Aortic arch replacement with prophylactic aortic arch debranching during type A acute aortic dissection repair: initial experience with 23 patients

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European Journal of Cardio-Thoracic Surgery
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Aortic arch replacement with prophylactic aortic arch debranching during type A acute aortic dissection repair: initial experience with 23 patients

Mattia Glauber^a, Michele Murzi^{, a,} , Pierandrea Farneti^a, Stefano Bevilacqua^a, Massimiliano Mariani^a, Andrea Tognarelli^a, Tommaso Gasbarri^a and Sergio Berti^a

^a Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Monasterio Fondation-CNR, Via Aurelia Sud 54100, Massa, Italy

Received 2 September 2010; 

revised 30 November 2010; 

accepted 7 December 2010. 

Available online 2 February 2011.

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Abstract

Objective: To improve the long-term results of acute type A dissection repair, we developed a technique that combines radical surgical resection, and, at the same time, creates a safe and long landing zone for subsequent endovascular procedure on the descending aorta. Methods: Since November 2006, 23 patients (62 ± 13 years) underwent aortic arch replacement concomitant with prophylactic debranching of the supra-aortic vessels, with a specially designed arch graft. The technique consists of replacing the ascending aorta and the aortic arch, and, at the same time, relocating the origin of the supra-aortic vessels just above the sinotubular junction creating a long and safe proximal landing zone for subsequent stent-graft deployment. Perfusion was antegrade through the ascending aorta during cooling and through the vascular prosthesis during rewarming. Distal arch anastomosis was performed under moderate hypothermic circulatory arrest for 25 ± 7 min and antegrade selective cerebral perfusion (46 ± 14 min). Cardiopulmonary bypass and aortic cross-clamp time were 138 ± 46 and 63 ± 22 min. Results: Hospital mortality was 4.3% (1/23). Postoperative morbidity includes five acute renal failures and four lung failures. No major neurological complications were observed. At follow-up (22 ± 10 months), survival was 100% and two patients required an endovascular thoracic aorta repair for aneurysmal enlargement. In both cases, the stent grafts were successfully released in the landing zone created at the time of primary repair. Conclusions: Our technique extends the suitability of endovascular therapies during type A acute dissection repair, creating a long and stable landing zone that allows safe performance of a second endovascular step if needed, both in the short- and long term.

Keywords: Aortic dissection; Endovascular techniques; Re-operation

Article Outline

1.

Introduction

2.

Patient and methods

2.1. Patient selection

2.2. Rationale and indication for the procedure

2.3. Surgical technique

2.4. Endovascular procedure

2.5. Follow-up

3.

Results

4.

Discussion

Appendix A.

Conference discussion

References

1. Introduction

Although many patients never require subsequent operation after successful repair of type A acute aortic dissection (TAAD), residual aneurysms arising from the distal aortic arch to the descending aorta are seen in a small but fixed percentage of patients [1]. To reduce the high morbidity and mortality associated with standard surgical repair of these large-scale aneurysms, thoracic endovascular repair (TEVAR) has been recently proposed as an alternative and less invasive strategy [2]. However, the absence of an appropriate landing zone in the aortic arch represents the main limitation of TEVAR. Many surgical techniques for the relocation of the aortic arch's vessels have been proposed, but their application in patients with a previous TAAD remains difficult. In an effort to overcome this problem, we developed a technique that has the goal of removing all entry or re-entry tears accessible in the ascending aorta or aortic arch while performing an extensive supra-aortic vessels debranching with a specially designed vascular prosthesis, to facilitate a second-stage endovascular procedure on the thoracic aorta, if needed.

2. Patient and methods

2.1. Patient selection

Between November 2006 and March 2010, 23 patients with TAAD underwent ascending aorta and aortic arch replacement combined with prophylactic aortic arch debranching. All patients had operations on an emergency basis immediately after diagnosis (9 ± 7 h). Preoperative eval‎uation included a computed tomographic (CT) scan and echocardiography. In all the patients, the CT scan revealed the extension of the dissection in the thoracic aorta (type I DeBakey aortic dissection). Preoperative characteristics are reported in Table 1. Seventeen patients were male and six were female, with a mean age of 62 ± 13 years. Nineteen patients had a history of hypertension and one was diagnosed with Marfan's syndrome. One patient had previously undergone cardiac surgery (mechanical aortic valve replacement (AVR) and ascending aorta replacement). Seven patients were found to have severe aortic regurgitation and one patient had cardiac tamponade. A history of stroke was noted in one patient.

