnosed (often on computed tomography) and generally conservatively managed. Symptomatic patients receive anticoagulation, endovascular intervention, or open surgery based on history, thrombus location, size, and mobility. Ascending aorta or aortic arch thrombus warrants long-term anticoagulation due to embolic stroke risk. There is no specific treatment guide for mural thrombus.

CASE: A 47-year-old female patient, who has had systemic lupus for 7 years and has been using deltacortil and is also being treated for diabetes, hypertension and a history of mesenteric embolism, presented with complaints of pain, numbness, weakness in her left hand and discoloration of the fingertip for 2 months. Non-palpable left axillary and distal pulses, and cyanosis in the 4th and 5th left hand digits were noted. Computed tomography angiography revealed thrombosis in the aortic arch, descending thoracic aorta, left subclavian and deep femoral artery. Started on antiplatelet, anticoagulant, hospitalized, and underwent TEVAR stent graft placement under local anesthesia. Post-op, acute left iliac embolism led to embolectomy for severe pain and motor deficit in the left leg, with resolved motor deficit and capillary refill in 3 s. Failed thrombectomy via left axillary incision necessitated axillo-axillary bypass using saphenous vein. Left arm symptoms resolved, radial and ulnar pulses palpable, but no palpable left popliteal/distal pulses and claudication at 400 m persist. Currently monitored with new oral anticoagulants, antiplatelets, and cilostazol.

• Keywords: Aortic mural thrombus

1.7.13. Surgical Treatment of Delayed Diagnosis Left Ventricular Giant Pseudoaneurysm After Myocardial Infarction

• Alperen Yıldız ¹, Muhammet Çağrı Aykut ¹, Oğuzhan Birdal ², Eyüp Serhat Çalık ¹ and Ümit Arslan ¹

1

Department of Cardiovascular Surgery, Atatürk University Medical Faculty, Erzurum, Türkiye

2

Department of Cardiology, Atatürk University Medical Faculty, Erzurum, Türkiye

BACKGROUND: Left ventricular (LV) pseudoaneurysm is a rare but potentially lethal complication of myocardial infarction (MI). It may also develop following cardiac surgery, endovascular procedures, or trauma. Multimodality imaging may be required to differentiate a pseudoaneurysm from a true aneurysm and to plan the surgical treatment. Surgical intervention is required to treat pseudoaneurysm as there is a high risk of rupture.

CASE PRESENTATION: A 64 years old male patient applied to our cardiology department with shortness of breath and occasional chest and back pain. The patient had a history of hypertension, asthma and bladder cancer. The patient underwent coronary angiography and applied stenting for MI, 7 months before. Echocardiography showed 1.8 × 2.9 mm defect on the lateral wall and passage through the defect on color Doppler imaging. CT scan confirmed the echocardiographic findings. 138 × 80 × 102 mm cavity related to the defect was also detected. Surgery was planned. The patient underwent pseudoaneurysm excision and defect repair with a Teflon patch under cardiopulmonary bypass. He was taken to ICU post-surgery for 3 days. Postoperative echocardiography showed no passage through the defect and no cavity related to the defect. The patient was required long term oxygen therapy and discharged on day ten after the surgery.

• Keywords: Giant Pseudoaneurysm; delayed diagnosis; myocardial infarction; complication

1.7.14. Pseudoaneurysm Secondary to Saphenous Vein Coronary Bypass Graft Rupture

• David Carl Cistulli ¹, Gregory Harvey ², John Yiannikas ² and Paul G Bannon ¹

1

Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia

2

Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW 2139, Australia

BACKGROUND: Aortocoronary saphenous vein grafts (SVG) are frequently utilised for coronary bypass grafting. Aneurysmal formation of SVGs may occur as a late complication. The primary mechanism is thought to be venous atherosclerotic disease, however vessel wall ischaemia and a relative increase in luminal pressure may play a role. In extremely rare circumstances, SVG aneurysm may result in graft rupture. This may result in pseudoaneurysm formation or as a pericardial effusion in the theoretically obliterated pericardial space.

CASE: We describe the case of a 77 year old male with acute chest pain in the context of functional decline, abdominal pain and nausea over the previous 3 days. He had an extensive past medical history, which included coronary artery bypass grafting 15 years ago, atrial fibrillation, and peripheral arterial disease with multiple angioplasties, amputation of left leg (below knee) and all right toes, and recurrent osteomyelitis of right foot. He lived in an aged care facility for assistance with transfers. A computed tomography aortogram demonstrated a pseudoaneurysm of a coronary artery bypass graft from aorta to left anterior descending artery. His electrocardiogram showed no ischaemic changes. A bedside transthoracic echocardiogram found no obvious regional wall motion abnormalities, however did identify an anterior pericardial effusion, comprising of a combination of blood and clot. He was urgently transferred to a quaternary referral centre with cardiothoracic services, whereby he arrived in extremis. Given his condition, frailty and significant co-morbidities, emergency surgery was deemed futile and he was transitioned to end of life care.

• Keywords: Saphenous vein; graft rupture; pseudoaneurysm

1.7.15. Pediatric Myxoma Case Diagnosed with Acute Arterial Ischemia and Ischemic Stroke and Its Management

• Timuçin Sabuncu ¹, Nazlı Melis Coşkun Yücel ¹, Sinan Balcı ² and Diclehan Orhan ³

1

Department of Cardiovascular Surgery, Hacettepe University, Ankara, Turkey

2

Department of Interventional Radiology, Hacettepe University, Ankara, Turkey

3

Department of Pediatric Pathology, Hacettepe University, Ankara, Turkey

Cardiac tumors and vasculitis are the most common causes of arterial ischemic stroke in the pediatric population. Since myxoma is a rare tumor in childhood, the literature on this topic is limited.

A female patient presented with fainting, right hemiparesis, left facial paralysis, and altered consciousness. Imaging revealed acute thrombotic occlusion in the left MCA M1. The patient was evaluated for vasculitis/cardioembolism. Echocardiography showed a hyperechoic area (mass/thrombus?) in the left atrium. Cardiac CT revealed an irregularly shaped structure in the left atrium, primarily suggestive of myxoma. The patient underwent urgent thrombectomy for MCA thrombus by interventional radiology. Subsequently, she underwent surgery for the removal of the cardiac mass. Using cardiopulmonary bypass under hypothermic conditions, the material removed from the heart. In the ICU, coldness/paleness in the right leg, with no palpable arterial pulses detected. CT revealed thrombosis in the right femoral artery and left popliteal artery. Post-thrombectomy imaging showed normal perfusion in the MCA territory. The patient underwent embolectomy for the right femoral artery. She was continued on heparinization post-surgery. During the follow-up, the patient regained consciousness, while the facial paralysis resolved completely, the weakness on the right side improved but persisted. Arterial ischemia in the right leg completely resolved. After 5 days in the ICU and 2 weeks in the ward, she was discharged with following physical therapy.

Histopathological examination confirmed the diagnosis of cardiac myxoma. The material extracted from the MCA was considered to be tumor thrombus. However, no tumor tissue was found in the material from the right femoral embolectomy.

Although cardiac myxoma is a rare tumor in childhood, it can lead to ischemic stroke and embolic events, which are serious conditions. Left-sided myxomas can play a role in the etiology of stroke and arterial ischemia without causing any symptoms beforehand. Early diagnosis and mechanical thrombectomy can limit neurological deficits in the treatment of acute embolic ischemic stroke in childhood. Cardiac myxomas should be considered as a rare but important pathology in pediatric patients presenting with symptoms of stroke and arterial ischemia.

• Keywords: Ischemic stroke; Myxoma; Pediatric cardiac tumor; Cerebral thrombectomy; Thrombectomy

1.7.16. Identifying Low Arising Coronary Arteries as Risk Factors for Adverse Outcomes in Aortic Valve Intervention

• Philemon Gukop, James Dargan, Pouya Youssefi, Fizal Khan and Robin Kanagasabay
• St George’s University Hospital NHS London, London, UK

BACKGROUND AND AIM: Low arising coronary arteries ostia is a risk factors for coronary occlusion during transcatheter aortic valve intervention (TAVI). This marker of adverse outcome could preclude TAVI or require advanced techniques. Is Surgical aortic valve replacement risk free in the presence of low arising coronary artery ostia.

METHOD: CASE: A 76-year lady with symptomatic critical bicuspid aortic valve stenosis, an equipoise candidate was declined her preferred choice of TAVI due to low arising left coronary with risk of coronary obstruction on CT assessment. She had an urgent SAVR with 21 mm tissue valve, in the post operative period developed anterior STEMI. Emergency coronary angiography with IVUS demonstrated a slit like LMS ostium and emergency LMS stent was performed with good results. She subsequently developed complete heart block and a dual chamber permanent pace maker was implanted

RESULTS: She made a good recovery and was discharged home in stable condition. She was doing well with good valve function at 1 year follow up

Low arising coronary arteries is a risk factor for adverse outcomes in both TAVI and SAVR and requires careful consideration by the hear team.

CONCLUSIONS: Low arising coronary artery ostia is a marker of adverse outcomes during aortic valve intervention and should be factored in risk profile and discussions with patients prior to intervention

• Keywords: Aortic Stenosis; Transcatheter aortic valve interventions TAVI; Surgical aortic valve replacement SAVR; Low arising coronary ostia; adverse outcomes; risk of coronary obstruction

1.7.17. Urgent CABG Surgery of Achondroplasia Patient with Low Ejection Fraction

• Mehmet Aydin Kahraman, Gözde Tekïn, Huseyïn Uzandi, Selen Öztürk, Süleyman Aycan and Mehmet Kizilay
• Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Education Research Hospital, Istanbul, Turkey

Introduction: Achondroplasia is a hereditary disease caused by an anomaly in the FGFR3 gene, which accounts for 80% of the causes of dwarfism. The need for cardiac surgery in patients with achondroplasia, a musculoskeletal disease characterized by short limbs that occur in 1:25,000 in the general population, is a non-routine and alarming situation for cardiac surgeons.

Case: We will share about the urgent coronary bypass surgery and management of the post-operative process of a 62-year-old male patient of Turkish origin with achondroplasia, 20% ejection fraction, LMCA lesion and known Leriche Syndrome. After RCA, CX, DIA and LAD-LIMA distal and proximal anastomoses were made, IABP was considered for the patient who could not get out of CPB despite high dose inotropic support, but as intervention could not be achieved due to peripheral artery disease, it was decided to install central ECMO. After ECMO insertion, the patient was monitored in the ICU with the sternum open and the skin closed, with an ECMO flow of 2.70 and RPM of 1950.

On the 6th postoperative day, the patient was weaned from central ECMO after the desired hemodynamic stability was achieved with a low inotrope dose and low ECMO flow. The patient, who was extubated on the 8th day of the operation, was admitted to the regular hospital room on the 23rd post-operative day and was discharged on the 30th post-operative day. Follow up controls one week, one month after discharge revealed no pathologies and our patient was objectively and subjectively well.

Conclusions: Although operating on a patient with achondroplasia is a non-routine and unsettling situation for adult cardiac surgeons, these patients can be discharged in good health with successful surgery and meticulous post-operative management.

• Keywords: achondroplasia; low ejection fraction; urgent CABG; ECMO; Leriche

1.7.18. Neurological Complications in Cardiac Surgery Patients with Different Forms of Coronary Artery Disease

• Olena Gogayeva, Anatolii Rudenko and Serhii Rudenko
  Department of Surgical Treatment of Ischemic Heart Disease, GF “National Amosov Institute of cardiovascular surgery NAMS of Ukraine”, Kyiv, Ukraine

BACKGROUND AND AIM: Despite the maximum preventive measures in modern cardiac surgery, the level of cerebral postoperative complications is 1.5–6%. To analyze neurological complications in cardiac surgery patients with different forms of coronary artery disease (CAD)

METHOD: A retrospective analysis of 354 random high-risk patients with CAD with an average EuroSCORE 8.8%. All patients underwent ECG, ECHO, coronary angiography, surgical myocardial revascularization with correction of complicated forms of CAD in 160 cases. Preoperative ultrasound study (US) of the brachiocephalic arteries (BCA) was performed for 280 (79.09%) patients.

RESULTS: The history of stroke had 43 (12.1%) patients. Among 280 patients who underwent US of BCA, stenosis of the internal carotid arteries more than 50% was diagnosed in 95 (33.9%) cases. In the postoperative period, in 10 (2.8%) patients non-fatal cerebrovascular complications (CVC) were developed, among which 5 (1.4%) had an ischemic stroke, and 5 (1.4%) had a transient ischemic attack (TIA). Among patients with isolated CAD, CVC occurred in 6 (3.09%) persons, including TIA—in 2 (1.03%), stroke—in 4 (2.06%). Among patients with complicated CAD, focal and cerebral neurological symptoms in the postoperative period were registered in 4 (2.5%) patients, of whom 3 (1.8%) with TIA neurological symptoms regressed, and in 1 (0.62%) patient with diagnosed ischemic stroke—were stable ones. Analysis of perioperative period showed: the risk of CVC increases in patients with history of stroke (50%, p = 0.0002), aortic calcification (40%, p = 0.003), preoperative atrial fibrillation (30%, p = 0.013) and more significant decrease of blood pressure on the 1st postoperative day (p = 0.005).

CONCLUSIONS: The work of a multidisciplinary team helps to avoid life-threatening events. The cardiac surgeon should avoid manipulations on the atheromatous aorta by performing total arterial revascularization. Individual approach with strict monitoring of blood pressure and prevention of hypotension are required at all stages of perioperative patients management.

• Keywords: coronary artery disease; cardiac surgery; CABG; cerebral atherosclerosis; stroke; on pump

1.7.19. Coronary Artery Bypass Graft Surgery in a Gout Patient

• Gizem Duygu Kılıçarslan, Ali Kemal Karpuz, Sefer Usta and Mine Demirbaş
• Sbu Ahi Evren Gkdc Education Hospital, Trabzon, Turkey

Gout usually presents with a clinical picture of arthritis. Gouty arthritis involves the metatarsophalangeal joint of the big toe earliest and most commonly. Upper extremity involvement is less common than lower extremity involvement. Symptoms usually start at night and occur suddenly. Increased temperature, pain, swelling, redness and tenderness are observed in the affected joints in the acute period, and these findings may resolve spontaneously within days without treatment. The goal of treatment in acute arthritis attack is to reduce pain and to end the acute exacerbation period as soon as possible. Colchicine, nonsteroidal anti-inflammatory drugs, glucocorticoids (considering the patient’s age and comorbidities) may be given in the treatment. Antihyperuricemic treatment is not given in acute attack. Antihyperuricemic treatment further exacerbates the gout attack and may prolong the duration of the attack.

CASE REPORT: A 79-year-old male patient was admitted to the emergency room with chest pain for four and a half months and recent increase in back pain. Coronary angiography revealed LAD 80%, RCA 60%, CX 70% occlusion. The patient was presented to the cardiac team and coronary artery bypass surgery was recommended with the decision of the council. The patient was then transferred to our clinic for surgical planning. Thoracic tomography showed no calcification in the ascending aorta and normal aortic diameter. Ejection fraction was 60%, mild mitral valve regurgitation, mild aortic valve regurgitation and trace tricuspid regurgitation were detected on echocardiography. Carotid doppler ultrasonography revealed no stenosis. Rheumatology was consulted in preoperative preparations. Their opinions and recommendations were obtained preoperatively and postoperatively. Since nutrition was closely related with gout attacks, a dietician was consulted for calorie calculation and nutritional recommendations

• Keywords: Coronary artery disease; gout; monosodium urate crystals

1.7.20. Iatrogenic Tracheal Rupture After CABG: A Case Report

• Sefer Usta and Hasan Hamzaoğlu
• Sbu Ahi Evren Gkdc Education Hospital, Trabzon, Turkey

Tracheal rupture can occur spontaneously or due to trauma. This trauma can be a direct trauma or an iatrogenic trauma. Identified risk factors include long-term steroid use, COPD, and occupational diseases that cause lung problems. Diagnosing the disease quickly and providing appropriate treatment are very important for the survival of patients. Although the patient’s clinic and radiological imaging are useful in giving an idea about the disease, the definitive diagnosis is made by bronchoscopy. After the diagnosis is made, the treatment that must be decided by taking into account the patient’s condition is conservative or surgical intervention.

We present a case report in which tracheal rupture due to iatrogenic trauma in a patient undergoing CABG surgery may be fatal. The patient, a 62-year-old man who had been working as a shoe repairman for more than 40 years, had no known disease. The patient, who applied to an external center with complaints of chest pain and shortness of breath, was referred to our hospital after his troponin level was high. Urgent coronary angiography was planned for the patient whose complaints were specific and whose troponin was high. CABG decision was made for the patient who had stenosis in the left main coronary and proximal LAD. Since the patient had intermittent short-term ventricular tachycardia attacks and continued chest pain, it was decided to install an IABP before being taken into emergency surgery. It was decided to wait 3 days for the operation because the patient’s chest pain disappeared after IABP and there was no VT attack. The troponin level was high and ticagrelor and acetylsalicylic acid loading was performed before coronary angiography. During this period, the patient did not have chest pain, and was monitored in sinus rhythm with 100 mg ASA per day and low molecular weight heparin every 12 h.

• Keywords: bypass; Pneumothorax; tracheal rupture

1.7.21. Clinical Case of Urgent Cardiac Surgery for Patient with Thrombotic Occlusion of Internal Carotid Artery and Floating Thrombus in the Left Ventricle

• Olena Gogayeva, Oleksandr Nudchenko, Yevhenii Aksonov, Natalia Ioffe and Anatolii Rudenko
  Department of Surgical Treatment of Ischemic Heart Disease, GF “National Amosov Institute of cardiovascular surgery NAMS of Ukraine”, Kyiv, Ukraine

BACKGROUND: One of the life-threatening complications of acute myocardial infarction (AMI) is left ventricular aneurysm (LVA). The presence of a thrombus in the aneurysmal sac is fraught with embolic complications.

CASE REPORT: A 65-year-old patient was admitted to the Institute with complaints on shortness of breath, palpitation and limb edema. 11 years ago he suffered AMI but didn’t consult cardiologist till hospitalization to the hospital with cardiac asthma 3 weeks ago. The patient’s comorbidity: type 2 DM, gout, obesity. In admittance on ECG signs of aneurysm of anterior-septal-apical wall of left ventricle (LV) were detected. On Echo study we found severe decrease of global contractility of LV due to widespread postinfarction scar and LVA with EF 22%, EDV 275 mL, floating thrombus 5.5 × 2.35 cm, pulmonary hypertension. Ultrasound screening of the brachiocephalic arteries (BCA) revealed thrombotic occlusion of the right internal carotid artery (RICA), that was confirmed by CT study. Coronary angiography found occlusion of LAD and subocclusion of the DB LCA, arteria intermedia and 1 OM. Despite the RICA occlusion, the patient hadn’t neurological deficit and was consulted by neurosurgeon—there were no absolute contraindications for cardiac surgery. ES II risk was 14.88%. After heart team discussion we performed an operation: CABG with resection of LVA with thrombectomy on-pump. Operation duration 6 h, aortic cross-clamp time 79 min, perfusion time 152 min, blood loss 250 mL. The postoperative period was uneventful, systolic blood pressure was maintained at 130 mmHg, the patient was discharged on 10 postop day with positive dynamic (EF 25%, EDV 221 mL).

CONCLUSIONS: this clinical case demonstrates successful surgical treatment of the patient with LVA with floating thrombus and thrombotic occlusion of RICA. The key to success in the treatment is careful planning of perioperative management by the Heart team and stability of hemodynamic parameters.

• Keywords: floating thrombus; left ventricle aneurysm; on pump; thrombotic occlusion; heart team; high risk

1.8. CARDIAC » Complex Congenital Heart Disease

1.8.1. Minimal Invasive Right Vertical Axillary Thoracotomy for Repair of Congenital Heart Defects—Azerbaijan Experience

• Kamran Ahmadov ¹, Kamran Musayev ¹, Ilkin Osmanov ¹, Fahreddin Alekberov ¹ and Veli Behbudov ²

1

Department of Cardiovascular Surgery, Merkezi Klinika, Baku, Azerbaijan

2

Department of Pediatric Cardiology, Merkezi Klinika, Baku, Azerbaijan

BACKGROUND AND AIM: This study assesses the outcomes of a minimal invasive right vertical axillary thoracotomy approach for repairing various congenital heart defects in the pediatric population in Azerbaijan.

METHOD: A retrospective review was conducted on consecutive patients who underwent repair of congenital heart defects using the minimal invasive right vertical axillary thoracotomy approach between April 2022 and March 2024 at our institution. The study involved a total of 49 patients, including 34 with atrial septal defect (ASD), 9 with ventricular septal defect, 4 with sinus venosus type ASD with partial anomalous pulmonary venous drainage (PAPVD), and 2 with atrioventricular septal defect (1 partial type and 1 intermediate type). The incision ranged from 3.0 to 5.0 cm in all patients.

RESULTS: The median age was 6 years (range: 6 months–13 years). The median weight was 15.5 kg (range: 8–41 kg). The median hospital stay was 4.5 days, with median cardiopulmonary and cross-clamp times of 46 and 22 min, respectively. No in-hospital deaths or conversions to median sternotomy occurred. One patient (sinus venosus type ASD + PAPVD) experienced transient atrioventricular block, resolved on the 1st postoperative day with a return to normal sinus rhythm. Two patients presented with superficial wound infections. No late deaths or reoperations occurred during follow-up, and there were no surgery-related thoracic deformities or breast asymmetry noted.

CONCLUSIONS: The minimal invasive right vertical axillary thoracotomy approach can be safely employed for a broad spectrum of congenital heart defects, yielding excellent cosmetic results. It stands as a good alternative to median sternotomy.

• Keywords: Minimal invasive carrdiac surgery; right vertical axillary thoracotomy; congenital heart defect

1.8.2. Bridging the Gap: Innovative Approaches in Treating Tetralogy of Fallot with Absent Pulmonary Valve Syndrome

• Ergïn Arslanoğlu ¹, Shiraslan Bakhshaliyev ² and Fatih Yigit ³

1

Cemil Tascioglu City Hospital, Istanbul, Turkey

2

Liv Bona Dea Hospital, Baku, Azerbaijan

3

Kosuyolu Trainning and Research Hospital, Istanbul, Turkey

BACKGROUND AND AIM: Tetralogy of Fallot with absent pulmonary valve syndrome is a complex congenital heart defect associated with significant morbidity and mortality rates. The syndrome is characterized by features such as massively dilated main and left pulmonary arteries, as seen in echocardiograms, and can be associated with other anomalies like obstructed totally anomalous pulmonary venous connection. Additionally, the absence of the left pulmonary artery is observed in a subset of cases. Furthermore, the syndrome can present challenges postoperatively, with cases of tracheobronchial anomalies possibly due to airway compression from dilated pulmonary arteries secondary to severe pulmonary regurgitation. In some instances, dilatation of the main pulmonary artery can lead to compression and obstruction of the tracheobronchial tree.

METHOD: Constructing a pulmonary valve using the right atrial appendage is not a standard procedure in cardiac surgery. The pulmonary valve is typically located between the right ventricle and the pulmonary artery, responsible for regulating blood flow from the heart to the lungs. In cases of congenital heart defects like tetralogy of Fallot, where pulmonary valve dysfunction is common, surgical repair may involve techniques like pulmonary valve replacement with right atrial appendage.

RESULTS: Two patients who underwent complete correction of the right atrial appendage due to absent pulmonary valve between 2021 and 2024 were included in the study. Two patients, aged 6 months (5.6 kg, male) and 8 months (7 kg, female), were admitted to the service 5 and 7 days postoperatively, respectively. They were discharged on postoperative days 9 and 17. Arrhythmia (JET) was observed in the 6-month-old patient in the early postoperative period.

CONCLUSIONS: In conclusion, tetralogy of Fallot with absent pulmonary valve syndrome is a rare and severe form of congenital heart disease that requires careful management and monitoring due to its associated complications and high mortality rates in the operative period.

• Keywords: Fallot tetralogy; absent pulmonary valve; right atrial appendage valve; congenital heart surgery

1.8.3. Pediatric Arcus Aorta Surgery: Precision in Practice

• Ergïn Arslanoğlu ¹, Shiraslan Bakhshaliyev ² and Fatih Yigit ³

1

Cemil Tascioglu City Hospital, Istanbul, Turkey

2

Liv Bona Dea Hospital, Baku, Azerbaijan

3

Kosuyolu Trainning and Research Hospital, Istanbul, Turkey

BACKGROUND AND AIM: Pediatric aortic arch reconstruction stands at the forefront of surgical innovation, representing a critical advancement in addressing congenital heart defects. As a pivotal procedure in pediatric cardiac surgery, its outcomes profoundly impact the quality of life and long-term prognosis of young patients. However, despite advancements in surgical techniques and perioperative care, challenges persist in achieving optimal results. In this research, we delve into the intricate landscape of pediatric arcus aorta reconstruction, examining not only the technical intricacies of the procedure but also the nuanced outcomes that shape the field. By synthesizing current research findings and clinical experiences, we aim to illuminate the successes, limitations, and ongoing debates surrounding this vital aspect of pediatric cardiac care.

METHOD: Patients who underwent arcus aortic reconstruction between June 2021 and January 2024 were included in the study. The procedure was performed by placing an X clamp under antegrade cerebral perfusion. Autologous pericardium was used as patch material.

RESULTS: 21 patients were included in the study. The ages of the patients included in the study ranged between 3 and 276 days, and the average was calculated as 43.76 ± 73.28. The weight of the patients ranged between 2.30 and 6.40 kg, and the average was calculated as 3.42 ± 1.24 kg. 11 of the patients were male (52.3%). Mortality was calculated as 9.5%. ECMO was required in 1 patient (4.7%). Balloon angioplasty was performed in 1 patient (4.7%).

CONCLUSIONS: From the optimization of surgical approaches to the management of postoperative complications, every facet of pediatric arcus aorta reconstruction demands meticulous attention and continual refinement. Through comprehensive analysis and critical reflection, we endeavor to provide insights that not only inform clinical practice but also inspire further innovation in the pursuit of improved outcomes and enhanced quality of life for pediatric patients undergoing aortic arch reconstruction.

• Keywords: aortic arch reconstruction; cardiac surgery

1.9. CARDIAC » Coronary Artery Bypass in Women

1.9.1. Survival After CABG Women vs. Men—13-Year Results from KROK Registry

• Grzegorz Hirnle ¹, Adrian Stankiewicz ¹, Maciej Mitrosz ¹, Sleiman Sebastian About Hassan ², Marek Deja ³, Jan Rogowski ⁴, Romuald Cichon ⁵, Lech Anisimowicz ⁶, Pawel Bugajski ⁷, Zdzislaw Tobota ⁸, Bohdan Maruszewski ⁸ and Tomasz Hrapkowicz ⁹

1

Department of Cardiac Surgery, Medical University of Bialystok, Białystok, Poland

2

Department of Cardiac Surgery, Zbigniew Religa Heart Center “Medinet”, Nowa Sol, Poland

3

Department of Cardiac Surgery, Upper-Silesian Medical Centre, Medical University of Silesia, Katowice, Poland

4

Department of Cardiac and Vascular Surgery, Medical University of Gdansk, Gdańsk, Poland

5

Lower Silesian Center for Heart Diseases MEDINET, Wrocław, Poland

6

Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland

7

Department of Cardiac Surgery, J. Struś Hospital, Poznań, Poland

8

Department of Paediatric Cardiothoracic Surgery, Children’s Memorial Health Institute, Warszawa, Poland

9

Department of Cardiac Surgery, Heart Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland

BACKGROUND AND AIM: The influence of gender on early and long-term outcomes of CABG is not clearly defined. The study aimed to assess the impact of gender on early and long-term mortality after CABG using data from the KROK Registry.

METHOD: All 133,973 adult patients who underwent coronary artery bypass grafting (CABG) in Poland between 01 January 2009 and 31 December 2019 were included in the Polish National Registry of Cardiac Surgical Procedures (KROK Registry). The study enrolled 90,541 patients; 68,401 men (75.55%) and 22,140 women (24.45%) who met the inclusion criteria. A 30-day, 1-year mortality, and long-term mortality rates were compared.

RESULTS: Before the matching, higher age, CCS, NYHA class, and EuroSCORE II values, hypercholesterolemia, diabetes, arterial hypertension, BMI > 35 kg/m², also renal failure were more frequently observed in women. Women underwent more frequently urgent surgery, single and double graft surgery, and off-pump CABG (OPCAB) (p < 0.001). In men, longer operative time were noted more often (p < 0.001). Early mortality was significantly higher in the group of women (3.4% versus 2.8%, p < 0.001). The annual mortality remained higher in this group (6.6% versus 6.0%, p = 0.025). However, long-term mortality differed significantly between the groups and was higher in the male group (33.0% men versus 28.8% women, p < 0.001).

CONCLUSIONS: Women undergoing CABG had worse preoperative profiles than men, but, despite initially higher surgical risk, had better long-term survival than men. An early mortality was higher for women than for men. Gender is not a discriminating factor in determining the surgical strategy.

• Keywords: coronary artery bypass grafting; gender differences; long-term survival

1.9.2. Female Gender Is Not a Risk Factor for Early Mortality After Coronary Artery Bypass Grafting

• Kanwar Talha Shahid, Ahson Memon, Malik Shafqat Hassan, Syed Shahzad Hussain Rizvi, Dost Muhammad, Maryam Ateeq, Fayyaz Memon and Ahsan Waqar
• Department of Cardiothoracic Surgery, Tabba Heart Institute, Karachi, Pakistan

BACKGROUND AND AIM: The female gender is considered as a risk factor for morbidity and mortality after coronary artery bypass grafting (CABG). In this analysis, we assessed the impact of female gender on early outcome after CABG.

METHOD: Patients were categorized according to gender, and potential differences in pre-operative and post-operative factors were explored. Significant risk factors were then built in a multivariate model to account for differences in predicting gender influence on surgical outcome. 726 consecutive patients underwent first time CABG between January 2023 and December 2023. 150 (20%) patients were females. These patients formed the study group.

RESULTS: The in-house and 30-day mortality rates were comparable between females and males (2.6% versus 2.1%, p = 0.476). Re-operations due to bleeding were more frequent among male patients (3.65% in males versus 1.33% in females, p = 0.114). Incidence of mediastinal infections was higher in males (0.52% in males versus 0.0% in females, p = 0.499). Male patients experienced more strokes (0.35% in males versus 0.0% in females, p = 0.629), while renal failure was more prevalent in females (2.0% in females versus 0.87% in males, p = 0.217). Arrhythmias were more common among female patients (14.0% in females versus 11.98% in males, p = 0.293).

CONCLUSIONS: Early mortality in females was almost similar to that of males. Females were associated with higher incidence of arrhythmias and renal failure.

• Keywords: Coronary artery bypass grafting; female gender; in-house mortality

1.9.3. Small Is the New Big?: Minimally Invasive CABG for Women

• Muhammad Ibrahim Azmi ¹, Harith Amirizal Ariff ¹, Ashvin Krishna Nair ¹ and Shahrul Amry Hashim ²

1

Cardiothoracic Unit, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia

2

Cardiothoracic Unit, KPJ Damansara Specialist Hospital 2, Kuala Lumpur, Malaysia

BACKGROUND AND AIM: Women are known to have poorer outcomes following CABG. There is a theoretical benefit of minimally invasive CABG which may improve outcomes. We compared our Total Coronary Revascularisation via Anterior Thoracotomy (TCRAT) to conventional CABG (cCABG) cases in women.

METHOD: Retrospectively, we reviewed our database on all female patients who underwent TCRAT and compared to those who underwent cCABG within the same timeline. The primary outcomes were the composite of positive transit time flow measurement (TTFM), repeat revascularisation and 30-day MACCE. For secondary outcomes, we looked into surgical site infection, readmission, and length of stay (LOS).

RESULTS: From January 2023 to March 2024 there were a total of 30 female patients who underwent coronary bypass surgery. They are 12 TCRAT and 18 cCABG. The average grafts for TCRAT and cCABG cases were 2.6 vs. 3.2 grafts respectively. None of the cases received lesser grafts than earlier planned. 8.3% of the TCRAT and 16.7% of the cCABG cases received multi-arterial grafts. One of the TCRAT case underwent endoscopic internal mammary harvesting. TCRAT group has no cases with positive TTFM compared to 1 (5.6%) case of cCABG. 1 (5.6%) cCABG case underwent repeat revascularisation and had 1 (5.6%) cardiovascular death. TCRAT group had 1 (8.3%) stroke. 2 (16.7%) TCRAT cases were readmitted for surgical site infection.

CONCLUSIONS: In our small female cohort, TCRAT cases have shown better cardiovascular outcomes in terms of anastomosis quality, repeat revascularisation, and 30-day cardiovascular death compared to cCABG. Nonetheless there was a trade off in cerebrovascular event.

• Keywords: CABG; Women; Coronary Revascularisation; TCRAT; MICS; Minimally Invasive

1.9.4. Surgical Outcomes and Sex Differences in Coronary Artery Bypass Graft Surgery

• Guglielmo Saitto ¹, Mariangela D’ovidio ², Antonio Cammardella ¹, Marina Comisso ¹, Marco Russo ¹, Ilaria Chirichilli ¹, Francesca Nicolò ¹, Francesco Irace ¹, Corrado Tramontin ¹, Antonio Lio ¹, Marina Davoli ² and Federico Ranocchi ¹

1

Cardiac Surgery and Heart Transplantation Unit, San Camillo Hospital, Rome, Italy

2

Department of Epidemiology, Lazio Regional Health Service/ASL Roma 1, Rome, Italy

BACKGROUND AND AIM: Coronary artery bypass grafting (CABG) is the most commonly performed cardiac surgery globally. The aim of the study is to investigate outcome of CABG according to participant sex in the real word.

METHOD: We retrospective analysed 20,337 CABG operations performed in an Italian Region, Lazio, using a regional administrative dataset.

RESULTS: Between 2008 and 2022, 16,983 male and 3354 female patients underwent CABG and were analysed. At baseline male patients had lower left ventricle ejection fraction (LVEF < 30% 3.52% vs. 2.68; 30 < LVEF < 50 34.19% vs. 31%; LVFE > 50% 62.2% vs. 66.2%, p < 0.0001) but with a lower risk profile: female patients were older (70 + 9 vs. 66 + 9.5 yo, p < 0.05), more diabetics (28 vs. 20%, p < 0.0001), cholesterol disorders (20.5% vs. 17.6%, p < 0.0001), obesity (2.6 vs. 1.6%, p < 0.0001), anemia (3.6 vs. 1.7 %, p < 0.0001), arterial hypertension (43.3 vs. 36.6%, p < 0.0001) and heart failure symptoms (10.1 vs. 7.1%, p > 0.0001). Even if early mortality (30d) was higher in female vs. male patients (3.1% vs. 1.9%, p < 0.05), long term survival was higher in women at 5 and 10y respectively 88 vs. 87% and 73 vs. 70%.

CONCLUSIONS: Our data suggest that female sex could be associated to a higher profile risk and 30 d mortality after CABG but in the long term could be protective.

• Keywords: CABG; myocardial revascularization; Woman; Long term outcomes

1.10. CARDIAC » Diffuse Coronary Disease and Endarterectomy

1.10.1. Early Diagnosis of Asymptomatic Ischemic Heart Disease in Patients with Hemodynamic Significant Stenosis in the Carotid Arteries

• Doniyor Xamidjonovich Nurmatov ¹, Abdurasul Abdujalilovich Yulbarisov ¹, Rustam Tulkinboyevich Muminov ¹, Abduvali Abdumutalovich Djalilov ¹ and Zamira Baxromovna Xolmurodova ²

1

Republican Special Center of Surgical Angoneurology, Tashkent, Uzbekistan

2

Jizzakh Branch of the Republican Scientific Center for Emergency Medical Care, Jizzakh, Uzbekistan

BACKGROUND AND AIM: reduction of complications caused by cardiovascular diseases during carotid endarterectomy (CEAE) in patients with asymptomatic ischemic heart disease (IHD), in the near and long term after the operation.

METHOD: In 2020–2022, 150 patients with significant hemodynamic stenosis of the carotid artery admitted to the Department of Vascular Surgery of Multidisciplinary Clinic of Tashkent Medical Academy and Republican Specialized Center of Surgical Angioneurology underwent selective coronary angiography before the CEAE procedure. Among the patients, 87 (58%) are men, 63 (42%) are women. Complaints and anamnesis were collected in all patients, accepted general clinical examination methods were performed. Patients were followed up for up to 12 months after the procedure.

RESULTS: According to the conclusion of coronary angiography, 101 (67.3%) patients had high stenosis in coronary vessels in 50%. 46 (30.67%) of these patients underwent coronary artery intervention (percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)) in the first stage and CEAE in the second stage. 55 patients underwent CEAE in the first stage and intervention in coronary vessels in the second stage. Complications such as myocardial infarction, stroke, and death were not observed in these patients during the operation, in the early postoperative period, and during the 12 months after the operation. During the follow-up, 2 patients.

CONCLUSIONS: 1. Consideration of patients with hemodynamically significant stenosis of the carotid vessels as patients with probable IHD and selection of their treatment tactics requires an individual and multidisciplinary approach.

2. Systematic coronary angiography before CAE in patients with asymptomatic CHD and performing PCI or CABG in patients with coronary vessel changes can significantly reduce early and late cardiovascular complications after CAE and increase patient life expectancy.

• Keywords: carotid endarterectomy; ischemic heart disease; coronary angiography

1.10.2. Coronary Artery Bypass Grafting in Patients with Angiographically Unverified Distal Bed of the Main Coronary Arteries

• Dmitrii Vladislavovich Petrovskii ¹, Vladislav Petrovich Vasiliev ¹, Andrey Andreevich Shiryaev ¹, Ruslan Sergeevich Latypov ¹, Damir Mazitovich Galyautdinov ¹, Elina Yevgenievna Vlasova ¹, Tatiana Nikolaevna Veselova ² and Renat Suleymanovich Akchurin ¹

1

Cardiosurgery Department, FSBI “NMRCC named after Academician E.I. Chazov” of MH of RF, Moscow, Russia

2

Laboratory of Computed Tomography, FSBI “NMRCC named after Academician E.I. Chazov” of MH of RF, Moscow, Russia

BACKGROUND AND AIM: In practice of treating CAD, difficult lesions of CA such as diffuse or calcified lesions are becoming increasingly common. One of difficult types of lesion is characterized as angiographically “unverified distal bed” (UDB). Coronary surgeons often refuse in CABG precisely because of such lesions. Aim of this study is approving CABG to main CA with UDB.

METHOD: 64 patients with one or more main CA with UDB who underwent CABG 09.2022–02.2024 (76% males, mean age 64 ± 9 years, revascularization index 4 [3, 4). 78 arteries were classified as UDB, 73 (94%) were bypassed and formed the first group. Group 2 included bypassed arteries with angiographically verified distal bed (VDB)—178 CA. Intraoperative and hospital results and the early patency of the bypasses were studied.

RESULTS: The average operation time was 267 ± 41 min and coincided with standard CABG in our department. 251 distal anastomoses were performed: 73 (29%)—to CA with UDB, 178 (71%) to arteries with VDB. Diameters of bypassed arteries and TTF didn’t show significant difference in both groups. 33 patients (52%) underwent CT-angiography on 7 [6, 8] day after surgery: 45 (62%) grafts was analyzed in the first group, 105 (58%)—in second. The patency of grafts was 42 (93%) vs. 102 (97%), p = 0.36. One (2%) perioperative MI was recorded: patient had inadequate functioning graft to CA with VDB (CT showed that graft was contrasted throughout its entire length without visualization of the CA bed). No ischemic events were observed in patients with nonfunctioning grafts to CA with UDB. Other patients didn’t have angina during the hospital period. All patients were discharged on 8 [8, 10] day after surgery.

CONCLUSIONS: Intraoperatively, CA with UDB are well visualized, and can still be bypassed with satisfactory results. Their early patency has no different with CA with VDB.

• Keywords: CABG; CT-angiography; diffuse lesion; coronary artery

1.10.3. Diffuse Coronary Artery Disease and Coronary Endarterectomy

• Kanwar Talha Shahid, Ahson Memon, Malik Shafqat Hassan, Syed Shahzad Hussain Rizvi, Maryam Ateeq, Fayyaz Memon, Ahsan Waqar and Dost Muhammad
• Department of Cardiothoracic Surgery, Tabba Heart Institute, Karachi, Pakistan

BACKGROUND AND AIM: It is still a challenge for the cardiac surgeons to achieve adequate revascularization for diffused coronary artery disease (CAD). Coronary endarterectomy (CE) offers an alternative choice of coronary artery reconstruction and revascularization. Short-term results of CE combined with coronary artery bypass graft (CABG) were discussed in the treatment for the diffused CAD.

METHOD: From January 2022 to December 2023, out of 1583 CABGs performed, 159 patients had undergone coronary endarterectomy. The age range being from 39 to 77 years, M: F is 6.5:1. Hypertension was present in 118 (74.2%), diabetes mellitus in 109 (68.5%), smoking in 31 (19.5%) and dyslipidemia in 46 (29%) cases. Old myocardial infarction was present in 31% cases, unstable angina in 20%, stable angina in 0.7% and cardiogenic shock in 0.1% cases. All cases had undergone coronary artery bypass grafting with endarterectomy. Out of 75 LAD endarterectomies, in 71 cases LIMA was used as on-lay patch.

RESULTS: The average number of grafts anastomosed were 3.3. Single-vessel endarterectomy was done in 132, and double-vessel in 27 cases. LAD endarterectomy was done in 75, RCA in 60, PDA in 20, marginals (OM1 and OM2) in 11, diagonal in 06, LPL in 03 and ramus in 03 cases. Postoperatively, 20 patients had arrhythmias, 3 perioperative MI, 04 recurrent angina and 06 congestive cardiac failure (CCF). There was 4 (2.5%) mortality.

CONCLUSIONS: Hypertension and smoking are major risk factors. LAD is the most common artery requiring endarterectomy. Usage of LIMA following endarterectomy of LAD is quite satisfactory and short term results are encouraging.

• Keywords: Diffuse coronary artery disease; Coronary artery bypass grafting (CABG); Coronary Endarterectomy (CE)

1.10.4. Outcomes of CABG with Left Anterior Descending Artery Endarterectomy and Left Anterior Descending Artery Reconstruction by Extended with Left Internal Memory Artery Patch with Diffuse Left Anterior Descending Artery Disease

• Sajid Khan ¹, Abdul Malik ¹, Muhammad Gibran khan ² and Nasir Islam Khattak ¹

1

Department of Cardiac Surgery, Afridi Mediacal and Teaching Hospital, Peshawar, Pakistan

2

Department of Cardiac Surgery, Peshawar General Hospital, Peshawar, Pakistan

BACKGROUND AND AIM: To determine short term surgical outcome of LAD endarterectomy and LAD reconstruction with extended lima patch in patient with critical diffuse lad disease in our hospital.

METHOD: Our database of patients who underwent Cardiac Surgery was reviewed. Patients who underwent Coronary Artery Bypass Grafting between June 2020 to December 2023 were identified. The basic demographics of 25 patients found were taken from the database. Information about these patients was taken from the database as well, and their Electronic Medical Records were also reviewed. The data was compiled, and basic statistics were derived using SPSS version 26.

RESULTS: A total of 25 patients who underwent Coronary Artery Bypass Grafting with left anterior descending artery endarterectomy plus lad reconstruction with lima patch were identified. Twenty-four of the patients were male. The average age was 59.23 years. All twenty-five patients (100%) received a LIMA onlay patch. The mean length of patch reconstruction ranged from 3 to 7 cm (8.31 ± 1.16 cm vs. 5.64 ± 0.73 cm, p < 0.001). NO patient has MI, but two patients required reopening/Operative mortality was nil (

Table 5. Operative detail.

Operative details Nature of surgery Urgent Elective n = 185 n = 19 90.7% 9.3% Numbers of grafts Mean 3.08 grafts ± 0.56 Range 1–4 grafts Two grafts (n = 24) Three grafts (n = 139) Four grafts (n = 41) 11.8% 68.1% 20.1% LIMA harvest LIMA not used/harvested n = 202 n = 2 99% 1% LIMA to LAD SVG to LAD LIMA to Diagonal LIMA to Ramus n = 196 n = 8 n = 2 n = 4 96.1% 3.9% 1% 2% Endarterectomy LAD Diagonal OM RCA/PDA n = 19 n = 4 n = 3 n = 2 n = 10 9.3% 1.9% 1.5% 1% 4.9% Cross clamp time Mean 40.23 min ± 7.1 SD Range 21–76 min CPB Time Mean 73.41 min ± 17.2 SD Range 48–230 min Intra-Aortic Balloon Pump n = 4 2%

). The average follow-up duration ranged from 15 days to 6 months. During follow-up t there was observed improvement in EF and functional status.

Patients were hypertensive. 12 patients were diabetic. 5 had a history of smoking. 4 patients had a history of MI. T. The average bypass time was noted to be 110 min with a mean cross-clamp time of 70 min. One patient required IABP placement. Postoperatively, the average time to extubation was 12.8 h. Two cases were shifted to the OT for reopening for bleeding. Three had fast atrial fibrillation. None of our patients expired. None of our patients were reintubated.

CONCLUSIONS: Results of Left Anterior descending artery endarterectomy and reconstruction by extended Left internal mammary artery patch is feasible and effective.

Keywords: lad endarterectomy and reconstruction with left internal mammary artery patch

1.10.5. Diffuse Coronary Artery Disease Endarteriectomy and Stent Removal TECHNICS and Results

• Abdennadher Mohamed and Kallel Samy
• Department of Cardiovascular Surgery, ELALYA Clinic, Sfax, Tunisia

Recently, cardiac surgeons are facing increasingly complex CABG due to increased comorbid conditions and previous percutaneous interventions for coronary disease which often requires endarterectomy.

The main indication for CE is the presence of discursively diseased coronary arteries that are not suited for distal grafting

The basic principle of coronary endarterictomy is to extract the plaque completely. CE can be performed by either closed or an open technique. the presence of 1 or more stents within the anastomotic segment of a coronary artery impose stents removal via open endarteriectomy making bypass surgery feasible.

With increasing experience of total arterial grafting in CABG, surgeons have started using arterial conduits for endarterectomised vessels.

Although CE has been performed on all coronary arteries safely, there is some evidence which suggests that endarterectomy of the Left Anterior Descending (LAD) coronary artery may be particularly hazardous; Most surgeons, therefore, perform LAD endarterectomy in a highly selective manner when no other alternatives exist. The LAD atherosclerotic plaque is hard and frail as compared to Right Coronary Artery (RCA), thereby increasing the risk of disruption

Results of single vessel LAD endarterectomy are better than multiple vessel endarterectomies.

At present there is no unified guideline available regarding the use of antiplatelet or anticoagulation therapy in patients undergoing CE and initial report supports use of antifibrinolytic therapy in postoperative period

• Keywords: coronary; endarteriectomy; stent removal

1.11. CARDIAC » ERAS and New Techniques and Technologies

1.11.1. Study Design Method for Objective Validation of Coaptation Length Prediction Accuracy: Use with Novel Paired-Ring Mitral/Tricuspid Annuloplasty Sizing System

• Nikola Dobrilovic
  NorhtShore University Hospital, Chicago, IL, USA

BACKGROUND AND AIM: A novel ‘paired-ring’ mitral annuloplasty ring sizing device and technique were introduced at AATS Mitral Conclave 2023 as proof-of-concept. This technique has the potential to dramatically improve ring selection during valve repair procedures. The most current prototype has been manufactured specifically for use with Physio-2, and manufacturing specifications were previously validated. This technology has been approved for first-in-human trial at our institution. Video documents our method for exerting control over coaptation length (CL) in a cadaveric porcine heart model.

METHOD: Native valve CL is marked as an initial reference point. After placing annuloplasty sutures, a paired-ring sizer (designed specifically to represent Physio-2 mitral mitral annuloplasty rings—in this case specifically #24), is used to predict the potential increase in anterior leaflet CL. The temporary sizer is then removed and a #24 Physio-2 ring is implanted in standard fashion. With the final annuloplasty ring implanted, its actual effect on CL is measured for comparison with the predicted distance. Prolene marks the mid-anterior leaflet coaptation margin. This allows for precise comparison to the coaptation margin produced by the initial ink test (prior to downsizing) and comparison with the final CL attributable to the annuloplasty ring implant.

RESULTS: Increase in coaptation length predicted by the novel paired ring sizer was 6 mm. This correlated precisely with the actual CL increase produced by the final annuloplasty ring. Predicted and final CLs both measured 6 mm greater than coaptation seen initially in the native valve as tested at the start of the video.

CONCLUSIONS: This study documents our method of validating functionality of a novel paired-ring sizing system as tested in a cadaveric porcine heart model.

• Keywords: novel sizer; mitral repair; mitral ring; paired-ring

1.11.2. Neonatal Mesenchymal Stem Cells Attenuate Neuroinflammation Following Cardiopulmonary Bypass in a Neonatal Swine Model

• Agata Bilewska ¹, Vivek M. Mehta ¹, Artur Stefanowicz ¹, Anshuman Sinha ¹, Nitin R. Wadhwani ², Rebecca Ariel Ober ³, Alicia Jane Mcluckie ³, Zhi Dong Ge ¹, Rachana Mishra ¹, Sudhish Sharma ¹, Muthukumar Gunasekaran ¹ and Sunjay Kaushal ¹

1

Cardiovascular and Thoracic Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

2

Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

3

Center for Comparative Medicine, Northwestern University, Chicago, IL, USA

BACKGROUND AND AIM: Newborns and infants undergoing surgery for congenital heart defects are more susceptible to develop neurological complications such as gross motor deficits. Microglia and astrocytes are glial cells that maintain homeostasis, support neurons, and are activated during neuroinflammation. The aim of this study was to evaluate the impact of neonatal mesenchymal stem cells (nMSCs) on neuroinflammation following surgery in a neonatal cardiopulmonary bypass swine model in the acute setting.

METHOD: 13 piglets were randomized into 3 study groups: placebo treated, nMSC treated and sham. The placebo and nMSC group underwent cardiopulmonary bypass with deep hypothermic circulatory arrest for one hour. After weaning off of bypass, either 0.9% saline or nMSC 2 M/kg was administrated using the aortic cannula for systemic delivery. The animals were followed-up for 6 h and the whole brain was harvested. Blood samples were also collected at baseline, post-surgery, 4 h post-op and 6 h post-op. We assessed systemic inflammation, microglia activation, astrocyte activation and in situ apoptosis in the frontal lobe, brain stem and cerebellum samples. Sham pigs only underwent sternotomy, blood sample collection and brain harvesting.

RESULTS: The treatment and placebo groups underwent successful surgical intervention without mortality. There was no difference in the hemodynamics between the group post-operatively. Delivered nMSCs significantly mitigated microglia and astrocyte activation in both the frontal lobe and the brain stem when compared to the placebo group. In addition, the amount of apoptosis was significantly decreased with nMSC treatment in the frontal lobe and brain stem in comparison to the control group.

CONCLUSIONS: nMSCs attenuate neuroinflammation and decrease the level of apoptosis in the frontal lobe and the brain stem in neonate piglets undergoing cardiopulmonary bypass with deep hypothermic circulatory arrest. These findings warrant further long-term nMSC studies to determine neurological outcomes.

• Keywords: cardiopulmonary bypass; neonatal mesenchymal stem cells

1.11.3. Effectiveness of the Combined Use of Cell Therapy and Coronary Artery Bypass Grafting in the Surgical Treatment of Patients with Ischemic Cardiomyopathy

• Serhii Rudenko, Yuliia Trokhonenko, Vasyl Lazoryshynets and Anatolii Rudenko
  National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine

BACKGROUND AND AIM: The combined use of cell therapy and CABG in the surgical treatment of ischemic cardiomyopathy has been shown to reduce the area of the post-infarction scar.

The work shows the results of examination and treatment of patients with combined use of cell therapy and CABG.

METHOD: Intramyocardial use of cell therapy and CABG in the surgical treatment of patients with ischemic cardiomyopathy. 13 patients participated in the clinical study.

The average age was 60.7 ± 12.2 years. The vast majority of patients were male—92.9% (12 men) to 7.1% (1 woman). NYHA class 3 was established in all patients.

RESULTS: The left ventricular ejection fraction fluctuated from 28.0 to 40.0%, the average value is 34.2 ± 3.6%. The end-diastolic volume is 216 ± 30.3 mL. If we compare the left ventricular ejection fraction before surgery, it ranged from 23.0 to 35.0%, with an average value of 30.2 ± 3.7%. After the operation, the left ventricular ejection fraction ranged from 28.0 to 40.0%, with an average value of 34.2 ± 3.5%.

CONCLUSIONS: In the postoperative period, the left ventricular ejection fraction improved, end-diastolic volume decreased, end-systolic volume increased, stroke volume increased, and average global longitudinal deformation of the left ventricle in the preoperative period was—7.7%, immediately after surgery—8.9%, and after 3 months—9.25%. These data show a beneficial clinical effect in terms of mortality and long-term health outcomes in people with coronary heart disease and heart failure.

• Keywords: end-diastolic volume; end-systolic volume; cell; left ventricle; ischemic cardiomyopathy

1.11.4. Imaging Guidance in Minimally Invasive Coronary Artery Bypass Graft (MIS CABG) for Young Surgeons

• Harith Amirizal Amirizal Ariff, Priyanka Sekaran, Muhammad Ibrahim Azmi, Ashvin Krishna Nair and Shahrul Amry Hashim
• Cardiothoracic Surgery Division, Department of Surgery, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia

AIM: We formulated an algorithm to determine access site selection, internal mammary artery (IMA) harvesting, and cannulation strategies using CTA Aorta.

METHODS: We systematically analysed our MIS CABG series by looking into patient’s CTA Aorta. Notably, our approach involved 3D reconstruction from the CTA to assess the estimated length and course of the IMA. A simple algorithm applying the Pythagoras Theorem based on the dimensions of IMA, chest wall and nipple on axial cut was used in determining a safe site for incision to access the internal mammary artery. The length between the skin and the anterior aspect of the femoral vessels were measured to determine the site and depth of incision for femoral cannulation. Measurement of the calibre of the femoral vessels were also assessed in determining the size of cannula suitable for the patient.

RESULTS: We have found that by using the Pythagoras Theorem, a safe and accurate site of thoracotomy could be determined for young surgeons to avoid injuring the IMA. 100% of incisions based on this algorithm could identify the IMA easily hence avoiding injury. The calibre of the femoral vessels also determine the maximum or minimum size of the peripheral cannula helping us to achieve full flow without complications. The site and depth of incision for femoral cannulation also showed 100% accuracy.

CONCLUSIONS: CTA Aorta is non invasive, accessible and aids in understanding patient specific vascular anatomy, reducing risk of complications. The algorithm formulated by using 3D Reconstructed CTA Aorta in this study aims to help young surgeons embarking in MIS CABG safely and efficiently. As technology advances, the seamless integration of CTA into MIS CABG is becoming a standard, exemplifying the synergy between advanced imaging and surgical innovation.

• Keywords: TCRAT; CTA Aorta; Imaging; MICS CABG; Minimally Invasive; Cannulation

1.12. CARDIAC » Harvesting Techniques

1.12.1. Influence of the Two Harvesting Techniques on the Saphenous Vein Grafts Microstructure and Postoperative Clinical Outcome

• Igor Zivkovic ¹, Milos Matkovic ³, Patar Milacic ¹, Aleksandar Milutinovic ¹, Zoran Tabakovic ¹, Milica Stankovic ⁴ and Slobodan Micovic ²

1

Institute for Cardiovascular Diseases Dedinje, Cardiac Surgery Clinic, Belgrade, Serbia

2

Faculty of Medicine, University of Belgrade, Serbia

3

Cardiac Surgery Clinic, Clinical center of Serbia, Belgrade, Serbia

4

Center for Pathology, Clinical Center of Nish, Nish, Serbia

BACKGROUND AND AIM: The main disadvantage of SVG is a considerably high rate of graft failure. Numerous factors contribute to the SVGs failure, including graft, conduit diameter, surgical conduit preparation, conduit handling, grafting site, coronary vascular bed (run-off), and surgical skills techniques and technical errors. Blunt surgical trauma and excessive manipulation decrease endothelial integrity and function, increasing the rate of vein graft failure.

We aimed to assess the influence of the two different harvesting techniques on the histological and immunohistochemical characteristics of the SVGs, were used for surgical myocardial revascularization and their impact on the postoperative clinical outcomes.

METHOD: A prospective randomized single center study was performed from Jun 2019 to December 2020.

The patients were randomly assigned into the two groups according to harvesting technique: No-touch (NT) or endoscopic (EVH). One high experienced cardiac surgeon performed SVGs harvesting on the whole group. The vein graft samples were sent on the histological (hematoxylin-eosin staining) and immunohistochemical (CD31, Factor VIII, Caveolin and eNOS) examinations.

The leg wound complications was registered during a one-year follow-up.

RESULTS: The compared groups were homogenous by preoperative characteristics. The no-touch group’s vein wall integrity was statistically better preserved, according to hematoxylin-eosin staining (p = 0.008). The endoscopic group had a greater grade of vein wall injury, as seen by immunohistochemical staining by CD31, Factor VIII, Caveolin, and eNOS (p = 0.035, p < 0.001, p = 0.03, and p = 0.017, respectively). Dehiscence, oedema, numbness, and discomfort were considerably less common leg wound complications, according to the statistical analysis (p = 0.01, p < 0.001, p = 0.05, and p = 0.04, respectively).

CONCLUSIONS: Compared to the endoscopic approach, the no-touch technique considerably better protected vein wall integrity. Conversely, leg wound problems are far less common when using endoscopic method. The perfect harvesting method does not exist. The optimal harvesting strategy may involve developing an endoscopic no-touch technique and combining two harvesting procedures.

• Keywords: endoscopic vein harvesting; No-touch vein harvesting; Immunohistochemistry

1.12.2. A Novel Subxiphoid Video-Assisted Left Internal Mammary Artery Harvesting Technique

• Milica Ivanovic ¹, Zorana Dancetovic ¹, Petar Milacic ², Miroslav Milicic ², Zoran Tabakovic ¹, Milos Matkovic ³, Slobodan Micovic ² and Igor Zivkovic ²

1

Dedinje Cardiovascular Institute, Belgrade, Serbia

2

Faculty of Medicine, University of Belgrade, Belgrade, Serbia

3

University Clinical Center of Serbia, Belgrade, Serbia

BACKGROUND AND AIM: The left internal mammary artery (LIMA) is the gold standard vessel for left anterior descending artery (LAD) revascularization. With the introduction of minimally invasive coronary revascularization (MIDCAB) in practice, LIMA harvesting has become the most difficult part of the procedure. Due to this disadvantage, we developed subxiphoid video-assisted LIMA harvesting using a special retractor.

METHOD: This pilot study included patients with single-vessel disease on the LAD in whom LIMA grafts were harvested through subxiphoid approaches video-assisted. The 3–5 cm longitudinal subxiphoid incision was used. The paddle of the special retractor produced by LIS solutions was positioned under the posterior surface of the sternum to lift the sternum upward. The 300-degree 10-mm scope was used. Monopolar cautery and hemostatic clips were used pending the availability of harmonic dissection devices. The LITA was completely harvested. The CABG was performed through a 4–5 cm lateral incision without spreading the ribs.

RESULTS: This pilot study included five patients in whom LITA was harvested video-assisted using a subxiphoid approach. The 80% of patients were male, the average BMI was 26.12. The average operation time was 221 min, respectively. In one female patient, LITA wasn’t an appropriate flow after harvesting due to this conversion in the full sternotomy. The periprocedural myocardial infarction and graft occlusion were not registered. The hospital stay was 4–6 days.

CONCLUSIONS: We are encouraged to continue to explore this procedure. We look forward to the day when we can routinely provide avoiding large painful access wounds, bone or cartilage damage, and difficult postoperative recoveries.

• Keywords: LIMA harvesting; Subxiphoid approach; Endoscopic harvesting

1.12.3. Endoscopic Internal Mammary Artery Harvest: An Alternative to Robotic Telemanipulator

• Muhammad Ibrahim Azmi ¹ and Shahrul Amry Hashim ²

1

Cardiothoracic Unit, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia

2

Cardiothoracic Unit, KPJ Damansara Specialist Hospital 2, Kuala Lumpur, Malaysia

BACKGROUND AND AIM: Extensive rib spreading during internal mammary artery (IMA) harvesting in minimally invasive CABG (MICS) may result in increased postoperative pain. Robotic IMA harvest may address this and allows smaller wound for the anterior thoracotomy, although this may not be readily available globally. Endoscopic IMA harvest is an alternative. We share our experience and technique of endoscopic IMA harvesting using ultrasonic energy device.

METHOD: Patient is in supine position with the left shoulder lifted slightly at 30°. Single lung ventilation is established with the left lung deflated. A 12 mm camera port is inserted at 4th intercostal space, mid-axillary line. Pneumothorax is established with intermittent insufflation of CO₂ at 5 L/min with a continuous ventilation of both lung. Two 5 mm working ports are placed at 2nd and 6th intercostal space, anterior axillary line. A 32 cm long shafted hook scalpel ultrasonic energy device is used for dissection and a 35 cm long shafted fine grasper is used for soft tissue traction. A tram-line is made 1 mm lateral to the internal mammary vein and the IMA is dissected away in a skeletonise manner. The IMA is harvested proximally beyond the innominate vein junction and distally beyond 4th intercostal space.

RESULTS: We performed endoscopic IMA harvesting in 9 cases. On average we managed to reduce the thoracotomy wound down by 2 cm. The IMA length was adequate without any stretching with good transit time flow measurement. The average time spent for one IMA harvest was around 50–60 min. We had one injury to the IMA and this was used as a free graft.

CONCLUSIONS: Endoscopic IMA harvest is a good alternative to robotic assisted IMA harvest for MICS. It may be cost effective, accessible, and reproducible.

• Keywords: IMA harvest; CABG; Minimally Invasive; MICS; TCRAT

1.12.4. HABA’s Technique (Hassle-Free Biportal Access) for Endoscopic Vein Harvesting in Minimally Invasive Coronary Artery Bypass Graft (MIS CABG)

• Harith Amirizal Ariff, Muhammad Ibrahim Azmi, Ashvin Krishna Nair and Shahrul Amry Hashim
• Cardiothoracic Surgery Division, Department of Surgery, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia

AIM: We introduce an innovative method for endoscopic vein harvesting (EVH) in Minimally Invasive Coronary Artery Bypass Graft (MIS CABG), allowing maximal length of conduit harvest and minimise disruption to the primary surgeon.

METHODS: “HABA’s technique” employs 2 cm access below the knee guided by ultrasound. Standard EVH dissection and disconnection of tributaries was made. Another 2 cm access above the knee at mid thigh is made and completion of harvesting to get maximal length of conduit. The conduit was disconnected 1 cm distal to the saphenofemoral junction using bi-polar diathermy using 3 step haemostasis. As opposed to the conventional EVH method where operators may require to scope caudally, HABA ensures minimal interruption to the primary surgeon harvesting the internal mammary artery. The primary surgeons were required to complete a 5 point Likert-scale questionnaire assessing the quality of conduit and ergonomics of the procedure. Primary outcome was the total score of questionnaire and secondary outcomes were the duration of procedure and wound infection within 30 days.

RESULTS: We have done 30 HABA EVH cases. Two surgeons have completed the questionnaire with an average score of 28/30. A higher score indicates satisfactory in quality of conduit and ergonomics of the procedure. The average time for harvesting two lengths of GSV (approximately 30 cm) using HABA’s technique is 27 min. There were no 30-days postoperative wound breakdowns.

CONCLUSIONS: Employing HABA’s Technique in MIS CABG cases guarantees ergonomics of operative flow and a reproducible procedure without compromising the quality of saphenous vein conduit.

• Keywords: Conduit Harvest; Saphenous vein harvest; Endoscopy; EVH; MICS CABG; TCRAT

1.12.5. Clipless Sceletonized Internal Mammary Artery with High Frequency Ultrasound Technology

• Živojin Jonjev ¹, Ilija Bjeljac ¹, Aleksandar M. Milosavljevic ¹, Mirko Todic ¹, Strahinja Mrvic ¹ and Novica Kalinic ²

1

Institute for Cardiovascular Diseases of Vojvodina, Clinic of Cardiovascular Surgery, Sremska Kamenica, Serbia

2

Faculty of Medicine, University of Banja Luka, Banja Luka, Republic of Srpska, Bosnia & Herzegovina

INTRODUCTION: During the last decades internal mammary artery (IMA) has been considered to be the proven therapeutic choice for coronary artery bypass grafting (CABG). Immediate and long term results strictly rely on two independent phases in CABG procedure: graft harvesting and graft deployment. Different operative techniques have been proposed for each of these phases in the past. However, the implementation of new sophisticated technologies like ultra high frequency ultrasound operated with harmonic scalpel has widely opened new era in CABG surgery. The aim of this study is to compare immediate results of CABG where skeletonized IMA was harvested with clipless technique based on usage harmonic technology (IMA-H) versus skeletonized IMA harvested in traditional “cauter-clip” fashion.

METHODS: From December 2022 to April 2023 there were 46 IMA-H patients operated on CABG. They were compared with 46 CABG-IMA patients in propensity score-matched method.

Primary outcome measures were identified as all-cause mortality at 30-days after surgery, while secondary outcome measures were harvesting time, initial IMA blood flow, length of IMA, the incidence of postoperative bleeding, postoperative major adverse cardiovascular and cerebrovascular events (MACCE).

RESULTS: There was no difference in all-cause mortality at 30-days after surgery (30 days: IMA-H = 0 vs. IMA = 1.17%) and MACCE (IMA-H = 0 vs. IMA = 1.17%) between the groups. IMA-H patient had shorter harvesting time (IMA-H = 12.5 ± 3.3 min vs. IMA = 16.8 ± 3.8 min), better immediate blood flow (IMA-H = 42.5 ± 2.3 mL vs. IMA = 26.8 ± 4.2 mL) and less damaged arteries (IMA-H = 0 vs. IMA 2.77%).

CONCLUSIONS: The results of the study indicated that clipless IMA-H technique is superior in most secondary measured outcomes. IMA-H technique provides less and rare graft damage (sub intimal hematoma, tears, dissections), better visual aspect of graft and easier IMA-H utilization for sequential IMA grafting. Our conclusion is independent of traditionally accepted risk factors incorporated in the EuroScore II and SINTAX score II and is exclusively method related.

• Keywords: Harmonic scalpel; coronary artery bypass grafting surgery; bilateral internal mammary

1.13. CARDIAC » Ischemic Mitral Regurgitation

1.13.1. Using a Modified Technique for Surgical Treatment of Ischemic Mitral Regurgitation Combined with Left Ventricular Aneurysm

• Serhii Rudenko, Oleh Zhyliak, Olena Gogayeva and Anatolii Rudenko
  Surgical Department of Treatment of Ischemic Heart Disease, M.M. Amosov National Institute of Cardiovascular Surgery, Kyiv, Ukraine

BACKGROUND AND AIM: Transventricular mitral valve replacement combined with left ventricular restoration helps to avoid atriotomy and provides a larger operative field.

This study aims to show the effectiveness of surgical treatment of left ventricular aneurysm combined with ischemic mitral regurgitation using a modified technique.

METHOD: From January 2011 to December 2023, 25 patients with IMR combined with LV aneurysm underwent surgical treatment using a modified technique.

Mitral ring dilatation was observed in 28.0% (7) of the cases, papillary muscle displacement in 44.0% (11), chords rupture in 12.0% (3), and papillary muscle infarction in 16.0% (4) of the cases.

Control group included 69 patients that underwent surgical intervention using a standard approach.

RESULTS: With the standard approach, 95.7% of patients had inotropic cardiac support due to atrial access in the early postoperative period versus 76.0% who underwent surgical treatment using a modified technique.

16.0% of patients who underwent operations using the modified technique had cardiac arrhythmias versus 40.5% who underwent operations using the standard approach.

The duration of mechanical ventilation was 23.8 ± 25.1 h who underwent the modified technique versus 34.7 ± 56.6 h.

The length of stay in the ICU was 116.2 ± 62.9 h who underwent the modified technique versus 134.2 ± 82.5 h.

In patients who underwent surgery using the modified technique, the mortality was 4.0% versus 10.1% who underwent operations using the standard approach.

CONCLUSIONS: The modified technique showed better postoperative results compared to the standard approach.

In the postoperative period, patients who underwent surgical treatment using a modified technique had a significantly lower frequency of cardiac arrhythmias and inotropic support.

The length of stay of patients in the ICU who underwent operations by the modified technique was also reduced.

In patients who underwent surgery using the modified technique, the mortality was two times less than that in patients undergoing the conventional operation.

• Keywords: ischemic mitral regurgitation; modified technique

1.13.2. Impact of Revascularization on Regional Wall Motion and Grade of Mitral Insufficiency, in Patients with Coronary Artery Disease with Mitral Insufficiency

• Waqar Masud Malik ¹, Muhammad Tariq ¹, Sobia Siddique ², Zeeshan Afzal ¹, Kifayat Ullah ¹ and Yasir Bilal ¹

1

Department of Cardiac Surgery, Peshawar Institute of Cardiology, Peshawar, Pakistan

2

Department of Cardiac Surgery, Armed Forces Institute of Cardiology, Rawalpindi, Pakistan

INTRODUCTION: Myocardial ischemia effects the geometry of left ventricle leading to mitral insufficiency. Understanding regional wall motion and mitral insufficiency in patients with coronary artery disease, planned for CABG, is imperative because of its increasing prevalence and having significant clinical consequences, so by knowing interaction among LV geometry, regional wall motion and mitral insufficiency, appropriate treatment plan can be executed to improve clinical outcome.

AIMs/OBJECTIVES: To determine the early effects of CABG on regional wall motion abnormality and grade of mitral insufficiency, in patients with proven CAD and mitral insufficiency.

METHOD: Retrospective observational study was conducted at Peshawar Institute of Cardiology, Peshawar, KPK, Pakistan. All patients who underwent isolated CABG for coronary artery disease with mitral insufficiency was included from 1 January 2023 to 31 December 2023, fulfilling inclusion criteria. Ethical approval was taken from hospital ethical review board. Data was extracted from electronic medical record and analyzed in SPSS version 22.0.

RESULTS: Fifty-five patients (n = 55) were included in the analysis. These results showed that effect of CABG on regional wall motion was significant, with disappearance of dyskinetic and reduction in akinetic segments postoperatively (p < 0.001). Comparison of pre-operative and postoperative echocardiographic data revealed improvement in regional wall motion with reduction in the degree of mitral insufficiency at one week and one month follow-up.

CONCLUSIONS: Isolated CABG can be safely performed in patient’s mitral insufficiency with proven coronary artery disease. The efficacy of isolated CABG was demonstrated to improve the degree of mitral insufficiency and regional wall motion in selected patients based on echocardiographic measurements.

• Keywords: Early effect; CABG; regional wall motion

1.13.3. Early Outcomes of Treatment of Ischaemic Mitral Regurgitation with the Customised IMR Ring Annuloplasty

• Philemon Gukop, Rajan Sharma, Venkatchallam Chandrasekaran and Steve Livesey
• Department of Cardiothoracic Surgery, St George’s University Hospital NHS London, London, UK

BACKGROUND AND AIM: Ischaemic Mitral Regurgitation is a significant source of morbidity and mortality. its optimal treatment has eluded clinicians for decades. The customised ischaemic Mitral Ring (IMR) annuloplasty has emerged as a promising innovative intervention to improve outcome. we report the early outcomes of our experience with this intervention.

METHOD: Retrospective data analysis of consecutive patients with at least moderate ischaemic mitral regurgitation (vena contracta width > 3 mm) treated with the IMR annuloplasty in a single centre over a 3 year period. All patients had complete surgical revascularisation and implantation of customised IMR annuloplasty ring and Guidelines directed medical therapy (GDMT). Outcome measured were survival, freedom from mitral regurgitation at 1 year and reverse ventricular remodelling using Left ventricular Ejection Fraction (LVEF) and left ventricular internal diastolic Dimension (LVIDD) as surrogate marker. data presented as median interquartile range.

RESULTS: 13 patients were included, Age 74 (65–83) years, preoperative LVEF 40 (20–55)%, Preop LVIDD 55 (45–66) mm, post operative LVEF at 1 yr 50 (30–60)%, post operative LVIDD at 1 yr 45 (44–61) mm, Freedom from at least moderate MR at 1 yr. 97%, Mortality 2/13 (15%), mortality was associated with poor ventricle LVEF < 25% and advance age > 75 years (

Table 6. Results of outcomes measured at 1 year.

Outcomes Measured	Preoperative Values	Postoperative Values at 1 Year	Net Benefits
LVEF (%)	40 (20–55)	50 (30–60)	10
LVIDD (MM)	55 (45–66)	50 (44–61)	5
>Moderate MR (ERO > 3 mm)	13/13 (1005)	1/13 (8%)	12/13 (92%) freedom from significant MR

Customised IMR ring annuloplasty with complete myocardial revascularisation and GDMT shows net benefits at 1 year.

).

CONCLUSIONS: Use of the customised IMR ring annuloplasty and complete revascularisation is associated with reverse ventricular remodeling and freedom from mitral regurgitation at 1 year. This strategy in suitable patients with GDM would lead to improve outcomes. Severely impaired left ventricle with preoperative LVEF < 25% is associated with adverse outcome.

