Peter Benedikt

Background: Redo surgery of the aortic root in the context of prosthetic valve endocarditis (PVE) is among the most technically demanding procedures in cardiac surgery. This case series presents six male patients who underwent redo aortic root replacement following prior root interventions, focusing on surgical strategy, microbiological findings, complications, and outcomes. Cases: A total of 100 patients were treated surgically for aortic valve endocarditis between 2015 and 2025; 38 underwent aortic root procedures. Six patients required redo root replacements and were included in this study. Patient data were extracted from hospital and national databases, and detailed clinical analyses were performed. Five patients underwent homograft implantation, while one patient received a bovine biological conduit. For one patient, this follow-up procedure marked the third cardiac surgery overall and the second intervention on the aortic root. Conclusions: All patients were male with a median age of 61 years [Interquartile range (IQR) 11.5], a median ICU (intensive care unit) stay of 3 days [IQR 1.25], and a total hospital stay of 17 days [IQR 11.5]. No in-hospital mortality or perioperative stroke was noted. Identified pathogens included Streptococcus spp., Granulicatella adiacens, Enterococcus faecalis, and Pseudomonas spp. (PCR only). The cultures remained negative in one case. All patients received six weeks of intravenous antibiotics. Redo root surgery in the setting of PVE poses high operative risks, including technical complexity and reinfection. Surgical success depended on meticulous debridement, individualized conduit selection, and appropriate preoperative planning. Homografts were favored in extensive infections due to the associated resistance to reinfection. This case series demonstrates the feasibility and safety of redoing aortic root replacement for PVE, assuming appropriate surgical and postoperative strategies are implemented, with favorable outcomes, even in high-risk patients.

Objectives: To investigate 3-year outcomes of surgical aortic valve replacement using the INSPIRIS RESILIA aortic valve bioprosthesis in patients with severe aortic stenosis. Methods: IMPACT registry is a prospective, multicentre, international registry with a 5-year follow-up. After 3 years, haemodynamic performance, all-cause mortality, and valve-related mortality were determined. Results: A total of 556 patients who underwent surgical aortic valve replacement with the INSPIRIS RESILIA aortic valve were enrolled between December 2019 and June 2021. The mean age was 63.4 ± 8.5 years, 29.0% were female, with a EuroSCORE II of 2.2 ± 2.5% and an STS score of 1.7 ± 2.2%. Hypertension (66.2%), coronary artery disease (34.7%), and diabetes (18.4%) were the most common comorbidities. A total of 49.3% of patients underwent full sternotomy, 58.3% isolated aortic valve replacement. The most commonly implanted valve sizes were 23 mm (35.4%) and 25 mm (30.9%). At 3 years, overall survival was 91.0%, freedom from valve-related mortality was 97.5%, from prosthetic endocarditis 96.0%, from stroke 91.5%, from valve-related dysfunction 98.0%, from reintervention 96.2%, from structural valve deterioration stage 2 96.8%, and from stage 3 99.4%. The mean transvalvular gradient was 11.9 mmHg at 3 years, with an indexed effective orifice area of 0.8 cm2/m2. Functional class improved from 41.2% class III or IV at baseline to 5.7% at 3 years. Conclusions: Three-year outcomes, including survival and haemodynamic and functional status after surgical aortic valve replacement using the INSPIRIS RESILIA bioprosthetic aortic valve, were reported in a real-world patient population with severe aortic stenosis. ClinicalTrials.gov: NCT04053088.

Background: As minimally invasive and alternative approaches for aortic valve repair gain increased popularity, this trial reports on outcomes of an established program using the underreported novel right transaxillary (rTX) access for aortic valve surgery. Methods: Between June 2023 and May 2025, a total of 22 patients underwent aortic valve surgery using the rTx approach (female: n = 14 (63.6%); age: 64.5 (60.0–70.0) years; EuroSCORE II: 0.9 (0.6–1.1)), mainly for aortic valve stenosis (n = 17 (77.3%)) and primarily with cannulation of the right groin (n = 21 (95.5%)) for cardiopulmonary bypass (CPB). Results: The median aortic clamp time was 78.5 (74.8–90.3) minutes, and the median extracorporeal circulation time was 143.0 (134.8–178.3) minutes. One (4.5%) patient underwent acute surgical revision via sternotomy due to bleeding from the aortotomy, while aortic root replacement was successfully performed. One (4.5%) patient experienced a stroke, and one (4.5%) received a pacemaker for high-grade atrioventricular block. Regarding CPB and surgical access site complications, one (4.5%) patient had a postoperative hematoma at the right groin, and one (4.5%) had a surgically revised thoracic hematoma. The median intensive care unit stay was 1.0 (1.0–2.3) days. No patient died during the median follow-up period of 6.0 (3.0–16.5) months. Conclusion: Minimally invasive aortic valve surgery by rTX is feasible for a variety of valve pathologies, revealing good clinical outcomes even at the start of such a program. The low learning curve at experienced centers for minimally invasive cardiac surgery encourages other centers to adopt this approach as the potential future standard for aortic valve surgery.

