OBJECTIVES: Conventional treatment for acute type A dissection is the replacement of the ascending aorta. This study demonstrates the results of a conventional approach with isolated proximal repair combined with concomitant endovascular procedures. METHODS: Replacement of the ascending aorta with or without an open distal anastomosis was defined as isolated proximal repair and was performed in 562/588 patients between January 2004 and June 2017. A total of 68% were DeBakey type I and 32% were DeBakey type II aortic dissections. Concomitant procedures were thoracic endovascular aortic repair (3.6%); visceral, renal and iliac stents (2%); and peripheral bypasses (1.1%). Mean follow-up was 4.6 +/- 3.5 years with a 98% follow-up rate. Early and long-term survival, reintervention rates and risk factors were analysed. RESULTS: Overall, the in-hospital mortality rate was 10.7%, 5.6% in DeBakey type II and 13% in DeBakey type I aortic dissection (P = 0.008). Risk factors for in-hospital mortality were age [odds ratio (OR) 1.03], chronic obstructive lung disease (OR 3.98), coronary disease (OR 2.19), Penn class BC (OR 15.41) and cardiopulmonary bypass time (OR 1.01). The 5- and 10-year survival rates, including inhospital mortality, were 71% and 54% for type I and 73% and 65% for type II aortic dissection, respectively (P= 0.14). Freedom from reintervention after 5 and 10 years was 96% and 94% for DeBakey type II aortic dissection and 86% and 78% for type I (P < 0.001). CONCLUSIONS: Combined with concomitant endovascular procedures, good short- and long-term results can be achieved in DeBakey type I and II aortic dissection. The reintervention rate is higher in DeBakey type I but can be managed open and endovascularly with good results.

OBJECTIVES: The goal of this project was to assess the efficacy of a reoperative frozen elephant trunk (FET) operation for treating residual type A aortic dissections. METHODS: Between April 2015 and October 2023, a total of 237 patients underwent elective redo surgical aortic arch replacement via the FET technique to treat residual type A aortic dissection in 11 European aortic centres. Data were pooled and analysed retrospectively. RESULTS: The time between an acute type A dissection repair to an FET implant was 5 years. More than half of all patients (54%) presented with an entry within the aortic arch, and 174 patients (73%) presented residual dissections of supra-aortic vessels. During FET repair, the axillary artery was cannulated in 181 patients (76%), whereas 83 patients (35%) underwent additional cardiac procedures including 39 root replacements (16%) and 15 coronary bypass procedures (6%). Zone 2 was the most common arch anastomosis site (n = 163, 69%), and bilateral antegrade cerebral perfusion was most frequent (n = 159, 67%). Fifteen patients (6%) died in-hospital. Age in years (P < 0.001, odds ratio: 1.069) proved to be predictive for overall mortality in our Cox regression model. CONCLUSIONS: Elective redo surgical aortic arch replacement using the FET technique for treating residual type A aortic dissection following ascending aortic replacement revealed a favourable outcome. The decision to undertake stage two therapy of a residually dissected aortic arch should be made by an aortic team on a patient-by-patient basis.

The study aimed to review a multicenter experience of patients undergoing surgical intervention for infective endocarditis caused by Cutibacterium acnes and to analyze the diagnostic challenges and operative results. We retrospectively reviewed 8812 patients undergoing cardiac surgery for endocarditis at 12 cardiac surgical departments across Germany. The overall population was divided based on the type of endocarditis (ie, native and prosthetic valve endocarditis). Primary outcomes were in-hospital mortality, 1- and 5-year survival. C. acnes caused endocarditis in 269 patients (3.1%). Median age was 65 years (54-72 years) and 237(88.1%) were male. We observed significantly higher rates of native valve endocarditis in patients aged 21-40, whereas prosthetic valve endocarditis was more frequent in all other age groups (p < 0.001). The median EuroSCORE II of the cohort was 10.7 (5.0-29.6), with it being significantly higher in the prosthetic valve endocarditis group (p < 0.001). Blood culture negative infective endocarditis was initially reported in 54.3% of the patients. The in-hospital mortality was comparable between the groups (p = 0.340). Survival at one and five years was significantly higher in the native valve endocarditis group (p < 0.001). Cutibacterium acnes causes native valve endocarditis especially in younger patients. The incidence of endocarditis caused by C. acnes is alarming and is at par with well-known endocarditis pathogens such as the HACEK group. The pathogen has a low virulence and presents with a rather indolent course. The diagnosis of C. acnes endocarditis is challenging and requires a multimodal specialized approach. Surgical treatment is associated with acceptable outcomes.