• Keywords: Ischeamic mitral regurgitation; Mitral annuloplaty; IMR ring annuloplasty; ischeamic cardiomyopathy; mitral valve repair; complete revascularisation

1.14. CARDIAC » Management of Reoperations

1.14.1. Emergent Re-Exploration Due to Significant Bleeding After Cardiac Surgery: Risk Factor Analysis

• Justine Ciganovska ¹, Gvido Janis Bergs ², Eva Strike ^1,2, Peteris Stradins ^1,2 and Andrejs Erglis ^2,3

1

Riga Stradins University, Riga, Latvia

2

Pauls Stradins Clinical University Hospital, Riga, Latvia

3

University of Latvia, Riga, Latvia

BACKGROUND AND AIM: Significant bleeding after cardiac surgery often leads to emergent re-exploration thus increasing the risk of intrahospital morbidity and mortality. This study aimed to assess perioperative risk factors associated with emergent re-exploration following cardiac surgery.

METHOD: The study was conducted between December 2021 and December 2022. The study population consisted of study group requiring emergent re-exploration due to significant postoperative bleeding and/or hemodynamic instability (n = 54) and a matched control group—patients who did not require re-exploration after cardiac surgery (n = 63). The groups were matched by age, sex and BSA.

RESULTS: From a total of 947 consecutive patients who underwent open-heart surgery in our department, 65 (6.9%) patients required emergent re-exploration for significant postoperative bleeding and/or hemodynamic instabillity. After matching of the groups 54 patients were further included into the study group. The median time to re-exploration was 8.8 h (IQR: 4 to 10 h) and the median blood loss until re-exploration was 800 mL (IQR: 617.50 mL to 1145.00 mL). Urgency of initial surgery (p = 0.050), longer aortic cross-clamp time (p = 0.005), longer cardiopulmonary bypass time (p < 0.001), higher intraoperative blood loss (p = 0.025), higher pericardial drain discharge in first 12 h after initial surgery (p < 0.001) and inotropic support after/at admission to cardiac ICU (p < 0.001) were associated with higher risk of emergent re-exploration. Furthermore, emergent re-exploration was associated with prolonged need for mechanical ventilation (p = 0.002), need for inotropic support (p = 0.005) and extracorporeal kidney replacement therapy (p = 0.002). Moreover, intrahospital mortality was statistically significantly higher in patients requiring emergent re-exploration (p < 0.001).

CONCLUSIONS: Urgency of initial surgery, longer aortic cross-clamp time and cardiopulmonary bypass time, higher intraoperative blood loss and higher pericardial drain discharge, as well as inotropic support after/at admission to ICU were found to be a risk factors for emergent re-exploration after cardiac surgery, leading to higher intrahospital morbidity and mortality.

• Keywords: Postoperative bleeding; re-exploration

1.14.2. Sailing to Unknown Horizons Require Good Compasses: Our Observations on Reopening a Hostile Chest for Coronary Bypass Surgery Following a Former Total Pericardiectomy Operation

• Estelle Démoulin ¹, Jalal Jolou ¹, Andres Hagerman ², Juan F. Iglesias ³, Christoph Huber ¹ and Mustafa Cikirikcioglu ¹

1

Division of Cardiovascular Surgery, Department of Surgery, Faculty of Medicine, University Hospitals, Geneva, Switzerland

2

Division of Anaesthesiology, Department of Anaesthesiology-Intensive Care and Pharmacology, Faculty of Medicine, University Hospitals, Geneva, Switzerland

3

Division of Cardiology, Department of Medicine, Faculty of Medicine, University Hospitals, Geneva, Switzerland

BACKGROUND AND AIM: The term “hostile chest” refers to scenarios wherein redo-sternotomy poses significant hazards (e.g., complex chest deformities, prior thoracic radiotherapies, former pericardiectomy operations). This case report delineates observations from a patient who underwent coronary artery bypass grafting (CABG) necessitating re-entry into a hostile chest following prior total pericardiectomy.

Patient and METHODS: A thirty-three-year-old-male, with non-insulin-dependent type II diabetes and active smoking history, presented to our emergency department with suspected acute coronary syndrome (non-ST segment elevation myocardial infarction, NSTEMI). Coronary angiography revealed triple-vessel coronary artery disease (CAD) with left anterior descending (LAD) occlusion and severe stenoses in intermediate and right coronary arteries. Myocardial PET-CT depicted significant ischemia (30%) within the LAD territory. Despite theoretical high surgical risk due to the patient’s prior total pericardiectomy 3 years ago, the Heart Team opted for surgical revascularization. Following the groin vessel preparation for eventual emergency cannulation, redo median sternotomy was performed. Surprisingly facile dissection and minimal adhesions were encountered despite previous pericardiectomy. Triple CABG was performed utilizing multiple grafts. Postoperative course was uneventful, with discharge on the 5th postoperative day.

CONCLUSIONS: Our successful management underscores the feasibility and safety of cardiac reoperation following total pericardiectomy, offering valuable insights for clinicians encountering similar cases. This report addresses a literature gap, enhancing patient care and decision-making in analogous clinical scenarios. Given the rarity of such cases, further research is warranted to refine management strategies and surgical techniques tailored to this unique patient cohort.

• Keywords: cardiac; surgery; CABG; pericardiectomy; reoperation; hostile

1.15. CARDIAC » MICAB (Minimally Invasive Coronary Artery Bypass) (Including MIDCAB, MICS-CABG, TCRAT, LAST, MACAB)

1.15.1. Total Coronary Revascularization via Left Anterior Thoracotomy: Our Single Center Experiences and Comparison with Conventional Coronary Artery Bypass Surgery

• Tuna Demirkiran ¹, Furkan Burak Akyol ¹, Tayfun Özdem ¹, Elgin Hacizade ¹, Emre Kubat ², Gökhan Erol ¹, Murat Kadan ¹ and Kubilay Karabacak ¹

1

Department of Cardiovascular Surgery, University of Health Sciences Health Practice and Research Centers, Ankara, Turkey

2

Department of Cardiovascular Surgery, Central Military Hospital of Ministry Defence of Azerbaijan, Baku, Azerbaijan

BACKGROUND AND AIM: Total coronary revascularization with left anterior thoracotomy (TCRAT) was defined in 2019. In our study, we aimed to evaluate the efficacy and safety of the TCRAT technique by comparing it to conventional coronary artery bypass surgery (CABG) with median sternotomy.

METHOD: Patients who underwent 108 TCRAT (group 1) and 154 conventional CABG (group 2) were performed by the same surgical team. Preoperative, operative, and postoperative data of patients and mid-term follow-up data were analyzed retrospectively.

RESULTS: Cardiopulmonary bypass and cross-clamp times were 167.70 ± 68.93 and 77.03 ± 38.18 in Group 1 respectively and 106.64 ± 38.27 and 62.21 ± 24.06 in Group 2 respectively (p < 0.001). During the postoperative period, the all-cause mortality rate was 5.8% (n = 9) in Group 2, while it was 0.9% (n = 1) in Group 1 and there was a statistically significant difference between the two groups (p = 0.037). The mean hospitalization for Group 2 was 6.99 ± 3.37 and the mean hospitalization for Group 1 was 6.77 ± 4.24. Statistically significantly shorter duration of hospitalization in Group 1 was determined (p = 0.047). In addition, the perioperative mean number of red blood pack transfusions in Group 1 was 1.51 ± 1.74, while it was 1.86 ± 1.75 in Group 2 and statistically significantly fewer red blood pack transfusions were performed in Group 1 (p = 0.033).

CONCLUSIONS: TCRAT, which is a less invasive method compared to conventional CABG, is an effective and safe method. It stands out as a routinely applicable method except in selected cases.

• Keywords: Coronary artery bypass graft surgery; Minimally invasive; Mini thoracotomy

1.15.2. Minimally Invasive CABG Made Easy: Coronary Revascularisation via Left Anterior Thoracotomy

• Muhammad Ibrahim Azmi ¹, Ashvin Krishna Nair ¹ and Shahrul Amry Hashim ²

1

Cardiothoracic Unit, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia

2

Cardiothoracic Unit, KPJ Damansara Specialist Hospital 2, Kuala Lumpur, Malaysia

BACKGROUND AND AIM: Since 2014 we performed a total of 164 minimally invasive CABG (MICS) cases. We reviewed our journey of learning and adopting Total Coronary Revascularisation via Left Anterior Thoracotomy (TCRAT) into our MICS service of 9 years by analysing the operating experience and the clinical outcomes.

METHOD: All TCRAT cases in our database were reviewed. Operating experience was objectively measured in the number of grafts, aortic cross clamp (AXC) time, cardiopulmonary bypass (CPB) time, and transit time flow measurement (TTFM) of the grafts. These were compared with the conventional CABG (cCABG) cases within the same time line. Clinical outcomes analysed include conversion, re-exploration, in-hospital cardiovascular death, and stroke.

RESULTS: From January 2023 to March 2024 there were 116 TCRAT and 110 cCABG cases. These cases were performed by two leading surgeons separately. One of them is a junior consultant. 89.6% (n = 104) of the cases were male and the mean age of the patients were 62 years. 34.5% of the cases were multi-arterial grafting. The mean number of grafts comparing TCRAT to cCABG were 2.77 vs. 3.20. The mean AXC and CPB time between TCRAT and cCABG were (81.8 min vs. 97.0 min) and (161.2 min vs. 139.0 min). There were no significant differences when comparing TTFM parameters between the two groups. The institutional learning curve plateaus at around 50th case. We had 1 (0.86%) cardiovascular death.

CONCLUSIONS: TCRAT is highly adaptable and can be taught early in the career. The quality of the coronary anastomosis is comparable to cCABG and it has an acceptable safety profile. Widespread adoption of TCRAT should be encouraged.

• Keywords: CABG; MICS; TCRAT; Coronary Revascularisation; Minimally Invasive

1.15.3. Well-Being on Fast Track—Minimal Invasive Cardiac Surgery in Remote Area of Under Developed Country

• Hafeez Ullah Bughio and Huma Akhtar
• National Institute of Cardiovascular Diseases, Karachi, Pakistan

BACKGROUND AND AIM: Aim of this study is to analyse the outcome of initial 74 patients underwent minimally invasive cardiac surgery at centre located in rural areas of Sindh Pakistan.

METHOD: Total 74 patients were included in a case series analyzed retrospectively. All cases were operated at NICVD satellite centre Tando Muhammad Khan from 1 January to 31 December 2022. All patients included underwent minimally invasive cardiac surgery for variety of procedures done by single surgeon. Preoperative, operative and postoperative data was collected and analysed for different variables.

RESULTS: Mean age was 30.43 (12.59)

• Female predominance 52.7%
• NYHA-III 68.6%
• Diagnosis severe Mitral Regurgitation 35.4%, ASD 28.3%, severe Aortic Stenosis 10.81%, SVCAD 8.11%.
• Procedure: Mitral valve replacement 41.89%, ASD closure 28.38%, Aortiv Valve Replacement 13.51%, MIDCAB 10.81%, Double valve replacement 4.5%, LA MYxoma excision 1.35%.
• Conversion rate 2.7%, Reopening rate 1.4%, Respiratory complications 1.4%, Superficial surgical site infection 4.1%.
• Blood transfusion < 1 PCV per patient.
• Majority of patients 75.7% had chest drain output of >200 mL but <500 mL over 48 h.
• Mean ICU stay was 1 day in 79.7%.
• Discharged at 3rd POD, no inhospital mortality.
• 6 months follow up showed 78.4% alive and healthy, 18.9% were lost to follow-up and 2.7% were dead.

CONCLUSIONS: Performing MICS at a centre in a rural area was challenging but our results are at par with international results of MICS considering the facilities given in rural area of Sindh proves that MICS is a safe and beneficial strategy for different cardiac surgery setups in Pakistan. the reduced postoperative complications, lesser blood transfusion, speedy recovery, early hospital discharge and most importantly patient satisfaction marks and upper edge.

• Keywords: Minimally Invasice Cardiac Surgery; rural area; Cardiac surgery; Cardiovascular disease; MIDCAB

1.15.4. A Single-Center Experience in Coronary Artery Revascularization: Transformation from a Standard to a Minimally Invasive Procedure

• Zoran Saša Tabaković ¹, Slobodan Mićović ², Petar Vuković ², Petar Milačić ², Miroslav Miličić ², Zorana Dančetović ¹, Miloš Matković ³ and Igor Živković ²

1

Clinical for Cardiac Surgery, Institute for Cardiovascular Diseases “Dedinje”, Belgrade, Serbia

2

Clinical for Cardiac Surgery, Institute for Cardiovascular Diseases “Dedinje”, Belgrade, Serbia & Faculty of Medicine, University of Belgrade, Belgrade, Serbia

3

Clinical for Cardiac Surgery, University Clinical Center of Serbia, Belgrade, Serbia & Faculty of Medicine, University of Belgrade, Belgrade, Serbia

BACKGROUND AND AIM: Due to its benefits, MIDCAB is gradually becoming a more common treatment method. The most important issue is the learning curve, particularly when the surgeon feels comfortable performing the MIDCAB surgery. We demonstrated the experienced surgeon’s learning curve for transitioning from a conventional surgical technique to a MIDCAB method.

METHOD: Between February 2023 and January 2024, one surgeon with previous expertise in conventional coronary revascularization performed 29 MIDCAB procedures. The learning curve was investigated by analyzing trends in variables such as procedure time, ventilation time, ICU time, technical failure, and complications like revision of hemostasis, MI, LIMA occlusion, pneumothorax, death, and others.

RESULTS: This study included 29 patients, the majority of whom were male (75.9%), with an average age of 67.4 ± 7.1 years (

Table 7. Preoperative, intraoperative and postoperative characteristics.

Age (y)	67.4 ± 7.1 (min: 47; max: 77)
Sex: Male	22 (75.9%)
Female	7 (24.1%)
EF (%)	47 ± 10 (min: 25; max: 65)
HTA	28 (96.6%)
HLP	27 (93.1%)
DM	10 (34.5%)
MI	12 (41.4%)
AP	20 (69%)
AF	4 (13.8%)
CKF	4 (13.8%)
Smoke	4 (13.8%)
Previous PCI	8 (27.6%)
Procedure length (min)	160 ± 51 (min: 100; max: 330)
Subxiphoid LIMA harvesting	4 (13.8%)
Coronary artery diameter (mm)	1.6 mm (min 1; max: 2)
Conversion to full sternotomy	1 (3.4%)
Blood transfusion	0 (0%)
Intubation time (h)	7 ± 5 (min: 2; max: 25)
Chest drainage (mL)	522 ± 484 (min: 50; max: 2050)
Revision of haemostasis	1 (3.4%)
LIMA occlusion	1 (3.4%)
MI	0 (0%)
CVI	0 (0%)
Pneumothorax	1 (3.4%)
PCI	2 (6.9%)
ICU stay (h)	28 ± 12 (min: 24; max: 72)
In hospital stay (d)	5 ± 1 (min: 4; max: 9)
Death	0 (0%)

). The mean duration of the procedure was 160 ± 51 min, exhibiting a noteworthy decline with time. Dividing the patients into three groups every four months in a year will show that, over time, the procedure’s average duration has decreased from 180 ± 48 to 145 ± 31 min. The duration of intubation was 7 ± 5 h on average. In just 1 case (3.4%) conversion to medial sternotomy was performed. Except for one LIMA occlusion (3.4%), there were no significant cardiovascular problems throughout the postoperative phase. With a decreasing duration of time, the average ICU stay was 28 ± 12 h, and the average hospital stay was 5 ± 1 days, with no deaths. We should mention that during the study period, we performed 1 MIDCAB surgery with multi-vessel revascularization (CABG × 3), and 4 patients (13.8%) had the subxiphoid technique for LIMA harvesting.

CONCLUSIONS: Transferring from conventional to MIDCAB procedures requires a learning curve, whose length depends on the surgeon’s experience in conventional myocardial revascularization. Experienced surgeons may easily adapt to performing MIDCAB operations, with few adverse events.

• Keywords: MIDCAB; learning curve; CABG; subxiphoid technique

1.15.5. Minimally Invasive Multi-Vessel Coronary Artery Bypass Grafting for Complete Revascularization: A Single-Center Experience

• Muhammad Yasir Khan and Muhammad Hamid Chaudhary
• Chaudhary Pervaiz Elahi Institute of Cardiology Multan, Multan, Pakistan

BACKGROUND AND AIM: This study aimed to evaluate the outcome of the first 50 cases of isolated minimally invasive multivessel CABG in terms of complete revascularization and review the surgical technique in terms of efficacy, and safety.

METHOD: This retrospective analysis was done from January 2023 to February 2024. Only patients with isolated CABG and an EF of 35% or more were selected. All patients underwent minimally invasive multivessel CABG through a left anterior mini-thoracotomy in the fourth intercostal space. Chitwood clamp and del Nido cardioplegia were used. The procedure was completed either on beating heart, on-pump beating, or cardioplegic arrest. Femoral arterial and venous cannulation were performed with vacuum-assisted drainage for complete decompression. The left internal mammary artery and the long saphenous vein were used as conduits. We examined the number of grafts decided preoperatively on coronary angiography and the grafts completed postoperatively, operating time, and postoperative outcomes.

RESULTS: Of the 50 patients (

Table 8. Patient Characteristics.

Variables	Values
Age	57.86 ± 8.5 years
Gender	Male = 90% (n = 45) Female = 10% (n = 5)
LVEF	53.43 ± 7.79 (%)
Euro II score	2.5 ± 0.33
Total CPB time (min)	192.69 ± 41.02
Total Cross Clamp time (min)	105.825 ± 29.49
Icu stay duration (h)	25.56 ± 5.97
Ventilation time (h)	12.86 ± 7.28
Duration of inotropes (h)	8.85 ± 10.59 h
Hospital stay (days)	4.3 ± 2.3
Chest drianage (mean, mL)	689.9 ± 362.9 mL

), 10 (20%) underwent off-pump CABG, 40 (80%) underwent On-pump CABG, and three underwent on-pump beating CABG. One patient died of a stroke (watershed stroke), and two conversions to sternotomy. One patient had intramyocardial LAD and the second patient had pulmonary artery injury. One reopening due to bleeding was controlled via a thoracotomy. Among the 40 patients who underwent on-pump CABG, the total cardiopulmonary bypass time was 192.69 ± 41.02 min, and the aortic cross-clamp time was 105.825 ± 29.49 min. The average number of diseased vessels was 2.57 ± 0.72, and the average number of grafts done was 2.38 ± 0.86.

CONCLUSIONS: Complete coronary revascularization can be routinely performed using the aforementioned technique. No patient selection, based on the number of grafts, quality, location of coronary vessels, left ventricle function, age, gender, or body mass index, is required.

• Keywords: MICS; MIDCAB; OPCAB

1.15.6. Pleural Effusion Post-Total Coronary Revascularization via Left Anterior Thoracotomy

• Zhi Rong Low and Shahrul Amry Hashim
  Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, University of Malaya & University of Malaya Medical Centre, Kuala Lumpur, Malaysia

BACKGROUND AND AIM: The use of minimally invasive approaches such as total coronary revascularization via left anterior thoracotomy (TCRAT) for multi-vessel coronary disease is on the rise. However, data on the post-operative complications, specifically the occurrence of pleural effusion, is scarce. We aim to investigate the role of this novel technique as an alternative to conventional coronary artery bypass grafting (CABG) surgery with regards to its clinical outcomes.

METHOD: A retrospective study involving patients who underwent TCRAT surgery from January 2023 to February 2024 was conducted. Various pre-, intra- and post-operative parameters were determined and compiled. We identified patients who developed pleural effusion post-operatively which required pigtail insertion or readmission. Chi-Square test, univariate and multivariate logistic regression tests were used to assess correlation between the clinical parameters and incidence of pleural effusion.

RESULTS: A total of 109 patients with the mean age of 62.02 (SD = 9.32) were included in our study, 89.9% of which are male and majority werediagnosed with triple vessel disease. The mean left ventricular ejection fraction (LVEF) was 59.06% (SD = 10.67%) and most patients (90.9%) had normal renal function or mild renal dysfunction pre-operatively. 20 (18.3%) patients were complicated with post-operative pleural effusion which is defined by persistent chest tube drainage for at least 4 days. 3 patients required pigtail insertion and 9 needed readmission. The duration of chest tube insertion was found to be significantly associated with pleural effusion leading to pigtail insertion and readmission (X² = 18.98; df = 2; p < 0.001).

CONCLUSIONS: Our study shows that pleural effusion post-TCRAT surgeries requiring further intervention or readmission correlates with longer duration of chest tube insertion. Future research with a larger sample size should be carried out to evaluate other potential risk factors in order to improve the outcomes of this minimally invasive technique.

• Keywords: Pleural effusion; TCRAT; adult cardiac surgery

1.15.7. Patient-Reported Outcomes Measured Between Total Coronary Revascularization via Anterior Thoracotomy and Conventional Coronary Artery Bypass Graft: Where Quality of Life Matters

• Nur Nadiah Nazri ¹, Ummu Solehah Mohd Fauzi ¹, Fatimah Alia Mohd Afandi ¹, Muhammad Ibrahim Azmi ² and Shahrul Amry Hashim ³

1

Cardiothoracic Intensive Care Unit, University Malaya Medical Centre, Kuala Lumpur, Malaysia

2

Cardiothoracic Unit, University Malaya Medical Centre, Kuala Lumpur, Malaysia

3

Cardiothoracic Unit, KPJ Damansara Specialist Hospital 2, Kuala Lumpur, Malayisa

BACKGROUND AND AIM: We explored patient-reported outcome measures in patients who underwent Total Coronary Revascularization via Left Anterior Thoracotomy (TCRAT) and Conventional Coronary Artery Bypass Grafting (cCABG).

METHOD: A Telemedicine health survey was conducted for all TCRAT and cCABG patients from January 2023 to October 2023. Post-operative quality of life was assessed using a validated SF-36v2 questionnaire. All telephone calls were adapted to the language suitable for patients: English, Malay, Chinese, and Tamil. The questionnaire was done in December 2023. The survey outcomes were compared between the two groups using statistical analysis. There is a total of 83 TCRAT patients and 50 cCABG patients.

RESULTS: Following the exclusion of patients who refused participation, there were 60 TCRAT and 26 cCABG. The mean of duration follow-up assessment for TCRAT was 8 months and cCABG 10 months. SF36 questionnaire focuses on several categories: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health. Higher overall scores indicate better performance. The result shown in

Table 9. Overall SF36 score for TCRAT and cCABG.

Scale	TCRAT-Mean Score	CCABG-Mean Score	Difference (TCRAT-CCABG)
Physical Functioning	−40.44117647	−39.79166667	−0.649509804
Role-Physical	−66.91176471	−69.79166667	2.879901961
Bodily Pain	−11.61764706	−11.25	−0.367647059
General Health	17.86764706	1.354166667	16.51348039
Vitality	15.58823529	2.083333333	13.50490196
Social Functioning	−21.32352941	−15.36458333	−5.958946078
Role-Emotional	−80.39215686	−84.72222222	4.330065359
Mental Health	9.529411765	−1.5	11.02941176

The table compares the mean Quality of Life (QoL) ratings across eight measures for patients who had Total Coronary Revascularization via Anterior Thoracotomy (TCRAT) to those who received Conventional Coronary Artery Bypass Graft (cCABG). The results were converted using the SF-36 Health Survey scale, with higher scores indicating a better quality of life. Negative scores indicate a decrease in QoL, which may occur when the actual raw score is lower than the lowest feasible raw score owing to data input mistakes or other circumstances. Here’s an interpretation for each scale: Physical Functioning: The TCRAT group had a slightly lower average score than the cCABG group, with a difference of −0.65 points. This shows that both groups had equivalent physical functioning levels, with TCRAT patients scoring somewhat lower. Role-Physical: Patients in the TCRAT group had a mean score that was 2.88 points higher than those in the cCABG group. This shows a somewhat higher role-physical QoL for TCRAT patients, implying that they may have less difficulties with employment or other everyday activities owing to physical health. Bodily Pain: Both groups had negative mean ratings, with the TCRAT group having an extra −0.37 point decline over the cCABG group. This modest difference shows that physiological discomfort varies very little across the two patient groups. General Health: TCRAT patients scored much higher, by about 16.51 points, than the cCABG group. This large difference indicates that TCRAT patients believe their overall health is considerably better after surgery than cCABG patients. Vitality: The TCRAT group’s mean vitality score was 13.50 points greater than the cCABG group. This shows that TCRAT patients are more active and less exhausted than those who had cCABG. Social Functioning: TCRAT patients had a mean score around 5.96 points lower than cCABG patients. Although both groups had negative ratings, the bigger decline in TCRAT patients shows that they may have more difficulty with social functioning after surgery. Role-Emotional: TCRAT patients had a 4.33-point higher mean score on the role-emotional scale than the cCABG group. This shows that TCRAT patients may have less difficulties at work or in other everyday activities owing to emotional issues. Mental Health: The TCRAT group had a mean score improvement of 11.03 points over the cCABG group. This suggests that TCRAT patients had improved mental health after surgery, with less symptoms of anxiety, sadness, and psychological discomfort. Finally, the QoL results for the TCRAT and cCABG groups vary in many elements of life after surgery. Notably, TCRAT patients report improved overall health, vigour, and mental health, but their social functioning is reduced. The interpretation of these ratings must be taken with care, particularly given the unexpected negative results, which indicate possible flaws with the dataset that need additional research.

.

CONCLUSIONS: The postoperative survey from our series has shown better patient-reported outcomes in TCRAT patients when compared to cCABG patients. This suggests a desirable patient-centered benefit on top of the potential clinical superiority of the sternal-sparing approach to minimally invasive surgery.

• Keywords: quality of life; conventional coronary artery bypass graft; and total coronary revascularization via anterior thoracotomy

1.15.8. Prediction of Adverse Clinical Outcomes During 12 Months After Hybrid Myocardial Revascularization

• Aliaksandr Charniak, Vladislav Podpalov, Kiryl Rubakhov, Oleg Kozak and Alexey Ostrovsky
• Department of Cardiac Surgery, Minsk Scientific and Practical Center for Surgery, Transplantology and Hematology, Minsk, Belarus

BACKGROUND AND AIM: Hybrid myocardial revascularization (HMR) is debatable in modern cardiac surgery. The aim was to estimate 1-year outcomes after HMR in comparison with off-pump coronary artery bypass grafting (OPCAB) and to determine preoperative prognostic criteria for adverse clinical outcomes.

METHOD: 180 consecutive patients with multi-vessel coronary artery disease were randomized into 2 groups: 1st group—98 patients, who underwent OPCAB; 2nd group—82 patients with performed HMR. HMR consisted of 2 stages: minimally invasive direct coronary artery bypass grafting and later within 24–72 h PCI stage was performed.

RESULTS: HMR showed an advantage at the hospital stage in comparison with OPCAB due to reduction of myocardial damage, minimization of the intervention and faster postoperative rehabilitation with a comparable frequency of adverse clinical events. Within 12 months after surgery, the frequency of development of a combined endpoint, which included at least one of such events as myocardial infarction, stroke, restenosis of stent or the failure of anastomosis, repeated revascularization and cardiac mortality was lower among patients after HMR. Based on significant preoperative criteria, a multifactorial model was developed for predicting the unfavorable development of the disease after HMR, consisting of 3 factors: the level of CRP > 3.5 mg/mL in patients with BMI > 28.5; the concentration of glycated hemoglobin > 6.1% in people with a history of a stroke; a combination of hyperglycemia (glucose level > 6.6 mmol/L) and increased platelet aggregation (ADP > 664 AU*min).

CONCLUSIONS: HMR may be considered better surgical decision in patients with multi-vessel CAD. In our prognostic model the accuracy of predicting adverse clinical outcomes during 1 year after HMR is 91.7%.

• Keywords: Hybrid myocardial revascularization; off-pump coronary artery bypass grafting; prognostic model; multi-vessel coronary artery disease

1.15.9. Overcoming Challenges and Implementing Solutions in Establishing a Minimally Invasive Cardiac Surgery Program: Our Experience and Lessons Learnt

• Muhammad Hamid Chaudhary and Muhammad Yasir Khan
• Chaudhary Pervaiz Elahi Institute of Cardiology Multan, Multan, Pakistan

BACKGROUND AND AIM: Early return to work after cardiac surgery is of greater value in developing countries and this can be achieved through minimally invasive cardiac surgery (MICS). Nowadays most adult procedures and isolated coronary artery bypass grafting can be performed through MICS techniques. We present our experience, the strategies used, and the challenges faced while starting a minimally invasive cardiac surgery program at a newly established tertiary care center.

METHOD: We retrospectively collected our data on MICS procedures done in our hospital between September 2022 and February 2024. We analyzed our results regarding mortality, morbidity and complications, and other quality parameters like ICU stay, blood loss, ventilation time, strokes, re-exploration rate, hospital stay, etc. A step-wise approach was adopted that introduced every team member to the increasing complexity of the procedures.

RESULTS: Of the 125 patients (

Table 10. Patient Characteristics and outcomes.

Variable	Values
AGE	57.86 ± 8.5 years
Gender	Male = 90% (n = 113) Female = 10% (n = 12)
LVEF	56.22 ± 7.018%
Euro II score	2.9 ± 0.33
Total CPB time (min)	152.12 ± 51.903
Total Cross Clamp time (min)	94.87 ± 32.53
Icu stay duration (h)	24.15 ± 4.92
Ventilation time (h)	5.92 ± 5.64
Duration of inotropes (h)	7.70 ± 8.56 h
Hospital stay (days)	4.3 ± 2.3
Chest drianage (mean, mL)	551, 34.2 mL

), 74 (59.2%) were minimally invasive CABG, 12 (9.6%) were aortic valve replacement, 31 (24.8%) were mitral valve replacement, 5 (4%) were atrial septal defect repair 1 (0.8%) was Double valve replacement (aortic and mitral valve) and 1 (0.8%) was LA myxoma excision & and 1 (0.8%) was ventricular septal defect. Two patients had strokes, among those one patient died, and two conversions to sternotomy. One patient had intramyocardial LAD and the second patient had pulmonary artery injury. There were four reopenings due to bleeding which was controlled via a thoracotomy.

CONCLUSIONS: MICS follows the same principles of heart surgery, train your team, take good informed consent, individualize the access, and avoid extreme anatomy, flat chests, and tiny patients. Likewise, don’t be fanatic about it, don’t compromise the repair/results just for the sake of MICS, and never hesitate to convert. Local and Global alliances, industry support, and proctorship are mandatory.

MICS is an opportunity, not a threat, and can provide an edge for our high-tech healthcare system without colliding with the principles of value-driven outcomes.

• Keywords: Minimally invasive cardiac surgery; Cardiac Surgery; Mitral valve replacement

1.15.10. Advancements in Minimally Invasive Coronary Bypass Surgery for Obese Patients: Evolving Perspectives in Cardiac Care

• Altay Tandogan
• Istanbul NS Klinika, Baku, Azerbaijan

BACKGROUND AND AIM: Coronary artery disease (CAD) remains a leading cause of morbidity and mortality worldwide, with obesity representing a significant risk factor for its development and progression. Traditional coronary bypass surgery, while effective, may pose heightened risks and complications in obese patients due to associated comorbidities such as diabetes, hypertension, and dyslipidemia. Minimal invasive coronary bypass surgery (MICAB) has emerged as a potential alternative, offering the promise of reduced surgical trauma, shorter recovery times, and improved cosmetic outcomes. However, the efficacy and safety of MICAB specifically in obese individuals have not been comprehensively elucidated. Thus, a thorough evaluation of MICAB in this patient population is warranted to inform clinical practice and optimize treatment strategies for CAD in the context of obesity.

METHOD: This study aims to evaluate the efficacy and safety of minimal invasive coronary bypass procedures in patients diagnosed with obesity. Through a comprehensive analysis of relevant literature and clinical data, this investigation seeks to elucidate the benefits and potential drawbacks of employing minimal invasive techniques in coronary bypass surgery among this specific patient population. The findings of this research endeavor are anticipated to contribute to the optimization of treatment strategies for coronary artery disease in obese individuals, thus enhancing clinical outcomes and patient care.

CONCLUSIONS: In conclusion, this study underscores the potential utility of minimal invasive coronary bypass surgery in patients with obesity. Our findings suggest that MICAB procedures demonstrate comparable efficacy to traditional coronary bypass surgery while offering distinct advantages, including reduced operative trauma and enhanced postoperative recovery, particularly relevant in the context of obesity-associated comorbidities. However, further prospective studies with larger sample sizes and longer follow-up periods are warranted to validate these findings and elucidate the long-term outcomes and safety profile of MICAB in obese individuals. Nevertheless, the insights gleaned from this investigation provide valuable guidance for clinicians in navigating treatment decisions for coronary artery disease in this high-risk patient population, ultimately facilitating improved patient care and outcomes.

• Keywords: MICS; TCRAT; Obesity; Coronary bypass; Minimally Invasive

1.15.11. MIDCAB: Short-Term Results and Experience of Minimally Invasive Coronary Surgery in Azerbaijan

• Kamran Musayev, Ilkin Osmanov, Nigar Kazimzade and Kamran Ahmadov
• Department of Cardiovascular Surgery, Merkezi Klinika, Baku, Azerbaijan

BACKGROUND AND AIM: Minimally invasive direct coronary artery bypass grafting (MIDCAB) via lateral thoracotomy provides a less invasive alternative to the conventional median sternotomy approach in coronary surgery, a technique that we also employ in Azerbaijan within our institution. This study aims to analyze the short-term outcomes of operations performed using the MIDCAB strategy in our center over the last two years.

METHOD: A retrospective analysis of data from patients who underwent MIDCAB surgery at our medical center from January 2022 to January 2024 was conducted to assess the short-term results of this strategy in treating patients with coronary heart disease. The database included all patients who underwent MIDCAB for revascularization of left anterior descending artery (LAD) stenosis using the left internal mammary artery (LIMA). The study encompassed 10 patients with a median age of 58.5 years (range: 52–68), consisting of 8 males and 2 females, with angina pectoris class 2.

RESULTS: No mortality or severe morbidity was observed, indicating the safety profile of this surgical strategy. The median duration of intensive care unit (ICU) stay was 2 days, with a median hospital stay of 5.5 days, highlighting the rapid recovery of patients. All patients exhibited stable clinical improvement in the early postoperative period. Detailed operative and postoperative patient characteristics can be found in

Table 11. Operative and postoperative characteristics of the patients.

Patient	1	2	3	4	5	6	7	8	9	10	Median
Ventilation time, hours	9	6	9	19	10	6	7	6	7	7	7
ICU stay, days	2	2	2	2	2	1	1	2	2	2	2
Hospital stay, days	5	4	5	6	5	4	5	6	6	6	5
Complication, 0/1	0	0	0	0	0	0	0	0	0	0	0

.

CONCLUSIONS: Our study confirms the safety and efficacy of MIDCAB procedures in our institution. The absence of mortality or severe complications, coupled with rapid patient recovery and stable clinical improvement, underscores the success of this approach. Our findings align with international standards of coronary surgery, reaffirming the promising role of MIDCAB in our medical practice.

• Keywords: MIDCAB; minimally invasive coronary surgery; coronary revascularization

1.16. CARDIAC » Off-Pump CABG

1.16.1. Short-Term Results of Ivabradine Versus Metoprolol: The Effects on Atrial Fibrillation in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

• Esra Ertürk Tekin ¹, Mehmet Ali Yeşiltaş ², Ismail Haberal ², Ahmet Ozan Koyuncu ³, Necmi Köse ¹, Bahar Aydınlı ⁴ and Doğaç Ökşen ⁵

1

Department of Cardiovascular Surgery, Mersin City Training and Research Hospital, Mersin, Turkey

2

Department of Cardiovascular Surgery, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey

3

Department of Cardiovascular Surgery, Institute of Cardiology, Istanbul University-Cerrahpasa, Istanbul, Turkey

4

Department of Anesthesiology and Reanimation, Mersin City Training and Research Hospital, Mersin, Turkey

5

Department of Cardiology, Altınbas University, Istanbul, Turkey

BACKGROUND AND AIM: Classic coronary artery bypass grafting (CABG) surgery involves diastolic cardiac arrest under cardiopulmonary bypass, while off-pump CABG (OPCABG) has become widespread in recent years.

METHOD: 174 patients who underwent OPCABG were included in the study. Patients were divided into two groups. Group I (n = 90) received ivabradine and Group M (n = 84) received metoprolol before surgery until postoperative day 10. Intraoperative arrhythmias and hypotension were recorded. Postoperative atrial fibrillation (AF) and arrhythmia, mortality and morbidity rates were assessed based on the 30-day postoperative follow-up.

RESULTS: There were no significant differences in the intraoperative amount of inotropic support and red blood cell transfusion between groups (p = 0.87 and p = 0.31). However, the rates of intraoperative arrhythmias and hypotension were not significantly higher in Group M (p = 0.317 and p = 0.47). Ventricular tachycardia/ventricular fibrillation (VT/VF) was observed in 2 patients in both groups. Postoperative AF occurred in 7 patients (7.7%) in Group I and in 10 patients (11.9%) in Group M. Although there was a trend towards a higher prevalence of AF in Group M patients, this did not reach statistical significance. In addition, mortality and morbidity rates were comparable between groups.

CONCLUSIONS: As a result, in our study, ivabradine did not reduce the risk of AF in OPCABG patients compared to metoprolol. However, by effectively reducing the heart rate, surgical comfort during the operation was greatly improved. Ivabradine appears to be a useful choice to provide a more comfortable and effective anastomosis during OPCABG. It may be an effective strategy to reduce heart rate in selected OPCABG patients who cannot be given the targeted beta-blocker dose.

• Keywords: Ivabradine; Metoprolol; Beta-Blocker; Atrial Fibrillation; Coronary Artery Bypass; OPCABG

1.16.2. Objective to Determine the Incidence, Causes, and Predictors of Intra-Operative Conversion of Coronary Artery Bypass Grafting to On-Pump from Off-Pump Surgery

• Muhammad Ali Gohar, Dr Kifayat Ullah and Waqar Masud Malik
• Cardiac Surgery, Peshawar Institute of Cardiology, Peshawar, Pakistan

BACKGROUND AND AIM: To determine the incidence, causes, and predictors of intraoperative conversion of coronary artery bypass grafting to on-pump from off-pump surgery.

METHOD: This was a retrospective case-control (1:4) study conducted at the Peshawar Institute of Cardiology from 1 June 2021 to 31 December 2023. All patients who underwent off-pump coronary artery bypass surgery were registered in the study. Clinical charts were reviewed for demographic, preoperative, and intraoperative characteristics. Surgical notes were reviewed for the reason for conversion to cardiopulmonary bypass. Mean and standard deviation were reported for quantitative data and frequency/percentages for categorical variables. Binary logistic regression analysis was run for predictors of conversion and odds ratio with 95% confidence interval are reported.

RESULTS: Total 714 cases of isolated OPCABG were performed during the study and the incidence of conversion was 3.78% (27/714). The standard age of the participants in this were 59.0 ± 8.77 years and males constituted 82.96% (n = 112) of the participants. The most common reason for conversion was hemodynamic instability in 18 (66.66%) cases followed by poor targets in 14.81% (n = 4) cases. The only significant determinant of conversion was left main stenosis of 50–70% with an odds ratio of 7.60 (95% CI 2.91–19.83, p-value < 0.001).

CONCLUSIONS: Our study reports 3.78% of conversion to cardiopulmonary bypass, hemodynamic instability as a leading cause of conversion, and left main stenosis as the only predictor of conversion.

• Keywords: Off-pump coronary artery bypass; On-pump; Intraoperative conversion; coronary artery bypass; cardiopulmonary bypass

1.16.3. Off-Pump or On-Pump? Single-Vessel Coronary Artery Bypass Grafting Surgery

• Cüneyt Arkan, Ömer Faruk Akardere, Furkan Balcı, Tunahan Sarı, Fatih Yiğit and Mehmet Erdem Toker
• Koşuyolu High Specialization Education and Research Hospital, Istanbul, Turkey

BACKGROUND AND AIM: Some patients undergoing coronary artery bypass grafting surgery have single-vessel disease. Especially in lesions of the proximal left anterior descending artery, surgery is often preferred. Literature comparing off-pump and on-pump techniques has primarily focused on multi-vessel disease, with little attention given to single-vessel disease. Bypassing the LAD with the OPCAB technique is generally easier compared to bypassing the right coronary and circumflex coronary artery regions using the same technique. LAD can be exposed without excessive traction to the heart, and hemodynamic problems usually do not occur during anastomosis. One of the first questions that come to mind in patients with single-vessel disease for whom surgery is decided is whether to perform OPCAB or ONCAB. We believe that among surgeons, the OPCAB technique is more acceptable and feasible for single-vessel disease.

In this study, we will discuss the surgical strategy to be chosen in patients requiring single-vessel coronary artery bypass (1 × CABG).

METHOD: Our study included 336 patients aged between 20 and 80 years who underwent elective or emergency isolated left anterior descending coronary artery bypass grafting surgery between 1 January 2015, and 31 December 2021. Cases with median sternotomy were evaluated under two groups: “Off-Pump” (n = 125) and “On-Pump” (n = 211). The preoperative, intraoperative, and postoperative processes of the patients were examined.

RESULTS: The average age of the off-pump group was higher. Additionally, the mean ejection fraction was lower. However, no difference was observed between the groups in terms of mortality. The off-pump group had shorter intensive care and hospital stays. The on-pump group required more red blood cell and fresh frozen plasma transfusions.

CONCLUSIONS: In cases of single-vessel coronary artery disease, the Off-Pump technique is as reliable as On-Pump technique. In patients with single-vessel disease and no contraindications, the off-pump technique can be applied as the first choice.

• Keywords: Off-pump CABG; On-pump CABG; Coronary artery bypass grafting surgery

1.16.4. Complications and Mortality After CABG in Patients with Reduced Ejection Fraction

• Yurii Kashchenko, Serhii Rudenko and Anatolii Rudenko
  Surgical Department of Treatment of Ischemic Heart Disease, M.M. Amosov National Institute of Cardiovascular Surgery, Kyiv, Ukraine

BACKGROUND AND AIM: This study aims to determine the dominant complications and causes of fatal cases in patients with reduced EF after CABG. Prognostic factors for the development of complications include: ejection fraction less than 35%, emergency surgery, age over 70 years, acute myocardial infarction and/or multivessel coronary artery disease.

METHOD: The study included 210 patients with LV EF 35% or less, who underwent CABG heart for the period from 1 January 2015 to 31 December 2020.

The control group included 100 patients with EF more than 35%, who were operated for the period from 2015 to 2020.

RESULTS: Complications such as heart failure (15% vs. 3% in the control group), respiratory and renal failure (25% and 10%, respectively vs. 1% and 2% in the control group) often occur in patients with reduced EF. In addition, the frequency of their occurrence is higher than in patients with with reduced EF and increases according to its decrease. 4 (1.9%) fatal cases were registered. The immediate cause of death was HF.

CONCLUSIONS: In patients with reduced EF, such complications as heart failure, respiratory failure and renal failure, complications of the central nervous system most often occur. Along with a decrease in EF in patients with reduced EF, the duration of mechanical ventilation, the length of stay in the intensive care unit and in the hospital as a whole increases. One of the most frequent and life-threatening complications in this group of patients was acute HF. Despite the significant percentage of complications in patients with reduced LV contractility, the mortality rate is only 1.9%, so they are recommended to perform CABG.

• Keywords: CABG; reduced ejection fraction; heart failure; complications and mortality

1.16.5. It Is Safe to Established Off-Pump Coronary Artery Bypass Services in Newly Established Cardiac Center in Developing World

• Abdul Nasir and Aamir Iqbal
• Cardiac Surgery Department, Peshawar Institute of Cardiology, Peshawar, Pakistan

BACKGROUND AND AIM: Cardiopulmonary bypass during coronary artery bypass surgery (CABG) has been link with increased morbidity and mortality. The arrival of Off Pump myocardial revascularization technique is considered effective to reduce mortality and morbidity and safely performed around the globe. The objective of this study was to present our early results and share our experience in establishing this service in newly build tertiary care cardiac center in developing country.

METHOD: This retrospective observational study was conducted from 2020–2023 at tertiary care hospital. We included a number of (n = 75) patients who underwent for off-pump coronary artery bypass grafting surgery. Ethical consideration was taken from institutional review board committee. Data was extracted from Electronic Medical Record, entered and analyzed in SPSS version 23.0.

RESULTS: The mean age of the patients was (57.67 ± 10.058), mean weight (74.24 ± 12.514), mean Intensive Care Unit stay (32 ± 12.683), mean hospital stay (3.79 ± 1.189) and mean number of grafts (1.73 ± 0.890) was assessed in our study. 88% patient’s shows no post-operative complications, Arrhythmia 2.6%, wound infection 4%, re-exploration for bleeding 4% and pneumonia 1.3%.

CONCLUSIONS: Our early result shows safety and feasibility of off pump coronary artery bypass surgery at newly build tertiary care cardiac center, Peshawar Institute of Cardiology (PIC) with comparable early outcomes in terms of morbidity with other well-established OPCAB Centre.

• Keywords: Coronary Artery Bypass Grafting; OPCAB; Myocardial Revascularization

1.16.6. Creative Approaches to Sequential Anastomosis Enabled Excellent Patency and Long-Term Outcomes

• Yuki Endo and Yoshiei Shimamura
  Department of Cardiovascular surgery, Saitama City Hospital, Saitama City, Japan

BACKGROUND AND AIM: Positioning of the heart, visualization of coronary artery anastomosis, and maintenance of hemodynamics are important techniques in OPCAB. Here, we introduce the sequential anastomosis method in multi-graft bypass at our facility and discuss its utility and long-term outcomes.

METHOD: We targeted 158 cases of OPCAB performed from January 2008 to December 2016. A dispersed multi-directional heart positioner was utilized for cardiac stabilization. Target vessels were identified, and grafts were secured with a side graft holder (Astech Inc., Vassar, MI, USA) and anastomosed using a diamond technique.

RESULTS: Among the 158 cases of OPCAB, sequential anastomosis was performed in 76 cases (48.1%). The mean age was 68.4 ± 9.7 years, with 60 cases being male (78.9%). The median follow-up duration was 10.1 ± 2.59 years (range 6.4–16.0), with only one case lost to follow-up. Among these cases, 65 had triple-vessel disease, 30 had left main trunk lesions, and the mean left ventricular ejection fraction (LVEF) was 58.5 ± 12.6%. There were 16 urgent or emergent cases, and the mean number of reconstructed grafts was 3.4 ± 0.8.

During the follow-up period, there were 19 deaths (3 cardiac-related deaths, including one sudden/unexplained death), with no in-hospital mortality. Postoperative graft confirmation angiography was performed in 74 cases (97.3%), showing a graft patency rate of 98.3%.

Remote cardiac or cerebrovascular events included 10 cases of repeat revascularization (no repeat CABG), 2 cases of cerebrovascular events, and 5 cases of exacerbation of heart failure.

The overall survival rates at 5, 10, and 13 years postoperatively were 92.1%, 75.9%, and 64.6%, respectively, while the MACCE avoidance rates were 76.3%, 59.7%, and 47.8%.

CONCLUSIONS: Sequential anastomosis resulted in favorable graft patency rates and long-term outcomes. Adequate visualization during anastomosis and maintaining stable hemodynamics are indeed crucial techniques in OPCABG.

• Keywords: OPCAB; sequential anastomosis; long-term result; side-graft holder

1.17. CARDIAC » On-Pump CABG

1.17.1. Percutaneous Coronary Intervention with Drug-Eluting Stents Versus Coronary Bypass Surgery for Complex Coronary Artery Disease: A Bayesian Analysis of Randomized Trials

• Michal J. Kawczynski ¹, Andrea Gabrio ², Jos G. Maessen ¹, Arnoud W.j. Van’t Hof ³, James M. Brophy ⁴, Can Gollmann Tepeköylü ⁵, Peyman Sardari Nia ¹, Pieter A. Vriesendorp ³ and Samuel Heuts ¹

1

Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands

2

Department of Methodology and Statistics, University Maastricht, Maastricht, The Netherlands

3

Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands

4

McGill University Health Center, Center for Health Outcome Research (CORE), Montreal, QC, Canada

5

Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria

BACKGROUND AND AIM: We aimed to assess the totality of randomized evidence comparing percutaneous coronary interventions with drug-eluting stents (DES-PCI) to coronary artery bypass grafting (CABG) for complex coronary artery disease (CAD), under the Bayesian statistical framework.

METHOD: A Bayesian re-analysis of trials comparing DES-PCI to CABG with 5-year follow-up was performed. The primary outcome was all-cause mortality at five years; secondary outcomes were stroke, myocardial infarction, and repeat revascularization. Endpoints were reported in relative risks (RR) and absolute risk differences (ARD), with 95% credible intervals (CrI). Kaplan-Meier curves were used to reconstruct individual patient data. This study was registered in PROSPERO (CRD42024512897, date: 25 February 2024).

RESULTS: Six studies (SYNTAX, NOBLE, EXCEL, PRECOMBAT, BEST, FREEDOM) comprising 8269 patients (DES-PCI n = 4134, CABG n = 4135) were re-analyzed using Bayesian statistics. All-cause mortality at 5 years was increased with PCI (median RR 1.23 (95%CrI 1.01–1.45), with a median ARD of +2.3% (95%CrI 0.1–4.5%). For stroke, MI, and repeat revascularization, the median RRs were 0.79 (95%CrI 0.54–1.25), 1.84 (95%CrI 1.23–2.75), and 1.80 (95%CrI 1.51–2.16) for PCI, respectively. Illustratively, in a sample of 1000 patients undergoing DES-PCI instead of CABG for complex CAD, a median of 23 additional deaths, 46 myocardial infarctions and 85 repeat revascularizations occurred at five years, while 10 strokes were prevented.

CONCLUSIONS: In complex CAD, CABG provides a clinically relevant benefit over DES PCI at five years. These findings offer an intuitive interpretation of revascularization outcomes in complex CAD, and may guide the heart-team and the shared decision-making process.

• Keywords: Percutaneous coronary intervention; coronary artery bypass grafting; randomized clinical trials; Bayesian statistics; methodology

1.17.2. Obesity Is the Major Killer in Coronary Artery Bypass Grafting (CABG) Surgery

• Muhammad Wasim Sajjad, Azam Jan, Rokhan Yousaf Zai and Rashid Qayyum
• Department of Cardiothoracic & Vascular Surgery, Rehman Medical Institute, Peshawar, Pakistan

BACKGROUND AND AIM: To explore the impact of BMI on the short-term mortality and morbidity of patients undergoing CABG.

METHOD: Observational study on retrospective data of CABG patients at a tertiary care hospital from 1 July 2017 to 31 December 2022. Ethical approval was granted and inclusion criteria were met. Patients were then categorized according to their BMI groups & perioperative variables were extracted. For statistical analysis, Chi-square, t-test & multivariate regression analysis was employed. A p-value of <0.05 was considered statistically significant.

RESULTS: Total of 2599 isolated CABG patients were included with mean age of 57.86 ± 9.2 years. The majority was overweight (42%). Approximately 78.1% were male. Hypertension was our dominant co-morbidity (68.7%) followed by dyslipidemia (65.4%) & DM (50.1%). Majority of patients had NYHA-III symptoms (51.2%). The morbidly obese patients had the highest in-hospital mortality (11.3%) while overweight had the lowest (2.6%) with a p-value of 0.008. Generally, there is a significant increasing trend of DM & HTN incidence with increasing BMI compared to normal (<0.001). The insertion of IABP was significantly highest among the underweight having low EF when compared with preserved EF (0.05). Most of the underweight were elderly with a high incidence of postoperative complications (e.g., prolonged mechanical ventilation, blood product requirement, reopening & re-intubation), but not significant. However, they have significantly longer mechanical ventilation time compared to normal (<0.001). Multivariate regression analysis showed that mean age (p < 0.034), cross-clamp time (p < 0.018) & mechanical ventilation (p < 0.001) were significantly associated with in-hospital mortality.

CONCLUSIONS: Both extreme categories of the BMI showed higher incidence of perioperative complications, such as morbidly obese patients had the highest in-hospital mortality while overweight had the lowest confirming a partial obesity paradox, whereas underweight patients had significantly higher mechanical ventilation time.

• Keywords: Body mass index; CABG (coronary artery bypass grafting); obesity; mortality

1.17.3. Gender Difference and Its Outcomes in Anemic Patients Undergoing Coronary Artery Bypass Grafting Surgery

• Muhammad Wasim Sajjad ¹, Azam Jan ¹, Saif Ullah ¹, Muhammad Salman Farsi ¹, Aamir Iqbal ², Rashid Qayyum ¹ and Sarmad Saeed ¹

1

Department of Cardiothoracic & Vascular Surgery, Rehman Medical Institute, Peshawar, Pakistan

2

Department of Cardiac Surgery, Peshawar Institute of Cardiology, Peshawar, Pakistan

BACKGROUND AND AIM: According to some studies female gender is considered as an independent predictor of mortality in CABG. We sought to further identify the impact of anemia on outcomes according to gender.

METHOD: The observational study on retrospective data was conducted at a Tertiary care hospital from December 2020 to December 2023. A total of 1346 anemic patients were included, with 1029 male & 317 female patients. Institutional review board approval was granted and inclusion criteria were met. For statistical analysis, Chi-square & t-test were used. Data was analyzed using SPSS 25. A p-value of <0.05 was considered statistically significant.

RESULTS: The database of cardiovascular & thoracic department was searched for the patients who underwent isolated CABG. A total of 2570 patients were identified, amongst them only 1346 patients who met the criteria were included in the study, with the majority of the male population (76.4%) having a mean age of 59.2 ± 9.1 years. Most of the patients had NYHA III (54.7%) & CCS III (53.3%) functional class symptoms. Hypertension was our most common co-morbidity (72.8%), followed by DM (66.6%) & dyslipidemia (54.6%). Anemia is more prevalent in female patients & requires markedly higher rates of intra- & post-operative blood/products transfusion. In terms of post-operative outcomes, there was no notable difference in mean ventilation time, re-admission to ICU, re-intubation & in-hospital mortality. However male patients had significantly higher rates of re-opening (p = 0.005) with prolonged ventilation hours (p = 0.02).

CONCLUSIONS: There is no comparable gender difference in terms of mortality in anemic patients undergoing CABG. However female anemic patients required a substantially higher rate of blood/products transfusion.

• Keywords: Gender; Anemia; Coronary Artery Bypass Grafting (CABG); outcomes; mortality

1.17.4. The Role of AKIN, KDIGO, and RIFLE Criteria in Coronary Artery Bypass Surgery

• Melïke Elïf Teker Açikel, Erman Süreyya Kiriş, Ülkü Ziyaoğlu, Mehmet Ziyaddin Altun, Tolga Demir and Ismail Koramaz
  Cardıvascular Surgery of Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi, İstanbul, Turkey

BACKGROUND AND AIM: Acute kidney injury is a loss of kidney function defined by an acute increase in serum creatinine and a decrease in hourly urine output. Our aim in this study is to determine the role of AKIN, KDIGO and RIFLE criteria in the prediction of mortality in diabetic patients who underwent Pump-Assisted Coronary Artery Bypass Graft operation.

METHOD: Among 1258 patients who were operated on in our clinic between January 2019 and December 2022, 310 diabetic patients who underwent Pump-Assisted Coronary Artery Bypass Graft operation were included in this study. In the cardiovascular surgery intensive care unit follow-up of the patients, anesthesia card, intensive care follow-up charts, need for continuous renal replacement therapy, use of diuretics, use of inotropic agents, mechanical ventilator therapy, The RIFLE, KDIGO and AKIN scores of the patients were calculated daily and the highest value during the hospitalization was recorded. In addition to the length of stay in the intensive care unit and hospital, the death and discharge status of the patients were also evaluated.

RESULTS: The mean age of 310 patients included in our study was 57.4 ± 10.5 years. 132 (42.6%) of our patients were female and 178 (57.4%) were male. 92% of the research group were discharged and 7.8% were exitus. It was observed that all of our exitus patients were at any AKI stage according to the KDIGO, AKIN and RIFLE classifications. According to the RIFLE, AKIN and KDIGO classifications, it was found that the mortality rate increased statistically as the Acute kidney injury stage increased

CONCLUSIONS: According to RIFLE, AKIN and KDIGO classifications, the mortality rate increases statistically as the stage of acute kidney injury increases. Checking these scores in patients scheduled for coronary artery bypass surgery may reduce mortality.

• Keywords: AKIN Criteria; KDIGO Criteria; RIFLE Criteria; Coronary Artery Bypass Graft Surgery

1.17.5. Preoperative Effect of Cilostazol Usage on Myocardial Protection and Perioperative Myocardial Infarction

• Ahmet Ibrahim Balkaya, Begum Ozuekren Kasapoglu, Helin El Kilic, Tolga Demir and Ismail Koramaz
• Department of Cardiovascular Surgery, Hamidiye Etfal Training and Research Hospital, Health Science University, Istanbul, Turkey

BACKGROUND AND AIM: Myocardial protection during cardiac surgery is critically important. Cardioplegic solutions enriched with various molecules have been used for this reason. In this study, the effect of preoperative Cilostazol usage on perioperative myocardial protection is investigated by measuring troponin I levels.

METHOD: A hundred consecutive patients (28 females, 72 males; mean age 67 ± 2.3 years) who underwent on pump coronary surgery are divided into two groups according to the preoperative Cilostazol usage. Troponin I investigation was done before surgery and following cross-clamp (after 1–3–6–12–24–48 h).

RESULTS: The average levels of Troponin I at six and twelve hours for the second group were significantly lower than the first group. There was no significant difference in other measured Troponin I levels.

CONCLUSIONS: Cilostazol usage before cardiac surgery partly lowers the myocardial damage during operative and early postoperative period.

• Keywords: Cilostazol; ischemia reperfusion; cardioplegia; myocardial protection; cardiopulmonary bypass; coronary artery bypass grafting

1.17.6. Impact of Aortic Cross Clamp Time on Post Operative Outcomes in Patient Undergoing Cardiopulmonary Bypass Grafting

• Adnan Shah
• Department of Cardiac Perfusion, Peshawar Institute of Cardiology, Peshawar, Pakistan

BACKGROUND AND AIM: Aortic cross clamping is a surgical instrument used in the cardiac surgery to clamp the aorta and separate the systemic circulation from outflow of the heart. Historically, aortic clamp time was linked to the adverse outcome following cardiac surgery. The aim of the study was to determine the effect of aortic cross clamp time and its impact on post operative outcomes.

METHOD: It was cross sectional study conducted over a period of six months from July 2023 to December 2023. All those patients were included in this study who undergone for adult cardiac surgery for coronary artery bypass grafting and valvular abnormalities. We excluded those patients who were presented with congenital cardiac abnormalities and re- do surgeries. Data was collected through non probability consecutive sampling method technique.

RESULTS: A total of (n = 100) patients were included in this study after meeting the inclusion criteria. As per the gender distribution 60% males and 40% females and the mean age of the patients were (48.13 ± 6.029), Mean aortic cross clamp time (54.37 ± 21.738) mean bypass time is (92.70 ± 36.487). If we talk about the post operative outcomes, we assessed that only 3% patients were detected with respiratory complications and 10% with renal complications.

Mean intensive care unit stay was (4.83 ± 2.147). It is also assessed that aortic cross clamp time is significantly associated with post operative out comes at p value < 0.05.

CONCLUSIONS: This study was conducted to assess the impact of aortic cross clamp time on post operative outcomes in patients. It is indicated that prolonged cross clamp time significantly correlates with Post operative morbidity and mortality in cardiac surgery patients. This effect is increasing with the increase of cross clamp time.

• Keywords: Aortic Cross clamp; Cardiopulmonary Bypass; Arrhythmia; valvular

1.17.7. Pre-Operative Cardiac Troponin I Levels with Post Operative Outcome After Coronary Artery Bypass Grafting at Peshawar Institute of Cardiology

• Zeeshan Afzal, Asif Khan, Hasan Zeb, Waqar Masud Malik, Zeeshan Abdul Nasir and Ubaid Ur Rehman
• Department of Adult Cardiac Surgery, Medical Teaching Institute, Peshawar Institute of Cardiology, Peshawar, Khyber Pakhtunkhwa, Pakistan

BACKGROUND AND AIM: To find out the role of pre-operative cardiac Troponin I level with post operative outcome following a Coronary Artery Bypass Grafting (CABG).

METHOD: Selection of subjects was done according to the inclusion and exclusion criteria. They were divided into two cohorts. Acute MI patients with raised pre-CABG troponin I (Group A N = 64) and a second group with normal pre operative troponin I (Group B N = 59). Post operative outcome was assessed in terms of post operative (CABG) chest pain and hospital stay. The data was analyzed using SPSS version 26.0 for MacBook Pro and organized as tables.

RESULTS: Troponin I level showed statistical difference (p < 0.05) for both groups, with higher values for group A (5.14 ng/mL ± 2.16 ng/mL) in comparison with group B (0.09 ng/mL ± 0.06 ng/mL) subjects. Group A subjects had a prolonged hospital stay (10 days ± 2 days) and higher post operative (CABG) chest pain for longer periods of time in comparison to group B (5 days ± 1 day) and lower post operative pain.

CONCLUSIONS: In conclusion, this study found a direct relation between raised pre operative troponin levels and post CABG complications (hospital stay and post operative chest pain). This makes cardiac troponin I not only a diagnostic but a relatively fair and good marker or prognosis in assessing post CABG outcomes. The raised Troponin I in group A are associated with the post CABG outcomes.

• Keywords: Troponin I; Biomarker; Coronary Artery Bypass Grafting; Cardiac Surgery

1.17.8. Perioperative Evaluation of Kidney Function for Patients with Postinfarcton Aneurysm of Left Ventricle

• Olena Gogayeva, Anatolii Rudenko, Serhii Rudenko and Vasyl Lazoryshynets
  Department of Surgical Treatment of Ischemic Heart Disease, GF “National Amosov Institute of Cardiovascular Surgery NAMS of Ukraine”, Kyiv, Ukraine

BACKGROUND AND AIM: To analyze kidney function in the perioperative period for patients with postinfarction aneurysms of left ventricle (ALV).

METHOD: Retrospective analysis of random 110 high-risk pts with complicated forms of coronary artery disease (CAD). For all pts we performed ECG, ECHO, coronary angiography, coronary artery bypass grafting with correction of postinfarction aneurysm of left ventricle on pump and perioperative evaluation of kidney function by calculation of glomerular filtration rate (GFR).

RESULTS: Preoperative analysis of comorbidity shown: 86 (78.1%) pts had metabolic syndrome, 81 (73.59%)—disorders of glucose metabolism, 82 (74.5%)—chronic obstructive pulmonary disease and 38 (34.5%)—chronic kidney disease (CKD) 3–5 stage. Preoperative risk stratification with EuroSCORE II scale was 9.4%. All operations performed on pump with Custodiol cardioplegia in 53 (48.1%) cases. The average perfusion time was 111 min, average cross-clamping time was 73.9 min. All pts underwent ALV resection with thrombectomy in 57 cases. Correction of mitral insufficiency had 11 pts, between which 9 had mitral valve replacement and 2—mitral valve repair rings. Tricuspid valve repair was performed in 4 pts, interventricular septum defect repair—in 2 pts. The average number of grafts was 2.7, the internal thoracic artery was used in 18 (16.3%) patients. The average duration of the ventilation was 8.03 h. The average level of serum creatinine, glucose and hemoglobin in the perioperative period presented in

Table 12. The average level of serum creatinine, glucose and hemoglobin in the perioperative period, n-110 (n, M ± m).

Average Levels	On Admission	1st Postoperative Day	At Discharge
Serum creatinine, umol/L	108.3 ± 26.3	126.2 ± 38.9	106.2 ± 33.3
Glucose, mmol/L	6.7 ± 2.2	10.7 ± 3.1	6.3 ± 1.9
Hemoglobin, g/L	141 ± 21.3	108 ± 19.6	116 ± 15.3

. Acute kidney injury in the early postoperative period had 9 (8.1%) patients.

CONCLUSIONS: At the admittance 38 (34.5%) pts with complicated forms of CAD had CKD. Analysis of the GFR dynamic in the early postoperative period shown a decrease of GFR in 71.05% of pts. Transient acute kidney injury with 50% sCr growth occurred in 9 (8.1%) cases but didn’t require hemodialysis due to timely correction of drug therapy.

• Keywords: coronary artery disease; postinfarction aneurysm of left ventricle; comorbidity; chronic kidney disease; glomerular filtration rate; on-pump

1.18. CARDIAC » Pulmonary Valve Intervention

Pulmonary Artery Sarcoma: A Case Report and Review of Therapeutic Options

• Alev Gumus ¹ and Bogdan Florin Trifan ²

1

Department of Cardiovascular Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium

2

Department of Cardiovascular Surgery, Grand Hôpital de Charleroi, Hopital Saint-Joseph, Charleroi, Belgium

Pulmonary artery sarcoma (PAS) is a rare and aggressive cancer arising from the intimal layer of the pulmonary artery, often misdiagnosed as pulmonary thromboembolism due to similar clinical presentations. This case report discusses the challenging management of PAS, highlighting the significance of multidisciplinary approaches for precise diagnosis and treatment.

This case report involves a 52-year-old female presenting with PAS, where imaging techniques and a therapeutic test played a crucial role in identifying the tumor, and differentiating it from pulmonary embolism.

The primary treatment was a surgical approach consisting of the resection of the pulmonary trunk and valve “in block” with the tumor, followed by reconstruction. However, radical oncological resection was not practicable because surgical exploration and biopsies highlighted wide infiltration of the endocardium of the right ventricle. The oncological status of the patient did not allow the feasibility of a cardiac transplant.

Additionally, the patient underwent adjuvant radiotherapy. Short-term follow-up showed positive outcomes, but late follow-up revealed disease progression and recurrence. The patient died three years after diagnosis.

The discussion underscores the absence of clear guidelines for PAS management. Various surgical options are possible, depending on tumor characteristics. Nonetheless, there is a lack of evidence in the literature regarding the indications and effectiveness of adjuvant treatments such as chemotherapy and radiotherapy.

The paper concludes that multidisciplinary teams are essential for optimal decision-making, emphasizing the need for further research to establish effective therapeutic pathways for this challenging disease.

• Keywords: Pulmonary artery intimal sarcoma; surgical treatment

1.19. CARDIAC » Role of Heart Team

The Effect of Care Dependency Levels of Individuals with Cardiovascular Disease on Quality of Life: A Structural Equation Modelling

• Özlem Ceyhan, Betül Özen, Derya Dağdelen and Ayser Döner
• Department of Nursing, Faculty of Health Sciences, Erciyes University, Kayseri, Turkey

BACKGROUND AND AIM: This study was conducted using Structural equation modelling to determine the level of care dependency and its effect on quality of life of individuals with cardiovascular disease.

METHOD: This study was a descriptive correlational research design using Structural Equation Modelling (SEM). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was used to report the study. The study was conducted with 512 individuals with a diagnosis of cardiovascular disease who applied to 7 family health centres in a certain region of a province. The data were collected with the information form, Care Dependency Scale and MacNew Heart Disease Specific Quality of Life Questionnaire. The data were analysed using IBM SPSS and IBM AMOS Version 21.0 package programmes. Confirmatory factor analysis-CFA and Maximum Likelihood Estimation-MLE method were used on the model. The factor loadings of the scales ranged from 0.30 to 0.83.

RESULTS: Participants with cardiovascular disease were 60.12 ± 14.36 years, 53.3% were female, 63.5% were hospitalised for heart disease, 84.2% were polypharmacy, 46.7% had a diagnosis of coronary artery disease, and 45.6% had additional chronic diseases other than cardiovascular diseases.

The mean total score of the care dependency scale was 76.96 ± 11.28 and the mean global score of the MacNew Heart Disease Quality of Life Scale was 4.62 ± 1.05. It was determined that there was a moderate positive significant relationship between the care dependency scale and MacNew heart disease quality of life scale scores (0.40 < r < 0.49, p < 0.001). It was determined that care dependency had a statistically significant positive effect on the MacNew heart disease quality of life scale.

CONCLUSIONS: According to SEM, care dependency (β = 0.473, p < 0.05) is a positive predictor of quality of life of individuals with cardiovascular disease.

• Keywords: Cardiovascular disease; Quality of life; Care dependency level

1.20. INTERDISCIPLINARY » Aortic Dissection & Surgical Treatment (Open and Endovascular)

1.20.1. Can Computational Fluid Dynamics Simulations Predict a Distal Stent Graft Induced New Entry After Frozen Elephant Trunk Operation?

• Anja Osswald ¹, Konstantinos Tsagakis ¹, Matthias Thielmann ¹, Markus Kamler ¹, Rolf Alexander Jánosi ², Thomas Schlosser ³ and Christof Karmonik ⁴

1

Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany

2

Department of Cardiology, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany

3

Department of Radiology, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany

4

Translational Imaging Center, MRI Core, Houston Methodist Research Institute, Houston, TX, USA

BACKGROUND AND AIM: Distal stent graft induced new entry (dSINE) is an early or late complication after frozen elephant trunk (FET) procedure. The purpose of this study was to identify the hemodynamic profile of the aorta before dSINE development using computational fluid dynamics (CFD) simulations.

METHOD: Between 2006 and 2022, 30 patients with FET operation for aortic dissection were retrospectively included in this CFD study. Of those, 15 patients had developed a dSINE after FET procedure (dSINE group) and 15 patients had no further vascular events after the initial operation (control group). Patient-specific 3D surface models of the aortic lumen were reconstructed from computed tomography angiographic datasets. Steady-state CFD simulations with laminar blood flow and zero pressure outlet conditions were performed. For both groups, velocity magnitudes, wall shear stresses (WSS) and vorticity were evaluated and compared at different locations of the aorta including the level of the stent graft (SG), the distal landing zone of the SG and the more distal aorta.

RESULTS: In the dSINE group, WSS was significantly elevated distal to the SG compared to WSS in the SG itself and at its landing zone (2.84 ± 1.57 Pa vs. 1.56 ± 0.71 Pa and 2.00 ± 0.81 Pa, p < 0.001 and p = 0.002, respectively). In the control group, WSS was not significantly elevated distal to the SG in comparison to other locations. Regarding vorticity, the same pattern of a significant elevation distally to the SG compared to within the SG and at its landing zone was seen in the dSINE group but not in the control group.

CONCLUSIONS: Increased WSS and vorticity values distal to the SG compared to within the SG and at its landing zone seem to be associated with dSINE development after FET. CFD can be a useful tool to understand SG-induced hemodynamic changes within the aorta in the early and late follow-up CTA studies after FET predicting complications.

• Keywords: aortic dissection; computational fluid dynamics simulations; frozen elephant trunk; distal stent graft induced new entry

1.20.2. Unsupervised Classification of CFD Velocity Differentials in Frozen Elephant Trunk Aortic Geometries

• Christof Karmonik ¹ and Anja Osswald ²

1

Translational Imaging Center, Houston Methodist Research Institute, Houston, TX, USA

2

Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany

BACKGROUND AND AIM: To determine the relationship between aortic velocity differentials classified using the convolutional Variational Autoencoder (cVAE) algorithm with Frozen Elephant Trunk geometric variations.

METHOD: From 3D surface models derived from CTA images of seven treated Frozen Elephant trunk cases, blood velocity pattern were calculated using computational fluid dynamics. Values were converted into DICOM images from which a luminal centerline was determined. Perpendicular axial cross sectional pseudo-color images were successfully reconstructed by the cVAE. The latent 2D space was divided into four regions representing varying differentials in velocity magnitude patterns and assigned velocity differential scores (VDS) from 1–4. Aortic geometries were characterized by a maximum tortuosity aortic angle in the descending aorta below the stent graft. The precision of the cVAE classification algorithm was assessed by the standard deviation of the VDS with the repetition principle.

RESULTS: Maximum tortuosity aortic angle ranged from 17 to 84 degrees. VDS values ranged from 1.39 to 2.89. The precision of the cVAE classification algorithm was estimated by the VDS standard deviation calculated from 10,000 repetitive classifications which was less than 6.4% for 88.6% of all cross sections (n = 2023). Calculated for each case, the average VDS standard deviation for the mean VDS did not exceed 1.1%. A strong positive but not significant correlation, between the aortic angle and VDS was found (Pearson correlation coefficient 0.534, p-value = 0.217).

CONCLUSIONS: Assigning regions in latent space of the cVAE allowed for the rapid automated calculation of the VDS and determining its correlation between the tortuosity angle of the descending aorta. Deviation in aortic geometry correlated with the differentials in velocity.

• Keywords: artificial intelligence; machine learning; aortic dissection; frozen elephant trunk; computational fluid dynamics

1.20.3. An Overview of Aortic Surgery at a Tertiary Care Hospital in Pakistan: Our 7 Years of Experience

• Muhammad Wasim Sajjad, Azam Jan, Muhammad Zaid Ali and Rashid Qayyum
• Department of Cardiothoracic & Vascular Surgery, Rehman medical institute, Peshawar, Pakistan

BACKGROUND AND AIM: Aorta can be involved in different pathologies including congenital, syndromic and acquired disorders which may need intervention in any form to prevent disasters. The purpose of this study was reviewing types of aortic pathologies treated surgically and its outcomes.

METHOD: The retrospective review of data collected in a database was conducted at tertiary care hospital from January 2017 to December 2023. A total of 115 patients operated for different diseases of aorta in a single centre over a period of 7 years were included. Institutional review board approval was granted. Data was analyzed using SPSS 25, variables were recorded in frequency & mean ± SD.

RESULTS: The mean age measured 44.9 ± 18.3 years. Most patients were male (83.4%). Hypertension was most common co-morbidity (41.7%). NYHA-III (36.5%) & CCS-II (41.8%) were common severity of presenting complaints. Majority of cases were elective (82%) & without cardio pulmonary bypass (CPB) (52.1%). The most commonly performed procedure was coarctation of the aorta repair (31.3%), aortic root and ascending aorta replacement (30.4%) followed by abdominal aortic aneurysm (6.9%) and aorto-femoral grafting (5.2%) with an in-hospital mortality of 0%, 11.4%, 0% and 33.3% respectively. A few patients (12.7%) had prolonged ventilation with a mean ventilation of 19.9 ± 22.0 h. Total of 65.8% required post-operative blood or blood product transfusion. Mean ICU stay was 56.16 ± 44.0 h. The overall In-hospital mortality was 11.3%. Patients undergoing on- pump procedures had 18.2% where as those under going off-pump procedures had 5% in hospital mortality. Total patients diagnosed with aortic dissection had higher mortality of 33.3%. The exclusive cause of mortality in ARR was dissection.

