Baroreflex regulates blood pressure and heartbeat through specific mechanosensitive baroreceptors. However, the current knowledge is derived only from animal experiments. No data about human aortic baroreceptors have been reported so far. Therefore, in this study, we performed extended histological, proteomics and transcriptomics analyses of the aortic arch to identify potential human baroreceptors. Three healthy human aortic arches from autopsies, six abdominal aortic aneurysms and four control abdominal aortic tissue samples from our vascular biobank were analysed. For histological analyses, antibodies against various neuronal markers were used. Laser capture microdissection and macrodissection were performed to selectively analyse nerves in the adventitia of the human aorta using proteomics and RNA sequencing. Histological analysis revealed a heterogeneous distribution of nerves in the adventitia along the entire aortic arch, predominantly in the ascending aorta up to the left subclavian artery. Proteome analysis identified three putative human baroreceptors PIEZO1, TRPV2, and TRPM4. Transcriptomics confirmed that these ion channels do not originate from cells within the aortic wall but presumably from the cell body of the vagus nerve. Interestingly, these ion channels were also detected in the healthy abdominal aorta and abdominal aneurysm without any significant differences in their abundance. Our study identified, for the first time, putative baroreceptors in the human aortic arch. Further studies are necessary to validate our current results and elucidate the role of these putative baroreceptors in the human aortic arch.

Leakage of bone cement is a known complication after percutaneous kyphoplasty. In rare cases, bone cement can reach the venous system and cause life-threatening embolism. We present the case of a 73-year-old male, who was admitted to our hospital with new-onset chest pain and dyspnoea. He had a history of percutaneous kyphoplasty. Multimodal imaging showed intracardiac cement embolism in the right ventricle with penetration of the interventricular septum and perforation of the apex. The bone cement was successfully removed during open cardiac surgery.

We report an unusual case of multiple penetrating cerebral, cardiac and abdominal injuries following a suicidal attempt using a nail gun. Successful treatment required several emergency procedures and resulted from a wise interdisciplinary management and timing of surgery.

BACKGROUND AND AIMS Large-bore catheter aspiration embolectomy reduces thrombus burden and right ventricle strain, and improves hemodynamics after pulmonary embolism (PE). Sparse data is available for patients with high-risk PE and contraindications to thrombolysis or thrombolysis failure, particulary if veno-arterial extracorporal membrane oxygenation (VA-ECMO) is required. METHODS All patients with acute high-risk PE and contraindications to thrombolysis undergoing FlowTriever® percutaneuous embolectomy and VA-ECMO circulatory support (or standby) at the University Hospital Zurich between April 2021 and August 2022 were retrospectively analyzed. The primary outcome was the combination of recurrent PE, heart failure hospitalization, and all-cause death at 30 days. RESULTS The analysis included 15 patients: mean age was 63.1 years and 14 (93%) were men. Overall, 4 (27%) patients presented with cardiac arrest, 8 (53%) with ongoing obstructive shock, and 3 (20%) with persistent arterial hypotension. VA-ECMO was implanted prior to aspiration embolectomy in 8 (53%) patients. Three of 7 patients without initial VA-ECMO support experienced periprocedural cardiac arrest, of whom 2 received ECMO support before completion of embolectomy. VA-ECMO weaning was successful in all patients after a mean of 5.4 days. There was one periprocedural death in a patient who did not receive VA-ECMO support following a periprocedural cardiac arrest. The primary outcome at 30 days occurred in 5 (33.3%; 95%CI 13.0-61.3%) patients. CONCLUSIONS This study provides preliminary evidence for the feasibility of percutaneous large-bore aspiration embolectomy in combination with VA-ECMO support (or standby) in patients with high-risk PE and contraindications to thrombolysis.

