OBJECTIVE:It remains controversial whether extended arch repair for acute type A aortic dissection reduces dissection-related distal aortic events and improves long-term outcomes in patients with ascending aortic entry tears. Accordingly, we evaluated long-term surgical outcomes in acute type A aortic dissection, focusing on the extent of arch repair. METHODS:This international retrospective study included 914 patients with acute type A aortic dissection (mean age 66 ± 13 years) with ascending entry tears who underwent surgery at 2 specialized centers between 1997 and 2024. Patients were stratified into hemiarch replacement (n = 495) or extended arch replacement (partial or total arch; n = 419) groups. The primary end point was all-cause mortality; the secondary end point was dissection-related distal aortic events. Propensity score matching was performed using 18 baseline and operative variables. Mean follow-up was 5.9 ± 5.7 years (5390 patient-years). RESULTS:In-hospital mortality decreased significantly over time (1997-2006: 19%; 2007-2016: 11%; 2017-2025: 9.0%; P = .007), driven mainly by improvements in the extended arch replacement group (24%, 8.7%, and 7.4%, respectively; P = .016). In a well-matched cohort of 182 patient pairs, extended arch replacement was associated with lower 10-year all-cause mortality (27% vs 39%; P = .011) and a lower cumulative incidence of distal aortic reintervention (11% vs 19%; P = .036). On multivariable analysis, extended arch replacement independently protected against a composite end point of death or distal aortic events (adjusted hazard ratio, 0.60; 95% CI, 0.47-0.78; P < .001). CONCLUSIONS:In patients with acute type A aortic dissection with ascending aortic entry tears, extended arch replacement was associated with a progressive reduction in in-hospital mortality and superior long-term outcomes compared with hemiarch replacement, supporting its use in selected patients.

OBJECTIVES:This study aimed to assess long-term outcomes of automated titanium fasteners versus hand-tied knots in mitral valve surgery. METHODS:In this retrospective, single-centre analysis, 2678 adult patients who underwent mitral valve repair or replacement between November 2008 and November 2024 at the Medical University of Vienna were included. Patients were grouped according to the suture-securing technique used: automated titanium fasteners versus hand-tied knots. The primary endpoint was prosthetic dehiscence (either mitral annuloplasty ring or valve replacement prosthesis) requiring reintervention. Secondary endpoints comprised ischaemic stroke, intracranial bleeding, and all-cause mortality during the follow-up period. RESULTS:Among the study population, 1072 (40%) underwent mitral valve surgery using an automated titanium fastener device, and 1606 (60%) with conventional hand-tied sutures. A total of 31 patients (1.2%) had prosthetic dehiscence during the follow-up period. The risk of prosthetic dehiscence was significantly lower in the automated titanium fastener group in both univariable (crude sub-hazard ratio [sHR] 0.32; 95% confidence interval [CI], 0.12-0.86, P = .023) and multivariable competing risk regression analysis (adjusted sHR 0.34; 95% CI, 0.12-0.91, P = .033). Automated titanium fastener group was not associated with an increased risk of ischaemic stroke (adjusted sHR 0.92; 95% CI, 0.67-1.27, P = .600), intracranial bleeding (adjusted sHR 0.89; 95% CI, 0.52-1.52, P = .675), or all-cause mortality (adjusted hazard ratio 0.93; 95% CI, 0.74-1.18, P = .559). CONCLUSIONS:The use of an automated titanium fastener device seems to be associated with a lower risk of prosthetic dehiscence in mitral valve surgery. Due to the limited number of prosthetic dehiscence events and the potential for residual confounding, the results should be interpreted with caution.

