Background:The simplified delivery frozen elephant trunk (SD-FET) technique enables a one-step repair of type A acute aortic dissection (AAD) with stent proximalisation and very short normothermic circulatory arrest. This study reports early and 1-year clinical outcomes together with aortic remodelling in the residual dissected aorta. Methods:Thirty consecutive patients underwent SD-FET for AAD between 2018 and 2023. Preoperative, postoperative, 1-year follow-up computed tomography scans were analyzed. True lumen (TL), false lumen (FL), and total aortic diameters were measured in four segments (proximal descending, distal descending, coeliac trunk, infra-renal) using the centerline method. Aortic remodelling was classified as positive, stable, or negative. Early and mid-term outcomes were assessed, including mortality, neurologic complications, and aortic reinterventions. Results:Four patients (13%) died in-hospital, and four (13%) sustained postoperative stroke; no spinal cord injury occurred. During follow-up, one patient died of an aortic event and two required secondary reinterventions for downstream enlargement, yielding an overall 1-year freedom from reintervention of 92.5% [95% confidence interval (CI): 83-100%]. At the proximal descending aorta, TL increased and FL decreased significantly at 3 months and 1 year (P<0.001), with 92% of patients showing positive or stable remodelling. At the distal descending aorta and coeliac level, positive/stable remodelling was observed in 53% and 63% of cases, respectively, whereas infra-renal changes were limited. Conclusions:SD-FET simplifies total arch repair for AAD, reduces circulatory arrest under normothermia, and achieves acceptable early results. One-year clinical outcomes and remodelling are comparable to conventional FET, may supports its safety and efficacy, though larger cohorts and longer follow-up remain warranted.

Background Thoracic aortic aneurysms (TAA) are predominantly degenerative. Non-infectious inflammatory aortitis, including giant cell arteritis (GCA), Takayasu arteritis and clinically isolated aortitis (CIA), represents a less understood aetiology with poorly characterised growth patterns. While GCA is linked to higher TAA risk, preoperative growth data for inflammatory TAA are scarce. This study compares growth rates in histologically proven inflammatory aortitis.Methods We conducted a retrospective case–control study, including patients with histologically proven aortitis and matched controls with degenerative TAA. Cases and controls were matched for age, sex, surgical year and procedure type. Aneurysm growth rate (mm/month) was calculated from serial imaging.Results This study included 23 patients with histologically confirmed aortitis (13 GCA, 9 CIA) and 42 matched controls with degenerative TAA. The mean growth rate was significantly higher in the aortitis group (0.177±0.01 mm/month; 2.12 mm/year) compared with controls (0.039±0.02 mm/month; 0.47 mm/year), representing a 4.5-fold acceleration (p<0.001). Among inflammatory etiologies, CIA demonstrated faster growth (0.338±0.06 mm/month; 4.06 mm/year) than GCA (2.1 mm/year; p<0.01). Patients with CIA more frequently required Bentall procedures (33% vs 0%, p=0.047). No differences were observed in baseline demographics, cardiovascular risk factors or baseline aortic diameters between groups. Histologically, 70% of aortitis cases exhibited granulomatous inflammation.Conclusion Inflammatory aortitis is associated with a 4.5-fold faster preoperative TAA growth rate compared with degenerative aneurysms, with CIA exhibiting two times the growth rate of GCA. Prospective studies are warranted to validate these results and optimise surveillance and management strategies for this high-risk population.

OBJECTIVES:We report three-year safety and clinical outcomes in patients younger than 60 years undergoing bioprosthetic surgical aortic valve intervention. METHODS:The INSPIRIS RESILIA Durability Registry (INDURE) is a prospective, multicentre registry to assess clinical outcomes of patients under 60 years. Patients with planned surgical aortic valve replacement with or without concomitant replacement of the ascending aorta and/or coronary bypass surgery were included. Time-related valve safety, haemodynamic performance, and quality-of-life (QoL) at three years were assessed. RESULTS:The study cohort included 415 patients with a mean age of 53.5 years, 76.9% being male and 27.1% in New York Health Association (NYHA) class III/IV. Outcomes after three years included cardiovascular-related mortality (0.4%), thromboembolic events (0.6%), valve-related bleeding (0.0%) and new permanent pacemaker implantation (0.4%). QoL increased over the time course of the study from baseline to three-year follow-up. Three-year freedom from all-cause mortality was 95.4% (95% CI 93.3-97.6), and 84.5% were NYHA I versus 22.0% at baseline. No patient developed haemodynamic valve deterioration stage 3. The mean aortic pressure gradient was 13.7 mmHg at three years, and the mean effective orifice area was 1.8 cm. CONCLUSIONS:The three-year data from the INSPIRIS RESILIA valve demonstrate reassuring safety findings and stable haemodynamic performance as well as a high QoL.