Table 1. Preoperative characteristics.

Demographics	No	%
Age (years)	62 ± 13
Female	6	26
Body surface area	1.81 ± 0.1
Dyslipidemia	13	54
Hypertension	19	86
Diabetes	4	18
COPD	6	27
Chronic renal failure	1	4
Previous AMI	3	13
Cardiac tamponade	1	4
Marfan's syndrome	1	4
Bicuspid aortic valve	2	8
Previous aortic operation	1	4

Full-size table

COPD: chronic obstructive pulmonary disease and AMI: acute myocardial infarction.

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2.2. Rationale and indication for the procedure

The rationale to apply our technique consists in replacing the ascending aorta and part of the aortic arch and, at the same creating, the conditions for a second-stage endovascular procedure on the descending aorta. The arch replacement, combined with prophylactic aortic arch debranching, is usually performed in those patients with a TAAD who also present: a tear in the arch, arch aneurysm or dilatation, a tear in the descending aorta, relatively young age less than 75 years and Marfan's syndrome.

2.3. Surgical technique

The procedure is performed through standard median sternotomy. After systemic heparinization, the ascending aorta is cannulated using Seldinger's technique under transesophageal echocardiography (TEE) assistance. In those patients who have a contraindication to ascending aorta cannulation, we use a femoral artery for arterial return. Venous return is established with a two-stage venous cannula introduced in the right atrium. With pressure monitoring in both the radial arteries and one femoral artery, as well as bilateral oxygen cerebral saturation monitoring (INVOS^?, Somnetics, Troy, MI, USA), cardiopulmonary bypass is initiated. While cooling the patient to 26 °C, the ascending aorta is clamped, opened, and cardioplegia is directly delivered into the coronary arteries. During body cooling, aortic valve and root procedures are performed, if indicated. Consecutively, epi-aortic vessels are dissected and when the target core temperature is achieved, the cardiopulmonary bypass is discontinued. The ascending aorta and the aortic arch are transected at a predetermined line between the left common carotid artery (LCCA) and the left subclavian artery (LSA), and selective antegrade cerebral perfusion (SACP) is started (10 ml kg⁻¹ min⁻¹) via the innominate artery (IA) and LCCA with two selective balloon-tipped cannulas. Under SACP with systemic circulatory arrest, the distal end of an appropriate branched vascular prosthesis (The Plexus 4-Branch; Vascutek Terumo Inc, Scotland, UK) is sutured to the descending aortic stump just proximal to the LSA. Consecutively, antegrade systemic perfusion and body rewarming are restarted from the side branch of the graft. Then, the proximal end of the graft is sutured to the ascending aortic stump and coronary circulation is resumed. At this moment, attention is paid to tailor the graft so that the arch's branches originate just above the proximal anastomosis. Moreover, we pay attention to make these grafts branch off on the right side of the main tube graft, lying on the wall of the superior vena cava (SVC), to avoid any further compression of the grafts after sternal closure. Finally, the IA and the LCCA are selectively anastomized to the corresponding branches of the graft ([Fig. 1] and [Fig. 2]).

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Fig. 1. 

Schematic overview of the surgical procedure. The brachiocephalic trunk as well as the left common carotid artery is relocated just above the sinotubular junction, creating a long prosthetic landing zone for stent-graft deployment.

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Fig. 2. 

3D postoperative CT scan reconstruction.

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2.4. Endovascular procedure

At our institution, indications for subsequent TEVAR after TAAD repair are: a maximal thoracic aorta diameter greater than 60 mm or a documented increase of aortic diameter of more than 1.0 cm within 1 year.

The TEVAR procedure is conducted under general anesthesia and with TEE control using spinal fluid drainage to minimize the risk of paraplegia. Through a left-femoral-artery access, a self-expanding stent graft (Relay Thoracic Stent Graft System/Bolton Medical, USA) is deployed into the thoracic aorta using the new ascending aorta as the proximal landing zone (Fig. 3).

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Fig. 3. 

3D postprocedural CT scan reconstruction. The extensive aortic arch debranching allows the release of the stent graft directly on the new prosthetic ascending aorta.

