OBJECTIVES: The aim of this study was to evaluate early- and long-term outcomes of cryopreserved aortic homograft (CAH) implantation for aortic valve replacement (AVR) or aortic root replacement (ARR) in patients with or without complex infective endocarditis. METHODS: All adult patients undergoing AVR or ARR with CAH at our institution between January 1993 and July 2021 were included in the study. RESULTS: One hundred four patients, 75 males and 29 females, aged 59 ± 17 years, underwent AVR or ARR with CAH for infective endocarditis (n = 94, 90%) or aortic valve disease (n = 10, 10%). There were 33 (35%) native valve endocarditis and 61 (65%) prosthetic valve endocarditis, which were complicated by annular abscess in 77 (82%) patients, mitral valve endocarditis in 13 (14%) and tricuspid valve endocarditis in 13 (14%). The mean cardiopulmonary bypass time was 214 ± 80 min and the mean aortic cross-clamping time was 164 ± 56 min. There were 12 (12%) hospital deaths and 7 (7%) postoperative low cardiac output syndrome requiring extracorporeal membrane oxygenation in 4 patients and intra-aortic balloon pump in 3. Thirty-nine (42%) patients died during the follow-up (94% complete). The mean survival time was 13.9 ± 1.2 years. Twenty-five patients (26%) underwent late reoperation for aortic homograft degeneration (n = 17, 18%), homograft endocarditis (n = 6, 7%), homograft dehiscence (n = 1, 1%) and mitral valve regurgitation (n = 1, 1%). The mean survival free from reintervention was 15.7 ± 1.2 years. CONCLUSIONS: AVR or ARR with a CAH for complex endocarditis is associated with satisfactory hospital survival, considering the critical patient presentation at surgery, and excellent survival free from recurrent infection. Need for reoperation late after surgery is similar to other biological prostheses.

As spontaneous ascending aortic thrombi (AATs) are uncommon in modern clinical practice, despite the application of new technology and the widespread use of contrast-enhanced computer tomography during primary assessments in patients without underlying predisposing conditions, a thrombus floating in the ascending aorta is rarely discovered in a timely manner; moreover, the ascending tract represents an unusual site for thrombus formation. The clinical presentation of AATs is also often in the form of peripheral arterial embolization, which can cause a wide variety of symptoms, from stroke to limb ischemia, and thus delay correct diagnosis. Medical management is a risky strategy, while surgical treatment is usually challenging due to the risk of thrombus dislodgement and difficulties related to prior embolization complication management. In this study, faced with a peculiar case of embolic stroke in an otherwise healthy 71-year-old woman, we analyzed the status of knowledge on spontaneous ascending aortic thrombus treatments and outcomes. A multidisciplinary approach represents the best choice for defining a patient’s timing of surgery and ensuring the management of complications. Sequential multistage treatment minimizes further complications and prevents worsening patient outcomes, leading to the best management for every possible clinical presentation. A less invasive surgical approach could lead to complete resolution of the pathology, avoiding further potentially lethal complications, facilitating postoperative management, avoiding delayed treatments, and resulting in better outcomes.

OBJECTIVES: Hyperkalaemic depolarized myocardial arrest is the cornerstone of myocardial protection, although some potassium-related cytotoxicity has been demonstrated. Polarized arrest has gained interest because of a reported better myocardial protection in preclinical studies. The goal of this study was to analyse the quality of myocardial protection and hospital outcome after normokalaemic adenosine–lidocaine–magnesium (ALM) blood polarizing cardioplegia, compared to hyperkalaemic blood Buckberg depolarizing cardioplegia, in elective routine adult cardiac surgery. METHODS: One thousand consecutive elective adult cardiac patients [627 undergoing ALM-polarizing cardioplegia (ALM-POL) vs 373 Buckberg depolarized cardioplegia (BUCK-DEPOL)] who were operated on were analysed. Perioperative leakage of high-sensitivity troponin I (Hs-TnI), peripheral lactate, inotropic and vasoactive daily requirement [maximal vasoactive inotropic score (VISMAX)], hospital mortality and morbidity were collected and compared in the overall population and in the propensity score (PS) matched population (206 pairs). RESULTS: A significantly lower leakage of Hs-TnI during hospitalization was detected in patients receiving ALM-POL versus those receiving BUCK-DEPOL (group time P < 0.001 for overall population and PS matched pairs). The maximum value of postoperative Hs-TnI was also lower after ALM-POL (P < 0.001 in both cohorts), and spontaneous recovery of sinus rhythm at aortic declamping was higher (P < 0.001 in favour of ALM-POL). Maximal VISMAX during hospitalization was significantly higher after BUCK-DEPOL in both cohorts (P = 0.019 for overall population; P = 0.031 for PS matched population), with significantly higher VISMAX on the day of surgery in BUCK-DEPOL PS matched patients (P = 0.042). No other significant differences in hospital morbidity and mortality were found. CONCLUSIONS: Despite comparable short-term clinical outcomes, ALM-POL cardioplegia proved superior in terms of quality of myocardial protection compared to BUCK-DEPOL cardioplegia in elective routine adult cardiac surgery.

Background/Objectives: The Bentall procedure represents the gold standard therapy in patients with ascending aorta or aortic root aneurysm combined with aortic valve disease precluding a valve-sparing procedure. The aim of this study was to compare early and late outcomes in patients undergoing a Bentall procedure with either a biological or a mechanical valved conduit. Methods: All patients undergoing the Bentall procedure with either a biological or a mechanical valved conduit at our institution between 2001 and 2022 were retrospectively reviewed. A propensity-score (PS) matching analysis was performed to account for imbalances between the two groups. Clinical outcomes of interest included mortality and reintervention. Results: 548 patients underwent the Bentall procedure with a biological (n = 356, 65%) or a mechanical (n = 192, 35%) valved conduit during the study period. After PS-matching, two homogeneous groups of 154 patients were obtained, and no difference was observed in mean survival time between patients with mechanical Bentall and patients with biological Bentall (16 ± 0.8 vs. 16.3 ± 0.7 years, respectively; p = 0.72). Patients with a mechanical Bentall had a significantly higher mean survival time free from reintervention compared to patients with a biological Bentall (23.6 ± 0.4 vs. 21.4 ± 0.7 years, respectively, p = 0.02). PS-adjusted Cox regression showed that age >65 years, postoperative ECMO, and CVA were predictive risk factors of mortality. Conclusions: Bentall operation is a safe procedure for the treatment of ascending aorta and aortic root disease with good early and long-term survival and a low rate of reintervention. PS-matched analysis showed no difference in mortality between patients with a mechanical Bentall and patients with a biological Bentall; however, patients with a mechanical Bentall had a lower rate of reintervention.