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Jakob H, Leins T, Avci-Adali M, Schlensak C, Wendt D, Mehta Y, Thielmann M, Görlinger K, Song SW, Tsagakis K. Standardized in vitro bleeding tests in a non-coated novel hybrid prosthesis for frozen elephant trunk demonstrates minimal oozing during full heparinization, supported by clinical data. Front Cardiovasc Med 2023; 10:1303816. [PMID: 38155987 PMCID: PMC10752973 DOI: 10.3389/fcvm.2023.1303816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/23/2023] [Indexed: 12/30/2023] Open
Abstract
Introduction Recent reports have questioned the blood impermeability of the novel frozen elephant trunk (FET) device E-vita Open NEO© (EO-NEO). Therefore, standardized in vitro bleeding tests using porcine heparinized blood were performed, as well as stress testing on the blood tightness of the collar suture line, to investigate this observation. Material and methods EO-NEO prostheses were examined in vitro for blood permeability in three test series. Initially, antegrade perfusion with heparinized porcine blood [activated clotting time (ACT) of 500 s, with a 60 min duration] was performed, followed by ante/retrograde testing via the EO-NEO side port. Testing of the collar suture line under a tension of 10 Newton (N) within a suspension device (blood pressure 120 mmHg, ACT of 560 s, 1 min duration) was carried out with the suture material force fiber white (FFWs) yarn, using standard fixation (5 stitches/cm), FFWh yarn in hemostatic fixation (15 stitches/cm), and flow weave yarn (FWYh). Results Blood permeability testing of EO-NEO through the prosthetic lumen or via the side port demonstrated minor leakage without statistical difference between the standard and hemostatic suture lines or suture materials used, or positioning on the crimped or tapered portion (p > 0.05). The specific collar anastomosis testing demonstrated leakage volumes of 140 ml/min for FFWs vs. 16 ml/min for FFWh (p = 0.02), vs. 9 ml/min with the FWYh (p = 0.01). Conclusion Different blood leakage tests showed minimal oozing and no difference in blood loss through the fabric and different collar suture lines, but unphysiological pressurized retrograde perfusion of the collar region showed significantly less leakage using FWYh and FFWh, prompting production modification of EO-NEO. Clinical results confirmed low blood loss using this novel FET device.
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Affiliation(s)
- Heinz Jakob
- Diagnosticum Mülheim, Mülheim, Germany
- Department of Thoracic- and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
| | - Timo Leins
- Medira GmbH, Balingen, Germany
- JOTEC-Artivion, Hechingen, Germany
| | - Meltem Avci-Adali
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Daniel Wendt
- Department of Thoracic- and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
- CytoSorbents Europe, Berlin, Germany
| | - Yatin Mehta
- Medanta Institute of Critical Care and Anesthesiology, Medanta - The Medicity, Gurgaon, India
| | - Matthias Thielmann
- Department of Thoracic- and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
| | | | - Suk-Won Song
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Konstantinos Tsagakis
- Department of Thoracic- and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
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Werner P, Stelzmüller ME, Mahr S, Ehrlich M. The 10 Commandments of Open Aortic Arch Repair. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:259-265. [PMID: 35916005 PMCID: PMC9403391 DOI: 10.1177/15569845221112636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Paul Werner
- Department of Cardiac Surgery, 27271Medical University of Vienna, Austria
| | | | - Stephane Mahr
- Department of Cardiac Surgery, 27271Medical University of Vienna, Austria
| | - Marek Ehrlich
- Department of Cardiac Surgery, 27271Medical University of Vienna, Austria
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NEO E-vita—NEO era! Indian J Thorac Cardiovasc Surg 2022; 38:83-90. [PMID: 35463705 PMCID: PMC8980984 DOI: 10.1007/s12055-021-01303-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 10/31/2022] Open
Abstract
AbstractIn this review article, the history of the first commercially available thoracic aortic hybrid graft, the E-vita Open, later modified to the blood-impermeable E-vita Open Plus, is reported from its beginning in 2005 until its newest variation, the E-vita Open NEO, European conformity (CE) marked in 2020. Besides the background of its design and clinical experience in Essen, concomitant evolutionary steps in surgery as well as in strategic approaches like the hybrid operating room concept are displayed, finally leading to a well-rounded surgical package with a device that can be applied in all elective as well as emergency situations with complex arch involving aortic pathologies. With the E-vita Open NEO, now, surgery has been facilitated to convenient anastomosing in any of the arch zones, with the opportunity to use the island technique with a straight graft variation as well as individual head vessel anastomosing with either a trifurcated graft for zone 0 or the branched graft for zone 2 or 3 implantation. With its proven long-term stability, the surgical armamentarium to cope with complex multisegmental thoracic aortic pathologies has been significantly improved.