Background Surgical explantation of transcatheter aortic valves (TAV-explant) is an emerging but uncommon procedure, increasingly required as TAVI is performed in younger and lower-risk patients. Contemporary evidence on outcomes, timing, and valve type remains limited. Methods We conducted a multicenter retrospective study of patients undergoing surgical TAV-explant. Clinical characteristics, indications, surgical strategies, and outcomes were analyzed. Outcomes were compared according to the interval between index TAVI and explantation (< 1 month, 1-12 months, > 12 months). The indication and the type of initial transcatheter valve (balloon-expandable vs. self-expanding) were also analyzed. The primary outcome was 30-day mortality. Results A total of 62 patients were included. Indications for TAV-explantation were predominantly bioprosthetic valve dysfunction (45.2%), infective endocarditis. (21%), and procedural failure (33.9%)The 30-day mortality was 16.1% and did not differ according to the delay of explantation (p = 0.816). Overall mortality did not differ according to the indication of explantation, nor by type of explanted valve. Concomitant aortic surgery was required in 18% of cases. Although EuroSCORE II values were elevated in this cohort, this tool underestimated the operative risk, as it was not designed for complex redo surgery. Conclusions TAV-explantation is technically feasible but remains associated with substantial early mortality. Outcomes are not influenced by the timing of explantation or by valve type. These findings highlight the limitations of current surgical risk scores and underscore the importance of thorough pre-operative planning and Heart Team evaluation. Continued multicenter data collection is essential to optimize patient selection and refine management strategies.

Background Bioprosthetic heart valves (BHVs) are widely used in cardiac surgery but are limited by structural valve deterioration (SVD). The Translink study showed that immune responses to xenogeneic glycans contribute to SVD. Hyaluronan (HA), a glycosaminoglycan with size-dependent biological functions, has been implicated in inflammation, xenoreactivity, and valve calcification. This study investigated humoral immune responses to HA oligosaccharides in a subgroup of the Translink cohort.Patients and methods Serum samples from 258 BHV recipients and 78 cardiac surgery controls were analyzed by ELISA, and a representative subset was further profiled using a printed glycan array (PGA). BHV recipients were classified with clinically significant SVD (A), as de novo implantation (B1), or long-term without SVD (B2). Controls included mechanical valve replacement or coronary artery bypass patients, either de novo (B1C) or long-term post-surgery (B2C). ELISA quantified IgG and IgM antibodies against HA fragments of increasing length (HA2, HA24, HA84), while PGA mapped fine specificity across HA2-HA40.Results All subjects exhibited measurable baseline anti-HA IgG and IgM antibodies. ELISA revealed a fragment-length dependence, with the shortest fragment, HA2, showing the highest antibody binding, and progressively lower reactivity with longer oligomers. Following de novo cardiac surgery, both BHV recipients and controls showed a transient increase in anti-HA antibodies, peaking at one month and declining within 6-12 months. In contrast, PGA consistently identified HA34 as the dominant immunogenic fragment across all cohorts and time points.Conclusions Anti-HA antibodies are constitutively present in humans, undergo transient amplification after cardiac surgery, regardless of prosthesis type, and display marked fragment-length specificity. Short HA2 fragments predominate in ELISA responses, whereas intermediate-length oligomers, such as HA34, emerge as conserved, immunodominant targets in PGA. These findings extend the Translink paradigm from xenogeneic to matrix-derived glycan immunity and identify anti-HA antibodies as potential biomarkers of postoperative inflammation and tissue remodeling, which could be relevant to SVD.

