Trilateral versus Bilateral Antegrade Cerebral Perfusion in Frozen Elephant Trunk: A Propensity Score Analysis.

OBJECTIVE: Spinal cord injury (SCI) with subsequent paraplegia and/or stroke after arch repair with frozen elephant trunk (FET) remain the most devastating complications. In this study, we aim to examine the impact of different cerebral perfusion strategies on the neurological outcome comparing bilateral antegrade cerebral perfusion (bACP) and trilateral antegrade cerebral perfusion (tACP). METHODS: Between 2009 and 2021, 88 patients underwent total arch replacement using a hybrid prosthesis in FET technique for acute (40.4%) and chronic (59.6%) aortic pathologies. After excluding 14 patients who underwent FET with unilateral ACP the remaining 74 patients were divided into two groups. Propensity score matching was performed based on pre- and perioperative patient characteristics resulting in 22 patients in each group. The primary endpoint was a combination of major cerebral event and SCI. Secondary end point was all-cause mortality. RESULTS: Major cerebral events occurred in 9% of the patients in bACP versus 13.6% in tACP group (p = 0.63). No postoperative SCI was observed in patients with bACP and only one patient suffered SCI with tACP (p = 0.31). There was no significant difference in 30-day mortality between the two groups (22.7% in bACP vs. 13.6% in tACP; p = 0.43). CONCLUSION: In patients undergoing total aortic arch repair using FET technique, both perfusion strategies (bilateral and trilateral ACP) are safe and effective. The rates of neurological complications as well as mortalities are acceptably low in both groups. Further studies with larger patient cohorts are warranted.

Effect of using smaller blood volume tubes and closed blood collection devices on total blood loss in patients undergoing major cardiac and vascular surgery.

BACKGROUND: Diagnostic laboratory tests are an integral part of managing hospitalized patients. In particular, patients in the intensive care units (ICUs) can experience a concerning amount of blood loss due to diagnostic testing, which can increase the risk developing iatrogenic anemia. Several interventions exist to curtail avoidable blood loss, for example computerized decision support, smaller phlebotomy tubes, and other blood conservation devices. Nevertheless, use of these interventions is not standardized. Therefore, the objective of our study was to quantify the daily phlebotomy volume taken from patients who had undergone major cardiac or vascular surgery. METHODS: We estimated the number of blood analyses and volumes of drawn blood of 400 consecutive patients (≥ 18 yr) undergoing major cardiac or vascular surgery. The amount of blood saved using small-volume tubes and in combination with blood conservation device rather than standard-volume tubes was estimated for serum chemistry (serum), ethylenediaminetetraacetic acid (EDTA) tubes, sodium citrate coagulation (SCC) tubes, and arterial blood gas (ABG) analysis. RESULTS: The mean total blood loss due to phlebotomy drawing using standard-volume tubes during hospitalization was 167.9 mL (95% confidence interval [CI], 158.0 to 177.8), 255.6 mL (95% CI, 226.5 to 284.6), and 695.3 mL (95% CI, 544.1 to 846.4) for patients undergoing cardiac surgery with a hospital length of stay (LOS) of 0-10, 11-20, and ≥ 21 days, respectively. The mean total blood loss due to phlebotomy during hospitalization was 80.5 mL (95% CI, 70.5 to 90.6), 225.0 mL (95% CI, 135.1 to 314.8 mL) and 470.3 mL (95% CI, 333.5 to 607.1) for vascular surgery patients with LOS 0-10, 11-20, and ≥ 21 days, respectively. Patients with at least a two-day stay at the ICU had a mean blood loss of 146.6 mL (95% CI, 134.6 to 158.6 mL) and those with ≥ 11 days incurred a loss of 1,428 mL (95% CI, 1,117.8 to 1,739.2). The use of closed blood collection device and small-volume tubes (serum, EDTA, SCC, and ABG) reduced blood loss by 82.8 mL for patients with an ICU stay of 2 days and up to 824.0 mL for patients with a ICU stay of ≥ 11 days. CONCLUSION: Diagnostic laboratory tests are associated with significant patient blood loss, but are a modifiable risk factor. The use of small-volume tubes and closed blood collection devices decreases the volume of patient blood drawn for analysis and prevents blood waste.