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2.5. Follow-up

All patients underwent our standard follow-up protocol after TAAD repair. Between postoperative days 7 and 15, all surviving patients underwent CT angiography, as well as after 6 and 12 months, and annually thereafter. At these time intervals, the patients were also seen in our outpatient clinic.

3. Results

We have successfully cannulated the ascending aorta in all patients except one, who had had a previous ascending aorta replacement. In this patient, we have used the left femoral artery for arterial return. The mean cardiopulmonary bypass time was 138 ± 46 min, aortic cross-clamp time was 63 ± 22 min, SACP time was 46 ± 14 min, and lower body arrest time was 25 ± 7 min.

Concomitant procedures were the Bentall procedure in 19 patients, AVR in three patients, and coronary artery bypass grafting in two patients (Table 2).

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Table 2. Operative data.

Operative Data	No	%
CPB time (min)	138 ± 46
Cross-clamp time (min)	63 ± 22
SACP time (min)	46 ± 14
Circulatory arrest time (min)	25 ± 7
Additional procedures
Aortic valve replacement	3	13
Bentall operation	19	82
CABG	2	8

Full-size table

SACP: selective antegrade cerebral perfusion.

View Within Article

There was one in-hospital death (4.3%): a 56-year-old man, who died intra-operatively of an unstoppable bleeding syndrome. Postoperative morbidity is presented in Table 3. One patient who had an history of stroke 3 years before the operation, developed postoperative delirium, which resolved 2 days after the operation. Another patient presented a transient neurologic event with left hemiplegia, which resolved in 24 h. No permanent neurologic deficit was observed. Five patients developed postoperative renal failure (seric creatinine >2 mg dl⁻¹ or an increase of at least 1.5 times of the preoperative baseline concentrations) and among these, three required a temporary hemodialysis filtration. Prolonged mechanical ventilation (>48 h) support was needed in four patients. Three patients underwent re-operations because of postoperative bleeding. Mean intensive care unit stay was 5.8 days (range, 2–16 days) and overall hospital stay was 16.4 days (range, 7–26 days). At follow-up (mean 22 ± 10 months), there were no late deaths or major neurologic events. The follow-up CT scans showed, postoperatively, early thrombosis of the distal false lumen in the proximal descending and thoracic aorta in 26% (six) patients and 17% (four) patients immediately after the surgery and in 47% (11) patients and 39% (nine) patients at 1 year postoperatively. No patient needed a proximal re-operation. Distal re-intervention was needed in two patients. The first patient was a 61-year-old man, who presented a rapidly expanding proximal descending aorta enlargement (59 mm) 16 months after surgery. The second patient was a 37-year-old male with Marfan's syndrome, who developed a descending thoracic aorta aneurysm (61 mm) 11 months after surgery. These two patients underwent successful percutaneous TEVAR through the left femoral artery with deployment of the stent graft in the new prosthetic ascending aorta. In both, the origin of the LSA was covered by the stent graft without any related complications. At 6 months follow-up, they are in good health. CT scan follow-up documented exclusion of the residual dissecting aneurysm in both cases, and no procedure-related complications were observed.

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Table 3. Postoperative morbidity and follow-up.

Complication	No	%
30 days mortality	1	4
Respiratory failure	4	18
Stroke	0	0
Transient neurologic events	1	4
Postoperative delirium	1	4
Renal failure	5	21
Follow-up
Mean follow-up (months)	22 ± 10	100% complete
Late mortality	0	0
Neurologic events	0	0
False lumen thrombosis
Proximal descending aorta	11	47
Distal thoracic aorta	9	39
Proximal re-intervention	0	0
Distal re-intervention (TEVAR)	2	9

