The perioperative management in adult cardiac surgery patients remains highly variable across centres and regions. The APECx study (Anaesthesia, Perfusion and surgical practicEs in Cardiac surgery) aims to describe the incidence of key clinical patient outcomes, map global variation in anaesthesia, perfusion and surgical practices in cardiac surgery, identify potential modifiable factors associated with relevant clinical outcomes, and explore global, socioeconomic and sex-based differences within these practices. APECx is a prospective multicentre observational study scheduled to start in 2026 that will be conducted in cardiac surgery centres worldwide. Through a modular design, the research focus will evolve over time by going through multiple study phases during a 10-year period. Participating centres can join or leave each study phase and will be actively recruited over the course of the entire study period. Data collection will occur biannually, including all consecutive eligible cases during two prospectively pre-specified locally defined consecutive weeks within a 3-month window. Data will be collected using a web-based electronic case report form. Collected data will be limited to a clearly delineated minimised dataset. All data are routinely obtained as part of standard clinical care. Overall clinical outcomes include, but are not limited to, intensive care unit (ICU) and hospital length of stay, and in-hospital mortality with a maximum follow-up of 30 days. A pilot study will evaluate the feasibility and quantify the workload for participating sites. This study protocol was approved by the Medical Ethics Review Committee of Amsterdam UMC and will be conducted in accordance with local regulations at each participating centre. APECx is a modular, multiphase, large-scale, international, multicentre cohort study with the potential to contribute to standardised, evidence-based care worldwide. By minimising site burden, APECx will allow centres with varying amounts of resources from various economies to join. The modular design uniquely positions it to provide a broad overview of global perioperative practices in cardiac surgery, while enabling detailed investigation of specific evidence gaps.

Background and Objective:The frozen elephant trunk (FET) repair has transitioned from a niche procedure to a widely adopted strategy across Asia, Europe, and North America. Multicenter registries demonstrate improving early outcomes over time, consistent with learning curve effects. Regional differences persist in case mix, device availability, and utilization. No study has systematically measured these regional differences. We aim to describe the history, evolution, and current landscape of FET worldwide. Methods:A narrative review of English-language adult studies from PubMed, Google Scholar and International Clinical Guidelines (January 2010-September 2025) was performed using procedural and device terminology. Multicenter registries and large single-center series reporting case volumes and outcomes (mortality, stroke, spinal cord ischemia) were included. Data on indication, regional techniques, device use, and clinical outcomes were extracted to identify global and temporal trends. Key Content and Findings:FET utilization demonstrates wide regional variability, further obscured by heterogeneity in published studies reporting either acute type A aortic dissection (ATAAD) specific or mixed pathology cohorts. China exhibits the highest utilization (48-78% of ATAAD patients). Japan has shown substantial growth over the past decade, with contemporary data indicating FET use in 20% of thoracic aortic cases. In contrast, United States utilization remains low (<5% in mixed cohorts) and European adoption is similarly modest (<10% across arch series). Evidence suggests a procedural learning curve, with higher institutional volume and contemporary practice associated with improved outcomes. Global FET series report operative mortality of 4-12% for ATAAD and 2.5-13% across mixed pathologies, stroke rates of 3-9%, and paraplegia rates of 2-6%. Recent systematic reviews demonstrate 5-year survival of 78-82% and freedom from reintervention of 87%. These gains appear linked to convergence toward moderate hypothermia with selective antegrade cerebral perfusion, proximalization of the distal anastomosis to zone 2, and shorter stents to reduce spinal cord injury. Conclusions:Global FET volume has risen markedly over two decades, driven by standardization of neuroprotective techniques and advanced hybrid prostheses. A core set of principles has emerged establishing FET as a safe and versatile option for complex aortic disease worldwide. However, differences in devices, patient populations, and procedural indications remain.

