Objectives: Visceral malperfusion remains a major determinant of early mortality in acute type A aortic dissection. Rapid identification and classification of malperfusion mechanisms are crucial to guide treatment decisions and improve outcomes. Methods: We retrospectively analyzed 108 patients undergoing surgical repair for acute type A aortic dissection. Transpericardial ultrasound was performed intraoperatively in 75 patients at 1 or more timepoints (pre-, intra-, or postcardiopulmonary bypass). Visceral flow in the superior mesenteric artery and celiac trunk was graded semiquantitatively. Flow improvement after cardiopulmonary bypass was considered diagnostic of dynamic malperfusion. Postoperative outcomes and causes of death were analyzed in relation to perfusion trends. Results: Visceral malperfusion was diagnosed in 26 patients (24.1%). Superior mesenteric artery flow normalized intraoperatively in 22 (84.6%), indicating dynamic obstruction. Patients with flow normalization had significantly lower mortality (9.1%) than those with persistent malperfusion (60%). Transpericardial ultrasound findings guided surgical decision making, supporting extended arch repair or endovascular adjuncts only when flow remained impaired. Thirty-day mortality was 22.2% overall, with multiorgan failure and ischemia accounting for most deaths in patients with malperfusion. Conclusions: Transpericardial ultrasound is a valuable tool for intraoperative assessment of visceral perfusion. It enables real-time distinction between reversible and irreversible malperfusion, supports a perfusion-guided repair-first strategy, and may reduce unnecessary interventions while improving risk stratification and outcomes.

OBJECTIVE:To report the early and late results of patients treated with an aortic homograft for complex aortic native and prosthetic valve endocarditis. METHODS:Clinical data of patients undergoing aortic valve/root replacement with an aortic homograft for infective endocarditis from 2000 to 2025 in 5 European cardiac centers were collected in the EUropean REgistry of Cryopreserved Aortic Homografts (EURECAH) and retrospectively analyzed. Follow-up data were collected until December 2025. RESULTS:In total, 544 patients, 78% of whom were male, with a median age of 65 [54-73] years, have been enrolled in the EURECAH, including 188 (35%) with native and 356 (65%) with prosthetic valve endocarditis complicated by 369 (68%) annular abscess, 187 (34%) mitroaortic discontinuity, 84 (15%) mitral valve, and 24 (4%) right-sided endocarditis. Aortic homografts were implanted with full root (85%), freehand subcoronary (11%), and the inclusion technique (4%). Median cardiopulmonary bypass time was 192 [150-239] minutes and aortic crossclamping time was 147 [115-182] minutes. In total, 247 (45%) patients died during follow-up, including 85 (15%) periprocedural, 32 (6%) early and 130 (24%) late deaths. Median survival time was 10.2 [1.9-19.8] years. Overall survival rates were 87.9% at 30 days, 78.5% at 1 year, 67.1% at 5 years, and 52.8% at 10 years. In total, 77 (14%) patients underwent reintervention for structural valve dysfunction (6%), infective endocarditis (3%), nonstructural valve dysfunction (1%), mitral valve regurgitation (2%), coronary artery disease (1%), heart transplantation (1%), and aortic aneurysm (1%). CONCLUSIONS:The results of the EURECAH registry show that the use of an aortic homograft for native and prosthetic aortic valve and root endocarditis is safe and provides satisfactory early and late survival despite the complexity of the condition, with good long-term durability and low rates of recurrent endocarditis.

