Annals of cardiothoracic surgery最新文献

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.

The frozen elephant trunk (FET) technique has become a cornerstone in the management of complex aortic arch disease, yet reinterventions, both proximally on the root and distally on the thoracoabdominal aorta, remain common. Conventional FET prostheses were designed to recreate standard arch anatomy with the distal anastomosis beyond the left subclavian artery (LSA) and the supra-aortic branches in proximal-to-distal sequence. However, the current trend towards more proximal anastomosis in zones 0-2, brings the arch branches closer to the aortic root, which can limit root access during reoperation by reducing the available clamping zone, and also creates unfavorable angulations for antegrade visceral vessel cannulation during distal endovascular repair. Here, we describe the step-by-step operative technique for a new graft, the T-NEXT, a customized modification of the Thoraflex hybrid prosthesis, designed for improved life-time management of complex aortic disease, featuring a transverse and distal alignment of the arch branches. This configuration leaves an unobstructed proximal graft segment to facilitate safe distal clamping in future proximal reoperations, while preserving a smooth, bidirectional pathway for antegrade and retrograde endovascular access.

Background: The frozen elephant trunk (FET) technique has revolutionized the surgical management of aortic dissection. However, distal stent-graft-induced new entry (dSINE) and reinterventions remain major challenges. This study presents the long-term results of a dissection-specific (DS) "Soft Elephant Trunk" (SET) (MedEng, Penza, Russia) hybrid prosthesis and its impact on distal remodeling compared to conventional hybrid prosthesis.

Methods: A retrospective review of hybrid aortic repairs from 2014 to 2024 identified 241 patients with aortic dissection. Patients were categorized into two cohorts: DS SET prosthesis (n=170) and conventional prosthesis (non-DS, n=71). Propensity score matching was performed. Primary endpoints included the incidence of dSINE and aortic reinterventions. Secondary endpoints evaluated perioperative complications and long-term survival. Cox regression analysis identified independent predictors of dSINE.

Results: Survival rates, freedom from reoperation, and the incidence of dSINE did not differ between the groups. However, cumulative incidence of new events-including distal aortic reoperations and dSINE-was significantly lower in the DS group versus non-DS both before matching (12.9% vs. 29.6%, P<0.001) and after matching (15.5% vs. 29.6%, P=0.04). Long-term endoleak rates (>5 years) were significantly higher in the non-DS group (31.4% vs. 7.1%, P=0.009). According to multivariable Cox regression analysis, the key predictors for dSINE included connective tissue disease [hazard ratio (HR) =3.22, 95% confidence interval (CI): 1.09-9.52, P=0.034], Stanford type B aortic dissection (HR =4.3, 95% CI: 7-14.61, P=0.019), and chronic phase of dissection (HR =7.8, 95% CI: 0.72-84.21, P=0.09). The highest dSINE risk was observed in non-DS patients with chronic dissection (P=0.009), Type B dissection (P=0.012), CTD (P=0.005), and aortic dilation >45 mm (P=0.004).

Conclusions: In comparison to conventional hybrid grafts, the SET graft exhibits a protective trend against dSINE, particularly in high-risk cases. This strategy may reduce distal complications and the need for secondary interventions, thereby improving long-term patient outcomes.

The frozen elephant trunk (FET) technique represents a significant advancement in the surgical management of complex aortic pathologies involving the aortic arch and descending thoracic aorta. This review traces the evolution of the FET procedure from its conceptual origins in the conventional elephant trunk (ET) technique to its current application as a hybrid, single-stage intervention. The FET technique integrates open surgical repair with endovascular technology, allowing for simultaneous aortic arch replacement and stent-graft deployment into the descending aorta. Key indications include acute and chronic aortic dissections, arch aneurysms, and malperfusion syndromes. Surgical considerations such as cannulation strategy, cerebral protection, and spinal cord preservation are discussed in detail, with emphasis on techniques that enhance safety and outcomes. The development of commercially available FET prostheses-such as E-vita Open Neo, Thoraflex Hybrid, and Frozenix-has improved procedural versatility and enabled individualized treatment strategies. Innovations in graft design, including proximalization of distal anastomosis and integration of side branches, have further simplified the procedure and broadened its applicability. Despite variability in outcomes across patient populations, the FET procedure is associated with favorable early and mid-term results, including reduced inter-stage mortality and enhanced aortic remodeling. The technique continues to evolve, driven by advances in device technology and a growing emphasis on tailored, patient-specific surgical approaches.