Objective: The undisputed gold standard of treatment for type A aortic dissections (TAAD) is open surgery. Anecdotal reports have assessed thoracic endovascular aortic repair (TEVAR) as a last resort for highly selected candidates. The present study aims to evaluate endovascular outcomes in TAAD patients who are unsuitable for open surgery whilst having TEVAR-compatible aortic anatomy. Methods: A PRISMA-compliant systematic search of the PubMed, Scopus, and Cochrane databases was performed up to 19 May 2022. Time-to-event data were reconstructed using Kaplan–Meier curves from the source literature. Results: In 20 eligible studies, 311 patients underwent TEVAR for acute, subacute, or chronic TAAD. Mean age at the time of the operation was 60.70 ± 8.00 years and 75.48% (95% Confidence Interval [CI], 60.33–88.46%) of the included patients were males. Mean operative time was 169.40 ± 30.70 min. Overall, 0.44% (95% CI, 0.00–4.83%) of the cases were converted to salvage open surgery. Technical failure, stroke, and endoleaks occurred in 0.22%, 0.1%, and 8.52% of the cohort, respectively. Thirty-day postoperative complication rate was 7.08% (95% CI, 1.52–14.97%), whereas late complications developed in 16.89% (95% CI, 7.75–27.88%) of the patients. One-, three-, and five-year survival rates were estimated at 87.15%, 82.52% and 82.31%, respectively. Reintervention was required in 8.38% of the cohort over a mean follow-up of 32.40 ± 24.40 months. Conclusions: TEVAR seems to be feasible in highly selected patients with TAAD who cannot tolerate open surgery. Overcoming technical limitations and acquiring long-term data are warranted to safely define the place of endovascular treatment in the armamentarium of TAAD repair.

VA ECMO has emerged as an effective rescue therapy in patients with cardiogenic shock refractory to standard treatment protocols and its use is rising worldwide in the last decade. Although experience and availability are growing, outcomes remain poor. There is need for evidence to ameliorate clinical practice and improve outcomes. We retrospectively reviewed the medical records of all patients who were supported with VA ECMO for cardiogenic shock at our institution between January 2015 and January 2023. The study purpose was to compare outcomes between patients who were supported with central versus peripheral configuration. ECMO was applied in 108 patients of whom central configuration in 48 (44%) and peripheral in 60 (56%). Patients supported with central VA ECMO were more likely to be supported for post cardiotomy shock [OR 4.6 (CI 95% 2.03 - 10.41)], while patients in the peripheral group for chronic heart failure decompensation [OR 9.4 (CI 95% 1.16 - 76.3]. Central VA ECMO had worse survival during ECMO support (29.2% vs 51.7%, p=0.018) and at discharge (8% vs 37%, p=0.001). These patients were at high risk of complications, such as acute kidney injury (AKI), [OR 2.37 (CI 95% 1.06 - 5.3), p = 0.034] and major bleeding [OR 3.08 (CI 95% 1.36 - 6.94), p<0.001]. Patients on central VA ECMO were supported mainly for post cardiotomy shock, presented with more complications such as major bleeding and AKI and had worse survival to hospital discharge, compared with patients on peripheral VA ECMO. Patient selection, timing of implementation, cannulation strategy and configuration remain main determinants of clinical outcome.

Acute kidney injury is a common complication following cardiac surgery (CSA-AKI). Serum creatinine levels require a minimum of 24–48 h to indicate renal injury. Nevertheless, early diagnosis remains critical for improving patient outcomes. A PRISMA-compliant systematic review of the PubMed and CENTRAL databases was performed to assess the role of Klotho as a predictive biomarker for CSA-AKI (end-of-search date: 17 February 2024). An evidence quality assessment of the four included studies was performed with the Newcastle–Ottawa scale. Among the 234 patients studied, 119 (50.8%) developed CSA-AKI postoperatively. Serum Klotho levels above 120 U/L immediately postoperatively correlated with an area under the curve (AUC) of 0.806 and 90% sensitivity. Additionally, a postoperative serum creatinine to Klotho ratio above 0.695 showed 94.7% sensitivity and 87.5% specificity, with an AUC of 92.4%, maintaining its prognostic validity for up to three days. Urinary Klotho immunoreactivity was better maintained in samples obtained via direct catheterization rather than indwelling catheter collection bags. Storage at −80 °C was necessary for delayed testing. Optimal timing for both serum and urine Klotho measurements was from the end of cardiopulmonary bypass to the time of the first ICU lab tests. In conclusion, Klotho could be a promising biomarker for the early diagnosis of CSA-AKI. Standardization of measurement protocols and larger studies are needed to validate these findings.

Surgical aortic valve replacement has been the mainstay of treatment against severe aortic insufficiency despite the high incidence of prosthesis-related complications and better long-term outcomes following aortic valve repair. Annuloplasty and leaflet reconstruction are the integral parts of the procedure. Safety and efficacy of HAART internal annuloplasty ring are hereby investigated through mid-term outcomes of a single referral center. Forty-three consecutive patients with either trileaflet or bicuspid aortic insufficiency along with ascending aorta and/or aortic root enlargement were included. Annular stabilization via the internal ring implantation was attempted, whereas leaflet repair was performed whenever required. Maximum follow-up was 6.3 years, whereas the mean was 2.7 years. Mean age was 54.2 years. At least moderate aortic insufficiency was noted in 69.8% (30/43) of patients, whereas 93% (40/43) of them had an ascending aorta or aortic root over 45 mm. Overall mortality was 2.3% (1/43). No more than mild aortic insufficiency was detected early postoperatively. At the last follow-up, there were 2 cases of ring-related adverse events who were reoperated for aortic valve replacement (4.7%). Mid-term outcomes revealed no more than mild aortic insufficiency, while aortic diameter was less than 50 mm in the vast majority of the patients. New York Heart Association class was also significantly lower compared to preoperatively, although moderate aortic stenosis was present in 16% of our cohort. Geometric ring annuloplasty is an easily reproducible valve-sparing approach. Midterm results, revealing 2.3% mortality and 95.3% freedom from reoperation, are promising, but long-term outcomes are yet to be discovered.