Background/Objectives: Enhanced recovery after surgery (ERAS) protocols aim to improve clinical outcomes, shorten hospital length of stay (LOS), and reduce costs through a multidisciplinary perioperative approach. Although introduced in colorectal surgery, they are less established in cardiac surgery, especially in combination with on-table extubation (OTE). This study evaluates the impact of a novel ERAS concept with OTE (RERACS) in elective aortic-valve-replacement and coronary bypass surgery. Methods: In a monocentric study, we compared a prospective RERACS-group (n = 114) to a retrospective control group (n = 119) (TRIAL Registration (DRKS00031402). The RERACS concept contained multiple perioperative treatment measures such as respiratory training, short fasting, and OTE. The control group received standard care. Results: Primary endpoint: postoperative LOS. Secondary measurements: length of postoperative vasoactive drug support, duration of mechanical ventilation, complication rate, and patient satisfaction on the second postoperative day. RERACS patients showed significantly shorter postoperative length of stay (ICU: 40 ± 34 h vs. 56 ± 51 h, p = 0.005; hospital: 9 ± 4 d vs. 11 ± 6 d, p = 0.028), lower nosocomial infection rates (24% vs. 40%), fewer cases of postoperative cognitive dysfunction ((subsyndromal) delirium 40% vs. 57%), reduced nausea and vomiting (14.9% vs. 32.8%), and faster weaning from catecholamines (22 ± 30 h vs. 42 ± 48 h, p < 0.001), as well as high patient satisfaction. Conclusions: Our study indicated that an ERAS concept with OTE is safe and associated with faster and improved recovery, including lower catecholamine requirements, reduced LOS, and high patient satisfaction in low-risk cardiac surgery.

The pericardium is an important anatomical landmark for cardiologists and cardiac surgeons. Detailed knowledge of the anatomy and morphology of the pericardium is essential for the diagnosis and treatment of associated diseases. Pericardial tamponade in particular requires a rapid diagnosis and treatment. Constrictive pericarditis as a cause of diastolic heart failure, can be successfully treated by surgical pericardiectomy. Tumors of the pericardium and pericardial cysts are comparatively rare and do not always require immediate surgical treatment. This article provides an overview of the relevant pericardial diseases and their treatment options.

Delayed sternal closure (DSC) is a well-established strategy used to manage patients with hemodynamic instability and perioperative coagulopathy following cardiac surgery. The study aims to present our 15-year surgical experiences with DSC.Between 2007 and 2022, DSC was performed in 227 out of 14,210 patients (1.7%) who underwent cardiac surgery at our institution. Perioperative data, outcomes, and long-term survival were analyzed. Quality of life (QoL) was assessed utilizing the EuroQol-5D-5L questionnaire.Indications for DSC included low cardiac output syndrome (LCOS) (44.1%) and coagulopathy during the index procedure (32.2%), as well as postoperative tamponade (22.9%). In coronary artery bypass grafting, LCOS was the primary indication for DSC (72.7%), whereas in acute type A aortic dissection, coagulopathy was the leading indication (70.6%). For other procedures, DSC indications were more evenly distributed. The overall 30-day survival was 57.5%, with survival rates of 43.3% for LCOS, 72.0% for coagulopathy, and 65.4% for tamponade. Multivariate logistic regression identified body mass index, postoperative renal replacement therapy, aggravated heart failure, and intraoperative packed red blood cell transfusion as negatively associated with 30-day survival. The mean follow-up period was 6.58 ± 3.19 years. Younger patients and DSC patients upon bleeding related indications reported higher QoL in comparison to older patients and patients with LCOS. Longer follow-up interval correlated with higher QoL.The study emphasizes the significant impact of LCOS on outcomes in patients undergoing DSC. We provide QoL data demonstrating good rehabilitation potential upon survival of the acute phase.

