The 36th EACTS Annual Meeting | Daily News 07.10.22

HIGHLIGHTS FROM THURSDAY

IMPACTING PATIENT CARE WITH LATE BREAKING CLINICAL TRIALS

The quality of submissions to this year’s Late Breaking Clinical Trials sessions has been outstanding, reinforcing the EACTS Annual Meeting as a key event in the calendar for the cardiothoracic community. Delegates will hear the latest results and data from studies designed to help us make further improvements in outcomes for patients. Given the number of submissions this year, we are delighted there are two dedicated sessions on late breaking clinical trials.

Taking place today and on Saturday, presentations include:

• The results of CAST-HF, a potentially practice changing prospective randomised controlled trial exploring cardiac shockwave therapy in patients with ischemic cardiomyopathy.

• The preliminary results of a first in human trial of a device facilitating robotic coronary artery bypass grafting.

Shockwave therapy is a novel approach, aiming to improve outcomes for patients who present with complications. Although shockwave therapy is already used in other specialties, notably in interventional cardiology, this is the first application in a trial for cardiac surgery.

Gender differences, a current hot topic in cardiothoracic surgery, will be explored with interesting data from the multi-centre Italian registry on the gender differences in minimally invasive mitral valve surgery. With 90% of patients enrolled in studies routinely being men, the data from Italy will help identify where the gaps are and how the outcomes are different dependent on gender.

Fractional flow reserve (FFR) is useful in PCI, and is increasingly used in our Heart Team discussions to manage patients. High quality data from the well-recognised SWEDEHEAR T Registry on the short and midterm outcomes of Fractional

Flow Rese rve (FFR)-guided CABG will be presented, which will provide data on applicability of FFR to our CABG practice in a large patient population.

In Friday’s session delegates can also look forward to a teaser on the LeAAPS trial – an extension to the LAAOS 3 trial – which will explore whether the left atrial appendage should be closed in more cardiac surgery patients than currently is the case.

Late Breaking Clinical Trials on Saturday

The preliminary first in human results of the Excimer Laser Assisted Non Occlusive Anastomosis (ELANA) Heart Bypass System will be presented during Saturday’s Late Breaking Clinical Trials session. Rather than sewing the anastomosis by hand, this robotics device aims to make coronary artery bypass grafting quicker and easier as well as minimally invasive.

WELCOME

HIGHLIGHTS FROM THURSDAY

Following on from the successful Techno-College, our fantastic scientific programme kicked off yesterday with stimulating discussions, new scientific insights and a look at some of the innovations in cardiothoracic surgery. Thursday’s focus sessions began with an update on ongoing and upcoming trials in myocardial revascularisation. Presenters included Mario Gaudino who discussed the pericardiotomy trials – PALACS and EPIC and Jolanda Kluin who explored whether it’s time for a trial of revascularisation in women.

A fascinating focus session on cardiac xenotransplantation looked at the history and science behind xenotransplantation leading to a debate about the future of this procedure. Presenters included Dr Bartley Griffith who discussed breakthroughs in cardiac xenotransplantation. Dr. Bartley Griffith and his team transplanted a heart from a genetically modified pig into a human at the University of Maryland Medical Centre.

HIGHLIGHTS FROM THURSDAY

Honoured guest

We were delighted to welcome Manfred Mueller as this year’s honoured guest speaker. Speaking to a packed auditorium, Manfred shared his knowledge and insights about flight safety and how to implement safety strategies from aviation into the medical world.

High-quality abstract sessions

This year’s Annual Meeting includes over 30 high quality abstract sessions in the scientific programme. Abstract sessions are a fantastic opportunity to learn more about the latest research and techniques in cardiothoracic surgery. Thursday’s sessions began with ‘Deep dive in mitral pathologies’ which addressed long-term results of mitral treatment including repair for degenerative and functional mitral regurgitation as well as replacement and explored the value of imagebased technology to predict annuloplasty ring sizes.

INNOVATION AND TRANSFORMATION

As in the early days of

surgery, surgeons need to implement

innovation in the near future and some form of transformation in

to deliver new ways to improve patient outcomes and save lives.

Professor Friedhelm Beyersdorf EACTS President

In his Presidential Address, EACTS President Professor Friedhelm Beyersdorf will urge today’s surgeons to take inspiration from the past, highlighting how cardiothoracic surgeons in the 1950s and 60s were very successful in treating untreatable diseases through remarkable forward-thinking innovations such as cross circulation and the development of the heart lung machine.

These techniques have been refined over the past decades but, as Professor Beyersdorf notes, the quality and effectiveness of current techniques can, of course, always be improved. In his speech he will give examples of successful and unsuccessful alternative techniques, noting that the necessity for changes in method are not always dependent on the quality of previous solutions.

Harnessing innovation in other disciplines

He will say that we need to continually strive for innovative solutions to improve current techniques but, in order to do this, surgeons must look outside of medicine and surgery. There are fantastic research programmes and innovations being undertaken in other disciplines which offer huge possibilities for surgeons. In order to harness this great work for the benefit of patients, surgeons need to build links and make connections with industries such as engineering and explore opportunities to work together.

Highlighting the huge potential in today’s medicine, Professor Beyersdorf will cite examples such as multi-organ repair and even atherosclerosis and cancer and discuss promising new findings and surgical techniques which could provide a solution to treating this condition.

Improving postoperative care

Despite data demonstrating the long-term advantages of surgical techniques such as bypass surgery, some patients choose interventional techniques. Professor Beyersdorf will use his Presidential Address to call for improvements to patient care during the early postoperative period, noting that patients should be discharged from hospital the day after surgery and prevent conditions such as atrial fibrillation and infection. He will present new data on the impact of redox medicine and consider how this can be used in practical terms to improve postoperative care for patients.

October

EACTS GENERAL ASSEMBLY

LEARNING FROM WORLD-CLASS EXPERTS

EACTS Residents Committee at the 36th EACTS Annual Meeting

Our Residents Committee has developed an exciting, educational and interactive programme at this year’s EACTS Annual meeting. Join the committee to explore the latest innovations in cardiothoracic surgery, take part in hands-on Learning Lab sessions and engage in enriching debates alongside world-class experts.

There will be plenty of opportunities to learn together, explore new scientific insights, connect with new and old friends and colleagues, and immerse in a wealth of quality education.

The Residents’ programme kicked off yesterday with a fascinating focus session ‘Breaking the Taboo- Everyone has a graveyard’. Focusing on complications in cases within the fields of aortic, interventional, thoracic and heart failure residents had a unique opportunity to hear young surgeons, supported by their consultant surgeons, talk openly about complications in their cases, lessons learnt and how subsequent changes have been made in their clinical practices.

Today, there will be a great opportunity to learn from world class experts about how major trials are established and performed. ‘Behind the scenes of groundbreaking trials – How to perform a major trial’ includes presentations from Mario Gaudino on the ROMA 3 trial and a behind the scenes look at the VIOLET trial by Michael Shackcloth.

Friday afternoon includes two exciting Learning Labs. This is an excellent opportunity to enhance skills across two practical simulation sessions: video-assisted thoracoscopic surgery (VATS) and virtual reality 3D planning for surgery. So come, try out the instruments and have some fun with the Residents Committee.

Make sure to join the Residents Case Corner – live on stage on Saturday, where you’ll get to expand your specialist knowledge with an enlightening mix of five cases presented by residents. This will be a lively discussion between residents, chiefs and senior consultants to promote clinical skills in diagnosis and decision-making in complex cases based on scientific evidence.

And finally, the Committee is delighted to be hosting its not-to-missed traditional luncheon, which is a fantastic opportunity to talk to some of the world’s best cardiac and thoracic surgeons in a relaxed, friendly environment while enjoying delicious food. Just remember to register in advance at the EACTS stand.

