Search Results (33)

Contemporary evaluation and surgical approaches in congenital aortic valve disease have yielded limited success. The ability to evaluate and understand detailed flow characteristics surrounding surgical repair may be beneficial. This study explores the feasibility and utility of echocardiographic-based blood speckle imaging (BSI) in assessing pre- and post-operative flow characteristics in those with non-stenotic congenital aortic root disease undergoing aortic valve repair or valve-sparing root replacement (VSRR) surgery. Transesophageal echocardiogram was performed during the pre-operative and post-operative assessment surrounding aortic surgery for ten patients with non-stenotic congenital aortic root disease. BSI, utilizing block-matching algorithms, enabled detailed visualization and quantification of flow parameters from the echocardiographic data. Post-operative BSI unveiled enhanced hemodynamic patterns, characterized by quantified changes suggestive of the absence of stenosis and no more than trivial regurgitation. Rectification of an asymmetric jet and the reversal of flow on the posterior aspect of the ascending aorta resulted in a reduced oscillatory shear index ($OSI$) of $0.0543\pm 0.0207$ (pre-op) vs. $0.0275\pm 0.0159$ (post-op) and $p=0.0044$, increased peak wall shear stress of $1.9423\pm 0.6974$ (pre-op) vs. $3.6956\pm 1.4934$ (post-op) and $p=0.0035$, and increased time-averaged wall shear stress of $0.6885\pm 0.8004$ (pre-op) vs. $0.8312\pm 0.303$ (post-op) and $p=0.23$. This correction potentially attenuates cellular alterations within the endothelium. This study demonstrates that children and young adults with non-stenotic congenital aortic root disease undergoing valve-preserving operations experience significant improvements in flow dynamics within the left ventricular outflow tract and aortic root, accompanied by a reduction in $OSI$. These hemodynamic enhancements extend beyond the conventional echocardiographic assessments, offering immediate and valuable insights into the efficacy of surgical interventions. Full article

Background: Aortic valve infective endocarditis (IE) complicated by an aortic root abscess is a challenging problem that leads to increased morbidity and mortality. Aortic root repair or replacement are two potential treatment options. We aimed to compare patients undergoing aortic root repair or replacement with short- and mid-term outcomes. Methods: Consecutive patients with active aortic valve IE complicated by aortic root abscess undergoing cardiac surgery from January 2012 to January 2022 were included. Patients receiving aortic root repair were compared to patients undergoing aortic root replacement. Endpoints included overall mortality, incidence of recurrent IE and re-intervention during a two-year follow-up period. Inverse propensity weighting was employed to adjust for confounders. Results: Seventy-three patients with aortic valve IE with root abscess underwent surgical therapy. Fifty-six patients received aortic root repair and seventeen patients underwent aortic root replacement. Patients undergoing root replacement had significantly higher surgical risk (EuroSCORE II: 9 versus 19, p = 0.02) and extended disease (circumferential annular abscess: 9% versus 41%, p < 0.01). Inverse propensity weighted analysis revealed no relationship between surgical strategy and outcome. Weighted regression analysis revealed EuroSCORE II and disease extension as significant predictors of 30-day and 2-year mortality. Conclusions: In patients with aortic valve IE with root abscess, root repair is mostly performed in lower-risk patients with limited disease extension. Short- and mid-term mortality, recurrent endocarditis and reintervention were comparable between surgical strategies during follow-up. Surgical risk and disease extension, rather than surgical strategy, seem to be significant predictors of short- and mid-term mortality. Full article