Central MessageCerebral perfusion during repair of acute aortic dissection is a controversial topic: attention should not only be drawn to cerebral protection but also to the manipulation of supra-aortic vessels. Cerebral perfusion during repair of acute aortic dissection is a controversial topic: attention should not only be drawn to cerebral protection but also to the manipulation of supra-aortic vessels. Since the introduction of cerebral perfusion as a brain-protection method during the surgical repair of the aortic arch, a significant number of papers have analyzed which type of perfusion may provide the most optimal cerebral protection:•antegrade cerebral perfusion (ACP) via the supra-aortic branches or retrograde cerebral perfusion via the superior vena cava;•unilateral ACP performed through the subclavian artery cannula of the cardiopulmonary bypass circuit; or•bilateral ACP with 2 selective perfusion catheters introduced in the innominate artery (respectively advanced into the right common carotid artery) and the left common carotid artery. This topic is still a matter of debate, and highly contradictory opinions are reported in the literature. Although some surgeons defend unilateral ACP as the simplest and most efficient method of cerebral protection, other prefer to "mimic" the normal physiology and use bilateral ACP with 2 catheters combined or not to the occlusion of the left subclavian artery.1Angleitner P. Stelzmueller M.E. Mahr S. Kaider A. Laufer G. Ehrlich M. Bilateral or unilateral antegrade cerebral perfusion during surgery for acute type A dissection.J Thorac Cardiovasc Surg. 2020; 159: 2159-2167Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 2Piperata A. Watanabe M. Pernot M. Metras A. Kalscheuer G. Avesan M. et al.Unilateral versus bilateral cerebral perfusion during aortic surgery for acute type A aortic dissection: a multicentre study.Eur J Cardiothorac Surg. 2022; 61: 828-835Crossref PubMed Scopus (5) Google Scholar, 3Angeloni E. Melina G. Refice S.K. Roscitano A. Capuano F. Comito C. et al.Unilateral versus bilateral antegrade cerebral protection during aortic surgery: an updated meta-analysis.Ann Thorac Surg. 2015; 99: 2024-2031Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 4Spielvogel D. Kai M. Tang G.H. Malekan R. Lansman S.L. Selective cerebral perfusion: a review of the evidence.J Thorac Cardiovasc Surg. 2013; 145: S59-S62Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 5Bachet J. I have only 1 brain but 2 hemispheres: please perfuse both adequately!.J Thorac Cardiovasc Surg. 2017; 154: 765-766Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 6Takayama H. Borger M.A. Bilateral antegrade cerebral perfusion during aortic dissection surgery: if no harm, then why not?.J Thorac Cardiovasc Surg. 2017; 154: 776-777Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Other groups still favor retrograde cerebral perfusion and/or demonstrated that the latter method may be associated with fewer radiographic neurologic injuries than ACP or no significant clinical difference.7Leshnower B.G. Rangaraju S. Allen J.W. Stringer A.Y. Gleason T.G. Chen E.P. Deep hypothermia with retrograde cerebral perfusion versus moderate hypothermia with antegrade cerebral perfusion for arch surgery.Ann Thorac Surg. 2019; 107: 1104-1110Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar,8Okita Y. Miyata H. Motomura N. Takamoto S. A study of brain protection during total arch replacement comparing antegrade cerebral perfusion versus hypothermic circulatory arrest with or without retrograde cerebral perfusion: analysis based on the Japan Adult Cardiovascular Surgery database.J Thorac Cardiovasc Surg. 2015; 149: S65-S73Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar In this short paper, we would like to focus on cerebral protection during repair of acute type A aortic dissection because the handling of the supra-aortic branches (clamping, snaring, occlusion with balloons) in the setting of a weakened arterial wall may cause injuries that need particular attention. Furthermore, we report on some clinical observations made following clamping of the innominate artery. In a recent paper from Vienna, 184 patients received aortic repair because of acute type A aortic dissection using bilateral (n = 91) and unilateral (n = 93) ACP. Overall, clinical outcomes were similar.1Angleitner P. Stelzmueller M.E. Mahr S. Kaider A. Laufer G. Ehrlich M. Bilateral or unilateral antegrade cerebral perfusion during surgery for acute type A dissection.J Thorac Cardiovasc Surg. 2020; 159: 2159-2167Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar However, subgroup analyses suggested that bilateral ACP was associated with superior survival in patients requiring a duration of circulatory arrest of 50 minutes or longer. The decision to proceed with unilateral or bilateral ACP depended on the surgeon's preference and experience, as well as the estimation of the required duration of circulatory arrest. Before starting unilateral ACP, the surgeons at Vienna University Hospital clamped all 3 vessels (Figure 1). During ACP, oxygen saturation was monitored bilaterally using near-infrared spectroscopy. If the latter decreased by 15% to 20% during unilateral perfusion, the left common carotid artery was also cannulated and cerebral protection switched to bilateral ACP. In this series, the rate of bilateral cerebral lesions and unilateral left-sided lesions was greater in patients receiving unilateral ACP, whereas the rate of unilateral right-sided lesions was greater in patients receiving bilateral ACP. From these findings, the authors concluded that the insertion of an additional perfusion cannula into the left common carotid artery does not increase the risk of left-sided cerebral lesions. In contrast to this publication, Piperata and colleagues2Piperata A. Watanabe M. Pernot M. Metras A. Kalscheuer G. Avesan M. et al.Unilateral versus bilateral cerebral perfusion during aortic surgery for acute type A aortic dissection: a multicentre study.Eur J Cardiothorac Surg. 2022; 61: 828-835Crossref PubMed Scopus (5) Google Scholar published recently the results of a retrospective, multicenter study that compared unilateral (39% of the patients) versus bilateral (61%) ACP during the repair of acute type A aortic dissection. In this study, the flow for ACP was accomplished through the right subclavian artery arterial line from the main pump of the cardiopulmonary bypass circuit (1/3) and through a separate pump for the left carotid and left subclavian arteries (2/3). The relative blood flow through these 2 separated perfusion lines was regulated according to the observed near-infrared spectroscopy values, bilateral radial artery pressure monitoring, and the pump line pressure. Using a propensity score analysis, the authors demonstrated that patients who received bilateral ACP had a significantly greater incidence of permanent neurologic deficits (P < .001), left brain hemisphere stroke (P = .007), and all-combined complications (P < .001). The hypothesis for this observation was that more manipulations around and within both carotid arteries during bilateral perfusion as well as some dysfunction of the cerebral autoregulation with significant unequal blood flow into both hemispheres may precipitate adverse cerebral outcomes. In addition to the discussion regarding perfusion and its characteristics, we would like to add one important point, namely the concern regarding manipulation of the supra-aortic branches, especially in the setting of a weakened arterial wall. The first author of this paper introduced hypothermic circulatory arrest combined with bilateral ACP during the repair of aortic dissection and any type of aortic arch aneurysm at a previous institution in 2002 with a case load of 80 to 100 hypothermia