Surgery of thoracoabdominal aortic aneurysms (TAAA) is associated with high incidence of serious complications. Ischemia/reperfusion (I/R) injury may be responsible for these complications. We investigated the effect of degree of anticoagulation on remote organ I/R injuries and whether heparin is protective against I/R injury in addition to its anticoagulant properties.
Spraque Dawley rats were used to determine both liver and kidney concentrations of HSP-70,IL-6, MPO in four groups: ischemic control (operation with cross-clamping and intraperitoneal administration of 0.9% saline, n = 7), sham (operation without cross-clamping, n = 7), heparin (ACT level about 200), and high dose heparin (ACT level up to 600). Histological analyses of the organs were performed.
Histopathological evaluation of kidney presented significant differences between groups with regards to the cytoplasmic vacuole formation, hemorrhage, tubular cell degeneration and tubular dilatation while heparinized group had best results. The kidney MPO and HSP-70 levels significantly decreased (p < 0.05), but IL-6 level was not significant (p > 0.05) in heparinized group when compared to ischemic control group. No statistically significant intergroup differences were detected in the tissue samples of liver. Immunohistochemical markers of the liver were compared and no statistically significant difference was found among the groups.
Heparin is an important anticoagulation agent in TAAA surgical procedures but the use of higher levels of heparin in the present study revealed no beneficial effects. Bleeding complications is much less when heparin is used in the real-world clinical practice as ACT levels of 200.
Heparin; Ischemia; Reperfusion; Lung; Kidney
Although temporary cardiac pacing is infrequently needed, temporary epicardial pacing wires are routinely inserted after valve surgery. As they are associated with infrequent, but life threatening complications, and the decreased need for postoperative pacing in a group of low risk patients; this study aims to identify the predictors of temporary cardiac pacing after valve surgery.
A retrospective analysis of data collected prospectively on 400 consecutive valve surgery patients between May 2002 and December 2012 was performed. Patients were grouped according to avoidance or insertion of temporary pacing wires, and were further subdivided according to temporary cardiac pacing need. Multiple logistic regression was used to determine the predictors of temporary cardiac pacing.
170 (42.5%) patients did not have insertion of temporary pacing wires and none of them needed temporary pacing. 230 (57.5%) patients had insertion of temporary pacing wires and among these, only 55 (23.9%) required temporary pacing who were compared with the remaining 175 (76.1%) patients in the main analysis. The determinants of temporary cardiac pacing (adjusted odds ratios; 95% confidence interval) were as follows: increased age (1.1; 1.1, 1.3, p = 0.002), New York Heart Association class III- IV (5.6; 1.6, 20.2, p = 0.008) , pulmonary artery pressure ≥ 50 mmHg (22.0; 3.4, 142.7, p = 0.01), digoxin use (8.0; 1.3, 48.8, p = 0.024), multiple valve surgery (13.5; 1.5, 124.0, p = 0.021), aorta cross clamp time ≥ 60 minutes (7.8; 1.6, 37.2, p = 0.010), and valve annulus calcification (7.9; 2.0, 31.7, p = 0.003).
Although limited by sample size, the present results suggest that routine use of temporary epicardial pacing wires after valve surgery is only necessary for high risk patients. Preoperative identification and aggressive management of predictors of temporary cardiac pacing and the possible modulation of intraoperative techniques can decrease the need of temporary cardiac pacing. Prospective randomized controlled studies on a larger number of patients are necessary to draw solid conclusions regarding the selective use of temporary epicardial pacing wires in valve surgery.
Pacing heart; Temporary pacing; Heart valves
We hypothesized that the influence of cyanotic disease on postoperative blood loss is closely related to age in children undergoing cardiac surgery. Here, we demonstrate that the presence of a cyanotic disease is associated with increased postoperative blood loss in children aged 1 to 6 months. Children with cyanotic disease and aged < 1 month who received fresh frozen plasma during cardiopulmonary bypass had less postoperative blood loss and higher maximal clot firmness on FIBTEM than cyanotic children from all other groups. Additional studies are needed to define optimal pathophysiology-based management in children undergoing cardiac surgery.