Background Available data about sex differences in patients with acute aortic dissection (AAD) are scant and conflicting. The aim of this study is to assess sex‐related differences in clinical characteristics, presentation, diagnostic findings, management, and outcomes among patients with type A (TA‐AAD) and type B AAD (TB‐AAD). Methods Data about 11 586 patients enrolled in the IRAD (International Registry of Acute Aortic Dissection) from 1996 to 2022, were analyzed; 7819 (67.5%) experienced TA‐AAD and 3867 (33.0%) TB‐AAD. Men and women were compared with regard to diagnosis, treatment, and in‐hospital and long‐term survival. Results One third of patients were women (TA‐AAD, 34.4%; and TB‐AAD, 34.5%). Women were older than men for both types of AAD. The median time from hospital admission to diagnosis was longer in women for both TA‐AAD and TB‐AAD ( P <0.001). For TA‐AAD, symptoms of hypotension and coma/altered mental status were more common in women, whereas for TB‐AAD women were more likely to present with congestive heart failure. Surgical repair for TA‐AAD was less frequent in women than men (84.6% versus 89.0%; P <0.001). For both types of AAD, medical management was more common among women than men (TA‐AAD, 16.5% versus 11.6%; P <0.001; TB‐AAD, 65.6% versus 54.2%; P <0.001). The overall as well as surgical in‐hospital mortality rate was higher among women with TA‐AAD compared with men ( P <0.001), whereas it was similar in those managed medically ( P =0.23). No difference in overall ( P =1), medical ( P =0.38), endovascular ( P =1), and surgical ( P =0.51) mortality rates was observed for TB‐AAD between men and women. After TA‐AAD, women showed lower 4‐year survival compared with men (81.4% versus 86.6%, P <0.001). Conclusions The present study highlights important sex‐related differences in AAD; there is a need to design tailored aortic disease management programs to improve outcomes in women.

This video tutorial presents a step-by-step minimally invasive approach to combined aortic valve and ascending aortic replacement using circulatory arrest and antegrade cerebral perfusion. Upper hemisternotomy provides sufficient exposure for complex aortic procedures while reducing surgical trauma compared to full sternotomy. Central arterial inflow is established via innominate artery cannulation using a side graft, enabling selective antegrade cerebral perfusion without an additional axillary incision. Key technical steps include upper hemisternotomy, cannulation strategy, initiation of antegrade cerebral perfusion, distal open anastomosis during circulatory arrest, and subsequent aortic valve replacement with a proximal aortic anastomosis. Emphasis is placed on the perfusion setup, operative technique, and technical details critical to procedural safety. This video tutorial demonstrates that minimally invasive techniques combined with appropriate perfusion strategies can be safely applied to selected aortic procedures requiring circulatory arrest.

The choice of cannulation technique for cardiopulmonary bypass remains a critical decision in cardiac surgery with direct consequences for intraoperative management and patient outcomes. Central and femoral cannulation represent the 2 dominant approaches, each associated with unique anatomical considerations, hemodynamic implications, and perioperative risks. The correct selection of a cannulation strategy should limit the risk of embolic events and associated complications such as vascular injury and stroke. The purpose of this review is to provide a detailed comparison of central and femoral cannulation techniques, with an emphasis on clinical scenarios and outcomes, recent innovations, and state-of-the-art technology. By critically analyzing current evidence, we aim to offer insights into the optimal cannulation strategy tailored to specific patients.

BACKGROUND:This study evaluated operative mortality and morbidity in acute type A aortic dissection (ATAAD) over 25 years, focusing on the impact of evolving surgical techniques and patient selection. METHODS:A retrospective analysis was conducted of 498 patients undergoing ATAAD repair between 1998 and 2022 at a tertiary aortic center. Patients were stratified into surgical eras 1 (1998-2010, n = 190) and 2 (2011-2022, n = 308). The primary outcome was operative mortality, and secondary outcomes included major adverse events, stratified by organ system. RESULTS:Patients in era 2 were older (era 1, 58 [SD, 13.7] years vs era 2, 60.4 [SD, 13.4] years; P = .06), had higher rates of preoperative malperfusion (era 1, 45.8% vs era 2, 55.8%; P = .034), and higher German Registry for Acute Aortic Dissection Type A risk scores (era 1, 18.8% [SD, 10.8%] vs era 2, 22.1% [SD, 14.4%]; P = .004). Surgical strategies evolved, with increased use of total arch procedures (era 1, 5.3% vs era 2, 12%; P = .012), axillary artery cannulation (era 1, 44.2% vs era 2, 80.2%; P < .001), and antegrade cerebral perfusion (era 1, 44.2% vs era 2, 95.8%; P < .001). Operative mortality remained unchanged (era 1, 15.3% vs era 2, 14.0%; P = .7). Multivariable analysis identified axillary cannulation (odds ratio [OR], 0.4; P = .002) associated with improved survival, whereas cardiopulmonary bypass time (OR, 1.009; P < .001) and higher German Registry for Acute Aortic Dissection Type A scores (OR, 1.05; P < .001) were associated with decreased survival. CONCLUSIONS:ATAAD surgery has become more complex, with increased use of arch repairs and advanced neuroprotection strategies. Despite an older, higher-risk cohort, surgical outcomes remain stable. Axillary artery cannulation was associated with improved survival.