cases per year (approximately 50% being cases of acute type A aortic dissection). Unilateral ACP was used only exceptionally, mainly when the introduction of a perfusion catheter into one of the common carotid arteries was technically not possible (kinking, severe ostial stenosis, or occlusion). The classical setting for bilateral selective ACP was an additional small pump in the cardiopulmonary bypass circuit (identical to that one used for cardioplegia) and a tubing system connected to an "octopus" with 2 arms (similar to what is used for selective cardioplegia) (Figure 2, A). As alternative, the ACP line is connected with a Y to the arterial return line that is clamped during ACP (Figure 2, B). For the purpose of bilateral ACP, a special very smooth and small perfusion catheter with balloon occlusion was developed in the department and later commercialized by LeMaitre Vascular (Figure 2, C). There are 3 potential advantages to using this approach. First, there is no need to clamp or snare any of the supra-aortic vessel in the context of a particularly fragile vessel wall through acute dissection (especially when it is dissected) with the risk of an additional injury to these vessels with subsequent flow obstruction or complete occlusion. Second, the introduction of a smooth balloon into the true lumen may favor expansion of the dissected cylinder from inside the vessel and bring the dissected layers somewhat together, especially when biologic glue has been introduced in-between the layers. In fact, the balloon is inflated very gently just to avoid retrograde flow. Third, balloon inflation into the carotid arteries (or simply into the innominate artery on the right side) may obviate unperceived glue entrapment, a critical event that has been reported, when glue was routinely introduced for aortic dissection repair.9Carrel T. Maurer M. Tkebuchava T. Niederhäuser U. Schneider J. Turina M. Embolization of biologic glue during repair of aortic dissection.Ann Thorac Surg. 1995; 60: 1118-1120Abstract Full Text PDF PubMed Scopus (50) Google Scholar The first author moved recently to another tertiary care center, with an annual volume of 60+ acute type A aortic dissections (2021: 82 cases) with a strategy of unilateral ACP. In a consecutive series of 55 patients operated during an 8-month interval, 5 cases (10%) of postoperative occlusion of the innominate artery were observed. All patients underwent replacement of ascending aorta with an open distal anastomosis at the level of the proximal aortic arch. ACP was performed according to the following characteristics: core temperature 26 to 30 °C, tympanic temperature <24 °C, cerebral flow 10 to 15 mL/kg body weight, and pressure 50 to 60 mm Hg. Occlusion of the innominate artery was thought to be caused or aggravated by clamping or snaring this vessel during unilateral ACP through the right subclavian arterial line. In 4 patients, the innominate artery was already dissected at preoperative computed tomography scan, and in 1 case, it was intact. All patients suffered from a major ipsilateral neurologic injury, and 1 patient died. Two underwent emergency revascularization, with a vascular graft interposition between the ascending aorta and the bifurcation of the innominate artery in one (Figure 3) and complex stenting of the innominate artery up to the bifurcation of the right common carotid artery in the second case (Figure 4). In the 2 other cases, no additional revascularization was performed, since the dissecting membrane extended distally to the carotid artery bifurcation up to the intracranial part of the internal carotid artery, and the neurologic deficit was thought to be irreversible.Figure 4A, Angiographic imaging of the innominate artery shows retention of the contrast agent in the false lumen of the dissected common carotid artery (arrowheads). B, The dissected innominate artery and the right common carotid artery were treated with 2 kissing stents, which reached out into the aortic arch (star). The technique of the kissing stents ensures optimal distal perfusion of both the right subclavian and right carotid arteries and precludes compression or occlusion of one vessel through the other one. In addition, kissing stents allowed a safe closure of the supposed entry in the trunk, whereas vascular access in the true lumen was secured using ultrasound-guided puncture of the right carotid artery. C, Postinterventional computed angiography showing the 2 parallel stents in the innominate artery (arrows).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Patients who received revascularization showed significant improvement of their neurologic deficit and were discharged with a mild residual hemiparesis, whereas the 2 patients treated conservatively still suffered from significant hemiparesis at discharge to neurorehabilitation. The institutional review board/ethical review board of our university hospital granted a waiver for this work, since all patients signed the general consent form that allows the use of anonymized data for research purposes. When weighing the risks and benefits of unilateral versus bilateral ACP, interest should not only focus on the quality of cerebral protection but also the potential dangers during manipulation of the supra-aortic branches, which has emerged to be extremely important as well. First, those who do not use or support bilateral ACP argue the potential danger of manipulating supra-aortic vessels during the introduction of perfusion catheters into the innominate artery and the left common carotid artery and warn about the risk of carotid dissection or embolization of atherosclerotic particles. In fact, the presence of aortic arch and branch atherosclerosis is extremely uncommon in patients presenting with acute aortic dissection. In addition, it does not seem logical to believe that potential mobilization of thrombotic material from the false lumen may be better avoided by clamping a vessel than by occluding it with an intraluminal balloon. Second, one should be aware that clamping an already-dissected supra-aortic vessel through a vascular clamp or a tourniquet for snaring represents an additional severe trauma, which has practically never been addressed in the literature. Third, a gently expanded intravascular balloon may safely occlude the vessel and also prevent the embolization of glue or thrombotic material during the sealing process at the level of the distal aortic anastomosis when the aortic arch is open. This is also a rarely discussed potential advantage. We have used the technique with small perfusion catheters and balloon blockage extensively in the setting of thoracoabdominal and abdominal aneurysms repair to perfuse and/or occlude either spinal or visceral arteries and to block retrograde blood flow. We never observed any compression injury, because the balloon is inflated smoothly, just until there is no backflow out of the perfused artery. Finally, monitoring of the right radial artery pressure to assess the efficacy and safety of ACP may not be optimal because the individual positioning of the cannula in the subclavian artery and/or the angle of the side-graft anastomosed to the subclavian artery may cause significant variations in flow and pressure during perfusion. These are a few considerations regarding unilateral and bilateral ACP that should provide additional information regarding the potential dangers of clamping the supra-aortic vessels, in particular, the innominate artery when it is dissected. Endovascular balloon occlusion seems at least safer in terms of additional trauma to an already-fragile arterial wall. Nevertheless, only prospective randomized studies would be able to definitively clarify a question that surfaced in the introduction of cerebral protection more than 2 decades ago.

