Can the beating heart be advantageous during aortic arch replacement using frozen elephant trunk?

In the recent issue of the Annals of Cardiothoracic Surgery, Mosbahi and colleagues demonstrated a surgical treatment of a relatively young male patient presenting with a 55-mm aneurysm at the level of proximal descending aorta who previously underwent mechanical aortic root replacement and hemiarch replacement due to acute type A aortic dissection (ATAAD) (1). The authors are to be congratulated for the successful management of this challenging case using a relatively novel approach. A beating heart technique with hypothermia on a ventilated, well-perfused heart has obvious advantages in reducing the oxygen debt incurred during a prolonged procedure on the distal aorta/arch (essentially a ‘non-cardiac’ procedure for which technically the heart does not really need to be arrested). Previously, other authors have reported branch-first, normothermic techniques, albeit with reduced periods of cardiac and visceral ischemia, to reduce the morbidity and mortality of arch surgery (2).

The authors reported that the beating-heart frozen elephant trunk (FET) technique was advantageous in significantly reducing cardiac ischemic time since an ascending aorta or a previously placed graft can be clamped distally, allowing delivery of 32 ℃ blood at 250–300 mL/min to maintain root pressure around 50–70 mmHg. Since brain magnetic resonance imaging was performed preoperatively and the circle of Willis was found to be abnormal, bilateral antegrade cerebral perfusion was used. However, the authors reported a few contraindications, such as ATAAD due to the risk of pressure-related rupture, and moderate or severe aortic regurgitation due to left ventricular dilatation. Low perfusion pressure in the aortic root with an empty ventricle can cause significant prosthetic regurgitation across a mechanical valve (the disks may not close fully). It would also be interesting to know if this technique allowed the authors to reduce their cross-clamp time or whether the patient had impaired left ventricular function preoperatively.

A similar technique has been previously reported. De Silva and colleagues recently reported how they adopted a beating heart strategy in selected cases to reduce the cardiac ischaemic time once the proximal aortic repair has been completed (3). They emphasized the main advantage of this technique, a tendency for reduced post-operative inotropic requirements without compromising postoperative outcomes when performed in high-volume centres by experienced multidisciplinary teams.

Importantly, Ernst and colleagues reported 67 patients who underwent FET with the beating heart technique. Interestingly, aortic cross-clamp (P=0.042) and cerebral perfusion (P=0.003) times were significantly shorter in the beating heart group as compared to the cardioplegic arrest group (4). In addition, postoperative cardiac biomarkers and in-hospital mortality were lower, although non-significantly, while the incidence of postoperative renal replacement therapy was significantly lower (P=0.027) in the beating heart group.

Furthermore, Martens and colleagues compared 36 patients who underwent aortic arch repair with continuous myocardial perfusion to 108 patients protected with cardioplegic arrest, and found that both low cardiac output syndrome (3% vs. 22%, P=0.005) and 30-day mortality were significantly lower in the continuous myocardial perfusion group (6% vs. 21%, P=0.040) (5). Therefore, the authors concluded that protection of the heart during complex aortic arch repair with continuous myocardial perfusion can be a feasible and safe approach, which does not prolong the duration of surgery, but can reduce myocardial damage and improve postoperative outcomes.

However, the surgical technique described by Mosbashi and colleagues is limited by the lack of a large sample size and a control group for comparison in order to validate the advantages of this approach, eliminate selection bias and compare postoperative outcomes.

In conclusion, Mosbahi and colleagues reported a successful aortic arch repair on a beating heart despite the technical complexity and risk of perioperative complications. Each patient undergoing complex arch repair has a unique clinical presentation and an individual patient-tailored surgical strategy is important in achieving a satisfactory outcome (6,7). This report highlights that the beating-heart technique is beneficial in a selected patient cohort undergoing FET procedure and it could be considered when technically feasible and depending on institutional expertise. However, further comparative studies with longer follow-up are required to validate advantages of this approach.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery. The article has undergone external peer review.

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0021/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0021/coif). D.S. serves as an unpaid editorial board member of Journal of Visualized Surgery from September 2025 to December 2027. The other author has no conflicts of interest to declare.

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References

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