Percutaneous versus open surgical cannulation for minimal invasive cardiac surgery; immediate postprocedural outcome analysis.

Objectives: Open surgical cannulation (SC) is traditionally used for cardiopulmonary bypass cannulation in minimally invasive cardiac surgery (MICS). The percutaneous cannulation (PC) technique using arterial closure devices has also been used in select centers. The aim of this study was to compare outcomes between patients undergoing the PC or SC approach, with a particular focus on cannulation-related groin complications. Methods: A retrospective analysis of patients undergoing MICS at our institution between January 2018 and April 2022 was performed. Starting from June 2020, 3 surgeons at our institution started using the PC approach. For patients in the PC group, a primary suture-based technique (ProGlide) complemented by a small-sized plug-based closure device (AngioSeal) was used. The primary end point of the study was groin complications following the procedures. Results: A total of 524 patients underwent MICS through a right lateral minithoracotomy during the study time period. Of these, 88 patients (17%) were cannulated using PC approach and 436 (83%) using SC approach. The total number of cannulation-related groin complications was greater in the SC group (4% vs 0%, P = .05). Propensity score matching resulted in 2 comparable groups, with 172 patients in the SC group and 86 patients in the PC group. The number of groin complications remained greater in the SC group (P = .05). In-hospital mortality was comparable between groups (1% PC vs 0% SC, P = .3). Conclusions: The PC approach is a safe cannulation technique for patients undergoing MICS. It minimizes postoperative groin complications with no obvious negative impact on outcomes.

The parasternal technique: alternative technique for temporary right ventricular assist device implantation.

Right heart failure is a feared complication in cardiac surgery especially after heart failure surgery. Right ventricular assist device (RVAD) implantation is inevitable in severe forms of right heart failure. Different techniques for RVAD implantation exist. We here present our experience with a novel parasternal cannulation technique that allows early mobilization, high RVAD flow rates and easy RVAD removal.

Minimally invasive ventricular assist device implantation.

Durable mechanical circulatory support (MCS) systems are established therapy option in patients with end-stage heart failure, with increasing importance during the last years due to donor organ shortage. Left ventricular assist devices (LVADs) are traditionally implanted through median sternotomy (MS). However, improvement in the pump designs during the last years led to evolvement of new surgical approaches that aim to reduce the invasiveness of the procedure. Numerous reports and studies have shown the viability and possible advantages of less-invasive approach compared to the sternotomy approach. The less invasive implant strategies for LVADs, while vague in definition, are characterized by minimizing surgical trauma and if possible, cardio-pulmonary bypass related complications. Usually it involves minimizing or completely avoiding sternal trauma, avoiding heart luxation while simultaneously leaving the major part of pericardium intact. There is no consensus between the centers regarding the ideal approach for LVAD implantation. Some centers, like our center, perform by default VAD implantation using less invasive approach in almost all patients and some centers use only sternotomy approach. The aim of this review article is to shed light on the currently available less invasive options of LVAD implantation, with particular focus on the centrifugal pumps, and their possible advantages compared to traditional sternotomy approach.

Midterm results after St Jude Medical Epic porcine xenograft for aortic, mitral, and double valve replacement.

BACKGROUND: The aim of this study was to evaluate the results after stented porcine xenograft implantation (Epic, SJM, St Paul, MN) with Linx anticalcification treatment in elderly patients at our high-volume tertiary care center. METHODS: A total of 3825 patients undergoing aortic (AVR = 2441), mitral (MVR = 892), or double valve (DVR = 492) replacement between 11/2001 and 12/2017 with Epic xenografts were evaluated. Outcomes were assessed by reviewing the prospectively acquired hospital database results, and regular annual follow-up information was acquired from questionnaires or telephone interviews. RESULTS: For patients undergoing AVR, MVR, DVR, age at surgery were 76.4 ± 6, 71.2 ± 9, 72.9 ± 8 years; active endocarditis was an indication for valve surgery in 4.5%, 20.7%, 19.7%; and the predicted median (interquartile range [IQR]) mortality risk (EuroSCORE II) was 5.2% (3.1%-9.4%), 7.5% (3.9%-16.2%), 9.9% (6.0%-19.6%), respectively. Median follow-up was 3.04 (IQR: 0.18-5.21). Thirty-day survival was 91.2% ± 0.6%, 87.6% ± 0.1.1%, 84.7% ± 1.6%; and 10-year survival was 56.7% ± 1.0%, 59.4% ± 2.5%, 50.45% ± 3.1%, respectively. Patients who underwent MVR versus AVR were at significant increased risk for reoperation for endocarditis (adjusted odds ratio; 2.2, 95% confidence interval; 1.29-3.7; P = .003). There was no significant difference in all-cause mortality at midterm in AVR vs MVR in the matched cohort (P = .85). CONCLUSIONS: Implantation of the Epic stented porcine xenograft is associated with acceptable survival and freedom from valve-related complications or reoperation due to structural valve disease at midterm follow-up.