Members of the Residents Committee are available throughout the Annual Meeting so please don’t hesitate to ask questions about mentoring and training.

Target Audience

Target Audience

Overview

Overview

Sessions & Dates

Sessions & Dates

Target

Overview

Sessions

EACTS Case Corner Course Directors: A Zientara, London; C Gollmann-Tepeköylü, Innsbruck

TOGETHER, EXPLORE NEW SCIENTIFIC INSIGHTS, CONNECT WITH NEW AND OLD FRIENDS AND COLLEAGUES, AND IMMERSE IN A WEALTH OF QUALITY EDUCATION.

Alicja Zientara

ICVTS GOES INTERDISCIPLINARY

ICVTS – the fully open access, online journal published by EACTS will relaunch in January next year as Interdisciplinary CardioVascular and Thoracic Surgery.

This forward thinking new ICVTS will encourage collaboration across multidisciplinary teams in cardiac, thoracic and vascular surgery, by focusing on highly innovative, interdisciplinary research that, according to Peyman Sardari Nia, Editor in Chief of ICVTS, ‘directly impacts surgical practice within the field’. This in turn will help deliver better outcomes for patients.

Commenting on the relaunch, Peyman says, “The Journal aims to bring all those involved in cardiovascular and thoracic research together, focusing on treatment of a disease condition rather than accepting the status quo of researchers conducting research and publishing in different silos on the same pathology”.

Technological advances in healthcare are now driven by interdisciplinary research that covers medical, biomedical, physical, engineering and computer sciences and beyond so it’s important this approach is echoed by EACTS Journals. These advances are key to refining and improving treatments, as well as ‘opening the door’ to new treatment options, meaning that ICVTS will support multidisciplinary teams – in cardiac, thoracic and vascular surgery – advance their work in that direction.

Ludwig K. von Segesser, Founding Editor of ICVTS, says, ‘This is a good very move because this is how the discipline is evolving – from a single specialty to a multi-disciplinary approach for our patients. People have to work together to bring in their expertise from different views and from different

fields. I think that is going to be the future’.

From a thoracic perspective, Thoracic Assistant Editor for ICVTS, Cecilia Pompili, believes that these changes will encourage more and more interdisciplinary oncology driven research.

ICVTS has been steadily and successfully evolving since 2002 (as Interactive CardioVascular Thoracic Surgery) and converted to open access in August 2021. The new interdisciplinary format will not only strengthen its position within the surgical community, but, crucially, will also highlight research by related disciplines that impacts cardiothoracic surgery, which previously may not have been visible to the relevant surgical community.

ICVTS publishes original articles, reviews on multidisciplinary or interdisciplinary subjects, brief communications, case reports, letters to the editor and editorials.

The fundamental reasons behind the name change and relaunch are to acknowledge the fact that patients are increasingly supported by multidisciplinary teams, from surgeons and nurses to anaesthetists and perfusionists, who all work together to address the vital needs and longterm health management of individuals.

“The Journal aims to bring all those involved in cardiovascular and thoracic research together, focusing on treatment of a disease condition rather than accepting the status quo of researchers conducting research and publishing in different silos on the same pathology.”

From 2023, the new journal will focus on the treatment of a disease condition and mirror the changing surgical landscape. Ash Merrifield, EACTS Publications Director, stresses, “It is an important part of my role to ensure that our publications are truly set up for the future and are able to adapt to changes within the surgical community, but also within the publishing community”.

The publication will have a clear mission, with a definite purpose for its broader readership, that will create a more distinctive ICTVS publication –as well as a more inclusive one.

Matthias Siepe, Editor in Chief of EJCTS, and Council Member, is confident about the ‘huge sense’ the relaunch changes make, while Filip De Somer, Chairman of the European Board of Cardiovascular Perfusion, acknowledges that “ICVTS has now claimed its rightful position of being an inclusive journal for everyone who wants to innovate in the field of cardiovascular and thoracic surgery”.

Meet the publishers at booth B33 to discuss

and advertising

Peyman Sardari Nia

Acute Type A Aortic DissectionRisks and Decisions

Brown 3

08:15 - 09:45

Outcomes of acute type A aortic dissection with cardiopulmonary arrest: Tokyo Acute Aortic Super-Network Registry

Objectives: To save the patients of acute type A aortic dissection (ATAAD) with presenting cardiopulmonary arrest (CPA) may be extremely difficult. We investigated the early outcomes of those patients.

Acute Type A Aortic DissectionRisks and Decisions

Brown 3 08:15 - 09:45

Efficacy of the GERAADA score in predicting mortality after Type A aortic dissection surgery

Background and aim: No reliable scores are available to predict mortality following surgery for Type A Acute Aortic Dissection (TAAAD). Recently, the GERAADA score has been developed. We aim to compare how the GERAADA score performs in predicting operative mortality for TAAAD compared to EUROSCORE II and the Penn Classification.

Methods: 207 consecutive patients underwent TAAAD repair over a seven-year period at the Bristol Heart Institute. For each patient, we calculated the EUROSCORE II, Penn Classification and GERAADA score. As there are no precise criteria to calculate the GERAADA score, we used two methods: a ClinicalGERAADA score, which evaluated malperfusion with clinical and radiological evidence, and a Radiological-GERAADA score, where malperfusion was assessed by CT scan alone. We ran univariable logistic regression models for each of the scoring systems, then ROC curves and AUC were used to evaluate their ability to predict operative mortality.

Results: The Clinical-GERAADA score showed the strongest predictive ability with an AUC of 76.9% (95% CI: 67.2 – 87.5), while the RadiologicalGERAADA score showed a lesser predictive ability with an AUC of 74.6% (64.7 – 84.4). Euroscore II had an AUC of 75% (64.6 – 85.3) and the Penn Classification had an AUC of 71.8% (61.8 – 81.8). The best threshold for the Clinical- GERAADA score was 16.9 (sensitivity: 0.79; specificity: 0.67).

Conclusions: GERAADA score, using clinical and radiological evidence of malperfusion, is a reliable risk scoring system for predicting operative mortality after surgery for TAAAD.

Manabu Yamasaki / M.D., St Luke’s International Hospital, Tokyo, Japan

Q. Where did you carry out your training?

Department of cardiovascular surgery, St Luke’s International Hospital, Tokyo, Japan.

Methods: 3307 patients with ATAAD were transported to the hospitals that belong to Tokyo Acute Aortic Super-Network between January 2015 to December 2019, we assessed the early mortality of 434 patients (13.1%) presenting with CPA.

Results: Overall mortality of ATAAD patients with CPA was 88.2% (383/434); it was 94.5% in those with out-of-hospital CPA (n=254) and 79.4% in in-hospital CPA (n=180) (p<0.001). According to multivariable analysis, only aortic surgery lowered the mortality of ATAAD patients with CPA [odds ratio (OR) 46.204, 95% confidence interval (CI) 17.080 to 124.991, p<0.001], out-of-hospital CPA [OR 171.273, 95%CI 32.654 to 898.336, p<0.001], and

Q. What are your main areas of interest within cardiothoracic surgery?

Minimum invasive cardiac surgery, Aortic surgery.

Q. What are your interests outside of your work?

Running, watching NBA Basketball games.

in-hospital CPA [OR 24.330, 95%CI 7.297 to 81.121, p<0.001].

Conclusions: The mortality rate of patients of ATAAD with CPA was extremely high, although the outcome of in-hospital CPA was better than that of out-of-hospital CPA. Aortic surgery was only related to better outcome of patients of ATAAD with CPA.

Marco Gemelli / Resident in Cardiac Surgery, University of Padova, Italy

Q. Where did you carry out your training?

I am a two-year resident in Cardiac Surgery at the University of Padova in Italy. I have also spent almost a year as Clinical Fellow at the Bristol Heart Institute in the UK, where I have

also done research in aortic dissection.