BACKGROUND:The DeBakey classification remains a cornerstone for describing acute type A aortic dissection, yet it is unclear whether types 1 and 2 represent distinct pathophysiologic entities or merely different extents of the same condition. This study evaluated detailed morphologic features to explore whether these subtypes arise from divergent structural and biomechanical conditions of the ascending aorta. METHODS:We performed a retrospective analysis of 429 patients surgically treated for acute type A dissection at Siena University Hospital (2000-2025). Only cases with clearly classifiable DeBakey type 1 (n = 258) or type 2 (n = 171) morphology were included. RESULTS:Patients with type 1 dissection were significantly younger than those with type 2 (65.5 vs 77 years; P < .001). Type 2 dissections occurred in larger (56.2 vs 46.7 mm; P < .001) and longer (128 vs 109 mm; P < .001) ascending aortas, reflected in higher TAIPAN scores (2.4 vs 0.7; P < .001), indicating greater geometric deformation. Tear morphology also differed; transverse tears predominated in type 1 (85%), whereas longitudinal tears were characteristic of type 2 (61%; P < .001). Cardiovascular risk factors, anthropometric variables, and congenital and genetic markers were comparable between groups. CONCLUSIONS:DeBakey types 1 and 2 demonstrate distinct morphologic and geometric profiles. Type 2 dissections are associated with larger and more elongated aortas, whereas type 1 dissections arise in smaller and less remodeled vessels. These findings challenge diameter-based prevention strategies for type 1 and support incorporating aortic length and geometric indices into risk assessment. Preservation of the DeBakey classification remains clinically relevant and should not be abandoned in favor of overly unified classification schemes.

BACKGROUND:A careful preoperative evaluation of patients with mitral regurgitation (MR) is pivotal to optimize the timing of intervention and clinical outcome. The aim of this study was to evaluate preoperative prognostic parameters, among basic and speckle tracking echocardiography (STE), in patients undergoing MR surgery. METHODS:We prospectively enrolled patients with severe MR who underwent preoperative clinical, biohumoral and echocardiographic evaluation, before mitral valve surgery. After surgery, patients were followed to investigate clinical outcome. The primary endpoint was a composite of heart failure hospitalizations and all cause-mortality, the secondary endpoint was to identify the best predictors of postoperative functional capacity assessed by New York heart association (NYHA) class. RESULTS:The final study cohort consisted of 110 patients with a mean age of 64 ± 13 years, 59% male. All strain parameters were reduced, while myocardial work (MW) showed normal values. Median follow-up was 17 (10-29) months. The primary endpoint occurred in 10 patients. Two echocardiographic predictors for the primary endpoint were global peak atrial longitudinal strain (PALS) ≤ 21.5% and free wall right ventricular longitudinal strain (fwRVLS) ≥ -22% with ROC curves. The study population was then divided into 3 groups (Group 1, n = 32: PALS>21.5% and fw-RVLS < -22%, Group 2, n = 46: either global PALS or fwRVLS reduced, Group 3, n = 32: PALS ≤ 21.5% and fwRVLS ≥ -22%). Kaplan-Meier curves showed good risk stratification of the composite endpoint across the three groups. Global wasted work(GWW) was an independent predictor of symptoms persistence (NYHA class > II) at follow-up. CONCLUSIONS:STE, particularly with the combination of left atrial and right ventricular strain analysis, can provide additional prognostic value for the preoperative evaluation of patients with MR referred for surgery.

OBJECTIVES:Aortic valve-sparing root replacement using the reimplantation technique and mitral valve (MV) repair are well-established surgical approaches for the treatment of aortic root pathologies and mitral valve insufficiency. However, the management of concomitant diseases with a dual valve-preserving strategy remains poorly described. Therefore, the aim of this study is to evaluate the long-term outcomes of concomitant valve-sparing surgery and MV repair. METHODS:This case series includes all the patients who underwent combined valve-sparing root replacement and MV repair at Cliniques Universitaires Saint-Luc (Brussels, Belgium) between January 2000 and June 2022. Actual survival rate and freedom from reoperation were calculated by the Kaplan-Meier method, and the log rank test was used for statistical evaluation. RESULTS:Forty-five patients were included in the study; they were divided into two groups (13 patients with and 32 patients without connective tissue disorders). There was no hospital mortality. Three patients (7%) required pacemaker implantation. Overall survival at 10 years was 90% (95% confidence interval [CI]: 64-97%). Furthermore, freedom from all reoperations at 10 years was 84% (95% CI: 64-93%). Analysing the two subgroups, we found no statistically significant difference in terms of 10-year survival (log rank P = 0.146). However, freedom from reoperation at 10 years was significantly lower in the connective tissue disorder group (63% vs 91%, log rank P = 0.031). Most patients treated with transaortic edge-to-edge repair required MV reoperation. CONCLUSIONS:Combined valve-sparing root replacement with the reimplantation technique and MV operations are complex surgeries. However, they can be performed safely, with excellent long-term survival and repair durability. Applying standard Carpentier techniques for MV repair is crucial, especially in patients with connective tissue disorders.