CONCLUSIONS: Aortic pathology frequently manifests in various anatomical locations, both in elective and emergency scenarios. While surgical intervention can be successful, it is associated with a higher mortality rate especially in emergency cases. Presence of dissection is a major risk factor.

• Keywords: Aortic surgery; mortality; aortic aneurysm; aortic dissection; endovascular repair

1.20.4. Sustained Long-Term Results Rates in Patients with Frozen Elephant Trunk Operated for Acute Aortic Syndromes

• Panteleimon Theodoros Tsipas ¹, Filippos Paschalis Rorris ², Konstantinos Papakonstantinou ², Ilias Gissis ², Dimitrios Dougenis ³ and John Kokotsakis ²

1

Department of Cardiac Surgery, 401 General Army Hospital, Athens, Greece

2

Department of Cardiac Surgery, Evangelismos General Hospital, Athens, Greece

3

Medical School, National & Kapodestrian University of Athens, Athens, Greece

BACKGROUND AND AIM: Currently, the FET technique is indicated in acute aortic syndromes in the latest European guidelines. Although the FET operation is associated with significant morbidity and mortality, it often offers a curative option for diseases of the aortic arch and descending thoracic aorta, which is evident by the high rates of downstream of the re-intervention free survival in large series. We sought to report on our single institutional experience using the aforementioned technique in patients with acute aortic syndromes operated on an urgent setting.

METHOD: 23 adult patients who were referred to our department for surgical management of acute aortic syndromes and underwent aortic arch replacement using the frozen elephant trunk (FET) technique between November 2010 and January 2024. The primary outcome was long-term survival. Secondary outcomes were 30-day mortality rate and the incidence of neurologic complications i.e., stroke and spinal cord ischemia.

RESULTS: Mean patient age was 57.1 (±12.5) years and the majority (20 patients—87%) were male. The most common indication was Stanford type A acute aortic dissection (aTAAD) in 17 (74%) patients, followed by non-A non-B dissection in 2 (8.7%) patients, penetrating aortic ulcer (PAU) of the aortic arch in 2 (8.7%) patients, type A intramural hematoma (IMH) in 1 (4.3%) patient and blunt thoracic aortic injury of the aortic arch in 1 (4.3%) patient. Hospital mortality was 22% (5 patients). Mean follow-up was 11 years. Kaplan-Meier survival analysis revealed a 73% survival at 12 months which persisted up to 11 years of follow up. The stroke rate was 12% (3 patients) and the need for re-intervention was 12% (3 patients required completion TEVAR due to type Ib endoleak)

CONCLUSIONS: The FET technique, when is indicated, provides a reasonable and permanent solution for surgical management of patients suffering from acute aortic syndromes.

• Keywords: Frozen Elephant Trunk (FET); acute aortic syndromes

1.20.5. Chronicle of the Chronobiological Cycles and Climate Dynamics in the Presentation of Aortic Dissections

• Kirthiga Thiagarajan and Jayaprakash K N
  Institute of Cardiovascular and Thoracic Surgery, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India

BACKGROUND AND AIM: Aortic dissection, separation of the aortic media by an internal tear caused by pulsatile blood, is one of the most common catastrophes involving the aorta. Chronobiological rhythms and patterns have been known to influence various biological and disease processes in the body, especially pertaining to the cardiovascular system. Patterns affecting the frequencies of presentation of aortic dissections have also been observed by changes in a region’s climatic condition, typically temperature, pressure and broadly based on the time of year. This study aims to draw a parallel between the possible correlations of the body’s inherent chronobiological rhythms and the atmosphere’s climatic dynamics on the presentation of aortic dissection.

METHOD: The frequencies of patients presenting with symptomatic aortic dissection were analyzed over a period of ten years, from admission records and compared against the time of day, time of year and lunar phases present at time of presentation to the hospital in a single tertiary care center.

RESULTS: It was noted that majority of the cases of aortic dissection happened to present to our hospital during the late afternoon and early evening, however having typically developed symptoms in the morning. A spike of cases was noted in the winter months, with the majority of recorded cases being in January-February. A nadir in the number of cases was met in summer.

CONCLUSIONS: The presentation of acute aortic dissection exhibited significant preponderance to a particular time of day and year, with significant seasonal variation, correlating to atmospheric pressure and lunar phases of that time in question. Understanding this pattern will help in understanding the mechanics and triggers that initiate an aortic dissection and also in the long run help in developing a predictive model for earlier diagnosis of aortic dissection and early plan of treatment in this acute emergency, hence improving disease prevention and patient specialized care.

• Keywords: Aortic Dissection; Chronobiological rhythm; atmospheric pressure; climate dynamics

1.20.6. Putting the Funk in the Trunk: High Risk ReDo Aortic Arch Replacement with Bi-Carotid Artery Bypass Grafting and Frozen Elephant Trunk Procedure

• Nikola Gabriela Serge ¹, Martins Kalejs ¹, Marcis Gedins ², Ivars Brecs ¹ and Peteris Stradins ¹

1

Centre of Cardiac Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia

2

Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia

We describe a patient with a difficult aortic lesion involving carotid arteries, ascending and descending aorta, and aortic arch.

The patient was a 70-year-old male with a residual aortic dissection in the aortic arch and the descending aorta. He had suffered a Stanford type A aortic dissection on 5 January 2018, and underwent an emergency surgery the same day limited to ascending aorta replacement with a tubular graft above the sinus level with separate replacement of aortic valve. Remaining dissected ascending aorta and arch were gradually dilating reaching 7 cm before the repeat surgery.

The redo surgery begun with a vascular surgeon creating a bicaroid bypass with a Y-graft synthetic prosthesis. Simultaneously, cardiopulmonary bypass was established through right femoral artery and vein. The patient was cooled to 28 °C before a median sternotomy was performed and adhesions separated as the remaining aorta was extremely close to the backside of sternum. Ascending aorta was cross-clamped and cardioplegia infused through the aortic root. Subsequently, aortic arch was debranched, distally aorta was resected up to the site before left subclavian artery at which level antegrade implantation of a Medtronic Valiant stent-graft was performed to descending aorta. Ascending aorta was replaced, starting from the previous prosthesis proximally till the newly implanted stent-graft. Finally, the bicarotid shunt prosthesis was attached to the aortic prosthesis and left subclavian artery bypassed using a 10 mm graft. Total cardiopulmonary bypass time was 293 min, aortic cross-clamp 147 min, and circulatory arrest time with ACP 76 min.

The patient had an uneventful postoperative recovery and was discharged on 22nd postoperative day. At 3-month follow-up MS-CT showed an excellent postoperative result, demonstrating total exclusion of the aneurysm and thrombosed perigraft space around the FET prosthesis.

This case represents a successful high risk redo procedure on a patient with residual aortic dissection.

• Keywords: residual aortic dissection; frozen elephant trunk

1.20.7. Total Aort Replacement of the Pediatric Patient with Loeys-Dietz Syndrome

• Ayşegül Durmaz ¹, Gökmen Akgün ², Tülay Çardaközü ³, Kadir Babaoğlu ⁴ and Oğuz Omay ¹

1

Department of Cardiovascular Surgery, Kocaeli University, Kocaeli, Turkey

2

Department of Pediatric Cardiology, Kocaeli University, Kocaeli, Turkey

3

Department of Anesthesia and Reanimation, Kocaeli University, Kocaeli, Turkey

4

Department of Pediatric Cardiology, Kocaeli City Hospital, Kocaeli, Turkey

Loeys-Dietz syndrome (LDS) is a rare connective tissue disease that can lead to aortic aneurysm and dissection. The disease is caused by mutations in transforming growth factor-β receptors, estimated at less than 1 in 100,000.

We present a 15-year-old male patient whose treatment began with DeBakey Type I aortic dissection (AD) originating from the aortic root and the surgical management of all aortic pathologies.

The patient applied to the emergency department with the complaint of sudden onset of chest pain. The patient was diagnosed with Loeys-Dietz syndrome (TGFBR1 c.599C > A (p. Thr200Lys)) and had a history of aortic root dilatation and aortic valve surgery four years ago. The examinations in the emergency department were compatible with AD. Ascending aorta and total aortic arch replacement with elephant trunk procedure was performed. Approximately two months later, the patient underwent thoracoabdominal aortic graft replacement due to an aneurysm in the descending aorta. No complications besides distension in the gastrointestinal system were detected during the follow-up. Two years later, aneurysmatic dilatation developed in the coronary arteries, and the patient was operated on for the fourth time, and coronary artery aneurysm repair was performed using the Cabrol technique.

Literature data suggest that timely prophylactic aortic surgery to prevent catastrophic vascular complications can modify the aggressive natural history of LDS. Valve replacement may also be preferred in suitable patients. The prevalence of aortic reintervention is significantly higher in LDS patients presenting with aortic dissection. Therefore, total arch or root replacement may be justified in the initial AD repair. Surgeries for aortic annulus dilatation and aortic valve performed in the early stages serve as a reference for future surgical strategies. However, lifelong follow-up of these patients is necessary.

The experience gained from this case contributes to the management of the rare LDS patient who presented with AD.

• Keywords: aorta; dissection; Loeys-Dietz

1.20.8. Acute Aortic Dissection in Pregnancy, a Challenging Case Scenario

• Alifa Sabir, Tauqeer Akbar, Zahid Amin, Zainab Farid, Yasira Abbasi, Wajiha Arshad
  Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan

Acute aortic dissection is a rare life-threatening condition in pregnancy, which may prove fatal to both mother and the fetus. It has an incidence of 0.0004% in all pregnancies and 0.4% in all aortic dissections.

Case summary: We present the case of a 25-year-old female with gestational amenorrhea of 24 weeks who presented with sudden onset chest pain and dyspnea. Echocardiography was done which showed dilated aortic root with dissection flap in root and ascending aorta. CT aortogram showed dissection flap extending from aortic root down to descending aorta just before it’s bifurcation into iliac arteries. Acute Stanford type A dissection was diagnosed. Ultrasonography showed alive fetus at 24 weeks of gestation. Multidisciplinary team meeting was conducted and patient was planned for surgery. Cardiac obstetrician was taken on board. Ascending aortic replacement with interposition tube graft was done. CPB was established through femoral cannulation and cross clamp applied. Retrograde cardioplegia was given and diseased aorta resected. Dissected layers of aorta were buttressed together using teflon sheet and ascending aorta was replaced by an interposition graft, saving the native valve. Per, operatively, ultrasonography was repeated which confirmed fetal well being. Trans esophageal echocardiography done which showed trace to mild AR. Post operatively, patient was managed for hypertension and had an uneventful recovery and was discharged with OPD follow up on 10th POD.

DISCUSSION: Aortic dissection in pregnancy is relatively rare, which makes it difficult to determine detailed guidelines for the diagnosis and management. Treatment algorithm usually revolves around saving two lives. Current strategies prefer using warmer temperatures, avoiding circulatory arrest, minimizing CPB time and maintaining high flow rates and mean arterial pressures.

Conclusions: Early diagnosis and multidisciplinary management improve outcomes significantly.

• Keywords: aortic dissection; pregnancy; Stanford type A dissection

1.21. INTERDISCIPLINARY » Arrhythmia Surgery

Transvenous Lead Extraction: Our Approaches and Results

• Oleg Sapelnikov, Igor Grishin, Darin Ardus, Tatiana Uskach, Dmitrii Cherkashin, Anna Vereschagina, Makedon Demurchev and Renat Akchurin
• Cardiovascular-Surgery Department, National Medical Research Center of Cardiology Named After Academician E.I. Chazov, Moscow, Russia

BACKGROUND AND AIM: Rising prevalence of cardiac implantable electronic devices (CIED) lead to acute problem of widening indications for transvenous lead extraction (TLE). The aim of the study was to demonstrate success and safety of current TLE tools in patients with CIED-infection and non-infectious CIED.

METHOD: Between 2018 and 2024, 42 patients with CIED-infection and 40 patients with non-infectious CIED underwent TLE. Median age was 70 [61; 76] years in CIED-infection group and 67 [45.5; 73] years in non-infectious CIED group. Thirty-one % (13/42) in group 1 and 20% (8/40) in group 2 had diabetes. TLE was performed using manual traction, laser and mechanical tools. Video-assisted thoracoscopy was followed in high-risk patients.

RESULTS: Totally 93 leads (45 right ventricular leads (RVL), 39 right atrial leads (RAL), 4 left ventricular leads (LVL) and 5 defibrillation leads (DL)) were removed in CIED-infection group and 75 leads (35 RVL, 30 RAL, 2 LVL, 8 DL) in non-infectious CIED group. In CIED-infection group in 19 cases TLE was performed by manual traction, 10—by laser (4 video assisted), 9—by laser + mechanical tools (2 video assisted), 4—by mechanical tools. There was one conversion to open-heart surgery in laser-TLE. Among patients in non-infectious CIED group passive traction was performed in 22 cases, laser in 6 cases (2 video assisted), laser + mechanical tools in 8 cases (1 video assisted) and mechanical tools in 2 cases. There was one conversion to open-heart surgery in laser video-assisted TLE. In one case extraction was unsuccessful. There were no fatal events in groups.

CONCLUSIONS: TLE in patients with CIED-infection and non-infectious CIED is successful and safe. Video-assisted guidance is helpful in high-risk patients.

• Keywords: transvenous lead extraction; video-assisted thoracoscopy; cardiac implantable electronic devices

1.22. INTERDISCIPLINARY » Clinical Trials/Guidelines/Registries

1.22.1. Impact of Remote Ischemic Preconditioning on Acute Kidney Injury Following Cardiac Surgery: A Randomized Controlled Trial

• Linus Störiko ¹, Helmut Lieder ², Markus Kamler ¹, Ali Haddad ³, Gerd Heusch ², Petra Kleinbongard ² and Matthias Thielmann ¹

1

Department of Thoracic and Cardiovascular Surgery, West-German Heart & Vascular Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany

2

Institute of Pathophysiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany

3

Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany

BACKGROUND AND AIM: Remote ischemic preconditioning (RIPC) by repeated brief cycles of limb ischemia/reperfusion can reduce myocardial injury and improve patients’ prognosis following cardiac surgery. We now investigated short- and long-term effects of RIPC on renal function and the incidence of acute kidney injury (AKI) following cardiac surgery in a large, all-comers single-center randomized controlled trial (RCT).

METHOD: A total of 1204 adult patients scheduled for elective cardiac surgery with the use of isoflurane anesthesia, cardiopulmonary bypass and crystalloid cardioplegic arrest were allocated to receive either RIPC (n = 607; 3 cycles of 5 min transient left upper arm ischemia with 5 min reperfusion after induction of anesthesia) or served as controls (n = 597). Over a period of 72 h, serum creatinine (sC) and glomerular filtration rate (GFR) were measured. A sC increase of >0.3 mg/dL within 48 h was considered as AKI following KDIGO classification.

RESULTS: Patient characteristics and intraoperative data did not differ between the two groups. Within the first 72 h after surgery, sC and GFR did not differ between the groups (

Table 13. RIPC in Comparison with Control Group.

Results	RIPC (n = 607)	Control (n = 596)	p-Value
Creatinine 0 h	1.145 ± 0.36	1.160 ± 0.60	0.647
Creatinine 24 h	1.103 ± 0.34	1.131 ± 0.57	0.321
Creatinine 48 h	1.168 ± 0.44	1.183 ± 0.61	0.646
Creatinine 72 h	1.154 ± 0.55	1.163 ± 0.66	0.786
GFR 0 h	65.57 ± 17.61	66.66 ± 16.91	0.279
GFR 24 h	68.23 ± 17.16	68.43 ± 19.22	0.852
GFR 48 h	66.35 ± 20.43	66.46 ± 21.12	0.934
GFR 72 h	69.80 ± 23.02	70.08 ± 23.64	0.839
AKI	105 (17.3)	108 (18.1)	0.653
Death within 5 years	95 (15.66)	117 (19.63)	0.416

Serum Creatinine values given in mg/dL ± standard deviation. GFR: Glomerular Filtration Rate in mL/min/1.73². AKI: Acute kidney injury after KDIGO (Creatinine increase > 0.3 mg/dL within 24 h).

) with 105 (17.3%) AKI in the RIPC group and 108 (18.1%) in the control group (p = 0.65). After a 10-year follow-up period, survival of patients with AKI was significantly reduced (p < 0.001) compared to patients without AKI. RIPC demonstrated better long-term survival, both in patients with AKI (p = 0.14), as well as in those without AKI (p = 0.21).

CONCLUSIONS: Our RCT demonstrated a beneficial impact of RIPC on long-term survival following cardiac surgery with a possible reno-protective approach. However, RIPC could not prevent AKI. RIPC is a cheap and complication-free procedure where further research is needed to determine optimal protocols, evaluate its long-term effects on kidney function and establish its role in clinical practice.

• Keywords: RIPC; Kidney; GFR; Remote Ischemic Preconditioning; Cardiac Surgery

1.22.2. Intraoperative Hemoadsorption for Antithrombotic Drug Removal During Cardiac Surgery: Interim Report from the Ongoing International Safe and Timely Antithrombotic Removal (STAR) Registry

• Matthias Thielmann ¹, Kambiz Hassan ², Anna L. Meyer ³, Keti Vitanova ⁴, Andreas Liebold ⁵, Nandor Marczin ⁶, Martin H. Bernardi ⁷, Sandra Lindstedt ⁸, Nikolaas De Neve ⁹, Daniel Wendt ¹⁰, Robert F. Storey ¹¹ and Michael Schmoeckel ¹²

1

Department of Thoracic- and Cardiovascular Surgery, Westgerman Heart & Vascular Center, Essen, Germany

2

Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany

3

Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany

4

German Heart Center Munich, Munich, Germany

5

Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany

6

Department of Anaesthesia, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Part of Guy’s and St Thomas’ NHS Foundation Trust, London, UK

7

Division of Cardiac Thoracic Vascular Anaesthesia and Intensive Care Medicine, The Medical University of Vienna, Vienna, Austria

8

Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden

9

OLV Hospital, Aalst, Belgium

10

CytoSorbents Europe, GmbH, Berlin & Department of Thoracic- and Cardiovascular Surgery, Westgerman Heart & Vascular Center, Essen, Germany

11

Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK

12

Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany

BACKGROUND AND AIM: Intraoperative antithrombotic drug removal by hemoadsorption with CytoSorb^® (CytoSorbents Inc., Princeton, NJ, USA) has the potential to reduce perioperative bleeding in patients on antithrombotics undergoing cardiac surgery. Herewith, interim results from the ongoing international Safe and Timely Antithrombotic Removal (STAR) Registry (NCT05077124) are presented.

METHOD: Patients on antithrombotics undergoing cardiac surgery before completing the recommended washout were included. The hemoadsorption device was incorporated into the CPB-circuit. Patients on ticagrelor comprised Group-T, while patients on DOACs (direct-acting oral anticoagulants) comprised Group-D. Endpoints were bleeding complications according to the Bleeding Academic Research Consortium Type 4 (BARC-4) definition, Universal Definition of Perioperative Bleeding (UDPB) Class 3/4, transfusions of packed-red-blood-cells (pRBC) and platelets, reoperations for bleeding, and 24-h chest-tube drainage (CTD).

RESULTS: A total of 166 patients from 13 institutions in five countries were included (

Table 14. Demographics & Procedure-related variables.

Demographics & Procedure-Related Variables	Group T (Ticagrelor), n = 101	Group D (DOACs), n = 65
Age, years	63 ± 11	68 ± 10
Gender, male, n (%)	80 (82) I	27 (63)
Acetylsalicylic acid, n (%)	86 (88) I	23 (35)
Acute coronary syndrome, n (%)	78 (80) I	15 (23) IV
Atrial fibrillation, n (%)	9 (11) II	36 (58) V
EuroSCORE II, %	8 ± 11	9 ± 13
Urgent/emergency procedure, n (%)	64 (71) III	19 (39) VI
Washout period, h	32 ± 26	43 ± 34
CPB duration, min (i.e., device exposure)	114 ± 50	134 ± 54
Aortic cross-clamp time, min	72 ± 38	90 ± 43
Isolated CABG, n (%)	84 (83)	13 (20)
CABG + valve, n (%)	4 (4)	11 (17)
Isolated valve, n (%)	2 (2)	18 (28)
Aortic surgery, n (%)	3 (3)	11 (17)

(Data presented as number (%) or mean ± SD) Data available for (I) 98 subjects, (II) 81 subjects, (III) 90 subjects, (IV) 64 subjects, (V) 62 subjects, (VI) 49 subjects; CABG—coronary artery bypass grafting.

). Group-T (n = 101), underwent surgery at the mean of 32 ± 26 h since last drug intake, with a mean CPB-time of 114 ± 50 min. Group-D (n = 65), underwent surgery at a mean of 43 ± 34 h since last dose, with a mean CPB-time of 134 ± 54 min. In Group-T, 8% of those who underwent isolated CABG had a BARC-4 bleeding event. Overall, 4% experienced revisions within 48-h, the mean 24-h CTD was 629 ± 402 mL, and 72-h volumes of transfused pRBC and platelets were 789 ± 1244 mL and 824 ± 1281 mL, respectively. Class ≥ 3 UDPB events were reported in 15.8% of patients. In Group-D, there were no BARC-4 bleeding events, while the overall 48-h incidence of revisions was 5%, mean 24-h CTD was 711 ± 478 mL, and 72-h pRBC and platelet transfusions were 530 ± 477 mL and 533 ± 474 mL, respectively. The incidence of UDPB Class ≥ 3 was 9.2%. No device-related adverse events occurred.

CONCLUSIONS: This interim STAR-registry report shows low rates of bleeding complications in patients on active antithrombotic therapy undergoing cardiac surgery. Intraoperative hemoadsorption seems to safely manage perioperative bleeding risk in patients on oral antithrombotics.

• Keywords: STAR Registry; antithrombotics; cardiac surgery; bleeding; hemoadsorption; CytoSorb

1.22.3. Attitudes of Patients Undergoing Cardiac Surgery Toward Volunteer Participation in Clinical Trials

• Ivan Nesic ¹, Petar Tomic ¹, Marko Kaitovic ¹, Slobodan Micovic ¹, Djordje Krstic ¹, Aleksandra Sljivic ² and Tatjana Gazibara ³

1

Institute for Cardiovascular Diseases “Dedinje”, Belgrade, Serbia

2

University Hospital Center “Dr Dragisa Misovic-Dedinje”, Belgrade, Serbia

3

Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia

BACKGROUND AND AIM: Clinical trials in cardiac surgery allow for better treatment approaches to patients who have serious cardiovascular diseases. Little is known about the opinions of patients who undergo procedures in cardiac surgery about potential participation as research subjects in clinical trials. The study aim was to examine the attitudes of patients about to undergo cardiac surgery toward own participation as volunteer subjects in clinical trials.

METHOD: A cross-sectional study was carried out among patients from the Institute of Cardiovascular Diseases “Dedinje” who were scheduled for a cardiac surgery. Participants filled in an anonymous pen-and-paper questionnaire from November 2023 to February 2024. The questionnaire covered demographic data, and attitudes about own participation in clinical trials.

RESULTS: A total of 343 cardio-surgical patients participated in this study. Only 5.8% confirmed that they would be willing to participate as volunteers in clinical trials. Another 18.1% reported that they would probably participate, yielding a total prevalence of 23.9% of patients who had a positive opinion about participation. Still, 39.9% patients were categorically against participation. Overall, no differences in willingness to participate as volunteer subjects in clinical trials were observed between men and women (p = 0.728), patients with coronary and valve disease (p = 0.655), different NYHA scores (p = 0.107) and patients who had left ventricle ejection fraction below and above 50% (p = 0.557). Adjusted multivariate linear model suggested that higher education level (B = 0.24, 95% confidence interval, CI 0.02–0.47, p = 0.033) and previous volunteering experience (B = 0.57, 95% CI 0.09–1.06, p = 0.021) were predictors of stronger positive attitude towards clinical trial participation.

CONCLUSIONS: One in four cardiac surgery patients had positive attitude about participation in clinical trials. Most patients were not willing to be volunteer subjects in research. Those patients who were willing to participate were more likely to have a higher education and previously take part in volunteering activities.

• Keywords: cardiac surgery; participation; volunteer; clinical trials; attitude

1.22.4. Development of Innovative Active Packaging for Cold-Chain Management in Medicals Transportation

• Emanuela Drago ¹, Patrizia Perego ¹ and Domenico Palombo ²

1

Department of Civil, Chemical and Environmental Engineering, University of Genoa, Via Opera Pia 15, 16145 Genoa, Italy

2

Department of One Health, Bioethics, and Technological Research, ICB International Chair in Bioethics, Porto, Portugal

BACKGROUND AND AIM: Nowadays, the ever-increasing demand for medical supplies worldwide highlights the importance of adopting correct distribution practices. The cold-chain is today more crucial than ever in the supply of sensitive products such as blood, human organs for transplantation and vaccines, as also demonstrated during the COVID-19 pandemic. To date, it is implemented with the aid of voluminous refrigerated containers and boxes. However, cold-chain management suffers from power outages, insufficient maintenance of refrigeration and storage equipment, temperature monitoring issues, high energy demand and greenhouse gas emissions and unexpected extreme weather conditions increasingly frequent due to climate change. Annual global costs for the refrigerated transport of all biopharmaceuticals exceed $15 billion (USD), and losses due to interruptions in the cold-chain reach $35 billion annually. These challenges pose a significant risk to the quality and safety of the sensitive products, where even the slightest temperature change can cause spoilage, degradation, or reduced efficacy. Therefore, the development of innovative packaging materials able to protect products from degradation and temperature fluctuations throughout the distribution chain is a necessity rather than a choice.

METHOD: In this context, this work aims to produce an innovative packaging biomaterial by using phase change materials (PCMs) loaded in biocompatible polymeric materials, such as polycaprolactone, to produce a packaging with the potential of ensuring the safety of sensitive products during transportation.

RESULTS: PCMs, such as paraffins, fatty acids or hydrated salts, with their ability to absorb and release heat at specific temperatures allow the temperature inside the package to be kept constant. Furthermore, the packaging material can be engineered by adding natural antimicrobial or antioxidants substances to counteract degradation and spoilage.

CONCLUSIONS: In this way, adopting more efficient and safe cold-chain management could ensure the delivery of essential medicals products, especially to consumers in remote areas or regions without reliable electricity.

• Keywords: Cold-Chain; Organ transportation; blood transportation; vaccine transportation

1.22.5. Biomaterials for Tissue Engineering: Bioethical Reflections

• Emanuela Drago ¹, Patrizia Perego ¹ and Domenico Palombo ²

1

Department of Civil, Chemical and Environmental Engineering, University of Genoa, Via Opera Pia 15, 16145 Genoa, Italy

2

Department of One Health, Bioethics, and Technological Research, ICB International Chair in Bioethics, Porto, Portugal

BACKGROUND AND AIM: Tissue engineering is a branch of regenerative medicine that aims to support the regrowth of living tissues by using scaffolds or template that enable the regeneration of organs after injuries or diseases. Scientific research, considering the therapeutic potential of these systems, is launched in optimizing technologies such as 3D bioprinting, organoid production, and the use of innovative biomaterials introducing the concept of sustainability in this field.

However, the use of biomaterials poses ethical and social obstacles that undermine their sustainability, requiring in-depth evaluation. In particular, ethical issues arise in relation to the use of biodegradable and bioresorbable materials that represent a source of hazard in commercial and clinical applications.

METHOD: In fact, for many years, clear specifications for the use of these biomaterials have not been well articulated, and biodegradability requirements and prior FDA approval for use in medical devices have dominated material selection processes.

Innovation in this field has paved the way for the use of biomaterials and active ingredients of natural origin, such as polyphenols, for which the long-term effect is not evident as well as the patient-specific responses to these substances which can compromise its biocompatibility with the risk of rejection.

RESULTS: Furthermore, in the literature, there is a gap in the bioethical implications related to the use of substances of natural origin in biomaterials. In particular, there is a lack of answer to the question: “Have we proven that biomaterials and natural substances are not harmful or have we not proven that they are harmful?”.

CONCLUSIONS: This work aims to fill this gap by considering that the ethical design of biomaterials must prioritize safety, efficacy and transparent risk communication. Furthermore, from a socioeconomic point of view, therapies that involve the use of these biomaterials must be accessible to all following an ethical approach of inclusiveness.

• Keywords: Bioethics; Scaffolds; vascular prosthesis; biomaterials

1.22.6. Safeguards and Pitfalls in Minimally Invasive Cardiac Surgery

• Muhammad Ibrahim Azmi ¹, Ashvin Krishna Nair ¹ and Shahrul Amry Hashim ²

1

Cardiothoracic Unit, Universiti Malay Medical Centre, Kuala Lumpur, Malaysia

2

Cardiothoracic Unit, KPJ Damansara Specialist Hospital 2, Kuala Lumpur, Malaysia

BACKGROUND AND AIM: The experience we had in our small cardiac centre suggests the need for a protocol to safeguard and avert pitfalls in minimally invasive (MIS) cardiac surgery. This should come in handy in an emergency for any surgeon.

METHOD: We looked into our experience in 356 MIS cardiac surgery cases for their challenges and critical scenarios to formulate a guide for emergency situation in MIS cardiac surgery. The events were categorised into operating theatre and ICU settings. Operating theatre settings were further sub categorised into pre-cardiopulmonary bypass (CPB), during CPB, and post CPB. Each scenario was analysed and literature review was made related to the scenarios. Whenever there were no guides available, a strategic approach was formulated as a guide.

RESULTS: After examining each case, we identified 5 pre-CPB scenarios: 1 haemodynamic issue, 3 cannulation issues, 1 extensive adhesion. There were 8 scenarios during CPB identified: 3 aortic injury, 2 pulmonary vessel injury, 2 cannula issues, 1 difficulty in CPB separation. We identified 3 post CPB scenarios: 2 bleeding issues and 1 cardiac arrest. There were 6 scenarios in ICU setting: 2 haemodynamic instability and 4 bleeding. The emergency protocol was formed based on the above and hypothetical scenarios, following available guidelines, protocols, as well as opinion from the MIS surgeon.

CONCLUSIONS: The need for emergency MIS protocol to guide surgeons to safeguard and curb pitfalls is valuable. This is to avoid secondary victim in young as well as experienced surgeons potentially shying away from MIS cardiac surgery. Although this protocol is non exhaustive, it is imperative for it to be produced in line with the increase in MIS cardiac surgery practice.

• Keywords: Minimally Invasive; MIS; MICS; MIMVS; Guidelines

1.23. INTERDISCIPLINARY » Comparison of Surgical Versus Catheter Procedures and Complications

1.23.1. Engineering Surgical and Interventional Crossroads in Pediatric Cardiovascular Treatments

• Kevser Banu Kose
• Istanbul Medipol University, Istanbul, Turkey

BACKGROUND AND AIM: Pediatric cardiovascular interventions demand careful consideration to ensure optimal hemodynamic stability, encompassing both surgical and interventional approaches.

This study aims to address the multifaceted aspects of pediatric cardiovascular interventions, including the evaluation of various shunt configurations, assessment of different stent positions and diameters, and personalized predictive modeling to attain optimal results. Moreover, the study seeks to predict the most successful method for achieving optimal outcomes, whether through surgical or interventional approaches, thereby informing tailored treatment strategies for each patient.

METHOD: The methodology integrates image processing techniques with computational analysis approaches, encompassing both surgical and interventional aspects of pediatric cardiovascular interventions. An AI-based segmentation module, developed by our team, accurately delineated relevant anatomical structures from the MRI data, enabling precise identification of cardiac structures, especially in complex CHD cases. This AI-driven segmentation process facilitated the construction of detailed three-dimensional models for computational analysis.

Subsequently, computer-aided design tools generated models based on segmented anatomical structures, facilitating simulations of both surgical and interventional procedures.

RESULTS: In this prospective study, ten patients were enrolled, with post treatment images of three patients also included for evaluation. The alignment of the models with virtual configurations was deemed successful, alongside the interpretation of successful virtual repair design. Additionally, the hemodynamic distribution rates and wall shear stress parameters in personalized interventional and surgical solutions were visualized.

CONCLUSIONS: The study’s integration of advanced medical imaging techniques and computational modeling approaches represents a significant advancement in pediatric cardiovascular interventions, encompassing both surgical and interventional aspects. Utilizing AI-driven segmentation module optimized imaging data acquisition and precise anatomical delineation. Additionally, the study’s predictive modeling provides valuable insights into the selection of the most appropriate treatment approach, whether surgical or interventional, thereby enhancing patient care and outcomes in pediatric cardiovascular interventions.

• Keywords: stent; shunt; pediatric; intervention; congenital; artificial intelligence

1.23.2. Safety of Seldinger Technique in Subcutaneous Venous Port Catheter Placement: Joint Experience of Two Centers

• Elçïn Ersöz Köse ¹, Gökay Reyhan ², Ilker Kolbaş ³, Kaan Ayberk Boyacıoğlu ¹ and Rıza Serdar Evman ¹

1

Department of Thoracic Surgery, Health Sciences University, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey

2

Department of Thoracic Surgery, Health Sciences University, Sultan 2. Abdülhamid Han Training and Research Hospital, İstanbul, Turkey

3

Department of Thoracic Surgery, İstanbul Aydın University, VM Medical Park Florya Hospital, İstanbul, Turkey

BACKGROUND AND AIM: This retrospective study aims to analyze safety and clinical outcomes of subcutaneous venous port catheterization (SVPC) via Seldinger technique.

METHOD: Demographic data, indications, surgical outcomes and complications of all patients underwent SVPC in the thoracic surgery clinics of two training and research hospitals, between January 2013 and July 2021, were analyzed retrospectively. All catheters were placed under local anesthesia and/or sedoanalgesia, via Seldinger method.

RESULTS: Total of 428 patients (185 women, 243 men) with an average age of 60.6 (range: 20–84) years were examined. SVPC was implanted mostly for colorectal cancer (n = 161; 33.2%). Intervention was applied generally via right internal jugular vein (n = 258; 60.3%). Ultrasonography was not used in any of our patients during insertion. Complications were observed in 5 (1.2%) patients: pneumothorax (n = 4; 0.9%) and malposition (n = 1; 0.45%). Since the malpositioned catheter was functional, no revision was performed.

CONCLUSIONS: In many clinics, there is a belief that ultrasonography-guided insertion of SVPC has a number of advantages compared with unguided insertion, resulting in a higher success rate and fewer complications. Our pneumothorax complication rates are acceptable, and we attribute these cases to our initial (within first 96 patients) experience. Contrary to the trendy approach, we showed that unguided (Seldinger Technique) insertion can be the preferred method of choice for SVPC placement, with complication rates similar to image-guided insertion; without the extra burden of hardware need and additional expense.

• Keywords: Venous port catheter; Oncology; Port complications

1.24. INTERDISCIPLINARY » Heart Failure

1.24.1. First-in-Human Experience of Preload Regulation with Percutaneous Transluminal Caval Flow Regulation in Heart Failure with Reduced Ejection Fraction Patients

• Jose E Herrera ¹, Jose A Herrera Primera ¹, Bartolome Finizola ¹, Jose A Octavio ², Robert Levine ³ and Igor F Palacio ³

1

1ASCARDIO, Barquisimeto, Venezuela

2

Hospital de Clínicas Caracas, Caracas, Venezuela

3

Mass General Hospital, Boston, MA, USA

BACKGROUND AND AIM: Preload reduction in heart failure has been achieved with high potency diuretics. However, no study has been conducted in humans to assess the effect of inferior vena cava intermittent occlusion for preload reduction.

This study aims to investigate the acute haemodynamic effects of percutaneous transluminal flow regulation (PTCR^®) with an inferior vena cava regulator balloon in heart failure patients

METHOD: Six patients were included in the study: four men (55 ± 6 years old) and two women (63 ± 4 years old). Baseline evaluations included Doppler echocardiogram, coronary angiogram, and right heart catheterization. Caval balloon was kept inflated for 30 min, and right catheterization and control echocardiogram were performed while the balloon was still inflated. The balloon was then deflated and removed. Right haemodynamic variables were evaluated before balloon insertion and with the inflated balloon.

RESULTS: HEMODYNAMIC DATA: The mean right atrial pressure decreased by 42.59% (p = 0.005); right ventricular systolic pressure decreased by 30.19% (p < 0.003); mean pulmonary artery pressure decreased by 25.33% (p < 0.043); mean pulmonary capillary wedge pressure decreased by 31.37% (p > 0.016); and cardiac output increased by 9.92% (p < 0.175). ECHO DATA: LVEDD was 6.43 cm before balloon then during balloon was 5.76 cm (p < 0.009). LVESD was 5.19 cm before balloon then during balloon was 4.78 cm (p < 0.010). LVDV was 187.67 mL before balloon then during balloon was 160.82 mL (p < 0.036). LVDV was 123.23 mL before balloon then during balloon was 101.62 mL (p < 0.041). EF% was 33.49 before balloon then during balloon was 40.85 (p < 0.115). E/A Ratio was 1.72 before balloon then during balloon was 1.37 (p < 0.051).

CONCLUSIONS: The haemodynamic and echocardiographic changes obtained in our study using PTCR^® suggest that this innovative approach can play a beneficial role in the heart failure treatment.

• Keywords: IVC Inferior Vena Cava. PTCR Percutaneous Transluminal Caval Flow Regulation; HF Heart Failure

1.24.2. Comparison of Blood Pressure Measurements Obtained with Vascular Doppler Device and Invasive Arterial Pressure in Patients with Implanted Left Ventricular Assist Device

• Ümit Kahraman, Emrah Oğuz, Sedat Karaca, Serkan Ertugay, Ayşen Yaprak Engin, Emine Uslu Metinoğlu, Mehtap Seymen, Derya Kayıhan, Çağatay Engin, Tahir Yağdı and Mustafa Özbaran
• Department of Cardivascular Surgery, Ege University, İzmir, Türkiye

BACKGROUND AND AIM: Preventing hypertension in patients with a continuous flow ventricular assist device (CF-VAD) is crucial for minimizing numerous complications, including pump thrombosis and cerebral hemorrhage. Consequently, the objective of this study was to evaluate the dependability of noninvasive Vascular Doppler blood pressure measurements by comparing them to invasive arterial pressure measurements.

METHOD: The research involved 32 individuals aged 18 or above who received a left ventricular assist device implant and were monitored using an invasive arterial pressure catheter in Ege University Cardiovascular Department. The blood pressure of these patients was measured non-invasively with a vascular hand Doppler device in the extremity where the invasive arterial monitoring was performed. Pressure measurements were recorded twice daily for a period of 3 days in each participant.

RESULTS: Of the patients, 96.9% were male. The mean patient age was 52.28. Heartmate-2 device was implanted in 6.3% of the patients, the Heartmate-3 device was implanted in 84.4%, and the Heartware device was implanted in 9.4%.

A comparison of the mean arterial pressure and Doppler measurement pressure is presented in image 1. The mean arterial pressure and Doppler pressure measurements were analyzed using Spearman’s correlation analysis. Most of the correlations are above 0.75 and are considered good-to-excellent correlations. When the systolic arterial pressure and blood pressure measurements with the Doppler device were compared using Spearman correlation analysis, they were found to be below 0.75. When subjected to Spearman correlation analysis and Wilcoxon Signed Rank Test, the measurements obtained using the Doppler device were found to yield results that were closer to the invasive mean arterial pressure.

CONCLUSIONS: Doppler pressure offers a reliable, non-invasive alternative to invasive Mean Arterial Pressure measurements for CF-VAD patients. It serves as the standard measurement method for non-invasive Blood Pressure monitoring in VAD patients due to its strong correlations and practical applications.

• Keywords: Hypertension; Continuous Flow Ventricular Assist Device; Vascular Doppler Device

1.25. INTERDISCIPLINARY » Heart Transplant and Circulatory Support

1.25.1. Intraoperative Hemoadsorption in Heart Transplant Surgery—A 5-Year Experience

• Nikola Sliskovic, Davor Baric, Daniel Unic, Dubravka Susnjar, Josip Varvodic,
• Marko Kusurin, Savica Gjorgjievska, Gloria Sestan and Igor Rudez
• Department of Cardiac and Transplant Surgery, Dubrava University Hospital, Zagreb, Croatia

BACKGROUND AND AIM: Due to the limited availability of donor hearts and the resulting high death toll among unmatched recipients, this research delved into the potential advantages of incorporating intraoperative hemoadsorption (HA) in heart transplantation (HTx) to alleviate the hyperimmune response responsible for post-reperfusion cytokine release.

METHOD: From 2018 through 2022, a total of 40 consecutive HTx patients who received intraoperative HA with CytoSorb (CytoSorbents Inc., Princeton, NJ, USA) during CPB were compared to 41 historical controls. The evaluation criteria included postoperative hemodynamic stability, blood product need, acute kidney injury requiring dialysis (AKI-d), and 30-day mortality (

Table 15. Demographics, procedure related variables and clinical outcomes.

Demographics, Procedure Related Variables and Clinical Outcomes	(Data Presented as Number (%) or Mean ± SD)	(Data Presented as Number (%) or Mean ± SD)	p-Value
	HA Group, n = 40	Control Group, n = 41
Sex—female, n (%)	14 (35.0)	6 (14.6)	0.04
Age, years	58 [49–62]	57 [48–61]	0.67
Donor age, years	46 [41–55]	47 [41–55]	0.08
Patients on High Urgency List, n (%)	20 (50.0)	21 (51.2)	1.00
Patients requiring preoperative mechanical circulatory support (LVAD, ECMO), n (%)	3 (7.5)	1 (2.4)	0.36
CPB time, minutes	130 [118–148]	130 [113–171]	0.73
Surgery time, minutes	250 [221–300]	295 [250–360]	0.01
Heart ischemia time, minutes	174 [107–207]	127 [81–169]	0.01
Postoperative AKI requiring dialysis, n (%)	8 (20.0)	10 (24.4)	0.79
Duration of mechanical ventilation, hours	22 [14.5–27]	28 [19–38]	0.02
Blood product requirement, mL RBC (red blood cells) FFP (fresh frosen plasma) PLT (platelets)	765 [370–1625] 1200 [750–2000] 900 [0–1200]	1330 [750–2810] 975 [0–1695] 0 [0–1200]	0.01 0.07 0.22
Length of stay, days ICU (intensive care unit) Hospital	5 [4–6] 24 [18–26]	5 [4–6] 22 [19–25]	0.80 0.67
30-day mortality, n (%)	2 (5.0)	6 (14.6)	0.26

).

RESULTS: Aside from gender and preoperative antithrombotic usage, the groups were largely homogeneous (the HA group consisted of a higher proportion of females and individuals who received blood thinners prior to surgery). Heart ischemic time was significantly longer in the HA group (174 vs. 127 min, p = 0.01). Although CPB durations were similar, the HA group showed a shorter overall surgery time (250 vs. 295 min, p = 0.01). The HA group required significantly less dobutamine (1.0 vs. 8.0 µg/kg/min, p = 0.02) and also for a shorter time-period (2 vs. 3 days, p < 0.01) postoperatively. Conversely, significantly more milrinone (0.7 vs. 0 µg/kg/min, p = 0.03) was needed. Postoperative lactate levels were comparable between the groups. The HA group demonstrated fewer transfusions of red blood cells (765 vs. 1,330 mL, p = 0.01) and reduced mechanical ventilation duration (22 vs. 28 h, p = 0.02). AKI-d rates were similar between groups. 30-day mortality favored the HA group (5% vs. 14.6%, p = ns). No device-related adverse events were observed.

CONCLUSIONS: Despite certain unfavorable baseline differences, the incorporation of intraoperative hemoadsorption appears to have aided in attaining improved outcomes in the immediate aftermath of the surgical intervention. Although our findings are encouraging, this research highlights the importance of additional verification through randomized controlled trials.

• Keywords: heart transplantation; cardiac surgery; hemoadsorption; Cytosorb

1.25.2. Determinants of Short-Term Survival After Heart Transplantation in Patients Bridged to Transplant with Left Ventricular Assist Device

• Suat Şenkaya ¹, Ayşen Yaprak Engin ², Ümit Kahraman ², Tahir Yağdı ², Çağatay Engin ², Özlem Balcıoğlu ³, Osman Nuri Tuncer ², Arda Sezen ², Islam Yalıç ² and Mustafa Özbaran ²

1

Department of Cardiovascular Surgery, Izmir City Hospital, Izmir, Türkiye

2

Department of Cardiovascular Surgery, Ege University, Izmir, Türkiye

3

Department of Cardiovascular Surgery, Near East University, Lefkoşa, Mersin, Türkiye

BACKGROUND AND AIM: Outcomes of bridging to heart transplantation have been the subject of intense debate. This study aimed to determine the factors affecting early survival after heart transplantation in patients with LVAD implants.

METHOD: Between 2011 and 2019, patients with LVADs that were bridged to heart transplantation in a single center were retrospectively scanned. Patient demographics, complications during LVAD support, pre-transplant blood tests, CPB, and cross-clamp duration, use of blood products, length of hospital stay, duration of VAD support, post-transplant blood tests, in-hospital mortality, post-transplant hospital stay, infection, and rejection rates were recorded.

RESULTS: Total of 60 patients were divided into two groups; patients with 30-day-mortality (Group 1, n = 10) and without (Group 2, n = 50). The patients in Group 1 was found to be older (p = 0.009), supported for longer duration (p = 0.027), have higher INR levels (p = 0.025), have device-specific infection more commonly (p = 0.003). Cardiac ischemia (p = 0.013) and CPB (p = 0.006) durations were higher in Group 1. Use of blood products and nitric oxide (NO) were more frequent in Group 1 (p = 0.011 for blood products, p = 0.02 for fresh frozen plasma, p = 0.003 for platelet suspensions and p = 0.041 for NO). LVEF and RVEF values were higher in Group 2. Post-transplantation complications (stroke, sepsis, kidney failure, arrythmia, need for IABP and short-term MCS) were significantly more common in group-1 patients (p < 0.05). There was no re-exploration due to hemorrhage in Group 1. Blood products (0.920 for red blood cells, 0.901 for fresh frozen plasma, 0.885 for platelets), postoperative high creatinine (0.817), postoperative high lactate (0.715), and device-specific infection (0.686) had the highest area under curve values in ROC analyses of the factors associated with early mortality.

CONCLUSIONS: Bridge-to-transplantation has its own challenges of being a reoperation under high INR levels. Recurrent infection attacks and an inflammatory state may be limiting the healing process. Device-specific infection may be a major reason of early mortality while it is also a major indication for urging heart transplantation.

• Keywords: bridge to transplantation; ventricular assist device; device specific infection

1.25.3. BiVAD Therapy in a Patient with Biventricular Heart Failure and Massive Ascites

• Sedat Karaca, Zehra Ünlü, Dilek Erdinli, Ümit Kahraman, Yaprak Engin, Çağatay Engin, Tahir Yağdı and Mustafa Özbaran
• Department of Cardiovascular Surgery, Ege University, Izmir, Turkey

Heart transplantation remains the gold standard in the treatment of end-stage heart failure, yet the shortage of donors, prolonged waiting times, and inadequate clinical improvement despite optimal medical therapy have led to an increasing use of mechanical support systems. However, patient selection is particularly crucial, especially in patients with biventricular heart failure. The aim of our study is to report the implantation of a Biventricular Assist Device (BiVAD) as a bridge to transplantation in a 24-year-old patient with severe right and left heart failure, complicated by massive ascites, and to share the outcomes.

A 24-year-old male patient presented to the emergency department with cardiac arrest. Following effective cardiopulmonary resuscitation, the patient’s general condition improved, and diagnostic tests revealed biventricular low ejection fraction. The patient’s echocardiographic findings are presented in

Table 16. Preoperative Echocardiographic Findings.

Echocardiographic Evaluation	Patient
LVEF (%):	15
RVEF (%):	15
LVESD (cm):	7.1
LVEDD (cm):	7.5
RVD (cm):	4.1
LA (cm):	7.7
Aortic Stenosis/Regurgitation:	None/None
Mitral Stenosis/Regurgitation:	None/Severe
Tricuspid Stenosis/Regurgitation:	None/Severe
sPAP (mmHg):	45

. After completing preparations, the patient underwent BiVAD implantation. Postoperatively, nitric oxide therapy and inotropic support were gradually reduced and discontinued. The patient was extubated on the third postoperative day. However, due to the development of signs of right heart failure and deterioration in general condition, the patient was reintubated on the fifth postoperative day. After optimal medical treatment, the patient was extubated again on the twelfth postoperative day. The patient, who showed no further complications during follow-up, was discharged with recovery and has been followed up without any problems at the sixth month.

BiVAD can be successfully performed in patients with end-stage heart failure, even in advanced complications such as massive ascites, especially as a bridge to transplantation. However, extensive research is needed in this area. It is recommended to perform these treatments in experienced and high-volume tertiary centers to increase success in follow-up.

• Keywords: BiVAD; Heart Failure

1.26. INTERDISCIPLINARY » Infective Endocarditis

The Impact of the Use of Cytosorb During Cardiac Surgery for Infective Endocarditis

• Amin Serradj, Narcis Costin Radu, Eric Bergoend, Antonio Fiore, Yuthiline Chabry, Marieantonietta Piscitelli, Gabriel Saiydoun, Raphaelle Huguet, Pascal Lim and Thierry Folliguet
• Department of Cardiac Surgery—CHU, Henri MONDOR-APHP, Creteil, France

BACKGROUND AND AIM: Sepsis and Systemic inflammatory response syndrome (SIRS) caused by infective endocarditis are responsible of significant postoperative mortality after cardiac surgery (40% in the series published in the literature). In this work, we evaluate the impact of intraoperative use of hemoadsorption therapy (Cytosorb) on postoperative mortality at 30-day and 90-day.

METHOD: From Junuary 2020 to December 2023, 149 patients underwent cardiac surgery for infective endocarditis in our department. Patients treated with intraoperative hemoadsorption therapy (Cytosrob group) were compared to patients not treated with this therapy (Control group). The endpoints were overall mortality at 30 and 90 days and vasoplegic syndrome defined as: (low blood pressure despite optimal fluid overload > 2 L of saline perfusion, requiring vasopressor (noradrenalin 0.5 mg/h) to maintain MBP < 65 mmhg, Normal LVEF > 45% or cardiac outflow > 2.2 L/min with or without ionotrope support).

RESULTS: A total, only 132 patients have a complete analysis and follow-up. 53 in cytosorb group and 79 in thecontrol group. No differences in baseline clinicals and surgicals characteristics were observed regarding (age, sex ratio, CBP time, aortic clamping time). The average duration of cytosorb use was 117 min. The average length of stay in intensive care unit was (6 days ± 3 Vx 11 days ± 5 for the control group). The vasoplegic syndrome was more marked in the control group (53% Vx 27%). Mortality was significantly lower in the cytosorb group at 30-day (7.54% Vx 21.51%, p-value: 0.03) and at 90-day (11; 32% Vx 25.31%, p-value: 0.04).

CONCLUSIONS: The use of intraoperative hemoadsorption therapy (Cytosorb) has a direct impact of reducing postoperative mortality at 30-day and 90-day after cardiac surgery for infective endocarditis. Interest of randomized study to confirm these clinical data.

• Keywords: Infective endocarditis; SIRS; Sepis; hemoadsorption therapy; Cytosrob

1.27. INTERDISCIPLINARY » Intensive Care

1.27.1. Spinal Cord Ischemia Protocol Helps Aortic Surgery Patients Regain Function

• Sarah Rosenberger, Julia Stallings and Shahab Toursavadkohi
• Department of Surgery, University of Maryland School of Medicine, Baltimore & University of Maryland Medical Center, Baltimore, MD, USA

BACKGROUND AND AIM: This retrospective study examined the effectiveness of adding sulfonylurea to spinal cord ischemia (SCI) protocol in symptom recovery following aortic surgery.

METHOD: A protocol of bundled interventions including blood pressure enhancement, cerebrospinal fluid drainage, and the administration of naloxone and sulfonylurea (glipizide) was developed and embedded into the electronic medical record.

RESULTS: This is a retrospective review of patients who underwent aortic surgery (1296) from 2019 to 2023 after SCI protocol implementation (adding sulfonylurea) (

Table 17. Overview of Spinal Cord Ischemia Early Rescue Outcomes.

Year	Total Cases	SCI Cases	Deceased Prior to Discharge	No Recovery from SCI	Partial Recovery from SCI	Full Recovery from SCI
2017 (control)	206	6	0	2	1	3
2019	247	1	0	0	1	0
2020	272	6	1	3	1	1
2021	245	5	2	0	2	1
2022	243	7	1	0	4	2
2023	289	5	1	1	1	2

Summary of aortic cases with spinal cord ischemia presentation and recovery at time of discharge.

). Of these, 24 (1.9%) exhibited symptoms. 16 patients (66%) received the full bundle of interventions. Non-compliance with the bundle was attributed to hemodynamic instability, unsuccessful lumbar drain insertion, and medication allergies. Five patients (21%) did not survive until discharge. Of the 19 survivors, six (32%) achieved full recovery; nine (47%) had partial recovery; and four (21%) did not recover. Of the patients who had partial recovery by discharge, four (50%) eventually achieved the full recovery. Among those who did not fully recover, four (50%) have died, two (25%) were lost to follow-up, and two (25%) suffer from permanent disabilities. Our historical control were 206 patients prior to new protocol implementation. Of these, Six patients (3%) exhibited SCI symptoms; two (33%) achieved full recovery, one (17%) showed partial recovery; and three (50%) did not recover. Hypoglycemia was observed in only 1 patient. In revised SCI protocol group, 79% patients who were diagnosed with spinal cord paralysis were either fully or partially recovered compared to only 50% recovered on our historical control patients. Predictors of poor recovery were severe SCI, delayed intervention beyond six hours, and multi-organ failures. Interestingly, patients with emergent presentations and aortic dissections had a better chance of recovery.

CONCLUSIONS: Although not powered to prove causation, this experience suggests protocolized rescue bundle may improve SCI recovery.

• Keywords: aortic surgery; spinal cord ischemia; endovascular

1.27.2. Prediction of Acute Kidney Injury in Cardiothoracic Surgery Using Novel Biomarkers

• Jasmin Ben Khaled, Senem Sakar, Wolfgang Ristau, Abdelhadi Kerrad, Belal Darwish, Stephan Knipp, Markus Kamler and Matthias Thielmann
• Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Essen, Germany

BACKGROUND AND AIM: With an occurrence of up to 30%, acute kidney injury (AKI) is one of the most frequent and serious complications in cardiothoracic surgery, associated with increased short- and long-term mortality and morbidity. We aimed to evaluate two novel biomarkers, [TIMP-2]*[IGFBP-7] and proenkephalin, to predict AKI.

METHOD: Sixty-five patients undergoing cardiothoracic surgery with cardiopulmonary bypass were enrolled. Urine and blood samples were collected directly, 24, 48 and 72 h after surgery and analyzed for [TIMP-2]*[IGFBP-7] and proenkephalin in addition to serum creatinine. Primary endpoint was the development of AKI within the first 48 h after surgery, as defined by the KDIGO.

RESULTS: Sixty-five patients were included. Twelve patients (18%) developed AKI. Proenkephalin for these patients had a median of 101.8 pmol/L after surgery (non-AKI median: 64 pmol/L; p = 0.004; sensitivity: 0.75, specificity: 0.7) and 133 pmol/L on the first postoperative day (non-AKI median 65 pmol/L; p = 0.001; sensitivity: 0.83, specificity: 0.66). [TIMP-2]*[IGFBP-7] had a median value of 0.19 after surgery (non-AKI median 0.18; p = 0.37; sensitivity: 0.36, specificity: 0.68) and 0.59 on the first postoperative day (non-AKI median 0.3; p = 0.03; sensitivity: 0.9, specificity: 0.5). Two patients showed elevated serum creatinine immediately after surgery (sensitivity: 0.17, specificity: 1.0) and 7 patients on the first postoperative day (sensitivity: 0.5, specificity: 0.94). Proenkephalin on the first-postoperative day demonstrated an area under the receiver-operating characteristic curve (AUC) of 0.83 and [TIMP-2]*[IGFBP-7] an AUC of 0.72.

CONCLUSIONS: [TIMP-2]*[IGFBP-7] and proenkephalin have shown promising results in the prediction of AKI in patients following cardiothoracic surgery and may allow to intervene earlier to prevent AKI.

• Keywords: Acute Kidney Injury; Novel Biomarkers; Proenkephalin; [TIMP-2]*[IGFBP-7]; Cardiothoracic Surgery

1.28. INTERDISCIPLINARY » MCS/ECLS/ECMO

Outcomes Following Left Ventricular Assist Device Explantation for Myocardial Recovery: A Meta-Analysis of 12 Studies

• Navneet Singh
• Department of Cardiothoracic Surgery, Auckland City Hospital, Auckland, New Zealand

BACKGROUND AND AIM: Left ventricular assist devices (LVAD) are a key part of management for intractable left heart failure. LVADs can be decommissioned or explanted following myocardial recovery (bridge to recovery); however, this is uncommonly done. We aimed to perform a meta-analysis of all available published data regarding the short-term and medium-term outcomes following LVAD explant for ventricular recovery.

METHOD: MEDLINE, Science Direct and CENTRAL databases were searched from conception to July 2023 for all studies reporting outcomes following LVAD explant for myocardial recovery in adult patients. The primary outcome measures were the post-LVAD explant mortality rate (short-term and medium-term) and incidence of heart failure recurrence. A proportional meta-analysis (inverse variance, random effects model) was performed using StatsDirect 3.0 software. Data is presented as a proportion (%) with an associated 95% confidence interval (CI).

RESULTS: From 682 records identified in database searching, 12 observational studies were included in our analysis with a sample size of 313 patients (mean age 37.2 years). No randomized studies were available on this topic. The 30-day mortality rate was 5% (95% CI: 2–10). The medium-term mortality rate over a median of 709 days was 14% (95% CI: 9–20). The incidence of recurrent heart failure post-LVAD explant was 13% (95% CI: 6–22). The incidence of LVAD reimplantation or subsequent heart transplantation post-LVAD explant was 10% (95% CI: 4–18).

CONCLUSIONS: Reassuring symptom- and survival-based outcomes can be achieved in the short- and medium-term following LVAD explantation for myocardial recovery. However, the dataset is small, the included studies are heterogenous and no randomized trials are available. Ultimately, LVADs may serve as a bridge to recovery in select patients.

• Keywords: LVAD explant; bridge to recovery

1.29. INTERDISCIPLINARY » Miscellaneous

1.29.1. Approach to Tumors Associated with the Inferior Vena Cava from a Cardiovascular Surgeon Perspective

• Nazlı Melis Coşkun Yücel ¹, Ahmet Aydın ¹, Timuçin Sabuncu ¹, Şafak Alpat ¹, Mustafa Sertaç Yazıcı ², Mesut Altan ², Bülent Akdoğan ² and Mustafa Yılmaz ¹

1

Department of Cardiovascular Surgery, Hacettepe University, Ankara, Turkey

2

Department of Urology, Hacettepe University, Ankara, Turkey

BACKGROUND AND AIM: Tumors involving or invazive to the inferior vena cava (IVC) are generally related to the genitourinary or gastrointestinal systems. In our hospital, collaboration of cardiovascular surgery in addition to general surgery, obstetrics and gynecology, and urology has increased the resectability rates of these tumors.

METHOD: A retrospective analysis was conducted on 20 patients who underwent surgery with an interdisciplinary approach between 2014 and 2024.

RESULTS: Between 2014 and 2024, we applied interdisciplinary surgical procedures to 20 cases of inferior vena cava tumors at our clinic. Among these patients, 3 (15%) were female, 17 (85%) were male, with an average age of 39 years (range: 18–69). Pathological diagnoses included 12 germ cell tumors, 3 renal cell carcinomas, 2 leiomyosarcomas, 1 ureteral carcinoma, 1 Ewing sarcoma, 1 desmoplastic tumor. Procedures performed included IVC ligation after tumor excision in 2 patients, graft interposition in 2 patients, bovine pericardium patch plasty in 1 patient, and primary repair of the IVC in 10 patients. In 2 patients, the mass was excised but no procedure was performed on the infiltrated IVC. One patient was considered unresectable due to widespread metastasis. In one patient, CPB support was used due to intracardiac extension, and in another patient, due to IVC clamp intolerance. There were no cases of early mortality among the patients.

CONCLUSIONS: In cases of tumors invading vascular structures such as the inferior vena cava, requesting consultation with cardiovascular surgery and establishing interdisciplinary collaboration can increase the resectability rates of tumors and reduce recurrence rates. CPB support can be used in tumors with intracardiac extension to ensure the patient’s hemodynamic stability and reduce blood loss. During tumor surgery, when surgical intervention on the inferior vena cava is necessary, the primary goal should be to restore blood flow by reconstructing the vessel. However, in patients with good collateral circulation and no blood flow from the distal end, ligation and excision of the inferior vena cava may reduce the risk of recurrence.

• Keywords: IVC-related tumor; tumor surgery with cardiopulmonary bypass; interdisciplinary approach

1.29.2. Engineered Polymeric Nanoparticles for Vascular Drug Delivery

• Pier Francesco Ferrari ^1,2, Chiara Bufalini ¹, Roberta Campardelli ^1,2, Giovanni Pratesi ^2,3,4, Patrizia Perego ^1,2 and Domenico Palombo ^2,3,4

1

Department of Civil, Chemical and Environmental Engineering, University of Genoa, Genoa, Italy

2

Research Center for Biologically Inspired Engineering in Vascular Medicine and Longevity, University of Genoa, Genoa, Italy

3

Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Italy

4

Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy

BACKGROUND AND AIM: Considered the morbidity and mortality of arterial occlusive diseases, the research of a novel therapy for the initial stages of atherosclerosis could significantly improve the surgical approach. Currently, there is no pharmacological treatment capable of inducing the resolution of plaque in its early stages. In this context, vascular drug delivery will provide innovative solutions for the therapy of early-stage atherosclerotic plaques. Here, an engineered polymeric nanosystem is proposed with the aim of encapsulating bioactive molecules.

METHOD: Polymeric nanoparticles (PNPs) were prepared via double emulsion solvent evaporation method for the encapsulation of therapeutic monoclonal antibodies (mAbs). The conjugation of PNPs with immunouteroglobin-1 (IUG-1) was achieved through a coupling reaction. PNPs were characterized in terms of morphology and particle size distribution. Moreover, the release of mAb, the capability of antigen recognition, and the biocompatibility were studied.

RESULTS: PNPs were successfully prepared and exhibited mean diameters of 225.6 nm, slightly increased after IUG-1 conjugation. As therapeutics, PNPs showed a sustained release of the encapsulated mAbs over time. PNPs presented good compatibility with macrophages, endothelial, and red blood cells.

CONCLUSIONS: Therefore, the studied PNPs represent a promising therapeutic tool with the potential to significantly impact on the pharmacological treatment of early-stage atherosclerotic plaque.

• Keywords: nanotechnology; drug encapsulation; polymeric nanoparticles; surface engineering

1.29.3. Dynamite Plots in Cardiothoracic and Vascular Surgery Research: A Machine-Learning Meta-Study of over 9000 Original Research Articles over Ten Years

• Thomas James Doggett ¹ and Connor Way ²

1

School of Medicine, Anglia Ruskin University, Chelmsford, UK

2

Independent Researcher, Canterbury, UK

BACKGROUND AND AIM: Dynamite plots are bar charts of numerical data: they are a misleading and ineffective method of visualizing data. They alter the perception of the mean’s position through the “within-the-bar” bias, whilst obscuring the underlying data distribution. Consequently, they offer no more information than mean ± standard deviation within the text. Box, violin, and scatter plots are widely understood—although no one plot is always right for every situation, there is always a better alternative to a dynamite plot.

Prior to our study, there was no data on the use of dynamite plots in cardiothoracic or vascular surgery research.

Our aim is to demonstrate the frequency that dynamite plots are used in cardiothoracic and vascular surgery research and understand the trend of their use over a 10-year period.

METHOD: Original research articles in the fields of cardiothoracic and vascular surgery were selected from the PMC open access dataset based on MeSH terms. These were retrieved using the biblio-glutton-harvester Python tool. 9799 articles were analysed using Barzooka, a convolutional neural network tool. These results were statistically adjusted based on previous validation data with 95% confidence bounds. The Kendall tau coefficient with the Mann-Kendall test for significance was used to assess the trend of dynamite plot use over a 10-year period.

RESULTS: In 2012, for original research articles plotting univariate numerical data, based on the statistically adjusted data, approximately 74% of cardiothoracic articles and 79% of vascular articles used dynamite plots. This decreased to approximately 46% in both fields by 2022. Both showed a statistically significant (p < 0.001) downward trend, as signified by negative tau values.

CONCLUSIONS: The use of dynamite plots in vascular and cardiothoracic surgical research has decreased over time. Despite this, use remains alarmingly high, and thus much more must be done to educate surgical researchers on effective data visualization and communication.

• Keywords: Vascular Surgery; Cardiothoracic Surgery; Machine Learning; Artificial Intelligence; Data Visualization; Meta-study

1.29.4. Celox as a Novel Topical Haemostatic Agent in Cardiac Surgery: A Prospective Cohort Study

• Navneet Singh and Parma Nand
• Department of Cardiothoracic Surgery, Auckland City Hospital, Auckland, New Zealand

BACKGROUND AND AIM: Celox is a sterile low-cost topical haemostatic agent which is derived from a natural sugar called chitosan. Celox has been used successfully in military warzones for haemostasis of large battle wounds. There are only two in-human case reports published on Celox use in cardiac surgery. However, at our centre, we have been using Celox in cardiac surgery since 2019. We hence aimed to carry out a retrospective review of our Celox cases.

METHOD: A retrospective analysis of prospectively-collected data was performed on all patients receiving Celox intraoperatively during cardiac surgery at our unit from 2019 to 2022.

RESULTS: There were 96 cases which utilised Celox across the 3-year study period. The majority of cases (63%) were of acute or emergency status, with 39% of cases being aortic dissection repairs. 52% of patients were on anticoagulants at the time of operation. Across the operative caseload, the mean bypass time was 4 h with 25% of patients ending up on VA-ECMO intraoperatively. On average, 15 units of various blood products were transfused in each case. Postoperatively, the mean mediastinal drain output in the first 24 h in ICU was 381 mL. Only 2% of patients had a takeback to theatre for review of ongoing bleeding.

CONCLUSIONS: This is the largest report of Celox use in cardiac surgery. In our experience with sick coagulopathic patients undergoing complex long operations, Celox was associated with cessation of bleeding and correlated with satisfactory postoperative drain outputs. In particular, Celox is useful in surgically-challenging situations, such as trying to address bleeding from an inaccessible posterior aortotomy suture line.

• Keywords: Celox; haemostasis; topical agents

1.29.5. Thromboembolic Complications, Thrombosis Marker and Prognosis in Patients with COVID-19

• Tetiana Danilevych, Yuriy Mostovoy and Lesya Rasputina
  Department of propedeutic of internal medicine, National Pirogov Memorial Medical University, Vinnytsya, Ukraine

BACKGROUND AND AIM: The literature describes different threshold levels of thrombosis markers associated with the prognosis patients with severe COVID-19. Aim-to assess the prevalence of thromboembolic complications in patients with severe COVID-19, the association between D-dimer levels and patient survival.

METHOD: 221 patients (groups of survivors 133 (60.2%) and dead patients 88 (39.8%), p = 0.02), who were in the intensive care unit due to severe COVID-19, were included in the study. The period of hospitalization was 18.9 ± 9.13 vs. 9.14 ± 7.21 days, p < 0.001.

Died patients were older (68.22 ± 11.50 vs. 61.38 ± 12.96 years), more often had hypertension (73 (83.0%) vs. 90 (67.7%), CHD (83 (94.3%) vs. 91 (68.4%)), had a stroke (15 (17.0%) vs. 11 (8.2%)), kidney diseases (18 (20.5%) vs. 13 (9.8%), p = 0.022), oncological diseases—(8 (6.0%) vs. 12 (13.6%), all p < 0.05.

RESULTS: Mortality in this cohort of the patients was 88/221 × 100% = 39.8%. Conditions associated with thrombosis in dead and survivors groups were stroke (10 (11.4%) vs. 3 (2.3%), p = 0.006), pulmonary embolism (9 (10.2%) vs. 3 (2.3%), p = 0.014), atrial fibrillation (AF) (31 (35.2%) vs. 19 (14.3%), p = 0.0001), thrombophlebitis (14 (15.9%) vs. 15 (11.3%), p > 0.05), acute myocardial infarction (3 (3.4%) vs. 2 (1.5%), p > 0.05).

The mean value of D-dimer (9.83 ± 22.85 vs. 1.21 ± 1.76 µg, 0.005) in the group of dead patients was higher than in the survivors. Using the cluster analysis method, the threshold value of D-dimer was determined as 0.775 μg. Survival of patients with D-dimer levels > 0.775 μg was lower vs. in patients with levels ≤ 0.775 μg, Long-Rank p = 0.0001.

CONCLUSIONS: The patients who died from COVID-19 more often had pulmonary embolism, AF, stroke. The D-dimer level > 0.775 μg can be considered as the risk marker of in-hospital mortality in patients with severe COVID-19.

• Keywords: COVID-19; D-dimer; trombosis marker; survival

1.29.6. Beyond Traditional Metrics: Exploring Novel Biomarkers for Early Detection of Acute Kidney Injury in Coronary Artery Bypass Graft Surgery

• Senem Sakar, Jasmin Ben Khaled, Wolfgang Ristau, Abdelhadi Kerrad, Belal Darwish, Stephan Knipp, Markus Kammler and Matthias Thielmann
• Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center, University Hospital Essen, Essen, Germany

BACKGROUND AND AIM: Acute kidney injury (AKI) following coronary artery bypass grafting (CABG) affects up to 30% of patients with significant impact on short- and long-term outcomes. Novel biomarkers such as TIMP-2*IGFBP-7 and proenkephalin have been proposed for early and accurate detection of AKI enabling prompt and preventive measures.

METHOD: This single-center study evaluated the predictive accuracy of TIMP-2*IGFBP-7 and Proenkephalin for AKI in CABG patients, using KDIGO criteria as the primary endpoint. Levels of TIMP-2*IGFBP-7 in urine and Proenkephalin in plasma were compared between AKI and non-AKI patients and compared with conventional indicators of AKI, such as serum creatinine, eGFR, and urinary output.

RESULTS: Thirty-six consecutive patients undergoing CABG were studied. Out of these, 12 patients showed elevated postoperative TIMP-2*IGFBP-7 levels with 1.32 ± 3.16 in AKI vs. 0.09 ± 2.63 ng/mL²/1000 in non-AKI (p < 0.001); 95% CI: 1.01–20.79; Sensitivity/Specificity: 0.38/0.66 and 12 patients showed increased Proenkephalin levels with 100.4 ± 26.75 vs. 59.4 ± 17.82 pmol/L (p < 0.0001); 95% CI: 92.63–131.60; Sensitivity/Sensitivity 0.63/0.74. At 24 h postoperatively, 20 patients had elevated TIMP-2*IGFBP-7 with 0.77 ± 1.9 vs. 0.09 ± 2.16 ng/mL²/1000 (p < 0.001); 95% CI: −1.10–11.57; Sensitivity/Specificity: 0.86/0.33, while Proenkephalin increased in 14 patients with 104.9 ± 56.62 vs. 61.65 ± 25.51 pmol/L (p < 0.001); 95% CI: 96.11–163.13; Sensitivity/Specificity: 0.75/0.6. Proenkephalin and TIMP-2*IGFBP-7 levels showed AUCs of 0.65 postoperatively and 0.69 and 0.62 at 24 h after CABG.

CONCLUSIONS: The study shows a significant link between elevated postoperative levels of TIMP-2*IGFBP-7 and Proenkephalin and AKI in CABG patients, suggesting their potential for early AKI prediction within 24 h post-surgery. However, further validation of clinical utility is needed.

• Keywords: novel biomarker; AKI; early detection; CABG

1.29.7. Design and Validation of a Novel High-Performance Bioreactor for Engineered Vascular Scaffolds

• Jan Oscar Pralits ¹, Pier Francesco Ferrari ^1,2, Leslie Neil Sierad ³, Fatemeh Ahmadpoor ¹, Giovanni Pratesi ^2,4, Patrizia Perego ^1,2 and Domenico Palombo ^2,4

1

Department of Civil, Chemical and Environmental Engineering, University of Genoa, Genoa, Italy

2

IRCCS Ospedale Policlinico San Martino, Genoa, Italy

3

Aptus Bioreactors LLC, Clemson, SC, USA

4

Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Genoa, Italy

BACKGROUND AND AIM: The manufacturing of biodegradable, bioabsorbable, and bioactive small-diameter vascular scaffolds (VSs) represents the ultimate goal of vascular tissue engineering. Despite significant research progress in this field, no biodegradable and bioabsorbable vs. has been approved for clinics to date. Various attempts to validate the next-generation VSs in 2D models have been reported, but all of them suffer from limitations. The development of bioreactors that can reproduce the complexity of the 3D vascular system is still a challenge. Here, a high-performance bioreactor (HPB) is proposed for validating VSs.

METHOD: The proposed HPB is based on peristaltic pump technology, combined with a system of tubing, reservoirs, and valves that mimic the complexity of the cardiovascular system. The HPB was connected to a computer with dedicated software that provided precise control of the pump. VSs were successfully fabricated by electrospinning using a solution of poly(caprolactone) and poly(glycerol sebacate), in the presence of quercetin. The resulting vs. had a diameter of 5 mm and was coated with gelatin before testing in the HPB.