Q. What are your main areas of interest within cardiothoracic surgery?

The aorta and the aortic valve. I have published some studies on this field, and I am carrying on other projects about this topic. My current focus is the aortic dissection.

Q. What are your interests outside of your work?

I love skiing during the winter and trekking during the summer. I am a good tennis player and I love history.

Naoyuki Kimura

Machii

,Akio Matsuda

Daijiro Hori1,Manabu Shiraishi1, Atsushi Yamaguchi1,Kenji Matsumoto3, Masashi

Eguchi

Department of Cardiovascular Surgery,

Medical University, Saitama,

Medical Center,

Department of Cardiovascular

Nihon University Hospital, Tokyo,

Saitama Medical Center, Jichi Medical University.

Saitama Medical Center.

Department of Allergy

Clinical Immunology, National Research Institute

Health and Development, Setagaya-ku, Tokyo, Japan

We investigated whether false lumen (FL) status influences expression of cytokines in peripheral blood of patients with acute aortic dissection (AAD).

First, we divided 566 patients with type A treated surgically within 48 hours of symptom onset into two groups: those with a thrombosed FL (group T, n=130) and those with a patent FL (group P, n=435). Group T patients were older (median age: 72 years vs. 64 years, p<0.001) and more likely to be female (59% vs. 44%, p=0.002) than group P patients. Organ malperfusion (16% vs. 42%, p<0.001) and an aortic arch entry tear (9% vs. 22%, p=0.001) were less prevalent in group T. The leukocyte count (x10E3/µL) (10.8 [8.4, 12.9]) vs. 11.7 [8.8, 14.9], p=0.024) and D-dimer concentration (ng/dL)

Aortic disease, heart valve disease, coronary artery disease.

Spending time with my family.

(6.8 [2.8, 24.2]) vs. 34.3 [12.3, 91.7], p<0.001) were decreased in group T. Thirty-day mortality (4.6% vs. 7.8%, p=0.21) and five-year survival (84.4% vs. 81.8%, p=0.42) did not differ between groups.

We then measured serum concentrations of 29 cytokines within 24 hours of symptom onset in 44 AAD patients (none in shock or suffering organ malperfusion). We divided the patients into two groups based on FL status: group T (n=21; median age, 76 years) and group P (n=23; median age, 61 years). Stanford classifications did not differ between

groups. Cytokine concentrations were compared between each FL group and a control group (nondissecting thoracic aortic aneurysm: n=20; median age, 75 years). The leukocyte count (x10E3/µL) was significantly increased in the groups of interest (group T: 9.5 [7.7, 11.7]), group P: 14.0 [10.4, 18.0] vs. group C: 5.8 [5.0, 7.1]) (p<0.001). Seventeen cytokines (including IL-4, TNF-α) did not differ between the groups of interest, but 12 cytokines measured differed significantly. The differentially expressed cytokines fell into two clusters: cluster A (increased or decreased in either group [G-CSF, IL-6, IL-10, IL15, IL-5, VEGF) and cluster B (increased only in group P [GM-CSF, IL-1Ra, IL-1b, IL-8, IL-12p70, IP-10].

In summary, a robust inflammatory response to AAD occurs regardless of FL status, but the response is somewhat attenuated in patients with a thrombosed FL.

Naoyuki Kimura / Saitama Medical Center, Jichi Medical University

Q. Where did you carry out your training?

Q. What are your main areas of interest within cardiothoracic surgery?

Q. What are your interests outside of your work?

Current perioperative management strategies in CABG patients

Q. Where did you carry out your training?

• Hospital de Santa Cruz, Lisbon, Portugal

• Also, Fellow of Congenital Cardiac Surgery in Marie Lannelongue Hospital, Paris (April 2022-October 2022)

Q. What are your main areas of interest within cardiothoracic surgery?

• Coronary artery disease bypass grafting, offpump and anaortic surgery

• Mitral tricuspid repair techniques

• Congenital cardiac surgery

Q. What are your interests outside of your work?

• New technologies

• Cinematography

• Sports, including martial-arts and kayaking

Complete numeric revascularisation provides survival benefit at ten years

Introduction: Despite being a truism, the evidence supporting the concept of complete revascularisation (CR) in stable coronary artery disease is largely based on observational data. The lack of a universal definition of CR and the somehow limited follow-up in most studies adds to the controversy.

Objective: Present a straightforward and reproducible definition of complete revascularisation based on numeric criteria and show how it relates to long-term all-cause survival.

Figure

Methods: 866 consecutive multivessel CAD patients undergoing CABG in our centre were retrospectively classified as having complete or incomplete revascularisation depending on number of disease territories and number of distal anastomoses performed. Adjustment for confounders with clinical plausibility to influence completeness of revascularisation was performed using inverse propensity weighing. Both unadjusted and adjusted cumulative survival were studied using KaplanMeier (KM) analysis.

Results: Numeric incomplete revascularisation rate was 29%. Overall, IR patients presented a worse risk profile regarding baseline characteristics.

Both unadjusted and adjusted KM analysis demonstrated a lower two-year, five-year and tenyear cumulative survival for IR when compared with CR. A median follow-up time of 11.2 years (95% CI 11.2-11.3) demonstrated a higher survival probability with CR than with IR (unadjusted p<0.001; adjusted p<0.001). Adjusted survival advantage corresponded to a hazard ratio of 0.68 (95% CI, 0.53-0.87, p=0.003).

When patients were divided regarding percentage of diseased territories revascularised (0-33%; 34-66%; and 67-100%) the estimated adjusted survival benefit was 54% for patients with 34-66% of diseased territories revascularised and 65% for patients with 67-100% of diseased territories revascularised (when compared to 0-33%).

Conclusions: In our study, CR by numeric definition presented a survival advantage of 32% at 11 years. The higher the percentage of diseased territory revascularised, the higher the survival advantaged reported. Maximal coronary territory recruitment, when feasible, is rational and supported by our findings.

Pedro Magro / Hospital de Santa Cruz, Lisbon, Portugal

“Despite being a truism, the evidence supporting the concept of complete revascularisation (CR) in stable coronary artery disease is largely based on observational data.”

Current perioperative management strategies in CABG patients

Thomas Schwann / University of MassachusettsBaystate

Q. Where did you carry out your training?

Yale New Haven Medical Center, New Haven CT, USA.

Q. What are your main areas of interest within cardiothoracic surgery?

Multi arterial CABG, anemia/transfusions, quality improvement.

Q. What are your interests outside of your work?

Tennis, skiing, history, behavioral economics.

Does practice make perfect: institutional coronary artery bypass case volumes and outcomes: a report from the Society of Thoracic Surgeons and the American Hospital Association databases

The hypothesis that greater institutional surgical case volumes are associated with better outcomes is based on the intuitive validity of the principle that practice makes perfect. High institutional case volumes logically allow surgeons to develop superior technical skills which, in conjunction with tacit institutional learning inherent in high surgical volumes and in concert with appropriate resource allocation more readily available at large volume institutions, cumulatively result in improved peri-operative outcomes.

Despite the robust literature on case volumes and outcomes (V/O), the data supporting this hypothesis of practice makes perfect in both cardiac and non-cardiac surgery are, however, contradictory, showing only small or no association and are based on analyses with significant methodologic concerns. Moreover, the available studies focusing on coronary artery bypass (CABG) are decades old and hence not generalisable to contemporary practice patterns given the technical advances in CABG, the growing popularity of percutaneous revascularisation techniques, declining CABG volumes and the rapidly changing American healthcare eco system characterised by continuing focus on healthcare quality, public reporting of surgeon and hospital level outcomes, market consolidation and democratisation of CABG procedures across an ever growing number of hospitals.