Full-size table

View Within Article

4. Discussion

Surgical repair of TAAD still represents one of the most challenging procedures for the cardiothoracic surgeon [3]. Patients with a TAAD are treated with emergency surgical repair of the ascending aorta and various portions of the aortic arch to prevent lethal complications such as aortic rupture, cardiac tamponade, aortic regurgitation, and myocardial infarction [4] and [5]. However, this standardized operation for the more extensive of acute type A dissection leaves the patient with a residual ‘type B’ dissection beyond the aortic arch. Several studies have investigated the fate of the residual dissected aorta after TAAD repair, showing that a small but fixed percentage of patients had to undergo surgery of the aortic arch or the descending aorta because of secondary aneurysmal dilatation [1] and [6]. Therefore, some authors, concerned by the high risk of re-operation, have recently proposed a more aggressive surgical approach during TAAD repair [7] and [8]. Since Kato and colleagues [9] in the mids 90's, first described the use of antegrade descending aorta stent grafting during TAAD repair, this technique, also known as the stented elephant trunk, has been popularized widely by an increasing number of institutions [7], [8], [10] and [11]. The rationale to use this technique is to obtain an early thrombosis of the patent false lumen in the descending aorta, and, in so doing, preventing late thoraco-abdominal aneurysm formation and the need for re-operation. However, the application of this technique during emergent repair of TAAD has raised some conceptual and technical concerns [12]. Introducing a stented graft into an acutely dissected aorta may be cumbersome, carrying the risk of aortic disruption, peripheral embolization, paraplegia, and malperfusion syndrome. In addition to this, whether early thrombosis of the residual patent false lumen after TAAD could really improve long-term outcome is still a matter of debate. Some studies have demonstrated that a residual patent lumen is not necessarily associated with a faster aortic growth rate and its presence does not affect the long-term outcome in patients, who had standard surgical repair of TAAD [1] and [13]. These findings are consonant with the recently published results of the first randomized study on elective stent-graft placement in survivors of uncomplicated type B aortic dissection (the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial), which failed to improve 2-year survival and adverse event rates in patients treated with stent grafting [14].

On the other hand, endovascular techniques may represent an attractive and less invasive alternative strategy in the treatment of residual dissecting aneurysm because these catheter-based techniques avoid extensive surgical incision, cardiopulmonary bypass, and deep hypothermic circulatory arrest. However, the limitations of endovascular therapy result from the need of an appropriate landing zone that allows to safely release the stent graft [15]. It is generally accepted that the proximal landing zone should be at least 2 cm proximal to the lesion. While additional aortic coverage is desirable for a durable repair, it is often limited by neighboring critical branch vessels, and the need for an additional landing zone must be balanced against the need for adjunctive revascularization procedures, especially in patients with a previous TAAD repair. In 2006, Shah and colleagues reported their initial experience with five TAAD patients treated with ascending aorta replacement and IA debranching without hypothermic systemic circulatory arrest as the first stage, followed by subsequent extra-anatomical carotid–carotid bypass and TEVAR [16]. The authors showed encouraging results and concluded that their staged hybrid procedure may offer advantage over the standard surgical approach.

Based on these considerations, it would seem that optimization of the short- and long-term results after TAAD repair could come from a surgical technique, which guarantees a radical surgical resection and at the same time creates the requisites for a future stent-graft deployment: a long and safe distance from the emergence of the cerebral arteries and the possibility of realizing the stent graft directly on an aortic wall that is non-degenerated.

For the above reasons, we developed a technique, which consisted of replacing the ascending aorta and the arch and relocating the origin of the neck vessels using a specially designed trifurcated vascular prosthesis. With this technique, in fact, the first-stage operation permits to combine a radical emergency surgical repair with an extensive debranching of the aortic arch with limited cardiopulmonary bypass, SACP and circulatory arrest time. In an effort to create a safe and long proximal landing zone in the aortic arch, we paid attention to relocate the origin of the supra-aortic vessels just above the sinotubular junction, leaving a 5–8-cm portion of the new prosthetic ascending aorta suitable for stent-graft deployment ([Fig. 1] and [Fig. 2]). Due to the fact that we leave the two branch grafts to the arch longer than 8 cm, reconstruction of the supra-aortic vessels is not difficult, even in patients with a large and deep barrel chest. In our series, three patients had to be re-opened for bleeding. Among these, the source of bleeding was the distal anastomosis in two and the LCCA anastomosis in one. In all, the source of bleeding was successfully controlled. In fact, another advantage of our method is that even after the reconstruction is completed, all suture lines are easily visible and accessible.

In our series, we performed a secondary TEVAR in two patients. In both, the prophylactic aortic arch debranching allowed a safe and successful stent-graft deployment (Fig. 3).