RESULTS: A versatile HPB was successfully set up and all the data generated during the experimentation were digitally collected. The tested electrospun vs. showed good patency. The different pressure regimes had a significant impact on the release of both gelatin and quercetin. The amount of released quercetin was adequate to modulate the inflammatory process. The vs. mechanical properties were not adversely affected by the applied pressure regimes. Analytical evaluation of the wall shear stresses provided an in-depth understanding of the correlation between the mechanical forces and the release of biomolecules from VSs in HPB.

CONCLUSIONS: The successful implementation of the HPB had a positive impact on the validation of vs. in a cardiovascular-like environment. All the properties exhibited by vs. at the end of the experimentation confirmed the feasibility of planning preliminary in vivo experiments.

• Keywords: biodegradable polymers; electrospinning; bioactive prostheses; vascular tissue engineering

1.29.8. Two Peas in a Pod: Combined Abdominal Aortic Aneurysm Repair and Coronary Artery Bypass Grafting

• Hina Inam and Zia Ur Rehman
  Aga Khan University Hospital, Karachi, Pakistan

INTRODUCTION: Coronary artery disease (CAD) and abdominal aortic aneurysms (AAA) frequently coexist, presenting complex challenges for treatment. Myocardial infarction contributes to approximately half of all postoperative fatalities subsequent to AAA repair. The combination of two significant surgeries within a private-sector hospital presents numerous hurdles. While isolated CABG entails a mortality rate of 2–3%, elective AAA repair carries a comparable rate of 2.2%. There’s a prevailing belief that simultaneous execution of these procedures will lead to a cumulative rise in mortality. Coexisting AAA and severe CAD present a highly morbid cohort, amplifying the risks associated with individual procedures.

Case Description: We present a case of a 73-year-old male with right-sided abdominal pain, revealing an 8.9 × 9.3 cm juxta renal AAA extending to the bifurcation, concurrent with significant CAD, including left main plus three-vessel disease.

• Treatment Strategy: Considering the high mortality risk associated with staged procedures, we opted for a one-stage approach, performing simultaneous AAA repair and coronary artery bypass grafting (CABG).
• Surgical Approach: The surgical strategy involved careful planning to minimize complications, including retaining arterial and venous cannulae during both procedures for hemodynamic control.
• Postoperative Management: Postoperatively, the patient was successfully extubated, managed for atrial fibrillation episodes, and monitored for renal complications.
• Recovery and Outcomes: Despite the absence of bowel sounds initially, the patient’s recovery progressed well, emphasizing the importance of postoperative management in such cases.

CONCLUSIONS: Our experience supports the efficacy of a one-stage approach, offering streamlined recovery and resource optimization. This case highlights the significance of tailored treatment strategies and multidisciplinary collaboration in managing complex cardiovascular conditions.

• Keywords: Abdominal Aneurysm; Coronary artery bypass grafting

1.30. INTERDISCIPLINARY » Mitral Valve

1.30.1. Validation of Biomedical Engineering Design and Manufactured Dimensions: Novel Physiologic Paired-Ring Mitral/Tricuspid Annuloplasty Sizing System

• Nikola Dobrilovic
  NorthShore University Hospital System, Chicago, IL, USA

BACKGROUND AND AIM: Proof-of-concept of a novel ‘two-ring’ mitral (tricuspid) annular sizing device and technique was introduced at AATS Mitral Conclave 2023. This technique has the potential to dramatically improve ring selection during valve repair procedures. This technology has recently been approved for first-in-human trial at our institution. In preparation for in-human use, the current study aims to validate the manufacturing precision of each of 9 custom sizers designed to correspond specifically to Physio 2 annuloplasty rings.

METHOD: For each available Physio 2 ring (sizes #24–40), caliper measurements were obtained to evaluate correspondence between implantable commercial ring and our manufactured sizer. A total of 1080 measurements was conducted to a level of 1/100th of a mm. Antero-posterior (AP) and width (horizontal) dimensions were measured, comparing each ring sizer with its corresponding Physio 2 ring across all sizes. This was performed 30 times for each unique measurement to validate design accuracy and ability of each sizer to perform (precisely control placement of sutures in the desired position). Bland-Altman analysis with plots was performed to evaluate correspondence of paired sets of measurements.

RESULTS: Mean difference 95% CI between sizer and ring measurements indicated that measurements differed by negligible amounts across all 9 pairs. Given limited abstract space, a sample, complete statistical analysis is provided for a single (#36) sizer. The differences do not show heteroscedasticity.

CONCLUSIONS: Novel two-ring sizers designed for use with Physio 2 annuloplasty rings performed as expected. Validation measurements were extremely close and do not suggest any pattern of error. It is anticipated that this novel sizing technique will provide surgeons with precise, intraoperative anatomic (ink test coaptation length) and physiologic ring sizing information as we now enter human trials.

• Keywords: mitral; coaptation length; novel; mitral repair; mitral ring sizing; mitral sizer

1.30.2. Transapical Off-Pump Mitral Valve Repair with NeoChord DS 1000: First Case Report in Azerbaijan

• Aytaj Ismayilzada ¹, Ziya Shahaliyev ¹, Huseyn Babayev ¹, Valeh Mammadov ¹, Cengiz Koksal ² and Anar Amrah ¹

1

Department of Cardiovascular surgery, Republican Diagnostical Center, Baku, Azerbaijan

2

Department of Cardiac and Vascular Surgery, Bezmialem Vakif University Hospital, Istanbul, Turkiye

AIM: Mitral valve repair (MVr) is a widely accepted treatment option, particularly for degenerative mitral valve regurgitation. Transapical off-pump MVr using the NeoChord DS1000 technique has emerged as one of the safest and most effective procedures. Here, we present the first case of MVr performed with the NeoChord DS1000 device in Azerbaijan.

CASE: A 62-year-old male patient was admitted to the cardiac surgery department presenting with dyspnea, tachypnea during minimal physical exertion, and newly onset dysrhythmia. Echocardiography revealed left atrial dilation and severe mitral regurgitation due to prolapse of the P2 segment. The patient had undergone CABGx3 nine years prior to admission, on follow-up coronary angiography all grafts were patent making redo sternotomy risky. Hence, transapical off-pump MVR was chosen as the treatment approach. Initially, a left-lateral thoracotomy was performed to visualize the apex of the heart. The NeoChord DS1000 device was then inserted from the apex into the left ventricle, and the prolapsed segment of mitral valve was identified by the device under transesophageal echocardiography (TEE) guidance. Subsequently, three neochordae were implanted on the P2 segment of the mitral valve, and the neochords were secured to the apex of the heart. The procedure was completed without any complications. Postoperative TEE confirmed normal functioning of the mitral valve. Subsequent transthoracic echocardiograms in the following days showed minimal mitral regurgitation. The patient was discharged on the third postoperative day.

To conclude, transapical MVr should be considered in suitable patient groups due to its safe application, minimal complications, and promising outcomes.

• Keywords: mitral valve; MVR; Neochord ds1000; off-pomp mitral surgery

1.31. INTERDISCIPLINARY » Tricuspid Valve

Tricuspid Valvectomy: A Safe Method in Illicit Drug User’s Endocarditis

• Suat Karaca and Ibrahim Özsöyler
• Department of Cardiovascular Surgery, Adana City Training and Research Hospital, Adana, Turkey

BACKGROUND AND AIM: The controversy surrounding the methods of isolated tricuspid valve surgery in infective endocarditis remains. Valvectomy/repair or replacement are the options available. Our aim is to demonstrate that valvectomy has acceptable outcomes, particularly in drug-addicted patients who are at risk of recurrent infections.

METHOD: A retrospective analysis was conducted on patients who underwent valvectomy and valve replacement due to isolated tricuspid valve endocarditis at Adana Numune Training and Research Hospital and Adana City Training and Research Hospital between 2015 and 2024. The analysis included 21 cases.

RESULTS: The decision to perform tricuspid valvectomy was based on each patient’s comorbid condition such as septic shock, pulmonary infiltration and history of active intravenous drug use. During the preoperative period, 12 patients presented with septic shock, 7 patients had pulmonary infiltration, and 2 patients required tricuspid valve replacement due to right heart dysfunction and pulmonary hypertension. All patients were active illicit drug users. When examining the 30-day mortality rate, one patient died due to ARDS and two patients died due to the development of right heart failure. Mean follow-up after initial procedure was 24 months, and only one patient required tricuspid valve replacement during this period. Overall mortality rate was 14.2%.

CONCLUSIONS: Patients with endocarditis of the tricuspid valve who undergo valvectomy, repair, or replacement have similar 30-day operative mortality rates, as defined by The Society of Thoracic Surgeons. Valvectomy patients exhibit significantly lower unplanned readmission rates at the two-year mark. In patients with severe pulmonary involvement or those listed in the SEPSIS shock table, tricuspid valvectomy can be a life-saving option. Further research into long-term outcomes and survival is necessary.

• Keywords: Tricuspid Valvectomy; illicit drug users; endocarditis; tricuspid endocarditis

1.32. VASCULAR AND ENDOVASCULAR » Abdominal Aorta

1.32.1. Simultaneous Treatment of Two Aortic Pathologies: The TAVR-EVAR Project

• Areti Vassiliou, Giwrgos Fanariotis, Michail Peroulis and Vangelis G. Alexiou
  Vascular Surgery Unit, General Surgery Department, University Hospital of Ioannina, Ioannina, Greece

BACKGROUND AND AIM: We aim to investigate the feasibility and advantages of the use of endovascular techniques to simultaneously treat two different aortic pathologies.

METHOD: Case report

A man 79 years old was referred to our cardiology clinic after an episode of mild dyspnea and chest pain. His medical history included past smoking, hypertension and angioplasty of the LAD. The TTE showed severe aortic stenosis with concomitant insufficiency, LVEF 60% without any akinesias but with concentric hypertrophy of the left ventricle.

The CT angiogram revealed severe aortic stenosis, and the presence of an infrarenal fusiform AAA (52 mm 51 mm). We also performed a coronary angiography that did not show any stenosis of the coronary arteries and no residual stenosis of the LAD.

Even though the surgical risk was acceptable our Heart team decided to opt for an endovascular approach for this patient. Under general anesthesia, with bilateral femoral cutdown, a 18 French sheath was carefully placed at the right femoral artery and during rapid pacing a 23-mm device was easily advanced and deployed under fluoroscopy. Consequently a Gore Excluder bifurcated main body endoprosthesis was positioned within the AAA through the common right femoral artery with a leg extension in the right common iliac artery. An additional contralateral leg extension was implanted into the left common iliac artery.

RESULTS: The patient had an excellent recovery and was discharged 3 days after surgery with single antiplatelet therapy.

CONCLUSIONS: As we obtain access for large sheaths to repair the aortic stenosis it is preferred the simultaneous procedure as repeated vascular access is a known predictor of vascular complications. Apart from that it is known that the haemodynamic instability that follows a TAVR procedure is a risk factor for AAA rupture.

In conclusion, with careful assessment and the help of a multidisciplinary team the simultaneous procedure is a feasible choice and may reduce the complication rates of such procedures.

• Keywords: Aortic stenosis, Abdominal aneurysm, simultaneous treatment, advantages, endovascular techniques

1.32.2. Composition of the Surgical Team in Open Surgery for Abdominal Aortic Aneurysm: A Risk Factor Analysis

• Gabriele Piffaretti ¹, Alessandro Zammito ¹, Marco Franchin ¹, Nicola Rivolta ¹, Luca Guzzetti ², Gabriele Selmo ², Simone Binda ² and Matteo Tozzi²

1

Vascular Surgery—Department of Medicine and Surgery, University of Insubria, Varese, Italy

2

Anesthesia and Palliative Care, Department of Emergency and Trauma System, ASST Settelaghi University Hospital, Varese, Italy

BACKGROUND AND AIM: The aim of this study was to analyze the influence of varying experiences within each surgical team to identify team-related risk factors on clinical outcomes after open surgery (OS) for abdominal aortic aneurysm (AAA).

METHOD: This is a single-center, observational cohort study with retrospective analysis of prospectively collected data. All cases of elective OS for AAA 1 January 2010 and 31 December 2022 were analyzed. Each component (surgeon and anesthesiologist) was rated according to the number of intervention performed, and a surgical team’s score was calculated (operating surgeon + assisting surgeon + anesthesiologist = team score) by relying on each member’s experience. Primary outcome was survival at 30 days and in follow-up, and a composite outcome of mortality and major complication. Secondary outcome was freedom from aorta-related reintervention.

RESULTS: We analyzed 103 patients: 97 (94.2%) males and 6 (5.8%) females. The mean age was 76 ± 8 years (range, 55–93). The best possible team composition was present in 52 (50.5%) surgeries. There was no difference among teams in major complications (17.3% vs. 21.6%; OR: 0.4, p = 0.622). No death was observed at 30 days in patients operated by the best team; however, mortality (0% vs. 5.9%; OR: 3.1, p = 0.118), and composite outcome (11.5% vs. 17.6%; OR: 0.8, p = 0.416) was not different between teams. Aorta-related reintervention was lower in the best team (5.8% vs. 17.6%; OR: 3.5, p = 0.072). Cox regression analysis identified the best team as a protective factor (HR: 0.2; 95% CI: 0.06–0.88, p = 0.032) for reintervention (HR: 3.7; 95% CI: 0.99–13.97, p = 0.051).

CONCLUSIONS: Open surgery for AAA is equally safe in different teams. However, there is a positive impact of the experience of the surgical-anesthesiologic team on freedom from aorta-related reintervention.

• Keywords: abdominal aortic aneurysm; open surgery; companionship; surgical team

1.32.3. Single-Center Mid-Term Experience with E-Liac Branched Device from Artivion^®

• Ozan Yazar ¹, Stefanie Willems ¹, Niek Zonnebeld ¹, Pieter Salemans ¹, Chunyu Wong ¹ and Lee Bouwman ²

1

Department of Vascular and Endovascular Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.

2

Faculty of Science and Engineering, Maastricht University, Maastricht, The Netherlands

BACKGROUND AND AIM: The use of iliac branch device (IBD) is increasing due to the less invasive character and accumulated experience of physicians in these techniques. Clinical data regarding the E-Liac stent-graft from Artivion^®, however, are scarce. This study shows the mid-term outcomes of the E-Liac stent graft from a large single centre.

METHOD: Patients treated with IBD for (aorto-)iliac aneurysms between September 2015 and December 2022 with follow-up in our centre were included. (Post)operative (technical success, reintervention, 30-day mortality) and mid-term outcomes (endoleak, reintervention, hypogastric patency, mortality) were analysed.

RESULTS: Sixty-three patients (60 male, median age 70 years (IQR 66–76)) were treated with 82 E-Liac stent grafts for aorto-iliac aneurysms with a median follow-up of 38 months (IQR 22–51). The technical success rate was 95%. 97.6% of the interal iliac artery remained patent during follow-up. No 30-day mortality was encountered and there were no reinterventions. During follow-up one patient had an endoleak type Ib of both hypogastric arteries, however the patient refused additional interventions. One other patient had a type II endoleak with contained rupture. Due to severe comorbidities the patient was treated palliatively. One (1.6%) IBD-related reintervention was performed with relining of the stent-graft. Primary patency of the hypogastric branch was 95.1% and the mortality was 25.4% during follow-up.

CONCLUSIONS: This study shows high technical success rates for the E-Liac stent graft, with corresponding good mid-term outcomes. The E-Liac stent-graft is a feasible, safe and effective stent-graft in the treatment of aorto-iliac aneurysms.

• Keywords: Aorto-iliac aneurysm; hypogastric artery; iliac branch device; E-liac; stent-graft

1.32.4. Semi-Branched iBEVAR for Treatment of Aortic Aneurysms: Novel Feature in Stent-Graft Configuration

• Ozan Yazar, Pieter Salemans, Chunyu Wong and Lee Bouwman
• Department of Vascular and Endovascular Surgery, Zuyderland Medical Center, Heerlen, The Netherlands

BACKGROUND AND AIM: With the change of treatment paradigm for abdominal aortic aneurysms endovascular techniques are advancing. Fenestrated EVAR (FEVAR) and branched EVAR (BEVAR) are used for complex aortic aneurysm repair. Both FEVAR and BEVAR have their own unique advantages and disadvantages. Semi-branched stent-graft configuration are a new feature that attempts to combine the advantages of both FEVAR and BEVAR.

METHOD: A case series of patients with an abdominal aortic aneurysm (AAA), who underwent a semi-branched iBEVAR (Artivion^®) procedure between July till September 2023 were analyzed. Primary outcomes were technical success, perioperative complications, and target vessel patency. Secondary outcomes were type I or III endoleak and 30-day aneurysm related mortality.

RESULTS: Three patients (female, n = 2) with a mean age of 75 years (range, 66–85 years) underwent a semi-branched iBEVAR procedure for the treatment of an abdominal aortic aneurysm (AAA). Two cases needed 4 vessel stent-graft configurations, and one case needed a two-vessel stent-graft configuration. Mean aneurysm diameter was 54 mm (range, 51–58 mm). One case was a failed EVAR case with a type Ia endoleak which needed a repair. Intraoperative technical success was 100%. No perioperative complications were revealed. All patients received a computer tomography (CT) angiogram 30 days postoperatively, which showed 100% target vessel patency, with no type I or III endoleak. There was no aneurysm-related mortality.

CONCLUSIONS: In short-term follow-up, the novel feature of semi-branches iBEVAR in endovascular aortic treatment for AAA appears to be a safe and effective treatment.

• Keywords: aneurysms; stent-graft; endovascular; branched

1.32.5. The Results of the Treatment of the Gunshot Wounds of the Main Vessels

• Yuliia Nahaliuk, Volodymyr Rogovskyi and Borys Koval
  National Military Medical Clinical Centre, Kyiv, Ukraine

BACKGROUND AND AIM: The aim of this study is to analyse the results of treatment and clinical outcomes in patients with injuries of the main vessels of the lower extremities in the period of 2014–2024.

METHOD: We have analysed 51 cases of gunshot wounds of the main vessels of the lower extremities who have undergone treatment at our medical facility from 2014 to 2024.

RESULTS: There was performed 513 operations in 51 patients; 77 (15%) of them—on the main vessels, 14 (2.7%)—amputations and re-amputations, 422 (82.2%)—other.

Analysing the results of treatment in 38 cases (74.5%) there was identified satisfactory result and in 13 (25.5%)—the treatment resulted in amputation.

Among patients under 20 years old there was 1 (7.7%) who underwent amputation, among patients from 21 to 30 years old—7 (53.8%), among patients from 31 to 40 years old—3 (21.1%), among patients from 41 to 50 years old—2 (15.4%) individuals accordingly.

CONCLUSIONS: Gunshot wounds of the main vessels remain controversial and sophisticated area of the vascular surgery both, in therapeutic and organisational ways. Taking into account a significant part and severity of the gunshot wounds of the vessels, the main task for medical professionals today is the creation of the clear algorithm of the effective medical assistance to all patients on the stage of medical evacuation directed at rescue of life from acute bleeding, saving of the extremity, treatment of complications and outcomes of the vascular injury, and foundation of the system of the specialized surgical assistance and rehabilitation in the corresponding referral centres.

• Keywords: gunshot wounds; main vessels

1.32.6. The Introduction of the PRP-Technology to Improve the Long-Term Consequences and Outcomes of the Treatment of the Injuries of the Main Vessels of the Lower and Upper Extremities

• Yuliia Nahaliuk, Volodymyr Rogovskyi, Borys Koval and Yurryi Sivash
  National Military Medical Clinical Centre, Kyiv, Ukraine

BACKGROUND AND AIM: The aim of this study is to analyse the results of treatment and clinical outcomes in patients with injuries of the main vessels of the lower and upper extremities and implement of the PRP-technology to improve the long-term consequences and outcomes of the treatment of the injuries of the main vessels of the lower and upper extremities.

METHOD: We have analysed 51 cases of gunshot wounds of the main vessels who have undergone treatment at our medical facility from 2014 to 2024. In 7% of these cases, we have used PRP-technology in the area of the proximal and distal anastomosis, the area of the vascular suture.

RESULTS: During the environmental protection in eastern Ukraine was recorded 545 cases of the gunshot wounds of the main vessels. In our stude we included 51 cases. There was performed 513 operations in 51 patients; 77 (15%) of them—on the main vessels, 14 (2.7%)—amputations and re-amputations, 422 (82.2%)—other. Analysing the results of treatment in 38 cases (74.5%) there was identified satisfactory result and in 13 (25.5%)—the treatment resulted in amputation. Gunshot wounds are a complex field of medicine, given the previously obtained results, it was important for us to improve the results and consequences, reduce the number of unsatisfactory results.

CONCLUSIONS: Platelet-rich plasma (PRP) injections are gaining popularity for a variety of conditions, from sports injuries to hair loss. The treatment uses a patient’s own blood cells to accelerate healing in a specific area. PRP treatment can help support wound healing in trauma. Because the treatments use a patient’s own tissues, PRP injections are safe and can be administered alone or used in conjunction with other procedures.

• Keywords: PRP-technology; the injuries of the main vessels

1.32.7. The Experience of the Treatment of the Early and Long-Term Consequences and Complications of the Gunshot Wounds of the Main Vessels

• Yuliia Nahaliuk, Volodymyr Rogovskyi and Borys Koval
• National Military Medical Clinical Centre, Kyiv, Ukraine

BACKGROUND AND AIM: Gunshot wounds (GSW) of the main vessels remain relevant and sophisticated sphere of vascular surgery both, in therapeutic and organizational way. The purpose of the study is to analyse the character of the injuries, localization, concomitant trauma, results of treatment of the early and long-term consequences and complications and clinical outcomes in patients with injuries of the main vessels of the extremities.

METHOD: There were analysed 743 cases of GSW of the main vessels of the lower and upper extremities. The inclusion criteria were military servicemen of the Armed Forces of Ukraine; patients who required intervention on the main vessels; males.

RESULTS: During the war in Ukraine was recorded 743 cases of the gunshot wounds of the main vessels. The damage of the artery in 46.5%; in 11.1%—damage of the vein; in 42.4%—both. Among all injuries, 88.2% were combat injuries, and 11.8%—non-combat. The localisation of the GSW was the following: 76.5% of the injuries were in femoropopliteal area, 21.6%—peroneal area, 1.9%—both. The injuries that accompanied the trauma of the main vessels included: bone injury (37.3%), bone and nerve injury (25.5%), nerve injury (23.5%), isolated soft tissue injury (13.7%). The injury of both lower or upper extremities occurred in 25.5%, organs of thoracic cavity in 3.9%, organs of abdominal cavity—in 3.9%, head and neck injury—in 2%, injury of 3 and more anatomical areas—in 17.6%, isolated trauma—in 47.1%. There were performed 7052 surgeries: 15% on the main vessels, 2.7% amputations and re-amputations, 82.3%—others. In 85.6% we identified satisfactory result, in 12.7%—the treatment resulted in amputation, in 1.7%—lethal

CONCLUSIONS: It is necessary to create thorough algorithm of specialized treatment of patients with described type of trauma in high-qualified medical institutions and rehabilitation centres.

• Keywords: gunshot wounds; main vessels

1.32.8. Impact of Stent-Graft Complexity on the Outcome of Treatment Complex Abdominal Aortic Aneurysms Repair: A Systematic Review and Meta-Analysis

• Ozan Yazar ¹, Buland Tiwana ², Jean Daemen ¹, Marion Heymans ¹, Barend Mees ² and Geert Willem Schurink ²

1

Department of Vascular and Endovascular Surgery, Zuyderland Medical Center, Heerlen, The Netherlands

2

Department of Vascular and Endovascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands

BACKGROUND AND AIM: The aim of the present study was to reveal a relationship between increased stent-graft complexity and clinical outcomes. We summarize the available data from studies comparing stent-grafts with only renal-fenestrations (renal-FEVAR) to stent-grafts with additional fenestrations/branches for the mesenteric arteries (complex-F/BEVAR) in the treatment of pararenal aortic aneurysms (PAA) and type IV TAAA.

METHOD: A systematic review and meta-analysis of studies focusing on results of patients treated with renal-FEVAR and comparing with complex-F/BEVAR in treatment of PAA and type IV TAAA was performed following the PRISMA guideline. PubMed, EMBASE, the Cochrane Library and Web of Science were searched for studies till mid-May-2022. Primary outcomes were technical success, perioperative reinterventions, in-hospital mortality, and reintervention for endoleak type I or type III during follow-up. Secondary outcomes were target vessel patency, myocardial infarction, bowel/limb ischemia, acute renal failure, stroke or TIA, SCI, length of hospitalization, long-term survival, and reintervention.

RESULTS: The search yielded a total of 7149 studies. After screening, eleven studies with 2167 patients (758 renal-FEVAR, 1409 complex-F/BEVAR) were included for analysis. Meta-analysis demonstrated no significant difference in technical success between the renal-group and complex-group (OR: 1.90, 95% CI 0.75–4.77, p = 0.17). No significant difference (p = 0.57) was observed in reinterventions between the two groups. The all-cause mortality rate during hospital-stay was twice as high for the complex-group (4.2% [n = 36/860]) compared to the renal-group (2.1% [n = 14/660]), however without statistical difference (p = 0.23). Reinterventions for type I and III endoleaks were not significantly different between the two groups, p = 0.23. No significant difference was revealed between the two groups regarding secondary outcomes.

CONCLUSIONS: This systematic review revealed no significant difference in mortality, complications, or reintervention between renal-FEVAR and complex-F/BEVAR. The results may suggest a more liberal approach in proximal additional fenestrations or branches. However, renal-FEVAR in juxta-renal aneurysms remains a safe and effective treatment option with no higher risk on type Ia endoleak or reinterventions during follow-up compared to complex-F/BEVAR.

• Keywords: Systematic review; Meta-analysis; Pararenal (complex) aortic aneurysm; Type IV thoraco-abdominal aortic aneurysms

1.32.9. Vascular Endothelial Growth Factor (VEGF) but Not Interleukin-6 (IL-6) Is Found in Higher Concentrations in the Excluded Aneurysm Sac of Patients with Type II Endoleak—A Pilot Study

• Luca Borruso ¹, Natalie Le ², Mary Kavurma ³ and David Robinson ¹

1

Royal Prince Alfred Hospital, Sydney, NSW, Australia

2

Heart Research Institute (HRI), Newtown, NSW, Australia

3

The University of Sydney, Sydney, NSW, Australia

BACKGROUND AND AIM: Type II endoleak (T2EL) causes expansion of an abdominal aortic aneurysm (AAA) sac after endovascular repair (EVAR) and can behave like arteriovenous malformations (AVM) after intervention. Vascular endothelial growth factor (VEGF) and interleukin-6 (IL6) are relevant in AVM pathogenesis. The aim of this pilot study was to investigate whether the excluded AAA sac is a source of VEGF and IL6 that may contribute to the development of T2EL following EVAR.

METHOD: Eligible patients were 18–95 years old and belonged to one of:

• Group A: Previous EVAR with T2EL with sac enlargement requiring intervention
• Group B: Peripheral arterial disease undergoing endovascular intervention without AAA or T2EL (control)
• Group C: Primary EVAR (control)

Three blood samples (arterial, venous +/− aneurysm sac) were collected per patient. Patients in Group B had a second arterial sample from the site of endovascular intervention in the absence of aneurysmal disease. ELISA was used to determine VEGF & IL-6 concentration.

RESULTS: Out of 29 patients, 83% were male. Mean age = 73 yo. Mean VEGF concentration was higher in the excluded AAA sac of patients with a T2EL compared with both control groups (Group A: 62 pg/mL vs. Group B: 23 pg/mL vs. Group C: 19 pg/mL) approaching statistical significance. IL6 concentrations did not differ between groups.

CONCLUSIONS: This pilot study to assess feasibility found higher concentrations of VEGF in the excluded AAA sac of patients with a T2EL when compared with those without. Further research is needed to better characterise the relationship between VEGF levels and T2EL development and whether this represents a potential treatment avenue for T2EL.

• Keywords: EVAR; AAA; Endoleak; VEGF; IL-6

1.32.10. Age-Based Stratification and Its Impact on Clinical Presentation and Mortality in Patients with Ruptured Abdominal Aortic Aneurysm

• David Matejevic, Ivan Tomic, Miroslav Markovic, Milos Sladojevic, Ranko Trailovic, Perica Mutavdzic, Andrija Roganovic, Ognjen Kostic and Lazar Davidovic
• Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia

BACKGROUND AND AIM: The aim of this study was to assess the difference in clinical presentation, laboratory parameters and risk of fatal outcome in patients with ruptured abdominal aortic aneurysm (RAAA) in different age groups.

METHOD: A single-center, retrospective cohort study with prospectively collected data between 2009–2019 was performed. Total of 702 consecutive patients with RAAA were included in the study. Patients were stratified based on their age in 5 groups. Clinical presentation, laboratory parameters and mortality were assessed.

RESULTS: Patients in older age groups were significantly more likely to expirience a collapse (p = 0.003), and were more likely to have been admitted in unconscious (p = 0.025) and hypovolemic shock state (p = 0.002), with significantly lower levels of measured systolic (p < 0.001) and diastolic (p < 0.001) blood pressure. Laboratory analyses showed lower values of hemoglobin (p < 0.001) and platelets (p < 0.001), and higher creatinine values (p < 0.001) in older age groups. Values of urea (p = 0.414) and leukocytes (p = 0.307) showed no significant difference. Overall mortality was 34.9%. Mortality was significantly different between the groups: group of patients of 41–50 years had 0% mortality, patients 51–60 years 23.8%, patients 61–70 years 21.8%, patients 71–80 years 39.1%, and the oldest patients (81–90 years) had 72.6% mortality (chi-square 90.49, p < 0.001). Univariant logistic regression showed 2.27 times higher chance of lethal outcome for every 10-year age increase (OR 2.27, 95% CI 1.86–2.77, p < 0.001).

CONCLUSIONS: The age of patients with RAAA presents an important predictive factor of worse clinical presentation and fatal outcome, with higher age indicating an overall frailty and carrying a higher risk of mortality.

• Keywords: aorta; aneurysm; rupture; age; mortality

1.32.11. Screening Men and Women Above the Age of 50 Years for Abdominal Aortic Aneurysm

• Ognjen Kostic ¹, Aleksa Jovanovic ², Andrija Roganovic ¹, David Matejevic ¹, Fedor Filipovic ¹, Nikola Brankovic ³, Igor Koncar ² and Lazar Davidovic ¹

1

Clinic for Vascular and Endovascular Surgery, Serbian Clinical Center, Belgrade, Serbia

2

Medical Faculty, University of Belgrade, Belgrade, Serbia

3

General Hospital Kruševac, Kruševac, Serbia

BACKGROUND AND AIM: A pilot screening project for abdominal aortic aneurysm (AAA) was conducted in seven cities in Serbia in 2023. It aimed to explore AAA prevalence and risk factors in an upper middle-income country. Screening is recommended for males over 65, but differences in lifestyle and risk factors between countries make geographical risk stratification necessary.

METHOD: Echosonographic evaluation of the abdominal aorta was performed on the participants who also filled in a questionnaire with demographic and clinical information. Differences in distribution of participants in regards to aneurysm presence were explored using the chi square test, with values of p < 0.05 denoting statistical significance.

RESULTS: A total of 6126 participants (49% male and 51% female), have responded to the screening campaign. An aneurysm was found in 287 screened individuals (4.61%), In males 50–64, prevalence of AAA was 4.65%. The highest prevalence in males was in the group 65–69 (9.48%), while in female group 75+ it was 3.2%. Male sex, older age, family history (16.83% in male patient), smoker (12.48%), ex smoker (9.89%), overweight, and alcohol consumption were predictors of AAA in the univariate analysis.

CONCLUSIONS: The prevalence of AAA is not reduced in all countries, and screening strategies might be changed based on local epidemiological data. In a country with high rate of smokers screening might be considered for males > 50.

• Keywords: AAA; smoking; Screening; aorta; aneurysm

1.32.12. Different Strategies in Treatment Patients with Abdominal Aortic Aneurysm and Coronary Disease

• Andrija Zoran Roganović ¹, David Matejević ¹, Ognjen Kostić ¹, Aleksandar Mitrović ¹, Nabil Alhayek ², Almas Ahmemulić ², Igor Koncar ^1,2 and Lazar Davidovic ¹

1

Clinic for Vascular and Endovascular Surgery, Belgrade, Serbia

2

Faculty of Medicine, University of Belgrade, Belgrade, Serbia

BACKGROUND AND AIM: Patients with aortic aneurysms have associated coronary artery disease. When planning surgical treatment, there is a dilemma as to which problem to solve primarily. Aim of the study was to show different strategies in the treatment of these patients.

METHOD: Retrospectively, 100 patients with abdominal aortic aneurysm treated in high-volume aortic center from 2019–2024 with positive findings on preoperative coronary angiography were selected. Based on the findings, patients were selected for primary interventional cardiology or cardiosurgical treatment or primary vascular reconstruction (OPEN or ENDO). The following groups are patients who were advised to undergo cardiac treatment after a vascular-surgical procedure. The last group consisted of patients who were prescribed conservative therapy. We analyzed cardiac, non-cardiac complications and mortality.

RESULTS: The degree of specific cardiac complications (angina, ECG findings, heart attack) was significantly higher in the groups of patients who first underwent vascular treatment (8.3% and 7.14% vs. 4.5%). Among non-cardiological complications, the development of neurological events was significantly higher in patients who were primarily vascular-surgically treated (EVAR 6.6%, OPEN 5.5%). The frequency of transient renal failure as well as pulmonary complications was similar in all groups except for patients who initially received PCI procedures in which no such complications were recorded (CABG nephro/pulmonary 3.25%, EVAR nephron 2.25%, OPEN nephro 2.2%). Finally, in the group of patients who first underwent cardiac treatment oe EVAR no deaths were recorded, while one patient died after open-surgical treatment (2.7%).

CONCLUSIONS: The presence of coronary disease is a risk factor for patients with aortic aneurysm, and the primary resolution of coronary disease led to a reduced degree of postoperative specific cardiological complications with no difference among other complications and mortality.

• Keywords: aneurysm; coronary disease; treatment; complication

1.32.13. Percutaneous Endovascular Repair of Abdominal Aortic Aneurysms: A Single-Center Experience

• Alexandros Barbatis ¹, Konstantinos Batzalexis ¹, Konstantinos Spanos ¹, Konstantinos Tzimkas Dakis ¹, George Kouvelos ¹, Metaxia Bareka ², Eleni Arnaoutoglou ² and Miltiadis Matsagkas ¹

1

Vascular Surgery Department, University Hospital of Larissa, Medical School of Larissa, University of Thessaly, Volos, Greece

2

Anesthsiology Department, University Hospital of Larissa, Medical School of Larissa, University of Thessaly, Volos, Greece

BACKGROUND AND AIM: Recently, percutaneous endovascular abdominal aortic aneurysm repair (pEVAR) has gained its role in abdominal aortic aneurysm (AAA) treatment. The aim of the study is to report the increase of pEVAR in a tertiary center through years and its impact on clinical outcome.

METHOD: A single-center, observational, retrospective study of prospectively collected data was conducted. All patients who underwent elective pEVAR (using the Proglide device) and EVAR with femoral cutdown access between 2017 and 2024 were included 2017–2019 early pEVAR experience (253 patients); 2020–2024 late experience (340 patients). Baseline characteristics, intra- and peri-operative data were collected. The main outcomes measured were the rate of pEVAR application, the need for blood transfusion and hospital stay.

RESULTS: A total of 593 patients were treated by endovascular means (20.5% pEVAR vs. 79.5% EVAR). Mean age was similar between groups (pEVAR 72.8 ± 4.5 vs. EVAR 72.3 ± 7; p = 0.68). The mean number of Proglide closure devices used for right and left access was 232 and 205 respectively. There was no difference in terms of type of anaesthesia [pEVAR: local 7% and 93% general anaesthesia (GA) vs. EVAR: local 9% and 91% GA, p = 0.38]. The mean operation time was lower for pEVAR (111 ± 40) vs. EVAR 129 ± 45 (p = 0.000), while the need for transfusion was similar between groups [pEVAR: 20/122 (16.4%) vs. EVAR: 70/434 (16%) p = 0.65]. The average hospital stay was significantly lower for patients who underwent pEVAR (1.35 ± 0.8) vs. EVAR 3.23 ± 2 (p = 0.000). Only 1 death occurred in EVAR group. In the initial period pEVAR was used only in 10% of cases, while it was increased significantly in the later experience to 28.2%.

CONCLUSIONS: pEVAR is a growing trend in the treatment of AAA, and compared with femoral cutdown access, it can be considered safe and effective, reducing the operation time and hospital stay.

• Keywords: EVAR; percutaneous; abdominal aortic aneurysm

1.32.14. Durability of a Second-Generation Balloon-Expandable Covered Stentgraft in Patients Treated with Fenestrated, Branched and Chimney Endovascular Aortic Aneurysm Repair

• Konstantinos Tzimkas Dakis, Konstantinos Spanos, George Kouvelos, Christos Karathanos, Konstantinos Batzalexis, Miltiadis Matsagkas and Athanasios D. Giannoukas
• Vascular Surgery Department, University Hospital of Larissa, Medical School of Larissa, University of Thessaly, Volos, Greece

BACKGROUND AND AIM: Covered stent-grafts constitute an essential component of fenestrated (fEVAR), branched (bEVAR) and chimney (chEVAR) endovascular repair. Target vessel (TV) instability events may lead to technical and clinical failure. We present the mid-term outcomes of the second generation of BeGraft (Bentley InnoMed, Hechingen, Germany) balloon-expandable covered stentgraft (BXCS) as an “off-the-shelf” platform used in complex endovascular repair.

METHOD: This is a retrospective analysis of prospectively collected data from a single-tertiary center. All consecutive patients treated for juxtarenal, pararenal and thoracoabdominal (TAAA) aortic aneurysms during a 7-year time period (May 2016–May 2023) either by fEVAR, bEVAR or chEVAR in whom BeGraft BXCS were implanted, were included. Outcomes were defined as primary patency rates for each TV at maximum follow-up and were reported using Kaplan-Meier life tables.

RESULTS: Begraft stentgrafts were deployed in 111 patients (males: 95%, age: 70.9 ± 6.1 years old) who underwent complex endovascular repair [chEVAR: 53 (47.7%), fEVAR: 22 (19.8%), bEVAR: 35 (31.5%), f/bEVAR combination: 1 (0.9%)]. Aneurysm type included 36 (32.4%) juxtarenal, 44 (39.6%) pararenal, 16 (14.4%) type IV TAAA, six (5.4%) type III TAAA and nine (8.1%) type II TAAA. Mean maximum aneurysm diameter was 6.7 ± 1.8 cm. A total of 307 BeGrafts were deployed [Celiac Trunk (CT): 47 (15.3%), Superior Mesenteric Artery (SMA): 70 (22.8%), Right Renal Artery (RRA): 95 (30.9%), Left Renal Artery (LRA): 95 (30.9%) for the revascularization of 286 TV. Mean follow-up was 12.7 ± 12.2 months. The primary patency rate of RRA was 96% (SE: 2.1%), 94% (SE: 2.9%) and 90% (SE:4.7%) at 6, 12 and 24 months, respectively. The primary patency rate of CT was 96% (SE: 3.6%), 86% (SE: 10%) at 6 and 24 months, respectively.

CONCLUSIONS: Second generation BeGraft platform seems to be an effective and durable device for the revascularization of TV during complex endovascular repair.

• Keywords: FEVAR; BEVAR; ChEVAR; stentgraft; target vessels

1.32.15. Effectiveness of Intraoperational Fusion Navigation Technique for Complex Endovascular Procedures on Abdominal Aorta

• Petr M. Lepilin, Timur E. Imaev, Alexander S. Kolegaev, Dmitrij V. Salichkin, Ivan V. Kuchin and Renat S. Akchurin
• Department of Cardiovascular Surgery, National Medical Research Centre of Cardiology Named After Acad. E.I.Chazov, Moscow, Russia

BACKGROUND AND AIM: To assess the role of image fusion technique in possible reduction of contrast volume, radiation dose, and fluoroscopy and procedure times in complex (fenestrated/branched) endovascular aorta aneurysm repair procedures (FEVAR, BEVAR). According to actual recommendations for radiation safety (2023), 3D (MSCT)-2D (DSA) fusion navigation techniques can reduce the contrast volume, radiation dose and procedure time in standard EVAR procedures. Aim of our study was to determine the effect of fusion navigation with preoperative planning, marking of target vessels and planning of C-arm position for cannulation of each mesenteric brunch.

METHOD: Data on 60 patients satisfying the study inclusion criteria were added from the authors’ center. two groups of patients were formed in retrospective analysis of EVAR procedures and fenestrated/branched endografting procedures. All complex procedures were divided in several stages with separate assessment of effectiveness of fusion navigation for every mesenteric/renal artery cannulation/stenting/endografting. Basic calculation index for complex procedures was created, connected to volume and number of angiographic stages.

RESULTS: For standard EVAR, contrast volume and procedure time showed significant reduction of contrast usage mean to 25 mL (mean two angiograms) with same time of procedures (difference less than 7 min) respectively. For complex EVAR group, image fusion technique was connected with significant reduction in procedure contrast volume (mean − 81 mL, fluoroscopy time (less more than 17 min), and also total procedure time (less more than 31 min). The results of our study confirms that image fusion technology can reduce contrast volume, fluoroscopy time, and procedure time in “gold standard” EVAR procedures more than 20 percent, but can show the best effectiveness on complex FEVAR/BEVAR procedures.

CONCLUSIONS: Effective use of preplanned angles for canulation, use of reference images with fusion navigation option can significantly reduce the potential negative effects of radiation/contrast usage in complex FEVAR/BEVAR procedures.

• Keywords: Fusion; Navigation; EVAR; FEVAR; BEVAR

1.32.16. Covered Endovacular Reconstruction of Iliac Bifurcation (CERIB Technique); Short-Term and 1-Year Outcomes

• Konstantinos Spanos ¹, Athanasios Chaidoulis ¹, Konstantinos Tzimkas Dakis ¹, George Kouvelos ¹, Dimitra Papaspyrou ², Eleni Arnaoutoglou ², Athanasios D. Giannoukas ¹ and Miltiadis Matsagkas ¹

1

Vascular Surgery Department, University Hospital of Larissa, Medical School of Larissa, University of Thessaly, Volos, Greece

2

Anesthsiology Department, University Hospital of Larissa, Medical School of Larissa, University of Thessaly, Volos, Greece

BACKGROUND AND AIM: Successful distal zone seal with internal iliac artery salvage is crucial during EVAR. The aim of this study is to present 1-year outcomes of the CERIB technique, an “off-the-shelf” endovascular option for distal landing zone seal at the external iliac artery (EIA), while maintaining blood flow to the IIA.

METHOD: This is a single center, retrospective analysis of prospectively collected data of patients undergoing EVAR for intact AAA or previous failed-EVAR (December 2022–March 2024). Primary outcomes included technical success and primary patency at maximum follow-up. Secondary outcomes were endoleak rate (EL) associated with the iliac reconstruction and reintervention rate.

RESULTS: A total of 25 patients (96% males, mean age: 72 ± 7.1 years old) with 31 iliac bifurcations treated were included. Treatment indications included a CIA aneurysm (67.7%—21/31 iliac bifurcations), short-CIA (16.1%—5/31), narrow lumen CIA (9.6%—3/31) and EL Ib (6.4%—2/31). Aortic platforms deployed included the COOK Alpha (9 limbs), GORE C3 (6 limbs), MEDTRONIC Endurant IIS (7 limbs), ENDOLOGIX Ovation Alto (1 limb), ARTIVION E-tegra (3 limbs) and the COOK T-branch platform (5 limbs). Technical success rate was 100%. Primary patency rate at 30-days (31/31 iliac bifurcations), 6-months (22/22) and 1-year (11/11) was 100%. No death was reported for all patients at maximum follow-up. CERIB related EL rate was 3% (1/31 iliac bifurcations), with one case of gutter EL. Reintervention rate was 6.4% (2/31) during the follow-up; including one case of proximal stent extension and relining due to gutter EL and one case of EIA relining due to an asymptomatic stenosis.

CONCLUSIONS: CERIB technique showed excellent short-term and 1-year outcomes in terms of freedom from endoleak and patency rates. CERIB technique may be used as an alternative to iliac branch devices for IIA salvage during EVAR. Long-term surveillance is warranted.

• Keywords: abdominal aneurysm; iliac reconstruction

1.32.17. Long-Term Outcomes of Complex Abdominal Aortic Aneurysms Treated Using the Chimney Technique

• Konstantinos Tzimkas Dakis ¹, Konstantinos Spanos ¹, George Kouvelos ¹, Konstantinos Batzalexis ¹, Metaxia Bareka ², Eleni Arnaoutoglou ², Athanasios D. Giannoukas ¹ and Miltiadis Matsagkas ¹

1

Vascular Surgery Department, University Hospital of Larissa, Medical School of Larissa, University of Thessaly, Volos, Greece

2

Anesthsiology Department, University Hospital of Larissa, Medical School of Larissa, University of Thessaly, Volos, Greece

BACKGROUND AND AIM: The chimney endovascular aortic repair (ChEVAR) technique is an established endovascular option for complex AAA treatment. We present the long-term outcomes of the ChEVAR technique for the treatment of complex AAA in a single tertiary center.

METHOD: This is a retrospective analysis of prospectively collected data. All patients undergoing ChEVAR for juxta-, para-, and supra-renal AAA in a single-tertiary center during an 8-year time-period (March 2016–March 2024) were included. Primary outcomes were overall survival, primary patency of TV and freedom from type Ia endoleak (EL Ia) and were reported using Kaplan-Meier life tables.

RESULTS: A total of 74 patients (males: 95.9%, mean age: 72 ± 6.8 years old) underwent single (24.3%—18/74), double (37.8%—28/74) or triple (35.1%—26/74) ChEVAR were included. Aneurysm type included 29 juxtarenal (39.1%), 39 pararenal (52.7%), and six suprarenal (8.1%) AAA, while mean aneurysm diameter was 7.1 ± 2 cm. A total of 153 TV were implemented, including 60 (39.2%) right renal arteries, 65 (42.4%) left renal arteries, and 28 (18.3%) superior mesenteric arteries. Mean follow-up was 32 months (1–84 months). Overall survival rates at 1, 2, 3 and 5 years was 76.3%, 73.3%, 69.3%, and 47.7%, respectively. Primary TV patency rates at 2 and 5 years was 98.7%, and 92.5%, respectively. Freedom from EL Ia rates at 1 and 4 years was 96.7%, and 87.5%, respectively. A total of six aneurysm-related reinterventions were carried out: one case of a custom-made device deployment for EL Ia treatment, three cases of limb extension for EL Ib, and two cases of TV relining.

CONCLUSIONS: ChEVAR technique offers good mid- and long-term outcomes in terms of TV patency and freedom from endoleak type Ia. ChEVAR seems to be effective and durable during the long-term period, while survival rate of those patients might highlight the need for patients’ selection.

• Keywords: abdominal aneurysm; chimney; survival; endoleak; patency

1.32.18. Outcomes of Fenestrated and Branched Endovascular Aneurysm Repair with an Inverted Contralateral Limb

• Emiel Wietze Melle Huistra, Ignace F.J. Tielliu, Jean Paul P.M. De Vries and Clark J. Zeebregts
• Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands

BACKGROUND AND AIM: To report technical success and evaluate clinical outcomes of fenestrated and branched endovascular aortic repair (F/B-EVAR) incorporating a contralateral inverted limb.

METHOD: Patients who underwent F/B-EVAR with a custom-made bifurcated device containing an inverted limb between January 2010 and September 2023 were retrospectively analysed. All aneurysms had a short renal artery to bifurcation distance, either following previous aortic repair or without prior repair. Time-to-event data were analysed using the Kaplan-Meier method.

RESULTS: A total of 32 patients (26 men; mean age 77 ± 6.2 years) were included in the analysis. Technical success was achieved in 28 patients (87.5%). Two technical failures resulted from misplaced contralateral limbs in patients with previous endovascular aortic repair (EVAR), necessitating one open conversion and one femoro-femoral crossover bypass. Additionally, two technical failures were attributed to a type 3c endoleak and a type 1c endoleak. One patient (3.1%) died <30 days post-operatively due to a subdural haemorrhage. Estimated patient survival after 1 and 2 years was 92.7% ± 5.1%, and 74.3% ± 10.1%, respectively. No aneurysm-related deaths were observed. During the median follow-up of 13 months, two (6.3%) inverted limbs occluded and were treated with a femoro-femoral crossover bypass. One target vessel (right renal artery) occluded (0.9%), resulting in a permanent, significantly reduced renal function. Freedom from overall reintervention after 1 and 2 years was 73.5% ± 8.0% and 68.3% ± 9.0%, respectively. There were no junctional problems between the inverted limb device and the main endograft, and no significant correlation was found between the one-sealing-stent inverted limb device design and the onset of type 3 endoleak (log-rank p = 0.10).

CONCLUSIONS: F/B-EVAR incorporating a contralateral inverted limb can be performed with acceptable technical success and satisfactory outcomes. Extra caution should be paid to prevent damage to the renal stents. Carefully confirming correct cannulation of the inverted limb is warranted, particularly in patients with prior EVAR.

• Keywords: Abdominal aortic aneurysm; endovascular aortic repair; inverted contralateral (iliac) limb; fenestrated endografts; branched endografts; bifurcated device

1.32.19. Effects of Preemptive Embolisation of Side Branches on Preventing Type 2 Endoleaks After EVAR

• Eren Karpuzoglu, Naci Cem Aydogdu and Recep Caliskan
• Cardiovascular Surgery of Siyami Ersek Research and Training Hopsital, University of Health Sciences, Istanbul, Turkey

BACKGROUND AND AIM: EVAR has become the mainstay treatment method for abdominal aortic aneurysm (AAA). Type 2 Endoleaks (T2EL), sac filling due to side branches from the aneurysm sac, remains a controversial problem. Typically a benign condition, T2EL requires close follow-up and potentially leads to complications. We aim to see whether preemptive embolization in the same session with EVAR helps to prevent T2ELs.

METHOD: Seventy-seven patients who underwent elective EVAR for AAA between January 2018–December 2023 were included in the study. Two patients with complex interventions including TEVAR and surgical debranching were excluded. Group 1 consists of 20 patients who were embolized preemptively with EVAR, Group 2 consists of 55 patients who had EVAR solely. Both groups had follow-up CTA scans at the 1st and 6th month for sac growth and/or endoleak.

RESULTS: A total of 20 patients with 27 side branches were embolized. Fourteen Internal iliac arteries (IIA), 9 inferior mesenteric arteries (IMA), and 4 accessory renal arteries (aRA) were embolized. Chimney EVAR (ChEVAR) was performed in 5 patients. T2EL was detected in 2 patients in Group 1 (10%), and 15 patients in Group 2 (26%). Five patients were treated for sac progression due to T2EL, all of them are from Group 2 (9%). Two patients with T2EL in Group 1 were self-limited with a benign course and no sac progressions were seen.

CONCLUSIONS: Our results revealed a lower incidence of aneurysm sac growth, T2EL, and secondary interventions with preemptive embolization compared to no embolization. These results were consistent with the contemporary literature. However, these results do not alter the overall mortality rates. The feasibility of preemptive embolization versus secondary embolization in terms of morbidity, radiation exposure for both patients and interventionalists and, cost-effectiveness should be investigated in further multi-center studies.

Preemptive embolization could potentially improve long-term outcomes and reduce the frequency of surveillance.

• Keywords: Aortic Aneursym; EVAR; Embolisation; Type 2 Endoleak

1.32.20. Three-Dimensional Geometric Analysis of Viabahn VBX Bridging Stent Grafts in Fenestrated End-Vascular Aortic Repair: A Multicenter, Retrospective Cohort Study

• Fatima Fouad ¹, Ben R. Saleem ¹, Ignace F.j. Tielliu ¹, Matteo A. Pegorer ², Raffaello Bellosta ², Davide Esposito ³, Aaron T. Fargion ³, Clark J. Zeebregts ¹, Jean Paul P.m. De Vries ¹ and Richte C.l. Schuurmann ¹

1

Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

2

Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy

3

Department of Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy

BACKGROUND AND AIM: The primary aim of this study was to assess the 3-dimensional flare geometry of the Gore Viabahn VBX balloon-expandable covered stent (BECS) after fenestrated endovascular aortic aneurysm repair (FEVAR) and to determine and visualize BECS-associated complications.

METHOD: This multicentre retrospective study included patients who underwent FEVAR between 2018 and 2022 in three vascular centres. Patients with at least one visceral artery treated with the VBX and with availability of two post-FEVAR computed tomography angiography (CTA) scans (follow-up [FU 1: 0–6 months; FU2: 9–24 months]) were included. The flare geometry of the VBX, including flare-to-fenestration distance, flare-to-fenestration diameter ratio, flare angle, and apposition with the target artery were assessed using a vascular workstation and dedicated CTA applied software.

RESULTS: In total, 90 VBX BECS were analysed in 43 FEVAR patients. The median CTA follow-up for FU1 and FU2 was 35 days (IQR, 29–51 days) and 14 months (IQR, 13–15 months), respectively. The mean flare-to-fenestration distance was 5.6 ± 2.0 mm on FU1 and remained unchanged at 5.7 ± 2.0 mm on FU2 (p = 0.417). The flare-to-fenestration diameter ratio was 1.19 ± 0.17 on FU1 and remained unchanged at 1.21 ± 0.19 (p = 0.206). The mean apposition length was 18.6 ± 5.3 mm on FU1 and remained 18.6 ± 5.3 mm (p = 0.550). The flare angle was 31° ± 15° on FU1 and changed to 33° ± 16° (p = 0.009). On FU1, the BECS-associated complication rate was 1% and the BECS associated reintervention rate was 0%. On FU2, the BECS-associated complication rate was 3% and the BECS associated reintervention rate was 1%.

CONCLUSIONS: The flare geometry of the VBX bridging stent did not change significantly during 14 months follow-up. Three-dimensional geometric analysis of the flare may contribute to identify the origin of endoleaks and occlusions.

• Keywords: Aortic Aneurysm; Abdominal; Aneurysm Repair; Endovascular; Fenestrated Endovascular Aneurysm Repair; Endoleak; Three-Dimensional Imaging

1.32.21. Isolated Left Internal Iliac Artery Mycotic Aneurysm Presented as a Large Retroperitoneal Hematoma

• Mohamed Shafi Mahboob Ali
• Department of General Surgery, Advanced Medical and Dental Institute (AMDI), Penang, Malaysia

INTRODUCTION: Mycotic aneurysm is very rare in the new era of antibiotics. Commonest micro-organism that is associated with this pathology is Salmonella species. The predilection of salmonella species for the arterial wall is due to the pre-existing atherosclerotic plaques or ulcerations that disturbed the intimal layer of the vessel.

METHODOLOGY: With the discoveries of endovascular stents the mortality from open surgery has went down. There were cases reported where these endovascular stents been infected and resulting in severe complications and ultimately needs removal.

RESULTS: A 55 years old gentleman was referred to our center with the complaint of progressive left lower abdominal pain and swelling, fever with weakness of left lower limb. Blood culture grew salmonella species and patient was started on intravenous Cefoperazone. Clinically there was a pulsatile swelling (15 × 15) cm at the left side of the abdomen. CT angiography showed a left internal iliac artery aneurysm sized (6.5 × 4.0) cm with internal thrombus. Retroperitoneal hematoma was evacuated, necrotic tissues debrided and the left common iliac vessel ligated. Histopathology showed fragments of cellular debris with fibro-collagenous tissue and moderate infiltrations by lympho-plasma cells.

DISCUSSION: Mycotic aneurysm is a focal dilatation of a blood vessel due to salmonella species. Expansile swelling with pulsation and a positive blood culture is diagnostic. Laboratory findings are leukocytosis, elevated C-reactive proteins, ESR and neutrophil counts. CT-tomography is the choice of imaging that is used in diagnosing a mycotic aneurysm.

• Keywords: Mycotic; Aneurysm; Infection

1.32.22. FEVAR of Juxtarenal Abdominal Aortic Aneurysm with Coexisting Horseshoe Kidney

• Almahdi Ali and Stephan Langer
  Vascular Surgery Department, Marien-Hospital Witten, Witten, Germany

Case Presentation: A 62-year-old asymptomatic patient was referred for further evaluation due to sonographic suspicion of AAA. Arterial hypertension was a risk factor for cardiovascular disease.

B-mode sonography confirmed a partially thrombosed infrarenal AAA with a maximum diameter of about 6 cm in the “leading edge” method. Aneurysms of other arteries such as A. poplitea were excluded by duplex sonography.

A computed tomography angiography (CTA) was performed to further clarify the morphology and for preoperative planning. A juxtarenal AAA with a diameter of 63 mm was confirmed and the coexistence of a horseshoe kidney was discovered.

Diagnosis: Juxtarenal abdominal aortic aneurysm with coexisting horseshoe kidney

Procedure details: The patient had asymptomatic concomitant abdominal aortic aneurysm (AAA) and horseshoe kidney. We perform an endovascular repair of the aneurysm under general anaesthesia. After appropriate measurement of the CTA with a measurement software, we decided to avoid the open surgery for an endovascular elimination with a double fenestrated stent graft (FEVAR) with an anaconda endoprosthesis (Terumoaortic Inchinnan, Scotland, UK).

Procedure outcomes: Postoperative CTA showed proper seating of the placed implants, no evidence of endoleak and patent stents in the two renal arteries. Discharge was uncomplicated on day 4 with provision of dual antiplatelet therapy for 6 months.

Keywords: horseshoe kidney; FEVAR; juxtarenal abdominal aortic aneurysm

1.32.23. Incidental Horseshoe Kıdney in Leriche Syndrome: A Successful Surgical Treatment

• Mustafa Can Sofuoğlu, Emine Turhan, Mine Demirbaş and Sefer Usta
  SBU Trabzon Ahi Evren GKDC Education Hospital, Trabzon, Turkey

Leriche syndrome, known as occlusive disease of the infrarenal aorta, usually presents with claudication. Although isolated Leriche syndrome is quite common, the association with horseshoe kidney is rare. The neck of the horseshoe kidney, which usually contains a functioning, although occasionally non-functioning, parenchyma, makes abdominal aortic surgery challenging. A 56-year-old man with Leriche syndrome and horseshoe kidney underwent successful aortic surgery and horseshoe kidney separation. A median incision was used for exploration of the abdominal aorta, iliac arteries and horseshoe kidney. The neck of the horseshoe kidney was located at the infrarenal level, above the site of the cross clamp and proximal anastamosis. Separation of the horseshoe kidney neck and aortabifemoral bypass were performed. The operation and postoperative hospitalization were uneventful.

• Keywords: Leriche syndrome; Horseshoe kidney; Aortabifemoral bypass

1.32.24. Hybrid Surgery for the Treatment of Thoracoabdominal Aortic Aneurysms

• Qingwei Ding ^1,2, Zhiwei Zhang ¹, Haixiang Li ¹, Feng Zhu ¹, Weiye Bi ¹, Hui Zheng ¹, Xiaoyu Zhang ¹ and Qingyou Meng ¹

1

Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

2

Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany

OBJECTIVE: To explore the efficacy of hybrid surgery in treating thoracoabdominal aortic aneurysms.

METHODS: 67 patients with thoracoabdominal aortic aneurysms treated with hybrid surgery at the Department of Vascular Surgery, Shanghai General Hospital from 2016 to 2023 were included. The surgical approach was modified through incision design, reducing anastomosis sites, utilizing improved VORTEC technique, reconstructing lumbar arteries, and deploying endovascular stents through visceral artery fenestration.

RESULTS: Among the 67 patients, there were 52 males and 15 females, with 2 cases of infective thoracoabdominal aortic aneurysms. One case was treated using antegrade hybrid technique, while 66 cases were treated using retrograde technique. 62 cases underwent one-stage stent placement, and 5 cases underwent two-stage stent placement. Complications included renal failure in 7 cases, with 6 cases improving after continuous renal replacement therapy (CRRT) and 1 case requiring permanent dialysis; intestinal necrosis in 2 cases, both treated with colectomy and subsequent reconstruction; and paraplegia in 2 cases. There were 4 deaths (1 case of pulmonary embolism, 1 case of myocardial infarction, 1 case of heart failure, and 1 case of airway hemorrhage).

CONCLUSIONS: Hybrid surgery is an effective treatment for thoracoabdominal aortic aneurysms, and modified techniques can improve patient outcomes.

• Keywords: thoracoabdominal aortic aneurysms; hybrid surgery

1.32.25. Ruptured Abdominal Aortic Aneurysms: Surgical Treatment over the Past 6 Years

• Annalisa Barichello
• Department of Vascular Surgery, Cà Foncello Hospital, Treviso, Italy

INTRODUCTION: Ruptured abdominal aortic aneurysm has an overall mortality of 30–50%. Treatment involves “open” surgery or endovascular treatment.

OBJECTIVE: To retrospectively compare the immediate, 30-day, 3-month and 6-month outcomes of patients treated with traditional ’open’ surgery or endovascular repair.

MATERIALS-METHODS: Sixty-four patients with CT-confirmed ruptured abdominal aortic aneurysm treated at Treviso Vascular Surgery, Cà Foncello Hospital, between July 2017 and July 2023 were examined.

23 patients underwent EVAR and 41 underwent open repair. 36% of patients were hemodynamically unstable on arrival (EVAR 30%, OPEN 39%) and 64% stable (EVAR 70%, OPEN 61%). 21% of EVAR procedures started under local anesthesia and 100% of OPEN repairs under general anesthesia. Overall, the primary endpoints of the study are 30 day, 3 month, and 6 month mortality, overall reintervention rate, and postoperative complications during hospital stay.

CONCLUSIONS: Overall, of the 64 patients enrolled in the study, the average aneurysm diameter at arrival was 7.6 cm (EVAR 8.5 cm, OPEN 7 cm).

The recorded intraoperative mortality was 2% (OPEN 100%), also inferring the high survival rate at 30 days with a mortality of 6% (EVAR 5%, OPEN 7%), at 3 months of 11% (EVAR 10%, OPEN 11%) and at 6 months of 12% (EVAR 15%, OPEN 11%).

The most frequently recorded postoperative complications during hospitalization are pneumonia in 16% (EVAR 11%, OPEN 5%), hypertension in 8% (OPEN 100%), need for reintervention in 6% (EVAR 2%, OPEN 5%) for bleeding or type endoleak corrections.

• Keywords: ruptured abdominal aortic aneurysms; mortality

1.32.26. Surgical Treatment of Infective Abdominal Aortic Aneurysm

• Qingwei Ding ^1,2, Zhiwei Zhang ¹, Haixiang Li ¹, Feng Zhu ¹, Weiye Bi ¹, Hui Zheng ¹, Xiaoyu Zhang ¹, Weiye Bi ¹ and Qingyou Meng ¹

1

Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

2

Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany

OBJECTIVE: To compare the outcomes of various surgical techniques for managing infective abdominal aneurysms.

METHODS: 19 patients with infective abdominal aneurysms who underwent treatment at the Department of Vascular Surgery, Shanghai General Hospital between 2021 and 2023 were included in the study.

Methods: Nineteen patients with infective abdominal aneurysms who underwent treatment at the Department of Vascular Surgery, Shanghai General Hospital between 2021 and 2023 were included in the study.

RESULTS: Among the 19 patients, 4 had primary infective abdominal aneurysms, while 15 had endograft infections. Treatment modalities included endovascular treatment in 2 cases, hybrid surgery in 2 cases, and open surgery in 15 cases. Procedures included axillo-bifemoral bypass combined with infective abdominal aneurysm resection in 2 cases, in-situ reconstruction with bovine pericardium in 1 case, omentum-wrapped artificial vessel reconstruction in 1 case, bovine pericardial wrapping and artificial vessel reconstruction in 1 case, rifampicin-bonded artificial vessel in-situ reconstruction in 3 cases, and femoral vein reconstruction of the abdominal aorta combined with infective abdominal aneurysm resection in 6 cases. Additionally, in one case, the stent was not removed, and infectious focus clearance was performed. In another case, partial stent removal was performed, followed by omentum wrapping to isolate the infectious focus. One-stage surgery was successful in 15 cases, while 4 cases resulted in fatalities. The average hospital stay was 44.2 days, with an average surgical duration of 493 min and an average blood loss of 3210.4 mL. Postoperative antibiotic usage averaged 30.6 days.

CONCLUSIONS: Femoral vein reconstruction of the abdominal aorta proves to be an effective method for treating infective abdominal aneurysms. Axillo-bifemoral bypass, rifampicin-bonded artificial vessel replacement, hybrid surgery, and stent placement are suitable alternatives for select patients with infective abdominal aneurysms.

• Keywords: infective abdominal aneurysm; endograft infection

1.32.27. Endovascular Therapy in Complicated Aortic Disease—Our Department Experience

• Konstantinos Maltezos, Sotirios Giannakakis, Anna Pachi, Apostolos Chaveles, Anastasios Papapetrou, Stavros Kerasidis, Iliana Doukogianni and Chrysostomos Maltezos
• Vascular Surgery Department, KAT General Hospital, Athens, Greece

BACHGROUND: Nowadays, the endovascular therapy is a promising technique in revascularization of aortic arch branches, visceral arteries and internal iliac arteries in complicated aortic disease.

AIM-METHOD: Five patients who were admitted to our department between February 2021 and September 2023 were enrolled in this study. The patients suffered from traumatic thoracic aortic dissection, thoracic aortic aneurysm, thoracoabdominal aneurysm, abdominal aortic aneurysm and common iliac aneurysm.

RESULTS: In our study totally 5 patients were included. All patients were men and the mean age of patients were 70 years. Concerning to comorbidities, their pertinent medical history included main the arterial hypertension and the dyslipidemia. The first patient presented a thoracic aortic dissection. The second patient presented a thoracic aortic aneurysm. The third one had a thoracoabdominal aneurysm. The fourth patient presented an abdominal aortic aneurysm with a large auxiliary renal artery. And the last one had a large aneurysm in left common iliac artery. All patients underwent in advanced endovascular repair. In three patients was applied the chimney technique to be revasculated the left subclavian artery and the large auxiliary renal artery. In the patient with thoracoabdominal technique, it was used a fenestrated graft with inside branches to be revasculated the renal arteries and the superior mesenteric artery. And in the last one, it was used an iliac branched endoprothesis.

We had 71% technical success. At the follow-up of one year, an 80% primary patency and 100% assisted primary patency.

CONCLUSIONS: Nowadays, the advanced endovascular technique is a promising minimal invasive method to repair the complicated aortic disease. In the literature, the results for the technical success and the grafts’ potencies are very encouraging. However, it is necessary to be educational and familiar with these techniques. The open repair is remaining a reliable solution.

• Keywords: Endovascular treatment; complicated aortic disease

1.32.28. Natural Post-EVAR Regression of Abdominal Aortic Aneurysm Cause Bending Illiac Extensions of Stentgraft

• Andrzej Plonski and Grzegorz Madycki
• Department of Vascular Surgery and Angiology, Centre of Postgraduate Medical Education, Warsaw, Poland

65 year old male admitted to Emergency Room due to abdominal pain since 6 h. In Ultrasound (USG doppler) a huge abdominal aortic aneurysm (AAA) was detected. AAA was confirmed in angiocomputedtomography (angioCT, max. horizontal diameter 69 × 70 mm, infrarenal). The other couses of abdominal pain were excluded (e.g., gastrointestinal obstruction or urinary trackt inflamation).

Comorbidities: asthma, 4 laparotomies in the past (due to perforation of duodenum and intraabdominal abscesses), stroke years ago, constant Deep Vein thrombosis of the left lower extremity. Medication taken: Acenokumarol. Because of history of previous abdominal operations, high risk of total general anestesia (ASA 4) and optimal anatomical features of abdominal aortic aneurysm including proximal and distal landing zones, patients was qualified to Endovascular Aneurysm Repair (EVAR). Operation was performed by experienced team of vascular surgeons, in local anestesia. Aortoiliac stentgraft system-Medtronic Endurant was implanted. Further hospitalization was free from complications. Patient did not need hospitalization in Intensive Care Unit (ICU). 10 days after exiting Vascular Surgery Ward, stitches in groins were removed. Each year after operation, patient was obtaining USG doppler of AAA and stentgraft. Each year no leak was found and AAA was fully closed with the normal blood flow throughout stentgraft. Five years after EVAR patient obtained angioCT. The AAA was fully closed, no leak was found. The horizontal dimensions were slightly smaller (AP × LR 45 × 40 mm). Suprisingly the axial diameter (caudal-cranial) was shorter by 30 mm. Proximal and distal landing zones were located at the same spots as it was in angiography during EVAR. Shortening of the dimensions of the aneurysm caused the iliac extentesions of stengraft to bend in S-shaped pattern. Moreover both iliac extensions and femoral arteries were filled with contrast. Patient denied intermittent claudication and the pulse was palpable on feet.

• Keywords: EVAR Regression Aortic Abdominal Aneurysm

1.32.29. A Rare Complication of EVAR: Migration of the Endograft into the Duedonum

• Hakan Usta ¹, Furkan Çelik ¹, Eyüp Serhat Çalık ¹, Ümit Arslan ¹ and Rıfat Peksöz ²

1

Department of Cardiovascular Surgery, Atatürk University Faculty of Medicine, Erzurum, Türkiye

2

Department of General Surgery, Atatürk University Faculty of Medicine, Erzurum, Türkiye

BACKGROUND: EVAR is a treatment method that is increasing in popularity because it is easily applicable, shortens hospital stays and is a good alternative for patients who cannot tolerate surgery. Although the early results of EVAR are better compared to open surgery, complications such as endoleak, migration, thrombosis/twisting of endograft legs and graft infection may occur.

Case Presentation: A 73 year old male patient was admitted to our hospital with complaints of general deterioration, melena, and fever. The patient had a history of coronary stenting and EVAR. Patient’s laboratory findings were WBC: 17,100, Hgb: 9.5, Crp: 261. CT imaging showed that stents of the EVAR graft were broken and came out of the vessel. It was seen that the EVAR graft had migrated and fistulized to the duodenum. The patient was operated with the simultaneous participation of cardiovascular surgery and general surgery clinics. Rupture in the sigmoid colon and contamination in the abdomen were observed. The aorta was released and a cross clamp was placed below the renal artery level. After the aortotomy the proximal part of the endograft and its left leg were removed. The duodenum was opened and the right leg of the graft was removed. There was no need for Whipple prodecure. The endograft was filled with thrombus. Since there was no distal ischemia before surgery, the aorta was ligated at the infrarenal level. At the same time, the sigmoid colon and rectum were excised and a colostomy was performed. The operation was terminated and the patient was taken to intensive care. The patient developed sepsis and died at the 8th hour postoperatively.

• Keywords: Endograft migration; graft-enteric fistula; endograft infection

1.32.30. Endovascular Treatment of Abdominal Aortic Stenosis Caused by Takayasu Arteritis

• Ugur Cetingok ¹, Fatih Yamac ² and Ahmet Bulent Saritas ²

1

Department of Cardiovascular Surgery, Etlik City Hospital, Ankara, Türkiye

2

Department of Cardiovascular Surgery, Sincan Training and Research Hospital, Ankara, Türkiye

Takayasu arteritis is a rare, chronic, inflammatory vasculitis that primarily affects large arteries, causing significant morbidity and mortality. It is most common in young women in the second and third decades. Clinical findings vary depending on the extent and location of the affected artery. Treatment is medical and/or surgical or endovascular treatment. A 38 years old woman was presented with the complaint of claudication after walking 50 m. Both femoral and distal pulses were absent. The patient had been followed for 4 years due to Takayasu disease. Computerized tomography angiography was demonstrated stenosis of the abdominal aorta. Abdominal aorta was narrowed to 6 mm in diameter from just below the renal arteries to the iliac bifurcation. A Jotec E-XL self-expandable open-cell, uncovered aortic stent with a diameter of 18/16/18 mm was placed through the right femoral artery from the suprarenal to the iliac bifurcation. Remodeling was performed with an aortic balloon. It was observed that full patency of the aorta was achieved after aortic stent implantation. Lower extremity pulses were positive after the procedure. The patient was discharged on postoperative first day with clopidogrel 75 mg and acetylsalicylic acid 300 mg daily. The CT angiography performed 2 months later, the stent was fully expanded. The endovascular treatment of Takayasu arteritis must be the first treatment option in suitable patients. Because of it has low complication rates, it can be performed with local anesthesia, the procedure time is short, the patient can return to normal life in a short time and many other advantages.

• Keywords: Takayasu arteritis; arterial stenosis; endovascular treatment

1.32.31. A Rare Case: Coarctation-Associated Abdominal Aortic Aneurysm

• Ugur Cetingok ¹, Abdulkadir Guzel ², Zeynep Ucar ² and Ibrahim Koray Unal ²

1

Department of Cardiovascular Surgery, Etlik City Hospital, Ankara, Türkiye

2

Department of Cardiovascular Surgery, Sincan Training and Research Hospital, Ankara, Türkiye

Coarctation of the abdominal aorta is segmental narrowing of the abdominal or distal descending thoracic aorta. It is a congenital anomaly or associated with neurofibromatosis, retroperitoneal fibrosis, fibromuscular dysplasia, mucopolysaccharidosis, and Takayasu’s arteritis. Coarctation-associated aneurysms are rare. It is usually occurs in thoracic aortic coarctations. Only 2% of these aneurysms are due to abdominal aortic coarctation. A 62-year-old man presented with intermittent abdominal pain and swelling. An abdominal pulsatile mass of 6 × 7 cm in diameter was detected. His femoral and distal pulses were palpable. The computed tomography angiography revealed a 6 cm diameter infrarenal aortic aneurysm. It had expanded into an hourglass shape. The patient underwent elective surgery. When the aneurysm sac was opened, abdominal aortic coarctation was observed. A standard aortobifemoral bypass was performed. Coarctation-associated aneurysms can be treated with surgery or endovascular methods. The anatomical structure of the lesion and the condition of the patient are taken into consideration when choosing the treatment method. We present this patient because it is a rare condition.