Within this contextual framework, the aim of this retrospective analyses of 241,902 CABG patients (2018-2019) at 1,014 US hospitals by 2,718 surgeons is to investigate the association between institutional and surgeon characteristics,

including case volumes, and their interaction with peri-operative outcomes using contemporary well validated databases of the Society of Thoracic Surgeons (STS) and the American Hospital Association. Primary risk adjusted outcomes are observed to expected (O/E) ratios based on the STS perioperative risk models for operative mortality (OM) and Mortality and Major Morbidity (MM), a composite of operative mortality, stroke, acute renal failure, prolonged mechanical ventilation, deep sternal wound infections and surgical reexploration.

Institutional excess OM and MM rates were derived as the difference between observed and expected outcomes. Generalised estimating equations with seemingly unrelated linear regression were used to estimate coefficients between institutional CABG case volumes and outcomes.

The average institutional CABG volume over the two-year study period was 188 (SD 156) with 33% of institutions performing fewer than 100 cases annually. The overall predicted mortality was 1.92% (SD 3.31%). 65% of institutions had a medical school association and 18% were members of the Council of Teaching Hospitals. The observed OM and MM rates were 2.1% and 11.1%. Predicted OM risk showed increasing variation with decreasing institutional volumes and little correlation with increasing institutional volumes (Figure 1A). OM O/E showed little correlation with predicted OM risk (Fig 1B) or institutional CABG volumes (Fig 1C) when analyzed at institutional level. When analysed with hospitals grouped by increasing case volumes with each hospital group comprising 10,000 patients, outcomes improved with increasing case volumes (Fig 2A, 2B).

We conclude, that although increasing institutional case volumes are generally associated

with improved CABG outcomes, there is little correlation between individual institutional CABG case volumes and OM and MM. Other hospital and surgeon specific factors are being currently evaluated for associations with outcomes. Hence, institutional CABG volumes should not be viewed as a surrogate for quality.

“The average institutional CABG volume over the two-year study period was 188 (SD 156) with 33% of institutions performing fewer than 100 cases annually.”

Figure

Figure

Figure

Figure

Thoracic Rapid Response

Prognostic Impact of lymph node spreading pattern in stage IIIA/ B-N2 NSCLC patients

Objective: About one-third of non-small cell lung cancer (NSCLC) patients are diagnosed with locally advanced disease. Despite multimodal treatment, the long-term survival of patients in stage IIIA/B-N2 remains poor, with a wide range of five-year survival varying from 16% to 42%. These significant differences in five-year survival cannot be explained by patient morbidity alone but probably by the heterogeneity of the stage IIIA/B-N2. In this study, we compared the overall survival of stage IIIA/B-N2 patients with superior mediastinal lymph nodes (SML) (lymph node stations 2-6) with patients with infracarinal- or inferior mediastinal lymph nodes (IML) (lymph node stations 7-9) and with patients with multilevel disease (MLD) (lymph node stations 2-9).

Methods: One-, three-and five-year survival rates were measured. KaplanMeier curves and the Cox proportional hazards model assessed survival and were used to identify prognostic factors for overall survival. All patients received adjuvant or neoadjuvant chemoradiation therapy according to European guidelines.

Results: We reviewed data of 129 consecutive stage IIIA/B-N2 patients who underwent surgery for NSCLC between 2012 and 2020. Patients with SML (n=62) were compared to ILM (n=37) and MLD (n=30). Baseline characteristics did not differ between groups. SML patients showed significantly better one- (SML: 95.2% vs. IML: 78.6% vs. MLD: 69.4%, p=0.03), three- (78.8% vs. 27.7 vs. 13.3%; p=<0.001) and five-year (61.1% vs. 17.1 vs. 3%; p<0.001) survival rates, compared to IML and MLD patients. Kaplan-Meier curves showed a prolonged overall survival for SML patients (log-rank SML, ILM, MLD p<0.0001).

Q. Where did you carry out your training?

Department of Cardiothoracic Surgery, University Hospital Cologne, Germany.

Q. What are your main areas of interest within cardiothoracic surgery?

Clinical Interests: Minimal invasive surgery, RATS, Intensive care medicine, ERAS.

Research: Locally advanced NSCLC, Lymph node involvement in NSCLC, Pulmonary metastasectomy for solid tumors.

Q. What are your interests outside of your work?

Running, road cycling, football and traveling.

Conclusion: In this study, we demonstrated that patients with superior mediastinal lymph nodes had significantly better long-term survival than those with infracarinal or inferior mediastinal lymph nodes and those with multilevel disease. The long-term survival of patients with ILM and MLD was equally poor regardless of whether adjuvant or neoadjuvant therapy was administered. These results emphasise that stage IIIA/B-N2 is very heterogeneous and that lymph node spreading patterns have a prognostic impact on long-term survival.

Georg Schlachtenberger / Department of Cardiothoracic Surgery University Hospital Cologne, Germany

Maximilian Kreibich / Department of Cardiovascular Surgery at the Hospital of the University of Frieburg

Q. Where did you carry out your training?

I studied medicine in Vienna and Freiburg and carried out my training at the Department of Cardiothoracic Surgery in Freiburg where I am still practicing. I was an Aortic Research Fellow at the University of Pennsylvania from 2017 to 2018.

Q. What are your main areas of interest within cardiothoracic surgery?

Conventional open and endovascular treatment of the entire aorta from the aortic root beyond the aortic bifurcation.

Q. What are your interests outside of your work?

I like spending my time in the Alps during summer and winter where I hike, climb, tour and ski.

Concomitant aortic root replacement during frozen elephant trunk implantation does not increase perioperative risk

While the frozen elephant trunk (FET) procedure has evolved as an effective and common treatment in patients with thoracic aortic pathologies involving the aortic arch, the procedure remains complex. Hence, surgeons may be hesitant to perform concomitant cardiac and/or aortic root procedures. Therefore, our aim was to evaluate the risk of concomitant aortic root replacement during FET total arch replacement.

This single centre study included 303 patients who underwent the FET procedure. After propensity score matching, there were no statistically significant differences in preoperative characteristics including the underlying pathology. There was no statistically significant difference regarding arterial inflow-cannulation or concomitant cardiac procedures, while cardiopulmonary bypass (p<0.001) and aortic cross-clamp (p<0.001) times were significantly longer in the root replacement group. Postoperative outcome was similar between the groups and there were no proximal reoperations in the root replacement group. Root replacement was not predictive for mortality (p=0.133, odds ratio: 0.291) in our regression model and long-term survival tended to be better in the root replacement group, but the difference did not reach statistical significance (log rank: p=0.062).

To conclude, concomitant FET total arch replacement and aortic root replacement prolongs operative times but does not impact postoperative outcomes or increase operative risk. Therefore, the FET procedure should not be a contraindication for concomitant aortic root replacement by itself, particularity in patients with borderline indications for aortic root replacement.

Kaplan-Meier curve of overall survival of patients following frozen elephant trunk total arch replacement with (turquois)

“While the frozen elephant trunk (FET) procedure has evolved as an effective and common treatment in patients with thoracic aortic pathologies involving the aortic arch, the procedure remains complex.”

MEDICAL UNIVERSITY GRAZ

MAASTRICHT

Sam

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Final, taking

The winning

CENTER

LVAD therapy lifelong?

Amber 1 & 2

10:15 - 11:45

Concomitant tricuspid valve repair in left ventricular assist device implantation may increase the risk for temporary right ventricular support but does not impact overall outcomes.

Right heart failure (RHF) after left ventricular assist device (LVAD) implantation is associated with worse outcomes and remains a challenge. We know that tricuspid regurgitation (TR) can be a major contributor to RHF, but it remains a disputed topic among surgeons whether a concomitant tricuspid valve repair (TVR) can significantly decrease the risk for RHF and other clinical outcomes specifically in LVAD candidates. Therefore, we sought to investigate the impact of concomitant TVR and LVAD implantation.