Background:As cardiac surgery becomes more complex and patient profiles heterogeneous, real-world data are essential to evaluate bioprosthetic valve performance beyond controlled trials. The Avalus Clinical confidencE (ACE) registry evaluates safety and hemodynamic performance of the Avalus (Medtronic) bioprosthesis. Methods:The ACE registry is a prospective, multicenter, single-arm, observational study including 1250 adult patients undergoing surgical aortic valve replacement with the Avalus valve in 27 European centers (2021-2024). Exclusion criteria were age <18 years and salvage surgery. Baseline characteristics, procedural details, and outcomes were collected. Echocardiography was performed at discharge and at 1 year. Results:Mean age was 71.5 ± 6.5years, 22.2% female, and mean European System for Cardiac Operative Risk Evaluation-II was 3.5 ± 5.7. Isolated surgical aortic valve replacement was performed in 39.8% of patients; the remainder underwent combined procedures, most common was coronary artery bypass grafting (26%). Prosthesis sizes ranged from 19-29 mm, with a mean of 24.0 ± 2.2 mm; 18% of valves were 19-21 mm. Mean effective orifice area increased from 0.96 ± 0.63 cm2 preoperatively to 1.99 ± 0.60 cm2 at discharge and 1.80 ± 0.37 cm2 at 1 year. Mean gradients were low (discharge, 11.4 ± 5.1 mm Hg; 1 year, 12.2 ± 5.0 mm Hg). Patient-prosthesis mismatch rates at discharge were 20.8% moderate, and 4.8% severe; at 1 year, mismatch rates were 20.6% moderate, and 2.6% severe. Conclusions:In this 1250-patient, real-world registry, the Avalus valve demonstrated low gradients, favorable effective orifice area, and low severe patient-prosthesis mismatch rates, with reassuring early clinical outcomes across the spectrum of prosthesis sizes.

Exploring the hemocompatibility of bioprosthetic heart valves (BHVs) has been challenging due to the scarcity of non-degenerated material. This study has two complementary objectives (1) To characterize the extent and temporal kinetics of endothelial coverage of BHVs implanted in humans; (2) To investigate, in a rat model, the impact of pericardial endothelialization on tissue calcification. We employed histology and electron microscopy to assess cellular organization in non-degenerated BHVs and conducted hemodynamic simulations to evaluate shear stress fields in the ejection valves area. Furthermore, we investigated the impact of pericardium endothelial coverage on calcification using endothelial colony-forming cells (ECFCs) cultured on bovine pericardium discs implanted in athymic nude rats for 18 days. Calcium content was quantified through acetylene flame atomic absorption spectrophotometry. We observed inflammatory cell infiltration within all explanted BHVs, as well as fibrin deposit on top of the leaflets. Endothelial coverage emerged in long-term implants (> 180 days) but remained incomplete in aortic valves, which could be linked to high shear stress levels in aortic position confirmed in hemodynamic simulations. Besides, the rat experiments revealed that the discs covered with fibrin + ECFCs were significantly less calcified than those covered with fibrin alone (respectively, median = 0.9 µg Ca/mg tissue; IQR: 0.7–1.1 vs median = 18.3 µg Ca/mg tissue; IQR: 9–34.9; p = 0.0003), and less extensively colonized by neutrophils. Human explanted BHVs showed intact leaflets with a fibrin layer and organized endothelial coverage, without detectable calcification over the short observation period. In rats, endothelialization was associated with significantly reduced pericardial calcification, suggesting a potential protective effect. However, the limited follow-up in humans precludes conclusions on a causal role of endothelial coverage in hemocompatibility or protection against calcification.

OBJECTIVE:This study compared the results of the conventional Frozen Elephant Trunk (FET) technique with those of a new approach for the treatment of Acute Aortic Dissection (AAD). SUMMARY BACKGROUND DATA:Frozen Elephant Trunk has revolutionized the treatment of extensive aortic pathologies. Hypothermic circulatory arrest is a recommendation for its implementation but remains the greatest burden. Our approach for the FET (Simplified Delivery-FET) procedure allows distal suturing in normothermia with a shorter circulatory arrest time. METHODS:This was a non-randomized, multicenter, retrospective study of all patients who underwent total arch replacement for AAD using either the normothermia (SD-FET) or conventional FET (control) techniques. The primary endpoints were in-hospital mortality, stroke, and spinal cord injury. RESULTS:One hundred and fifty-three patients were included (n=90 SD-FET; n=63 control FET). Overall, in-hospital mortality was 13.3% (n=20), 10.3% (n=9) in the SD-FET group and 27.5% (n=11) in the control FET group ( P =0.206). There were no differences in the rates of postoperative stroke and spinal cord injury. SD-FET was protective for combined outcome (death and/or neurological event) with a corresponding population-average percentage of events of 17.8% (5.3-27.7) in the SD-FET group versus 30.7% (16.5-52.8) in the FET group. The Kaplan-Meier showed a survival rate at 12 and 24 months of 87% in the SD-FET group versus 83% in the FET group and 86% in the SD-FET group versus 80% FET ( P =0.625), respectively. CONCLUSIONS:The SD-FET technique allows hybrid arch surgery to be performed without cooling and is associated with a lower incidence of the combined criteria of death and/or neurological events.