RéSUMé: CONTEXTE: Les tests diagnostiques de laboratoire font partie intégrante de la prise en charge des personnes hospitalisées. Plus spécifiquement, la patientèle des unités de soins intensifs (USI) peut perdre une quantité inquiétante de sang en raison des tests de diagnostic, ce qui peut augmenter le risque d'anémie iatrogène. Plusieurs interventions existent pour réduire les pertes de sang évitables, par exemple une aide à la décision informatisée, des tubes de phlébotomie plus petits et d'autres dispositifs de conservation du sang. Néanmoins, le recours à ces interventions n'est pas normalisé. Par conséquent, l'objectif de notre étude était de quantifier le volume quotidien de phlébotomie prélevée chez des patient·es ayant bénéficié d'une chirurgie cardiaque ou vasculaire majeure. MéTHODE: Nous avons estimé le nombre d'analyses sanguines et les volumes de sang prélevés de 400 personnes consécutives (≥ 18 ans) bénéficiant d'une chirurgie cardiaque ou vasculaire majeure. La quantité de sang économisée à l'aide de tubes de petit volume et en combinaison avec un dispositif de conservation du sang plutôt que des tubes de volume standard a été estimée pour la chimie sérique (sérum), les tubes d'acide éthylène-diamine-tétra-acétique (EDTA), les tubes de coagulation au citrate de sodium (CCS) et l'analyse des gaz du sang artériel (GSA). RéSULTATS: La perte sanguine totale moyenne due au prélèvement de phlébotomie à l'aide de tubes de volume standard pendant l'hospitalisation était de 167,9 mL (intervalle de confiance [IC] à 95 %, 158,0 à 177,8), 255,6 mL (IC 95 %, 226,5 à 284,6) et 695,3 mL (IC 95 %, 544,1 à 846,4) chez les patient·es bénéficiant d'une chirurgie cardiaque avec une durée de séjour à l'hôpital de 0 à 10, 11 à 20, et ≥ 21 jours, respectivement. La perte sanguine totale moyenne due à la phlébotomie pendant l'hospitalisation était de 80,5 mL (IC 95 %, 70,5 à 90,6), 225,0 mL (IC 95 %, 135,1 à 314,8 mL) et 470,3 mL (IC 95 %, 333,5 à 607,1) chez les patient·es ayant bénéficié d'une chirurgie vasculaire avec des durées de séjour de 0-10, 11-20 et ≥ 21 jours, respectivement. Les patient·es ayant séjourné au moins deux jours à l'USI ont eu une perte de sang moyenne de 146,6 mL (IC 95 %, 134,6 à 158,6 mL) et celles et ceux ayant séjourné ≥ 11 jours ont subi une perte de 1428 mL (IC 95 %, 1117,8 à 1739,2). L'utilisation d'un dispositif de prélèvement sanguin fermé et de tubes de petit volume (sérum, EDTA, SCC et gsa) a réduit la perte de sang de 82,8 mL pour les patient·es ayant séjourné à l'USI 2 jours et jusqu'à 824,0 mL pour les patient·es ayant séjourné en USI ≥ 11 jours. CONCLUSION: Les tests de laboratoire diagnostiques sont associés à une perte de sang importante chez les patient·es, mais constituent un facteur de risque modifiable. L'utilisation de tubes de petit volume et de dispositifs fermés de prélèvement sanguin diminue le volume de sang prélevé pour analyse et prévient le gaspillage de sang.

Right-Sided Minimally Invasive Direct Coronary Artery Bypass: Clinical Experience and Perspectives.

Objective: Minimally invasive direct coronary artery bypass grafting (MIDCAB) using the left internal thoracic artery to the left descending artery is a clinical routine in the treatment of coronary artery disease. Far less is known on right-sided MIDCAB (r-MIDCAB) using the right internal thoracic artery (RITA) to the right coronary artery (RCA). We aimed to present our experience in patients with complex coronary artery disease who underwent r-MIDCAB. Materials and Methods: Between October 2019 and January 2023, 11 patients received r-MIDCAB using RITA to RCA bypass in a minimally invasive technique via right anterior minithoracotomy without using a cardiopulmonary bypass. Underlying coronary disease was complex right coronary artery stenosis (n = 7) and anomalous right coronary artery (ARCA; n = 4). All procedure-related and outcome data were evaluated prospectively. Results: Successful minimally invasive revascularization was achieved in all patients (n = 11). There were no conversions to sternotomy and no re-explorations for bleeding. Furthermore, no myocardial infarction, no strokes, and, most importantly, no deaths were observed. During the follow-up period (median 24 months), all patients were alive and 90% were completely angina free. Two patients received a repeated revascularization after surgery but independently from the RITA-RCA bypass, which was fully competent in both patients. Conclusion: Right-sided MIDCAB can be performed safely and effectively in patients with expected technically challenging percutaneous coronary intervention of the RCA and in patients with ARCA. Mid-term results showed high freedom from angina in nearly all patients. Further studies with larger patient cohorts and more evidence are needed to provide the best revascularization strategy for patients suffering from isolated complex RCA stenosis and ARCA.