One may argue that performing a standard elephant trunk concomitant with aortic arch replacement beyond the LSA would result in a similar landing zone for subsequent TEVAR. However, in our opinion, using the new prosthetic ascending aorta as a proximal landing zone rather than the conventional elephant trunk seems to be crucial to optimize the sealing of the endovascular stent graft and to minimize the risk of a type 1 endoleak that still represents the major adverse complication of TEVAR. Indeed, a short elephant trunk could result in difficulties with inserting the endograft and in possible complications resulting in the failure to fix the stent graft in place. On the other side, if the elephant trunk is too long, there could be issues of dislocation and mobilization of the stent graft [17]. Whether an extended aortic arch replacement can result in a better long-term outcome compared with limited arch replacement after TAAD repair is still under debate. Many authors reported that there were no differences of late survival and freedom from re-operation between patients who had a hemiarch replacement or a total arch replacement [18] and [19]. At our institution, we prefer to replace just a limited part of the arch and perform the distal anastomosis proximal to the origin of the LSA. Doing so permits to avoid an extensive dissection in the deepest part of the dissecting aortic arch or descending aorta, reducing the risk of bleeding and disruption. Moreover, this approach appears to be more reproducible also by those surgeons, who are untrained in aortic arch repair. However, a possible drawback of our technique is the fact that, in case of subsequent TEVAR, the origin of the LSA needs to be covered. For this reason, before TEVAR, we use brain imaging to define the status of the cerebral circulation and help determine the safest approach to managing the LSA. In addition, we assess the effectiveness of compensation occluding the LSA with a balloon inserted from the radial artery and we check the symptoms of the patient during a handgrip and after release of a 5-min left-arm ischemia. If the patient presents an LSA-dependent vertebral circulation or an anatomical variant of the subclavian, vertebral, basilar arteries or of the circle of Willis, we perform an carotid–subclavian extra-anatomical bypass before the endovascular procedure.

One of the two patients, who underwent TEVAR procedure, was diagnosed to have Marfan's syndrome. The feasibility of endovascular repair in patients with Marfan's syndrome is widely debated because of the potential risk induced by radial forces of the stent graft on the fragile aortic wall. Despite this, studies have reported encouraging results with endovascular stent grafts used to treat persistent distal aortic dissection after previous aortic procedures [20] and [21].

The low number of patients and the relatively short follow-up period remains a weakness of this study. Our favorable experience in this small initial series will require confirmation with a larger number of patients. We believe that our technique could permit to obtain a standard surgical repair, while extending the suitability of endovascular therapies in patients with TAAD. If the patient will need a second procedure on the descending aorta, this preventive debranching will allow a safe and effective endovascular treatment.

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Appendix A. Conference discussion

Dr M. Kolowca (Rzeszow, Poland): Let me be provocative, since my task is to stimulate this discussion. I have some concerns about your study.

The first one is its conceptual framework. You performed prophylactic aortic debranching believing that some patients, in fact only a few, will need a future distal re-intervention. But what we learned yesterday during the postgraduate course, is that TEVAR is not the best option for treatment of the patient with fast-expanding post-dissection aortic aneurysm, and that open surgery seems to be superior in this kind of patient. Also, it's not easy to find a good distal landing zone. Since we have a good proximal landing zone, we also need a good distal landing zone.

You performed two TEVAR implants, one in Marfan syndrome. So again, I’m not sure if TEVAR is the best option for Marfan syndrome, the young Marfan patient with fast-expanding post-dissection aortic aneurysm. So only a few patients, if any, could benefit from this kind of prophylactic operation.

My second concern is the selection bias in your study. I’m afraid your results could be biased by selection. Between 2006 and 2010 you enrolled 23 patients into the study. Are they consecutive patients with aortic type A dissection, DeBakey I? What were the inclusion and exclusion criteria for the study?

And I would like to know the indication for arch replacement in your practice. Is it dissection per se? Is it intimal tear re-entry in the arch? If so, what's going on if there is re-entry below the subclavian artery? Because in all patients, you left the subclavian artery untouched. Is it size which is the strongest risk factor for late aneurysm-related complication, is it age, or is it Marfan syndrome?

And my last concern, why didn’t you use the right subclavian artery for the brain perfusion? Because it's always better to have bilateral brain perfusion than unilateral brain perfusion when you do it in normothermic patients.

Dr Glauber: A lot of questions that need to be answered.