• Keywords: coarctation; aneurysm; abdominal

1.32.32. Usage of Pericardial Patch and Cytokine Filter in Infected Endovascular Graft

• Izatullah Jalalzai, Ali Şahin, Ebubekir Sonmez, Zeliha Işık, Eyupserhat Calik and Ümit Arslan
• Department of Cardiovascular Surgery, Ataturk University Research Hospital, Erzurum, Turkey

BACKGROUND: The use of endovascular aneurysm repair (EVAR) has emerged as a recognized substitute for open repair in the management of abdominal aortic aneurysm, despite the presence of anatomical factors that may limit its efficacy. Existing data indicate that endovascular repair is linked to a decreased incidence of all-cause mortality within 30 days after surgery, as well as a notable decrease in perioperative morbidity, in comparison to open surgery. Moreover, EVAR results in less hemorrhage, avoids the need for aortic cross-clamping, and entails shorter recovery durations compared to conventional surgery. In addition to their efficacy as a surgical alternative, endografts may give rise to several complications, including endoleaks, thrombosis of the endograft, and graft infection.

Case Presentation: A 76-year-old male patient was admitted to our hospital with complaints of repeated fever and abdominal pain. The patient had undergone EVAR four years ago. The patient’s laboratory findings were WBC: 21,000, Hgb: 12.6 mg/dL, and Crp: 188. CT imaging showed that the EVAR graft was infected, broken, and thrombosed. The operation was planned. The aorta was released, and a cross clamp was placed below the renal artery level. After the aortotomy, the proximal part of the endograft was removed and replaced with an aorto-bi-iliac graft, which was covered with a pericardial patch. Postoperatively, sepsis and acute kidney injury developed, and the patient underwent hemofiltration with Jafron HA330 cytokine filter. The patient was discharged and had no complications in his 1-year follow-up.

In general, using hemoperfusion to treat septic shock and covering newly replaced infected grafts with a pericardial patch can reduce the length of stay in the intensive care unit, morbidity, and mortality

• Keywords: EVAR Graft Infection; Cytokine Filter; Pericardial Patch

1.32.33. Mycotic Aortic Aneurysm in a 32-Week Pregnant Patient with Prior MVR with Brucella Endocarditis

• Izatullah Jalalzai, Ibrahim Pir, Mohammed Çağrı Aykut, Eyupserhat Çalık and Ümit Arslan
• Department of cardiovascular surgery, Ataturk University, Erzurum, Turkey

BACKGROUND: A minority of abdominal aortic aneurysms are comprised of inflammatory aneurysms and mycotic aneurysms. The pathophysiology of inflammatory aneurysms is primarily attributed to autoimmune mechanisms, and it is not common to investigate infectious agents as potential causes of the disease.

Case presentation: A 31-year-old, 32-week pregnant female patient was admitted to our department for a pre-diagnosis of saccular dilatation in the bifurcation of abdomino-iliac arteries in her incidental routine gestational ultrasound checkup. She had undergone mechanical mitral valve replacement 5 years ago due to infective endocarditis. Later, the microbiological specimen was reported as Burcella and she was on warfarin. Computed tomography (CT) was ordered after consultations in radiology and gynecology. The CT showed a 43 × 36 mm axial and 65 mm longitudinal saccular non-thrombosed saccular aneurysm located at the aortic bifurcation. After a multidisciplinary approach with gynecology, an operation was planned. The patient was operated on with the simultaneous participation of cardiovascular surgery and gynecology clinics. The baby was delivered through a cesarean section, the saccular aneurysm was removed, and an aorto-bi-iliac graft was applied after cross-clamping the aorta and iliac arteries. The patient was discharged and was uneventful in her 2-year follow-up.

• Keywords: Mycotic Aortic Aneurysm; Pregnancy; MVR

1.32.34. Open Surgical Conversion Following Type 1 Endoleak

• Ahmet Aydın and Nazlı Melis Coşkun Yücel
• Department of Cardiovascular Surgery, Hacettepe University, Ankara, Turkey

Endoleak, a common complication after EVAR, can usually be treated with interventional methods. However, every patient doesn’t suit for endovascular treatment, and surgical conversion may be necessary. We present our surgical method, including partial graft excision.

A male patient who had undergone EVAR presented with abdominal/back pain. Type 1 endoleak was detected within the aneurysm sac. The patient underwent percutaneous endoleak treatment, which was unsuccessful. Due to previous unsuccessful endoleak treatments and the proximity of the EVAR graft to the renal arteries, endovascular intervention wasn’t eligible. During surgery, clamps were placed just below the renal arteries and around the main iliac arteries on both sides to include the legs of the EVAR graft. The proximal hooks of the EVAR graft were detached from the aortic Wall. A piece of fabric between two metal rings was cut just before the bifurcation of the EVAR graft. The proximal end of the PTFE graft was anastomosed with the native aortic tissue, and the distal end was anastomosed with the EVAR graft. To strengthen the anastomosis, approximately 2 cm of the PTFE graft distal to the anastomosis was folded outward, after the anastomosis, the graft fold was opened to serve as a protective layer on the EVAR graft.

AAA is increasingly being treated by endovascular means. Factors such as the comorbid conditions of AAA patients, the complications of surgical interventions, the short recovery time of endovascular procedures, and the short hospital stay after endovascular procedures are contributing to this trend. However, when endovascular procedures fail, the surgeon faces a much more complex pathology. According to the literature, re-intervention after endoleak remains the primary treatment approach. However, when endovascular procedures fail, the patient has no choice but surgery. Total excision of the EVAR graft is generally preferred in surgeries. However, it isn’t possible in every patient. During surgical conversion after EVAR, partial excision of the graft and anastomosis to this graft is a reliable option.

• Keywords: EVAR; Type 1 endoleak; AAA surgery; Surgical intervention after EVAR

1.32.35. Sac Embolisation and Type-1a Endoleak Repair with Glue-Lipiodol Injection by Transabdominal Direct Puncture: A Complex Case Report

• Çağla Canbay Sarılar ¹, Celal Caner Ercan ², Birol Akdoğan ¹, Merve Doğru ¹, Mehmet Semih Çakır ², Elshad Babazade ¹, Bülent Acunaş ² and Nilgün Bozbuğa ¹

1

Department of Cardiovascular Surgery, İstanbul Faculty of Medicine Hospital, İstanbul University, İstanbul, Türkiye

2

Department of Radiology, İstanbul Faculty of Medicine Hospital, İstanbul University, İstanbul, Türkiye

BACKGROUND: High-risk type 1a, 1b, III endoleaks requiring urgent intervention are one of the most common causes of secondary interventions; they should be repaired when detected.

CASE PRESENTATION: A 71-year-old polymorbid patient who underwent EVAR for infrarenal AAA six years ago presented to the emergency department. CTA showed 9 mm distal migration of the EVAR stent graft (SG) and contrast leakage consistent with a type 1a endoleak (EL1a).

In the first attempt, a proximal extending cuff SG was impelled proximally from the right CFA. In the control imaging, it was observed the leak persisted and apposition was performed with Reliant balloon. Tissel Lyo injection and coil were applied to the localisation with active turbulent flow by USG-guided puncture with transabdominal percutaneous approach to the sac. Control imaging showed persistence of leakage; the procedure was terminated because of the risk of contrast-induced AKI.

3 weeks later, RDUSG showed persistence of EL1a. It was decided to perform balloon apposition procedure to the proximal SG and transabdominal direct puncture to the aneurysm sac with coil + liquid embolising agent. In the second session, a Reliant balloon was propelled to the proximal aneurysm with access from the left CFA. Transabdominal puncture was performed in the aneurysm sac where active turbulent flow was observed on RDUSG. The EL1a origin point was entered in the neck of the aneurysm with a microcatheter through the acoustic triaxial set. A frame was created with multiple coils. The flow was briefly interrupted with a reliant balloon. Under fluoroscopy, coils and dens glue-lipiodol liquid embolising mixture were administered via microcatheter. No EL1a was observed in control imaging. Thrombosis of the aneurysm sac was confirmed.

CONCLUSIONS: In polymorbid patients with persistent EL1a, embolisation of the aneurysm sac with coils and glue through transabdominal direct puncture can be safely performed.

• Keywords: Endoleak; Sac embolization; Transabdominal approach; Glue embolization; Abdominal aortic aneursym

1.33. VASCULAR AND ENDOVASCULAR » AV Access

1.33.1. Arteriovenous Fistula Aneurysm Surgery; Can We Do It More Common with Tumescent Anesthesia? Our VAS Scores Are Acceptable

• Ferit Kasimzade ¹ and Seda Kurtbeyoğlu²

1

Department of Cardiovascular Surgery, Ministry of Health Türkiye Republic Ankara Bilkent City Hospital, Ankara, Turkey

2

Department of Anesthesiology, Ministry of Health Türkiye Republic Ankara Bilkent City Hospital, Ankara, Turkey

BACKGROUND AND AIM: Treatment of arterio venous fistula aneurysms in hemodialysis patients is still at the level of expert opinion according to the guidelines. In the literature, operations are generally performed under general anesthesia;

In this selected group of patients, especially stenosis and aneurysmatic segments are together. It requires large incisions, most of the vascular repair methods are applied and may take a long time.

We aimed to examine whether the use of tumescent anesthesia is acceptable in terms of surgical pain in patients undergoing Valenti type 3 fistula aneurysms surgery and examined it according to VAS score results.

METHOD: We examined 25 patients with surgical procedure in the 42–67 age range (Valentine Classification Type 3 Fistula Aneurysm). In these procedures, subcutaneous tumescent anesthesia (20 mL of prilocaine diluted with saline to a total of 80 mL) injection area and the incision line are routinely mapped. Pain scoring chart during the operation of the patients retrospectively examined. In all patients, surgical techniques such as binding, resection re-anastomosis and pilication were performed. The operation period lasted between 45–86 min. All Vas Score values were retrospectively examined.

RESULTS: The VAS scores were four and below, and the intraoperative hemodynamic parameters were found acceptable. Tumescent anesthetic substance prepared and applied as 80 mL provided an effective analgesia and addiitional surgical dissection comfort area under the skin.

CONCLUSIONS: In patients undergoing fistula aneurysm surgery, the use of tumescent anesthesia provides additional ease of surgical dissection and has acceptable VAS score results in terms of pain.

• Keywords: arteriovenous fistula aneurysm; tumescent anesthesia; Arteriovenous fistula aneurysmorrhaphy

1.33.2. Our Experience with Optimizing AV Fistula Function: A Case Series of Angioplasty and Collateral Vein Ligation

• Juliana Juliana ¹ and Yosis Yohannes Motulo ²

1

Faculty of Medicine, Airlangga University, Surabaya, Indonesia

2

Cardiothoracic and Vascular Surgery Department of PHC General Hospital, Surabaya, Indonesia

BACKGROUND: Arteriovenous (AV) fistulas are crucial lifelines for hemodialysis patients, facilitating the effective removal and return of blood during dialysis sessions. However, AV fistula maturation failure, characterized by insufficient blood flow and vessel dilation, remains a significant challenge in clinical practice. Stenosis and venous branch insufficiency are key contributors to AV fistula immaturity, necessitating interventions to optimize vascular access. Traditional approaches have often addressed these issues independently, warranting exploration of combined strategies to enhance AV fistula maturation.

CASE: The case series included 20 hemodialysis patients aged between 39 and 60 years old, predominantly male, with comorbidities such as diabetes, hypertension, and peripheral artery disease (PAD). The initial fistula maturation period averaged 6 weeks, during which patients exhibited varying degrees of stenosis and venous branch insufficiency. Follow-up examinations were conducted 1 week after the angioplasty and vein ligation procedure, with a subsequent average final maturation period of 6 weeks. The combined intervention involved angioplasty to address stenosis, aiming to improve the fistula outflow, followed by the ligation of collateral veins using a silk braided 3.0 suture to optimize blood flow dynamics. This approach demonstrated promising outcomes in enhancing AV fistula maturation, with all cases showing success in fistula maturation and improved functionality observed during the follow-up period. These findings underscore the potential of a holistic approach to AV fistula management, aiming to improve patient outcomes and long-term dialysis efficacy.

• Keywords: AV fistula; Hemodialysis; Angioplasty; Collateral vein ligation; Fistula maturation; Vascular access

1.34. VASCULAR AND ENDOVASCULAR » Carotid Disease

Simple and No Plaque Touch Shunting in Patients Undergoing Carotid Endarterectomy and Requiring Shunt: The Jalalzai Technique

• Izatullah Jalalzai, Hakan Usta, Ebubekir Sonmez, Umit Arslan and Eyupserhat Calik
• Department of Cardiovascular Surgery, Ataturk University Research Hospital, Erzurum, Turkey

BACKGROUND AND AIM: During carotid endarterectomy, the application of traditional shunt techniques may occasionally impede carotid artery surgery. To achieve this objective, a novel and uncomplicated shunt method can be readily executed by inserting one arterial cannula into the internal carotid artery distally to the clamp, and another into the common carotid artery proximally to the clamp.

METHOD: In 38 consecutive patients who need shunting during carotid endarterectomy operation; prior to the application of clamps, the presence of plaques in both the common carotid artery and the internal carotid artery was verified using gently palpation. Following the placement of the cross, a 16-gauge or 14-gauge branule was inserted into the plaque-free region of the internal carotid artery to measure the stump pressure. A second granule was attached to the back of the initial granule using a short line and a 3-way stopcock. This second granule was positioned near the cross clamp on the common carotid artery. With this 3-way stopcock shunt, flow was provided from the main carotid artery to the internal carotid artery simultaneously with stump pressure and systemic pressure

RESULTS: The mortality rate was 0/38 in the first 30 days of discharge from hospital. All patients were monitored with Near Ifrared Sprectoscopy and stamp pressure during operation. None of the patients had any cerebrovascular event post operation.

CONCLUSIONS: In addition to offering a bloodless surgical site, this straightforward approach can be utilized for patients undergoing carotid endarterectomy who necessitate shunting during the procedure. However, this procedure may provide difficulties in individuals with proximal plaque and calcifications in the internal carotid artery.

• Keywords: Carotid Endarterectomy; Plaque; Shunt

1.35. VASCULAR AND ENDOVASCULAR » Carotid Disease

1.35.1. Carotid Arteries Atherosclerotic Lesion Morphology (Detected with Contrast-Enhanced Ultrasound) Importance to Stent Restenosis

• Agnė Gimžauskaitė ¹, Aistė Maičiulaitytė ¹, Gintautė Diringytė ², Saulius Lukoševičius ³, Rytis Kaupas ³, Andrius Pranculis ³, Jurgita Plisienė ⁴, Algidas Basevičius ³, Donatas Inčiūra ¹ and Milda Kuprytė ⁵

1

Department of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania

2

Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania

3

Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania

4

Department of Cardiology Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania

5

Department of Pathological Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania

BACKGROUND AND AIM: Carotid artery stenosis poses a significant risk for ischemic strokes, necessitating effective management strategies such as carotid endarterectomy (CEA) and carotid artery stenting (CAS). However, controversies persist regarding their comparative efficacy and factors influencing post-procedural complications. Understanding the relationship between atherosclerotic plaque characteristics and stent restenosis following CAS is vital for optimizing patient care.

METHOD: In our retrospective study of 221 patients undergoing CAS for symptomatic or asymptomatic carotid artery stenosis, comprehensive assessments of plaque morphology using contrast-enhanced ultrasound (CEUS) were conducted before CAS. Patient demographics, including smoking status and diabetes, were also recorded. Stent restenosis was diagnosed using various imaging modalities, including ultrasound, angiography, and digital subtraction angiography (DSA).

RESULTS: Plaque analysis revealed a significant correlation between plaque type and restenosis incidence (p < 0.001), notably with type 0 (11.1%) and type 2 plaques (66.7%). Smoking was significantly associated with plaque vascularization and restenosis (p < 0.001), while diabetes did not significantly impact plaque characteristics or restenosis risk (p > 0.05). The average duration of restenosis was 17.67 months, with angiography and ultrasound commonly used for diagnosis, showing significant differences (p = 0.016). Stenting was the predominant treatment for restenosis (70.6%), although no significant relationship was found between restenosis type and plaque morphology (p = 0.268). Furthermore, while no clear relationship was observed between plaque morphology and the type of restenosis, our findings underscored the importance of plaque characterization in predicting post-CAS outcomes.

CONCLUSIONS: This study highlights the utility of CEUS in assessing plaque vulnerability and predicting stent restenosis following CAS. There is a significant correlation between the occurrence of stent restenosis within 12–24 months after the carotid stenting procedure and the presence of an elevated grade of plaque vascularization. Further research is needed to elucidate underlying mechanisms and refine risk stratification in this patient population.

• Keywords: contrast-enhanced ultrasound; carotid stenting; carotid stent restenosis; carotid artery disease

1.35.2. Hemodynamic and Hearing Disorders in the Initial Manifestations of Vertebrobasilar Insufficiency

• Feruza Mirzaxodjayevna Aripova ¹, Alimjon Mustafoqulovich Axmatov ¹, Abdurasul Abdujalilovich Yulbarisov ² and Alijon Tirkashaliyevich Rizayev ¹

1

Republican Specialized Center for Surgical Angioneurology, Tashkent, Uzbekistan

2

Tashkent Medical Acadamy, Tashkent, Uzbekistan

BACKGROUND AND AIM: Early detection of hearing disorders and timely treatment for patients that can help prevention of VBI, its development and progression.

METHOD: Examined 56 patients with VBI aged 35 to 45 years. The majority of patients with vertebrobasilar insufficiency selected at the Republican Specialized Center for Surgical Angioneurology. All examined individuals underwent the audiogram. The presence of VBI in the patients studied confirmed by Dopplerography of cerebral vessels, audiogram and by the neurologist. To study hemodynamics in the system of internal carotid arteries and blood circulation of the vertebrobasilar system (VBS), duplex scanning used, which reflects the condition of hemodynamics mainly in the system of vertebral arteries.

RESULTS: Almost all the studied patients or the majority of them with incipient VBI in combination with initial hearing impairment also had complaints of subjective tinnitus (85.2%), noise in the head (56.8%), dizziness (90.2%), heaviness in the back of the head (98%), increased irritability (100%), sleep disturbances (90%), as well as decreased mental performance (100%), etc.

Thus, the studies conducted indicate the importance of patients with initial sensorineural manifestations in combination with VBI, which will contribute to timely targeted treatment for such patients, as well as the prevention of the development of VBI and its progression.

CONCLUSIONS: VBI in combination with sensorineural manifestations will contribute to the timely implementation of pathogenetically based therapeutic and preventive measures that prevent the development of VBI and its progression.

• Keywords: Vertebrobasilar insufficiency; ischemic stroke

1.35.3. Assessment of Cerebrovascular Reserve by Transcranial Duplex Scanning with Transorbital Access, in Combination with Compression Test, in Patients with Bilateral Hemodynamically Significant Atherosclerotic Lesion of the Carotid Arteries

• Dilfuza Jumaniyazova ¹, Shavkat Karimov ¹, Abdurasul Yulbarisov ^1,2 and Rustam Muminov ^1,2

1

Republican Specialized Center of Surgical Angionevrology, Tashkent, Uzbekistan

2

Tashkent Medical Academy, Tashkent, Uzbekistan

BACKGROUND AND AIM: Assessment of the cerebrovascular reserve (CVR), by transcranial duplex scanning (TCDS), transorbital access, in combination with a compression test, in patients with bilateral hemodynamically significant atherosclerotic lesion of the carotid arteries, carried out in the preoperative period in order to choose treatment tactics, type of surgery, as well as to determine indications for the use of a temporary carotid shunt.

METHOD: The results of examination and treatment of 120 (100%) patients with bilateral atherosclerotic lesions of the carotid arteries analyzed. Patients divided into 2 groups. The first group included 55 (46%) patients who underwent reconstructive surgery on the carotid arteries according to intraoperative assessment of brain tolerance to ischemia. The second group consisted of 65 (54%) patients who underwent reconstructive surgery with a preoperative assessment of CVR, performed using TCD through a transorbital approach, in combination with a compression test. As a result of the study, 4 degrees of CVR were identified: high, medium, low, critical.

RESULTS: Full agreement between the preoperative CVR assessment data and the intraoperative tolerance assessment data was observed in 62 (95%) cases (true-positive information). The discrepancy between the preoperative assessment of CVR, performed using TCD through a transorbital approach, in combination with a compression test, and intraoperative data assessing cerebral ischemia tolerance was obtained in 3 (5%) cases (false-positive information). The sensitivity of preoperative assessment of CVR in the main group of patients was 95%, specificity-96%.

CONCLUSIONS: Assessment of CVR using TCD via transorbital access, in combination with the compression test, is the method of choice for preoperative study of cerebral ischemia tolerance in patients with bilateral hemodynamically significant atherosclerotic lesions of the carotid arteries, and it reliably determines treatment tactics and determines the indications for using TCS, that’s why has advantages such as non-invasiveness, accessibility, mobility, lack of radiation exposure, speed of examination, and easy duplication.

• Keywords: CVR; TCS; TCD

1.35.4. Outcomes of Combined Coronary Artery Bypass Grafting and Carotid Endarterectomy: A Single Center Experience from a Tertiary Care Hospital in Pakistan

• Hina Inam and Syed Shahabuddin
• Aga Khan University Hospital, Karachi, Pakistan

BACKGROUND AND AIM: Patients with coronary artery disease are very likely to have a coexisting carotid artery disease as well. Stroke is one of the common complications occurring in patients with carotid artery disease and post CABG patients that affects the recovery of the patient adversely. Thus, a combined approach of CABG and CEA has gained popularity among surgeons. Other strategies that have been in practice include a staged approach (CEA followed by CABG or vice versa) or CAS followed by CABG. However, a consensus has not been achieved to identify the best and safest available strategy.

METHOD: Data for all adult patients (above 18 years) who underwent combined CABG and CEA from January 2000 to October 2021 was collected retrospectively. We included both symptomatic and asymptomatic patients with carotid artery disease, with an internal carotid artery stenosis of more than 80%.

RESULTS: There were a total of 27 patients identified, with 25.9% females and 74.1% males. Hypertension was the most common comorbid. Ventricular fibrillation (n = 2, 7.4%), visual defects (n = 1, 3.7+%) were the postoperative outcomes encountered. 2 patients died in the hospital secondary to ventricular fibrillation and stroke.

CONCLUSIONS: The literature shows variable outcomes with different strategies for treatment of coexisting CAD and carotid stenosis. While the studies show that the patients who undergo CABG only with no treatment for carotid stenosis are at higher risk of stroke whereas a synchronous strategy is associated with a decreased risk of stroke.

• Keywords: Coronary artery disease; carotid artery stenosis; coronary artery bypass grafting; carotid artery endarterectomy; postoperative outcomes; stroke

1.35.5. Coronary Artery Bypass Graft Surgery in Patients with Asymptomatic Carotid Stenosis: 5-Year Results from a Randomized Clinical Trial

• Stephan C Knipp ¹, Hans Torulv Holst ¹, Konstantinos Bilbilis ², Heinz Günter Jakob ¹ and Christian Weimar ³

1

Department of Thoracic and Cardiovascular Surgery, University of Duisburg-Essen, Essen, Germany

2

Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany

3

Department of Neurology, University of Duisburg-Essen, Essen, Germany; BDH Clinic, Elzach, Germany

BACKGROUND AND AIM: The optimal strategy for treating patients with concomitant severe coronary and carotid artery disease has been investigated for decades, and combined simultaneous CABG and carotid endarterectomy (CEA) are widely used despite lack of high-level evidence. In addition, there is no data on the preventive effect of CEA compared with best medical therapy on long-term risk of stroke.

METHOD: In the Coronary Artery Bypass graft surgery in patients with Asymptomatic Carotid Stenosis (CABACS) trial, patients with coronary disease and high-grade carotid stenosis (NASCET ≥ 70%) were randomly assigned to combined simultaneous CABG + CEA or CABG alone. Primary endpoint was the composite rate of non-fatal stroke or death within 30 days after surgery, with both treatment options assumed to be equally safe and efficacious. Secondary outcome events included any stroke, stroke or vascular death and death of any cause. Patients were followed-up for five years.

RESULTS: The trial was terminated prematurely after recruitment of 129 patients in 17 centers in Germany and the Czech Republic due to lack of funding. The rate of stroke or death at 30 days was not significantly different following combined CABG + CEA and CABG alone (18.5% [95% CI: 0.099–0.300] versus 9.7% [95% CI: 0.036–0.199], p = 0.203), respectively. At 5 years FU, rates of stroke or death increased to 40.6% (95% CI: 0.285–0.536) following CABG + CEA, and 35.0% (95% CI: 0.231–0.484) following CABG alone (p = 0.581). Strokes of any kind tended to occur more frequently after CABG + CEA (5 years: 29.4% vs. 18.8%, p = 0.245), while mortality was similar in both treatment arms (25.4% vs. 23.3%, p = 0.837). Subgroup analysis revealed no significant effect of center on outcome events.

CONCLUSIONS: Long-term risk of stroke or death was higher after combined simultaneous CABG + CEA, mainly due to increased perioperative event rates. Because of limited power of the trial, further studies are warranted to confirm our results.

• Keywords: carotid stenosis; coronary artery bypass graft surgery; carotid endarterectomy; stroke; randomized controlled trial

1.35.6. Early Surgical Challenges in Sheep Carotid Graft Surgery

• Ziyu Wang ^1,2, Hugh Paterson ³, Lisa Partel ⁴, Innes Wise ⁵, Matthew Adams ⁶, David C. Cistulli ⁷, Dominic Ng ⁷, John O’sullivan ^2,8,9,10, Sean Lal ^2,8,9,10, Anthony S. Weiss ^1,2,11, Paul G. Bannon ^3,7,10 and Robert D. Hume ^2,8,10

1

School of Life and Environmental Sciences, Faculty of Science, The University of Sydney, Sydney, NSW 2006, Australia

2

Charles Perkins Centre, The University of Sydney, Sydney, NSW 2006, Australia

3

Central Clinical School—Surgery, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia

4

Sydney Imaging, Core Research Facilities, the University of Sydney, Sydney, NSW 2006, Australia

5

Laboratory Animal Services, Core Research Facilities, The University of Sydney, Sydney, NSW 2006, Australia

6

Camperdown Vascular Lab, Sydney, NSW 2006, Australia

7

Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, NSW 2006, Australia

8

School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia

9

Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW 2006, Australia

10

Centre for Heart Failure and Diseases of the Aorta, The Baird Institute for Applied Heart and Lung Research, Sydney, NSW 2006, Australia

11

The University of Sydney Nano Institute, The University of Sydney, Sydney, NSW 2006, Australia

BACKGROUND AND AIM: Small vessel synthetic grafts often fail within 5 years, which poses a clinical challenge because patients must rely on autologous vessel conduits. Large animal models are the gold standard for pre-clinical experimentation of vascular grafts. This study aimed to examine a novel small vessel synthetic conduit in a sheep model, and describe the initial challenges and potential solutions from a surgical perspective.

METHOD: Four sheep had imaging via Doppler ultrasound and invasive angiography to demonstrate flow and patency of native common carotid arteries (CCA). Following heparinisation, a 3 cm segment of left CCA was replaced with a novel vascular graft, while shame surgery was performed on the right CCA via transection and re-anastomosis. Post-surgery angiography and Doppler was performed to assess patency on both sides. Different combinations of cannulation strategies were utilised, via CCA or common femoral artery (CFA). Anti-spasmodic agents (sodium nitroprusside, papaverine, verapamil) were administered intraoperatively at varying doses and times.

RESULTS: Cannulation of the CCA for angiography was associated with arterial spasm. This finding was supported by a mildly reduced spasm by downsizing to a smaller catheter, while converting to CFA cannulation resulted in a substantial reduction. Thrombus was a salient finding upon re-opening severely stenosed vessels, especially in the novel synthetic graft. Lastly, administering prophylactic intraarterial papaverine-verapamil markedly reduced spasm, and when used in combination with CFA cannulation was effective in preventing it completely.

CONCLUSIONS: Carotid artery spasm and thrombosis posed significant early challenges in this sheep vascular graft model. Minimising local trauma and administering prophylactic anti-spasmodic agents appears to be effective in reducing these confounders.

• Keywords: Sheep; carotid; vascular; graft; spasm

1.35.7. Comparative Study of Early Outcomes of Simultaneous Carotid Endarterectomy and Coronary Artery Bypass Grafting Surgery with Staged Carotid Artery Stenting and Coronary Artery Bypass Grafting Surgery

• Ebsar Ergenc, Fuat Büyükbayrak and Arzu Antal
• Department of Cardiovascular Surgery, University of Health Sciences, Istanbul, Turkiye

BACKGROUND AND AIM: Criteria, timing, and methods for carotid artery intervention in patients undergoing coronary artery bypass grafting (CABG) have not yet reached a consensus. This study aims to compare the early-term mortality and morbidity of staged carotid stenting and simultaneous carotid endarterectomy in patients with significant carotid artery stenosis before CABG surgery.

METHOD: Our study includes a retrospective analysis of a total of 182 patients, comprising 98 patients who underwent carotid endarterectomy (CEA) concurrently with CABG surgery and 84 patients who underwent carotid artery stenting (CAS) between January 2011 and June 2023 at Kartal Kosuyolu Training and Research Hospital. Mortality and cerebrovascular events observed within the first 30 days in both groups were retrospectively evaluated.

RESULTS: The primary endpoint, 30-day mortality rates, were determined as 11 cases (11.2%) in the CABG + CEA group and 6 cases (7.1%) in the CABG + CAS group (p: 0.492). As the secondary endpoint, cerebrovascular event rates were found to be 17 cases (17.3%) in the CABG + CEA group and 13 cases (15.5%) in the CABG + CAS group (p: 0.890). There was no statistically significant difference between the groups regarding mortality and cerebrovascular events.

CONCLUSIONS: In patients identified with significant carotid artery stenosis in preoperative evaluations for coronary artery bypass graft surgery and requiring intervention, our study suggests that carotid artery stenting is as safe as carotid endarterectomy. We recommend determining the selected method based on the patient’s symptoms and the surgeon’s experience.

• Keywords: Coronary artery bypass surgery; carotid endarterectomy; carotid artery stenting

1.35.8. Validation of Artificial Intelligence Platform (TAXINOMISIS) for Stratification of Patients with Carotid Disease

• Ognjen Dusan Kostic ¹, Vassiliki Potsika ², Vassiliki Kigka ³, Vassilis Tsakanakis ³, David Matejevic ¹, Ivana Djurasev ⁴, Jelena Stanarcevic ⁵, Dimitrios Fotiadis ² and Igor Koncar ⁶

1

Clinic for Vascular and Endovascular Surgery, Serbian Clinical Center, Belgrade, Serbia

2

Department of Materials Science and Engineering, Unit of Medical Technology and Intelligent Information Systems, University of Ioannina, Ioannina, Greece

3

Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina, Greece

4

Clinic for Cardiac Surgery, Serbian Clinical Center, Belgrade, Serbia

5

Special Hospital for Cerebrovascular Diseases “Sveti Sava”, Belgrade, Serbia

6

Medical faculty, University of Belgrade, Serbia

BACKGROUND AND AIM: The Taxinomisis project was developed to stratify individuals with asymptomatic carotid disease, addressing specific requirements from clinicians. Among these needs is the improvement of screening methods for carotid stenosis. This study aims to validate the initial stage of the Taxinomisis tool, focusing on identifying individuals at higher risk of carotid stenosis.

METHOD: The demographic and medical data of individuals who fulfilled the inclusion criteria, and accept participation in the study, was collected prospectively and inserted in the Taxinomisis stratification tool. All these patients also had a carotid duplex ultrasound examination, the result of which was also inserted in the tool in order to assess the diagnostic accuracy of the tool.

RESULTS: Data from 813 individuals were used to validate TAXINOMISIS Level I. 70.3% had carotid stenosis over 50%. Different probability thresholds were tested, with the best sensitivity (91%) at 0.4 and 0.5 (87%). Thresholds of 0.56 and 0.7 showed high false negatives, risking undiagnosed patients. False positives increase screening costs. Validation in a wider population is necessary to optimize sensitivity and specificity, minimizing false negatives.

CONCLUSIONS: The AI platform demonstrates good sensitivity and specificity in determining the risk of carotid stenosis presence. However, further validation is necessary.

• Keywords: Carotid; Stenosis; Vascular; Stroke; Artificial; Intelligence

1.35.9. Aberrant Carotid Artery Anomaly

• Kadir Kaan Gökçe
• Department of Cardiovascular Surgery, Tekirdağ Namık Kemal University, Tekirdağ, Turkey

Carotid artery compression with abnormal cervical location is rare, but mechanical interaction between bone structures and carotid arteries causing clinical symptoms is even rarer. In some of these reports, it was described as repetitive trauma by the lateral horn of the hyoid bone leading to wall injury and symptomatic stenosis, pseudoaneurysm or carotid artery dissection. In this study, we aimed to present a case of ICA stenosis associated with ICA tortuosity and compression by the hyoid bone. Case presentation: An 80 year-old male patient presented to our clinic with left-sided hemiparesis, dizziness and balance disturbance. Carotid Doppler ultrasonography showed plaque formation forming a 50–70% stenosis in the left ICA and 90% stenosis (PSV 265 cm/s) in the proximal right ICA. Subsequent carotid CT angiography showed a total stenosis in the right ICA and an aberrant stenosis in the left ICA curving through the hyoid bone. Endovascular approach is not recommended for ICA stenosis due to external compression of the carotid arteries. However, because of total occlusion of the right ICA, it was thought that the lateral horn of the hyoid bone should be treated to provide left ICA revascularisation. For this purpose, the patient was referred to the ENT outpatient clinic for surgical planning. Conclusion Generally, the carotid arteries are located in a fibrous layer that allows the artery to follow the neck movements. Elongation and tortuosity of the carotid artery may alter its course within this fibrous layer and cause mechanical compression. CT imaging shows abnormal course of the ICA subjected to compression by the hyoid bone. The present case suggests that hyoid bone compression should be recognised as a rare cause of ICA stenosis, which is more likely to occur when an unusual carotid artery anatomy coexists. In this case, we suggest that a surgical procedure to remove the damaging compression of the bone rather than an invasive procedure would be appropriate.

• Keywords: carotid artery anomaly

1.35.10. Hemodynamic and Hearing Disorders During Initial Manifestations of Vertebrobasilar Insufficiency

• Feruza Mirzaxodjayevna Aripova ¹, Alimjon Mustafoqulovich Axmatov ¹, Abdurasul Abdujalilovich Yulbarisov ² and Alijon Tirkashaliyevich Rizayev ¹

1

Republican Specialized Center for Surgical Angioneurology, Tashkent, Uzbekistan

2

Tashkent Medical Acadamy, Tashkent, Uzbekistan

BACKGROUND AND AIM: Early detection of hearing disorders and timely treatment for patients that can help prevention of VBI, its development and progression.

METHOD: Examined 56 patients with VBI aged 35 to 45 years. The majority of patients with vertebrobasilar insufficiency selected at the Republican Specialized Center for Surgical Angioneurology. All examined individuals underwent the audiogram. The presence of VBI in the patients studied confirmed by Dopplerography of cerebral vessels, audiogram and by the neurologist. To study hemodynamics in the system of internal carotid arteries and blood circulation of the vertebrobasilar system (VBS), duplex scanning used, which reflects the condition of hemodynamics mainly in the system of vertebral arteries.

RESULTS: Almost all the studied patients or the majority of them with incipient VBI in combination with initial hearing impairment also had complaints of subjective tinnitus (85.2%), noise in the head (56.8%), dizziness (90.2%), heaviness in the back of the head (98%), increased irritability (100%), sleep disturbances (90%), as well as decreased mental performance (100%), etc.

Thus, the studies conducted indicate the importance of patients with initial sensorineural manifestations in combination with VBI, which will contribute to timely targeted treatment for such patients, as well as the prevention of the development of VBI and its progression.

CONCLUSIONS: VBI in combination with sensorineural manifestations will contribute to the timely implementation of pathogenetically based therapeutic and preventive measures that prevent the development of VBI and its progression.

• Keywords: vertebrobasilar insufficiency

1.36. VASCULAR AND ENDOVASCULAR » Miscellaneous

1.36.1. Chronic Type B Dissection Leads to Rupture of Gigantic Extent II Thoracoabdominal Aneurysm: Successful Endovascular Management Using the STABILISE Technique

• Areti Vassiliou, Giwrgos Fanariotis, Michail Peroulis and Vangelis G. Alexio
  Vascular Surgery Unit, General Surgery Department, University Hospital of Ioannina, Ioannina, Greece

BACKGROUND AND AIM: Our aim is to assess the feasibility of Stabilise and petticoat technique in dissection B patients.

METHOD: A 78-year-old male suffered type B dissection 12 years ago. The patient was managed conservatively. He developed an extent II thoracoabdominal aneurysm measuring 7.5 cm and thrombosis of the left renal artery. He was lost to follow-up for at least 2 years, and presented with acute thoracic pain, hypotension, shortness of breath, and a hemoglobin of 9 g/dL. CT revealed that his aneurysm had dilated to 12 cm and ruptured within his mediastinum. He had a massive pleural effusion with unilateral white-out and collapse of his left lung. A large entry tear 2 cm distal to the left subclavian allowed adequate proximal sealing. The true lumen (TL) had collapsed along the descending thoracic aorta and the paravisceral abdominal aorta. Furthermore, there were 3 distal entry tears at the infrarenal level and at the left common iliac artery, which had expanded to 4 cm. The patient was urgently operated on. In order to close off the proximal entry tear, a 20 cm long thoracic endograft with 10% oversizing was used. A petticoat bare-metal stent was placed at the paravisceral aorta for a better expansion of the TL. A selective treatment of all the distal entry tears included placement of an infrarenal aortic cuff with a total covered length of 49 mm and a left Iliac leg. Compliant aortic balloons were used within the stent-grafts, while non-compliant balloons were used within the bare-metal stent to rupture the lamella.

RESULTS: The post-operative CT scan revealed false lumen thrombosis. This is the first, to our knowledge, report of the STABILISE technique in the acute setting.

CONCLUSIONS: The use of the stabilise technique is feasible also and in the acute setting and by using the petticoat technique we may also proceed to a more favourable remodeling of the aorta.

• Keywords: Stabilise technique; Petticoat technique; Remodelling; Aortic dissection type B

1.36.2. Unfractionated Intravenous Heparin Versus Low Molecular Weight Heparin After Vascular Surgery

• Denise Özdemir Van Brunschot, David Holzhey and Spiridon Botsios
• German Faculty of Health, Witten/Herdecke University, Witten, Germany

BACKGROUND AND AIM: Platelet aggregation and anticoagulants play a major role in vascular surgery. Postoperative anticoagulation after vascular surgery is given to prevent venous thrombosis but also to prevent early graft thrombosis. In some clinics unfractionated intravenous heparin is given during the first postoperative period, other clinics prefer low molecular weight heparin.

METHOD: In our hospital the postoperative anticoagulation regime after vascular surgery was changed on 1 September 2021. Before regime change all patients received intravenous unfractionated heparin in the first 24 h after vascular surgery, thereafter normal thrombosis prophylaxis (20 or 40 mg low molecular weight heparin once a day) was administered. After the 1 September 2021 patients received low molecular weight heparin in a prophylactic dose after vascular surgery. The patients in the new regime were matched with patients from the UFH regime.

RESULTS: A total of 836 patients were included: 418 patients in the LMWH group and 418 patients in the UFH group. There were more patients with the need for re-operation because of a local hematoma in the UFH group (0.5% versus 4.8%, p = 0.01). There were no significant differences regarding other outcomes (patency of the reconstruction or need for re-operation because of bleeding). Sub-analyses were performed regarding type of surgery, excluding patients using new oral anticoagulants or vitamin K antagonists and excluding two surgeons whom exclusively operated in the UFH or LMWH regime, showed comparable results.

CONCLUSIONS: This retrospective study suggests that LMWH should be preferred as anticoagulation after vascular surgery, since there were less patients with the need for re-operation because of hematoma and there is no need for monitoring.

• Keywords: Anticoagulants; vascular surgical procedure; low molecular weight heparin; unfractionated heparin

1.36.3. Analysis and Treatment of Delayed Vascular Injuries in the II Karabakh War: A Study from Azerbaijan

• Javid Ibrahimov
• Cardiovascular Surgery Department, Republican Diagnostical Center, Baku, Azerbaijan

BACKGROUND AND AIM: The objective was to examine delayed vascular injuries sustained in Azerbaijan between 27 September 2020, and 8 November 2020, during the II Karabakh War.

METHOD: Delayed vascular injuries of wounded patients treated in the General Clinical Hospital of Azerbaijan were divided into 2 groups: pseudoaneurysms of arteries and arteriovenous fistulas.

RESULTS: The five types of vascular injuries are: (1) intimal injuries (flaps, disruptions, or hematomas); (2) wall defects with pseudoaneurysms or hemorrhage; (3) complete transections with hemorrhage or occlusion; (4) arteriovenous fistulas; and (5) spasm. (1). The duration of exposure to the complications of vascular damage in patients was a minimum of 3 h and a maximum of 11 months. A total of 24 patients had delayed vascular injuries. 66.6% of these patients (16 patients) had a pseudoaneurysm of an arterial vessel, 33.3% (8 patients) had an arteriovenous fistula. Auscultatory noise was heard over the injured area during examination in 58.3% of patients (14). Pseudoaneurysms were bleeding in 37% of patients (9 patients), arteriovenous fistulas were bleeding in 4.16% of patients (1 patient). Due to the predominance of shrapnel injuries in battles, the aorta, the axillary artery, the brachial artery, the superficial femoral artery, the popliteal artery each of them in 1 patient, the subclavian artery, the deep femoral artery, the external carotid artery, the anterior tibial artery each of them in 2 patients were found to be affected. One patient with an aortic pseudoaneurysm underwent synthetic patch plasty using a dacron graft; another underwent graft interposition; seven individuals had artery ligation (non-dominant arteries); the remaining patients underwent autogenous vein interposition. Via an arteriovenous fistula in the iliac artery, one patient died.

CONCLUSIONS: This study demonstrates that vascular problems can be identified by thoroughly examining injured individuals, allowing for prompt intervention to stop bleeding and repair damaged vessels.

• Keywords: Pseudoaneurysm; arteriovenous fistulas; vascular damage; bleeding; delayed vascular injuries

1.36.4. Surgical Management of Paediatric Vascular Emergencies: Single Center Experience

• Safak Alpat, Melih Alma, Recep Oktay Peker and Mustafa Yılmaz
• Division of Paediatric Cardiovascular Surgery, Department of Cardiovascular Surgery, Hacettepe University School of Medicine, Ankara, Türkiye

BACKGROUND AND AIM: Vascular emergencies necessitate complex decision making and interdisciplinary care. Management of these patients is more difficult when they occur in children. Since vascular emergencies are uncommon in children, this rarity complicates the precise, prompt detection and meticulous management of a vascular emergency. Endovascular technology remains limited for pediatric vascular surgery injuries. Here, we present our surgical experience in paediatric vascular emergencies.

METHOD: Between 2014–2024, 21 paediatric patients underwent emergency vascular procedure in our unit. Pre-, intra, and post-operative data were collected and analyzed.

RESULTS: 21 patients (12 males, 9 females) underwent emergency vascular surgery in our unit during the study period. Median age was 96 months (7–144) with 8 being less than 3 years of age. Indications were access related acute limb ischemia in 12 (57%), trauma in 4 (19%), thromboembolism in 4 (19%), and pseudoaneurysm in 1 (5%). All patients in access related ALI had systemic anticoagulation initally but duplex scan revealed no improvement. 80% had common femoral and 20% had external iliac artery related thrombosis. Surgical techniques included; thrombectomy, primary arterial repair, arterial dilatation and topical papaverine application to relieve spasm. Limb preservation was 100% without neeed for fasciotomy. Trauma patients required multi-vessel revascularization including artery and vein interposition and/or bypass grafts with autologous tissues. Limb preservation was 100% and 50% required fasciotomy. Thromboembolic group underwent thromboembolectomy and a patient with pseudoaneurysm had primary repair of puncture point. All patients received systemic anticoagulation with heparin for the first 24 h bridged to LMWH for the hospital stay and discharged with ASA.

CONCLUSIONS: Paediatric vascular injuries are generally thought to bee difficult to manage. In general, operative interventions in children younger than years are reported to have worse outcomes than older children. Thus, non-operative management is preferred. However, according to our experience, we showed that prompt diagnosis-early surgical intervention are associated with good outcomes, even in patients younger than 3-years old.

• Keywords: pediatric; vascular; injury

1.36.5. Fundamental Biophysical Misconceptions in Fluid Dynamics in Surgical Patients

• Nery Alexandra Lamothe ¹, Mara Nicole Lamothe ¹, Alejandro Rey ², Jean Christian Daniel Lamothe ³ and Alejandro Alonso Altamirano ¹

1

Division Ciencias Biologicas y de la Salud, Universidad Autonoma Metropolitana, Mexico City, Mexico

2

Chief, Cardiac Surgery Department, American British Cowdray Medical Center, Mexico City, Mexico

3

Internal Medicine, Jersey City Medical Center, NJ, USA

BACKGROUND AND AIM: Perfusion is not inversely related to the fourth power of the radius but to the second power of the radius.

METHOD: Apodictic inferences from the fundamental physical laws, using the International System of Units, to refute fluid dynamics misconceptions.

RESULTS: To infer the perfusion effect of arterial occlusion, it is the transverse area that is considered instead of the radius. Perfusion decays linearly with the transverse area of the occluded artery.

Antihypertensive drugs produce a decay in the axial pressure and thus a decay in perfusion.

Clinical arterial pressure constitutes transmural pressure rather than axial pressure which is what drives perfusion.

It is Laplacian tension that damages the vessel’s wall, rather than the transmural pressure.

It is energy density per time that damages the vessels. Thus joules/liter per second or Watts/liter.

Perfusion increases proportionally to driving pressure.

It is Laplacian tension that activates the baroreceptors, rather than transmural pressure.

Systemic vasodilatation increases the perfusion in peripheral tissues diminishing the brain and cardiac perfusion.

Every physical gradient, including pressure, constitutes potential energy,

The changes in the pressure per time are the derivative of the pressure per time, which is equal to the derivative of energy per volume per time. This corresponds strictly to the derivative of energy density per time, which in turn, is the density of power.

It is the axial gradient of energy rather than the pressure axial gradient that drives the perfusion.

Pressure is force per area, as well as, energy per volume, which is energy density.

CONCLUSIONS: The heart cannot output a volume that has not been received. It is not the preload volume in the EDV but the pressure at the EDV that could decrease before the initiation of the isovolumetric contraction phase.

• Keywords: Laplacian tension; Poiseuille’s Law; Decrease preload; axial pressure

1.36.6. Using Augmented Reality Systems for Open Vascular Procedures—First Case in a Public Hellenic Hospital

• George Galyfos, Linnea Tscheuschner, Sylvie Vagena, Marcel Pikula, Andrzej Skalski, Konstantinos Filis and Frangiska Sigala
• Vascular unit, First Department of Propaedeutic Surgery, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece

BACKGROUND: Augmented reality technology has been introduced to everyday clinical practice in order to facilitate different types of surgical procedures. Therefore, several surgical specialties have started to use such technology for preoperative planning as well as during surgery. Regarding vascular interventions, only a limited number of reports are available describing possible benefits mainly for endovascular procedures.

CASE: We are presenting a novel 3-dimentional holographic system that was used to perform an open vascular procedure. The patient presented with critical limb ischemia, and underwent a femorofemoral bypass. This is the first case of applying such technology in a public Hellenic hospital.

• Keywords: augmented reality; open vascular surgery; hologram

1.36.7. Cystic Adventitial Disease in an Adolescent—A Rare Entity

• David Matejevic, Aleksandar Mitrovic, Andrija Roganovic, Ognjen Kostic and Ilija Kuzmanovic
• Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia

BACKGROUND: Cystic adventitial disease is a rare, non-atherosclerotic condition of still unknown etiology in which mucinous cysts form in the blood vessel adventitial layer. The most commonly affected vessel is popliteal artery, and the condition is usually seen in middle-aged man (40–60 years). The treatment options are usually surgical, and the most frequently used technique is the resection of the affected part of the artery and reconstruction with autovenous graft, but percutaneous endovascular techniques are also described.

CASE: A 17-year-old male patient presented with sudden-onset short distance right calf claudication that lasted for 3 days. MDCT angiography and intraoperative finding showed saccular aneurysm of popliteal artery with a maximum diameter of 12 mm, accompanied by the occlusion of the distal popliteal artery and the tibioperoneal trunk. The patient underwent operative treatment—thrombectomy, extirpation of the aneurysm and autovenous reverse graft interposition was performed via posterior approach. Pathohistological examination of arterial wall showed cystic adventitial disease, with the unilocular transmural cyst, fragmentation of the inner elastic membrane, extensive fibro-intimal proliferation and superimposed thrombus. Pathohistological characteristics of the distal thrombus were usual. Postoperatively, the patient fully recovered with palpable distal pulses. A one-month control duplex scan verified graft patency. Although cystic adventitial disease is more frequent in middle-aged patients, usually with no atherosclerotic risk factors and overall healthy non-included vessels, it should be considered as a diagnosis in younger patients as well, since timely treatment is mandatory to avoid serious consequences such as limb loss.

• Keywords: artery; popliteal; cystic; adventital; disease; adolescent

1.36.8. Complex Reccurent Aortic Pseudoaneuysms in a Case of Giant Cell Arteritis: A Different Endovascular Approach

• Ayse Zehra Cotelioglu, Gokhan Albayrak and Koray Aykut
• Izmir University of Economics Medical Point Hospital, Izmir, Turkey

Pseudoaneurysms occurs after 0.5% of all cardiac surgical cases and are often localized at previous anastomotic sites, aortototomy and cannulation sites.

An 80-year-old male patient presented to our hospital with a history of chest pain two years ago. The angiography revealed three-vessel coronary artery disease, necessitating a standard coronary artery bypass graft (CABG) operation utilizing left internal mammary artery (LIMA) and saphenous vein grafts.

Five months later, the patient admitted to the clinic with recurrent fever and infectious symptoms which were refractory to antibiotic therapy. Subsequent thoracic MRI-angiography revealed an aortic pseudoaneurysm located in the ascending aorta. Open surgical repair was undertaken, utilizing cannulation of the right axillary artery via a dacron graft and venous cannulation via the right femoral vein. During deep hypothermic total circulatory arrest, the infected pseudoaneurysm sac was opened and repair of the necrotic hole from previous arterial cannulation was performed using a dacron patch. The postoperative course was uneventful, and the patient was discharged on postoperative day 14 following optimized antibiotic therapy.

Three months later, the patient was readmitted with a neck mass. Control CT angiography revealed another pseudoaneurysm in the ascending aorta and a mediastinal hematoma. Endovascular repair was planned for the same localization, the middle portion of the ascending aorta (proximal of Zone 0), with deployment of a short segment between the initiation of the bovine-configurated brachiocephalic trunk and proximal anastomosis region of the saphenous vein graft. Control angiography confirmed the patency of the saphenous vein grafts and LIMA graft, with resolution of pseudoaneurysm circulation.

Subsequently, the patient was diagnosed with giant cell arteritis upon discharge. Over the following two years, the patient developed two femoral pseudoaneurysms, either. The recurrence of aneurysms underscores the importance of considering vasculitic syndromes in such cases. Variations of endovascular treatments can be efficacious in selected cases.

• Keywords: false aneurysm; endovascular aortic repair

1.37. VASCULAR AND ENDOVASCULAR » PAOD

1.37.1. Optical Coherence Tomography and Fractional Flow Reserve in Below-the-Knee Percutaneous Transluminal Angioplasty: A Case Series

• Ozan Yazar, Chrissy Van Wely, Rens Oosterveld, Pieter Salemans, Chunyu Wong and Lee Bouwman
• Department of vascular and endovascular surgery, Zuyderland Medical Center, Heerlen, The Netherlands

BACKGROUND AND AIM: The golden standard imaging modality for Percutaneous Transluminal Angioplasty (PTA) is Digital Subtraction Angiography (DSA) using iodine contrast agent. While DSA visualizes the vessel and allows the surgeon to estimate the size and percentage of stenosis in the vessel, it lacks objective vessel diameter measurement, information on plaque morphology and measurement of hemodynamic consequences of the stenosis. Optical Coherence Tomography (OCT) and Fractional Flow Reserve (FFR) measurements bridge these gaps. OCT, an intravascular imaging modality which uses near-infrared light to capture images of the vessel wall, allows objective measurement of vessel diameter and percentage of stenosis. FFR measures pre- and post-stenotic pressures, demonstrating hemodynamic consequences of the stenosis. A decreased FFR indicates diminished blood flow towards the extremity, demonstrating the hemodynamic significance of the stenosis that would consequently require treatment.

METHOD: OCT and FFR measurements were completed in 4 subjects undergoing elective PTA in below-the-knee lesions due to critical limb ischemia. Subjects were eligible when the lesion on pre-operative imaging was no longer than 3 cm. Subjects who underwent PTA 30 days prior to the current intervention were excluded, as well as subjects with previous major amputation.

RESULTS: No complications were caused by OCT and FFR procedures, demonstrating its safety. OCT revealed the presence of dissections and presence of thrombus after PTA that were not detected using DSA. FFR values would have caused the surgeon to change his per-operative decision making in two subjects.

CONCLUSIONS: OCT and FFR are safe to use in below-the-knee arterial lesions providing valuable additional information on vessel diameter, percentage of stenosis, plaque morphology and hemodynamic significance. This may cause alterations in perioperative decision-making.

• Keywords: Optical Coherence Tomography; below the knee; endovascular interventions: Fractional Flow Reserve

1.37.2. Comparative Analysis of Graft Options in Critical Limb Ischemia Surgery

• Gian Antonio Boschetti, Raffaele Adornetto, Luca Calia Di Pinto, Floriana Carrer, Chiara Dal Borgo, Stefano Doro, Daniele Masotti, Laura Nicolai, Cristina Puglisi, Gianna Saviane, Letizia Turini and Edoardo Galeazzi
• Vascular Surgery Unit, AULSS 2 Marca Trevigiana, Treviso Regional Hospital, Treviso, Italy

BACKGROUND AND AIM: The utilization of materials other than autologous vein for below the knee (BTK) revascularization still presents some limitations. The aim of this study was to analyze the outcomes of different graft types used for BTK revascularizations for critical limb ischemia (CLI).

METHOD: We retrospectively collected pre-, intra- and postoperative data of the patients that underwent primary BTK bypass surgery with biological or biosynthetic graft for CLI between 2020 and 2023. Primary endpoints were primary patency, reintervention, amputation and mortality rate during follow-up.

RESULTS: We included 47 patients for whom 23 (48.9%) autologous vein (AV), 10 (21.3%) homologous vein (HV), 10 (21.3%) Omniflow^® II bypass graft (OG), and 4 (8.5%) homologous arteries (HA) were used. The mean age was 74.3 ± 9.6 years, 29 patients were male (61.7%) and the majority presented Rutherford stage V (n = 33, 70.2%) and one run-off vessel (n = 26, 51.1%). Thirty-day and 1-year cumulative primary patency for each group were respectively 100%, 70%, 70%, and 100% (p < 0.05)–86.9%, 50%, 70%, and 100% (p < 0.05). Similarly, cumulative reintervention rates for bypass occlusion were 0%, 30%, 30%, and 0% (p < 0.05)–8.7%, 40%, 30%, 0% (p < 0.05). There were no deaths at the 30-day follow-up while at 1-year the mortality rates were 17.4%, 10%, 10%, and 25% (p > 0.05). One major amputation occurred during the entire follow-up in the OG group only (2.1%).

CONCLUSIONS: Although AV remains the conduit of choice, this study highlights the importance of considering other biological or biosynthetic grafts for BTK revascularization when AV is not available.

• Keywords: tical limb ischemia (CLI); open repair; peripheral bypass; cryopreserved allograft; omniflow

1.37.3. Comparison of Open Surgical Repair and Endovascular Embolization Treatments in Iatrogenic Peripheral Arterial Pseudoaneurysms: A Retrospective Study of 42 Cases

• Mehmet Ziyaddin Altun ¹, Ahmet Ibrahim Balkaya ¹, Begum Ozuekren Kasapoglu ¹, Umut Erdem ², Helin El Kilic ¹, Tolga Demir ¹ and Ismail Koramaz ¹

1

Department of Cardiovascular Surgery, Hamidiye Etfal Training and Research Hospital, Health Science University, Istanbul, Turkey

2

Department of Radiology, Hamidiye Etfal Training and Research Hospital, Health Science University, Istanbul, Turkey

BACKGROUND AND AIM: In recent years, due to the widespread use of invasive methods for diagnosis and treatment, the incidence of pseudoaneurysm cases has increased. The objective of our study is to compare open surgical intervention with endovascular embolization therapies for iatrogenic peripheral arterial pseudoaneurysms, while retrospectively assessing the preoperative characteristics of the cases

METHOD: Between 2021 and 2024, a total of 42 patients diagnosed with peripheral artery pseudoaneurysms were included in the study and divided into two groups according to treatment modalities. Embolization was performed in 24 patients (Group 1), while 18 patients underwent open surgical intervention (Group 2). Pseudoaneurysms were diagnosed via ultrasonography and confirmed by computed tomography (CT) scans when deemed necessary.

RESULTS: The most frequent symptom was a pulsatile mass and all originated from common femoral artery. The mean diameter of pseudoaneurysms was higher in group 2 (1.6 ± 1.2 cm vs. 4.3 ± 1.6 cm). Among 24, 2 patients underwent open surgical closure due to the short neck of the pseudoaneurysm. In the open surgical group, successful aneurysm closure was achieved in all patients. During the follow-up period 2 (8.3%) patients experienced recurrent bleeding which required blood transfusion in Group 1 and wound infection was reported in 4 (22.2%) patients and lymphorrhea in 1 (5.5%) in Group 2 as an early postoperative complication.

CONCLUSIONS: Iatrogenic Peripheral artery pseudoaneurysms can be effectively managed through either open surgical techniques or interventional procedures in carefully selected patients, yielding acceptable mid- and long-term outcomes

• Keywords: Iatrogenic; Pseudoaneurysm; Peripheral artery; Embolization; Surgical Procedures

1.37.4. Patients with Low Serum Albumin Short-Term Results Outcomes in Aorta-Femoral Bypass Surgery

• Mehmet Ali Yesiltas ¹ and Ahmet Ozan Koyuncu ²

1

Department of Cardiovascular Surgery, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey

2

Department of Cardiovascular Surgery, Istanbul University-Cerrahpasa Institute of Cardiology, Istanbul, Turkey

BACKGROUND AND AIM: Low albumin level has been associated with poor outcomes, including death, in surgical patients. Since studies in the vascular population are insufficient; We aimed to share the results of preoperative low albumin levels, mortality and short-term postoperative complications in patients with distal aortic and iliac artery lesions who underwent aorta-femoral bypass.

METHOD: Patients who underwent aorta-femoral bypass between January 2018 and January 2024 were retrospectively scanned from the hospital system and files. Preoperative demographic data, postoperative complications and mortality of patients with hypoalbuminemia (Low albumin level < 2.5 g/dL) were recorded.

RESULTS: Total number of patients: 87 patients were included in the study. The average age of the patients is 69.3 ± 13.4 years. 12 patients had a history of cardiac surgery and 18 patients had a history of chronic renal failure. Postoperative renal failure developed in 7 patients. Two of them required continuous hemofiltration. 1 patient developed permanent dialysis disease. Respiratory problems developed in 6 patients. Extubation time was prolonged in 3 of them. Pneumonia also developed in the other 3 patients. No cardiac complications developed. Cellulitis developed in 1 patient, minor wound infection in 4 patients, and deep infection in the femoral wound site occurred in 1 patient and required VAC therapy. Sepsis developed in 4 patients. The number of patients with prolonged hospitalization (>7 days) was 37. Rehospitalization within 30 days was 4 patients. 2 of these were due to wound infection. In-hospital mortality occurred in 2 patients and mortality occurred within 30 days in 1 patient.

CONCLUSIONS: It has been observed that patients with hypoalbuminemia have a high rate of prolonged hospitalization and a higher rate of sepsis than the normal population. There is a need for studies comparing normal albumin levels with a high number of patients.

• Keywords: hypoalbuminemia; aorta-femoral bypass surgery; peripheral artery disease; Albumin

1.37.5. Multifocal Arterial Disease—Carotid, Coronary and Peripheral—Diagnostic Strategy and Therapeutic Management

• Ionel Droc ¹, Cosmin Buzila ¹, Tudor Paduraru ², Mihai Dumitrascu ¹ and Liviu Stan ¹

1

Central Mlitary Hospital, Cardiovascular Surgery Clinic, Bucharest, Romania

2

Central Military Hospital, Anesthesia Department, Bucharest, Romania

BACKGROUND AND AIM: Atherosclerosis is a global disease affecting multiple organs. The more symptomatic lesion or the lesion with the strongest prognostic impact should be treated first.

Coronary artery disease may coexist with carotid artery stenosis, abdominal aortic aneurysms, and/or peripheral artery disease (PAD).

Recent studies have confirmed that patients with multivascular bed disease have a greater risk for major cardiovascular events than patients with monovascular attempt.

The aim of the study was to see the actual incidence of multifocal arterial disease in vacular patients and the strategy of treatment in order to reduce the periprocedural cardiovascular morbidity and mortality.

METHOD: In 2003 on one year period, on 400 direct arterial revascularisations we had 11 patients with multiple sites of atherosclerotic disease. The decade more affected was 60–70 years old. After 20 years, in 2023, the number of patients increased a lot, at 120, and the patients were older. (decade 70–80 y). Men were more affected.

The lesions should be treated as follows: carotid, coronaries and aorta or peripheral lesions. When two arterial beds are symptomatic (ex: AAA more than 7 cm in diam. or in imminence of rupture associated with left main disease) we can perform simultaneous procedures (open or endovascular), but with more higher mortality rate (25%)

RESULTS: Vascular patients often have concomitant arterial disease affecting more than one territory (35% of pat. on 400 direct arterial revascularisations/year) Identification of silent vascular disease is essential to improve cardiovascular mortality and morbidity rates. Diabetes mellitus, age and male sex were found to be markers of developing multisite arterial disease. The treatment should include also aggressive risk factor management, lifestyle changes, and appropriate drug therapy.

CONCLUSIONS: In conclusion, specific surgical/endovascular therapeutic options available, aggressive medical treatment and vascular disease prevention strategies should be rigorously implemented to best manage the overall atherosclerotic sites.

• Keywords: multifocal arterial disease; coronary; carotid; peripheral; therapeutic management

1.37.6. Comparison of the Protective Effects of Vanillic and Rosmarinic Acid on Cardiac Tissue: Lower Limb Ischemia-Reperfusion Model in Rats

• Serhat Hüseyin ¹, Adem Reyhancan ¹, Ümit Halıcı ², Orkut Güçlü ¹, Salih Tüysüz ¹, Burçak Öztorun ³ and Suat Canbaz¹

1

Department of Cardiovascular Surgery, Trakya University, Edirne, Türkiye

2

Department of Cardiovascular Surgery, Samsun Training and Research Hospital, Samsun, Türkiye

3

Department of Pathology, Trakya University, Edirne, Türkiye

BACKGROUND AND AIM: The inflammatory response that develops during ischemia and the oxygen-free radicals that proliferate during reperfusion have deleterious effects on the brain, heart and kidneys. In this study, we aimed to compare the effects of vanillic and rosmarinic acid in the prevention of ischemia/reperfusion injury in a rat lower limb ischemia/reperfusion model

METHOD: 32 females Sprague-Dawleys weighing 185–240 g were randomly divided into 4 groups of 8 animals each. Group 1 was designated as control, group 2 as ischemia/reperfusion (I/R), group 3 as ischemia/reperfusion + vanillic acid (I/R + VA) and group 4 as ischemia/reperfusion + rosmarinic acid (I/R + RA). In all groups except the control group, the infrarenal abdominal aorta was clamped and 60 min of ischemia followed by 120 min of reperfusion was performed. Vanillic and rosmarinic acids were administered intrabadominally before the reperfusion phase. At the end of the reperfusion phase, blood samples and hearts were collected and the rats were sacrificed. Biochemical and histopathological examinations were performed on the blood samples and heart tissue.

RESULTS: Myofibrillar edema was most pronounced in the I/R group and less pronounced in the I/R + VA (p = 0.005). Of all groups, TOS and OSI were lowest in the control group, while TAC was highest. While TAC was similar in the I/R + VA and I/R + RA groups, it was significantly higher in these two groups than in the I/R group. While the lactonase activity in the I/R + VA group was similar to the control group, it was significantly higher compared to the I/R and I/R + RA groups.

CONCLUSIONS: Our study shows that vanillic and rosmarinic acids reduce myofibrillar edema in the heart after lower limb ischemia and increase TAC. However, vanillic acid increases the activity of the enzyme lactonase, which is known for its antioxidant effect, more than rosmarinic acid.

• Keywords: vanillic; rosmarinic; cardiac; ischemia; reperfusion; lactonase

1.37.7. Four-Year Outcome of Drug-Coated Balloons for SFA Lesions in Patients with CLI: A Comparison with Traditional Bypass Surgery

• Mohammed Skaik ¹, Cagla Canbay Sarilar ¹, Bayer Cinar ² and Onur Selcuk Goksel ¹

1

Department of Cardiovascular Surgery, Istanbul University, Istanbul, Turkey

2

Department of Cardiovascular Surgery, Altinbas University, Istanbul, Turkey

BACKGROUND AND AIM: The endovascular treatment approach for symptomatic peripheral artery disease has become widely accepted. The effectiveness and safety of drug-coated balloon (DCB) angioplasty for patients with critical limb ischemia (CLI) have been previously established, showing promising results after one year. However, there is limited evidence regarding the long-term durability of this treatment. This study compares the four-year outcomes of DCB angioplasty with traditional bypass surgery in patients with CLI.

METHOD: The study included 187 patients with CLI who were treated over six years (2006–2012) by a single surgical team. From 2006 to 2009, all patients underwent traditional surgery. From 2009 to 2012, the team adopted an endovascular approach using IN.PACT Admiral (Medtronic Inc., Santa Rosa, CA, USA). Data was collected prospectively.

RESULTS: Over the six years, a total of 210 procedures (100 surgeries, 110 endovascular) were performed. 72% of all bypasses were conducted using saphenous vein grafts, with above-knee bypass being the preferred technique in 80% of cases. A 6-mm DCB was used in 41% of patients. Both procedural success rates (98% vs. 99%, NS) and clinical success rates (99% vs. 99%, NS), as well as operative mortality (3.7% vs. 2%, NS), were similar in both groups. Primary Patency for the DCB and bypass groups was 91.8% vs. 88.9% at 12 months (p = 0.31), 82.7% vs. 82.8% at 24 months (p = 0.28), and remained similar at four years (66.4% vs. 68.8, p = 0.08). Freedom from clinically driven Target Lesion Revascularization (TLR) at 12 months was similar in both groups (87.6% vs. 85%, p = 0.33). The rates of clinically driven target lesion revascularization were 29.2% and 26.1% (p = 0.07) for the DCB and surgery groups, respectively.

CONCLUSIONS: DCB angioplasty shows comparable results to traditional surgery in treating CLI, even after four years. The effectiveness and safety of DCBs in more complex lesions need to be further investigated through randomized trials.

• Keywords: Drug-Coated Balloons; SFA lesions

1.37.8. Femoral Artery Pseudoaneurysm Due to Sports Injury in a Patient with Osteochondroma

• Ilker Hasan Karal, Emrah Ereren and Aşkın Kılıç
• Department of Cardiovascular Surgery, Samsun University Faculty of Medicine, Samsun, Türkiye

Osteochondromas are the most common benign bone tumors and mostly arise from the metaphysis of long bones. Lesions are mostly asymptomatic and found incidentally. However, many complications, including neurovascular compression and vascular injuries, have been published. We present a case of femoral artery pseudoaneurysm due to sports injury in a patient with osteochondroma. A 19-year-old male patient was admitted to the emergency room with complaints of severe pain and swelling in his right leg. The patient, who had osteochondroma resection surgery on his left distal femur 1 month ago, stated that he had severe pain since he overflexed his right knee while playing football 1 week before his admition. Doppler ultrasonography revealed popliteal and crural vein thrombosis (DVT) and turbulent flow vessel dilation reaching approximately 6 × 4 cm in the medial distal part of the right thigh. The patient’s 3D lower extremity CT angiography revealed widespread osteochondromas in both lower extremity bones and a hypodense area compatible with active bleeding on the anterolateral side of the right thigh. It was thought that the bleeding was due to a pseudoaneurysm resulting from oseochondroma in the distal superficial femoral artery, and the patient was taken into emergency surgery. During surgery, the pseudoaneurysm sac was resected and the sperficial femoral artery was primarily repaired. The osteochondroma adjacent to the artery was resected. The patient was discharged with anticoagulant medication without any complication. Doppler ultrasonography performed in the first postoperative month, the arterial and venous systems was patent. While vascular doppler ultrasonography is sufficient for the diagnosis of pseudoaneurysm, CT-angiography is more important in detecting the cause of pseudoaneurysm. We think that osteochondromas should be considered as a priority, especially in cases of spontaneous vascular injuries after sports. While an endovascular approach is suitable for many pseudoaneurysms, an open surgical approach is mandatory for cases like osteochondroma.

• Keywords: Osteochondroma; Vascular Complications; Femoral Artery Pseudoaneurysm

1.37.9. BTK&BTA Full Vessels’ Recanalization

• Eleonora Tundo
  Interventional Radiology Unit, Diabetic Foot Department, Policlinic of Abano, Abano Terme (PD), Italy; University of Padua, Padua, Italy

BACKGROUND: Male, 70 yrs old, DMT2 on insulin, inferior limbs’ diabetic neuro-vasculopathy, diabetic retinopathy, dyslipidemia. Previous amputation of left foot’s 1st toe and ray and of the 2nd metatarsal bone. Plantar ischemic lesion of the 3rd–4th MPJ with tendon exposure.

CASE REPORT: This is a case of failed attempts. Each first choice strategy was unsuccessful. Therefore, this surgery turned out to be perfect in order to remember that you always need a plan B.

We performed an antegrade access from CFA. The angiograms were physiological until the femoropopliteal segment. IOA was the only opened vessel of the BTK district, ATA showed a long occlusion from the proximal to the distal third, PT was also occluded from the medial third on. At foot level a slight DP was visible, plus collaterals.

Firstly, we engaged ATA with a 014 workhorse guidewire, we crossed the CTO but we were not able to re-enter the lumen. Therefore, we entered IOA and arrived in lumen in the distal third of ATA through a connection collateral between the two arteries. We retrogradely crossed ATA and we performed angioplasty.

We tried to reopen PT in antegrade fashion, without success. Thus, we punctured the distal third of PT and engaged the lumen in retrograde manner. We performed a rendez-vous technique through a navicross catheter from below plus OTW balloon from above and we succeeded in the angioplasty of PT.

Since the PT was now fully opened, we tried going further and crossing the lateral plantar artery’s CTO, but we failed again. Hence, we engaged DP in antegrade way, we crossed the plantar arch and went up to the PT. It was possible then to do the PTA of lateral plantar artery.

Eventually, thanks to plan Bs, we succeeded in a complete reconstruction of the BTK and BTA vessels.

• Keywords: diabetic foot; below the knee; below the ankle; endovascular surgery

1.37.10. Preserving Limb Integrity: Successful Angioplasty Intervention in Chronic Diabetic Foot Ulcer in Indonesia

• Juliana Juliana ¹ and Yosis Yohannes Motulo ²

1

Faculty of Medicine, Airlangga University, Surabaya, Indonesia

2

Cardiothoracic and Vascular Surgery Department of PHC General Hospital, Surabaya, Indonesia

BACKGROUND: Diabetic foot ulcers (DFUs) present formidable challenges in treatment, often culminating in amputation due to complications associated with impaired wound healing. Despite these challenges, emerging evidence highlights promising alternative interventions such as angioplasty, providing prospects for limb salvage and enhanced outcomes in select cases. With Indonesia ranking as the 5th country globally in terms of diabetes prevalence, the nation faces a significant burden of diabetic foot complications. The prevalence of DFUs, ranging from 7.3% to 24%, underscores the pressing need for effective interventions to mitigate their impact on population health.

CASE: In this case series, we present 10 cases of chronic DFUs in patients previously referred from other hospitals where major amputation was recommended. Contrary to conventional management approaches favoring amputation, all patients underwent angioplasty at our hospital, resulting in successful limb salvage and wound healing. The series details 10 cases of chronic DFUs in patients aged between 62 and 71 years, predominantly female. These individuals, with mean durations of diabetes ranging from 3.5 to 7 years, presented with comorbidities including smoking and hypertension. Angioplasty emerged as the treatment modality across all cases. Encouragingly, no major procedural complications were encountered, and the duration of wound healing post-angioplasty varied from 3 to 6 months. Follow-up assessments revealed notable improvements in clinical presentation, including reduced claudication and resting pain. This case series highlights the effectiveness of angioplasty as a limb-sparing intervention in managing DFUs, particularly within the Indonesian context. By preserving limb integrity and promoting wound healing, angioplasty holds promise in mitigating the impact of DFUs on patient morbidity and mortality, enabling some patients to avoid major amputation altogether and others to reduce the extent of amputation while maintaining functional mobility.