Reply to Jasinski M et al.: "Indeed, there is still room for improvement in long-term durability of BAV repair".

We read the letter to the editor by Dr Jasinski et al. entitled "Long-term durability of valve-sparing or repair procedures in BAV-Is there room for improvement?" with great interest.

Longer-term outcomes after bicuspid aortic valve repair in 142 patients.

BACKGROUND: The aim of this study was to evaluate the longer-term results of bicuspid aortic valve (BAV) repair with or without aortic root replacement. METHODS: From 1999 to 2017, 142 patients with or without aortic root dilatation who underwent repair of a regurgitant BAV were included in the study. Ninety-four patients underwent isolated BAV repair (Group 1; median age 43 years) and 48 patients underwent valve-sparing aortic root replacement plus BAV repair (aortic valve reimplantation-Group 2; median age 48 years). Median clinical follow-up time was 5.9 years (range 0.5-15) in Group 1 and 3 years (range 0.5-16) in Group 2, respectively. RESULTS: In-hospital mortality was 1% in Group 1, and 2% in Group 2 (p = .6). The 5- and 10-year survival was 93 ± 2.9% and 81 ± 5.8% in Group 1 and 96 ± 3.1% and 96 ± 3.1% in Group 2, respectively (p = .31). Eleven patients of Group 1 (1.7%/patient-year) and five patients of Group 2 (2.2%/patient-year) underwent reoperation of the aortic valve (p = .5). The 5- and 10-year freedom from reoperation were 93.0 ± 2.1% and 77.1 ± 7.1% in Group 1 and 93.0 ± 5.0% and 76.7 ± 9.6% in Group 2 (p = .83), respectively. At the latest follow-up, only two patients of Group 1 and 1 patient of Group 2 had AV regurgitation = 2° (p = .7). The cumulative linearized incidence of all valve-related complications (bleeding, stroke, endocarditis, and reoperation) was 2.9%/patient-year in Group 1% and 4%/patient-year in Group 2, respectively (p = .6). CONCLUSIONS: Isolated BAV repair and combined aortic valve reimplantation plus BAV repair provide good clinical longer-term outcomes with relatively low reoperation rate and durable valve function.

Mitral Valve Surgery via Upper Ministernotomy: Single-Centre Experience in More than 400 Patients.

Background: Minimally invasive mitral valve (MV) surgery has emerged as an alternative to conventional sternotomy aiming to decrease surgical trauma. The aim of the study was to describe our experience with minimally invasive MV surgery through partial upper sternotomy (PUS) regarding short- and long-term outcomes. Methods: From January 2004 through March 2014, 419 patients with a median age of 58.9 years (interquartile range 18.7; 31.7% females) underwent isolated primary MV surgery using PUS. Myxomatous degenerative MV disease was the predominant pathology (77%). The patients' mean EuroSCORE II risk profile was 3.9 ± 3.6%. Results: Mitral valve repair was performed in 384 patients (91.6%) and replacement in 35 patients (8.4%). Thirty-day mortality was 3.1%. In total, 29 (6.9%) deaths occurred during the follow-up. The overall estimated survival at 1, 5, and 10 years was 93.1 ± 1.3%, 87.1 ± 1.9%, and 81.1 ± 3.4%. Reoperation was necessary in 14 (3.3%) patients. The overall freedom from MV reoperation at 1, 5, and 10 years was 98.2 ± 0.7%, 96.1 ± 1.2%, and 86.7 ± 6.7% and the overall freedom from recurrent MV regurgitation > grade 2 in repaired valves at 1, 5, and 10 years was 98.8 ± 0.6%, 98.8 ± 0.6%, and 94.6 ± 3.3%. Conclusions: Minimally invasive MV surgery via PUS can be performed with particularly good early and late results. Thus, the PUS approach with the use of standard surgical instruments and cannulation techniques can be a valuable option for the MV surgery either in patients contraindicated or not suitable to minithoracotomy.

