The frozen elephant trunk technique for the treatment of complex aortic arch and descending thoracic aorta pathologies: long term outcomes and distal reintervention

Background: The frozen elephant trunk(FET) technique is one of the last evolution in the treatment of complex pathologies of the aortic arch and the descending thoracic aorta.Materials and methods: Between January 2007 and March 2021, a total of 396 patients underwent total aortic arch replacements with the FET technique in our centre.The main indications were thoracic aortic aneurysm(n=104,28.2%), chronic aortic dissection(n=224,53.4%) and acute aortic dissection(n=68, 18.4%). We divided the population in two groups according the position of the distal anastomosis (zone 2 vs zone 3) and the length of the stent graft (< 150 mm vs > 150 mm): conservative group (Zone 2 anastomosis + stent length < 150mm, n. 140 pts) and aggressive group (zone 3 anastomosis + stent length > 150mm, n. 141). Results: The overall 30-day mortality rate was 13%(48/369); the risk factor analysis showed that an aggressive approach was neither a risk factor for major complication (permanent dialysis, tracheostomy, bowel malperfusion and permanent paraplegia) neither for 30-day mortality. The survival rate at 1, 5,10 and 15 years was 87.7%,75%,61.3% and 58.4% respectively. During the follow up, an aortic reintervention was performed in 122 patients (38%), 5 patients received a non-aortic cardiac surgery. Freedom from aortic reintervention at 1-,5- and 10-year was 77%,54% and 44% respectively. The freedom from aortic reintervention was higher in the ‘aggressive’ group (62.5%vs40.0% at 5 years, log-rank=0.056). An aggressive approach was not protective for aortic reintervention at follow up and for death at follow up. Conclusions: The FET technique represents a feasible and efficient option in the treatment of complex thoracic aortic pathologies. An aortic reintervention after FET is very common and the decision-making approach should consider and balance the higher risk of an aggressive approach in terms of post-operative complication versus the higher risk of a second aortic reintervention at follow-up.

Nuovi approcci al trattamento della valvulopatia aortica

Background L’incidenza di malattie valvolari aortiche è in costante aumento. La terapia definitiva è chirurgica o interventistica, determinando un evidente miglioramento della qualità di vita, a fronte di un rischio operatorio ormai estremamente basso. Le linee guida internazionali più recenti pongono in classe I entrambe le procedure nella fascia di età fra 65 e 80 anni. Materiali e metodi È stata effettuata un’analisi retrospettiva dei pazienti di età compresa fra 65 e 80 anni, sottoposti a sostituzione valvolare aortica isolata chirurgica con bioprotesi sutureless (gruppo SU-AVR), oppure trans-catetere (gruppo TAVR), presso Maria Cecilia Hospital tra gennaio 2011 e dicembre 2021. Mediante propensity score matching sono stati analizzati, nei due gruppi risultanti, gli outcomes di mortalità e complicanze intraospedaliere, a 30 giorni, ad un anno e attuariale. Risultati Sono stati inclusi nello studio 638 pazienti, di cui 338 (52.98%) nel gruppo SU-AVR e 300 (47.02%) nel gruppo TAVR. Dopo propensity score matching, sono stati ottenuti due gruppi di pazienti (124 per gruppo) senza differenze statisticamente significative nelle comorbidità preoperatorie. La mortalità a 30 giorni è risultata sovrapponibile nei 2 gruppi. Il gruppo TAVR ha mostrato un’incidenza significativamente maggiore di impianto di pacemaker definitivo e di danni vascolari maggiori, mentre il gruppo SU-AVR ha mostrato una maggior incidenza di fibrillazione atriale, di trasfusioni e di insufficienza renale. La mortalità per tutte le cause a un anno è risultata significativamente maggiore per il gruppo TAVR e il divario continua ad aumentare con il tempo. Conclusioni La sostituzione valvolare aortica trans-catetere (TAVR) mostra risultati molto buoni nel breve termine nei pazienti fra 65 e 80 anni di età. Al follow-up a medio termine, tuttavia, i risultati preliminari mostrano un miglior outcome dei pazienti sottoposti a sostituzione valvolare chirurgica, sia in termini di mortalità per qualsiasi causa che di eventi cardiovascolari e cerebrovascolari maggiori.

