No abstract

Background: Cardiac surgery often represents the only treatment option in patients with infective endocarditis (IE). However, IE surgery may lead to a sudden release of inflammatory mediators, which is associated with the severity of postoperative organ dysfunction. We investigated the impact of hemoadsorption during IE surgery on postoperative organ dysfunction. Methods: This multi-center, randomized, non-blinded, controlled trial assigned patients undergoing cardiac surgery for IE to hemoadsorption [integration of CytoSorb® to cardiopulmonary bypass (CPB)] or control. The Primary outcome (ΔSOFA) was defined as the difference between the mean total postoperative sequential organ failure assessment score (SOFA), calculated maximally to the 9th postoperative day, and the basal SOFA score. The analysis was by modified intention-to-treat. A predefined inter-group comparison was done using a linear mixed model for ΔSOFA including surgeon and baseline SOFA as fixed effect covariates and with the surgical center as random effect. The SOFA score assesses dysfunction in six organ systems, each scored from zero to four. Higher scores indicate worsening dysfunction. Secondary outcomes were 30-day mortality, durations of mechanical ventilation, vasopressor and renal replacement therapy. Cytokines were measured in the first 50 patients. Results: Between January 17, 2018 and January 31, 2020, A total of 288 patients were randomly assigned to hemoadsorption (n=142) or control (n=146). Four patients in the hemoadsorption and two in the control group were excluded as they did not undergo surgery. The primary outcome ΔSOFA did not differ between the hemoadsorption and the control group (1.79 ± 3.75 and 1.93 ± 3.53, respectively, 95% CI: −1.30 to 0.83, p=0.6766). Mortality at 30 days (21% hemoadsorption vs 22% control, p=0.782), the durations of mechanical ventilation, vasopressor and renal replacement therapy did not differ between groups. Levels of IL-1β and IL-18 at the end of CPB were significantly lower in the hemoadsorption than in the control group. Conclusions: This randomized trial failed to demonstrate a reduction in postoperative organ dysfunction through intraoperative hemoadsorption in patients undergoing cardiac surgery for IE. Although hemoadsorption reduced plasma cytokines at the end of CPB, there was no difference in any of the clinically relevant outcome points.

The frozen elephant trunk technique is associated with an excellent clinical outcome in a complex cohort of patients, and also effectively induces remodelling in downstream aortic segments in acute and chronic thoracic aortic dissections. The need for secondary interventions in downstream segments, which mainly depends on the extent of the underlying disease process, remains substantial. Further studies are required to assess the long-term outcome of this approach.

The FET technique is an attractive method for the repair of acute complicated Type B aortic dissection without a suitable landing zone for primary thoracic endovascular aortic repair. It should be considered as an alternative in patients who are at high risk for retrograde Type A aortic dissection, in patients with an unfavourable anatomy or in patients with connective tissue disease.

During descending thoracic aortic and thoracoabdominal aortic aneurysm repairs, the use of deep hypothermic circulatory arrest results in improved postoperative adverse outcome rates compared with non-deep hypothermic circulatory arrest techniques. The development of reversible adverse outcomes is strongly associated with the development of permanent adverse outcomes.

Aortic arch replacement using a trifurcated graft is highly durable, with excellent patency in the branch grafts, and is associated with a low incidence of cerebral embolization. However, the long-term outcome in these patients is compromised by extensive comorbidities.

Patients with infectious aortic disease present in a frail state and the initial and the late mortality is substantial. Yet, surgical treatment of native and prosthetic aortic infection with xenopericardial tube grafts shows promising short-term results with regard to durability and freedom from reinfection in any aortic segment. Further studies are needed to learn of the long-term behavior of these grafts.

SummaryThe development of new devices to improve treatment and to explore new indications that have not yet been adequately addressed is a natural consequence of the clinical demand for solutions to as yet unmet needs. The frozen elephant trunk technique was one of the major steps within the last 15 years to improve on existing treatments as well as to explore new indications. The goal of this article is to provide technical details about advances in implantation techniques for the treatment of acute and chronic thoracic aortic pathological conditions.