BACKGROUND:Iatrogenic aortocoronary dissection emerges from the coronary arteries and represents a catastrophic complication of coronary intervention. CASE SUMMARY:A patient undergoing percutaneous coronary intervention for ST-segment elevation myocardial infarction developed an extensive iatrogenic aortocoronary dissection complicated by cerebral malperfusion. He underwent complex surgery, including David's procedure, total arch replacement with frozen elephant trunk, coronary artery bypass grafting, and extra-anatomical carotid artery bypass. Despite a prolonged postoperative course, the patient achieved complete neurological and functional recovery and remains in excellent clinical condition 2 years postoperatively. DISCUSSION:Although iatrogenic aortocoronary dissection carries high morbidity and mortality, appropriately tailored surgical strategies can result in favorable long-term outcomes, even in extensive dissections complicated by malperfusion syndrome. TAKE-HOME MESSAGE:This case underscores aggressive surgical management in complex aortic dissections and the importance of close cardiology-surgery collaboration for severe procedural complications.

Abstract Background A growing body of evidence shows that choosing an arterial graft as a second graft for coronary artery bypass grafting (CABG), has a superior patency and a survival benefit when compared to a saphenous vein graft (SVG). However, surgeons are wary to utilize the right internal mammary artery (RIMA), because of concerns of sternal wound infections (SWI). This study aims to evaluate the risk of SWI in bilateral internal mammary artery (BIMA) usage while performing skeletonized harvesting. Methods Between January 2020 and July 2023, 1785 consecutive patients suffering from coronary artery disease (CAD) underwent a CABG operation at our hospital. Propensity score matching was performed where 259 single internal mammary artery (SIMA) patients were compared to 259 BIMA patients. We assessed sternal wound infections, and performed univariate and multivariate analysis identifying risk factors for SWI. Results There were six (1.2%) wound infections, evenly divided between SIMA (n = 3, 1.2%) and BIMA (n = 3, 1.2%) groups. Multivariate testing showed female gender (OR: 3.21, 95%CI: 1.58–6.55, p = 0.001), diabetes (OR: 3.07, 95%CI: 1.42–6.61, p = 0.004, NYHA class ≥ 3 (OR: 2.38, 95%CI: 1.09–5.20, p = 0.029) and postoperative delirium (OR: 1.92, 95%CI: 1.29–2.85, p = 0.001) to be significant risk factors for SWI. BIMA grafting was not confirmed as an independent risk factor for SWI (OR: 0.66, 95%CI: 0.19–2.27, p = 0.506). Conclusion This study shows that skeletonized BIMA grafting does not increase the risk of SWI. Female gender, diabetes, NYHA ≥ 3 and postoperative delirium did increase the risk for a sternal wound infection.

Objectives:There are several studies from all over the world reporting on frozen elephant trunk implantation and total arch replacement in acute aortic syndrome demonstrating mostly favourable outcomes. Most of these studies present younger study populations carrying a rather low perioperative risk for adverse outcomes. Herein, we present our single centre experience with the frozen elephant trunk procedure in patients with acute aortic syndrome. The patients in this cohort carried a rather high perioperative risk. A considerable number of patients had undergone resuscitation, presented with neurological disorders or presented with malperfusion syndrome. We demonstrate that favourable outcomes are achievable in such high-risk patients using the frozen elephant trunk technique. Methods:All patients who underwent frozen elephant trunk implantation in a setting of acute aortic syndrome between March 2008 and March 2023 were included in this retrospective study. Results:Overall, 90 patients underwent frozen elephant trunk implantation due to acute aortic syndrome. Mean age was 60.0 (±11.6) years, 74 patients (82%) were male. All had extensive aortic pathologies with involvement of the aortic arch, supraaortic vessels or descending aorta. 27 patients (30%) presented with neurological disorders, including aphasia, hemiparesis, paraparesis and coma. Predicted 30-day mortality by the so called GERAADA score was 23.9% on average. In our cohort, we observed an actual 30-day mortality of 17.4%. Postoperatively, neurological disorders were observed in 34 patients (38%). Aortic redo surgery was required in 8 patients (9%). Several preoperative and intraoperative parameters were tested for prediction of 30-day-survival. Preoperative hemiparesis (p = 0.012), visceral malperfusion (p = 0.004) and preoperative resuscitation (p = 0.003) served as significant predictors in a multivariable cox regression. Conclusions:The recent adaptation of frozen elephant trunk implantation in acute aortic syndrome led to an improved outcome. Overprediction trend of early mortality by the GERAADA score and a low rate of aortic redo surgery in the long-term course support this idea.