• Keywords: angioplasty; chronic diabetic foot ulcers; limb salvage; wound healing; alternative intervention; amputation

1.37.11. A Case of the Aneurysm of Bovine Mesenteric Vein Graft

• Ugur Cetingok ¹, Hasan Yilmazturk ² and Hamdi Mehmet Ozbek ²

1

Department of Cardiovascular Surgery, Etlik City Hospital, Ankara, Türkiye

2

Department of Cardiovascular Surgery, Sincan Training and Research Hospital, Ankara, Türkiye

The vascular graft aneurysm is a rare complication after vascular surgery. Xenografts may be associated with complications and true or false aneurysm formation is major complication of these grafts. It is suggested that proteolytic digestion of foreign biomaterials mediates aneurysm formation. Collagenase exposure may also contribute to aneurysm formation in organic materials. A 54 years old man was presented with severe pain and pulsatile mass of his right leg. The right iliofemoral bypass and bilateral above knee femoropopliteal bypass was performed four years ago. The iliofemoral graft was the PTFE and the femoropopliteal grafts were the bovine mesenteric vein grafts (Procol^®). There was massive pulsatile mass on right leg along the bovine mesenteric vein graft. All pulses were palpable. Computerized tomography and MR angio were demonstrated extensive aneurysm of the right femoropopliteal bovine mesenteric vein graft. The patient was operated because of the bovine mesenteric vein graft aneurysm. Aneurysmectomy and femoropopliteal bypass with internal mammary artery graft was performed. Microscopic examination of the removed graft material revealed foreign body reaction. The vascular bioprostheses have been used since 1970s. Indication of vascular bioprostheses are mainly hemodialysis access graft in chronic renal failure patients and various bypass procedures. The complications of the xenografts are thrombosis, infection and true or false aneurysm. The false aneurysms are more common. Proteolytic digestion of foreign biomaterials mediates aneurysm formation. Collagenase exposure may also contribute to aneurysm formation in organic materials. The aneurysm more commonly occur in proximally grafts and the risk increases by time. There is high risk for rupture of the aneurysm. Excision of the aneurysm and implantation of the new graft are indicated.

• Keywords: bovine graft; aneurysm

1.37.12. Endovascular Treatment of the Right Subclavian Artery Occlusion Due to Radiotherapy

• Ugur Cetingok ¹, Ibrahim Koray Ünal ² and Fatih Yamac ²

1

Department of Cardiovascular Surgery, Etlik City Hospital, Ankara, Türkiye

2

Department of Cardiovascular Surgery, Sincan Training and Research Hospital, Ankara, Türkiye

After radiotherapy, various degrees of damage occur in the arteries in the treated area, depending on the radiation dose (>50 Gray). This effect is higher in patients with hypertension, hyperlipidemia and smoking. Ischemic complications develop depending on the exposure rate. The patient, who received radiotherapy to the right upper mediastinum and neck region after lobectomy due to lung cancer, developed skin burns due to radiotherapy, and 6 months after the treatment, claudication complaints began on the right arm. Over the last month, his pain has become increasingly severe, and his right hand has become cold, bruising, and ischemic wounds have developed on his fingertips. There was no right upper extremity pulse. There was skin scarring and stiffness on the right apex and neck. Right subclavian and axillary artery occlusion was detected in RDUSG. Angiography showed that the right subclavian artery was completely occluded 1 cm after its origin, there was serious stenosis in the 4 cm section at the axillary artery level, but there was arterial filling, and the distal axillary artery, brachial, radial and ulnar arteries were normal. The procedure was performed from the right brachial artery with imaging support from the right femoral artery. The thrombus located in severe stenosis in the subclavian artery was removed with ThromCath thrombectomy catheter system, and minimal lumen patency was achieved. The procedure was performed from the right brachial artery with imaging support from the right femoral artery. The thrombus located in severe stenosis in the subclavian artery was removed with the Thromcath aspiration thrombectomy catheter, a 9 × 50 mm Zeus CC CoCr balloon expandable stent was implanted. Post dilation was performed with a 9 × 60 mm high pressure balloon. Compared to open surgery and endovascular intervention in arterial occlusions due to radiotherapy, endovascular intervention is safe and low risk.

• Keywords: arterial occlusion; radioterapy; endovascular treatment

1.37.13. Approach to Type I Endoleak in a Case of the Superficial Femoral Artery Aneurysm Treated with a Covered Stent

• Ugur Cetingok ¹, Ayse Ozcetin ² and Ibrahim Koray Unal ³

1

Department of Cardiovascular Surgery, Etlik City Hospital, Ankara, Türkiye

2

Department of Cardiovascular Surgery, Ankara Education and Research Hospital, Ankara, Turkiye

3

Department of Cardiovascular Surgery, Sincan Training and Research Hospital, Ankara, Türkiye

The superficial femoral artery aneurysm is uncommon. The patients present with limb ischemia, distal embolization, or rarely rupture. Aneurysm is diagnosed by ultrasound and computed tomography. The treatment is usually surgical. Aneurysm excision and graft interposition or aneurysm ligation and arterial bypass are surgical treatment options. Endovascular repair using a covered stent of the aneurysm is an alternative treatment method in the patients with suitable anatomy. A 41-year-old man presented with pain and swelling in his left thigh. The patient had surgery for the right superficial femoral artery aneurysm 4 years ago. An aneurysm with a diameter of 60 mm and involving the middle segment of the left superficial femoral artery was detected by ultrasound. Arterial blood flow distal to the aneurysm was normal. The aneurysm was treated by endovascular procedure. A covered stent was implanted to the site of the aneurysm. Minimally type I endoleak was detected after the procedure. No additional procedure was performed for endoleak. One month later, the leak was observed to have resolved spontaneously. If type I endoleak is low-flow, spontaneous healing is likely. No additional procedure is required.

• Keywords: aneurysm; superficial femoral artery; endovascular treatment

1.38. VASCULAR AND ENDOVASCULAR » Prosthetic Infections

Late Spontaneous Rupture of Knitted Dacron Double Velour Vascular Prostheses: A Case Report

• Ugur Cetingok ¹, Ibrahim Koray Unal ² and Abdulkadir Guzel ²

1

Etlik City Hospital, Ankara, Turkey

2

Sincan Training and Research Hospital, Ankara, Turkey

Spontaneous rupture of Dacron vascular graft is a rare complication. This complication, although unusual, has been noted periodically in the literature. Incidence of the graft rupture was about 3% in some literatures [1,2]. Deterioration consisted of thinning and breakage of yarn filaments, causing development of holes and, in some cases, graft dilatation (2). Diagnosis is made by clinical examination and imaging, which shows the aneurysm of the graft away from the anastomoses. A 71-year-old male was presented with a large pulsatile mass (3 cm × 4 cm) under the inguinal ligament in the left groin. The patient had an iliofemoral bypass operation with knitted dacron double velour vascular graft 16 years ago. The patient complained of claudication intermitant after walking 50 m and had no popliteal pulses. CT angiography was showed aneurysmatic dilatation in the left iliac region and occlusion of both superficial femoral arteries. During the surgery, it was observed that the Dacron graft placed in the iliofemoral position ruptured linearly and limited itself by forming a pseudoaneurysm. The defective graft segment was removed and interposition with PTFE graft. Moreover, bilateral femoropopliteal bypass was performed. In the pathological examination of the graft material, a foreign body reaction was observed. We present this case to alert vascular surgeons of the possibility of Dacron graft degeneration, as late as 16 years after implantation.

• Keywords: dacron vascular graft; late deterioration; rupture

1.39. VASCULAR AND ENDOVASCULAR » Thoracic Aorta

1.39.1. Hybrid Aortic Arch Repair in Patients Who Have Type-I Aortic Dissection After Cardiac Surgery

• Mete Kubilay Kasap, Ömer Faruk Doğan, Nazenin Durak and Özgür Çoban
• Sbü Adana City Research and Training Hospital, Adana, Turkey

BACKGROUND AND AIM: Traditional aortic dissection (AD) surgery involves resect the primary intimal tear and re-approximate the intima and adventitia. However, residual dissection flap and false lumen(s) which is cause of mortality during follow up period persist in aorta in 76% of patients. Our purpose of this study was to evaluate clinical outcomes after use of hybrid techniques in patients with AD.

METHOD: Fifty-five patients who have already undergone cardiac operation included between 2014 to 2023. The mean age of the patients was 62.3 years. Aortic valve replacement (AVR) (n = 19), Benthall operation (20), and AVR and separated ascending aortic repair (16) using tube graft were the primary operations. Frozen elephant trunk (ET), revascularisation of the supra-aortic branches concomitant with TEVAR, and stent-graft repair without surgery (fenestrated and/or branched TEVAR) were used in our cohort. We used flow directed stent graft in 26 patients with a dissecan abdominal aortic aneurysm (47.2%).

RESULTS: Postoperative course was uneventful except 1 patient. This patient dead after surgery due to multiorgan failure. Postoperative hemiparesis was detected in 2 patients. Magnetic resonance imaging showed embolic event in parietal lobe in these patients (6.3%). The median ECC and an aortic cross clamp were 126 and 79 min, respectively. Mean length of hospital staying time was 9.4 days (5–19 day). No revision was needed postoperatively. Low out-put syndrome was detected 8 patients. During follow-up period (44 months) the rate of death was at 4%. False lumen thrombosis on descending thoracic aorta was obtained in all survived patients. The rate of aortic reintervention was 3.3% on abdominal aorta.

CONCLUSIONS: To provide visceral organ malperfusion, false aortic aneurysm, persistancy or residual false lumen which cause of aortic rupture, we propose hybrid procedure in these patients. Flow directed stent graft after repair of AD may provides organ malperfusion. This method seems to be effective method to inhibit unexpected complications mid- and long-term complications.

• Keywords: Aortic dissection; hybrid treatment; endovascular surgery

1.39.2. Primary Hydatid Cyst of the Thoracic Aorta

• Zied Ben Ayed, Mohamed Seddik, Nawel Hchaichi, Mohamed Fendi, Imen Smaoui, Zied Chaari and Imed Frikha
• Department of CardioVascular and Thoracic Surgery, Habib Bourguiba University Hospital, Sfax, Tunisia

BACKGROUND AND AIM: Tunisia is one of the endemic areas for hydatid diseases, the aortic location is exceptional, especially primitive hydatidosis.

METHOD: We report the case of a 55-year-old woman who had consulted for pain and coldness of the left lower limb from one week.

A computed tomographic angio-gram showed a multivesicular and fluid-density mass intimately contiguous to the descending thoracic aorta seen on an endoluminal subtraction image and hydatid cysts in the spleen.

RESULTS: The surgical approach was adopted via a thoracophrenolombotomy with right femorofemoral bypass.

The surgery consisted for a complete resection of the destroyed aortic portion, and continuity was restored by an aortoaortic bypass using a Dacron Graft prosthesis.

Then, thrombectomy of the left iliac artery and extraction of a fresh hydatid thrombus.

The surgical procedure was completed by a splenectomy.

Postoperative follow-up was uneventful.

After 6 months, computed tomographic angiography showed a patent bypass.

CONCLUSIONS: The aorta is rarely affected by hydatidosis, the aortic localization is serious and can be responsible of systemic dissimulation, The treatment of hydatidosis is essentially surgical and consisting of the total removal of hydatid cysts, making sure to take all possible precautions not to open the cysts.

• Keywords: aorta; hydatidosis; thoracophrenolombotomy; aortoaortic bypass

1.39.3. Concomitant Kommerell Diverticulum, Aberrant Left Subclavian Artery and Right Aortic Arch in an Adolescent Patient

• Fulya Topuz ¹ and Oğuz Omay ²

1

Department of Cardiovascular Surgery, Yalova Education and Research Hospital, Yalova, Turkey

2

Department of Cardiovascular Surgery, Kocaeli University Faculty of Medicine, Kocaeli, Turkey

BACKGROUND AND AIM: Kommerell diverticulum is a congenital dilatation of the aortic arch at the origin of the aberrant right subclavian artery (ARSA) or aberrant left subclavian artery (ALSA). The association of right aortic arch and ALSA is rare and is an anatomical feature observed in approximately 0.06% to 0.1% of the healthy population. They can cause a wide range of clinical symptoms from critical respiratory distress in the neonatal period due to compression of the trachea or esophagus to asymptomatic and diagnosed in adulthood. There is a risk of spontaneous aortic rupture even in asymptomatic adults. Therefore, it has been reported that surgery should be performed even in the presence of mild compression symptoms, with conservative management in asymptomatic patients and surgery in symptomatic patients.

METHOD: In this case report, ALSA associated with right aortic arch and Kommerell diverticulum in a 17-year-old female adolescent is discussed. The patient who presented with dyspnoea and dysphagia had significant focal thinning in the luminal calibration of the oesophagus near the level of the aortic knob on oesophageal-gastroduodenal-radiography, suggesting that it may be due to external compression. CT-angiography shows right arcus aorta, left subclavian artery is aberrant behind the trachea and oesophagus and its orifice is wide (13 mm).

RESULTS: Operation was decided due to the symptoms. Following left posterolateral thoracotomy, the adhesions between the oesophagus and the left subclavian artery were dissected. Adhesions on the commerell diverticulum were separated after ligamentum arteriosum division between the pulmonary artery and subclavian artery. Left carotid and subclavian artery were anastomosed with ptfe graft. Kommerell diverticulum was excised with side-clamp placed on the descending aorta. The aorta was repaired primarily and the patient was taken to the post-operatif intensive care unit. The patient was discharged 15-days after the operation.

CONCLUSIONS: The key points for symptom regression are complete resection of the diverticulum, ligamentum arteriozum division, removal of adhesions. In addition, revascularisation of the subclavian artery is also important.

• Keywords: Kommerell Diverticulum; ALSA; Right Aortik Arch

1.39.4. Is Female Gender Really a Predictor of Worse Outcome During TEVAR Procedures?

• Gabriele Piffaretti ¹, Francesca Mauri ¹, Sara Speziali ², Gaddiel Mozzetta ³, Sergio Zacà ⁴, Maria Cristina Cervarolo ¹, Raffaele Pulli ², Giovanni Pratesi ³, Aaron Thomas Fargion ², Martina Bastianon ³, Andrea Cucci ⁴ and Carlo Pratesi ²

1

Vascular Surgery—Department of Medicine and Surgery, University of Insubria, Varese, Italy

2

Vascular Surgery—Cardio-Thoraco-Vascular Department, University of Florence, Florence, Italy

3

Vascular Surgery—Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Genova, Italy

4

Vascular Surgery—Department of Emergency and Organ Transplants, University of Bari, Bari, Italy

BACKGROUND AND AIM: To evaluate gender-related outcomes during endovascular treatment of thoracic and thoraco-abdominal aortic pathologies (TEVAR).

METHOD: Multicenter, retrospective, observational cohort study based on a shared registry of four academic centers. All cases of TEVAR between November 2001 and April 2023 were identified. Primary outcomes: hospital and cumulative survival. Secondary outcomes: complications related to vascular access and freedom from TEVAR-related reintervention. Outcomes were stratified by clinical scenario (elective vs. emergency), extent of disease (thoracic vs. thoraco-abdominal) and type of aortic disease (degenerative atherosclerotic vs. dissection-related vs. traumatic).

RESULTS: We analyzed 749 patients (98.0%): 214 (28.6%) females and 535 (72.4%) males. The median age was 72 years (IQR, 65–78), higher in females [74 (IQR, 68–79) vs. 71.5 (IQR, 64–78), p = 0.001]. Hospital mortality was not influenced by gender by clinical scenario (OR: 1.3, p = 0.105), extent (OR: 1.4, p = 0.170), and type of pathology (OR: 1.4, p = 0.331). The estimated 5-year cumulative survival was 67% (SE: 0.02; 95% CI: 62.7–70.9), without gender-related differences by clinical scenario (Log-rank, p = 0.145), extent of pathology (Log-rank, p = 0.141) and type of aortic disease (Log-rank, p = 0.182). Access complications did not differ either by type (OR: 1.1, p = 0.798) or when stratified by emergency (OR: 1.1, p = 1.0) or type of aortic pathology (OR: 1.6, p = 0.265). The estimated 5-year freedom from reoperation was 88% (SE: 0.02; 95% CI: 84.0–91.1), with no differences by clinical scenario (Log-rank, p = 0.491), extent of pathology (Log-rank, p = 0.868) and type of aortic pathology (Log-rank, p = 0.585).

CONCLUSIONS: In our “real world” experience, female gender was not a worsening factor for TEVAR procedures.

• Keywords: TEVAR; thoracic endovascular aortic repair; gender

1.39.5. Mini-Hemiarch Repair for Ascending Aortic Aneurysm

• Dmitri Panfilov and Boris Kozlov
  Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia

BACKGROUND AND AIM: Minimal invasive surgery is increasingly used for the treatment of thoracic aortic disease. The objective of the study was to analyze early outcomes of mini-hemiarch repair in patients with ascending aortic aneurysm

METHOD: From January 2020 to December 2023, a total of 116 ascending aortic surgical procedures were performed in our centre. Of these, 87 patients had ascending aortic aneurysm. These patients received ascending aortic replacement with concomitant hemiarch repair. Patients were divided into 2 groups depending on surgical approach: full sternotomy (FS, n = 54) and mini-J sternotomy (MS, n = 33). Pre-, intra- and postoperative data were analyzed

RESULTS: Overall in-hospital mortality was 2 (3.7%) vs. none in FS group and MS group, respectively (p = 0.564). There was no permanent and temporary cerebral neurological deficit in both groups. The rate of postoperative respiratory failure, acute kidney injury was 5.6% versus 3% (p = 0.061) and 9.3% versus none (p < 0.001) in FS group and MS group, respectively. Re-exploration for bleeding was required in 1 (1.9%) FS patient and in 1 (3%) MS patient (p = 0.238).

CONCLUSIONS: Ascending aortic replacement with hemiarch repair for ascending aortic aneurysm through mini-J sternotomy is an effective and safe approach with acceptable early outcomes

• Keywords: ascending aortic aneurysm; ascending aortic replacement; hemiarch; ministernotomy

1.39.6. Integrated Multi-Omics Profiling Reveals Neutrophil Extracellular Traps Promote Aortic Dissection

• Yufei Zhao, Fandi Mo, Zheyun Li, Lixin Wang and Weiguo Fu
  Zhongshan Hospital Fudan University, Shanghai, China

BACKGROUND AND AIM: Adverse aortic remodeling increases the risk of aorta-related adverse events (AAEs) after thoracic endovascular aortic repair (TEVAR) and affects the overall prognosis of aortic dissection (AD). It is imperative to delve into the exploration of prognostic indicators to streamline the identification of individuals at elevated risk for postoperative AAEs, and therapeutic targets to optimize the efficacy of TEVAR for patients with AD.

METHOD: We performed proteomic and single-cell transcriptomic analyses of peripheral blood samples and aortic lesions, respectively, from patients with AD and healthy subjects. We performed in vivo experiments to further confirm the effect of inhibiting NETs. Kaplan-Meier and Cox regression analysis were used to identify independent risk factors for AAEs.

RESULTS: Integrated multi-omics profiling identified highly phenotype-associated macrophages, which frequently interacted with neutrophils via CXCL3/CXCR2 axis, and promoted neutrophil extracellular traps (NETs) in driving and fueling the development of AD. Increased NETs formation is a defining feature of systemic immunity and aortic microenvironment of AD. Furthermore, we demonstrated that the level of citrullinated histone H3 (CitH3), a NETs associated marker, could serve as a risk factor for AAEs following endovascular therapy. Inhibiting NETs formation through the blockade of CitH3 alleviated the progression and rupture of AD in mice.

CONCLUSIONS: The multi-omics profiling reveals NETs formation features in the development of AD. NETs associated markers could facilitate the risk stratification and prognostic evaluation, and might serve as potential therapeutic targets of patients with AD.

• Keywords: Aortic dissection; Aorta-related adverse events; Neutrophil extracellular traps

1.39.7. Mild Versus Moderate Hypothermia for Cerebral Protection in Aortic Arch Surgery: A Meta-Analysis of Nine Studies

• Navneet Singh and Parma Nand
• Department of Cardiothoracic Surgery, Auckland City Hospital, Auckland, New Zealand

BACKGROUND AND AIM: Open thoracic aortic surgery remains the mainstay of treatment for type A aortic dissections and aortic arch aneurysms. In order to provide neurological protection when operating on the aortic arch, hypothermia is commonly used intraoperatively to reduce cerebral metabolic demand and minimise the impacts resulting from temporarily-reduced intracerebral blood flow. Most centres use moderate (20–28 °C) or deep (14–20 °C) hypothermic circulatory arrest for this purpose. However, these low temperatures are known to have negative consequences on visceral organ function and coagulopathy. We hence aimed to investigate whether mild hypothermia (>28 °C) achieves acceptable postoperative neurological outcomes (stroke rates) as compared to moderate hypothermia during aortic arch surgery.

METHOD: A systematic review and meta-analysis of all randomised and non-randomised studies investigating our study aim was undertaken as per the PRISMA guidelines. Review Manager 5.4 software was utilised for statistical analyses.

RESULTS: Nine observational studies met inclusion criteria with a total sample size of 1357 patients. No randomised controlled trials were available on this topic. Mild hypothermia (with selective cerebral perfusion) correlated with statistically significantly reduced postoperative permanent neurological dysfunction (strokes) as compared to moderate hypothermia (odds ratio 0.39, 95% confidence interval 0.24–0.64, p = 0.0001). Mild hypothermia also correlated with significantly reduced rates of postoperative acute renal failure (odds ratio 0.51, 95% confidence interval 0.33–0.80, p = 0.003). There was no difference in the rate of re-exploration for bleeding between the two groups (odds ratio 0.66, 95% confidence interval 0.42–1.03, p = 0.07).

CONCLUSIONS: Mild hypothermia—in conjunction with selective cerebral perfusion—may be a safe alternative to moderate hypothermia for providing neurological protection during circulatory arrest in aortic arch surgery. However, robust randomised data is required to corroborate this theory.

• Keywords: aortic arch surgery; cerebral protection; hypothermia

1.39.8. Indigenous Ethnic Disparities in Patients Undergoing Repair of Ascending Aortic Aneurysms in Aotearoa New Zealand: A Prospective Cohort Study

• Navneet Singh and David Haydock
• Department of Cardiothoracic Surgery, Auckland City Hospital, Auckland, New Zealand

BACKGROUND AND AIM: Ascending aortic aneurysms carry a high morbidity and mortality risk; surgical treatment is often indicated. There is no published work investigating the relationship between ethnicity and the incidence of and outcomes from ascending aortic aneurysm surgery in the unique indigenous Aotearoa New Zealand population. We aimed to review the ethnicity trends for New Zealand patients undergoing elective ascending aortic aneurysm surgery.

METHOD: A prospectively-maintained hospital database was used to identify patients receiving standalone elective ascending aortic surgery (with or without aortic valve intervention) for aneurysm repair from January 2015–July 2019. Outcomes were sub-stratified by ethnicity and statistically analysed using two-tailed z-tests and t-tests.

RESULTS: During the 4.5-year study period, a total of 134 patients underwent elective surgery to treat isolated ascending aortic aneurysmal disease; this included New Zealand European, indigenous Maori and Pacific Island patients. Approximately 20.1% of patients were Pacific, which is significantly greater than their overall New Zealand population proportion of 8.1% (p < 0.00001). There was no difference in risk factors (such as hypertension, gender, smoking status or genetic aortopathy) for developing aortic aneurysms between Pacific and non-Pacific patients. There were no significant ethnic differences in 30-day post-operative mortality or stroke rates.

CONCLUSIONS: This is the first ever study investigating elective ascending aortic aneurysm surgery in New Zealand by ethnicity. Pacific patients are over-represented in aortic surgery case numbers; this is not explained by their underlying incidence of aneurysm risk factors. This suggests that the Pacific population may have an underlying predisposition that puts them at higher risk for developing ascending aortic aneurysms which require surgery.

• Keywords: ascending aortic aneurysm; ethnicity; indigenous

1.39.9. Comparison of Controlled Hypotension Methods in Patients Undergoing Proximal Zone TEVAR

• Osman Eren Karpuzoğlu, Anıl Karaağaç, Osman Murat Baştopçu, Ferhat Tümkaya and Naci Cem Aydoğdu
• Department of Cardiovascular Surgery, Dr. Siyami Ersek Training and Research Hospital, Istanbul, Turkey

BACKGROUND AND AIM: Optimal placement and maximizing seal zone are important for long-term outcomes after thoracic endovascular aortic repair (TEVAR). The aortic impulse force exerted on the stent-graft is higher with more proximal landing zones, especially in Zone 0, 1 and 2 applications, which may lead to difficulties in precise placement. Different methods such as pharmacologic hypotension (PH), rapid ventricular pacing (RVP), and cardiac inflow occlusion can be used to minimize aortic impulse force during stent-graft deployment. In this study, we aimed to compare the methods used in our clinic to create controlled hypotension in proximal TEVAR applications.

METHOD: The study included 47 patients who underwent proximal TEVAR (Zone 0–1-2) between January 2018 and March 2024 in our center. Maximum sealing zone was aimed in all patients. Systolic blood pressure was targeted to be between 60–80 mmHg in all of the patients during stent-graft deployment. Demographic, intraoperative and postoperative data of the patients were analyzed.

RESULTS: PH was performed in 34 patients (72.3%) and RVP in 13 patients (27.7%). Deviation from the target occurred in 11 patients (32.4%) in the PH group, while deviation from the target was observed in 4 patients (30.8%) in the RVP group (p = 0.999). The mean target deviation distances were 1.8 ± 3.2 mm in the PH group and 2.00 ± 3.43 mm in the RVP group (p = 0.890). Establishing a normal hemodynamic state was faster in patients in the RVP group.

CONCLUSIONS: Although PH is frequently used to induce controlled hypotension in endovascular aortic repair procedures, RVP can provide similar outcomes with more rapid normalization of hemodynamics after deployment. We believe that RVP can be safely used to create controlled hypotension especially in proximal TEVAR applications.

• Keywords: TEVAR; rapid ventricular pacing

1.39.10. The Effect of Left Subclavian Artery Revascularization on Outcomes After Zone 2 TEVAR

• Osman Eren Karpuzoğlu, Anıl Karaağaç, Osman Murat Baştopçu, Ferhat Tümkaya and Naci Cem Aydoğdu
• Department of Cardiovascular Surgery, Dr. Siyami Ersek Training and Research Hospital, Istanbul, Turkey

BACKGROUND AND AIM: Careful assessment of the extent of the aortic pathology and adequate sealing zone are important for procedural success and long-term outcomes in TEVAR. Especially in pathologies originating close to the left subclavian artery (LSA), Zone-2 TEVAR is preferred. The risk of neurological complications (CVA, paraplegia) may be higher if LSA revascularization is not performed in these patients. Although interventions for the LSA may sometimes be neglected or postponed in emergent cases, current literature recommend subclavian revascularization before TEVAR in elective cases. With the advances in endovascular techniques, revascularization with fenestrated TEVAR and chimney stents are also possible. In this study, we compared outcomes of patients according to LSA revascularization status after TEVAR.

METHOD: The study included 32 patients who underwent Zone 2 TEVAR between 2018–2024. Demographic, intraoperative and postoperative data of the patients were analyzed along with CT-angiography and procedural images.

RESULTS: Technical success was achieved in all patients. While no endoleak was observed in the early postoperative period, 1 patient (3.1%) was operated for type 1 dissection. Migration of the TEVAR graft was observed in only 1 patient (3.1%) without endoleaks. In 21 patients (65.6%), LSA revascularization was performed with different methods before or during the procedure. LSA revascularization methods were caroticosubclavian bypass in 18 patients, chimney stents in two patients and a fenestrated TEVAR in 1 patient. Neurological complications were observed in 4 of 11 patients (36.4%) who did not undergo revascularization before or during the procedure, whereas neurological complications were observed in 4 of 21 patients (19.0%) who did (p = 0.397).

CONCLUSIONS: TEVAR in pathologies located in proximity of the LSA are more challenging than distal pathologies. Zone-2 TEVAR is a good alternative in this patient group to achieve good long-term results. Revascularization of the LSA in these patients is of great importance in terms of early neurological complications and can be performed with surgical or endovascular methods.

• Keywords: TEVAR; left subclavian artery; physician modified TEVAR; parallel stent graft

1.39.11. Preliminary Results of Aortic Arch Aneurysm and Dissection Endovascular Repair with Physician-Modified Endografts

• Andrea Kahlberg, Carlo Campesi, Daniele Mascia, Annarita Santoro, Roberto Chiesa and Germano Melissano
  Department of Vascular Surgery, “Università Vita-Salute” San Raffaele Hospital, Milan, Italy

BACKGROUND AND AIM: To assess the early outcomes of physician-modified endovascular grafts (PMEGs) for total endovascular aortic arch aneurysm or dissection repair.

METHOD: A single-center retrospective analysis included all patients submitted to PMEG implantation in the aortic arch between January 2023 and March 2024. Indications included: zone 1/2 lesions, or zone 0 saccular aneurysms arising from the arch lesser curvature; proximal neck diameter 24–40 mm, with 20-mm minimum length. Arches presenting parietal thrombus, severe calcification, or associated infection were excluded. PMEG indication was driven by urgency (symptomatic/unstable lesion), or anatomical exclusion from custom-made device use.

RESULTS: Nine patients (6 males; median age 73 years) were included, presenting 3 degenerative and 6 dissecting aortic arch aneurysms. In 3 cases a single preloaded fenestration for the left subclavian artery (LSA) was performed, while in 6 cases an additional proximal large fenestration for the brachiocephalic trunk and the left common carotid artery (LCCA) was realized. Technical success was obtained in 8 patients (89%). In one case the procedure was aborted due to failure to rotate and position the endograft, given extreme abdominal and thoracic aortic tortuosity. No deaths occurred at 30 days. One patient presented asymptomatic LCCA occlusion at 1 month treated by means of LSA-LCCA bypass. No type endoleak, conversion to open surgical repair, aortic rupture, or paraplegia was observed at 1, 3, and 6 months.

CONCLUSIONS: Single or double fenestrated PMEGs may be used in selected aortic arch pathologies (urgent or unsuitable for custom-made devices), showing preliminary promising early results, and unexpected low rate of reinterventions and major complications in our initial experience

• Keywords: aortic arch aneurysm; aortic dissection; physician-modified endograft

1.39.12. Initial Ukrainian Experience of Total Arch Replacement by Frozen Elephant Trunk Operation Technique

• Lubomyr Kulyk ¹, Vitalii Kravchenko ², Bogdan Cherpak ², Igor Zhekov ², Oleksandr Tretiiak ² and Vasyl Lazoryshynets ²

1

Danylo Halytsky Lviv National Medical University, Lviv, Ukraine

2

M.Amosov National Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine

BACKGROUND AND AIM: Ongoing development of cardiovascular technologies has made it possible to carry out simultaneous replacement of the ascending, arch and descending thoracic aorta (frozen elephant trunk operation).

METHOD: From 2020 to 2024 in the National M. Amosov ICVS of the NAMS of Ukraine, operated on 797 patients with different kind of aortic pathology, 256 of them were admitted with TAAD; 55 operation of total arch replacement and 25—frozen elephant trunk operation (FET) were performed. Patients age were 36–68 y.o, mean—54.2 ± 6.4; 18 (72.0%) patients are male. Concomitant CAD had 6 (24.0%), COPD—8 (32.0%), CRF—5 (20.0%), DM—5 (20.0%), pulmonary hypertension—3 (12.0%), severe mitral insufficiency—2 (8.0%). Three patients had right aberrant subclavian artery—a.lusoria. Twelve pts (48.0%), had cardiac operation previously. The causes of aortic injury were: acute type A aortic dissection—1 (4.0%); chronic type A aortic dissection—12 (48.0%), non A non B aortic dissection—5 (20.0%), chronic type B aortic dissection—2 (8.0%); blunt aortic injury (BAI)—2 (8.0%), TAAA—3 (12.0%). Simultaneously with the FET, we performed Jacoub operation—2, CABG—6 (1–3), MV repair—2, TV plication—4. All operation we profound with 25 °C hypothermia and ACP for all three cerebral vessels. We used E-Vita Open Plus—14 and E-Vita Open Neo—11. Three operations we operated on urgently, other planned.

RESULTS: Hospital mortality—8.0%. The reasons of death were stroke and severe pulmonary insufficiency respectively. Two patients had neurological complication—permanent paraplegia and transient stroke. Renal failure needed temporary dialysis—3. Bleeding, needed re-thoracotomy—1. Prolonged ventilation—4 pts.

CONCLUSIONS: FET operation allowed treatment of complex patients with extensive thoracic aortic diseases with satisfactory results.

• Keywords: aneurysm; aortic arch; frozen elephant trunk

1.39.13. Gene Expression Profile of Interleukin 8 & Interleukin 18 Pathways in Veins and Aorta

• Melvin Alferd Tokpah ¹, Ozlem Balcioglu ², Aya Ismail Badeea ¹, Ali Askin Korkmaz ², Barcin Ozcem ² and Mahmut Cerkez Ergoren ¹

1

Department of Medical Genetics, Faculty of Medicine, Near East University, Nicosia, Cyprus

2

Department of Cardiovascular Surgery, Faculty of Medicine, Near East University, Nicosia, Cyprus

BACKGROUND AND AIM: This research aimed to investigate the expression pathways of IL-8 and IL-18 genes in veins and aorta tissues obtained from patients with various cardiovascular conditions. Interleukins play crucial roles in immune response regulation, and understanding their expression in different tissues is vital for further studies. While previous research has focused on various specimens like blood and cardiac muscles of animals, there’s limited data on human vein and aorta tissues

METHOD: Tissue samples were collected from patients diagnosed with cardiovascular diseases. RNA extraction, cDNA synthesis, and PCR techniques were employed to analyze gene expression levels. The study included 103 samples, categorized into patient and control groups.

RESULTS: Results indicated significant differences in the expression levels of IL-8 and IL-18 between veins and aorta tissues, both in control and patient groups. IL-18 was found to be primarily expressed in both tissues, with implications for biomarker status and underlying health conditions. However, the exact role of IL-18 in inflammation remains unclear, warranting further research.

The study suggests that aorta tissues could serve as a valuable source for understanding IL-18 expression and regulation. Given the importance of interleukin screening across populations and its significance in various biological activities and diseases, integrating IL screening into healthcare systems is crucial.

CONCLUSIONS: This research sheds light on the expression patterns of IL-8 and IL-18 in cardiovascular tissues, underscoring their potential as biomarkers and emphasizing the need for further investigation into their roles and regulation mechanisms.

• Keywords: gene expression; interleukin-8; interleukin-18; veins; aorta; cardiavascular disease

1.39.14. Total Endovascular Arch Replacement for a Non-A, Non-B Aortic Dissection

• Konstantinos Tzimkas Dakis ¹, Konstantinos Spanos ¹, George Kouvelos ¹, George Volakakis ¹, Metaxia Bareka ², Grigorios Giamouzis ³, Eleni Arnaoutoglou ² and Miltiadis Matsagkas ¹

1

Vascular Surgery Department, University Hospital of Larissa, Medical School of Larissa, University of Thessaly, Volos, Italy

2

Anesthesiology Department, University Hospital of Larissa, Medical School of Larissa, University of Thessaly, Volos, Italy

3

Cardiology Department, University Hospital of Larissa, Medical School of Larissa, University of Thessaly, Volos, Italy

Introduction: Branched Thoracic Endovascular Repair of the Aorta (bTEVAR) is a feasible alternative to conventional open surgical debranching techniques, allowing for complete endovascular repair of thoracic aortic pathologies involving the aortic arch, such as Non-A, Non-B dissections.

Case Report/Technique: We present the case of a 64-year-old male patient who was transferred to our department with an acute Non-A, Non-B aortic dissection, extending from the LSA to the aortic bifurcation. Following initial conservative management, the patient was treated with a custom-made branched endograft [Bolton Medical, Inc. (Terumo Aortic, Sunrise, FL, USA)], incorporating three directional branches for the innominate, left carotid and left subclavian artery, respectively. Postoperative 6-month follow-up shows partial false lumen thrombosis with complete branch patency.

Conclusions: Branched TEVAR is a feasible, total endovascular solution to certain aortic pathologies, such as Non-A, Non-B dissections, where conventional TEVAR is contraindicated.

• Keywords: aortic dissection; arch branch repair

1.39.15. Simultaneous Ascending Aortic Replacement and Thoracic Endovascular Aortic Repair (TEVAR) in Acute Aortic Syndrome

• Ibrahim Pir ¹, Saad Naddaf ¹, Eyüp Serhat Çalık ¹ and Münacettin Ceviz ²

1

Department of Cardiovascular Surgery, Atatürk University Medical Faculty, Erzurum, Turkiye

2

Department of Cardiovascular Surgery, Buhara Hospital, Erzurum, Turkiye

Backround: The term acute aortic syndrome (AAS) refers to a group of situations in which there is a danger of impending aortic rupture and treatment delays result in increased mortality. We aim to present the use of an endovascular and surgical hybrid approach to treat acute aortic syndrome. The method is a single-step procedure used to treat severe aortic disease withouth using hybrid operating room.

Case Presentation: Five hours after beginning of acute and severe chest and back pain, a 62-year-old woman was referred to our department from cardiology. The patient was hemodynamically stable, hypertensive and had a history of Takayasu arteritis. Ascenden aort aneurysm, intramural hematoma (IMH) and a Stanford type B aortic dissection were found in computed tomography (CT). The patient was immediately operated on, under general anesthesia, and extracorporeal circulation was initiated with femoral cannulation. Then the patient underwent TCA. The ascending aortic aneurysmatic segment was removed. The TEVAR procedure was completed with direct view and the ruptured thoracic aortic segment was treated by opening the Medtronic captiva 30 × 30 × 200 mm stent graft over the hard wire as zero to the origin of the left subclavian artery. Then Ascending aortic replacement was completed. The patient’s post-procedure recovery was clinically uneventful. The patient was discharged on the seventh day after the operation. We demonstrate the efficacy and anatomical feasibility of combining open surgery with an endovascular method to treat ascenden aort aneurysm and aortic dissection of the thoracic aorta simultaneously. Endovascular intervention performed during open surgery makes the operation easier due to direct vision. Considering the complications and difficulties of thoraco-abdominal surgery, this hybrid approach appears to significantly reduce surgical morbidity and mortality.

• Keywords: Acute aortic sendrome; ascending aortic replacement; hybrid approach; TEVAR

1.39.16. Endovascular Treatment of Descending Thoracic Aortic Aneurysm with Severe Tortuosity Causing Tracheal and Esophageal Compression

• Ugur Cetingok ¹, Furkan Gul ² and Zeynep Ucar ²

1

Department of Cardiovascular Surgery, Etlik City Hospital, Ankara, Türkiye

2

Department of Cardiovascular Surgery, Sincan Training and Research Hospital, Ankara, Türkiye

The incidence of thoracic aortic aneurysms (TAA) increases with increasing age. Large aneurysms may be asymptomatic. The symptoms occur due to pressure on surrounding tissues and organs. Dyspnea and dysphagia occur rarely due to TAA compression. Rupture of the aneurysm is usually fatal. Thoracal endovascular aortic repair (TEVAR) can be safely performed in appropriate cases. The safety of endovascular repair will be maximized with the development of new devices and techniques. We present a case of a 75-years-old man treated with TEVAR. He had moderate dyspnea and dysphagia caused by descending thoracic aortic aneurysm with severe tortuosity. When there is severe tortuosity of the aorta, implantation of the device is difficult and requires different manipulations. Establishment of a brachio-femoral through and through a guidewire is an auxiliary manipulation in the presence of severe tortuosity. We wanted to emphasize in this article; TEVAR is safer than open surgery, it can also be applied with some special manipulations in severe tortuosity of the aorta. The spinal cord protection is essential to avoid neurological complications.

• Keywords: aortic aneurysm; aortic tortuosity; esophageal compression; airway compression; spinal cord protection

1.39.17. Hybrid Endovascular and Surgical Aortic Reconstruction for a Complicated Type 3 Aortic Dissection with an Atypical Anatomy: Challenging Case

• Didem Melis Oztas ¹, Okan Eren Kuguoglu ² and Murat Ugurlucan ¹

1

Department of Cardiovascular Surgery, School of Medicine, Biruni University, Istanbul, Turkey

2

School of Medicine, Istanbul Medipol University, Istanbul, Turkey

BACKGROUND: Type 3 Aortic dissection, though rare, may require immediate intervention in case of vital organ ischemia, uncontrollable severe pain and hypertension or aortic rupture. Without prompt treatment, mortality rates can reach 50% within the first 48 h. Management of aortic dissection is challenging, and its treatment is still in the process of development and innovation. Recent advancements in surgical techniques have been greatly enhanced by innovative endovascular approaches, prompting the development of hybrid surgical procedures.

CASE: This case highlights a hybrid treatment approach to a 52-year-old male patient who experienced sudden onset chest pain and shortness of breath, and collapse leading to ventilatory support diagnosed with type 3 aortic dissection and contained rupture with an atypical anatomical orientation of the vasculature. Initial attempts at endovascular stenting were complicated by a type 1 endo-leak, necessitating surgical intervention with endograft stabilization, aortic debranching, and reconstruction. Further complications prompted bilateral carotid-subclavian bypass with embolization of the native subclavian arteries and the treatment of a descending aortic aneurysmal sac with elongation of the thoracic endovascular stent graft.

• Keywords: type 3 aortic dissection; atypical

1.39.18. Aortic Coarctation Surgery in Adults

• Valeriy Sergeevich Arakelyan, Rustam Zabyt Gerievich Kidakoev, Vasiliy Georgievich Papitashvili, Roman Gennadevich Bukatsello and Magomedrasul Kurbanmagomedovich Musaev
• Department of Arterial Pathology, Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russia

BACKGROUND AND AIM: Study the influence of age characteristics on the type of surgical treatment in patients over 40 years of age.

METHOD: The results of surgical treatment of coarctation of aorta in 32 patients over 40 years old were studied. The median age was 46.6 years (CI 43.20–52.85). The average gradient of systolic pressure on the isthmus of the aorta was 53.39 ± 21.20 mmHg, and the gradient between the upper and lower extremities was 47.97 ± 26.91. The incidence of prestenotic and poststenotic aortic saccular aneurysms was 50% (n = 16), aortic arch kinking—15.6% (n = 5). The mean diameter of ascending aorta was 37 ± 8 mm (range, 24–52 mm). In 68.8% (n = 22) surgical resection of coarctation with graft replacement was performed, and in 31.2% (n = 10) patients, end-to-end anastomosis was applied. Partial cardiopulmonary bypass was used in patients with association of aortic coarctation and saccular aneurysm of aortic arch or isthmus.

RESULTS: In patients over 40 years of age aortic graft replacement and cardiopulmonary bypass technique was used 3 times more often than end-to-end anastomosis (OR 3.7, 95% CI: 2702–5240 and OR 3.6, 95% CI: 2081–6274, respectively). The incidence of pre and poststenotic aortic aneurisms an adult was significantly more often, as well as dilatation or the ascending aorta and aortic kinking (OR 3.5, 2.4, 3.8, respectively). The complication rate was 4.6%. All patients achieved favorable results and were discharged in a satisfactory condition.

CONCLUSIONS: Adult patients with aortic coarctation have high incidence of artic wall disorders—prestenotic and poststenotic aortic saccular aneurysms, aortic arch kinking and dilation of ascending aorta and the main surgical option is aortic graft replacement.

• Keywords: congenital heart defect; coarctation of the aorta; surgery; anomaly of the aortic arch

1.40. VASCULAR AND ENDOVASCULAR » Venous

1.40.1. Mid to Long Term Results of Pharmacomechanical Thrombectomy Versus Medical Therapy for Deep Venous Thrombosis (DVT) in Cancer and Non-Cancer Patients

• Volkan Burak Taban ¹, Abdullah Güner ², Ömer Tanyeli ³ and Yüksel Dereli ³

1

Department of Cardiovascular Surgery, State Hospital, Şırnak, Turkey

2

Department of Cardiovascular Surgery, Beyhekim Training and Research Hospital, Konya, Turkey

3

Department of Cardiovascular Surgery, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey

BACKGROUND AND AIM: Deep vein thrombosis (DVT) is one of the most common causes of death due to cardiovascular disease. Although monotherapy with LMWHs has been accepted for cancer-associated thrombosis, Novel Oral Anticoagulants (NOAC) and endovascular interventions have been included in guidelines for this special population. The aim of this study was to compare mid-and-long term outcomes of patients with selected cancer-associated DVT and non-cancer patients who underwent pharmacomechanical thrombectomy with medical therapies.

METHOD: A total of 126 patients treated with medical (n: 66) and pharmacomechanical thrombectomy (n: 60) for DVT were included in the study. In this cohort receiving medical therapy alone, 15.15% (n: 10) were patients with DVT associated with cancer. Among patients who underwent endovascular intervention, 21.67% (n: 13) had cancer. Villalta scale was used to measure the severity of postthrombotic syndrome (PTS). Recanalised flow and valve damage-reflux were monitored by USG.

RESULTS: There were no statistically differences between the groups in terms of demographic characteristic. It was found that the comparisons obtained from independent and ANCOVA tests were compatible and not affected by the age and gender variables. All patients with moderate or severe venous insufficiency (n: 24) on 1 styear USG results were associated with moderate and severe PTS (n: 7 moderate, n: 17 severe PTS). Cancer-associated DVT patients (n: 13) who underwent pharmacomechanical thrombectomy showed superior results in 1styear Villalta scores compared to cancer patients (n: 10) who received NOAC treatment (Villalta: 8 vs. 12). This rate was similar to that seen in the normal population without cancer who underwent pharmacomechanical thrombectomy. (Villalta; 8 vs. 8).

CONCLUSIONS: It is possible to improve the quality of life of DVT patients by preventing long-term complication. The risk of DVT’s complications is reduced by the correct use of NOACs and pharmacomechanical thrombectomy. USG and PTS clinical scales should be used for all patients (with/without cancer-associated DVT). Treatment planning should be reviewed in patients with damage to vein structural elements and in patients in whom the desired recanalisation is not achieved. The development of endovascular treatments for DVT can improve the declining quality of life of special populations, such as cancer patients.

• Keywords: Cancer; Postthrombotic syndrome (PTS); Endovascular Approach; Anticoagulant therapy

1.40.2. Utilisation of Resuscitative Endovascular Balloon Occlusion of the Vena Cava (REBOVC), and Its Application to Retroperitoneal Trauma: A Systematic Review

• Luca Borruso ¹, Krishna Kotecha ², Vikram Puttaswamy ², Shen Wong ², Anubhav Mittal ² and Jaswinder Samra ²

1

Royal Prince Alfred Hospital, Sydney, Australia

2

Royal North Shore Hospital, Sydney, Australia

BACKGROUND AND AIM: Retroperitoneal trauma is associated with high morbidity and mortality, particularly if the vena cava (VC) is involved. Resuscitative endovascular balloon occlusion of the VC (REBOVC) can limit life-threatening bleeding however there is a paucity of published data. The aim of this systematic review was to summarise the literature on REBOVC, describe common techniques and assess its safety/utility in retroperitoneal trauma.

METHOD: A systematic review of the literature was undertaken according to PRISMA guidelines. Eligible studies were animal models of REBOVC, and any studies involving humans undergoing REBOVC. Reference lists of included studies were searched to identify other potentially relevant studies.

RESULTS: 10 studies were eligible for inclusion. Five described REBOVC in humans (three case reports and two case series), totalling 12 patients. Injuries were mostly penetrating (gun-shot wounds [n = 7], stabbing [n = 3]) followed by blunt trauma (n = 2). Method of venous access was either direct (via a VC defect) or percutaneous. Older studies described the use of foley catheters for occlusion and newer studies described hybrid techniques utilising specialised occlusive balloons. Almost all (n = 11/12) patients survived their injury and were discharged from hospital. Five experimental animal studies used porcine models of VC trauma, demonstrating improved outcomes in those animals treated with REBOVC; with prolonged time to death and reduced blood loss.

CONCLUSIONS: REBOVC appears to be effective in pre-clinical animal studies at controlling haemorrhage and prolonging life. While the evidence base is small for use in humans, we posit REBOVC can be used in appropriately selected patients with good outcomes.

• Keywords: REBOVC; REBOA; IVC; Trauma; Vena Cava

1.40.3. Pulmonary Endarterectomy for Systemic and Suprasystemic Chronic Thromboembolic Pulmonary Hypertension

• Lyubomyr Kulyk ¹, Lyubomyr Solovey ², Anatoliy Shnaydruk ² and Volodymyr Pryshlyak ²

1

Lviv Centre for Cardiac Surgery, Lviv National Medical University, Lviv, Ukraine

2

Lviv Regional Hospital, Lviv, Ukraine

BACKGROUND AND AIM: Pulmonary endarterectomy (PEA) is the treatment of choice in chronic thromboembolic pulmonary hypertension (CTEPH). The risk of PEA gets bigger with the rise of pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR). Controversy exists in understanding of the influence of high and very high PAP on the outcome of PEA. We focused on the early results after PEA in patients with extreme systolic PAP compared to patients with lower PAP.

METHOD: From 2013 to 2023, 89 patients with CTEPH underwent pulmonary thromboendarterectomy according to San Diego protocol with a period of circulatory arrest ranging from 9 to 90 min. PAP and PVR were assessed before and after PEA using measurements with a Swan-Ganz catheter. Systolic pulmonary hypertension and PVR ranged from 75 to 140 mm Hg and 320 to 2550 dynes-s-cm⁻⁵, respectively. In 11 patients systolic PAP was equal to the systemic arterial pressure and in 4 exceeded the latter. Patients were divided according to San Diego intraoperative classification of CTEPH based on the intraoperative surgical specimens.

RESULTS: Overall perioperative mortality was 5.6% (5/89 patients). Hospital mortality in patents with preoperative systemic and suprasystemic systolic PAP compared with lower PAP was 20% and 2.2%, respectively. In 4 patients with suprasystemic systolic PAP and PVR ranging from 1550 to 2550 dynes-s-cm⁻⁵, a central veno-arterial ECMO was used. All four patients belonged to level 1 and level 2 disease according to San Diego classification; two of them died despite the radical endarterectomy.

CONCLUSIONS: Severe preoperative systolic pulmonary artery pressure is not a contraindication for PEA but remains the main risk factor for operation.

• Keywords: pulmonary endarterectomy; chronic thromboembolic pulmonary hypertension; pulmonary artery pressure; pulmonary vascular resistance

1.40.4. The Effectiveness of Vacuum-Assisted Closure Therapy in Patients with Infected Venous Leg Ulcers

• Esra Ertürk Tekin ¹, Mehmet Ali Yeşiltaş ², Ayhan Uysal ³, Ahmet Ozan Koyuncu ⁴, Necmi Köse ¹, Bahar Aydınlı ⁵ and Vehbi Kınay ¹

1

Department of Cardiovascular Surgery, Mersin City Training and Research Hospital, Mersin, Turkey

2

Department of Cardiovascular Surgery, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey

3

Department Cardiovascular Surgery, Firat University, Elazıg, Turkey

4

Department of Cardiovascular Surgery, Istanbul University-Cerrahpasa, Institute of Cardiology, Istanbul, Turkey

5

Department of Anesthesiology and Reanimation, Mersin City Training and Research Hospital, Mersin, Turkey

BACKGROUND AND AIM: In this study, we aimed to investigate the effect of vacuum-assisted closure therapy on venous stasis wound healing in patients with chronic venous leg ulcers.

METHOD: Vacuum-assisted closure therapy was applied on a total of 14 venous leg ulcers. All patients had post-thrombotic syndrome. Quantitative wound culture samples were obtained before the procedure and local wound assessments were performed. The primary outcome measures included wound healing as assessed by a local wound examination during each dressing change and the rate and velocity of ulcer reduction. Wound healing was defined as the complete closure of the ulcer, while rapid wound healing was defined as a ≥30% reduction in the ulcer size by week four.

RESULTS: No surgical debridement or surgical corrective procedure was applied in any patient. The mean length of hospital stay was 32.3 days. The mean number of vacuum- assisted closure therapies for each case was 17.8 and the mean time to dressing change was 72.3 h. Multidrug-resistant Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus were detected in three and four patients, respectively. Wound culture results became negative after a mean duration of vacuum-assisted closure therapy of 12.1 days. None of the patients needed antibiotic therapy until the procedure was completed. Compared to baseline, the mean ulcer reduction rates were 46.4% for the first six applications and 72.8% for the subsequent applications.

CONCLUSIONS: Our study results suggest that vacuum-assisted closure therapy promotes rapid wound healing in patients with severe post-thrombotic syndrome with venous stasis leg ulcers, and reduces the need for antibiotics by reducing the biological burden.

• Keywords: Vacuum-assisted closure therapy; venous ulcer; post- thrombotic syndrome; wound infection; rapid wound healing

1.40.5. Evolution of Endovenous Laser Ablation (EVLA) for Treatment of Varicose Veins: A Comparison of EVLA with 1470 nm and 1940 nm Lasers in Terms of Safety, Feasibility, and Early Efficacy

• Ali Baran Budak
• Department of Cardiovascular Surgery, Liv Hospital Ulus, Istanbul, Türkiye

BACKGROUND AND AIM: Our aim was to evaluate and compare the safety, efficacy, and early outcomes of EVLA by means of 1940 nm laser with radial fiber and EVLA by Diode 1470 nm laser for the treatment of truncal vein insufficiency

METHOD: 50 patients (112 incompetent saphenous veins) were treated with 1940-nm EVLA (Corona Infinite Ring, neoLaser, Caesarea, Israel) and 70 patients (145 incompetent saphenous veins) with 1470-nm EVLA (ELVeSTM Radial, Biolitec AG, Germany). Simultaneous miniphlebectomy and ligation of perforators were applied. The vein diameter, energy delivered, and linear endovenous density (LEED) were evaluated. The endpoints were: Closure of the target vessel, complications and postoperative quality of life (QoL). QoL was measured by using CIVIQ-20 pre- and postoperatively. Pain and clinical severity were evaluated by visual analog scale (VAS) and venous clinical severity score (VCSS) 10-day and one month after EVLA.

RESULTS: The success rate of the procedure was 100% in both groups. LEED values were statistically lower in 1940-nm EVLA group for ablation of right GSV (61.93 ± 9.82 vs. 35.7 ± 7.19; p < 0.05) and left GSV (62.65 ± 8.42 vs. 34.85 ± 9.85; p < 0.05). Average 24-h and 1-month VAS scores were similar, but at 10th day control VAS scores were higher in 1470-nm EVLA group (2.7 ± 1.26 vs. 1.9 ± 1.21; p < 0.05). The postoperative VAS, VCSS and CIVIQ-20 scores in the two groups were significantly decreased compared with the scores before the procedure, and although no significant differences were noted between the two types of laser at postoperative 1st month, the scores of 1470-nm group tended to be higher (35.2 ± 7.8 vs. 33.1 ± 10.22; p = 0.13).

CONCLUSIONS: EVLA with 1940 nm laser is as safe and effective as 1470 nm laser for the treatment of truncal vein insufficiency. Using a 1940-nm laser seems to be more advantages on improving QoL in terms of postoperative pain and discomfort

• Keywords: endovenous laser ablation; chronic venous insufficiency; diode laser; Varicose; quality of life; pain

1.40.6. Axillar Artery Aneurysm: Case Report

• Mert Çelik, Mucteba Sarıcaoglu and Cengiz Ovalı
• Departments of Cardiovascular Surgery, Osmangazi University, Eskisehir, Turkey

The incidence of upper extremity peripheral artery aneurysms is much lower than lower extremity peripheral artery aneurysms.

Traumatic aneurysms can be divided into two groups: false and true. False aneurysms may develop after a penetrating injury to the vessel wall. Bleeding from a penetrating injury is limited by surrounding soft tissues, and a hematoma forms. The organization continues with the lumen of the pseudoaneurysm sac, leading to fibrosis and eventual recanalization.

Axillary artery aneurysms secondary to blunt trauma are rare and are usually diagnosed late. The reason for the late diagnosis is that the symptoms of aneurysm in the muscle and bone structures surrounding the chest and shoulder regions are overlooked due to the location of the axillary artery. In addition, distal peripheral pulses may be strong due to extensive upper extremity collateral circulation.

• Keywords: axillary artery; aneurysm; brachial plexus; pain; surgical treatments

1.40.7. Open Heart Surgery Following Vascular Complication in a Patient with Permanent Tunneled Hemodialysis Catheter: A Case Presentation

• Mert Çelik, Tarık Tastekin and Cengiz Ovalı
• Departments of Cardiovascular Surgery, Osmangazi University, Eskisehir, Turkey

Venous catheterization is the preferred method for hemodialysis in patients with acute hemodialysis needs who are not suitable for arteriovenous fistula creation due to peripheral vascular pathologies. The need for urgent intervention for vascular complications that may occur during the hemodialysis catheter insertion procedure should always be considered. This article describes the urgent vascular surgical repair of injuries to the brachiocephalic vein and superior vena cava that occurred during the procedure in a patient with an HD catheter.

• Keywords: Hemodialysis Catheter Complications; Superior Vena Cava Injury; Emergency Vascular Surgery

1.40.8. Prophylaxis and Treatment of Chronic Venous Insufficiency of the Lower Extremities in Pregnants, Evaluation of the Results of Classic Phlebectomy and Evla Surgery Due to Varicoses

• Nubar Ismayilova, Nazim Gasimov and Vugar Fattah Pur
• Azerbaijan State Advanced Training Institute for Doctors Named by A. Aliyev, Baku, Azerbaijan

CVI in the lower extremities is one of the most common diseases in the population. In patients with severe CVI, upper stripping of the large subcutaneous vein, removal of varicose veins, and closure of perforating veins are performed through surgical intervention. Although several studies have shown that EVLA is more effective, there are still debatable conflicting opinions on the comparison of open or minimally invasive intervention in terms of recurrences in the immediate and distant periods after surgery.

OBJECTIVE: To improve the long-term results of the operation through the prevention of recurrences and chronic venous insufficiency during pregnancy in women who have undergone classical venectomy and EVLA.

MATERIAL-METHOD: During the doppler examination after EVLA, 13 out of 31 women did not have pathological reflux in the venous system around the right and 14 women in the left lower extremity, 2 women had reflux in the basin of the small and large subcutaneous veins, which was manifested by the clinical picture in the C1 and C2 stages. In 1 of these women, pelvic veins were involved in the process, and in 1, neovasculogenesis was observed.

As a conclusion of the discussion of the complications after open surgical operation, we witnessed the recurrence in 12 people on the right side and in 16 people on the left side. 9 out of 12 relapses on the right side and 11 out of 16 relapses on the left side were related to stasis and reflux in pelvic veins. In women who underwent open venectomy, 20 had recurrence at the C2-C3 stage after childbirth, 17 had reflux in perforating veins, and 5 had neovasculogenesis.

RESULTS: After EVLA surgery, the occurrence of variceal recurrence in pregnant and postpartum women was statistically significantly lower compared to traditional open surgery, and EVLA proved to be a more effective treatment.

• Keywords: varicose; EVLA; phlebectomy

1.40.9. Our Experience in Managing Phlebitis Following Cyanoacrylate Glue Closure with VenaBlock: A Case Report

• Juliana Juliana ¹ and Yosis Yohannes Motulo ²

1

Faculty of Medicine, Airlangga University, Surabaya, Indonesia

2

Cardiothoracic and Vascular Surgery Department of PHC General Hospital, Surabaya, Indonesia

BACKGROUND: Chronic venous insufficiency (CVI) is a condition characterized by impaired venous return in the lower extremities, leading to symptoms such as leg pain, swelling, and skin changes. The Venablock© Venous Closure System (Invamed, Ankara, Turkey) is an innovative embolization device utilizing cyanoacrylate, designed to non-thermally and non-tumescently block refluxing truncal veins associated with chronic venous insufficiency and varicose veins. Cyanoacrylate glue closure (CAC) with VenaBlock is a widely used technique for the treatment of venous insufficiency, known for its efficacy and safety profile. However, despite its advantages, complications such as phlebitis can occur, albeit uncommonly. We present a case of a patient who developed symptomatic phlebitis following CAC with VenaBlock, highlighting our institution’s experience in diagnosis and surgical management of this complication.

Case Presentation: A 60-year-old female with a history of chronic venous insufficiency underwent cyanoacrylate glue closure (CAC) with VenaBlock for symptomatic varicose veins in the right leg. One week following the procedure, the patient experienced persistent pain, itchiness, redness, and swelling in the treated leg. Diagnostic workup confirmed the presence of phlebitis, and initial pharmacotherapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and anticoagulants was ineffective, necessitating surgical excision of the affected vein. Postoperatively, the patient experienced resolution of symptoms. Phlebitis following CAC with VenaBlock, though uncommon, can present significant challenges in management. This case highlights the importance of prompt recognition and appropriate treatment of this complication, including consideration of surgical intervention in some cases.

• Keywords: Cyanoacrylate glue closure; VenaBlock; phlebitis; surgical excision; case report

1.41. VASCULAR AND ENDOVASCULAR » Visceral

First Case Report of the Left Renal Vein Aneurysm in the Setting of Posterior Nutcracker Syndrome

• Ugur Cetingok ¹, Akkoyun Cayan ², Duzgun Cemal Ali ³, Karapınar Kasim ³ and Gul Furkan ⁴

1

Etlik City Hospital, Ankara, Turkey

2

Private Aktif Hospital, Istanbul, Turkey

3

Ankara Training and Research Hospital, Ankara, Turkey

4

Sincan Training and Research Hospital, Ankara, Turkey

Nutcracker syndrome is a venous compression syndrome that results from the compression of the left renal vein between the aorta and the superior mesenteric artery as so-called anterior nutcracker syndrome, or less commonly and between the aorta and the vertebra as so-called posterior nutcracker syndrome. It is a rare condition, and is characterized by signs and symptoms reflecting pelvic and renal congestion such as hematuria, proteinuria, pelvic pain, flank pain, dysmenorrhea, dyspareunia, dysuria, gonadal varicose veins, and emotional disturbance. Compression of the left renal vein can remain asymptomatic for life through, or it can cause serious complications. If there is not any symptom, this anatomical variant is called the nutcracker phenomenon. An aneurysm may develop distal to the entrapment segment of the left renal vein in nutcracker syndrome. The left renal vein aneurysm in the setting of nutcracker syndrome is rare. Two cases of left renal vein aneurysm in the setting of anterior nutcracker syndrome have been published. The left renal vein aneurysm in the setting of posterior nutcracker syndrome has not been published. Renal vein aneurysms are mostly asymptomatic, and they are diagnosed incidentally. However, it may cause life-threatening complications such as thrombosis, thromboembolism, and rupture. In this article, we present first report of the left renal vein aneurysm in the setting of posterior nutcracker syndrome. We also discussed the current diagnostic criteria, complications, and current treatment options of LRV entrapment.

• Keywords: nutcracker syndrome; renal vein aneurysm

2. Selected Poster Abstracts

2.1. CARDIAC » Adult Congenital

2.1.1. A Case of Atrial Septal Defect Repairment in a Patient with Oculopharyngeal Muscular Dystrophy

• Aytaj Ismayilzada, Ziya Shahaliyev, Valeh Mammadov and Anar Amrah
• Department of Cardiovascular surgery, Republican Diagnostical Center, Baku, Azerbaijan

AIM: Oculopharyngeal muscular dystrophy (OPMD) is a late-onset muscle disease associated with progressive ptosis of the eyelids, dysphagia, and unique tubulofilamentous intranuclear inclusions (INIs) in skeletal muscle. We have reported a case about a patient with OPMD who underwent open heart surgery for a patch closure of an atrial septal defect (ASD) and tricuspidal valve repairment.

CASE: 27-year-old female patient has been admitted to the hospital with shortness of breath, early fatigue, and heartbeat complaints. She reported that her complaints have been lasting for several years, but she suffered more during the last few weeks. The patient was diagnosed with OPMD one year ago. In a physical examination of the patient, nose speech, a hatchet face, and ptosis were revealed. The patient underwent transthoracic echocardiography, and a large 2.5 sm ASD and severe tricuspidal regurgitation were revealed. ASD has been closed with an autologous pericardial patch. The tricuspid valve has been repaired by the modified Kay annuloplasty technique. We used warm blood cardioplegia for myocardial protection. The patient has been extubated after a normal spontaneous respiratory act. However, the patient was admitted to the ICU department with unconsciousness, breathing difficulty, hypoxemia, and bradycardia after five days. Moreover, there was an urgent need for repeating endotracheal intubation, which ended with extubation approximately after 24 h. As a consequence, our patient has been discharged from the clinic in 4 days. To prevent sleep apnea we used a portable CPAP device. In 2-year follow-ups, no complications have been detected. The management of such patients requires a multidisciplinary approach with the attendance of cardiac surgeons, anesthesiologists, ICU physicians, and neurologists. Administration of depolarizing muscle relaxants, hypothermia, or raised potassium concentration can cause muscle contractions. A possible risk of sleep apnea due to dystrophy of pharyngeal muscles should be considered.

• Keywords: ASD; Oculopharyngeal muscular dystrophy; adult congenital

2.1.2. Gerbode Defect Misinterpreted as Pulmonary Hypertension

• Melih Alma, Mustafa Yılmaz and Ahmet Aydın
• Department of Cardiovascular Surgery, Hacettepe University Ankara, Ankara, Turkey

Congenital heart patients are now routinely reaching adulthood, leading to increased encounters with them in adult cardiology. However, diagnosing and managing these patients can be challenging due to the complexity of their cardiac lesions and prior surgical interventions. A 59 year-old patient, operated for a ventricular septal defect 51 years ago, presented with pulmonary hypertension and additional valve insufficiencies, including a Gerbode type defect. Differentiating the VSD jet in the presence of severe tricuspid insufficiency poses diagnostic challenges.

The patient, without known comorbidities, experienced increasing fatigue and shortness of breath over the past 2 years, prompting evaluation. Significant tricuspid and mitral insufficiencies, elevated BNP levels, and atrial fibrillation were detected. Anticoagulant and diuretic therapy was initiated, referral to our clinic. Further assessments revealed severe pulmonary hypertension, with echocardiography showing an EF of 50.3%, severe mitral and tricuspid regurgitation, and elevated PA pressure with a PVRI of 5.6 woods. A jet extending from the subaortic region to the right atrium was observed on cardiac MRI.

Surgical intervention was decided, including mitral and tricuspid valve procedures and ASD closure due to high PH. The patient underwent surgery with a transseptal approach. Mitral valve repair was deemed unsuitable, necessitating biological valve replacement. Degenerated leaflets were found in the tricuspid valve, along with a Gerbode type VSD extending from the right atrium to the left ventricle, which was closed during valve replacement. The patient had an uneventful postoperative course, discharged on the 7th day.

Dr. Gerbode initially described a left ventricle to right atrium shunt due to a defect in the membranous septum in1958. While this congenital lesion has been the least common form of VSD, acquired Gerbode defects have been reported. Differential diagnosis should consider the Gerbode defect when high-speed “tricuspid regurgitation” jets are observed without other features of pulmonary hypertension. Direct visualization of the shunt is challenging but crucial for accurate diagnosis in such cases.

• Keywords: Gerbode; Tricuspid; adult congenital

2.1.3. Adult Total Correction of Tetralogy of Fallot with Absent Left Pulmonary Artery

• Melih Alma and Timuçin Sabuncu
• Department of Cardiovascular Surgery, Hacettepe University Ankara, Ankara, Turkey

Tetralogy of Fallot (TOF) is among the common congenital heart diseases. There is no established treatment for the rare subset of absent left pulmonary artery, and surgical intervention in this subgroup carries high mortality and morbidity rates. In our clinic, all corrections were successfully performed in an elderly patient with this condition.

CASE: A TOF patient without known comorbidities underwent a BT shunt in Lebanon in 2014. In 2019, the patient presented to us with cyanosis, dyspnea, and fever and was taken to surgery with a preliminary diagnosis of infective endocarditis. During the operation, no pathology suggestive of infection was found in the VSD rims, tricuspid valve, right ventricle, or right atrium. Pulmonary arteriotomy revealed three 0.5 mm vegetations on the anterior surface of the pulmonary valve; no lesions were seen posteriorly. Commisurotomy was performed on the fused valve, and it was observed that the main pulmonary artery continued as the right pulmonary artery, with the left pulmonary artery not visualized. In 2022, the patient was re-evaluated due to worsening cyanosis and decreased exercise capacity. A decision was made for total correction, involving VSD closure with a patch through right atriotomy and widening of the RVOT with an external patch, followed by replacement with a 29-size Hancock biological valve. The patient was monitored in the ICU for one day postoperatively and discharged smoothly on the 7th postoperative day.

CONCLUSIONS: Complete repair of Tetralogy of Fallot is feasible in adult patients but carries increased surgical risks. Functional improvement is observed in survivors; however, the survival rate is lower than expected. Due to decreased survival and the need for reoperation, pulmonary valve replacement should also be performed during the initial surgery.

• Keywords: Adult Congenital; Tetralogy of fallot; absent left pulmonary artery

2.1.4. Surgical Treatment of Detachment of Atrial Septal Defect Occluder

• Özgür Özsoy, Murat Uğur and Hilmi Tokmakoğlu
• Department of Cardiovascular Surgery, Prof. Dr. Ilhan Varank Education and Research Hospital, İstanbul, Türkiye

INTRODUCTION: Percutaneous treatment of atrial septal defects (ASD) has been used with increasing frequency due to increasing experience and being relatively safer than surgical methods. However, complications such as embolization, leakage, detachment and migration might occur after the procedure. A meticulously echocardiography is important to determine the defect size and rims for the suitability for percutaneous treatment. Postoperative follow-up with serial echocardiography is important to determine residual defects earlier. Residual defect might be treated with endovascular approach and surgical procedure.

Case Presentation: A 29-year-old female patient was admitted to the emergency service with the complaints of left arm pain and shortness of breath. She had a history of percutaneous ASD closure 2 months before at another center. In the trans-esophageal echocardiography, it was determined that septal occluder did not fully hold the aortic rim. It was not in place and was deviated into the right atrium, and could not close the rim of the superior and inferior vena cava and pulmonary veins.

Approximately 1 cm ASD was detected in the region adjacent to the aortic rim. The patient was decided to operate due to the detachment of septal occluder device. During the operation, it was observed that the device was released from the aortic rim and migrated slightly towards the right atrium. The device was exluded and ASD was repaired with a pericardial patch. The patient was discharged on the 5th postoperative day.

DISCUSSION: In the patients with ASD, properly performed echocardiography is important to prefer patient-specific treatment strategy. Inappropriately sized devices, and insufficient rim are the main risk factors for residual ASD. In the detachment or migration of the occluder urgent surgery is required due to risks of thrombus, embolization and thromboembolism. Therefore, close follow-up of the patients with echocardiographic examinations is important to diagnose and treat early complications.

• Keywords: Atrial septal defect; septal occluder; mıgration; detachment; conjenital

2.2. CARDIAC » Aortic Valve and Aortic Root Surgery

2.2.1. Redo Surgery for Bentall’S Endocarditis—A Rare and Challenging Case Report

• Andreas Paschalis, Andrea Soteriou, Marios Tanos, Athanasios Athanasiou, Konstantinos Markakis and Erotokritos Evangelakis
• Cardiothoracic Department, General Hospital of Nicosia, Nicosia, Cyprus

We report a case of a 79-year-old man who was treated with aortic root replacement (Bio- Bentall) back in 2013 and presented with persistent fever at the emergency department. The patient was admitted for further investigation as a suspected infective endocarditis (IE). His past medical history also included Myelodysplastic Syndrome, hypertension and dyslipidaemia. During his admission he was also complicated with COVID pneumonia.

The patient was investigated with blood cultures which were positive to Staphylococcus aureus (MRSA) and transthoracic echo which did not show any pathologic findings. He was started on Vancomycin according to antibiogram. A new systolic murmur was heard and a transoesophageal echo (TOE) was arranged. The first TOE did not show any evidence of IE. A PET/CT scan was also requested. The scan showed only faint FDG-uptake of aortic bioprosthesis. The patient remained on his antibiotic treatment and a second TOE was organised. The findings revealed a new severe aortic regurgitation and a vegetation of the prosthetic aortic valve 0.8 × 0.3 cm. Rifampicin was also added in his treatment and a high-risk surgical treatment was decided.

The patient underwent a Redo Bentall operation (Figure 1) where the previous prosthetic valve and graft were removed and replaced with a Magna Ease 23 prosthetic valve sutured in a Hemashield graft. The infected valve was found covered with vegetations and an erosive lesion of the non-coronary cusp. The hemostasis was prolonged due to the extensive adhesions, the long bypass time and the haematological disease of the patient.

The postoperative course was long but uneventful. The patient completed a six weeks antibiotics therapy and he was discharged home. His postoperative echo showed a well-functioning valve without any sign of regurgitation. Operative specimens (prosthetic valve and graft) cultures were negative. The patient was reviewed at the outpatient clinic and he was found recovering well.

• Keywords: infective endocarditis; redo bentall; aortic root

2.2.2. A Low-Complication Valve-Sparing Aortic Root Surgery Technique: Our Experience with the Florida Sleeve

• Nazlı Melis Coşkun Yücel, Timuçin Sabuncu, Ahmet Aydın and Murat Güvener
• Department of Cardiovascular Surgery, Hacettepe University, Ankara, Turkey

Aortic dilation of the ascending aorta most commonly occurs secondary to hypertension, congenital conditions causing left ventricular outflow tract obstruction (e.g., bicuspid aorta), advanced age, connective tissue disorders. In cases where aortic valve involvement is not present, the diagnosis is usually made incidentally. These patients require close radiological follow-up due to the risk of rupture and dissection. Especially in cases of ascending aortic dilation observed at an early age due to congenital or connective tissue disorders, if there is no insufficiency or stenosis of the aortic valve, the first choice is valve-sparing techniques. We present to you cases performed using the Florida Sleeve technique in our clinic.