Objectives: Several conditions associated with type A aortic dissection may require preoperative invasive mechanical ventilation (IMV). The current literature lacks data on this subset of patients’ prevalence and postoperative outcomes. This study aims to investigate this unexplored issue in a multicenter European registry. Methods: Data from 3735 patients included in the European Registry of Type A Aortic Dissection (ERTAAD) were the subject of this analysis. Bootstrapped Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression was performed for variable selection to identify key predictors of hospital death. In the second step, a multilevel multivariable logistic regression (MMLR) was carried out, given the clustered structure of the data. Results: A total of 346 (9.3%) out of 3735 patients required preoperative IMV. Compared to the non-IMV patients, patients requiring IMV had a significantly higher rate of organ malperfusion (52% vs. 35%, p < 0.001) and a higher proportion of tears in the aortic root (p = 0.048). The in-hospital mortality rate among IMV patients was 38% vs. 15% in non-IMV patients (p < 0.001), without a difference in post-discharge survival (p = 0.84). At the MMLR, patients who required IMV had 135% higher odds of in-hospital death compared to the remaining patients. IMV yielded the second highest odds in the prediction model for in-hospital mortality (OR 2.13, CI 1.60 to 2.85, p < 0.001). Among IMV patients, the extension of surgery to the aortic arch was significantly associated with increased in-hospital mortality (p < 0.001, OR 2.98). In multivariable analysis, preoperative IMV was independently associated with increased odds of in-hospital mortality. Conclusions: The need for invasive mechanical ventilation before surgical repair for type A aortic dissection is not infrequent. In this subpopulation, the in-hospital mortality rate was twofold compared to patients who did not require IMV. The awareness of the preoperative risk profile and outcomes of this subset of patients should urge surgeons to tailor the surgical strategy more appropriately to improve the immediate postoperative results. Full article

Transseptal puncture (TSP) is an essential step for left heart procedures that allows access to the left atrium (LA) through the fossa ovalis (FO) of the interatrial septum (IS). Initially developed for diagnostic purposes, today, it is performed for procedures that require large-bore device delivery systems and complex three-dimensional navigation in the left atrium. TSP supports various interventions, including atrial fibrillation ablation, left atrial appendage closure, and transcatheter mitral valve repair and replacement. While traditionally performed with Brockenbrough needles under fluoroscopic guidance, the integration of transesophageal and intracardiac echocardiography (TEE/ICE) has significantly improved its safety and precision. Despite its generally high success rate, TSP poses challenges in complex anatomies or for less experienced operators, with complications such as cardiac tamponade, aortic root puncture, and embolic events. Anatomical variations, such as thickened or floppy septa, further complicate the procedure. Technological advancements, including radiofrequency-based systems and specialized guidewires, have enhanced safety in difficult cases. Effective training, including echocardiography and complication management, is vital for operator proficiency. This review outlines the procedural steps for safe TSP, emphasizing proper equipment selection, anatomical considerations, and vascular access techniques. Common complications are discussed alongside management strategies. Advanced tools and techniques for addressing challenging scenarios are highlighted. Full article

Background: Pathogenic variants within the gene encoding transforming growth factor β (TGF-β) are responsible for Loeys-Dietz syndrome (LDS), a heritable thoracic aortic disease sharing clinical features with Marfan syndrome, including craniofacial and skeletal abnormalities as well as aortic root aneurysms and dissections. In contrast to Marfan syndrome patients, who rarely develop aneurysms or dissections beyond the aortic root, LDS patients frequently exhibit vessel aneurysms in locations other than the aortic root. Here, we report the case of a 61-year-old patient who initially presented with marfanoid characteristics and an aortic root aneurysm and was presumed to have Marfan syndrome two decades ago. Later, the patient developed an abdominal aorta aneurysm, necessitating endovascular repair and stent placement. That fact raised doubts regarding the initial diagnosis of Marfan syndrome, and we decided to investigate the genetic cause of the disorder. Methods: Genetic testing was performed using WES analysis and Sanger sequencing. Results: The genetic analysis detected a de novo heterozygous pathogenic variant c.896G>A in exon 5 of the TGFB2 gene, resulting in the amino acid substitution p. Arg299Gln that has devastating destabilizing structural effects on 3D folding of the protein, as demonstrated by the molecular modeling study we performed. This variant is pathogenic for LDS type 4, partially consistent with the patient’s clinical presentation. Conclusions: Our case emphasizes the significance of precise clinical assessment and genetic verification in patients exhibiting marfanoid characteristics. Furthermore, our findings contribute to the understanding of the diverse clinical spectrum associated with this specific pathogenic variant of TGFB2, underscoring the importance of detailed clinical assessment in expanding knowledge of genotype-phenotype correlations. Accurate diagnosis is crucial for tailored and appropriate management of individuals with heritable thoracic aortic diseases. Full article