OBJECTIVES:To assess surgical challenges and outcomes associated with arch anomalies in patients undergoing frozen elephant trunk (FET) for acute and chronic dissections. METHODS:From January 2007 to January 2024, 401 patients underwent FET procedure in our centre. We included 285 patients with acute type A/B, chronic type A/B, and residual dissection. Patients were divided into normal arch group (n = 216) and arch anomalies group (n = 69), including aberrant right subclavian artery, bovine trunk, arch vertebral artery, and gothic arch. RESULTS:Overall in-hospital mortality was 15.4% (17.4% in arch anomalies vs 14.8% in arch normal). In-hospital thoracic endovascular aortic repair (TEVAR) occurred in 7.2% (n = 5) of patients with arch anomalies. Stent graft-induced new entry tear at follow-up was 26.1% in arch anomalies vs 17.1% in arch normal group. Long-term survival in the overall patients was not different between the 2 groups (P = .383). In the subgroup of patients treated for chronic aortic dissection, freedom from TEVAR was higher in those with normal arch anatomy (P = .026). CONCLUSIONS:Aortic arch anomalies, especially in chronic dissection, were associated with increased endovascular reintervention. The gothic arch is the most challenging configuration due to frequent stent kinking.

Objective Redo mitral valve surgery (MVS) poses technical challenges and high operative risks as the result of adhesions and sternal re-entry. Right minithoracotomy has emerged as an alternative to repeat sternotomy. This study evaluated feasibility and perioperative outcomes of redo MVS through right minithoracotomy and compared 3 different myocardial protection strategies: cardioplegia, ventricular fibrillation (VF), and beating-heart. Methods All patients who underwent redo MVS via right minithoracotomy between 2015 and 2023 were identified from the Mini-Mitral International Registry. The primary end point was in-hospital mortality. Secondary end points included stroke, low cardiac output, bleeding requiring revision, conversion to sternotomy, and major complications. Moreover, 3 myocardial protection strategies were analyzed: cardioplegic arrest (n = 373), VF (n = 105), and beating-heart (n = 24). Results A total of 502 patients were included (median age 68 years). Overall in-hospital mortality was 7.6% (4.1% in elective and 24.4% in urgent cases). Conversion to sternotomy occurred in 3%. Stroke rate was 2.8% and reoperation for bleeding was 8.8%. After adjustment, VF was independently associated with a greater risk of low cardiac output (adjusted odds ratio, 3.5; P = .004). Beating-heart surgery was associated with increased in-hospital mortality (adjusted odds ratio, 6.6; P = .02). No significant association was observed between myocardial protection strategy and stroke or major complications. Conclusions Redo MVS via right minithoracotomy is feasible and safe in experienced centers. Cardioplegic arrest was associated with more favorable early outcomes and should be considered the default myocardial protection strategy whenever feasible. No-clamp techniques remain valuable in selected high-risk scenarios but are associated with trade-offs that warrant careful patient selection.

Mitral valve regurgitation is the second most common valvular heart disease in Europe, and an estimated 10% of individuals older than 75 years have severe mitral regurgitation. Mitral valve repair is the preferred strategy to treat mitral regurgitation and is associated with better outcomes than mitral valve replacement. Despite the proven efficacy of surgical repair, available data in functional aetiologies reported a non-negligible rate of echocardiographically detected severe mitral regurgitation within ten years of the index procedure, in some cases resulting in redo interventions. Data on the optimal management of patients with failed mitral repair remain limited. The aim of this review is to present the available approaches for treating failed mitral valve repair and to describe criteria for selecting the most appropriate strategy on the basis of the underlying mechanism of repair failure, with respect to possible surgical re-repair and novel transcatheter edge-to-edge repair techniques in the presence of favourable mitral valve anatomies.