Meindert Palmen *, Emiliano Navarra, Johannes Bonatti, Ulrich Franke, Stepan Cerny, Francesco Musumeci, Paul Modi, Sandeep Singh, Elena Sandoval, Matteo Pettinari , Patrique Segers , Monica Gianoli, Frank van Praet, Herbert de Praetere, Jan Vojacek , Theodor Cebotaru, Burak Onan, Cengiz Bolcal, Cem Alhan, Ahmed Ouda, Ludovic Melly, Ghislain Malapert, Louis Labrousse , Alfonso Agnino, Tine Phillipsen, Jean-Luc Jansens, Thierry Folliguet, Piotr Suwalski , Koen Cathenis,

Abstract Aortic wrapping is a controversial repair in patients presenting with acute type A aortic dissection or intramural haematoma, but this method may be a potential alternative to medical treatment or conventional repair in patients aged >80 years and in those presenting with prohibitive co-morbidities such as stroke, circulatory collapse, full oral anticoagulation with the last generation drugs. We report on 5 high-risk and/or patients over 80 years who received external aortic wrapping with or without cardiopulmonary bypass during the last 18 months. All survived the procedure and could be extubated early postoperatively. No patient remained on the intensive care longer than 2 days and all were discharged without additional complications. Postoperative radiological control was acceptable and no patient had any new aortic event up to 18 months postoperatively.

