Combined Minimally Invasive Mitral Valve Surgery and Percutaneous Coronary Intervention: A Hybrid Concept for Patients with Mitral Valve and Coronary Pathologies.

We evaluated the feasibility of hybrid percutaneous coronary intervention (PCI) and minimally invasive mitral valve surgery (MIMVS) in patients with concomitant coronary and mitral disease. Of 534 patients who underwent MIMVS at our institution between 2012 and 2018, those with combined mitral and single vessel coronary pathologies who underwent MIMVS and PCI were included. Patients were excluded if they had endocarditis or required emergency procedures. Preprocedural, procedural, and postprocedural data were retrospectively analyzed. In total, 10 patients (median age, 75 years; 7 males) with a median ejection fraction (EF) of 60% were included. Nine patients underwent PCI before and one after MIMVS. The success rate was 100% in both procedures. There were no postoperative myocardial infarctions or strokes. Two patients developed delirium and one required re-thoracotomy for bleeding. The median stay in intensive care and the hospital was 3 and 8 days, respectively. The 30-day survival rate was 100%. A hybrid PCI and MIMVS approach is feasible in patients with mitral valve and single vessel coronary disease. In combined pathologies, the revascularization strategy should be evaluated independent from the mitral valve pathology in the presence of MIMVS expertise. Extension of this recommendation to multivessel disease should be evaluated in future studies.

Interventional Treatment of Recurrent Ventricular Septal Defect Planed by 3D-Printed Reconstruction of the Heart.

We report a complex case of a 53-year-old male patient with recurrent ischemic ventricular septal defect that had been occluded by a surgical patch. Treatment was accomplished utilizing a 3-dimensional-printed model for preprocedural planning. In the future, printing of 3-dimensional models could offer new therapeutic strategies on an individual level. (Level of Difficulty: Intermediate.).

Atomic-level characterization and cilostazol affinity of poly(lactic acid) nanoparticles conjugated with differentially charged hydrophilic molecules.

Nanotherapeutics is a promising field for numerous diseases and represents the forefront of modern medicine. In the present work, full atomistic computer simulations were applied to study poly(lactic acid) (PLA) nanoparticles conjugated with polyethylene glycol (PEG). The formation of this complex system was simulated using the reactive polarizable force field (ReaxFF). A full picture of the morphology, charge and functional group distribution is given. We found that all terminal groups (carboxylic acid, methoxy and amino) are randomly distributed at the surface of the nanoparticles. The surface design of NPs requires that the charged groups must surround the surface region for an optimal functionalization/charge distribution, which is a key factor in determining physicochemical interactions with different biological molecules inside the organism. Another important point that was investigated was the encapsulation of drugs in these nanocarriers and the prediction of the polymer-drug interactions, which provided a better insight into structural features that could affect the effectiveness of drug loading. We employed blind docking to predict NP-drug affinity testing on an antiaggregant compound, cilostazol. The results suggest that the combination of molecular dynamics ReaxFF simulations and blind docking techniques can be used as an explorative tool prior to experiments, which is useful for rational design of new drug delivery systems.

Current perspectives in endoscopic vessel harvesting for coronary artery bypass grafting.

Coronary artery bypass grafting is still the most commonly performed procedure in cardiac surgery. Minimally invasive or endoscopic vessel harvesting was developed a decade ago. It has been shown that these less traumatic techniques significantly reduce wound healing problems and improve patient satisfaction. However, there are some concerns regarding bypass patency and long-term outcomes. The aim of this article is to describe the historic development of endoscopic vessel harvesting, different harvesting techniques and to give an update of the scientific evidence and the current debate regarding outcome and safety of these minimally invasive techniques.

Is the SYNTAX score a predictor of long-term outcome after coronary artery bypass surgery?

BACKGROUND: The SYNTAX score was introduced to measure the complexity of coronary artery disease. Although a high SYNTAX score is indicative of a worse long-term outcome after percutaneous coronary intervention (PCI), it remains unclear whether it is also true for coronary artery bypass grafting (CABG). METHODS: We analyzed 200 consecutive CABG patients who underwent operations in 2002. Demographic and intraoperative data, perioperative outcomes, and 5-year outcomes were obtained. The SYNTAX score was calculated retrospectively by reviewing the original diagnostic angiograms. After excluding patients who had undergone CABG or PCI treatment within 6 months before surgery, we included 154 patients in the study. Patients were partitioned into tertiles according to the SYNTAX score (low, < or =18; intermediate, >18-26; high, >26). Cox regression analysis was used to identify baseline and procedural predictors for the combined end point of 5-year major adverse cardiac and cerebrovascular events (MACCE) and its components. Cumulative event rates were estimated by Kaplan-Meier methods. RESULTS: The mean (+/-SD) age was 66.6 +/- 8.5 years, the mean ejection fraction was 56.4% +/- 13.6%, and the mean logistic EuroSCORE was 4.2% +/- 4.7%. The SYNTAX score ranged between 2 and 52. The overall survival rate was 94.8% at 1 year and 84.1% at 5 years. The rate of freedom from MACCE was 92.9% and 78.0% at 1 and 5 years, respectively. Only a higher EuroSCORE, a New York Heart Association class of III to IV, and smoking could be identified with Cox regression as risk factors for MACCE during follow-up. The overall survival and MACCE rates of the 3 SYNTAX score subgroups were not significantly different. CONCLUSIONS: Complex coronary pathology as measured by the SYNTAX score did not affect the long-term outcome after CABG in this study.

Beating heart aortic valve replacement after previous coronary artery bypass surgery with a patent internal mammary artery graft.

Re-sternotomy for aortic valve replacement (AVR) in patients with a patent internal mammary artery (IMA) graft may present a challenging surgical problem. Thus, strategies to prevent IMA graft injury include avoiding its dissection and leaving the graft open. However, when aortic cross clamping and cardioplegia are required, this approach may be associated with cardioplegia washout, suboptimal myocardial protection, and anterior myocardial wall injury. We herein describe an alternative technique for AVR on the beating heart in 4 patients with patent IMA grafts. The IMA was left unclamped and continuous retrograde coronary sinus perfusion (RCSP) was administered. Additional simultaneous antegrade venous bypass graft perfusion was established according to the extent of native coronary artery disease as well as patency and level of aortic proximal anastomoses. Using additional coronary ostia backflow control, the aortic valve was successfully replaced on the beating heart in all four cases without perivalvular leak. Postoperatively, low creatine kinase-MB fraction levels and preserved or improved ventricular function suggested very good myocardial protection. No myocardial infarction occurred in any patient. In our experience, aortic valve replacement on the beating heart using simultaneous antegrade-retrograde blood perfusion is a safe and effective method in this challenging subset of patients to prevent myocardial injury and to minimize the risk of patent IMA injury.