Background:Degree of malperfusion on presentation is a known determinant of early mortality in acute Type A aortic dissection (TAAD). Its prediction of mortality when stratified by complexity of central repair has not been well-described. Methods:Over a 6-year period, 183 patients had a central repair for TAAD, 146 of whom had a spontaneous etiology and an acute presentation (≤14 days). Each patient was assigned a Penn Class based on ischemia (malperfusion): A-none, B-regional, or C-global. The index operation was identified as simple (ascending aorta and/or hemiarch replacement) or complex (concomitant root replacement, arch replacement, or coronary artery bypass grafting). Early mortality was defined as in-hospital or within 30 days of surgery, if discharged. Results:The overall early mortality was 10.3% (15/146), and it was significantly different in each Penn Class: 1.5% (1/65) for A, 8.7% (4/46) for B, 22.8% (8/35) for C (p = 0.002). Six patients in Penn Class C had preincision cardiac arrest with cardiopulmonary resuscitation, three surviving. The early mortality differences, however, between the simple (8.3%) and complex (14.0%) operative groups overall and within each Penn Class were not significant. Of the six groups, the lowest mortality was evident in the 41 patients in Penn Class A who had a simple operation, whereas the highest was seen in the 13 Penn Class C patients who underwent a complex operation (0 vs. 23.1%, p = 0.001). Conclusion:In spontaneous acute TAAD, degree of malperfusion on presentation, rather than operative complexity, was the dominant factor in early mortality.

Type A aortic dissection (TAAD) has been associated with thoracic endovascular aortic repair (TEVAR) for aortic conditions: dissection and aneurysm. Our purpose was to study a subset of patients who had an initial TEVAR for type B aortic dissection, followed by a TAAD, which was treated by open ascending aortic repair. Over a 6-year period, 171 consecutive patients underwent open ascending aortic repair for TAAD, of whom 21(12%) had a previous cardiovascular procedure, 17 of which were endovascular. A total of 9 (5.2%) of 171 patients with TAAD had a previous TEVAR for a type B. The mean interval from TEVAR to open ascending aortic repair for TAAD was 4.6 years, with only 1 occurring within a month. Only 1 patient had abnormal aortic media by histology. In 5 of the 9 patients, the entry tear was in the proximal ascending aorta, remote from the endograft, which suggests that a TAAD late after TEVAR for type B represents a new spontaneous event. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

A congenitally malformed aortic valve, unicuspid (UAV), or bicuspid (BAV), occurs in about 1% of the population and is known to be more frequent in patients with aortic dissection. The clinical and operative findings in a series of 134 patients with spontaneous, acute type A aortic dissection were studied, comparing patients with normal and abnormal aortic valve morphology. The aortic valve was normal in 123 of 134 (92%) patients and abnormal in 11 of 134 (8%) patients: BAV in 10 of 134 (7.5%) and UAV in 1 of 134 (0.7%). Demographics were similar between groups, except for a lower frequency of systemic hypertension in the UAV/BAV group (46 vs 82%, p <0.01). The University of Pennsylvania malperfusion class stratification was also similar in the 2 groups. The UAV/BAV group had a greater frequency of aortic root aneurysm (64 vs 18%, p <0.01) and a larger median root diameter (5.7 vs 4.6 cm, p = 0.02). In the UAV/BAV group, the entry tear was more frequently in proximal (intrapericardial) zone 0 (91 vs 62%, p = 0.049). The frequency of abnormal aortic media histology was similar. The rate of root replacement was higher in the UAV/BAV group and early mortality was similar. The frequency of congenitally malformed aortic valve in this series was 8 times higher than in the normal population. The 1 UAV in the series was the only severely stenotic valve. In patients with type A aortic dissection with a congenitally malformed valve, aortic root aneurysm was more common and the entry tear was nearly always proximal. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Introduction: Coronary artery bypass grafting (CABG) is commonly performed for treating coronary artery disease (CAD) in octogenarians. This entails higher risk and resource utilization compared to younger patients. This retrospective multicenter study evaluates CABG outcomes in octogenarians, with a particular focus on the impact of off-pump (OPCAB) versus on-pump (ONCAB) CABG techniques.Methods: We conducted a retrospective analysis of isolated OPCAB and ONCAB procedures in octogenarians from January 1, 2015, to June 30, 2023, across 8 centers within a single health system. All cases submitted to the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database were included. The primary outcome was 30-day mortality; secondary outcomes included STS-defined postoperative complications. We performed a stabilized inverse probability treatment weighted (sIPTW) matching technique to balance baseline covariates between the two groups.Results: Across eight centers, 470 (7%) CABG procedures were performed in octogenarians, with 207 (44%) underwent OPCAB and 263 (56%) ONCAB. Prior to matching, overall 30-day all-cause mortality rate was 6.6% in octogenarians. After sIPTW matching, 30-day mortality (primary outcome) rates were comparable between OPCAB and ONCAB (2.4% vs. 4.4%; p = 0.71). However, OPCAB was associated with lower rates of composite complications (28% relative risk reduction (RRR), p = 0.003), including pneumonia (89% RRR, p = 0.023), atrial fibrillation (30% RRR, p = 0.013), and discharge-to-acute care facilities (ACFs) (36% RRR, p = 0.003). Resource utilization was also lower in the OPCAB group, with shorter median hospital stays (6 [3-7] vs. 7 [6-9] days, p = 0.002) and reduced ventilator time (4.3 [0.8-9] vs. 8.4 [4.7-21] hours, p = 0.009).Conclusion: In octogenarians, OPCAB and ONCAB found comparable 30-day mortality. However, OPCAB was associated with fewer complications, shorter hospital stays, reduced ventilator hours, lower blood transfusion requirements, and higher discharge-to-home rates, suggesting potential advantages in resource utilization and patient recovery.

