Transit time flow measurement (TTFM) is a quality control tool for intraoperative graft evaluation in coronary artery bypass graft (CABG) surgery. A critical review of the literature available using TTFM in CABG surgery is the focus of this article. The main objectives will be to detail precise parameters for flow evaluation, to show limitations of TTFM and to prove its predictive impact on postoperative graft failure rate. Publications listed in the PubMed database were reviewed, searching for intraoperative graft verification in coronary surgery by TTFM, with postoperative imaging follow-up (FU) modality and with a special focus on publications released after European guidelines from 2010. Nine included publications revealed an overall graft failure rate of ∼12%. Mean graft flow had a positive predictive value in the largest study, and cut-offs, of at least 20 ml/min for internal mammary artery (IMA) grafts, therein partially confirming guidelines, and 30–40 ml/min for saphenous venous grafts (SVGs) were proposed. An explicit correlation between graft flow, patency rate and severity of coronary stenosis, by indicating the fractional flow reserve, was found for IMA grafts. Increased pulsatility index and increased systolic reverse flow probably predict worse outcome and may help identifying competitive flow. Diastolic filling, rarely indicated, could not be confirmed as the predictive marker. No significant correlation of TTFM and graft failure rate for radial and other arterial grafts could be found, partially due to the small number of these types of grafts analysed. Larger target vessels and lower postoperative CK-MB levels may predict better graft patency rates. Low sensitivity for TTFM to reliably detect graft failure is certainly a major issue, as found in randomized analyses. However, methodical limitations and varying threshold values for TTFM render a general consensus difficult. Influence of quantity (vessel territory distribution) and quality (myocardial scar) of the graft perfusion area, on TTFM and FU outcome, was not included by anyone and should be part of future research. TTFM is probably not the tool of choice to detect progressive late graft failure of SVG. Peroperative TTFM values should be correlated with one type of conduit, differentiating between early and late graft failure (by applying a uniform, appropriated definition), to precise and confirm threshold values.

Current guidelines recommend prophylactic replacement of the ascending aorta at an aneurysmal diameter of >55 mm to prevent acute Type A aortic dissection (TAAD) in non-Marfan patients. Several publications have challenged this threshold, suggesting that surgery should be performed in smaller aneurysms to prevent this devastating disease. We reviewed our experience with measuring aortic size at the time of TAAD to validate the existing recommendation for prophylactic ascending aorta replacement. All patients who had been admitted for TAAD to our emergency department from 2014 to 2019 and underwent ascending aorta replacement were included. Marfan patients were excluded. The maximum diameter of the dissected aorta was measured preoperatively using CT scan. We estimated the aortic diameter at the time of dissection to be 7 mm smaller than the measured maximum diameter of the dissected aorta (modelled pre-dissection diameter). Overall, 102 patients were included. Of these, 67 were male (65.6%) and 35 were female (34.4%), and the cohort’s mean age was 65 ± 12.1 years. In addition, 66% were treated for arterial hypertension. The mean maximum modelled pre-dissection diameter was 39.6 ± 4.8 mm: 39.1 ± 5.1 mm in men and 40.7 ± 2.8 mm in women (P = 0.1). The cumulative 30-day mortality rate was 19.6% (20/102). TAAD occurred at a modelled aortic diameter below 45 mm in 87.7% of our patients. Therefore, the current aortic diameter threshold of 55 mm excludes ∼99% of patients with TAAD from prophylactic replacement of the ascending aorta. The maximum diameter of the ascending aorta warrants reappraisal and this parameter should be a distinct part of a personalized decision-making process that also takes into account age, gender and body surface area to establish the surgical indication for preventive aorta replacement aimed to improve the survival benefit of this procedure.

Guidelines proposed bioprosthesis implantation for aortic valve disease if the patients were at least 65 years old at the time of surgery, with a trend towards even younger patients in recent years. Considering the adverse effects of lifetime anticoagulation, new biological valves (less prone to degeneration) and new technologies may lead patients and surgeons to different choices. Therefore, it is interesting to analyse the results of aortic bioprosthetic valve replacement in patients aged <65 years at the time of surgery. From January 2000 to December 2010, 84 patients aged <65 years at the time of surgery had undergone an aortic bio-prosthetic valve replacement. A mid-term follow-up [(FU) mean FU time: 54.4 ± 39.2 months] was done in August 2011 in all patients (FU completeness: 100%). Results were compared with patients who had a mechanical prosthetic aortic valve replacement during the same period. The reoperation rate for structural valve degeneration (SVD) of bioprostheses was 6% and occurred exclusively among patients <56 years. Contraindications for anticoagulation determined the choice of a bioprosthesis among 83% of these patients. The personal preference to avoid anticoagulation was the leading cause in 68% of the older patients (56–65 years). Neurological complications occurred more frequently in the mechanical control group. Reoperations for SVD after bioprosthesis implantation occurred exclusively among younger patients (<56 years), not suitable for systemic anticoagulation. Previous studies, together with our experience, are in favour of an age limit between 56 and 60 years, taking into consideration alternative transcatheter approaches to SVD treatment.

The Inspiris Resilia aortic valve® (INSPIRIS) is a pericardial bio-prosthesis with a new sterilization procedure that shows promising results in terms of reduced calcification. The 30-day mortality and morbidity were analyzed, comparing the INSPIRIS implanted between May 2017 and the end of January 2019, with its "predecessor", the Carpentier-Edwards Perimound Magna Ease (ME). Echocardiography was performed one-week after surgery. 125 consecutively operated patients were included (59 INSPIRIS, 66 ME). One patient in the ME group died and one patient in the INSPIRIS group had a complicated postoperative course due to right heart failure. Two patients (one INSPIRIS, one ME patient) suffered a perioperative stroke. The hemodynamic evaluation shows an effective reduction of mean transvalvular pressure gradients after surgery in both groups. INSPIRIS tended to have lower trans-prosthetic pressure gradients (9 mm Hg, Interquartile range [IQR] 11-7 mm Hg versus 12 mm Hg, IQR 15-9 mm Hg; P=0.001), reduced trans-prosthetic blood flow acceleration (209 cm/s, IQR 220-190 cm/s versus 227 cm/s, IQR 263-191 cm/s; P=0.003) and increased permeability indices (57%, IQR 67%-47% versus 42%, IQR 48%-38%; P<0.001). There are only few clinical data available from INSPIRIS, and the present analysis confirms good results initial postoperatively with a tendency towards possibly improved hemodynamics compared to ME.

Objective: Ascending aortic dissection still remains a poorly understood dramatic disease with unpredictable results for the patient in spite of all

Right ventricular (RV) rupture in cases of mediastinitis following cardiac surgery is a rare and dangerous complication. Bleeding from the right vent