OBJECTIVES:Risk factors, presentation, treatment, and outcomes were evaluated for iatrogenic aortic dissection (iAD) in comparison with spontaneous aortic dissection (sAD). METHODS:Patients with acute aortic dissection (AD) enrolled in International Registry of Acute Aortic Dissection from 1996 to 2023 were separated into 2 groups: iAD (n = 333 [2.5% of total ADs]; type A: 252, type B: 81) and sAD (n = 13,122; type A: 8846, type B: 4276). RESULTS:The etiology of iAD was predominantly cardiac surgery (n = 146; 51% type A, 32% type B) and catheter-induced (n = 134; 41% type A, 47% type B). Patients with iAD were more likely to be older, with a greater preponderance of atherosclerosis, known aortic aneurysm, valve disease, and peripheral arterial disease. Patients with type A iAD had smaller aortic size and less frequent aortic regurgitation, in addition to pericardial effusion. They also had less typical symptoms of AD. Medical management of type A AD was used more frequently in iatrogenic compared with spontaneous cases (13% vs 8%, P = .016); management was statistically similar for type B. Overall type A iAD had a greater hospital (25.8% vs 18.4%, P = .005) and 4-year mortality (P = .003), although mortality was similar for type B AD (P = not significant). In a multivariable model, there was no difference in type A hospital mortality between sAD and iAD. CONCLUSIONS:iAD occurs in older patients with known atherosclerosis and frequently without typical symptoms. Medical management is used more frequently for type A iAD. Mortality was greater for type A iAD compared with sAD; however, no differences were seen for type B or in overall mortality for type A in a multivariable model.

Objectives: Thoracic endovascular aortic repair is the method of choice in patients with complicated type B acute aortic dissection. However, thoracic endovascular aortic repair carries a risk of periprocedural neurological events including stroke and spinal cord ischemia. We aimed to look at procedure-related neurological com-plications within a large cohort of patients with type B acute aortic dissection treated by thoracic endovascular aortic repair.Methods: Between 1996 and 2021, the International Registry of Acute Aortic Dissection collected data on 3783 patients with type B acute aortic dissection. For this analysis, 648 patients with type B acute aortic dissection treated by thoracic endo-vascular aortic repair were included (69.4% male, mean age 62.7 +/- 13.4 years). Patients were excluded who presented with a preexisting neurologic deficit or received adjunctive procedures. Demographics, clinical symptoms, and outcomes were analyzed. The primary end point was the periprocedural incidence of neuro-logical events (defined as stroke, spinal cord ischemia, transient neurological deficit, or coma). Predictors for perioperative neurological events and follow-up outcomes were considered as secondary end points.Results: Periprocedure neurological events were noted in 72 patients (11.1%) and included strokes (n = 29, 4.6%), spinal cord ischemias (n = 21, 3.3%), transient neurological deficits (n = 16, 2.6%), or coma (n = 6,1.0%). The group with neuro-logical events had a significantly higher in-hospital mortality (20.8% vs 4.3%, P < .001). Patients with neurological events were more likely to be female (40.3% vs 29.3%, P = .077), and aortic rupture was more often cited as an indica-tion for thoracic endovascular aortic repair (38.8% vs 16.5%, P <.001). In patients with neurological events, more stent grafts were used (2 vs 1 stent graft, P = .002). Multivariable logistic regression analysis showed that aortic rupture (odds ratio, 3.12, 95% confidence interval, 1.44-6.78, P = .004) and female sex (odds ratio, 1.984, 95% confidence interval, 1.031-3.817, P = .040) were significantly associated with perioperative neurological events.Conclusions: In this highly selected group from dedicated aortic centers, more than 1 in 10 patients with type B acute aortic dissection treated by thoracic endo-vascular aortic repair had neurological events, in particular women. Further research is needed to identify the causes and presentation of these events after thoracic endovascular aortic repair, especially among women.

