Search Results (46)

Background: Non-cholera Vibrio species are rare waterborne pathogens that can cause severe infections. Among these, few cases of Vibrio metschnikovii infections have been reported, especially in the gastrointestinal tract, with no cardiac tissue involvement as a result. Following the PRISMA checklist, we conducted a literature review, and thirteen articles for twenty-two cases overall were included: seven cases of sepsis (in three cases, the echocardiographic results were negative), seven cases of pneumonia, two skin infections, eleven cases of diarrhoea, and a gastroenteritis outbreak. This report documents the expanding clinical spectrum and the role played by V. metschnikovii in infective endocarditis. Case report: A 28-year-old male patient was referred to the cardiac surgery unit for urgent mitral valve replacement due to suspicion of infective endocarditis. Microbiological tests yielded negative results. Following recovery and discharge with antimicrobial therapy for 6 weeks, the patient experienced prosthesis detachment, necessitating re-hospitalisation for an emergency valve replacement. Vibrio metschnikovii was identified on the prosthesis valve through PCR and successfully treated with ciprofloxacin. However, a spontaneous rupture of the ascending thoracic aorta led to a neurological injury. Discussion: This case represents the first case of valve infection caused by Vibrio metschnikovii, characterised by diagnostic and therapeutic challenges and the involvement of the great vessels. Also considered in this case, for a disease with a median age of 58 years (11–83) and a male-to-female ratio of 2.2, were one male neonate and six cases for whom neither sex nor age was indicated. Excluding gastrointestinal cases, the septic forms are associated with high morbidity, although the single case described involved a young and healthy subject. Risk factors for the pathogen or predisposing/pathological conditions for endocarditis did not emerge. The routes and the time of infection could not be determined, deepening the possibility of occupational exposure via the patient’s position as a boat worker. Poor sensitivity to third-generation cephalosporins has been reported in the literature: the absence of an antibiogram does not allow for a comparison, although resolution was achieved with ciprofloxacin. Conclusion: The rising global incidence of non-cholera Vibrio infections, driven by environmental changes, calls for urgent research into the factors behind their pathogenicity and infection routes. Diagnostic complexities have emerged together with clinical severity. Full article

Background/Objectives: Patients undergoing open thoracic aortic surgery have the highest bleeding complication rates within cardiac–vascular surgery, but research on coagulation management mostly targets general cardiac surgery. This scoping review evaluates current evidence on intraoperative hemostatic agents and their effect on bleeding and blood transfusions in these patients. Methods: We searched MEDLINE (PubMed), Embase, and Cochrane Library on 2 July 2024. Eligible studies included randomized controlled (RCT) and observational trials with a comparison group and at least a sub-analysis regarding thoracic aortic surgery (excluding thoracoabdominal and isolated descending aorta surgery). Results: Our search yielded 4697 articles, with 33 included. These covered antifibrinolytics (3 RCTs, 10 observational studies), fibrinogen supplementation (3 RCTs, 4 observational studies), recombinant factor VIIa (rFVIIa, 8 observational studies), blood products (3 observational studies), and factor eight inhibitor bypassing activity (FEIBA, 1 RCT, 1 observational study). The impact of blood product transfusion on bleeding control is unclear due to a lack of placebo or no-transfusion comparisons, though it appears associated with more complications. Both FEIBA studies suggest reduced blood product use in aortic dissection surgery—one as rescue therapy, the other as standard treatment. Evidence on fibrinogen supplementation is mixed: a multicenter RCT showed increased transfusions, while smaller RCTs and observational studies showed reductions, possibly due to differences in pretreatment fibrinogen levels and patient selection. Observational studies on rFVIIa show conflicting results, likely due to selection bias. Two small RCTs—one on TXA, one on aprotinin—suggest reduced transfusions and blood loss. Comparative studies of different types of antifibrinolytics yielded conflicting results. Conclusions: Evidence on hemostatic agents in thoracic aortic surgery is limited. Small studies suggest potential for the routine use of antifibrinolytics, FEIBA, and fibrinogen supplementation—but only in bleeding patients with hypofibrinogenemia. High-quality RCTs focused on thoracic aortic procedures are needed to determine optimal coagulation management. Full article

