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\"At the end of the Civil War, an escaped slave first returns to his old plantation and then walks across the ravaged South in search of his lost wife\"--Provided by the publisher.

Background and Objectives: Minimally invasive valve surgery (MIVS), integrated within enhanced recovery after surgery (ERAS) programs, is a pivotal advancement in modern cardiac surgery, aiming to reduce perioperative morbidity and accelerate recovery. This systematic review analyzes the integration of ERAS components into MIVS programs and evaluates their impact on perioperative outcomes and patient recovery. Materials and Methods: A systematic search of PubMed/Medline, conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, identified studies on ERAS in MIVS patients. Coronary and robotic surgery were excluded to prioritize widely adopted minimally invasive valve methods. Studies were included if they applied ERAS protocols primarily to MIVS patients, with at least five participants per study. Data on study characteristics, ERAS components, and patient outcomes were extracted for analysis. Results: Eight studies met the inclusion criteria, encompassing 1287 MIVS patients (842 ERAS, 445 non-ERAS). ERAS protocols in MIVS were heterogeneous, with studies implementing 9 to 18 of 24 ERAS measures recommended by the ERAS consensus guideline, reflecting local hospital practices and resource availability. Common elements include patient education and multidisciplinary teams, early extubation followed by mobilization, multimodal opioid-sparing pain management, and timely removal of invasive lines. Despite protocol variability, these programs were associated with reduced morbidity, shorter hospital stays (intensive care unit-stay reductions of 4–20 h to complete omission, and total length of stay by ≥1 day), and cost savings of up to EUR 1909.8 per patient without compromising safety. Conclusions: ERAS protocols and MIVS synergistically enhance recovery and reduce the length of hospital stay. Standardizing ERAS protocols for MVS could amplify these benefits and broaden adoption.

Abstract Objectives: Total arch replacement using the frozen elephant trunk technique remains the gold standard for a definite aortic arch repair. To facilitate surgical management of the left subclavian artery (LSA), a new hybrid frozen elephant trunk device was recently developed. Methods: A 62-year-old female patient presented with acute type A aortic dissection and underwent emergent aortic root and total arch replacement using the novel custom-made Evita Neo EDE hybrid arch device for frozen elephant trunk implantation. To facilitate the management of the LSA, a covered stent connected to the device was inserted into the LSA via guidewire prior to performing the distal anastomosis in zone two. Results: Postoperative computed tomographic angiography demonstrated excellent outcome and technical success with no signs of endoleak or device-related complications. The patient was discharged home 11 days after surgery in a stable clinical condition. Conclusions: The new Neo EDE hybrid arch device for frozen elephant trunk implantation is easy to use and simplifies surgical management of the LSA without adding technical complexity. The frozen elephant trunk (FET) technique remains the gold standard for total arch replacement in the case of complex aortic arch pathologies.

Background: Perioperative stroke remains a devastating complication in the operative treatment of acute type A aortic dissection. To reduce the risk of perioperative stroke, different perfusion techniques can be applied. A consensus on the preferred cerebral protection strategy does not exist. Methods: To provide an overview about the different cerebral protection strategies, literature research on Medline/PubMed was performed. All available original articles reporting on cerebral protection in surgery for acute type A aortic dissection and neurologic outcomes since 2010 were included. Results: Antegrade and retrograde cerebral perfusion may provide similar neurological outcomes while outperforming deep hypothermic circulatory arrest. The choice of arterial cannulation site and chosen level of hypothermia are influencing factors for perioperative stroke. Conclusions: Deep hypothermic circulatory arrest is not recommended as the sole cerebral protection technique. Antegrade and retrograde cerebral perfusion are today’s standard to provide cerebral protection during aortic surgery. Bilateral antegrade cerebral perfusion potentially leads to superior outcomes during prolonged circulatory arrest times between 30 and 50 min. Arterial cannulation sites with antegrade perfusion (axillary, central or carotid artery) in combination with moderate hypothermia seem to be advantageous. Every concept should be complemented by adequate intraoperative neuromonitoring.

The treatment of DeBakey type I aortic dissection remains a major challenge in the field of aortic surgery. To upgrade the standard of care hemiarch replacement, a novel device called an “Ascyrus Medical Dissection Stent” (AMDS) is now available. This hybrid device composed of a proximal polytetrafluoroethylene cuff and a distal non-covered nitinol stent is inserted into the aortic arch and the descending thoracic aorta during hypothermic circulatory arrest in addition to hemiarch replacement. Due to its specific design, it may result in a reduced risk for distal anastomotic new entries, the effective restoration of branch vessel malperfusion and positive aortic remodeling. In this narrative review, we provide an overview about the indications and the technical use of the AMDS. Additionally, we summarize the current available literature and discuss potential pitfalls in the application of the AMDS regarding device failure and aortic re-intervention.