Introduction The use of biological heart valves (BHV) is constantly growing but their durability remains a main concern. Structural valve degeneration (SVD) occurs gradually and seems to reiterate, at least in part, the processes described in native valve stenosis. Lipoprotein (a) [Lp(a)] has been described as one of the main triggers of native valve calcification but its association with SVD remains unclear. Objective We aim to determine whether Lp(a) plasma levels and/or the Lp(a) polymorphic sizes, determined by the apolipoprotein (a) [apo(a)] Kringle-IV copy number, were associated with SVD. Method Three hundred and thirty-two patients with BHV for at least 4 years from the Translink study were included. SVD was assessed on echocardiography and computed tomography. Lp(a) concentration was determined by immunoturbidimetry method and the apo(a) Kringle-IV copy number by liquid chromatography-tandem mass spectrometry. Univariable and multivariable models, adjusted for clinically relevant and statistically significant variables, were used to determine the independent association between Lp(a) concentrations and/or apo(a) Kringle-IV copy numbers with SVD. Results Among the 332 patients included in this study, 76 (23%) presented clinically significant SVD on echocardiography. Bioprosthetic valve calcification was significantly higher in patients with versus without SVD (128 [24–259] vs 42 [0–150] mm3, P=0.005). Low apo(a) Kringle-IV copy number was associated with an increased risk of SVD (OR=2.71 [1.34–5.50], P=0.006), but not Lp(a) concentration (OR=0.99 [0.84–1.15], P=0.85). This association remained significant (OR=3.21 [1.31–7.84], P=0.01) after multivariable adjustments including Lp(a) concentration. The analysis of the transprosthetic mean gradient and bioprosthetic valve calcification provided consistent results (all P≤0.05). Conclusion This cross-sectional study from the Translink trial demonstrates the association between Lp(a) polymorphic size and SVD, highlighting a potential therapeutic option to limit the occurrence of SVD in selected patients who underwent AVR with surgical or transcatheter BHV.

BACKGROUND:Severe calcific aortic stenosis (AS) is the most common valvular heart disease in the elderly and carries a poor prognosis without intervention. The introduction of transcatheter aortic valve implantation (TAVI) in 2002 profoundly reshaped therapeutic strategies. This study aimed to evaluate changes in patient management and outcomes at the Departmental Hospital Center of La Roche‑sur‑Yon over three time periods: 2005 (pre‑TAVI era), 2015 (early TAVI integration), and 2022 (TAVI‑dominant era). METHODS:We conducted a retrospective, single-center observational study including all patients hospitalized for symptomatic severe AS or reduced left ventricular ejection fraction. Clinical characteristics, operative risk scores, management strategies, and one-year outcomes were analyzed. RESULTS:Between 2005 and 2022, the number of patients managed for SAS increased by 158% (65 in 2005, 136 in 2015, 168 in 2022). Mean age (79 years in 2022) and male proportion (60%) remained stable. Therapeutic strategies shifted markedly (p < 0.001): surgery predominated in 2005 (67%), whereas TAVI became the most frequent treatment in 2022 (55%), followed by surgery (21%) and medical therapy (24%). Surgically treated patients were increasingly selected, with a median EuroSCORE II falling from 3,95 % (2005) to 1.1% (2022). One-year all-cause mortality in 2022 was 0% after surgery, 5.9% after TAVI (down from 28.8% in 2015, p = 0.008), and 68% with medical therapy (p < 0.001). Heart failure rehospitalizations were also more frequent in the medical group (33% vs 6% after TAVI and 2% after surgery; p = 0.016). The proportion of patients not presented at the heart team meeting declined significantly (17% in 2022 vs 35% before 2015; p < 0.001). The waiting times nevertheless remained significant (median of 70 days between admission and the MDT meeting, plus 41 days before the procedure). CONCLUSIONS:Integration of TAVI has profoundly transformed AS management in our center, now the dominant strategy with significantly improved one-year prognosis. Medically treated patients still experience poor outcomes, underscoring the need to reduce delays and streamline the care pathway.

