Annals of cardiothoracic surgery最新文献

Background: Annular calcification [mitral annular calcification (MAC)] may complicate mitral valve (MV) surgery, and long‑term outcome data are limited.

Methods: We reviewed adult patients undergoing MV surgery at our Clinic between January 2000 and December 2024. MAC was identified on preoperative imaging, and operative strategy prioritized repair when feasible and employed conservative debridement when necessary. Patients with MAC were matched 1:1 with patients without MAC using a propensity score.

Results: Among 11,350 MV operations with or without concomitant procedures, 1,603 patients (14.1%) had MAC, the median age was 72.6 years [interquartile range (IQR), 65.3-78.6 years], 54.8% were female. In the MAC cohort, 21% of patients had a prior sternotomy. Concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) were performed in 32% and 24% of cases, respectively. Compared with propensity-matched controls, MAC patients did not exhibit significantly prolonged cardiopulmonary bypass times (115 vs. 112 minutes, P=0.485) or aortic cross-clamp durations (86 vs. 81 minutes, P=0.273). The 30-day hospital readmission rate was significantly higher among MAC patients (15.9% vs. 9.9%, P<0.001). Although 30-day mortality was elevated in the MAC group (5.8% vs. 4.2%), the difference was not statistically significant (P=0.171). In a subgroup analysis of matched groups undergoing primary isolated MV surgery, early mortality was 2.7% in patients with MAC and 0.5% in patients without MAC (P=0.111). Long-term, 10-year survival was significantly lower in MAC patients (43.6%) compared to matched controls (49.6%, P<0.001).

Conclusions: In this large single-center series, patients with MAC often had associated aortic valve and coronary artery disease, and 21% of them were undergoing a second procedure. Compared to matched patients without MAC, long-term survival was reduced in patients with MAC. This experience highlights the importance of accurate preoperative assessment and tailored surgical strategy to achieve acceptable outcomes of MV surgery in the presence of MAC.

Mitral annular calcification (MAC) is a chronic process that presents a complex clinical pathology. In the setting of a growing elderly population, the incidence of MAC has been increasing and it is often associated with other degenerative conditions most importantly atherosclerosis. While its clinical impact has previously been underappreciated, more recent evidence suggests that MAC has significant implications on cardiovascular and cerebrovascular morbidity as well as mortality. Commonly MAC is associated with mitral valve disease, which can require non-medical treatment in the form of conventional mitral valve surgery, transcatheter mitral valve replacement or a hybrid approach. The presence of MAC has important implications on both the interventional methods and subsequently on clinical outcomes. This review focuses on the diagnosis, clinical implications, and implications on mitral valve surgery and/or transcatheter interventions of MAC.

Transcatheter mitral valve intervention (TMVI) has emerged as a potential alternative to surgery for patients with mitral annular calcification (MAC)-associated mitral valve disease, a population often deemed high-risk due to clinical and anatomic complexities. However, MAC also presents significant challenges to TMVI itself. In transcatheter edge-to-edge repair (TEER), procedural success may be limited by fibrotic and short leaflets, reduced mitral valve area, and subvalvular calcium protrusion. Transcatheter mitral valve replacement (TMVR) poses further anatomical hurdles, including a small, eccentric, or non-conforming annuli; insufficient MAC to ensure anchoring; narrow aortomitral angle; septal hypertrophy; elongated anterior mitral leaflet predisposing to left ventricular outflow tract (LVOT) obstruction; and heterogeneous MAC morphology leading to paravalvular leak or suboptimal fixation. Mechanical injury to adjacent structures such as the circumflex artery and atrioventricular groove is also a concern. Balloon-expandable valves, used off-label for TMVR, may be delivered via transapical, transfemoral, transseptal, or hybrid transatrial approaches. While early data show high mortality for valve-in-MAC (ViMAC) procedures, a shift toward transfemoral transseptal access has improved outcomes. The hybrid transatrial approach offers advantages including resection of the anterior leaflet, septal myectomy, and reinforcement of the valve skirt with Teflon felt. Among dedicated self-expanding TMVR systems, only Tendyne has both CE mark and US Food and Drug Administration (FDA) approval and is delivered transapically. New transfemoral transseptal systems-such as Intrepid, AltaValve, and Cephea-are under active investigation. Techniques like LAMPOON (Laceration of the Anterior Mitral leaflet to Prevent Outflow ObstructioN) and BATMAN (Balloon-Assisted Translocation of the Mitral Anterior Leaflet) have been developed to mitigate the risk of fatal LVOT obstruction. Despite progress, mid-term mortality after ViMAC TMVR remains high. Continued innovations in technique, device design, and patient selection are critical to establishing TMVI as a viable treatment for MAC-associated mitral valve disease.