Background: Postoperative de novo atrial fibrillation (POAF) is one of the most frequently encountered complications following cardiac surgery. Despite the identification of several risk factors, the link between sleep-disordered breathing (SDB) and POAF has barely been examined. The objective of this prospective observational study was to determine whether severe SDB is associated with POAF in patients after elective coronary artery bypass grafting (CABG) surgery. Study design and methods: The incidence and preoperative predictors of in-hospital POAF were assessed in 272 patients undergoing CABG surgery at the University Medical Center Regensburg (Germany). In-hospital POAF was detected by continuous telemetry-ECG monitoring and 12-lead resting ECGs within the first seven postoperative days. POAF that occurred after hospital discharge within 60 days post CABG surgery was classified as post-hospital POAF and was ascertained by standardized phone interviews together with the patients’ medical files, including routinely performed Holter-ECG monitoring at 60 days post CABG surgery. The night before surgery, portable SDB monitoring was used to assess the presence and type of severe SDB, defined by an apnea–hypopnea index ≥ 30/h. Results: The incidence of in-hospital POAF was significantly higher in patients with severe SDB compared to those without severe SDB (30% vs. 15%, p = 0.009). Patients with severe SDB suffered significantly more often from POAF at 60 days post CABG surgery compared to patients without severe SDB (14% vs. 5%, p = 0.042). Multivariable logistic regression analysis showed that severe SDB (odds ratio, OR [95% confidence interval, CI]: 2.23 [1.08; 4.61], p = 0.030), age ≥ 65 years (2.17 [1.04; 4.53], p = 0.038), and diabetes mellitus (2.27 [1.15; 4.48], p = 0.018) were significantly associated with in-hospital POAF. After additional adjustment for heart failure, the association between sleep apnea and postoperative atrial fibrillation was attenuated (1.99 [0.92; 4.31], p = 0.081). Conclusions: Amongst established risk factors, severe SDB was significantly associated with in-hospital POAF in patients undergoing CABG surgery. Whether SDB contributes to POAF independently of heart failure and whether risk for POAF may be alleviated by proper treatment of SDB merits further investigation.

Background: Nocturnal hypoxemia has been linked to increased cardiovascular morbidity and mortality. Several common diseases, such as sleep-disordered breathing (SDB), heart failure (HF), obesity, and pulmonary disease, coincide with an elevated nocturnal hypoxemic burden with and without repetitive desaturations. Research question: This study aimed to evaluate the association of relevant common diseases with distinctive metrics of nocturnal hypoxemic burden with and without repetitive desaturations in patients undergoing coronary artery bypass grafting surgery. Study design and methods: In this subanalysis of the prospective observational study, CONSIDER-AF (NCT02877745) portable SDB monitoring was performed on 429 patients with severe coronary artery disease the night before cardiac surgery. Pulse oximetry was used to determine nocturnal hypoxemic burden, as defined by total recording time spent with oxygen saturation levels < 90% (T90). T90 was further characterized as T90 due to intermittent hypoxemia (T90desaturation) and T90 due to nonspecific and noncyclic SpO2-drifts (T90non-specific). Results: Multivariable linear regression analysis identified SDB (apnea–hypopnea-index ≥ 15/h; B [95% CI]: 6.5 [0.4; 12.5], p = 0.036), obesity (8.2 [2.5; 13.9], p = 0.005), and mild-to-moderate chronic obstructive pulmonary disease (COPD, 16.7 [8.5; 25.0], p < 0.001) as significant predictors of an increased nocturnal hypoxemic burden. Diseases such as SDB, obesity and HF were significantly associated with elevated T90desaturation. In contrast, obesity and mild-to-moderate COPD were significant modulators of T90non-specific. Interpretation: SDB and leading causes for SDB, such as obesity and HF, are associated with an increased nocturnal hypoxemic burden with repetitive desaturations. Potential causes for hypoventilation syndromes, such as obesity and mild-to-moderate COPD, are linked to an increased hypoxemic burden without repetitive desaturations. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT02877745.

Abstract Background Emerging evidence is linking sleep-disordered breathing (SDB) to diastolic dysfunction. SDB-induced hypoxia may stimulate the development of cardiac fibrosis which then causes diastolic dysfunction. We investigated the association between SDB and myocardial collagen and PDGF mRNA levels and how collagen mRNA levels are linked to parameters of diastolic dysfunction. Methods RA biopsies were collected from 31 patients undergoing elective coronary artery bypass grafting in the prospective observational study CONSIDER-AF. Tissue mRNA levels of collagen type I (Col1A), PDGFα, and PDGFβ were quantified using real-time qPCR on ViiA 7 real-time PCR system. NT-pro-BNP levels were measured in the serum via ELISA blots. The apnea-hypopnea-index (AHI) was registered in portable SDB-monitoring. Echocardiography was performed to assess diastolic function. Results First, we investigated an association of SDB and cardiac fibrosis. AHI was correlated with tissue mRNA levels of Col3a (p = 0.0239, Fig A), PDGFα (p = 0.0414, Fig B), and PDGFβ (p = 0.0024, Fig C). Then, we investigated an association between cardiac fibrosis and diastolic dysfunction. Tissue mRNA levels of Col3A were inversely correlated with lateral (p = 0.0196, Fig D) and septal E’ (p = 0.0006, Fig E) as a marker for diastolic relaxation. Higher ratios of E/E’mean were correlated with increased tissue mRNA levels of Col3A (p = 0.0368, Fig F). NT-pro-BNP which is a diagnostic criterion for heart failure with preserved ejection fraction was correlated with Col3 levels (p = 0.0247, Fig G). Discussion: Our findings indicate that SDB is linked to fibrosis which is associated with diastolic dysfunction.