Congenital heart surgery; Bleeding management; Age; Point-of-care monitoring
Bochdalek hernia is the most common type of congenital diaphragmatic hernia. It appears frequently in infants but rarely in adults. We present the case of a 50-year-old female han patient with tremendous left-sided congenital posterolateral diaphragmatic hernia (Bochdalek hernia) who also has a pair of supernumerary breasts and pulmonary hypoplasia of the lower-left lobe. The patient had an experience of misdiagnosis and she was treated for bronchitis for one year until being admitted to our hospital. This case study emphasizes the rare presentation of Bochdalek hernia in adults and the necessity of high clinical attention to similar cases.
Congenital diaphragmatic hernia; Bochdalek hernia; Diaphragmatic eventration
Rupture of the left ventricle after mitral valve replacement, although infrequent, may be a highly lethal complication. This report describes the early diagnosis and successful repair of rupture of atrioventricular groove in an elderly patient who underwent mitral valve replacement.
Elderly; Mitral valve replacement; Rupture
Quadricuspid aortic valve (QAV) is a rare congenital anomaly. We investigate the mid-term results of aortic valve reconstruction by tricuspidization in patients with QAV.
We analyzed the outcome of eight consecutive patients who underwent aortic valve reconstruction surgery (AVRS) with pericardial leaflets with symptomatic quadricuspid aortic valve (QAV) disease between December 2007 and May 2012. AVRS consists of leaflet reconstruction and fixation of the sino-tubular junction in order to maintain coaptation of the new valve.
Six males and two females were included; ages ranged from 19 to 63 years (mean age, 51 years). According to Hurwitz and Roberts’s classification, three patients had type A, three patients had type B, one patient had type C, and one patient had type E. All patients had significant aortic regurgitation (AR): moderate in three patients, moderate to severe in one patient, and severe in four patients. Concomitant ascending aorta wrapping with an artificial vascular graft was performed in one case. There was no occurrence of mortality during the follow-up period (42.4 ± 18.0 months). No redo-operation was required. The NYHA functional class showed improvement from 2.1 ± 0.2 to 1.1 ± 0.2 (p = 0.008). The latest echocardiograms showed AR absent or trivial in seven patients, and mild in one patient. The aortic valve orifice area index (AVAI) was 1.03 ± 0.49 cm2/m2. Compared with preoperative echocardiograms, the left ventricular (LV) ejection fraction showed improvement from 57.6 ± 17.0 to 63.7 ± 13.2% (p = 0.036); the end-diastolic and end-systolic LV dimensions showed a significant decrease, from 63.5 ± 9.6 to 49.5 ± 3.1 mm (p = 0.012) and 43.6 ± 11.8 to 32.1 ± 5.4 mm (p = 0.012), respectively.
In patients with QAV, AVRS with tricuspidization showed satisfactory early and mid-term results. Long-term follow-up will be necessary in order to study the durability of AVRS; however, it can be considered as a potential standard procedure.
Aortic valve; Quadricuspid; Reconstructive surgical procedure; Outcome
Airway gastric fistula (AGF) is a rare but catastrophic complication after esophagectomy. Surgical repair with viable tissue interposed between the airway and alimentary tracts remains the definitive treatment. However, it is challenging for surgeons, and only anecdotally described in sporadic case reports due to the complexity of the techniques necessary for successful surgical intervention. Here, we report two cases successfully managed via single-stage surgical re-exploration. On outpatient follow-up, the two Chinese patients were progressing satisfactorily without complaint of any dyspnea or dysphagia.
Airway gastric fistula; Esophageal cancer; Esophageal surgery; Reoperation
Ruptured sinus of the valsalva aneurysm (RSVA ) is a rare cardiac anomaly. Nearly 80% of patients will have symptom when RSVA ruptures into one of the cardiac chambers. The conventional treatment of RSVA is surgical repair under cardio-pulmonary bypass (CPB) or percutaneous catheter closure. Here, we present one case of RSVA undergo transthoracic minimally invasive closure, which is a novel methods for the treatment of RSVA. We describe a thirty four-year-old Asian man with chest pain and palpitation for 3 days. Echocardiography showed that RSVA presented in the right coronary cusp. The sinus opened into the right atrium, and the diameter of the opening was 5 mm. The opening was successfully closed by transthoracic minimally invasive closure with a ventricular septal defect (VSD) occluder.