Opening Pandora's Box - Presumed ST Segment Elevation Myocardial Infarction with Symptomatic Ventricular Tachycardia is Cured by Resection of a Huge Left Ventricular Aneurysm.

A 76-year-old male patient with history of hypertension, type 2 diabetes, and smoking was admitted to the emergency department with chest pain. The patient reported severe and sudden chest pain accompanied by cold sweating, dizziness, and palpitations.

Epicardial left atrial appendage AtriClip occlusion reduces the incidence of stroke in patients with atrial fibrillation undergoing cardiac surgery.

Aims: Left atrial appendage (LAA) occlusion has emerged as an interesting alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF). We report the safety, efficacy, and durability of concomitant device-enabled epicardial LAA occlusion during open-heart surgery. In addition to long-term follow-up, we evaluate the impact on stroke risk in this selected population. Methods and results: A total of 291 AtriClip devices were deployed epicardially in patients (mean CHA2DS2-VASc-Score: 3.1 ± 1.5) undergoing open-heart surgery (including isolated coronary artery bypass grafting, valve, or combined procedures) comprising of forty patients from a first-in-man device trial (NCT00567515) and 251 patients from a consecutive institutional registry thereafter. In all patients (n = 291), the LAA was successfully excluded and overall mean follow-up (FU) was 36 ± 23months (range: 1-97 months). No device-related complications were detected throughout the FU period. Long-term imaging work-up (computed tomography) in selected patients ≥5years post-implant (range: 5.1-8.1 years) displayed complete LAA occlusion with no signs of residual reperfusion or significant LAA stumps. Subgroup analysis of patients with discontinued OAC during FU (n = 166) revealed a relative risk reduction of 87.5% with an observed ischaemic stroke-rate of 0.5/100 patient-years compared with what would have been expected in a group of patients with similar CHA2DS2-VASc scores (expected rate of 4.0/100 patient-years). No strokes occurred in the subgroup with OAC. Conclusion: The long-term results from our first-in-man prospective human trial plus our institutional registry of epicardial LAA occlusion with the AtriClip in patients with AF undergoing cardiac surgery demonstrate the safety and durability of the procedure. In addition, our data are suggestive for the potential efficacy of LAA occlusion in reducing the incidence of stroke. If validated in future large randomized trials, routine LAA occlusion in patients undergoing cardiac surgery (with contraindications to treatment with oral anticoagulants) may represent a reasonable adjunct procedure to reduce the risk of future stroke. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00567515.

Long-Term Outcomes after Minimally Invasive Aortic Valve Surgery through Right Anterior Minithoracotomy.

Background Minimally invasive aortic valve surgery (MIAV) through a right anterior minithoracotomy evolved to an accepted procedure with favorable short- and mid-term outcomes, whereas long-term results lack. The aim of this study was to evaluate the long-term outcomes. Materials and Methods All our MIAV patients were included (n = 225). Mean age was 68 ± 12 years, 29% were older than 75 years, and median EuroSCORE was 5 (0-11). Baseline characteristics, inhospital outcomes, and follow-up information about survival, major adverse cardiac and cerebrovascular events (MACCE), and need for reoperation were collected and analyzed. Results In this study, 30-day mortality was 1.3%, and there was no permanent stroke. Mean follow-up time was 69.65 ± 24 months, being the longest so far reported in the literature. At 1 and 7 years, survival was 95.8 and 79%, freedom from MACCE 98.1 and 95.7%, and from reoperation 99.5 and 98.7%, respectively. Conclusion MIAV is safe and feasible with favorable long-term outcomes. In the future, it could serve as benchmark for interventional methods as soon as indications are expanded to young and low-risk patients. Randomized studies are needed to compare the long-term outcomes of these approaches.

Effects of conventional CPB and mini-CPB on neutrophils CD162, CD166 and CD195 expression.

OBJECTIVE: Cardiac surgery is known to trigger a systemic inflammatory response. While the use of conventional cardiopulmonary bypass (CPB) results in profound inflammation, modified mini-CPB is considered less harmful. We evaluated the impact of cardiac surgery on the expression of CD162, CD166, CD195 molecules and their association with the type of CPB used. METHODS AND RESULTS: Twenty-four patients were enrolled in our study. Twelve of them were operated using conventional CPB while the other twelve patients underwent surgery with mini-CPB. Blood samples were analysed by flow cytometry. We observed a significant increase in median fluorescence intensity of CD162 and CD195 that peaked instantly after surgery and normalized to the baseline value on the 1st day post surgery, whereas CD166 was initially down-regulated and its median fluorescence intensity (MFI) value increased to the baseline in the next few days. CONCLUSION: We observed immediate changes in the expression of CD162, CD166, and CD195 molecules on the neutrophils after surgery in both study groups of patients. The intensity of the observed changes was significantly greater in the group of patients who underwent conventional CPB compared to patients who underwent mini-CPB cardiac surgery.