“We know that tricuspid regurgitation (TR) can be a major contributor to RHF, but it remains a disputed topic among surgeons whether a concomitant tricuspid valve repair (TVR) can significantly decrease the risk for RHF and other clinical outcomes specifically in LVAD candidates.”

A large multicentre retrospective study was conducted between three institutions in Switzerland, Germany and the USA, which enrolled adult patients who received a primary continuous flow LVAD between 2006 and 2017. Patients were grouped according to the concomitant tricuspid valve repair (‘TVR group’ vs. ‘no TVR group’). Primary outcomes were severe right ventricular failure necessitating temporary right ventricular assist device (tRVAD) support (early RHF) and RHF-related rehospitalisations requiring inotropic or diuretic treatment (late RHF).

Maks Mihalj / University Hospital Bern, University of Bern, Switzerland

Q. Where did you carry out your training?

My training in cardiac surgery was carried out at my home institution at the Department of Cardiovascular Surgery at University Hospital Bern, where I have spent six years training as a resident in cardiac surgery (PGY 6). Currently, I am doing focused research in the field of advanced heart failure and cardiac transplantation as a research fellow at the host institution Center for Advanced Cardiopulmonary Therapies and Transplantation (ACTAT) at Memorial Hermann Heart and Vascular Institute Texas Medical Center of the University of Texas Health Science Center Houston.

Q. What are your main areas of interest within cardiothoracic surgery?

My main areas of interest and focused research are in the field of advanced heart failure, mechanical circulatory support, cardiac transplantation and cardiac xenotransplantation.

Q. What are your interests outside of your work?

My interests outside of work include travelling, exploring new places, meeting new people and embracing new cultures. When I get the time I like to go on adventurous hikes and cycle trips with friends, as well as paint and read short novels. I also Iike to cook, and I am a passionate, though not very talented, karaoke singer.

Out of a total of 526 patients who underwent LVAD implantation, 110 (21%) received a concomitant TVR. Those patients had more comorbidities, underwent more concomitant procedures at LVAD implantation, and the majority had either moderate or severe tricuspid regurgitation. In those LVAD patients who underwent concomitant tricuspid annuloplasty, we observed a significantly higher incidence of tRVAD support (18% vs. 11%, P = .049), with a significantly elevated risk for tRVAD (sHR 1.68 [95% CI 1.042.72], P = .037). After adjusting for confounders, no significant differences were found in the incidence and risk of most clinical outcomes, including RHF-related rehospitalisations (aHR 1.06 [95% CI 0.57-1.89], P = .891) or death (aHR 0.89 [95% CI 0.61-1.31], P = .563).

We conclude that concomitant TVR, when deemed necessary in LVAD implantation, increases the initial risk of early RHF requiring tRVAD, but without significant difference in both incidence and risk of death or rehospitalisations due to late RHF. The results of this study should be confirmed in a large multicentre randomised control trial.

Considering particular

The cumulative incidence of IE in TAVI is reported to be 6% at five years and it occurs most commonly early after TAVI implantation. The most common cause are Enterococcus species.

It is reported that there is a higher in-hospital mortality of IE-TAVI explantation than after nonIE patients. Therefore, preoperative considerations are of utmost importance and should include:

• Indication for TAVI implantation

• Surgical risk at the time of TAVI implantation and before TAVI explantation

• Which type of TAVI and which generation

• Degree of TAVI oversizing

• Important anatomical landmarks (coronary arteries, annulus, aortic root, LVOT, ascending aorta)

• Symetis Accurate Neo (Boston Scientific) is also self-expanding and has upper crowns with sharp hooks, which may be directed towards the sino-tubular junctions. Removing the stent may be challenging and several groups use suture to tie the arches first, insert them through a small cylindrical valve sizer and very carefully explant the TAVI valve.

Nevertheless, of utmost importance is caution at the coronary ostia, aortic annulus, aortic sinus, anterior mitral leaflet, and the membranous septum.

How to deal with infective endocarditis in TAVI?

Due to the increase in Transcatheter Aortic Valve Implantations (TAVI) there will be a growing number of patients requiring TAVI explantation.

Even though published reports are still limited, mortality and morbidity rates after TAVI explantation are significantly higher compared to redo-aortic valve replacement after Surgical Aortic Valve Replacement (SAVR).

There are four main failure modes of chronically implanted TAVI:

• Malposition (unstable, inadequate, paravalvular leakage)

• Structural valve deterioration

• Infectious endocarditis (IE)

• Significant thrombosis

Intraoperatively, after median (re-)sternotomy, double venous cannulation, distal aortic clamping, aortotomy distal to the distal end of TAVI and anteand retrograde delivery of blood cardioplegia, TAVI is carefully mobilised from the aortic wall using sharp and blunt dissection to remove the tissue adhesions. This is the most important part of the operation and varies according to the implanted TAVI type. For example:

• Edwards Sapien Valves (Edwards Lifesciences) are low-profile and the aortotomy can be done at the usual place. This valve usually does not obstruct the coronary ostia and reoperation is often straightforward.

• CoreValve (Medtronic) is high-profile, selfexpanding and ranges from LVOT to the ascending aorta. Therefore, the aortic root, coronaries, and ascending aorta are at risk.

In conclusion, the incidence of IE after TAVI implantation will increase, and meticulous preoperative preparation, sophisticated intraoperative surgical techniques and careful perioperative treatment of the patient will be of benefit in this very demanding patient group.

“The cumulative incidence of IE in TAVI is reported to be 6% at five years and it occurs most commonly early after TAVI implantation. The most common cause are Enterococcus species.”

Friedhelm Beyersdorf / Professor of the Medical Faculty of the Albert-LudwigsUniversity Freiburg

Transcather mitral session

Lenard Conradi / University Heart and Vascular Center Hamburg

Q. Where did you carry out your training?

University Heart and Vascular Center Hamburg, Germany.

Q. What are your main areas of interest within cardiothoracic surgery?

Endoscopic mitral and beating-heart tricuspid valve surgery, minimally-invasive coronary surgery (MIDCAB), complex combined and redo cardiac surgery, transcatheter mitral valve implantation (TMVI), transcatheter aortic valve implantation (TAVI).

Transcatheter edge-to-edge repair (TEER) for secondary mitral regurgitation – a surgeon´s perspective

Mitral regurgitation (MR) is one of the most prevalent cardiac valvular lesions in western societies and diagnostic and therapeutic algorithms are determined by the underlying pathophysiological mechanism. Traditionally, type of MR is characterised as primary or

secondary. Primary MR (also classified as Carpentier type II) represents the immediate valvular lesion involving leaflets and/or chordae and frequently is degenerative in nature. Surgical repair, in a minimally-invasive approach whenever possible remains the gold standard therapy due to the morphological and functional complexity of the disease and it is usually curative and has excellent long-term results in experienced hands. Secondary MR is typically characterised by a morphologically intact mitral valve which is functionally incompetent due to dilatation of the left atrium and mitral annulus, mostly due to atrial fibrillation (also classified as Carpentier type I) or of the left ventricle in the wake of cardiomyopathy (also classified as Carpentier type III). While mitral valve repair is well established in type I MR using downsizing ring annuloplasty and is causal in nature, especially when combined with concomitant atrial ablation and left atrial appendage occlusion, surgical correction of type III MR is more controversial both in terms of technical approach (repair vs. replacement) as well as results (recurrence or MR) or surgical risk (many patients are elderly and present with depressed left ventricular function and an overall increase risk profile). Accordingly, recommendations as well as level of evidence are lowest for secondary MR surgery according to the recent ESC / EACTS guidelines for the management of valvular heart disease (Vahanian A, Eur J Cardiothorac Surg 2021; figure 1). As a matter of fact, mitral TEER has been upgraded to receive a class IIa, level of evidence B recommendation for treatment of isolated severe, symptomatic secondary MR if “criteria suggesting an increased chance of responding to the treatment” are met. This recommendation exceeds that of surgery (class IIb, level of evidence C) and mainly relies on the findings of the recent COAPT study (Stone GW, N Engl J Med 2018). However, a few important considerations need to be clearly stated: guideline

recommendations are valid exclusively for the socalled “COAPT-like” patients and these may only represent a fraction of a given total of secondary MR patients (Koell B, J Am Coll Cardiol 2021). Also, the survival benefit demonstrated in the COAPT trial has not been replicated by other investigators (Obadia JF, N Engl J Med 2018). Finally, recent advances in secondary MR surgery such as subannular repair strategies have not been tested on a sufficiently large scale, are thus not included in current recommendations but hold the promise to improve on historical results.