We present the case of a 42-year-old man with a remarkably thin left ventricular (LV) wall in whom a covered rupture of the LV was suspected. Because of the suggestive imaging and the unusual history, the decision to explore through sternotomy was made. Intraoperative inspection revealed a limited area with a lack of myocardial tissue but did not con fi rm perforation of the LV. We would like to report this case because of the rarity of such a presentation and to critically discuss our decision. This young patient collapsed during sport exercise and was found with a ventricular tachycardia that was converted successfully by the emergency team. He had never suffered from cardiac symptoms or arrhythmias in the past. At admission, he was conscious without any symptoms; even immediately prior to collapse, he had no pains, dys-pnoea, or palpitations. Electrocardiogram and cardiac markers were normal. Computed tomography was performed to exclude aortic dissection or pulmonary embolism. This examination raised the sus-picion of a covered perforation of the lateral wall of the LV with a contrast agent observed immediately under the epicardial surface ( Figure 1A and B ). No leakage into the pericardial cavity was observed. rmed this fi nding and a limited area

The arterial baroreflex is a key autonomic regulator of blood pressure whose dysfunction has been related to several cardiovascular diseases. Changes in blood pressure are sensed by specific mechanosensory proteins, called baroreceptors, particularly located in the outer layer of the carotid sinus and the inner curvature of the aortic arch. The signal is propagated along the afferent nerves to the central nervous system and serves as negative feedback of the heart rate. Despite extensive research, the precise molecular nature of baroreceptors remains elusive. Current knowledge assumes that baroreceptors are ion channels at the nerve endings within the outer layer of the arteries. However, the evidence is based mainly on animal experiments, and the specific types of mechanosensitive receptors responsible for the signal transduction are still unknown. Only a few studies have investigated mechanosensory transmission in the aortic arch. In addition, although aortic dissection, and particularly type A involving the aortic arch, is one of the most life-threatening cardiovascular disorders, there is no knowledge about the impact of aortic dissection on baroreceptor function. In this review, we aim not to highlight the regulation of the heart rate but what mechanical stimuli and what possible ion channels transfer the corresponding signal within the aortic arch, summarizing and updating the current knowledge about baroreceptors, specifically in the aortic arch, and the impact of aortic pathologies on their function.