Aneurysm of the sinus of valsalva; Transthoracic; Closure
This compares outcome measures of current pectus excavatum (PEx) treatments, namely the Nuss and Ravitch procedures, in pediatric and adult patients. Original investigations that stratified PEx patients based on current treatment and age (pediatric = 0–21; adult 17–99) were considered for inclusion. Outcome measures were: operation duration, analgesia duration, blood loss, length of stay (LOS), outcome ratings, complications, and percentage requiring reoperations. Adult implant patients (18.8%) had higher reoperation rates than adult Nuss or Ravitch patients (5.3% and 3.3% respectively). Adult Nuss patients had longer LOS (7.3 days), more strut/bar displacement (6.1%), and more epidural analgesia (3 days) than adult Ravitch patients (2.9 days, 0%, 0 days). Excluding pectus bar and strut displacements, pediatric and adult Nuss patients tended to have higher complication rates (pediatric - 38%; adult - 21%) compared to pediatric and adult Ravitch patients (12.5%; 8%). Pediatric Ravitch patients clearly had more strut displacements than adult Ravitch patients (0% and 6.4% respectively). These results suggest significantly better results in common PEx surgical repair techniques (i.e. Nuss and Ravitch) than uncommon techniques (i.e. Implants and Robicsek). The results suggest slightly better outcomes in pediatric Nuss procedure patients as compared with all other groups. We recommend that symptomatic pediatric patients with uncomplicated PEx receive the Nuss procedure. We suggest that adult patients receive the Nuss or Ravitch procedure, even though the long-term complication rates of the adult Nuss procedure require more investigation.
Pectus excavatum; Pediatrics; Adults; Nuss procedure; Ravitch procedure
Transforming growth factor beta (TGF-β1) is a pleiotropic cytokine, which is deregulated in atherosclerosis; however the role of age in this process is unknown. We aimed to assess whether TGF-β1 signaling is affected by age.
Vascular smooth muscle cells (VSMC) were obtained from patients undergoing abdominal surgery. Levels of TGF-β1 were measured by ELISA in sera from 169 patients undergoing coronary artery bypass grafting (CABG). The p27 expression was determined by Western blot from internal mammary arteries (IMA) obtained from CABG patients (n = 13). In VSMC from these patients undergoing abdominal surgery, secretion of TGF-β1 was determined by ELISA of cell-conditioned media.
In VSMC from aged patients we observed a lower TGF-β1 secretion, measured as TGF-β1 concentration in cell conditioned medium (p < 0.001). This effect was correlated to an age-dependent decrease of p27 expression in IMA from aged CABG patients. In a similar manner, there was an age-dependent decrease of serum TGF-β1 levels in CABG patients (p = 0.0195).
VSMC from aged patients showed a higher degree of cellular senescence and it was associated to a lower TGF-β1 secretion and signaling.
Growth factors; Coronary disease; Aging; Surgery
The Editors of Journal of Cardiothoracic Surgery would like to thank all our reviewers who have contributed to the journal in Volume 8 (2013).
Complications due to hemodilution (hematocrit value less than 22%) after cardiopulmonary bypass inevitably resulted with significantly greater intensive care requirements, long hospital stays, more operative costs, and increased mortality rates. We tried to identify whether crystalloid cardioplegia is the strongest predictor of intraoperative hemodilution or not.
Materials and methods
One hundred patients were included into this randomized prospective study. Patients were divided into the two groups. Crystalloid cardioplegia were given to the odd-numbered patients (Group 1, n = 50 patients) and blood cardioplegia were given to the even-numbered patients (Group 2, n = 50 patients). St. Thomas-II solution was used in Group-1 and Calafiore cold blood cardioplegia was in Group-2.
Average intraoperative hematocrit value was 18.4% ± 2.3 in crystalloid group 24.2% ±3.4 in blood cardioplegia group (p < 0.001). The lowest hematocrit value was 15% and 20% in two groups respectively (p < 0.001). In crystalloid group average intraoperative packed red blood cell (RBC) transfusion was 2.3 ± 0.41 units, 0.7 ± 0.6 units blood cardioplegia group (p = 0.001). Average transfused RBC was 2.7 ± 0.8 units in crystalloid group, 0.9 ± 0.4 units blood cardioplegia group (p < 0.001). Multivariate analyses confirmed age (p = 0.005, OR = 3.78), female gender (p = 0.003, OR = 2.91), longer cross-clamp time (>60 minutes) (p = 0.001, OD = 0.97), body surface area <1.6 m2 (p = 0.001, OR = 6.01) and crystalloid cardioplegia (p < 0.001, OR = 0.19) as predictor of intraoperative hemodilution.