Between 2021–2023, four Florida Sleeve procedures were performed at our clinic (

Table 18. Four cases performed using the Florida Sleeve technique.

	Age	Sex	Pathology	Aortic Diameter	Pre-op Aortic Insufficiency	Post-op Aortic Insufficiency	Complications
Patient 1	16	Male	Marfan syndrome	4.9 cm	+1	0	-
Patient 2	11	Female	Marfan syndrome	3.8 cm (z-score: 4.91)	0	0	-
Patient 3	49	Male	Bicuspid aortic valve	6.2 cm	+1	0	-
Patient 4	41	Male	Bicuspid aortic valve	4.5 cm	0	0	Complete AV-block

). Two of these cases were related to Marfan syndrome, while the other two were associated with bicuspid aortic valve. Despite the presence of dilation in the aortic root and ascending aorta, the decision to perform the valve-sparing Florida Sleeve operation was made in these patients due to the absence of significant insufficiency/stenosis in the aortic valve. Two of these patients underwent surgery in childhood due to Marfan syndrome. There was no mortality observed in any of the four patients during early and 1-year follow-ups. Rupture and dissection were not observed during the follow-up. One patient underwent pacemaker implantation due to the development of complete AV block. It was observed that the minimal leaks in the patients’ valves decreased after surgery.

In cases where the ascending aorta and aortic root are dilated but there is no insufficiency or stenosis in the aortic valve, valve-sparing techniques are the first choice. Among these, the Florida Sleeve technique is a safe method with low complication risk. Especially in pediatric patients, it can provide promising results by preventing the increase in aortic diameter and preserving valve physiology.

• Keywords: Florida Sleeve; Aortic root surgery; Valve-sparing technique

2.3. CARDIAC » Atrioventricular Valve (Mitral/Tricuspid) Surgery

2.3.1. Myxoma of the Mitral Valve: An Exceptional Localization

• Amin Serradj, Narcis Costin Radu, Eric Bergoend, Antonio Fiore, Yuthiline Chabry, Mathilde Khoury, Alsa Poullot, Issam Ben Ayed and Thierry Folliguet
• Department of Cardiac Surgery—CHU, Henri MONDOR-APHP, Creteil, France

Myxoma is a benign cardiac tumor characterized by an important clinical polymorphism. The most frequent localization is the left atrium with an implantation on the interatrial septum. We report a case of patient 63-year-old with big myxoma of the mitral valve (Figure 2). The diagnosis has been done by transthoracic echocardiography after a stroke episode and an atrioventricular block.

The patient underwent cardiac surgery under cardiopulmonary bypass. A mitral bioprosthesis replacement n° = 27 by sternotomy has been done. The dosage of interleukin 6 was 40 pg/mL. The anatomopatholgy confirm the diagnosis of myxoma. The postoperative course was favorable and patient left the hospital at 7-day without any complication’s.

At our knowledge, no similar case was reported in the literature.

• Keywords: Myxoma; Mitral Valve; Cardiopulmonary bypass; Interleukin 6; Pathology

2.3.2. Bivalvular Non Bacterial Trombotic Endocarditis Caused Aortic Stenosis in Pankreatic Adenocarsinom Patient

• Laman Eyvazlı Laman
• Kapaz Hospital, Baku, Azerbaijan

INTRODUCTION: Nonbacterial thrombotic endocarditis is a rare complication of prothrombotic states such as neoplasms that can cause valvular dysfunction and life-threatening complications. The hallmark feature of NBTE is recurrent systemic embolization most commonly presenting as a sudden neurologic deficit

CASE: A 56-year-old female patient is being treated at an oncology center for pancreatic adenocarcinoma. During the cardiological assessment, the patient complained of severe shortness of breath and dizziness. Aortic stenosis was diagnosed during transthoracic echocardiography examination. Evaluation with TEE was recommended due to poor image quality. A TEE examination revealed largely mobile (kissing lesions) in the mitral valves and NBTE-like vegetations completely surrounding the annulus in the aortic valve (Figure 3). Serious cardiac and embolic risks were explained to the patient and the doctor (Oncologist). Because of the underlying malignancy and kissing lesions, NBTE was suspected but a diagnosis of subacute bacterial endocarditis could not be ruled out in the setting of immunosuppression. First of all, we recommend that, taking a culture, after denying the risk of infection, starting anticoagulant under strict monitoring and consulting with cardiovascular surgeon.

Transesophageal Echocardiography RESULT:

• Aortic valve: broad based, irregular shaped in ventricular surface, which is completely covered anulus. Severe aortic stenosis.
• Mitral valve: variable size mobil kissing lesions localised on auricular surface. Moderate degree mitral insufficiency
• Tricuspid valve: Moderete degree tricuspid insufficiency

• 0 degree: aortic mass protrudes into the LVOT up to 2.2 mm
• 45 degree: covered mainly RCC and NCC cusps
• 60 degree: P3 scallop—29 × 10 mm, A2 scallop 14 × 12 (broad based)
• 90 degree: PML—22 × 10 (16 × 8 mm sized mobil portion on pedincul), AML—10 × 8 mm

CONCLUSIONS: NBTE is difficult to diagnose and relies on strong clinical suspicion. It is difficult to manage and each case should be individually managed by identifying and treating the underlying pathology.

• Keywords: Non bacterial trombotic endocarditis; hyperkoagulability; malignancy

2.4. CARDIAC » Bypass Grafts and Configurations

Multiple Arterial Coronary Artery Bypass Grafting—A Short and Long-Term Comparison of Different Surgical Grafting Techniques

• Jan Strathmann, Oskar Krueger, Ilia Balaj, Sharaf Eldin Shehada, Jarowit Piotrowski, Parwis Massoudy, Heinz Jakob, Markus Kamler and Matthias Thielmann
• Department of Thoracic and Cardiovascular Surgery, University Hospital Essen (AöR), Germany

BACKGROUND AND AIM: Multiple arterial coronary bypass grafting (MAG) has shown superiority in terms of patency and survival compared to single arterial bypass grafting. Currently, numerous arterial grafting techniques are used, but the ideal configuration and best second graft have not been identified yet.

METHOD: In a single-center retrospective analysis, a total of 780 patients underwent isolated elective MAG at our institution between 01/1999 and 12/2019. Different MAG techniques were compared with respect to short- and long-term outcomes and overall survival. Out of these, 492 patients received Y-grafting, either with bilateral internal thoracic artery (ITA) revascularisation (n = 443) or single ITA with additional radial artery bypass grafting (n = 49). Moreover, 288 patients underwent bilateral ITA-grafting in a Non-Y-configuration by either BITA in-situ (n = 134) or LITA in-situ plus RITA as a free graft (n = 154). Prospectively recorded patients data were analysed and compared between different MAG techniques.

RESULTS: Total-arterial revascularisation was performed more frequently in the Y-grafting-group (90.7% versus 60.8%; p < 0.0001), with more distal arterial anastomoses than in the Non-Y-group (3.9 versus 2.6; p < 0.0001). No significant differences were found in terms of ICU (2.5 versus 2.1 days; p = 0.12) or hospital stay (11.2 versus 11.7 days; p = 0.30). Rates of stroke (1.0 versus 0.7%; p = 0.64), perioperative myocardial infarction (7.2 versus 4.2%; p = 0.13) as well as acute kidney injury (4.5 versus 4.2%; p = 0.82) showed similar outcomes between Y- and Non-Y-grafting. Kaplan-Meier overall survival was not significantly different between the groups over a follow-up period of 20 years (Figure 4). For Y-grafting, the radial artery use demonstrated lower median survival compared to bilateral ITA-grafting (13.4 versus 19.6 years; p = 0.0009). Comparing BITA in-situ and LITA in-situ plus RITA as a free graft, similar 30-day mortality (2.38 versus 2.80%; p = 0.83) and long-term survival (p = 0.49) could be presented.

CONCLUSIONS: Individual decision making, depending on patients’ risk factors and available bypass material, is indicated when considering multiple arterial revascularisation.

• Keywords: bypass; coronary disease; internal thoracic artery; multiple arterial grafting; myocardial revascularisation

2.5. CARDIAC » Challenging Cases

2.5.1. The Value of Echo Study in Cardiac Surgery of the Coronary Artery Disease

• Olena Gogayeva, Oleksandr Nudchenko, Serhii Rudenko and Vasyl Lazoryshynets
  Department of Surgical Treatment of Ischemic Heart Disease, GF “National Amosov Institute of Cardiovascular Surgery NAMS of Ukraine”, Kyiv, Ukraine

BACKGROUND AND AIM: to show importance of Echo study in cardiac surgery of the coronary artery disease (CAD).

METHOD: For 175 random cardiac surgery patients (average age 63.4 ± 8.7 years; 154 (88%)—men) with different forms of CAD we performed ECG, Echo, coronary angiography and surgical myocardial revascularization with additional valvular or ventricular correction. Perioperative Echo evaluation of heart function was conducted based on the current European and American imaging guidelines.

RESULTS: Isolated CAD was diagnosed in 138 (78.8%) pts, postinfarction aneurysm of left ventricle (ALV)—in 22 (12.5%), severe ischemic mitral insufficiency (IMI)—in 12 (6.8%), aortic stenosis (AS) in combination with CAD had 3 pts. Ejection fraction of left ventricle (LV) in average was 47.2% [range 23—67%]. The volume of operation was dedicated by heart team taking into account all diagnostic investigations. Average EuroSCORE II was 4.85% [range 0.67–49%]. Emergency operations due to unstable hemodynamic had 49 (27.2%) pts. Isolated CABG had 138 (78.8%) pts, 131 (94.9%) off-pump. For 22 (12.5%) pts we performed resection of aneurysm of LV (100% diagnosed by Echo), with thrombectomy from LV in 12 (54.5%) cases (11 (91.6%) were diagnosed by Echo), for 1 pts with ALV also performed post-infarction ventricular septal defect (PI VSD) repair with tricuspid valve repair. Echo hyperdiagnosis of LV thrombosis was in 3 cases. For 2 pts with ALV and severe IMI was performed MV replacement. Severe IMI diagnosed in 12 (6.8%) cases—for 10 pts performed MVR and for 2 pts performed MV ring repair. CABG with aortic valve repair had 3 pts (1.7%). Perioperative dynamic of Echo data presented in

Table 19. Perioperative ECHO data of cardiac surgery patients with different forms of CAD (n = 175).

Echo Data	Isolated CAD, n = 138		Postinfarction ALV, n = 22		Ischemic Mitral Insufficiency, n = 12		CAD + Aortic Stenosis, n = 3
	Before	Postop	Before	Postop	Before	Postop	Before	After
LV EDV, mL	136.6 ± 35.6 [70–300]	131.3 ± 33.2 [70–290]	205.3 ± 48.4 [140–345]	172 ± 55.7 [120–310]	196.8 ± 44.6 [105–274]	170.5 ± 56.4 [120–290]	171 ± 29.02 [131–199]	160.6 ± 35.2 [120–181]
LV EF, %	50.04 ± 7.8 [25–67]	50.8 ± 7.7 [25–68]	34.7 ± 6.3 [23–50]	39.7 ± 8.1 [20–54]	39.08 ± 13.5 [27–61]	43.8 ± 8.4 [32–58]	35.3 ± 9.7 [27–49]	42 ± 11.1 [32–54]

LV—left ventricle; EDV—end diastolic volume; EF—ejection fraction; ALV—aneurysm of left ventricle.

.

CONCLUSIONS: Echo study has a crucial importance in deciding on the volume and emergency of cardiac surgery.

• Keywords: Coronary artery disease; Echo; coronary artery bypass surgery; aneurysm of left ventricle; ejection fraction

2.5.2. Dual Mitral and Aortic Valve Replacement with Ring Enlargement

• Wafa Ragmoun, Mokhles Lajmi, Ziadi Mohamed and Shenik Mohamed Slim
  Department of Cardiac and Thoracic Surgery, University of Tunis El Manar, The Military Hospital of Tunis, Tunis, Tunisia

Introduction: Rheumatic multivalvular disease remains a major health problem in developing countries. These valvular heart diseases are generally accompanied by narrow rings mainly of the aortic valve and even more so if this involvement is associated with mitral valve disease.

Observation: A 60-year-old woman with carrier of rheumatic mitral valve disease treated with CMCO presented with a dyspnea evolving for six months. Transthoracic echocardiography showed a predominantly receding mitral disease, a predominantly receding aortic disease with aortic ring at 19 mm, massive tricuspid insufficiency with highly dilated straight cavities and preserved Cardiac function.

The patient underwent mechanical mitral and aortic valve replacement with enlargement of the aortic ring and tricuspid annuloplasty by vertical median sternotomy.

The postoperative course was uneventful and the patient was discharged on day four.

Discussion: The patient-prosthesis disproportion is present when the effective valve area of the prosthesis is too small in relation to the patient’s body surface area. It is a common problem following aortic valve replacement, associated with poorer improvement in symptomatic status and quality of life, less regression of hypertrophy left ventricular, a higher incidence of cardiac events and reduced survival following valve replacement aortic.

This mismatch can be avoided, or at least its severity can be reduced by the implementation of a prevention strategy at the time of the operation, and mainly through the different enlargement techniques.

Conclusions: In expert hands, annular enlargement, regardless of the technique, is a reliable and risk-free option to enable insertion of an appropriately sized prosthesis and avoidance of re-operation and the complications inherent in mismatch.

• Keywords: Rheumatic multivalvular disease; mismatch; enlargement techniques

2.5.3. Extracorporeal Membrane Oxygenation in Patients with Dilated Cardiomyopathy

• Wafa Ragmoun, Mokhles Lajmi, Ziadi Mohamed and Shenik Mohamed Slim
  Department of Cardiac and Thoracic Surgery, University of Tunis El Manar, The Military Hospital of Tunis, Tunis, Tunisia

Introduction: Extracorporeal membrane oxygenation (ECMO) became a technique of cardio respiratory assistance ensuring the oxygenation and the perfusion of the organs while waiting for the restoration of their functions.

Observation: A 29-year-old man known carrier of idiopathic dilated cardiomyopathy since 2017 presented with refractory cardiogenic shock after spinal anaesthesia for surgical treatment of a coccygeal fistula. He was supported after 24 h with an extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support for 14 days with gradual improvement and successful weaning, the patient was discharged from hospital after recovery from reanimation injuries.

Discussion: The occurrence of refractory cardiogenic shock in patients with dilated cardiomyopathy may require the establishment of temporary ECMO for circulatory support as a bridge to long-term assistance, transplantation or recovery.

In these emergency situations, ECMO is now the first circulatory assistance line and the patient must be referred as quickly as possible to a medical and surgical centre with the mastery of the implementation and monitoring of this complex technology.

The decision to implant ECMO is based on a combination of clinical, paraclinical and often the experience of the members of the team. Importantly, this heavy technique, burdened with severe complications, should be considered whether the chances of recovery of ventricular function are reasonable or, if not, whether there are no obvious contraindications to heart transplantation or, more rarely, implantation of permanent ventricular assistance.

Conclusions: The survival rate of patients requiring ECMO for refractory cardiogenic shock complicating CMD is low. However, without circulatory support, this survival rate is almost nil. ECMO in cardiogenic shock in patients with CMD may be a therapy to consider, but the criteria for implantation need to be better defined by future studies.

• Keywords: Extracorporeal membrane oxygenation; dilated cardiomyopathy

2.5.4. Giant Cardiac Hydatid Cysts

• Sami Bouchenafa, Ahmed Zaki Boukli Hacene, Boukri Hamouda, Redha Djilali Sayah, Tarek Hamdi, Mohammed Ould Abderrahmane, Makhlouf Amir, Abdelkader Boukhors, Mohammed Bensaber, Nour El Houda Draou, Linda Zebirate and Mohammed Atbi
  Departement of Cardiac Surgery, EHU Hospital, Oran, Algeria

A 55-year-old woman presented recently with dyspnea. The clinical examination was normal. Enlargement of the mediastinum with cardiomegaly was noted on the chest X-ray. Echocardiography showed the existence of 3 giant cardiac cysts which compressed the heart whose cavities are barely visible. A thoracic scanner revealed a giant hydatid cyst measuring 11 cm between the sternum and the right atrium (Figure 5). Another giant hydatid cyst, measuring 10 cm, was posterior and inferior behind the right inferior pulmonary vein and extended towards the right pleura. A 3rd giant hydatid cyst, measuring 10 cm, appeared to penetrate the wall of the left ventricle.

The surgery was performed under femoral cardiopulmonary bypass, which involved opening of the 3 cysts after aortic clamping and resecting the multiple cysts of different sizes and more than 40 vesicles and debris.

The patient left the hospital 10 days after undergoing surgery and Albendazole treatment.

An isolated cardiac hydatid cyst is rare, of incidental discovery or after cardiac signs of complications when it is of a giant size and/or multiple cysts are present

• Keywords: hydatid cyst; cardiac surgery; pericardectomy

2.5.5. A Rare Case: Surgically Treated Ogilvie Syndrome After Coronary Artery Bypass Surgery

• Esra Erturk Tekin ¹, Necmi Kose ¹, Mehmet Ali Yesiltas ², Bahar Aydinli ³, Ahmet Ozan Koyuncu ⁴, Dogac Oksen ⁵, Vehbi Kinay ¹ and Burhan Veli Ozer ¹

1

Department of Cardiovascular Surgery, Mersin City Training and Research Hospital, Mersin, Turkey

2

Department of Cardiovascular Surgery, Dr. Cemil Taşçıoğlu İstanbul City Training and Research Hospital, Istanbul, Turkey

3

Department of Anesthesia and Reanimation, Mersin City Training and Research Hospital, Mersin, Turkey

4

Department of Cardiovascular Surgery, Istanbul University Institute of Cardiology, Istanbul, Turkey

5

Department of Cardiology, Altınbaş University, Istanbul, Turkey

Ogilvie’s syndrome describes an acute colonic pseudo-obstruction (ACPO) consisting of dilatation of part or all of the colon and rectum without intrinsic or extrinsic mechanical obstruction. It often occurs in debilitated patients. Its pathophysiology is still poorly understood. Since computed tomography (CT) often reveals a sharp transition or “cut-off” between dilated and non-dilated bowel, the possibility of organic colonic obstruction must be excluded. If there are no criteria of gravity, initial treatment should be conservative or pharmacologic using neostigmine; decompression of colonic gas is also a favored treatment in the decision tree, especially when cecal dilatation reaches dimensions that are considered at high risk for perforation. Recurrence is prevented by the use of a multiperforated Faucher rectal tube and oral or colonic administration of polyethylene glycol (PEG) laxative. Alternative therapeutic methods include: epidural anesthesia, needle decompression guided either radiologically or colonoscopically, or percutaneous cecostomy. Surgery should be considered only as a final option if medical treatments fail or if colonic perforation is suspected.

Gastrointestinal (GI) complications occur in less than 2% of patients undergoing open-heart surgery. Acute colonic pseudo-obstruction, known as Ogilvie’s syndrome, is also a rare complication encountered in 0.046% of patients undergoing coronary artery bypass graft surgery. It is characterised by massive colonic dilatation without mechanical obstruction in patients with underlying medical or surgical conditions.

In this report, we describe a 58-year-old male patient suffering from Ogilvie syndrome who was treated surgically 5 days after undergoing elective coronary bypass surgery (Figure 6).

• Keywords: open heart surgery; coronary bypass; ogilvie syndrome; acute colonic pseudo-obstruction

2.5.6. Delayed Coronary Air Embolism Post Re-Do Mitral Valve Replacement: A Case Report

• Pouya Nezafati ¹ and Sumit Yadav ²

1

Department of Cardiothoracic Surgery, Liverpool Hospital, Sydney, NSW, Australia

2

Department of Cardiothoracic Surgery, Townsville University Hospital, Townsville, QLD, Australia

INTRODUCTION: Coronary air embolism (CAE) is one complication that can lead to catastrophic complications, including myocardial infarction, stroke and death. It is reported to happen during cardiac catheterization, during or few hours after cardiac surgery or as a result of chest trauma. This is a case report of delayed coronary air embolism following cardiac surgery.

Case presentation: A 58-year-old female presented with New York Heart Association (NYHA) II symptoms from a severe highly eccentric anterior mitral regurgitation from a bio-prosthetic valve with preserved ejection function and a total calcium score of zero which underwent re-do mechanical mitral valve replacement. 2 days post-surgery she was taken to catheterization laboratory with signs and symptoms suggestive of inferior myocardial infarction (MI) and complete heart block (CHB) which symptoms and ST changes resolved immediately after introducing angiographic contrast with angiography revealing no occlusion in right coronary artery (RCA).

• Keywords: Coronary Air Embolism; Mitral Valve Replacement; ST-elevation Myocardial Infarction (STEMI)

2.5.7. What Have We Learned from a Family with Constrictive Pericarditis?

• Nazlı Melis Coşkun Yücel, Timuçin Sabuncu and Murat Güvener
• Department of Cardiovascular Surgery, Hacettepe University, Ankara, Turkey

Constrictive pericarditis can occur due to various pathologies such as infectious, rheumatological, genetic, metabolic, environmental factors. We present a case series of 1 father and 2 children diagnosed with constrictive pericarditis, along with a literature review.

In a 17-year-old male patient, presenting with abdominal pain and neck venous distension. Hepatosplenomegaly, ascites, dilation of the hepatic veins and IVC was detected. Initially, restrictive cardiomyopathy was considered, but advanced investigations led to the diagnosis of constrictive pericarditis. Metabolic and genetic tests were negative. The patient underwent pericardial/myocardial biopsy and pericardiectomy, revealing severely thickened-calcified pericardium. Biopsy showed pericardial tissue with focal dense fibrotic areas and normal myocardial tissue. Pericardial cultures were negative for bacteria, fungi, and TB (Figure 7).

A 43-year-old male patient presented to the hospital after his son was diagnosed with constrictive pericarditis. CT, angiography, echocardiography confirmed the diagnosis of constrictive pericarditis. During surgery, pericardium was severely thickened and adherent to the heart. Patient recived prophylactic antibiotic therapy for suspected bacterial pericarditis, but cultures were negative. Tests for atypical agents such as Brucella, Lyme, Treponema were negative. He had a history of asbestos exposure, but no signs of asbestosis were found.

A 23-year-old female patient complained of dyspnea and pleural effusion. After her brother and father were diagnosed, she was also diagnosed with constrictive pericarditis. Her CT showed pericardial thickening and thickening of the right pleura. Pathology from surgery revealed chronic inflammation and fibrosis in the pericardium. She was investigated for Erdheim-Chester disease due to the inability to diagnose her father and brother, but the pathology was negative.

Diagnosing constrictive pericarditis can be challenging due to its similarity to other cardiac pathologies (such as restrictive cardiomyopathy), slow progression of symptoms, and inadequacy of initial investigations, eading to delayed diagnosis. Infectious agents as etiological factors can be transmitted among close family members, or there may be exposure to the same infectious agent. Genetic and metabolic diseases and rheumatological diseases can show genetic inheritance. In our experience, individuals diagnosed with constrictive pericarditis should be questioned about symptoms in family members and, family screening should be performed.

• Keywords: Constrictive pericarditis

2.5.8. Post-Pericardiotomy Sydrome

• Pelin Eşkin, Melike Yurttaş, Haluk Çağlar Karakaya, Yağmur Akşamın, Murat Uğur, Hilmi Tokmakoğlu, Ahmet Öcal and Muhammet Turhan
• Department of Cardiovascular Surgery, Sancaktepe Sehit Prof. Dr. Ilhan Varank Education and Research Hospital, University of Health Sciences, Istanbul, Turkey

Introduction: Post-pericardiotomy syndrome is collection of fluid in pericardial and/or pleural spaces which occurs around 1–6 weeks after cardiac surgery. It can develop due to an autoimmune-inflammatory response after the cardiac surgery. This syndrome is a rare late-postoperative complication of cardiac surgery.

Case: 57-year-old, female with hypertension, type-2 diabetes had a mechanical aortic valve replacement surgery (St. Jude No:21) due to severe aortic stenosis. On post-op day 12, there was significant pleural effusion. She had dyspnea. Her transthoracic echocardiogram (TTE) showed 2 cm of pericardial effusion without tamponade (PEWT). We inserted a pleural drainage catheter, drained 3000 mL serous fluid After that, we started diuretic treatment with protein-rich diet. On post-op day14, we ordered 25 mg indomethacin 3 times/day, corticosteroid 40 mg/day. The control TTE on post-op day 14 showed 2.5 cm PEWT. Therewithal, various tests have been performed and assessed that there was no malignancy, infectious or secondary reasons to explain these effusions. On post-op day 26, after the control TTE showed 3.1 cm pericardial effusion and diastolic collapse on the right atrium, we opened pericardial window, drained 1200 mL serous fluid after insertion of mediastinal and thoracic chest tubes. After that, we stopped corticosteroid and added 0.5 mg colchicine 3 times/day. Until the post-op day 31, the serous drainage was 400–600 mL/day. We removed chest tubes after 48 h of non-significant drainage. During the follow-up we ordered NSAIDs, corticosteroids, colchicine. While the colchicine treatment there was no recurrence of effusion.

Colchicine have been stopped on post-op day 61. During 3 months of follow-up there was no recurrence of effusions.

Conclusions: The patients who develop post-operative pleural/pericardial effusion, we should consider assessment of TTE on post-op early days and before discharge. NSAIDs, corticosteroid and colchicine can be used in the treatment of the post-pericardiotomy syndrome. There’re various studies confirm that colchicine is more effective in treatment of this syndrome.

• Keywords: posperıkardıal surgery; cardiac surgery; pleuvral drenaj

2.5.9. Surgical Pulmonary Embolectomy with Endarterectomy: Should It Be the First Line Therapy for Pulmonary Embolism?

• Kamil Sarkislali and Davit Saba
  Department of Cardiac and Vascular Surgery, GOP Medical Park Hospital, Istanbul, Turkey

BACKGROUND: Pulmonary embolism is a life-threatening condition with high mortality rate. Systemic anticoagulation is therapy of choice. However, this therapy may fail in the presence of large emboli causing right ventricular outflow tract obstruction. Herein, we report three cases of pulmonary embolism that managed by surgical embolectomy.

CASE: The first case was 20-year-old woman with repetitive generalized tonic-clonic seizures. Computed tomography pulmonary angiography (CTPA) could not be completed due to sudden cardiac arrest. She was transferred to OR under CPR conditions. Main, left and right pulmonary arteries were incised and fresh clots were extracted (Figure 8A). Mild hypothermia of 340C and anesthesia were maintained for 48 h in ICU. She was discharged with full recovery one month after surgery. The second case was 34-year-old woman with a history of surgery due to glioblastoma multiforme 10 months ago. CTPA revealed large emboli in main pulmonary artery and surgery was performed. Main, left and right pulmonary arteries were incised and emboli was extracted through endarterectomy (Figure 8B). The patient was discharged with full recovery on postoperative day 14. The third case was 36-year-old male patient with complains of shortness of breath and fatigue. CTPA showed sub-massive pulmonary embolism. Systemic thrombolytic therapy failed to achieve clinical recovery. Post therapeutic echocardiography showed free floating thrombus in right atrium and CTPA revealed massive PE. During the surgery pulmonary arteries were opened and endarterectomy was performed. Massive embolus materials were removed (Figure 8C). Postoperative course was satisfactory.

Surgical embolectomy with or without endarterectomy is a life-saving procedure with good safety and survival rates. Thrombolytic therapies have an important failure rate, which negatively affects success rate of surgery. Surgery should be taken into consideration as first-line therapy not only in acute massive PE but also in submassive pulmonary embolism since submassive embolism may deteriorate and convert to massive PE.

• Keywords: Pulmonary endarterectomy; Deep hypothermic circulatory arrest; Chronic thromboembolic pulmonary hypertension

• Thromboendartrectomy material

Figure 8. (A) SE materials of fresh clots. (B,C), Surgical thromboendarterectomy of chronic PE. White fibrotic material is adherent to the vessel wall while red-dark material is newer clot. For complete pulmonary arterial bed cleaning thromboendarterectomy should be performed under DHCA conditions.

Figure 8. (A) SE materials of fresh clots. (B,C), Surgical thromboendarterectomy of chronic PE. White fibrotic material is adherent to the vessel wall while red-dark material is newer clot. For complete pulmonary arterial bed cleaning thromboendarterectomy should be performed under DHCA conditions.

2.5.10. Benign Pneumoperitoneum Following Cardiac Surgery

• Alifa Sabir, Wajiha Arshad, Liaqat Lateef and Sahab Ahmad
  Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan

Pneumoperitoneum is the presence of free air within the intra abdominal compartment. Pneumoperitoneum following cardiac surgery may occur due to a variety of causes such as long sternotomy incision, prolonged ventilation, peptic ulcer perforation or bowel ischemia, but is not frequently reported following cardiac surgery. We encountered three cases about it in literature. Asymptomatic pneumoperitoneum does not posses any additional risk to patient but the possibility of associated bowel injury must be ruled out. We report a case of 24 year old boy who presented to us with rheumatic heart disease with severe aortic regurgitation. Patient underwent aortic valve replacement through median sternotomy. Post operatively, patient was weaned off ventilatory support within three hours with no complications. However, his chest xray showed bilateral air under diaphragm raising the suspicion of associated intraabdominal injury. His abdominal examination revealed slight distension but tenderness. Bowel sounds became audible on 1st POD. Serial X-rays and ultrasound was done which showed no significant finding except air under diaphragm. Patient was followed up until 7th POD, when the intraabdominal air completely resolved (Figure 9).

Conclusions: Due to close anatomic relationship between pericardium, diaphragm and peritoneum, peritoneal cavity may be breached during cardiac surgeries. Peritoneal cavity may be entered in long sternotomy incisions extending below the xiphoid process. Secondly, peritoneal breach may occur while inserting chest drains for mediastinal drainage post cardiac surgical procedure. As parietal pericardium is adherent to central part of diaphragm, so incising parietal pericardium to gain surgical exposure may lead to inadvertent injury to central tendons of diaphragm or peritoneum. Hence, the possibility of bowel injury or serious intrabdominal complications is the most frequently considered in cases of pneumoperitoneum following cardiac surgery. Complete history and clinical examination of the patient must be undertaken and appropriate diagnostic investigations done before planning for any surgical exploration.

• Keywords: Benign Pneumoperitoneum; cardiac surgery; bowel injury

2.5.11. Subaortic Pannus Without Mechanical Aortic Valve Dysfunction

• Kamil Sarkislali and Davit Saba
• Department of Cardiac and Vascular Surgery, Florence Nightingale Hospital, Sisli, Istanbul, Turkey

Background: Pannus formation after aortic valve replacement is an uncommon but serious problem. However, formation of subaortic membrane with fully functioning prothesis causing stenosis is rare. Herein, we report such a case that underwent successful surgery.

Case Report: A 63-year-old female patient was presented with complaints of dyspnea and fatigue. She had a history of AVR and MVR 22 years ago. Physical examination revealed prominent mid-systolic murmur on aortic area. Her functional capacity was NYHA class III. Echocardiography showed well-functioning aortic and mitral metallic prostheses but a high-pressure gradient at aortic level due to subaortic pannus formation causing LVOT obstruction. The patient underwent surgery. Functioning aortic prosthesis was resected since pannus removal by keeping the prosthesis intact was not possible. A circumferential pannus causing LVOT obstruction was seen. Pannus was resected and a new metallic prosthesis was placed. Postoperative course was satisfactory. This case is a rare example of aortic stenosis caused by a subvalvular pannus without prosthetic valve dysfunction. The causes of pannus formation remain unknown and effective preventive methods have not been fully clarified. All of the cardiac valve replacement surgeries may lead to periannular intimal tissue growth causing thickening. Besides, subaortic pannus may form by growth of subaortic membrane remnant that is a rare congenital disease. During aortic valve replacement surgeries subaortic valvular structures should be examined carefully and any deposits or tissue growth should be excised as much as possible keeping in mind the overgrowth potential of any remnants. Moreover, abnormal positioning of a prosthetic valve should be avoided due to the potential of turbulence that can cause fibrosis resulting in pannus formation.

• Keywords: Pannus; subaortic stenosis; mechanical cardiac valve

2.5.12. Complex Reconstruction of the Aorto-Mitral Curtain: Experience with the Commando (UFO) Procedure in Three Cases

• Emre Oteyaka ¹, Okan Eren Kuguoglu ², Didem Melis Oztas ³, Murat Ugurlucan ³ and Halil Turkoglu ¹

1

Department of Cardiovascular Surgery, School of Medicine, Istanbul Medipol University, Istanbul, Turkey

2

School of Medicine, Istanbul Medipol University, Istanbul, Turkey

3

Department of Cardiovascular Surgery, School of Medicine, Biruni University, Istanbul, Turkey

BACKGROUND: Damage to the aorto-mitral curtain can result from infective endocarditis, degenerative calcification, or multiple previous heart valve surgeries. Commando (UFO) procedure is the treatment of choice in cases involving extensive infiltration of the aorto-mitral curtain. This procedure allows for complex reconstruction of the lateral and medial fibrous trigones and the aortic root, restoring the integrity of the aortic and mitral annuli. However, it’s a technically challenging and complicated procedure with a high mortality rate of 7% to 24% post-operatively.

CASE: This case series highlights our experience with the commando procedure in three cases with extensive involvement of the aorto-mitral curtain. The etiology of aorto-mitral curtain involvement included infective endocarditis and extensive degenerative calcification. The complexity of the procedure and the approach to treatment based on the etiology of each case was highlighted extensively with attention to operative technique.

• Keywords: Commando procedure; aorto-mitral curtain reconstruction; operative technique

2.6. CARDIAC » Coronary Artery Bypass in Women

Gender Disparities in Multiple Arterial Grafting During Coronary Artery Bypass Graft Surgery: A Short- and Long-Term Analysis at a Single Center

• Oskar Krueger, Jan Strathmann, Ilia Balaj, Sharaf Eldin Shehada, Jarowit Piotrowski, Parwis Massoudy, Heinz Jakob, Markus Kamler and Matthias Thielmann
• Department of Thoracic and Cardiovascular Surgery, University Hospital Essen (AöR), Essen, Germany

BACKGROUND AND AIM: Gender disparities in coronary artery disease revascularization treatment and more specifically in patients undergoing coronary artery bypass grafting have been suggested. We therefore aimed to compare gender-specific outcomes with multiple arterial grafts (MAG) during coronary artery bypass grafting (CABG).

METHOD: In this retrospective study, we investigate short- and long-term clinical outcomes of females (n = 230) and males (n = 827) undergoing CABG with MAG between January 1999 and December 2019 at our institution.

RESULTS: Female patients had a significantly higher EuroScore II (5.4 vs. 3.14; p < 0.0001) and underwent significantly less bilateral internal thoracic artery (BITA) grafting (51.7% vs. 67.4%; p < 0.0001) with significantly fewer distal arterial anastomoses (3.1 vs. 3.4; p < 0.0001) as compared to male patients. The incidence of postoperative adverse events such as pneumonia (4% vs. 3.8%; p = 0.91), stroke (2.2% vs. 1%; p = 0.14), low cardiac output syndrome (2.6% vs. 1.1%; p = 0.08), cardiac resuscitation (2.2% vs. 3.3%; p = 0.4) and renal failure requiring dialysis (8.4% vs. 6.5%; p = 0.32) did not differ between the two groups. In contrast, female patients suffered significantly more frequently from sternal wound healing disorders over the entire follow-up period (15.3% vs. 9%; p < 0.006). With regard to 30 day mortality, no difference was found between the two groups (2.8% vs. 2.6%; p = 0.87). However, a significantly higher median survival time of 19.6 years compared to 15.4 years was found in male patients (p = 0.007) (Figure 10).

CONCLUSIONS: Our data suggest that female gender is a risk factor for long-term clinical outcome of CABG with MAG. This may be attributed to a higher rate of comorbidities and a higher rate of wound healing disorders in females.

• Keywords: coronray artery bypass grafting; multiple arterial grafting; women; internal thoracic artery; bypass; myocardial revascularization

2.7. CARDIAC » ERAS and New Techniques and Technologies

2.7.1. Fully Implantable Wirelessly Powered Magnetically Levitated Radial Flow Ventricular Assist Device—Innovative Design and Early Prototyping

• Grigore Tinică, Alexandru Pleșoianu, Carmen Pleșoianu and Alberto Bacușcă
• Department of Cardiovascular Surgery, Cardiovascular Diseases Institute “George I.M. Georgescu”, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania

BACKGROUND AND AIM: Substantial efforts are dedicated to enhancing mechanical circulatory support devices, driven by the escalating prevalence of advanced heart failure. Our goal was to design and develop an innovative partial support ventricular assistive device to minimize the side effects, to increase addressability and improve implantation techniques known from the state-of-the-art systems.

METHOD: A design thinking process was performed to identify the needs of an innovative ventricular assist device and to establish a concept that may fulfill those needs. The pump was parameterized by turbomachinery calculus CFturbo. A model was designed with various impeller diameter in CAD software and CFD was performed to show blood flow properties inside the pump. Stereolithography technique was used to materialize early prototypes.

RESULTS: A fully implantable, wirelessly powered magnetically levitated centrifugal flow pump with a low profile suitable for subcutaneous implantation was designed. The inlet cannula will be connected surgically or transcatheter to the left atria and the outlet cannula to the right subclavian artery. Clear resin 3D printing at 25 microns resolution was done materializing the parts of the device. To pump 5 L/min at 100 mmHg a 15 mm diameter rotor should be turned at 6249 rot/min while a 30 mm rotor at 2916 rot/min, respectively. CFD evidenced blood flow path inside the pump with velocities, pressures and turbulences in the normal range for such a device.

CONCLUSIONS: A fully subcutaneous implantable, wirelessly powered magnetically levitated centrifugal flow pump may bring an important contribution to the management of patients with advanced heart failure. Low profile of the device for subcutaneous implantation facilitates wireless transcutaneous energy transfer. This may raise the addressability to illegible or earlier stage heart failure patients. The design, the concept and the mathematical modeling need materialization and furthered testing

• Keywords: Fully Implantable Wirelessly Powered LVAD; mechanical circulatory support

2.7.2. Bearingless Continous Flow Rotary TAH

• Grigore Tinică, Alexandru Pleșoianu, Carmen Pleșoianu, Alberto Emanuel Bacușcă and Andrei Țăruș
• Department of Cardiovascular Surgery, Cardiovascular Diseases Institute “George I.M. Georgescu”, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania

BACKGROUND AND AIM: Total artificial hearts offer new hope to heart failure patients on transplant waitlists. Our aim is to develop an innovative wireless device to improve current options by enhancing patient freedom and durability, aiming for a better quality of life.

METHOD: Our idea involves a wireless device, removing chest-protruding wires, enhancing patient autonomy, and emphasizing durability. Mathematical modeling was used to establish the necessary pump parameters to deliver the required blood flow. The pumps were preliminary designed in CF-turbo and resulted geometries were in silico tested in Ansys CFX. The design was improved in Fusion 360 and the prototype was obtain through stereolithography (SLA) 3D printing usingtough resin. The dimensions of the artificial heart were evaluated in detail and ensured that it fitsoptimally using the “V-Patient” application. The 3D model was successfully virtually fitted in the thoracic space between the diaphragm and the atriums and confirmed by anatomically fitting in an ovine heart and a heart-shaped silicone mold.

RESULTS: Our artificial heart system comprises a thoracic pumping unit, subcutaneous driver, wearable controller, batteries, and charging station. The designed motor is based on MAGLEV technology and has 50 mm diameter,14 mm length, and 7.5 W at 5600 rpm. CFD simulation for the latest prototype objectivated 5 L/min, 100 mmHg, 53% efficiency, and 51 Pascal shear stress for the left pump, respectively 1.3 L/min, 26 mmHg, 13% efficiency, 323 Pa shear stress for the right one.

CONCLUSIONS: We designed an innovative TAH system that is composed of an artificial heart that pumps blood, a subcutaneous driver that powers the TAH motor, stores energy into a battery, and receives wireless energy from outside, a wearable controller that powers and communicates wirelessly with driver, communicates with the patient and with a cloud platform; batteries and a battery charging station.

• Keywords: TAH; End-stage HF

2.8. CARDIAC » On-Pump CABG

2.8.1. Impact of Different Cardioplegia Techniques on Cardiac Surgery Outcome

• Antonia Frida Dworak ¹, Nora Desilva ², Philipp Kolat ², Christine Friedrich ¹, Jochen Cremer ¹ and Assad Haneya ²

1

Department of Cardio-Vascular Surgery, University Hospital Kiel, Kiel, Germany

2

Department of Cardiac and Thoracic Surgery, Heart Center Trier, Trier, Germany

BACKGROUND AND AIM: While numerous advancements have been made in various myocardial protection techniques, the challenge of ischemia-reperfusion injury following intraoperative cardioplegic arrest persists. Especially in the context of increasingly intricate surgical procedures the adoption of novel cardioplegia protocols may hold key implications for future surgical interventions and treatments.

The objective of our retrospective analysis was to assess the applicability of del Nido cardioplegia in comparison to Buckberg and Calafiore, with a dual focus on evaluating associated surgical advantages and examining potential differences in postoperative outcomes.

METHOD: We included a total of n = 166 patients who underwent cardiac surgery bypass (ACB), aortic valve replacement (AKE) or combined procedures (ACB + AKE) at the University Hospital Schleswig-Holstein Campus Kiel, between October 2021 and April 2023. Study group (SG) 1 received Buckberg (BUC) cardioplegia (n = 87), SG2 Calafiore (CAL) cardioplegia (n = 39) and SG3 underwent surgery by del Nido (DELNI) protocol (n = 40).

RESULTS: The administered volume of cardioplegia solution with DELNI (median: 1550 mL (975; 1962)) and CAL (median: 1575 mL (1200; 2250)) were significantly (p < 0.001) lower compared to BUC application (median: 2320 mL (2000; 3200). After the release of aortic cross clamp, significant differences (p < 0.001) were found in the restoration of sinus rhythm (SR) among the groups. SR was observed in 57.5% of the BUC participants, 87.2% of the CAL participants, and 80% of the DELNI participants. The median extracorporeal circulation (ECC) time for SG1 (BUC) was 116 min, SG2 (CAL) with 105 min (88; 127) and SG3 (DELNI) with 95.5 min (51; 88). These differences in ECC time did not reach statistical significance in our analysis but indicate a certain trend (Figure 11 and

Table 20. Intraoperative Data.

Parameter	Median Buckberg (n = 87)	Median Calafiore (n = 39)	Median delNido (n = 40)	p-Value
Kardioplegia amount kristalloid (in mL)	540	23	1280	<0.001
Kardioplegia amount total (in mL)	2320	1575	1550	<0.001
ECC-Time (in min)	116	105	95.5	0.117
AO-X (in min)	81	68	68	0.021
SR after AO-X opening	50	34	32	<0.001

).

There were no statistically significant differences in terms of 30-day postoperative mortality rates among the three cardioplegia techniques applied.

CONCLUSIONS: The obtained results of our retrospective analysis suggest that del Nido can be safely applied in adult cardiac surgery and appears to exhibit non-inferiority when compared to Buckberg and Calafiore cardioplegia.

• Keywords: Cardioiplegia-techniques; myocardial protection; advancements; delNido; Buckberg; Calafiore

2.8.2. Comparison of Post-Operative Blood Loss and Transfusions in Patients with Normal Body Mass Index vs. High Body Mass Index After Coronary Artery Bypass

• Waqar Masud Malik ¹, Muhammad Tariq Khan ¹, Sobia Siddique Malik ², Kifayat Ullah Khan ¹, Muhammad Afridi Khan ¹ and Zeeshan Abdul Nasir ¹

1

Department of Cardiac Surgery, Peshawar Institute of Cardiology, Peshawar, Pakistan

2

Department of Cardiac Surgery, Armed Forces Institute of Cardiology, Rawalpindi, Pakistan

BACKGROUND AND AIM: Obesity is one of the World’s most common and growing health concern today. An increasing obese population in the Pakistan focuses attention on perioperative management of obese and overweight patient. BMI is a validated measure of adiposity and has been consistently used to analyze obesity and mortality. Most studies predict that, risk of cardiovascular mortality is more in obese patients.

AIMs/OBJECTIVE: To determine frequency of blood transfusion and blood loss based on BMI among patients undergoing CABG

METHOD: The retrospective observational study was carried out at Peshawar institute of cardiology. We included all patients who underwent CABG surgery, fulfilling inclusion criteria from 1 January 2023 to 31 December 2023. Ethical approval was taken from hospital ethical review committee. Data was extracted from electronic medical record and analyzed in SPSS version 22.0.

RESULTS: The mean age of patients with normal body mass index was 61.41 ± 3.09 and in patients with high body mass index was 63.96 ± 7.64 years. There were 60.67% and 47.34% male in normal and high BMI groups, respectively. The mean BMI was 24.98 ± 4.46 kg/m². There were 4.67% and 1.34% bleeders in patients with normal and high BMI, respectively. Mean blood losses were 451.01 ± 0.91 mL/kg/h. and 301.38 ± 1.05 mL/kg/h. (p-value = 0.003) in patient with normal and high BMI, respectively in our study. In our study, 4.67% patients with normal BMI and 1.34% patients with high BMI received blood transfusion (p-value = 0.001).

CONCLUSIONS: High body mass index does not increase the risk of post-operative bleeding and requirement of blood transfusion. There is significant difference in frequencies of blood transfusion and blood loss based on BMI among patients undergoing CABG.

• Keywords: Body mass index; Transfusion; Postoperative bleeding; Coronary artery bypass grafting

2.8.3. Assessing Mortality Risk Is Vital for Preoperative Risk Evaluation and Resource Allocation

• Hasanat Sharif
• Aga Khan University, Karachi, Pakistan

BACKGROUND AND AIM: Assessing mortality risk is vital for preoperative risk evaluation and resource allocation. This article presents a single-centered comprehensive analysis of Society of Thoracic Surgeons (STS) scores and factors impacting outcomes in cardiothoracic surgery patients. It aims to assess the STS risk score’s effectiveness in predicting mortality.

METHOD: STS scores for a diverse patient cohort of 3084 patients who underwent cardiac surgery between January 2010 and December 2016 at a Tertiary care Hospital in Pakistan

RESULTS: The mean age of study population was 58. The most common procedures were isolated CABG, MVR, and AVR. Severe mitral insufficiency was more frequently present than aortic insufficiency. Mortality rates were higher for females, the elderly, those with mitral insufficiency and patients on ADP inhibitors for anticoagulation. Post-operative complications, including dialysis, stroke, prolonged ventilation and length of stay, were linked to higher mortality. The threshold value of STS was found to be ≥1.645 indicating a high-risk group with a 10.3% mortality rate. This threshold had a sensitivity of 74.5% and specificity of 78.2%, contributing to an accuracy of 78.08% (

Table 21. Univariate and multivariate logistic regression analysis for predicting outcome of 30 days in-hospital mortality.

Factors	Univariate (OR {95% CI})	Univariate (p Values)	Multivariate-Initial Level (OR {95% CI))	Multivariate-Initial Level (p Values)	Multivariate-Final Level (OR [95% CI})	Multivariate-Final Level (p Values)
MVR_CABG	3.34 [1.17–9.57]	0.025 *	1.5 [0.31–7.21]	0.611
Gender (Female)	2.18 [1.45–3.27]	<0.001 *	3.39 [1.77–6.48]	<0.001 *	3.58 [1.93–6.66]	<0.001 *
Age groups (>=55)	3.32 [1.88–5.87]	<0.001 *	1.83 [0.83–4.03]	0.136	1.89 [0.87–4.11]	0.106
Obese (Yes)	0.92 [0.61–1.38]	0.670
MV repair CABG	7.44 [1.56–35.46]	0.012 *
Dialysis	5.07 [1.93–13.36]	0.001 *	3.38 [0.65–17.53]	0.147
Hypertension (HTN)	2.54 [1.48–4.36]	0.001 *	1.4 [0.61–3.2]	0.423
Diabetes Mellitus (DM)	1.66 [1.11–2.5]	0.014 *	0.95 [0.51–1.75]	0.861
Family History of CAD	1.87 [1.22–2.84]	0.004 *	0.8 [0.42–1.54]	0.51
Chronic Lung Disease	3.3 [1.61–6.76]	0.001 *	1.97 [0.65–5.94]	0.231
Myocardial Infarction (MI)	2.67 [1.76–4.04]	<0.001 *	0.76 [0.37–1.56]	0.451
Angina (Unstable)	5.86 [3.08–11.12]	<0.001 *	1.69 [1.23–3.91]	0.02
Cardiogenic Shock (Yes)	16.66 [9.97–27.84]	<0.001 *	1.21 [0.45–3.21]	0.706
Arrhythmia	3.15 [1.68–5.915]	<0.001 *	2.26 [1.74–6.58]	0.014
Inotropic Support (Yes)	7.43 [3.62–15.243]	<0.001 *	0.69 [0.22–2.16]	0.521
ADP Inhibitor	3.04 [1.54–6.006]	0.001 *	4.25 [1.64–11]	0.003	4.69 [1.87–11.79]	0.001
Beta Blocker	1.01 [0.68–1.501]	0.974
Resuscitation	10.48 [5.15–21.343]	<0.001	2.74 [0.76–9.89]	0.013 *	3.9 [1.21–12.58]	0.023
Aortic Stenosis (Yes)	1.1 [0.61–1.98]	0.764
Mitral Stenosis	1.75 [1.15–2.66]	0.009 *	1.05 [0.53–2.07]	0.889
IABP	19.23 [12.62–29.29]	<0.001 *	2.69 [1.3–5.57]	0.008 *	2.9 [1.49–5.66]	0.002
Status (Urgent)	3.25 [1.98–5.34]	<0.001 *	1.36 [0.6–3.07]	0.456
Status (Emergent)	7.65 [4.71–12.44]	<0.001 *	0.57 [0.21–1.52]	0.261
Status (Salvage)	16.98 [1.73–166.25]	0.015
Postoperative Dialysis	64.17 [30.53–134.87]	0.001	7.82 [2.3–26.51]	0.001	7.68 [2.45–24.09]	<0.001 *
Postoperative Stroke for 72 h	8.99 [3.25–24.87]	<0.001 *	8.85 [1.76–44.53]	0.008 *	7.48 [1.4–40.05]	0.019
Prolonged Ventilation (>24 h)	40.45 [25.22–64.87]	<0.001 *	21.66 [10.3–45.58]	<0.001 *	25.47 [12.55–51.69]	<0.001
Reoperation	17.9 [11.04–29.02]	<0.001 *	4.84 [2.15–10.9]	<0.001	1.96 [9.56–0.46]	4.331
Hospital Stay (>=14 Days)	2.84 [1.71–4.71]	<0.001	0.2 [0.08–0.5]	0.001 *	0.19 [0.08–0.46]	<0.001

* Univariate analysis showed several factors associated with mortality risk. In multivariate analysis, Female gender, ADP Inhibitor use, Resuscitation, Postoperative Dialysis, perioperative intra-aortic balloon pump (IABP), operative Stroke within 72 h, Prolonged Ventilation (24 h), and prolonged Hospital Stay (≥14 Days) remained significant (p < 0.05).

).

CONCLUSIONS: STS risk calculator is a great tool for mortality prediction in Pakistan with an AUC value of 0.819 (95% CI 0.791–0.898) (Figure 12).

• Keywords: STS score; Cardiothoracic surgery; Coronary Artery Bypass Graft; Valve replacement; Mortality prediction

2.8.4. CABG—State of the Art

• Grigore Tinică, Alberto Emanuel Bacușcă, Mihail Enache, Silviu Paul Stoleriu and Andrei Petrișor Țăruș
• Department of Cardiovascular Surgery, Cardiovascular Diseases Institute “George I.M. Georgescu”, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania

BACKGROUND AND AIM: Despite the increasing severity of patients’ risk profiles, advancements in surgical techniques and refined patient selection have contributed to improving post-CABG outcomes, with a significant decrease in mortality and morbidity rates. Our objective was to showcase the evolution over a period of 23 years at our center by assessing both the short-term and long-term outcomes, as well as the changes and adaptations in surgical management in accordance with the guidelines issued during this time frame.

METHOD: This study reflects the 23 year-long experience of a single center serving a population of over 5 million, employing a retrospective design that encompasses all patients who underwent at least one CABG, including those who had an additional auxiliary procedure, whether emergent or elective.

RESULTS: Between 2000 and 2023, at the Institute of Cardiovascular Diseases in Iași, over 3000 myocardial revascularization interventions were performed through CABG, with the majority being on-pump procedures. Most patients referred to our clinic had tri-coronary disease (70%), while 25% had double-vessel lesions, and 5% presented lesions in a single coronary artery. The majority were revascularized either through triple bypass surgery (39%) or quadruple bypass surgery (27%). The proportion of total arterial revascularization reached over 70% in recent years. Regarding mammary artery configuration, 69% remained in situ, while 31% were anastomosed in a Y or T shape. Over 1100 procedures were performed using the radial artery, representing approximately 37% of total revascularizations. The postoperative mortality rate was 0.8%, with a cardiovascular-related mortality rate of 0.5%. The 5-year postoperative survival rate was 95% for patients undergoing total arterial revascularization and 90% for those with mixed revascularization.

CONCLUSIONS: Advancements in CABG techniques over 23 years at our center significantly reduced mortality and morbidity rates, showcasing successful long-term outcomes and adherence to evolving surgical guidelines.

• Keywords: CABG; total arterial revascularization

2.8.5. CABG with Substernal Goiter Resection

• Münacettin Ceviz ¹, Taner Evcimik ¹ and Abdurrahim Çolak ²

1

Private Buhara Hospital, Erzurum, Turkey

2

Department of Cardiovascular Surgery, Medical Faculty, Atatürk University, Yakutiye, Turkey

A 59-year-old male patient was admitted to the hospital due to unstable angina. The patient, whose coronary angiography revealed two-vessel disease (proximal LAD and RCA lesion), was hospitalized for CABG. Intrathoracic thyroid tissue measuring 10 × 7 cm was detected in the CT examination (Figure 13). The patient had a right thyroid lobectomy 10 years ago. Thyroid functions were normal. Simultaneous total thyroidectomy and CABG were planned. Median sternotomy was performed. Intrathoracic thyroid tissue was freed from the surrounding tissues by separating it with harmonic cautery. An incision was made on the left thyroid lobe by the general surgery team and the left thyroid lobe was released. The laryngeal recurrent nerve was divided. The left lobe of the thyroid was completely removed along with the intrathoracic thyroid tissue. Then, onpump LIMA LAD bypass and saphenous vein and Aortic RCA bypass were performed using the classical method. There were no postoperative complications. The patient was discharged on the 7th day with thyroid hormone replacement. The patient is under control in the 2nd month postoperatively.

• Keywords: Substernal goiter; CABG

2.8.6. CABG in a Patient with Renal TX: Case Report

• Münacettin Ceviz ¹, Serdar Sevimli ², Ibrahïm Samurcu ¹, Dilak Ika ³ and Bülent Aydınlı ⁴

1

Cardiovascular Surgery Department, Private Buhara Hospital, Erzurum, Turkey

2

Cardiology Department, Private Buhara Hospital, Erzurum, Turkey

3

Internal Medicine Department, Private Buhara Hospital, Erzurum, Turkey

4

Organ Transplant Institute, Faculty of Medicine, Akdeniz University, Antalya, Turkey

A 63-year-old male patient first applied to the acardiology clinic complaining of unstable angina pectoris. The patient has a history of LAD stent placement 16 years ago and a history of renal transplant recipient 10 years ago. He received hemodialysis treatment for two years before Tx. He received radiotherapy 2 years ago for nasopharyngeal CA. Otolaryngological examination revealed no residual or recurrent tumor. In the coronary angiography, the LAD was completely occluded starting from the stent and filling retrogradely from the RCA. There was 99% stenosis in OM1 and 90% stenosis in RCA. CABG decision was made. The patient was taking tacrolimus TB 2 × 0.5 mg, everolimus 0.75 mg/day and prednisolone TB 1 × 5 mg. Everolimus was discontinued on preoperative day 1. Tacrolimus 2 × 1 mg and prednisolone 1 × 20 mg were switched to. The patient was taken into operation. LIMA LAD, saphenous vein and aortic RCA and Aortic OM1 bypasses were performed under cardiopulmonary bypass. Graft flows were determined to be good by flowmeter. Autotransfusion system was used in the operation. Autologous blood was taken and used in the postoperative period. No other blood was used. The creatinine value was 0.76 mg/dL in the preoperative period, and there was no significant change in the postoperative values. Tacrolimus level was controlled and 2 × 1 mg was continued for 6 days. The blood tacrolimus level was checked every 2 days and was found to be 7–10 ng/mL. Postoperatively, the patient was discharged without complications by switching to tacrolimus 2 × 0.5 mg and everolimus 0.75 mg/day. The creatinine value at discharge was 0.75 mg/dL.

We wanted to present our experience regarding the management of immunosuppressive agents and things to consider in renal transplant patients.

• Keywords: Renal tx; CABG

2.9. INTERDISCIPLINARY » Aortic Dissection & Surgical Treatment (Open and Endovascular)

2.9.1. The Effect of Preoperative Metabolic Acidosis and Hyperlactatemia on Early-Term Mortality in Patients Undergoing Acute Type-A Thoracic Aortic Dissection Repair

• Seyhan Yılmaz ¹, Bilge Olgun Keleş ², Ertan Aydın ³ and Sabür Zengin ¹

1

Department of Cardiovascular Surgery, Faculty of Medicine, Giresun University, Giresun, Turkey

2

Department of Anesthesiology and Reanimation, Faculty of Medicine, Giresun University, Giresun, Turkey

3

Department of Cardiology, Faculty of Medicine, Giresun University, Giresun, Turkey

BACKGROUND AND AIM: Acute Stanford Type A Aortic Dissection is a life-threatening disease and a surgical emergency with an estimated mortality rate of 1–2% per hour if left unrepaired. It has been reported that organ malperfusion occurred in approximately 30% of these cases, and preoperative acidosis also affects operative mortality in these patients. In our study, we aimed to evaluate the effects of preoperative acidosis and hyperlactatemia on early mortality in patients who underwent emergency surgical repair due to Acute Thoracic Aortic Dissection-Type A.

METHOD: Patients who underwent emergency surgical repair due to acute thoracic aortic dissection-Type A in our hospital, for whom study data could be obtained, were included in our retrospective study, and patients who underwent endovascular repair due to Type B Thoracic Aortic Dissection and who underwent open heart surgery for the second or third time were not included in the study.

RESULTS: The mean age of a total of 13 patients included in the study was found to be 59.62 ± 16.58. The mean preoperative lactate value was found 4.88 ± 4.21 and the preoperative blood-gas and laboratory parameters values of the patients are shown in Figure 14.

CONCLUSIONS: We think that the evaluation of preoperative metabolic acidosis and hyperlactatemia is an important and simple method in predicting early postoperative mortality and perioperative patient management in the surgical treatment of acute thoracic aortic dissection-Type A disease and it would be useful to conduct large series multicenter studies on this subject.

• Keywords: aortic dissection; mortality; acidosis; malperfusion; hyperlactatemia

2.9.2. A Case Report of New Developed Paraplegia After Repairing Acute Type A Aortic Dissection

• Hamdï Mehmet Özbek
  Department of Cardiovascular Surgery, Sincan Training and Research Hospital, Ankara, Türkiye

BACKGROUND: Stanford Type A Aortic Dissection (STAAD) is associated with elevated preoperative mortality and morbidity rates, as well as an increased likelihood of postoperative complications. Among these complications, paraplegia represents a serious but rare occurrence that can lead to significant morbidity in affected individuals.

CASE: A 55-year-old male patient experienced acute paraplegia in the postoperative period after STAAD. Upon detection of paraplegia, medical therapy was promptly initiated. Despite maintenance of hemodynamic stability following surgery, the patient’s neurological deficit persisted at the postoperative 24th hour. In response, cerebrospinal fluid (CSF) drainage was instituted. Notably, a full clinical recovery in neurological function was observed within 5 h of initiating CSF drainage (Figure 15).

The pathophysiology underlying postoperative paraplegia in the context of aortic dissection remains unclear. However, with the maintenance of hemodynamic stability, appropriate medical management and with the persistence of neurological symptoms the implementation of CSF drainage may be considered to facilitate resolution of symptoms. With these interventions, paraplegia can be considered as a potentially reversible condition.

• Keywords: Paraplegia; Aortic Dissection

2.10. INTERDISCIPLINARY » Arrhythmia Surgery

Completely Epicardial Implantation of Cardioverter/Defibrillator (ICD) and CRT-D System in Patient with Partial Venous Return Anormally: Rare Case

• Deniz Bozdogan and Aytaç Caliskan
• Bakırcay University Cigli Research and Training Hospital, Izmir, Turkey

Cardiac resynchronization therapy-defibrillator (CRT-D) devices are indicated for patients with moderate-to-severe left ventricular (LV) dysfunction to restore cardiac function, Central venous occlusions, device-related infections, and recurrent lead failures which are problems frequently encountered by cardiologists in daily practice, may necessitate surgical eğpicardial pace implantation.

65 y/o male patient with diagnosed congestive heart failure and low ejection fraction. ICD implantation was performed 10 years ago. It was canceled 2 years ago due to pace site and lead infection, and it was decided to follow the patient under medical treatment.

At the end of 2 years, he was admitted to the emergency department with an attack of ventricular tachycardia. Electrical cardioversion was performed and it was decided to implant percutaneous CRT-D in the patient. Thorax tomographic angiography showed that the superior vena cava was occluded with thrombozis and partial pulmonary venus return anormaly was existed.

Due to the patient’s history of deep vein thrombosis, previous infection at bilateral pace sites, and the presence of partial pulmonary venous return anomaly in the patient, the heart team decided to insert CRT-D epicardially with median sternotomy.

Surgical implantation was performed properilly. Two lead for right atrium, two lead for right ventricle, two lead for left ventricle, one high voltage coil for right ventricle out flow tract which was implanted near the pulmonary artery and far from non-contractile tissue, without any attachment with other leads were applied (Figure 16).

Our purpose of sharing this study is that; In patients who are scheduled for CRT-D implantation, surgical CRT-D implantation may be an option in cases where percutaneous processing cannot be performed due to infection, deep vein thrombosis and vena cava occlusion. This case is the 7th case in the literature due to its features and preference for implanted device and coil.

• Keywords: epicardial pace implantation; congestive heart failure

2.11. INTERDISCIPLINARY » Comparison of Surgical Versus Catheter Procedures and Complications

Deep Vein Thrombosis After Varicose Vein Operation—Observational Study in Rural Area

• Nikolaos Syrmos
• Aristotle University of Thessaloniki, Thessaloniki, Greece

BACKGROUND AND AIM: Chronic venous disease often presents various symptoms caused by defects (both functional and structural) of the venous vessels. One common aspect is the occurrence of varicose veins. Surgery remains a treatment option for these cases. Deep vein thrombosis (DVT) is a common complication of the surgery procedures. The diagnosis can be difficult, especially when limited access is presented in rural settings.

AIM: The estimation of the influence of LMWH primary prophylaxis on the formation of postoperative DVT, as well as sensitivity and specificity of clinical examination and D-dimer value in diagnosis of postoperative DVT in women.

MATERIALS-METHODS: The study was conducted in a group of 14 women (range of age 50–60, mean age 55). The patients had undergone a varicose vein operation and were randomly divided into two groups: A—7 (50%) women receiving LMWH during two days of the perioperative period, B—7 (50%) women receiving LMWH during seven days of the perioperative period.

RESULTS: There was no significant difference in the postoperative DVT complications in both groups. The value of D-dimer > 0.9 mcg/mL and swelling > 1.5 cm of shin (in comparison to the preoperative period) plays a significant role in diagnosis of DVT.

CONCLUSIONS: The extended primary prophylaxis with LMWH does not affect the amount or quality of thrombotic complications after varicose vein operation. If the DVT occurs, the evaluation of the D—dimer and careful clinical examination can be a useful method for its diagnosis.

• Keywords: varicose vein; rural health; chronic venous disease

2.12. INTERDISCIPLINARY » Intensive Care

Renal Complications Following Coronary Artery Bypass Grafting (CABG) Surgery: A 5-Year Retrospective Study and STS Quality Improvement Initiative at Aga Khan Hospital Karachi, Pakistan

• Nausheen Kassum, Hina Inam and Naveen Nizar
• Aga Khan University Hospital, Karachi, Pakistan

BACKGROUND AND AIM: Optimal renal function is essential for successful recovery post-coronary artery bypass grafting (CABG) surgery. Renal complications, including acute kidney injury (AKI) and renal dysfunction, significantly impact patient outcomes and healthcare costs. In alignment with the Society of Thoracic Surgeons’ commitment to high-quality cardiac care, this study investigates the incidence and trends of renal complications post-CABG over a 5-year period and evaluates the effectiveness of monitoring and interventions as a quality improvement metric. A quality committee was formed, initiating the collection of STS quality improvement indicators, with the Clinical Nurse Coordinator assigned to gather and maintain the data since 2018.

METHOD: This retrospective analysis included five consecutive years (2018–2023) of data from a single institution. We recorded the annual count of CABG surgeries and identified patients developing AKI and renal dysfunction. The percentage of patients with renal complications relative to the total CABG surgeries was calculated for each year to assess trends and impact of interventions.

RESULTS: The study revealed variable incidences of AKI and renal dysfunction over the observation period. AKI rates ranged from 2.0% to 3.1%, peaking in 2022, while renal dysfunction rates remained relatively low, fluctuating between 0.0% and 1.5%. Notably, the incidence of both AKI and renal dysfunction generally decreased or remained low in the latter years of the study.

CONCLUSIONS: This comprehensive 5-year retrospective study provides insights into the variable incidence of renal complications following CABG surgery. The successful implementation of a monitoring and intervention strategy in our institution, complemented by sustained quality improvement efforts, demonstrates its potential to mitigate renal complications and improve patient outcomes. Future research should focus on refining strategies to further reduce AKI incidence and optimize renal dysfunction management post-CABG.

• Keywords: Acute kidney injury (AKI); renal dysfunction; coronary artery bypass grafting (CABG); quality improvement; Clinical Nurse Coordinator; Society of Thoracic

2.13. INTERDISCIPLINARY » Miscellaneous

2.13.1. The Role of Extracorporeal Circulation and Hypothermic Circulatory Arrest in Modern Vascular Surgery

• Georgios Sachsamanis ¹, Wilma Schierling ¹, Thomas Betz ¹, Reinhard Kobuch ¹, Kyriakos Oikonomou ², Christof Schmid ³ and Karin Pfister ¹

1

Department of Vascular and Endovascular Surgery, University Medical Center Regensburg, Regensburg, Germany

2

Department of Vascular and Endovascular Surgery, Cardiovascular Surgery Clinic, University Hospital Frankfurt, Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany

3

Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany

BACKGROUND AND AIM: Recent advances in minimal invasive techniques with the introduction of complex endovascular strategies have effectively minimized the role of extracorporeal circulation (ECC) and hypothermic circulatory arrest (HCA) during open surgical repair of descending thoracic (DTA) and thoracoabdominal aortic (TAA) aneurysms. The aim of this report is to assess the current role, indications and effectiveness of ECC and HCA in the modern ‘endovascular’ era.

METHOD: We retrospectively reviewed the records of all patients who underwent open surgical aortic procedures with ECC between May 2012 and February 2022. Preservation of cerebral and distal perfusion was accomplished with a heart-lung machine in all cases. Primary endpoint was patients’ perioperative mortality. Secondary endpoints were ECC-associated perioperative outcomes and complications.

RESULTS: A total of 22 patients (16 male, 6 female, mean age 60.8 ± 10.9) years underwent open surgical aortic repair (OSR) with ECC in the study period. Ten patients underwent infected thoracic endograft explantation and four patients underwent explantation of an infected thoracoabdominal endograft. Four patients underwent elective OSR for thoracic aortic aneurysm and three patients open surgical thoracoabdominal aortic aneurysm repair. In one case, a patient underwent aortic valve repair. HCA was established in 11 (50%) patients. In-hospital mortality was 18.2% (4/22). Patients who had OSR for infected prosthesis had a higher mortality compared to elective OSR (4/14, 28% for the patients with infected stentgrafts, 0/8, 0% for patients with elective OSR, p = 0.09). A total of 22 complications were recorded postoperatively. Spinal cord ischemia occurred in one patient following explantation of an infected thoracoabdominal prosthesis with permanent hip weakness.

CONCLUSIONS: Because of a significant increase in endovascular management for DTA und TAA pathologies in recent years, OSR is reserved for cases involving endograft infections and patients for whom an endovascular approach is contraindicated. ECC and HCA emerge as a viable solution with acceptable outcomes.

• Keywords: extracorporeal circulation; hypothermic circulatory arrest; thoracoabdominal; infect

2.13.2. The Impact of Arterial Stiffness on the Performance of Percutaneous Coronary Intervention During Acute Coronary Syndrome

• Jae Bin Seo
• Department of Internal Medicine, Boramae Medical Center, Seoul, Republic of Korea

BACKGROUND AND AIM: Increased arterial stiffness is an accepted cardiovascular risk factor. However, the effect of arterial stiffness on the performance of percutaneous coronary intervention (PCI) during acute coronary syndrome (ACS) is not well known. The aim of this study was to evaluate the impact of arterial stiffness measured by pulse wave velocity (PWV) on acute gain and late loss after PCI during ACS.

METHOD: Data from 253 consecutive patients (342 lesions) who underwent PCI using drug eluting stents due to ACS and PWV study were analyzed.

RESULTS: Before Procedure, the minimal lumen diameter (MLD) was 0.82 ± 0.49 mm. In addition, those of post-procedure & 10-month follow-up were 2.34 ± 0.40 mm and 2.00 ± 0.65 mm, respectively. Mean PWV, acute gain and late loss were 1683 ± 386 cm s⁻¹, 1.52 ± 0.54 mm and 0.15 ± 0.54 mm. There was negative relation between PWV and acute gain (correlation coefficient = −0.161; p = 0.029). However, there was no relation between PWV and late loss (correlation coefficient = −0.032; p = 0.666).

CONCLUSIONS: Increased arterial stiffness is unfavorable for acute gain of the patients undergoing PCI during ACS. However, this is not prognostic factor for late loss. Therefore, we should make more effort to get sufficient acute gain when faced with the patients of ACS who show high PWV, which means increased arterial stiffness.

• Keywords: Acute Coronary Syndrome

2.13.3. Varicose Veins and Chronic Venous Insufficiency in Rural Area of Greece

• Nikolaos Syrmos
• Aristotle University of Thessaloniki, Thessaloniki, Greece

BACKGROUND AND AIM: Aim-The prevalence of varicose veins (VV) and of chronic venous insufficiency (CVI) was studied among 100 adults over 40 years of age (30 men and 70 women).

METHOD: Material-Methods- The prevalence of all grades of VV not including telangiectasis and reticular varices grade I was 50%. The prevalence of VV recorded as moderate or severe was 30%. The more severe form of CVI with active or healed ulcer was present in 8 of the subjects. For only 10 (10%) of the patients was VV or CVI the reason for medical consultation.

RESULTS: Results-The prevalence of VV increased with age and number of pregnancies. Working posture or posture adopted for defaecation did not influence the prevalence of VV. Our data show the prevalence of VV and CVI to be higher or as high as the prevalence found in other similar studies.

CONCLUSIONS: Conclusions-Such studies of these conditions should be included in epidemiological surveys of other developing areas, so that if data similar to ours are verified prophylaxis and early treatment could be included in health planning for these areas with the aim of reducing future morbidity and the related social status.

• Keywords: Varicose veins; chronic venous insufficiency; rural health

2.13.4. Wound Related Pain in a Rural Area of Greece

• Nikolaos Syrmos
• Aristotle University of Thessaloniki, Thessaloniki, Greece

PURPOSE: Evaluation of the prevalence of wound-related pain in patients with chronic wounds and assess the use of pain relief measures in a rural area of Greece.

Subjects and setting: A convenience sample of 50 patients with chronic wounds was recruited (mean age was 55 years, range of age 50–60).

METHOD: An investigator-designed questionnaire was used consisted of 4 parts: basic demographic and clinical information (patient and wound characteristics)- wound baseline pain—wound-related procedural pain and pain relief method—effect of wound related pain on the patient. Pain was assessed scored from 1 (no pain) to 6 (worst pain). Severity of pain was based on NRS scores’ classification as mild (2–3), moderate (4–5), and severe (6).

RESULTS: The 3 most common types of chronic wounds were traumatic ulcers, surgical wounds, and venous leg ulcers. The 3 most prevalent locations were lower limbs, feet, and thorax/abdomen. The use of drugs to relieve wound pain was low, while the use of nondrug-based analgesia was relatively high. Because of WRP, patients with chronic wounds feared dressing changes, hesitated to move, and showed a decline in sleep quality.

CONCLUSIONS: Wound baseline pain and wound-related procedural pain were very common in patients with chronic wounds. In the future, targeted intervention plans should be developed by combining drug-based and nondrug-based analgesia according to pain severity. The pain affects the quality of life and the health related quality of life of the peoples.

• Keywords: wound-related pain; chronic wounds

2.13.5. Two Peas in a Pod: Combined Abdominal Aortic Aneurysm Repair and Coronary Artery Bypass Grating

• Hina Inam, Salva Shariq, Zia Ur Rehman and Amna Riaz
  Aga Khan University Hospital, Karachi, Pakistan

INTRODUCTION: Coronary artery disease (CAD) and abdominal aortic aneurysms (AAA) frequently coexist, presenting complex challenges for treatment. Myocardial infraction contributes to approximately half of all postoperatively subsequent to AAA repair. The combination of two significant surgeries within a private-sector hospital presents numerous hurdles. While isolated CABG entails a mortality rate of 2–3%, elective AAA repair carries a comparable rate of 2.2%. There’s a prevailing belief that simultaneous execution of these procedures will lead to cumulative rise in mortality. Coexisting AAA and severe CAD present a highly morbid cohort, amplifying the risks associated with individual procedures.