Background:This study investigates pre- and intra-operative risk factors for re-operation after valve sparing aortic root replacement using the David technique to develop a risk model. Methods:A retrospective cohort study of two European centers, comprising data from 07/1993 to 01/2025 was performed. Follow up time was 120 (IQR: 141) months. Primary outcome was aortic valve re-operation. Prediction model was developed using uni- and multivariable logistic regression analysis. A risk score was derived. Calibration in the large and slope were performed. Receiver operating characteristic (ROC) analysis allowed discrimination assessment. Results:1,074 patients were included. Male sex (OR: 1.98; 95% CI: 1.16-3.39, p = 0.012), age at operation (OR: 0.98; 95% CI: 0.97-0.996; p = 0.011), pre-operative AI grade (OR: 1.61; 95% CI: 1.21-2.14; p = 0.001), NYHA (OR: 1.29; 95% CI: 1.0043-1.67; p = 0.046), bicuspid aortic valve (OR: 2.03, 95% CI: 1.18-3.49; p = 0.011) and prosthesis size (OR: 0.76; 95% CI: 0.66-0.86; p < 0.001) remained independent predictors in multivariable analysis. The risk model showed moderate discrimination [AUC: 0.722 (95% CI: 0.677-0.766)] and good calibration in the original cohort [intercept: -0.00 (95% CI: -0.49-0.49); slope: 1.00 (95% CI: 0.75-1.26)]. Conclusion:Bicuspid aortic valve, higher pre-operative AI, NYHA grade and male sex were independent risk factors for re-operation. Higher age and larger prosthesis sizes were protective factors. Further multi-center research is needed to validate and refine the prediction model.

BACKGROUND:Since the introduction of Frozen Elephant Trunk in 2007, our center has refined surgical techniques, patient selection, and perioperative management. This study assesses how nearly two decades of institutional experience influenced indications, outcomes, and technical strategies. METHODS:This is a retrospective, single-center analysis of 417 patients undergoing Frozen Elephant Trunk between 2007 and 2024, stratified into three Periods (2007-2013; 2014-2019; 2020-2024). Indications included Stanford type A/B acute and chronic aortic dissections, residual dissections and degenerative aneurysms. Survival, freedom from thoracic endovascular aortic repair, and distal stent graft-related complications were assessed using Kaplan-Meier analysis. RESULTS:Across Periods, acute type A dissections increased significantly (10% to 29.4%, OR 2.24, 95% CI 1.27-3.96, P<0.001). Surgical refinements included shifting distal anastomosis from zone 3 to zone 2, transitioning from island to separate supra-aortic vessel reimplantation, and adopting the Thoraflex Hybrid prosthesis. Visceral ischemia time decreased significantly (60 [IQR29] to 32 [IQR11] minutes, MD 11.83, 95% CI 15.94-7.72, P<0.001), and spinal cord injury rates declined (12.8% to 2.8%, OR 0.23, 95% CI 0.07-0.77, P<0.001). Thirty-day mortality remained stable, while 5-year survival improved (75.2% to 91.3%, P=0.29). Distal stent graft-induced new entry increased in Period 3. Endovascular repair for graft kinking became more frequent consistent with increasingly complex anatomies. CONCLUSIONS:Progressive institutional experience with Frozen Elephant Trunk has broadened indications to more complex cases, reduced ischemia times, and improved neurological outcomes without compromising survival. Institutional learning is pivotal in optimizing outcomes and expanding applicability in complex aortic surgery.