We present the case of a 52-year-old with a history of aortic valve replacement and replacement of the ascending aorta with the graft inclusion technique presenting with dizziness and collapse. Computed tomography and coronary angiography revealed pseudoaneurysm formation at the anastomotic site causing aortic pseudostenosis. Due to severe calcification of the graft inclusion surrounding the ascending aorta, we performed a redo ascending aortic replacement using a two-circuit cardiopulmonary bypass to avoid deep hypothermic cardiac arrest.

Abstract Objectives Treatment of destructive endocarditis with abscess formation is a surgical challenge and associated with significant morbidity and mortality. A root replacement is often performed in case of an annular abscess. This retrospective study was designed to assess the long-term outcome of extensive debridement and patch reconstruction as an alternative approach. Methods Between November 2007 and November 2016, a selected group of 79 patients (29.6% of all surgical endocarditis cases) with native valve endocarditis (NVE, 53.2%) or prosthetic valve endocarditis (PVE, 46.8%) valve endocarditis underwent surgical therapy with extensive annular debridement and patch reconstruction. Their postoperative course, freedom from recurrent endocarditis, and survival at 1, 5, and 7 years were evaluated. Results About two-thirds of patients were in a stable condition, one-third of patients were in a critical state. The median logistic EuroSCORE I was 17%. Infected tissue was removed, and defect closure was performed, either with autologous pericardium for small defects, or with bovine pericardium for larger defects. Overall, in-hospital mortality was 11.3% (NVE: 9.7%, PVE: 13.2%; p = 0.412). In single valve endocarditis survival at 1, 5, and 7 years was 81, 72, 72%, respectively for NVE, and 80, 57, 57%, respectively for PVE (p = 0.589), whereas in multiple valve endocarditis survival at 1, 5, and 7 years was 82, 82, 82% for NVE, and 61, 61, and 31%, respectively for PVE (p = 0.132). Confirmed late reinfection was very low. Conclusion Surgical treatment of destructive endocarditis with abscess formation using patch repair techniques offers acceptable early and long-term results. The relapse rate was low. PVE and involvement of multiple valves were associated with worse outcomes.

Abstract Background Structural remodelling, which includes increased fibrosis and collagen production, is a hallmark of atrial cardiomyopathy. Echocardiographic strain measurements allow detailed assessment of atrial function. We investigated the association between right atrial (RA) strain and collagen mRNA levels in human RA. Methods RA biopsies were collected from 21 patients undergoing elective coronary artery bypass grafting in the prospective observational study CONSIDER-AF. Tissue mRNA levels of collagen type I (Col1A) and of collagen type III (Col3A) were quantified using real-time qPCR on ViiA 7 real-time PCR system. Echocardiographic RA strain (reservoir, conduit, and booster function) was measured in the four-chamber view using the designated software Philips QLAB. We performed uni- and multivariable linear regression analysis to elucidate the relationship between RA strain and collagen mRNA levels. Results There was a strong correlation between RA reservoir strain and Col1A mRNA levels (p=0.0152, r²=0.2608, Fig A) and Col3A mRNA levels (p=0.0058, r²=0.3374, Fig B) as well as between RA conduit strain and Col1A mRNA levels (p=0.0301, r²=0.2141, Fig C) and Col3A mRNA levels (p=0.0232, r²=0.2430, Fig D). However, there was no correlation between RA booster function and Col1A levels (p=0.5572, Fig E) or Col3A levels (p=0.3426, Fig F). Multivariate regression analysis revealed that RA conduit and RA reservoir function are predictors for Col1A and Col3A mRNA levels independent from clinical covariates (age, sex, body-mass index, systolic blood pressure). Discussion Our findings show that RA strain measurements are associated with RA collagen mRNA levels in humans and therefore highlight the potential of strain analysis to identify structural remodelling in atrial cardiomyopathy.FigureTable