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Jubouri M, Abdelhaliem A. BioGlue and E-Vita Open NEO graft oozing: Long-term solution or band aid? J Card Surg 2021; 37:561-562. [PMID: 34914136 DOI: 10.1111/jocs.16181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND The introduction of the single-step total arch replacement (TAR) with frozen elephant trunk (FET) has revolutionised the field of aortic surgery. TAR is indicated when the aortic arch is involved in aortic pathologies such as Type A aortic dissection and thoracic aortic aneurysms. Several FET devices are available commercially for global use, and example is the E-Vita Open NEO hybrid prosthesis (HP) developed by CryoLife-JOTEC. Unlike other FET devices available, this HP in particular features a design that puts it at a disadvantage as it does not incorporate gelatine or collagen in its structure, which makes it permeable to blood. Several studies have reported incidence of post-anastomotic blood oozing through the E-Vita Open NEO right after weaning from cardiopulmonary bypass. AIMS This commentary aims to discuss the recent study by Tan et al. which investigated E-Vita NEO device oozing as well as the implications of using BioGlue to overcome this serious complications. METHODS We carried out a literature search on multiple electronic databases including PUBMED and Scopus in order to collate research evidence on E-Vita NEO device oozing, BioGlue health risks, and other commercially available and globally used FET devices such as Thoraflex Hybrid. RESULTS It is proven fact that the E-Vita NEO excessively oozes blood, and while BioGlue is a safe and effective agent when used in small amounts, the amount needed to coat the E-Vita Open NEO and achieve haemostasis exceeds this by a wide margin which poses patients to great potential health risks. The Thoraflex Hybrid Prosthesis developed by Terumo Aortic is a commercially available and globally used FET device with long-standing favourable outcomes. DISCUSSION Tan et al. recently conducted an interesting study which proved that the E-Vita NEO HP does excessively ooze blood and tackled the issue of pre-emptive BioGlue use to tackle this complication as suggested by Ho et al. This leads on to the main question, is the use of BioGlue with E-Vita Open NEO to overcome oozing a long-term sustainable solution or is it merely a band aid? CONCLUSION In the face of fierce commercial competition, the choice of design and material of the E-Vita Open NEO HP would benefit from reconsideration.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Amr Abdelhaliem
- Department of Vascular and Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
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Tan SZCP, Bashir M. Prevention versus cure: Is BioGlue priming the optimal strategy against E-Vita NEO graft oozing? J Card Surg 2021; 37:555-560. [PMID: 34907587 DOI: 10.1111/jocs.16179] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Since the introduction of the E-Vita Open NEO aortic prosthesis in 2020, several incidences of post-anastomotic oozing from the polyester portion of the graft have emerged. The use of BioGlue to prime E-Vita Open NEO to prevent this has been suggested as a way to mitigate this worrying complication. We investigate the extent of graft oozing in E-Vita Open NEO and evaluate the use of BioGlue in preventing oozing, both experimentally and in terms of potential clinical complications. MATERIALS AND METHODS E-Vita Open NEO (in straight and branched configurations) was implanted in a perfused model. The distal stent graft and side branches were clamped, and the graft was pressurized with blood to 120 mmHg. The volume of blood (ml) oozing from the graft within 60 s was measured. Nonpressurized grafts were coated with BioGlue up to a thickness of 1, 2, and 3 mm, and the volume (mm3 ) of BioGlue required to do so was recorded. RESULTS Within 60 s, 250.0 ml of blood oozed from the grafts tested. 43.694, 87.389, and 174.778 mm3 of BioGlue were required to coat the device with 1, 2, and 3 mm of BioGlue. CONCLUSION Graft oozing from E-Vita Open NEO represents an omnipresent and worrying risk. The use of BioGlue herein is likely associated with several adverse consequences, which are an additional risk on top of that posed by graft oozing. These risks call into question the suitability of E-Vita Open NEO, especially when compared to alternative devices not affected by oozing.
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Affiliation(s)
- Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health & Education Improvement, Wales, UK
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Bashir M, Abo Aljadayel H, Mousavizadeh M, Daliri M, Rezaei Y, Tan SZ, Mohammed I, Hosseini S. Correlation of coagulopathy and frozen elephant trunk use in aortic arch surgery: A systematic review and meta-analysis. J Card Surg 2021; 36:4699-4714. [PMID: 34550616 DOI: 10.1111/jocs.16001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/14/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The advent of frozen elephant trunk (FET) for reconstruction of elective and nonelective aortic arch surgery has augmented the treatment of complex aortic pathologies in a single-stage operation. To date, no studies have been focused on the prevalence and predictors of coagulopathy potentiated by FET procedure. METHODS In a systematic review, we searched databases up to June 2020 to find studies reporting coagulopathy complications after FET procedure. A proportional meta-analysis was carried out using STATA software (StataCorp). RESULTS A total of 46 studies consisting of 6313 patients were eligible. The pooled estimation of reoperation for postoperative bleeding was 7% (95% confidence interval [CI:] 5-8; I2 = 84.73%; reported by 39 studies including 4796 patients). The mean volume of transfused packed blood cells and fresh frozen plasma was 1677 ml (95% CI: 1066.4-2287.6) and 1016.5 ml (95% CI: 450.7-1582.3). The subgroup by the stent type showed a decrease in the heterogeneity (I2 = 0.01%, I2 = 53.95%, I2 = 0.01%, and I2 = 54.41% for Thoraflex® Hybrid, E-vita®, Frozenix®, and Cronus®, respectively). The subgroup by the chronicity of operation resulted in less heterogeneity among patients undergoing elective compared with nonelective operation (I2 = 29.22% vs. I2 = 80.56% in nonelective). Meta-regression analysis showed that age and male gender significantly impacted on the reoperation for postoperative bleeding. CONCLUSIONS The FET procedure for arch replacement is associated with coagulopathy complications and the transfusion of blood products. Male, age, and selective choice of FET use were found to be the heterogeneity sources of reoperation for postoperative bleeding.
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Affiliation(s)
- Mohamad Bashir
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.,Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India.,Vascular and Endovascular Surgery, Velindre University NHS Trust, Health & Education Improvement Wales (HEIW), Wales, UK
| | - Hadi Abo Aljadayel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mousavizadeh
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahdi Daliri
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Sven Zcp Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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