Crystalloid cardioplegia, compared to blood cardioplegia not only causes much more intra-operative hemodilution but also increases the blood transfusion requirement. Hemodilution and increased transfusion increases the intensive care unit and hospital stay, in the early postoperative period.
Cardioplegia; Crystalloid; Coronary artery; Bypass; Hemodilution
We describe surgical resection of an extralobar pulmonary sequestration via single-incision thoracoscopic surgery (SITS), which we recommend as a suitable surgical option. A 45-year-old Japanese woman was admitted to our hospital for further examination of chest abnormal shadow. A rigid 5-mm 30° video-thoracoscope, an endograsper and an electric cautery were passed within the same single small incision. The tumor was suspended using articulating endograspers and resected after clipping and ligation of the anomalous vessel. The final pathology was determined an extrapulmonary sequestration.
Extralobar pulmonary sequestration; Video- assisted thoracoscopic surgery; Single- incision thoracoscopic surgery
Anomalous origin of the right coronary artery from the left coronary sinus is rare but potentially dangerous if any ischemic signs are present. Multiple therapeutic options were advocated so far. We experienced three different situations and surgical approaches to these anomalies, and reviewed retrospectively. For the first case, we made a neo-ostium on the right sinus of Valsalva and anastomosed with the right coronary artery after arteriotomy. For the second and third cases, we applied coronary artery bypasses emergently: patient 2 the gastroepiploic artery during off-pump coronary artery bypass and patient 3 the left internal thoracic artery during surgery for acute aortic dissection. For the better outcomes, it is important to understand anatomic and hemodynamic characteristics of each patient and select the surgical options considering each characteristic.
Coronary artery anomaly; Anomaly
Postoperative Acute Kidney Injury (AKI) after coronary artery bypass grafting (CABG) is a common complication associated with significant morbidity and mortality. Cardiopulmonary bypass (CPB) is accepted to contribute to the occurrence of AKI and is of particular importance as it can be avoided by using the off-pump technique. However the renoprotective properties of off-pump (CABG) are controversial. This analysis evaluates the impact of cardiopulmonary bypass on renal function.
A matched-pair analysis of 1428 patients undergoing coronary artery bypass grafting was conducted. The patients were stratified according to their preoperative renal function and to risk factors for postoperative AKI. The development of the glomerular filtration rate (GFR) from before surgery until hospital discharge was analyzed. Incidence of AKI were analyzed. Furthermore the impact of CPB duration on postoperative GFR was assessed.
The occurrence of AKI increases the risk of thirty-day mortality (odds ratio of 4.3). The postoperative GFR decreases significantly after coronary artery bypass grafting but does not differ between onpump and offpump CABG (60.2 ± 24.5 vs 60.7 ± 24.8; p = 0.54). No difference regarding the incidence (26.6% vs 25%) and severity of AKI between cardiopulmonary bypass and the off-pump technique could be found. Duration of cardiopulmonary bypass does not correlate with the decline in postoperative glomerular filtration rate (Pearson Product Moment Correlation; p > 0.050).
Neither the mere use nor duration of cardiopulmonary bypass proofed to be a risk factor for developing postoperative AKI in CABG patients with a comparable preoperative risk profile for postoperative renal dysfunction. Furthermore, the severity of postoperative AKI is not affected by the use of cardiopulmonary bypass.
Cardiopulmonary bypass; Coronary artery bypass grafting; Acute kidney injury
The study was designed to evaluate the effects of moderate prosthesis-patient mismatch (defined as 0.65 cm2/m2 < indexed effective orifice area ≤ 0.85 cm2/m2) on midterm outcomes after isolated aortic valve replacement with a 17-mm St. Jude Medical Regent valve in a large series of patients, and to determine if these effects are influenced by patient confounding variables.
One-hundred and six patients with and without moderate prosthesis-patient mismatch early after implantation of a 17-mm Regent valve at aortic position were included. Both clinical and echocardiographic assessments were performed preoperatively, at discharge and during follow-up period (mean follow-up time 52.6 ± 11.9 months).