Pentraxin 3 and other inflammatory biomarkers related to atrial fibrillation in cardiac surgery.

OBJECTIVES: The aim was to evaluate the association between perioperative inflammatory biomarkers and atrial fibrillation (AF) in cardiac surgical patients. METHODS: Forty-two patients undergoing cardiac surgery were divided into three groups according to the occurrence of AF: Group A (n = 22) - patients with no AF, Group B (n = 11) - patients with new onset AF postoperatively and Group C (n = 9) - patients with preoperative history of atrial fibrillation. The serum levels of PTX3, CRP, TLR2, IL-8, IL-18, sFas, MMP-7 and MMP-8 were measured at the following time points: before surgery, immediately and 6 h after surgery and on the 1st, 3rd and 7th postoperative days (POD). RESULTS: Serum levels of PTX3 showed a significant difference between Groups A and C on the 3rd POD (p<0.05) and on the 7th POD (p<0.0001). IL-8 levels were different between Groups A and C immediately after surgery (p<0.05), 6 hours after surgery (p<0.05) and on the 3rd POD (p<0.05). There was a difference between Groups B and C on the 1st POD in IL-8 levels (p<0.05). The sFas levels differed between Groups A and C on the 3rd POD (p<0.01) and the 7th POD (p<0.05). There was also a difference on the 7th POD (p<0.05) between the Groups B and C. No significant differences between the groups was seen for other biomarkers. CONCLUSION: This study demonstrates significantly different dynamics of PTX3, IL-8 and sFas levels after cardiac surgery in relation to AF.

Clinical performance of a new bidirectional rotational mechanical lead extraction sheath.

AIMS: We investigated the safety and efficacy of a new bidirectional rotational mechanical extraction sheath (Evolution RL, Cook Medical, USA). METHODS AND RESULTS: From April 2013 until September 2014, we performed lead extraction procedures in 71 patients with 112 leads scheduled for extraction. During this time period, we used the new Evolution RL rotational sheath in 40 patients on 52 leads (24 pacemaker leads and 28 implantable cardioverter-defibrillator leads) scheduled for extraction. The mean lead implant duration in these patients was 100.2 (22-271) months. Forty leads were right ventricular leads, 10 right atrial leads, and 2 coronary sinus leads. Clinical success among the leads approached with the Evolution RL device was 98.1%. Operative mortality was zero. Major complications did not occur. Four minor complications were encountered (all pocket haematomas). No device-related complications were noted. In cases with multiple leads in situ, no wrapping of companion leads was seen. The average number of extraction tools used per lead was 2.4 (2-4) in the Evolution RL cohort. CONCLUSION: Based on the presented results of our initial experience with the new bidirectional rotational mechanical extraction device, its use is safe and efficient with high success rates in long implanted leads.

Implementation of a patient blood management monitoring and feedback program significantly reduces transfusions and costs.

BACKGROUND: Patient blood management (PBM) measures have been shown to be effective in reducing transfusions while maintaining patient outcome. The issuance of transfusion guidelines is seen as being key to the success of PBM programs. As the introduction of guidelines alone did not visibly reduce transfusions in our center, a monitoring and feedback program was established. The aim of our study was to show the effectiveness of such measures in reducing transfusions and cost. STUDY DESIGN AND METHODS: We designed a prospective, interventional cohort study with a 3-year time frame (January 1, 2012 to December 31, 2014). In total, 101,794 patients aged 18 years or older were included. The PBM monitoring and feedback program was introduced on January 1, 2014, with the subsequent issuance of quarterly reporting. RESULTS: Within the first year of introduction, transfusion of all allogeneic blood products per 1000 patients was reduced by 27% (red blood cell units, -24%; platelet units, -25%; and fresh-frozen plasma units, -37%; all p < 0.001) leading to direct allogeneic blood product related savings of more than 2 million USD. The number of blood products transfused per case was significantly reduced from 9 ± 19 to 7 ± 14 (p < 0.001). With an odds ratio of 0.86 (95% confidence interval, 0.82-0.91), the introduction of our PBM monitoring and feedback program was a significant independent factor in the reduction of transfusion probability (p < 0.001). CONCLUSION: Our PBM monitoring and feedback program was highly efficacious in reducing the transfusion of allogeneic blood products and transfusion-related costs.