A 63-year-old male Jehovah’s Witness with a history of Stanford type B aortic dissection presented after a stable course over the years with a rapid expansion of the thoraco-abdominal aorta, necessitating intervention. Due to religious beliefs prohibiting blood transfusions, open surgical treatment of the aortic arch was not viable. Instead, endovascular aortic septotomy with electrosurgery of the abdominal aorta and endovascular repair of the aortic arch were successfully performed, followed by thoracic endovascular aortic repair to ensure sufficient lumen expansion for further prosthetic deployment. Five months later, the total endovascular repair of the aorta was completed by fenestrated endovascular aortic repair. Two type II endoleaks in the thoracic and abdominal aorta were treated with a percutaneous embolization. The patient remained in good general condition at the follow-up examinations, with no neurological abnormalities. The case highlights the feasibility and advantages of established and emerging endovascular techniques as alternative to open aortic surgery for patients who refuse blood transfusions.

Adipose tissue enlargement in obesity leads to hypoxia, which may promote premature aging. This study aimed to understand the hypoxic response in 3D cultures of SGBS cells, a model for brown-like adipose tissue expressing uncoupling protein 1 (UCP1). Single-nucleus RNA sequencing of SGBS organoids revealed a heterogeneous composition and sub-population-specific responses to hypoxia. The analysis identified a cluster of transcriptional repression, indicating dying cells, and implied a role of ferroptosis in this model. Further experiments with SGBS cells and white adipose tissue-derived stem/progenitor cells showed that Acyl-CoA synthetase long-chain family member 4 (ACSL4), a key enzyme in ferroptosis, is expressed only in the presence of browning factors. Hypoxia downregulated ACSL4 protein in SGBS organoids but induced an inflammaging phenotype. Analysis of brown-like epicardial adipose tissue from cardiac surgery patients revealed a significant positive correlation of ACSL4 mRNA with UCP1 and hypoxia-inducible pro-inflammatory markers, while ACSL4 protein appeared to be inversely correlated. In conclusion, this study demonstrates that adipocytes’ capability to undergo ACSL4-mediated ferroptosis is linked to brown-like adipogenesis, suggesting an opportunity to modulate ferroptotic signaling in adipose tissue. The dual role of hypoxia by inhibiting ACSL4 but promoting inflammaging indicates a relationship between ferroptosis and aging that warrants further investigation.

Zusammenfassung: Die Trikuspidalklappeninsuffizienz (TI) wurde in der Vergangenheit zu selten diagnostiziert und behandelt. Jüngste Fortschritte bei minimal-invasiven Reparaturtechniken bieten vielversprechende Alternativen zu den herkömmlichen chirurgischen Verfahren. Dieser Artikel soll einen Überblick über die TI und über die neuen Eingriffsmöglichkeiten geben, wobei der Schwerpunkt auf den Mechanismen, den klinischen Ergebnissen und den aktuellen Erkenntnissen liegt.