“While mitral valve repair is well established in type I MR using downsizing ring annuloplasty and is causal in nature, especially when combined with concomitant atrial ablation and left atrial appendage occlusion, surgical correction of type III MR is more controversial both in terms of technical approach (repair vs. replacement) as well as results (recurrence or MR) or surgical risk (many patients are elderly and present with depressed left ventricular function and an overall increase risk profile).”

programme consisting of interactive lectures, live-in-a-box cases and keynote

topics including preoperative

optimal treatment in advanced heart failure patients, telemedicine and new options for percutaneous LVAD use.

Professor Volkmar Falk

“The field of MCS is rapidly evolving. Besides all aspects of VAD therapy, the 6th EACTS Mechanical Circulatory Support Summit will cover new concepts for short term assist in the treatment of cardiogenic shock, new devices and the latest developments for mechanical support in right heart failure. Inspiring lectures by the international leaders in the field and interesting live-in-a-box cases will ensure the leading role of the EACTS MCS Summit in the field of MCS.”

EACTS MCS Summit

EACTS LEARNING

GET ‘HANDS-ON’ IN THE EACTS LEARNING LAB

Learn specialist techniques and draw on the knowledge of some of the world’s most experienced and expert surgeons with the EACTS Learning Lab training sessions. These ‘hands-on’ workshops

wet and dry labs and other small practice sessions. These can only be purchased upon registering for the 36th EACTS Annual Meeting and are available to book now.

FRIDAY 7 OCTOBER

TAVI/TMVR Simulator Session

Touch and play with guidewires, valves, delivery systems and simulators and take a fascinating journey through the latest transcatheter valve devices and technologies.

TEVAR Simulator Session

Come and practise your skills with our hands-on training on endovascular stent graft thoracic aortic treatment.

Thoracic Surgery

Learn how exponential technologies (including artificial intelligence, virtual reality and computational modelling) contribute to surgical planning and intraoperative image-guidance of anatomical (sub)lobar resections. In addition, patient-specific virtual reality (VR) simulators will be used to highlight the added value of VR for both surgical planning and surgical training/educational purposes. The educational focus will be on pulmonary lobar and segmental bronchovascular anatomy from a surgical perspective.

SATURDAY 8 OCTOBER

Coronary Surgery

Learn how to perform coronary anastomoses and the techniques for proximal and distal anastomoses, sequential and composite grafts. Techniques and devices for conduit harvesting and methods for intraoperative graft assessment will also be presented.

– 11:00

– 14:30

– 17:30

11:00

EACTS TV GUIDE

Watch EACTS

TIME PROGRAMME PANELLISTS

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10:30

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Surgery

Paulis

Milton, Leeds,

Hörer,

Bavaria,

Keogh,

Sardari

Maastricht

Kluin, Amsterdam, M. Grabenwöger, Wien, F. Melfi, Pisa, A. Zientara, London, N. Hussein, Cottingham

HIGHLIGHTS FROM THURSDAY'S TV STUDIO

The big issues debated live on EACTS TV

R. Sádaba, Pamplona, P. Myers, Genève, M. Hazekamp, Leiden

with...

- a

Aortic

Science Friction - The Daily

(Episode

A. Zientara, London, J. Bavaria, Philadelphia, V. Dayan, Montevideo

The EACTS TV channel lifts the lid on the 36th EACTS Annual Meeting, giving those tuning in the chance to stay on top of hot topics, hear from global experts and key opinion leaders. Hosted by Roy Sheppard, delegates in the studio or those viewing online can enjoy live broadcasts, panel discussions and in-focus interviews. The studio is buzzing and sits in the exhibition hall where the atmosphere is alive with discussion and discovery. Delegates in the area are encouraged to sit in the audience and participate in stimulating debate throughout the day. The morning began with The Daily Preview, an exciting overview of the busy day ahead and discussion between expert panellists, Filip Casselman, Gry Dahle and Alicja Zientara who identified key, must-see sessions. The first episode of The Big Debate dissected European standards in training and asked the question, are we there yet? The topic sparked an engaging in-depth discussion between panellists. We also heard from Mario Gaudino, Ottavio Alfieri and Patrick Perier discussing how they got into the field with tips for younger surgeons starting out in their career.

TIME

10:00

10:30

PANELLISTS

J. Grau, Ridgewood, M.

Angers, C. GollmannTepeköylü, Innsbruck

SATELLITE SYMPOSIA

SATURDAY

AORTIC

3-D Matrix A04

Abbott B12

ABIOMED B10

Advancis Surgical C06

American Association for Thoracic Surgery (AATS) A30

AMT Medical B.V. C32

Andocor NV B24

AngioDynamics A16

Artivion EMEA GmbH B14

Artivion EMEA GmbH - Learning Lab C03a

Asanus Medizintechnik GmbH C13

AtriCure Europe B.V. B16

AtriCure Europe B.V. - Learning Lab B02

BD Interventional - Becton Dickinson A09 & A11

BioCer Entwicklungs-GmbH C18

Bio Sud Medical Systems Srl A03bis

Cardia Innovation AB A23

Cardio Medical GmbH C20

CARL. B20

CARMAT A10

Chalice Medical Ltd B26

Cook Medical Europe LTD B07

Corcym S.r.l. B08

CTSNet.org A28

CUI INTERNATIONAL LIMTED A06

CytoSorbents Europe GmbH B21 & B23 & B25

Delacroix-Chevalier C22&C24

Dendrite Clinical Systems Ltd A25

Dr. Franz Koehler Chemie GmbH C15 & C28

EACTS - The European Association For Cardio-Thoracic Surgery C13

EACTS - Learning Lab C01

EACTS - TV Studio A17

Edwards Lifesciences C09

EpiHeart Oy C34

Eurosets s.r.l. C07

Exstent Limited B31

Fehling Instruments GmbH & Co KG C21 & C23

FIAB Spa B27 & B29

Foldax, Inc. A21

GEISTER Medizintechnik GmbH B06

Genesee BioMedical Inc A15

HAART- Aortic Valve Repair Technologies by BioStable Science & Engineering C17 Hemonart Medikal Sistemler Sanayi Ticaret A.S. A12

ISMICS/HVS (International Society for Minimally Invasive Cardiothoracic Surgery & Heart Valve Society) A01 & A03

Jafron Biomedical Co., Ltd. A07BIS Jarvik Heart Inc C19

Johnson & Johnson Medical Devices Companies A14 Kapp Surgical Instrument, Inc. A05bis

KLS Martin Group A08 & B09 LifeTec Group A19 LSI Solutions A18 & A20 Medela AG B05 Medistim ASA B04

Medtronic International Trading SÁRL C05 Medtronic International Trading SÁRL - Learning Lab C03 Meril Endo Surgery Pvt Ltd C02 & C04

NEOS SURGERY C30

Osypka AG B03

Oxford University Press B33

Peters Surgical B04a PHOENIX s.r.l. B11

POSTHORAX ltd. B01 Qualiteam s.r.l. B19

REDAX Spa B15 & B17

Scanlan International, Inc C08 & C10 & C12 & C14

STS-The Society Of Thoracic Surgeons A27 Sunoptic Technologies A02

Terumo Aortic & Terumo Europe N.V. B18

Thompson Surgical Instruments, Inc.

tisgenx, Inc. B13

Transonic Systems, Inc. A05&A07

Quality in thoracic surgery

Quality assessment: How many lobectomies do you do? – Implementation of new regulations in Germany

Although routine in the hands of experienced thoracic surgeons, lobectomy remains a complex surgical procedure with high potential for complications. Compared to colorectal or breast surgery, it is a rare operation.