In acute type A dissection, the coagulation system is impaired by the dissection and its complications as well as the use of the heart-lung machine with hypothermia. Because of the critical importance of effective haemostasis at the end of the operation, the use of coagulation products and blood transfusions is usually unavoidable. This retrospective study aims to analyse the use of blood products and coagulation factors in the context of acute aortic dissections, and the factors influencing their use. Between 2017 and 2022, 369 patients were operated on for acute type A dissection. Clinical details, including the status at presentation and perioperatively administered transfusions and coagulation factors were obtained, and patients were stratified according to the Penn classification. A multivariable linear regression analysis for transfusions and coagulation factors was conducted, including typical risk factors. The use of perioperatively required transfusions and coagulation factor (prothrombin complex concentrate and fibrinogen) substitution increased significantly with a higher ischaemic burden, including both localized and generalized malperfusion (Penn A<B<C<BC; P≤0.017). Multivariable linear regression analysis revealed that, besides generalized ischaemia, duration of cardiopulmonary bypass, extent of surgery and patient size were other significant factors. Surgical repair for acute type A dissection remains major surgery, requiring transfusions and coagulation factors in almost all patients. The ischaemic burden was identified as the most important factor that necessitates the use of these products, and was associated with early death. With proper management, acceptable rethoracotomy and chest drain rates with good clinical outcomes can be achieved.

Direct true lumen cannulation (DTLC) of the aorta is an alternative cardiopulmonary bypass cannulation technique in the context of type A acute aortic dissection (A-AAD). DTLC has been reported to be effective in restoring adequate perfusion to jeopardized organs. This study reports and compares operative outcomes with DTLC or alternative cannulation techniques in a large cohort of patients with A-AAD. All patients who underwent surgery for A-AAD between January 2006 and January 2017 in Mainz university hospital were reviewed. The choice of cannulation technique was left to the operating surgeon, however DTLC was our preference in patients who were in state of shock or showed signs of tamponade or hypoperfusion, in cases of potential cerebral malperfusion, as well as in patients who were under resuscitation. A total of 528 patients (63% males, mean age 64±13.8 years) underwent emergency surgery for A-AAD. The DTLC technique was used in 52.4% of patients. The DTLC group of patients had worse clinical status at the time of presentation with more shock, tamponade, true lumen collapse, cerebral and other malperfusion states. New neurologic events were diagnosed in around 8% of patients in each group following surgery, but there was a trend for quicker neurological recovery in the DTLC-group. Early mortality rates, short-term and long-term survival rates did not differ between the two groups. DTLC is a safe cannulation technique that enables effective antegrade true lumen perfusion in complicated A-AAD scenarios, and is an advantageous addition to the aortic surgeons’ armamentarium.

OBJECTIVES: The island technique for reimplantation of supra-aortic vessels in frozen elephant surgery is commonly used but might be questioned for dissected vessels. This study analyses the remodelling of reimplanted supra-aortic vessels after FET in acute and chronic aortic dissection (CAD).METHODS: Between June 2017 and April 2021, 133 patients were operated for acute and CAD using the frozen elephant technique. The island technique for reimplantation of the supra-aortic vessels was used in 94/133 patients. In 68 acute and 21 chronic patients, the total vessel lumen (VL), true lumen, false lumen (FL) and perfused FL area were measured in the innominate, right common carotid and left common carotid artery. Relative luminal changes were compared.RESULTS: In acute aortic dissection, 80% innominate, 40% right carotid and 59% left carotid arteries were dissected preoperatively, but postoperatively FL was only patent in 29%, 12% and 10% (P < 0.001). FL disappearance resulted in >20% total VL reduction in innominate, right carotid and left carotid artery (P < 0.01). In CAD, only 38% innominate, 14% right carotid and 43% left carotid arteries were dissected preoperatively, but postoperatively FL was patent in 19% (ns), 10% (ns) and 5% (P = 0.009).CONCLUSION: Vascular remodelling is frequently found after the island technique. In acute aortic dissection, the island technique frequently initiates FL disappearance associated with VL decrease. Continuously dissected head vessels show positive remodelling with true lumen increase without VL increase. FL disappearance is frequently found in CAD.