BACKGROUND:Management of degenerated aortic bioprostheses through valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) or redo surgical aortic valve replacement (Re-SAVR) shows similar short-term safety and efficacy. However, long-term survival and haemodynamic performance data are limited. AIM:To compare clinical characteristics, haemodynamics and outcomes at 3 years between ViV-TAVR and Re-SAVR techniques. METHODS:This retrospective two-centre study included 266 patients treated for isolated aortic bioprosthesis degeneration (130 Re-SAVR, 136ViV-TAVR) from 2009 to 2018, with up to 3 years of follow-up. RESULTS:The ViV-TAVR group was older (83 vs. 77 years; P=0.005) with higher surgical risk (Logistic EuroSCORE 22% vs. 13%; P=0.005). At 3 years, univariate analysis showed no significant difference in all-cause deaths (22.1% vs. 17.7%; P=0.37). ViV-TAVR was associated with fewer first-month complications, including major bleeding (11.0% vs. 52.3%; P=0.007) and acute renal failure grade 2/3 (5.1% vs. 14.6%; P=0.053). Inverse probability of treatment weighting analysis revealed no difference in all-cause deaths at 1 year (hazard ratio [HR] 0.78, 95% confidence interval [CI] 0.36-1.67; P=0.52) or between 1 and 3 years (HR 1.56, 95% CI 0.82-2.99; P=0.17). Composite events were similar at 1 year (HR 0.80, 95% CI 0.44-1.44; P=0.45) and between 1 and 3 years (HR 1.41, 95% CI 0.83-2.38; P=0.21). Mean gradients at 3 years were similar (16.1±11.4 vs. 13.2±5.3mmHg; P=0.17). In patients with small bioprostheses (true internal diameter≤20mm [n=151]), death rates at 3 years were similar (21.1% vs. 20.0%; P=0.86), as was haemodynamic performance (mean gradient 19.2±14.0mmHg for ViV-TAVR vs. 13.7±4.12mmHg for Re-SAVR [P=0.38]). Compared to balloon-expandable, self-expandable valves showed better 1-year mean gradients (16.4±10.5 vs. 13.7±4.12mmHg; P=0.012). CONCLUSIONS:ViV-TAVR and Re-SAVR had similar mortality and haemodynamic outcomes at 3 years, including in patients with small bioprostheses where self-expandable valves yielded the best results.

Background: Non-infectious aortitis encompasses various histological patterns, but their specific cardiovascular outcomes remain unclear. Objective: To evaluate the mortality associated with non-infectious surgical thoracic aortitis. Methods: This retrospective multicenter study included patients who underwent thoracic aortic surgery and had histological evidence of aortitis. The study analyzed the characteristics of patients with non-infectious aortitis presenting either a granulomatous/giant cell histological pattern or a lymphoplasmacytic pattern. Factors associated with mortality were identified using multivariate analysis. Results: Among 5666 patients who underwent thoracic aortic surgery, 197 were found to have non-infectious aortitis with either a granulomatous/giant cell histological pattern (n = 138) or a lymphoplasmacytic pattern (n = 59). The overall standardized mortality rate (SMR) for patients with non-infectious surgical thoracic aortitis was 1.61 (95 % CI: 1.05; 2.39), with 31.5 % of patients dying within 10 years of the initial procedure. After a median follow-up of 3.5 years [IQR: 0.5-6.8] post-surgery, 31 % of deaths were due to aortic dissection or rupture. The 10-year cumulative incidence of death was 40.1 % (95 % CI, 17.7-61.8) for patients with a granulomatous/giant cell pattern and 14.4 % (95 % CI, 2.6-35.6) for those with a lymphoplasmacytic pattern. Granulomatous/giant cell histological pattern (HR 4.71 [vs lymphoplasmacytic pattern]; 95 % CI, 1.37-16.2; p = 0.023) and aortic dissection at diagnosis (HR 6.07 [vs aneurysm]; 95 % CI, 2.89-12.7; p < 0.0001) were independently associated with increased mortality. Conclusion: This multicenter study found that 31.5 % of patients with non-infectious surgical thoracic aortitis are expected to die within 10 years of their initial surgery. The granulomatous/giant cell histological pattern is associated with higher mortality.

Malgré des progrès majeurs dans le traitement médical de l’IC (IC) au cours des 20 dernières années, le pronostic des patients atteints d’IC avancée reste très sombre et les données épidémiologiques suggèrent que leur proportion devrait augmenter dans les années à venir. En l’absence de contre-indications, la prise en charge de ces patients nécessite le recours à des thérapeutiques lourdes telles que la transplantation, l’assistance circulatoire ou le cœur artificiel total. Les innovations technologiques réalisées depuis les années 2000 grâce à la miniaturisation des pompes et le développement de dispositifs à lévitation magnétique, ont permis une amélioration de la survie, une réduction des principales complications associées à ces systèmes et une amélioration significative de la qualité de vie. La transplantation reste encore le traitement de référence de l’IC sévère, mais elle est limitée par l’accès restreint aux greffons cardiaques. Un des défis majeurs est l’identification précoce des patients qui échapperont au traitement médical afin de ne pas retarder leur orientation vers des équipes spécialisées. Le parcours de soins doit être donc être structuré dans le cadre d’un réseau de centres d’IC primaires, secondaires et tertiaires animés par des unités médico-chirurgicales spécialisées dans l’IC avancée.