Compression coil provides increased lead control in extraction procedures.

AIMS: We investigated a new lead extraction tool (Compression Coil; One-Tie, Cook Medical) in an experimental traction force study. METHODS AND RESULTS: On 13 pacemaker leads (Setrox JS53, Biotronik) traction force testing was performed under different configurations. The leads were assigned to three groups: (i) traction force testing without central locking stylet support (n = 5), (ii) traction force testing with the use of a locking stylet (Liberator, Cook Medical) and a proximal ligation suture (n = 4), (iii) traction force testing with the use of a locking stylet and a compression coil (n = 4). The following parameters were obtained for all groups: stress-strain curves, maximal forces, elastic modulus, post-testing lead length and lead elongation. In Groups 2 and 3 retraction of the locking stylet within the lead was measured [lead tip-locking stylet distance (LTLSD)]. Maximal forces for the three groups were: (i) 28.3 ± 0.3 N; (ii) 30.6 ± 3.0 N; (iii) 31.6 ± 2.9 N (1 vs. 2, P = 0.13; 1 vs. 3, P = 0.04; 2 vs. 3, P = 0.65). Elastic modulus was (i) 22.8 ± 0.1 MPa; (ii) 2830.8 ± 351.1 MPa; (iii) 2447.0 ± 510.5 MPa (1 vs. 2, P < 0.01; 1 vs. 3, P < 0.01; 2 vs. 3, P = 0.26). Mean LTLSD in Group 2 was 19.8 ± 3.2 cm and was 13.8 ± 1.7 cm in Group 3 (P = 0.02). The ratio of LTLSD/post-testing lead length was 0.37 ± 0.03 for Group 2 and 0.24 ± 0.03 for Group 3 (P < 0.01). CONCLUSION: The application of a compression coil leads to an increased lead control expressed by less retraction of the locking stylet within the lead. This enables improved central support of extraction sheaths in the case of challenging extraction procedures.

Mid-Term Outcomes of Minimally Invasive Direct Coronary Artery Bypass Grafting.

BACKGROUND: Minimally invasive direct coronary artery bypass grafting (MIDCAB) has gained wide acceptance for the treatment of single vessel disease of the left anterior descending artery (LAD). Here, we present our single center experience of 152 consecutive patients. MATERIALS AND METHODS: All patients underwent MIDCAB through a left anterior minithoracotomy between January 1, 2009, and December 31, 2012. Preoperative, intraoperative, postoperative, and follow-up data including major adverse cardiac and cerebrovascular events (MACCE) and need for re-intervention were collected. RESULTS: Mean age was 64.4 ± 11 years, median additive EuroSCORE 3 (0-11), 84% were male. All except one patient were successfully operated without cardiopulmonary bypass. Seven patients with unexpected severely calcified LADs were converted to sternotomy (4.6%); 91.3% were extubated in the operating room or on the day of surgery. Median stay at the intensive care unit and in hospital were 1 (0-97) and 7 (1-49) days, respectively. Thirty-day mortality was 1.9%. There was no stroke. Five patients (3.2%) had to be re-explored for bleeding and 95% received no transfusion. Median follow-up was 24 months (0-97) and complete in 93.3% with overall survival of 92.4 ± 0.2% and MACCE-free survival of 96.1 ± 1.7%. Two patients had a re-intervention of the LAD. CONCLUSION: MIDCAB is a safe procedure with low postoperative morbidity, mortality, and favorable mid-term MACCE-free survival in selected patients that should be discussed in a heart team setting to evaluate the "ideal" individual treatment option.

Use of extracellular matrix patches in cardiac surgery.

A noncellular xenogeneic extracellular matrix derived from the porcine small intestinal submucosa can be used as a new patch material with potential advantages. We review the literature on the use of this material in cardiac surgery.

Does implantation technique influence lead failure?