Surgical options in infective valve endocarditis with neurological complications.

BACKGROUND: Surgery is a common treatment option for patients with infective endocarditis. We present a large cohort of surgically managed patients with infective endocarditis and evaluate the long-term mortality of those with and without neurological complications. METHODS: We performed a retrospective review of patients surgically managed for infective endocarditis between 1994 and 2017. Demographic and outcome data were collected using a hospital database. Time-to-event analysis was performed with Kaplan-Meier curve and compared statistically with log-rank testing. RESULTS: At the time of admission, 680 (27.7%) patients with infective endocarditis showed neurological complications. The mean age was 62.6±14.0 years and 70% were male. Two thousand two hundred and sixty-one (92%) patients had left-sided valve endocarditis. Isolated aortic valve endocarditis was present in 59% of patients and 35% of patients had isolated infective endocarditis of the mitral valve. Mean logistic EuroSCORE was 21.2±21.6. Microbiologic cultures were positive in 1,939 patients (79%). The most common bacteria were Staphylococcus aureus (26%). In-hospital mortality in the group of patients with Staphylococcus aureus was significantly higher than in the group infected with other pathogens (18.2% vs. 13.4%, P=0.004). Patients with vegetations ≥1 cm had significantly more systemic embolization (P<0.001). 44% of patients had septic embolization with the most common site being the spleen, followed by the brain. Patients presenting with neurological complications had significantly higher in-hospital and long-term mortality (P<0.0001). CONCLUSIONS: Infective endocarditis patients with neurological complications have a significantly higher risk of mortality than patients without neurological complications. Surgery is an effective treatment in patients presenting with infective endocarditis, and may be undertaken in patients with neurological complications to prevent poorer prognosis.

Two Decades of Contemporary Surgery of Primary Cardiac Tumors.

Objective The decision to operate cardiac tumors is an issue of balancing surgical outcome and survival with quality of life (QOL). We report our single-center experience in managing primary cardiac tumors between 1994 and 2014. Methods and Results In this study, 269 patients were subjected to our standardized operative protocols, preoperative preparations, postoperative follow-up, and consents of participation. Demographic and preoperative/intraoperative/postoperative variables were collected with focus on long-term follow-up and survival. A total of 72,000 cardiac procedures were performed within 20 years at our institution. Two hundred sixty-nine patients were diagnosed with primary cardiac tumors (0.37%), with a male:female ratio of 1:1.68, mean age of 57.4 ± 19.5 years, and body mass index of 25.49 ± 6.5. The most presenting symptoms were dyspnea ( n = 94), arrhythmias ( n = 53), embolic event ( n = 36), and chest pain ( n = 29), and 33 patients were accidentally discovered. Isolated tumor excision and concomitant ablation were performed on 181 patients, while the rest needed additional procedures such as coronary artery bypass grafting ( n = 27) or valve surgery ( n = 61). Focus on pathology, tumor location was done reporting the commonest pathology such as myxoma ( n = 177) and fibroelastoma ( n = 56). The frequent site was the left atrium ( n = 162). Our primary results showed incidence of bleeding in 9 patients (3.3%), arrhythmias in 76 patients (28.25%), and mortality in 49 patients (18.2%). Five patients (1.8%) showed recurrence and 220 patients (81.8%) showed complaint-free survival. Conclusion Complete excision of primary cardiac tumors is the golden rule in management as it improves survival and decreases morbidity expected from the progressing tumors process. The progression of minimally invasive techniques improves QOL and should be performed whenever possible.

Curative therapy of a hepatitis C infection due to an infected heart donor: 5-year outcomes after heart transplantation.

Heart transplantation is the gold standard therapy for patients diagnosed with end-stage heart failure. Despite the shortage of appropriate donor organs, the transplantation of hepatitis C-infected hearts is disputed. Previous research has shown that long-term results are controversial, and the risk of severe clinical infection should not be underestimated.

New insights into valve-related intramural and intracellular bacterial diversity in infective endocarditis.