A 63-year-old man who had acute aortic dissection type A with signs of cerebral malperfusion and hemodynamic instability underwent immediate carotid artery cannulation. A Bentall procedure and total arch repair with frozen elephant trunk implantation were performed with extended cervical access to address supraaortic vessel involvement. We demonstrate that prudent cannulation and repair strategies can be successful even in the most complicated cases of aortic dissection.

Background This single center study compares the different surgical techniques used in the treatment of acute aortic dissection type A (AADA) analyzing the influence of the extent of the surgical approach on outcome. Methods From 1988 to 2012, 407 patients were operated for AADA. The cohort was divided into subgroups according to the surgical approach. These groups were compared with the supracommissural replacement group (SCR; n = 141). Groups included aortic valve sparing techniques (AVS; n = 29), Composite replacement (COMP; n = 119), COMP with total arch replacement (COMP+TAR; n = 27) and SCR with TAR (n = 75). Results Compared to SCR alone, operation (p = 0.005), bypass-, cross-clamp and circulatory arrest times were longer in SCR + TAR (all p < 0.001). Moreover, operation, bypass and cross clamp times were longer in COMP+TAR (p = 0.003, p = 0.002 and p < 0.001 respectively). COMP alone and AVS required longer cross-clamp time, too (p < 0,001 and p = 0.002, respectively). Overall 30-day mortality was 21% with the observed lowest rate after AVS (14%, SCR 18%, COMP 25%) but differences in 30-day mortality were not statistically significant. The estimated 10-year survival was 42%, especially AVS demonstrated a good 10-year survival (69%). David technique was superior to Yacoub technique concerning incidence of redo interventions (p = 0.036). Risk factors for early mortality included age, circulatory arrest, general malperfusion, bypass and operation time. Circulatory arrest per se was revealed as risk factor for long-term survival. Conclusions Within our single center retrospective study concomitant aortic root repair or aortic arch replacement for AADA demonstrated acceptable early and long-term survival. Circulatory arrest, long bypass and operation times per se might be important risk factors for early mortality. AVS techniques can be performed safely and have good outcomes in acute aortic dissection repair.

The frozen elephant trunk (FET) technique was developed to facilitate the two-stage surgery of extensive pathologies of the thoracic aorta and is now routinely applied in acute and chronic aortic syndromes. From 11/2006 to 07/2017, 68 patients underwent aortic arch repair using the FET technique. Patients received either the Jotec E-vita Open graft (n = 57) or the Vascutek Thoraflex hybrid prosthesis (n = 11). Both, group 1 (acute aortic dissection type A and B; symptomatic penetrating aortic ulcer) and group 2 (aortic aneurysm; chronic aortic dissection) included 34 patients each. Early mortality was 13.2% (14.7% in group 1 vs. 11.7% in group 2, p = 0.720). Neurological complications occurred in 12 patients (17.6%) (stroke: 8.8 vs. 11.7%; p = 0.797 and spinal cord injury: 8.8 vs. 5.9%; p = 0.642 in groups 1 vs. 2 respectively). Cardiopulmonary bypass time and cross clamp time were significantly longer in group 1 (252.2 ± 73.5 and 148.3 ± 34 min vs. 189.2 ± 47.8 and 116.3 ± 34.5 min; p <  0.001). The overall 1-, 3- and 7-year-survival was 80.9, 80.9 and 74.2% with no significant differences between groups 1 and 2. Expansion of true lumen after FET implantation was significant at all levels in both groups for patients with aortic dissection. One-, 3-, and 7-year-freedom from secondary (re-)intervention for patients for aortic dissection was 96.9, 90.2 and 82.7% with no significant differences between groups 1 and 2; p = 0.575. The FET technique can be applied in acute aortic syndromes with similar risks regarding adverse events or mortality when compared to chronic degenerative aortic disease. Postoperative increase in true lumen diameter mirrors decrease of false lumen diameter, goes along with favorable midterm outcome and prolongs freedom from secondary interventions in acute aortic dissection.