The prevalence of moderate prosthesis-patient mismatch was documented in 46 patients (43.4%) at discharge. During the follow-up period, no difference in the regression of left ventricular mass, decrease of transvalvular pressure gradients, mortality and prosthesis-related complications was observed between patients with and without moderate prosthesis-patient mismatch. After adjustment for several risk factors, moderate prosthesis-patient mismatch was associated with increased midterm mortality in patients with baseline left ventricular ejection fraction < 50% (HR: 1.80, p = 0.02), but with normal prognosis in those with preserved LV function. Younger age (cut off value = 65 years) was not an independent predictor of increased midterm mortality and valve-related complications in patients with moderate prosthesis-patient mismatch.
Moderate prosthesis-patient mismatch after aortic valve replacement with a small mechanical prosthesis is associated with increased mortality and adverse events in patients with pre-existing left ventricular dysfunction. Selected patients with small aortic annulus can experience satisfactory clinical improvements and midterm survival after aortic valve replacement with a 17-mm Regent valve.
Prosthesis-patient mismatch; 17-mm Regent valve; Aortic valve replacement; Clinical outcome
We assessed the midterm outcome and the incidence of major adverse cardiovascular events in UK’s largest Da Vinci assisted robotic coronary revascularisation cohort. This study was set up at the Imperial College NHS Trust, St. Mary’s Hospital, London, United Kingdom.
Benchmarking approach through retrospective audit of the regional outcomes against standards in the published literature. Data was collected from the patient’s records, communication with the primary care physicians and the national strategic tracing service. The results were compared with the published literature. Patients who underwent robotic assisted coronary revascularisation were included. Other robotic procedures or minimally invasive revascularisation without the use of the Da Vinci robot were excluded. The main outcome measure was the midterm survival up to five years and the incidence of major adverse cardiovascular events (MACE) up to three years.
Since April 2002, one hundred consecutive patients underwent either off pump robotic assisted single vessel small thoracotomy (SVST, n = 88), or off pump total endoscopic coronary artery bypass grafting (TCAB, n = 12). All patients were operated on by the same primary surgeon but different assisting surgeons. All patients received a left internal mammary arterial (LIMA) graft as planned. The primary outcome of total one month and three years MACE and up to five year survival was 0, 9 and 96% respectively.
The procedural success rates in terms of morbidity and mortality up to five years are compatible to the outcomes observed outside the United Kingdom. These results are not inferior to that of conventional off pump single vessel coronary surgery or percutaneous coronary intervention to the LAD.
Da Vinci; Robotic; Coronary artery bypass grafting; MACE
Superior vena cava (SVC) reconstruction is occasionally required in the treatment of benign and malignant conditions. We report a patient with symptomatic SVC obstruction secondary to mediastinal fibrosis successfully reconstructed with an aortic allograft.
Allograft; Homograft; Venous disease; Revascularization (superior vena cava); Surgery/incisions/exposure/techniques; Mediastinum
The Nuss procedure, which is a minimally invasive approach for treating pectus excavatum, has better functional and cosmetic outcomes than other invasive procedures. Cardiac perforation is the most serious complication and several methods for the prevention of intraoperative events has been developed. Although most cardiac injuries are detected in the operating room, in the case described herein the patient experienced sudden hypovolemic shock during the postoperative recovery period. This indicates that special caution is mandatory even after successful execution of the Nuss procedure.
Pectus excavatum; Nuss procedure; Cardiac complication
Swyer-James-McLeod Syndrome (SJMS) is an uncommon, emphysematous disease characterized by radiologic hyperlucency of pulmonary parenchyma due to loss of the pulmonary vascular structure and to alveolar overdistension.
We herein describe a 15-year-old Caucasian patient with well-established SJMS since childhood who presented with spontaneous pneumothorax. Video-assisted thoracoscopic bullectomy with apical pleurectomy was performed. Since SJMS is considered an on-going inflammatory process, the patient one year after surgery exhibits excellent quality of life with no pneumothorax recurrence.
Acute kidney injury (AKI) after cardiac surgery procedures is associated with poor patient outcomes. Cystatin C as a marker for renal failure has been shown to be of prognostic value; however, a wide range of its predictive accuracy has been reported. The aim of the study was to evaluate whether the measurement of pre- and postoperative serum cystatin C improves the prediction of AKI.