AIMS: In infective endocarditis (IE), a severe inflammatory disease of the endocardium with an unchanged incidence and mortality rate over the past decades, only 1% of the cases have been described as polymicrobial infections based on microbiological approaches. The aim of this study was to identify potential biodiversity of bacterial species from infected native and prosthetic valves. Furthermore, we compared the ultrastructural micro-environments to detect the localization and distribution patterns of pathogens in IE. MATERIAL AND METHODS: Using next-generation sequencing (NGS) of 16S rDNA, which allows analysis of the entire bacterial community within a single sample, we investigated the biodiversity of infectious bacterial species from resected native and prosthetic valves in a clinical cohort of 8 IE patients. Furthermore, we investigated the ultrastructural infected valve micro-environment by focused ion beam scanning electron microscopy (FIB-SEM). RESULTS: Biodiversity was detected in 7 of 8 resected heart valves. This comprised 13 bacterial genera and 16 species. In addition to 11 pathogens already described as being IE related, 5 bacterial species were identified as having a novel association. In contrast, valve and blood culture-based diagnosis revealed only 4 species from 3 bacterial genera and did not show any relevant antibiotic resistance. The antibiotics chosen on this basis for treatment, however, did not cover the bacterial spectra identified by our amplicon sequencing analysis in 4 of 8 cases. In addition to intramural distribution patterns of infective bacteria, intracellular localization with evidence of bacterial immune escape mechanisms was identified. CONCLUSION: The high frequency of polymicrobial infections, pathogen diversity, and intracellular persistence of common IE-causing bacteria may provide clues to help explain the persistent and devastating mortality rate observed for IE. Improved bacterial diagnosis by 16S rDNA NGS that increases the ability to tailor antibiotic therapy may result in improved outcomes.

Early and late outcomes of complex aortic root surgery in patients with aortic root abscesses.

OBJECTIVES: To evaluate the early and long-term outcomes in patients undergoing complex aortic root reconstructions for complicated aortic root abscesses. METHODS: A total of 1199 patients underwent aortic valve surgery for aortic valve endocarditis between July 1999 and June 2012. Of these, 150 patients, who underwent complex isolated aortic root operations for aortic root abscesses, were included in this study. Radical resection of the abscess was performed in all patients followed by an aortic root replacement (ARR) in 91 (61.7%) or an aortic valve replacement with patch reconstruction of the aortic root in 59 (39.3%) patients. Prosthetic valve endocarditis was observed in 74 patients (49.3%). Logistic regression analysis identified the predictors of 30-day mortality. Estimated mean follow-up was 7.0 ± 0.5 years (range 0-12.6 years). RESULTS: Mean age was 62 ± 15 years and 87% (n = 130) were male. The majority of patients (91%; n = 137) underwent urgent or emergent surgery. Overall 30-day mortality was 19% (n = 29; ARR 21%; AVR 17%; P = 0.4). Postoperative low cardiac output, stroke and dialysis developed in 10.7, 4.7 and 25.3% of patients, respectively. Sepsis was the only independent predictor of 30-day mortality (odds ratio: 2.8; 95% confidence interval: 1.1-7.3; P = 0.03). The 1-, 5- and 10-year survival was 66 ± 5, 54 ± 5 and 51 ± 6%, respectively. Overall, 9% of surviving patients required a reoperation for recurrent endocarditis resulting in a 1-, 5- and 10-year freedom from reoperation of 93 ± 2, 91 ± 3 and 85 ± 5%, respectively, which was not influenced by surgical technique used (ARR vs AVR with patch reconstruction; log rank P = 0.9). CONCLUSIONS: The surgical treatment of aortic root abscess is a challenging operation and is associated with a high early morbidity and mortality. However, the long-term survival and freedom from reoperation is satisfactory.

Proteome profiles of HDL particles of patients with chronic heart failure are associated with immune response and also include bacteria proteins.

Besides modulation of reverse cholesterol transport, high density lipoprotein (HDL) is able to modulate vascular function by stimulating endothelial nitric oxide synthase. Recently, it could be documented that this function of HDL was significantly impaired in patients with chronic heart failure (CHF). We investigated alterations in the HDL proteome in CHF patients. Therefore, HDL was isolated from 5 controls (HDLhealthy) and 5 CHF patients of NYHA-class IIIb (HDLCHF). Proteome analysis of HDL particles was performed by two-dimensional liquid chromatography-mass spectrometry (SCX/RP LC-MS/MS). In total, we identified 494 distinct proteins, of which 107 proteins were commonly found in both groups (HDLCHF and HDLhealthy) indicating a high inter-subject variability across HDL particles. Several important proteins (e.g. ITGA2, APBA1 or A2M) varied in level. Functional analysis revealed regulated pathways. A minor proportion of bacteria-derived proteins were also identified in the HDL-particles. The extension of the list of HDL-associated proteins allows besides their mere description new insights into alterations in HDL function in diseases. In addition, the detection of bacterial proteins bound to HDL will broaden our view of HDL not only as a cholesterol carrier but also as a carrier of proteins.