Background: Nocturnal hypoxemic burden (T90) has been linked to increased cardiovascular morbidity and mortality. Several previuous studies fell short to identify, in addition to sleep-disordered breathing (SDB), common diseases that may contribute to increased nocturnal T90. Aims and objectives: to evaluate the association of relevant common diseases with distinctive metrics of nocturnal T90 with and without repetitive desaturations. Methods: In this sub-analysis of the prospective observational study, CONSIDER-AF (NCT02877745) portable SDB monitoring was performed in 429 patients with severe coronary artery disease. Nocturnal T90 was defined by total recording time spent with oxygen saturation <90%. Distinctive metrics included T90 due to intermittent hypoxemia (T90desaturation) and T90 due to non-specific and non-cyclic SpO2-drifts (T90non-specific). Results: Multivariable linear regression analysis identified SDB (apnea-hypopnea-index ≥15/hour; B [95% CI]: 8.2 [3.3;13.1], p=0.001), obesity (8.5 [3.6;13.3], p=0.001) and mild to moderate chronic obstructive pulmonary disease (COPD, 16.9 [6.9;26.9], p=0.001) as predictors of increased T90. While SDB, obesity and chronic heart failure (HF) were significantly associated with an elevated T90desaturation, obesity and COPD were significant modulators of T90non-specific. Conclusions: In addition to SDB, also obesity and COPD, but not chronic HF, contribute to increased nocturnal T90. SDB and leading causes for SDB, such as obesity and chronic HF, are associated with an increased nocturnal T90desaturation. Potential causes for hypoventilation syndromes such as obesity and COPD are linked to an increased nocturnal T90non-specific.

Letter to: Leserbrief zum Beitrag: "Reanimation nach außerklinischer ECMO-Anlage - eine außerordentliche Erfolgsgeschichte"NOTARZT 2022; 38(01): 36-36DOI: 10.1055/a-1700-1439

BACKGROUND:Use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in elderly patients is controversial because of presumed poor outcome. Our primary aim was to determine the influence of advanced age on short- and long-term outcome; the secondary aim was to analyze risk factors for impaired outcome.METHODS:Between January 2006 and June 2020, 645 patients underwent VA-ECMO implantation in our department. The patients were categorized into four groups:<50, 50-59.9, 60-69.9 and ≥70 years old. Data were retrospectively analyzed for short- and long-term outcome. Risk factors for in-hospital mortality and mortality during follow-up were assessed using multivariate regression analysis.RESULTS:VA-ECMO support duration was comparable in all age groups (median 3 days). Weaning rates were 60.8%/n = 104 (<50 years), 51.4%/n = 90 (50-59.9 years), 58.8%/n = 107 (60-69.9), and 67.5%/n = 79 (≥70, p = 0.048). Hospital mortality was highest in the patients aged 50-59.9 years (68%/n = 119), but not in the elderly patients (60-69.9, ≥70:62.1%/n = 113, 58,1%/n = 68). At discharge, the cerebral performance category scores were superior in the patients <50 years. Multivariate logistic regression analysis revealed chronic kidney failure requiring hemodialysis, duration of cardiopulmonary resuscitation, and elevated blood lactate levels before VA-ECMO, but not age as predictors of in-hospital mortality. Cox's regression disclosed age as relevant risk factor for death during follow-up. The patients' physical ability was comparable in all age groups.CONCLUSION:VA-ECMO support should not be declined in patients only because of advanced age. Mortality and neurological status at hospital discharge and during follow-up were comparable in all age groups.