Introduction The frozen elephant trunk technique (FET) has become routine for aortic arch and descending aortic repair. New hybrid prosthesis models are constantly being developed to increase effectiveness and durability of aortic repair. Recently, concerns were raised regarding increased post-operative bleeding using a new-generation hybrid prosthesis (E-vita^® OPEN NEO, CryoLife Inc. JOTEC GmbH, Hechingen, Germany). We report the outcomes of a multi-centre experience of using the E-vita OPEN NEO. Methods All patients undergoing aortic surgery at five European centres using the E-vita OPEN NEO from 2020 to 2022 were included (n = 22). The primary endpoint was the amount of chest drain fluid after 24 h and re-thoracotomy rate for bleeding. Results Median patient age was 62.5 ± 12.6 years, 50.0% (11/22 patients) were female and 27.3% (6/22) of procedures were re-operative cardiac surgeries. Aortic dissection was present in 54.5% (12/22). The median cardiopulmonary bypass time was 148 min and ischaemia time was 84 min. Mortality at 30 days was 4.5% (1/22) and the stroke rate was 18.2% (4/22). The rate of re-thoracotomy for bleeding was 4.5% (1/22) with a median amount of chest drain fluid within 24 h of 569 (IQR 338–910) ml. There were no device-associated adverse events. Conclusions Use of this new-generation hybrid prosthesis for FET was safe and effective. Patient follow-up was largely uneventful given the extent of the procedures performed. In particular, bleeding events were uncommon in this cohort of patients comprising many aortic dissections and re-operative procedures. No increase in oozing was observed. Graphical Abstract

Background: Degenerative aortic valve disease accounts for 10–20% of all cardiac surgical procedures. The impact of pre-existing comorbidities on the outcome of patients undergoing surgical aortic valve replacement (SAVR) needs further research. Methods: The IMPACT registry is a non-interventional, prospective, open-label, multicenter, international registry with a follow-up of 5 years to assess the impact of pre-existing comorbidities of patients undergoing SAVR with the INSPIRIS RESILIA aortic valve on outcomes. IMPACT will be conducted across 25 sites in Austria, Germany, The Netherlands and Switzerland and intends to enroll approximately 500 patients. Patients will be included if they are at least 18 years of age and are scheduled to undergo SAVR with the INSPIRIS RESILIA Aortic Valve with or without concomitant ascending aortic root replacement and/or coronary bypass surgery. The primary objective is to determine all-cause mortality at 1, 3, and 5 years post SAVR. Secondary objectives include cardiac-related and valve-related mortality and structural valve deterioration including hemodynamics and durability, valve performance and further clinical outcomes in the overall study population and in specific patient subgroups characterized by the presence of chronic kidney disease, hypertension, metabolic syndrome and/or chronic inflammation. Discussion: IMPACT is a prospective, multicenter European registry, which will provide much-needed data on the impact of pre-existing comorbidities on patient outcomes and prosthetic valve performance, and in particular the performance of the INSPIRIS RESILIA, in a real-world setting. The findings of this study may help to support and expand appropriate patient selection for treatment with bioprostheses. Trial registration: ClinicalTrials.gov identifier: NCT04053088.

Zusammenfassung: Die chirurgische Versorgung der akuten Typ-A-Aortendissektion erfuhr in den letzten Jahrzehnten v. a. im Hinblick auf das Perfusions- und Temperaturmanagement eine ständige Entwicklung. Neurologische Komplikationen sind die Hauptursache der postoperativen Morbidität und Mortalität. Die Verwendung einer Herz-Lungen-Maschine, des Kreislaufstillstands in tiefer Hypothermie, die temporäre Unterbrechung der zerebralen Perfusion oder Hypoperfusion des Gehirns und die Manipulation an der Aorta können zu neurologischen Schäden führen. Der Kreislaufstillstand in tiefer Hypothermie ermöglicht Eingriffe an der thorakalen Aorta, die für die Sanierung einer akuten Dissektion notwendig sein können. Dies hat allerdings Limitationen: Einerseits ist die Eingriffszeit begrenzt, andererseits führt die tiefe Hypothermie selbst zu Schäden. Experimentelle und klinische Studien konnten zeigen, dass der Grad der Hypothermie einen Einfluss auf die Komplikationsrate hat. Auch über den Nutzen der retrograden Hirnperfusion besteht noch Uneinigkeit. Das Konzept des Kreislaufstillstands mit zusätzlicher Hirnperfusion, besonders wenn der Grad der Hypothermie entsprechend der erwarteten Kreislaufstillstandzeit angepasst wird, erwies sich als sichere Methode. Es ermöglicht komplexe Eingriffe an der Aorta bei geringen Komplikationsraten und wird zunehmend als Standardverfahren bei der Versorgung der akuten Typ-A-Dissektion angewandt.