Background/Objectives: Type A aortic dissection repair using Polytetrafluorethylene (PTFE) felt inlay and tissue glue has been proposed as a treatment modality. It remains unclear, if this method performs superiorly to tissue glue only. Methods: Between January 2011 and December 2015, 139 patients underwent surgical repair for type A aortic dissection, and 48 patients were excluded (n = 29 after receiving a composite graft, n = 18 in which no tissue glue was used, and n = 1 due to missing data). In the remaining patients, proximal aortic repair was performed either using PTFE felt inlay and tissue glue or tissue glue only. We analyzed the need for repeated surgery on the aorta during follow-up as a primary endpoint. The secondary endpoint was all-cause mortality at follow-up. Inverse probability of treatment weighting was used to balance the distribution of measured baseline covariates. Results: Sixty-six patients (73%) were treated with a tissue-glue-only approach—the Control Group. Twenty-five patients (27%) underwent proximal PTFE felt inlay and tissue glue—the Intervention Group. In the Intervention Group, 40% (n = 10) underwent reoperation due to re-dissection or pseudoaneurysm vs. 12% (n = 8) in the Control Group. The felt inlay increased the hazard of re-operation by 8.38 (1.63 to 43.0) after IPTW with death modeled as competing risk. Conclusions: Reoperation due to aortic complications was 10 times higher in patients treated with a combination of gluing and PTFE felt inlay vs. gluing only. These results are potentially caused by an interaction of PTFE, tissue glue, and aortic tissue. Full article

Objective: We reviewed the available literature on patients undergoing aortic repair for acute type A aortic dissection (ATAAD) with either aortic root preservation (RP) or root replacement (RR). Methods: Original research studies that evaluated short- and mid-term hemostatic properties of RP versus RR groups were identified, from 2000 to 2024. Intraoperative transfusions of red blood cells (RBCs), reoperation for bleeding, strategy of hemostatic sealing of the anastomosis in root repair following the reapproximation of the dissected layers of the aortic wall (with/without biological glue), and operative mortality were the primary endpoints. Postoperative morbidity and overall and reoperation-free survival at one and five years were the secondary endpoints. A sensitivity analysis was performed using the leave-one-out method. Results: Ten studies were included in the qualitative and quantitative synthesis, incorporating data from 6850 patients (RP: 4389 patients; RR: 2461 patients). Root preservation demonstrated a lower median transfusion of RBCs (WMD: −1.00; 95% CI: −1.41, −0.59; p < 0.01) and incidence of reoperation for bleeding compared to root replacement (OR: 0.67; 95% CI: 0.58, 0.77; p < 0.01). The majority of studies did not use biological glue in root repair to avoid the risk of an anastomotic pseudoaneurysm. No difference was found regarding postoperative morbidity, along with mid-term overall and reoperation-free survival. Conclusions: Root preservation without the use of biological glue during aortic repair is associated with enhanced hemostatic traits compared to the root replacement approach. A future well-designed Randomized Controlled Trial should further validate our outcomes. Full article