This study investigates differences in short- and midterm outcomes in patients without malperfusion undergoing surgery for acute type A aortic dissection between specialized aortic surgeons and non-aortic surgeons.OBJECTIVESThis study investigates differences in short- and midterm outcomes in patients without malperfusion undergoing surgery for acute type A aortic dissection between specialized aortic surgeons and non-aortic surgeons.Patients who underwent surgery for acute type A aortic dissection between 2013-2023 defined as M0 (no malperfusion) according to the Type-Entry-Malperfusion classification were included and divided into two groups according to the surgeon's expertise: aortic surgeon versus non-aortic surgeon group, whereas an aortic surgeon was defined by expertise in extensive aortic arch surgery including frozen elephant trunk implantation on a regular basis (average ≥5/year). After propensity score matching, the groups were compared in terms of intraoperative variables and outcomes including a primary combined end-point consisting of thirty-day mortality and/or CT-confirmed stroke.METHODSPatients who underwent surgery for acute type A aortic dissection between 2013-2023 defined as M0 (no malperfusion) according to the Type-Entry-Malperfusion classification were included and divided into two groups according to the surgeon's expertise: aortic surgeon versus non-aortic surgeon group, whereas an aortic surgeon was defined by expertise in extensive aortic arch surgery including frozen elephant trunk implantation on a regular basis (average ≥5/year). After propensity score matching, the groups were compared in terms of intraoperative variables and outcomes including a primary combined end-point consisting of thirty-day mortality and/or CT-confirmed stroke.The matched cohort comprised two balanced groups with 234 patients (117 each group). Cardiopulmonary bypass, cross-clamp and distal arrest times did not differ significantly between the groups. However, more extensive aortic surgery was performed by aortic surgeons: aortic root replacement (Bentall) (p = 0.007; OR 1.18 (CI 1.05-1.32)), valve-sparing root replacement (David) (p = 0.013; OR 1.05 (CI 1.01-1.10)) and frozen elephant trunk implantation (p < 0.001; OR 1.18 (CI 1.09-1.27)). The combined end-point of thirty-day mortality and/or CT-confirmed stroke was 26% in the non-aortic surgeon vs 23% in the aortic surgeon group (p = 0.54; OR 0.97 (CI 0.86-1.08)). Further clinical outcomes, including five-year survival, did not differ significantly (p = 0.170).RESULTSThe matched cohort comprised two balanced groups with 234 patients (117 each group). Cardiopulmonary bypass, cross-clamp and distal arrest times did not differ significantly between the groups. However, more extensive aortic surgery was performed by aortic surgeons: aortic root replacement (Bentall) (p = 0.007; OR 1.18 (CI 1.05-1.32)), valve-sparing root replacement (David) (p = 0.013; OR 1.05 (CI 1.01-1.10)) and frozen elephant trunk implantation (p < 0.001; OR 1.18 (CI 1.09-1.27)). The combined end-point of thirty-day mortality and/or CT-confirmed stroke was 26% in the non-aortic surgeon vs 23% in the aortic surgeon group (p = 0.54; OR 0.97 (CI 0.86-1.08)). Further clinical outcomes, including five-year survival, did not differ significantly (p = 0.170).Patients without preoperative malperfusion undergoing surgery for ATAAD show no differences in terms of short- and midterm outcomes between specialized aortic and non-aortic surgeons. However, more extensive aortic repair may be performed safely by specialized aortic surgeons. These results support the definition of an aortic surgeon based on experience with the FET technique and may advocate call coverage by an aortic surgeon for type A repair at high-volume centers.CONCLUSIONSPatients without preoperative malperfusion undergoing surgery for ATAAD show no differences in terms of short- and midterm outcomes between specialized aortic and non-aortic surgeons. However, more extensive aortic repair may be performed safely by specialized aortic surgeons. These results support the definition of an aortic surgeon based on experience with the FET technique and may advocate call coverage by an aortic surgeon for type A repair at high-volume centers.

Abstract Objectives This study investigates differences in short- and mid-term outcomes in patients without malperfusion undergoing surgery for acute type A aortic dissection between specialized aortic surgeons and non-aortic surgeons. Methods Patients who underwent surgery for acute type A aortic dissection between 2013 and 2023 defined as M0 (no malperfusion) according to the type-entry-malperfusion classification were included and divided into 2 groups according to the surgeon’s expertise: aortic surgeon vs non-aortic surgeon group, whereas an aortic surgeon was defined by expertise in extensive aortic arch surgery including frozen elephant trunk implantation on a regular basis (average ≥5/year). After propensity score matching, the groups were compared in terms of intraoperative variables and outcomes including a primary combined end-point consisting of 30-day mortality and/or CT-confirmed stroke. Results The matched cohort comprised 2 balanced groups with 234 patients (117 in each group). Cardiopulmonary bypass, cross-clamp and distal arrest times did not differ significantly between the groups. However, more extensive aortic surgery was performed by aortic surgeons: aortic root replacement (Bentall) (P = .007; odds ratio [OR] 1.18 [CI, 1.05-1.32]), valve-sparing root replacement (David) (P = .013; OR 1.05 [CI, 1.01-1.10]), and frozen elephant trunk implantation (P < .001; OR 1.18 (CI, 1.09-1.27]). The combined end-point of 30-day mortality and/or CT-confirmed stroke was 26% in the non-aortic surgeon vs 23% in the aortic surgeon group (P = .54; OR 0.97 [CI, 0.86-1.08]). Further clinical outcomes, including 5-year survival, did not differ significantly (P = .170). Conclusions Patients without preoperative malperfusion undergoing surgery for ATAAD show no differences in terms of short- and mid-term outcomes between specialized aortic and non-aortic surgeons. However, more extensive aortic repair may be performed safely by specialized aortic surgeons. These results support the definition of an aortic surgeon based on experience with the frozen elephant trunk technique and may advocate for call coverage by an aortic surgeon for type A repair at high-volume centres. Acute type A aortic dissection (ATAAD) is associated with high morbidity and mortality, demanding urgent surgical repair according to current guidelines. Graphical abstract