Background:Cerebral protection is a key determinant of perioperative outcomes in aortic arch surgery. Despite significant advances, optimal strategies regarding temperature, perfusion modality, and cannulation site remain controversial, with heterogeneous evidence and lack of standardized protocols. Methods:This narrative review summarizes experimental and clinical evidence from the last 15 years, focusing on the main determinants of cerebral protection: cerebral blood flow (CBF), autoregulation, perfusion pressure, temperature management, cannulation strategies, and antegrade (ACP) versus retrograde cerebral perfusion (RCP). Results:Available evidence consistently shows that any form of cerebral perfusion is superior to no perfusion during circulatory arrest (CA). Selective antegrade cerebral perfusion (SACP) has progressively emerged as the most widely adopted strategy worldwide, supported by its more physiological flow pattern and encouraging clinical outcomes. Axillary artery cannulation is currently the preferred approach and is associated with a lower stroke risk compared to femoral access, although femoral cannulation remains a valid alternative in unstable patients requiring rapid cardiopulmonary bypass (CPB) initiation. Comparative studies between ACP and RCP demonstrate no clear superiority in terms of mortality or permanent neurological dysfunction (PND), particularly for short CA times. However, SACP may reduce temporary neurological deficits (TNDs). A global shift towards moderate-to-mild hypothermia combined with cerebral perfusion has been observed, with favorable outcomes. Nonetheless, substantial variability persists in perfusion parameters, including flow, pressure, and the choice between unilateral and bilateral cerebral perfusion. Conclusions:Contemporary practice is moving toward strategies that better replicate physiological cerebral perfusion, favoring antegrade flow with moderate hypothermia. However, the lack of high-quality randomized evidence and persistent heterogeneity limit definitive recommendations, highlighting the need for standardized protocols and individualized approaches.

Historically, aortic aneurysms were considered incurable with rupture leading to catastrophic outcomes. But over the centuries, with advances in surgery and in medicine generally, significant progress has been achieved often by small steps, but occasionally by critical insights and major breakthroughs. Understanding the historical evolution of aortic repair illustrates how incremental innovations transformed a once incurable condition into a treatable disease. A number of important advances took place in America, and many historical reviews have, justly, highlighted these contributions. But this manuscript focuses on the ground-breaking innovations that occurred in Europe and divides the history into successive eras: "The Beginnings;" the 18th-century, marked by ligation techniques that laid foundational principles; the 19th-century, characterized by early reconstructive attempts; and the 20th-century, where breakthroughs were made at an exponential pace, culminating in the endovascular era, in which Europe led the first clinical evaluation and regulatory approval of aortic stent grafts.

OBJECTIVES:This study aims to assess whether aortic arch anatomy, classified as Arch Type I, II, and III configuration, was associated with the Stanford aortic syndrome type at presentation. METHODS:This is a retrospective, single-centre study including patients admitted between 2006 and 2023. Stanford type A/B acute and chronic aortic syndromes, including intramural haematoma and penetrating aortic ulcer, were evaluated. Aortic anatomy and aortic syndrome patterns were assessed via contrast-enhanced CT angiography performed at disease onset. Patients underwent follow-up through outpatient visits. RESULTS:Throughout the study period, 846 patients presented with acute or chronic Type A or B aortic syndrome. Of these, 605 patients with baseline contrast-enhanced CT angiography were analysed. Patients were grouped by arch configuration: Arch Type I (n = 199, 32.9%), Arch Type II (n = 190, 31.4%), and Arch Type III (n = 216, 35.7%). Mean ascending aorta length and maximum diameter were significantly greater in Arch Type I, compared to Arch Type II and III (10.2 cm vs 10 cm vs 9.7 cm, MD Arch Type I vs Arch Type III 0.68, 95% CI 0.31-1.06, P < .001; 46 mm vs 43 mm vs 40.5 mm, MD Arch Type I vs Arch Type III 4.21, 95% CI 1.81-6.61, P < .001). Arch Type I was significantly associated with Type A aortic syndrome (OR 2.14, 95% CI 1.51-3.03, P < .001) and Arch Type III with Type B aortic syndrome (OR 2.28, 95% CI 1.62-3.20, P < .001). During hospital stay, 344 (56.8%) patients underwent open surgery, 147 (24.3%) endovascular treatment, 110 (18.2%) medical treatment, and 4 (0.7%) died before treatment. Thirty-day mortality in Arch Type I, Type II and Type III was 12.1%, 9.5% and 6.9% (P = .2). Kaplan-Meier analysis, restricted to treated patients with available follow-up (n = 432), showed higher 5-year survival rate in Arch Type I compared to Arch Type II and Arch Type III (HR 1.83, 95% CI 1.12-2.97, 90.1% vs 88.2% vs 87.8%, P = .05). CONCLUSIONS:Aortic arch morphology may be associated with aortic syndrome type. Arch Type I was associated with larger and longer ascending aorta and Type A aortic disease, whereas Arch Type III emerged as a potential indicator for Type B disease.