In a single-centre, prospective study of 70 patients (74 ± 9ys; range 47-85ys; 77% male), cystatin C was measured six times: (T1 = preoperative, T2 = start cardiopulmonary bypass (CPB), T3 = 20 min after CPB, T4 = end of operation; T5 = 24 h postoperatively; T6 = 7d postoperatively). Predictive property, in terms of the need for renal replacement therapy (RRT), was analysed by receiver operating characteristics (ROC) statistics and described by the area under the curve (AUC).
With respect to RRT (n = 8), serum cystatin C was significantly higher at the end of the operation (T4), 24 h postoperatively at T5 and at T6. The AUCs for preoperative T1 and intraoperative T2/3 cystatin C were <0.7 (95% CI, 0.47-0.85). The earliest significant predictive AUCs were found at the end of the operation (T4: p = 0.03 95% CI 0.58-0.88 AUC 0.73) and 24 h postoperatively (T5: p = 0.003 95% CI 0.74-0.96 AUC 0.85).
Early postoperative serum cystatin C increase appears to be a moderate biomarker in the prediction of AKI, whereas a preoperative and intraoperative cystatin C increase has only a limited diagnostic and predictive value.
Cystatin C; Cardiac surgery; Cardiopulmonary bypass; Acute kidney injury
The Na+/Ca2+ exchange inhibitor SEA0400 prevents myocardial injury in models of global ischemia and reperfusion. We therefore evaluated its potential as a cardioplegia additive.
Isolated rat cardiomyocytes were exposed to hypoxia (45 min) followed by reperfusion. During hypoxia, cells were protected using cardioplegia with (n = 25) or without (n = 24) SEA0400 (1 μM), or were not protected with cardioplegia (hypoxic control, n = 8). Intracellular Ca2+ levels were measured using Ca2+ sensitive dye (fura-2 AM). Isolated rat hearts were arrested using cardioplegia with (n = 7) or without (n = 6) SEA0400 (1 μM) then reperfused after 45 min of ischemia. Left ventricular (LV) function, troponin release, and mitochondrial morphology were evaluated.
Cardiomyocytes exposed to hypoxia without cardioplegia had poor survival (13%). Survival was significantly improved when cells were protected with cardioplegia containing SEA0400 (68%, p = 0.009); cardioplegia without SEA0400 was associated with intermediate survival (42%). Cardiomyocytes exposed to hypoxia alone had a rapid increase in intracellular Ca2+ (305 ± 123 nM after 20 minutes of ischemia). Increases in intracellular Ca2+ were reduced in cells arrested with cardioplegia without SEA0400; however cardioplegia containing SEA0400 was associated with the lowest intracellular Ca2+ levels (110 ± 17 vs. 156 ± 42 nM after 45 minutes of ischemia, p = 0.004). Hearts arrested with cardioplegia containing SEA0400 had better recovery of LV work compared to cardioplegia without SEA0400 (23140 ± 2264 vs. 7750 ± 929 mmHg.μl, p = 0.0001). Troponin release during reperfusion was lower (0.6 ± 0.2 vs. 2.4 ± 0.5 ng/mL, p = 0.0026), and there were more intact (41 ± 3 vs. 22 ± 5%, p < 0.005), and fewer disrupted mitochondria (24 ± 2 vs. 33 ± 3%, p < 0.05) in the SEA0400 group.
SEA0400 added to cardioplegia limits accumulation of intracellular Ca2+ during ischemic arrest in isolated cardiomyocytes and prevents myocardial injury and improves recovery of LV function in isolated hearts.
Myocardial protection/cardioplegia; Myocardium; Ischemia; Ischemia/reperfusion injury; Cardiac function
We report the case of a 64-year old Caucasian male patient with a tear of the left ventricular driveline just above the driveline-air tube junction. We describe the repair technique and the necessary set of tools.
Artificial heart; Cardiac failure; Heart assist devices
Occurrence of acute aortic dissection after aortic valve replacement is rare, however, it is associated with high mortality and morbidity rates. We report two Asian cases in which acute aortic dissection occurred after urgent aortic valve replacement for infective endocarditis. Successful graft replacement was carried out with preservation of the prosthetic valves in both cases. Our experience with these cases suggests that, even in urgent or emergent situations, surgical intervention for associated aortic dilatation should be considered when aortic valve replacement is performed.
Aortic valve replacement; Aortic dissection; Aortic dilatation; Urgent surgery