BackgroundEuropean surgeons were the first worldwide to use robotic techniques in cardiac surgery and major steps in procedure development were taken in Europe. After a hype in the early 2000s case numbers decreased but due to technological improvements renewed interest can be noted. We assessed the current activities and outcomes in robotically assisted cardiac surgery on the European continent.MethodsData were collected in an international anonymized registry of 26 European centers with a robotic cardiac surgery program.ResultsDuring a 4-year period (2016–2019), 2,563 procedures were carried out [30.0% female, 58.5 (15.4) years old, EuroSCORE II 1.56 (1.74)], including robotically assisted coronary bypass grafting (n = 1266, 49.4%), robotic mitral or tricuspid valve surgery (n = 945, 36.9%), isolated atrial septal defect closure (n = 225, 8.8%), left atrial myxoma resection (n = 54, 2.1%), and other procedures (n = 73, 2.8%). The number of procedures doubled during the study period (from n = 435 in 2016 to n = 923 in 2019). The mean cardiopulmonary bypass time in pump assisted cases was 148.6 (63.5) min and the myocardial ischemic time was 88.7 (46.1) min. Conversion to larger thoracic incisions was required in 56 cases (2.2%). Perioperative rates of revision for bleeding, stroke, and mortality were 56 (2.2%), 6 (0.2 %), and 27 (1.1%), respectively. Median postoperative hospital length of stay was 6.6 (6.6) days.ConclusionRobotic cardiac surgery case numbers in Europe are growing fast, including a large spectrum of procedures. Conversion rates are low and clinical outcomes are favorable, indicating safe conduct of these high-tech minimally invasive procedures.

Matto Pettinari *†, Monica Gianoli†, Meindert Palmen , Stepan Cerny, Burak Onan, Sandeep Singh, Patrique Segers , Cengiz Bolcal, Cem Alhan, Emiliano Navarra, Herbert De Praetere, Jan Vojacek, Theodor Cebotaru, Paul Modi, Fabien Doguet , Ulrich Franke, Ahmed Ouda, Ludovic Melly, Ghislain Malapert, Louis Labrousse , Alfonso Agnino, Tine Philipsen, Jean-Luc Jansens, Thierry Folliguet, Daniel Pereda , Francesco Musumeci, Piotr Suwalski , Koen Cathenis, Frank Van Praet, Johannes Bonatti and Wouter Oosterlinck; on behalf of the European Robotic CardioThoracic

Purpose: To explore the effect of undergoing coronary artery bypass grafting on sexual quality of life as an integral part of patients’ health-related quality of life. Methods: This cross-sectional study included 265 men ages 18 to 60 years (median age, 55) who underwent coronary artery bypass grafting 1 to 5 years before the study. Standardized questionnaires were implemented to evaluate participant pre- and postoperative sexual quality of life and the quality of counseling provided to patients. Results: Among the patients, 77% were in a steady relationship. The general health score was 5.5 ± 2.8 (mean ± standard deviation) preoperatively and 6 ± 2.2 at follow-up (P = .01). No sexual counseling was given to 83% and 77% of the patients pre- and postoperatively, respectively. The mean sexual satisfaction score dropped from 6.5 ± 2.6 preoperatively to 4.7 ± 3 postoperatively (P < .001). The decline in sexual intercourse frequency and masturbation frequency was significant (P < .001 and P = .006, respectively). Linear regression analysis showed that general health status (P = .008), higher-quality counseling (P = .027), and preoperative sexual quality of life (P < .001) correlated positively with sexual quality of life, whereas sternal pain (P < .001), erectile dysfunction (P < .001), and fear of excessive cardiac burden (P < .001) correlated negatively. Conclusions: Middle-aged men experience decreased sexual quality of life after coronary artery bypass grafting. Preoperative sexual quality of life, general health, and higher-quality counseling positively affect postoperative sexual quality of life, whereas sternal pain, fear, and erectile dysfunction play a negative role. Pre- and postoperative care guidelines should be improved. Further prospective large cohort studies for males and females are required.

Background The current standard for donor heart preservation consists of cold organ storage in three sequential plastic bags. This technique can cause freezing injuries of the donor heart as the temperature inside the transport box is not monitored routinely. The SherpaPak™ Cardiac Transport System (CTS) (Paragonix Technologies, Cambridge, MA, USA) aims to resolve this problem by maintaining a controlled preservation temperature between 4 and 8 °C. This study reports the first single-centre experience in Switzerland with this innovative single-use disposable device. Methods Between May and December 2020, four heart procurements using SherpaPak™ CTS were performed at our heart centre. Donor heart preservation fluid and ambient temperature were monitored using the InTempConnect® application (Onset Computer Corporation, Bourne, MA, USA). All patient data were collected retrospectively from the local hospital patient data capture system. Results Four recipients of a donor heart preserved with SherpaPak™ CTS were included in this study (3 male, 1 female). Mean transport distance was 86 km (range, 45–276 km). Mean storage time in the cooler was 73.5±19.33 minutes. Mean cold ischemic time was 199.25±11.67 minutes. The device kept the average organ temperature between 5.2 and 8.8 °C and hereby reached the recommended temperature range of 5–10 °C. Modifications of the procurement and storage process provided an optimization of the temperature course in the transportation box. There were no incidents during the transport. Organs transported with this novel storage system showed normal function after transplantation. Conclusions The SherpaPak™ CTS provides constant organ temperatures during transportation, prevents freezing injury and ensures mechanical protection of the graft. Keywords Heart transplantation; organ procurement; cold storage; hypothermic injury; graft transport