Introduction: The impact of aortic inflammation on aortic surgery is still unclear. Hypothesis: Aortic inflammation affects the freedom from reintervention in the distal native aorta following the aortic arch surgery. Methods: This is a retrospective observational study performed on the aortic histology of patients over 18 years old who underwent aortic arch surgery in a single centre, from 2000 to 2023. Variables included demographics, cardiovascular risk factors and indication for surgery. The follow-up verified death or reintervention on the distal native aorta. The relationship between aortic inflammation and cardiovascular risk factors was tested with Logistic Regression, expressed as odds ratio (OR) and 95% confidence interval (CI95%). The Cox regression evaluated if inflammation was a significant predictor for mortality and reintervention, expressed as hazard ratio (HR) and 95%CI. The Kaplan-Meier curves for the freedom from reintervention stratified by inflammation were compared with the Tarone-Ware test. Results: Data concerning 568 patients were gathered: 62(10.9%) had aortic inflammation. The median follow-up was 5.1 years (Interquartile 0.79-8.65 years). The inflammation was independently associated with females (OR2.96 CI95% 1.66-5.28 p<0.01), age (OR1.06 CI95% 1.02-1.09 p<0.01), and aneurysmatic aorta (OR3.81 CI95% 1.29-11.28 p=0.016), but not with aortic dissection (OR0.67 CI95% 0.19-2.32 p=0.53). Inflamed aorta did not increase mortality (HR0.93 CI95% 0.55-1.57 p=0.78). However, inflammation was a risk factor for reintervention on the distal aorta (HR1.9 CI95% 1.04-3.51 p=0.038), especially not feasible with endovascular treatment (HR3.64 CI95% 1.01-13.13 p=0.048) independently from aortic dissection (HR0.82 CI95% 0.55-1.22 p=0.32). The Kaplan-Meier curves confirmed that an inflamed aorta provided lower freedom from reintervention than one without inflammation (Tarone-Ware Test p<0.037). Conclusions: Aortic inflammation in patients treated with aortic arch surgery is associated with age, female gender, and aneurysmatic pathology. Inflammation doesn’t affect survival after surgery. However, it strongly increases the risk of reintervention in the distal native aorta.

The prevalence of mechanical complications following acute myocardial infarction has steadily declined in recent years owing to advances in prompt coronary revascularization, and they now occur in <1% of acute myocardial infarction cases. Nevertheless, significant haemodynamic impairment may already be present at hospital admission, requiring immediate diagnostic evaluation and urgent intervention. Until recently, surgical repair was the only treatment option, with non-negligible in-hospital mortality rates, particularly among patients with acute cardio-circulatory failure. Advances in transcatheter percutaneous procedures have now introduced alternative treatment strategies, especially for high-risk or inoperable patients. Recurrence of post-acute myocardial infarction mechanical complications, even shortly after the repair of the underlying lesion, has a critical impact on patient outcome and underscores the need for careful monitoring during hospitalization as well as after discharge. The role of concomitant coronary revascularization remains controversial, with variable effects on both early and late outcomes, and warrants further investigation. Temporary mechanical circulatory support has shown encouraging results, either for pre-procedural haemodynamic stabilization ('bridge-to-procedure') or for prophylactic, extended peri-procedural support to facilitate myocardial recovery ('bridge-to-recovery'). Optimal management should be guided by a multidisciplinary Heart Team approach (including Shock Team involvement where appropriate) with integration of palliative care into the decision-making process.