Surgery of the aortic arch remains a complex procedure, with neurological events such as stroke remaining its most dreaded complications. Changes in surgical technique and the continuous innovation in neuroprotective strategies have led to a significant decrease in cerebral and spinal events. Different modes of cerebral perfusion, varying grades of hypothermia, and a number of pharmacological strategies all aim to reduce hypoxic and ischemic cerebral injury, yet there is no evidence indicating the clear superiority of one method over another. While surgical results continue to improve, novel hybrid and interventional techniques are just entering the stage and the question of optimal neuroprotection remains up to date. Within this perspective statement, we want to shed light on the current evidence and controversies of cerebral protection in aortic arch surgery, as well as what is on the horizon in this fast-evolving field. We further present our institutional approach as a large tertiary aortic reference center.

OBJECTIVES:Mechanical composite valve grafts (MCVGs) are the first-line therapy for aortic root replacement in young adults. Decellularized aortic homografts (DAH) present a promising novel alternative due to their lower thrombogenicity. We aimed to compare both treatment options regarding survival and valve-related adverse events. METHODS:This study was designed as a single-centre retrospective cohort study including patients who underwent root replacement with MCVG or DAH between 2000 and 2022. Urgent or emergent procedures were excluded. RESULTS:The study cohort included 289 patients (MCVG n = 216, DAH n = 73) with a mean age of 48.5 ± 12 years (MCVG 49 ± 12 years vs DAH 47 ± 11 years; P = 0.23) and a median EuroScore II of 1.7% (1.2, 2.6). The 30-day mortality was 1% (n = 3). Cumulative survival at 3 years was 99% for DAH and 94% for MCVG, respectively (P = 0.15). Mean follow-up was 98.9 ± 72.7 months. Bleeding events (n = 14, 6.5%) and thromboembolism (n = 14, 6.5%) were only observed in the MCVG group (P = 0.19 and 0.09, respectively). Four cases (5%) of moderate structural valve deterioration occurred, all in the DAH group (P ≤ 0.001). The cumulative incidence of a composite end point of valve-related adverse events was significantly higher in the MCVG group (P = 0.0295). CONCLUSIONS:Aortic root replacement with MCVGs and decellularized aortic homografts showed low mortality in an elective setting. Patients in the homograft cohort demonstrated significantly higher freedom from valve-related adverse events. DAH present a promising treatment option for young patients requiring root replacement; however, data on long-term durability are needed.

ObjectivesTo date, there is no evidence regarding the safety of automated titanium fastener compared with hand-tied knots for prosthesis fixation in infective endocarditis.MethodsBetween January 2016 and December 2022, a total of 220 patients requiring surgery for infective endocarditis were included in this retrospective analysis. The primary study endpoint was re-endocarditis during follow-up. The secondary study endpoints included stroke onset, all-cause mortality, and a composite outcome of either re-endocarditis, stroke, or all-cause mortality during follow-up.ResultsSuture-securing with an automated titanium fastener was performed in 114 (51.8%) patients, whereas the conventional technique of hand knot-tying was used in 106 (48.2%) patients. The risk of re-endocarditis was significantly lower in the automated titanium fastener group, as shown in a multivariable proportional competing risk regression model (adjusted sub-hazard ratio 0.33, 95% confidence interval 0.11–0.99, p = 0.048). The multivariable Cox proportional hazards regression analysis showed that the automated titanium fastener group was not associated with an increased risk of stroke-onset or attaining the composite outcome, respectively, (adjusted hazard ratio 0.54, 95% confidence interval 0.27–1.08, p = 0.082), (adjusted hazard ratio 0.65, 95% confidence interval 0.42–1.02, p = 0.061). Also, this group was not associated with an increased risk of all-cause mortality, as demonstrated in the multivariable Poisson regression analysis (adjusted incidence-rate ratio 1.42, 95% confidence interval 0.83–2.42, p = 0.202).ConclusionsThe use of automated titanium fastener device seems to be safe for infective endocarditis. Analyses of larger cohorts are required.