The introduction of the Y(ang)-technique for aortic root enlargement has sparked a renewed interest in annular and root enlargement procedures world-wide. In order to execute these procedures proficiently however, it's important to understand the complex three-dimensional structure of the aortic root and left ventricular outflow tract, and also be familiar with the different enlargement techniques. Herein, we are providing a description of the aortic root anatomy and the most commonly utilized root enlargement procedures. This should facilitate clinical decision making and guidance of patients towards the most appropriate procedure, which should not only treat the patients' acute symptoms, but should also set the patient up for potentially needed future procedures and respective life-time management of aortic valve disease.

Background The correlation between diabetes and aortic dissection is not fully understood yet, although in literature many studies have suggested that there may be an association between the two conditions. The purpose of this study is to evaluate whether diabetes represents a short- and long-term risk factor for mortality from type A acute aortic dissection. Materials and methods A total of 340 patients with the diagnosis of type A acute aortic dissection underwent aortic surgery between January 2002 and March 2023. The sample was divided into 2 cohorts according to the presence of diabetes ( n = 34) or not ( n = 306). Results The mean age was 66 (±12.4) years and 60.9% were male. The primary endpoint was 30-day mortality. Hospital mortality was 12 (35.3%) for the diabetes group and 70 (22.9%) for nondiabetes group ( P = 0.098). Overall survival at 10 years was 48.3% [95% confidence interval (CI): 41.6–54.7%], while the 10-year survival for people with diabetes was 29.5% (95% CI: 13.2–47.9%) and for nondiabetes group 50.6% (95% CI: 43.4–57.3%) (Log-rank, P = 0.024). Conclusion Diabetes was not found to be a risk factor associated with 30-day mortality in patients undergoing surgery for type A acute aortic dissection. It was a risk factor for long-term survival, but this may be related to diabetes complications.

OBJECTIVES: The progressive increase in the use of implantable electronic devices, vascular access for dialysis and the increased life expectancy of patients with congenital heart diseases has led in recent years to a considerable number of right-side infective endocarditis, especially of the tricuspid valve (TV). Although current guidelines recommend TV repair for native tricuspid valve endocarditis (TVE), the percentage of valve replacements remains very high in numerous studies. The aim of our study is to analyse our experience in the treatment of TVE with a reparative approach. METHODS: This case series includes all the patients who underwent surgery for acute or healed infective endocarditis on the native TV, at the Cliniques Universitaires Saint-Luc (Bruxelles, Belgium) between February 2001 and December 2020. RESULTS: Thirty-one patients were included in the study. Twenty-eight (90.3%) underwent TV repair and 3 (9.7%) had a TV replacement with a mitral homograft. The repair group was divided into 2 subgroups, according to whether a patch was used during surgery or not. Hospital mortality was 33.3% (n = 1) for the replacement group and 7.1% (n = 2) for repair (P = 0.25). Overall survival at 10 years was 75.6% [95% confidence interval (CI): 52-89%]. Further, freedom from reoperation on the TV at 10 years was 59.3% (95% CI: 7.6-89%) vs 93.7% (95% CI: 63-99%) (P = 0.4) for patch repair and no patch use respectively. Freedom from recurrent endocarditis at 10 years was 87% (95% CI: 51-97%). CONCLUSIONS: Considering that TVE is more common in young patients, a repair-oriented approach should be considered as the first choice. In the case of extremely damaged valves, the use of pericardial patch is a valid option. If repair is not feasible, the use of a mitral homograft is an additional useful solution to reduce the prosthetic material.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery being associated with poorer outcomes. Revealing before the operation of left atrial subtle structural/functional abnormalities may help to identify patients at increased risk of POAF. We investigated the role of left atrial strain parameters by preoperative speckle tracking echocardiography as independent predictors of POAF in patients undergoing coronary artery bypass graft. METHODS: Consecutive patients undergoing isolated coronary artery bypass graft were prospectively enrolled at three Italian centers. All patients underwent transthoracic echocardiography before the operation. The occurrence of POAF up to discharge was monitored. RESULTS: Overall, a total of 310 patients were included. POAF was demonstrated in 103 patients (33%). At receiver operating characteristic curve analysis, lower global peak atrial longitudinal strain (PALS) values significantly predicted the risk of POAF (area under the curve, 0.74; P <0.001). The optimal cutoff value for the arrhythmia prediction was a global PALS value <28%, with a specificity of 86% and a sensitivity of 36%. The incidence of POAF was 51% in patients with global PALS <28% versus 14% in those with PALS ≥28% ( P <0.001), with a POAF-free survival at Kaplan-Meier analysis of 45.4% and 85.7%, respectively ( P <0.001). At multivariate analysis, a global PALS <28% carried a 3.6-fold higher risk of POAF (hazard ratio, 3.6 [95% CI, 2.2–5.9]; P <0.001). The risk increase was even higher when PALS <28% was associated with age ≥70 years (adjusted hazard ratio, 11.2 [4.7–26.6], P <0.001). CONCLUSIONS: A presurgery global PALS <28% is a specific parameter to stratify patients at increased risk of POAF after coronary artery bypass graft. This assessment can be useful to identify patients at higher arrhythmic risk in whom perioperative preventive strategies and stricter monitoring aimed at early diagnosing and treating POAF may be applied.