Background Multimodality imaging plays a central role in the evaluation of cardiac masses (CMs), yet the comparative performance of integrated imaging strategies including cardiac magnetic resonance (CMR), cardiac computed tomography (CCT), and 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) remains incompletely defined. Objectives This study sought to compare the diagnostic accuracy of multiparametric scores derived from echocardiography, CMR, CCT, and 18F-FDG PET, individually and in combination, for identifying malignant CMs using histology as the reference standard. Methods In this prospective study, patients with suspected CMs underwent echocardiography, CCT, CMR, and 18F-FDG PET within 2 months of first medical contact. Final diagnosis was established by histology or radiological resolution after anticoagulation therapy for thrombi. Diagnostic performance was assessed using receiver-operating characteristic curves, and the areas under the curve (AUCs) were compared with the DeLong test, applying Bonferroni correction for multiple comparisons. CART (Classification And Regression Tree) analysis assessed the incremental value of PET following CMR or CCT. Results Among 142 patients, 54% had malignant CMs. Echocardiography showed the lowest diagnostic accuracy (AUC: 0.77). CMR demonstrated the highest standalone performance (AUC: 0.94), outperforming CCT and 18F-FDG PET (both AUCs: 0.85). The combination of CMR and 18F-FDG PET was associated with high diagnostic accuracy (AUC: 0.97; positive predictive value 95.1%; negative predictive value 100%), whereas CCT combined with 18F-FDG PET achieved an AUC of 0.92. The addition of PET after CMR or CCT was associated with improved diagnostic classification in selected cases, as supported by CART analysis. Conclusions CMR provides the highest standalone accuracy for malignancy detection. In inconclusive cases, adding 18F-FDG PET further improves diagnostic performance, while CCT combined with 18F-FDG PET represents a reliable alternative.

OBJECTIVES:Sutureless aortic valve prostheses reduce surgical times and facilitate minimally invasive approaches, improving patient outcomes. However, it remains unclear whether these devices provide specific benefits to female patients, in whom sex-related differences in valve surgery outcomes remain a matter of debate. METHODS:Up to September 2024, 535 subjects (261 women) received Perceval Plus at 35 investigational sites from Mitral, Aortic aNd Tricuspid Post-maRket Study in a reAl-world Setting observational prospective registry. Moreover, meta-regression was performed to assess whether sex modifies outcomes. RESULTS:Men have a larger body size (body surface area: male 2.0 ± 0.2 vs female 1.8 ± 0.2, P < .001), resulting in a larger prosthesis size (size S: male 2.9% vs female 34.9%). Surgery was still significantly faster in women (cross-clamp time: male 63.7 ± 29.4 min vs female 56.8 ± 29.4 min, P = .002), partly because approximately 10% of procedures in male patients were combined, increasing duration. Early outcomes were comparable between sexes (hospital deaths: male 3 [1.1%] vs female 5 [1.9%], P = .49). At follow-up, no significant differences were observed (follow-up deaths: male 9 [3.3%] vs female 5 [1.9%], P = .42). Meta-regression showed no effect of female sex prevalence. CONCLUSIONS:Our registry and meta-regression analysis did not reveal significant differences in outcomes between men and women. Preoperative characteristics, however, differ between sexes and may influence outcomes and prosthesis choice. Long-term conclusions are limited by the current follow-up duration and will be further explored as data collection progresses. CLINICAL REGISTRATION NUMBER:NCT05002543, ClinicalTrials.gov (https://clinicaltrials.gov/study/NCT05002543).