Congenitally corrected transposition of the great arteries (ccTGA) is an infrequent and complex congenital malformation, which accounts for approximately 0.5% of all congenital heart defects. This defect is characterized by both atrioventricular and ventriculoarterial discordance, with the right atrium connected to the morphological left ventricle (LV), ejecting blood into the pulmonary artery, while the left atrium is connected to the morphological right ventricle (RV), ejecting blood into the aorta. Due to this double discordance, the blood flow is physiologically normal. Most patients have coexisting cardiac abnormalities that require further treatment. Untreated natural course is often associated with progressive failure of the systemic right ventricle (RV), tricuspid valve (TV) regurgitation, arrhythmia, and sudden cardiac death, which occurs in approximately 50% of patients below the age of 40. Some patients do not require surgical intervention, but most undergo physiological repair leaving the right ventricle in the systemic position, anatomical surgery which restores the left ventricle as the systemic ventricle, or univentricular palliation. Various types of anatomic repair have been proposed for the correction of double discordance. They combine an atrial switch (Senning or Mustard procedure) with either an arterial switch operation (ASO) as a double-switch operation or, in the cases of relevant left ventricular outflow tract obstruction (LVOTO) and ventricular septal defect (VSD), intra-ventricular rerouting by a Rastelli procedure. More recently implemented procedures, variations of aortic root translocations such as the Nikaidoh or the half-turned truncal switch/en bloc rotation, improve left ventricular outflow tract (LVOT) geometry and supposedly prevent the recurrence of LVOTO. Anatomic repair for congenitally corrected ccTGA has been shown to enable patients to survive into adulthood. Full article

Background: Aortic valve-sparing aortic root replacement (VSARR) David procedure has not been routinely performed via minimally invasive access due to its complexity. Methods: We compared our results for mini-VSARR to sternotomy-VSARR from another excellence center. Results: Eighty-four patients, 62 in the sternotomy-VSARR group and 22 in the mini-VSARR group, were included. A baseline, the aneurysm dimensions were higher in the mini-VSARR group. Propensity matching resulted in 17 pairs with comparable characteristics. Aortic cross-clamp and cardiopulmonary bypass times were significantly longer in the mini-VSARR group, by 60 and 20 min, respectively (p < 0.001). In-hospital outcomes were comparable between the groups. Drainage volumes were numerically lower, and hospital length of stay was, on average, 3 days shorter (p < 0.001) in the mini-VSARR group. At a median follow-up of 5.5 years, there was no difference in mortality (p = 0.230). Survival at 1, 5 and 10 years was 100%, 100%, and 95% and 95%, 87% and 84% in the mini-VSARR and sternotomy-VSARR groups, respectively. No repeat interventions on the aortic valve were documented. Echocardiographic follow-up was complete in 91% with excellent durability of repair regardless of the approach: no cases of moderate/severe aortic regurgitation were reported in the mini-VSARR group. Conclusions: The favorable outcomes, reduced drainage, and shorter hospital stays associated with the mini-sternotomy approach underscore its potential advantages expanding beyond cosmetic outcome. Full article

A sinus of valsalva aneurysm (SVA) is an asymmetrical dilatation of the aortic root located between the aortic valve anulus and the sino-tubular junction. Congenital weakness of the elastic lamina in the aortic media layer or trauma and infection as acquired events are the most principal causes of SVA. Presentation may be acute when rupture has occurred or SVA may be discovered fortuitously on echocardiography or CT scan when patients are examined because of unspecific chest pains, dyspnea or arrhythmias. Although endovascular treatment has been performed successfully in individual cases, surgical closure of the aneurysm aiming at preservation of the aortic valve whenever possible is the established procedure. This short report emphasizes the fact that individual treatment is required when SVA need to be operated, depending on the presentation, the location and the size of the finding. Surgery may consist of simple patch closure, bilateral tunnel closure (entry and exit) or more radical operation like Bentall in case the whole aortic root should be addressed. Overall results are excellent, independently of the clinical presentation (acute or elective) with a mortality approaching zero. Full article