In 2017, Nimptsch et al analysed mortality in 25 types of inpatient treatment in German hospitals recorded in a national database. This showed that mortality declines below the mean of 2.9% for lobectomies in lung cancer if a hospital performed more than 108 procedures per year.

This caught the attention of the Federal Joint Committee (G-BA), which is the highest decisionmaking body of the joint self-government of physicians, dentists, hospitals and health insurance funds in Germany.

In 2017, anatomical resections for lung cancer were performed in 328 hospitals varying from 1-428 cases/year (mean 43). Thirty-eight departments performed more than 100 while 81 did only 1-5 cases.

Gunda Leschber / German Society of Thoracic Surgery (DGT), Berlin, Germany

Q. What are your main areas of interest within cardiothoracic surgery?

Oncologic thoracic surgery, mediastinoscopy and VATS, training and teaching.

Q. What are your interests outside of your work?

My own YouTube channel (in preparation), my dog Taiga and my garden.

G-BA initiated a literature search for evidence of hospital volume and mortality as well a simulation of different minimum case loads to be eligible for coverage by the insurance companies. Eventually, the decision was made to set the minimum case load to 40 anatomical lung cancer resections in 2024 and 75 starting in 2025.

According to the simulation of case redistribution only 91 hospitals in 2025 will be allowed to perform lung cancer surgery in Germany. For patients simulation showed a travel time/distance of 31 min./35 km (+9 km from now).

It is expected that all centres will be certified and that training will be better because of higher case load. However, it will have severe implications for

some hospitals, including major reorganisation of infrastructure and medical staff for centres with large case shift and severe financial impact on centres just below the minimum number.

Nimptsch U, Mansky T, Hospital volume and mortality for 25 types of inpatient treatment in German hospitals: observational study using complete national data from 2009 to 2014. BMJ Open 2017;7(9):e016184

“Although routine in the hands of experienced thoracic surgeons, lobectomy remains a complex surgical procedure with high potential for complications.”

Q. Where did you carry out your training? Berlin and Boston, USA.

Acute aortic syndrome

a

view

Latrogenic aortic dissection – medical or surgical management?

John A. Elefteriades / Yale University School of Medicine, New Haven

Q. Where did you carry out your training?

All my training, including college, medical school, General Surgery Residency, and Cardiothoracic Surgical Residency were done at Yale University.

Q. What are your main areas of interest within cardiothoracic surgery?

Earlier in my career, I had special interests in the failing left ventricle, coronary artery bypass, and cardiac transplantation. In subsequent years, I have specialised in aortic surgery.

Q. What are your interests outside of your work?

Exercise, writing for the general public (“Extraordinary Hearts”, “Transplant”), and British, Italian, and American sports cars.

As cardiac care specialists, we are accustomed to treating aortic dissections, not causing them. However, there are circumstances where aortic dissections are incurred via iatrogrenic mechanisms. Such situations are seen with 1) cardiac catheterisation and angioplasty (especially of the proximal RCA (right coronary artery)), 2) femoral perfusion for cardiopulmonary bypass, and 3) TAVR (transcatheter aortic valve replacement).

Cardiac catheterisation. In the cardiac catheterisation setting, the guiding catheter (especially the Amplatz) can lacerate the inner wall of the RCA, allowing blood to enter the media, and subsequently propagating proximally to dissect the ascending aorta. Local dissection of the aortic root or generalised dissection of the entire aorta can occur. Remarkably, many of these dissections can be treated medically, by B-blockade and afterload reduction–with prompt, complete healing. Insertion of a coronary stent in the catheterisation laboratory helps to encourage recovery by sealing the site of origin of the dissection process. Some cases, of course, do require urgent surgical aortic replacement, but the risk of surgery is high (due to concurrent CAD (coronary artery disease), concomitant anticoagulation for catheterisation/angioplasty, and, often, evolving acute myocardial infarction. Femoral perfusion for CPB (cardiopulmonary bypass). Femoral perfusion for CPB is remarkably safe, effective, and convenient. In rare cases,

intraoperative retrograde dissection of the descending aorta may be incurred. We believe such cases can be minimised by avoiding use of the femoral artery when there is iliofemoral occlusive arteriosclerotic disease. The femoral artery was “designed” to carry only the flow to one leg. Yet, in CPB, we obligate the blood flow for the entire body to traverse the femoral artery. Occlusive disease, understandably, will lead to great arterial stress during retrograde perfusion.

TAVR. Rarely, the traumatic nature of the TAVR process can induce aortic dissection, either descending or ascending. Descending cases can be treated by stenting. Ascending cases usually require immediate open surgical intervention to prevent rupture.

While we all subscribe to the ancient Hippocratic dictum premum non nocere, our interventions do, on rare occasions, produce acute aortic dissection phenomena.

“In the cardiac catheterisation setting, the guiding catheter (especially the Amplatz) can lacerate the inner wall of the RCA, allowing blood to enter the media, and subsequently propagating proximally to dissect the ascending aorta. Local dissection of the aortic root or generalised dissection of the entire aorta can occur.”

CT Scan immediately after RCA angioplasty and stent placement. A Note aortic hematoma around R sinus. B. Dissection extending into the descending aorta. C. Extensive dissection in the aortic arch, as well as severe calcification.

Follow-up CT scans at five days (top) and one month (bottom). Note progressive, and ultimately complete, normalisation of entire aorta.

“As cardiac care specialists, we are accustomed to treating aortic dissections, not causing them. However, there are circumstances where aortic dissections are incurred via iatrogrenic mechanisms.”

Acute

Get with the guidelines-lessons from the recent AATS/STS and ESC expert consensus documents.

Acute aortic dissection (AAD) is a time dependent disease. Delays in diagnosis come at a severe cost to the patient. The risk of death is estimated to be 1% to 2% per hour and nonoperative treatment is associated with mortality in nearly 60% of patients 1

In the last decades the clinical and scientific communities registered a strong improvement in the outcomes of patients treated for AAD. For this reason, the American and European societies recently revised three new expert consensus documents (ECD)2-4 on AADs. They represented a big step forward, providing language framework to allow more granular reporting and improve quality of care through evidence-based recommendations.

The Vascular Domain of EACTS provided a strong effort not only providing the ECD on type B AAD but also contributing on drafting the documents of the STS/AATS societies. It represents a renowned achievement that brings EACTS to the core of the international community.

The first document focusing on type A AAD2 was released by the American Societies of Thoracic and Cardiac surgery. It was the refresh of past 2010 guidelines and substantially confirmed that cardiac surgery remains the standard of care for acute type A dissection. The main features focus on operative aspects. A supracoronary ascending aorta replacement with valve resuspension using an open distal anastomosis remained the most effective procedure in case of intimal teal located in the ascending aorta. However, a more aggressive aortic arch replacement (especially with the frozen elephant trunk) was now recommended in case of arch tear location and distal body malperfusion.