OBJECTIVES:We described short- and mid-term outcomes of hybrid thoraco-abdominal aortic aneurysm repair (HTAR), combining visceral debranching and thoracic endovascular aortic repair (TEVAR). METHODS:This multicentric, retrospective cohort study analysed prospectively collected data from 2 Italian referral centres on patients undergoing HTAR with at least one renal artery bypass between 2003 and 2024. These patients were deemed unfit for open surgery. Primary outcomes were early (≤30 days) and mid-term survival, and freedom from aorta-related mortality (ARM). Secondary outcomes included spinal cord injury (SCI), freedom from reintervention, and bypass patency. RESULTS:The population included 86 patients, 12 (13.9%) of which were urgent. Median age was 69 years. In-hospital mortality occurred in 20 patients (23.3%), with major complications in 33 (38.4%), mainly acute kidney injury (AKI) (20; 23.3%) and pneumonia (9; 10.5%). Spinal cord injury rate was 5.8%. A 2-stage strategy was used in 68 patients (79.1%). Median follow-up was 17.5 months. At 1-, 2-, and 5-years, survival was 68.6%, 67%, and 50.9%, freedom from ARM was 82.4%, 82.4%, and 82.4%; freedom from reintervention was 97.4%, 97.4%, and 87.7%, and patency was 95%, 89%, and 84%. Late reintervention occurred in 12.1% of patients. Female gender and rupture were significant predictors of reintervention and mortality, respectively. Quartile of experience correlated with improved outcomes. CONCLUSIONS:HTAR provides an alternative to open repair in high-risk thoracoabdominal aortic aneurysm (TAAA) patients, with acceptable early and mid-term outcomes. While in-hospital mortality remains notable, SCI rates are low thanks to the 2-stage approach, and freedom from ARM and bypass patency are satisfactory. IRB APPROVAL:No. 121/2022/Disp/AUOBo/10/2023.

OBJECTIVES:To evaluate the impact of preoperative renal function on early clinical outcomes of patients undergoing aortic arch surgery with hypothermic circulatory arrest and visceral ischaemia. METHODS:This single-centre retrospective study included 1077 consecutive patients who underwent aortic arch surgery between 1996 and 2024 at the University Hospital of Bologna. Patients were stratified by preoperative estimated glomerular filtration rate into 4 stages. Regression analysis, including adjustment for confounders and cubic splines, was applied to assess the impact of estimated glomerular filtration on 30-day mortality and major complications. RESULTS:A lower estimated glomerular filtration value was significantly associated with increased 30-day mortality (-0.015; CI: -0.025; -0.005), prolonged intubation (-0.018; CI: -0.024; -0.012), higher incidence of temporary dialysis (-0.021; CI: -0.032; -0.011), and gastrointestinal complications (-0.014; CI: -0.025; -0.003) in univariate logistic regression models, and after adjustment for confounders these associations remained significant. CONCLUSIONS:Preoperative renal function is a powerful predictor of early morbidity and mortality following aortic arch surgery. The preoperative estimated glomerular filtration value is a key factor in surgical risk stratification and the development of tailored intraoperative strategies.

AIMS:Left ventricular assist device (LVAD) implantation is an established therapy for advanced heart failure, either as bridge-to-transplantation (BTT) or destination therapy (DT). The Italian National Transplant Center supported the development of the Italian multicentre registry for mechanically assisted circulatory support (ITAMACS). We report the first analysis of the ITAMACS registry, focusing on durable intracorporeal LVADs. METHODS:All durable LVAD implantations performed in Italy between January 2010 and December 2021 were collected, including follow-up data, and submitted by participating centres to a centralized database. Demographic characteristics, procedural variables, and clinical outcomes were analysed. Survival was assessed using Kaplan-Meier analysis, and Cox proportional hazards models were used to identify independent predictors of long-term mortality. RESULTS:A total of 1061 patients from 12 centres underwent durable LVAD implantation. BTT was the indication in 40.5% and DT in 38.8% of cases; 14.8% of patients were in INTERMACS class 1, and 16.3% underwent minimally invasive implantation. Overall survival at 1, 3, and 5 years was 73%, 54%, and 42%, respectively. On multivariable analysis, older age (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1.01-1.04) and redo surgery (HR 1.25, 95% CI 1.02-1.55) were associated with higher mortality, whereas INTERMACS class >1 (HR 0.66, 95% CI 0.50-0.87) and BTT indication (HR 0.63, 95% CI 0.48-0.83) were protective. CONCLUSION:ITAMACS is the first national registry reporting real-world outcomes of durable LVAD therapy in Italy. These data provide an overview of national practice and may support optimization of LVAD programs and patient care.