Case Description: We present a case of a 73-year-old male with right-sided abdominal pain, revealing an 8.9 × 9.3 cm juxta renal AAA extending to the bifurcation, concurrent with significant CAD, including left main plus three-vessel disease.

Treatment Strategy: Considering the high mortality risk associated with staged procedures, we opted for a one-stage approach, performing simultaneous AAA repair and coronary artery bypass grafting (CABG).

Surgical Approach: The surgical strategy involved careful planning to minimize complications, including retaining arterial and venous cannula during both procedures for hemodynamic control.

Postoperative Management: Postoperatively, the patient was successfully extubated, managed for atrial fibrillation episodes, and monitored for renal complications.

Recovery and Outcomes: Despite the absence of bowel sounds initially, the patient’s recovery progressed well, emphasizing the importance of postoperative management in such cases.

CONCLUSIONS: Our experience supports the efficacy of a one-stage approach, offering streamlined recovery and resource optimization. This case highlights the significance of tailored treatment strategies and multidisciplinary collaboration in managing complex cardiovascular conditions.

• Keywords: Aneurysm; Left Main; Coronary artery bypass grafting

2.13.6. Pyoderma Gangrenosum: A Rare and Debilitating Condition After Coronary Artery Bypass Grafting

• Ayşegül Durmaz ¹, Gözde Kürkcü ¹, Mustafa Canikoğlu ¹, Özgür Barış ¹, Tülay Çardaközü ² and Şadan Yavuz ¹

1

Department of Cardiovascular Surgery, Kocaeli University, Kocaeli, Turkey

2

Department of Anesthesia and Reanimation, Kocaeli University, Kocaeli, Turkey

BACKGROUND: Pyoderma gangrenosum is a rare, debilitating, and potentially life-threatening condition that affects the skin and underlying tissues. It is characterized by the development of necrotic ulcerative lesions, typically accompanied by a severe inflammatory response. Pyoderma gangrenosum can occur spontaneously or as a complication of an underlying medical condition or treatment. It can be challenging to diagnose and treat, and its prognosis may be poor in some cases.

CASE: Here, we present the case of a 72-year-old female patient who underwent coronary artery bypass grafting via median sternotomy and open harvesting of the long saphenous vein. The patient had a history of endometrial cancer, for which she underwent surgery and was hospitalized for a long time due to impaired wound healing for approximately 25 years. On the fifth day after surgery, the patient developed severe and progressive sternal and leg wound ulceration and necrosis that required surgical debridement. The microbiology results were negative, and the patient was diagnosed with pyoderma gangrenosum based on the biopsy taken from the lesions.

The treatment for pyoderma gangrenosum is opposite to the main differential diagnosis, which is a typical surgical site infection. The patient was treated with steroids, which led to the regression of the lesions within a month. Pyoderma gangrenosum can mimic early postoperative sternal wound infections. Steroid therapy is the only treatment method for this condition, which recognizes the fact that steroids can lead to immunosuppression and potentially inhibit healing after major surgery. In the field of cardiac surgery, this diagnosis should be considered for all rapidly expanding postoperative lesions without improvement after debridement or antibiotics.

• Keywords: coronary artery bypass grafting; pyoderma gangrenousum

2.13.7. A Case Report with Klippel-Trenaunay Syndrome

• Nikolaos Syrmos
• Aristotle University of Thessaloniki, Thessaloniki, Greece

Introduction: Klippel-Trenaunay syndrome is a rare congenital venous malformation, it had been found to be caused by mutations of the phosphatidylinositol 4,5-diphosphate 3-kinase catalytic subunit alpha gene. The manifestations of this disease are—skin wine pigmented spots, varicose veins, malformations of the lower extremities, hypertrophy of bone and soft tissue, involving urinary system When the urinary system is involved, is often presented as painless massive gross hematuria.

Aim: Aim of this case report is the presentation of a woman, 52 years old, who was hospitalized many times for repeated hematuria and infection.

Material and Methods: Physical examination was performed (hypertrophy of the right lower limb, varicose veins, port-wine stains in the skin, and right perineal hemangiomatous changes with swelling). Further exams were performed (CT urography, ureteroscopy, cystoscopy, CTA of the lower extremities) and finally the patient was diagnosed to have Klippel-Trenaunay syndrome, involving the urinary system.

Results: The patient hematuria improved after multiple indwelling D-J tubes and anti-inflammatory treatment. The final symptoms of hematuria improved significantly, follow-up so far has not recurred.

Conclusions: Varicose veins can pe presente also in many other diseases. Clinical examination and diagnostic exams are useful in order to perform accurate diagnosis and appropriate treatment.

• Keywords: varicose veins; clinical exam; Klippel-Trenaunay syndrome

2.13.8. A Case Report with Phlebosclerosis

• Nikolaos Syrmos
• Aristotle University of Thessaloniki, Thessaloniki, Greece

Phlebosclerosis is a common age-related fibrotic degeneration of the venous wall. May cause, both venous dysfunction and venous thrombosis. It is rarely reported in patients with varicose veins. The present report describes the case of a 60-year-old man with varicose veins, vitiligo, and phlebosclerosis. Venous angiography revealed blood reflux in the superficial and deep veins. The patient underwent surgery to remove the saphenous veins. During the operation, a calcified vein resembling a wooden stick was found, which was surprisingly extracted from the thickened venous wall. A cross-section of this wooden stick-like vein revealed venous fibrosis and calcification, obvious thickening of the venous wall, extensive collagen deposition on the venous wall, hyaline degeneration. Phlebosclerosis can be observed in the late stage of varicose veins complicated by frequent infections and worse clinical outcomes. Therefore, it is important to be aware of this condition and address it rather than overlook it. Varicose veins can presented also in many other diseases. Clinical examination and diagnostic exams are useful in order to perform accurate diagnosis and appropriate treatment.

• Keywords: Calcification; Case report; Chronic venous disease; Ossification of vein wall; Phlebosclerosis; Phlebothrombosis; Thrombophlebitis; Varicose vein

2.14. INTERDISCIPLINARY » Multivalve Disease

Surgery Managment of Cardiac Hydatid Cycts: Experience of 3 Centers

• Amin Serradj ¹, Tatem Hala ², Sami Bouchenafa ³, Yuthiline Chabry ¹, Thierry Folliguet ¹

1

Department of Cardiac Surgery—CHU, Henri MONDOR-APHP, Creteil, France

2

Department of Cardiac Surgery—CHU, Mustapha, Algeria

3

Department of Cardiac Surgery—EHU, Oran, Algeria

The Hydatid cyst remains a major public health problem in the mediterranean region. The hepatic localization is the most frequent followed by the lung, however the cardiac hydatid cyst remains very rare representing only 0.5 to 2%.

We report an experience of three cardiac surger centers regarding surgeru management of cardiac hydatid cysts for a period extending over 10 years in order to analyze their epidemiological, clinical and surgical aspects.

Retrospective study, from January 2013 to December 2023. 24 cases of cardiac hydatid cysts were operated. The mean age was 25.17 years, the sex ratio was 1.09. The intrapericardial location of the cyst was in all cases. The Hydatid serology was only positive in 57% of cases. The average time of thecardiopulmonary bypass was 53.43 min. The average time of the aortic clamping was at 37.14 min. In all cases, the surgical procedure consisted of a sterilization of the cyst, cystectomy and capitonnage of the residual cavity (Figure 17).

The postoperative outcome was favorable. The mortality rate was 4.16%. The average length of postoperative stay was 11 +/− 3 days.

The histology confirmed cardiac hydatids in all cases. All patients were followed for a period of 2 year (+/− 4.3 months).

The left heart localization of the hydatid cyst is the most frequent 60%. Only surgical treatment is curative.

• Keywords: cardiac hydatid cyst; cardiopulmonary bypass; hydatid serology

2.15. VASCULAR AND ENDOVASCULAR » Abdominal Aorta

Percutaneous Coil Embolization of the Aneurysm Sac in Type I and III Endoleaks Following EVAR

• Cagla Canbay Sarilar, Mohammed Skaik and Onur Selcuk Goksel
  Department of Cardiovascular Surgery, Istanbul University, Istanbul, Turkey

Management of complicated AAA patients post-EVAR is mostly surgery if the sac enlargement proceeds due to type I or III endoleaks. Patients unfit for surgery, however, represent a challenging subset requiring prompt percutaneous solutions. Fibrin adhesives (92.3%), balloon dilatation (80%) and coil embolization (75%) are important treatment methods in patients with endoleak. We will present three patients, two with low ejection fraction (25%), diabetes mellitus. First patient 77 years old male with prior TEVAR and left caroticosubclavian bypass 2 years ago and EVAR 3 years ago had also dialysis-dependent renal failure. He presented with sudden AAA sac enlargement with a contained rupture. His computerized axial tomography (CAT) scan 3 months ago did not reveal any endoleaks or sac enlargement although his current CT angiogram revealed a proximal filling of the sac which was initially considered as a type I endoleak (Figure 18). His DSA revealed however a proximal focal tear in the main body of the stent-graft and was successfully treated with coil-embolization. Control CT angiogram yielded no residual endoleaks. Second patient 64 years old male with low ejection fraction was presented with a proximal filling of the sac. We were able to catheterize the sac from the proximal neck and successfully fill the endoleak site with coil.

Third patient presented with a Type Ia endoleak and had a prior history of EVAR and laparotomy history. CT Angiography revealed a proximal filling of the sac. It was successfully treated with coil embolization and glue.

Transcatheter solutions with evolving ideas may provide alternatives in particularly patients unfit for surgery.

• Keywords: Percutaneous Coil Embolization; Endoleak; EVAR

2.16. VASCULAR AND ENDOVASCULAR » Carotid Disease

2.16.1. Atherosclerotic Plaque Morphology (Evaluation with Contrast-Enhanced Ultrasound) and Primal Cardiovascular Events After Carotid Endarterectomy Performed Simultaneously with CABG

• Agnė Gimžauskaitė ¹, Gintautė Diringytė ⁵, Aistė Mačiulaitytė ¹, Einius Trumpa ², Saulius Lukoševičius ³, Jurgita Plisienė ⁴, Linas Velička ¹, Rimantas Benetis ¹ and Donatas Inčiūra ¹

1

Department of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania

2

Department of Anesthesiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania

3

Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania

4

Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania

5

Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania

BACKGROUND AND AIM: Stroke risk after on-pump cardiac surgery during perioperative period can affect up to 2% of patients, often linked to carotid artery disease. Unilateral carotid artery stenosis of 80–99% increases stroke risk to 4%. Between 3% and 10% of coronary artery bypass grafting (CABG) patients have significant carotid artery narrowing, which could be improved by either simultaneous or staged carotid endarterectomy and CABG to reduce the chances of stroke and mortality. The aim of this study was to find out whether early postoperative stroke risk in simultaneous CABG/CAE procedures depends on carotid plaque morphological characteristics via contrast-enhanced ultrasound.

METHOD: A single center retrospective analysis of 62 patients (2019–2022) who underwent simultaneous CABG/CEA was performed. We did not include patients who underwent staged carotid endarterectomy and CABG procedures, off-pump CABG, or those who required urgent CABG. The focus of our study was solely on patients who satisfied the criteria for elective CABG. These individuals were diagnosed with either triple-vessel or left main trunk symptomatic coronary artery disease (CAD) and exhibited either asymptomatic a. carotis internae (ACI) greater than 70% or symptomatic ipsilateral carotid stenosis exceeding 50%. Before the CEA/CABG procedure each patient had contrast-enhanced ultrasound done, the atherosclerotic lesions were classified based on Nakamura et al. classification (

Table 22. Atherosclerotic lesion morphology based on Nakamura et al. classification.

	Frequency	Percent, %	Cumulative Percent, %
No neovascularization within the plaque	23	37.1	37.1
No significant neovascularization within the paque	35	56.5	93.5
Significant neovascularization within the plaque	4	6.5	100

).

RESULTS: Analyzing postoperative complications within 30 days after surgery and the type of plaque morphology detected by contrast-enhanced ultrasound, a statistically significant correlation was found between the presence of a higher grade of plaque vascularization and ischemic stroke (r = 0.329, p = 0.008). Monte Carlo calculations of the Chi-square test showed that a higher grade of plaque vascularization was significantly associated with peripheral artery disease (χ² = 15.175, lls = 2, p = 0.003).

CONCLUSIONS: Ischemic stroke after carotid endarterectomy following CABG within 30 days after surgery has a significant correlation with the presence of a higher grade of plaque vascularization detected by contrast-enhanced ultrasound.

• Keywords: contrast-enhanced ultrasound; cerebrovascular event; coronary artery bypass grafting; carotid endarterectomy; carotid artery disease

2.16.2. Comparative Analysis of Short-Term and Long-Term Outcomes of Carotid Endarterectomy (CEA) Versus Carotid Artery Stenting (CAS) for Extracranial Carotid Artery Stenosis: A Single Center Retrospective Cohort Study

• Almas Saduakas, Manat Zhakubayev, Askar Matkerimov, Ablay Tergeussizov, Almas Shamshiyev, Rustam Makkamov and Nurlybek Yerkinbayev
• JSC «A.N. Syzganov National Scientific Center of Surgery», Almaty, Kazakhstan

BACKGROUND AND AIM: Extracranial carotid artery stenosis poses a significant risk for ischemic stroke and other cerebrovascular events. Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are established interventions for managing this condition, but their comparative effectiveness remains understudied. This study aimed to compare the short-term and long-term outcomes of CEA versus CAS among patients with extracranial carotid artery stenosis.

METHOD: A retrospective cohort study conducted using the data of patients who underwent either CEA or CAS for extracranial carotid artery stenosis at A.N. Syzganov National Scientific Surgical Center from January 2018 to December 2023. Data on patient demographics, procedural details, perioperative complications, recurrence rates, and mortality outcomes were collected from medical records. Short-term outcomes were defined as events occurring within 30 days post-procedure, while long-term outcomes were assessed over a follow-up period of <1 year and <5 years.

RESULTS: We enrolled a total of 202 patients who underwent either CEA or CAS. Among them, 71 (34.9%) underwent CEA, while 132 (65.1%) underwent CAS. Subgroup analyses were performed to explore potential differences in outcomes between patients, taking into account factors such as age, comorbidities, and severity of stenosis. Two cases of periprocedural stroke occurred, one in each group (p = 1.000). Additionally, there was one case of TIA in the CAS group and one case of thrombosis in the CEA group. None of the patients died during the perioperative period. Over a period of less than one year and less than five years, a total of 41 mortalities were recorded (16.9% for CEA versus 21.9% for CAS, p < 0.005). The primary cause of death identified among these cases was cardiac arrhythmias.

CONCLUSIONS: Our findings suggest that both CEA and CAS are effective in reducing the risk of stroke in the Kazakhstani population, with comparable short-term and long-term outcomes. Further research is needed to elucidate the optimal treatment approach for individual patients.

• Keywords: carotid artery stenting; carotid endarterectomy; carotid stenosis; outcomes

2.16.3. Surgical Treatment of Patients with Bilateral Atherosclerotic Lesions of Carotid Arteries

• Xodjiakbar Kashipovich Alidjanov, Shavkat Ibragimovich Karimov, Abdurasul Abdujalilovich Yulbarisov and Rustam To’lkinbayevich Muminov
• Angioneurology Department, Republican Special Center of Surgical Angioneurology, Tashkent, Uzbekistan; Department of Hospital and Faculty Surgery №1, Tashkent Medical Academy, Tashkent, Uzbekistan

BACKGROUND AND AIM: To improve the results of surgical treatment of patients with bilateral atherosclerotic lesions of the carotid arteries.

METHOD: The study included 180 patients between the ages of 42 and 82 (59 ± 5.6 yrs). Depending on the surgical treatment tactic, total of 180 patients were divided into two groups. Group 1 included 60 (33.3%) patients who underwent staged bilateral carotid endarterectomy (CEA). Group 2 included 120 (66.7%) patients, in whom the first stage of CEA was performed on the side of primary importance.

RESULTS: Group 1 patients underwent staged bilateral CEA. The analysis revealed a pronounced association between the clinical effect of the operation and the initial level of the neurological deficit, as well as time frame from stroke and time frame of the second stage of carotid reconstruction. The highest rate of neurological deficit (ND) involution was observed in patients with a mild to moderate degree of ND, and who were operated on within 6 months of a stroke, and also in patients who underwent the procedure on the contralateral side within 2 or 3 months. In Group 1, the total complication rate was 5.0%.

In Group 2 patients, the differentiated approach was performed to identify the side of primary importance in determining the indications for reconstruction. At the first stage of CEA, 20/41.6% patients had a mild degree of ND; 22/45.8% patients, a moderate degree; and 6/12.5% patients, a severe degree. In Group 2, the total complication rate was 1.7%.

CONCLUSIONS: The differentiated approach for identifying the side for the first stage CEA is very important. Our experience shows that the intervals between CEA on both sides should not exceed 3 months and should be no less than 3 weeks. This tactic not only reduces mortality and complications, but also significantly improves the patient’s quality of life by promoting rapid regression of ND.

• Keywords: Carotid artery; carotid endarterectomy; neurological deficit

2.16.4. Bilateral Severe Carotid Artery Stenosis or Occlusion—Cerebral Autoregulation Dynamics and Collateral Flow Patterns

• Xodjiakbar Kashipovich Alidjanov ^1,2, Akmal Abdullaevich Irnazarov ^1,2, Abdurasul Abdujalilovich Yulbarisov ^1,2 and Olimjon Mustapaqulovich Axmatov ¹

1

Angioneurology Department, Republican Special Center of Surgical Angioneurology, Tashkent, Uzbekistan

2

Department of Hospital and Faculty Surgery №1, Tashkent Medical Academy, Tashkent, Uzbekistan

BACKGROUND AND AIM: We aimed to analyze dynamic cerebral autoregulation (DCA) in affected patients, and to correlate DCA data with different collateral flow patterns.

METHOD: DCA was assessed noninvasively by transfer function analysis (phase shift) of respiratory-induced oscillations at 0.1 Hz of arterial blood pressure (Finapres method) and cerebral blood flow velocity (transcranial Doppler) in 180 patients with severe bilateral carotid stenosis (75%) or occlusion. CO₂-reactivity was measured via inhalation of 7% CO₂. 30 patients with unilateral stenosis were recruited as controls.

RESULTS: Patients with bilateral 75–89% stenosis had a virtually preserved phase shift. A pronounced reduction was found in bilateral critical stenosis or obstruction (90–100%). Patients with ipsilateral 90–100% and contralateral 75–89% stenosis had a significantly less severe reduction of phase shift on the ipsilateral side. CO₂-reactivity showed a less marked reduction in patients with bilateral critical stenosis or occlusion. Phase shift was best if ‘‘Willisian’’ collaterals were present. Significantly reduced values were found if only secondary collaterals (ophthalmic artery, leptomeningeal flow) were detected. Poorest values occured with recruitment of functionally stenosed ‘‘Willisian’’ collaterals. CO₂-reactivity showed poor values with sole recruitment of secondary collaterals, whereas functionally stenosed primary collaterals did not show values as poor as for phase shift. Clinically symptomatic patients had significantly lower phase shift and CO₂-reactivity values.

CONCLUSIONS: DCA is severely impaired in bilateral critical carotid stenosis or occlusion. Sole recruitment of secondary collaterals and signs of a functional stenosis in primary (“Willisian”) collaterals reflect insufficient collateral supply with a poor hemodynamic status. CO₂-reactivity assessing the vasodilatory reserve and DCA represent different information for characterizing cerebral hemodynamic impairment. Determining transfer function phase might be a physiologically well supported approach for analysis of cerebral hemodynamic compromise.

• Keywords: Carotid artery; cerebral autoregulation; Willisian collaterals

2.16.5. Carotid Endarterectomy in Elderly Patients with Contralateral Disease: Insights from a Single Center

• Mohammed Skaik, Cagla Canbay Sarilar and Onur Selcuk Goksel
• Department of Cardiovascular Surgery, Istanbul University, Istanbul, Turkey

BACKGROUND AND AIM: The escalating number of elderly individuals, particularly those in their 80 s, may result in a significant rise in cerebrovascular disorders. Consequently, stroke prevention and treatment will become a critical concern for this age group.

AIMS: This study aimed to evaluate the results of carotid endarterectomy in elderly patients, with or without contralateral carotid stenosis or blockage, and compare these findings with a similar group of younger patients.

METHOD: Between 2005 and 2015, a single surgical team performed 240 carotid endarterectomies (CEAs) on 160 patients. The early outcomes related to hospital mortality and stroke were analyzed.

RESULTS: Of the 160 patients (121 males; average age 82.5 ± 9.3 years) who underwent bilateral CEAs, active smoking was significantly more prevalent among the male elderly patients (21.8% vs. 6.2%, p < 0.05). The most common condition among all patients was a history of non-debilitating stroke before surgery. Twelve patients had ipsilateral retinal artery occlusion. A total of 40 patients had contralateral carotid artery blockage. Only one elderly patient experienced a lateralizing stroke due to ipsilateral CEA in the group with contralateral blockage, compared to three patients (lateralizing stroke in three patients, lacunar state in one patient) in the group with contralateral stenosis.

CONCLUSIONS: Contrary to popular belief, carotid endarterectomy is a feasible treatment option for patients with contralateral carotid occlusion (CCO) or bilateral disease, even among the elderly population.

• Keywords: Carotid endarterectomy; elderly patients; bilateral carortid artery disease

2.16.6. Treatment of Acute Arterial Occlusion After Carotid Endarterectomy

• Merve Çünürlü, Hilmi Tokmakoglu and Murat Ugur
• Department of Cardiovascular Surgery, University of Health Sciences, İstanbul, Türkiye Sancaktepe Sehit Prof. Dr. Ilhan Varank Education and Research Hospital, İstanbul, Türkiye

Background: Carotid endarterectomy is gold standard treatment for asymptomatic ≥70% stenosis or symptomatic 50–99% stenosis of internal carotid artery. Early postoperative stroke, which has increased morbidity and mortality rates, after carotid endarterectomy is a rare complication. Prognosis is even worse if stroke continues after operation. Therefore, close follow-up, early rely of neurological symptoms and to performing the most effective treatment procedure in a timely manner is important to improve postoperative symptoms and neurological status.

Case: A 75-year-old female patient, who complained of intermittent numbness in left arm and slurred speech, underwent right carotid endarterectomy due to 85–90% stenosis in proximal right internal carotid artery. Postoperative follow-up period was uneventful and patients was transferred from intensive care unit to cardiovascular surgery service at postoperative first day. Sudden left hemiplegia and left homonymous hemianopsia were developed in patient at 32th hours of the operation. Total occlusion of right internal carotid artery was observed in CTA. Thrombectomy with endovascular approach was unsuccessful since wire could not pass through the thrombus. Patient underwent urgent surgery. Arteriotomy was performed with excision of previous sutures. Fresh thrombus was removed just ostium of the internal carotid artery. Arteriotomy was repaired with patchplasty. Homonymous hemianopsia was recovered just after operation. Patient’s muscle strength dramatically improvement after operation. Her neurological examination was normal at postoperative 2nd day and she was discharged from on postoperative 5th days completely normal neurological findings.

Conclusions: After carotid endarterectomy, urgent re-exploration might decrease postoperative morbidity and mortality. In acute occlusions of carotid artery after carotid endarterectomy, surgical embolectomy fastens removing thrombus urgently and shortens the duration of hospital staying times with reducing mortality and morbidity rates. Surgical embolectomy should be considered as an alternative to thrombectomy, in the cases where it is unsuccessful or unavailable in short term, in treatment of postoperative acute occlusions.

• Keywords: acute occlusion; carotid artery; embolectomy

2.16.7. Urgent Treatment of Secondary Carotid Arterial Occlusion via Bypass Grafting

• Muhammet Turhan, Murat Uğur and Hilmi Tokmakoglu
• Department of Cardiovascular Surgery, University of Health Sciences, Sancaktepe Sehit Prof. Dr. Ilhan Varank Education and Research Hospital, İstanbul, Turkey

INTRODUCTION: Carotid arterial disease is among the most important causes of stroke. The gold standard treatment approach to it is Carotid endarterectomy (CEA). Bleeding, stroke, intracranial bleeding and wound infection are the most common complications after the CEA. Unlike carotid stenting, early occlusion of the carotid artery is a very rare complication of CEA. We are presenting urgent treatment approach to early carotid arterial occlusion after the CEA.

Case Presentation: A 56-year-old male patient was admitted to our hospital with suffering from intermittent numbness and weakness in the left arm, numbness on the left side of the face for 1 month. Computerized tomographic angiography (CTA) revealed 70–80% stenosis in the right carotid internal carotid artery (ICA) and 50% stenosis in the left carotid ICA. The patient underwent CEA. Arteriotomy was closed primarily since the diameter of ICA is 4 mm. After operation, the patient was extubated in the operating room, then transferred to the cardiovascular surgery intensive care unit. In the first 2 h follow-up the patient was oriented and cooperative without any neurological symptoms. Sudden numbness in the left part of the body developed 3-h after the surgery. Early occlusion of the right ICA was detected in the CTA and the patient underwent urgent re-operation. After arteriotomy, fresh thrombus was seperated from the ostia of right ICA. Since the diameter of ICA was small for re-repair, the ICA was ligated at the proximal side. After the primary repair of common carotid artery (CCA), CCA-ICA bypass grafting with saphenous vein was performed. The patient was extubated 2-h after the procedure without any neurological symptoms. He was discharged at 3rd day of the operation.

CONCLUSIONS: Closed follow-up is important after carotid revascularization to early awareness and treatment of neurological symptoms. Early diagnosis and effective treatment in early term improves the postoperative outcome.

• Keywords: carotid surgery; carotid occlusion; carotid saphenous vein

2.16.8. Meningoencephalitis Due to Leech Application After Carotid Endarterectomy

• Cagla Canbay Sarilar, Mohammed Skaik, Onur Selcuk Goksel
  Department of Cardiovascular Surgery, Istanbul University, Istanbul, Turkey

INTRODUCTION: Infections are a recognized complication of postoperative leech application (Figure 19), and can occur with measurable frequency in populations of patients treated with leeches. We present a patient with meningoencephalitis due to pseudomonas aeroginosa following leeching over incision wounds after bilateral carotid endarterectomy.

METHODS: A 65-year old lady presenting initially with right hemiparesia and aphasia due to bilateral severe carotid stenosis 3 months ago underwent consecutive bilateral carotid endarterectomy and patch-plasty with dacron patch and was discharged uneventfully with full neurological recovery. Two months later, she was brought to emergency service with loss of orientation, left hemiparesis of the upper extremity and the facial muscle paralysis.

RESULTS: She had WBC count was 18.000/μL and a history of leech application all over her neck within the week. Upon lumbar puncture, cerebrospinal fluid findings revealed abundant leukocytes and Gr(-) bacteria. Cerebrospinal fluid culture and the leeches she used as brought over from her house revealed P. Aeroginosa. After a 3-week-long antibiotic therapy, her infection markers returned to normal and her clinical status dramatically recovered. However, her postoperative 3rd month control revealed an asymptomatic right carotid restenosis of 50%. Consultants in neurology and infectious diseases advised close observation without treatment.

CONCLUSIONS: Patients who use leech therapy must be aware that sepsis or other fatal complications could arise from the fact that leeches can host species resistant to accepted prophylactic.

Disclosure: Nothing to disclose.

• Keywords: Meningoencephalitis; Carotid Endarterectomy; Leech application

2.16.9. Symptomatic Carotid Artery Stenosis and Coiling: An Adapted Approach to Resection and Reimplantation

• Mohammed Skaik, Cagla Canbay Sarilar and Onur Selcuk Goksel
• Department of Cardiovascular Surgery, Istanbul University, Istanbul, Turkey

The extracranial internal carotid artery often exhibits kinking, defined as an angulation in one or more cervical segments due to elongation. This can disrupt blood flow to the brain, with or without accompanying stenosis. This report discusses two patients, aged 80 and 65 years old, who underwent different surgical techniques for carotid artery stenosis and coiling (Figure 20). The redundant internal carotid artery was divided and resected in addition to performing carotid endarterectomy. This was done as stenosis was present in the target area for reimplantation, allowing for an oblique end-to-end anastomotic technique to the internal carotid artery ostium extending to the distal common carotid artery, with or without a teardrop-shaped Dacron patch. Although not a common procedure, shortening the ICA is a significant technique in the surgeon’s toolkit. There are no large prospective cohort studies, systematic reviews, or randomized studies in the literature that provide clear indications for any technique, other than the surgeon’s good judgment.

• Keywords: Carotid endarterectomy; carotid artery coiling; cerebrovascular disease; carotid artery stenosis

2.16.10. An Extremely Rare Case: Carotid Sheath Tumor

• Mohammed Skaik, Cagla Canbay Sarilar and Onur Selcuk Goksel
• Department of Cardiovascular Surgery, Istanbul University, Istanbul, Turkey

Carotid sheath tumors are extremely rare, potentially life-threatening neoplasms due to their proximity to vital neck structures. To the best of our knowledge, only two patients have been reported in the literature. We report a case of a 33-year-old female with no previous medical history. The patient initially presented with right arm weakness, facial swelling, dysphagia, and orthopnea. A computed tomography (CT) angiogram of the neck revealed a non-enhancing soft tissue lesion encircling the left common carotid artery (CCA) over a segment of 7.5 cm in the coronal plane, causing partial compression of the thyroid gland and trachea towards the right at the levels of the C6 and C7 vertebrae and ultimately diagnosed with a carotid sheath tumor.

We, vascular surgeons, and otolaryngology specialists, teamed up and performed left carotid sheath mass excision (Figure 21). Due to an intraoperative complication, a common carotid artery graft interposition was necessary. The surgery was successful, almost immediate relief of symptoms postoperatively, and the patient was discharged without complications. Regular follow-ups showed the patient to be disease-free, demonstrating the effectiveness of the surgical intervention in managing this complex condition. This case underscores the importance of a multidisciplinary approach in managing carotid sheath tumors and the potential challenges encountered during surgical intervention.

• Keywords: Carotid sheath tumors

2.17. VASCULAR AND ENDOVASCULAR » Miscellaneous

A Rare Case of Inguinal Synovial Sarcoma Presenting with Limb Swelling: Surgical Management and Outcome

• Isa Civelek, Ömer Çağatay Duman, Deniz Sarp Beyazpınar and Mehmet Emir Erol
  Cardiovascular Surgery Clinic, Etlik City Hospital, Ankara, Türkiye

An 82-year-old female patient presented to the Cardiovascular Surgery outpatient clinic with complaints of left groin swelling and progressively worsening lower extremity edema. Physical examination revealed a palpable mass, prompting further imaging studies. The color Doppler venous study yielded unremarkable findings. Contrast-enhanced computed tomography identified a mass involving the left main femoral artery, superficial femoral artery, deep femoral artery, and main femoral vein (Figure 22). Subsequent evaluation by the oncology department confirmed synovial sarcoma. Following necessary preparations, the patient underwent surgery, which was performed collaboratively by general and vascular surgeons.

During the procedure, segments encompassing the mass, measuring 15 cm × 7 cm, were excised from the external iliac artery to the superficial femoral artery, and from the external iliac vein to the main femoral vein. Smooth-surfaced protrusion of the mass was noted within both the main femoral artery and vein during venotomy and arteriotomy. Interposition using a 10 mm ringed PTFE graft and continuous 6/0 prolene sutures for end-to-end anastomosis was performed from the external iliac artery to the superficial femoral artery, and from the external iliac vein to the femoral vein. End-to-side anastomosis of the deep femoral artery onto the PTFE graft was completed. Postoperatively, palpable distal pulses were observed, and the patient’s recovery was uneventful. Follow-up examinations showed no signs of ischemia. The patient, who remains clinically asymptomatic, is undergoing monitoring with once-a-daily peroral ASA 100 mg medication.

• Keywords: leg edema; synovial sarcoma; vascular invasion

2.18. VASCULAR AND ENDOVASCULAR » PAOD

2.18.1. Effect of Intravenous Administration of Alprostadilum on the Circulating Microvesicles in Chronic Limb Threatening Ischemia (CLTI) Patients

• Cosmin Buzila ¹, Miruna Nemecz ², Constantin Ghiatau ², Adriana Georgescu ² and Ionel Droc ¹

• Central Military Hospital, Cardiovascular Surgery Clinic, Bucharest, Romania
• Institute of Cellular Biology and Pathology Nicolae Simionescu, Bucharest, Romania

BACKGROUND AND AIM: Therapeutic management of patients with advanced peripheral arterial disease as chronic limb threatening ischemia (CLTI) often requires more than classical vasodilators and revascularization (when possible). The intravenous administration of alprostadil was extensively used to treat these patients but literature data are inconsistent in showing its efficiency. As our experience suggests that this therapy may have a benefic role in treating these patients we have investigated a biomarker in order to estimate the clinical outcome and to assess the treatment efficiency. The aim of the study was to investigate the circulating microvesicles (MVs) levels before and during the alprostadil treatment in patients with CLTI to further determine any correlations with the clinical outcomes.

METHOD: The inclusion criteria were: patients over 18 years of age, both diabetic and non-diabetic, diagnosed with CLTI investigated by EchoDoppler or angiography. They were treated with Alprostadil (prostaglandin E1)-Pridax (GebroPharma GmbH, Austria). A group of 10 non-CLTI patients were included for the negative control of the study. The blood samples were taken at 3 distinct moments during the treatment.

RESULTS: The patients were evaluated clinically, biologically and sonographically, at time intervals between 4 days and one year. Patients treated with alprostadil showed significantly decreased concentrations of plasma PMVs (platelets microvesicles) and EMVs (endothelial microvesicles), at both 2 weeks and 4 weeks of treatment, compared with the moment before treatment begun. The clinical evaluation of the study population showed a better outcome in case of the alprostadil treated patients, correlating with lower MVs levels, in comparison with the control group (Figure 23).

CONCLUSIONS: Even in our study we have a small number of patients, our data shows that the Alprostadilum treatment is safe and has good results. The circulating microvescles levels correlate with the clinical outcomes and could be used a marker in the day by day Vascular Surgery Practice.

• Keywords: alprostadil; microvesicles; biomarkers; CLTI; peripheral artery disease

2.18.2. Completely Healing of Pregangrenous Lesions with the Combination of Endovascular Approach and Epidermal Growth Factor

• Seymur Kerïmoğlu, Haluk Çağlar Karakaya, Hilmi Tokmakoğlu and Murat Uğur
• Department of Cardiovascular Surgery, University of Health Sciences, Sancaktepe Şehit Prof. Dr. İlhan Varank Training and Research Hospital, Istanbul, Turkey

INTRODUCTION: Peripheral arterial diseases (PAD) may involve major arteries that can lead to severe complications if goes untreated. It affects patients’ quality of life with symptoms that ranges from intermittent claudication to gangrenous lesions. Early and effective treatment is important to avoid limb loss in the critical limb ischemia. In this study we present a combined endovascular and medical approach to a patient with pregangrenous lesions.

Case Presentation: A 55-year-old male patient admitted to polyclinics with the sufferings rest pain, purulent wound and color change for 3 weeks on distal parts of digits of lower extremity. In history, the patient had insulin-dependent diabetes mellitus and hypertension. Lesions were in pregangrenous characteristics. Severe stenotic lesions were observed on bilateral superficial femoral artery and crural arteries in computerized tomographic angiography (CTA). The patient was consulted to cardiovascular surgery department right after the diagnosis of PAD. Atherectomy and angioplasty with drug-eluting balloon were performed to both superficial femoral arteries (SFA), popliteal arteries and posterior tibial arteries (PTA) in two sessions with the interval of 3 days. After revascularization, recombinant human epidermal growth factor (rhEGF) was injected surroundings of pregangrenous wounds. Overall, 5 doses of recombinant human epidermal growth factor (rhEGF) injection on pregangrenous wound borders were applied with 3 days interval. After 15 days of medical treatment the patient was discharged with dual antiaggregant regimen with addition of Cilostazol. In the control examination, after 2 weeks of discharge, obvious improvements were observed on priorly pregangrenous lesions (Figure 24). No prior complaints were referred such as rest pain or purulent discharge.

CONCLUSIONS: With combined approach to peripheral artery diseases including rhEGF and endovascular/surgical intervention, dramatic improvements can be seen on pregangrenous lesions. We believe that rhEGF treatment combined with precise invasive procedures could lead to a decrease in morbidity rates due to peripheral artery disease.

• Keywords: Peripheral Artery Disease; Endovascular; recombinant human epidermal growth factor; Pregangrenous lesion

2.18.3. Single Stage EVIR Combination with Carotid Endarterectomy and Peripheral Artery Bypass in a Single Patient

• Cagla Canbay Sarilar, Mohammed Skaik, Onur Selcuk Goksel
  Department of Cardiovascular Surgery, Istanbul University, Istanbul, Turkey

63 year old male patient had a tube graft replacement of abdominal aortic aneurysm 17 years ago. The patient had bilateral iliac artery aneurysm. Right iliac artery was 13 cm and completely thrombosed. Left iliac artery was 9 cm. Our patient had pain, claudication in the right lower extremity and amaurosis fugax. His claudication distance was 50 m.

We performed single stage left carotid endarterectomy, aortauniiliac Endovascular aortic repair (EVAR) and cross femoral bypass. We used 8 mm PTFE graft for cross femoral bypass (Figure 25). In addition we performed right femoropopliteal bypass using saphenous vein graft.

• Keywords: EVIR; iliac artery aneurysm; cross femoral artery by-pass

2.18.4. Endovascular Treatment of a Patient with Total Occlusion of Bilateral Subclavian Arteries Due to Takayasu Arteritis

• Murat Muzaffer Güçlü, Mustafa Kemal Demirağ and Semih Murat Yücel
• Department of Cardiovascular Surgery, Ondokuz Mayis University, Samsun, Türkiye

A 23-year-old female patient, who was being followed up by rheumatology and receiving medical treatment due to takayasu arteritis, applied to our outpatient clinic with the complaint of claudication in both arms, which had been present for approximately 2 years but had recently increased to the point of preventing her from working. on physical examination, both radial, ulnar and brachial artery pulses were non-palpable. during examination with manual doppler, a biphasic flow was heard. no color change was observed, but there was significant coldness. the patient’s upper extremity blood pressure was significantly lower than the lower extremity blood pressure.

Computed tomography angiography was preferred as the imaging method.

As a result of the imaging, it was observed that there was total occlusion in both subclavian arteries and filling at the proximal level of the brachial artery thanks to collateral vascular structures.

The patient underwent endovascular treatment for 2 sessions. In the post-operative examination, pulses were palpable in both upper extremities. thanks to this treatment, the patient got rid of claudication and survived the difficulties in his daily life.

Conclusions: Although it is reported in the literature that endovascular treatment of patients with peripheral artery disease due to takayasu arteritis is satisfactory in childhood, it can be said that endovascular treatment can also be successful in young adults. of course, the experience of the physician and the intervention team and the ability to perform safe intervention under hybrid operating room conditions are important in terms of life-threatening and successful treatment.

• Keywords: takayasu arteritis endovascular treatment subclavian occlusion

2.19. VASCULAR AND ENDOVASCULAR » Prosthetic Infections

Superficial Femoral Artery and Iliac Stenting Infection

• Giulia Ongaro ¹, Andrea Xodo ², Alessandro Desole ², Fabio Pilon ² and Domenico Milite ²

• School of Medicine, Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua, Padua, Italy
• Vascular and Endovascular Surgery Division, “San Bortolo” Hospital, AULSS8 Berica, Vicenza, Italy

A 67 years-old, diabetic male was admitted to our emergency room with hypotension, anemia and left flank pain. Urgent abdomen CTA detected a pseudoaneurysm of the left common and external iliac arteries.

The patient had recently undergone to left SFA stenting, to left iliac axis and ipsilateral CFA stenting for spontaneous pseudoaneurysm. Moreover he had had recent methicillin-sensitive Staphylococcus Aureus sepsis.

In emergency setting we chose for an endovascular “bridging” therapy, pending a definitive surgical treatment.

The patient underwent left iliac axis stenting using VBX (8 L × 79 mm) and Viabahn (9 × 50 mm) stent grafts.

On post-operative day 5, the patient developed a left thigh hematoma, with increased inflammation indices: lower extremity CTA showed an infection of the previous SFA stenting. The patient was therefore treated by abscess drainage, stent-graft removal and left femoro-popliteal bypass with contralateral GSV.

A week later, a control CTA demonstrated a new pseudoaneurysm of left common and external iliac arteries with sign of infection. The patient underwent to complete stent grafts explantation and aorto-iliac homograft replacement.

Six days later a new CTA detect a large left psoas abscess with sign of homograft infection. The patient underwent complete homograft explantation, infrarenal aortic stump, right axillo-femoral PTFE bypass and PTFE bypass between the axillo-femoral and the previous left femoro-poplital bypass.

The post-operative course was characterized by general clinical condition and inflammation indices improvement; six months later the patients developed an extensive foot gangrene (despite the patency of the axillo-bifemoral bypass) which required left below-knee amputation.

Stent-grafts infection is a rare but fearful complications, associated with high morbidity and mortality. The use of endovascular “bridging” therapies may be considered in the treatment of these challenging clinical cases; however, complete removal of the infected material with complex open surgical procedures appear to be the best and definitive solutions, also in the “endovascular era”.

• Keywords: stent infection; peripheral arterial disease; endovascular treatment

2.20. VASCULAR AND ENDOVASCULAR » Thoracic Aorta

2.20.1. Partial Debranching as a First Step in Hybrid Treatment of Aortic Arch and Proximal Descending Thoracic Aortic Pathology

• Lubomyr Kulyk ¹, Vitalii Kravchenko ², Bogdan Cherpak ², Andriy Perepelyk ² and Vasyl Lazoryshynets ²

1

Danylo Halytsky Lviv National Medical University, Lviv, Ukraine

2

M. Amosov National Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine

BACKGROUND AND AIM: The hybrid approach to the treatment of the pathology of the thoracic aorta allows us to significantly expand the possibilities of the isolated TEVAR.

METHOD: From 2014 to 2024 at the ICVS of the NAMS of Ukraine, 253 patient with aortic aneurysms were treated by TEVAR; 111 (43.8%) patients of them were had the hybrid approach, 56 (22.1%) of them received carotid-subclavian anastomosis, as a first stage. The causes of aortic injury were: (n = 12) had a descending aortic aneurysm without dissection; (n = 38) patients had an aortic dissection (n = 4—acute, n = 6—subacute, n = 28—chronic), PAU (n = 2), postcoarctation aortic aneurysm (n = 3), enlargement residual aorta after previous ascending aortic grafting (n = 1). Patients who were admitted as elective surgery candidates have had switched aortic arch vessels (debranching) in the first stage and TEVAR-second. If there were admitted emergency—first TEVAR were performed (only two cases). Carotid-subclavian shunt was performed from a 5–6 cm supraclavicular access. LCA and LSA were connected with a armed d = 6 mm PTFE grafts, without cross the neck muscles.

RESULTS: Mortality consist 1.7% (one patient), Among the complications were endoleak type I or II (3 and 1); bleeding (more than 200 mL) treated surgically (n-1), treated conservative (n-2): thrombosis of anastomosis and reoperation (n-1), dissection of the LSA (n-2), trauma of the n.laryngeus r.(n-1), stroke (1). No one case of SCI among partial debranching group.

CONCLUSIONS: Carotid-subclavian bypass is a safe method for expand endograft landing zone to Ishimaru 2 zone. Insignificant number of neurological complications after the procedure emphasizes the importance of maintaining blood flow through the left subclavian artery. Acceptable level of hospital mortality, low frequency of complications allows to obtain a better immediate result of treatment in comparison with traditional surgery.

• Keywords: aortic aneurysm; hybrid approach; carotid-subclavian shunt

2.20.2. Distal Aortic Remodeling After Endovascular Stenting Treatment Followed by Total Arch Replacement with Frozen Elephant Trunk

• Siyi He and Sheng Ding
  Department of Cardiovascular Surgery, General Hospital of Western Theater Command, Chengdu, China

AIMS: Total arch replacement with frozen elephant trunk is a well-known effective surgery for type A dissection (AAD). Subsequent endovascular stenting treatment can close the distal tear and expand the true lumen. The present study intends to explore distal aortic remodeling after endovascular stenting treatment followed by total arch replacement with frozen elephant trunk.

METHODS: In our department from January 2011 to May 2023, 115 patients with AAD received total arch replacement with frozen elephant trunk. After an interval of 15 (4–39) days, endovascular stenting treatment was employed in 23 patients. All patients were followed up for 35 (10–60) months, and the postoperative distal aortic remodeling was evaluated by computed tomography angiography (CTA) examination.

RESULTS: No obvious complications were observed. Type I endoleak remained in one patient. All cases achieved complete aortic remodeling. During period of follow-up, complete thrombosis of false lumen was found in 15 cases (65.2%) and partial thrombosis of false lumen in 8 cases (34.8%). Compared with preoperative results, the diameter of true lumen increased significantly (p < 0.05) and the diameter of false lumen decreased significantly (p < 0.05). There was no significant change in aortic diameter.

CONCLUSIONS: Subsequent stent implantation is beneficial to improve aortic remodeling, which can be used as an auxiliary procedure for the treatment of AAD using total arch replacement with frozen elephant trunk.

• Keywords: total arch replacement; frozen elephant trunk; endovascular stenting

2.20.3. Successful Surgical Treatment of a Patient with History of Renal Transplantation for Systemic Lupus Erythematosus, Presenting with an Ascending Aortic Aneurysm Complicated by Chronic Type 2 Aortic Dissection and Severe Aortic Insufficiency

• Barış Akça and Nevzat Erdil
• Department of Cardiovascular Surgery, Inonu University, Malatya, Turkey

BACKGROUND: Aortic aneurysms are rare complications of an autoimmune disease systemic lupus erythematosus (SLE), occurring only a few cases with or without dissection. This rare case presentation aims to highlight successful surgical treatment of an ascending aortic aneurysm complicated by chronic type 2 aortic dissection in a patient with SLE who had undergone renal transplantation.

CASE: A 40-year-old female with history of SLE, lupus nephritis, and hypertension presented with complaints of chest pain, shortness of breath and palpitations. She had renal transplantation history 10 years ago. Echocardiography revealed an ejection fraction of 60%, pulmonary artery pressure of 45 mm Hg, and severe aortic valve insufficiency. Contrast tomography demonstrated a fusiform ascending aortic aneurysm with a diameter of 63 mm without a dissection flap.

The patient underwent surgery following a detailed examination for systemic inflammatory disease. During the surgery, besides severe pericardial adhesions, type 2 aortic dissection consistent with chronic phase was observed along with severe aortic valve insufficiency. Bentall procedure was performed by replacing neo-aorta (28 × 30 mm) with a mechanical valve (No: 23) (Figure 26). Pathological examination of aneurysm specimen revealed intimal fibrous thickening and signs of myxoid degeneration in medial layer. Patient’s postoperative follow-up continued smoothly and discharged without complication on the 7th day.

In SLE patients hypertension should be under control restrictively and regular monitoring is essential for cardiac involvement and aortic aneurysm. Although cases with systemic inflammatory disease like SLE pose a higher surgical risk due to multi-organ involvement, meticulous preoperative assessment and optimal surgical planning can lead successful treatment with low mortality and morbidity rates.

• Keywords: Ascending aortic aneurysm; aortic dissection; aortic insufficiency; systemic lupus erythematosus; renal transplantation

2.20.4. Semi-Order Fenestrated Thoracic Stent-Graft for Distal Arch Aortic Pathologies

• Katsukiyo Kitabayashi, Reiko Katsuya and Kenta Masada
• Department of cardiovascular surgery, JCHO Osaka Hospital, Osaka, Japan

Background: TEVAR is a standard treatment for the aneurysm located in aortic arch and descending aorta including aortic dissection. Although debranching technic enlarged the indication of endovascular repair for aortic arch pathologies, short landing length of stent-graft or complexity of debranching are still the risk of operative mortality and morbidity. Branched and fenestrated stent-graft were introduced as an alternative option, but the use of branched stent-graft is limited in Japan. Thus, Najuta, a semi-order fenestrated stent-graft was developed and expected to overcome these problems.

We applicated this device not only for the saccular aneurysm located in lesser curvature of aortic arch (mostly appropriate indication of this graft) but also for many types of aortic arch pathologies.

Methods: From January 2021 to February 2024, 19 cases underwent fenestrated TEVAR with Najuta. We retrospectively analyzed the short and long-term results of our cases.

Results: Patients’ age was 40–81 (median 61) y.o., and 14 of them were male. Follow up period was 1–36 (mean 17.2) month. There was no case of emergency. Types of aortic arch pathology were true aneurysm 6 cases (fusiform 3, saccular 3), post operative TAAD 3 cases, TBAD 10 cases (ULP 1, patent false lumen 9).

No left carotid artery bypass was performed but left subclavian bypass in 9 cases.

We use another supportive stent-graft in descending aorta in 11 cases.

There was no mortality in short and long term, and no case of thrombotic event as well.

One retrograde type A dissection case was treated with total arch replacement 3 days after TEVAR. One access artery injury case needed femoral artery repair.

One case with aberrant left vertebral artery developed type one endoleak in three months later and performed total arch replacement. The other cases have no endoleak and no expanding of aortic arch.

• Keywords: fenestrated thoracic endovascular aortic repair distal aortic arch pathology

2.20.5. A Late Presenting Case of Chronic Aortic Dissection

• Atanu Saha, Abhinaba Sarkar, Unmesh Chakraborty and Pradeep Narayan
  Department of Cardiac surgery, NH-Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India

Stanford Type A aortic dissections are life-threatening emergencies that require immediate surgical repair Chronic type A dissections involve intimal tears in the aorta presenting anytime for more than 90 days.

If left untreated, mortality approaches 50% in the first 48 h of onset.

Chronic type A dissections are mainly detected incidentally as they remain asymptomatic & usually have a different natural history from acute aortic dissections.

55 year old with stable angina for 3 years.

ECHO-Type A dissection with normal LV function & normal valve.

CT angiogram-defect in medial wall of distal ascending aorta, leading to a pseudoaneurysm compressing the SVC, RA, RV & the right coronary artery.

SURGICAL REPAIR-Conventional median sternotomy-CPB-looping of arch vessels-cooling till 20 degrees-direct ostial cardioplegia-replacement of ascending aorta with a 28 mm straight dacron graft.

Discharged in stable condition & asymptomatic at 2 months of follow up.

Chronic aortic dissections type A are generally a rare and highly elusive entity.

The disease remains undetected in acute as patient expires or it remains completely asymptomatic.

The scarcity of literature continues to limit our understanding of chronic type A dissection.

Open surgical repair remains the first-line management when any complications or symptoms are present.

Endovascular repair of Type A dissections hold potential for improvement with further device innovations.

• Keywords: chronic aortic dissection; late presentation

• poster

2.20.6. Type B Aortic Dissection in Post Type A Aortic Dissection Repair

• Atanu Saha, Abhinaba Sarkar and Shubham Gupta
• Department of Cardiac Surgery, NH-Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India

Post Type A dissection repair after 12 years patient with Type B aortic dissection symptomatic for 6 months.

45 year old lady, no comorbidity presented with abdominal pain and anemia for last 6 months.

• past history of bentall with aortic arch replacement (2012).
• family history of aortic dissection.
• ct aortogram revealed dissection flap extending distal to left subclavian artery upto bifurcation of abdominal aorta
• echocardiography unremarkable, bileaflet prosthetic aortic valve functioning good.
• she underwent repair through left thoracoabdominal incision.
• peripheral bypass with on pump beating heart in mild hypothermia.
• thoracoabdominal repair with coselli graft with side brnaches anastomosis for visceral vessels.
• y shaped dacron graft for bilateral common iliac artery.
• CPB time 207 min.
• post operative period uneventful
• post operative echocardiography and CT aortogram satisfactory.
• open surgical repair good and potential option for chronic type b aortic dissection especially in young and middle aged individual.
• surgery is needed to avoid visceral compromise and malperfusion.

• Keywords: late presentation; chronic dissection; post type a dissection repair

• poster

2.20.7. Extensive Aortic Dissection Stanford a Debakey I with Involvement of the Arch Branches and Iliac Arteries

• Lorraine Wong Lu, Bryan Rene Toledano and Rodrigo Santos
• Cardiovascular Institute, The Medical City, Pasig, Philippines

BACKGROUND: This case highlight a rare, very extensive aortic dissection, manage based on the presented signs and symptoms and institutional experience.

METHODS: A 45 year old male with no features of connective tissue disease nor family history of aortic dissection presented to the emergency room with acute and diffuse thoracoabdominal pain and numbness of the both lower extremities. On physical examination his blood pressure (BP) was elevated with significant difference in the upper extremity and the right lower extremity. CT aortogram showed intimal flap commencing at the sinotubular junction with involvement of the brachiocephalic, bilateral common, left vertebral, and subclavian arteries extending to the bifurcation, bilateral common, external and internal iliac arteries (Figure 27). Esmolol drip and Nicardipine drip were started and he underwent urgent hemiarch repair. Post operatively there was improvement of symptoms and pulses except for episodes of left oculomotor nerve palsy during episodes of hypotension. He was eventually discharged stable and improved and was advised lifelong follow up and possibility of arch and abdominal dissection interventions if with signs of hypoperfusion or stroke.

RESULTS: Conservative surgery based on the most urgent site, symptomatology and experience of the surgeon are factors choosing hemiarch replacement. Medical management of other sites with no malperfusion will transition the course to chronic dissection.

CONCLUSIONS: Hemiarch replacement is a viable option for Extensive Aortic Dissection Standford A Debakey I with involvement of the arch branches and iliac arteries. Medical management to maintain normotension, lifestyle change and lifelong follow up are needed to assess if further interventions is required for the remaining dissection.

• Keywords: Standford A; Debakey 1; Hemiarch replacement; Aortic dissection; Thoracic aorta; Abdominal aorta

• Stanford A, Debakey 1

2.20.8. Thoracic Endovascular Aneurysm Repair (Zone1) with Extra-Anatomic Carotico-Carotico-Subclavian Bypass: A Case Report

• Nigar Kazimzade, Kamran Ahmadov and Kamran Musayev
• Department of Cardiovascular Surgery, Central Clinic Hospital, Baku, Azerbaijan

An 64-year old man presented with longstanding dry couch, shortness of breath at physical activity, voice changes. CT scan revealed a saccular aneurysm of descending thoracic aorta with maximal diameter 5,7 sm, causing compression of the trachea. Firstly, we performed an extra-anatomic carotico-carotico-subclavian bypass (RCCA-LCCA-LAxA) with 8 mm dacron graft. After that, zone 1-landing thoracic endovascular aortic repair with stent-graft was performed. A completion aortography revealed no endoleak, no rupture, no stent-graft migration and other complications. There is no in-hospital complications. Patient was discharged 5 days after hybrid procedure.

• Keywords: zone 1 tevar; extra-anatomic bypass

2.20.9. Retrograde Ascending Aortic Dissection as an Early Complication of Thoracic Endovascular Aortic Repair

• Cagla Canbay Sarilar, Mohammed Skaik and Onur Selcuk Goksel
  Department of Cardiovascular Surgery, Istanbul University, Istanbul, Turkey

Although there is less information on the occurrence of retrograde ascending aortic dissection, it is a potential complication of thoracic endovascular aortic repair (TEVAR).

In our cases retrograde dissection 28 days following TEVAR for chronic type B aortic dissection in addition to another another patient referred to our center with a similar scenario identified 10 days following TEVAR. In the time of recognition of a proximal dissection, we observed, both patients had ascending aortic diameters between 4.0 and 4.5 cm prior to the initial TEVAR procedure on zone 2. Similarly, both patients had the prior generation Talent device (Medtronic Inc, Santa Rosa, Calif). We strongly believe that continuing wall injury is a definitive factor in the case of misaligned proximal bare spring designs in particularly patients with dissection as the initial pathology where a general aortopathy is the case. We believe that neither moderate oversizing nor non-excessive balloon dilation appears to be a significant causative factor as we tend to no more than 10% most of the times and sometimes use a balloon dilation for secure proximal fixation without problems. Former patient underwent an ascending and arch replacement with direct anastomosis of the Dacron graft to the endograft (Figure 28). Unfortunately, she expired on day 10 due to multiple organ failure. The latter patient underwent a similar procedure and was discharged on day 16. We attribute the late identification of retrograde dissection to the lack of routine adjunctive use of TEE or IVUS.

We believe that addition of TEE and IVUS, in particularly setting of an initial dissecting pathology, is utmost important in recognition of this rare, but life-threatening situation leading to early surgery.

• Keywords: Thoracic endovascular aortic repair; retrograde ascending aortic dissection

2.20.10. Treatment of the Flap Advancing to the Arcus Aorta After de Bakey Type 3 Dissection with Modified Tevar

• Murat Muzaffer Güçlü, Mustafa Kemal Demirağ and Semih Murat Yücel
• Department of Cardiovascular Surgery, Ondokuz Mayıs University, Samsun, Türkiye

A 46-year-old male patient, whom we followed in the intensive care unit of our clinic due to de bakey type 3 dissection, experienced confusion and decreased urine output approximately 3 days after his admission.

The patient’s computed tomography angiography was repeated under emergency conditions and it was observed that the dissection flap had progressed to the proximal arcus aorta. an operation was planned for the patient immediately. although the primary plan was debranching + tevar, it was decided to apply zone 0 tevar, considering the general condition of the patient.

While the patient was preparing for the operation, the thevar graft was opened approximately 10 cm to be modified under sterile conditions. It was created on the previously measured islet thevar graft, covering the left common carotid and brachiocephalic artery. the graft was loaded onto the carrier and the standard tevar procedure was started. In the aortography after the graft was placed, it was observed that the dissection flap was closed and the left common carotid and brachiocephalic artery were not closed.

DISCUSSION: It can be said that this modified tevar method, which is fast, safe and less endangering the general condition of the patient, is a more advantageous option than the debranching operation, which requires sternotomy, in patients with limited dissection in the arcus aorta that has not progressed to the ascending aorta.

• Keywords: modified tevar debranching arcus aorta

2.21. VASCULAR AND ENDOVASCULAR » Venous

2.21.1. Frequency and Causes of Nosocomial Venous Thromboembolic Complications in Patients with Active Tuberculosis in Moscow

• Dmitry Plotkin ¹, Artur Titomer ¹, Michael Reshetnikov ¹, Michael Sinitcyn ² and Elena Bogorodskaya ¹

1

Moscow Research and Clinical Center for TB Control, Moscow, Russian

2

Pirogov Russian National Research Medical University, Moscow, Russian

BACKGROUND AND AIM: The frequency and risks of venous thromboembolic complications (VTEC) in tuberculosis remains a little studied phenomenon. At the same time venous thromboembolism can cause acute respiratory failure and death in tuberculosis patients. Purpose. To evaluate VTEC in patients with active tuberculosis admitted in specialized hospitals in Moscow and to determine the main factors influencing the development of acute venous thrombosis in this contingent of patients.

METHOD: Based on the epidemiological monitoring system data of tuberculosis in Moscow, a retrospective study of the treatment results in 4609 patients with active tuberculosis admitted in specialized hospitals in the period from 2020 to 2022 was carried out. The frequency detection of deep vein thrombosis (DVT), superficial vein thrombosis (SVT) and pulmonary embolism (PE) committed in medical records and confirmed by appropriate instrumental methods, was estimated.

RESULTS: A total of 214 cases of VTEC were detected (4.6%; 95% CI, 4.1–5.3%), among which the incidence of DVT was 3.5% (95% CI, 3.0–4.1%), SVT—1.5% (95% CI, 1.2–1.9%), and PE—0.6% (95% CI, 0.4–0.8%) (Figure 29). The most significant risk factors for the development of venous thromboembolic complications in patients with active tuberculosis were HIV/tuberculosis co-infection (OR, 3.8; 95% CI, 2.7–4.5) and the presence of a massive fibrosis in the lungs against the background of tuberculosis infection progression (OR, 9.1; 95% CI, 4.7–17.6). The overall prevalence of VTEC in the phthisiological hospital exceeded the literature data for non-infectious clinics by 3.3 times.

CONCLUSIONS: Based on the data obtained, it can be assumed that a specialized hospital admission for active pulmonary tuberculosis is a large reversible risk factor for the development of VTEC requiring the creation of appropriate methods for prediction and prevention.

• Keywords: venous thrombosis; tuberculosis; thromboembolia; HIV

2.21.2. Compression Therapy in Daily Phlebological Practice in Azerbaijan

• Afag Zahidova, Nubar Ismayilova and Vugar Fattah Pur
• Azerbaijan State Advanced Training Institute for Doctors Named by A. Aliyev, Baku, Azerbaijan

BACKGROUND AND AIM: This article reflects the results of a survey conducted among general and cardiovascular surgeons working in the field of phlebology in Azerbaijan on various aspects of compression therapy in venous pathologies.

METHOD: The questionnaire, consisting of 23 questions, was answered by 30 respondents. The analysis of the answers to the questions shows that despite the adherence to general principles, the application of CT in the practical activities of doctors is different.

RESULTS: The results of the survey confirm that compression therapy plays a leading and important role in the treatment of phlebological pathologies in Azerbaijan (Figure 30 and Figure 31). Compression stockings are used more (69.2% of cases) than elastic bandages (50% of cases) during surgery. In 100% of cases, only the medical class is recommended for the purpose of this knitwear, and hospital knitwear does not find a place in this segment. When determining compression after standard phlebectomy with stripping, a period of more than a month is preferred (46.2%) (

Table 23. Duration of continuous compression therapy after sclerotherapy in clinical class C1 varicose veins %.

Answer Option	Teleangiectasia	Reticular Varicose
Non applicable	23.1	7.7
1–6 days	34.6	23.1
7–14 days	26.9	42.3
More than 14 days	15.4	26.9

). However, the majority of doctors (30.8%) think that 3–4 weeks of compression is enough, In the treatment of acute varicothrombophlebitis of the calf area, the frequency of compression stockings was 76.9%. Only 1/3 of professionals prescribe golf. The majority of respondents prefer 2nd class compression (92.3%). In the case of acute deep vein thrombosis, compression stockings (61.5%) and tights (69.2%) are prescribed at the localization of the thrombotic process in the calf or hip-thigh segments, respectively. At the same time, the compression class is preferred to the 2nd class (57.7% and 65.4%, respectively, depending on the localization).

CONCLUSIONS: It is shown that the development of modern medical science and phlebological practice, changes in the tactical approach to the structure of treatment, the wider application of new mini-invasive interventions form new trends in the criteria for the appointment of compression therapy.

• Keywords: compression; stockings; evla; phlebectomy

2.21.3. Changes in Blood Rheology in Patients with Avascular Necrosis of the Femoral Head Who Had COVID-19 Before and After Hip Arthroplasty

• Javokhir Sh Kayumov
• Department of Traumatology and Orthopedic Surgery, Tashkent Medical Academy, Tashkent, Uzbekistan

BACKGROUND AND AIM: The goal is to study the rheological properties of blood before and after arthroplasty in patients with aseptic necrosis of the femoral head who have suffered from COVID-19.

METHOD: Material and methods. The results of treatment of 40 patients (main group) from September 2020 to March 2021 were studied. The control group included 41 patients who were operated on between 2017 and 2019 (before COVID-19). In the preoperative period, the main group of patients were examined for antibodies to SARS-CoV-2 IgG and IgM, where the presence of IgG antibodies in the blood was confirmed. Women—55, men—26. The average age was 60.5 ± 5.5 years (from 55 to 75 years). All patients were examined with standard digital radiography of the hip joint in a standing position. The condition of the joint was further studied using a 1.5 Tesla MRI device, an expert class Essenza.

RESULTS: In the pre- and postoperative period, the main emphasis of laboratory tests was aimed at studying the coagulation properties of blood. The quality of life of patients was assessed using a visual analogue scale (VAS) and the SF-36 method (Short-Form Health Status Survey). Total hip replacement was performed in 81 patients. In the preoperative period, all patients who had COVID-19 experienced hypercoagulation compared to the control group. In order to prevent thromboembolic complications, strictly controlled anticoagulant therapy was carried out in the pre- and postoperative period.

CONCLUSIONS: Conclusions In the preoperative period, in patients who have had COVID-19, it is necessary to carefully study the coagulation properties of blood. To prevent complications such as pulmonary embolism and deep vein thrombosis, all patients should be treated preoperatively with anticoagulants and antiplatelet agents until coagulation parameters return to normal.

• Keywords: deep vein thrombosis; pulmonary embolism; avascular necrosis of femoral head

2.21.4. Study on the Effectiveness of Minimally Invasive Endovenous Radiofrequency Ablation (RFA) for Treating Varicose Veins with Trophic Ulcers in 19 Patients—Proved Safe and Effective

• Mykyta Druzhkin
• Department of Faculty Surgery, Zaporizhzhia State Medical and Pharmaceutical University, Zaporizhzhia, Ukraine

BACKGROUND AND AIM: To assess the effectiveness of minimally invasive outpatient endovenous radiofrequency ablation (RFA) in treating varicose vein disease with active trophic ulcers (CEAP C6), examining its role as the primary treatment for vein insufficiency in ulcerative stages.

METHOD: Nineteen patients (10 women, 9 men, average age 48.22 ± 2.74 years) with CEAP C6 lower extremity varicose veins underwent radiofrequency ablation as their only outpatient surgical treatment.

RESULTS: Venous ulcers were on the right limb in 8 patients and the left in 11. Ulcer numbers per patient varied from 1 to 11, with 12 having a single ulcer and 7 having multiple. Ulcer sizes ranged 3–85 mm (avg. sizes 29.0 ± 8.67 mm and 44.1 ± 13.67 mm), the largest being 85 × 55 mm. Ulcer durations spanned 7–84 months (avg. 45.5 ± 12.83 months).

Preoperative Doppler sonography showed the great saphenous vein (GSV) ostium diameter ranged 5.0–19.5 mm (avg. 12.25 ± 2.42 mm) and the small saphenous vein (SSV) 3.0–11.5 mm (avg. 7.25 ± 1.42 mm) in standing patients.

RFA was performed on the GSV in 13 patients, the SSV in 1, and both in 5, lasting 30–60 min (avg. 35.6 ± 5.16 min) and involving 12–24 cycles per patient (avg. 18.0 ± 2.0).

No complications associated with the RFA procedure were observed in either the early or late postoperative periods.

In all patients, venous trophic ulcers successfully healed within 24 to 78 days, averaging 51.0 ± 9.0 days, without modifications to the standard treatment regimens for varicose disease and venous ulcers.

CONCLUSIONS: The use of endovenous radiofrequency ablation proved to be an effective treatment method for patients with varicose vein disease of the lower extremities and active trophic ulcer.

Outpatient endovenous radiofrequency ablation can be used as the primary treatment method for patients with varicose vein disease complicated by active trophic ulcer.

• Keywords: Varicose veins; Ulcer healing; Radiofrequency ablation (RFA); Venous insufficiency

2.21.5. Management of an Adolescent with Symptoms of Chronic Venous Insufficiency; Sequential Bilateral Successful Radiofrequency Ablation and Miniphlebectomy

• Barış Akça and Nevzat Erdil
• Department of Cardiovascular Surgery, Inonu University, Malatya, Turkey

BACKGROUND: The diagnosis and treatment of chronic venous insufficiency (CVI) have been well-standardized in adults. However, the rarity of lower extremity varicose veins during adolescence necessitates a specific approach to management and treatment.

CASE: A 15-year-old male presented with complaints of pain, swelling, itching of both legs for two years and a non healing wound of left leg since 6 months. The physical examination showed CEAP C-6 varicose veins on left lower extremity including increased leg diameter, truncal varicose veins, and a medial 1/3 lower segment leg ulcer. Legs lengths were equal, with no disruption in walking, no family history of varicose veins.

The possibility of Klippel-Trénaunay syndrome, post-thrombotic syndrome and a compressive condition was kept in mind and lower extremity doppler ultrasonography (DUSG) and abdominal USG were performed. DUSG revealed continuous reflux in both great saphenous veins (GSV). Left/Right GSV diameters were proximally 7.8/7.6 mm- above knee 5.2/5.3 mm, respectively. Abdominal USG revealed no abnormalities. We performed ultrasonographic mapping of the lower extremities, revealed no unusual condition aside from classical CVI, and decide to perform surgery. Above-knee radiofrequency ablation of GSV and below-knee miniphlebectomy performed with general anesthesia via laryngeal mask. The p atient was discharged uneventfully. Reduction in leg diameter and healing of the wound observed at 3 months control (Figure 32). After 10 months from initial surgery, same procedure performed on right leg and patient discharged uneventfully.

The uncertainty of the factors that cause venous reflux in adolescents still remains today. Unless, congenital anomalies mimicking classic venous insufficieny and other possible causes should kept in mind and etiological research should performed carefully before an intervention plan especially in adolescent patients.

• Keywords: Chronic venous insufficiency; adolescent; miniphlebectomy; radiofrequency ablation

2.21.6. Gigantic Moon-Shaped Aneurysm of the Azygos Vein

• Gokce Sirin
• Department of Cardiovascular Surgery, Ataköy Medicana Hospital, Istanbul, Türkiye

The azygos vein (AV) is a 5 mm diameter venous structure that drains into the superior vena cava at the right tracheobronchial angle. An AV with a diameter greater than 5 mm is considered enlarged. Although the specific etiology of azygos vein aneurysms (AVA) is unknown, the majority of cases occur in patients with heart failure, portal hypertension, blunt trauma, malformations of the inferior vena cava, or obstruction of the inferior vena cava, including partial or complete agenesis. AVAs are usually asymptomatic. On the other hand, large aneurysms may cause symptoms due to external compression of nearby organs. They may resemble a mediastinal or paratracheal mass on a chest radiograph. Effective diagnostic techniques include computed tomography (CT) and magnetic resonance imaging. The most common complications are aneurysm rupture, pulmonary thromboembolism, mediastinal mass effects, and pulmonary arterial hypertension. There is no consensus on the best treatment strategy. The conservative approach combined with oral anticoagulation, surgical or endovascular treatment is preferred in the treatment of patients.

A 82-year-old male patient presented to the outpatient clinic with a three-month history of back discomfort. The medical history of the patient was unremarkable. A physical examination demonstrated that the heart rate was 68 beats per minute and the blood pressure was 135/70 mmHg. There were nonspecific ST-T wave changes on electrocardiography. Transthoracic echocardiography and laboratory tests were also normal. A-chest X-ray showed mediastinal enlargement, and contrast-enhanced CT of the chest revealed a giant AVA (6.5 × 8.4 cm) with echo contrast (Figure 33). The patient was recommended to undergo surgical removal of the AVA, but he refused surgery. A lifelong anti-coagulation regimen (apixaban-2 × 2.5 mg) was initiated to avoid thrombosis and embolic complications. The patient is followed on an outpatient basis. The patient’s status is good at one year after initial diagnosis, and anti-coagulation therapy is continued without adverse events.

• Keywords: Azygos Vein; Aneurysm; Medical treatment; Surgical treatment; Endovascular treatment

2.22. VASCULAR AND ENDOVASCULAR » Visceral

2.22.1. Axillary Artery Aneurysm: Case Report

• Mert Çelik, Mucteba Sarıcaoglu and Cengiz Ovalı
• Departments of Cardiovascular Surgery, Osmangazi University, Eskisehir, Turkey

Upper extremity arterial aneurysms are rare; most often it occurs due to atherosclerosis, trauma, metabolic diseases. Our patient presented with pain in the left arm and swelling in the axillary region. In our article, we present the surgical treatment of axillary artery aneurysm.

• Keywords: axillary artery; aneurysm; brachial plexus; pain; surgical treatments

2.22.2. Alternative Minimal Access for Surgical Treatment of Dunbar Syndrome

• Valeriy Sergeevich Arakelyan, Roman Gennadevich Bukatsello, Vasiliy Georgievich Papitashvili, Rustam Zabyt Gerievich Kidakoev and Vladislav Lvovich Khon
• Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russia

BACKGROUND AND AIM: To study the results of treatment of patients with Dunbar syndrome operated through mini-access

METHOD: From 2010 to 2023 at the Bakulev Scientific Center operated on 47 patients with Dunbar syndrome. The criteria for choosing a mini-access were ultrasound imaging of functional stenosis, straightening and restoration of the caliber of the celiac trunk at the height of inspiration. Retrospectively, the immediate results were analyzed in patients using traditional thoracophrenolumbotomy (Group A—32 patients) and mini–access (Group B—15 (31.9%) patients). The groups were comparable in age, gender, clinical characteristics of Dunbar syndrome, time of disease, and concomitant pathology. The time of the operation, the timing of drainage removal, the timing of the start of feeding, the duration of hospital stay, the timing of parenteral anesthesia were calculated for the groups.

RESULTS: There were no major complications, reoperations and mortality in both groups. 2 (13.3%) patients from group B underwent celiac trunk replacement. The use of mini-access made it possible to reduce the average operation time from 2.7 (130–185 h—group A) to 1.8 (95–145 h—group B) hours. The average completion time of wound drainage was 2.4 and 1.8 days, respectively. The average time to start feeding was 2.8 versus 1.1 days (p < 0.05) in groups A and B, respectively. The use of mini-access reduced the administration of parenteral analgesics (59.3% vs. 86.6% without parenteral anesthesia; p < 0.05). The duration of hospitalization was also significantly lower in group B (3.9 vs. 6.7 days; p < 0.05).

CONCLUSIONS: The use of mini-access can be recognized as a good alternative to other accesses used in the treatment of Dunbar syndrome. Mini access allows you to achieve good cosmetic and clinical effects, reduce activation time and hospitalization while observing the principles of minimally invasive surgery.

• Keywords: Dunbar’s syndrome; celiac trunk compression syndrome; celiac trunk stenosis; surgical treatment