Cardiac surgery, post-cardiotomy cardiogenic shock (PCCS), and temporary mechanical circulatory support (tMCS) provoke substantial inflammation. We therefore investigated whether a selenium-based, anti-inflammatory strategy would benefit PCCS patients treated with tMCS in a post-hoc analysis of the sustain CSX trial. Post-hoc analysis of patients receiving tMCS for PCCS in the Sustain CSX trial, which investigated the effects of high-dose selenium on postoperative organ dysfunction in cardiac surgery patients. Primary outcome: duration of tMCS therapy. Secondary outcomes: postoperative organ dysfunction and 30-day mortality. Thirty-nine patients were treated with tMCS for PCCS. There was no difference in the median duration of tMCS between the selenium and the placebo group (3 days [IQR: 1–6] vs. 2 days [IQR: 1–7], p = 0.52). Median dialysis duration was longer in the selenium group (1.5 days [0–21.8] vs. 0 days [0–1.8], p = 0.048). There was no difference in 30-day mortality (53% vs. 41%, OR 1.44, 95% CI 0.32–6.47, p = 0.62). In this explorative study, a perioperative high-dose selenium-supplementation did not show beneficial effects on organ dysfunctions and mortality rates in patients with PCCS receiving tMCS. •Cardiac surgery and mechanical circulatory support provoke substantial inflammation.•High-dose, anti-inflammatory selenium could serve as an anti-inflammatory strategy.•Selenium does not reduce organ dysfunction in post-cardiotomy cardiogenic shock.

Abstract OBJECTIVES The goal of this study was to investigate the impact of onset-to-cut time on mortality in patients undergoing surgery for stable acute type A aortic dissection. METHODS Patients who underwent surgery for acute type A aortic dissection between January 2006 and December 2021 and available onset-to-cut times were included. Patients with unstable aortic dissection (preoperative shock, intubation, resuscitation, coma, pericardial tamponade and local/systemic malperfusion syndromes) were excluded. After descriptive analysis, a multivariable binary logistic regression for 30-day mortality was performed. A receiver operating characteristic curve for onset-to-cut time and 30-day mortality was calculated. Restricted cubic splines were designed to investigate the association between onset-to-cut time and survival. RESULTS The final cohort comprised 362 patients. The median onset-to-cut time was 543 (376–1155) min. The 30-day mortality was 9%. Only previous myocardial infarction (P = 0.018) and prolonged cardiopulmonary bypass time (P < 0.001) were identified as independent risk factors for 30-day mortality. The corresponding area under the receiver operating characteristic curve showed a value of 0.49. Restricted cubic splines did not indicate an association between onset-to-cut time and survival (P = 0.316). CONCLUSIONS Onset-to-cut time in the setting of stable acute type A aortic dissection does not seem to be a valid predictor of 30-day mortality in patients undergoing surgery and stayed stable during the preoperative course. Acute type A aortic dissection (ATAAD) is associated with high morbidity and mortality [1, 2].

Mitral valve prolapse (MVP) is common among heart valve disease patients, causing severe mitral regurgitation (MR). Although complications such as cardiac arrhythmias and sudden cardiac death are rare, the high prevalence of the condition leads to a significant number of such events. Through next-generation gene sequencing approaches, predisposing genetic components have been shown to play a crucial role in the development of MVP. After the discovery of the X-linked inheritance of filamin A, autosomal inherited genes were identified. In addition, the study of sporadic MVP identified several genes, including DZIP1, TNS1, LMCD1, GLIS1, PTPRJ, FLYWCH, and MMP2. The early screening of these genetic predispositions may help to determine the patient population at risk for severe complications of MVP and impact the timing of reconstructive surgery. Surgical mitral valve repair is an effective treatment option for MVP, resulting in excellent short- and long-term outcomes. Repair rates in excess of 95% and low complication rates have been consistently reported for minimally invasive mitral valve repair performed in high-volume centers. We therefore conceptualize a potential preventive surgical strategy for the treatment of MVP in patients with genetic predisposition, which is currently not considered in guideline recommendations. Further genetic studies on MVP pathology and large prospective clinical trials will be required to support such an approach.