Background: The Sun procedure has been widely adopted across China for the treatment of acute type A aortic dissection (ATAAD). Although favorable outcomes have been reported from high-volume centers, institutional series offering detailed early data using modern operative protocols remain limited. This study is structured in two parts: first, a review of the literature on the development and reported outcomes of the Sun procedure in different aortic populations across China; and second a presentation of contemporary operative characteristics and early outcomes in patients undergoing the Sun procedure for ATAAD at a single institution.

Methods: A retrospective analysis was conducted on 729 consecutive patients with ATAAD treated at DeltaHealth Hospital from 2016 to 2024. Among these, 573 patients (78.6%) underwent total arch replacement with frozen elephant trunk (FET) using the Sun procedure. Baseline characteristics, operative variables, and early outcomes were analyzed. Neurologic, renal, pulmonary, and systemic complications are reported.

Results: The mean age of patients was 52.7±14.1 years, and 73.5% were male. Cardiac tamponade was present in 19.1% of patients at presentation. The history of cerebrovascular disease was noted in 4.1%, 3.4% had chronic kidney disease and 13.6% had Marfan syndrome. In-hospital mortality was 4.1%. Major complications included stroke (10.2%), spinal cord injury (SCI) (2.6%), acute renal failure (8.4%), gastrointestinal complications (4.1%), and reoperation for bleeding (14.3%). Sternal dehiscence and limb ischemia occurred in 1.8% and 1.6% of patients, respectively. Outcomes were achieved despite the presence of significant preoperative malperfusion syndromes, cerebral (8.2%), coronary (13.6%), and spinal cord malperfusion (2.2%).

Conclusions: The Chinese experience with the Sun procedure highlights the potential of standardized surgical strategies in complex aortic disease. This dataset affirms the technique's safety, durability, and adaptability across acute, chronic, and heritable aortic pathologies.

Background: The frozen elephant trunk (FET) technique is a well-established procedure for chronic and acute aortic arch (AA) pathologies. Over time, practice has shifted from deep to moderate hypothermic circulatory arrest (HCA), especially for elective cases. This strategy might, however, impact neurological and renal outcomes. The aim of this single-center study is to assess the safety of very mild HCA (MiHCA) in patients who underwent FET with a core temperature ≥30 ℃.

Methods: Data on all consecutive patients who electively or urgently underwent FET requiring HCA at Cardiac Surgery Unit of the University of Pisa were collected. In all cases, antegrade selective cerebral perfusion was performed, and hypothermia was maintained only during circulatory arrest (CA). We assessed postoperative acute kidney injury (AKI), neurological events, and bleeding as primary endpoints. Multivariable analysis was performed to evaluate the predictors of the three outcomes.

Results: We included 92 patients, 86% of which presented with an acute aortic syndrome. Of this cohort, 17% had neurological deficits at baseline and 9% were intubated at arrival; the German Registry of Acute Aortic Dissection Type A (GERAADA) score was 24%±14%. The mean bladder temperature was 30±1.6 ℃, and the mean cardiopulmonary bypass (CPB) and CA times were 219±78 and 15 (I-III quartile, 13-19) min, respectively. Median cerebral perfusion time was 59 (I-III quartile, 31-113) min, bilateral antegrade cerebral perfusion (ACP) was performed in 96% of cases, and unilateral in 4%. Packing for bleeding was necessary in 4% of cases, and 21% of patients required surgical revision for bleeding within the first 24 hours from surgery. We had one (1%) fatal, eight (9%) disabling, and five (5%) non-disabling strokes, while 6% of patients developed renal impairment requiring temporary venovenous hemofiltration. Thirty-day mortality was 14%. Bladder temperature was not associated with outcomes, while retrograde perfusion and GERAADA score were predictors of neurological events. GERAADA score also tended to predict postoperative bleeding, while the involvement of the descending aorta tended to predict renal impairment.

Conclusions: CA with core temperatures above 30 ℃, paired with selective bilateral cerebral perfusion, resulted in the best outcomes in patients undergoing FET in case of acute aortic syndromes.

Aortic arch surgery is associated with substantial perioperative risks. New techniques and novel prostheses have been developed to reduce the risks of these procedures. The application of these new techniques has helped to reduce the perioperative risk factors of aortic arch repair. From a technical standpoint, the supra-aortic vessel anastomoses, especially those to the left subclavian artery, can sometimes be technically challenging, resulting in the need for longer circulatory arrest. Therefore, various techniques and devices have been developed in recent years to simplify the supra-aortic vessel anastomosis. A new hybrid graft to simplify the supra-aortic vessel anastomosis during total arch replacement is described.