The other two documents coming from EACTS3 and the joint STS/AATS societies4 focused on the controversial management of type B AAD. It is the results of better outcomes obtained with endovascular procedures and better patient selection based on aortic anatomy and clinical status.

The new guidelines try to answer most of these issues, especially for the subgroup of patients considered uncomplicated or likely to became complicated in a short period of time.

The first interesting recommendation in the EACTS guidelines is about developing a TEVAR programme. The same aortic team should be closely involved from diagnosis to treatment to follow-up.

This team should include cardiac and/ or vascular surgeons, as well as cardiologists, radiologists, anaesthesiologists, and other specialties if needed.

A key component of a successful programme is the availability 24/7 of cardiac and vascular surgeons on site to treat potential complications or to switch the surgical strategy if needed.

Another crucial aspect, reported in both ECD3,4, describes ACUITY of type B aortic dissection, which was defined as1 complicated, 3 uncomplicated and 2 high-risk for a complicated course. High-risk is a new category, and includes patients without an immediate life-threatening condition but at significant risk of early or late complications. According to that, uncomplicated

patients with any of the morphologic features of the high-risk subgroups should go for TEVAR after 15 days from the onset of symptoms.

All of the above-mentioned features of the new expert consensus documents and many other controversial aspects will be illustrated and discussed in a 360° degrees journey around acute aortic dissections. Don’t miss the opportunity to be part of the crew!

Figure 1: New expert consensus documents on acute aortic dissections

1. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283:897-903.

2. Malaisrie SC, Szeto WY, Halas M, Girardi LN, Coselli JS, Sundt III TM, et al. 2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg. 2021 Sept;162(3), 735–758.e2.

3. Czerny M, Pacini D, Aboyans V, Al-Attar N, Eggebrecht H, Evangelista A et al. Current options and recommendations for the use of thoracic endo- vascular aortic repair in acute and chronic thoracic aortic disease: an expert consensus document of the European Society for Cardiology (ESC) Working Group of Cardiovascular Surgery, the ESC Working Group on Aorta and Peripheral Vascular Diseases, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the European Association for CardioThoracic Surgery (EACTS). Eur J Cardiothorac Surg 2021;59:65–73.

4. MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM et al. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg. 2022 Apr;163(4):1231-1249.

Professor Davide Pacini / Division of Cardiac Surgery, IRCCS, Azienda OspedalieroUniversitaria di Bologna, Alma Mater Studiorum - University of Bologna, Italy.

THE FRANCIS FONTAN FUND

The Francis Fontan Fund supports surgical education, fosters professional development and strengthens the global cardiothoracic community through increased knowledge share. The Fund’s mission is to create a global community sharing and learning rom the highest standards of cardiothoracic care.

On Thursday evening, Fellows, past and present, came together at the Annual Meeting for a welcome reception. Here we talk to four Fellows about their experience of the Francis Fontan Fellowship programme.

ADVANCED POSTOPERATIVE CARE FELLOWSHIP

Gvido Bergs, Latvia

“I was a Francis Fontan Fellow for advanced post operative care in Barcelona. It has been amazing, extremely fruitful for me. I had the opportunity to meet great surgeons, including Dr. Eduard Quintana, who has had a great impact on my development.”

UKRAINIAN SUPPORT FELLOWSHIP

Polina Danchenko, Ukraine

“I'm currently doing the Fellowship with the support of the Francis Fontan Fund in Barcelona, under the supervision of Dr. Eduard Quintana. I'm having the best time with him and he's providing me with high quality specialty training that I could never dream of. And the new technologies like robotic surgery, which are just outstanding, I always say I'm kind of in the surgical Disneyland in Barcelona.

“The Department of Cardiovascular Surgery does all kinds of types of surgical procedures and interventions, including minimally invasive and robotic surgery itself. So this allows you to see the full spectrum of the cardiac surgery interventions that exist. And for trainee residents like me, it's a perfect setting to see the whole of cardiac surgery with top quality specialists around you who are at the same time mentoring and training you.”

OFF-PUMP CORONARY ARTERY BYPASS FELLOWSHIP, IN PARTNERSHIP WITH MEDTRONIC

Ian Cummings, UK

“When I applied for this programme I considered it the start of an educational journey (under the umbrella of EACTS), providing mentorship and support at an important phase in my development as I approach the end of the formal London Cardiac Surgery training programme.

“The experience so far has been excellent, and I am privileged to be part of the Fellowship programme. In my mind however, this is just the beginning of an educational process which will enable me to become ‘expert’ in the field of OPCAB.

“Professor Sousa Uva and I have already discussed the next phase of my progression in this field. I have no doubt being part of the Francis Fontan Fellowship programme will lay strong foundations for my future career and training once I complete my surgical programme.”

THORACIC SURGERY FOUNDATION / FRANCIS FONTAN FUND INTERNATIONAL TRAVELING FELLOWSHIP

Gianluca, Folesani, Italy

“I started in Philadelphia a month ago and it’s been fantastic. I will stay there until the end of November. I am very interested in mitral valve surgery – a specialty with so much debate - minimally invasive techniques and the use of robotic surgery. I am very grateful to those at the hospital who are teaching me. The next two months will be even more fantastic. I am learning a lot and I hope to bring all these things back to my hospital.”

MAGNIFICENT MILAN

One of the largest cities in Italy, Milan is famed for its culture, history and fashion. Here's a few ideas on the places to visit and things to do if you have a few hours after the Annual Meeting.

Enjoy Milan’s architectural treasures

Beyond the modern metropolitan bustle of Milan lies spectacular architecture and a rich history. Adorned with magnificent palaces, grand churches and Gothic cathedrals, the city is home to some of the most iconic landmarks in the world.

Start with the remarkable Duomo di Milano, a Gothic-style cathedral in the heart of Milan that took almost six centuries to complete - but luckily takes only an hour or so to explore. Then there’s the Santa Maria Delle Grazie church, where Leonardo de Vinci painted his masterpiece The Last Supper. The antique Basilica di Sant’Ambrogio, a 4th Century church, is also worth a visit for its charm and mystical atmosphere.

Eat, drink and culture

There is plenty to scope out near the Duomo, including the city’s legendary opera house, La Scala and Sforza castle, a 14th-century medieval fortress.

Nearby is the extravagant, glass-vaulted shopping arcade Galleria Vittorio Emanuele II filled with luxury designer shops. You can splash the cash on Gucci and Prada or simply take in the stunning architectural beauty while sipping a delicious cappuccino.

For the De Vinci lovers, Leonardo’s statue in Piazza Della Scala is a must, or visit the Pinacoteca Ambrosiana museum, which is home to the largest collection of his paintings and drawings.

For the football fans

Not all of Milan’s aesthetic lies in its historical and architectural landmarks. The city also has an extraordinary culinary scene. The bustling neighbourhood of Navigli offers an array of gourmet restaurants, quirky bars and riverside boutiques. If you love seafood, Le Tournedos offers seafood specialities cooked to perfection. Or, if you prefer to sample some of Italy’s more traditional dishes, Pizzium offers some of the tastiest pizzas in town. Pinch, Iter and Rita are just a few of the area’s many cocktail bars and definitely worth a trip for a lively night out.

Close to Duomo and Galleria Vittorio, restaurant Luini is a particular favourite among the Milanese. Other great places for dining can be found in Via Dente, located just in front of Sforza castle. As one of the most famous streets in Milan for shopping and cuisine, Via Dente boasts some of Milan’s best restaurants that also serve typical Milanese food.

Finally, Milan’s artist’s quarter, Brera, is a unique maze of art shops, colourful street markets, restaurants and bars and known for its quirky, boho-chic vibe.

Home to two of the world’s most famous football teams - AC Milan and Inter Milan - football fans can get their fix by visiting Milan’s enormous San Siro football stadium located at Piazzale Angelo Moratti.

Edwards

Uncovering