Abstract Background There is ambiguity in the literature regarding the continuous suture technique (CST) for aortic valve replacement (AVR). At our center, there has been a gradual shift towards CST over the interrupted pledgeted technique (IPT). This study aims at comparing outcomes for both techniques. Methods We performed a retrospective analysis of a single-center study of patients undergoing AVR between January 2011 and July 2020. Patients were divided into two groups: Continuous suture technique and interrupted pledget-reinforced sutures. The pre-operative and In-hospital clinical characteristics and echocardiographic hemodynamics (i.e. transvalvular gradients and paravalvular leakage) were compared between CST and IPT. Results We compared 791 patients with CST to 568 patients with IPT (median age: 73 and 74 years, respectively, p = 0.02). In CST there were 35% concomitant procedure vs. 31% in IPT (p = 0.16). Early mortality was 3.2% in CST versus 4.8% in IPT (p = 0.15), and a second cross-clamp due to a paravalvular-leak in 0.5% vs. 1.2%, respectively (p = 0.22). The CST was not associated with new-onset conduction-blocks mandating pacemaker implants(OR 1.07, 95% CI 0.54–2.14; P = 0.85). The postoperative gradients on echocardiography were lower in CST compared to IPT, especially in smaller annuli (peak gradients: 15.7mmHg vs. 20.5mmHg, in valve size < 23 mm, p < 0.001). Conclusions The continuous suture technique was associated with lower postoperative gradients and shorter cross-clamp time compared to interrupted pledgeted technique. Differences in paravalvular leaks were non-significant, although slightly less in the continuous suture technique. There were no further differences in valve-related complications. Hence, continues suture technique is safe, with better hemodynamics compared to the interrupted pledgeted technique. This may be of clinical importance, especially in smaller size annular size.

AIMS:Myocardial work (MW) estimation by pressure-strain loops using speckle tracking echocardiography (STE) has shown to evaluate left ventricular (LV) contraction overcoming the load-dependency limit of LV global longitudinal strain (GLS). This has proved useful in hemodynamic variation settings e.g. heart failure and valvular heart disease. However, the variation of MW and strain parameters across different stages of primary mitral regurgitation (MR) and its impact on symptoms, which was the aim of our study, has never been investigated. METHODS AND RESULTS:Consecutive patients with mild, moderate and severe MR were prospectively enrolled. Exclusion criteria were: chronic atrial fibrillation, valvular heart prosthesis, previous cardiac surgery. Clinical evaluation, blood sample tests, ECG and echocardiography with STE and MW measurement were performed. Patients were then divided into groups according to MR severity. Differences among the groups and predictors of symptoms (as NYHA class≥2) were explored as study endpoints. Overall, 180 patients were enrolled (60 mild,60 moderate,60 severe MR). LV GLS and global peak atrial longitudinal strain (PALS) reduced according to MR severity. Global constructive work (GCW) and global wasted work (GWW) significantly improved, while global work efficiency (GWE) reduced, in patients with moderate and severe MR. Among echocardiographic parameters, global PALS emerged as the best predictor of NYHA class (p < 0.001;area under curve,AUC = 0.7). CONCLUSIONS:MW parameters accurately describe the pathophysiology of MR, with initial attempt of LV increased contractility to compensate volume overload parallel to the disease progress, although with low efficacy, while global PALS is the most associated with the burden of MR symptoms.

