Annals of cardiothoracic surgery最新文献

Background: The frozen elephant trunk (FET) provides single-stage repair of complex, concomitant aortic arch and descending aortic disease, integrating both conventional and endovascular approaches. While multiple meta-analyses affirm short-term safety, long-term outcomes remain largely unknown, especially regarding overall survival and freedom from re-intervention. This current systematic review and meta-analysis aims to summarize the short- and long-term outcomes following the use of FET in aortic pathology.

Methods: Studies with at least two years of follow-up data on FETs were identified in five electronic databases, which were searched from inception of records until July 2025. The primary outcome of interest was mortality, with short-term data presented as either 30-day or in-hospital mortality, and long-term data as aggregated Kaplan-Meier curves. Subgroup analysis was also compared by etiology. Secondary outcomes included relevant morbidity outcomes.

Results: Following independent screening, 28 studies were included for analysis, with 11,292 patients and a mean follow-up period of 40.4 months. Actuarial overall survival at 1, 5 and 10 years was 86.2%, 78.8% and 67.9%, respectively. Long-term survival for acute dissection for these points was marginally higher, at 86.2%, 82.4%, and 75.2%, respectively. Overall freedom from distal reintervention at 1, 5, and 10 years was 93.9%, 87.4% and 81.5%, respectively. Comparatively, pooled short-term mortality was marginally higher in the aortic dissection cohort than the overall cohort at 7.7% [95% confidence interval (CI): 6-11%] and 7% (95% CI: 5-9%), respectively. The breakdown for these was 254/3,379 and 742/9,428 patients, respectively. For the overall cohort, postoperative spinal cord injury (SCI), postoperative cerebrovascular accident (CVA), and acute renal failure (ARF) requiring dialysis were 4%, 8% and 11%, respectively. Pooled mean intensive care unit (ICU) length of stay was 7 days. A high level of heterogeneity was present, likely due to the mixed etiologies included.

Conclusions: Our long-term data expands on previous literature while affirming similar favorable long-term survival for the FET procedure. The consistent pattern of improved late-survival in acute dissections supports the hypothesis that early false-lumen exclusion and acute remodeling result in clear long-term benefits. The need for re-intervention has remained consistent with the published literature, further highlighting the importance of patient selection.

Background: Marfan syndrome (MFS) is a connective tissue disease which can lead to aortic aneurysm and dissection. The performance outcomes of total aortic arch replacement with frozen elephant trunk (FET) are not well known in these patients. This study summarizes our experience with FET in MFS.

Methods: Between August 2001 and December 2021, 435 patients underwent FET at Hannover Medical School. Of these, 34 patients had MFS. The mean age was 43.3±11.9 years and 27 (79%) were male. The indication for surgery was aortic aneurysm in 1 (3%), acute aortic dissection in 12 (35%), and chronic aortic dissection in 21 (62%) patients.

Results: All patients underwent total aortic arch replacement with FET. In addition, the following procedures were performed: conventional aortic root replacement (Bentall operation, n=8), valve-sparing aortic root replacement (David procedure, n=8), coronary artery bypass grafting (n=3), mitral valve surgery (n=2), and tricuspid valve surgery (n=1). Cardiopulmonary bypass (CPB) and aortic cross clamp times were 270±87 and 139±69 minutes, respectively. Postoperatively, there were 2 (6%) disabling strokes, and 0 (0%) patients required permanent dialysis or suffered from permanent paraplegia, respectively. In-hospital mortality was 12% (n=4). The mean follow-up time was 8.4±5.9 years. The 1-, 5-, 10, and 15-year survival rates were 82%, 70%, 70% and 65, respectively. There were 18 (53%) re-interventions on the distal aorta. Mean time to re-intervention was 2.7±3.1 years. The majority of patients underwent open surgical repair (n=14, 77%), while only 4 (22%) had endovascular therapy. The freedom from distal aortic re-intervention at 1-, 5-, 10- and 15 years was 86%, 61%, 55% and 44%, respectively.

Conclusions: The main indication for FET surgery in MFS is acute or chronic aortic dissection. Despite multiple concomitant procedures, early mortality was relatively low, suggesting that FET is feasible and effective to treat complex aortic pathology in MFS. However, our study showed a high incidence of distal aortic re-interventions, underscoring the progressive nature of the disease and the need for tailored long-term management strategies.