BACKGROUND:Minimally invasive mitral valve surgery (MVS) via right mini-thoracotomy has recently attracted a lot of attention. Minimally invasive MVS shows postoperative results that are comparable to those of conventional MVS through the median sternotomy as per various earlier studies.METHODS:Between 2000 and 2016, a total of 669 isolated mitral valve procedures for isolated mitral valve regurgitation were performed. A propensity score-matched analysis was generated for the elimination of the differences in relevant preoperative risk factors between the cohorts and included 227 patient pairs. Only degenerative mitral valve regurgitation was included. The aim of our study was to examine if the minimally MVS is superior to the conventional approach through sternotomy based on a retrospective propensity-matched analysis. The primary endpoints were early mortality and long-term survival. The secondary endpoints included postoperative complications.RESULTS:The in-hospital mortality rate was significantly higher within the conventional sternotomy cohort (3.1%, n = 7 vs 0.4%, n = 1 for the minimally invasive cohort; p = 0.032). The incidence of stroke and exploration for bleeding was comparable. In contrast, the necessity for dialysis was significantly lower in the minimally invasive cohort (p = 0.044). Postoperative pain was not significantly lower in the minimally invasive MVS cohort (p = 0.862). While patients who underwent minimally invasive MVS experienced longer bypass and cross-clamp times, their lengths of stay in the intensive care unit and in the hospital, did not differ from the conventionally operated collective (p = 0.779 and p = 0.516), respectively. The mitral valve repair rate of 81.1% in the minimally invasive cohort was significantly superior to that of the conventional approach, which was 46.3% (p < 0.0001). The one-, five-, and 10-year survival rates were significantly higher in the minimally invasive cohort compared to the conventional approach (96%, 90%, and 84% vs. 89%, 85%, and 70%; log rank p = 0.004).CONCLUSION:Despite prolonged cardiopulmonary bypass and cross-clamping times, the minimally invasive MVS may be considered a safe approach that is equivalent to standard median sternotomy with lower early mortality and superior long-term survival.

Objective: Open surgical repair of thoracoabdominal aortic aneurysm remains an important treatment option and continues to be challenging. The objective of this study was to investigate the results after open repair of thoracoabdominal aortic aneurysms in a contemporary non-high-volume center collective. Methods: A total of 38 patients underwent operation for thoracoabdominal aortic aneurysm between August 2007 and April 2017. Patients had aortic aneurysm and chronic aortic dissection. The majority of patients had already undergone previous aortic interventions. Results: The mean age was 54.4 +/- 13.4 years (range, 29-72.5 years), and 22 patients (57.9%) were female. Most commonly, patients (57.9%) presented with Crawford type II aneurysms. The mean cardiopulmonary bypass time was 159 +/- 65 minutes. The operative mortality was 10.5% (n = 4). The paraplegia rate and the incidence of stroke were 7.9% (n = 3). Postoperatively, 4 patients (10.5 %) required temporary hemodialysis. In 4 patients (10.5 %), reexploration due to bleeding was necessary. Sepsis developed in 4 patients (10.5%). Preoperative renal insufficiency was identified as a predictor of mortality. The patients were discharged from the hospital after a median length of stay of 21.5 days. The 1-year survival was 83%. Conclusions: Despite the invasiveness of open thoracoabdominal aortic repair and significant risk of major complications, surgical repair can be accomplished in a non-high-volume center with acceptable results.