Objective: Over the last ten years, aortic surgery has transitioned from a high-risk procedure to a well-established operation, offering favorable outcomes and survival when performed by experienced hands. Advances in surgical techniques and evolving technologies allow treatment of older and more complex patients with reoperations. However, outcome data are limited. This study aims to identify risk factors for adverse outcomes after reoperation on the aortic root. Methods: This retrospective study included patients who received aortic root reoperation from 1999 to 2023 in a high-volume center, with a history of previous surgery on the thoracic aorta or aortic valve. Patients under the age of 18 or those with transcatheter aortic valve implantation as an index procedure were excluded. Results: A total of 192 patients were analyzed. Mean age was 57 ± 13 years, and 77.6% were men. The main procedure was Bentall (88.5%). An elective operation was performed in 54.7% of the patients. The mean time between the index operation and reoperation was 8.61 (3.01–16.05) years. Mortality at 30 days was 13%. Survival rates at one, five, and ten years were 84%, 81%, and 71%, respectively. Female gender, non-elective surgery, concomitant procedures, and combined procedures on the aortic root and arch were associated with worse survival. In the Cox regression, age (HR = 3.98, p < 0.01), EuroSCORE II (HR = 1.46, p < 0.01), concomitant procedures at reoperation (HR = 2.53, p = 0.01), prolonged cardiopulmonary bypass time (HR = 1.01, p < 0.01), bleeding complications (HR = 6.11, p < 0.01), and need for temporary mechanical circulatory support (HR = 4.86, p = 0.01) were significantly associated with a higher mortality. Analysis of the receiver operating characteristic curve revealed that age > 60 years at reoperation is a strong predictor for poor outcomes (AUC = 0.712, p < 0.01). Conclusions: Mortality following aortic root reoperation is primarily driven by baseline patient risk and perioperative complications. Reduced survival was observed in patients over 60 years of age, females, those having non-elective surgery, combined root and arch operations, and procedures with additional concomitant operations. Bleeding events, the use of temporary mechanical circulatory support, and concomitant interventions at reoperation emerged as independent predictors of mortality. Full article

Objectives: Direct innominate artery cannulation is a viable and effective alternative for arterial inflow during thoracic aorta surgery, applicable in elective and emergent cases. This technique ensures reliable circulatory control. Methods: A single-center retrospective study of 208 cases that underwent thoracic aortic surgery between January 2010 and December 2021 was performed. The primary outcomes were in-hospital and remote mortality and the secondary outcomes were adverse neurologic events. Results: The median age of the patients was 69 years. The male gender accounted for 63.9% of the cases. The most represented surgical interventions consisted of hemiarch replacement in 105 cases (50.5%) and ascending aorta and aortic valve replacement (wheat procedure) in 71 cases (34.1%). The operative mortality rate was 5.3%, with six cases attributed to aortic-type dissection. The overall remote mortality rate at five years was 7.7. Postoperatively, 70 patients experienced alterations in the level of consciousness, with 12 of these cases belonging to the dissection group. Six patients with permanent neurologic symptoms had a positive computed tomography scan. Of the eleven patients with negative brain computed tomography scans, nine experienced temporary neurological deficits, while two suffered from permanent neurological damage. Conclusions: Direct innominate artery cannulation represents a safe and effective method for providing arterial inflow during cardiopulmonary bypass, offering an outstanding alternative to traditional sites for both planned and urgent surgical interventions. Full article

Background: Surgical indication of ascending thoracic aortic aneurysms (ATAA) is generally performed in prevention. Guidelines use aortic diameter as a predictor of rupture and dissection; however, this single parameter alone has a limited value in predicting the real-world risk of acute aortic syndromes. The novel photon-counting CT scan(pc-CT) is capable of better-analyzing tissue composition and aortic characterization. The aim of the study is to assess whether the correlation between aortic wall thickness measured with a pc-CT scan and histology exists. Methods: 14 Patients, with a mean age of 47 years, undergoing cardiac surgery for ATAA, who had preoperatively undergone a pc-CT scan, were retrospectively analyzed. Histology analyses of the resected aortic wall aneurysm were reviewed, and minimum/maximum measurements of intima+media of the aortic wall were performed. Radiology images were also examined, and aortic wall thickness measures were taken. Bland-Altman plots and Passing-Bablock regression analyses were conducted to evaluate the correlation between the values. Results: pc-CT scan mean measurements were 1.05 and 1.69 mm, minimum/maximum, respectively. Mean minimum/maximum histology measurements were 1.66 and 2.82 mm, respectively. Bland Altman plots and Passing-Bablock regression analyses showed the absence of systematic bias and confirmed that measurement values were sufficiently similar (minimum −0.61 [CI 95% 0.16–1.38]; maximum −1.1 [0.73–2.99]). Conclusions: Despite results being merely preliminary, our study shows encouraging sufficiently similar results between aortic wall thickness measurements made with pc-CT scan and histology analyses. Full article