OBJECTIVE: We aimed to analyse whether different lead implantation techniques influence lead failure based on implant duration. METHODS AND RESULTS: Eighty-two transvenous leads were extracted due to lead failure. Median implant duration (MID) of the extracted leads was 68 months. Failed leads were retrospectively divided into 5 subgroups according to predefined technical procedural aspects, potentially triggering lead failure: venous approach, lead disorder in the generator pocket, sharp lead angulation, lead-lead interaction and number of leads in situ. The subgroups were correlated to the MID and compared. The MID was 81 vs 59 months in medial vs lateral venous puncture (P=0.453). In subgroups without/with lead disorder the MID was 59 vs 107 months (P=0.006) and 57 vs 84 months (P=0.012) in subgroups without/with sharp lead angulation, respectively. In subgroups without/with more than 1 lead-lead interaction the MID was 59 vs 81 months (P=0.029) and 65 vs 86 months (P=0.128) without/with more than 2 lead-lead interactions, respectively. In subgroups without/with more than 1 lead in situ the MID was 73 vs 67 months (P=0.453), 81 vs 27 months (P=0.296) in subgroups without/with more than 2 leads in situ and 68 vs 77 months (P=0.264) in subgroups without/with more than 3 leads in situ, respectively. CONCLUSIONS: Although, we were able to confirm our hypothesis only partially, technical aspects of lead implantation technique should be kept in mind as a potential reason causing lead failure.

Could pentraxin 3 be a new diagnostic marker for excessive inflammatory response in cardiac surgery?

BACKGROUND: The aim of this study was to compare the dynamics of two inflammatory response biomarkers pentraxin 3 (PTX3) and C-reactive protein (CRP) after cardiac surgery with particular regard to different postoperative clinical manifestation of inflammatory response. PATIENTS AND METHODS: In this study, 42 patients undergoing open heart surgery with the use of cardiopulmonary bypass were included and divided in two groups according to the extent of clinical manifestation of inflammatory response: Group A (n=21)-patients with different severity of systemic inflammatory response syndrome (SIRS) and Group B (n=21)-patients with uneventful postoperative period (no SIRS). The serum levels of PTX3 and CRP were evaluated and compared at the following time points: before and at the end of surgery, 6 hours, 1st, 3rd, and 7th day after surgery. RESULTS: The dynamics of CRP levels were comparable between both groups and showed the classical characteristics after cardiac surgery with a peak on the 3rd postoperative day (113 vs. 132 mg/L). In contrast, the dynamics of PTX3 showed an earlier increase of serum levels with the peak on the 1st postoperative day in both groups (36.3 vs. 42.7 ng/mL). Importantly, a significant difference of PTX3 levels was found on the 3rd postoperative day (31.1 vs. 7.0 ng/mL; p<0.006) between the two groups showing significantly delayed decrease of PTX3 levels in patients with SIRS (Group A). CONCLUSION: This study demonstrates considerably different dynamics of PTX3 levels after cardiac surgery in patients with SIRS and patients without SIRS, thus it may be indicative to start the appropriate therapy.

Valve cuspidity: a risk factor for aortic valve repair?

BACKGROUND: The aim of this study was to analyze short- and mid-term results after aortic valve (AV) repair with particular regard to the impact of valve cuspidity (bicuspid versus tricuspid aortic valve). METHODS: One hundred patients with aortic regurgitation (AR) undergoing aortic valve repair between November 2007 and October 2012 were included in the study. Sixty patients had bicuspid AV (BAV group; 11 females) and 40 patients had tricuspid AV (TAV group; 13 females). AR > grade 2 was present in 47 (78%) patients in the BAV and in 35 (88%) patients in the TAV group. Follow-up was complete in 100% and median was 25 months. RESULTS: Isolated aortic valve repair was performed in 27 (45%) of BAV patients and in six (15%) of TAV patients. Replacement of the ascending aorta and/or aortic root was performed in 33 (55%) of BAV patients and in 34 (86%) of TAV patients. There was no death within 30 days postoperatively, while two patients died (TAV group) during the follow-up period. There was no statistical difference between BAV and TAV groups with regard to the survival (100 ± 0% vs. 95 ± 4%, p = 0.102), the three-year freedom from AV-related reoperation (90 ± 5% vs. 89 ± 6%, p = 0.456), and the three-year freedom from AR grade > 2 (86 ± 6% vs. 82 ± 7%, p = 0.866), respectively. CONCLUSIONS: This study demonstrates no difference in mid-term results after regurgitant bicuspid and tricuspid aortic valve repair, suggesting that bicuspid valve may not be a risk factor for aortic valve repair.