Myocarditis and acute myocardial infarction (AMI) have been reported after COVID-19 messenger ribonucleic acid vaccination. Nearly all reported patients with myocarditis or AMI after COVID-19 vaccination have survived and become asymptomatic. Described herein is a previously healthy man who developed severe heart decompensation shortly after receiving a COVID-19 vaccination and died approximately 40 hours later. An autopsy disclosed massive AMI.

Ascending aortic dissection is a catastrophic cardiovascular event within the pericardial sac. The fatal consequences of aortic dissection within the pericardial sac are primarily cardiac tamponade from aortic rupture, myocardial ischemia from coronary malperfusion, and severe aortic valve regurgitation that is uncompensated. Ascending aortic dissection, or type A aortic dissection (TAAD), presents in various ways, differentiated primarily by timing (hyperacute, acute, subacute, chronic), etiology (spontaneous or previous cardiovascular procedure), and malperfusion (absent, regional, global). A cardiovascular surgeon examining a patient with TAAD has the responsibility of deciding whether and when to perform the central aortic repair. Sabe et al1 1 recently addressed this subject of "deferral of surgery." For some cardiovascular surgeons, the decision and treatment may indeed be wisely deferred to an aortic surgeon at an aortic center. The purpose of this review is to present practical criteria to decline a central repair in TAAD, or to delay the operation from emergent status, or perhaps even to delay and eventually decline.

Surgery for type A aortic dissection (TAAD) is associated with a high risk of early mortality. The prognostic impact of a new classification of the urgency of the procedure was evaluated in this multicenter cohort study. Data on consecutive patients who underwent surgery for acute TAAD were retrospectively collected in the multicenter, retrospective European Registry of TAAD (ERTAAD). The rates of in-hospital mortality of 3,902 consecutive patients increased along with the ERTAAD procedure urgency grades: urgent procedure 10.0%, emergency procedure grade 1 13.3%, emergency procedure grade 2 22.1%, salvage procedure grade 1 45.6%, and salvage procedure grade 2 57.1% (p <0.0001). Preoperative arterial lactate correlated with the urgency grades. Inclusion of the ERTAAD procedure urgency classification significantly improved the area under the receiver operating characteristics curves of the regression model and the integrated discrimination indexes and the net reclassification indexes. The risk of postoperative stroke/global brain ischemia, mesenteric ischemia, lower limb ischemia, dialysis, and acute heart failure increased along with the urgency grades. In conclusion, the urgency of surgical repair of acute TAAD, which seems to have a significant impact on the risk of in-hospital mortality, may be useful to improve the stratification of the operative risk of these critically ill patients. This study showed that salvage surgery for TAAD is justified because half of the patients may survive to discharge.

Transcatheter aortic valve implantation (TAVI) has brought in recent years relief of cardiac-induced symptoms to a large number of patients with aortic stenosis. Whether it is better to use TAVI for the treatment of aortic valve stenosis superimposed on a congenitally bicuspid valve has been debated in contrast to its proved usefulness in aortic valve stenosis involving a tricuspid aortic valve. From January 2020 to March 2023, surgical aortic valve replacement of TAVI valve and native aortic valve was done in 6 patients. The clinical findings of the patients and morphologic findings from the surgical specimens submitted to the cardiac pathology department were subsequently examined. All the 6 native aortic valves had bicuspid configuration. The TAVI valve in each patient was excised from 9 to 88 months (mean 36 months) after it had been implanted because of paravalvular leak in 4, severe stenosis of the prosthetic valve in 1, and bioprosthetic cuspal degeneration in 1. Prosthetic valve endocarditis was clinically suspected in 2 patients, but the specimen culture was negative. Before surgical aortic valve replacement, 3 patients experienced stroke after TAVI. All 6 patients had low hemoglobin levels (mean 9.5 mg/100 ml) and low hematocrit levels (mean 29.5%). Reticulocyte count was available in 4 patients and was increased in all (mean 3.5%). When the stenotic native aortic valve configuration is bicuspid, the raphe tends to be calcified first and located perpendicular to the flow of the blood and may prevent the ring of the caged bioprosthesis from being transferred to the aortic wall, which is a requirement for full opening of the lumen of the bioprosthesis. Thus, thorough consideration needs to be made before performing TAVI in patients whose native aortic valve is stenotic and bicuspid.