Background/Objectives: The frozen elephant trunk (FET) technique was introduced as a possible single-stage procedure for treating aortic arch pathologies. However, up to a third of patients are reported to need subsequent completion (extension). This retrospective analysis aimed to evaluate the impact of early (within 30 days; EC group) versus late (>30 days; LC group) endovascular completion with thoracic endovascular aortic repair (TEVAR) in patients treated with FET. Methods: A single-center, retrospective analysis of all consecutive patients for the period between June 2017 and December 2023 who underwent FET and received endovascular extension was conducted. Indications for endovascular extension were aneurysms of the descending aorta, aneurysmal progress, endoleak, malperfusion, distal stent-induced new entry (dSINE), and aortic rupture. Results: A total of 37 of 232 FET patients received endovascular extension (15.9%). Average age at the time of TEVAR was 63.3 ± 10.3 years. There was an increase in the maximum total aortic diameter post-FET from 40.8 ± 9 mm to 45.1 ± 14 mm prior to TEVAR. Only 14 patients (37.8%) had the desired complete occlusion of the false lumen or aneurysm prior to extension; 23 (62.2%) still had relevant perfusion of the false lumen or aneurysm. The EC and LC groups were defined by time between FET and TEVAR: a mean of 4.8 ± 5.2 days in the EC group and 18.4 ± 18 months in the LC group. The EC group had markedly more complex procedures, reflected in intensive care (10.7 ± 6.9 vs. 0.1 ± 0.3 days, p < 0.001) and hospitalization (22.4 ± 14.0 vs. 8.1 ± 5.6 days, p = 0.003) durations. There was one early death due to multiorgan failure in the EC group and there were none in the LC group. There were no major cardiac events in either group. In the EC group, seven patients (50%) suffered from postoperative respiratory failure and four (28.6%) developed acute kidney failure requiring dialysis. Only one patient in the LC group (4.3%) experienced complications. During follow-up, another three patients (21.4%) of the EC group died, but none of the LC group did. Post-extension aortic remodeling was similar in both groups, with complete occlusion achieved in 27 cases (72%) during early follow-up and increased to 90.6% after a mean of 22.0 ± 23.4 months. Conclusions: Following aortic arch repair using FET, there is still a need for second-stage repair in 16% of patients. Endovascular completion post-FET is safe and feasible with a technical success rate of 100%, but early completion is associated with greater morbidity and mortality. TEVAR extension surgery may be better delayed, if possible, until after recovery from the hybrid arch repair. Full article

Thoracoabdominal aortic aneurysms (TAAAs) are rare but serious conditions characterized by dilation of the aorta characterized by remodeling of the vessel wall, with changes in the elastin and collagen content. Individuals with Marfan syndrome have a genetic predisposition for elastic fiber fragmentation and elastin degradation and are prone to early aneurysm formation and progression. Our objective was to analyze the medial collagen characteristics through histological, polarized light microscopy, and electron microscopy methods across the thoracic and abdominal aorta in twenty-five patients undergoing open surgical repair, including nine with Marfan syndrome. While age at surgery differed significantly between the groups, maximum aortic diameter and aneurysm extent did not. Collagen content increased from thoracic to infrarenal segments in both cohorts, with non-Marfan patients exhibiting higher collagen percentages, notably in the infrarenal aorta (729.3 nm vs. 1068.3 nm, p = 0.02). Both groups predominantly displayed mature collagen fibers, with the suprarenal segment containing the highest proportion of less mature fibers. Electron microscopy revealed comparable collagen fibril diameters across segments irrespective of Marfan status. Our findings underscore non-uniform histological patterns in TAAAs and suggest that ECM remodeling involves mature collagen deposition, albeit with lower collagen content observed in the infrarenal aorta of Marfan patients. Full article