Traditional risk factors and lifetime risk of acute coronary events

Objective: To investigate the association between the four traditional coronary heart disease (CHD) risk factors (hypertension, smoking, hypercholesterolemia, and diabetes) and outcomes of first ACS. Methods: Data were drawn from the ISACS Archives. The study participants consisted of 70953 patients with first ACS, but without prior CHD. Primary outcomes were patient’ age at hospital presentation and 30-day all-cause mortality. The risk ratios for mortality among subgroups were calculated using a balancing strategy by inverse probability weighting. Trends were evaluated by Pearson's correlation coefficient (r). Results: For fatal ACS (n=6097), exposure to at least one traditional CHD-risk factor ranged from 77.6% in women to 74.5% in men. The presence of all four CHD-risk factors significantly decreased the age at time of ACS event and death by nearly half a decade compared with the absence of any traditional risk factors in both women (from 67.1±12.0 to 61.9±10.3 years; r=-0.089, P<0.001) and men (from 62.8±12.2 to 58.9±9.9 years; r=-0.096, P<0.001). By contrast, there was an inverse association between the number of traditional CHD-risk factors and 30-day mortality. The mortality rates in women ranged from 7.7% with four traditional CHD-risk factors to 16.3% with no traditional risk factors (r=0.073, P<0.001). The corresponding rates in men were 4.8% and 11.5% (r=0.078, P<0.001), respectively. The risk ratios among individuals with at least one CHD-risk factors vs. those with no traditional risk factors were 0.72 (95%CI:0.65-0.79) in women and 0.64 (95%CI:0.59-0.70) in men. This association was consistent among patient subgroups managed with guideline-recommended therapeutic options. Conclusions: The vast majority of patients who die for ACS have traditional CHD-risk factor exposure. Patients with CHD-risk factors die much earlier in life, but they have a lower relative risk of 30-day mortality than those with no traditional CHD-risk factors, even in the context of equitable evidence‐based treatments after hospital admission.

Valutazione non invasiva dell'epatopatia Fontan indotta

Introduzione: L’intervento di Fontan comporta un aumento istantaneo della pressione venosa centrale che causa, nel medio-lungo termine, una forma di epatopatia specifica detta FALD. Il monitoraggio della FALD è complesso ma potrebbe consentire di bloccarne o rallentarne l’insorgenza. Lo studio ha valutato l’efficacia delle modalità di monitoraggio non invasivo. Materiale e metodi: Sei pazienti (età media 24 anni) operati presso l’IRCCS Azienda Ospedaliero Universitaria di Bologna sono stati sottoposti a RMN 4D-Flow e ad Ecodoppler epatico. Sono stati raccolti i dati anagrafici, morfologici, anamnestici e i markers sierologici per il calcolo degli scores MELD-XI, APRI, FIB4, i valori di Shear Stress assiale e circonferenziale e gli indici di pulsatilità e resistenza delle arterie epatica e renale. Risultati: Il tempo trascorso tra la Fontan e lo studio è stato di 17,8 anni. Età media alla Fontan 6,8 anni. Tutti i pazienti avevano un quadro compatibile con epatopatia. I markers sierologici e gli scores MELD-XI,APRI e FIB4 si sono dimostrati di scarsa utilità. All’ecografia tutti i pazienti avevano ecostruttura irregolare, splenomegalia e valori elevati di pulsatilità e resistenza dell’arteria epatica e splenica. La rigidità epatica media è stata di 12,4 Kpa. Alla RMN 4DF lo Shear stress assiale è stato massimo a livello del condotto (0,16 Pa) e minimo a livello delle vene sovra epatiche (0,05 Pa). Lo Shear Stress si è mostrato massimo nei pazienti con emodinamica sfavorevole e peggior quadro ecografico addominale, evidenziando aree di inefficienza energetica. Conclusioni: La combinazione delle diagnostiche di imaging non invasive potrebbe rivelarsi adeguata per il monitoraggio della FALD. In particolare, la RMN 4D Flow potrebbe rivelare aree di inefficienza energetica predisponenti alla FALD. Questo potrebbe indirizzare in modo specifico la terapia dei pazienti operati o addirittura indurre la modifica del disegno della Fontan verso forme più efficienti.

Non-invasive detection of acute cell-mediated graft rejection in paediatric heart transplant recipients: the role of cardiovascular magnetic resonance

Background and Aim: Acute cardiac rejection is currently diagnosed by endomyocardial biopsy (EMB), but multiparametric cardiac magnetic resonance (CMR) may be a non-invasive alternative by its capacity for myocardial structure and function characterization. Our primary aim was to determine the utility of multiparametric CMR in identifying acute graft rejection in paediatric heart transplant recipients. The second aim was to compare textural features of parametric maps in cases of rejection versus those without rejection. Methods: Fifteen patients were prospectively enrolled for contrast-enhanced CMR followed by EMB and right heart catheterization. Images were acquired on a 1,5 Tesla scanner including T1 mapping (modified Look-Locker inversion recovery sequence – MOLLI) and T2 mapping (modified GraSE sequence). The extracellular volume (ECV) was calculated using pre- and post-gadolinium T1 times of blood and myocardium and the patient’s hematocrit. Markers of graft dysfunction including hemodynamic measurements from echocardiography, catheterization and CMR were collated. Patients were divided into two groups based on degree of rejection at EMB: no rejection with no change in treatment (Group A) and acute rejection requiring new therapy (Group B). Statistical analysis included student’t t test and Pearson correlation. Results: Acute rejection was diagnosed in five patients. Mean T1 values were significantly associated with acute rejection. A monotonic, increasing trend was noted in both mean and peak T1 values, with increasing degree of rejection. ECV was significantly higher in Group B. There was no difference in T2 signal between two groups. Conclusion: Multiparametric CMR serves as a noninvasive screening tool during surveillance encounters and may be used to identify those patients that may be at higher risk of rejection and therefore require further evaluation. Future and multicenter studies are necessary to confirm these results and explore whether multiparametric CMR can decrease the number of surveillance EMBs in paediatric heart transplant recipients.