Background: The frozen elephant trunk (fET) has become the preeminent choice for aortic arch repair with easier second-stage endovascular solutions compared to the conventional elephant trunk (cET). Traditionally, the major advantage of cET implantation is reduced risk of spinal cord injury (SCI). With increased rates of implantation and refinement in technique, we aim to investigate if previous adverse events of fET, such as SCI, have been reduced to a level comparable to the cET.

Methods: Four databases were searched from inception to January 2025. All studies reporting 30-day mortality and SCI in conventional or fETs were identified. Papers that included emergency surgery in a mixed cohort or novel and handmade prosthesis were excluded. Relevant data was extracted, and meta-analysis was conducted using a random effects model.

Results: Twenty-eight studies were included with a total of 1,504 patients (122 cET, 1,382 fET). Cohort sizes ranged from 12 to 126 patients. The aggregate mean age was 60.7 years for fET and 65.6 years for cET. The 30-day mortality was 5.4% for fET and 3.9% for cET. There was a signal towards increased SCI for fET at 4.4% compared to 1.2% in cET.

Conclusions: In non-emergent total arch replacement, there were similar rates of 30-day mortality. There was a signal towards increased SCI for fETs compared to cETs. Meta-regression identified a non-significant trend towards decreasing rates of SCI in fETs over time.

At first glance, the frozen elephant trunk (FET) appears as a disruptive innovation in aortic surgery. Like any important surgical innovations, however, be it a product or a procedure, the prefabricated, four-branched device has undergone a stepwise, iterative phase of development prior to its first clinical implantation in 2010. In parallel, the surgical procedure of aortic arch replacement itself has had to mature towards a level of quality and risk control to allow for refinement via a new device. These preparatory technical steps included mastering circulatory arrest, including brain and spinal cord protection, which required decisive innovation in extracorporeal circulation (ECC) management. In addition, patient selection with respect to age and risk factors, but also his or her underlying disease-aneurysm, dissection, atherosclerosis-has been optimized prior to the introduction of the prefabricated substitute for aortic arch replacement. Of utmost importance were those steps, taken by individual surgeons and institutions by use of self-fabricated substitutes, combining various commercially available devices. Thus, the frozen elephant technique, as applied today, did not crash into the armamentarium of unprepared aortic surgeons via device engineering and industrial product development alone. Instead, it resembles an evolutionary process, guided by a number of international institutions exploring preliminary approaches, and learning from each other via scientific exchange. This process, however, would have remained unthinkable without the tremendous advances in medical imaging via tomographic techniques, including their increasing resolution and 3D depiction. This communication will focus on the intermediary surgical steps and the technological advances between the prefabrication of the FET by the medical product industry and its first successful clinical application, as it is used today.

Background: Aortic arch surgery has evolved significantly with novel techniques aimed at reducing morbidity and mortality. Traditional approaches rely on hypothermic circulatory arrest (HCA), which remains associated with neurological and systemic complications. This study presents our initial experience with a normothermic frozen elephant trunk (FET) technique that eliminates circulatory arrest while maintaining continuous cerebral and systemic perfusion.

Methods: A retrospective analysis was conducted on consecutive patients who underwent FET without HCA at Polytechnic University of Marche from September 2019 to January 2025. The surgical strategy included femoral and innominate artery cannulation for extracorporeal circulation, antegrade selective cerebral perfusion (ASCP), and retrograde stent graft deployment with balloon occlusion. Perioperative outcomes, complications, and mid-term follow-up data were evaluated.

Results: Twenty-three patients (median age, 73 years) underwent FET without HCA. Indications included degenerative aneurysm (n=14), type I endoleak (n=4), acute aortic dissection (n=2), chronic penetrating ulcer (n=2), and Kommerell's diverticulum (n=1). Technical success was 100%. Two in-hospital deaths occurred due to septic shock and stroke. No cases of permanent spinal cord injury were reported. The median intensive care unit and hospital stays were 4 and 10 days, respectively. The median peak intraoperative lactate level was 1.8 mmol/L (range, 1-4.8 mmol/L). At a median follow-up of 27 months, three patients required distal aortic reintervention due to type Ib (n=2) and type II (n=1) endoleaks.

Conclusions: Normothermic FET without circulatory arrest is a feasible and potentially advantageous alternative to traditional techniques, reducing ischemia-reperfusion injury while maintaining cerebral and systemic perfusion. Early outcomes suggest promising results in selected patients, though further studies with larger cohorts are necessary to validate long-term safety and efficacy.

Keywords: Frozen elephant trunk (FET); normothermic frozen elephant trunk (normothermic FET); cardiac arrest; FET without circulatory arrest; aortic arch surgery.