Non-A non-B aortic dissection remains a complex and controversial topic in cardiovascular management, eliciting varied approaches among cardiologists and surgeons. Due to the limited evidence surrounding this condition, existing guidelines are limited in the complexity of their recommendations. While most patients are initially managed medically, invasive treatment becomes necessary in a large proportion of patients. When surgery is considered, the most utilized techniques include the frozen elephant trunk procedure and endovascular repair strategies targeting the arch and descending thoracic aorta. This narrative review aims to synthesize current knowledge and clinical experiences, highlighting the challenges and evolving practices related to non-A non-B dissection management. Full article

Background: Stent-graft implantation is a widely recognized method for endovascular treatment of aortic aneurysms. In cases where the aneurysm involves the thoracic and abdominal aorta, repair including fenestrated and branched stent grafts provides a viable alternative. This approach, initially reserved for patients unsuitable for open surgery, has become preferred for anatomically appropriate thoracoabdominal aortic aneurysms. The Zenith t-Branch system has been extensively studied, demonstrating high technical success rates and acceptable mortality and morbidity. However, complications such as endoleaks, kinking, and stent-graft branch rupture remain significant challenges. Methods: We present the case of an 82-year-old male with a thoracoabdominal aortic aneurysm treated with endovascular aneurysm repair using the Zenith t-Branch. Four years post-implantation, he developed a spontaneous rupture of the stent-graft branch, leading to dangerous leakage and aneurysm sac enlargement. An urgent surgical intervention was performed, implanting additional Be-Graft into the damaged branch, restoring stent-graft continuity and revascularizing the superior mesenteric artery. Results: The procedure was completed successfully. We conducted a review of the latest literature on endovascular treatment of thoracoabdominal aortic aneurysms with particular emphasis on the possibility of repairing postoperative complications, especially endoleaks. Conclusions: While modern technologies have significantly improved outcomes, serious complications persist. Studies emphasize the importance of regular imaging follow-up for early complication detection and management. Continuous advancements in stent-graft technology aim to reduce complications further and improve outcomes. This case underscores the necessity of experienced operators in managing complex and rare complications and highlights the promising future of endovascular techniques in treating thoracoabdominal aortic aneurysms. Full article

Aortitis, defined as inflammation of the aorta, can lead to aneurysms and dissections. Intra-operative sampling is essential for diagnosis, with many cases presenting asymptomatically as clinically isolated aortitis. Previous studies investigating aortitis in major aortic surgery have been limited by low intra-operative sampling. We performed an 11-year, retrospective, cross-sectional study to investigate the true prevalence of aortitis in thoracic aortic aneurysms and dissections by analysing all major aortic operations performed in a single centre. We collected medical histories, histological reports, post-operative outcomes and follow-up data; 537 patients met the inclusion criteria, representing an 88% histological sampling rate. The prevalence of aortitis was 10.6% (n = 57), of which 75% were clinically isolated. The re-operation rate in aortitis was twice that of non-aortitis patients (17.5% vs. 9.4%, p = 0.054). Multivariate logistic regression identified increased age, female sex, current smoking, and other inflammatory diseases as significantly associated with aortitis, with a bicuspid aortic valve associated with a significantly decreased likelihood of aortitis. The true prevalence of aortitis is likely higher than reported in previous studies, with our study showing twice the prevalence found in previous studies with lower sampling rates. Due to the increased re-intervention in aortitis, specialist multi-disciplinary follow-up and aortitis centres should be formed. Full article

Background: The frozen elephant trunk method combines the implantation of a Dacron prosthesis with a self-expanding stent graft, which allows for complex repairs of the aortic arch and thoracic aorta in one procedure. Despite the advantages of hybrid treatment for aortic arch aneurysms, in Poland, only a few such surgeries are performed annually compared to in Western countries. The aim of this study was to demonstrate the 8-year outcomes of treatment at the center where the Aortic Team operates, which is one of the centers in Poland with the most extensive experience in hybrid FET treatment. Methods: Patients who underwent frozen elephant trunk surgery for chronic and acute pathologies of the aortic arch and thoracic aorta between March 2016 and March 2024 were comprehensively analyzed retrospectively. Frozen elephant trunk procedures were performed under three consecutive clinical conditions: acute aortic dissection, chronic aortic dissection and redo surgery. Results: A total of 40 patients (median age: 60 years (53–66), 67.5% male) were admitted to our hospital and underwent an FET procedure. The median Euroscore II was 25.9% and the 30-day mortality was 7.5%. The 1-year and 5-year mortalities were the same, equal to 15%, with mortality cases observed only in the first and second groups of consecutive patients during the first two months of follow-up. Spinal cord injury was observed in 2.5% of patients. Conclusions: The FET technique can be successfully used to treat aortic aneurysms with optimal results and low complication rates. The surgery length, including the cardiopulmonary bypass and aortic cross-clamp times, decreased significantly with increasing experience. Full article

