Objectives: The Heart Team (HT) approach plays a key role in selecting the optimal treatment strategy for patients with aortic stenosis. Little is known about the HT decision process and its impact on outcomes. The aim of this study was to identify the factors associated with the HT decision, and evaluate clinical outcomes according to the treatment choice. Methods: The study included a total of 286 consecutive patients with aortic stenosis referred for discussion in the weekly HT meeting in a cardiovascular institute over 2 years. Patients were stratified according to the selected therapeutic approach: medical treatment (MT), surgical (SAVR) or transcatheter (TAVR) aortic valve replacement. Baseline characteristics involved in making a therapeutic choice were identified and a decision-making tree was built using CART methodology. Results: Based on HT discussion 53 patients were assigned to SAVR, 210 to TAVR and 23 to MT. Older patients (≥88-years-old) were mainly assigned to TAVR or MT according to the Logistic EuroSCORE (< or ≥28, respectively). While among younger patients (<88 years), significant mitral regurgitation (≥grade III), frailty, STS score and estimated glomerular filtration rate were the most relevant factors influencing treatment allocation. One-year all-cause mortality was 16.6% in the invasive groups (TAVR 17.2%, SAVR 14.0%) and 68.7% in the MT arm. Conclusions: The HT decision was determined by well-recognized risk factors which were used to define a treatment decision algorithm. Future studies with younger and lower risk patients may identify new contributory factors which may alter the selection process and treatment choice.

Background: We report our experience in aortic arch repair with the E-vita Open hybrid prosthesis and describe the changes in our technique over time. Methods: Between October 2013 and December 2019, 56 patients underwent a total aortic arch replacement with the E-vita Open hybrid prosthesis. Main indications were thoracic aorta aneurysm (n=27) and acute type A aortic dissection (n=18). We analyze the technique and results in the overall series, and compare both between our early (Group I, 25 patients) and late experience (Group II, 31 patients). Results: Overall in-hospital mortality was 7.1% (4), and permanent stroke and spinal cord injury were 3.6% and 1.8% respectively. 15 patients (26.8%) underwent a planned second procedure on the distal aorta: 13 endovascular, 1 open and 1 hybrid. Survival at 1 and 3 years was 90.7% and 80.7%. Group II included more patients with acute dissection (45.2% vs 16%, p=0.02), a higher rate of bilateral cerebral perfusion (100% vs 64%, p<0.001), left subclavian artery perfusion during lower body circulatory arrest (87.1% vs 0%, p<0.001), early reperfusion (96.8% vs 40%, p<0.001), and zone 0-2 distal anastomosis (100% vs 72%, p=0.02). In-hospital mortality (3.2% vs 12%) and permanent stroke (0% vs 8%) tended to be lower in Group II. Conclusions: Total arch replacement with E-vita Open hybrid prosthesis in complex thoracic aorta disease is safe. One-stage treatment is feasible when pathology does not extend beyond the proximal descending thoracic aorta. In any case, it facilitates subsequent procedures on distal aorta if needed.