I will start with the patient selection criteria. As I said before, the most important criteria selection was age. We need certain life expectancy of at least 5 years, because I think that evolution of a thoraco-abdominal aneurysm in patients over 75 will not modify the life expectancy of these patients. So age is for me the most important criteria.

In all of these patients we had intimal tear located in the ascending aorta, representing a real type A aortic dissection. The frequency of admission of acute type A patients is not so high due to the fact that I’m working in a small center with a low surrounding population and that is the reason why the number of patients is not so high.

But in all the patients we treated in these 4 years, we debranched the supra-aortic vessel. The concept of leaving the subclavian arteries in place is due to the lesser technical difficulty in performing the anastomosis before the subclavian artery, with a low risk of bleeding and where bleeding can eventually be controlled more easily. A good reason to do it is the fact that often during the night, on call, it is easier for the less experienced surgeon. In case of TEVAR, the subclavian artery can easily be closed with a plug, and if in case of ischemia or steal syndrome of the left arm, it is possible to perform a bypass for revascularization. So the subclavian artery is, in my opinion, really not the problem.

And about the Marfan patient, this was a patient in whom we had ulceration of the thoracic aorta. So a second tear was still present which was creating an isolated aneurysm and which was an evolving, vs probably a rupture in the thoracic aorta.

Dr R. Di Bartolomeo (Bologna, Italy): What is the difference between your technique and the Lupiae technique described by our friend Giampiero Esposito?

And secondly, in your conclusion you say that the recent cost of stented elephant trunk can be avoided. In the experience of the group with the frozen elephant trunk used in acute type A aortic dissection, and type B acute dissection, there is complete thrombosis of the false lumen in the first stage. And there is a big advantage. And after 6–12 months in these patients, we have found complete healing of the aorta.

Dr Glauber: That's a good point. The advantage of this technique in my mind is that you can exactly tailor the endovascular prosthesis. So with E-vita Open, you have a fixed length of about 15 cm. With this technique you can also, after 2 days, 1 week, 1 month, or later, you can decide to implant an endovascular stent which has the length you need, to cover the length of the aorta you need.

And about the Lupiae technique, probably Dr Esposito can better answer. I never performed this procedure, but here in any case we don’t need to open the abdomen to create an anastomosis in this region and probably Giampiero can make a comment on his technique.

Dr G. Esposito (Lecce, Italy): Just to comment. We don’t, of course, open the abdomen. The abdomen is opened in the atherosclerotic aneurysm. We have to do reimplantation of the celiac trunk and the mesenteric artery to put the device in the second stage. We did about 50 dissections with the Lupiae technique and, of course, with the second stage done only when there is a problem with the false lumen. And we describe it in the Annals that will be published in November.

And commenting on your technique, the carotid artery going under the sternum, will be a problem. It's very long. So there is also a problem when the sternum is closed, the carotid artery will be a little bit disturbed. And the subclavian artery for us is very, very important. In 50 dissections we also replaced the subclavian artery in 47 cases. And in the cases that we left, there was no problem with the second stage. So this is my comment.

Dr J. Bachet (Abu Dhabi, United Arab Emirates): I will go in the same direction as Dr Kolowca. I had a little difficulty in understanding the concept of your technique.

You explained to us in your first slides that your technique was based on the fact that stenting the descending aorta cannot increase the life expectancy of the patients. Can you explain how increasing the length of the proximal landing zone helps to solve the problem of the distal aorta?

My second comment would be that, for me, you were far from acute dissection surgery. Acute dissection surgery is not a simple elective procedure. At least in my experience, it is often very, very difficult surgery. The problem is not to extend the landing zone of a future stent, it is to treat the aortic insufficiency, the rupture of the root, the malperfusion of the brain or the belly, et cetera. How can your technique of increasing the landing zone solve all of those problems? How do you solve, for instance, the problem of bleeding?

Dr Glauber: Most of these operations need an open technique with hypothermic circulatory arrest. Once I have done the first distal anastomosis, I immediately start perfusion and I do a second healing suture. In this way it is possible to test well the distal anastomosis before performing the proximal anastomosis, and, believe me, bleeding is not a major problem.

Dr Bachet: You never had bleeding at that site? Well then, I will go to Massa if I need an operation.

Presented at the 24th Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 11–15, 2010.

Corresponding author. Tel.: +39 0585493604; fax: +39 0585493613.

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