The advent of endovascular aortic surgery has led to the rise of novel techniques and devices in treating pathologies of the aorta. While endovascular surgery has been well established in the descending thoracic and abdominal aorta, the endovascular treatment of the aortic arch represents a new and exciting territory for aortic surgeons. This article will discuss the different aortic diseases amenable to endovascular treatment, currently available aortic arch stent grafts and their limitations, and the future of endovascular aortic arch therapies. Full article

Background: There is a paucity of data concerning the feasibility and value of thoracic aortic stent graft implantation (TEVAR) applications for removing tumors infiltrating the aortic wall. This analysis aimed to demonstrate the feasibility of TEVAR and monitor the perioperative risks of morbidity and mortality. Additionally, a literature review was performed. Methods: A retrospective data analysis was performed on patients who received TEVAR prior to thoracic malignancy resection between January 2010 and April 2024. The primary endpoint was technical success. Results: A total of 15 patients (median age: 67 years; range: 23–75; 66.7% female) received TEVAR prior to thoracic surgery of different tumor entities. In 80% of cases (n = 12), the proximal landing zone was in aortic zone 3. In three cases, the supra-aortic debranching of LSA and/or LCCA via bypass implantation or in situ laser fenestration was necessary. No postoperative endograft-related complications were observed. In eight patients, aortic wall infiltration was confirmed intraoperatively. In total, R0 resection was achieved in seven patients (46.7%). The 30-day mortality rate was 6.7% (n = 1). Technical success was achieved in all patients (100%), while procedural success was achieved in 80% due to incomplete tumor resection in three patients. Conclusions: To the best of our knowledge, this is the largest analysis to date that confirms the results of previous smaller studies. Aortic stent grafting prior to thoracic tumor resection allows for extensive resection while maintaining low morbidity and a low 30-day mortality risk. Full article

The treatment of complex aortic pathologies requires specialized techniques and tailored approaches due to each patient’s unique anatomical and clinical challenges. The European Association for Cardiothoracic Surgery (EACTS) and the Society of Thoracic Surgeons (STS) new guidelines identify the aorta as the body’s 24th organ and reiterate that multidisciplinary aortic teams are recommended for shared decision-making to determine optimal treatment strategies. Patients treated for conditions such as aneurysms, dissections, intramural hematomas, or penetrating aortic ulcers may develop complex forms over time, necessitating careful follow-up and timely corrective actions. Endovascular solutions can be favorable for older patients with complex anatomies and multiple comorbidities. However, when endovascular treatment is not feasible, hybrid treatments or open surgery must be considered if the patient’s condition allows it. The risk–benefit ratio of each procedure must be carefully evaluated; choosing the best intervention or deciding not to intervene becomes a critical and challenging decision. At our Cardiac Surgery Center in Verona, a multidisciplinary team with over 20 years of experience in treating complex aortic arch pathologies extensively discussed different cases of complex aortic pathologies treated with endovascular, hybrid, or surgical approaches, emphasizing the importance of considering both anatomical and patient-specific characteristics. The decisions and treatments were often challenging, and unanimity was not always achieved, reflecting the complexity of finding the best solutions. Full article

Lymphocele formation is a rare complication after surgical procedures involving the mediastinum. While uncomplicated lymphoceles show high rates of spontaneous closure and are usually treated conservatively, surgical treatment might be required in cases with persistent or recurrent lymphoceles. We present the case of a 53-year-old male with reoccurring cervical swelling after two surgeries of the thoracic aorta. After 1.5 years, the swelling occurred for the first time and appeared for the next 2 years repeatedly without clinical or laboratory signs of infection. A cervical lymphocele was suspected, and the decision for surgical revision was made. Fibrin glue was applied to the potential leakage of the thoracic duct, and the cavity was filled with a free omental flap. This resulted in a complete regression of the swelling. Full article