After recovering from severe COVID-19 infection, 2 women presented with chest pain. Computed tomographic angiography suggested acute ascending aortic dissection. At operation in both patients, the ascending aorta was encased in dense fibrous tissue, within which were focal collections of mononuclear cells, including many plasma cells. There was no entry tear or dissection. Such findings we have not encountered previously, and PubMed search of "periaortic fibrosis and COVID-19" yielded no similar cases or possible relation.

Described herein are necropsy findings in 97 patients aged 22 to 82 years (mean 55), 37 women, 60 men, studied at necropsy with acute aortic dissection (AD) with the intimal-medial tear in the ascending aorta. The cases were studied from 1966 to 1989, a period when echocardiography and computed tomography were relatively infrequently available for diagnosis of AD. Arteriography was the method for diagnosis in most cases. Of the 97 cases, 30(31%) had operative intervention and 67 did not. Most appeared to have had systemic hypertension before the acute AD; only 4 had previous heart failure; only 8 had considerable atherosclerotic coronary disease; only 4 had a left ventricular (LV) scar and in each it was small; most (96%) had a normal-sized LV cavity (suggesting normal cardiac indices in them), and the other 4 had only a mildly dilated cavity; the heart weight in all 97 patients was increased; the quantity of subepicardial adipose tissue was increased in most patients, and the frequency of a congenitally malformed aortic valve was much higher than in the general population (6% - vs- 1%), but still uncommon. Thus, in > 90% of patients with acute Type A AD, coronary atherosclerosis was insignificant, myocardial fibrosis is absent, and the aortic valve has 3 cusps without stenosis.

Acute aortic dissection is a relatively common disease involving the aorta. All aortic dissections start with an intimal-medial tear prior to the medial dissection. Several cases of aortic intimal-medial tear without dissection have been reported previously, but only one article presented a photograph of the intimal-medial tear. Herein, we describe 16 patients whose ascending aortas were operatively excised because of what clinically was believed to be acute aortic dissection. Of the 16 patients, 14 had aortic intimal-medial tears without dissection and the other 2 had acute medial dissection of the aorta adjacent to a healed aortic intimal-medial tear without dissection. These aortic intimal-medial tears have been seen in the Marfan syndrome, but none of our 16 patients had the Marfan syndrome. At least 9 of the 16 patients, however, had had aortas similar to those seen in the Marfan syndrome (forme fruste variety). Although the 8 surgeons who operated on these 16 patients described the intimal-medial tears as "aortic dissection", only 2 had acute dissection adjacent to a healed intimal-medial tear without dissection. In conclusion, although the aortic intimal-medial tear is the initiator of aortic dissection, some patients with intimal-medial tears have no accompanying dissection.

Described herein is a morbidly obese 57-year-old man with an aneurysm involving the tubular portion of the aorta. Examination of the wall of the operatively resected aneurysm disclosed classic findings of aortic syphilis, a condition that clearly has not disappeared. If there is an aneurysm involving the tubular portion of the ascending aorta in the absence of aortic dissection or involvement of the sinuses of Valsalva, the most likely diagnosis is aortic syphilis. In these circumstances, the serologic test for syphilis is often negative.

Described herein are findings in 15 infected bioprostheses that had been in place from 5 to 120 months (mean 42). The major purpose was to show multiple photographs of the operatively-excised bioprostheses to illustrate the variable causes prompting excision of the bioprostheses. Eleven patients survived ≥ 30 days following the bioprosthetic excision and 9 patients lived longer than 1 year postoperatively. The techniques to explant the infected bioprosthesis appears to vary a bit among the operating surgeons.

Described here are some clinical and morphological observations in 37 adults having mitral valve replacement for active infective endocarditis limited to the mitral valve. The operatively-excised mitral valves are illustrated in 11 of the 37 patients, and photographs in them show that mitral valve repair in them would have been fruitless. Of the 37 patients, 32 (86%) survived the early operative period (30 days) and 31 (84%) were alive one year after the mitral operation. Of the 37 patients, 34 (92%) appeared to have had anatomically normal mitral valves before the infective endocarditis appeared.