BACKGROUND:The outcome after veno-venous extracorporeal membrane oxygenation in elderly patients is supposed to be unsatisfactory. Our primary aim was to determine the influence of advanced age on short- and long-term outcomes; the secondary aim was to analyze risk factors for impaired outcomes.METHODS:Between January 2006 and June 2020, 755 patients received V-V ECMO support at our department. Patients were grouped according to age (18-49.9, 50-59.9, 60-69.9, ≥70 years old), and then retrospectively analyzed for short- and long-term outcomes. Risk factors for in-hospital mortality and death during follow-up were assessed using multivariate regression analysis.RESULTS:Duration of V-V ECMO support was comparable between all groups median (8-10 days, p = 0.256). Likewise, the weaning rate was comparable in all age groups 68.2%-76.5%; (p = 0.354), but in-hospital mortality was significantly climbing with increasing age (<50 years 30.1%/n = 91 vs. 50-59.9 years 37.1%/n = 73, vs. 60-69.9 years 45.6%/n = 78 vs. ≥70 years 51.8%/n = 44; p < 0.001). Older age groups also showed significantly reduced cerebral performance category scores. The multivariate logistic analysis yielded age, acute and chronic hemodialysis, bilirubin on day 1 of support, malignancy, and primary lung disease as relevant risk factors for in-hospital mortality. Age, coronary artery disease, presence of another primary lung disease, malignancy, and immunosuppression were risk factors for death during follow-up.CONCLUSION:In V-V ECMO patients, advanced age is associated with more comorbidity, impaired short- and long-term outcome, and worse neurological outcome.

Background: In reverse-mode, cardiac sodium-calcium exchanger (NCX) can increase the cytoplasmic Ca2+ concentration in response to high intracellular Na+ levels, which may contribute to diastolic contractile dysfunction. Furthermore, increased spontaneous Ca2+ release from intracellular stores can activate forward mode NCX. The resulting transient inward current causes delayed afterdepolarization (DAD)-dependent arrhythmias. Moreover, recently, NCX has been associated with impaired relaxation and reduced cardiac function in heart failure with preserved ejection fraction (HFpEF). Since NCX is upregulated in human chronic atrial fibrillation (AF) as well as heart failure (HF), specific inhibition may have therapeutic potential. Objective: We tested the antiarrhythmic, lusitropic and inotropic effects of a novel selective NCX-inhibitor (SAR296968) in human atrial myocardium. Methods and Results: Right atrial appendage biopsies of 46 patients undergoing elective cardiac surgery in a predominant HFpEF cohort (n = 24/46) were investigated. In isolated human atrial cardiomyocytes, SAR296968 reduced the frequency of spontaneous SR Ca2+ release events and increased caffeine transient amplitude. In accordance, in isolated atrial trabeculae, SAR296968 enhanced the developed tension after a 30 s pause of electrical stimulation consistent with reduced diastolic sarcoplasmic reticulum (SR) Ca2+ leak. Moreover, compared to vehicle, SAR296968 decreased steady-state diastolic tension (at 1 Hz) without impairing developed systolic tension. Importantly, SAR296968 did not affect the safety parameters, such as resting membrane potential or action potential duration as measured by patch clamp. Conclusion: The novel selective NCX-inhibitor SAR296968 inhibits atrial pro-arrhythmic activity and improves diastolic and contractile function in human atrial myocardium, which may have therapeutic implications, especially for treatment of HFpEF.

Objectives Type A aortic dissection with true lumen collapse and malperfusion downstream is associated with a devastating prognosis. This study compares the clinical outcomes of two operative strategies for this disease: hybrid approach of ascending aorta (and hemiarch replacement) supplemented with retrograde stenting of the descending aorta (thoracic endovascular aortic repair [TEVAR]) and standard ascending aorta (and hemiarch) replacement without stent placement. Methods From January 1, 2016 to December 31, 2019, 81 patients with type A aortic dissection were studied. The hybrid technique was applied in 30 patients (group 1), while 51 patients received standard surgical repair (group 2). Patient demographics, clinical and operative findings, postoperative outcome, follow-up interventions, and mid-term survival were analyzed. Results Baseline characteristics were similar among the groups, except that more preoperative malperfusion was evident in group 1. The postoperative incidence of visceral malperfusion (0 vs. 15.7%, p = 0.02) and low cardiac output syndrome requiring extracorporeal membrane oxygenation support (3.3 vs. 19.6%, p = 0.04) was significantly less in group 1. In-hospital mortality was also significantly lower in group 1 as in group 2 (13.3 vs. 33.3%, p = 0.04). At follow-up, the need for secondary endovascular stenting (3.3 vs. 7.8%, p = 0.65) and surgical aortic reintervention (6.7 vs. 2.0%, p = 0.55) was comparable. One-year, 2-year, and 3-year survival rates were 83.3, 83.3, and 62.5% in group 1, and 58.7, 58.7, and 52.6% in group 2 ( p = 0.05), respectively. Conclusion The combination of open surgical replacement of the ascending aorta (and hemiarch) with TEVAR of the descending aorta for true lumen compromise is a feasible treatment option for patients with type A aortic dissection and is associated with a better perioperative outcome and improved mid-term survival rate.

