Guidelines Session at the 37th EACTS Annual Meeting

Martin Czerny, Medical Director of the Clinic for Cardiovascular Surgery, University Medical Centre Freiburg

In 2022 EACTS council commissioned the elaboration of aortic guidelines – or better – guidelines upon diagnosing and treating acute and chronic syndromes of the aortic organ. This task had a level of importance that it naturally brought EACTS, STS and AATS together, to collaboratively compile a comprehensive document. This practice guideline aims to provide support for both, specialists in aortic disease and clinicians involved in diagnosis, endovascular, open surgical or hybrid treatment, as well as surveillance. Moreover, it should provide a transparent basis for informed patients to comprehend the treatment offered by their specialists. Finally, the recommendations have also been aligned with the European Society of Cardiology (ESC) publishing their aortic guidelines in 2024 with a slightly different focus according to the needs of their target community.

A group of 28 aortic specialists has been formed with a timeline of a year which was a sportive through pass and finally was successful due to an excellent interaction of everybody involved.

The major metrics of the document are nearly 300 recommendations. One of the major achievements is the fact that there was unanimous agreement that the aorta should be viewed, interpreted and treated in the context of an organ, where diagnosis, treatment and surveillance should be considered with this perspective. So, the aorta is now officially named the 24th organ of the human body. Definitions have been updated and standards have been redefined where the routine use of the TEM classification and the GERAADA score in acute aortic dissection form a basis in acute aortic pathology, by using Ishimaru zones, to describe extent of disease and extent of repair, semiquantitative terms are now superseded.

Regarding proximal thoracic aortic disease, exact cutoffs in indicating treatment for the aortic root and the ascending aorta have been defined in both non-syndromic as well as syndromic disease. For the first time, aortic length has been implemented into the decision making process. In this context, the fundamental need for establishing aortic centers in order to be able to provide the entire treatment spectrum under one umbrella to do the right things at the right timepoint in the right patients was underlined.

Diagnostics, and here imaging cannot be overemphasised, has been a substantial part of the document where modality and approach to measure was a particular focus. Also certain anatomical structures such as the circle of Willis have been highlighted as there is fundamental need to know about the patency in order to plan the selective antegrade perfusion strategy in aortic arch replacement of various extent.

The next major leap was the redefinition of a common language in defining the degree of hypothermia during operations using hypothermic circulatory arrest for organ protection in aortic surgery. This new definition will enable direct comparison between centers and treatment strategies in these scenarios.

Furthermore, very clear treatment algorithms in patients with acute aortic dissections irrespective of extent has been provided in flow charts where the location of the primary entry tear and the presence or absence of malperfusion (according to the TEM classification) plays a major role.

Treatment approaches of the aortic arch as well as the entire thoracoabdominal aorta have been provided in detail and also rare diseases including native and prosthetic aortic infections have been addressed in detail. Finally, mode and frequency of follow-up as well as the potential for physical exercise after treatment or during surveillance have been addressed.

Our understanding of the aortic organ is continually evolving, especially with regard to its pathophysiology, timing for treatment, and the application of currently available and the development of new therapeutic strategies. Aortic disease has emerged as a specialty with significant health economic relevance. Several components of this guideline already establish the foundational structure necessary to meet the needs of treating the aortic organ within a specialised centre and by a dedicated interdisciplinary aortic team.

With all the incredible progress we have seen in the past two decades, combined with where we stand today and the bright future we see surrounding aortic medicine, we truly believe that this guideline provides a valuable platform for everyday practice. It serves as a comprehensive resource, and lays the groundwork for ongoing collaborative efforts in our field.

The task force has put in diligent work, ensuring each section is enriched with informed insights and practical advice. Now, we’re turning to the boards of our three societies, anticipating their official approval. Once we have their backing, clinicians around the world will benefit from a resource designed not just to aid daily practice, but also to elevate the quality of patient care on a global scale.

ESC Guidelines for Management of Infective Endocarditis

Eduard Quintana 1, Michael Borger 2 , Torsten Doenst 3, Nikolaos Bonaros 4 , Carlos Mestres5

Affiliations:

1. Hospital Clínic Barcelona. University of Barcelona. Spain

2. University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany

3. Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich Schiller University of Jena, Germany

4. Innsbruck Medical University, Cardiac Surgery, Austria

5. Department of Cardiovascular Surgery and the Robert WM Frater Cardiovascular Research Centre. The University of the Free State (South Africa)

The newly released ESC guidelines on endocarditis, endorsed by EACTS, covers extensively most aspects of care for these complex patients1. A strong multidisciplinary collaboration with prominent input from cardiovascular surgeons has resulted in a sound and balanced document.

The most relevant changes relate to a more stringent definition for the timing of surgery. Operations with urgent indications are recommended to be performed within 3-5 days of when surgical criteria are met. This change may reflect an existing practice that has been adopted by many centers in the last years with improved outcomes.

Furthermore, recommendations for surgery after stroke have been refined. Growing observational information seems to support an undelayed approach to surgery for patients after ischemic stroke. As opposed to the 2015 recommendation to delay an operation for 1 month after intracranial bleed,

the new document opens the door to offer surgery, when necessary, in selected patients that would face dismal prognosis without surgery, particularly if favorable brain bleed criteria are present.

For embolic prevention, a more aggressive approach is favored in patients that have other existent indications for surgery with a class I recommendation. Also, preventive surgery may now be considered in vegetations larger than 1 cm in patients without severe valve dysfunction, provided that the operative risk is low.

These are some highlights from the recently published version of these guidelines. Given its relevance and impact on practice, the role of the Endocarditis Team, in fact the oldest of the heart teams, has been upgraded to class I. The multidisciplinary cooperation in the development of this ESC guideline is a strong example of such collaboration.