OBJECTIVE:In literature, various risk scores have been described to predict in-hospital mortality of patients undergoing surgery for acute type A dissection. We want to evaluate which factors are most correlated with a negative outcome and testing the validity of the current scores in literature analyzing our experience of over 20 years in the surgery of type A aortic dissections.MATERIALS AND METHODS:A total of 324 patients were included in the study. Patients were divided into two groups according to 30-day survival or mortality. The preoperative variables analyzed are the parameters necessary for the calculation of scores: Penn Classification, Leipzig Halifax and adjusted Leipzig Halifax score, GERAADA score and EuroSCORE II. Intra- and post-operative mortality were 10.2% and 17.5%, respectively. In multivariate analysis, the preoperative predictors of 30-day mortality were age greater than 70 years, low eject fraction levels, visceral and coronary malperfusion. Both GERAADA and EuroSCORE II were statistically significant predictors of 30-day mortality. However, EuroSCORE II underestimates the mortality compared to GERAADA score probably due to the lack of evaluation of fundamental preoperative factors in the course of type A aortic dissection.RESULTS:The study has demonstrated the efficacy of the GERAADA score in predicting the outcome of patients undergoing surgery and the underestimation of the mortality of EuroSCORE II in our population.

We present a case of valve-sparing root reimplantation in a patient with severe aortic regurgitation, in the setting of a bicuspid aortic valve with an aberrant circumflex coronary artery arising from the right coronary artery, thus rendering standard dissection of the aortic root during a David procedure challenging and risky.

Elephant trunk and frozen elephant trunk are established procedures for the treatment of aortic arch pathologies, such as aneurysm or dissection. The aim of open surgery is to re-expand the true lumen, favouring correct organ perfusion and the thrombosis of the false lumen. Frozen elephant trunk, with its stented endovascular portion, is sometimes associated with a life-threatening complication: the stent graft-induced new entry. In the literature, many studies reported the incidence of such issue after thoracic endovascular prosthesis or frozen elephant trunk, but in our knowledge, there are no case studies about the occurrence of stent graft-induced new entry with the use of soft grafts. For this reason, we decided to report our experience, highlighting how the use of a Dacron graft can cause distal intimal tears. We decided to coin the term soft-graft-induced new entry to indicate the development of an intimal tear induced by the soft prosthesis in the arch and proximal descending aorta.

Abstract Endoleaks represent a main issue of endovascular approach of thoracic aorta diseases and their treatment continue to be challenging. According to some authors, type II endoleaks sustained by intercostal arteries should not be treated because of the technical difficulties. However, the persistence of a pressurized aneurysmal may confer an ongoing risk of enlargement and/or aortic rupture. We describe the successful treatment of type II endoleak in 2 patients with an intercostal artery’s access. In both cases, the endoleak was discovered during follow-up and was treated with its direct coil embolization under local anaesthesia.

The pulmonary artery aneurysm (PAA) is a rare disease with no well-defined guidelines about the diagnostic criteria and its management. In fact, the indications for surgical treatment and the type of surgical approach are not clear. However, in case of giant PAAs with hypertension and pulmonary valve abnormalities, surgery should be considered as an effective and safe approach to prevent dissections or ruptures. In this report, we describe a successful case of surgical repair, using a Bioconduit with a pericardial patch to recreate the pulmonary artery bifurcation in a 72-year-old male with aneurysm of the pulmonary artery (max diameter: 72 mm), associated with quadricuspid pulmonary valve stenosis and pulmonary hypertension. The procedure was uncomplicated and the follow-up computed tomography scan at 4 months showed correct positioning of the graft with no sign of contrast leakage.