Acute type A aortic dissection (TAAD) remains a morbid condition; although overall outcomes have improved, patients presenting with preoperative malperfusion syndromes continue to have excessive mortality following conventional open surgical repair. Mesenteric malperfusion is generally associated with the worst prognosis and postoperative mortality in this group. With advances in the endovascular treatment of aortic pathology, options now exist to percutaneously manage mesenteric malperfusion prior to central aortic repair. This strategy may be associated with improved outcomes. To review this, a best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with acute type A aortic dissections with mesenteric malperfusion, does management of the malperfusion prior to central aortic repair reduce perioperative mortality'. Overall, more than 309 papers were found as a result of the reported search, of which 11 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that, in patients with acute TAAD complicated by mesenteric malperfusion, initial management with percutaneous interventional procedures to reverse the malperfusion followed by delayed central aortic repair is a reasonable strategy; this is because of the extremely poor prognosis associated with immediate central aortic repair in this group.

The "branch-first" technique described brings us closer to the goal of arch surgery with cerebral, vital organ, and survival outcomes similar to those we expect from ascending aortic and root procedures.

A best evidence topic was written according to a structured protocol. The question addressed was 'In patients requiring an aortic valve replacement, are rapid deployment aortic valve systems better than conventional aortic valve prostheses in terms of mortality, morbidity and/or valve function?' A total of 508 papers were found using the reported search, of which 11 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The rapid deployment valves (RDVs) implanted in these studies include balloon expandable [Intuity (Edwards Lifesciences, CA, USA) and 3F Enable (Medtronic, MN, USA)] and self-expanding [Perceval (Sorin, Saluggia, Italy)] stented bioprostheses. Available data from these studies demonstrate that rapid deployment valves are invariably associated with shorter aortic cross-clamp times (30-56 vs 49-88 min). Despite this, postoperative mortality (0-5.8 vs 0-6%), ICU (1-3 vs 0.9-2.8 days) and hospital length of stay (6-14.1 vs 6-15.9 days) are similar compared with conventional aortic valve replacement (AVR). However, reduced postoperative bleeding (328 vs 564 ml), blood transfusion requirements (1.4 vs 2.4 units), ventilation time (4.9-9.5 vs 7-16.6 h) and renal injury (5.3 vs 14.7%) have been demonstrated with RDVs indicating possible clinical benefit to shorter procedural time. Importantly, patient risk profiles were similar to or higher across studies in patients undergoing RDVs compared with conventional AVR. From a functional perspective, transvalvular gradients were frequently lower with rapid deployment valves compared with conventional AVR, indicating an improved haemodynamic profile. However, in some studies using the Perceval RDV, the transvalvular gradients were higher than with conventional AVR. Also, mean valve sizes were often larger in those receiving RDVs. Rates of paravalvular regurgitation were similar between RDVs and conventional AVR in most studies, although pacemaker implantation occurred more often with RDV in some studies (2-28.5 vs 0-8.5%). Accepting these limitations, and without long-term data, RDVs would appear to be a reasonable alternative to conventional aortic valve prostheses in selected cases.

Current techniques for endoscopic carpal tunnel release use an infraretinacular approach, inserting the endoscope deep to the flexor retinaculum. We present a supraretinacular endoscopic carpal tunnel release technique in which a dissecting endoscope is inserted superficial to the flexor retinaculum, which improves vision and the ability to dissect and manipulate the median nerve and tendons during surgery. The motor branch of the median nerve and connections between the median and ulnar nerve can be identified and dissected. Because the endoscope is inserted superficial to the flexor retinaculum, the median nerve is not compressed before division of the retinaculum and, as a result, we have observed no cases of the transient median nerve deficits that have been reported using infraretinacular endoscopic techniques.