BACKGROUND The aim of this study was to investigate the clinical presentation, operative data, and early and late outcomes of a large patient cohort undergoing surgical treatment for cardiac tumors in our institution. MATERIAL AND METHODS A total of 181 patients underwent surgery because of suspected cardiac tumor in our institution between 1998 and 2016. In 162 cases, the diagnosis was confirmed postoperatively and these patients were included in this study. Preoperative baseline characteristics, operative data, and postoperative early and long-term outcomes were analyzed. RESULTS Mean age at presentation was 56.6±17.6 years, and 95 (58.6%) patients were female. There were 126 (77.8%) patients with benign cardiac tumors, while the remaining patients had malignant tumors (primary and metastasized). The mean follow-up time was 5.2±4.7 years. The most frequent histologically verified tumor type was myxoma (63%, n=102). In terms of malignant tumors, various types of sarcomas presented most primary malignant cardiac tumors (7.4%, n=12). The mean ICU length of stay was 1.7±2.2 days and overall in-hospital mortality was 3.1% (n=5). Frequent postoperative complications included mediastinal bleeding (5.8%, n=9), wound infection (1.3%, n=2), acute renal failure (5.6%, n=9), and major cerebrovascular events (n=7, 4.6%). The overall cumulative survival after cardiac tumor resection was 94% at 30 days, 85% at 1 year, 72% at 5 years, and 59% at 15 years. CONCLUSIONS Surgical treatment of cardiac tumors is a safe and highly effective strategy associated with good early and long-term outcomes.

BACKGROUND Overall, life expectancy at the age of 80 has significantly increased in the industrialized world and the proportion of this age class undergoing cardiac surgery has also grown. In this context, we have analyzed a contemporary series of octogenarians undergoing mitral valve surgery at our institution. MATERIAL AND METHODS We performed a retrospective analysis of 138 consecutive octogenarians receiving mitral valve surgery between January 2006 and April 2017. Preoperative comorbidities, early mortality, postoperative clinical course, and predictors of mortality were examined. RESULTS The mean age was 82.4±2.0 years and 50% (n=69) were male. Preoperative comorbidities included history of heart infarction (24.6%, n=34), chronic renal failure (37.7%, n=52), and COPD (27.5%, n=38). A total of 52.9% (n=73) had a history of previous cardiac decompensation, while 20 (14.5%) presented with cardiogenic shock or cardiac arrest. In all, 33 patients (23.9%) underwent emergency surgery. There were only 39 isolated mitral valve procedures, while 99 patients (71.7%) underwent various concomitant procedures. The intensive care unit average length of stay was 5.3±7.5 days. Respiratory complications and sepsis were the most frequent postoperative complications. Emergency surgery and concomitant coronary artery bypass grafting were the most important predictors of early mortality. The overall 30-day mortality was 18.1% (n=25). The mean follow-up time was 1.7±2.3 years. CONCLUSIONS Octogenarians are increasingly represented in cardiac surgery and combined procedures. Prudent patient selection is necessary for optimizing postoperative outcomes among the elderly. In our seriously ill octogenarian cohort, mitral valve surgery was associated with moderate but acceptable mid-term survival.

BACKGROUND We reviewed our clinical experience with cardiac papillary fibroelastoma from 2005 to 2017. The objective of this study was to investigate the clinical and operative data, as well as the early survival rate and immediate postoperative complications. MATERIAL AND METHODS We performed a retrospective analysis of 11 patients (eight males and three females) who underwent resection of cardiac papillary fibroelastoma in our institution. RESULTS Mean age at tumor diagnosis was 60±14 years. The mean dimension of the tumor was 14±11 mm. The most common symptoms were dyspnea, palpitation, and angina pectoris, while one patient had recurrent fever attacks and another patient had a transient ischemic attack. Two patients had concomitant malignant tumors (cervical and colon carcinoma) and another two had concomitant benign neoplasms (liver cyst and thyroid adenoma). Bypass and cross clamp times were 77±32 minutes and 54±18 minutes, respectively. The tumors were found predominantly on cardiac valves (n=7). In eight cases, only tumor extirpation was performed, whereas in the other three cases, the valves had to be replaced. The mean intensive care unit length of stay was 1.1±0.3 days and there was no in-hospital mortality. All patients were alive at one-year follow-up and the survival rate was 91% in the mean follow-up period of 4.15 years. CONCLUSIONS The surgical treatment of cardiac papillary fibroelastoma was curative and safe. Thus, potential complications such as embolization or mechanical irritation of the valves can be avoided without high surgical risk.