Hemoadsorption was used in a 59-year-old patient with an acute type A aortic dissection, who was on rivaroxaban and dual antiplatelet therapy with clopidogrel and acetylsalicylic acid. Our aim was to expeditiously remove rivaroxaban preoperatively. After 8 h of hemoadsorption, the rivaroxaban blood plasma concentration (RBPC) did not decrease below 42.1 μg/l. Intraoperatively, hemoadsorption was repeated during extracorporeal circulation. Sixteen hours after surgery and a total of 13 h of hemoadsorption, the RBPC was 40.1 μg/l. Thereafter, the RBPC spontaneously decreased to 24.7 μg/l within 14 h. In our patient, hemoadsorption may have enhanced rivaroxaban removal at higher RBPC (cutoff value 40–50 μg/l). At lower RBPC, the removal of rivaroxaban may depend solely on the natural drug elimination process. The evolution of the RBPC under hemoadsorption in vivo warrants a thorough investigation. Further clinical studies are required to assess the effectiveness and limitations of hemoadsorption to preclude a fatal bleeding event in patients with rivaroxaban in need of major emergency surgery.

We present a case of a 36-year-old male patient with known arthrogryposis multiplex congenita and an associated unicuspid aortic valve. The patient later developed a significant aneurysm of the ascending aorta, however refused surgical intervention and missed follow-up appointments for 5 years. During an urgent, general practitioner-initiated transthoracic echocardiography follow-up, a chronic type A aortic dissection was diagnosed as a result of progressive aortic dilatation. Due to the stationary pressure gradients and non-progressive leaflet fibrosis, a conservative approach for to the unicuspid aortic valve was chosen, combined with replacement of the ascending aorta and partial replacement of the aortic arch.

Aims Coronary computed tomography angiography (CTA) has emerged as a non-invasive diagnostic method for patients with suspected coronary artery disease, but its usefulness in patients with complex coronary artery disease remains to be investigated. The present study sought to determine the agreement between separate heart teams on treatment decision-making based on either coronary CTA or conventional angiography. Methods and results Separate heart teams composed of an interventional cardiologist, a cardiac surgeon, and a radiologist were randomized to assess the coronary artery disease with either coronary CTA or conventional angiography in patients with de novo left main or three-vessel coronary artery disease. Each heart team, blinded for the other imaging modality, quantified the anatomical complexity using the SYNTAX score and integrated clinical information using the SYNTAX Score II to provide a treatment recommendations based on mortality prediction at 4 years: coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or equipoise between CABG and PCI. The primary endpoint was the agreement between heart teams on the revascularization strategy. The secondary endpoint was the impact of fractional flow reserve derived from coronary CTA (FFRCT) on treatment decision and procedural planning. Overall, 223 patients were included. A treatment recommendation of CABG was made in 28% of the cases with coronary CTA and in 26% with conventional angiography. The agreement concerning treatment decision between coronary CTA and conventional angiography was high (Cohen's kappa 0.82, 95% confidence interval 0.74-0.91). The heart teams agreed on the coronary segments to be revascularized in 80% of the cases. FFRCT was available for 869/1108 lesions (196/223 patients). Fractional flow reserve derived from coronary CTA changed the treatment decision in 7% of the patients. Conclusion In patients with left main or three-vessel coronary artery disease, a heart team treatment decision-making based on coronary CTA showed high agreement with the decision derived from conventional coronary angiography suggesting the potential feasibility of a treatment decision-making and planning based solely on this non-invasive imaging modality and clinical information.

The SYNTAX III Revolution trial reported a high level of agreement on treatment recommendation (i.e. CABG or PCI) between heart teams assessing the coronary anatomy either with coronary computed tomography angiography (CCTA) or conventional angiography plus clinical information; this occurred