INTRODUCTION:Omental flap (OF) is a traditional surgical option to counteract severe postcardiotomy mediastinal infection and to cover extensive sternal defects. We reviewed our experience with omental flap transfer (OFT) in various clinical circumstances, in which omentoplasty may be considered by cardiac surgeons. METHODS:Twenty-one patients, who underwent OFT from January 2012 to December 2021, were studied. The main indication was treatment of infected foreign material implants including vascular grafts and ventricular assist devices or prevention of its infection (16 patients). In five patients, an OFT was used to cure mediastinitis following deep sternal wound infection after median sternotomy. RESULTS:All patients had a high surgical risk with 3 ± 1.9 previous sternotomies and a mean Euro Score II of 55.0 ± 20.1. OF was successful in its prophylactic or therapeutic purpose in all patients, no complications related to the operative procedure were noted, that is, no early or late flap failure and no herniation of abdominal organs occurred. In-hospital mortality was six patients as three patients each died from multiple organ dysfunction syndrome and cerebral hemorrhage. All fifteen patients discharged demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. The mean follow-up of 18 months was uneventful. CONCLUSION:OFT seems to be an excellent solution for extensive mediastinal and deep sternal wound infections.

Background: Sleep-disordered breathing (SDB) is associated with increased oxidant generation. Oxidized Ca/calmodulin kinase II (CaMKII) can contribute to atrial arrhythmias by the stimulation of sarcoplasmic reticulum Ca release events, i.e., Ca sparks. Methods: We prospectively enrolled 39 patients undergoing cardiac surgery to screen for SDB and collected right atrial appendage biopsies. Results: SDB was diagnosed in 14 patients (36%). SDB patients had significantly increased levels of oxidized and activated CaMKII (assessed by Western blotting/specific pulldown). Moreover, SDB patients showed a significant increase in Ca spark frequency (CaSpF measured by confocal microscopy) compared with control subjects. CaSpF was 3.58 ± 0.75 (SDB) vs. 2.49 ± 0.84 (no SDB) 1/100 µm−1s−1 (p < 0.05). In linear multivariable regression models, SDB severity was independently associated with increased CaSpF (B [95%CI]: 0.05 [0.03; 0.07], p < 0.001) after adjusting for important comorbidities. Interestingly, 30 min exposure to the CaMKII inhibitor autocamtide-2 related autoinhibitory peptide normalized the increased CaSpF and eliminated the association between SDB and CaSpF (B [95%CI]: 0.01 [−0.1; 0.03], p = 0.387). Conclusions: Patients with SDB have increased CaMKII oxidation/activation and increased CaMKII-dependent CaSpF in the atrial myocardium, independent of major clinical confounders, which may be a novel target for treatment of atrial arrhythmias in SDB.

BACKGROUND: We reported on a decade of aortic surgery for type A aortic dissection to assess surgical techniques employed and outcomes over time in an all-comer analysis of a mid-size university cardiosurgical center.METHODS: From 2009 to 2018, 283 patients (189 males and 94 females, mean age 62 years, range 30-85 years), who underwent surgical therapy for type A aortic dissection in our institution were included in a retrospective statistical analysis.RESULTS: Among all the patients, 55.5% of them were hemodynamically stable, 10.3% came in intubated. A neurological deficit was present in 18.9% of cases, extremity malperfusion was noted in 17.4%, and abdominal malperfusion detected in 8.2%. The extent of the aortic dissection corresponded to DeBakey type I in 88% of cases, a thoracoabdominal involvement was seen in 64%. In 51.9% of patients, only the ascending aorta replaced, another 40.6% of patients had proximal arch replacement too. A separate stent placement into the descending aorta was achieved in 13.4% of patients, during surgery (5.7%) or thereafter (7.7%). Overall survival to discharge was 79.5%. Most frequent complications were stroke and paralysis (15.2%), but only visceral malperfusion (OR 9.0) and heart failure mandating ECMO therapy (OR 29.5) were associated with significantly increased mortality.CONCLUSIONS: Surgery for type A aortic dissection is still challenging. Along with the refinement of surgical techniques, the indication for the various procedures has moved from a simplified general strategy to a more individualized concept.