Locally destructive infective endocarditis (IE) of the aortic valve complicated by abscess formation in the aortic root may seriously affect patients’ outcomes. Surgical repair of such conditions is often challenging. This is a single-center observational analysis of consecutive patients treated surgically for IE between 2009 and 2019. We divided the cohort into two groups considering the presence of an aortic root abscess and compared the characteristics and postoperative outcomes of patients accordingly. Moreover, we examined three different procedures performed in abscess patients regarding operative data and postoperative results: an isolated surgical aortic valve replacement (AVR), AVR with patch reconstruction of the aortic root (AVR + RR) or the Bentall procedure. The whole cohort comprised 665 patients, including 140 (21.0%) patients with an aortic root abscess and 525 (78.9%) as the control group. The abscess group of patients received either AVR (66.4%), AVR + RR (17.8%), or the Bentall procedure (15.7%). The mean age in the whole cohort was 62.1 ± 14.8. The mean EuroSCORE II was 8.0 ± 3.5 in the abscess group and 8.4 ± 3.7 in the control group (p = 0.259). The 30-day and 1-year mortality rates were 19.6% vs. 11.3% (p = 0.009) and 40.1% vs. 29.6% (p = 0.016) in the abscess compared to the control group. The multivariable regression analysis did not reveal aortic root abscess as an independent predictor of mortality. Rather, age > 60 correlated with 30-day mortality and infection with Streptococcus spp. correlated with 1-year mortality. In the analysis according to the performed procedures, KM estimates exhibited comparable long-term survival (log-rank p = 0.325). IE recurrence was noticed in 12.3% of patients after AVR, 26.7% after AVR + RR and none after Bentall (p = 0.069). We concluded that patients with an aortic root abscess suffer worse short and long-term outcomes compared to other IE patients. The post-procedural survival among ARA patients did not significantly vary based on the procedures performed. Full article

Surgical repair for regurgitant bicuspid aortic valve (BAV) is promising but underutilized due to perceived complexities and lack of long-term data. This study evaluated the efficacy of valve-sparing root remodeling (VSRR) or isolated valve repair combined with calibrated external ring annuloplasty in BAV versus tricuspid aortic valve (TAV) patients. All patients operated on for aortic regurgitation and/or aneurysm at our institution between 2014 and 2022 were included and entered into the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR). Patients with successful repair at index surgery (100% in the BAV group, 93% in the TAV group, p = 0.044) were included in a systemic follow-up with echocardiography at regular intervals. Among 132 patients, 58 were in the BAV (44%) and 74 in the TAV group (56%). There were no inter-group differences in preoperative patient characteristics, except BAV patients being significantly younger (47 ± 18 y vs. 60 ± 14 y, p < 0.001) and having narrower aortic roots at the level of sinuses (41 ± 6 mm vs. 46 ± 13 mm, p < 0.001) and sinotubular junctions (39 ± 10 mm vs. 42 ± 11, p = 0.032). No perioperative deaths were recorded. At four years, there was no significant difference in terms of overall survival (96.3% BAV vs. 97.2% TAV, p = 0.373), freedom from valve reintervention (85.2% BAV vs. 93.4% TAV, p = 0.905), and freedom from severe aortic regurgitation (94.1% BAV vs. 82.9% TAV, p = 0.222). Surgical repair of BAV combined with extra-aortic annuloplasty can be performed with low perioperative morbidity and mortality and excellent mid-term results which are comparable to TAV repair. Full article

Type A acute aortic dissection (TAAAD) is a serious condition within the acute aortic syndromes that demands immediate treatment. Despite advancements in diagnostic and referral pathways, the survival rate post-surgery currently sits at almost 20%. Our objective was to pinpoint clinical indicators for mortality and morbidity, particularly raised arterial lactate as a key factor for negative outcomes. Methods: All patients referred to the three cardiovascular centres between January 2005 and December 2022 were included in the study. The inclusion criteria required the presence of a lesion involving the ascending aorta, symptoms within 7 days of surgery, and referral for primary surgical repair of TAAAD based on recommendations, with consideration for other concomitant major cardiac surgical procedures needed during TAAAD and retrograde extension of TAAAD. We conducted an analysis of both continuous and categorical variables and utilised predictive mean matching to fill in missing numeric features. For missing binary variables, we used logistic regression to impute values. We specifically targeted early postoperative mortality and employed LASSO regression to minimise potential collinearity of over-fitting variables and variables measured from the same patient. Results: A total of 633 patients were recruited for the study, out of which 449 patients had complete preoperative arterial lactate data. The average age of the patients was 64 years, and 304 patients were male (67.6%). The crude early postoperative mortality rate was 24.5% (110 out of 449 patients). The mortality rate did not show any significant difference when comparing conservative and extensive surgeries. However, malperfusion had a significant impact on mortality [48/131 (36.6%) vs. 62/318 (19.5%), p < 0.001]. Preoperative arterial lactates were significantly elevated in patients with malperfusion. The optimal prognostic threshold of arterial lactate for predicting early postoperative mortality in our cohort was ≥2.6 mmol/L. Conclusion: The arterial lactate concentration in patients referred for TAAAD is an independent factor for both operative mortality and postoperative complications. In addition to mortality, patients with an upper arterial lactate cut-off of ≥2.6 mmol/L face significant risks of VA ECMO and the need for dialysis within the first 48 h after surgery. To improve recognition and facilitate rapid transfer and surgical treatment protocol, more diligent efforts are required in the management of malperfusion in TAAAD. Full article

Objective: bicuspid aortic valve (BAV) stands as the most prevalent congenital heart condition intricately linked to aortic pathologies encompassing aortic regurgitation (AR), aortic stenosis, aortic root dilation, and aortic dissection. The aetiology of BAV is notably intricate, involving a spectrum of genes and polymorphisms. Moreover, BAV lays the groundwork for an array of structural heart and aortic disorders, presenting varying degrees of severity. Establishing a tailored clinical approach amid this diverse range of BAV-related conditions is of utmost significance. In this comprehensive review, we delve into the epidemiology, aetiology, associated ailments, and clinical management of BAV, encompassing imaging to aortic surgery. Our exploration is guided by the perspectives of the aortic team, spanning six distinct guidelines. Methods: We conducted an exhaustive search across databases like PubMed, Ovid, Scopus, and Embase to extract relevant studies. Our review incorporates 84 references and integrates insights from six different guidelines to create a comprehensive clinical management section. Results: BAV presents complexities in its aetiology, with specific polymorphisms and gene disorders observed in groups with elevated BAV prevalence, contributing to increased susceptibility to other cardiovascular conditions. The altered hemodynamics inherent to BAV instigate adverse remodelling of the aorta and heart, thus fostering the development of epigenetically linked aortic and heart diseases. Employing TTE screening for first-degree relatives of BAV patients might be beneficial for disease tracking and enhancing clinical outcomes. While SAVR is the primary recommendation for indicated AVR in BAV, TAVR might be an option for certain patients endorsed by adept aortic teams. In addition, proficient teams can perform aortic valve repair for AR cases. Aortic surgery necessitates personalized evaluation, accounting for genetic makeup and risk factors. While the standard aortic replacement threshold stands at 55 mm, it may be tailored to 50 mm or even 45 mm based on patient-specific considerations. Conclusion: This review reiterates the significance of considering the multifactorial nature of BAV as well as the need for further research to be carried out in the field. Full article

Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying cases in which surgery needs to be performed on an emergency (within 24 h) or urgent (within 7 days) basis, irrespective of the duration of antibiotic treatment, or cases where surgery can be postponed to allow a brief period of antibiotic treatment under careful clinical and echocardiographic observation. Mainly, guidelines put emphasis on the importance of an endocarditis team in the handling of systemic complications and how they affect the timing of surgery and perioperative management. Neurological complications, acute renal failure, splenic or musculoskeletal manifestations, or infections determined by multiresistant microorganisms or fungi can affect long-term prognosis and survival. Not to be outdone, anatomical and surgical factors, such as the presence of native or prosthetic valve endocarditis, a repair strategy when feasible, anatomical extension and disruption in the case of an annular abscess (mitral valve annulus, aortic mitral curtain, aortic root, and annulus), and the choice of prosthesis and conduits, can be equally crucial. It can be hard for surgeons to maneuver between correct pre-operative planning and facing unexpected obstacles during intraoperative management. The aim of this review is to provide an overview and analysis of a broad spectrum of specific surgical scenarios and how their challenging management can be essential to ensure better outcomes and prognoses. Full article